[Diagnostic value of high resolution sonography in Crohn's disease and ulcerative colitis]

OBJECTIVE

To evaluate the diagnostic accuracy of high resolution sonography in patients with inflammatory bowel disease (MICI).

PATIENTS AND METHODS

In patients with Crohn's disease (n = 48), ulcerative colitis (n = 23), indeterminate colitis (n = 3), inflammatory (n = 21) and non-inflammatory (n = 23) controls, high resolution sonography was performed and compared to colonoscopy (+/- retrograde ileoscopy) and/or baryum studies of the small bowel and the colon.

RESULTS

Diagnosis of intestinal inflammation or not was correct in 69/74 MICI patients (sensitivity: 94.4%, specificity: 66.7%, global accuracy: 93.2%). Segment location was accurate in 58/74 (sensitivity: 80.3%, specificity: 66.7%, global accuracy: 79.7), more frequently in Crohn's disease, than in ulcerative colitis. Five out of six complications of Crohn's disease were diagnosed. In Crohn's disease, the method was more accurate in case of colonic or ileocolonic involvement.

CONCLUSION

High resolution sonography is a reliable diagnostic tool for the detection of intestinal inflammation and related complications in MICI. In can be of value in the follow-up and seems particularly interesting in the case of temporary contraindication of invasive methods.

Management of common bile duct stones by laparoscopic cholecystectomy and endoscopic sphincterotomy: pre-, per- or postoperative sphincterotomy?

BACKGROUND/AIMS

The aim of this study was to evaluate the treatment of common bile duct stones (CBDS) by endoscopic sphincterotomy (ES) and laparoscopic cholecystectomy (LC), ES being performed either pre-, per- or postoperatively.

METHODS

Between January 1990 and June 1997, 386 patients with a median age of 60 (range 18-92) years were treated for suspected or confirmed CBDS. The CBDS were uncomplicated in 264 cases (70%) but associated with a complication in 122 cases (30%), namely, cholangitis (69 cases) or acute pancreatitis (53 cases). ES combined with LC was carried out in 233 cases (60%): ES was preoperative (sequential treatment in two stages) in 197 cases (51%); peroperative in 30 cases (7%), or postoperative in 6 cases (2%). Laparoscopic extraction was performed in 58 cases (15%) and conventional surgery in 82 cases (21%).

RESULTS

With respect to sequential treatment, endoscopic retrograde cholangiography showed the presence of CBDS in 117 cases (60%) and preoperative ES allowed the release of the CBDS in 82% of these cases. The complication rate of sequential treatment was 8% (15 cases) after ES and 7% (13 cases) after LC, with 1 death (0.5%). A peroperative ES performed after LC enabled evacuation of the CBDS in 28 cases (93%) without any complications or mortality. Postoperative ES was successful in 100% of cases with residual lithiasis in 16% (1 case) and a complication rate of 16% (1 case).

CONCLUSION

Along with conventional surgery and laparoscopic extraction, ES combined with LC represents an effective alternative in the management of CBDS. Since it can be performed peroperatively, it allows a one-stage, minimally invasive treatment of most uncomplicated CBDS.

Failure of intravenously administered immunoglobulin in the treatment of neonatal myasthenia gravis

Neonatal myasthenia gravis is uncommon and life threatening. We describe the use of intravenously administered immunoglobulin, in addition to conventional modalities, in a neonate with severe neonatal myasthenia gravis. However, despite this aggressive management, the child had a prolonged period of weakness requiring intensive care.

Metachromatic activity of beta-cyclodextrin sulfates as heparin mimics

Heparin is a versatile biologically active substance which has been reported to have an inhibitory effect on angiogenesis if administered together with hydrocortisone. Since very little is known about the mechanism of this activity, beta-cyclodextrin sulfates were prepared to mimic heparin. The sulfate groups were introduced into beta-cyclodextrin regioselectively using protecting groups. The obtained polyanions were tested for their complex binding properties by mixing them with cationic dyes and measuring the metachromatic response which proved to be a very useful tool to evaluate the biological activity of these compounds. The results reveal that the activity depends largely upon the charge density at the surface of the beta-cyclodextrin sulfates: a large number of sulfate groups or anionic groups relatively close to each other display high activity, whereas molecules with fewer sulfate groups or with them more distant from each other exhibit smaller activities.

Frequent factor II G20210A mutation in idiopathic portal vein thrombosis

BACKGROUND & AIMS

Despite extensive investigations of portal vein thrombosis, no underlying cause is identifiable in up to 30% of patients. A recently described mutation of the prothrombin gene at nucleotide position 20210 is associated with history of venous thrombosis and was assessed in this study.

METHODS

We compared the frequency of factor II G20210A and factor V G1691A (factor V Leiden) mutations in 10 patients with idiopathic portal vein thrombosis, 10 patients with nonidiopathic portal vein thrombosis, 60 patients with deep vein thrombosis of the legs, and 42 control subjects.

RESULTS

The frequency of factor II G20210A mutation was increased in patients with idiopathic portal vein thrombosis (40.0%; confidence interval, 3.1%-76.9%) compared with controls (4.8%; confidence interval, 0%-11.5%) or patients with nonidiopathic portal vein thrombosis or deep vein thrombosis (P = 0.0001). In contrast, the frequency of the factor V G1691A mutation was similar in subjects with portal vein thrombosis and in controls but was increased in patients with deep vein thrombosis (P = 0.0001).

CONCLUSIONS

The factor II G20210A mutation is frequent in patients with idiopathic portal vein thrombosis and should therefore be assessed under this circumstance.

The influence of ionizing radiation on the CLARION 1.2 cochlear implant during radiation therapy

OBJECTIVE

This study aimed to determine the maximum dose of radiation the CLARION 1.2 cochlear implant can withstand safely.

INTRODUCTION

Cochlear implants restore functional hearing to patients with sensorineural deafness. Because some patients may need radiation therapy, it is important to investigate the influence of ionizing radiation on cochlear implant function.

METHODS

This study tested the function of four CLARION 1.2 implants (Advanced Bionics, Sylmar, CA, U.S.A.) after varying radiation treatments with gamma rays. The first implant received a cumulative dosage of 69 Gy over nine treatments (single doses between 0.1-30 Gy). The second was irradiated with a total of 90 Gy, receiving three treatments of 30 Gy each. The third and fourth received doses more typical of patient therapy (i.e., 2 Gy) approximately 30 times, for a cumulative dosage of approximately 60 Gy. Implant function was tested after every treatment; the CLARION implant incorporates a back-telemetry system, allowing impedance and current output testing.

RESULTS

Despite the type of treatment, the results were quite consistent: difficulties in function occurred when the cumulative dosage inside the implant was approximately 60 Gy. The first implant recovered completely and the second recovered partially.

DISCUSSION

The CLARION 1.2 cochlear implant seems to safely withstand approximately 60 Gy of radiation before experiencing functional difficulties. In a clinical situation, the implant would not likely be in the target volume irradiated, and thus the patient's therapeutic cumulative dosage might be higher.

High signal in the adenohypophysis on T1-weighted images presumably due to manganese deposits in patients on long-term parenteral nutrition

Hypermanganesaemia is reported in patients on long-term parenteral nutrition. Deposition of manganese, giving high signal on T1-weighted images, may involve the basal ganglia. MRI in nine patients (mean age 51 years, range 31-75 years) on long-term parenteral nutrition (mean duration 30 months, range 6-126 months), demonstrated high signal in the anterior pituitary gland on T1-weighted sagittal and coronal images. The gland appeared normal on T2-weighted images. Signal intensity in the basal ganglia on T1-weighted images was increased in all patients. Endocrine assessment showed no significant abnormality. Neurological examination showed a mild parkinsonian movement disorder in one patient. Hypermanganaesemia was present in all nine (1.3-2.8 micromol/l, mean 1.87 micromol/l). The high signal in the anterior pituitary gland was probably related to deposition of paramagnetic substances, especially manganese.

The position of the ZEBRA activation domain does not influence its biological activity

Epstein-Barr virus (EBV) is a human herpesvirus which latently infects B lymphocytes. EBV encodes a unique transcriptional activator, known as ZEBRA, which can disrupt viral latency in B cells and induce lytic viral replication. Furthermore, ZEBRA has been shown to bind at the EBV origin of lytic replication, and is necessary for viral DNA replication to occur. Previously we demonstrated that heterologous activation domains can fully substitute for the ZEBRA activation domain. Here we extend those results by showing that the position of the ZEBRA activation domain or a heterologous replacement domain does not influence its ability to function in the disruption of EBV latency. In this study three novel clones were constructed in which the ZEBRA activation region was repositioned to the carboxy terminus of the protein. These mutants were used to demonstrate that the ability of ZEBRA's wild type domain to function in the complex biological process of virus activation is not compromised by altering its position within the protein.

Tracing cellular and molecular mechanisms involved in endometriosis

The aetiology and pathogenesis of endometriosis, defined as the presence of endometrium-like tissue outside the uterine cavity, is largely unknown. In this paper we present and discuss possibilities to study the putative pathogenic properties of endometriotic cells in vitro. The current focus of our investigations is on the invasive phenotype of the disease, assuming that this might contribute to the pathogenesis of endometriosis. So far, we have shown that: (i) cytokeratin-positive and E-cadherin-negative endometriotic cells have an invasive phenotype in a collagen invasion assay in vitro similar to metastatic carcinoma cells; (ii) the invasiveness of endometriotic but not of eutopic endometrial cells can be stimulated by a heat-stable protein present in peritoneal fluid; and (iii) the endometriotic cell line EEC145T, which we established, may be a useful tool for the identification of gene products which are, positively or negatively, invasion-related. Finally, our studies suggest that the invasive phenotype in endometriosis shares aspects with tumour metastasis, but might also have unique mechanisms.

[Epiphysis-metaphysis bone ischemia in hemorrhagic rectocolitis and Crohn's disease]

Aseptic osteonecrosis is a rare extraintestinal manifestation in patients with inflammatory bowel disease; its true prevalence is not precisely known. Steroid treatment undoubtedly participates in the pathophysiology of avascular osteonecrosis, however, other factors like hypercoagulability may be involved. Two cases of bilateral osteonecrosis of the knees--the first occurring during the course of ulcerative colitis, the second in a patient presenting with Crohn's disease--are described. Specific location of the lesions and regression of symptoms, as well as the importance of magnetic resonance imaging for early recognition of osteonecrosis, are noteworthy.

Monk seal mortality: virus or toxin?

During the past few months, more than half of the total population of about 300 highly endangered Mediterranean monk seals (Monachus monachus) on the western Saharan coast of Africa, died in a mysterious disease outbreak. Epizootiological and postmortem findings were reminiscent of similar outbreaks amongst pinniped and cetacean species in recent years, which were caused by an infection with newly discovered morbilliviruses (for review see osterhaus et al.). Virological, as well as toxicological, analysis performed on tissue samples collected from relatively fresh carcasses during the outbreak indicate that infection with a virus closely related to dolphin morbillivirus (DMV), possibly originating from affected dolphins in the same area, was the primary cause of the outbreak. Therefore it is concluded that vaccination with a safe and effective non-replicating vaccine should be considered as a management tool in the conservation of Mediterranean monk seals.

[Treatment with cyclosporine of severe colitis in hemorrhagic rectocolitis. Apropos of 7 cases]

Cyclosporin has been suggested as an alternative treatment in severe acute ulcerative colitis. In a retrospective study, the outcome of seven ulcerative colitis patients treated by intravenous cyclosporin (mean dose 3.6 mg/kg/day) has been evaluated. Short-term results indicated full remission in 3/7 (43%) patients. At long term follow-up (one year), only 2/7 patients could avoid ileal pouch-anal anastomosis. Two complications (one colonic perforation and one septicemia) were observed. Our results suggest that intravenous cyclosporin should not be recommended as a standard therapy in severe acute ulcerative colitis. Its use has to be limited in patients presenting a major contraindication for surgery and has to be performed by those experienced in both immunosuppressive treatment and inflammatory bowel disease.

Adenosine 3':5'-cyclic monophosphate (cAMP)-inducible pyrimidine 5'-nucleotidase and pyrimidine nucleotide metabolism of chick embryonic erythrocytes

Terminally differentiating erythrocytes degrade most of their RNA with subsequent release of mononucleotides. Pyrimidine mononucleotides are preferentially cleaved by an erythrocyte-specific pyrimidine 5'-nucleotidase; deficiency of this enzyme causes hemolytic anemia in humans. Details of the regulation of its activity during erythroid differentiation are unknown. The present study arose from the observation that the immature red blood cells (RBCs) of mid-term chick embryos contain high concentrations of uridine 5'-triphosphate (UTP) (5 to 6 mmol/L), which decline rapidly from days 13 to 14 onward. We analyzed two key enzymes of RBC pyrimidine nucleotide metabolism: pyrimidine nucleoside phosphorylase (PNP) and pyrimidine 5'-nucleotidase (P-5'-N), to evaluate if changes of enzyme activity during embryonic development are correlated with changes of RBC UTP. Secondly, we tested if these enzymes are under hormonal control. The results show that embryonic RBCs contain only minimal activity of PNP. In contrast, P-5'-N increases from day 13 on, suggesting that the enzyme is a limiting factor in UTP degradation. Activation of beta-adrenergic and A2A-adenosine receptors causes transcription-dependent de novo synthesis of P-5'-N. Because beta-adrenergic and adenosine receptors are also found on adult erythroid cells, P-5'-N might be an enzyme of differentiating RBCs whose expression is in part controlled by adenosine 3':5'-cyclic monophosphate (cAMP).

Significance of diminished factor XIII in Crohn's disease

OBJECTIVE

Coagulation factor XIII is a plasma transglutaminase involved in crosslinking of fibrin, the last step of the coagulation system and a connective tissue factor contributing to the wound healing process. It circulates as a heterotetrameric molecule consisting of two identical proenzyme subunits (factor XIIIA) and two carrier protein subunits (factor XIIIS). The aim of this study was to determine the disease features associated with the diminution of factor XIII in Crohn's disease.

METHODS

Factor XIIIA and factor XIIIS levels were assessed in patients presenting with Crohn's disease, ulcerative colitis, infectious colitis, or diverticulitis, in patients with rheumatoid arthritis, and in control subjects. Prothrombin fragment 1 + 2 assay, as a marker of the generation of thrombin and measurement of C-terminal telopeptide of type I collagen as an estimate of degradation of collagen type I, were performed.

RESULTS

Factor XIIIA was significantly decreased in Crohn's disease, in ulcerative colitis, and in infectious colitis by comparison with subjects presenting with diverticulitis, normal, and rheumatoid subjects p = 0.0001). Factor XIIIS was unmodified in patients with Crohn's disease by comparison with controls but was reduced in those presenting with intestinal bleeding (p = 0.0002). In Crohn's disease, the lowest level of factor XIIIA was observed in patients with intestinal bleeding (p = 0.0003). Factor XIIIA was correlated with the Van Hees index (r = -0.5661; p = 0.0001) and with the C-terminal telopeptide of type I collagen (r = -0.4110; p = 0.0011) but not with prothrombin fragment 1 + 2. The multiple regression analysis showed that only Van Hees index and intestinal bleeding were independent variables for explaining the diminution of Factor XIIIA in Crohn's disease.

CONCLUSIONS

Factor XIIIA subunit is an indicator of Crohn's disease activity. Our study suggests that a low factor XIIIA level is related to the presence of intestinal lesions and might be linked to intestinal repair mechanisms; loss in intestinal lumen could be also involved, especially in patients with intestinal bleeding.

[Spontaneous hyperintensity of the anterior pituitary gland in MRI T1-weighted images related to manganese deposits in a patient undergoing prolonged parenteral nutrition]

The signal abnormalities found on MRI in the basal ganglia in patients with an increased plasmatic level of manganese are well known. We report a case with a hyperintense signal in a patient with a high plasmatic level of manganese due to long term parenteral nutrition. The normal signal intensity of T2-weighted imaging in the anterior pituitary gland helps to differentiate the increased signal intensity of T1 weighted imaging due to deposition of manganese from hemorrhagic or fatty lesions.

Antioxidants inhibit the in vitro production of inflammatory cytokines in Crohn's disease and ulcerative colitis

BACKGROUND

Modulation of cytokine secretion may be of interest in the treatment of Crohn's disease or ulcerative colitis.

METHODS

The effect of three antioxidants - butylated hydroxyanisol, tetrahydropapaveroline and nordihydroguaiaretic acid - on the production of tumour necrosis factor (TNF), interleukin (IL) 1, IL-6 and IL-8 (measured by enzyme-linked immunosorbent assay) by peripheral mononuclear cells and biopsies of inflamed colonic mucosa from inflammatory bowel disease patients were studied.

RESULTS

We observed a decrease in IL-1 and IL-6 production by peripheral mononuclear cells from inflammatory bowel disease patients (approximately 50% of control). The three drugs did not decrease IL-6 and IL-8 secretion by colonic biopsies, whereas they did inhibit IL-1 and, to some degree, TNF production. The cytokine-inhibitory effect of antioxidants seems to be more pronounced in ulcerative colitis than in Crohn's disease.

CONCLUSION

Our results suggest that the studied antioxidants, or related compounds, may be of interest in inflammatory bowel disease treatment.

Activation domain requirements for disruption of Epstein-Barr virus latency by ZEBRA

Latent infection of B lymphocytes by Epstein-Barr virus (EBV) can be disrupted by expression of the EBV ZEBRA protein. ZEBRA, a transcriptional activator, initiates the EBV lytic cascade by activating viral gene expression. ZEBRA is also indispensable for viral replication and binds directly to the EBV lytic origin of replication. The studies described herein demonstrate that the activation domain. ZEBRA activation can be replaced by a heterologous acidic, proline-rich, or glutamine-rich activation domain. ZEBRA activation domain swap constructs retain ZEBRA's native abilities to activate specific EBV promoters, to disrupt EBV latency, and to stimulate replication at the EBV lytic origin. Additional work, employing sequential and internal deletions of ZEBRA's N-terminal activation domain, indicates that its separate activities are not attributable to specific subdomains but are spread throughout its N terminus and therefore cannot be inactivated by deleting localized regions.