Effects of peripheral or central GLP-1 receptor blockade on leptin-induced suppression of appetite

Leptin and glucagon-like peptide-1 (GLP-1) were proved to act in concert to control the activity of feeding centres. Since leptin receptor was identified in the gut endocrine L cells and neurons producing GLP-1, we have checked whether GLP-1 mediates the effects of leptin on feeding and drinking behaviour. To this aim, an intraperitoneal or intracerebroventricular injection of exendin (9 - 39), a GLP-1 antagonist, (50 or 10 microg per rat, respectively) followed by leptin (100 or 5 microg per rat, respectively) was made and 24-hour food intake and body weight changes were measured. Previous injection of exendin (9-39) completely abolished the supressory effect of peripheral leptin on food intake and body weight gain. Moreover, exendin (9-39) significantly attenuated the effect of intracerebroventricular leptin on food but not water consumption. It is concluded that intact GLP-1 signalling is necessary to mediate the effect of leptin on food intake in the rat. Conversely, leptin seems to affect the thirst center function independently of GLP-1. Also, these findings produce further evidence for close interactions between long- and short-term factors regulating the activity of feeding centres.

Insulin resistance and glucose tolerance in obese women: the effects of a recreational training program

AIM

This study was designed to investigate whether recreational physical activity based on aquatic training may improve lipid profile and glucose tolerance in obese subjects. Additionally, we intended to assess a possible correlation between insulin resistance index HOMA(IR) with another index including serum adiponectin concentrations.

METHODS

Study population consisted of 12 obese women aged 44-61, who volunteered for an aquatic training 1 h twice a week for 3 months. Before entering the training program, and after completing it patients' oral glucose tolerance test was performed. Glucose, insulin and adiponectin concentrations, levels of antibodies to oxidatively modified low-density lipoproteins (oLAB), and lipid profiles were measured in blood samples collected before the oral glucose tolerance test (OGTT). Glucose and insulin concentrations were also assessed in blood samples collected at 30 and 120 min of OGTT. Atherogenic index of plasma (AIP), and insulin sensitivity indexes HOMA(IR) and HOMA(AD) were calculated on the basis of the obtained data.

RESULTS

The 3-month, recreational aquatic training had no influence on body mass, but it resulted in improved glucose tolerance (at t = 0 and t = 120 min), decreased index (HOMA(IR)), and decreased levels of total and LDL-cholesterol (P<0.05). Adiponectin concentrations and values of HOMA(AD) remained unchanged. We found a significant correlation between adiponectin levels and concentrations of total and LDL cholesterol, and between insulin indexes HOMA(IR) and HOMA(AD) both before, and after the training (P<0.01).

CONCLUSION

The results of our study indicate that a 3-month recreational training consisting in water aerobic results in favorable changes in glucose and lipid metabolism in obese subjects, even despite the lack of improvement in body mass.

Interactions between leptin and exendin-4, a glucagon-like peptide-1 agonist, in the regulation of food intake in the rat

Leptin interplays with other peptides to control feeding behaviour in humans and animals. Using exendin-4, an agonist of glucagon-like peptide-1, we investigated whether leptin modifies its effect on food intake in the rat. In the first series, exendin-4 alone (0.1, 2 or 10 microg per rat), leptin alone (0.1, 2, 10 or 100 microg per rat) or exendin-4 and leptin together (0.1 + 0.1, 2 + 2, 10 + 10, or 2 + 100 microg per rat, respectively) were injected once intraperitoneally. In the second series animals were injected either with exendin-4 (2 microg) alone, leptin (10 microg) alone, or leptin (10 microg) + exendin-4 (2 microg) daily for 5 subsequent days. At the lowest dose used, leptin and exendin-4 injected once together, but not separately, reduced significantly a 24-hour food intake. When used in higher doses, however, leptin did not change the exendin-4-dependent suppressory effect on food consumption. No significant differences in food intake were seen between rats treated repeatedly with exendin-4 only and animals injected with both drugs. Hence, leptin and exendin-4 may act additively to inhibit appetite when present in low concentrations while, at high leptin doses, this effect is abolished. The lack of synergistic effects of exendin-4 and high leptin concentrations on food intake may explain, at least in part, mechanisms responsible for leptin resistance in subjects with hyperleptinaemia.

Use of sedation for routine diagnostic upper gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy Survey of National Endoscopy Society Members

BACKGROUND/AIMS

Sedation rates may vary among countries, depending on patients' and endoscopists' preferences. The aim of this survey was to investigate the rate of using premedication for routine diagnostic upper gastrointestinal (UGI) endoscopy in endoscopy societies, members of the European Society of Gastrointestinal Endoscopy (ESGE).

METHODS

We evaluated a multiple-choice questionnaire which was e-mailed to representatives of national endoscopy societies, which are members of the ESGE. The questionnaire had 14 items referring to endoscopy practices in each country and the representatives' endoscopy units.

RESULTS

The response rate was 76% (34/45). In 47% of the countries, less than 25% of patients undergo routine diagnostic UGI endoscopy with conscious sedation. In 62% of the responders' endoscopy units, patients are not asked their preference for sedation and do not sign a consent form (59%). Common sedatives in use are midazolam (82%), diazepam (38%) or propofol (47%). Monitoring equipment is not available 'in most of the endoscopy units' in 46% (13/28) of the countries. Though they were available in 91% of the national representatives' endoscopy units, they are rarely (21%) used to monitor unsedated routine diagnostic UGI endoscopy.

CONCLUSIONS

In about 50% of ESGE-related countries, less than 25% of patients are sedated for routine diagnostic UGI endoscopy. Major issues to improve include availability of monitoring equipment and the use of a consent form.

Somatostatin receptor expression, tumour response, and quality of life in patients with advanced hepatocellular carcinoma treated with long-acting octreotide

Octreotide may extend survival in hepatocellular carcinoma (HCC). Forty-one per cent of HCCs have high-affinity somatostatin receptors. We aimed to determine the feasibility, safety, and activity of long-acting octreotide in advanced HCC; to identify the best method for assessing somatostatin receptor expression; to relate receptor expression to clinical outcomes; and to evaluate toxicity. Sixty-three patients with advanced HCC received intramuscular long-acting octreotide 20 mg monthly until progression or toxicity. Median age was 67 years (range 28–81 years), male 81%, Child–Pugh A 83%, and B 17%. The aetiologies of chronic liver disease were alcohol (22%), viral hepatitis (44%), and haemochromatosis (6%). Prior treatments for HCC included surgery (8%), chemotherapy (2%), local ablation (11%), and chemoembolisation (6%). One patient had an objective partial tumour response (2%, 95% CI 0–9%). Serum alpha-fetoprotein levels decreased more than 50% in four (6%). Median survival was 8 months. Thirty four of 61 patients (56%) had receptor expression detected by scintigraphy; no clear relationship with clinical outcomes was identified. There were few grade 3 or 4 toxicities: hyperglycaemia (8%), hypoglycaemia (2%), diarrhoea (5%), and anorexia (2%). Patients reported improvements in some symptoms, but no major changes in quality of life were detected. Long-acting octreotide is safe in advanced HCC. We found little evidence of anticancer activity. A definitive randomised trial would identify whether patients benefit from this treatment in other ways.

BOLD-MRI for the assessment of renal oxygenation in humans: acute effect of nephrotoxic xenobiotics

Hypoxia of renal medulla is a key factor implicated in the development of drug-induced renal failure. Drugs are known to influence renal hemodynamics and, subsequently, affect renal tissue oxygenation. Changes in renal oxygenation can be assessed non-invasively in humans using blood oxygenation level-dependent magnetic resonance imaging (BOLD-MRI). This study was designed to test the acute effects of administration of specific drugs in healthy human kidney oxygenation using BOLD-MRI. Acute changes in renal tissue oxygenation induced by the non-steroidal anti-inflammatory drug indomethacin, the iodinated radio-contrast media (RCM) iopromidum, and the calcineurin inhibitors cyclosporine micro-emulsion (CsA-ME) and tracrolimus were studied in 30 healthy volunteers. A modified Multi Echo Data Image Combination sequence was used to acquire 12 T(2)(*)-weighted images. Four coronal slices were selected to cover both kidneys. The mean R(2)(*) (1/T(2)(*)) values determined in medulla and cortex showed no significant changes induced by indomethacin and tacrolimus administration. CsA-ME decreased medullary (P=0.008) and cortical (P=0.004) R(2)(*) values 2 h after ingestion. Iopromidum caused a significant increase in medullary R(2)(*) within the first 20 min after injection (P<0.001), whereas no relevant changes were observed in renal cortex. None of the measurements showed left-right kidney differences. Significant differences in renal medullary oxygenation were evidenced between female and male subjects (P=0.013). BOLD-MRI was efficient to show effects of specific drugs in healthy renal tissue. Cyclosporine increased renal medullary oxygenation 2 h after ingestion of a single dose, whereas indomethacin and tacrolimus showed no effect on renal oxygenation. Injection of iodinated RCM decreased renal medullary oxygenation.

Subjective assessment of depth of anaesthesia by experienced and inexperienced anaesthetists

BACKGROUND AND OBJECTIVE

To measure 'depth of anaesthesia', anaesthesiologists use a combination of observable end-points such as immobility and autonomic stability. Unconsciousness and amnesia are not reliably observable end-points, but correlate with parameters derived from the electroencephalogram. We investigated the association of subjective assessment and electroencephalographic measures of anaesthetic depth in a group of experienced (>4 yr of experience) and a group of inexperienced (<2 yr of experience) anaesthesiologists.

METHODS

One hundred ASA I or II patients were assigned to either group. Anaesthesiologists assessed 'anaesthetic depth' using an 11-point numeric and a 5-point verbal scale. Bispectral index and spectral entropy were recorded as electroencephalogram parameters. The association between the subjective assessment and the electroencephalogram parameters was calculated using the prediction probability, PK.

RESULTS

Association between subjective assessment and electroencephalographic parameters showed a tendency to a better prediction probability in the experienced group. The difference was significant (P < 0.05) for the bispectral index (PK 0.76 +/- 0.01 for experienced and 0.71 +/- 0.01 for inexperienced anaesthesiologists). In both groups, a large percentage of the data points recorded during surgery showed bispectral index values above the recommended value of 60 (13.2% in the experienced and 34.3% in the inexperienced group) despite a subjective assessment of 'deep' or 'very deep' anaesthetic depth.

CONCLUSION

The study demonstrates that the association between subjectively assigned values of anaesthetic depth and electroencephalographic parameters of anaesthetic depth is better for anaesthesiologists with more clinical experience. However, in the 'inexperienced' as well as 'experienced' group a high percentage of bispectral index and entropy values above 60 occurred despite a subjective assessment of adequate anaesthetic depth. Although there was no evidence for explicit memory, this may indicate a risk for memory formation.

Biochemical markers of bone metabolism in healthy elderly men. The relationship to physical activity

The purpose of the present study was to examine the serum levels of bone turnover markers and interleukin 1beta in healthy elderly men with different levels of habitual physical activity. The study was conducted on 40 healthy men aged between 65 and 85 years (mean 74.0 +/- 7.55 years). The study population was divided into two groups with respect to the level of physical activity: 22 less active subjects (energy expenditure related to physical activity below 1600 kcal per week) and 18 more active subjects (above 1600 kcal per week). To estimate the physical activity of the study population, weekly energy expenditure was measured in each subject with use of Caltrac accelerometer. In the blood serum levels of bone formation marker--osteocalcin and resorption marker--the C-terminal telopeptide of collagen I (ICTP), and interleukin-1beta were determined. Concentrations of osteocalcin and ICTP in less active subjects were significantly higher (by 3.62 ng/ml and by 1.21 mug/l respectively, p < 0.05), reflecting the higher bone turnover in comparison to values determined in more active subjects. Positive correlations between ICTP and osteocalcin levels (r = 0.5814 and r = 0.6526; p < 0.05), and between ICTP and IL-1beta (r = 0.5823 and r = 0.6040; p < 0.05) in less and more active men were found. On the ground of the presented study it can be concluded that the decreased bone turnover occurred in men with higher level of habitual physical activity. This study showed the relationship between serum level of IL-1beta and bone resorption but the habitual physical activity has no effect on this cytokine activity.

The importance of magnesium status in the pathophysiology of mitral valve prolapse

Idiopathic mitral valve prolapse (IMVP) refers to the systolic displacement of one or both mitral leaflets into the left atrium, with or without mitral regurgitation. It is one of the most common forms of cardiac abnormalities among young people, especially in women. IMVP usually appears to be a benign condition and even capable of recovery. In a minority of cases IMVP may predispose to complications. The data suggest an autosomal dominant inheritance of IMVP that exhibits both sex- and age-dependent penetrance with variable expressivity and genetic heterogeneity. IMVP appear to be one form or aspect of latent tetany due to magnesium deficit (MDLT). The prevalence, latent nature, and symptomatology of these two conditions appear to be strictly similar. Primary magnesium (Mg) deficit may result from Mg deficiency (insufficient Mg intake) and Mg depletion (excessive urinary Mg loss). Constitutional factors (e.g. HLA-B35, type A behavior pattern) should be considered in the aetiology of Mg deficit (MD). MD may cause abnormal fibrosis, abnormalities in collagen synthesis as well as in the myocardium, capable of inducing mitral apparatus dyskinesia. MD is a part of a picture of metabolic abnormalities, alteration of immune and autonomic nervous systems, cardiac arrhythmias and thromboembolic phenomena in IMVP. Laboratory evaluation must involve plasma Mg, erythrocyte Mg, calcemia, calciuria, and daily magnesuria. Normal plasma Mg concentration does not rule out the diagnosis of primary chronic MD. The diagnosis of MD requires the oral Mg load test. Correction of symptomatology by this oral physiological Mg load (5 mg/kg/day) is the best proof that it was due to Mg deficiency. Mg therapy is essential and specific for IMVP. In the majority of cases MD is due to Mg depletion and the oral Mg supplementation must be combined with Mg-sparing diuretics or physiological doses of vitamin D. Partial "Mg analogues" (beta-blockers, verapamil, phenytoin) may prove to be useful in some cases.

Singular case of shooting a football fan with a signal rocket

The authors present a very rare case of fatal injuries resulting from shooting a parachute signal rocket with a hand operated launcher of signal pistol kind by pseudo-football fans. A 16-year-old football fan sustained extensive thermal burn of his lower extremities and abdomen, lacerated wound of his left thigh with a deep signal rocket-shot canal which caused injuries in subcutaneous tissue, fascia and both medial and posterior muscles of the thigh as well as injured both femoral vein and artery with subsequent hemorrhagic, burn and traumatic shocks. In spite of specialistic surgical treatment, the victim was not rescued. Analysis of medical documentation and our autopsy results were supplemented with an expert's opinion on physicochemical examinations supported by photographic documentation.

Public awareness of risk factors and screening for colorectal cancer in Europe

Colorectal cancer (CRC) is the commonest site for malignancy in Europe. The Commissioner for Health wishes to promote screening for colorectal, breast and cervical cancer in Europe. The aim of this study was to assess public knowledge of CRC in Europe and likely take up of free screening. To this end 20710 members of the public from 21 European countries were interviewed by means of a regular survey amongst consumers (Omnibus survey) using 13 stem questions. Forty-eight per cent thought the population were at equal risk of CRC, only 57% were aware of age and 54% of family history as risk factors. Although 70% were aware of dietary factors, only 30% knew that lack of exercise might be a risk factor. Only 51% had knowledge of CRC screening but 75% were 'very', or 'quite interested, in taking up faecal occult blood (FOB) screening if offered free. Barriers to screening were lack of awareness of risk (31%), youth (22%) and an un-anaesthetic test (19%). There was a big cultural difference in willingness of the public to discuss bowel symptoms: there was a major barrier in Finland (91%), Britain (84%), Luxembourg (82%), Poland (81%) and Portugal (80%); less of a barrier in Spain (49%), Italy (44%) and Iceland (39%). In conclusion, the challenge of achieving high compliance for CRC screening must be a major objective amongst EU member states and non-aligned countries of Europe in the next decade, because it is known that the non-compliant group are those at greatest risk of death from CRC. This study has shown that awareness of CRC is low in Europe and that an educational programme will be essential to achieve high compliance for CRC screening as a means of reducing deaths from bowel cancer.

Can von Willebrand factor, platelet-endothelial cell adhesion molecule-1 and thrombomodulin be used as alternative markers of endothelial cell injury in human glomerulonephritis?

PURPOSE

There is growing evidence that endothelial cells (EC) are active participants of an inflammatory process in glomeruli.

MATERIAL AND METHODS

We compared the glomerular expression of three EC-coupled molecules, i.e. platelet-endothelial cell adhesion molecule-1 (PECAM-1 or CD31), von Willebrand factor (vWF) and thrombomodulin (TM) in 60 patients with glomerulonephritis (GN) and five normal kidneys (NK). The alkaline phosphatase anti-alkaline phosphatase method was used to examine the expression of these proteins in the biopsy specimens.

RESULTS

In NK, the expression of CD31 and vWF comprised the whole glomerular network. In contrast, the expression of TM was much lower and localized mainly to EC at the vascular pole and adjacent areas. In GN, the glomerular staining for CD31 and vWF was significantly reduced. A fall in the expression of both these EC antigens was more pronounced in proliferative forms of GN (PGN) than in non-proliferative GN (NPGN) (CD31: NPGN vs. PGN, p < 0.02; vWF: NPGN vs. PGN, p < 0.05). In addition, a linear relationship between the expression of CD31 and vWF was found in GN (r = 0.8, p < 0.001). Conversely to CD31 and vWF, a marked increase in glomerular reactivity for TM was observed in all the patients with GN (GN: 2.12 +/- 0.32, NK: 0.95 +/- 0.05, p < 0.02). However, the highest expression of TM was found in membranoproliferative GN and lupus GN.

CONCLUSIONS

Our results suggest that CD31 and vWF may be used as markers of glomerular EC loss during GN, whereas TM staining seems to reflect EC activation in response to circulating and/or released in situ procoagulant factors.

Tamoxifen for hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (primary liver cancer) is the third commonest cause of cancer mortality world-wide. Survival is poor for patients with advanced disease. Trials of tamoxifen for hepatocellular carcinoma have conflicting results.

OBJECTIVES

To conduct a systematic review of the literature to assess the effect of tamoxifen on overall survival, quality-of-life, tumour response, and treatment toxicity in people with advanced hepatocellular carcinoma.

SEARCH STRATEGY

We identified trials from The Cochrane Hepato-Biliary Group Controlled Trials Register (January 2004), The Cochrane Central Register of Controlled Trials on The Cochrane Library (Issue 3, 2003), and MEDLINE database (1966 to November 2003). We searched bibliographies of review articles and identified trials, and hand-searched abstracts from relevant other meetings.

SELECTION CRITERIA

All randomised clinical trials of treatment with tamoxifen compared to a control treatment without tamoxifen in people with hepatocellular carcinoma, including trials of tamoxifen versus placebo, tamoxifen versus best supportive care, and tamoxifen plus other treatment versus the same other treatment alone.

DATA COLLECTION AND ANALYSIS

Three independent reviewers selected studies for inclusion, rated them for methodologic quality components (generation of allocation sequence; allocation concealment; blinding; and follow-up), and extracted data on the specified outcomes. Hazard ratios were derived for overall survival where possible. Meta-analysis was performed using a fixed-effect model.

MAIN RESULTS

Ten randomised trials randomising 1709 patients were included. Tamoxifen versus placebo/no intervention had no significant effect on overall survival (hazard ratio 1.05; 95% CI 0.94 to 1.16; P = 0.4). This comparison showed no statistical heterogeneity (P = 0.2 and I(2 ) = 25.9%). Subgroup analysis showed that tamoxifen tended to increase mortality in trials with three adequate/three methodological components (hazard ratio 1.15; 95% CI 0.99 to 1.34; P = 0.06), showed no significant effect in trials with two adequate/three methodological components (hazard ratio 1.00; 95% CI 0.84 to 1.18; P = 0.98), and tended to reduce mortality in trials with one or less adequate/three methodological components (hazard ratio 0.82; 95% CI 0.60 to 1.12; P = 0.2), although this may have been confounded by the use of higher doses of tamoxifen in the better quality trials. Tamoxifen was associated with adverse effects. One trial measured patient quality of life, but the results were not reported in detail.

REVIEWERS' CONCLUSIONS

These data do not support the use of tamoxifen for patients with hepatocellular carcinoma. Further research on the effects of tamoxifen in hepatocellular carcinoma does not seem warranted.

Digestive endoscopy from rigid to fiber-optic instruments; the Polish contribution to the development of gastrointestinal endoscopy

In 1987 on the occasion of the 50(th) anniversary of the British Society of Gastroenterology Sir Francis Avery-Jones (1) wrote (perhaps a little exaggerating) in his introductory remarks: "In 1937 the alimentary tract was invisible, impalpable and inaccessible-except the top and the bottom". Indeed, diagnostics in gastroenterology was very weak and uncertain at the beginning and even in the middle of the last century. Endoscopy and radiology, developing first apart and then together revolutionized the diagnostics and consequently the practice in gastroenterology. Endoscopy brought a new access to operative procedures alleviating the burden of open surgery as well. The method, apart from knowledge, needs personal skills and so new problems of postgraduate education and ethics appeared. Due to the enormous progress in science and in technology it has reached the present level of accuracy. Polish gastroenterology with its early achievements in gastric secretion (Leon Popielski, histamine), abdominal surgery (Ludwik Rydygier, first gastric resection), endoscopy (Jan Mikulicz-Radecki) and later research upon the neuro-hormonal brain-gut axis (Stanisław J. Konturek) tried to keep pace with the world-wide progress in this field. The Polish contributions to the growing knowledge and improving practice may be traced from the very beginning of the 20(th) century.

Acute biliary pancreatitis in a 9-year-old child treated with endoscopic sphincterotomy

Acute biliary pancreatitis is a well recognized complication of gallstone disease in adults. Acute pancreatitis in childhood is usually caused by congenital anomalies of the pancreatico-biliary ducts, viral infections, drug toxicity or abdominal trauma. We report the case of a 9-year-old girl with acute biliary pancreatitis and cholangitis. On urgent endoscopic retrograde cholangiopancreatography a bulging papilla with impacted stone was seen. She was treated with endoscopic sphincterotomy without complications. The disease resolved rapidly and uneventfully after the endoscopic treatment.

[Glucosamine in the blood serum of young people with diabetes mellitus type 1]

The observations of some authors have shown that prolonged hyperglycemia may increase the process of hexosamin biosynthesis. The purpose of our study was to determine glucosamine levels in young patients with poorly controlled diabetes mellitus type 1. The study group consisted of 31 girls and boys whose ages ranged from 7 to 17 and who were newly diagnosed with type 1 diabetes mellitus. The diagnosis of diabetes mellitus was based on increased anti-insulin antibody levels, raised glycated hemoglobin and glucose concentrations and decreased insulin and C-peptide levels. In the studied group impairments in acid-base homeostasis as well as a correlation between the degree of blood acidification and free fatty acids, total cholesterol, and triglyceride levels were found. Despite evident hyperglycemia observed in all patients, glucosamine levels were within the normal range. Based on the present and previous investigations, where we observed increased hexosamine levels only in patients with hyperinsulinemia, we can draw the conclusion that increased enzymatic glycation of proteins requires not only increased glucose but also insulin access.

Oxidative stress and antioxidant defense system in healthy, elderly men: relationship to physical activity

The aim of the present study was to compare selected markers of oxidative stress and the antioxidant system between groups of men aged 65 or more, differentiated by their level of physical activity. Thirty-one community-dwelling healthy, elderly men (mean age 73.4 +/- 6.1 years) with a good nutritional status participated in the study. The Caltrac accelerometer was used to estimate energy expenditure related to physical activity. Subjects were divided into two groups according to the criteria proposed by Bauman: less active (< 1600 kcal/week) and more active (> 1600 kcal/week). In all the men, plasma total antioxidant status (TAS), thiobarbituric acid reactive substances (TBARS) concentrations and hydrogen peroxide (H2O2) levels were determined. The reduced glutathione (GSH) content and glutathione peroxidase (GPx) activity in hemolyzed red blood cells were also measured. There were no significant differences in TAS, H2O2 concentrations and the activity of GPx between less and more active men. In the group of more active subjects, plasma levels of GSH were higher, while TBARS concentrations were lower compared with the group of less active men (p < 0.05). Negative correlation between GSH and TBARS levels was observed (r = -0.71; p < 0.01), and GSH concentrations positively correlated with level of physical activity (r = 0.63; p < 0.05). The results indicate that habitual physical activity can favorably affect antioxidant potential and prevent lipid peroxidation in healthy, elderly men.

Even young patients with no alarm symptoms should undergo endoscopy for earlier diagnosis of gastric cancer

BACKGROUND AND STUDY AIMS

There has been a tendency in recent years to omit endoscopy in dyspeptic patients younger than 45 years with no so-called "alarm symptoms." This study was conducted to test whether this policy might lead to an increased rate of delayed diagnosis of gastric cancer, especially in a population with a high prevalence of the disease.

PATIENTS AND METHODS

The study included 860 patients (465 women, 395 men; median age 44) referred for the first time for upper gastrointestinal endoscopy because of suspected upper gastrointestinal pathology, to a secondary referral center between 1983 and 1993. Symptoms were assessed using a special questionnaire prior to endoscopy. The endoscopic diagnosis was always confirmed by histology.

RESULTS

Gastric cancer was found in 83 patients (12 early cancers, 71 advanced). Patients with cancer were predominantly male (68 %, compared with 44 % in the no-cancer group; P < 0.001), and significantly older (median age 56, 44 and 42 years for advanced, early cancer, and no cancer, respectively; P < 0.001). As many as 24 % of patients with cancer were aged under 45 years. Symptoms occurring more frequently in the gastric cancer group compared with the no-cancer group were weight loss (11 % vs. 0.1 %; P < 0.001), gastrointestinal bleeding (18 % vs. 8 %; P < 0.001), anorexia (43 % vs. 25 %; P < 0.001), and fatigue (53 % vs. 30 %; P < 0.001). In 27 % of cancer patients none of the above symptoms was observed. No statistical difference was seen for pain, nausea, vomiting, and other symptoms. The mean symptom score (1 point for one symptom) was higher in patients with cancer compared with those without (3.1 vs. 2.4; P < 0.001). The duration score (1 to 4 points for durations of less than 6, less than 12, less than 24, and more than 24 months) was lower (1.3 vs. 1.8; P < 0.001) in cancer patients. In three-quarters of cancer patients the duration of symptoms was shorter than 6 months.

CONCLUSIONS

Symptoms suggesting gastric cancer are gastrointestinal bleeding, weight loss, and to a lesser degree anorexia and fatigue. Gastric cancer patients show a greater intensity but shorter duration of symptoms than patients with no cancer. Age and alarm symptoms cannot determine the need for upper gastrointestinal endoscopy, at least in areas of high prevalence of gastric cancer.

[Combined outpatient alcoholism therapy and occupational rehabilitation on welfare recipients--results of a pilot study]

This study tested the feasibility of outpatient abstinence treatment among alcohol dependent subjects on welfare. Patients had a long history of alcohol dependence and prolonged unemployment. Over a period of six months a total of 250 patients were approached by the social welfare office and asked to participate in the program. The program involved detoxification and a three month combined alcohol treatment and personal job training. Of the 250 persons approached 96 patients (about 40 %) appeared for the initial examination, 19 patients (13 %) finished detoxification and a total of 5 patients completed the program. The majority of a group of patients considered to be highly therapy resistant did not complete the program. Still it was important to demonstrate that a subgroup of patients did successfully complete this program. We consider this pilot project a successful starting point for further development of treatment approaches targeted more specifically at this group of patients.

Accuracy of linear endoscopic ultrasonography in the evaluation of patients with suspected common bile duct stones

BACKGROUND AND STUDY AIMS

Endoscopic ultrasonography (EUS) with radial scanning is an efficient diagnostic tool where there is suspicion of common bile duct (CBD) stones. Little is known about the use of linear EUS in this condition. The aim of this study was to evaluate the diagnostic efficiency of linear EUS in a large group of patients suspected to have bile duct stones, using endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy and exploration of the CBD using a Dormia basket, or surgical choledochotomy with choledochoscopy, as diagnostic "gold standards."

PATIENTS AND METHODS

134 patients with clinical suspicion of CBD stones were included in the study and prospectively evaluated, using EUS, and ERCP with endoscopic sphincterotomy (127 patients), or choledochotomy with choledochoscopy where ERCP was unsuccessful (seven patients). EUS was done before ERCP using an echo endoscope (Pentax FG 32 UA; 5 - 7.5 MHz) and Hitachi EUB 405 ultrasound machine. ERCP was done using the TFJ 100 or TJ 20 Olympus duodenoscope. ERCP was carried out within a mean of 2 days after EUS. The longest time between EUS and ERCP was 3 days. The examiners were blinded to the results of the other method used.

RESULTS

CBD stones were found in 91 (68 %) patients at ERCP with ES or at surgery. The correct diagnosis was established by EUS in 85 patients. The remaining 43 patients without CBD stones were correctly diagnosed in 41 cases by means of EUS, giving an accuracy of 94 %, sensitivity of 93 %, specificity of 93 %, a positive predictive value of 98 %, a negative predictive value of 87 %, and a Youden's index of 89 %.

CONCLUSIONS

Linear EUS is a fairly reliable method for the evaluation of patients with high suspicion for CBD stones. The usefulness of linear EUS in the evaluation of patients with low or moderate suspicion for CBD stones warrants further study.

[Chylous ascites following resection of abdominal aortic aneurysm]

Chylous ascites is an extremely rare complication of abdominal aortic surgery. We report on a case of chyloperitoneum following resection of aortic aneurysm. The diagnosis of lymphatic tear was confirmed by paracentesis which revealed milky fluid characterized by very high content of triglicerydes. Conservative management with a low-fat diet and diuretics resulted in a successful outcome.

A prospective, randomized, placebo-controlled trial of prednisone and allopurinol in the prevention of ERCP-induced pancreatitis

BACKGROUND AND STUDY AIMS

Acute pancreatitis is the most frequent and difficult-to-avoid complication of endoscopic retrograde cholangiopancreatography (ERCP). Corticosteroids, potent anti-inflammatory drugs, and allopurinol--a xanthine oxidase inhibitor that blocks the generation of oxygen-derived free radicals--may be potentially effective in preventing post-ERCP pancreatitis. The aim of this prospective study was to determine the effect of prophylactic oral corticosteroids and allopurinol on the incidence and severity of procedure-induced pancreatitis.

PATIENTS AND METHODS

300 patients were randomly assigned to receive oral prednisone (40 mg), allopurinol (200 mg), or placebo 15 h and 3 h prior to ERCP. The diagnosis and grading of ERCP complications were based on commonly accepted criteria. Patients receiving prednisone or allopurinol were compared with the placebo group in a search for differences in pancreatitis rates associated with endoscopic techniques.

RESULTS

The overall incidence of pancreatitis was 10.7 %, with 12 % in the prednisone group, 12.1 % in the allopurinol group, and 7.9 % in the placebo group. There were no statistical differences in the incidence or distribution of severity grades between the groups, although severe pancreatitis occurred only in the prednisone and allopurinol groups. Multiple cannulations and prolonged manipulations of the papilla of Vater were identified as risk factors for ERCP-induced pancreatitis.

CONCLUSIONS

Neither prednisone nor allopurinol showed a beneficial influence on the incidence and severity of post-ERCP pancreatitis.

The frequency of bile duct crystals in patients with presumed biliary pancreatitis

BACKGROUND

Previous studies of biliary microlithiasis in acute pancreatitis of uncertain etiology were conducted a few weeks to months after the acute episode. Bile obtained during urgent ERCP (less than 24 hours after admission) was studied for the presence of microlithiasis during the acute phase of acute pancreatitis of suspected biliary origin.

METHODS

Fifteen consecutive patients with acute pancreatitis of suspected biliary origin were recruited from a population of 309 patients with acute pancreatitis (5%) treated during the last 4 years. Patients with gallstones on US and/or ERCP and those in whom the etiology of acute pancreatitis was certain were excluded.

RESULTS

Microlithiasis (mostly calcium bilirubinate granules) was found in 12 (80%) cases. Despite endoscopic sphincterotomy 3 patients died within 2 weeks because of multisystemic organ failure. Among the 12 remaining patients, 2 (16%) developed gallbladder stones and 1 underwent cholecystectomy for cholecystitis (8%) during follow-up. The average length of follow-up was 30 months. No episodes of acute pancreatitis were noted during follow-up.

CONCLUSIONS

In the acute phase of acute pancreatitis of suspected biliary origin, biliary microlithiasis was found in most cases. Endoscopic sphincterotomy appears to protect patients from further episodes of acute pancreatitis.

[Adolescent endometriosis]

DESIGN

The aim of our study was estimation of frequency of occurrence endometriosis at girls operated from different indications, research of predisposing factors and estimation of selected biophysical parameters.

MATERIAL AND METHODS

Material determined 14 of patients in 13 to 21 years old of life operated on account of endometriosis of sexual organs in our Clinic in years 1996-1999. We study the frequency of occurrence of illness, analysis of perceptible clinical reasons, clinical stage of disease using ASF classification. It was analysed according to gynaecological age of girls, periodical complaints, cystical changes in ultrasound investigation. In serum of blood the level of CA125 was analysed with ready sets of firm Abbott. Congenital malformations were classed according to Buttram classification.

CONCLUSIONS

On base obtained of results one ascertained, that protracted pain in pelvis not responding to analgesic and antiphlogistic treatment is indication to complex diagnostics with regard of laparoscopy making possible diagnosis of endometriosis. One ascertained also, that sensibilizing of doctors on predisposing factors to formations of endometriosis (congenital malformations, intrauterine device) can contribute to preventive activities.

[Effectiveness of a micronized purified flavonoid fraction (MPFF) in the healing process of lower limb ulcers. An open multicentre study, controlled and randomized]

OBJECTIVE

To determine the increase in healing rate of venous ulcer in patients receiving a micronised purified flavonoid fraction (MPFF) as supplementation to standard local care.

METHODS

DESIGN

A randomised, open, controlled, multicentre study.

SETTING

Departments of Dermatology and University Outpatients Clinics.

PATIENTS

One hundred and forty patients with chronic venous insufficiency and venous ulcers.

INTERVENTION

PATIENTS received standard compressive therapy plus external treatment alone or 2 tablets of MPFF daily in addition to the above treatment for 24 weeks.

MAIN OUTCOME MEASURE

Healing of ulcers and their reduction in size after 24 weeks of treatment.

RESULTS

The percentage of patients whose ulcers healed completely was found to be markedly higher in those receiving MPFF in addition to standard external and compressive treatment than in those treated with conventional therapy alone (46.5% vs 27.5%; p<0.05. OR=2.3, 95% CI 1.1-4.6). Ulcers with diameters <3 cm were cured in 71% of patients in the MPFF group and in 50% of patients in the control group, whereas ulcers between 3 and 6 cm in diameter were cured in 60% and 32% of patients (p<0.05), respectively. The mean reduction in ulcer size was also found to be greater in patients treated with MPFF (80%) than in the control group (65%) (p<0.05). The cost-effectiveness ratio (cost per healed ulcer) in the MPFF group was 1026.2 compared with 1871.8 in the control group.

CONCLUSIONS

These results indicate that MPFF significantly improves the cure rate in patients with chronic venous insufficiency.

Dimension of interaction dynamics

A method allowing one to distinguish interacting from noninteracting systems based on available time series is proposed and investigated. Some facts concerning generalized Rényi dimensions that form the basis of our method are proved. We show that one can find the dimension of the part of the attractor of the system connected with interaction between its parts. We use our method to distinguish interacting from noninteracting systems on the examples of logistic and Hénon maps. A classification of all possible interaction schemes is given.

[Serum lipid levels in hypercholesterolemic post-menopausal women treated with transdermal sequential combined hormone replacement therapy only or in combination with simvastatin]

The aim of the study was to evaluate the effects of transdermal sequential combined hormone replacement therapy alone or combined with simvastatin on the serum lipid profile in hypercholesterolaemic post-menopausal women.

[Second primary malignant tumor in patients with nasopharyngeal cancer]

Clinical analysis of 90 patients with malignant nasopharyngeal tumors treated in 1985-1996 was performed. The real frequency of second tumors, immunity to second malignant tumor, therapy and genetical factors were described. Second malignant nasopharyngeal tumors occur rarely than in other head and neck tumors (in our material approx. 4%). An attention should be paid to the young age of our patients, mean 46 years.

Fetal compensatory renal hypertrophy with a unilateral functioning kidney

OBJECTIVE

To evaluate the possibility of fetal compensatory renal hypertrophy with a unilateral functioning kidney.

METHODS

A nomogram of renal length was established from 254 normal fetuses. Renal length was also obtained in 14 fetuses with unilateral renal agenesis and 22 fetuses with a unilateral multicystic kidney.

RESULTS

Compensatory renal hypertrophy, defined as a renal length > 95th percentile for gestational age, occurred in 16 of 36 cases (44.4%).

CONCLUSIONS

Compensatory renal hypertrophy is detectable in utero and may occur as early as 22 weeks' gestation.

Society of self: the emergence of collective properties in self-structure

Using cellular automata, the authors show how mutual influences among elements of self-relevant information give rise to dynamism, differentiation, and global evaluation in self-concept. The model assumes a press for integration that promotes internally generated dynamics and enables the self-structure to operate as a self-organizing dynamical system. When this press is set at high values, the self can resist inconsistent information and reestablish equilibrium after being perturbed by such information. A weak press for integration, on the other hand, impairs self-organization tendencies, making the system vulnerable to external information. Paradoxically, external information of a random nature may enhance the emergence of a stable self-structure in an initially disordered system. The simulation results suggest that important global properties of the self reflect the operation of integration processes that are generic in complex systems.

[Vascular changes of colonic mucosa as a cause of lower gastrointestinal bleeding in patients with liver cirrhosis]

Gastrointestinal bleeding is the common complication of the portal hypertension. Endoscopy is the most accessible diagnostic technique, but the investigation is often limited to the endoscopy of upper gastrointestinal tract. Colonoscopy in the case of bleeding from the colon is often limited by the possibility of good bowel preparation to that procedure. However diagnostic colonoscopy in these cases increases chances for correct diagnosis and application of adequate treatment. Increasing number of gastrointestinal bleeding cases in the last decade causes the necessity of focusing on this problem.

Cardiovascular changes after treatment with dexfenfluramine and yohimbine in obese women measured by thoracic electrical bioimpedance

An anorectic drug, dexfenfluramine (dF) is commonly used in obesity treatment. The aim of our study was to investigate if dexfenfluramine used alone or together with alpha 2-adrenolitic yohimbine (Y), can change cardiovascular state in obese women.

[Laparoscopy in the diagnosis and treatment of pathology of sexual organs in girls]

DESIGN

The aim of our study was a clinical analysis of laparoscopies in girls which were performed in the Clinic of Gynaecological Surgery.

MATERIAL AND METHODS

Laparoscopic procedures were carried out between 1996-1998. Patients were divided in to three groups: aged under 15, between 15-19 and over 19. 44% of patients from the youngest group had laparotomy. 43.8% of laparoscopic interventions were in aged group 20-24.

CONCLUSION

Laparoscopy is very good diagnostic method in gynaecological diseases. It gave enabled operative treatment in 40-43.8% girls.