Do conventional cleaning and disinfection techniques avoid the risk of endoscopic Helicobacter pylori transmission?

BACKGROUND AND STUDY AIMS

The aim of the present study was to determine whether endoscopes serve as a reservoir for Helicobacter pylori and whether the disinfection technique currently recommended for manual cleaning and disinfection of the instruments completely removes the risk of H. pylori transmission.

PATIENTS AND METHODS

A prospective study was carried out in 400 patients who were undergoing upper gastrointestinal endoscopy for routine clinical indications. The patients' H. pylori status of the patients was identified using a urea detection system (HUT) and culture. H. pylori contamination was assayed by culturing rinsing samples from the endoscopes before and after manual cleaning and disinfection. Gastric biopsies were assayed using rapid urease testing (Helicobacter urease test, HUT) of two antral and gastric body biopsies and cultures.

RESULTS

A total of 128 of the 400 patients examined were found to be H. pylori-positive using HUT testing. Endoscopes were contaminated in 54 of the 128 rinsing samples from endoscopes used in H. pylori-positive patients (42 %) before cleaning and disinfection. One of the 128 rinsing samples (0.8 %) was found to be contaminated with H. pylori even after routine manual cleaning and disinfection - indicating that these cleaning and disinfection procedures may be insufficient to eradicate H. pylori from endoscopes completely. No seroconversion was observed during serological follow-up in the patient who had previously been examined with an endoscope contaminated with H. pylori. The patient was still found to be seronegative 5 months after inoculation.

CONCLUSIONS

Endoscopes are frequently contaminated with H. pylori immediately after gastroduodenal endoscopy in H. pylori-infected patients. Iatrogenic transmission is possible, as H. pylori can survive manual cleaning and disinfection with 2 % glutaraldehyde, particularly when there is ineffective cleaning before disinfection.

Replacement of conventional glucocorticoids by oral pH-modified release budesonide in active and inactive Crohn's disease: results of an open, prospective, multicenter trial

Glucocorticosteroids (GCS) are established in the treatment of active Crohn's ileitis and ileocolitis. Recently, the topical steroid budesonide was found to be effective in untreated patients with Crohn's disease (CD) causing less side effects than conventional GCS. No clinical data have been reported about the effects of switching from conventional GCS to budesonide in terms of side effects and disease activity. The primary aim of this study was to evaluate the development of side effects after switching from conventional GCS treatment to Eudragit L-coated budesonide (pH-modified release formulation) in patients taking 5-30 mg prednisolone equivalent per day for at least two weeks. In all, 178 patients with active CD (N = 88) or CD in remission during GCS treatment (N = 90) were included. Conventional GCS treatment was tapered down during a maximum of three weeks, with simultaneous intake of 3 x 3 mg budesonide. Thereafter, patients received 3 x 3 mg budesonide alone for six weeks. GCS-related side effects, disease activity and adverse events were documented at study entry and after 0, 2, 4, and 6 weeks of budesonide treatment. The percentage of patients with GCS-related side effects decreased from 65.2% (intention-to-treat-population) at entry to 43.3% (P < 0.0001) at the end of the trial. The total number of GCS-related side effects decreased significantly from 269 to 90. Of the patients who entered the study with active disease under conventional GCS therapy, 38.6% were in remission at the end of the study. Of the patients who entered the study with CD in remission, 78% stayed in remission after switching from conventinal GCS to budesonide. In conclusion, switching from conventional GCS treatment to budesonide leads to a significant reduction of GCS related side effects in patients with CD without causing rapid deterioration of the disease.

[Askin's tumor--a rare entity. Case report with references to the literature]

Askin's Tumour (synonym: primitive neuroectodermal tumour) is a rare neoplasm of the chest wall. In 1979 Askin and Rosai described an unique clinicopathological entity, characterised as a malignant small-cell tumour of the soft tissues of the chest wall in childhood and adolescence. We report on a case of a 28-year old male who had a massive tumour in the left thorax with association to the chest wall. The clinical symptoms were dyspnoea and increasing chest pain. The tumour was revealed as a sarcoma of the lung by CT-guided fine needle aspiration. A pneumectomy of the left lung with partial resection of ribs IV. and V. was performed. Postoperative histology revealed an Askin's tumour of the chest wall with infiltration of the lung. After surgical treatment in our hospital we transferred the patient to an oncological centre for adjuvant chemotherapy. As a consequence of aggressive growth of tumour therapy should be performed in oncological centres in clinical studies. The treatment includes radical surgical resection, neoadjuvant and adjuvant chemotherapy plus radiation. In our case the primary resection was performed because of increasing symptoms. It is difficult to establish an accurate preoperative diagnosis of Askin's tumour. Microscopy and immunohistological stain of the specific marker--neuron-specific enolase--are essential. Multimodal treatment allows a long-term survival, but often the prognosis is infaust.

[Interventional procedures of the bile duct in patients after stomach resections (Billroth II)]

In the hands of an experienced endoscopist ERCP is an important method for the diagnosis of biliopancreatic diseases of Billroth II patients, but less effective than in nonoperated patients. Percutaneous procedures increase the success rate of nonoperative therapy. We report our own results of in 386 Billroth II patients: Success rate of diagnostic ERCP was 73.6% (284/386). Interventional endoscopy was performed in 192 patients: Successful EST was carried out in 93.6% (160/171), and complete extraction of bile duct stones was achieved in 74.8% (107/143), sufficient bile drainage was achieved by placement of transpapillary endoprostheses in 96.3% (79/82), while successful PTCD and percutaneous therapy were performed in 21 cases. Technical problems result from a long afferent loop, the upside-down position in the duodenal stump and difficult bile duct anatomy. We observed a complications rate of 3.6% (14/386) and a mortality of 0.5% (2/386). Our results are comparable with those in the literature, in which a similar number of difficult patients are included.

Intraoperative guidance in maxillofacial and craniofacial surgery

The authors' experiences with intraoperative computer assisted guidance in interventions in oromaxillofacial and craniofacial surgery are reported. The guidance system SPOCS (Surgical Planning and Orientation Computer Systems, Aesculap, Germany) consists of an infrared light emitting system of diodes and camera, an imaging workstation and assorted freehand instruments. The software is an updated version of the well-known Viewing Wand software (ISG Technologies, Canada). In tests on phantoms, the system proved a mean accuracy of less than 1.5 mm. Within the last 15 clinical tests, the system has achieved an accuracy better than 3 mm which, at the moment, the authors estimate to be sufficient to proceed with its clinical evaluation. Using bone screws to register the patient's position, an accuracy in the range of less than 2 mm in relation to bony reference points has been achieved. By visualizing the tip of the instrument in real time, this technique allows surgical interventions, even in anatomically complicated situations, without endangering vital neighbouring structures. The 'offset' function of the software, by which the surgeon can elongate the tip of the instrument virtually, allows the surgeon to analyse structures before they are penetrated by the instrument as in a 'look ahead' operation. The authors expect computer assisted simulation and guidance systems to improve surgical quality and reduce the risks associated with surgical interventions.

A new oscillating saw for robotic aided surgery

In this paper a brief description of a computer and robotic aided surgery system is given with a detailed overview of the necessity to develop special tools for robotic surgery. The application range of this robotic system has been specially focused on the orthopaedics field and, more particularly, on the execution of osteotomies. It was therefore necessary to develop a new saw device which would meet medical and--from the robot system point of view--mechanical as well as functional requirements. After describing the device which was developed on the basis of these requirements, a detailed comparative study of off-the-shelf oscillating saws and the new device is given at the end of the paper.

Oral pH-modified release budesonide versus 6-methylprednisolone in active Crohn's disease. German/Austrian Budesonide Study Group

OBJECTIVE

Corticosteroids are effective in acute Crohn's disease (CD). The present study assessed the effectiveness and safety of oral pH-modified release budesonide (BUD) in patients with active CD in comparison with 6-methylprednisolone (MPred).

DESIGN

This was a prospective multicentre, randomized, double-blind, double-dummy study.

METHODS

A total of 67 patients with active CD (CDAI > 150) were included. Patients were treated with 3 x 3 mg BUD (n = 34) or MPred (n = 33) according to a weekly tapering schedule (48-32-24-20-16-12-8 mg). The primary aim was remission of CD (CDAI < 150 and decrease by at least 60 points from baseline) after eight weeks.

RESULTS

Baseline demographics, disease activity and localization of CD in the small bowel and the colon were similar in both treatment groups. On an intention-to-treat basis 19/34 patients in the BUD group (55.9%) and 24/33 patients in the MPred group (72.7%) were in remission after eight weeks (P = 0.237). Therapy failed in 15/34 patients (44.1%) of the BUD group and in 9/33 patients (27.3%) of the MPred group. The mean CDAI decreased from 262 +/- 50 to 118 +/- 69 in the BUD-group and from 262 +/- 81 to 95 +/- 61 in the Mored group (P = 0.183, final CDAI BUD vs. MPred). Steroid-related side effects appeared in 28.6% of the patients in the BUD group and in 69.7% of the patients in the Mored group (P = 0.0015).

CONCLUSIONS

Oral pH-modified release budesonide (3 x 3 mg/day) is almost as effective as a conventional corticosteroid in patients with active CD but causes significantly less corticosteroid-related side effects.

Protective effects of hydroxyethyl starch-deferoxamine in early sepsis

The protective effects of hydroxyethyl starch-conjugated deferoxamine (HES-DFO), a macromolecular iron chelator, on the initial pathophysiological cascade in septic shock were evaluated following cecal ligation puncture (CLP) in rats. Animals were given an intravenous dose of 3.0 mL of either vehicle (HES) or HES-DFO immediately following completion of the CLP procedure. Animals were sacrificed 30, 60, 120, and 240 min following CLP, and samples of lung, kidney, bowel, and liver were collected for subsequent analysis of glutathione, myeloperoxidase, and evidence for lipid peroxidation based on measurement of thiobarbituric acid reactive substances and conjugated dienes. In addition, the endotoxin levels were determined in the plasma and histomorphological examination was conducted on tissue samples collected at each time point. At almost all time points, a reduction in lipid peroxidation was noted in the HES-DFO-treated rats (p < .05). Glutathione and myoloperoxidase levels were less affected. Lung tissue from animals receiving HEs demonstrated marked microatelectases, septal destruction, and splicing of basal membranes, which were greatly attenuated in animals having received HES-DFO. Similarly, tubulotoxic and mitochondrial damages observed in kidney samples from HES-treated animals were noticeably reduced in the animals having received the chelator. Liver and gut samples demonstrated unspecific inflammatory injury in both groups of animals. In summary, oxygen radical-mediated tissue damage occurs rapidly following CLP-induced sepsis. Based on histological and biochemical endpoints, treatment with the polymeric iron chelator, HES-DFO, significantly attenuates systemic oxidant injury, the degree of protection being most impressive in the lung and kidney.

[Lesions of the pancreatic duct epithelium and histogenesis of exocrine pancreatic carcinomas]

The bad prognosis of exocrine pancreas carcinoma manifests itself by a high incidence of recidivation, early metastasis formation and a low 5-year survival rate of 1-2% on an average has not essentially been improved in recent times although progress is evident in diagnosis as well as in surgical, radiological and cytostatic therapy. The unfavourable course of illnesses is due to the symptomless early phase rather than the existing diagnostic potential. Thus, a recording, standardization and definition of pancreatic duct atypias is a necessity for optimizing the pattern of examinations. Topographically, the structure of pancreatic parenchyma may be classified by 1) interlobular ducts; 2) intralobular ducts; 3) intercalated ducts; 4) centroacinar cells, and 5) acinar cells. Based on this matrix, entities of varying diagnostic relevance may be derived, i.e. 1) orthological histiomorphological tissue formations; 2) hyperplastic epithelial changes; 3) metaplastic epithelial formations; and 4) atypical hyperplasias. Beyond this, there are numerous indications of a redifferentiation of numerous pancreatic cell types, primarily of acinar cells. The close relationships between ductal and acinar cells may be subsumed as a terminal ductulo-acinar intercalated duct complex. Against the background of chronic pancreatitis and corresponding length of history (< 6.5 years), cancer may develop in up to 16% of cases. On the molecularbiological level, point mutations of the K-ras gene, a mutation or deletion of the p53 suppressor gene and an excess production of the c-erbB-2 protooncogene are found in a great number of pancreatic carcinomas.(ABSTRACT TRUNCATED AT 250 WORDS)

Measuring of AgNORs using image analysis

A method is presented for the measurement of AgNORs in histological section using an image analysis system. Measurements are performed at the highest magnification (objective 100x) using a CCD camera. In the first step the AgNORs are segmented, counted and measured. In the second step the AgNOR clusters are segmented. Several features for the description of the AgNORs, the AgNOR clusters and their spatial distribution throughout the nucleus are given. As an internal reference, lymphocytes are used and the size features are given relative to the mean size of AgNORs in the lymphocytes. The reproducibility of the features was tested on a series of astrocytomas. This should be carried out with at least 150 tumor cells and 20 reference cells in order for accurate measurements.

[Neuroendocrine system and its tumors]

The original classification of neuroendocrine tumours proposed by Pearse was based on a common embryologic origin in the neuroectoderm. The term, carcinoid, literally means carcinoma-like, was coined in 1907 to describe the histologic similarity of these tumors to carcinomas on the one hand and their generally indolent biologic behaviour on the other hand. Neuroendocrine tumours represent a group with complex biological, histological, ultrastructural and immunocytochemical properties. This concept was replaced by another classification based on results of modern techniques (electron microscopy, immunocytochemistry, molecular and DNA analyses). This permits a more reliable classification of tumours, that can be used to determine their biological behaviour and prognosis.

[Prenatally diagnosed mesenchymal hamartoma of the liver]

Reported in this paper is the case of a female newborn with mesenchymal hamartoma of the liver. High-accuracy ultrasonography diagnostics were applied to the mother admitted for examination for suspicion of fetal hydronephrosis in the 31st week of pregnancy. A 7 x 4 cm compartmental process was delineable in the abdominal region of the foetus and was variably viewed in ultrasonography in cystic or solid form. A girl, 2,650 g in body weight and 47 cm in body length, was delivered by caesarean section in the 35th week of pregnancy. Postnatal nutritional disorders were accompanied with recurrent vomiting. Sonography, computed tomography and scintigraphy were performed, and the prenatally diagnosed process was identified as a cystic growth in the right liver lobe with enclosure of the V. cava inferior. A typical hepatolobectomy was performed on the newborn on her 15th day of age, with the V. cava enclosing part being left unextirpated. Mesenchymal hamartoma of the liver was the histological diagnosis. Only one prenatally diagnosed case of this kind had been known from literature before.

[Acute pancreatitis--etiology, pathological anatomy and pathogenesis]

Acute pancreatitis is a disease characterized by abdominal pain, low-grade fever, abdominal tenderness and rigidity, and moderate elevation of the white blood cell count. A widely used revised classification of pancreatitis is that proposed in 1984 at Marseille. It only distinguishes between acute and chronic pancreatitis. In 61 cases were 40 men and 21 women. The mean age in the total series was 52.5 years. The etiology of the acute condition was alcoholism in 32.8% and biliary tract disease in 23%. In 9.8% the acute pancreatitis is associated with alimentary tract diseases (adipositas, hyperlipidemia). The severity of acute pancreatitis is pathological anatomy determined by three stages. In pathogenesis the process of digestion is caused by activated pancreatic enzyme with acinar cell injury. The acinar cell is normally protected from the action of its own enzymes by elaborate intracellular compartmentation of enzymes. Acute pancreatitis is triggered by pancreatic phospholipase A leading to necrosis of lipolytically active fat cells with release of membrane-toxic fatty acids with following destruction of adjacent tissue. Fat necrosis initiates an acute inflammatory reaction with immigration of granulocytes and liberation of kinins, which activate pancreatic enzyme. Pancreatic enzymes are similar to lysosomal enzymes with regard to substrate specificity. Activation will be also triggered by lysosomal enzymes of necrotic acinar cells.

[Tuberculosis of the pelvic girdle]

Between 1955 and 1980 a total of 67 patients (42 female, 25 male) with advanced tuberculosis of the pelvic girdle underwent surgery at the authors' clinic. In 43 patients the sacroiliac joint was affected (in 2 cases bilaterally), in 11 the ischium, in 9 the pubic bone, and in 2 each the ilium and the sacrum. The average of the patients (who included 4 migrant workers) was 44. The youngest patient was 8, the oldest 67 years old. The average interval between the onset of complaints and diagnosis was 4.6 years (minimum 1 month, maximum 20 years). Thirty-eight of the patients had already had treatment for an organic or osteoarticular tuberculosis. Although 24 (35.8%) of the patients were simultaneously suffering from a florid, specific infection localized elsewhere, and abscesses, fistulas, or a combination of these were identified in 40 patients (59.7%), only 17 (25.4%) were in slightly impaired general condition, and in over one-half of the patients, the hourly blood sedimentation rate was normal or only slightly elevated (up to 20 mm n.W.). In 9 cases (13.4%) the only pointers to tuberculosis were the patient's history, clinical and radiological findings, and the subsequent evolution of the disease. In these cases the diagnosis could not be confirmed either by histologic or by bacteriologic study of focal tissue. In 67 patients, 66 osseous foci were removed and in 2 cases merely an abscess (after an average of 2-3 weeks' tuberculostatic therapy), the bone cavities were filled with a mixture of heterogeneous or autogenous spongiosa and tuberculostatics or merely with chemotherapeutic drugs, and primary closure of the wound was performed.(ABSTRACT TRUNCATED AT 250 WORDS)