Efficacy of high dose systemic versus combined (systemic and intratympanic) corticosteroid therapy in idiopathic sudden sensorineural hearing loss: A prospective randomized trial and risk factor analysis

The pathophysiology and the proper treatment of idiopathic sudden sensorineural hearing loss (ISSNHL) are an ongoing subject of debate. Locally or systemic administered corticosteroids are the most accepted drugs of treatment in reference to ISSNHL (idiopathic sudden sensorineural hearing loss), however, no strong evidence nor guidelines regarding their effectiveness yet exists. In our prospective, randomized, controlled trial 78 participants were enrolled. Patients were randomly assigned based on the day of admission to two groups according to treatment: group SS (n = 43) received intravenous systemic methylprednisolone alone, and group CT (n = 35) received intratympanic dexamethasone + systemic methylprednisolone. The primary outcome was to compare the hearing outcomes between the treatment groups based on different, widely accepted categories (Siegel, Kanzaki, modified Siegel and PTA4 gain). In consideration of the secondary outcome, we examined the effect of the various risk factors on the hearing improvement. No differences were detected regarding hearing improvement between the two groups, based on any criteria [Siegel's criteria (p = 0.604); Kanzaki's criteria (p = 0.720); modified Siegel's criteria (p = 0.524) and PTA 4 gain (p = 0.569)]. However, several clinical factors such as vertigo (p = 0.039), or cardiovascular comorbidity (p = 0.02) and the severity of initial hearing loss (p = 0.033) were found to bear a significant impact upon the hearing outcome. To the best of our knowledge, this is the first randomized controlled trial comparing high dose systemic and combination corticosteroid therapy in ISSNHL patients. Our findings suggest coexisting cardiovascular comorbidity, vertigo and severity of the initial hearing loss may bear a significantly higher impact upon hearing improvement, than the additional intratympanic steroid administration. The presented trial was registered in the European Union Drug Regulating Authorities Clinical Trials Database (name: Combinated systemic and intratympanic steroid therapy in idiopathic sudden sensorineural hearing loss, No.: 2017-000658-20) and with the ethical approval of The National Institute of Pharmacy and Nutrition (OGYÉI) (protocol No.: 7621, on 2017.02.16.).

Dietary fumonisin may compromise the nutritive value of feed and distort copper and zinc digestibility and retention in weaned piglets

Fumonisins (FUM) have been reported to impede gut functioning in pigs. However, investigations into the possible effect on mineral metabolism are limited. Thus, the trial studied the apparent total tract digestibility (ATTD) and retention of dietary nitrogen and minerals, intestinal architecture, digestive enzymes activity and heat-shock protein 70 (Hsp70) activity. Eighteen weaned piglets of 7 weeks old were assigned to three groups and their feed either contained 0, 15 or 30 mg FUM/kg for 21 days. ATTD and retention of dietary N and minerals were measured in a 5- day long balance trial between Day 17 and Day 21. The digestible and metabolisable energy (DE and ME) content of the feeds were also determined. The body weights, cumulative feed intake, relative organ weights, digestive enzymes activity and intestinal morphology were not affected (p > 0.05) by dietary treatments. The DE content was significantly lower (p < 0.05) when the feed contained 15 mg/kg FUM, but no statistically reliable treatment effect was confirmed for ME content. Dietary FUM significantly lowered (p < 0.05) the ATTD of Ca and P but not (p > 0.05) N, K, Mg and Na. The relative retention rate of N, Ca, P, K, Mg and Na in all groups were not impacted (p > 0.05) by treatments. The ATTD and relative retention of Cu and Zn were remarkably (p < 0.05) lower in piglets fed FUM-contaminated feed. In addition, the expression of Hsp70 activity in the liver was significantly elevated (p < 0.05) in the highest treatment group. These findings suggest that a dietary dose of 15 or 30 mg FUM/kg diet distorts the nutritive value of the mixed feed, results in poor ATTD and retention rates of Zn and Cu, and elevate Hsp70 activity in the liver without altering intestinal architecture or digestive enzymes' activity in weaned piglets.

Elevated osteopontin and IFNy serum levels and increased neutrophil-to-lymphocyte ratio are associated with the severity of symptoms in schizophrenia

Introduction

Inflammation and immune dysregulation could contribute to the pathogenesis of schizophrenia. Osteopontin (OPN) is a key cytokine-like molecule in cellular immune response and it can directly modulate the cytokine expression and survival of microglia. Furthermore, its mRNA expression is elevated in first episode psychosis. Imbalance of T-helper subtypes could also represent a vulnerability factor for schizophrenia.

Objectives

The aim of this study was to evaluate the relevance of T-helper subtype associated cytokines, OPN and NLR in the assessment of the severity of schizophrenia.

Methods

22 patients with schizophrenia were assessed for the intensity of their symptoms by PANSS and CGI scores. Serum OPN, IFNy, IL-10 and IL-8 concentrations were measured by ELISA kits and NLR was calculated from blood count. Statistical evaluation was performed using Mann-Whitney U test, Student’s t test and Spearman correlation.

Results

We found significant correlation between the level of OPN and PANSS-total, PANSS-general scores. IFNy level and NLR showed significant correlation with PANSS-total, PANSS-positive, PANSS-general and CGI score. Antipsychotic therapy only had significant effects on NLR and OPN levels, both of which were significantly reduced after long-term antipsychotic treatment.

Conclusions

Our results indicate that elevated OPN and IFNy concentrations, and increased NLR are associated with severe symptoms in schizophrenia and suggest the importance of Th1 subtype in patients with high PANSS-positive and PANSS-general score. Antipsychotic treatment had significant effects on the level of OPN and NLR, but not on the level of IFNy. Overall our results strengthen the inflammation hypothesis of schizophrenia.

Disclosure

No significant relationships.

A systematic review and meta-analysis of implicit Theory of Mind in schizophrenia

Introduction

Everyday social interactions are based on Theory of Mind (ToM) or mentalizing, whose complex processes are involved in understanding, representing one’s own and other people’s mental states. ToM is supposed to have two systems. The implicit ToM seems to be a fast, automatic, non-verbal processing. The explicit ToM is characterized by a slower, but more flexible processing, which is mostly verbal, interpretative. Several studies have described explicit ToM deficit in schizophrenic patients. Less research has investigated implicit ToM in patients, however recently, there has been a growing number of articles examining implicit ToM of patients with schizophrenia.

Objectives

The aim of our systematic review and meta-analysis is to summarize the results of the implicit ToM in schizophrenia.

Methods

A systematic search was performed in four major databases. We included 11 publications. 7 studies; and 5 studies were included the quantitative synthesis and the qualitative synthesis, respectively.

Results

We found significant differences in accuracy, reaction time and brain activation patterns during implicit ToM between schizophrenic patients and controls. The systematic review revealed further alterations in visual scanning, cue fixation, face looking time, and difficulties in perspective taking.

Conclusions

Based on our results implicit ToM is affected in schizophrenia in addition to explicit ToM deficit. However, based on these results we cannot exclude the possibility, that implicit ToM or at least some elements of it might be relatively unaffected (e.g. detection of intentionality), however its effectiveness is limited by non-mentalizing deficits (e.g. certain neurocognitive impairments). Our results may have important implications for the remediation of mentalizing skills.

Disclosure

The research is supported by the Hungarian National Excellence Centrum Grant (FIKP II) and Hungarian Brain Research Program (KTIA-13-NAP-A-II/12).

Some approximation results for mild solutions of stochastic fractional order evolution equations driven by Gaussian noise

We investigate the quality of space approximation of a class of stochastic integral equations of convolution type with Gaussian noise. Such equations arise, for example, when considering mild solutions of stochastic fractional order partial differential equations but also when considering mild solutions of classical stochastic partial differential equations. The key requirement for the equations is a smoothing property of the deterministic evolution operator which is typical in parabolic type problems. We show that if one has access to nonsmooth data estimates for the deterministic error operator together with its derivative of a space discretization procedure, then one obtains error estimates in pathwise Hölder norms with rates that can be read off the deterministic error rates. We illustrate the main result by considering a class of stochastic fractional order partial differential equations and space approximations performed by spectral Galerkin methods and finite elements. We also improve an existing result on the stochastic heat equation.

Adherence to the Porto Criteria Based on the Hungarian Nationwide Pediatric Inflammatory Bowel Disease Registry (HUPIR)

Objectives: According to the Porto criteria, upper endoscopy and ileocolonoscopy with histology for patients with pediatric inflammatory bowel disease (pIBD) are recommended with small bowel imaging (SBI). We aimed to evaluate the adherence to the Porto criteria and biopsy sampling practice and to evaluate the diagnostic yield of magnetic resonance enterography (MRE) first time in a nationwide pIBD inception cohort. Methods: Newly diagnosed pIBD cases (ages 0-18 years) are registered in the prospective, nationwide Hungarian Paediatric IBD Registry (HUPIR). We analyzed the diagnostic workup of patients recorded between the 1st of January 2007 and the 31st of December 2016. Results: Data for diagnostic workup was available in 1,523 cases. Forty percent of the cases had complied with the Porto criteria. Adherence to the Porto criteria increased significantly from 20 to 57% (p < 0.0001) between 2007 and 2016. The most frequent reason for the incomplete diagnostic work-up was the lack of small bowel imaging (59%). In 2007, 8% of cases had a biopsy from all segments, and this rate reached 51% by 2016 (p < 0.0001). We analyzed the diagnostic yield of MRE in 113 patients (10.1%), who did not have any characteristic lesion for Crohn's disease. The MRE was positive for the small bowel in 44 cases (39%). Conclusions: Adherence to the Porto criteria increased significantly during the 10-year period. This is the first study that reports multiple biopsy sampling as the less accepted recommendation. The diagnostic yield of MRE in patients without characteristic lesion for Crohn's disease is 39%.

Oral administration of fumonisin B1 and T-2 individually and in combination affects hepatic total and mitochondrial membrane lipid profile of rabbits

Weaned rabbits were fed diets contaminated with 2 mg/kg diet T-2 toxin alone, or 10 mg/kg diet fumonisin B₁ (FB₁) alone, and both toxins in combination (2 + 10 mg/kg, respectively) compared to a toxin-free control diet. Samplings were performed after 4 weeks (blood and liver). Bodyweight of T-2-fed group was lower after 4 weeks; the liver weight was increased dramatically (threefold of control). Liver total phospholipids (PLs) provided slight alterations in the fatty acid (FA) composition; all three toxin-treated groups showed a decrease in palmitoleic acid (C16:1 n7) proportion. In the liver mitochondrial PL FA composition, margaric acid (C17:0) proportion decreased in the separated toxin treatments compared to the combined setting. Oleic acid (C18:1 n9) proportion was increased and arachidonic acid (C20:4 n6) was decreased in the FB₁-treated group, while docosapentaenoic acid (C22:5 n3) was decreased in the separated treatments. The total monounsaturation was significantly higher in the FB₁ group's mitochondrial PL FA profile. After 4 weeks, all toxin treatments decreased the blood plasma reduced glutathione and glutathione peroxidase activity, and FB₁ increased the plasma sphinganine/sphingosine ratio. Both mycotoxins seem to cross the hepatocellular and the hepatic mitochondrial membrane, without drastic membrane disruption, as assessed from the PL FA composition, but inducing detectable lipid peroxidation.

Individual and combined effects of feed artificially contaminated with with fumonisin B1 and T-2 toxin in weaned rabbits

Co-contamination of feed and feed raw materials with two or more mycotoxins is frequently reported, however, only a few studies have investigated the combined effects of low doses of multiple mycotoxins. In the present study the individual and combined effects of 10 mg/kg fumonisin B1 and 2 mg/kg T-2 toxin (n=12/group) were investigated in weaned rabbits. Mycotoxin contaminated feed was produced by adding fungal cultures of Fusarium verticillioides and Fusarium sporotrichioides, and fed to 40 days old rabbits during 28 days. Feed intake and body weight were measured weekly, serum biochemistry and antioxidant parameters on day 0, 14 and 28, while histopathological examination and comet assay were performed at the end of the experiment. T-2 exposure both alone and in combination resulted in 15-18% less final body weight compared to the control and FB1 treatment. There was a significant increase in the concentration of plasma total protein, albumin, fructosamine and creatinine in the group treated with FB1 compared to the control. The liver and the kidney of most animals treated with T-2 toxin, FB1 and their combination showed pathological changes, occurring more frequent in animals exposed to both toxins. T-2 resulted in depletion of lymphocytes in the spleen. FB1 and T-2 exerted synergistic effect on the antioxidant/oxidative parameters after 2 weeks of exposure, manifesting in less glutathione and glutathione peroxidase, while more malondialdehyde was produced. Both toxins caused DNA damage in the lymphocytes, which was more pronounced in the group fed T-2 toxin and T-2 combined with FB1, without additive or synergistic effects.

Comparison of the amount of bioaccessible fumonisin B1 and B2 in maize and rice inoculated with Fusarium verticillioides (MRC 826) and determined by in vitro digestion-preliminary results

In this study the occurrence of hidden fumonisin B1 (FB1) and fumonisin B2 (FB2) was analysed, on two cereal substrates (maize and rice), inoculated with Fusarium verticillioides (MRC 826), in order to determine the ratio of hidden FB1 and FB2. Two parallel methods were applied: an in vitro human digestion sample pre-treatment and the routine extraction procedure, in both cases with subsequent LC-MS analysis. It was found that all samples showed higher concentration of total fumonisin B1 after digestion, as compared to that of free fumonisin analysed only after extraction. The percentage of the hidden form by maize was 18.8 % (±2.4) for FB1 and 36.8 % (±3.8) for FB2, while for rice it was 32.3 % (±11.3) and 58.0 (±6.8), respectively, expressed as the proportion to total fumonisin B1, for the total dataset. Significant differences were found in the FB1 and FB2 concentration measured after the different digestion phases (saliva, gastric and duodenal) in case of both matrixes. The results are useful for human risk assessment, since both humans and animals may be exposed to markedly higher toxin load, as determined merely by conventional analytical methods.

Dietary supplementation of Digestarom® herbal formulation: effect on apparent digestibility, faecal and caecal microbial counts and live performance of growing rabbits

<p>The experiment aimed to study the effect of Digestarom® dietary inclusion (herbal formulation containing a mixture of essential oils, herbs, spices and extracts) on apparent digestibility and digestive ecosystem of growing rabbits, as well as the effects of its supplementation before and after weaning on growth performance. At kindling, rabbit does and litters were divided into 2 dietary groups (51 does/group) and fed either a control diet (C) or a diet supplemented with 300 mg Digestarom®/kg diet (D) until weaning, which occurred at 35 d (before weaning supplementation). Each group was further divided into 3 dietary groups: CC received the control diet and DD received the D diet from 5 to 12 wk of age, and DC were fed with D (from 5 to 8 wk of age) and C diets (from 8 to 12 wk of age) (after weaning supplementation; 54 kits/group). An in vivo digestibility trial and a faecal microbial count were carried out on growing rabbits that received only the C or D diets during the trial. The C group showed higher DM intake than D group (215 vs. 196 g/d; P&lt;0.05). The faecal digestibility of ether extract (75.9 vs. 59.8%; P&lt;0.001), cellulose (25.9 vs. 20.6%; P&lt;0.05) and gross energy (51.8 vs. 49.1%; P&lt;0.05) was higher for C than for D group, whereas that of starch (98.9 vs. 98.8%; P&lt;0.001) and the digestible protein to digestible energy ratio (13.9 vs. 13.2 g digestible protein/MJ digestible energy; P&lt;0.01) was the highest for rabbits fed D diet. Stomach and caecal pH, caecal and faecal microbial counts were independent of the dietary treatment. The only exception was the stomach pH in 8 wk-old rabbits, which had the lowest value in C rabbits (P&lt;0.05). The D supplementation before weaning improved feed conversion ratio throughout the growing phase (4.3 vs. 4.4 for D and C, respectively; P&lt;0.05), whereas significant differences in daily weight gain, feed conversion ratio and mortality were observed only in the first period after weaning. Based on the results obtained, dietary supplementation with Digestarom® does not seem to confirm the positive results previously reported for growing rabbits.</p>

Determination of the amount of bioaccessible fumonisin B1 in different matrices after in vitro digestion

Conventional analytical methods used for the analysis of fumonisin content in animal feeds fail to take into account the fumonisin content bound to the matrix, which is otherwise bioaccessible and can be absorbed from the gastrointestinal tract. Moreover, underestimation of fumonisin content using routine analytical methods can affect animal experiments using cereals contaminated by fungi. In the present study, hidden fumonisin B1 was analysed in two cereal substrates (maize and wheat) which were inoculated with Fusarium verticillioides (MRC 826). The study compared a routine extraction procedure with an in vitro digestion sample pre-treatment. We found that all samples showed a higher content of fumonisin B1 after digestion, compared to the free fumonisin obtained only by extraction. The percentage of the hidden form was 38.6% (±18.5) in maize and 28.3% (±17.8) in wheat, expressed as the proportion of total fumonisin B1. These results indicate that the toxin exposure of the animals determined by the routine fumonisin analysis was underestimated, generally by 40%, as bioaccessibility was not taken into consideration. This is crucial in interpretation (and maybe in re-evaluation) of the results obtained from (other) animal experiments.

[Role of pulse oximetric monitoring during gastrointestinal endoscopy. Prospective multicenter study of the Gastroenterology Working Group of the Veszprém Regional Committee of the Hungarian Academy of Sciences (VEAB)]

INTRODUCTION

Recent guidelines recommend routine pulse oximetric monitoring during endoscopy, however, this has not been the common practice yet in the majority of the local endoscopic units.

AIMS

To draw attention to the importance of the routine use of pulse oximetric recording during endoscopy.

METHOD

A prospective multicenter study was performed with the participation of 11 gastrointestinal endoscopic units. Data of pulse oximetric monitoring of 1249 endoscopic investigations were evaluated, of which 1183 were carried out with and 66 without sedation.

RESULTS

Oxygen saturation less than 90% was observed in 239 cases corresponding to 19.1% of all cases. It occurred most often during endoscopic retrograde cholangiopancreatography (31.2%) and proximal enteroscopy (20%). Procedure-related risk factors proved to be the long duration of the investigation, premedication with pethidine (31.3%), and combined sedoanalgesia with pethidine and midazolam (34.38%). The age over 60 years, obesity, consumption of hypnotics or sedatives, severe cardiopulmonary state, and risk factor scores III and IV of the American Society of Anestwere found as patient-related risk factors.

CONCLUSION

To increase the safety of patients undergoing endoscopic investigation, pulse oximeter and oxygen supplementation should be the standard requirement in all of the endoscopic investigation rooms. Pulse oximetric monitoring is advised routinely during endoscopy with special regard to the risk factors of hypoxemia.

Use of computed tomography and histopathologic review for lung lesions produced by the interaction between Mycoplasma hyopneumoniae and fumonisin mycotoxins in pigs

Mycoplasma hyopneumoniae has a primary role in the porcine respiratory disease complex (PRDC). The objective of this study was to determine whether fumonisin mycotoxins influence the character and/or the severity of pathological processes induced in the lungs of pigs by Mycoplasma hyopneumoniae. Four groups of pigs (n = 7/group) were used, one fed 20 ppm fumonisin B1 (FB1) from 16 days of age (group F), one only infected with M. hyopneumoniae on study day 30 (group M), and a group fed FB1 and infected with M. hyopneumoniae (group MF), along with an untreated control group (group C). Computed tomography (CT) scans of infected pigs (M and MF) on study day 44 demonstrated lesions extending to the cranial and middle or in the cranial third of the caudal lobe of the lungs. The CT images obtained on study day 58 showed similar but milder lesions in 5 animals from group M, whereas lungs from 2 pigs in group MF appeared progressively worse. The evolution of average pulmonary density calculated from combined pixel frequency values, as measured by quantitative CT, was significantly influenced by the treatment and the age of the animals. The most characteristic histopathologic lesion in FB1-treated pigs was pulmonary edema, whereas the pathomorphological changes in Mycoplasma-infected pigs were consistent with catarrhal bronchointerstitial pneumonia. FB1 aggravated the progression of infection, as demonstrated by severe illness requiring euthanasia observed in 1 pig and evidence of progressive pathology in 2 pigs (group MF) between study days 44 and 58.

[Good laboratory practice of equilibrium solubility measurement II. Study of pH-dependent solubility of ionizable compounds]

In this paper the pH-equilibrium solubility profiles of ionizable drugs are presented. The aim of the present work was to study the validity of the Henderson-Hasselbalch (HH) relationship in the case of structurally diverse weak bases. In the case of monoprotic bases, namely papaverine, promethazine and propafenone the experimental equilibrium solubility data precisely follow the theoretical HH curve until the limit of salt solubility. The common ion effect on salt solubility was found to be significant at low pHs. Deviation from the HH equation in the case of dibasic quetiapine hydrogen fumarate can be easily interpreted with the formation of different salt compositions. The significance of pH control and the effect of the salt form (e.g., fumarate) was also investigated. It is critical that the pKa value and the intrinsic solubility are accurately determined when the HH relationship is used to predict the pH-dependent aqueous solubility of drugs.

Investigation of potential stress parameters in rainbow trout (Oncorhynchus mykiss)

The transportation of rainbow trout in the presence of the anesthetic clove oil was investigated. Before the transportation tests, an acute experiment was conducted to verify that removal of the fish from the water for one minute does not significantly increase the glucose or cortisol concentration of the blood plasma. In the main experiment two different transportation conditions were compared: transport in water only and in water with anesthetic. During transportation without addition of clove oil, blood plasma glucose and cortisol concentrations changed significantly. The concentration of glucose increased from 4.92 mmol/L prior to transportation to 6.16 mmol/L and values similar to the initial ones (4.95 mmol/L) were observed 5 hours after transportation. Concentration of the stress hormone cortisol increased from the initial 37.2 ng/mL to 89.2 ng/mL and returned to a value of 36.1 ng/mL 3 hours post transportation. Respective values of glucose concentration have not changed significantly during transportation in the presence of clove oil (4.3; 4.4; 4.4 mmol/L), whereas those of cortisol showed a slight decrease with the passing of time (28.1; 26.7; 20.18 ng/mL). Results show that transportation stress can significantly be reduced by the use of anesthetics.

Analysis of infliximab treated pediatric patients with Crohn disease in Hungary

A terápiarezisztens, súlyos Crohn-beteg gyermekek kezelésére új lehetőséget nyújt az antitumornekrózis-faktor-α-terápia (infliximab). Jelen vizsgálat célja az infliximabterápia hatékonyságának, mellékhatásainak felmérése hazánkban, a gyógyszer gyermekgyógyászati alkalmazásának engedélyezésétől a 2008. december 31-ig terjedő időszakban. A vizsgált periódusban országosan 23 gyermek részesült infliximabkezelésben. Az indukciós terápia során a betegek 5 mg/ttkg infliximabot kaptak a 0., a 2. és a 6. héten, ahol meghatároztuk a betegség aktivitását jelző mutatót (pediatric Crohn disease activity index). Az infliximabkezelés során kedvező terápiás választ 18 betegnél (81,8%) tapasztaltunk, teljes remisszióba 13 gyermek került (59,1%). A számításokat 22 beteg adatai alapján végeztük. A kezelés 6. hetére a fistulák 70%-a bezárult. A gyógyszerrel összefüggésbe hozható akut infúziós reakció 2 betegnél jelentkezett, egy másik esetben anaphylaxiás reakció alakult ki. Késői mellékhatás három gyermeknél jelentkezett. A vizsgálatunkban részt vett, hagyományos terápiára rezisztens, súlyos Crohn-betegek döntő többségénél az indukciós infliximabterápia hatásosnak bizonyult.

Small bowel alterations in portal hypertension: a capsule endoscopic study

BACKGROUND/AIMS

The endoscopic appearance in portal hypertension is well described in the stomach and the colon, but there is a limited number of data available on small bowel changes. The present retrospective, comparative study was aimed to analyse the diagnostic yield and describe the small bowel findings with capsule endoscopy in cirrhotic patients with gastrointestinal bleeding of unknown origin.

METHODOLOGY

Capsule endoscopy findings of 11 cirrhotic patients with portal hypertension and 22 non-cirrhotic patients with gastrointestinal bleeding who had undergone non-diagnostic upper endoscopy and colonoscopy, which were then compared.

RESULTS

In total, 9A and 2B cirrhotic patients were examined based on Child-Pugh score with a mean age of 66.2 (+/- 7.6) years. Lesions originated to portal hypertension were found in all cirrhotic patients, most frequently multiple angiodysplasias (63.6%), while in the control group multiple angiodysplasias were a seldom finding (18.2%). None of the radiological and endoscopic examinations of the small bowel before capsule endoscopy showed positive findings in cirrhotic patients.

CONCLUSION

Capsule endoscopy is an effective diagnostic method with high diagnostic yield in portal hypertension. Multiple angiodysplasias are the most probable findings as the source of small bowel bleeding in these patients.

Comparative analysis of IL6 promoter and receptor polymorphisms in myelodysplasia and multiple myeloma

The serum levels of interleukin 6 (IL6) are known to be elevated in two diseases of the elderly age, myelodysplastic syndrome (MDS) and multiple myeloma (MM). Authors suppose that one of the possible causes of this elevation could be a difference between these patients and healthy subjects in the frequency of polymorphic variants of the genes regulating IL6 levels. Scarce and contradictory comparative data are available for MM and to our best knowledge this is the first study on IL6 promoter and IL6 receptor (IL6R) polymorphism in MDS. Therefore we determined the Asp358Ala polymorphism of the IL6 receptor gene and the -174 G>C promoter polymorphism of the IL6 gene in blood samples of 102 MDS and 100 MM patients and 99 age- and sex-matched hospitalized controls had been tested for this purpose as well. There was no significant difference between patients with either disease and controls regarding IL6 promoter/L-6R. Authors therefore assume other mechanisms causing high IL6 levels are not related to either of these polymorphisms. Moreover authors consider important to propose a hypothesis how elements of signal transduction in iron metabolism might be involved in the development of MM and MDS in elderly age.

[Capsule endoscopy for the diagnostics of small intestine tumours]

Three to six percent of all gastrointestinal tumours and one to two percent of all malignant gastrointestinal tumours develop in the small intestine. These occur more frequently in men than in women and the peak of occurrence is at the age of 50 to 60 years. According to epidemiological investigations to date the most frequently developing primary tumours in the small intestine are adenocarcinomas, carcinoid tumours, lymphomas and small bowel gastrointestinal stromal tumours. Clinical appearance of the tumours is the same, independent of their histological type. Fifty percent of the benign tumours is asymptomatic and is only discovered incidentally at autopsy. In comparison, 80% of malignant tumours is symptomatic. The prognosis of small intestine malignant tumours is very poor as at the time of diagnosis they have already formed metastases in 45-75% and at the time of surgery they are in 20-50% irresectable. The reason for the late diagnosis is on the one hand the non-specific nature of the symptoms, on the other hand, the limited visualisation of the entire small intestine via traditional radiological and endoscopic methods. Capsule endoscopy (CE) revolutionised the diagnostics of the small intestine by enabling non-invasive, pain-free investigation of the entire small intestine. The timely application of CE may replace a range of expensive assays with limited diagnostic value. Initial results indicate a higher prevalence of small intestine tumours than it had been estimated based on earlier epidemiological investigations. The new method provides an early diagnosis, enabling a definitive therapy, eventually significantly improving patient survival.

[Small intestine capsule endoscopy in the diagnostics of coeliac disease]

Coeliac disease is an autoimmune enteropathy precipitated by the gluten content of cereals. It had for long been considered a childhood condition as clinical symptoms manifested when gluten was introduced into the diet. The introduction of specific serological markers changed our understanding of the epidemiology and semiology of the syndrome. The main difficulty of the diagnostics arises from the fact that over 50% of patients with gluten-sensitive enteropathy show atypical symptoms, while coeliac-disease patients with extra-gastrointestinal manifestations show no gastrointestinal symptoms at all. Diagnostics of coeliac disease is currently based on the detection of specific antibodies and the histological assessment of the duodenum. Macroscopic signs of villous atrophy (reduction in the number or loss of Kerking's folds, vascular pattern visible through the mucosa, "mosaic or micronodular" pattern, "scalloped" folds) are clearly visible in untreated patients. Capsule endoscopy, contrary to conventional endoscopic approaches, enables non-invasive, pain-free investigation of the entire small intestine. Duodenal mucosa is visualised at an 8:1 magnification during the investigation, enabling the assessment of villous atrophy by an experienced investigator. Based on preliminary experience, standard upper tract endoscopy and capsule endoscopy appear to exhibit equal levels of sensitivity and specificity for coeliac disease. The advantage of CE versus upper tract endoscopy lies in the complete assessibility of the small intestine, thus also enabling the assessment of the spread and severity of the disease. The disadvantage associated with the approach is the lack of histological biopsy samples. CE is recommendable as a first line approach for patients with proven coeliac disease when alarm conditions appear.

[Screening and surveillance for hereditary polyposis and non-polyposis syndromes with capsule endoscopy]

The hereditary polyposis syndromes and non-polyposis colorectal carcinoma have been considered as scarcely occurring but inheritable dominant autosomal syndromes. The increasing risk of small bowel carcinoma and prevention of obstruction and intussusception have been making frequent and acute surgical interventions unavoidably led to the necessity of screening and surveillance the patients. Earlier the diagnosis of these symptoms was difficult to establish because traditional radiological methods have a low yield for small polyps. Furthermore, small bowel is only partially accessible with traditional endoscopic techniques such as upper endoscopy, colonoscopy and push-enteroscopy. The "wireless" capsule endoscopy has opened the way then for the non-invasive and painless test of the entire small intestine. - Test results have been cumulated to justify the efficiency and safety of capsule endoscopy concerning the syndromes above. This method can be applied safely even consequently to repeatedly performed surgical interventions by low risk of capsule retention. As the results compared of the diagnosed familial adenomatous polyposis and of Peutz-Jeghers syndrome reflect on capsule endoscopy, its diagnostic sensitiveness is stated as significantly higher than the Barium-contrast X-Ray and MR-enterography. Nevertheless, determination of size and location of polyps has become more problematic when evaluating the test results.

[Screening and surveillance for hereditary polyposis and non-polyposis syndromes with capsule endoscopy]

The hereditary polyposis syndromes and non-polyposis colorectal carcinoma have been considered as scarcely occurring but inheritable dominant autosomal syndromes. The increasing risk of small bowel carcinoma and prevention of obstruction and intussusception have been making frequent and acute surgical interventions unavoidably led to the necessity of screening and surveillance the patients. Earlier the diagnosis of these symptoms was difficult to establish because traditional radiological methods have a low yield for small polyps. Furthermore, small bowel is only partially accessible with traditional endoscopic techniques such as upper endoscopy, colonoscopy and push-enteroscopy. The "wireless" capsule endoscopy has opened the way then for the non-invasive and painless test of the entire small intestine. - Test results have been cumulated to justify the efficiency and safety of capsule endoscopy concerning the syndromes above. This method can be applied safely even consequently to repeatedly performed surgical interventions by low risk of capsule retention. As the results compared of the diagnosed familial adenomatous polyposis and of Peutz-Jeghers syndrome reflect on capsule endoscopy, its diagnostic sensitiveness is stated as significantly higher than the Barium-contrast X-Ray and MR-enterography. Nevertheless, determination of size and location of polyps has become more problematic when evaluating the test results.

[The role of capsule endoscopy in the diagnosis of small bowel Crohn's disease]

Historically, there have been several modalities available for diagnosing small bowel diseases, but - until recently - endoscopic examination of this part of the gastrointestinal tract was not possible. With its direct visualization of bowel mucosa, the 2002 premier of capsule endoscopy was a major break-through in gastroenterology. The most important indication of small bowel capsule endoscopy is Crohn's disease, it provides valuable diagnostic information in patients with suspected, proven and post-operative disease, too. Several clinical studies proved CE's superiority over other methods. Although young age was a contraindication initially, numerous studies have proved its safety and efficacy in pediatric patients. Complications of CE are rare, the main risk is capsule retention and consequent small bowel ileus which can be prevented by a previous trial examination with a digestible, biodegradable patency test-capsule.

[Small bowel stromal tumors diagnosed by capsule endoscopy]

Small intestinal stromal tumors account for approximately 35% of all gastrointestinal stromal tumors. Gastrointestinal bleeding is considered as one of the main clinical symptoms for SISTs. Capsule endoscopy has brought revolution in small bowel diagnostics, as it is considered the best method of visualisation of the entire small intestine. Besides, it is well tolerated by patients and is accompanied by a low number of complications. It is also indicated as the first diagnostic method in gastrointestinal bleeding of obscure origin, following negative upper endoscopy and colonoscopy.

CASE REPORT

2 patients (a male and a female, aged 58 and 69, respectively) presented with obscure gastrointestinal bleeding have been examined by capsule endoscopy after negative upper endoscopy and colonoscopy. Videorecords have been assessed in both cases by two independent experts. The capsule reached the Bauchin-valve in both cases during the 8 hours of the testing time and the entire small bowel was clearly visible. - Based on the capsule endoscopic images, for one of the two cases a tumor has been reported as the background of the small intestinal bleeding. In the other case we could mark the location of the bleeding, while we were unable to ascertain the type of the actively bleeding lesion during the test. In order to determine the accurate bleeding source double-balloon enteroscopy was performed in the second case. After surgery the histological and immunohistochemical tests have justified the presence of spindle cell GISTs. Taking into consideration the Fletcher-classification, for the tumor size and the mitotic index, both cases can be classified as a GIST of low malignant potential.

CONCLUSIONS

An early diagnosis and application of a definitive therapy become possible by using capsule endoscopy, therefore the chance of survival of the patients might be increased.

[Multiple angiodysplasias diagnosed by capsule endoscopy]

Angiodysplasias are the most frequent vascular lesions of the gastrointestinal tract and sources of significant mortality from bleeding. Small bowel angiodysplasias account for approximately 40% of cases of gastrointestinal bleeding with obscure origin and represent the single most common cause for hemorrhage in this subset of patients. Their cause is unknown but most are probably acquired and the result of a degenerative process associated with aging. The difficulty of their diagnosis stems from their multiple appearance and small size. Examinations that have been performed so far support that the sensitivity of capsule endoscopy (CE) performed during active bleeding was higher than in case of previous overt bleeding and occult bleeding.

CASE REPORT

A 61-year-old female patient, who has received anticoagulant therapy for 13 years, presented with recurrent gastrointestinal bleeding of obscure origin underwent wireless capsule endoscopy after negative upper endoscopy and colonoscopy. CE showed non-bleeding typical angiodysplasia in the antrum of the stomach and active bleeding in the first third of jejunum without a visible bleeding source. As the next diagnostic step we performed selective mesenteric angiography to clarify the diagnosis and at the same time we also applied radiological intervention.

CONCLUSION

Capsule endoscopy changed in practice guidelines for obscure bleeding and became the first-line method for evaluation of patient after upper endoscopy and colonoscopy have been shown to be negative. If the examination is performed early, CE could shorten considerably the time to diagnosis, lead to definitive treatment and numerous examinations with low yield could be avoided. The therapy of small bowel angiodysplasias is questionable. Radiological intervention poses the least load for the patient.

Identification of the genes directly controlled by the response regulator CiaR in Streptococcus pneumoniae: five out of 15 promoters drive expression of small non-coding RNAs

The two-component regulatory system CiaRH of Streptococcus pneumoniae has been implicated in beta-lactam resistance, maintenance of cell integrity, competence and virulence, but the genes that are regulated directly by the system have not been defined. Using transcriptional mapping, in vitro CiaR binding, and in vivo analysis of CiaR-mediated regulation, 15 promoters were identified to be directly controlled by the response regulator CiaR. A direct repeat, TTTAAG-N5-TTTAAG, was found to be essential for CiaR binding and regulation. It is present, either completely or with subtle changes, in all promoter regions. Fourteen promoters of the regulon are activated by CiaR, and one was found to be controlled negatively. The genes that are transcribed from these promoters included ciaRH, loci that are predicted to be involved in the modification of teichoic acids (lic), in sugar metabolism (mal, man), stress response (htrA), chromosome segregation (parB), protease maturation (ppmA) and unknown functions. Remarkably, the five strongest promoters of the CiaR regulon drive expression of small RNAs. These small RNAs, designated csRNAs for cia-dependent small RNAs, are non-coding, between 87 and 151 nt in size, and show a high degree of similarity to each other. The analysis of deletion mutants in the csRNA genes revealed that csRNA4 and csRNA5 affect stationary-phase autolysis. The identification of five small non-coding regulatory RNAs opens new perspectives to approach the physiological role of the CiaRH two-component regulatory system.

[Role of capsule endoscopy in patients with portal hypertension and obscure gastrointestinal bleeding]

BACKGROUND AND AIMS

Limited number of data are available on small bowel changes due to portal hypertension. The present retrospective, comparative study was aimed to analyse the diagnostic yield and to describe the findings with capsule endoscopy of cirrhotic patients with obscure gastrointestinal bleeding.

PATIENTS AND METHODS

Capsule endoscopy findings of 11 cirrhotic patients with portal hypertension and 22 non-cirrhotic patients with gastrointestinal bleeding who had undergone non-diagnostic upper endoscopy and colonoscopy were compared. Capsule video recordings were evaluated by two investigators at both workplaces. Patients after capsule endoscopy were followed-up until a mean of 19 (1-42) months.

RESULTS

In total 7 men and 5 women were examined at two medical centres in 48 months with a mean age of 66.2 (+/-7.6) years. The average period between the first clinical symptoms and capsule endoscopy was 15.7 (+/-14.9) months. During this period patients were hospitalized in an average of 2.8 (+/-1.3) times and 7.9 examinations were performed per patients prior to capsule endoscopy. A small bowel bleeding source was diagnosed in all 11 patients. Two definitive bleeding sources were observed in 7 patients (63%). Lesions connected to portal hypertension were found in all patients (8 angiodysplasias, 2 portal hypertensive enteropathies and 1 bowel varix). During the follow-up period rebleeding occurred in 27.3% of cirrhotic patients compared with 18.2% rebleeding rate in the control group.

CONCLUSION

Capsule endoscopy is a useful method in patients with portal hypertension and obscure gastrointestinal bleeding after negative upper endoscopy and colonoscopy. Multiple angiodysplasias are often diagnosed in the background of small bowel bleedings, and several bleeding sources frequently occur in these patients.

[Chronic intestinal pseudoobstruction due to visceral myopathy]

A case is reported of a chronic intestinal pseudoobstruction with lethal outcome in a 6-year-old boy. The clinical symptoms and radiology examination showed ileus without mechanical obstruction. During the observation the patient developed left sided mydriasis and grand mal seizures with lactacidosis. He was treated conservatively which included total parenteral nutrition, fluid-sodium supplements, intravenous erythromycin and somatostatin, correction of acidosis. On the 48th day he died suddenly of cardiac failure at the intensive care unit. The gastrointestinal and neurologic symptoms with lactacidosis suggested the possibility of mitochondrial myopathy. Postmortem histopathology showed visceral myopathy. Molecular genetic analysis could not confirm the presence of the mDNA mutation.

[Identification of a Meckel's diverticulum bleeding by urgent capsule endoscopy]

A 10 year-old patient was admitted to our hospital due to severe gastrointestinal bleeding. His symptoms included hematochezia and fainting. Neither emergency upper endoscopy nor colonoscopy had identified the site of bleeding. During the colonoscopy they noticed that fresh blood entered the cecum from the ileum. An urgent capsule endoscopy was performed 8 hours after the patient admission. They placed the capsule with specific endoscopic technique into the proximal duodenum under general anesthesia. During 3,5 hours by the small bowel passage the capsule moved to the ileum and a focal bleeding lesion was detected at this site, suggesting the typical picture of bleeding Meckel's diverticulum. The patient was transfused by 1 unit of blood, with a minimum haemoglobin level 95 g/l. By surgery the ulcerated Meckel's diverticulum was identified and resected. Histopathology showed ectopic gastric mucosa. Surgical resection of the diverticulum resulted complete healing of this patient. The capsule endoscopy diagnosis was prompt, precise, and the all examinations were carried out within 24 hours. Involving urgent small bowel capsule endoscopy into the diagnostic workup of the obscure bleeding patient could considerably shorten the time to achieve a correct diagnosis and allowed the early institution of definitive treatment. By this one could spare a great number of costly alternative investigations with low diagnostic yield.

[Evaluation of diagnostic yield and clinical impact of capsule endoscopy in patients with obscure gastrointestinal bleeding]

BACKGROUND AND AIMS

The major indication of small bowel capsule endoscopy is the diagnostics of obscure gastrointestinal bleeding. The present retrospective study was aimed to analyze the diagnostic yield, positive and negative predictive values and clinical impact of capsule endoscopy in patients with obscure gastrointestinal bleeding.

PATIENTS AND METHODS

During a 36 month period at two workplaces 66 capsule endoscopy studies were performed in 62 patients with gastrointestinal bleeding who had undergone non-diagnostic upper endoscopy and colonoscopy. Capsule video recordings were evaluated by two investigators at both workplaces. Capsule endoscopy findings were divided into 3 groups according to the bleeding source: definitive bleeding source (48 patients), uncertain bleeding potential (5 patients), and negative finding (8 patient). Patients after capsule endoscopy were followed-up until a mean of 20 (1-41) months.

RESULTS

A definitive small bowel bleeding source was detected in 78.7% of the cases studied by capsule endoscopy. Definitive bleeding sources included angiodysplasia (28 cases), small bowel Crohn's disease (5 cases), small bowel tumor (5 cases), small bowel stenosis (2 cases), NSAID therapy related ulcer (1 case), non-specific inflammation (1 case) and helminthiasis (1 case) respectively. The positive and negative predictive values of capsule endoscopy studies were 95.8% and 84.6% respectively. In cases with definitive bleeding sources 72% of patients received therapy in accordance with capsule endoscopy findings (surgery in 18 patients, medical treatment modification in 16 patients, chemoembolisation in 1 patient). During the follow-up period 17.7% of the patients had rebleeding.

CONCLUSIONS

Capsule endoscopy is a useful and effective diagnostic method in cases with obscure gastrointestinal bleeding. Effective therapy may be introduced in accordance with the majority of positive capsule endoscopy results.

A functional dlt operon, encoding proteins required for incorporation of d-alanine in teichoic acids in gram-positive bacteria, confers resistance to cationic antimicrobial peptides in Streptococcus pneumoniae

Streptococcus pneumoniae is one of the few species within the group of low-G +C gram-positive bacteria reported to contain no d-alanine in teichoic acids, although the dltABCD operon encoding proteins responsible for d-alanylation is present in the genomes of two S. pneumoniae strains, the laboratory strain R6 and the clinical isolate TIGR4. The annotation of dltA in R6 predicts a protein, d-alanine-d-alanyl carrier protein ligase (Dcl), that is shorter at the amino terminus than all other Dcl proteins. Translation of dltA could also start upstream of the annotated TTG start codon at a GTG, resulting in the premature termination of dltA translation at a stop codon. Applying a novel integrative translation probe plasmid with Escherichia coli 'lacZ as a reporter, we could demonstrate that dltA translation starts at the upstream GTG. Consequently, S. pneumoniae R6 is a dltA mutant, whereas S. pneumoniae D39, the parental strain of R6, and Rx, another derivative of D39, contained intact dltA genes. Repair of the stop codon in dltA of R6 and insertional inactivation of dltA in D39 and Rx yielded pairs of dltA-deficient and dltA-proficient strains. Subsequent phenotypic analysis showed that dltA inactivation resulted in enhanced sensitivity to the cationic antimicrobial peptides nisin and gallidermin, a phenotype fully consistent with those of dltA mutants of other gram-positive bacteria. In addition, mild alkaline hydrolysis of heat-inactivated whole cells released d-alanine from dltA-proficient strains, but not from dltA mutants. The results of our study suggest that, as in many other low-G+C gram-positive bacteria, teichoic acids of S. pneumoniae contain d-alanine residues in order to protect this human pathogen against the actions of cationic antimicrobial peptides.

Aflatoxin and ochratoxin A content of spices in Hungary

In October and November 2004, 91 spice samples (70 ground red pepper, six black pepper, five white pepper, five spice mix and five chilli samples), the majority of which originated from commercial outlets, were analysed for aflatoxins B1, B2, G1 and G2 (AFB1, AFB2, AFG1, AFG2) and ochratoxin A (OTA) content by high-performance liquid chromatography (HPLC) after immunoaffinity column clean-up. Eighteen of the 70 ground red pepper samples contained AFB1, seven of them in a concentration exceeding the 'maximum level' of 5 microg kg(-1) (range 6.1-15.7 microg kg(-1)). Of the other spices assayed, the AFB1 contamination of one chilli sample exceeded 5 microg kg(-1) (8.1 microg kg(-1)). Thirty-two of the 70 ground red pepper samples contained OTA, eight of them in a concentration exceeding the 10 microg kg(-1) 'maximum level' (range 10.6-66.2 microg kg(-1)). One chilli sample was contaminated with OTA at 2.1 microg kg(-1). The AFB1 and OTA contamination of ground red pepper exceeding the 'maximum level' (5 and 10 microg kg(-1), respectively) was obviously the consequence of mixing imported ground red pepper batches heavily contaminated with AFB1 and OTA with red pepper produced in Hungary. This case calls attention to the importance of consistently screening imported batches of ground red pepper for aflatoxin and ochratoxin A content and strictly prohibiting the use of batches containing mycotoxin concentrations exceeding the maximum permitted level.