Single pill treatment in daily practice is associated with improved clinical outcomes and all-cause mortality in cardiovascular diseases: results from the START project

Objective

Current guidelines for the management of arterial hypertension, dyslipidemia, or secondary cardiovascular (CV) prevention recommend combination drug treatments with single pill combinations (SPC). This concept is expected to improve adherence to treatment and, as a consequence, to reduce the risk of adverse CV outcomes associated with these clinical conditions. Aim of our study was to assess whether SPC are clinically superior to multi pill combination (MPC) with identical drugs in reducing CV events and al-cause mortality in a huge population under real world conditions in daily practice.

Methods

We analyzed an anonymized claims dataset (AOK PLUS, a statutory German sickness fund) including patients with hypertension and other CV diseases in the years 2012–2017; minimum follow-up was 1 year or until date of death, After 1:1-Propensity Score Matching (PSM), selected CV outcomes (myocardial infarction, stroke, transitory ischemic attack, coronary artery disease, heart failure, acute renal failure, cardiovascular hospitalization, all cause hospitalization) as well as all-cause mortality were compared using Incidence Rate Ratios (IRRs) and non-parametric tests.

Results

50,622 patients (25,311 patients in SPC versus MPC group) aged ≥18 years treated with SPC or identical MPC were followed up for at least 1 year or until death. No significant differences in baseline characteristics were observed after PSM. Nine different clinical outcomes were compared for each group. In all comparisons, significantly lower incidence rate ratios (IRR) were identified for SPC, confirmed by comparison of Kaplan-Meier estimates: stroke (IRR=0.77; 95% CI 0.67–0.88; p<0.001), transitory ischemic attack (IRR=0.61; 95% CI 0.48–0.78; p<0.001), myocardial infarction (IRR=0.76; 95% CI 0.63–0.90; p=0.0016), coronary artery disease (IRR=0.66; 95% CI 0.57–0.77; p<0.001), heart failure (IRR=0.59; 95% CI 0.54–0.64; p<0.001), acute renal failure (IRR=0.54; 95% CI 0.56–0.64; p<0.001) all cause hospitalization (IRR=0.72; 95% CI 0.71–0.74; p<0.001), cardiovascular hospitalization (IRR=0.63; 95% CI 0.57–0.69; p<0.001), and all-cause mortality (IRR=0.62; 95% CI 0.57–0.68; p<0.001). The mean time to first events and time to death were also in favor to SPC (any event: SPC 966.052 days/median 873; MPC 846.936 days/median 647; death: SPC 1,719.424 days; MPC 1,657.248 days; log rank for both comparisons: p<0.001).

Conclusion

In clinical practice, the SPC regimen is associated with a lower incidence of CV events and lower all-cause mortality. Time to the event is also significantly longer in the SPC group compared to MPC. These results strongly support the concept of SPC and the implementation into daily practice to improve patient's prognosis.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): APONTIS PHARMA GmbH & Co. KG

Persistence and cardiovascular outcomes with ramipril, atorvastatin, ASA as a single pill compared to the multi pill combination. A subanalysis of the START study, a claims data analysis

Background/Introduction

Large randomized clinical trials have shown the efficacy of aspirin (ASA), angiotensin converting enzyme inhibitors (ACEI) and statins (S) in secondary prevention. However, adherence to medication is low in patients suffering from a cardiovascular event and decreases with each additional tablet. Therefore, a single pill (SP) approach is considered to increase drug persistence and decrease cardiovascular events in this patient population.

Purpose

Data that show an advantage for a SP regimen containing ASA, ACEI, and S compared to the identical loose combination (LC) regarding persistence, and clinical outcomes under conditions of daily practise in one study are missing. We conducted the START study to answer these questions. A subset, in which we anlysed data from patients in secondary prevention is presented here.

Methods

The START study was a retrospective, non-interventional analysis of an anonymised claims dataset covering patients suffering from cardiovascular diseases insured by the German AOK PLUS public health insurance in the years 2012–2017. Patients at age ≥18 years with an indication for the use of a combination treatment in cardiovascular disorders – including the use of ASA, ramipril, and atorvastatin - in a SP or identical LC were followed up to 1 year. After 1:1-Propensity Score Matching (PSM) persistence (defined as redemption of prescription with a lack >60 days) and clinical outcomes were compared using non-parametric tests.

Results

Before PSM, 564,941 patients had a cardiovascular event in the medical history, 427,046 suffered from coronary artery disease. 275 received the three substances described above as SP, 6,662 as LC. After PSM, data from 211 patients were suitable for further analysis in each group. Baseline characteristics were comparable between SP and LC groups. Persistence to treatment was significant lower in the LC group (Hazard Ratio, HR, 0.25 [95% CI 0.19–0.34], p<0.001). 8 clinical outcomes were analysed. Lower Incidence Rate Ratio (IRR) was found in the SP group for myocardial infarction (IRR 0.46; 95% CI 0.07–2.36), stroke (IRR 0.51; 95% CI 0.04–4.46), transitory ischemic attac (IRR 0.77; 95% CI 0.01–60.12), coronary artery disease (IRR 0.60; 95% CI 0.25–1.43), and all cause mortality (IRR 0.38; 95% CI 0.06–1.79). All cause hospitalisation was significant lower in the SP group (IRR 0.58; 95% CI 0.47–0.72; p<0.001).

Conclusion

The number of patients receiving a SP regimen in secondary prevention was relatively low. However, persistence to medication was significantly higher in the SP group. In addition, a tendency for a lower IRR was also observed for cardiovascular events and all cause mortality in the SP group. The results of our analysis support the use of a SP regimen in secondary prevention of cardiovascular events.

Funding Acknowledgement

Type of funding source: None

Single pill regimen improves persistence and leads lo better clinical outcome compared to identical multi pill combination. Results of START, a German claims data analysis

Background/Introduction

The current ESC/ESH-Guidelines for the treatment of arterial hypertension (AH) recommend initiation and escalation of medical treatment using renin–angiotensin–aldosterone system (RAAS) blocker, diuretics (D) and/or calcium channel blockers (CCB). They also recommend a single pill (SP) regimen to improve persistence, to increase blood pressure control and to reduce cardiovascular events.

Purpose

Data showing an advantage for a SP regimen compared to the identical loose combination (LC) regarding all these parameters in a single study are missing. We report now the results comparing SP with identical LC regarding persistence and cardiovascular outcomes in daily practice.

Methods

This was a retrospective, non-interventional analysis of an anonymized claims dataset covering patients suffering from cardiovascular diseases insured by the German AOK PLUS public health insurance in the years 2012–2017. Patients at age ≥18 years with an indication for the use of a combination of RAAS-blockers, D and/or CCB as SP or identical LC were followed up for 1 year. After 1:1-Propensity Score Matching (PSM) persistence (defined as redemption of prescription with a lack >60 days) and clinical outcomes were compared using non-parametric tests.

Results

After PSM, baseline characteristics were comparable between SP and LC groups. Each group included 10,801 patients with valsartan/amlodipine, 1,026 with candesartan/amlodipine, 1,823 with amlodipine/valsartan/hydrochlorothiazide (HCT), and 15,349 with ramipril/amlodipine as SP or identical LC. 8 clinical outcomes were compared for each combination. Persistence to treatment was significant higher in the SP group. In 27 of 32 comparisons a significantly lower Incidence Rate Ratio (IRR) was identified for SP. This was confirmed by time-to-event-analysis. The largest patient group (ramipril/amlodipine) showed a significant lower risk for SP observed for stroke (IRR=0.746; 95% CI 0.627–0.886; p<0.001), transitory ischemic attack (IRR=0.693; 95% CI 0.496–0.963; p=0.023), myocardial infarction (IRR=0.623; 95% CI 0.493–0.784; p<0.001), coronary artery disease (IRR=0.579; 95% CI 0.462–0.723; p<0.001), heart failure (IRR=0.468; 95% CI 0.409–0.534; p<0.001), all cause hospitalization (IRR=0.670; 95% CI 0.652–0.687; p<0.001), cardiovascular hospitalization (IRR=0.596; 95% CI 0.519–0.685; p<0.001), and all cause mortality (IRR=0.526; 95% CI 0.463–0.596; p<0.001) compared to LC.

Conclusion

A SP regimen improves persistence to medication, reduces cardiovascular events and total mortality compared to identical LC. The results of the START study strongly support the use of a SP concept in the AH medication treatment as recommended by the current ESH/ESC-Guidelines for the treatment of AH.

Funding Acknowledgement

Type of funding source: None

[Efficacy and tolerability of pantoprazole in the treatment of gastroesophageal reflux disease]

BACKGROUND

Proton pump inhibitors (PPI) are considered first-line therapies in the treatment of gastroesophageal reflux disease (GERD) and are prescribed frequently.

METHODS

In two non-interventional trials 3040 patients with GERD were treated with 20 mg/40 mg pantoprazole per day. Symptoms were assessed by the investigators as well as the patients by means of the symptom questionnaire ReQuest at study start and after 1 week of treatment with pantoprazole. Data were pooled and analysed.

RESULTS

At study start, 80% of patients had moderate/severe heartburn, 65% acid regurgitation, 20% painful swallowing and 32% suffered from moderate/severe steep dysfunction. After 1 week of treatment only 3.6% reported moderate/severe heartburn, 2.8% acid regurgitation, and 1.0% painful swallowing. Only 3.6% still suffered from sleep dysfunction. Improvement of symptoms was already observed after 1 to 2 days.

CONCLUSION

Treatment with pantoprazole not only reliefs typical daily core symptoms but also improves the hitherto hardly noted sleep dysfunction and can, hence, bring a recovery of quality of life.

[Effectiveness of screening colonoscopy in a community-based study]

In 2002 screening colonoscopy was introduced in Germany for the prevention of colorectal cancer (CRC) and CRC mortality. Individuals took part in a prospective study from October 2002 until September 2005 performed at a single centre for gastroenterology. Histopathological data, surgical-pathological stages and further follow-up events were recorded until 31st of December 2006. For screened individuals without symptoms, the data obtained were compared to those from age-matched patients who presented with clinical symptoms/signs and who underwent colonoscopy during the same period in time. A total of 5066 individuals underwent screening colonoscopy. In this group, colorectal cancer was detected in 46 individuals (0.9%). Endoscopic treatment was considered adequate for 21 cancers. In this group of 46 patients, 94.5% were classified into UICC stages I-II by pathological staging. In 504 screened individuals, colorectal polyps were detected (12.2%) and removed by polypectomy. Of these polyps, 16 were classified as cancer, 496 as adenomas and 1 as a carcinoid tumour. High grade dysplasia was noted in 41 polyps (8.3% of adenomas). In comparison, 4099 symptomatic patients underwent colonoscopy. In this group 100 cancers (2.4%) were detected. Advanced malignant tumours were noted in 39% of these; endoscopic treatment was feasible in 16% of the cancers. As of December 2006, cancer-related deaths were observed in 20% of symptomatic patients with CRC. Screening colonoscopy detects colorectal cancers in the early stages. Given the favourable prognosis in these stages, screening can reduce CRC-related mortality.

[Financial restrictions in health care systems could affect treatment quality of GERD-patients]

AIMS

To directly compare the efficacy and safety of pantoprazole 40 mg VS. omeprazole 20 mg in patients with gastroesophageal reflux disease (GERD).

MATERIAL AND METHODS

915 Patients suffering from symptomatic GERD B-D (Los Angeles classification) were included in a double-blind randomized multicenter clinical trial and treated with either pantoprazole 40 mg od or omeprazole 20 mg od for six weeks. Primary efficacy criterion was the first time to reach normal symptoms as assessed by the questionnaire ReQuest-GI.

RESULTS

Compared to omeprazole 20 mg, pantoprazole 40 mg achieved a significantly faster rate of symptom relief (p = 0.0298). Thus, as assessed with the ReQuest questionnaire, patients treated with pantoprazole 40 mg experienced relief from the 7 leading GERD symptoms 2 days earlier than those treated with omeprazole 20 mg. Long-lasting sustained relief from symptoms was also achieved earlier with pantoprazole than with omeprazole; in patients treated with pantoprazole, the daily symptom load was lower than in those treated with omeprazole. After 6 weeks of treatment, over 90 percent of patients were free from symptoms in both treatment groups (93.7 % in the pantoprazole, vs. 91.8 % in the omeprazole group, PP). Both medications were well tolerated.

CONCLUSIONS

GERD patients treated with pantoprazole 40 mg experience a significantly faster relief from their leading symptoms than those treated with omeprazole 20 mg.

[Laparoscopic versus open appendectomy: which factors influence the decision between the surgical techniques?]

BACKGROUND

Although in hospitals focussing on minimal invasive surgery laparoscopic appendectomy (LA) is widely practiced as method of choice in patients with acute appendicitis, the decision for the laparoscopic or the conventional technique (OA) is usually ensued by individual viewpoints. Aim of this prospective observation study was to analyse the decision algorithm for both procedures in patients with the presumptive diagnosis "appendicitis".

PATIENTS AND METHODS

Between January 1996 and July 2001 512 patients with the presumptive diagnosis "acute appendicitis" underwent surgery and, assigned by intention-to-treat, were subdivided in a laparoscopic (I) and a conventional group (II). The choice of surgical procedure was analysed with regard to patient characteristics (age, gender, comorbidity), severity of appendicitis (clinical manifestation, preoperative inflammation signs), surgeon (clinical experience) and daytime (during the day, in the evening, at night). Furthermore, the outcome of either method was related to postoperative diagnosis, perioperative morbidity, analgesia, length of hospital stay and cosmetic results.

RESULTS

In group I 265 patients and in group II 247 patients underwent surgery. Conversion from LA to OA was necessary in 6.4 %. Group I consisted of significantly more female (67.9 % vs. 45.7 %) and younger patients (21 yrs. vs. 30 yrs.) with less medical history as well as minor severity of tissue inflammation and significantly lower preoperative serum inflammation parameters (leukocytes (1000/ml): 10.6 +/- 4.3 vs. 13.5 +/- 4.9; CRP (mg/l): 2.3 +/- 3.3 vs. 5.6 +/- 7.5, I vs. II: p < 0.001). In group I more patients underwent surgery during day-time as well as by more laparoscopic-experienced surgeons. In the postoperative histopathologic evaluation there were significantly fewer cases with complicated appendicitis (33.2 % vs. 52.2 %, p < 0.001). Additionally, patients after LA revealed a lower postoperative complication rate (9.3 % vs. 18.3 %), length of hospital stay (median 3 vs. 4 days) and duration of analgesia (2.1 +/- 1.8 vs. 4.1 +/- 7.1 days).

CONCLUSIONS

Important factors for decision algorithm between a laparoscopic or an open appendectomy include severity of appendicitis, gender, day-time as well as the surgeon's individual laparoscopic experience. With appropriate indication for each technique, both procedures are of equal value in the treatment of acute appendicitis. Furthermore the positive patient selection for laparoscopic appendectomy contributed to a better postoperative outcome in this study.

Arzneimittelinteraktionen

During the last few years 3 important drugs (terfenadine, mibefradil, cisapride) had to been withdrawn from the market because of serious drug-drug interactions. Polypragmacy, not only in advanced age, is often applied. Consequently the possibility of pharmacokinetic and/or pharmacodynamic drug interactions has always to be taken into account which can cause adverse effects, therapeutic failures, hospital admissions and extra costs. Clinically relevant interactions can be observed especially on the level of drug metabolism and transport. Both pharmacokinetic processes can be induced or inhibited by numerous agents. Taking proton pump inhibitors as an example it could be shown that the various compounds can differ in their interaction potential.

[Antiphospholipid antibody syndrome as the cause of clinical rapidly progressing vasculopathy]

HISTORY AND ADMISSION FINDINGS

For 3 weeks a 54-year-old man had been unsuccessfully treated with antibiotics for ulcerating tonsillitis with fever, weight loss, occasional headaches, and hypertension. A year before he had suffered a transitory cerebral ischaemic attack. On admission he had a fever of 38.6 degrees C, blood pressure of 185/100 mmHg and a nonspecific 2/6 apical systolic murmur.

INVESTIGATIONS

Erythrocyte sedimentation rate was 100/120 mm, C-reactive protein 1.5 mg/dl, serum creatinine 2.45 mg/dl, urinary protein 0.8 g/d. Tests for antinuclear antibodies (ANCA) against neutrophil granulocytes and for native DNA antibodies were negative, as were serological tests for Coxsackie virus, Cytomegalovirus and Epstein-Barr virus. Sonography and computed tomography revealed thrombosis along the entire aortic wall, renal artery stenosis and a contracted left kidney. Transoesophageal echocardiography demonstrated small thrombi on the aortic valve leaflets. Coloscopy showed ulcerative colitis.

TREATMENT AND COURSE

The patient was anticoagulated. Local cold produced livedo reticularis. Tests for cardiolipin antibodies in serum and a skin biopsy provided the diagnosis of antiphospholipid antibody syndrome (APS). As the skin biopsy showed vasculitis, immunosuppressive treatment was started. This stabilized the condition and he was discharged to be followed by his general practitioner.

CONCLUSION

APS can cause complex symptoms in many organs, but effective treatment (anticoagulation, corticosteroids, immunosuppressives) is available, as this case demonstrates.

Gastric cancer in pregnancy: do pregnancy, age or female sex alter the prognosis? Case reports and review

The coincidence of gastric cancer and pregnancy is a rare event. By literature research of the last three decades only 31 cases from outside Japan were identified including two own patients. The analysis of these and another 61 cases from Japan revealed the same predominance of poorly differentiated diffuse carcinomas with peritoneal and lymphatic metastases as in other young patients (<40 years). The survival rate is not obviously affected by pregnancy, young age or female sex. Experimental and epidemiological data suggest a protective effect of oestrogen against the induction of (intestinal) gastric cancer, while the cancer growth itself seems to be enhanced. Oestrogen receptors (ER) are found in about 22% of gastric cancer cells, especially in the poorly differentiated type. In contrast to target organs like the breast, ER in gastric cancer seem to be a sign of tumour adaptation involving e.g. the pathway of the epidermal growth factor. The results of treatment with anti-oestrogen are controversial in experimental and clinical settings. Due to the very common epigastric complaints early diagnosis of gastric cancer is even more difficult in pregnancy, so that early gastroscopy is advisable in patients on risk. Main effort should be given, however, to primary prevention.

Vitamin supplementation during weight reduction--favourable effect on homocysteine metabolism

Moderately elevated homocysteine concentrations, reflecting deficiency of some nutritional factors required for homocysteine metabolism (folate, vitamin B-6, vitamin B-12) and/or less severe genetic defects, are common in the general population. Several studies have indicated the role of homocysteine as an independent risk factor for vascular disease. A pilot study published recently suggested that plasma homocysteine levels increase during weight reduction in slightly overweight, otherwise healthy subjects (group A). We examined a comparable group of 13 overweight subjects (group B) using a standardised caloric intake and defined vitamin supplementation (Medyn: folate 0.2 mg/ vitamin B-68.0 mg/ vitamin B-120.010 mg three times the day orally) to determine the effect of weight reduction on serum homocysteine levels and to compare the results with those of the pilot study. Mean body weight declined from 87.0 +/- 20.2 to 84.2 +/- 20.1 kg (P < 0.05) in group A and 85.7 +/- 11.3 to 82.5 +/- 9.9 kg (P = 0.049) in group B. Serum homocysteine levels rose from 7.9 +/- 2.0 to 8.7 +/- 2.3 mumol/l (P < 0.0001) in group A and decreased from 8.19 +/- 1.73 to 7.35 +/- 0.88 mumol/l (P = 0.0022) in group B. No correlation was found between the changes in body weight and in homocysteine levels (r = 0.02 in group A, r = 0.18 in group B). Additionally, no correlation was found between serum folate levels and changes in homocysteine levels (r = 0.03 in group A, r = 0.09 in group B). The results suggest that an adequate oral vitamin-supplementation protects against increased homocysteine production during weight reduction.

[Intramural pseudodiverticulosis of the esophagus. Diagnosis on second look]

HISTORY

Case 1. A 56-year-old man had experienced increasing dysphagia for 6 months, accompanied by a weight loss of 20 kg. A stenosing oesophageal carcinoma was suspected. Case 2. A 82-year-old man had been suffering intermittently from nausea for some years but had maintained his weight (80 kg; height 173 cm). Endoscopy 4 months before this admission had revealed a duodenal ulcer; its treatment briefly improved the symptoms.

INVESTIGATIONS, DIAGNOSIS AND TREATMENT

Endoscopy in case 1 detected a severe oesophageal stenosis which could not be passed, and its cause could not be ascertained despite biopsy, barium swallow and computed tomography. After bougie dilatation an endoscope was finally passed and the typical picture of oesophageal pseudodiverticulosis (OPD) seen. In case 2, endoscopy at first indicated only marked Candida oesophagitis. But after antimycotic treatment a second endoscopy revealed OPD. No treatment is known nor necessary since OPD causes no clinical symptoms unless there are complications.

CONCLUSIONS

OPD, a rare condition, presents in various ways, both in its symptoms and at endoscopy. In case of oesophageal stenosis of unknown cause or Candida oesophagitis repeat endoscopy my be necessary to establish the true diagnosis: OPD should be included in the differential diagnosis.

Gastric ulcer healing in the rat: kinetics and localisation of de novo procollagen synthesis

BACKGROUND AND AIMS

To gain further insight into the role of the extracellular matrix during healing of peptic ulcers, sequential changes of procollagen expression were studied over 30 days of ulcer healing.

MATERIALS AND METHODS

Procollagens alpha 1 (I), alpha 1 (III), and alpha 1 (IV) RNA and their polypeptides were assessed in acetic acid induced rat gastric ulcers by in situ hybridisation and immunohistochemistry.

RESULTS

Three days after ulcer induction, intense hybridisation signals were obtained with all probes, with procollagen alpha 1 (I) showing the highest transcript levels. Procollagen gene expression remained elevated up to day 15, but was reduced to initial low levels on day 30. Immunohistochemical staining documented increased deposition of the three procollagen types parallel to their respective transcript levels, again with type I showing the earliest and the most prominent deposits. The highest procollagen transcript levels were found in the intact submucosa surrounding the ulcer margins, followed by the muscularis propria and the serosa, with the lamina propria exhibiting the lowest transcript levels.

CONCLUSION

The procollagens studied are regulated differentially at the transcriptional and post-transcriptional levels. The early onset and long duration of procollagen expression as well as the involvement of all layers of the gastric wall points to their central structural and functional role in gastric ulcer healing.

Simultaneous restitution of matrix and cells in gastric ulcer: use of a combined in-situ hybridization and immunohistochemistry technique applicable to paraffin-embedded tissue

The restoration of gastric tissue after ulceration involves cellular and matrix components. Our aim was to investigate the kinetics of collagen expression and cellular proliferation in an animal model of gastric ulcer. To demonstrate the expression of type I and IV collagen mRNAs by proliferating cells, a method combining in-situ hybridization and immunohistochemistry was devised. In order to avoid the disadvantages of radioisotopes, digoxigenin-labeled RNA-riboprobes were utilized and combined with single-step immunohistochemistry. This method proved sensitive enough to detect type I and IV procollagen mRNA transcripts in the submucosal area beneath the ulcer crater or adjacent to the ulcer rim. In addition, a subset of cells transcribing either procollagen type I or IV RNA was concomitantly positive for proliferating cell nuclear antigen by immunohistochemistry. Focal proliferation of cells simultaneously expressing extracellular matrix components may therefore occur in the gastric submucosa after ulceration, starting as soon as 3 days after the insult and continuing for several weeks. The devised method of combined in-situ hybridization and immunohistochemistry can be used with standard paraffin-embedded tissues, yields results within 2 days, and avoids radioisotopes.

[Intraductal ultrasound in the pancreaticobiliary duct system]

BASIC PROBLEM AND OBJECTIVE OF STUDY

The power of resolution of conventional imaging methods is too low for the diagnosis of very small pancreaticobiliary tumours. High-frequency ultrasound transducers (20 MHz), adapted to the dimensions of the pancreaticobiliary systems (2 mm diameter), make intraductal ultrasound examination possible during endoscopic retrograde cholangiopancreatography (ERCP). In a prospective study the invasiveness and diagnostic value of intraductal ultrasound (IDUS) was compared with ERCP, endosonography (ES) and computed tomography (CT).

PATIENTS AND METHODS

During ERCP in 51 consecutive patients an intraductal ultrasound transducer was introduced into the pancreaticobiliary duct system, the results being compared with those obtained with the other imaging modalities and histopathological findings, if available.

RESULTS

IDUS of the pancreatic and bile duct systems is a rapid, simple and reliable method during ERCP and provides valuable additional information on periductal tissues. In the diagnosis of carcinoma of the pancreas its sensitivity was 75% (six of eight cases), that of ERCP 37% (3/8), ES 50% (4/8) and CT 37% (3/8). In the diagnosis of biliary tract tumour the sensitivity of the different modalities (in the above order) was 89% (8/9), 78% (7/9), 33% (3/9) and 33% (1/3). Specificity was 67% (2/3), 67% (2/3), 67% (2/3) and 33% (3/9); predictability 89%, 88%, 75% and 60%.

CONCLUSIONS

The use of small ultrasound catheter transistor system in the biliary and pancreatic ducts, introduced during ERCP, is technically simple and has few complications. It is a valuable addition to ERCP in the precise diagnosis of small pancreaticobiliary lesions.

Expression of type I and IV collagen mRNAs in healing gastric ulcers--a comparative analysis using isotopic and non-radioactive in situ hybridization

The sensitivity and practicability of in situ hybridization methods utilizing isotopic or non-radioactive labeling were compared. The aim of this study was to determine whether digoxigenin-labeled riboprobes are as sensitive as 35S-labeled probes to detect changes in type I and IV procollagen expression in an animal model of rat gastric ulcer. Both labeling and detection methods yielded similar results, with a superimposable signal distribution in the specimens. High levels of procollagen type I and IV transcripts were observed in spindle-shaped cells, presumably fibroblasts or myofibroblasts, localized in the ulcer base and rim. The increased expression of these collagen types suggests a remarkable upregulation of collagen expression during the healing of gastric ulcers. Liver tissue adhering to perforated ulcers displayed signals related to non-parenchymal cells, with hepatocytes demonstrating no detectable transcripts of type I or IV collagen genes. Due to the identical pattern of signal distribution by both hybridization techniques it is concluded that non-radioactive in situ hybridization is of value in monitoring highly expressed genes and yields results similar to those achieved with radioactive probes. In these cases, non-radioactive techniques are preferable because they are performed more rapidly and do not require handling of isotopes.

[Acute sigmoid diverticulitis--current diagnosis]

Acute sigmoid diverticulitis may present in different forms. Firstly, symptomatic diverticulosis and acute diverticulitis have to be differentiated to allow for the proper selection of treatment. In the initial phase of diagnostic procedures in addition to clinical features a few laboratory data, plain X-ray films of the abdomen and abdominal ultrasound are helpful to obtain information about the potential presence of perforation, abscess, tumor masses and the structure of the colonic wall. Computed tomography is capable to answer most of the questions in the diagnostic work-up of acute diverticulitis. On the other hand, contrast barium enema provides little additional information and should be considered as contraindicated in acute diverticulitis. If at all, water-soluble contrast media should be employed. Endoscopy has its place in the differential diagnostic evaluation of severe bleeding and suspected tumor, but should be reserved for these limited indications.

Diffuse esophageal spasm: a malfunction that involves nitric oxide?

OBJECTIVE

As recently suggested, nitric oxide (NO) may play an important role in the regulation of esophageal motility, being partly responsible for the latency period and latency gradient between the onset of a swallow and contractions of esophageal circular smooth muscles. Diffuse esophageal spasm appears to be a classical example in which the mechanisms normally responsible for the physiologic timing of the contractions occurring in the esophageal body after swallowing are disturbed.

METHODS

Five patients (one male and four female; age, 18-48 years) with symptomatic esophageal spasm were give glyceryl trinitrate (GTN) intravenously in gradually increasing doses or L-arginine on two separate occasions and underwent manometric measurements of esophageal motility after wet swallows, using a multilumen perfused catheter system (Synetics Medical, Stockholm, Sweden). The amplitude, duration, and propagation of the contractions and the latency period were analyzed, using specially designed software. Additionally, during the GTN infusion period arterial blood pressure was measured every 5 min,

RESULTS

GTN infusion given at a dose of 100 to 200 micrograms/kg-h intravenously caused the occurrence of and a dose-dependent elongation of the latency period after swallowing. The mean amplitude of the contractions did not show any significant alterations, whereas the mean duration of the contractions decreased significantly, from 11.2 +/- 4.8 sec to 5.4 +/- 0.8 sec. These effects were accompanied by significant alleviation of symptoms during swallowing. Interestingly, no adverse side effects such as headache or flush were observed at any dose of GTN. The blood pressure did not show any changes during the studies in any of the five patients. Administration of L-arginine (300 mg/kg-h intravenously) did not cause any significant alterations of motility pattern or alleviation of dysphagia.

CONCLUSIONS

1) NO may play an important role in the control of human esophageal motility, being involved in the mechanisms responsible for the timing of propulsive contractions in the body after swallowing; 2) GTN may to be of benefit in the treatment of diffuse esophageal spasm in symptomatic patients; and 3) patients with diffuse esophageal spasm may have a malfunction in endogenous NO synthesis and/or degradation.

Eradication of Helicobacter pylori restores the inhibitory effect of cholecystokinin on postprandial gastrin release in duodenal ulcer patients

Helicobacter pylori infection may be associated with duodenal ulcer (DU) and accompanied by enhanced gastrin release but the mechanism of this H pylori related hypergastrinaemia in DU patients is unclear. Cholecystokinin (CCK) has been implicated in the feedback control of gastrin release and gastric acid secretion in healthy subjects. This study therefore investigated if CCK participates in the impairment of postprandial gastrin release and gastric secretion in six DU patients. Tests were undertaken with and without elimination of endogenous CCK by loxiglumide, a selective CCK-A receptors antagonist, before and after eradication of H pylori with triple therapy (omeprazole, amoxicyllin, bismuth). In H pylori positive DU patients, the post-prandial decline in pH (with median pH 3.5) was accompanied by a pronounced increment in plasma gastrin but the administration of loxiglumide did not affect significantly this postprandial rise in plasma gastrin and gastric pH profile. After eradication of H pylori, the plasma gastrin concentration was reduced while the median postprandial pH was significantly increased (median pH 4.3). The administration of loxiglumide resulted in significantly greater increase in postprandial plasma gastrin and greater decrease in pH (median pH 3.1) in these patients. This study shows that (a) infection with H pylori is accompanied by an enhanced gastrin release and gastric acidity in DU patients, (b) the failure of loxiglumide to affect plasma gastrin or gastric acid secretion in H pylori infected DU patients could be attributed, at least in part, to the failure of endogenous CCK to control gastrin release and gastric secretion by releasing somatostatin, and (c) the test with loxiglumide may be useful in the identification of patients with impaired feedback control of gastrin release and gastric secretion resulting from infection with H pylori.

Evidence of de novo collagen synthesis in healing human gastric ulcers

BACKGROUND

The fibrillar collagens, types I and III, have been demonstrated in healthy human gastric mucosa as well as in the submucosa of gastric ulcer edges, where they are remarkably increased.

METHODS

To verify the occurrence and activity of de novo collagen synthesis, we examined gastric biopsy specimens from six patients with antral ulcers and six normal controls. By means of in situ hybridization, using a 35S-labeled RNA probe, we could localize the specific procollagen mRNA for type-I collagen.

RESULTS

In normal gastric mucosa this mRNA was expressed by only a very limited number of cells, whereas at the ulcer edges the specific signal could be demonstrated in a large number of submucosal cells.

CONCLUSION

These results suggest a substantial role of fibroneogenesis in the process of gastric ulcer healing.

Collagen mRNA and fibronectin are increased in healing gastric ulcers in man

The fibrillar collagens, types I and III, have been demonstrated in healthy human gastric mucosa as well as in the submucosa of gastric ulcer edges, where they were found to be remarkably increased. In order to verify the occurrence and activity of de novo collagen synthesis, we examined gastric biopsy specimens from six patients with antral ulcers and six normal controls. By means of in situ hybridization, using a 35-S-labelled RNA probe, we could identify the specific procollagen mRNA for type I collagen. Fibronectin was stained immunohistochemically employing specific polyclonal antibodies. In normal gastric mucosa, procollagen type I mRNA was expressed by only a very limited number of cells while at the ulcer edges the specific signal could be demonstrated in a large number of submucosal cells. Fibronectin as marker of newly built connective tissue was found to be markedly increased in the submucosa of healing gastric ulcers as compared to normal controls. These results suggest a substantial role of fibroneogenesis in the process of gastric ulcer healing.

[The significance of cytokines and extracellular matrix for stomach ulcer healing]

The healing process of gastric ulcers is regulated by many factors. Cytokines play a central role in the different stages of healing. In the early stage of inflammation, TNF-alpha and interleukins regulate cell-migration and -proliferation. In the ulcer's base revascularisation is stimulated by b-FGF, collagen synthesis by TGF-beta. The reepithelialization is mediated by EGF, which accelerates ulcer healing in animal models, while TGF-alpha is involved in mucosal protection. The extracellular matrix (ECM) is important for the stability and quality of the ulcer scar, as known from dermatological experiments. An increase of collagen types I and III in healing gastric ulcers was demonstrated recently, which might illuminate the particular role of ECM proteins for the gastric ulcer healing process.

Distribution of collagen types I, III, and IV in peptic ulcer and normal gastric mucosa in man

The quality of peptic ulcer healing does not only mean complete epithelial restitution of the mucosal surface but also adequate repair of the underlying connective tissue. To obtain more information about the metabolism of extracellular matrix proteins in gastric mucosa and submucosa, we investigated biopsy specimens from six patients with antral peptic ulcers and six normal controls by staining of collagen types I, III, and IV with an immunofluorescence technique. In normal mucosa we found a certain amount of collagen types I and III in equal distribution and almost no collagen type IV. In contrast, there was a remarkable increase of collagen types I and III in peptic ulcers predominantly located at the ulcer edges. These results are compatible with the view that extracellular matrix proteins play some part in the ulcer healing process.

Myofibroblast-like cells produce mRNA for type I and III procollagens in chronic active hepatitis

In chronic active hepatitis the rate of collagen biosynthesis is largely determined by intracellular mRNA concentrations. To localize procollagen mRNA-producing cells, we investigated biopsy specimens from five patients with hepatitis B surface antigen-positive chronic active hepatitis and five patients without liver disease by in situ hybridization. We used type I and III procollagen cDNAs for transcription to (35S)-labeled probes. Parallel sections were stained with anti-actin monoclonal antibodies. Our results show that cells in which collagen synthesis is ostensibly enhanced can be localized by in situ hybridization of procollagen mRNAs. These cells were also anti-actin-positive in parallel sections and were localized in areas of inflammatory cell infiltration and necrosis. We conclude that myofibroblast-like cells may express procollagen mRNAs in chronic active hepatitis. Moreover, in situ hybridization may be a valuable diagnostic tool for providing additional morphologic information on the degree of fibrogenesis activity.

[Identification of procollagen mRNA in chronic active hepatitis B]

In situ hybridization is a tool for staining intracellular procollagen mRNAs with specific probes. Our study shows the amounts of procollagen mRNAs of types I and III to be increased in liver biopsies of five patients with chronic active hepatitis B as compared with five healthy controls. Parallel staining employing anti-smooth-muscle-actin antibodies was able to identify myofibroblast-like cells at the same localization where procollagen mRNAs were found. Consequently, these transformed Ito-cells might be the procollagen-producing cells.