Acute pancreatitis precedes chronic pancreatitis in the majority of patients: Results from the NAPS2 consortium

INTRODUCTION

The mechanistic definition of chronic pancreatitis (CP) identifies acute pancreatitis (AP) as a precursor stage. We hypothesized that clinical AP frequently precedes the diagnosis of CP and is associated with patient- and disease-related factors. We describe the prevalence, temporal relationship and associations of AP in a well-defined North American cohort.

METHODS

We evaluated data from 883 patients with CP prospectively enrolled in the North American Pancreatitis Studies across 27 US centers between 2000 and 2014. We determined how often patients had one or more episodes of AP and its occurrence in relationship to the diagnosis of CP. We used multivariable logistic regression to determine associations for prior AP.

RESULTS

There were 624/883 (70.7%) patients with prior AP, among whom 161 (25.8%) had AP within 2 years, 115 (18.4%) within 3-5 years, and 348 (55.8%) >5 years prior to CP diagnosis. Among 504 AP patients with available information, 436 (86.5%) had >1 episode. On multivariable analyses, factors associated with increased odds of having prior AP were a younger age at CP diagnosis, white race, abdominal pain, pseudocyst(s) and pancreatic duct dilatation/stricture, while factors associated with a lower odds of having prior AP were exocrine insufficiency and pancreatic atrophy. When compared with patients with 1 episode, those with >1 AP episode were diagnosed with CP an average of 5 years earlier.

CONCLUSIONS

Nearly three-quarters of patients were diagnosed with AP prior to CP diagnosis. Identifying which AP patients are at-risk for future progression to CP may provide opportunities for primary and secondary prevention.

Lifetime smoking history and cohort-based smoking prevalence in chronic pancreatitis

BACKGROUND/OBJECTIVE

Smoking prevalence in patients with chronic pancreatitis [CP] is high. We aimed to understand lifetime history of smoking and cohort trends in CP patients to inform effective strategies for smoking cessation.

METHOD

Data on 317 CP patients from the North American Pancreatitis Study 2 [NAPS2] Continuation and Validation Study and the NAPS2 Ancillary Study were analyzed. Smoking history was assessed for each phase of life from the onset of smoking to study enrollment. Data on second-hand smoke and drinking history were also collected. We compared demographic factors, drinking history, pain level and pancreas morphology by smoking status at age 25 (non-smoking, <1 pack per day [PPD], ≥1 PPD). We compared smoking prevalence by birth cohorts: 1930-1949, 1950-1969, 1970-1989.

RESULT

Fifty-one percent of CP patients reported smoking at the time of enrollment. Those who smoked ≥1 PPD at age 25 smoked a cumulative total of 30.3 pack-years of cigarettes over a lifetime. Smoking at age 25 was associated with greater lifetime drinking and greater exposure to second-hand smoke at home and at workplace. Pancreatic atrophy and pseudocysts were more common among smokers. Pancreatic pain was more severe among smokers, and 12-13% of smokers reported smoking to alleviate pain. Male CP patients born in 1950-1969 reported the highest peak prevalence of smoking, and female CP patients born in 1970-1989 reported highest peak prevalence of smoking.

CONCLUSION

CP patients exhibit intense and sustained smoking behavior once established in the 20s. Regardless, cohort analyses demonstrate that the behaviors could potentially be altered by policy changes.

Constant-severe pain in chronic pancreatitis is associated with genetic loci for major depression in the NAPS2 cohort

BACKGROUND

Pain is the most debilitating symptom of recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) and often requires chronic opioids or total pancreatectomy with islet autotransplantation to manage. Pain is a complex experience that can be exacerbated by depression and vice versa. Our aim was to test the hypothesis that depression-associated genes are associated with a constant-severe pain experience in RAP/CP patients.

STUDY

A retrospective study was done using North American Pancreatitis Study II (NAPS2) genotyped RAP and CP patients with completed case report forms (n = 1,357). Subjects were divided based on pattern of pain and pain severity as constant-severe pain (n = 787) versus not constant-severe pain (n = 570) to conduct a nested genome-wide association study. The association between reported antidepressant medication use and depression gene loci was tested.

RESULTS

Constant-severe pain was reported in 58% (n = 787) of pancreatitis patients. No differences in sex or alcohol consumption were found based on pain severity. Antidepressant use was reported in 28% (n = 223), and they had lower SF-12 mental quality of life (MCS, p < 2.2 × 10^- 16). Fifteen loci associated with constant-severe pain (p < 0.00001) were found to be in or near depression-associated genes including ROBO2, CTNND2, SGCZ, CNTN5 and BAIAP2. Three of these genes respond to antidepressant use (SGCZ, ROBO2, and CTNND2).

CONCLUSION

Depression is a major co-factor in the pain experience. This genetic predisposition to depression may have utility in counseling patients and in instituting early antidepressant therapy for pain management of pancreatitis patients. Prospective randomized trials are warranted.

CLINICAL TRIALS REGISTRATION

Clinicaltriasl.gov.# NCT01545167.

Low serum trypsinogen levels in chronic pancreatitis: Correlation with parenchymal loss, exocrine pancreatic insufficiency, and diabetes but not CT-based cambridge severity scores for fibrosis

BACKGROUND

Chronic pancreatitis (CP) is a complex inflammatory disorder of the pancreas affecting acinar cells, duct cells, islet cells and inflammatory cells including fibrosis-producing stellate cells. Serum trypsinogen is a biomarkers of acinar cell function.

AIM

To define the degree of correlation between low trypsinogen levels as a marker of acinar cell function and variable features of CP.

METHODS

Serum samples from previously ascertained and well phenotyped case and control subjects from the North American Pancreatitis Study II (NAPS2) were used to measure serum trypsinogen levels in a commercial laboratory. Control samples were used to define normal ranges and compared with levels in CP patients with defined features.

RESULTS

A final cohort of 279 CP patients and 262 controls from the NAPS2 studies were evaluated. In controls trypsinogen had a mean of 34.96 ng/ml and SD = 11.99. Cut-off values for low trypsinogen ranged from <20 to 10 ng/ml and very low trypsinogen at <10 ng/ml. Compared to controls, CP was associated with very low trypsinogen levels (p < 0.0001). Within CP, very low trypsinogen levels correlated with parenchymal loss (pancreatic surgery [p < 0.05]; atrophy with calcifications, [p < 0.001]), EPI (p < 0.01, trend p < 0.001) and diabetes (trend p < 0.01) but not CT-based criteria for fibrosis (pancreatic duct dilation, irregularity, strictures).

CONCLUSIONS

Very low serum trypsinogen levels correlate with measures of acinar cell loss including surgical resection, atrophic-calcific CP, diabetes and functional symptoms EPI but not duct morphology criteria. Serum trypsinogen levels correlate with decreased acinar cell function and therefore have biomarker utility clinical management.

Comparative study for intermediate crystal size of NaI(Tl) scintillation detector

The distinctive features of a well-known NaI(Tl) scintillation detector, by virtue of its crystal size, are experimentally investigated by observing changes in parameters such as intrinsic efficiency (ε_i), photo-peak efficiency (ε_p), resolution, and response function to incident gamma photon energy. This study provides a better understanding for the choice of crystal size of the scintillation detector in Compton scattering experiments. The response function of the NaI(Tl) detector is in the form of an inverse matrix focusing on the retort of the crystal when gamma photons are incident upon it. The response function of the NaI(Tl) detector depends upon the distance between the source and the detector, composition of the material for the crystal itself, photo-fraction, solid angle, incident gamma energy, and geometry of the experimental setup. The factors responsible for broadening of full energy and backscattered peaks are discussed for present investigations. The observed results indicate that the resolution of the detector varies with the incident energy of gamma radiation, and it also depends upon the size of the crystal of the detector. Statistical fluctuations related with the scintillation mechanism are found to be responsible for broadening of instrumental line width (photo-peak). The signal-to-noise ratio and photo-fraction for different crystal sizes of the scintillation detector corrected for efficiency of the detector are also discussed.

Lifetime Drinking History of Persons With Chronic Pancreatitis

AIMS

Cumulative consumption of alcohol and variations of alcohol intake by age are unknown in chronic pancreatitis (CP) patients in North America. This study summarizes the lifetime drinking history (LDH) by physician attribution of alcohol etiology, smoking status and sex in persons with CP.

METHODS

We analyzed data on 193 CP participants who completed the LDH questionnaire in the North American Pancreatitis Continuation and Validation Study (NAPS2-CV). We collected data on frequency of drinking and drinks per drinking day for each drinking phase of their lives. We examined differences in total number of alcoholic drinks and weight of ethanol consumed by physician's assessment of CP etiology, sex and smoking status. We also compared intensity of drinking in 20, 30 and 40s by timing of CP diagnosis.

RESULTS

Persons diagnosed with alcoholic CP consumed median of 34,488 drinks (interquartile range 18,240-75,024) prior to diagnosis of CP, which occurred earlier than in persons with CP of other etiology (47 vs. 52 years). Cumulative drinking was greater in male vs. female patients. Male CP patients with a diagnosis of CP before the age of 45 drank more intensely in their 20s as compared to those with later onset of disease. Current smoking was prevalent (67%) among those diagnosed with alcoholic CP. Twenty-eight percent of patients without physician attribution of alcohol etiology reported drinking heavily in the past.

CONCLUSIONS

Lifetime cumulative consumption of alcohol and prevalence of current smoking are high in persons diagnosed with alcoholic pancreatitis. Intense drinking in early years is associated with earlier manifestation of the disease.

Nutrition and Inflammatory Biomarkers in Chronic Pancreatitis Patients

BACKGROUND

Chronic pancreatitis (CP) patients frequently experience malabsorption and maldigestion, leading to micronutrient and macronutrient deficiencies. Comorbid diabetes and lifestyle habits, such as alcohol consumption, may impact nutrition status.

METHODS

We compared micronutrient antioxidant, bone metabolism, serum protein, and inflammatory marker levels in 301 CP patients and 266 controls with no known pancreatic disease. We analyzed serum prealbumin and retinol binding protein; vitamins A, D, E, and B12; osteocalcin; tumor necrosis factor-α; and C-reactive protein (CRP). We also evaluated biomarkers among subsets of patients, examining factors including time since diagnosis, body mass index, alcohol as primary etiology, diabetes mellitus, vitamin supplementation, and pancreatic enzyme replacement.

RESULTS

After correcting for multiple comparisons, CP patients had significantly lower levels than controls of the following: vitamin A (40.9 vs 45.4 μg/dL) and vitamin E (α-tocopherol [8.7 vs 10.3 mg/L] and γ-tocopherol [1.8 vs 2.2 mg/L]), as well as osteocalcin (7.9 vs 10 ng/mL) and serum prealbumin (23 vs 27 mg/dL). Both patients and controls who took vitamin supplements had higher serum levels of vitamins than those not taking supplements. Compared with controls, in controlled analyses, CP patients had significantly lower levels of vitamins A, D, and E (both α-tocopherol and γ-tocopherol). CP patients also had significantly lower levels of osteocalcin, serum prealbumin, and retinol binding protein, and higher CRP.

CONCLUSIONS

CP patients demonstrated lower levels of selected nutrition and bone metabolism biomarkers than controls. Diabetes and alcohol did not impact biomarkers. Vitamin supplements and pancreatic enzyme replacement therapy improved nutrition biomarkers in CP patients.

Known genetic susceptibility factors for chronic pancreatitis in patients of European ancestry are rare in patients of African ancestry

BACKGROUND

Multiple pathogenic genetic variants are associated with pancreatitis in patients of European (EA) and Asian ancestries, but studies on patients of African ancestry (AA) are lacking. We evaluated the prevalence of known genetic variations in African-American subjects in the US.

METHODS

We studied prospectively enrolled controls (n = 238) and patients with chronic (CP) (n = 232) or recurrent acute pancreatitis (RAP) (n = 45) in the NAPS2 studies from 2000-2014 of self-identified AA. Demographic and phenotypic information was obtained from structured questionnaires. Ancestry and admixture were evaluated by principal component analysis (PCA). Genotyping was performed for pathogenic genetic variants in PRSS1, SPINK1, CFTR and CTRC. Prevalence of disease-associated variants in NAPS2 subjects of AA and EA was compared.

RESULTS

When compared with CP subjects of EA (n = 862), prevalence of established pathogenic genetic variants was infrequent in AA patients with CP, overall (29 vs. 8.19%, OR 4.60, 95% CI 2.74-7.74, p < 0.001), and after stratification by alcohol etiology (p < 0.001). On PCA, AA cases were more heterogeneous but distinct from EA subjects; no difference was observed between AA subjects with and without CP-associated variants. Of 19 A A patients with CP who had pathogenic genetic variants, 2 had variants in PRSS1 (R122H, R122C), 4 in SPINK1 (all N34S heterozygotes), 12 in CFTR (2 CFTR^sev, 9 CFTR^BD, 1 compound heterozygote with CFTR^sev and CFTR^BD), and 1 in CTRC (R254W).

CONCLUSION

Pathogenic genetic variants reported in EA patients are significantly less common in AA patients. Further studies are needed to determine the complex risk factors for AA subjects with pancreatitis.

Recurrent Acute Pancreatitis Significantly Reduces Quality of Life Even in the Absence of Overt Chronic Pancreatitis

OBJECTIVES

The impact of recurrent acute pancreatitis (RAP) on quality of life (QOL) is unknown. We hypothesized that RAP would reduce QOL even in the absence of chronic pancreatitis (CP).

METHODS

Data were pooled from three prospective, cross-sectional studies conducted across 27 U.S. centers (the North American Pancreatitis Studies); these included subjects with chronic pancreatitis (n = 1086), RAP alone (n = 508), and non-disease controls (n = 1025). QOL was measured using the Short Form 12 (SF-12), generating a Physical Component Summary (PCS) and the Mental Component Summary score (MCS). Multivariable regression models were developed to measure the effect of RAP on QOL, the predictors of lower QOL in those with RAP, and the differential effect QOL predictors between CP and RAP.

RESULTS

Compared to controls (51.0 ± 9.4), subjects with RAP (41.1 ± 11.4) and CP (37.2 ± 11.8) had lower PCS (p < 0.01). Subjects with CP had lower PCS compared to those with RAP (p < 0.01). Similarly, MCS was lower among RAP (44.6 ± 11.5) and CP (42.8 ± 12.2) subjects compared to controls (51.7 ± 9.1, p < 0.01). Subjects with CP had lower MCS compared to those with RAP (p < 0.01). After controlling for independent predictors of PCS, RAP was associated with lower PCS (estimate -8.46, p < 0.01) and MCS (estimate -6.45, p < 0.0001) compared to controls. The effect of endocrine insufficiency on PCS was differentially greater among RAP subjects (-1.28 for CP vs. -4.9 for RAP, p = 0.0184).

CONCLUSIONS

Even in the absence of CP, subjects with RAP have lower physical and mental QOL. This underscores the importance of identifying interventions to attenuate RAP before the development of overt CP.

Exploring animal rabies endemicity to inform control programmes in Punjab, India

Previous studies estimate that one-third of the annual global burden of rabies (~20,000 cases) occurs in India. Elimination of canine rabies is essential to reduce this burden. Surveillance of animal cases can assess both the risk to humans and the efficacy of control strategies. The objective of this study was to describe the spatial and temporal occurrence of reported confirmed cases of rabies in animals in Punjab, India, from 2004 to 2014. We analysed passive surveillance data on 556 samples submitted from 2004 to 2014 to GADVASU, Ludhiana, Punjab, India. Regression and time series analyses were conducted to understand seasonal and long-term variation of cases and identify cross-correlation of monthly cases between species. Spatio-temporal analyses assessed spatial autocorrelation of date of reporting, mean geographic centres of disease occurrence and clustering of cases using Kulldorff's space-time permutation statistic. The annual number of submissions and proportion of confirmed cases were consistent throughout 2004-2014. Most submissions (320; 57.6%) were confirmed rabies cases, including dogs (40.6%), buffalo (29.7%) and cattle (23.1%). Regression analysis of monthly cases in dogs showed seasonal variation with significant increases in cases in March and August. Monthly case numbers in buffalo decreased over time. Long-term temporal trend was not detected in dog and cattle cases. Time-series models identified significant cross-correlation between dog and buffalo cases, suggesting that buffalo cases were spillover events from dogs. Significant spatio-temporal variation or clusters of cases were not detected. These results indicate that rabies cases in animals-and therefore, the potential for exposure to humans-were temporally and spatially stable during 2004-2014 in Punjab, India. The endemic nature of rabies transmission in this region demands a coordinated, sustained control programme. This study provides baseline information for assessing the efficacy of rabies control measures and developing seasonally targeted dog vaccination and rabies awareness strategies.

Non-destructive study of wood using the Compton scattering technique

A simple nondestructive method is presented in this study to characterize woods having different densities, thus estimating the size and depth of inhomogeneities in given wood samples using the Compton scattering technique (CST). This technique uses a collimated beam of 662-keV energy from ¹³⁷Cs radioactive source, and the scattered flux is detected by an NaI(Tl) detector. To characterize different wood samples on the basis of their densities, both scattering and transmission experiments were performed. The presence of inhomogeneities such as knots in wood was simulated by drilling cylindrical voids of diameter 9mm in the samples and then filling them with a high-density material (aluminum). Furthermore, different sizes of inhomogeneities (Al cylinders) were filled in the wood samples to estimate the depth and size of the inhomogeneity using the CST. A higher linear correlation (R² ~ 0.96) was found between the scattered intensity and the density of different woods using the CST than that using the transmission (R² ~ 0.83) method by measuring the density range. An increase of 24.6% in the average scattered intensity was observed at the location where the knot was present, and it was found that an inhomogeneity of the order of ~4mm or more could be detected by the CST.

Patient and Disease Characteristics Associated With the Presence of Diabetes Mellitus in Adults With Chronic Pancreatitis in the United States

OBJECTIVES

Diabetes mellitus (DM) is a common complication of chronic pancreatitis (CP). Past studies for DM risk factors in CP have been limited to single centers or highly focused on a single etiology such as alcoholic or hereditary disease. We studied risk factors for DM in a large population of patients with CP of all etiologies enrolled in the North American Pancreatitis 2 studies.

METHODS

Participants (1,171) with CP (n=383 with DM, n=788 without DM) were enrolled prospectively from 26 participating centers. Questionnaires were completed by patients and physicians in a cross-sectional assessment. Patient demographics and disease characteristics were compared for CP with DM vs. without DM. Logistic regression was performed to assess the variables associated with DM diagnosis in a multivariable model.

RESULTS

Diabetics were more likely to be black (P=0.02), overweight, or obese (P<0.001), and with a family history of DM (P=0.0005). CP patients with DM were more likely to have pancreatic calcifications (63% vs. 54%, P=0.002), atrophy (44% vs. 32%, P<0.0001), and prior pancreas surgery (26.9% vs. 16.9%, P<0.0001). In multivariate logistic regression modeling, the strongest risk factors for DM were obesity (odds ratio (OR) 2.8, 95% confidence interval (CI) 1.9, 4.2) and exocrine insufficiency (OR 2.4, 95% CI 1.8, 3.2).

CONCLUSIONS

In this large multicenter cohort of patients with CP, exocrine insufficiency, calcifications, and pancreas surgery conveyed higher odds of having DM. However, the traditional 'type 2 DM' risk factors of obesity and family history were similarly important in conveying risk for DM.

Validation of Demographics, Etiology, and Risk Factors for Chronic Pancreatitis in the USA: A Report of the North American Pancreas Study (NAPS) Group

BACKGROUND/OBJECTIVES

Our aim was to validate recent epidemiologic trends and describe the distribution of TIGAR-O risk factors in chronic pancreatitis (CP) patients.

METHODS

The NAPS-2 Continuation and Validation (NAPS2-CV) study prospectively enrolled 521 CP patients from 13 US centers from 2008 to 2012. CP was defined by definitive changes in imaging, endoscopy, or histology. Data were analyzed after stratification by demographic factors, physician-defined etiology, participating center, and TIGAR-O risk factors.

RESULTS

Demographics and physician-defined etiology in the NAPS2-CV study were similar to the original NAPS2 study. Mean age was 53 years (IQR 43, 62) with 55% males and 87% white. Overall, alcohol was the single most common etiology (46%) followed by idiopathic etiology (24%). Alcohol etiology was significantly more common in males, middle-aged (35-65 years), and non-whites. Females and elderly (≥65 years) were more likely to have idiopathic etiology, while younger patients (<35 years) to have genetic etiology. Variability in etiology was noted by participating centers (e.g., alcohol etiology ranged from 27 to 67% among centers enrolling ≥25 patients). Smoking was the most commonly identified (59%) risk factor followed by alcohol (53%), idiopathic (30%), obstructive (19%), and hyperlipidemia (13%). The presence of multiple TIGAR-O risk factors was common, with 1, 2, ≥3 risk factors observed in 27.6, 47.6, and 23.6% of the cohort, respectively.

CONCLUSION

Our data validate the current epidemiologic trends in CP. Alcohol remains the most common physician-defined etiology, while smoking was the most commonly identified TIGAR-O risk factor. Identification of multiple risk factors suggests CP to be a complex disease.

Morphometric and scanning electron microscopy based identification of Ancylostoma caninum parasites in dog

Ancylostoma caninum, a blood feeding nematode parasite (Family: Ancylostomatidae, Superfamily: Ancylostomatoidea) can cause anaemia, dark reddish-brown to black haemorrhagic diarrhoea, dehydration, wasting and deaths due to heavy blood loss. Adult hook worm parasites recovered from the intestine of a stray dog at the time of necropsy were identified as A. caninum based on morphological characters and morphometric observations involving scanning electron microscopy (SEM). Different developmental stages of hookworm eggs viz. 8 cell stage, morula, gastrula and vermiform were observed during the culture process of faecal sample. High quality SEM photographs showed teeth of dimensions 52.5, 42.3 and 23.5 μm on one side and 55.4, 43.8 and 21.0 μm on the other side along with the presence of characteristic transverse cuticular striations on body surface of A. caninum parasites.

Quality of Life in Chronic Pancreatitis is Determined by Constant Pain, Disability/Unemployment, Current Smoking, and Associated Co-Morbidities

OBJECTIVES

Chronic pancreatitis (CP) has a profound independent effect on quality of life (QOL). Our aim was to identify factors that impact the QOL in CP patients.

METHODS

We used data on 1,024 CP patients enrolled in the three NAPS2 studies. Information on demographics, risk factors, co-morbidities, disease phenotype, and treatments was obtained from responses to structured questionnaires. Physical and mental component summary (PCS and MCS, respectively) scores generated using responses to the Short Form-12 (SF-12) survey were used to assess QOL at enrollment. Multivariable linear regression models determined independent predictors of QOL.

RESULTS

Mean PCS and MCS scores were 36.7±11.7 and 42.4±12.2, respectively. Significant (P<0.05) negative impact on PCS scores in multivariable analyses was noted owing to constant mild-moderate pain with episodes of severe pain or constant severe pain (10 points), constant mild-moderate pain (5.2), pain-related disability/unemployment (5.1), current smoking (2.9 points), and medical co-morbidities. Significant (P<0.05) negative impact on MCS scores was related to constant pain irrespective of severity (6.8-6.9 points), current smoking (3.9 points), and pain-related disability/unemployment (2.4 points). In women, disability/unemployment resulted in an additional 3.7 point reduction in MCS score. Final multivariable models explained 27% and 18% of the variance in PCS and MCS scores, respectively. Etiology, disease duration, pancreatic morphology, diabetes, exocrine insufficiency, and prior endotherapy/pancreatic surgery had no significant independent effect on QOL.

CONCLUSIONS

Constant pain, pain-related disability/unemployment, current smoking, and concurrent co-morbidities significantly affect the QOL in CP. Further research is needed to identify factors impacting QOL not explained by our analyses.

Validation of Romanowsky staining as a novel screening test for the detection of faecal cryptosporidial oocysts

Cryptosporidiosis is an emerging waterborne protozoan disease and one of the major causes of neonatal diarrhea in humans and animals. But the disease remains under diagnosed due to lack of availability of special stains in majority of laboratories at primary health centers. Therefore, it requires a rapid screening test for routine diagnosis in conventional laboratory set up. In this pursuit, the present study was planned. During this study, fecal samples from 100 representative animals randomly selected from 17 out breaks of bovine calf diarrhea, were stained with modified Ziehl Neelsen staining (mZN) and Leishman's stain to demonstrate cryptosporidial oocysts and for routine fecal examination, respectively. By mZN staining, 25 cases confirmed the presence of cryptosporidial oocysts. However, examination of Leishman's stained fecal smears revealed round hollow unstained bodies resembling cryptosporidia in 20 cases. Therefore, a comparative morphometric analysis was made between the two techniques to determine their relative efficacy in demonstrating cryptosporidia in the feces of affected animals. The analyses showed that the Leishman's stain can be effective in making a presumptive diagnosis of cryptosporidiosis with a little experience. Confirmation of cryptosporidiosis was done by histopathological examination of intestinal sections of calves died during these out breaks. The findings appear to have great clinical value for routine laboratory screening of fecal samples for cryptosporidiosis as conventional Romanowsky stains are readily available and used for multipurpose examination in most of the laboratories at grass root level. Perusal of literature proved this to be the first attempt at easy diagnostics for cryptosporidiosis.

Incoherent scattering of gamma photons for non-destructive tomographic inspection of pipeline

A scanner system, operating in a non-destructive and non-invasive way, is presented for pipeline to determine its location in land soil, wall thickness, type of liquid flowing and crack/blockage position. The present experiment simulates a real case where pipe corrosion (wall thinning) under insulation can be known from the study of incoherent scattering of 662 keV gamma photons. The incoherent scattered intensity, obtained by unfolding (deconvolution) the experimental pulse-height distribution of NaI(Tl) scintillation detector with the help of inverse response matrix, provides the desired information. The method is quite sensitive for small change (approximately 1 mm) in the thickness of pipe wall, locating a defect of 1mm width under insulation and a small change (approximately 0.1 gm cm(-3)) in the density of liquid flowing through pipe.

Response function of NaI(Tl) detectors and multiple backscattering of gamma rays in aluminium

The response function, converting the observed pulse-height distribution of a NaI(Tl) detector to a true photon spectrum, is obtained experimentally with the help of an inverse matrix approach. The energy of gamma-ray photons continuously decreases as the number of scatterings increases in a sample having finite dimensions when one deals with the depth of the sample. The present experiments are undertaken to study the effect of target thickness on intensity distribution of gamma photons multiply backscattered from an aluminium target. A NaI(Tl) gamma-ray detector detects the photons backscattered from the aluminium target. The subtraction of analytically estimated singly scattered distribution from the observed intensity distribution (originating from interactions of primary gamma-ray photons with the target) results in multiply backscattered events. We observe that for each incident gamma photon energy, the number of multiply backscattered photons increases with increase in target thickness and then saturates at a particular target thickness called the saturation thickness (depth). Saturation thickness for multiply backscattering of gamma photons is found to decrease with increase in energy of incident gamma-ray photons.

Rabies in South Asia: epidemiological investigations and clinical perspective

A five year study (1995-1999) was conducted in Northern India to investigate epidemiological aspects of rabies in domestic animals. For this purpose, brain tissue samples were collected from rabies suspect animals including 231 dogs, 79 buffaloes, 46 cattle and 28 wild species. Out of the 384 rabies suspected cases, 56% were positive for rabies by fluorescent antibody test (FAT), the mouse inoculation test (MIT) and histopathological techniques. Variations in clinical signs of rabies were recorded for individual animals with significant differences observed between dogs and bovines with respect to hypersalivation, paralysis, recognition of owners and aggression. Likewise, differences in the clinical course of disease between cows and buffaloes regarding hypersalivation and micturition were observed. Rabies incidence was highest among adult male dogs and indicated a seasonal pattern with more rabies cases during certain months of the year (January to April, and August to November). Its impact on cow/buffalo rabies is discussed. Accumulated history records revealed that 78% of owned rabid dogs were not prophylactically vaccinated against rabies.

Recurrent flares of pancreatitis predict development of exocrine insufficiency in chronic pancreatitis

BACKGROUND & AIMS

The natural history of specific morphologic stages of chronic pancreatitis (CP) is not well defined. The aim of this study was to determine if worsening morphologic stages of CP are associated with poorer clinical outcomes.

METHODS

A retrospective analysis of 159 subjects with CP was performed. The baseline stage of CP was categorized according to the Cambridge classification. Pain was categorized as type A (intermittent acute), B (continuous), or combined. Exocrine failure was defined by steatorrhea; endocrine failure was characterized as diabetes mellitus. Complications were defined clinically.

RESULTS

Pancreatic duct (PD) morphology was equivocal in 37.1%, minimal in 12.6%, moderate in 7.5%, and severe in 42.8% of the patients. Over a median follow-up period of 3.7 years, the risk of developing exocrine insufficiency and diabetes was 28% and 19%, respectively. Recurrent acute flares of pancreatitis predicted the development of exocrine insufficiency (P = .004). Severe PD morphology predicted the likelihood of having persistent pain (P = .008). Patients with concurrent type A and B pain and older age at diagnosis had a greater likelihood of having persistent pain (P = .021). The risk of developing bile duct stricture was higher in the advanced morphologic stages of CP (P = .005).

CONCLUSIONS

Recurrent flares of pancreatitis predispose to the development of exocrine insufficiency in CP. Patients with complex-type pain, older age at diagnosis, and advanced morphologic stage are more likely to have persistent pain. PD morphology does not correlate with the risk of developing exocrine failure and/or diabetes. Pain does not necessarily decrease or disappear with the onset of exocrine insufficiency and diabetes.

A management algorithm for esophageal perforation

Despite the prolonged morbidity caused by a major surgery and the high occurrence of continued leakage, primary repair has been the standard treatment for esophageal perforations. We believe that management using removable esophageal stents is both simpler and more effective. Over the past 3 years, we have treated 14 patients using esophageal stents, and the procedure was successful in all patients. Because of the shorter bed rest that follows endoscopic Polyflex stent (Rush, Inc; Teleflex Medical, Duluth, GA) placement, it is very likely that the care of patients with esophageal perforation will be changed over time.

Management Of Primary Sclerosing Cholangitis

Management of primary sclerosing cholangitis (PSC) can be divided into endoscopic, medical, and surgical treatments. Whereas endoscopic therapy is primarily used to manage dominant strictures, medical treatment is directed both at modifying course of the disease and at symptomatic relief. Ursodeoxycholic acid is the most promising disease-modifying agent. Corticosteroids and other immunosuppressive agents do not have a proven role. Cholestyramine and rifampicin improve pruritis but response to these agents cannot be reliably predicted. Opioid antagonists are useful in refractory pruritis. All patients with advanced PSC should be offered bone mineral-density measurement and, if needed, treatment for osteoporosis. These approaches are not mutually exclusive and are often used concurrently or in sequence depending on the clinical situation. Liver transplantation is the only therapy that improves survival. In this review, we discuss the various management options for PSC.

Effect of detector collimator and sample thickness on 0.662MeV multiply Compton-scattered gamma rays

The simultaneous effect of detector collimator and sample thickness on 0.662 MeV multiply Compton-scattered gamma photons was studied experimentally. An intense collimated beam, obtained from 6-Ci (137)Cs source, is allowed to impinge on cylindrical aluminium samples of varying diameter and the scattered photons are detected by a 51 mm x 51 mm NaI(Tl) scintillation detector placed at 90 degrees to the incident beam. The full energy peak corresponding to singly scattered events is reconstructed analytically. The thickness at which the multiply scattered events saturate is determined for different detector collimators. The parameters like signal-to-noise ratio and multiply scatter fraction (MSF) have also been deduced and support the work carried out by Shengli et al. [2000. EGS4 simulation of Compton scattering for nondestructive testing. KEK proceedings 200-20, Tsukuba, Japan, pp. 216-223] and Barnea et al. [1995. A study of multiple scattering background in Compton scatter imaging. NDT & E International 28, 155-162] based upon Monte Carlo calculations.

Norfloxacin and cisapride combination decreases the incidence of spontaneous bacterial peritonitis in cirrhotic ascites

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is a serious complication of cirrhosis with ascites, having high recurrence despite antibiotic prophylaxis. Small bowel dysmotility and bacterial overgrowth have been documented to be related to SBP. The purpose of the present paper was (i) to study whether addition of a prokinetic agent to norfloxacin ameliorates the development of SBP in high-risk patients; and (ii) to identify risk factors for SBP development.

METHODS

A prospective, single blinded, randomized controlled trial was conducted in high-risk cirrhotic patients with ascites who had either recovered from an episode of SBP or who had low ascitic fluid protein. Norfloxacin 400 mg once daily (group I) or norfloxacin 400 mg once daily with cisapride 20 mg twice a day (group II) was given and occurrence of side-effects of therapy and mortality were recorded.

RESULTS

Of the 94 patients, 48 (51%) were in group I, and 46 (49%) in group II. The actuarial probability of developing SBP at 12 month in group I was 56.8% and in group II, 21.7% (P = 0.026). Treatment failure was observed in five patients (10%) in group I and none in group II (P = 0.003). The actuarial probability of death at 18 months was 20.6% in group I and 6.2% in group II (P = 0.1). Low serum albumin, low ascitic fluid protein and alcoholic cirrhosis were related to development of SBP (P < 0.05). Additionally, low serum albumin (2.8 g/dL), gastrointestinal bleeding, alcoholic cirrhosis and low ascitic fluid protein were significantly associated with multiple occurrences of SBP.

CONCLUSIONS

Prophylaxis with norfloxacin and cisapride significantly reduces the incidence of SBP in high-risk cirrhosis patients; low serum albumin, low ascitic fluid protein and alcoholic cirrhosis predispose to the development of SBP in high-risk cirrhosis patients; and low ascitic fluid protein should also be considered as a risk factor for the development of SBP requiring prophylaxis.

Beneficial effects of 'lamivudine pulse' therapy in HBeAg-positive patients with normal ALT*

Currently no therapy is given to patients with chronic hepatitis B virus (HBV) infection who are HBeAg positive with normal alanine aminotransferase (ALT) levels. Steroid priming has been shown to enhance T-helper-1 (Th-1) cell response. Lamivudine may restore immunologic competence against HBV by causing a sudden decline in the level of the virus. We examined the efficacy of lamivudine pulse therapy on the seroconversion from HBeAg to anti-HBe. This was a prospective single-blinded trial including 27 patients with chronic hepatitis B, HBeAg positive with ALT < or =1.5 times upper limit of normal (ULN). Lamivudine was administered initially for 4 weeks, then stopped for 2 weeks and later restarted and continued till 3 months after seroconversion or completion of 2 years of therapy. Twenty-six patients completed the study. Lamivudine withdrawal led to a rise in ALT levels above the ULN in 11 (42.3%) patients at 6 weeks; seven of them (63.6%) lost HBeAg compared with only two of the 15 patients (13.3%), in whom ALT levels did not rise (P = 0.011). As one patient showed a relapse, a total of eight (31%) patients responded to lamivudine pulse therapy over a mean period of 17.3 +/- 4.5 months. Responders had a higher serum albumin (P < 0.05), a lower fibrosis score (P < 0.05), and a relatively high baseline serum ALT levels (P = 0.024) than the nonresponders. YMDD mutations developed in three patients and none responded. No patient developed hepatic decompensation. Hence lamivudine pulse therapy has potential in converting HBeAg-positive, 'not-treat-worthy' (ALT < 1.5 ULN) patients to treat-worthy (ALT > 1.5 ULN) in 42%, with sustained HBeAg and HBV DNA loss in 31% patients. The effects are possibly because of a combination of antiviral and immunomodulating activities of lamivudine.

Achalasia cardia in mother and son

Familial occurrence of achalasia cardia is rare. Most associations are among siblings or in monozygotic twins. Parent-child association is even rarer and only six such instances have been reported till date. We report a 29-year-old man with achalasia cardia and his mother who had the same illness two and half years later. Both of them were successfully treated with balloon dilatation.

Efficacy of endoscopic wire guided biliary brushing in the evaluation of biliary strictures

Endoscopic brush cytology is a valuable technique for the evaluation of biliary strictures. The sensitivity of this technique varies from 30% to 83%, however, it can have specificity of 100%. We retrospectively evaluated the usefulness of wire-guided biliary brush cytology in biliary strictures in our hospital over a 3 years period from 1997 to 2000. Brushings from 58 biliary strictures were obtained during endoscopic retrograde cholangiography. They were compared with histological proof obtained by surgical biopsy or percutaneous fine-needle aspiration cytology and/or clinical findings. These were reported as benign or malignant. Eleven patients were excluded due to incomplete data. Eighteen patients had benign brushings. Fourteen of the 29 patients in whom histological confirmation of malignancy brushings was obtained were also reported as malignant. The sensitivity of endoscopic brushings was 48.2%, specificity 100% and diagnostic accuracy 55.2%. No major complications were seen in our study group.

Pregnancy and liver disease

Liver disease has an impact on women's health during pregnancy because of the complex interactions between the physiologic changes induced by pregnancy and the pathophysiologic changes of liver disease. In particular, liver diseases that predominantly afflict females, such as primary biliary cirrhosis and autoimmune hepatitis, pose a special problem for conception and management of pregnancy. Pregnancy, moreover, specifically is associated with several potentially life-threatening liver diseases. This article reviews comprehensively the impact of liver diseases on pregnancy and of pregnancy on liver function and liver disease.

Considerations for esthetic facial surgery in the African-American patient

Due to the diverse ethnic nature of most communities, the perception of beauty is not homogeneous. Beauty is a perception of good balance, symmetry, harmony, and features that are pleasing to the eye. It is not possible to quantitate beauty. Many attempts have been made to standardize what is and is not beautiful by establishing the ethnic norms. Surgeons commonly attempt to achieve these ideal norms, but they may not necessarily be considered beautiful by the individual patient. Therefore, it is imperative for the surgeon to completely understand the patients' goals for surgery, which may not fit the ideal norms published in studies for that specific ethnic community. It also has become essential for patients to be made aware of the limitations of surgery, especially if their goals are unrealistic, to avert future distress and medicolegal problems. Thus, what is "normal" is not necessarily beautiful, and perhaps it would be better to strive for what is considered beautiful to the individual patient, rather than normal. Within the African-American population, the concept of what is beautiful can be extremely diverse. The number of African Americans who seek cosmetic or esthetic facial surgery is limited. As the number of esthetic procedures performed in the African-American population increases, however, the more educated this population will become regarding these procedures, and the more comfortable the surgeon will become regarding his or her own sense of "African-American beauty" and specific esthetic facial considerations for this population. It should be mentioned that as the number of African-American surgeons increases, their influence within the African-American population regarding the availability of esthetic procedures will also be felt.

Paraganglionoma of extrahepatic biliary tract causing obstructive jaundice

We report a young woman with paraganglionoma arising from the extrahepatic bile duct presenting with acute obstructive jaundice. The patient underwent excision of the gall bladder and extrahepatic bile duct with the tumor, and Roux-en-Y hepaticojejunostomy. She is asymptomatic 9 months later, with normal biochemical investigations and imaging.

Haematological and biochemical studies in broiler chicks fed ochratoxin and inoculated with inclusion body hepatitis virus, singly and in concurrence

Day-old broiler chicks, which had been shown to be negative for maternal antibodies against inclusion body hepatitis (IBH) virus and for viral antigen in cloacal swabs, were divided into four groups of 20 chicks each. One group was fed ochratoxin-A at 0.5 ppm from 3 to 38 days of age, another group was inoculated with 1 ml of IBH virus containing 10(6.5) EID50 per 0.2 ml. A third group was given both ochratoxin-A and infected with IBH virus. The fourth group served as the control. Anaemia was observed in all three treated groups but the changes were more pronounced in the combined group. The biochemical changes also suggested a cumulative damaging effect by ochratoxin-A and IBH virus.

Giant cavernous hemangiomas of liver mimicking metastasis

Most hepatic hemangiomas are small and symptomless. These are now being increasingly diagnosed with the greater use of scanning procedures. Hemangiomas can occasionally grow to a large size and become manifest to the patient and the clinician. Giant hemangiomas can produce symptoms including awareness of abdominal mass, pain due to thrombosis, and very rarely, rupture. Though ultrasound is known to be quite suggestive of the diagnosis, large hemangiomas may be mistaken for liver metastases due to their enormous size and variegated picture on the scanning procedure. Dynamic CT scan and at times MRI may be required for confirmation of the diagnosis. Needle biopsy is contraindicated if the diagnosis is suspected.

Pathological studies in broiler chicks fed aflatoxin or ochratoxin and inoculated with inclusion body hepatitis virus singly and in concurrence

Day-old broiler chicks found negative for maternal antibodies against inclusion body hepatitis (IBH) virus by agar gel precipitation test and viral antigen in cloacal swabs by dot enzyme immunoassay were divided into 6 groups of 20 chicks each. Group A was fed aflatoxin B1 at 1.25 ppm from 3 to 38 days of age; group O was fed ochratoxin A at 0.5 ppm from 3 to 38 days of age; group V was inoculated with 1 ml of IBH virus of titre log10 6.5 EID50 per 0.2 ml. Groups AV and OV were given aflatoxin B1 and ochratoxin A, respectively, and also infected with the virus. Group C served as control. There was mild enlargement and paleness of the liver up to 18 days post inoculation in group V; there were no lesions in group A; and there was gradual enlargement of the kidneys from 10 days post feeding of mycotoxin onwards in group O. In the combined groups AV and OV the gross lesions were slightly more severe. In group V, varying degrees of degenerative histopathological changes, congestion and haemorrhages were seen particularly in the liver, followed by the kidneys, bursa, spleen, myocardium and lungs, along with intranuclear inclusion bodies in the hepatocytes, mostly in the early stages of infection. Similar microscopic changes, but without inclusion bodies, were seen in groups A and O and the changes were pronounced in the later stages. In group O, the kidney lesions were more pronounced than the liver lesions. In the concurrently infected groups, AV and OV, the changes were similar but slightly more marked than in the corresponding individual groups. Inclusion bodies in hepatocytes were more frequent, more prominent and appeared earlier in the concurrent groups.

Sustained release methadone salts and methadone-naloxone mixtures. Part 2: In vitro studies of methadone release

Various tablet formulations, using two methadone salts namely methadone-alpha-naphthalenesulfonate and methadone-o-benzoylbenzoate and a number of methadone-naloxone combinations were prepared. The quantities of methadone released from these tablets in simulated gastric and intestinal fluids were examined using spectrophoto-metric studies. All formulations followed a typical release pattern, indicating a high degree of consistency of the formulations.

Methadone salts. Part 1: preparation and identification

The preparation of two methadone salts, namely: methadone-alpha-naphthalenesulfonate and methadone-o-benzoyl-benzoate is described. The prepared compounds were confirmed by t.l.c. and IR spectroscopic studies.