Endoscopic management of pancreatic collections. Endoscopic Ultrasound Group from the Spanish Society of Digestive Endoscopy (GSEED-USE) Clinical Guidelines

Acute pancreatitis is associated with significant morbidity and mortality. It can develop complications such as fluid collections and necrosis. Infection of necrosis occurs in about 20-40% of patients with severe acute pancreatitis, and is associated with organ failure and worse prognosis. In the past years, the treatment of pancreatic collections has shifted from open surgery to minimally invasive techniques, such as endoscopic ultrasound guided drainage. These guidelines from a selection of experts among the Endoscopic Ultrasound Group from the Spanish Society of Gastrointestinal Endoscopy (GSEED-USE) have the purpose to provide advice on the management of pancreatic collections based on a thorough review of the available scientific evidence. It also reflects the experience and clinical practice of the authors, who are advanced endoscopists or clinical pancreatologists with extensive experience in managing patients with acute pancreatitis.

Training and competence in Digestive Endoscopy: Statement Position Paper from the Spanish Society of Digestive Diseases

Gastrointestinal (GI) Endoscopy is a basic competence for the management of gastrointestinal diseases. However, it should not be regarded as an independent training technique. Rather it is a part of a continuous and accredited process that requires clinical knowledge from the gastroenterologist to keep skills up-to-date in a constantly evolving medical subspecialty. Thus, the only official accredited way for training in GI endoscopy is through the Specialized Health Training program in the Management of the Digestive Diseases administered by the Spanish Ministry of Health.

Training and competence in Digestive Endoscopy: Position Paper from the Spanish Society for Digestive Diseases (SEPD)

Digestive Endoscopy is a basic competence regarding the management of the Digestive System that should be taken as an independent training technique. Learning it is part of an accredited and constant process that requires clinical knowledge from the gastroenterologist to keep skills alive and updated in a constant and rapidly evolving medical subspecialty like this. Therefore, the only official accredited way for training in Digestive Endoscopy is through the Specialized Health Training program in the Management of the Digestive System run by the Spanish Ministry of Health.

Endoscopic ultrasound (EUS) guided fine needle biopsy (FNB) with the Procore™ needle provides inadequate material for the histological diagnosis of early chronic pancreatitis

BACKGROUND

diagnosis of early chronic pancreatitis (CP) is hampered due to the low accuracy of current imaging techniques and the absence of methods for histological confirmation. We aimed to evaluate the efficacy of endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) for the histological diagnosis of early CP.

METHODS

a prospective, cross-sectional, single-center study was designed. Consecutive patients referred for EUS with a clinical suspicion of CP were evaluated for inclusion into the study. Inclusion criteria were age > 18 years and indeterminate EUS findings for the diagnosis of CP according to the Rosemont classification. EUS-FNB of the body of the pancreas was performed with Procore™ needles. Tissue samples were immersed into a methanol-based buffered preservative solution for cytohistological evaluation. The quality of the samples obtained and the histological findings were evaluated. Procedure-related complications were recorded.

RESULTS

the study was stopped after eleven patients were included due to safety concerns and poor diagnostic yield. The mean age of the patients was 50.3 years (range 33-70 years) and six were male. Samples were of poor quality in five cases, but were sufficient for cell-block evaluation. An inflammatory infiltration with mild fibrosis was identified in two cases and neither inflammatory infiltration nor fibrosis was identified in three cases. With regard to the other six cases, isolated inflammatory cells were observed in one case, although the cellularity was poor and unsuitable for cytological evaluation in five cases. There was one major complication (9.1%) of acute pancreatitis that required hospitalization for 48 hours.

CONCLUSION

EUS-FNB is technically feasible in patients with EUS findings categorized as indeterminate for a CP diagnosis. However, the diagnostic yield is poor and there is a non-negligible risk of complications.

The issue of 'molecular radiators' in microwave-assisted reactions. Computational calculations on ring closing metathesis (RCM)

A DFT computational mechanistic study of the ring closing metathesis (RCM) reaction of diallyl ether or N,N-diallyl-p-toluenesulfonamide catalyzed by a second generation Grubbs-type ruthenium carbene complex has been carried out. This study was performed at the PCM(CH2Cl2)-B3LYP/6-311+G(2d,p)//B3LYP/SDD theory level. The aim of this work was to shed light on the influence that microwave irradiation has on these reactions and to gain insight into the so-called 'molecular radiator' effect. The outcomes obtained indicate that thermal effects induced by microwave irradiation decrease the catalytic induction period. The presence of a polar reagent and/or polar species in the reaction that increases the polarity of the medium may enhance this thermal effect.

[Endoscopic ultrasound-guided biopsy for the evaluation of pancreatic tumors]

In the classical approach to pancreatic lesions, the key used to be to exclude malignancy and evaluate tumor resectability and the patient's suitability for surgery. Pancreatic biopsy was rejected because a negative result does not exclude malignancy, the risk of seeding, which could make curative surgery impossible, the low surgical risk of morbidity and mortality, and the high diagnostic efficacy of imaging techniques. In this context, pancreatic biopsy was limited to irresectable tumors, and cases with suspicion of tuberculosis, lymphoma, neuroendocrine tumors or cystic tumors. Currently, pancreatic biopsy is becoming essential for the correct management of all types of pancreatic lesions, improving therapeutic management. Endoscopic ultrasound-guided biopsy has been proven to be safe, with a low complications rate, and with higher diagnostic efficacy than that of other procedures and is probably the technique of choice for the study of pancreatic lesions.

[Intraductal papillary mucinous tumor: diagnostic and therapeutic approach]

Primary cystic pancreatic neoplasms are rare tumors, with an approximate prevalence of 10% of cystic pancreatic lesions. Most of these lesions correspond to mucinous cystic neoplasm, serous cystoadenoma and intraductal papillary mucinous tumor (IPMT). IPMT is characterized by diffuse dilatation of the main pancreatic duct and/or side branches with inner defects related to mucin or tumor, or mucin extrusion from a patent ampulla. IPMT has a low potential for malignancy, with a low growth rate, a low rate of metastatic spread and postsurgical recurrence. Over the last few years, major advances have been made in the diagnostic and therapeutic management of this tumor.

Are AM1 ligand-protein binding enthalpies good enough for use in the rational design of new drugs?

We have examined the performance of semiempirical quantum mechanical methods in solving the problem of accurately predicting protein-ligand binding energies and geometries. Firstly, AM1 and PM3 geometries and binding enthalpies between small molecules that simulate typical ligand-protein interactions were compared with high level quantum mechanical techniques that include electronic correlation (e.g., MP2 or B3LYP). Species studied include alkanes, aromatic systems, molecules including groups with hypervalent sulfur or with donor or acceptor hydrogen bonding capability, as well as ammonium or carboxylate ions. B3LYP/6-311+G(2d,p) binding energies correlated very well with the BSSE corrected MP2/6-31G(d) values. AM1 binding enthalpies also showed good correlation with MP2 values, and their systematic deviation is acceptable when enthalpies are used for the comparison of interaction energies between ligands and a target. PM3 otherwise gave erratic energy differences in comparison to the B3LYP or MP2 approaches. As one would expect, the geometries of the binding complexes showed the known limitations of the semiempirical and DFT methods. AM1 calculations were subsequently applied to a test set consisting of "real" protein active site-ligand complexes. Preliminary results indicate that AM1 could be a valuable tool for the design of new drugs using proteins as templates. This approach also has a reasonable computational cost. The ligand-protein X-ray structures were reasonably reproduced by AM1 calculations and the corresponding AM1 binding enthalpies are in agreement with the results from the "small molecules" test set.

Improvement of ligand economy controlled by polymer morphology: the case of polymer-supported bis(oxazoline) catalysts

A functionalized chiral bis(oxazoline) is used as a chiral monomer in polymerization reactions leading to homo- and copolymers of different morphology. Polymers with a high content of chiral monomer lead to enantioselectivities that are higher than those obtained with the soluble ligand, but the chiral ligand is not used in an optimal way. A hyperbranched polymer, obtained by using a hexavinyldendrimer as the cross-linker, leads to the same enantioselectivities with a more efficient use of the chiral ligand.

Bis(oxazoline)copper complexes covalently bonded to insoluble support as catalysts in cyclopropanation reactions

Chiral bis(oxazolines) are readily dialkylated in the methylene bridge, opening the way to immobilization at that position, keeping the C(2) symmetry of the chiral ligand. Bis(oxazolines) functionalized with two allyl or vinylbenzyl groups are easily grafted onto mercaptopropylsilica. Another approach to immobilization is the polymerization of the ligands bearing vinylbenzyl groups to yield insoluble polymers. The Cu(OTf)(2) complexes of the immobilized ligands promote the enantioselective cyclopropanation reaction between styrene and ethyl diazoacetate. The results depend on the nature of the support and the method of immobilization. With regard to the type of solid, the best results, which are similar to or even better than those obtained with the corresponding dibenzylated homogeneous catalysts, are obtained with homopolymers. With regard to the bis(oxazoline), that bearing indan groups leads to good results both onto silica and polymers, whereas with the ligand bearing tert-butyl groups good enantioselectivities are only obtained with homopolymeric catalysts. Some of the heterogeneous catalysts can be easily recovered and reused, as much as five times, with the same yield and stereoselectivities.

Theoretical (DFT) insights into the mechanism of copper-catalyzed cyclopropanation reactions. Implications for enantioselective catalysis

The mechanism of the copper(I)-catalyzed cyclopropanation reaction has been extensively investigated for a medium-size reaction model by means of B3LYP/6-31G(d) calculations. The starting ethylene complex of the N,N'-dimethylmalonaldiimine--copper (I) catalyst undergoes a ligand exchange with methyl diazoacetate to yield a reaction intermediate, which subsequently undergoes nitrogen extrusion to generate a copper--carbene complex. The cyclopropanation step takes place through a direct carbene insertion of the metal--carbene species to yield a catalyst--product complex, which can finally regenerate the starting complex. The stereochemical predictions of a more realistic model (by considering a chiral bis(oxazoline)--copper (I) catalyst) have been rationalized in terms of steric repulsions, showing good agreement with experimental data.

Do secondary orbital interactions really exist?

A revision of the most typical examples used to illustrate the existence of secondary orbital interactions (SOI) has been achieved. However, our analysis indicates that no conclusive evidence can be obtained from these cases. All five examples proposed by Woodward and Hoffmann in The Conservation of Orbital Symmetry have been revisited. A combination of well-known mechanisms (such as solvent effects, steric interactions, hydrogen bonds, electrostatic forces, and others) can be invoked instead to justify the endo/exo selectivity of Diels-Alder reactions.

Distribution of Pb, V, Cr, Ni, Cd, Cu and Fe in particles formed from the combustion of waste oils

The determination of Pb, V, Cr, Ni, Cd, Cu and Fe in particles of different size obtained from the combustion of waste oils has been carried out. The study consists of the separation of several fractions according to the size of particles, the wet digestion and the individual analysis by graphite furnace atomic absorption spectrometry of the mentioned metals. Taking into account the volatilization temperature of different compounds containing the metals and their distribution on the size fractions, the mineral speciation of metals is proposed.

Isolation of a cDNA encoding the rat MAP-kinase homolog of human p63mapk

Using a combination of screening, RACE, and RT-PCR, we have isolated a new rat brain cDNA, we refer to as rMNK2, that showed strong homology to known MAP-kinases. The deduced amino acid sequence of rMNK2 indicated that it is the rat homolog of human p63(mapk), showing 94.5% identity. rMNK2 showed 77% homology with rat ERK3 and its human homolog p97(mapk), and 43% homology with both rat genes rMNK1(ERK1) and ERK2, within the kinase domain. This suggest that rMNK2 and ERK3 belong to a separate subfamily within the rat MAP-kinase multigene family. The most interesting difference lies in subdomain VIII, where this new subfamily contain a SEG/SPR motif instead of the TEY/APE found in the ERK subfamily, the TPY/APE found in the JNK/SAPK subfamily or the TGY/APE found in the p38/RK subfamily. The human homologs of ERK3 and rMNK2 (p97(mapk) and p63(mapk)) also show this significant change. Expression of rMNK2 has been detected in brain and to a lesser extent in lung by reverse transcription/PCR (RT-PCR). In situ hybridization of rat brain slices demonstrated a restricted expression of rMNK2 in the choroid plexus and hippocampus. This is interesting because the human homolog p63(mapk) maps to 18q12-21, a region that might be implicated in manic-depressive illness.

Clinical expression of secondary syphilis in a patient with HIV infection

There are increasing reports of unusual clinical features and atypical courses of syphilis in patients with acquired immunodeficiency syndrome. Recently, we had the opportunity to study an HIV-positive female patient with strong manifestations of secondary syphilis. The case is discussed together with the implications of secondary syphilis in her concomitant ocular affliction. Moreover, we comment on the clinico-therapeutic controversies brought about by the association of infection with Treponema pallidum and HIV.

[Newborn of diabetic mother. Glucose in amniotic fluid and clinical conditions (author's transl)]

Clinical and analytical data of sixteen newborns of insulin dependant mothers are studied. Relation between these data and newborn conditions as Apgar score and hypoglicemia are considered.