Real-world effectiveness and safety of vedolizumab induction therapy for ulcerative colitis: A prospective nationwide Polish observational study

BACKGROUND

Vedolizumab is recommended as a first-line biological treatment, along with other biological drugs, in ulcerative colitis (UC) patients in whom conventional therapy failed and as a second-line biological treatment following a failure of a tumor necrosis factor alpha (TNF-α) antagonist.

OBJECTIVES

We aimed to assess the real-world effectiveness and safety of vedolizumab induction therapy in UC patients treated in the scope of the National Drug Program (NDP) in Poland.

MATERIAL AND METHODS

The endpoints were the proportions of patients who reached clinical response, clinical remission and mucosal healing at week 14. Partial Mayo scores, Mayo subscores and C-reactive protein (CRP) levels were also evaluated.

RESULTS

Our study population consisted of 100 patients (55 biologic-naïve and 45 biologic-exposed). The median total Mayo score at baseline was 10 (interquartile range (IQR): 9-11), and 52 patients (52%) had extensive colitis. The clinical response at week 14 was achieved in 83 (83%) and clinical remission in 24 (24%) cases. Mucosal healing was observed in 56 (62%) patients at week 14. In patients with prior failure of biologic treatment (n = 25), 17 (68%) responded to vedolizumab treatment. A decrease in the median CRP level (from 3.7 mg/L to 2.6 mg/L) and the median total Mayo score (from 10 to 4) was observed. No new safety concerns were recorded and no patients discontinued the treatment due to adverse events (AEs).

CONCLUSIONS

Vedolizumab was effective and safe as induction therapy for UC in a Polish real-world population including patients with severely active UC and a low number of patients with prior biological treatment failures.

Successful Use of an Exclusion Diet with Partial Enteral Nutrition in a Patient After Total Gastrectomy: A Case Report

BACKGROUND Gastric cancer is the 5th most common malignancy worldwide. Treatment consists of excision of the entire stomach. Malnutrition is a common problem in patients diagnosed with gastric cancer and has a negative impact on the course of treatment and the quality of life. CASE REPORT The paper presents a case report of a patient after total gastrectomy performed on 11/04/2016 due to G3 mucocellulare carcinoma. The patient had been on home parenteral nutrition for 2.5 years due to chronic malnutrition. After this period of time, an attempt was made to introduce an exclusion diet with the addition of Modulen IBD (Nestle Health Science), which is routinely used in the nutritional treatment of patients with Crohn's disease, with simultaneous discontinuation of parenteral nutrition. After 3 months, the patient was readmitted to the hospital to assess his nutritional status. He continued the diet as recommended. He maintained his body weight and reported improvement in eating habits. CONCLUSIONS In the described case, the patient presented with symptoms of impaired bowel function resulting from long-term cessation of oral nutrition. It is possible that the nutritional and immunomodulatory effect of Modulen, in combination with the anti-inflammatory elimination diet, resulted in better nutrition of intestinal epithelial cells and gradual improvement of intestinal motility and absorption, which in turn enabled the patient to completely withdraw from parenteral nutrition. We propose that this type of nutritional management could also be considered in other cases of intestinal dysfunction.

Real-world outcomes of 54-week vedolizumab therapy and response durability after treatment discontinuation in ulcerative colitis: results from a multicenter prospective POLONEZ study

Background

Vedolizumab is a gut-selective anti-lymphocyte trafficking agent used to treat ulcerative colitis (UC) and Crohn's disease.

Objectives

We aimed to evaluate the effectiveness, safety, and durability of the therapeutic effect of vedolizumab after treatment discontinuation in a real-world cohort of patients with UC treated in Poland.

Design

This was a multicenter, prospective study involving patients with moderate to severely active UC from 12 centers in Poland who qualified for reimbursed treatment with vedolizumab between February and November 2019.

Methods

The primary endpoints were clinical response (⩾2-point improvement from baseline on partial Mayo score) and clinical remission (partial Mayo score 0-1), including steroid-free remission, at week 54. Other outcomes included response durability at 26 weeks after treatment discontinuation, identification of predictors of response and remission, and safety assessment.

Results

In all, 100 patients with UC were enrolled (55 biologic naïve and 45 biologic exposed). At baseline, 68% of patients were on corticosteroids and 45% on immunomodulators. Clinical response was observed in 62% of patients, clinical remission in 50%, and steroid-free remission in 42.6% at week 54. Within 26 weeks after treatment discontinuation, 37% of patients who maintained response by week 54 relapsed. The decreased number of liquid stools and rectal bleeding and endoscopic response at week 14 were predictive factors for response at week 54. Time from diagnosis ranging 2-5 years, decreased stool frequency, and non-concomitant use of corticosteroids at baseline and at week 14 were predictive factors for remission at week 54. Partial Mayo score < 3 with no subscale score > 1 at week 54 was a predictive factor for durable response after treatment discontinuation. The rate of serious adverse events related to treatment was 3.63 per 100 patient-years.

Conclusion

Vedolizumab is effective and safe in UC treatment in Polish patients. However, the relapse rate after the treatment cessation was high.

Registration

ENCePP (EUPAS34119).

Mucosal p-STAT1/3 correlates with histologic disease activity in Crohn's disease and is responsive to filgotinib

The validity and relevance of histologic disease activity in Crohn's disease (CD) is unclear, owing to disconnects with endoscopic pathology. Here, we explore relationships between endoscopic, histologic, and molecular activity. This post hoc analysis of the Phase 2 FITZROY trial (NCT02048618) assessed baseline and week 10 (W10) inflammation across matched ileal and colonic segments in CD patients receiving filgotinib 200 mg (n = 42) vs placebo (n = 18). Macroscopic and microscopic disease were assessed by Simple Endoscopic Score for CD ulceration subscore (uSES-CD) and Global Histologic Activity Score activity subscore (aGHAS), respectively. Molecular activity was quantified by phosphorylated signal transducer and activator of transcription (pSTAT)1 and pSTAT3 in epithelium and nonepithelium. Segments were classified as "low" or "high" activity; correlations and concordance were calculated. Logistic regression identified W10 outcome predictors. Overall, 300 segments in 60 patients were assessed. Baseline uSES-CD and aGHAS correlations were 0.72 and 0.53 in colon and ileum, respectively. pSTAT levels had poor-to-moderate concordance with uSES-CD (κ range, 0.11-0.49) but moderate-to-good concordance with aGHAS (0.43-0.77). With filgotinib vs placebo, uSES-CD and aGHAS decreased in significantly more segments with high baseline uSES-CD and aGHAS, and significantly more segments with high baseline pSTAT improved at W10. pSTAT1 was more sensitive to change than uSES-CD and aGHAS. Low baseline pSTAT3 in colon nonepithelium predicted W10 low uSES-CD (P = .044). There was better concordance between histologic and molecular disease activity associated with higher sensitivity to change vs endoscopic severity in ileocolonic CD. Our results suggest histologic activity be included in the assessment of CD inflammatory burden.

Profile of homeless people in emergency departments

OBJECTIVES

For homeless people, emergency departments (ED) are the place of medical care and satisfying physiological, safety and social needs. The treatment of the homeless in EDs is a common issue in many countries. The aim of study was to analyze selected parameters of health care to homeless people in EDs. The authors examined the frequency and the seasonality of admissions, their causes, stay duration, insurance status, and the type of radiological diagnostics performed.

MATERIAL AND METHODS

A retrospective analysis of stays of homeless patients in 3 EDs in one of the largest cities in Poland in 2013-2015 was carried out. Patients were qualified to the population of homeless people based of their registering in ED. Data was obtained on the total number of homeless patients' stays in all 3 EDs, which amounted to 3133.

RESULTS

During the 3 years of analysis: 1042 homeless individuals were identified staying 3133 times in EDs; 46.3% of the stays concerned uninsured homeless people; 31% were under influence of alcohol. On average, men used ED services 3 times, while women only twice. No significant seasonality of admissions was observed. Homeless people were admitted mainly for mental disorders and head injuries. Radiological tests were performed 1577 times, including 83% being CT scans. On average, women and those >30 stayed in EDs for the shortest time. The hospital wards admitted 9.3% of the patients.

CONCLUSIONS

Almost half of homeless patients repeatedly use ED services, regardless of the season. A patient's stay typically lasts 6 h. Half of them were uninsured. The main reasons for admission include mental and behavioral disorders, mostly due to alcohol use and head injuries. The primary radiological diagnostics used were CT scans. Int J Occup Med Environ Health. 2022;35(2):157-67.

Guidelines for the management of patients with Crohn's disease. Recommendations of the Polish Society of Gastroenterology and the Polish National Consultant in Gastroenterology

This paper is an update of the diagnostic and therapeutic recommendations of the National Consultant for Gastroenterology and the Polish Society of Gastroenterology from 2012. It contains 46 recommendations for the diagnosis and treatment, both pharmacological and surgical, of Crohn's disease in adults. The guidelines were developed by a group of experts appointed by the Polish Society of Gastroenterology and the National Consultant in the field of Gastroenterology. The methodology related to the GRADE methodology was used to assess the quality and strength of the available recommendations. The degree of expert support for the proposed statement, assessment of the quality of evidence and the strength of the recommendation was assessed on a 6-point Likert scale. Voting results, quality and strength ratings with comments are included with each statement.

A 39-Year-Old Woman with Cervicofacial and Mediastinal Emphysema 10 Hours After an Elective Lower Molar Dental Extraction

Patient: Female, 39-year-old

Final Diagnosis: Pneumodeiastinum

Symptoms: Chest discomfort • dyspnea • oedema of the face

Medication: —

Clinical Procedure: Antibiotics • CT scan

Specialty: Critical Care Medicine

Characteristics of patients with moderate-to-severe ulcerative colitis treated with vedolizumab: results from a Polish multicenter, prospective, observational real-life study (the POLONEZ study)

BACKGROUND

Vedolizumab, a humanized antibody targeting the α₄β₇ integrin, was proven to be effective in the treatment of moderate-to-severe ulcerative colitis (UC) in randomized clinical trials. The aim of the POLONEZ study is to determine the demographic and clinical characteristics of the patients with UC treated with vedolizumab within the scope of the National Drug Program in Poland and to assess the real-world effectiveness and safety of vedolizumab in the study population. Here we report the demographic and clinical characteristics of these patients.

METHODS

This prospective study included adult patients eligible for UC treatment with vedolizumab who were recruited from 12 centers in Poland between February and November 2019. Collected data included sex, age, disease duration, presence of extraintestinal manifestations or comorbidities, status of previous biologic treatment, and current concomitant treatment. Disease extent was determined according to the Montreal classification, and disease activity was measured with the Mayo Score.

RESULTS

A total of 100 (55 biologic-naïve and 45 biologic-exposed) patients were enrolled in the study (51% female, median age 35 years). Among biologic-exposed patients (mostly infliximab-treated), 57% had failed to respond to the therapy. The disease duration was significantly shorter in biologic-naïve (median 5 years) than in biologic-exposed (8 years, p = 0.004) or biofailure patients (7 years, p = 0.04). In the overall population the median Total Mayo Score was 10. Disease extent and activity were similar between the subgroups.

CONCLUSIONS

Our study indicates that patients treated with vedolizumab in Poland receive the drug relatively early after UC diagnosis, but their disease is advanced. More than half of the patients had not been treated with biologic drugs before initiating vedolizumab. The study was registered in ENCePP database (EUPAS34119).

LAY SUMMARY

Characteristics of patients treated for ulcerative colitis with vedolizumab in Poland Treatment of moderate-to-severe ulcerative colitis (UC) with the integrin antagonist vedolizumab became available within the Polish National Drug Program (NDP) in 2018. In this study, for the first time, we provide detailed demographic and clinical characteristics of 100 patients (median age 35 years, 51% female) treated with vedolizumab in Poland, of whom 55 were biologic-naïve and 45 biologic-exposed. The median duration of disease was 6 years. The disease duration was shorter in biologic-naïve than in biologic-exposed patients. Most patients were affected by extensive colitis (52%) or left-sided colitis (42%). Median disease activity was 10 according to the Total Mayo Score. Sixty-eight patients received concomitant systemic corticosteroids and 45 patients received immunomodulators. Our findings indicate that Polish patients receiving vedolizumab have a high disease activity and are treated relatively early after UC diagnosis. This might be due to the criteria for inclusion of a patient in the NDP.

Long-Term Safety and Efficacy of the Anti-Mucosal Addressin Cell Adhesion Molecule-1 Monoclonal Antibody Ontamalimab (SHP647) for the Treatment of Crohn's Disease: The OPERA II Study

BACKGROUND

Patients with Crohn's disease (CD) experience intestinal inflammation. Ontamalimab (SHP647), a fully human immunoglobulin G2 monoclonal antibody against mucosal addressin cell adhesion molecule-1, is a potential novel CD treatment. OPERA II, a multicenter, open-label, phase 2 extension study, assessed the long-term safety and efficacy of ontamalimab in patients with moderate-to-severe CD.

METHODS

Patients had completed 12 weeks of blinded treatment (placebo or ontamalimab at 22.5, 75, or 225 mg subcutaneously) in OPERA (NCT01276509) or had a clinical response to ontamalimab 225 mg in TOSCA (NCT01387594). Participants received ontamalimab at 75 mg every 4 weeks (weeks 0-72), then were followed up every 4 weeks for 24 weeks. One-time dose reduction to 22.5 mg or escalation to 225 mg was permitted at the investigator's discretion. The primary end points were safety and tolerability outcomes. Secondary end points included changes in serum drug and biomarker concentrations. Efficacy end points were exploratory, and used non-responder imputation methods.

RESULTS

Overall, 149/268 patients completed the study. The most common adverse event leading to study discontinuation was CD flare (19.8%). Two patients died; neither death was considered to be drug related. No dose reductions occurred; 157 patients had their dose escalated. Inflammatory biomarker concentrations decreased. Serum ontamalimab levels were consistent with known pharmacokinetics. Remission rates (Harvey-Bradshaw Index [HBI] ≤ 5; baseline, 48.1%; week 72, 37.3%) and response rates (baseline [decrease in Crohn's Disease Activity Index ≥ 70 points], 63.1%; week 72 [decrease in HBI ≥ 3], 42.5%) decreased gradually.

CONCLUSIONS

Ontamalimab was well tolerated; treatment responses appeared to be sustained over 72 weeks.ClinicalTrials.gov ID: NCT01298492.

Long-term Safety and Efficacy of the Anti-MAdCAM-1 Monoclonal Antibody Ontamalimab [SHP647] for the Treatment of Ulcerative Colitis: The Open-label Study TURANDOT II

BACKGROUND AND AIMS

Ontamalimab, a fully-human monoclonal antibody targeting MAdCAM-1, induced remission in patients with moderate-to-severe ulcerative colitis [UC] in the TURANDOT study. We aimed to assess long-term safety, tolerability, and efficacy of ontamalimab in TURANDOT II.

METHODS

TURANDOT II was a phase 2, multicentre, open-label [OL] study in patients with moderate-to-severe UC who completed TURANDOT on placebo or ontamalimab (NCT01771809). Patients were randomised to 75 mg or 225 mg ontamalimab every 4 weeks for 72 weeks [OL1]. The dosage could be increased to 225 mg from Week 8 at the investigator's discretion. All patients then received 75 mg every 4 weeks for 72 weeks [OL2], followed by 6-month safety follow-up. The primary objective was safety, measured by adverse events [AEs], serious AEs [SAEs], and AEs leading to withdrawal. Mucosal healing [MH; centrally read endoscopy] was assessed.

RESULTS

Of 330 patients, 180 completed OL1; 94 escalated to 225 mg; 127 completed OL2. Overall, 36.1% experienced drug-related AEs. The most common SAE [10.0%] was worsening/ongoing UC; 5.5% of patients had serious infections, the most common being gastroenteritis [0.9%]. One death and four cancers [all unrelated to ontamalimab] occurred. No PML [progressive multifocal leukoencephalopathy]/lymphoproliferative disorders occurred. Geometric mean high-sensitivity C-reactive protein [hsCRP] and faecal calprotectin decreased across OL1 in both dose groups. The proportion of patients assigned to placebo in TURANDOT achieving MH increased from 8.8% [6/68] at baseline to 35.3% at Week 16 [24/68; non-responder imputation]. The corresponding increase in the ontamalimab group was from 23.3% [61/262] to 26.7% [70/262].

CONCLUSIONS

Ontamalimab was well tolerated up to 144 weeks in patients with moderate-to-severe UC, with good safety and efficacy.

Affective temperament in inflammatory bowel diseases: Another brick in the wall of differentiation

Psychiatric disorders are significantly common complications among patients suffering from inflammatory bowel diseases (IBD). Affective temperament is a concept of core personality traits, which can decribe the vulnerability to mood disorders, therefore its evaluation might convey useful information about patients' mental status in autoimmune disorders. The aim of the study was to evaluate the affective temperament in patients with Crohn's disease (CD) and ulcerative colitis (UC) as characteristic features of these diseases, but also in the clinical course and the severity of anxiety and depression.Due to our knowledge this is the first study of this kind. The study enrolled 130 patients with IBD, including 68 with CD and 62 with UC. We used TEMPS-A to evaluate affective temperament and HADS scales to assess the intensity of depressive and anxiety symptoms. Harvey Bradshaw scale, Crohn’s Disease Activity Index (CDAI) and Mayo Score were used to evaluate clinical severity of the diseases. We observed significantly higher prevalence of depressive, cyclothymic and anxiety temperaments in CD patients compared to the control group. Harvey Bradshaw scale, CDAI and Mayo Self Report showed statistically significant outcomes, including significant positive correlations with depressive, cyclothymic and anxiety subscales of TEMPS-A, and negative correlation with the hyperthymic temperament in CD subjects. Our findings indicate significant differences between CD and UC due to temperament traits, and suggest distinct pathogenesis of mood disorders in IBD.

Cardiac and autonomic function in patients with Crohn's disease during remission

PURPOSE

The aim of the study was to assess cardiac and autonomic function in patients with Crohn's disease and explore their relation to disease duration using cardiovascular reflex tests.

MATERIALS AND METHODS

Cardiovascular parameters, baroreflex sensitivity, spectral-indices of short-term heart rate variability and blood pressure variability were compared between patients with Crohn's disease in remission (n = 30) and a control group (n = 29). Cardiac autonomic function was assessed during response to standing (tilt) and deep breathing test (expiration/inspiration ratio-E/I). Aortic pulse wave velocity, aortic augmentation index and central systolic blood pressure were measured oscillometrically.

RESULTS

At rest, Crohn's disease patients had significantly higher systolic (p = 0.03) and diastolic (p = 0.03) blood pressure, total peripheral resistance index (p = 0.003), sympathetic-parasympathetic ratio (p = 0.033) and lower baroreceptor effectiveness (p = 0.047), myocardial variables (stroke index; p = 0.03, cardiac index; p = 0.025, Heather index; p = 0.039, left ventricular ejection time; p = 0.038), as compared to controls. Orthostatic response to the tilt test in the Crohn's disease group and the control group was similar, no intergroup differences were observed for E/I ratio and autonomic parameters. In Crohn's disease patients, disease duration was negatively associated with baroreflex sensitivity and positively correlated with normalised high frequency heart rate variability, sympathetic-parasympathetic ratio at rest and post-tilt changes in Δsystolic blood pressure, p < 0.05. The control group had significantly lower central systolic blood pressure (p = 0.043) compared to Crohn's disease patients.

CONCLUSIONS

Crohn's disease patients in remission have preserved cardiac and autonomic function in response to cardiovascular reflex tests with a shift in cardiovascular autonomic regulation towards sympathetic predominate in the rest position.

Possible undertreatment of women with Crohn disease in Poland. A subgroup analysis from a prospective multicenter study of patients on anti-tumor necrosis factor therapy

INTRODUCTION    In Poland, anti-tumor necrosis factor (TNF) therapy for Crohn disease (CD) is reimbursed in inflammatory disease (CD activity index [CDAI] >300 points) or perianal disease, in cases where conventional treatment has failed.  OBJECTIVES    We assessed patients receiving TNF inhibitors to establish how limited access to the therapy influences the selection of the population for treatment. PATIENTS AND METHODS    Consecutive adult patients with CD starting infliximab or adalimumab in the years 2014 to 2015 were included in the study. Age at symptom onset and diagnosis of CD, disease location and behavior, previous treatment, CDAI, and body mass index (BMI) were evaluated. Subsequently, the age and sex of all patients with CD on anti‑TNF therapy reimbursed by the Polish National Health Fund were analyzed. RESULTS    Among 256 patients, there were 113 women (44.1%) and 143 men (55.9%). The median time from diagnosis to enrollment was longer in women than in men (9 years vs 5.5 years; P = 0.02), and the proportion of women receiving TNF inhibitors for 5 years or less since diagnosis was lower than that of men (42.5% vs 57.7%; P = 0.017). Disease locations, behavior, and CDAI were similar between the groups, while the median BMI was lower in women than in men (20.6 kg/m2 vs 22.6 kg/m2; P = 0.01). In Poland in general, in the years 2010 to 2015, TNF inhibitors for CD were taken by fewer women than men (2208 vs 4789; 46%; 95% confidence interval, 45-48). The median age of treated women was 29 years and that of men-27 years (P <0.001). CONCLUSIONS    Compared with their male counterparts, women with CD receive TNF inhibitors less frequently, at an older age, and following a longer disease duration. It is unknown whether this is a regional or more widespread phenomenon.

Blood glucose and lipid concentrations after overload are not associated with the risk of alcohol relapse

AIMS

There is evidence for the functioning of feedback between alcohol consumption and fat (positive) and carbohydrate (negative) intake. We tried to verify the hypothesis that blood glucose and lipid concentration in a fasting state and after loading may affect the risk of relapse in alcohol-dependent male patients during withdrawal therapy.

METHODS

Blood glucose, total cholesterol (TC) and triglycerides (TG) were determined at the beginning of the study, and again after 4 weeks and 6 months of observation in 54 alcohol-dependent male patients treated against drinking relapse. Glucose concentration was checked after fasting and 2h after loading with a 75 g water solution of glucose, and blood lipids were determined on an empty stomach and 5h after butter loading (0.5 g of butter per kilogram of body mass).

RESULTS

Patients who relapsed compared to subjects who remained abstinent during the 6-month observation did not differ significantly in relation to blood glucose, TC or TG blood concentrations, either in a fasting state or after loading. Patients with an initial above-median increase in TG blood concentration after butter loading (>38%) before the beginning of the study, and who smoked cigarettes with a greater content of nicotine and tar, preferred vodka and had lower values of aminotransferases.

CONCLUSION

Fasting and postprandial blood glucose, TC and TG concentrations had no relationship with the outcome of anti-relapse treatment. However, they presented some associations with the pathomechanism of addiction to nicotine.

Contrast-enhanced Ultrasound for Detection of Crohn's Disease Activity: Systematic Review and Meta-analysis

BACKGROUND AND AIMS

Reports on imaging of active Crohn's disease (aCD) using contrast-enhanced ultrasound (CEUS) are encouraging. However, the statistical power of most published papers is limited due to the small size of the patient groups included. This study was performed to verify the diagnostic value of CEUS in detecting aCD.

METHODS

A systematic literature search was performed by two independent reviewers for articles on the test characteristics of CEUS for the identification of aCD. The quality of the analysed studies was evaluated using a quality assessment tool for diagnostic accuracy studies (QUADAS-2). Pooling was performed using a diagnostic random-effect model and bivariate analysis.

RESULTS

Eight articles were included in the final analysis, with a total of 332 patients. There was no significant publication bias. Significant heterogeneity was found regarding CEUS methodology and sonographic definitions of aCD. In a bivariate analysis, pooled sensitivity was 0.94 (95% CI 0.87-0.97) and pooled specificity was 0.79 (95% CI 0.67-0.88). Spearman correlation statistics presented no significant diagnostic threshold effect (r = 0.12, p > 0.9). Subgroup analysis showed that relative intestine wall enhancement had the highest diagnostic value (area under the curve 94%), while the presence of enhancement and analysis of the slope were less useful (area under the curve 91 and 90%, respectively).

CONCLUSIONS

CEUS presents good sensitivity and moderate specificity in the detection of the aCD. Large-scale randomized trials with quantitative evaluation of CEUS images are necessary to promote this technique in clinical practice.

Oxidoreductive homeostasis in alcohol-dependent male patients and the risk of alcohol drinking relapse in a 6-month follow-up

Disturbances in the central signaling of reactive oxygen species (ROS) in response to energy intake are recognized as taking part in appetitive and consummative phases of eating disorders. This study aimed to verify the hypothesis that blood oxidoreductive balance can also affect demand for energy substances, such as alcoholic beverages in alcohol-dependent individuals, as well as the severity of their alcohol dependence and risk of drinking relapse. The following values were determined in the blood of 54 alcohol-dependent male patients after alcohol withdrawal, again after 4 weeks and after 6 months: the aldehyde products of lipid peroxidation (malonyl dialdehyde [MDA] and 4-hydroxynonenal [4-HNE]), nitric oxide (NO) metabolites, total antioxidant status (TAS), the blood activities of glutathione peroxidase (GSHpx), superoxide dismutase (SOD), glutathione reductase (GSHred), blood glucose, and lipids. Alcoholics who relapsed during 6 months of observation (n = 31, 57%) compared with patients who maintained alcohol abstinence for 6 months (n = 23, 43%) differed only in relation to initial and final NO metabolite serum concentrations. The risk of alcohol drinking relapse was lower in patients with an above-median initial blood concentration of NO metabolites and TAS. The oxidative stress parameters correlated with alcohol-dependence severity markers. No significant correlations between the studied antioxidant balance parameters and markers of nutritional status, including blood glucose and lipids, were found. Although the results of our study have some limitations and require further investigation, they suggest the role of oxidoreductive balance in the pathomechanisms of alcohol dependence and drinking relapse. In addition, due to a lack of association found between blood oxidative stress parameters and BMI, blood glucose, and lipid concentrations, they show the presence of disturbances in systemic ROS signaling in response to energy availability in alcoholics after alcohol withdrawal.

New pharmaceuticals in inflammatory bowel disease

This paper complements the previously published Guidelines of the Working Group of the Polish Society of Gastroenterology and former National Consultant in Gastroenterology regarding the management of patients with Crohn's disease and ulcerative colitis. Attention was focused on the new pharmaceutical recently registered for inflammatory bowel disease treatment.

Contrast-Enhanced Ultrasonography in Crohn's Disease Diagnostics

The chronic nature of Crohn's disease (CD) implicates necessity of multiple control assessments throughout patient's life. It is accepted that in patients with CD requiring disease monitoring, magnetic resonance enterography (MRE) and computed tomography enterography (CTE) are--apart from endoscopy--imaging studies of first choice. In practice, diagnostic imaging of patients with CD is troublesome, since MRE is an expensive and complicated study, and CTE exposes patients to high doses of ionizing radiation. Therefore, there is a need for new, both non-invasive and effective, methods of imaging in CD. Contrast-Enhanced Ultrasonography (CEUS) is a relatively new method using gas-filled microbubbles serving as contrast agent. It allows for detailed assessment of blood perfusion within intestine wall and peri-intestinal tissues, which enables detection and monitoring of inflammation and its qualitative assessment. The purpose of this paper is to describe CEUS examination technique and its clinical applications in patients with Crohn's disease.

Working Group Guidelines on the nursing roles in caring for patients with Crohn's disease and ulcerative colitis in Poland

Inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, present a major challenge for present-day gastroenterology due to their increasing incidence, chronic nature, risk of permanent worsening of quality of life of patients, and the costs of conservative and invasive treatment. Basic and advanced nursing care are important parts of the multidisciplinary care for patients. The developed guidelines on the nursing care, which are compliant with the European guidelines published by Nurses-European Crohn's & Colitis Organisation (N-ECCO), were adjusted to the current situation in Poland. Significant issues that are important for nursing teams have been identified, with particular emphasis on the specificity of working in centres specialising in the care of IBD patients. The Working Group paid attention to the conditions that should be satisfied in order to optimise the nursing care for IBD patients, and the necessity to develop professional and scientific cooperation with European centres within European Crohn's & Colitis Organisation (ECCO) and N-ECCO.

Brain-gut axis in the pathogenesis of Helicobacter pylori infection

Helicobacter pylori (H. pylori) infection is the main pathogenic factor for upper digestive tract organic diseases. In addition to direct cytotoxic and proinflammatory effects, H. pylori infection may also induce abnormalities indirectly by affecting the brain-gut axis, similar to other microorganisms present in the alimentary tract. The brain-gut axis integrates the central, peripheral, enteric and autonomic nervous systems, as well as the endocrine and immunological systems, with gastrointestinal functions and environmental stimuli, including gastric and intestinal microbiota. The bidirectional relationship between H. pylori infection and the brain-gut axis influences both the contagion process and the host’s neuroendocrine-immunological reaction to it, resulting in alterations in cognitive functions, food intake and appetite, immunological response, and modification of symptom sensitivity thresholds. Furthermore, disturbances in the upper and lower digestive tract permeability, motility and secretion can occur, mainly as a form of irritable bowel syndrome. Many of these abnormalities disappear following H. pylori eradication. H. pylori may have direct neurotoxic effects that lead to alteration of the brain-gut axis through the activation of neurogenic inflammatory processes, or by microelement deficiency secondary to functional and morphological changes in the digestive tract. In digestive tissue, H. pylori can alter signaling in the brain-gut axis by mast cells, the main brain-gut axis effector, as H. pylori infection is associated with decreased mast cell infiltration in the digestive tract. Nevertheless, unequivocal data concerning the direct and immediate effect of H. pylori infection on the brain-gut axis are still lacking. Therefore, further studies evaluating the clinical importance of these host-bacteria interactions will improve our understanding of H. pylori infection pathophysiology and suggest new therapeutic approaches.

Clinical significance of Helicobacter pylori infection in patients with acute coronary syndromes: an overview of current evidence

Although Helicobacter pylori (Hp) primarily colonizes gastric mucosa, it can occasionally inhabit in atherosclerotic plaques. Both forms of Hp infection may be involved in the pathogenesis of atherosclerosis via activation of a systemic or local inflammatory host reaction and induction of plaque progression and/or instability, possibly leading to coronary syndromes. The association between Hp infection and cardiovascular endpoint prevalence remains uncertain; however, it has been reported in many epidemiological investigations and may be reasonably explained by pathophysiological mechanisms. Besides the inflammatory pathway, Hp infection may trigger acute coronary syndromes by enhanced platelet reactivity and increased risk of gastrointestinal bleeding (type 2 myocardial infarction). The former seems to be predominantly related to the stimulatory effect of Hp infection on von Willebrand factor-binding and P-selectin activation, and the latter results from cytotoxic bacteria properties and aggravation of digestive tract injury related to aspirin or dual antiplatelet therapy. Despite these premises, the role of Hp infection in cardiovascular syndromes should still be recognized as controversial and requiring randomized, controlled trials to evaluate the outcome of Hp eradication in both cardiac and gastroenterological endpoints. Such need is also justified by potential bias of previous studies resulting from (1) using different diagnostic methods for identification of Hp infection, since only a small number of studies required confirmation of active Hp infection; and from (2) common lack of adjustment for important confounders such as socioeconomic status, smoking and effectiveness of eradication therapy, as well as the genetic characteristics of both the host and the bacterium.

Contrast-enhanced ultrasonography for the determination of Crohn's disease activity - preliminary experience

Background

Contrast-enhanced ultrasound (CEUS) is a recent non-invasive modality, which may partially replace currently used techniques (endoscopy, CT enterography and MR enterography) in the diagnostics and assessment of Crohn’s disease (CD). The aim of the study was to analyze early experience in the use of CEUS for the measurement of activity and staging of CD.

Material/Methods

Eleven patients previously diagnosed with CD were included in the study. They underwent contrast-enhanced ultrasonography (SonoVue, Bracco), low-dose CT enterography (LDCTE), assessment of laboratory markers of inflammation and clinical CD activity index (CDAI). Contrast enhancement was evaluated using a semi-quantitative method and a quantitative method that included measurement of peak enhancement (PE), enhancement curve rise time (RT) and wash-in-rate (WiR).

Results

Ileal wall thickening was observed in all patients. Semi-quantitative method was used to observe CD activity in CEUS in 10 cases that perfectly matched LDCTE findings. There was a moderate positive correlation between PE and CDAI (r=0.65, p<0.001). There was no significant relationship between perfusion parameters and laboratory markers of inflammation.

Conclusions

CEUS is a promising modality for non-invasive assessment of pathologic ileal vascularization in the course of Crohn’s disease. Intensity of enhancement in CEUS reflects activity of the disease detected in LDCTE and correlates with CDAI.

Improvement in health-related quality of life after therapy with omeprazole in patients with coronary artery disease and recurrent angina-like chest pain. A double-blind, placebo-controlled trial of the SF-36 survey

Background

Many patients with coronary artery disease (CAD) have overlapping gastroenterological causes of recurrent chest pain, mainly due to gastroesophageal reflux (GER) and aspirin-induced gastrointestinal tract damage. These symptoms can be alleviated by proton pump inhibitors (PPIs). The study addressed whether omeprazole treatment also affects general health-related quality of life (HRQL) in patients with CAD.

Study

48 patients with more than 50% narrowing of the coronary arteries on angiography without clinically overt gastrointestinal symptoms were studied. In a double-blind, placebo-controlled, cross-over study design, patients were randomized to take omeprazole 20 mg bid or a placebo for two weeks, and then crossed over to the other study arm. The SF-36 questionnaire was completed before treatment and again after two weeks of therapy.

Results

Patients treated with omeprazole in comparison to the subjects taking the placebo had significantly greater values for the SF-36 survey (which relates to both physical and mental health), as well as for bodily pain, general health perception, and physical health. In comparison to the baseline values, therapy with omeprazole led to a significant increase in the three summarized health components: total SF-36; physical and mental health; and in the following detailed health concept scores: physical functioning, limitations due to physical health problems, bodily pain and emotional well-being.

Conclusions

A double dose of omeprazole improved the general HRQL in patients with CAD without severe gastrointestinal symptoms more effectively than the placebo.

Treatment with double dose of omeprazole increases β-endorphin plasma level in patients with coronary artery disease

INTRODUCTION

The proton pump inhibitor empirical trial, besides the analysis of symptoms, is the main method in the diagnosis of gastro-oesophageal reflux disease-related chest pain. β-Endorphin acts as an endogenous analgesia system. The aim of the study was verify whether β-endorphin plasma level is affected by omeprazole administration and influences the severity of anginal symptoms and outcome of the "omeprazole test" in patients with coronary artery disease (CAD) and chest pain of suspected non-cardiac origin.

MATERIAL AND METHODS

Omeprazole was administered to 48 patients with CAD in a randomized, placebo-controlled, crossover study design. At the beginning of the study, and again after the 14-day omeprazole and placebo treatment, the β-endorphin plasma concentration was determined.

RESULTS

The level of plasma β-endorphin after the administration of omeprazole was significantly greater than at the start of the study and following the placebo. Responders to omeprazole had an average lower β-endorphin plasma concentration than subjects who failed to respond to this therapy. Subjects with symptoms in class III (according to the Canadian Cardiovascular Society classification) after omeprazole administration had a greater β-endorphin plasma level than subjects in class II for anginal symptom severity.

CONCLUSIONS

Fourteen-day therapy with a double omeprazole dose significantly increases the β-endorphin plasma concentration in patients with CAD. Circulating β-endorphin does not seem to be involved in the mechanism for the "omeprazole test" outcome, although an individually different effect on pain threshold cannot be excluded.

The effect of double dose of omeprazole on the course of angina pectoris and treadmill stress test in patients with coronary artery disease--a randomised, double-blind, placebo controlled, crossover trial

BACKGROUND

Gastroesophageal reflux (GER) and coronary artery disease (CAD) frequently overlap, making the proper diagnosis of chest pain more difficult. GER symptoms may mistake anginal chest pain, and oesophageal acidification may induce myocardial ischaemia both in the rest and in the effort. Increase of oesophageal pH should prevent these conditions.

AIM

To estimate the effect of double omeprazole dose on the course of angina pectoris and treadmill stress test in patients with coronary artery disease (CAD), using double-blind, crossover randomised, placebo-controlled study design.

METHODS

We studied 48 patients with angina pectoris symptoms and significant narrowing of coronary vessels in angiography. After baseline examination and treadmill stress test all subjects were randomised to treat either with omeprazole (20 mg b.i.d.) or placebo for 14 days, using a double-blind, crossover placebo controlled design.

RESULTS

Seventeen (35%) subjects reported more than by half decrease in symptoms severity after omeprazole and 6 (12%) after placebo (p=0,01). Omeprazole significantly decreased the number of chest pain episodes and number of nitroglycerin doses taken in the second week of both study phases, as well as the percentage of subjects with significant decrease of ST interval during the stress test (64% vs. 73%, p<0,05). However majority of other stress test parameters (i.e. test duration, DUKE index) have improved both after omeprazole and placebo administration (by 9-38%).

CONCLUSION

Double dose of omeprazole significantly decreased symptoms severity in 35% of patients with CAD, as well as frequency of some electrocardiographic signs of myocardial ischaemia during stress test.

[Factors affecting the concentration of plasma tumour necrosis factor alpha (TNF-alpha) and liver function tests values in alcohol dependent males after alcohol drinking cessation]

AIMS

In our work, the factors affecting the plasma level of cytokine, tumour necrosis factor (TNF-alpha) and liver function tests values in alcohol dependent males after alcohol abuse period were analysed.

METHODS

We studied forty-seven alcoholics, without severe liver disease, who were abstinent no longer than 14 days before the study beginning. In all 24-h gastric pH-metry, endoscopy, serum liver function tests and TNF-alfa concentration were estimated.

RESULTS

The amount of alcohol drunk within 90 days before the study start correlated with plasma activity of AST, ALT and GGT. The plasma presence of TNF-alpha in 26 subjects was found, but in 21 patients this cytokine level was lower than the method sensitivity (< 0.05 pg/ ml). Using the step-wise method of multiple regression we found, that TNF-alfa level at the study commencement was determined by history of delirium tremens, Michigan Alcoholism Screening Test score, length of alcohol dependence, ALT activity, % of total monitoring time with gastric pH >3, intensity of antral H. pylori colonisation and number of standard drinks drunk for 90 days before the study start (ns). Similar factors determined liver function tests values variance.

CONCLUSION

Values of TNF-alpha and liver function tests two weeks after alcohol withdrawal were independently determined by gastric pH, H.pylori infection and smoking, which suggests their potential synergism with a hepatotoxic effect of alcohol drinking.

[Influence of Helicobacter pylori infection on the results of 24-hour gastric pH-metry in patients diagnosed because of atypical chest pain]

Changes in gastric acidity induced by Helicobacter pylori (Hp) infection, may influence intensity of symptoms in patients diagnosed because of chest pain. The aim of this study was to compare the results of 24-hours gastric pH-metry in patients suffering from atypical chest pain infected and not-infected by Hp.

PATIENTS AND METHODS

In 99 men diagnosed because of atypical chest pain performed were: interview, physical examination, gastroduodenoscopy with musoca biopsy from gastric corpus and antrum, as well as 24-hour gastric pH-metry. Hp infection was diagnosed on the basis of positive urease test or/and histologic examination.

RESULTS

78% of subjects were infected by Hp. Hp positive patients had lower total and night-time percentage of monitoring time with gastric pH<4 and greater with pH > 6. Patients with isolated antral Hp colonization and subjects with pangastritis didn't differ in respect to gastric pH-metry parameters values. However in patients, with Hp colonization only in gastric corpus the time with gastric pH < 4 was shorter and with pH > 6 longer than in other groups.

CONCLUSIONS

Hp-positive patients with atypical chest pain had lower gastric acidity than Hp-negative subjects. In patients with corporal Hp gastric mucosa colonization higher intra-gastric pH was observed than in the rest of patients.

[Gastroesophageal acid reflux as a causative factor of paroxysmal atrial fibrillation]

We present a case of a patient with very frequent episodes of paroxysmal atrial fibrillation (AF) who, besides hypertension and well-controlled post-amiodarone thyreotoxicosis, had no other potential causes of AF. Because of symptoms of gastroesophageal acid reflux, the patient was treated with omeprazole which significantly reduced the frequency of AF episodes. Next, the patient underwent anti-reflux surgery and has now only sporadic recurrences of AF. Our observations suggest that gastroesophageal acid reflux may be a triggering factor of AF.

Improvement in clinical course and laryngeal appearance in selected patients with chronic laryngitis after eight weeks of therapy with rabeprazole

BACKGROUND

One well-known extraesophageal manifestation of gastroesophageal reflux disease (GERD) is chronic laryngitis. The aim of this study was to estimate the efficiency of eight weeks of treatment with the PPI rabeprazole in a selected group of patients with chronic idiopathic laryngitis without typical GERD symptoms.

MATERIAL/METHODS

Seventeen patients (nine men and eight women) aged 35-72 years, with long histories (0.5 to 6 years) of chronic idiopathic laryngitis were included in the study. Larynx appearance was estimated by laryngostroboscopy. This examination, as well as interview and physical examination were performed in all patients at the start of the study and after 8 weeks of treatment with 20 mg rabeprazole taken orally twice a day.

RESULTS

There was remarkably good therapeutic outcome, clinical symptoms such as hoarseness and pharyngeal pain resolved, respectively, in 68.7 and 78.5% of patients and laryngeal signs in 50-80%, except for weak tension of the vocal cords which was observed in 12 patients at the start and end of the study.

CONCLUSIONS

Treatment with a proton pump inhibitor can be considered as a first-line diagnostic and therapeutic method in patients with idiopathic chronic laryngitis. Weak tension of vocal cords was often seen in these patients and persisted after the 8-week-long treatment.

Suppression of gastric acid production may improve the course of angina pectoris and the results of treadmill stress test in patients with coronary artery disease

BACKGROUND

Coronary artery disease (CAD) and gastro-esophageal reflux disease (GERD) often coexist in the same patients. The aim of this study was to estimate the effects of gastric acid output suppression with rabeprazole on course of angina pectoris and results of the treadmill stress test in patients with CAD.

MATERIAL/METHODS

We studied 34 patients with stable angina pectoris. In all subjects a medical history, a physical examination, and a stress test were performed at the beginning of the study and after two weeks of add-on rabeprazole therapy (20 mg b.i.d.).

RESULTS

Rabeprazole therapy significantly improved the outcome of the stress test in 27 patients (79%), prolonging mean stress exercise time (449+/-147 vs. 489+/-156s, p=0.027) and exercise time, leading to a maximum ST interval depression (360+/-167 vs. 467+/-148s, p=0.001), and also decreasing ST interval depression delta (1.9+/-1.1 vs. 1.5+/-0.9; p=0.013).

CONCLUSIONS

In 79% of our study subjects, rabeprazole improved stress test results in CAD patients, which implies that at least some of their symptoms were related to GERD. A proton pump inhibitor exerted a favorable effect on the frequency of angina-like chest pain and the results of the treadmill stress test.

Autonomic nervous function in Helicobacter pylori-infected patients with atypical chest pain studied by analysis of heart rate variability

OBJECTIVES

Cardiovascular autonomic nervous system (ANS) activity estimated by analysis of heart rate variability (HRV) was compared in Helicobacter pylori-positive and H. pylori-negative male patients suffering from atypical chest pain to verify the hypothesis that autonomic neural system might be the way linking chronic H. pylori infection with gastrointestinal tract disorders.

METHODS

We have analysed data obtained from 101 male patients examined in our clinic due to atypical chest pain, without evidence of serious cardiovascular, respiratory and digestive tract or metabolic diseases. In each patient, besides interview and physical examination, were performed: gastroscopy with mucosa biopsy (for urease test and histology), oesophageal pH-metry and manometry, ultrasound abdomen examination, chest X-ray, exercise test on running track, 24-h ECG Holter monitoring with time-domain and frequency-domain HRV analysis, and echocardiography.

RESULTS

In comparison with H. pylori-negative, in all H. pylori-infected patients (n = 63) a significantly greater low frequency power, an index of sympathetic activity, and higher values of vagal tone parameters [pNN50, percentage of differences between RR intervals that are greater than 50 ms; high-frequency power in HRV analysis (HF)] were observed. The relationship between H. pylori infection and the HF value was confirmed in multi-factorial analysis. The aforementioned ANS activity differences were accompanied by: significantly fewer gastro-oesophageal acid reflux episodes, lower gastric acidity and more effective and complete oesophageal peristalsis in H. pylori-positive patients.

CONCLUSIONS

H. pylori infection may affect ANS activity and via this way also contribute to gastro-oesophageal and cardiovascular pathology.

The effect of eight weeks of rabeprazole therapy on nitric oxide plasma level and esophageal pH and motility and motility nitric oxide plasma level in patients with erosive esophagitis

BACKGROUND

Esophageal clearance, an important pathogenetic factor in gastroesophageal reflux disease, depends mainly on motility. Motility disturbances can be secondary to gastric output reflux. Nitric oxide influences esophageal motility. The aim of this study was to determine the effect of eight weeks of gastric acid secretion suppression with rabeprazole (20 mg/day) on esophageal motility.

MATERIAL/METHODS

20 patients with erosive esophagitis were studied. At study start and two weeks after the end of therapy, we recorded the results of interview, endoscopy, gastric and esophageal mucosa biopsy, 24-h esophageal pH-metry and manometry, and NO metabolites plasma concentration, determined spectrophotometrically (OXIS).

RESULTS

All patients reported improvement and remained free of symptoms two weeks later. In 60% of cases, improvement of esophageal mucosa appearance was observed in endoscopic and histological examination. In follow-up we found a significantly smaller number of acid gastrooesophageal refluxes (p<0.05), reduced DeMeester score for pH range >7 (p<0.05), and greater % of time within the esophageal pH range 6-7 (p<0.05). Other esophageal pH-metry and 24-h manometry parameters did not change significantly. NO metabolites plasma concentration increased significantly (p=0.039).

CONCLUSIONS

Clinical improvement after eight weeks of therapy with rabeprazole was connected with endoscopic changes only in 60% of our patients. Rabeprazole therapy did not influence esophageal motility, despite increased plasma levels of NO metabolites. Patients with erosive esophagitis need maintenance therapy, since as soon as two weeks after the end of treatment the % of monitoring time with esophageal pH<4 was similar to study start.

[Effect of Helicobacter pylori infection on the gastroesophageal reflux in patients with atypical chest pain]

The role of Helicobacter pylori (Hp) infection in the course of gastroesophageal reflux disease (GERD) is still controversial. The aim of this study was to compare the results of endoscopic, histologic and pH-metric examinations of esophagus in patients diagnosed because of atypical chest pain, infected and not-infected by Hp. In 172 patients diagnosed because of atypical chest pain were made: interview, physical examination, gastroduodenoscopy with esophageal and gastric mucosa biopsy as well as esophageal pH-metry. Hp infection was diagnosed on the basis of positive urease test or/and histologic examination. In 49 (28%) subjects pathological gastroesophageal acid reflux was diagnosed (above 4.5% of monitoring time with pH < 4). Percentage of Hp infected patients among subjects with pathological (69%) and not-pathological (74%) gastroesophageal acid reflux did not differ significantly. Hp infected patients, in comparison to Hp-negative, had similar esophageal mucosa endoscopic appearance and greater intensity of histologic changes in esophageal mucosa. Studied patients group did not differ in respect of esophageal pH-metry parameters values, besides of greater number of esophageal alkalization (pH > 7) episodes in Hp-negative subjects.

CONCLUSIONS

1) Hp infection was diagnosed in 72% of patients with atypical chest pain. 28% had pathological gastroesophageal acid reflux. 2) Gastroesophageal acid reflux was not related to Hp infection. 3) Greater intensity of histologic changes in esophageal mucosa of Hp-positive patients with accompanying lack of differences in endoscopic estimation and similar endanger on gastric acid in pH-metry suggests protective role of esophageal alkalization against esophageal mucosa injury or higher intensity of regenerative inflammatory processes in Hp-positive patients.

Parameters of the functional and morphological status of the upper digestive tract in alcohol-dependent male patients with depression and alexithymia in the context of autonomic nervous system activity and nitric oxide plasma level

BACKGROUND

Psychosomatic factors play an important role in the pathogenesis of many diseases. The aim of this study was to compare the results of upper digestive tract examinations in alcoholics with depression and/or alexithymia diagnosed with atypical chest pain.

MATERIAL/METHODS

In 52 alcohol dependent male patients with atypical chest pain we performed gastroduodenoscopy, esophageal and gastric pH-metry, 24-h esophageal manometry, treadmill stress test, Holter monitoring, and blood sampling. Depression was diagnosed using the Beck Depression Inventory (BDI), and alexithymia according to the Toronto Alexithymia Scale (TAS).

RESULTS

Depression and/or alexithymia were diagnosed in 37 patients (71%). Depressive and alexithymic patients, in comparison to subjects with lower BDI and TAS scores, had less intensive Helicobacter pylori antral colonization, higher values of gastro-esophageal acid reflux parameters in 24h pH-metry, higher mean amplitude of contraction, longer mean contraction duration, higher percentage of hypertensive contractions, and a greater percentage of effective peristalsis, in spite of a similar percentage of peristaltic and simultaneous contractions. The patient groups did not differ in relation to gastric pH-metry parameters or factors potentially connecting mental status and esophageal function regulation, such as plasma nitric oxide metabolite concentration and heart rate variability (HRV), which correlate with autonomic nervous system activity.

CONCLUSIONS

In alcoholic patients with depression and alexithymia there is a tendency to greater functional disturbances in the upper digestive tract. The observed differences between groups were not related to changes in ANS activity and nitric oxide metabolism.

[The effects of chronic alcohol abuse on morphology and function of the gastrointestinal tract]

In this review we described the effects of chronic alcohol consumption upon the morphology and function of the gastrointestinal tract. Especially the attention was paid to the motility disorders, their pathogenesis and influence on symptoms occurrence and systemic consequences of alcoholism. Some recent publications, concerning the role of neuroendocrine small intestine system and ileum as an extrahepatic source of cytokine production in alcoholics, were reviewed.

Lipoprotein(a) in alcohol-dependent male patients during a six-month abstinence period

AIMS

The best known and probably most important mechanism of health-protective moderate alcohol drinking is beneficial changes in plasma lipid levels. We determined changes in main plasma lipid levels in alcohol-dependent patients over a 6-month abstinence period.

METHODS

Fifty-four alcohol-dependent male patients, who were abstinent for less than 14 days, and 20 non-alcoholic males, who had not drunk alcohol for the last month, were studied. In all patients at the study start and after 4 weeks and 6 months observation, lipoprotein(a) [Lp(a)], total cholesterol (TC), HDL cholesterol (HDL), LDL cholesterol (LDL) and triglyceride concentrations, both fasting and 5 h after a fatty meal, were determined.

RESULTS

Alcohol-dependent patients had similar mean fasting and post-prandial plasma lipid levels as the control group, both at the study start and after 4 weeks of abstinence. Whereas, in alcohol-dependent patients after 4 weeks of abstinence, a significant decrease in Lp(a) and fasting HDL levels, as well as a significant increase in fasting LDL level and pro-atherogenic indices of plasma lipids [TC/HDL, (TC-HDL)/HDL, LDL/HDL, Lp(a)/HDL] were observed. Post-prandial levels of studied plasma lipids, except HDL, did not change over the 6-month observation period. In patients who did not remain abstinent for the whole observation period (n = 9), in comparison to abstinent patients, significantly higher HDL levels and a tendency to higher values of LDL, LDL/HDL, Lp(a) and Lp(a)/HDL were found.

CONCLUSIONS

(1) Higher Lp(a) levels soon after alcohol withdrawal may be a factor potentially responsible for the increase of acute cardiac syndromes prevalent in the drinking and early abstinence period, in spite of high HDL concentration; (2) in alcohol-dependent male patients, after a 6-month abstinence period, pro-atherogenic plasma cholesterol fraction changes occurred, expressed by a decrease in HDL level and an increase in LDL concentration.

[Serine protease inhibitors in plasma of patients with ulcerative colitis]

Serine protease inhibitors (serpins) are the important factors regulating hemostasis and inflammatory mediators activity. The aim of this study was to determine relationships between plasma serine protease inhibitors activities and the course of ulcerative colitis (uc).

PATIENTS AND METHODS

42 patients with uc, 21 in active and 21 in inactive disease phase, and 26 healthy persons (control group) were studied. In all investigated persons activities of alpha 1-proteinase inhibitor (alpha 1-PI), alpha 2-macroglobulin (alpha 2-M), alpha 2-antiplasmin (alpha 2-AP), antithrombin III (ATIII) and plasminogen activator inhibitor type 1 (PAI-1) were determined.

RESULTS

Patients with uc had higher level of alpha 1-PI than control group. In patients with active uc lower alpha 2-M activity was found than in patients with us remission. Alpha 2-M activity below 100% had 58% sensitivity and 71% specificity, and predictive value (odds ratio = 6.25) for histologic appearance of active uc. The correlation between alpha 2-M value and uc activity and time of symptoms duration before the study start was found. Patients with inflammatory process beyond sigmoid had lower alpha 2-AP activity than patients with less extended inflammatory process.

CONCLUSIONS

Inflammatory process in large bowel changed the level of plasma serine protease inhibitors activities, what was a result of acute phase reaction (alpha 1-PI) and inhibitors consumption in inflammatory processes (alpha 2-M, alpha 2-AP).

[Relationship between results of electrocardiographic exercise tests and intraesophageal pH in men with atypical chest pain]

Changes in intraesophageal pH can influence myocardium perfusion via neural reflexes. The aim of this study was to estimate the relationships between intraesophageal pH and the course of electrocardiographic exercise test. 38 male patients with atypical chest pain in mean age 41.1 +/- 7.8 years were studied. In all among other 24-hours oesophageal pH monitoring and exercise test on running track with simultaneous oesophageal pH monitoring were made. Pathological acid reflux in 24-hours monitoring had 11 (29%) patients, exertional acid gastroesophageal reflux in 8 (21%) patients was found and significant ST interval depression in ecg in 11 (29%) patients was observed. The differences in patients quantity in respective subgroups were not significant. Patients with significant ST interval depression during exercise test, in comparison with patients without significant ecg changes, had lower HDL cholesterol level and higher values of daily and exertional gastroesophageal acid reflux parameters. Multiple-regression analysis showed that indicators of functional (pH-metry) and morphological (endoscopy and histology) oesophageal status were the independent factors determining variance of: exercise test duration, percentage of maximal heart rate during exercise test, double product value and maximal ST interval depression. In conclusion, changes in intraesophageal pH can influence exercise test course.

[Blood coagulation activation in patients with ulcerative colitis]

Hemostasis disturbances in patients with ulcerative colitis (uc) can result from quantity and quality changes in blood coagulation factors synthesis (acute phase reaction) as well as their consumption in inflammatory processes affecting in large bowel. The aim of this study was to estimate a coagulation system activation in patients with uc.

PATIENTS AND METHODS

42 patients with uc, 21 in active and 21 in inactive disease phase as well as 26 healthy persons were studied. In all concentration of thrombin-antithrombin III complexes (TAT), antithrombin III and prekallikrein activities, von Willebrand factor (vWf) and fibrinogen concentrations, kaolin-kephalin time (aPTT), prothrombin level and platelets count were determined.

RESULTS

In patients with uc higher level of TAT, fibrinogen and platelets count, lower level of prekallikrein activity and shorter aPTT were found than in control group. No significant differences in obtained results of hemostatic parameters between patients with active and inactive uc were found. Whereas, it was disclosed lower platelets count and fibrinogen concentration in cases with inflammatory process only to rectum limited in comparison with more extended inflammatory changes. Using multiple regression method it was found that in studied group the TAT concentration, marker of thrombin in vivo generation, was determined by: aPTT, fibrinogen level, disease severity, inflammatory process extension in large bowel, systemic acute phase reaction.

CONCLUSIONS

1) In patients with uc independently of activity and extension of inflammatory process, the increase of in vivo throminogenesis expressed by higher TAT level was found. 2) Observed coagulation system disturbances may exert an influence on inflammatory process affecting large bowel and increase the risk of thrombotic complications in the course of uc.

Naltrexone exerts a favourable effect on plasma lipids in abstinent patients with alcohol dependence

Epidemiological studies suggest that abstinence periods in some patients with alcohol dependence may increase their cardiovascular risk via proatherogenic changes in plasma lipid levels. Because of this, drugs administered in withdrawal therapy should not exacerbate these effects. The aim of this study was to estimate the influence of naltrexone, carbamazepine, and lithium carbonate on plasma lipid levels in 160 alcohol-dependent males during withdrawal therapy. Plasma concentrations of total cholesterol (TC), HDL cholesterol (HDL-C), LDL cholesterol (LDL-C), and triglycerides (TGL) were determined every 2 weeks for 20 weeks. Pharmacotherapy (naltrexone 50 mg, carbamazepine 600-800 mg, lithium carbonate 500-1000 mg once per day or placebo) was given within the framework of a double-blind study between the fourth and twentieth weeks of the study. The results of 116 patients who maintained abstinence during the whole 20-week observation period were analysed. In patients treated with naltrexone significant decreases in TC (239 +/- 58 vs 216 +/- 52 mg/dl; P < 0.01) and TGL (125 +/- 68 vs 86 +/- 33 mg/dl; P < 0.02) concentrations after 16 weeks of pharmacotherapy were observed. In patients treated with carbamazepine, significant increases in TC (224 +/- 39 vs 243 +/- 54 mg/dl, P < 0.04) and HDL (40 +/- 10 vs 44 +/- 8 mg/dl, P < 0.01) after 16 weeks of pharmacotherapy were observed. After 16 weeks of pharmacotherapy, patients treated with naltrexone had lower mean TC (P < 0.03) and LDL-C (P < 0.01) concentrations than patients treated with carbamazepine, lower mean LDL-C levels than patients treated with lithium carbonate (149 +/- 54 vs 164 +/- 57 mg/dl, P < 0.01), and lower TGL concentrations than patients of the remaining pharmacotherapy groups. We conclude that naltrexone, by its hypolipaemic effect, could be useful for withdrawal therapy in alcoholic patients, because it may decrease the cardiovascular risk in abstinent patients with alcohol dependence by lipid mechanisms.

[Oxygen metabolism disturbances in the pathogenesis of gastric and duodenal diseases]

Oxygen metabolism disturbances are the pathogenetic factors of many diseases, including digestive tract diseases. Last time much attention was given to importance of active oxygen form, oxygen free radicals. Free radicals are one of the tissue aggressive factors and they are the pathogenic factor of gastritis and duodenitis, stress ulcer, gastric and duodenal ulcer disease and gastric cancer. In this paper the review of investigations of oxygen metabolism in gastric and duodenal diseases was presented.

[Hypersensitivity reactions in patients with irritable colon syndrome]

In a group of 74 patients with irritable colon syndrome the studies were carried out evaluating the frequency of abnormal reactions after meal and positive skin reactions with extracts of inhalatory and alimentary substances, 0.1% histamine and 1% codeine. An assessment was also done of the correlation of skin reactions with the degree of irritability of the large bowel expressed as score. Abnormal reactions after meal were reported by 89% of the studied patients with irritable colon syndrome. All meals giving abnormal reactions after consumption may be the source of allergens and may trigger allergic reactions in predisposed persons, but many of them, in view of the contents of histamine, tyramine, and the ability of release or synthesis and release of mast cell mediators, may cause reactions of pseudoallergic mechanism. Intensity of skin reaction in the form of oedema and erythema after intracutaneously administered codeine varied between the studied groups. The highest intensity was found in patients with irritable colon syndrome (ICS) who had intermittent diarrhoeas. The intensity of oedematous skin reaction after codeine in patients with ICS was correlated with the degree of irritability of the large bowel evaluated by the accepted score. The obtained results may be an indirect evidence of the participation of pseudoallergic reaction in the pathological mechanism of ICS in certain patients.

[Type I allergy and indices of immune response in patients with ulcerative colitis]

In a group of 24 patients with ulcerative colitis and in 15 persons in the control group allergological studies were carried out which included history taking, cutaneous tests, assessment of total concentration and presence of specific IgE in the serum, and selected immune response indices (Ig levels, immune complex concentration and numbers of T- and B-cells). In our studies it was found that in two-thirds of patients with ulcerative colitis clinical reactions after meal occurred, in 54% atopy coexisted, and immunological abnormalities occurred more frequently than in the control group. Our studies proved that the role of various reactions to consumed meal, including early allergic reactions, cannot be rejected with full certainty. A number of indirect evidence that type I allergy according to Gell and Coombs, and immunological abnormalities participated in the pathological mechanism of that disease was also found.