Low-dose rectal diclofenac for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a randomized controlled trial

Background

Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Rectal nonsteroidal anti-inflammatory drugs (specifically, 100?mg of diclofenac or indomethacin) have shown promising prophylactic activity in post-ERCP pancreatitis (PEP). However, the 100-mg dose is higher than that ordinarily used in Japan.

Methods

We performed a prospective randomized controlled study to evaluate the efficacy of low-dose rectal diclofenac for the prevention of PEP. Patients who were scheduled to undergo ERCP were randomized to receive a saline infusion either with 50?mg of rectal diclofenac (diclofenac group) or without (control group) 30?min before ERCP. The dose of diclofenac was reduced to 25?mg in patients weighing <50?kg. The primary outcome measure was the occurrence of PEP.

Results

Enrollment was terminated early because the planned interim analysis found a statistically significant intergroup difference in the occurrence of PEP. A total of 104 patients were eligible for this study; 51 patients received rectal diclofenac. Twelve patients (11.5%) developed PEP: 3.9% (2/51) in the diclofenac group and 18.9% (10/53) in the control group (p?=?0.017). After ERCP, the incidence of hyperamylasemia was not significantly different between the two groups. Post-ERCP pain was significantly more frequent in the control group than in the diclofenac group (37.7 vs. 7.8%, respectively; p?Conclusions Low-dose rectal diclofenac can prevent PEP.     

Transanal endoscopic microsurgery with 3-D (TEM) or high-definition 2-D transanal endoscopic operation (TEO) for rectal tumors. A prospective,randomized clinical trial

Purpose

Transanal endoscopic microsurgery (TEM) is a three-dimensional viewing endoscopic system procedure which provides access to rectal tumors through a rectoscope. Two-dimensional transanal endoscopic operation (TEO), with the introduction of high-definition vision, achieves results that are comparable to those of the classical TEM. The main aim of the study was to compare the effectiveness of TEO and TEM systems in a prospective, randomized clinical trial.

Method

Study population: patients meeting inclusion criteria for diagnosis of rectal tumors with curative intent. Sample size, 36 patients. Patients were randomized to receive one of the two procedures. Study variables recorded were the following: preoperative data (time taken to assemble equipment, surgical time, quality of pneumorectum), postoperative morbidity and mortality, pathology study of the tumors, and economic analysis.

Results

Thirty-six patients were analyzed according to intention to treat. Two patients were excluded. The final per-protocol analysis was 34 patients. There were no significant differences in the preoperative or operative variables, quality of pneumorectum, postoperative variables, or pathology results. A trend toward benefit was observed in favor of TEO in time required for assembly, surgical suture time, and total surgical time though the differences were not statistically significant. Statistically significant differences were found in terms of the total cost of the procedure, with mean costs of 2,031 €?±?440 for TEO and 2,603 €?±?507 for TEM (95 % CI 218.15–926.486 €, p?=?0.003).

Conclusion

No technical or clinical differences were observed between the results obtained with the two systems except lower cost with TEO.     

Molecular epidemiology of pneumococci obtained from Gambian children aged 2–29 months with invasive pneumococcal disease during a trial of a 9-valent pneumococcal conjugate vaccine

Background

Rabies is a major public-health problem in developing countries such as China. Although the recent re-emergence of human rabies in China was noted in several epidemiological studies, little attention was paid to the reasons behind this phenomenon paralleling the findings of the previous reports. The purpose of this study is thus first to characterize the current trends of human rabies in China from 1990 to 2007, and then to define better recommendations for improving the post-exposure prophylaxis (PEP) schedules delivered to rabies patients.

Methods

The most updated epidemiological data for 22527 human rabies cases from January 1990 to July 2007, retrieved from the surveillance database of reportable diseases managed by the Ministry of Health of China, were analysed. To investigate the efficiency for the post-exposure treatment of rabies, the details of 244 rabies patients, including their anti-rabies treatment of injuries or related incidents, were ascertained in Guangdong provincial jurisdiction. The risk factors to which the patients were predisposed or the regimens given to 80 patients who received any type of PEP were analysed to identify the reasons for the PEP failures.

Results

The results from analysis of the large number of human rabies cases showed that rabies in China was largely under control during the period 1990–1996. However, there has been a large jump in the number of reported rabies cases since 2001 up to a new peak (with an incidence rate of 0.20 per 100000 people) that was reached in 2004, and where the level has remained until present. Then, we analysed the PEP in 244 rabies cases collected in the Guangdong province in 2003 and 2004, and found that 67.2% of the patients did not seek medical services or did not receive any PEP. Further analysis of PEP for the 80 rabies patients who received any type of PEP indicated that almost all of the patients did not receive proper or timely treatment on the wounds or post-exposure vaccination or rabies immunoglobulins.

Conclusion

While the issue of under-reporting of rabies in previous years may well be a factor in the apparent upwards trend of human rabies in recent years, the analysis of PEP in the Guangdong province provides evidence that suggests that the failure to receive PEP was a major factor in the number of human cases in China. Thus, the data underline the need for greatly improved availability and timely application of high-quality anti-rabies biologicals, both vaccines and immunoglobulins, in the treatment of human bite victims. Controlling dog rabies through pet vaccination schemes may also play a huge role in reducing the rate of human exposure. Education of the public, health care staff and veterinarians will also help to change the current situation.     

Hepatitis delta: on soft paws across Germany

Introduction

Globally, more than 350 million people are considered to be chronic carriers of the hepatitis B virus (HBV) infection; thereof, 15?C20 million of these individuals are thought to be coinfected with hepatitis delta virus (HDV). The clinical course depends on the mode of transmission; whereas coinfection commonly resolves, superinfection aggravates the disease and progresses to chronicity in over 90?% of the cases, which, again, results in cirrhosis.

Objective

Although many tests are performed in HBV carriers, data on the prevalence of anti-HDV-IgG in Germany are only rarely available and outdated. Therefore, we retrospectively evaluated the seroprevalence of anti-HDV-IgG from the results of our routine service.

Materials and methods

Between January 2000 and October 2011, serum samples from 2,844 patients (carrying hepatitis B surface antigen) admitted to University Hospital Frankfurt am Main, Frankfurt, Germany, were tested for anti-HDV-IgG by enzyme-linked immunosorbent assay (ELISA).

Results

The overall seroprevalence of anti-HDV-IgG in the collective of Frankfurt (n?=?2,844) is 7.4?% [95?% confidence interval (CI): 6.4?C8.4]. The amount of seropositive men (8.3?%, 95?% CI: 6.9?C10) significantly exceeds the female proportion (5.7?%, 95?% CI: 4.3?C7.5). The rate of seropositivity to anti-HDV-IgG in this collective of Frankfurt reached a maximum in the year 2003 (10.1?%, 95?% CI: 8.9?C11.1). The lowest rate was observable in 2004, where 5.4?% were positive to anti-HDV-IgG.

Conclusion

Of the HBV carriers in Germany, 5?C8?% reveal serologic evidence of coinfection with HDV. The vaccination against HBV is the key to prevent HDV infection; therefore, vaccination must strongly be propagated further on.     

Family outbreak of an infection with a recombinant Coxsackie A virus in eastern Switzerland

Purpose

We report on an unusual familial outbreak of a coxsackie virus infection in Switzerland in which five family members were affected. Most of the patients presented with signs of meningitis, and four were hospitalized.

Methods

In three individuals, the virus was detected in the cerebrospinal fluid, pharynx, and stool, respectively. The genome was sequenced in specimens of two patients.

Results

The nucleotide sequences of both virus strains were identical. Blast search revealed that the first half of the sequence was 88 % homologous to Enterovirus 75 (EV-75), 87 % with Echovirus 11 (E-11), and 84 % homologous to Coxsackie virus A9 (CV-A9). The second half of the sequence was 77 % homologous to EV-75, 75 % to E-11, and 91 % to CV-A9.

Conclusion

We propose that the isolated virus strain is a recombinant strain with a 5′ untranslated region and with the start of the VP4 sequence originating from E-11/EV-75 and the rest of the genome originating from CV-A9. Interestingly, this novel virus strain showed an exceptional virulence and rapid spread. Two weeks after the initial outbreak in this family, a similar outbreak was observed in a second geographic area roughly 100 km distant to the primary identification site, and another 2 months later this virus strain was found to circulate in the western part of Switzerland some 250 km distant to the primary locus. These findings suggest that genetic recombination has resulted in a novel enterovirus with features of high virulence, contagiosity, and spreading.     

Hypofractionated stereotactic radiotherapy (hfSRT) after tumour resection of a single brain metastasis: report of a single-centre individualized treatment approach

Purpose

Standard treatment of single brain metastases so far is tumour resection in combination with postoperative whole-brain radiotherapy or stereotactic radiosurgery. Here, we report retrospectively our first experience with postoperative hypofractionated stereotactic radiotherapy (hfSRT) to the resection cavity in order to replace upfront WBRT with respect to treatment efficacy and safety.

Methods

Between March 2006 and October 2011, 33 patients with a single newly diagnosed intracranial metastasis were treated with hfSRT following microsurgical resection. Fractionation concepts were 10?×?4?Gy (n?=?22), 7?×?5?Gy (n?=?7) and 5?×?6?Gy (n?=?4). Planning target volume enclosed the tumour resection cavity with a safety margin of 4?mm.

Results

No patient demonstrated toxicity grade 2 or higher. Actuarial median overall survival summed up to 20.2?months, and 12-month survival was 64?%. Actuarial mean local brain control was 30.6?months, median distant brain control 12.4?months and intracranial control 8.8?months, respectively. Actuarial 1-year rates of local, distant brain and intracranial control were 71, 57 and 43?%. Salvage whole-brain radiotherapy due to recurrent brain metastases was performed in 13 patients (39?%).

Conclusion

Postoperative hfSRT appears to be a feasible treatment option in patients with a single newly diagnosed brain metastasis. Replacing the standard postoperative whole-brain radiotherapy necessitates compliant patients and regular MRI follow-up analysis.     

Previous maternal infection protects offspring from enterovirus infection and prevents experimental diabetes development in mice

Aims/hypothesis

Enterovirus (e.g. Coxsackie B virus serotypes [CVBs]) infections may be associated with development of type 1 diabetes. Studies conducted in several European countries have, however, shown an inverse correlation between the incidence of type 1 diabetes and the prevalence of enterovirus infections. These findings could in part be explained by an extension of the poliovirus hypothesis, suggesting that the absence of maternally transferred antibodies protecting offspring from early infection increases the risk for diabetes development. Experimental evidence supporting this hypothesis in type 1 diabetes is, however, lacking. As maternally transferred protection from infection is a crucial component of the extended poliovirus hypothesis, we here tested the hypothesis that previously infected females transfer protection against infection and diabetes to offspring.

Methods

The induction of CVB-specific maternal antibodies and transfer of protection from virus infection, replication and development of virus-induced diabetes to offspring was assessed using NOD and Socs1-transgenic NOD mice.

Results

Infected mice produced neutralising antibodies to CVB. Offspring from infected females were positive for neutralising antibodies and were strongly protected from both infection and experimental diabetes.

Conclusions/interpretation

Our study shows that maternally transferred antibodies protect offspring from enterovirus infection and virus-induced diabetes. This suggests that the absence of maternally provided protection increases the risk for severe outcomes after an enterovirus infection in offspring. Moreover, our findings may have implications for the design of prospective studies aimed at investigating the possible role of enterovirus infections in the aetiology of human type 1 diabetes.     

Prophylactic pancreatic stent placement and post-ERCP pancreatitis: an updated meta-analysis

Background and aim

Pancreatitis is one of the most frequent post-endoscopic retrograde cholangiopancreatography (ERCP) complications. Previous meta-analyses show that prophylactic pancreatic stent (PS) placement after ERCP is beneficial for the prevention of post-ERCP pancreatitis (PEP). However, the results of these meta-analyses are controversial due to the limited sample size of the eligible studies, in which six additional randomized controlled trials (RCTs) are not included. Our aim is, therefore, to update the current meta-analyses regarding PS placement for prevention of PEP.

Methods

We conducted a meta-analysis to identify RCTs comparing PS placement and the subsequent incidence of PEP. The primary outcome was the incidence of PEP.

Results

Fourteen studies were enrolled in this meta-analysis. Of the 1,541 patients, 760 patients received a PS and 781 patients were allocated to the control group. PS placement was associated with a statistically significant reduction of PEP [relative risk (RR) 0.39; 95 % confidence interval (CI) 0.29–0.53; P < 0.001]. Subgroup analysis stratified according to the severity of PEP showed that a PS was beneficial in patients with mild to moderate PEP (RR 0.45; 95 % CI 0.32–0.62; P < 0.001) and in patients with severe PEP (RR 0.26; 95 %CI 0.09–0.76; P = 0.01). In addition, subgroup analysis performed according to patient selection demonstrated that PS placement was effective for both high-risk and mixed case groups.

Conclusions

This meta-analysis showed that PS placement prevented PEP after ERCP as compared with no PS placement. We therefore recommend PS placement after ERCP for the prevention of PEP.     

Hepatitis C Virus-Associated Primary Hepatocellular Carcinoma in Non-cirrhotic Patients

Background

There is limited literature on hepatocellular carcinoma (HCC) in patients with chronic hepatitis C virus (HCV) infection in the absence of cirrhosis.

Aims

To investigate the relationship between HCV and HCC in the absence of cirrhosis and to characterize patients with HCV infection presenting with HCC in the absence of cirrhosis.

Methods

We identified all adult patients with histological confirmation of HCC between 1994 and 2007 (404 patients). A case?Ccontrol design (four controls for each case with non-cirrhotic HCC) was chosen to compare characteristics and survival of HCV in HCC patients without (cases) and with (controls) cirrhosis. Conditional logistic regression analysis was used to identify factors independently associated with HCV in non-cirrhotic HCC.

Results

Eighty-seven patients with non-cirrhotic HCC were identified, six (7?%) had HCV infection in comparison with 107 of 317 (55.7?%) with cirrhotic HCC (P?<?0.001). Compared with the HCV-associated HCC cirrhotic group, patients with HCV-associated HCC in the absence of cirrhosis were more likely to present with a single nodule (100 vs. 66.7?%), larger nodule size (>5?cm) (100 vs. 16.7?%), and macrovascular invasion (66.7 vs. 17.4?%) at time of diagnosis. Four of six patients with HCV-associated HCC in the absence of cirrhosis where alive at three years (all had resection), which was better survival than for HCC arising in cirrhotic livers of HCV-infected individuals (66.7 vs. 39.1?%).

Conclusion

We found that HCV is responsible for a small minority of non-cirrhotic HCC cases representing an uncommon and poorly defined subgroup of HCC.     

Antiviral effects of peginterferon alpha-2b and ribavirin following 24-week monotherapy of telaprevir in Japanese hepatitis C patients

Background/aims

Anemia is commonly observed as a side effect in a treatment with protease inhibitors combined with peginterferon alpha and ribavirin for hepatitis C virus infection. This study assessed the safety, tolerability, viral kinetics, and selection of variants in telaprevir monotherapy for 24?weeks, and outcomes of the off-study treatment with peginterferon alpha-2b and ribavirin among Japanese female patients at a median age of 54?years who were difficult to treat with the standard therapy (peginterferon alpha-2b and ribavirin) alone in Japan.

Methods

Four treatment-na?ve patients with chronic hepatitis C virus subtype 1b infection received telaprevir (750?mg every 8?h) alone for 24?weeks. All patients then started the off-study treatment with peginterferon alpha-2b and ribavirin. Safety, tolerability, hepatitis C virus RNA levels, and emergence of telaprevir-resistant variants were monitored.

Results

During the 24?weeks of telaprevir monotherapy, there was no discontinuation due to adverse events, but 2 patients stopped the intake at weeks 6 and 15 because of viral breakthrough. Emergence of telaprevir-resistant variants was observed in 3 patients who showed viral breakthrough. These variants were eliminated by the off-study treatment, and sustained virological response was achieved in all patients.

Conclusions

Anemia was manageable by carefully adjusting the ribavirin dosage in the standard therapy that followed telaprevir monotherapy. This sequential regimen seems to be safer and more tolerable than the triple combination of telaprevir, peginterferon alpha, and ribavirin, especially among elderly females with low baseline hemoglobin.     

Recurrent infection in the left thumb

Introduction

Infections of the hand may be associated with lymphangitis and lymphadenitis. In most cases, bacterial infections are responsible but these may be also due to viral infections.

Material and Methods

We describe a clinical case of a recurrent infection in the left thumb of a health male. Bacterial and viral cultures were performed.

Results

Herpes simplex virus (HSV) type 2 was isolated on viral culture and on direct fluorescent antibody testing; so, the final diagnosis was herpetic whitlow.

Conclusions

Herpetic whitlow should be considered in cases of recurrent finger infections.     

The results of the Tokyo Trial of Prevention of Post-ERCP Pancreatitis with Risperidone (Tokyo P3R): a multicenter, randomized, phase II, non-placebo-controlled trial

Background

A previous study suggested that ulinastatin effectively prevented post-ERCP pancreatitis (PEP) and hyperenzymemia (PEH) in patients at average risk. In experimental models, risperidone, a selective serotonin 2A antagonist, ameliorated acute pancreatitis. We assessed the effect of risperidone combined with ulinastatin for the prevention of PEP in high-risk patients.

Methods

In a multicenter, randomized, controlled, phase II trial, patients undergoing therapeutic ERCP were randomly assigned to receive ulinastatin (150000 U) with or without risperidone (1 mg). A risperidone tablet was taken orally 30–60 min before ERCP and ulinastatin was administered intravenously for 10 min immediately prior to ERCP. The primary end point was the incidence of PEP; secondary end points were PEH severity and enzyme levels (amylase, pancreatic amylase, lipase).

Results

A total of 226 patients (113 per group) were included in the study. Six patients in the risperidone + ulinastatin group and ten patients in the ulinastatin group developed pancreatitis (5.3 vs. 8.8 %, p = 0.438). The incidence of moderate/severe PEP was lower in the risperidone + ulinastatin group (1.8 %) than in the ulinastatin group (4.4 %), but this difference was not significant. Although the incidence of PEH did not differ significantly, post-ERCP levels of all pancreatic enzymes were significantly lower in the risperidone + ulinastatin group.

Conclusions

Prophylactic oral risperidone administration in combination with ulinastatin did not reduce the incidence and severity of PEP in high-risk patients as compared with ulinastatin alone. However, risperidone showed an additive effect with ulinastatin, reducing serum pancreatic enzyme levels.     

HHV6 meningoencephalitis sequelae in previously healthy children

Introduction

Human herpes virus 6 (HHV6) infection is a self-limiting illness occurring in early childhood. As with other herpes viruses, the encephalopathy associated with HHV6 is often attributable to the reactivation of a virus previously latent in human brain tissue. Previous reports on HHV6 encephalopathy dealt mainly with virus reactivation in immune-depressed older children and, above all, refer to encephalitis and not to meningoencephalitis. Complications are rare in healthy children. Encephalopathy has rarely been associated with HHV6 infection in children not affected by chronic disease.

Purpose

The aim of this study was to evaluate sequelae of HHV6 meningoencephalitis in previously healthy children.

Results

We report three cases of HHV6 meningoencephalitis in previously healthy children followed for a 10-year period. Two of the patients presented invalidating sequelae. In detail, one patient developed speech disturbance and the other persistent hemiplegia and bilateral visual deficit. To our knowledge, this is the first case in which an ocular complication developed in the course of HHV6 meningoencephalitis.

Conclusion

HHV6 meningoencephalitis can be associated with a wide range of clinical outcomes, from long-term neurological sequelae to a benign post-infectious clinical course.     

Effect of chemotherapy on survival after whole brain radiation therapy for brain metastases: a single-center retrospective analysis

Background and purpose

Whether chemotherapy for systemic disease affects survival of patients with brain metastases or not has not been elucidated before. We performed comprehensive analysis of patients with newly-diagnosed brain metastases primarily treated with whole brain radiation therapy (WBRT) alone.

Materials and methods

Data from 134 patients with newly-diagnosed brain metastases primarily treated with WBRT from 2007 to 2008 was retrospectively reviewed. Univariate and multivariate analyses were performed to identify significant prognostic factors.

Results

Median survival time (MST) of this cohort from the start of WBRT was 5.7?months. MST of patients with RPA Class 1, 2 and 3 were 10.3, 7.8 and 2.2?months, respectively. Multivariate analysis revealed that karnofsky performance status (≥70, p?p?p?=?0.015), time to develop brain metastasis (<3?months, p?=?0.042) and use of chemotherapy after WBRT (multiple regimens, p?Conclusions Systemic chemotherapy for chemo-responsive cancer prolongs survival despite the presence of treated brain metastases. Irradiated brain metastases will lose their prognostic significance in a large number of patients. Systemic chemotherapy will be a treatment of choice for patients who have systemic disease after WBRT for brain metastases. These results should be validated in the future prospective clinical trials.     

Hepatocellular Carcinoma Screening in a Hepatitis B Virus-Infected Korean Population

Background

Hepatocellular carcinoma (HCC) screening has been recommended for hepatitis B virus (HBV)-infected individuals in an effort to detect HCC at a sufficiently early stage to provide potentially curative treatments. The study reported here is the first to address the rate of HCC screening use in an HBV endemic area.

Methods

Data were collected from 11,147 adults aged???40?years who participated in the 2007?C2009 Korea National Health and Nutrition Examination Survey and had a valid HBV surface antigen test. Current HCC screening was defined as either receiving an ultrasonography or an ??-fetoprotein measurement in the past year. Prevalence estimates were weighted.

Results

The response rate was 78.4?%, and 436 cases of HBV infection were identified. The overall seroprevalence of the HBV surface antigen was 4.1?% [95?% confidence interval (CI) 3.9?C4.4?%]. Of the 436 HBV-infected subjects, only 23.2?% (95?% CI 19.5??C27.4?%) were aware that they had been infected, and approximately 27?% (27.1 %; 95?%CI 23.2?Cto 31.5?%) were up to date with their HCC screening tests; more than half (52.9?%, 95?% CI 48.2?C57.5) had never been screened. In a multivariate analysis that included various sociodemographic variables, only self-reported awareness of HBV infection was significantly associated with current HCC screening tests (odds ratio?2.82; 95?% CI 1.64?C4.84).

Conclusions

Adoption of HCC screening as a standard practice among HBV-infected Korean adults aged???40?years is suboptimal. Evidence-based programs in communities and education for both healthcare providers and HBV-infected persons are needed to improve the implementation of HCC screening in clinical practice.     

Causes of moderate to large pericardial effusion requiring pericardiocentesis in 140?Han Chinese patients

Background

Causes of pericardial effusion requiring pericardiocentesis are very complex; a summary of 140?patients, especially those having iatrogenic pericardial effusion, is rare.

Methods

We prospectively analyzed the clinical data and etiology of moderate to large pericardial effusion requiring pericardiocentesis and drainage in 140?consecutive Han Chinese patients from January?2007 to December?2009.

Results

Pericardiocentesis was successfully performed and effective in all patients. There were 9?cases with transudates, while the remaining 131?cases were diagnosed with exudates (neoplastic in 54?patients, tuberculous in 40?patients, 9?cases of connective tissue diseases, 12?cases undergoing cardiac catheterization, and 8?cases of acute myocardial infarction). Among the 54?malignancies, 30?patients had lung cancer, 7?had breast cancer, and 4?had liver cancer. No differences in the clinical characteristics and the results of routine and biochemistry studies in the pericardial fluid between tuberculous and malignant groups were found. Of the 12?patients undergoing cardiac catheterization, 6?cases had undergone catheter ablation for tachycardia and 4?cases had undergone percutaneous coronary intervention. The 6?patients undergoing catheter ablation were women and the ratio of pericardial effusion was higher in women (6/436) than in men (0/462; p<0.05). Pericardiocentesis and drainage was effective in the 6?patients who underwent catheter ablation, and the remaining 6?patients underwent surgical intervention after pericardiocentesis and drainage. All 8?patients with acute myocardial infarction died during hospitalization.

Conclusion

In China, most moderate to large pericardial effusions requiring pericardiocentesis and drainage were exudates and bloody, which were mainly caused by malignancy and tuberculosis. However, the incidence of iatrogenic pericardial effusion has been increasing and should not be ignored. Pericardiocentesis and drainage were effective.     

Is l-Glutathione More Effective Than l-Glutamine in Preventing Enteric Diabetic Neuropathy?

Background

Diabetes and its complications appear to be multifactorial. Substances with antioxidant potential have been used to protect enteric neurons in experimental diabetes.

Aim

This study evaluated the effects of supplementation with l-glutamine and l-glutathione on enteric neurons in the jejunum in diabetic rats.

Methods

Rats at 90 days of age were distributed into six groups: normoglycemic, normoglycemic supplemented with 2 % l-glutamine, normoglycemic supplemented with 1 % l-glutathione, diabetic (D), diabetic supplemented with 2 % l-glutamine (DG), and diabetic supplemented with 1 % l-glutathione (DGT). After 120 days, the jejunums were immunohistochemically stained for HuC/D+ neuronal nitric oxide synthase (nNOS) and vasoactive intestinal polypeptide (VIP). Western blot was performed to evaluate nNOS and VIP. Submucosal and myenteric neurons were quantitatively and morphometrically analyzed.

Results

Diabetic neuropathy was observed in myenteric HuC/D, nNOS, and VIP neurons (p < 0.05). In the submucosal plexus, diabetes did not change nitrergic innervation but increased VIPergic neuronal density and body size (p < 0.05). Supplementation with l-glutathione prevented changes in HuC/D neurons in the enteric plexus (p < 0.05), showing that supplementation with l-glutathione was more effective than with l-glutamine. Myenteric nNOS neurons in the DGT group exhibited a reduced density (34.5 %) and reduced area (p < 0.05). Submucosal neurons did not exhibit changes. The increase in VIP-expressing neurons was prevented in the submucosal plexus in the DG and DGT groups (p < 0.05).

Conclusion

Supplementation with l-glutathione exerted a better neuroprotective effect than l-glutamine and may prevent the development of enteric diabetic neuropathy.     

Comparison of Three Types of Precut Technique to Achieve Common Bile Duct Cannulation: A Retrospective Analysis of 274 Cases

Background

The aim of this retrospective study was to evaluate the success rate and complications of three precut techniques of sphincterotomy after failure of conventional techniques of cannulation of common bile duct (CBD).

Patients and Methods

Between January 2003 and October 2011, 2,903 consecutive ERCPs were performed in patients with na?ve major papilla. In 283 patients in whom biliary cannulation was not achieved, precut technique was performed and these patients were included in the study.

Results

A total of 274 patients were included in the final analysis. Needle-knife papillotomy (NKP) was performed in 129 cases (47.1?%), suprapapillary fistulotomy (SPF) in 78 patients (28.5?%), and transpancreatic sphincterotomy (TPS) in 67 cases (24.5?%). No significant difference was observed in the initial and eventual success rate of biliary cannulation between the three groups. Overall, complications occurred in 54 patients (19.7?%), of which 33 (25.6?%) were with NKP, 6 (7.7?%) with SPF and 15 (22.4?%) with TPS, respectively, a difference statistically significant favoring the SPF group (p?=?0.006). Post-procedure acute pancreatitis was developed in 27 cases (20.9?%) with NKP, compared to two cases (2.6?%) with SPF and 15 cases (22.4?%) with TPS, a difference statistically significant favoring the SPF group. No difference was observed between the groups with regard to the occurrence of post-procedure hemorrhage and perforation.

Conclusions

The three types of precut sphincterotomy have no different overall CBD cannulation rates; SPF reduces post-ERCP pancreatitis risk.     

Risk factors for postoperative recurrence of non-B non-C hepatocellular carcinoma

Background/purpose

The majority of hepatocellular carcinomas are associated with chronic infection with hepatitis B or C virus. Recently, however, the proportion of non-B non-C hepatocellular carcinomas has been increasing. It is necessary to determine the optimal surgical approach for non-B non-C hepatocellular carcinoma.

Methods

Seventy-seven patients with non-B non-C hepatocellular carcinoma who underwent curative hepatic resection were included in this study. Univariate and multivariate analyses were performed to clarify risk factors for postoperative recurrence of non-B non-C hepatocellular carcinoma.

Results

On univariate analysis, surgical margin <5?mm (P?=?0.001) and the presence of multiple tumors (P?=?0.002) were significantly associated with lower disease-free survival rate. On multivariate analysis, surgical margin <5?mm and the presence of multiple tumors were independent risk factors for postoperative recurrence.

Conclusion

Curative resection with adequate surgical margins for single non-B non-C hepatocellular carcinoma can achieve a good outcome.     

First evidence of simultaneous occurrence of West Nile virus and Usutu virus neuroinvasive disease in humans in Croatia during the 2013 outbreak

Purpose

We report on first evidence of simultaneous occurrence of West Nile virus (WNV) and Usutu virus (USUV) neuroinvasive infection in humans in Croatia during the transmission season 2013.

Methods

From June to December 2013, a total of 95 patients with clinically suspected WNV infection (WNV fever and neuroinvasive disease) were tested for WNV IgM/IgG antibodies using enzyme-linked immunosorbent assay. Twenty-six reactive samples were further tested by virus neutralization test for confirmation.

Results

WNV neuroinvasive infection was confirmed in 20 patients, while in three patients USUV neutralizing antibodies were detected. Cases occurred during the 11-week interval (from 24 July to 07 October 2013). Both WNV and USUV cases were distributed in three north-western Croatian counties. In addition to human cases, recent asymptomatic WNV infection (detection of IgM antibodies) was recorded in 9/3,460 (0.3 %) tested sentinel horses. Infected animals were recorded in two eastern and one north-western county.

Conclusions

Our results indicate co-circulation of WNV and USUV in Croatia. WNV infection could be misdiagnosed with other emerging infectious diseases presenting with neurological symptoms such as USUV infection.