CD4+CD25+ regulatory T cell-mediated changes in the expression of endocytic receptors and endocytosis process of human dendritic cells

CD4⁺CD25⁺ regulatory T cells (Tregs) are known to inhibit immune responses to antigens. Since, the process of antigen uptake by dendritic cells (DC) is central to induction of immune responses, we analyzed the effect of Tregs on the expression of endocytic receptors on DC and its repercussion on antigen uptake. Our results demonstrate that Tregs down-regulate the expression and uptake of antigens via C-type lectin-like receptors CD206 and DC-SIGN, restrain the pinocytosis process of DC and augment the expression of FcγRIIB, an inhibitory Fcγ receptor the engagement of which by IgG-bound antigens leads to inhibition of DC activation. Our results thus provide an additional insight on the pertinence of strategies aimed at blocking Treg functions towards improved vaccination protocols.     

Elevated anti-Müllerian hormone (AMH) and inhibin B levels in prepubertal girls with type 1 diabetes mellitus

Objective Elevated anti‐Müllerian hormone (AMH) and adrenal androgen levels have been observed during childhood in girls at risk of developing polycystic ovarian syndrome (PCOS). The aim of this study was to evaluate ovarian function and adrenal steroid levels in prepubertal girls with type 1 diabetes mellitus (T1D). Design Cross‐sectional study. Patients/Measurements We evaluated hormonal and ultrasonographic characteristics in girls with T1D (N = 73) and compared them to characteristics found in a control group of healthy girls (N = 86). Data are reported as geometric means (95% CI). Results Prepubertal girls with T1D had higher levels of AMH (29·1 pmol/l (23·2–36·3) vs 20·9 pmol/l (16·6–26·1), P = 0·038), inhibin B (arithmetic mean: 16·7 pg/ml (11·6–21·7) vs 11·7 pg/ml (10·0–13·5), P = 0·044) and dehydroepiandrosterone sulphate (DHEAS) (0·3 nmol/l (0·2–0·6) vs 0·2 nmol/l (0·1–0·3)) than controls (P = 0·045). During puberty, decreasing AMH levels were observed in girls with T1D only (P < 0·0001). Girls with T1D in Tanner stages 4–5 had lower AMH levels than their paired healthy controls (10·1 pmol/l (7·4–13·9) vs 15·7 pmol/l (11·6–21·3), respectively, P = 0·047). Conclusions Our observations indicate that prepubertal girls with T1D may exhibit similar endocrine findings to those of other girls at risk of developing PCOS. The elevated levels of AMH and inhibin B suggest that higher numbers of follicles are present in the ovary during childhood in these patients and that insulin treatment may act as a local growth factor. In addition, AMH levels differed in prepubertal and pubertal girls, suggesting that the effect of T1D on ovarian folliculogenesis changes once gonadotrophin levels rise during puberty .     

Esophageal perforation following a biopsy in a patient with eosinophilic esophagitis

Eosinophilic esophagitis is an underdiagnosed disease that should be suspected in all patients with dysphagia and food impaction. Although these are the leading symptoms, the clinical and endoscopic spectrum is highly varied. Clinicians should be aware of the risk of endoscopy-related complications in this disorder. Precautions should be maximized in endoscopic examinations to avoid iatrogenic damage. We describe the case of a young patient with esophageal stricture and dysphagia who suffered a perforation following a biopsy.     

Signet ring cell carcinoma of the ampulla of Vater

Introduction

Signet ring cell carcinoma of the ampulla of Vater is a rare entity and less than 20 cases have been described in the literature. We report the cases of two patients with this disease and provide a literature review of previous studies.

Case report

We describe two patients with obstructive jaundice. Abdominal ultrasonography and abdominal computed tomography showed dilatation of the intrahepatic and common bile duct. Duodenoscopy indicated a protruding mass on the ampulla of Vater. Histopathological examination showed round cells and their nuclei were located on one side with prominent signet-ring features. One patient underwent a cephalic pancreatoduodenectomy with lymphadenectomy and the other a total pancreatectomy.

Discussion

Signet ring cell carcinoma of the ampulla of Vater has only been described in isolated cases in the literature. Therefore, the clinicopathological features and prognosis of this disease have not yet been well defined.     

Emergency care of patients with upper gastrointestinal bleeding in regional hospitals in Catalonia

Objective

To evaluate the resources available in Catalan regional hospitals for the emergency care of upper gastrointestinal hemorrhage.

Methods

We analyzed a survey sent to 32 hospitals on the availability, composition and resources of a duty endoscopy service for the year 2009.

Results

Responses were obtained from 24 centers, covering 3,954,000 inhabitants. Duty endoscopists were available in 12 hospitals. A total of 1,483,000 inhabitants were unable to access a duty endoscopist in the referral center. Centers with duty endoscopists had more beds and had a larger catchment area. Duty services were composed of 4.5 endoscopists (range 2-11), covering 82.1 (33.2-182.5) duty shifts/year. Seventeen centers reported 1,571 episodes (51%, range: 3-280, 39.68/100,000 inhabitants). Centers with a duty service reported a greater number of cases (76 vs. 43, p = 0.047). Centers without this service referred a greater number of patients (147 vs. 17, p = 0.001). Patients in the emergency department were under the care of the internal medicine department in four centers, the surgery department in 14 centers and under the care of both departments in six. Admitted patients were under the care of the gastroenterology department in only six hospitals. The most widely used procedures were ligation of varicose bleeding and injection therapies in non-varicose bleeding. Twenty-one percent of centers did not perform combined treatment.

Conclusions

A significant proportion of the population does not have access to a duty endoscopist in referral centers. Duty shifts represent significant workload in regional hospitals. Coordination among health professionals and centers would allow the efficient application of therapeutic resources and a duty endoscopy service to be established in centers lacking this resource.     

Can fast-component of nystagmus on caloric vestibulo-ocular responses predict emergence from vegetative state in ICU?

The aim of the study was to determine if bedside caloric vestibulo-ocular responses (VOR) are able to predict consciousness recovery from clinically determined vegetative state (VS) in the ICU. Twenty-six severely brain injured patients that were clinically in VS were included. Horizontal VOR were tested at bedside by cold-water irrigation of the external auditory canal. Visual inspection evaluated the presence of a slow drift toward the side of stimulation (slow-component of nystagmus or tonic deviation) as well as the presence of a rapid compensatory movement/jerk back to the midline (fast-component of nystagmus). Patients were then divided into two groups according to whether they eventually regained consciousness or not. Patients were 59 ± 21 years old. Thirteen out of 26 patients ultimately recovered consciousness and 13 remained unconscious. Thirteen patients (100%) presented a slow-component of nystagmus during VOR testing in the group that recovered consciousness and 11 (85%) in the group that remained unconscious. All the patients that recovered consciousness (13, 100%) presented a fast-component of nystagmus during VOR testing compared to only one of 11 patients (8%) in the group that remained unconscious. Sensitivity of fast-component of nystagmus during VOR testing to predict recovering of consciousness was 1.00, specificity was 0.92, positive predictive value was 0.93 and negative predictive value was 1.00. Bedside VOR testing in clinically VS patients seems able to predict consciousness recovery from vegetative state and could help to preclude active medical treatment withdrawal and to indicate the need for further complementary explorations, i.e. event-related potentials, functional MRI or PET-scan.