Cefiderocol heteroresistance associated with mutations in TonB-dependent receptor genes in Pseudomonas aeruginosa of clinical origin.

The siderophore-cephalosporin cefiderocol(FDC) presents a promising treatment option for carbapenem-resistant (CR) P. aeruginosa (PA). FDC circumvents traditional porin and efflux mediated resistance by utilizing TonB-dependent receptors (TBDRs) to access the periplasmic space. Emerging FDC resistance has been associated with loss of function mutations within TBDR genes or the regulatory genes controlling TBDR expression. Further, difficulties with antimicrobial susceptibility testing (AST) and unexpected negative clinical treatment outcomes have prompted concerns for heteroresistance, where a single lineage isolate contains resistant subpopulations not detectable by standard AST. This study aimed to evaluate the prevalence of TBDR mutations among clinical isolates of P. aeruginosa and the phenotypic effect on FDC susceptibility and heteroresistance. We evaluated the sequence of pirR , pirS , pirA , piuA or piuD from 498 unique isolates collected before the introduction of FDC from 4 clinical sites in Portland, OR (1), Houston, TX (2), and Santiago, Chile (1). At some clinical sites, TBDR mutations were seen in up to 25% of isolates, and insertion, deletion, or frameshift mutations were predicted to impair protein function were seen in 3% of all isolates (n=15). Using population analysis profile testing, we found that P. aeruginosa with major TBDR mutations were enriched for a heteroresistant phenotype and undergo a shift in the susceptibility distribution of the population as compared to susceptible strains with wild type TBDR genes. Our results indicate that mutations in TBDR genes predate the clinical introduction of FDC, and these mutations may predispose to the emergence of FDC resistance.

Evolving landscape of carbapenem-resistant Pseudomonas aeruginosa at a single centre in the USA.

Objectives: The increased identification of carbapenem-resistant Pseudomonas aeruginosa (CR-PA) is an ongoing concern. However, information on the evolving antimicrobial resistance profile and molecular epidemiology of CR-PA over time is scarce. Thus, we conducted a cross-sectional analysis to investigate the phenotypic and genotypic characteristics of CR-PA recovered over different time periods, focusing on the isolates exhibiting a ceftolozane/tazobactam resistance phenotype. Methods: A total of 169 CR-PA isolated from clinical specimens at a single centre in Houston, TX, USA were studied. Among them, 61 isolates collected between 1999 and 2005 were defined as historical strains, and 108 collected between 2017 and 2018 were defined as contemporary strains. Antimicrobial susceptibilities against selected ß-lactams was determined. WGS data were used for the identification of antimicrobial resistance determinants and phylogenetic analysis. Results: Non-susceptibility to ceftolozane/tazobactam and ceftazidime/avibactam increased from 2% (1/59) to 17% (18/108) and from 7% (4/59) to 17% (18/108) from the historical to the contemporary collection, respectively. Carbapenemase genes, which were not identified in the historical collection, were harboured by 4.6% (5/108) of the contemporary strains, and the prevalence of ESBL genes also increased from 3.3% (2/61) to 16% (17/108). Genes encoding acquired ß-lactamases were largely confined to the high-risk clones. Among ceftolozane/tazobactam-resistant isolates, non-susceptibility to ceftazidime/avibactam, imipenem/relebactam and cefiderocol was observed in 94% (15/16), 56% (9/16) and 12.5% (2/16), respectively. Resistance to ceftolozane/tazobactam and imipenem/relebactam was primarily associated with the presence of exogenous ß-lactamases. Conclusions: Acquisition of exogenous carbapenemases and ESBLs may be a worrisome trend in P. aeruginosa.

Assessment of the water sources for potential channels of faecal contamination within Vhembe District Municipality using sanitary inspections and hydrogen sulphide test.

Numerous human activities and poor sanitation management cause public health concern, particularly in rural communities without reliable water supply systems and resources for the monitoring of the quality of their water sources. This study assessed the relationship between observed sanitary risks and hydrogen sulphide (H2S) strip test results in the identification of faecal contamination of various water sources used at household level in rural areas of the Vhembe District Municipality. The highest percentage sanitary risk scores ranging from 50 to 100% were recorded for both river and dam water commonly used by the households for multiple purposes, including drinking. All the surface water samples (100%) also tested positive for H2S production, which is linked to the contamination of water sources by bacteria of faecal origin. The overall results showed a significant and positive correlation (r = 0.623, p = 0.003 in the wet season and r = 0.504, p = 0.017 in the dry season) between sanitary risk scores and H2S strip test results. In low resource settings, the use of sanitary inspections combined with the inexpensive and easy-to-use H2S strip tests can be effective as drinking water quality management tools to raise an awareness among community members of the faecal contamination of their water sources.

Tuning water chemistry for the recovery of greener products: pragmatic and sustainable approaches.

The environmental impact and denaturing propensity of organic solvents in the extraction of plant bioactives pose great challenges in extraction systems. As a result, proactive consideration of procedures and evidence for tuning water properties for better recovery and positive influence on the green synthesis of products become pivotal. The conventional maceration approach takes a longer duration (1-72 h) for product recovery while percolation, distillation, and Soxhlet extractions take about 1 to 6 h. An intensified modern hydro-extraction process was identified for tuning water properties with an appreciable yield similar to organic solvents within 10-15 min. The percentage yield of tuned hydro-solvents achieved close to 90% recovery of active metabolites. The additional advantage of using tuned water over organic solvents is in the preservation of the bio-activities and forestalling the possibility of contamination of the bio-matrices during extractions with an organic solvent. This advantage is based on the fast extraction rate and selectivity of the tuned solvent when compared to the traditional approach. This review uniquely approaches the study of biometabolite recovery through insights from the chemistry of water under different extraction techniques for the very first time. Current challenges and prospects from the study are further presented.

Association of genetic polymorphism at tumor necrosis factor-α gene promoter - 1031T/C and parasitic infections among children in Northern South Africa.

Intestinal parasitic diseases are common in developing countries including South Africa and have been documented to be the most common in children under the age of five. The present study aimed to identify any potential association that may exist between TNF-α promoter gene polymorphism and parasitic infections. A total of 199 blood samples were evaluated from children who were part of the MAL-ED study cohort. The DNA was used to investigate polymorphism in the promoter region of the TNF-α gene at position -1031T/C. The polymorphisms were detected by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay. The TC genotype at position -1031 was significantly higher in healthy controls children than in children who were infected with Entamoeba species (59.9% vs 29.4%, P = 0.015) and Entamoeba coli (59.1% vs 30.8%, P = 0.046), indicating that TC genotype may be protective against Entamoeba infections and Entamoeba coli infections. The CC genotype at position -1031 was more common among children with parasite and diarrhea and the results was statistically significant (P = 0.04). This study has revealed that the CC genotype may be is a risk factor for symptomatic parasitic infections while the TC genotype might be protective of Entamoeba infections among children in Dzimauli community.

Seasonality and within-subject clustering of rotavirus infections in an eight-site birth cohort study.

Improving understanding of the pathogen-specific seasonality of enteric infections is critical to informing policy on the timing of preventive measures and to forecast trends in the burden of diarrhoeal disease. Data obtained from active surveillance of cohorts can capture the underlying infection status as transmission occurs in the community. The purpose of this study was to characterise rotavirus seasonality in eight different locations while adjusting for age, calendar time and within-subject clustering of episodes by applying an adapted Serfling model approach to data from a multi-site cohort study. In the Bangladesh and Peru sites, within-subject clustering was high, with more than half of infants who experienced one rotavirus infection going on to experience a second and more than 20% experiencing a third. In the five sites that are in countries that had not introduced the rotavirus vaccine, the model predicted a primary peak in prevalence during the dry season and, in three of these, a secondary peak during the rainy season. The patterns predicted by this approach are broadly congruent with several emerging hypotheses about rotavirus transmission and are consistent for both symptomatic and asymptomatic rotavirus episodes. These findings have practical implications for programme design, but caution should be exercised in deriving inferences about the underlying pathways driving these trends, particularly when extending the approach to other pathogens.

Antibiotic resistance patterns and beta-lactamase identification in Escherichia coli isolated from young children in rural Limpopo Province, South Africa: The MAL-ED cohort.

BACKGROUND: Antibiotic resistance is a growing problem worldwide. Mechanisms of resistance vary, and some can confer resistance to multiple classes of antibiotics. OBJECTIVE: To characterise the antibiotic resistance profiles of Escherichia coli isolates obtained from stool samples of young rural children exposed or unexposed to antibiotics. METHODOLOGY: The samples were collected from children aged 4 - 12 months who were participants in the Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) project at the South Africa research site. We isolated 87 E. coli samples (clones) from 65 individual participants, all of which were subjected to disc diffusion assay to determine resistance. We characterised the minimum inhibitory concentration of antibiotics in a subset of strains as well as the mechanism by which these strains were resistant to beta-lactam antibiotics. RESULTS: Our results revealed high resistance rates to co-trimoxazole (54.0%), penicillin (47.1%) and tetracycline (44.8%) in our isolates, and indicated that the beta-lactamase TEM-1 is a prevalent source of beta-lactam resistance. We also identified two isolates with the extended-spectrum beta-lactamase CTX-M-14. CONCLUSIONS: This study identified antibiotic-resistant E. coli in children with and without prior exposure to antibiotics, with some isolates showing resistance to multiple classes of antibiotics. Clinicians should bear in mind that transmission of extended-spectrum beta-lactamase-resistant E. coli exists at the community level, and that children as young as 2 years may be harbouring these resistant phenotypes.

Tramadol-Paracetamol Combination for Postoperative Pain Relief in Elective Single-level Microdisectomy Surgery.

BACKGROUND: The tramadol and paracetamol combination is used frequently for postoperative pain management. The literature on the use of this combination for vertebral surgery is limited. Our objective was to compare a combination of paracetamol 1 g and a lower dose of tramadol (1 mg/kg: group 1T) with a combination of paracetamol 1 g and a higher dose of tramadol (1.5 mg/kg: group 1.5T) for postoperative pain after microdisectomy surgery. Our main outcome measure was Visual Analogue Scale pain scores for 4 hours postoperatively. METHODS: This prospective randomized triple-blind clinical trial was conducted at Aga Khan University Hospital, Karachi. Ninety-four patients aged between 18 and 50 years scheduled for elective single-level microdisectomy were allocated randomly into 1 of 2 groups. Twenty minutes before the end of the surgery, patients received the study drugs. RESULTS: There was no significant demographic difference between groups. None of the patients experienced severe pain (VAS>6). There was no significant difference in the mean pain score between groups. The mean score at 4 hours was 2.17 (1.38) in group 1.5T and 1.74 (1.37) in group 1T. The difference was not statistically significant (P=0.14). In group 1.5T, 13 patients reported having nausea and vomiting compared with 2 patients in group 1T. This was a statistically significant difference (P=0.004). The sedation score was similar between groups. CONCLUSIONS: The combination of low-dose tramadol (1 mg/kg) and paracetamol has comparable analgesia and a decreased incidence of nausea and vomiting compared with the higher dose of tramadol (1.5 mg/kg) and paracetamol combination.

Prevalence and risk factors of Cryptosporidium species among domestic animals in rural communities in Northern South Africa.

To determine the prevalence and possible risk factors for the transmission of Cryptosporidium species among animals in rural Limpopo Province, South Africa. A total of 314 stool samples from 64 households were collected from animals in three villages situated in the Vhembe and Mopani Districts, South Africa and examined for Cryptosporidium, using the modified Ziehl Neelsen technique and confirmed by the real time PCR method. A questionnaire was developed to capture demographic data as well as other household information from the owners of the animals. Positive samples were further sequenced for the identification of the species present in the samples. The overall prevalence of Cryptosporidium among the animals was 31.2%. Of all the animal types tested goats (47.7%) appeared to be the most infected followed by cattle (26.8%) and chicken (7.4%). From the 64 households surveyed 43 (67.2%) had at least one or more infected animals. Adult animals were more infected (32%) compared to young animals (29%) but the difference was not statistically significant (p=0.793). The gender of the animal as well as the consistency of the stool did not affect the occurrence of Cryptosporidium; however, the level of education as well as the gender of the owners significantly affected the prevalence of Cryptosporidium among the animals they kept. C. parvum was the most commonly isolated organism while C. andersoni was identified in our region for the first time as well and occurred in both goats and cattle. This study showed a high prevalence of Cryptosporidium in domestic animals, which could constitute a health threat to both animals and humans in the region. The gender of the head of the Household and level of education were very significant factors in the prevalence of Cryptosporidium among the animals. Community education will be useful in helping reduce the impact of these infections.

A patient with a hyperechoic band-shaped structure in the right hepatic vein.

Cement (polymethylmethacrylat) is frequently and increasingly used in vertebral surgery. Complications can occur by spillage of this material; however the vast majority of the patients remain free of symptoms and do not require any specific therapy.Internists, gastroenterologists and radiologists regularly performing abdominal ultrasound and computed tomography should be aware of this complication.A case of spillage of cement in the right hepatic vein is presented.

Association of interleukin-8 gene polymorphisms in HIV patients with opportunistic infections in Limpopo Province, South Africa.

Opportunistic infections (OIs) are common among human immunodeficiency virus (HIV) patients; however, genetic susceptibility to these infections has not been studied. Recent studies have shown that interleukin-8 (IL-8) A/T genotype carriers are more susceptible to a variety of diseases. In this study, we showed the effects of IL-8 gene polymorphisms on OIs and symptoms such as sexually transmitted diseases (STDs), tuberculosis (TB), diarrhea, shortness of breath, weight loss, and viral load, in HIV and acquired immunodeficiency syndrome patients. Genomic DNA was purified from mouthwash samples collected from patients attending HIV centers in the Vhembe district. The IL-8 (-251) A/T locus was genotyped using allele-specific polymerase chain reaction followed by agarose gel electrophoresis. The results showed a weak association between the IL-8 AA genotype and OIs such as STDs (P = 0.143), diarrhea (P = 0.906), and TB (P = 0.762). Significant associations were found between the IL-8 AT genotype and weight loss (P = 0.019), shortness of breath (P = 0.043), and skin problems (P = 0.003). Low viral load was also found to be significantly associated with IL-8 AA genotype (P = 0.009). The present study suggests that different IL-8 genotypes are associated with resistance to various OIs. However, further studies using larger samples sizes are needed to confirm this hypothesis.

Effects of different sulphur amino acids and dietary electrolyte balance levels on performance, jejunal morphology, and immunocompetence of broiler chicks.

As alterations of dietary electrolyte balance (DEB) can influence amino acid metabolism via changes the ions incur in their configurations, performance and immunological responses of broiler chicks might be affected. So, the current study was carried out to investigate the effects of different levels of sulphur amino acids (SAA) and DEB on performance, jejunal morphology and immunocompetence of broiler chicks. A total of 360 1-day-old male Ross 308 broiler chicks were randomly assigned to nine experimental treatments with four replicates of 10 birds each. Experimental treatments consisted of three levels of SAA (100, 110, and 120% of NRC recommendation, provided by methionine supplementation in diets with the same cysteine level) and three levels of DEB (150, 250, and 350 mEq/kg) that were fed during the entire of trial in a 3 × 3 factorial arrangement. Results showed that the relative weights of intestine and abdominal fat were decreased markedly (p < 0.001) with increasing levels of SAA and DEB respectively. Antibody titre against sheep red blood cell was neither individually nor in combination influenced by supplementation of SAA or DEB. Nevertheless, a decrease in DEB level led to a suppression in heterophile (p < 0.05) and an increase in lymphocyte counts (p = 0.06); consequently, heterophile to lymphocyte ratio was significantly decreased (p < 0.05) by decremental levels of DEB. Albumin to globulin ratio was increased after inclusion of at least 10% SAA (p < 0.001) and 150 mEq DEB/kg in the diet (p = 0.11). Although feeding high-DEB level led to a remarkable decrease in villus height (p < 0.01) and goblet cell numbers (p < 0.001), supplementing the highest level of SAA improved the height of jejunal villus. During the entire trial period, average daily feed intake (ADFI) was increased by incremental SAA levels (p < 0.05). However, inclusion of 150 mEq/kg led to not only a remarkable increase (p < 0.0001) in both ADFI and average daily weight gain (ADWG) but also to improved (p < 0.001) feed conversion ratio (FCR) both during the growing and over the entire trial periods. The present findings indicated that inclusion of low DEB decreased the heterophile to lymphocyte ratio and improved both the albumin to globulin ratio and intestinal health indices. The best growth performance was obtained with 150 mEq DEB/kg in the diet for each level of SAA.

Interleukin-7 receptor gene polymorphism at +1237 locus and its effect on susceptibility to opportunistic infections among HIV and AIDS patients in Limpopo Province, South Africa.

Over the past decade, an increasing number of studies have demonstrated correlations between host genetics and susceptibility to diseases. However, few studies have investigated the effects of host genetics on the occurrence of opportunistic infections among human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) patients. In the present study, the frequency of the interleukin (IL)-7Rα+1237 A/G single nucleotide polymorphisms was determined in relation to opportunistic infection occurrence among HIV and AIDS patients in the Vhembe District. Demographic, clinical, and socioeconomic status data were collected from patients using a structured questionnaire. Genomic DNA was extracted from mouthwash samples using the QIAmp Blood Mini Kit. Genotyping of the IL-7Rα+1237 gene was conducted using a sequence-specific polymerase chain reaction method. We found that the IL-7Rα+1237 genotype distribution in our study population differed from those in European populations with a predominance of the A/G genotype. Individuals carrying the A/G genotype primarily suffered from chest pain (χ(2) = 5.016, P = 0.025), while individuals carrying the G/G genotype were protected from chest pain but had a higher prevalence of sexually transmitted disease (23 vs 16.9%); however, the difference was not statistically significant (P = 0.435). Individuals carrying the A/A genotype were more susceptible to diarrhea (32 vs 13.6%) (P = 0.034). Our data will support gene therapy and may be used to modify the course of diseases among HIV patients as well as the general population. Further studies using larger populations are needed to confirm these hypotheses.

Distribution of CXCR2 +1208 T/C gene polymorphisms in relation to opportunistic infections among HIV-infected patients in Limpopo Province, South Africa.

Interleukin 8 (IL-8) is a chemokine produced by macrophages and other cell types, including epithelial cells, and its receptor is CXCR2. IL-8 plays an important role in the initiation and amplification of inflammatory diseases, including opportunistic infections. With the advent of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome, opportunistic infections have become major health concerns. However, the role of host genetics on the occurrence of these infections has not been clearly defined. In this study, genomic DNA was extracted from 185 HIV-infected individuals in the Limpopo Province, South Africa. Allele-specific polymerase chain reaction was used to genotype the CXCR2 +1208 T/C gene. Genotypes CC, TT, and TC were associated with chest pains, frequent headaches, loss of weight, diarrhea, and loss of appetite among HIV patients. A significant association between the CC genotype and chest pains was found (P=0.035). The TC genotype was associated with loss of appetite (P=0.044) and chest pains (P=0.042). A weak association between diarrhea and the TT genotype was found (P=0.082). No association was observed between tuberculosis and the genotypes. Immunological characteristics, such as viral load and CD4 count, were not significantly associated with the genotypes. The results of the present study suggest that carriers of the TC genotype are more susceptible to chest pain, but that this genotype confers a protective effect against loss of appetite. The CC genotype was found to confer protection against chest pain but appeared to increase susceptibility to headaches. Further studies using larger samples are necessary to confirm these results.

Endoscopic procedures in patients under clopidogrel or dual antiplatelet therapy: a survey among German gastroenterologists and current guidelines.

BACKGROUND: Because of the higher risk of bleeding, guidelines recommend cessation of clopidogrel seven days prior to high-risk endoscopic procedures. However, premature cessation of clopidogrel may lead to catastrophic cardiovascular sequelae due to stent thrombosis. We aimed to assess the current clinical practice among German gastroenterologists regarding endoscopic procedures in patients under clopidogrel/dual antiplatelet therapy. METHODS: A 10-item questionnaire on endoscopic procedures in patients under clopidogrel/dual antiplatelet therapy was sent by e-mail to all 220 members of the ALGK. RESULTS: 73 (33 %) chief gastroenterologists returned completed questionnaires, 35 (48 %) of whom conduct high-volume endoscopic units performing more than 4000 procedures per annum. 62 (85 %) endoscopic units perform endoscopic biopsies under clopidogrel alone, while just in 30 (41 %) departments biopsies are carried out under dual antiplatelet therapy. In 36 (49 %) GI-units endoscopic polypectomy under clopidogrel monotherapy is performed, in contrast to only 4 (5.5 %) in the case of combined antiplatelet therapy. However, in emergency situations more than 60 % of all participants do perform endoscopic sphincterotomy in patients under clopidogrel/dual antiplatelet therapy. Percutaneous endoscopic gastrostomy is carried out in 32 endoscopic units (44 %) under clopidogrel monotherapy, but only in 4 (5.5 %) under dual antiplatelet therapy. CONCLUSION: Current guidelines on endoscopic procedures in patients under clopidogrel/dual antiplatelet therapy are mainly based on expert opinion and therefore, backed by only weak evidence. Our survey shows that in this setting the clinical decision making takes place on an individual basis, as there are no data to support the recommendations of the present guidelines.

Genotypic detection and evaluation of the removal efficiency of Giardia duodenalis at municipal wastewater treatment plants in Northern South Africa.

Over the past decade, Giardia duodenalis has increasingly been implicated in diarrheal outbreaks and water and wastewater have been recognized as important vehicles for diseases. Although studies have reported the occurrence of these parasites in developed countries, their occurrence in water and wastewater bodies in these countries including South Africa has not been thoroughly investigated. In the present study, wastewater samples from 6 different sewage treatment plants in the Vhembe District were collected for a period of 12 months. The samples were concentrated and tested for the presence of G. duodenalis using both microscopy and polymerase chain reaction methods targeting the tpi gene. Of the 79 wastewater samples tested, 25 (31.65%) were positive. Of these, 15 (60%) were assemblage A, while 8 (32%) were assemblage B and 2 samples (8%) were positive for both genogroups. Assemblage A was more common in February 2010 while assemblage B showed two peaks in December-January and March-April and was not detected in May 2010. The general removal rate was 40% for plants using biological filters and 20% for plants using activated sludge. The present study has shown that Giardia assemblage A is more common in sewage treatment plants in the Vhembe District, but the removal efficiency was low. This represents a public health hazard since these organisms might contaminate drinking water sources. Therefore action needs to be taken for the design of more effective procedures or methods for the removal of these parasites from the environment in order to avoid potential outbreaks.

Effect of different levels of black cumin (Nigella sativa L.) on performance, intestinal Escherichia coli colonization and jejunal morphology in laying hens.

This study was conducted to investigate the effects of different levels of black cumin seeds (Nigella sativa L.) on performance, intestinal Escherichia coli count and morphology of jejunal epithelial cells in laying hens. A total of 100 Leghorn laying hens (Hy-Line W-36) of 49 weeks old were randomly distributed among five cage replicates of five birds each. Experimental diets consisted of different levels (0%, 1%, 2% and 3% of diet) of dietary black cumin inclusion. The experimental period lasted for a total of 10 weeks, and egg quality indexes and laying hens' performance were measured as two 35-day trial periods. At the final day, two hens per replicate were slaughtered to investigate the influence of dietary treatments on intestinal E. coli colonization and morphology of jejunal cells. Although dietary black cumin in all supplementation levels decreased (p < 0.05) the enumeration of ileal E. coli, the morphological and histological alterations in small intestine such as enhancement of villus height to crypt depth ratio, increased goblet cell numbers and proliferation of lamina propria lymphatic follicles were observed after dietary supplementation with at least 2% black cumin. Dietary treatments decreased (p < 0.05) the concentration of serum cholesterol and triglycerides and increased (p < 0.05) serum HDL concentration and relative weight of pancreas; however, the egg yolk cholesterol was not influenced by dietary treatments. In addition, dietary supplementation with black cumin improved (p < 0.05) eggshell quality and Haugh unit. The best feed conversion ratio was obtained when diets were supplemented with 2% black cumin. This improvement was due to the increase (p < 0.05) in egg mass and contemporaneous decrease (p < 0.01) in feed consumption. The present results indicated that regardless of supplementation level, dietary inclusion of black cumin decreased E. coli enumeration in ileal digesta and improved serum lipid profile and eggshell quality, whereas the best intestinal health indices and haying hens' performance were obtained by at least 2% black cumin seeds.

Spontaneous intramural small-bowel hematoma secondary to anticoagulant therapy: a case series.

Spontaneous small-bowel hematomas most commonly involve the jejunum, followed by the ileum and duodenum, and occur in patients who receive excessive anticoagulation with phenprocoumon/warfarin or who have additional risk factors for bleeding. We report three cases of intramural small-bowel hematoma, all complications of treatment with phenprocoumon, which nowadays is used extensively for therapeutic and prophylactic purposes. Diagnosis can be readily attained by sonography and confirmed using computed tomography. Early diagnosis is crucial because most patients can be treated successfully without surgery. Based on this experience and data from the literature, conservative treatment is recommended for intramural intestinal hematomas, when other complications needing laparotomy have been excluded.

Safety of endoscopic sphincterotomy in patients under dual antiplatelet therapy.

BACKGROUND/AIMS: Dual antiplatelet therapy has to be used for at least one month after placement of bare metal coronary stents and for a minimum of one year after placement of drug eluting stents. Because of the higher risk of bleeding, guidelines strongly recommend to delay elective surgery until dual antiplatelet therapy is terminated. However, no data are available regarding the bleeding risk in patients on combined aspirin/clopidogrel therapy undergoing high-risk endoscopic procedures, such as emergency endoscopic biliary sphincterotomy. METHODOLOGY: We retrospectively analyzed the medical reports of patients who had to undergo endoscopic retrograde cholangiography with endoscopic sphincterotomy (ES) while on dual antiplatelet therapy in our unit between January 2009 and December 2011. RESULTS: In our series, ES was safely performed in eight consecutive patients on dual antiplatelet therapy with no evidence of bleeding. CONCLUSION: ES may be safely performed in patients on dual antiplatelet therapy.