Network meta-analysis of prophylactic pancreatic stents and non-steroidal anti-inflammatory drugs in the prevention of moderate-to-severe post-ERCP pancreatitis.

BACKGROUND: There is an ongoing debate that non-steroidal anti-inflammatory drugs (NSAID) or prophylactic pancreatic stents (PPS) are more beneficial in preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). In our present network meta-analysis, we aimed to compare PPSs to rectal NSAIDs in the prevention of moderate and severe PEP in average- and high-risk patients. METHODS: We performed a systematic search for randomized controlled trials (RCT) from MEDLINE (via PubMed), Embase and Cochrane Central databases. RCTs using prophylactic rectal NSAIDs or PPSs in patients subjected to ERCP at average- and high-risk population were included. The main outcome was moderate and severe PEP defined by the Cotton criteria. Pairwise Bayesian network meta-analysis was performed, and interventions were ranked based on surface under cumulative ranking (SUCRA) values. RESULTS: Seven NSAID RCTs (2593 patients), and 2 PPS RCTs (265 patients) in the average-risk, while 5 NSAID RCTs (1703 patients), and 8 PPS RCTs (974 patients) in the high-risk group were included in the final analysis. Compared to placebo, only PPS placement reduced the risk of moderate and severe PEP in both patient groups (average-risk: RR = 0.07, 95% CI [0.002-0.58], high-risk: RR = 0.20, 95% CI [0.051-0.56]) significantly. Rectal NSAID also reduced the risk, but this effect was not significant (average-risk: RR = 0.58, 95% CI [0.22-1.3], high-risk: RR = 0.58, 95% CI [0.18-2.3]). Based on SUCRA, PPS placement was ranked as the best preventive method. CONCLUSION: Prophylactic pancreatic stent placement but not rectal NSAID seems to prevent moderate-to-severe PEP better both, in average- and high-risk patients.

Risk factors of post-ERCP pancreatitis in high-risk patients despite prevention with prophylactic pancreatic stents.

Objectives: To analyze risk factors of post-ERCP pancreatitis (PEP) in high risk patients in whom prophylactic pancreatic stents (PPSs) were intended to use to prevent endoscopic retrograde cholangiography (ERCP)-related complications.Patients and methods: Three hundred and seventeen high-risk patients for developing PEP were considered for preventive pancreatic stent placement in our endoscopy unit over 5 years. 5 Fr, 3-5 cm long PPSs were used. All data were collected in a predefined database. Development of PEP despite PPS placement was analyzed.Results: PEP occurred in 29 of 288 successfully stented patients (10.07%; 24 mild, four moderate, one severe). PPS was protective against all risks factors except for sphincter of Oddi dysfunction (SOD). PPS related complication rate was 2.78% (n = 8). Unsuccessful stenting occurred in 29 patients (9.15%), PEP developed in 41.38% (n = 12; seven mild, four moderate, one severe). Those patients who had more patient related risk factors were more likely to develop PEP despite preventive measures with PPS. On the contrary, PPS placement was less successful in patients who had more procedure related risk factors.Conclusions: PPS is protective against all risks factors of PEP except for SOD in high-risk patients. More vulnerable patients who have more patient-related risk factors are more likely to develop PEP despite PPS is used, while more complex procedures predispose to unsuccessful PPS placement in patients with more procedure-related risk factors. PPS insertion in high-risk patients is effective and safe preventive method and the procedure related complication rate is reasonably low.

Improved adenoma detection with linked color imaging technology compared to white-light colonoscopy.

OBJECTIVES: Linked color imaging (LCI) is a new endoscopic technology that may increase colorectal adenoma detection rate (ADR) and polyp detection rate (PDR) by virtual chromoendoscopy. Aim of the present study was to evaluate the effectiveness of LCI in ADR and PDR compared to the HD white-light colonoscopy (WLC) technique. MATERIALS AND METHODS: Between October 2016 and June 2018, we enrolled consecutive outpatients prospectively. Eligible patients allocated randomly to undergo HD WLC or LCI colonoscopy technique during instrument withdrawal. Each colonoscopy was performed in a single center by the same three expert endoscopists (with expertise more than 5000 colonoscopies). RESULTS: A total of 1278 patients underwent colonoscopy in the study period. ADR and PDR were significantly higher in the LCI group compared to the WLC group (34.4% vs. 26.8%; p = .007; and 53.3% vs 46.4%; p = .023, respectively). Similarly, the mean number of adenomas per patient (MAP) was significantly higher with the LCI than WLC (0.64 vs 0.44, respectively; p = .002). The mean age of patients at the time of colonoscopy was 51.95 years (SD = 13.861) in the LCI group and 51.96 years (SD = 14.028) in the WLC group. No significant differences observed in patient demographic characteristics (there was no difference in gender and age distribution, p = .986), quality of colonoscopy preparation and withdrawal times (WT) between the two groups (WLC and the LCI groups, 493.9 (SD: 143.5) and 514.0 (SD: 139.5) sec, respectively). CONCLUSIONS: According to our results, LCI virtual chromoendoscopic technology was superior compared to conventional HD WLC in detecting colorectal polyps and adenomas.

Effect of Hydrolyzed Infant Formula vs Conventional Formula on Risk of Type 1 Diabetes: The TRIGR Randomized Clinical Trial.

Importance: Early exposure to complex dietary proteins may increase the risk of type 1 diabetes in children with genetic disease susceptibility. There are no intact proteins in extensively hydrolyzed formulas. Objective: To test the hypothesis that weaning to an extensively hydrolyzed formula decreases the cumulative incidence of type 1 diabetes in young children. Design, Setting, and Participants: An international double-blind randomized clinical trial of 2159 infants with human leukocyte antigen-conferred disease susceptibility and a first-degree relative with type 1 diabetes recruited from May 2002 to January 2007 in 78 study centers in 15 countries; 1081 were randomized to be weaned to the extensively hydrolyzed casein formula and 1078 to a conventional formula. The follow-up of the participants ended on February 28, 2017. Interventions: The participants received either a casein hydrolysate or a conventional adapted cow's milk formula supplemented with 20% of the casein hydrolysate. The minimum duration of study formula exposure was 60 days by 6 to 8 months of age. Main Outcomes and Measures: Primary outcome was type 1 diabetes diagnosed according to World Health Organization criteria. Secondary outcomes included age at diabetes diagnosis and safety (adverse events). Results: Among 2159 newborn infants (1021 female [47.3%]) who were randomized, 1744 (80.8%) completed the trial. The participants were observed for a median of 11.5 years (quartile [Q] 1-Q3, 10.2-12.8). The absolute risk of type 1 diabetes was 8.4% among those randomized to the casein hydrolysate (n = 91) vs 7.6% among those randomized to the conventional formula (n = 82) (difference, 0.8% [95% CI, -1.6% to 3.2%]). The hazard ratio for type 1 diabetes adjusted for human leukocyte antigen risk group, duration of breastfeeding, duration of study formula consumption, sex, and region while treating study center as a random effect was 1.1 (95% CI, 0.8 to 1.5; P = .46). The median age at diagnosis of type 1 diabetes was similar in the 2 groups (6.0 years [Q1-Q3, 3.1-8.9] vs 5.8 years [Q1-Q3, 2.6-9.1]; difference, 0.2 years [95% CI, -0.9 to 1.2]). Upper respiratory infections were the most common adverse event reported (frequency, 0.48 events/year in the hydrolysate group and 0.50 events/year in the control group). Conclusions and Relevance: Among infants at risk for type 1 diabetes, weaning to a hydrolyzed formula compared with a conventional formula did not reduce the cumulative incidence of type 1 diabetes after median follow-up for 11.5 years. These findings do not support a need to revise the dietary recommendations for infants at risk for type 1 diabetes. Trial Registration: clinicaltrials.gov Identifier: NCT00179777.

Insulin pump therapy in children with type 1 diabetes: analysis of data from the SWEET registry.

BACKGROUND: Intensified insulin delivery using multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII) is recommended in children with type 1 diabetes (T1D) to achieve good metabolic control. OBJECTIVE: To examine the frequency of pump usage in T1D children treated in SWEET (Better control in Paediatric and Adolescent diabeteS: Working to crEate CEnTers of Reference) centers and to compare metabolic control between patients treated with CSII vs MDI. METHODS: This study included 16 570 T1D children participating in the SWEET prospective, multicenter, standardized diabetes patient registry. Datasets were aggregated over the most recent year of treatment for each patient. Data were collected until March 2016. To assess the organization of pump therapy a survey was carried out. RESULTS: Overall, 44.4% of T1D children were treated with CSII. The proportion of patients with pump usage varied between centers and decreased with increasing age compared with children treated with MDI. In a logistic regression analysis adjusting for age, gender and diabetes duration, the use of pump was associated with both: center size [odd ratio 1.51 (1.47-1.55), P < .0001) and the diabetes-related expenditure per capita [odd ratio 1.55 (1.49-1.61), P < .0001]. Linear regression analysis, adjusted for age, gender, and diabetes duration showed that both HbA1c and daily insulin dose (U/kg/d) remained decreased in children treated with CSII compared to MDI (P < .0001). CONCLUSIONS: Insulin pump therapy is offered by most Sweet centers. The differences between centers affect the frequency of use of modern technology. Despite the heterogeneity of centers, T1D children achieve relatively good metabolic control, especially those treated with insulin pumps and those of younger age.

Preventive pancreatic stents in the management of acute biliary pancreatitis (PREPAST trial): pre-study protocol for a multicenter, prospective, randomized, interventional, controlled trial.

BACKGROUND: The outcome of the most common biliary form of acute pancreatitis has not changed even with the better described indications for early endoscopic intervention. It may be due to the fact that this intrevention theoretically can cause further pancreatic injury or cannot always relieve the pancreatic duct obstruction. We hypothesize that maintaining the outflow of the pancreatic duct with preventive pancreatic stents at the early ERCP improves the outcome of acute biliary pancreatitis. METHODS/DESIGN: PREPAST is a prospective, randomized, controlled, multicenter trial. Patients with acute biliary pancreatitis with coexisting cholangitis are randomized to undergo urgent endoscopic intervention with or without pancreatic stenting within 48 h from the onset of pain, and in addition patients without signs of cholangitis but cholestasis are randomly allocated to recieve conservative treatment or early endoscopic intervention with or without pancreatic stenting within 48 h from the onset of pain. Patients without acute cholangitis and signs of cholestasis recieve conservative treatment. 230 patients are planned to be enrolled during a 48 months period from different centers. The primary endpoint is the outcome of acute biliary pancreatitis as described by the latest guidelines. Secondary endpoints include mortality data, and other variables not analyzed as a primary endpoint but related to the pancreatitis or the pancreatic stenting. DISCUSSION: The PREPAST trial is designed to show whether early endoscopic intervention with the usage of preventive pancreatic stenting improves the outcome of acute biliary pancreatitis. The study has been registered at the International Standard Randomised Controlled Trial Number (ISRCTN) Register (trial ID: ISRCTN13517695).

[The effect of endoscopic sphincterotomy on the motility of the gallbladder and of the sphincter of Oddi in patients with acalculous biliary pain syndrome]. / Endoszkópos sphincterotomia hatása az epehólyag és az Oddi-sphincter motilitására, valamint az epeürülés dinamikájára acalculosus biliaris fájdalom szindrómás betegekben.

INTRODUCTION: Sphincter of Oddi dysfunction usually occurs after cholecystectomy, but it can sometimes be detected in patients with intact gallbladder too. The diagnostic value of the non-invasive functional tests is not established in this group of patients and the effects of sphincterotomy on transpapillary bile outflow and gallbladder motility are unknown. AIMS: The aim of this study was to determine the effect of endoscopic sphincterotomy on the gallbladder ejection fraction, transpapillary bile outflow and the clinical symptoms of patients with acalculous biliary pain syndrome. PATIENTS AND METHODS: 36 patients with acalculous biliary pain syndrome underwent quantitative hepatobiliary scintigraphy, and all of them had decreased cholecytokinin-induced gallbladder ejection fraction. The endoscopic manometry of the sphincter of Oddi showed abnormal sphincter function in 26 patients who were enrolled the study. Before and after endoscopic sphincterotomy all patients had ultrasonographic measurement of cholecystokinin-induced gallbladder ejection fraction with and without nitroglycerin pretreatment and scintigraphy was repeated as well. The effects of sphincterotomy on gallbladder ejection fraction and transpapillary biliary outflow were evaluated. In addition, changes in biliary pain score with a previously validated questionnaire were also determined. RESULTS: All 26 patients had decreased gallbladder ejection fraction before sphincterotomy measured with scintigraphy (19+18%) and ultrasound (16+9.7%), which was improved after nitroglycerin pretreatment (48.2+17%; p<0.005). Detected with both methods, the ejection fraction was in the normal range after sphincterotomy (52+37% and 40.8+16.5%), but nitroglycerin pretreatment failed to produce further improvement (48.67+22.2%, NS). Based on scintigraphic examination sphincterotomy significantly improved transpapillary biliary outflow (common bile duct half time 63±33 min vs. 37±17 min; p<0.05). According to results obtained from questionneries, 22 of the 26 patients gave an account of significant symptom improvement after sphincterotomy. CONCLUSIONS: Endoscopic sphincterotomy improves cholecystokinin-induced gallbladder ejection fraction, transpapillary biliary outflow as well as biliary symptoms in patients with acalculous biliary pain syndrome and sphincter of Oddi dysfunction. Cholecystokinin-induced gallbladder ejection fraction with nitroglycerin pretreatment, measured with ultrasonography can be useful to select a subgroup of patients who can benefit from sphincterotomy.

[Endoscopic ultrasound-guided fine needle aspiration cytology in the mediastinum]. / Endoszkópos ultrahang vezérelte finomtu-aspirációs citológia a mediastinumban.

INTRODUCTION: Endoscopic ultrasound and endoscopic ultrasound-guided fine needle aspiration in the posterior mediastinum is technically a relatively simple and safe procedure, and it can provide important information for the further management of patients. AIM: To analyze and compare the results of mediastinal endoscopic ultrasound-guided fine needle aspiration with the data available in the literature. PATIENTS AND METHODS: The authors retrospectively analyzed their prospective database on mediastinal endoscopic ultrasound-guided fine needle aspiration of 49 patients referred to their endoscopy centre between 1 November 2009 and 1 November 2012. For the fine needle aspiration 22 and 25 G needles were used. Two to six needle passes were performed in each patient. All slides were prepared at the endoscopy unit and analyzed at the cytology laboratory. RESULTS: The authors performed mediastinal endoscopic ultrasound-guided fine needle aspiration for enlarged lymph nodes or suspected mediastinal malignancy in all but 4 patients (2 suspected oesophageal cancers, 1 suspected benign oesophageal stenosis with wall thickening and 1 cardia tumour, all with non-diagnostic endoscopic biopsies). Five patients were excluded from the analysis since fine needle aspiration was not performed in them. Benign lesions were suspected based on the endoscopic ultrasound morphology in 7, and malignant disease in 37 patients. In 3 cases samples obtained by biopsy were not informative for cytological analysis. Cytology confirmed all benign lesions and showed malignancy in 28 cases. Cytology failed to reveal malignancy in 6 patients, although it was suspected based upon endoscopic ultrasound finding. Furthermore, endoscopic ultrasound-guided fine needle aspiration provided the diagnosis in 15 of the 17 patients when bronchoscopy was non-diagnostic. The diagnostic accuracy of the EUS-FNA was the following: sensitivity 82%, specificity 100%, positive predictive value 1.0, negative predictive value 0.54. Only one infectious complication was encountered after fine needle aspiration despite antibiotic prophylaxis. DISCUSSION: Endoscopic ultrasound-guided fine needle aspiration of mediastinal pathology is an accurate, safe and technically relatively easy procedure, however it requires practice and skills in mediastinal anatomy. It has an excellent positive predictive value, a very good sensitivity, but slightly poor negative predictive value. The results of this study are concordant with the literature data. The authors suggest that at least 4 needle passes in the absence of on-site pathologist should be performed in order to minimize the number of false-negative results.

[Cholangitis and cholecystitis: diagnostic criteria and management]. / Epeút- és epehólyag-gyulladás: diagnosztikus kritériumok és terápia.

In developed countries, diseases of the gallbladder and the biliary tract count as some of the most frequent gastrointestinal disorders. The inflammation of the gallbladder/biliary tree is a potentially severe, even lethal condition that requires rapid diagnosis and early multidisciplinary approach to be treated. Although the frequency of these diseases is high, the treatment is not unified in Hungary yet. The aim of the evidence-based recommendation is to clarify the diagnostic criteria and severity grading of these diseases and to highlight the indications and rules of proper application of the numerous available therapeutic interventions. The recent guideline is based on the consensus of the Board members of the Endoscopic Section of the Hungarian Gastroenterology Society in contribution with renown experts of surgery, infectology as well as interventional radiology and it counts as a clear and easy applicable guide during the all-day healthcare practice. Our guidelines are based on Tokyo guidelines established on the basis of the consensus reached in the International Consensus Meeting held in Tokyo which were revised in 2013 (TG13) and in 2018 (TG18). Orv Hetil. 2023; 164(20): 770-787.

Heterogeneity in the systems of pediatric diabetes care across the European Union.

BACKGROUND: It is known that the systems of pediatric diabetes care differ across the member states of the European Union (EU). The aim of this project was to characterize some of the main differences among the national systems. METHODS: Data were collected using two questionnaires. The first one was distributed among leading centers of pediatric diabetes (one per country) with the aim of establishing an overview of the systems, national policies, quality control (QC) and financing of pediatric diabetes care. Responses were received from all 27 EU countries. The second questionnaire was widely disseminated among all 354 International Society for Pediatric and Adolescent Diabetes members with a domicile in an EU country; it included questions related to individual pediatric diabetes centers. A total of 108 datasets were collected and processed from healthcare professionals who were treating more than 29 000 children and adolescents with diabetes. Data on the reimbursement policies were verified by representatives of the pharmaceutical and medical device companies. RESULTS: The collected data reflect the situation in 2009. There was a notable heterogeneity among the systems for provision of pediatric diabetes care across the EU. Only 20/27 EU countries had a pediatric diabetes register. Nineteen countries had officially recognized centers for pediatric diabetes, but only nine of them had defined criteria for becoming such a center. A system for QC of pediatric diabetes at the national level was reported in 7/26 countries. Reimbursement for treatment varied significantly across the EU, potentially causing inequalities in access to modern technologies. CONCLUSIONS: The collected data help develop strategies toward improving equity and access to modern pediatric diabetes care across Europe.

Good practice recommendations on paediatric training programmes for health care professionals in the EU.

Part of the SWEET Project: EU (European Union), Better Control in Paediatric and Adolescent Diabetes: Working to Create Centres of Reference, was specifically to examine the training of health care professionals (HCPs) across the EU. Several types of information were collected during 2009, and these included a literature search, workshops of the SWEET members, examination of the data collected by the Hvidøre Study Group and the Diabetes Attitudes, Wishes, and Needs (DAWN) Youth initiative, and a questionnaire distributed to SWEET members and professional colleagues who cared for children and young people (CYP) with diabetes. It was clear from the information collected that there was no European or global consensus either on a curriculum for the training of the paediatric diabetes multidisciplinary team (MDT) or individual professions in paediatric diabetes. A minority of countries had well-established training but, for the majority, there was little standardisation or accreditation. Moreover, most countries did not have available courses for training the diabetes MDT and training was not mandatory. Of the courses that were available more were accredited for doctors and nurses but fewer for the other professions. As a consequence, the majority of HCP posts in paediatric diabetes do not demand prior experience in the specialty. Standardised accredited training and continuous professional development (CPD) opportunities are severely limited. The SWEET Project supports a standardised, accredited approach to training and CPD of the MDT and for individual professions. As a consequence, a curriculum for the training of the MDT was developed, and this is now ready for implementation.

Early ERCP and biliary sphincterotomy with or without small-caliber pancreatic stent insertion in patients with acute biliary pancreatitis: better overall outcome with adequate pancreatic drainage.

OBJECTIVE: To analyze the efficacy of pancreatic duct (PD) stenting following endoscopic sphincterotomy (EST) compared with EST alone in reducing complication rate and improving overall outcome in acute biliary pancreatitis (ABP). METHODS: Between 1 January 2009 and 1 July 2010, 141 nonalcoholic patients with clinical, laboratory and imaging evidence of ABP were enrolled. Emergency endoscopic retrograde cholangiopancreatography (ERCP) was performed within 72 h from the onset of pain. Seventy patients underwent successful ERCP, EST, and stone extraction (control group); 71 patients (PD stent group) had EST, stone extraction and small-caliber (5 Fr, 3-5 cm) pancreatic stent insertion. All patients were hospitalized for medical therapy and jejunal feeding and were followed up. RESULTS: The mean age, Glasgow score, symptom to ERCP time, mean amylase and CRP levels at initial presentation were not significantly different in the PD stent group compared to the control group: 60.6 vs. 64.3, 3.21 vs. 3.27, 34.4 vs. 40.2, 2446.9 vs. 2114.3, 121.1 vs. 152.4, respectively. Complications (admission to intensive care unit, pancreatic necrosis with septicemia, large (>6 cm) pseudocyst formation, need for surgical necrosectomy) were less frequent in the PD stent group resulting in a significantly lower overall complication rate (9.86% vs. 31.43%, p < 0.002). Mortality rates (0% vs. 4.28%) were comparable, reasonably low and without any significant differences. CONCLUSIONS: Temporary small-caliber PD stent placement may offer sufficient drainage to reverse the process of ABP. Combined with EST the process results in a significantly less complication rate and better clinical outcome compared with EST alone during the early course of ABP.

[Endoscopic submucosal dissection in our practice -- new possibilities in the endoscopic treatment of neoplastic changes in the alimentary canal]. / Endoszkópos submucosus dissectio saját gyakorlatunkban -- új lehetoség a tápcsatorna korai neoplasztikus elváltozásainak endoszkópos kezelésében.

UNLABELLED: Endoscopic submucosal dissection is a promising new endoscopic technique for en block resection of early, superficial, flat, and laterally spreading gastrointestinal neoplasms. The primary aims of this prospective study were to summarize the first Hungarian experience with endoscopic submucosal dissection, and to compare the experimental in vivo procedures in pigs with the human application of this technique in two academic centers. METHODS: The ex vivo Erlangen pig model was used until initial competence was achieved. Thereafter 15 endoscopic submucosal dissection procedures were performed in up to 5 sessions in living pigs under general anesthesia. After submucosal injection with saline Fujinone ball tip, a Flush knife was used with a transparent hood for circumferential incision and submucosal dissection. The following variables were analyzed: specimen size, complete and en bloc resection rate, total duration of the procedure, and complications. Furthermore, between 2009 and 2012, 14 endoscopic submucosal dissections were carried out in humans; 1 duodenal, 3 gastric and 10 colorectal interventions were performed due to large laterally spreading intramucosal neoplasms. The specimen size, en bloc resection rate, total duration of the procedure and complications were next analyzed. RESULTS: 87% complete resection rate, 29.4 ± 19.5 cm2 specimen size and 136.2 ± 26.8 min of procedure duration were achieved in the live pig models. Nontransmural damages of the muscular layer occurred in 3/15 (20%) cases which were successfully closed with hemoclips, except in one pig that died due to fatal esophageal perforation. All bleedings were easily managed with hot biopsy forceps coagulation and hemoclips without hemodynamic instability. In humans, endoscopic submucosal dissection was accomplished with an 11/14 (79%) en block resection rate, with average resected specimen size of 11.56 ± 4.9 cm2 and with 157 ± 55 min of operating time. Two cases of bleeding and 2 cases of perforation occurred (14%), all of which were managed endoscopically. After 1.5 year of average follow up, local recurrence occurred in one case only. In addition, due to the 3 incomplete resections and unsuccessful endoscopic submucosal dissection, surgical intervention was required in 4 cases altogether. CONCLUSIONS: This study demonstrates the first Hungarian experience with endoscopic submucosal dissection. Training in live pig models could help endoscopists to overcome the learning curve and minimize the risk of complications before starting the procedure in humans. Reduction in the resection time and low risk of complications, especially bleeding, could be achieved by the application of a flush knife.

Complications of endoscopic retrograde cholangiopancreatography / Az endoszkópos retrográd cholangiopancreatographia szövodményei

During the more than 50-year history of endoscopic retrograde cholangiopancreatography (ERCP), it has become an almost exclusively therapeutic procedure from a diagnostic method. This was the result of the evolution of far less invasive diagnostic procedures and the identification of its complications. Nowadays, being aware of these complications is fundamental. Remarkable knowledge has been gathered over the past decades about the risk factors, preventive methods and endoscopic treatments. A significant number of relevant publications from Hungarian authors can be found in this field. In our article, we summarize the complications of ERCP, their definitions, severity classifications, risk factors, prophylactic methods and endoscopic treatments.

First prospective European study for the feasibility and safety of magnetically controlled capsule endoscopy in gastric mucosal abnormalities.

BACKGROUND: While capsule endoscopy (CE) is the gold standard diagnostic method of detecting small bowel (SB) diseases and disorders, a novel magnetically controlled capsule endoscopy (MCCE) system provides non-invasive evaluation of the gastric mucosal surface, which can be performed without sedation or discomfort. During standard SBCE, passive movement of the CE may cause areas of the complex anatomy of the gastric mucosa to remain unexplored, whereas the precision of MCCE capsule movements inside the stomach promises better visualization of the entire mucosa. AIM: To evaluate the Ankon MCCE system's feasibility, safety, and diagnostic yield in patients with gastric or SB disorders. METHODS: Of outpatients who were referred for SBCE, 284 (male/female: 149/135) were prospectively enrolled and evaluated by MCCE. The stomach was examined in the supine, left, and right lateral decubitus positions without sedation. Next, all patients underwent a complete SBCE study protocol. The gastric mucosa was explored with the Ankon MCCE system with active magnetic control of the capsule endoscope in the stomach, applying three standardized pre-programmed computerized algorithms in combination with manual control of the magnetic movements. RESULTS: The urea breath test revealed Helicobacter pylori positivity in 32.7% of patients. The mean gastric and SB transit times with MCCE were 0 h 47 min 40 s and 3 h 46 min 22 s, respectively. The average total time of upper gastrointestinal MCCE examination was 5 h 48 min 35 s. Active magnetic movement of the Ankon capsule through the pylorus was successful in 41.9% of patients. Overall diagnostic yield for detecting abnormalities in the stomach and SB was 81.9% (68.6% minor; 13.3% major pathologies); 25.8% of abnormalities were in the SB; 74.2% were in the stomach. The diagnostic yield for stomach/SB was 55.9%/12.7% for minor and 4.9%/8.4% for major pathologies. CONCLUSION: MCCE is a feasible, safe diagnostic method for evaluating gastric mucosal lesions and is a promising non-invasive screening tool to decrease morbidity and mortality in upper gastro-intestinal diseases.

Diagnostic sensitivity of endoscopic ultrasonography in patients with suspected choledocholithiasis / Az endoszkópos ultrahangvizsgálat diagnosztikus érzékenysége epeúti kövesség gyanúja esetén.

Összefoglaló. Bevezetés: Az epeúti kövesség meglétének valószínusége különbözo klinikai prediktorok alapján megbecsülheto, e faktorok szenzitivitása és specificitása azonban nem kielégíto. Az endoszkópos ultrahangvizsgálat az epeúti kövesség diagnosztizálásának szemiinvazív precíz eszköze. Célkituzés: Célunk az endoszkópos ultrahangvizsgálat diagnosztikus érzékenységének vizsgálata gyanított epeúti kövesség esetén. Módszer: A prospektív vizsgálat során a betegeket az Amerikai Emésztoszervi Endoszkópos Társaság (ASGE) ajánlása szerint meghatározott prediktorok alapján közepes és magas valószínuségi csoportokba osztottuk, és endoszkópos ultrahangvizsgálatot, valamint amennyiben szükséges volt, endoszkópos retrográd kolangiopankreatográfiát (ERCP) végeztünk. Eredmények: Összesen 95 beteget vizsgáltunk. Az endoszkópos ultrahangvizsgálat 53 (56%) beteg esetében írt le epeúti kövességet: 55%-ban (39/71) a közepes valószínuségi és 58%-ban (14/24) a magas valószínuségi csoportban. Az ERCP mindegyik choledocholithiasisos esetet megerosítette. A két valószínuségi csoport között nem volt szignifikáns különbség (p = 0,56) az ERCP által igazolt epeúti kövesség tekintetében. Az ERCP csupán 1 esetben detektált epeúti kövességet a negatív endoszkópos ultrahangvizsgálat ellenére. Az endoszkópos ultrahangvizsgálat specificitása 100%, szenzitivitása 98%, míg pozitív és negatív prediktív értéke 100%, valamint 98% volt. Megbeszélés: Az epeúti kövesség meglétének becslése különbözo klinikai prediktorok alapján kihívást jelenthet. Következtetés: Az endoszkópos ultrahangvizsgálat szenzitív és pontos diagnosztikus eszköz a choledocholithiasis kimutatására és értékelésére, olyan esetekben is, amelyeknél az elozetes képalkotók nem találtak kövességet. Orv Hetil. 2022; 163(10): 400-406. INTRODUCTION: The likelihood of common bile duct stones can be prognosticated by various clinical predictors, however, the sensitivity and specificity of these factors are moderate. Endoscopic ultrasonography has been shown to be a semi-invasive precise test for the detection of common bile duct stones. OBJECTIVE: Our aim was to assess the diagnostic accuracy of endoscopic ultrasonography in patients with suspected choledocholithiasis. METHOD: Patients of this prospective study were categorized and divided into intermediate likelihood and high likelihood groups according to the clinical predictors defined by the American Society of Gastrointestinal Endoscopy (ASGE) guidelines and referred for linear endosonography. Endoscopic retrograde cholangiopancreatography (ERCP) was performed if needed. RESULTS: A total of 95 patients were assessed. Common bile duct stones were detected by endoscopic ultrasonography overall in 53 (56%) patients: 55% (39/71) in the intermediate likelihood and 58% (14/24) in the high likelihood group of patients. The detected common bile duct stones in all patients were confirmed by ERCP. There was no significant difference (p = 0.56) in the detection of stones by ERCP between the two likelihood groups. ERCP confirmed choledocholithiasis only in one patient whose preceding endosonography did not detect stone. The specificity and sensitivity of endoscopic ultrasonography were 100% and 98%, the positive predictive value and negative predictive value were 100% and 98%, respectively. DISCUSSION: Estimating the likelihood of choledocholithiasis based on various clinical predictors might be challenging. CONCLUSION: Endoscopic ultrasonography is a highly sensitive and accurate diagnostic tool for the detection and evaluation of common bile duct stones also in patients with previous normal imaging findings. Orv Hetil. 2022; 163(10): 400-406.

PPAR-gamma2 pro12Ala polymorphism is associated with post-challenge abnormalities of glucose homeostasis in children and adolescents with obesity.

AIM: The aim of the study was to investigate the association between PPAR-gamma2 Pro12Ala polymorphism and laboratory characteristics of carbohydrate metabolism in children and adolescents with obesity. In addition, serum levels of tumor necrosis factor (TNF)-alpha, and soluble form of its receptors (sTNFR1 and sTNFR2) were assessed. METHODS: In a cross-sectional study, 79 obese children and adolescents of Caucasian origin were investigated. PPAR-gamma2 Pro12Ala polymorphism was determined using polymerase chain reaction--restriction fragment length polymorphism technique. Serum levels of TNF-alpha, sTNFR1 and sTNFR2 were measured by enzyme amplified sensitivity immunoassay. RESULTS: The minor Ala allele frequency was found to be 14.56% in our cohort. No significant differences in age, BMI, waist circumference, blood pressure, serum lipid, uric acid, TNF-alpha, sTNFR1 and sTNFR2 values were found between carriers of the Ala allele (Pro/Ala and Ala/Ala; n=21) vs. homozygous carriers of the Pro allele (Pro/Pro; n=58). However, post-challenge (120 min) plasma glucose and insulin values were significantly lower in Ala allele carriers vs. homozygous Pro allele carriers (6.56 +/- 0.26 vs. 7.36 +/- 0.25 mmol/L and 65.9 +/- 13.8 vs. 111.8 +/- 20.7 microU/mL, respectively; p < 0.05); while no significant differences were found at fasting state. CONCLUSIONS: The association between PPAR-gamma2 Prol2Ala polymorphism and glucose metabolism is already present in children and adolescents with obesity who might be at the very beginning of the natural course of type 2 diabetes. At this stage, higher insulin sensitivity can be detected in Ala allele carriers compared to homozygous Pro subjects at post-challenge but not in fasting state; however, the TNF-system seems not to be involved in the alteration of glucose homeostasis due to PPAR-gamma2 Pro12Ala polymorphism.

[Prediction and prevention of type 1 diabetes mellitus: initial results and recent prospects]. / Az 1-es típusú diabetes mellitus predikciója és prevenciója: kezdeti eredmények - újabb lehetoségek.

Epidemiological studies indicate that the incidence and prevalence of type 1 diabetes mellitus is rising worldwide. The increase in incidence has been most prominent in the youngest age group of childhood. Prediction of type 1a autoimmune diabetes can be established by a positive family history or by genetic, immunological or metabolic markers. Prevention of type 1 diabetes can be implemented at three different levels of pathogenesis: primary prevention in individuals without any sign of beta-cell damage, secondary prevention in individuals with signs of beta-cell destruction and tertiary prevention in patients with newly diagnosed type 1 diabetes. In recent years our knowledge of the disease pathogenesis has grown quickly, and several new prevention trials have been initiated worldwide. Immunologic intervention for type 1 diabetes will prove to be probably the most effective.

Prophylactic stents in the prevention of pancreatitis following endoscopic retrograde cholangiopancreatography / Profilaktikus sztentek alkalmazása az endoszkópos retrográd cholangiopancreatographiát követo pancreatitis megelozésében.

Összefoglaló. Bevezetés: Az endoszkópos retrográd cholangiopancreatographiát (ERCP) követo pancreatitis (PEP) incidenciája a magas kockázatú betegcsoportban 14,7%. Célkituzés: A munkacsoportunk által szerzett tapasztalatok elemzése. Módszerek: A profilaktikus pancreassztentes (PPS), magas kockázatú betegek adatait tartalmazó prospektív adatbázisunkat elemeztük retrospektív módon. Az adatokat a PEP-incidencia és a súlyosság tekintetében összehasonlítottuk a korábbi, hasonlóan magas kockázatú, sztent nélküli beteganyagunkkal, illetve a sztenteléssel kapcsolatos szövodményeket és a különbözo sztenttípusokat is elemeztük. A Cotton-kritériumok szerint értékeltük a PEP-t. Eredmények: A 317, magas kockázatú betegbol 288 esetben (90,9%) volt sikeres a PPS-implantáció. A sztent nélküli kontrollcsoportba 121, magas kockázatú beteget választottunk be. A sikeresen sztentelt betegekben a PEP incidenciája 10,0% volt. Ez és a PEP súlyossága (enyhe: 8,3%, középsúlyos: 1,4%, súlyos: 0,3%) is szignifikánsan alacsonyabb volt a PPS nélküli beteganyaghoz (PEP: 31,4%, enyhe: 15,7%, középsúlyos: 10,7%, súlyos: 5,0%) és a sikertelenül sztentelt betegekhez (PEP: 41,3%, enyhe: 24,1%, középsúlyos: 13,8%, súlyos: 3,4%) képest. Az utóbbi két csoport közötti különbség nem volt szignifikáns. A sztenttel kapcsolatos szövodmények közül a leggyakrabban a korai sztentkicsúszást (5/288 beteg, 1,74%) és a proximalis sztentmigrációt (3/288 beteg, 1,04%) észleltük. A sztenttípusok közül a legkedvezobb mellékhatás-profilúnak a Freeman-típusú, belso füllel és külso "pigtail" véggel ellátott sztenteket találtuk. Következtetés: A profilaktikus pancreassztentelés hatékonyan csökkenti a PEP incidenciáját, és a súlyosságát az enyhébb esetek felé tolja el. Alkalmazása viszonylag egyszeru, azonban ismerni kell használatának megfelelo technikáját, idoben történo eltávolításának és a szövodmények felismerésének fontosságát. Eredményeink és a nemzetközi ajánlások alapján magas PEP-rizikójú betegekben a PPS rutinszeru alkalmazása minden ERCP-laborban ajánlott. Orv Hetil. 2021; 162(1): 31-38. INTRODUCTION: The most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP) is post-ERCP pancreatitis (PEP). Its incidence in the high-risk patient population is 14.7%. OBJECTIVE: To analyze 10 years experiences of our working group. METHODS: We retrospectively analyzed our prospective database of high-risk patients treated with prophylactic pancreatic stents (PPS) including the period between 2009 and 2014. We compared PEP incidence and severity findings with our historical data of pre-PPS period of similarly high-risk patients (no-stent group), furthermore analyzed the complications of PPS insertion and different stent types. PEP was defined and categorized according to the Cotton criteria. RESULTS: In 317 high-risk patients, PPS implantation was successful in 288 cases (90.9%). The no-stent group comprised of 121 patients. Incidence and the severity of PEP in the successfully stented group (all: 10.0%; mild: 8.3%, moderate: 1.4%, severe: 0.3%) were significantly lower compared to the no-stent group (all: 31.4%; mild: 15.7%, moderate: 10.7%, severe: 5.0%) and the unsuccessfully stented group (all: 41.3%; mild: 24.1%, moderate: 13.8%, severe: 3.4%). The difference between the latter two groups was not significant. Only early dislodgment (5/288 patients, 1.74%) and proximal migration (3/288 patients, 1.04%) were observed as stent-related complications. Freeman type (single inner flange, outer pigtail end) stent was the best based on the complication profile. CONCLUSION: Prophylactic pancreatic stenting effectively lowers the incidence and severity of PEP. We should recognize the proper technic of its application and the importance of proper timing of its extraction and identification of complications. Utilization of PPSs in high-risk patients is strongly recommended in every ERCP center. Orv Hetil. 2021; 162(1): 31-38.

Transitional elevation of anti-tissue transglutaminase antibodies in children with type 1 diabetes mellitus without coeliac disease / A szöveti antitranszglutamináz átmeneti emelkedése coeliakiával nem társult I-es típusú cukorbeteg gyermekekben.

Összefoglaló. Bevezetés: Az 1-es típusú diabetes mellitus és a coeliakia gyakori társulása jól ismert. Néhány tanulmány beszámol átmeneti antitranszglutamináz-emelkedésrol 1-es típusú diabeteses betegekben, akiknél az emelkedett antitestszint gluténmentes diéta bevezetése nélkül normalizálódik. Célkituzés: Kutatásunk során az átmeneti antitranszglutamináz-emelkedés gyakoriságának meghatározását tuztük ki célul. További célunk volt a coeliakia gyakoriságának megállapítása 1-es típusú diabetesszel gondozott betegeink között. Módszer: A Semmelweis Egyetem I. Gyermekgyógyászati Klinikáján 1-es típusú diabetesszel gondozott betegeket vontuk be vizsgálatunkba (238 lány, 265 fiú, medián [IR] életkor az 1-es típusú diabetes diagnózisakor: 7,83 [4,67-11] év). Vizsgáltuk a jelenség idobeli megjelenését, az emelkedés mértékét, gyakoriságát és az antitest típusát. Leíró statisztikai módszereket és khi-négyzet-próbát alkalmaztunk. Eredmények: A vizsgált populációban a coeliakia gyakorisága 12,52%. Átmeneti antitranszglutamináztiter-emelkedést 48 gyermeknél (10,9%) észleltünk. Összesen 71-szer mértünk átmeneti antitranszglutamináz-emelkedést. A gyermekek közül 34 esetben (70,83%) egyszer fordult elo emelkedést mutató antitest, a többi betegnél 2-8 alkalommal. Gyakrabban tapasztaltunk izolált IgA-típusú emelkedést, mint izolált IgG-típusút (54 vs. 5). Következtetés: Az átmeneti antitranszglutamináz-emelkedés gyakorisága magas, összevetheto a valódi coeliakiás csoporttal. Kutatásunk alátámasztja a nemzetközi ajánlást, miszerint mérsékelt mértéku antitranszglutamináz-emelkedés esetén, tünetmentes 1-es típusú diabetesszel gondozott betegben a gluténfogyasztás folytatása és az antitestszintek gyakori kontrollja javasolt. Orv Hetil. 2021; 162(48): 1924-1930. INTRODUCTION: The frequent association of type 1 diabetes mellitus with coeliac disease is well known. Development of transitional elevation of anti-tissue transglutaminase antibodies in the diagnosis of type 1 diabetes is reported in some studies. In these cases, the anti-tissue transglutaminase antibodies returned to normal without gluten-free diet. OBJECTIVE: Our aim was to assess the frequency of transitional elevation of anti-tissue transglutaminase in our type 1 diabetes patients. We aimed to investigate the prevalence of coeliac disease in patients with type 1 diabetes. METHOD: Patients with type 1 diabetes at the Ist Department of Paediatrics, Semmelweis University, were enrolled in the study (238 girls, 265 boys; the median age at the time of type 1 diabetes diagnosis was 7.83 [4.67-11] years). Descriptive statistical analysis was done and the time of appearance, extent, frequency and type of elevated anti-tissue transglutaminase antibodies were examined. RESULTS: The proportion of children with diagnosed coeliac disease was 12.52%. We detected transitional anti-tissue transglutaminase elevation in 48 cases (10.9%). Temporarily elevated antibody levels were measured 71 times. In 34 children (70.83%), the temporary elevation occured once, while in the others, antibody levels became positive 2-8 times. The elevation of the IgA antibody was more frequent than the elevation of the IgG antibody (54 vs. 5). CONCLUSION: The frequency of temporary elevated anti-tissue transglutaminase levels is considered high. Our study confirms the recommendation that in the case of moderate anti-tissue transglutaminase levels with lack of clinical symptoms, control antibody measurement is necessary with ongoing gluten consumption. Orv Hetil. 2021; 162(48): 1924-1930.