Type 1 autoimmune pancreatitis and IgG4-related sclerosing cholangitis is associated with extrapancreatic organ failure, malignancy, and mortality in a prospective UK cohort.

OBJECTIVES: Type I autoimmune pancreatitis (AIP) and IgG4-related sclerosing cholangitis (IgG4-related SC) are now recognized as components of a multisystem IgG4-related disease (IgG4-RD). We aimed to define the clinical course and long-term outcomes in patients with AIP/IgG4-SC recruited from two large UK tertiary referral centers. METHODS: Data were collected from 115 patients identified between 2004 and 2013, and all were followed up prospectively from diagnosis for a median of 33 months (range 1-107), and evaluated for response to therapy, the development of multiorgan involvement, and malignancy. Comparisons were made with national UK statistics. RESULTS: Although there was an initial response to steroids in 97%, relapse occurred in 50% of patients. IgG4-SC was an important predictor of relapse (P<0.01). Malignancy occurred in 11% shortly before or after the diagnosis of IgG4-RD, including three hepatopancreaticobiliary cancers. The risk of any cancer at diagnosis or during follow-up when compared with matched national statistics was increased (odds ratio=2.25, CI=1.12-3.94, P=0.02). Organ dysfunction occurred within the pancreas, liver, kidney, lung, and brain. Mortality occurred in 10% of patients during follow-up. The risk of death was increased compared with matched national statistics (odds ratio=2.07, CI=1.07-3.55, P=0.02). CONCLUSIONS: Our findings suggest that AIP and IgG4-SC are associated with significant morbidity and mortality owing to extrapancreatic organ failure and malignancy. Detailed clinical evaluation for evidence of organ dysfunction and associated malignancy is required both at first presentation and during long-term follow-up.

Use of an improved atpA amplification and sequencing method to identify members of the Campylobacteraceae and Helicobacteraceae.

UNLABELLED: Emerging Campylobacter and Arcobacter spp. have been increasingly isolated from human clinical samples, food, veterinary samples and the environment. Unambiguous species identification of such organisms is of obvious importance in epidemiological studies, but is also necessary to accurately assess their host range and determine their prevalence in the food chain and in the environment. Species identification methods for the Campylobacteraceae have been described; however, some with high resolving power are limited to a small number of taxa, while other broader-range methods cannot distinguish between closely related species. We present in this study a novel species identification method, based on amplification and sequencing of a portion of the atpA gene. This method, which uses a single primer pair, was able to amplify and accurately identify all current taxa within Campylobacter and Arcobacter as well as several members of the Helicobacteraceae, although unambiguous identification of the Camp. fetus subspecies could not be achieved. In addition, five putative novel Campylobacter taxa were recognized, making this new species identification method valuable in the characterization of novel epsilonproteobacteria. Thus, a single-locus method that can accurately identify multiple epsilonproteobacterial species will prove important in the characterization of emerging organisms and those associated with illness. SIGNIFICANCE AND IMPACT OF THE STUDY: The atpA-based species identification method described here uses a single primer pair to amplify DNA from all current validly-described Campylobacter and Arcobacter taxa, as well as multiple members of the Helicobacteraceae. This method unambiguously identified all taxa tested, although it could not discriminate the subspecies of Camp. fetus. Furthermore, five putative novel Campylobacter taxa were observed following testing of environmental campylobacters with this method. The scope and resolution of this method make it an important addition to studies of epsilonproteobacterial epidemiology and evolution.

A combination of serum leucine-rich α-2-glycoprotein 1, CA19-9 and interleukin-6 differentiate biliary tract cancer from benign biliary strictures.

BACKGROUND: Biliary tract cancer (BTC) and benign biliary strictures can be difficult to differentiate using standard tumour markers such as serum carbohydrate antigen 19-9 (CA19-9) as they lack diagnostic accuracy. METHODS: Two-dimensional difference gel electrophoresis and tandem mass spectrometry were used to profile immunodepleted serum samples collected from cases of BTC, primary sclerosing cholangitis (PSC), immunoglobulin G4-associated cholangitis and healthy volunteers. The serum levels of one candidate protein, leucine-rich α-2-glycoprotein (LRG1), were verified in individual samples using enzyme-linked immunosorbent assay and compared with serum levels of CA19-9, bilirubin, interleukin-6 (IL-6) and other inflammatory markers. RESULTS: We report increased LRG1, CA19-9 and IL-6 levels in serum from patients with BTC compared with benign disease and healthy controls. Immunohistochemical analysis also demonstrated increased staining of LRG1 in BTC compared with cholangiocytes in benign biliary disease. The combination of receiver operating characteristic (ROC) curves for LRG1, CA19-9 and IL-6 demonstrated an area under the ROC curve of 0.98. In addition, raised LRG1 and CA19-9 were found to be independent predictors of BTC in the presence of elevated bilirubin, C-reactive protein and alkaline phosphatase. CONCLUSION: These results suggest LRG1, CA19-9 and IL-6 as useful markers for the diagnosis of BTC, particularly in high-risk patients with PSC.

Experience of propofol sedation in a UK ERCP practice: lessons for service provision.

OBJECTIVE: Endoscopic retrograde cholangiopancreatography (ERCP) in the UK has been historically performed under conscious sedation. However, given the increasing complexity of cases, the role of propofol-assisted ERCP (propERCP) is increasing. We describe our experience of propERCP and highlight the importance of this service. DESIGN: Our prospective ERCP database was interrogated between January 2013 and January 2014. Data collection included procedural information, patient demographics, American Association of Anaesthesiologists (ASA) status, Cotton grade of endoscopic difficulty and endoscopic and anaesthetic complications. Comparison was made with patients undergoing conscious sedation ERCP (sedERCP). RESULTS: 744 ERCPs were performed in 629 patients (53% male). 161 ERCPs were performed under propofol. PropERCP patients were younger compared with the sedERCP group (54 vs 66 years, p<0.0001) but ASA grade 1-2 status was similar (84% vs 78%, p=0.6). An increased number of Cotton grade 3-4 ERCPs were performed in the propERCP group (64% vs 34%, p<0.0001). Indications for propERCP included sphincter of Oddi manometry (27%), previously poorly tolerated sedERCP (26%), cholangioscopy (21%) and patient request (8%). 77% of cases were elective, 12% were urgent day-case transfers and 11% were urgent inpatients. 59% of cases were tertiary referrals. ERCP was completed successfully in 95% of cases. Anaesthetic and endoscopic complications were comparable between the two groups (5% and 7% vs 3% and 5%). Where sedERCP had been unsuccessful due to patient intolerance, the procedure was completed successfully using propofol. CONCLUSIONS: PropERCP is safe and is associated with high endoscopic success. The need for propERCP is likely to increase given patient preference and the high proportion of complex procedures being undertaken. All endoscopy units should look to incorporate propofol-assisted endoscopy into aspects of their services.

Characterization of a genetic difference in the platelet aggregation response of two inbred mouse strains, C57BL/6 and C3H/He.

An in vitro platelet aggregation assay has been used to characterize the platelet response of two inbred mouse strains, C57BL/6J and C3H/J. Arachidonic acid, ADP, ristocetin, and collagen, but not epinephrine, were effective inducers of platelet aggregation in C57BL/6 mice. In C3H mice, however, platelets responded differently to some, but not all, inducers of platelet aggregation. The difference between the two strains was particularly striking for arachidonic acid; at 0.375 microM arachidonic acid, platelets from C57BL/6 mice aggregated well, but platelets from C3H mice failed to aggregate. The two strains also differed in serotonin release from platelets. When the pool of platelet serotonin was labeled by incubating platelets with [14C]serotonin, the amount of label subsequently released from platelets in response to 0.375 microM arachidonic acid was 20.5% +/- 2.5 SE for C57BL/6 mice and 1.5% +/- 1.5 SE for C3H mice. The platelets from F1 progeny of a cross between C57BL/6 and C3H mice were indistinguishable in aggregation response from the C57BL/6 parent. The defect in aggregation response found in C3H mice appears to reside in the platelets rather than in the plasma. Experiments which involved adding the plasma of one strain to the washed platelets of the other strain indicated that C57BL/6 platelets aggregated well whether they were resuspended in plasma from C57BL/6 or C3H mice, while C3H platelets failed to aggregate regardless of the origin of the plasma. Strain C57BL/6 is susceptible to diet-induced formation of atherosclerotic lesions, but strain C3H is resistant to lesion formation. This genetic difference in atherosclerosis susceptibility is not related to the genetic difference in platelet aggregation since a recombinant inbred strain, BXH-9, is susceptible to atherosclerosis like the C57BL/6 parent but has the reduced platelet aggregation response of the C3H parent.

Sandostatin LAR (long-acting octreotide acetate) for malignant carcinoid syndrome: a 3-year experience.

BACKGROUND: Somatostatin analogues are the best therapy for controlling the symptoms of malignant carcinoid syndrome. Octreotide acetate given as subcutaneous injection up to three times daily, intramuscular Lanreotide injection given once per 1-2 weeks and monthly intramuscular Sandostatin LAR have demonstrated similar efficacy in short-term studies. AIM: To assess the long-term effect of Sandostatin LAR on the management of patients with malignant carcinoid syndrome. METHODS: This was a 3-year retrospective study. Twenty-seven patients were assessed with a median follow-up of 23 months. Thirteen patients were switched from subcutaneous octreotide and 14 patients were octreotide naive. All patients showed avid uptake on indium-111 octreotide imaging. RESULTS: Ten of the 13 patients previously on subcutaneous octreotide and 13 of the 14 patients who were octreotide naive had good symptom control on Sandostatin LAR. Over the period of follow-up, many patients showed progression of their tumour and required additional therapies. Patients expressed a preference for monthly intramuscular Sandostatin LAR as opposed to daily subcutaneous injections of octreotide. Although Sandostatin LAR was difficult to administer in certain instances, overall it was well tolerated. CONCLUSIONS: Sandostatin LAR provides good long-term symptomatic control in patients with malignant carcinoid syndrome; it is well tolerated and patients expressed improved satisfaction in their management.

Processing tangerine tomatoes: effects on lycopene-isomer concentrations and profile.

Because lycopene is a powerful biological antioxidant, its delivery to humans is of major concern. cis-Lycopene isomers are more bioavailable than the all-trans isomers and thus more efficiently absorbed. Tangerine tomatoes, whose lycopene isomeric content is almost all tetra-cis, provide a useful food source for comparing cis- and trans-isomer absorption. Tangerine tomatoes were processed into sauce in the Univ. of California, Davis Pilot Plant for subsequent use in a human feeding study described in another publication. Samples were taken at several stages during processing and carotenoids extracted and analyzed for carotenoid-isomer profiles and concentrations. Analyses showed that total lycopene concentration decreased considerably during the 1st step of processing, which included heating and juicing operations. Processing resulted in a large decrease in tetra-cis lycopene concentration accompanied by increases in trans- and other cis-lycopene isomers.

Cellular analysis of limb development in the mouse mutant hypodactyly.

The limb defect in the mouse Hypodactyly (Hd) affects only the distal structures. Heterozygotes (Hd/+) lack all or part of the distal phalanx and the terminal claw of digit on the hindlimbs; mice homozygous (Hd/Hd) for the mutation have just one digit on each of the four limbs. Early limb development in the mutant appears normal and a change in morphology can only be detected later. Limb buds of Hd/+ and Hd/Hd embryos become reduced in width, with Hd/Hd buds becoming very pointed instead of rounded. This change in bud shape is correlated with an increase in cell death anteriorly in Hd/+ hindlimbs and both anteriorly and posteriorly in Hd/Hd fore- and hindlimb buds. The apical ectodermal ridge is very pronounced in pointed Hd/Hd limb buds. Mesenchyme cells from the Hd/Hd mutant in culture show a cell-autonomous change in behaviour and less cartilage differentiates.

Co-administered oral metoclopramide does not enhance the rate of absorption of oral diazepam.

Intravenous metoclopramide is known to increase the rate of absorption of oral diazepam if administered at the same time. It has been suggested that oral metoclopramide has the same effect. In this study, six healthy volunteers received oral diazepam (0.2 mg/kg) on two separate occasions, either alone or with oral metoclopramide (10 mg), given simultaneously. In contrast to the effects of intravenous metoclopramide, oral metoclopramide did not increase the rate of absorption of oral diazepam.

Review of efficiencies and patient satisfaction in Australian and New Zealand day surgery units: a pilot study.

A pilot study was performed in eight Australasian day surgery facilities with a purpose of identifying common trends and differences. A prospective study was designed in which information was collected on 826 patients over a two-week period. Patients were well matched for age, anaesthetic type and mean surgical time. Three facility types were identified and results were statistically corrected for any differences that ASA status, age and surgical time may have made. Patient preoperative waiting time, recovery room times, delayed discharge time and unanticipated admission rates showed favourable outcome trends for free-standing facilities compared with hospital-integrated facilities where day patients had a shared recovery with inpatients. Similar trends were seen with patient opinions of waiting times and recovery periods. In summary, this pilot study has demonstrated the impact of different facility types on efficiencies and patient satisfaction both of which have important cost implications and relevance to those involved in continuous quality improvement processes in day surgery.