Antibacterial activity of traditional spices against lower respiratory tract pathogens: combinatorial effects of Trachyspermum ammi essential oil with conventional antibiotics.

The aim of this study was to investigate the effects of ajowan essential oil (AjEO)/thymol and antibiotics combinations against three standard strains and six resistant clinical isolates of major respiratory bacteria (Pseudomonas aeruginosa, Staphylococcus aureus and Streptococcus pneumoniae). The broth microdilution method was conducted to determine the minimum inhibitory concentrations (MIC) of essential oil/thymol and antibiotics. The checkerboard method was used to investigate the interactions between the essential oil/thymol and antibiotics by means of the fractional inhibitory concentration index (FICI). The chemical composition of essential oil was also analysed by GC-MS and GC-FID. Thymol (50·75%), γ-terpinene (25·94%) and p-cymene (18·31%) were identified as major constituents of the oil. The most sensitive organisms to ajowan volatile oil were Strep. pneumoniae bacteria (MIC = 0·125-0·5 mg ml-1 ). Synergistic effects were observed with AjEO/thymol and amoxicillin combinations on methicillin-resistant Staph. aureus clinical isolates (FICI = 0·37-0·50) and with essential oil and ciprofloxacin combinations against P. aeruginosa ATCC 27853, Staph. aureus ATCC 25923 and penicillin (P)-resistant Strep. pneumoniae bacteria (FICI = 0·37-0·50). Combination of thymol and ciprofloxacin produces synergistic effects only against P. aeruginosa ATCC 27853 and P-resistant Strep. pneumoniae clinical isolate (FICI = 0·46-0·49).

Risk of hepatitis B virus reactivation in hepatitis B virus + hepatitis C virus-co-infected patients with compensated liver cirrhosis treated with ombitasvir, paritaprevir/r + dasabuvir + ribavirin.

Hepatitis B virus may reactivate in patients with chronic hepatitis C treated with direct-acting antivirals. The aim of this study was to investigate the risk of hepatitis B virus (HBV) reactivation in HBV + hepatitis C virus (HCV)-co-infected patients with compensated liver cirrhosis treated with paritaprevir/ombitasvir/ritonavir, dasabuvir with ribavirin. We reviewed prospectively gathered data from a national cohort of 2070 hepatitis C virus patients with compensated liver cirrhosis who received reimbursed paritaprevir/ombitasvir/r, dasabuvir with ribavirin for 12 weeks from the Romanian National Health Agency during 2015-2016. Twenty-five patients in this cohort were HBs antigen positive (1.2%); 15 untreated with nucleotide analogues agreed to enter the study. These patients were followed up: ALT monthly, serology for HBV and DNA viral load at baseline, EOT and SVR at 12 weeks. Hepatitis B virus (HBV)-co-infected patients were all genotype 1b and 52% females, with a median age of 60 years (51 ÷ 74); 76% were pretreated with peginterferon + ribavirin; 72% were with severe necroinflammatory activity on FibroMax assessment; 40% presented comorbidities; and all were HBe antigen negative. Hepatitis C virus (HCV) SVR response rate was 100%. Hepatitis B virus (HBV)-DNA viral load was undetectable in 7/15 (47%) before therapy, and for the other 8 patients, it varied between below 20 and 867 IU/mL. Five patients (33%) presented virological reactivation (>2 log increase in HBV-DNA levels) during therapy. One patient presented with hepatitis associated with HBV reactivation, and two started anti-HBV therapy with entecavir. Hepatitis B virus (HBV) virological reactivation was present in 33% in our patients. Generally, HBV-DNA elevations were mild (<20 000 IU/mL); however, we report one case of hepatitis associated with HBV reactivation.

VITAMIN D DEFICIENCY, A NONINVASIVE MARKER OF STEATOHEPATITIS IN PATIENTS WITH OBESITY AND BIOPSY PROVEN NONALCOHOLIC FATTY LIVER DISEASE.

CONTEXT: Nonalcoholic fatty liver disease (NAFLD) includes simple steatosis, steatohepatitis (NASH) which can evolve with progressive fibrosis, cirrhosis and hepatocellular carcinoma. As liver biopsy cannot be used as a screening method, noninvasive markers are needed. OBJECTIVE: The aim of this study was to test if there is a significant association between vitamin D deficit and the severity of NAFLD. DESIGN: The patients were divided into two groups (vitamin D insufficiency/deficiency) and statistical analyses were performed on the correlation of clinical and biochemical characteristics with histopathological hepatic changes. SUBJECTS AND METHODS: We prospectively studied 64 obese patients referred for bariatric surgery between 2014 and 2016 to our Surgical Unit. Anthropometric, clinical measurements, general and specific biological balance were noted. NAFLD diagnosis and activity score (NAS) were evaluated on liver biopsies. RESULTS: Increased serum fibrinogen was correlated with NASH (p=0.005) and higher NAS grade. T2DM was positively correlated with liver fibrosis (p=0.002). 84.37% of the patients had vitamin D deficit and 15.62% were vitamin D insufficient. Lobular inflammation correlated with vitamin D deficit (p=0.040). Fibrosis (p=0.050) and steatohepatitis (p=0.032) were independent predictors of low vitamin D concentration. CONCLUSIONS: Vitamin D status in conjunction with other parameters - such as T2DM - or serum biomarkers - namely fibrinogen level and PCR level - may point out the aggressive forms of NAFLD and the need for liver biopsy for appropriate management.

Adalimumab and Infliximab in Crohn's disease - real life data from a national retrospective cohort study.

AIM: to compare the efficacy and safety of Adalimumab(ADA) and Infliximab(IFX), in a large Romanian population and to identify predictors of response. Methods We performed a national retrospective cohort study including 265 patients (136 ADA, 129 IFX) between 2008-2014. Binary logistic regression was performed with the statistical program Minitab. RESULTS: Patients were half women, with a median age of 36, a median disease duration of 2.5 years, 80% received Azathioprine. Mean therapy duration was 20 months in ADA group and 36 months in IFX group. Complete response to Adalimumab respectively Infliximab was recorded in 77%vs.65%, secondary loss of response in 18%vs.28%, statistically comparable. We failed to identify predictors of response. In 79.2%of patients with secondary loss of response to ADA, the dose was escalated, 12.5% were switched to Infliximab. In 70%of patients that lost response to IFX, the dose was increased, 30% were switched to Adalimumab. CONCLUSIONS: Adalimumab and Infliximab have similar efficacy, with a complete response rate of~70%. In case of secondary loss of response to IFX, the best solution is to switch to ADA, with 83% response rate, while in case of secondary loss of response to ADA, increasing the dose leads to 84 % response rate.

ASSESSMENT OF ADRENOCORTICAL DYSFUNCTION IN PATIENTS WITH STABLE LIVER CIRRHOSIS.

INTRODUCTION: Relative adrenal insufficiency (RAI) is common in the setting of critical illness as well as in hemodynamically instable cirrhotic patients with sepsis. Several studies have also shown that RAI is frequent in patients with stable cirrhosis without sepsis. The aim of this study was to prospectively assess the incidence of RAI in patients with stable cirrhosis. PATIENTS AND METHODS: Forty-seven patients with hemodynamically stable liver cirrhosis without sepsis were prospectively included. RAI, assessed by using low dose-short Synacthen test (LD-SST), was defined as either a basal total cortisol concentration below 3.6 µg/dL or a peak total serum cortisol ≤ 16 µg/dL at 30 min after stimulation. RESULTS: RAI was present in 10 (21.3%) of 47 cirrhotic patients. Peak cortisol level was negatively correlated with the severity of cirrhosis evaluated by Child-Turcotte-Pugh (CTP) (r=-0.46; P=0.001) and Model for End-Stage Liver Disease (MELD) (r=-0.51; P=0.001) scores. The frequency of RAI increased from CTP-A (10%) to CTP-B (30%) to CTP-C (60%). CONCLUSION: RAI diagnosed by LD-SST is frequent in patients with stable cirrhosis and is related to the severity of liver disease. Further studies are needed to define clinical importance of RAI in stable cirrhotic patients.

Clostridium difficile infection in patients with liver disease: a review.

Over the past two decades, there has been a dramatic worldwide increase in both the incidence and severity of Clostridium difficile infection (CDI). Paralleling the increased incidence of CDI in the general population, there has been increased interest in CDI among patients with liver disease, particularly in those with liver cirrhosis and post liver transplantation. MEDLINE and several other electronic databases from January 1995 to December 2014 were searched in order to identify potentially relevant literature. Patients with cirrhosis and liver transplant recipients are at high risk for the development CDI because of antibiotics and proton pump inhibitors use, frequent and prolonged hospitalization, immunosuppressant therapy, and multiple comorbidities. Enzyme immunoassay to detect C. difficile toxins A and B in stool remains the most widely used test for CDI diagnosis, although, more recently, polymerase chain reaction (PCR)-based assays have become the preferred diagnostic test in many laboratories. Metronidazole and vancomycin, given orally, have proved to be effective in the treatment of CDI. Both cirrhotic patients and liver transplant recipients with CDI have longer length of hospital stay, increased mortality, and higher healthcare costs than those without CDI. A rapid diagnosis and adequate therapy of CDI are of paramount importance to improve liver disease patients' outcome. The aim of this review is to provide up-to-date information on the epidemiology, risk factors, pathogenesis, treatment, and outcomes in liver disease patients with CDI.

Clostridium difficile infection and inflammatory bowel disease: what gastroenterologists and surgeons should know.

Over the past two decades there has been a dramatic increase worldwide in both incidence and severity of Clostridium difficile infection (CDI). Paralleling the rising incidence of CDI in the general population, there has been an even higher increase in the incidence of CDI among patients with inflammatory bowel disease (IBD). CDI may mimic a flare of IBD as symptoms and laboratory parameters are often similar, and therefore, screening for CDI is recommended at every flare in such patients. Enzyme immunoassay to detect Clostridium difficile toxin A and B in stool is still the most widely used test for CDI diagnosis despite its low sensitivity. Metronidazole for mild/moderate CDI,and vancomycin for severe CDI are the preferred agents for the treatment of infection. CDI has a negative impact both on short- and long- term IBD outcomes, increasing the need for surgery, as well as the mortality rate and healthcare costs. All gastroenterologists and surgeons should have a high index of suspicion for CDI when evaluating a patient with IBD flare, as prompt diagnosis and adequate treatment of infection improve outcomes. Measures must be taken to prevent spreading of infection in gastroenterology /surgery settings.

Single-balloon enteroscopy following videocapsule endoscopy for diagnosis of small bowel tumors: preliminary experiences.

BACKGROUND AND AIM: Small bowel tumors (SBTs), either benign or malignant, are rare, accounting for 3-6% of all digestive neoplasms. Videocapsule endoscopy (VCE) and double-balloon enteroscopy (DBE) have revolutionized the diagnosis and management of patients with small bowel diseases, including SBTs. A novel method using the single-balloon enteroscopy (SBE) has recently been developed. The aim of present study was to present our preliminary experience with SBE in patients with suspected SBTs on VCE examination. PATIENTS AND METHODS: Patients in whom VCE showed one or more lesions suggesting SBTs underwent SBE. RESULTS: Three patients (2 males, 1 female; mean age 52 +/- 11 years) underwent SBE, and then surgery. There were two gastrointestinal stromal tumors and one adenocarcinoma. Clinically, all patients had iron-deficiency anemia and abdominal pain, and one patient had episodes of nausea/ vomiting. SBE was well tolerated without adverse events. CONCLUSIONS: SBE is a safe procedure and overcomes the limitations of VCE. Both procedures are complimentary in patients with suspected SBTs. VCE should be used first for initial diagnosis, followed by SBE for histopathological confrmation of the diagnosis and, if necessary, endoscopic therapy.

Small-bowel neoplasms in patients undergoing video capsule endoscopy: a multicenter European study.

BACKGROUND AND STUDY AIM: Small-bowel tumors account for 1% - 3% of all gastrointestinal neoplasms. Recent studies with video capsule endoscopy (VCE) suggest that the frequency of these tumors may be substantially higher than previously reported. The aim of the study was to evaluate the frequency, clinical presentation, diagnostic/therapeutic work-up, and endoscopic appearance of small-bowel tumors in a large population of patients undergoing VCE. PATIENTS AND METHODS: Identification by a questionnaire of patients with VCE findings suggesting small-bowel tumors and histological confirmation of the neoplasm seen in 29 centers of 10 European Countries. RESULTS: Of 5129 patients undergoing VCE, 124 (2.4%) had small-bowel tumors (112 primary, 12 metastatic). Among these patients, indications for VCE were: obscure gastrointestinal bleeding (108 patients), abdominal pain (9), search for primary neoplasm (6), diarrhea with malabsorption (1). The main primary small-bowel tumor type was gastrointestinal stromal tumor (GIST) (32%) followed by adenocarcinoma (20%) and carcinoid (15%); 66% of secondary small-bowel tumors were melanomas. Of the tumors, 80.6% were identified solely on the basis of VCE findings. 55 patients underwent VCE as the third procedure after negative bidirectional endoscopy. The lesions were single in 89.5% of cases, and multiple in 10.5%. Retention of the capsule occurred in 9.8% of patients with small-bowel tumors. After VCE, 54/124 patients underwent 57 other examinations before treatment; in these patients enteroscopy, when performed, showed a high diagnostic yield. Treatment was surgery in 95% of cases. CONCLUSIONS: Our data suggest that VCE detects small-bowel tumors in a small proportion of patients undergoing this examination, but the early use of this tool can shorten the diagnostic work-up and influence the subsequent management of these patients.

Pancreatic enzymes replacement therapy in chronic pancreatitis: an update.

Chronic pancreatitis is the major cause of exocrine pancreatic insufficiency which should be compensated by pancreatic enzyme replacement therapy. There are now available a great number of pancreatic enzyme preparations, but encapsulated enteric-coated microspheres and minimicrospheres are considered the enzyme treatment of choice. However, full compensation of pancreatic exocrine insufficiency with enzyme replacement therapy cannot be obtained in all patients with chronic pancreatitis.

[Seizures during the treatment with interferon for chronic C hepatitis]. / Crise comitiale au cours d'un traitement par interféron alpha, aux faibles doses, dans un cas d'hépatite chronique virale C.

Interferon alpha (IFN-alpha) is a well-established first-line treatment for chronic viral hepatitis. Side effects of IFN-alpha therapy are common but generally mild and self-limited. Generalized seizures during IFN-alpha therapy are very uncommon and are present in clinical isolated cases and usually in association with high doses of IFN-alpha. In our case a female of 39 years old, seizures have occurred at low doses of IFN-alpha used as therapy for chronic C viral hepatitis. As it comes to our knowledge, till now, there were published only 4 cases of generalized seizures that occurred during treatment with IFN-alpha for chronic C viral hepatitis. The physiopathology of this complication is unknown. Generalized seizures can be reasonable due to IFN-alpha therapy, as long as the patient didn't have any seizure history, or other factors, which can develop seizures. Neurological examination, EEG and brain scan were normal. The recurrence of these seizures was absent stopping IFN-alpha therapy without any other seizure treatment.

Helicobacter pylori infection, nonsteroidal anti-inflammatory drugs, and gastroduodenal pathology: current status.

Non-steroidal anti-inflammatory drugs (NSAIDs) are now widely used medicines and their relationship with gastroduodenal injury is well established. The overall risk for serious gastrointestinal side effects in patients taking NSAIDs is three times greater than that of control groups and this risk rises to more than five times in elderly patients. Moreover, the risk of gastrointestinal surgery is ten times greater in elderly patients taking NSAIDs than in controls. Therapeutic aspects like the necessity of eradication of Helicobacter pylori (H. pylori) in order to reduce the gastroduodenal risks for NSAIDs users, the indication for eradication of H.pylori of those with past history of peptic ulcer and require NSAID therapy, the role of eradication when the NSAIDs are used in association with misoprostol.

Inhibition of progressing primary esophageal peristalsis by pharyngeal water stimulation in humans.

BACKGROUND & AIMS: Sensory impulses initiated from the pharynx exert differing effects on the deglutitive apparatus. They have an inhibitory effect on the lower esophageal sphincter but an excitatory effect on the upper esophageal sphincter. The aim of this study was to systematically investigate the effect of pharyngeal sensory impulses evoked by water stimulation on the progressing esophageal peristalsis. METHODS: Sixteen healthy young volunteers were studied in the supine position. The presence of normal peristalsis was verified. Esophageal peristalsis was recorded 3, 6, 9, 12, 15, and 18 cm above the lower esophageal sphincter. Pharyngeal stimulation was performed by injecting a predetermined threshold volume into the pharynx 2 cm above the upper esophageal sphincter, directed posteriorly. The injections were timed to coincide with the arrival of the peristaltic wave induced by dry swallows at respective recording sites. RESULTS: Injection of the threshold volume (0.5 +/- 0.1 mL) stopped the progression of peristalsis at both the striated and smooth muscle esophagus. Topical pharyngeal anesthesia blocked this inhibitory effect (P < 0.01). CONCLUSIONS: Sensory impulses initiated from the pharynx evoked by water injection inhibit the progression of primary esophageal peristalsis. Although the clinical significance of these findings is not determined, they may explain the mechanism of some of the failed esophageal peristalsis.

Inhibition of resting lower esophageal sphincter pressure by pharyngeal water stimulation in humans.

BACKGROUND/AIMS: Normal inhibition of lower esophageal sphincter (LES) tone occurs during swallowing and belching. However, it is known that it may occur independently of these functions. The aim of this study was to characterize the effect of pharyngeal water stimulation on resting LES pressure. METHODS: The effect of rapid-pulse and slow continuous intrapharyngeal injection of minute increments of water on the resting tone of the upper and LES of 14 healthy young volunteers was evaluated by concurrent manometry, submental electromyography, and respirography. RESULTS: At a threshold volume, pharyngeal water injection induced an isolated LES relaxation in all volunteers. The threshold volume inducing LES relaxation by rapid-pulse injection, 0.16 +/- 0.01 mL, was significantly lower than that with slow continuous injection (0.5 +/- 0.05 mL) (P < 0.05). The duration and magnitude of LES relaxation were not volume dependent. The duration of LES relaxation induced by rapid-pulse injection was significantly longer than that of swallows. CONCLUSIONS: Minute amounts of liquid injected into the pharynx induce LES relaxation different from that of the normal swallow. Neither the duration nor the magnitude of this relaxation is volume dependent. Whereas the contribution of this finding to the mechanism of transient LES relaxation remains to be ascertained, it may partially explain the variability of the basal LES pressure.

[Retrograde cholangiopancreatography (ERCP) and endoscopic sphincteropapillotomy (ES) in the diagnosis and treatment of common bile duct (CBD) lithiasis]. / Colangiopancreatografia retrograda (ERCP) si sfincteropapilotomia endoscopica (ES) in diagnosticul si tratamentul litiazei caii biliare principale (CBP).

The common bile duct (CBD) stones often gives real difficulties of diagnosis and treatment. The ultrasound (US) does not offer in a significant percentage of cases certain diagnostic data, and the unconventional imaging techniques such as computer tomography (CT) are yet less accessible. ERCP appeared in the last period as an optional method for the diagnosis of common bile duct stones, and, moreover, permitted the development of the nonsurgical treatment possibilities. ES and the extraction of stones revealed in this frame as preferable, especially in the high surgical risk cases. This study presents the results of ERCP performed in 547 and the therapeutic value of ES in 284 cases with CBD stones (conclusions of the ERCP and ES used in the clinical practice, in our clinic, in the last three years). In 81.69% cases ES managed the dezobstruction of the CBD, with a frequency of complications of 4.33% and a related mortality rate of 0.78%.