Diagnostic yield of endoscopic markers for celiac disease.

RATIONALE: In the setting of open access endoscopy, the recognition of suggestive endoscopic features in the duodenum can select patients with probability of celiac disease (CD). This could add to the current efforts to increase the diagnostic rate of this disease. AIM: The aim of this study was to evaluate the diagnostic accuracy of these markers for CD in an adult population undergoing endoscopy, without a prior serological testing. METHODS AND RESULTS: Over a period of 3 years, between June 2012 and 2015, all the patients who underwent upper gastrointestinal endoscopy and presented one or more of the endoscopic markers consistent with CD, or those suspected for CD, irrespective of the presence of these markers, were included. Sensitivity, specificity, positive and negative predictive values were calculated for these markers in CD diagnosis. Among the 182 patients, 56.04% were females, with a mean age of 47.6 ± 13.9 years. 20/182 (10.99%) had a final diagnosis of CD. The presence of any endoscopic marker had a high sensitivity (95%) and a negative predictive value (98.41%). Bulb atrophy and reduced folds in the descending duodenum had a low diagnostic accuracy, while scalloping, mosaic pattern and fissures were highly specific for CD (98.77%, 99.38% and 98.77%) and their presence greatly increased the probability of CD, with a positive likelihood ratio of 24.3, 24.3 and 12.15, respectively. DISCUSSIONS: A wide set of endoscopic markers, including the duodenal bulb, were evaluated in this study. Our results showed that the endoscopy with a careful examination of the duodenum is a sensitive indicator for CD. ABBREVIATIONS: CD = celiac disease, GI = gastrointestinal, VA = villous atrophy, NSAID = nonsteroidal anti-inflammatory drug, Sn = sensitivity, Sp = specificity, PPV = positive predictive value, NPV = negative predictive value, AUC = area under the curve, ROC = receiver operating characteristics, WLE = white light endoscopy, NBI = narrow band imaging, tTG = tissue transglutaminase, EMA = anti-endomysial antibodies.

Predictors for in-hospital mortality and need for clinical intervention in upper GI bleeding: a 5-year observational study.

BACKGROUND: Upper GI bleeding (UGIB) is a potentially life threatening gastrointestinal emergency whose effective management depends on early risk stratification. METHODS: We retrospectively studied 151 patients admitted to our unit with UGIB between 1st January 2007 and 31st December 2011 and in whom we calculated the clinical and complete Rockall, the Glasgow-Blatchford and modified Glasgow-Blatchford risk scores. We performed an analysis of the predictive value of these scores for in-hospital mortality and need for clinical intervention. RESULTS: Of the 151 patients enrolled, 68.87% were male, and the mean age was 59.48 years. One in three patients had a history of chronic liver disease and one in eight had a previous episode of UGIB. Clinically, 58.3% of the patients presented with melena, 18.5% with hematemesis and 23.1% with both hematemesis and melena. 22% of cases were variceal hemorrhages and the other non-variceal. 16 patients died during hospitalization. The prognostic accuracy of all four scores for in-hospital death and need for clinical intervention was good, the complete Rockall score having the best performance (AUROC 0.849 and 0.653 respectively). CONCLUSIONS: The Rockall and Blatchford scores were good predictors of mortality and need for clinical intervention in our study. The good predictive performance of these scores highlight the need for their use in day-to-day practice to select patients with likelihood of poor clinical outcome.

[Preliminary data on post-pancreatectomy diabetes mellitus treated by islet-cell autotransplantation]. / Date preliminare despre tratamentul diabetului postpancreatectomie prin autotransplant de insule pancreatice.

The present study describes the first islet autotransplant program in Romania, and the first 3 cases of subtotal pancreatectomy for chronic pancreatitis combined with islet autotransplant. The primary objective was to pain relief by pancreatic resection, but also to preserve the endocrine function by islet autotransplant. Extensive distal pancreatectomy is effective in relieving pain, but should be limited to patients with small duct disease, in whom more conservative methods have failed, because of severe metabolic consequences. Islets were prepared by Liberase digestion of the excised pancreas, and infused unpurified into the portal vein in one case and in the omental pouch and peritoneum in two cases. All patients were relieved of pain, have achieved insulin independence, and positive C peptide levels, but one patient died of a acute bronchopneumonia 60 days post-transplantation. The mean islet yields were 2100 islet equivalents/Kg body weight. Islet autotransplantation can be considered a useful therapeutic option serving to prevent the occurrence of surgically-induced diabetes. The results have indicate that the omental pouch is a viable site for islet autotransplantation, that can accommodate a large tissue volume, is easy to access to implant, and the IBMIR (instant blood mediated inflammatory reaction) may be less severe.

Predicting splice variant from DNA chip expression data.

Alternative splicing of premessenger RNA is an important layer of regulation in eukaryotic gene expression. Splice variation of a large number of genes has been implicated in various cell growth and differentiation processes. To measure tissue-specific splicing of genes on a large scale, we collected gene expression data from 11 rat tissues using a high-density oligonucleotide array representing 1600 rat genes. Expression of each gene on the chip is measured by 20 pairs of independent oligonucleotide probes. Two algorithms have been developed to normalize and compare the chip hybridization signals among different tissues at individual oligonucleotide probe level. Oligonucleotide probes (the perfect match [PM] probe of each probe pair), detecting potential tissue-specific splice variants, were identified by the algorithms. The identified candidate splice variants have been compared to the alternatively spliced transcripts predicted by an EST clustering program. In addition, 50% of the top candidates predicted by the algorithms were confirmed by RT-PCR experiment. The study indicates that oligonucleotide probe-based DNA chip assays provide a powerful approach to detect splice variants at genome scale.

Analysis of drug pharmacology towards predicting drug behavior by expression profiling using high-density oligonucleotide arrays.

An important aspect of the drug development process is prediction of efficacious and toxic side effects. Profiling of mRNA expression is a powerful approach to analyze the molecular phenotype of cells under various conditions, for example, in response to stimulation by compounds. We attempt to explore the approach of using expression profiling to identify patterns or fingerprints that are correlated with specific drug properties or behaviors. Identification of such expression patterns may also lead to revelation of the potential action mechanism of drugs and fingerprints indicative of certain drug efficacy or side effects. We describe here a strategy that was used to identify a set of genes whose differential expression pattern correlates with activation mode and target specificity of a specific group of drug compounds.

Usefulness of serological IgG antibody determinations for confirming eradication of Helicobacter pylori infection.

OBJECTIVE: Prior studies have suggested that IgG antibody titers may be useful to confirm successful treatment of Helicobacter pylori (H. pylori) infection. However, the diagnostic value of decreasing IgG titers is limited by the necessity to perform pre and posttreatment tests in parallel which requires stored sera. Our objective was to assess the accuracy of IgG antibody titers using the HM-CAP IgG EIA kit (Enteric Products) in monitoring treatment of H. pylori infection and to compare the relative accuracy of parallel versus serial determinations. METHODS: The 14C urea breath test (UBT) was used to confirm H. pylori infection in 83 dyspeptic patients and eradication of the organism at 4 wk and 6 months posttreatment. IgG titers pretherapy and 6 months posttherapy were determined either serially (separate EIA plates) or in parallel (same EIA plate), and the relative percent decline in antibody titer was calculated. RESULTS: When a decline of > or = 25% at 6 months was used as the cut-off for H. pylori eradication, mean sensitivities of serial and parallel determinations were 87.5% and 86.8%, respectively, and mean specificities of both were 100%. In 68 of 75 patients in whom the organism was eradicated, the mean decrease in IgG titer at 6 months was 41.1% for serial determinations and 41.5% for parallel determinations. CONCLUSIONS: Serial or parallel IgG titers offer equivalent diagnostic accuracy for confirming H. pylori eradication after therapy. A > or = 25% decline in titer 6 months after therapy is a sensitive and specific marker for eradication of the infection. Serial evaluation of IgG titers does not require serum storage, and is a cost-effective and accurate alternative to the UBT or endoscopy-based methods.

Sustained esophageal contraction: a marker of esophageal chest pain identified by intraluminal ultrasonography.

BACKGROUND & AIMS: Intraluminal pressure recording systems have not demonstrated predictable esophageal motor correlates of unexplained chest pain. This study used continuous high-frequency intraluminal ultrasonography to characterize esophageal contraction at the time of spontaneous and provoked chest pain. METHODS: Intraluminal pressure, pH, and ultrasound images of the esophagus were recorded for a maximum of 24 hours in 10 subjects with unexplained chest pain. Changes in esophageal muscle thickness were measured as a marker of muscle contraction. Ten additional subjects with suspected esophageal chest pain were studied after edrophonium chloride injection to provoke symptoms. Ten healthy subjects were studied as controls. RESULTS: Eighteen of 24 spontaneous chest pain episodes were preceded by a sustained esophageal contraction (SEC) detected on ultrasonography (mean duration, 68.0 seconds). This motor pattern was not accompanied by changes in intraluminal pressure. Four of 24 asymptomatic control periods were accompanied by SEC, although these contractions were of shorter mean duration (29.0 seconds; P < 0.001). SEC was observed in 5 subjects with a positive chest pain response to edrophonium and in none of the 5 subjects with a negative response. SEC was not detected in normal subjects. CONCLUSIONS: There is a strong temporal correlation between a previously unrecognized esophageal motor event, SEC, and both spontaneous and provoked esophageal chest pain.

Network computing.

Pioneering health care organizations are saving money and gaining greater control of their networks by trading their PCs in for thin clients. But the devices are far from pervasive in health care.

Data entry on the run.

An ambulance service in Louisiana equips medics with pen-tablet computers to speed collection of accurate and complete information.

Strategies for clinics. How integrated delivery systems are applying automation at their group practices.

Integrated delivery systems that have created or acquired physician group practices are attempting to determine the best way to apply information technology at these sites. This involves standardizing on one practice management system for all sites, determining the feasibility of installing electronic patient records systems and expanding computer networks to accommodate the exchange of data among outpatient as well as inpatient sites.

Pioneers assess the role Java can play in health care.

Since Sun Microsystems Inc. introduced Java in 1995, the new object-oriented programming language has attracted a great deal of attention. While many CIOs continue to sort the hype from the substance, a handful of health care organizations are deploying Java-based applications.

Median arcuate ligament syndrome: a possible cause of idiopathic gastroparesis.

The median arcuate ligament syndrome (MALS) is characterized by abdominal pain, nausea, and vomiting attributed to compression of the celiac axis by a fibrous band (the median arcuate ligament) connecting the diaphragmatic crura. The pathophysiologic origin of these symptoms is not clearly understood. Theories invoking either a neurogenic or vascular origin for the clinical features associated with MALS have been proposed, but objective evidence to support these theories is lacking. We describe the clinical course and gastric myoelectrical features of a patient with postprandial epigastric pain, weight loss, gastroparesis, and gastric dysrhythmias in whom a diagnosis of MALS was established. Surgical decompression of the celiac axis in our patient resulted in resolution of abdominal pain, return to a full diet within 4 weeks without nausea or vomiting, improvement in radionuclide gastric emptying, and restoration of the gastric electrical rhythm to a normal 3 cycle/min conduction rate. This is the first demonstration of altered gastric myoelectrical activity in a patient with MALS. The regularization of the gastric electrical rhythm in our patient after surgical decompression of the celiac axis would support a neurogenic basis for the symptoms associated with MALS. MALS should be excluded in patients with idiopathic gastroparesis and unexplained epigastric pain.

Nasogastric omeprazole: effects on gastric pH in critically Ill patients.

OBJECTIVE: The efficacy of omeprazole administered by the nasogastric route has not been adequately studied. We sought to determine whether nasogastrically administered omeprazole could effectively maintain an intragastric pH greater than 4.0 in patients hospitalized in a medical intensive care unit. METHODS: Patients were considered eligible for the study if they had a nasogastric feeding tube in place and had not received omeprazole, antacids, or histamine-2 blockers in the 5 days preceding study enrollment. Exclusionary criteria included active GI bleeding or a mean baseline gastric pH greater than 4.0. Patients served as their own controls during a 24-h lead-in period, during which baseline intragastric pH was measured by gastric aspirate. Omeprazole, 20 or 40 mg, was administered once daily with water through a nasogastric tube. Intragastric pH was measured every 4-8 h for a maximum of 3 days following drug administration. RESULTS: Twenty patients were considered eligible for the study; 10 were excluded because of an elevated baseline gastric pH (n = 8) or because proper gastric aspirates could not be obtained (n = 2). The mean baseline intragastric pH in four patients receiving omeprazole 20 mg q.d. was 2.4 +/- 1.1 and increased to 3.7 +/- 1.6 after drug administration (p = 0.013). The mean baseline intragastric pH in six patients receiving omeprazole 40 mg q.d. was 2.8 +/- 0.8 and increased to 5.7 +/- 1.1 after drug administration (p < 0.001). The percentage of intragastric pH values greater than 4.0 after drug administration was 34.2% in patients receiving omeprazole 20 mg q.d. and 84.7% in those receiving omeprazole 40 mg q.d. CONCLUSIONS: Nasogastric omeprazole 40 mg q.d. is effective in maintaining an intragastric pH greater than 4.0 in critically ill patients. The nasogastric administration of omeprazole offers a cost-effective therapeutic option for acid suppression in patients at risk for stress mucosal ulceration.