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Background Autoimmune pancreatitis is a steroid-responsive inflammatory pancreatic disease considered to be part of an immunoglobulin G4 (IgG4)-associated systemic disease. Aim To review the management of autoimmune pancreatitis. Methods We conducted a PubMed search using the following key words: autoimmune pancreatitis, IgG4-associated systemic disease, IgG4-associated cholangitis, diagnosis, natural history, treatment. Results Although there are reports of spontaneous resolution of autoimmune pancreatitis, steroids have been shown to be effective in inducing remission, reducing the frequency of relapse and that of long-term unfavourable events compared to historical controls. There are no randomised data on autoimmune pancreatitis treatment. Oral steroids are used for induction of remission. Reported response results are excellent with variable proportions of patients achieving remission in different studies. After a period of 2-4 weeks, steroids are tapered and usually withdrawn within several months, although long-term maintenance therapy for all autoimmune pancreatitis patients has also been proposed. Disease relapse occurs in more than 40% of patients and can be effectively treated with additional immunosuppression, including azathioprine. Conclusions Steroids are effective in inducing remission and in treating relapse in patients with autoimmune pancreatitis. Randomised trials on autoimmune pancreatitis therapy are lacking. To date, questions concerning the timing, choice and duration of long-term immunosuppression remain unanswered. [ABSTRACT FROM AUTHOR]

This retrospective study was conducted to evaluate the safety and complications profile of general anaesthesia (GA) compared with that of regional anaesthesia (RA) for BM harvesting (BMH). The study included 281 donations carried out between 1992 and 1999. Of these, 204 (73%) were allogeneic donations, and GA was carried out in 69% (140 of 204) and RA in 31% (64 of 204) of cases. The other 77 donations were autologous (27%), using GA in 87% (67 of 77) and RA in 13% (10 of 77) of cases. No life-threatening complications occurred, but there were minor intra- and postoperative events during 26 (9%) and after 58 (21%) donations. Postoperative nausea and vomiting was reported in 40 (14%) cases and post-spinal headache after five out of 58 (8.6%) donations in which spinal anaesthesia was carried out. The incidence of intra- and postoperative events did not differ significantly between the GA and RA groups. However, the incidence of postoperative events was higher in the allogeneic group compared with that in the autologous group (25 vs 10%, P<0.01) and in female donors compared with male donors (29 vs 14%, P=0.002). In conclusion, both GA and RA are comparable with regard to BMH. Nevertheless, non-severe intra- and postoperative events were frequent. [ABSTRACT FROM AUTHOR]

Data from the USA suggest that morphological specificity is insufficient to permit an assumption of malignancy in nodal staging with endoscopic ultrasound (EUS). This may not hold true elsewhere as the background lymph node burden may vary in different geographic regions. We aimed to assess the prevalence and features of mediastinal and abdominal lymph nodes at EUS in a Northern European population without malignant disease. A total of 129 consecutive patients without malignant disease referred for radial EUS were prospectively evaluated for the prevalence and echo features of lymph nodes in the mediastinum and upper abdomen. Sixty-two percent of patients had mediastinal lymph nodes and 17% had abdominal nodes at EUS. A mean of 1.4 (standard deviation 1.3, range 0–8) nodes were found per patient. No celiac nodes were seen. The majority of detected nodes were 0.5 cm or less in short axis, had oval shape, centrally echogenic pattern, and indistinct borders. The most common node locations were the subcarinal and paraesophageal areas, and the hepatoduodenal ligament. In multivariate analysis mediastinal lymphadenopathy was related to body mass index and abdominal lymphadenopathy to acute pancreatitis. The occurence of mediastinal lymphadenopathy is markedly lower in Northern Europeans than reported for US patients. Celiac nodes are extremely rare in patients without malignancy. The majority of nodes have a width of 0.5 cm or less, have oval shape, centrally echogenic pattern, and indistinct borders. The characterization of the background lymph node burden may improve the selection of lymph nodes for fine needle aspiration. [ABSTRACT FROM AUTHOR]

Aim To evaluate the long-term prognosis of patients diagnosed with drug-induced liver injury, and the nature of the liver injury. Methods Patients with a diagnosis of drug-induced liver injury between 1994 and 2005 were identified in a university hospital clinic. Patients surviving drug-induced liver injury-associated liver failure were excluded. Results Seventy-seven cases were identified and those who were alive (69) were invited to attend follow-up. Of those patients who had died, none had died of liver disease. Of those patients who had survived, 59 were reviewed in the clinic. Patients had a median follow-up of 48 months. Before the diagnosis of drug-induced liver injury, nine had a chronic liver disease, four with autoimmune hepatitis, two with non-alcoholic liver disease, one each with non-alcoholic fatty liver disease, primary biliary cirrhosis and primary sclerosing cholangitis. There was no evidence of progression of their liver disease during follow-up. Among 50 patients without a known liver disease prior to the drug-induced liver injury, 10 had abnormal liver tests. Diagnostic work-up revealed alternative cause of liver disease in all except three patients (6%), who had asymptomatic abnormal liver tests (but normal bilirubin in all). Conclusions Chronic abnormalities in liver tests, not explained by an identified liver disease, are very rare in patients previously diagnosed with drug-induced liver injury. This group of patients did not seem to have a clinically significant liver injury at long-term follow-up. [ABSTRACT FROM AUTHOR]

Background Drug-induced liver injury may be immunologically mediated or metabolically induced. Peripheral eosinophilia and liver eosinophilia in suspected drug-induced liver injury generally supports the role of drug aetiology. Aim To assess the importance of eosinophilia and hepatic necrosis on outcome in patients with suspected drug-induced liver injury. Methods We performed search of MEDLINE for case reports on drug-induced liver injury associated with: amoxicillin/clavulanic acid, carbamazepine, diclofenac, disulfiram, erythromycin, flucloxacillin, halothane, isoniazid, phenytoin, sulindac and trimethoprim/sulfametoxazol. Results A total of 570 case reports were retrieved. Mortality/transplantation occurred in 112 (20%). Eosinophilia in peripheral blood was reported in 34% of cases, eosinophilia in liver biopsies in 40%, and hepatic necrosis in 41%. Bilirubin levels were lower in patients with peripheral eosinophilia [5.5 × upper limit of normal (interquartile range 2.9–10) vs. 7.7 (4–17); P = 0.02] and patients with liver eosinophilia [5 × upper limit of normal (2.7–10) vs. 10 (5.4–20); P = 0.003] as compared with those without eosinophilia. Eosinophilia in peripheral blood and eosinophilia in liver biopsies were more common in patients who recovered (37% vs. 15.6%; P = 0.0001 and 48% vs. 18.8%; P < 0.0001, respectively). Hepatic necrosis was present in 24% in the survivors vs. 84% in non-survivors ( P < 0.0001). Conclusions In drug-induced liver injury, a favourable outcome was related to the occurrence of eosinophilia, whereas hepatic necrosis was associated with a poor prognosis. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article by J. Newton and C. P. Day about fatigue in patients with non-alcoholic fatty liver disease that was published in the previous issue.

Introduction Peroral cholangioscopy (POC) enables direct visual examination of bile ducts, tissue sampling and therapeutic interventions. The authors aimed to evaluate the diagnostic utility of Spyglass POC for indeterminate biliary lesions and its usefulness in electrohydraulic lithotripsy (EHL) of bile duct stones not amenable to conventional endoscopic therapy. Methods A total of 141 consecutive patients (mean age 61 years (SD15); 62F), undergoing 149 attempted Spyglass procedures, in 3 UK tertiary referral centres between 2008 and 2010 were retrospectively enrolled. The authors estimate that >80% of all Spyglass procedures performed for indeterminate biliary lesions or EHL of stones in the UK are included. Brush cytology or POC-directed biopsies were obtained as clinically indicated. Patients were followed up for a mean of 9 months (7). The operating characteristics of POC for detecting malignant biliary lesions were calculated using a composite reference standard that included surgery, tissue sampling and follow-up. Bile duct clearance after POC-EHL was also determined using stone recurrence at follow-up as a reference standard. Results Indications for Spyglass procedures included 108/149 (72%) stricture assessment, 16/149 (11%) intraluminal mass assessment and 25/149 (17%) EHL for stones. The Spyglass cholangioscope could be inserted in the bile duct in 140/149 (94%) and adequate mucosal visualisation was achieved in 121/149 (81%). A diagnosis of cancer was made in 36/149 (24%). Brush cytology sampling was performed in 60/149 (40%) with 50/60 (83%) yielding sufficient samples. POC-directed biopsies were performed in 67/149 (45%) with 52/67 (78%) yielding sufficient samples. The sensitivity, specificity, positive and negative predictive values and accuracy of POC for the diagnosis of malignant lesions were 72%, 97%, 93%, 86% and 88%, respectively. 17 out of 36 (42%) malignant lesions were correctly identified at Spyglass POC (with/without tissue confirmation). In all 27 EHL procedures were performed in 25 patients. Bile duct clearance was achieved in 17/25 (68%) with a further 2/25 (8%) awaiting further procedures. There were 11/149 (7%) adverse events (8 cholangitis/sepsis, 1 postsphincterotomy bleed, 1 hypotension, 1 pancreatitis). Two adverse events were severe (1 death and 1 ITU admission both with sepsis) and one was moderate (sepsis). Conclusion In experienced hands, Spyglass POC is very accurate in the diagnosis of malignant biliary lesions and effective for the treatment of bile duct stones not amenable to conventional endoscopic therapy. The complication rate is comparable to that of conventional ERCP with sepsis being the most common adverse event. [ABSTRACT FROM PUBLISHER]

Hepatic encephalopathy has a negative impact on health-related quality of life (QoL) in liver cirrhosis. There are scarce and conflicting data on whether type or etiology of liver cirrhosis could be related to hepatic encephalopathy in patients with cirrhosis. We aimed to determine the impact of cirrhosis etiology on hepatic encephalopathy and whether hepatic encephalopathy affects health-related QoL among patients with cirrhosis of different etiologies.~Background~Background~A total of 156 cirrhotic patients were prospectively evaluated for the presence of hepatic encephalopathy according to the West-Haven criteria as well as by means of two psychometric tests. Patients with cryptogenic cirrhosis or cirrhosis due to mixed hepatocellular/cholestatic etiologies were excluded. Fasting plasma glucose levels were also measured. QoL was evaluated by means of a validated questionnaire (SF-36).~Methods~Methods~Diabetes mellitus was more common in patients with hepatocellular cirrhosis compared to those with cholestatic cirrhosis but the two groups did not differ in cirrhosis severity or the prevalence of hepatic encephalopathy (p > 0.05). The groups of patients with cirrhosis due to alcohol, hepatitis C, or cholestatic liver disease did not differ in severity of liver cirrhosis or the prevalence of hepatic encephalopathy (p > 0.05). Patients with cirrhosis of different etiologies did not differ in any SF-36 domain (p > 0.05). In multivariate analysis, performance at neuropsychological testing was independently related only to age, diabetes mellitus, and the Child-Pugh score whereas the SF-36 physical component summary only to the Child-Pugh score and hepatic encephalopathy.~Results~Results~Cirrhosis etiology does not seem to be related to hepatic encephalopathy or health-related QoL. Cognitive impairment is associated mainly with age, liver disease severity and diabetes mellitus.~Conclusion~Conclusions [ABSTRACT FROM AUTHOR]

Background: Colorectal cancer is internationally the third leading cause of death from a malignant disease. The aim of screening colonoscopy in adults > 45 years of age is early diagnosis and treatment of precancerous polyps. Endoscopic polyp removal (polypectomy) can be achieved with various techniques depending on the size, morphology, and location of the polyp. According to current guidelines, small non-pedunculated polyps should be removed with a cold snare after the colorectal lumen has been insufflated with air (conventional cold snare polypectomy).In recent years, several studies have described the benefits of water aided colonoscopy, as well as the safety and efficacy of underwater cold snare polypectomy for large colon polyps. However, there are insufficient data on conventional and underwater techniques for small polyps, the most commonly diagnosed colorectal polyps. Methods: We have designed a prospective randomized double-blind clinical trial to compare the safety and efficacy of conventional and underwater cold snare polypectomy for non-pedunculated polyps 5–10 mm in size. A total of 398 polyps will be randomized. Randomization will be carried out using the random numbers method of Microsoft Excel 2016. The primary endpoint is the muscularis mucosa resection rate. Secondary endpoints are the depth and percentage of R0 excisions, complications, and the recurrence rate at follow-up endoscopy 6–12 months after polypectomy. Discussion: We hypothesize underwater polypectomy will result in a higher muscularis mucosa resection rate. The results of our study will provide useful data for the development of guidelines in polypectomy techniques for non-pedunculated polyps 5–10 mm in size. Clinical trial registration: Clinicaltrials.gov, NCT05273697. [ABSTRACT FROM AUTHOR]

We investigated the usefulness of the concentration of total proteins, albumin, creatinine, calcium (Ca), magnesium (Mg) and the activities of aspartate aminotransferase (AST) and gamma-glutamyltransferase (GGT) in aqueous humor in estimating the ante mortem levels of the same biochemical analytes in sheep blood. A blood sample was taken ante mortem and aqueous humor was collected 12 h post mortem from 63 sheep. Linear Regression Analysis was run to determine the equations predicting the serum value of each parameter based on the value determined in aqueous humor for those parameters that were significantly correlated. A strong relationship was found for Mg and creatinine concentration as well as for AST and GGT activities in aqueous humor and serum. Aqueous humor analysis of creatinine, Mg, AST and GGT levels can be used for the estimation of the corresponding concentration in blood, while, total proteins, albumin and Ca levels are of limited value. [ABSTRACT FROM AUTHOR]

Data from various studies indicate that the ovarian function in dairy cows can be compromised during intramammary infections. Therefore, in this study, we investigated if an experimentally induced mastitis has an effect on corpus luteum (CL) function in 14 lactating cows. On d 9 of the estrous cycle (d 1 = ovulation), cows received a single dose of 200 μg of Escherichia coli lipopolysaccharide (LPS; dissolved in 10 mL of NaCL; n = 8) or 10 mL of saline (control; n = 6) into one quarter of the mammary gland. Measurements included plasma cortisol, haptoglobin, and progesterone (P4) concentrations, as well as luteal size (LTA) and relative luteal blood flow (rLBF). Sampling was performed on d 1, 4, and 8. On d 9, the main examination day, sampling was performed immediately before (0 h), every 1 h (or at 3-h intervals for LTA and rLBF) until 9 h, as well as 12 and 24 h after treatment. Thereafter, measurements were taken on d 12, 15, 18, and then every 2 d until ovulation. Luteal tissue was collected for biopsy 24 h before and 6 h after treatment. Quantitative real-time PCR was applied to assess mRNA expression of steroidogenic factors (STAR, HSD3B), caspase 3, toll-like receptors (TLR2, -4), tumor necrosis factor a (TNFA), and prostaglandin-related factors (PGES, PGFS, PTGFR). Intramammary LPS infusion caused considerable inflammatory responses in the treated udder quarters. No decrease in plasma P4 concentrations was noted after LPS-challenge, and P4 levels did not differ between LPS-treated and control cows. Furthermore, LTA and rLBF values were not decreased after LPS challenge compared with the values obtained immediately before treatment. However, LPS infusion increased plasma levels of cortisol and haptoglobin compared with the control group. In the CL, mRNA abundance of TLR2 and TNFA was increased in cows after LPS-challenge (but not in control cows), whereas TLR4, steroidogenic, and prostaglandin-related factors remained similar to the mRNA abundance before treatment. In conclusion, intramammary LPS challenge induces systemic inflammatory reactions which alter the luteal mRNA abundance of TLR2 and TNFA but does not induce lysis of the CL. [ABSTRACT FROM AUTHOR]

Increased incidence and severity of Clostridium difficile infections (CDIs) is of major concern. However, by minimizing known risk factors, the incidence can be decreased. The aim of this investigation was to calculate the incidence and assess risk factors for CDI in our population. A 1-year prospective population-based nationwide study in Iceland of CDIs was carried out. For risk factor evaluation, each case was matched with two age- and sex-matched controls that tested negative for C. difficile toxin. A total of 128 CDIs were identified. The crude incidence was 54 cases annually per 100,000 population >18 years of age. Incidence increased exponentially with older age (319 per 100,000 population >86 years of age). Community-acquired origin was 27 %. Independent risk factors included: dicloxacillin (odds ratio [OR]: 7.55, 95 % confidence interval [CI]: 1.89-30.1), clindamycin (OR: 6.09, 95 % CI: 2.23-16.61), ceftriaxone (OR: 4.28, 95 % CI: 1.59-11.49), living in a retirement home (OR: 3.9, 95 % CI: 1.69-9.16), recent hospital stay (OR: 2.3, 95 % CI: 1.37-3.87). Proton pump inhibitors (PPIs) were used by 60/111 (54 %) versus 91/222 (41 %) ( p = 0.026) and ciprofloxacin 19/111 (17 %) versus 19/222 (9 %) ( p = 0.027) for cases and controls, respectively. In all, 75 % of primary CDIs treated with metronidazole recovered from one course of treatment. CDI was mostly found among elderly patients. The most commonly identified risk factors were broad-spectrum antibiotics and recent contact with health care institutions. PPI use was significantly more prevalent among CDI patients. [ABSTRACT FROM AUTHOR]

Abstract: Background: In chronic heart failure (CHF) it has been proposed that a dysfunction of the gastrointestinal barrier could lead to translocation of endotoxin into the systemic circulation. A secondary inflammatory reaction, observed as increased levels of cytokines, could negatively affect cardiac function. The aims of this paper were therefore to determine whether patients with CHF have a disturbed mucosal barrier and whether it was possible to detect endotoxin in venous blood. Methods: Nineteen stable patients with CHF (New York Heart Association II–III, EF≤40% or EF>40% and earlier hospitalisation for heart failure) were investigated. Twenty healthy subjects (HS group) and 25 patients, who were admitted for bone marrow transplantation (BMT group), served as controls. Gastrointestinal permeability was assessed by a 51Cr-EDTA absorption test. Results: Eleven patients with and eight without peripheral oedema were included. Median age was 76.5 years. Intestinal permeability was 1.82±1.96% in the CHF patients and 1.54±.59% and 1.9±.9% in HS and BMT groups, respectively (p =0.4 and p =0.7, CHF vs HS and BMT, respectively). No difference was found between patients with and without oedema and endotoxins were below the detection limit in all patients. Discussion: This study does not support the hypothesis that patients with CHF have a dysfunctional gastrointestinal barrier, at least as assessed by the 51Cr-EDTA resorbtion test. [Copyright &y& Elsevier]

The main purpose of the study was to investigate whether the feeding system applied has any effect on the status of blood selenium (Se) and vitamins A and E in dairy sheep. In total 200 dairy sheep from 10 flocks were used in the study (20 animals per flock). Group A consisted of 100 sheep (five flocks) reared under the intensive feeding system and group B of 100 sheep (five flocks) reared under the semi-intensive feeding system. The 100 sheep of each group consisted of 25 lambs aged 3–6 months, 25 ewes 1–3 years, 25 ewes more than 3 years and 25 non-lactating ewes in late gestation. Another purpose was to evaluate the potential effect of the age and the reproductive stage of the animals on these parameters. To determine the effect of age, 150 of these animals were divided into three subgroups: 50 lambs, 50 non-pregnant lactating ewes aged 1–3 years and 50 non-pregnant lactating ewes aged more than 3 years. For the evaluation of the effect of the reproductive stage the 50 non-lactating ewes in late gestation and the 100 non-pregnant lactating ewes were used. Blood samplings were performed once, between December and January for non-lactating ewes in late gestation and March to May for lambs and lactating ewes. Whole blood Se and vitamin E and A serum concentrations were determined. The main conclusion is that the feeding system significantly affects Se and serum vitamin A concentration, as they were higher in the intensive one. It was secondly concluded that age affects the serum concentrations of vitamin A. [ABSTRACT FROM AUTHOR]