Papel del mecanismo de inmunoadherencia de "Leishmania" en la infección humana

La leishmaniosis es una enfermedad parasitaria causada por protozoos hemoflagelados del genero Leishmania que se transmite al hombre y a otros vertebrados a través de la picadura de un díptero de la familia Plebotominae. Cuando un flebótomo infectado pica al hospedador vertebrado, perfora la piel con su probóscide buscando las vénulas de la dermis, las lacera y provoca un pequeño hematoma donde deposita los promastigotes. Tras el contacto con la sangre tiene lugar la activación del complemento y deposición del C3 en la superficie del parásito. En primates, los promastigotes opsonizados se unen a eritrocitos y posteriormente son transferidos a las células aceptoras de la sangre: los leucocitos...

Outcomes and Predictors of Mortality in Neurosurgical Patients at Mbarara Regional Referral Hospital

Background:

Knowing the scope of neurosurgical disease at Mbarara Hospital is critical for infrastructure planning, education and training. In this study, we aim to evaluate the neurosurgical outcomes and identify predictors of mortality in order to potentiate platforms for more effective interventions and inform future research efforts at Mbarara Hospital.

Methods:

This is retrospective chart review including patients of all ages with a neurosurgical disease or injury presenting to Mbarara Regional Referral Hospital (MRRH) between January 2012 to September 2015. Descriptive statistics were presented. A univariate analysis was used to obtain the odds ratios of mortality and 95% confidence intervals. Predictors of mortality were determined using multivariate logistic regression model.

Results:

A total of 1876 charts were reviewed. Of these, 1854 (had complete data and were?) were included in the analysis. The overall mortality rate was 12.75%; the mortality rates among all persons who underwent a neurosurgical procedure was 9.72%, and was 13.68% among those who did not undergo a neurosurgical procedure. Over 50% of patients were between 19 and 40 years old and the majority of were males (76.10%). The overall median length of stay was 5 days. Of all neurosurgical admissions, 87% were trauma patients. In comparison to mild head injury, closed head injury and intracranial hematoma patients were 5 (95% CI: 3.77, 8.26) and 2.5 times (95% CI: 1.64,3.98) more likely to die respectively. Procedure and diagnostic imaging were independent negative predictors of mortality (P <0.05). While age, ICU admission, admission GCS were positive predictors of mortality (P <0.05).

Conclusions:

The majority of hospital admissions were TBI patients, with RTIs being the most common mechanism of injury. Age, ICU admission, admission GCS, diagnostic imaging and undergoing surgery were independent predictors of mortality. Going forward, further exploration of patient characteristics is necessary to fully describe mortality outcomes and implement resource appropriate interventions that ultimately improve morbidity and mortality.

Tratamento Endovascular de Patologia da Aorta Torácica: Experiência Institucional

Introdução: O tratamento endovascular da aorta torácica (TEVAR) é uma modalidade terapêutica emergente que tem vindo a revolucionar a abordagem de diferentes tipos de patologia da aorta na sua localização torácica. Objetivos: Avaliação da experiência institucional do serviço de angiologia e cirurgia vascular. Métodos: Análise retrospetiva da série consecutiva de todos os doentes com patologia da aorta torácica e/ou toracoabdominal submetidos a TEVAR na nossa instituição. Foram excluídos aqueles com uso concomitante de endopróteses fenestradas/ramificadas abdominais. Resultados: Desde abril de 2005 até abril de 2014, 79 doentes foram submetidos a TEVAR, com idade média de 66 ± 12,83 anos (máx: 86; mín: 14). As indicações incluíram: 46 aneurismas (58%), 17 dissecções aórticas clássicas tipo B (22%), 13 no contexto de outras síndromes aórticas agudas (16%), 2 por ateroembolismo (3%) e um por fístula aortoesofágica (1%). Na patologia aneurismática, a distribuição anatómica da doença foi a seguinte: 5 na aorta ascendente e arco aórtico (11%), 35 na aorta torácica descendente (76%) e 6 toracoabdominal (13%). O diâmetro médio das dilatações aneurimáticas foi de 69,64 mm (máx: 150 mm). A rotura foi uma apresentação da patologia em 21,5% dos doentes (n = 17); 20,9% dos doentes tinham antecedentes de cirurgia aórtica prévia. A dissecção aórtica tipo B complicada foi a segunda indicação mais comum, sendo de apresentação aguda em 13 (76%) e crónica em 4 (24%). As complicações na base da intervenção foram dilatação aneurismática em 35% (n = 6), malperfusão com isquemia de órgão alvo 47% (n = 8), desconhecida em 18% (n = 3). Foi realizada extensão distal com stent descoberto (Petticoat) em 9 casos (41,2%) e foram realizados procedimentos adjuvantes em 18% (stenting renal n = 2; stenting ilíaco n = 1). Dentro das outras síndromes aórticas agudas, o TEVAR foi realizado no contexto de úlcera aórtica penetrante (n = 4), hematoma intramural (n = 4) e os restantes por rotura/pseudoaneurisma (n = 5). As endopróteses utilizadas foram: 32 Valiant Medtronic®, 15 TAG Gore®, 25 Zenith TX2 Cook®, 2 Zenith TX1 Cook®, uma Relay Plus®, 3 Talent Medtronic® e outras em 1%. A mediana de dias de cuidados intensivos foi 2 (intervalo 0-42) e a mediana de suporte tranfusional foi de 2 UCE. A taxa de mortalidade aos 30 dias ou intra-hospital foi de 18% (n = 14). Atendendo ao timing da cirurgia, a taxa de mortalidade aferida nos casos electivos foi de 8% (4/50) e nos urgentes atinge os 35% (10/29). Intraoperatoriamente foram tratadas 7 complicações relacionadas com vaso de acesso membro, 2 casos de dissecção aórtica iatrogénica, um caso de trombose arterial inferior e um endoleak tipo IA. A taxa de reintervenções foi de 17%, com as seguintes indicações: 9 endoleaks, 2 isquemias mesentéricas e 2 fístulas aortoesofágicas. Conclusões: A série apresentada traduz uma experiência institucional favorável com resultados reprodutíveis e que o TEVAR é um procedimento seguro e eficaz para o tratamento de diferentes patologias da aorta torácica, quando comparado com o tratamento cirúrgico aberto.

A Standardized Classification for Subdural Hematomas- I

Subdural hematomas are a frequent and highly heterogeneous traumatic disorder, with significant clinical and socioeconomic consequences. In clinical and medicolegal practice, subdural hematomas are classified according to its apparent age, which significantly influences its intrinsic pathogenic behavior, forensic implications, clinical management, and outcome. Although practical, this empirical classification is somewhat arbitrary and scarcely informative, considering the remarkable heterogeneity of this entity. The current research project aims at implementing a comprehensive multifactorial classification of subdural hematomas, allowing a more standardized and coherent assessment and management of this condition. This new method of classification of subdural hematomas takes into account its intrinsic and extrinsic features, using imaging data and histopathological elements, to provide an easily apprehensible and intuitive nomenclature. The proposed classification unifies and organizes all relevant details concerning subdural hematomas, hopefully improving surgical care and forensic systematization.

Vitamines B, éléments clés de l'efficacité métabolique : Effets de la nature de la diète sur les apports

Les travaux sur la nutrition en vitamines B des ruminants montrent des résultats très variés sur les quantités de ces nutriments disponibles pour l’animal selon la nature de la ration. Ces divergences sont dues à des changements des populations microbiennes dans le rumen, causées par les facteurs physico-chimiques de la ration. Une amélioration de la compréhension des effets de la nature de la diète sur la synthèse et l’utilisation des vitamines B dans le rumen pourrait aider à identifier les conditions sous lesquelles une supplémentation en ces vitamines serait bénéfique pour la vache. Le but de ce travail de thèse est donc d’améliorer la compréhension des effets de l’espèce fourragère, de la maturité et de la longueur des particules de fourrage sur les apports en vitamines B chez la vache laitière. Pour évaluer chacune de ces variables, les concentrations de thiamine, riboflavine, niacine, vitamine B6, folates et vitamine B12 ont été mesurées dans les échantillons d’aliments et de digesta duodénal recueillis lors de trois projets réalisés à l’Université du Michigan par l’équipe du Dr. M. Allen. Dans la première étude, l’effet de l’espèce fourragère des ensilages a été évalué au cours de deux expériences similaires durant lesquelles les vaches recevaient une diète à base d’ensilage de luzerne ou de dactyle. Les diètes à base de luzerne ont été associées à une augmentation de la dégradation de la thiamine et de la vitamine B6 dans le rumen par rapport aux diètes à base d’ensilage de dactyle. La deuxième étude visait à évaluer les effets de la maturité des plantes lors de la mise en silo sur les quantités de vitamines B disponibles pour la vache; les deux expériences se différenciaient par l’espèce fourragère étudiée, soit la luzerne ou le dactyle. Une récolte à un stade de maturité plus élevé a augmenté les flux duodénaux de thiamine, de niacine et de folates lorsque les vaches recevaient des diètes à base d’ensilage de luzerne mais n’a diminué que le flux duodénal de riboflavine chez les animaux recevant des diètes à base d’ensilage de dactyle. La troisième étude a comparé les effets de la longueur de coupe (10 vs. 19 mm) d’ensilages de luzerne et de dactyle sur le devenir des vitamines B dans le système digestif de la vache laitière. Cette étude a permis de constater qu’une augmentation du temps de séchage au champ diminuait les concentrations de vitamines B dans les ensilages. Cependant, la taille des particules des ensilages de luzerne et de dactyle n’a pas affecté les quantités des vitamines B arrivant au duodénum des vaches. En général, les résultats de ces études montrent qu’il existe une corrélation négative entre la synthèse de riboflavine, de niacine et de vitamine B6 et leur ingestion, suggérant une possible régulation de la quantité de ces vitamines B par les microorganismes du rumen. De plus, l’ingestion d’amidon et d’azote a été corrélée positivement avec la synthèse de thiamine, de folates et de vitamine B12, et négativement avec la synthèse de niacine. Ces corrélations suggèrent que les microorganismes qui utilisent préférentiellement l’amidon jouent un rôle majeur pour la synthèse ou la dégradation de ces vitamines. De plus, la présence d’une quantité suffisante d’azote semble avoir un impact majeur sur ces processus. La suite de ces travaux devrait viser la modélisation de ces données afin de mieux appréhender la physiologie de la digestion de ces vitamines et permettre la création de modèles mathématiques capables de prédire les quantités de vitamines disponibles pour les vaches. Ces modèles permettront, lorsqu’intégrés aux logiciels de formulation de ration, d’élaborer une diète plus précise, ce qui améliorera la santé du troupeau et la performance laitière et augmentera les profits du producteur.

Delayed and occult splenic rupture: a diagnostic puzzle

Splenic rupture is a common complaint encountered in emergency surgery. Trauma is the most common cause of splenic rupture, while non-traumatic or occult splenic rupture (OSR) is a rare condition. The differential diagnosis weighs on treatment that ranges between close monitoring, splenorrhaphy, splenic conservation and splenectomy. We report a case of an 63-year-old man presenting with acute atraumatic left upper quadrant pain. Preliminary diagnosis was subsequently determined to be a hematoma secondary to OSR. More accurate detailed history revealed a previous trauma, which occurred more than one year before and mimicked an OSR. Delayed and occult splenic rupture are as different diagnosis as different treatment. Even in emergency surgery, the key for a target therapeutic strategy should consider an accurate diagnostic time.

Non-Celiac Gluten Sensitivity and Autoimmunity. A Case Report

Introduction, objective: To present a case report in which the finding of non-coeliac gluten sensitivity was decisive for the treatment of a complex autoimmune disease. Materials and methods: A 43-year-old woman with polyarthritis, psoriatic features, anti-SSA/Ro and anti-cyclic citrullinated peptide antibodies, with refractory course, was evaluated for gluten sensitivity despite negative serology for coeliac disease. Results: The patient carried the HLA DQ2 haplotype and duodenal biopsy showed lymphocytic enteritis. A gluten-free diet resolved the clinical picture and permitted tapering of immunosuppressive therapy. Conclusion: Non-coeliac gluten sensitivity can be associated with autoimmunity despite the absence of the specific autoantibodies of coeliac disease.

A Standardized Classification for Subdural Hematomas- I

Subdural hematomas are a frequent and highly heterogeneous traumatic disorder, with significant clinical and socioeconomic consequences. In clinical and medicolegal practice, subdural hematomas are classified according to its apparent age, which significantly influences its intrinsic pathogenic behavior, forensic implications, clinical management, and outcome. Although practical, this empirical classification is somewhat arbitrary and scarcely informative, considering the remarkable heterogeneity of this entity. The current research project aims at implementing a comprehensive multifactorial classification of subdural hematomas, allowing a more standardized and coherent assessment and management of this condition. This new method of classification of subdural hematomas takes into account its intrinsic and extrinsic features, using imaging data and histopathological elements, to provide an easily apprehensible and intuitive nomenclature. The proposed classification unifies and organizes all relevant details concerning subdural hematomas, hopefully improving surgical care and forensic systematization.

Profilaxis antibiótica en la reparación de la hernia inguinal con prótesis: estudio clínico controlado utilizando profilaxis antibiótica en hernioplastias con prótesis, efectuando en los hospitales cantonales del Sígsig y Paute de la provincia del Azuay, 2000-2001

Se realiza un ensayo clínico controlado de Profilaxis antibiótica en la reparación hernia inguinal con prótesis en los hospitales cantonales de Sigsig y Paute, Azuay, Ecuador en el 2000-2001, con el fin de determinar el uso de antibiótico profilaxis en la hernioplastia inguinal utilizando la técnica de Lichteinten [hernioplastia con prótesis] como alternativa quirúrgica, cuando se realiza el abordaje anterior abierto en hernias primarias. Se estudiaron 60 pacientes divididos en dos grupos comparables en cuanto a edad, sexo, procedencia, ocupación, tipo de hernia y su localización. Al grupo de estudio se le administró 2 horas antes del acto quirúrgico 500 mg. de Ciprofloxacina vía oral, realizándose controles a las 72 horas, 8 días y al mes de la intervención quirúrgica, para valorar signos de infección de la herida quirúrgica y posibles complicaciones. La infección de la herida se presentó en un paciente [3.3 por ciento correspondió al grupo que no recibió profilaxis. En el grupo de estudio el seroma se presentó el 6.7 por ciento y el hematoma en el 3.3 por ciento. En el grupo control seroma u orquitis presentaron el 6.7 por ciento, hematoma el 3.3 por ciento y recurrencia de la herida el 3.3 por ciento. No existiendo diferencia al comparar los grupos [p mayor 0.05]. La estadia hospitalaria en ambos grupos fue menor a 24 horas en más del 80 5 de los casos, pudiendo convertirse al prótesis de hernia inguinal en un procedimiento ambulatorio

Spontaneous Dissection of the Renal Artery in Vascular Ehlers-Danlos Syndrome

Ehlers-Danlos syndrome (EDS) is a rare heterogeneous group of connective tissue disorders. The vascular type (vEDS) is an autosomal dominant disorder caused by heterozygous mutations in the COL3A1 gene predisposing to premature arterial, intestinal, or uterine rupture. We report a case of a 38-year-old woman with a recent diagnosis of vEDS admitted in the Emergency Department with a suspicion of a pyelonephritis that evolved to a cardiopulmonary arrest. A fatal retroperitoneal hematoma related with a haemorrhagic dissection of the right renal artery was found after emergency surgery. This case highlights the need to be aware of the particular characteristics of vEDS, such as a severe vascular complication that can lead to a fatal outcome.

Intravascular Lymphoma as an Uncommon Cause of Anasarca

Objectives: To report a case of intravascular lymphoma (IVL) in a Caucasian patient who presented with anasarca as his sole clinical sign. Material and Methods: A man presented with anasarca-type oedema and fatigue. After excluding heart failure, hepatic cirrhosis, nephrotic syndrome, hypothyroidism, AL-amyloidosis and adverse drug reaction which can all cause oedema, we turned our attention to capillary permeability disorders. Results: Closer review of the bone marrow aspirate demonstrated haemophagocytic histiocytosis, while core, renal and duodenal biopsies showed a B-cell IVL. Conclusion: The differential diagnosis of anasarca, a relatively common clinical sign, should include IVL although the diagnosis may still be challenging.

Effects of supplemental osteopontin on intestinal development and serum antibody responses to rotavirus vaccination in piglets

Milk contains numerous bioactive substances including immunoglobulins, cytokines, growth factors and components that exert antibiotic and prebiotic activity (Field, 2005). Little is known about the biological effects of individual milk bioactives, despite the fact that natural milk improves intestinal development and immune system functions in neonates (Donovan et al., 1994; Field, 2005) relative to milk formula. Characterization of the biological effects of such components is important for optimal production of infant milk formulas to be used when mother’s milk is not available. Milk components with preliminary evidence of positive effects on the intestinal growth and mucosal immunity include osteopontin (OPN). Osteopontin is a phosphorylated acidic glycoprotein expressed by a number of different immune and non-immune cells and tissues (Sodek et al., 2000). It is also present in body fluids including blood, bile and milk (Sodek et al., 2000). Osteopontin is a multifunctional protein that is implicated in a wide number of biological processes including cell survival, bone remodeling, and immune modulatory functions (Sodek et al., 2000). Furthermore, Schack and colleagues (2009) demonstrated that the concentration of OPN in human milk is considerably higher than in bovine milk and infant formulas. Taken together, it is likely that OPN plays a role in the early development of gastrointestinal tract and mucosal immune responses in infants. Since the neonatal pig shares anatomical, physiological, immunological, and metabolic similarities with the human infants (Moughan, et al., 1992), they were selected as the animal model in our studies. Our first aim was to investigate the effects of OPN on piglet intestinal development. Newborn, colostrum-deprived piglets (n=27) were randomized to receive three treatments: formula with bovine OPN (OPN; 140 mg/L); formula alone (FF); or sow reared (SR) for 21 days. Body weight, intestinal weight and length, mucosal protein and DNA content, disaccharidase activity, villus morphology, and crypt cell proliferation were measured. Statistical significance was assigned at P<0.05. No significant effects of OPN were observed for body weight, intestinal weight and length. Mucosal protein content of SR piglets was lower than FF and OPN piglets in the duodenum, but higher than FF and OPN piglets in the ileum. No significant effects of diet in mucosal DNA content were detected for the three regions of the small intestine. Lactase and sucrase activities of SR piglets were higher than the two formula-fed groups in the duodenum, lower in the ileum. No significant effects of diet on lactase and sucrase activities were noted between two formula-fed groups in the duodenum and ileum. Jejunal lactase activity of FF piglets was higher than SR piglets, whereas no significant effect of diet was observed in jejunal sucrase activity among the three groups. Duodenal and ileal villus height and villus area of SR piglets were lower than two formula-fed groups, while OPN piglets did not differ from FF piglets. There was a significant effect of diet (P<0.0001) on jejunal crypt cell proliferation, with proliferation in OPN piglets being intermediate between that of FF and SR. In summary, supplemental OPN increased jejunal crypt cell proliferation, independent of evident morphological growth, and had a minor impact on disaccharidase activity in the small intestine of neonatal piglets. Rotavirus (RV) is the most common viral cause of severe gastroenteritis in infants and young children worldwide (Parashar et al., 2006). Maeno et al. (2009) reported that OPN knockout (OPN-KO) suckling mice were more susceptible to RV infection compared to wild-type (WT) suckling mice. To detect the role of OPN in intestinal immune responses of neonates, the goal of the second study was to evaluate whether supplemental OPN influenced the serum antibody responses to RV vaccination in neonatal piglets. Newborn, colostrum-deprived piglets were randomized into two dietary groups: formula with bovine OPN (OPN; 140 mg/L) and formula alone (FF) for 35 days. On d7, piglets in each dietary group were further randomized to receive rotavirus (RV) vaccination (Rotarix®) (FF+RV and OPN+RV) or remained non-vaccinated (FF+NV and OPN+NV). Booster vaccination was provided on d14. Blood samples were collected on d7, 14, 21, 28 and 35. RV-specific serum immunoglobulin (Ig) G, IgA, IgM and total serum IgG, IgA, IgM were measured by ELISA. Statistical significance was assigned at P<0.05, with trends reported as P<0.10. Body weight gain was unaffected by diet and/or vaccination. No significant effect of oral OPN supplementation was observed for RV-specific antibody responses and total Igs levels. After the combination of dietary groups, RV piglets had significantly higher RV-specific IgM concentrations compared to NV piglets. Although there were higher means of RV-specific IgG and RV-specific IgA concentrations in RV group than their counterparts in NV group, the difference did not reach statistical significance. RV-specific IgM reached a peak at d7 post booster vaccination (PBV), whereas the RV-specific IgG and IgA peaked later at PBV 14 or 21. Total Igs were unaffected by RV vaccination but were significantly increased over time, following similar pattern as RV-specific Igs. In summary, neonatal piglets generated weak antibody responses to RV vaccination. Supplemental OPN did not enhance RV-specific serum antibody responses and total serum Igs levels in neonatal piglets with or without RV vaccination. In conclusion, we observed normal developmental changes in the small intestine and serum Igs levels in neonatal piglets over time. Oral OPN supplementation showed minimal impacts on intestinal development and no effect on serum Igs levels. The role of supplemental OPN on the growth and development of infants is still inconclusive. Future studies should measure other physiological and immunological parameters by using different models of vaccination or infection.

Medizinischer und gesundheitsökonomischer Nutzen der Untersuchung auf Helicobacter pylori-Besiedlung mittels 13C-Harnstoff-Atemtest in der Primärdiagnostik im Vergleich zu invasiven und nichtinvasiven diagnostischen Verfahren

Hintergrund: Helicobacter pylori (H. pylori) zählt trotz abnehmender Inzidenz zu den häufigsten bakteriellen Infektionskrankheiten des Menschen. Die Infektion mit H. pylori ist ein Risikofaktor für Krankheiten wie gastroduodenale Geschwüre, Magenkarzinomen und MALT (Mucosa Associated Lymphoid Tissue)-Lymphomen. Zur Diagnostik von H. pylori stehen verschiedene invasive und nichtinvasive Verfahren zur Verfügung. Der 13C-Harnstoff-Atemtest wird zur Kontrolle einer Eradikationstherapie empfohlen, kommt in der Primärdiagnostik von H. pylori derzeit jedoch nicht standardmäßig in Deutschland zum Einsatz. Fragestellung: Welchen medizinischen und gesundheitsökonomischen Nutzen hat die Untersuchung auf H. pylori-Besiedlung mittels 13C-Harnstoff-Atemtest in der Primärdiagnostik im Vergleich zu invasiven und nichtinvasiven diagnostischen Verfahren? Methodik: Basierend auf einer systematischen Literaturrecherche in Verbindung mit einer Handsuche werden Studien zur Testgüte und Kosten-Effektivität des 13C-Harnstoff-Atemtests im Vergleich zu anderen diagnostischen Verfahren zum primären Nachweis von H. pylori identifiziert. Es werden nur medizinische Studien eingeschlossen, die den 13C-Harnstoff-Atemtest direkt mit anderen H. pylori-Testverfahren vergleichen. Goldstandard ist eines oder eine Kombination der biopsiebasierten Testverfahren. Für die gesundheitsökonomische Beurteilung werden nur vollständige gesundheitsökonomische Evaluationsstudien einbezogen, bei denen die Kosten-Effektivität des 13C Harnstoff-Atemtests direkt mit anderen H. pylori-Testverfahren verglichen wird. Ergebnisse: Es werden 30 medizinische Studien für den vorliegenden Bericht eingeschlossen. Im Vergleich zum Immunglobulin G (IgG)-Test ist die Sensitivität des 13C-Harnstoff-Atemtests zwölfmal höher, sechsmal niedriger und einmal gleich, und die Spezifität 13-mal höher, dreimal niedriger und zweimal gleich. Im Vergleich zum Stuhl-Antigen-Test ist die Sensitivität des 13C-Harnstoff-Atemtests neunmal höher, dreimal niedriger und einmal gleich, und die Spezifität neunmal höher, zweimal niedriger und zweimal gleich. Im Vergleich zum Urease-Schnelltest sind die Sensitivität des 13C-Harnstoff-Atemtests viermal höher, dreimal niedriger und viermal gleich und die Spezifität fünfmal höher, fünfmal niedriger und einmal gleich. Im Vergleich mit der Histologie ist die Sensitivität des 13C-Harnstoff-Atemtests einmal höher und zweimal niedriger und die Spezifität zweimal höher und einmal niedriger. In je einem Vergleich zeigt sich kein Unterschied zwischen 13C-Harnstoff-Atemtest und 14C-Harnstoff-Atemtest, sowie eine niedrigere Sensitivität und höhere Spezifität im Vergleich zur Polymerase-Kettenreaktion (PCR). Inwieweit die beschriebenen Unterschiede statistisch signifikant sind, wird in sechs der 30 Studien angegeben. Es werden neun gesundheitsökonomische Evaluationen in dem vorliegenden Bericht berücksichtigt. Die Test-and-Treat-Strategie mittels 13C-Harnstoff-Atemtest wird in sechs Studien mit einem Test-and-Treat-Verfahren auf Basis der Serologie sowie in drei Studien mit einem Test-and-Treat-Verfahren auf Basis des Stuhl-Antigen-Tests verglichen. Dabei ist das Atemtestverfahren dreimal kosteneffektiv gegenüber der serologischen Methode und wird von der Stuhl-Antigen-Test-Strategie einmal dominiert. Vier Studien beinhalten einen Vergleich der Test-and -Treat-Strategie auf Basis des 13C-Harnstoff-Atemtests mit einer empirischen antisekretorischen Therapie, wobei sich das Atemtesverfahren zweimal als kosteneffektive Prozedur erweist und zwei Studien einen Vergleich mit einer empirischen Eradikationstherapie. In fünf Studien wird das Test-and-Treat-Verfahren mittels 13C-Harnstoff-Atemtest einer endoskopiebasierten Strategie gegenübergestellt. Zweimal dominiert die Atemteststrategie die endoskopische Prozedur und einmal wird sie von dieser Strategie dominiert. Diskussion:Sowohl die medizinischen als auch die ökonomischen Studien weisen mehr oder minder gravierende Mängel auf und liefern heterogene Ergebnisse. So werden in der Mehrzahl der medizinischen Studien keine Angaben zur statistischen Signifikanz der berichteten Unterschiede zwischen den jeweiligen Testverfahren gemacht. Im direkten Vergleich weist der 13C-Harnstoff-Atemtest überwiegend eine höhere Testgüte als der IgG und der Stuhl-Antigen-Test auf. Aus den Vergleichen mit dem Urease-Schnelltest lassen sich keine Tendenzen bezüglich der Sensitivität ableiten, wohingegen die Spezifität des 13C-Harnstoff-Atemtests höher einzuschätzen ist. Für die Vergleiche des 13C-Harnstoff-Atemtest mit der Histologie, dem 14C-Harnstoff-Atemtest und der PCR liegen zu wenige Ergebnisse vor. In der eingeschlossenen ökonomischen Literatur deuten einige Studienergebnisse auf eine Kosten-Effektivität der Test-and-Treat-Strategie mittels 13C-Harnstoff-Atemtest gegenüber dem Test-and-Treat-Verfahren auf Basis der Serologie und der empirischen antiskretorischen Therapie hin. Um Tendenzen bezüglich der Kosten-Effektivität der Atemteststrategie gegenüber der Test-and-Treat-Strategie mittels Stuhl-Antigen-Test sowie der empirischen Eradikationstherapie abzuleiten, mangelt es an validen Ergebnissen bzw. ökonomischer Evidenz. Die Untersuchungsresultate hinsichtlich eines Vergleichs mit endoskopiebasierten Verfahren fallen diesbezüglich zu heterogen aus. Insgesamt kann keines der ökonomischen Modelle der Komplexität des Managements von Patienten mit dyspeptischen Beschwerden gänzlich gerecht werden. Schlussfolgerungen/Empfehlungen: Zusammenfassend ist festzuhalten, dass die Studienlage zur medizinischen und ökonomischen Beurteilung des 13C-Harnstoff-Atemtests im Vergleich zu anderen diagnostischen Methoden nicht ausreichend ist, um den Atemtest als primärdiagnostisches Standardverfahren im Rahmen einer Test-and-Treat-Strategie beim Management von Patienten mit dyspeptischen Beschwerden für die deutsche Versorgungslandschaft insbesondere vor dem Hintergrund der Leitlinien der Deutschen Gesellschaft für Verdauungs- und Stoffwechselkrankheiten (DGVS) anstelle einer endoskopiebasierten Methode zu empfehlen.

Imaging of thoracic aortic injury

International audience

Prevalence of celiac disease among first degree relatives of Brazilian celiac patients

Background - Several studies have shown that celiac disease, an autoimmune disorder that occurs in genetically susceptible individuals, is highly prevalent among relatives of celiac patients. Aim - To determine the prevalence of celiac disease in a group of first degree relatives of Brazilian celiac patients. Methods - First degree relatives of celiac patients attending the Brasilia University Hospital Pediatric Gastroenterology Outpatient Clinic or the Celiac Disease Investigation Center, Brasília, DF, Brazil, between March 2001 and November 2004 were invited to undergo serological screening for celiac disease applying the IgA anti-endomysium antibody test (IgA-EMA). All positive IgA-EMA sera underwent a second screening using the IgA anti-tissue transglutaminase antibodies test. Duodenal or small intestinal biopsies were performed in all subjects positive to serological testing. Biopsy samples were classified as type (O) normal, (I) infiltrative, (II) infiltrative hyperplastic, (III) flat destructive, and (IV) atrophic hypoplastic. The final diagnosis was ascertained in subjects showing positive serological tests and a grade I to III small intestinal lesion. Results - Nine new cases of celiac disease were found among the 188 first degree relatives tested (4.8%). Conclusion - The present study confirms the high prevalence of celiac disease among first degree celiac patients’ relatives and reinforces the need of extensive diagnostic screening in this specific group.