Jaroslav Zivny

Analysis of plasma viral RNA levels during acute dengue virus infection using quantitative competitor reverse transcription-polymerase chain reaction

There is increasing recognition of the potential importance of viral burden in the pathogenesis of dengue hemorrhagic fever (DHF). There is little data available, however, describing the kinetics of viral replication in humans with natural dengue virus (DV) infection. Standard procedures for measuring titers of infectious virus in clinical specimens are either laborious or insensitive. We developed a method for measurement of DV RNA in plasma samples based on reverse transcription‐polymerase chain reaction (RT‐PCR) using a mutant RNA target as a competitor. This technique was reproducible and accurate for samples containing any of the four DV serotypes, and could be applied to samples containing as few as 250 copies of RNA per reaction. We examined plasma viral RNA levels in 80 children with acute DV infection; sequential plasma samples were tested in 34 of these children. Plasma viral RNA levels ranged as high as 109 RNA copies/ml, and correlated with titers of infectious virus measured in mosquitoes (r = 0.69). Plasma viral RNA levels fell rapidly during the last several days of the febrile period. We did not find a significant difference in maximal plasma viral RNA levels between children with DHF and children with dengue fever, but peak viral RNA levels were identified in only 16 subjects. We conclude that this quantitative RT‐PCR method will be valuable for further studies of natural DV infections. J. Med. Virol. 63:29–34, 2001.

Ubiquitin as a Marker of Cell Injury in Nonalcoholic Steatohepatitis

Ubiquitin (UB), an intracellular protein that binds to other proteins to target them for proteolysis, is associated with Mallory hyalin (MH), which supports a biopsy diagnosis of nonalcoholic steatohepatitis (NASH). We analyzed 54 liver biopsy specimens from 49 patients with a clinical diagnosis of NASH for immunoreactive UB and multiple features of necroinflammation, fibrosis, and Prussian blue-positive iron to determine whether the presence of immunoreactive UB increases detection of MH or correlates with other features of cell injury or mutations of the HFE gene. MH and UB were graded. Analysis for HFE gene mutations was performed in 48 patients. Biopsy diagnoses were distributed as follows: NASH, 42; steatosis, 10; and nonspecific changes, 2. UB was present in 20 specimens and MH in 23. Of 31 specimens with 0 MH, 6 had UB; of 14 with 1 + (questionable) MH, 7 had 1+ or 2+ UB. UB correlated positively and significantly with the diagnosis and grade of NASH, presence of MH, cell swelling, lobular inflammation, and fibrosis. Immunostaining for UB may enhance detection of MH in questionable cases, support the diagnosis of NASH, and indicate which patients may be at risk for progression of disease.

Improved implantation rate after chemical removal of the zona pellucida

OBJECTIVE To evaluate the implantation rate achieved after chemical removal of the zona pellucida from day 5 human in vitro-derived embryos. DESIGN Prospective, randomized, controlled study. SETTING A tertiary care infertility clinic. PATIENT(S) Two hundred fifty-seven patients undergoing IVF with transfer of morulas or blastocysts on day 5 after oocyte retrieval. All patients had had at least two previous implantation failures. INTERVENTION(S) Chemical removal of zona pellucida by using acidic Tyrodes solution vs. no removal (controls). MAIN OUTCOME MEASURES Clinical pregnancy rate and implantation rate per transfer. RESULT(S) Embryos without zona pellucida implanted at nearly twice the rate of control embryos (15.7% vs. 27.5%). The pregnancy rate was also significantly higher in the zona pellucida-free group than the control group (31.0% vs. 46.1%). Removal of zona pellucida was most effective in embryos with delayed development, which reached the morula or early cavitating stage on day 5 of in vitro culture (implantation rate, 12.1% vs. 25.7%). CONCLUSION(S) Chemical removal of zona pellucida from day 5 in vitro cultured human embryos is an effective and safe method of significantly improving the implantation rate, especially of embryos with delayed development.

Role of therapy or monitoring in preventing progression to gastric cancer.

Abstract It is generally accepted that intestinal‐type gastric adenocarcinoma arises through a multistep process originating with chronic gastritis, progressing through stages of atrophy, intestinal metaplasia, and dysplasia and finally invasive carcinoma. This sequential process, known as the “Correa cascade” is in many instances initiated by Helicobacter pylori infection and perpetuated by a number of environmental and host factors. Given that the development of carcinoma can be the end point of this sequential process, there is great interest in determining which if any of these steps may be reversible. Clinical studies have shown that the eradication of H. pylori can lead to resolution of chronic gastritis, and a few studies have suggested some improvement in gastric atrophy. Intestinal metaplasia, however, does not appear to be as reversible. Nevertheless, results of several intriguing studies of high‐risk populations support the notion that eradication of H. pylori may decrease or delay progression to gastric carcinoma despite the inability to reverse all mucosal damage. The applicability of these findings to low‐risk countries such as the United States and the United Kingdom remain uncertain. Currently, in the United States, there is no widely accepted screening program for H. pylori infection in asymptomatic individuals, and consensus regarding surveillance for gastric intestinal metaplasia or dysplasia is lacking. The purpose of this report is to evaluate the available data regarding the epidemiology of H. pylori and associated carcinoma, discuss relevant human and animal data that address eradication strategies in the prevention of gastric carcinoma, and finally discuss current recommendations regarding screening programs aimed at high‐risk populations.

Thirty-day outcomes underestimate endocrine and exocrine insufficiency after pancreatic resection.

BACKGROUND Long-term incidence of endocrine and exocrine insufficiency after pancreatectomy is poorly described. We analyze the long-term risks of pancreatic insufficiency after pancreatectomy. METHODS Subjects who underwent pancreatectomy from 2002 to 2012 were identified from a prospective database (n = 227). Subjects who underwent total pancreatectomy or pancreatitis surgery were excluded. New post-operative endocrine and exocrine insufficiency was defined as the need for new pharmacologic intervention within 1000 days from resection. RESULTS 28 (16%) of 178 subjects without pre-existing endocrine insufficiency developed post-operative endocrine insufficiency: 7 (25%) did so within 30 days, 8 (29%) between 30 and 90 days, and 13 (46%) after 90 days. 94 (43%) of 214 subjects without pre-operative exocrine insufficiency developed exocrine insufficiency: 20 (21%) did so within 30 days, 29 (31%) between 30 and 90 days, and 45 (48%) after 90 days. Adjuvant radiation was associated with new endocrine insufficiency. On multivariate regression, pancreaticoduodenectomy and chemotherapy were associated with a greater risk of exocrine insufficiency. CONCLUSION Reporting 30-day functional outcomes for pancreatic resection is insufficient, as nearly 45% of subjects who develop disease do so after 90 days. Reporting of at least 90-day outcomes may more reliably assess risk for post-operative endocrine and exocrine insufficiency.

CASE REPORT: CD4+ T-Cell Lymphoproliferative Disorder of the Gut Clinically Mimicking Celiac Sprue

Primary gastrointestinal T-cell lymphoproliferative disorders are less common than those of B cell origin and, at present, are not well characterized. There appears to be a spectrum of behavior from low-grade lymphomas which overlap with celiac sprue, such as “refractory sprue,” to high-grade large-cell lymphomas that do not respond well to any forms of therapy (1). Of the latter, enteropathy-associated T-cell lymphoma (EATL), the predominant subtype, is believed to arise in preexisting celiac disease (2). We present a case of extensive monoclonal CD4 + T-cell infiltration of the small bowel and stomach in a patient with weight loss and intermittent diarrhea. Although the diagnoses of celiac sprue or possibly refractory sprue were suspected on clinical grounds, histopathology and immunohistochemistry were consistent with a diagnosis of low-grade T-cell lymphoma. Comparison of immunohistochemical staining of duodenal biopsies between our patient and four other patients with celiac sprue revealed striking differences in the amount and distribution of T cells in the mucosa. A novel feature in this case compared to the previous reports of similar entities is the involvement of the stomach and colon in the absence of extraintestinal involvement.

Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass

BACKGROUND AND AIMS The obesity epidemic has led to increased use of Roux-en-Y gastric bypass (RYGB). These patients have an increased incidence of pancreaticobiliary diseases, yet standard ERCP is not possible because of surgically altered gastroduodenal anatomy. Laparoscopy-assisted ERCP (LA-ERCP) has been proposed as an option, but supporting data are derived from single-center small case series. Therefore, we conducted a large multicenter study to evaluate the feasibility, safety, and outcomes of LA-ERCP. METHODS This is a retrospective cohort study of adult patients with RYGB who underwent LA-ERCP in 34 centers. Data on demographics, indications, procedure success, and adverse events were collected. Procedure success was defined when all the following were achieved: reaching the papilla, cannulating the desired duct, and providing endoscopic therapy as clinically indicated. RESULTS A total of 579 patients (median age, 51; 84% women) were included. Indication for LA-ERCP was biliary in 89%, pancreatic in 8%, and both in 3%. Procedure success was achieved in 98%. Median total procedure time was 152 minutes (interquartile range [IQR], 109-210), with a median ERCP time of 40 minutes (IQR, 28-56). Median hospital stay was 2 days (IQR, 1-3). Adverse events were 18% (laparoscopy related, 10%; ERCP related, 7%; both, 1%) with the clear majority (92%) classified as mild/moderate, whereas 8% were severe and 1 death occurred. CONCLUSIONS Our large multicenter study indicates that LA-ERCP in patients with RYGB is feasible with a high procedure success rate comparable with that of standard ERCP in patients with normal anatomy. The ERCP-related adverse events rate is comparable with conventional ERCP, but the overall adverse event rate was higher because of the added laparoscopy-related events.

Solid pseudopapillary tumor of the pancreas mimicking pancreatic pseudocyst

Solid pseudopapillary tumor of the pancreas is a low-grade malignancy, which is very rare and predominantly occurs in young women. We report a case of this tumor in a 30 year-old woman who was initially misdiagnosed with pancreatic pseudocyst based on CT scan findings. EUS with FNA revealed the diagnosis of solid pseudopapillary tumor and guided the surgical approach. This case emphasizes the importance of tissue diagnosis in patients with cystic lesions of the pancreas on CT scan and no obvious history of pancreatitis.

Acute Exacerbation of Recurrent Pelvic Inflammatory Disease: Laparoscopic Findings in 141 Women With a Clinical Diagnosis

OBJECTIVE To evaluate the accuracy of the clinical diagnosis of recurrent pelvic inflammatory disease (PID) and to determine the positive and negative predictive value of laboratory tests for the diagnosis of PID. STUDY DESIGN According to a prospective study design, 141 consecutively hospitalized patients with the clinical diagnosis of PID were evaluated. The basic inclusion criterion was a history of at least one episode of PID. Standard laboratory tests were performed, specimens for aerobic and anaerobic culture and for Chlamydia trachomatis isolation were obtained, and temperature was regularly monitored. All patients underwent laparoscopy under general anesthesia within 24 hours of admission. RESULTS The clinical diagnosis of PID was confirmed by laparoscopy in 30% of patients. In almost one-third of patients, at laparoscopy the pelvic organs were within normal limits. Adhesions without signs of PID were found in 16%. The third-most-frequent finding was endometriosis (14%). Neither the individual monitored parameters nor their combination reached satisfactory positive and negative predictive values for diagnosing PID. CONCLUSION Recurrent clinical symptoms and laboratory signs of PID should be an indication for confirming or excluding the clinical diagnosis by laparoscopy.