Value of adding an IGRA to the TST to screen for latent tuberculous infection in Greek health care workers.

SETTING: Ioannina University Hospital, Ioannina, Greece. OBJECTIVE: To evaluate the value of adding an interferon-gamma release assay (IGRA) to the tuberculin skin test (TST) for detecting latent tuberculous infection (LTBI) in a Greek university hospital among health care workers (HCWs) predominantly vaccinated with bacille Calmette-Guérin (BCG). DESIGN: Of 788 HCWs enrolled, 68.1% were BCG-vaccinated. A TST ⩾ 10 mm was considered positive and was followed by the QuantiFERON-TB(®) Gold In-Tube assay (QFT-GIT) in a two-step strategy. RESULTS: Of the enrolled HCWs, 36.4% were TST-positive, of whom only 14.4% were IGRA-positive. Agreement between the tests was poor (κ = 0.019; 95%CI -0.014-0.05, P = 0.355). Both TST and IGRA positivity increased with TST diameter, from 5.7% in TST 10-14 mm to 48.8% in TST ⩾20 mm. TST-positive, IGRA-negative results were most likely in younger, recently BCG-vaccinated HCWs (84.6% in those aged 20-29 years) and less likely in older HCWs (45% in those aged 50-59 years). The two-step strategy would have been more cost saving compared to the TST-only approach if adherence to LTBI treatment in our cohort had been ⩾24%. CONCLUSIONS: Poor overall agreement between TST and QFT-GIT was found. Use of IGRA as a second step in TST-positive cases offers an appropriate tool for LTBI detection among BCG-vaccinated HCWs in low-TB-incidence settings.

Interferon-gamma release assay clarifies the effect of bacille Calmette-Guérin vaccination in Greek army recruits.

OBJECTIVE: To compare the most recent commercial interferon-gamma release assay (IGRA), the QuantiFERON-TB Gold In-Tube (QFT-GIT), with the tuberculin skin test (TST) in Greek army recruits who were bacille Calmette-Guérin (BCG) vaccinated during childhood and had no history of tuberculosis (TB) exposure. METHOD: We conducted a cross-sectional comparison study of 1750 young army recruits. TST was performed on all participants, while QFT-GIT was performed in all subjects with TST > 0 mm and in 18 TST-negative controls (TST = 0 mm). RESULTS: Among the study subjects, 5.4% (96/1750) had TST indurations of >or=10 mm, and 3.4% (59/1750) had indurations of >or=15 mm. Among subjects with a positive TST, 11.4% (11/96) tested positive on QFT-GIT. All those with QFT-GIT positivity had TST indurations of >or=15 mm, and none of those with TST indurations of 10-14 mm were positive by QFT-GIT. The overall agreement between TST and QFT-GIT was poor (kappa = 0.02). CONCLUSION: We found a significant discordance between TST and QFT-GIT in BCG-vaccinated Greek army recruits consistent with previous studies showing that BCG received after infancy produces false-positive TST reactions. Our findings underline the need for a two-step approach in diagnosing latent TB infection in all BCG-vaccinated individuals: initial TST screening, followed by an IGRA to confirm TST positivity.

Tuberculin skin test overestimates tuberculosis hypersensitivity in adult patients with psoriasis.

BACKGROUND: Tuberculin skin testing (TST) is still the reference method for the diagnosis of latent tuberculosis infection (LTBI). OBJECTIVE: To evaluate the effect of psoriasis on TST. METHODS: Comparison of TST results of consecutive dermatology (n = 91) and internal medicine (n = 615) inpatients. TST was uniformly ordered, performed and evaluated according to the Mantoux method using purified protein derivative. RESULTS: (a) Significantly larger TST indurations were measured in dermatology (median: 7 mm) compared to internal medicine inpatients (median: <1 mm; p < 0.0001). More dermatology inpatients showed 'positive' (>5 mm) and 'strongly positive' (>or=15 mm) TST results (53 vs. 29% and 22 vs. 13%, respectively). (b) Among dermatology inpatients, the TST reactions were significantly larger (p < 0.01) in psoriatics (n = 28) compared to the remaining patients (n = 63). (c) In psoriatics, the TST correlated positively with the psoriasis area and severity index score (p = 0.015). CONCLUSION: Overt psoriasis is associated with increased TST measurements. This observation is suggestive of a possible overtreatment of these patients for LTBI.

The clinical significance of soluble E-cadherin in nonsmall cell lung cancer.

AIM: Aberrant expression of the epithelial transmembrane adhesion molecule E-cadherin (E-cad) has been associated with many human malignancies. In the present study the clinical significance of serum levels of soluble E-cadherin (sE-cad) in newly diagnosed patients with non small cell lung cancer (NSCLC) was investigated. MATERIAL AND METHODS: An enzyme linked immunospecific assay (ELISA) to determine the circulating levels of sE-cad in 20 newly diagnosed patients with NSCLC as well as in 29 healthy volunteers (control group) was used. RESULTS: NSCLC patients exerted increased circulating levels of sE-cad compared with individuals of the control group (p < 0.001). An association was also detected between serum sE-cad levels and the development of distant metastases. On the contrary, no statistically significant correlation could be established with histological type, gender and smoking habits. Patients with increased sE-cad levels at diagnosis had worser outcome, although multivariate analysis failed to demonstrate that sE-cad levels represent an independent prognostic factor of survival. CONCLUSION: Our data suggest that E-cad plays a role in the pathogenesis of NSCLC. sE-cad levels may be further studied as a potential prognostic biomarker.

Management of ureteral stones in pediatric patients.

PURPOSE: We report our 5-year experience in the management of ureteral stones in pediatric patients using shockwave lithotripsy (SWL) in combination with ureteroscopy. PATIENTS AND METHODS: A total of 25 children (age range 12 months-14 years; mean 8.7 years) underwent SWL for ureteral lithiasis. Stones were located in the upper ureter in 6 children (24%), the middle ureter in 8 (32%), and the lower ureter in 11 (44%). Their size ranged from 5 to 14 mm (mean 10.9 mm). The children who failed SWL underwent ureteroscopic treatment. RESULTS: In the SWL-only group, the overall stone clearance rate at 3 months was 84% (21 of 25 children). Four children (16%) who failed SWL underwent successful ureteroscopic treatment. Complications were infrequent and generally minor in both groups. CONCLUSIONS: Shockwave lithotripsy is a safe and efficient treatment modality for ureteral stones in pediatric patients. In expert hands, ureteroscopy can be successfully applied in case of SWL failure.

Long-term results after percutaneous minimally invasive procedure treatment of symptomatic simple renal cysts.

OBJECTIVE: To assess the effectiveness and long-term results of two repeated ethanol injections in the treatment of symptomatic renal cysts. METHODS: Sixty-eight patients 47 to 75 years old with 77 large (6.3-14.8 cm; mean 8.62 cm) symptomatic cysts were included in this study. Of the 68 patients, in 4 cases there were renal cysts associated with renal calculi. An 8FR Pigtail catheter was inserted into the cyst under ultrasound guidance followed by aspiration of cystic fluid. Two repeated ethanol 95% injections were performed every 24 hours. Patients were followed-up by ultrasonography for a period of 12-48 months (mean 30). RESULTS: In two patients the cyst puncture was not feasible because of poor visualization of puncture site while in one patient there was communication of cystic cavity with the pelvocaliceal system. In these patients surgical resection of cysts was performed. Complete and partial regression rates were 57/68 (83.82%) and 8/68 (11.76%) respectively. In four patients with renal stones and renal cysts, extracorporeal shock wave lithotripsy (ESWL) was successfully executed I month after sclerotherapy. CONCLUSION: Our results suggest that percutaneous aspiration followed by two repeated ethanol injections is highly effective on reducing recurrence of simple renal cysts.

Intraureteral metallic endoprosthesis in the treatment of ureteral strictures.

OBJECTIVE: We report our experience on intraureteral metallic stents placement for the treatment of malignant and benign ureteral strictures. METHODS: Eight patients (six men and two women) with inoperable malignant or benign ureteral strictures, underwent insertion of metallic stents through percutaneous tracts. Six lesions (three malignant, three benign) involved ureterointestinal anastomoses after cystectomy for bladder cancer and ureteroileal urinary diversion or bladder substitution, and two malignant lesions involved the midureter. Self-expandable stents were used in seven cases and a balloon-expandable stent in the remaining one case. One stent was sufficient in seven ureters, and in one ureter, two overlapping stents were placed. RESULTS: Metallic stents were inserted without technical difficulties in all obstructed ureters and patency was achieved in all patients. Ultrasonography revealed resolution of pre-existing hydronephrosis. The duration of follow-up was 6-17 months (mean, 9 months). One ureter was occluded 8 months after stent placement because of ingrowth of tumor and granulation tissue. The other ureters showed no signs of obstruction during follow-up. No major complications directly attributable to the metallic stent occurred. CONCLUSIONS: Our results suggest that insertion of a metallic stent in the ureter is feasible and safe for the treatment of benign or malignant ureteral strictures. However, more work needs to be done to establish the use of these stents for the treatment of ureteral obstruction.

Association between the IgG subclass response, inflammation and disease status in Helicobacter pylori infection.

BACKGROUND: In many viral, bacterial and parasitic infections the Immunoglobulin G (IgG) subclass response has been shown to correlate with severity of inflammation and disease outcome. The aim of the present study was to investigate the association between the IgG subclass response to Helicobacter pylori infection and disease and inflammation. METHODS: Eighty-three symptomatic patients undergoing endoscopic examination were included in the study. Upon endoscopic examination, the presence of ulceration was noted and biopsy specimens were collected from the gastric antrum, body and transitional zone. Blood was also collected from each patient. Gastric biopsy sections were graded using the Sydney system. H. pylori specific IgG, IgG1, IgG2, IgG3 and IgG4 were measured by ELISA. The IgG subclass was also examined retrospectively in sera collected from 20 patients previously proven to have duodenal ulcer (DU). RESULTS: The results of histological examination and IgG serology showed 35 subjects to be H. pylori negative and 48 to be H. pylori positive. Of the 48 H. pylori positive subjects, 25 were diagnosed with functional dyspepsia (FD), 14 with current DU and 9 with evidence of past DU. Significantly higher levels of IgG2 antibodies were found in patients with DU as compared with patients with FD (P < 0.01). In addition, significantly higher IgG3 subclass antibody levels were associated with chronic inflammatory cells in the body (P < 0.05) and active inflammatory cells in the transitional zone (P < 0.01). A significantly increased level of IgG1 antibodies was associated with lower levels of colonization in the gastric antrum. CONCLUSION: The results of this study suggest that the IgG subclass response in subjects infected with H. pylori may be a marker of DU disease as well as increased levels of inflammation.

Ureteral drainage by double-J-catheters during pregnancy.

PURPOSE: To access the safety and effectiveness of Double-J-stents in treating symptomatic hydronephrosis during pregnancy. MATERIAL AND METHODS: From 1994 to 1999, 21 women were hospitalized in the Urology Clinic at the University Hospital of Crete. Fourteen patients presented acute pyelonephritis, six painful hydronephrosis and one spontaneous renal rupture. In four cases the hydronephrosis was caused by calculus in the upper 3rd quadrant of the ureters. In 13 out of 14 cases of urinary febrile infection and one with spontaneous renal rupture, the dilatation resulted from direct compression of the ureters by the gravid uterus. Using ultrasound guidance, 21 ureteral stents were successfully placed under local ane- sthesia. RESULTS: In 14 out of 21 patients with urinary infection, we observed remission of fever during the first 24 hours after the placement of the ureteral stents. In the patient with spontaneous renal rupture the remission of symptoms was observed a few hours after the ureteral drainage. Complications were reported in six cases, such as, voiding symptoms and discomfort. CONCLUSION: Double-J-ureteral stenting is an effective, simple and safe method in treating symptomatic hydronephrosis during pregnancy.

Urinary incontinence, the hidden health problem of Cretan women: report from a primary care survey in Greece.

OBJECTIVE: The prevalence of urine leakage and care-seeking rates of women 35-75 years of age who visited GPs in two rural areas of Crete were investigated. PARTICIPANTS: All the women who visited their family physician in two primary care units during the period of August to November 1997 (N = 251) were asked if they had experienced symptoms of involuntary urine leakage. A set of questions was addressed to the women who replied positively. RESULTS: Sixty-nine of the 251 women (27.5%) reported symptoms of involuntary urine leakage, and among the incontinent women 11 (15.9%) had previously contacted the health services about their problem. Only six out of thirty (20%) of the incontinent women who report effects on household activities, social and sexual life had contacted a physician about urinary incontinence (UI). The most common reason reported for not consulting the physicians was that the symptoms were not considered serious (35 women out of 58, 60.3%). CONCLUSION: This study points out the need for further awareness programs for both women and healthcare professionals to be set up in countries like Greece, in which a low care-seeking rate of incontinent women has been reported.

Solitary crossed renal ectopia.

A case of a solitary crossed renal ectopia in a 45-year-old male patient with a simple renal bruise during traffic accident is presented. A brief review of the literature and the embryogenesis of this extremely rare congenital anomaly are discussed.

MRI and CT features in two unusual cases of xanthogranulomatous pyelonephritis.

Two unusual cases of xanthogranulomatous pyelonephritis studied by both magnetic resonance imaging and computed tomography, are presented. Extension of the disease depicted by both computed tomography and magnetic resonance imaging was compatible with the findings at surgery. Computed tomography seems to be sufficient for xanthogranulomatous pyelonephritis imaging evaluation, while magnetic resonance imaging is not recommended on a routine basis, since no additional valuable information is yielded.

Experience with the Dornier lithotriptor MPL 9000-X for the treatment of vesical lithiasis.

Between February 1994 and March 1995, 52 patients (48 men and 4 women) with vesical lithiasis were treated by extracorporeal shock wave lithotripsy (ESWL), using the MPL 9000-X Dornier lithotriptor. Twenty-five patients showed bladder outlet obstruction. In 9 patients, there was evidence of associated bladder neuropathy. In 6 patients, calculi presented idiopathically in normal bladders. Two patients had silent migration of ureteral calculi and increase in bladder volume, 8 were high risk and 2 others refused other methods of up to date treatment. Vesical stone sizes ranged from 10 to 22 mm in greatest diameter (mean 15 mm). The treatments were performed without the use of anaesthesia and on an outpatient basis. Complete fragmentation was achieved after a single session in 46 patients and 3 required 2 sessions. Postoperative adjunctive endourological procedures included cystoscopy in 9 patients and urethroscopy in 1 patient for evacuation of stone fragments. The overall stone-free rate was 94.2% (49 out of 52 patients) with ESWL and adjunctive measures as needed. No major complications were noted. We find ESWL with the MPL 9000-X lithotriptor to be a simple, effective and safe modality for the treatment of most patients with vesical lithiasis, especially in high risk patients.

Influence of a proton pump inhibitor-based therapy on Helicobacter pylori strain selection.

The influence of the proton pump inhibitor lansoprazole on strain diversity in Helicobacter pylori infected patients was investigated. Multiple isolates of Helicobacter pylori obtained pre- and post-therapy from gastric antral and body biopsies in 22 patients were compared using the random amplified polymorphic DNA-polymerase chain reaction (RAPD-PCR) for analysis. Post-therapy strains exhibiting novel RAPD-profiles were found in 5 of 22 patients (4 of 11 patients treated with lansoprazole alone and 1 of 11 patients treated with lansoprazole plus amoxicillin). Proton pump inhibition may affect the microecology of the stomach by influencing the colonisation patterns of specific strains.

Extracorporeal shockwave lithotripsy for urinary calculi in autosomal dominant polycystic kidney disease.

Autosomal dominant polycystic kidney disease (ADPKD) is an inherited systemic disorder. Renal stones have a high rate of occurrence among patients with ADPKD and are a significant cause of morbidity in this disorder. Thirteen patients with ADPKD and symptomatic or obstructive renal stones presented to our hospital for evaluation and treatment with extracorporeal shockwave lithotripsy (SWL). A total of 16 renal units were treated. The auxiliary procedures included placement of a double-J stent in nine kidneys when the stone was larger than 8 mm in diameter. Eleven patients (85%) were stone free 3 months after lithotripsy; a second treatment was necessary in two patients. We conclude that SWL can be used as a primary management tool for renal stones in patients with ADPKD.

A standardized mouse model of Helicobacter pylori infection: introducing the Sydney strain.

BACKGROUND & AIMS: Currently available Helicobacter pylori models show variable and, in some instances, poor colonization. There is a need for a strain with high colonizing ability to act as a standard for animal studies. METHODS: After screening a range of fresh clinical isolates and long-term adaptation in mice, a strain of H. pylon has been isolated with a very good colonizing ability. RESULTS: This strain, named the Sydney strain of H. pylori (strain SS1), is cagA and vacA positive. High levels of colonization (10(6)-10(7) colony-forming units/g tissue) were achieved consistently in C57BL/6 mice. Colonization levels varied depending on the mouse strain used with BALB/c, DBA/2, and C3H/He, all being colonized but in lower numbers. In all strains of mice, bacteria were clearly visible at the junctional zone between the antrum and the body. The phenotype was stable with colonizing ability remaining after 20 subcultures in vitro. The bacterium attached firmly to gastric epithelium. During 8 months, a chronic active gastritis slowly developed, progressing to severe atrophy in both C57BL/6 and BALB/c mice. CONCLUSIONS: The Sydney strain of H. pylori is available to all and will provide a standardized mouse model for vaccine development, compound screening, and studies in pathogenesis.

Concurrent platinum and docetaxel chemotherapy and external radical radiotherapy in patients with invasive transitional cell bladder carcinoma. A preliminary report of tolerance and local control.

PURPOSE: The present study aims to evaluate the feasibility, toxicity, and efficacy of concurrent chemotherapy with cisplatinum and docetaxel, and external radical radiotherapy for transitional cell carcinoma of urinary bladder. MATERIALS AND METHODS: 42 patients (34 men, 8 females) with invasive bladder carcinoma (clinical stages T1-4) were treated after transurethral biopsy with chemotherapy and concomitant external radiotherapy. Chemotherapy consisting of cisplatin infusion (30 mg/m2) and Docetaxel (40 mg/m2) was given twice a week simultaneously with-irradiation during the whole treatment period (6-8 weeks) as follows: Cisplatin (D1,D8,D15,D22, D25,D36,D43,D50) and Docetaxel (D4, D11, D18, D25, D32, D39, D46, D53). An external irradiation scheme 1.8 to 2.0 Gy per fraction, 5 days a week was used up to 68-74 Gy (6MeV photons) total tumor dose. RESULTS: All but S patients completed the planned chemoradiation protocol. The complete response rate (CR-rate) assessed at 3 months after completion of combined treatment was 100%, 63.6%, 46.15% and 95% for clinical stage (c) cT1 (9/9), cT2 (7/11), cT3 (6/13) and cT4 (1/4) cases respectively. None of 9 patients with T1 tumors had any local failure at 36.1 months mean follow-up time. In total, 9 of 37 patients (24.32%) relapsed locally and/or distantly and were followed for 25.04 months (mean time), 50% of the relapses occurred at a mean time of 7.25 months. The mortality rate was 10.81% (4/37). All these patients died with a mean time of 11 months. 32 cases remain alive 19-46 months after treatment; 27 of those are with no evidence of disease with a mean follow-up time of 32.24 months. In total, there was a 78.50% (30/37) and a 75.67%, (28/37) rate of overall survival and pelvic control respectively at 25.04 months mean follow-up time. Chemotherapy was discontinued in 2 cases due to acute gastrointestinal toxicity and in 3 more, due to patient compliance. There was 1 toxic death 2 months after treatment completion due to ureteral obstruction and impaired renal function. The acute toxicity was estimated as moderate to severe and caused the interruption of treatment for 5 to 10 days in 8 of 37 patients (21.62%). Myelotoxicity appeared in 22/37 patients but febrile grade III and IV neutropenia was observed in 3 patients (8.10%) and thrombocytopenia (Grade I-III) in 8 (21.62%). Concerning late effects a sigmoid stricture, a transient small bowel obstruction, 4 patients with contracted bladder and 1 case with renal failure were found. Grade I to III hypersensitivity reactions appeared in 8/37 patients (21.62%) while stomatitis (grade I-II) and grade II skin toxicity appeared in 3 and 4 patients respectively. These and other symptoms (Grade I to II peripheral edema, transient myalgias and arthralgias in 7/37 cases), paresthesias or numbness (3/37) and peripheral motor dysfunction (1/37) were responsible for early reduction of docetaxel dose from 40 mg/m2 to 20 mg/m2. CONCLUSION: This preliminary analysis suggest that the radiosensitizing effect of cisplatin and docetaxel to megavoltage irradiation yielded a high CR-rate in transitional cell bladder carcinoma patients with medium to severe early and late side effects. The value of such a combined treatment as far as the tumor eradication is concerned requires further evaluation, because of the small number of patients, the short follow-up, and the absence of other studies using docetaxel as a radiosensitizer in urothelial cell cancer.

Multiple strain colonization and metronidazole resistance in Helicobacter pylori-infected patients: identification from sequential and multiple biopsy specimens.

Helicobacter pylori strain diversity was investigated in infected persons by collection of multiple biopsies before and after therapy failure. It was demonstrated by random amplification of polymorphic DNA polymerase chain reaction that patients may be infected with a mixed population of H. pylori strains. Most patients were colonized with a predominant strain accompanied by up to 5 variant strains. The use of antimicrobials resulted in an altered distribution of the strains present, but the predominant strain usually remained. Patients may be infected with a mixed population of metronidazole-sensitive and -resistant strains at one time, with metronidazole-based therapy selectively enriching for a resistant population.

Coexisting non-functioning pheochromocytoma and renal oncocytoma: a case report and review of the literature.

We report a case of an oncocytoma, coexisting with a non-functioning pheochromocytoma in a patient who was operated on for suspicion of a renal tumor with metastases to the ipsilateral adrenal gland. As oncocytoma is a relatively rare lesion of the kidney, estimated to account for approximately 3-5% of renal neoplasms, its coexistence with non-functioning pheochromocytoma, to the best of our knowledge, has not hitherto been described in the medical literature.