Guideline for the diagnosis and treatment of chronic pancreatitis

BACKGROUND: Chronic pancreatitis (CP) is defined as a continuing inflammatory disease of the pancreas characterised by irreversible morphological changes, often associated with pain and with the loss of exocrine and/or endocrine function that may be clinically relevant. Alcohol is the predominant cause of CP in the western world and is particularly prevalent in South Africa, especially in the indigent patient. CP ranks high among intractable diseases of the gastrointestinal tract. The tendency for substance abuse in the alcohol-induced group poses major psychological and socioeconomic problems. OBJECTIVE: CP is a disease with significant clinical and pathological heterogeneity. Level 1 evidence to support definitive guidelines for diagnosis, medical management and interventional therapy is lacking. Despite this paucity of robust scientific evidence, it is important to provide some assistance based on the best available evidence as to the current standard of care for CP in the South African context; this will aid all involved in the management of the disease, and includes clinicians, health care managers and funders. Scope. The guidelines were developed as recommendations addressing the diagnosis, medical management and interventions, both endoscopic and surgical, for the management of a very complex and heterogeneous disease of the pancreas. The recommendations are particularly relevant in the South African context where the predominant patho-aetiological agents are alcohol-associated with smoking. RECOMMENDATIONS: The guidelines provide clear recommendations regarding the diagnostic modalities available, both imaging (which includes MRI and endoscopic ultrasound (EUS)) and pancreatic function tests. The section on medical management makes recommendations on the use of analgesics, enzyme replacement and other therapeutic options in the non-interventional management of the majority of patients with CP. The section on interventional procedures identifies the indications and options available for the interventional management of both uncomplicated and complicated CP. The role of endoscopic and surgical modalities is defined, but it is in this context especially that the best available evidence, combined with the experience of the group, influenced the recommendations put forward. Owing to the lack of evidence and the complexity of the disease, it is recommended that, where possible, CP is managed in the context of a multidisciplinary team. Validation. The guidelines are based on best practice principles determined by the available evidence and the opinions of the group, which comprised 7 medical and surgical gastroenterologists with significant experience in dealing with patients with chronic pancreatitis in the South African context. The group convened between May 2009 and August 2010 under the auspices of the Hepato-Pancreatico-Biliary Association of South Africa (HPBASA) and the South African Gastroenterology Society (SAGES), and the guidelines are the result of broad consensus within this group. The draft was presented to other experts in this field of endeavour to ensure broader participation and consensus. Plans for guideline revision. HPBASA and SAGES will publish a revised modification of the recommendations when new levels 1 and 2 evidence data are published

The relationshipb etweenp re- and post-weaningp erformanceo f lambs on Italian ryegrass

The relationship between pre- and post-weaning performance of lambs on Italian ryegrass was investigated by grazing tambsa t differents tockingr ates.A positivec orrelationw asf ound betweenb oth the pre-weanings tockingr ate (P = 0.008)a nd weaningm ass( P = 0.001)a ndt he posGweaninga veraged aily gain, wherep ost-weanings tocking rate was not siSnificantw hen relatedt o animal performanceT. he correlationb etweent he w€aningm assi n early August and the final mass of lambs in Novembeq after 83 days on ryegnss, was highly significant (p = 0.001). Lambs stocked at a low stocking rate (20 ewes with lambVha) prior to weaning gained 13.3 kg, while lambs in the high pre-weanings tockingr ate( 36 ewesw ith lambVha)g ained1 1.9k g duringt hep ost-weaningp eriod.T he smaller lambs,o riginatingf tom pasturesw ith heavys tockingr ates,c ouldn ot catchu p on ryegrassp asturesi,n termso fmass gain, to achievea cceptables laughterm assw ithin a reasonablpee dod of time. The optimum pre-weaning stocking rate for ewes and lamb vhao n ryegrassw ill dependn oi only on the weaningm assd esired,b ut alsoo n the marketins strategyo f the producerf or the lambsafter weaning.Die verwantskaptu ssenv oor-e n na-speenp restasiev anl ammersw, at Italiaansera aigraste env erskillendev eebeladings gewei het, is ondersoek'.n Positiewek orrelasieis gevindt ussenb eidev oorspeenv eebelading(P = 0.008) en speenmass(aP = 0.001)o p na-speeng emiddelded aagliksem assatoenamme,e t na-speenv eebeladingn ie betekenisvol verwanta and iereplestasinei e.D ie korrelasietu ssens peenmassvar oegi n Augustuse n die finale massav and ie lammersi n Novembern a 83 daeo p raaigrasis hoogsb etekenisvo(lP = 0.001).L ammersi n die yoorsDeenla e veebelading( 20 ooie met lammers/hah) et 13.3k g en die lammersin die hod voorspeenv eebelading(3 6 ooie met lammers/ ha)h et I1.9 kg in massag edurended ie na-speenp eriodet oegeneemD. ie kleinerl ammers,a fkomstigv an hod veebeladingsh,e t nie op die weidingi n termev anm assatoenamoep gevango m 'n aanvaarbarsel agmassbai nner edelike tyd te bereik nie. Die optimum voorspeenv eebeladingv ir ooie en lammers/hao p raaigrass al nie slegsb epaal word deurd ie speenmasswaa t bereikw il word nie,m aaro ok deurd ie bemarkilg strategiev and ie produsenmt et die lammers na speen,Keywords: ltalian ryegrass, lambs, pre- and post-weaning performance

Degradation of aflatoxin B1 by fungal laccase enzymes

The enzymatic degradation of aflatoxin B1 (AFB1) by white rot fungi through laccase production was investigated in different liquid media. A significant (P < 0.0001) correlation was observed between laccase activity and AFB1 degradation exhibited by representatives of Peniophora and Pleurotus ostreatus cultivated in minimal salts (MSM) (r = 0.93) and mineral salts - malt extract (MSB-MEB) (r = 0.77) liquid media. Peniophora sp. SCC0152 cultured in MSB-MEB liquid medium supplemented with veratryl alcohol and sugarcane bagasse showed high laccase activity (496 U/L), as well as 40.45% AFB1 degradation as monitored using high performance liquid chromatography. P. ostreatus St2-3 cultivated in MSM liquid medium supplemented with veratryl alcohol resulted in laccase activity of 416.39 U/L and 35.90% degradation of AFB1. Aflatoxin B1 was significantly (P < 0.0001) degraded when treated with pure laccase enzyme from Trametes versicolor (1 U/ml, 87.34%) and recombinant laccase produced by Aspergillus niger D15-Lcc2#3 (118 U/L, 55%). Aflatoxin B1 degradation by laccase enzyme from T. versicolor and recombinant laccase enzyme produced by A. niger D15-Lcc2#3 coincided with significant (P < 0.001) loss of mutagenicity of AFB1, as evaluated in the Salmonella typhimurium mutagenicity assay. The degradation of AFB1 by white rot fungi could be an important bio-control measure to reduce the level of this mycotoxin in food commodities. © 2009 Elsevier B.V. All rights reserved.Articl

Efficacy and tolerability of pantoprazole 40 mg versus 80 mg in patients with reflux oesophagitis

Background: Pantoprazole is a substituted benzimidazole which is a potent inhibitor of gastric acid secretion by its action upon H+,K+-ATPase. Methods: Pantoprazole 40 mg and 80 mg were compared in a randomized double-blind study in 192 out-patients with stage II or III (Savary-Miller classification) reflux oesophagitis. Patients received either pantoprazole 40 mg (n = 97) or pantoprazole 80 mg (n = 95), once daily before breakfast for 4 weeks. Treatment was extended for a further 4 weeks if the oesophagitis had not healed. Results: After 4 weeks complete healing of the reflux oesophagitis was seen in 78% of protocol-correct patients given pantoprazole 40 mg daily (n = 86), and in 72% in the 80 mg (n = 87) group. The cumulative healing rates after 8 weeks were 95 and 94%, respectively (P > 0.05, Cochran-Mantel-Haenszel), and time until healing of oesophagitis comparable in both groups. Differences between doses were also not significant in an intention-to-treat analysis. Both dosing schedules were well tolerated and the patients experienced remarkable symptom relief. No adverse event or changes in laboratory values of clinical significance could definitely be ascribed to the trial medication. Conclusion: The 40 mg pantoprazole dosage is comparable to 80 mg in reflux oesophagitis, both in efficacy and tolerability.Articl

Adult liver transplantation in Johannesburg, South Africa (2004 - 2016): Balancing good outcomes, constrained resources and limited donors

Background. Liver transplantation is the standard of care for the treatment of liver failure worldwide, yet millions of people living in sub-Saharan Africa remain without access to these services. South Africa (SA) has two liver transplant centres, one in Cape Town and the other in Johannesburg, where Wits Donald Gordon Medical Centre (WDGMC) started an adult liver transplant programme in 2004.Objectives. To describe the outcomes of the adult liver transplant programme at WDGMC.Methods. This was a retrospective review of all adult orthotopic liver transplants performed at WDGMC from 16 August 2004 to 30 June 2016 with a minimum follow-up of 6 months. The primary outcome was recipient and graft survival and the effect of covariates on survival. Kaplan-Meier survival analysis included all adults who underwent their first transplant for end-stage liver disease (ESLD) (N=275). Proportional hazards regression analysis using hazard ratios (HRs) was conducted to determine which covariates were associated with a significantly increased risk of mortality.Results. A total of 297 deceased-donor liver transplants were performed during the study period; 19/297 (6.4%) were for acute liver failure (ALF) and the remainder were for ESLD. The median age of recipients was 51 years (interquartile range 41 - 59), and two-thirds were male. The most common cause of ESLD was primary sclerosing cholangitis. The median follow-up was 3.2 years, and recipient survival was characterised in the following intervals: 90 days = 87.6% (95% confidence interval (CI) 83.1 - 91.0), 1 year = 81.7% (95% CI 76.6 - 85.8), and5 years = 71.0% (95% CI 64.5 - 76.5). Allograft survival was similar: 90 days = 85.8% (95% CI 81.1 - 89.4), 1 year = 81.0% (95% CI 75.8 - 85.2), and 5 years = 69.1% (95% CI 62.6 - 74.7). The most significant covariates that impacted on mortality were postoperative biliary leaks (HR 2.0 (95% CI 1.05 - 3.80)), recipient age >60 years at time of transplant (HR 2.06 (95% CI 1.06 - 3.99)), theatre time >8 hours (HR 3.13 (95% CI 1.79 - 5.48)), and hepatic artery thrombosis (HR 5.58 (95% CI 3.09 - 10.08)). The most common infectious cause of death was invasive fungal infection.Conclusions. This study demonstrates that outcomes of the adult orthotopic liver transplant programme at WDGMC are comparable with international transplant centres. Management of biliary complications, early hepatic artery thrombosis and post-transplant infections needs to be improved. Access to liver transplantation services is still extremely limited, but can be improved by addressing the national shortage of deceased donors and establishing a national regulatory body for solid organ transplantation in SA