Bewertung sommertrockener Bäche des Tieflands : Entwicklung einer Methode für die Bewertung und das Management temporärer Fließgewässer nach Europäischer Wasserrahmenrichtlinie

Im Rahmen des Klimawandels werden Veränderungen im Abflussverhalten von Fließgewässern erwartet, die zu einer Zunahme von sommertrockenen Bächen führen können. Für diese im Sommer austrocknenden Bäche gibt es aktuell kein biologisches Bewertungsverfahren, um den ökologischen Zustand mittels Tieren der Gewässersohle (Makrozoobenthos, Abk.: MZB) zu erfassen. Es wurde eine Bewertungsmethode für das Management dieser Fließgewässer entwickelt, welche die Anforderungen der Europäischen Wasserrahmenrichtlinie (WRRL) für das MZB erfüllt. Das entwickelte Verfahren orientiert sich an der aktuell vorhandenen offiziellen Bewertungsmethode (PERLODES) für ständig wasserführende Fließgewässer in Deutschland. Im Emscher-Lippe Raum wurden 33 Probestellen aus sommertrockenen Bächen auf ihre Besiedlung durch das MZB untersucht. An den Probestellen wurden zusätzlich chemisch-physikalische Parameter und Strukturgüteparameter aufgenommen. Durch die Auswertung dieser Datengrundlage wurden biologische Messgrößen abgeleitet, die signifikant und vorhersagbar auf strukturelle Verschlechterungen reagieren. Aus den biologischen Messgrößen wurde dann ein Index entwickelt, der die Einteilung von sommertrockenen Bächen des Tiefland in ein fünf Klassensystem zur Beurteilung des ökologischen Zustands nach WRRL ermöglicht

Encapsulating Peritoneal Sclerosis in the Netherlands: A study on incidence, risk factors and clinical consequences

Patients with chronic renal failure have an accumulation of extracellular fluid and waste products (uremic toxins) which are normally excreted by the kidney. There are diff erent renal replacement therapies, which can partially correct these abnormalities. Peritoneal dialysis (PD) is one of these modalities. Since the introduction of continuous ambulatory peritoneal dialysis (CAPD) in 1976, the use of PD has increased steadily and is now used worldwide. On January 1st 2009, 6292 patients were on dialysis in The Netherlands, of which 18.1 % (n=1139) were on PD (source:RENINE www.renine.nl). In PD the peritoneal membrane is used as a dialyzer membrane. By gravity a sterile dialysis solution is instilled in the peritoneal cavity via an intra-abdominal catheter. Through a combination of diff usion and convection waste products and fl uid are transported between the peritoneal capillaries and the dialysis fluid. After a few hours an equilibration is reached, and the effl uent is drained. In the regular CAPD scheme, this cycle is performed 4 times a day for 4 hours with a long night dwell. Dialysis solutions contain varying concentrations of glucose in order to provide an osmotic gradient necessary for the transport and removal of excess body water. The glucose is absorbed by the peritoneal capillaries, which leads to a decrease of the osmotic gradient. In the early nineties icodextrin was introduced as a new dialysis fl uid. This is a glucose polymer derived from starches, which is absorbed slowly by the capillaries. Therefore it is very eff ective for ultrafi ltration, particularly in long dwells. Although, the side eff ects of icodextrin appear to be limited, sterile peritonitis due to icodextrin has been reported. Normal peritoneum comprises diff erent components; a thin layer of mesothelial cells and a submesothelial layer with vessels and fi broblasts. The inner abdominal wall is lined with a parietal membrane, where as a visceral membrane covers the intestines. Continuous exposure to dialysis solutions and other exogenous factors results in changes of the peritoneal membrane. In long term PD there is mesothelial denudation, the submesothelial layer becomes thicker and new vessels develop

Post-transplantation encapsulating peritoneal sclerosis without inflammation or radiological abnormalities

Background: Post-transplantation encapsulating peritoneal sclerosis (EPS) causing bowel obstruction has been identified as a serious complication after kidney transplantation in patients previously treated with peritoneal dialysis. Systemic inflammation and abnormalities on an abdominal computed tomography (CT) scan are important hallmarks of EPS. To our knowledge, this is the first report of a case being diagnosed with late-onset post-transplantation EPS without systemic inflammation or abnormalities on a CT scan which could only be diagnosed by laparotomy. Case presentation. A 59-year old female presented because of symptoms of bowel obstruction 33 months after kidney transplantation. The patient had a 26-month history of peritoneal dialysis before her first kidney transplantation and was treated with peritoneal dialysis for 4 years before undergoing a second kidney transplantation. Physical examination was unremarkable and laboratory tests showed no signs of systemic inflammation (C-reactive protein <1 mg/L). An abdominal CT scan did not reveal any abnormalities fitting the diagnosis of EPS, except a "feces sign". Given the severity of the progressive symptoms, a diagnostic laparotomy was performed, visualizing a classical EPS. Total peritonectomy and enterolysis were performed, leading to restoration of peristalsis. Conclusion: EPS may occur several years after kidney transplantation in the absence of inflammation and typical radiological abnormalities. Obtaining a diagnosis of post-transplantation EPS is challenging, however, a low threshold for surgical exploration in case of high clinical suspicion and negative findings on the CT scan is mandatory

CD4-positive T cells and M2 macrophages dominate the peritoneal infiltrate of patients with encapsulating peritoneal sclerosis

Background Encapsulating peritoneal sclerosis (EPS) is a severe complication of peritoneal dialysis (PD). Previously, it has been shown that infiltrating CD4-positive T cells and M2 macrophages are associated with several fibrotic conditions. Therefore, the characteristics of the peritoneal cell infiltrate in EPS may be of interest to understand EPS pathogenesis. In this study, we aim to elucidate the composition of the peritoneal cell infiltrate in EPS patients and relate the findings to clinical outcome. Study Design, Setting, and Participants We studied peritoneal membrane biopsies of 23 EPS patients and compared them to biopsies of 15 PD patients without EPS. The cellular infiltrate was characterized by immunohistochemistry to detect T cells(CD3-positive), CD4-positive (CD4+) and CD8-positive T cell subsets, B cells(CD20-positive), granulocytes(CD15-positive), macrophages(CD68-positive), M1(CD80-positive), and M2(CD163-positive) macrophages. Tissues were analysed using digital image analysis. Kaplan-Meier survival analysis was performed to investigate the survival in the different staining groups. Results The cellular infiltrate in EPS biopsies was dominated by mononuclear cells. For both CD3 and CD68, the median percentage of area stained was higher in biopsies of EPS as opposed to non-EPS patients (p<0.001). EPS biopsies showed a higher percentage of area stained for CD4 (1.29%(0.61-3.20)) compared to CD8 (0.71%(0.46-1.01), p = 0.04), while in the non-EPS group these cells were almost equally represented (respectively 0.28% (0.05-0.83) versus 0.22%(0.17-0.43), p = 0.97). The percentage of area stained for both CD80 and CD163 was higher in EPS than in non-EPS biopsies (p<0.001), with CD163+ cells being the most abundant phenotype. Virtually no CD20-positive and CD15-positive cells were present in biopsies of a subgroup of EPS patients. No relation was found between the composition of the mononuclear cell infiltrate and clinical outcome. Conclusions A characteristic mononuclear cell infiltrate consisting of CD4+ and CD163+ cells dominates the peritoneum of EPS patients. These findings suggest a role for both CD4+ T cells and M2 macrophages in the pathogenesis of EPS

CD4-positive T cells and M2 macrophages dominate the peritoneal infiltrate of patients with encapsulating peritoneal sclerosis

Background: Encapsulating peritoneal sclerosis (EPS) is a severe complication of peritoneal dialysis (PD). Previously, it has been shown that infiltrating CD4-positive T cells and M2 macrophages are associated with several fibrotic conditions. Therefore, the characteristics of the peritoneal cell infiltrate in EPS may be of interest to understand EPS pathogenesis. In this study, we aim to elucidate the composition of the peritoneal cell infiltrate in EPS patients and relate the findings to clinical outcome. Study Design, Setting, and Participants: We studied peritoneal membrane biopsies of 23 EPS patients and compared them to biopsies of 15 PD patients without EPS. The cellular infiltrate was characterized by immunohistochemistry to detect T cells(CD3-positive), CD4-positive (CD4+) and CD8-positive T cell subsets, B cells(CD20-positive), granulocytes(CD15-positive), macrophages(CD68-positive), M1(CD80-positive), and M2(CD163-positive) macrophages. Tissues were analysed using digital image analysis. Kaplan-Meier survival analysis was performed to investigate the survival in the different staining groups. Results: The cellular infiltrate in EPS biopsies was dominated by mononuclear cells. For both CD3 and CD68, the median percentage of area stained was higher in biopsies of EPS as opposed to non-EPS patients (p<0.001). EPS biopsies showed a higher percentage of area stained for CD4 (1.29%(0.61-3.20)) compared to CD8 (0.71%(0.46-1.01), p = 0.04), while in the non-EPS group these cells were almost equally represented (respectively 0.28%(0.05-0.83) versus 0.22%(0.17-0.43), p = 0.97). The percentage of area stained for both CD80 and CD163 was higher in EPS than in non-EPS biopsies (p<0.001), with CD163+cells being the most abundant phenotype. Virtually no CD20-positive and CD15-positive cells were present in biopsies of a subgroup of EPS patients. No relation was found between the composition of the mononuclear cell infiltrate and clinical outcome. Conclusions: A characteristic mononuclear cell infiltrate consisting of CD4+ and CD163+ cells dominates the peritoneum of EPS patients. These findings suggest a role for both CD4+ T cells and M2 macrophages in the pathogenesis of EPS

Histological and clinical findings in patients with post-transplantation and classical encapsulating peritoneal sclerosis: A European multicenter study

Background: Encapsulating peritoneal sclerosis (EPS) commonly presents after peritoneal dialysis has been stopped, either post-transplantation (PT-EPS) or after switching to hemodialysis (classical EPS, cEPS). The aim of the present study was to investigate whether PT-EPS and cEPS differ in morphology and clinical course. Methods: In this European multicenter study we included fifty-six EPS patients, retrospectively paired-matched for peritoneal dialysis (PD) duration. Twenty-eight patients developed EPS after renal transplantation, whereas the other twenty-eight patients were classical EPS patients. Demographic data, PD details, and course of disease were documented. Peritoneal biopsies of all patients were investigated using histological criteria. Results: Eighteen patients from the Netherlands and thirty-eight patients from Germany were included. Time on PD was 78(64-95) in the PT-EPS and 72(50-89) months in the cEPS group (p>0.05). There were no significant differences between the morphological findings of cEPS and PT-EPS. Podoplanin positive cells were a prominent feature in both groups, but with a similar distribution of the podoplanin patterns. Time between cessation of PD to the clinical diagnosis of EPS was significantly shorter in the PT-EPS group as compared to cEPS (4(2-9) months versus 23(7-24) months, p<0.001). Peritonitis rate was significantly higher in cEPS. Conclusions: In peritoneal biopsies PT-EPS and cEPS are not distinguishable by histomorphology and immunohistochemistry, which argues against different entities. The critical phase for PT-EPS is during the first year after transplantation and therefore earlier after PD cessation then in cEPS

A multicenter randomized clinical trial investigating the cost-effectiveness of treatment strategies with or without antibiotics for uncomplicated acute diverticulitis (DIABOLO trial)

Background. Conservative treatment of uncomplicated or mild diverticulitis usually includes antibiotic therapy. It is, however, uncertain whether patients with acute diverticulitis indeed benefit from antibiotics. In most guidelines issued by professional organizations antibiotics are considered mandatory in the treatment of mild diverticulitis. This advice lacks evidence and is merely based on experts' opinion. Adverse effects of the use of antibiotics are well known, including allergic reactions, development of bacterial resistance to antibiotics and other side-effects. Methods. A randomized multicenter pragmatic clinical trial comparin

2013 WSES guidelines for management of intra-abdominal infections

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