Appropriateness of colonoscopy in Europe (EPAGE II). Iron-deficiency anemia and hematochezia.

BACKGROUND AND STUDY AIMS: To summarize the published literature on assessment of appropriateness of colonoscopy for the investigation of iron-deficiency anemia (IDA) and hematochezia, and report appropriateness criteria developed by an expert panel, the 2008 European Panel on the Appropriateness of Gastrointestinal Endoscopy, EPAGE II. METHODS: A systematic search of guidelines, systematic reviews and primary studies regarding the evaluation and management of IDA and hematochezia was performed. The RAND/UCLA Appropriateness Method was applied to develop appropriateness criteria for colonoscopy for these conditions. RESULTS: IDA occurs in 2 %-5 % of adult men and postmenopausal women. Examination of both the upper and lower gastrointestinal tract is recommended in patients with iron deficiency. Colonoscopy for IDA yields one colorectal cancer (CRC) in every 9-13 colonoscopies. Hematochezia is a well-recognized alarm symptom and such patients are likely to be referred for colonoscopy. Colonoscopy is unanimously recommended in patients aged > or = 50. Diverticulosis, vascular ectasias, and ischemic colitis are common causes of acute lower gastrointestinal bleeding (LGIB); CRC is found in 0.2 %-11 % of the colonoscopies performed for LGIB. Most patients with scant hematochezia have an anorectal or a distal source of bleeding. The expert panel considered most clinical indications for colonoscopy as appropriate in the presence of IDA (58 %) or hematochezia (83 %). CONCLUSION: Despite the limitations of the published studies, guidelines unanimously recommend colonoscopy for the investigation of IDA and hematochezia in patients aged > or = 50 years. These indications were also considered appropriate by EPAGE II, as were indications in patients at low risk for CRC with no obvious cause of bleeding found during adequate previous investigations.

Is it appropriate to index glomerular filtration rate for body surface area

Purpose: Obesity is an established independent risk factor for chronic kidney disease. Thus, measurement of glomerular filtration rate (GFR) is important in this population. Traditionally, GFR has been indexed for body surface area (BSA), but this indexation may not be appropriate in obese individuals. Therefore, the objective of the study was to compare absolute GFR with GFR indexed for BSA and with GFR indexed for height. Methods and materials: The study was conducted in 66 families from the Seychelles islands that included several members with hypertension. GFR and effective renal plasma flow (ERPF) were measured using inulin and PAH clearances, respectively. Antihypertensive treatment, if used, was withheld 2 weeks before conducting the clearances. Participants with diabetes mellitus were excluded from the analysis. BSA was calculated using the Dubois formula. We assessed trend across BMI categories using a non parametric test. Results: Participants included 174 women and 127 men. The prevalence of hypertension was 61%, of which 68% were treated. The table shows that absolute GFR, GFR indexed for height, ERPF, filtration fraction were significantly higher across BMI categories. When GFR was indexed for BSA, the association between GFR and BMI categories was lost. Conclusion: Indexing GFR for BSA in overweight and obese individuals leads to a substantial underestimation of GFR. Filtration fraction, which does not depend on BSA, is higher in obese individuals, which suggests glomerular hyperfiltration. Indexing GFR for BSA therefore would mask the underlying glomerular hyperfiltration. As the number of nephrons does not increase with weight gain, absolute GFR represents a better marker of single nephron GFR and is more appropriate.

Airway stenting with the LT-Mold? for severe glotto-subglottic stenosis or intractable aspiration: experience in 65 cases.

The purpose of this study was to assess the safety and efficacy of stenting in upper airway reconstructions for benign laryngotracheal stenosis (LTS) with a newly designed prosthesis, the LT-Mold?. The LT-Mold and its proper use during open surgery and endoscopy are described, and the experience gathered from a prospectively collected database on 65 patients treated for complex LTS or severe aspiration is reported. This series is compared to the results of other stenting methods. All patients were available for evaluation. In all but one case, the prosthesis was removed at the end of the study. The new prosthesis did not induce any stent-related trauma to the supraglottis, glottis and subglottis. Before adding a distal round-shaped silicone cap to the LT-Mold, granulation tissue was usually seen at the stent-mucosal interface at the tracheostoma level. In 14 cases, there has been a spontaneous extrusion of the prosthesis through the mouth; this problem was solved by fixing the prosthesis through the reinforced portion of the prosthesis at the cap level and by adding one fixation stitch in the supraglottis. We have to document the loss of the silicone cap in three cases. This problem was resolved by designing a new prototype with an integrated cap, glued with a slow hardening silicone glue. Fifty-four (83 %) of 65 patients were decannulated after a mean duration of stenting of 3 months (range 1-12 months). The mean follow-up after decannulation was 23 months (range 1 month to 10 years). The experience gathered with the LT-Mold shows that long-term stenting for complex LTS is safely achieved when the prosthesis is used with its distal integrated silicone cap. The softness and smoothness of the prosthesis with a round-shaped configuration of both extremities help avoid ulceration and granulation tissue formation in the reconstructed airway. Adequate fixation is mandatory to avoid extrusion.

Transcranial Doppler Pulsatility Index: What it is and What it Isn't.

BACKGROUND: Transcranial Doppler (TCD) pulsatility index (PI) has traditionally been interpreted as a descriptor of distal cerebrovascular resistance (CVR). We sought to evaluate the relationship between PI and CVR in situations, where CVR increases (mild hypocapnia) and decreases (plateau waves of intracranial pressure-ICP). METHODS: Recordings from patients with head-injury undergoing monitoring of arterial blood pressure (ABP), ICP, cerebral perfusion pressure (CPP), and TCD assessed cerebral blood flow velocities (FV) were analyzed. The Gosling pulsatility index (PI) was compared between baseline and ICP plateau waves (n = 20 patients) or short term (30-60 min) hypocapnia (n = 31). In addition, a modeling study was conducted with the "spectral" PI (calculated using fundamental harmonic of FV) resulting in a theoretical formula expressing the dependence of PI on balance of cerebrovascular impedances. RESULTS: PI increased significantly (p < 0.001) while CVR decreased (p < 0.001) during plateau waves. During hypocapnia PI and CVR increased (p < 0.001). The modeling formula explained more than 65% of the variability of Gosling PI and 90% of the variability of the "spectral" PI (R = 0.81 and R = 0.95, respectively). CONCLUSION: TCD pulsatility index can be easily and quickly assessed but is usually misinterpreted as a descriptor of CVR. The mathematical model presents a complex relationship between PI and multiple haemodynamic variables.

In vitro organogenesis in watermelon cotyledons

The objective of this work was to study the in vitro organogenesis of Citrullus lanatus, by the induction of adventitious buds in cotyledon segments cultured in medium supplemented with cytokinin. Explants were collected from one, three and five-day-old in vitro germinated seedlings, considering the distal and proximal cotyledon regions. The data obtained showed that in vitro organogenesis of watermelon occurred with higher efficiency, when cotyledon segments from the proximal region collected from three-day-old seedlings were cultivated in medium MS, supplemented with BAP (1 mg L-1) and coconut water (10%). The histological study showed that the organogenesis occurs directly, without callus formation, on epidermal and subepidermal layers of the explants. Adventitious shoots were characterized by the development of shoot apical meristem and leaf primordia. The formation of protuberances, that do not develop into adventitious buds, was also observed.

Syndrome hypothénarien du marteau: étiologie peu connue de phénomène de Raynaud secondaire [Hypothenar hammer syndrome: little-known etiology of secondary Raynaud's phenomenon]

Hypothenar hammer syndrome is an uncommonly encountered cause of Raynaud's phenomenon associated with professional or recreational activities. We report 6 consecutive cases seen in our angiology unit between 1988 and 1990. Clinical findings include a history of repeated microtraumatisms of the dominant hand, male sex, unilaterality, sudden onset, and severe Raynaud's phenomenon of the last three fingers. Investigations reveal an aneurysm or thrombosis of the distal cubital artery or of the superficial palmar branch, associated with occlusion of digital arteries. Avoidance of the aggravating conditions or resection and/or plasty of the affected vascular segment usually leads to disappearance of the symptoms.

Design, synthesis and biological evaluation of a class of bioisosteric oximes of the novel dual peroxisome proliferator-activated receptor α/γ ligand LT175.

The effects resulting from the introduction of an oxime group in place of the distal aromatic ring of the diphenyl moiety of LT175, previously reported as a PPARα/γ dual agonist, have been investigated. This modification allowed the identification of new bioisosteric ligands with fairly good activity on PPARα and fine-tuned moderate activity on PPARγ. For the most interesting compound (S)-3, docking studies in PPARα and PPARγ provided a molecular explanation for its different behavior as full and partial agonist of the two receptor isotypes, respectively. A further investigation of this compound was carried out performing gene expression studies on HepaRG cells. The results obtained allowed to hypothesize a possible mechanism through which this ligand could be useful in the treatment of metabolic disorders. The higher induction of the expression of some genes, compared to selective agonists, seems to confirm the importance of a dual PPARα/γ activity which probably involves a synergistic effect on both receptor subtypes.

Nephrocalcinosis (enamel renal syndrome) caused by autosomal recessive FAM20A mutations.

BACKGROUND/AIMS: Calcium homeostasis requires regulated cellular and interstitial systems interacting to modulate the activity and movement of this ion. Disruption of these systems in the kidney results in nephrocalcinosis and nephrolithiasis, important medical problems whose pathogenesis is incompletely understood. METHODS: We investigated 25 patients from 16 families with unexplained nephrocalcinosis and characteristic dental defects (amelogenesis imperfecta, gingival hyperplasia, impaired tooth eruption). To identify the causative gene, we performed genome-wide linkage analysis, exome capture, next-generation sequencing, and Sanger sequencing. RESULTS: All patients had bi-allelic FAM20A mutations segregating with the disease; 20 different mutations were identified. CONCLUSIONS: This autosomal recessive disorder, also known as enamel renal syndrome, of FAM20A causes nephrocalcinosis and amelogenesis imperfecta. We speculate that all individuals with biallelic FAM20A mutations will eventually show nephrocalcinosis.

Thoracoscopic segmentectomy: one vessel may hide a second one.

We report the case of an asymptomatic neonate prenatally diagnosed with a left basal pulmonary sequestration. The preoperative chest computed tomography with contrast showed 2 aberrant arteries arising from the distal thoracic aorta and supplying the intralobar left inferior lung malformation. Strategy and treatment by thoracoscopic segmentectomy are presented.

Independent relations of left ventricular structure with the 24-h urinary excretion of sodium and aldosterone

Objective: Previous studies reported on the association of left ventricular mass index (LVMI) with urinary sodium or with circulating or urinary aldosterone.We investigated the independent associations of LVMI with the urinary excretion of both sodium and aldosterone. Design and method: We randomly recruited 317 untreated subjects from a White population (45.1%women; mean age 48.2 years).Measurements included echocardiographic left ventricular (LV) properties, the 24 h urinary excretion of sodium and aldosterone, plasma renin activity (PRA), and proximal (RNaprox) and distal (RNadist) renal sodium reabsorption, assessed fromthe endogenous lithium clearance. Inmultivariable-adjusted models,we expressed changes in LVMI per 1 SD increase in the explanatory variables, while accounting for sex, age, systolic blood pressure and the waist-to-hip ratio. Results: LVMI increased independentlywith the urinary excretion of both sodium (+2.48 g/m2; P=0.005) and aldosterone (+2.63 g/m2; P=0.004). Higher sodium excretion was associated with increased mean wall thickness (MWT: +0.126 mm, P=0.054), but with no change in LV end-diastolic diameter (LVID: +0.12mm, P=0.64). In contrast, higher aldosterone excretion was associated with higher LVID (+0.54 mm; P=0.017), but with no change in MWT (+0.070mm; P=0.28).Higher RNadistwas associatedwith lower relativewall thickness (−0.81×10−2, P=0.017), because of opposite trends in LVID(+0.33 mm; P=0.13) and MWT (−0.130mm; P=0.040). LVMI was not associated with PRA or RNaprox. Conclusions: LVMI independently increased with both urinary sodium and aldosterone excretion. IncreasedMWT explained the association of LVMI with urinary sodium and increased LVID the association of LVMI with urinary aldosterone.

Shoulder pathology: estimating dominant upper-limb activity using 3D kinematic sensors.

Introduction. Quantification of daily upper-limb activity is a key determinant in evaluation of shoulder surgery. For a number of shoulder diseases, problem in performing daily activities have been expressed in terms of upper-limb usage and non-usage. Many instruments measure upper-limb movement but do not focus on the differentiations between the use of left or right shoulder. Several methods have been used to measure it using only accelerometers, pressure sensors or video-based analysis. However, there is no standard or widely used objective measure for upper-limb movement. We report here on an objective method to measure the movement of upper-limb and we examined the use of 3D accelerometers and 3D gyroscopes for that purpose. Methods. We studied 8 subjects with unilateral pathological shoulder (8 rotator cuff disease: 53 years old ± 8) and compared them to 18 control subjects (10 right handed, 8 left handed: 32 years old ± 8, younger than the patient group to be almost sure they don_t have any unrecognized shoulder pathology). The Simple Shoulder Test (SST) and Disabilities of the Arm and Shoulder Score (DASH) questionnaires were completed by each subject. Two modules with 3 miniature capacitive gyroscopes and 3 miniature accelerometers were fixed by a patch on the dorsal side of the distal humerus, and one module with 3 gyroscopes and 3 accelerometers were fixed on the thorax. The subject wore the system during one day (8 hours), at home or wherever he/she went. We used a technique based on the 3D acceleration and the 3D angular velocities from the modules attached on the humerus. Results. As expected, we observed that for the stand and sit postures the right side is more used than the left side for a healthy right-handed person(idem on the left side for a healthy left-handed person). Subjects used their dominant upper-limb 18% more than the non-dominant upper-limb. The measurements on patients in daily life have shown that the patient has used more his non affected and non dominant side during daily activity if the dominant side = affected shoulder. If the dominant side affected shoulder, the difference can be showed only during walking period. Discussion-Conclusion. The technique developed and used allowed the quantification of the difference between dominant and non dominant side, affected and unaffected upper-limb activity. These results were encouraging for future evaluation of patients with shoulder injuries, before and after surgery. The feasibility and patient acceptability of the method using body fixed sensors for ambulatory evaluation of upper limbs kinematics was shown.

Spatial learning by rats across visually disconnected environments

Two spatial tasks were designed to test specific properties of spatial representation in rats. In the first task, rats were trained to locate an escape hole at a fixed position in a visually homogeneous arena. This arena was connected with a periphery where a full view of the room environment existed. Therefore, rats were dependent on their memory trace of the previous position in the periphery to discriminate a position within the central region. Under these experimental conditions, the test animals showed a significant discrimination of the training position without a specific local view. In the second task, rats were trained in a radial maze consisting of tunnels that were transparent at their distal ends only. Because the central part of the maze was non-transparent, rats had to plan and execute appropriate trajectories without specific visual feedback from the environment. This situation was intended to encourage the reliance on prospective memory of the non-visited arms in selecting the following move. Our results show that acquisition performance was only slightly decreased compared to that shown in a completely transparent maze and considerably higher than in a translucent maze or in darkness. These two series of experiments indicate (1) that rats can learn about the relative position of different places with no common visual panorama, and (2) that they are able to plan and execute a sequence of visits to several places without direct visual feed-back about their relative position.

Repair of tracheal aspergillosis perforation causing tension pneumothorax.

Tracheobronchial aspergillosis is a rare entity mainly observed in immune-compromised patients or those who have undergone transplantation. It may cause airway ulcerations or bleeding. We report the case of a 17-year-old patient receiving chemotherapy for acute lymphoblastic leukemia who presented with right-sided tension pneumothorax. Chest tube drainage revealed a massive air leak without reexpansion of the lung, and bronchoscopy showed a 15- × 15-mm defect of the distal trachea related to aspergillosis infection. The defect was closed by an intrathoracic transposition of a pedicled latissimus dorsi muscle flap, which was sutured into the debrided defect followed by temporary endotracheal stenting and antifungal medication.

Changes in nuclear 3,5,3'-triiodothyronine receptor expression in rat dorsal root ganglia and sciatic nerve during development: comparison with regeneration.

The action of the thyroid hormones on responsive cells in the peripheral nervous system requires the presence of nuclear triiodothyronine receptors (NT3R). These nuclear receptors, including both the alpha and beta subtypes of NT3R, were visualized by immunocytochemistry with the specific 2B3 monoclonal antibody. In the dorsal root ganglia (DRG) of rat embryos, NT3R immunoreactivity was first discretely revealed in a few neurons at embryonic day 14 (E14), then strongly expressed by all neurons at E17 and during the first postnatal week; all DRG neurons continued to possess clear NT3R immunostaining, which faded slightly with age. The peripheral glial cells in the DRG displayed a short-lived NT3R immunoreaction, starting at E17 and disappearing from the satellite and Schwann cells by postnatal days 3 and 7 respectively. In the developing sciatic nerve, Schwann cells also exhibited transient NT3R immunoreactivity restricted to a short period ranging from E17 to postnatal day 10; the NT3R immunostaining of the Schwann cells vanished proximodistally along the sciatic nerve, so that the Schwann cells rapidly became free of detectable NT3R immunostaining. However, after the transection or crushing of an adult sciatic nerve, the NT3R immunoreactivity reappeared in the Schwann cells adjacent to the lesion by 2 days, then along the distal segment in which the axons were degenerating, and finally disappeared by 45 days, when the regenerating axons were allowed to re-occupy the distal segment.(ABSTRACT TRUNCATED AT 250 WORDS)

Neuroarthropathy of the foot revealing primary systemic amyloidosis: case report and literature review.

The aims of this review were to describe the case of a patient with debilitating neuroarthropathy of the ankles and feet and reveal a primary systemic (amyloid light chain, AL) amyloidosis and to review the relevant literature concerning the peripheral neuropathy and neuroarthropathy due to amyloidosis. We will emphasize the diagnostic pitfalls and discuss prognosis and treatments of both the peripheral neuropathy and the arthropathy related to AL amyloidosis. This is a descriptive case report of a patient with neuroarthropathy of the lower limbs due to AL amyloidosis. A review and discussion of relevant literature were conducted, based on a PubMed search from 1973 to December 2013. A 51-year-old female was diagnosed with AL amyloidosis after 20 months of investigation of small painful deformities of the feet. Chronic peripheral neuropathy occurs as a manifestation of AL amyloidosis in 25 % of cases. It may exceptionally be complicated by neuroarthropathy. In this case, the paucity of clinical and electrophysiological signs of the neuropathy delayed the diagnosis, leading to a severe arthropathy. The massive destruction of the joints dominated the clinical and the poor functional outcome. Diagnosis of AL amyloidosis should be considered in the presence of a mild peripheral neuropathy and a distal destructive and painless arthropathy. The two key diagnostic procedures are serum protein electrophoresis and nerve biopsy. Delay in treatment worsens the prognosis.