Ischemic colitis during interferon-ribavirin therapy for chronic hepatitis C: A case report

Ischemic colitis is a rare complication of interferon administration. Only 9 cases in 6 reports have been described to-date. This report describes a case of ischemic colitis during pegylated interferon and ribavirin treatment for chronic hepatitis C, and includes a review of the relevant literature. A 48-year-old woman was treated with pegylated interferon α-2a and ribavirin for chronic hepatitis C, genotype Ib. After 19 wk of treatment, the patient complained of severe afebrile abdominal pain with hematochezia. Vital signs were stable and serum white blood cell count was within the normal range. Abdominal computed tomography showed diffuse colonic wall thickening from the splenic flexure to the proximal sigmoid colon, which is the most vulnerable area for the development of ischemic colitis. Colonoscopy revealed an acute mucosal hyperemic change, with edema and ulcerations extending from the proximal descending colon to the sigmoid colon. Colonic mucosal biopsy revealed acute exudative colitis. Polymerase chain reaction and culture for Mycobacterium tuberculosis were negative and the cultures for cytomegalovirus, Salmonella and Shigella species were negative. After discontinuation of interferon and ribavirin therapy, abdominal pain and hematochezia subsided and, following colonoscopy showed improvement of the mucosal ulcerations. Ischemic colitis cases during interferon therapy in patients with chronic hepatitis C reported so far have all involved the descending colon. Ischemic colitis is a rarely encountered complication of interferon administration in patients with chronic hepatitis C and should be considered when a patient complains of abdominal pain and hematochezia.

Identification of a terminal ileum carcinoid tumour during bowel screening colonoscopy - should terminal ileoscopy be performed as best practice?

The UK National Bowel Cancer Screening Programme invites men and women aged between 60 - 74 years old to be routinely screened every 2 years. A 90% caecal intubation rate or intubation of the terminal ileum is considered to be the best practice means of identifying completeness. This case report describes how terminal ileal intubation carried out during a routine screening colonoscopy led to the identification and treatment of a carcinoid tumour. Despite evidence for improving colonic diagnoses, completion of colonoscopy by passing through the ileocaecal valve is not performed routinely due to the perceived difficulty of the manoeuvre. With practice, ileoscopy has been shown to be achievable in at least 85% of routine colonoscopies and contributes significantly to quality assurance and to the diagnostic yield.

Proactive management of peritoneal metastases from colorectal cancer: the next logical step toward optimal locoregional control

SUMMARY Although surgery for colorectal cancer has improved over the last decade, locoregional recurrence and peritoneal metastases continue as a mechanism of surgical treatment failure in 10–20% of patients. These patients have a dismal prognosis. Clinical information is available in order to identify patients who are at high risk for locoregional recurrence and peritoneal metastases. These patients, once identified, should be offered new treatment options shown to be of benefit in selected patients. Using perioperative chemotherapy at the time of colorectal cancer resection improves locoregional control and diminishes peritoneal metastases. Also, in patients at high risk, a proactive second-look surgery utilizing peritonectomy and hyperthermic intraperitoneal chemotherapy is of benefit, with reasonable morbidity and mortality.

Torque measures of common therapies for the treatment of loss of knee flexion

BACKGROUND

Conservative treatment protocols to effectively treat knee flexion motion restrictions are dependent in part on the torque applied to the joint.

HYPOTHESES

Clinicians apply greater torque with the test leg in a simulated prone position than in a seated position. Clinicians also apply greater torque than a dynamic splint or a static progressive stretch brace. Finally, clinicians apply a torque equal to the high-intensity stretch device.

STUDY DESIGN

bservational study.

METHODS

An instrumented test leg was used to record peak torque applied by 14 licensed clinicians (7 women, 7 men; age, 44.3 ± 10.2 years; height, 172.9 ± 13.2 cm; weight, 72.6 ± 13.0 kg) during knee flexion mobilizations and 3 types of mechanical therapy (dynamic splint, static progressive stretch, and high-intensity stretch).

RESULTS

The dynamic splint applied 5.1 ± 0.1 N·m, while the static progressive stretch brace applied 20.8 ± 2.2 N·m. Clinicians applied 49.5 ± 22.4 N·m with the test leg in a seated position and 55.8 ± 22.0 N·m with the leg in a prone position. The high-intensity stretch device applied up to 214.7 ± 29.2 N·m. All comparisons were statistically significant (P ≤ 0.02) with the exception of the 2 testing positions (P = 0.94).

CONCLUSIONS

The results demonstrate that the torques applied to the knee differ between passive stretching therapies. Clinicians should be cognizant of these torque differences when constructing treatment protocols for patients with limited knee flexion range of motion.

Spontaneous spinal epidural hematoma at the 16th week of a twin pregnancy

Spontaneous spinal epidural hematoma without discernable underlying conditions is a rare complication during pregnancy. We report a pregnant woman who developed the hematoma at 16 weeks of pregnancy; the earliest occurrence ever reported. A 36-year-old Japanese primipara with twins felt shoulder, neck and back pain at 16(+1) weeks with progressive quadriplegia. Magnetic resonance imaging revealed a mass in the C3-7 epidural space, compatible with a spinal epidural hematoma, and decompression was performed 9 h after symptom onset. Rehabilitation started and she gave birth abdominally to healthy twin infants at the 29th week. Motor, sensory and sphincter disturbances remained. This case demonstrates that spinal epidural hematoma can occur even without known underlying conditions and even at an early gestational age.

Endotracheal Tube Cuff Pressure Monitoring in Peripheral Hospitals

BACKGROUND

An improvised monitor was designed in a peripheral hospital to measure the tracheal tube cuff pressures in patients intubated under anaesthesia. The aim of the study was to assess the efficacy of assessment of cuff pressure by the traditional palpatory method and to compare the improvised monitor with the standard monitor commercially available. The effect of nitrous oxide on the cuff-pressure was also studied.

METHODS

The tracheal tube cuff pressure of 80 patients undergoing general anaesthesia was assessed by palpation and measured with an improvised and standard monitor.

RESULTS

The study showed that the tracheal cuff pressure recorded were higher than normal tracheal perfusion pressure in 40% of the cases with satisfactory palpatory assessment. The pressures recorded by the improvised monitor were comparable to that of the standard monitor. The use of nitrous oxide resulted in increase in cuff pressures over a period of time.

CONCLUSION

An objective measurement by any equipment is superior to assessment of cuff pressure by palpation. The improvised monitor can be used to give a fair idea of the cuff pressures, in places where a standard monitor is not available.

Single-cell Tsc1 knockout during corticogenesis generates tuber-like lesions and reduces seizure threshold in mice

Tuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by mutations in Tsc1 or Tsc2 that lead to mammalian target of rapamycin (mTOR) hyperactivity. Patients with TSC suffer from intractable seizures resulting from cortical malformations known as tubers, but research into how these tubers form has been limited because of the lack of an animal model. To address this limitation, we used in utero electroporation to knock out Tsc1 in selected neuronal populations in mice heterozygous for a mutant Tsc1 allele that eliminates the Tsc1 gene product at a precise developmental time point. Knockout of Tsc1 in single cells led to increased mTOR activity and soma size in the affected neurons. The mice exhibited white matter heterotopic nodules and discrete cortical tuber-like lesions containing cytomegalic and multinucleated neurons with abnormal dendritic trees resembling giant cells. Cortical tubers in the mutant mice did not exhibit signs of gliosis. Furthermore, phospho-S6 immunoreactivity was not upregulated in Tsc1-null astrocytes despite a lower seizure threshold. Collectively, these data suggest that a double-hit strategy to eliminate Tsc1 in discrete neuronal populations generates TSC-associated cortical lesions, providing a model to uncover the mechanisms of lesion formation and cortical hyperexcitability. In addition, the absence of glial reactivity argues against a contribution of astrocytes to lesion-associated hyperexcitability.

[Signet ring cell carcinoma of the ampulla of Vater]

INTRODUCTION

Signet ring cell carcinoma of the ampulla of Vater is a rare entity and less than 20 cases have been described in the literature. We report the cases of two patients with this disease and provide a literature review of previous studies.

CASE REPORT

We describe two patients with obstructive jaundice. Abdominal ultrasonography and abdominal computed tomography showed dilatation of the intrahepatic and common bile duct. Duodenoscopy indicated a protruding mass on the ampulla of Vater. Histopathological examination showed round cells and their nuclei were located on one side with prominent signet-ring features. One patient underwent a cephalic pancreatoduodenectomy with lymphadenectomy and the other a total pancreatectomy.

DISCUSSION

Signet ring cell carcinoma of the ampulla of Vater has only been described in isolated cases in the literature. Therefore, the clinicopathological features and prognosis of this disease have not yet been well defined.

Chiari type I malformation: a mimicker of myasthenia gravis

INTRODUCTION

Myasthenia gravis is an autoimmune disease, which commonly presents with extraocular muscle weakness, eyelid ptosis, bulbar dysfunction, and proximal limb weakness. We report an unusual differential diagnosis for myasthenia gravis.

CASE REPORT

A 56-year-old woman presented with worsening blurry vision, double vision, eyelid droopiness, slurred speech, and fatigable limb weakness, worsening over a 6-month period. On neurological examination, she showed dysarthric speech, ptosis, and proximal limb weakness with preserved reflexes. Myasthenia gravis was considered strongly, but serological and electrodiagnostic testing did not confirm the diagnosis of myasthenia gravis. At subsequent visits, the patient developed headaches and downbeating nystagmus, and a magnetic resonance imaging of the brain showed a Chiari type I malformation.

CONCLUSIONS

Chiari type I malformation is an unusual differential for sero-negative myasthenia gravis. Magnetic resonance imaging of the brain, carried out in patients with all classical signs and symptoms of myasthenia gravis, helps identify this anomaly. Headaches, although a classic feature of Chiari type I malformation, need not be an early manifestation. Eyelid ptosis as a manifestation of Chiari malformation has not been reported in the literature.

The severity of endoscopic gastric atrophy could help to predict Operative Link on Gastritis Assessment gastritis stage

BACKGROUND AND AIMS

The aims of the present study were to evaluate the role of moderate-to-severe endoscopic gastric atrophy (EGA) on predicting Operative Link on Gastritis Assessment (OLGA) gastritis stage, and to assess the association of high-stage OLGA gastritis with gastric neoplasia in patients with non-ulcer dyspepsia.

METHODS

A cross-sectional study was carried out on 280 dyspeptic outpatients. EGA was assessed according to the Kimura-Takemoto classification. Gastritis stage was established according to the OLGA staging system and gastric neoplasia was assessed according to the Vienna classification. The pathologists who read the specimens were kept blind to the endoscopic results.

RESULTS

The mean age of patients was 46.1 years (range 20-78 years) with a male-to-female ratio of 1:1. High-stage gastritis (e.g. stage III or IV) was confirmed in 13 (4.6%) patients. All of these patients were more than 40 years-of-age (P = 0.01), had Helicobacter pylori infection (P = 0.0006) and moderate-to-severe EGA (P < 0.001). Low-grade dysplasia was found in seven patients: 4/13 (30.7%) with high-stage gastritis versus 3/267 (1.1%) with low-stage gastritis (P < 0.001). Six of these patients had moderate-to-severe EGA (P = 0.048). The sensitivity, specificity, positive predictive value and negative predictive value of this endoscopic finding in high-stage gastritis diagnosis were 100%, 57.7%, 10.3% and 100%, respectively.

CONCLUSIONS

OLGA high-stage gastritis was associated with gastric dysplasia and was mostly diagnosed in patients with moderate-to-severe EGA. The absence of this endoscopic finding could effectively rule out the possibility of having high-stage gastritis.

Treatment of HBeAg-negative chronic hepatitis B patients with nucleos(t)ide analogues

Current agents used in the treatment of chronic hepatitis B (CHB) can be classified into interferons-α (IFN-α: standard or pegylated) and nucleos(t)ide analogues (NUCs). NUCs are now used in most CHB patients for several reasons. They can be given to all CHB patients, even those with contraindications to IFN-α. NUCs are more convenient to use (one oral tablet daily) than IFN-α (subcutaneous injections) and are well tolerated with a good safety profile, while IFN-α has frequent and potentially severe side effects and worsens the patient's quality of life. All NUCs are potent anti-hepatitis B virus agents (all but adefovir are more potent than IFN-α) with entecavir(ETV) and tenofovir offering the highest potency and most importantly minimal to negligible risk of resistance during long-term monotherapy [corrected]. Prolongation of entecavir or tenofovir monotherapy maintains and slightly increases the initially high virological remission rates (67-76% of HBeAg-positive and 90-93% of HBeAg-negative patients) and this is expected to result in improved long-term outcomes. The need for long-term, perhaps indefinite, treatment is the main limitation of NUCs and the finite duration (48 weeks) the main advantage of IFN-α. However, only a minority of IFN-α-treated patients achieve durable sustained off-treatment responses (HBeAg-positive: 30-35%, HBeAg-negative: 20-25%), while NUCs may be safely discontinued in HBeAg-positive patients with stable HBeAg seroconversion. Because there will always be concerns for safety and family planning issues with long-term therapy, NUCs should be used judiciously and should not be prescribed in young CHB patients with mild liver disease.

Intraoperative radiofrequency ablation combined with 125iodine seed implantation for unresectable pancreatic cancer

AIM: To evaluate the feasibility, efficacy and safety of intraoperative radiofrequency ablation (RFA) combined with ¹²⁵iodine seed implantation for unresectable pancreatic cancer.

METHODS: Thirty-two patients (21 males and 11 females) at the age of 68 years (range 48-90 years) with unresectable locally advanced pancreatic cancer admitted to our hospital from January 2006 to May 2008 were enrolled in this study. The tumor, 4-12 cm in diameter, located in pancreatic head of 23 patients and in pancreatic body and tail of 9 patients, was found to be unresectable during operation. Diagnosis of pancreatic cancer was made through intraoperative biopsy. Patients were treated with FRA combined with ¹²⁵iodine seed implantation. In brief, a RFA needle was placed, which was confirmed by intraoperative ultrasound to decrease the potential injury of surrounding vital structures, a ¹²⁵iodine seed was implanted near the blood vessels and around the tumor border followed by bypass palliative procedure (cholangio-jejunostomy and/or gastrojejunostomy) in 29 patients.

RESULTS: The serum CA 19-9 level was decreased from 512 ± 86 U/mL before operation to 176 ± 64 U/mL, 108 ± 42 U/mL and 114 ± 48 U/mL, respectively, 1, 3 and 6 mo after operation (P < 0.05). The pain score on day 7 after operation, 1 and 3 mo after combined therapy was decreased from 5.86 ± 1.92 before operation to 2.65 ± 1.04, 1.65 ± 0.88 and 2.03 ± 1.16, respectively, after operation (P < 0.05). The rate of complete response (CR), partial response (PR), stable disease (SD), progressive disease (PD) in 32 patients was 21.8% (7/32), 56.3% (18/32), 15.6% (5/32) and 6.3% (2/32), respectively, 6 mo after operation, with a median overall survival time of 17. 5 mo. The median survival time of patients at stage III was longer than that of those at stage IV (19 mo vs 10 mo, P = 0.0026). The median survival time of patients who received and did not receive chemotherapy after operation was 20 mo and 16 mo, respectively (P = 0.0176). Of the 32 patients, 3 (10.6%) experienced postoperative complications including transient biliary leaks in 2 patients and acute pancreatitis in 1 patient. All the patients recovered well after conservative support treatment.

CONCLUSION: Intraoperative RFA combined with ¹²⁵iodine seed implantation is a feasible and safe procedure for unresectable pancreatic cancer with acceptable minor complications, and can prolong the survival time of patients, especially those at stage III.

Idiopathic orbital inflammatory syndrome without pain: a case report

BACKGROUND

Idiopathic orbital inflammatory syndrome (IOIS) is a collection of primary orbital inflammatory expressions manifested in a variety of clinical presentations. Because the process is idiopathic, it lacks association with neoplastic, infectious, or systemic immunologic and inflammatory diseases. Therefore, an extensive analysis is required to exclude secondary etiologies of orbital inflammation.

CASE REPORT

Exhibited is a case of a 68-year-old white man presenting with a recent history of viral conjunctivitis and acute complaints of monocular vision loss, epiphora, photophobia, and generalized irritation without pain. On examination, he was found to have chemosis, a serous retinal detachment, and choroidal detachments. Magnetic resonance imaging found evidence of dacryoadenitis, posterior scleritis, and mild diffuse orbital inflammation. Extensive history and physical examination found no evidence of systemic inflammatory disease. IOIS was diagnosed and treated successfully with prednisone, without recurrence.

CONCLUSIONS

Pain is historically considered a cardinal sign of acute inflammation and a predominant symptom of IOIS. The authors present a case of acute IOIS, atypical because of its presentation in the absence of pain. In addition, a review of the literature is conducted to identify predominant clinical and radiologic characteristics of IOIS along with current accepted and proposed treatment options. Differentials are discussed to distinguish this disease from systemic immunologic and inflammatory conditions such as syphilis, sarcoidosis, and Wegener's granulomatosis as well as potentially fatal neoplastic conditions.

Detection of Metabolites by Proton Ex Vivo NMR, in Vivo MR Spectroscopy Peaks and Tissue Content Analysis: Biochemical-Magnetic Resonance Correlation: Preliminary Results

*Aim*: Metabolite concentrations by in vivo magnetic resonance spectroscopy and ex vivo NMR spectroscopy were compared with excised normal human tissue relaxation times and tissue homogenate contents.*Hypothesis*: Biochemical analysis combined with NMR and MR spectroscopy defines better tissue analysis.

Materials and Methods:

Metabolites were measured using peak area, amplitude and molecular weights of metabolites in the reference solutions. In normal brain and heart autopsy, muscle and liver biopsy tissue ex vivo NMR peaks and spin-lattice (T1) and spin-spin (T2) relaxation times, were compared with diseased tissue NMR data in meningioma brain, myocardial infarct heart, duchene-muscular-dystrophy muscle and diffused-liver-injury liver after respective in vivo proton MR spectroscopy was done. NMR data was compared with tissue homogenate contents and serum levels of biochemical parameters.*Results*: The quantitation of smaller NMR visible metabolites was feasible for both ex vivo NMR and in vivo MR spectroscopy. Ex vivo H-1 NMR and in vivo MRS metabolite characteristic peaks (disease/normal data represented as fold change), T1 and T2, and metabolites in tissue homogenate and serum indicated muscle fibrosis in DMD, cardiac energy depletion in MI heart, neuronal dysfunction in meningioma brain and carbohydrate-lipid metabolic crisis in DLI liver tissues.*Conclusion*: This preliminary report highlights the biochemical-magnetic resonance correlation as basis of magnetic resonance spectroscopic imaging data interpretation of disease.