Systematic review with meta-analysis: endoscopic balloon dilatation for Crohn's disease strictures

BACKGROUND

Endoscopic balloon dilatation (EBD) is recognised treatment for symptomatic Crohn's strictures. Several case series report its efficacy. A systematic analysis for overall efficacy can inform the design of future studies.

AIM

To examine symptomatic (SR) and technical response (TR) and adverse events (AE) of EBD. Stricture characteristics were also explored.

METHODS

A systematic search strategy of COCHRANE, MEDLINE and EMBASE was performed. All original studies reporting outcomes of EBD for Crohn's strictures were included. SR was defined as obstructive symptom-free outcome at the end of follow-up, TR as post-dilatation passage of the endoscope through a stricture, and adverse event as the presence of complication (perforation and/or bleeding). Pooled event rates across studies were expressed with summative statistics.

RESULTS

Twenty-five studies included 1089 patients and 2664 dilatations. Pooled event rates for SR, TR, complications and perforations were 70.2% (95% CI: 60-78.8%), 90.6% (95% CI: 87.8-92.8%), 6.4% (95% CI: 5.0-8.2) and 3% (95% CI: 2.2-4.0%) respectively. Cumulative surgery rate at 5 year follow-up was 75%. Pooled unweighted TR, SR, complication, perforation and surgery rates were 84%, 45%, 15%, 9% and 21% for de novo and 84%, 58%, 22%, 5% and 32% for anastomotic strictures. Outcomes between two stricture types were no different on subgroup meta-analysis.

CONCLUSIONS

Efficacy and complication rates for endoscopic balloon dilatation were higher than previously reported. From the few studies with 5 year follow-up the majority required surgery. Future studies are needed to determine whether endoscopic balloon dilatation has significant long-term benefits.

Lack of effect of sacral nerve stimulation for incontinence in patients with systemic sclerosis

AIM

Systemic sclerosis (SSc) is a multisystem disorder of unknown aetiology leading to the deposition of excessive connective tissue in the skin, blood vessels and internal organs. Gastrointestinal involvement occurs in 90% of cases and the prevalence of faecal incontinence (FI) is 38%. This study comprises the largest case series assessing the efficacy of sacral nerve stimulation (SNS) treatment for incontinence in this patient group.

METHOD

A retrospective analysis on prospectively collected data was performed on all SSc patients from our two centres who had undergone SNS for FI.

RESULTS

Ten female patients of mean age of 54 (37-72) years had temporary SNS performed. The mean duration of FI was 13 (2-25) years. All had passive FI. Each patient had preprocedure anorectal physiology and endoanal ultrasound examinations documenting internal sphincter atrophy/fragmentation or reduced anal resting pressure. Overall there was no statistically significant difference (P = 0.57) in the total Wexner incontinence scores before (mean 15.1 ± 2.6 SD) and during temporary SNS procedures (mean 13.1 ± 3.6 SD). Two patients with a significant improvement went on to have permanent SNS with only one achieving a favourable outcome at 1 year.

CONCLUSION

This study showed that SNS failed to reduce episodes of leakage in nine out of 10 patients with systemic sclerosis affected with incontinence.

[Management of urinary tract infections in children. Recommendations of the Pediatric Infectious Diseases Group of the French Pediatrics Society and the French-Language Infectious Diseases Society]

Urine dipsticks have to be used more frequently for the screening of urinary tract infections (UTI) in febrile infants and children (grade A). Confirmation of the UTI by urine culture should prefer other methods of sampling than the urine bag: sampling jet, urethral catheterization, or pubic puncture (grade A). The percentage of Escherichia coli producing extended-spectrum beta-lactamases (ESBL) in children accounts for less than 10 % in France and does not justify revising the 2007 recommendations (grade B). An increase in the use of carbapenems in first-line treatment is a major environmental hazard and exposes the patient to the risk of untreatable infections. For febrile UTI, the expert group recommended: (1) recover the results of susceptibility testing as soon as possible to quickly adapt treatment for possible resistant strains; (2) favor initial treatment with aminoglycosides (particularly amikacin) which remain active in the majority of ESBL strains for patients seen in the pediatric emergency department and/or hospital; (3) ceftriaxone (IV or IM) remains an appropriate treatment for patients seen in the emergency department or outpatient clinic because the percentage of ESBL-producing enterobacteria strains remains low; (4) use oral cefixime (grade B) in nonsevere cases and low-risk patients defined as age>3 months, general condition preserved, disease duration of fever<4 days, no associated comorbidity, and no history of urinary tract infection, uropathy, or prior antibiotic therapy in the last 3 months; (5) oral relay for parenteral treatment is guided by in vitro susceptibility testing, in an attempt to reduce the use of oral cephalosporins to limit the selection of resistant bacterial strains. The total duration of treatment recommended is usually 10 days. Except for special circumstances, there is no need to prescribe retrograde cystography or antibiotic prophylaxis after a first febrile urinary tract infection. For cystitis, the panel recommends systematic urinalysis and initial prescription before the results of the urine culture of one of the three following oral antibiotics: amoxicillin-clavulanate, cotrimoxazole, cefixime. The total duration of antibiotic treatment is 5days to tailor treatment based on clinical progression and antibiotic susceptibility.

Evolution of the doping regimes in the Al-doped SnO2 nanoparticles prepared by a polymer precursor method

In this study, we report on the structural and hyperfine properties of Al-doped SnO2 nanoparticles synthesized by a polymer precursor method. The x-ray diffraction data analysis carried out using the Rietveld refinement method shows the formation of only rutile-type structures in all samples, with decreasing of the mean crystallite size as the Al content. A systematic study of the unit cell, as well as the vicinity of the interstitial position show strong evidence of two doping regimes in the rutile-type structure of SnO2. Below 7.5 mol% doping a dominant substitutional solution of Al(+3) and Sn(4+)-ions is determined. However, the occupation of both substitutional and interstitial sites is determined above 7.5 mol% doping. These findings are in good agreement with theoretical ab initio calculations.

Recurrence rates and clinical outcome for dogs with grade II mast cell tumours with a low AgNOR count and Ki67 index treated with surgery alone

Grade II mast cell tumours (MCT) are tumours with variable biologic behaviour. Multiple factors have been associated with outcome, including proliferation markers. The purpose of this study was to determine if extent of surgical excision affects recurrence rate in dogs with grade II MCT with low proliferation activity, determined by Ki67 and argyrophilic nucleolar organising regions (AgNOR). Eighty-six dogs with cutaneous MCT were evaluated. All dogs had surgical excision of their MCT with a low Ki67 index and combined AgNORxKi67 (Ag67) values. Twenty-three (27%) dogs developed local or distant recurrence during the median follow-up time. Of these dogs, six (7%) had local recurrence, one had complete and five had incomplete histologic margins. This difference in recurrence rates between dogs with complete and incomplete histologic margins was not significant. On the basis of this study, ancillary therapy may not be necessary for patients with incompletely excised grade II MCT with low proliferation activity.

Mid-luteal phase injection of subcutaneous leuprolide acetate improves live delivered pregnancy and implantation rates in younger women undergoing in vitro fertilization-embryo transfer (IVF-ET)

PURPOSE

To see if the single injection of one mg of the gonadotropin releasing hormone agonist (GnRHa) leuprolide acetate given in the mid-luteal phase can increase live delivered pregnancy and implantation rates. Furthermore the purpose was to determine if improvement was found, did the mechanism involve increased secretion of human chorionic gonadotropin (hCG).

MATERIALS AND METHODS

A prospective study was conducted in women aged 35 who were undergoing in vitro fertilization-embryo transfer (IVF-ET). They were advised of data from Tesarik et al. and a previous pilot study conducted in the present IVF center showing improved pregnancy rates with the injection of a GnRHa three days after embryo transfer. They were offered the option of returning for a one-mg injection s.c. of leuprolide acetate or not. Clinical and live delivered pregnancy rates were compared according to those taking or not the leuprolide acetate one-mg injection. Chi-square analysis was used for statistical comparisons. Serum beta-hCG levels were compared between those conceiving with or without the extra injection of leuprolide.

RESULTS

There was a non-significant trend for higher live delivered pregnancy rates in those taking leuprolide (47.8%, 64/134) vs. those not taking it (38.6%, 76/197). For those pregnant there was no difference in hCG levels according to taking the GnRHa or not.

CONCLUSIONS

The 25% increased live delivered pregnancy rate per transfer was insufficiently powered to detect a significant difference. The results do justify continuing the study. Perhaps the difference could be wider using a slightly older age group whose embryos are frequently less hearty.

The effect of oocyte reserve on pregnancy rates per oocyte harvest in women aged 36-39

PURPOSE

To determine the relative effect of diminished oocyte reserve on clinical viable and live delivered pregnancy rates per transfer and live delivery pregnancy rate per oocyte harvest in women aged 36-39.

MATERIALS AND METHODS

A retrospective comparison of pregnancy outcome was performed over a ten-year time period in women with normal oocyte reserve (day 3 serum FSH ≤ 11 mIU/mL) vs. diminished reserve (day 3 serum FSH ≥ 12 mIU/mL). Pregnancy rate per oocyte harvest equals the odds of conceiving with fresh or frozen embryos from a given retrieval before proceeding to another oocyte retrieval.

RESULTS

The clinical and viable (at end of first trimester) pregnancy rate per transfer was only 20% lower for the group with diminished oocyte reserve, but was 50% lower for the pregnancy rate per oocyte harvest.

CONCLUSIONS

Mild stimulation for women with diminished oocyte reserve allows a higher percentage of chromosomally normal embryos in women with diminished oocyte reserve, leading to only a 20% lower clinical and viable pregnancy rate per transfer. However, overall, there are less normal total number of normal embryos leading to a pregnancy rate per oocyte harvest only half as good in the group with lower reserve vs. normal.

Improved implantation and live delivered pregnancy rates following transfer of embryos derived from donor oocytes by single injection of leuprolide in mid-luteal phase

PURPOSE

To determine if the use of a single injection of one-mg leuprolide acetate in mid-luteal phase can increase pregnancy rates in donor oocyte recipients.

MATERIALS AND METHODS

Prospective study where couples were made aware of a study using the gonadotropin releasing hormone agonist (GnRHa) triptorelin that in the mid-luteal phase found improved pregnancy rates following embryo transfer in donor oocyte recipients. They were given the option of a single one-mg injection of the GnRHa leuprolide acetate. Pregnancy outcome was compared according to whether leuprolide was given or not. Also compared were the average first serum beta-hCG level in those who conceived according to taking leuprolide or not.

RESULTS

Chi-square analysis showed a significantly higher clinical and live delivered pregnancy rate (63.9% and 52.8%) in those supplementing with leuprolide than those who did not (39.5% and 32.9%). Similarly implantation rates were significantly higher (44.2% vs. 25.2%). The average first serum beta-hCG level for those conceiving and taking leuprolide was 294 mIU/mL vs. 325 mIU/mL for those who did not.

CONCLUSIONS

Similar to triptorelin the mid-luteal injection of leuprolide acetate improves pregnancy outcome in donor oocyte recipients.

Complete resolution of frozen shoulder syndrome in a woman treated with dextroamphetamine sulfate for chronic urinary urgency

PURPOSE

To evaluate the efficacy of dextroamphetamine sulfate for idiopathic frozen shoulder in a woman being treated for blad- der urgency and inability to lose weight despite dieting.

MATERIALS AND METHODS

Dextroamphetamine sulfate was initiated at 15 mg extended release capsules increasing to 25 mg extended release capsules to a 47-year-old woman.

RESULTS

She lost 19 pounds in four months, her bladder urgency disappeared, and she had complete resolution of the idiopathic frozen shoulder problem.

CONCLUSIONS

Idiopathic frozen shoulder syndrome can be added to the long list of conditions that are related to hypofunction of the sympathetic nervous system and all respond to dextroamphetamine sulfate therapy. They gynecologist is more familial with this syndrome be- cause of it being the main cause of pelvic pain. Thus the gynecologist may become the physician who subsequently treats orthopedic or rheumatological problems or other health issues.

Sexual infantilism in a normal karotypic female related to ovarian agenesis associated with Müllerian agenesis--Case report

PURPOSE

To describe an unusual case of Müllerian agenesis associated with gonadal agenesis and thus sexual infantilism.

MATERIALS AND METHODS

Pelvic magnetic resonance imaging (MRI) and sonography were performed and MRI of the kidneys. Pelvic sonography and serum follicle stimulating hormone (FSH) were also obtained.

RESULTS

The only pelvic organ that this 15-year-old girl had was the distal portion of the vaginal canal. The kidneys were normal.

CONCLUSIONS

This case suggests that at least in some cases some possible viral damaging process may lead to damage to both the ovaries and the Müllerian system. If there was a problem with the anti-Müllerian hormone (AMH), the kidney may be affected. Furthermore, AMH has nothing to do with the ovaries and a chance association of these two entities though possible, seems less likely than a common factor causing both problems.

The effect of conventional vs. mild ovarian hyperstimulation on the total number of live babies born from a given oocyte retrieval

PURPOSE

To compare pregnancy outcome in women with normal oocyte reserve according to whether they received conventional or mild follicle stimulating hormone (FSH) controlled ovarian hyperstimulation (COH) further stratified by age.

MATERIALS AND METHODS

A ten-year retrospective study including all cycles (even multiple in given patients) was performed. Mild stimulation including all cycles initiated and continued with 150 IU FSH or less from early follicular phase. Everything else was considered conventional stimulation. Mild stimulation included natural cycles or those with just a boost of 75 IU FSH from the mid to late follicular phase. Only women with normal oocyte reserve were selected--serum FSH < 12 mIU/mL and serum E2 < 50 pg/mL. Live delivered pregnancy rates within three age groups (≤ 35, 36-39, and 40-42 years) were compared per embryo transfer and per embryo retrieval, i.e., the percentage of women having a live baby without proceeding to another IVF-ET cycle. Also compared were the average number of babies born from one retrieval.

RESULTS

For aged ≤ 35 there were no differences in pregnancy rates per transfer but a trend for higher pregnancy rates per retrieval with conventional stimulation. For all other age groups both pregnancy rates per transfer and retrieval were significantly higher with conventional stimulation. This was reflected with a higher average number of babies born per retrieval with conventional.

CONCLUSIONS

For women with normal oocyte reserve in general, there is no advantage of mild vs. conventional COH other than cost saving. Of course there are exceptions, e.g., ovarian hyperstimulation with conventional COH.

An update on the treatment of female alopecia and the introduction of a potential novel therapy

PURPOSE

To review treatment options for hair loss in women.

MATERIALS AND METHODS

Suggestions for treatment were based on a thorough literature search plus the present authors' experience.

RESULTS

There are controlled studies that support the present authors' typical treatment regimen of identifying if there are increased androgens, and if so, identify the source (ovary and/or adrenal) and then suppress with drugs, e.g., oral contraceptives or glucocorticoids. If serum androgens are normal, agents that block dihydrotestosterone at the hair shaft level, e.g., spironolactone or 5a reductase inhibitors seem to be effective. However, a recent Cochrane systematic review concludes that the only drug proven to improve alopecia by randomized controlled studies using rigorous criteria is minoxidil.

CONCLUSIONS

The present authors will add minoxidil to their normal treatment paradigm based on this later study. The previous reasons for it was the quality of the hair produced (generally much shorter than other head hair). For alopecia related to inflammation, the present authors may have discovered a novel therapy--dextroamphetamine sulfate.

The effect of a rise or fall of serum estradiol the day before oocyte retrieval in women aged 40-42 with diminished egg reserve

PURPOSE

To determine the effect of a drop in serum estradiol the day after injection of human chorionic gonadotropin (hCG) in in vitro fertilization-embryo transfer (IVF-ET) cycles in women aged 40-42 with diminished oocyte reserve.

MATERIALS AND METHODS

Retrospective study with further requirement that the female partner had a day 3 serum follicle stimulating hormone (FSH) of ≥ 12 miU/mL and ≥ five antral follicles.

RESULTS

A drop in serum estradiol the day after hCG injection is not associated with a lower chance of pregnancy compared to those women whose serum estradiol increases. However, their chances of releasing the oocyte before retrieval is significantly higher.

CONCLUSIONS

A drop in serum estradiol in women of advanced reproductive age with diminished oocyte reserve should not signal the need to cancel the retrieval.

Frailty Clinical Phenotype: A Physical and Cognitive Point of View

Frailty is recognized as a clinical geriatric syndrome used to describe the weakest or most vulnerable older adults. Although the term frailty is commonly used in clinical practice, and the theoretical phenomenon is well accepted, it remains an evolving concept that lacks a universally accepted definition and specific diagnostic criteria. Different perspectives on frailty have led to two distinct viewpoints of this phenomenon in the literature. The first describes the phenomenon based solely on physical attributes and capabilities. In contrast, more recent perspectives describe the phenomenon in broader, multidimensional terms by incorporating the concept of cognitive frailty. In support of this view, there is increasing evidence that consideration of both cognitive and physical factors can better improve the ability to predict adverse health outcomes among frail older adults over physical factors alone. The recent recognition of the importance of cognitive factors has increased the complexity of this phenomenon and difficulty in developing a consensus definition. To add to this challenge, frailty can present in different stages of severity (from mild to severe), and there appears to be a dynamic relationship between these stages. Despite these challenges, a consensus on an international definition of frailty including physical and cognitive criteria is essential in order to advance research and treatment of this condition.

Effect of taking a one time injection of one mg leuprolide acetate three days after embryo transfer on pregnancy outcome and level of first beta human chorionic gonadotropin (beta-hCG) level

PURPOSE

To determine if the injection of a gonadotropin releasing hormone agonist (GnRHa) three days after embryo transfer will improve pregnancy and implantation rates.

MATERIALS AND METHODS

One mg s.c. of leuprolide acetate was randomly given based on patient decision three days after embryo transfer to some patients undergoing in vitro fertilization-embryo transfer (IVF-ET).

RESULTS

For women aged ≤ 43 the clinical pregnancy rate for those not taking the GnRHa was 39.5% (68/122) vs. 54.5% (42/77) for those taking leuprolide acetate (Chi-square, p = 0.0275). The respective implantation rates were 22.6% vs. 30.2% (p = 0.0495). There was no difference in first serum beta human chorionic gonadotropin (beta-hCG) levels according to whether leuprolide was used or not.

CONCLUSIONS

Leuprolide acetate similar to other GnRH agonists can improve implantation rates following IVF-ET when injected once in mid-luteal phase. The beneficial effect may be on GnRH receptors in the endometrium rather than the embryo (which had been hypothesized to direct increased placental production of hCG).