Role of ultrasonography in the diagnosis of postsurgical recurrence of Crohn's disease

OBJECTIVE

Ultrasonography is a valid tool in the diagnosis of Crohn's disease, but its sensitivity, specificity, and overall accuracy in the diagnosis of postoperative recurrence are still not well established. The aim of this study was to evaluate the accuracy of ultrasonography compared with endoscopy in the diagnosis of postoperative recurrence of Crohn's disease.

METHODS

Forty-seven patients resected for Crohn's ileitis were studied by ultrasonography and colonoscopy to detect possible recurrence of the disease; 10 patients operated on for cancer of the right colon were used as controls. Six patients with Crohn's disease were excluded from the study because of failure to endoscopically reach the anastomosis; the remaining 41 patients had both ultrasonography and colonoscopy over a period of 14 days. Sonographic recurrence was defined as the presence of >5 mm thickness of the ileal wall.

RESULTS

Sensitivity, specificity, and overall accuracy of ultrasonography in diagnosis of postoperative recurrence were 81%, 86%, and 83% respectively. Positive predictive value was 96% and negative predictive value was 57%.

CONCLUSION

This study is the first to assess the role of ultrasonography in comparison with endoscopy in detecting Crohn's disease recurrence after surgery. Our data suggest that ultrasonography should be used first in the case of clinical suspicion of Crohn's disease recurrence, reserving ileocolonoscopy for negative or uncertain cases.

Body composition and androgen pattern in the early period of postmenopause

Body composition is related to age, genetic factors, and hormonal patterns throughout life, Peak bone mass seems to be an important protective factor against osteoporosis, although diet and life-style (smoking, physical activity) are able to influence bone mass. While it is well known that estrogens exert a protective action against bone loss in postmenopausal women, the role of androgens is still not clear. Twenty-five women in the early postmenopausal period (age: 52.8 +/- 5.1 years) were measured by dual-energy x-ray absorptiometry (DXA) to assess the relationship between body composition (fat mass and lean mass), bone mineral content (BMC), bone mineral density (BMD) and androgen pattern. Waist/hip ratio was used to divide the study population in three groups: gynecoid (gluteo-femural fat distribution), android abdominal fat distribution), and intermediate. In all subjects an inverse significant correlations between estradiol and fat mass was found. In the abdominal fat distribution group significant correlations between estradiol and weight (inversely correlated), androstenedione and BMD, learn mass an BMC were found. The data show the important role of androgens (androstenedione, particularly) and lean body mass on the BMD and BMC, respectively, in the early period of postmenopause.

Risk of inflammatory bowel disease attributable to smoking, oral contraception and breastfeeding in Italy: a nationwide case-control study. Cooperative Investigators of the Italian Group for the Study of the Colon and the Rectum (GISC)

BACKGROUND

Using data from a case-control study carried out in Italy 1989-1992, we estimated the odds ratios (OR) and the population attributable risks (AR) for inflammatory bowel diseases (IBD) in relation to smoking, oral contraception and breastfeeding in infancy.

METHODS

The study focused on 819 cases of IBD (594 ulcerative colitis: UC; 225 Crohn's disease: CD) originating from populations resident in 10 Italian areas, and age-sex matched paired controls.

RESULTS

Compared with non-smokers, former smokers were at increased risk of UC (OR = 3.0; 95% confidence interval [CI]: 2.1-4.3), whereas current smokers were at increased risk of CD (OR = 1.7; 95% CI: 1.1-2.6). Females who reported use of oral contraceptives for at least one month before onset of symptoms had a higher risk of CD (OR = 3.4; 95% CI: 1.0-11.9), whereas no significant risk was observed for UC. Lack of breastfeeding was associated with an increased risk of UC (OR = 1.5; 95% CI: 1.1-2.1) and CD (OR = 1.9; 95% CI: 1.1-3.3). Being a 'former smoker' was the factor with the highest attributable risk of UC both in males (AR = 28%; 95% CI: 20-35 %) and in females (AR = 12%; 95% CI: 5-18%). Smoking was the factor with the highest attributable risk for CD in males (AR = 31%; 95% CI: 11-50%). Lack of breastfeeding accounted for the highest proportion of CD in females (AR = 11%; 95% CI: 1-22%). Oral contraceptive use accounted for 7% of cases of UC and for 11% of cases of CD.

CONCLUSIONS

Taken together, the considered factors were responsible for a proportion of IBD ranging from 26% (CD females) to 36% (CD males). It is concluded that other environmental and genetic factors may be involved in the aetiology of IBD.

Analytic assessment of the various bioimpedance methods used to estimate body water

Knowledge of patient fluid distribution would be useful clinically. Both single-frequency (SF) and impedance modeling approaches are proposed. The high intercorrelation between body water compartments makes determining the best approach difficult. This study was conducted to evaluate the merits of an SF approach. Mathematical simulation was performed to determine the effect of tissue change on resistance and reactance. Dilution results were reanalyzed, and resistance and parallel reactance were used to predict the intracellular water for two groups. Results indicated that the amount of intracellular and extracellular water conduction at any SF can vary with tissue change, and reactance at any SF is affected by all tissue parameters. Modeling provided a good prediction of dilution intracellular and extracellular water, but an SF method did not. Intracellular, extracellular, and total body water were equally predicted at all frequencies by SF resistance and parallel reactance. Extracellular and intracellular water are best measured through modeling, because only at the zero and infinite frequencies are the results sensitive only to extracellular and intracellular water. At all other frequencies there are other effects.

Fat-free mass by bioelectrical impedance vs dual-energy X-ray absorptiometry (DXA)

Body composition (BC) assessment is a useful tool for a careful evaluation of nutrition status. Bioelectrical impedance analysis (BIA) is a safe, low-cost and reliable method for BC assessment. For epidemiological and clinical research in children, paediatric-age specific formula for fat-free mass (FFM) prediction from BIA is needed. Thus, in 35 children (age 7.7-13.0 years) with different levels of body fatness (relative weight for age 70.6-133.8%), FFM was calculated from dual-energy X-ray absorptiometry (DXA). A regression equation from BIA and DXA data was elaborated. The impedance index (ZI = height2/bioelectrical impedance) was the strongest predictor of FFM, explaining 89% of its variance. However, the variance increased to 96% when body weight was added with ZI in the regression model. No variable, including sex and age, contributed to the prediction of FFM in the presence of ZI and body weight. The regression formula [FFM = 2.330 + 0.588 ZI (cm2/omega) + 0.211 Weight (kg) (r = 0.96, SEE = 1.0 kg)], allows a reliable prediction of FFM in children from body impedance values.

Cardiologic complications of subarachnoid hemorrhage

Cardiac complications are frequent in patients with subarachnoid hemorrhage (SAH). They include ECG abnormalities, cardiac arrhythmias, myocardial damage, and neurogenic pulmonary edema. The pathophysiology of these abnormalities is related to an imbalance of the autonomic cardiovascular control and to increased circulating and local myocardial tissue catecholamines. Cardiac involvement is more common in patients with severe neurological deficits and it may increase the morbidity associated with SAH because of the occurrence of life-threatening arrhythmias or pulmonary edema. Monitoring of cardiac events in patients with SAH might result in a better understanding of their clinical outcome, as well as providing a basis for specific treatment capable of preventing myocardial necrosis and cardiac arrhythmias.

Validity of diurnal sleep recording performed by an ambulatory device in the diagnosis of obstructive sleep apnoea

The objective of this study was to compare the results of oxygen desaturations and sleep apnoea during a daytime nap (D) versus nocturnal sleep (N) evaluation, recorded by a portable multichannel monitoring device in patients with a clinical suspicion of obstructive sleep apnoea (OSA). Two polysomnographic studies were performed, by means of the Healthdyne NightWatch System, in 82 subjects (mean age 57.9 years). No difference was found in the apnoea + hypopnoea index (AHI) and mean SaO2 between D and N recordings. At an AHI threshold of 20, in the D recordings, compared to the N ones, the sensitivity was 91% and the specificity 100%. A good correlation was found for AHI and oxygen desaturation index (ODI) between the two experimental conditions (r = 0.89 and 0.79, respectively). Our study shows that D recordings seem to be accurate for OSA diagnosis in the majority of patients with a clinical suspicion of sleep apnoea syndrome.

Whole body and regional body composition analysis by dual-energy X-ray absorptiometry in cirrhotic patients

OBJECTIVES

To compare whole body and regional (arms, legs and trunk) fat mass, fat-free mineral-free mass bone mineral content and bone mineral density, measured by DXA, in cirrhotic patients and age, sex and BMI matched healthy volunteers.

DESIGN

Cross-sectional study.

SETTING

Two medical research institutions.

SUBJECTS

Twenty-two non ascitic cirrhotic patients and 16 age, sex and BMI matched healthy volunteers.

INTERVENTIONS

The Lunar DPX whole-body X-ray densitometer with Lunar software version 3.6z (Lunar Radiation Corp., Madison WI, USA) was used. Regional analysis was performed on the arms, legs, trunk and head.

RESULTS

Compared to controls, cirrhotic patients showed a significant reduction in percentage body fat. When differentiated by gender, however, the reduction in percentage body fat was evident in female cirrhotics only, particularly in the trunk. In male cirrhotic patients fat-free mineral-free mass was reduced in absolute terms in the whole body and the limbs. For both genders and in each body segment bone mineral content and density were reduced in cirrhotics compared to controls. In cirrhotic patients bone mineral density was significantly correlated to both fat-free, mineral-free mass (r = 0.85; P < 0.001) and to the Physical Activity Index (r = 0.52; P < 0.01).

CONCLUSIONS

Two different patterns of soft tissue loss may be found in cirrhotic patients: in women lean tissue is maintained while fat stores are reduced, as in early starvation; in men lean tissue is reduced, as seen under conditions of stress. Moreover, factors influencing lean body mass, such as nutritional depletion and physical inactivity, may contribute to the reduction of bone density frequently observed in cirrhotic patients.

Low-grade adenocarcinoma of endolymphatic sac mimicking jugular paraganglioma at clinical and neuroradiological examination

We report a case of low-grade adenocarcinoma of endolymphatic sac origin mimicking jugular paraganglioma at clinical and neuroradiological examination. The lesion occurred in a 72-year-old male who presented with a long-standing history of right-sided hearing loss and a few-week history of progressive facial nerve palsy and right aural pain. At histology, the tumor was composed of pseudoglandular spaces with papillary infoldings. Lumina contained colloid-like material. The lesion was surgically removed with suboccipital approach following endoarterial embolization. This study emphasizes that low-grade adenocarcinomas of endolymphatic sac origin extending to posterior cranial fossa and jugular paraganglioma may be indistinguishable preoperatively at clinical and radiological levels.

Assessment of body hydration in subjects with schistosomiasis

Total body water (TBW) was measured by deuterium oxide dilution (D2O) and predicted by bioelectric impedance analysis (BIA) (Deurenberg, Schouten, Andreoli and De Lorenzo 1993) in 21 subjects with Schistosoma mansoni infection and 17 healthy controls of similar age (32.8 +/- 13.7 years, n=38). Patients were selected to have no visible fluid retention and no cardiac or renal abnormalities. Body hydration (TBW per kg of body weight) was significantly higher in patients with schistosomiasis than in controls (62.9 +/- 3.6 vs 57.4 +/- 4.3%, p < 0.0005). A significant correlation was found between albumin levels and TBW% on the pooled sample (n=38; r=0.660, p < 0.0001). This relationship was not influenced by the presence of disease, as determined by ANCOVA. Values of TBW predicted by BIA were highly correlated and not significantly different (p=n.s., ANOVA) from those measured by D2O in both controls and patients (r=0.854, p < 0.001, SEE = 2.3 1, CV=5.9% and r=0.848, p < 0.001, SEE=4.0 1, CV=9.3%, respectively). The bias (TBW by BIA - TBW by D2O) was of 0.9 +/- 3.7 in controls and of -1.3 +/- 4.2 1 in patients. This bias was significantly correlated to TBW% in patients (r=0.575, p < 0.05) but not in controls (p=n.s.). It is concluded that subjects with schistosomiasis show an apparent subclinical increase in body hydration which could affect the prediction of TBW from BIA.

Predicting body cell mass with bioimpedance by using theoretical methods: a technological review

The body cell mass (BCM), defined as intracellular water (ICW), was estimated in 73 healthy men and women by total body potassium (TBK) and by bioimpedance spectroscopy (BIS). In 14 other subjects, extracellular water (ECW) and total body water (TBW) were measured by bromide dilution and deuterium oxide dilution, respectively. For all subjects, impedance spectral data were fit to the Cole model, and ECW and ICW volumes were predicted by using model electrical resistance terms RE and Rt in an equation derived from Hanai mixture theory, respectively. The BIS ECW prediction bromide dilution was r = 0.91, standard error of the estimate (SEE) 0.90 liter. The BIS TBW prediction of deuterium space was r = 0.95, SEE 1.33 liters. The BIS ICW prediction of the dilution-determined ICW was r = 0.87, SEE 1.69 liters. The BIS ICW prediction of the TBK-determined ICW for the 73 subjects was r = 0.85, SEE = 2.22 liters. These results add further support to the validity of the Hanai theory, the equation used, and the conclusion that ECW and ICW volume can be predicted by an approach based solely on fundamental principles.

Impedance ratio as a measure of water shifts

Total and segmental body compositions (left arm and left leg) were measured by bioelectrical impedance analysis at 5 and 100 kHz and by dual-energy X-ray absorptiometry (DXA) in 14 healthy young males (body mass index, mean +/- SD, 23.5 +/- 2.7 kg/m2) every 20 min for a period of 100 min. During the measurements the subjects remained in the supine position on the examination table, except for the time between the last two measurements, where they got up to walk around. This study focuses on the impact of orthostatic fluid shifts on impedance ratios in body segments and the total body. After 20 min of lying supine lean tissue (DXA) was slightly but significantly lower for the total body and the left leg, but all other consecutive DXA measurements at different times did not differ. Total body impedance and leg impedance increased during the time the subjects were in the recumbent position. Impedance changes in the leg were more pronounced than in the total body, and at 5 kHz the changes were more pronounced compared to 100 kHz. After the subjects got up the impedance values again decreased. Impedance ratios (Z5/Z100) increased for both the leg and to a lesser extent for the total body during the time lying supine, but again decreased after getting up. The results of this study indicate a fluid shift from the legs to the trunk after lying supine and show that this fluid shift is mainly extracellular water. DXA measurements were not able to detect these changes, probably because the magnitude of these changes is below the detection level for lean tissue with DXA methodology. The observations have important implications in the interpretation of impedance measurements in the clinical situation when measurements are made in patients who have been reclining for some time.

Recent benzodiazepine use in depressed patients: a confound of psychoimmunologic studies?

Several studies have indicated that benzodiazepines influence immunity in both animals and humans. As these medications are commonly utilized by and for psychiatric patients, investigation of psycho-immunologic relationships in human psychiatric disorders may be confounded by use of these medications.

METHOD

We undertook an investigation for possible effects of recent benzodiazepine use on depression-immune relationships by comparing 43 patients with current major depressive disorder (MDD) who used benzodiazepines in the week prior to study to 27 patients with current MDD but no use of benzodiazepines in the past month. Both functional and ennumerative measures were investigated.

RESULTS

We found no differences in absolute numbers of lymphocytes or the lymphocyte and NK functional measures. We did find differences between these two groups in the percentage of lymphocytes and of NK cells. Upon further analysis, controlling for symptom severity, these differences were shown to not be independently predicted by benzodiazepine use.

CONCLUSION

Immune measures in subjects with current MDD and recent benzodiazepine use did not differ from those without such recent use. Therefore, such recent use is unlikely to confound PNI results.

An antibiotic regimen for the treatment of active Crohn's disease: a randomized, controlled clinical trial of metronidazole plus ciprofloxacin

OBJECTIVES

Bacteria in the gut lumen may play a role in the etiology and/or the symptoms of Crohn's disease (CD). Although various antibacterial drugs have been employed in clinical practice, few controlled trials have been conducted, and those had conflicting results. The aim of this study was to investigate the efficacy and the safety of a combination of metronidazole and ciprofloxacin, compared with methylprednisolone, in treating 41 consecutive patients with active CD.

METHODS

Eligible patients, 13 men and 28 women, mean age 38 yr, were randomly allocated to receive, for 12 wk, ciprofloxacin 500 mg twice daily plus metronidazole 250 mg four times daily or methylprednisolone 0.7-l mg/kg/day, with variable tapering to 40 mg, followed by tapering of 4 mg weekly.

RESULTS

Ten of the 22 antibiotic patients (45.5%) and 12 of the 19 steroid patients (63%) obtained clinical remission (Crohn's Disease Activity Index < or = 150) at the end of the 12-wk study (p = NS). Five patients on antibiotics (22.7%) and five patients on steroids (26.3%) were considered treatment failures because of deterioration or persistent symptoms. Six patients receiving antibiotics (27.3%) and two on steroids (10.6%) were withdrawn from the trial because of side effects. One patient on antibiotics was not compliant.

CONCLUSIONS

metronidazole and ciprofloxacin could be an alternative to steroids in treating the acute phase of CD.

Multi-frequency bioelectrical impedance: a comparison between the Cole-Cole modelling and Hanai equations with the classical impedance index approach

Total body water and extracellular water were measured by deuterium oxide and bromide dilution respectively in 23 healthy males and 25 healthy females. In addition, total body impedance was measured at 17 frequencies, ranging from 1 kHz to 1350 kHz. Modelling programs were used to extrapolate impedance values to frequency zero (extracellular resistance) and frequency infinity (total body water resistance). Impedance indexes (height2/Zf) were computed at all 17 frequencies. The estimation errors of extracellular resistance and total body water resistance were 1% and 3%, respectively. Impedance and impedance index at low frequency were correlated with extracellular water, independent of the amount of total body water. Total body water showed the greatest correlation with impedance and impedance index at high frequencies. Extrapolated impedance values did not show a higher correlation compared to measured values. Prediction formulas from the literature applied to fixed frequencies showed the best mean and individual predictions for both extracellular water and total body water. It is concluded that, at least in healthy individuals with normal body water distribution, modelling impedance data has no advantage over impedance values measured at fixed frequencies, probably due to estimation errors in the modelled data.

Comparison of the body composition of age-matched Italian, Ukrainian, and Dutch children

In the present study, the body composition was measured in 35 Ukrainian children, 14 boys and 21 girls, aged 8-12 years, by dual-energy X-ray absorptiometry (DEXA), anthropometry, and bioelectrical impedance. The results were compared with those obtained from a sample of the same number of Italian and Dutch children of the same sex and range of age. The Ukrainian children were slightly smaller, had a lower body weight, and had a lower body fat percentage, as measured by skinfolds, as compared with the Italian and Dutch children, as well as a lower calculated fat-free mass (FFM) by impedance. Comparison between FFM as determined by different methods in the Ukrainian children showed that all assessed values differed significantly. In particular, all methods overestimated the FFM as compared with DEXA, but the differences between DEXA and the other methods were not dependent on the level of FFM as determined by DEXA. Furthermore, the difference between predicted FFM and FFM values obtained by DEXA was correlated for skinfolds and body mass index (r = 0.77, p < 0.01), but not for body mass index and impedance, or skinfolds and impedance. The mean differences were 1.8 +/- 1.5 for body mass index, 1.0 +/- 1.4 for impedance, and 3.6 +/- 1.6 for skinfolds. Some differences in the body composition have also been found between boys and girls. The boys had higher values of lean tissue (23.3 +/- 3.1 vs. 20.7 +/- 3.3; p < 0.01) and FFM (24.5 +/- 3.3 vs. 21.8 +/- 3.5; p < 0.01) as compared with the girls and slightly higher values of bone mineral content. It should be noted, however, that the differences between different groups and different methods are always small, even when they are statistically significant.

[Levels of the training of psychotherapists and results of analytic psychotherapy]

The purpose of this study was to investigate therapists experience as predictor of psychotherapy outcome. We studied consecutive patients (n = 76) assigned to psychoanalytic psychotherapy after being referred to the Geneva University Psychiatric Center for psychiatric treatment. Fifty-seven subjects were treated by trainees and nineteen had certified psychotherapists. Each treatment was carefully evaluated at intake, at the sixth session and at 1-year follow-up. Those patients treated by trainees appeared to be clearly improved (p < 0.01), but 49.1% of them did not completed the psychotherapy. In addition, increased therapist's training and experience (certified psychotherapist vs trainee) was associated with better global outcome, reduced early termination and more improvement after six psychotherapy sessions (p < 0.01). The present data indicate that increased therapist's experience is associated with more compliance and more improvement after the initial phase of the treatment in psychiatric subjects assigned to psychoanalytical psychotherapy.

Crisis intervention and affective disorders: a comparative cost-effectiveness study

In recent years, psychiatric institutions have been increasingly urged to justify their clinical policies in order to ensure both effective treatment and efficient management. Assessment instruments for effectiveness and costs are essential to respond to these needs. The aim of this study was to determine the cost-effectiveness of treatments for major depressive disorders. We conducted a comparative pilot investigation of treatment costs in patients with a major depressive episode assigned to specialised out-patient crisis intervention, to specialised in-patient treatment and to standard mental hospital care. The study included 122 subjects. The inclusion criteron was a diagnosis of DSM-III-R major depressive episode. Costs were assessed by determining the average cost for each treatment and the modalities of payment systems. Treatment duration and costs were high, but specialised crisis intervention may considerably reduce the duration of hospitalisation and its associated costs. The average costs of treating major depression were about 4 times greater in the specialised hospital unit than in the standard hospital unit and the crisis intervention centre. The burden of payment was comparatively higher for the state and reduced for insurance companies when the treatment of major depressive disorders involved less in-patient care.

Improved prediction formula for total body water assessment in obese women

OBJECTIVE

To validate an improved formula for the calculation of total body water (TBW) from impedance values in obese women.

SUBJECTS

A sample of 37 overweight females BMI ranging from 29.5 to 44.1 kg/m2.

MEASUREMENTS

The reference measurements for TBW were obtained by deuterium oxide dilution. Body height (h), hip circumference (C) as well as body impedance at 100 kHz (Z100) were also measured.

RESULTS

The values obtained for h, C and Z100 were introduced in the calculations and the following developed formula for total body water was determined: TBW = 0.069 [hC2/(4 pi .Z100)]+19.671. The validity of this formula was assessed through the statistical test of Bland and Altman which we also performed for other formulas containing the weight and/or the height.

CONCLUSION

We found that the accuracy of the prediction of TBW by our formula, although lower than those formulas using body weight, is higher than that which takes into account only body height. We conclude that body volume, expressed through body height and hip circumference, is a good choice of parameter in bioelectrical impedance measurements. The new approach can be useful in clinical settings for repeated monitoring of obese women, during diet-restricted treatment.