Standardisation of intestinal ultrasound scoring in clinical trials for luminal Crohn's disease

BACKGROUND

Intestinal ultrasound (IUS) is a valuable tool for assessment of Crohn's disease (CD). However, there is no widely accepted luminal disease activity index.

AIMS

To identify appropriate IUS protocols, indices, items, and scoring methods for measurement of luminal CD activity and integration of IUS in CD clinical trials.

METHODS

An expert international panel of adult and paediatric gastroenterologists (n = 15) and radiologists (n = 3) rated the appropriateness of 120 statements derived from literature review and expert opinion (scale of 1-9) using modified RAND/UCLA methodology. Median panel scores of 1 to ≤3.5, >3.5 to <6.5 and ≥6.5 to 9 were considered inappropriate, uncertain and appropriate ratings respectively. The statement list and survey results were discussed prior to voting.

RESULTS

A total of 91 statements were rated appropriate with agreement after two rounds of voting. Items considered appropriate measures of disease activity were bowel wall thickness (BWT), vascularity, stratification and mesenteric inflammatory fat. There was uncertainty if any of the existing IUS disease activity indices were appropriate for use in CD clinical trials. Appropriate trial applications for IUS included patient recruitment qualification when diseased segments cannot be adequately assessed by ileocolonoscopy and screening for exclusionary complications. At outcome assessment, remission endpoints including BWT and vascularity, with or without mesenteric inflammatory fat, were considered appropriate. Components of an ideal IUS disease activity index were identified based upon panel discussions.

CONCLUSIONS

The panel identified appropriate component items and applications of IUS for CD clinical trials. Empiric evidence, and development and validation of an IUS disease activity index are needed.

How to perform gastrointestinal ultrasound: Anatomy and normal findings

Gastrointestinal ultrasound is a practical, safe, cheap and reproducible diagnostic tool in inflammatory bowel disease gaining global prominence amongst clinicians. Understanding the embryological processes of the intestinal tract assists in the interpretation of abnormal sonographic findings. In general terms, the examination principally comprises interrogation of the colon, mesentery and small intestine using both low-frequency and high-frequency probes. Interpretation of findings on GIUS includes assessment of bowel wall thickness, symmetry of this thickness, evidence of transmural changes, assessment of vascularity using Doppler imaging and assessment of other specific features including lymph nodes, mesentery and luminal motility. In addition to B-mode imaging, transperineal ultrasonography, elastography and contrast-enhanced ultrasonography are useful adjuncts. This supplement expands upon these features in more depth.

WFUMB Position Paper. Learning Gastrointestinal Ultrasound: Theory and Practice

Gastrointestinal ultrasound (GIUS) is an ultrasound application that has been practiced for more than 30 years. Recently, GIUS has enjoyed a resurgence of interest, and there is now strong evidence of its utility and accuracy as a diagnostic tool for multiple indications. The method of learning GIUS is not standardised and may incorporate mentorship, didactic teaching and e-learning. Simulation, using either low- or high-fidelity models, can also play a key role in practicing and honing novice GIUS skills. A course for training as well as establishing and evaluating competency in GIUS is proposed in the manuscript, based on established learning theory practice. We describe the broad utility of GIUS in clinical medicine, including a review of the literature and existing meta-analyses. Further, the manuscript calls for agreement on international standards regarding education, training and indications.

Novel association of achalasia with hereditary sensory and motor neuropathy with sensorineural deafness

Achalasia is a primary esophageal motility disorder. Unlike diffuse esophageal spasm, it has not previously been described in association with hereditary sensory and motor neuropathy (HSMN). An 18-year-old-male with HSMN with sensorineural deafness presented with a 2-day history of dysphagia to solids and liquids. Achalasia was diagnosed after extensive investigations, and his symptoms resolved with endoscopic and definitive surgical management. His monozygotic twin brother had also been diagnosed with HSMN and suffered from chronic dysphagia, which was also subsequently diagnosed with achalasia. This is the first case to illustrate an association between HSMN with sensorineural deafness and achalasia.

Splanchnic Hemodynamics and Intestinal Vascularity in Crohn's Disease: An In Vivo Evaluation Using Doppler and Contrast-Enhanced Ultrasound and Biochemical Parameters

Crohn's disease (CD) is characterized by inflammation and angiogenesis of affected bowel. We evaluated the correlation among vascularity of intestinal wall in CD, splanchnic hemodynamics, clinical activity and biochemical parameters of inflammation and angiogenesis. Sixteen patients with ileal CD and 10 healthy controls were investigated by means of Doppler ultrasound of the superior mesenteric artery and color Doppler and contrast-enhanced ultrasound of the ileal wall. In parallel, serum levels of vascular endothelial growth factor, tumor necrosis factor-α (TNF-α) and nitric oxide, before and 30 min after a standard meal, were evaluated. In CD patients, there was a significant post-prandial reduction in the resistance index and pulsatility index of the superior mesenteric artery, associated with increased levels of nitric oxide and decreased amounts of TNF-α. A correlation was observed between vascular endothelial growth factor and contrast-enhanced ultrasound parameters of intestinal wall vascularity (r = 0.63-0.71, p < 0.05) and between these parameters and superior mesenteric artery blood flow after fasting (resistance and pulsatility indexes: r = -0.64 and -0.72, p < 0.05). Our results revealed a post-prandial increase in nitric oxide and decrease in TNF-α in CD patients in vivo. They also confirm the role of vascular endothelial growth factor in angiogenesis and in pathologic vascular remodeling of CD and its effect on splanchnic blood flow.

Irritable bowel syndrome in quiescent inflammatory bowel disease: a review

Ongoing troublesome bowel symptoms despite quiescent inflammatory disease are a frequent management challenge when caring for patients with inflammatory bowel disease (IBD). Even when active disease has been excluded the prevalence of residual gastrointestinal symptoms is surprisingly high and the cause often obscure. The presence of a concurrent functional disorder such as irritable bowel syndrome (IBS) is associated with worse quality of life, worse physical functioning, higher prevalence of anxiety and greater health care utilization. Potential etiological mechanisms leading to the development of IBS like symptoms include the development of visceral hypersensitivity following the original inflammatory insult, alteration in cortical processing, dysbiosis and residual subacute inflammation. Therapeutic options for managing IBS in patients with IBD include dietary modification, interventions targeted at correction of visceral sensory dysfunction or cortical processing and modulation of the gut microbiota. As there are few studies specifically examining the treatment of IBS in patients with IBD, the majority of therapeutic interventions are extrapolated from the IBS literature. Given the frequency of residual functional symptoms in IBS, significantly more research is warranted in this field.

The impact of symptoms, irritable bowel syndrome pattern and diagnostic investigations on the diagnostic delay of Crohn's disease: A prospective study

BACKGROUND

We investigated symptoms and tests performed prior to a formal diagnosis of Crohn's disease and the reasons for diagnostic delay.

METHODS

Consecutive patients recently diagnosed with Crohn's disease were enrolled between October 2012 and November 2013. Clinical data, symptoms including Rome III criteria at onset and at diagnosis, location and disease phenotype were recorded. Faecal calprotectin, radiological and endoscopic examinations performed prior to diagnosis were analysed. Diagnostic delay, stratified into tertiles and median time, was analysed using parametric and nonparametric tests.

RESULTS

83 patients (49.4% males, median age 31 years) were enrolled. The median diagnostic delay was 8 (0-324) months. Twenty-six patients did not consult a general practitioner until diagnosis (31.3%), 18 presented to the emergency department (21.7%) and 8 directly to a gastroenterologist (9.6%). Diagnostic delay was not associated with specific symptoms. However, patients with bloating at presentation had a longer delay compared to those who did not (median, 6.1 vs. 16.8 months, respectively; p=0.016). Nineteen patients underwent incomplete ileocolonoscopies (22.9%) and 7 had no biopsies (8.4%), with a consequent diagnostic delay (median, 24 and 24 vs. 6 months, respectively; p=0.025 and p=0.008).

CONCLUSION

Diagnostic delay for Crohn's disease is significantly associated with incomplete ileocolonoscopies, but not with symptoms, except bloating at presentation.

Perianal disease is associated with psychiatric co-morbidity in Crohn's disease in remission

BACKGROUND AND AIM

Crohn's disease is a life-long inflammatory disease which can impair quality of life, in particular in patients with psychiatric co-morbidities such as depression and anxiety. The aim of this prospective cohort study was to assess the prevalence of depression and anxiety and related risk factors in patients with quiescent Crohn's disease.

METHODS

A consecutive series of adult patients with confirmed diagnosis of Crohn's disease, in clinical remission, were included and investigated during ambulatory visits using a standard questionnaire assessing demographic and clinical features of the disease. Within 1 month after the ambulatory visit, all patients were interviewed by phone to assess the presence of psychiatric disorders using standardized questionnaires. The questionnaire assessed the development of psychiatric disorders after the diagnosis of Crohn's disease, the use of antidepressant or antianxiety therapy and current anxiety or depression by means of the Hospital Anxiety and Depression Scale.

RESULTS

One hundred and ninety-five patients were included. Seventy-two (36.9 %) patients showed anxiety and/or depression symptoms, 46 (23.6 %) patients showed anxiety symptoms, 6 (3.1 %) patients showed depression symptoms and 20 (10.3 %) patients showed both symptoms. Forty-eight of these patients (58 %) were without any antidepressive or antianxiety treatment. Anxiety with or without depression was significantly correlated with female sex (p = 0.017), history of perianal disease (p = 0.003) and perianal surgery (p = 0.042).

CONCLUSION

Anxiety is a frequent, often untreated, condition in patient affected by Crohn's disease in clinical remission. Female sex, history of perianal disease and perianal surgery are major risk factors for anxiety.

Mixed pulmonary infection in an immunocompromised patient: a rare case report

Patients who are immunocompromised are predisposed to a variety of common and uncommon pulmonary infections. We report a case of mixed pulmonary infection by drug resistant tuberculosis with a nocardiosis in a 49-year-old man who was a known case of chronic obstructive pulmonary disease, on prolonged corticosteroid use with diabetes mellitus. Chronic use of corticosteroids is a predisposing factor for opportunistic infections, such as nocardiosis or tuberculosis. Since such a mixed infection is rare, maybe a combined approach to therapy early in the course of disease would be effective in such cases.

Vancomycin-resistant Enterococcus faecium: report of two cases

Vancomycin-resistant Enterococci (VRE), especially Enterococcus faecium has emerged as an important nososcomial pathogen and represents a serious threat to patients with impaired host defense. Early detection of patients colonised or infected with VRE is an essential component of any hospital program designed to prevent nosocomial transmission of this organism. The authors report two cases of VRE isolated from blood and surgical site pus of two neonates admitted in the same neonatal unit, highlighting that early detection, prompt and appropriate infection control measures were keys to successful containment of this dreaded pathogen.

Variations in the formation of the median nerve and its clinical correlation

Variations in the formation of the median nerve are of interest to anatomists, radiologists, and surgeons. These variations may be vulnerable to damage in surgical operations, but their knowledge also helps in the interpretation of a nervous compression having unexplained clinical symptoms. We studied the variation in the formation of the median nerve in 87 cadavers, i.e. 174 upper limbs of formalin preserved cadavers at the department of Anatomy, Subharti medical college. We observed an additional root taking part in the formation of the median nerve in 26.4% of upper limbs, unusual low formation of the median nerve in the arm in front of the brachial artery in 18.4% of upper limbs, and median nerve formation medial to the axillary artery in 10.3% of upper limbs. Knowledge of such anatomical variations is of interest to the anatomist and clinician alike. Surgeons who perform procedures involving neoplasm or trauma repair need to be aware of these variations.

Variant origin of superior polar artery and unusual hilar branching pattern of renal artery with clinical correlation

Classically, a single renal artery arising from the abdominal aorta supplies the respective kidney on each side. Near the hilum of the kidney each renal artery divides into anterior and posterior branchs, which in turn divide into segmental arteries supplying the different renal segments. A total of 84 formalin fixed cadavers (73 male and 11 female, 168 kidneys in total) constituted the material for the study. During routine abdominal dissection conducted for medical undergraduates, the kidneys and their arteries were explored and variations in morphological patterns of renal arteries were noted. We observed superior polar renal artery in 22.6% cases. Superior polar renal arteries had different sources of origin. In 10.7% of cases it came directly from the abdominal aorta as an accessory renal artery; in 5.4% of cases as a direct branch from the main renal artery; in 3.6% of cases from the superior hilar renal artery (from one of the duplicated renal arteries); and in 3.0% of cases from a segmental branch of the renal artery. We also observed unusual hilar branching patterns of renal arteries, which included a fork pattern in 11.3% of cases, ladder pattern in 7.7% of cases, net pattern in 5.9% of cases, and triplicate in 3.0% of cases. Understanding the anatomy of vascular variations of the kidney is essential for the clinician to be able to perform procedures such as renal transplantation, interventional radiological procedures, and renal vascular operations more safely and efficiently.

Micropathological changes in the sub-epidermal zone of normal appearing skin in leprosy

Leprosy is a chronic inflammatory disease caused by Mycobacterium leprae, which affects not only the peripheral nerves and skin but also various internal viscera through the hematogenous spread, especially in lepromatous cases. The micropathological changes in epidermis, nerves and skin appendages from lesioned skin reported by various authors but reports of involvement of apparently normal sites are few. We investigated skin biopsy material taken from 130 patients with clinically diagnosed leprosy. Biopsies were taken at least 10 cm away from site of lesion. Hematoxylin and Eosin staining and Harada's modified Allochrome method for acid-fast bacilli were applied for histological investigations. The pattern of leprosy among the patients were indeterminate in 53 cases (40.8%), tuberculoid in 29 cases (22.3%), borderline tuberculoid in 14 cases (10.8%), borderline leprosy in ten cases (7.7%), borderline lepromatous in nine cases (6.9%) and lepromatous leprosy in 15 cases (11.5%). The changes were seen in sub-epidermal zone of normal appearing skin in all type of leprosy, but involvement was greater at the lepromatous end of the spectrum compared to tuberculoid end. Acid-fast bacillus (AFB) was seen in subepidermal zone of normal appearing site. Presence of AFB is significant as far as dissemination and transmission of disease is concerned.

Renal artery variations: embryological basis and surgical correlation

Understanding anatomy of the vascular variations of kidney is essential for the clinician to perform procedures such as renal transplantation, interventional radiological procedures and renal vascular operations more safely and efficiently. In order to facilitate the clinical approaches, we studied renal arterial pattern in 50 formalin-fixed cadavers, on 100 kidneys. We observed prehilar multiple branching patterns in 11 (11.66%) cases, duplication of renal artery in eight (8.33%) cases and superior polar artery in seven (6.66%) cases. In the present study findings discussed with its clinical correlation.

Pulmonary hydatidosis: An unusual cause of haemoptysis

A 28-year-old female patient was referred to us with complaints of massive haemoptysis and cough with expectoration, of two years' duration. Her chest radiograph, computed tomography scan and video-bronchoscopy revealed a cystic lesion in the right upper and lower zones of the lungs. Aspiration from the cyst fluid was grossly hemorrhagic and full of inflammatory cells. On digestion of the fluid with potassium hydroxide, it showed plenty of hooklets and scolices of Echinococcus granulosus. An intact brood capsule was also seen. Diagnosis of hydatidosis was further confirmed by a positive serological and therapeutic response to albendazole.

Recurrence of carcinoma cervix in the scar of previous cesarean section: a case report

Although rare, reports of carcinoma cervix recurring in abdominal incision, episiotomy scars, laparoscopic port sites, and drain sites are available. However, recurrence in the scar of a previous cesarean section (CS) is unreported. A 49-year-old female with a diagnosis of keratinizing squamous cell carcinoma (SCC) of cervix, stage IIB, was treated by radical radiotherapy. She had undergone CS, through midline abdominal incision, for three previous deliveries. Twenty months later, she presented with a nodule of size 2.5 x 2 cm(2) on the 26-year-old abdominal CS scar. Infiltration of the skin and extension into the deeper structures of the abdominal wall was present in an area of 5 x 4 cm(2). There was no evidence of disease on the cervix. A fine-needle aspiration cytologic examination from the nodule revealed keratinizing SCC. Ultrasonography and computerized tomography scan revealed a mass lesion along the abdominal CS scar with subcutaneous nodule and peritoneal extension. Multiple metastatic lesions were present in the liver. She was treated with chemotherapy and radiotherapy. The patient has lived for more than 12.5 months. The first report of recurrence of carcinoma cervix in a CS scar is presented. Literature on surgical scar recurrence in carcinoma cervix is reviewed.

Hand preference in patients with allergy, juvenile cancer, and schizophrenia

Patients with allergy (n = 50), juvenile cancer (n = 50), and schizophrenia (n = 37), and nonpatient controls (n = 200) were asked to indicate their hand preferences on a 7-point scale (1 = left always, 7 = right always) for the 32-item Waterloo Handedness Questionnaire. Except for patients with schizophrenia, who exhibited a higher incidence of mixed hand preference, groups showed a clear rightward bias. Further analyses suggested that mixed hand preference in schizophrenia was evident more often for unskilled than skilled hand activities.

Carcinoma of the gallbladder presenting as scalp tumour

Carcinoma of the gallbladder is characterized by rapid tumour growth associated with lymphatic and local tumour invasion. The peritoneum, GIT and lungs are common sites of seeding. Distant metastasis to bone rarely occurs. Here we document a case of silent gallbladder carcinoma presenting as scalp tumour with improved survival.

Germ cell tumour of testis

Germ cell tumour, though rare, represents most common malignancy among young men aged between 15 to 35 years. In 1990's dramatic improvement has taken place in survival rate of testicular tumours (from 10% in 1970's and 90% in 1990's). This has been possible because of effective diagnostic techniques, accurate monitoring with biological markers and use of effective platinum based combination chemotherapy in its management. The most significant improvement in survival rate has occurred in advanced stage germ-cell tumours. Seminomas are sensitive to radiation therapy and NSGCT (Non Seminomatous Germ Cell Tumours). are effectively treated by combination chemotherapy of 3 drugs of which Bleomycin is most expensive and many patient can not afford it and so compliance is poor. In the present series we have tried only 2 drug regimen consisting of Platinum and Etoposide (PE). Since January 1992 to December 1994, 40 cases of testicular tumours were treated. 16 cases received PEB regimen and 24 cases were treated by PE regimen of which only 6 cases in the former and 20 cases in the later group completed the scheduled course. Patients were given 6 cycles of PE regimen (inj. Platinum 20 mg/m2 D1-D5, VP-16 (ETOPOSIDE), 100 MG/M2 1.V. D1-D5) repeated every three weeks. Final evaluation was done in June 1996. 17/20 (85%) patients on PE regiment exhibited complete regression of the disease by the end of June 1996, I was lost to follow up, and 2 of them had the disease in progressive stage and were considered for another regimen. 18 months disease free survival was 85%. Table I. Royal Marsden Staging System Stage I: Disease econfined to testes Stage II: Intradiaphragmatic node involvement A: Less than 2 cm B: 2-5 cm C: Greater than 5 cm Stage III: Supradiaphragmatic node involvement Stage IV: Extralymphatic disease Lung, Liver, Bone etc.

Embryonal rhabdomyosarcoma of the mastoid in an infant

A case of embryonal rhabdomyosarcoma of the mastoid in a six weeks old infant is reported because of rarity and unusually early onset of the disease.

Radiation therapy for symptomatic vertebral haemangioma

Vertebral haemangiomas are slowly growing benign tumours and are usually asymptomatic. They rarely cause symptoms and signs related to cord compression. Larger lesions create significant problems during surgery because of haemorrhage and vascular supply crucial to spinal cord function. In such severely symptomatic vertebral haemangiomas, radiation therapy has been tried and good results obtained, especially in terms of good functional recovery. We have treated 17 patients (including nine paraplegic patients) with radiotherapy (Co-60). Treatment was given by single posterior field, encompassing the involved area with a dose of 35-40 Gy in 3 to 4 weeks (five fractions per week). All patients with pain and tenderness were relieved completely (87.5%) or partially (12.5%). Similarly patients with numbness and paresis showed either complete (66.7%) or partial response (33.3%) from symptoms on follow-up. Out of nine paraplegic patients six (66.6%) had recovered completely, one (11.2%) partially and two (22.2%) had no response. The two patients who did not show any marked relief, had paraplegia of longer duration (more than 6 months). Our study indicates that severely symptomatic vertebral haemangioma can be successfully treated by radiation therapy and it can be chosen as first line of treatment with an optimum dose of 35-40 Gy in 3 to 4 weeks.

Clinico-epidemiological profiles of post-kala-azar dermal leishmaniasis in Varanasi

Twenty-seven cases of Post Kala-Azar Dermal Leishmaniasis (P. K. D. L.) were detected in an endemic focus of Kala-azar in Sujabad village in Varanasi Distt. Male-Female ratio of cases was 4.4:1. Majority (66.6 per cent) of cases had macular lesions. Histopathology of one case showed Leishmania donovani (L. D.) bodies. Densities of sand fly were more in pockets where P. K. D. L. cases were detected. All the 13 cases, which were treated with sodium antimony gluconate, responded well to therapy.

Mitomycin C extravasation ulcers

In a four-year period, eight patients with mitomycin C extravasation ulcers were encountered. Mitomycin C extravasation produces a painful indolent ulcer that does not have any tendency to heal. If extravasation of the drug is recognized, infusion should be stopped immediately, and the site of infusion should be changed. The ulcers should be excised, and primary closure is recommended; if it is not possible then the defect is covered by a partial thickness skin graft.

Incidence, pattern and direction of hair distribution on the dorsum of phalanges of the hands of male medical students of Uttar Pradesh, India

In the present investigation direction and pattern of hair distribution were observed on the dorsum of phalanges of hands in 115 male medical students from Uttar Pradesh, India. Inproximal phalanges of the hands the direction of hair showed the relation with fingers. Observation of hair from little finger to thumb revealed the changes in direction from ulnar to radial (p less than 0.05). Probability of incidence of hair distribution was also studied among the fingers of both the hands. This correlation was significant on the proximal phalanges (p less than 0.05). However, no significant correlation coefficient was observed in the middle phalanges of the hands.