Fecobionics in proctology: review and perspectives

Fecobionics is a novel integrated technology for assessment of anorectal function. It is a defecatory test with simultaneous measurements of pressures, orientation, and device angle (a proxy of the anorectal angle). Furthermore, the latest Fecobionics prototypes measure diameters (shape) using impedance planimetry during evacuation of the device. The simultaneous measurement of multiple variables in the integrated test allows new metrics to be developed including more advanced novel defecation indices, enabling mechanistic insight in the defecation process at an unprecedented level in patients with anorectal disorders including patients suffering from obstructed defecation, fecal incontinence, and low anterior resection syndrome. The device has the consistency and shape of a normal stool (type 3-4 on the Bristol Stool Form Scale). Fecobionics has been validated on the bench and in animal studies and used in clinical trials to study defecation phenotypes in normal human subjects and patients with obstructed defecation, fecal incontinence, and low anterior resection syndrome after rectal cancer surgery. Subtypes have been defined, especially of patients with obstructed defecation. Furthermore, Fecobionics has been used to monitor biofeedback therapy in patients with fecal incontinence to predict the outcome of the therapy (responder versus non-responder). Most Fecobionics studies showed a closer correlation to symptoms as compared to current technologies for anorectal assessment. The present article outlines previous and ongoing work, and perspectives for future studies in proctology, including in physiological assessment of function, diagnostics, monitoring of therapy, and as a tool for biofeedback therapy.

Cross-tissue immune cell analysis reveals tissue-specific features in humans

Despite their crucial role in health and disease, our knowledge of immune cells within human tissues remains limited. We surveyed the immune compartment of 16 tissues from 12 adult donors by single-cell RNA sequencing and VDJ sequencing generating a dataset of ~360,000 cells. To systematically resolve immune cell heterogeneity across tissues, we developed CellTypist, a machine learning tool for rapid and precise cell type annotation. Using this approach, combined with detailed curation, we determined the tissue distribution of finely phenotyped immune cell types, revealing hitherto unappreciated tissue-specific features and clonal architecture of T and B cells. Our multitissue approach lays the foundation for identifying highly resolved immune cell types by leveraging a common reference dataset, tissue-integrated expression analysis, and antigen receptor sequencing.

4 Cardiovascular Disease in Women with and Without Rheumatoid Arthritis

Compare the incidence of coronary artery disease (CAD) in women with rheumatoid arthritis (RA) with that in women without RA, adjusting for traditional CAD risk factors (age, smoking, race, diabetes mellitus, hypercholesterolemia, hypertension, physical inactivity, family history, and obesity). A logistic regression analysis is used to control for confounders and other variables. To compare the incidence of coronary artery disease (CAD) in women with rheumatoid arthritis (RA) with that in women without RA, adjusting for traditional CAD risk factors (age, smoking, race, diabetes mellitus, hypercholesterolemia, hypertension, physical inactivity, family history, and obesity). A logistic regression analysis will be used to control for confounders and other variables. Data analysis is limited to all women who participated in the 2010 survey and of the 7844 who completed the 2010 Women's Health Survey, 7338 (93.5%) participants did not have rheumatoid arthritis, 310 (3.9%) have rheumatoid arthritis, and 196 (2.4%) were missing. Incidence rate of CAD is measured in both groups. Data analysis will be limited to all women who participated in the 2010 survey and of the 7844 who completed the 2010 Women's Health Survey, 7338 (93.5%) participants did not have rheumatoid arthritis, 310 (3.9%) have rheumatoid arthritis, and 196 (2.4%) were missing

Effect of sildenafil on maternal hemodynamics in pregnancies complicated by severe early-onset fetal growth restriction: planned subgroup analysis from a multicenter randomized placebo-controlled double-blind trial

OBJECTIVES

Fetal growth restriction (FGR) is associated with maternal cardiovascular changes. Sildenafil, a phosphodiesterase type-5 inhibitor, potentiates the actions of nitric oxide, and it has been suggested that it alters maternal hemodynamics, potentially improving placental perfusion. Recently, the Dutch STRIDER trial was stopped prematurely owing to excess neonatal mortality secondary to pulmonary hypertension. The main aim of this study was to investigate the effect of sildenafil on maternal hemodynamics in pregnancies with severe early-onset FGR.

METHODS

This was a cardiovascular substudy within a UK multicenter, placebo-controlled trial, in which 135 women with a singleton pregnancy and severe early-onset FGR (defined as a combination of estimated fetal weight or abdominal circumference below the 10^th centile and absent/reversed end-diastolic flow in the umbilical artery on Doppler velocimetry, diagnosed between 22 + 0 and 29 + 6 weeks' gestation) were assigned randomly to receive either 25 mg sildenafil three times daily or placebo until 32 + 0 weeks' gestation or delivery. Maternal blood pressure (BP), heart rate (HR), augmentation index, pulse wave velocity (PWV), cardiac output, stroke volume (SV) and total peripheral resistance were recorded before randomization, 1-2 h and 48-72 h post-randomization, and 24-48 h postnatally. For continuous data, analysis was performed using repeated measures ANOVA methods including terms for timepoint, treatment allocation and their interaction.

RESULTS

Included were 134 women assigned randomly to sildenafil (n = 69) or placebo (n = 65) who had maternal BP and HR recorded at baseline. At 1-2 h post-randomization, compared with baseline values, sildenafil increased maternal HR by 4 bpm more than did placebo (mean difference, 5.00 bpm (95% CI, 1.00-12.00 bpm) vs 1.25 bpm (95% CI, -5.38 to 7.88 bpm); P = 0.004) and reduced systolic BP by 1 mmHg more (mean difference, -4.13 mmHg (95% CI, -9.94 to 1.44 mmHg) vs -2.75 mmHg (95% CI, -7.50 to 5.25 mmHg); P = 0.048). Even after adjusting for maternal mean arterial pressure, sildenafil reduced aortic PWV by 0.60 m/s more than did placebo (mean difference, -0.90 m/s (95% CI, -1.31 to -0.51 m/s) vs -0.26 m/s (95% CI, -0.75 to 0.59 m/s); P = 0.001). Sildenafil was associated with a non-significantly greater decrease in SV index after 1-2 h post-randomization than was placebo (mean difference, -5.50 mL/m² (95% CI, -11.00 to -0.50 mL/m² ) vs 0.00 mL/m² (95% CI, -5.00 to 4.00 mL/m² ); P = 0.056).

CONCLUSIONS

Sildenafil in a dose of 25 mg three times daily increases HR, reduces BP and reduces arterial stiffness in pregnancies complicated by severe early-onset FGR. These changes are short term, modest and consistent with the anticipated vasodilatory effect. They have no short- or long-term clinical impact on the mother. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Camel-related pancreatico-duodenal injuries: a report of three cases and review of literature

BACKGROUND

Human pancreatico-duodenal injuries caused by camels are extremely rare.

OBJECTIVE

We report three patients who sustained camel-related pancreatico-duodenal injuries and review the literature on this topic.

RESULTS

A 32-year camel caregiver was kicked by a camel which then stepped on his abdomen trying to kill him. The patient's abdomen was soft and lax. CT scan of the abdomen showed free retroperitoneal air. Laparotomy revealed a complete tear of the anterior wall of the second part of duodenum which was primarily repaired. A 40-year camel caregiver was directly kicked into his abdomen by a camel. He developed traumatic pancreatitis which was treated conservatively. A 31-year-old male fell down on his abdomen while riding a camel. Abdominal examination revealed tenderness and guarding. Abdominal CT Scan showed complete transection of the neck of the pancreas which was confirmed by laparotomy. The patient had distal pancreatectomy with preservation of the spleen. All patients were discharged home in good condition.

CONCLUSION

These cases demonstrate the misleading presentation of the camel-related pancreatico-duodenal injuries and their unique mechanism of injury.

Evaluation of offline analysis of archived three-dimensional volume datasets in the diagnosis of fetal brain abnormalities

OBJECTIVE

To retrospectively evaluate the reliability of offline manipulation of archived three-dimensional (3D) ultrasound volumes in the assessment of the normal fetal brain and the diagnosis of fetal brain abnormalities.

METHODS

Seventy-nine 3D volume datasets, archived at the time of scanning, from women attending a tertiary center, were analyzed. They comprised 52 cases with brain abnormalities and 27 normal controls. Postnatal magnetic resonance imaging or postmortem examination confirmed the final diagnosis in all cases with brain anomalies. Offline analysis of the 79 anonymized 3D volume datasets was carried out by three fetal medicine experts, examiner one (E1), examiner two (E2) and examiner three (E3), using 4D View software. The experts were blinded to any prior diagnosis or history. Data were collected on a specially designed data sheet and entered into a specialized database for analysis. Results were compared between examiners, with the initial two-dimensional (2D) diagnosis and with the final definitive diagnosis by calculation of percentage agreement and kappa coefficients.

RESULTS

Of the 52 cases with brain anomalies, the correct diagnosis was reached in 88.5% (46/52), 98.1% (51/52) and 92.3% (48/52) of cases on analysis of the 3D volumes by E1, E2 and E3, respectively, whereas only 82.7% (43/52) of cases were correctly diagnosed on the initial 2D examination when compared with the definitive diagnosis. Fetuses without brain anomalies were identified as such by the three experts with 100% agreement. There was good agreement between the initial 2D examination and the analysis of 3D volumes by each of the experts: 86.1% for E1 (κ = 0.7), 89.9% for E2 (κ = 0.79) and 88.6% for E3 (κ = 0.76).

CONCLUSIONS

3D volume datasets are an appropriate and reliable format for storing data from examination of the fetal brain. Offline analysis of 3D datasets is a reliable method that can be used to help in the assessment of brain anomalies and could be a useful adjunct to realtime 2D ultrasonography.

The spectrum of pediatric eosinophilic esophagitis beyond infancy: a clinical series of 30 children

OBJECTIVES

Eosinophilic esophagitis, previously confused with esophageal inflammation due to gastroesophageal reflux, has recently begun to be distinguished from it. We undertook this analysis of our large series of children with the condition to clarify its spectrum: its presenting symptoms; its relation to allergy, respiratory disease, and reflux; its endoscopic and histological findings; and its diagnosis and therapy.

METHODS

We analyzed the details of our clinical series of 30 children with eosinophilic esophagitis, defining it as > or =5 eosinophils per high power field in the distal esophageal epithelium. Retrospective chart review was supplemented by prospective, blinded, duplicate quantitative evaluation of histology specimens, and by telephone contact with some families to clarify subsequent course. Presentation and analysis of the series as a whole is preceded by a case illustrating a typical presentation with dysphagia and recurrent esophageal food impactions.

RESULTS

Presenting symptoms encompass vomiting, pain, and dysphagia (some with impactions or strictures). Allergy, particularly food allergy, is an associated finding in most patients, and many have concomitant asthma or other chronic respiratory disease. A subtle granularity with furrows or rings is newly identified as the endoscopic herald of histological eosinophilic esophagitis. Histological characteristics include peripapillary or juxtaluminal eosinophil clustering in certain cases. Association with eosinophilic gastroenteritis occurs, but is not common. Differentiation from gastroesophageal reflux disease is approached by analyzing eosinophil density and response to therapeutic trials. Therapy encompasses dietary elimination and anti-inflammatory pharmacotherapy.

CONCLUSION

Awareness of the spectrum of eosinophilic esophagitis should promote optimal diagnosis and treatment of this elusive entity, both in children and in adults.

Multi-centre evaluation of repeatability and reproducibility of the direct agglutination test for visceral leishmaniasis

OBJECTIVE

To evaluate the repeatability and reproducibility of the serological direct agglutination test (DAT) for visceral leishmaniasis (VL) with aqueous antigen in a multi-centre study in VL-endemic areas in Sudan, Kenya and Nepal.

METHODS

Repeatability within each centre and reproducibility between the centres' results and an external reference laboratory (Belgium) was assessed on 1596 triplicate plain blood samples collected on filter paper.

RESULTS

High kappa values (range 0.86-0.97) indicated excellent DAT repeatability within the centres. The means of the titre differences between the reference laboratory and the centres in Sudan, Kenya and Nepal (2.3, 2.4 and 1.1, respectively, all significantly different from 0) showed weak reproducibility across centres. 95% of the titre differences between the reference laboratory and the respective centres were accounted for by large intervals: 0.6-9 fold titre variation for Sudan, 0.7-8 fold for Kenya and 0.26-4 fold for Nepal.

CONCLUSION

High repeatability of DAT confirms its potential, but reproducibility problems remain an obstacle to its routine use in the field. Reproducibility was hindered by alteration of the antigen through temperature and shaking, especially in Kenya and Sudan, and by nonstandardization of the test reading. DAT handling procedures and antigen quality must be carefully standardized and monitored when introducing this test into routine practice.

Blood groups and types, hemoglobin variants, and G-6-PD deficiency among Abu Dhabians in the United Arab Emirates

Some erythrocyte genetic factors were studied in the indigenous population of Abu Dhabi, the capital of the United Arab Emirates, on the southeastern coast of the Arabian peninsula. Determinations carried out included blood groups and types ABO, MNS, Rh0, KkJsa, FyaFyb, P1, Lea, Vela, hemoglobin variants, and screening for G-6-PD deficiency. Prevalence of most blood groups and types harmonized with that among neighboring Arabs and some Arabs elsewhere. The MS and NS gene complexes were noticeably high. African admixture was expressed by the presence of Jsa and HbS and large numbers of Fy. G-6-PD deficiency was rather high.