Efficacy of Tumor Necrosis Factor Antagonist Treatment in Patients With Refractory Ulcerative Proctitis

BACKGROUND & AIMS

It is a challenge to manage patients with ulcerative proctitis (UP) refractory to standard therapy. We investigated the effectiveness of tumor necrosis factor (TNF) antagonists in a large cohort of patients with refractory UP.

METHODS

We conducted a nationwide retrospective cohort study of 104 consecutive patients with active UP refractory to conventional therapies, treated at 1 of 15 centers in France or 1 center in Belgium (the GETAID cohort). Patients received at least 1 injection of anti-TNF (infliximab, adalimumab, golimumab) from October 2006 through February 2017. Clinical response was defined as significant improvement in UC-related symptoms, and remission as complete disappearance of UC-related symptoms, each determined by treating physicians. We collected demographic, clinical, and treatment data. The median duration of follow-up was 24 months (interquartile range, 13-51 months). The primary outcome was clinical response of UP to anti-TNF treatment.

RESULTS

Overall, 80 patients (77%) had a clinical response to anti-TNF therapy and 52 patients (50%) achieved clinical remission. Extra-intestinal manifestations (odds ratio OR, 0.24; 95% CI, 0.08-0.7), ongoing treatment with topical steroids (OR, 0.14; 95% CI, 0.03-0.73), and ongoing treatment with topical 5-aminosalycilates (OR, 0.21; 95% CI, 0.07-0.62) were significantly associated with the absence of clinical remission. Sixty percent (38/63) of the patients who had endoscopic assessment during follow up had mucosal healing. Among the overall population (n = 104), the cumulative probabilities of sustained clinical remission were 87.6% ± 3.4% at 1 year and 74.7% ± 4.8% at 2 years.

CONCLUSIONS

In a retrospective study of 104 patients with refractory UP, anti-TNF therapy induced clinical remission in 50% and mucosal healing in 60%. About two thirds of the patients were still receiving anti-TNF therapy at 2 years.

Total midgut volvulus in adults with intestinal malrotation. Report of eleven patients

OBJECTIVE

Total small-intestinal volvulus with malrotation (TSIVM) classically presents in the neonatal period; it occurs much less frequently in the adult and is often misdiagnosed. Prognosis is directly related to the degree and duration of intestinal ischemia. Our goal is to describe our experience with TSIVM in the adult, to identify any specific findings and to discuss its management.

METHOD

Eleven patients who had undergone surgery for TSIVM at three centers between 1992 and 2012 were included. Surgery was performed as an emergency for five patients and surgery was elective for six.

RESULTS

Mean follow-up was 63 months (range: 12-270). Six patients had had previous abdominal surgery. In nine cases, the diagnosis of TSIVM was made preoperatively, mainly by CT scan in eight cases. Seven patients had associated congenital failure of retroperitoneal fixation of the right colon and all of these underwent a Ladd procedure. The mortality rate was zero. Of the five patients who underwent emergency surgery, three required intestinal resections, one of whom developed a short bowel syndrome. The six patients who underwent surgery electively had no surgical complications.

CONCLUSION

TSIVM is a very unusual finding in adult patients. The diagnosis can be made by CT scan with IV and oral contrast, but it often comes to light only at the time of surgery, even though the patients have often had recurrent episodes of abdominal symptomatology that dated back to childhood. The Ladd procedure, consisting of division of Ladd's bands, widening of the mesentery, and incidental appendectomy, remains the standard surgical repair. Digestive surgeons who care for adults should be familiar with this procedure, and it should be performed, as often as possible, with the assistance of a pediatric surgeon.

Model-driven harmonic parameterization of the cortical surface: HIP-HOP

In the context of inter subject brain surface matching, we present a parameterization of the cortical surface constrained by a model of cortical organization. The parameterization is defined via an harmonic mapping of each hemisphere surface to a rectangular planar domain that integrates a representation of the model. As opposed to previous landmark-based registration methods we do not match folds between individuals but instead optimize the fit between cortical sulci and specific iso-coordinate axis in the model. This strategy overcomes some limitation to sulcus-based registration techniques such as topological variability in sulcal landmarks across subjects. Experiments on 62 subjects with manually traced sulci are presented and compared with the result of the Freesurfer software. The evaluation involves a measure of dispersion of sulci with both angular and area distortions. We show that the model-based strategy can lead to a natural, efficient and very fast (less than 5 min per hemisphere) method for defining inter subjects correspondences. We discuss how this approach also reduces the problems inherent to anatomically defined landmarks and open the way to the investigation of cortical organization through the notion of orientation and alignment of structures across the cortex.

Circulation and suspended sediment transport in a coral reef lagoon: the south-west lagoon of New Caledonia

The south-west lagoon of New Caledonia is a wide semi-open coral reef lagoon bounded by an intertidal barrier reef and bisected by numerous deep inlets. This paper synthesizes findings from the 2000-2008 French National Program EC2CO-PNEC relative to the circulation and the transport of suspended particles in this lagoon. Numerical model development (hydrodynamic, fine suspended sediment transport, wind-wave, small-scale atmospheric circulation) allowed the determination of circulation patterns in the lagoon and the charting of residence time, the later of which has been recently used in a series of ecological studies. Topical studies based on field measurements permitted the parameterisation of wave set-up induced by the swell breaking on the reef barrier and the validation of a wind-wave model in a fetch-limited environment. The analysis of spatial and temporal variability of suspended matter concentration over short and long time-scales, the measurement of grain size distribution and the density of suspended matter (1.27 kg l(-1)), and the estimation of erodibility of heterogeneous (sand/mud, terrigenous/biogenic) soft bottoms was also conducted. Aggregates were shown to be more abundant near or around reefs and a possible biological influence on this aggregation is discussed. Optical measurements enabled the quantification of suspended matter either in situ (monochromatic measurements) or remotely (surface spectral measurements and satellite observations) and provided indirect calibration and validation of a suspended sediment transport model. The processes that warrant further investigation in order to improve our knowledge of circulation and suspended sediment transport in the New Caledonia lagoon as well as in other coral reef areas are discussed, as are the relevance and reliability of the numerical models for this endeavour.

Optimization of patent foramen ovale detection by contrast transthoracic echocardiography using second harmonic imaging

BACKGROUND

Patent foramen ovale is an anomaly responsible for paradoxical embolizations and cerebral ischemic events. Aims. - We want to show second harmonic transthoracic echography sensitized by contrast agent perfusion is as well as transesophageal echography to patent foramen ovale detection.

METHODS

Onene hundred twenty one patients referred for transesophageal echocardiography for patent foramen ovale detection, underwent additive second harmonic transthoracic echocardiography with one of three randomized contrast agents: a mixture A of dextrose and air, mixture B of dextrose and air and blood, or mixture C of hydroxyethylamidon. The severity of atrial shunting was evaluated on recordings by semi-quantitative scoring. Intensity of contrast was also assessed by objective quantitative videodensitometry.

RESULTS

No difference was observed between the two techniques, nor between mixture A, B and C in terms of PFO detection during each exam. However, quantitative contrast analysis showed higher intensity with mixtures B and C with mixture A during transthoracic echography.

CONCLUSIONS

When performed with a contrast agent, second harmonic transthoracic echography and transoesophageal echography are comparable when it comes to patent foramen ovale detection. Although the composition of the contrast agent does not appear to affect the rate of this detection, contrast quality in the right atrium during transthoracic exam is better with mixtures B and C than with mixture A.

[Use of echocardiography in the diagnosis of carcinoid tumors. Report of 4 cases]

Carcinoid tumours are the most common neuro-endocrine tumours but cardiac involvement is rarely symptomatic although often observed at post-mortem and rarely revelatory of the disease. The authors report 4 cases in which echocardiographic detection of characteristic right ventricular involvement led to the confirmation of the diagnosis of carcinoid tumour leading to the secondary diagnosis of the primary carcinoid tumour. The clinical, physiopathological echocardiographic and therapeutic characteristics of this condition are discussed.

[Criteria of localization of the bundle of Kent]

The high success rate (> 90%) of radiofrequency ablation of accessory pathways is related to accurate mapping. This determines the site of the accessory pathway and the best target for ablation with the object of reducing the number of applications and the associated morbidity. Analysis of the surface ECG is the first step of localisation of a Kent bundle. Different algorithms may be used based on the correlation between the polarity of the delta wave, of the QRS and the site of the accessory pathway confirmed at surgery or during radiofrequency ablation procedures. Some of the recent algorithms allow localisation of certain postero-septal or sub-epicardial pathways, the ablation of which can only be accomplished via the coronary sinus or one of its branches, or in an abnormally dilated coronary sinus, the so-called diverticulum. A relatively accurate localisation of the accessory pathway from the surface ECG reduces the duration of an ablation procedure and may economise the need for left-sided catheterisation. However, the endocavitary electrogrammes determine the precise target of ablation whether this be the ventricular or atrial pole of the bundle of Kent. The association of the criteria obtained by bipolar and unipolar recordings in sinus rhythm, during pacing or reentrant tachycardia enables accurate localisation in the majority of cases. Ablation of some pathways may be more complex because of their site or the presence of associated congenital or acquired cardiac disease which alters the anatomical or electrical markers. In these cases, the electrical criteria, especially those of the surface ECG may be erroneous and non invasive investigations such as Doppler echocardiography, isotopic ventriculography with phase analysis are most valuable with a positive predictive value of over 90%.

Teleonomical optimization of a fractal model of the pulmonary arterial bed

Modeling the pulmonary arterial tree (PAT) is considered here as an optimal synthesis problem. Firstly, a class of candidate models is specified: the three-dimensional symmetric dichotomous fractal trees of elastic tubes described by Womersley's equations. Secondly, the parameters are shown to be constrained by interactions of PAT with the rest of the body; these constraints are used to limit the volume of the parametric space to which attention will be directed in the synthesis step. Thirdly, a teleonomical hypothesis is proposed: a naturally selected PAT must have a minimal input impedance under conditions keeping total arterial volume and distensibility as small as possible. This hypothesis is translated in mathematical terms and the resulting cost-function minimized in the limited parametric volume. The optimal model has parameter values and an impedance spectrum corresponding satisfactorily with real data. Moreover this model gives a clear picture of the internal hemodynamic behavior of PAT as an impedance matching device.

Parvalbumins and muscle relaxation: a computer simulation study

The distribution of Ca2+ and Mg2+ among the 'regulatory' cation binding sites of troponin (T-sites) and the strong, Ca2+-Mg2+ binding sites of troponin and parvalbumins (P-sites) in the sarcoplasm of a muscle was calculated. At rest, 60% of the T-sites were metal free, while 92% of the P-sites were loaded with Mg2+. In response to a Ca2+ pulse, troponin-calcium (T-Ca) complexes were rapidly formed, while the binding of Ca2+ to P-sites was limited by the slow rate of dissociation of the parvalbumin-magnesium (P-Mg) complexes. Muscle activation was not prevented by a high content of parvalbumins. Parvalbumin and the sarcoplasmic reticulum (SR) pump were complementary relaxing factors that removed Ca2+ from the cytosol and from the T-sites. Parvalbumins dominated the first part of relaxation, while the action of the SR was essential to ensure the return to a very low level of free Ca2+ ion and of T-Ca. After relaxation, a large fraction of the Ca2+ pulse was still bound to parvalbumins and returned slowly to the SR during the recovery. When the SR activity was reduced, the presence of parvalbumins preserved a fast rate of relaxation, at least for a few contractions. This may have a high adaptive value in cold-blooded animals.

Free-wall shortening and relaxation during ejection in the canine right ventricle

Relations between shortening, velocity of shortening, and relaxation of inflow and outflow segments of the right ventricular (RV) free wall (FW) were examined during ejection in 12 open-chest dogs after pharmacologic blockade by recording RV pressures, RVFW dimensions (piezoelectric crystals), and pulmonary blood flow. At heart rates of 113 +/0 8 (SD) beats/min, investigated segments remained isometric or even lengthened before the end of ejection. Tension-length data in the outflow tract converged at the time of peak systolic tension toward a common linear relation (average slope 65 +/- 10 cmH2O/mm, average intercept 5.9 +/- 0.9 mm), but markedly deviated from this line at the end of ejection. Consistent relations between peak tension and mean velocity of shortening were only observed during the first part of ejection. In addition the rate of segmental isometric relaxation, estimated from RV pressure fall was load dependent (e.g., +60% increase in relaxation rate when RVFW end-diastolic segment length increased from 12.9 +/- 0.8 to 13.5 +/- 0.8 mm). We conclude that under normal conditions, the tension-velocity-length relations of the RVFW are comparable to those of the left ventricle during the first part of ejection only. We also conclude that RV relaxation is load dependent and that a significant part of RV ejection occurs during RVFW relaxation.

[Isotopic study of fluid and electrolyte disturbances in decompensated chronic respiratory insufficiency (author's transl)]

The study of fluid and electrolyte disturbances by isotope radiodilution method is carried out in 22 patients with chronic respiratory insufficiency and cardiac failure. The simultaneous measurements of hydro-ionic compartments have been carried out with tritiated water (HTO), labelled sodium (22Na), labelled potassium (42K) and labelled bromine (82Br). From these measurements, the various water spaces are calculated: total water (ET) and extracellular fluids (LEC), also exchangeable electrolytes: sodium (NaE), potassium (KE), chlorine (ClE) and derived values. Results are compared to corresponding values in controls with the same obesity index. Patients with respiratory insufficiency show a fluid and sodium rise, similar to that found in cardiac failure and denutrition. The (NaE + KE)/ET ratio is not significantly decreased and the natremia is only slightly lower. There is no real potassium depletion in most patients.