Clinical features and bleeding risk factors of angiodysplasia lesions in a Tunisian population

INTRODUCTION

Gastrointestinal angiodysplasia (GIAD) is the most common vascular anomaly in the gastrointestinal (GI) tract, yet little is known about the factors favoring their bleeding. Our study aim was to determine the characteristics of patients with GIAD lesions in a Tunisian population and identify the risk factors of bleeding.

PATIENTS AND METHODS

A retrospective study was carried out from January 2010 to February 2020 at a tertiary care medical center in Tunisia. Clinical and endoscopic data were collected from each patient's medical reports. We divided the patients into two groups: group A, patients with symptomatic GIAD; and group B, patients with incidental lesions. Group A was subsequently divided into two subgroups, according to the presence or absence of recurrent bleeding. The groups were compared by clinical, laboratory, and endoscopic features.

RESULTS

GIAD was diagnosed in 114 patients, with a mean age of 70 ± 13.3 years. GIAD lesions were mainly located in the colon (n = 72, 63%). Fifty-four patients (47%) presented with GIAD-related bleeding. The bleeding diagnosis was made during endoscopic procedures by visualizing active bleeding and the stigmata of recent hemorrhage in 10 (18.5%) and 12 (22.2%) cases, respectively. Most of the patients were treated by argon plasma coagulation (93%). Predictive factors of bleeding were age > 75 years, number of lesions >10, chronic kidney disease, diabetes mellitus, and coronary artery disease (p: 0.008; 0.002; 0.016; 0.048; and 0.039, respectively).

CONCLUSION

Knowledge of the predictive factors of bleeding aids endoscopists in the decision-making process in cases of angiodysplasia.

A Case of Mirtazapine-Induced Pancreatitis

Acute pancreatitis is a concerning cause of hospitalization in the United States, with the most common etiologies being secondary to alcohol abuse and gallstones. Rarely, medications can trigger this inflammatory response, whether via direct toxic effects or other metabolic derangements. Mirtazapine is an antidepressant that has been associated with elevations in triglyceride levels on initiation. Relatedly, high triglyceride levels and autoimmune disorders are other causes of pancreatitis exacerbations. Here, we present the case of a female who was started on mirtazapine therapy and found to have elevated triglyceride levels. The course was complicated by acute pancreatitis requiring plasmapheresis, despite medication discontinuation, to which she responded well.

Acrophialophora: A Comprehensive Review of Clinical Guidelines and Diagnosis

Acrophialophora is a saprotrophic genus of fungi found in both temperate and tropical regions. The genus is comprised of 16 species, with the subspecies A. fusispora and A. levis necessitating the most clinical concern. Acrophialophora is an opportunistic pathogen with a broad range of clinical manifestations; the fungus has been implicated in cases of fungal keratitis, lung infection, and brain abscess. Acrophialophora infection is particularly of concern for immunocompromised patients, who often present with a more severe disease course involving disseminated infection and may not exhibit typical symptoms. Early diagnosis and therapeutic intervention are critical to the successful clinical management of Acrophialophora infection. Guidelines for antifungal treatment have yet to be established, partially due to the lack of documented cases. Aggressive use of antifungal agents and long-term treatment is required, especially in immunocompromised patients and patients with systemic involvement, due to the potential for morbidity and mortality. In addition to outlining the rarity and epidemiology of the disease, this review provides an overview of the diagnosis and clinical management of Acrophialophora infection to facilitate an early diagnosis and appropriate interventions.

To Bleed or Not to Bleed

The location of gastrointestinal (GI) bleeding can be characterized based on the characteristics of the bowel movements these patients present with. Bright red blood per rectum is usually associated with a lower bleed; if brisk and significant enough, however, upper bleeds can present similarly. Melenic or "tar-colored" bowel movements are more likely to occur from upper bleeds as the color is secondary to digestion of hemoglobin as it passes through the GI tract. At times, there can be a mix of the two which can make a clinical decision for intervention less obvious. To make matters more difficult, some of these patients can be on anticoagulation therapy for a myriad of reasons. Risks versus benefits at these times need to be weighed as holding this therapy may make the patients more prone to clotting while continuation would increase likelihood of bleeding. We present a case of a hypercoagulable patient who was started on rivaroxaban for history of pulmonary embolism; this led to the onset of an acute GI bleed from a duodenal diverticulum requiring endoscopic intervention. Although this can be a known effect of the therapy, the severity of bleed and changes in hemodynamics can warrant very different management strategies.

A Rare Case of Hypothyroidism-Induced Rhabdomyolysis

Rhabdomyolysis is a condition caused by muscle breakdown. It can be usually associated with pain, weakness, and elevated creatinine kinase levels on laboratory testing. There are various triggers, some of which can include trauma, dehydration, infections, and, as in this case, autoimmune disorders. Here, we present a case of a patient with worsening muscle pain who was found to have elevated creatinine kinase levels and undiagnosed hypothyroidism, with symptoms improving with intravenous hydration and thyroid supplementation.

A Rare Manifestation of Hepatitis A Associated Cryoglobulinemia

Cryoglobulins can precipitate in the blood when exposed to lower temperatures. These abnormal immunoglobulins are more commonly affiliated with Hepatitis C infection but there have been cases reported with Hepatitis A association for which we present this case. The patient was treated with steroids which did show gradual improvement of symptoms but, ultimately, the patient developed renal failure and required temporary hemodialysis. Care should be taken to assess patients with cryoglobulins for other viral serologies besides Hepatitis C.

Two fine-scale channels for encoding motion and stereopsis within the human magnocellular stream

In humans and non-human primates (NHPs), motion and stereopsis are processed within fine-scale cortical sites, including V2 thick stripes and their extensions into areas V3 and V3A that are believed to be under the influence of magnocellular stream. However, in both species, the relative functional organization (overlapping vs. none overlapping) of these sites remains unclear. Using high-resolution functional MRI (fMRI), we found evidence for two minimally-overlapping channels within human extrastriate areas that contribute to processing motion and stereopsis. Across multiple experiments that included different stimuli (random dots, gratings, and natural scenes), the functional selectivity of these channels for motion vs. stereopsis remained consistent. Furthermore, an analysis of resting-state functional connectivity revealed stronger functional connectivity within the two channels rather than between them. This finding provides a new perspective toward the mesoscale organization of the magnocellular stream within the human extrastriate visual cortex, beyond our previous understanding based on animal models.

Yeasts from Iranian traditional milk kefir samples: isolation, molecular identification and their potential probiotic properties

Milk kefir is a fermented dairy product with numerous attributed health benefits due to the presence of a complex eukaryotic and prokaryotic microbiota. In this study, a total number of 26 yeast isolates were obtained from eight kefir samples from three different cities of Iran. The isolates belonged to Kluyveromyces marxianus, Saccharomyces cerevisiae, Pichia fermentans and P. kudriavzevii. The potential probiotic characteristics of the isolates were evaluated based on their ability to tolerate the stimulated condition of the gastrointestinal tract. In addition, hemolytic activity, adherence to different solvents, auto-aggregation, adhesion to the epithelial intestine-derived cells and antimicrobial activity of the selected isolates were evaluated. Overall, four yeast strains (three strains of S. cerevisiae and one strain of P. fermentans) showed resistance and survival ability against the gastrointestinal physiological conditions including acidic pH, presence of bile salt and digestive enzymes. They were able to grow at 37 °C and had the capacity to adhere to epithelial intestine-derived cells. These results suggest that the selected strains can be proper candidates as probiotic yeast strains for the development of novel functional foods.

The future of bypassing agents for hemophilia with inhibitors in the era of novel agents

Bypassing agents are presently the standard of care for the treatment of bleeding episodes in patients with hemophilia and high-titer inhibitors and are also used for bleed prevention. Only two bypassing agents are available to patients, and these products trace their lineage to the 1970s (activated prothrombin complex concentrates) and the 1980s (recombinant factor VIIa). Given the limited repertoire of available products, clinicians have relied on experience, empirical observation, registry data and individualized care to improve clinical outcomes on a case-by-case basis. Research over the past two decades has culminated in a greatly improved understanding of human coagulation; resulting from this, new products have been developed that offer treatment options and mechanisms of actions that differ from current bypassing agents. The most advanced in clinical development is emicizumab, a bispecific antibody that mimics the function of FVIIIa in the intrinsic Xase complex and is indicated for once-weekly or every-other-week prophylactic dosing in inhibitor patients. Other non-traditional products in clinical development include fitusiran and antibodies directed against tissue factor pathway inhibitor. As non-factor-based therapies become more widely utilized over time, the use of bypassing agents may be expected to decrease; however, bypassing agents will remain essential for the foreseeable future. As such, clinical development of bypassing agents continues, with some products (e.g. eptacog beta) under regulatory review. In this review we examine the optimal use of bypassing agents and their mechanism of action. We also discuss newer products and how these might theoretically be administered in conjunction with traditional bypassing agents.

H-bonding in liquid N-methylformamide as studied by X-ray scattering

A structural investigation of liquid N-methylformamide, C(2)H(5)NO, was performed at room temperature and atmospheric pressure using X-ray scattering. Experimental data are analysed to yield the molecular structure factor and the distinct pair correlation function. The more dominant form (cis or trans) is considered and the H-bonding parameters are deduced. In order to describe the local arrangement in the liquid, different models are examined.

Atrial natriuretic peptide levels in geriatric patients with nocturia and nursing home residents with nighttime incontinence

OBJECTIVES

To determine if nocturnal polyuria in geriatric patients with nocturia and nocturnal incontinence is associated with elevated plasma atrial natriuretic peptide (ANP) levels.

DESIGN

Case series.

SETTING

Four nursing homes and two board and care facilities.

PARTICIPANTS

Fifty-four nursing home residents and 26 board and care residents with a mean age of 86.

MEASUREMENTS

Daytime (7:00 a.m. to 7:00 p.m.) and nighttime (7:00 p.m. to 7:00 a.m.) urine volumes of incontinent nursing home residents were measured over 3 days and 3 nights by reweighing preweighed adults diapers and toileting inserts emptied by research staff for the board and care group. Blood was drawn in the early morning (5:00 a.m. to 7:00 a.m.) before subjects arose and in the evening after an hour of lying in bed (8:00 p.m. to 11:00 p.m.), and plasma ANP levels were determined by radioimmunoassay.

RESULTS

Forty-nine (61%) of the subjects had nocturnal polyuria as defined by night/total urine volume ratios > or = 50%. There was no significant difference between those with night/total ratios > or = 50% versus < 50% in plasma levels of ANP in the early morning (44.2+/-33.3, median 35.7 pg/mL vs 40.9+/-39.2, median 28.5; P = .36 by Mann Whitney U) or in the evening (43.4+/-28.8, median 36.4 pg/mL vs 49.6+/-53.1, median 34.4; P = .58). Nor was there any significant correlation between night/total urine volume ratio and morning or evening ANP levels (r = .01, P = .96 and r = .23, P = .31, respectively).

CONCLUSIONS

In this sample of geriatric patients with nocturia and nursing home residents with nighttime urinary incontinence, ANP levels were elevated, but increased nighttime urine production was not associated with higher levels. Because of the variability in ANP levels, our power to detect such an association was low, and we cannot draw any definitive conclusions. Although high plasma ANP levels are unlikely to be a primary cause of nocturia and nighttime incontinence, they may, when combined with other factors such as low antidiuretic hormone levels, sleep disorders, and low functional bladder capacity, contribute to these symptoms in some geriatric patients.

Inhibition of tissue repair by spironolactone: role of mineralocorticoids in fibrous tissue formation

Mineralocorticoids have been implicated in promoting fibrous tissue formation in various organs. In the present study, we sought to address the potential contribution of mineralocorticoids to fibrous tissue formation using a skin pouch model which has proved valuable for the analysis of inflammatory and wound healing responses. Skin pouches were induced in rats by administration of a phorbol ester, croton oil (0.5 ml of a 1% solution). After 2 weeks, rats were killed and intact pouch tissue collected. Pouch weights of control and aldosterone-treated (0.75 microg/h via osmotic minipump) rats were similar (3.33 +/- 0.44 g vs. 3.70 +/- 0.28 g respectively). However, pouch weights were reduced by more than 50% in spironolactone-treated (25 mg/day powdered in food) animals (1.62 +/- 0.22 g and 1.27 +/- 0.23 g respectively in aldosterone and spironolactone alone groups). To ascertain the effects of different treatments on collagen accumulation, hydroxyproline concentration was measured. Compared with controls, hydroxyproline concentration was significantly reduced following spironolactone treatment (17.1 +/- 0.08 vs. 7.5 +/- 2.0 microg/mg dry wt, respectively, p < 0.01). This response to spironolactone was negated by coadministration of aldosterone (hydroxyproline concentration was 18.6 +/- 2.1 microg/mg dry wt). Following bilateral adrenalectomy, spironolactone reduced pouch weight and hydroxyproline concentration, which was not the case for adrenalectomy alone. Two week aldosterone administration in uninephrectomized rats on high salt diet was deemed ineffective in modulating pouch development (pouch wet wts were 3.48 +/- 0.4 g vs. 3.00 +/- 0.19 g in controls and aldosterone-treated rats, respectively). Mineralocorticoid receptor expression in pouch tissue was demonstrated by RT/PCR. Furthermore, NADP+-dependent 11beta-hydroxysteroid dehydrogenase 1 (11beta-HSD1) activity was detected in pouch tissue, together with lower levels of NAD+-dependent 11beta-HSD2. Spironolactone (p < 0.05) significantly reduced 11beta-HSD1 activity compared with controls. Thus, fibrous tissue possesses requisite components of MC action, and antagonism of mineralocorticoid receptors by spironolactone attenuates its formation. Pouch formation is under the influence of circulating MC and, we would like to propose, is also mediated through corticosteroids generated de novo at the site of tissue repair.

A single gene for human TRAF-3 at chromosome 14q32.3 encodes a variety of mRNA species by alternative polyadenylation, mRNA splicing and transcription initiation

Human TRAF-3 is a signaling molecule that interacts with the cytoplasmic tails of CD40 and other TNF-receptor family members. TRAF-3 mRNA is expressed as two major classes of approximately 2 and 8 kb and a number of TRAF-3 encoding cDNA clones differ in discrete gene segments. Because this variety of mRNA species could result from mRNA processing events and/or multiple genes, the structure and localization of TRAF-3 encoding gene elements were determined. FISH and radiation hybrid mapping demonstrated that TRAF-3 is located at chromosome 14q32.3, approximately 1 Mb centromeric to the Ig heavy chain gene complex. Physical mapping of four overlapping genomic PAC clones established that TRAF-3 transcripts are encoded by a single gene, comprised of 13 exons and spanning 130 kb. Alternative polyadenylation in the mRNA segment encoded by exon 12 accounts for the difference between the 2 kb and the 8 kb classes of transcripts. Alternative mRNA splicing in the coding region (encoded by exons 3-12) generates transcripts which delete exons 8 (75 nt), 7+8 (156 nt) or 8+9 (168 nt) and that encode distinct protein isoforms (delta25, delta52 and delta56 aa, respectively). Alternative splicing of exon 2 (139 nt) and alternative transcriptional initiation result in mRNA species with distinct 5'UTRs. Together, these data indicate that a single TRAF-3 gene encodes a variety of mRNA species by a combination of alternative polyadenylation, alternative mRNA splicing and/or alternative initiation.

An immunofluorescent assay for acute promyelocytic leukemia cells

Sequential treatment with all-trans retinoic acid followed by chemotherapy significantly improves the long-term survival of patients who have acute promyelocytic leukemia (APL). Consequently, a simple and accurate test is needed to establish the diagnosis of APL and to identify those patients having a relapse of the disease. We describe an accurate, 2-hour indirect immunofluorescent assay for identifying APL cells in bone marrow specimens. The assay uses the PML (PG-M3) murine monoclonal antibody that is directed against the amino-terminal portion of the PML gene product. We observed a distinctive, finely speckled pattern of fluorescence in the NB4 cell line (a positive control), as well as in 15 clinical specimens that were confirmed to have APL by cytogenetic, cytochemical, and immunophenotypic studies, including four cases of microgranular variant of APL. By contrast, a coarse globular pattern of fluorescence was observed in 53 other clinical specimens that did not contain APL. When we performed dilution studies using artificial mixtures of APL cells with normal bone marrow cells, we detected as few as 5% APL cells in the mixture. Finally, there was complete concordance between the immunofluorescent assay and a polymerase chain reaction-based assay for the PML-retinoic acid receptor alpha chimeric gene in 12 other clinical specimens. We conclude that the immunofluorescent assay for PML protein is a rapid, sensitive, and accurate method for determining the presence of APL cells in clinical specimens. This assay therefore should be considered as a cost-effective alternative to other diagnostic tests, such as karyotyping or polymerase chain reaction, for the diagnostic evaluation of APL.

An automated image analysis method for the measurement of neutrophil alkaline phosphatase in the prenatal screening of Down syndrome

OBJECTIVES

(1) To develop an image analysis method for the measurement of neutrophil alkaline phosphatase (NAP); (2) To establish a correlation of urea-resistant fraction of NAP (URNAP)/NAP scoring between the manual and automated methods, and (3) to assess the value of URNAP/NAP in the prenatal screening of Down syndrome.

STUDY DESIGN

Slides from 15 unaffected controls were blindly scored by both methods. The Pearson test was used for correlation analysis. Slides from 15 Down syndrome pregnancies and 25 unaffected controls were scored manually.

RESULTS

A coefficient r = 0.93 was obtained comparing the URNAP/NAP scores generated by the two methods. Average time for scoring by the automated method was 8 min. The median URNAP/NAP values for Down syndrome and unaffected controls were 112/86.1 and 51/51.5, respectively.

CONCLUSIONS

Scores obtained by both methods highly correlate. Automated scoring is threefold faster. Down syndrome cases have higher URNAP/NAP scores compared to unaffected controls, which suggests that URNAP/NAP is an extremely useful marker for mid-trimester prenatal screening.

HCV-associated hepatocellular carcinoma without cirrhosis

BACKGROUND/AIMS

Hepatocellular carcinoma is an aggressive malignancy and carries a poor prognosis. Hepatitis B and C virus infection, cirrhosis and aflatoxin B1 exposure are considered major risk factors. The role of hepatitis C virus in the causation of hepatocellular carcinoma has been debated. It is a positive, single-stranded RNA virus without a DNA intermediate in its replicative cycle, so that integration of hepatitis C virus nucleic acid sequences into the host genome seems unlikely. The most plausible explanation of hepatitis C virus-associated hepatocellular carcinoma so far is that the virus causes necroinflammatory hepatic disease with vigorous regeneration, fibrosis, and eventually cirrhosis. The aim of this study was to examine the relationship of hepatitis C, cirrhosis and hepatocellular carcinoma.

METHODS

Sixty-six consecutive patients with hepatocellular carcinoma undergoing resection or transplantation at the Royal Free Hospital were reviewed. A combination of serological data and polymerase chain reaction assay was used to assign hepatitis C virus and hepatitis B virus infection.

RESULTS

We found four HCV-RNA positive patients with hepatocellular carcinoma without cirrhosis. All four cases were positive for HCV-RNA and negative for all markers of hepatitis B virus infection.

CONCLUSIONS

These four cases show that hepatocellular carcinoma may develop in patients with hepatitis C virus without pre-existing cirrhosis. However, the precise role of hepatitis C virus in hepatocarcinogenesis, the carcinogenic potential of the different genotypes and whether this role is influenced by other risk factors still have to be clarified.

Large granular lymphocyte proliferation with the natural killer-cell phenotype

Lymphoproliferated disorders involving large granular lymphocytes (LGL) can be divided into a common T-cell subset (CD3+, CD8+) and a rarer natural killer (NK)-cell subset (CD2+, CD3-). The immunophenotype, clinical pathologic features, and cytogenetic and molecular genetic analyses are reported for seven patients with NK-cell-LGL proliferation. The typical immunophenotype was CD2+, CD3-, CD4-, CD11b+, and CD16+ or CD56+. A low but variable percentage of cells were CD8+ or CD57+. Unusual phenotypes with CD2- (1 of 7), CD11b- (1 of 7), or CD16-/CD56- (1 of 7) cells were seen. Strong NK-cell activity was observed in all cases, indicating that none of the NK-cell markers (CD11b, CD16, CD56, CD57) is essential for NK-cell activity. One patient died shortly after diagnosis from coexistent refractory multiple myeloma and another patient died within 1 month from the LGL proliferation. The other patients had been followed for 12 to 70 months, with a median follow-up period of 38 months. There was no progression of their LGL proliferation. Lymphocyte counts varied from 3.3 x 10(3)/microL to 58.4 x 10(3)/microL at the time of diagnosis. Unexplained anemia and neutropenia were observed in one patient. Cytogenetic abnormalities were detected in two of four patients studied with t(6;12) in one and der(5), der(6), and der(11) in the other. The approximately T gamma and T beta genes were in the germline configuration and Epstein-Barr virus DNA was undetectable in five of five patients studied. Natural killer-cell LGL proliferations were morphologically indistinguishable from T-cell LGL proliferations. However, the two were immunophenotypically and genotypically distinct and NK-cell activity was consistently observed in the former. Most of the NK-cell proliferations also were chronic indolent disorders and the incidence of associated cytopenias seemed to be lower than T-cell LGL proliferations.

Characterization of an intron 12 splice donor mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene

Cystic fibrosis, the most common lethal genetic disease in the white population, is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Analysis of DNA from a pancreatic insufficient patient by chemical mismatch cleavage and subsequent DNA sequencing led to the identification of a potential splice mutation in the CFTR gene. A transition of the invariant guanosine to adenosine (1898 + 1G > A) was found at the splice donor site of intron 12. To determine the effect of this mutation on the patient's CFTR transcripts, RNA from the nasal epithelium was reverse transcribed and amplified by the polymerase chain reaction (RT-PCR). Direct sequencing of the PCR products revealed that the transcript from the chromosome with the 1898 + 1G > A mutation had skipped exon 12 entirely, resulting in a joining of exons 11 and 13. Deletion of exon 12 results in the removal of a highly conserved region which encodes the Walker B consensus sequence of the first nucleotide-binding fold of CFTR.

Effects of recombinant interferon-gamma and interleukin-2 on the generation of lymphokine-activated killer cells in vitro

In order to determine if recombinant interferon-gamma (rIFN-gamma) can augment the effect of recombinant interleukin-2 (rIL-2) in generating lymphokine-activated killer (LAK) cells, we have incubated normal peripheral blood mononuclear cells (PBMC) with these lymphokines for 3 days and then tested their LAK and natural killer (NK) cell activity. We have found that LAK activity in PBMC from 13 out of 13 normal donors was increased by the combined lymphokines above that due to either lymphokine alone, provided that rIL-2 was present at suboptimal concentration: Optimal levels of rIFN-gamma (100 U/ml) were able to enhance the LAK-inducing activity of suboptimal levels (5 U/ml) but not optimal levels (100 U/ml) of rIL-2. NK activity showed a similar response to these concentrations of lymphokines. Activation of LAK/NK cells was accompanied by increases in the percentages of Leu 19+ (CD56) cells and TAC+ (IL-2-receptor) cells, and in the intensity of TAC antigen expression. These results indicate that combination rIFN-gamma and rIL-2 may be more effective in generating LAK/NK cells than rIL-2 alone, particularly with suboptimal concentrations of rIL-2 such as occur during continuous infusion therapy with this agent.

A phase I study of interleukin-2 in children with cancer and evaluation of clinical and immunologic status during therapy. A Pediatric Oncology Group Study

The authors performed a Phase I study to assess the toxicity and hematologic effect of recombinant human interleukin-2 (rIL-2) in seven children with advanced malignancies. The rIL-2 was given as a bolus injection of 1 or 3 X 10(6) U/m2/dose three times a week (Monday, Wednesday, and Friday) for 3 weeks. No life-threatening toxicity occurred with the dose of 1 X 10(6) U/m2 of rIL-2. At a dose of 3 X 10(6) U/m2, therapy had to be terminated due to cardiovascular toxicity in two patients. Toxic effects at low-dose rIL-2 included fever, nausea, vomiting, and mild hypotension. High-dose rIL-2 toxicity included fluid retention, increased creatinine, oliguria, elevated liver enzymes, and significant hypotension. Immunologic studies showed that rIL-2 caused a drop in the number of circulating peripheral blood mononuclear cells, T-cells, and natural killer cells which returned to pretherapy levels or above by 24 to 48 hours. The rIL-2 exerted no growth or stimulatory activity on the leukemic cell population. To the authors' knowledge, this is the first report of a Phase I study of IL-2 therapy in children.