Anismus: Fact or fiction?

PURPOSE: Although anismus has been considered to be the principal cause of anorectal outlet obstruction, it is doubtful whether contraction of the puborectalis muscle during straining is paradoxical. The present study was conducted to answer this question. METHODS: During the first part of the study, we retrospectively reviewed 121 patients with constipation and/or obstructed defecation (male:female, 10/111; median age, 51 years). All of these patients underwent electromyography (EMG) of the pelvic floor and the balloon expulsion test (BET) in the left lateral position. Evacuation proctography was performed in all of these patients in the sitting position. Both the posterior anorectal angle and the central anorectal angle were measured. EMG and BET were also performed in ten controls (male:female, 4/6; median age, 47). In 147 patients with fecal incontinence (male:female, 24/123; median age, 58) only EMG activity was recorded. Criteria for anismus during straining were increase or insufficient (<20 percent) decrease of EMG activity, failure to expel an air-filled balloon on BET, and decrease or insufficient (<5 percent) increase of anorectal angle on evacuation proctography. Between June 1994 and March 1995, we conducted a second prospective study in a consecutive series of 49 patients with constipation and/or obstructed defecation and 28 patients with fecal incontinence. Both groups were compared with 19 control subjects. In this study, all three tests were performed. EMG and BET were performed both in the left lateral position and in the sitting position. RESULTS: The retrospective study was undertaken by comparing the constipated patients with the incontinent patients and the controls, and the anismus detected by EMG was found in, respectively, 60, 46, and 60 percent. Failure to expel the air-filled balloon was observed in 80 constipated patients (66 percent) and in 9 control subjects (90 percent). Based on posterior anorectal angle and central anorectal angle measurements, anismus was diagnosed in, respectively, 21 and 35 percent of constipated patients. In the prospective study, none of the tests showed significant differences regarding the prevalence of anismus between the two subgroups of patients and the control subjects. The prevalence of anismus only differed between constipated and incontinent patients when the diagnosis was based on BET in the sitting position (67 vs.32 percent;P <0.005). Our study shows that contraction of the puborectalis muscle during straining is not exclusively found in patients with constipation and/or obstructed defecation. The three tests most commonly used for the diagnosis of anismus showed an extremely poor agreement. CONCLUSION: Based on these findings, we doubt the clinical significance of anismus.     

Percutaneous valve replacement: Fact or fiction?

Percutaneous catheter-based interventions are an emerging area in the treatment of valvular heart disease. Despite many limitations related to device technology, valve durability and stability, and anatomical obstacles, the early results of percutaneous catheter-based valve repair and replacement are promising. The procedures are currently aimed at high-risk patients who cannot undergo conventional surgical management. The first percutaneous heart valve replacement occurred in 2002 in the pulmonary position. Subsequently, the early experience in the literature has reported over 50 human cases. The anatomical complexities of the aortic root have made success more elusive for percutaneous aortic valve replacement. Only a few cases have been reported, with variable success described. Percutaneous mitral valve replacement has not been reported to date; however, clinical trials are underway evaluating catheter-based techniques of mitral valve repair. Present enthusiasm should be tempered because scarcely more than 100 patients worldwide have undergone percutaneous valve interventions. Nonetheless, it is inevitable that as technology develops to overcome the present limitations and develop safe and effective techniques, percutaneous heart valve repair and replacement will undoubtedly increase in frequency. Scrupulously designed clinical trials must be performed to definitively determine the short- and long-term results of these procedures as compared with the gold standard of open surgical repair, as well as to define the appropriate patient population that will benefit the most.     

Gynecologic complications of bacterial vaginosis: Fact or fiction?

Bacterial vaginosis is a complex alteration of vaginal flora causing mild symptoms in women characterized by a milky vaginal discharge associated with a fishy odor worsened after unprotected vaginal coitus. It is the most common cause of vaginitis. It is now clear that this seemingly harmless disorder causing nuisance symptoms is linked to a number of important adverse reproductive tract sequelae, including the obstetrical sequelae of preterm labor and delivery. Literature published over the past year continue to support the association of bacterial vaginosis with adverse gynecologic sequelae in women.     

Seronegative rheumatoid arthritis. Fact or fiction?

Patients with clinical features of rheumatoid arthritis (RA) but negative rheumatoid factor (RF) present a diagnostic challenge. The seronegative spondyloarthropathy (SNSA) syndromes, previously believed to be "rheumatoid arthritis variants," eg, Reiter's syndrome and psoriatic arthritis, are now considered to be genetically separate from RA and have been shown to be closely associated with HLA-B27. This syndromic discrimination has raised question as to the validity of RF negative RA (ie, seronegative RA). Demographic, clinical, and roentgenologic features of seronegative RA and SNSA are compared. Also, more common diagnoses that may stimulate seronegative RA are outlined according to onset age of arthritis. Recent concepts of RF positivity and HLA-DR4 correlations are reviewed. Multiple unknown factors contribute to the currently recognized syndrome of RA. Its diagnosis continues to rest on an aggregate of host, clinical, immunologic, and radiologic features.     

Aspirin resistance: Fact or fiction? A point of view

Aspirin is a wonder drug that has been used for well over 100 years for its analgesic and antipyretic effects. For the past three decades, it has increasingly been used for the prevention of primary and secondary cardiovascular events. Lately, it has been suggested that a significant number of individuals taking aspirin have become resistant to this drug. The phenomenon of "aspirin resistance" is based on the observation of clinical events in some patients taking aspirin, and/or a diminished platelet aggregation inhibitory response to aspirin therapy. Unfortunately, laboratory assays used to monitor the efficacy of aspirin are far from accurate and the results are not reproducible. Furthermore, results of different platelet function tests are often not congruent. In addition, platelet aggregation studies show marked inter-individual and intra-individual variability. Patients with coronary heart disease take many drugs that interfere with the effect of aspirin on platelet aggregation. Besides inhibiting formation of thromboxane A(2) from arachidonic acid, aspirin has a host of platelet-independent effects that complement its platelet inhibitory effects. Laboratory assays designed to measure platelet function do not take into account these pleiotropic effects of aspirin. In our view, use of the term "aspirin resistance" based on inadequate knowledge of imperfect laboratory tests does a disservice to physicians and patients.     

Cardiovascular risk in the metabolic syndrome: Fact or fiction?

In population-based studies, a cluster of cardiovascular risk factors comprising the metabolic syndrome (MetS) has been documented as predictive of cardiovascular disease events and type 2 diabetes. Currently, there are several proposed definitions of the MetS, although data support some advantages of using the 2005 National Cholesterol Education Program Adult Treatment Panel III definition, which is considered superior to most others, including the one from the 2005 International Diabetes Federation study. One controversial issue is that some of the conventional cardiovascular risk factors included in the MetS cluster appear to be equally predictive of cardiovascular outcomes as the syndrome itself (eg, the influence of smoking habits). Further observational and intervention studies are needed to explore this issue and target the core problem of the syndrome, which is proposed to be insulin resistance. Useful therapies for the metabolic syndrome include lifestyle modification and drugs that lower conventional cardiovascular risk factors, such as metformin, the "glitazones," and evidence-based drugs.     

The mitochondrial KATP channel—Fact or fiction?

The mitochondrial ATP-dependent K⁺ channel (mitoK_ATP) is widely considered by many to play a central role in cardioprotection by ischemic and pharmacological preconditioning and by ischemic postconditioning. Nevertheless, several laboratories have questioned the existence of mitoK_ATP. This article summarizes the evidence for and against and addresses two key questions: How strong is the evidence for the presence of a K_ATP channel in mitochondria? Are the pharmacological agents used to modulate mitoK_ATP activity sufficiently specific to allow the role of these channels in cardioprotection to be established?     

Hepatitis B virus infection and metabolic syndrome: Fact or fiction?

Although hepatitis C virus infection is known to be linked with insulin resistance, dyslipidemia, and hepatic steatosis, the relationship between hepatitis B virus (HBV) infection and metabolic factors remains unclear. HBV infection is a health problem worldwide, especially in endemic regions such as Asia and Africa. It induces liver decompensation, cirrhosis, hepatocellualr carcinoma, and premature mortality. The prevalence of metabolic syndrome continues to increase in parallel with the epidemic of obesity, which is closely associated with the development of diabetes, cardiovascular disease, or even cancer. The systemic review shows that chronic HBV infection protects against instead of promotes fatty liver. The mechanism is possibly due to a lower frequency of dyslipidemia profile in patients with chronic HBV infection. The association of HBV with metabolic syndrome, insulin resistance, and the risk of arteriosclerosis is still inconclusive. In addition, obesity, diabetes, and metabolic syndrome may accelerate the progression of liver disease in patients with chronic HBV infection and synergistically induce cirrhosis or even hepatocellualr carcinoma development.     

The relationship between migraine and right-to-left shunt: Fact or fiction?

The prevalence of a right-to-left shunt, both cardiac and pulmonary, is high in patients with migraines, especially migraine with aura. Percutaneous closure of a right-to-left shunt seems to be associated with a pronounced decrease in the number of migraine attacks or its prevalence. In this review, the relationship between migraine and right-to-left shunting is described by highlighting the different pathophysiologic hypotheses.     

An association between Helicobacter pylori and upper respiratory tract disease: Fact or fiction?

Helicobacter pylori(H. pylori) is a major cause of chronic gastritis and gastric ulcers and considerable evidence supports the notion that infection with this bacterium is also associated with gastric malignancy in addition to various other conditions including pulmonary, vascular and autoimmune disorders. Gastric juice infected with H. pylori might play an important role in upper respiratory tract infection. Although direct and/or indirect mechanisms might be involved in the association between H. pylori and upper respiratory tract diseases, the etiological role of H. pylori in upper respiratory tract disorders has not yet been fully elucidated. Although various studies over the past two decades have suggested a relationship between H. pylori and upper respiratory tract diseases, the findings are inconsistent. The present overview describes the outcomes of recent investigations into the impact of H. pylori on upper respiratory tract and adjacent lesions.     

Patients with liver cirrhosis suffer from primary haemostatic defects? Fact or fiction?

Patients with cirrhosis can have abnormalities in laboratory tests reflecting changes in primary haemostasis, including bleeding time, platelet function tests, markers of platelet activation, and platelet count. Such changes have been considered particularly relevant in the bleeding complications that occur in cirrhosis. However, several studies have shown that routine diagnostic tests, such as platelet count, bleeding time, PFA-100, thromboelastography are not clinically useful to stratify bleeding risk in patients with cirrhosis. Moreover, treatments used to increase platelet count or to modulate platelet function could potentially do harm. Consequently the optimal management of bleeding complications is still a matter of discussion. Moreover, in the last two decades there has been an increased recognition that not only bleeding but also thrombosis complicates the clinical course of cirrhosis. Thus, we performed a literature search looking at publications studying both qualitative and quantitative aspects of platelet function to verify which primary haemostasis defects occur in cirrhosis. In addition, we evaluated the contribution of qualitative and quantitative aspects of platelet function to the clinical outcome in cirrhosis and their therapeutic management according to the data available in the literature. From the detailed analysis of the literature, it appears clear that primary haemostasis may not be defective in cirrhosis, and a low platelet count should not necessarily be considered as an automatic index of an increased risk of bleeding. Conversely, caution should be observed in patients with severe thrombocytopenia where its correction is advised if bleeding occurs and before invasive diagnostic and therapeutic procedures.     

Gallbladder Dyskinesia: Fact or Fiction?

Gallbladder dyskinesia is a functional (motility) disorder of the gallbladder resulting in episodic abdominal pain that, in carefully selected cases, resolves with cholecystectomy. It is a diagnosis of exclusion: several functional and organic disorders have to be excluded, and confounding factors addressed, before a diagnosis of gallbladder dyskinesia can be entertained. The combination of high clinical suspicion and an abnormally low gallbladder ejection fraction on cholecystokinin stimulated-cholescintigraphy predict benefit from removing the gallbladder.     

Changing pollen types/concentrations/distribution in the United States: Fact or fiction?

The buildup of greenhouse gases in the atmosphere has resulted in global climate change that is having a significant effect on many allergenic plants through increases in plant productivity and pollen allergenicity and shifts in plant phenology. Based on experimental studies, increased atmospheric levels of carbon dioxide have directly increased plant productivity. This has affected the total amount of pollen produced in some species. Research has also shown increased levels of birch allergen at warmer temperatures. Warmer temperatures have resulted in earlier flowering for many spring-flowering species in many countries, recorded through visual observations of flowering and by airborne pollen. Increases in the cumulative season totals of various pollen types also have been recorded; some of these increases may be explained by changes in plant distribution.