Is push enteroscopy useful in patients with malabsorption of unclear origin?

OBJECTIVE: The aim of this study was to determine the diagnostic value of push enteroscopy in patients with chronic diarrhea and malabsorption of unclear origin. METHODS: From January, 1997, to September, 1999, 16 consecutive patients with chronic diarrhea and biological signs of intestinal malabsorption but no evidence of celiac disease were explored by push enteroscopy. Previous duodenal histological findings had been normal in seven patients and abnormal but inconclusive in nine patients. Endoscopic and histological findings in the duodenum and in the jejunum were compared. RESULTS: Push enteroscopy with jejunal biopsy yielded a diagnosis in comparison with duodenal biopsy in two of 16 (12%) patients, respectively, in two of the nine (22%) patients with abnormal but inconclusive findings on duodenal biopsy, and none of the seven patients with normal duodenal histology. In the two patients in whom jejunal biopsy had diagnostic value but duodenal biopsy did not, the final diagnoses were invasive intestinal lymphoma and microsporidiosis. CONCLUSION: Push enteroscopy had diagnostic value in only 12% of patients with malabsorption of unclear origin, all of whom had had abnormal but inconclusive duodenal histological findings. Push enteroscopy with jejunal biopsy appears to have limited diagnostic value in patients with chronic diarrhea and malabsorption, especially when duodenal biopsies are histologically normal.     

Procalcitonin and pneumonia: Is it a useful marker?

An ideal biomarker for pneumonia should allow an early diagnosis and differential diagnosis from noninfectious conditions and should inform about the course and prognosis of the disease. Procalcitonin (PCT) covers these features better as compared to more commonly used biomarkers like C-reactive protein or leukocyte count. PCT complements and improves the assessment of pneumonia based on careful patient history, dedicated physical examination, and appropriate cultures. Importantly, a PCT-based therapeutic strategy can safely and markedly reduce antibiotic courses in community-acquired pneumonia. However, as is the cast with all diagnostic surrogate markers, PCT can be increased in noninfectious conditions and may remain low in bacterial infections, especially localized infections. This stresses the importance of follow-up measurements, because PCT levels in these patients often show a gradual increase during follow-up. Although PCT is better than more common biomarkers for the prognosis of pneumonia and to predict survival and outcome, novel biomarkers show an even better prognostic accuracy.     

Lung surgery in haematological patients: useful? hazardous?

Respiratory complications are frequent in haematological patients. Lung surgery, either for diagnosis or treatment, is considered useful but hazardous in these patients. We performed a reappraisal study of this purpose; retrospective study in a university centre, located in the Paris area, France. We analysed the entire records of all the haematological patients admitted in the Thoracic Surgery department from October 2001 to January 2009, among 400 haematological patients with pulmonary complications admitted to the Respiratory Diseases department. Seventeen patients (male: n = 13, mean age 47 ± 15 years) underwent lung surgery. Underlying haematological disease was acute (n = 7) or chronic (n = 5) leukaemia, lymphoma (n = 4), and eight have had stem cell transplantation. Thirteen patients had been exposed to a cytotoxic chemotherapy with known pulmonary toxicity. Respiratory diseases have been evolving for 112 days (10–663 days), and 14 patients received previously antibiotic and/or antifungal therapy. One patient was neutropenic and three had thrombopenia. Five patients underwent curative surgery for a residual pulmonary nodule after medical treatment of invasive aspergillosis, and 12 had a diagnostic procedure (open lung biopsy by video-assisted thoracoscopy [n = 2]; thoracotomy [n = 8]). Surgery permitted a final diagnosis in all 12 cases: non-specific infiltrative pneumonia (n = 4), pulmonary graft versus host disease (n = 3), granulomatous pneumocystosis (n = 1), invasive aspergillosis (n = 1), bronchial carcinoma (n = 1), EBV-related lymphoproliferation (n = 1), and tuberculosis (n = 1). Therapeutic regimens were modified according to the surgical results in ten cases (84%). All patients were extubated at the end of surgery. Post-operative complications were: prolonged air leaks (n = 3), pneumonia (n = 1), parenchymal hematoma (n = 1), acute coronary syndrome (n = 1). Seven patients were admitted in the Intensive Care Unit, and five had non-invasive ventilation. Three patients died from respiratory failure: NSIP (n = 2), pneumocystosis (n = 1). Lung surgery for selected haematological patients has two indications: (1) curative surgery, for a residual pulmonary nodule after medical treatment of invasive aspergillosis; (2) diagnostic procedure, leading frequently to modifications of therapeutic regimens, with low rate of complications, in highly selected patients.     

Evaluation of hands-on training in colonoscopy: Is a computer-based simulator useful?

Background and aimsThe advantages of using a computer-based simulator during colonoscopy training are debated. We aimed to explore its usefulness in objectively measuring trainees’ competence in colonoscopy.MethodsTwelve colonoscopy trainees (fully trained in upper GI endoscopy) were evaluated using a computer-based simulator (GI-Mentor, Symbionix) before and during hands-on training (i.e. after 60 colonoscopies); the controls were 15 experts (>90% of caecal intubation). Both trainees and experts performed two “screening” simulations (easy and difficult) in a randomised order, and the time to reach the caecum and withdrawal time was assessed.ResultsThe percentage of caecal intubation progressively increased during hands-on training. All of the trainees intubated the caecum during the easy and difficult simulations, both before and during hands-on training. The median time (interquartile range) to reach the caecum upon easy simulation was the only variable influenced by hands-on training: 2.7 min (2.1–3.2) before and 1.9 min (1.6–2) during training (p < 0.01). Withdrawal time was ≥6 min in the case of five trainees before training, and three during hands-on training. Computer-based simulator performance did not correlate with hands-on training performance.ConclusionsThe computer-based simulator was not found to be useful in evaluating competence during hands-on training in colonoscopy.     

Markers of electrical instability in hypertensive patients with and without ventricular arrhythmias. Are they useful in identifying patients with different risk profiles?

BACKGROUND: Markers of electrical instability of the ventricular myocardium, namely abnormal repolarization and late potentials, are frequently observed in patients with hypertension when both ventricular arrhythmias and left ventricular hypertrophy are present. This information cannot be extrapolated to the population of hypertensive patients with ventricular arrhythmias but without left ventricular hypertrophy. OBJECTIVE: To evaluate QT duration, QT dispersion and the incidence of ventricular late potentials in patients with essential hypertension, already on anti-hypertensive therapy, both with and without non-sustained ventricular arrhythmia. DESIGN: The study population consisted of 49 patients with essential hypertension who were compared to 89 control normotensive subjects both with and without frequent (> 30 per h) ventricular ectopic beats (VPBs). Patients were divided into four groups: (1) hypertensive patients without VPBs (H, n = 19), (2) hypertensive patients with VPBs (HA, n = 30), (3) normotensive subjects without VPBs (C, n = 28), and (4) normotensive subjects with VPBs (CA, n=61). METHODS: Echocardiographic parameters, QT interval, QT dispersion and signal-averaged ECG were evaluated without withdrawing anti-hypertensive drugs. RESULTS: In no case was left ventricular hypertrophy documented. The number of VPBs during 24 h Holter recording (median 11 343 versus 7617) and the incidence of repetitive VPBs (37 versus 46% of patients) were similar in the two groups of patients (HA versus CA). Signal-averaged ECG parameters were normal and not different between the four groups. QT interval was longer in hypertensive patients compared to controls irrespective of the presence of VPBs. QT dispersion was slightly greater in subjects with VPBs, both hypertensive and normotensive, compared to subjects without arrhythmias. CONCLUSIONS: In patients with hypertension well-controlled by drug therapy and without left ventricular hypertrophy, frequent VPBs are not associated with markers indicating an electrophysiological substrate for re-entrant arrhythmias. However, QT prolongation suggests the persistence of a higher risk of cardiovascular mortality that is independent of the presence of VPBs.     

Behçet's disease in patients of German and Turkish origin living in Germany: a comparative analysis

OBJECTIVE: To evaluate the relationship between ethnic origin and manifestations of Beh?et's disease (BD) in patients of German and Turkish origin living in Germany. METHODS: Between 1995 and 2000, 32 patients of German and 33 patients of Turkish origin living in Germany were evaluated for the entire spectrum of disease manifestations, disease severity, HLA associations, sex, age at disease manifestation, and time to diagnosis. RESULTS: There were no statistically significant differences between German and Turkish patients. There was no association of sex or HLA-B51 with any manifestation of BD. The only significant difference between the 2 groups was the median time from the first manifestation of the disease to diagnosis, which was 0 years for the Turkish, but 3.5 years for the German patients (p = 0.0005). Additionally, 4 patients of German origin had been misdiagnosed as having spondyloarthropathy (SpA) before the final diagnosis of BD was made (12%). In comparison to Turkish patients living in Turkey (data from the literature), only 2 differences were found: one concerned the frequency of ocular involvement (lower in the patients in Turkey), and the other the male to female ratio, which was reported as 1.03:1 in Turkey, but 3.7:1 in Germany. CONCLUSION: Our results do not favor an ethnic influence on the expression of BD. Environmental influences may be responsible for the higher frequency of ocular manifestations and the higher male to female ratio in patients living in Germany compared to those living in Turkey.     

Epidemiology of febrile neutropenia in patients with hematological disease——a prospective multicentre survey in China

<正>Objective To investigate the incidence,clinical and microbiological features of febrile,and risk factors during neutropenia periods in patients with hematological diseases.Methods From October 20,2014 to March 20,2015,consecutive patients who had hematological diseases and developed neutropenia during hospitalization were