Celiac disease: Do not miss that diagnosis!

Background

Celiac disease (CD) is a chronic autoimmune disorder induced in genetically susceptible individuals after ingestion of gluten proteins

Aim of the work

To highlight the utility of abdominal CT/enterography in diagnosis of CD.

Subjects & methods

This retrospective study included 12 patients presented to our institute during the period from May 2011 till April 2013 with vague abdominal symptoms, performed abdominal CT/enterography. The final diagnosis was reached in all patients through upper GI endoscopy, duodenal biopsy and serological tests including anti-tissue transglutaminase and anti-endomysial antibodies.

Results

The sensitivity of different CT signs was calculated against the diagnostic standard of reference (biopsy & serology). The jejuno-ileal fold reversal pattern was detected in 100% of patients. Other findings included (in descending order): Enlarged mesenteric lymph nodes in eight patients (66.5%); jejunal wall thickening, dilated jejunal loops, and cavitating lymph nodes in six patients (50%); dilated ileal loops in four patients (33%); ileal wall thickening in three patients (25%); thickened duodenum, and small bowel intussusception in two patients (16.5%).

Conclusions

CT is an efficient imaging tool in diagnosis of CD. The jejuno-ileal fold reversal pattern is highly in favor of the diagnosis of CD.     

Required Suspension of Do Not Resuscitate and/or Do Not Intubate Orders in Interventional Radiology: A Survey of Prevalence and Practices

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Attitudes of medical practitioners towards "Do Not Resuscitate" orders

When the desires of a patient are unknown or cannot be ascertained, cardio-pulmonary resuscitation (CPR) is the default procedure. Explicit, Do Not Resuscitate (DNR), orders are required to prevent implementation of CPR. We studied the response of general medical internists in specific clinical situations demanding consideration of DNR orders and respect for patient preferences; their current practice regarding slow codes and participation in CPR attempts considered futile provide information as to how often they discuss DNR issues with patients or families. Eighty-five internists attending the monthly meeting of the Internal Medicine Forum participated in the study. The physicians demonstrated their consent to participate by accepting a remote transmitter that elicited a response 2-3 minutes following the presentation of case vignettes or practice-related questions. The survey showed that 73% of the physicians agreed to assign a DNR order for a terminally ill patient unable to express her preferences. Only 55% agreed to do the same for a competent patient who specifically requested that CPR be withheld in the event of a cardiopulmonary arrest (p<0.05). 77% reported to have performed CPR, at least three times, in situations where they expected no benefit. 59% affirmed that their team had performed a partial CPR (slow code) at least once. Only 28% discussed the subject of DNR with patients or family more than 5 times a year. Paternalism, disregard for patients' preferences and poor communication skills influence normative behaviour in end-of-life decision-making.     

To Absorb or Not to Absorb: That Is the Question!

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Laboratory-Based Gait Variability and Habitual Gait Entropy Do Not Differentiate Community-Dwelling Older Adults from Those with Subjective Memory Complaints

BackgroundAge-related cognitive decline may be delayed with appropriate interventions if those at high risk can be identified prior to clinical symptoms arising. Gait variability assessment has emerged as a promising candidate prognostic indicator, however, it remains unclear how sensitive gait variability is to early changes in cognitive abilities.Research questionDo community-dwelling adults over 65 years of age with subjective memory complaints differ from those with no subjective memory concerns in terms of laboratory-measured or free-living gait variability?MethodsThis cross-sectional study recruited 24 (age = 73.5(SD 6.4) years) community-dwelling people with subjective memory complaints and twenty seven (age = 70.9(4.3) years) individuals with no subjective memory concerns. A sample of 9 individuals with diagnosed mild dementia were also assessed (age = 86.5(7.0) years). Gait variability was assessed in a laboratory during walking at preferred pace (single-task) and while counting backward by seven (dual-task). Sixteen passes over a 4.88 m walkway in each condition were recorded and step length and duration variability was analysed. Free-living gait was assessed with a waist-worn accelerometer by identifying gait bouts of at least one min duration, and the mean multiscale sample entropy in one mins non-overlapping epochs is reported. Statistical inferences were based on analysis of variance using sex and group as the factors.ResultsNo difference between those with subjective memory complaints and those without were observed in either laboratory- or free-living gait variability estimates. Both laboratory- and free-living gait variability were higher in those with mild dementia compared to the other groups.SignificanceAssuming that subjective memory complaints are on the pathway from cognitively intact to cognitively frail, the findings raise the hypothesis that subjective memory complaints occur earlier in the pathophysiology than measurable changes in laboratory or free living gait. Alternatively the gait variability assessments utilised may have been too insensitive.     

Kinks of the Transplant Renal Artery Without Accompanying Intraarterial Pressure Gradient Do Not Require Correction: Five-Year Outcome Study

Significant transplant renal artery stenosis (TRAS) results in an intraarterial pressure gradient and increasing graft dysfunction correctable by endovascular therapy. Kinks of the transplant artery cause velocity gradients on Doppler ultrasound, but some will have no intraarterial pressure gradient across the kink. It is not known whether these nonflow limiting kinks progress further to threaten graft function and should undergo endovascular correction. This is a longitudinal study of conservatively managed arterial kinks to define their natural history. Fourteen patients who had undergone angiography over a 5-year period for suspected TRAS had kinks of the renal artery. True intraarterial pressures were measured in all cases by slow withdrawal of an end-hole catheter after intraarterial injection of a vasodilator. Those with a significant pressure change (10% change in peak systolic pressure across the area of suspicion) underwent endovascular treatment. The rest were managed conservatively, with maximal antihypertensive therapy. Outcome of all 14 cases was determined by follow-up of creatinine levels, blood pressure (BP) control and graft outcome over a 3–5-year period (median 4 years). Of the 14 patients with kinks, 10 were male and 4 female; age range 23–67 years (mean 47 years). Eleven had received cadaveric transplants and 3 were allografts; 12 had end-to-side and 2 end-to-end anastomosis, 11/14 cases had an intraarterial pressure ratio of <10% and at median 4 years follow-up on conservative treatment, the serum creatinine of these 11 patients did not differ significantly from those who underwent successful endovascular treatment (mean 118 µmol/l versus 149 µmol/l; p = 0.30, Mann Whitney test). Mean blood pressure was 137/82 mmHg, with a range of 124–155/56–95 mmHg. Only one patient has required an unexplainable increase in antihypertensive medication. Grafts (2/11) were lost and both had chronic rejection on histology. There were no unexplained graft failures. Kinks of the renal transplant artery with normal intraarterial pressures do not appear to progress and threaten renal graft function. Satisfactory graft outcome was seen on 5-year follow-up with conservative therapy alone.