Takayasu’s arteritis occurring under TNF blockers in a patient with spondyloarthritis: is it an association or a paradoxical effect?

Coexistence of spondyloarthritis (SpA) and Takayasu’s arteritis is not a common finding, but such cases have been discussed, particularly in the context of choice of therapy. Inhibition of inflammation by tumor necrosis factor inhibitors (TNFi) is a key aspect of the treatment of SpA and also positive effects of such treatment in concomitant large vessel vasculitis have been reported. However, TNFi is also associated with the possibility of initiating vasculitis.The present article based on a case study and the available literature is an attempt to discuss coexistence of these two diseases and the impact of treatment with biological drugs from the anti-TNF group in the course of SpA with Takayasu’s arteritis.     

Safety of endovascular treatment of intracranial aneurysms with a new,complex shaped Guglielmi detachable coil

Introduction The Guglielmi detachable coil (GDC) 360°, a new complex shaped bare platinum coil, became available in Europe for aneurysm treatment in September 2005. The purpose of this study was to assess the feasibility and safety of selective embolization of intracranial aneurysms with the GDC 360° in 52 consecutive patients. Methods All patients included in this study were registered in a prospectively maintained database. We assessed the patient clinical history, aneurysm shape and dimensions, technical details and complications of the procedures, degree of aneurysm occlusion, and clinical findings upon discharge. In all patients, the first coil deployed was a GDC 360°. Results Over a 6-month period, we intended to treat 52 aneurysms with the GDC 360° in 52 patients. Of these 52 patients, 42 (81%) were treated in the context of subarachnoid haemorrhage. In 51 of 52 patients, the underlying aneurysm was successfully treated by coil embolization. Six procedures (11.5%) were complicated by the formation of thrombus in the parent artery during the intervention. One patient suffered a stroke related to the procedure. Angiograms obtained immediately after the procedure showed complete occlusion of the aneurysmal sac in 38 of 51 procedures (74.5%), a neck remnant in 11 (21.6%), and a residual aneurysm in 2 (3.9%). In 43 of 51 patients (84.3%), clinical assessment demonstrated independent clinical status, whereas 7 patients (13.7%) required assistance in the activities of daily living upon hospital discharge. One patient (2.0%) died after development of a severe vasospasm 10 days after the endovascular procedure. Conclusion The GDC 360° can be safely used for the endovascular occlusion of intracranial aneurysms.     

Bile Gastritis Following Laparoscopic Single Anastomosis Gastric Bypass: Pilot Study to Assess Significance of Bilirubin Level in Gastric Aspirate

Introduction

Laparoscopic single anastomosis gastric bypass (SAGB) is increasingly performed for morbidly obese patients.

Aim of Work

This pilot study aims primarily at evaluating the incidence of bile gastritis after SAGB. The occurrence of reflux oesophagitis and reflux symptoms were also assessed.

Patients and Methods

This study included 20 patients having no reflux symptoms. All patients underwent a SAGB as a primary bariatric procedure by a single surgeon. Patients included consented to have an upper GI endoscopy done at 6 months postoperatively. Gastric aspirate was sent for bilirubin level assessment. Gastric and esophageal biopsies were submitted for histopathology and campylobacter-like organism (CLO) test.

Results

In our study, the rate of bile gastritis was 30%. In 18 patients, the level of bilirubin in gastric aspirate seems to be related to the degree of mucosal inflammation. The remaining two patients had microscopic moderate to severe gastritis with normal aspirate bilirubin level. Two patients with bilirubin level in aspirate more than 20 mg/dl had severe oesophagitis, gastritis with erosions, and metaplasia. Relationship between bilirubin level and histopathological findings of gastric biopsy examination was statistically significant with a P value of 0.001.

Conclusion

The incidence of bile gastritis in this cohort is higher than reported in the literature, and this may be worrying. The correlation between endoscopic findings and patients’ symptoms is poor. Bilirubin level and pH in aspirate might be useful tools to confirm alkaline reflux. Its level might help to choose candidates for revision surgery after SAGB. This needs further validation with larger sample size.

     

Advancing the tracheal tube over a flexible fiberoptic bronchoscope by a sleeve mounted on the insertion cord

The advancement of an endotracheal tube (ETT) over a flexible fiberoptic bronchoscope (FOB) is often impeded at the glottis. This is attributed to the creation of a cleft by the difference in the outer diameter of the fiberscope and the internal diameter of the tube. We designed a conical-shaped polyvinyl chloride sleeve to fit the insertion cord. This report compares the ease of advancement of the tube over a sleeved versus a nonsleeved bronchoscope. General anesthesia was induced, and one anesthesiologist introduced the FOB (a 3.8-mm Olympus LF2). Patients were randomly assigned to undergo tracheal intubation with the regular bronchoscope (25 patients) or the sleeved bronchoscope (25 patients). The FOB was advanced to approximately 1 cm above the carina. A blinded operator advanced the tube over the bronchoscope. The ETT was successfully advanced over the nonsleeved bronchoscope into the trachea on the first attempt in 64% of the patients, whereas tracheal intubation succeeded from the first attempt in 96% of patients when the sleeved FOB was used (P < 0.05). Advancement of the ETT over the fiberscope can be facilitated by using a conically shaped sleeve mounted on the insertion cord. IMPLICATIONS: This report shows that a conical sleeve mounted on the insertion cord of a fiberoptic bronchoscope will facilitate advancing the endotracheal tube into the trachea.     

Supplementation of general anaesthesia with tramadol or fentanyl in parturients undergoing elective Caesarean section

Purpose

Tramadol has been recommended for analgesia in parturients undergoing vaginal delivery. The present report investigated the effect of tramadol versus fentanyl on umbilical vein (UV) blood gases and Apgar scores of neonates delivered via elective Caesarean section under general anaesthesia.

Methods

Forty ASA I or II parturients undergoing elective Caesarean section were included in a randomized double-blinded study. The patients were divided into a tramadol (n = 20) and fentanyl groups (n =.20). During preoxygenation, one group received 100 mg tramadoliv, while the second received 100 μg fentanyl. Anaesthesia was induced in both groups by 3 mg·kg^?1 thiopentone and 1.5 mg·kg^?1 succinylcholine was given to facilitate tracheal intubation. Anaesthesia was maintained during the induction-delivery period with nitrous oxide 50% in oxygen.

Results

The umbilical vein PO₂ was higher in the fentanyl (34 ± 5 mmHg) than in the tramadol group (24 ± 6 mmHg) (P < 0.01), while the UV PCO₂ was higher in the tramadol group (50 ± 5vs 45 ± 4 mmHg) (P 0.01). The Apgar scores at one and five minutes were not different between the two groups. Post operatively, two patients in the tramadol group recalled the crying of their newborn at delivery.

Conclusion

Tramadol is associated with a high incidence of intraoperative maternal recall and can result in lower umbilical vein PO₂ and higher PCO₂ than in the fentanyl group.     

Putative role of 67 kDa elastin-laminin receptor in tumor invasion

Cellular regulatory mechanisms normally maintain a delicate balance between cell proliferation, quiescence and death. The imbalance between these functions resulting from molecular intracellular changes is a key factor in tumorigenesis. Tumor cells detaching from the primary tumor possess a propension for invasion and metastasis formation. These tumor cells can attach, migrate, proliferate and grow in host tissue. The surrounding extracellular matrix (ECM) modulates these functions. It is now widely accepted that cell-matrix interactions play an important role in these processes. Most investigators concentrated their attention on the role of integrins in the above processes. There are, however, only scant data on the role of elastin and its receptors in tumor invasion. Nevertheless, experimental evidence indicates that the 67 kDa elastin-laminin receptor (ELR) subunit plays an important role in tumor invasion by mediating essential tumor cell functions leading to metastases. In this review we will concentrate on the putative role of the 67 kDa ELR subunit in tumor invasion.     

Melatonin improves sleep quality of patients with chronic schizophrenia

BACKGROUND: Accumulating evidence indicates decreased melatonin levels in patients with schizophrenia. Insomnia, mainly difficulty in falling asleep at night, is commonly reported in this population. Association of insomnia with low or abnormal melatonin rhythms has been repeatedly documented. Melatonin is an endogenous sleep promoter in humans. We hypothesized that insomnia in patients with schizophrenia may be partially due to diminished melatonin output. In this study, we measured melatonin output in patients with chronic schizophrenia and assessed the effects of melatonin replacement on their sleep quality. METHOD: In a randomized, double-blind, cross-over, clinically based trial, 19 patients with DSM-IV schizophrenia who were treated with the normal treatment regimen were given melatonin (2 mg, controlled release) or placebo for 2 treatment periods of 3 weeks each with 1 week washout between treatment periods (7 weeks total). For measuring endogenous melatonin production, urine was collected from each patient every 3 hours between 9:00 p.m. and 9:00 a.m. Actigraphy was performed for 3 consecutive nights at the end of each period. Activity- and rest-derived sleep parameters were compared for the whole population with treatment arm as the intervening variable. A separate analysis was performed for patients subgrouped into high versus low sleep efficiency. RESULTS: All patients had low melatonin output. Melatonin replacement significantly improved rest-derived sleep efficiency compared with placebo (83.5% vs. 78.2%, p = .038) in this population. Improvement of sleep efficiency was significantly greater (p < .0014) in low-efficiency (80% vs. 67%) than high-efficiency sleepers (88% vs. 90%). In addition, during melatonin therapy, tendencies toward shortened sleep latency (by 40 minutes, p < .056) and increased sleep duration (by 45 minutes, p < .078) were observed in low- but not high-efficiency sleepers. CONCLUSION: Melatonin improves sleep efficiency in patients with schizophrenia whose sleep quality is low.