MRI evaluation of inflammatory activity in Crohn's disease

OBJECTIVE: We wanted to assess the capability of MRI to quantitatively evaluate the therapeutic response to Crohn's disease (CD) relapse. SUBJECTS AND METHODS: Twenty patients with histologically proven CD were prospectively evaluated with MRI and ileocolonoscopy over a 2-year period. The MRI protocol included axial and coronal T2-weighted and contrast-enhanced T1-weighted sequences. MRI examinations were performed twice, once during an acute relapse of CD and the other at clinical remission. The terminal ileum and colon were divided into six segments/patient, and the endoscopy and histology findings were considered the standard of reference. These were compared on a segmental basis with the quantitative MRI findings regarding wall thickness and contrast enhancement. The results obtained in active and remission CD phases were likewise compared with the findings in 10 control subjects who underwent complete ileocolonoscopy for other reasons and had no pathological findings on ileocolonoscopy. RESULTS: Fifty three of 120 (44.2%) bowel segments showed pathologic changes on endoscopy and histology consistent with CD in active phase. On changing from the active disease phase to clinical remission, a significant decrease was observed in the wall thickness and contrast enhancement of the affected bowel wall. In the active phase of CD, the pathologic bowel segments presented with significantly greater contrast enhancement and wall thickness values compared with the healthy segments of CD and controls. On converting clinically into remission, contrast enhancement tended to normalize, whereas bowel wall thickness remained increased compared with the controls. CONCLUSION: MRI is able to detect pathologic bowel segments in CD, as it allows the measurement of significant variations in wall thickness and contrast enhancement on changing from the active phase of the disease to remission.     

Reconstruction of chest wall defects after resection of large neoplasms: ten-year experience

We review our experience in the treatment of complex large chest-wall defects needing a multidisciplinary approach due to primary or secondary neoplasms. Non-small cell lung cancer with chest-wall invasion cases are excluded. Fifteen patients underwent whole thickness resection of the chest wall due to lesions affecting at least three ribs, sternum, clavicle or thoracic spine and the surrounding soft tissue. Previously operated breast cancer and sarcoma were the most frequent diagnoses. Partial or total sternectomy plus rib resection was performed in 8 patients. Immediate closure of the defects was performed in all cases: 12 with single prosthesis placement and 3 with a rigid one of methylmethacrylate. Coverage was achieved using myocutaneous flaps in most cases and, in one case, using the greater omentum that supported a free split-thickness skin graft. No 30-days mortality was recorded. Three patients had a post-operative complication. Mean hospital stay was 11.7+/-9 days. All cases of primary tumours were alive at the time of review (range: 6-126 months). In conclusion, resection and immediate reconstruction of large chest wall defects can be accomplished without operative mortality and low morbidity whenever close cooperation between plastic and thoracic teams exists.     

The Bispectral Index Scale: its use in the detection of brain death

OBJECTIVE: To evaluate the Bispectral Index Scale (BIS) monitor as a method of brain death (BD) detection. PATIENTS AND METHODS: We performed an observational prospective study in an intensive care unit (ICU) of a university hospital of 19 patients hospitalized nonconsecutively in the ICU with serious neurologic pathology and evolution toward BD. A BIS monitor, XP model, and the sensor "BIS Quatro" were used to continuously record values: suppression ratio (SR), quality of the signal index, and electromyographic (EMG) activity. RESULTS: The BD diagnosis was made through neurological clinical exploration and electroencephalogram (EEG) in all the cases. Additionally, transcranial Doppler was used in 13 patients. Coincident with clinical worsening, it was observed that there was a gradual decrease of the BIS value, together with a rise in the SR. In all the patients in which the BD diagnosis was confirmed, the BIS showed values of 0 and suppression rates of 100. Only one patient showed interferences, due to EMG activity, the same problem was detected when a conventional EEG was performing. After using a neuromuscular blocker, the values of BIS and SR were 0 and 100, respectively. CONCLUSIONS: The BIS is a noninvasive, simple, and easy to interpret method. All the patients with BD diagnosis except for one had a BIS value of 0 and TS of 100, showing a perfect correlation with the other diagnostic methods. The BIS cannot be used on its own for the confirmation of the BD, but it is a useful tool to detect the beginning of brain herniation.     

Factors associated with patients' loss to follow-up after finishing randomized clinical trial participation

OBJECTIVES: To study patient's follow-up after finishing participation in randomized clinical trials (RCTs), and to identify factors associated with loss to follow-up (FU). PATIENTS AND METHODS: Medical charts of 212 rheumatoid arthritis (RA) and osteoarthritis (OA) patients from a rheumatological out-patient center were analyzed. Loss to FU was considered when patients did not return to their regular appointments within the first year after finishing their participation in an RCT assessing anti-cyclooxygenase-2 non-steroidal anti-inflammatory drugs (anti-COX-2 NSAIDs). Mann-Whitney U-test, chi2 test and Wilcoxon test were performed as appropriate. Logistic regression was performed to identify factors which might be related to loss to FU. A survey was conducted to obtain lost to FU patients' opinions. p values less than 0.05 were considered significant. RESULTS: The mean frequency of patients' visits in the year before enrollment in an RCT was 3.73 SD 2.06, and during the year after participation was 2.6 SD 1.96 (p<0.0001). Fifty patients (23.6%) did not return to their usual rheumatologic visit. On multivariate analysis, the number of daily tablets of study medication (odds ratio (OR)=2.64, 95% confidence interval (CI) 1.1 to 6.3) and the frequency of clinical visits (OR=0.56, 95% CI 0.37 to 0.85) were associated with loss to FU (p<0.008). Lost to FU patients' opinions did not support these findings. CONCLUSIONS: After participating in a RCT assessing anti-COX-2 NSAIDs, many patients return with less frequency, or do not return at all to their regular rheumatologic visit. Although a high number of tablets of the investigational drug and a low frequency of protocol visits may be contributors to patient loss to FU, investigators should consider that personal situations not related to the RCTs may also influence patients' return to consultation in the private setting.     

Strain differences of dopamine receptor levels and dopamine related behaviors in rats

Here we have investigated whether differences in levels of dopamine D1-like, D2-like receptors, dopamine D3 receptors, and dopamine transporter could be related to behaviors such as immobility response and locomotion between Wistar rats and Sprague-Dawley rats. The levels of the dopamine receptors and transporter were measured by autoradiographic study at the level of basal ganglia and the limbic subregion. The behavioral study was done by open-field and immobility response tests. The Wistar rats exhibited a higher level of D1 receptor binding in the basal ganglia subregions than Sprague-Dawley rats. The Wistar rats have higher levels of dopamine D2 receptor binding and dopamine transporter binding in the dorsolateral part of the caudate-putamen. In addition, the dopamine transporter binding were also higher in the Wistar rats than in Sprague-Dawley rats in the ventral part of the caudate-putamen and nucleus accumbens core. However, there were no differences in the level of D3 receptor binding in the limbic or basal ganglia subregions between these two strains. In Wistar rats, the duration of the immobility responses was longer and with less locomotor activity after these immobility responses compared with Sprague-Dawley rats. These data suggest that the differences in dopamine receptors in these two rat strains may in part relate to the behavioral differences reported in these two strains.     

Effects of selective vegetative denervation on the urinary bladder of the adult rat

The present work is a study of the plastic capacity of the peripheral nervous system subjected to different aggressions in the case of 28 rats of the Wistar breed. They were divided into four groups: 1) sympathetic deafness (n=9); 2) parasympathetic deafness (n=9); 3) evaluation of regeneration (n=9); 4) control group (n=5). An image analyser was used to study the acetylcholinesterase (AChE) and Tyrosine Hydroxylase (TH) positive ganglionic neurones of the pelvic ganglion (GP) as well as the dorsal ganglions (GRD) compared with the control group. With group 3 a study was also made of the possible plasticity of the transacted axons using a wheat germ agglutinin conjugated-horseradish peroxidase (WGA-HRP) neurotracer. The statistical study was carried out by means of the analysis of variance (ANOVA), Fisher test and Scheffe method, with a p<0.05 taken as significant. The results show the predominant role of the pelvic nerve in the modulation of the plastic changes produced at the ganglionic level, with a lesser influence of the hypogastric nerve. Further studies are needed in order to define the specific role of each of these in the act of miction.     

Phylogenetic analysis of the NS5 gene of dengue viruses isolated in Ecuador

Dengue virus (DENV) is a member of the genus Flavivirus of the family Flaviviridae. DENV causes a wide range of diseases in humans, from the acute febrile illness dengue fever (DF) to life-threatening dengue hemorrhagic fever/dengue shock syndrome (DHF/DSS). There is not knowledge of the genetic relations among DENV circulating in Ecuador. Given the emerging behaviour of DENV, a single tube RT-PCR assay using a pair of consensus primers to target the NS5 coding region has been recently validated for rapid detection of flaviviruses. In order to gain insight into the degree of genetic variation of DENV strains isolated in Ecuador, DENV NS5 sequences from 23 patients were obtained by direct sequencing of PCR fragments using the mentioned one step RT-PCR assay. Phylogenetic analysis carried out using the 23 Ecuadorian DENV NS5 sequences, as well as 56 comparable sequences from DENV strains isolated elsewhere, revealed a close genetic relation among Ecuadorian strains and DENV isolates of Caribbean origin. The use of partial NS5 gene sequences may represent a useful alternative for a rapid phylogenetic analysis of DENV outbreaks.     

Strawberry-like gingival tumor as the first clinical sign of Wegener's granulomatosis

BACKGROUND: Wegener's granulomatosis (WG) is a complex disease, characterized by a necrotizing vasculitis that usually involves the upper airways, lungs, and kidneys; occasionally, other organs may also be affected. Because of the severity and rapid progression of the disease, early diagnosis and treatment are critical; this type of vasculitis is potentially fatal if left unchecked. METHODS: A 64-year-old woman presented with a chief complaint of a gingival mass that had appeared 2 months before and had grown rapidly. In the previous months she complained of malaise without weight loss. An intraoral examination revealed the presence of a solitary gingival mass, 2 cm in diameter, affecting the area above the upper central incisors. The lesion displayed a granular, erythematous, speckled surface with petechiae, characteristic of WG. RESULTS: A biopsy of the lesion, a thoracic computed tomography, and the presence of high titers of antineutrophil cytoplasmic antibodies (ANCA) in the blood established the diagnosis of WG. An initial combination therapy of prednisone and cyclophosphamide successfully abated most of the patient's symptoms. CONCLUSIONS: The occurrence of an extremely rare tumor-like form of strawberry gingiva was the primary clinical sign that led to a diagnosis of WG. This case emphasizes the important role of the dentist in the diagnosis of this potentially fatal disease.