Increase in Interleukin-6 in the First Hour after Coronary Stenting: An Early Marker of the Inflammatory Response

Background: Inflammation after coronary stenting presages adverse outcomes after percutaneous coronary intervention (PCI). While changes in inflammatory markers have been defined 24–72 hours after PCI, potential changes during the first few hours have not. This study was designed to determine if a systemic inflammatory response could be measured within the first hour after stenting. Methods: Patients (n = 25) undergoing coronary stenting, with predominantly (n = 23) acute coronary syndromes were enrolled prospectively in this registry. Blood samples were collected before PCI, and 10 minutes, 1 hour and 18–24 hours later. No patient received a glycoprotein IIb-IIIa inhibitor. Concentrations of C-reactive protein (CRP), interleukin-6 (IL-6), and interleukin-1 receptor antagonist (IL-1Ra) and soluble CD40 ligand (sCD40L) were measured using ELISA. Results: CRP and sCD40L did not change in the first hour after stenting. By contrast, IL-6 increased in the first hour (before = 7.6 ± 7.7 pg/ml, 1 hour = 12 ± 12 pg/ml; p < 0.001). The concentration of IL-1Ra tended to be greater after 1 hour (before = 426 ± 261 pg/ml, 1 hour = 511 ± 406 pg/ml; p = 0.11). Increase in IL-1Ra was apparent only in female subjects (p = 0.004 for the difference in trend between the two genders). A correlation was not observed between the increase in IL-6 at 1 hour and the increase in CRP at 24 hours (r = –0.21). Conclusions: In patients undergoing coronary stenting, increase in IL-6 can be detected 1 hour after PCI, and thus IL-6 may be an early initiator of the systemic inflammatory response to stenting.     

Bronchoscopy in sarcoidosis: diagnostic and therapeutic interventions

Flexible bronchoscopy has revolutionized the evaluation of patients with suspected sarcoidosis and the treatment of sarcoid patients with significant endobronchial disease. The authors explore the diagnostic and therapeutic utility of flexible bronchoscopy by reviewing the pertinent literature with a special interest in recent studies. Bronchoscopy allows multiple diagnostic modalities in suspected sarcoidosis. Recent studies show sometimes surprising results, and the authors review the additive contributions of transbronchial lung biopsy, endobronchial biopsy, transbronchial needle aspiration, and bronchoalveolar lavage to diagnose sarcoidosis. New data specifically show the additive benefit of routine endobronchial biopsy and transbronchial needle aspiration to traditional transbronchial biopsy specimens. In addition, the techniques have been optimized via recent studies and these results are discussed. Endobronchial therapy is reviewed with the recent findings of the superiority of balloon bronchoplasty. Flexible bronchoscopy has a very high diagnostic yield in all stages of suspected sarcoidosis. Transbronchial lung biopsy and endobronchial biopsy should be used routinely, and transbronchial needle aspiration should be considered in cases of significant adenopathy. Bronchoalveolar lavage should be used routinely to exclude alternative diagnoses. Therapeutic bronchoscopy is rarely needed, but when necessary the authors' procedure of choice is bronchoscopic balloon dilatation.     

Axial spondyloarthritis criteria and modified NY criteria: issues and controversies

The Assessment of Spondyloarthritis International Society (ASAS) classification criteria for axial spondyloarthritis (axSpA) developed in 2009 was a major step forward, since the 1984 modified New York (mNY) criteria for classification of ankylosing spondylitis (AS) were too insensitive to identify patients with early signs of axial inflammation. In the absence of “diagnostic” criteria for either axSpA or AS, both of these “classification” criteria are routinely used in clinical practice to diagnose patients. However, there is a real danger of “misdiagnosis” if classification criteria are applied erroneously by ticking “yes” or “no” boxes in an undiagnosed patient. This concern was raised and discussed at the FDA Arthritis Advisory Committee meeting in June 2013, and the committee warned that if TNF inhibitors are approved to treat axSpA, such misdiagnosis could lead to serious consequences. To gauge the SPARTAN members’ familiarity with these criteria and these issues surrounding them, as well as to investigate how they are using these criteria in daily practice, two questionnaires (one each for mNY and ASAS axSpA criteria) were sent to the “full” members of SPARTAN before the annual meeting. The results showed that more than 60 % of the responders used these criteria most of the time in practice to help them diagnose a patient, and nearly three fourth of responders agreed with the FDA Advisory Committee and would like to see some objective signs before prescribing TNF inhibitors to axSpA patients. A majority of responders looked at the sacroiliac joint x-rays themselves to diagnose sacroiliitis, even though they had difficulty in grading the x-rays. In a live vote at the meeting, 88 % of the members suggested that SPARTAN should engage in either modifying the existing criteria or develop new diagnostic criteria for axial spondyloarthritis.     

Volvulus of ileal S-pouch: A rare complication of ileal pouch anal anastomoses

INTRODUCTION

Ileal pouch anal anastomosis (IPAA) after total proctocolectomy is a frequently performed surgery for medically refractory ulcerative colitis (UC). Volvulus of the ileal pouch as a complication of IPAA is extremely rare. We present a case of volvulus of S-type ileal pouch.

PRESENTATION OF CASE

A 28 year old male, with history of total proctocolectomy with IPAA for severe UC in 2009 presented with signs of bowel obstruction. Emergency laparotomy was done and a volvulus of the S-type ileal pouch was derotated and pouchpexy done.

DISCUSSION

The IPAA has a wide spectrum of complications, with obstruction of proximal small bowel occurring frequently. Volvulus of the ileal pouch is extremely rare with only 3 reported cases. Early diagnosis and intervention is important to salvage the pouch. Computed tomography (CT) may aid the diagnosis in stable patients.

CONCLUSION

The diagnosis of ileal pouch volvulus although rare, should be kept in mind when dealing with patients complaining of recurrent obstruction following IPAA.