The role of endoscopy in patients with chronic pancreatitis

• ERCP and EUS are useful for the diagnosis of CP and associated pancreatic ductal complications (B).

• ERCP for the diagnosis of CP should be reserved for patients in who the diagnosis has not been established by noninvasive or less-invasive studies (C).

• Endoscopic therapy of pancreatic ductal obstruction can provide short-term relief of abdominal pain and long-term relief in some patients (B).

• ERCP is effective for the short-term treatment of common bile duct obstruction resulting from CP (B) and long-term treatment in poor operative candidates (C).

• Endoscopically placed pancreatic duct stents are effective for the nonsurgical management of pancreatic strictures, duct leaks, and disruptions (B).

• EUS-guided celiac blockade can effectively provide short-term pain relief in patients with CP (B).

An internally covered (lined) self-expanding metal esophageal stent: tissue response in a porcine model

BACKGROUND: Self-expandable metal stents (SEMS) palliate malignant dysphagia but may embed in tissue, produce granulation tissue, and prevent removal. OBJECTIVE: Our purpose was to evaluate in a porcine model the tissue response induced by a new esophageal SEMS completely coated internally rather than externally. DESIGN: Eight Yucatan pigs were studied. Each animal underwent placement of 2 stents: 1 study stent and 1 control stent. SEMS were placed proximally or distally by random assignment. Follow-up endoscopy was performed 1, 2, 3, and 4 weeks after implantation. Ease of stent removal was assessed at 2 weeks and 4 weeks after placement. SETTING: Animal laboratory. INTERVENTIONS: Endoscopic placement of study stents (Alveolus ES-STS, Alveolus, Inc, Charlotte, NC; 18 mm diameter, fully covered internally) and control stents (Ultraflex stent, Boston Scientific, Natick, Mass; microvasive, 18 mm midbody, subtotally covered externally). MAIN OUTCOME MEASUREMENTS: Extent of granulation tissue and stent-induced esophageal injury. RESULTS: The tissue hyperplasia response of the study stents was endoscopically graded as mild to moderate. All study stents were endoscopically removed easily and atraumatically. Control stents produced severe granulation tissue formation with complete embedding of the uncovered stent ends; endoscopic removal was possible but resulted in trauma and endoscopically visible bleeding. Histopathologic findings revealed minimal tissue response at the ends of the study stents and severe pseudopolyps in the embedded portion of the control stent. Stent migration occurred in 7 of 8 study stents and 4 of 8 control stents. LIMITATIONS: Animal model lacks stricture. CONCLUSIONS: Fully internally lined SEMS may resist tissue embedding and hyperplasia and may be removable. Human studies are needed to assess applicability to treatment of benign and malignant esophageal disease.     

Depletion of resting zone chondrocytes during growth plate senescence

With age, the growth plate undergoes senescent changes that cause linear bone growth to slow and finally cease. Based on previous indirect evidence, we hypothesized that this senescent decline occurs because growth plate stem-like cells, located in the resting zone, have a finite proliferative capacity that is gradually depleted. Consistent with this hypothesis, we found that the proliferation rate in rabbit resting zone chondrocytes (assessed by continuous 5-bromo-2'-deoxy-uridine labeling) decreases with age, as does the number of resting zone chondrocytes per area of growth plate.Glucocorticoid excess slows growth plate senescence. To explain this effect, we hypothesized that glucocorticoid inhibits resting zone chondrocyte proliferation, thus conserving their proliferative capacity. Consistent with this hypothesis, we found that dexamethasone treatment decreased the proliferation rate of rabbit resting zone chondrocytes and slowed the numerical depletion of these cells. Estrogen is known to accelerate growth plate senescence. However, we found that estradiol cypionate treatment slowed resting zone chondrocyte proliferation.Our findings support the hypotheses that growth plate senescence is caused by qualitative and quantitative depletion of stem-like cells in the resting zone and that growth-inhibiting conditions, such as glucocorticoid excess, slow senescence by slowing resting zone chondrocyte proliferation and slowing the numerical depletion of these cells, thereby conserving the proliferative capacity of the growth plate. We speculate that estrogen might accelerate senescence by a proliferation-independent mechanism, or by increasing the loss of proliferative capacity per cell cycle.     

General practitioners' fear-avoidance beliefs influence their management of patients with low back pain

The objectives of this cross-sectional study conducted in primary care practice in France were to describe general practitioners' (GPs) fear-avoidance beliefs about low back pain (LBP), investigate the impact of these beliefs on their following guidelines for bed rest, physical activities, and sick leave, and uncover factors associated with GPs' fear-avoidance beliefs. A total of 864 GPs completed a 5-part self-administered questionnaire. Parts 1, 2, and 3 concerned demographic, professional data, and personal history of back pain, respectively. Part 4 dealt with GPs' education about LBP and practice for LBP. Part 5 assessed GPs' fear-avoidance beliefs on the Fear-Avoidance Beliefs Questionnaire (FABQ). GPs' mean age was 48.2+/-7.0 years, 80% were male, 88% had been practicing for more than 10 years, and 52% reported a previous personal episode of acute LBP. Forty-six percent had participated in an educational session on LBP during the last 3 years. Mean scores for the FABQ Phys and Work were 9.6+/-4.8 and 17.5+/-6.7, respectively. Sixteen percent of participants had high rating on the FABQ Phys (FABQ Phys score>14). FABQ Phys score was associated with recommendation of bed rest or rest during sick leave (p<0.0001) for acute LBP and less advice to maintain maximum bearable physical activities (p<0.001) for chronic LBP. FABQ Work score was associated with prescribing sick leave during painful periods (p<0.005) for acute LBP and less advice to maintain maximum bearable physical activities (p<0.001) for chronic LBP. GPs' fear-avoidance beliefs about LBP negatively influence their following guidelines concerning physical and occupational activities for patients with LBP.     

Caregiver distress in parkinsonism

This study examined the frequency and degree of caregiver burden in persons with parkinsonism, a group of disorders with four primary symptoms that include tremor, rigidity, postural instability, and bradykinesia. We assessed associations between perceived caregiver burden and physical, cognitive, and functional impairments using well-established tools for persons with parkinsonism. The 49 individuals with parkinsonism ranged in age from 61 to 87 (mean = 75), while their caregivers (N = 49) ranged in age from 48 to 83 (mean = 70). The caregivers were predominantly either wives (82%) or daughters (6%), with other family members, friends, and/or neighbors (12%) making up the rest. The caregivers reported a relatively high ability for coping (mean scores = 4.6/6). Caregiver burden was significantly negatively associated with activities of daily living and motoric difficulties as measured on the Unified Parkinson's Disease Rating Scale (UPDRS). Likewise, caregiver burden was negatively associated with caregiver self-reported sleep and coping ability. Results did not demonstrate an association on the UPDRS among mentation, behavior, and mood. We found a significant negative correlation for mentation between the Folstein Mini-Mental Status Examination and caregiver burden measures; however, we did not find this association with the Dementia Rating Scale-2. Patient's self-reported pain and caregiver burden were not associated.     

A novel in vitro system to generate and study latently HIV-infected long-lived normal CD4+ T-lymphocytes

Studies of mechanisms of HIV-latency and its reactivation in long-lived resting CD4+ T-lymphocytes in patients have been limited due to the very low frequency of these cells ( approximately 1-10 cells per 10(6) CD4+ T-cells). To circumvent this obstacle, an in vitro culture system for post-activation long-term survival of normal CD4+ T-cells in a quiescent (non-cycling) state was developed and used to generate latently infected, long-lived quiescent CD4+ T-cells from HIV-infected, activated normal CD4+ T-lymphocytes. This yielded a frequency of approximately 5x10(4) latently infected cells per 10(6) cells in culture, which is approximately 10(3)- to 10(4)-fold higher than that available from patients. Moreover, 5-10% of long-term surviving non-cycling T-cells were found to make infectious HIV continuously at low levels, showing that HIV production from infected T-cells does not require full cellular activation. This model system should facilitate studies of long-lived, latently infected and persistently HIV-producing quiescent normal CD4+ T-lymphocytes.     

Nucleotide sequencing for diagnosis of sinusal infection by Schizophyllum commune, an uncommon pathogenic fungus

Schizophyllum commune, a basidiomycete fungus, is a rare cause of mycotic disease. We report here a case of sinusitis in a 35-year-old woman that underscores the value of molecular biology for the diagnosis of this fungal infection.     

Endothelial dysfunction in cold type complex regional pain syndrome

The authors examined endothelial function in cold type chronic complex regional pain syndrome (CRPS) I using acetylcholine- and sodium nitroprusside-induced vasodilation combined with laser Doppler flowmetry in 14 patients and 10 controls. On the affected side, acetylcholine-induced vasodilation was significantly reduced in comparison to controls and the unaffected extremity. No significant differences were found after application of sodium nitroprusside. The results demonstrate impaired endothelial function in chronic CRPS I.