Effect of nitazoxanide in persistent diarrhea and enteritis associated with Blastocystis hominis.

BACKGROUND & AIMS: The aim of this study was to evaluate the efficacy of nitazoxanide for the treatment of diarrhea and enteritis associated with Blastocystis hominis as the sole identified pathogen in children and adults from the Nile delta of Egypt. METHODS: Two prospective, randomized, double-blind, placebo-controlled studies were conducted. Nitazoxanide 500 mg (as a 500-mg tablet) was administered twice daily for 3 days in patients aged 12 years or older, 200 mg (as 10 mL of an oral suspension) was administered twice daily for 3 days in patients aged 4-11 years, and 100 mg (as 5 mL of an oral suspension) was administered twice daily for 3 days in patients aged 1-3 years. RESULTS: Four days after the completion of therapy, 36 (86%) of the 42 patients who received nitazoxanide showed resolution of symptoms compared with 16 (38%) of 42 patients who received placebo (P<.0001). Thirty-six (86%) of the 42 patients who received nitazoxanide were free of B hominis organisms in each of 3 posttreatment stool samples compared with only 5 (12%) of 42 patients who received placebo (P<.0001). Response rates in patients receiving the tablets and the suspension were identical. CONCLUSIONS: These findings suggest that B hominis is pathogenic in some patients and can be treated effectively with nitazoxanide. Alternatively, the possibility that nitazoxanide is effective in treating other unidentified causes of persistent diarrhea and enteritis warrants further study.     

A regional trauma system to optimize the pre-hospital triage of trauma patients

IntroductionPre-hospital triage is a key element in a trauma system that aims to admit patients to the most suitable trauma center, and may decrease intra-hospital mortality. We evaluated the performance of a pre-hospital procedure in a regional trauma system through measurements of the quality of pre-hospital medical assessment and the efficacy of a triage protocol.MethodsOur regional trauma system included 13 hospitals categorized as Level I, II or III trauma centers according to their technical facilities. Each patient was graded A, B or C by an emergency physician, according to the seriousness of their injuries at presentation on scene. The triage was performed according to this grading and the categorization of centers. This study is a registry analysis of a three-year period (2009 to 2011).ResultsOf the 3,428 studied patients, 2,572 were graded using the pre-hospital grading system (Graded group). The pre-hospital gradation was closely related with injury severity score (ISS) and intra-hospital mortality rate. The triage protocol had a sensitivity of 92% (95% confidence interval (CI) 90% to 93%) and a specificity of 41% (95% CI 39% to 44%) to predict adequate admission of patients with ISS more than 15. A total of 856 patients were not graded at the scene (Non-graded group). Undertriage rate was significantly reduced in the Graded group compared with the Non-graded group, with a relative risk of 0.47 (95% CI 0.40 to 0.56) according to the definition of the American College of Surgeons Committee on Trauma (P <0.001). Where adjusted for trauma severity, the expected mortality rate at discharge from hospital was higher than observed mortality, with a difference of +2.0% (95% CI 1.4 to 2.6%; P <0.01).ConclusionsImplementation of a regional trauma system with a pre-hospital triage procedure was effective in detecting severe trauma patients and in lowering the rate of pre-hospital undertriage. A beneficial effect on outcome of such an organization is suggested.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0835-7) contains supplementary material, which is available to authorized users.     

Mycoplasma hominis,a Rare but True Cause of Infective Endocarditis

Mycoplasma spp. are rarely recognized agents of infective endocarditis. We report a case of Mycoplasma hominis prosthetic valve endocarditis diagnosed by 16S ribosomal DNA (rDNA) PCR and culture of valves in a 74-year-old man. We reviewed the literature and found only 8 other cases reported.     

Indium scanning in assessment of acute Crohn's disease

The aim of this study was to determine whether the sensitivity of indium-111 (¹¹¹In) scanning in the assessment of the activity and extent of Crohn's disease correlates with the severity of intestinal lesions as measured by the newly validated Crohn's disease endoscopic index of severity (CDEIS). Nineteen patients with active (CDAI>200) colonic (N=11) or ileocolonic (N=8) Crohn's disease were assessed by colonoscopy and indium scanning. The intestine was divided into five segments in both studies (rectum, sigmoid and left colon, transverse colon, right colon, and ileum). Seventy of the 86 intestinal segments seen at colonoscopy presented macroscopic lesions of Crohn's disease. On third-hour scintigrams¹¹¹In uptake was observed in 52 segments, 51 of which were found to be abnormal at colonoscopy. Predictive positive and negative values of scanning with respect to disease extent assessment were equal to 98% and 44%, respectively. Complete agreement between endoscopic and scintigraphic findings was observed in only six of the 19 patients (32%). Segmental endoscopic indexes of severity (SEIS) were significantly (P<0.001) lower in false negative (7.9±4.2) (mean ±sd) than in true positive (18.0±9.7) segments as defined by scintigraphy. SEIS values above which¹¹¹In uptake was constantly observed did not differ in the different disease locations. When comparing macroscopically abnormal intestinal segments according to their¹¹¹In uptake grade, the corresponding mean SEIS values increased significantly as the grade increased. Scintigraphic activity, as assessed by the fall in splenic activity, was equal to 23±11% (N=19). It correlated significantly with CDEIS (r=0.63,P<0.005), but even more so when the highest SEIS of each patient had been taken into account (r=0.75,P<0.0005). In conclusion, when considering disease extent and activity, scanning results correlate well with the endoscopic severity of intestinal lesions in active Crohn's disease. Nevertheless, minor endoscopic lesions can be missed by¹¹¹In scanning.     

Specific contribution of estrogen receptors on mitogen-activated protein kinase pathways and vascular cell activation

Randomized clinical trials have not provided conclusive data that hormone replacement therapy confers cardioprotection against coronary artery disease in postmenopausal women. However, other studies have shown that estrogens can induce beneficial effects on the vasculature. Nevertheless, the specific contribution of estrogen receptors (ERs) alpha and beta on vascular cells is not well characterized. Therefore, we used an antisense gene therapy approach to investigate the contribution of ERalpha and ERbeta on p38 and p42/44 mitogen-activated protein kinase (MAPK) activation and on vascular cell responsiveness. Treatment of porcine smooth muscle cells (PSMCs) with platelet-derived growth factor-BB induced p38 and p42/44 MAPK activation and their migration and proliferation. These effects were prevented by pretreatment with 17beta-estradiol (17betaE). The inhibitory effects of 17betaE on PSMCs were abrogated by the downregulation of ERbeta protein expression with selective ERbeta mRNA antisense oligomers, whereas the downregulation of ERalpha had no effect. However, treatment of porcine aortic endothelial cells with 17betaE promoted p38 and p42/44 MAPK phosphorylation and their migration and proliferation. These effects were ERalpha dependent, as defined by antisense gene therapy. These results suggest that in PSMCs, 17betaE reduces p42/44 and p38 MAPK activity through ERbeta stimulation, whereas in contrast, in porcine aortic endothelial cells, 17betaE induces p42/44 and p38 MAPK through ERalpha activation. 17betaE may contribute to the vascular healing process and to the prevention of restenosis by improving reendothelialization through ERalpha activation and by decreasing smooth muscle cell migration and proliferation through ERbeta stimulation.     

A sero-epidemiological study of malaria in human and monkey populations in French Guiana

This paper describes a sero-epidemiological study of malaria prevalence in French Guiana. An immunofluorescence assay and an enzyme-linked immunosorbent assay were used to detect antibodies against blood-stage antigens and synthetic peptides mimicking the repetitive epitope of the sporozoites of Plasmodium falciparum, Plasmodium vivax and Plasmodium malariae/brasilianum, in 218 human sera and 113 non-human primate sera collected in French Guiana. Almost all the monkey sera tested had antibodies against malaria blood-stages (98%) and a large majority (73%) also tested positive with the P. malariae/brasilianum circumsporozoite peptide. A number of primate samples also reacted positively with P. falciparum NANP repeats in a very specific manner, suggesting that monkeys in the rainforest are bitten by mosquitoes infected with human malaria parasites. Seroprevalences were lower in the humans tested but Indian tribes on the borders with Suriname and Brazil were clearly more exposed to malaria than other ethnic groups, with a prevalence of nearly 70% seropositivity. P. vivax infections accounted for much of the observed pattern of reactivity, but there was also a high frequency of positive reactions to the P. brasilianum/malariae peptide. Similarly, a large proportion of the sera obtained from Bush Negro populations tested positive for P. malariae/brasilianum repeats. These data add to the emerging evidence that non-human primates might constitute a natural reservoir, not only for simian, but also for human malaria, and therefore suggest that they might be responsible for the maintenance of foci of P. malariae, and possibly of other malaria species, in isolated areas of the Amazonian rainforest.     

Preoperative assessment of pancreatic tumors using magnetic resonance imaging, endoscopic ultrasonography, positron emission tomography and laparoscopy.

BACKGROUND: The appropriate preoperative evaluation of a pancreatic tumor remains a matter of debate. METHODS: We retrospectively evaluated an institutional strategy including magnetic resonance imaging (MRI), endoscopic ultrasonography (EUS), positron emission tomography (PET) and laparoscopy (LAP) for detection and staging of pancreatic tumors suspected to be malignant. RESULTS: In a consecutive series of 59 patients screened by MRI, PET, EUS and LAP between July 1998 and November 2002, 48 patients were found to bear pancreatic adenocarcinoma and surgery was performed in 27 of them. For tumor detection, the sensitivity of EUS was superior to MRI and PET (98 vs. 87.5 and 87.5%, respectively, p = 0.13). MRI best assessed loco-regional staging, i.e. arterial involvement. For the detection of distant metastases, the sensitivity of all preoperative examinations taken separately was low. When laparotomy was performed with a curative intent according to all four examinations, occult metastasis or carcinomatosis was discovered in 7/27 patients and the overall predictive value of resectability was thus 74%. Five-year and median survival were significantly better in resected vs. non-resected patients (39% and 26 months vs. 0% and 8 months, p = 0.0006). CONCLUSIONS: MRI can be recommended has the first examination in patients bearing pancreatic tumors, complemented by EUS if the findings of MRI are non-conclusive. For detection of distant metastasis, only the combination of all preoperative examination was proved to be more accurate than a single technique.     

A human mutation in Phox2b causes lack of CO2 chemosensitivity, fatal central apnea, and specific loss of parafacial neurons

Breathing is maintained and controlled by a network of neurons in the brainstem that generate respiratory rhythm and provide regulatory input. Central chemoreception, the mechanism for CO(2) detection that provides an essential stimulatory input, is thought to involve neurons located near the medullary surface, whose nature is controversial. Good candidates are serotonergic medullary neurons and glutamatergic neurons in the parafacial region. Here, we show that mice bearing a mutation in Phox2b that causes congenital central hypoventilation syndrome in humans breathe irregularly, do not respond to an increase in CO(2), and die soon after birth from central apnea. They specifically lack Phox2b-expressing glutamatergic neurons located in the parafacial region, whereas other sites known or supposed to be involved in the control of breathing are anatomically normal. These data provide genetic evidence for the essential role of a specific population of medullary interneurons in driving proper breathing at birth and will be instrumental in understanding the etiopathology of congenital central hypoventilation syndrome.     

EMR of large sessile colorectal polyps

BACKGROUND: EMR optimizes histopathologic assessment of resected lesions. This study evaluated the outcome of EMR of large sessile colorectal polyps in terms of complications and recurrence. METHODS: An uncontrolled prospective study was conducted of a cohort of 136 patients with sessile colorectal polyps referred for EMR. After submucosal injection, EMR was performed piecemeal by either snare polypectomy alone or with cap aspiration. RESULTS: In 136 patients, a total of 139 sessile polyps were resected, 86 of which were in the right colon. Median polyps diameter was 20 mm in the right colon and 30 mm in the other colonic segments. Intraprocedure bleeding occurred after 15 polypectomies (10.8%) and was controlled endoscopically in all cases; there was no delayed bleeding. Post-polypectomy syndrome occurred in 5 patients (3.7%). There was no perforation. Invasive carcinoma was found in 17 sessile colorectal polyps, and surgery was performed in 10 of 17 cases. Follow-up colonoscopy in 93 patients without invasive carcinoma (96 polyps), over a median of 12.3 months, disclosed local recurrence of 21 adenomatous polyps (21.9%). Colonoscopic follow-up in 5 of the 7 patients, who had sessile colorectal polyps with invasive carcinoma and did not undergo surgery, disclosed no local recurrence. CONCLUSIONS: EMR, including EMR with cap aspiration, is effective and safe for removal of sessile colorectal polyps throughout the colon.     

Adrenalectomy for Clinically Isolated Metastasis from Colorectal Carcinoma: Report of Eight Cases

Purpose  Metastasis to the adrenal glands is a relatively frequent finding at autopsy. Adrenal metastasis of colorectal carcinoma is rare (14 percent). Isolated adrenal metastasis is even rarer, and presents a therapeutic dilemma. Methods  Between 1997 and 2006, eight patients (5 men; mean age, 62 years) underwent adrenalectomy for metastasis of colorectal carcinoma. The tumors were Stage D in four cases, Stage B in two cases, and Stage C in the remaining two. Adjuvant chemotherapy was instituted. Results  All patients were asymptomatic, and adrenal metastasis was suspected from an elevated serum level of carcinoembryogenic antigen or discovered by computed tomography. Adrenal metastases were metachronous in seven patients, with median disease-free interval of 3.75 years. At the time of follow-up, one patient remained alive and free of disease 12 months after adrenalectomy, one patient was lost to follow-up after 22 months, and 6 patients have died from malignancy. The mean survival for the patients who died was 32 months. Conclusions  The rarity of isolated adrenal metastasis of colorectal carcinoma makes a randomized, prospective trial comparing surgery vs. nonsurgical management highly unlikely. Our results provide further support for surgical resection of solitary adrenal metastasis, which may translate into survival benefit. Presented in part in abstract form at European Society of ColoProctology (ESCP) meeting. Lisbon, Portugal, September 13–15, 2006. Reprints are not available.