Long-term Outcomes of Endoscopic Variceal Ligation to Prevent Rebleeding in Children with Esophageal Varices

After an episode of acute bleeding from esophageal varices, patients are at a high risk for recurrent bleeding and death. However, there are few reports regarding the long-term results of secondary prophylaxis using endoscopic variceal ligation (EVL) against variceal rebleeding in pediatrics. Thirty-seven, who were followed for over 3 yr post-eradication, were included in the study. The mean duration of follow up after esophageal variceal eradication was 6.4±1.9 yr. The mean time required to achieve the eradication of varices was 3.25 months. The mean number of sessions and O-bands needed to eradicate varices was 1.9±1.2 and 3.8±1.5, respectively. During the period before the first EVL treatment, 145 episodes of bleedings developed in 37 children. Over the 3 yr of follow-up after variceal eradication, only 4 episodes of rebleeding developed in 4 of 37 patients. The four rebleeding episodes consisted of an esophageal variceal bleed, a gastric variceal bleed, a duodenal ulcer bleed, and a bleed caused by hemorrhagic gastritis. There was no mortality during long-term follow up after variceal eradication. During long-term follow up after esophageal variceal eradication using solely EVL in children with esophageal variceal bleeds, rebleeding episodes and recurrence of esophageal varices were rare. EVL is a safe and highly effective method for the long-term prophylaxis of variceal rebleeding in children with portal hypertension.     

New Metrics in High-Resolution and High-Definition Anorectal Manometry

Purpose of Review

To review recently published diagnostic methods that use high-resolution (HR-) or high-definition- (HD-) anorectal manometry (ARM) techniques.

Recent Findings

The integrated pressurized volume (IPV) is a new measure based on spatiotemporal plots obtained from HR-ARM. The IPV may be clinically useful for improving the prediction of abnormal balloon expulsion test in patients with constipation and for discriminating patients with anorectal disorders from asymptomatic controls. Combination of IPV parameters was superior to conventional manometric parameters in predicting the responsiveness to biofeedback therapy. Moreover, several novel parameters including the HR-ARM resting integral, HR-ARM squeeze profile, and anorectal asymmetry index may each be useful as predictive factors for identifying patients with fecal incontinence.

Summary

HR- and HD-ARM are increasingly performed worldwide for evaluation of anorectal function. Here, we describe new metrics whose clinical significance has not been fully established. Further standardization and validation of these metrics could provide clinically important new information and could help improve our understanding of the pathophysiology of anorectal disorders.

     

Bisphosphonate-associated peri-implant fractures: a new clinical entity?: A series of 10 patients with 11 fractures

Background and purpose

The current definition of atypical femoral fractures (AFFs) associated with bisphosphonate use includes only de novo fractures. However, in recent years reports of bisphosphonate-associated periprosthetic fractures involving stemmed arthroplasty implants have emerged. In a case series of peri-implant fractures in femurs with plate/screw constructs, we aimed to assess similarities with classical AFFs and how their location may have implications for the pathogenesis and management of AFFs.

Patients and methods

We retrospectively identified 10 patients with 11 peri-implant fractures.

Results

The patients were ambulant women, mean age 80 (70–92) years. Mean duration of bisphosphonate use was 5 (1–10) years. The peri-implant fractures were sustained an average of 4 years (6 months to 9 years) from the time of index surgery. They were all associated with low-energy mechanisms. 8 fractures occurred near the tip of a plate, while 3 traversed the penultimate screwhole of a plate. The peri-implant fractures showed clinical and radiological features of atypicality such as lateral cortical thickening, simple fracture pattern, and lack of comminution. The patients underwent revision surgery, with bone grafting used in all but 1 case. Radiological union was evident after 2–4 months.

Interpretation

Atypical peri-implant fractures of the femur associated with bisphosphonate use may be a new entity. Stress lesions and atypical fractures may tend to develop over stress risers along the operated femur. This finding has implications for the pathogenesis and clinical management of AFFs.Bisphosphonates form the cornerstone of antiresorptive therapy in the management of post-menopausal osteoporosis. They are used in the treatment of malignant and osteoclast-mediated metabolic bone disease. Their use in patients who have undergone total joint arthroplasty of the lower limb is associated with higher periprosthetic bone mineral density and longer implant survival (Bhandari et al. 2005). Bisphosphonates exert their therapeutic effect by reducing bone turnover and increasing overall mineralization. This translates to increased bone mineral density and bone strength, corresponding clinically to reduced risk of vertebral and non-vertebral fragility fractures (Black et al. 1996).In recent years, several published reports have described atypical femoral fractures (AFFs) of the proximal femoral diaphysis and subtrochanteric region, in association with bisphosphonate use (Goh et al. 2007, Neviaser et al. 2008, Isaacs et al. 2010). Bisphosphonates are associated with a higher age-adjusted relative risk of AFF in women than in men, which is higher in alendronate users than in risedronate users (Schilcher et al. 2015). Bisphosphonates may cause changes in bone matrix composition and bone mechanical properties, increasing the propensity for accumulation of microdamage. Impaired target remodeling would contribute to the progression of macrocracks. High interfragmentary strain from physiological loads at a thin fracture line may be a mechanical factor in lack of bone healing (Aspenberg et al. 2010).Periprosthetic/peri-implant fractures are currently excluded from the definition of AFFs. We suggest that peri-implant fractures of the femur with features of atypicality may be linked to bisphosphonate use and that they should be recognized as a clinical entity.     

Phylogenetic Analyses of HBV Pre-S/S Genes in Mother-Child Pairs with Long-Term Infection by Presumed Vertical Transmission

Vertical transmission from mother to child, the main route of chronic hepatitis B virus (HBV) infection in the East Asia, is considered one of the most important predictors for the response to antiviral therapies as well as its complications such as cirrhosis and hepatocellular carcinoma. Therefore, it is critical in both etiologic and prognostic aspects to confirm whether or not chronic HBV infection is acquired vertically. This study investigated whether mother-to-child infection could be proved by the phylogenetic analyses of HBV pre-S/S genes ever since several decades have elapsed in mother-child pairs with presumed vertical transmission. The pre-S and S regions of HBVs were compared and analyzed phylogenetically in a total of 36 adults (18 mother-child pairs) with chronic HBV infection. All of the isolates of HBV were genotype C and serotype adr. The divergence between mothers and offsprings was 0 to 1.5%. Phylogenetic trees revealed that 17 of 18 pairs (94%) with presumed vertical transmission were grouped into the same cluster. Vertical transmission from mother to child could be strongly suggested even in adults with a history of several decades of HBV infection using the phylogenetic analyses of pre-S and S genes.

Graphical Abstract

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