Stress, urge, and mixed types of partial fecal incontinence: pathogenesis, clinical presentation, and treatment

The authors investigated the hypothesis that partial fecal incontinence (PFI) had variable manifestations that can be categorized as different types of PFI with different pathogeneses and treatment. Anal and rectal pressures as well as external and internal anal sphincter electromyographic activity were recorded in 163 patients with PFI and in 25 healthy volunteers. Patients were treated with biofeedback or surgically. Three types of PFI were encountered: stress fecal incontinence (SFI; 55 patients), urge fecal incontinence (UFI; 72 patients), and mixed fecal incontinence (MFI; 36 patients). Anal pressure decreased in three groups in which MFI had the lowest pressure. A significant reduction in external anal sphincter electromyographic activity occurred in SFI, in internal anal sphincter electromyographic activity in UFI, and of both sphincters in MFI. Biofeedback cured 36 of 55 patients and postanal repair cured 10 of 19 patients with SFI. Forty-eight of 72 patients with UFI responded to biofeedback and 16 of 24 responded to internal anal sphincter repair. Biofeedback failed in MFI patients. Twenty-four of 27 patients who consented to operative correction of the sphincteric defect were cured. Three types of PFI could be identified: SFI, UFI, and MFI. Each type has its own etiology and symptoms, and requires individual treatment. Biofeedback succeeded in treating the majority of SFI and UFI patients. Surgical correction of the anal sphincter was performed after biofeedback failure.     

Significance of zeta-associated protein (ZAP-70) and CD38 expression in chronic lymphocytic leukemia

Chronic lymphocytic leukemia (CLL) is a disease with a highly variable clinical course; some patients never need treatment, while others require intensive treatment early after diagnosis. Some new prognostic factors, such as immunoglobulin variable heavy chain (IgVH) mutational status, zeta-associated protein (ZAP-70) and CD38 expression in leukemic cells were introduced to identify attenuated versus progressive types of CLL bearing the potential to facilitate risk-adapted treatment strategies. So, the aim of this work is to evaluate the clinical value of ZAP-70 and CD38 as predictors of disease progression. We assessed the expression of these markers by flowcytometry in 38 patients with CLL and correlated their levels with genetic abnormalities detected by fluorescence in situ hybridization (FISH) and the clinical outcome. We found that 18 patients (47.4 %) were positive for ZAP-70 (> or = 20%) and 16 patients (42.1%) were positive for CD38 (> or = 20%). Positive ZAP-70 and CD38 status were associated with an unfavorable clinical course including high leukocytic count, lymphocytosis, high lactate dehydrogenase (LDH) serum level, advanced disease stage, trisomy 12 and del (11q); negative ZAP-70 and CD38 status were correlated with del (13q). The treatment-free survival time was 30 months for ZAP-70-positive patients and 18 months for ZAP-70-nagative patients (p < 0.01). Combined analysis of ZAP-70 and CD38 yielded discordant results in 10 patients (26.3 %), whereas 16 patients (42.1%) were concordantly negative and 12 patients (31.6%) were concordantly positive for ZAP-70 and CD38 expression. Median treatment-free survival times in patients whose leukemic cells were ZAP-70+CD38+ was 27 months as compared to 100 months in patients with a ZAP-70(-)CD38(-) status. In patients with discordant ZAP-70/CD38 results, the median treatment-free survival time was 40 months. Thus, ZAP-70 and CD38 expression analyses provide complementary prognostic information and allow distinguishing the patients groups with the most favorable prognosis as well as those with the worst. The current findings suggest that both ZAP-70 and CD38 protein expression should be assessed in patients with CLL for the definition of prognostic subgroups.     

Effects of big endothelin-1 in comparison with endothelin-1 on the microvascular blood flow velocity and diameter of rat mesentery in vivo

Synthetic big endothelin-1 (ET-1), a 39-residue precursor of ET-1, has been reported to elicit potent contractile action on helical strip specimens obtained from the porcine coronary artery, but its molar potency was found to be 140-fold lower than that of ET-1 [Saito, Y., Nakao, K., Mukoyama, M., Imura, H., 1990. Increased plasma endothelin level in patients with essential hypertension. N. Engl. J. Med. 322, 205]. It has been hypothesized that the increased rate of production and/or release of ET-1 from the vascular endothelium may contribute to the pathogenesis of hypertension. However, the effects of big ET-1 in comparison with ET-1 on the macrocirculation and microcirculation of the rat mesentery have not been well documented. Thus, our main purpose for this study was to examine the effects of both big ET-1 and ET-1 to clarify the role of phosphoramidon in inhibiting the conversion of big ET-1 to ET-1, by investigating the systemic blood pressure, microvascular blood flow velocity, and diameters of arterioles and venules of the rat mesentery. For this purpose, two groups of experiments were performed. In these experiments, the mesentery was arranged for in situ intravital microscopic observation under transillumination. In the first group of experiments, intravenous cumulative injections of big ET-1 or ET-1 were infused through a catheter inserted into the right jugular vein. Infusion of big ET-1 (1-8 nmol/kg) elicited a long-lasting significant pressor effect. Infusion of big ET-1 (1-2 nmol/kg) elicited a significant dose-dependent increase in the microvascular blood flow velocity both in arterioles (20-30 microm) and venules (30-40 microm). Microvascular diameters exhibited a slight but significant vasodilator effect. However, the infusion of big ET-1 (4-8 nmol/kg) elicited a dose-dependent significant decrease in the blood flow velocities, and diameters returned to control measurements. The administration of ET-1 (0.25-2 nmol/kg) induced a dose-dependent significant decrease in the blood flow velocity of arterioles and venules, and their diameters exhibited a vasoconstrictive effect more prominent in arterioles than in venules. In the second group of experiments, cumulative injections of phosphoramidon (30 mg/kg/10 min) were administered 10 min prior to the infusion of big ET-1. Phosphoramidon significantly suppressed the long-lasting significant pressor effect and significantly inhibited the dose-dependent increase and dose-dependent decrease in the microvascular blood flow velocity produced by big ET-1 in the rat mesenteric microcirculation. This study observed differences in the effects big ET-1 and ET-1 have on the rat mesenteric microcirculation and proposes a possible mechanism explaining these differences. Moreover, phosphoramidon markedly inhibited the conversion of big ET-1 to ET-1 in the rat mesenteric microcirculation, which may suggest an inhibition of the enzyme which converts big ET-1 to ET-1.     

Pattern of neuropsychiatric manifestations and outcome in juvenile systemic lupus erythematosus

The aim of this study was to study the neuropsychiatric (NP) manifestations, diagnostic evaluation, treatment and outcome in juvenile systemic lupus erythematosus (SLE). We reviewed the charts of all children with SLE and evidence of NP manifestations as defined by the presence of at least one of the following: headache, cerebrovascular accident (CVA), chorea, seizure, papilledema, and psychiatric or spinal cord manifestations. Out of 90 children with SLE, 20 (16 female) had NP manifestations. The mean age at onset was 8.8 years. The mean period between onset of SLE and NP manifestations was 10.2 months. NP manifestations were the presenting feature in 3 patients. Eleven patients had headache, 10 had psychiatric manifestations, 10 had seizure and 6 had CVA. Coma was seen in 5 patients, chorea in 4, transverse myelitis in 2 and papilledema in 2. Anticardolipin antibodies were high in 12 patients. Five patients had an abnormal CSF study. Nine patients had EEG abnormalities and 13 showed MRI abnormalities. All patients received oral prednisone and 17 were treated with IVMP and immunosuppressive therapy (cyclophosphamide or azathioprine); 85% of our patients recovered completely, but 15% had persistent NP sequelae; 10% died from severe infection. In conclusion, NP involvement in juvenile SLE is common. However, early diagnosis and early treatment with adjunctive intravenous pulse cyclophosphamide may improve the outcome.Abbreviations CVA Cerebrovascular accident - IVMP Intravenous methylprednisolone - NP Neuropsychiatric - SLE Systemic lupus erythematosus     

Parker Flex-It stylet is as effective as GlideRite Rigid stylet for orotracheal intubation by Glidescope

Objectives:

To evaluate Parker Flex-It stylet as an alternative to GlideRite Rigid stylet to aid tracheal intubation with the Glidescope.

Methods:

This prospective randomized trial was conducted at King Abdulaziz University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia between May and December 2014. Sixty American Society of Anesthesiologists I-II patients were randomly assigned to one of 2 equal groups receiving intubation by Glidescope using either GlideRite Rigid stylet (Group GS) or Parker Flex-It stylet (Group PS). The total intubation time, ease of intubation, incidences of successful intubation at first attempt, number of intubation attempts, use of optimization maneuvers, and possible complications were recorded.

Results:

No significant differences between both groups regarding the total intubation time (p=0.08) was observed. Intubation was significantly easier in group PS compared with group GS as measured by visual analogue scale (p=0.001) with no significant differences between the groups regarding the rate of successful tracheal intubation from first attempt (p=0.524). However, the number of attempts at intubation and usage of external laryngeal manipulation were similar in both groups (p>0.05). The incidence of sore throat, dysphagia, hoarseness, and trauma were significantly higher in group GS (p<0.05).

Conclusion:

Parker Flex-It stylet is as effective as GlideRite Rigid stylet when used by experienced operators in patients with normal airways using Glidescope; however, it is easier and less traumatic.The GlideScope Ranger (GVL; Verathon Medical Inc., Bothell, WA, USA) is a novel portable, reusable video laryngoscope that has provided superior laryngeal visualization to facilitate tracheal intubation especially in the management of difficult airways; it provides indirect visualization of the glottis with a pronounced angle of 60° in the blade.1 It has a separate monitor connected to the handle via a cable. The tip of the blade is equipped with a high-resolution digital video camera, an LED light, and an antifogging system.2,3 Unlike the Macintosh laryngoscope, an indirect laryngoscope such as the GlideScope device provides a view of the glottis without the need to align the oral pharyngeal and laryngeal axes facilitating an excellent glottic visualization.4 However, insertion and advancement of the endotracheal tube (ETT) may be more difficult to pass through the vocal cords than direct laryngoscopy,5,6 and trauma is possible.7,8 The GlideScope have shown to function better when used in conjunction with use of a stylet to guide insertion of endotracheal tube.9,10 The GlideRite Rigid stylet (GRS) is a reusable rigid steel stylet, specifically designed by the manufacturer to resemble the distal part of the Glidescope video laryngoscopy blade for clear view of the airway, enabling quick intubation, its curvature approaches 90° with a radius of curvature of approximately 6 cm.11 Various investigators have recommended different curvatures of the ETT/stylet to optimally direct it into the trachea, including matching the blade’s 60° angle,11 configuring the ETT with a 90° bend,6,12 or using a J-shaped ETT.13 Other potential strategies may include the use of a flexible stylet that allows active modification of the tip of the tracheal tube during use.14,15 The Parker Flex-It Directional Stylet (FIS, Parker Medical, Highlands Ranch, CO) is a 2-piece plastic stylet that can be used for oral intubation, and allows continuous adjustment of the tube curvature during an intubation to enable the tube to follow the curvature of the airway.14,16 We hypothesized that the use of Parker Flex-It stylet to guide ETT might offer some benefit over the GRS. Therefore, the purpose of this study was to determine the optimal stylet-tracheal tube strategy for use with the GlideScope^® laryngoscope. We compared efficacy of the 2 intubating aids including GRS versus Parker Flex-It stylet for orotracheal intubation in terms of the total intubation time (primary outcome), ease of intubation, the number of intubation attempts, the number of optimization manoeuvres, and possible trauma (secondary outcomes) when used by experienced GlideScope operators.