Predictive Factors of Malignancy in Adults with Intussusception

Introduction Adult intussusception is an unusual entity, and its etiology differs from that in pediatric patients. The aim of this study was to evaluate our experience of 60 adult patients with intussusception and determine if there are any preoperative factors predictive of malignancy. Methods The records of 60 adult patients (> 18 years of age) with a diagnosis of intussusception surgically treated at Singapore General Hospital and Changi General Hospital between 1990 and 2004 were retrospectively reviewed. The intussusceptions were classified as enteric or colonic. Preoperative predictive factors of malignancy were analyzed using univariate and multivariate analyses, and P < 0.05 was considered statistically significant. Results There were 60 patients with a median age of 57.5 years (range 21–85 years). Altogether, 34 (56.7%) patients were male, and there were 31 enteric and 29 colonic intussusceptions. A lead point was identified in 54 patients (90%). A total of 22 (36.7%) patients presented with intestinal obstruction, and the correct preoperative diagnosis of intussusception was made in 31 patients (51.7%). Computed tomography was the most useful diagnostic modality, correctly identifying an intussusception in 24 of 30 patients. A malignant pathology was present in 8 of 31 (26%) enteric versus 20 of 29 (69%) colonic intussusceptions. Age (P = 0.009), the presence of anemia (P < 0.001), and the site of the intussusception (P = 0.001) showed significant differences between the benign and malignant groups by univariate analyses. On multivariate analysis, intussusception in the colon (P = 0.004) and the presence of anemia (P = 0.001) were independent predictive factors of malignancy. Conclusions Adult intussusception is most commonly secondary to a pathologic lead point. The site of intussusception in the colon and the presence of anemia are independent preoperative predictors of malignancy. All colonic intussusceptions should be resected en bloc without reduction, whereas a more selective approach can be applied for enteric intussusceptions.     

Cellular/extracellular matrix cross‐talk in scar evolution and control

The principles of scar evolution and control are recognized and defined. Further clarity has been shed on these principles with the elucidation and elaboration of the sequence of events occurring at a molecular level. Cellular cross‐talk among structures in the cell cytosol, in the cellular nucleus, and outside the cell within in the extracellular matrix is continuous and controlling in nature. This interaction or “dynamic reciprocity” takes place via a series of signals, ionic messenger shifts, protein activation, and receptor transactions. The described principles are now able to be defined in terms of cellular/extracellular matrix interactions and the identification of the cross‐talk involved in scar evolution and maturation presents the possibility of influencing the “wording” of this cross‐talk to improve scar outcome. The principles of mechanostimulation and scar support, hydration occlusion, controlled inflammation, and collagen/extracellular remodeling are discussed with possible interventions in each category.     

Identification of cervicothoracic intervertebral spaces by surface landmarks and ultrasound

Purpose

Precise localization of the cervicothoracic vertebral levels is essential for accurate placement of epidural catheters. Previous studies have demonstrated that anesthesiologists are inaccurate when using surface anatomy to locate lumbar vertebral levels. Our study was designed to determine the agreement between anatomical landmarks and the ultrasound technique in identifying the T7-8 and C7-T1 intervertebral spaces.

Methods

Adult healthy volunteers were assessed for the identification of cervicothoracic intervertebral spaces, initially in the anatomic position (AP)—upright, back straight, arms at the sides, and palms forward and then in the epidural position (EP) routinely used for epidural placement—seated, back arched, neck flexed, and arms across the chest. The T7 and C7 spinous processes were identified by one investigator using the inferior tip of the scapula and the vertebra prominens, respectively, as landmarks. Ultrasound was then used by a second investigator to identify the intervertebral spaces corresponding to the previously marked levels.

Results

Fifty-five volunteers (23 males, 32 females) were recruited. The T7-8 intervertebral space determined by ultrasound coincided with the landmark findings in the AP and in the EP in 18% and 36% of the cases, respectively. The C7-T1 interspace identified by ultrasound corresponded with the surface landmarks in the AP and in the EP in 53% and 58% of the cases, respectively. In most cases, when the surface landmark and ultrasound findings of T7-8 did not agree, the surface landmark identified a lower interspace than ultrasound.

Conclusion

Identification of cervicothoracic intervertebral spaces by surface landmarks corresponded poorly with their identification using ultrasound. However, compared with the upright position, agreement in identifying the T7-8 interspace improved in the epidural position.     

Is the Anatomical Protrusion on the Posterior Hypopharyngeal Wall Associated with Cadavers of Only the Elderly?

Cricopharyngeal bars are commonly seen on a barium swallow radiologic examination and represent the failure of the cricopharyngeus to relax. Traditionally, the bars have been considered as functional or physiologic protrusions. Recently, anatomical cricopharyngeal protrusion has been found in about 30% of cadavers of the elderly, suggesting that such a structural change may become a physical barrier that affects the normal deglutition in a living person. This suggests that such a radiographic finding should be carefully considered when interpreting radiologic and manometrical examinations and managing dysphagia of the elderly. However, the finding of the anatomical cricopharyngeal protrusion was based on the observation of cadavers of the elderly (mean age = 77 years). The aim of this study was to further investigate whether such an anatomical cricopharyngeal protrusion exists in cadavers of other ages. Using the dissection method, we examined 63 human cadavers that were divided into three age groups: young adult (6 females and 10 males, age = 16–24 years old), adult (8 females and 23 males, age = 25–64 years old), and early elderly (5 females and 11 males, age = 65–69 years old). We found that 57 of the 63 cadavers had a smooth mucosal surface on the posterior hypopharyngeal and upper esophageal wall. A slightly thickened posterior muscular wall was observed at the cricoid level in six cadavers (five from the adult group and one from the early elderly group), but its boundary was not clearly identified. Taking the previous reports together, our results suggest that an anatomical cricopharyngeal protrusion is closely associated with the aging process.     

Validity/Reliability of PHQ-9 and PHQ-2 Depression Scales Among Adults Living with HIV/AIDS in Western Kenya

Background  Depression greatly burdens sub-Saharan Africa, especially populations living with HIV/AIDS, for whom few validated depression scales exist. Patient Health Questionnaire-9 (PHQ-9), a brief dual-purpose instrument yielding DSM-IV diagnoses and severity, and PHQ-2, an ultra-brief screening tool, offer advantages in resource-constrained settings. Objective  To assess the validity/reliability of PHQ-9 and PHQ-2. Design  Observational, two occasions 7 days apart. Participants  A total of 347 patients attending psychosocial support groups. Measurements  Demographics, PHQ-9, PHQ-2, general health perception rating and CD4 count. Results  Rates for PHQ-9 DSM-IV major depressive disorder (MDD), other depressive disorder (ODD) and any depressive disorder were 13%, 21% and 34%. Depression was associated with female gender, but not CD4. Construct validity was supported by: (1) a strong association between PHQ-9 and general health rating, (2) a single major factor with loadings exceeding 0.50, (3) item-total correlations exceeding 0.37 and (4) a pattern of item means similar to US validation studies. Four focus groups indicated culturally relevant content validity and minor modifications to the PHQ-9 instructions. Coefficient alpha was 0.78. Test-retest reliability was acceptable: (1) intraclass correlation 0.59 for PHQ-9 total score, (2) kappas 0.24, 0.25 and 0.38 for PHQ-9 MDD, ODD and any depressive disorder and (3) weighted kappa 0.53 for PHQ-9 depression severity categories. PHQ-2 ≥3 demonstrated high sensitivity (85%) and specificity (95%) for diagnosing any PHQ-9 depressive disorder (AUC, 0.97), and 91% and 77%, respectively, for diagnosing PHQ-9 MDD (AUC, 0.91). Psychometrics were also good within four gender/age (18–35, 36–61) subgroups. Conclusions  PHQ-9 and PHQ-2 appear valid/reliable for assessing DSM-IV depressive disorders and depression severity among adults living with HIV/AIDS in western Kenya.     

The potential impact of antiretroviral therapy on fertility in sub-Saharan Africa

Approximately 14 million women of child-bearing age are living with HIV/AIDS in sub-Saharan Africa. Women with HIV infection have between 25% and 40% lower fertility than noninfected women. As antiretroviral (ARV) therapy becomes increasingly accessible in sub-Saharan Africa, it is important to understand whether and how the associated clinical improvements correspond with changes in the incidence of pregnancy and fertility. Accordingly, this paper reviews the literature on the potential impact of ARV therapy on the fertility of women with HIV infection in sub-Saharan Africa. We use Bongaarts‘ proximate determinants of fertility framework (adapted for conditions of a generalized HIV epidemic) to examine the underlying mechanisms through which use of ARV therapy may impact the fertility of women with HIV infection. A conceptual framework is proposed to guide future research aimed at understanding how widespread use of ARV therapy may impact fertility in sub-Saharan Africa.