Eosinophilic oesophagitis: a frequently missed cause of dysphagia

Oesophageal dysphagia is the subjective feeling that there is a problem with the passage of solids or liquids through the oesophagus. The differential diagnosis of dysphagia is long and can be divided into mechanical and motility disorders. Dysphagia is an alarming symptom which requires short-term endoscopic evaluation. An emerging cause of dysphagia is eosinophilic oesophagitis. The typical eosinophilic oesophagitis patient is a young adult man, often with an atopic constitution, who has intermittent symptoms of dysphagia. The diagnosis of 'eosinophilic oesophagitis' is based on characteristic histological findings in the oesophagus, seen in a fitting clinical context. Best evidence for the effects of treatment of eosinophilic oesophagitis is available for topical glucocorticoids.     

Cerebellar contributions to neurological soft signs in healthy young adults

Neurological soft signs (NSS) are frequently found in psychiatric disorders of significant neurodevelopmental origin, e.g., in patients with schizophrenia and autism. Yet NSS are also present in healthy individuals suggesting a neurodevelopmental signature of motor function, probably as a continuum between health and disease. So far, little is known about the neural mechanisms underlying these motor phenomena in healthy persons, and it is even less known whether the cerebellum contributes to NSS expression. Thirty-seven healthy young adults (mean age = 23 years) were studied using high-resolution structural magnetic resonance imaging (MRI) and “resting-state” functional MRI at three Tesla. NSS levels were measured using the “Heidelberg Scale.” Cerebellar gray matter volume was investigated using cerebellum-optimized voxel-based analysis methods. Cerebellar function was assessed using regional homogeneity (ReHo), a measure of local network strength. The relationship between cerebellar structure and function and NSS was analyzed using regression models. There was no significant relationship between cerebellar volume and NSS (p < 0.005, uncorrected for height, p < 0.05 corrected for spatial extent). Positive associations with cerebellar lobule VI activity were found for the “motor coordination” and “hard signs” NSS domains. A negative relationship was found between lobule VI activity and “complex motor task” domain (p < 0.005, uncorrected for height, p < 0.05 corrected for spatial extent). The data indicate that in healthy young adults, distinct NSS domains are related to cerebellar activity, specifically with activity of cerebellar subregions with known cortical somatomotor projections. In contrast, cerebellar volume is not predictive of NSS in healthy persons.     

Health-related quality-of-life and health-utility reporting in critical care

Mortality is a well-established patient-important outcome in critical care studies. In contrast, morbidity is less uniformly reported (given the myriad of critical care illnesses and complications of each) but may have a common end-impact on a patient’s functional capacity and health-related quality-of-life (HRQoL). Survival with a poor quality-of-life may not be acceptable depending on individual patient values and preferences. Hence, as mortality decreases within critical care, it becomes increasingly important to measure intensive care unit (ICU) survivor HRQoL. HRQoL measurements with a preference-based scoring algorithm can be converted into health utilities on a scale anchored at 0 (representing death) and 1 (representing full health). They can be combined with survival to calculate quality-adjusted life-years (QALY), which are one of the most widely used methods of combining morbidity and mortality into a composite outcome. Although QALYs have been use for health-technology assessment decision-making, an emerging and novel role would be to inform clinical decision-making for patients, families and healthcare providers about what expected HRQoL may be during and after ICU care. Critical care randomized control trials (RCTs) have not routinely measured or reported HRQoL (until more recently), likely due to incapacity of some patients to participate in patient-reported outcome measures. Further differences in HRQoL measurement tools can lead to non-comparable values. To this end, we propose the validation of a gold-standard HRQoL tool in critical care, specifically the EQ-5D-5L. Both combined health-utility and mortality (disaggregated) and QALYs (aggregated) can be reported, with disaggregation allowing for determination of which components are the main drivers of the QALY outcome. Increased use of HRQoL, health-utility, and QALYs in critical care RCTs has the potential to: (1) Increase the likelihood of finding important effects if they exist; (2) improve research efficiency; and (3) help inform optimal management of critically ill patients allowing for decision-making about their HRQoL, in additional to traditional health-technology assessments.     

Optimization of folic acid, vitamin B(12), and vitamin B(6) supplements in pediatric patients with sickle cell disease

Using homocysteine as a functional marker, we determined optimal folic acid, vitamin B(12), and vitamin B(6) dosages in 21 pediatric sickle cell disease (SCD) patients (11 HbSS, 10 HbSC; 7-16 years). Daily supplements of folic acid (400, 700, or 1,000 microg), vitamin B(12) (1, 3, or 5 U.S. 1989 RDA), and vitamin B(6) (1 or 3 U.S. 1989 RDA) were gradually increased in an 82-week dose-escalation study. Blood was taken at 9 occasions for measurements of erythrocyte (RBC) and serum folate, plasma vitamin B(12), whole-blood vitamin B(6), and plasma homocysteine. Augmentation of folic acid from 700 to 1,000 microg and vitamin B(12) from 3 to 5 RDA did not further decrease homocysteine. Percentages of patients exhibiting significant individual homocysteine decreases amounted to 43% (folic acid from 0 to 400 microg, vitamins B(12) and B(6) from 0 to 1 RDA), 14% (folic acid from 400 to 700 microg), 24% (vitamin B(12) from 1 to 3 RDA), and 18% (vitamin B(6) from 1 to 3 RDA ). The lowest plasma homocysteine at 82 weeks was 5.9 +/- 2.2 micromol/L. Patients with HbSS had higher RBC folate than HbSC. The entire group exhibited an inverse relation between RBC folate and hemoglobin. We conclude that RBC folate is less valuable for folate status assessment in SCD patients. Optimal dosages are as follows: 700 microg folic acid (3.5-7 U.S. 1989 RDA), 3 U.S. 1989 RDA vitamin B(12) (4.2-6.0 microg), and 3 U.S. 1989 RDA vitamin B(6) (4.2-6.0 mg). A practical daily combination is 1 mg folic acid (4.3-8.5 U.S. 1998 RDA when taken with meals), 6 microg vitamin B(12) (2.5-5 U.S. 1998 RDA), and 6 mg vitamin B(6) (4.6-10 U.S. 1998 RDA). This combination may by simple and relatively inexpensive means reduce these patients' inherently high risk of endothelial damage.     

Feasibility and Safety of Vascular Closure Devices in an Antegrade Approach to Either the Common Femoral Artery or the Superficial Femoral Artery

Introduction

The purpose of the present study was to analyze complications following antegrade puncture of the common femoral artery (CFA) and the superficial femoral artery (SFA) using vascular closure systems (VCS).

Methods

A single-center, retrospective study was performed after obtaining approval from the institutional review board and informed consent from all patients. At our center, the CFA or SFA are used for arterial access. All patients were evaluated clinically on the same day. If there was any suspicion of an access site problem, Duplex ultrasound was performed.

Results

Access location was the CFA in 50 patients and the SFA in 130 patients. The sheath size ranged from 4F to 10F. Two patients had to be excluded because of lack of follow-up. Successful hemostasis was achieved in 162 of 178 cases (91?%). The following complications were observed in 16 patients (8.9?%): 4 pseudoaneurysms (2.2?%), 11 hematomas (6.2?%), and 1 vascular occlusion (0.5?%). The two pseudoaneurysms healed spontaneously, in one case an ultrasound-guided thrombin injection was performed, and one aneurysm was compressed manually. No further medical therapy was needed for the hematomas. The one vascular occlusion was treated immediately with angioplasty using a contralateral approach. No significant difference was noted between the CFA and the SFA group with respect to complications (p?=?1.000).

Conclusions

The use of closure devices for an antegrade approach up to 10F is feasible and safe. No differences in low complication rates were observed between CFA and SFA.     

Antimicrobial resistance in hospital wastewater in Scotland: a cross-sectional metagenomics study

BackgroundAntimicrobial resistance (AMR) is a global health crisis. It is well established that hospital wastewater can contain organisms that are on the WHO priority list of antibiotic-resistant organisms. We aimed to use metagenomics to study whether the abundances of resistance genes in hospital wastewater reflects clinical activity within the hospital.MethodsHospital wastewater was collected over a 24-h period in June, 2017 from multiple collection points representing different specialties within a tertiary hospital site in Scotland, UK and simultaneously from community sewage works. High throughput shotgun sequencing was done using Illumina HiSeq4000. Sequence reads were assigned taxonomically and to the AMR genes in the ResFinder database. The measured AMR gene abundances were correlated to hospital antimicrobial usage in defined daily doses per 100 occupied bed-days, mean patient length of stay in hospital, mean patient age per hospital collection point, and resistance levels in clinical isolates.Findings1047 bacterial genera and 174 different AMR genes were detected across all samples. Microbiota composition and AMR gene abundance and diversity varied between each collection point and AMR gene abundance was higher in hospital wastewater than in community influent. The composition of AMR genes correlated with microbiota composition (Procrustes analysis, p=0·002). Increased antimicrobial consumption at a class level was associated with higher AMR gene abundance within that class in hospital wastewater (incidence rate ratio 2·80, 95% CI 1·2–6·5, p=0·016). Prolonged mean patient length of stay was associated with higher total AMR gene abundance in hospital wastewater (2·05, 1·39–3·01, p=0·0003). No overall association was found between resistance in clinical isolates at an antimicrobial class level and AMR gene abundance in hospital wastewater.InterpretationAntimicrobial usage is a major driver of AMR gene outflow from hospitals into the sewage environment. The positive relationship between length of stay and AMR gene abundance is consistent with prolonged admission being a risk factor for carriage and infection with resistant microorganisms. Our findings show that hospital wastewater does reflect inpatient activity. With further evaluation this method might represent a useful surveillance tool to monitor hospital AMR gene outflow and guide environmental policy on AMR.FundingAcademy of Medical Sciences.     

Characterization of the deformation behavior of intermediate porosity interconnected Ti foams using micro-computed tomography and direct finite element modeling

Under load-bearing conditions metal-based foam scaffolds are currently the preferred choice as bone/cartilage implants. In this study X-ray micro-computed tomography was used to discretize the three-dimensional structure of a commercial titanium foam used in spinal fusion devices. Direct finite element modeling, continuum micromechanics and analytical models of the foam were employed to characterize the elasto-plastic deformation behavior. These results were validated against experimental measurements, including ultrasound and monotonic and interrupted compression testing. Interrupted compression tests demonstrated localized collapse of pores unfavorably oriented with respect to the loading direction at many isolated locations, unlike the Ashby model, in which pores collapse row by row. A principal component analysis technique was developed to quantify the pore anisotropy which was then related to the yield stress anisotropy, indicating which isolated pores will collapse first. The Gibson–Ashby model was extended to incorporate this anisotropy by considering an orthorhombic, rather than a tetragonal, unit cell. It is worth noting that the natural bone is highly anisotropic and there is a need to develop and characterize anisotropic implants that mimic bone characteristics.     

Burnout chez les résidents en médecine tunisiens : à propos de 149 cas

Background

Burnout is a professional psychological chronic stress-induced syndrome defined by three dimensions: emotional exhaustion, depersonalization, and low personal accomplishment. This syndrome concerns all professions but especially healthcare staff. Numerous studies have attempted to document the impact of work activities on the doctor's mental health. According to the literature, junior doctors are more vulnerable to develop this syndrome.

Chest wall segmentation in automated 3D breast ultrasound scans

In this paper, we present an automatic method to segment the chest wall in automated 3D breast ultrasound images. Determining the location of the chest wall in automated 3D breast ultrasound images is necessary in computer-aided detection systems to remove automatically detected cancer candidates beyond the chest wall and it can be of great help for inter- and intra-modal image registration. We show that the visible part of the chest wall in an automated 3D breast ultrasound image can be accurately modeled by a cylinder. We fit the surface of our cylinder model to a set of automatically detected rib-surface points. The detection of the rib-surface points is done by a classifier using features representing local image intensity patterns and presence of rib shadows. Due to attenuation of the ultrasound signal, a clear shadow is visible behind the ribs. Evaluation of our segmentation method is done by computing the distance of manually annotated rib points to the surface of the automatically detected chest wall. We examined the performance on images obtained with the two most common 3D breast ultrasound devices in the market. In a dataset of 142 images, the average mean distance of the annotated points to the segmented chest wall was 5.59 ± 3.08 mm.     

A threshold explanation for the lack of variation in negative composite time trade-off values

Quality of Life Research - Recent studies concluded that for health states considered worse than dead (WTD), as measured with the time trade-off (cTTO) method, negative mean values were insensitive...