Radical Surgery in the Presence of Biliary Metallic Stents: Revising the Palliative Scenario

Background  

The application of endobiliary self-expandable metallic stents (SEMS) is considered the palliative treatment of choice in patients with biliary obstruction in the setting of inoperable malignancies. In the presence of SEMS, however, radical surgery is the only curative option when the resectability status is revised in case of malignancies or for overcoming complications arising from their application in benign conditions that masquerade as inoperable tumours. The aim of our study was to report our surgical experience with patients who underwent an operation due to revision of the initial palliative approach, whilst they had already been treated with biliary SEMS exceeding the hilar bifurcation.     

Comparison of clinicians and an artificial neural network regarding accuracy and certainty in performance of visual field assessment for the diagnosis of glaucoma

Purpose: To compare clinicians and a trained artificial neural network (ANN) regarding accuracy and certainty of assessment of visual fields for the diagnosis of glaucoma. Methods: Thirty physicians with different levels of knowledge and experience in glaucoma management assessed 30‐2 SITA Standard visual field printouts that included full Statpac information from 99 patients with glaucomatous optic neuropathy and 66 healthy subjects. Glaucomatous eyes with perimetric mean deviation values worsethan ?10 dB were not eligible. The fields were graded on a scale of 1–10, where 1 indicated healthy with absolute certaintyand 10 signified glaucoma; 5.5 was the cut‐off between healthy and glaucoma. The same fields were classified by a previously trained ANN. The ANN output was transformed into a linear scale that matched the scale used in the subjective assessments. Classification certainty was assessed using a classification error score. Results: Among the physicians, sensitivity ranged from 61% to 96% (mean 83%) and specificity from 59% to 100% (mean 90%). Our ANN achieved 93% sensitivity and 91% specificity, and it was significantly more sensitive than the physicians (p < 0.001) at a similar level of specificity. The ANN classification error score was equivalent to the top third scores of all physicians, and the ANN never indicated a high degree of certainty for any of its misclassified visual field tests. Conclusion: Our results indicate that a trained ANN performs at least as well as physicians in assessments of visual fields for the diagnosis of glaucoma.     

Dysgraphia in elderly delirious medical inpatients

BACKGROUND AND AIMS: Dysgraphia is a recognized clinical finding in delirium, but few studies have evaluated handwriting, and results have been inconsistent. In particular, handwritten signatures, which may be a motor automatism, have not been previously evaluated in delirious patients. The aim was to assess abnormalities of signature and spontaneous writing in delirious patients and to investigate their clinical utility in the detection of delirium. METHODS: Secondary analysis of data was collected from a prospective observational study of acutely ill inpatients 70 years or older. Mini-Mental State Examination, Confusion Assessment Method, Delirium Rating Scale, Activities of Daily Living, and APACHE II were administered to each subject, their signatures were evaluated from the consent form, and their handwriting from the spontaneous sentence written as part of the MMSE. RESULTS: The signatures of patients with delirium were significantly more impaired than those without (Chi-square= 14.749, df=1, p<0.0001). The sensitivity of the signature for delirium as defined by CAM was 0.54, with specificity of 0.88. Handwriting abnormalities of omission (p=0.018), illegibility (p=0.034) and spelling (p=0.035) were significantly more common in delirious patients than others (Chi-square with Fisher's Exact tests. This difference was mainly attributable to the fact that a large number of delirious patients were unable to provide any response to the handwriting questions. CONCLUSIONS: An abnormal signature may be an indicator of delirium. People with delirium have handwriting problems, which may be partly caused by cognitive impairment but also by disorders of motor function.     

Wireless capsule endoscopy in the investigation of patients with chronic renal failure and obscure gastrointestinal bleeding （preliminary data）

AIM: To investigate the role of wireless capsule endoscopy (WCE) in detection of small bowel (SB) pathology in patients with chronic renal failure (CRF) and obscure bleeding. METHODS: Consecutive CRF patients with obscure bleeding were prospectively studied. Patients with normal renal function and obscure bleeding, investigated during the same period with WCE, were used for the interpretation of results. RESULTS: Seventeen CRF patients (11 overt, 6 occult bleeding) and 51 patients (33 overt, 18 occult bleeding) with normal renal function were enrolled in this study. Positive SB findings were detected in 70.6% of CRF patients and in 41.2% of non-CRF patients (P < 0.05). SB angiodysplasia was identified in 47% of CRF patients and in 17.6% of non-CRF patients. Univariate logistic regression revealed CRF as a significant predictive factor for angiodysplasia (P < 0.05). Therapeutic measures were undertaken in 66% of the patients with the positive findings. CONCLUSION: According to our preliminary results, SB angiodysplasia was found in an increased prevalence among CRF patients with obscure bleeding. WCE is useful in diagnosis of gastrointestinal pathologies and in planning appropriate therapeutic intervention and, therefore, should be included in the work-up of this group of patients.     

Role of soluble triggering receptor expressed on myeloid cells in inflammatory bowel disease

AIM: To investigate the probable role of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) in the pathogenesis of inflammatory bowel disease (IBD). METHODS: Fifty-eight patients were enrolled; nineteen healthy volunteers served as controls; 8 patients were diagnosed with Crohn's disease, and 31 with ulcerative colitis. Clinical and endoscopic activity indexes of patients with Crohn's disease and ulcerative colitis respectively were estimated. Upon admission blood was sampled; sTREM-1 and TNFαwere measured by an immunoassay and malondialdehyde (MDA) by the thiobarbitourate assay, after passage through an HPLC system. RESULTS: Median±SE of TNFαof controls, patients with Crohn's disease and patients with ulcerative colitis were 6.02±3.94, 7.98±5.08 (P = NS vs controls), and 8.45±4.15 ng/L (P = 0.018 vs controls) respectively. Respective values of sTREM-1 were 53.31±32.93, 735.10±197.17 (P = 0.008 vs controls) and 435.82±279.71 ng/L (P = 0.049 vs controls). sTREM-1 was positively correlated with Crohn's disease activity index and clinical and endoscopic activity indexes of ulcerative colitis (P = 0.002, 0.001 and 0.009, respectively). sTREM-1 of patients with ulcerative colitis was positively correlated with TNFa (P = 0.001). CONCLUSION: sTREM-1 seems to behave as a novel mediator in IBD in correlation with the degree of the inflammatory reaction of the intestinal mucosa.     

Prevalence of symptomatic knee, hand, and hip osteoarthritis in Greece. The ESORDIG study

OBJECTIVE: To assess the prevalence of symptomatic knee, hand, and hip osteoarthritis (OA) in the general adult population of Greece. METHODS: This cross-sectional population based study was conducted on the total adult population of 7 communities (8547 subjects) and on 2100 out of 5686 randomly selected subjects in an additional 2 communities. Sixteen rheumatologists visited the target population at their homes; an interview based on a standardized questionnaire was conducted and clinical evaluation and laboratory investigations were done, when necessary. ACR classification criteria were used for diagnosing symptomatic OA. RESULTS: Of the final target population of 10,647 subjects, 8740 (82.1%) participated in the study. The age and sex adjusted prevalence of symptomatic knee, hand, and hip OA was 6.0% (95% CI 5.6-6.4), 2% (1.8-2.2), and 0.9% (0.7-1.1), respectively. Symptomatic knee, hand, and hip OA prevalence was significantly higher among women than men and increased significantly with age. Symptomatic knee OA was significantly more common in the rural compared to urban and suburban populations. Logistic regression analysis showed a significant association of female sex and age > or = 50 years with all sites of OA, of obesity with knee and hip OA, and of a low level of education with knee OA. CONCLUSION: Symptomatic knee, hand, and hip OA is common in the general adult population of Greece, showing a female preponderance and a prevalence increasing with age. Female sex and age are risk factors for all sites of OA, obesity for knee and hip OA, and a low level of education for knee OA.     

Bone mineral density of both genders in Type 1 diabetes according to bone composition

AIMS: This study is an investigation of the impact of Type 1 diabetes on bone mineral density (BMD) with regard to bone composition. MATERIAL AND METHODS: Thirty male and 30 premenopausal female patients with Type 1 diabetes (IDD) were retrospectively compared with an equal number of healthy individuals, matched on a person-to-person basis and to the reference population mean. BMD was measured at the L2-L4 vertebrae and femoral neck (FN) by dual energy X-ray absorptiometry (DXA). RESULTS: BMD absolute values were significantly lower in the diabetic than in the healthy males at vertebrae and FN (P<.05). The vertebral BMD values of diabetic women did not significantly differ, whereas those of FN were significantly lower compared with those of the healthy participants. FN age-adjusted BMD values (Z scores) were significantly lower than those of the healthy persons and the population reference mean in both genders (P=.01, <.001 for males and <.01 for females), whereas regarding the vertebrae, only in the diabetic males (P<.05 and <.01 respectively). The percentages of osteopenia and osteoporosis were significantly higher in the male compared to the female diabetic patients (P<.001). No significant correlations existed between the BMD values and diabetes duration, glycosylated hemoglobin (HbA1c) concentration, or age of diabetes onset. Similar results were obtained when applying stepwise multiple regression analysis to explain the BMD value variance. CONCLUSIONS: Young males with Type 1 diabetes exhibit significantly lower BMD values of trabecular and mixed cortical-trabecular bone, compared with matched healthy persons. Premenopausal females with Type 1 diabetes present significantly lower BMD values of mixed bone only. Blood glucose control and diabetes duration do not appear to influence BMD behavior.