Effectiveness of pneumatic reduction of ileocolic intussusception in children

A total of 158 consecutive therapeutic air enemas were performed upon 133 patients during a 2-year period. Perforation and/or an impairment of the general condition of the children were the only main contraindications for the reduction attempt (five patients). Successful reductions were achieved in 89% of cases with no complications. Operation was performed in all 17 cases of unsuccessful reduction: resection in four cases, easy manual reduction in nine, difficult manual reduction in two, and spontaneous reduction in two. There were 16 (12%) patients with one or more recurrent episodes. In 23 (16%) cases, following pneumatic reduction, a swollen ileocecal valve showing a multiple appearance was observed. This fact sometimes results in a differential diagnosis with incomplete reduction; in all these cases, small bowel aeration was always a sign of complete reduction. No significant difference was noted between a swollen ileocecal valve and patient age, duration of symptoms, presence of small bowel obstruction, and further recurrences. Air enema has improved our previous success obtained with hydrostatic reduction (79%), as well as being a simpler, cleaner, and faster technique for intussusception reduction in children.     

Diurnal variations of cardiac rhythm,arterial pressure,and urinary catecholamines in borderline and established essential hypertension

Ambulatory continuous ECG and arterial pressure (BP) were recorded simultaneously (Delmar Avionics Pressurometer II) for 24 hours in 13 age-matched normotensive subjects, 11 patients with borderline hypertension (HBP), and in 10 patients with uncomplicated established essential HBP. Urinary concentrations of epinephrine, norepinephrine, and dopamine were simultaneously collected over four successive 4-hour periods and one 8-hour period. Prevalence and total number of ventricular and supraventricular ectopic beats was low and not affected by arterial BP. Twenty-four-hour heart rate (HR) and 4-hourly excretion of epinephrine, norepinephrine, and dopamine were comparable between normotensive and HBP persons and no correlation between urinary catecholamines and arterial BP (systolic, diastolic, or mean), HR, or prevalence of ectopic beats was found in any of the three groups or in the total study population. We conclude that HBP patients without ECG evidence of left ventricular hypertrophy do not have a higher prevalence of supraventricular or ventricular ectopic beats. Urinary catecholamines are not related to circadian fluctuations or variability in arterial BP, HR, or prevalence of ectopic beats.     

Prolonged Elevated Heart Rate is a Risk Factor for Adverse Cardiac Events and Poor Outcome after Subarachnoid Hemorrhage

Introduction

Sympathetic nervous system hyperactivity is common after subarachnoid hemorrhage (SAH). We sought to determine whether uncontrolled prolonged heart rate elevation is a risk factor for adverse cardiopulmonary events and poor outcome after SAH.

Methods

We prospectively studied 447 SAH patients between March 2006 and April 2012. Prior studies define prolonged elevated heart rate (PEHR) as heart rate >95 beats/min for >12 h. Major adverse cardiopulmonary events were documented according to the predefined criteria. Global outcome at 3 months was assessed with the modified Rankin Scale (mRS).

Results

175 (39 %) patients experienced PEHR. Nonwhite race/ethnicity, admission Hunt–Hess grade ≥4, elevated APACHE-2 physiological subscore, and modified Fisher score were significant admission predictors of PEHR, whereas documented pre-hospital beta-blocker use was protective. After controlling for admission Hunt–Hess grade, Cox regression using time-lagged covariates revealed that PEHR onset in the previous 48 h was associated with an increased hazard for delayed cerebral ischemia, myocardial injury, and pulmonary edema. PEHR was associated with 3-month poor outcome (mRS 4–6) after controlling for known predictors.

Conclusions

PEHR is associated with major adverse cardiopulmonary events and poor outcome after SAH. Further study is warranted to determine if early sympatholytic therapy targeted at sustained heart rate control can improve outcome after SAH.     

Complete pathological response to Imatinib mesylate in an extraintestinal gastrointestinal stromal tumor

INTRODUCTION

Gastrointestinal stromal tumors (GIST) are the most frequent mesenchymal tumors of the digestive tract. Extraintestinal locations (EGIST) have been described showing similar pattern of immunohistochemical markers than GIST. Inhibitors of tyrosine kinases such as Imatinib or Sunitinib are the mainstay treatment in the management of advanced or metastatic GIST. Complete pathological response to these agents is an extremely rare event, especially in the case of EGIST due to its more aggressive behavior reported.

PRESENTATION OF CASE

Here we describe the case of a 61 years old woman, with an advanced GIST, who was operated after 10 months of Imatinib mesylate. The biopsy demonstrated the extra intestinal location of the tumor and a complete pathological response was confirmed.

DISCUSSION

Complete pathological response to Imatinib is a rare event. To our knowledge, this is the first report of complete response in an EGIST. New clinical, radiological and metabolic criteria of tumoral response to neoadjuvant treatment are revised.

CONCLUSION

EGIST complete pathological response to Imatinib can be achieved. However, recommendation of systematic neoadjuvant therapy with Imatinib remains investigational and more studies are warranted in the future.     

The Adoption and Discontinuation of Clinical Services by Local Health Departments

Objectives. We identified factors associated with local health department (LHD) adoption and discontinuation of clinical services.Methods. We used multivariate regression with 1997 and 2008 LHD survey and area resource data to examine factors associated with LHDs maintaining or offering more clinical services (adopter) versus offering fewer services (discontinuer) over time and with the number of clinical services discontinued among discontinuers.Results. Few LHDs (22.2%) were adopters. The LHDs were more likely to be adopters if operating in jurisdictions with local boards of health and not in health professional shortage areas, and if experiencing larger percentage increase in non-White population and Medicaid managed care penetration. Discontinuer LHDs eliminated more clinical services in jurisdictions that decreased core public health activities’ scope over time, increased community partners’ involvement in these activities, had larger increases in Medicaid managed care penetration, and had lower LHD expenditures per capita over time.Conclusions. Most LHDs are discontinuing clinical services over time. Those that cover a wide range of core public health functions are less likely to discontinue services when residents lack care access. Thus, the impact of discontinuation on population health may be mitigated.The role of local health departments (LHDs) in offering clinical services is hotly contested in public health practice. Some LHD leaders believe that offering clinical services is critical to their mission1 and public image.2 Others embrace the position of the Institute of Medicine (IOM) on the future of public health, which calls for LHDs to focus on core public health functions of assessment, assurance, and policy development and away from clinical services.3,4Most LHDs have decreased clinical service offerings over time (discontinued).1,3,5,6 Some have done so because their leaders believe that offering clinical services is inconsistent with the LHD’s mission,6,7 diverts resources from population-based services,3,8 or distracts from core public health functions.1,7 Leaders of LHDs may rely on non-LHD public health system partner organizations to provide clinical services for vulnerable populations rather than providing them directly.1 They may see the private sector as more appropriate than LHDs in delivering clinical care.1,6,9 For example, in some regions, Medicaid managed care organizations collaborate with LHDs to ensure clinical services.5,10,11However, some LHDs have maintained or increased their clinical service offerings over time (adopted) because their leaders view clinical services as part of their mission,1 derive satisfaction from patient contact,5 or believe that offering such services is part of the core public health function of ensuring access to care to their patients if care is not available elsewhere.2,3,8,12 They offer clinical services if no private sector alternatives exist,6,12 or if the LHD is uniquely qualified in dealing with specific vulnerable populations2,5 or for certain conditions (e.g., infectious disease control).1 These LHDs may offer clinical services if no other safety net providers are available or community need is high. For instance, 63.3% of LHD directors in 2000 believed that LHDs should offer clinical services when no other organization was available to do so, compared with 23.6% of directors who believed that LHDs should offer clinical services unequivocally.7 Other LHDs may offer clinical services to generate revenue to fund other operations.1,13,14We posit that 3 main drivers underlie LHD decisions to offer clinical services. First, a conflicting goal driver suggests that LHD leaders may view offering clinical services as conflicting with core public health functions, particularly when they have few resources.1,7 Performance of these functions by LHDs varies with jurisdiction-level sociodemographic factors, and LHD organizational and public health system attributes.15–18 Second, an assurance driver suggests that LHDs offer clinical services if leaders believe that residents lack access to care, that the LHD has important expertise in providing clinical services to vulnerable patient populations, and that LHDs should provide these services when these services are limited. Third, an entrepreneurial driver suggests that LHDs leverage revenue-generating clinical services to fund needed public health services.5,13,19 The 3 drivers are not mutually exclusive. For instance, an LHD may stop offering comprehensive primary care because of the conflicting goal driver, and simultaneously start offering tuberculosis screening because of the assurance driver.The drivers provide a framework for understanding LHD decisions about the provision of clinical services, elucidating how LHDs change their clinical service offerings in response to strategic and environmental changes. We explored how the 3 drivers relate to 2 decisions: (1) whether an LHD departs from the majority and the IOM recommendations and maintains or offers more clinical services over time (an adoption decision) and (2) conditional on the LHD’s decision to discontinue services, how many fewer clinical services to offer over time (a degree of discontinuation decision). Institutional theory suggests that conformity pressures lead organizations to become more similar in behavior over time,20 but others resist such pressures for strategic reasons.21 Thus, we expected that LHDs adopting clinical services over time (adopters) would do so for different reasons than LHDs following the norm of discontinuing clinical services over time (discontinuers), and that leaders at discontinuer LHDs deciding how many clinical services to discontinue may do so for yet other reasons. Because we compared LHDs that followed the norm of decreasing the number of clinical service offerings1,3,5,6 with those that departed from the norm, we defined adoption to include offering the same number of clinical services over time. Our focus on the number of clinical services does not mean that the actual mix of clinical services offered stayed the same across time.2,5 number of community clinical service providers, and Medicaid reimbursement levels. Public health system attributes measure the LHD jurisdiction’s delivery on core public health functions across 3 dimensions: differentiation, integration, and concentration. Differentiation indicates the jurisdiction’s emphasis on public health needs, with high differentiation indicating that the jurisdiction offers many core programs or services. Integration indicates how different organizations interact in providing these services, with high integration indicating that many partnering organizations offer these services. Concentration measures the LHD’s role, with high LHD concentration indicating that the LHD bears primary responsibility for offering these services. Mays et al.22 described these 3 dimensions in further detail.

TABLE 1—

Conceptual Model Describing the Conflicting Goal, Assurance, and Entrepreneurial Drivers and the Factor Categories Associated With Adoption and Degree of Discontinuation of Clinical Services by Local Health Departments

Identification of the Vitamin D Receptor in Osteoblasts and Chondrocytes But Not Osteoclasts in Mouse Bone

Bone is clearly a target of vitamin D and as expected, the vitamin D receptor (VDR) is expressed in osteoblasts. However, the presence of VDR in other cells such as osteocytes, osteoclasts, chondroclasts, and chondrocytes is uncertain. Because of difficulties in obtaining sections of undecalcified adult bone, identification of the site of VDR expression in adult bone tissue has been problematic. In addition, the antibodies to VDR used in previous studies lacked specificity, a property crucial for unambiguous conclusions. In the present study, VDR in the various cells from neonatal and adult mouse bone tissues was identified by a highly specific and sensitive immunohistochemistry method following bone decalcification with EGTA. For accurate evaluation of weak immunosignals, samples from Demay VDR knockout mice were used as negative control. Molecular markers were used to identify cell types. Our results showed that EGTA‐decalcification of bone tissue had no detectable effect on the immunoreactivity of VDR. VDR was found in osteoblasts and hypertrophic chondrocytes but not in the multinucleated osteoclasts, chondroclasts, and bone marrow stromal cells. Of interest is the finding that immature osteoblasts contain large amounts of VDR, whereas the levels are low or undetectable in mature osteoblasts including bone lining cells and osteocytes. Proliferating chondrocytes appear devoid of VDR, although low levels were found in the hypertrophic chondrocytes. These data demonstrate that osteoblasts and chondrocytes are major targets of 1α,25‐dihydroxyvitamin D, but osteoclasts and chondroclasts are minor targets or not at all. A high level of VDR was found in the immature osteoblasts located in the cancellous bone, indicating that they are major targets of 1α,25‐dihydroxyvitamin D. Thus, the immature osteoblasts are perhaps responsible for the vitamin D hormone signaling resulting in calcium mobilization and in osteogenesis. © 2014 American Society for Bone and Mineral Research.     

Balloon Cinch Deformity during Angioplasty Procedures: An Indication for Impending Rupture

Percutaneous transluminal balloon angioplasty (PTA) is a commonly performed procedure for hemodialysis vascular access dysfunction including thrombosis. While PTA is generally safe, balloon rupture during the procedure is a potential complication. Because such a rupture can cause damage to the blood vessel, indication of an imminent balloon rupture might help avoid such a complication. This analysis reports on six PTA procedures that were complicated by balloon rupture. All cases demonstrated terminal (caudal/cranial) cinch deformation. There was a loss of sharp terminal tapering and its replacement with banana silhouette before the balloon rupture. Importantly, the contour deformation and balloon rupture occurred at a pressure that was lower than the rated burst pressure. The cinch deformity can be used as an indication for impending balloon rupture. We suggest deflation of balloons that demonstrate shape deformations to avoid vascular injury.