Overt Rectal Prolapse and Fecal Incontinence

PURPOSE  Rectal prolapse is frequently associated with fecal incontinence; however, the relationship is questionable. The study was designed to evaluate fecal incontinence in a large consecutive series of patients who suffered from rectal prolapse, focusing on both past history, anal physiology, and imaging. METHODS  Eighty-eight consecutive patients who suffered from an overt rectal prolapse (72 women, 16 men; mean age, 51.1 ± 19.5 years) as a main symptom were analyzed; 48 patients also experienced fecal incontinence compared with 40 without incontinence. Logistic regression analyses were performed. RESULTS  The two groups of patients did not differ with respect to parity, weekly stool frequency, main duration of symptoms before referral, occurrence of dyschezia, and digital help to defecate. Patients with prolapse who were older than 45 years (odds ratio (OR), 4.51 (1.49–13.62); P = 0.007) and those with a past history of hemorrhoidectomy (OR, 9.05 (1.68–48.8); P = 0.01) were significantly more incontinent. Incontinent group showed frequent internal anal sphincter defect compared with the continent group (60 vs. 6.2 percent; P = 0.0018). CONCLUSIONS  In patients with overt rectal prolapse, the occurrence of fecal incontinence needs special consideration for age and previous hemorrhoid surgery as causative factors. Anal weakness and sphincter defects are frequently observed.     

HIV infection: pre-highly active antiretroviral therapy IL-7 plasma levels correlate with long-term CD4 cell count increase after treatment

Highly active antiretroviral therapy (HAART) in HIV patients generally increases the CD4 cell count, but the level of CD4 cell restoration remains very heterogeneous. IL-7 is the main cytokine controlling the size of the T-cell pool. We assessed the hypothesis that pre-HAART IL-7 plasma levels may affect CD4 cell restoration after treatment. A positive correlation was found in a cohort of 18 patients between pre-HAART IL-7 plasma levels and CD4 cell increases after 20 +/- 7.8 months of HAART.     

A randomized comparison of direct stenting with conventional stent implantation in selected patients with acute myocardial infarction.

OBJECTIVES: We sought to determine whether direct stenting might prevent the adverse events associated with stent implantation during primary angioplasty and to compare it with conventional stent implantation in patients with acute myocardial infarction (AMI). BACKGROUND: No trial has demonstrated that stents favorably influence mortality rate. Recent studies have even suggested a negative impact of stents on coronary blood flow and clinical outcome. METHODS: Of 409 patients treated by primary angioplasty with stent implantation in our center, 206 (50%) were enrolled in this randomized, single-center trial and allocated to direct stent implantation (n = 102) or stent implantation after balloon pre-dilation (n = 104). The study end points included angiographic results (final corrected Thrombolysis In Myocardial Infarction [TIMI] frame count and a composite end point of slow and no-reflow or distal embolization), an electrocardiogram marker of myocardial reperfusion assessment (ST-segment resolution) and in-hospital clinical outcome (death and recurrent infarction). RESULTS: Direct stent implantation failed in eight patients but succeeded after pre-dilation in all. A non-significant increase in TIMI flow grade 3 was achieved after direct stenting (95.1% vs. 93.3%, p = 0.74) without significant difference in the corrected TIMI frame count (31.5 +/- 17 and 35.2 +/- 20 frames after direct and conventional stent, respectively, p = 0.42). The composite angiographic end point was significantly reduced by direct stent implantation (11.7% vs. 26.9%, p = 0.01). ST-segment resolution was also significantly improved after direct stent (no ST-segment resolution in 20.2% vs. 38.1% after direct and conventional stent, respectively, p = 0.01). Death and/or recurrent infarction occurred in six patients after conventional stent implantation and in two patients after direct stenting (p = 0.28). CONCLUSIONS: In selected patients with AMI, direct stenting can be applied safely and effectively. This strategy may result in a significant reduction of microvascular injury, as suggested by improved ST-segment resolution after reperfusion with major potential clinical consequences.     

Amplification of low-frequency antiviral CD8 T cell responses using autologous dendritic cells.

OBJECTIVE: To utilize the potent antigen-presenting capacity of mature dendritic cells (MDC) in order to develop a rapid, sensitive method for quantifying antigen-specific CD8 T cells present at low frequency in peripheral blood. DESIGN: Peripheral blood mononuclear cells (PBMC) were obtained from seven HIV-1-positive individuals with low to moderate CD8 T cell responses, including five on highly active antiretroviral therapy (HAART). IFN-gamma ELISPOT assays were performed using either monocytes or MDC to present antigens expressed by recombinant vaccinia viruses (r-VV). METHODS: Peripheral blood-derived monocytes were cultured for 5-6 days in the presence of IL-4 and granulocyte macrophage colony-stimulating factor, then matured in monocyte-conditioned medium. MDC were infected with r-VV and co-cultured in an ELISPOT assay with autologous monocyte-depleted PBMC. RESULTS: Relative to autologous monocytes, MDC amplified detection of antigen-specific CD8 T cells by 2-30-fold in response to antigens from HIV-1, Epstein-Barr virus and cytomegalovirus. Furthermore, antigenic specificities were revealed that had not been detected using standard ELISPOT of PBMC. CONCLUSION: This assay will prove useful for the detection of memory T cells present at low frequency, and may be of interest for identifying subdominant cytotoxic T lymphocyte epitopes. This method may have broad applications for the detection of antiviral CD8 T cell responses in patient populations in whom such responses have been difficult to detect, including HIV-1-seropositive individuals with advanced disease or undergoing HAART.     

Diastolic asynchrony is more frequent than systolic asynchrony in dilated cardiomyopathy and is less improved by cardiac resynchronization therapy.

OBJECTIVES: To compare the incidence of diastolic and systolic asynchrony, assessed by tissue Doppler imaging (TDI), in patients with congestive heart failure (CHF) and severe left ventricular (LV) dysfunction, and to assess TDI changes induced by cardiac resynchronization therapy (CRT). BACKGROUND: Thirty percent of CRT candidates are nonresponders. Besides QRS width, the presence of echographic systolic asynchrony has been used to identify future responders. Little is known about diastolic asynchrony and its change after CRT. METHODS: Tissue Doppler imaging was performed in 116 CHF patients (LV ejection fraction 26 +/- 8%). Systolic and diastolic asynchrony was calculated using TDI recordings of right ventricular and LV walls. RESULTS: The CHF group consisted of 116 patients. Diastolic asynchrony was more frequent than systolic, concerning both intraventricular (58% vs. 47%; p = 0.0004) and interventricular (72 vs. 45%; p < 0.0001) asynchrony. Systolic and diastolic asynchrony were both present in 41% patients, but one-third had isolated diastolic asynchrony. Although diastolic delays increased with QRS duration, 42% patients with narrow QRS presented with diastolic asynchrony. Conversely, 27% patients with large QRS had no diastolic asynchrony. Forty-two patients underwent CRT. Incidence of systolic intraventricular asynchrony decreased from 71% to 33% after CRT (p < 0.0001), but diastolic asynchrony decreased only from 81% to 55% (p < 0.0002). Cardiac resynchronization therapy induced new diastolic asynchrony in eight patients. CONCLUSIONS: Diastolic asynchrony is weakly correlated with QRS duration, is more frequent than systolic asynchrony, and may be observed alone. Diastolic asynchrony is less improved by CRT than systolic. Persistent diastolic asynchrony may explain some cases of lack of improvement after CRT despite good systolic resynchronization.     

Influence of sex on disease severity in patients with rheumatoid arthritis

OBJECTIVE: To determine whether patient's sex influences the severity of rheumatoid arthritis (RA) in terms of clinical severity or need for treatments. METHODS: This was a retrospective, single-center study. We compared 133 male patients with 133 female patients presenting with RA and matched for disease duration. Data collection included demographic characteristics, pattern of joint involvement, extraarticular manifestations, medical treatment, and joint surgery. Biological measures, HLA genotypes, Larsen radiological scores on radiographs of hands and feet, and Health Assessment Questionnaire (HAQ) results were obtained. RESULTS: Mean disease duration was 7.4 +/- 6.9 years. Concerning clinical pattern of involvement, sicca syndrome was more frequent in women than in men (p = 0.0003). There were no significant differences concerning absence or presence of at least one disease associated gene (HLA-DRB1*01 or *04) in our patients; however, women more often carried 2 disease associated genes (21% vs 11%). No other difference in clinical, biological, or radiological indicators was noted between the 2 populations. Concerning treatment, there was no difference for large joint arthroplasties; female patients underwent significantly more distal joint arthrodesis, 6.7% vs 1.5% (p = 0.03); they were prescribed slightly more disease modifying drugs, 3.33 vs 2.83 (p = 0.04); and showed a trend toward more large joint arthrodesis, 15% vs 7.5% (p = 0.05), and metacarpophalangeal joint arthroplasties, 5.2% vs 0.7% (p = 0.08). CONCLUSION: When patients are matched for RA duration, sex has little effect on the disease pattern and severity, yet women undergo more distal joint surgery.     

Distinct surrogate markers for protection against Plasmodium falciparum infection and clinical malaria identified in a Senegalese community after radical drug cure

Plasmodium falciparum expresses many antigens, which elicit various immune responses in exposed individuals, but no simple surrogate marker for protection has yet been developed. In this prospective survey, we looked for immune responses predictive of protection at various stages of progression from parasite inoculation to onset of disease. We studied 110 Senegalese volunteers from an area in which malaria is mesoendemic after they had received eradication therapy. We evaluated 4 protection-related outcomes (reappearance of parasitemia, duration of asymptomatic carriage, time to first clinical episode, and incidence of clinical episodes) in terms of levels of immunoglobulin G (IgG) against 3 crude parasite extracts and 5 conserved antigens during a 5-month period. Kaplan-Meier estimates and age-adjusted regression models showed these 4 outcomes to be associated with different patterns of IgG response to PfEMP3-cl5 (derived from P. falciparum erythrocyte membrane protein 3), PfEB200, MSP-1(19) (derived from merozoite surface protein-1), [NANP]10, infected red blood cell membrane, and merozoite and schizont extracts. It should, therefore, be possible to develop surrogate markers for each end point on the basis of IgG response to a limited number of conserved antigens.     

Residential Trajectories of Street Youth—the Montréal Cohort Study

Little is known about the course of homelessness among youth between the ages of 18 and 25 despite the many characteristics distinguishing them from adolescents and from older street-involved populations. We examined the residential trajectories of homeless young adults in Montréal over a 21-month period and identified determinants of various trajectory profiles. The 365 study participants (79 % men, mean age 21.9 years) were followed for an average of 515 days (range 81–630 days). We assessed housing status with a questionnaire based on the residential follow-back calendar designed by the New Hampshire Dartmouth Research Center. Using latent growth analysis to examine achievement of residential stability over time, we observed three different trajectories: group 1 presented a low probability of housing throughout the entire study period; group 2 showed a high probability of early and stable housing; group 3 displayed a fluctuating pattern. Protective correlates of residential stability included high school education, birth in Canada, and presence of mental health problems. Drug abuse or dependence was associated with a decreased probability of housing.     

Ethical considerations of providers and clients on HIV testing campaigns in Burkina Faso

Background

Campaigns have been conducted in a number of low HIV prevalence African settings, as a strategy to expand HIV testing, and it is important to assess the extent to which individual rights and quality of care are protected during campaigns. In this article we investigate provider and client perceptions of ethical issues, including whether they think that accessibility of counseling and testing sites during campaigns may hinder confidentiality.

Methods

To examine how campaigns have functioned in Burkina Faso, we undertook a qualitative study based on individual interviews and focus group discussions with 52 people (providers and clients tested during or outside campaigns and individuals never tested). Thematic analysis was performed on discourse about perceptions and experiences of HIV-testing campaigns, quality of care and individual rights.

Results

Respondents value testing accessibility and attractiveness during campaigns; clients emphasize convenience, ripple effect, the sense of not being alone, and the anonymity resulting from high attendance. Confronted with numerous clients, providers develop context-specific strategies to ensure consent, counseling, confidentiality and retention in the testing process, and they adapt to workplace arrangements, local resources and social norms. Clients appreciate the quality of care during campaigns. However, new ethical issues arise about confidentiality and accessibility. Confidentiality of HIV-status may be jeopardized due to local social norms that encourage people to share their results with others, when HIV-positive people may not wish to do so. Providers’ ethical concerns are consistent with WHO norms known as the ‘5 Cs,’ though articulated differently. Clients and providers value the accessibility of testing for all during campaigns, and consider it an ethical matter. The study yields insights on the way global norms are adapted or negotiated locally.

Conclusions

Future global recommendations for HIV testing and counseling campaigns should consider accessibility and propose ways for testing services to respond to new ethical issues related to high demand.