Histopathology and TB-PCR kit analysis in differentiating the diagnosis of intestinal tuberculosis and Crohn��s disease

AIM: To compare the histopathologic features of intestinal tuberculosis (ITB) and Crohn’s disease (CD) and to identify whether polymerase chain reaction for Mycobacterium tuberculosis (TB-PCR) would be helpful for differential diagnosis between ITB and CD.METHODS: We selected 97 patients with established diagnoses (55 cases of ITB and 42 cases of CD) who underwent colonoscopic biopsies. Microscopic features of ITB and CD were reviewed, and eight pathologic parameters were evaluated. Nine cases of acid fast bacilli culture-positive specimens and 10 normal colonic tissue specimens were evaluated as the positive and negative control of the TB-PCR test, respectively. PCR assays were done using two commercial kits: kit detected IS6110 and MPB64, and kit detected IS6110 only; a manual in-house PCR method was also performed on formalin-fixed, paraffin-embedded colonoscopic biopsy specimens.RESULTS: Statistically significant differences were noted between ITB and CD with regard histopathologic criteria: size of granulomas (P = 0.000), giant cells (P = 0.015), caseation necrosis (P = 0.003), confluent granulomas (P = 0.001), discrete granulomas (P = 0.000), and granulomas with lymphoid cuffs (P = 0.037). However, 29 cases (52.7%) of ITB showed less than five kinds of pathologic parameters, resulting in confusion with CD. The sensitivities and specificities of the TB-PCR test by kit , kit , and the in-house PCR method were 88.9% and 100%, 88.9% and 100%, and 66.7% and 100% in positive and negative controls, respectively. The PCR test done on endoscopic biopsy specimens of ITB and CD were significantly different with kit (P = 0.000) and kit (P = 0.000). The sensitivities and specificities of TB-PCR were 45.5% and 88.1%, 36.4% and 100%, and 5.8% and 100%, for kit and kit and in-house PCR method on endoscopic biopsy specimens. Among the 29 cases of histopathologically confusing CD, 10 cases assayed using kit and 6 cases assayed using kit were TB-PCR positive. A combination of histologic findings and TB-PCR testing led to an increase of diagnostic sensitivity and the increase (from 47.3% to 58.2) was statistically significant with kit (P = 0.000).CONCLUSION: The TB-PCR test combined with histopathologic factors appears to be a helpful technique in formulating the differential diagnosis of ITB and CD in endoscopic biopsy samples.     

Impact of recurrent disease and chronic allograft nephropathy on the long‐term allograft outcome in patients with IgA nephropathy

Although recurrent IgA nephropathy (IgAN) may lead to graft dysfunction after transplantation, donation from living related donor (LRD), with whom the risk of recurrence may be higher, is not a contraindication. Herein, we evaluated the natural history of allograft in recipients with IgAN and the risk factors influencing long‐term allograft outcome. Recurrence rate and graft survival were assessed retrospectively in 221 IgAN patients, including transplants from 139 LRDs (62.9%). Ten‐year cumulative rate for recurrent IgAN was 30.8%. The operation at younger age and donation from LRD were significant for the recurrence by multivariate analysis. Ten‐year graft survival was affected by recurrent IgAN (61.0% in recurrent IgAN group vs. 85.1% in nonrecurrent, P < 0.01). However, transplants from LRDs did not show poor graft survival when compared with those from other types of donors. In transplants from LRDs, the incidence of chronic allograft nephropathy (CAN) was lower than those in grafts from deceased donors (10.8% vs. 19.5%, P < 0.05). When CAN was considered in addition to recurrence, the variance of graft survival was affected significantly by the development of CAN than by the recurrence. These results suggest that the detection and adequate management of CAN could improve graft outcome in transplant recipients with IgAN.     

Chronological changes in the systemic manifestations of intestinal Behcet’s disease and their significance in diagnosis

Purpose

Intestinal Behçet's disease (BD) is challenging to diagnose, especially if the patient presents with typical colonoscopic findings of intestinal BD without systemic manifestations of BD. We performed this study to evaluate the systemic manifestations of BD in patients with typical colonoscopic findings of intestinal BD at the time of initial presentation and to identity the chronologic changes of these features during an extended follow-up period.

Methods

One hundred twenty-six consecutive patients who showed typical colonoscopic findings of intestinal BD at a single institution in Korea were enrolled. Clinical and endoscopic data were collected from a medical database and using a written questionnaire. Parameters including demographic characteristics and the subset type of BD at the initial and endpoints of the follow-up were analyzed.

Results

The mean follow-up period was 63.9?±?50.9 months. The number of cases that satisfied the International Study Group for Behçet’s Disease criteria at initial diagnosis, 19.0%, increased to 53.2% by the end of follow-up. When the Japanese criteria were used for classification, the proportion of complete and incomplete type BD increased (2.4% and 26.2% to 18.3% and 49.2%, respectively), while that of suspected and not-satisfied subtype BD decreased (22.2% and 49.2% to 19.0% and 13.5%, respectively) during the follow-up period.

Conclusions

Our data suggest that patients who lack the systemic manifestations of BD could be included in the category of intestinal BD when typical intestinal lesion is identified, indicating that close examination and early treatment should be considered in such patients.     

Comparison of procedural sequences in same‐day bidirectional endoscopy without benzodiazepine and propofol sedation: starting at the bottom or the top

Background and Study Aims: Same‐day bidirectional endoscopy including esophagogastroduodenoscopy (EGD) and colonoscopy is routinely performed to evaluate anemia and gastrointestinal bleeding, as well as to conduct cancer surveillance. Numerous questions have been raised regarding the most appropriate procedural sequence and the resulting potential procedure interactions. We compared the quality and feasibility of performing EGD and colonoscopy without sedation in patients subjected to EGD‐colonoscopy (Group I) or colonoscopy‐EGD (Group II) sequences. Patients and Methods: A total of 80 patients were prospectively randomized into two groups (40:40). All EGD examinations were recorded on videotape, and the quality of 18 EGD steps was assessed by three endoscopists. In addition, we analyzed the colonoscopic parameters and subjective discomfort scores of patients. Results: Group I displayed significantly superior quality for retroflexion‐related steps (P11–13; all median of Group I vs Group II = 2:3; P < 0.01), visualization of the angular fold (P10; Group I vs Group II = 2:3; P = 0.048), and general assessment of the stomach (P17; Group I vs Group II = 2:3; P = 0.008) and upper GI tract (P15; Group I vs Group II = 2:3; P = 0.047). Colonoscopic insertion time, total time, and prolonged insertion ratio did not differ between the two groups. Questionnaire responses indicated that EGD was perceived to be more stressful in Group II sequence. Conclusions: The quality of EGD steps is influenced by the sequence of bidirectional endoscopy. EGD is perceived to be more stressful to patients when preceded by colonoscopy. Therefore, EGD followed by colonoscopy may be the preferable procedural sequence for same‐day bidirectional endoscopy.     

Topical formulation of retinyl retinoate employing nanostructured lipid carriers

Topical formulation of retinyl retinoate (RR) was developed with nanostructured lipid carriers (NLCs), composed of Compritol or Precirol as a solid lipid, canola oil as an oil, and Tween 80 as a surfactant. Hot high pressure homogenization method was efficiently employed to yield a homogenous nanodispersion in the size range of 230?C300?nm with PDI values of <0.2, regardless of lipid selection. Precirol-based NLC (P-NLC) showed higher drug entrapment than that of Compritol-based NLC (C-NLC): RR encapsulation efficiency (%) of P- and C-NLC was 97.8 and 93.8 in average, respectively; drug loading (mg RR/g lipid) was 89.6 and 83.3 in average, respectively. Processing condition at relatively low temperature of 60?°C was a key factor for maintaining RR stability. Drug release of P-NLC was greater than that of C-NLC, even though both NLCs revealed controlled release pattern. Therefore, P-NLC system was considered as a suitable vehicle for topical drug delivery, especially for heat-labile ingredient like RR.     

Surgical strategies using cerebral revascularization in complex middle cerebral artery aneurysms

Objectives

To describe surgical strategies using cerebral revascularization for complex middle cerebral artery aneurysms unsuitable to microsurgical clipping.

Materials and methods

In this study, the clinical features, case management, and results in 9 consecutive patients who underwent 10 cerebral revascularization procedures between January 1999 and April 2008 were retrospectively analyzed. The patient population consisted of 6 men and 3 women whose ages ranged from 15 to 71 years (mean, 42.4 years). The size of the aneurysms ranged from 12 to 35 mm (mean, 24.3 mm). Treated aneurysms were located in the M1 segment in 2 patients, the middle cerebral artery (MCA) bifurcation in 3 patients, the distal M3 segment in 3 patients, and the anterior temporal artery (ATA; the early cortical branch of the M1 segment) in 1 patient. A total of 10 revascularizations were performed. Three aneurysms were saccular and six aneurysms were fusiform. For the fusiform aneurysms of the M1 segment in 2 patients, superficial temporal artery (STA) trunk–saphenous vein (SV)–MCA bypasses followed by trapping were performed. For the large saccular MCA bifurcation aneurysms in 3 patients, STA–MCA bypasses followed by complete neck clipping, including the revascularized branch with the preservation of the flow of the other branch, were performed in 2 cases, and a STA trunk–SV–MCA bypass secondary to direct neck clipping with the preservation of both M2 branches was performed in 1 case. For the fusiform distal MCA aneurysms, STA–MCA bypasses in 2 patients and in situ MCA–MCA bypasses in 2 patients were performed. In one case involving distal MCA fusiform aneurysm, STA–MCA bypass and MCA–MCA bypass were performed simultaneously. In a case involving fusiform ATA aneurysm, primary reanastomosis after aneurysm excision was performed in 1 patient.

Results

The post-operative 3-month Glasgow outcome scales were good recovery in 6 patients, severe disability in 1 patient, a vegetative state in 1 patient, and death in 1 patient. A follow-up angiography was performed in 6 patients and revealed a patent bypass in 5 patients. In one case treated by direct neck clipping secondary to cerebral revascularization, the angiography obtained 2 weeks later showed graft occlusion, but there were no neurologic symptoms. Among the unfavorable outcomes of 3 patients who did not undergo follow-up angiography, surgery-related morbidity secondary to cerebral infarction was due to the size discrepancy between the donor and recipient vessels in 1 patient with severe disability. In the other 2 patients, the preoperative conditions were Hunt and Hess grade V.

Conclusions

Cerebral revascularization is a safe and effective technique of treatment for selective cases of complex large or giant aneurysms and unclippable fusiform aneurysms in the MCA.     

Association of UCP2 and UCP3 gene polymorphisms with serum high-density lipoprotein cholesterol among Korean women

Decreased serum high-density lipoprotein (HDL-C) cholesterol is a major risk factor for atherosclerosis and vascular disease. In this study, we assessed the association of 10 uncoupling protein (UCP) 2 and UCP3 polymorphisms with serum HDL cholesterol levels and atherogenic indexes among 658 Korean women. Among the 10 single nucleotide polymorphisms (SNPs) in the UCP2 and UCP3 genes, 2 SNPs in UCP2, -866G>A and +4787C>T (A55V) that were tightly linked (r(2) = 0.97), were significantly associated with decreased HDL cholesterol levels after Bonferroni correction (P = .003 in the recessive model). +4589C>T (Y210Y) in UCP3, a silent variation of Tyr210Tyr in exon 5, was also significantly associated with HDL cholesterol after multiple comparison correction. These 3 SNPs also exhibited some association with increases in the atherogenic index. Source-of-variation analysis revealed that -866G>A SNP accounted for 8.09% of the variation in serum HDL cholesterol levels independent of body mass index. We believe that our results may provide clues to the association of UCP genes with the risk of atherosclerosis through their effects on HDL cholesterol.     

The effects of pioglitazone on cerebrovascular resistance in patients with type 2 diabetes mellitus

Atherosclerosis is one of the major causes of morbidity and mortality in patients with type 2 diabetes mellitus. Pioglitazone has been reported to have antiatherogenic effects. The aim of this study was to investigate whether pioglitazone affects pulsatility index (PI) of the cerebral arteries and the carotid intima-media thickness in type 2 diabetic patients. A total of 40 type 2 diabetic patients were included in this study. They were divided into 2 groups: the pioglitazone-treated group (pioglitazone 15 mg/d with gliclazide 80-320 mg/d for 12 weeks) and the gliclazide-treated group (gliclazide 80-320 mg/d for 12 weeks). Transcranial Doppler ultrasonography was performed for each cerebral artery, and PI was calculated as (systolic velocity-diastolic velocity)/mean velocity. The pioglitazone treatment significantly increased high-density lipoprotein cholesterol and decreased triglyceride levels and insulin resistance. This study revealed that the change in mean intima-media thickness was not significant in both groups, but the change in PI was significantly decreased with pioglitazone compared to gliclazide. In conclusion, pioglitazone decreased PI and improved cerebrovascular resistance in type 2 diabetic patients.     

Influence of abdominal circumference on the inappropriateness of left ventricular mass and diastolic function in non-obese patients

BACKGROUND AND OBJECTIVE: Adipose tissue may be one of the sources of the humoral factors increasing left ventricular mass (LVM) via non-hemodynamic mechanisms. The involvement of visceral obesity in excessive or inappropriate LVM has not been established. We investigated the effect of abdominal circumference on the inappropriateness of LVM in non-obese patients. METHODS: Echocardiographic parameters for LVM and the indices for diastolic function were analyzed in 312 non-obese patients. Inappropriate LVM was defined as observed/predicted ratio (OPR) of LVM > 130%. Predicted LVM was calculated by the equation of 54.9 + 7.62 x height (m(2.7)) + 0.67 x stroke work--13.2 x sex (male = 1, female = 2). Abdominal obesity was defined by abdominal circumference > 80 cm in females and > 90 cm in males. RESULTS: Multiple regression analysis showed abdominal circumference was a significant factor for OPR of LVM (beta = 0.256) which was independent of age (beta = 0.215), sex, systolic blood pressure (beta = -0.232), body mass index (beta = 0.232), and fasting blood glucose (beta = 0.146). Odds ratio (OR) of abdominal obesity for inappropriate LVM was 3.28 (1.72-6.28), which was independent of age > or = 55 [OR: 2.17(1.11-4.25)], body mass index > or = 22.5 kg/m2 [OR: 2.24(1.13-4.41)], and diabetes mellitus [OR: 2.27 (1.06-4.85)]. Age and sex adjusted abdominal circumference (86.4 +/- 0.9 vs 82.1 +/- 0.5), abdominal obesity (28.1% vs 54.1%), and metabolic syndrome (19.4% vs 51.6%) were higher in the inappropriate LVM group than the appropriate LVM group (p < 0.001). CONCLUSIONS: Abdominal obesity or the presence of metabolic syndrome is an important factor to predict the inappropriateness of LVM even in non-obese patients.