Colonic malacoplakia and abdominal tuberculosis in a child

A 41/2-year-old girl had colonic malacoplakia of two years' duration, the presenting symptom being rectal bleeding. Abdominal tuberculosis andEscherichia coli lumbar abscess were diagnosed at the age of 31/2 years. Despite antituberculous treatment, there was no improvement and she died from protein-losing enteropathy. The patient is discussed and the literature reviewed, with special emphasis on the incidence of malacoplakia in children, the aggressive nature of colonic malacoplakia, and the lack of response to treatment. A brief review of the pathogenesis of malacoplakia is considered.     

Reflux from the continent ileostomy reservoir

The reflux from the continent ileostomy reservoir was studied with radiologic and pressure recording techniques in ten patients. The contrast used was poly-iodine-styrene with a density of 0.8 to 1.1 gm/cm3. Reflux into the afferent loop was demonstrated in all patients at a filling volume of approximately 30 percent of the maximal volume capacity of the reservoir. The magnitude of reflux increased with the increasing volume of the reservoir contents and a rise in reservoir pressure. The reflux could temporarily be influenced by antiperistaltic or isoperistaltic motor activity in the afferent loop. Although no adverse effects were seen from the amount of reflux demonstrated in the present investigation, the finding of increasing reflux with increased fullness and intraluminal pressure of the reservoir would indicate that the reservoir should be emptied at regular intervals and before high pressures are built up.     

Sensory retraining is key to biofeedback therapy for formed stool fecal incontinence

OBJECTIVES: Biofeedback is a nonsurgical treatment that reportedly produces good results in 65-75% of fecally incontinent patients. However, previous studies have not ruled out nonspecific treatment effects. It is also unknown whether biofeedback works primarily by improving the strength of the striated pelvic floor muscles or by improving the rectal perception. We aimed to 1) evaluate the efficacy of biofeedback in formed-stool fecal incontinence, 2) assess the relative contribution of sensory and strength retraining to biofeedback outcomes, and 3) identify patient characteristics that predict a good response to treatment. METHODS: Twenty-four patients with frequent (at least once a week) solid-stool incontinence were provided with three to four biofeedback sessions. They were taught to squeeze in response to progressively weaker rectal distentions. Patients were re-evaluated by anorectal manometry and symptom diary 3 months after completing training and by diary and interview 6-12 months after training. RESULTS: Seventeen (71%) were classified responders; 13 became continent and four reduced incontinence frequency by at least 75%. Clinical improvements were maintained at 12-month follow-up. At 3-month follow-up, responders had significantly lower thresholds for perception of rectal distention and for sphincter contraction, but squeeze pressures did not significantly differ from those of nonresponders. Baseline measures that predicted a favorable response were sensory threshold (50 ml or less), urge threshold (100 ml or less), lower threshold for sphincter contraction, and lower threshold for the rectoanal inhibitory reflex; neither anal squeeze pressure nor severity of incontinence predicted treatment outcome. CONCLUSIONS: In solid-stool fecal incontinence biofeedback training effects are robust and seem not to be explained by expectancy or nonspecific treatment effect. Sensory retraining appears to be more relevant than strength training to the success of biofeedback.     

Women With Cardiogenic Shock Derive Greater Benefit From Early Mechanical Circulatory Support: An Update From the cVAD Registry

Objectives

The aim of this analysis was to assess survival differences between men and women supported with Impella 2.5 (Abiomed Inc., Danvers) in the setting of acute myocardial infarction (AMI) complicated by cardiogenic shock (CS).

Background

Data on sex differences in outcomes of CS with mechanical circulatory support are sparse.

Methods

Patients enrolled in the cVAD Registry who underwent percutaneous coronary intervention (PCI) and Impella 2.5 support for CS complicating an AMI were included. Differences between men and women were examined.

Results

In total, 180 patients were analyzed. Women (n = 49, 27.2%) were older (71.0 ± 12.8 years vs 63.8 ± 13.0, P = 0.001), smaller (BSA 1.82 ± 0.22 vs 2.04 ± 0.24 m², P < 0.001), and had a higher STS mortality risk score than men (27.9 ± 17.0 vs. 20.8 ± 16.8 P = 0.01). There was no difference in survival to discharge (P = 0.3). Patients receiving the Impella 2.5 pre‐PCI had significantly lower inpatient mortality than those who received support post‐PCI (P = 0.003). However, the magnitude of the survival benefit was significantly greater in women who received the Impella pre‐PCI as compared to men. Overall, 68.8% of women survived with pre‐PCI Impella 2.5 versus 24.2% post‐PCI (P = 0.005) whereas 54.2% of men survived with pre‐PCI Impella 2.5 versus 40.3% post‐PCI (P = 0.1, p‐interaction = 0.07). No differences in timing to intervention were found between men and women.

Conclusions

Early initiation of hemodynamic support prior to PCI with Impella 2.5, in the setting of AMI complicated by CS, was associated with a greater survival benefit to hospital discharge in women compared to men, despite a higher predicted risk of mortality and a greater revascularization failure rate for women. (J Interven Cardiol 2016;29:248–256)

     

Proximal subcutaneous interstitial fluid pressure during cross-clamping of the descending thoracic aorta: A study of patients operated on for thoracic-or thoracoabdominal aortic aneurysms

Seven patients were operated on for thoracic (n=2) or thoracoabdominal (n=5) aortic aneurysms during cross-clamping of the aorta. Interstitial tissue fluid pressure was measured at the neck during cross-clamping of the descending thoracic aorta by the wick-in-needle technique, whereas control measurements were obtained prior to cross-clamping. The subcutaneous interstitial fluid pressure was significantly higher on the neck during cross-clamping of the thoracic aorta compared with control measurements (median 3.7 mmHg vs –0.6 mmHg, p<0.05). Increased subcutaneous interstitial tissue pressure of the upper part of the body is probably caused by increased capillary filtration rate induced by inhibited autoregulatory functions during aortic cross-clamping. The pressure measurements objectively confirm the problem of edema formation of the head and neck during these operations. The edema may occasionally affect the upper airways and represent a problem for intubation of the patient in the postoperative phase.     

Propafenone: An Effective Agent for the Management of Supraventricular Arrhythmias

Propafenone in SVT. Propafenone is a sodium channel blocking antiarrhythmic drug. It also has β-adrenergic, potassium channel, and weak calcium channel blocking activity. The drug is metabolized in the liver with rates dependent on the debrisoquin phenotype. The saturable metabolism results in nonlinear pharmacokinetics. The metabolites retain sodium channel blocking activity but little β-adrenergic blocking activity. Both controlled and noncontrolled studies have documented its efficacy in a variety of supraventricluar arrhythmias. Intravenous propafenone is effective in converting atrial fibrillation to normal sinus rhythm. Chronic oral administration decreases the frequency of recurrence of atrial fibrillation and paroxysmal supraventricular tachycardia. The drug is particularly effective in the Wolff-Parkinson-White syndrome. The drug may produce SA block in patients with underlying sinus node dysfunction. Propafenone has comparatively few noncardiac side effects. It is a useful primary drug or an alternative to more commonly used drugs used for the treatment of supraventricular arrhythmias.     

Influenza A/Philippines/2/82 outbreak in a nursing home: Limitations of influenza vaccination in the aged

The failure of the 1982-1983 influenza vaccine to protect elderly NHCU residents from clinical infection with influenza A/Philippines/2/82 resulted primarily from antigenic drift of the epidemic strain, inasmuch as the attack rates in the vaccinated and nonvaccinated patients were not significantly different. This experience supports the decision to replace A/Bangkok/1/79 with A/Philippines/2/82 virus antigen in the 1983-1984 influenza vaccine.