Gastric variceal bleeding caused by an intrahepatic arterioportal fistula that formed after liver biopsy: a case report and review of the literature

An intrahepatic arterioportal fistula is a rare cause of portal hypertension and variceal bleeding. We report on a patient with an intrahepatic arterioportal fistula following liver biopsy who was successfully treated by hepatectomy after unsuccessful arterial embolization. We also review the literature on symptomatic intrahepatic arterioportal fistulas after liver biopsy. A 48-year-old male with bleeding gastric varices and hepatitis B virus-associated liver cirrhosis was transferred to our hospital; this patient previously underwent percutaneous liver biopsies 3 and 6 years ago. Abdominal examination revealed a bruit over the liver, tenderness in the right upper quadrant, and splenomegaly. Ultrasonographic examination, computed tomography, and angiography confirmed an arterioportal fistula between the right hepatic artery and the right portal vein with portal hypertension. After admission, the patient suffered a large hematemesis and developed shock. He was treated with emergency transarterial embolization using microcoils. Since some collateral vessels bypassed the obstructive coils and still fed the fistulous area, embolization was performed again. Despite the second embolization, the collateral vessels could not be completely controlled. Radical treatment involving resection of his right hepatic lobe was performed. For nearly 6 years postoperatively, this patient has had no further episodes of variceal bleeding.     

Influence of 5 Different Caging Types and the Use of Cage-Changing Stations on Mouse Allergen Exposure

Animal allergens constitute a serious health risk in laboratory animal facilities. To assess possibilities for allergen reduction by technical and organizational measures, we studied personnel exposure to mouse urinary aeroallergens in an animal facility with a holding capacity of 30,000 cages. Short-term (2 h) and intermediate-term (12 h) stationary samples (n = 107) and short-term (2 h) personnel samples (n = 119) were collected on polytetrafluorethylene filters by using air pumps. Long-term (14 d) stationary dust samples containing airborne allergens (n = 165) were collected with electrostatic dust fall collectors (EDC). Mouse allergens were quantified by ELISA. Personnel samples were collected during bedding disposal and refilling of clean cages as well as during cage changing with and without use of cage-changing station. Animal rooms were equipped with either open cages, cages with a soft filter top, cages with a rigid filter top (static microisolation caging), or with individually ventilated cages (IVC) with either a sealed or nonsealed lid, each in positive- or negative-pressure mode. Highest personnel allergen exposure was detected during cage change and emptying of soiled cages. Allergen concentrations were lowest in rooms with sealed IVC under positive or negative pressure, with unsealed IVC under negative pressure, and with static microisolation caging. The use of cage-changing stations and a vacuum bedding-disposal system reduced median personnel exposures 14- to 25-fold, respectively. Using sealed IVC and changing stations minimized allergen exposure, indicating that state-of-the-art equipment reduces exposure to mouse allergens and decreases health risks among animal facility personnel.Abbreviations: CS, cage-changing station; EDC, Electrostatic dust fall collector; IVC, Individually ventilated cages; LAA, Laboratory animal allergy; MUA, Mouse urinary aeroallergen; NSL, nonsealed lid; SL, sealed lidThe use of laboratory mice in contemporary biomedical research is constantly increasing. In particular, research with genetically modified mice, which serve as model organisms for functional studies of human diseases, has grown markedly recently.^2,14 The number of rodent facilities involved in systemic phenotyping, archiving, and distribution of mouse models has increased during the last 2 decades, and the mode of interactions between researchers and mice has changed simultaneously. Whereas previously mice typically were bred and held in barrier facilities with restricted access by scientific staff, an increasing number of researchers are demanding direct access to their animals. This need is particularly relevant in phenotyping facilities, in which mouse rooms are connected directly to procedure rooms and in which mice are handled extensively during phenotyping.¹⁷ Under such experimental conditions, both researchers and animal care staff have intense contact with mice and, therefore, to mouse allergens. Consequently, the number of personnel directly exposed to laboratory animal allergens is growing constantly, and an even greater number of persons may be exposed indirectly to mouse allergens.To accommodate the increasing access of scientific and animal care staff to mouse facilities as well as for the growing exchange of transgenic mice between institutions and the associated increased health risks, individually ventilated cages (IVC) have become the state-of-the-art caging system. In addition, IVC are used particularly to reduce the exposure of staff to airborne allergens in the animal rooms, to better control the potential for spread of infections within and between facilities.Cross-sectional surveys indicate that between 5% and 40% of persons in contact with laboratory animals report allergic symptoms within the first year of exposure, and as many as 10% develop occupational asthma.¹⁰ In a study of newly employed animal facility workers, 55% developed laboratory animal allergy within the first 2 y⁵ (for a review, see reference ⁷). Because allergic reactions constitute a serious health problem for persons in contact with laboratory animals, and about one third of exposed staff develops symptoms of laboratory animal allergy,^{3,4,12,15,29,30} the prevention of these allergies should be a major objective in occupational health and safety programs.¹⁰The goal of the current study was to assess the exposure of scientific and animal care staff to mouse allergens in mouse breeding and holding rooms using 5 different types of caging and to evaluate the effect of using cage-changing stations (CS) on mouse allergen reduction. In addition, levels of mouse allergens were evaluated in different areas of the facility, including mouse breeding and holding rooms, corridors, wash rooms, a procedure room, and offices. Particular emphasis was placed on allergen levels in the breathing zone of individual employees and the assessment of background values by long-term passive sampling by using electrostatic dust fall collectors (EDC) compared with stationary pump sampling.     

Postoperative Change of Mucosal Inflammation at Strictureplasty Segment in Crohn’s Disease: Cytokine Production and Endoscopic and Histologic Findings

PURPOSE This study was designed to examine postoperative change of mucosal inflammation at strictureplasty segment in Crohns disease mainly by cytokine measurements.METHODS Patients who underwent strictureplasty for Crohns disease in the terminal ileum were investigated. Mucosal samples at the strictureplasty site were obtained during operation. At 3, 6, and 12 months after operation, biopsy specimens were taken from the strictureplasty site and macroscopically normal ileum at endoscopy. Mucosal cytokine concentrations were measured by enzyme-linked immunosorbent assay.RESULTS The mucosal concentrations of proinflammatory cytokines (interleukin-1, interleukin-6, interleukin-8, and tumor necrosis factor-) and anti-inflammatory mediator (interleukin-1 receptor antagonist) at the strictureplasty segment greatly increased at the time of operation. Interleukin-1, interleukin-1 receptor antagonist, interleukin-6, interleukin-8, and tumor necrosis factor- concentrations at the strictureplasty segment decreased during a 12-month period after operation. Twelve months after operation there was no significant difference in each cytokine concentration between the strictureplasty and macroscopically normal segments. The mucosal interleukin-1 receptor antagonist/interleukin-1 ratio at the strictureplasty segment increased during a 12-month period after operation. Twelve months after operation there was no significant difference in the ratio between the strictureplasty and macroscopically normal segments. The endoscopic and histologic severities of mucosal inflammation at the strictureplasty site also decreased; however, their findings were not normalized during the study.CONCLUSIONS During one year after strictureplasty for Crohns disease, cytokine production at the strictureplasty segment was decreased to the level of the macroscopically normal ileum and an imbalance between proinflammatory and anti-inflammatory cytokines was corrected.     

Bone material properties in premenopausal women with idiopathic osteoporosis

Idiopathic osteoporosis (IOP) in premenopausal women is characterized by fragility fractures at low or normal bone mineral density (BMD) in otherwise healthy women with normal gonadal function. Histomorphometric analysis of transiliac bone biopsy samples has revealed microarchitectural deterioration of cancellous bone and thinner cortices. To examine bone material quality, we measured the bone mineralization density distribution (BMDD) in biopsy samples by quantitative backscattered electron imaging (qBEI), and mineral/matrix ratio, mineral crystallinity/maturity, relative proteoglycan content, and collagen cross‐link ratio at actively bone forming trabecular surfaces by Raman microspectroscopy and Fourier transform infrared microspectroscopy (FTIRM) techniques. The study groups included: premenopausal women with idiopathic fractures (IOP, n = 45), or idiopathic low BMD (Z‐score ≤ ?2.0 at spine and/or hip) but no fractures (ILBMD, n = 19), and healthy controls (CONTROL, n = 38). BMDD of cancellous bone showed slightly lower mineral content in IOP (both the average degree of mineralization of cancellous bone [Cn.Ca_Mean] and mode calcium concentration [Cn.Ca_Peak] are 1.4% lower) and in ILBMD (both are 1.6% lower, p < 0.05) versus CONTROL, but no difference between IOP and ILBMD. Similar differences were found when affected groups were combined versus CONTROL. The differences remained significant after adjustment for cancellous mineralizing surface (MS/BS), suggesting that the reduced mineralization of bone matrix cannot be completely accounted for by differences in bone turnover. Raman microspectroscopy and FTIRM analysis at forming bone surfaces showed no differences between combined IOP/ILBMD groups versus CONTROL, with the exceptions of increased proteoglycan content per mineral content and increased collagen cross‐link ratio. When the two affected subgroups were considered individually, mineral/matrix ratio and collagen cross‐link ratio were higher in IOP than ILBMD. In conclusion, our findings suggest that bone material properties differ between premenopausal women with IOP/ILBMD and normal controls. In particular, the altered collagen properties at sites of active bone formation support the hypothesis that affected women have osteoblast dysfunction that may play a role in bone fragility. © 2012 American Society for Bone and Mineral Research.     

Psychometric Properties of Brief-Balance Evaluation Systems Test Among Multiple Populations: A Systematic Review and Meta-analysis

ObjectiveTo synthesize evidence regarding the psychometric properties of the Brief-Balance Evaluation Systems Test (BESTest) in assessing postural controls across various populations.Data SourcesArticles were searched in 9 databases from inception to March 2020.Study SelectionTwo reviewers independently screened titles, abstracts, and full-text articles to include studies that reported at least 1 psychometric property of the Brief-BESTest. There were no language restrictions.Data ExtractionThe 2 independent reviewers extracted data (including psychometric properties of Brief-BESTest) from the included studies. The methodological quality of the included studies was appraised by the Consensus-based Standards for the Selection of Health Status Measurement Instruments checklist, and the quality of statistical outcomes was assessed by the Terwee et al method. A best-evidence synthesis for each measurement property of the Brief-BESTest in each population was conducted.Data SynthesisTwenty-four studies encompassing 13 populations were included. There was moderate to strong positive evidence to support the internal consistency (Cronbach α>0.82), criterion validity (ρ≥0.73, r≥0.71), and construct validity (ρ≥0.66, r≥0.50, area under curve>0.72) of the Brief-BESTest in different populations. Moderate to strong positive evidence supported the responsiveness of the Brief-BESTest in detecting changes in postural controls of patients 4 weeks after total knee arthroplasty or patients with subacute stroke after 4-week rehabilitation. However, there was strong negative evidence for the structural validity of this scale in patients with various neurologic conditions. The evidence for the reliability of individual items and measurement errors remains unknown.ConclusionsThe Brief-BESTest is a valid (criterion- and construct-related) tool to assess postural control in multiple populations. However, further studies on the reliability of individual items and minimal clinically important difference of the Brief-BESTest are warranted before recommending it as an alternative to the BESTest and Mini-BESTest in clinical research/practice.     

Effect of Severe Distal Tibia,Ankle, and Mid- to Hindfoot Trauma on Meeting Physical Activity Guidelines 18 Months After Injury

ObjectiveTo examine the effect of severe lower extremity trauma on meeting Physical Activity Guidelines for Americans (PAGA) 18 months after injury and perform an exploratory analysis to identify demographic, clinical, and psychosocial factors associated with meeting PAGA.DesignSecondary analysis of observational cohort study.SettingA total of 34 United States trauma centersParticipantsA total of 328 adults with severe distal tibia, ankle and mid- to hindfoot injuries treated with limb reconstruction (N=328).InterventionsNone.Main Outcome MeasuresThe Paffenbarger Physical Activity Questionnaire was used to assess physical activity levels 18 months after injury. Meeting PAGA was defined as combined moderate- and vigorous-intensity activity ≥150 minutes per week or vigorous-intensity activity ≥75 minutes per week.ResultsFewer patients engaged in moderate- or vigorous-intensity activity after injury compared with before injury (moderate: 44% vs 66%, P<.001; vigorous: 18% vs 29%; P<.001). Patients spent 404±565 minutes per week in combined moderate- to vigorous-intensity activity before injury compared with 224±453 minutes postinjury (difference: 180min per week; 95% confidence interval [CI], 103-256). The adjusted odds of meeting PAGA were lower for patients with depression (adjusted odds ratio [AOR], 0.45; 95% CI, 0.28-0.73), women (AOR, 0.59; 95% CI, 0.35-1.00), and Black or Hispanic patients (AOR, 0.49; 95% CI, 0.28-0.85). Patients meeting PAGA prior to injury were more likely to meet PAGA after injury (odds ratio, 2.0; 95% CI, 1.20-3.31).ConclusionsPatients spend significantly less time in moderate- to vigorous-intensity physical activity after injury. Patients with depression are less likely to meet PAGA. Although the causal relationship is unclear, results highlight the importance of screening for depression.     

Differences in Cardiometabolic Comorbidities Between Black and White Persons Living With Multiple Sclerosis

ObjectiveTo determine differences in obesity, type 2 diabetes, and hypertension in Black patients compared with White patients with multiple sclerosis (MS).DesignCross-sectional database review.SettingLarge academic medical center research records database.ParticipantsA total of 3191 patient cases (N=3191; 77% female, 34% Black) identified by MS diagnosis within the medical record.InterventionsNot applicable.Main Outcome MeasuresDiagnosis codes for type 2 diabetes and hypertension. Body mass index (BMI), race, age, and sex were collected. Analysis of variance (continuous variables) and chi-square analyses (categorical variables) were conducted to determine differences in obesity, diabetes, and hypertension between race and sex. Logistic regression was conducted to determine odds ratios (ORs) of developing diabetes and hypertension based on race, sex, BMI, and age.ResultsBlack patients were more than twice as likely to be diagnosed as having diabetes (OR, 2.15 [95% CI, 1.70-2.72]; P<.0001) or hypertension (OR, 2.44 [95% CI, 2.05-2.91], P<.0001) compared with White patients. Sex did not present a greater likelihood of being diagnosed as having diabetes; however, men were 1.22 times more likely be diagnosed as having hypertension compared with women (95% CI, 1.01-1.49; P=.0439). Increased age and BMI were also significantly associated with likelihood of diagnosis of diabetes and hypertension (age: diabetes OR, 1.05 [95% CI, 1.04-1.06], P<.0001; hypertension OR, 1.06 [95% CI, 1.05-1.06], P<.0001; BMI: diabetes obese vs normal: OR, 2.11 [95% CI, 1.43-3.11], P=.0002; hypertension: obese vs normal: OR, 1.72 [95% CI, 1.39-2.13], P<.0001).ConclusionsBlack patients with MS are significantly more likely to have cardiometabolic conditions than White patients. These conditions have been associated with poorer health outcomes for people with MS and may have some effect on the differences in MS disease course reported in Black patients.     

Effects of Early Postdischarge Rehabilitation Services on Care Needs–Level Deterioration in Older Adults With Functional Impairment: A Propensity Score–Matched Study

ObjectiveTo examine the effects of early postdischarge rehabilitation on care needs–level deterioration in older Japanese patients.DesignPropensity score–matched retrospective cohort study.SettingA secondary data analysis was conducted using medical and long-term care insurance claims data from a suburban city in Japan.ParticipantsWe analyzed patients (N=2746) aged 65 years or older who were discharged from hospital to home between April 2012 and March 2014 and had care needs certification indicating functional impairment.InterventionsThe provision of early rehabilitation services by rehabilitation therapists within 1 month of discharge. Propensity score matching was used to control for differences in characteristics between patients with and without early rehabilitation services.Main Outcome MeasuresAny deterioration in care needs level during the 12-month period after discharge. Cox proportional hazards analyses were conducted to identify the association between the exposure and outcome variables after matching.ResultsAmong 2746 patients, 573 (20.9%) used early rehabilitation services. Care needs–level deterioration occurred in 508 patients (incidence: 18.3 per 1000 person-months), of which 76 used early rehabilitation services (12.3 per 1000 person-months) and 432 did not use early rehabilitation services (20.0 per 1000 person-months). One-to-one propensity score matching produced 566 matched pairs that adjusted for the differences in all covariables. In these matched pairs, the hazard of care needs–level deterioration was significantly lower among patients who used early rehabilitation services (hazard ratio=0.712, 95% CI, 0.529-0.958). A Kaplan-Meier survival analysis showed similar results (log-rank: P=.023).ConclusionsEarly rehabilitation services provided by rehabilitation therapists after hospital discharge appeared effective in preventing care needs–level deterioration, and involving rehabilitation therapists in transitional care may aid the optimization of health care for older Japanese adults with functional impairment.     

Risk of colorectal neoplasia in patients with celiac disease: A multicenter study

Background and aimsThe association of celiac disease with colorectal neoplasia is controversial. The aim of this study was to determine the risk of colorectal neoplasia among patients with celiac disease.MethodsWe carried out a multicenter, retrospective case–control study, within four community hospitals. Celiac disease patients with a complete colonoscopy were regarded as cases and those without celiac disease as controls. For each case, two controls matched for age, sex, indication for colonoscopy and colorectal cancer family history, were randomly selected. The main outcome evaluated was risk of colorectal polyps, adenomas, advanced neoplastic lesions and cancer.ResultsWe identified 118 patients with celiac disease and 236 controls. The risk of polyps, adenomas and advanced neoplastic lesions was similar in both groups (OR 1.25, CI 0.71–2.18, p = 0.40; OR 1.39, CI 0.73–2.63, p = 0.31; and OR 1.00, CI 0.26–3.72, p = 1.00, respectively). On multivariate analysis, age > 75 years old, and first-grade CRC family history were associated with adenomas (OR 2.68 CI 1.03–6.98, OR 6.68 CI 1.03–47.98 respectively) and advanced neoplastic lesions (OR 15.03, CI 2.88–78.3; OR 6.46 CI 1.23–33.79, respectively). With respect to celiac disease characteristic, a low adherence to a gluten free diet was independently associated with the presence of adenomas (OR 6.78 CI 1.39–33.20 p = 0.01).ConclusionsCeliac disease was not associated with an increased risk of colorectal neoplasia. Nonadherence to a strict gluten free diet was associated with the presence of adenomas. Further studies addressing celiac disease characteristics are needed to confirm this observation.