Capsule endoscopy: Improving transit time and image view

AIM: To evaluate the effect of various methods of small bowel preparation on the transit time and the quality of visualization of the entire small bowel mucosa.METHODS: Ninety-five patients underwent capsule endoscopy (CE) by easily swallowing the capsule. They were divided into three study groups according to the preparation used: group A (n = 26) by polyethylene glycol (PEG) liter or with sodium phosphate (SP) 12 h prior to the CE study; group B (n = 29) by erythromycin 1 h prior to the CE study; and group C (n = 40) without any preparation. Visualization ranged from good to satisfactory to poor.RESULTS: The gastric emptying time in the group prepared with erythromycin was shorter but without statistical significance and the small bowel transit time was unaffected. In elderly subjects prepared by PEG or SP, the gastric emptying time was significantly longer (163.7 min, P = 0.05). The transit times of the three sub-groups were not affected by gender or pathology.The grade of cleaning of the entire study group was 3.27±1.1. The erythromycin group presented significantly the worst quality of images (P = 0.05) compared to the other sub-groups. Age, gender, and pathology had no effect on the quality of the cleaning of the small bowel in the sub-groups. One (1.05%) case had no natural excretion.CONCLUSION: Erythromycin markedly reduces gastric emptying time, but has a negative effect on the quality of the image in the small bowel. The preparation of elderly subjects with PEG or SP has a negative effect on the small bowel transit time.

年长男子的生育年龄对生育质量的影响

Women have been increasingly delaying the start of motherhood in recent decades. The same trend is seen also for men. The influence of maternal age on fertility, chromosomal anomalies, pregnancy complications, and impaired perinatal and post-natal outcome of offspring, has been thoroughly investigated, and these aspectsare clinically applied during fertility and pregestational counseling. Male aging and reproductive outcome has gained relatively less attention. The purpose of this review is to evaluate updated and relevant literature on the effect of paternal age on reproductive outcome.

Clostridium difficile and inflammatory bowel disease: Role in pathogenesis and implications in treatment

Clostridium difficile(C.difficile)is the leading cause of antibiotic associated colitis and nosocomial diarrhea.Patients with inflammatory bowel disease(IBD)are at increased risk of developing C.difficile infection(CDI),have worse outcomes of CDI-including higher rates of colectomy and death,and experience higher rates of recurrence.However,it is still not clear whether C.difficile is a cause of IBD or a consequence of the inflammatory state in the intestinal environment.The burden of CDI has increased dramatically over the past decade,with severe outbreaks described in many countries,which have been attributed to a new and more virulent strain.A parallel rise in the incidence of CDI has been noted in patients with IBD.IBD patients with CDI tend be younger,have less prior antibiotic exposure,and most cases of CDI in these patients represent outpatient acquired infections.The clinical presentation of CDI in these patients can be unique-including diversion colitis,enteritis and pouchitis,and typical findings on colonoscopy are often absent.Due to the high prevalence of CDI in patients hospitalized with an IBD exacerbation,and the prognostic implications of CDI in these patients,it is recommended to test all IBD patients hospitalized with a disease flare for C.difficile.Treatment includes general measures such as supportive care and infection control measures.Antibiotic therapy with either oral metronidazole,vancomycin,or the novel antibiotic-fidaxomicin,should be initiated as soon as possible.Fecal macrobiota transplantation constitutes another optional treatment for severe/recurrent CDI.The aim of this paper is to review recent data on CDI in IBD:role in pathogenesis,diagnostic methods,optional treatments,and outcomes of these patients.

Effect of smoking on inflammatory bowel disease: Is it disease or organ specific?

吸烟与在 ulcerative (UC ) 和 Crohn 的疾病(CD ) 的不同效果是在煽动性的肠疾病(IBD ) 的一个重要环境因素。从来不吸烟并且先前吸烟增加 UC 的风险，而吸烟加重 CD 的功课。涉及这种双关系的潜在的机制是还未知的。一个合理假设是吸烟穿上不同效果小并且大肠。这个假设基于动物，人学习在 CD 和 UC 上烟 / 烟碱的效果取决于的那表演发炎并且不在疾病的类型上的地点。

Role of antibiotics for treatment of inflammatory boweldisease

Inflammatory bowel disease is thought to be caused by an aberrant immune response to gut bacteria in a genetically susceptible host. The gut microbiota plays an important role in the pathogenesis and complications of the two main inflammatory bowel diseases: Crohn's disease(CD) and ulcerative colitis. Alterations in gut microbiota, and specifically reduced intestinal microbial diversity, have been found to be associated with chronic gut inflammation in these disorders. Specific bacterial pathogens, such as virulent Escherichia coli strains, Bacteroides spp, and Mycobacterium avium subspecies paratuberculosis, have been linked to the pathogenesis of inflammatory bowel disease. Antibiotics may influence the course of these diseases by decreasing concentrations of bacteria in the gut lumen and altering the composition of intestinal microbiota. Different antibiotics, including ciprofloxacin, metronidazole, the combination of both, rifaximin, and anti-tuberculous regimens have been evaluated in clinical trials for the treatment of inflammatory bowel disease. For the treatment of active luminal CD, antibiotics may have a modest effect in decreasing disease activity and achieving remission, and are more effective in patients with disease involving the colon. Rifamixin, a non absorbable rifamycin has shown promising results. Treatment of suppurative complications of CD such as abscesses and fistulas, includes drainage and antibiotic therapy, most often ciprofloxacin, metronidazole, or a combination of both. Antibiotics might also play a role in maintenance of remission and prevention of post operative recurrence of CD. Data is more sparse for ulcerative colitis, and mostly consists of small trials evaluating ciprofloxacin, metronidazole and rifaximin. Most trials did not show a benefit for the treatment of active ulcerative colitis with antibiotics, though 2 meta-analyses concluded that antibiotic therapy is associated with a modest improvement in clinical symptoms. Antibiotics show a clinical benefit when used for the treatment of pouchitis. The downsides of antibiotic treatment, especially with recurrent or prolonged courses such as used in inflammatory bowel disease, are significant side effects that often cause intolerance to treatment, Clostridium dificile infection, and increasing antibiotic resistance. More studies are needed to define the exact role of antibiotics in inflammatory bowel diseases.

Capsule endoscopy in pediatric patients

Wireless capsule endoscope (WCE) for the investigation of the small bowel is an approved technique both in adults and children (more than 10 years old). The present review provides data on the indications, diagnostic yield, adverse events and limitations of the WCE technique in children and tries to predict the future of WCE usage in this population of patients.

板层黄斑裂孔与正常中心凹厚度的黄斑假洞的比较(英文)

目的比较与视网膜前膜(ERM)相关的黄斑板层裂孔(ILH)和具有正常中心凹厚度的黄斑假洞(MPH),在定量和形态学上的差异。方法27眼(25例)具有黄斑洞或黄斑假洞(MPH)的临床形态的黄斑前膜患者,应用视网膜光学相干断层扫描(OCT)评价其中心凹厚度与形态。当每个患者至少两次不同的扫描结果显示中心凹厚度≥135μm时,可诊断为MPH;当厚度介于0与135μm之间时,可诊断为ILH。而能够影响数据的中心凹厚度>202μm的MPH、全层黄斑裂孔及黄斑部玻璃体牵拉及其他黄斑病变的患者,则被排除出本试验。结果6例6眼(22.2%),年龄56±18岁被诊断为ILHs,4例4眼(14.4%),年龄70±9岁被诊断为正常厚度的黄斑假洞。ILH与NT-MPHs的最小中心凹厚度范围分别为74～108(平均87±12.6)μm,135～191(平均166±27)μm。所有NT-MPHs和其中4例ILH患者,被发现具有囊样变。其他17眼,厚度都>203μm,具有更加明显的中心凹囊样变。结论OCT的定量检测能够鉴别ILHs与NT-MPHs。囊样变的ILH能够增厚变为MPHs,定量和随访重复测量的结果能够有助于确定囊样变ERMs的手术时机和手术适应症。

Importance of 3-D image reconstruction of spectraldomain OCT on outcome of grid laser photocoagulation for diffuse diabetic macular edema

AIM:To present the outcome of modified grid laser photocoagulation(GLP)in diffuse diabetic macular edema(DDME)in eyes without extrafoveal and/or vitreofoveal traction.METHODS:Inclusion criteria for the retrospective study were DDME eyes of patients with typeⅡdiabetes mellitus that had≥4 months of follow-up following GLP.Only one eye per patient was analyzed.Using 3-D spectral-domain optical coherence tomography(3-D SDOCT),eyes that had either extrafoveal or vitreofoveal traction,or had been previously treated by an intravitreal medication(s)were excluded.Treated DDME eyes were divided into 4 groups:A)"Classic"DDME that involved the central macula;B)edema did not involve the macular center;C)eyes associated with central epiretinal membrane(ERM);D)DDME that was associated with macular capillary dropout≥2 disc-diameter(DD).RESULTS:GLP outcome in 35 DDME eyes after 4-24(mean,13.1±6.9)months was as follows:Group A)18eyes with"classic"DDME.Following one or 2(mean,1.2)GLP treatments,best-corrected visual acuity(BCVA)improved by 1-2 Snellen lines in 44.4%(8/18)of eyes,and worsened by 1 line in 11.1%(2/18).Central macular thickness(CMT)improved by 7%-49%(mean,26.6%)in77.8%(14/18)of eyes.Causes of CMT worsening(n=4)were commonly explainable,predominantly(n=3)associated with emergence of extrafoveal traction,5-9months post-GLP.Group B)GLP(s)in DDME that did not involve the macular center(n=6)resulted in improved BCVA by 1-2 lines in 2 eyes.However,the central macula became involved in the edema process after the GLP in 3(50%)eyes,associated with an emergence of extrafoveal traction in one of these eyes 4months following the GLP.Group C)GLP failed in all 5eyes associated with central ERM.Group D)GLP was of partial benefit in 2 of 6 treated eyes with macular capillary dropout≥2DD.CONCLUSION:Eyes with DDME that involved the macular center were found to achieve favourable outcomes after GLP(s)during mid-term follow-up,unless complicated pre-GLP or post-GLP by vltreoretinal interface abnormalities,often extrafoveal traction or ERM,or by capillary dropout≥2DD.Prospective studies with larger cohorts are required.

Impact of computed tomography image and contact force technology on catheter ablation for atrial fibrillation

AIM:To investigate the impact of using computed tomography(CT) and contact force(CF) technology on recurrence of atrial tachyarrhythmia after atrial fibrillation(AF) ablation.METHODS: This non-randomized study included 2 groups of patients. All patients had symptomatic recurrent paroxysmal or persistent AF and were treated with at least 1 anti arrhythmic medication or intolerant to medication. The first group included 33 patients who underwent circumferential pulmonary veins isolation(PVI) for AF during 2012 and 2013 guided by CT image integration(Cartomerge, Biosense Webster, Diamond Bar, CA, United States) of left atrium and pulmonary veins into an electroanatomic mapping(EAM) system(CT group) using standard irrigated radiofrequency catheter(Thermo Cool, Carto, Biosense Webster, Diamond Bar, CA, United States) or irrigated catheter with integrated CF sensor(Smart Touch, Carto, Biosense Webster, Diamond Bar, CA, United States). The second group included immediately preceding 32 patients who had circumferential PVI by standard irrigated catheter(Thermo Cool) using only EAM(Carto) system(EAM group). Linear lesions were performed according to the discretion of operator. RESULTS: Sex, age, and persistent AF were not different between groups. PVI was achieved in all patients in both groups. Linear ablations including cavo-tricuspid isthmus and or roof line ablation were not different between groups. Free of atrial tachyarrhythmia during follow-up of 24 mo was significantly higher among CT group compared to EAM group(81% vs 55%; respectively; P = 0.027). When 11 patients from CT group who had ablation using Smart Touch catheter were excluded, the difference between CT group and EAM became non significant(73% vs 55%; respectively; P = 0.16). Sub analysis of CT group showed that patients who had ablation using Smart Touch catheter tend to be more free of atrial tachyarrhythmia compared to patients who had ablation using standard irrigated catheter during follow-up(100% vs 73%; respectively; P = 0.07). Major complications(pericardial effusion, cerebrovascular accident/transient ischemic attack, vascular access injury requiring intervention) did not occurred in both groups.CONCLUSION:These preliminary results suggest that CT image integration and CF technology may reduce the recurrence of atrial tachyarrhythmia after catheter ablation for AF.

Hydrodynamics based transfection in normal and fibrotic rats

AIM: Hydrodynamics based transfection (HBT), the injection of a large volume of naked plasmid DNA in a short time is a relatively simple, efficient and safe method for in vivo transfection of liver cells. Though used for quite some time, the mechanism of gene transfection has not yet been elucidated. METHODS: A luciferase encoding plasmid was injected using the hydrodynamics based procedure into normal and thioacetamide-induced fibrotic Sprague Dawley rats. Scanning and transmission electron microscopy images were taken. The consequence of a dual injection of Ringer solution and luciferase pDNA was followed. Halofuginone, an anti collagen type I inhibitor was used to reduce ECM load in fibrotic rats prior to the hydrodynamic injection. RESULTS: Large endothelial gaps formed as soon as 10’ following hydrodynamic injection; these gradually returned to normal 10 d post injection. Hydrodynamic administration of Ringer 10 or 30 m prior to moderate injection of plasmid did not result in efficient transfection suggesting that endothelial gaps by themselves are not sufficient for gene expression. Gene transfection following hydrodynamic injection in thioacetamide induced fibrotic rats was diminished coinciding with the level of fibrosis. Halofuginone, a specific collagen typeⅠ inhibitor, alleviated this effect. CONCLUSION: The hydrodynamic pressure formedfollowing HBT results in the formation of large endothelial gaps. These gaps, though important in the transfer of DNA molecules from the blood to the space of Disse are not enough to provide the appropriate conditions for hepatocyte transfection. Hydrodynamics based injection is applicable in fibrotic rats provided that ECM load is reduced.

Pancreatic cyst dilemma: Between physical and biochemical markers

Physical analysis of the pancreatic cystic lesions(PCLs)fluid as expressed by the rheological behavior(“string sign”)can improve the diagnostic yield and should be integrated in every multimodal PCLs workup.

Metabolic syndrome: a risk factor for high intraocular pressure in the Israeli population

AIM: To evaluate the association among elevated intraocular pressure(IOP), the metabolic syndrome(Met S), body mass index(BMI), and some of their components in the Israeli population.METHODS: We retrospectively reviewed the charts of12 747 soldiers of the Israeli Defense Forces, aged 35 y or older, who underwent a routine periodical medical examination between 1991 and 2004. None of the subjects received medical treatment for either glaucoma or ocular hypertension. High IOP(】21 mm Hg) was correlated with age, sex, arterial blood pressure, total blood cholesterol levels, triglyceride levels, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, smoking, BMI and Met S.RESULTS: A statistically significant difference was found between the IOP of subjects with a low risk and higher risk for the development of Met S(P 【0.0001 for males, P =0.0026 for females). A statistically significant positive correlation was found in male subjects between high BMI and elevated IOP(r =0.11677, P 【0.0001).CONCLUSION: Met S and BMI were significantly more prevalent in subjects with increased IOP levels. We suggest that both should be taken into consideration in the assessment of glaucoma suspects.

Role of microRNA in regulation of myeloma-related angiogenesis and survival

Multiple myeloma(MM)is a malignant disease causedby clonal proliferation of plasma cells that result in monoclonal gammopathy and severe end organ damage.Despite the uniform clinical signs,the disease is very diverse in terms of the nature and sequence of the underlying molecular events.Multiple cellular processes are involved in helping the malignant cells to remain viable and maintain proliferative properties in the hypoxic microenvironment of the bone marrow.Specifically,the process of angiogenesis,triggered by the interactions between the malignant MM cells and the stroma cells around them,was found to be critical for MM progression.In this review we highlight the current understanding about the epigenetic regulation of the proliferation and apoptosis of MM cells and its dependency on angiogenesis in the bone marrow that is carried out by different micro RNAs.

Pegylated interferon alfa and ribavirin for children with chronic hepatitis C

AIM:To study current treatment options for pediatric hepatitis C infection and their associated success rates.METHODS:We retrospectively reviewed charts of thirty children who had been treated with combination therapy of pegylated interferon alfa plus ribavirin for chronic hepatitis C infection.Patients had been treated with ribavirin(15 mg/kg per day) and either pegylated interferon alfa 2a(180 mg/m 2 once weekly) or pegylated interferon alfa 2b(1.5 mg/kg once weekly).Patients' follow-up included subjective assessment of complaints,physical examination including weight and height,as well as laboratory evaluations for viral load [before treatment,at 12 wk,and 6 mo following treatment completion,as determined by sustained viral response(SVR)],complete blood count,liver enzymes,alkaline phosphatase,bilirubin,renal function tests,and thyroid function tests.For patients not achieving a two log decrease in viral load at treatment week 12,treatment was discontinued and the patient was considered a treatment non-responder.RESULTS:Thirty children aged 3-18 years were included in the study.Twenty patients(11 males,9 females) received pegylated interferon alfa 2b and ten patients(6 males,4 females) received pegylated interferon alfa 2a.Twenty-three patients were infected with genotype 1,six patients were infected with genotype 3,and one patient was infected with genotype 2.Twenty patients(67%) achieved SVR.Treatment success rates were 90% with pegylated interferon alfa 2a vs 55% with pegylated interferon alfa 2b.Although a trend was noted for improved outcomes in the group receiving pegylated interferon alfa 2a,there were no statistically significant outcome differences between the two treatment groups(P = 0.1).Treatment success was 56.5% for patients infected with genotype 1 virus,compared to 100% for patients infected with other genotypes(P = 0.064).There was no difference in treatment response between males and females.A cut-off age of twelve years was used to dichotomize younger vs older participants;however,no difference in treatment response was observed between these groups.Using multivariate regression analysis,we could not determine predictors for achieving SVR from among the variables we examined(age,sex,and viral genotype).Although we noted a trend toward SVR with peginterferon alfa-2a,there was no statistical difference between the two peginterferons.A high incidence of adverse reactions to treatment was noted.Twenty-five patients(83%) suffered from at least one adverse reaction,but most experienced more than one adverse reaction.All patients except one became leukopenic(white blood cell count less than 5500 leukocytes/μL),six(20%) became anemic(hemoglobin less than 110 g/L),and one(3.3%) became thrombocytopenic(platelets less than 100 000/μL).CONCLUSION:Combination therapy to treat hepatitisC in children is as effective as in adults.There may be a benefit for treatment with pegylated interferon alfa 2a.

Clinical presentation predicts the outcome of patients with colon cancer

AIM: To elucidate the relationship between clinical presentation and outcome. METHODS: A single institution retrospective chart review of patients admitted with the diagnosis of colon cancer. We used univariate and a multivariate analysis to identify symptoms association with mortality. An odds ratio based clinical score was created to evaluate the contribution of the quality of symptoms to outcome. Primary measure of outcome was survival. RESULTS: During the study period, 236 patients met the inclusion criteria. Overall survival was 60.6%, mean follow-up 3.0 years. A bivariate analysis showed that increasing number of symptoms is not associated with mortality. However, a symptom-specific analysis performed using a logistic regression model controlling for age, stage and the duration of complaints revealed that the presence of melena was independently associated with mortality [P = 0.04, odds ratio (OR) 7.4],while rectal bleeding was associated with survival (P = 0.004, OR 3.9). Applying the proposed clinical score to an receiver operating characteristic curve showed that score > 1 had a strong association with mortality. The same logistic regression model was applied. The results showed that a score > 1 was an independent predictor of mortality (P < 0.001) and associated with node-positive disease (P = 0.008). CONCLUSION: The quality of symptoms rather than quantity is correlated with outcome among patients with colon cancer. The proposed clinical scoring system may correctly predict the patient's outcome.

Significance of low level infliximab in the absence of anti-infliximab antibodies

AIM:To evaluate the prevalence of double negative(DN)sera and the mechanisms responsible for DN status.METHODS:Sera of inflammatory bowel disease patients treated with infliximab(IFX)were tested for drug/antibodies to infliximab(ATI)trough levels and the proportion of DN results was compared between a commercially available double antigen ELISA(with labeled IFX as the detection antibody)and an antilambda ELISA(with anti-human lambda chain detection antibody).Repeat testing with lower than customary serum dilution(1:10)was performed.Patients with DN status were matched with IFX+/ATI-controls and were followed-up for subsequent development of nontransient ATI to investigate if DN status precedes ATI.RESULTS:Of 67 sera obtained at time of loss of response,only 6/67(9%)were DN by anti-lambda ELISA compared to 27/67(40%)with double antigen ELISA(P<0.001,Fisher’s Exact test).Of the latter27 sera,22%were also DN by anti-lambda ELISA,whereas 44%were actually IFX positive(IFX+ATI-),30%were ATI positive(IFX-ATI+)and 4%were double positive(IFX+ATI+).Re-testing using a 1:10 dilution converted most DN results into IFX+and/or ATI+status.Patients with DN status had shorter survival free of non-transient ATI compared with matched controls(log rank test,P<0.001).In 9/30(30%)of these patients,non transient ATI occurred before and after the event at which the DN serum was obtained,supporting the view that a DN result may represent aparticular time-point along the two curves of ATI titer rise and infliximab drug level decline.CONCLUSION:DN status may result from false negative detection of IFX or ATI by double antigen ELISA,suggesting a transitional state of low-level immunogenicity,rather than non-immunological clearance.

Low Friction Traction for Cervical Spine Dislocation

In order to reduce the magnitude of the force applied to skull for treatment of acute cervical spine dislocation, we developed a method of skeletal traction based on reduction of friction forces under the patient’s head. Traction force was applied to sculls of five patients with cervical fracture-dislocations. A difference in friction interface between the patient’s head and shoulder girdle was created. The traction weight required for the reduction of the vertebral dislocation was significantly lower than an expected minimal traction weight in the commonly used techniques (p = 0.013). The presented method permits an effective and safe reduction of dislocated cervical vertebra by a relatively low traction force.

High Degree Atrioventricular Block Complicated Cardiac Sarcoidosis: Case Report

Cardiac Sarcoidosis (CS) is a rare and deceptive disease affecting young adults with catastrophic results including life threatening arrhythmia, congestive heart failure and even sudden death as the initial presentation. CS has been linked to a significant high morbidity & mortality. We present two patients: The first patient with an initial cardiac event that led us to a diagnosis of Pulmonary and Cardiac Sarcoidosis. A second patient, who was diagnosed initially with pulmonary Sarcoidosis, presented with a severe heart conduction abnormality. Both patients were successfully treated with permanent pacemakers. The dual purpose of our study is first to emphasize the importance of follow up on patients with Non-Cardiac Sarcoidosis for cardiac involvement and secondly to increase awareness of CS as part of a differential diagnosis among young adults with unexplained arrhythmia.

累范特地区的螫蝇（双翅目：蝇科）名录及黎巴嫩、叙利亚、约旦和埃及西奈山的新记录种

在累范特地区采集到8种螫蝇亚科种类，包括螫蝇属3种，厩螫蝇Stomoxyscalcitrans（Linnaeus，1758），南螫蝇StomoxyssitensRondani，1873，黑螫蝇StomoxysnigraMaequart，1851，角蝇属2种，西方角蝇Haematobiairritans（Linnaeus，1758），微小角蝇Haematobiaminuta（Bezzi，1892），袭蝇属1种，斑袭蝇StygeromyiamaculosaAusten，1907，血喙蝇属2种，刺扰血喙蝇Haematoboscastimulans（Meigen，1824）和长毛血喙蝇Haematobosca ATRIPALPIS（Bezzi，1895）。其中厩螫蝇S．ealcitrans和西方角蝇Mirritans为这些国家和地区的广布种，黑螫蝇．S．NIGRa和长毛血喙蝇日．atripalpis为该地区的新记录种。南螫蝇S．sitens，微小角蝇H．minuta和斑袭蝇S．maculosa为以色列外累范特地区的新记录种，刺扰血喙蝇Hstimulans已知仅分布在以色列。