Axillary Recurrences after Sentinel Node Surgery—Results over Ten Years in a University Hospital

Background: Sentinel node biopsy (SNB) was introduced at Ullevaal University Hospital in 2000. This article presents results from the first ten years use of the method. Material and Methods: A prospective registration of 2762 patients was made from 2000 through 2009. Results: The median follow-up time was 51 months. The overall detection rate was 93%. 36% of the patients with positive SNs had non-sentinel metastases. These were significantly associated with a macrometastatic SN and a primary tumour>20 mm. 18% of patients with sentinel metastasis≤2 mm had non-sentinel metastases. 14 patients with negative SN (0.7%) developed axillary recurrence. 32% with a preoperative diagnosis of ductal carcinoma in situ (DCIS) were upstaged to infiltrating carcinoma on final histology. None of the patients with pure DCIS had positive SNs. Conclusion: Few late events (0.7%) in SN negative axillas demonstrate the safety of the technique.

Chronic hepatitis B virus infection in Eastern Ethiopia:Clinical characteristics and determinants of cirrhosis

BACKGROUND Chronic hepatitis B(CHB)virus infection is a major cause of liver-associated morbidity and mortality,particularly in low-income countries.A better understanding of the epidemiological,clinical,and virological characteristics of CHB will guide appropriate treatment strategies and improve the control and management of CHB in Ethiopia.AIM To investigate the characteristics of CHB in Eastern Ethiopia and assess the efficacy and safety of antiviral treatment.METHODS This cohort study included 193 adults who were human immunodeficiency virus-negative with CHB between June 2016 and December 2019.Baseline assessments included chemistry,serologic,and viral markers.χ^(2) tests,Mann-Whitney U tests,and logistic regression analyses were used to identify the determinants of cirrhosis.Tenofovir disoproxil fumarate(TDF)was initiated using treatment criteria from the Ethiopian CHB pilot program.RESULTS A total of 132 patients(68.4%)were men,with a median age of 30 years[interquartile range(IQR):24-38].At enrollment,60(31.1%)patients had cirrhosis,of whom 35(58.3%)had decompensated cirrhosis.Khat use,hepatitis B envelope antigen positivity,and a high viral load were independently associated with cirrhosis.Additionally,66 patients(33.4%)fulfilled the treatment criteria and 59(30.6%)started TDF.Among 29 patients who completed 24 months of treatment,the median aspartate aminotransferase to platelet ratio index declined from 1.54(IQR:0.66-2.91)to 1.10(IQR:0.75-2.53)(P=0.002),and viral suppression was achieved in 80.9%and 100%of patients after 12 months and 24 months of treatment,respectively.Among the treated patients,12(20.3%)died within the first 6 months of treatment,of whom 8 had decompensated cirrhosis.CONCLUSION This study highlights the high prevalence of cirrhosis,initial mortality,and the efficacy of TDF treatment.Scaling up measures to prevent and control CHB infections in Ethiopia is crucial.

Optimal transcorneal electrical stimulation parameters for preserving photoreceptors in a mouse model of retinitis pigmentosa

Retinitis pigmentosa is a hereditary retinal disease that affects rod and cone photoreceptors,leading to progressive photoreceptor loss.Previous research supports the beneficial effect of electrical stimulation on photoreceptor survival.This study aims to identify the most effective electrical stimulation parameters and functional advantages of transcorneal electrical stimulation(tcES)in mice affected by inherited retinal degeneration.Additionally,the study seeked to analyze the electric field that reaches the retina in both eyes in mice and post-mortem humans.In this study,we recorded waveforms and voltages directed to the retina during transcorneal electrical stimulation in C57BL/6J mice using an intraocular needle probe with rectangular,sine,and ramp waveforms.To investigate the functional effects of electrical stimulation on photoreceptors,we used human retinal explant cultures and rhodopsin knockout(Rho^(-/-))mice,demonstrating progressive photoreceptor degeneration with age.Human retinal explants isolated from the donors’eyes were then subjected to electrical stimulation and cultured for 48 hours to simulate the neurodegenerative environment in vitro.Photoreceptor density was evaluated by rhodopsin immunolabeling.In vivo Rho^(-/-)mice were subjected to two 5-day series of daily transcorneal electrical stimulation using rectangular and ramp waveforms.Retinal function and visual perception of mice were evaluated by electroretinography and optomotor response(OMR),respectively.Immunolabeling was used to assess the morphological and biochemical changes of the photoreceptor and bipolar cells in mouse retinas.Oscilloscope recordings indicated effective delivery of rectangular,sine,and ramp waveforms to the retina by transcorneal electrical stimulation,of which the ramp waveform required the lowest voltage.Evaluation of the total conductive resistance of the post-mortem human compared to the mouse eyes indicated higher cornea-to-retina resistance in human eyes.The temperature recordings during and after electrical stimulation indicated no significant temperature change in vivo and only a subtle temperature increase in vitro(~0.5-1.5°C).Electrical stimulation increased photoreceptor survival in human retinal explant cultures,particularly at the ramp waveform.Transcorneal electrical stimulation(rectangular+ramp)waveforms significantly improved the survival and function of S and M-cones and enhanced visual acuity based on the optomotor response results.Histology and immunolabeling demonstrated increased photoreceptor survival,improved outer nuclear layer thickness,and increased bipolar cell sprouting in Rho^(-/-)mice.These results indicate that transcorneal electrical stimulation effectively delivers the electrical field to the retina,improves photoreceptor survival in both human and mouse retinas,and increases visual function in Rho^(-/-)mice.Combined rectangular and ramp waveform stimulation can promote photoreceptor survival in a minimally invasive fashion.

A novel saliva-based miRNA profile to diagnose and predict oral cancer

Oral cancer (OC) is the most common form of head and neck cancer. Despite the high incidence and unfavourable patient outcomes, currently, there are no biomarkers for the early detection of OC. This study aims to discover, develop, and validate a novel saliva-based microRNA signature for early diagnosis and prediction of OC risk in oral potentially malignant disorders (OPMD).The Cancer Genome Atlas (TCGA) miRNA sequencing data and small RNA sequencing data of saliva samples were used to discover differentially expressed miRNAs. Identified miRNAs were validated in saliva samples of OC (n=50), OPMD (n=52), and controls(n=60) using quantitative real-time PCR. Eight differentially expressed miRNAs (miR-7-5p, miR-10b-5p, miR-182-5p, miR-215-5p,miR-431-5p, miR-486-3p, miR-3614-5p, and miR-4707-3p) were identified in the discovery phase and were validated. The efficiency of our eight-miRNA signature to discriminate OC and controls was:area under curve (AUC):0.954, sensitivity:86%, specificity:90%,positive predictive value (PPV):87.8%and negative predictive value (NPV):88.5%whereas between OC and OPMD was:AUC:0.911,sensitivity:90%, specificity:82.7%, PPV:74.2%and NPV:89.6%. We have developed a risk probability score to predict the presence or risk of OC in OPMD patients. We established a salivary miRNA signature that can aid in diagnosing and predicting OC,revolutionising the management of patients with OPMD. Together, our results shed new light on the management of OC by salivary miRNAs to the clinical utility of using miRNAs derived from saliva samples.

The big data challenge-and how polypharmacology supports the translation from pre-clinical research into clinical use against neurodegenerative diseases and beyond

Introductory comments:The identification and validation of disease-modifying proteins are fundamental aspects in drug development.However,the m ultifactority of n eurodegen era tive diseases poses a real challenge for targeted therapies.Furthermore,the behavior of individually(over-)expressed to rget proteins in vitro is likely to differ from their actual functional behavior when embedded in cascades and pathways in vivo.

Recurrence and rejection in liver transplantation for primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a chronic progressive inflammatory disease affecting the bile ducts, leading to f ibrosis and eventually cirrhosis in most patients. Its etiology is unknown and so far no effective medical therapy is available. Liver transplantation (LTX) is the only curative treatment and at present PSC is the main indication for LTX in the Scandinavian countries. Close to half of the PSC patients experience one or more episodes of acute cellular rejection (ACR) following transplantation and approximately 1/5 of the transplanted patients develop recurrent disease in the graft. In addition, some reports indicate that ACR early after LTX for PSC can infl uence the risk for recurrent disease. For these important post-transplantation entities affecting PSC patients, we have reviewed the current literature on epidemiology, pathogenesis, treatment and the possible infl uence of rejection on the risk of recurrent disease in the allograft.

Chronic fatigue is associated with increased disease-related worries and concerns in inflammatory bowel disease

AIM:To investigate the impact of chronic fatigue on disease-related worries in inflammatory bowel disease (IBD) and the potential multicolinearity between subjective questionnaires.METHODS:Patients in remission or with mild-tomoderate disease activity completed the fatigue questionnaire (FQ),the rating form of IBD patient concerns (RFIPC),the Short-Form 36 (SF-36),and IBD questionnaire (N-IBDQ).In addition,clinical and epidemiological data were obtained.RESULTS:In total,140 patients were included;of which 92 were diagnosed with ulcerative colitis and 48 with Crohn's disease.The mean age of patients with chronic fatigue was 44.2 years (SD=15.8) and for non-fatigued patients was 44.7 years (SD=16.0).Chronic fatigued patients had clinically significantly increased levels of disease-related worries,as measured by Cohen's d effect size.Worries about having an ostomy bag,loss of bowel control,and energy levels were most prominent in both chronic fatigued and non-chronic fatigued IBD patients.Variance inflation factor (VIF) and tolerance indicated that there were no problematic multicolinearity among the FQ,RFIPC,SF-36 and N-IBDQ responses (VIF < 5 and tolerance > 2).CONCLUSION:Chronic fatigue is associated with increased levels of disease-related worries and concerns in IBD.Increased levels of worries were also associated with impaired health-related quality of life.

Methodology to develop machine learning algorithms to improve performance in gastrointestinal endoscopy

Assisted diagnosis using artificial intelligence has been a holy grail in medical research for many years, and recent developments in computer hardware have enabled the narrower area of machine learning to equip clinicians with potentially useful tools for computer assisted diagnosis(CAD) systems. However, training and assessing a computer's ability to diagnose like a human are complex tasks, and successful outcomes depend on various factors. We have focused our work on gastrointestinal(GI) endoscopy because it is a cornerstone for diagnosis and treatment of diseases of the GI tract. About 2.8 million luminal GI(esophageal, stomach, colorectal) cancers are detected globally every year, and although substantial technical improvements in endoscopes have been made over the last 10-15 years, a major limitation of endoscopic examinations remains operator variation. This translates into a substantial inter-observer variation in the detection and assessment of mucosal lesions, causing among other things an average polyp miss-rate of 20% in the colon and thus the subsequent development of a number of post-colonoscopy colorectal cancers. CAD systems might eliminate this variation and lead to more accurate diagnoses. In this editorial, we point out some of the current challenges in the development of efficient computer-based digital assistants. We give examples of proposed tools using various techniques, identify current challenges, and give suggestions for the development and assessment of future CAD systems.

Iatrogenic esophago-tracheal fistula:Challenges in diagnosis and management

Esophageo-tracheal fistula is a rare condition,and in most cases such fistulas are caused by malignant disease or emergency endotracheal intubation.A case where a wrapped tablet produced a fistula between the esophagus and trachea is described.The patient is a male born in 1938 who swallowed a tablet without unwrapping it.The patient was treated with selfexpanding metal stents(SEMS),but closure of the fistula was not achieved.Different examinations and treatment options are discussed.Surgical treatment for this condition has demonstrated considerable mortality and morbidity.In some cases closure of the fistula can be achieved by use of SEMS.Although we advise treatment of such cases with SEMS,in some cases treatment with stents will prove troublesome and the risk/benefit analysis will have to be reevaluated.

Effect of liver regeneration on malignant hepatic tumors

Liver regeneration after major surgery may activate occult micrometastases and facilitate tumor growth,leading to liver tumor recurrence.Molecular changes during liver regeneration can provide a microenvironment that stimulates intrahepatic tumor propagation through alterations in cellular signaling pathways,where activation and proliferation of mature hepatocytes,hepatic progenitor cells,non-parenchymal liver cells might favor both liver regeneration and tumor growth.This review highlights recent advances of tumor growth and development in the regenerating liver,possible mechanisms and clinical implications.

Updated therapeutic outcome for patients with periampullary and pancreatic cancer related to recent translational research

Chemotherapy with improved effect in patients with metastatic pancreatic cancer has recently been established, launching a new era for patients with this very aggressive disease. FOLFIRINOX and gemcitabine plus nab-paclitaxel are different regimens, both capable of stabilizing the disease, thus increasing the number of patients who can reach second line and even third line of treatment. Concurrently, new windows of opportunity open for nutritional support and other therapeutic interventions, improving quality of life. Also pancreatic surgery has changed significantly during the latest years. Extended operations, including vascular/multivisceral resections are frequently performed in specialized centers, pushing borders of resectability. Potentially curative treatment including neoadjuvant and adjuvant chemotherapy is offered new patient groups. Translational research is the basis for the essential understanding of the ongoing development. Even thou biomarkers for clinical management of patients with periampullary tumors have almost been lacking, biomarker driven trials are now in progress. New insight is constantly made available for clinicians; one recent example is selection of patients for gemcitabine treatment based on the expression level of the human equilibrium nucleoside transporter 1. An example of new diagnostic tools is identification of early pancreatic cancer patients by a three-biomarker panel in urine: The proteins lymphatic vessel endothelial hyaluronan receptor 1, regenerating gene 1 alpha and translation elongation factor 1 alpha. Requirement of treatment guideline revisions is intensifying, as combined chemotherapy regimens result in unexpected advantages. The European Study Group for Pancreatic Cancer 4 trial outcome is an illustration: Addition of capecitabine in the adjuvant setting improved overall survival more than expected from the effect in advanced disease. Rapid implementation of new treatment options is mandatory when progress finally extends to patients with this serious disease.

Epidemiology and clinical course of Crohn's disease:Results from observational studies

The authors review the clinical outcome in patients with Crohn's disease(CD)based on studies describing the natural course of the disease.Population-based studies have demonstrated that the incidence rates and prevalence rates for CD have increased since the mid-1970s.The authors search for English language articles from 1980 until 2011.Geographical variations,incidence,prevalence,smoking habits,sex,mortality and medications are investigated.An increasing incidence and prevalence of CD have been found over the last three decades.The disease seems to be most common in northern Europe and North America,but is probably increasing also in Asia and Africa.Smoking is associated with an increased risk of developing CD.Age <40 at diagnosis,penetrating/stricturing complications,need for systemic steroids,and disease location in terminal ileum are factors associated with higher relapse rates.A slight predominance of women diagnosed with CD has been found.Ileocecal resection is the most commonly performed surgical procedure,and within the first five years after the diagnosis about one third of the patients have had intestinal surgery.Smoking is associated with a worse clinical course and withincreased risk of flare-ups.In most studies the overall mortality is comparable to the background population.To date,the most effective treatment options in acute flares are glucocorticosteroids and tumor necrosis factor(TNF)-α-blockers.Azathioprine/methotrexate and TNF-α-blockers are effective in maintaining remission.

Role of surgery in pancreatic cancer

Treatment of pancreatic cancer is multimodal and surgery is an essential part,mandatory for curative potential.Also chemotherapy is essential,and serious postoperative complications or rapid disease progression may preclude completion of multimodal treatment.The sequence of treatment interventions has therefore become an important concern,and numerous ongoing randomized controlled trials compare clinical outcome after upfront surgery and neoadjuvant treatment with subsequent resection.In previous years,borderline resectable and locally advanced pancreatic cancer was most often considered unresectable.More effective chemotherapy together with the latest improvements in surgical expertise has resulted in extended operations,pushing the borders of resectability.Multivisceral resections with or without resection of major mesen-teric vessels are now performed in numerous patients,resulting in better outcome,recorded as overall survival and/or patient reported outcome.But postoperative morbidity increases concurrently,and clinical benefit must be carefully evaluated against risk of potential harm,associated with new comprehensive multimodal treatment sequences.Even though cost/utility analyses are deficient,extended surgery has resulted in signifi-cantly longer and better life for many patients with no other treatment alternative.Improved selection of patients to surgery and/or chemotherapy will in the near future be possible,based on better tumor biology insight.Clinically available biomarkers enabling personalized treatment are forthcoming,but these options are still limited.The importance of surgical resection for each patient’s prognosis is presently increasing,justifying sustained expansion of the surgical treatment modality.

New Concepts and Evidence Based Practice in Physiotherapy：Examples from Stroke Rehabilitation

Objective:The purpose of this paper is to give an overview of new concepts and evidence based physiotherapy practice in stroke rehabilitation in the acute,post acute and chronic stage of stroke. Background:Historically physiotherapy has developed through the years from a focus on health,beauty,and equilibrium between spiritual,moral and physical powers,to a client centered service to people and populations to develop,to maintain and to restore maximum movement and functional ability throughout the lifespan. Still the health perspective is strong and divided into first,second and third prophylaxis. New concepts like Evidence Based Medicine,Evidence Based Practice,International Classification of Function and research within neurophysiology have had a deep impact on physiotherapy services,practice and education. The highest levels of documentation are Meta analyses and Randomised Controlled Trials,and today many of the physiotherapy methods used in rehabilitation of neurological conditions are tried out in different trials,bringing up-to date knowledge into practice. This paper focuses on rehabilitation of persons with stroke and physiotherapy methods in particular. Result:Physiotherapy in the acute stage improves motor function and enhances mobility. Rehabilitative efforts within the first few weeks as opposed to later favors better recovery. Type of physiotherapy in the acute stage is task oriented training with a focus on intensity and variability. Post acute therapy-based rehabilitation services targeted towards stroke patients living at home appear to improve independence in personal activities of daily living. In the chronic stage there is good evidence that aerobic exercise is beneficial for improving aerobic capacity in people with mild and moderate stroke. Progressive resistance strength training programmes reduce musculoskeletal impairment after stroke,without increasing tone or spasticity.

Importance of physical capacity and the effects of exercise in heart transplant recipients

One of the most important prognostic factors in heart failure patients is physical capacity. Patients with very poor physical performance and otherwise eligible, may be listed as candidates for heart transplantation(HTx). After such surgery, life-long immunosuppression therapy is needed to prevent rejection of the new heart. The dark side of immunosuppression is the increased risk of infections, kidney failure, cancer and advanced atherosclerosis(cardiac allograft vasculopathy), with the two latter conditions as the main causes of later mortality. In a worldwide perspective, 50% of the HTx patients survive past 10 years. Poor aerobic capacity prior to graft deterioration is not only limited to the failing heart, but also caused by peripheral factors, such as limited function in the skeletal muscles and in the blood vessels walls. Exercise rehabilitation after HTx is of major importance in order to improve physical capacity and prognosis. Effects of high-intensity interval training(HIT) in HTx recipients is a growing field of research attracting worldwide focus and interest. Accumulating evidence has shown that HIT is safe and efficient in maintenance HTx recipients; with superior effects on physical capacity compared to conventional moderate exercise. This article generates further evidence to the field by summarizing results from a decade of research performed at our center supported by a broad, but not strict formal, literature review. In short, this article demonstrates a strong association between physical capacity measured after HTx and long-term survival. It describes the possible "HITeffect" with increased levels of inflammatory mediators of angiogenesis. It also describes long-term effects of HIT; showing a positive effect in development of anxiety symptoms despite that the improved physical capacity was not sustained, due to downregulation ofexercise and intensity. Finally, our results are linked to the ongoing HITTS study, which investigates safety and efficiency of HIT in de novo HTx recipients. Together with previous results, this study may have the potential to change existing guidelines and contribute to a better prognosis for the HTx population as a whole.

Prospective evaluation of the cause of acute pancreatitis,with special attention to medicines

AIM: To investigate the cause of acute pancreatitis(AP) by conducting a thorough investigation of drugs and their possible etiological role.METHODS: We investigated the cause of AP in a large retrospective cohort of 613 adult patients admitted with AP at the Akershus University Hospital, Norway, from 2000 until 2009, who were evaluated with standard ward investigations. This group was compared with a prospectively evaluated group(n = 57) admitted from January 2010 until September 2010 who investigated more extensively using medical history and radiological assessment.RESULTS: The groups were comparable with regards to gender, age, comorbidity and severity. The most common etiology was bile stones and alcohol, occurring in 60% in both groups. The prospective group was examined more thoroughly with regards to the use of alcohol and medicines. An increased number of radiological investigations during hospital stay and at follow-up were also performed. A more extensive use of radiological evaluation did not increase the detection frequency of bile stones. In the prospective group, more than half of the patients had two or more possible causes of pancreatitis, being mostly a combination of bile stones and drugs. No possible cause was found in only 3.5% of these patients, compared with 29.7% in the retrospective group.CONCLUSION: A detailed medical history and extensive radiological evaluation may determine a possible etiology in almost all cases of AP. Many patients have several possible risk factors, and uncertainty remains in establishing the definitive etiology.

Radiofrequency ablation for early oesophageal squamous neoplasia:Outcomes form United Kingdom registry

AIM:To report outcomes on patients undergoing radiofrequency ablation(RFA)for early oesophageal squamous neoplasia from a National Registry.METHODS:A Prospective cohort study from 8 tertiary referral centres in the United Kingdom.Patients with squamous high grade dysplasia(HGD)and early squamous cell carcinoma(ESCC)confined to the mucosa were treated.Visible lesions were removed by endoscopic mucosal resection(EMR)before RFA.Following initial RFA treatment,patients were followed up 3monthly.Residual flat dysplasia was treated with RFA until complete reversal dysplasia(CR-D)was achieved or progression to invasive Squamous cell cancer defined as infiltration into the submucosa layer or beyond.The main outcome measures were CR-D at 12 mo from start of treatment,long term durability,progression to cancer and adverse events.RESULTS:Twenty patients with squamous HGD/ESCC completed treatment protocol.Five patients(25%)had EMR before starting RFA treatment.CR-D was 50%at12 mo with a median of 1 RFA treatment,mean 1.5(range 1-3).Two further patients achieved CR-D with repeat RFA after this time.Eighty per cent with CR-D remain dysplasia free at latest biopsy,with median follow up 24 mo(IQR 17-54).Six of 20 patients(30%)progressed to invasive cancer at 1 year.Four patients(20%)required endoscopic dilatations for symptomatic structuring after treatment.Two of these patients have required serial dilatations thereafter for symptomatic dysphagia with a median of 4 dilatations per patient.The other 2 patients required only a single dilatation to achieve an adequate symptomatic response.One patient developed cancer during follow up after end of treatment protocol.CONCLUSION:The role of RFA in these patients re-mains unclear.In our series 50%patients responded at12 mo.These figures are lower than limited published data.

Navigated liver surgery:State of the art and future perspectives

Background:In recent years,the development of digital imaging technology has had a significant influence in liver surgery.The ability to obtain a 3-dimensional(3D)visualization of the liver anatomy has provided surgery with virtual reality of simulation 3D computer models,3D printing models and more recently holograms and augmented reality(when virtual reality knowledge is superimposed onto reality).In addition,the utilization of real-time fluorescent imaging techniques based on indocyanine green(ICG)uptake allows clinicians to precisely delineate the liver anatomy and/or tumors within the parenchyma,applying the knowledge obtained preoperatively through digital imaging.The combination of both has transformed the abstract thinking until now based on 2D imaging into a 3D preoperative conception(virtual reality),enhanced with real-time visualization of the fluorescent liver structures,effectively facilitating intraoperative navigated liver surgery(augmented reality).Data sources:A literature search was performed from inception until January 2021 in MEDLINE(Pub Med),Embase,Cochrane library and database for systematic reviews(CDSR),Google Scholar,and National Institute for Health and Clinical Excellence(NICE)databases.Results:Fifty-one pertinent articles were retrieved and included.The different types of digital imaging technologies and the real-time navigated liver surgery were estimated and compared.Conclusions:ICG fluorescent imaging techniques can contribute essentially to the real-time definition of liver segments;as a result,precise hepatic resection can be guided by the presence of fluorescence.Furthermore,3D models can help essentially to further advancing of precision in hepatic surgery by permitting estimation of liver volume and functional liver remnant,delineation of resection lines along the liver segments and evaluation of tumor margins.In liver transplantation and especially in living donor liver transplantation(LDLT),3D printed models of the donor’s liver and models of the recipient’s hilar anatomy can contribute further to improving the results.In particular,pediatric LDLT abdominal cavity models can help to manage the largest challenge of this procedure,namely large-for-size syndrome.

Real-life chromoendoscopy for dysplasia surveillance in ulcerative colitis

AIM To evaluate the use of chromoendoscopy for surveillance of ulcerative colitis in a real-life community hospital setting.METHODS Patients with extensive ulcerative colitis, having disease duration of more than 8 years and who presented between the years of 1999 to 2013, were offered enrolment in this single cohort prospective study. All participants underwent standard bowel preparation with sodium phosphate and chromoendoscopy. Two expert endoscopists, novice to chromoendoscopy, evaluated each segment of the colon with standarddefinition colonoscopes after spray application of 0.4% indigo carmine. All observed lesions were recorded and evaluated before being removed and/or biopsied. In addition, nontargeted biopsies were taken from each segment of the colon. The dysplasia detection rate and dysplasia detection yield were ascertained. RESULTS A total of 21 neoplastic lesions(2 carcinomas, 4 of high-grade dysplasia and 15 of low-grade dysplasia) and 27 nondysplastic lesions were detected in 16 of the total 67 patients(70% male; median disease duration: 17 years; median age at diagnosis: 25 years; 92% aminosalicylate-treated). The dysplasia detection rate was 10.5%(7/67 patients). The dysplasia detection yield was 20.8%(10/48) for targeted biopsies and 3.5%(11/318) for nontargeted biopsies. The sensitivity and specificity for the macroscopic evaluation of neoplasia using chromoendoscopy were 48% [95% confidence interval(CI): 26%-70%] and 96%(95%CI: 93%-98%), respectively. The positive predictive and negative predictive values were 42%(95%CI: 27%-59%) and 97%(95%CI: 95%-98%), respectively. A total of 19/21 dysplastic lesions were detected in mucosa with histologic inflammation.CONCLUSION Chromoendoscopy seems to be of value for dysplasia surveillance of ulcerative colitis in a community hospital setting. The yield of non-targeted biopsies is negligible.

Routine diagnosis of intestinal tuberculosis and Crohn's disease in Southern India

AIM:To investigate whether routinely measured clinical variables could aid in differentiating intestinal tuberculosis(ITB)from Crohn’s disease(CD).METHODS:ITB and CD patients were prospectively included at four South Indian medical centres from October 2009 to July 2012.Routine investigations included case history,physical examination,blood biochemistry,ileocolonoscopy and histopathological examination of biopsies.Patients were followed-up after 2 and 6 mo of treatment.The diagnosis of ITB or CD was re-evaluated after 2 mo of antituberculous chemotherapy or immune suppressive therapy respectively,based on improvement in signs,symptoms and laboratory variables.This study was considered to be an exploratory analysis.Clinical,endoscopic and histopathological features recorded at the time of inclusion were subject to univariate analyses.Disease variables with sufficient number of recordings and P<0.05 were entered into logistic regression models,adjusted for known confounders.Finally,we calculated the odds ratios with respective confidence intervals for variables associated with either ITB or CD.RESULTS:This study included 38 ITB and 37 CD patients.Overall,ITB patients had the lowest body mass index(19.6 vs 22.7,P=0.01)and more commonly reported weight loss(73%vs 38%,P<0.01),watery diarrhoea(64%vs 33%,P=0.01)and rural domicile(58%vs 35%,P<0.05).Endoscopy typically showed mucosal nodularity(17/31 vs 2/37,P<0.01)and histopathology more frequently showed granulomas(10/30vs 2/35,P<0.01).The CD patients more frequently reported malaise(87%vs 64%,P=0.03),nausea(84%vs 56%,P=0.01),pain in the right lower abdominal quadrant on examination(90%vs 54%,P<0.01)and urban domicile(65%vs 42%,P<0.05).In CD,endoscopy typically showed involvement of multiple intestinal segments(27/37 vs 9/31,P<0.01).Using logistic regression analysis we found weight loss and nodularity of the mucosa were independently associated with ITB,with adjusted odds ratios of 8.6(95%CI:2.1-35.6)and 18.9(95%CI:3.5-102.8)respectively.Right lower abdominal quadrant pain on examination and involvement of≥3 intestinal segments were independently associated with CD with adjusted odds ratios of 10.1(95%CI:2.0-51.3)and 5.9(95%CI:1.7-20.6),respectively.CONCLUSION:Weight loss and mucosal nodularity were associated with ITB.Abdominal pain and excessive intestinal involvement were associated with CD.ITB and CD were equally common.