Fully versus partially covered self-expandable metal stents in benign esophageal strictures.

Self-expandable plastic stents are currently recommended for refractory benign esophageal strictures but they show disappointing results in terms of migration and long-term efficacy. We report here our experience in the management of benign esophageal strictures with partially covered (PCSEMS) and fully covered self-expandable metal stents (FCSEMS). We performed a retrospective analysis of self-expandable metal stent (SEMS) placements for benign esophageal strictures from 1998 to 2011 in Rouen University Hospital. Twenty-two patients (15 men, 7 women) attempted 40 esophageal SEMS placements (17 PCSEMS, 23 FCSEMS) during this period. All technical complications were migrations. Migration was noted after 3/17 PCSEMS (17.6%) and 4/23 FCSEMS placement (17.4%, P = ns). Clinical complications occurred after 6/17 PCSEMS and 2/23 FCSEMS placements (35.3% vs. 8.7%, P = 0.053). PCSEMS caused two major complications (fistulae) whereas FCSEMS did not cause any major complication (11.7% vs. 0%). Mean dysphagia score was significantly lower after SEMS placement (1.68 vs. 3.08, P < 0.001) with similar results for PCSEMS and FCSEMS. Stent placement resulted in long-term clinical success for 23.5% of PCSEMS and 34.7% of FCSEMS (P = 0.0505). FCSEMS provide satisfying clinical success rate with an acceptable complication rate and they could constitute a relevant therapeutic option in the management of benign esophageal strictures.

Yield and impact of emergency capsule enteroscopy in severe obscure-overt gastrointestinal bleeding.

BACKGROUND AND STUDY AIMS: Patients with obscure-overt gastrointestinal bleeding (OOGIB) are defined by overt hemorrhage and negative upper and lower endoscopy findings. At present, the place of emergency capsule enteroscopy in patients with severe OOGIB is unknown. The aim of this study was to assess the diagnostic yield and the impact of emergency capsule enteroscopy on further management in patients with severe OOGIB. PATIENTS AND METHODS: Between 2003 and 2010, we retrospectively included all patients with severe OOGIB who underwent emergency capsule enteroscopy in the 24-48 h following negative urgent upper and lower endoscopy. Severe OOGIB was defined by ongoing bleeding with hemodynamic instability and/or the need for significant red blood cell transfusion. RESULTS: Out of 5744 patients hospitalized in our Gastrointestinal Bleeding Unit, 55 (1%) presented with severe OOGIB and underwent emergency capsule enteroscopy. Capsule enteroscopy showed blood in 41 patients (75%) and lesions in 37 patients (67%). Findings included small bowel angiodysplasia in 19 patients (35%), ulcers in 7 (13%), tumors in 5 (9%), small-bowel varices in 2 (3%), cecum angiodysplasia in 4 (7%), fresh blood in small bowel without identified lesion in 12 (22%). Specific diagnostic and therapeutic procedures were undertaken in 78 % of patients. Further management included endoscopy (54%), surgery (22%), and radiology (2%). CONCLUSIONS: Emergency capsule enteroscopy identified bleeding lesions in 67 % of patients with severe OOGIB. Emergency capsule enteroscopy seems to be a promising diagnostic tool with a subsequent impact on clinical management in patients with severe OOGIB.

Intracerebroventricular administration of human umbilical cord blood cells delays disease progression in two murine models of motor neuron degeneration.

The lack of effective drug therapies for motor neuron diseases (MND), and in general for all the neurodegenerative disorders, has increased the interest toward the potential use of stem cells. Among the cell therapy approaches so far tested in MND animal models, systemic injection of human cord blood mononuclear cells (HuCB-MNCs) has proven to reproducibly increase, although modestly, the life span of SOD1G93A mice, a model of familial amyotrophic lateral sclerosis (ALS), even if only few transplanted cells were found in the damaged areas. In attempt to improve the potential efficacy of these cells in the central nervous system, we examined the effect and distribution of Hoechst 33258-labeled HuCB-MNCs after a single bilateral intracerberoventricular injection in two models of motor neuron degeneration, the transgenic SOD1G93A and wobbler mice. HuCB-MNCs significantly ameliorated symptoms progression in both mouse models and prolonged survival in SOD1G93A mice. They were localized in the lateral ventricles, even 4 months after administration. However, HuCB-MNCs were not found in the spinal cord ventral horns. This evidence strengthens the hypothesis that the beneficial role of transplanted cells is not due to cell replacement but is rather associated with the production and release of circulating protective factors that may act both at the central and/or peripheral levels. In particular, we show that HuCB-MNCs release a series of cytokines and chemokines with antiinflammatory properties that could be responsible of the functional improvement of mouse models of motor neuron degenerative disorders.

Lugol chromo-endoscopy versus narrow band imaging for endoscopic screening of esophageal squamous-cell carcinoma in patients with a history of cured esophageal cancer: a feasibility study.

To date, Lugol chromo-endoscopy is the reference technique to detect an esophageal neoplasia in patients with prior esophageal squamous-cell carcinoma (ESCC), but is not easy to perform without general anesthesia, which can limit its use in routine practice. The objective of this study were to compare the accuracy of white light, narrow band imaging (NBI), and Lugol to detect esophageal neoplasia in patients with a history of cured ESCC, in a prospective study. Thirty patients were prospectively included between June 2006 and June 2009. They all had a history of cured ESCC. Esophageal mucosa was examined first using white light, second NBI, and third after Lugol staining. Histology was obtained in all abnormalities detected by white light, NBI, and/or Lugol. Five neoplastic lesions in five different patients were identified at histology, four cancers, and one high-grade dysplasia. NBI and Lugol both detected all esophageal neoplastic lesions, whereas white light detected the four cancers but missed the high-grade dysplasia. In this feasibility study, NBI and Lugol both detected all identified esophageal neoplasia in very high-risk patients of ESCC. This result suggests that NBI could be used instead of Lugol to detect an esophageal neoplasia in patients with high risk of ESCC, but needs to be confirmed in a larger study.

Unraveling the complexity of amyotrophic lateral sclerosis: recent advances from the transgenic mutant SOD1 mice.

Amyotrophic Lateral Sclerosis (ALS), which accounts for the majority of motor neuron disorders, is a progressive and fatal neurodegenerative disease leading to complete paralysis of skeletal muscles and premature death usually from respiratory failure. About 10% of all ALS cases are inherited, with the responsible gene having been identified in approximately 25% of these individuals. Mutations in the copper-zinc superoxide dismutase (SOD1) gene were the first to be recognized nearly twenty years ago, and since then different animal models, in particular transgenic rodents, have been developed. They replicate many of the clinical, neuropathological and molecular features of ALS patients and have contributed significantly to our understanding of the pathogenic mechanisms of this disease. Although results obtained so far with mutant SOD1 mice have not translated into effective therapies in ALS patients, these models still represent the only experimentally accessible system to study multiple aspects of disease pathogenesis and to provide proof-of-principle for the development of new therapeutic strategies. This review will examine the most recent discoveries obtained from these animal models in an attempt to elucidate the complex mechanisms of the disease. In particular it will focus on the contribution of multiple cell types in governing the disease development and progression.

Endoscopic band ligation could decrease recurrent bleeding in Mallory-Weiss syndrome as compared to haemostasis by hemoclips plus epinephrine.

BACKGROUND: Mallory-Weiss syndrome (MWS) with active bleeding at endoscopy may require endoscopic haemostasis the modalities of which are not well-defined. AIM: To compare the efficacy of endoscopic band ligation vs. hemoclip plus epinephrine (adrenaline) in bleeding MWS. METHODS: From 2001 to 2008, 218 consecutive patients with a MWS at endoscopy were hospitalized in our Gastrointestinal Bleeding Unit. In 56 patients (26%), an endoscopic haemostasis was required because of active bleeding. Band ligation was performed in 29 patients (Banding group), while hemoclip application plus epinephrine injection was performed in 27 patients (H&E group). Treatment efficacy and early recurrent bleeding were retrospectively compared between the two groups. RESULTS: Primary endoscopic haemostasis was achieved in all patients. Recurrent bleeding occurred in 0% in Banding group vs. 18% in H&E group (P = 0.02). The use of hemoclips plus epinephrine (OR = 3; 95% CI = 1.15-15.8) and active bleeding at endoscopy (OR = 1.9; 95% CI = 1.04-5.2) were independent predictive factors of early recurrent bleeding. CONCLUSIONS: Haemostasis by hemoclips plus epinephrine was an independent predictive factor of rebleeding. This result suggests that band ligation could be the first choice endoscopic treatment for bleeding MWS, but requires further prospective assessment.

Translocation of an intra-uterine contraceptive device with sigmoid penetration through an endometriosic nodule.

The intra-uterine device (IUD) is the most common existing reversible contraception. Uterine perforation occurs in 0.6 to 3.4 per 1000 insertions. We describe the first report of IUD translocation and subsequent penetration of the sigmoid through an endometriosic nodule. A 44-year-old gravida 2 para 2 woman consulted for rectal bleeding and melena. Rectosigmoidoscopy revealed ischemic colitis secondary to the use of NSAIDs, which explained the bleeding, but also sigmoid perforation from part of an intra-uterine device. This was discovered by chance. Perforation had occurred though an endometriosic nodule.

Safety and outcome of definitive chemoradiotherapy in elderly patients with oesophageal cancer.

Little is known about chemoradiotherapy (CRT) in elderly patients with a locally advanced oesophageal cancer (OC). The aim of our study was to evaluate the tolerance and the outcome of elderly patients older than 70 years treated with CRT for a non-metastatic OC. Chemoradiotherapy was based on radiotherapy combined with a cisplatin-based chemotherapy. Clinical complete response (CCR) to CRT was evaluated on upper digestive endoscopy and computed tomography scan 6-8 weeks after CRT completion. One hundred and nine consecutive patients were included. A CCR was observed in 63 patients (57.8%) and 2-year survival was 35.5%. Adverse events > or =grade 3 were observed in 26 (23.8%) patients. Chemotherapy dose reduction, chemotherapy delays more than 1 week, and treatment discontinuation were observed in 33 (30.3%), 45 (41.3%), and 17 patients (15.6%), respectively. Comorbidity index according to Charlson score was significantly associated with treatment tolerance. In multivariate analysis, a CCR to CRT (P<0.01), a dose of radiotherapy > or =80% (P=0.02), and a Charlson score < or =2 (P=0.046) were identified as independent prognostic factors of overall survival. These results suggest that CRT could be considered as an effective treatment without major toxicity in elderly patients with OC.

[Epidemiology of the resistance to antibiotics at the Hospital Center of Aulnay-sous-Bois]. / Epidémiologie de la résistance aux antibiotiques au Centre Hospitalier d'Aulnay-sous-Bois.

Over the 14 month period (1/6/87-1/8/88) the majority of the bacteremia observed in the intensive unit (C.H. d'Aulnay) was due to Gram-positive bacteria (16/23 cases). The incidence of resistant to methicillin Staphylococcus aureus (SAMR) in blood culture was 10% in 1986 and 14% in 1987. Resistance of S. pneumoniae to penicillin was not detected; 30% of the 72 strains were resistant to erythromycin and 26% to tetracycline. Among Enterobacteriaceae, third generation cephalosporin is uncommon (2.8%) as gentamicin resistance (4.5%). Among the anaerobes, 57% of non Bacteroides fragilis group are resistant to penicillin. Nitroimidazole resistance was not detected.