A large multicenter cohort on the use of full-thickness resection device for difficult colonic lesions.

BACKGROUND: Introduction of the full-thickness resection device (FTRD) has allowed endoscopic resection of difficult lesions such as those with deep wall origin/infiltration or those located in difficult anatomic locations. The aim of this study is to assess the outcomes of the FTRD among its early users in the USA. METHODS: Patients who underwent endoscopic full-thickness resection (EFTR) for lower gastrointestinal tract lesions using the FTRD at 26 US tertiary care centers between 10/2017 and 12/2018 were included. Primary outcome was R0 resection rate. Secondary outcomes included rate of technical success (en bloc resection), achievement of histologic full-thickness resection (FTR), and adverse events (AE). RESULTS: A total of 95 patients (mean age 65.5 ± 12.6 year, 38.9% F) were included. The most common indication, for use of FTRD, was resection of difficult adenomas (non-lifting, recurrent, residual, or involving appendiceal orifice/diverticular opening) (66.3%), followed by adenocarcinomas (22.1%), and subepithelial tumors (SET) (11.6%). Lesions were located in the proximal colon (61.1%), distal colon (18.9%), or rectum (20%). Mean lesion diameter was 15.5 ± 6.4 mm and 61.1% had a prior resection attempt. The mean total procedure time was 59.7 ± 31.8 min. R0 resection was achieved in 82.7% while technical success was achieved in 84.2%. Histologically FTR was demonstrated in 88.1% of patients. There were five clinical AE (5.3%) with 2 (2.1%) requiring surgical intervention. CONCLUSIONS: Results from this first US multicenter study suggest that EFTR with the FTRD is a technically feasible, safe, and effective technique for resecting difficult colonic lesions.

Acupuncture for gastrointestinal and hepatobiliary disorders.

Acupuncture has been used for various gastrointestinal (GI) conditions. Voluminous data support the effect of acupuncture on the physiology of the GI tract, including acid secretion, motility, neurohormonal changes, and changes in sensory thresholds. Much of the neuroanatomic pathway of these effects has been identified in animal models. A large body of clinical evidence supports the effectiveness of acupuncture for suppressing nausea associated with chemotherapy, postoperative state, and pregnancy. Prospective randomized controlled trials have also shown the efficacy of acupuncture for analgesia for endoscopic procedures, including colonoscopy and upper endoscopy. Acupuncture has also been used for a variety of other conditions including postoperative ileus, achalasia, peptic ulcer disease, functional bowel diseases (including irritable bowel syndrome and nonulcer dyspepsia), diarrhea, constipation, inflammatory bowel disease, expulsion of gallstones and biliary ascariasis, and pain associated with pancreatitis. Although there are few prospective randomized clinical studies, the well-documented physiological basis of acupuncture effects on the GI tract, and the extensive history of successful clinical use of acupuncture, makes this a promising modality that warrants further investigation.

Use of acupuncture by American physicians.

OBJECTIVES: Little is known about the characteristics of American physicians who currently practice acupuncture. We asked: (1) Do the demographics of physicians practicing acupuncture differ from the general physician population? (2) Do these physicians use or endorse other alternative therapies? (3) For which conditions is acupuncture most commonly used? (4) For which conditions is acupuncture perceived to be most efficacious? DESIGN: Mailed survey of physicians who incorporate acupuncture into their practice. PARTICIPANTS: Membership of the American Academy of Medical Acupuncture (AAMA). OUTCOME MEASURES: Demographic information regarding physicians and practice characteristics; specific illnesses treated, and perceived efficacy; use of other complementary modalities; personal reasons for practicing acupuncture. RESULTS: Compared with national data, respondents were more likely to be nonspecialists, in private practice, and age 35 to 54. There was an equal proportion of men and women. Most had been doing acupuncture for < 5 years; most use it on < 25% of their patients. Endorsement or use of other complementary methods (spinal manipulation, herbal medicine, supplements, homeopathy) was common. Acupuncture was more commonly used for pain conditions than general medical problems or addiction management. Reasons for use included: efficacy of the technique, an alternative in cases of inadequacy of standard medical approach, and a multidimensional approach to health care. CONCLUSIONS: Physicians surveyed in this study who incorporate acupuncture into their practice do so mainly to treat pain problems. They are more likely to be in the 35 to 54 age group, nonspecialists, and in private practice when compared with national averages. These physicians are also more likely to use or endorse other complementary modalities.

Biliary interleukin-6 and tumor necrosis factor-alpha in patients undergoing endoscopic retrograde cholangiopancreatography.

Cytokines are low-molecular-weight protein mediators that possess a wide spectrum of inflammatory, metabolic, and immunomodulatory properties. Cytokines have been shown to be produced by monocytes/macrophages, lymphocytes, fibroblasts, endothelial cells, and more recently, hepatocytes and biliary epithelium. The aim of this study was to define biliary levels of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) in various disease states. Fifty-four patients undergoing ERCP comprised the study group. IL-6 and TNF-alpha were measured in aspirated bile using an ELISA technique. Levels of both TNF-alpha and IL-6 were significantly higher in patients with cholangitis (P < 0.00001). Moreover, IL-6 was 100% specific for cholangitis since none of the patients without bacterial cholangitis-including patients with biliary obstruction secondary to cholangiocarcinoma or pancreatic carcinoma-had measurable IL-6 in their bile. Low levels of biliary TNF-alpha were detectable in five patients without cholangitis; the sensitivity and specificity of TNF-alpha for cholangitis were 100% and 82%, respectively. There was a strong statistical correlation between biliary IL-6 and TNF-alpha levels (r = 0.819, P < 0.0001). In contrast, the correlations between biliary cytokines and serum biochemical parameters were weak. These results suggest that IL-6 and TNF-alpha are sensitive markers for cholangitis and may differentiate it from other types of biliary tract disease.

The influence of iris pigmentation on the miotic effect of thymoxamine.

We performed a randomly assigned, double-masked, placebo-controlled study in 78 patients with varied iris pigmentation to evaluate the influence of iris pigmentation on the ability of 0.1% thymoxamine to reverse mydriasis produced by 2.5% phenylephrine. Patients were chosen so that a 1.6:1 ratio of dark to light irides was obtained. Within one-half hour after medication, thymoxamine-treated nonbrown irides constricted significantly compared to their fellow placebo-treated irides (P less than .001). Thymoxamine-treated pupils of nonbrown irides were 1.0 to 3.1 mm smaller than placebo-treated fellow eyes. Thymoxamine-treated light brown irides constricted less (0.6 to 2.0 mm) and more slowly compared to fellow placebo-treated irides. Thymoxamine did not reverse the mydriasis in eyes of patients with dark brown irides. Thymoxamine appears similar to other adrenergic agents that bind to melanin, delaying onset and strength of action. Its efficacy as presently formulated may be limited, in part, by iris color.

Cytomegalovirus esophagitis in patients with AIDS. A clinical, endoscopic, and pathologic correlation.

OBJECTIVE: To examine the clinical presentation, endoscopic features, laboratory diagnosis, and outcome of cytomegalovirus esophagitis in patients with the acquired immunodeficiency syndrome (AIDS). DESIGN: Retrospective review of endoscopy records and esophageal biopsy material from patients with AIDS during the 24-month period from 1986 to 1988. SETTING: Urban medical center, central receiving county hospital. PARTICIPANTS: Sixteen inpatients or outpatients seen by gastroenterology consultants at a single hospital. INTERVENTIONS: Endoscopy with multiple mucosal biopsies and viral culture of all esophageal mucosal lesions. Proven or suspected cyclomegalovirus disease was verified in patients using immunohistochemical antibody staining of mucosal biopsy specimens. MEASUREMENTS AND MAIN RESULTS: Odynophagia was the most prominent esophageal symptom, seen in 14 of 16 patients with cytomegalovirus esophagitis confirmed by immunohistochemical staining. Ulcerations of the esophagus were identified in all but 1 patient and typically appeared as large, solitary, shallow lesions. Routine hematoxylin and eosin staining of esophageal mucosal and submucosal specimens showed intranuclear inclusions in all patients, whereas cytomegalovirus culture was positive in only 8 of 14 patients. Cytomegalovirus esophagitis was associated with a poor long-term prognosis. CONCLUSION: Cytomegalovirus esophagitis in patients with AIDS is a well-defined entity with characteristic clinical symptoms and endoscopic findings, as well as histopathologic abnormalities.

Topical timolol decreases plasma high-density lipoprotein cholesterol level.

beta-Adrenergic antagonists taken orally adversely alter plasma lipid profiles. This study was designed to determine whether 0.5% topical timolol maleate has a similar effect. Forty volunteers who were not using medications known to alter plasma lipid levels were recruited for an unmasked study in which each subject served as his or her own control. Twelve subjects did not complete the study because of ocular and systemic side effects or extraneous factors. Twenty-eight subjects used topical timolol for an average of 76 days, with two 12-hour fasting plasma specimens obtained at the beginning and end of the period. Mean total cholesterol and low-density lipoprotein cholesterol levels did not change significantly with treatment. Triglyceride values increased 12%; high-density lipoprotein cholesterol levels decreased 9%; and the total cholesterol-high-density lipoprotein cholesterol ratio increased 8%. Higher baseline high-density lipoprotein cholesterol levels were associated with larger reductions in high-density lipoprotein cholesterol levels. Changes in high-density lipoprotein cholesterol levels of this magnitude have been estimated to increase the risk of coronary artery disease by 21%.

Prevalence and significance of optic disc hemorrhage in a longitudinal study of glaucoma.

We determined the prevalence of hemorrhage within 1 disc diameter of the optic nerve head by masked examination of stereoscopic color and red-free fundus photographs in a multilayer study of 1123 patients. At the first (baseline) examination, disc hemorrhages were present in none of the normal subjects (0 of 661), 0.44% (6/1377) of "glaucoma suspect" subjects, and 2.44% (3/123) of glaucomatous eyes. Disc hemorrhage prevalence in glaucomatous eyes was significantly higher than in normal or glaucoma suspect eyes. Glaucoma suspect eyes with disc hemorrhage, compared with matched suspect eyes without disc hemorrhage, had a larger mean vertical cup-disc ratio, an increased rate of nerve fiber layer atrophy 1 year following disc hemorrhage, and a higher rate of conversion to initial visual field loss (numerically higher conversion though not statistically significant). While the number of eyes with disc hemorrhages in this study is small, in a patient with glaucoma or ocular hypertension, disc hemorrhage appears to be associated with a greater likelihood of ongoing damage. The low disc hemorrhage prevalence in an unselected population limits its usefulness as a screening tool for glaucoma.

Nanophthalmos in sisters, one with exfoliation syndrome.

In a consanguineous family of two siblings, both with nanophthalmos, one was found to also have bilateral exfoliation syndrome. This combination of conditions has not, to our knowledge, previously been reported and has not had any apparent negative consequences. Her sister has manifested typical complications of nanophthalmos, including angle-closure glaucoma initially and, eventually, severe uveal effusion after cataract surgery.

DIAG: a computer-assisted dermatologic diagnostic system--clinical experience and insight.

Over the past few decades, the computer has been utilized in various ways to assist physicians in formulating their differential diagnoses, usually on an experimental basis. Following a review of the three major technics employed in computer-assisted diagnosis, statistical pattern classification, production rules, and cognitive models, a new system (DIAG) is described. The sole function of DIAG is to assist in the formulation of the differential diagnosis of skin diseases. At the beginning of the fourth year of development, the accuracy of the program in reaching diagnoses has been shown, on many occasions, to be comparable to its expert counterparts. However, it has been demonstrated that the system is not utilized within the dermatology clinic routinely. In response to this, aspects of DIAG have been modified in order to improve its clinical acceptability. Until this acceptance is achieved, these tools will not fulfill their potential to affect patient care.

Computer diagnosis of skin disease: system design and preliminary results.

A system for computer-assisted diagnosis of dermatological disease is described. This is an 'expert system' whose knowledge base has been prepared with the aid of a dermatological specialist. The user enters the key elements of the patient's disease history and physical examination into the computer. The computer then returns a summary of the patient's medical record, and a differential diagnosis. The rules of operation by which a given diagnosis was included or rejected is accessible to the user. The system is currently being evaluated in a large dermatology clinic. Preliminary evaluation of the accuracy of diagnosis by the computer indicates that while it nearly always includes the correct diagnosis in its differential diagnosis (94% of cases), it frequently also includes diseases thought to be inappropriate (34% of diseases listed).

Histological characterization of a lingual mass using thyroglobulin immunoperoxidase staining.

We report a patient with a lingual mass clinically diagnosed as lingual thyroid. Due to marked distortion of the normal thyroidal architecture from prior 131I therapy, pathological examination of the mass was consistent with a mixed salivary gland tumor. Immunoperoxidase staining for thyroglobulin was utilized to correctly characterize the lingual mass as ectopic thyroid.

Oral slough caused by dentifrice detergents and aggravated by drugs with antisialic activity.

A unusual type of oral desquamation appeared as grayish-white gelatinous membranes on the floor of the mouth, lips, vestibules, and gingiva in a 50-year-old woman. The painless desquamation was caused by synthetic dentifrice detergents (foaming agents) and was exacerbated by the patient's use of drugs with antisialic action.