Associations Between Eating, Mobility, and Toileting Functional Dependence and COVID-19 Symptoms.

OBJECTIVES: The first goal of this study was to explore associations between functional dependence levels during activities of daily living (eg, functional mobility, eating, and toileting) before COVID-19 and presence of COVID-19 symptoms (eg, fever, dehydration, lethargy, and shortness of breath) during illness. The second goal of this study was to explore associations between presence of specific COVID-19 symptoms and level of functional decline from before to after illness. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: A total of 375 residents at a single skilled nursing facility in New York City. METHODS: Data were extracted from the Minimum Data Set 3.0 and chart reviews. Multiple linear regressions analyzed relationships between baseline functional dependence in eating, functional mobility, and toileting and presence of dehydration, lethargy, shortness of breath, and fever. Ordinal linear regressions analyzed associations between COVID-19 symptom presence and changes in functional dependence from before to after illness. RESULTS: Pre-COVID-19 eating dependence was significantly associated with dehydration during COVID-19. Dehydration during COVID-19 was significantly associated with greater functional declines in functional mobility from before to after illness. Shortness of breath was significantly associated with increased functional declines in eating and functional mobility. CONCLUSIONS AND IMPLICATIONS: Patients with COVID-19 should be monitored for shortness of breath and dehydration, as these symptoms are associated with functional decline. Individuals experiencing functional decline before COVID-19 onset are especially vulnerable to these symptoms. Future research should further explore the relationship between functional status and COVID-19 symptoms.

The effect of trunk and shank position on the hip-to-knee moment ratio in a bilateral squat.

OBJECTIVES: The effect of knee position on joint moments during squats has been studied; however, the effect of trunk angle has been less well investigated. This study evaluated the effect of both trunk and knee sagittal plane position on the distribution of moments between the hip and knee extensors during the bilateral squat. DESIGN: Observational study. SETTING: Biomechanics laboratory. PARTICIPANTS: One hundred individuals performed bilateral squats. MAIN OUTCOME MEASURES: Motion and force data were collected using motion capture and force plates. Trunk and shank angles and hip and knee moments were calculated. A linear regression was used to associate the ratio between the hip and knee moments (hip-to-knee moment ratio) with the sagittal plane trunk and shank angles, while accounting for six squat depths (between 60° and 110° of knee flexion) and side. RESULTS: Trunk angle and shank angle each contributed to the hip-to-knee moment ratio (P < .001) with trunk accounting for a higher proportion of variance than the other variables. The hip-to-knee moment ratio increased with increasing trunk angle and with decreasing shank angle. CONCLUSIONS: This large cohort study supports the use of trunk position to instruct squat technique with the goal of modifying hip and knee moments.

Predictive Ability of Pressure-Corrected Arterial Stiffness Indices: Comparison of Pulse Wave Velocity, Cardio-Ankle Vascular Index (CAVI), and CAVI0.

BACKGROUND: Pulse wave velocity (PWV) is blood pressure (BP) dependent, leading to the development of the BP-corrected metrics cardio-ankle vascular index (CAVI) and CAVI0. We aimed to assess risk prediction by heart-to-ankle PWV (haPWV), CAVI, and CAVI0 in a US population. METHODS: We included 154 subjects (94.8% male; 47.7% African American) with and without heart failure (HF). Left and right haPWV, CAVI, and CAVI0 were measured with the VaSera 1500N device. We prospectively followed participants for a mean of 2.56 years for the composite endpoint death or HF-related hospital admission (DHFA). RESULTS: Left and right haPWV, CAVI, and CAVI0 values did not differ significantly. In unadjusted analyses, haPWV (left standardized hazard ratio [HR] = 1.51, P = 0.007; right HR = 1.66, P = 0.003), CAVI (left HR = 1.45, P = 0.012; right HR = 1.58, P = 0.006), and CAVI0 (left HR = 1.39, P = 0.022; right HR = 1.44, P = 0.014) significantly predicted DHFA. Predictive ability showed a decreasing trend from haPWV to CAVI to CAVI0; in line with the increasing amount of BP correction in these metrics. In Cox models, right-sided metrics showed a trend toward stronger predictive ability than left-sided metrics. After adjustment for baseline HF status, the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) risk score, and systolic BP, right haPWV (HR = 1.58, P = 0.025) and CAVI (HR = 1.44, P = 0.044), but no other stiffness metrics, remained predictive. CONCLUSIONS: Although conceptually attractive, BP-corrected arterial stiffness metrics do not offer better prediction of DHFA than conventional arterial stiffness metrics, nor do they predict DHFA independently of systolic BP. Our findings support PWV as the primary arterial stiffness metric for outcome prediction.

Impact of Chronic Obstructive Pulmonary Disease in Heart Failure With Preserved Ejection Fraction.

COPD often coexists with HFpEF, but its impact on cardiovascular structure and function in HFpEF is incompletely understood. We aimed to compare cardiovascular phenotypes in patients with Chronic Obstructive Pulmonary Disease (COPD), Heart Failure with Preserved Ejection Fraction (HFpEF), or both. We studied 159 subjects with COPD alone (n = 48), HFpEF alone (n = 79) and HFpEF + COPD (n = 32). We used MRI and arterial tonometry to assess cardiac structure and function, thoracic aortic stiffness, and measures of body composition. Relative to participants with COPD only, those with HFpEF with or without COPD exhibited a greater prevalence of female sex and obesity, whereas those with HFpEF + COPD were more often African-American. Compared to the other groups, participants with HFpEF and COPD demonstrated a more concentric LV geometry (LV wall-cavity ratio 1.2, 95%CI: 1.1-1.3; p = 0.003), a greater LV mass (67.4, 95%CI: 60.7-74.2; p = 0.03, and LV extracellular volume (49.4, 95%CI: 40.9-57.9; p = 0.002). Patients with comorbid HFpEF + COPD also exhibited greater thoracic aortic stiffness assessed by pulse-wave velocity (11.3, 95% CI: 8.7-14.0 m/s; p = 0.004) and pulsatile load imposed by the ascending aorta as measured by aortic characteristic impedance (139 dsc; 95%CI=111-166; p = 0.005). Participants with HFpEF, with or without COPD, exhibited greater abdominal and pericardial fat, without difference in thoracic skeletal muscle size. In conclusion, individuals with co-morbid HFpEF and COPD have a greater degree of systemic large artery stiffening, LV remodeling, and LV fibrosis than those with either condition alone.

Effect of Sickle Cell Anemia Therapies on the Natural History of Growth and Puberty Patterns.

As pediatric patients with sickle cell anemia (SCA) have impaired growth and puberty patterns, we studied the effect of disease-modifying therapies on growth and puberty patterns for patients with SCA receiving hydroxyurea (HU), transfusions, or no therapy. We performed a retrospective study of children with SCA in whom anthropometric measurements and therapy type were recorded. Penalized smoothing splines were fitted to estimate growth curves and growth velocity, and linear mixed models were used to examine differences across treatment groups. Across group analyses were divided into early childhood (4.0 to 7.9 y) and peripubertal (8.0 to 12.0 y). We analyzed growth data on 157 SCA patients. From 8.0 to 12.0 years, girls on transfusion therapy were significantly taller than girls on HU (range, 5.7 to 7.2 cm; P-value range 0.002 to 0.01). From 10.0 to 12.0 years, boys on transfusion therapy were significantly taller than boys on HU (range, 4.1 to 9.4 cm; P-value range <0.0001 to 0.04). In addition, boys on transfusion therapy had an earlier peak height velocity as compared with boys on either HU or no therapy. In conclusion, children receiving transfusions tended to be taller than children on HU or no therapy. Children on HU did not demonstrate superior growth pattern when compared with children on no therapy in the peripubertal years.

Primary membranous nephropathy: comprehensive review and historical perspective.

Membranous nephropathy (MN) is the most common cause of nephrotic syndrome in non-diabetic Caucasian adults over 40 years of age. It has an estimated incidence of 8-10 cases per 1 million. Fifty per cent of patients diagnosed with primary MN continue to have nephrotic syndrome and 30% of patients may progress to end-stage renal disease over 10 years. Although it was recognised as a distinct clinic-pathological entity in 1940s by immunofluorescence and electron microscopy, the pathogenesis and treatment have become more apparent only in the last decade. Discovery of M-type phospholipase A2 receptor (PLA2R) antibodies and thrombospondin type 1 domain-containing 7A antibodies has given new perspectives in understanding the pathogenesis of the disease process. Anti-PLA2R antibody is the first serologic marker that has promising evidence to be used as a tool to prognosticate the course of the disease. More importantly, therapeutic agents such as rituximab and adrenocorticotropic hormone analogues are the newer therapeutic options that should be considered in the therapy of primary MN.

Red blood cell transfusion therapy for sickle cell patients with frequent painful events.

BACKGROUND: Recurrent pain events or chronic pain are among the most common complications of sickle cell disease. Despite attempts to maximize adherence to and dosing of hydroxyurea, some patients continue to suffer from pain. Our institution developed a program to initiate chronic red blood cell transfusions for one year in patients clinically deemed to have high healthcare utilization from sickle cell pain, despite being prescribed hydroxyurea. PROCEDURE: An institutional review board approved retrospective study to evaluate the health outcomes associated with a one-year red blood cell transfusion protocol in sickle cell patients experiencing recurrent pain events as compared with the health outcomes for these patients in the one year prior to receiving transfusion therapy. We performed a matched-pair analysis using a Wilcoxon signed rank to determine the impact of transfusion therapy on clinic visits, emergency department visits, hospital admissions, hospitalization days, and opioid prescriptions filled. RESULTS: One year of transfusion therapy significantly reduced the number of total emergency department visits for pain (6 vs 2.5 pain visits/year, P = 0.005), mean hospitalizations for pain (3.4 vs 0.9 pain admissions/year), and mean hospital days per year for pain crisis (23.5 vs 4.5, P = 0.0001), as compared with the one year prior to transfusion therapy. We identified no significant difference in opioid prescriptions filled during the year of transfusion therapy. CONCLUSION: Patients with frequent pain episodes may benefit from one year of transfusion therapy.

Outcomes in Mild to Moderate Isolated Thrombocytopenia.

OBJECTIVES: Incidental isolated mild to moderate thrombocytopenia is a frequent laboratory finding prompting a referral to pediatric hematology-oncology. We tested the hypothesis that patients with isolated asymptomatic mild thrombocytopenia would not progress to require an intervention from a pediatric hematologist-oncologist. METHODS: This is a 5-year retrospective review of 113 patients referred to pediatric hematology-oncology for isolated thrombocytopenia. Initial, lowest, and current platelet counts along with clinical course and need for interventions were recorded. Thrombocytopenia was categorized as mild (platelet count: 101-140 × 103/µL), moderate (platelet count: 51-100 × 103/µL), severe (platelet count: 21-50 × 103/µL), and very severe (platelet count: ≤20 × 103/µL). RESULTS: Eight of 48 patients (17%) referred for initial mild isolated thrombocytopenia progressed to moderate thrombocytopenia at 1 visit. At present, 2 of these patients have moderate thrombocytopenia, 17 remain with mild thrombocytopenia, and 29 patients have resolved thrombocytopenia. Nine of 65 patients (14%) referred for moderate thrombocytopenia progressed to severe or very severe thrombocytopenia on 1 occasion. At present, no patients have severe thrombocytopenia, 18 remain with moderate thrombocytopenia, 14 improved to mild thrombocytopenia, and 33 have resolved thrombocytopenia. Only 3 patients required interventions from a hematologist, whereas 10 patients required therapy from other subspecialties. CONCLUSIONS: We only identified 3 patients (3%) with mild to moderate thrombocytopenia who required an intervention from a hematologist to improve platelet counts. Patients with isolated mild thrombocytopenia with a normal bleeding history and physical examination findings frequently have normalized their platelet counts within 1 month.

An activity canyon characterization of the pharmacological topography.

BACKGROUND: Highly chemically similar drugs usually possess similar biological activities, but sometimes, small changes in chemistry can result in a large difference in biological effects. Chemically similar drug pairs that show extreme deviations in activity represent distinctive drug interactions having important implications. These associations between chemical and biological similarity are studied as discontinuities in activity landscapes. Particularly, activity cliffs are quantified by the drop in similar activity of chemically similar drugs. In this paper, we construct a landscape using a large drug-target network and consider the rises in similarity and variation in activity along the chemical space. Detailed analysis of structure and activity gives a rigorous quantification of distinctive pairs and the probability of their occurrence. RESULTS: We analyze pairwise similarity (s) and variation (d) in activity of drugs on proteins. Interactions between drugs are quantified by considering pairwise s and d weights jointly with corresponding chemical similarity (c) weights. Similarity and variation in activity are measured as the number of common and uncommon targets of two drugs respectively. Distinctive interactions occur between drugs having high c and above (below) average d (s). Computation of predicted probability of distinctiveness employs joint probability of c, s and of c, d assuming independence of structure and activity. Predictions conform with the observations at different levels of distinctiveness. Results are validated on the data used and another drug ensemble. In the landscape, while s and d decrease as c increases, d maintains value more than s. c ∈ [0.3, 0.64] is the transitional region where rises in d are significantly greater than drops in s. It is fascinating that distinctive interactions filtered with high d and low s are different in nature. It is crucial that high c interactions are more probable of having above average d than s. Identification of distinctive interactions is better with high d than low s. These interactions belong to diverse classes. d is greatest between drugs and analogs prepared for treatment of same class of ailments but with different therapeutic specifications. In contrast, analogs having low s would treat ailments from distinct classes. CONCLUSIONS: Intermittent spikes in d along the axis of c represent canyons in the activity landscape. This new representation accounts for distinctiveness through relative rises in s and d. It provides a mathematical basis for predicting the probability of occurrence of distinctiveness. It identifies the drug pairs at varying levels of distinctiveness and non-distinctiveness. The predicted probability formula is validated even if data approximately satisfy the conditions of its construction. Also, the postulated independence of structure and activity is of little significance to the overall assessment. The difference in distinctive interactions obtained by s and d highlights the importance of studying both of them, and reveals how the choice of measurement can affect the interpretation. The methods in this paper can be used to interpret whether or not drug interactions are distinctive and the probability of their occurrence. Practitioners and researchers can rely on this identification for quantitative modeling and assessment.

Correlation Between Stereoacuity and Experimentally Induced Graded Monocular and Binocular Astigmatism.

INTRODUCTION: Stereopsis, the highest grade of binocular single vision, is affected by various factors, such as mis-alignment of visual axes, refractive errors especially anisometropia and astigmatism, both of which may result in amblyopia. There are very few studies in literature regarding the relationship between stereoacuity and refractive errors, especially astigmatism. AIM: The present study was conducted to determine the correlation between stereoacuity and experimentally induced graded astigmatism in emmetropes. MATERIALS AND METHODS: A randomized study was conducted on 2000 individuals of either gender, between the ages of 8-35 years, at tertiary care centre attached to a medical college during the period of August 2012 to August 2014, All subjects were emmetropic with normal binocular single vision. Participants were randomly divided into four groups of 500 individuals each. Two groups were subjected to induced myopic astigmatism, either uni-ocularly or binocularly, using + 1.0 D and + 2.0 D cylinders at varying axes i.e., 45(0), 90(0) and 180(0). Similarily, the remaining two groups were subjected to induced hypermetropic astigmatism, using - 1.0 D and - 2.0D cylinders at varying axes i.e. 45(0), 90(0) and 180(0). Near stereoacuity was determined by the Titmus Fly Stereo Test, both before and after induction of astigmatism. Statistical analysis was done using paired t-test and ANOVA. RESULTS: The mean stereoacuity in emmetropes was 28.81±4.97 seconds of arc. There was a decrease in stereoacuity with increase in dioptric power of astigmatism (p<0.001). Oblique astigmatism reduced the stereoacuity maximally, while stereoacuity was least affected at 180(o) axis. Hypermetropic astigmatism caused more deterioration in stereoacuity than myopic astigmatism. A gross reduction in stereoacuity was noted in induced monocular astigmatism as against binocular astigmatism. CONCLUSION: This study suggests that stereoacuity is significantly affected by even minor degrees of monocular or binocular astigmatism.

A Case of Lingual Thyroid Presenting with Severe Hematemesis in Pregnancy.

Lingual thyroid is a rare anomaly with symptoms such as upper airway obstruction, dysphagia, or hypothyroidism. However, bleeding is a very rare manifestation. This report describes a case of lingual thyroid in women with 28 weeks of amenorrhea and hematemesis, and its course of diagnosis and treatment. The pathogenesis of lingual thyroid is unknown. Although ectopic lingual thyroid is usually not managed surgically, excision of ectopic lingual thyroid can be lifesaving when it is causing bleeding or airway obstruction. However, during pregnancy, surgery is the preferred mode of treatment.

Periorbital Dirofilariasis: A Rare Case from Western India.

Dirofilariasis is a zoonotic disease caused commonly by Dirofilaria repens and Dirofilaria immitus. The definitive hosts are domestic dogs and cats. Human beings are accidental dead end hosts, and acquire infestation through mosquito bites. So far, very few cases have been reported from western India. We report a case of a 27-year-old male who presented with preseptal cellulitis right eye and a firm mass in the lower lid. Histopathological examination after surgical excision of the mass revealed a diagnosis of dirofilariasis. Although rare in Western India a diagnosis of dirofilariasis should be considered in cases of preseptal cellulitis associated with a periorbital mass.

Pseudoaneurysm of anomalous cystic artery due to calculous cholecystitis.

Pseudoaneurysm of the cystic artery is a rare cause of haemobilia resulting from either an inflammatory process in the abdomen or abdominal trauma. We report a case of a patient with chronic calculous cholecystitis associated with a pseudoaneurysm arising from an anomalous cystic artery who presented with haemobilia. The patient was managed successfully with multimodality treatment that included angioembolisation of the pseudoaneurysm and stenting of the common bile duct to relieve jaundice followed by elective open cholecystectomy.

Bilateral optic nerve aplasia: a rare isolated central nervous system anomaly.

Optic nerve (ON) aplasia is a rare developmental anomaly comprising of absence of the ON, ganglion cells and the central retinal vessels. It is usually accompanied by a variety of central nervous system (CNS) malformations. We report an extremely rare case of bilateral true ON aplasia occurring as an isolated CNS anomaly. A 10-month-old female child was detected with bilateral absence of fixation, associated with multiple ocular findings of microcornea, anterior embryotoxon, pupillary corectopia, partial aniridia and lens coloboma. The optic disc locations were visible as avascular whitish areas. There were no retinal vessels seen in the disc area or elsewhere. There were bilateral multiple chorioretinal atrophic patches present. B-scan ultrasonography showed bilateral absence of ONs. Magnetic resonance imaging showed thinned out bilateral ONs with a hypoplastic optic chiasma and optic tract. There were no other CNS anomalies. Flash visually evoked potential was unrecordable.

A Clinical Study of Subtype-based Prevalence of Dry Eye.

INTRODUCTION: Dry Eye is a multifactorial disease of the tearfilm and the ocular surface which may be due to reduced tear production or excessive tear evaporation resulting in discomfort, visual disturbance, and tear film instability with a potential damage to the ocular surface. Various population-based studies have been done to find out the prevalence and the magnitude of the problem. Women Health Study reported prevalence of 7.8% after screening 36995 subjects above 49 years by interview. The prevalence reported by Blue Mountain Study was 15.3% .The Beaver Dam Study and Shiphai Eye studies are other studies reporting prevalence of 14.5% and 33.7% respectively. McMonnies questionnaire is a widely used screening instrument for Dry-Eye syndromes with sensitivity reportedly varying between 87% and 98% and specificity between 87% and 97%. Prevalence studies use McMonnie's questionnaire for screening individuals for Dry Eye, whereafter tests like Schirmer's test, Tear Film Break Up Time test, Rose Bengal test, Lissamine Green test and Meibomian Gland Dysfunction test are useful for further evaluation. While these tests help to differentiate the subtypes of Dry Eye such as Lipid Anomaly Dry Eye, Aqueous Tear Deficiency and Mucin Layer Deficiency, however, their sensitivity and specificity has not been widely studied. Additionally, very few studies have reported the prevalence of the various subtypes of Dry Eye. AIM AND OBJECTIVES: To determine the subtype-based prevalence of Dry Eye, to study the specificity and sensitivity of clinical tests for Dry Eye and to correlate McMonnies questionnaire with Dry Eye tests results. MATERIAL AND METHODS: A prospective, cross-sectional, observational study, duly approved by the Institutional Ethics Committee, was conducted from October 2010 to April 2012. A total of 4750 subjects above 18 yrs of age were screened by the McMonnies questionnaire. Respondents having a score greater than 14.5 were subjected to clinical Dry Eye tests. The data obtained was analyzed using chi-square test. p value < 0.005 was considered statistically significant.The specificity and sensitivity of each clinical test was calculated using Schirmer's test as gold standard. RESULTS: The prevalence of Dry Eye was 15.4%, with a female preponderance (p = 0.01) and a significant increase with age above 60 years was noted (p<0.0001). Tear Film Break Up Time was the most reliable test with a good sensitivity (68.85%) and specificity (78.32%). Lipid Anomaly Dry Eye was the most prevalent (14.48%) followed by Aqueous Tear Deficiency (13.36%) and Mucin Layer Deficiency (3.51%). A positive correlation between McMonnies score and severity of Dry Eye was seen. CONCLUSION: This study suggests that Lipid Layer Anomaly is the most prevalent subtype in Dry Eye. Tear Film Break Up Time test is the most likely test to diagnose mild Dry Eye. McMonies Questionnaire can be effectively used for screening of a large population. Tear Film Break Up Time was found to have better sensitivity as well as specificity than other tests used for diagnosing Dry Eye.

Galactomannan testing in bronchoalveolar lavage fluid facilitates the diagnosis of invasive pulmonary aspergillosis in patients with hematologic malignancies and stem cell transplant recipients.

Invasive pulmonary aspergillosis (IPA) is a major cause of mortality in patients with stem cell transplants and hematologic malignancies. Timely diagnosis of IPA improves survival but is difficult to make. We evaluated the effectiveness of bronchoalveolar lavage (BAL) galactomannan (GM) in diagnosing IPA in these populations by retrospectively reviewing records of 67 consecutive patients, in whom 89 BAL GM tests were performed. For patients with IPA, only the first BAL sample linked to the IPA episode was analyzed. Eighty samples were associated with proven, 12 with probable, and 32 with possible invasive fungal infections (IFI), and 37 were associated with no IFI. Among patients with IFIs, 4 had proven, 11 probable, and 32 possible IPA. Using BAL GM ≥ 0.5 (cutoff for serum GM) and ≥ 0.85 (optimal cutoff identified by receiver-operating characteristic curve), the sensitivity in diagnosing proven or probable IPA was 73% (11/15) and 67% (10/15), respectively, and specificity was 89% (33/37) and 95% (35/37). At these cutoffs, positive and negative predictive values were 73% (11/15) and 83% (10/12), and 89% (33/37) and 87% (35/40), respectively. BAL GM was more sensitive than cytology (0%, 0/14), BAL culture (27%, 4/15), transbronchial biopsy (40%, 2/5), or serum GM (67%, 10/15) for diagnosing IPA. BAL GM was ≥ 0.85 and ≥ 0.5 in 86% (6/7) and 100% (7/7) of patients with proven or probable IPA who received a mold-active agent for ≤ 3 days. BAL GM added sensitivity to serum GM and other means of diagnosing IPA, and was not impacted by short courses of mold-active agents.

Clinical experience with a new removable tracheobronchial stent in the management of airway complications after lung transplantation.

BACKGROUND: Airway complications are among the most challenging problems after lung transplantation. This article describes the use of a new tracheobronchial stent that can be placed and removed easily by flexible bronchoscopy. METHODS: A retrospective review was done of 24 consecutive patients requiring tracheobronchial stent placement after lung transplantation. A new self-expanding hybrid nitinol stent was used, and changes in airway diameter and spirometry were assessed. Stent related complications were recorded. RESULTS: Between February 2007 and April 2008, 24 patients underwent stent placement, and 49 stents were placed for 36 anastomoses at risk. Indications included bronchial stenosis in 12, bronchomalacia in 12, bronchial stenosis plus bronchomalacia in 20, and partial bronchial dehiscence in 5. Adjunctive procedures included electrocautery in 1, balloon dilatation in 7, and electrocautery plus balloon dilatation in 4. The average degree of stenosis decreased from 80% to 20%. After stent placement, the average increase was 0.28 liters in forced vital capacity and 0.44 liters in forced expiratory volume in 1 second. Complications included granulation tissue formation in 10 stents, migration in 9, thick mucus formation in 2, and fracture in 3. CONCLUSION: Airway complications in lung transplant patients were effectively palliated. Our complication rate with this new stent is comparable with other airway stents. This stent has the advantage of easy removability during flexible bronchoscopy if complications from the stent outweigh the benefits of palliation.

Ileal polyposis as manifestation of neurofibromatosis syndrome.

A 13-year-old girl presented with features of intestinal obstruction. At surgery, the terminal 25 cm of ileum, which was resected along with the right colon, showed plexiform neurofibromatosis of the serosa and mesentery, hyperplastic submucosal and myenteric nerve plexuses and proliferation of neural tissue in the lamina propria, which manifested as diffuse polyposis of the ileal mucosa. The patient had a single inconspicuous external neurofibroma and a few café-au-lait spots on the back.