Rectal Bleeding in the Clinic.

Anal cancer is a rare malignancy with an estimated 8,580 new cases each year in the USA where hematochezia, a common condition, is often the initial presenting sign. We describe a 51-year-old woman who presented with painful hematochezia, with a delayed diagnosis of anal cancer in the setting of missed and misdiagnosed digital rectal exams in an otherwise low-risk patient. This case highlights the importance of maintaining a broad differential diagnosis for hematochezia and the utility of thorough physical exams.

Primary sclerosing cholangitis and inflammatory bowel disease comorbidity: an update of the evidence.

Comorbid primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD) represent a unique disease phenotype with a different risk profile than PSC or IBD alone. While the pathogenetic mechanisms behind both diseases remain unclear, recent studies have targeted several immune-mediated pathways in an attempt to find a potential therapeutic target. Patients with PSC-associated IBD typically exhibit pancolitis with a right-to-left intestinal inflammatory gradient associated with a greater incidence of backwash ileitis and rectal sparing. Although there is an increased incidence of pancolitis in this population, bowel symptoms tend to be less significant than in IBD alone. Likewise, the degree of inflammation and symptoms of PSC-associated IBD are characteristically less clinically significant. Despite the relatively quiescent clinical presentation of PSC-associated IBD, there is an increased risk for colorectal and hepatobiliary malignancy making vigilance for malignancy essential.

Operative versus nonoperative treatments for Legg-Calvé-Perthes disease: a meta-analysis.

BACKGROUND: Legg-Calvé-Perthes disease (LCPD) is an idiopathic avascular necrosis of the femoral head primarily affecting children of ages 4 to 12 years. There is no clear consensus on nonoperative or operative treatment protocols for pediatric patients presenting with LCPD. This study uses meta-analysis and a binary logistic regression model to analyze the radiographic outcomes of these treatment modalities in pediatric patients. METHODS: Clinical studies describing patients undergoing either nonoperative or operative treatment of LCPD published from 1960 through 2010 were searched electronically and manually. Eligible studies consisted of (1) a minimum of 10 patients; (2) listed age at the time of diagnosis or treatment; (3) performed an initial severity assessment using the Herring or Catterall classification; (4) detailed the type of intervention; and (5) reassessment of radiographic outcome after a minimum of 1 year after treatment using the Mose or Stulberg classification. RESULTS: Twenty-three studies, 1232 patients, and 1266 hips met the inclusion criteria. Among patients younger than 6 years, operative and nonoperative treatments are equally as likely to results in a successful radiographic outcome [odds ratio (OR)=1.071; P=0.828; 95% confidence interval (CI), 7.377-32.937]. In patients older than 6 years, operative treatment is nearly twice as likely to result in a successful radiographic outcome (OR=1.754; P<0.0001; 95% CI, 1.299-2.370). For age at treatment less than 6 years, a patient treated with a pelvic rather than femoral procedure was approximately 5 times as likely to have a good radiographic outcome (χ=4.488; P=0.034; unadjusted OR=5.20; 95% CI, 1.021-26.471). Among patients ages 6 or older, pelvic procedures were equally as likely as femoral procedures to yield a successful radiographic outcome (χ=1.845; P=0.174; unadjusted OR=1.329; 95% CI, 0.881-2.004). Sex had no significant influence on radiographic outcome (OR=1.248; P=0.486; 95% CI, 0.670-2.325). CONCLUSIONS: This meta-analysis suggests that operative treatment is more likely to yield a spherical congruent femoral head than nonoperative methods among patients 6 years or older. Among patients younger than 6 years, operative and nonoperative methods have the same likelihood to yield a good outcome. Patients who were 6 years or older were treated operatively, and had the same likelihood of a good radiographic outcome regardless of treatment with femoral or pelvic procedures. Among patients younger than 6 years, pelvic procedures were more likely to result in a good radiographic outcome than femoral procedures. LEVEL OF EVIDENCE: Level IV meta-analysis.

New orthopedic devices and the FDA.

Each year the field of orthopedics is introduced to an influx of new medical devices. Each of these medical devices has faced certain hurdles prior to being approved for marketing by the U.S. Food and Drug Administration (FDA). Among the regulatory pathways available, the 510(k) premarket notification is by far the one most commonly used. The 510(k) premarket notification allows the manufacturer to receive prompt approval of their device by demonstrating that it is "substantially equivalent" to an existing legally marketed device. In most instances, this proof of substantial equivalence allows manufacturers of medical devices to bypass the use of clinical trials, which are a hallmark of the approval process for new drugs. As a result, most medical devices are approved without demonstrating safety or effectiveness. This article reviews the regulatory processes used by the FDA to evaluate new orthopedic devices.

The major glycerophospholipids of the predatory and parasitic bacterium Bdellovibrio bacteriovorus HID5.

Bdellovibrio are small motile bacteria that attack and parasitize larger Gram-negative bacteria and since they might have practical applications, these organisms are attracting the attention of researchers as indicated by the sequencing of the B. bacteriovorus genome. There is an earlier report showing that B. bacteriovorus scavenges fatty acids from the host cell during its parasitic phase otherwise the biochemical nature of its lipids, particularly its complex lipids, remains unknown. We here report on the phospholipid classes of an axenically cultured host-independent strain (HID5). Phospholipids and fatty acids were identified by a variety of chromatographic procedures and high-resolution mass spectrometric techniques. Phosphatidylethanolamine was the major phospholipid and phosphatidylserine, cardiolipin, phosphatidylglycerol, and N-acylphosphatidylethanolamine were also identified. The major fatty acids were 16:0, 16:1, 18:1, and 9,10-Mt C16:0 (cyC17:0). Unlike another predatory bacterium, Bacteriovorus stolpii strain UKi2, sphingolipids were not detected in B. bacteriovorus by the procedures used in this study. This is consistent with the apparent lack of genes coding for sphingolipid biosynthesis enzymes in the B. bacteriovorus genome database. The results are consistent with the separation of Bdellovibrio and Bacteriovorus into separate genera.