Carditis: a relevant marker of gastroesophageal reflux disease. Data from a prospective central European multicenter study on histological and endoscopic diagnosis of esophagitis (histoGERD trial).

The columnar-lined mucosa at the gastroesophageal junction may contain an inflammatory infiltrate, commonly referred to as carditis (or cardia gastritis). The etiology of carditis is not entirely clear since published data are conflicting. Some authors believe it to be secondary to gastroesophageal reflux disease (GERD) and others to Helicobacter pylori gastritis. This prospective study aims at clarifying the relationship between carditis and the histological, clinical, and endoscopic findings of GERD, in a large cohort of individuals negative for H. pylori infection. Eight hundred and seventy-three individuals (477 females and 396 males, median age 53 years) participated in this study. Biopsy material was systematically sampled from above and below the gastroesophageal junction. Reflux-associated changes of the esophageal squamous epithelium were assessed according to the Esohisto consensus guidelines. Grading of carditis was performed according to the Updated Sydney System, known from the histological evaluation of gastritis. In total, 590 individuals (67.5%) had chronic carditis. Of these, 468 (53.6%) had mild chronic inflammation, with 321 individuals (68.6%) showing no or minimal changes on endoscopic examination (Los Angeles Categories N and M). The presence of chronic carditis was associated with several GERD-related parameters of the esophageal squamous epithelium (P < 0.0001), and data retained statistical significance even when analysis was restricted to individuals with mild chronic carditis and/or endoscopically normal mucosa. Chronic carditis was also associated with the presence of intestinal metaplasia (P < 0.0001). In addition, chronic carditis had a statistically significant association with patients' symptoms of GERD (P = 0.0107). This observation remained valid for mild chronic carditis in all patients (P = 0.0038) and in those with mild chronic carditis and normal endoscopic mucosa (P = 0.0217). In conclusion, chronic carditis appears to be the immediate consequence of GERD, correlating with patients' symptoms and endoscopic diagnosis. These results are valid in individuals with nonerosive reflux disease, which indicates a higher sensitivity of histological diagnosis. Our findings may impact the routine assessment of reflux patients.

[Inflammatory esophageal polyp with bizarre stromal cells: possible diagnostic pitfall]. / Bizarre Stromazellen in einem inflammatorischen Ösophaguspolypen: Ein möglicher diagnostischer Fallstrick.

In the gastrointestinal tract an accurate diagnosis of tumor-like lesions can be challenging. In patients with reflux disease regenerative hyperplasia of esophageal squamous epithelium may show marked pleomorphism and atypia thereby simulating malignancy. Bizarre stromal cells are another diagnostic pitfall. We present the case of a 46-year-old patient with symptoms of reflux disease who was diagnosed with a benign inflammatory polyp at the distal end of the esophagus. Histology revealed bizarre cells within the stroma of the polyp characterized by nuclear hyperchromatism and enlargement. Mitoses were not observed. The atypical cells were positive for vimentin. The Ki67/MIB-1 proliferation rate was low. The morphology and etiology of bizarre stromal cells, including helpful features for differential diagnosis are thoroughly discussed.

Opportunistic cytomegalovirus infection causing colonic perforation in a patient with systemic lupus erythematosus.

We present the case of a 58-year-old woman with a long-standing history of systemic lupus erythematosus (SLE) who developed a cytomegalovirus (CMV) infection with colonic perforation and subsequent purulent peritonitis whilst using combined immunosuppressive therapy. The pathogenesis and the clinical presentation of this unique case is discussed in detail. Opportunistic infection should always be kept in mind in SLE patients presenting with fever. Viral serology should be routinely performed in these patients, especially when immunosuppressive therapy is given, to avoid delay in instituting adequate management and therapy.

[Hereditary gastric cancer]. / Hereditäres Magenkarzinom.

Hereditary diffuse gastric cancer is an autosomal dominant cancer syndrome with approximately 70%-80% penetrance. The cumulative lifetime risk of clinically detected gastric cancer is 63%-83% for women and 40%-67% for men. The average age at diagnosis is 40 years. Approximately 25%-40% of patients carry a germline mutation of the CDH1 gene. This gene encodes the transmembrane protein E-cadherin which plays a central role in cell adhesion and signal transduction. Classified according to Laurén, patients develop multifocal diffuse signet-ring cell carcinoma and, in late stages, linitis plastica. In the foveolar neck region, the site of gastric stem cells, in situ signet-ring cell carcinoma has been identified as a precursor lesion of invasive cancer. Therein, pagetoid spread of tumour cells below the preserved epithelium within the basal membrane represents the characteristic morphology. PAS staining may facilitate detection of tiny lesions.The present article provides detailed information on this cancer syndrome from the point of view of the pathologist as well as the human geneticist, focussing on the multidisciplinary management of affected patients.

Modification in the proposed diagnostic criteria for Internet addiction.

The Internet is a new technology that has impacted the world and provided many benefits to its users. At the same time the Internet has had negative ramifications. Some people are becoming preoccupied with the Internet, are unable to control their use, and are jeopardizing employment and relationships. The concept of "Internet addiction" has been proposed as an explanation for uncontrollable, damaging use of this technology. Symptoms of excessive Internet use are compared to the criteria used to diagnose other addictions. In particular, pathological gambling is compared to problematic Internet use because of overlapping criteria. This article suggests some modifications to the diagnostic criteria that has been commonly proposed for Internet addiction.

Transdeltoid palpation (the rent test) in the diagnosis of rotator cuff tears.

The purpose of this study was to assess the diagnostic accuracy of transdeltoid palpation (the rent test) for the diagnosis of full thickness rotator cuff tear. Clinical and arthroscopic findings were documented prospectively for 109 consecutive patients undergoing shoulder arthroscopy by the senior author. A retrospective analysis was then performed on these data to assess the accuracy of transdeltoid palpation in the diagnosis of full thickness rotator cuff tear. Transdeltoid palpation was found to have a sensitivity of 95.7% and specificity of 96.8% for the diagnosis of full thickness rotator cuff tear. The positive and negative predictive values for transdeltoid palpation were 95.7% and 96.8%, respectively. Overall, the diagnostic accuracy of transdeltoid palpation was 96.3%. We conclude that transdeltoid palpation is highly accurate for the clinical diagnosis of full thickness rotator cuff tear.

Arthroscopic rotator cuff interval capsular closure.

Closure of the rotator cuff interval is an important component of open stabilization techniques in shoulder surgery. This study describes a technique in which the deep layer of the capsule within the rotator cuff interval is closed arthroscopically. The effect of closure of this capsule within the rotator cuff interval on glenohumeral motion also is quantified. Sutures were placed from the superior glenohumeral ligament to the middle glenohumeral ligament and tied intra-articularly in fresh-frozen cadaveric shoulders. Closure of the interval capsule resulted in statistically significant limitation of humeral elevation, external rotation, and extension. Arthroscopic closure of the deep layer of the rotator cuff interval capsule produced a visible superior shifting of the middle and inferior glenohumeral ligaments and imbricated the anterosuperior capsule of the shoulder. In addition, this procedure can be performed in conjunction with arthroscopic capsulolabral reconstruction.

Arthroscopic reconstruction for acromioclavicular joint dislocation.

We describe an arthroscopic reconstruction technique for acromioclavicular joint dislocation. Subsequent to Baum's first repair of the coracoclavicular complex in 1886, over 60 operative procedures have been described in the literature. This procedure is the first described arthroscopic approach used in reconstruction for acromioclavicular dislocation. It provides an anatomically correct and structurally sound reconstruction of the coracoclavicular ligament complex. This arthroscopic technique is also a cosmetically pleasing alternative to previously described open procedures for reconstruction of acromioclavicular joint dislocations. As with most arthroscopic procedures, this technique achieves its goals with minimal morbidity and violation of the surrounding soft tissues.

Comparison of bone-patellar tendon-bone interference screw fixation and hamstring transfemoral screw fixation in anterior cruciate ligament reconstruction.

While bone-patellar tendon-bone (BPTB) interference screw anterior cruciate ligament (ACL) reconstruction is a biomechanically sound construct, alternative techniques have been developed secondary to potential donor site morbidity. This study evaluates a system designed to address this problem that involves a transfemoral screw fixation device and stapling of hamstring tendons. Seven pairs of cadaveric knees underwent ACL reconstruction using either BPTB interference screw technique or semitendinosus gracilis (STG) transfemoral screw fixation and stapling. Tensile testing was performed. There was no significant difference between the two fixation types with regard to stiffness, maximum load to failure, elongation, energy to failure and yield load, displacement, and energy.

Tear of the posterior shoulder stabilizers after posterior dislocation: MR imaging and MR arthrographic findings with arthroscopic correlation.

OBJECTIVE: The purpose of this article is to describe the findings on MR imaging and MR arthrography in posterior capsular tear and teres minor muscle injury after posterior dislocation. We also correlate MR imaging with the arthroscopic findings and present treatment options for these patients. CONCLUSION: MR imaging is helpful in diagnosing abnormalities caused by posterior dislocation injuries and in directing therapy. Teres minor muscle and capsular injuries may occur without the typical reverse Bankart lesion. Isolated teres minor muscle tears seen on MR imaging after posterior dislocation injury may cause pain. However, no consensus exists as to whether the lesions seen on MR images in these patients should be treated surgically or conservatively.

Arthroscopic capsular plication for posterior shoulder instability.

Seventeen patients with recurrent posterior shoulder instability underwent posterior capsular plication with or without suture anchors, between 1990 and 1992. Minimum 2-year follow-up was available for 14 patients (average, 33 months; range, 24 to 45 months). The etiology involved trauma in 9 cases, recurrent microtrauma in 4 cases, and no trauma in 1 case. Posterior capsular laxity was present in all 14 cases and was believed to be the primary pathology, although 12 patients showed some form of labral pathology. The patients were interviewed and assessed in six categories: pain, strength, function, stability, range-of-motion, and satisfaction. Twelve patients had excellent results and 2 had fair results. Nine of 10 patients who participate in recreational or competitive athletics reported full return to their preinjury level of function in their respective sports. There was one recurrence of posterior shoulder instability which was remedied with a second arthroscopic posterior capsular reconstruction. All 14 patients were satisfied with the results of their surgery, and no complications were noted. Capsular plication is a promising technique in the treatment of recurrent posterior shoulder instability.

Pigmented villonodular synovitis of the shoulder after anterior capsulolabral reconstruction.

Pigmented villonodular synovitis (PVNS) is a proliferative disorder of the synovium affecting joints, bursae, or tendon sheaths. PVNS is further classified into diffuse and localized forms and rarely affects the shoulder. We report a case of nodular synovitis of the shoulder after arthroscopic and open anterior capsulolabral reconstruction. The histopathology and treatment of a nodular form of PVNS of the shoulder is discussed.

Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability.

The avulsion of the glenohumeral ligament labral complex at the glenoid (Bankart lesion), as well as ligamentous laxity are well known causes of anterior shoulder instability. A lesser known entity, the humeral avulsion of glenohumeral ligaments (HAGL), was studied to determine its incidence and its role in anterior glenohumeral instability. Sixty-four shoulders with the diagnosis of anterior instability were prospectively evaluated by arthroscopy for intraarticular pathology, including Bankart, capsular laxity, and HAGL lesions. Six shoulders were found to have HAGL lesions (9.3%), 11 shoulders with generalized capsular laxity (17.2%), and 47 shoulders with Bankart lesions (73.5%). In patients with documented anterior instability without a demonstratable "primary" Bankart lesion, a HAGL lesion should be ruled out. This lesion is readily recognized arthroscopically, and an appropriate repair of this lesion can restore anterior stability to the patient. The pathological anatomy of the HAGL lesion and our treatment of this lesion is discussed.

School sexuality education and adolescent risk-taking behavior.

School sexuality education programs have been studied as a means to prevent sexual behavior that puts adolescents at risk for incurring an unwanted pregnancy or a sexually transmitted disease. This review examines and critiques research that measures effects of school sexuality education programs on the sexual risk-taking behavior of adolescents. First, methodological problems common in the literature are discussed. Second, studies measuring effects of school sexuality education programs are examined. Finally, suggestions for future research are made.

PIP: Studies measuring the impact of school-based sex education programs on the prevention of adolescent pregnancy and sexually transmitted diseases have produced inconsistent findings. In part, this may reflect the measurement problems inherent in subsuming under the term "sex education" programs that differ dramatically in terms of their goals, delivery agents, length, structure, and theoretical orientation. A reliance on self-report behavioral data and the infrequent use of unexposed control groups represent additional methodological weaknesses. Only one large-scale study has demonstrated that school sex education can be effective in delaying first intercourse. Although several studies have documented increases in knowledge among sex education course participants, they have failed to record significant increases in contraceptive usage. Most effective appear to be programs that combine a sex education curriculum with free school-based pregnancy prevention clinic services. Methodological refinements in terms of standardization of the definition of sex education, use of objective measures of behavioral change, and case-control studies are essential to facilitate the design of programs that will prevent sexual risk-taking among adolescents.

Collaborative needs assessment for child mental health program development.

A needs assessment for child mental health program development involving a collaboration between a state university clinical psychology training program and a coalition of publicly funded child-serving agencies is described. The benefits of the joint research effort for all partners are highlighted as well as the lessons learned about the processes of such a partnership. Application of the results included curricular modifications to the university's training program, the addition of new programming and the improvement of existing services to address child mental health needs, and interventions to increase community awareness of available services.

Office arthroscopy of the shoulder. A diagnostic alternative.

Office arthroscopy of the shoulder is a technically demanding procedure and is significantly more challenging than office arthroscopy of the knee. With the proper equipment and in the hands of an experienced shoulder arthroscopist, the procedure offers many advantages. Patients unanimously prefer office arthroscopy to MR imaging because of the ability to view their pathology personally in a medium more palatable and understandable than MR imaging. Office arthroscopy appears to be a safe, accurate, and cost-effective alternative to MR imaging for the diagnosis of shoulder pathology in select patients.

Arthroscopic capsulolabral repair using suture anchors.

This article presents a different arthroscopic approach to the diagnosis and treatment of anterior shoulder instability. Surgical technique, the postoperative regimen, and the results and pitfalls of surgery using suture anchors are discussed.

Anterior portals in shoulder arthroscopy.

The anterior portal has been the major operative portal through which hand and motorized instrumentation have been introduced into the glenohumeral joint. This portal has been limited with respect to its access to structures in the anteroinferior aspect of the joint. Anatomical and clinical studies were undertaken to evaluate the safety and effectiveness of the use of an anterior inferior, as well as an anterior superior portal. Seventy-eight unembalmed cadaver specimens and 34 operative cases were used in the studies. Only an "inside out" technique using blunt instrumentation is recommended in creating the anterior inferior portal. The margin of safety with respect to the musculocutaneous nerve is increased with adduction. The use of these two anterior portals greatly enhanced our ability to visualize and work directly on lesions of the glenohumeral ligament labral complex. These anterior portals can be safely created if guidelines are carefully followed by surgeons with considerable experience in shoulder arthroscopy.