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Contains fulltext : 174756.pdf (Publisher’s version ) (Closed access) INTRODUCTION: Worldwide induction and cesarean delivery rates have increased rapidly, with consequences for subsequent pregnancies. The majority of intrapartum cesarean deliveries are performed for failure to progress, typically in nulliparous women at term. Current uterine registration techniques fail to identify inefficient contractions leading to first-stage labor arrest. An alternative technique, uterine electromyography has been shown to identify inefficient contractions leading to first-stage arrest of labor in nulliparous women with spontaneous onset of labor at term. The objective of this study was to determine whether this finding can be reproduced in induction of labor. MATERIAL AND METHODS: Uterine activity was measured in 141 nulliparous women with singleton term pregnancies and a fetus in cephalic position during induced labor. Electrical activity of the myometrium during contractions was characterized by its power density spectrum. RESULTS: No significant differences were found in contraction characteristics between women with induced labor delivering vaginally with or without oxytocin and women with arrested labor with subsequent cesarean delivery. CONCLUSION: Uterine electromyography shows no correlation with progression of labor in induced labor, which is in contrast to spontaneous labor.

International audience; Training based on rhythmic auditory stimulation (RAS) can improve gait in patients with idiopathic Parkinson's disease (IPD). Patients typically walk faster and exhibit greater stride length after RAS. However, this effect is highly variable among patients, with some exhibiting little or no response to the intervention. These individual differences may depend on patients' ability to synchronize their movements to a beat. To test this possibility, 14 IPD patients were submitted to RAS for four weeks, in which they walked to music with an embedded metronome. Before and after the training, patients' synchronization was assessed with auditory paced hand tapping and walking to auditory cues. Patients increased gait speed and stride length in non-cued gait after training. However, individual differences were apparent as some patients showed a positive response to RAS and others, either no response, or a negative response. A positive response to RAS was predicted by the synchronization performance in hand tapping and gait tasks. More severe gait impairment, low synchronization variability, and a prompt response to a stimulation change foster a positive response to RAS training. Thus, sensorimotor timing skills underpinning the synchronization of steps to an auditory cue may allow predicting the success of RAS in IPD.

Objectives. Validation of electrohysterography (EHG) as a method for uterine activity monitoring during labour by comparing with intra-uterine pressure catheter (IUPC) recordings.Design. Prospective observational study.Setting. Labour ward in a tertiary centre in the Netherlands.Population. Thirty-two women in labour.Methods. Simultaneous recording of uterine activity with EHG and IUPC for at least 30 min.Main outcome measures. Number of uterine contractions detected by both EHG and IUPC (sensitivity). Number of contractions detected by EHG only [positive predictive value (PPV)]. Correlation between contraction amplitude and duration measured by EHG and IUPC.Results. EHG detects uterine contractions accurately: sensitivity = 94.5% (95%CI: 87.5–100), PPV = 88.3% (95%CI: 76.2–100). The correlation of contractions' duration and amplitude between both methods is r = 0.31 (95%CI: 0.23–0.39) and r = 0.45 (95%CI: 0.38–0.52), respectively.Conclusions. EHG detects uterine contractions accurately during labour but ...

Although evidence exists linking smoking to precancerous colorectal adenomatous polyps, few studies have examined the association between cigarette smoking and recurrence of colorectal polyps. This association was investigated prospectively with data from the Polyp Prevention Trial. Cigarette smoking data were collected through baseline interviews. The study was completed by 1872 men and women with presence of adenomas at baseline colonoscopy. Multiple logistic regression analysis was used to examine the association between cigarette smoking and polyp recurrence (adenomatous and hyperplastic) up to four years from baseline. Adenoma recurrence was not related to cigarette smoking. Current smokers had increased odds of hyperplastic polyps at follow-up compared to never smokers (OR 2.88, 95% CI 2.06–4.01). Current smoking was associated with subsequent distal (OR 3.44, 95% CI 2.38–4.95) and rectal (OR 3.53, 95% CI 2.15–5.78) hyperplastic polyps, but not subsequent proximal hyperplastic polyps. Cigarette smoking was associated with subsequent multiple and small size (4 mm) hyperplastic polyps. Significant linear trends were observed between development of subsequent hyperplastic polyps and all smoking variables. Although no association with recurrent adenomas was observed, cigarette smoking was significantly associated with hyperplastic polyp development, except for those in the proximal colon. This prospective study confirms that cigarette smoking has a significant effect on the development of hyperplastic colorectal polyps.

Endoscopy has provided a significant improvement in the surgical rejuvenation of the upper face. It offers a minimally invasive alternative that avoids many of the undesirable effects associated with the coronal approach. The standard minimal access forehead endoscopic procedure consists of a subperiosteal undermining through three small triangular prehairline incisions. To successfully elevate the eyebrows, it is essential to release the periosteum at the level of the supraorbital rims and ablate the brow depressor muscles of the glabella. Until the periosteum reattaches itself, elevation is maintained by a temporary suspension suture between staples at the incision sites and 5 cm posterior to the hairline. The transverse closure of the triangular skin incisions achieves some additional elevation. The biplanar approach adds a partial subcutaneous undermining of the forehead to the endoscopic technique and allows plication of the frontalis muscle and excision of excess forehead skin. It is offered to patients with very ptotic eyebrows, deep transverse wrinkles, or a high forehead. The prehairline incision is a disadvantage but is tolerated quite well in older patients. The medical records of 393 consecutive patients who underwent endoscopic forehead lift from 1994 to 2000 were reviewed. Because seven patients had the endoscopic forehead lift repeated, the number of forehead endoscopies totaled 400. The complication rate was quite acceptable and did not markedly increase when a forehead lift was performed in combination with other facial procedures. The endoscopic forehead lift consistently attenuated the transverse forehead wrinkles, reduced the glabellar frown lines, and raised the eyebrows. It provided an appearance that was less tired and angry in addition to opening the area around the eyes. Long-term follow-up has shown that the endoscopic forehead lift produces lasting and predictable results.

The midface is an area where definite and consistent improvement is still hard to achieve. Vertical suspension of the malar fat pad is an effective midface lift that complements facial rejuvenation to obtain an overall appearance of youth and beauty while maintaining the personal features of the patient. To substantiate its effectiveness, the authors evaluated the complications and long-term results of the malar fat pad elevation proper and in conjunction with other facial procedures. A retrospective review of the medical records of 458 consecutive patients who underwent malar fat pad elevation by the senior author (B.C.D.) from January of 1994 to January of 2000 was conducted. Because 14 patients had their malar fat pad re-elevated, the number of midface lifts totaled 472. Of these, 437 had a combined superficial musculoaponeurotic system excision and tightening, 19 had a combined limited superficial musculoaponeurotic system plication/imbrication, and 16 had elevation of the malar fat pad only. Elevating the malar fat pad appears to be a sound, straightforward, and effective means of rendering a youthful midface. It consistently reshapes the malar eminence, softens the nasolabial fold, and rejuvenates the lower eyelid. This technique provides lasting results, with an acceptable complication rate. Facial nerve injury, in particular, was infrequent and temporary. In addition, the prehairline scar happened to be quite inconspicuous, especially in patients older than 55 years. This experience confirms that malar fat pad elevation is a safe and effective method to rejuvenate the central third of the face.

Since the introduction of acetylsalicylic acid in 1899 and the development of non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) in the 1960s, NSAIDs have become the most widely used medications in the world.1 It is estimated that 40 billion aspirin tablets are used every year around the world. More than 30 million people use NSAIDs each day worldwide.2,3 As with any medication, there are adverse as well as beneficial effects. NSAIDs are believed to injure the GI mucosa by inhibition of prostaglandin biosynthesis and through the uncoupling of mitochondrial oxidative phosphorylation. Although the stomach and duodenum have been the main focus in published reports of NSAID-induced GI damage, more recently there has been greater recognition of the adverse effects of NSAIDs on the colon.

Esophageal cancer is a common cause of dysphagia and upper endoscopy is the accepted standard for making the diagnosis; however, the accuracy of endoscopy is not known. The purpose of this study is to determine the sensitivity of upper endoscopy in making the diagnosis of esophageal cancer in clinical practice. All patients with a new diagnosis of esophageal cancer from 1997 to 2001 in the Tumor Registry of Wake Forest University Baptist Medical Center were identified. The medical records were reviewed to identify all patients who had undergone a previous endoscopy within two years that failed to diagnose esophageal cancer. The reason for failure was recorded. One hundred ten new cases of esophageal carcinoma were identified, and ten patients had had a previous false-negative endoscopy within two years for a sensitivity of 90.9% in clinical practice. The reasons for the failure of endoscopy were (1) lesion not seen in seven patients, (2) lesion seen and biopsied with benign histology in two patients, and (3) lesion seen but felt to be benign and not biopsied in one patient. Given the uncertain natural history of esophageal cancer, the data were also analyzed using a one-year window; this resulted in a sensitivity of 94.5%. The sensitivity of upper endoscopy in the diagnosis of esophageal cancer in general clinical practice is 90.9% using a two-year window and 94.5% using a one-year window. Understanding the reasons for the failure of endoscopy may allow us to improve the practice of endoscopy.

BACKGROUND AND STUDY AIMS Many lesions found during push enteroscopy to evaluate obscure gastrointestinal bleeding are within the reach of standard endoscopes. The aim of this study was to determine whether the rate of proximal lesions varies in relation to the type of obscure bleeding that is present. PATIENTS AND METHODS A retrospective review of consecutive push enteroscopies carried out for obscure gastrointestinal bleeding between July 1996 and July 2000 was conducted. The patients were categorized into three groups: those with recurrent obscure/overt gastrointestinal bleeding; those with persistent obscure/overt gastrointestinal bleeding; and those with obscure/occult gastrointestinal bleeding. RESULTS A total of 63 patients (24 men, 39 women; mean age 69.8) were included. Push enteroscopy examinations were conducted for recurrent obscure/overt bleeding in 32 patients; for persistent obscure/overt bleeding in 12 patients; and for obscure/occult bleeding in 19 patients. The overall diagnostic yield of push enteroscopy was 47 % (15 of 32) in the group with recurrent obscure/overt bleeding; 66 % (eight of 12) in the group with persistent obscure/overt bleeding; and 63 % (12 of 19) in the group with obscure/occult bleeding. However, when lesions within the reach of standard esophagogastroduodenoscopy (EGD) were excluded, the yield of push enteroscopy was slightly higher in the group with recurrent obscure/overt bleeding (41 %) than in the groups with persistent obscure/overt bleeding (33 %) and obscure/occult bleeding (26 %). There were fewer lesions within the reach of EGD in the group with recurrent obscure/overt bleeding than in the groups with persistent obscure/overt bleeding (6 % vs. 33 %; P < 0.05) or obscure/occult bleeding (6 % vs. 37 %; P < 0.05). CONCLUSIONS Patients undergoing push enteroscopy for recurrent obscure/overt bleeding were significantly less likely to have lesions within the reach of EGD than patients with persistent obscure/overt bleeding or obscure/occult bleeding. Patients in the latter two groups would be able to undergo a repeat EGD examination before more intense evaluation with push enteroscopy or capsule endoscopy.

Upper eyelid ptosis can present both functional and aesthetic problems. Because proper correction of ptosis can be difficult to achieve, numerous surgical procedures have been developed. Plication of levator aponeurosis can be combined with aesthetic blepharoplasty and facial rejuvenation procedures to successfully address ptosis. The authors assessed the effectiveness of levator aponeurosis plication for correction of acquired upper eyelid ptosis in patients presenting for concomitant cosmetic facial procedures. The medical records of 74 consecutive patients (68 women and six men) who had upper eyelid ptosis correction in conjunction with cosmetic facial procedures from January of 1994 to January of 2000 were reviewed. During this period, 400 endoscopic forehead lifts and 479 face lifts were performed. The correction was performed through an external upper blepharoplasty approach removing an ellipse of skin and orbicularis muscle. Once the orbital septum was opened, a plication of the levator aponeurosis was accomplished by one or more horizontal mattress sutures of 6-0 clear nylon (with the first bite placed at or just medial to the vertical level of the pupil). The average follow-up period was 14 months. Long-term correction of the ptosis was excellent. The complications were minor, with the most common occurrence being asymmetry. Revisions were performed on only four patients. Correction of ptosis can be performed safely and effectively in conjunction with periorbital and facial rejuvenation. The technique described is simple, reliable, and reproducible.

Background & Aims: Virtual colonoscopy using abdominal spiral computed tomography scanning allows total colonic evaluation with minimal invasiveness. Two-dimensional images and selective 3-dimensional images of the colon are used to detect colorectal lesions. This trial used conventional colonoscopy with segmental unblinding to determine the ability of virtual colonoscopy to identify patients with colorectal lesions who need conventional colonoscopy. Methods: We studied 205 patients with virtual colonoscopy using oral iodinated contrast preceding conventional colonoscopy. Colonic lavage was achieved with an oral sodium phosphosoda preparation and colonic distention with a carbon dioxide electronic insufflator. Results: The overall sensitivity and specificity of virtual colonoscopy in identifying patients with colorectal lesions was 61.8% and 70.7%, respectively. Virtual colonoscopy was more accurate in identifying patients with lesions ≥6 mm (sensitivity 84.4% and specificity 83.1%) and those with lesions ≥10 mm (sensitivity 90% and specificity 94.6%). The negative predictive value of virtual colonoscopy was 95% for a 6-mm cutoff size and 98.9% for a 10-mm cutoff. Using a 10-mm cutoff, virtual colonoscopy precludes the need for conventional colonoscopy in 86% of patients with a 1% false-negative rate (68% with a 3.4% false-negative rate when using a 6-mm cutoff). Conclusions: Virtual colonoscopy has a high sensitivity and specificity for detecting patients with significant colorectal lesions. Its high negative predictive value may help reduce the number of negative screening colonoscopies. Further studies are needed to determine what lesion cutoff size is clinically acceptable and the appropriate interval time for repeat virtual colonoscopy when it detects lesions below this cutoff size.

Primary suture suspension of the malar fat pad has been described as a safe and simple component of global facial rejuvenation. This review evaluates the efficacy and indications for re-elevation of the malar fat pad elevation. A retrospective review of the medical records of patients who underwent malar fat pad elevation was performed between 1994 and 2000. Of 472 procedures, 14 involved re-elevation of the malar fat pad. These cases were examined for complications, risks, and results. Secondary midface elevation was performed using a subcutaneous approach to the malar fat pad through a pre-hairline incision and vertical suspension of the malar fat pad to the temporoparietal fascia. The indications for re-elevation of the malar fat pad included nasolabial asymmetry, malar fat pad malposition, and malar fat pad asymmetry. Primary elevation of the malar fat was performed in 472 patients. Fourteen of these patients had suboptimal results that necessitated re-elevation of their malar fat pads. Their average age was 57.5 years. Of the 14 malar fat pad elevations, 12 included SMAS procedures, nine were combined with platysmal plication/ submental lipectomy, six with forehead lift, and three with eyelid procedures. The average interval between original malar fat pad elevation and the re-elevation was 40 months. Average follow-up was 15 months. Complications were seen in five patients, with the most significant being persistent eye irritation. Two patients had some minimal scar hypertrophy, which was self-limiting. Minor preauricular skin slough developed in one patient. Restoration of the youthful position of the deep structures in patients with a previous mid-facelift was successfully achieved by re-elevating the malar fat pad in a vertical direction. Re-elevation of the malar fat pad demonstrated effective and reliable long-term results. It is appropriate in the small number of patients who require revision or improvement of midface rejuvenation using the malar fat pad suspension technique.

Cholecystokinin-stimulated hepatobiliary scintigraphy (CCK-HBS) is a noninvasive method reported to be highly accurate in the diagnosis of sphincter of Oddi dysfunction. Our primary aim was to assess the specificity of CCK-HBS by evaluating its ability to exclude disease in 20 asymptomatic postcholecystectomy individuals. Secondary aims were to assess the interobserver reliability in scoring the CCK-HBS examinations between three blinded observers and to assess reproducibility of CCK-HBS repeated in the same individuals.Twenty asymptomatic postcholecystectomy individuals with normal liver serum chemistries underwent CCK-HBS on two separate occasions. Three nuclear medicine specialists read each CCK-HBS study in a blinded fashion.There was good agreement between the three observers reading the same scans for both the first scan (kappa = 0.554) and the second scan (kappa = 0.507). There was poor agreement between the first and second scans on the same patient, read by the same nuclear medicine specialist (kappa = 0.062-0.385). The overall specificity of the CCK-HBS score was 77.5%; however, the specificity was only 60% when a true negative was defined as two negative CCK-HBS examinations.Quantitative CCK-HBS is of poor specificity in asymptomatic postcholecystectomy individuals. Hence, it is of questionable value in excluding sphincter of Oddi dysfunction in patients suspected to suffer from this disorder.

Esophageal sarcoma is an uncommon tumor, sporadically reported in the literature. Radiation therapy is frequently employed in the treatment of carcinoma of the esophagus, and the increased risk of development of sarcoma arising in irradiated fields is well known. However, to our knowledge, the occurrence of radiation-associated sarcoma of the esophagus after radiation therapy for carcinoma of the esophagus has not been reported. We therefore report the case of a 43-year-old female who developed a gastrointestinal stroma sarcoma 9 years following radiation therapy for esophageal squamous cell carcinoma. The patient underwent resection of her gastrointestinal stromal sarcoma by transhiatal esophagectomy with cervical anastomosis and is doing well 18 months later. The increasing use of radiation therapy for esophageal carcinoma suggests that radiation-associated sarcoma of the esophagus may be seen more frequently in the future.

ContextConventional colonoscopy is the best available method for detection of colorectal cancer; however, it is invasive and not without risk. Computed tomographic colonography (CTC), also known as virtual colonoscopy, has been reported to be reasonably accurate in the diagnosis of colorectal neoplasia in studies performed at expert centers.ObjectiveTo assess the accuracy of CTC in a large number of participants across multiple centers.Design, Setting, and ParticipantsA nonrandomized, evaluator-blinded, noninferiority study design of 615 participants aged 50 years or older who were referred for routine, clinically indicated colonoscopy in 9 major hospital centers between April 17, 2000, and October 3, 2001. The CTC was performed by using multislice scanners immediately before standard colonoscopy; findings at colonoscopy were reported before and after segmental unblinding to the CTC results.Main Outcome MeasuresThe sensitivity and specificity of CTC and conventional colonoscopy in detecting participants with lesions sized at least 6 mm. Secondary outcomes included detection of all lesions, detection of advanced lesions, possible technical confounders, participant preferences, and evidence for increasing accuracy with experience.ResultsA total of 827 lesions were detected in 308 of 600 participants who underwent both procedures; 104 participants had lesions sized at least 6 mm. The sensitivity of CTC for detecting participants with 1 or more lesions sized at least 6 mm was 39.0% (95% confidence interval [CI], 29.6%-48.4%) and for lesions sized at least 10 mm, it was 55.0% (95% CI, 39.9%-70.0%). These results were significantly lower than those for conventional colonoscopy, with sensitivities of 99.0% (95% CI, 97.1%->99.9%) and 100%, respectively. A total of 496 participants were without any lesion sized at least 6 mm. The specificity of CTC and conventional colonoscopy for detecting participants without any lesion sized at least 6 mm was 90.5% (95% CI, 87.9%-93.1%) and 100%, respectively, and without lesions sized at least 10 mm, 96.0% (95% CI, 94.3%-97.6%) and 100%, respectively. Computed tomographic colonography missed 2 of 8 cancers. The accuracy of CTC varied considerably between centers and did not improve as the study progressed. Participants expressed no clear preference for either technique.ConclusionsComputed tomographic colonography by these methods is not yet ready for widespread clinical application. Techniques and training need to be improved.

This paper presents the results of one year of Home Care treatment of 77 acutely ill psychiatric patients. Home Care treatment was successful in 83.1% of 77 patients during the first year. Since only four patients failed during the second six months of treatment, hospitalization was effectively prevented, and not delayed, during the first year of treatment. Finally, a history of previous psychiatric hospitalization is not an accurate predictor of success or failure in the patients receiving Home Care treatment in this study. It appears more likely that the psychosocial supports available to the patient, and the relationship between the patient, his family and the Home Care treatment team, are more important in determining the success or failure of treatment at home.

Objective We sought to study whether uterine electromyography (EMG) can identify inefficient contractions leading to first-stage labor arrest followed by cesarean delivery in term nulliparous women with spontaneous onset of labor. Study Design EMG was recorded during spontaneous labor in 119 nulliparous women with singleton term pregnancies in cephalic position. Electrical activity of the myometrium during contractions was characterized by its power density spectrum (PDS). Results Mean PDS peak frequency in women undergoing cesarean delivery for first-stage labor arrest was significantly higher (0.55 Hz), than in women delivering vaginally without (0.49 Hz) or with (0.51 Hz) augmentation of labor (P = .001 and P = .01, respectively). Augmentation of labor increased the mean PDS frequency when comparing contractions before and after start of augmentation. This increase was only significant in women eventually delivering vaginally. Conclusion Contraction characteristics measured by uterine EMG correlate with progression of labor and are influenced by labor augmentation.

Our objective was to develop a novel approach to generate individual maps of white matter (WM) innate immune cell activation using (18)F-DPA-714 translocator protein PET and to explore the relationship between these maps and individual trajectories of worsening disability in patients with multiple sclerosis (MS). Methods: Patients with MS (n = 37), whose trajectories of worsening disability over the 2 y preceding study entry were calculated, and healthy controls (n = 19) underwent MRI and (18)F-DPA-714 PET. A threshold for significant activation of (18)F-DPA-714 binding was calculated with a voxelwise randomized permutation-based comparison between patients and controls and used to classify each WM voxel in all subjects as characterized by a significant activation of innate immune cells (DPA+) or not. Individual maps of innate immune cell activation in the WM were used to calculate the extent of activation in WM regions of interests and to classify each WM lesion as DPA-active, DPA-inactive, or unclassified. Results: Compared with the WM of healthy controls, patients with MS had a significantly higher percentage of DPA+ voxels in the normal-appearing WM (NAWM) (NAWM in patients, 24.6% ± 1.4%; WM in controls, 14.6% ± 2.0%; P < 0.001). In patients with MS, the percentage of DPA+ voxels increased significantly from the NAWM to the perilesional areas, T2 hyperintense lesions, and T1 hypointense lesions (38.1% ± 2.6%, 45.0% ± 2.6%, 51.8% ± 2.6%, respectively; P < 0.001). Among the 1,379 T2 lesions identified, 512 were defined as DPA-active and 258 as DPA-inactive. A higher number of lesions classified as DPA-active (odds ratio, 1.13; P = 0.009), a higher percentage of DPA+ voxels in the NAWM (odds ratio, 1.16; P = 0.009), and a higher percentage of DPA+ voxels in T1 spin-echo lesions (odds ratio, 1.06; P = 0.036) were significantly associated with a retrospectively more severe clinical trajectory in patients with MS. Conclusion: A more severe trajectory of disability worsening in MS is associated with innate immune cell activation inside and around WM lesions. (18)F-DPA-714 PET may provide a promising biomarker to identify patients at risk of a severe clinical trajectory.

International audience; Background:To obtain reliable clinical data of human immunodeficiency virus type 1 group O (HIV-1/O) infection, and immunovirological responses to combination antiretroviral therapy (cART), in a large series of 101 patients.Methods:Piecewise linear models were used to estimate CD4 count before and after cART initiation. Kaplan-Meier survival curves were used to estimate time to reach clinical stage C before antiretroviral therapy (ART) and to analyze time to achieve a plasma viral load (pVL)