Case report: Crohn's-like mycophenolate-induced colitis, a fallout in steroid-free regimens

BACKGROUND

Diarrhea is considered to be a common side effect after renal transplantation, due to a number of infective or drug-related causes. Over the past decade the etiology has perhaps changed with the evolution of immunosuppression. In an attempt to minimize early acute rejection and potential steroid use, the recent introduction of mycophenolic acid-based therapies has increased the incidence of diarrheal symptoms. Histologic and macroscopic appearance of mycophenolate-induced colitis is not well documented.

CASE REPORT

Three patients with immunosuppression-induced colitis had received deceased-donor renal transplantations and presented with diarrhea and/or abdominal pain. All patients made a full recovery after decreasing the dose or withdrawing mycophenolate mofetil or myfortic with corticosteroid-free regimens.

CONCLUSIONS

Patients with immunosuppression-induced colitis require prompt intervention by dose reduction or withdrawal. Both myocophenolate mofetil and myfortic can induce a Crohn's-like colitis even after a long period of exposure. The symptoms may require 6 months to resolve, suggesting that surgery should be considered only as a last resort after a significant period off therapy.

Factors responsible for delayed enrollment for anti-retroviral treatment

BACKGROUND

Late presentation followed by delayed diagnosis and further delayed initiation of anti-retroviral therapy (ART) increases the risk of opportunistic infections and neoplasms among the HIV infected patients. Furthermore, this leads to not only poor response to therapy but also early death among them.

METHODS

An institution based cross-sectional study was undertaken to identify the factor(s) responsible for delayed registration for initiation of therapy among the HIV infected patients with absolute CD4 count <250 cells/μL based on self reports. ART naïve adult HIV patients (age ≥18 years) with baseline CD4 count of <250 cells/μL were included in this study.

RESULTS

Most patients 95 (95%) were unaware of the available 'Integrated Counseling and Testing Centres'. Although 13 (13%) respondents had multiple reasons for delayed enrollment, majority 47 (47%) of the delays were due to the physician's failure to suspect and refer them for HIV testing at the earliest opportunity. Other causes include health seeking behavior 13 (13%), fear of stigma 5 (5%), depression 3 (3%), and lack of family support 6 (6%).

CONCLUSIONS

Even though delays in pre-ART enrollment have been realized since long, prevention efforts are poor, mostly due to the lack of understanding of the nature of the problem in its social context. Lack of clinical suspicion for HIV infection at the primary and secondary levels of health care still remains the most important reason for the delay. In order to prevent these delays in enrollments, intervention efforts need to be focused on not only the people infected with HIV but the primary health care providers as well, especially the practicing physicians.

Cardiological Society of India practice guidelines for angiography in patients with renal dysfunction

PREAMBLE: The potential risk of contrast-induced acute kidney injury (CI-AKI) has made utilization of coronary angiography in the work-up for the diagnosis of coronary artery disease in CKD quite low.(1) This is in contrast to increasing prevalence and severity of CAD as the serum creatinine rises.(2) In fact most CKD patients will succumb to CAD and not to ESRD.(3) Thus the judicious use of CAG/PCI in this setting is of prime importance but underused. The CSI began to develop guidelines for Indian context as most guidelines are those developed by ACC/AHA or ESC. The aim was to assist the physicians in selecting the best management strategy for an individual patient under his care based on an expert committee who would review the current data and write the guidelines with relevance to the Indian context. The guidelines were developed initially in June 2010 as an initiative of Delhi CSI. Three interventional cardiologist (SB, AS, KKS), one nephrologist (SCT) and two clinical cardiologists (ST, RG) along with Dr. Roxana Mehran (New York) and Dr. Peter McCullough (Missouri), U.S.A.; were involved in a three-way teleconference to discuss/debate the data. This was presented by SB, and over the next two hours each data subset was debated/agreed/deleted and this resulted in the "Guidelines for CAG in Renal Dysfunction Patients". These were then written and re- circulated to all for final comments. Further, these guidelines were updated and additional Task Force Members nominated by Central CSI were involved in the formation of the final CSI Guidelines. Both (Roxana Mehran and Peter McCullough) reviewed these updated Guidelines in October 2012 and after incorporating the views of all the Task Force members-the final format is as it is presented in this final document.

Stress and Recurrent Miscarriage

Stress has long been suspected as a possible cause of unexplained recurrent miscarriage. But while a relationship has been noted, we didn't know exactly how a woman's stress could cause miscarriage. Three “Super-systems”-the endocrine, immune, and nervous systems engage in multiple interactions during the body’s response to stress. Here we briefly discuss the possible mechanisms of stress induced changes on these systems leading to miscarriage. NJOG 2011 Nov-Dec; 6 (2): 2-6 DOI: http://dx.doi.org/10.3126/njog.v6i2.6747

Impact of a behaviour change intervention model for promotion of condoms amongst young adult males in an occupational setting

BACKGROUND

Studies have justified that social and cultural factors influence young people not to use condoms. Sexually active people associate condoms with lack of trust, while others believe carrying them could imply sexual inexperience. The aim of this study was to provide an intervention model based on this social perception and assess the impact of the intervention in improving condom use.

METHODS

2083 personnel in the intervention group were subjected to behaviour change intervention based on perception and use of condoms. Using a cluster design, we randomly assigned 40 departments to department-based intervention (20) or assessment (20) groups. Around 100 persons in the same age group of 18-45 years were again randomly assigned to each group. Chi Square test was used to assess the effectiveness of the intervention.

RESULTS

Over 6% individuals in the control group (Table 2) had non-regular partners and out of them 23.5% had used a condom. Again, in the same group (Fig. 1), 45.36% individuals thought it is acceptable for single men to use condoms with their partners and 8.15% agreed that it is alright for married women to use condoms with their husbands. The perception significantly increased in the intervention group (p < 0.001).

CONCLUSION

This study thus highlights the importance of continued behavioural intervention in filling certain gaps in the social and structural perception to improve condom use for effective HIV prevention in the community.

Imaging assessment of desmoid tumours in familial adenomatous polyposis: is state-of-the-art 1.5 T MRI better than 64-MDCT?

OBJECTIVE

Desmoid tumour is a common extraintestinal manifestation of patients with familial adenomatous polyposis (FAP) who have undergone prophylactic colectomy. We aimed to determine whether MRI provides equivalent or better assessment of desmoid tumours than CT, the current first-line investigation.

METHODS

Following ethics approval and informed consent, FAP patients with known desmoid tumour underwent contrast-enhanced 64-slice multidetector CT (MDCT) and 1.5 T MRI (incorporating T(1) weighted, T(2) weighted, short tau inversion-recovery and T(1) weighted with contrast, axial, sagittal and coronal sequences). The number, site, size, local extent, tumour signal intensity and desmoid-to-aorta enhancement ratio were analysed.

RESULTS

MRI identified 23 desmoid tumours in 9 patients: 9 intra-abdominal desmoid (IAD) tumours, 10 abdominal wall desmoid (AWD) tumours and 4 extra-abdominal desmoid (EAD) tumours. CT identified only 21 desmoids; 1 EAD and 1 AWD were not identified. The two modalities were equivalent in terms of defining local extent of desmoid. Five IAD tumours involved the bowel, six caused ureteric compression and none compromised the proximal superior mesenteric artery. There was no difference in median desmoid size: 56.7 cm(2) (range 2-215 cm(2)) on MDCT and 56.3 cm(2) (3-215 cm(2)) on MRI (p=0.985). The mean MRI enhancement ratio, at 1.12 (standard deviation 0.43), was greater than the CT enhancement ratio, which was 0.48 (0.16) (p<0.0001). High signal intensity on T(2) MRI was associated with increased MRI enhancement ratio (p=0.006).

CONCLUSIONS

MRI is at least equivalent (and may be superior) to MDCT for the detection of desmoid tumours in FAP. Coupled with the advantage of avoiding radiation, it should be considered as the primary imaging modality for young FAP patients.

Efficacy and tolerability of accelerated-dose low-molecular-weight iron dextran (Cosmofer) in patients with chronic kidney disease

INTRODUCTION

The Renal NSF advocates correction of anaemia in chronic kidney disease patients. Oral iron is often insufficient, while intravenous supplementation replenishes and maintains iron stores. There is a need to administer high doses of iron in a single rapid infusion to enable efficient costs, effective utilisation of time for patients and staff and optimal use of resources.

METHODS

We performed a prospective study of consecutive patients referred for iron dextran (Cosmofer) therapy. This was administered over 2 h 40 min compared with the normal regime of 4-6 h. Blood pressure was recorded throughout administration. Adverse drug reactions were recorded over 2 weeks. Serum ferritin, haemoglobin and estimated glomerular filtration rate were measured at baseline and 3 months.

RESULTS

One hundred patients (59 male, mean age 69 years), received a median dose of 1,000 mg Cosmofer in a median time of 2 h 40 min. Mean serum ferritin rose from 178 at baseline to 413 μg/l (p < 0.001). Mean haemoglobin rose by 1.5 g/dl (p < 0.001). There was no decline in estimated glomerular filtration rate after 3 months. No adverse reactions were noted.

CONCLUSION

We demonstrated that accelerated administration of iron dextran is safe and effective with no short-term effects on renal function. This resulted in a time saving of approximately 67 hours.

Accelerated total dose infusion of low molecular weight iron dextran is safe and efficacious in chronic kidney disease patients

BACKGROUND

Low molecular weight iron dextran (LMWID) is licensed for use as a total dose infusion (TDI) over 4-6 h. In order to improve patient convenience and cost-effectiveness of therapy, we investigated the safety and efficacy of adopting accelerated dosing regimens and compared this with a standard rate LMWID infusion.

METHODS

A retrospective study of patients undergoing accelerated and standard rate TDI of LMWID was conducted across three centres. A total of 1904 doses of LMWID were administered at an accelerated rate of 1 g over 1 h 40 min. This was compared with 395 patients who had standard rate infusion of 1 g LMWID over 3-4 h.

RESULTS

There were eight minor adverse events in patients receiving accelerated dose LMWID (8/1904, 0.42%) in comparison to one adverse event in patients receiving a standard regimen (1/395, 0.25%). No serious adverse events occurred. Serum haemoglobin and ferritin significantly improved in both groups.

CONCLUSION

TDI LMWID is a safe and efficacious method of iron replacement. Accelerated infusion regimen is safe and compares well with standard rate infusion regimen. Furthermore, accelerated TDI of LMWID enables greater numbers of patients to be treated and consequently there appear to be advantages for both patient and health resources.

Growth performance and gastrointestinal microbial ecology responses of piglets receiving Saccharomyces cerevisiae fermentation products after an oral challenge with Escherichia coli (K88)

The effects of Saccharomyces cerevisiae fermentation products (YFP) on growth performance and gastrointestinal (GIT) microbial ecology in 90 weanling pigs orally challenged with Escherichia coli K88(+) (ETEC) were investigated. The YFP were an original YFP product (XPC) and a water-suspendable yeast fermentation prototype (WSYFP) from a commercial company. Treatments consisted of a negative control (NC, no in-feed or in-water additive), carbadox (AB, 55 mg of carbadox/kg of feed), XPC (in feed, 0.2%), and WSYFP (in water, 0.5, 1, or 2 g/pig per day), and each was allotted to 5 pens (3 pigs/pen). The diets met the 1998 NRC specifications. Pigs were acclimated to treatments for a 7-d period before an ETEC challenge. On d 8, blood was collected from pigs to determine the baseline packed cell volume (PCV) measurement, and pigs were orally challenged with ETEC. At various time points postchallenge, blood samples were taken, performance measures and fecal consistency scores were recorded, and gut digesta and tissue samples were taken to evaluate GIT morphology, microbial ecology, and metabolites. Preplanned contrasts were used for comparison. Pigs receiving YFP had greater ADFI than NC pigs on d 3 (424 vs. 378 g/d; P = 0.01) and d 7 (506 vs. 458 g/d; P = 0.03) postchallenge. This effect of YFP on ADFI was similar to that of AB on d 3, but pigs receiving AB ate more (576 vs. 506 g/d; P = 0.03) at d 7 than pigs receiving YFP. Pigs exhibited reduced (P < 0.001) PCV upon ETEC challenge; however, pigs receiving additives sustained a greater (P < 0.05) PCV at 72 h compared with the NC group. Compared with the NC pigs, pigs receiving YFP showed a smaller (P < 0.05) number of ileal mucosa adherent ETEC and prevalence of the order Enterobacteriales in the ileal digesta, which corresponded to less (5.09 vs. 6.97 mg/dL; P = 0.03) colonic ammonia on d 7 postchallenge. Most of the indices for ileal digesta bacterial richness and diversity were greater (P < 0.01) for YFP pigs compared with NC pigs. However, results also indicated that the influence of YFP on the piglet intestinal microenvironment might differ when given in feed or water during ETEC challenge. In conclusion, pigs receiving YFP showed a better appetite in the presence of ETEC, which, together with the greater ileal digesta bacteria richness and diversity and decreased ETEC adhering to the mucosa and reduced colonic ammonia, indicates a healthier GIT environment.

Analysis of risk factors for mortality of incident patients commencing dialysis in East Yorkshire, UK

BACKGROUND

The change in the demographics and the presence of multiple risk factors and co-morbidities in UK patients starting dialysis may lead to poor survival on dialysis. Many of these risk factors are present in the pre-dialysis period allowing a potential window of opportunity to intervene with risk modification measures.

AIM

To examine various potential factors that may predict early and overall mortality.

DESIGN AND METHODS

We carried out an observational prospective study of a cohort of incident patients starting dialysis in a UK centre. Univariate analysis of factors and co-morbidities potentially affecting survival on dialysis were analysed to potential predictors. Factors affecting 1 year mortality were analysed using the t-test, the Mann-Whitney U-test or the chi-square test as appropriate. Mortality over the 5-year follow-up period was analysed using the Kaplan-Meier method.

RESULTS

Ninety-four patients [predominantly Caucasian (98%)], of mean age 63 years (15.6) (56% > 65 years) with a slight male preponderance were studied. Vascular disease (39%) and sepsis (33%) accounted for most of the deaths and a significant proportion of mortality was seen in the first year (56%). Patients with early mortality were older (68 vs. 61 years, P = 0.05) with lower haemoglobin (8.4 vs. 9.4 g/dl, P = 0.01) at the start of dialysis, commenced dialysis with a lower eGFR (5.4 vs. 6.5 ml/min/1.73 m(2), P = 0.06) and had more peripheral vascular disease (PVD) (39% mortality in patients with PVD vs. 18.5% in those without PVD, P = 0.04). Diabetes mellitus, high calcium phosphate product, older age and presence of vascular co-morbidities including ischaemic heart disease and peripheral vascular disease were associated with overall mortality over the 5-year follow-up period.

SUMMARY

In this study, elevated calcium phosphate product and diabetes mellitus in addition to the presence of vascular disease were associated with poor survival. Patients with low haemoglobin and lower first pre-dialysis eGFR suffered higher early mortality. These potentially modifiable factors that could be identified in the pre-dialysis stage provide a valuable opportunity for intervention.

Diagnosis and management of deep vein thrombosis

Awareness of deep venous thrombosis has increased considerably in the last decade including recognition of the importance of thromboprophylaxis for acutely ill hospital inpatients as preventative therapy. Combinations of a pre-test probability score plus a D-Dimer analysis can identify those patients where the chances of DVT are very low and radiological investigation can be obviated. The gold standard for diagnosis is still either ascending venography or venous Doppler ultrasound. Low molecular weight heparin has taken over from unfractionated calcium heparin as the initial treatment of choice. There are many challenges in management, especially deciding the optimum duration of anticoagulant treatment in order to balance the risks of drug induced bleeding against recurrent venous thromboembolic events.

Tunable Nanostructures and Crystal Structures in Titanium Oxide Films

Controllable nanostructures in spin coated titanium oxide (TiO(2)) films have been achieved by a very simple means, through change of post deposition annealing temperature. Electron beam imaging and reciprocal space analysis revealed as-deposited TiO(2) films to be characterized by a dominant anatase phase which converts to the rutile form at 600 degrees C and reverts to the anatase modification at 1,200 degrees C. The phase changes are also accompanied by changes in the film microstructure: from regular nanoparticles (as-deposited) to nanowires (600 degrees C) and finally to dendrite like shapes at 1,200 degrees C. Photoluminescence studies, Raman spectral results, and X-ray diffraction data also furnish evidence in support of the observed solid state phase transformations in TiO(2).

Balloon sphincteroplasty for removing difficult bile duct stones

BACKGROUND AND STUDY AIMS

Extraction of common bile duct stones at endoscopic retrograde cholangiopancreatography can be technically challenging when the size of the stone exceeds that of an endoscopic sphincterotomy. The aim of this study was to evaluate the efficacy and safety of papillary balloon dilation after sphincterotomy for extraction of these difficult-to-remove bile duct stones.

PATIENTS AND METHODS

This was a prospective study of all patients with large common bile duct stones that could not be extracted using a stone retrieval balloon and basket after endoscopic sphincterotomy. These patients underwent papillary dilation using a radial expansion balloon after maximum sphincterotomy. Biliary ductal clearance was then reattempted using a stone retrieval balloon and/or basket. The success rate and the complication rate for the papillary balloon dilation technique were assessed.

RESULTS

A total of 60 patients (16 men, 44 women; mean age 58, range 28 - 73) were enrolled in this study. The mean stone size was 16 mm (range 12 - 20 mm). After maximum sphincterotomy and papillary balloon dilation, ductal clearance was achieved in 57/60 patients (95 %); three patients required adjunctive mechanical lithotripsy for stone extraction. Bleeding occurred in five patients (8.3 %) and was managed conservatively in all cases.

CONCLUSIONS

Papillary balloon dilation after endoscopic sphincterotomy is an effective and safe technique for retrieval of difficult common bile duct stones. The procedure is technically safe and obviates the need for mechanical lithotripsy in a majority of patients.

Endotherapy for chronic pancreatitis with intracanalar stones

Endotherapy for pancreatic stone is an emerging specialty. The judicious application of extracorporeal shock-wave lithotripsy (ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) in selected groups of patients has increased the success rates of endotherapy, with excellent long-term results. In this review the authors share their vast experience of treating patients with pancreatic stones. The article will focus on the basic principles of pancreatic endotherapy, the instrumentation required, details of the ESWL technique and its applications, as well as the limitations, success rate, and complications of endotherapy in selected patients.

Prevalence of otitis media in school going children in Eastern Nepal

OBJECTIVES

To find out the prevalence of otitis media in school going children from lower socio-economic strata.

MATERIAL AND METHODS

This study was carried out in a government school, Shree Naragram Secondary School in Morang district, eastern Nepal, and included 1050 children aged between 5-15 years.

RESULTS

Of the 1050 school children, 346 children were found to have various ENT related problems. Hearing assessment revealed a conductive hearing loss on one or both sides in 114 cases (87%). Various middle ear pathologies were detected in these children, out of which chronic suppurative otitis media "Tubotympanic type" was the most common, followed by otitis media with effusion. The prevalence of otitis media in these children was found to be13.2% and those with hearing loss comprised 12.47%. Prevalence of otitis media is found to be much higher in school going children as compared to adults, and is even higher amongst children belonging to the lower socio-economic strata. Conditions complicating otitis media are more common and severe in children as compared to adults.

CONCLUSION

Primary ear care education to teachers, students and guardians can prevent these vulnerable children from developing hearing impairment. School based study could be one of the useful and cost-effective modality aimed at community oriented program.