Natural History of Perianal Fistulising Lesions in Patients With Elderly-onset Crohn's Disease: A Population-based Study

INTRODUCTION

Most studies of elderly-onset Crohn's disease [CD; diagnosed in patients aged 60 or over] have described a mild course. However, data on the natural history of perianal fistulising CD [pfCD] in this population are scarce. In a population-based cohort study, we described the prevalence, natural history, and treatment of pfCD in patients with elderly-onset CD vs patients with paediatric-onset CD.

METHOD

All patients diagnosed with CD at or after the age of 60 between 1988 and 2006, were included [n = 372]. Logistic regression, Cox models, and a nested case-control method were used to identify factors associated with pfCD.

RESULTS

A total of 34 elderly patients [9% of the 372] had pfCD at diagnosis. After a median follow-up of 6 years (interquartile range [IQR]: 3; 10), 59 patients [16%] had pfCD; the same prevalence [16%] was observed in paediatric-onset patients. At last follow-up, anal incontinence was more frequent in elderly patients with pfCD than in elderly patients without pfCD [22% vs 4%, respectively; p < 10-4]. Rectal CD at diagnosis was associated with pfCD: hazard ratio (95% confidence interval [CI] = 2.8 [1.6-5.0]). Although 37% of the patients received immunosuppressants and 17% received anti-tumour necrosis factor agents, 24% [14 out of 59] had a definitive stoma at last follow-up.

CONCLUSION

During the first 6 years of disease, the prevalence of pfCD was similar in elderly and paediatric patients. Rectal involvement was associated with the appearance of pfCD in elderly-onset patients. Around a quarter of patients with elderly-onset CD will have a stoma. Our results suggest that treatment with biologics should be evaluated in these patients.

Clinique de l’expertise

L’expertise est une activité psychiatrique à part entière nécessitant des compétences diverses en plus de la formation de base du psychiatre. Parmi celles-ci figurent celles qui ont trait aux particularités des populations rencontrées. Chacun pense d’abord aux auteurs d’agressions sexuelles bien connus maintenant mais les délinquants ou criminels peuvent réserver des surprises diverses. Dans cette session, il n’est pas envisageable d’aborder toute la spécificité de cette clinique. Nous ciblons 3 situations de survenue plus ou moins rare mais ayant une valeur heuristique quant aux compétences que doit développer l’expert et éclairant l’intérêt de cette clinique. Les meurtres au cours du sommeil doivent être connus notamment pour faire le diagnostic différentiel avec des psychoses brèves lors d’actes sans lendemain. La pédopornographie sur Internet se développe et est de plus en plus souvent rencontrée en expertise. Enfin le cannibalisme pour extraordinaire qu’il soit révèle une catégorie de patients intrigants et fascinants.

Coding of medically unexplained symptoms and somatoform disorders by general practitioners - an exploratory focus group study

BACKGROUND

Medically unexplained symptoms (MUS) and somatoform disorders are common in general practices, but there is evidence that general practitioners (GPs) rarely use these codes. Assuming that correct classification and coding of symptoms and diseases are important for adequate management and treatment, insights into these processes could reveal problematic areas and possible solutions. Our study aims at exploring general practitioners' views on coding and reasons for not coding MUS/somatoform disorders.

METHODS

We invited GPs to participate in six focus groups (N = 42). Patient vignettes and a semi-structured guideline were used by two moderators to facilitate the discussions. Recordings were transcribed verbatim. Two researchers analyzed the data using structuring content analysis with deductive and inductive category building.

RESULTS

Three main categories turned out to be most relevant. For category a) "benefits of coding" GPs described that coding is seen as being done for reimbursement purposes and is not necessarily linked to the content of their reference files for a specific patient. Others reported to code specific diagnoses only if longer consultations to explore psychosomatic symptoms or psychotherapy are intended to be billed. Reasons for b) "restrained coding" were attempting to protect the patient from stigma through certain diagnoses and the preference for tentative diagnoses and functional coding. Some GPs admitted to c) "code inaccurately" attributing this to insufficient knowledge of ICD-10-criteria, time constraints or using "rules of thumb" for coding.

CONCLUSIONS

There seem to be challenges in the process of coding of MUS and somatoform disorders, but GPs appear not to contest the patients' suffering and accept uncertainty (about diagnoses) as an elementary part of their work. From GPs' points of view ICD-10-coding does not appear to be a necessary requirement for treating patients and coding might be avoided to protect the patients from stigma and other negative consequences. Our findings supply a possible explanation for the commonly seen difference between routine and epidemiological data. The recent developments in the DSM-5 and the upcoming ICD-11 will supposedly change acceptance and handling of these diagnoses for GPs and patients. Either way, consequences for GPs' diagnosing and coding behavior are not yet foreseeable.

Dramatic Increase in Incidence of Ulcerative Colitis and Crohn's Disease (1988-2011): A Population-Based Study of French Adolescents

OBJECTIVES

Few data are available to describe the changes in incidence of pediatric-onset inflammatory bowel disease (IBD). The aim of this study was to describe changes in incidence and phenotypic presentation of pediatric-onset IBD in northern France during a 24-year period.

METHODS

Pediatric-onset IBD (<17 years) was issued from a population-based IBD study in France between 1988 and 2011. Age groups and digestive location were defined according to the Paris classification.

RESULTS

1,350 incident cases were recorded (8.3% of all IBD) including 990 Crohn's disease (CD), 326 ulcerative colitis (UC) and 34 IBD unclassified (IBDU). Median age at diagnosis was similar in CD (14.4 years (Q1=11.8-Q3=16.0)) and UC (14.0 years (11.0-16.0)) and did not change over time. There were significantly more males with CD (females/males=0.82) than UC (females/males=1.25) (P=0.0042). Median time between onset of symptoms and IBD diagnosis was consistently 3 months (1-6). Mean incidence was 4.4/10⁵ for IBD overall (3.2 for CD, 1.1 for UC and 0.1 for IBDU). From 1988-1990 to 2009-2011, a dramatic increase in incidences of both CD and UC were observed in adolescents (10-16 years): for CD from 4.2 to 9.5/10⁵ (+126%; P<0.001) and for UC, from 1.6 to 4.1/10⁵ (+156%; P<0.001). No modification in age or location at diagnosis was observed in either CD or UC.

CONCLUSIONS

In this population-based study, CD and UC incidences increased dramatically in adolescents across a 24-year span, suggesting that one or more strong environmental factors may predispose this population to IBD.

Extra-intestinal Manifestations at Diagnosis in Paediatric- and Elderly-onset Ulcerative Colitis are Associated With a More Severe Disease Outcome: A Population-based Study

BACKGROUND AND AIMS

Data on extra-intestinal manifestations [EIM] and their impact on the disease course of ulcerative colitis [UC] in population-based cohorts are scarce, particularly in paediatric- and elderly-onset UC patients. The aims of this population-based study were to assess: 1] the occurrence of EIM in paediatric- and elderly-onset UC; 2] the factors associated with EIM; and 3] their impact on long-term disease outcome.

METHODS

Paediatric-onset [< 17 years at diagnosis] and elderly-onset UC patients [> 60 years at diagnosis] from a French prospective population-based registry [EPIMAD] were included. Data on EIM and other clinical factors at diagnosis and at maximal follow-up were collected.

RESULTS

In all, 158 paediatric- and 470 elderly-onset patients were included [median age at diagnosis 14.5 and 68.8 years, median follow-up 11.2 and 6.2 years, respectively]. EIM occurred in 8.9% of childhood- and 3% of elderly-onset patients at diagnosis and in 16.7% and 2.2% of individuals during follow-up [p < 0.01], respectively. The most frequent EIM was joint involvement [15.8% of paediatric onset and 2.6% of elderly-onset]. Presence of EIM at diagnosis was associated with more severe disease course [need for immunosuppressants or biologic therapy or colectomy] in both paediatric- and elderly-onset UC (hazard ratio [HR] = 2.0, 95% confidence interval [CI]: 1.0-4.2; and HR = 2.8, 0.9-7.9, respectively). Extensive colitis was another independent risk factor in both age groups.

CONCLUSIONS

Elderly-onset UC patients had lower risk of EIM either at diagnosis or during follow-up than paediatric-onset individuals. EIM at diagnosis predicted more severe disease outcome, including need for immunosuppressive or biologic therapy or surgery, in both paediatric- and elderly-onset UC.

Evolution of Glucose Tolerance After Treatment of Acromegaly: A Study in 57 Patients

The aim of our study was to evaluate the evolution of glucose metabolism in 57 patients after treatment of their acromegaly and to determine risk factors for the persistence of abnormal glucose tolerance. Therefore, we performed IGF-I measurements, oral glucose tolerance tests (OGTTs), and HOMA to evaluate insulin sensitivity (HOMA-S) and β-cell function (HOMA-β) at diagnosis and at last visit (median follow-up 7 years). At diagnosis of acromegaly, 14 patients (25%) were diabetic and 15 (26%) had impaired glucose tolerance, whereas at the last visit, 32% were diabetic and 26% remained glucose intolerant. There was a decrease in fasting glucose (median - 7.0 mg/dl) in the 20 patients cured by surgery, whereas it increased in the 28 patients controlled under medical therapy (median + 2.0 mg/dl; p<0.05 vs. cured group) and in the 9 patients with active disease (median + 4.0 mg/dl). Loss of β-cell function was more pronounced in the patients under medical treatment (median - 87.9%) vs. the cured group (median - 30.4%; p<0.05). There was a decrease in HbA1c between diagnosis and last visit in patients under pegvisomant (mean - 19.2 mmol/mol) vs. a small increase in patient treated by somatostatin analogues (+ 3.4 mmol/mol; p<0.05). Independent risk factors for persistent abnormal glucose tolerance were the glucose tolerance status at diagnosis and ongoing treatment with somatostatin analogues. In conclusion, we found that more than 50% of patients still have IGT or diabetes after treatment of acromegaly. Improvement of glucose metabolism is mainly observed in cured patients and in patients treated with pegvisomant.

Les divers statuts juridiques des patients rencontrés par les psychiatres

Le principe est la liberté de chacun sur son corps et donc l’intervention de la Société pour imposer des soins est une dérogation qui suppose des règles strictes et précises.

À partir des années 50 des soins ont été imposés aux alcooliques présumés dangereux puis, avec beaucoup moins de succès, à partir de 1970 à certains toxicomanes.

Les années récentes ont considérablement rénové, amélioré et complexifié la situation des soins pénalement ordonnés.

On retrouve quelques cas rares où le soin est une véritable contrainte ne laissant au sujet aucune liberté d’accepter ou de refuser. La plupart du temps il s’agit d’une injonction ou d’une obligation prononcée par un magistrat ou une juridiction, autorisant le sujet à se soustraire à l’autorité avec le risque de se voir appliquer une sanction plus ou moins sévère.

Ces patients consultent de plus en plus souvent les psychiatres et les psychologues. Leur statut est bien différent selon qu’ils sont astreints à une obligation de soins, à une injonction thérapeutique ou à une injonction de soins dans le cadre d’un suivi socio-judiciaire. La loi a prévu, selon les cas, une procédure plus ou moins complexe et l’intervention d’acteurs divers. Il est particulièrement utile que les praticiens comprennent en quoi la rencontre avec ces patients est différente et quels peuvent être leurs rapports avec le système judiciaire.

Chronic necrotising aspergillosis mimicking ACTH-secreting tumour in a case of Cushing's disease

An 18-year-old man presenting with speech and behaviour disorders was found to suffer from Cushing's syndrome. Ectopic ACTH secretion was initially suspected on the basis of very high cortisoluria and ACTH concentrations, severe hypokalemia, a lung hypermetabolic lesion and a normal pituitary on conventional magnetic resonance imaging (MRI). After lung surgery, this lesion proved to be chronic necrotising aspergillosis (CNA). Diagnostic reevaluation by bilateral inferior petrosal sinus sampling disclosed a right-sided petrosal sinus gradient consistent with Cushing's disease (CD). A new high resolution thin-section MRI demonstrated a 5 mm pituitary adenoma, which could be removed successfully. Thus, a lung mass associated with several clues in favour of ectopic ACTH secretion may hide a diagnosis of CD. Such a mass can be CNA, an opportunistic infection favoured by immunosuppression, which to our knowledge, is the first case reported in CD.

Characteristics of French users of child pornography: description of a cohort subjected to forensic evaluation

Child pornography is a form of sexual exploitation of children. The virtual aspect of this offence appears to be encouraged by the internet. It is important to know the profiles of the people downloading these images. The aim of our study was to identify the characteristics of people who are drawn to child pornography. Our study was based on psychiatric assessments carried out at the request of the law courts. The feeling of loneliness and poor social integration are evoked by a lot of users of child pornography. Generally, they have no criminal record.

[Psychological effects of orthognatic surgery and postoperative dissatisfaction: presentation of a research protocol]

INTRODUCTION

The causes of postoperative dissatisfaction in orthognathic surgery are difficult to grasp. The aims of our study are to analyze the effects of orthognathic surgery on self-esteem, body image, psychological morbidity, and quality of life. We also want to assess the combined effects of these factors on postoperative dissatisfaction, and to study the interest of personality assessment (especially neuroticism) as a predictive factor of dissatisfaction.

METHOD

Three hundred patients candidates for maxillo-mandibular osteotomy will be included in the study. They will answer a questionnaire assessing self-esteem, body image, psychological morbidity, quality of life, and personality. The evaluation will be conducted preoperatively and postoperatively at 3 months and at 1 year. The degree of satisfaction will be measured postoperatively.

EXPECTED RESULTS

The results should help evaluate the psychological effects of orthognathic surgery and identify predictors of postoperative dissatisfaction, and especially the role of neuroticism.

Group C meningococcal vaccine trial: safety, immunogenicity and parents' views of participation

In 1995, the Oxford Vaccine Group evaluated the safety and immunogenicity of a Group C meningococcal conjugate vaccine in 182 infants using the UK vaccination schedule. During and after the study we sought the views of parents about the vaccine and about their participation in the trial. The vaccine was well tolerated and resulted in fewer local reactions than the routine vaccinations, with no increase in systemic reactions. Post-vaccination antibody levels increased progressively after each dose of conjugate vaccine. We concluded that this meningococcal C conjugate vaccine is safe and immunogenic. The research process and the views of parents provide important lessons for researchers undertaking trials on infants.

Activin A and activin receptors in thyroid cancer

Proliferation is controlled by a network of mitogenic and growth inhibitory factors. Transforming growth factor-beta1 (TGF-beta1) and activin A are the most important growth inhibitors of benign follicular epithelial cells of the human thyroid. The effects of these substances on malignant primary thyrocytes are not known. We have examined the growth regulatory effects of activin A and TGF-beta1 in primary cultures derived from four papillary cancers, two follicular thyroid cancers, and three benign thyroid tissues. Malignant cells demonstrated resistance to activin and TGF-beta1 or reversal to a weak but significant mitogenic effect (p < 0.001). We also evaluated the activin receptor transcription pattern. Isoforms alk4-1, 4-2, and 4-3 were found in benign (n = 12) and malignant (n = 22) tissues. Two subtypes of type I and type II activin receptors were demonstrated. Semiquantitative reverse transcription-polymerase chain reaction (RT-PCR) demonstrated a significant threefold downregulation of alk4-1 receptors in papillary (n = 25) and follicular (n = 18) thyroid cancers as compared to normal thyroids (n = 12) (p < 0.001). To our knowledge these are the first data to demonstrate reversal of activin and TGF-beta1 effects in thyroid malignancy and to demonstrate changes of the type Ib activin receptor expression in thyroid malignancy.

Activin A and activin receptors in the human thyroid: a link to the female predominance of goiter?

Activin A belongs to the TGF-beta family of growth factors involved in control of tissue formation by growth inhibition and to a family of hormones involved in human reproduction. Serum levels of dimeric activin A display a sexual dimorphism with significantly higher circulating hormone concentrations in men than in women after menopause. Since goiter is far more frequent in women than in men, we investigated the role of this sex-related growth factor in the human thyroid. Primary cultures were obtained from 3 patients with goiter, and 4 with recurrent goiter. Activin A significantly inhibited the proliferation of human thyroid follicular epithelial cells in vitro in concentrations between 0.5 and 50 ng/ml and was almost as potent as TGFbeta-1. Analysis in native tissues from 12 normal thyroids, 16 goiters, and 5 Graves thyroids demonstrated mRNA expression of the activin subunit betaA, TGFbeta-receptor type I and II, activin receptors type I receptors alk2 and alk4, and activin type II receptors actRII and actRIIb. Isoform analysis of the major functional type I activin receptor alk4 revealed the full-length transcript SKR2-1 and transcripts for the partially truncated proteins SKR2-2 and SKR2-3 in normal thyroids and goiters. Semi-quantitative RT-PCR revealed a significant 2.5-fold decrease of mRNA for alk4-1 type I activin receptors in goiter as compared to normal thyroid (p < 0.05), whereas expression of the type II receptor actRII was unchanged. These data identify a novel growth inhibitory pathway by activin in the human thyroid. Down-regulation of activin receptor type lb in goiter hints towards end-organ changes which could contribute to deficient growth inhibition. These data provide a mechanistic model how the sexually dimorphic hormone activin A may protect males from goitrogenesis.

Treatment of patients with low-grade B-cell lymphoma with the combination of chimeric anti-CD20 monoclonal antibody and CHOP chemotherapy

PURPOSE

To determine the safety and efficacy of the combination of the chimeric anti-CD20 antibody, Rituxan (Rituximab, IDEC-C2B8; IDEC Pharmaceuticals Corporation, San Diego, CA), and cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy.

PATIENTS AND METHODS

Forty patients with low-grade or follicular B-cell non-Hodgkin's lymphoma received six infusions of Rituxan (375 mg/m2 per dose) in combination with six doses of CHOP chemotherapy.

RESULTS

The overall response rate was 95% (38 of 40 patients). Twenty-two patients experienced a complete response (55%), 16 patients had a partial response (40%), and two patients, who received no treatment, were classified as nonresponders. Medians for duration of response and time to progression had not been reached after a median observation time of 29 + months. Twenty-eight of 38 assessable patients (74%) continued in remission during this median follow-up period. The most frequent adverse events attributable to CHOP were alopecia (38 patients), neutropenia (31 patients), and fever (23 patients). The most frequent events attributed to Rituxan were fever and chills, observed primarily with the first infusion. No quantifiable immune response to the chimeric antibody was detected. In a subset of 18 patients, the bcl-2 [t(14;18)] translocation was positive in eight patients; seven of these patients had complete remissions and converted to polymerase chain reaction (PCR) negativity by completion of therapy.

CONCLUSION

This is the first report demonstrating the safety and efficacy of Rituxan anti-CD20 chimeric antibody in combination with standard-dose systemic chemotherapy in the treatment of indolent B-cell lymphoma. The clinical responses suggest an additive therapeutic benefit for the combination with no significant added toxicity. The conversion of bcl-2 from positive to negative by PCR in blood and/or marrow suggests possible clearing of minimal residual disease not previously demonstrated by CHOP chemotherapy alone.

Eradication of Helicobacter pylori: why does it fail?

Currently, the first therapeutic attempt to eradicate Helicobacter pylori fails in one case out of six in intention to treat analysis. The main causes of failure are bad compliance, partly because of side effects that are severe in 1 to 4% of cases, absence of local validation of the treatment scheme, since some differences do exist between regions and countries, primary and secondary resistance of the strain (stable for Imidazole-derivates, but increasing for Macrolides), and, to a lesser extent, smoking and pre-treatment with proton pump inhibitors. Moreover, in routine medicine, inappropriate treatment cocktails are still prescribed, even by gastroenterologists. Obviously, there is a need for careful medical education and information both as far as concerns doctors and patients, for well-designed prescription, based on local experience and the precise previous history of every patient, as well as for continuous monitoring of the bacterial resistance to antibiotics. Culture of the strain is recommended after eradication failure with the classic one-week triple therapy, but if reliable culture and resistance testing are not available, the quadruple therapy as a second-line treatment is, so far, the best choice.

Strategies for Helicobacter pylori eradication in 1995: a review of international and Belgian experience

After a decade of research, Helicobacter pylori eradication is still a problem because of the steady increase of bacterial resistance (imidazole, macrolides), pH-dependent efficiency of antibiotics, poor compliance of patients and frequent side effects of the therapies. After the failure of various monotherapies and the unefficiency of Amoxicillin-Imidazole combination for Imidazole-resistant strains, the two weeks ¿Oral Triple Therapy' with a 85% mean eradication rate, was abandoned because of a mean 35% side effects rate. The current goal is to obtain 90% eradication rate and the excellent results of german studies with a 2 weeks regimen combining a Proton Pump Inhibitor (PPI) with Amoxicillin have not been confirmed elsewhere in Europe. PPI plus Clarithromycin (two weeks) gave a mean 72% eradication rate on an ITT basis. The short, low-dose combination PPI-Clarithromycin-Imidazole for one week proposed by Bazzoli is very efficient in a population where Imidazole resistant strains are rare. The recent result of one week with (Omeprazole 20-Clarithromycin 250-Tinidazole 500) BID or (Omeprazole 20-Clarithromycin 500-Amoxi 1000) BID reached a 95% eradication rate but these very promising results are not confirmed in Belgium in an on-going study including 147 patients.

Omeprazole-based antimicrobial therapies: results in 198 Helicobacter pylori-positive patients

AIM

To compare the efficacies of omeprazole-based antimicrobial therapies in Helicobacter pylori-positive patients.

PATIENTS AND METHODS

We report the results of seven therapeutic trials combining omeprazole, clarithromycin, amoxycillin, colloidal bismuth subcitrate and tinidazole in 198 patients (peptic ulcer disease/non-ulcerative dyspepsia, 137/61) to eradicate H. pylori infection. The diagnosis of infection was performed by Sydney system biopsies, compliance was checked after a pill count at the end of the treatment and eradication was assessed at least 4 weeks after the end of the treatment either by the Sydney system for peptic ulcer disease or the urease breath test for non-ulcerative dyspepsia.

RESULTS

When results were analysed on a protocol basis, the only significant difference in eradication (P = 0.006) was found between the total population of patients treated with amoxycillin-based combinations (27 eradications out of 48 patients) and those given a treatment that included clarithromycin (84 eradications out of 108). Forty-two patients (21%) dropped out either because of side effects (10 among patients taking clarithromycin and two taking amoxycillin) or because they were lost to follow-up (27 patients). Out of 64 patients with active ulcers, 43 (67%) were both H. pylori-negative and ulcer-free 4-8 weeks after the end of therapy, 12 out of 64 (19%) were ulcer-free but remained H. pylori-positive and nine out of 64 (14%) were H. pylori-positive and had active ulceration.

Gastric carcinoma: the Helicobacter pylori trail

Gastric carcinoma is the world's overall second most common cancer. Besides obvious environmental factors, recent epidemiological studies and a better knowledge of Helicobacter Pylori biological properties revealed that the microorganism is involved in the first steps of gastric carcinogenesis as proposed by the Correa model (from normal gastric tissue through superficial gastritis, multifocal atrophic gastritis, intestinal metaplasia and dysplasia to carcinoma). Significant correlation between the prevalence of H. pylori infection and incidence of gastric carcinoma (mainly the intestinal type) in various geographical areas has been reported. The high prevalence of HP in pre-neoplastic states and in cases of early gastric cancer indicates the infection would precede the development of gastric cancer. HP-related chronic inflammation of gastric mucosa with increased mucosal cell proliferation, deficit in local ascorbic acid concentration, topical ammonia toxicity are putative mechanisms that overexpose a weakened gastric mucosa to environmental carcinogens.

[Role of psychiatry in the preoperative phase of facial reconstructive surgery]

Nowadays, the place of psychiatrist is currently admitted in facial plastic surgery, but is still discussed in reconstructive surgery. This page will stress the importance of a cooperation between surgeon and psychiatrist, preoperatively in orthognathic surgery. After a brief review of literature, we will try to precise when psychiatrist's advice would help, preoperatively, maxillofacial surgeon. On the other end, we will see that psychiatrist having in charge patients with major facial deformity can head them to undergo a reparatrice surgery. A clinical case will end this paper.

[The new penal code and the psychiatrist]

The new criminal law taking effect from the first of march 1994 contains many changes. Some of them will have important result for the psychiatric practice: it is the case of the new writing of criminal defense for mental insanity, specially in its second part, and also about the new 226.13 & 14 articles on medical confidentiality. The new infraction of endangering someone by deliberate breach of a rule could have serious consequences too. Other changes are of less impact but are worth knowing.

Influence of some bacterial and host factors on colonization and invasiveness of Escherichia coli K1 in neonatal rats

Of 209 healthy infants examined, 44 (21.1%) carried Escherichia coli K1 in their feces. Of these 44 isolates, 36 (81.8%) were attributed to 10 different known clonal groups of E. coli K1 and 4 isolates represented unknown types. The influence of mannose-resistant (MR) adhesins, aerobactin production, and resistance to serum on colonization and invasiveness of E. coli K1 in orally infected inbred LEW baby rats was investigated. Strains expressing MR adhesins had significantly higher colonization and invasion rates than non-MR strains did. Mixed-infection experiments of LEW rats revealed interactions between different types of E. coli K1 strains affecting colonization and invasion rats. P-fimbriated strains appeared to have a selective advantage for colonization. The bacteremic potentials of different E. coli K1 strains could not be associated with their resistance to sera from LEW rats free of members of the family Enterobacteriaceae. No differences in virulence between fecal E. coli K1 isolates and clinical isolates from diseased humans were found. An influence of the major histocompatibility complex on host susceptibility to invasive E. coli K1 was indicated by comparing the parental LEW rat strain with different congenic LEW strains (RT1).

Biomedical research on incapacitated people according to French law

In France, a law concerning biomedical research came into operation on 20 December 1988. This law is called loi Huriet after the senator who chaired the investigation committee. This law provides rules to be applied when research is conducted on incapacitated people. Different rules apply depending on whether the person concerned is an adult or not and whether he or she will benefit directly from the research. This law, and the law of 3 January 1968 concerning adult incapacitated persons, are discussed and their deficiencies are highlighted. Recommendations for improvements are made by the authors.

Streptobacillus moniliformis isolated from otitis media of conventionally kept laboratory rats

Streptobacillus moniliformis (Sm) was isolated from the middle ear of two inbred albino rats (strain CAP/Kuv) suffering from murine respiratory mycoplasmosis and purulent bilateral otitis media. The animals were kept under conventional conditions and used for immunological studies. The biochemical pattern of the isolate was identical with that of four other Sm strains of different origin but differed in its ability to lyse erythrocytes in sheep blood agar. This is the first Sm strain with hemolysis described. Pathogenicity of the strain was demonstrated in C57BL/6Han mice known to be susceptible to streptobacillosis. Three of five mice inoculated orally developed characteristic signs of a septic lymphadenitis. In the homologous system and with Sm strain ATCC 49567 as antigen, all five sera showed positive titers in the indirect immunofluorescence assay. Possible improvements in the diagnosis and the role of this "forgotten pathogen" in laboratory animal medicine are discussed.

A randomized, multi-observer, comparative evaluation of conventional fiberendoscopy and videoendoscopy in the upper GI tract

In a comparative, histologically controlled study, no significant difference was found in the accuracy of conventional fiberendoscopy and videoendoscopy in the diagnosis of upper gastrointestinal tract lesions. Both techniques permitted accurate description of focal and/or ulcerative lesions, but videoendoscopy did not provide better sensitivity than fiberendoscopy in the diagnosis of superficial, non-ulcerative, inflammatory changes. The same results were obtained on checking the reproducibility of the macroscopic diagnosis by a delayed review of recorded videotapes.

[Endoscopic findings compared with clinical findings in diverticular disease of the colon]

In a retrospective study of 702 consecutive colonoscopies, the authors observed 185 cases of diverticulosis or moderate diverticulitis. They studied the colonic diseases associated with the presence of diverticula (78 cases) and discussed the role of endoscope in the approach of colonic diverticulosis.

Juxtapapillary duodenal diverticula: association with biliary stone disease

In order to explore the relationship between duodenal diverticula and biliary stone disease, we reviewed 2231 endoscopic retrograde cholangio-pancreatography procedures. We found at least one juxtapapillary diverticulum per 239 patients (10.8%). The occurrence of duodenal diverticula increases with age. Patients with duodenal diverticula were older, had more gallbladder stones, more common bile duct stones, had undergone cholecystectomy more frequently, and experienced more frequently common bile duct stone recurrence after cholecystectomy. We thus confirm an association between the presence of diverticula of the second part of the duodenum, and biliary stone pathology, including gallbladder stones, common bile duct stones, and recurrent stones after cholecystectomy. We discuss the aetiopathogeny of this affection.

The reliability of urease tests, histology and culture in the diagnosis of Campylobacter pylori infection

The accuracy of various staining techniques for immersion microscopy, of five media for culture and five urease test modalities for the detection of Campylobacter pylori infection is reported. It was found that 2% urea unbuffered gel preparation is the most accurate urease test (sensitivity: 89%, specificity: 98%) but a minimal amount of 10,000 CFU/ml is necessary to observe positivity and the sensitivity of urease tests drops to 52% in patients under antimicrobial treatment. For histological diagnosis, modified Giemsa staining was shown to be slightly superior to H&E. The most valuable diagnosis technique is culture when the biopsy specimen is transported and processed under appropriate conditions. A 94% sensitivity rate was observed with 'BCC agar', a new medium containing brain heart infusion, activated charcoal and horse serum.