The value of pre-operative outpatient flexible sigmoidoscopy in patients with deep infiltrating endometriosis

BACKGROUND

Deep infiltrating endometriosis (DE) is a particularly severe disease which affects 10-20% of women with endometriosis. 90% of DE is rectovaginal and when suspected, some clinicians have suggested the routine use of flexible sigmoidoscopy to identify intraluminal disease. We aimed to assess the value of sigmoidoscopy prior to surgery for rectovaginal DE, both in terms of diagnosis and planning management.

OBJECTIVES

We aimed to assess the value of sigmoidoscopy prior to surgery for rectovaginal DE.

MATERIALS AND METHODS

A retrospective case series study was performed from a consecutive cohort of patients with DE referred for outpatient flexible sigmoidoscopy between January 2010 and January 2020. All patients were under the care of a specialist endometriosis multidisciplinary team.

MAIN OUTCOME MEASURES

The primary outcome measure was the incidence of luminal disease.

RESULTS

102 consecutive cases were analysed with no cases confirming intraluminal disease. Non-specific evidence of endometriosis such as tight angulation of the bowel was found in 36.3%. Following sigmoidoscopy 100 patients proceeded to surgery and the risk of bowel resection during surgery was 4%.

CONCLUSIONS

Due to the low incidence of luminal endometriosis, performing sigmoidoscopy routinely is of limited benefit. We recommend the selective use of sigmoidoscopy where serious pathology such as colorectal neoplasia is considered or to determine the location of endometriosis lesions which aids subsequent resectional surgery planning.

WHAT IS NEW?

This large case series details a very low incidence of intraluminal disease and makes recommendations for the specific scenarios where flexible sigmoidoscopy should be used.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Disaster declarations associated with bushfires, floods and storms in New South Wales, Australia between 2004 and 2014

Australia regularly experiences disasters triggered by natural hazards and New South Wales (NSW) the most populous State is no exception. To date, no publically available spatial and temporal analyses of disaster declarations triggered by hazards (specifically, bushfires, floods and storms) in NSW have been undertaken and no studies have explored the relationship between disaster occurrence and socio-economic disadvantage. We source, collate and analyse data about bushfire, flood and storm disaster declarations between 2004 and 2014. Floods resulted in the most frequent type of disaster declaration. The greatest number of disaster declarations occurred in 2012–2013. Whilst no significant Spearman’s correlation exists between bushfire, flood and storm disaster declarations and the strength of the El Niño/Southern Oscillation (ENSO) phase, we observe that bushfire disaster declarations were much more common during El Niño, and flood disaster declarations were five times more common during La Niña phases. We identify a spatial cluster or ‘hot spot’ of disaster declarations in the northeast of the State that is also spatially coincident with 43% of the most socio-economically disadvantaged Local Government Areas in NSW. The results have implications for disaster risk management in the State.

Hypothemycin inhibits the proliferative response and modulates the production of cytokines during T cell activation

Hypothemycin, a resorcylic acid lactone antibiotic, was identified as active in a screen for inhibitors of T cell activation. It was found to inhibit the proliferation of mouse and human T cells stimulated with anti-CD3 mAb + PMA and of human PBMC stimulated with anti-CD3 mAb alone. This inhibition was partially reversed by exogenous IL-2 indicating that it is not due to non-specific toxicity. Hypothemycin potently suppressed the production of IL-2 (IC50: 9 nM) but affected IL-2-induced proliferation to a lesser extent (IC50: 194 nM). Hypothemycin also inhibited IL-6, IL-10, IFN-gamma and TNF-alpha production. By contrast, it markedly enhanced the production of IL-4, IL-5 and IL-13. These effects were seen both at the mRNA and protein secretion levels. Analysis of the effect of hypothemycin on CD69 induction suggested that it disrupts calcineurin-independent rather than calcineurin-dependent signaling. Furthermore, hypothemycin was able to inhibit the phosphorylation of ERK1/2 induced by PMA treatment of T cells. Therefore, hypothemycin represents an inhibitor of T cell activation with a novel mode of action and unique modulatory activity on cytokine production.

The immunosuppressive and toxic effects of FK-506 are mechanistically related: pharmacology of a novel antagonist of FK-506 and rapamycin

FK-506 inhibits Ca(2+)-dependent transcription of lymphokine genes in T cells, and thereby acts as a powerful immunosuppressant. However, its potential therapeutic applications may be seriously limited by several side effects, including nephrotoxicity and neurotoxicity. At present, it is unclear whether these immunosuppressive and toxic effects result from interference with related biochemical processes. FK-506 is known to interact with FK-binding protein-12 (FKBP-12), an abundant cytosolic protein with cis-trans peptidyl-prolyl isomerase activity (PPIase) activity. Because rapamycin (RAP) similarly binds to FKBP-12, although it acts in a manner different from FK-506, by inhibiting T cell responses to lymphokines, such an interaction with FKBP-12 is not sufficient to mediate immunosuppression. Recently, it was found that the complex of FKBP-12 with FK-506, but not with RAP, inhibits the phosphatase activity of calcineurin. Here, we used L-685,818, the C18-hydroxy, C21-ethyl derivative of FK-506, to explore further the role of FKBP-12 in the immunosuppressive and toxic actions of FK-506. Although L-685,818 bound with high affinity to FKBP-12 and inhibited its PPIase activity, it did not suppress T cell activation, and, when complexed with FKBP-12, did not affect calcineurin phosphatase activity. However, L-685,818 was a potent antagonist of the immunosuppressive activity of both FK-506 and RAP. Moreover, L-685,818 did not induce any toxicity in dogs and rats or in a mouse model of acute FK-506 nephrotoxicity, but it blocked the effect of FK-506 in this model. Therefore, FK-506 toxicity involves the disruption of biochemical mechanisms related to those implicated in T cell activation. Like immunosuppression, this toxicity is not due to the inhibition of the PPIase activity of FKBP-12, but may be linked to the inhibition of the phosphatase activity of calcineurin by the drug FKBP-12 complex.

Growth and academic achievement in inner-city kindergarten children. The relationship of height, weight, cognitive ability, and neurodevelopmental level

Measures of height, weight, nonverbal cognitive ability (Ravens progressive matrix), visual-motor-perceptual ability (Beery-Buktenica test of Visual Motor Integration [VMI]), the imitation-of-gestures technique, and academic achievement (Stanford Early Achievement) were obtained for a sample of 82 children from a poor inner-city community. In contrast to prior reports from the United States and about other developed countries, anthropometric measures were related both to academic achievement and to these measures of neurodevelopment. They were not consistently related to measures of nonverbal cognitive ability. Regression analyses revealed that general cognitive ability contributed more variance (39%) to predictions of achievement than all other variables, including weight for age (13%) and VMI (6%). Children with reduced somatic growth were likely to do poorly in school, but the data do not show that undernutrition causes learning failure. Rather, they suggest that environmental problems affecting the development of thought processes and nutrient intake precede both growth and learning failure.

American and British data on a three dimensional assessment of personality in college students

Reported data on American and British college student samples for the new Psychoticism, Extraversion, and Neuroticism (PEN) Inventory. Descriptive statistics for PEN dimensions for five American female samples (total 492 subjects), five American male samples (total 399 subjects), one British female sample (700 subjects) and one British male sample (700 subjects) were summarized. Intercorrelations of PEN dimensions for most of the American samples were reported. The pattern of significant intercorrelations tended to be in accord with previous work on prior related inventories. Similarities and differences among the sample descriptive statistics were discussed.

X-ray analysis and circular dichroism of the acid protease from Endothia parasitica and chymosin

The structure of an acid proteinase from Endothia parasitica has been solved by x-ray diffraction using multiple isomorphous replacement. A 3 A resolution map was interpreted in terms of a bilobal structure with a long 25 A cleft. The secondary structure is mostly distorted beta-sheet. The circular dichroism was measured and model curves for different secondary structures were fitted by least squares indicating a large component of beta-structure. The structure was seen to be homologous with that of the acid proteinase from R. Chinensis and hence with pepsin and chymosin. A rotation function against diffraction data from chymosin crystals confirm confirm this and suggested an approach to the solution of this structure.