Alain Braillon

METRONIDAZOLE IN PREVENTION OF CHOLESTASIS ASSOCIATED WITH TOTAL PARENTERAL NUTRITION

The effect of metronidazole on liver function tests was studied in patients given total parenteral nutrition (TPN) for an acute attack of Crohns disease. In those receiving TPN and metronidazole, serum activities of alkaline phosphatase and gamma-glutamyl-transferase decreased or remained normal after 30 days of TPN. In contrast, serum activities of these enzymes increased significantly after 30 days of TPN alone. These results suggest that intrahepatic cholestasis associated with TPN may be related to intestinal overgrowth of anaerobic bacteria.

Pseudomonas aeruginosa liver abscesses following endoscopic retrograde cholangiography. Report of a case without biliary tract disease.

SummaryWe report a case ofPseudomonas aeruginosa liver abscesses following endoscopic retrograde cholangiopancreatography (ERCP) in a patient without evidence of biliary tract disease and of any known cause of hepatic infection. Computer tomography (CT) scan was the best method of diagnosis, allowing, through guided percutaneous puncture of the abscesses, isolation of the organism, which was sensitive to carbenicillin. One month of antibiotherapy with repeated aspirations of the largest abscesses was successful. This report suggests that ERCP may induce cholangitic sepsis by inoculating pathogens in the biliary tree even in the absence of extrahepatic obstruction.

Nalmefene in alcohol misuse: junk evaluation by the European Medicines Agency

> “If you torture the data long enough, it will confess.” Ronald Coase. Spence claims that nalmefene in alcohol misuse is bad medicine.1 In my opinion it is junk evaluation by the European Medicines Agency. Firstly, the authorisation was granted on subgroup analysis of two randomised controlled studies of six months’ duration.2 This subgroup comprised only a quarter …

Colonic pseudolipomatosis: clinical, endoscopical and pathological features in nine cases

UNLABELLED Colonic pseudolipomatosis is a rare and benign condition. It is not well known by gastroenterologists and its pathogenesis is still unclear. METHODS All cases of colonic pseudolipomatosis seen between February 2002 and June 2004 at the Amiens Universisty Hospital were identified and analyzed. RESULTS During this period, 2099 colonoscopies were performed and 9 cases of colonic pseudolipomatosis were diagnosed (0.4%). Patients were all males aged from 41 to 67 (median age 52 years). They consulted for rectal bleeding (two patients), diarrhea (two patients) or abdominal pain (two patients). In three patients, colonic pseudolipomatosis was a fortuitous discovery during colonoscopy for polyp surveillance. The lesions presented as whitish and yellowish slightly elevated plaques ranging in size from a few millimeters to 4 cm. They extended over a two to 20 cm-long area, located in the right (two patients), transverse (four patients) or left colon (three patients). Microscopic examination showed empty spaces in the lamina propria measuring from 50 to 600 microm. They were negative for anti-CD31, CD34 and PS100 antibodies at immunohistochemistry and negative for Sudan black in three cases. The ultrastructural study showed in two cases round spaces containing small fibrillary protein-like deposits that might be lymph. CONCLUSION Colonic pseudolipomatosis is rare. Its pathogenesis is not well-known but could be due to gas invasion or extravasation of lymph into lamina propria, maybe induced by mucosal lesions related to barotrauma or certain colonoscope cleaning solutions.

Is the American Association for the Study of Liver Diseases recommendation for hepatocellular carcinoma screening a cul-de-sac?

The American Association for the Study of Liver Diseases just confirmed a grade I recommendation for hepatocellular carcinoma (HCC) screening despite growing controversy. Why should HCC be an exception in the long list of other cancers where the feasibility and the efficacy of screening were investigated by randomized trials? Only 12.0% of United States patients are screened, a fact that precludes efficacy, and there are no relevant figures on the benefit-risk ratio. The ethics of belief is a treacherous reef. Screening is not just performing a test, but is a public health issue: a national program is needed to ensure minimal participation, quality controls and evaluation of the results to improve the process. There are also serious concerns regarding undisclosed potential conflicts of interest.

Drug industry is now biggest defrauder of US government

Stephen Whitehead, the new head of the Association of the British Pharmaceutical Industry, thinks that the bad press given to the drug industry is largely undeserved.1 A paragraph heading calls for collaboration. Facts are clear and this call is frightening because in the US laws exist and are implemented. Public Citizen has made the diagnosis: “While …

Medical Devices and the Approval Processes: United States vs France

have an impact on different outcomes or require ongoing engagement. Second, a truly interdisciplinary team, as we have now, may have had an impact, whereas the physician-focused PMC did not. The following limitations temper our results. Findings from 1 institution may not be generalizable, though patients enrolled had common conditions. Although we relied on self-report measures, such reporting is standard and would not account for lack of effect. Prior descriptive and other rigorous studies have demonstrated benefits of PMC. Therefore, the lack of positive findings in our randomized trial should not dissuade clinicians from referring to a palliative care consultation service but highlights the need for further rigorously designed research to demonstrate which approach to palliative care provided to which patients would improve patient outcomes.

Secondhand smoke is the most frequent cause of child maltreatment

Sir, Jud et al. recently published an interesting paper on characteristics associated with maltreatment types in children [1]. They are obviously quite experienced in the field of child maltreatment. Yet, to our surprise, they do not express any concern about the most frequent of all thinkable forms of physical harm namely exposure to secondhand tobacco smoking. Children are especially sensitive. When exposed to secondhand smoke, they have double the rate of respiratory and lung disorders and are more often absent from school, which affects their behaviour and learning abilities. Even if a child does not suffer from asthma but both parents smoke, he or she will have a 40% higher rate of being absent from school due to bronchitis, pneumonia or bronchiolitis. Lastly, a smoking mother doubles the risk of cot death [2]. A comparable failure to classify the harm of smoking as a type of child maltreatment occurs during pregnancy where smoking is the first avoidable cause of preterm birth and intrauterine growth retardation [3]. Similar to the other maltreatments described in the paper, smoking and low socioeconomic status are correlated. We do not hesitate to label smoking as child maltreatment despite the lack of intentionality of the child’s carers. Smoking is a disease; a very powerful addiction with the most devastating consequences. Healthcare providers and practitioners are not acting effectively about diagnosis and treatment (e.g. cognitive behavioural therapy, nicotine substitutes or varenicline). It is shameful that social security schemes fail to properly reimburse such treatments despite their high cost-effectiveness. It is predicted that 2 billion people will smoke in 2025 with a dramatic increase in lowand middle-income countries. Paediatricians must recognise smoking as child maltreatment to prevent one of the most dramatic modern epidemics.

Public health, politicians’ decisions, and the citizen

If prioritisation in healthcare is required, Werntof and dberg sadly observed that politicians will be afraid of disleasing voters, while physicians will be afraid of making edically incorrect decisions [1]. They proposed that the itizens must take part in the debate. The facts are clear, ut their proposal is far from enough. In June, French representatives of both Chambers voted major law to reform the healthcare system and improve ublic health. At the same time, they: (a) allowed adverising on the Internet for alcoholic beverages; (b) rejected proposal protecting children from advertising of foods igh in fat and sugar; (c) did not increase taxes on tobacco roducts (the last one was 5 years ago). Evidently, these decisions may be dangerous and ven worse are inconsistent. At a population level, conumption is driven by availability (price) and marketing. veryone knows the pivotal role of promoting and adverising these products in increasing consumption and arm. Politicians also have an open disrespect of the majority. ools indicated that 8 out of 10 citizens supported oppo-

Electronic Cigarettes: From History to Evidence-Based Medicine

There is no harm reduction with smokelesstobacco,asitsuseisonlyanindicatorofalackoftobaccocontrol policy.The electronic cigarette, a young bastard, has beenrapidly legitimated: the tobacco industry is now buyinge-cigarette companies (www.theguardian.com/business/2014/jun/26/e-cigarettes-market-vaporisers), expecting anew entrance in addiction. Nicotine plus flavors are agreat combination, as weknow from mentholcigarettes.