Dan Carter

Obesity, Metabolic Syndrome and the Risk of Development of Colonic Diverticulosis

Introduction: Colonic diverticulosis is a common condition with obscure pathogenesis. Obesity, hyperlipidemia and hypertension have been demonstrated to increase the risk of complicated diverticular disease, but the impact of metabolic risk factors on the prevalence of uncomplicated diverticulosis has not been clearly determined. Aims: The aim of the study was to examine the impact of obesity and metabolic syndrome on the prevalence of colonic diverticulosis. Methods: This retrospective case-control study included patients aged 40–85 years who were followed up by the Institute of Medical Screening in Israel and underwent colonoscopy in 2006–2011 for indication of colorectal cancer screening. Patients with diverticulosis as detected by colonoscopy were compared to patients without diverticulosis. The comparison parameters included medical history, biometric parameters, biochemical and lipid profile. Results: The study included 3,175 patients. Diverticulosis was diagnosed in 17.4% of the cohort. On univariate analysis, age, male gender, BMI (continuous variable), obesity, systolic blood pressure, low-density lipoprotein cholesterol level, history of hypertension, ischemic heart disease, hypothyroidism, and absence of diabetes mellitus were associated with an increased risk of colonic diverticulosis. On multivariate analysis, advanced age, male gender, obesity (BMI >30), history of hypothyroidism and absence of diabetes mellitus were associated with an increased risk of diverticulosis. Prevalence of colonic polyps was similar in patients with and without diverticulosis. Conclusion: Colonic diverticulosis was associated with age, male gender, obesity and hypothyroidism. Diabetes mellitus was associated with a decreased risk of colonic diverticulosis.

Crush Syndrome: Saving More Lives in Disasters: Lessons Learned From the Early-Response Phase in Haiti

T he Israel Defense Forces Medical Corps Field Hospital was fully operational 89 hours after the Haiti earthquake in January 2010. In earthquake scenarios, crush injuries are a major cause of death. The incidence of crush syndrome can be as high as 25% in earthquake victims. Acute renal failure (ARF), a complication of crush syndrome that is commonly encountered in the first days following earthquakes, has an excellent outcome when renal replacement treatment (RRT) is available. The incidence of ARF related to crush syndrome depends on the intensity of the earthquake and the amount of time spent under rubble, and ranges from 0.5% to 25%. More than half of those with renal failure will require RRT.

Simultaneous deep vein thrombosis and transverse myelitis with negative serology as a first sign of antiphospholipid syndrome: a case report and review of the literature

Transverse myelitis is a rare manifestation of antiphospholipid syndrome, usually secondary to systemic lupus erythematosus (Rheum Dis Clin North Am 20:129–158, 1994). Only about 110 reports of this complication have been reported (Lupus 10:851–856, 2001). A connection has been demonstrated between positive serology for antiphospholipid and transverse myelitis (Lupus 8:109–115, 1999). Herein, we report of a young patient admitted with deep vein thrombosis and neurological manifestations of transverse myelitis with negative serology for systemic lupus erythematosus and antiphospholipid, who developed positive anticardiolipin antibody during pulse therapy with cyclophosphamide and methylprednisolone.

Endoscopic assessment of the small bowel.

Background: Small bowel imaging and endoscopy in IBD have undergone a tremendous change and advancement in the recent years. Modalities shifted from gastroscopy, colonoscopy and small bowel follow through to ileocolonoscopy, CT or MR enteroscopy, wireless video capsule endoscopy and balloon-assisted enteroscopy. Methods: We reviewed the present role of endoscopy in assessing the small bowel in the context of IBD. Results: Endoscopy has a major role in the diagnosis of IBD, in the assessment of its extent, treatment of complications, assessment of the success of various medications and as a predictor of disease course. Wireless capsule endoscopy (WCE) is a relatively new tool allowing direct, patient-friendly visualization of the entire small bowel mucosa. It has gained a substantial role in the evaluation of patients with suspected Crohns disease (CD) and indeterminate colitis. WCE has a high positive predictive value in patients with suspected CD, when one uses more than two of the International Conference on Capsule Endoscopy criteria, and not less important a very high negative predictive value in patients with suspected CD. Its role in patients with known CD, in the assessment of their disease activity and extent, assessment of postsurgical small bowel recurrence and evaluation of mucosal healing is still unclear. Balloon-assisted enteroscopy has established its role as a complementary tool in cases where there is a need for biopsy or treatment (dilatation of strictures). Conclusions: The present review summarizes the role of endoscopy in the assessment of the small bowel in the context of IBD.

Current role of endoscopy in inflammatory bowel disease diagnosis and management.

Purpose of review This review will summarize the role of endoscopy in the diagnosis of inflammatory bowel disease (IBD), in assessing its activity, its management, interventional endoscopy, and cancer surveillance. Recent findings Endoscopy in IBD underwent major advances in the recent years, with the emergence of new techniques such as wireless video capsule endoscopy (WCE), device-assisted enteroscopy (DAE), chromoendoscopy, and confocal endomicroscopy. WCE is a minimally invasive tool, enabling the visualization of the entire small bowel mucosa. It has gained a substantial role in the evaluation of patients with suspected Crohns disease and indeterminate colitis. With the correct use of the International Conference on Capsule Endoscopy criteria, WCE has a high positive predictive value in patients with suspected Crohns disease. Moreover, WCE has a very high negative predictive value in patients with suspected Crohns disease. DAE has established its role as a complementary tool in cases where there is need of biopsies or dilatation of strictures. Chromoendoscopy and confocal endomicroscopy are techniques that may assist in cancer surveillance in IBD patients. Summary Endoscopy has a major role in the diagnosis of IBD, assessing its extent, treating some of its complications, assessing the success of various treatments, and as a predictor of disease course.

Effect of G-Force on Bicuspid Aortic Valve in Aviators

Background and Aims: Bicuspid aortic valve (BAV) is a common congenital cardiac malformation. The major complications are aortic stenosis (AS), aortic regurgitation (AR), infectious endocarditis and aortic dissection. This paper aims to assess the hemodynamic importance of incidentally-found BAV in military aviators and evaluate the effect of high G-force on disease progression. Methods: Aviators with BAV were detected by reviewing all cardiac assessment records between 1987 and 2005. All aviators underwent annual flight surgeon examination. Echocardiography was performed as recommended by our cardiologists and flight surgeons. Results: Eight newly diagnosed cases of BAV were found. All of the aviators continued active aviation throughout the study period. Repeat echocardiography demonstrated progressive widening of the aortic diameter in five of the eight aviators. No worsening of valve dysfunction was seen in those with mild aortic regurgitation at diagnosis. Left ventricular dimensions and function did not deteriorate. No new valve complications, including infectious endocarditis, were seen. The age at diagnosis strongly correlated with the root diameter change; both total (r = 0.74, p = 0.02) and annualized (r = 0.78, p = 0.02) change. Over a mean follow-up period of 12.1 years, no difference was seen in the progression of BAV in high-performance as compared to low-performance aviators. Conclusions: Exposure to G-force and anti-G maneuvers does not appear to worsen cardiac and valve function in aviators with BAV.

Are there specific endosonographic features in Crohn's patients with perianal fistulae?

Both 2-dimensional and 3-dimensional endoanal ultrasounds have been shown to be accurate in the definition of the anatomy of complex fistulae-in-ano in patients with perianal Crohns disease. Recently, a Crohns Ultrasound Fistula Sign (CUFS) has been suggested as a discriminating feature of perianal Crohns disease as has the presence of fistulous debris and fistular bifurcation. We blindly assessed 197 patients (39 Crohns fistulae and 158 cryptogenic fistulae) to determine if these signs differentiated fistula types. The incidence of CUFS in Crohns cases was 17/39 (43.6%) and in cryptogenic cases was 4/158 (2.5%) (P<0.0001). The sensitivity, specificity, positive and negative predictive values and accuracy for CUFS were 43.6%, 97.5%, 80.9%, 87.5% and 86.8%, respectively. The presence of debris and fistula bifurcation in evaluable cases had a high specificity (87.2% and 81.8%, respectively) but poor sensitivity. The kappa values for or against CUFS, debris and bifurcation in Crohns cases between 2 observers blinded to the diagnosis were 0.85, 0.72 and 0.93, respectively and in cryptogenic fistulae were 0.89, 0.85 and 0.80, respectively. The kappa values of an agreed consensus for CUFS in Crohns disease, cryptogenic fistulae and overall with a third observer with no ultrasound experience were 0.62, 0.85 and 0.77, respectively. The presence of CUFS differentiates Crohns-related from cryptogenic fistulae-in-ano with a high level of agreement for this sign between experienced and inexperienced observers blinded to the underlying diagnosis.

Predictive Factors for the Diagnosis of Irritable Bowel Syndrome in a Large Cohort of 440,822 Young Adults

Background: The prevalence of irritable bowel syndrome (IBS) in the community has been reported in numerous cross-sectional surveys. However, little is known about the incidence and predictive factors for the clinical diagnosis of IBS. Methods: We examined the association of socioeconomic, anthropometric, and occupational factors with the incidence of IBS in a cohort of 440,822 young Israeli adults aged 18 to 39 who served in active military service during the years 2005 to 2011. Results: During the follow-up of 1,925,003 person-years, IBS was diagnosed de novo in 976 patients, giving an incidence rate of 221:100,000 (0.2%) person-years for the diagnosis of IBS. On multivariable Cox analysis, higher socioeconomic status [hazard ratio (HR) 1.629; 95% confidence interval (CI), 1.328-1.999; P<0.0001], Israeli birth (HR 1.362; 95% CI, 1.084-1.712; P=0.008), Jewish ethnicity (HR 2.089; 95% CI, 1.344-3.248; P=0.001), education ≥than 11 years (HR 1.674; 95% CI, 1.019-2.751; P=0.042), and a noncombat military position (HR 1.196; 95% CI, 1.024-1.397; P=0.024) were found to be risk factors for the diagnosis or for the worsening of IBS. Overweight (HR 0.744; 95% CI, 0.589-0.941; P=0.014), obesity (HR 0.698; 95% CI, 0.510-0.95; P=0.025), living in a rural settlement (HR 0.705; 95% CI, 0.561-0.886; P=0.003), and Middle Eastern (HR 0.739; 95% CI, 0.617-0.884; P=0.001,) or North African and Ethiopian origin (HR 0.702; 95% CI, 0.585-0.842; P<0.001) were found to be protective for the diagnosis or the worsening of IBS. Conclusions: This study provides novel data on the socioeconomic, anthropometric, and occupational factors predictive for IBS development. The predictive factors for IBS diagnosis may point to the fact that stress had a lower impact on IBS incidence in our study cohort.

Physical examination and ECG screening in relation to echocardiography findings in young healthy adults.

Background and Aims: Cardiovascular screening in young adults is an important tool in many occupational settings. Our aim was to test whether screening physical examination and ECG influence the rate of abnormal echocardiogarphic findings in young healthy subjects. Methods: Consecutive echocardiography results of 18- to 20-year-old flight candidates were analyzed retrospectively. Echocardiographies were performed as part of a screening protocol, which includes ECG, physical examination and referral for echocardiography for any positive finding. A second stage includes universal echocardiography for all candidates. Results: 1,066 subjects were evaluated; 489 subjects underwent echocardiography following referral because of abnormal auscultatory or ECG findings. Findings (mostly mild valvular insufficiencies) were demonstrated in 12.7%, with only 0.6% of subjects disqualified. In subjects who underwent universal echocardiography (n = 577), findings (mostly mild valvular insufficiencies) were detected in 18%, with only 0.5% of subjects disqualified. Conclusions: The rate of significant echocardiography findings is extremely low in this young and healthy population. The presence of abnormal findings on either physical examination or ECG screening was not demonstrated to alter the rate of abnormal echocardiographic findings. We suggest that the low yield of screening should be weighed against the cost of an unidentified congenital cardiac lesion in the specific setting.

Monitoring of small bowel Crohn’s disease

ABSTRACT Introduction: In recent years, the therapeutic paradigm in Crohn’s disease has shifted from a mere symptom-oriented approach, to aiming to healing of the underlying inflammation and prevention of long-term structural complications. Such ‘treat-to-target’ approach may allow for a more stable disease course with less hospitalizations, lower requirement for surgery and improved quality of life. In Crohn’s disease, the small bowel is affected in the majority of patients; frequently, Crohn’s involves only the small bowel, which remains inaccessible to conventional ileocolonoscopic techniques. Thus, non-invasive monitoring techniques are crucial for accurate disease assessment. Areas covered: This review addresses the indications and clinical implications of non-invasive small bowel monitoring modalities (magnetic resonance enterography, intestinal ultrasound, capsule endoscopy) in the assessment and management of Crohn’s disease. Expert commentary: This review addresses the limitations of the current knowledge and future areas of research, including the possible utilization of transmural healing as an imaging target and the need to establish clear quantitative target values to guide treatment by imaging findings in Crohn’s disease.