Recurrent spinal meningeal melanocytoma at lumbar spine level: a case report.

INTRODUCTION: Spinal meningeal melanocytoma is an extremely rare tumour with an estimated annual incidence of 1 per 10 million people. It usually arises from the intradural extramedullary compartment at the cervical levels. Although these tumours are histologically benign, they may behave aggressively. Local recurrence could occur even after total tumour excision. CASE REPORT: We report a case of a 33-year-old Asian male who developed progressive weakness and numbness of the bilateral lower extremities as well as urinary retention five years after complete tumour resection of lumbar spinal meningeal melanocytoma. Magnetic resonance imaging of the lumbar spine revealed a mass with thecal sac compression which was hypointense on T2-weighted images and hyperintense on T1-weighted images. The patient underwent total tumour removal. Histologic examination was compatible with recurrent meningeal melanocytoma. After a 4-week inpatient rehabilitation programme, he was able to ambulate without assistance and to do clean intermittent catheterisation for micturition on a regular basis. DISCUSSION: This is the first reported case of intradural extramedullary meningeal melanocytoma located at the lumbar region. Clinicians should consider the possibility of these rare tumours at any level of the spine, and be aware of sphincter dysfunction in addition to motor and sensory deficits of extremities.

Left Atrial Fibroelastoma as a Cause of Stroke: A Case Report.

Cardiac papillary fibroelastoma is a benign and rare primary tumor of the heart that is most frequently located in the aortic or the mitral valves. Papillary fibroelastoma arising from the left atrium is exceedingly rare, comprising less than 7% of all cardiac papillary fibroelastomas. Tumors in this location could be a source of cardioembolic stroke, often in the anterior circulation of the cerebrum. A 66-year-old female presenting with right hemiparesis, central facial palsy, homonymous hemianopia, and dysarthria received intravenous thrombolysis for stroke without apparent improvement. Magnetic resonance imaging of the brain revealed ischemic infarction in the territories of the left middle and posterior cerebral arteries. A tumor with a maximal diameter of 2.3 cm was disclosed during workup for possible cardioembolic stroke with transthoracic echocardiography and computed tomography of the heart. The clinical course was complicated by stroke-in-evolution and hemorrhagic transformation. The patient underwent left atrial tumor excision and left atrium appendage closure. In-patient stroke rehabilitation programs were also initiated after the conditions stabilized. No clinically significant complications developed after the operation. Neurological functions improved and the patient was able to perform most basic daily living activities with some assistance. An exhaustive search for the cause of cardioembolic stroke is paramount, as management strategies may differ from patients with thrombotic stroke.

Double-balloon enteroscopy for pediatric patients: Application and feasibility evaluation in a medical center in northern Taiwan.

BACKGROUND/PURPOSE: The diagnostic and therapeutic benefits of double-balloon enteroscopy (DBE) in adults are established, but few data are available on pediatric patients. The aim of this study was to evaluate the clinical efficacy and safety of DBE in pediatric patients in Taiwan. METHODS: From April 2005 to September 2015, DBE procedures performed for diagnosis or therapy of small-bowel disease in children less than 18 years of age at Linkou Chang Gung Memorial Hospital, Taiwan were evaluated. The clinical decision to perform DBE via the oral or anal approach was based on the patient's primary clinical presentation. Data on indications, endoscopic findings, treatment outcome, and complications associated with the procedure were collected and reviewed retrospectively. RESULT: In total, 20 pediatric patients underwent a total of 29 DBEs due to suspicion of small-bowel disease. Among them, nine patients were evaluated for suspected small-bowel bleeding, six for Peutz-Jeghers syndrome, two for chronic abdominal pain, two for chronic diarrhea, and one for suspected protein-losing enteropathy. After excluding the six Peutz-Jeghers syndrome patients, 9 of the 14 patients (64%) got a positive endoscopic finding and diagnosis in 8 of the 14 patients (57%). DBE resulted in a further therapeutic intervention (endoscopic or surgical) in 50% of the patients (10/20) without serious complications. CONCLUSION: DBE has a high diagnostic yield and leads to therapeutic interventions in pediatric patients and shows promise for assessment and treating small-intestinal diseases in children in Taiwan.

Entrapment neuropathy of common peroneal nerve by fabella: A case report.

BACKGROUND: Neuropathy of the common peroneal nerve caused by compression by a fabella is an extremely rare form of compression neuropathy. Involving both the superficial and deep peroneal nerves, it usually manifests as either impaired sensation from the lower lateral leg to the top of the foot or drop foot, or as a combination of both. CASE SUMMARY: We report the case of a 58-year-old Asian female who presented with inversion of the right foot during the stance phase of gait without sensory complaints related to the lower leg. Electrodiagnostic testing revealed the neuropathy of the common peroneal nerve at the level of the knee, exclusively affecting the muscular branch of the superficial peroneal nerve. A neuromuscular ultrasound disclosed swelling of the right common peroneal nerve just before it crossed over a large fabella as well as atrophy and fatty infiltration of the right peroneus longus and peroneus brevis muscles. Surgical excision of the fabella and neurolysis were performed. Subsequently, the strength of the right foot evertors improved, but the unsteady gait with occasional falls persisted for nine months after the surgery. Therefore, another procedure was performed to transfer the split posterior tibialis tendon to the peroneus brevis in order to correct the gait. CONCLUSION: This is the first case of neuropathy of the common peroneal nerve caused by compression by a fabella affecting exclusively the muscular branch of the superficial peroneal nerve. Clinicians should be aware of this unusual peripheral neuropathy while evaluating and treating patients with gait disturbance.

Factors that influence cecal intubation rate during colonoscopy in deeply sedated patients.

BACKGROUND AND AIM: The technical performance of colonoscopy performed in deeply sedated patients differs from that performed without sedation or under minimal to moderate sedation. The aim of this study is to evaluate the factors affecting cecal intubation during colonoscopy performed under deep sedation. METHODS: A total of 5352 consecutive subjects who underwent a screening colonoscopy as part of a health check-up between January 2008 and December 2008 at an academic hospital were reviewed. All endoscopies were performed with deep sedation using combination propofol or propofol alone. Data collected included characteristics of the patients (age, gender, body mass index, bowel habits, history of abdominal or pelvic surgery, quality of bowel preparation, and presence/absence of colonic diverticula) and characteristics of the colonoscopists (experience level, colonoscopy procedure volume, and instrument handling method). These factors were analyzed to evaluate their impact on cecal intubation rates. RESULTS: The crude cecal intubation rate was 98% and the adjusted cecal intubation rate was 98.3%. The mean cecal intubation time was 5.6 ± 3.2 min. Multivariate logistic regression analysis demonstrated that patient age greater than 60 years, constipation, poor colon preparation and a two-person colonoscopy procedure were independently associated with lower cecal intubation rates. CONCLUSIONS: Colonoscopy performed under deep sedation by experienced colonoscopists results in high cecal intubation rates. Among the significant patient-related predictors influencing the cecal intubation, the quality of the bowel preparation was the only modifiable factor. When performed by experienced hands, the one-person method was associated with higher cecal intubation rates than the two-person method.

Agreement Between Caregivers' Concerns of Children's Developmental Problems and Professional Identification in Taiwan.

Objective: Early detection of developmental delays relies on the accuracy of the caregivers' concerns of children's developmental problems. The aim of this study was to investigate the agreement between the caregivers' awareness of children's developmental problems and professional identification. Methods: Caregivers of 1,963 children (age range: 5-71 months; mean: 38.4 months) younger than 6 years old who were at risk of developmental delays and referred to the center for a comprehensive evaluation were enrolled in this study. Children were identified by a transdisciplinary team including a pediatric neurologist, a pediatric psychiatrist, two psychologists, two occupational therapists, two physical therapists, two speech therapists, a social worker, and a special instructor. A series of standardized developmental assessments were used to identify children with developmental delay. Retrospective chart reviews were conducted on all children to confirm specific developmental disorders. Results: The caregivers' initial concerns of cognitive, speech/language, emotional/behavioral, and motor and global development showed low agreement with the results of professional identification. The major disagreement was observed in the cognitive domain. Speech/language developmental concern was an important red-flag indicator of cognitive and emotional/behavioral developmental delays. The presence of intellectual disability, autism spectrum disorder, and attention deficit hyperactivity disorder was high in this study. When having caregivers' concerns about speech/language and emotional/behavioral development, the odds of children with autism spectrum disorder was 2.37 and 2.17 times greater than those without autism spectrum disorder, respectively. The presence of attention deficit hyperactivity disorder was significantly associated with concerns about cognitive and emotional/behavioral developmental delays. Child's age and mothers' level of education were significant indicators for detecting the child's developmental problems. Conclusion: It is recommended that assessing the cognitive developmental status is essential for all children in the identification process. Practitioners should not overlook caregivers' concern about speech/language and emotional/behavioral development. Transdisciplinary practitioners provide educational guidance to caregivers, especially in the domains of cognitive, speech/language, and emotional/behavioral development.

Balloon-assisted enteroscopy with prophylactic polypectomy for Peutz-Jeghers syndrome: experience in Taiwan.

BACKGROUND: Peutz-Jeghers syndrome (PJS) is a very rare disease that often causes severe complications such as bowel obstruction or gastrointestinal tract bleeding. In the past, it was usually treated by using surgical intervention despite the associated complications. Balloon-assisted enteroscopy (BAE) has been documented as an effective and safe method for the diagnosis and treatment of small bowel lesions. Hence, we conducted this study to verify whether BAE is useful for patients with PJS. AIM: To evaluate the safety and efficacy of BAE with prophylactic polypectomy in patients with PJS. METHODS AND PATIENTS: From August 2005 to February 2010, 6 consecutive patients were diagnosed with PJS after pathological and clinical examination, and underwent BAE examination and polypectomy at Chang Gung Memorial Hospital, an academic tertiary referral center. RESULTS: Six consecutive patients (4 men and 2 women) diagnosed with PJS underwent BAE with polypectomy. BAE was performed 17 times for complete examination of the entire small bowel. The range of the diameter of the removed polyps was 1-6 cm. No immediate complications such as hemorrhage or hollow organ perforation were noted during the procedure, and no patient developed intussusception during the follow-up period (32 ± 17.5 months). CONCLUSION: BAE with polypectomy is useful for patients with PJS in order to reduce the complications of the condition.

Botulinum Toxin Injections for Treatment of Drooling in Children with Cerebral Palsy: A Systematic Review and Meta-Analysis.

BACKGROUND: We aimed to review and analyse the effectiveness and safety of botulinum toxin type A (BoNT-A) injections for drooling in children with cerebral palsy. DATA SOURCES: We searched the EMBASE, MEDLINE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) databases from inception to January 2020. METHODS: We included randomized controlled trials and observational studies which (1) involved children with cerebral palsy, (2) used BoNT-A for control of drooling, and (3) provided quantitative evaluations of drooling before and after intervention with BoNT-A. RESULTS: Twenty-one trials met the inclusion criteria. Most studies showed that BoNT-A injections are safe and efficacious as a treatment for drooling in children with cerebral palsy. Four trials had sufficient data to pool the results for the meta-analysis. Both the drooling quotient (p = 0.002) and drooling Ffrequency and severity scale (p = 0.004) supported this conclusion. CONCLUSION: BoNT-A injections are a safe, reversible, effective treatment for drooling control in children with cerebral palsy that can offer effectiveness for more than 3 months with few side effects. The dosage of BoNT-A should not exceed 4 units/kg. Further studies are required to determine the optimal dosage and target glands.

Botulinum toxin injection for Cockayne syndrome with muscle spasticity over bilateral lower limbs: A case report.

BACKGROUND: Cockayne syndrome (CS) is a rare inherited disease characterized by progressive motor symptoms including muscle weakness, joint contracture, ataxia, and spasticity. Botulinum neurotoxin type A has been used for conditions such as dystonia and spasticity, but it has rarely been used in patients with CS. CASE SUMMARY: We report a 6-year-and-9-mo old girl diagnosed with CS who received an injection of botulinum neurotoxin type A to manage her difficulty with walking. A total dose of 210 units of botulinum neurotoxin type A was administered into the bilateral tibialis posterior and gastrocnemius muscles. To evaluate the treatment effects on spasticity, joint contracture, pain, and ataxia, measurement tools including the Modified Ashworth Scale, the passive range of motion, the Faces Pain Scale-Revised, and the Scale for the Assessment and Rating of Ataxia, were employed. The first week after the injection, the Modified Ashworth Scale score for the plantar flexors and foot invertors improved bilaterally, along with advancements in the passive range of motion of the bilateral ankles and a lower score for the Faces Pain Scale-Revised. These treatment effects persisted to the 8th week post-injection, but returned to baseline values at the 12th week post-injection, except for the pain scale. CONCLUSION: Botulinum toxin injection can thus be considered as a treatment option for lower extremity spasticity, joint contracture, and pain derived from CS.

Clinical manifestations, risk factors, and prognostic factors of cytomegalovirus enteritis.

BACKGROUND: To comprehensively analyze the risk factors, clinical characteristics, outcomes, and prognostic factors of Cytomegalovirus (CMV) enteritis. METHODS: This retrospective cohort study enrolled patients who had undergone pathological examinations for CMV enteritis. They were divided into CMV and non-CMV groups according to immunohistochemistry staining results. The risk factors, clinical presentations, endoscopic features, treatments, outcomes, and prognostic factors of CMV enteritis were then analyzed. RESULTS: Forty-two patients (18 CMV, 24 non-CMV group) were included in the study. Major clinical presentations in the CMV group included gastrointestinal bleeding (72.2%), abdominal pain (55.6%), and fever (33.3%); ulcers (72.2%) were the most common endoscopic findings. In-hospital and overall mortality rates were 27.8% and 38.9%, respectively; and longer hospital stays and higher overall mortality rates were observed. Radiotherapy and C-reactive protein levels were prognostic factors for in-hospital mortality. The risk factors for CMV enteritis included immunocompromised status (p = 0.013), steroid use (p = 0.014), shock (p = 0.031), concurrent pneumonia (p = 0.01), antibiotic exposure (p < 0.001), radiotherapy (p = 0.027), chronic kidney disease (p = 0.041), and CMV colitis (p = 0.031). CONCLUSIONS: Physicians should pay attention to the characteristics of CMV enteritis in high-risk patients to make an early diagnosis and potentially improve the clinical outcome.

Multiple Beneficial Effects of High-dose BoNT-A Injection to Improve Wound Healing and Spasticity in a Patient With Hypoxic Encephalopathy Due to High-voltage Electrical Injury.

INTRODUCTION: High-voltage electrical injuries remain a difficult challenge for physicians. The survivors often have complicated wounds over the trunk or extremities, and some of them may develop hypoxic encephalopathy. The emergence of spasticity following hypoxic encephalopathy may further interfere with the healing of wounds. CASE REPORT: The authors report the case of a 17-year-old male with strong spasticity of finger flexors graded 4 by the Modified Ashworth Scale (0-5) after electric shock. He also had a nonhealing wound on the flexor side of the left index finger after 6 weeks of standard wound care. The wound measured 0.3 cm × 0.3 cm × 0.2 cm in size. The authors hypothesized that wound healing was negatively affected by spasticity and expected the wound might heal gradually after reducing the strong spasticity of the index finger. The authors employed electrical stimulator for guidance and injected high-dose (50 units/muscle) botulinum toxin type A into the flexor digitorum superficialis and the flexor digitorum profundus of his left index finger. At 7 days following administration, focal spasticity of these muscles in the left index finger decreased from 4 to 1 on the Modified Ashworth Scale. At 21 days post administration, the wound healed completely. CONCLUSIONS: For patients with hypoxic encephalopathy due to high-voltage electrical injury, botulinum toxin type A injection may be an option of therapeutic approach for both reduction of spasticity and facilitation of wound healing.

Treatment decision for potential bleeders in obscure gastrointestinal bleeding during double-balloon enteroscopy.

Double-balloon enteroscopy (DBE) is an effective tool for diagnosing and treating obscure gastrointestinal bleeding. The aim is to describe how outcomes differ with patient setting (with DBE diagnosis and intervention, with DBE diagnosis but without intervention, and without DBE diagnosis), and thus demonstrate the value of endoscopic intervention when encountering potential bleeder during DBE. From November 2003 to January 2008, 90 patients with obscure gastrointestinal bleeding presented with DBE at our tertiary referral center. A total of 113 DBE procedures were carried out. Overall diagnostic yield was 75.6% (68/90). Endoscopic intervention was performed in 58 (85.3%) of the 68 patients with potential bleeder. The 90 patients were divided into three settings: with endoscopic diagnosis and intervention (n = 58), with endoscopic diagnosis but without intervention (n = 10), and without endoscopic diagnosis (n = 22). Rebleeding rates for the three groups were 22.4%, 60%, and 22.7%, respectively. For the 35 patients diagnosed with vascular lesions, the rebleeding rates in patients with and without endoscopic intervention, were 38.5% (10/26) and 66.7% (6/9), respectively. One (0.9%) severe adverse event occurred during the 113 procedures, and the patient died. DBE is an effective tool for diagnosing and treating obscure gastrointestinal bleeding. DBE involves relatively safe procedures and has an acceptable complication rate. When potential bleeders are encountered during the procedure, especially for vascular lesions, therapeutic intervention should be attempted, since the intervention-related complication rate is acceptable, and such intervention can reduce the rebleeding rate and enhance the cost-effectiveness of DBE.

Altered expression patterns of lipid metabolism genes in an animal model of HCV core-related, nonobese, modest hepatic steatosis.

BACKGROUND: Because the gene expression patterns of nonobese hepatic steatosis in affected patients remain unclear, we sought to explore these patterns using an animal model of nonobese hepatic steatosis. METHODS: We developed mice that conditionally express the hepatitis C virus (HCV) core protein regulated by the tetracycline transactivator (tTA). Microarray analyses and reverse-transcription polymerase chain reaction were performed using liver samples of both the double transgenic mice (DTM), which express both the HCV core and tTA, and single transgenic mice (STM), which express tTA alone, at 2 months of age. Functional categories of genes with altered expression were classified using gene ontology programs. Serum glucose, lipid levels, and systemic blood pressure were also measured. RESULTS: Approximately 20-30% of hepatocytes from the DTM were steatotic. No significant differences were observed in the serum glucose, lipid content, or blood pressure levels between the DTM and STM. Gene expression analyses revealed Sterol-regulatory element-binding protein (SREBP) pathway activation and dysregulation of the following genes involved in lipid metabolism: 3-hydroxy-3-methylglutaryl-coenzyme A synthase 1, Apolipoprotein AII, Apolipoprotein CI, acyl-CoA thioesterase I, and fatty acid binding protein 1; in mitochondrial function: solute carrier family 25 member 25 and cytochrome c oxidase subunit II; in immune reaction: complement component 3, lymphocyte antigen 6 complex, locus A, lymphocyte antigen 6 complex, locus C, lymphocyte antigen 6 complex, locus D, and lymphocyte antigen 6 complex, locus E. CONCLUSION: Some genes of lipid metabolism, mitochondrial function, and immune reaction and the SREBP pathway are involved in HCV core-related, nonobese, modest hepatic steatosis.

Acute expression of hepatitis C core protein in adult mouse liver: Mitochondrial stress and apoptosis.

OBJECTIVE: In infection with hepatitis C virus (HCV), spontaneous clearance of the virus occurs in 30-40% of cases. By contrast, in chronic infection, this is rare. The basis for viral clearance in acute disease is unknown. Whereas cellular immune responses have been studied in detail, few data exist on the role of viral structural proteins, such as the core protein. The purpose of this study was to investigate the effects of core produced de novo within adult mouse hepatocytes by using a new transgenic mouse line in which expression of HCV core is regulated by tetracycline (tet-off). MATERIAL AND METHODS: In this work, transgenic mice with conditional HCV core were created, to study the acute expression of HCV core protein in the context of the mature liver. The subcellular distribution of the core, hepatocellular oxidative stress and apoptosis were monitored. RESULTS: Core protein is readily detectable and strongly associated with cytoplasmic lipid vesicles, endoplasmic reticulum and mitochondria. Mitochondrial oxidative stress was evidenced by a reduction in thioredoxin-2 (trx2). Concurrently, caspase-3 activity and TUNEL increased and, over time, the level of core protein in the liver declined. CONCLUSIONS: Mice that are conditionally transgenic for HCV core protein, which is readily detected and morphologically associated with steatosis in individual hepatocytes, were developed. Acute expression of core protein causes mitochondrial stress, as demonstrated by a reduction in trx2 and in the apoptosis of core-positive hepatocytes. We speculate that these events could be involved in the clearance of virus during acute hepatitis C, by both reducing the burden of virus in the liver and effectively priming the immune response.

Experience of double balloon enteroscopy.

BACKGROUND: To evaluated the experiences of double balloon enteroscopy (DBE) for obscure gastrointestinal bleeding. METHODS: From October 2003 to November 2009, a total of 124 patients with obscure gastrointestinal bleeding were investigated using DBE. A total of 142 procedures (84 per oral and 58 per rectal route) were performed by the same endoscopist. RESULTS: The average insertion time was 71.4 (20-199) minutes per-orally; the average insertion time was 139.2 min for the first 5 procedures, 109.4 min for 6-10 procedures, 76.6 min for 11-15, 66.4 min for 16-20, 67.4 min for 21-25, 59 min for 26-30, 66 min for 31-35, 52 min for 36-40, 42.9 min for 41-45, 44.6 min for 46-50, 42.2 min for 51-55, 38.6 min for 56-60, 44.6 min for 61-65, 37.8 min for 66-70, 38.8 min for 71-75, 44.3 min for 76-80, and 36.6 min for 61-84 procedures; there was no statistical difference after the first ten procedures. The average insertion time was 92.1 (22-260) minutes per-rectally; the average insertion time was 159.6 min for the first 5 procedures, 98.4 min for 6-10 procedures, 86.6 min for 11-15, 76.4 min for 16-20, 82.4 min for 21-25, 75.0 min for 26-30, 78.2 min for 31-35, 72.4 min for 36-40, 68.2 min for 41-45, 66.9 min for 45-50, and 71.4 min for 51-58 procedures; there was no statistical difference after the first five procedures. For the different genders these was no statistically significant difference. There were no differences regarding the diagnostic yield between the previous factors. The overall diagnostic yield was 82.4%. CONCLUSION: DBE is a safe and effective means of diagnosing and managing patients with obscure gastrointestinal bleeding. However, because of its time-consuming, DBE has a learning curve to overcome before a physician can become an expert to achieve adequate insertion times with good diagnostic and therapeutic rates.

Botulinum toxin injection to improve functional independence and to alleviate parenting stress in a child with advanced pantothenate kinase-associated neurodegeneration: A case report and literature review.

RATIONALE: Pantothenate kinase-associated neurodegeneration (PKAN) is a rare autosomal recessive disease. Progressive motor symptoms such as dystonia and spasticity begin in childhood and relentlessly become incapacitating later in life. Treatments including anticholinergics and iron chelation are usually ineffective. Botulinum toxin type A (BoNT-A) is effective for adult patients with dystonia or spasticity. PATIENT CONCERNS: We reported a 10-year-old female patient with advanced PKAN, manifesting as generalized dystonia and spasticity. DIAGNOSIS: The patient was diagnosed with PKAN by a pediatric neurologist. INTERVENTIONS: The patient received BoNT-A injection. OUTCOMES: The effect was obvious at four weeks after the injection, with an improvement of 25% in Barry-Albright Dystonia Scale and 4% in Functional Independence Measure for Children score. Furthermore, there was a 3.8% reduction in Parenting Stress Index Short Form score and 8.3% improvement in Pain and Impact of Disability domain in the score of Cerebral Palsy Quality of Life for Children. LESSONS: BoNT-A injection was effective to improve functional independence and to alleviate stress of caregivers in the patient with advanced PKAN.

Spinal cord infarction during physical exertion due to polycythemia vera and aortoiliac occlusive disease: A case report.

RATIONALE: Spinal cord infarction is rarely caused by hypercoagulable states. Polycythemia vera (PV) is a myeloproliferative neoplasm that can contribute to thrombotic events due to increased blood viscosity. We report a case of spinal cord infarction due to extensive aortic thrombosis caused by PV. PATIENT CONCERNS: A 56-year-old man presented with acute paraplegia and urinary retention during heavy physical exertion. DIAGNOSES: Imaging studies revealed spinal cord infarction at the T9 to T12 levels and aortoiliac occlusive disease. PV was diagnosed during workup for elevated hemoglobin level INTERVENTIONS:: The patient received intravenous hydration and anticoagulation for spinal cord infarction. PV was managed with phlebotomy and hydroxyurea. Courses of inpatient and outpatient rehabilitation programs were also given. OUTCOMES: The patient became urinary catheter-free 5 months after disease onset, and was able to walk with walker. The American Spinal Injury Association Impairment scale also improved from C at diagnosis to D during last follow-up. LESSONS: Etiologic workup is important for patients with spinal cord infarction to direct specific treatment strategies. Physical exertion may act as a trigger for infarction in patients at risk for thrombotic events, and monitoring of neurologic status during and after periods of exercise is warranted.

Angiodysplasia and bleeding in the small intestine treated by balloon-assisted enteroscopy.

OBJECTIVE: This study aimed to evaluate the outcomes in patients undergoing balloon-assisted enteroscopy (BAE) with heat probe or argon plasma coagulation and to identify risk factors for recurrent bleeding. METHODS: Data of the patients who were consecutively referred to our institution with angiodysplastic bleeding of the small intestine between August 2005 and February 2010 were reviewed. These 39 patients underwent BAE and were followed up for 6 months. RESULTS: In all, 31 patients had melena and 8 had hematochezia. On BAE, 26 patients received endoscopic therapy, 3 underwent surgical intervention due to endoscopic therapy failure, and 10 underwent observation because a definite source of bleeding was not identified. Ten patients (25.6%) had recurrent bleeding during follow-up, including eight patients in the endoscopic therapy group and two in the observation group. Higher rates of recurrent bleeding were observed in association with the presence of melena initially (P = 0.028), but there were no significant differences in the rate of recurrence between patients who did and did not receive endoscopic therapy (P = 0.470). Age greater than 65 years (P = 0.058) and jejunal bleeding (P = 0.050) tended to increase the risk of recurrent bleeding compared with other factors. CONCLUSIONS: BAE may be a beneficial approach to treat angiodysplastic bleeding in the small intestine. Elderly patients and those with melena or jejunal bleeding should be closely monitored for recurrent bleeding.

Polymicrobial peritonitis following colonoscopic polypectomy in a peritoneal dialysis patient.

Patients undergoing continuous ambulatory peritoneal dialysis (CAPD) are at an increased risk of peritonitis following colonoscopy with or without polypectomy. Guidelines for peritoneal dialysis patients recommend administration of prophylactic antibiotics and drainage of the abdomen before colonoscopy. In this report, we describe a 53-year-old woman on CAPD who underwent colonoscopy with polypectomy and developed peritonitis within 24 hours. She presented with severe abdominal pain, typical rebounding tenderness, and turbid dialysate containing increased white blood cells with a predominance of neutrophils. A culture of the patient's peritoneal fluid grew polymicrobial species including Escherichia coli, Klebsiella pneumoniae, and Enterococcus faecalis. She was treated with intraperitoneal and intravenous administration of combination antibiotics, and she fully recovered within 3 weeks. We suggest that nephrologists and endoscopists should be familiar with the risks and follow the guidelines to prevent such complications in CAPD patients. If peritonitis occurs, medical therapy with antibiotics should be considered before surgical intervention for catheter salvage.

Long-term outcome and efficacy of endoscopic hemorrhoid ligation for symptomatic internal hemorrhoids.

AIM: To assess the long-term outcome of endoscopic hemorrhoid ligation (EHL) for the treatment of symptomatic internal hemorrhoids. METHODS: A total of 759 consecutive patients (415 males and 344 females) were enrolled. Clinical presentations were rectal bleeding (593 patients) and mucosal prolapse (166 patients). All patients received EHL at outpatient clinics. Hemorrhoid severity was classified by Goligher's grading. The mean follow-up period was 55.4 mo (range, 45-92 mo). RESULTS: The number of band ligations averaged 2.35 in the first session for bleeding and 2.69 for prolapsed patients. Bleeding was controlled in 587 (98.0%) patients, while prolapse was reduced in 137 (82.5%) patients. After treatment, 93 patients experienced anal pain and 48 patients had mild bleeding. Patient subjective satisfaction was 93.6%. Repeat treatment or surgery was performed if symptoms were not relieved in the first session. In the bleeding group, the recurrence rate was 3.7% (22 patients) at 1 year, and 6.6% and 13.0% at 2 and 5 years. In the prolapsed group, the recurrence rate was 3.0%, 9.6% and 16.9% at 1, 2 and 5 years, respectively. CONCLUSION: EHL is an easy and well-tolerated procedure for the treatment of symptomatic internal hemorrhoids, with good long-term results.