Persistence of levator ani sonographic defect detected by three-dimensional transperineal sonography in primiparous women.

OBJECTIVES: Correlation of the sonographic appearance of levator ani muscle (LAM) injury soon after delivery with that at long-term follow-up has not been described fully. We aimed to compare results of three-dimensional (3D) transperineal sonographic (TPS) evaluation of the LAM from the period immediately postpartum with long-term follow-up, to determine whether sonographic findings persist over time. METHODS: Primiparous women (n = 210) who had been examined by 3D-TPS in a previous study to determine LAM trauma 24-72 hours after delivery were invited to participate in a follow-up examination 3-21 months postpartum. We included in this study only women who were not pregnant when approached and who had not given birth in the interim. LAM trauma was diagnosed with 3D-TPS when we observed discontinuity and distortion of the most anteromedial part of the pubovisceral muscle in the coronal C-plane or rendered image. Initial and follow-up 3D-TPS results were compared using Cohen's kappa test for inter-rater agreement. RESULTS: Among the 87 women included in this study we found strong correlation between earlier and later sonographic appearance of LAM: 17/21 women with a sonographic finding of LAM injury in the period immediately postpartum were positive in the follow-up examination, and only 2/66 women negative for LAM damage at the first examination were found to have sonographic evidence of LAM defect at follow-up (Cohen's kappa, 0.805 (95% CI, 0.656-0.954), P < 0.001). CONCLUSIONS: Our findings suggest that 3D-TPS of the LAM is a reliable examination. A sonographic finding of LAM defect identified in the period immediately postpartum persists months or years after delivery; therefore, this test may be performed following delivery, or may be delayed without impacting the result. It is likely that this sonographic defect represents real anatomical disruption and is not an imaging artifact.

Systematic examination of the fetal abdominal precordial veins: a cohort study.

OBJECTIVES: Examination of the fetal venous system is a necessary part of complete fetal organ scanning to confirm landmark anatomy, such as the ductus venosus and course of the umbilical veins, and, whenever cardiovascular anomalies are identified, to exclude associated anomalous development of the fetal veins. We aimed to develop a protocol for systematic examination of the fetal venous system during midtrimester targeted organ scanning. METHODS: We included low-risk women with a singleton fetus presenting between January 2011 and June 2013 to our center for routine midtrimester (20-24 weeks) targeted organ scanning. Imaging of the venous system was added to the booked scan and comprised two-dimensional color Doppler scanning of the fetal abdomen in three discrete planes, two transverse and one longitudinal. The more caudal plane was obtained in a ventral or lateral transverse abdominal plane to image the umbilical vein, left portal vein, portal sinus, anterior right portal vein, posterior right portal vein, main portal vein and splenic vein and artery. Moving cephalad, a ventral or lateral transverse plane was obtained to image the right, middle and left hepatic veins and inferior vena cava (IVC). Finally, a longitudinal anteroposterior plane showed the umbilical vein, ductus venosus, IVC and left hepatic vein. In some cases the pulsed Doppler waveform of a given target vessel was also examined. Three-dimensional/4D ultrasound was applied as necessary, when anomalous cases were encountered. RESULTS: We examined 1810 women. Their body mass index ranged from 19 to 40 (mean, 24.7). In 38 (2.1%) women, the target anatomy was not visualized satisfactorily owing to maternal body habitus. A T-shaped configuration of the portal system vessels was observed in 63% of cases, an X-shaped configuration in 25% and an H-shaped configuration in 12%. During the study period, 24 congenital anomalies of the precordial venous system were diagnosed: nine cases of persistent right umbilical vein, seven of agenesis of the ductus venosus, five of anomalous portal venous drainage and three of interrupted IVC with azygos continuation. CONCLUSIONS: Examination of the fetal venous system is feasible with the application of three abdominal planes. While a venous system scan is not practicable as part of a screening-level examination, mastery of the normal anatomy is an essential part of the professional knowledge base, in order to provide ready and complete scanning of the system in cases of suspected anomalies or disordered cardiac function.

Sonographic finding of postpartum levator ani muscle injury correlates with pelvic floor clinical examination.

OBJECTIVES: Correlation of the sonographic finding of levator ani muscle (LAM) injuries with clinical examination in primiparous women following vaginal delivery has not been fully described. We aimed to examine the correlation of three-dimensional transperineal ultrasound (3D-TPS) finding of LAM defects with results of clinical examination of the pelvic floor, at intermediate follow-up. METHODS: Subjects were primiparae 3-21 months following vaginal delivery, who had not become pregnant or delivered in the interim. On 3D-TPS, LAM trauma was diagnosed when discontinuity and distortion were visible in the most anteromedial part of the pubovisceral muscle in the coronal C-plane or rendered image. Clinical examination was performed by a physiotherapist who was blinded to the ultrasound results, and included palpation of the medial and lateral parts of the LAM mass, evaluation of tissue quality and whether there was any palpable gap. Muscle strength was evaluated using the modified Oxford scale. RESULTS: Eighty-seven women were included, 19 (21.8%) of whom were found to have a sonographic LAM injury. Oxford score palpation parameter of asymmetric muscle mass or texture was significantly correlated with the finding of a LAM defect: of 68 women with normal 3D-TPS, 22 (32.4%) were found to have asymmetry of muscle mass or tissue quality on clinical examination vs 12 (63.2%) of 19 women with sonographic evidence of LAM injury (P = 0.016). Muscle strength and endurance parameters did not significantly correlate with the 3D-TPS findings. CONCLUSION: Our findings suggest that persistent 3D-TPS LAM injury after primary vaginal delivery has clinical expression in changes in mass and texture of the LAM, as assessed by palpation.

Fetal tricuspid annular plane systolic excursion (f-TAPSE): evaluation of fetal right heart systolic function with conventional M-mode ultrasound and spatiotemporal image correlation (STIC) M-mode.

OBJECTIVES: Fetal tricuspid annular plane systolic excursion (f-TAPSE) is a modified method to measure the vertical movement of the tricuspid valve annulus by M-mode ultrasound, in order to assess the fetal right heart. Evaluation of right heart function is well-recognized in pediatric and adult cardiology, but has not been studied widely in the fetus. We aimed to study f-TAPSE in the second half of gestation in normal fetuses, to establish reference ranges for this measure, to evaluate the usefulness of spatiotemporal image correlation (STIC) M-mode in obtaining it, and to compare conventional M-mode and STIC M-mode-based measures of f-TAPSE. METHODS: We recruited gravidae presenting to our centers from 20 to 38 weeks for targeted organ scans, fetal echocardiography or third-trimester fetal surveillance, with structurally normal singleton fetuses and verified gestational age (GA). Because of the small number of subjects at the lower limit, fetuses at 20 and those at 21 weeks were combined into a single group ('21 weeks'). During the booked scan, in addition to standard biometry, M-mode was applied to the tricuspid annulus, parallel to the ventricular septum, and the amplitude of the resulting wave was measured. To allow comparison with STIC M-mode, a STIC volume was acquired and saved. In post-processing, the volume was rotated to show an apical four-chamber view, and f-TAPSE was investigated in a similar fashion to that used for conventional M-mode. Two to three measures of TAPSE were taken and the results averaged. In thirty women, measurements were performed by two observers and inter- and intraobserver variation were calculated. RESULTS: We examined 341 fetuses at GA 20-39 weeks. Conventional M-mode f-TAPSE values ranged from a mean of 3.6 (± 1.1) mm at 21 weeks to a mean of 8.6 (± 1.5) mm at 39 weeks. In 45 cases we were unable to perform conventional M-mode ultrasound because of fetal lie; in eight cases STIC volumes were found in post-processing to be unsuitable for analysis. STIC f-TAPSE values ranged from a mean of 4.2 (± 1.4) mm at 21 weeks to a mean of 8.3 (± 1.5) mm at 39 weeks. Scatterplots of f-TAPSE measures obtained with conventional M-mode and with STIC M-mode were created vs GA and estimated fetal weight (EFW). For both modalities, f-TAPSE increased linearly with GA and with EFW. Good correlation was found between the two methods (Pearson's R(2) = 0.904). No significant difference was found in mean or variance of the distributions or slopes of the regression equations. Inter- and intraobserver variation (intraclass correlation coefficient) in conventional M-mode and STIC M-mode f-TAPSE measures were 0.94 and 0.97, respectively. CONCLUSION: F-TAPSE in normal fetuses increases over the course of gestation and correlates to EFW. F-TAPSE measurement is easy to perform and available on all ultrasound machines; STIC f-TAPSE is possible on machines with STIC capability and produces similar measures with a greater success rate. We suggest the addition of f-TAPSE measurement to fetal right cardiac function evaluation.

Functional assessment of the fetal heart: a review.

The purpose of this review is to evaluate the current modalities available for the assessment of fetal cardiac function. The unique anatomy and physiology of the fetal circulation are described, with reference to the difference between in-utero and ex-utero life. M-mode, early/atrial ratio, myocardial performance index, three-dimensional and four-dimensional ultrasound, tissue Doppler including strain and strain rate, speckle tracking, magnetic resonance imaging and venous flow assessment are described. The modalities are analyzed from the perspective of the clinician and certain questions are posed. Does the modality assess systolic function, diastolic function or both? Is it applicable to both ventricles? Does it require extensive post-processing or additional hardware, or does it make use of technology already available to the average practitioner? The reproducibility and reliability of the techniques are evaluated, with reference to their utility in clinical decision-making. Finally, directions for future research are proposed.

Fetal cardiac function: M-mode and 4D spatiotemporal image correlation.

Fetal cardiac function has been shown to be a marker of disease severity in many conditions, including intrauterine growth restriction, congenital heart defects or disease (CHD), twin-to-twin transfusion syndrome, idiopathic hydrops, fetal arrhythmias, and others. It is often targeted for evaluation of patient management, for providing complete and accurate diagnoses in CHD, for patient counseling, or in referring for fetal cardiac interventions. In this review we will describe the use of M-mode and 4D spatiotemporal image correlation in fetal cardiac evaluation, the parameters that can be measured, and their application to clinical practice.

Randomised placebo-controlled trial of teduglutide in reducing parenteral nutrition and/or intravenous fluid requirements in patients with short bowel syndrome.

BACKGROUND AND AIMS: Teduglutide, a GLP-2 analogue, may restore intestinal structural and functional integrity by promoting repair and growth of the mucosa and reducing gastric emptying and secretion, thereby increasing fluid and nutrient absorption in patients with short bowel syndrome (SBS). This 24-week placebo-controlled study evaluated the ability of teduglutide to reduce parenteral support in patients with SBS with intestinal failure. METHODS: In 83 patients randomised to receive subcutaneous teduglutide 0.10 mg/kg/day (n = 32), 0.05 mg/kg/day (n = 35) or placebo (n = 16) once daily, parenteral fluids were reduced at 4-week intervals if intestinal fluid absorption (48 h urine volumes) increased ≥ 10%. Responders were subjects who demonstrated reductions of ≥ 20% in parenteral volumes from baseline at weeks 20 and 24. The primary efficacy end point, a graded response score (GRS), took into account higher levels and earlier onset of response, leading to longer duration of response. The intensity of the response was defined as a reduction from baseline in parenteral volume (from 20% to 100%), and the duration of the response was considered the response at weeks 16, 20 and 24. The results were tested according to a step-down procedure starting with the 0.10 mg/kg/day dose. RESULTS: Using the GRS criteria, teduglutide in a dose of 0.10 mg/kg/day did not have a statistically significant effect compared with placebo (8/32 vs 1/16, p=0.16), while teduglutide in a dose of 0.05 mg/kg/day had a significant effect (16/35, p = 0.007). Since parenteral volume reductions were equal (353 ± 475 and 354 ± 334 ml/day), the trend towards higher baseline parenteral volume (1816 ± 1008 vs 1374 ± 639 ml/day, p=0.11) in the 0.10 mg/kg/day group compared with the 0.05 mg/kg/day group may have accounted for this discrepancy. Three teduglutide-treated patients were completely weaned off parenteral support. Serious adverse events were distributed similarly between active treatment groups and placebo. Villus height, plasma citrulline concentration and lean body mass were significantly increased with teduglutide compared with placebo. CONCLUSIONS: Teduglutide was safe, well tolerated, intestinotrophic and suggested pro-absorptive effects facilitating reductions in parenteral support in patients with SBS with intestinal failure. ClinicalTrials.gov number NCT00172185.

Shunt diameter in agenesis of the ductus venosus with extrahepatic portosystemic shunt impacts on prognosis.

OBJECTIVES: Agenesis of the ductus venosus (ADV) is a rare condition in which there are two variants of umbilical vein drainage: intrahepatic shunt or extrahepatic (portosystemic) shunt. It has been posited that the extrahepatic variant carries a poorer prognosis. However, in the absence of associated anomalies there is still a wide variation in outcome. We evaluated the portal system in cases of ADV and aimed to identify parameters that might predict outcome. METHODS: We conducted a retrospective study of cases of ADV with extrahepatic shunt that had been examined in two centers, and collected new cases prospectively. The route of the shunt was depicted using two-dimensional (2D) and three-dimensional (3D) ultrasound imaging. In an attempt to characterize portal system and shunt developmental variations and their possible impact on outcome, the diameter of the shunt was compared with the diameter of the umbilical vein and the entire portal vasculature was assessed. Poor outcome was defined as persistent morbidity or fetal or neonatal death. RESULTS: Twenty-two cases of ADV were identified: nine retrospectively and 13 prospectively. Aberrant shunts from the umbilical vein were identified to the right atrium, coronary sinus, inferior vena cava (IVC) and iliac vein. In seven of 22 cases (32%) a wide connection was observed. In six of these seven cases (86%) the outcome was poor, including four with severe associated anomalies and two with hepatic dysfunction. In five of these cases, cardiomegaly with tricuspid regurgitation was observed, as well as underdevelopment of the portal system. In only five of 15 cases with a narrow shunt (33%) was the outcome poor, and in all five cases the poor outcome was related to associated anomalies. CONCLUSION: In cases of ADV with extrahepatic shunt, portal system development is impacted by the diameter of the shunt. If the shunt is narrow, the portal system will have developed normally. A wide shunt is associated with underdevelopment or absence of the portal system. In cases of ADV with extrahepatic shunt, prognosis is determined by the severity of associated anomalies, the diameter of the shunt and development of the portal system.

Added value of three-/four-dimensional ultrasound in offline analysis and diagnosis of congenital heart disease.

OBJECTIVE: Many published studies have shown that application of three-dimensional (3D) and real-time 3D (4D) ultrasound modalities can improve certain aspects of fetal echocardiography, but have left open the question of whether these modalities improved the accuracy of prenatal detection of anatomical fetal cardiovascular malformations. We aimed to determine whether 3D/4D ultrasound improved diagnostic ability in cases of congenital heart disease (CHD). METHODS: Women who attended for early- or midtrimester targeted organ scans had complete fetal echocardiography according to our five-planes protocol, as well as examination of the ductus venosus and longitudinal aortic arch planes, performed with 2D ultrasound combined with 2D color Doppler, spatiotemporal image correlation (STIC), STIC with color Doppler, and STIC with B-flow. Ultrasound data of cases of CHD were stored in a dedicated archive. Stored cases were anonymized and the list order was randomized. Stored 2D ultrasound cineloops and 4D ultrasound volumes were reviewed separately according to a standardized table of 23 specified structures on five required planes of visualization: the upper abdomen, four-chamber view, five-chamber view, pulmonary artery bifurcation view, and three vessels and trachea plane. Separate diagnoses were recorded and finally compared. Diagnoses were confirmed by pathological examination or neonatal echocardiography. RESULTS: During the study period, 13 101 examinations were performed; 181 diagnoses of CHD were made. In 12 of these, 3D/4D ultrasound added to the accuracy of our diagnosis: one right aortic arch with anomalous branching; one transposition of the great arteries with pulmonary atresia diagnosed with tomographic ultrasound imaging (TUI); one segmental interrupted aortic arch diagnosed with TUI; one right ventricle aneurysm diagnosed with B-flow; two agenesis of ductus venosus to the coronary sinus diagnosed by multiplanar reconstruction (MPR) and B-flow; two total anomalous pulmonary venous connection diagnosed with MPR; and four ventricular septal defect (VSD) diagnosed with the aid of virtual planes. There were 12 missed diagnoses and no false-positive results. CONCLUSIONS: 3D/4D ultrasound modalities may have advantages in some aspects of fetal cardiovascular evaluation, however, overall 3D/4D ultrasound modalities had added value in only about 6% of cases of fetal anatomical cardiovascular anomalies.

Fetal heart ventricular mass obtained by STIC acquisition combined with inversion mode and VOCAL.

OBJECTIVE: Estimation of fetal heart ventricular mass is important for fetal cardiac evaluation in cases of structural or functional cardiac disorders or extracardiac factors. It may be used with other cardiac parameters to ascertain the severity and prognosis of such disorders, or the nature and timing of intervention. We applied a novel technique combining spatiotemporal image correlation (STIC) with three-dimensional inversion mode and Virtual Organ Computer-aided AnaLysis (VOCAL™) for fetal cardiac mass assessment in healthy fetuses in the second and third trimesters. METHODS: STIC acquisition was performed during fetal quiescence with the abdomen uppermost, at an angle of 30-50°, without color Doppler mapping. Myocardial volume measurements were performed in postprocessing using VOCAL mode, set to 15°. Beginning with the heart in four-chamber view at end diastole, a trace was drawn manually including the myocardium and interventricular septum. Inversion mode colors the intraventricular (anechoic, fluid-filled) voxels; this intraventricular volume was subtracted automatically from the total. Mass was determined by multiplying the result by the estimated fetal myocardial density (1.050 g/cm(3) ). The process was repeated for right and left ventricles. RESULTS: Data from 106 fetuses at 21-38 weeks' gestation were obtained and scatterplots of fetal cardiac ventricular mass distribution were created. Several cases of fetuses with disordered cardiac ventricle (supraventricular tachycardia, hypoplastic left heart syndrome, dilated cardiomyopathy, twin-to-twin transfusion syndrome, Ebstein anomaly, non-immune hydrops fetalis, septate right atrium and diaphragmatic hernia) were examined. Ventricular mass parameters were markedly affected as compared with normal cases of similar gestational age. CONCLUSIONS: STIC acquisition combined with inversion mode and VOCAL is a feasible method of cardiac ventricular mass quantification. This methodology may have added value in fetal cardiac evaluation in cases of anatomic malformation or cardiac dysfunction, or in cases of maternal diabetes.

The fetal venous system, part I: normal embryology, anatomy, hemodynamics, ultrasound evaluation and Doppler investigation.

Since its introduction in the mid-1980s sonographic evaluation of the human fetal venous system has advanced dramatically. The venous system is well-recognized as a target for investigation in cases of circulatory compromise, and a broad spectrum of malformations affecting this system has been described. Appreciation of the normal embryology, anatomy and physiology of this system is essential to an understanding of structural anomalies and the sequential changes encountered in intrauterine growth restriction or other developmental disorders. We review the normal embryology, anatomy, and hemodynamics of the human fetal venous system, and provide an overview of Doppler investigation, as well as three- and four-dimensional ultrasound modalities and their application to this system.

The fetal venous system, Part II: ultrasound evaluation of the fetus with congenital venous system malformation or developing circulatory compromise.

The human fetal venous system is well-recognized as a target for investigation in cases of circulatory compromise, and a broad spectrum of malformations affecting this system has been described. In Part I of this review, we described the normal embryology, anatomy and physiology of this system, essential to the understanding of structural anomalies and the sequential changes encountered in intrauterine growth restriction and other developmental disorders. In Part II we review the etiology and sonographic appearance of malformations of the human fetal venous system, discuss the pathophysiology of the system and describe venous Doppler investigation in the fetus with circulatory compromise.

[Intestinal failure: from adaptation to transplantation]. / Insuffisance intestinale: de l'adaptation à la transplantation.

Optimised Home Parenteral Nutrition is still, after 35 years of progress, the << gold standard >> of benign but chronic Intestinal Failure. A better recognition of chronic Intestinal Failure, in its multiple facets, is warranted for a better approach of associated treatment to Home Parenteral Nutrition, i.e., intestinal trophic factors (growth hormone, Glucagon Like Peptide-2), rehabilitative surgery (reestablishment of colonic continuity, reverse jejunal segment in severe short gut type II) and/or reconstructive surgery (intestinal transplantation for end stage intestinal failure patients). Boundaries of permanent, judged irreversible, intestinal failure will be certainly modified in the following years by combining the various and effective therapies which optimise management by ameliorating absorption of the remnant short gut. The work done on short bowel syndrome in the past 20 years should be done in the next years for chronic-intestinal - pseudo-obstruction patients presenting with intestinal failure on a large European scale because chronic-intestinal - pseudo-obstruction is a group of heterogeneous but rare intestinal diseases. Intestinal transplantation is now a mature therapy with formal indication especially in case of Home Parenteral Nutrition failure (mainly Home Parenteral Nutrition-associated severe liver disease) where combined Liver-intestine transplantation is indicated before end-stage liver failure occurs. For high-risk patients, "preemptive" indication for intestinal transplantation alone will be discussed before home parenteral nutrition complications occur. No doubt that, for improving overall outcome in intestinal failure patients, reference centres should have in expert hands the whole spectrum of medicosurgical therapies for intestinal failure.

[Chronic intestinal pseudo-obstruction and anti-Hu syndrome: 13 years of follow-up without neoplasia]. / Pseudo-obstruction intestinale chronique et syndrome des anti-Hu: 13 ans de suivi sans apparition de néoplasie.

Chronic intestinal pseudo-obstruction (CIPO) is a heterogeneous group of rare disorders characterised by symptoms of intestinal obstruction with no mechanical evidence of obstruction. It is caused by ineffective intestinal contractions due to visceral neuropathy and/or neuropathy. In adults, CIPO is mostly secondary. The most common causes are metabolic disorders, connective tissue disorders, neuropathic drug related injuries, paraneoplasic and post-infectious syndromes and amyloidosis. Secondary forms of CIPO have been reported with anti-Hu antibodies. This corresponds to an antineuronal antibody that recognizes a protein expressed in the nuclei of neuron (ANNA-1) and neoplasic cells. The anti-Hu antibody must be searched for in patients over 40 years old with CIPO (associated with small cell lung cancer in 75% of cases). Recently, the association of CIPO and the anti-Hu antibody has been described without associated neoplasia. We report a case of an association of CIPO and anti-Hu antibody without cancer after 13 years of follow-up.

Faecal bacterial mass and energetic losses in healthy humans and patients with a short bowel syndrome.

OBJECTIVE: In addition to non-digested nutrients, human stools contain endogenous substrates, among which bacteria are a major component, whose growth may be stimulated when more dietary nutrients are available for bacterial fermentation, as in patients with malabsorption syndrome. We assessed the energy content and composition of both stools and faecal bacteria in healthy volunteers and patients with a short bowel and colon in continuity (SBC). Our goal was to clarify the magnitude of error introduced by the faecal bacteria in the measurement of the digestibility of ingested energy and nutrients. SUBJECTS AND METHODS: We studied six healthy volunteers and six patients with a SBC under free oral intake. The bacterial mass of stools was isolated. In the bacterial fractions and fresh stools, calorie, fat, nitrogen and short-chain fatty acid contents were determined. The Wilcoxon signed rank or the Mann-Whitney tests were used for comparison. RESULTS: In healthy volunteers and patients with SBC, faecal bacterial mass accounted for 44 and 35% of faecal dry weight, and contained 50 and 34% of total faecal energy. In healthy volunteers, the apparent digestibilities when corrected by bacterial constituents (88-97% according to nutrients) were significantly higher than the apparent non-corrected digestibilities (84-94%). In patients with SBC, the corrected apparent digestibilities (69-89% according to nutrients) were significantly higher than the apparent non-corrected digestibilities (54-83%). CONCLUSION: The error introduced by the faecal bacterial fraction when assessing the extent of nutrient digestibility is small in healthy volunteers; it is more pronounced in patients with SBC, reaching 18% for the digestibility of ingested fat.

Human papillomavirus tumour status is not associated with a positive depression screen for patients with oropharyngeal cancer.

BACKGROUND: Several risk factors for depression in patients with oropharyngeal cancer have been determined. However, it is unknown whether human papillomavirus associated oropharyngeal cancer, which has a distinct clinico-demographic profile, modulates this risk. METHODS: A retrospective analysis was conducted of patients with oropharyngeal cancer. These patients had completed a 10-item depression screening questionnaire before receiving treatment for their disease from 2011 to 2014. Associations between patient or disease characteristics and depression screening questionnaire results were investigated. RESULTS: The study comprised 69 patients, 31 (44.9 per cent) of whom screened positive for depression. There were no significant differences in distributions of clinico-demographic or histopathological characteristics, including human papillomavirus tumour status, by depression screen result. CONCLUSION: This population has a high risk for depression, but no obvious risk factors, including human papillomavirus tumour status, were associated with an elevated risk. This inability to risk-stratify patients by clinico-demographic or disease characteristics emphasises the importance of regular depression screening for all patients in this population.

Ethical and legal aspects of enteral nutrition.

European ethical and legal positions with regard to EN vary slightly from country to country but are based on a common tradition derived from Graeco Roman ideas, religious thought and events of the 20th century. The Hippocratic tradition is based on 'beneficience' (do good) and 'non-maleficience' (do no harm). Religious thinking is based upon the presumption of providing food and drink by whatever means unless burden outweighs benefit. The concept of 'autonomy' (the patients right to decide) arose following in the decades after the Second World War and is enshrined in Human Rights law. The competent patient has the right to participate in decision making and to refuse treatment although the doctor is not obliged to give treatment which he or she considers futile or against the patient's interests. The incompetent patient is protected by law. The fourth principle is that of 'justice' i.e. equal access to healthcare for all. The law regards withholding and withdrawing treatment as the same. It also defines the provision of food and drink by mouth as basic care and feeding by artificial means as a medical treatment. It requires doctors to act in the best interests of the patient.

Prognostic significance of erythrocyte sedimentation rate in clinical stages I-II of Hodgkin's disease.

A prospective study was undertaken in 1963 on the respective prognostic significances of erythrocyte sedimentation rate (ESR) and presence or absence of systemic symptoms in Hodgkin's disease. Six hundred seventy-six patients with clinical stages I or II were included in this study; 376 from 1963 to 1971 who were included in the H1 trial of the European Organization for Research and Treatment of Cancer (EORTC) and 300 who had been enrolled in the EORTC H2 trial from 1972 to 1976. All relevant data and long-term follow-up are available from 649 patients who were analyzed in this study. Multivariate analysis (Cox model) was carried out to assess the prognostic value of ESR independently of the other prognostic parameters and of the treatment. The results showed that of all the prognostic indicators studied, ESR is the one which has the highest correlation with relapse-free survival; however, initial ESR is not correlated with the probability of death after relapse. The presence or absence of systemic symptoms has less prognostic impact. Despite a close correlation between systemic symptoms and ESR, the two are not redundant and it is useful to combine both.

Efficacy of 2-month total parenteral nutrition in AIDS patients: a controlled randomized prospective trial. The French Multicenter Total Parenteral Nutrition Cooperative Group Study.

OBJECTIVE: To evaluate the efficacy of total parenteral nutrition in AIDS patients. DESIGN: A prospective, randomized, controlled, multicentre trial. METHODS: Over a period of 2 months, 31 malnourished and severely immunodepressed AIDS patients were assigned to receive either dietary counselling (n = 15) or home total parenteral nutrition (TPN; n = 16) via a central venous access after an educational program. Results were analysed by intent-to-treat basis. RESULTS: Bodyweight change was +8 kg (+13 +/- 3%) in the TPN group and -3 kg (-6 +/- 2%) in the control group (P < 0.0006). Lean body mass increased in the TPN group (+9 +/- 3%) and decreased in the control group (-5 +/- 3%; P < 0.004) while body cell mass increased in the former (+15 +/- 4%) and decreased in the latter (-12 +/- 6%; P < 0.002). Nutritional subjective global assessment, subjective self-reported health feeling and Karnofsky index were also improved by TPN. Infection line sepsis incidence remained low (0.26 per 100 patient-days). However, no difference in survival rate was exhibited between the two groups by the log-rank test. CONCLUSION: We conclude that home TPN is an efficient treatment of malnutrition in severely immunodepressed AIDS patients.