An artificial intelligence algorithm that identifies middle turbinate pneumatisation (concha bullosa) on sinus computed tomography scans.

OBJECTIVE: Convolutional neural networks are a subclass of deep learning or artificial intelligence that are predominantly used for image analysis and classification. This proof-of-concept study attempts to train a convolutional neural network algorithm that can reliably determine if the middle turbinate is pneumatised (concha bullosa) on coronal sinus computed tomography images. METHOD: Consecutive high-resolution computed tomography scans of the paranasal sinuses were retrospectively collected between January 2016 and December 2018 at a tertiary rhinology hospital in Australia. The classification layer of Inception-V3 was retrained in Python using a transfer learning method to interpret the computed tomography images. Segmentation analysis was also performed in an attempt to increase diagnostic accuracy. RESULTS: The trained convolutional neural network was found to have diagnostic accuracy of 81 per cent (95 per cent confidence interval: 73.0-89.0 per cent) with an area under the curve of 0.93. CONCLUSION: A trained convolutional neural network algorithm appears to successfully identify pneumatisation of the middle turbinate with high accuracy. Further studies can be pursued to test its ability in other clinically important anatomical variants in otolaryngology and rhinology.

Physiological changes in the size of the septal swell body correlate with changes in inferior turbinate size.

OBJECTIVE: The nasal septal swell body is a normal anatomical structure located in the superior nasal septum anterior to the middle turbinate. However, the impact of the septal swell body in nasal breathing during normal function and disease remains unclear. This study aimed to establish that the septal swell body varies in size over time and correlates this with the natural variation of the inferior turbinates. METHOD: Consecutive patients who underwent at least two computed tomography scans were identified. The width and height of the septal swell body and the inferior turbinates was recorded. A correlation between the difference in septal swell body and turbinates between the two scans was performed using a Pearson's coefficient. RESULTS: A total of 34 patients (53 per cent female with a mean age of 58.3 ± 20.2 years) were included. The mean and mean difference in septal swell body width between scans for the same patient was 1.57 ± 1.00 mm. The mean difference in turbinate width between scans was 2.23 ± 2.52 mm. A statistically significant correlation was identified between the difference in septal swell body and total turbinate width (r = 0.35, p = 0.04). CONCLUSION: The septal swell body is a dynamic structure that varies in width over time in close correlation to the inferior turbinates. Further research is required to quantify its relevance as a surgical area of interest.

An artificial intelligence algorithm that differentiates anterior ethmoidal artery location on sinus computed tomography scans.

OBJECTIVE: Deep learning using convolutional neural networks represents a form of artificial intelligence where computers recognise patterns and make predictions based upon provided datasets. This study aimed to determine if a convolutional neural network could be trained to differentiate the location of the anterior ethmoidal artery as either adhered to the skull base or within a bone 'mesentery' on sinus computed tomography scans. METHODS: Coronal sinus computed tomography scans were reviewed by two otolaryngology residents for anterior ethmoidal artery location and used as data for the Google Inception-V3 convolutional neural network base. The classification layer of Inception-V3 was retrained in Python (programming language software) using a transfer learning method to interpret the computed tomography images. RESULTS: A total of 675 images from 388 patients were used to train the convolutional neural network. A further 197 unique images were used to test the algorithm; this yielded a total accuracy of 82.7 per cent (95 per cent confidence interval = 77.7-87.8), kappa statistic of 0.62 and area under the curve of 0.86. CONCLUSION: Convolutional neural networks demonstrate promise in identifying clinically important structures in functional endoscopic sinus surgery, such as anterior ethmoidal artery location on pre-operative sinus computed tomography.

Long-term outcome of anti-tumor necrosis factor alpha blockade in the treatment of juvenile spondyloarthritis.

OBJECTIVES: A significant proportion of patients with juvenile spondyloarthritis (JSpA) are refractory to treatment with established medications. The objective of this study was to assess long-term efficacy of treatment with anti-TNF agents in patients with JSpA. METHODS: An observational study of 16 patients with JSpA from 3 centres treated with infliximab (n=10) and etanercept (n=6) was performed, with a median follow-up period of 7.2 years. Prospective data was collected according to a standardized protocol. Outcomes examined were TEC, TAJC, markers of inflammation (ESR, CRP), functional assessments (C-HAQ, BASDAI, BASFI), and ongoing requirement for anti-TNF treatment. RESULTS: 13/16 patients (83%) had achieved clinical remission 6 months into the treatment. Improvement was sustained over time, with a median TAJC and TEC of 0 at any time point after 6 weeks. 6/16 patients (38%) showed a flare of arthritis after a median of 3.5 years. Two patients with hip disease prior to treatment required an arthroplasty 3 and 8 years post anti-TNF initiation. Patients showed progression of sacroiliitis with median modified New York score of 1 (range 0-3) at time of diagnosis and 3 (range 0-4) at last follow-up (p=0.002). Median BASDAI at last follow up was 1.6, median BASFI 3.1. Two patients developed transient reactions (one generalised, one local); no patient developed other adverse effects during the study. CONCLUSIONS: Anti-TNF treatment in JSpA refractory to standard treatment results in good long-term disease control except for pre-existing hip disease. However, radiographic evidence suggests inferior efficacy for control of sacroiliac joint disease.

The metabolic syndrome - an ongoing story.

The metabolic syndrome refers to the clustering of cardiovascular risk factors that include diabetes, obesity, dyslipidaemia and hypertension. Due to various definitions and unexplained pathophysiology it is still a source of medical controversy. Insulin resistance and visceral obesity have been recognized as the most important pathogenic factors. Insulin resistance could be defined as the inability of insulin to produce its numerous actions, in spite of the unimpaired secretion from the beta cells. Metabolic abnormalities result from the interaction between the effects of insulin resistance located primarily in the muscle and adipose tissue and the adverse impact of the compensatory hyperinsulinaemia on tissues that remain normally insulin-sensitive. The clinical heterogeneity of the syndrome can be explained by its significant impact on glucose, fat and protein metabolism, cellular growth and differentiation, and endothelial function. Visceral fat represents a metabolically active organ, strongly related to insulin sensitivity. Moderating the secretion of adipocytokines like leptin, adiponectin, plasminogen activator inhibitor 1 (PAI-1), tumor necrosis factor alfa (TNF-alfa), interleukin-6 (IL-6) and resistin, it is associated with the processes of inflammation, endothelial dysfunction, hypertension and atherogenesis. In 2005, the International Diabetes Federation (IDF) has proposed a new definition, based on clinical criteria and designed for global application in clinical practice. Visceral obesity measured by waist circumference is an essential requirement for diagnosis; other variables include increased triglyceride and decreased HDL levels, hypertension and glucose impairment. Whatever the uncertainties of definition and etiology, metabolic syndrome represents a useful and simple clinical concept which allows earlier detection of type 2 diabetes and cardiovascular disease.

Therapy of nonalcoholic fatty liver disease: current status.

Nonalcoholic fatty liver disease (NAFLD), the hepatic manifestation of the metabolic syndrome, has become a common entity in clinical practice. In most of the patients it presents as simple steatosis with nonprogressive clinical course. However, some patients have progressive form of NAFLD, nonalcoholic steatohepatitis (NASH), and are at increased risk of developing cirrhosis and hepatocellular carcinoma. NAFLD treatment includes lifestyle modifications and pharmacotherapy aiming at increasing insulin sensitivity, and attenuating inflammation and hepatic fibrosis. Weight reduction has consistently been shown to reduce levels of liver enzymes and insulin resistance. Although dietary intervention and exercise remain the first-line therapy, due to low patients compliance to these measures pharmacotherapy or surgical approaches are often required. Metformin and thiazolidinediones may improve insulin sensitivity, serum aminotransferase level and liver histology. However, little evidence exists regarding their sustained effects after drug discontinuation which, together with their side effects, limits their widespread use in clinical practice. Statins appear to be safe agents for the treatment of hyperlipidemia, although trials documenting their efficacy in NAFLD are scarce. Based on the recent clinical trials, weight loss medication orlistat, ursodeoxycholic acid and antioxidant agents could potentially be used as adjunctive therapy. Considering still largely controversial clinical data regarding pharmacological agents, their high cost and known side-effects, lifestyle modifications at present remain the only essential considerations in the NAFLD treatment.

Pericarditis in exacerbation of ulcerative colitis.

Acute pericarditis occurs very rarely in association with inflammatory bowel disease (IBD). It has been described both as an extraintestinal manifestation of IBD and as an adverse drug reaction in IBD treatment. We present a case of a 26-year-old female patient with a severe exacerbation of ulcerative colitis, who was previously under long-term treatment with mesalazine and low-dose prednisone. The literature on pericardial involvement in IBD is reviewed.

Hepatocyte growth factor levels in Croatian healthy and alcoholic liver cirrhosis patients.

Hepatocyte growth factor (HGF) is a most potent hepatocyte mitogen, and plays a mayor role in liver regeneration during injury. The aim of this study was to evaluate HGF values in Croatian healthy and alcoholic liver cirrhosis patients (AC). The HGF and standard laboratory tests of liver damage were measured in 33 AC patients, and 41 healthy subjects. HGF was measured by using an ELISA method. The HGF levels were higher in cirrhotic patients than in healthy subjects (median value is 0.78 vs. 0.19 ng/ml, p < 0.001). Japanese study showed similar values of HGF for healthy subjects and AC subjects. The HGF values in patients depend on grade of illness. There was found significant correlation between HGF and almost all standard liver damage tests. The ROC analysis showed that measuring of HGF had convincingly best accuracy than other parameters, and seems to be useful in classifying grade of illness.

Perforation--a rare complication of a small-bowel carcinoid.

Carcinoids are rare compared to other tumours of the gastrointestinal tract, but present a significant portion of tumours of the small intestine. The case of a 50-year-old man who suffered perforation of a small-bowel carcinoid after failed diagnostic trials is reported here. Since intestinal perforation is rarely the first sign of the presence of a carcinoid, it is useful to bear this in mind when dealing with unclear pathological changes of the small intestine.

Use of octreotide-acetate in preventing pancreatitis-like changes following therapeutic endoscopic retrograde cholangiopancreatography.

Acute pancreatitis is a serious complication of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterectomy (EST). In addition, serum pancreatic enzymes increase without clinical symptoms in up to 75% of patients undergoing endoscopic procedures. The aim of this trial was to investigate the effects of octreotide in the prevention of these possible complications in patients undergoing therapeutic ERCP. The study was carried out in 209 subjects who were randomly allocated to two groups (A and B). Group A received 0.5 mg of octreotide-acetate subcutaneously one hour prior to ERCP; group B was given placebo. Serum amylase and lipase values were measured before premedication and 1.5, 2, 6 and 24 hours following endoscopy. Following ERCP, the increase in both amylase and lipase values was significantly greater in the control (placebo) group, but this significance disappeared 24 hours following the procedure. Symptoms of acute pancreatitis developed in 4 (3.85%) patients who were given octreotide-acetate, compared to 10 (9.52%) patients in the control group. The results obtained in our study seem to indicate that octreotide could prevent the increase in serum pancreatic enzymes, but no significant difference was observed in the prevention of post-ERCP pancreatitis.

Whipple's disease: a case study with unexpected prognosis.

Due to the systemic nature of Whipple's disease, its clinical presentation may be highly variable. The diagnosis may, therefore, be unduly delayed. Untreated, Whipple's disease is still potentially lethal. Although it traditionally presents with signs and symptoms of small intestine involvement, such as diarrhea and malabsorption, Whipple's disease can involve many other organs. Typically, the diagnosis is established by biopsy of the small intestine. The authors describe a case of Whipple's disease in order to stress the importance of bearing this polymorphic disease in mind, with special emphasis on its possible lethal outcome in spite of therapy.

Factors predictive of the healing of pancreatic pseudocysts treated by percutaneous evacuation.

BACKGROUND/AIMS: Pseudocyst formation is a well-known complication of pancreatitis which develops over 1 to 4 weeks in approximately 15% of patients. Nearly one-third of pancreatic pseudocysts resolve spontaneously; however, if there is no resolution within six weeks, evacuation must be performed. The aim of this study was to prospectively assess the reliability of the following: etiology; location; amount of pseudocyst liquid; and concentrations of certain biochemical parameters (LDH, glucose, proteins, sodium, potassium, bilirubin, lipase and amylase) in the pseudocyst content and patients' serum, in terms of the efficacy of ultrasound-guided percutaneous evacuation as a therapeutic approach. METHODOLOGY: Pseudocyst fluid was obtained by ultrasound-guided percutaneous evacuation in 67 patients, with a history of pancreatitis and pancreatic pseudocysts larger than five centimeters in diameter, with a matured membraneous wall that persisted for more than six weeks. RESULTS: There is a prognostic value associated with the location of the pseudocyst, the amount of pseudocyst liquid and the concentration of proteins, potassium, lipase and amylase in the evacuated material. CONCLUSION: Analysis of the aforementioned parameters provides an early forecast of the outcome of percutaneous evacuation.

Tuberculous peritonitis--a case report.

Tuberculosis continues to be a major health problem worldwide and, due to its systemic nature, its clinical presentation may be highly variable. The diagnosis may, therefore, be unduly delayed. A 67-year old male refugee was admitted to our Department with a diagnosis of intra-abdominal carcinomatosis. During hospitalization, tuberculous peritonitis was found to be the cause of his symptoms. Antituberculosis therapy was administered and the patient responded adequately, achieving total clinical remission. The importance of considering this polymorphous disease is emphasized.

[An approach to dyspepsia in primary health care]. / Pristup dispepsiji u primarnoj zdravstvenoj zastiti.

Dyspepsia is a common problem in primary health care and involves a great deal of physician's time, if we assume that the prevalence in general population is 25-50%. Since the definition of dyspepsia has been elusive, which has resulted in confusion about diagnosis and therapy, the need for management guidelines that would produce satisfactory results has been manifested. The International Gastro Primary Care Group has developed practical framework, which identifies the predominant symptom of dyspepsia as a guide in the selection of the most appropriate treatment, and is also used as a tool in dealing with common therapeutical dilemmas until new evidence become available.

The protective effect of zinc sulphate pretreatment against duodenal ulcers in the rat.

Exogenously administered zinc compounds have been shown to possess antiulcer activity in the development of gastric lesions. The aim of this study was to investigate the effects of zinc sulphate pretreatment of rats on cysteamine-induced duodenal ulcers and to correlate them with changes in zinc serum and tissue levels. Atomic absorption spectrophotometry was used to determine zinc serum and tissue concentrations in all animal groups. Cysteamine produced marked duodenal ulceration in control animals 24 h after application, with an increase in endogenous zinc tissue concentrations and a marked decrease in serum concentrations. Zinc sulphate (20, 40 or 80 mg kg-1) applied per os one hour prior to cysteamine application inhibited the development of duodenal lesions in a dose-related manner. The application of zinc sulphate in a single intraperitoneal (i.p.) application (80 mg kg-1) did not, however, prevent the formation of duodenal lesions. In order to assess zinc absorption from the gastrointestinal tract, one group of rats received a single oral dose of zinc sulphate (80 mg kg-1) without cysteamine application. The observations of this study seem to indicate that zinc plays an important cytoprotective role in duodenal ulcer disease.

Endogenous zinc concentrations in cysteamine-induced duodenal ulcers in the rat.

Exogenously administered zinc compounds have been shown to possess anti-ulcer activity against a wide variety of ulcerogenic agents, both in laboratory animal models and in human peptic ulcer disease. However, a strong possibility exists that endogenous zinc may also play an important role during noxious events by various mechanisms. Therefore, the aim of this study was to focus on the changes of endogenous zinc serum and tissue concentrations in cysteamine-induced duodenal lesions. We used atomic absorption spectrophotometry to determine the tissue and serum concentrations of zinc in normal (control) rats and those with cysteamine-induced duodenal ulcers. The results obtained in this study indicated that the onset, development and spontaneous healing of ulcer lesions were associated with certain shifts in zinc serum and tissue concentrations. Prior to ulcer formation, a significant increase was noted in serum zinc values. With the onset of duodenal lesions, zinc serum concentrations significantly decreased, while there was a significant increase in duodenal tissue concentrations when compared to healthy control animals. Zinc tissue concentrations decreased and returned to starting values by the end of the first week of spontaneous healing. This decrease in zinc tissue concentration corresponded to the healing rate of the duodenal ulcers. Serum zinc concentrations also returned to starting values within the first week period. These observations indicate and confirm that zinc could play an important role in duodenal ulcer disease and represent a natural defense system in the body.

The dynamics of endogenous zinc in different animal models of gastroduodenal ulceration.

The body possesses many various endogenous substances that enable it to protect itself from various noxious events. One of the nonspecific reactions is the increase of endogenous zinc concentrations in various tissues. The aim of this study was to focus on the changes of zinc serum and tissue concentrations in well-established models of gastric (24 h restraint stress and 5 min ethanol) and duodenal ulceration (24 h cysteamine). Ten female Wistar rats, weighing 180-250 g were used in each of the experimental groups. Upon sacrificing, the ulcer index was recorded. Zinc serum and tissue concentrations were determined using atomic absorption spectrophotometry. Ten unstressed animals served as a healthy control group. The results of our study clearly indicated certain changes in serum zinc in all these ulcer models. Changes in tissue concentrations, varying from model to model, were also observed. In conclusion, all this data confirm the fact that endogenous zinc represents a natural line of the body's defense system when exposed to stress.

Giant peptic ulcers in patients undergoing maintenance hemodialysis.

The aim of the study was to investigate the clinical characteristics of hemodialyzed uremic patients with upper gastrointestinal lesions. A total of 20 (7.2%) out of 276 patients on hemodialysis program underwent endoscopy and rentgenography of the upper gastrointestinal tract. The incidence of peptic ulcer disease in the patients with end-stage renal disease was 4.3%. Six (30%) out of 20 uremic hemodialyzed patients with gastrointestinal complications had giant peptic ulcers of duodenum or prepyloric area. In three (50%) out of six subjects, giant peptic ulcers were located in the second portion of the duodenum. Gastrointestinal hemorrhagic complications occurred in 12 (60%) patients. The most frequent sources of bleeding were duodenal ulcers alone (8 patients) or in combination with gastric and/or duodenal flat erosions (6 patients), angiodysplasia of the duodenum (3 patients) and duodenal erosions (one patient). Two patients with bleeding from giant ulcers died from perforation and hemorrhagic shock. The uremic hemodialyzed patients with giant ulcers were older than 65, had higher basal gastrin concentration (305.3 +/- 183.8 pmol/l), and lower basal (1.6 +/- 0.16 mmol/h) and stimulated gastric acid secretion (14.4 +/- 8.63 mmol/h).

Preoperative evaluation of rectal carcinoma by transrectal ultrasonography.

The aim of the study was to assess the diagnostic value of transrectal ultrasonography (TRUS) in detecting the depth of tumor infiltration as well as the involvement of lymph nodes in patients with rectal carcinoma diagnosed after rectoscopy and proven by examination of the biopsy specimen. TRUS was performed on thirty-three patients with rectal carcinoma prior to surgery, the first assessment of tumor growth, and extension by pathological examination of the operative specimen. TRUS correctly assessed perirectal growth in 18 out of 22 cases proven by pathology (two understaged, accuracy 86 percent), while in 12 cases with no perirectal growth proven by pathology this method was correct in 9 cases (three overstaged, accuracy 75 percent). The results of this study indicate that TRUS, combined with endoscopy and biopsy, is a useful procedure in the preoperative staging of malignant rectal lesions and provides valuable data for the therapeutic planning of patients with rectal carcinoma.

The beneficial effect of BPC 157, a 15 amino acid peptide BPC fragment, on gastric and duodenal lesions induced by restraint stress, cysteamine and 96% ethanol in rats. A comparative study with H2 receptor antagonists, dopamine promotors and gut peptides.

The protection of stomach and duodenum in conjecture with anti-inflammatory effect was demonstrated for a novel 15 amino acid peptide, coded BPC 157, a fragment of the recently discovered gastric juice peptide BPC. BPC 157 (i.p./i.g.) was investigated in rats in comparison with several reference standards in three experimental ulcer models (48 h-restraint stress, subcutaneous cysteamine, intragastrical 96% ethanol ulcer tests) (pre-/co-/post-treatment). Only BPC 157 regimens were consistently effective in all of the tested models. On the other hand, bromocriptine, amantadine, famotidine, cimetidine and somatostatin were ineffective (restraint stress). A dose-dependent protection (cysteamine) and/or partial positive effect (related to treatment conditions) (ethanol), was obtained with glucagon, NPY and secretin whereas CCK/26-30/was not effective. Based on Monastral blue studies BPC 157 beneficial effect appears to be related to a strong endothelial protection.