Three-item loneliness scale: psychometric properties and normative data of the Spanish version.

Loneliness is a common social phenomenon across countries with negative effects in health. Thus, the measurement of loneliness is of paramount importance. The Three-Item Loneliness Scale (TILS) was designed to be used in large-population surveys as a quick measure of loneliness. The aim of this study is to provide a Spanish validation of the TILS. A representative sample of the Spanish population (N = 1951) was used. We analysed the psychometric properties, factor structure, and distribution demographics characteristics of the Spanish TILS. Analyses showed differences regarding age, gender, educational level, employment status, household composition and annual gross income in line with previous literature. The confirmatory factor analysis revealed a unifactorial structure, with significant moderate correlations between the TILS and depression, anxiety, paranoia and well-being, and mild significant correlations with belongingness and mistrust. The internal consistency of the Spanish TILS was good (α = 0.82). Our study indicates that the TILS is a valid and reliable measure of loneliness in the Spanish population. Loneliness is a modern epidemic and a precursor of mental and health problems that reduced the quality of life. Therefore, it is important to have reliable measures of this phenomenon.

EFSUMB statement on medical student education in ultrasound [short version].

The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) recommends that ultrasound should be used systematically as an easy accessible and instructive educational tool in the curriculum of modern medical schools. Medical students should acquire theoretical knowledge of the modality and hands-on training should be implemented and adhere to evidence-based principles. In this paper we summarise EFSUMB policy statements on medical student education in ultrasound.

Bone mineral density and bone turnover in non-cirrhotic patients with chronic hepatitis C and sustained virological response to antiviral therapy with peginterferon-alfa and ribavirin.

UNLABELLED: Patients with chronic hepatitis C have low bone mineral density and increased bone resorption related to serum transaminase levels. Elevated serum soluble tumor necrosis factor (sTNFR-55) receptor levels may play a role in the bone mass loss in these patients. Bone mass is improved and bone turnover normalized in patients who respond to antiviral therapy with interferon and ribavirin. INTRODUCTION: Low bone mineral density (BMD) has been described in patients with chronic hepatitis C (HCV). The study objective was to evaluate the effect of antiviral therapy on BMD and bone metabolism in non-cirrhotic HCV patients with sustained virological response. METHODS: We conducted a prospective study in 36 consecutive outpatients from the general community with non-cirrhotic HCV and an early and sustained virological response to peginterferon-alfa and ribavirin therapy. Determinations of BMD (dual X-ray absorptiometry at lumbar spine and femoral neck) and biochemical measurements of bone metabolism and sTNFR-55 were made at baseline, after 24 and 48 weeks of antiviral therapy, and at 48 weeks after the end of treatment. RESULTS: Patients had a significantly reduced BMD, which significantly increased during the follow-up. Serum levels of sTNFR-55 and bone turnover markers were increased at baseline and significantly reduced at all subsequent time points. We found an inverse correlation between BMD and both serum aminotransferase levels and urine deoxypyridinoline (D-pyr) and a positive correlation between serum aminotransferases and both urine D-Pyr and serum sTNFR-55. CONCLUSIONS: Patients with chronic hepatitis C have low bone mass associated with increased bone resorption, and some relationship can be expected between serum aminotransferase levels and the degree of bone mass loss. Bone mass may be improved and bone turnover normalized in patients who respond to antiviral therapy. Elevated serum sTRFR-55 levels may play a role in the bone mass loss of these patients.

Systematic review of clinical trials on antithrombotic therapy with factor XI inhibitors.

INTRODUCTION AND OBJECTIVE: Data from phase 2 clinical trials suggest that factor XI inhibitors may exhibit a more favorable efficacy/safety profile compared to current antithrombotic therapies. The aim of this systematic review is to analyze the available evidence derived from these studies. METHODS: A literature search in the PubMed, Cochrane Library, Scopus, EMBASE databases, and clinical trial registration platforms Clinical Trials and Cochrane Central Register of Controlled was conducted. In accordance with the PRISMA statement, results were reported. RESULTS: A total of 18 completed or ongoing clinical trials addressing multiple scenarios, including atrial fibrillation, stroke, myocardial infarction, and venous thromboembolism, were identified. Evidence from 8 studies with available results was analyzed. Phase 2 studies with factor XI inhibitors, overall, demonstrated an acceptable efficacy and safety profile. The benefit-risk balance, in terms of reducing venous thromboembolism in patients undergoing total knee arthroplasty, was more favorable. For this scenario, factor XI inhibitors showed a 50% reduction in the overall rate of thrombotic complications and a 60% reduction in the rate of bleeding compared to enoxaparin. Modest results in studies involving patients with atrial fibrillation, stroke, and myocardial infarction were observed. CONCLUSIONS: Factor XI inhibitors offer new prospects in antithrombotic treatment and prophylaxis. Ongoing phase 3 studies will help define the most suitable drugs and indications.

Dolly for dinner? Assessing commercial and regulatory trends in cloned livestock.

As cloning technologies become more widely established, will products enter the food chain sooner than regulatory agencies and the public might be prepared for?

Biliary sphincterotomy dilation for the extraction of difficult common bile duct stones.

BACKGROUND AND AIM: Endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy (BS) is the usual method for extracting common bile duct stones. However, following BS and by means of extraction balloons and Dormia baskets a complete bile duct clearance cannot be achieved in all cases. We present a study on the impact that hydrostatic balloon dilation of a previous BS (BSD) may have in the extraction rate of choledocholithiasis. PATIENTS AND METHODS: A prospective study which included 91 consecutive patients diagnosed with choledocholithiasis who underwent ERCP. For stone removal, extraction balloons and Dormia baskets were used, and when necessary BSD was employed. RESULTS: Complete bile duct clearance was achieved in 86/91 (94.5%) patients. BSD was used in 30 (33%) cases. In these cases, extraction was complete in 29/30 (97%); 23 (76%) patients in the BSD group had anatomic difficulties or bleeding disorders. The most frequently used hydrostatic balloon diameter was 15 mm (60%). There were 7 (7.6%) complications: two self-limited hemorrhage episodes in the BSD group and one episode of cholangitis, one of pancreatitis, and three of bleeding in the group in which BSD was not used. CONCLUSIONS: BSD is a very valuable tool for extracting common bile duct stones. In our experience, there has been an increase in the extraction rate from 73% (Rev Esp Enferm Dig 2002; 94: 340-50) to 94.5% (p = 0.0001, OR 0.1, CI 0.05-0.45), with no increase in complications.

[Palliative management of malignant gastric outlet obstruction with endoscopically inserted self-expanding metal stents].

AIM AND BACKGROUND: the insertion of self-expanding metal stents to palliate malignant gastric outlet obstruction is a minimally invasive procedure that is being increasingly used. We discuss experience with this technique in a level-II hospital in the Spanish National Health System. PATIENTS AND METHODS: a retrospective five-year study (2003-2007) was conducted in 23 patients who underwent 27 procedures aimed at resolving malignant gastric outlet obstruction (mean, 0.45 procedures per month) using endoscopically inserted noncovered stents (Wallstent and Wallflex). RESULTS: insertion was technically feasible in all 27 (100%) attempts, with satisfactory clinical results in 25 cases (92.5%). Endoscopy alone was used 10 times (37%), and both endoscopy and fluoroscopy on 17 (63%) occasions. After stent insertion, one patient was intervened for treatment, and a patient with an unsuccessful prosthesis received a palliative surgical bypass. Four stents became obstructed by tumoral ingrowth, and patency was reestablished by inserting a new stent. Obstructive jaundice caused by stents covering the papilla of Vater occurred in three cases. There were no other complications or mortality due to the procedure. Mean survival was 104 days (range 28-400, SD +/- 94). CONCLUSIONS: in our experience endoscopic insertion of self-expanding metal stents appears to be a safe and efficient palliative method for malignant gastric outlet obstruction, and can be performed successfully in a center with our characteristics.

Long-term follow-up of patients with small-bowel angiodysplasia on capsule endoscopy. Determinants of a higher clinical impact and rebleeding rate.

BACKGROUND: the clinical impact of small-bowel angiodysplasia has not been defined. We present a prospective study to determine the features of individuals with a higher risk of rebleeding or a worse clinical outcome. PATIENTS AND METHODS: thirty patients with angiodysplasia found on CE were included and followed for 12 months. Angiodysplasia were classified by their size as small ( 10 mm). We also studied angiodysplasia lesion numbers in each patient. Rebleeding was defined as a hemoglobin drop of more than 2 g/dl in the absence of melena or hematochezia in the case of occult GI bleeding, or with any or both manifestations. RESULTS: a therapeutic procedure was carried out in 13 patients (43.4%). Individuals with large angiodysplasia had higher transfusion requirements, a higher proportion of therapeutic procedure performed after CE, lower hemoglobin concentration, and a lower rebleeding rate. Patients with ten or more angiodysplasia lesions had also higher transfusion requirements and lower hemoglobin levels, but we found no differences in the number of therapeutic procedures or rebleeding rate between both groups. On follow up rebleeding was detected in 5 patients (16.7%), all of them with small angiodysplasias. Rebleeding was more frequent in patients who did not receive further interventions (23.53 vs. 7.69%; p = 0.037). CONCLUSIONS: angiodysplasia size >or= 10 mm determines a worse clinical impact and more possibilities of receiving a therapeutic procedure. Our findings support that patients with large lesions would benefit from therapeutic interventions with a reduction in rebleeding rate.

Outcomes of bile duct drainage by means of ERCP in geriatric patients / Resultados del drenaje de la vía biliar por CPRE en pacientes con edad geriátrica.

BACKGROUND AND OBJECTIVE: Endoscopic retrograde cholangiopancreatography (ERCP) is usually the procedure of choice for relieving bile duct obstruction. a large number of patients undergoing this intervention are geriatric population (aged 75 years of age and older). Our aim was to assess the efficacy of ERCP in this group of patients as compared to younger ones. PATIENTS AND METHODS: A retrospective study. All patients in whom a therapeutic biliary endoscopy had been performed over a four-year period of time (2002-2005) were included. RESULTS: 178 geriatric patients and 159 younger ones underwent ERCP. No differences were found in successful biliary drainage (97.7 vs. 98.7%), complication number (11.8 vs. 14.4%), or mortality rate (1.1 vs. 0.6%). On the other hand, more common bile duct stones were found in geriatric patients (57.3 vs. 39.6%, p = 0.004), and also more self-expanding metal stents were employed to drain malignant obstructive jaundice (47 vs. 8%, p = 0.0035). In the youngest group, more ERCPs were repeated in the same patients (4 vs. 10%, p = 0.001). CONCLUSIONS: The geriatric population showed similar success and morbidity and mortality rates when compared to younger patients in draining their bile duct by means of ERCP. Common bile duct stones were more frequently found in geriatric patients. No patients needing an ERCP should be excluded only because of their age.

Introduction of Basic Dermatologic Ultrasound in Undergraduate Medical Education.

Purpose: Teaching ultrasound procedures to undergraduates has recently been proposed to improve the quality of medical education. We address the impact of applying standardized dermatologic ultrasound teaching to our undergraduates. Materials and Methods: Medical students were offered an additional theoretical and practical seminar involving hands-on ultrasound dermatologic ultrasound during their mandatory dermatology practical training. The students' theoretical knowledge and dermatologic ultrasoud skills were tested with a multiple choice questionnaire extracted from Level 1 Spanish Society of Ultrasound Dermatologic Ultrasound accreditation exam before and after the course. After the course, the students were asked to answer a course evaluation questionnaire Results: The multiple-choice question scores after the course showed statistically significant improvement (5.82 vs. 8.71%; P<0.001). The questionnaire revealed that students were satisfied with the course, felt that it increased both their dermatologic and ultrasound knowledge, and indicated that they wanted more sonographic hands-on training in both dermatologic ultrasound and other medical fields. Conclusion: Using both objective and subjective methods, we showed that the introduction of standardized ultrasound training programs in undergraduate medical education can improve both students' understanding of the technique and the quality of medical education in dermatology.

EFSUMB Statement on Medical Student Education in Ultrasound [long version].

The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) recommends that ultrasound should be used systematically as an easy accessible and instructive educational tool in the curriculum of modern medical schools. Medical students should acquire theoretical knowledge of the modality and hands-on training should be implemented and adhere to evidence-based principles. In this paper we report EFSUMB policy statements on medical student education in ultrasound that in a short version is already published in Ultraschall in der Medizin 1.

A risk score for prediction of recurrence in patients with unprovoked venous thromboembolism (DAMOVES).

BACKGROUND: In patients with unprovoked venous thromboembolism (VTE), the optimal duration of anticoagulation is anchored on estimating the risk of disease recurrence. We aimed to develop a simple risk assessment model that improves prediction of the recurrence risk. METHODS: In a prospective cohort study, 398 patients with a first unprovoked VTE were followed up for a median of 21.3months after discontinuation of anticoagulation. We excluded patients with a strong thrombophilic defect. Preselected clinical and laboratory variables were analyzed based on the independent confirmation of the impact on the recurrence risk, simplicity of assessment, and reproducibility. Multivariable Cox regression analysis was used to develop a recurrence score that was subsequently internally validated by bootstrap analysis. RESULTS: A total of 65 patients (16.3%) had recurrent VTE. In all patients, VTE recurred spontaneously. Male sex (HR=2.89 [95% CI 1.21-6.90] P=0.016), age (HR=1.0310 per additional decade [95% CI 1.01-1.07] P=0.011), obesity (HR=3.92 [95% CI 1.75-8.75] P=0.0001), varicose veins (HR=4.14 [95% CI 1.81-9.43] P=0.0001), abnormal D-dimer during anticoagulation (HR=13.66 [95% CI 4.74-39.37] P=0.0001), high factor VIII coagulant activity (HR=1.01 [95% CI 1.00-1.02] P=0.028) and heterozygous of factor V Leiden and/or Prothrombin G20210A mutation (HR=13.86 [95% CI 5.87-32.75] P=0.0001) were related to a higher recurrence risk. Using these variables, we developed a nomogram [hereafter referred to as DAMOVES score (D-dimer, Age, Mutation, Obesity, Varicose veins, Eight, Sex)] for prediction of recurrence in an individual patient. CONCLUSIONS: The DAMOVES score can be used to predict recurrence risk in patients with a first unprovoked VTE and may be useful to decide whether anticoagulant therapy should be continued indefinitely or stopped after an initial treatment period of at least 3months.

The expression level of the 3a movement protein determines differences in severity of symptoms between two strains of tomato aspermy cucumovirus.

Two strains of tomato aspermy cucumovirus, 1-TAV and V-TAV, differ in the severity of the symptoms induced in Nicotiana tabacum: 1-TAV induces a severe chlorotic mottle that appears 5 days post inoculation (d.p.i.) in the second systemic leaf, while V-TAV-infected plants show a mild chlorotic mottle, unevenly distributed in the leaf lamina, that appears 7 d.p.i. in the third or fourth systemic leaf. The manipulation of full-length cDNA clones giving infectious transcripts of V-TAV RNAs 1, 2, and 3 and 1-TAV RNA 3 revealed that the slow, mild phenotype of V-TAV maps to the movement protein (MP) gene. By site-directed mutagenesis it was further shown that this phenotype co-segregates with a single nucleotide substitution that introduces an in-frame UAA stop codon at the fourth position of the MP open reading frame of V-TAV. The presence of this stop codon results in a diminished expression of the MP in both tobacco protoplasts and leaves. Analyses of the progress of infection and of the time course of MP and coat protein accumulation show that the low level of MP in V-TAV-infected leaves limits the rate of cell-to-cell movement and leads to the mild phenotype. Data from the infectivity of RNA 3 transcripts with or without this stop codon, plus data from in vitro translation of virion or transcript RNA 3, suggest that the small amount of MP observed in V-TAV-infected leaves is expressed from a minor RNA 3 subpopulation lacking the stop codon.

Hepatic fibrin-ring granulomas: a clinicopathologic study of 23 patients.

Twenty-three patients with characteristic hepatic fibrin-ring granulomas were studied. Q fever accounted for 10 cases (43%), visceral leishmaniasis for five cases (22%), boutonneuse fever for two cases (9%), and toxoplasmosis, Hodgkin's disease, and allopurinol hypersensitivity for one case each (4%). The etiology remained undetermined in three cases (13%). This report broadens the range of etiologies of hepatic fibrin-ring granulomas to include boutonneuse fever and toxoplasmosis in the differential diagnosis of ring granulomas, and it could serve as a guideline to the clinician and pathologist for the most frequent categories of disease associated with this morphologic pattern.

Chayote mosaic virus, a New Tymovirus Infecting Cucurbitaceae.

ABSTRACT Chayote mosaic virus (ChMV) is a putative tymovirus isolated from chayote crops in Costa Rica. ChMV was characterized at the host range, serological, and molecular levels. ChMV was transmitted mechanically and induced disease symptoms mainly in Cucurbitaceae hosts. Asymptomatic infections were detected in other host families. Serologically, ChMV is related to the Andean potato latent virus (APLV) and the Eggplant mosaic virus (EMV), both members of the genus Tymovirus infecting solanaceous hosts in the Caribbean Basin and South America. The sequence of the genomic RNA of ChMV was determined and its genetic organization was typical of tymoviruses. Comparisons with other tymoviral sequences showed that ChMV was a new member of the genus Tymovirus. The phylogenetic analyses of the coat protein gene were consistent with serological comparisons and positioned ChMV within a cluster of tymoviruses infecting mainly cucurbit or solanaceous hosts, including APLV and EMV. Phylogenetic analyses of the replicase protein gene confirmed the close relationship of ChMV and EMV. Our results suggest that ChMV is related to two tymoviruses (APLV and EMV) of proximal geographical provenance but with different natural host ranges. ChMV is the first cucurbit-infecting tymovirus to be fully characterized at the genomic level.

A Novel Geminivirus of Ipomoea indica (Convolvulacae) from Southern Spain.

A cutting of Ipomoea indica displaying yellow vein symptoms was collected from Nerja in southern Spain in 1995, rooted, and maintained by vegetative propagation under glasshouse conditions at the John Innes Centre, Norwich. Although this member of the Convolvulaceae is native to the New World, it has escaped from cultivation as an ornamental and has now been naturalized in many tropical and warm temperate regions of the world, such as southern Spain. The same plant was found to host a population of whiteflies that were also brought back to containment facilities, and maintained in colony. Total plant DNA was extracted from the I. indica plant and universal primers for begomovirus A component (1) were used to amplify an approximately 2.8-kb fragment that was cloned and sequenced. The sequence is available in the DDJB, EMBL, and GenBank nucleotide sequence data bases under accession number AJ132548. A GENEMBL search with the complete sequence of the clone showed 70.8% identity to the AC1 gene of Ageratum yellow vein virus (AYVV). A search with the coat protein gene sequence showed highest homology to tomato leaf curl virus from southern India, another monopartite virus. Typical geminivirus vein yellowing symptoms, nucleotide sequence similarity, and EM detection of geminate virus particles strongly suggest that a geminivirus is present in this plant. The low level of homology to other sequenced geminiviruses suggests that it is an uncharacterized Begomovirus sp. With degenerate DNA-B primers (2), no B component has so far been detected. This virus is provisionally named Ipomoea yellow vein virus (IYVV). With techniques already established for identifying Bemisia spp. (3), the whiteflies collected with this Ipomoea plant were confirmed as Bemisia tabaci. Transmission studies to healthy I. indica showed that this whitefly population (named biotype S), the Q biotype from Spain, and the B biotype from Israel were all unable to transmit IYVV to healthy I. indica, tobacco, tomato, or nightshade. This may be due to many years of vegetative propagation of the host plant as an ornamental, resulting in loss of virus transmissibility by insects, which has occurred with Abutilon mosaic virus (AbMV) and honeysuckle yellow vein mosaic virus (HYVMV). This is the first report of a novel geminivirus on I. indica. It highlights the importance of weeds as hosts and potential reservoirs of both viruses and pests. We acknowledge support from the British Council, The Royal Society, BBSRC, and MAFF. References: (1) R.W. Briddon and P. G. Markham. Mol. Biotechnol. 1:202, 1994. (2) M. R. Rojas et al. Plant Dis. 77:340, 1993. (3) R. C. Rosell et al. Ann. Entomol. Soc. Am. 90:575, 1997.

First Report of the Cymbidium Mosaic Potexvirus (CymMV) Infecting the Terrestrial Orchid Phaius tankervilliae in Costa Rica.

In 1996, plants of the terrestrial orchid Phaius tankervilliae from a nursery in the Central Valley of Costa Rica were observed with mild to severe foliar symptoms of chlorotic streak. No differences were observed in growth, bulb production, flowers, or flowering time between symptomatic and asymptomatic plants, except the symptomatic plants had earlier senescence. Occasionally, the flowers displayed symptoms of chlorosis and white rings in the sepals. Extracts from symptomatic leaves were concentrated by differential centrifugation and analyzed after sucrose gradients. Negative staining of fractions from gradients from symptomatic plants showed the presence of filamentous viral particles 500 by 17 nm. Purified particles contained a single major protein of about 28 kDa as estimated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and a single RNA of about 7 kb, which is greater than the 6.2 kb reported (GenBank). These data suggest the presence of a potexvirus in symptomatic plants (1,2). In enzyme-linked immunosorbent assays, symptomatic plants reacted strongly with antiserum specific for Cymbidium mosaic potexvirus (CymMV). This is the first report of CymMV in P. tankervilliae in Costa Rica. References: (1) J. A. Frowd and J. H. Tremaine. Phytopathology 67:43, 1977. (2) H. T. Hsu et al. Phytopathology 82:491, 1992.

Virus-like particules in the poison glant of the parasitic wasp Opius concolor.

Virus-like particles (VLP's) have been found in the poison glands of adult females of the parasitic wasp Opius concolor Szèpl. (Hymenoptera, Braconidae). These VLP's are found in the secretory cells either free in the cytoplasm or within cytoplasmic vesicles, sometimes associated to a secretory apparatus. Negative staining of these VLP's has revealed the occurrence of two different particles. The first type exhibits icosahedral symmetry (diameter around 70nm) and hollow surface spikes, this morphology being typical of the genus Cypovirus (Reoviridae). The other type is pleomorphic and presents an envelope with clubshaped projections (diameter ranging from 30 to 60nm), as classical textbook examples of Coronaviruses, but smaller. Function and full characterisation of these particles are not yet known.

[Gastroenteritis eosinophilic presenting as colitis with acute abdomen]. / Presentación de gastroenteritis eosinofílica como brote de colitis con abdomen agudo.

Eosinophilic gastroenteritis is rare. Fewer than 30 cases have been published in the Spanish literature, although Kaijser first described this entity in 1937. Its etiology is still unknown and it has frequently been reported to involve the stomach and small bowel, with characteristic eosinophilic infiltration of the bowel wall. The colon has rarely been reported as a site of this condition, which manifests as acute abdominal pain due to intestinal obstruction. We report the case of a 38-year-old woman who presented eosinophilic gastroenteritis. Onset was acute colitis causing acute abdomen. The patient received conservative treatment and responded well to steroids. To our knowledge, such a case has not previously been reported.

[Treatment of malignant colorectal obstruction by means of endoscopic insertion of self-expandable metallic stents]. / Tratamiento de la obstrucción neoplástica del colon meciante la inserción endoscópica de prótesis metálicas autoexpandibles.

BACKGROUND AND AIM: Self-expandable metallic stents are being used increasingly to treat the obstruction of different segments of the digestive tract and biliary tree. We present our centre experience on the initial resolution of malignant colorectal obstruction by means of this type of stents. PATIENTS AND METHODS: During a 18-month period, 13 patients patients suffering from malignant obstruction at the level of rectum, sigmoid or descending colon tried to be initially treated by means of endoscopic insertion of stents (non covered enteral Wallstents). Ten procedures were performed with both endoscopy and fluroscopy and three with only endoscopy. RESULTS: In 12 of the 13 patients (92,3%) the obstruction was solved by means of correct stent insertion. All the exclusively endoscopic procedures (without fluoroscopy) were successful. Six (50 %) patients with tumours at the rectosigmoid underwent later scheduled surgery. In the remaining six ones (a patient with an ovarian carcinoma and five with colonic adenocarcinoma) the stents were considered to be a palliative definitive treatment. Stent migration was observed in two of these patients and both were extracted endoscopically. Only one patient needed to have another stent inserted. A tumoural colo-vesical fistula developed in another patient in the palliative group, inside the previous inserted stent, and was treated by coaxial insertion of an esophageal Ultraflex. There were no other complications or mortality related to the endoscopic procedures. CONCLUSIONS: Self-expandable metallic stents might be considered, in general, as the initial treatment for the malignant obstruction at the level of rectum, sigmoid and descending colon