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C N Bernstein

Publications and source records attributed to C N Bernstein.

At least 55 records · Page 3Linked to original sources
PubMed1999

Perianal Crohn's disease and pregnancy: role of the mode of delivery.

OBJECTIVE: Elective cesarean section (CS) is a standard recommendation for pregnant women with perianal Crohn's disease. In this study we examined the mode of delivery for pregnant women with Crohn's disease and assessed the relationship between perianal disease activity and delivery mode. METHODS: The University of Manitoba's Inflammatory Bowel Disease Database, a population-based database, was interfaced with a provincial birth database to compare the mode of delivery for women with Crohn's disease and ulcerative colitis to that of the general population for the years 1985-1995. To describe clinical issues related to perianal Crohn's disease in relation to mode of delivery, data were obtained from a subset of women with Crohn's disease who had given birth between 1985 and 1995 using a standardized questionnaire. Data regarding Crohn's disease and birth history were verified through chart review (93.8%) and corroboration with the personal physician (87.5%). RESULTS: The total and (elective) CS rates were higher for Crohn's disease 20.9% (9.0%), and for UC 20.8% (9.3%) than the general population 15% (5.4%) (p < 0.01 for each). Among primiparous women, patients with Crohn's disease and UC were also significantly more likely to have CS than the general population. In the target group of 281 women, 52 had births in the years in question and were contactable. There were 54 vaginal births and 10 sections. Fifteen of 54 vaginal births were predated by perianal disease; 4 of 15 reported active perianal disease at birth; and all reported worsening of perianal symptoms postpartum. Those with inactive perianal disease (n = 11) had no relapse of perianal disease in 1 yr of follow-up postpartum. Of 39 vaginal deliveries with no known perianal disease, only 1 ultimately developed perianal disease within 1 yr of postpartum follow-up. CONCLUSIONS: Women with inflammatory bowel disease undergo CS more often compared to the general population. For those with either no history of perianal disease or inactive perianal disease at birth, the risk of perianal disease relapse is very low and does not justify CS. Active perianal disease at time of delivery is an indication for CS.

Adolescent↗
PubMed1999

Crohn's disease and the Melkersson-Rosenthal syndrome.

A 30-year-old woman with a 10-year history of recurrent bloody diarrhea and documented colitis of the descending colon, consistent with Crohn's disease, presented with an exacerbation of her gastrointestinal disease and an 18-month history of recurrent facial and genital swelling. Her course evolved to include severe ear pain, dysphagia and colonic dysmotility. She was diagnosed with Melkersson-Rosenthal syndrome and treated with multiple agents. The neurological aspects of her presentation are highlighted, and the Melkersson-Rosenthal syndrome is reviewed.

Adult↗
PubMed1999

Placebos in medicine.

Although placebo may be defined as a treatment that does not have a specific effect on the illness for which it is being used, or as an intervention for which there is no scientific theory explaining its mechanism of action, placebo can be an effective therapeutic intervention. Placebo can be administered as a drug or as a procedural intervention. Multiple factors affect the ultimate intensity of the placebo response. One of these factors is the approach taken by the health care provider in administering an intervention. The medical literature is replete with clinical studies showing beneficial results of placebo administration. Physicians should attempt to better understand placebo to harness its beneficial effects, avoid nocebo or negative effects, and maximize the placebo response.

Adult↗
PubMed1998

Beta2 integrin/ICAM expression in Crohn's disease.

We have previously reported on the expression of the beta2 integrin family of adhesion molecules and their ligands, the ICAM molecules, in the normal human intestine. These molecules likely have a role to play in the inflammatory response and, therefore, were studied in a group of patients with Crohn's disease. A comprehensive study was undertaken in both colon (n = 8) and ileum (n = 10) specimens from 15 patients who underwent surgical resections. Immunohistochemistry was performed for CD18, CD11a, CD11b, CD11c, alphad, ICAM-1, ICAM-2, and ICAM-3. Each of the mucosal, submucosal, muscle, and adventitial layers were scored for expression. Specimens from normal colon (n = 15), normal ileum (n = 6), and ulcerative colitis (n = 7) were used for comparisons. Compared with normal, the expression in the colon mucosa and submucosa in Crohn's disease was increased for all beta2 integrins. Mucosal CD11c expression was significantly greater in Crohn's disease than in ulcerative colitis. In the colon muscle and adventitial layers the expression in Crohn's disease was similar to normal but increased compared with ulcerative colitis. In Crohn's disease ileum, the beta2 integrin mucosal and submucosal expression was similar to normal; however, muscle and adventitial expression was increased, particularly for CD11c. Colon ICAM-1, ICAM-2, and ICAM-3 expression in Crohn's disease was similar to that seen in ulcerative colitis. ICAM-1 was predominantly expressed on endothelium but in the inflammatory bowel diseases was also evident on mucosal mononuclear cells. ICAM-1 and ICAM-2 expression was increased in Crohn's disease colon and ileum compared with normals. This was most notable in ileal mucosa since ICAM-2 is typically absent in normal ileal mucosa. In summary, we are reporting a comprehensive immunohistochemical study of the differential expression of beta2 integrins, including the newly described alphad molecule, and the ICAM molecules in all layers of the colon and ileum from patients with Crohn's disease. The increased expression of these molecules may have implications for therapeutic interventions in Crohn's disease.

Antigens, CD↗
PubMed1997

The diagnostic yield of lower endoscopy plus biopsy in nonbloody diarrhea.

BACKGROUND: Patients presenting with diarrhea frequently undergo lower endoscopy plus biopsy as part of their diagnostic evaluation. The diagnostic yield of this approach has not been systematically evaluated. METHODS: To evaluate the diagnostic yield of endoscopy and biopsy in the investigation of nonbloody diarrhea, we performed a retrospective analysis using the endoscopy unit database of a tertiary care university hospital over a 3-year period. The database was searched for cases in which colonoscopy was performed for the single indication of diarrhea. The endoscopic findings and initial biopsy reports were extracted from a chart review, and each clinician was interviewed for the patient's current clinical diagnosis. The clinical diagnoses were compared with the endoscopy and biopsy results to determine whether the tests had contributed to making the clinical diagnoses. RESULTS: Three hundred six patients were identified. One hundred one were excluded for standardized predefined exclusion criteria, leaving 205 evaluable patients, of whom 77 had flexible sigmoidoscopy and 128 had colonoscopy. Eighteen percent had specific clinical diagnoses facilitated by endoscopy and/or biopsy. Endoscopy and biopsy results were normal in 74% of cases. In 8% of the cases either the endoscopy or biopsy findings were inconsistent with the final clinical diagnoses. CONCLUSIONS: Endoscopy and biopsy are important diagnostic tools in the evaluation of patients with nonbloody diarrhea, leading to a specific diagnosis in nearly one fifth of cases.

Adult↗
PubMed1997

Peripheral blood lymphocyte beta 2 integrin and ICAM expression in inflammatory bowel disease.

The beta 2 integrin intercellular adhesion molecule (ICAM) adhesion pathway is likely pivotal in the immunopathogenesis of inflammatory bowel disease (IBD). We have undertaken a comprehensive study of peripheral blood lymphocyte (PBL) expression of all beta 2 integrins and ICAMs in patients with IBD using flow cytometry and assessed our data on the basis of IBD diagnosis, disease state of activity, and use of corticosteroids. Blood was collected from patients with Crohn's disease (N = 49), ulcerative colitis (N = 43), and normal control volunteers (N = 15). Mononuclear cells were separated using a Ficoll-Hypaque gradient and prepared for flow cytometry. The data were analyzed for percentage expression, mean fluorescent intensity (MFI) as well as for histogram patterns. The analysis was stratified for disease diagnosis, disease activity level, and for use of prednisone among patients with active disease. There was decreased percentage expression of CD11a, CD18, and ICAM-3 in Crohn's disease and ulcerative colitis compared with normal, but an increased MFI for these molecules among patients with Crohn's disease. Active Crohn's disease showed a greater change in this pattern compared with both inactive disease and active ulcerative colitis. CD11a and CD18 histograms typically had two peaks of expression. The predominance of one peak over the other varied with disease diagnosis and activity. CD11b and alpha d expression patterns were not different in IBD compared with normal. CD11c was not expressed by PBLs and, ICAM-2, typically an endothelial ligand, was expressed on PBLs. There were changes in the expression of beta 2 integrins in IBD, which were more evident in Crohn's disease than ulcerative colitis. We hypothesize that the decreased percentage expression and increased MFI of CD11a, CD18, and ICAM-3 may suggest that cells up-regulate these ligands following activation and are egressing into tissue.

Adult↗
PubMed1997

Escherichia coli O157:H7 infection mimicking Crohn's disease.

Two patients presented with abdominal pain, diarrhea, and tender right lower-quadrant masses. Both patients had computerized tomographic scans showing cecal thickening and mass effects with multiple mesenteric lymph nodes and sparing of the rest of the colon. Colonoscopy in each patient also revealed disease confined to the right colon, and the mucosal pattern was consistent with that of Crohn's disease. The patients were both treated as having Crohn's disease until stool testing showed the presence of Escherichia coli O157:H7 serotype and follow-up computerized tomography scans and endoscopies revealed no evidence of chronic inflammatory bowel disease. E. coli O157:H7 is an increasingly recognized enteric infection, and these cases highlight how this infection may mimic right colonic Crohn's disease in its presentation. Furthermore, the submucosal nature of the clinical findings is discussed. Patients presenting with acute bloody diarrhea and displaying clinical and computerized tomographic features of Crohn's disease should have E. coli O157:H7 infection excluded before therapy for Crohn's disease is initiated.

Adult↗
PubMed1997

Quantification of the placebo response in ulcerative colitis.

BACKGROUND & AIMS: There is consistently a measurable benefit noted among placebo users in treatment trials of ulcerative colitis (UC). The aim of this study was to define the placebo response in active UC and identify study features that influence the placebo response. METHODS: MEDLINE database was searched for placebo-controlled treatment studies of active UC. Data extraction was performed by two reviewers, and one separate investigator reviewed all trials and data extraction before data tabulation. Placebo remission and benefit rates were determined for clinical, endoscopic, and histological outcomes. Synthesis analysis on the weighted proportions from the different studies explored the placebo response as it related to eight study variables. RESULTS: Thirty-eight of 44 studies identified were included in the analysis. The clinical remission rate was 9.1% (confidence interval [CI], 6.6-11.6) and the benefit rate was 26.7% (CI, 24.1-29.2). Similar rates were observed endoscopically and histologically. The number of study visits (< or =3 vs. >3) modified placebo response as assessed by clinical benefit (P = 0.05), endoscopic remission (P = 0.02), and histological remission (P = 0.04). Other study variables were not significant placebo response modifiers. CONCLUSIONS: In trials of active UC, the placebo remission rate is approximately 10% and the placebo benefit rate is approximately 30%. These rates are consistent regardless of assessment end point. The placebo response is greater in trials with more frequent study visits (more than three).

Colitis, Ulcerative↗
PubMed1997

A prospective randomized comparison between small bowel enteroclysis and small bowel follow-through in Crohn's disease.

BACKGROUND & AIMS: Small bowel enteroclysis (SBE) has been suggested to be superior to the small bowel follow-through (SBFT) for diagnosing the presence and extent of Crohn's disease. The aim was to perform a prospective randomized study at a single university medical center comparing SBE with SBFT in patients with Crohn's disease. METHODS: Consecutive patients with known Crohn's disease were randomized to receive either SBE or SBFT as the initial study and had the alternate study performed within 2 weeks. RESULTS: Twenty-six patients were enrolled. The mean time between studies was 8.7 +/- 0.8 days. Both studies were normal in 7 cases. The SBE was negative in 3 cases with positive findings of Crohn's disease by SBFT. One of these cases was a false-positive SBFT. The SBE and SBFT were both diagnostic of Crohn's disease in 15 cases; in 6 cases there was uniform agreement regarding disease pattern. The SBFT more accurately reported mucosal detail (n = 3) and a greater number of fistulas (n = 2). The SBE missed duodenal disease (n = 4). CONCLUSIONS: In known Crohn's disease, the SBFT is the procedure of choice. It is safer, preferred by patients, and will not miss gastroduodenal disease, and when the result is normal, there is no need to perform SBE.

Administration, Oral↗
PubMed1997

Primary adrenal lymphoma associated with adrenal insufficiency: a distinct clinical entity.

We describe a case of a 42 year old male who presented with Addison's disease resulting from primary lymphoma of the adrenals. Our case and a review of the literature indicates that this distinct entity has some unique clinical and radiologic features. In this entity, the lymphoma tends to be extranodal and have a poor prognosis. In addition, the computed tomography (CT) images have the unique appearance of enlargement of the adrenal gland with maintenance of the adreniform shape. We suggest that primary adrenal lymphoma is a distinct clinical entity and should be considered in patients with an elevated serum lactate dehydrogenase, characteristic CT findings and Addison's disease.

Addison Disease↗
PubMed1997

Characterization of afferent mechanisms in ileoanal pouches.

OBJECTIVES: The afferent innervation of ileoanal pouches plays an important role in perception and in reflex regulation of pouch function. We aimed to characterize afferent nerve function in ileoanal pouches and thereby explain the clinical presentation of patients with such pouches. METHODS: In eight patients who underwent surgery for active ulcerative colitis, perception of balloon distention of the pouch was measured using an electronic visceral distention device. In addition, pouch compliance and ileoanal reflex function were determined. Studies were performed during the initial stage of pouch creation (pouch without connection to proximal ileum, study 1) and a mean of 6.6 wk (range = 2-12 wk) after the second stage of the surgery (proximal ileum in continuity with the pouch, study 2). Nine normal volunteers made up the control group. RESULTS: When expressed as intrapouch pressure, thresholds for stool and discomfort sensations were similar in patients with a pouch and controls. However, during ramp distention, patients with a pouch had a lower volume threshold for stool sensation (143 +/- 45 ml vs 300 +/- 30 ml, p = 0.009). The initial sensation of discomfort was experienced in the perineum at the S3 dermatome in all eight patients. At higher distention pressures, all patients with a pouch referred sensations to the abdomen, as opposed to only one of nine controls with such a referral pattern (p < 0.0001). Pouch compliance was markedly reduced during study 1 but normalized after continuity was established with the proximal ileum. Anal sphincter function in patients with a pouch was similar to that in controls. CONCLUSIONS: Afferent pathways from both the ileum and rectum play a role in the mediation of sensations during mechanical distention of the ileoanal pouch and can explain a number of clinical features of patients with a pouch. The thresholds for activation of these pathways are not significantly altered by long-standing colorectal inflammation or by creation of the ileoanal pouch. Continuity with the proximal ileum significantly influences pouch compliance.

Adult↗
PubMed1996

Neuroimmune mechanisms in health and disease: 2. Disease.

In the second part of their article on the emerging field of neuroimmunology, the authors present an overview of the role of neuroimmune mechanisms in defence against infectious diseases and in immune disorders. During acute febrile illness, immune-derived cytokines initiate an acute phase response, which is characterized by fever, inactivity, fatigue, anorexia and catabolism. Profound neuroendocrine and metabolic changes take place: acute phase proteins are produced in the liver, bone marrow function and the metabolic activity of leukocytes are greatly increased, and specific immune reactivity is suppressed. Defects in regulatory processes, which are fundamental to immune disorders and inflammatory diseases, may lie in the immune system, the neuro endocrine system or both. Defects in the hypothalamus-pituitary-adrenal axis have been observed in autoimmune and rheumatic diseases, chronic inflammatory disease, chronic fatigue syndrome and fibromyalgia. Prolactin levels are often elevated in patients with systemic lupus erythematosus and other autoimmune diseases, whereas the bioactivity of prolactin is decreased in patients with rheumatoid arthritis. Levels of sex hormones and thyroid hormone are decreased during severe inflammatory disease. Defective neural regulation of inflammation likely plays a pathogenic role in allergy and asthma, in the symmetrical form of rheumatoid arthritis and in gastrointestinal inflammatory disease. A better understanding of neuroimmunoregulation holds the promise of new approaches to the treatment of immune and inflammatory diseases with the use of hormones, neurotransmitters, neuropeptides and drugs that modulate these newly recognized immune regulators.

Acquired Immunodeficiency Syndrome↗
PubMed1996

Neuroimmune mechanisms in health and disease: 1. Health.

A novel scientific discipline that examines the complex interdependence of the neural, endocrine and immune systems in health and disease has emerged in recent years. In health, the neuroimmunoregulatory network is fundamental to host defence and to the transfer of immunity to offspring; the network also plays important roles in intestinal physiology and in tissue regeneration, healing and reproduction. The proliferation of lymphocytes in primary lymphoid organs (bone marrow, bursa of Fabricius [in birds] and thymus) and in secondary lymphoid organs (spleen, lymph nodes and mucosal lymphoid tissue) depends on prolactin and growth hormone. These hormones allow immune cells to respond to antigen and to soluble mediators, called cytokines. Immune-derived cytokines are capable of inducing fever and of altering neuro-transmitter activity in the brain and hormone secretion by the pituitary gland. The activation of the hypothalamus-pituitary-adrenal axis by cytokines leads to immunosuppression. Lymphoid organs are innervated, and tissue mast cells respond to neurologic stimuli. In general, acetylcholine and substance P exert immunostimulatory and proinflammatory effects, whereas epinephrine and somatostatin are immunosuppressive and anti-inflammatory. In this article, the authors predict that novel approaches to immunomodulation will be possible by altering the level or efficacy of immunoregulatory hormones and neurotransmitters.

Humans↗
PubMed1996

Rectal afferent function in patients with inflammatory and functional intestinal disorders.

Chronic symptoms of abdominal pain and discomfort are reported by patients with inflammatory bowel disease (IBD) and functional disorders of the gut, such as Irritable Bowel Syndrome (IBS). It has recently been suggested that transient inflammatory mucosal events may result in long-lasting sensitization of visceral afferent pathways. To determine the effect of recurring intestinal tissue irritation on lumbosacral afferent pathways, and to identify a plausible mechanism that could account for the overlap in symptomatology between IBD and IBS, we compared rectal afferent mechanisms in patients with Crohn's disease (inflammation limited to the ileum) with those observed in patients with diarrhea-predominant IBS. Continuous volume ramp and phasic pressure step distension of a rectal balloon were performed in 9 healthy male control subjects, 12 male patients with isolated ileal Crohn's disease and 9 male patients with diarrhea-predominant IBS using an electronic visceral stimulation device. The response of rectal afferents to distension was evaluated by measuring thresholds for the perception of physiological (stool) and aversive (discomfort) sensations, viscerosomatic referral patterns, skin conductance responses, receptive relaxation, and rectoanal reflex responses. In response to slow ramp distension, thresholds for aversive sensations were significantly higher in Crohn's disease patients, but similar between the two other groups. In response to rapid phasic distension, IBS patients reported discomfort at lower distension pressures, while all other thresholds were similar between groups. Skin conductance responses to aversive distension were greatly reduced in Crohn's disease patients while IBS patients had greater responses when compared to normals. Changes in viscerosomatic referral patterns and receptive relaxation rate were similar in Crohn's disease and IBS patients. These findings demonstrate that chronic ileal inflammation is associated with increased thresholds for discomfort and greatly diminished systemic autonomic reflex responses. In contrast, IBS patients show lowered thresholds for discomfort associated with increased autonomic responses. The findings in Crohn's patients may result from descending bulbospinal inhibition of sacral dorsal horn neurons in response to chronic intestinal tissue irritation.

Adult↗