Wire-Guided Cannulation Versus Contrast-guided Cannulation In Pediatric Endoscopic Retrograde Cholangiopancreatography

Background/Aim:

Wire-guided cannulation (WGC) of the common bile duct may be associated with fewer complications and higher success rate compared with contrast-guided cannulation (CGC) in adults. Data in children are lacking. The aim of this study was to compare the successful cannulation and complication rate of WGC and CGC in pediatric endoscopic retrograde cholangiopancreatography (ERCP).

Patients and Methods:

We report a retrospective cohort study comparing WGC to CGC in a pediatric cohort. We reviewed the medical records of 167 children who underwent ERCP over a 10-year time period (CGC, 1999-2003, WGC, 2003-2009). Indications, findings, and success were analyzed.

Results:

A total of 93 patients (56%) underwent WGC and 74 (44%) CGC. Children in the WGC group were younger (9.5 ± 4.7 vs. 11.5 ± 4.6 years in CGC; P = 0.006) and underwent more therapeutic ERCP interventions (70% vs. 40% in CGC), whereas diagnostic ERCP was more common in the CGC group (60%; P < 0.005). The overall success (96%) and complication rate (8%) were identical in both groups but a trend toward a reduction in the complication rate over time was noted in the WGC group. Post-ERCP pancreatitis (PEP) was documented in one patient in the WGC group (1.1%) and three patients (4.2%) in the CGC group (P-NS).

Conclusion:

The success and complication rate in both CGC and WGC are comparable in children but considering the patient and procedure complexity and the trend toward lower PEP in the WGC group, WGC may be the preferable cannulation technique for ERCP in children.     

Platelet-activating factor in bronchoalveolar lavage fluid from asthmatic subjects

Bronchoalveolar lavage (BAL) was performed on 28 asthma patients, 7 patients with emphysema and 11 control subjects. Total and differential cell counts were performed and cellular metabolic activity was assessed using luminol and lucigenin amplified chemiluminescence. BAL supernatants were assayed for platelet-activating factor (PAF) and lyso-PAF using a sensitive guinea-pig bioassay. Eight of the asthma patients but none of the emphysema patients or control subjects had PAF in their BAL fluid. Lyso-PAF was measurable in BAL fluid in most subjects and no differences were detected between groups. Among the asthma patients, the presence of PAF in BAL supernatant was significantly associated with a combination of low neutrophil and high lymphocyte counts (p less than 0.05) and with macrophage metabolic activity as assessed by lucigenin chemiluminescence (p less than 0.05).     

Management and treatment perceptions among young adults with asthma in Melbourne: the Australian experience from the European Community Respiratory Health Survey

OBJECTIVES: As part of the European Community Respiratory Health Survey (ECRHS) in 1992-1993 we assessed management practices and treatment perceptions among young asthmatic adults in Melbourne, Australia. METHODOLOGY: We conducted a postal questionnaire survey of 4500 randomly selected adults (aged 20-44 years), drawn from three electoral districts, of whom 3200 (71%) subjects responded. A randomly selected sample of 1642 respondents, 'enriched' by a further 433 symptomatic subjects, was invited to complete a second phase respiratory questionnaire. RESULTS: The questionnaire was completed by 757 subjects who underwent laboratory testing. A further 119 subjects who were unable to attend the laboratory completed an identical questionnaire by telephone interview (42% response rate). In the second phase, 16% of subjects reported 'current asthma' (group I) as defined by physician confirmation and a recent attack (within 1 year), 10% had confirmed asthma but reported no recent attack (group II) and 74% did not have asthma (group III). Inhaled corticosteroid use was significantly higher in group I than in group II subjects (45% vs 24%, P<0.01), but only 11% of asthmatic subjects overall reported daily prophylactic use. Regular treatment in any form was considered to be 'bad' by 65% of asthmatic subjects and only 43% took medication as prescribed all of the time. CONCLUSION: Despite national education campaigns, the majority of young asthmatic adults in Melbourne did not adhere to prescribed treatment, but continued to rely upon beta2-agonists alone with neglect of regular inhaled corticosteroid which has probably contributed to Australia's continued high asthma morbidity and mortality rates.     

Cost effectiveness of expanded antenatal HIV testing in London

BACKGROUND: Recently the Department of Health announced the introduction in England of voluntary universal HIV screening in early pregnancy to prevent vertical transmission. New data have shown the importance of HIV infection in infants born to mothers who were HIV-negative in early pregnancy and who acquired HIV later in pregnancy or during lactation. This requires consideration of repeat testing in late pregnancy and testing of partners of pregnant women (expanded antenatal HIV testing). OBJECTIVE: To estimate cost effectiveness of expanded antenatal HIV testing in London (England) within the framework of universal voluntary HIV screening in early pregnancy. DESIGN: Incremental cost-effectiveness analysis. METHODS: Cost estimates of service provision for HIV-positive children and adults by stage of HIV infection were combined with estimates of health benefits for infants and parents and with costs of counselling and testing (testing costs). In a pharmacoeconomic model cost effectiveness was estimated for expanded antenatal HIV testing in London for universal and selective strategies. RESULTS: Testing costs in the plausible range of pounds sterling 4 to pounds sterling 40 translate into favourable incremental cost-effectiveness estimates for expanded antenatal HIV testing in London which is already at low numbers of vertical transmissions averted per 100000 pregnant women who test HIV-negative in early pregnancy. Favourable cost effectiveness for universal expanded testing would require testing costs in the lower range, whereas selective expanded testing may produce favourable cost effectiveness at testing costs close to pounds sterling 40. CONCLUSION: Based on pharmaco-economic considerations, the authors believe that implementation of expanded HIV testing in London should be considered.     

Angioembolisation of pulmonary artery pseudoaneurysm arising in H1N1 influenza viral pneumonia

A 51 year-old Aboriginal woman was diagnosed with H1N1 influenza virus and methicillin-resistant Staphylococcus aureus. Contrasted CT of the pulmonary and bronchial vasculature undertaken for investigation for of haemoptysis revealed an 11 mm left upper lobe pulmonary artery pseudoaneurysm (PAP). The PAP was successfully treated with angioembolisation of the parent artery with two platinum coils. Pulmonary artery pseudoaneurysms are uncommon but potentially life-threatening and have not previously been reported in association with H1N1 influenza viral pneumonia, which has been prominent in recent times in both medical literature and popular press.     

Severe pneumococcal pneumonia in previously healthy children: the role of preceding influenza infection.

An outbreak of severe pneumococcal pneumonia among children occurred in Iowa from November 1995 through January 1996. An associated outbreak of influenza disease was predominantly caused by influenza A (H1N1) for the first time since 1989. We conducted a case-control study to determine whether preceding influenza infection was directly associated with pneumococcal illness. We identified 13 children with severe pneumococcal pneumonia. Patients were more likely than control subjects to report experiencing an influenza-like illness in the 7-28 days preceding admission (matched odds ratio [OR], 12.4; 95% confidence interval [CI], 1.7-306). Likewise, family members of patients were more likely than those of control subjects to report experiencing an influenza-like illness in the 28 days preceding their admission date (OR, 2.6; 95% CI, 1.0-6. 3). Patients were more likely than control subjects to have a positive influenza A (H1N1) convalescent serology (matched OR, 3.7; 95% CI, 1.0-18.1). This study provides direct and indirect evidence that influenza infection led to severe pneumococcal pneumonia among these children. Prevention of pneumococcal disease should be included among the potential benefits of influenza vaccination.     

Incidence of acute myocardial infarction in patients with exercise-induced silent myocardial ischemia

Fifty-five patients with angiographically proved coronary artery disease (CAD) underwent Bruce protocol exercise stress testing with thallium-201 imaging. Twenty-seven patients (group I) showed myocardial hypoperfusion without angina pectoris during stress, which normalized at rest, and 28 patients (group II) had a similar pattern of reversible myocardial hypoperfusion but also had angina during stress. Patients were followed for at least 30 months. Six patients in group I had an acute myocardial infarction (AMI), 3 of whom died, and only 1 patient in group II had an AMI (p = 0.05), and did not die. Silent myocardial ischemia uncovered during exercise stress thallium testing may predispose to subsequent AMI. The presence of silent myocardial ischemia identified in this manner is of prognostic value, independent of angiographic variables such as extent of CAD and left ventricular ejection fraction.     

Influence of pulmonary capillary wedge pressure on central apnea in heart failure

BACKGROUND: Recent studies suggest that acute pulmonary congestion induces hyperventilation and that hyperventilation-related hypocapnia leads to ventilatory control instability and central sleep apnea. Whether chronic pulmonary congestion due to congestive heart failure (CHF) is associated with central apnea is unknown. We hypothesized that CHF patients with central apnea would have greater pulmonary capillary wedge pressure (PCWP) than patients without central apnea and that PCWP would correlate with central apnea severity. METHODS AND RESULTS: Seventy-five stable CHF patients underwent right heart catheterization and, on the basis of overnight sleep studies, were divided into central apnea (n=33), obstructive apnea (n=20), or nonapnea groups (apnea-hypopnea index [AHI] <5 events per hour). Mean PCWP was significantly greater in the central than in the obstructive and nonapnea groups (mean+/-SEM [range]: 22. 8+/-1.2 [11 to 38] versus 12.3+/-1.2 [4 to 21] versus 11.5+/-1.5 [3 to 28] mm Hg, respectively; P<0.001). Within the central apnea group, PCWP correlated with the frequency and severity of central apnea (AHI: r=0.47, P=0.006) and degree of hypocapnia (PaCO2: r=-0.42, P=0. 017). Intensive medical therapy in 7 patients with initially high PCWP and central apneas reduced both PCWP (29.0+/-2.6 [20 to 38] to 22.0+/-1.8 [17 to 27] mm Hg; P<0.001) and central apnea frequency (AHI) (38.5+/-7.7 [7 to 62] to 18.5+/-5.3 [1 to 31] events per hour; P=0.005). CONCLUSIONS: PCWP is elevated in CHF patients with central apneas compared with those with obstructive apnea or without apnea. Moreover, a highly significant relationship exists between PCWP, hypocapnia, and central apnea frequency and severity.     

Omeprazole produces parietal cell hypertrophy and hyperplasia in humans

While there is evidence that omeprazole may induce changes in parietal cells, the effect of acid suppression on parietal cells in humans is poorly documented. This study was undertaken to evaluate the effects of omeprazole in human parietal cells over time. The light microscopic morphology of parietal cells in gastric biopsies from 17 patients on omeprazole were compared with those from 13 patients on ranitidine and 20 patients on no acid-lowering medication. Light microscopic and ultrastructural morphology of parietal cells was also evaluated in an additional 14 patients before and after omeprazole administration. Objective measurements of parietal cell height, mass and number were analyzed using analyses of variance. Electron microscopy was used to evaluate parietal cell enlargement. Twenty-five of 31 biopsies from patients on omeprazole, 1 of 13 from patients on ranitidine, and 0 of 20 from patients on neither drug showed parietal cell enlargement. Parietal cell height, mass, and number were increased in omeprazole-treated patients compared with ranitidine-treated patients and those on neither drug, and with the group also evaluated prior to beginning omeprazole treatment. Parietal cell height and mass were increased in patients on omeprazole longer than 12 months compared with biopsies from patients on the drug for less than 12 months. Resin-embedded sections and electron microscopy showed enlarged parietal cells with prominence of cytoplasmic tubulovesicles with sparse secretory canaliculi. Parietal cell hypertrophy and hyperplasia develops in patients on chronic omeprazole therapy; this can be recognized on routine examination of histologic sections. These morphologic changes increase with duration of therapy.