Liver transplantation for severe hepatic trauma： Experience from a single center

Liver transplantation has been reported in the literature as an extreme intervention in cases of severe and complicated hepatic trauma. The main indications for liver transplant in such cases were uncontrollable bleeding and postoperative hepatic insufficiency. We here describe four cases of orthotopic liver transplantation after penetrating or blunt liver trauma. The indications were liver failure, extended liver necrosis, liver gangrene and multiple episodes of gastrointestinal bleeding related to portal hypertension, respectively. One patient died due to postoperative cerebral edema. The other three patients recovered well and remain on immunosuppression. Liver transplantation should be considered as a saving procedure in severe hepatic trauma, when all other treatment modalities fail.     

Chronic pancreatitis in Eastern India: Experience from a tertiary care center

There is a wide variation in the clinical presentation of chronic pancreatitis (CP) in the different parts of India. Data regarding the clinical profile of CP from eastern India are scarce. We describe the clinical and demographic profiles of patients with CP in eastern India. Consecutive patients were evaluated for the clinical presentation, etiology and complication of CP. One hundred and thirty-nine patients with CP (mean age 39.57±14.88 years; M/F 3.48:1) were included. Idiopathic CP (50.35%) was the most common etiology followed by alcohol (33.81%); 68.34% had calcific CP and 31.65% had noncalcific CP. The median duration of symptoms was 24 (1–240) months. Pain was the most common symptom, being present in 93.52% of the patients. Diabetes, steatorrhea and pseudocyst were present in 45.32%, 14.38% and 7.19% of the cases, respectively. Moderate to severe anemia was revealed in 16.53% of the patients. Benign biliary stricture was diagnosed in 19.42% of the cases (symptomatic in 6.47%). The common radiological findings were the following: pancreatic calculi (68.34%), dilated pancreatic duct (PD) (58.99%), parenchymal atrophy (25.89%) and PD stricture (23.74%). In our center, idiopathic CP followed by alcoholic CP was the most frequent form of CP. Tropical CP was distinctly uncommon.     

Prenatal Diagnosis of HbE-β-Thalassemia: Experience of a Center in Western India

The clinical presentation of HbE-β-thalassemia is extremely variable, however, many cases are severe and transfusion dependent. We offered prenatal diagnosis to 108 couples, 20 of whom came prospectively. CVS was done in 93 cases (9.5–13 weeks of gestation) while amniocentesis/cordocentesis was done for 15 cases in the second trimester. Diagnosis was done by reverse dot blot hybridization, ARMS, DNA sequencing and in a few cases by HPLC analysis of fetal blood. The genetic combinations in the couples at-risk were the following: HbE trait/β-thal trait-95, HbE-thal/HbE trait-5, HbE homozygous/β-thal trait-3, HbE-thal/β-thal trait-3, HbE Lepore/β-thal trait-1, HbE trait/HbD^Punjab trait-1. IVS1-5(G>C) was the commonest β-thalassemia mutation followed by codon15(G>A), codon30(G>C), codons41/42(-CTTT), the 619 bp deletion and codon8/9(+G) in the β-thalassemic parent. However, several rare mutations seen in India like -90(C>T), -88(C>T),codon15(-T), IVS1-129(A>C), IVS1-130(G>C), IVSII-1(G>A), IVSII-837(C>T) and IVSII 848(C>A) were also encountered. Twenty-one fetuses were affected (HbE-β-thal-20, β-thal major-1) and all the couples opted for termination of the pregnancies. Couples with affected children wish to undergo prenatal testing for HbE-β-thal in subsequent pregnancies. More regional centers are needed for these services, particularly in West Bengal and the North-East where HbE is very common.     

Mortality Patterns in Childhood Lupus – 10 Years’ Experience in a Developing Country

Over the last 10 years we have seen 31 children with systemic lupus: 10 (32%) of these have died. The commonest primary determinant of mortality was uncontrolled disease activity (60%), possibly contributed to by late referrals leading to delays in diagnosis and the institution of therapy. Thromboembolic disease was responsible for two deaths and tuberculosis for one. The major contributory factors were nephritis in two patients and myocarditis, endocarditis, lupus pneumonia and CNS disease in one patient each. Concomitant infections, predominantly nosocomial, occurred in a significant proportion of patients (40%) but were only cofactors in mortality. Autopsies were done in three cases. These patterns of death are significantly different from those seen in the developed world, where disease activity has ceased to be an important factor owing to early recognition of cases. Avoiding late referrals and delays in diagnosis can reduce mortality in childhood-onset lupus. Received: 2 July 2002 / Accepted: 14 April 2002 Correspondence and offprint requests to: Dr Surjit Singh, Additional Professor of Pediatric Allergy and Immunology, Advanced Pediatric Centre, Post Graduate Institute of Medical Education and Research, Chandigarh-160012, India. Tel: 0091-172-747585 ex. 504; 235 (Off.); 0091-172-710786 (Res.); Fax: 0091-172-744401; 0091-172-745078; E-mail: surjitsingh@i91.net.in; apcpgi@glide.net.in     

Endoscopic ultrasonography in pediatric patients—Experience from a tertiary care center in India

Background and Aims

Although endoscopic ultrasound (EUS) is used in the management of various gastrointestinal (GI) diseases in adults, data on its role in children is limited. This study evaluated the indications, safety, and impact of EUS in children.

Methods

Records of children (<18 years age) who underwent EUS between January 2006 and September 2014 were reviewed retrospectively and analyzed.

Results

One hundred and twenty-one children (70 males, 51 females) aged 15.2?±?2.9 years (mean?±?SD) underwent 123 diagnostic (including fine needle aspiration cytology (FNAC) in 7) and 2 therapeutic EUS procedures. Conscious sedation was used in 81 procedures (65 %) and general anesthesia in 44 (35 %). The pancreaticobiliary system was evaluated in 114 (118 procedures), mediastinum in 5, and stomach in 2 patients. EUS diagnosed chronic pancreatitis (21 patients), pancreatic necrosis (1), splenic artery pseudoaneurysm (1), gastric varix (1), pseudocysts (3), insulinomas (2), other pancreatic masses (2), choledocholithiasis (2), choledochal cysts (2), portal biliopathy (1), esophageal leiomyoma (1), gastric neuroendocrine tumor (NET) (1), and GI stromal tumor in stomach (1). EUS-guided FNAC was positive in four of seven patients (two had tuberculosis, one pancreatic solid pseudopapillary tumor, and one gastric NET). Three patients had minor adverse events. EUS had a positive clinical impact in 43 (35.5 %) patients.

Conclusions

EUS is feasible and safe in children. It provides valuable information that helps in their clinical management.

     

Electromagnetic Navigation Bronchoscopy: Where Are We Now? Five Years of a Single-Center Experience

Introduction

Electromagnetic navigation (ENB) is a guidance tool used in the diagnosis of solitary pulmonary nodules (SPNs) and masses. Its diagnostic yield is highly variable (38–71%) and a recent study has put in doubt the role of ENB in sampling SPNs in a real-life setting. The aim of this study is to describe the 5-year experience of our center with ENB, analyzing the population, possible confounding factors, and the diagnostic yield and accuracy of this technique.

Methods

We conducted a retrospective observational study including all consecutive patients who underwent ENB for SPNs and masses from January 2011 to December 2015.

Results

We included 113 patients; 79% had SPNs, 21% masses. The majority were localized in the upper and middle lobes (80%) and 61% presented a bronchus sign. 54% of the patients had a previous negative fluoroscopy-guided bronchoscopy. ENB achieved the diagnosis in 78 patients (69%) with 64 malignant and 14 were benign lesions. The diagnostic yield and accuracy of ENB were respectively 0.69 and 0.76. The only factor influencing the ability to reach a diagnosis was the presence of bronchus sign (p?=?0.002). No procedural complications were reported.

Conclusion

ENB is a safe procedure with a similar diagnostic yield in the real-life and research setting. Bronchus sign is an important factor in determining the diagnostic yield. ENB efficacy can be maximized by expertise and by a careful selection of each case.

     

Serologically HLA-DR—Mismatched Unrelated Donors Might Provide a Valuable Alternative in Allogeneic Transplantation: Experience from a Single Japanese Institution

To clarify the clinical significance of a serologic HLA-DR mismatch after unrelated-donor transplantation, we evaluated for hematologic malignancies 123 cases of unrelated bone marrow transplantation carried out in a single institution between 1995 and 2004. Of the patients in these cases, 12 were serologically mismatched at the single HLA-DR locus. Eighty-two patients who received HLA-matched transplantations were used as controls. Conditioning consisted of a conventional total body irradiation-based regimen or a fludarabine-based reduced-intensity regimen. Prophylaxis for graft-versus-host disease (GVHD) consisted of tacrolimus plus short-term methotrexate. Graft failure did not develop. With a median follow-up of 42 months (range, 11-99 months), rates of overall survival, nonrelapse mortality, and relapse at 4 years were 63%, 38%, and 0%, respectively, all of which were comparable with those after HLA-matched transplantation. The frequency of acute GVHD of grades II to IV was 75%, significantly higher than after HLA-matched transplantation (42%, P = .046), and there was a trend toward an increased incidence of acute GVHD of grades III to IV after serologically HLA-DR-mismatched unrelated transplantation (27% versus 10%, P = .093). Chronic GVHD developed in 4 of 11 evaluable patients, an incidence comparable with that after HLA-matched transplantation. In summary, serologically HLA-DR-mismatched unrelated transplantation is feasible and might be an acceptable alternative for the Japanese population, although the higher incidence of acute GVHD is notable.     

Experience with similar biologic rituximab in 77 patients of granulomatosis with polyangiitis—a real-life experience

Clinical Rheumatology - To present single centre experience on the efficacy and safety of similar biologic of rituximab in patients with granulomatosis with polyangiitis (GPA). This was a...     

Laparoscopic Cholecystectomy as a Day Surgery Procedure: Is it Safe?—An Egyptian Experience

Background/Aim:

Major surgery performed as a day surgery procedure is not uncommon. The aim of this study is to evaluate the feasibility of day surgery procedures in laparoscopic cholecystectomy (LC).

Patients and Methods:

A total of 210 patients scheduled for elective LC between 2006 and 2008 were included in our study. The mean age was 40.63 years (range, 25 - 70 years). The indication for surgery was symptomatic cholelithiasis confirmed by ultrasonography without clinical or radiological evidence of acute cholecystitis. All patients were informed about the same-day discharge policy and received the postoperative instruction form on discharge. Preoperative work-up included history taking and physical examination in addition to standard laboratory and radiological tests. Patients above 35 years of age had an ECG done. All patients were examined in the outpatient clinic by a consultant anesthesiologist the night before surgery. Operative time, hospital stay, and complications were recorded. Telephonic feedback, on the morning after surgery was routinely done as an early follow-up.

Results:

Out of the total number of patients, 140 patients were ASA (I) and 70 were ASA (II) (40 patients were controlled hypertensives and 30 were controlled diabetics). Conversion rate was 1.4%. The mean hospital stay was 6.7 hours (range, 6 - 8 hours). The mean operative time was 31.2 minutes (range, 20 - 60 minutes). None of the patients required an abdominal drain. No morbidities or mortalities were reported in this series.

Conclusion:

LC may be done as a day surgery procedure with optimal patient satisfaction and without complications.     

Early Initiation of Prostacyclin in Portopulmonary Hypertension: 10 Years of a Transplant Center’s Experience

Background

Portopulmonary hypertension (PoPH) is a subgroup of Group 1 pulmonary arterial hypertension (PAH) with particularly poor prognosis. Delay in initiation of parenteral therapy may be the reason for poor outcome.

Methods

We conducted a prospective observational study of all patients with Group 1 PoPH evaluated at Henry Ford Hospital between January 2002 and July 2012. The cohort of the REVEAL Registry patients with PoPH was used as the comparator group. The patient survival rates at 5 years after diagnosis and 2 years after enrollment, treatment trends, and the freedom from all-cause hospitalization rates at 2 years after enrollment were compared using χ ² analysis.

Results

Twenty-one patients were enrolled in the PH Clinic with PoPH from January 2002 through July 2012. Our patients were significantly more likely to be on prostacyclin IV at 90 days as compared to REVEAL PoPH patients (67 vs. 31 %; p = 0.002). Despite this, early outcomes were not significantly different between the groups: 2-year survival from enrollment (70 and 67 %, respectively; p = 0.77) and 2-year freedom from hospitalization (35 vs. 49 %, respectively; p = 0.29). However, 5-year survival from time of diagnosis was significantly higher in our cohort of PoPH patients (71 and 40 %, respectively; p = 0.02).

Conclusions

Early initiation of parenteral prostacyclin therapy in PoPH patients at a single institution was associated with improved 5-year patient survival from diagnosis as compared to the REVEAL Registry of PoPH patients and allowed for clearance for transplant in 52 % of patients within 1 year.     

Perinuclear anti-neutrophil cytoplasmic antibodies （p-anca） in chronic ulcerative colitis： Experience in a Mexican institution

AIM: To assess the prevalence and clinical value of p-ANCA in a sample of Mexican ulcerative colitis (UC) patients. METHODS: In a prospective, IRB-approved protocol, p-ANCA was determined in 80 patients with UC (mean age, 32±12.9 years). The severity and extension of disease were determined by clinical methods, searching a statistical association with p-ANCA status. RESULTS: p-ANCA were detected in 41 (51%) patients. Severity of disease was the only clinical variable statistically associated with their presence (P < 0.0001; OR = 9; CI 95% = 3.2-24.7). CONCLUSION: The prevalence of p-ANCA was similar to that reported in other countries. Their presence was associated to UC severity, but offered no more information than the obtained by clinical methods.     

Outcomes of Percutaneous Coronary Intervention in the Very Elderly：One-center Experience in a Chinese Patient Group

Objective To investigate the clinical and perioperative characteristics of patients ≥ 75 who undergoing percutaneous coronary intervention (PCI) and to evaluate the risk factors related to short-term post-PCI mortality in this specific patients group. Methods 1,035 consecutive subjects who underwent PCI from December 2011 to November 2013 were divided into four categories: (1) patients with stable angina (SA) ≥ 75 years (n = 58); (2) patients with SA < 75 years (n = 218); (3) patients with acute coronary syndrome (ACS) ≥ 75 years (n = 155); (4) patients with ACS < 75 years (n = 604). A multivariable logistic regression analysis was conducted to detect risk factors of six-month mortality in patients ≥ 75 years who had undergone PCI. Clinical comorbidities, in-hospital biochemical indicators, perioperative data, in-hospital and six-month outcomes were analyzed and compared among the four groups. Results Compared with the younger group, pa?tients ≥ 75 years were more likely to have hypertension, history of stroke, chronic obstructive pulmonary disease, peripheral vascular disease, cardiogenic shock and malignant arrhythmia, and they were admitted to hospital with relative lower weight, hemoglobin, albumin, trigly?ceride, higher creatinine, uric acid, urea nitrogen and pro-BNP. Left main artery lesions, multi-vessel, calcified lesions, chronic totally occlusion were also more likely to be seen in the elderly group. Univariate analysis revealed that age ≥ 85 years, cardiogenic shock or severe arrhythmia at admission, emergency PCI, prior stroke and chronic kidney disease were related to six-month mortality in elderly patients ≥ 75 years who underwent PCI. Multivariable logistic regression showed that cardiogenic shock or severe arrhythmia at admission, chronic kidney disease and prior stroke were independent risk factors predicting six-month mortality in elderly patients ≥ 75 years who had undergone PCI. Conclusions Our data showed that, compared with patients under 75 years, elderly patients (≥ 75 years) who had undergone PCI had a relative higher risk of mortality, and more often accompanied with multi-comorbidities, severer admission conditions and complex coronary lesions. Better eva?luation of risk factors and more intensively care should be taken to patients ≥ 75 years who had undergone PCI therapy to reduce complications.     

Cryothermal Ablation Treatment of Atrial Flutter—Experience with a New 9 French 8 mm Tip Catheter

Background: Cardiac cryoablation has been used to successfully treat a variety of arrhythmias.Objective: This study documents our experience with a new 9 French (FR) 8 mm cryocatheter for ablation treatment of symptomatic atrial flutter.Methods: A total of 77 consecutive patients with symptomatic atrial flutter were treated. Electrophysiological studies (EPS) were performed with diagnostic catheters and ablation was performed with a 9FR, 8 mm tip, quadripolar cryocatheter (Freezor® MAX catheter, CryoCath Technologies Inc., Kirkland, Canada). Cryoablation at –75°C for 8 minutes was performed, beginning at the inferior rim of the coronary sinus (CS) os and creating a posterior line to the Eustachian ridge. Safety, bidirectional isthmus block at intervention, and recurrence at 3 months post procedure were assessed.Results: There were no adverse events reported. All patients remained free of discomfort on cryoenergy delivery. The acute success rate at intervention was 96% for all patients and 100% for those with common atrial flutter. Follow-up data from 47 patients showed 33 (70%) patients without conduction recurrence on repeat EPS at 3 months. Although, 1 (2%) patient had both symptom and conduction recurrence. Data available from 53 acutely successful patients at 6 month clinical follow-up showed that 48 (91%) patients were asymptomatic and 5 (9%) patients had recurrence documented by ECG and/or patient diary records.Conclusions: Our experience with a new 9FR, 8 mm tip, quadripolar cryocatheter yielded a high success rate at intervention and an excellent safety profile. Although repeat EPS at 3 months post ablation identified conduction recurrence in 30% of patients, at 6 month clinical follow-up only 9% of patients had recurrence. Further monitoring is necessary to assess whether the relatively low recurrence rate observed at 6 month clinical follow-up is maintained over the long term.     

Is screening for pancreatic cancer in high-risk groups cost-effective? – Experience from a Danish national screening program

ObjectivePancreatic cancer (PC) is the fourth leading cause of cancer death worldwide, symptoms are few and diffuse, and when the diagnosis has been made only 10–15% would benefit from resection. Surgery is the only potentially curable treatment for pancreatic cancer, and the prognosis seems to improve with early detection. A hereditary component has been identified in 1–10% of the PC cases. To comply with this, screening for PC in high-risk groups with a genetic disposition for PC has been recommended in research settings.DesignBetween January 2006 and February 2014 31 patients with Hereditary pancreatitis or with a disposition of HP and 40 first-degree relatives of patients with Familial Pancreatic Cancer (FPC) were screened for development of Pancreatic Ductal Adenocarcinoma (PDAC) with yearly endoscopic ultrasound. The cost-effectiveness of screening in comparison with no-screening was assessed by the incremental cost-utility ratio (ICER).ResultsBy screening the FPC group we identified 2 patients with PDAC who were treated by total pancreatectomy. One patient is still alive, while the other died after 7 months due to cardiac surgery complications. Stratified analysis of patients with HP and FPC provided ICERs of 47,156 US$ vs. 35,493 US$ per life-year and 58,647 US$ vs. 47,867 US$ per QALY. Including only PDAC related death changed the ICER to 31,722 US$ per life-year and 42,128 US$ per QALY. The ICER for patients with FPC was estimated at 28,834 US$ per life-year and 38,785 US$ per QALY.ConclusionsWith a threshold value of 50,000 US$ per QALY this screening program appears to constitute a cost-effective intervention although screening of HP patients appears to be less cost-effective than FPC patients.     

Clinical correlation of gallstone disease in a Chinese population in Taiwan： Experience at Cheng Hsin General Hospital

AIM: To explore the prevalence of gallstone disease (GSD) in Taiwan and condition-associated factors related to it. METHODS: We studied a total of 2386 healthy adults (1235 males and 1151 females) voluntarily admitted to Cheng Hsin General Hospital for a paid physical check-up between January 2002 and December 2002. Blood samples and ultrasound sonography results were collected. RESULTS: The overall prevalence of GSD among this study-population was 5.3%, including 1.7% (n=40) having a single stone, 2.3% (n=55) having multiple stones, and 1.3% (n=31) having cholecystectomy. The prevalence revealed a statistically significant increase with increasing age (P<0.0001). Females exhibited a greater prevalence of multiple stones than did males (3.0% vs 1.7%, P=0.04). Using multiple logistic regression analysis, the following appeared to be significantly related to the prevalence of GSD: older age (40-49 years vs < 40 years, OR=1.63 [95% CI: 0.76-3.48], 50-59 years vs < 40 years, OR=4.93 [95% CI: 2.43-9.99], 60-69 years vs < 40 years, OR=6.82 [95% CI: 3.19-14.60], > or = 70 years vs < 40 years, OR=10.65 [95% CI: 4.78-23.73]), higher BMI (> or = 27 kg/m2 vs < 24 kg/m2, adjusted OR=1.74 [95% CI: 1.04-2.88]), and higher FPG (> or = 126 mg/dL vs < 110 mg/dL, OR=1.71, 95%CI: 1.01-2.96). CONCLUSION: Older age (> or = 50 years), obesity (BMI > or = 27 kg/m2), and type 2 diabetes (FPG > or = 126 mg/dL) are associated with the prevalence of GSD.