Combined radiologic and endoscopic treatment (using the “rendezvous technique”) of a biliary fistula following left hepatectomy

Despite the ongoing decrease in the frequency of complications after hepatectomy, biliary fistulas still occur and are associated with high morbidity and mortality rates. Here, we report on an unusual technique for managing biliary fistula following left hepatectomy in a patient in whom the right posterior segmental duct joined the left hepatic duct. The biliary fistula was treated with a combined radiologic and endoscopic procedure based on the “rendezvous technique”. The clinical outcome was good, and reoperation was not required.     

RhoA signaling and blood pressure: The consequence of failing to “Tone it Down”

Uncontrolled high blood pressure is a major risk factor for heart attack, stroke, and kidney failure and contributes to an estimated 25% of deaths worldwide. Despite numerous treatment options, estimates project that reasonable blood pressure (BP) control is achieved in only about half of hypertensive patients. Improvements in the detection and management of hypertension will undoubtedly be accomplished through a better understanding of the complex etiology of this disease and a more comprehensive inventory of the genes and genetic variants that influence BP regulation. Recent studies (primarily in pre-clinical models) indicate that the small GTPase RhoA and its downstream target, Rho kinase, play an important role in regulating BP homeostasis. Herein, we summarize the underlying mechanisms and highlight signaling pathways and regulators that impart tight spatial-temporal control of RhoA activity. We also discuss known allelic variations in the RhoA pathway and consider how these polymorphisms may affect genetic risk for hypertension and its clinical manifestations. Finally, we summarize the current (albeit limited) clinical data on the efficacy of targeting the RhoA pathway in hypertensive patients.     

Lot to give,got to live - the restless minds of the “Liver on Tour” project

The Liver on Tour was a special project devoted to increase the public awareness on Liver Health and Liver Diseases that the Portuguese Association for the Study of Liver Diseases launched throughout the country in 2010.     

Mechanical analysis of insertion problems and pain during colonoscopy: Why highly skill-dependent colonoscopy routines are necessary in the first place... and how they may be avoided

BACKGROUND:

Colonoscopy requires highly skill-dependent manoeuvres that demand a significant amount of training, and can cause considerable discomfort to patients, which increases the use of sedatives. Understanding the underlying fundamental mechanics behind insertion difficulties and pain during colonoscopy may help to simplify colonoscopy and reduce the required extent of training and reliance on sedatives.

METHODS:

A literature search, anatomical studies, models of the colon and colonoscope, and bench tests were used to qualitatively analyze the fundamental mechanical causes of insertion difficulties and pain. A categorized review resulted in an overview of potential alternatives to current colonoscopes.

RESULTS:

To advance a colonoscope through the colon, the colon wall, ligaments and peritoneum must be stretched, thus creating tension in the colon wall, which resists further wall deformation. This resistance forces the colonoscope to bend and follow the curves of the colon. The deformations that cause insertion difficulties and pain (necessitating the use of complex conventional manoeuvres) are the stretching of ligaments, and stretching of colon wall in the transverse and longitudinal directions, and the peritoneum.

CONCLUSIONS:

Four fundamental mechanical solutions to prevent these deformations were extracted from the analysis. The current results may help in the development of new colonoscopy devices that reduce – or eliminate – the necessity of using highly skill-dependent manoeuvres, facilitate training and reduce the use of sedatives.     

Listening to Turkish classical music decreases patients＇ anxiety, pain, dissatisfaction and the dose of sedative and analgesic drugs during colonoscopy： A prospective randomized controlled trial

AIM: To determine whether listening to music decreases the requirement for dosages of sedative drugs, patients' anxiety, pain and dissatisfaction feelings during colonoscopy and makes the procedure more comfortable and acceptable. METHODS: Patients undergoing elective colonoscopy between October 2005 and February 2006 were randomized into either listening to music (Group 1, n = 30) or not listening to music (Group 2, n = 30). Anxiolytic and analgesic drugs (intravenous midazolam and meperidine) were given according to the patients' demand. Administered medications were monitored. We determined their levels of anxiety using the State-Trait Anxiety Inventory Test form. Patients' satisfaction, pain, and willingness to undergo a repeated procedure were self-assessed using a visual analog scale. RESULTS: The mean dose of sedative and analgesic drugs used in group 1 (midazolam: 2.1 +/- 1.4, meperidine: 18.1 +/- 11.7) was smaller than group 2 (midazolam: 2.4 +/- 1.0, meperidine: 20.6 +/- 11.5), but without a significant difference (P > 0.05). The mean anxiety level in group 1 was lower than group 2 (36.7 +/- 2.2 vs 251.0 +/- 1.9, P < 0.001). The mean satisfaction score was higher in group 1 compared to group 2 (87.8 +/- 3.1 vs 58.1 +/- 3.4, P < 0.001). The mean pain score in group 1 was lower than group 2 (74.1 +/- 4.7 vs 39.0 +/- 3.9, P < 0.001). CONCLUSION: Listening to music during colonoscopy helps reduce the dose of sedative medications, as well as patients' anxiety, pain, dissatisfaction during the procedure. Therefore, we believe that listening to music can play an adjunctive role to sedation in colonoscopy. It is a simple, inexpensive way to improve patients' comfort during the procedure.     

Stimulation of gluconeogenesis by palmitic acid in rat hepatocytes: Evidence that this effect can be dissociated from the provision of reducing equivalents

When hepatocytes isolated from fasted rats were incubated in medium containing 5 mmol/L pyruvate, addition of albumin-bound palmitate (0.5 mmol/L) increased fatty acid oxidation and the conversion of pyruvate to glucose. Similar stimulation of gluconeogenesis occurred when palmitate was added to hepatocytes in medium containing 5 mmol/L alanine. Addition of 0.5 mmol/L (+)-octanoylcarnitine, an inhibitor of fatty acid oxidation, prevented the increment in beta-oxidation, but not the increase in glucose formation from pyruvate or alanine, induced by palmitate. These studies and other data to be considered subsequently indicate that palmitate can stimulate hepatic gluconeogenesis from three-carbon precursors under conditions that preclude an increase in the formation of reducing equivalents by beta-oxidation.     

A premounted stent that can be implanted in infants and re‐dilated to 20 mm: Introducing the Edwards Valeo Lifestent

Intravascular stenting (IS) for vascular stenoses in congenital heart disease provides superior gradient relief and angiographic results over balloon angioplasty (BA) alone. The advantages of IS, however, are difficult to apply to infants, toddlers, and small children due to technical challenges in placing large, long sheaths and the risk of creating future stenoses in stents that cannot be re‐dilated to keep pace with somatic growth. This report highlights the Edwards premounted re‐dilatable biliary stent, which was safely placed in four infants and small children with excellent hemodynamic and angiographic results. Bench testing revealed the stent has adequate radial strength and can be re‐dilated to a maximal diameter of 20 mm. © 2009 Wiley‐Liss, Inc.     

Evaluation of the gel test for antibody screening in a tertiary hospital in Hong Kong; insensitivity for some cold antibodies that are reactive at 37°C by conventional indirect antiglobulin tests

Summary The antiglobulin gel test (DiaMed) was compared with conventional IAT methods in pre-transfusion antibody screening in a tertiary hospital in Hong Kong. Antibody titrations showed that the gel system was more sensitive than the tube IAT method in detecting anti-D, anti-S, anti-s, but slightly less sensitive with anti-E. The gel tests detected all clinically significant warm reacting allo-antibodies detected by conventional IAT methods except one case of weak anti-E. It detected a case of anti-C missed in conventional screening. The number of serological investigations due to false positive screens, non-specific antibodies and clinically insignificant cold antibodies (anti-P, and anti-Lewis) were reduced. The gel system was fast and easy to use. It would reduce delays and inconvenience caused to patients due to false positive screens and non-specific antibodies without compromising detection of clinically significant antibodies. However, of concern was the failure to detect several cases of anti-Le^a and anti-P₁ that were reactive at 3 7°C by conventional IAT and one case of anti-H in a patient with Parabombay A.     

Evaluation of mitral valve area by the proximal isovelocity surface area method in mitral stenosis: could it be simplified?

AIM: One limitation for a wider use of the proximal isovelocity surface area method (PISA) for the evaluation of the mitral valve area (MVA) in patients with mitral stenosis (MS) is the requirement of an angle correction factor (angle alpha between the mitral leaflets) which cannot be obtained using the machine's built-in software and requires a manual measurement. The aim of the present study was to evaluate if the use of a fixed angle could provide an acceptable MVA estimation. METHODS AND RESULTS: In 48 patients (53 +/- 14 years, 75% female and 32% atrial fibrillation), MVA was prospectively measured by planimetry (MVA(2D)) and PISA (PISA(mes)). The angle alpha was manually measured on paper prints using a protractor. MVA(2D) was 1.38 +/- 0.56 cm(2) [0.5-2.40]. PISA(mes) (alpha = 104 +/- 13 degrees inter-quartiles 90-115) was 1.34 +/- 0.64 cm(2) [0.31-2.95] and did not differ from and correlated well with MVA(2D) (P = 0.25; r = 0.93, P < 0.0001). MVA estimated using the PISA method and a fixed angle value from 90 to 110 (MVA(alpha)(=90) to MVA(alpha)(=110)) progressively increased from 1.20 +/- 0.66 to 1.48 +/- 0.81 cm(2). Only MVA(alpha)(=100) (1.34 +/- 0.74 cm(2)) did not differ from and correlated well with both MVA(2D) and PISA(mes) (both P > 0.35 and r > 0.90, P < 0.0001). CONCLUSION: The angle formed by the mitral leaflet only slightly changes in between patients and use of a fixed angle value of 100 degrees provides an accurate estimation of the MVA by the PISA method in patients with MS. This simplification would facilitate and extend the use of the PISA as an additional method for the assessment of MS severity in routine practice.     

Angioplasty without the use of “Y connector”: A new,easier, bloodless method

The “Y connector” that is used in angioplasty has the following disadvantages: 1) it is not blood-tight; 2) we need to “screw and unscrew” every time we want to inject contrast material or measure the pressure; and 3) it does not allow the advancement of the guidewire or the balloon catheter during the injection of contrast material. We created a new type of connection composed of a cut sheath for the femoral artery, connected with a cut (at the “hub”) guiding catheter. The aim of this study was to examine the feasibility, efficacy, and safety of the new method. Using the new technique we performed plain-balloon angioplasty, implantation of stent, and atherectomy in 350 patients. The technical success of the method was 100%, and no complications related to the method were seen. In conclusion, the novel connection that we created eliminated all the disadvantages of the “Y connector” and was found to have 100% technical success and safety. Cathet. Cardiovasc. Diagn. 41:445–448, 1997. © 1997 Wiley-Liss, Inc.     

Evaluation of a combination digital retinal camera with spectral-domain optical coherence tomography (SD-OCT) that might be used for the screening of diabetic retinopathy with telemedicine: A pilot study

Aims

Pilot study to determine whether an instrument combining a non-mydriatic retinal camera and spectral domain optical coherence tomography (SD-OCT) is effective for screening patients with diabetic retinopathy (DR).

Practical parameters that can be used for nutritional assessment in patients hospitalized in the intensive care unit with the diagnosis of chronic obstructive pulmonary disease: Prognostic nutritional index,neutrophil-to-lymphocyte,platelet-to-lymphocyte,and lymphocyte-to-monocyte ratio

Malnutrition is an important condition in patients diagnosed with chronic obstructive pulmonary disease (COPD). There is a need for practical and objective nutritional assessment methods in patients hospitalized in the intensive care unit with the diagnosis of COPD. In this study, it was aimed to determine the parameters that can practically evaluate the nutritional status of these patients. It was aimed to determine the relationship between prognostic nutritional index (PNI), and nutritional risk screening (NRS)-2002, nutrition risk in the critical ill (Nutric) Score and to determine a cut-off value for PNI, neutrophil-to-lymphocyte (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and other complete blood count parameters.Hemogram values, albumin values, NLR, PLR, LMR, NRS-2002, PNI and modified Nutric Score calculations of the patients hospitalized in the intensive care unit due to COPD were recorded. The relationship between PNI and NRS-2002 and modified Nutric Score, as well as the relationship between NLR, PLR, LMR, hemogram parameters and PNI were analyzed using statistical methods.The PNI cut-off value for nutritional assessment in patients hospitalized in the intensive care unit due to COPD was determined as 38.5 (area under curve = 0.891, sensitivity 80.8%, specificity 88.1%, positive predictive value 92.9%, negative predictive value 88%). High-risk group according to PNI compared to low-risk group, lymphocyte count (P < .001), basophil count (P = .004), red blood cell (P < .001), hemoglobin (P < .001), hematocrit (P < .001), and LMR (P = .001) were statistically significantly lower, while NLR (P < .001) and PLR (P = .001) were statistically significantly higher. Cut-off values for lymphocyte count, basophil count, NLR, PLR, and LMR were found to be 1.18, 0.035, 7.97, 291.10, and 2.606, respectively.Nutritional risk assessment can be made in a practical way by using PNI in patients hospitalized in intensive care unit due to COPD. For this, the PNI cut-off value was determined as 38.5 in our study. In addition, NLR, PLR, LMR, basophil and lymphocyte values, which can be calculated using complete blood count parameters, may also be useful in the evaluation of nutritional status in these patients. In our study, the cut-off values determined for NLR, PLR, LMR, basophil and lymphocyte were 7.97, 291.10 and 2.606, 0.035 and 1.18, respectively. We think that the results we have obtained can provide preliminary information for future research.     

Further evidence that methods based on spot urine samples should not be used to examine sodium‐disease relationships from the Science of Salt: A regularly updated systematic review of salt and health outcomes (November 2018 to August 2019)

The aim of this eighth Science of Salt outcomes review is to identify, summarize, and critically appraise studies on dietary sodium and health outcomes published between November 1, 2018, and August 31, 2019, to extend this series published in the Journal since 2016. The standardized Science of Salt search strategy was conducted. Studies were screened based on a priori defined criteria to identify publications eligible for detailed critical appraisal. The search strategy resulted in 2621 citations with 27 studies on dietary sodium and health outcomes identified. Two studies met the criteria for detailed critical appraisal and commentary. We report more evidence that high sodium intake has detrimental health effects. A post hoc analysis of the Dietary Approaches to Stop Hypertension (DASH) sodium trial showed that lightheadedness occurred at a greater frequency with a high sodium DASH diet compared to a low sodium DASH diet. In addition, evidence from a post‐trial analysis of the Trials of Hypertension (TOHP) I and II cohorts showed that estimates of sodium intake from methods based on spot urine samples are inaccurate and this method alters the linearity of the sodium‐mortality association. Compared to measurement of 24‐hour sodium excretion using three to seven 24‐hour urine collections, estimation of average 24‐hour sodium excretion with the Kawasaki equation appeared to change the mortality association from linear to J‐shaped. Only two high‐quality studies were identified during the review period, both were secondary analyses of previously conducted trials, highlighting the lack of new methodologically sound studies examining sodium and health outcomes.     

Patients with severe von Willebrand disease are insensitive to the releasing effect of DDAVP: evidence that the DDAVP-induced increase in plasma factor VIII is not secondary to the increase in plasma von Willebrand factor

Summary It is generally held that factor VIII (FVIII) does not increase in the plasma of severe von Willebrand disease (vWD) patients treated with DDAVP because they lack von Willebrand factor (vWF), which is the plasma carrier for FVIII. To test this hypothesis, FVIII plasma levels were monitored in severe vWD patients treated with DDAVP after normalization of vWF plasma levels with infusions of cryoprecipitate. Each of four severe vWD patients underwent four different treatments at intervals of at least 15 d: (1) cryoprecipitate plus DDAVP; (2) cryoprecipitate plus saline; (3) cryoprecipitate plus recombinant FVIII (rFVIII); (4) saline plus rFVIII. Cryoprecipitate increased the plasma levels of FVIII and vWF. The infusions of saline or DDAVP after cryoprecipitate did not further increase FVIII and vWF plasma levels and had no effect on the plasma levels of tissue plasminogen activator (tPA), which are raised by DDAVP in normal subjects and in patients with vWD of other types. The infusion of rFVIII further increased by 182 ± 32 U/dl (mean ± SEM) the plasma levels attained after cryoprecipitate, which disappeared from the circulation with a half-life of 11.95 ± 0.86 h. In contrast, the infusion of rFVIII after saline increased by only 107 ± 18 U/dl the plasma levels of FVIII, which disappeared from the circulation with a half-life of 2.68 ± 0.14 h, indicating that the vWF infused with cryoprecipitate is able to bind additional FVIII. These studies indicate that DDAVP does not increase the plasma levels of FVIII in patients with severe vWD even after normalization of plasma vWF. The possibility is discussed that severe vWD patients may be insensitive to the releasing effect of DDAVP.