How Should Biliary Stones be Managed?

Minimally invasive therapy is currently invaluable for the treatment of biliary stones. Clinicians should be familiar with the various endoscopic modalities that have been evolving. I reviewed the treatment of biliary stones from the common practice to pioneering procedures, and here I also briefly summarize the results of many related studies. Lithotripsy involves procedures that fragment large stones, and they can be roughly classified into two groups: intracorporeal modalities and extracorporeal shock-wave lithotripsy (ESWL). Intracorporeal modalities are further divided into mechanical lithotripsy (ML), electrohydraulic lithotripsy, and laser lithotripsy. ESWL can break stones by focusing high-pressure shock-wave energy at a designated target point. Balloon dilation after minimal endoscopic sphincterotomy (EST) is effective for retrieving large biliary stones without the use of ML. Peroral cholangioscopy provides direct visualization of the bile duct and permits diagnostic procedures or therapeutic interventions. Biliary stenting below an impacted stone is sometimes worth considering as an alternative treatment in elderly patients. This article focuses on specialized issues such as lithotripsy rather than simple EST with stone removal in order to provide important information on state-of-the-art procedures.     

CTO Pathophysiology: How Does this Affect Management?

Chronic total occlusion (CTO) pathophysiology has been described in a few, small studies using post mortem histology, and more recently, in vivo intravascular ultrasound (IVUS) to analyse the constituents of occluded segments. Recent improvements in equipment and techniques have revealed new insights into physical characteristics of occluded coronaries, which in turn enable predictable procedural success. The purpose of this review is to consider the published evidence describing CTO pathophysiology from the perspective of the hybrid algorithm approach to CTO PCI. Methods: Literature searches using “Chronic Occlusion”, “angioplasty”, and” pathology” as keywords. Further searches on “coronary” “collateral”, “Viability”. Bibliographies were scrutinised for further key publications in an iterative process. Papers describing animal models were excluded.     

Endoscopic Management of Gallbladder Stones: Can We Eliminate Cholecystectomy?

The gold standard for the management of acute cholecystitis is laparoscopic cholecystectomy. In patients that are not fit for surgery, percutaneous cholecystostomy is the standard treatment. However, the procedure is only a temporary measure for controlling gallbladder symptoms and it is frequently associated with morbidities. Recently, endoscopic options for management of acute cholecystitis have been developed. The approach avoids the need for a percutaneous drain and may allow endoscopic treatment of the gallstone. The aim of this article is to provide an overview on the current status of endoscopic management of acute cholecystitis.     

Does Age Affect the Short- and Long-Term Outcomes of Coronary Bypass Grafting?

The etiology of coronary artery disease (CAD) is multifactorial, stemming from both modifiable and nonmodifiable risk factors such as age. Several studies have reported the effects of age on various outcomes of coronary artery bypass grafting (CABG). This article reviews age-related outcomes of CABG and offers direction for further studies in the field to create comprehensive, evidence-based guidelines for the treatment of CAD. Ninety-two primary sources were analyzed for relevance to the subject matter, of which 17 were selected for further analysis: 14 retrospective cohort studies, 2 randomized clinical trials, and 1 meta-analysis. Our review revealed four broad age ranges into which patients can be grouped: those with CAD (1) below the age of 40 years, (2) between the ages of 40 and 60 years, (3) between the ages of 60 and 80 years, and (4) at or above 80 years. Patients below the age of 40 years fare best overall with total arterial revascularization (TAR). Patients between the ages of 40 and 60 years also fare well with the use of multiarterial grafts (MAGs) whereas either MAGs or single-arterial grafts may be of significant benefit to patients at or above the age of 60 years, with younger and diabetic patients benefitting the most. Arterial grafting is superior to vein grafting until the age of 80 years, at which point there is promising evidence supporting the continued use of the saphenous vein as the favored graft substrate. Age is a factor affecting the outcomes of CABG but should not serve as a barrier to offering patients CABG at any age from either a cost or a health perspective. Operative intervention starts to show significant mortality consequences at the age of 80 years, but the increased risk is countered by maintenance or improvement to patients'' quality of life.     

HCV and Chemotherapy: Does Infection Change Management?

Hepatitis C infects 1.6% of the United States adult population, and the peak prevalence of infection is present in the Baby Boomer generation. HCV infection predisposed patients to both hepatic and non-hepatic malignancies, leading to an increasing number of HCV infected patients needing chemotherapy. Since the liver is the most important site of drug metabolism, it is critical to understand how HCV impacts chemotherapy. Clinical decisions regarding chemotherapy dosing are traditionally based on serum biochemical tests; however these do not measure liver function, and liver biopsy combined with the Child classification are better measures of true liver function. Fortunately, patients without cirrhosis have intact synthetic function. However, patients with cirrhosis, some of whom have normal liver function tests, may not. Not only can HCV infection increase the risk of hepatotoxicity from chemotherapy, but chemotherapy can accelerate the progression of HCV related liver disease.     

How Do Storms Affect Asthma?

Purpose of Review

There are observations in various geographical areas that thunderstorms occurring during pollen seasons can induce severe asthma attacks in pollinosis patients.

Recent Findings

An accredited hypothesis explaining the association between thunderstorms and asthma suggests that storms can concentrate pollen grains at ground level, which may then release allergenic particles of respirable size in the atmosphere after their imbibition of water and rupture by osmotic shock. During the first 20–30 min of a thunderstorm, patients affected by pollen allergy may inhale a high quantity of the allergenic material that is dispersed into the atmosphere as a bioaerosol of allergenic particles, which can induce asthmatic reactions, often severe. Subjects without asthma symptoms, but affected by seasonal rhinitis can also experience an asthma attack. A key message is that all subjects affected by pollen allergy should be alerted to the danger of being outdoors during a thunderstorm in the pollen season, as such events may be an important cause of severe asthma exacerbations. In light of these observations, it is useful to predict thunderstorms and thus minimize thunderstorm-related events. Patients with respiratory allergy induced by pollens and molds need to be informed about a correct therapeutic approach of bronchial asthma by inhalation, including the use of bronchodilators and inhaled corticosteroids.

Summary

The purpose of this review is to focalize epidemiological, etiopathogenetic, and clinical aspects of thunderstorm-related asthma.

     

How Do Elevated Triglycerides and Low HDL-Cholesterol Affect Inflammation and Atherothrombosis?

This review article summarizes recent research into the mechanisms as to how elevated levels of triglyceride (TG) and low levels of high- density- lipoprotein cholesterol (HDL-C) contribute to inflammation and atherosclerosis. Evidence supports the role of TG-rich lipoproteins in signaling mechanisms via apolipoproteins C-III and free fatty acids leading to activation of NFKβ, VCAM-1 and other inflammatory mediators which lead to fatty streak formation and advanced atherosclerosis. Moreover, the cholesterol content in TG-rich lipoproteins has been shown to predict CAD risk better than LDL-C. In addition to reverse cholesterol transport, HDL has many other cardioprotective effects which include regulating immune function. The “functionality” of HDL appears more important than the level of HDL-C. Insulin resistance and central obesity underlie the pathophysiology of elevated TG and low HDL-C in metabolic syndrome and type 2 diabetes. Lifestyle recommendations including exercise and weight loss remain first line therapy in ameliorating insulin resistance and the adverse signaling processes from elevated levels of TG-rich lipoproteins and low HDL-C.     

Does Preheating Resin Cements Affect Fracture Resistance of Lithium Disilicate and Zirconia Restorations?

This paper assesses the impact of preheating of adhesive cement on the fracture resistance of lithium disilicate and zirconia restorations. Methods: A total of 80 human maxillary premolar teeth were assigned into 8 groups (n = 10) according to material type (either lithium disilicate or zirconia) and type of resin cement (either LinkForce or Panavia SA) with preheating temperature at 54 °C or at room temperature (25 °C). Teeth were prepared and restored with either lithium disilicate or zirconia restorations. After cementation, specimens were thermal cycled (10,000 cycles, 5 °C/55 °C), then load cycled for 240,000 cycles (50 N). Each specimen was statically loaded until fracture and the load (N) at fracture was recorded, then the failure mode was detected. Statistical analysis of data was performed (p ≤ 0.05). Results: There was no significant difference (p = 0.978) in fracture mean values between LinkForce and Panavia SA. Statistically significant difference (p = 0.001) was revealed between fracture resistance of lithium disilicate restorations cemented with LinkForce at 25 °C and at 54 °C; however there was no significant difference (p = 0.92) between the fracture resistance of lithium disilicate restorations cemented with Panavia SA used at 25 °C and at 54 °C. Regarding the interaction between ceramic material, cement type, and cement preheating, there was no significant effect (p > 0.05) in fracture resistance. The cement type does not influence the fracture resistance of ceramic restorations. Preheating of resin cement has negatively influenced the fracture resistance of all tested groups, except for lithium disilicate cemented using LinkForce cement.     

Sinonasal and Laryngeal Sarcoidosis—An Uncommon Presentation and Management Challenge

Sarcoidosis is a chronic inflammatory disease of uncertain etiology characterized by the formation of noncaseating granulomas. The thorax is involved in 95% of cases, but any organ can be involved. Sinonasal or laryngeal involvement is uncommon and can be difficult to diagnose. The reported incidence of sarcoidosis in the upper airway clearly depends on study characteristics, and this creates uncertainty about the actual incidence. In a large prospective study in the United States, upper respiratory tract involvement occurred in 3% of the patients. Some patients have upper airway involvement without thoracic disease, and this presentation may cause delays in diagnosis. These patients have nonspecific symptoms which range from minimal nasal stuffiness to life-threatening upper airway obstruction. Currently, there is no established standard therapy for the management of upper airway sarcoidosis. These patients often respond poorly to nasal and/or inhaled corticosteroids and require long courses of oral corticosteroids. Patients with poor responses to oral corticosteroids or severe side effects may respond to tumor necrosis factor alpha inhibitors. In this review, we will discuss the clinical presentation, pathogenesis, diagnostic tests, drug treatment, surgical management options and the challenges clinicians have managing these patients.     

The Microbial Aspects of Sepsis: Does the Organism and Its Treatment Affect Outcome?

Sepsis, by definition, requires the presence of an infection as the cause of the systemic inflammatory response. At its inception, it may be difficult to distinguish sepsis from non-infectious systemic inflammatory response syndrome (SIRS). This distinction is probably important as documented infection complicated by sepsis is generally associated with a more marked activation of the systemic inflammatory mediators. Additionally, sepsis may be more amenable to therapy than non-infectious SIRS.There is clear evidence that appropriate and timely intervention with bactericidal antimicrobial agents improves the prognosis of Gram-negative bacteremia. It is clinically evident that early surgical management of the infectious focus (surgical drainage, removal of obstruction) is beneficial to the patient. However, it is difficult quantify the magnitude of this benefit in clinical studies. Gram-positive bacterial sepsis has significantly different microbial and host-derived mediators than those found in Gram-negative sepsis. The clinical relevance of these differences needs to be determined. Antibiotic-induced endotoxin release continues to be a concern but more convincing data of its clinical relevance in humans needs to be collected. Expeditious management of the precipitating infectious source of sepsis is of paramount importance in the successful management of sepsis.     

Dietary Management in the Prevention and Treatment of Hypertension: Does It Work?

During a meeting of the American Society of Hypertension in New Orleans, LA, in May 2008, an expert panel was convened to discuss nonpharmacologic therapy in hypertension. This is an update of a panel discussion that was held in March 2007. The panel was co-moderated by Marvin Moser, MD, Clinical Professor of Medicine at Yale University School of Medicine, New Haven, CT, and Mark Houston, MD, Associate Clinical Professor at the Vanderbilt University School of Medicine, Nashville, TN. Panelists included Laura Svetkey, MD, Professor of Medicine at Duke University, Durham, NC, and Brent Egan, Professor of Medicine at the Medical University of South Carolina, Charleston, SC.     

Does Conversion of a Laparoscopic Colectomy Adversely Affect Patient Outcome?

PURPOSE Conversion during laparoscopic colectomy varies in frequency according to the surgeons experience and case selection. However, there remains concern that conversion is associated with increased morbidity and higher hospital costs.METHODS From January 1999 to August 2002, 430 laparoscopic colectomies were performed by two surgeons, with 51 (12 percent) cases converted to open surgery. Converted cases were matched for operation and age to 51 open cases performed mostly by other colorectal surgeons from our department. Data collected included gender, American Society of Anesthesiology score, operative indication, resection type, operative stage at conversion, in-hospital complications, direct hospital costs, unexpected readmission within 30 days, and mortality.RESULTS There were no significant differences between the groups for age (converted, 55 ± 19; open, 62 ± 16), male:female ratio (converted, 17:34; open, 23:28), or American Society of Anesthesiology score distribution. Indications for surgery were neoplasia (converted, 16; open, 31); diverticular disease (converted, 21; open, 13); Crohns disease (converted, 12; open, 5); and other disease (converted, 2; open, 2). Operative times were similar (converted, 150 ± 56 minutes; open, 132 ± 48 minutes). Conversions occurred before defining the major vascular pedicle/ureter (50 percent), in relation to intracorporeal vascular ligation (15 percent), or during bowel transection or presacral dissection (35 percent). Specific indications for conversion were technical (41 percent), followed by adhesions (33 percent), phlegmon or abscess (23 percent), bleeding (6 percent), and failure to identify the ureter (6 percent). Median hospital stay was five days for both groups. In-hospital complications (converted 11.6 percent; open 8 percent), 30-day readmission rate (converted 13 percent vs. open 8 percent), and direct costs were similar between groups. There were no mortalities.CONCLUSION Conversion of a laparoscopic colectomy does not result in inappropriately prolonged operative times, increased morbidity or length of stay, increased direct costs, or unexpected readmissions compared with similarly complex laparotomies. A policy of commencing most cases suitable for a laparoscopic approach laparoscopically offers patients the benefits of a laparoscopic colectomy without adversely affecting perioperative risks.Read at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.