Percutaneous Transhepatic Cholangiodrainage as Rescue Therapy for Symptomatic Biliary Leakage Without Biliary Tract Dilation After Major Surgery

Symptomatic biliary leakage following major upper abdominal surgery is a severe complication resulting in increased morbidity and mortality. Treatment options usually include either endoscopic intervention or surgical revision. These options may be burdened by a high perioperative risk for the patient (e.g., patients with severe disease) or simply may not be possible (e.g., nonpreserved gastroduodenal passage). In the past, percutaneous transhepatic cholangiodrainage did only seem to be a viable option for patients with dilated bile ducts. Here, we present our experience in a consecutive series of patients with symptomatic biliary leakage following major upper abdominal surgery and without dilation of the biliary system that underwent percutaneous transhepatic cholangiodrainage. Percutaneous transhepatic cholangiodrainage was feasible in 15 of 18 patients (83.3%). The procedure was technically not possible in three patients (16.7%). In 10 of the 15 patients (66.6%) with feasible percutaneous transhepatic cholangiodrainage, biliary leakage was definitely controlled without the need for surgical revision. Depending on the experience with the interventional procedure, percutaneous transhepatic cholangiodrainage should be considered as an alternative for treatment of symptomatic biliary leakage instead of immediate reoperation. Presented at the Digestive Disease Week 2005 (DDW), Chicago, IL, May 14–19, 2005 (poster presentation).     

The effect of simulator training on clinical skills acquisition, retention and transfer

Context  Prior research has demonstrated that residents have poor clinical skills in cardiology and respirology. It is not clear how these skills can be improved because the number of patients with suitable clinical findings whose cooperation might help residents to better develop these clinical skills is limited.
Objectives  Our objective was to evaluate the effect of training on a cardiorespiratory simulator (CRS) on skills acquisition, retention and transfer.
Methods  We randomly allocated 146 students to CRS training in either chest pain or dyspnoea and compared each student's performance on the clinical presentation in which he or she had received CRS training with performance on the control presentation.
Results  Immediately after training, students were more accurate in identifying abnormal clinical findings on the CRS (70.0% versus 52.2%; d = 7.6, P  < 0.0001) and showed improved diagnostic performance (72.1% versus 55.6%; d = 4.3, P  = 0.0007) on the training clinical presentation. At the end of the course they were still better at identifying abnormal findings (57.1% versus 51.7%; d = 2.5, P  = 0.004) and diagnosing correctly (50.0% versus 38.1%; d = 3.0, P  = 0.002) on problems included in the training clinical presentation. However, they showed no difference between training and control presentations in diagnostic performance when required to transfer their skills between problems (45.9% versus 43.8%; P  = 0.5) or in performance on multiple-choice questions (64.1% versus 63.6%; P  = 0.8).
Conclusions  Students can acquire and retain clinical skills with CRS training, but demonstrate limited ability to transfer these to other problems. Further studies are needed to explore ways of improving learning and transfer with CRS training.     

Intra-abdominal packing for uncontrollable haemorrhage during ruptured abdominal aortic aneurysm repair.

OBJECTIVE: Intra-abdominal packing is a valuable adjunct in patients with abdominal trauma and uncontrollable bleeding but few data exist regarding early and late outcome associated with this technique in patients with ruptured abdominal aortic aneurysm (AAA). METHODS: Interrogation of a prospective vascular surgical database identified 23 patients (22 men; median age 69, range 59-82, years) with ruptured AAA who required intra-abdominal packing for control of coagulopathic haemorrhage after insertion of an aortic graft between January 1982 and December 2003. Co-morbidity, operative and outcome data were retrieved. RESULTS: Haemostasis was achieved and packs were removed within 48 h in 20 patients. In those patients who had a graft inserted, the peri-operative mortality rate was 12 of 23 (52%) patients (vs. 172 of 455 (38%) patients who were not packed, NS). Three (13%) patients developed early intra-abdominal sepsis, which was universally fatal: graft-enteric fistula, intra-abdominal abscess with necrotizing fasciitis of the abdominal wound, and infected retroperitoneal haematoma. Two of 11 (18%) survivors developed late graft-related infective complications: major aortic graft infection at 6 months and symptomatic infected para-anastomotic aortic false aneurysm at 39 months. Early and late intra-abdominal infective complications were significantly more common in patients who were packed than in those who were not (packed: five of 23, 22% vs. non-packed: five of 455, 1%; p < 0.001). CONCLUSION: These data demonstrate that intra-abdominal packing in coagulopathic patients with ruptured AAA can achieve an acceptable survival rate. However, this technique may be associated with an increased incidence of early and late intra-abdominal infective complications.     

Radionuclide ventriculography (equilibrium gated blood pool scanning) —its present clinical position and recent development

Myocardial scanning (MS) and radionuclide ventriculography (RNV) are the foundation of nuclear cardiology. These procedures aim in two completely different directions: RNV tries to image heart motion, that is, mechanical (pump) function, and therefore belongs to the group of first-order functional imaging (FI, imaging mechanical function), whereas MS is based on myocardial metabolism, and therefore can be attributed to third-order functional imaging (metabolism). This statement is relevant for the assessment of the clinical position of RNV: Third-order (metabolism) functional imaging is the domain of nuclear medicine (NM), whereas first-order FI has to face the competition of alternative noninvasive procedures such as ultrasound (US), digital subtraction angiography (DSA), computer tomography (CT), and nuclear magnetic resonance (NMR). The domain of RNV includes stages two (acute infarction) and three (postinfarction period) of coronary arterial disease (CAD). The advantageous combination of quantitative data on global, left ventricular (LV) function and imaging of regional motion ensures the superiority of RNV over US. However, RNV is inferior to MS in physical examinations in the preinfarction stage of CAD, whereas US is clearly inferior to both NM procedures. Recent progress could be attained by gated SPECT (GASPECT). A proposal is presented for simplification of this time-consuming procedure. Technetium-labeled isonitriles offer the chance for the combination of perfusion-motion imaging of the myocardium. However, even standard RNV offers new possibilities. The multitude of parameters produced by quantitation has not yet been exploited completely. This can be done by discriminant analysis. The computer finds out an optimal subset from the whole set of parameters for the solution of a significant clinical problem. The software learns to find the label of a special pathognomonic entity. This computer work is supported by a relational data bank (Oracle) and an optical disk. Two examples for the effectiveness of the computer in problem solving are presented. It is concluded that RNV, even in the very competitive class of first-order functional imaging, enjoys a preferred position. The future indeed seems brighter because labeled isonitriles offer the chance for the combination of perfusion-motion imaging of the myocardium.Dedicated to Prof. Heinz Hundeshagen on the occasion of his 60th birthday     

Atypical sexual behavior during sleep

OBJECTIVE: This article reports a case series of atypical sexual behavior during sleep, which is often harmful to patients or bed partners. METHODS: Eleven subjects underwent clinical evaluation of complaints of sleep-related atypical sexual behavior. Complaints included violent masturbation, sexual assaults, and continuous (and loud) sexual vocalizations during sleep. One case was a medical-legal case. Sleep logs, clinical evaluations, sleep questionnaires, structured psychiatric interviews, polysomnography, actigraphy, home electroencephalographic monitoring during sleep, and clinical electroencephalographic monitoring while awake and asleep were used to determine clinical diagnoses. RESULTS: Atypical sexual behaviors during sleep were associated with feelings of guilt, shame, and depression. Because of these feelings, patients and bed partners often tolerated the abnormal behavior for long periods of time without seeking medical attention. The following pathologic sleep disorders were demonstrated on polysomnography: partial complex seizures, sleep-disordered breathing, stage 3 to 4 non-rapid eye movement (REM) sleep parasomnias, and REM sleep behavior disorder. These findings were concurrent with morning amnesia. CONCLUSIONS: The atypical behaviors were related to different syndromes despite the similarity of complaints from bed partners. In most cases the disturbing and often harmful symptoms were controlled when counseling was instituted and sleep disorders were treated. In some cases treatment of seizures or psychiatric disorders was also needed. Clonazepam with simultaneous psychotherapy was the most common successful treatment combination. The addition of antidepressant or antiepileptic medications was required in specific cases.     

A mixture of ammonium perchlorate and sodium chlorate enhances alterations of the pituitary-thyroid axis caused by the individual chemicals in adult male F344 rats

Ammonium perchlorate (AP) and sodium chlorate (SC) have been detected in public drinking water supplies in many parts of the United States. These chemicals cause perturbations in pituitary-thyroid homeostasis in animals by competitively inhibiting iodide uptake, thus hindering the synthesis of thyroglobulin and reducing circulating T(4) (thyroxine). Little is known about the short-term exposure effects of mixtures of perchlorate and chlorate. The present study investigated the potential for the response to a mixture of these chemicals on the pituitary-thyroid axis in rats to be greater than that induced by the individual chemicals. Adult male F-344 rats were exposed, via their drinking water, to the nominal concentrations of 0.1, 1.0, 10 mg/L AP or 10, 100, 1000 mg/L SC and their mixtures for 7 days. Serum T(4) levels were significantly (p < 0.05) reduced in rats following exposure to the mixtures, but not after exposure to the individual chemicals. Serum T(3) (triiodothyronine) was not altered by treatment and TSH (thyroid stimulating hormone) was only increased after the high-dose chlorate treatment. Histological examination of the thyroid gland showed colloid depletion and hypertrophy of follicular epithelial cells in high-dose single chemical and all mixture-treated rats, while hyperplasia was observed only in some of the rats treated with mixtures (AP 10 + SC 100, AP 0.1 + SC 1000, and AP 10 + SC 1000 mg/L). These data suggest that short-term exposure to the mixture of AP and SC enhances the effect of either chemical alone on the pituitary-thyroid axis in rats.