Factors predicting adverse short-term outcomes inpatients with acute cholangitis undergoing ERCP: Asingle center experience简

AIM: To identify potential factors that can predict adverse short-term outcomes in patients with acute cholangitis undergoing endoscopic retrograde cholangiopancreatography (ERCP).METHODS: Retrospective analysis of consecutive patients admitted to our center for acute cholangitis and underwent ERCP from 2001 to 2012. Involvement of two or more organ systems was termed as organ failure (OF). Cardiovascular failure was defined based on a systolic blood pressure of < 90 mmHg despite fluid replacement and/or requiring vasopressor treatment; respiratory failure if the Pa0₂/Fi0₂ ratio was < 300 mmHg and/or required mechanical ventilation; coagulopathy if the platelet count was < 80; and renal insufficiency if serum creatinine was > 1.9 mg/dL. Variables associated with short term adverse clinical outcomes defined as persistent OF and/or 30-d mortality was determined.RESULTS: A total of 172 patients (median age 62 years, 56.4% female) were included. The median door to ERCP time was 17 h. Bile duct stones were the most common etiology (n = 67, 39.2%). In multivariate analysis, factors that were independently associated with persistent OF and/or 30-d mortality included American Society of Anesthesiology (ASA) physical classification score > 3 (OR = 7.70; 95%CI: 2.73-24.40), presence of systemic inflammatory response syndrome (OR = 3.67; 95%CI: 1.34-10.3) and door to ERCP time greater than 72 h (OR = 3.36; 95%CI: 1.12-10.20). Door to ERCP time greater than 72 h was also associated with 70% increase in the mean length of stay (P < 0.001). Every one point increase in the ASA physical classification and every 1 mg/dL increase in the pre-ERCP bilirubin level was associated with a 34% and 2% increase in the mean length of hospital stay, respectively. Transfer status did not impact clinical outcomes.CONCLUSION: Higher ASA physical classification and delays in ERCP are associated with adverse clinical outcomes and prolonged length of hospital stay in patients with acute cholangitis undergoing ERCP.     

Early precut sphincterotomy and the risk of endoscopic retrograde cholangiopancreatography related complications: An updated meta-analysis

AIM: To study the cannulation and complication rates of early pre-cut sphincterotomy vs persistent attempts at cannulation by standard approach.METHODS: Systematic search of PubMed, EMBASE, Web of Science, and the Cochrane Library for relevant studies published up to February 2013. The main outcome measurements were cannulation rates and postendoscopic retrograde cholangiopancreatography(ERCP) complications. A comprehensive systematic search of the Cochrane library, PubMed, Google scholar, Scopus, National Institutes of Health, meta-register of controlled trials and published proceedings from major Gastroenterology journals and meetings until February 2013 was conducted using keywords. All Prospective randomized controlled trials(RCT) studies whichmet our inclusion criteria were included in the analysis. Prospective non-randomized studies and retrospective studies were excluded from our meta-analysis. The main outcomes of interest were post-ERCP pancreatitis, overall complication rates including cholangitis, ERCPrelated bleeding, perforation and cannulation success rates. RESULTS: Seven RCTs with a total of 1039 patients were included in the meta-analysis based on selection criteria. The overall cannulation rate was 90% in the pre-cut sphincterotomy vs 86.3% in the persistent attempts group(OR = 1.98; 95%CI: 0.70-5.65). The risk of post-ERCP pancreatitis(PEP) was not different between the two groups(3.9% in the pre-cut sphincterotomy vs 6.1% in the persistent attempts group, OR = 0.58, 95%CI: 0.32-1.05). Similarly, there was no statistically significant difference between the groups for overall complication rate including PEP, cholangitis, bleeding, and perforation(6.2% vs 6.9%, OR = 0.85, 95%CI: 0.51-1.41). CONCLUSION: This meta-analysis suggests that precut sphincterotomy and persistent attempts at cannulation are comparable in terms of overall complication rates. Early pre-cut implementation does not increase PEP complications.     

Soft Tissue Paraspinal Inflammatory Malignant Fibrous Histiocytoma Presenting as a Lumbar Abscess

The rarest subtype of malignant fibrous histiocytoma (MFH) is the inflammatory type, which due to its peculiar clinical presentation may mimic an infectious process such as an abscess. The rarity of this disease and the unique features of its presentation may mislead the surgeon with consequent catastrophic results for the patient. In this study, a case report of a 65-year-old female patient with a soft-tissue inflammatory MFH presenting as a lumbar abscess and a review of the current literature are presented.Key words: Malignant fibrous histiocytoma, inflammatory type; Soft-tissue sarcoma     

Analyzing the presentation and the stigma of schizophrenia in French newspapers

Purpose

It has been suggested that the stigmatizing presentation of people with schizophrenia by newspapers is an example of structural stigma. In this study, we explore how French newspapers contribute to the stigma of people with schizophrenia.

Methods

All the articles of eight major newspapers (four national and four regional) that include the term schizophr* and that were published in 2015 were therefore analyzed using a coding scheme that we developed inductively.

Results

This analysis showed that among the identified themes, 40.4% of the articles used the term schizophrenia metaphorically and 28.3% referred to dangerousness. The first concerned mostly national newspapers, while the second were mostly published by regional newspapers. A more selective analysis was also carried out on these major themes in order to investigate how the “us” against “them” distinction is created and how negative stereotypes are associated with this distinction. In the case of the metaphorical use of the term, schizophrenia was presented as a “split personality” disorder and the label used in order to devalue the political opposition. Schizophrenia was presented either as a deterministic cause of dangerousness or as a potential cause of crime. In either case, the question of control was clearly present in these articles.

Conclusions

These results are discussed in terms of the “us” against “them” distinction as a double process of stigmatization of people with schizophrenia and of reinforcement of one’s own identity and security.

     

Mirizzi syndrome type Va: A rare coexistence of double cholecysto-biliary and cholecysto-enteric fistulae

Mirizzi syndrome is a rare cause of intermittent obstructive jaundice, where an impacted stone in the cystic duct or Hartmann's pouch mechanically obstructs the common bile duct (CBD). We report a rare case of double cholecysto-biliary and cholecysto-enteric fistulae, in a 75-year-old female patient, presenting with a right upper quadrant abdominal pain and intermittent obstructive jaundice. Endoscopic retrograde cholangiopancreatography suggested Mirizzi syndrome. Operative findings included erosions of the lateral wall of the CBD and the second portion of the duodenum due to impacted gallstones. The defects were reconstructed primarily and a Kehr tube was inserted. The patient had an uneventful postoperative course and was discharged on the 14th postoperative day.