Endoscopic and radiologic interventions as the leading causes of severe cholangitis in a tertiary referral center

BACKGROUND: Iatrogenic factors became the leading mechanisms of severe cholangitis in a referral center. PATIENTS AND METHODS: The records of the 58 patients treated for severe cholangitis between 1996 and May 2004 (inclusive) were evaluated. RESULTS: The most frequent underlying diseases were periampullary tumors and mid-bile duct carcinomas (22), followed by proximal cholangiocarcinomas (14). The triggering mechanism was an incomplete endoscopic retrograde cholangiopancreatography (ERCP) in 32 patients, incomplete or inappropriate percutaneous transhepatic biliary drainage (PTBD) in 6, apparently successful ERCP and stenting in 1, and percutaneous transhepatic cholangiography in 1. PTBD was the treatment of choice (38). Mortality was 29% (17/58); the major causes were refractory sepsis (8) and incomplete biliary drainage (advanced tumor, technical failure, or hemobilia) (8). CONCLUSIONS: In this series composed predominantly of patients referred after development of sepsis, ERCP and PTBD complications were the leading mechanisms of severe cholangitis. Nonoperative biliary manipulations are invasive procedures with potentially fatal complications. The decisions to perform such procedures and periprocedural management are responsibilities of an experienced multidisciplinary team.     

Caudal epidural neuroplasty

Epidural fibrosis and adhesions can have many causes. Postsurgical bleeding and the healing process frequently produce scarring. The associated irritation or inducement of epidural venous engorgement may contribute to pain production. Lysis of epidural adhesions could be performed after rest, drug therapies such as NSAID and muscle relaxants, physical therapy with activity programs and epidural steroid injections.     

Partial sleep deprivation therapy combined with sertraline affects subjective sleep quality in major depressive disorder

BACKGROUND AND PURPOSE: Earlier studies have shown an association between mood disorders and sleep regulation. Total or partial sleep deprivation was demonstrated to have rapid antidepressive effects in depression. Depressive symptoms recur after one night of recovery sleep, but relapse is less when patients are receiving medication. In this study, we examined the subjective sleep quality changes with the antidepressive therapy using partial sleep deprivation plus sertraline and sertraline monotherapy in patients with major depressive disorder. PATIENTS AND METHODS: Thirteen patients received six partial sleep deprivation therapies in addition to sertraline; the sleep schedule on deprivation nights started at 11:00 p.m. and ended at 3:00 a.m. Eleven patients were treated with sertraline monotherapy as a control group. Six nights of partial sleep deprivation were completed in the first two weeks. Subjective sleep quality was evaluated with the Pittsburgh Sleep Quality Index (PSQI); depression and the accompanying anxiety were also assessed at baseline and at the end of the fourth week. RESULTS: The late partial sleep deprivation (LPSD) group showed less increase in estimated sleep duration and less significant improvement in subjective sleep quality than the control group. Although decreased sleep latency and increased sleep efficiency are associated with the sleep deprivation, contrary results were found in our study. CONCLUSIONS: In conclusion, changes in subjective sleep quality could occur relative to the combined partial sleep deprivation therapy and to pharmacotherapy and must be differentiated from the rapid effects of sleep deprivation therapy and objective polysomnographic measures.     

Case report: Foreign body granuloma mimicking liver metastasis

In this study, foreign body granuloma mimicking liver metastasis diagnosed on routine follow-up examination in a 41-year-old woman with rectal adenocarcinoma is reported. To our knowledge, this is the first study in English-language literature reporting foreign body granuloma indistinguishable from liver metastasis on radiological examination.     

Role of scintigraphy in congenital thyroid anomalies

Thyroid scintigraphy using Tc-99m pertechnetate is a frequently performed procedure in routine nuclear medicine practice. The indications for thyroid scintigraphy are investigation of hyperthyroidism, nodularity of the gland, cause of thyroid stimulating hormone elevation and localization of an ectopic thyroid gland. In the pediatric population, the most common request is for the evaluation of neonatal hypothyroidism. This imaging procedure is helpful in the identification of the underlying cause as well as in making a differential diagnosis. Early diagnosis is essential for appropriate therapy planning in this age group, and thyroid scintigraphy provides important diagnostic data. This article is written to review the scintigraphic findings in various congenital thyroid anomalies and to underline its use in the differential diagnosis.     

Single-session percutaneous ethanol sclerotherapy in simple renal cysts in children: long-term follow-up

Background: Simple renal cysts are rare in children and managed conservatively unless symptomatic. Objective: To demonstrate the efficacy and long-term results of single-session ethanol sclerotherapy in symptomatic simple renal cysts in children. Materials and methods: Three simple renal cysts in three children (age 1, 5 and 16 years) were included in the study. Indications for treatment were flank pain (n=1), hypertension (n=1), and increasing cyst size and urinary tract infection (n=1). The mean follow-up period was 5.5 years (range 3–7 years). The procedures were performed with the guidance of US and fluoroscopy and under IV sedation. After the cystogram, 95% ethanol with a volume of 40% of the cyst volume (but not more than 100 ml) was used as the sclerosing agent. Results: Two cysts disappeared completely, while the volume reduction was 99% for the third cyst at the end of the first year. CT demonstrated calcification of the cyst without an enhancing soft-tissue component in the third one 7 years after sclerotherapy. After the procedures, hypertension and pain resolved without any medication. There were no complications during the procedures or during follow-up. Cytological examination was unremarkable in all patients. Conclusions: Percutaneous treatment of symptomatic simple renal cysts in children with single-session ethanol sclerotherapy is a safe, effective and minimally invasive procedure. Calcification owing to sclerotherapy can be observed on follow-up.     

Familial high factor VIII level in a child with necrotizing fasciitis complicating primary varicella infection

This article describes an unusual association of familial high plasma factor VIII level and necrotizing fasciitis in a 4-year-old girl with primary varicella infection.     

The related causes in very early morning onset of stroke

We investigated the influence of early awakening and related factors on onset of cerebrovascular disease (CVD). Totally 1199 stroke patients, in whom the onset time was known, at 3 reference hospitals were included in this study. The effects of demographic, medical, and pathophysiological factors on the circadian pattern of an unselected series of patients with ischemic stroke were analyzed. Nine-hundred seventeen CVD patients with cerebral infarction (CI), 240 patients with intracerebral hemorrhage (CH), and 42 patients with subarachnoid hemorrhage (SAH) were identified. The greatest portion of strokes (32.5%) occurred between 03:00 and 06:00 a.m. Nearly one half of the strokes in this series occurred in the very early- to mid-morning hours. This analysis of strokes provides strong evidence with a higher risk in the early morning hours (03:00 a.m. to 06:00 a.m.), and lower risk during the night time period (21:00 p.m. to midnight). Approximately 1 of every 3 strokes (1 of 3 ischemic strokes, 1 of 6 hemorrhagic strokes, and 1 of 8 subarachnoid hemorrhages) is attributable to the early morning excess. This difference tried to be explained by three ways: cold weather, religious factors, and physiological mechanisms.     

Effects of atorvastatin on blood-brain barrier permeability during L-NAME hypertension followed by angiotensin-II in rats

Recent studies suggest that 3-hydroxy-3 methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, statins, can have direct effects on blood vessels beyond their cholesterol-lowering effects. We investigated the effects of atorvastatin on the functional and structural properties of blood-brain barrier (BBB) and the activity of astrocytes during the N(omega)-nitro-L-arginine methyl ester (L-NAME) hypertension followed by angiotensin (ANG) II. We found that decreases in concentration of serum catalase and plasma nitric oxide (NO) induced by L-NAME were significantly ameliorated by atorvastatin, whereas L-NAME-induced serum malondialdehyde and cholesterol concentration increases were significantly reduced by atorvastatin. The content of Evans blue (EB) dye significantly increased in cerebellum, left cerebral cortex and diencephalon regions but atorvastatin markedly reduced the increased BBB permeability to EB in the brain regions of animals treated with L-NAME and L-NAME plus ANG II. Brain vessels of L-NAME-treated animals showed a considerable loss of immunoreactivity of tight junction proteins, zonula occludens (ZO)-1 and occludin. Immunoreactivity for ZO-1 and occludin increased in animals treated with atorvastatin and L-NAME plus atorvastatin. Glial fibrillary acidic protein (GFAP) immunoreactivity was seen in few astrocytes in the brain sections of L-NAME, but immunoreactivity for GFAP increased in L-NAME plus atorvastatin-treated animals. We suggest that long-term L-NAME treatment may affect BBB permeability through disruption of tight junction proteins, at least partly, via decreased NO concentration and increased oxidant capacity; the improvement of BBB integrity and astrocytic activity would be more closely associated with the action of atorvastatin favoring the increase in anti-oxidant capacity and expression of tight junction proteins and GFAP.     

Percutaneous management of parapneumonic effusions

Parapneumonic effusions continue to be a significant source of morbidity and mortality. Treatment at earlier stages before fibrous peel and loculations occur has a much better prognosis. Using image guidance, addition of intracavitary fibrinolytic instillation, close follow-up with drainage of residual or new collections are some of the other factors that improve prognosis. In this article, we discussed treatment strategies, percutaneous management of parapneumonic effusions, its alternatives and results.