Percutaneous Alcohol Sclerotherapy of Simple Hepatic Cysts. Results From a Multicentre Survey in Italy

The increased use of Ultrasonography (US) has led to increased detection of simple hepatic cysts. For symptomatic cysts treatment is necessary. Until some years ago surgery was the only therapy. We have treated a large number of patients with Percutaneous Alcohol Sclerotherapy (PAS) and evaluated retrospectively the efficacy of this approach.Data on 21 patients with symptomatic simple hepatic cysts were reviewed retrospectively. Cysts had a mean diameter of 9 cm (range: 7–15 cm). PAS was always performed under local anesthesia and US guidance. 25% of the volume was replaced with 95% ethanol and then completely aspirated after 20–30 minutes.No complications or deaths occurred. In all patients symptoms disappeared after treatment. In 15 out of 21 cases there was no evidence of residual cyst on US, computed tomography (CT) or magnetic resonance (MRI). In 6 patients with shorter follow-up, cysts showed a mean reduction in diameter of 50%. The mean follow-up was 18 months (range 6–60 months).We conclude that PAS is easy with low risk for the patients and with good long-term results; it should therefore become the procedure of choice for simple hepatic cysts.     

Interventional computed tomography

Due to the development and refinement of computed tomography (CT), sonography, and interventional techniques, the field of interventional radiology has seen tremendous growth in recent years. In particular, the precise anatomic detail provided by CT and sonography has allowed percutaneous biopsies and abscess drainages to be performed safely and effectively. Percutaneous biopsies are now becoming the most common interventional radiographic procedures in many institutions. The usual indications for a biopsy are to determine the etiology of a mass, neoplasm, or inflammation, and to determine whether masses in known oncologic patients represent scarring or residual viable tumor. Accuracy rates for most percutaneous CT-directed biopsies are well over 90%, and the complication rate is very low. CT-directed percutaneous abscess drainages are also safe and effective and, in most cases, will be preferable to surgical drainage. The initial indications for percutaneous drainage (single, unilocular fluid collections) have been greatly expanded to include multiloculated collections, interloop abscesses, periappendiceal abscesses, and even percutaneous cholecystotomies. Biopsy and drainage procedures, together with their accuracy rates, indications and complications, are reviewed in this monograph.     

Effects of new fish oil derivative on fatty acid phospholipid-membrane pattern in a group of Crohn's disease patients

Fish oil has been recently proposed as a possible effective treatment in inflammatory bowel disease (IBD); however, a lot of annoying side effects (ie, belching, halitosis, diarrhea, etc) affect patient compliance. We carried out a study of patient tolerance in a group of Crohn's disease (CD) patients with a new fish oil derivative consisting of 500-mg capsules of eicosapentaenoic-docosahexaenoic (EPA 40%-DHA 20%), a free fatty acid mixture (Purepa), and we also evaluated its incorporation into phospholipids, both in plasma and in red cell membranes. Five groups of 10 CD patients in remission received nine Purepa capsules daily in four different preparations (A: uncoated, B: coated, pH 5.5; C: coated, pH 5.5, 60 min time release; D: coated, pH 6.9) and 12 × 1-g capsules daily of a triglyceride preparation (Max-EPA, EPA 18%-DHA 10%), respectively. We coated three of the four Purepa preparations in order to delay the release of contents in an attempt to minimize the side effects. After six weeks of treatment, the group taking Purepa capsules, coated, pH 5.5, 60 min time release (group C) showed the best incorporation of EPA and DHA in red blood cell phospholipid membranes (EPA from 0.2 to 4.4%, DHA from 3.7 to 6.3%), and no side effects were registered, whereas in all other groups side effects were experienced in 50% or more of subjects. This new preparation will make it possible to treat patients for long periods.     

Acute mastoiditis — Relevant once again

Summary During recent years, a significantly increased incidence of acute mastoiditis was observed at the University Children's Hospital, Tübingen, Germany (1975–1979: 1.4 patients/year; 1987–1992: 4.2 patients/year; p<0.05). We therefore reviewed the records of all patients with acute mastoiditis (n=58) that had been treated at the Children's Hospital between 1975 and 1992 and at the Clinic of Otorhinolaryngology between 1978 and 1992. The male to female ratio was 1.8:1 and 60.4% of the patients were younger than 24 months. Retroauricular swelling was more often observed (n=49) than protrusion of the pinna (n=45) and retroauricular redness (n=38).Streptococcus pneumoniae was the most frequently isolated pathogen. Several factors predisposing for the development of acute mastoiditis were identified. These included withholding antimicrobials for treatment of the preceding episode of otitis media; use of suboptimal agents for therapy of otitis media (penicillin and, possibly, erythromycin ethylsuccinate); and insufficient duration of treatment.

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Akute Mastoiditis — wieder ein aktuelles Problem

Zusammenfassung In den letzten Jahren wurde an der Univ.-Kinderklinik Tübingen eine signifikante Zunahme der Inzidenz der akuten Mastoiditis beobachtet (1975–1979: 1,4 Patienten/Jahr; 1987–1992: 4,2 Patienten/Jahr; p<0,05). Wir analysierten daher die Krankengeschichten aller Patienten mit akuter Mastoiditis (n=58), die zwischen 1975 und 1992 an der Universitäts-Kinderklinik und zwischen 1978 und 1992 an der Universitäts-Hals-Nasen-Ohrenklinik behandelt worden waren. Das Verhältnis von Jungen zu Mädchen betrug 1,8:1, und 60,4% der Patienten waren jünger als 24 Monate. Eine retroaurikuläre Schwellung wurde häufiger beobachtet (n=48) als ein abstehendes Ohr (n=45) und eine retroaurikuläre Rötung (n=38).Streptococcus pneumoniae war der häufigste Erreger. Mehrere für das Auftreten einer akuten Mastoiditis prädisponierende Faktoren wurden gefunden: die Nichtbehandlung der vorausgegangenen Otitis media mit Antibiotika, der Einsatz suboptimaler Antibiotika (Penicillin und möglicherweise Erythromycin-Ethylsuccinat) für die Otitis-Behandlung und eine ungenügende Therapiedauer.

     

Could bipolar vessel sealers prevent bile leaks after hepatectomy?

BACKGROUND AND AIMS: The aim of this work was to test the feasibility of using a bipolar low thermal acting system inducing collagenic sealing but not protein coagulation to secure hepatic parenchyma cutting. MATERIALS AND METHODS: Thirty consecutive hepatectomies were carried out using kellyclasy plus ligatures and clips (controls), while the following 50 hepatectomies used kellyclasy plus bipolar vessels sealer (BVS). Blood loss, duration of hepatic pedicle clamping, length of hospital stay, and complications were recorded. RESULTS: There was no statistically significant difference in blood loss and duration of clamping between controls and BVS. Specific complications (9/21 in the control group vs 1/49 for the BVS group, p<0.00045) and length of hospital stay (14 days in the control group vs 11 days in the BVS group, p<0.014) were statistically lower in BVS group than in the controls, mainly due to prevention of bile duct leakages. CONCLUSIONS: Our data suggest that BVS may be particularly efficient to achieve bilistasis leading to the highest level of safety in performing hepatectomies. Further studies are now needed to confirm its superiority on the classical biliary ducts occlusion techniques.     

Generation and survival of midbrain dopaminergic neurons in weaver mice

Generation and survival of midbrain dopaminergic (DA) neurons were investigated using tyrosine hydroxylase (TH) immunocytochemistry combined with tritiated thymidine autoradiography at appropriate anatomical levels throughout the anteroposterior (A/P) axes of the substantia nigra pars compacta (SNc) and the ventral tegmental area (VTA). The wild-type (+/+) and homozygous weaver (wv/wv) mice used here were the offspring of pregnant dams injected with the radioactive precursor when the mesencephalic neurons were being produced (gestational days 11-15). Data reveal that, at postnatal day 90, depletion of TH-stained cells in the wv/wv presented an A/P pattern of increasing severity and, therefore, the DA cells located in posterior parts of the SNc or the VTA appear to be more vulnerable than the settled anterior neurons. When the time of neuron origin is inferred for each level of these cell groups, it is found that the neurogenesis span is similar for both experimental groups, although significant deficits in the frequency of wv/wv late-generated neurons were observed in any level considered. On the other hand, it has been found that TH-positive neurons were settled along the extent of the SNc and the VTA following precise and differential neurogenetic gradients. Thus, the acute rostrocaudal increase in the proportion of late-generated neurons detected in both+/+DA-cell groups is disturbed in the weaver homozygotes due to the indicated A/P depletion.     

Antibody Response Against the Glomerular Basement Membrane Protein Agrin in Patients with Transplant Glomerulopathy

Chronic allograft nephropathy (CAN) of renal allografts is still the most important cause of graft loss. A subset of these patients have transplant glomerulopathy (TGP), characterized by glomerular basement membrane (GBM) duplications, but of unknown etiology. Recently, a role for the immune system in the pathogenesis of TGP has been suggested. In 11 of 16 patients with TGP and in 3 of 16 controls with CAN in the absence of TGP we demonstrate circulating antibodies reactive with GBM isolates. The presence of anti-GBM antibodies was associated with the number of rejection episodes prior to diagnosis of TGP. Sera from the TGP patients also reacted with highly purified GBM heparan sulphate proteoglycans (HSPG). Indirect immunofluorescence with patient IgG showed a GBM-like staining pattern and colocalization with the HSPGs perlecan and especially agrin. Using patient IgG, we affinity purified the antigen and identified it as agrin. Reactivity with agrin was found in 7 of 16 (44%) of patients with TGP and in 7 of 11 (64%) patients with anti-GBM reactivity. In conclusion, we have identified a humoral response against the GBM-HSPG agrin in patients with TGP, which may play a role in the pathogenesis of TGP.     

Quality assurance, efficiency indicators and cost-utility of the evaluation workup for liver transplantation.

We report the results of a retrospective review of the outpatient pretransplantation workup for United Network for Organ Sharing (UNOS) 3 patients adopted at a liver transplantation (LT) center and illustrate the efficiency indicators used for quality evaluation and cost-analysis. A single-center, pre-LT evaluation workup was performed on an outpatient basis at a cost per patient evaluation of 2,770 Euros (). Objective measures were: the number of patients admitted to and excluded from each phase of the algorithm; the rate of patients admitted to pre-LT evaluation out of the total of referred patients (the referral efficiency rate); the rate of waitlisted patients out of those admitted to pre-LT evaluation (the evaluation efficiency rate); the rate of waitlisted patients out of those referred for LT (the process efficiency rate); and the cost per waitlisted patient, as the ratio of the cost per patient evaluation to the evaluation efficiency rate. From January 1, 1996, to October 1, 2004, 1,837 patients were referred for LT on an outpatient basis. Based on preemptive evaluation of the available clinical data, 412 patients (22.4%) were excluded from pre-LT evaluation and 1,425 (77.6%) were admitted to preliminary consultation. Among these, 603 (42.3%) were excluded from and 822 (57.7%) were admitted to pre-LT evaluation with a referral efficiency rate of 44.7% (822 of 1,837). Out of the patients evaluated for LT, 484 were waitlisted with a cost-utility and evaluation efficiency rate of 58.8% each (484 of 822). Of the 1,837 patients originally addressed for LT 484 were waitlisted, yielding a process efficiency rate of 26.3% (484 of 1,837) and a cost per waitlisted patient of 4,710.8. In conclusion, the 3 indicators allowed monitoring of the efficiency of the pre-LT evaluation algorithm. The current process efficiency rate at our center is low (26.3%), but avoiding early referrals we might increase it to 31.6%, with a 12% net saving on costs per waitlisted patient (from 4,710.8 to 4,165.4).