NASOGALLBLADDER DRAINAGE FOR MIRIZZI’S SYNDROME

The authors experienced a case of Mirizzi’s syndrome successfully treated with endoscopic nasogallbladder drainage (ENGBD). The patient was a 63‐year‐old man. He was admitted with abdominal pain and jaundice. Laboratory data indicated leukocytosis and elevation of serum bilirubin level. Abdominal ultrasound showed marked swelling of gallbladder and debris in the gallbladder, therefore, the authors strongly suspected Mirizzi’s syndrome. He had past history of acute myocardial infarction and treated with anticoagulation therapy. Then, the authors couldn’t perform surgical removal or percutaneous transhepatic drainage, and tried endoscopic transpapillary drainage. Endoscopic retrograde cholangiopancreatography revealed smooth stricture in the superior portion of common bile duct and occlusion of the cystic duct, and ENGBD was then performed. After ENGBD, his complaints, laboratory data, swelling of gallbladder and stricture of common bile duct were all remarkably improved.     

Injection sites utilized for DPT immunizations in infants.

The purpose of this investigation was to determine the site utilized by nurses for administering Diphtheria and Tetanus Toxoids and Pertussis (DPT) injections to infants under 7 months of age. Twenty-six of the 28 agencies identified in a metropolitan area as administering DPT injections chose to participate in the study. Those individuals administering DPT injections in the agencies completed a questionnaire with a return rate of 69% (n = 55). Forty-four participants indicated that they used the anterolateral thigh, the recommended site, 100% of the time. The participants in the study administered a total of 1,453 DPT injections per month. Eighty-seven percent of those injections were administered in the anterolateral thigh, 3.6% were given in the deltoid, 5.1% were given in the dorsal gluteal, and 4% were given in the ventrogluteal. The estimated proportion of DPT injections administered at the correct site was 84.65% which is much lower than the critical value 94.06% for alpha = .05 (p less than .00001).     

Cabergoline compared to levodopa in the treatment of patients with severe restless legs syndrome: results from a multi-center, randomized, active controlled trial.

We report the first large-scale double-blind, randomly assigned study to compare two active dopaminergic therapies for Restless Legs Syndrome (RLS), the dopamine agonist cabergoline (CAB) and levodopa/benserazide (levodopa). Patients with idiopathic RLS were treated with fixed daily doses of 2 or 3 mg CAB or 200 or 300 mg levodopa for 30 weeks. Efficacy was assessed by changes in the IRLS (International RLS Severity Scale) and by time to discontinuation of treatment due to loss of efficacy or augmentation. 361 of 418 screened patients (age 58 +/- 12 years, 71% females) were randomly assigned and treated (CAB: n = 178; levodopa: n = 183) in 51 centers of four European countries. Baseline IRLS total score was 25.7 +/- 6.8. The baseline-adjusted mean change from baseline to week 6 in IRLS sum score was d = -16.1 in the CAB group and d = -9.5 in the levodopa group (d = -6.6, P < 0.0001). More patients in the levodopa group (24.0%) than in the CAB group (11.9%, P = 0.0029, log-rank test) discontinued because of loss of efficacy (14.2% vs. 7.9%, P = 0.0290) or augmentation (9.8% vs. 4.0%, P = 0.0412). Adverse events (AEs) occurred in 83.1% of the CAB group and in 77.6% of the levodopa group. In both groups, most frequent AEs were gastrointestinal symptoms (CAB: 55.6%, levodopa: 30.6%, P < 0.0001). This first large-scale active controlled study in RLS showed superior efficacy of cabergoline versus levodopa after a 30-week long-term therapy. Tolerability was found more favorable with levodopa than with cabergoline.     

Buccal mucosal graft for urethral reconstruction.

Urethral reconstruction with graft substances, such as skin and bladder mucosa, has been previously used when primary anastomosis cannot be achieved. However, stricture and meatal prolapse are associated with these grafts. We report the use of buccal mucosa for the reconstruction of urethral defects in 3 patients. One patient with failed operation for hypospadias received tube buccal mucosal graft for urethral replacement. Two patients with urethral necrosis and stricture received onlay buccal mucosal graft. All patients were disease-free during follow-up (range, 12 to 49 months; mean, 36 months). One patient had a pinhole fistula that was successfully managed with simple repair. This technique appears to be useful for urethral reconstruction when a local graft is not available, even in patients with complicated conditions.     

133Granulation Tissue Induction by Lassar Ointment vs. Collagen‐Polyvynilpyrrolidone in Venous Ulcers

Venous leg ulcers derived from tissue destruction is the consequence of a chronic inflammatory process that produces pain and physical disability, diminishing quality of life in patients. In this work, Lassar ointment and lyophilized collagen‐polyvinylpyrrolidone were administered separated each on one half in the same ulcer to 9 patients at the beginning and every 4 days. On day 16, all patients were auto‐grafted with partial thickness skin. Granulation tissue and graft integration were assessed clinically during 3 months. Inflammatory infiltrate, type I and III collagens, elastic fibers, alkaline phosphatase as well as blood vessels were evaluated histologically or histochemically in biopsies taken at the beginning and 16 days after the local treatment. Clinically and morphologically, both treatments demonstrated appropriate granulation tissue promotion and optimal graft integration since the beginning. Nevertheless, in Lassar ointment treated group regionalization of alkaline phosphatase activity was observed, as well as the presence of granuloma in 2 of the 9 patients. In conclusion, Lassar ointment or lyophilized collagen‐polyvinylpyrrolidone are two different promoters of granulation tissue in venous leg ulcers, however Lassar ointment has the capability to produce granuloma and an exacerbated immune response; in consequence, ulcer recidivism could be present, may be due to mineral deposits in the wound.     

Reduced expression of CD69 and adhesion molecules of T lymphocytes in asthmatic children receiving immunotherapy

T lymphocytes play a fundamental role in the initiation and regulation of chronic inflammatory responses in patients with asthma. CD69 is an early marker of T‐cell activation. The levels of intercellular adhesion molecule‐1 (ICAM‐1, CD54) and L ‐selectin have been reported to increase in patients with allergic diseases and asthma. The present study was therefore undertaken to investigate the expression of CD69, CD54, and L ‐selectin by T lymphocytes of children with asthma, before and after immunotherapy. Eighteen children newly diagnosed with asthma, 11 good and nine poor responders to immunotherapy, and 16 normal subjects, were enrolled in this study. The percentages of CD69⁺, CD54⁺, and CD62L⁺ cells in T lymphocytes were measured by using flow cytometry. The levels of CD69, CD54, and CD62L in serum and culture supernatants were determined by using enzyme‐linked immunosorbent assay (ELISA). The expression of CD69 and CD54 on CD3⁺ T lymphocytes was significantly higher in children with asthma than in control patients. All the patient groups expressed (spontaneously and following stimulation with phorbol myristate acetate and ionomycin together with mite‐extract proteins) greater amounts of CD69 and CD54 than did control subjects. With long‐term immunotherapy, the percentages of CD69⁺ and CD54⁺ T lymphocytes were significantly lower in patients with a good response to immunotherapy. Our results also showed significantly lower serum L ‐selectin levels following immunotherapy. In conclusion, successful immunotherapy resulted in decreased expression and production of CD69 and CD54. These results may explain, in part, the clinical efficacy of immunotherapy.     

Prospective randomised comparison of current coagulation and injection sclerotherapy for the outpatient treatment of haemorrhoids

The feasibility and early results of a new technique of outpatient proctoscopic coagulation of haemorrhoids by means of an electronic probe (Ultroid^®, Microvasive Inc., USA) were evaluated in comparison to conventional injection sclerotherapy. Age, symptom and sex-matched groups were analysed before and 6 weeks after outpatient treatment, using scoring systems (n=51). A mean of 6.2±0.4 ml of phenol in oil were injected over 2.4±0.2 min compared to a mean current of 15.8 ±0.2 mA over a period of 11.9±0.8 min (p<0.001, treatment time). Sclerotherapy was found significantly less tedious than coagulation. More patients complained of discomfort during coagulation, but the difference in tolerance scores between the 2 groups was not significant. Three patients in the coagulation group but none in the injection group refused to be treated by the same method again due to discomfort. Significant benefits were achieved by both modes of treatment after 6 weeks. The early cure rates for bleeding were 84% for sclerotherapy and 64% for coagulation (p=0.2) and for prolapse 56% and 44% respectively (p=0.72). Injection sclerotherapy is preferable to Ultroid^® coagulation for the outpatient treatment of haemorrhoids because it is a quicker, less tedious and more comfortable procedure with equally effective early results.

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Résumé La réalisation et les premiers résultats d'une nouvelle technique de coagulation ambulatoire des hémorroïdes au moyen d'une sonde électronique (Ultroïd, Microvasive inc. USA) on été évalués par comparaison avec la sclérothérapie conventionnelle. Deux groupes appariés selon l'âge, les signes et le sexe ont été analysés avant et six semaines après un traitement ambulatoire en utilisant un score (n=51). Une moyenne de 6,2±0,4 ml d'huile phéniquée a été injectée en 2,4±0,2 mn comparée à une application de courant moyen de 15,8±0,2 mA dans une période de 11,9±0,8 mn (p<0,001, temps de traitement). La sclérothérapie a été trouvée moins pénible que la coagulation. Plus de malades se plaignaient d'inconfort durant la coagulation mais la différence de tolérance n'était pas significative entre les deux groupes. Trois malades dans le groupe de coagulation ont refusé de poursuivre le traitement en raison du disconfort contre aucun malade dans le groupe d'injection. Les résultats furent bons dans les deux groupes après six semaines. Les résultats immédiats pour les saignements étaient de 84% et de 64% pour la coagulation (p=0,2) et pour les procidences de 56% pour la scléro-thérapie contre 44% pour la coagulation (p=0,72). Les injections sclérosantes sont préférables à la coagulation Ultroid comme traitement ambulatoire des hémorroïdes car il s'agit d'un procédé plus rapide, moins pénible et plus confortable avec des résultats immédiats aussi bons.

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Paper presented at the Spring Meeting of the British Society of Gastroenterology, University of Warwick, UK, March 1990     

Differential risks of subsequent vascular events for transient ischaemic attack and minor ischaemic stroke.

Using a prospective hospital-based registry, 146 patients with transient ischaemic attack (TIA) were compared with 376 patients with minor first-ever ischaemic stroke with respect to the 3-month risk of subsequent vascular events, in order to clarify the distinctions between the disease entities. All patients were enrolled within 48 h of onset. The risk factor distribution for the two groups was comparable, except that the TIA patients had more previous TIAs. Large artery atherosclerosis (34%) and small vessel occlusion (32%) were the main aetiologies in the TIA group, whereas small vessel occlusion (49%) was the major cause in the stroke group. The 3-month risk of combined endpoints of stroke, myocardial infarction, and vascular death for TIA patients was higher than that for the minor stroke group (15.1% vs. 3.2%; hazard ratio 4.6, 95% confidence interval 2.3-9.3 in multivariate analysis). Large artery atherosclerosis and male sex were the other significant predictors. TIA may demand more urgent management than minor stroke. The fact that aetiology is a predictor, highlights the need for rapid diagnostic tests to establish pathogenesis.     

SUICIDE ATTEMPT DUE TO METOCLOPRAMIDE-INDUCED AKATHISIA

Akathisia as a side-effect of metoclopramide has received increasing attention in consultation-liaison psychiatry in recent years. A case of metoclopramide-induced akathisia resulting in a suicide attempt is reported in order to highlight the suffering of such patients and the factors that lead to misdiagnosis.