Endoscopic transpapillary stenting of pancreatic duct disruption

BACKGROUND/AIMS: Endoscopic transpapillary stenting of the pancreatic duct is increasingly being used in the management of pancreatic duct disruption. In contrast to its more established role in pancreatic duct obstruction, little is reported on the spectrum of indications and outcome in management of pancreatic duct disruption. METHODS: The indication for and outcome of transpapillary pancreatic duct stenting was analysed retrospectively in a UK supra-regional specialist pancreatobiliary centre, between January 1998 and August 2004. RESULTS: Data were obtained on 30 patients (19 male, 11 female, median age 53 years). The main indications for pancreatic duct stenting were: pancreatic pseudocyst, pancreatic ascites, pancreatic duct leak following necrosectomy, and pancreaticopleural fistula. The median duration of stenting was 6 weeks for fistulae and 10 weeks for pseudocysts. Twenty-one patients (70%) had complete resolution. After a median follow-up of 45 months, no recurrence was noted in successfully treated patents. CONCLUSION: Endoscopic transpapillary pancreatic duct stenting is an increasingly valuable treatment option in the management of pancreatic fistulae and pseudocysts.     

Contemporary management of bile duct injuries

Laparoscopic cholecystectomy is the standard of care for symptomatic cholelithiasis, but it is associated with a higher incidence of bile duct injury (BDI) than the open approach. BDI can lead to mortality, significant morbidity and impaired quality of life. Immediate management of BDI recognized during cholecystectomy depends on the type of injury, the condition of the patient, and the experience of the surgeon. For patients presenting after cholecystectomy with a bile duct injury, the priority should be accurate assessment of the type of injury and early repair if possible; however for patients presenting after 2 weeks with established sepsis, it may be preferable to wait to allow appropriate control of sepsis and plan for definitive biliary reconstruction after 3 months. Proximal hepaticojejunostomy Roux-en-Y is the operation of choice in almost all situations, but other options may be possible in specific scenarios. The early reported association between an associated arterial injury and subsequent failure of biliary repair has not been confirmed by the largest studies. Excellent early and long-term results are possible when repair is undertaken in specialist units but long-term follow-up is required as late complications can occur.     

Turn-specific and pigment-dependent differences in the stria vascularis of normal and gentamicin-treated albino and pigmented guinea pigs.

The aims of the present study were to determine which structures in the stria vascularis (SV) may depend upon the presence of pigmented melanocytes both for normal morphology and for the expression of gentamicin ototoxicity in the inner ear. These pigment-dependent influences were inferred through comparisons of the SV in pigmented guinea pigs and in albinos containing nonpigmented melanocytes. Results were obtained from 6 albino and 8 pigmented guinea pigs given gentamicin, and from 3 albino and 3 pigmented control animals not receiving the drug. One-month old animals received gentamicin daily (100 mg/kg) for 14 days and recovered for an additional 14 days before being prepared for electron microscopy. The SV from each of the 4 cochlear turns was analyzed using stereological point counting procedures. In control animals, differences were found in the higher cochlear turns, where volume density for the marginal cells in albinos was abnormally large (turns 3 and 4), while the volume density for intermediate cells (melanocytes) was abnormally small (turn 3). Cell volume estimates for the intermediate cells were significantly smaller in the albino than pigmented control animals in the higher cochlear turns, indicating that functional abnormalities may be found in the albino cochlea. In animals exposed to gentamicin, marginal cell volume density was reduced significantly in turn 4 of albinos, but not in any region of the pigmented inner ears. Radial area of SV and estimates of the absolute volumes for marginal cells in albinos given gentamicin also were significantly reduced in turn 1 compared to their controls; such differences were not observed in the pigmented animals. The results indicate that marginal cell size is significantly reduced in albino but not pigmented animals 14 days after gentamicin exposure, and further suggest a role of pigmented melanocytes in ameliorating gentamicin-induced cochlear damage.     

Mildly anaemic toddlers respond to iron.

Thirty eight children with a haemoglobin concentration of 106-110 g/l were given either oral iron (n = 17) or placebo (n = 21) for two months. The treated group achieved a significantly higher rise in haemoglobin concentration; in a quarter it was greater than 20 g/l. While those with the lower mean corpuscular volume and ferritin showed greater rises in haemoglobin these indices were of little value in predicting response in an individual child.     

Selenium status of New Zealand infants fed either a selenium supplemented or a standard formula

Objective: New Zealand soils are deficient in the essential micronutrient, selenium. New Zealand infants have low selenium levels at birth and experience a further decline if fed cows milk based formula. This study examined the selenium status of infants fed with a new commercially available selenium supplemented formula.
Methodology Forty-four newborn infants, whose mothers wished to formula feed, were randomized in an open controlled trial to be fed a commercially available selenium supplemented cows milk formula (containing 17 μg Se/L) or an unsupplemented formula (containing 4.6 μg Se/L). Cord, 1 and 3 month blood samples were obtained for selenium status (plasma and red cell selenium and glutathione peroxidase) and thyroid function.
Results Mean plasma selenium and glutathione peroxidase values were significantly higher in supplemented than unsupplemented infants at 1 month (unpaired t -tests; P <0.0001 and P = 0.001 respectively) and 3 months ( P <0.0001 and P = 0.0005). Analysis within treatment groups between time points (paired t -tests) showed that selenium supplementation prevented the fall in plasma selenium from birth to 1 month seen in unsupplemented infants and was associated with a rise in levels between 1 and 3 months ( P = 0.002).
Conclusions Supplementing cows milk formula with selenium to replicate the levels found in breast milk is nutritionally sound. Feeding from a few days of age with a formula containing 17 μg Se/L in infants with low selenium status at birth is sufficient to cause a rise to 80% of adult levels at 3 months of age.     

Screening for amblyopia in preverbal children with photoscreening photographs. III. improved grading criteria for hyperopia

OBJECTIVE: To examine the ability of the Medical Technology and Innovations (MTI), Inc., Photoscreener (Cedar Falls, IA) to detect hyperopia and to improve the photograph grading criteria to screen for amblyopiogenic levels of hyperopia. DESIGN: Cross-sectional study and reanalysis. PARTICIPANTS AND TESTING: In previous work, 392 participants received a complete ophthalmologic examination and were photographed using the MTI Photoscreener. For this study, all 209 participants with normal examination findings (65 children) or hyperopia without anisometropia (144 children) were selected. The data were reanalyzed using modified photograph grading and ophthalmologic examination failure criteria. Potential reasons for why many children with hyperopia passed photoscreening were explored. MAIN OUTCOME MEASURES: We determined whether a study participant would pass or fail screening with a given photograph grading and ophthalmologic examination failure criteria. RESULTS: Most children with hyperopia of +2.00 to +3.50 diopters (D) passed screening with the MTI instrument, in most cases because their photographs lacked bright crescents. When bright crescents in at least two of the four possible meridians were the grading guideline for screening failure and the pediatric ophthalmologists' consensus hyperopia failure criteria (> +3.50 D) were adopted, the sensitivity for hyperopia detection was 100% and the specificity was 88%. Identical results were obtained using the American Academy of Ophthalmology Preferred Practice Pattern hyperopia failure criteria (>/= +4.50 D). CONCLUSIONS: The MTI photograph grading guidelines can be simplified, and the ophthalmologic examination failure criteria for hyperopia can be improved. The presence of a bright crescent in the lower or the left pupillary margin indicate hyperopia in an amblyopiogenic range (> +3.50 D).     

Technical aspects of multifocal ERG recording

There are a wide range of variables which can influence the quality of the multifocal response. It is possible to place these variables into one of four categories. First, the method of stimulus delivery will determine the field of view, interference levels and the duration of on-state stimulation. Second, data acquisition variables such as electrode type and placement, amplifier specifications and filter bandwidth settings will have a direct impact on waveform shape and on the topographic distribution of signal amplitudes. Third, patient variables such as fixation, pupil dilation and refractive error will also contribute to the multifocal response. Fourth, there are many measurements that can be taken from multifocal recordings. In addition to standard amplitude and implicit time measures (the implicit time measure in the multifocal response is becoming increasingly important particularly in early stages of disease processes), the scalar product measure provides information on waveform shape. The conventional impulse and higher order responses will be different for different modes of stimulation such as Cathode Ray Tube (CRT) and Liquid Crystal Display (LCD) systems and latency shifts will be introduced if not corrected in software. Procedures which could lead to misleading interpretation include artefact rejection, averaging with neighbours and summing of responses. These procedures should be handled with caution. This revised version was published online in July 2006 with corrections to the Cover Date.     

The sphincteric and sensory components of preserved continence after ileoanal reservoir

Sphincteric and sensory components of anal continence were investigated before and after restorative proctocolectomy and three loop ileal reservoir. Bowel habit, appearance of small intestinal mucosa, resting tone, squeeze pressure, anal canal length, pouch capacity and ileal sensation were investigated in 50 patients. The physiologic, endoscopic and histologic patterns were related to the occurrence of functional disturbances. The pressures in the anal canal as measured by manometry were found to be within the range of normality. The length of the sphincter was 3.4 +/- 0.6 centimeters; the maximal capacity of the reservoir was 450 +/- 204 milliliters of air. An ileorectoanal inhibitory reflex was recorded postoperatively in 52 per cent of the patients and normal postoperative continence was observed in 86 per cent of the patients, with no instances of gross incontinence. According to the results of the present study, the anatomic rearrangement that occurs after this surgical procedure preserved a satisfactory continence due to the integrity of the anal sphincters; minor leakage rarely occurred and was mainly related to a long inflamed distal portion of the ileum requiring self catheterization after operations for colitis. The best results were obtained in patients with polyposis who neither had staged procedures nor preoperative steroids.