Biliary endoprostheses. Insertion using a combined peroral-transhepatic method

The transhepatic placement of adequately sized endoprostheses for the palliation of malignant biliary obstruction is painful and requires large hepatic parenchymal tracks. Endoscopically placed biliary stents are smaller, but may not be adequate for long-term patency. The authors have used a combined peroral-transhepatic approach successfully to pull large endoprostheses through the alimentary track and into the biliary tree.     

Zones of increased perfusion (hot spots) on perfusion lung scans: correlation with pulmonary arteriograms

Perfusion lung scans are occasionally characterized by focal zones of apparent hyperperfusion ("hot spots"). To investigate the frequency and significance of this phenomenon, ventilation-perfusion lung scans and pulmonary arteriograms were reviewed in 72 patients who underwent both procedures for the evaluation of suspected pulmonary embolism. Hot spots were present in the scans of 13 patients and usually occupied less than one pulmonary segment. Most hot spots were detected within a region of atelectasis identified on chest radiographs (38%). A substantial number of the remaining hot spots were located in the lung adjacent to regions of embolus. In patients with massive embolus, hot spots actually represented normally preserved perfusion in the presence of globally reduced perfusion elsewhere.     

Ectopic pregnancy: a malpractice paradigm

Subtle sonographic findings and other nonspecific clinical presentations often lead to missed diagnoses that can have significant legal implications. This communication discusses current diagnostic and laboratory methods used to evaluate patients with a suspected ectopic pregnancy in light of the concepts of "missed lesions" as they relate to negligence and malpractice theory.     

Timing of oocyte activation, pronucleus formation and cleavage in humans after intracytoplasmic sperm injection (ICSI) with testicular spermatozoa and after ICSI or in-vitro fertilization on sibling oocytes with ejaculated spermatozoa

In the first study, we evaluated 101 oocytes [2, 4, 6, 8, 16, 18 and 20 h after intracytoplasmic sperm injection (ICSI)] that had been microinjected with testicular spermatozoa. Of the 70 normally fertilized oocytes (69%) 30 (43%) had two pronuclei by 6 h after ICSI. Fifty-one (73%) by 8 h, 69 (99%) by 16 h and four of them by 20 h cleaved to the 2-cell stage. In the second study, 95 cumulus-corona- oocyte complexes (CCOC) were divided into two groups. Forty-seven CCOC were inseminated by conventional in-vitro fertilization (IVF) and 40 metaphase-II oocytes by ICSI. Oocytes were evaluated at 2, 4, 6 (only after ICSI), 8, 10, 12, 18, 20, 22, 24, 26, 28 and 30 h after both ICSI and IVF. After IVF, 35 oocytes were fertilized normally (75%), four of which (11%) had two pronuclei by 8 h, 11 (31%) by 10 h, 27 (77%) by 12 h and 35 (100%) by 14 h. The first cleavages had occurred by 24 h after insemination (four oocytes, 11%). After ICSI, 34 oocytes were fertilized normally (79%), 13 of which (38%) had two pronuclei by 6 h, 27 (79%) by 8 h and 32 (94%) by 10 h. Three oocytes cleaved by 20 h after microinjection (9%) and 19 by 24 h (56%). Pronuclei developed asynchronously in six oocytes after ICSI (18%) as opposed to 16 oocytes after IVF (46%). The results of this study suggest that the timing of pronuclear formation is no different when a testicular spermatozoon is microinjected into the oocytes from when an ejaculated spermatozoon is injected. Secondly, pronuclear development and first cleavage generally take place 4 h sooner after ICSI than after IVF. On the other hand, a higher proportion of oocytes develop two pronuclei asynchronously after IVF than after ICSI.      

SOLITARY RECTAL ULCER: CLINICO PATHOLOGICAL PROFILE OF A STUDY

Eighteen rectal biopsies of eleven patients were histologically diagnosed as solitary rectal ulcer (SRU) during a period of three years. Their clinical and sigmoidoscopic features were analysed. Correct clinical diagnosis of SRU was made in only two out of eleven cases, the rest were diagnosed after sigmoidoscopy and biopsy. Presenting features were protean predominated by an altered bowel habit or bleeding per rectum. Sigmoidoscopically the location of the lesion varied from 6 to 12 cm from the anal verge. Anterior rectal wall was more commonly affected (10 out of 11 cases). Single rectal ulcer was found in 7 patients, other 4 showing multiple ulcers or polypoidal non-ulcerative lesions. Three patients required multiple biopsies. Prominent histological findings were obliteration of lamina propria by fibromuscular strands, splaying and hypertrophy of muscularis musosae as well as infiltrate in both these layers. The necessity of biopsy to diagnose SRU is stressed.KEY WORDS: Rectal diseases, Sigmoidoscopy     

THERAPEUTIC BILIARY ENDOSCOPY: EXPERIENCE AT A SERVICE HOSPITAL

Therapeutic Biliary Endoscopy (TBE) is becoming a popular mode of treatment for patients with obstructive jaundice. This paper highlights our early experience of TBE at Armed Forces Medical College and Command Hospital (SC), Pune with this mode of treatment. TBE was used as a primary therapeutic option in 46 patients with obstructive jaundice. The age of the patients ranged from 11 to 80 (mean and SD:45.5 ± 16) years and majority 29 (63%) were males. The cause of obstructive jaundice in these patients was choledocholithiasis (n=31), benign biliary stricture (n=8), post cholecystectomy recurrent stones (n=3), carcinoma of pancreas (n=3) and papillary stenosis (n-1). Endoscopic Sphincterotomy (ES) was technically successful in all the 46 patients and brought prompt symptomatic relief in 43 patients. Sixteen patients (34.8%) required additional drainage such as stenting or nasobiliary drain. In patients with choledocholithiasis, bile duct could be cleared of stones in 29 (93.5%) patients and in two surgical removal was required. Of the remaining patients, surgery was required in 4 (50%) patients with benign biliary structure, in 1 (33.3%) of those with malignant stricture and none of the patients presenting with papillary stenosis or recurrent bile duct stones after cholecystectomy. Complications were seen in only two patients (4.4%): one had mild acute pancreatitis and another had GI bleed, which did not require blood transfusion. Both the complications were self-limiting. No procedure related deaths were noted. Endoscopic therapy, thus, a simple, effective and safe method of treatment in patients with choledocholithiasis and selected patients with malignant biliary obstruction.KEY WORDS: Biliary obstruction, Endoscopic sphincterotomy, Endotherapy, Gall stones, Obstructive jaundice, Therapeutic endoscopy     

Weaning practices in children up to 19 months of age in Madrid

The weaning practices of 344 children in Madrid, aged 3-19 months, were investigated by controlled interview of their mothers or caretakers. The results were compared with national and international guidelines for the introduction of complementary foods; there are no Spanish guidelines. We found only minor differences between the practices in three different socioeconomic groups. Generally, mothers in Madrid followed national and international guidelines well. However, more attention should be paid to aspects such as the timing of the introduction of the first complementary food, the nature of gluten, the addition of salt and sugar to baby meals and the introduction of potentially allergenic foods. Also, manufacturers of baby foods that are sold in Spain could play a useful role by reducing the number of ingredients used in products advised for the initial phase of weaning and by avoiding the use of salt and sugar in their products. Complementary food, infant nutrition, socioeconomic group, weaning
SAM van den Boom, Dona Juana I de Castillo 56, 4-A, 28027 Madrid, Spain