Comparison of Surgical Treatments of Gallstone Ileus: Preliminary Report

Abstract Gallstone ileus is an uncommon cause of small bowel obstruction, accounting for only 1% to 4% of all intestinal obstructions. In the group of patients over 65 years of age, gallstones cause about 25% of all non-strangulated obstructions of the small bowel. Gallstone ileus is burdened with high mortality rate, ranging from 12% to 18%, and most patients are of advanced age, with many other concomitant diseases that may increase the operative risk. The purpose of this study was to compare the two investigated surgical procedures: treatment of intestinal obstruction alone or combined with urgent cholecystectomy and fistula repair. Analysis of 30 patients undergoing operation for gallstone ileus at the Clinical Hospital “Sestre milosrdnice” between 1985 and 2001 is presented. Patients were treated either for ileus alone (group 1, 11 patients) or as one-stage procedure with urgent fistula closure (group 2, 19 patients). Operating time was significantly longer for the one-stage procedure. Complications occurred in 3 of 11 patients (27.3%) from group 1 and in 11 of 18 patients (61.1%) from group 2 (one tailed, p = 0.043). One patient in group 1 died and two patients in group 2 died. Urgent fistula repair was significantly associated with the occurrence of complications (odds ratio [OR] 12.1, 95% confidence internal [95% CI] 1.2–121.5). Simple enterotomy should be the procedure of choice for patients with gallstone ileus. The one-stage procedure including urgent fistula repair should be reserved only for highly selected patients with absolute indications.     

Periacinar clefting and p63 immunostaining in prostatic intraepithelial neoplasia and prostatic carcinoma

The aim of the present study was to correlate the presence and extent of retraction clefting and the expression of p63 in neoplastic glands and glands with prostatic intraepithelial neoplasia (PIN) in needle core biopsies. We analyzed needle core biopsies from 28 patients with PIN and 41 patients with adenocarcinoma. Neoplastic glands and those with PIN were analyzed on high power field (400x) and classified in three groups according to the extent of clefting. Immunohistochemical staining was performed following Microwave Streptavidin ImmunoPeroxidase (MSIP) protocol on DAKO TechMate Horizon automated immunostainer. Periacinar retraction clefting was significantly more prominent in prostatic carcinoma compared to PIN (p<0.0001) and nonneoplastic glands (p<0.0001). There was no difference between normal glands and PIN regarding clefting (p=0.8064). p63 was positive around the whole circumference in 12 out of 28 cases with PIN, and discontinuously positive in remaining 16 PIN cases suggesting initial disruption of the basal cell layer. p63 immunostaining was also positive in all nonneoplastic glands, and negative in all carcinomas. We conclude that retraction clefting was associated with cancer and lack of basal cells, but not with PIN. The relationship between clefting and p63 immunostaining in prostatic cancer should be further analyzed.     

The effect of the replacement of calcium by strontium on excitation-contraction coupling in frog skeletal muscle

1. In frog skeletal muscle strontium can replace calcium in potassium contractures for 5 hr, though it is less effective than Ca. Sr can restore the responsiveness to K after it had been lost in the presence of Mn.2. Muscles refractory to caffeine following repeated exposure to it in the absence of Ca, recover in part following addition of Sr.3. The uptake of (85)Sr was increased during mechanical activity, whereas the uptake of (58)Co was not changed. Resting uptake of (58)Co was 3-4 times greater than that of (85)Sr.4. Sr fully activated the myofibrillar adenosine triphosphatase (ATP-ase), though its affinity was about 30 times less than Ca.5. The sarcoplasmic reticulum took up Sr, though less effectively than Ca.     

Esophagotracheal fistula after lithium disc battery ingestion successfully treated with hyperbaric oxygen therapy

We report a case of a 12-month-old child who acquired an esophagotracheal fistula of 5 mm in diameter after an ingested lithium disc battery impaction. Failure to recognize foreign body on chest X-rays resulted in a delay of 28 days in establishing the diagnosis. Feeding via nasogastric tube and hyperbaric oxygen treatment (HBOT) resulted in a complete closure of the fistula after 17 HBOT 60 min sessions at 2.2 bars.     

Neck auricles with microtia and low position of the right ear: a case report

Neck auricles are relatively rare malformation. We report the case of a 22-year-old male with two auricles on the anterior borders of sternocleidomastoid muscles, associated with microtia and low position of the right ear.     

How Long Can an Escalation of Dose Override Tolerance to the Hypotensive Efficacy of Nitroglycerin Infusion in Coronary Care Patients

Summary. Tolerance to nitroglycerin infusion (NG) can be overridden by dose escalation. The aim of this study was to define for how long it can be done for hypotensive efficacy of NG, in a coronary care setting.A prospective trial with an intra-individual therapeutic comparison was performed in 60 patients with acute myocardial infarction or unstable angina. Initial efficacy of NG was confirmed by a 10% blood pressure decrease (measured by cuff). Seventy-two-hour NG infusion was interrupted, for 30 minutes, every 12 hours. If blood pressure increased by 10% after infusion interruption, the infusion was continued at the previous rate. If blood pressure did not increase (detected tolerance<197>weakened efficacy of NG), the dose was increased until pressure decreased by 10% and the infusion was continued at the new dose. Failure to achieve hypotensive response, despite a 5-fold dose increase, indicated onset of resistance<197>completely lost hypotensive efficacy of NG.The majority of patients (49 out of 55) who developed tolerance, developed it during the first 36 hours, while the majority of those who developed resistance (33 out of 40), developed it within 60 hours of the infusion. Tolerance was overridden by dose escalation in 41 out of 55 patients, which was repeated in 31 patients. Complete restoration of NG action was possible over 24 hours in half the patients, and over 48 hours in one third of the patients. Three out of 34 patients who developed tolerance before the 13^th hour did not develop resistance during the following 60 hours of dose up-titration.The conclusion is that tolerance to NG can be overridden by dose escalation in the majority of patients for a significant period of time, which is useful in clinical practice.     

The correlation of inflammation and epithelial changes in the Pap smears of cervix uteri

A modification of The Bethesda System classification of cytologic findings of uterine cervix named Zagreb 1990 has been accepted in Croatia as a unique classification, the use of which has begun after the publication and printing of the new, uniform method of cytologic examination. AIM: The aim of this study was to assess the number and type of cytologic abnormalities of uterine cervix classified according to Zagreb 1990, on routinely examined Pap smears during the 6-year period, and to investigate the connection of these abnormalities with lower genital tract infections. MATERIAL AND METHODS: The retrospective study included Pap smears from the City of Zagreb and from the town of Imotski. A total of 59901 Pap smears (patients aged 17-79) were routinely examined: the cytopathologic diagnosis of CIN I or higher recorded in 3664 (6.12%) of them. The control group consisted of 401 Pap smears of age-matched women referred by the same gynecologists and free from cytologic abnormalities. The most frequently diagnosed epithelial change was CIN 1 (84.57% of all epithelial changes, and 5.17% of total study population), followed by CIN II (10.92%; 0.67%), CIN III (3.11%; 0.19%), and invasive squamous carcinoma (1.31%; 0.08%). Endocervical adenocarcinoma was cytologically diagnosed in only 0.0055% of all Pap smears examined. Inflammation was significantly more common in the group with epithelial dysplasia/carcinoma than in the control group (p < 0.01). Of specific causative agents HPV and Chlamydia trachomatis were significantly more frequently found in the group with epithelial dysplasia/carcinoma than in the control group (p < 0.05 both), however, Gardnerella vaginalis, Trichomonas vaginalis or Candida yielded no significant differences. It is concluded that inflammation very likely contributes to the development of precancerous lesions of the cervix, HPV and Chlamydia showing strongest correlation, at least in a part of our population.     

Herbal incense-related sudden death: case report

Currently, there are over 100 legally available synthetic cannabimimetics (SCBs). Serious adverse effects and deaths have been related to use of these substances. Despite their known hazards, many of them are still not banned for use in Croatia and grow in popularity among drug users. We report the case of a young man who suffered a cardiorespiratory arrest and eventually died several hours after smoking herbal incense containing a sprayed mixture of SCBs and consuming alcohol. He had no history of health problems and the autopsy revealed no pathological findings. We discuss hazards related to herbal incense smoking and draw attention to the rise in a number of cases related to use of SCBs in our community.