Treatment of iatrogenic biliary obstruction by balloon dilatation of a biliary jejunal fistula

Biliary obstruction and multiple hepatic abscesses occurred in a patient after ligation of a segmental branch of the right hepatic duct. The patient was successfully managed by transhepatic biliary drainage and balloon dilatation of an internal fistula that developed between the ligated duct and a Roux limb of jejunum. Internal biliary fistulas may be dilated using interventioanl radiologic techniques to permit nonobstructed bile flow. Implications for the nonsurgical treatment' of biliary strictures are discussed.     

Pectus excavatum defect on liver-spleen scintigraphy

A 58-year-old man with a pectus excavatum demonstrated a photon-deficient defect within the left lobe of the liver on liver-spleen scintigraphy using Tc-99m SCOL. Computed tomography of the liver clearly revealed the abnormal defect seen on the liver-spleen scan to be due to the pectus excavatum. This case confirms the impression that these skeletal aberrations may cause false-positive hepatic defects.The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense     

Not Geropharmacotherapy 101

Critical to survival is the geriatric concept, allostasis, defined as the ability to achieve stability through change. It is appropriate that allostasis is an introduction to this commentary, which may partially apply to the medical and pharmacy profession as currently constituted.     

A clinical comparison of the Laryngeal Tube™ and the Laryngeal Mask™ in spontaneously breathing anesthetized patients

Abstract: Background: The laryngeal mask airway (LMA) can be used in general anaesthesia without neuromuscular block. The laryngeal tube (LT) is a new airway device with similar airway features as LMA. LT is provided with a distal cuff to prevent regurgitation. In this study we compared the LMA and LT concerning patient and user aspects. Methods: Sixty patients with ASA (American Society of Anestesiologists) score 1–2 scheduled for minor surgery were randomized to be ventilated either through LMA or LT. After insertion, the number of insertion attempts, and “positioning” and “airway-assessment” was evaluated. The patients reported on “sore throat” after 30 and 60 minutes and the day after anaesthesia. Results: Gender and mean age were equal in both groups. The first insertion attempt was successful in 25 of 28 patients randomised to LMA and in 23 of 27 patients randomised to LT. LMA was evaluated to be easier in “positioning” whereas no difference in “sore throat” was reported. Conclusion: We found no difference between the LMA and the LT in terms user and patient friendliness and safety.     

Photometrics: a new method of measuring the cross-sectional area of the subglottis.

A new endoscopic method of measuring the cross-sectional area of a subglottic stenosis is presented. The method was tested against existing techniques using a model. By standardizing the distance from the objective of the endoscope to the stenotic area we were able to measure the cross-sectional area using a graduated grid held against the video screen. This technique was then compared with the standard one of estimating the diameter of a stenosis from the external diameter of the bronchoscope which can be passed through the stenosis. The methods were found to be equally accurate in measuring the lumen diameter. However, when measuring the minimum cross-sectional area, three of five observers were significantly better (P less than 0.01) using the photometric method rather than the standard method (Wilcoxon's rank sum test for paired data). The photometric technique of measuring the cross-sectional area of the subglottis is easily performed, non-traumatic, and allows a visual record to be kept.     

Willard Parker's 1841 orbital operation

There are few records detailing the techniques and tribulations of early American surgeons who dared venture into the treacherous recess of the human orbit. The authors present a recently discovered letter written by a young woman who in 1841 underwent an orbital operation performed by the prominent New York City surgeon, Willard Parker. The letter details the patient's experiences in an era without anesthesia or antibiotics, and her subsequent development of conjunctival adhesions.     

Sexual sequelae of antihypertensive drugs: Treatment effects on self-report and physiological measures in middle-aged male hypertensives

Antihypertensive drugs are commonly associated with adverse side effects in both clinical and laboratory studies. We investigated the sexual sequelae of several major classes of antihypertensive drugs (e.g., beta blockers, central alpha agonists, diuretics) in normal males and in hypertensive patients. We compared the effects of four widely used agents (methyldopa, propranolol, atenolol, hydrochlorothiazide-triamterene) and placebo, in a selected sample of 21 sexually dysfunctional male hypertensives, 13 of whom completed all five phases of the study. Each study drug was administered for a 1-month treatment period, followed by a 2-week, single-blind washout phase, according to a randomized, Latin square crossover design. Dependent variables for the study included a broad range of hormonal, NPT, and self-report measures of sexual response. Results indicated a lack of consistent drug effects on measures of sexual response, although more frequent sexual and nonsexual side effects were observed with methyldopa and propranolol. As in our previous studies, age was negatively correlated with both hormonal and NPT measures, whereas changes in blood pressure were not significantly related to sexual function scores. Results do not support the hypothesis that sexually dysfunctional males are at greater risk for adverse sexual sequelae when treated with centrally active agents or diuretics.     

Specific statistical considerations relevantto the design and analysis of gingivitis trials demonstrating

Simulation studies were conducted to address specific statistical issues which arise in the design and analysis of gingivitis studies whose principal aim is the demonstration of superiority or equivalence of one product to another. The effects of measurement scale, using differences or ratios of group means, particular statistical test produces and specific rules demonstrating superiority or equivalence were investigated. An alternative concept to equivalence—denoted “least as good”—was also defined and evaluated. For a wide class of possible distributions of gingivitis scores, characterized by specific gamma distributions, the student-t test applied to means of subject GI gingivitis scores proved to be the most powerful of the test produces considered, having statistical properties quite similar to the randomization or permutation test procedure. Transformations of subject GI mean gingivitis scores did not produce an advantage in demonstrating either superiority or equivalence, and in some cases made it more difficult. Little difference was observed in test results when using the difference in group means as compared with using the ratio of group means for demonstrating either equivalence or superiority. The clinically significant rule produced the lowest false-positive rates for products slightly better than the active control, and similar false-positive and -negative rates as the statistically significant rule for products clearly superior to the active control. Demonstration of product equivalence will require more subjects per group than demonstrating product superiority, the size of this difference being a function of the definition of superiority that is accepted. Showing that the 90% confidence interval for 100*R is completely contained within the [90%, 110%] interval is the preferred method of demonstrating equivalence today, although much more research needs to be done to improve methods for demonstrating product equivalence. The “least as good” alternative to “equivalence” makes it easier to demonstrate “equivalence” for products slightly better than the active control product, but both experience great difficulty in demonstrating equivalence for lest products not quite as good as the active control.