Percutaneous transhepatic biliary drainage for bile leaks and fistulas

Percutaneous transhepatic cholangiography and biliary drainage were performed in 12 patients with major injuries to the bile ducts manifested by biliary leaks and fistulas. Eleven of the 12 patients had had inadvertent biliary trauma during surgery. In six patients, the biliary leaks sealed with percutaneous drainage. In other patients requiring definitive surgical procedures on the biliary tract, initial percutaneous drainage allowed these procedures to be delayed until the patients' clinical condition improved. Percutaneous biliary drainage is an important adjunct to the management of patients with traumatic extravasation of bile into the peritoneal cavity or biliary-cutaneous fistula.     

Investigation of bacteremia after orthodontic banding and debanding following chlorhexidine mouth wash application.

This study investigates the prevalence of bacteremia after orthodontic banding and debanding, following the application of a 0.2% chlorhexidine gluconate mouthwash. The banding and debanding groups were each composed of 40 young adult patients. In the banding group, patients were asked to rinse their mouth with chlorhexidine gluconate for 60 seconds just prior to fitting of the bands. In the debanding group, they were asked to use the mouthwash immediately before removal of bands and brackets. In both groups pre- and post-treatment blood samples were obtained with a strict aseptic technique. In the banding group, no bacteremia was detected in the pretreatment sample and 2.5% post-treatment bacteremia was detected in the post-treatment sample. In the debanding group, 2.5% bacteremia was found in both the pre- and post-treatment samples. The prevalence of post-treatment bacteremia found in the present study were compared with the findings of 2 preliminary studies in which the prevalence of bacteremia had been investigated after banding and debanding without a prior application of chlorhexidine mouthwash. The application of chlorhexidine mouthwash resulted in a decrease in the prevalence of bacteremia after banding and debanding, but the decrease was not statistically significant.     

Clinical implementation of coronary computed tomography angiography for routine detection of cardiac allograft vasculopathy in heart transplant patients

Cardiac allograft vasculopathy (CAV) is an accelerated form of coronary artery disease that affects long-term outcomes in heart transplant (HTx) patients. We prospectively evaluated the feasibility of coronary computed tomography angiography (CCTA) for the detection of CAV during clinical implementation at our center. All consecutive HTx patients >4 years post-transplant were actively converted from myocardial perfusion imaging to CCTA for the annual assessment of CAV. Between February 2018 and May 2019, 129/172 (75%) HTx patients underwent a CCTA. Renal impairment (n = 21/43) was the most frequent reason for patients could not undergo CCTA. CCTA image quality was good–excellent in 118/129 (92%) patients, and the radiation dose was 2.1 (1.6–2.8) mSv. CCTA showed obstructive CAV in 19/129 (15%) patients. Thirteen (10%) patients underwent additional tests, of which 8 patients underwent coronary revascularization within 90 days of CCTA. After 1 year, 3 additional coronary angiograms were performed, resulting in one revascularization in a patient with known severe CAV who developed ventricular tachycardia. One myocardial infarction after coronary stenting and 2 non-cardiac deaths were observed. CCTA can be successfully implemented for routine detection of CAV with good image quality and low radiation dose. CCTA allows CAV evaluation with the limited need for additional invasive testing.     

Achilles tendon-splitting approach and double-row suture anchor repair for Haglund syndrome

BackgroundHaglund syndrom is characterized as a painful posterosuperior deformity of the heel with possible causes as tight Achilles tendon, high-arched foot and tendency to walk on the outside of the heel. Surgical treatment may be recommended in cases where of insufficient response to nonoperative treatment. This study aims to evaluate the clinical and radiographic results of central Achilles tendon splitting and double-row suture anchor technique in the surgical treatment of patients with Haglund syndrome.Methods27 patients with Haglund syndrome who underwent central Achilles tendon splitting and double-row suture anchor were retrospectively evaluated. The results were evaluated by the pre- and post-operative American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale and visual analogue scale (VAS). All patients were evaluated radiographically to assess lateral talus-first metatarsal angle (TMTA), Calcaneal pitch angle (CPA), and the Fowler-Philip angle (FPA) preoperatively and postoperatively.ResultsThe mean preoperative AOFAS score was 47 ± 7 points; at the end of the follow-up period, it increased to 92 ± 4 points (p < 0.001). The mean preoperative VAS score was 9 ± 0.9 points; at the end of the follow-up period, it was 2 ± 0.6 points (p < 0.001). The lateral TMTA (preoperative: 5° ± 2°; follow-up: 4° ± 2°; p < 0.001), CPA (preoperative: 21° ± 5°; follow-up: 20° ± 5°; p = 0.005) and FPA (preoperative: 55° ± 6°; follow-up: 32° ± 3°; p < 0.001) values decreased at the end of the follow-up period.ConclusionIn the absence of an improvement to nonoperative treatment methods, central Achilles tendon-splitting approach appears to be an effective and safe treatment option.Level of evidenceLevel IV, retrospective case series.     

Vitamin E Levels in Ethnic Communities in Malaysia and Its Relation to Glucose Tolerance,Insulin Resistance and Advanced Glycation End Products: A Cross-Sectional Study

Malaysian national morbidity surveys on diabetic prevalence have shown ethnical variation among prediabetic and diabetic populations. In our attempt to understand this variation, we studied the α-tocopherol, insulin resistance, β-cell function and receptor of advanced glycation end-products (RAGE) levels, as risk factors of type 2 diabetes, among the different ethnicities. In total, 299 subjects of Malay, Chinese, Indian and aboriginal Orang Asli (OA) heritage were recruited from urban and rural areas of Malaysia by stratified random sampling. Serum α-tocopherol concentrations were measured using high performance liquid chromatography (HPLC) and insulin concentrations were measured using enzyme-linked immunosorbent assay (ELISA). In subjects with pre-diabetes, OAs had the highest α-tocopherol level, followed by Chinese and Malays (0.8938, 0.8564 and 0.6948 respectively; p < 0.05). In diabetic subjects, Malays had significantly higher RAGE levels compared to Chinese and Indians (5579.31, 3473.40 and 3279.52 pg/mL respectively, p = 0.001). Low α-tocopherol level (OR = 3.021, p < 0.05) and high insulin resistance (OR = 2.423, p < 0.05) were linked strongly to the development of pre-diabetes. Low β-cell function (OR = 5.657, p < 0.001) and high RAGE level (OR = 3.244, p < 0.05) were linked strongly to the development of diabetes from pre-diabetes. These factors might be involved in the development of diabetes, along with genetic and environmental factors.     

Risk factors for postoperative mortality in congenital diaphragmatic hernia: a single-centre observational study

Background

The management of congenital diaphragmatic hernia (CDH) is a major challenge. The mortality is dependent on associated malformations, the severity of pulmonary hypoplasia, pulmonary hypertension and iatrogenic lung injury associated with aggressive mechanical ventilation. The aims of the study were to investigate the mortality over time in a single paediatric surgical centre, to compare the results with recent reports and to define the risk factors for mortality.

Methods

The medical records of infants with CDH from two time periods: 1995–2005 and 2006–2016 were reviewed. Cox regression was used for statistical analysis.

Results

The study included 113 infants. The mortality rate was significantly decreased in the later time period, compared to the earlier, 4.4 and 17.9%, respectively. At the early time period five patients (7.5%) were treated with ECMO and in the later time period ECMO was used in three patients (6.5%). The mortality in ECMO-treated patients was 50% in both time periods. Prenatal diagnosis, intrathoracic liver, low Apgar score and low birth weight were defined as independent risk factors for mortality.

Conclusion

Despite no significant differences in the incidence of independent risk factors and the use of ECMO between the two time periods, mortality decreased over time. The mortality was lower than previously reported. The results indicate that there are many important factors involved in a successful outcome after CDH repair. Large multicentre studies are necessary to define those critical factors and to determine optimal treatment strategies.

     

Measuring the beliefs on alcohol craving by using craving beliefs questionnaire: preliminary results of its psychometric properties in a Turkish sample

Introduction: Therapist can assess patients’ maladaptive beliefs about drug via Craving Beliefs Questionnaire (CBQ), which was originally developed by Wright to measure beliefs about the craving phenomenon. The aim of the study is to assess the psychometric properties of CBQ and its usefulness in the patients with alcohol dependency. Method: The study population was consisted of 70 alcohol addict male patients. Beliefs about substance use questionnaire (BSU), craving beliefs questionnaire (CBQ), Beck anxiety inventory (BAI), clinical institute withdrawal assessment (CIWA), automatic thoughts questionnaire (ATQ) and dysfunctional attitudes scale (DAS) were used as the assessment tools. Results: The internal consistency of the CBQ for the alcohol dependent was adequate (Cronbach’s alpha 0.94). Item-total score correlations were between 0.50 and 0.84 for alcohol-dependent patients. The principal component analysis revealed one main factor. Positive correlations found between CBQ, and BSU, BAI and ATQ. In discriminant validity analysis, mean CBQ scores were found significantly higher than occasional drinkers and none-alcohol drinkers. Conclusion: Our results supported that the Turkish version of the CBQ has an adequate instrument for evaluating alcohol-related craving beliefs in alcoholic patients. However, further studies should be performed for assessing its validity in large number of social drinkers and alcohol-dependent patient.     

Principles of treatment of epilepsy

Epilepsy is a common chronic neurological condition with a prevalence of 4-8 per 1000. The present classification of epilepsy is based on: 1) the etiology, which distinguishes symptomatic epilepsies from those that are idiopathic and cryptogenic, and 2) the localization of the disorder in the brain, separating the generalized seizures from epilepsies with partial or focal onset. The majority of patients with epilepsy will go into remission and two-thirds will remain so 2 years after drug withdrawal. The impact of epilepsy on individual patients varies. Employment, driving and learning may constitute major problems. There is a small but definite increase in mortality in patients suffering from epilepsy. Treatment of epilepsy usually involves long-term medical treatment, with the ultimate aim being no seizures and no drugs. Before starting treatment, the diagnosis of epilepsy should be assured. Initiation of antiepileptic drug therapy needs a full and adequate discussion with the patient and the choice of the minimum effective dose of an appropriate monotherapy. Nonpharmacological treatments may be necessary at a relatively early stage if pharmacologic treatment is ineffective. In choosing between different anti-epileptic drugs, consideration should be given to the efficacy of the drug for an individual patient and the tolerability of the drug. There is good evidence from many studies that the chief factor determining relative effectiveness is likely to be the spectrum and incidence of adverse effects of antiepileptic drugs. Some 20% of patients developing epilepsy have a chronic disorder uncontrolled by drugs. In patients receiving and complying with optimal doses of a single antiepileptic drug, the addition of further agents is likely to result in a significant improvement in seizure control in only about 10% of patients, but inevitably it increases the risks of dose-related, idiosyncratic and chronic toxicity due to both pharmacokinetic and pharmacodynamic drug interactions. For this group of patients an appropriate aim may not be complete remission of seizures but a compromise of reduced seizure frequency with less severe seizures, to be achieved with one or, at most, two drugs. The management of these patients with unremitting seizures constitutes a treatment challenge for epileptologists.