Pneumomediastinum after Endoscopic Sphincterotomy

Pneumomediastinum is a rare complication of endoscopy that usually indicates free peritoneal or retroperito-neal perforation. We report an unusual case of self-limiting pneumomediastinum after endoscopic sphincterotomy in which there was no radiological evidence of gut wall perforation. We postulate that this was due to interstitial tracking of air from the duodenal wall, and we discuss the possible pathophysiology. This complication should be recognized as distinct from pneumomediastinum associated with perforation, particularly as it appears to be benign and therefore does not require surgical or radiological intervention.     

Lessons from case studies of integrating mental health into primary health care in South Africa and Uganda

Background

Studies on the mental health of refugees have tended to focus upon the impact of traumatic experiences in the country of origin, and acculturation processes in exile. The effects of crises in the country of origin on refugees living in exile have been little studied. This article examines how the final stages of the civil war in Sri Lanka in 2009 influenced members of pro-LTTE Tamil NGO's in Norway.

Method

Ethnographic fieldwork methods were employed within Tamil NGO's in the two largest cities in Norway between November 2008 and June 2011.

Results

The findings suggest that collective resources became severely drained as a result of the crisis, severely disrupting the fabric of social life. Public support from the majority community remained scarce throughout the crisis.

Conclusions

The study suggests that there is a need for public support to exile groups indirectly affected by man-made crises in their country of origin.     

Inhibin and ovarian cancer]

Previous observations from our laboratory have demonstrated that the levels of immunoreactive inhibin (ir-inh) are elevated in almost all patients with granulosa cell tumors and in the majority of postmenopausal women with mucinous ovarian cancers. The present report confirms these findings in a larger group of post-menopausal women. Immunohistochemistry for the inhibin alpha. beta A and beta B sununits shows predominantly epithelial staining in granulosa cell tumors and in the majority of mucinous cancers. Serous cystadenocarcinomas also frequently show positive staining. Studies seeking to identify G alpha i-2 or FSH receptor mutations have provided negative results in contrast to other reports. Further studies of the roles of the inhibin-related family of peptides in ovarian cancer diagnosis and monitoring are clearly indicated.     

Monitoring antimalarial drug resistance in India via sentinel sites: outcomes and risk factors for treatment failure, 2009–2010

Objective

To describe India’s National Antimalarial Drug Resistance Monitoring System, measure the efficacy of first-line malaria treatments, and determine risk factors for treatment failure.

Methods

In 2009–2010, prospective studies with 28 days of follow-up were conducted at 25 sentinel sites. Patients infected with Plasmodium falciparum were given artesunate plus sulfadoxine-pyrimethamine (AS+SP); those infected with P. vivax were given chloroquine. Polymerase chain reaction was used to distinguish post-treatment reinfection from treatment failure. Isolates of P. falciparum were checked for dhfr and dhps mutations.

Findings

Overall, 1664 patients were enrolled. Kaplan–Meier survival analysis showed an efficacy of 98.8% for AS+SP. Most patients with P. falciparum parasitaemia cleared their parasitaemias within 24 hours of treatment initiation, but six, including four with treatment failure, remained parasitaemic after 72 hours. Double mutants in dhfr were found in 68.4% of the genotyped isolates. Triple or quadruple mutants in dhfr and mutations in dhps were rare. A daily dose of artesunate of < 3 mg per kg of body weight, age of less than 5 years, and fever at enrolment were associated with an increased risk of treatment failure. Chloroquine remained 100% efficacious and generally cleared P. vivax parasitaemias within 48 hours. Vomiting (seen in 47 patients) was the most common adverse event.

Conclusion

India’s National Antimalarial Drug Resistance Monitoring System provides wide coverage. The first-line antimalarials used in the country remain safe and efficacious. The treatment of malaria in young children and the relative benefits of age- and weight-based dosing need further exploration.     

Revisiting Non-Compaction Cardiomyopathy Through a Case with Cyanosis and Complete Heart Block

Left ventricular non-compaction or “spongy myocardium”, is a rare congenital cardiomyopathy that should be considered as a possible diagnosis because of its potential complications. Echocardiography is the diagnostic tool of choice, and cardiomagnetic resonance (CMR) can confirm or rule out this disease. Herein, we report the case of an 8-month-old female child who presented with congestive cardiac failure (CCF) and symptomatic complete heart block (CHB). An echocardiogram established the diagnosis as non-compaction cardiomyopathy (NCCM). An associated double outlet right ventricle with ventricular septal defect and valvular pulmonary stenosis was found. Cardiac magnetic resonance study confirmed the findings. This singular case report of NCCM highlights the importance of clinical awareness of this rare abnormality, its varied presentation and associated cardiac anomalies. The article revisits NCCM and focuses on the practical issues for a proper echodiagnosis.     

A case of prenatally diagnosed limited dorsal myeloschisis with good prognosis

Diagnosis of fetal spinal dysraphism is a challenge. It is difficult to distinguish between a meningocele, myelomeningocele, and a recently described entity called limited dorsal myeloschisis (LDM). Although myelomeningocele is associated with a poor prognosis, LDM can have a good outcome. We present a case of prenatally diagnosed LDM. Because sonographic examination revealed a round, cystic, septated cervical mass without associated cerebral anomalies, the lesion was initially considered an isolated meningocele. Fetal MRI contributed to correct the diagnosis. A diagnostic error can lead to the wrong surgical support or even the termination of pregnancy. Therefore, we highlight the importance of fetal MRI in such cases, particularly when no cerebral abnormalities are observed on sonographic examination.     

Tobacco use and substance use disorders as predictors of postoperative weight loss 2 years after bariatric surgery

Although evaluations of tobacco and substance use disorders (SUDs) are required before bariatric surgery, the impact of these factors on postsurgical outcomes is unclear. This study describes (1) the prevalence of tobacco and SUDs in 61 veterans undergoing bariatric surgery, (2) associations between presurgical tobacco use and postsurgical weight loss, and (3) relationships between presurgical SUDs and postsurgical weight loss. Height, weight, tobacco, and SUDs were assessed from medical charts at presurgery and 6, 12, and 24?months postsurgery. Thirty-three patients (55%) were former or recent tobacco users; eight (13%) had history of SUDs. All patients who quit smoking within 6?months before surgery resumed after surgery, which was associated with increased weight loss at 6 and 12?months. Presurgical SUDs were related to marginally worse weight loss at 12 and 24?months. Bariatric surgery candidates with history of smoking and/or SUDs might benefit from additional services to improve postsurgical outcomes.     

Predicting and preventing Post-ERCP pancreatitis

Pancreatitis is rightly the most feared complication of endoscopic retrograde cholangiopancreatography (ERCP). Ten percent to 15% of cases of post-ERCP pancreatitis (PEP) are severe by clinical and radiologic criteria. Such cases carry significant morbidity and mortality and are responsible for the vast majority of ERCP-related deaths. The prediction and prevention of PEP have been of great interest to endoscopists since the introduction of ERCP 30 years ago. Prediction and diagnosis of PEP have become more accurate with the widespread availability of serum amylase estimation. A variety of cytokines (eg, interleukin [IL]-1, IL-6, and IL-8) and acute phase reactants (eg, C-reactive protein) are also elevated in the serum in acute pancreatitis, and these form the basis of evolving tests for PEP. Urine testing (for amylase) in acute pancreatitis is obsolete, but it may soon undergo a revival in the form of a rapid (3-minute) dipstick test for trypsinogen-2, a sensitive and specific test for this disease. The prevention of PEP takes multiple forms. The following steps are recommended for clinicians: 1) avoid ERCP when other, less invasive or noninvasive imaging tests can do the job (eg, CT or magnetic resonance imaging); 2) avoid highrisk (of PEP) procedures, such as needle-knife papillotomy, balloon dilation of the biliary sphincter, and pancreatic sphincterotomy, and take steps to reduce risk when these procedures are unavoidable; 3) ensure that those who perform ERCP have adequate training and experience; and 4) consider pharmacologic intervention. Despite a depressing catalog of drug interventions that have failed over the years (eg, antihistamines, anticholinergics, and corticosteroids), three agents have recently shown promise: somatostatin; its octapeptide analogue, octreotide; and gabexate mesylate, a protease inhibitor.