Percutaneous cholecystography in children

Percutaneous cholecystography was performed on 13 children who had biliary system abnormalities: two had biliary hypoplasia, five had sclerosing cholangitis, three had cirrhosis, two had distal choledochal obstruction, and one had an obstructed portoenterostomy. In 12 patients transcholecystic cholangiography showed, without significant complications, the intra-and extrahepatic bile ducts. In one patient with primary sclerosing cholangitis, the intrahepatic bile ducts were not opacified satisfactorily; dilatation of the gallbladder required surgical drainage. The transcholecystic technique is indicated when the intrahepatic bile ducts are either mildly dilated or not dilated.     

Immunopathogenesis and therapeutic approaches in acquired immunologic deficiency syndrome (AIDS)

The immunopathogenesis of AIDS and the problems arising from the infection of immunocompetent cells with the human immunodeficiency virus (HIV) are being discussed. Recent investigations point at the fact that CD4-positive T cells are not the only targets of HIV, but that also other cells of the immune system which are involved in the generation of the immune answer might be affected by the infection. This could result from a direct effect of HIV upon the respective cell function or as a consequence of other cells involved in the regulation of the immune response. Although many efforts are being undertaken, no clear-cut therapeutic modality has been yet discovered to counter the effects of HIV upon the immune system.     

Significance of hormone receptors of breast cancer cells for the duration of a disease-free interval

The importance of the presence of hormone receptors of cells derived from breast cancer tissue for the duration of the relapse-free interval was evaluated in 41 patients with stage II breast cancer. After modified radical mastectomy with axillary lymphadenectomy the patients received radiotherapy and adjuvant polychemotherapy and/or hormone therapy. There was no indication of metastases in any patient at the time of operation. There was a significant correlation of the relapse-free interval to tumor size (p less than 0.05), to the number of involved lymph nodes (p less than 0.0005), and also to the presence of the progesterone receptor (PgR), which seemed to play a more important role in this context than the oestrogen receptor (ER) (p less than 0.001). We conclude from this study that the evaluation of the PgR in breast cancer cells is important for the prognosis of the duration of the relapse-free interval.     

Association between continuity of care in Swedish primary care and emergency services utilisation: a population-based cross-sectional study

Objective: The primary objective of this study was to determine the association between longitudinal continuity of care (CoC) in Swedish primary care (PC) and emergency services (ES) utilisation.

Study design: A cross-sectional analysis of longitudinal population data. Setting. PC centres, out-of-hours PC facilities and emergency departments (EDs) in Blekinge County in southern Sweden. Subjects: People of all ages who lived in Blekinge County and who had made two or more visits per year to a general practitioner (GP) during office hours from 1 January 2012 to 31 December 2014.

Main outcome measure: ES utilisation.

Results: Eight-thousand one-hundred and eighty-five people were included in the study. CoC was quantified using three different indices—Usual Provider of Care index (UPC), Continuity of Care index (CoCI), and Sequential Continuity index (SECON). The CoC that the PC centres could offer their enrolled patients varied significantly between the different centres, ranging from 0.23–0.57 for UPC, 0.12–0.43 for CoCI, and 0.25–0.52 for SECON. Association between the three CoC indices and ES utilisation was computed as an incidence rate ratio which ranged between 0.50 and 0.59.

Conclusion: Longitudinal CoC was shown to have a negative association with ES utilisation. The association was significant and of a magnitude that implies clinical relevance. Computed incidence rate ratios suggest that patients with the lowest CoC had twice as many ES visits compared to patients with the highest CoC.     

Validation of AAST EGS Grade for Acute Pancreatitis

Background

The AAST recently developed an emergency general surgery (EGS) disease grading system to measure anatomic severity. We aimed to validate this grading system for acute pancreatitis and compare cross sectional imaging-based AAST EGS grade and compare with several clinical prediction models. We hypothesize that increased AAST EGS grade would be associated with important physiological and clinical outcomes and is comparable to other severity grading methods.

Methods

Single institution retrospective review of adult patients admitted with acute pancreatitis during 10/2014–1/2016 was performed. Patients without imaging were excluded. Imaging, operative, and pathological AAST grades were assigned by two reviewers. Summary and univariate analyses were performed. AUROC analysis was performed comparing AAST EGS grade with other severity scoring systems.

Results

There were 297 patients with a mean (±SD) age of 55?±?17 years; 60% were male. Gallstone pancreatitis was the most common etiology (28%). The overall complication, mortality, and ICU admission rates were 51, 1.3, and 25%, respectively. The AAST EGS imaging grade was comparable to other severity scoring systems that required multifactorial data for readmission, mortality, and length of stay.

Conclusions

The AAST EGS grade for acute pancreatitis demonstrates initial validity; patients with increasing AAST EGS grade demonstrated longer hospital and ICU stays, and increased rates of readmission. AAST EGS grades assigned using cross sectional imaging findings were comparable to other severity scoring systems. Further studies should determine the generalizability of the AAST system.Level of Evidence: IVStudy Type: Single institutional retrospective review

     

What is a safe waiting time for coronary artery bypass surgery?

To determine the factors that influenced doctors' prioritization and decisions on safe waiting time for coronary artery bypass surgery, 50 'paper patients', based on a random sample of cases who actually had surgery, were assessed by 33 clinicians. We used linear regression models to reflect the impact of clinical and non-clinical 'cues' on safe waiting time and priority decisions. The benefits of surgery tended to be over-estimated. For example, the average perceived gain in life expectancy for patients with left main-stem disease was 6.74 years. However, models incorporating only the perceptions of benefit as independent variables (i.e. the anticipated symptom reduction, MI risk reduction and life expectancy extension), had only modest explanatory power (mean R2 was 0.55 for safe waiting time, and 0.56 for priority decisions). Models which incorporated perceptions of benefit and the cases' clinical and non-clinical characteristics had generally much higher explanatory power (mean R2, 0.83 and 0.86, respectively). Lifestyle and demographic variables had much less impact on the doctors' judgements than the major clinical cues of angina severity and left main-stem stenosis. Demographic and lifestyle cues had different impacts on safe waiting time and priority for about 25% of doctors.      

Thrombosis in inflammatory bowel disease: clinical setting, procoagulant profile and factor V Leiden

Patients with inflammatory bowel disease have an increased frequency of thromboembolism, and microvascular thrombosis has been proposed as a contributory pathogenic factor. The mechanism of enhanced procoagulant activity is not understood. We examined the clinical setting of thromboembolic events in 52 patients with Crohn's disease or ulcerative colitis, and assessed the procoagulant laboratory profile, including Factor V Leiden, in a subset of 20 patients to identify procoagulant risk factors. Patients who developed thrombosis tended to be young; 60% of thrombotic events occurred in patients under 50 years. Multiple thromboembolic episodes occurred in 13% and unusual sites of thrombosis (e.g. intracardiac, cerebral, inominate veins) in 11%. No risk factor was identifiable in 52% of cases and two-thirds of thromboses occurred in an out-patient setting. The mortality rate was 8%. Evidence for inflammatory disease activity was found in only 45% of patients with ulcerative colitis at the time of the thromboembolic event, in contrast to 89% of those with Crohn's disease. Assays for specific coagulation defects were negative in all cases tested (protein S, C were normal in 17/17; anti-thrombin III, anti-phospholipid antibodies and activated protein C resistance were negative in 20/20, and only 1/20 patients was found to be heterozygous for Factor V leiden. Thrombosis in inflammatory bowel disease is important because it occurs in a young population, often in unusual sites, and has a high mortality. The development of thrombosis is related to active inflammatory disease in most patients with Crohn's disease but apparently not in those with ulcerative colitis. Since approximately half of the patients had no other identifiable risk factor, there remains a substantial group of patients with IBD who develop thrombosis for unknown reasons.      

Effect of freezing on the in vivo recovery of irradiated red cells

BACKGROUND: Transfusion-associated graft-versus-host disease can be prevented by gamma radiation of blood components. The increased use of blood components donated for patients by their family members has resulted in an increased demand for the storage and handling of irradiated units, and the ability to freeze the cells would allow storage beyond their current expiration date. STUDY DESIGN AND METHODS: To assess the effect of freezing and deglycerolization on irradiated red cells, studies of autologous radiolabeled red cell recovery were performed using normal volunteers. Each unit of CPDA-1 red cells was immediately divided into two equal volumes. Further handling of each half was identical except that one was irradiated (3500 cGy). The units were grouped under three protocols: I, irradiated on Day 0 and frozen on Day 5 (n = 4); II, irradiated on Day 7, rejuvenated, and frozen on Day 14 (n = 5); and III, irradiated on Day 14, rejuvenated, and frozen on Day 18 (n = 3). All cells were frozen for 3 to 10 months at -80 degrees C. RESULTS: Irradiated and control units showed no significant differences in supernatant potassium or hemoglobin. Autologous 24-hour posttransfusion recoveries (mean +/− SD) for the three groups were: I, 89.7 +/− 5.6 percent (control, 90.6 +/− 3.2%); II, 85.3 +/− 5.7 percent (control, 83.7 +/− 3.0%); and III, 79.5 +/− 1.4 percent (control, 82.6 +/− 5.2%). CONCLUSION: Irradiated red cells can be frozen after being stored under various conditions and can still meet established guidelines requiring 75-percent recovery 24 hours after transfusion.