Clinical comparison of extracorporeal piezoelectric lithotripsy (EPL) and intracorporeal electrohydraulic lithotripsy (EHL) in difficult bile duct stones

Today, nearly 90% of common bile duct stones are extracted endoscopically. Problems are encountered if there are large stones or a duct stenosis. Extracorporeal piezoelectric lithotripsy (EPL) as well as intracorporeal electrohydraulic lithotripsy (EHL) serve as an alternative to surgical intervention for those few patients in whom endoscopic measures have failed. A total of 35 patients with common bile duct stones in whom conventional endoscopic treatment had failed were selected on the condition that stone visualization through ultrasound was possible and that the papilla was within easy reach of the endoscope. Patients fulfilling the inclusion criteria were randomly treated either by EPL or EHL. The average age of our patients was 73 years. The main reasons for failure of conventional endoscopy were due to the large size of the stones (13 patients), impacted stones (16), or the presence of a biliary stricture (6). In the EPL group, visualization of the stones by ultrasound and ensuing treatment were possible in 16 of 18 patients (89%); stones could be fragmented in 15 patients. In 13 patients, the biliary tree could then be completely freed of calculi; the success rate was 72% for all the patients (13 of 18). On average, the patients had 2.3 treatments on the lithotripter, and 3870 shock waves were applied per treatment. In the EHL group stones were successfully fragmented in 13 of 17 patients (76.5%). The average number of treatments was 1.4. Comparing both therapies, there was no difference in stone-free rates. In both groups, additional endoscopic interventions were necessary to clear the bile duct. The mean number of lithotripsy sessions was less in the EHL group (1.4 vs 2.3). There were no major differences in average hospital stay, 30-day mortality was zero in both groups. Combined treatment including EPL, EHL, and intracorporeal laser lithotripsy was finally successful in 32 patients (91.5%). It is concluded that EHL might be the method of choice for smaller, single stones in the more proximal parts of the common bile duct. In these cases, complete duct clearance in one lithotripsy session can be achieved. Multiple and large stones are probably best accessible to EPL. With a combination of the methods described, the bile duct can be cleared of concrements in almost every instance. As a result, surgery for choledocholithiasis has become the absolute exception.This work was presented in part at the 1993 Annual Meeting of the american Gastroenterological Association in Boston and published in abstract form (Gastroenterology 104:A347, 1993).     

Improving programme-led and focused interventions for eating disorders: An experts' consensus statement—A UK perspective

Objective

Eating disorders are associated with significant illness burden and costs, yet access to evidence-based care is limited. Greater use of programme-led and focused interventions that are less resource-intensive might be part of the solution to this demand-capacity mismatch.

Method

In October 2022, a group of predominantly UK-based clinical and academic researchers, charity representatives and people with lived experience convened to consider ways to improve access to, and efficacy of, programme-led and focused interventions for eating disorders in an attempt to bridge the demand-capacity gap.

Results

Several key recommendations were made across areas of research, policy, and practice. Of particular importance is the view that programme-led and focused interventions are suitable for a range of different eating disorder presentations across all ages, providing medical and psychiatric risk are closely monitored. The terminology used for these interventions should be carefully considered, so as not to imply that the treatment is suboptimal.

Conclusions

Programme-led and focused interventions are a viable option to close the demand-capacity gap for eating disorder treatment and are particularly needed for children and young people. Work is urgently needed across sectors to evaluate and implement such interventions as a clinical and research priority.     

Management of common bile-duct stones and associated gallbladder stones: surgical aspects

In most countries, endoscopic sphincterotomy is the first-choice treatment for common bile-duct stones. In patients with residual gallbladder stones, laparoscopic cholecystectomy is the next step. The optimal timing of laparoscopic cholecystectomy after endoscopic sphincterotomy remains to be determined. An alternative approach of combined cholecystocholedocholithiasis consists of laparoscopic cholecystectomy together with laparoscopic stone removal. The advantage of this ‘single-stage’ therapy appears to be limited to patients with stones that can be removed transcystically. This approach is successful in about half of the patients. Laparoscopic common bile-duct exploration is technically more demanding, more time-consuming, and associated with increased postoperative morbidity. If transcystic removal is not possible, a postoperative ERCP with endoscopic sphincterotomy is a good option. Intraoperative ERCP and endoscopic sphincterotomy are also feasible, but require specific organisational efforts.Recurrence of choledocholithiasis after ES is reported in a considerable number of patients (6–21%), resulting from de novo primary stone formation or recurrent secondary migration from the gallbladder. Primary choledocholithiasis is associated with bactobilia and delayed bile-duct clearance, indicated by CBD dilation. Endoscopic reintervention is safe and usually easy to perform. Surgery should be reserved for intractable cases. In selected patients, an underlying lithogenic bile composition (low-phospholipid-associated cholelithiasis) should be identified, and preventive medical treatment with UDCA could be considered.

• in patients with combined cholecystocholedocholithiasis, endoscopic sphincterotomy should be followed by elective laparoscopic cholecystectomy, even in the elderly; however, a ‘wait-and-see’ policy does not lead to higher mortality, and therefore expectant management can be advocated in case of significant contraindications to surgery

• laparoscopic cholecystectomy combined with laparoscopic stone removal offers a one-stage treatment of patients with combined cholecystocholedocholithiasis. Laparoscopic transcystic duct clearance is associated with low morbidity and short hospital stay. In contrast, laparoscopic common bile-duct exploration remains a procedure with increased risk of biliary complications and prolonged hospital stay. In case of stones that cannot be removed transcystically, it may be wise to perform an intraoperative or early postoperative ERCP

• performing an endoscopic sphincterotomy during laparoscopic cholecystectomy using a ‘rendezvous’ procedure may be beneficial in selected patients (especially in case of earlier failed ERCP)

• laparoscopic cholecystectomy after endoscopic sphincterotomy is associated with increased conversion rates to open procedure compared to laparoscopic cholecystectomy for uncomplicated gallstones; laparoscopic cholecystectomy planned early after endoscopic sphincterotomy may reduce this risk

• morphological or functional bile-duct defects, indicated by a dilated CBD, may lead to bactobilia and biliary stasis, thus promoting primary stone formation

• in a subgroup of patients with recurrent bile-duct stones, an MDR3 gene mutation must be considered, resulting in low-phospholipid-associated cholelithiasis. These patients are characterised by early onset of symptoms, recurrence after cholecystectomy, hyperechogenic foci in the liver, and often a history of intrahepatic cholestasis of pregnancy. Ursodeoxycholic acid is beneficial in these patients

• the optimal timing or ERCP in patients scheduled for laparoscopic cholecystectomy (before, during, or after the operation) still needs to be defined.

• further data are needed to determine potentially increased incidence of conversion and postoperative complications for laparoscopic cholecystectomy after endoscopic sphincterotomy compared to laparoscopic cholecystectomy for uncomplicated gallstones

Subjects with allergic rhinitis show signs of more severely impaired paranasal sinus functioning during viral colds than nonallergic subjects

BACKGROUND: Viral cold is thought to be the major contributing factor in the pathogenesis of sinusitis, as it causes ostiomeatal obstruction. The aim was to evaluate whether paranasal sinus functioning during viral colds is similar in subjects with and without allergic rhinitis. METHODS: Forty-eight volunteers were examined during an early (2-4 days) natural cold and again 3 weeks later. The examinations included computed tomography (CT) scans, nasal mucosal biopsies, and viral and bacterial specimens. Subjects with positive skin prick tests and persistent or intermittent rhinitis were considered to have allergic immunoglobulin E (IgE)-mediated rhinitis. In addition, specific IgE antibodies to staphylococcal enterotoxin B (SEB) were measured. RESULTS: Nine subjects (19%) had allergic rhinitis. The allergic subjects were significantly more often IgE sensitized to SEB than the nonallergic subjects (33%vs 3%, P = 0.02). Viral etiology of the cold was identified in 32 (67%) subjects. The subjects with allergic rhinitis had significantly higher CT scores compared with nonallergic subjects during the colds (median (range) scores 16 (6-22) vs 6 (0-17), P = 0.004). In both groups, the median scores declined markedly during convalescence, but the difference remained significant (P = 0.009). Among the allergic subjects, those who were IgE sensitized to SEB tended to have the highest CT scores [median (range) 16 (16-22)]. Total serum IgE and the nasal subepithelial eosinophil counts correlated with the CT scores during the cold (rs = 0.38, P = 0.008 and rs = 0.46, P = 0.001, respectively). CONCLUSIONS: Subjects with allergic IgE-mediated rhinitis had more severe paranasal sinus changes in CT scans than nonallergic subjects during viral colds. These changes indicate impaired sinus functioning and may increase the risk of bacterial sinusitis.     

Nasal mucosa in natural colds: effects of allergic rhinitis and susceptibility to recurrent sinusitis

The mechanisms of virus-induced airway hyperresponsiveness in asthma and allergy and the failure of host defence in patients suffering from secondary airway infections are still largely unknown. The aim of this study was to examine whether the presence of allergic rhinitis or susceptibility to recurrent sinusitis affects the structural and cellular changes in nasal mucosa during natural colds and convalescence. We compared the mucosal changes in biopsy samples during acute natural colds (days 2-4 of illness) and convalescence (3 weeks later) in patients with allergic rhinitis (n = 9), patients with susceptibility to sinusitis (n = 19) and healthy controls (n = 20). We saw similarly increased numbers of mucosal T and B lymphocytes and mast cells and increased vascular density during the acute colds compared to convalescence in all the three groups. The allergic subjects had elevated levels of eosinophils in the acute phase (P = 0.03), and the allergic and sinusitis-prone subjects had elevated levels of epithelial T cells (P = 0.04) and low levels of mast cells (P = 0.005) in convalescence compared to the control group. The sinusitis-prone subjects lacked intraepithelial cytotoxic cells in convalescence. In the allergic subjects, the reticular basement membrane was thicker in the acute phase compared to the convalescence (P = 0.05). These results suggest that various cells of the airways, including inflammatory and structural cells, are involved during viral respiratory infections in subjects with allergic rhinitis. The small numbers of mast cells and cytotoxic lymphocytes in the sinusitis-prone subjects may be related to their susceptibility to bacterial complications.     

Effects of protein synthesis inhibitors on the sensitization of a defensive response in common snails and potentiation of the cholinosensitivity of command neurons

The effects of protein synthesis inhibitors on short-term sensitization of a defensive reaction in common snails and the potentiation of the cholinosensitivity of command neurons were studied. The protein synthesis inhibitor anisomycin did not prevent behavioral sensitization. Anisomycin and the irreversible protein synthesis inhibitor saporin changed the dynamics of potentiation of command neuron cholinosensitivity. We suggest that the sensitization of the defensive response of the common snail studied here does not require the synthesis of new proteins. __________ Translated from Zhurnal Vysshei Nervnoi Deyatel’nosti imeni I. P. Pavlova, Vol. 56, No. 3, pp. 355–362, May–June, 2006.     

Analysis of toll-like receptor-dependent production of proinflammatory cytokines <Emphasis Type="Italic">in vitro</Emphasis> by human peripheral blood mononuclears of donors and patients with primary immunodeficiency

The production of TNF-α and IFN-α cytokines by peripheral blood mononuclears in response to stimulation by TLR2/6, TLR4, TLR5, TLR9 ligands (zymosan, LPS, flagellin, and CpG-oligodeoxynucleotide, respectively) was studied in donors and patients with common variable immunodeficiency. Individual characteristics of TNF-α production by mononuclears were revealed in donors. Reduced stimulated production of TNF-α in response to stimulation with TLR4 and TLR5 ligands in vitro was detected in patients with common variable immunodeficiency. __________ Translated from Byulleten’ Eksperimental’noi Biologii i Meditsiny, Vol. 144, No. 7, pp. 68–71, July, 2007     

腓总神经卡压综合征的解剖学研究

目的为腓总神经卡压综合征的诊断和治疗提供解剖学资料。方法在50具成人尸体标本上对腓总神经的走行及分支位置等进行了观察和测量。结果腓总神经从坐骨神经分出至小腿之前,走行在致密的胭窝外侧沟和腓管内。胭窝外侧沟的长度为82．5±2．3mm。在腓管内,神经与腓骨颈处的骨膜紧紧相贴,腓管的长度为26．5±1．5mm,腓总神经在腓管内的长度为23．5±1．7mm。腓总神经分为腓浅神经和腓深神经位置,在进入腓管之前者占42％,在腓管内者占58％。结论致密的胭窝外侧沟,以及腓总神经在狭窄的腓管内与腓骨颈处的骨膜紧密相贴,是腓总神经容易受卡压的两处解剖学位置。