Alpha-1-antitrypsin deficiency resulting in a hitherto unseen presentation of hepatocellular carcinoma： Polycythemia but with normal alpha fetoprotein

Polycythemia is a known paraneopastic manifestation of hepatoma, but only in the presence of alpha-fetopro (AFP). We present a case of polycythemia in the absence of AFP, and suggest concurrent alpha-1-antitrypsin deficiency as the cause for breaking this rule. We also suggest a reason for the apparent constant conjunction between polycythemia and AFP in hepatoma.     

Early experience of laparoscopic ultrasonography in the management of pancreatic carcinoma

Summary A 7.5-MHz linear array ultrasound probe has been developed for the evaluation of solid organs at laparoscopy. Twelve patients with suspected carcinoma of the head of the pancreas, considered at initial investigation to have resectable disease, were submitted to laparoscopy. In 4 patients, diagnostic laparoscopy revealed hepatic metastases (4 patients), peritoneal dissemination of tumor (2), and malignant ascites (1). Laparoscopic ultrasonography demonstrated hepatic metastases in four patients and hepatic cysts in two further patients. Ultrasound evaluation of the pancreas revealed lymphadenopathy (4 patients), local infiltration (2), and portal vein displacement or invasion (4). An anomalous right hepatic artery arising from the superior mesenteric artery was identified in one patient. Overall, laparoscopy identified advanced disease in four patients. Laparoscopic ultrasonography, while detecting advanced disease in a further two patients, predicted resectable disease in six patients (50%). Only one of the six patients submitted to laparotomy was found to have irresectable disease due to lymph-node metastases. Laparoscopic ultrasound examination of the pancreas and liver has improved the early staging of pancreatic carcinoma and should be undertaken at an early stage in the management of such patients.     

Ascaris in the common bile duct: diagnosis by ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) and extraction by balloon catheter.

This is a case report of ascaris worm in the common bile duct in a 61 year old lady. Ultrasound diagnosis was initially made based on the presence of linear hyperreflective foci within the common bile duct. ERCP confirmed a single worm within the duct. Balloon extraction was then successfully carried out following papillotomy. This case illustrates the value of ultrasound in the definitive diagnosis of biliary ascariasis and the therapeutic role of ERCP.     

The role of selective visceral angiography in the management of pancreatic and periampullary cancer

A prospective study was undertaken to evaluate selective visceral angiography (SVA) in the management of patients with pancreatic and periampullary cancer. Over a 30-month period 52 patients with potentially resectable pancreatic or periampullary cancer underwent SVA; 4 patients had obvious angiographic evidence of widely disseminated disease and were not subjected to laparotomy while 2 further patients were eventually considered too frail for resection. The remaining 46 patients (median age 58 years, range 37–73 years, males 26, females 20) had no evidence of disseminated disease on ultrasonography and/or CT scanning and had both SVA and surgery and form the basis of this study. Vascular anomalies were detected in 16/46 (35%) patients. Hepatic metastases were wrongly diagnosed by angiography in 7 out of 9 patients (77%). SVA correctly predicted resectability or irresectability in 28/46 patients (overall predictive value 61%). Of the 27 patients who proved to have irresectable disease at operation, 11 were correctly identified by SVA (sensitivity 41%). Of the 13 patients reported to have irresectable disease, 2 underwent resection (false-positive rate 15%). Of the 33 patients reported to have resectable disease, 16 were irresectable (false-negative rate 48%). Overall there was a poor relationship between resectability and the angiographic features. On the basis of these data, SVA cannot be considered a sufficiently accurate means of assessing resectability. Its use for this purpose in patients with pancreatic and periampullary cancer is not justified.

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Resumen Se realizó un estudio prospectivo con el objeto de valorar la angiografía visceral selectiva (AVS) en el manejo de pacientes con cancer pancreático y periampular. En un período algo mayor de 30 meses se practicó AVS en 52 pacientes con cáncer pancreático y periampular potencialmente resecable; cuatro pacientes presentaban evidencia angriográfica obvia de enfermedad ampliamente diseminada y no fueron sometidos a laparotomía, en tanto que otros dos pacientes fueron eventualmente considerados como muy frágiles para Ilevarlos a resección. El resto, 46 pacientes (edad media 58 años, rango 37 a 73 años, 26 hombres y 20 mujeres), no presentaron evidencia de enfermedad diseminada en ultrasonografia y/o tomografía computadorizada y fueron sometidos a AVS y a cirugía y constituyen el fundamento del estudio. Se detectaron anomalías vasculares en 16/46 (35%) pacientes. Metástasis hepáticas fueron erróneamente diagnosticadas por la angiografía en 7 de 9 pacientes (77%). La AVS predijo correctamente la resecabilidad o la irresecabilidad en 28/46 pacientes (valor global de prediccíon 61%). De los 27 pacientes que probaron poseer enfermedad no resecable durante la operación, 11 fueron correctamente identificados por la AVS (sensibilidad 41%). De los 13 pacientes en que se reportó enfermedad no resecable, dos fueron sometidos a resección tasa de resultados falsos positivos, 15%). De los 33 pacientes en que se reportó enfermedad resecable, 16 probaron ser no resecables (tasa de falsos negativos, 48%). Globalmente se observó una pobre correlación entre la tasa de resecabilidad y las características angiográficas. Con base en estos datos, no se puede considerar la AVS como un método suficientemente certero para determinar resecabilidad ni justificar su uso para tal propósito en pacientes con cáncer pancreático o periampular.

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Résumé L'utilité de l'angiographie viscérale sélective (AVS) a été évaluée rétrospectivemnt dans le traitement des patients ayant un cancer pancréatique ou périampullaire. Pendant 30 mois, 52 patients ayant un cancer du pancréas ou de la région périampullaire ont eu une AVS. Quatre patients avaient des signes évidents de maladie étendue et n'ont pas été opérés alors que deux autres patients ont été considérés comme étant trop fragiles pour subir une telle intervention. Les 46 patients restants (âge médian=58 ans, extrêmes 37 à 73 ans, hommes: 26, et femmes: 20) qui n'avaient aucun signe de maladie disséminée aux examens échographiques et/ou tomodensitométriques, ont eu et une AVS et une intervention et sont l'objet de cette étude. Des anomalies vasculaires ont été détectées chez 16/46 (35%) patients. Des métastases hépatiques ont été diagnostiquées à tort par l'angiographie chez 7 de 9 patients (77%). L'AVS a correctement prédit la résecabilité chez 28/46 patients (valeur prédictive globale=61%). Des 27 patients qui avaient éventuellement une tumeur non résecable, 11 avaient été correctement identifiés par l'AVS (sensibilité=41%). Des 13 patients que l'on pensait avoir un cancer non résecable, deux ont eu une résection (taux de faux positifs=15%). Des 33 patients que l'on pensait avoir un cancer résecable, 16 n'ont pas été réséqués (taux de faux négatifs=48%). Globalement, le rapport entre les signes angiographiques et la résecabilité n'était pas bon. Basé sur ces données, on ne peut considérer que l'ASV soit un bon examen pour évaluer la résecabilité des cancers du pancréas et en particulier de la région périampullaire.

     

YouTube as a source of information on cardiopulmonary resuscitation

Objective

Widespread knowledge of cardiopulmonary resuscitation (CPR) is critical to improving survival in sudden cardiac death. We analyzed YouTube, an Internet video-site which is a growing source of healthcare information for source, content and quality of information about CPR.

Methods

YouTube was queried using keywords “CPR”, “Cardiopulmonary resuscitation”, “BLS” and “Basic life support”. Videos in English demonstrating CPR technique were included. Videos were classified by upload source, content, structure of course, subject for CPR demonstration, etc. Videos were scored for ‘accuracy of demonstration’ of CPR steps on a scale of 0-8 and for ‘viewability’.

Results

Of 800 videos screened 52 met the inclusion criteria with mean duration of 233 (±145) s and view count 37 (±77) per day. 48% (n = 25) videos were by individuals with unspecified credentials. No differences were noted in view count/day, ‘accuracy of demonstration’ and ‘viewability’ among videos based on source. No information was provided about scene safety assessment in 65% (n = 34) videos. Only 69% (n = 31/45) videos demonstrated the correct compression-ventilation ratio while 63.5% (n = 33), 34.6% (n = 18) and 40.4% (n = 21) gave information on location, rate and depth of chest compressions respectively. 19% (n = 10) videos incorrectly recommended checking for pulse.

Conclusion

Videos judged the best source for CPR information were not the ones most viewed. Information on this platform is unregulated, hence content by trusted sources should be posted to provide accurate and easily accessible information about CPR. YouTube may have a potential role in video-assisted learning of CPR and as source of information for CPR in emergencies.