Early repeat endoscopic retrograde cholangiopancreatography: Predictive factors and interventions required

Background/aims: Early repeat endoscopic retrograde cholangiopancreatography may be required due to various conditions in patients who underwent planned endoscopic retrograde cholangiopancreatography. We aimed to assess the factors leading to early repeat endoscopic retrograde cholangiopancreatography and to determine the patients who need closer follow-up. Materials and Methods: A total of 691 patients with a mean age of 60.3±16.4 years who had naive papilla on endoscopic retrograde cholangiopancreatography were involved in the study. The patients who required repeat endoscopic retrograde cholangiopancreatography were identified. Presentations, predictive factors, treatment modalities, and outcomes of the patients were investigated. Results: Early repeat endoscopic retrograde cholangiopancreatography was needed in 19 (2.7%) patients. The most common presentation was cholangitis in 10 (52.6%) and unresolved jaundice in 4 (21.1%). Multivariate analysis identified biliary stricture (p=0.024), stricture at the hilus (p=0.005) and unilateral drainage in the presence of hilar stricture (p=0.017) as the independent risk factors for early repeat endoscopic retrograde cholangiopancreatography. Stent migration or dysfunction was the most common underlying cause. Therapeutic interventions were nasobiliary drainage in 13, stent exchange in 4 and stone removal in 2. Additionally, percutaneous drainage in 4 patients, drainage of abscess in 2 patients and percutaneous drainage of gallbladder in 1 patient were performed. Three patients died due to their underlying illness. Conclusions: Unilateral stenting especially in hilar strictures is a predictive factor for early repeat endoscopic retrograde cholangiopancreatography with high mortality. These patients should be under close follow-up.     

Endovascular management of traumatic arterial emergencies: A single center retrospective study

Objectives: To present our experience in delivering endovascular therapies for emergent vascular traumas with various vascular structures. Methods: Between September 2013 and February 2018, patients who underwent endovascular intervention due to penetrating, blunt and iatrogenic arterial traumas were analyzed, retrospectively. Demographic data, trauma site, mechanism of injury, angiographic findings or arterial injury patterns, treatment methods, and outcomes were recorded. Results: A total of 30 patients were included. The mean age of patients was 39 years (range: 15-87 years). Arterial trauma locations were in the compressible area with a rate of 43％ (n=13) and in the noncompressed area with a rate of 57％ (n=17). Mechanisms of injuries were blunt [53％ (n=16)], penetrating [17％ (n=5)], and iatrogenic [30％ (n=9)]. The most common indication for endovascular treatment was blunt noncompressible injury (n=12). Methods used for treatment were stent-graft (46％, n=14) and coil embolization (54％, n=16). Immediate success was obtained in all procedures. The mean follow-up duration was 5 months (range: 1-12 months). Conclusions: Endovascular treatments performed in traumatic arterial emergencies are effective and minimally invasive with very low complication rates even in hemodynamically unstable patients.     

A procedure for evaluation of non-invasive blood pressure simulators

Non-invasive blood pressure (NIBP) simulators are used in clinical environment for quick checks of blood pressure monitors as a part of technical maintenance and health-care quality assurance system. They are also included in various tests within the procedures for testing NIBP monitors. In practice simulators are often subject to mechanical and electromagnetic shocks which could effect their measuring function. Our objective was to design a procedure for testing the reliability and quality of simulators in order to ensure reliable testing of NIBP monitors. Procedure for evaluation of NIBP simulators, consisting of a static and dynamic test, is proposed. Static test consisted of procedures derived from common electro-mechanical manometer calibration, while dynamic test included testing of repeatability of simulator’s output. A commercial simulator was tested. Among others, the results indicated that evaluations of NIBP simulators should be performed regularly with a suitable time interval in order to track the metrological quality of the simulator in time. Acceptance criteria for a reliable simulator in both static and dynamic sense are proposed.     

Comparison of endotracheal tube cuff pressure values before and after training seminar

It is recommended that endotracheal cuff (ETTc) pressure be between 20 and 30 cm H₂O. In this present study, we intend to observe average cuff pressure values in our clinic and the change in these values after the training seminar. The cuff pressure values of 200 patients intubated following general anesthesia induction in the operating theatre were measured following intubation. One hundred patients whose values were measured before the training seminar held for all physician assistants, and 100 patients whose values were measured after the training seminar were regarded as Group 1 and Group 2, respectively. Cuff pressures of both groups were recorded, and the difference between them was shown. Moreover, cuff pressure values were explored according to the working period of the physician assistants. There was no significant difference between the groups in terms of age, gender and tube diameters. Statistically significant difference was found between cuff pressure values before and after the training (p?<?0.001). Average pressure measure for Group I was 54 cm H₂O, while average pressure in Group II declined to 33 cm H₂O. It was observed that as the working period and experience of physician assistants increased, cuff pressure values decreased, however no statistically significant different was found (p?<?0.375). We believe that clinical experience does not have significant effects on cuff pressure and that training seminars held at intervals would prevent high cuff pressure values and potential complications.     

The Metric Features of Teeth in Female-to-Male Transsexuals

The aim of the study was to evaluate the odontometric characteristics of female-to-male transsexuals (FtM) in comparison to control groups of males and females. A total of 48 FtM, aged 20–28 years, were studied. For each tooth, two standard measurements were taken: the mesiodistal (MD) and the buccolingual (BL) diameter of the crown. Significant differences between males and females were found in BL measures of all maxillary teeth as well as mandibular lateral incisor and canine. Within the MD measures, the most distinguishing were maxillary and mandibular canines and the first molars. For seven teeth, there were a total of 14 comparisons of MD (half for the maxilla and half for the mandible) between the control men and women. Of these, the men had larger diameters for 12, of which four were statistically significant. There were also a total of 14 comparisons of BL diameter; of these, the men had larger diameters for 13, of which nine were statistically significant. For seven teeth, there were a total of 14 comparisons of MD between the control men and the FtM. Of these, the men had larger diameters for 12, of which seven were statistically significant. There were also 14 comparisons of BL; of these, the men had larger diameters for 10, of which six were statistically significant. For seven teeth, there were a total of 14 comparisons of MD between the control women and the FtM. Of these, the women had larger diameters for nine, of which three were statistically significant. There were also a total of 14 comparisons of BL; of these, the FtM had larger diameters for 13, of which five were statistically significant. Our study revealed that the shift of values of metric features in teeth of FtM towards males was more frequent in the more sexually dimorphic BL diameters characterized by significantly greater width of the crown of five teeth: maxillary canine, first and second molars, as well as mandibular incisors. The results showed intermediate status of female-to-male transsexuals’ teeth between the males and females, which may suggest a genetic basis of transsexualism.     

Integrating quantitative and qualitative methodologies for the assessment of health care systems: emergency medicine in post-conflict Serbia

Background  

Due to the complexity of health system reform in the post-conflict, post-disaster, and development settings, attempts to restructure health services are fraught with pitfalls that are often unanticipated because of inadequate preliminary assessments. Our proposed Integrated Multimodal Assessment - combining quantitative and qualitative methodologies - may provide a more robust mechanism for identifying programmatic priorities and critical barriers for appropriate and sustainable health system interventions. The purpose of this study is to describe this novel multimodal assessment using emergency medicine in post-conflict Serbia as a model.     

Dissociable effects of acetylcholinesterase inhibitors and phosphodiesterase type 5 inhibitors on object recognition memory: acquisition versus consolidation

Rationale Phosphodiesterase enzyme type 5 (PDE5) inhibitors and acetylcholinesterase (AChE) inhibitors have cognition-enhancing properties. However, it is not known whether these drug classes affect the same memory processes.Objective We investigated the memory-enhancing effects of the PDE5 inhibitor sildenafil and AChE inhibitors metrifonate and donepezil in the object recognition task to find out whether acquisition or consolidation processes were affected by these drugs.Methods The object recognition task measures whether rats remembered an object they have explored in a previous learning trial. All drugs were given orally 30 min before or immediately after learning to study acquisition and consolidation, respectively.Results Sildenafil given immediately after the first trial improved the memory performance after 24 h and resulted in an inverted U-shaped dose–effect curve with the peak dose at 3 mg/kg. When given before the first trial, sildenafil also improved the memory performance. However, the dose needed for the best performance under this condition was 10 mg/kg, suggesting that the dose–effect curve shifted to the right. This can be explained by the metabolic clearance of the high dose of sildenafil. Donepezil had no memory improving effect when given after the first trial. However, when given before the first trial, a gradually increasing dose–effect curve was found which had its maximum effect at the highest dose tested (1 mg/kg). Likewise, only when metrifonate (30 mg/kg) was given before the first trial did rats show an improved memory performance.Conclusion Our data strongly suggest that PDE5 inhibitors improve processes of consolidation of object information, whereas AChE inhibitors improve processes of acquisition of object information.     

Late onset spondyloarthropathy mimicking polymyalgia rheumatica

We report a 55-year-old woman with late onset spondyloarthropathy who had widespread body pain and pitting oedema of both ankles. She had been followed up for polymyalgia rheumatica for nearly 10 years. On laboratory examination, ESR: 62 mm/h and CRP: 16.1 mg/dl. HLA was positive. There was tenderness on both of her ankles. We diagnosed late onset spondyloarthropathy according to clinic and radiographic findings. The patient was treated with sulphasalazine 200 mg/day and indomethacin 100 mg/day. As a conclusion, LoSPA may mimic a variety of rheumatic conditions such as PMR and reflex sympathetic dystrophy syndrome. Careful examination should be warranted in such conditions.     

The advantages of live/real time three-dimensional transesophageal echocardiography during assessments of pulmonary stenosis

This report sought to compare live/real-time three-dimensional transesophageal echocardiography (3D-TEE) with two-dimensional transesophageal echocardiography (2D-TEE) and to determine whether there are advantages to using 3D-TEE on patients with pulmonary stenosis (PS). Sixteen consecutive adult patients (50 % male and 50 % female; mean age 33 ± 13.4 years) with PS and indications of TEE were prospectively enrolled in this study. Following this, initial 2D-TEE and 3D-TEE examinations were performed, and 3D-TEE images were analyzed using an off-line Q-lab software system. Finally, the 2D-TEE and 3D-TEE findings were compared. In the present study, 3D-TEE allowed us to obtain the en face views of pulmonary valves (PVs) in all but one patient. While this patient was without a PV due to a previous tetralogy of Fallot operation, we could detect the type of PV in the other 15 (93.7 %) patients by using 3D-TEE. Due to poor image quality, the most stenotic area was not measurable in only one (6.2 %) of the patients. In eight (50 %) of the patients, severity and localization of stenosis were more precisely determined with 3DTEE than with 2D-TEE. The PVs’ maximal annulus dimensions were found to be significantly larger when they were measured using 3D modalities. This study provides evidence of the incremental value of using 3D-TEE rather than 2D-TEE during assessments of PS, specifically in cases where special conditions (pregnancy, pulmonary regurgitation, and concomitant atrial septal defects) cause recordings of the transvalvular peak gradient to be inaccurate. Therefore, 3D-TEE should be used as a complementary imaging tool to 2D-TEE during routine echocardiographic examinations.     

The evaluation of myomectomies performed during cesarean section in our clinic

Background:

We evaluated the data of patients who had applied myomectomy during cesarean section operation in our clinic between April, 2008 and December, 2010. Objective: I0 n this period, 3689 cesarean sections were done in our clinic, we analyzed their data retrospectively and determined 27 myomectomy cases during cesarean section operation. The age of the patients, the numbers of pregnancy, parities, the rates of abortus, indications of cesarean, pregnancy weeks, residential areas of myoms detected during the cesarean and their size, were recorded. Furthermore, pre-operative and post-operative hemoglobin (Hb) values, differences between hemoglobin values, whether there was bleeding or not, the need of blood transfusion if it occurred, the duration of operation and hospitaization and the pathological diagnoses of myomectomy materials, were examined.

Materials and Methods:

Retrospective study of myomectomies.

Results:

The mean age of patients was 29.6±5.9 (19-42) and mean gestational age was 39.2±1.0(37-42) weeks. The mean size of the fibroids was 5.94±6.29 cm³ (0.96-26.50 cm3). Subserous myoms were the most frequently seen ones (24 of 27 patients=89%) with fundal, corporal localizations in most of the instances. T0 he pre-operative and post-operative values of Hb were 11.8±1.52 (8.6-10.5) and 10.3±2.6 (6.9-13.3) g/dl respectively and the difference was statistically significant (P<0.001). Blood transfusion was not necessary in any patient. The mean duration of the operation was found to be 40.7±13.9 (13-60) minutes.

Conclusion:

Myomectomies can be performed safely during cesarean section by experienced obstetricians and gynecologists, and myomectomy performed for fibroids in appropriate localizations does not increase post-operative bleeding or maternal morbidity or mortality.