Endoscopic retrograde cholangiopancreatography in infants and children with cholestasis

Reports of ERCP in children are still limited. We present an experience with ERCP in 50 consecutive patients of the pediatric group. Children with obstructive jaundice indicated for ERCP are included in this study. ERCP was performed using the Olympus XPJ 230 in children older than one year, whereas in children less than one year old an Olympus PJF fiber duodenoscope was used. ERCP was able to diagnose 17 patients [34%] with choledochal cysts. Nine [18%] cases with choledocholithiasis either associated with hemolytic anemia or not were diagnosed and treated by ERCP [ES and stone extraction]. Fourteen cases with suspicion of EHBA were examined by ERCP and EHBA was diagnosed in 5 main out of 6 patients. In eight patients ERCP examination revealing normal biliary ductal system was very helpful and exploratory laparotomy to exclude EHBA was avoided. Two cases with parasitic worms obstructing the CBD were diagnosed by ERCP and treated also by ES and worm extraction by basket. Three cases of Caroli's disease [intrahepatic biliary radicles dilatation] were also diagnosed by ERCP and drainage of the IHBR also achieved by ES and internal biliary prosthesis placement in two of these patients. One case with sclerosing cholangitis was confirmed by ERCP. Biliary obstruction by thick inspissated bile was diagnosed and treated by ERCP in one case. Two postoperative obstruction of biliary system one case an old blocked stent was removed. The other case was diagnosed with ligated CBD and was sent back for revision of surgery. One case with congenital hepatic fibrosis and dilated IHBR on ultrasound was examined by ERCP which showed no IHBR dilatation and therefore excluding associated Caroli's disease. Only two cases with mild post ERCP, cholangitis and pancreatitis. ERCP is an important diagnostic modality in infants and children with cholestasis offering valuable detailed information on the biliary and pancreatic ductal system and it has the advantage over MRCP and CT in offering diagnostic as well as therapeutic capabilities, with very minimal complications

[Critical appraisal of the submitted theses by medical students of Rafsanjan medical school during 1993- 2003]

Submitting thesis is one of the most important tasks of medical students. Moreover medical theses can be considered as a basic source for improving the health statues of the society. The aim of this study was critical appraisal of the submitted theses by medical students of Rafsanjan Medical School during 1993- 2003.In the present cross- sectional study, 332 Medical theses were evaluated by using a questionnaire. Data analysis was done by using simple descriptive methods and Chi- square test.According to the results, 258 theses [77.7%] have been well written. Theses submitted during the recent years had better quality comparing to others [92.4% versus 73.9%]. Theses supervised by more than one leader were better in comparison to those with only one leader [91.5% versus 73.9%, P= 0.002]. Moreover theses with at least one advisor had a better quality than those conducted without any advisor [88.4% versus 39.7%, P= 0.0001].Better quality of theses submitted during the recent years can show the beneficial effect of participation of both medical students and their supervisors in Research Methodology Workshops held in the recent years. This fact has also been reported in other studiesSubmitting thesis is one of the most important tasks of medical students. Moreover medical theses can be considered as a basic source for improving the health statues of the society. The aim of this study was critical appraisal of the submitted theses by medical students of Rafsanjan Medical School during 1993- 2003.In the present cross- sectional study, 332 Medical theses were evaluated by using a questionnaire. Data analysis was done by using simple descriptive methods and Chi- square test.According to the results, 258 theses [77.7%] have been well written. Theses submitted during the recent years had better quality comparing to others [92.4% versus 73.9%]. Theses supervised by more than one leader were better in comparison to those with only one leader [91.5% versus 73.9%, P= 0.002]. Moreover theses with at least one advisor had a better quality than those conducted without any advisor [88.4% versus 39.7%, P= 0.0001].Better quality of theses submitted during the recent years can show the beneficial effect of participation of both medical students and their supervisors in Research Methodology Workshops held in the recent years. This fact has also been reported in other studies

Laryngeal tube, laryngeal mask airway and endotracheal tube in difficult intubation: a comparative study

Forty five patients, ASA physical status I and II were studied. They were scheduled for elective surgical procedures in supine or lithotomy positions, in which neuromuscular blockade was part of anesthetic technique and the use of laryngeal mask airway [LMA] was appropriate. They were classified as Mallampati class 3 or 4. Exclusion criteria included: cardiovascular, respiratory disorders, morbid obesity, esopilageal reflux, hiatus hernia, any contraindication of inhalatinn induction of anesthesia and diseases of the neck. The patients were randomly divided lhto tIlrbb groups, 15 patients each, according to the intubating device: Group I [n=15]: endotracheal tube [ETT] [Control group], Group II: [LMA] and Group III: laryngeal tube [LT]. Each patient received 0.2mg Atropine Sulfate, no other pre-medication was given. After pre-oxygenation, anesthesia was induced using Volatile Induction and Maintenance Anesthesia [VIMA], N2O:O, [1:1] in sevoflurane concentrations- increased from I MAC by I %, gradually, until there is loss of lash reflex, relaxation of jaw, absence of movement, and absent response to painful stimulus. ETT was inserted using the laryngoscope. The classic LMA was inserted according to the manufacturer's instruction manual. Size 3 was used in the females and size 4 for males. The LT was inserted according to manufacturer's instructions, size 3 was used for patients less than 155 cm, a size 4 for those between 155-180 cm, and size 5 for those taller than 180 cm. Systolic and diastolic arterial pressure [SAP, DAP], and heart rate [HR] were recorded; before induction, and before insertion of the ETT or airway device, and 1,5,10 and 15 min after airway cotablishment and before reversal of the residual muscle relaxant effect. Blood samples were collected before induction, 1,5,10 and 15 min after intubation or insertion of the airway device and just before extubation/removal of the device: to determine plasma epinephrine, norepinephrine and cortisol levels. There were no significant demographic differences between the three groups. The duration of insertion of the ETT was relatively the longest [29.2+/-11.7 sec], compared to the LT [17.7+/-4.6] which was the shortest. Airway pressure was 22.7+/-4.3 cm H20 in case of ETT, 17.6+/-8.1 in LMA and 29.3+/-5.1 in LT. Ventilation was excellent in case of ETT. In LMA, ventilation was excellent in 5 cases, it in 3, fair in 4 and poor in 3 patients. In case of LT [Group III], ventilation was excellent in 9 cases, good in 4, fair in I and poor in I patient. In EU, [GI], HR increased from 64.3+/-11.7 before induction to 97.1+/-9.4, and reached 101.5+/-8.7 just before extubation. In LMA it was 69.6+/-9.4 after introduction of device, compared to 62.9+/-9.1 in case of LT. just before removal of the device; HR in LMA was 81.6+/-17.4 and 83.2+/-11.2 in LT. In case of ETT there was an increase SBP. DBP tip to [143 +/- 19 and 93 +/- 15 mmHg] 1mm after intubation, [141+/-21 and 91+/-12 mmHg] before extubation respectively. This increase was higher than that detected with the insertion of LMA [127+/-12 and 74+/-11mmHg] and LT [115 +/-7 and 65 +/- 16 mmHg]. Just before removal of airway devices SBP and DBP reached [126+/-13 and 80+/-15 mmHg] with LMA and [119+/-15 and 73+/-14 mmHg]. The mean maximal epinephrine and norepinephrine plasma concentrations after insertion of the ETT [51.3+/- 23.3 and 248+/-83pg/mL] respectively. LMA [22.1+/- 11.2 and 163+/-63 pg/mL, respectively] and LT [23.1+/- 17.4 and 153+/- 67pg/mL, respectively]. Just before extubation they reached [81.4+/-22.5 and 363+/-82 pg/mL] in ETT group, [47.1+/-26.2 and 246+/-78 pg/mL] in LMA group and [43.6+/-24.6 and 233+/-66 pg/mL] in LT. Plasma cortisol reached up to 403+/-21 nmo/L 1 min after intubation in ETT, 342+/-19 nmo/L in LMA group, and 348+/-13 nmo/L in LT group. Just before extubation plasma cortisol was 613+/-41 nmo/L in ETT [Group I 363+/-23 nmo/L and 371+/-13 nmo/L in LMA and LT groups respectively