Outcomes of endoscopic retrograde cholangiopancreatography in patients with situs inversus viscerum

Background/Aims@#Situs inversus viscerum (SIV) is a congenital condition defined by left-to-right transposition of all visceral organs. This anatomical variant has caused technical challenges in endoscopic retrograde cholangiopancreatography (ERCP). Data on ERCP in patients with SIV are limited to case reports of unknown clinical and technical success rates. This study aimed to evaluate the clinical and technical success rates of ERCP in patients with SIV. @*Methods@#Data from patients with SIV who underwent ERCP were retrospectively reviewed. The data were collected by querying the nationwide Veterans Affairs Health System database for patients diagnosed with SIV who underwent ERCP. Patient demographics and procedural characteristics were collected. @*Results@#Eight patients with SIV who underwent ERCP were included. Choledocholithiasis was the most common indication for ERCP (62.5%). The technical success rate was 63%. Subsequent ERCP with interventional radiology–assisted rendezvous has increased the technical success rate to 100%. Clinical success was achieved in 63% of cases. Among cases of subsequent rendezvous ERCP after conventional ERCP failure, clinical success was achieved in 100%. @*Conclusions@#The clinical and technical success rates of ERCP in patients with SIV were both 63%. In patients with SIV in whom ERCP fails, interventional radiology–assisted rendezvous ERCP can be considered.

The Clinical and Metabolic Effects of Intragastric Balloon on Morbid Obesity and Its Related Comorbidities

Obesity is becoming increasingly prevalent worldwide, and its metabolic sequelae lead to a significant burden on healthcare resources. Options for the management of obesity include lifestyle modification, pharmacological treatment, surgery, and endoscopic bariatric therapies (EBTs). Among these, EBTs are more effective than diet and lifestyle modification and are less invasive than bariatric surgery. In recent years, there have been significant advances in technologies pertaining to EBTs. Of all the available EBTs, there is a significant amount of clinical experience and published data regarding intragastric balloons (IGBs) because of their comparatively long development period. Currently, the United States Food and Drug Administration (FDA) has approved three IGBs, including Orbera (Apollo Endosurgery, Austin, TX, USA), ReShape Duo (ReShape Medical, San Clemente, CA, USA), and Obalon (Obalon Therapeutics, Carlsbad, CA, USA). The aim of this review is to summarize the available literature on the efficacy of IGBs in weight loss and their impact on obesity-related metabolic diseases.

Seasonal Impacts on the Incidence of Esophageal Variceal Hemorrhage: A Nationwide Analysis across a Decade

Background/Aims@#Seasonal variation has previously been reported in relation to the incidence of non-variceal upper gastrointestinal bleeding; however, the impact of seasonal variation on variceal bleeding is not known. @*Methods@#We conducted a cross-sectional study using the Nationwide Inpatient Sample database from 2005 to 2014. International Classification of Diseases, Clinical Modification- 9th Revision codes were used to identify patients hospitalized with a primary or secondary diagnosis of esophageal variceal hemorrhage. The data were analyzed based on the month of hospitalization. Our primary aim was to assess seasonal variations in variceal bleeding-related hospitalizations. The secondary aims were to assess the impact of seasonal variation on outcomes in variceal bleeding including in-hospital mortality and healthcare resource utilization. @*Results@#A total of 348,958 patients hospitalized with esophageal variceal bleeding were included. The highest number of hospitalizations was reported in December (99.3/day) and the lowest was reported in June (90.8/day). In-hospital mortality was highest in January (11.5%) and lowest in June (9.8%). There was no significant difference in hospital length of stay or total hospitalization costs across all months in all years combined. @*Conclusions@#There appears to be a seasonal variation in the incidence and mortality of variceal hemorrhage in the United States. December was the month with the highest number of daily hospitalizations while the nadir occurred in June.

A Nationwide Assessment of the “July Effect” and Predictors of Post-Endoscopic Retrograde Cholangiopancreatography Sepsis at Urban Teaching Hospitals in the United States

BACKGROUND/AIMS: To analyze the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) sepsis in the early (July to September) and later (October to June) academic months to assess the “July effect”. METHODS: The National Inpatient Sample (2010–2014) was used to identify ERCP-related adult hospitalizations at urban teaching hospitals by applying relevant procedure codes from the International Classification of Diseases, 9th revision, Clinical Modification. Post-ERCP outcomes were compared between the early and later academic months. A multivariate analysis was performed to evaluate the odds of post-ERCP sepsis and its predictors. RESULTS: Of 481,193 ERCP procedures carried out at urban teaching hospitals, 124,934 were performed during the early academic months. The demographics were comparable for ERCP procedures performed during the early and later academic months. A higher incidence (9.4% vs. 8.8%, p<0.001) and odds (odds ratio [OR], 1.07) of post-ERCP sepsis were observed in ERCP performed during the early academic months. The in-hospital mortality rate (7% vs. 7.5%, p=0.072), length of stay, and total hospital charges in patients with post-ERCP sepsis were also equivalent between the 2 time points. Pre-ERCP cholangitis (OR, 3.20) and post-ERCP complications such as cholangitis (OR, 6.27), perforation (OR, 3.93), and hemorrhage (OR, 1.42) were significant predictors of higher post-ERCP sepsis in procedures performed during the early academic months. CONCLUSIONS: The July effect was present in the incidence of post-ERCP sepsis, and academic programs should take into consideration the predictors of post-ERCP sepsis to lower health-care burden.

Paraneoplastic pemphigus as a presentation of acute myeloid leukemia: early diagnosis and remission

Skin lesions are frequently encountered in clinical practice which can be a presentation of systemic diseases not excluding an occult malignancy. Commonly reported paraneoplastic dermatologic manifestations include acanthosis nigricans, dermatomyositis, erythroderma, hypertrophic osteoarthropathy, Sweet syndrome, and paraneoplastic pemphigus [PNP]. PNP is a rare autoimmune mucocutaneous disease characterized by severe stomatitis, polymorphic skin eruptions, and associated underlying neoplasms most commonly non-Hodgkin's lymphoma, chronic lymphocytic leukemia, and Castleman disease. PNP is characterized on histopathology as dyskeratotic epithelial cells with acantholysis with a typical immunofluorescence staining pattern of direct and/or indirect staining of intercellular, basement membrane, and dermoepidermal junction with immunoglobulin-G and C3. PNP has been described to have poor prognosis with a mortality range of 75-90% and a mean survival of less than 1 year. We describe a previously unreported case of PNP associated with acute myeloid leukemia [AML] where the patient presented with a nonhealing ulcer and hemorrhagic crusting on the face that did not respond to antimicrobials and steroids. Investigations revealed leukocytosis with peripherally circulating blasts. Skin biopsy revealed an evolving PNP and bone marrow biopsy confirmed evidence of AML. The patient underwent induction, consolidation, and then successful allogenic bone marrow transplantation with complete remission. The skin lesion, which was initially refractory to treatments, surprisingly resolved within 7 days of starting induction chemotherapy. In this case, the skin lesion was a key factor in early diagnosis and instituting treatment for the underlying AML. Early intervention gave our patient a better outcome with an ongoing survival of 18 months since diagnosis, maintaining complete remission

Distal esophageal duplication cyst with gastro-esophageal reflux disease: a rare association and a management challenge

Esophageal duplication cysts are rare congenital abnormalities of the foregut and may be associated with other conditions. Association of esophageal duplication with Gastro-Esophageal Reflux Disease [GERD] has not been reported in children. We are reporting a case of a 16 months baby who had antenatal diagnosis of diaphragmatic hernia. Postnatal CT chest, however, suggested a distal esophageal duplication cyst and a contrast esophagogram showed grade-IV GER. A thoracoscopy in another hospital excluded esophageal duplication at that time. Later, he presented with hematemesis in our department and was re-evaluated. Repeat CT confirmed a persistent 2.5 x 1.3 cm cyst in distal esophagus. Upper GI endoscopy suggested grade-II esophagitis with a wide patent gastro-esophageal junction. The child was treated with left thoracotomy, excision of the duplication cyst and thoracic fundoplication. He had an uneventful post-operative recovery and is doing well at 6 months follow-up

Hand hygiene practices among nursing students: importance of improving current training programs.

Background: Although numerous studies have demonstrated that hand hygiene reduces health care–associated infection rates, adherence to hand hygiene guidelines remains uniformly low among health care workers. The present study was undertaken to assess the hand hygiene practices among the nursing students of Bareilly and to suggest the suitable corrective and preventive measures to be taken in future. Methods: These six months cross sectional study was carried out among the nursing students of Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India. A total of 50 students participated in the study. A structured, self-administered pretested questionnaire was used to collect detailed information about the subjects‟ self-reported hand washing practices. Knowledge was assessed using 25 questions which included multiple choice and “yes” or “no” questions. A scoring system was used where 1 point was given for each correct response to knowledge, positive attitudes and practices and 0 was given for incorrect knowledge, negative attitudes, and poor practices. Data entry and statistical analysis were performed using the Microsoft Excel and SPSS windows version 14.0 software. Results: Majority of the healthcare workers were females (72.0%), were aged between 31-40 years (60.0%) and had received formal training in hand hygiene in the last 3 years (90.0%). A higher proportion of them routinely used alcohol based hand rub (52.0%). Nearly 28% had poor knowledge and 72% had moderate knowledge regarding hand hygiene. Conclusions: The knowledge about good hand washing practices and compliance of the same according to WHO guidelines amongst health care workers is essential for lowering the health care associated infections. Our study shows the importance of improving the current training programs targeting hand hygiene practices among nursing students.

Laparoscopy in urology practice at a tertiary care centre

To describe the results of laparoscopic procedures at a Urology - Nephrology tertiary care centre. Case series / observational study. The Kidney Centre Postgraduate Training Institute, Karachi, from August 2007 to March 2012. Medical records of all planned laparoscopic surgery conducted during the study period were reviewed. Those cases which to open surgery were excluded. All were performed by a single surgeon, initially as supervised and later independently. Data was maintained for demographic data, procedure details, length of hospital stay, and complications including conversion to open surgeries. Data was analyzed through SPSS 17.0. There were 36 planned laparoscopic surgeries in the specified period. Out of 36 cases, 8 were converted to open surgery. Those who underwent laparoscopic surgery include two diagnostic procedures and renal cyst deroofing each, four ureterolithotomy, nineteen simple nephrectomy and one radical nephrectomy. So in total 28 cases were performed on 15 females and 13 males with mean age of 33.01 A +/- 10.9 years. The mean operative time was 216 A +/- 100 minutes and mean length of hospital stay was as 2.7 A +/- 1.04 days. There were 10 complications in 28 cases, majority being Clavien Grade II including 7% [2/28] blood transfusion. There are technical challenges in learning laparoscopy for practicing urologists. Following some learning model in a systematic manner will help surmounting the technical challenges in learning laparoscopy

Influence of gender, BMI, and ethnicity on serum ALT levels of healthy students of a medical school

Alanine Aminotransferase [ALT] is an enzyme found in Liver and indicates injury to Hepatocytes. It is influenced by various factors. The objectives of this study were to identify the correlates of ALT activity among healthy medical students of Army Medical College, National University of Sciences and Technology, aged 18-22 years. This was to establish the mean ALT levels of the students and compare them with those in various parts of the world and observe various correlations that exist and factors that may influence ALT levels. This population included 143 volunteer students [93 men and 50 women] selected on the basis of negative answers to a detailed medical questionnaire including past medical history, drug and alcohol consumption, on the absence of clinical signs of liver disease, on the negativity of serological testing for Hepatitis B and C virus. The mean ALT level of the entire population was 28.7 IU/L. A major sex-difference in ALT value was observed, the mean ALT value being higher in men than in women [32.1 +/- 21.7 vs. 22.6 +/- 9.7 IU/L, p<0.004]. According to WHO criteria for Asians, normal BMI was taken from 18.5-23.0 Kg/m[2]. There was a positive significant correlation between serum ALT level and BMI [p<0.002]. ALT level strongly correlates with body mass index and gender. There was no significant variation in ALT levels among Punjabis and Sindhis, Balochis, Pathans, and Kashmiris. We suggest the need of taking into account these parameters in a clinical interpretation of ALT level

Frequency of fistula formation after two stage repair of cleft palate

To estimate the frequency of fistula formation after two stage repair of cleft palate. A total of 50 patients having completed cleft palate repair with or without lip repair were recruited from December 2007 to February 2009. Patients were diagnosed on history and oral examination. Informed consent was taken from parents. Width of the cleft measured preoperatively. Two stage repairs were done by a single surgeon with a time lapse of six months. Five patients developed clinically significant oronasal fistula. All these fistulas occurred at the junction of hard palate and soft palate within 3 weeks time. The overall rate of true fistula development was 12% over a mean follow up period of 6 months. The incidence of true fistulas that were symptomatic and subsequently required surgical repair was 10%. Fistula rates were higher for more wide clefts but were not affected by gender or age

Awareness of novel h1n1 pandemic influenza among non-medical personnel, medical students and medical professionals

To study the awareness of swine flu among general population, medical students and medical professionals Descriptive study. Place and Duration of Study: Study was carried out in the department of Pathology [Microbiology], Army Medical College, the Military Hospital [MH] and Combined Military Hospital, Rawalpindi, from 17th January 2010 to 24th January 2010. Materials and A total of 519 people were included in this study, 228 were medical students, 181 were doctors and 110 were non health care professionals. A questionnaire with closed questions regarding the awareness of the basics of swine flu was required to be filled by all participants. It was found that the general population was totally unaware to the extent that 1/3rd had never heard of this disease. The survey of medical students showed reasonable knowledge in the senior classes [80-85%] knew the main features of the disease], whereas the 2nd year students had the awareness around 40-45%. Among the medical professionals the knowledge was excellent in the seniors, whereas the trainees and house officers had suboptimal knowledge of swine flu. The result of this study show a significant gap between the seniors specialists and the juniors and this gap warrants immediate bridging. The general public also need to be informed by various means more comprehensively

One stage resection of sigmoid volvulus: an experience of 50 cases

To assess the outcome of one stage resection and primary anastomosis without intraoperative colonic lavage in patients with acute sigmoid volvulus. A prospective, descriptive study was carried out in the Surgical department of Lady Reading Hospital, Peshawar from Jan 2002 to Dec 2003. Fifty patients with sigmoid volvulus were included in the study. Patients with serious co morbidity, hemodynamic instability, gangrenous or compound volvulus on laparotomy were excluded from the study. All the patients were assessed and operated upon by a senior surgeon. Resection of the sigmoid colon and primary anastomosis was done after only manual decompression in all cases. The demographic data, clinical features, radiologic and operative findings, out come of the procedure in terms of postoperative complications and duration of hospital stay were recorded on a proforma. The data was entered and processed on the SPSS 10 version. The patients included 44 males and 6 females. Male to female ratio was 7.3:1. Mean age was 57 years. Most frequent clinical features were abdominal pain, distension and constipation. Postoperatively, superficial wound infection was seen in 14% patients [n=7], transient paralytic ileus in 22% cases [n=11]. Pulmonary complications occurred in 6% patients [n=3]. No deaths or clinical anastomotic leak occurred. Duration of hospital stay ranged from 6-17days [mean 11 days]. Resection of sigmoid colon primary anastomosis can safely be carried out without on-table colonic lavage in selected patients with viable colon