The use of infliximab for treatment of hospitalized patients with acute severe ulcerative colitis.

BACKGROUND/AIM: The use of infliximab in severe ulcerative colitis (UC) is established; however, its role in severe acute UC requires clarification. The present multicentre case series evaluated infliximab in hospitalized patients with steroid-refractory severe UC. METHODS: Patients from six hospitals were retrospectively evaluated. Data collection included demographics, duration of disease and previous treatments. The primary end point was response to in-hospital infliximab; defined as discharge without colectomy. RESULTS: Twenty-one patients (median age 26 years) were admitted between May 2006 and May 2008 with severe UC requiring intravenous steroids and given infliximab (median time to infusion eight days). Sixteen (76%) patients were discharged home without colectomy; three of these underwent colectomy at a later date. Of the remaining 13 patients (62%), all but two did not require further courses of steroids; six patients had infliximab as a bridge to azathioprine and seven patients were maintained on regular infliximab. Five patients required in-hospital colectomy after the initial infliximab. CONCLUSIONS: In this real-life experience of infliximab in patients with steroid-refractory severe UC, infliximab appears to be a viable rescue therapy. The majority of patients were discharged without surgery and 62% maintained response either as a bridge to azathioprine or maintenance infliximab.

Cost-effectiveness in Canada of intravenous proton pump inhibitors for all patients presenting with acute upper gastrointestinal bleeding.

BACKGROUND: The administration of proton pump inhibitors intravenously after endoscopic treatment of peptic ulcers significantly reduces the recurrence of bleeding. AIM: To evaluate the incremental cost-effectiveness in Canada of intravenous proton pump inhibitor before endoscopic therapy to patients presenting with acute upper gastrointestinal bleeding, compared with endoscopic treatment alone. METHODS: From a third-party payer perspective, we modelled the costs and effectiveness over 60 days of the two approaches using decision analysis. The probabilities of various outcomes, such as re-bleeding and the need for surgery, were taken from the published literature. We included the costs of intravenous proton pump inhibitor, therapeutic endoscopy, surgical procedures and hospitalizations, all expressed in 2001 Canadian dollars. RESULTS: In a hypothetical cohort of 1000 patients, the intravenous proton pump inhibitor approach resulted in mean savings of 20,700 Canadian dollars with 37 re-bleeding episodes averted. The investigation of uncertainty resulted in a likelihood of intravenous proton pump inhibitor being cost-effective of at least 0.73. CONCLUSION: It is common in Canada to administer intravenous proton pump inhibitors to patients with upper gastrointestinal bleeding even before endoscopic confirmation of bleeding peptic ulcers. Our results suggest that this approach has a high likelihood of being cost-effective.

Radiologic manifestations of sclerosing cholangitis with emphasis on MR cholangiopancreatography.

Magnetic resonance cholangiopancreatography (MRCP) is a relatively new, noninvasive cholangiographic technique that is comparable with invasive endoscopic retrograde cholangiopancreatography (ERCP) in the detection and characterization of extrahepatic bile duct abnormalities. The role of MRCP in evaluation of the intrahepatic bile ducts, especially in patients with primary or secondary sclerosing cholangitis, is under investigation. The key cholangiographic features of primary sclerosing cholangitis are randomly distributed annular strictures out of proportion to upstream dilatation. As the fibrosing process worsens, strictures increase and the ducts become obliterated, and the peripheral ducts cannot be visualized to the periphery of the liver at ERCP. In addition, the acute angles formed with the central ducts become more obtuse. With further progression, strictures of the central ducts prevent peripheral ductal opacification at ERCP. Cholangiocarcinoma occurs in 10%-15% of patients with primary sclerosing cholangitis; cholangiographic features that suggest cholangiocarcinoma include irregular high-grade ductal narrowing with shouldered margins, rapid progression of strictures, marked ductal dilatation proximal to strictures, and polypoid lesions. Secondary sclerosing and nonsclerosing processes can mimic primary sclerosing cholangitis at cholangiography. These processes include ascending cholangitis, oriental cholangiohepatitis, acquired immunodeficiency syndrome-related cholangitis, chemotherapy-induced cholangitis, ischemic cholangitis after liver transplantation, eosinophilic cholangitis, and metastases.

Pancreatitis complicated by gland necrosis: evolution of findings on contrast-enhanced CT.

PURPOSE: The purpose of this work was to investigate the natural history of pancreatic necrosis on contrast-enhanced CT in patients managed nonoperatively. METHOD: A computer-based radiology information search revealed 32 patients with pancreatic necrosis who had had serial contrast-enhanced CT scans and were managed nonoperatively. There were 23 men and 9 women with a mean age of 51 years. One hundred forty-five contrast-enhanced CT scans were retrospectively reviewed for the location and extent of necrosis. The medical records of all patients were reviewed. RESULTS: The 32 patients had a mean Ranson clinical grade of 5.8 (range 3-8). Eighteen of these 32 patients were managed nonoperatively, and 14 patients required a necrosectomy after initial nonoperative management. In the 32 patients, the location of necrosis was in the head (3), body (6), tail (2), head/body (2), head/body/tail (9), body/tail (9), and head/tail (1). Extent of necrosis was 0-25% (9), 26-50% (6), 51-75% (6), and 76-100% (11). The extent of necrosis remained stable during follow-up in 22 (69%) patients and increased during follow-up in 10 (31%). Necrosectomy was performed in six (60%) patients in whom there was an increase in necrosis and eight (36%) patients in whom necrosis was stable. No patient had restoration of normal enhancement in an area that was previously necrotic. There were five patients who were managed nonoperatively (mean follow-up 318 days) in whom the necrosis eventually resorbed, forming a focal parenchymal cleft reminiscent of a scar. Five of the 32 patients died. CONCLUSION: Pancreatic necrosis as demonstrated by CT tends to remain stable in most patients treated nonoperatively. If the extent of necrosis increases, patients are more likely to require a necrosectomy. In some patients managed nonoperatively, the pancreatic necrosis will resorb, resulting in a fat-replaced cleft reminiscent of a scar.

The role of ERCP in diagnosis and management of accessory bile duct leaks after cholecystectomy.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) plays an important role in the management of bile leaks after cholecystectomy. Although most leaks occur from the cystic duct stump, clinically significant leakage from accessory bile ducts is less common and has not been investigated systematically. We report our experience with endoscopic diagnosis and treatment of accessory bile duct leaks after cholecystectomy. METHODS: Patients with accessory bile duct leaks were identified from a computerized database. Hospital charts and cholangiograms were reviewed to determine the outcome of diagnostic and therapeutic interventions. RESULTS: Of 86 patients with postcholecystectomy leaks, 15 (17%) were diagnosed with accessory bile duct leaks. ERCP established the diagnosis of accessory bile duct leaks in 11 of 15 patients (73%); percutaneous fistulography (2) and percutaneous transhepatic cholangiography (2) were diagnostic in 4 patients. Endoscopic therapy led to resolution of the leak in 12 patients. One patient underwent successful percutaneous biliary drainage, and two patients required surgical repair. CONCLUSIONS: Accessory bile ducts are rare sites of significant bile leakage after cholecystectomy. ERCP identifies the leak in the majority of patients; percutaneous fistulography or percutaneous transhepatic cholangiography may help clarify the diagnosis if ERCP is nondiagnostic. Most patients can be successfully treated with endoscopic stenting. If endoscopic therapy fails, percutaneous drainage or surgical repair needs to be considered.

The factor structure of the Wechsler Adult Intelligence Scale-Revised: one or two but not three factors.

One-, 2-. and 3-factor solutions for the WAIS-R normative samples were examined using principal components analysis with varimax rotations. Factors were examined across age groups by computing congruence coefficients and root mean square differences to determine the equivalence and consistency of factors across age groups. There is strong evidence for the general (g) and 2-factor (verbal and perceptual organization) solutions but noticeably less support for memory/freedom from distractibility in the three-factor solution. Verbal and perceptual organization factors were also attenuated in the three-factor solution. One and 2-factor solutions were essentially equally justifiable but because the 1-factor solution was weighted most heavily with verbal measures, the 2-factor solution may be advantageous because this solution does distinguish between verbal and performance measures.

Immediate antecedents to adolescents' offenses.

The current research examined importance ratings by adolescent offenders of immediate antecedents to their offenses. One hundred and fifteen adolescent offenders consecutively admitted to an inpatient psychiatric unit for court-ordered assessment completed the High Risk Situations Questionnaire for Young Offenders (HRSQ-YO), an instrument designed to assess the self-reported importance of various antecedents to a past, highly salient, offense. Principal components analysis of responses to the 71 items of the HRSQ-YO resulted in three factors which were rotated to a varimax criterion and labelled Negative Affectivity, Delinquency, and Aggressivity. Delinquency factor scores were significantly higher for property offenses than for violent offenses, whereas Aggressivity factor scores were significantly higher for violent offenses than for property offenses. Negative Affectivity factor scores did not differ between property and violent offenses. Implications of the results for relapse prevention approaches to the reduction of recidivism among adolescent offenders are discussed.