The Cuffless Blood Pressure Measurement with Multi-dimension Regression Model based on Characteristics of Pulse Waveform.

According to the advancement of wearable technology, many physiological monitoring instruments are gradually converted into wearable devices. But, the blood pressure monitor still is a cuff-type device in the consumer market, which also does not do the beat-by-beat continuous blood pressure measurement. Now, the cuffless blood pressure measurement has been developed based on the pulse transit time (PTT) but its accuracy is not better. According to the cardiac hemodynamic theorem, the blood pressure relates with the arterial characteristics. Therefore, the purpose of this study was to use the characteristics of the pulse wave measured by photoplethysmography (PPG) to estimate the blood pressure with a multi-dimension regression model. The contour of pulse wave includes some characteristics of the artery. There were 10 subjects participating the experiment, and the blood pressure of the subject was changed by the exercise. The results showed that the cumulate root mean square error of the estimated systolic and diastolic pressures with the multi-parameters were 69.3 mmHg and 39.8 mmHg were better than only using one parameter, PTT, 82.1 mmHg and 45.2 mmHg, respectively.

A composite of exhaled LTB4 , LXA4 , FeNO, and FEV1 as an "asthma classification ratio" characterizes childhood asthma.

BACKGROUND: Aberrant generation of eicosanoids is associated with asthma, but the evidence remains incomplete and its potential utility as biomarkers is unclear. Major eicosanoids in exhaled breath condensates (EBCs) were assessed as candidate markers for childhood asthma. METHODS: Ten exhaled eicosanoid species was evaluated using ELISA in the discovery phase, followed by prediction model-building and validation phases. RESULTS: Exhaled LTB4 , LTE4 , PGE2, and LXA4 showed significant difference between asthmatics (N = 60) and controls (N = 20). For validation, an expanded study population consisting of 626 subjects with asthma and 161 healthy controls was partitioned into a training subset to establish a prediction model and a test sample subset for validation. Receiver operating characteristic (ROC) analyses of the training subset revealed the level of exhaled LTB4 to be the most discriminative among all parameters, including FeNO, and a composite of exhaled LTB4 , LXA4 , together with FeNO and FEV1 , distinguishing asthma with high sensitivity and specificity. Further, the Youden index (J) indicated the cut point value of 0.598 for this composite of markers as having the strongest discriminatory ability (sensitivity = 85.2% and specificity = 83.6%). The predictive algorithm as "asthma classification ratio" was further validated in an independent test sample with sensitivity and specificity being 84.4% and 84.8%, respectively. CONCLUSIONS: In a pediatric study population in Taiwan, the levels of exhaled LTB4 , LTE4 , LXA4, and PGE2 in asthmatic children were significantly different from those of healthy controls, and the combination of exhaled LTB4 and LXA4 , together with FeNO and FEV1 , best characterized childhood asthma.

Longitudinal investigation of nasopharyngeal methicillin-resistant Staphylococcus aureus colonization in early infancy: The PATCH birth cohort study.

OBJECTIVES: The study aimed to determine the long-term Staphylococcus aureus colonization patterns and strain relatedness, and the association between maternal and infant colonization in infancy. METHODS: A birth cohort study was conducted from January 2012 to November 2014. Nasopharyngeal swabs for S. aureus detection were collected from infants at the age of 1, 2, 4, 6 and 12 months and from mothers when their children were 1-month-old. RESULTS: In total, 254 samples were collected at each planned visit during the first 12-month study. The prevalence of S. aureus colonization decreased in the first year of life, ranging from 61.0% (155/254) at the age of 1 month to 12.2% (31/254) at 12 months. Persistent colonization, defined as a positive culture on four or five occasions, was detected in only 13.8% (35/254) of carriers. Most of the persistent carriers were colonized with methicillin-resistant S. aureus (MRSA) only, and among persistent MRSA carriers, 61.1% (11/18) had indistinguishable genotypes. Of the mothers with MRSA colonization, 77.1% (27/35) had infants who were concomitantly colonized at the age of 1 month; 70.4% (19/27) of the infant-mother paired isolates belonged to indistinguishable or related subtypes, which suggests that surrounding carriers, probably their mothers, may be the possible source for MRSA acquisition in early infancy. CONCLUSIONS: Staphylococcus aureus colonization including MRSA was commonly observed in our cohort. Strains of persistent MRSA among infant-mother pairs were usually of indistinguishable genotypes. Therefore, horizontal spread within households is possibly an important factor related to infant MRSA colonization.

Tobacco smoke exposure and multiplexed immunoglobulin E sensitization in children: a population-based study.

BACKGROUND: Although there is evidence that exposure to tobacco smoke is harmful to children's respiratory health, the effects of tobacco smoke exposure on the regulation of immunoglobulin E (IgE)-mediated immune responses to specific allergens remain unclear. This study aimed to investigate the relationship between objectively assessed tobacco smoke exposure and specific IgE profiles for a broad spectrum of allergens in a population setting. METHODS: Children aged 5-18 years (N = 1315) were assessed using serum cotinine measurement and microarray-based multiplexed detection of specific IgE against 40 allergens. RESULTS: Serum cotinine levels were positively associated with sensitization to foods (adjusted odds ratio [AOR] = 4.95; 95% CI: 1.59-15.34), cockroaches (AOR = 3.77; 95% CI: 1.49-9.51), and pollen (AOR = 2.84; 95% CI: 1.20-6.73) while the association was borderline significant for animals (AOR = 2.53; 95% CI: 0.92-6.93). No associations were found for sensitization against mites, mold, and latex. When considering the degree of allergic sensitization, serum cotinine levels were positively correlated to the number of sensitization to cockroaches (P = 0.004), pollen (P = 0.006), and foods (P < 0.001), with statistically significant positive dose-response relationships (all P < 0.01). Similar results were observed when summing up specific IgE concentrations for the aforementioned allergen categories. CONCLUSIONS: The association between tobacco smoke exposure and IgE sensitization to environmental allergens varies for different allergens among children. This study demonstrates that elevated serum cotinine levels are significantly associated with IgE sensitization to cockroaches, grass pollen, and certain foods, with potential dose-dependent relationships.

Associations of depression with impaired glucose regulation, newly diagnosed diabetes and previously diagnosed diabetes in Chinese adults.

AIM: To examine the association between depression and impaired glucose regulation, newly diagnosed diabetes and previously diagnosed diabetes in middle-aged and elderly Chinese people, and whether depression was associated with different treatment regimens or durations of diabetes. METHODS: A cross-sectional study was performed among 229,047 adults living in the community aged ≥ 40 years from 25 centres in China. The self-reported depression rating scale Patient Health Questionnaire 9 (PHQ-9) was used to diagnose probable and sub-threshold depression. Glucose metabolism status was determined according to World Health Organization 1999 diagnostic criteria. RESULTS: The numbers of participants with normal glucose regulation, impaired glucose regulation, newly diagnosed diabetes and previously diagnosed diabetes were 120,458, 59,512, 24,826 and 24,251, respectively. The prevalence of sub-threshold depression in the total sample of participants was 4.8% (4.8%, 4.8%, 4.4% and 5.6% from normal glucose regulation to previously diagnosed diabetes, respectively), and the prevalence of probable depression was 1.1% (1.1%, 1.0%, 0.9% and 1.8% from normal glucose regulation to previously diagnosed diabetes, respectively). Compared with participants with normal glucose regulation, those with previously diagnosed diabetes had increased odds of probable depression [odds ratio (OR) = 1.61, 95% confidence interval (CI) 1.39-1.87] and sub-threshold depression (OR = 1.14, 95% CI 1.06-1.24), after adjustment for multiple confounding factors. Newly diagnosed diabetes or impaired glucose regulation was not associated with depression. Among those with previously diagnosed diabetes, insulin treatment was associated with greater odds of depression compared with no treatment or oral anti-diabetic medicine. CONCLUSION: Previously diagnosed diabetes, but not newly diagnosed diabetes or impaired glucose regulation, was associated with a higher prevalence of depression. Patients receiving insulin were more likely to have depression than those not receiving treatment or being treated with oral anti-diabetic medicine.

Multiplexed immunoglobulin E sensitization in relation to exhaled nitric oxide in a population sample of children.

This study investigated the relationship between the specific immunoglobulin E (IgE) profile for 40 allergens using a novel microarray technique (BioIC) and fraction of exhaled nitric oxide (FeNO) in a population sample of 1321 children. Significant positive associations were found between FeNO and sensitization to mites (P < 0.001), animals (P = 0.001), cockroaches (P < 0.001), and foods (P = 0.042), and furthermore, between FeNO and the number of sensitizations (all P < 0.05) or the sum of specific IgE (all P ≤ 0.01) against the aforementioned allergen categories. Specifically, sensitization to the following allergens was significantly related to higher FeNO: Dermatophagoides pteronyssinus, Dermatophagoides farina, Blomia tropicalis, cat, German cockroach, Oriental cockroach, codfish, crab, shrimp, and cheese (all P ≤ 0.01). In conclusion, IgE sensitization to mites, pets, cockroaches, seafood, and cheese, respectively, is significantly associated with elevated FeNO levels in a dose-dependent fashion in children. Our results provide new evidence that sensitization to certain food allergens may contribute to prompt inflammation in the airways.

Interactions between two magnetohydrodynamic Kelvin-Helmholtz instabilities.

Kelvin-Helmholtz instability (KHI) driven by velocity shear is a generator of waves found away from the vicinity of the velocity-shear layers since the fast-mode waves radiated from the surface perturbation can propagate away from the transition layer. Thus the nonlinear evolution associated with KHI is not confined near the velocity-shear layer. To understand the physical processes in multiple velocity-shear layers, the interactions between two KHIs at a pair of tangential discontinuities are studied by two-dimensional magnetohydrodynamic simulations. It is shown that the interactions between two neighboring velocity-shear layers are dominated by the propagation of the fast-mode waves radiated from KHIs in a nonuniform medium. That is, the fast-mode Mach number of the surface waves M(Fy), a key factor of the nonlinear evolution of KHI, will vary with the nonuniform background plasma velocity due to the existence of two neighboring velocity-shear layers. As long as the M(Fy) observed in the plasma rest frame across the neighboring velocity-shear layer is larger than one, newly formed fast-mode Mach-cone-like (MCL) plane waves generated by the fast-mode waves can be found in this region. As results of the interactions of two KHIs, reflection and distortion of the MCL plane waves generate the turbulence and increase the plasma temperature, which provide possible mechanisms of heating and accelerating local plasma between two neighboring velocity-shear layers.

Synthesis of La0.6Nd0.2Na0.2MnO3 nanowire and its magnetism.

The colossal magnetoresistance (CMR) manganite La0.6Nd0.2Na0.2MnO3 nanowires were synthesized in porous anodic alumina oxide (AAO) membrane via the sol-gel template route. X-ray diffraction (XRD) results of La0.6Nd0.2Na0.2MnO3/AAO composites verified the purity of the perovskite structure of La0.6Nd0.2Na0.2MnO3. Field emission scanning electron microscopy (FE-SEM) confirmed that the monodisperse cylindrical pores of alumina membrane were filled with manganite nanowire arrays. The nanowires were found to be essentially polycrystalline materials by high-resolution transmission electron microscope (HRTEM) images and selected electron diffraction (SAED) analysis. The Curie temperature of the La0.6Nd0.2Na0.2MnO3 nanowires determined by superconducting quantum interference device (SQUID) was much less than the the Curie temperature of the bulk material. According to our experimental results, we proposed the single domain size should be less than 50 nm conservatively. The result suggested that the finite size effect may play an important role in the reduction of the Curie temperature of the La0.6Nd0.2Na0.2MnO3 nanowires.

Validity of symptoms and radiographic features in predicting positive AFB smears in adolescents with tuberculosis.

SETTING: A cohort of 78 adolescents was selected for evaluation with culture or histologically proven pulmonary tuberculosis (PTB) from a tertiary paediatric facility in northern Taiwan. OBJECTIVE: To assess the validity of clinical features and radiographic findings for predicting positive smears of acid-fast bacilli (AFB) in adolescents with PTB. DESIGN: A retrospective descriptive study of adolescents with a confirmed diagnosis of PTB. Clinical symptoms and chest radiographs were assessed. Univariate analysis identified risk factors suggestive of a positive AFB smear, and the adjusted odds ratio (aOR) for these features was calculated using logistic regression. RESULTS: Patients who were AFB smear-positive and those who were smear-negative differed significantly on univariate analysis (P < 0.05) with respect to chronic cough, haemoptysis, multilobar or superior segment of lower lobe involvement, cavitations or presence of pleural effusions. Logistic regression analysis revealed that risk factors of positive smear in adolescents with PTB were chronic cough >4 weeks (aOR 13.8, 95%CI 2.3-83.1), lower lobe involvement (aOR 12.6, 95%CI 1.2-134.8) and pulmonary cavitations (aOR 7.7, 95%CI 1.0-57.7). CONCLUSIONS: For adolescents with PTB, those suffering from chronic cough for >4 weeks, with involvement of the superior segment of the lower lobe or with cavitary lesions, have a greater likelihood of transmitting tuberculosis due to smear positivity.

Peri-implant and systemic release of metallic elements following insertion of a mandibular modular endoprosthesis in Macaca fascicularis.

The aim of this study was to assess the release of metal elements from a Ti6Al4V modular endoprosthesis for mandibular reconstruction. Ten monkeys were included, seven of the animals had an endoprosthesis inserted and three served as controls. Mucosa, regional lymph nodes and distant organs, were assessed after the implant had been in place for 12 months, using light (LM) and transmission electron microscopy (TEM) and inductively coupled plasma optical emission spectroscopy (ICP). Blood was also drawn from all animals for elemental analysis using ICP. LM and TEM evaluation showed no detectable metal particles in the mucosa surrounding the endoprosthesis, nor in the regional lymph nodes and distant organs. Blood analysis revealed that titanium and vanadium were detectable in comparable amounts in the test (Ti: 1.63+/-0.54, Va: 0.42+/-0.08) as well as in the control group (Ti: 2.07+/-0.55, Va: 0.37+/-0.07). The amount of aluminum appeared to be higher in the control group (31.77+/-11.67) compared with the test group (20.41+/-9.13), but this difference was not statistically significant. ICP showed that no titanium, vanadium or aluminum was detectable in the mucosa surrounding the endoprosthesis. In addition, no titanium and vanadium were found in the lymph nodes and distant organs using ICP. On the other hand, using ICP, the aluminum content was found to be higher in the right regional lymph nodes and all examined distant organs as compared to the control group (lymph nodes: 11.55+/-22.15 vs. 0.36+/-0.61, lung: 6.24+/-11.28 vs. 1.40+/-2.15, liver: 1.66+/-0.99 vs. 0, kidney: 15.69+/-24.88 vs 0, spleen: 2.75+/-3.09 vs. 0.49+/-0.43). However, only for the kidney and liver the higher amount of aluminum was statistically significant. In conclusion, this study quantified the release of only aluminum in lymph nodes and distant organs, when using a modular endoprosthesis made of Ti-6Al-4V for mandibular reconstruction.

Ferromagnetism in CaMn(1-x)Ir(x)O(3).

The crystallographic, magnetic, and electric properties of CaMn(1-x)Ir(x)O(3) (0≤x≤0.6) were investigated. The lattice constants increase with increasing content of Ir. Specimens of 0.05≤x≤0.2 show antiferromagnetic behavior; however, ferromagnetism is observed for specimens of 0.3≤x≤0.6. T(N) decreases as the Ir content increases. T(N) is superseded by T(C) without passing 0 K and T(C) continues to increase in the ferromagnetic composition range. The effective moment µ(eff) decreases as the Ir content increases. The Weiss temperature is negative for small x; however, it continues to increase while changing its sign at about x = 0.3. The results were explained by assuming a mixed valence state of Mn(3+), Mn(4+), Ir(4+), and Ir(5+) ions. The composition dependence of µ(eff) could be explained qualitatively using the ion fractions estimated from the Ir content dependence of the unit cell volume. Experimental results suggest the coexistence of antiferromagnetic and ferromagnetic phases. When the volume fraction of the ferromagnetic phase dominates that of the antiferromagnetic phase, the system seems to show ferromagnetism.

Nimesulide-induced hepatotoxicity and fatal hepatic failure.

Non-steroidal anti-inflammatory drugs (NSAIDs) and cyclo-oxygenase-2 (cox-2) inhibitors are structurally heterogeneous drugs that share similar therapeutic actions and adverse effects. Hepatotoxicity, although a relatively rare adverse effect of this class of drugs, can be severe. This has led to the withdrawal of some NSAIDs from the market. Nimesulide is an NSAID, with cox-2 preference, which has been reported to cause death from hepatic failure. However, most reports have been from European countries. Asian reports include that from Israel and India. We report three patients who presented with acute hepatitis after being prescribed nimesulide, one of whom died from fulminant hepatic failure.

Scoring system for empyema thoracis and help in management.

OBJECTIVE: To evaluate the implications of a newly defined severity scoring of empyema in children for the prediction of surgical management and to compare the length of hospitalization as an outcome measure of patients treated using medical therapy, salvage video-assisted thoracoscopic surgery (VATS) vs early elective VATS. METHODS: A retrospective chart review of parapneumonic empyema of patients below 18 years of age admitted to a tertiary children's hospital in northern Taiwan from April 1993 to December 2002 was performed. Patients were categorized into a medical group who received antibiotic therapy, needle aspirations with/without tube thoracostomy; a salvage VATS group when the patients required surgery for the relief of persistent fever > 38 degrees C, chest pains or dyspneic respirations despite initial medical therapy; an early VATS group when the patients received elective surgery early after admission. The demographic data, clinical features, laboratory findings, and duration of hospitalization were compared using a severity score of empyema (SSE). RESULTS: Streptococcus pneumoniae was the most common infecting organism, followed by Staphylococcus aureus, Pseudomonas aeruginosa. No organisms were recovered in 39% of patients. A pleural pH < 7.1 increases the odds of requiring surgical intervention by 6 times among this cohort. Children who required decortication of empyema had a higher severity score (mean 4.8 vs 3.0, p < 0.005). The duration of hospitalization for patients having early VATS showed a shortening stay (mean 18 vs 28 days) as compared to salvage VATS. CONCLUSION: A pleural pH < 7.1 and a newly designed clinical severity score of empyema 4 are two predictors of surgical intervention for fibrinopurulent empyema in the present study. Early elective VATS may be adopted not later than 7 days after failure of appropriate antibiotic therapy and adequate drainage of empyema to decrease the length of stay and minimize morbidity.

Investigation of a pyoderma outbreak caused by methicillin-susceptible Staphylococcus aureus in a nursery for newborns.

An outbreak of pyoderma caused by methicillin-susceptible Staphylococcus aureus occurred in a nursery for newborns over 26 days. During this period, six neonates were involved. The mother of the first case had trunk pyoderma before delivery, which was regarded as the source of the outbreak. Contamination of the environment and equipment were implicated as the reservoirs of further pathogen spread, as supported by pulsed-field gel electrophoresis (PFGE) results, which showed that some screening isolates were indistinguishable from the epidemic strain. Termination of the outbreak was achieved by the reinforcement of infection control practices and disinfection of environmental surfaces.

Hand, foot and mouth disease in Singapore: a comparison of fatal and non-fatal cases.

AIM: An epidemic of hand, foot and mouth disease (HFMD) occurred in Singapore between September and November 2000. During the epidemic, there were four HFMD-related deaths and after the epidemic, another three HFMD-related deaths. This study sought to determine the risk factors predictive of death from HFMD disease. METHODS: The risk factors for fatal HFMD were determined by comparing clinical and laboratory findings between fatal cases (n = 7) and non-fatal controls (n = 131) admitted between September 2000 and April 2001. Enterovirus 71 positive fatal cases (n = 4) and non-fatal controls (n = 63) were also compared. RESULTS: In total, 138 HFMD cases with a mean age of 32 mo were studied. The majority of fatal cases died from interstitial pneumonitis, of whom three also had brainstem encephalitis. Of the 131 non-fatal cases, 3 had concomitant infections (respiratory syncytial virus bronchiolitis, right-sided pneumonia, Haemophilus influenzae type b meningitis), 2 had aseptic meningitis, and 1 each had transient drowsiness, intravenous immunoglobulin-related complications and transverse myelitis. By multivariate logistic regression analysis, atypical physical findings (p = 0.0006), raised total white cell count (p = 0.0128), vomiting (p = 0.0116) and absence of mouth ulcers (p = 0.043) were predictive of a fatal course. Although previous epidemics have described neurogenic pulmonary oedema as the main cause of death, the fatal cases in this study died mainly from interstitial pneumonitis alone or with myocarditis or encephalitis. CONCLUSION: Although HFMD is generally a benign disease, risk factors such as vomiting, absence of mouth ulcers, atypical presentation and raised total white cell count should alert the physician of a fatal course of illness.

Risk factors in the acquisition of extended-spectrum beta-lactamase Klebsiella pneumoniae: a case-control study in a district teaching hospital in Taiwan.

A case-control study was performed to find the risk factors in the acquisition of extended-spectrum beta-lactamase (ESBL) Klebsiella pneumoniae. From 1 May 2001 to 30 September 2001, 422 isolates ofK. pneumoniae identified by the microbiological laboratory in Hsin-Chu hospital were collected, 59 of which were ESBL-producing strains. The prevalence rate was 14% (59/422). There were 43 case patients (ESBL-producing K. pneumoniae) and 86 controls (non-ESBL-producing K. pneumoniae). Tracheostomy, insertion of a Foley catheter, endotracheal tube, nasogastric tube and central venous catheter were found to be risk factors in the acquisition of K. pneumoniae with ESBLs by univariate analysis. Tracheostomy (odds ratio, 5.13; 95% CI, 1.24-21.1;P =0.023) and ceftazidime use (odds ratio, 13.40; 95% CI, 1.21-148.85; P=0.035) remained as risk factors by multivariate analysis with logistic regression. Other anti-pseudomonal agents should be used as empirical therapy to treat possible Pseudomonas aeruginosa infection in order to reduce ceftazidime use and thereby decrease the prevalence of ESBL producing strains of Enterobacteriaceae.

Ossifying lipoma of the hand: a case report.

INTRODUCTION: Ossifying lipoma is an uncommon tumour and its occurrence in the hand is rare. It is often not diagnosed preoperatively. CLINICAL PICTURE: Our case presented with a lump in the hand which was painful with activity. The lipomatous component of the tumour was radiologically not distinguishable. TREATMENT: The hand was explored through a wide palmar incision, revealing a lipomatous tumour. The tumour was completely excised and diagnosis made after histological examination. OUTCOME: After 1 year, the patient has had normal function of the hand with no tumour recurrence. DISCUSSION: The diagnosis of ossifying lipoma could be made with certainty only after radiological examination, excision and histological examination. The bony component is of mesenchymal origin and may come about as a result of metaplastic transformation.

Effect of hypocapnia in the first three days of life on the subsequent development of periventricular leukomalacia in premature infants.

Several etiologies for causing periventricular leukomalacia (PVL) in preterm infants have been investigated worldwidely. The aim of this study is to investigate whether hypocapnia plays a role in the pathogenesis of the subsequent development of PVL. From Jan. 1997 to June 1998, 91 premature infants (mean gestational age 28.8 +/- 2.5 weeks and birth body weight 1169 +/- 385 g) born in Chung Gung Children's Hospital requiring mechanical ventilation in the first 72 hrs were enrolled in our study. Serial neuorosonogram were followed on day 1, 3, 7 and then at least every 2 to 3 weeks until discharge. These infants were divided into two groups defined as the PVL group and non-PVL group. Variables comprising perinatal data were analyzed and compared between these two groups to screen out possible risk factors related to the development of PVL. There was no difference noted. As for the effect of PaCO2, we found the infants with PVL to have mean lower PaCO2 during the first 72 hours of life. (P = 0.004). Logistic regression model revealed that the incidence for PVL increased significantly when mean PaCO2 is lowered to less than 25 mmHg. Hypocapnia during the first three days of life seems to be an important etiological factor associated with the development of periventricular leukomalacia. Therefore, the ventilatory strategy in the care of the premature neonates should not only provide adequate ventilation but also careful avoidance of hypocapnia.

Idiopathic pulmonary hemosiderosis in a child: report of one case.

Idiopathic pulmonary hemosiderosis (IPH) is uncommon in children. We report a 3-year-old girl who was presented with acute pale-looking appearance, hemoptysis, hematemesis and shortness of breath. This patient was confirmed to have pulmonary hemorrhage by the presence of hemosiderin-laden macrophages in the bronchoalveolar lavage fluid using a flexible bronchoscope. Other causes of PH including glomerular, cardiac and immunological disorder were excluded by normal laboratory studies. She was primarily treated by oral prednisolone, but due to recurrent hemoptysis, immunosuppressive agent was added for maintenance therapy. Pediatricians should consider PH in a patient who has recurrent dyspnea, hemoptysis and iron deficiency anemia.

Fatal retroperitoneal haemorrhage: an unusual complication of percutaneous endoscopic gastrostomy.

A 93-year-old lady with dementia, neurological dysphagia and aspiration pneumonia, died from massive retroperitoneal haemorrhage which developed as a rare and, it is believed, hitherto unreported, complication of percutaneous endoscopic gastrostomy (PEG), which was performed for feeding purposes. It is postulated that the initial, unsuccessful attempt at needle puncture of the stomach, under endoscopic guidance, had resulted in iatrogenic perforation and laceration of the splenic and superior mesenteric veins close to their confluence with the portal vein. It would also appear that dense fibrous adhesions between the pyloro-antral region of the stomach and the posterior hepatic surface had altered the immediate anatomical relations of the stomach in such a manner as to have predisposed to these events.