Conformational variations of the medial epicondyle of the humerus: A case study of fusion anomaly on dry bones.

The estimation of a biological profile in biological anthropology is a central point in the study of human remains. To specify this profile, the observation of variations, and pathologies on the skeleton is a tool that makes an individual unique. In this research, the focus was on the distal part of the humerus. Through the study of five individuals from an osteo-archaeological collection, conformational anomalies of the medial epicondyle of the humerus were highlighted. The aim is to describe them and to propose an etiology of appearance. For this purpose, observation of the rest of the skeleton was carried out, in order to search for the presence of other variations, in particular anomalies of fusion of secondary ossification centers. Overall, a non-fusion of the medial epicondyle of the humerus, two fused medial micro-epicondyles and two supplementary fusions were observed. These are very rare anomalies, with an estimated prevalence of 0.7%. Conformational abnormalities of this area can lead to pain. Therefore, medical imaging for diagnostic purposes may be available: useful data for antemortem documentation in case of a disturbing disappearance. Following the study of the entire skeleton, a common etiology for these different conformations cannot be proposed. However, two categories of etiologies can be proposed: a congenital anomaly and a developmental anomaly with an environmental influence (mechanical or deficiency). The new knowledge of this area will enrich the use of individualization factors, especially in the context of forensic anthropology.

The MELD Score Is Superior to the Maddrey Discriminant Function Score to Predict Short-Term Mortality in Alcohol-Associated Hepatitis: A Global Study.

INTRODUCTION: Several scoring systems predict mortality in alcohol-associated hepatitis (AH), including the Maddrey discriminant function (mDF) and model for end-stage liver disease (MELD) score developed in the United States, Glasgow alcoholic hepatitis score in the United Kingdom, and age, bilirubin, international normalized ratio, and creatinine score in Spain. To date, no global studies have examined the utility of these scores, nor has the MELD-sodium been evaluated for outcome prediction in AH. In this study, we assessed the accuracy of different scores to predict short-term mortality in AH and investigated additional factors to improve mortality prediction. METHODS: Patients admitted to hospital with a definite or probable AH were recruited by 85 tertiary centers in 11 countries and across 3 continents. Baseline demographic and laboratory variables were obtained. The primary outcome was all-cause mortality at 28 and 90 days. RESULTS: In total, 3,101 patients were eligible for inclusion. After exclusions (n = 520), 2,581 patients were enrolled (74.4% male, median age 48 years, interquartile range 40.9-55.0 years). The median MELD score was 23.5 (interquartile range 20.5-27.8). Mortality at 28 and 90 days was 20% and 30.9%, respectively. The area under the receiver operating characteristic curve for 28-day mortality ranged from 0.776 for MELD-sodium to 0.701 for mDF, and for 90-day mortality, it ranged from 0.773 for MELD to 0.709 for mDF. The area under the receiver operating characteristic curve for mDF to predict death was significantly lower than all other scores. Age added to MELD obtained only a small improvement of AUC. DISCUSSION: These results suggest that the mDF score should no longer be used to assess AH's prognosis. The MELD score has the best performance in predicting short-term mortality.

Handwriting skills of children with tic disorders.

INTRODUCTION: Although circumstantial evidence suggests children with tic disorders (TD) experience challenges in handwriting which may be attributed to their tics, few studies have systematically investigated handwriting performance among children with TD. This study examined the relationship between handwriting deficits and TD using a causal comparative research design. METHODS: Thirty-four children with TD completed the Test of Handwriting Skills-Revised (THS-R). The overall percentile ranks of the THS-R were analysed to determine if children with TD have lower scores compared to the test's normative values. Writing speed, letter reversals, touching letters and case errors were also evaluated. RESULTS: Data revealed the median percentile rank of the THS-R for the participants was significantly lower than the median percentile score of the THS-R for the normative sample. Close to 80% (n = 27) of writing samples were scored below 50th percentile. More than one-third (35.3%, n = 12) of the writing samples were scored greater than one standard deviation below the normative mean on the THS-R. Of the four ancillary scores, 82.4% (n = 28) of the participants' writing samples scored below 50th percentile (in the categories of watch or test further) on case errors and 67.6% (n = 23) scored below 50th percentile on writing speed. CONCLUSION: Findings suggested that children with TD took longer to complete the writing task, and committed more case substitution errors than the normative sample of the THS-R and were likely to exhibit handwriting deficits.

Characterization of the perinatal mandible growth pattern: preliminary results.

PURPOSE: The fetal development of the mandible is nowadays quite understood, and it is already known that craniofacial growth reaches its highest rate during the first 5 years of postnatal life. However, there are very few data focusing on the perinatal period. Thus, the present article is addressing this concern by studying the mandible morphology and its evolution around the birth with a morphometric method. METHODS: Thirty-one mandibles modelled in three dimensions from post-mortem CT-scans were analyzed. This sample was divided into two subgroups composed of, respectively, 15 fetuses (aged from 36 gestational weeks), and 16 infants (aged to 12 postnatal weeks). 17 distances, 3 angles, and 8 thicknesses were measured via the prior set of 14 landmarks, illustrating the whole mandible morphology. RESULTS: Although this methodology may depend on the image reconstruction quality, its reliability was demonstrated with low variability in the results. It highlighted two distinct growth patterns around birth: fetuses mandibles do not significantly evolve during the perinatal period, whereas, from the second postnatal weeks, most of the measurements increased in a homogeneous tendency and in correlation with age. CONCLUSIONS: The protocol developed in this study highlighted the morphologic evolution of the mandible around birth, identifying a different growth pattern from 2 postnatal weeks, probably because of the progressive activation of masticatory muscles and tongue. However, considering the small sample size, these results should be thorough, so identification and management of anatomic abnormalities could eventually be achieved.

No country for old livers? Examining and optimizing the utilization of elderly liver grafts.

Of the 1.6 million patients >70 years of age who died of stroke since 2002, donor livers were retrieved from only 2402 (0.15% yield rate). Despite reports of successful liver transplantation (LT) with elderly grafts (EG), advanced donor age is considered a risk for poor outcomes. Centers for Medicare and Medicaid Services definitions of an "eligible death" for donation excludes patients >70 years of age, creating disincentives to donation. We investigated utilization and outcomes of recipients of donors >70 through analysis of a United Network for Organ Sharing Standard Transplant Analysis and Research-file of adult LTs from 2002 to 2014. Survival analysis was conducted using Kaplan-Meier curves, and Cox regression was used to identify factors influencing outcomes of EG recipients. Three thousand one hundred four livers from donors >70, ≈40% of which were used in 2 regions: 2 (520/3104) and 9 (666/3104). Unadjusted survival was significantly worse among recipients of EG compared to recipients of younger grafts (P < .0001). Eight independent negative predictors of survival in recipients of EG were identified on multivariable analysis. Survival of low-risk recipients who received EG was significantly better than survival of recipients of younger grafts (P = .04). Outcomes of recipients of EG can therefore be optimized to equal outcomes of younger grafts. Given the large number of stroke deaths in patients >70 years of age, the yield rate of EGs can be maximized and disincentives removed to help resolve the organ shortage crisis.

[Duplication of the acromioclavicular joint: A case dating from the end of the 19th century]. / Duplication de l'articulation acromio-claviculaire : un cas datant de la fin du 19e siècle.

The duplication of the acromioclavicular joint is a very rare anomaly of shoulder girdle. Here, we present a new case of unilateral duplication of the acromioclavicular joint observed on an individual from the 19th century. In the literature, two hypotheses are proposed to explain the origin of this anomaly. The first is a congenital origin that could be explained by in utero displacement of one of the clavicle's primary ossification centers, or the existence of an additional ossification center. The second is a traumatic origin resulting from an acromioclavicular fracture that occurred during the growth period of the individual. Our macroscopic observations and CT-scan images show no sign of a healed fracture, of complications, or of a bone callus after healing. The hypothesis of a congenital origin for this acromioclavicular duplication is therefore preferred.

The American Society of Transplantation Consensus Conference on the Use of Hepatitis C Viremic Donors in Solid Organ Transplantation.

The availability of direct-acting antiviral agents for the treatment of hepatitis C virus (HCV) infection has resulted in a profound shift in the approach to the management of this infection. These changes have affected the practice of solid organ transplantation by altering the framework by which patients with end-stage organ disease are managed and receive organ transplants. The high level of safety and efficacy of these medications in patients with chronic HCV infection provides the opportunity to explore their use in the setting of transplanting organs from HCV-viremic patients into non-HCV-viremic recipients. Because these organs are frequently discarded and typically come from younger donors, this approach has the potential to save lives on the solid organ transplant waitlist. Therefore, an urgent need exists for prospective research protocols that study the risk versus benefit of using organs for hepatitis C-infected donors. In response to this rapidly changing practice and the need for scientific study and consensus, the American Society of Transplantation convened a meeting of experts to review current data and develop the framework for the study of using HCV viremic organs in solid organ transplantation.

Novel association between serum pentraxin-2 levels and advanced fibrosis in well-characterised patients with non-alcoholic fatty liver disease.

BACKGROUND: Pentraxin-2 (PTX-2), a serum protein, inhibits inflammation and fibrosis, and recombinant PTX-2 is being tested as an anti-fibrotic agent. AIM: To evaluate the association between serum PTX-2 levels and fibrosis stage in patients with non-alcoholic fatty liver disease (NAFLD). METHODS: Serum pentraxin-2 levels were compared between four groups of well-characterised patients including NAFLD with no fibrosis, NAFLD with mild-moderate fibrosis (stage 1-2), NAFLD with advanced fibrosis (stage 3-4), and age-sex matched non-NAFLD controls. RESULTS: Sixty subjects were included in the study. The mean age was 58.9 years, 68% were male and 58% were Caucasian. In univariate analysis, serum PTX-2 levels significantly decreased from non-NAFLD controls to mild NAFLD with no fibrosis, to NAFLD with mild-moderate fibrosis and were lowest in patients with NAFLD and advanced fibrosis, in a dose-dependent manner (P < 0.0001). In multivariable-adjusted analyses controlling for age, sex, albumin, and CRP, the results remained consistent and statistically significant. Serum PTX-2 level had an AUROC of 0.84 (95% CI: 0.71-0.97) for the diagnosis of NAFLD, and an AUROC of 0.77 (95% CI: 0.65-0.90) for the diagnosis of advanced fibrosis in NAFLD. Serum PTX-2 levels also decreased with increasing liver stiffness as estimated by magnetic resonance elastography (r = -0.31, P = 0.02). CONCLUSIONS: PTX-2 levels are significantly lower in patients with NAFLD compared to non-NAFLD controls, and decline further in patients with advanced fibrosis. PTX-2 may therefore be both a biomarker of disease and a potential target for anti-fibrotic therapy with the recombinant pentraxin-2.

Comparative diagnostic accuracy of magnetic resonance elastography vs. eight clinical prediction rules for non-invasive diagnosis of advanced fibrosis in biopsy-proven non-alcoholic fatty liver disease: a prospective study.

BACKGROUND: Two-dimensional magnetic resonance elastography (2D-MRE) is an advanced magnetic resonance method with high diagnostic accuracy for predicting advanced fibrosis in non-alcoholic fatty liver disease (NAFLD) patients. However, no prospective, head-to-head comparisons between 2D-MRE and clinical prediction rules (CPRs) have been performed in patients with biopsy-proven NAFLD. AIM: To compare the diagnostic utility of 2D-MRE against that of eight CPRs (AST:ALT ratio, APRI, BARD, FIB-4, NAFLD Fibrosis Score, Bonacini cirrhosis discriminant score, Lok Index and NASH CRN model) for predicting advanced fibrosis in a prospective cohort with paired liver biopsy as the gold standard. METHODS: This is a cross-sectional analysis of a prospective study of 102 patients (58.8% women) with biopsy-proven NAFLD, 2D-MRE and clinical research assessment within 90 days of biopsy. Receiver operating characteristic (ROC) analysis was performed to assess the performance of 2D-MRE and CPRs for predicting advanced fibrosis. RESULTS: The mean (±s.d.) age and BMI were 51.3 (±14.0) years and 31.7 (±5.5) kg/m(2) respectively. 48, 26, 9, 13 and 6 patients had stage 0, 1, 2, 3 and 4 fibrosis respectively. The area under ROC curve (AUROC) was 0.957 for 2D-MRE and between 0.796 and 0.861 for the CPRs. FIB-4 was the best-performing CPR at predicting advanced fibrosis with AUROC of 0.861. In head-to-head comparisons using the DeLong test, 2D-MRE had significantly better AUROC (P < 0.05) than each CPR for predicting advanced fibrosis. CONCLUSION: Compared to clinical prediction rules, 2D-MRE provides significantly higher accuracy for the diagnosis of advanced fibrosis in NAFLD patients.

Avaliação do efeito de diferentes lasers de alta intensidade no tratamento de superfície da cerâmica Y-TZP pré e pós sinterização / Effect evaluation of different high-intensity lasers on the surface treatment of Y-TZP ceramic before and after sintering

O objetivo deste estudo foi avaliar os efeitos dos lasers de Nd:YAG, CO2 e Er,Cr:YSGG no tratamento de superfície da cerâmica Y-TZP antes e depois da sinterização final, por meio de Microscopia Eletrônica de Varredura (MEV), mensuração da rugosidade de superfície (Ra) e teste de resistência adesiva por microcisalhamento (RAD). Para tanto, barras de Y-TZP foram confeccionadas e distribuídas entre as 3 fases do experimento, sendo as duas primeiras fases seletivas para a identificação dos parâmetros lasers a serem utilizados na fase 3 de análise da RAD. Na fase 1 MEV - foram testados parâmetros que variavam entre 50 e 100 mJ para o laser de Nd:YAG, 2 a 4W para o laser de CO2 e 1 a 3,5W para o laser de Er,Cr:YSGG, testados antes ou após a sinterização da Y-TZP. Observou-se que a maioria dos tratamentos foram capazes de promover alterações na cerâmica com diferentes intensidades dependendo do parâmetro utilizado. Para a fase 2 Ra foram selecionados apenas os tratamentos com os lasers de Nd:YAG e Er,Cr:YSGG aplicados antes da sinterização da cerâmica, sendo que cada laser foi avaliado individualmente e comparados ao tratamento de superfície com o sistema Rocatec. Os tratamentos com os maiores valores de Ra foram: para o laser de Nd:YAG - 1,6W-20Hz (11.623±3,419) e para o laser de Er,Cr:YSGG - 3W (6,051±1,991).

O sistema Rocatec apresentou os menores valores de rugosidade (1,297±0,026). Para a fase 3 do estudo RAD foram selecionados os parâmetros que apresentaram os maiores valores de Ra para cada laser, além do parâmetro com características favoráveis à adesão observado na fase 1 MEV. Sendo assim, o teste de microcisalhamento foi realizado entre a cerâmica Y-TZP tratada com os lasers antes da sinterização final, nos parâmetros de 1,6W e 1,2W para o laser de Nd:YAG e 3W para o laser de Er,Cr:YSGG; e com o sistema Rocatec, utilizando-se dois cimentos resinosos de dupla ativação (Panavia e RelyX U100). A análise estatística ANOVA Split-Plot dos dados de RAD obtidos revelou que não houve diferença estatística entre os cimentos estudados. Porém, no fator tratamentos de superfície observou-se que os maiores valores de RAD foram obtidos para o sistema Rocatec (20,92±3,4MPa). Os dois parâmetros utilizados para o laser de Nd:YAG foram semelhantes entre si com valores de RAD intermediários (1,2W=9,79±4 MPa e 1,6W=11,35±3,64 MPa) e o tratamento com o laser de Er,Cr:YSGG apresentou os menores valores de RAD (1,43±1,21MPa). Pôde-se concluir que os tratamentos de superfície com todos os lasers testados nos parâmetros de irradiação após a sinterização, provocaram danos à cerâmica Y-TZP. Os tratamentos com os lasers de Nd:YAG e Er,Cr:YSGG antes da sinterização, apesar de apresentarem características micromorfológicas sugestivas de aumento da área de superfície, não foram suficientes para aumentar a resistência adesiva entre a Y-TZP e os cimentos resinosos testados.

The aim of this study was to evaluate the effects of Nd:YAG, CO2 and Er,Cr:YSGG lasers on the surface treatment of Y-TZP ceramic before and after the final sintering by means of Scanning Electron Microscope (SEM), surface roughness measurement (Ra) and microshear bond strength adhesive resistance test (RAD). In order to do so, Y-TZP bars were produced and distributed among the three experimental phases, being the two first ones selective in what regards identifying parameters for the lasers used in phase 3 of the RAD analysis. In phase 1 SEM parameters varying from 50 to 100 mJ were tested for the Nd:YAG laser, from 2 to 4W for the CO2 laser and from 1 to 3,5W for the Er,Cr:YSGG laser, either before or after the Y-TZP sintering. It was observed that most treatments were able to promote changes in the ceramic with varied intensity according to the parameter used. In phase 2 Ra only treatments with Nd:YAG and Er,Cr:YSGG lasers applied before ceramic sintering were selected, and each laser was individually evaluated and compared to the surface treatment with Rocatec system. The treatments which had the highest Ra values were: 1,6W-20Hz (11.623±3,419) for the Nd:YAG laser and 3W (6,051±1,991) for Er,Cr:YSGG. Rocatec system showed the lowest roughness levels (1,297±0,026). As for phase 3 of the study RAD the highest Ra parameters for each laser were selected as well as the parameter with favorable characteristics to adherence observed in phase 1 SEM.

Therefore, the microshear bond strength test was done not only in the Y-TZP ceramic treated with lasers before the final sintering (using 1,6W and 1,2W parameters for the Nd:YAG laser and 3W for Er,Cr:YSGG), but also in the Rocatec system, making use of two double activation resin cements (Panavia e RelyX U100). The ANOVA Split-Plot statistical analysis of the RAD data showed that there were no statistical variations concerning the studied cements. However, in what regards the surface treatments, it was observed that the highest RAD values were obtained for the Rocatec system (20,92±3,4MPa). Both parameters used for the Nd:YAG laser were similar, presenting intermediate RAD values (1,2W=9,79±4 and 1,6W=11,35±3,64 MPa). The treatment which used Er,Cr:YSGG laser presented the lowest RAD values (1,43±1,21MPa). It was possible to conclude that surface treatments with all tested lasers in the irradiation parameters after sintering caused damage to the Y-TZP ceramic. Treatments making use of Nd:YAG and Er,Cr:YSGG lasers before the sintering were not enough in order to increase the adhesive resistance between Y-TZP and the resin cements tested, even though they presented micromorphological characteristics that indicated growth in the surface area.

Recurrence of intracardiac large B-cell non-Hodgkin's lymphoma (NHL) encasing and nearly obliterating the right coronary artery: a case report.

Among malignant tumors of the heart, primary malignant lymphomas are unusual and they are typically non-Hodgkin's B-cell cancers. A 73-year-old man affected by non-Hodgkin lymphoma (NHL) treated with four cycle of chemotherapy and radiotherapy was admitted to the Emergency Department for chest pain. Echocardiography showed a mass inside the right ventricle obstructing blood outflow in the pulmonary artery. The ECG-gated angio-multidetector computed tomography (MDCT) examination confirmed a solid mass in the right ventricle encasing the proximal-middle tract of the right coronary artery (RCA); RCA stenosis was confirmed by coronary angiography. After trans-thoracic CT-guided biopsy the mass was characterized as a recurrence of NHL and the patient started a new cycle of chemotherapy. After 15 days a MDCT exam showed both mass reduction and absence of RCA significant stenosis. MDCT imaging allows an accurate assessment of tumour extension and it represents an useful guide during biopsy procedures, necessary for a precise histological characterization of neoplasms.

The impact of hepatitis C and biliary complications on patient and graft survival following liver transplantation.

Recurrent hepatitis C (HCV) and biliary complications (BC) are major causes of post liver transplant morbidity and mortality. The impact of these complications may be additive or synergistic. We performed a retrospective cohort study to analyze the effects of HCV and BC on all patients transplanted at two institutions over 6 years. BC was defined by imaging findings in the setting of abnormal liver function tests that required intervention. The primary outcomes were graft and patient survival over a mean 3.4 years. 709 patients (619 deceased, 90 living donor) were included, 337 with HCV and 372 without. BC was diagnosed more frequently in patients with HCV, 26% versus 18% (p = 0.008). One-year and overall patient and graft survival were significantly lower in patients with HCV, but BC impacted only 1-year graft survival. The combination of BC and HCV had no additional impact on survival or fibrosis rates on 1-year protocol biopsies. Multivariate analysis revealed HCV (HR 2.1) and HCC (HR 1.9) to be independent predictors of mortality. Since BC are diagnosed more frequently in HCV patients and only affect early graft loss, it is likely that recurrent HCV rather than BC accounts for the majority of adverse graft outcomes.

Tratamento marginal de restaurações cerâmicas com laser de Nd: YAG - avaliação da microinfiltração / Marginal treatment of ceramic restorations using Nd: YAG laser - microleakage evaluation

Introdução - O objetivo deste estudo in vitro foi avaliar a microinfiltração em restaurações de porcelana com tratamento das margens com laser de Nd:YAG (1064 nm). Material e Métodos - Cavidades Classe V para restaurações indiretas, com término em esmalte e cemento/dentina, foram preparadas na face vestibular de 20 dentes bovinos. Após condicionamento ácido e aplicação do sistema adesivo nos preparos cavitários, e tratamento da superfície interna da porcelana com ácido fluorídrico e silano, as restaurações foram cimentadas com cimento resinoso de dupla ativação RelyX ARC (3M ESPE). As amostras foram distribuídas aleatoriamente em 4 grupos (n = 5): G1: controle - sem irradiação; G2, G3 e G4 foram irradiados com laser de Nd:YAG com diferentes parâmetros. Todas as amostras foram imersas em água destilada (37°C, 7 dias) submetidas à ciclagem térmica, impermeabilizadas e imersas em solução de nitrato de prata a 50% (8h). Posteriormente as restauraçõrs foram seccionadas longitudinalmente e imersas em solução fotoreveladora sob luz fluorescente por 16h. O grau de microinfiltração foi avaliado por três examinadores previamente calibrados, através da análise de fotografias, e os valores foram submetidos à análise estatística de Kruskal-Wallis e Mann-Whitney (p < 0,05). Resultados - Os resultados mostraram que em esmalte houve diferença significante entre o grupo controle e os tratados com laser, sem diferença entre os grupos irradiados; em dentina não houve diferença significante entre os grupos. Conclusão - A irradiação com laser de Nd:YAG influenciou negativamente na microinfiltração marginal das restaurações indiretas de cerâmica cimentadas com cimento resinoso

Intraductal ultrasound for the evaluation of patients with biliary strictures and no abdominal mass on computed tomography.

BACKGROUND AND STUDY AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is the diagnostic procedure of choice in patients with biliary strictures and no culprit mass lesion on abdominal imaging, but it is limited in its diagnostic accuracy. The aim of this prospective study was to determine the value of intraductal ultrasound (IDUS) in distinguishing between benign and malignant biliary strictures in this clinical setting. PATIENTS AND METHODS: Sixty-one patients with painless jaundice and no mass lesion on abdominal computed tomography, who were found to have a biliary stricture at ERCP, underwent IDUS with a high-frequency (20-MHz) wire-guided probe. Histopathological confirmation or clinical follow-up was used to establish the final diagnosis. The diagnostic performances of IDUS, ERCP, and IDUS plus ERCP in the identification of malignant strictures were evaluated. RESULTS: Forty-three patients had malignant strictures and 18 had benign strictures. ERCP produced 25 false-negative diagnoses, 22 of which were identified as malignant by IDUS. IDUS provided seven false-negative and three false-positive diagnoses. The proportion of patients with malignant strictures who tested positive with IDUS was 2.06 times that of ERCP (95 % CI, 1.37 - 3.10; 83.3 % vs. 40.5 %, P = 0.0004). When used in conjunction, IDUS increased the accuracy of ERCP from 58 % to 90 %. Patients with operable lesions on IDUS and no contraindication to surgery underwent resection; most patients with pancreatic parenchymal invasion on IDUS underwent EUS, which identified a pancreatic mass in more than 50 % of cases. Patients with negative IDUS and a low clinical suspicion for malignancy were treated endoscopically, while a more aggressive work-up was performed in all patients with high pretest probability, regardless of the IDUS results. CONCLUSIONS: IDUS is a valuable adjunct to ERCP in the characterization of biliary strictures in patients who present with painless jaundice in the absence of a culprit mass on abdominal imaging.

Therapeutic endoscopic retrograde cholangiopancreatography without fluoroscopy in four critically ill patients using wire-guided intraductal ultrasound.

Emergent endoscopic retrograde cholangiopancreatography cannot be performed at the bedside in critically ill patients in an intensive care unit because of the requirement for fluoroscopy. Moving such patients to a safe location where fluoroscopy is available can pose practical problems, and can lead to delayed intervention, which may adversely affect the outcome. We report the use of intraductal ultrasound to facilitate therapeutic biliary interventions in four critically ill patients in an intensive care unit. Cannulation was performed endoscopically at the bedside using a sphincterotome and a guide wire. Intraductal ultrasound, rather than fluoroscopy, was then used to confirm the location of the wire within the common bile duct prior to performing endoscopic sphincterotomy or stent placement. This technique was successful in all four patients.