Palliation of Malignant Biliary Obstruction: Adverse Events are Common after Percutaneous Transhepatic Biliary Drainage.

BACKGROUND AND AIM: Endoscopic stents in the common bile duct is the first treatment choice to alleviate symptoms of biliary obstruction due to malignant disease. When endoscopic stenting fails in palliative patients, one option is to use a percutaneous transhepatic biliary drainage, but it is not clear whether and how it can reduce the symptom load. The aim of this study was to evaluate benefits and disadvantages of percutaneous transhepatic biliary drainage in palliative care. MATERIAL AND METHODS: Inclusion criteria were malignant disease and bilirubin ≥26 µmol/L in plasma. A structured protocol for obtaining data from the medical records was used. Data were collected from the time of last computed tomography scan before the percutaneous transhepatic biliary drainage was placed and during 14 days afterward. RESULTS AND CONCLUSION: Inclusion criteria were fulfilled in 140 patients. Median age was 70 years (33-91 years). Some 126 patients had a remaining external percutaneous transhepatic biliary drainage. Jaundice was the initial symptom in 62 patients (44%). Within the first week after percutaneous transhepatic biliary drainage, the bilirubin decreased from 237 µmol/L (31-634) to 180 µmol/L (17-545). Only 25% reached a level below the double upper reference value. Pruritus occurred in 27% before the percutaneous transhepatic biliary drainage, but the bilirubin value did not differ from patients without pruritus. However, the pruritus was relieved in 56% with percutaneous transhepatic biliary drainage. Antibiotic prophylaxis protected to some extent from infectious complications. Adverse events were common and early mortality was high (16% within 14 days). Jaundice should not by itself be an indication for percutaneous transhepatic biliary drainage for palliation except when the aim is to prepare the patient for chemotherapy. It is mandatory that the patients are informed carefully about what can be expected regarding the positive effects and the risks of adverse events.

Energy expenditure of genuine laughter.

OBJECTIVE: To measure energy expenditure (EE) and heart rate (HR) during genuine laughter. DESIGN: Experimental trial of viewing film clips in four cycles either intended to evoke laughter (humorous -10 min) or unlikely to elicit laughter (not humorous -5 min) under strictly controlled conditions of a whole-room indirect calorimeter equipped with audio recording system. PARTICIPANTS: Forty five adult friend dyads in either same-sex male (n=7), same-sex female (n=21) and mix-sex male-female (n=17); age 18-34 years; body mass index 24.7+/-4.9 (range 17.9-41.1). MEASUREMENTS: Energy expenditure in a whole-room indirect calorimeter, HR using Polar HR monitor. Laugh rate, duration and type from digitized audio data using a computerized system and synchronized with HR and EE results. RESULTS: Laughter EE was 0.79+/-1.30 kJ/min (0.19+/-0.31 kcal/min) higher than resting EE (P<0.001, 95% confidence interval=0.75-0.88 kJ/min), ranging from -2.52 to 9.67 kJ/min (-0.60-2.31 kcal/min). Heart rate during laughter segments increased above resting by 2.1+/-3.8 beats/min, ranging from -7.6 to 26.8 beats/min. Laughter EE was correlated with HR (r (s)=0.250, P<0.01). Both laughter EE and HR were positively correlated with laughter duration (r (s)=0.282 and 0.337, both P<0.001) and rate (r(s)=0.256 and 0.298, both P<0.001). CONCLUSION: Genuine voiced laughter causes a 10­20% increase in EE and HR above resting values, which means that 10­15 minutes of laughter per day could increase total EE by 10­40 kJ (2­10 kcal) [corrected].

Transitioning to independence: challenges for young people with disabilities and their caregivers.

For all teens, the process of moving from childhood to adulthood is challenging. For young people with disabilities, transitioning to independence presents even more challenges. Barriers to successful transition for young people with disabilities include low expectations by parents and other significant people in the community, lack of knowledge of existing career and vocational education services, and lack of self-advocacy skills. This article provides an overview of issues related to transitioning to adult independence and offers suggestions for assessment, planning, and intervention that can help nurses be effective partners with families and other caregivers in transition efforts. Nurses caring for children with disabilities can help families see strengths in their children and develop realistic, developmentally-appropriate expectations for skill development, attitudes, and behaviors that will promote self-sufficiency in adulthood. Nurses can help families think about possibilities for independence and refer families to community resources that can help young people with disabilities pursue postsecondary education, obtain and maintain jobs, and live independently.

The morphologic relationship of sinus and fistula formation to intestinal stenoses in children with Crohn's disease.

Sinus and fistula (SF) formation in adults with Crohn's disease has been ascribed to increased intraluminal pressure from stenotic lesions or to inflammation. We retrospectively evaluated 55 surgically resected specimens from 30 children with Crohn's disease for stenotic lesions, sinuses, fistulas, and inflammation. Eighteen of 30 children had one operation, and there were 12 multiple surgeries. Thirty-one of 55 specimens (56%) contained stenoses. SF formation was seen in 16 of 31 specimens with stenosis; it developed proximal to the stenosis in seven patients, distal in five, and both proximal and distal in four. SF formation was also noted in 12/24 specimens without stenosis. In 93% of the cases, the SF was associated with moderate to severe inflammation. Although 56% of the patients had stenoses, SF frequently developed independent of stenosis. All SF were associated with inflammation. Therefore, inflammation rather than increased intraluminal pressure appears to be the primary factor in SF formation in children with Crohn's disease.

Living arrangements, visit patterns, and health problems in a nurse-managed clinic for the homeless.

The purpose of this article is to describe living arrangements, clinic visit patterns, and health problems of clients by age and gender in a nurse-managed clinic serving the homeless. The conceptual framework for this project was derived from a nursing perspective of community health. The problem classification scheme used included four domains of community health practice: environmental, psychosocial, physiological, and health-related behavior. Data were collected during each visit to a nurse-managed health clinic for the homeless for 18 months. The findings indicate that living arrangements and visit patterns vary by age and gender. Health problems associated with integument and income were identified as primary and secondary problems across all age groups. Six other health problems were shared across all age and gender groups as either primary or secondary: circulation, respiration, pain, nutrition, communication, and prescription medication. Substance misuse was not a primary problem noted by clients, but was commonly a secondary problem. Genitourinary problems were noted primarily to be problems of younger women. Implications for planning nursing services for the homeless are discussed.

Children with dermatological disease and their mothers.

Our study hypotheses are based on extensive, clinical experience of patients with psoriasis and atopic eczema and on observations of emotions these patients tend to provoke in nursing personnel. We wanted to see whether there were statistically significant differences between these patient categories. We also wanted to compare dermato not equal to logical patients with patients seeking help for psychological problems (alexithymia-hypothesis). Since psoriasis starts and atopic eczema often gets worse in puberty or young adulthood, we chose to study teenagers. On this occasion, we will discuss the Rorschach test results of our female subjects (n: 99) and their mothers (n: 68) scored by Holt's "Method for Assessing Primary Process Manifestations and Their Control in Rorschach Responses" and the girls' scores on Edwards Personal Preference Schedule--questionnaire. The results seem to confirm the alexithymia-hypothesis and our control group of young psychiatric outpatients (mainly neurotics) produce more varied Rorschach protocols consisting of more primary process material and more creative solutions. In contrast, protocols of psoriatics are strict and formally good with occasional outbursts of slightly shocking primary process material. Girls suffering from atopic eczema produce long and varied, but rather defensive, Polly Anna-like protocols. The statistical differences between mothers and daughters within each diagnostic group suggest that the psychiatric patients differ most from their mothers in the following areas: they give more libidinal answers which often are of more primitive kind than the answers of their mothers, and, they seem to have better means of coping with their impulses than the mothers.(ABSTRACT TRUNCATED AT 250 WORDS)

Merkel cell carcinoma arising in the oral mucosa.

This is the first reported case of a Merkel cell carcinoma arising in the oral mucosa. The tumor occurred in a 53-year-old white man, and it originated in the right mucobuccal fold. The Merkel cell origin was confirmed by electron microscopic and immunohistochemical studies.

Effects of physical conditioning on information-processing efficiency.

This study investigated changes in information-processing efficiency that occur when physical fitness improves. Information-processing variables were Sternberg's memory-scan rate, Posner's name-access time, the Cattell Culture Fair Intelligence Test, and numbers of words remembered from word lists. At present and posttest 10 to 12 wk. later, 66 adults between the ages of 18 and 48 yr. took all cognitive tests and rode a bicycle ergometer to estimate physical fitness. A 2 X 2 (improved/stable fitness groups by pretest/posttest trials) analysis of variance with repeated measures indicated that the group who improved 15% or more in physical fitness improved significantly more on the name-access time than the group whose fitness remained stable. There was a trend toward improvement in memory-scan rate and number of words remembered on the first word trial by people who became more fit. The results may have implications for assessment and training of personnel in occupations where speeded perception and responses are required.

Late-onset Hallervorden-Spatz disease presenting as familial parkinsonism.

We studied a 68-year-old man who died after 13 years of progressive dementia, rigidity, bradykinesia, mild tremor, stooped posture, slow and shuffling gait, dystonia, blepharospasm, apraxia of eyelid opening, anarthria, aphonia, and incontinence. At autopsy, he had generalized brain atrophy with large deposits of iron pigment in the globus pallidus, caudate, and substantia nigra. Axonal spheroids were found in the globus pallidus, substantia nigra, medulla, and spinal cord. The neurochemical analysis of the brain revealed marked loss of dopamine in the nigral-striatal areas, with relative preservation of dopamine in the limbic areas. This is the oldest case of familial Hallervorden-Spatz disease reported and the first with neurochemical analysis of the brain.

CT diagnosis of congenital lobar emphysema.

Congenital lobar emphysema can be diagnosed by conventional chest films, but it may be difficult to determine which is the affected lobe or the etiology. This report presents the computed tomographic (CT) appearance of this entity and also emphasizes the significant role CT may have in its diagnosis.