Treatment Outcome of Endoscopic Ultrasound Radiofrequency Ablation for Incidentaloma Pancreatic Neuroendocrine Tumor in Young Female Patient: A 2-year Follow-Up.

Pancreatic neuroendocrine tumors (PNETs) or islet cell tumors are neuroendocrine neoplasms that arise from cells of the endocrine and nervous system within the pancreas. Patients with PNET sometimes do not show any symptoms, known as nonfunctioning (NF) sporadic PNET. It is still debatable regarding the best approach in the NF for small PNET. Currently, the surgical approach is considered the best; however, it is a highly invasive procedure, and it has a potentially high risk of complications as it requires a skilled and experienced operator. Herewith, we reported a 48-year-old female with incidentaloma of nonfunctioning PNET (NF-PNET) whose tumor has been successfully treated with endoscopic ultrasound guided radiofrequency ablation (EUSRA). There was no adverse event observed during and after the EUS procedure, and even 1 week after the procedure. One year later, abdominal magnetic resonance imaging (MRI) examination was carried out and size of the tumor was significantly getting smaller where it could hardly be seen anymore. After 2 years of follow-up, the latest abdominal MRI study showed no solid part of the tumor could be seen anymore. In conclusion, EUSRA can be an alternative option for incidentaloma of NF-PNET management.

Bedside Percutaneous Approach in a Critically Ill ICU Patient with Complex Pancreatobiliary Disorder Followed by Endoscopic Approach: Lessons Learnt from a Tertiary Referral Center.

Pancreatobiliary disorder is a challenging clinical condition, especially when this condition is causing severe infection or biliary sepsis, and sometimes it requires intensive care unit (ICU) treatment. Biliary drainage is the mainstay of therapy; however, the choice of the drainage method is dependent on the patient's clinical condition and the disease itself. A 79-year-old female was transferred on a ventilator to our ICU from another hospital due to biliary sepsis, a large common bile duct stone, and an infected pancreatic pseudocyst. The patient also has other comorbidities such as heart problems, hypothyroidism, and diabetes mellitus. Bedside percutaneous transhepatic biliary drainage without fluoroscopy and percutaneous cyst aspiration was successfully performed, which improved the patient's condition; this was followed by an endoscopic approach, i.e., endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound-guided pancreatic pseudocyst drainage. The clinical improvement showed itself in the change of the patient's respiratory status and ventilator mode. In conclusion, the percutaneous approach has a big role in managing critically ill patients in the ICU setting. However, expertise, training experience, and a multidisciplinary team approach are very important for successful management and patient outcome.

Prevalence of Non-Alcoholic Fatty Pancreas Disease (NAFPD) and its risk factors among adult medical check-up patients in a private hospital: a large cross sectional study.

BACKGROUND: The clinical significance of non-alcoholic fatty pancreatic disease (NAFPD) or fatty pancreas is largely unknown. It is often an incidental finding on abdominal ultrasound, which is not explored further, especially its association with metabolic condition and the risk of pancreatic malignancy. The aim of this study is to evaluate the presence of NAFPD and its associated risk factors among adult medical check-up patients. METHOD: A large cross-sectional study was done among adult medical check-up patients underwent abdominal ultrasound between January and December 2013 in Medistra Hospital, Jakarta. Data was obtained from the patients' medical record and include demographic data, blood pressures, fasting blood glucose level, and lipid profile. The presence of fatty pancreas was diagnosed by ultrasound. Bivariate and multivariate analyses were done to find associated risk factors for NAFPD. Statistical analysis was done using SPSS version 17. RESULTS: A total of 1054 cases were included in this study; pancreas cannot be visualized in 153 cases and were excluded from the analysis. Fatty pancreas was present in 315 (35.0%) patients. Bivariate analyses found associations among fatty pancreas and several risk factors such as gender, age, systolic and diastolic blood pressures, body mass index (BMI), fasting plasma glucose (FPG), triglycerides (TG) and cholesterol levels. CONCLUSION: Fatty pancreas is a common finding during medical check-up with a prevalence of 35%. Fatty pancreas has significant association with metabolic factors and it might have an important role in risk of malignancy.

Development of non-alcoholic fatty liver disease scoring system among adult medical check-up patients: a large cross-sectional and prospective validation study.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease in the community. However, NAFLD remains undiagnosed in most people with limited access to imaging facilities in most developing countries. OBJECTIVE: To examine the prevalence of NAFLD and to develop the risk scoring model for predicting the presence of NAFLD among adult medical check-up patients. METHOD: A large prospective cross-sectional study was conducted among medical check-up patients who underwent transabdominal ultrasound examination between January and December 2013 in Medistra Hospital, Jakarta. Data were obtained from the patients' medical records. Logistic regression analyses were undertaken to identify the best combination of risk factors for predicting fatty liver using the backward (likelihood ratio) approach. The adjusted odds ratio and 95% confidence interval were estimated using the logistic regression coefficient. The prediction model was assessed using the receiver operating characteristic curve and the Hosmer-Lemeshow goodness-of-fit test and was validated on a new, prospective cohort. Statistical analysis was done using SPSS version 17. RESULTS: A total of 1,054 cases was included in this study. Fatty liver was present in 538 (51.0%) patients. Bivariate analyses found associations among fatty liver and several risk factors. Six risk factors were incorporated to build the final prediction model. All scores were summed up to obtain the total score. A probability equation was developed by applying linear regression analysis on the total score. The prediction model had good diagnostic performance with an area under the receiver operating characteristic curve =0.833 (95% confidence interval =0.809-0.857). The Hosmer-Lemeshow goodness-of-fit P-value was 0.232, which indicated the appropriateness of the logistic regression model to predict fatty liver. On the validation set, the scoring system proved to be moderately accurate and can potentially be applied to larger population setting. CONCLUSION: The presence of fatty liver in NAFLD patients can be predicted using our proposed fatty liver scoring system.

Hemostatic status of pre and post intracoronary injection of peripheral blood stem cells in patients with recent myocardial infarction.

AIM: to investigate hemostatic parameter changes, such as platelet aggregation, blood and plasma viscosity, prothrombin time, APTT, CRP and fibrinogen, before and after administration of stem cell therapy. METHODS: a total of 24 patients were enrolled. Peripheral blood stem cells (PBSCs) were harvested and injected into the infarct-related artery after 5 consecutive days of G-CSF administration. Recombinant human erythropoietin was administered at the time of intracoronary PBSCs injection. RESULTS: we were able to evaluate 11 from 24 of patients regarding hemostatic status pre-post stem cell injection. There were no significant difference between baseline vs 3 months in spontaneous aggregation (p=0.350), PT (p=0.793), aPTT (p=0.255) and TT (p=0.254). There were also no significant difference between baseline vs 3 months in plasma viscosity (p=0.442) and blood viscosity (p=0.843). Nevertheless the patient who had their blood and plasma viscosity above or below normal laboratory range return to normal level after the treatment. Both PT and APTT also show normalization value. Both Fibrinogen and CRP level show significant decrease between baseline and 3 months after treatment (p=0.009) and (p=0.04) respectively. CONCLUSION: combined G-CSF and EPO based-intracoronary infusion of PBSCs may open new perspective in the treatment of hypercoagulable state post AMI.

Safety and feasibility of combined granulocyte colony stimulating factor and erythropoetin based-stem cell therapy using intracoronary infusion of peripheral blood stem cells in patients with recent anterior myocardial infarction: one-year follow-up of a phase 1 study.

AIM: to assess the safety and feasibility of combined granulocyte colony-stimulating factor (G-CSF) and erythropoietin (EPO) based intracoronary peripheral blood stem cells (PBSCs) therapy in patients with recent myocardial infarction (RMI) who had successful reperfusion therapy with drug-eluting stent. METHODS: a total of 18 patients diagnosed with anterior ST-segment elevation AMI who had successful percutaneous coronary intervention (PCI) with drug-eluting stent implantation within 15 days after onset of symptom were enrolled. PBSCs were harvested and injected into the infarct-related artery after 5 consecutive days of G-CSF administration. Recombinant human erythropoietin was administered at the time of intracoronary PBSCs injection. RESULTS: there were no procedural and periprocedural complications, such as ventricular arrhythmia, visible thrombus formation, distal embolization, injury of the coronary artery associated with the cell infusion catheterization procedure or elevation of CK-MB of more than two-times. After PBSCs injection, all patients had grade III myocardial blush grade. At follow-up of 21.1±5.5 months (range 12 to 30 months) there was no death, no re-infarction, no target lesion revascularization nor re-hospitalization for heart failure. Paired cardiac MRI demonstrated no change in left ventricular end-diastolic volume (LVEDV) and left ventricular end-systolic volume (LVESV) at 3 months, but they increased significantly at one year. Despite this, left ventricular ejection fraction (LVEF), wall motion score index (WMSI) and perfusion score index (PSI) improved at 3 months and remained stable at one year. The percentage of late gadolinium enhancement to LV mass (%LGE) were continuously improved until one year. There was no correlation between the level of CD34+, CD 45+, other cell subtypes as well as total number of PBSCs injected to the changes of LVEDV, LVESV, LVEF, WMSI, PSI, and %LGE (p >0.05). CONCLUSION: combined G-CSF and EPO based- intracoronary infusion of PBSCs in patients RAMI is safe and feasible.

Deep vein thrombosis in patients with advanced liver cirrhosis: a rare condition?

PURPOSE: Patients with liver cirrhosis are generally considered to be "auto-anticoagulated" because of coagulopathy and thrombocytopenia. However, deep vein thrombosis (DVT) has been reported in patients with liver cirrhosis. The objectives of this study were to know the prevalence of DVT among cirrhotic patients and to compare clinical pictures between cirrhotic patients with and without DVT. METHODS: A case-control study was performed on the basis of medical record data of patients with liver cirrhosis admitted between August 2004 and July 2007 in Medistra hospital in Jakarta. Diagnosis of DVT was established by duplex Doppler ultrasonography of the lower extremities. Patients with splanchnic thrombosis were excluded from this study. Diagnosis of liver cirrhosis was based on history and clinical manifestation, consistent with liver cirrhosis and confirmed by ultrasonography or computed tomography. RESULTS: A total of 256 patients with liver cirrhosis were included in this study; 164 (64.1%) among them were men. Patients' mean age was 60.5 +/- 12.5 years, ranging from 16 to 88 years. Viral hepatitis accounted for 74.6% of patients with liver cirrhosis. DVT was found in 12 (4.7%) patients. There was no significant laboratory difference between cirrhotic patients with and without DVT (serum albumin, platelet count, aminotransferases, gamma-glutamyl transpeptidase, alkaline phosphatase, total bilirubin levels, and prothrombin time). Diabetes mellitus was significantly higher in the DVT group than that in the control group (66.6 vs. 34.0%, P = 0.025). Multivariate analysis confirmed diabetes mellitus as an independent risk factor for the occurrence of DVT (odds ratio = 4.26; 95% confidence interval = 1.206-15.034; P = 0.024). CONCLUSIONS: The prevalence of DVT in patients with liver cirrhosis was 4.7%, and Deep vein thrombosis is not a rare condition in cirrhotic patients with coagulopathy and warrants further studies on the mechanisms and prevention.