Obstructive jaundice in autoimmune pancreatitis can be safely treated with corticosteroids alone without biliary stenting.

OBJECTIVE: Autoimmune pancreatitis (AIP) responds dramatically to corticosteroids treatment. We reviewed our experience to determine the safety and effectiveness of treating obstructive jaundice in definitive AIP with corticosteroids alone without biliary stenting. METHODS: From our AIP database, we retrospectively identified type 1 AIP subjects whose jaundice was treated with corticosteroids alone without biliary stenting. Their medical records were reviewed and clinical data were evaluated to determine the outcomes. RESULTS: Fifteen AIP subjects (87% male, mean age 68.4 years) were treated with corticosteroids at initial presentation (n = 8), first (n = 5) or subsequent (n = 2) relapse. Mean values (upper limit of normal, ULN) of liver tests prior to corticosteroids were aspartate aminotransferase (AST) 203.5u/l (4 × ULN), alanine aminotransferase (ALT) 325.8u/l (6 × ULN), alkaline phosphatase (ALP) 567.4u/l (5 × ULN), and total bilirubin (TB) 5.9 mg/dl (5.9 × ULN). At first follow-up (mean 4 days) the decrease was 54.9% for AST, 51.6% for ALT, 33% for ALP and 47.2% for TB (all p < 0.05). After 15-45 days, all patients had normal AST, 3/15 had ALT > 1.5 × ULN, 1/15 had ALP > 1.5 × ULN, 1/15 had TB > 1.5 × ULN. No patient required biliary stent placement, or developed cholangitis or other infectious complications during steroid treatment. CONCLUSION: Under the supervision of an experienced pancreatologist and with close monitoring of patients, obstructive jaundice secondary to definitive AIP can be safely and effectively managed with corticosteroids alone, without the need for biliary stenting.

Pituitary tumor apoplexy in adolescents.

OBJECTIVE: The aim of this study was to determine whether there are differences in pituitary apoplexy and subclinical apoplexy secondary to adenoma hemorrhage in the adolescent population with regard to symptomatology, neuroimaging features, pathology, and outcomes compared with adults. METHODS: A retrospective series of 9 consecutive patients with a diagnosis of pituitary hemorrhage who were surgically treated at Rady's Children's Hospital San Diego, between 2008 and 2013 were evaluated for clinical, endocrine, neuroradiographic, and pathologic features in association with clinical outcomes. RESULTS: Nine patients (6 girls, age 14-21 years) presented to our institution with headache (9/9), nausea (3/9), dizziness (4/9), and visual disturbances (6/9) in the setting of a sellar hemorrhagic tumor on magnetic resonance imaging (MRI). Three patients presented with apoplexy and 6 with subclinical apoplexy. Duration of symptoms ranged from 3 days to 1 year. MRI revealed hemorrhage (9/9), rim enhancement (6/9), sphenoid sinus mucosal thickening (2/9), mass effect on the optic chiasm (8/9), and sellar remodeling (9/9). The percentage of hemorrhage preoperatively observed on MRI ranged from 50% to greater than 95%. On presentation, hyperprolactinemia was recorded in 7 patients, 6 of whom had galactorrhea and/or amenorrhea. Open transsphenoidal decompression was performed in 8/9 patients; 7 of 9 were diagnosed with prolactinoma. Biopsy specimens revealed 10%-90% hemorrhage and no infarction in any of the cases. All patients treated showed improvement of symptoms after surgery (average follow-up, 28.2 months). Postoperative complications included transient diabetes insipidus (n = 5), persistent cerebrospinal fluid rhinorrhea (n = 3), and meningitis (n = 1). Five patients had long-term endocrine sequelae of hyperprolactinemia requiring ongoing medical treatment. CONCLUSIONS: Pituitary hemorrhage resulting in apoplexy or subclinical apoplexy in adolescents may represent a distinct entity with a more indolent symptomatology and more favorable neurologic and endocrine outcome compared with adults that is worthy of further validation in a multi-institutional cohort.

Evaluating critical factors to the economic feasibility of semi-intensive pig rearing in western Kenya.

The purpose of this research is to assess how season, ADG, opportunity costs of farm-grown feeds, pig weight, and butcher price variation impact the economic potential of semi-intensive pig rearing. We developed a unique algorithm that emulates least-cost pig feeding and used it to assess the impact of the aforementioned factors on farmers' maximum revenue and profit potential when pigs are sold to local butchers in western Kenya. When considered as independent factors influencing feed costs to grow a pig to a market weight of 30 kg, variation in ADG, opportunity cost of feed, and weaning season resulted in feed cost differences of up to 982, 947, and 379 Kenyan shillings (KES), respectively. The variation in revenues attributable to butcher or butcher negotiation and seasonal variance of butcher prices for a 30 kg pig was 744 and 225 KES, respectively. Feed items most commonly chosen for least-cost feed rations were small dried fish, cooked ground maize, whole maize, millet, cassava foliage, sweet potato vines, bone meal, avocado, and mango. Smallholder farmers who can feed pigs to reach higher ADG, have lower opportunity costs of feeds and/or who effectively bargain with butchers can benefit from semi-intensive pig rearing. Farmers without access to at least some zero-cost feeds and farmers with opportunity costs of feeds exceeding 50 % of the market price will not earn positive returns from semi-intensive pig rearing.

A description of local pig feeding systems in village smallholder farms of Western Kenya.

We used face-to-face interviews to gather data on pig feeding practices in rural Busia District, Kenya. We visited 164 pig farms three times in the course of the study period. The pigs were weighed in kilograms during the visits. Feeds offered to pigs were described during the interviews. The most frequently fed feedstuffs were; ground maize or "ugali" (88%), kitchen leftovers (83%) and dried fish locally called "omena" (78%). Farmers provided pigs with water separately from the feeds. Sweet potatoes, "ugali" and cassava were available and could serve as good sources of energy for pigs in the district. Fruits and vegetables were also available and could potentially act as good sources of vitamins. Sweet potato vines, "omena" fish and slaughter blood were available and could provide pigs with proteins. The average daily gain (ADG) for pigs ≤ 5 months of age, pigs of 5.1-9.9 months of age and pigs of ≥ 10 months old was 94.5 (± 43), 127 (± 49.8) and 99 (± 92) g, respectively (p = 0.000). This study has outlined the different local pig feeds available in Busia district. We recommend two things: first, additional research on nutrient composition for the identified local feeds, and second, developing and validating simple local feed combinations that would achieve balanced local pig rations.

Evaluating the efficacy of teaching methods regarding prevention of human epilepsy caused by Taenia solium neurocysticercosis in Western Kenya.

Taenia solium neurocysticercosis is a major cause of adult-onset epilepsy in developing countries. A questionnaire was administered to 282 Kenyan farmers, followed by a workshop, a second questionnaire, one-on-one training, and a third questionnaire. People who attended workshops were more likely to know how T. solium causes epilepsy in humans in the third visit than the second (P = 0.001). The likelihood that farmers would tether their pigs 100% of the time, limiting exposure to tapeworm eggs, increased after the first (P < 0.001) and second visits (P < 0.001). Farmers were more likely to have heard of Cysticercus cellulosae in the second (P = 0.001) and third visits (P = 0.007), and to know how pigs acquire infection in the second (P = 0.03) and third visits (P = 0.003). Farmers with at least a grade 8 education were more likely to know how T. solium is transmitted to humans in the second (P = 0.001) and third visits (P = 0.009), and were more likely to understand the relationship between epilepsy and T. solium in the second (P = 0.03) and third visits (P = 0.03). Grade 8 education may enhance learning from written material. Workshops followed by individual on-farm training enhanced knowledge acquisition and behavior changes. Training local government extension workers contributed to the sustainability of this project.

Blood-conservation techniques in craniofacial surgery.

Attempts at reducing exposure to allogeneic transfusions, using blood conservation techniques such as controlled hypotension and normovolemic hemodilution, have met with mixed results and are not always practical in small infants. Recombinant human erythropoietin (RHE), a hormone that stimulates RBC production, increases the hematocrit when administered to infants. A retrospective chart review of all patients undergoing fronto-orbital advancement for craniosynostosis by the same plastic surgeon between January 2002 and December 2002 was conducted. A subgroup of patients (10/19) received RHE as a blood-conservation strategy. Transfusion requirements were lower in the RHE group (5/10) versus the control group (9/9). Total volume of blood products transfused was statistically lower in the RHE group (154 mL RHE group versus 421 mL control) (P < 0.03). RHE combined with blood-conservation techniques was associated with a decreased need for blood transfusion, thus exposing the patient to fewer risks associated with allogeneic transfusion.

Guidelines for the management of head injuries in remote and rural Alaska.

Numerous recommendations on the initial evaluation and treatment of the head injured patient have been proposed over the last several years. Most assume there is readily available access to computed tomography and neurosurgical specialists. Many clinicians in Alaska must evaluate and begin treatment of head injured patients in circumstances quite different from this. Vast distances, severe weather and limited medical evacuation capability are factors that come into play while caring for these patients. The current medicolegal climate also contributes to clinician anxiety over missing rare but potentially serious injuries. These guidelines developed by Alaska clinicians from multiple specialties are meant to assist clinicians dealing with this very common problem and represent a reasonable approach to these patients in remote and rural Alaska.