Is insertion of a plastic stent better and safer than epinephrine injection in post sphincterotomy bleeding?

OBJECTIVES: Epinephrine injection is the therapy of first choice in post sphincterotomy bleeding (PSB), but may not be efficient in all cases and can cause postprocedural myocardial infarction. Plastic stent insertion (PSI) may be a better treatment. The aim of this retrospective study was to compare epinephrine injection with PSI with respect to efficacy and safety. METHODS: Clinical success, number of reinterventions and hospital stays after therapy, postprocedural myocardial infarction, bilirubin increase, and pancreatitis as well as factors influencing PSB were analyzed. RESULTS: Seventy-nine PSBs in 5798 endoscopic retrograde cholangiopancreaticographies (ERCPs) from August 2002 through October 2018 were treated by epinephrine injection, PSI or both (n = 34, 30, 15). Clinical success of PSB therapy showed no difference: 33/34 (97%), 30/30 (100%), 14/15 (93%). Reinterventions were more frequent (n = 30 versus n = 1; P ≤ 0.0001) and hospital stay was longer [median: 3 (2-10) versus 2 (1-3) days; P = 0.0357] in patients who received PSI (versus epinephrine injection). Postprocedural adverse events were very rare: bilirubin increase (1/2/0) and pancreatitis (0/2/1). Intraprocedural episodes of hypertension (≥180 mmHg) were documented in 45-54%. CONCLUSIONS: Epinephrine injection is better than PSI in PSB. PSI may be an adequate treatment in patients with otherwise indicated stent insertion. Intraprocedural episodes of hypertension may be a risk factor for PSB.

Homozygous carrier of the NOD2 1007fs frame-shift mutation presenting with refractory community-acquired spontaneous bacterial peritonitis and developing fatal pulmonary mucormycosis: A case report.

Genetic variants of the innate immune system contribute to episodes of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis. We herein report the case of a patient with the homozygous nucleotide-binding oligomerization domain containing 2 (NOD2) frame-shift mutation 1007fs presenting with sepsis and community-acquired SBP by Escherichia coli. Secondary peritonitis, pancreatic ascites and malignant causes were excluded by extensive diagnostic work-up. First-line treatment with ceftriaxone was not successful despite in vitro sensitivity of the isolated strain. Despite prolonged second-line treatment with imipenem/cilastatin and intermittent ascites drainage, the ascitic fluid neutrophil count remained markedly elevated in this patient. In the course of the disease the patient developed pneumonia with identification of the typical hyphae of mucormycosis in the bronchoalveolar lavage and died of sepsis with multi-organ failure. On the basis of this observation, variants of the innate immunity have to be considered in therapy-refractory SBP, even when they are community-acquired and caused by cephalosporin-sensitive Enterobacteriaceae.

Six- and eightfold palladium-catalyzed cross-coupling reactions of hexa- and octabromoarenes.

Palladium-catalyzed sixfold coupling of hexabromobenzene (20) with a variety of alkenylboronates and alkenylstannanes provided hexaalkenylbenzenes 1 in up to 73 % and 16 to 41 % yields, respectively. In some cases pentaalkenylbenzenes 21 were isolated as the main products (up to 75 %). Some functionally substituted hexaalkenylbenzene derivatives containing oxygen or sulfur atoms in each of their six arms have also been prepared (16 to 24 % yield). The sixfold coupling of the less sterically encumbered 2,3,6,7,10,11-hexabromotriphenylene (24) gave the desired hexakis(3,3-dimethyl-1-butenyl)triphenylene (25) in 93 % yield. The first successful cross-coupling reaction of octabromonaphthalene (26) gave octakis-(3,3-dimethyl-1-butenyl)naphthalene (27) in 21 % yield. Crystal structure analyses disclose that, depending on the nature of the substituents, the six arms are positioned either all on the same side of the central benzene ring as in 1 a and 1 i, making them nicely cup-shaped molecules, or alternatingly above and below the central plane as in 1 h and 23. In 27, the four arms at C-1,4,6,7 are down, while the others are up, or vice versa. Upon catalytic hydrogenation, 1 a yielded 89 % of hexakis(tert-butylethyl)benzene (23). Some efficient accesses to alkynes with sterically demanding substituents are also described. Elimination of phosphoric acid from the enol phosphate derived from the corresponding methyl ketones gave 1-ethynyladamantane (3 b, 62 % yield), 1-ethynyl-1-methylcyclohexane (3 c, 85 %) and 3,3-dimethylpentyne (3 e, 65 %). 1-(Trimethylsilyl)ethynylcyclopropane (7) was used to prepare 1-ethynyl-1-methylcyclopropane (3 d) (two steps, 64 % overall yield). The functionally substituted alkynes 3 f-h were synthesized in multistep sequences starting from the propargyl chloride 11, which was prepared in high yields from the dimethylpropargyl alcohol 10 (94 %). The alkenylstannanes 19 were prepared by hydrostannation of the corresponding alkynes in moderate to high yields (42-97 %), and the alkenylboronates 2 and 4 by hydroboration with catecholborane (27-96 % yield) or pinacolborane (26-69 % yield).