Percutaneous cholecystostomy treatment of acute cholecystitis in pregnancy.

BACKGROUND: Medical treatment of acute cholecystitis in pregnancy may lead to prolonged management and recurrent hospitalizations, whereas surgical management predisposes the mother and fetus to the inherent risks of surgery and general anesthesia. Although percutaneous cholecystostomy has been proven to be an efficacious treatment in critically ill and general surgery patients who are at high risk for surgery, this technique has not been used routinely as a treatment for acute cholecystitis in pregnancy. CASES: We report two women (at 30 and 32 weeks' gestation, respectively) who presented with acute calculus cholecystitis. The first patient was a 33-year-old female who failed endoscopic retrograde cholangiopancreatography and papillotomy and had multiple return visits for nausea and vomiting. The second patient was a 23-year-old female with three previous admissions for cholecystitis during the pregnancy. These two patients underwent emergency ultrasound-guided percutaneous transhepatic cholecystostomy. Percutaneous cholecystostomy provided adequate biliary decompression for the remainder of the pregnancy; the patients delivered healthy infants and underwent successful uncomplicated elective laparoscopic cholecystectomy within 3 months of delivery. CONCLUSION: Percutaneous cholecystostomy may provide a safe and effective alternative for the palliation of acute cholecystitis in pregnancy until a postpartum cholecystectomy can be performed.

Angioplasty for the treatment of visceral ischemia.

PURPOSE: To evaluate percutaneous transluminal angioplasty (PTA) in the treatment of visceral ischemia. PATIENTS AND METHODS: Over a 14-year period, 25 focal visceral artery stenoses were treated with PTA in 16 patients with acute or chronic visceral ischemia. Thirteen patients were women and three were men, with a mean age of 64.7 years (range, 54-79 years). PTA was performed in seven celiac arteries, 17 superior mesenteric arteries, and one inferior mesenteric artery. RESULTS: PTA was technically successful in 14 of 16 patients (88%). Two patients were lost to follow-up. Nine of 12 patients (75%) demonstrated primary patency with relief of clinical symptoms at a mean follow-up of 2.3 years (range, 0.3-5 years). The remaining three patients underwent successful repeat PTA for recurrent symptoms. There was one postprocedural death, and one patient subsequently underwent successful surgical bypass for recurrent visceral ischemia. CONCLUSIONS: Angioplasty of the visceral arteries may provide relief for select patients with intestinal ischemia, but redilation may be required in some patients.

HLA-DR3 and DRw6: prognostic factors for the incidence of hypothyroidism in Graves' disease after radioiodine treatment.

Several studies demonstrated a relationship between HLA-B8 and -DR3 and the early course of thyroid function after treatment of thyrotoxicosis. However, the association between certain DR antigens and the outcome of thyroid function years after radioiodine treatment for Graves' disease remains unclear. We therefore determined the HLA pattern in 2 groups of female patients with different severity of hypothyroidism. From a total of 45 patients, 27 had developed pre-clinical hypothyroidism (normal serum levels of T4, FT4 and T3, normal or elevated basal TSH levels, but an exaggerated TSH response to TRH, Group A). Mean follow-up was 111 months (range 36-360 months) for this group. Eighteen patients had become overtly hypothyroid (T4 and FT4 levels in the hypothyroid range and an elevated basal TSH concentration, group B) after a mean interval of 51 months (range: 4-132 months) following treatment. Eighty-seven healthy blood donors served a controls. Positive plasma antibody titres (tanned red cell haemagglutination technique) were observed in 67% of all patients with a preponderance in group B (83% versus 56% in group A, n.s.). The whole group of Graves' disease patients showed the antigens B8, DR3 and Drw6 in 37.8%, 33.3% and 35.6%, respectively (P less than 0.02, less than 0.05, and less than 0.04 vs controls). In patients with pre-clinical hypothyroidism there was a significantly increased prevalence of antigen B8 (P less than 0.01) and DR3 (P less than 0.05) compared to the control group. In contrast, the overt hypothyroid group showed an augmented frequency of HLA-DRw6 (P less than 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)

Intra-arterial fibrinolytic therapy. Efficacy of streptokinase vs urokinase.

This study is a retrospective comparison of the results in 25 low-dose, intra-arterial streptokinase and 12 low-dose intra-arterial urokinase infusions for thromboembolic disease. Intra-arterial streptokinase was successful in 50% of infusions and was marked by significant abnormalities in the coagulation criteria. There was a high incidence of major and minor bleeding (48% overall), which could be attributed to systemic effects of the drug. Urokinase was successful in 100% of infusions, and showed no significant effects on systemic coagulation criteria. There were also fewer complications during urokinase infusion. The average pharmacy cost for a course of intra-arterial streptokinase was $165, while urokinase cost $1142. Despite the significant difference in expense, the increased efficacy and safety of urokinase make it the preferred agent for intra-arterial infusion. Theoretical reasons for the increased effectiveness of urokinase are discussed.

Differential effects of two ways of devaluing the unconditioned stimulus after Pavlovian appetitive conditioning.

Three experiments with rat subjects investigated the effects of two methods of devaluing a food unconditioned stimulus (US) after pairings of an auditory conditioned stimulus (CS) with that US. Experiment 1 found no effect of postconditioning pairings of the food US with lithium chloride (LiCl) on general activity to a tone CS, even though those pairings substantially reduced food consumption. Experiments 2 and 3 compared the effects on conditioned responding of postconditioning pairings of food with LiCl and with high-speed rotation. In these experiments the general activity measure was supplemented by a detailed visual analysis of the rats' behavior. Experiment 2 found that food-rotation pairings had larger effects than food-LiCl pairings on general activity responding and on two detailed behavioral measures but that food-LiCl pairings had larger effects on food consumption and on one behavioral measure. Experiment 3 replicated the findings of Experiment 2 and found that the ability of the CS to serve as a reinforcer for second-order conditioning after US devaluation was reduced more by food-LiCl pairings.