A Low Impact Approach to Infected Pancreatic Necrosis: Review of a Case Series.

BACKGROUND: Infected pancreatic necrosis develops in approximately one third of patients with necrotizing pancreatitis and can lead to significant morbidity and mortality rates. Historically, open necrosectomy has been the mainstay of management for these patients but is in itself a morbid procedure. In recent times, minimally invasive techniques have evolved to allow a less invasive approach to these patients. Percutaneous catheter drainage of infected pancreatic necrosis is a technique that has been demonstrated to be potentially useful in the treatment of this group of patients. PATIENTS AND METHODS: The aim of this study was to review outcomes and define the technique of percutaneous catheter drainage in patients with infected pancreatic necrosis. All patients with infected pancreatic necrosis were exclusively treated with percutaneous drainage over the study period. Acute Physiology and Chronic Health Evaluation (APACHE) II score, number and size of drains, drainage technique and drain management, hospital and intensive care unit (ICU) stay, nutritional requirements, and morbidity and mortality data were evaluated for the patient group. Computed tomography (CT) scans were used to assess the progression of the disease process and the effectiveness of the treatment. RESULTS: There were nine patients with infected pancreatic necrosis in this case series between 2007 and 2012, all of whom were treated with percutaneous catheter drainage alone. The median APACHE II score in the patient group was 11, with a median stay in the ICU of 3 d and median hospital stay of 41 d. On average, nine CT scans were performed per patient during the hospital admission. A median of three drains were inserted per patient, and in the course of the study, it was evident that the larger drain size was the most effective. In eight of the nine patients in the group, complications developed that were both directly and indirectly related to the pancreatitis, but were effectively managed. There were no deaths. CONCLUSION: Percutaneous catheter drainage as a stand-alone intervention is an alternative strategy for infected pancreatic necrosis and can be used with acceptable morbidity and mortality rates in this challenging group of patients.

TDP-43 and ubiquitinated cytoplasmic aggregates in sporadic ALS are low frequency and widely distributed in the lower motor neuron columns independent of disease spread.

Ubiqitinated and TDP-43 immunoreactive cytoplasmic aggregates are hallmark features of ALS molecular pathology. Since clinically most ALS begins focally and advances contiguously, it is important to characterize their distribution. Our objective was to determine the extent and distribution of TDP-43 immunoreactive aggregates in the lower motor neuron columns as a function of disease onset, and to correlate ubiquitinated with TDP-43 aggregates in the lumbar region. We examined TDP-43 cytoplasmic aggregates at four separate neuraxis levels - hypoglossal nucleus and cervical, thoracic, and lumbar anterior horns - in five controls and 20 sporadic ALS nervous systems from patients whose disease began in various sites, i.e. five bulbar, five arm, five trunk, and five leg onsets. We correlated ubiquitinated to TDP-43 aggregates on adjacent histological sections for the lumbar regions. We found that TDP-43 cytoplasmic aggregates are seen in about 8% of motor neurons but there is marked variability between nervous systems, ranging from 0.4% to 20.6%. The aggregates are uniformly distributed within individual nervous systems. There is no obvious correlation between site of disease onset and rate of spread. Almost all ubiquitinated aggregates correlate to TDP-43 aggregates. Thus, TDP-43 immunoreactive cytoplasmic aggregates have a low overall average frequency that does not correlate with either disease course or clinical spread and is the prime ubiquitinated protein.