Prospective study of the effectiveness of percutaneous transhepatic photodynamic therapy for advanced bile duct cancer and the role of intraductal ultrasonography in response assessment

BACKGROUND AND STUDY AIMS

We evaluated the therapeutic effects of percutaneous transhepatic photodynamic therapy (PDT) in patients with advanced bile duct cancer. The utility of intraductal ultrasonography (IDUS) for the assessment of responses and for regular follow up after PDT was also examined.

METHODS

Percutaneous transhepatic biliary drainage (PTBD) was initiated before PDT. Following dilation and maturation of the PTBD tract, percutaneous PDT was performed. Intraluminal photoactivation was carried out using percutaneous cholangioscopy 2 days after intravenous application of a hematoporphyrin derivative. All patients were additionally provided with percutaneous bile duct drainage catheters after PDT. IDUS was conducted monthly to measure the thickness of the tumor mass before and after PDT.

RESULTS

24 patients with advanced cholangiocarcinomas (Bismuth IIIa, n = 4; IIIb, n = 10; IV, n = 10) were treated with PDT. At 3 months after PDT, the mean thickness of the tumor mass had decreased from 8.7 +/- 3.7 mm to 5.8 +/- 2.0 mm (P < 0.01). At 4 months after PDT, the thickness of the mass had increased to 7.0 +/- 3.7 mm. Quality of life indices improved dramatically and remained stable 1 month after PDT; the Karnofsky index increased from 39.1 +/- 11.36 to 58.2 +/- 22.72 points (P = 0.003). The 30-day mortality rate was 0 %, and the median survival time was 558 +/- 178.8 days (current range 62 - 810 days).

CONCLUSIONS

PDT using percutaneous cholangioscopy is safe and effective for advanced hilar cholangiocarcinoma, and seems to prolong survival. IDUS is useful for evaluating changes in the thickness of the tumor mass after PDT.

Outbreak of Multi-drug Resistant Salmonella Typhi Enteric Fever in Mumbai Garrison

BACKGROUND

There was an epidemic of enteric fever in Mumbai garrison during Nov-Dec 2000 with more than 150 cases admitted to a tertiary care service hospital.

METHODS

All the cases presented with fever and some had splenomegaly, bradycardia, abdominal pain and diarrhoea. The epidemic was investigated by the station health organization (SHO) and the case and bacteriological study was carried out in pathology laboratory of the service hospital. The serological study was carried out at Armed Forces Medical College (AFMC), Pune and the Phage typing was carried out at Lady Harding Medical College, New Delhi.

RESULTS

Blood cultures were positive in 92(63%) for Salmonella typhi and Widal test was positive in 83(55%). All strains were resistant to four primary drugs i.e. ampicillin, chloramphenicol, co-trimoxazole and tetracycline. All but two were treated successfully with ceftriaxone. The Salmonella typhi belonged to phage group E1 and biotype I.

CONCLUSION

Extensive epidemiological investigation of cases and water sources of cantonment area pointed to a common source of the epidemic i.e. the well near 'Gurudwara'.

Management of malignant strictures of the cervical esophagus with a newly-designed self-expanding metal stent

Recently, the use of self-expanding metal stents has become a well-established method of palliative treatment for stenotic malignant diseases in the middle and distal esophagus. However, published results on the use of self-expanding metal stents in cervical esophageal cancer are somewhat limited by a paucity of clinical details and experience. A new self-expanding esophageal metal stent with a short upper flange 0.7 cm in length was studied prospectively in order to assess its efficacy for palliative treatment. This report presents experience in three patients in whom this new stent was used in the treatment of cervical esophageal cancers. Stent placement was successful in all three patients, with no serious complications such as esophageal perforation, hemorrhage, or foreign-body sensation. All of the patients experienced rapid improvement in dysphagia and clinical symptoms. The newly designed self-expanding stent can be of value in the treatment of stenotic cervical esophageal cancer.

Immediate haemostasis with recombinant factor VIIa for haemorrhage following Hickman line insertion in acute myeloid leukaemia

Bleeding following Hickman line insertion is not uncommon but can be life threatening, especially in the presence of coagulopathy and thrombocytopenia following chemotherapy. Treatment to control the bleeding can be challenging and treatment options are limited. We present our experience of a patient who had persisting haemorrhage immediately following Hickman line insertion for administration of chemotherapy for relapsed acute myeloid leukaemia. Haemostasis could not be achieved after FFP and platelet administration. A single dose of recombinant factor VIIa (rhFVIIa) stopped the bleeding immediately, avoiding the need for surgical intervention or line removal. Our experience indicates rhFVIIa may be an effective option for bleeding related to Hickman line insertion.

Eptifibatide-induced profound thrombocytopenia

We report a case of profound thrombocytopenia, 2 hours following eptifibatide therapy which got reversed within 12 hours of discontinuation of eptifibatide.

Invasive intraductal papillary mucinous tumor of the pancreas with simultaneous invasion of the stomach and duodenum

An 81-year-old woman was admitted with epigastric pain and weight loss. She had been diagnosed with an intraductal papillary mucosal tumor (IPMT) 7 years previously, but had refused surgery for religious reasons. Esophagogastroduodenoscopy revealed a nodular, elevated lesion that was discharging mucin into the duodenal bulb and posterior wall of the upper body of the stomach. Endoscopic ultrasonography, abdominal computed tomography, and endoscopic retrograde cholangiography were carried out, and a highly invasive IPMT with simultaneous invasion of the stomach and duodenum was diagnosed.

Constipation and its implications in the critically ill patient

BACKGROUND

Motility of the lower gut has been little studied in intensive care patients.

METHOD

We prospectively studied constipation in an intensive care unit of a university hospital, and conducted a national survey to assess the generalizability of our findings.

RESULTS

Constipation occurred in 83% of the patients. More constipated patients (42.5%) failed to wean from mechanical ventilation than non-constipated patients (0%), P<0.05. The median length of stay in intensive care and the proportion of patients who failed to feed enterally were greater in constipated than non-constipated patients (10 vs 6.5 days and 27.5 vs 12.5%, respectively (NS)). The survey found similar observations in other units. Delays in weaning from mechanical ventilation and enteral feeding were reported by 28 and 48% of the units surveyed, respectively.

CONCLUSIONS

Constipation has implications for the critically ill.

Do we practise what we preach?

There are recommendations regarding many facets of lifestyle. We proposed to look at hospital doctors' habits in East Yorkshire.

METHOD

A simple questionnaire was sent out to 574 doctors in the Hull and East Yorkshire Hospitals NHS Trust. Non-responders were re-mailed. Age, sex, grade, specialty, number of portions of fruit and vegetable per day, alcohol intake, smoking, exercise and hours worked.

RESULTS

301 doctors (238 males, 60 females) responded (response rate 58%). Approximately half of doctors who responded were consultants. Few respondents smoked (6.6%), and the mean alcohol consumption, 8.35 units per week (SE 0.54), was less than the recommended limits for men and women. Most doctors fell short of the "recommended" 5 portions of fruit and vegetables per day (median 3 per day) and nearly half worked more than 56 hours per week. Most respondents took at least the recommended amount of exercise per week (112 SE25 minutes) although 26% of doctors took no exercise at all.

Speciation of mercury in soil and sediment by selective solvent and acid extraction

In order to characterize the mercury hazard in soil, a sequential extraction scheme has been developed to classify mercury species based on their environmental mobility and/or toxicity for either routine lab analysis or on-site screening purposes. The alkyl mercury species and soluble inorganic species that contribute to the major portion of potential mercury toxicity in the soil are extracted by an acidic ethanol solution (2% HCl+10% ethanol solution) from soil matrices as "mobile and toxic" species. A High-Performance Liquid Chromatography (HPLC) system coupled with Inductively Coupled Plasma Mass Spectrometry (ICP-MS) detection has been developed to further resolve the species information into soluble inorganic species (Hg(2+)), methylmercury(II) (MeHg(+)) and ethylmercury(II) (EtHg(+)) species. Alternatively, these species can be separated into "soluble inorganic mercury" and "alkyl mercury" sub-categories by Solid-Phase Extraction (SPE). A custom Sulfydryl Cotton Fiber (SCF) material is used as the solid phase medium. Optimization of the SCF SPE technique is discussed. Combined with a direct mercury analyzer (DMA-80), the SCF SPE technique is a promising candidate for on-site screening purposes. Following the ethanol extraction, the inorganic mercury species remaining in soil are further divided into "semi-mobile" and "non-mobile" sub-categories by sequential acid extractions. The "semi-mobile" mercury species include mainly elemental mercury (Hg) and mercury-metal amalgams. The non-mobile mercury species mainly include mercuric sulfide (HgS) and mercurous chloride (Hg(2)Cl(2)).

Influences of the N- and C-termini of the distal nephron inward rectifier, ROMK

The inward rectifying potassium channels of the ROMK family are present in the distal nephron of the kidney. These channels have two membrane spanning portions, between which lies a hydrophobic domain thought to confer the majority of the conductive properties of the channel. The N- and C-termini are both intracellular. In this paper we have examined the contribution of the N- and C-termini to the pore by examining the interaction of Cs+ with the channels. ROMK1 has an additional 19 amino acids on its N-terminus in comparison to ROMK2. The C-terminus of ROMK2 was extended by addition of a streptavidin tag (sfROMK2). Currents were measured following expression in Xenopus oocytes using two-electrode voltage clamp. ROMK1, ROMK2 and sfROMK2 exhibited concentration- and voltage-dependent block of inward currents by extracellular Cs+. The Hill coefficients were not significantly different from one. The mean Kd values at 0 mV were 100.6 +/- 10.6, 63.1 +/- 3.9 and 40.6 +/- 9.4, respectively (p < 0.05). The electric distances (delta) were 0.94 +/- 0.06, 1.0 +/- 0.05 and 1.37 +/- 0.06 respectively. The delta of sfROMK2 was greater than either ROMK1 or ROMK2 (p < 0.001). ROMK1, ROMK2 and sfROMK2 are sensitive to extracellular Cs+. Block was both concentration- and voltage-dependent. sfROMK2 is most Cs+-sensitive. ROMK1 contains an additional N-terminal 19 amino acids. Thus the pore properties of these two isoforms are subtly different, and influenced by the N-terminus. The lower Kd in sfROMK2 suggests that the streptavidin tag, and perhaps the C-terminus, also affect the pore.

Biophysical effects of pore mutations of ROMK1

Potassium channels are ubiquitous, being present in all living organisms. These proteins share common structural elements, which confer common functional features. In general, all K+ channels have a high selectivity for K+, and are blocked by cations of similar dimensions, such as Cs+ and Ba2+. Mutations in the pore region tend to lead to either the total loss of function or K+ selectivity. We have made mutations to one of the most highly conserved residues of the pore, glycine-143, of the inward rectifier ROMK1 (Kir1.1), and examined the resulting channel properties in the Xenopus oocyte expression system with a two-electrode voltage clamp. Mutations G143A and G143R resulted in failure to express functional channels. Co-injection of wild-type ROMK1 cRNA with these mutants led to rescue of channel function, which was different from wild-type ROMK1. In both mutants, the sensitivity to Ba2+ and Cs+ was increased, the rate of onset of block by Ba2+ was enhanced, and the selectivity to potassium was reduced. Whereas the crystallographic evidence shows that cations bind to the carbonyl backbone of the pore-lining residues, the present results indicate that the side chains of these amino acids, which face away from the pore lining, also affect permeation.

Aspergillus spinal epidural abscess

Spinal abscess due to Aspergillus is rare. A young boy with chronic granulomatous disease and aspergillosis of the rib had been treated with antifungal treatment 3 months earlier. The patient presented with a brief history of progressive paraparesis. Imaging showed D9--11 vertebral involvement and destruction of the D10 vertebral body with angulation and a large dorsally placed, multiloculated epidural abscess extending from D6 to L2. There was also extensive granulation anterior to and on either side of the vertebrae. The patient underwent extensive laminectomy and decompression of all the loculi and partial removal of the granulation tissue. Aggressive medical treatment was started. The authors recommend an aggressive surgical and medical approach in such cases of disseminated invasive aspergillosis, even though the result may not be very satisfactory. This report discusses the full clinical profile and management of Aspergillus spinal epidural abscess and emphasizes the need to follow up these cases to detect recurrence and new lesions, even if the patients are on adequate medical treatment. In spite of all efforts, high morbidity and mortality is common in such patients.

A clinico-epidemiological study of organophosphorus poisoning at a rural-based teaching hospital in eastern Nepal

Thirty-seven patients with severe organophosphorus poisoning (OPP) presented to the emergency ward of BP Koirala Institute of Health Sciences between January 1995 and December 1996. The mean age of patients was 26.9 years. There were 17 (46%) males and 20 (54%) females, with male:female ratio being 1:1.2.Twenty-three (62%) patients were unmarried with 16 (46%) of them students. The most common reason for poisoning was suicide--32 patients (86.5%). The most commonly involved compound was Metacid (methyl-parathion)--23 (62%) patients. Ninety per cent of the patients presented within 2 h of ingestion. All patients were managed with intravenous atropine. Pralidoxime was given to patients with nicotinic symptoms and mechanical ventilation initiated in patients with respiratory distress. The mean dose of atropine used in the first 24 h and during the hospital stay was 30.6 mg and 136.7 mg, respectively. The mean duration of treatment was 5.5 days (range 2-20 days). Two patients developed intermediate syndrome and the overall mortality among hospitalized patients was 8%.

A triple dose of iron deficiency anaemia

A81-year-old ex-smoker, who previously smoked 20 cigarettes/day, and had an alcohol consumption of 8–10 units/week, presented with a 3-month history of ‘indigestion’ and breathlessness. He denied weight loss, dysphagia, vomiting, change in bowel habit or melaena. He denied taking aspirin or other non-steroidal anti-inflammatory medication. He suffered from ischaemic heart disease with biventriciular dysfunction. He was pale and had a blood pressure of 140/60 mmHg with no postural drop. The rest of the examination was unremarkable.

Investigations showed a hypochromic (mean corpuscular volume 56.1 fL) microcytic (mean corpuscular haemoglobin 13 pg) anaemia with numerous hypersegmented neutrophils on blood film, a haemoglobin of 7.1 g/dl and serum ferritin of 4 μg/litre. Vitamin B12 and serum folate concentrations were normal. Upper gastrointestinal endoscopy demonstrated a 5 mm prepyloric ulcer and a 10 mm benign duodenal ulcer. Multiple biopsies were negative for Helicobacter pylori. Histology showed chronic gastritis and no malignant or dysplastic cells.

He was transfused 3 units of packed cells, and commenced on ferrous sulphate and omeprazole before discharge home with a stable haemoglobin (11.4 g/dl). Six months later he again developed iron deficiency anaemia. His haemoglobin remained low (haemoglobin 8.2 g/dl, mean corpuscular volume 62.5 fL and ferritin 6 μg/litre). His appetite remained reasonable, weight steady and bowel habit unchanged.

Repeat upper gastrointestinal endoscopy showed an abnormal ulcerated duodenal cap. Biopsy excluded neoplasm, Helicobacter pylori or infestation with giardiasis. Flexible sigmoidoscopy revealed grade II haemorrhoids and a large 2 cm tubulovillous adenomatous polyp in the sigmoid colon at 30 cm (Figure 1). Chest X-ray, abdominal ultrasound and carcinoembryonic antigen level were normal. Double contrast barium enema showed sub-total obstruction in the ascending colon (Figure 2). Radical right hemicolectomy and mesenteric node clearance of a bulky, Dukes B moderately differentiated mucinous adenocarcinoma was performed. Three years on he remains well, his haemoglobin level is 11 g/dl and there is no evidence of tumour recurrence.