Hepatobiliary Metastasis of Colorectal Cancer in a Frail Patient and the Role of Immunohistochemistry and Endoscopic Retrograde Cholangiopancreatography (ERCP): A Case Report

Primary cholangiocarcinoma (malignancy of the bile ducts) is potentially a treatable malignancy via surgery. It presents with a derangement in the liver function blood test results, which results in raised bilirubin. It may also be accompanied by the complaint of itching of skin, dark urine, and light color stool. Bile duct metastasis from primary colorectal cancer, although a very rare condition presents with similar symptomatology and blood test results. Immunohistochemistry staining of tissue biopsy has significantly improved differentiation, detection, and hence plan management of both malignancies (cholangiocarcinoma and bile duct metastasis from primary colorectal cancer). The role of endoscopic retrograde cholangiopancreatography (ERCP) is important with the insertion of a stent towards symptom relief when palliative management is indicated in patients with an incurable disease.

Safety and tolerability of transcranial magnetic and direct current stimulation in children: Prospective single center evidence from 3.5 million stimulations

BACKGROUND

Non-invasive brain stimulation is being increasingly used to interrogate neurophysiology and modulate brain function. Despite the high scientific and therapeutic potential of non-invasive brain stimulation, experience in the developing brain has been limited.

OBJECTIVE

To determine the safety and tolerability of non-invasive neurostimulation in children across diverse modalities of stimulation and pediatric populations.

METHODS

A non-invasive brain stimulation program was established in 2008 at our pediatric, academic institution. Multi-disciplinary neurophysiological studies included single- and paired-pulse Transcranial Magnetic Stimulation (TMS) methods. Motor mapping employed robotic TMS. Interventional trials included repetitive TMS (rTMS) and transcranial direct current stimulation (tDCS). Standardized safety and tolerability measures were completed prospectively by all participants.

RESULTS

Over 10 years, 384 children underwent brain stimulation (median 13 years, range 0.8-18.0). Populations included typical development (n = 118), perinatal stroke/cerebral palsy (n = 101), mild traumatic brain injury (n = 121) neuropsychiatric disorders (n = 37), and other (n = 7). No serious adverse events occurred. Drop-outs were rare (<1%). No seizures were reported despite >100 participants having brain injuries and/or epilepsy. Tolerability between single and paired-pulse TMS (542340 stimulations) and rTMS (3.0 million stimulations) was comparable and favourable. TMS-related headache was more common in perinatal stroke (40%) than healthy participants (13%) but was mild and self-limiting. Tolerability improved over time with side-effect frequency decreasing by >50%. Robotic TMS motor mapping was well-tolerated though neck pain was more common than with manual TMS (33% vs 3%). Across 612 tDCS sessions including 92 children, tolerability was favourable with mild itching/tingling reported in 37%.

CONCLUSIONS

Standard non-invasive brain stimulation paradigms are safe and well-tolerated in children and should be considered minimal risk. Advancement of applications in the developing brain are warranted. A new and improved pediatric NIBS safety and tolerability form is included.

Delayed pseudoaneurysm after renal artery angioplasty

PURPOSE

To report delayed pseudoaneurysm formation after percutaneous renal artery angioplasty.

CASE REPORTS

A 56-year-old woman succumbed to complications of a ruptured right juxtarenal aortic pseudoaneurysm 2 years after right renal artery stenting for renal impairment. The juxtarenal aorta had been normal on aortography at the time of angioplasty. She gave a history of right-sided back pain that started within 8 months of the angioplasty. A 21-year-old woman with left renal artery stenosis due to fibromuscular dysplasia was treated with balloon angioplasty, after which there was evidence of active extravasation. The completion angiogram, after a period of observation, documented cessation of the leak. Follow-up angiography because of persisting hypertension disclosed a large, asymptomatic, intrarenal pseudoaneurysm that was repaired with bench surgery and autotransplantation.

CONCLUSIONS

We advise that patients with symptoms referable to the site of renal artery intervention and those who have had complicated interventions should have follow-up imaging to exclude pseudoaneurysm formation.

An audit of problems associated with urinary catheter withdrawal

Long-term catheterisation is associated with many complications, including urinary tract infections which may lead to encrustation and catheter blockage. Current management of catheters susceptible to frequent blocking is to attempt to prolong catheter life by using bladder maintenance solutions or to change catheters proactively by identifying a characteristic blocking pattern for the patient. However, catheter removal is associated with a number of problems. This article describes an audit conducted in one trust to identify the types of catheter material associated with removal difficulties. All-silicone catheters appeared to have a higher incidence of reported problems. The formation of a 'cuff' in all-silicone catheters when the catheter balloon fails to deflate to its original shape has been investigated as an important factor in difficult removal. The audit also examined what action was taken when nurses were unable to remove a catheter.

Optimization of debris removal during bladder irrigation

Debris build-up within the bladder is one of the main problems encountered by patients undergoing long term catheterization. One of the methods of ameliorating this is to wash out the bladder at regular intervals. In this paper, an alternative method of bladder irrigation is investigated experimentally. The effectiveness of several possible catheter designs has been examined, together with other relevant variables such as the proximity and alignment of the tube tip to the debris and the irrigation flow rate. Results show that debris removal is very sensitive to tube design, with best designs achieving almost complete removal and the worst practically none. The proprietary continuous irrigation catheter used was particularly poor for the type of debris used. Removal is insensitive to the distance of the tube tip from the bladder base up to a limiting value, above which it reduces rapidly. Where misalignment causes the inlet jet to miss the debris, removal rates are very low. Increasing flow rate increases removal up to a limiting value, above which it remains constant. Although the results show the general trends, to optimize the system requires further understanding of the detailed flow patterns within the bladder. A theoretical study using computational fluid dynamics is thus being undertaken.

Bladder washouts in the management of long-term catheters

It has been estimated that 40-50% of patients with long-term catheters can suffer with catheter blockage. This not only causes distress to the patient but also increases the demands on community nurses' time and resources. Infection with bacteria such as Proteus causes the urine to become alkaline. Crystalline deposits can then form inside the catheter lumen which causes blockage. Nurses often manage blocked catheters with the use of bladder 'washouts' or bladder instillations. However, the literature is confused over the terminology of 'bladder washouts', instillations and irrigation and a great deal of controversy surrounds the effectiveness of these procedures. Crisis management of catheters occurs when nurses wait for catheters to become blocked before changing them; this often occurs at inconvenient times and patients frequently have to wait several hours before help is available. To avoid crisis management, nurses should aim to assess individual patients' 'pattern of catheter life' and plan changes accordingly. This would improve patient care and allow nurses to utilize their time more effectively.

Catheterization and urinary tract infections: microbiology

Patients with urinary catheters are a substantial proportion of the total patient population and catheter care is an important area of nursing practice. Urinary tract infection associated with catheterization is known to be the most common nosocomial (hospital-acquired) infection. Urinary tract infections can be caused by exogenous microorganisms or endogenous faecal or urethral microorganisms. The different microorganisms which are responsible for causing urinary tract infections have particular characteristics. Many microorganisms form a biofilm, a living layer of cells which stick to the surfaces of the catheter and the catheter bag. Biofilms not only lead to urinary tract infections, but also they are associated with encrustation and catheter blockage. The article considers the microorganisms implicated in catheter-associated urinary tract infections and aims to develop an increased awareness of the characteristics of different pathogens which could lead to enhanced nursing practice and improved patient care.

The validity of the NART-RSPM index in detecting intellectual decline following traumatic brain injury: a controlled study

The present study replicated Van den Broek and Bradshaw's (1994) study by developing a multiple regression equation to predict Ravens Standard Progressive Matrices (RSPM) scores from participants' National Adult Reading Test (NART) scores and demographic variables. A test of the validity of this procedure was undertaken by applying both the Van den Broek and Bradshaw equation and the present study's equation to a mixed sample of orthopedic control (OC) and closed head injury (CHI) participants. Premorbid RSPM scores were estimated using both equations and then compared to obtained scores. Results indicated that both equations had good predictive accuracy in estimating RSPM scores and were able to detect significantly higher rates of impairment in general intelligence in the CHI participants (24%) compared to the OC sample (7%).

Management of long-term urethral catheters: minimizing complications

Urinary tract infections, tissue damage and encrustation of the catheter, which may cause blockage, are all complications that can arise during long-term catheterization. It is important for nurses to provide effective catheter care in order to minimize the incidence of these complications. There is still controversy in the nursing literature about certain aspects of catheter management. This article explores a number of aspects of catheter care and suggests a rationale for effective and safe management, including the choice of catheter, choice of drainage system, care of the individual and the care of catheter and drainage system.

Torsion of an ovarian cyst mimicking enteric duplication cyst on transabdominal ultrasound: two cases

We describe two girls with abdominal cysts which demonstrated the "double wall" or "muscular rim" sign. On the basis of this, the diagnosis of duplication cyst was made in each case. At surgery, both were found to have ovarian cysts, and histology revealed prominent haemorrhage within the cyst wall. To our knowledge, there has been no previous report of a false-positive "double wall sign".

Gonadotropin-producing benign cystic teratoma simulating a ruptured ectopic pregnancy

Benign cystic teratomas are asymptomatic in many cases. There are some reports of production of thyroid-stimulating hormone, estrogen, testosterone, and prolactin by these tumors. This article reports a patient in whom a twisted cystic teratoma simulated ruptured ectopic pregnancy by beta human chorionic gonadotropin production and hemorrhage into the peritoneal cavity.

The cloning, expression, and nucleotide sequence of a gene coding for an immunogenic Brucella abortus protein

Brucella abortus is the causative agent for brucellosis in cattle and man. Development of a single diagnostic test for the differentiation of vaccinated from infected animals and the development of a nonviable 'subunit' vaccine are top priorities of the brucellosis research program in the United States. Preliminary evidence previously showed that a purified 31-kDa protein (thought to be localized at or near the bacterial cell surface) protects against experimental brucellosis in rodents. The gene for this 31-kDa protein has now been cloned in Escherichia coli. The protein is expressed well, apparently from its native promoter, when placed in several different E. coli plasmids. The nucleotide sequence of the flanking and encoding sequences has been determined, and comparison with the N-terminal amino acid (aa) sequence of the mature protein indicates the presence of a putative 28-aa signal sequence. The availability of the 31-kDa protein free of Brucella contaminants now allows rigorous study of the immunological properties of this protein.

Lack of effect of gliclazide on platelet aggregation in insulin-treated and non-insulin-treated diabetes: a two-year controlled study

Previous studies have suggested that the sulphonylurea hypoglycaemic agent gliclazide has specific effects in inhibiting platelet aggregation, and other haemorrheological effects that could be beneficial in preventing diabetic microangiopathy. A double-blind trial of the effect of gliclazide on platelet aggregatory responses was performed in 51 diabetic patients. Insulin- and non-insulin-treated diabetics were assessed during an initial 12-month placebo period, and in a subsequent 24-month active period after randomisation into placebo and gliclazide groups in insulin-treated patients or to glibenclamide and gliclazide groups in non-insulin-treated patients. Platelet-rich plasma was obtained from patients at intervals of at least 6 months during the trial. Circulating platelet aggregates were estimated, platelet aggregation was studied in response to three concentrations of adrenaline, ADP and collagen and thromboxane B2 produced by platelets exposed to collagen was measured. No significant effect of gliclazide was demonstrated on any parameter of platelet function evaluated.

Supersensitivity to both tyramine and noradrenaline in diabetic autonomic neuropathy

Cardiovascular responses to intravenously infused tyramine and noradrenaline were measured in five normal subjects, five insulin-dependent diabetics and five insulin-dependent diabetics with autonomic neuropathy. Tyramine infusion produced a statistically significant increase in systolic blood pressure (BP) in the autonomic neuropaths only (p less than 0.001). No change occurred in diastolic BP. Noradrenaline infusion produced a statistically significant increase in systolic BP in the normal subjects (p less than 0.01) and in the autonomic neuropaths (p less than 0.001). The increase in systolic BP in the neuropaths was significantly greater (p less than 0.001) than in normal subjects. Diastolic BP rose significantly only in the normal subjects (p less than 0.05). There was no change in heart rate in response to either agent. Thus super-sensitivity to noradrenaline occurred in patients with diabetic autonomic neuropathy indicating post-denervation hypersensitivity. Tyramine hypersensitivity also occurred indicating that denervation is not complete and suggesting dysfunction at a pre-synaptic level.

Human poxvirus disease after smallpox eradication

A 5-year-old boy living in a small camp in the rural Ivory Coast had a disease resembling smallpox. This occurred 4 years after smallpox had been eradicated from the Ivory Coast and 1.5 years after the last case of smallpox was detected in West and Central Africa. Clinical, serological, and epidemiological evidence indicated this disease was probably monkeypox, a poxvirus of the variola/vaccina subgroup. A serologic survey of poxvirus antibodies in the wild animal population detected neutralizing antibodies in rodents, larger mammals, primates, and birds. The laboratory and ecological characteristics of poxviruses require further elucidation, especially those which have been found in animals near human monkeypox cases.

Comparisons of the Index of Return for Several Stocks of British Columbia Salmon to Study Variations in Survival

The "index of return" (ratio of offspring catch to parent catch) was used to compare annual survival among several stocks of British Columbia salmon. Over a period of almost 30 years the major stocks of pink salmon in the Province, excepting those of the Fraser River, exhibited quite similar annual variations in survival. The Fraser River stock behaved somewhat independently of the other stocks. There are indications that among pink salmon early ocean survival, probably during residence in estuarial and inshore waters, has played a major role in determining the level of final ocean survival. Among pink and sockeye salmon that entered the sea in the same year there is some similarity in early ocean survival. The latter relationship, if confirmed, may become useful for predicting sockeye ocean survival one or two years before the adult fish return.