Gastrointestinal manifestations of systemic mastocytosis

Systemic mastocytosis (SM) is a rare disease with abnormal proliferation and infiltration of mast cells in the skin, bone marrow, and viscera including the mucosal surfaces of the digestive tract. Gastrointestinal (GI) symptoms occur in 14%-85% of patients with systemic mastocytosis. The GI symptoms may be as frequent as the better known pruritis, urticaria pigmentosa, and flushing. In fact most recent studies show that the GI symptoms are especially important clinically due to the severity and chronicity of the effects that they produce. GI symptoms may include abdominal pain, diarrhea, nausea, vomiting, and bloating. A case of predominantly GI systemic mastocytosis with unique endoscopic images and pathologic confirmation is herein presented, as well as a current review of the GI manifestations of this disease including endoscopic appearances. Issues such as treatment and prognosis will not be discussed for the purposes of this paper.

腹腔镜下止血设备新进展

目的为提高血管闭合性能、手术效果和临床结局,市场上研发了许多新式的血管闭合系统。在微创手术中,爆破压、横向热扩散、闭合率和故障率是选择器备并获得最理想手术效果的重要考虑参数。本文详细介绍多种新式止血设备的物理学原理和基本运行机制,并回顾相关文献评价各个设备的优缺点。

在澳大利亚利用腹腔镜进行附件手术的现状和变化趋势

自从引入腹腔镜手术,普遍认为应用腹腔镜进行附件手术会取代开腹手术。然而事实证明,虽然腹腔镜手术开展了20多年,开腹附件手术仍未被淘汰。这份来自澳大利亚各州及地区关于附件手术病人的资料显示了在澳大利亚应用腹腔镜进行附件手术的变化趋势。同时还有一份来自悉尼利物浦医院病人的资料同样也说明了在附件手术中决定选择何种手术方式的影响因素。我们的研究认为,在所有附件手术中,应用腹腔镜进行手术已经增加到90%,然而大概还有10%的病人需要开腹手术。全国范围内附件手术在手术方式选择上的变化趋势受政府医疗保险政策变化的影响。利物浦医院的当地资料显示,不同个体在手术方式选择上的变化趋势与澳大利亚全国范围内附件手术方式变化趋势不同,是由于管理人员和资金的改变引起的。从病人利益角度考虑,一项对妇科医师问卷调查显示,下述因素是导致医师选择开腹手术的重要原因:术前怀疑肿瘤是恶性的;医生缺少腹腔镜技术的培训;急诊状况下。术前应用敏感性高和特异性好的肿瘤标志物改善附件恶性肿瘤术前诊断的准确性有利于更多病人进入腔镜组而不是开腹组,同时医师经过良好的训练和提高手术技术也可以在不久的将来促进腹腔镜手术的发展。

Factors associated with patient absenteeism for scheduled endoscopy

AIM: To identify risk factors to help predict which patients are likely to fail to appear for an endoscopic procedure. METHODS: This was a retrospective, chart review, cohort study in a Canadian, tertiary care, academic, hospital-based endoscopy clinic. Patients included were: those undergoing esophagogastroduodenoscopy, colonoscopy or flexible sigmoidoscopy and patients who failed to appear were compared to a control group. The main outcome measure was a multivariate analysis of factors associated with truancy from scheduled endoscopic procedures. Factors analyzed included gender, age, waiting time, type of procedure, referring physician, distance to hospital, first or subsequent endoscopic procedure or encounter with gastroenterologist, and urgency of the procedure. RESULTS: Two hundred and thirty-four patients did not show up for their scheduled appointment. Compared to a control group, factors statistically significantly associated with truancy in the multivariate analysis were: non-urgent vs urgent procedure (OR 1.62, 95% CI 1.06, 2.450), referred by a specialist vs a family doctor (OR 2.76, 95% CI 1.31, 5.52) and office-based consult prior to endoscopy vs consult and endoscopic procedure during the same appointment (OR 2.24, 95% CI 1.33, 3.78). CONCLUSION: Identifying patients who are not scheduled for same-day consult and endoscopy, those referred by a specialist, and those with non-urgent referrals may help reduce patient truancy.

Review of idiopathic pancreatitis

Recent advances in understanding of pancreatitis and advances in technology have uncovered the veils of idiopathic pancreatitis to a point where a thorough history and judicious use of diagnostic techniques elucidate the cause in over 80% of cases. This review examines the multitude of etiologies of what were once labeled idiopathic pancreatitis and provides the current evidence on each. This review begins with a background review of the current epidemiology of idiopathic pancreatitis prior to discussion of various etiologies. Etiologies of medications,infections,toxins,autoimmune disorders,vascular causes,and anatomic and functional causes are explored in detail. We conclude with management of true idiopathic pancreatitis and a summary of the various etiologic agents. Throughout this review,areas of controversies are highlighted.

临床检查可预测下肢周围动脉疾病?

Context: Lower extremity peripheral arterial disease(PAD) is common and associated with significant increases in morbidity and mortality. Physicians typically depend on the clinical examination to identify patients who need further diagnostic testing. Objective: To systematically review the accuracy and precision of the clinical examination for PAD. Data Sources, Study Selection, and Data Extraction: MEDLINE(January 1966 to March 2005) and Cochrane databases were searched for articles on the diagnosis of PAD based on physical examination published in the English language. Included studies compared an element of the history or physical examination with a reference standard of ankle- brachial index, duplex sonography, or angiogram. Seventeen of the 51 potential articles identified met inclusion criteria. Two of the authors independently extracted data, performed quality review, and used consensus to resolve any discrepancies. Data Synthesis: For asymptomatic patients, the most useful clinical findings to diagnose PAD are the presence of claudication(likelihood ratio [LR], 3.30; 95% confidence interval [CI], 2.30- 4.80), femoral bruit(LR, 4.80; 95% CI, 2.40- 9.50), or any pulse abnormality(LR, 3.10; 95% CI, 1.40- 6.60). While none of the clinical examination features help to lower the likelihood of any degree of PAD, the absence of claudication or the presence of normal pulses decreases the likelihood of moderate to severe disease. When considering patients who are symptomatic with leg complaints, the most useful clinical findings are the presence of cool skin(LR, 5.90; 95% CI, 4.10- 8.60), the presence of at least 1 bruit(LR, 5.60; 95% CI, 4.70- 6.70), or any palpable pulse abnormality(LR, 4.70; 95% CI, 2.20- 9.90). The absence of any bruits(iliac, femoral, or popliteal)(LR, 0.39; 95% CI, 0.34- 0.45) or pulse abnormality(LR, 0.38; 95% CI, 0.23- 0.64) reduces the likelihood of PAD. Combinations of physical examination findings do not increase the likelihood of PAD beyond that of individual clinical findings. However, when combinations of clinical findings are all normal, the likelihood of disease is lower than when individual symptoms or signs are normal. A PAD scoring system, which includes auscultation of arterial components by handheld Doppler, provides greater diagnostic accuracy. Conclusions: Clinical examination findings must be used in the context of the pretest probability because they are not independently sufficient to include or exclude a diagnosis of PAD with certainty. The PAD screening score using the hand- held Doppler has the greatest diagnostic accuracy.

Microbiology of discharging ears in Ethiopia

Objectives:To isolate and identify the bacterial etiologic agents,including their antibiotic susceptibility pattern isolated from patients with discharging ear infections.Methods:Between September 2006 and February 2007,178 patients with discharging ear visiting ENT clinics of St.Paul and Tikur Anbessa University Hospitals Addis Ababa,Ethiopia were investigated.Results:Of the patients investigated,52.8%were males and 47.2%were females resulting in an overall male to female ratio of 1.1:1.Ear discharge was the commonest clinical finding followed by hearing problem(91.2%),otalgia(ear pain)(74.7%),fever(17.9%) and itching of external ear(5.1%).S.aureus accounted for 30.2%of the total isolates followed by Proteus ssp. (P.mirabilis,P.vulgaris)(25.4%),and P.aeruginosa(13.4%).Both gram positive and negative bacteria isolated from ear infections showed low resistance rates to most antimicrobial agents tested.Overall ceftriaxone and ciprofloxacin were the most effective drugs when compared to other drugs tested against the grampositive and gram-negative bacteria.Conclusion:Otitis media was the most common clinical finding in patients with ear infection.With discharging ear,the gram-negative bacteria were the predominant isolates.The susceptibility pattern of isolates from the study showed that ceftriaxone,ciprofloxacin and gentamicin were the most effective drugs.It is recommended that treatment of ear infections should be based on culture and sensitivity at the study sites.Therefore,efforts should be directed towards early diagnosis and treatment of acute ear infection and continued re-evaluation of the resistant patterns of organisms to optimize treatments and reduce complications.

In vitro vasodilatory effect of aqueous leaf extract of Thymus serrulatus on thoracic aorta of Guinea pigs

Objective:To investigate the vasodilatory effecl of Thymus serrulatus(T.serrulatus) aqueous leaf extract on KCl(high K^+.80 mmol/L) induced precontracted isolated thoracic aorta rings on guinea pigs and the role of aorta endothelium on this action.Methods:Guinea pig thoracic aorta was removed and placed in an organ bath containing Krebs-Henseleit solution and aorta contractions were recorded isometrically.Results:The results revealed that T.serrulalus aqueous leaf extract(0.5-5 mg/mL)significantly(P<0.001) reduced KCl-induced contractions of guinea pig thoracic aorta in both intact(n=5) and denuded(n=5) endothelium in a concentration dependent manner,and the vasodilatory effect of the extract on intact endothelium was significantly(P<0.05) higher than that on denuded endothelium.Glibenclamide(10 μmol/L) significantly(P<0.001) increased the vasodilatory effect of extract in intact endothelium as compared to methylene blue(10μmol/L).atropine(10 μmol/L) and indomethacin(10 μmol/L).The effecl was more obvious on intact than that on denuded endothelium.Conclusions:The present findings demonstrate that T.serrulalus aqueous leaf extract has vasodilator)' activity which might result in antihypertensive effect and its vasodilatory effect is endothelium-dependent.This might support the traditional claim of the plant in hypertensive.

经皮经股动脉逆行主动脉瓣植入术

Background -Percutaneous aortic valve implantation by an antegrade transvenous approach has been described but is problematic. Retrograde prosthetic aortic valve implantation via the femoral artery has potential advantages. Percutaneous prosthetic aortic valve implantation via the femoral arterial approach is described and the initial experience reported. Methods and Results -The valve prosthesis is constructed from a stainless steel stent with an attached trileaflet equine pericardial valve and a fabric cuff. After routine aortic balloon valvuloplasty, a 22F or 24F sheath is advanced from the femoral artery to the aorta. A steerable, deflectable catheter facilitates manipulation of the prosthesis around the aortic arch and through the stenotic valve. Rapid ventricular pacing is used to reduce cardiac output while the delivery balloon is inflated to deploy the prosthesis within the annulus. Percutaneous aortic prosthetic valve implantation was attempted in 18 patients(aged 81±6 years) in whom surgical risk was deemed excessive because of comorbidities. Iliac arterial injury, seen in the first 2 patients, did not recur after improvement in screening and access site management. Implantation was successful in 14 patients. After successful implantation, the aortic valve area increased from 0.6±0.2 to 1.6±0.4 cm2. There were no intraprocedural deaths. At follow-up of 75±55 days, 16 patients(89%) remained alive. Conclusions -This initial experience suggests that percutaneous transarterial aortic valve implantation is feasible in selected high-risk patients with satisfactory short-term outcomes.

经皮经静脉二尖瓣环成形术:冠状窦内装置植入的初期人体经验

Background -Mitral annuloplasty is the most common surgical procedure performed for ischemic mitral regurgitation(MR). Surgical mitral annuloplasty is limited by morbidity, mortality, and MR recurrence. We evaluated the safety and feasibility of a transvenous catheter-delivered implantable device to provide a percutaneous alternative to surgical mitral annuloplasty. Methods and Results -Five patients with chronic ischemic MR underwent percutaneous transvenous implantation of an annuloplasty device in the coronary sinus. Implantation was successful in 4 patients. Baseline MR in the entire group was grade 3.0±0.7 and was reduced to grade 1.6±1.1 at the last postimplantation visit when the device was intact or the last postprocedural visit in the patient in whom the device was not successfully implanted. Separation of the bridge section of the device occurred in 3 of 4 implanted devices and was detected at 28 to 81 days after implantation. There were no postprocedural device-related complications. Conclusions -Percutaneous implantation of a device intended to remodel the mitral annulus is feasible. Initial experience suggests a possible favorable effect on MR. Percutaneous transvenous mitral annuloplasty warrants further evaluation as a less invasive alternative to surgical annuloplasty.

Surgical technique of video endoscopic inguinal lymphadenectomy via a hypogastric subcutaneous approach

Open inguinal lymphadenectomy is a necessary conventional management for the lower genitourinary malignancies,but the associated morbidity remains an issue for the conventional surgical approach.Video endoscopic inguinal lymphadenectomy via the limb subcutaneous approach （VEIL-L） has recently been reported as a potentially less invasive alternative to the open inguinal lymphadenectomy for patients with some genitourinary malignancies.1-4 The concept of VEIL-L was first described by the French gynecologists.1-2 Since then,this procedure has undergone a few technical changes.The triangular working space can be obtained by introducing the laparoscopic instruments through three1,2,4 or a single working port3 in the limbs.Thus,laparoscopic pelvic lymphadenectomy （LPL） had to be performed with three or more abdominal working ports if the frozen section revealed positive deep inguinal nodes.To avoid the need to operate both through the limb and the abdomen in this situation,a new approach described in this paper should resolve the issue of the number of access routes with the possible better reduction of infection and morbidity from wound breakdown.

Exploring salivary biomarkers and swallowing perceptions in Sjogren's syndrome:A case-control feasibility study

Background:The autoimmune disease Sjogren's syndrome(SS)is often characterized by salivary changes that may affect swallowing.No known study has investigated the association between salivary biomarkers and perceptions of swallowing in individuals with SS.Our objectives were to explore:(1)the operational feasibility of investigating saliva volume and composition,along with perceptions of swallowing,in those with and without SS;and(2)the relationship between saliva composition and perceptions of oral dryness,swallowing,and quality of life.Methods:We conducted a prospective,case–control feasibility study,collecting feasibility data(recruitment rate and optimal saliva collection methods)and whole mouth saliva samples(unstimulated and stimulated).We measured total protein content and conducted sialochemical(α-amylase,cortisol,C-reactive protein[CRP],and mucins),sialometric(flow rate),and perceptual(oral dryness and swallowing-related quality of life[SWAL-QOL])assessments.Our exploratory analyses focused on the main and fixed effects.We summarized all data descriptively,comparing:(a)outcomes between groups(t tests or Mann–Whitney U)and(b)salivary and perceptual data across participants(partial least-squares correlation[PLSC]).Results:We enrolled 12(N)participants(6 per group),all providing analyzable saliva.Cases had lower flow rate(p=0.003)and higher total protein,cortisol,and CRP concentrations(p<0.02)than controls.PLSC revealed inverse covariance between sialochemical and SWAL-QOL data across participants.Conclusion:Our study was feasible as designed.We explored novel relationships between salivary outcomes and participant-reported perceptions,distinguishing individuals with and without SS.Our findings support further study of saliva's role in perceptions of swallowing,specifically analytes with lubricative properties.

新型神经肌肉阻滞评价系统改善肌肉松弛效果的随机对照临床研究

背景传统的单次推注肌肉松弛药的给药方式存在着手术中可控性有限、潜在的苏醒延迟和麻醉恢复期残余阻滞等问题。为此，我们开发了一种新的自适应电脑程序，即神经肌肉阻滞评价系^（NMBAS）。该程序以六阶拉盖尔模型及患者的肌电反应记录为基础，向麻醉医师提供肌肉松弛药的时效及剂量的建议。本研究中，我们对使用NMBAS后的神经肌肉阻滞是否优于常规治疗方法进行了探讨。方法这是一项随机、双盲、平行对照的前瞻性临床研究。73例接受腹部手术的患者（ASAI～Ⅲ级），使用罗库溴铵为肌肉松弛剂，全身麻醉时间≥1．5小时。患者分别按常规方式或NMBAS指导下给予罗库溴铵。主要结果变量为反映肌肉松弛不完善的围手术期事件发生率。次级变量包括手术后拮抗前4个成串刺激（TOF）比值，罗库溴铵总量，拮抗剂、麻醉药物及其他药物的用量，手术后不良事件的发生率以及麻醉医师不依从NMBAS建议的发生率。结果73例患者中，每组有30例符合统计分析的要求。两组问患者一般资料具有可比性。与常规组相比，NMBAS组患者围手术期肌肉松弛不完善相关事件的发生率明显降低（19／30VS8／30；P=0．004），NMBAS组平均TOF比值明显增高（0.59[95％CI：0．48～0．69]vs0．14[95％CI：0．04～0．24]；P〈0．0001）。罗库澳铵总量、拮抗剂、其他药物应用及手术后不良事件的发生率无差异。结论与常规方法相比，NMBAS指导的肌肉松弛方案可改善肌肉松弛质量，提高手术后TOF比值，减少肌肉松弛残余的危险性，提高患者围手术期的安全。