1/25. Are expandable metallic stents better than conventional methods for treating difficult intrahepatic biliary strictures with recurrent hepatolithiasis?BACKGROUND: Conventional methods for treating patients with recurrent hepatolithiasis associated with complicated intrahepatic biliary strictures include balloon dilatation of the intrahepatic biliary strictures, lithotripsy, and the clearance of difficult stones as completely as possible, with the placement of an external-internal stent for at least 6 months. After these modalities are used, symptomatic refractory strictures remain. Recently we used internal Gianturco-Rosch metallic Z stents to treat patients who had refractory strictures. OBJECTIVE: To compare therapeutic results and complications of an internal expandable metallic Z stent with those of repeated external-internal stent placement. STUDY DESIGN: Case-control study. SETTING: A referral center. patients: From January 1992 to December 1996, 18 patients with recurrent hepatolithiasis and complicated intrahepatic biliary strictures underwent percutaneous dilatation of stricture and transhepatic percutaneous cholangioscopic lithotomy for recurrent stones. After their stones were completely cleared, their biliary strictures failed to dilate satisfactorily. The patients were randomly enrolled into 2 groups: group A (7 patients), who received an expandable metallic Z stent, and group B (11 patients), who had repeated placement of external-internal stents. INTERVENTIONS: Percutaneous stricture dilatation, electrohydraulic lithotripsy, balloon dilatation, percutaneous transhepatic cholangioscopic lithotomy, and biliary stenting by a Silastic external-internal catheter or a modified Gianturco-Rosch expandable metallic Z stent (for an internal stent). MAIN OUTCOME MEASURES: The number of procedures, days in hospital, procedure-related complications, incidents of stone recurrence and recurrence of cholangitis, readmissions to the hospital, treatment sessions required, and mortality rate. patients' limitations in ordinary activities were also compared. RESULTS: The follow-up period ranged from 28 to 60 (40.7 /-12.7 [mean /- SD]) months in group A and from 28 to 49 (36.0 /-7.2) months in group B. Fewer group A patients (3 [43%]) than group B patients (8 [73%]) tended to have recurrent cholangitis and to require readmission to the hospital, but this was not statistically significant (P = .33). When their cumulative probability of a first episode of cholangitis during follow-up was compared, however, it was significantly lower in patients treated with a metallic stent (P = .04). Compared with group B patients, group A patients had less frequent recurrence of stones (0% vs 64%; P = .01), fewer procedures for the clearance of biliary stones or sludge (1.7 /-2.2 vs 6.4 /-4.3; P = .03), and shorter hospital stays (8.0 /-11.5 days vs 17.0 /-12.0 days; P = .07). No patients in group A experienced limitation in ordinary activities, whereas 7 patients in group B did (P<.02). CONCLUSIONS: Compared with the repeated placement of external-internal stents, the use of a metallic internal stent effectively decreases stone recurrence, simplifies further procedures, and is more convenient. Its use is suggested as an alternative choice in the treatment of recurrent hepatolithiasis with refractory intrahepatic biliary strictures.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
2/25. A case of relapsing acute disseminated encephalomyelitis with high dose corticosteroid treatment.We report a 16-month-old boy with acute disseminated encephalomyelitis (ADEM) who had an early relapse despite prompt treatment with high dose methylprednisolone. The second episode responded to intravenous immunoglobulin (IVIg). This case illustrates the probability of relapses or treatment failures in ADEM after steroid treatment, and the use of alternative drugs.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
3/25. Parkinson's disease with recurrent pulmonary embolism.A patient with Parkinson's disease was admitted because of recurrent chest pain and dyspnea. Based on high clinical suspicion and a high-probability lung scan, the diagnosis of pulmonary embolism was made. Anticoagulation therapy was administered and the patient remained free of symptoms during the follow-up period of two years. pulmonary embolism is reported as a possible adverse reaction to levodopa therapy and a frequent, but under-recognized cause of death in patients with parkinsonism. Clinicians should think of pulmonary embolism, a common yet difficult diagnosis, when a parkinsonian patient presents with chest pain and dyspnea.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
4/25. High expression of MDR-1 gene and p-glycoprotein in initial and re-biopsy specimens of relapsed B-cell lymphoma.AIMS: Multidrug resistance (MDR) is a major obstacle in the treatment of lymphoma. The expression of MDR-1 mRNA and p-glycoprotein (MDR-1/P-gp) has been linked to MDR. We aimed to investigate the expression of MDR-1/P-gp in B-cell lymphoma. methods AND RESULTS: Samples at diagnosis and relapse from 10 patients with B-cell lymphoma were obtained. We also obtained 14 unselected control cases of B-cell lymphoma at diagnosis. The expression of mRNA and protein were determined semiquantitatively by RT-PCR and immunohistochemistry. High MDR-1 and P-gp expressions were found in seven and seven of 10 samples obtained at diagnosis, eight and eight of 10 samples obtained at relapse, and three and four of 14 control cases at diagnosis, respectively. The results of RT-PCR paralleled those of immunohistochemistry. Concordance of high MDR-1/P-gp expression was noted in 27 of 34 samples (r = 0.73, P = 0.001). There were no significant changes in MDR-1/P-gp expression in all cases at relapse and during the clinical course following chemotherapy. In the 14 control cases, the average survival time was 12.7 months in MDR-1/P-gp positive cases and 29.0 months in the MDR-1/P-gp negative cases (P = 0.20). CONCLUSIONS: Our results showed that at least some B-cell lymphomas express MDR-1/P-gp, which could be detected by different methods, and suggested that high MDR-1/P-gp expression in tumour cells may be associated with a high probability of relapse and poor prognosis.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
5/25. Preventing recurrent second trimester group B streptococcus chorioamnionitis by intermittent prophylactic ampicillin.BACKGROUND: Whereas carrying group B streptococcus during pregnancy is common, second trimester group B streptococcus chorioamnionitis with intact membranes is rare, and recurrence of the latter problem even more so. CASE: A 38-year-old multipara with a history of recurrent second trimester group B streptococcus chorioamnionitis resulting in pregnancy loss was treated, beginning at 14 weeks' gestation, with monthly prophylactic ampicillin therapy throughout pregnancy and delivered a healthy male infant at term. CONCLUSION: In women with recurrent pregnancy loss due to second trimester group B streptococcus chorioamnionitis, an intermittent prophylactic antibiotic regimen throughout pregnancy might increase the probability of successful pregnancy.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
6/25. Recurrent soft tissue abscesses caused by legionella cincinnatiensis.Recurrent soft tissue abscesses of the jaw, wrist, and arm developed in a 73-year-old housewife with nephrotic syndrome and immunoglobulin a(kappa) gammopathy of unknown etiology. Conventional cultures remained negative, despite visible gram-negative rods on microscopy. Broad-spectrum PCR revealed legionella cincinnatiensis, which was confirmed by isolation of the organism on special legionella medium. Infections due to legionella species outside the lungs are rare. L. cincinnatiensis has been implicated in only four cases of clinical infection; these involved the lungs in three patients and the central nervous system in one patient. We conclude that broad-spectrum PCR can be a valuable tool for the evaluation of culture-negative infections with a high probability of bacterial origin and that legionella might be an underdiagnosed cause of pyogenic soft tissue infection.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
7/25. Delayed recurrent SIADH associated with SSRIs.BACKGROUND: depression is a common problem in elderly patients and is frequently treated with selective serotonin-reuptake inhibitors (SSRIs). OBJECTIVE: To report a case of delayed recurrent hyponatremia after switching from one SSRI to another. CASE SUMMARY: An 87-year-old depressed woman began treatment with fluvoxamine. One week later, she was diagnosed with hyponatremia, most likely syndrome of inadequate antidiuretic hormone. Following discontinuation of fluvoxamine, the serum sodium concentration normalized. Later, she began treatment with paroxetine. Sixteen months after initiating paroxetine, she developed symptomatic recurrent hyponatremia. After paroxetine was discontinued, the sodium concentration normalized. DISCUSSION: In this case, unlike those previously reported, hyponatremia recurred 16 months after a different SSRI was initiated. The Naranjo probability scale indicates a probable relationship between recurrent hyponatremia and paroxetine. The mechanism of SSRI-induced hyponatremia is multifactorial. CONCLUSIONS: This case illustrates that replacement of one SSRI with another can cause delayed, recurrent hyponatremia in elderly patients. plasma sodium concentrations must be monitored, not only in the first weeks of treatment, but throughout the full course.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
8/25. Long-term remission of APL with a second allogeneic BMT after CNS relapse following HLA-identical allogeneic BMT.Second allogeneic bone marrow transplantation (BMT) for AML relapsing after an initial BMT has a poor prognosis, with a probability of a 2-y disease-free survival below 30 per cent, caused both by treatment-related mortality (TRM) and high relapse rate. While TRM is most likely due to heavy pretreatment, AML relapse after BMT may be due to resistant disease or to a poor graft-versus-leukaemia (GvL) effect of the transplant. The degree of GvL may depend on individual donor/recipient immunoreactivity. In most published cases of second allogeneic BMT, both transplants were performed from the same donor. Here, we describe a patient who was first transplanted for acute promyelocytic leukaemia (APL) (AML FAB M3v) from his HLA-identical brother and received intensive immunotherapy including donor lymphocytes and IL2. He remained free from GvHD >I degrees, but developed CNS relapse. After a second BMT from another HLA-identical brother, he spontaneously developed GvHD III degrees, and has now been disease free for nearly 3 years. In this patient, long-term remission of AML relapsing after BMT was achieved by combining remission induction using an individual chemotherapy protocol with a second BMT from an alternative matched related donor and transient GvHD III degrees, which probably conferred a GVL effect.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
9/25. Popliteal venous aneurysm, a cause of pulmonary embolism.Generally, most aneurysms of the venous system are probably congenital and rarely have clinical significance. Popliteal aneurysms are an exception of this rule and are known to be a source of recurrent pulmonary emboli. We present a previously healthy 42 year old man with multiple pulmonary emboli, diagnosed with a high probability lung scan. Venous duplex imaging and magnet resonance imaging showed a mass with connection to the popliteal vein of the left knee, suggesting a venous aneurysm. Despite therapeutic anticoagulation he suffered further pulmonary emboli. After insertion of a temporary vena cava inferior filter aneurysm resection and patch reconstruction of the popliteal vein was performed. By duplex imaging we proved the patency of the popliteal vein after surgical repair. Popliteal venous aneurysms should be kept in mind as possible thromboembolic source in young patients with pulmonary embolism. Our review of the current literature about popliteal venous aneurysms revealed a high rate of pulmonary embolism.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
10/25. An unusual cause of popliteal cyst.We describe a surgical treatment for popliteal cyst in a 41-year-old woman affected by diffuse pigmented villonodular synovitis (PVNS) of the knee with extra-articular spreading. The treatment consists of an arthroscopic synoviectomy followed immediately by an open removal of the cyst. At 28-month follow-up, the patient is asymptomatic and no evidence of recurrence of PVNS has been seen. We believe that this double surgical approach may reduce the probability of recurrence of PVNS.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
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