On demand pancreatic stenting in chronic pancreatitis might provide good palliation of pain.

BACKGROUND AND AIM: Chronic pancreatitis (CP)-related pain is a considerable problem in gastroenterology practice that frequently requires several endoscopic interventions. We aimed to investigate the efficacy of pancreatic duct stenting performed on demand, instead of at defined intervals, for the management of the CP-related pain. METHODS: This study is a retrospective evaluation of thirteen years of data. Sixty-seven patients with CP who suffered from intractable pain were enrolled in the study. Pancreatic stenting was performed mainly with single stents according to the diameter of the pancreatic duct and width of the stricture or, less frequently, with multiple stents aiming to achieve stricture resolution. The subsequent endoscopic session was scheduled based on the patient's symptoms. RESULTS: Overall, 65 of 67 patients underwent successful pancreatic cannulation (technical success rate 97%). Fifty-seven patients with a pancreatic stenting history were still undergoing follow-up. Of these patients, 26 patients still had pancreatic ductal stents; however, the stents were removed from 31 patients. Only 8 patients (25%) required further endoscopic or surgical intervention because of the re-emergence of pain after a median stent-free period of 17 months (3-127 months). One patient with a biliary stricture and one patient with a pancreatic mass underwent surgery. Pancreatic stents remained for a median length of 14 months (3-84 months). During the follow-up period, 55 of 65 patients became pain-free or had partial pain relief (clinical success rate 84%). CONCLUSIONS: On demand replacement of pancreatic stent is feasible in patients with CP and it might provide a good palliation of CP-related pain.

Influence of influenza vaccination on recurrent hospitalization in patients with heart failure.

BACKGROUND: The current study aimed to evaluate the influence of regular annual influenza vaccinations on cardiovascular (CV) death and heart failure-related hospitalizations (HFrH) in stable outpatients with heart failure with reduced ejection fraction. METHODS: The Turkish research team-HF (TREAT-HF) is a network undertaking multicenter, observational cohort studies in HF. This study is a subgroup analysis of TREAT-HF outpatient cohorts who completed a questionnaire on influenza vaccination status and for whom follow-up data were available. A total of 656 patients with available follow-up data for CV death and HFrH including recurrent hospitalization were included in the study. Patients were classified into two groups: those who received regular influenza vaccination (40 %) and those who did not receive vaccination. RESULTS: During a mean follow-up of 15 ±6 months, 113 (18 %) patients had CV death and 471 (72 %) patients had at least one HFrH. The CV death rate was similar in both groups of patients (16 vs. 19 %, p = 0.37), whereas, HFrH and recurrent HFrH were significantly less frequently encountered in patients who received regular influenza vaccination than in those who did not receive vaccination (43 vs. 92 % and 16 vs. 66 %, p < 0.001, respectively). In a multivariate Cox proportional hazards model - in addition to a few clinical factors - vaccination status (HR = 0.30, 95 % CI = 0.17-0.51, p < 0.001) and graduation from university (HR = 0.35, 95 % CI = 0.17-0.72, p = 0.004) remained independently associated with the risk of recurrent HFrH. CONCLUSION: Regular influenza vaccination does not influence CV deaths; however, it decreases HFrH including recurrent episodes of HFrH in outpatients with heart failure with reduced ejection fraction.

Does amnioreduction increase success of emergency cervical cerclage in cases with advanced cervical dilatation and protruding membranes?

OBJECTIVE: To investigate whether amnioreduction has any impact on emergency cervical cerclage outcome. MATERIALS AND METHODS: Data of women who underwent emergency cervical cerclage for advanced cervical dilatation and protruding membranes were analyzed retrospectively. RESULTS: During the study interval, a total of 56 women who were underwent amnioreduction (n=26) and who did not (n=30) were eligible for analysis of the study. Gestational age at cerclage, delivery, and prolongation of pregnancy interval were comparable between the groups (21.3 ±3.3 vs. 20.6 ±3.1 weeks; p = 0.44; 28.3 ±6.1 vs. 28.1 ±5.6 weeks; p = 0.74; 53.7± 46.1 vs. 47.3± 36.7 days; p = 0.56 respectively). Number of live birth rates and perinatal mortality rates were also not statistically significantly different between the groups (73.1% vs. 70.0%; p = 0.80; 15.4% vs. 13.3%; p = 0.83). CONCLUSIONS: Emergency cerclage yields live take home baby rates in more than half of the patients. The decision to perform amnioreduction should be based on suspicion of chorioamnionitis and patient's motivation to know exactly what is the risk of chorioamnionitis.

Value of apparent diffusion coefficient calculation in the differential diagnosis of parotid gland tumors.

BACKGROUND: The differential diagnosis of parotid gland tumors is often difficult with conventional magnetic resonance imaging. PURPOSE: To determine whether the calculation of the apparent diffusion coefficient (ADC) is valuable for making the differential diagnosis of parotid tumors. MATERIAL AND METHODS: Thirty parotid masses in 28 patients and 24 healthy parotid glands in 12 controls were examined in this prospective study. Diffusion-weighted magnetic resonance imaging with echo-planar spin-echo sequences was used to evaluate each subject. The ADC of each tumor and each healthy parotid gland was calculated. Tumor diagnoses were confirmed by the results of histopathologic analysis. RESULTS: The following types of masses were identified: 11 Warthin tumors, nine pleomorphic adenomas, seven malignant tumors, one basal cell adenoma, and two benign cysts. The mean ADC value for the Warthin tumors was 0.97+/-0.16 x 10(-3) mm(2)/s, for the pleomorphic adenomas was 1.74+/-0.37 x 10(-3) mm(2)/s, for the malignant tumors was 1.04+/-0.35 x 10(-3) mm(2)/s, and for the normal parotid glands was 0.34+/-0.20 x 10(-3) mm(2)/s. The respective ADC value for the single basal cell adenoma was 1.40 x 10(-3) mm(2)/s. Statistically significant differences were identified between the subjects with pleomorphic adenoma and those with another type of parotid tumor, and between subjects with healthy parotid glands and those with a tumor. CONCLUSION: Calculating the ADC appears to be useful in differentiating pleomorphic adenomas from other types of parotid gland tumors.

Endoscopic treatment of pancreatic fistulas.

BACKGROUND: Pancreatic fistulas are managed primarily by conservative treatment. Surgery is performed in cases of conservative treatment failure. Endoscopic treatment is reported to be both effective and safe as an alternative treatment method. METHODS: A total of 26 patients underwent endoscopic treatment after failure of conservative treatment between January 2002 and November 2004. The mean time between the onset of fistula and the endoscopic retrograde cholangiopancreatography (ERCP) procedure was 95 days. The mean fistula output volume was 400 ml per day. Four patients had pancreatic ascites. The aim of the endoscopic treatment was to bypass the ductal disruption by placing stents or drains where the origin of fistulous tract could be identified, and to lower the pancreatic duct pressure by performing pancreatic sphincterotomy or by placing stents where the site of the leak could not be identified. RESULTS: Pancreatography could be performed in all the patients except one. Partial duct disruption occurred in 16 patients. All of the fistulas closed after the ductal disruption was bypassed. Pancreatic sphincterotomy or endoprothesis placement was effective for eight of the remaining nine patients in whom the ductal disruption originated from the tail of the pancreas and hence could not be bypassed. The overall success rate was 94% for the patients with partial duct disruption. Four patients had side branch leaks. All of them closed after placement of an endoprothesis. Fistulas closed in only one (20%) of the five patients with complete duct disruption. Pancreatic ascites resolved in two of the four patients after endoscopic treatment. No serious complications resulted from endoscopic treatment other than proximally migrated stents in two patients. CONCLUSIONS: Endoscopic treatment is an effective and safe method for patients with pancreatic fistulas unresponsive to conservative treatment. The success rate is very high, especially for patients with partial and side branch duct disruption.

Myocardial performance index combining systolic and diastolic myocardial performance in doxorubicin-treated patients and its correlation to conventional echo/Doppler indices.

This study was designed to evaluate the utility of myocardial performance index (MPI) in anthracycline cardiotoxicity. The MPI measures the ratio of total time spent in isovolumic activity (isovolumetric contraction time and isovolumetric relaxation time) to the ejection time, thus giving a global index combining systolic and diastolic myocardial performance. In this study, MPI was measured in 35 doxorubicin-treated children (aged 108.5+/-55.31 months, 23 males and 12 females) in sinus rhythm and 32 age-matched controls, and it was compared with conventional Doppler echocardiographic parameters. The isovolumetric contraction time was prolonged (38.37+/-24.43 vs 26.37+/-15.53, p <0.02) and ejection time was shortened (231.91 +/- 28.87 vs 256.21+/-19.55, p<0.001) in doxorubicin-treated patients compared to that in normal children. The isovolumetric relaxation time did not show significant difference between patients and control group (60.11+/-10.92 vs 61.06+/-12.12, p>0.05). MPI was significantly increased in doxorubicin-treated patients compared with that in control groups (0.42+/-0.07 vs 0.34+/-0.06, p<0.001), and significant correlation was observed between MPI and fractional shortening, ejection fraction, and left ventricular end diastolic and end systolic diameters (respectively, r = -0.508, p <0.002; r = -0.532, p<0.001; r = 0.467 p<0.005; r=0.606, p<0.001). Also, a weak correlation was found between MPI and duration of the disease and patient ages (r = 0.393, p < 0.02; r = 0.379; p < 0.02). However, there was no correlation between MPI and cumulative doxorubicin dose (r = 0.311, p > 0.05) and diastolic Doppler parameters in doxorubicin-treated patients. We think that MPI may be a useful parameter in monitoring left ventricular dysfunction in anthracyline-treated patients.

Chronic pancreatitis and aortic pseudoaneurysm in Behçet's disease.

Behçet's disease is a chronic, recurrent, systemic disease characterized by orogenital ulcers and oculocutaneous inflammatory lesions. Cardiovascular, pulmonary, neurological, articular, and GI involvement are common features, but pancreatic involvement is very rare. We present a case of Behçet's disease with both chronic pancreatitis and abdominal aorta pseudoaneurysm.

Echocardiographic evaluation of cardiac functions and left ventricular mass in children with malnutrition.

OBJECTIVE: This study was undertaken to assess the left ventricular mass (LV Mass) and systolic and diastolic functions of the left ventricle in children with protein energy malnutrition (PEM). METHODOLOGY: Thirty children, aged between 2 months and 2 years with PEM (four kwashiorkor, seven marasmic- kwashiorkor, 19 marasmus), and 17 healthy, age-matched children, using Doppler echocardiography were studied. RESULTS: The mean LV Mass in the patients was lower than that in the controls (14.5 +/- 5.2 vs 19.8 +/- 4.7 g, P < 0.05). However, the LV Mass/body surface area was not different in the patients with PEM and in the control group (52 +/- 9.2 vs 53.9 +/- 8.2g/m(2), P > 0.05), indicating that LV Mass was reduced in proportion to decrease in body size in malnutrition. Left ventricular septal and posterior wall thickness in PEM were also lower than that in the controls, and the most significant reduction in the LV Mass, septal and posterior wall thickness were found in the kwashiorkor group. Cardiac output was reduced in proportion to decrease in body size in the patient group (1.6 +/- 0.5 vs 2.1 +/- 0.8 L/min, P < 0.05), therefore cardiac index was not significantly different between the patients and the control subjects (5.9 +/- 1.4 vs 5.7 +/- 1.6 L/min/m(2), P > 0.05). Systolic function indices including ejection fraction, fractional shortening, and diastolic function indices were not significantly different in the groups. CONCLUSIONS: We demonstrated that LV Mass and cardiac output were reduced in proportion to decrease in body size in patients with PEM, and LV systolic and diastolic functions were preserved in atrophic hearts.

Pulmonary arteriovenous fistula in the newborn: a case report of Rendu-Osler-Weber syndrome and a review of the literature.

In most instances, congenital arteriovenous fistula is only one manifestation of a more widespread abnormality; 60% of patients also have hereditary hemorrhagic telangiectasis (Rendu-Osler-Weber syndrome). Among those with congenital pulmonary arteriovenous fistula, the diagnosis is made during infancy in only 15% of patients. We present a case of pulmonary arteriovenous fistula in a newborn and review the literature. This rare condition of newborns can be treated with different surgical procedures. Only 17 cases of newborn pulmonary arteriovenous fistula/have been reported, and only two of those had associated Rendu-Osler-Weber syndrome. The results of surgical procedures were good in most of these cases. We treated our case with lobectomy successfully.

Evaluation of dysrhythmia in children with muscular dystrophy.

Myocardial involvement and dysrhythmia are common findings with muscular dystrophy and are among the leading causes of death. The authors evaluated rhythm and conduction abnormalities in children with muscular dystrophy by electrocardiography, signal-averaged electrocardiography, and Holter monitoring. Twenty-nine patients (mean age, 8 years) and 29 healthy control subjects were included in the study. Sixty-two percent of patients had electrocardiographic abnormalities defined as deep Q waves in V6, tall R waves in V1, and QRS axis deviation. The cardiomyopathy index was significantly greater in the patient group whereas QT and QTc dispersion values showed no significant difference. Holter monitoring revealed premature atrial and ventricular contractions more frequently than normal. However all were classified as Lown I and II. Mean heart rate was significantly higher in the patient group. The electrocardiograms of 41% of the patients showed late potentials. No relationship with these changes and cardiac function was observed. During the study, one patient died whose cardiomyopathy index was longer and had late potentials detected with signal-averaged electrocardiography. In conclusion, standard electrocardiography, cardiomyopathy index, signal-averaged electrocardiography, and Holter monitoring are valuable and reliable monitoring methods in children with muscular dystrophy.

Left ventricular diastolic functions in juvenile rheumatoid arthritis.

Cardiac involvement as pericarditis, myocarditis, and endocarditis is common in juvenile rheumatoid arthritis (JRA). Though there are many reports concerning systolic and diastolic functions of adults with rheumatoid arthritis, there are no studies on children with JRA. Thirty patients with JRA without any cardiac symptoms and 30 sex- and age-matched controls were included in the study. M-mode and pulsed-wave Doppler echocardiography were performed on each participant to assess the systolic and diastolic functions of the left ventricle. Left ventricular end-systolic diameter and volume were larger and ejection fraction and fractional shortening were decreased in the JRA group. Among the diastolic parameters, increased late flow velocity, decreased early flow velocity, and prolonged isovolumic relaxation time reflected an abnormal relaxation form of diastolic dysfunction. Mortality rate is increased in adults with rheumatoid arthritis, and ischemic heart disease is the leading cause of cardiovascular mortality. The abnormal relaxation form of diastolic dysfunction found in children with JRA is seen in ischemic heart disease. These children can therefore be candidates for ischemic heart disease in the future even though they are fully asymptomatic at present. In conclusion, children with JRA should be assessed for systolic and diastolic functions with serial echocardiography. In this way it may be possible to reduce the mortality and morbidity of the disease from cardiac causes.

Malformations Due to Warfarin: A Case Report.

We report a 5-month-old infant with severe growth retardation who was exposed to in utero warfarin for the first 4 months. She had a dysmorphic face with depressed nasal hypoplasia and low-set ears. Cranial computerized tomography revealed bifrontal atrophy, agenesis of corpus callosum, and dilation of lateral ventricles. In addition she had patent ductus arteriosus with pulmonary hypertension, which had to be ligated.

Complete atrioventricular heart block in congenital hypothyroidism.

Severe hypothyroidism in children is known to produce cardiac abnormalities such as asymmetric thickening or hypertrophy of the interventricular septum, smaller internal dimensions of the left ventricle, a smaller left ventricular outflow tract, and less systolic septal excursion. In this report, we present a 1.5-year-old boy who was admitted to our hospital because of growth retardation. According to the clinical and laboratory findings, congenital hypothyroidism, dilated cardiomyopathy (DCMP), atrioventricular complete heart block and secundum type atrial septal defect were diagnosed.

A comparison between MUGA and echocardiography in patients with muscular dystrophy in the early detection of cardiac involvement.

Muscular dystrophies are a group of sex-linked diseases with frequent myocardial involvement. In this study 14 patients with Duchenne Muscular Dystrophy (DMD), 7 with Becker Muscular Dystrophy (BMD), and 8 female carriers who were asymptomatic were evaluated with echocardiography and multigated radionuclide ventriculography (MUGA). All showed predominant systolic and minor diastolic left ventricular dysfunction determined both by echocardiography and MUGA when compared with healthy controls. In conclusion, it is recommended that DMD, BMD, and female carriers be evaluated and closely monitored for cardiac functions. Though MUGA and echocardiography are both effective and sensitive techniques, echocardiography is more convenient for availability and serial evaluation.

Chest pain in children referred to a cardiology clinic.

One hundred consecutive patients (54 girls, 46 boys) referred to a pediatric cardiology department with the primary complaint of chest pain were evaluated. The age distribution was 2.5-16.0 years (mean 11.3 years for girls and 9.9 years for boys). The history showed 17% of patients with chest pain, 22% with heart disease, and 19% with recent death in the family. The time course of the pain was longer than 1 week in 92 patients. Localization was on the left precordium in 60 patients, and there was no radiation from the original site in 66 cases. Ninety-two percent of cases were idiopathic in origin. Of the 74 patients who had a psychiatric interview, 55 (74%) had psychiatric symptoms and 5 required psychiatric care. Anxiety, conversion disorder, and depression were the main psychiatric symptoms.