Intraoperative Enteroscopy: A Rare Case of Blue Rubber Bleb Nevus Syndrome and a Rare Complication of Cyanoacrylate Glue.

Blue rubber bleb nevus syndrome (BRBNS) is a rare disorder characterized by venous malformations predominantly affecting the skin and gastrointestinal tract, commonly the small bowel. Small bowel gastrointestinal bleeding is often the presenting complaint and is difficult to diagnose and treat. Push enteroscopy, capsule endoscopy, and intraoperative enteroscopy are techniques described for the localization and management of small bowel bleeding. We present the case of a 68-year-old male with BRBNS who presented with symptomatic anemia and melena. Initial endoscopic evaluations identified intraluminal vascular blebs, which were injected; however, bleeding continued, prompting intraoperative enteroscopy. During the procedure, multiple small bowel vascular malformations consistent with BRBNS were identified. Cyanoacrylate glue was used endoscopically to treat active bleeding sites. The patient developed a rare postoperative complication of small bowel ischemia and obstruction secondary to cyanoacrylate glue, necessitating surgical resection. Small bowel bleeding in BRBNS poses diagnostic and therapeutic challenges. Intraoperative enteroscopy together with cyanoacrylate glue offers a valuable approach to localization and intervention. While cyanoacrylate glue is generally considered safe, rare complications, including ischemic events, have been reported. This case highlights the utility of intraoperative enteroscopy and endoscopic cyanoacrylate glue in managing small bowel bleeding associated with BRBNS. While effective, clinicians must be vigilant regarding potential complications, including ischemic events, associated with endoscopic hemostatic agents.

The Use of Inflammatory Markers for Treatment Response Monitoring in Acute Cholangitis: A Retrospective Cohort Study.

INTRODUCTION: In acute cholangitis (AC), monitoring treatment response to antimicrobial therapy allows for making timely decisions on early biliary decompression. The aims of this study were to compare the discriminating powers of traditional blood inflammatory markers and propose new inflammatory markers that have a better ability to distinguish between patients with and without biliary tract infection. METHODS: This was a retrospective cohort study. Patients who underwent endoscopic retrograde cholangio-pancreaticography for AC and those without biliary tract inflammation were randomly selected in the 4:3 ratio of their hospital admissions from our hospital endoscopic retrograde cholangio-pancreaticography database. The exclusion criterion was the absence of C-reactive protein (CRP) measurements. RESULTS: The discriminating powers of the neutrophil count, lymphocytes, albumin, neutrophil-to-lymphocyte ratio, and CRP were superior to that of white blood cell (P1 < 0.005; P2 = 0.004; P3 < 0.0005; P4 < 0.0005; P5 < 0.0005). In monitoring treatment response in AC, lymphocyte count, albumin, neutrophil-to-lymphocyte ratio, and CRP were better than neutrophil count (P6 = 0.037, P7 < 0.005, P8, 9 < 0.0005). The area under the receiver operating characteristic curve (AUC) of CRP was higher than the AUC for lymphocytes, 96% (95% confidence interval [CI]: 94-98%) versus 81% (95% CI: 76-86%) (P < 0.0005), and larger than the AUC for albumin, 88% (95% CI: 84-92%) (P < 0.0005), indicating a greater discriminating power of CRP. However, the discriminating power of CRP-to-lymphocyte ratio (CLR) was more than that for CRP (P = 0.006) but equal to CRP-to-(lymphocytes∗albumin) ratio (CLAR) (P = 0.249). The AUCs of CLR and CLAR were both 98% (95% CI: 96-99%). CONCLUSIONS: CLR and CLAR have superior discriminating powers than traditional inflammatory markers used for monitoring treatment response in AC.

Upconversion Fluorescence in Naturally Occurring Calcium Fluoride.

Fluorine can negatively interfere with leach and smelting processes during mineral processing. Real-time knowledge of the concentration and mineral hosts of fluorine in a mineral processing ore stream is important to protect process line equipment and product. Currently only offline methods of detection are available. Online sensors that determine specific fluorine-bearing mineral concentration in real-time would enable improved efficiency in processing decisions during mine production. Common excitation wavelengths used for fluorescence studies in minerals frequently provide signals that are not clearly host-specific, and hence of limited utility for mineral identification. We show that upconversion fluorescence, a process in which two or more photons are absorbed and one higher-energy photon is emitted, provides a more host-specific fluorescence output, minimizing spurious signals in complex environments and therefore greatly improving detection thresholds. Natural samples of fluorite (CaF2), a major fluorine host at many mine sites, have been analyzed by near-infrared excitation and have revealed upconversion fluorescence from rare earth inclusions. Upconversion fluorescence was detected in samples with rare earth concentrations as low as one part per million and is therefore considered a potential new sensing modality for real-time fluorite monitoring.

Routine Neurectomy of Inguinal Nerves During Open Onlay Mesh Hernia Repair: A Meta-analysis of Randomized Trials.

OBJECTIVE: The aim of the study was to establish whether an inguinal neurectomy at the time of hernia repair would reduce the risk of postoperative pain for open tension-free sutured mesh repair. BACKGROUND: Inguinal hernia repair is a common operative procedure. The development of postoperative pain is uncommon, but at times debilitating. The role of inguinal neurectomy is currently unknown, with no single large study available, and previous reviews included only a few heterogeneous studies. METHODS: Relevant randomized trials were identified from searches of MEDLINE, EMBASE, and EBM Review databases until October 2014. Meta-analysis was performed based on Cochrane Methods using RevMan v5.3 software. Pain, pain scores, sensory changes, and complications over short (half to <3 months), mid (3 to <12 mo), and long term (≥12 mo) were recorded. RESULTS: All included studies performed Lichtenstein hernia repair. Eleven studies on 1031 patients showed significant reduction in pain with neurectomy for short (RR = 0.61, 0.40-0.93) and midterm (RR = 0.30, 0.20-0.46), but not for long term (RR = 0.50, 0.25-1.01). Three studies (270 patients) showed significantly reduced short-term pain (RR = 0.69, 0.52-0.90). No studies included genitofemoral neurectomy. Rates of hematoma, infection, urinary retention, and recurrence were not different between groups. CONCLUSIONS: Routine ilioinguinal neurectomy during Lichtenstein-type herniorrhaphy seems to be a safe and effective method to reduce pain in the short and midterm, but may have little long-term impact. Iliohypogastric neurectomy seems to reduce pain in at least the short term.

Widespread subcutaneous emphysema and barotrauma resulting from high pressure gas injection.

Widespread subcutaneous emphysema is an unusual emergency presentation. We present a case of accidental high pressure insufflation, the pathophysiology and subsequent medical management in the acute setting. Such presentations are rare but dramatic and can have important life-threatening consequences that require immediate treatment.

Malignant progression of anal intra-epithelial neoplasia.

BACKGROUND: Anal intra-epithelial neoplasia (AIN) is believed to be a precursor to squamous cell carcinoma of the anus. The risk of developing anal cancer in patients with AIN, although known to occur, has been thought to be relatively low. This study reviews our experience with AIN, reviewing the incidence and risk factors for development of invasive malignancy and the outcome of present management strategies. METHODS: This study examined a cohort of 72 patients identified from a prospective database with AIN from a single institution between January 1996 and December 2004. A single pathologist examined all pathological specimens. RESULTS: There were 72 patients (52 women) and the median age was 49 years (range, 18-81 years). We identified progression of AIN to invasive malignancy in eight patients despite undergoing surveillance. Regression following treatment or biopsy was seen in 25 patients. Four patients required stomas for incontinence following treatment. CONCLUSION: This study has shown a high rate of progression to invasive malignancy (11%) with AIN despite surveillance. The patients at risk of developing squamous cell carcinoma were the immunocompromised and those with genital intra-epithelial field change. Treatment of AIN has significant complications and despite treatment, invasive cancers do occur. Decisions made for treatment of AIN can affect treatment choices if invasive malignancy develops.

River flow and associated transport of sediments and solutes through a highly urbanised catchment, Bradford, West Yorkshire.

The hydrological characteristics of catchments become drastically modified in response to urbanisation. The total contributions and dynamics of runoff, suspended sediment and solutes may change significantly and have important implications downstream where they may affect flooding, instream ecological habitat, water quality and siltation of river channels and lakes. Although an appreciation of the likely hydrological changes is crucial for effective catchment management they are still poorly understood. In this paper we present data from a network of river monitoring stations throughout the heavily urbanised Bradford catchment, West Yorkshire. Sites are upstream, within and downstream of the highly urbanised central part of the catchment. Flow, turbidity (calibrated to suspended sediment concentration) and specific conductance (surrogate for solute concentration), logged at 15-min intervals, are presented for a 12-month period (June 2000 to June 2001). The total amounts and dynamics of flow, solute and suspended sediment transport were investigated. Estimated total flow and suspended sediment transport for the monitoring period were found to be high in response to the high total rainfall. Flow and sediment transport regimes were extremely 'flashy' throughout the catchment and became increasingly flashy in a downstream direction. Suspended sediment discharged from the Bradford subcatchment makes an important contribution to downstream sediment transport on the river Aire at Beal. Data suggest that the urbanised part of the Bradford catchment is extremely important in contributing solutes to the Beck (river). Although flow and sediment are also contributed to the Bradford Beck in the urbanised part of the catchment the data suggest that significant amounts may enter the combined sewer system and bypass the river. Understanding the spatial and temporal variations of flow and the transport of suspended sediment and solutes in rivers in urbanized subcatchments is crucial to their effective management and monitoring. Furthermore, this knowledge may be extremely important to the management and monitoring of downstream rivers in large scale mixed catchments.

The temporal and spatial variability of sediment transport and yields within the Bradford Beck catchment, West Yorkshire.

Recent EU directives have emphasised the need to understand and limit potential water quality problems within urban river systems. Under certain conditions sediments and contaminants derived from industrial and domestic waste and the urban surface may be expelled into urban rivers via the sewer and drainage system. These discharges may lead to water quality problems within urban catchments. One aspect of water quality is the suspended sediment. This can be directly detrimental to water quality by affecting the habitat for fish and other biota but it is also closely associated with pollutants, such as heavy metals, which may be adsorbed onto the sediments surface. This paper presents a comparative analysis of sediment yields for a small mixed rural/urban catchment, the Bradford Beck in West Yorkshire, over a number of precipitation events. Flow and water quality parameters were monitored at a high temporal resolution at strategic sites within the urban watercourse over a 2-year period. Rainfall was measured at six locations within the catchment. Analysis of discrete rainfall events allowed an understanding of the temporal and spatial variability of sediment transport within the catchment to be developed. The results demonstrated that for individual storms the sediment yields from the urban sub-catchment were generally higher than those from the rural system although the annual yields were comparable. Sediment transport within the urban area, for large events, was dominated by the impact of the Combined Sewer Overflows discharging. Within these events peak suspended sediment concentration, SSC, were generally higher than the rural system. Within smaller events the main sediment source within the urban area was the surface runoff discharging directly to the urban river. Analysis of SSC and discharge relationships illustrated the different sources of sediment for contrasting events. Within the rural system clockwise hysteresis, indicating exhaustion of sediment supply, was noted for larger storms. The high temporal resolution monitoring has enabled a better understanding of sediment dynamics within the Bradford Beck system to be developed. The general conclusions drawn can provide guidance for addressing sediment related water quality issued in other urban systems.

The impact of a convectional summer rainfall event on river flow and fine sediment transport in a highly urbanised catchment: Bradford, West Yorkshire.

Urban watercourses are important assets to cities, but they often have extremely 'flashy' hydraulic regimes and poor water quality, making them potential hazards. Current knowledge of the impact of intense rainfall events on urban river water discharge and, in particular, fine sediment transport is limited. Continuous monitoring of flow and turbidity (subsequently calibrated to suspended sediment concentration) was undertaken at a network of four sites throughout the highly urbanised Bradford catchment in West Yorkshire, NE England. An intense convectional rainfall event, which occurred over central Bradford in June 2001, generated extreme flow and fine sediment transport responses at the most downstream site, Shipley Weir. In just 15 min, discharge increased from 0.45 to 34.6 m(3) s(-1) (median annual peak instantaneous discharge of 27.5 m(3) s(-1), 1983-2001) and suspended sediment concentration increased from 14 to 1,360 mg l(-1). A peak sediment flux of 47.2 kg s(-1) was recorded. It is demonstrated that this extremely large and urban flux of fine sediment is likely to have a major downstream impact on water quality in the River Aire.