Outcomes of endoscopic therapy in donation after cardiac death liver transplant biliary strictures.

BACKGROUND: Biliary strictures after donation-after-cardiac-death (DCD) liver transplantation (LT) require multiple endoscopic retrograde cholangiopancreatographies (ERCP). The outcomes of endoscopic dilation and maximal stenting are not well-characterized in this high-risk population. METHODS: DCD LT recipients who underwent LT and ERCP from 2012-2018 were selected. Anastomotic and non-anastomotic strictures were treated with balloon dilation and maximal stenting. A successful stent-free trial was defined as absence of biochemical, clinical or imaging evidence of strictures on follow-up exceeding 6 months. Adverse events were defined as unplanned admission or inpatient evaluation within 7 days of ERCP. RESULTS: Forty-nine DCD LT recipients underwent ERCP and 34 patients were diagnosed with strictures (20 anastomotic). Stent-free trial was successful in 27 patients. Adverse events occurred after 20 ERCPs. Patients with anastomotic strictures required fewer stents (1.43 ± 1.37 vs 2.63 ± 1.66; P < 0.001), shorter procedure and fluoroscopy times (34.15 ± 20.9 vs 59.6 ± 30.7 minutes, P < 0.001; 5.99 ± 7.4 vs 14.73 ± 10.74 minutes, P < 0.001), fewer relapses (10% vs 57%, P = 0.003), shorter intervals between initial ERCP and stent-free success (136.9 ± 118.3 vs 399.56 ± 234.7; P = 0.003), and between LT and stent-free success (227.8 ± 171.9 vs 464.1 ± 224.6 days; P = 0.005) compared to non-anastomotic strictures. CONCLUSION: Endoscopic dilation and maximal stenting resolves biliary strictures in DCD LT recipients with sustained success and relatively few adverse events.

Anatomical Location of Pathology Is Predictive of Prolonged Fluoroscopy Time During ERCP: A Multicenter American Study.

BACKGROUND: Different factors have been associated with prolonged fluoroscopy time (FT) during endoscopic retrograde cholangiopancreatography (ERCP). AIM: We hypothesize that FT depends on both the anatomical location of the pathology managed during ERCP and the complexity of the ERCP. METHODS: Three centers participated in a retrospective multi-center cohort study. Data on patient demographics, ERCP complexity, and the location of pathology were collected. The relationships between FT and the location of pathology, ERCP complexity, patient demographics, and ERCP maneuvers, respectively, were analyzed. Prolonged FT was defined as a FT > 10 min. RESULTS: A total of 442 cases underwent ERCP in three different centers (301 cases, 76 cases, and 65 cases in centers A, B, and C, respectively) by six endoscopists. The median FT for all cases was 282 (range 8-3,516) s. Mean FT increased progressively according to anatomical location in the order extrahepatic cases {n = 298; mean FT 292 [95 % confidence interval (CI) 263-322] s}, pancreatic cases [n = 27; mean FT 359 (95 % CI 200-517) s], and intrahepatic cases [n = 117; mean FT 736 s (95 % CI 635-836) s]. Mean FT increased progressively with the complexity scale, with mean FT for Grade I, 218 (95 % CI 138-299) s; Grade II, 295 (95 % 261-329) s; Grade III, 586 (95 % CI 508-663) s; Grade IV, 636 (95 % CI 437-834) s. Multivariable analysis confirmed that prolonged FT was independently associated with anatomical location of the targeted pathology during ERCP-but not with ERCP complexity and endoscopy center. CONCLUSION: Prolonged FT during ERCP is associated most strongly with intrahepatic cases. FT can be used most effectively as a quality measure if it is stratified according to presence or absence of intrahepatic cases.

Portal vein thrombosis in patients with end stage liver disease awaiting liver transplantation: outcome of anticoagulation.

BACKGROUND: The prevalence of portal vein thrombosis (PVT) increases with the severity of liver disease. Development of PVT is often accompanied by increased rate of morbidity and mortality and may affect patient candidacy for liver transplant. There is limited data regarding the role of anticoagulation therapy in patients with PVT and liver cirrhosis. OBJECTIVES: The aims of this study were to describe the prevalence of hypercoagulable disorders in patients with liver cirrhosis and PVT, and to describe the outcome of anticoagulation in patients with liver cirrhosis and PVT. METHODS: A retrospective chart review was conducted of patients with liver cirrhosis awaiting liver transplant who were diagnosed with PVT between January 2005 and November 2011. RESULTS: During the study period, 537 patients were evaluated for liver transplant. Sixty-nine (13 %) patients were diagnosed with portal vein thrombosis. Chronic hepatitis C was the cause of liver disease in 24/69 (35 %) patients, and hepatocellular carcinoma was present in 39 % of patients. In 22 patients screened for hypercoagulable disorders, hypercoagulable disorder was diagnosed in one patient (5 %). Twenty-eight (28/69) patients were treated during the study period with warfarin: PVT resolved in 11/28 (39 %), no change in 5/28 (18 %), and 12/28 (43 %) patients showed partial resolution of thrombus. Eight patients received liver transplant while on anticoagulation, and operative notes confirmed patency of PV in all eight patients. CONCLUSIONS: PVT is frequently seen in patients with end stage liver disease with prevalence of 13 %. Hypercoagulable disorder was detected in 5 % of the patients screened. Careful use of anticoagulation is safe and effective in patients with PVT.

Effect of fluoroscopy utilization monitoring on fluoroscopy times during ERCP.

AIM: The aim of the present study was to find whether informing endoscopists that their FT is being tracked would result in decreasing their overall fluoroscopy utilization as measured by FT. METHODS: We reviewed the medical charts of patients underwent ERCP from April 2011 to May 2012. On December 15, 2011, the endoscopists were informed about their mean FT during ERCP, were encouraged to decrease FT and were informed their FT would be monitored. We compared the mean FT of the endoscopists individually and as a group before and after December 15, 2011. RESULTS: The study included 293 patients and 3 endoscopists. Before informing the endoscopists that their FT was being tracked, utilization of fluoroscopy was significantly variable among endoscopists. The mean FT for all endoscopists was 9.04 minutes and for each endoscopist was 6.06, 11.43, and 7.67 minutes, respectively (P<0.02). After informing the endoscopists that their FT will be followed, there was a trend toward a decrease in FT among the group (9.04 vs. 7.4 minutes, P=0.06). However, the changes in FT among endoscopists individually were variable. The FT for first, second and third endoscopists changed from 6.06 min to 3.39 min, p<0.02, 11,43 min to 8.8 min, P=0.14 and 7.67 to 11.47 minutes, P=0.06, respectively. CONCLUSION: Fluoroscopic utilization during ERCP among endoscopists is variable. Endoscopists' knowledge that their FT during ERCP is being tracked leads to variable results among endoscopists. Nonetheless, overall it leads to a trend in reducing fluoroscopy utilization.

Intestinal parasites of endangered orangutans (Pongo pygmaeus) in Central and East Kalimantan, Borneo, Indonesia.

Faecal samples from 163 captive and semi-captive individuals, 61 samples from wild individuals and 38 samples from captive groups of Bornean orangutans (Pongo pygmaeus) in Kalimantan, Indonesia, were collected during one rainy season (November 2005-May 2006) and screened for intestinal parasites using sodium acetate-acetic acid-formalin-concentration (SAFC), sedimentation, flotation, McMaster- and Baermann techniques. We aimed to identify factors influencing infection risk for specific intestinal parasites in wild orangutans and individuals living in captivity. Various genera of Protozoa (including Entamoeba, Endolimax, Iodamoeba, Balantidium, Giardia and Blastocystis), nematodes (such as Strongyloides, Trichuris, Ascaris, Enterobius, Trichostrongylus and hookworms) and one trematode (a dicrocoeliid) were identified. For the first time, the cestode Hymenolepis was detected in orangutans. Highest prevalences were found for Strongyloides (individuals 37%; groups 58%), hookworms (41%; 58%), Balantidium (40%; 61%), Entamoeba coli (29%; 53%) and a trichostrongylid (13%; 32%). In re-introduction centres, infants were at higher risk of infection with Strongyloides than adults. Infection risk for hookworms was significantly higher in wild males compared with females. In groups, the centres themselves had a significant influence on the infection risk for Balantidium. Ranging patterns of wild orangutans, overcrowding in captivity and a shift of age composition in favour of immatures seemed to be the most likely factors leading to these results.

Embodied Motherhood: Exploring Body Image in Pregnant and Parenting Youth.

STUDY OBJECTIVE: There is a paucity of research on body image in pregnant and parenting youth (PPY). Study objectives were to examine: (1) profiles of PPY regarding body image, depression, and eating behaviors and any effects of age and pregnancy status on results; and (2) PPY perceptions of body image. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Demographic data and scores from measures related to self-esteem, body esteem, eating behaviors, and depression were collected from 101 PPY from 2 urban centers. Two focus group sessions were held to further explore survey findings. Sessions were audio-recorded and transcribed verbatim for analysis. RESULTS: Participants (mean age, 19.8 years) reported a history of depression (79/101; 78.2%), anxiety (75/101; 74.3%), drug/alcohol abuse (45/101; 44.6%), and eating disorder (32/101; 31.7%). Parenting (nonpregnant; n = 64) participants had lower body esteem (P = .041) and more eating disorder behaviors (P = .026) compared with pregnant (n = 37) participants. A history of depression or eating disorder both independently increased risk for lower body esteem and self-esteem and higher depressive symptoms in pregnant youth. Four dominant themes emerged from qualitative data: (1) adapting to rapidly changing bodies; (2) inter-relationship between body image and mood; (3) added attention and perceptions of pressure to return to prepregnancy body size; and (4) reconciling change and striving to find a new normal. CONCLUSION: This study highlights the importance of exploring past and current body image, mood, and eating disorder behavior in PPY for risk of current mental health issues. Future research exploring prepregnancy depression, eating disorder, body esteem, and depression in pregnant youth are needed.

Living donor liver transplantation in polycystic liver disease.

In the current Model for End-Stage Liver Disease system, patients with polycystic liver disease (PCLD) who have a poor quality of life secondary to their massive hepatomegaly are no longer competitive for a deceased donor liver transplant if their liver function is well preserved. Traditionally, a caval resection has been advocated in these patients because of the difficulty of the hepatectomy with hepatomegaly, which makes living donation impossible. This series looks at 3 patients who underwent a caval sparing hepatectomy and subsequent living donor liver transplantation (LDLT) for PCLD. Graft and patient survival was 100%, and there were few complications in either donors or recipients. LDLT is an ideal option for patients with PCLD and preserved liver function but poor quality of life.

An estimation of mineral losses through arm sweat of preadolescent children.

Balance studies were conducted to determine the effects of three levels of nitrogen intake on the loss of nitrogen through sweat in preadolescent boys and girls. During the studies, the losses of calcium, iron, magnesium, manganese, potassium, sodium, and zinc were determined in the arm sweat of the subjects. Sweat from the forearm was collected in a polyethylene bag for 1 hr on three different occasions. Using the concentrations of nitrogen in the arm bag and in the whole body collection and the concentration of minerals in the arm bag, the total body loss of minerals were estimated. Losses of minerals through sweat, expressed as a percentage of intake, ranged from 0.12 to 1.10%. Under conditions of these studies, sweat losses of the essential minerals were not a significant factor in estimating total losses.

Female physicians in Mexico: migration and mobility in the lifecourse.

To date there have been few studies of professional women in health care in the developing world. With the increased feminization of the Mexican health work force, an estimated 30 per cent of all physicians are female, there is an urgent need to study this group of workers in terms of their impact on the health service. In particular, the potential for female physicians to migrate could have a dramatic impact on the health service. Indeed, it has long been recognised by the Mexican health authorities that there is an uneven spatial distribution of physicians and yet little is known about the distribution and mobility of female physicians. To this end this paper will analyse the migration and mobility of female physicians through the lifecourse in provincial Mexico. The paper examines the factors that control and structure female physician migration in childhood, during their training and career development. Data for this study were obtained during a period of ten months fieldwork in Mexico. Primary data were obtained from interviews with a sample of physicians in five study states. The interviewees also completed a diary for three months to outline their daily, weekly and monthly routine activities. Secondary data sources were various health employment records, medical school output statistics and the Atlas of Professionals produced by the Mexican census service. Material presented in this paper demonstrates that female physicians in provincial Mexico are not highly mobile. A lack of mobility is due to the constraining factors of education, gender, institutional structures and family and household imperatives.

Mercury bougie dilation of benign esophageal strictures.

Dilation with mercury filled bougies is the oldest and simplest technique available for treatment of benign esophageal strictures. In the majority of patients, mercury-filled dilators are effective and quite safe. Dilation is successful in 80-90%, and the rate of complication is less then 0.2%. Maloney dilators have superseded Hurst dilators because their tapered, flexible tip allows better guidance of the dilators into the lumen of the stricture. Several cautions are in order when using Maloney dilators. Dilation of difficult strictures should be observed by fluoroscopy to prevent misdirection of the dilator and esophageal perforation. Where possible, Maloney dilators should not be used to treat narrow, elongated, or angulated strictures. Dilation need not be rushed. Treatments may be repeated over months to years, both to achieve symptomatic relief initially and to maintain that state. Finally, patients susceptible to endocarditis require antibiotic prohylaxis prior to treatment.

Accuracy of the actuator disc-RANS approach for predicting the performance and wake of tidal turbines.

The actuator disc-RANS model has widely been used in wind and tidal energy to predict the wake of a horizontal axis turbine. The model is appropriate where large-scale effects of the turbine on a flow are of interest, for example, when considering environmental impacts, or arrays of devices. The accuracy of the model for modelling the wake of tidal stream turbines has not been demonstrated, and flow predictions presented in the literature for similar modelled scenarios vary significantly. This paper compares the results of the actuator disc-RANS model, where the turbine forces have been derived using a blade-element approach, to experimental data measured in the wake of a scaled turbine. It also compares the results with those of a simpler uniform actuator disc model. The comparisons show that the model is accurate and can predict up to 94 per cent of the variation in the experimental velocity data measured on the centreline of the wake, therefore demonstrating that the actuator disc-RANS model is an accurate approach for modelling a turbine wake, and a conservative approach to predict performance and loads. It can therefore be applied to similar scenarios with confidence.

Successful Nonsurgical Treatment of Pneumomediastinum, Pneumothorax, Pneumoperitoneum, Pneumoretroperitoneum, and Subcutaneous Emphysema following ERCP.

Complications related to endoscopic retrograde cholangiopancreatography (ERCP) include pancreatitis, hemorrhage, cholangitis, and perforation. ERCP-related perforation is uncommon, but mortality rates are high. Diagnosis requires a high clinical suspicion for early detection to allow optimal management of the perforation and a better prognosis. Treatment depends on the location and mechanism and increasingly involves nonoperative management. We report a case of successful nonsurgical treatment of a patient with extensive air involving the peritoneum, retroperitoneum, thorax, mediastinum, and subcutaneous tissues following an ERCP perforation.

Identity and experience: a study of selected female physicians in five provincial states of Mexico.

The aim of this paper is to analyse the identity(ies) and experiences of a selected group of female physicians in five provincial states of Mexico. In the last 30 years the number of female physicians in Mexico has grown considerably and yet little is known about these women. Data for this work were drawn from two in-depth interviews with 99 female physicians during 1995-1996. In addition, physicians were asked to complete a personal diary to illustrate the nature of their daily experiences over a three-month period; the gap between the two interviews. Analysis reveals female physician identity is shaped by Mexican health care service structures, personal characteristics and goals, and career development choices and opportunities. Association with particular spaces and places influences female physician career development and identity. The multiple identities of these professional women and their lived experiences can result in various pressures and tensions in family and career life. As a result these women make choices about career development; some reassess their career goals given their family and household circumstances and thus their career development may appear to be constrained. The paper concludes by suggesting that changes in Mexican health institutions and the science of medicine may lead to changes in female physician identity.

Hobby or job? Mexican female health workers.

A critical analysis of the role and status of female health workers in the primary health care service (PHC) of the Secretary of Health in the Federal District of Mexico is presented. Women are key workers in the health service; however, since the creation of the PHC service, women appear to have been kept in low-pay, low-status jobs. Data from questionnaires and in-depth interviews with female health workers in the Federal District illustrate the situation. Female health workers' status is determined by the structure and operation of the PHC system; by family and personal needs; by the cultural context of Mexican society; and by the fact that some female health workers view their job as a hobby, placing family considerations above career enhancement.

PIP: The position of the female health worker in Mexican public health services has been marginalized by her perceptions, her lack of power and authority, and the decline in institutional conditions. The success of primary health care strategies may be dependent on the role women play in improving the system. Women have chosen a career because of the flexible work practices that allow for accommodating personal and family needs; a health workers may value flexibility equally with adequate wages, recognition as a professional, and job stability and mobility. However, health planners and administrators may not view the value of health workers as vital. Instead women health workers are low paid, low status employees. Data is obtained from 391 respondents from 54 primary health care (PHC) centers and in-depth interviews with female health workers on the structure and operation of the PHC system, family and personal needs, the cultural context, and the job definition as hobby rather than career opportunity. Women's role in heath care has been traditionally compatible with the view of women as caregiver and "natural" skills throughout the world and history. Women participate in health systems at the household level, community level, and within informal and formal health systems. Comprehensive PHC systems involve community participation, while selective systems emphasize use of professional workers. The Mexican Federal District system serves the need of about 30% of the population, while social security, private practices, traditional healers, and philanthropic organizations fulfill other health demands. The District system primarily serves the urban poor in PHC centers of various sizes in close proximity to marginal populations. 57% of health workers in the District system were women in 1987; positions involved all occupations at all levels. Staff shortages are common, but jobs provide no easily obtainable permanency. A review of wages from questionnaires reveals even physicians are paid less than the government minimum salary. Salaries vary between districts and the poorest paid physicians are in Iztalcalco and Venustiano Carranza. Tlahuac nurses are paid over the minimum wage. Most wages constitute 50% to 100% of household income. PHC jobs are chosen because of the need to serve people, be of some help to the community, and be close to home.

High-performance liquid chromatographic-mass spectrometric assay of high-value compounds for pharmaceutical use from plant cell tissue culture: Cinchona alkaloids.

The use of high-performance liquid chromatography (HPLC) interfaced with thermospray (TSP) mass spectrometry is described for the separation and identification of various alkaloids from Cinchona ledgeriana extracts. The use of water-acetonitrile-acetic acid (71:25:4) with 0.01 M ammonium acetate (pH 3.0) as the mobile phase gave good HPLC separation and good TSP sensitivity. The specificity obtained by single-ion monitoring allowed the analysis of commercially important alkaloids such as quinine and quinidine in plant material, transformed roots and in cells from tissue culture, with relatively simple extraction and work-up procedures. TSP gave protonated species with few fragment ions but collision-induced dissociation offers the promise of increased analytically specificity from the fragment ion data. This work has important implications for the biotechnological production of pharmaceuticals normally obtained from plant sources.

Determination of lysergide in urine by high-performance liquid chromatography combined with electrospray ionisation mass spectrometry.

A quantitative method which avoids derivatisation is described for the determination of lysergide (LSD) levels in urine. Sample preparation included addition of methysergide as an internal standard followed by solid-phase extraction. LSD was analysed on a system consisting of a C18 stationary phase and a mobile phase of 0.1 M acetate buffer pH 8.0-acetonitrile-triethylamine (75:25:0.25, v/v). LSD was detected by electrospray ionisation mass spectrometry with selected ion monitoring. The quantification limit was 0.5 ng/ml and the method was linear up to 10 ng/ml of LSD in urine.