Wall maturation in necrotic collections in acute pancreatitis: a computed tomography based evaluation.

Aim: To systematically investigate the timing of encapsulation of necrotic collections in acute necrotizing pancreatitis (ANP) using contrast-enhanced computed tomography (CECT). Methods: This retrospective study comprised consecutive patients of ANP who underwent CECT of the abdomen between the second and fourth weeks of illness. Number and site of collections and presence and completeness of the wall (defined as a thin smooth enhancing rim more than 1 mm in thickness) were documented. Results: A total of 195 patients of ANP were included. Seven hundred seventy-three collections were evaluated in 284 CECT scans. The most common site of the collection was anterior pararenal space (n=290, 37.5%). The mean maximum dimension of the collection was 8.1 cm (range, 3.1-16 cm). Two hundred twentytwo (28.7%) collections had a complete wall. The mean interval to complete wall maturation was 18 days (range, 8-28). Overall, 13.3%, 37.1%, and 56.2% of the collections showed complete encapsulation in the second, third, and fourth weeks, respectively. Conclusions: Our study suggests that a significant proportion of necrotic collections show complete encapsulation within 4 weeks of the onset of ANP.

Variability of contrast enhancement of pancreas on computed tomography in patients with acute pancreatitis and isolated extrapancreatic necrosis.

BACKGROUND AND STUDY AIM: To evaluate the variability in the enhancement of pancreas on computed tomography (CT) in patients with acute pancreatitis (AP) and isolated extrapancreatic necrosis (EPN) and to investigate whether it affects the extrapancreatic findings and patient outcomes. PATIENTS AND METHODS: This retrospective study comprised of consecutive patients with isolated EPN evaluated between April 2017 and April 2019. A radiologist measured the pancreatic attenuation values (PAV) of head, body, and tail on a contrast enhanced CT. Using a cut-off PAV of 100HU, patients were divided into two groups. The extrapancreatic CT findings and outcome parameters were compared between the two groups. RESULTS: Thirty patients (mean age, 42.13 years, 17 males) with isolated EPN were evaluated. The mean PAV in the head, body, and tail was 83.13 HU (range, 59-161), 84.17 HU (range, 60-160), and 82.23 HU (range, 53-137). The overall mean PAV was 83.12 HU (range, 58-152). There were six patients with overall mean PAV≥100 HU. The group with PAV≥100 HU had a higher number of patients with infected necrosis (66.6% vs. 14.2%, P=0.018). PAV had a significant association with length of hospitalization (P=0.045). CONCLUSION: There is significant variability in the pancreatic enhancement on CT among patients with AP and isolated EPN. Patients with PAV≥100 HU had a significantly longer hospital stay. This, however, may be related to a greater number of patients with infected necrosis in this group.

Role of computed tomography in prediction of gastrointestinal fistula in patients with acute pancreatitis.

AIM: To identify computed tomography (CT) features that predict gastrointestinal fistula (GIF) in patients with acute pancreatitis (AP). METHODS: This retrospective study comprised consecutive patients with AP and GIF from June 2017 to June 2018. The diagnosis of GIF was based on upper gastrointestinal endoscopy, colonoscopy or surgery. A cohort of 19 matched patients from a prospective database of AP served as control group. Measures of severity, and clinical outcome were evaluated. CT parameters were compared between the groups to assess the features that could predict the development of GIF. RESULTS: There was no difference between the two groups in terms of disease etiology, severity, drainage, and mortality. On univariate analysis, the CT features that were found to be significantly different between the two groups were the presence of bowel wall thickening (P=0.005), maximum thickness of the bowel wall (P=0.007), presence of air foci in extra pancreatic necrosis/ collection (P=0.013), discontinuity of the bowel wall (P=0.046) and the displacement/ compression of bowel by fluid collection (P=0.014). On multivariate analysis, all the above-mentioned CT findings except discontinuity of bowel wall were found to be statistically significant. CONCLUSION: CT is helpful in predicting GIF in patients with AP.

Effect of follicular fluid oxidative stress on meiotic spindle formation in infertile women with polycystic ovarian syndrome.

BACKGROUND: The effect of follicular fluid (FF) oxidative stress (OS) on meiotic spindle (MS) formation in oocytes and subsequent outcome in women with polycystic ovarian syndrome (PCOS) are evaluated in this study. METHODS: 326 oocytes from 35 PCOS women (group A) and 208 oocytes from 32 women with tubal infertility (group B) were visualized for MS using PolScope. FF was analyzed for OS markers including reactive oxygen species (ROS), lipid peroxidation and total antioxidant capacity (TAC). Group A was further classified into groups A1 and A2, and group B into groups B1 and B2 depending upon the presence or absence of MS, respectively. RESULTS: MS formation was absent in a significantly higher number of oocytes in group A compared to group B (p

When does the 'learning curve' of innovative interventions become questionable practice?

Demand for less invasive surgical intervention has increased in recent years resulting in surgeons occasionally being pressurised into adopting new techniques before evidence of safety and efficacy has been established. Unlike pharmaceutical research, most innovative surgical procedures enter surgical practice without regulatory oversight. This anomaly was recently highlighted in the 'Bristol Report' resulting in a recommendation that unproven therapies or surgical techniques be subjected to ethical overview or independent oversight. When a novel technique is introduced, the surgeon will find himself/herself gaining proficiency and experience on suitable patients. Hence the surgeon embarks on a 'learning curve'. A learning curve can be defined as a graphic representation showing the relationship between experience with a procedure and outcome. Studies demonstrate that learning curves generally 'flatten out' as experience increases, resulting in fewer complications and less of a need to convert to the standard procedure. In addition to lack of regulatory oversight, it is this learning curve that gives rise to many ethical and legal dilemmas. This paper considers the ethical issues relating to a surgeon's candour and clinical equipoise, the legal standard of care in a negligence action and the ethical and legal implications regarding risk disclosure during informed consent. The paper concludes by considering a more patient centred approach where new and innovative therapies are being considered in order to ensure good medical practice and avoid litigation for allegations of negligence or breach of human rights.

Functional ability correlates with cognitive impairment in Parkinson's disease and Alzheimer's disease.

BACKGROUND/AIMS: Previously we have shown that functional declines in Parkinson's disease (PD) and Alzheimer's disease (AD) correlate to global measures of cognitive decline. We now determine if the correlation between cognitive impairment and functional ability in PD is similar to that in AD using individual cognitive measures. METHODS: 93 PD subjects and 124 AD/MCI subjects underwent the Functional Assessment Staging (FAST), the Global Deterioration Scale (GDS), and a neuropsychological battery. RESULTS: In PD subjects, the FAST and GDS correlated significantly with Rey Auditory Verbal Learning Test (AVLT), Controlled Oral Word Association (COWA), Animal Fluency, and Stroop but not with Clock Draw or Judgment Line Orientation (JLO). In AD/MCI subjects, FAST and GDS correlated with all neuropsychological components except Stroop. In the AD/MCI group, the UPDRS significantly correlated with the FAST, GDS, MMSE, and all neuropsychological parameters except the Stroop. In the PD group, the motor UPDRS significantly correlated significantly with FAST, GDS, MMSE and all neuropsychological parameters except Digit Span, Stroop, Clock Draw and JLO. CONCLUSIONS: Similar to AD, functional decline in PD correlates with multiple measures of cognitive impairment. Some differences between PD and AD may be explained by the influence of motor disability and declines in visuospatial function in PD.

Both early and late cognitive dysfunction affects the electroencephalogram in Parkinson's disease.

We sought to define quantitative electroencephalographic (EEG) measures as biomarkers of both early and late cognitive decline in Parkinson's disease (PD). PD subjects classified as cognitively normal (PD-CogNL), mild cognitive impairment (PD-MCI), and dementia (PD-D) were studied. Cognitive status and neuropsychological testing was correlated with background rhythm and frequency band EEG power across five frequency bands. We conclude that global EEG measures have potential use as biomarkers in the study of both early and late cognitive deterioration in PD, including for evaluating its treatment. PD-MCI has mean quantitative EEG characteristics that represent an intermediate electrophysiological state between PD-CogNL and PD-D.

The implications of the David Glass case for future clinical practice in the UK.

A recent decision of the European Court of Human Rights (ECtHR) raises issues of considerable importance to medical practitioners and paediatricians in particular. The case concerns the parental right to withhold consent to medical intervention that doctors believe to be necessary in a child's best interests. The dramatic facts of this case (in which a boy's family felt they had to fight for his life) has significant repercussions for clinical practice. This is discussed in the light of previous and recent cases that have involved babies, infants and children. The worrying trend to use the Courts to resolve these difficult clinical cases is discussed.

An evidence-based approach to the management of low back pain and sciatica: how the evidence is applied in clinical cases.

BACKGROUND: Low back pain and sciatica are common complaints that affect a major proportion of the population at some time in their lives. The treatment and management of this condition may vary widely. OBJECTIVE: The present paper aims to provide an evidence-based approach to the management of low back pain and sciatica, and demonstrates how to search for the evidence and how to apply it practically in individual patients. The principles underlying evidence-based medicine are explained. The practice of evidence-based medicine requires initial formulation of the appropriate clinical question, followed by searching databases for relevant evidence. Finally evidence needs to be applied on a patient-specific basis. METHOD: Best Evidence, the Cochrane Library, Embase and Medline were searched to obtain quality controlled information regarding the management of low back pain and sciatica. RESULTS: Current evidence shows that an active exercise programme promotes early recovery. This may allow patients to resume an active and sportive lifestyle. Epidural corticosteroid injections may help to resolve additional troublesome symptoms of sciatica. Two clinical cases are used to show how evidence-based medicine can be individualized to specific patients. CONCLUSIONS: A patient-focused strategy combining best evidence and clinical expertise is suggested as the mainstay for the management of low back pain.