Eosinophilic cholangitis: a case of 'malignant masquerade'.

BACKGROUND: A variety of causes of inflammatory bile duct stricture can masquerade as hilar cholangiocarcinoma. Eosinophilic cholangitis is a further example. CASE OUTLINE: A 50-year-old woman with epigastric pain and deranged liver function was found to have a stricture of the common hepatic duct on ERCP with an associated mass on MRl.The lesion was excised with reconstruction of the right and left hepatic ducts, and the patient recovered well. Histopathological examination of the resected gallbladder and bile duct showed diffuse inflammation with a predominant eosinophil infiltrate.The presence of Candida albicans in the bile duct lumen can probably be attributed to the preoperative biliary stent.There was a modest postoperative rise in peripheral eosinophil count. DISCUSSION: A literature search reveals only six previous cases of eosinophilic cholangitis, but similar infiltrates have also been seen in occasional cholecystectomy specimens. As the present patient did not have gallstones, the aetiology remains unclear. Peripheral eosinophilia is an unreliable clue to the diagnosis, which is usually likely to escape detection until the biliary stricture has been resected.

Surgery for colorectal liver metastases with hepatic lymph node involvement: a systematic review.

BACKGROUND: Liver resection for colorectal metastases is the only known treatment associated with long-term survival; extrahepatic disease is usually considered a contraindication to such treatment. However, some surgeons do not regard spread to the hepatic lymph nodes as a contraindication provided that these nodes can be excised adequately. A systematic review of the literature was undertaken to address this issue. METHODS: An electronic search using Medline, Cancerlit and Embase databases was performed for studies reporting liver resection for colorectal metastases from 1964 to 1999. Data were extracted from papers reporting outcome for patients with positive hepatic nodes and analysed according to predetermined criteria. RESULTS: Fifteen studies were identified that gave survival data on 145 node-positive patients. Five patients were reported to have survived 5 years after liver resection; one was disease free, two had recurrent disease and the disease status was not described in the remaining two. Five studies containing 83 patients specified a formal lymph node dissection as part of the surgical procedure and four of the five node-positive 5-year survivors were from these studies. CONCLUSION: There are few 5-year survivors after liver resection, with or without lymph node dissection, for colorectal hepatic metastases involving the hepatic lymph nodes.

Inflammatory myopathy in hemiatrophy resulting from linear scleroderma.

Hemiatrophy caused by linear scleroderma is a race clinical entity of unknown etiology. We present a patient with an inflammatory myopathy in hemiatrophy resulting from linear scleroderma.

Elliptocytes and tailed poikilocytes correlate with severity of iron-deficiency anemia.

This study examines the relationships between abnormal RBC morphology, RBC indices measured with an automated hematology analyzer, serum iron studies, and severity of anemia in patients with findings indicative of iron-deficiency anemia. Counts and morphologic classification of 1,000 RBCs from each of 22 patients were performed, and correlations were determined between parameters. The Student t test was used to determine the level of significance for correlations between parameters. Several significant relationships were found. As the percentage of elliptocytes increased, hemoglobin concentration, hematocrit, RBC concentration, and mean corpuscular hemoglobin level decreased (r = .48, .44, .40, and .49, respectively; P < .05). As the percentage of tailed poikilocytes increased, hemoglobin concentration, hematocrit, and RBC concentration decreased (r = .70, .77, and .71, respectively; P < .01) and RBC distribution width increased (r = .73; P < .01). Of significance, serum ferritin levels, long considered the best single indicator of iron deficiency, showed no correlation with the morphologic abnormalities assessed, severity of anemia, or any of the analyzer-generated indices. Our results indicate that microscopic evaluation of RBC morphology remains an important tool for the pathologist to evaluate the severity of anemia in patients with iron deficiency.

Multifocal varicella-zoster virus leukoencephalitis in a patient with AIDS: MR findings.

We describe a patient with AIDS who presented with an acute encephalitis caused by infection with varicella-zoster virus. The hemorrhagic, necrotizing encephalitis had an unusual MR appearance, with innumerable discrete, small, targetlike lesions in the right cerebral hemisphere, which were coalescent in the posterior temporal, parietal, and occipital regions. Of the several known disease patterns of varicella-zoster viral infection in the CNS, this histopathologic pattern of multifocal leukoencephalitis is rare. It is important to recognize, as effective antiviral drug treatments are available.

Repeated ectopic pregnancy.

The literature concerning ectopic pregnancy is reviewed with regard to the information on multiple ectopic pregnancies. The epidemiology, causes, and treatments for multiple ectopic pregnancies are summarized. In addition, the results of radical and conservative surgical management procedures and medical management are discussed in the context of the fertility of patients with multiple ectopic pregnancies, and procedures appropriate for the infertile patient are discussed.

Decentralized budgeting: holding the purse strings, part 1.

A decentralized nursing structure allows the head nurse to become actively involved in the planning and budgeting process. In Nursing Decentralization: The El Camino Experience (published in November 1981 by Nursing Resources) the authors describe the development of a budgeting system that supports autonomy, accountability, and authority at the practitioner level. For JONA readers, we present, in two parts, an abridged version of the chapter "Budgeting: Holding the Purse Strings." Part 1, which follows, outlines important steps for the development of a successful and efficient budgeting program that can be adapted to meet the needs of other decentralized organizations. Part 2, which details a typical budget session, will appear in the next issue of JONA.

Nurse staffing in a decentralized organization: part II.

It must be emphasized that none of the steps described in this planning process emerged overnight. Rather, they were achieved through a process of evolution, sometimes through trial and error, and always with consultation and participation by many members of the hospital nursing staff. Participation by many in the process of planning for a workable staffing system has been essential to its success. Indeed, creative scheduling by the head nurse is possible because of the way in which the system has been organized. The fact that head nurses are responsible for staffing their own units makes it infinitely easier for them to see what they need to make their units operate effectively and efficiently. Creative scheduling includes the possibility of arranging nurses' hours outside the rigid three-shift schedule used by so many hospitals. Many El Camino nurses now report for work at different hours. In addition, the use of flexible work weeks has proven valuable. Some head nurses now allow for a ten-hour, four-day work week; in emergency staffing situations there have, on occasion, been twelve-hour days. Even as this system evolves, it faces change. Just as the requirements for staff cannot be rigid, so must problem solving be flexible and constantly under review. The fact that El Camino believes in constant monitoring of its system is essential to its success. A key philosophical foundation of decentralization is that it must be subject to change. This is no less true in staffing than in other parts of the decentralization structure. By agreeing that change is constant and necessary and that participation is required at all levels of the staffing planning process, we have constructed the outlines of a system that will work in the future as well as it does in the present. Our system centers around the head nurses. It involves their planning; thus it also involves the support of those members of the nursing staff who can provide essential information. But the decisions about how to use the information remain with the head nurse. And that, as much as anything, is at the heart of the decentralized nursing structure.