Percutaneous cholecystostomy - An option in selected patients with acute cholecystitis.

While urgent percutaneous cholecystostomy (PC) was introduced as an alternative to acute surgical treatment for acute cholecystitis (AC), the current place of PC in the treatment algorithm for AC is challenged. We evaluate demographics and outcomes of PC in routine clinical practice in a population-based cohort.Retrospective evaluation of consecutive patients treated with PC for AC between 2000 and 2015. The severity of cholecystitis was graded according to the 2013 Tokyo Guidelines.One hundred forty-nine patients were included (82; 55% males) (median age of 72.5 years; range, 21-92). The Tokyo Guidelines criteria of 2013 (TG13) severity grade distribution was 4%, 61.7%, and 34.2% for grades I, II, and III, respectively. No difference was observed between males and females with regard to age, American Society of Anesthesiologists (ASA) score, comorbidities, or previous history of cholecystitis. PC was successfully performed in all but 1 patient, and complications were few and minor. Less than half (48.3%) of all patients subsequently received definitive surgical treatment, mostly (83.3%) laparoscopy. No or minor complications were encountered in 58 (80.6%) patients. Operated patients were significantly younger (P = <.001) and had lower ASA scores (P = .005), less comorbidities (P < .001), and had more seldomly a severe grade 3 cholecystitis (P < .001) than non-operated patients.PC is useful in selected patients with AC. However, since only a half of the patients eventually received definitive surgical treatment, a better routine decision-making based on proper criteria may enable an improved allocation of the individual patient for tailored treatment according to the disease severity, the patient's comorbidity burden, and also to the treatment options available at the institution to prevent overutilization of a non-definitive treatment approach. Comprehension of this responsibility should be acknowledged by hospitals with an emergency surgical service, although the clinical decision-making remains a challenge of the responsible surgeon on call.

Race duration and blood pressure are major predictors of exercise-induced cardiac troponin elevation.

BACKGROUND: The underlying mechanisms of the exercise-induced increase in cardiac troponins (cTn) are poorly understood. The aim of this study was to identify independent determinants of exercise-induced cTn increase in a large cohort of healthy recreational athletes. METHODS: A total of 1002 recreational cyclists without known cardiovascular disease or medication, participating in a 91-km mountain bike race were included. Median age was 47 years and 78% were males. Blood samples were obtained 24 h prior to, and 3 and 24 h after the race. RESULTS: Cardiac TnI concentrations increased markedly from baseline [1.9 (1.6-3.0) ng/L] to 3 h after the race [52.1 (32.4-91.8) ng/L], declining at 24 h after the race [9.9 (6.0-20.0) ng/L]. Similarly, cTnT increased from baseline [3.0 (3.0-4.2) ng/L] to 3 h after the race [35.6 (24.4-54.4) ng/L], followed by a decline at 24 h after the race [10.0 (6.9-15.6) ng/L]. The 99th percentile was exceeded at 3 h after the race in 84% (n = 842) of subjects using the cTnI assay and in 92% (n = 925) of study subjects using the cTnT assay. Shorter race duration and higher systolic blood pressure (SBP) at baseline were highly significant (p < 0.001) independent predictors of exercise-induced cTn increase both in bivariate and multivariable analysis. The age, gender, body mass index, training experience and cardiovascular risk of participants were found to be less consistent predictors. CONCLUSION: Systolic blood pressure and race duration were consistent predictors of the exercise-induced cTn increase. These variables likely reflect important mechanisms involved in the exercise-induced cTn elevation. TRIAL REGISTRATION NUMBER: NCT02166216 https://clinicaltrials.gov/ct2/show/NCT02166216.

Adult pancreatic hemangioma in pregnancy--concerns and considerations of a rare case.

BACKGROUND: Pancreatic tumors in pregnancy are rare but clinically challenging. Careful diagnostic workup, including appropriate imaging examinations, should be performed to evaluate surgery indications and timing . In the present case a diagnosis of an adult pancreatic hemangioma was made. We were not able to identify a similar case in the very sparse literature on this rare disease. CASE PRESENTATION: A 30-year-old woman at 12 weeks of gestation was diagnosed with a large pancreatic tumor having a cystic pattern based on imaging. Although the preoperative diagnosis was uncertain, patient preference and clinical symptoms and signs suggested surgery. Open distal pancreatic resection including splenectomy was performed, and complete resection of the large cystic tumor was successfully achieved, with no postoperative complications. Although a solid pseudopapillary epithelial neoplasm (SPEN) was suspected, specimen morphology, including immunohistochemistry, supported the diagnosis of an adult benign pancreatic hemangioma. CONCLUSION: Although mucinous cystic neoplasm (MCN) and adenocarcinoma are the most common pancreatic tumors during pregnancy, various other malignant and benign lesions can be encountered. This report adds to the very small number of pancreatic hemangiomas reported in the literature and involves the first patient diagnosed with this rare condition during pregnancy. Careful clinical considerations regarding diagnostic workup and treatments are required to ensure that mother and child receive the best possible care.