Management of symptomatic Baker's cysts with ultrasound and fluoroscopic-guided aspiration followed by therapeutic injection with Depomedrone and Bupivacaine leads to a durable reduction in pain symptoms in a majority of patients; A case series and literature review.

Purpose: To evaluate the efficacy of ultrasound and fluoroscopic-guided aspiration and therapeutic injection of Baker's cysts in the relief of pain and pressure symptoms. Methods: A retrospective, observational, single-arm study of consecutive patients referred from the Orthopaedic service for image-guided aspiration followed by therapeutic injection of symptomatic Baker's cysts was performed with institutional approval in the context of a Quality Improvement project. Patients' pain was graded using a 10-point Likert scale. Under standard sterile conditions, a 10 cm 5 Fr Yueh centesis needle was advanced into the cyst under direct ultrasound guidance, septae disrupted as necessary, the contents of the cyst aspirated, and a sample sent for microbiological analysis. Bursography was performed in an attempt to identify the expected communication with the knee joint, the contrast was aspirated and 40 mg of DepoMedrone and 5 ml of Bupivacaine were injected. Results: Thirteen patients were referred, nine of whom satisfied the inclusion criteria (all female, average age 63.8 years). Over a 35-month period, 11 procedures were performed (bilateral in 1, repeated in another) yielding an average volume of 20.1 ml (range 10 - 50 mls). In 2/11 procedures the communication with the knee joint was outlined. The average follow up post-procedure was 8.3 months. The average patient's pain score reduced to zero from 5.7 for an average period of 5.96 months. After this period patients reported a gradual return of an ache, but none returned to the pre-procedure severity which, in some cases, had prevented them from sleeping. Conclusion: Aspiration of symptomatic Baker's cysts under Ultrasound and fluoroscopic guidance followed by therapeutic injection of DepoMedrone and Bupivacaine leads to a durable reduction in pain symptoms in a majority of patients.

Management of portal cavernoma-associated cholangiopathy: Single-centre experience.

BACKGROUND AND AIMS: Portal cavernoma associated cholangiopathy (PCC) is an uncommon disease in western countries. We describe our experience in seven patients with PCC, in particular the endoscopic management. We describe the mode of presentation, frequent symptoms and the outcome of different treatment modalities of patients with symptomatic PCC. METHODS: Prospectively maintained database was reviewed at a large tertiary referral unit in London, UK. Data included therapeutic interventions, outcomes and complications. RESULTS: Seven patients with PCC were followed for a median of 87 months [interquartile range (IQR), 62-107.5]. Causes of EHPVO included (hypercoagulable status, n=2, peritoneal tuberculosis n=1, neonatal sepsis, n=1, idiopathic, n=3). Acute cholangitis constituted the most recurring complications in all patients during the disease course. Endoscopic intervention was deemed required in all patients for biliary decompression, with 5 out 7 patients managed with repeat endoscopic sessions, (total=23 ERCPs). Surgical portal decompression (meso-caval shunt) was successfully performed in one patient and another patient underwent liver transplantation for decompensated liver cirrhosis. When endoscopic intervention was indicated, a fully covered self expanding metal stent (FcSEMS) provided a longer "symptoms free" period when compared to plastic stent, 7.5 (IQR, 4.75-18.25) and 4 (IQR, 3.5-7) months respectively, P=0.03. Bile duct bleeding occurred in two patients during ERCP procedure, however none of the patients had spontaneous haemobilia. Both patients were successfully treated by FcSEMS. CONCLUSION: Acute cholangitis is a common presentation and recurrent complication during the disease course. Spontaneous haemobilia seems to be uncommon, however it is a significant potential hazard during endoscopic intervention. Insertion of FcSEMS may remodel choledochal varices and provide a longer "symptoms free" period compared to plastic stents.

Leprosy in Panama: a study of its origin and spread

No record has been found of leprosy among the natives of Panama prior to the founding of the first Spanish settlement, Nombre de Dios, in 1509. Leprosy was introduced principally by the Spanish conquistadores, merchants and settlers, some of whom came directly from the Old World while others came by way of Colombia and Peru; and it has been maintained mostly by their descendants and direct familial contacts. In the majority of cases, the spread of leprosy in Panama has been along the routes of territorial invasion and of commercial travel. From 15 leprous West Indian negro laborers who came to Panama from the French and British colonies in the Caribbean Sea, there have developed nine secondary cases among descendants or contacts in a period of approximately 35 years. Among the 109 patients hospitalized in the Palo Seco Leper Colony, it was possible to obtain from 74 percent definite histories of contact with preexisting cases of leprosy. Of the new cases found in the provinces, those already hospitalized and whose families were visited in the provinces, and those studied in church or other records, -the total of these being approximately 116 - histories of prior contact with leprosy was established for all save one. At the present time residual endemic foci of leprosy in the Republic of Panama are the towns and villages of Las Tablas, Los Santos, Chepo, Taboga, Bocas del Toro, and probably Marica and Las Delicias. Leprosy, in Panama, appears to be a familial disease, which the writer interprets not as an example of biologic inheritance of the bacterial invasion but as evidence of inherited predisposition to leprosy, coupled with prolonged intimate contact with the disease.