Recent internal audit of the first 22 left hepatic trisegmentectomies carried out by this author has shown that 11 required Pringle’s manoeuvre and five needed a period of total vascular isolation fungus disease purchase 200mg nizoral. Eleven of the 22 patients required blood transfusion fungus in grass buy nizoral 200 mg mastercard, although the median requirement was only 1 antifungal quiz questions cheap nizoral uk. This may partly be explained by a high proportion of cholangiocarcinoma cases (32%) in this series as resection of these tumours is associated with a greater degree of operative difficulty fungus on face purchase nizoral with visa. In this group of 22 patients, six of the seven patients with major postoperative morbidity had required either Pringle’s manoeuvre or total vascular isolation, confirming our previous observation. It is also true to say that increasing experience helps to reduce the use of Ex-vivo resection for liver tumors 67 ischaemia and blood transfusion, and there has been little morbidity in a further 15 left trisectionectomies carried out recently by this author. Although orthoptic liver transplantation and cluster resection are the most radical forms of tumour clearance, results for otherwise unresectable tumours have been uniformly disappointing. Tumours account for only 3% of our liver transplant programme in terms of primary indication. However, transplantation remains a valuable option for patients with tumours as secondary indications: principally small hepatomas within cirrhosis. Our centre has been investigating cluster resection and multivisceral grafting as an alternative for extensive tumours and the neuroendocrine group lends itself neatly to this concept. These are most often tumours of midgut origin with foregut metastases and adequate lymphadenectomy involves both the coeliac and superior mesenteric arterial distributions, and if purely foregut (pancreatic tail) then a lesser cluster resection can also be appropriate. These concepts will be discussed at the end of this chapter as they are helpful in defining the place of ex-vivo liver resection in the spectrum of hepatic surgical techniques. In addition there are many lessons to be learnt from the practice of liver transplantation, not least anaesthesia and the role of veno-venous bypass. The short-term survival of untreated patients with both primary and secondary liver tumours, the unpredictability of chemotherapy response on an individual patient basis and the disappointing results of transplantation for cancer provide adequate impetus for attempts to extend the boundaries of liver resection as far as possible. Hilar involvement can be adequately dealt with by short periods of vascular isolation and warm ischaemia and this can often be done without caval or hepatic vein isolation. This fraction is expected to increase as more advanced cases are being considered and it accounts for 6% of cases during the past 12 months in our centre. Ex-vivo resection 18 – 20 offers a potential lifeline for this group of patients and this technique deserves discussion, although it accounts for less than 2% of this author’s total hepatic resection experience. The processes of patient selection and operative assessment of operability by more conventional yet advanced techniques have meant that we have found ex-vivo resection to be necessary in only five of 28 cases (21%) considered during the past 7 years. Before considering a surgical procedure of this scale it is essential to be as sure as possible that the patient is fit enough to withstand the operation. It is important to take a detailed history of previous cardiovascular disease, including myocardial infarction, angina pectoris and hypertension. Clearly, a history of smoking or peripheral vascular disease should raise the clinical suspicion of coronary artery disease. Respiratory diseases, particularly emphysema and chronic bronchitis, are quite prevalent in the Surgical management of hepatobiliary and pancreatic disorders 68 elderly population and clinical examination with chest radiology can be helpful. Patient selection Cardiorespiratory assessment Resting and exercise electrocardiography are the standard cardiological objective assessment tests in our centre. Failure to achieve an adequate heart rate for true stress testing can be a problem in the elderly population, most often due to osteoarthritis of the hips and knees. In this situation a great deal of useful information can be gained from echocardiography, with measurement of end diastolic and systolic volumes to calculate left ventricular ejection fraction, or by radioisotope assessment with dobutamine stress. This procedure is carried out in 10% of major liver surgery candidates in our experience, ruling out surgery in 3% but providing reassuring information in the rest. Only five patients in our experience have been suitable for preoperative coronary artery angioplasty, stenting or bypass grafting prior to liver surgery, but these are clearly potential treatment options to consider. Routine lung function tests including vital capacity and forced expiratory volume form part of our standard assessment as well as chest radiology. In cases where severe pulmonary hypertension is suspected a pulmonary artery wedge pressure line is placed at the commencement of anaesthesia before definitely deciding to proceed with the resection. If there is a very high index of suspicion then we prefer to check the pulmonary artery pressures as a day case procedure in advance of the planned surgical date so that the patient can be advised more accurately about operative risk. Hepatic reserve Preoperative blood tests necessary before proceeding to major resection include full blood count, urea and electrolytes, liver function tests, clotting screen and tumour marker studies. Prothrombin time, bilirubin and albumin give a fairly accurate indication of global hepatic function, but in some cases a liver biopsy of the residual tumour-free liver will also be necessary if there is a doubt about hepatic reserve, in particular in hepatoma. This is particularly important in the group of patients with a previous history of excess alcohol consumption or if there is serological evidence of hepatitis B or C. It is also useful when dealing with cholangiocarcinoma, as there may be underlying sclerosing cholangitis. Some consideration needs to be given to the number of viable tumour-free hepatic segments that will be reimplanted, but this should not usually be less than two, unless there is considerable hypertrophy of the tumour-free liver (Fig. It is inevitable that a degree of temporary hepatic failure will be induced in some patients undergoing very major resection. If the tumour-free segments are affected by biliary obstruction, it is our current practice to attempt biliary decompression by endoscopic or percutaneous techniques a few days in advance of surgery as this may speed up the postoperative recovery. Surgical management of hepatobiliary and pancreatic disorders 70 Tumour type It is reasonable to consider any malignant tumour of the liver, primary or secondary, for ex-vivo liver resection if there is an acceptable chance of clearance of all the disease. It is not our routine to biopsy the tumour unless there is a serious doubt about the diagnosis after radiological assessment. A biopsy can be useful if a benign tumour is suspected, for example hepatic adenoma occurring as a result of a glycogen storage disease, as liver transplantation may be more appropriate in that case. Small metastases or hepatomas not detected by other methods will rule out some candidates and variations in hepatic arterial anatomy can be helpful in some cases, particularly in cholangiocarcinoma. Venography to examine the inferior vena cava and hepatic veins is occasionally useful if all three major hepatic veins are involved with tumour as an adequate inferior or middle right hepatic vein (Fig. An isotope bone scan may be useful in hepatoma, cholangiocarcinoma and some metastatic tumours, and we have recently found it to be of use in colorectal metastatic disease. This is at variance with our usual practice for patients with hepatic metastases from colorectal cancer and may reflect the late stage of presentation of the ex-vivo candidates. New surgical techniques such as resections that rely on the presence of an inferior or middle right hepatic vein and the possibility of hepatic venous reconstruction in situ will mean that ex-vivo liver resection will rarely be performed. In-situ hypothermic perfusion and the ‘ante situm technique’, which do not require hepatic arterial or biliary reconstruction, may be preferable in some cases where it is anticipated that the parenchymal dissection will be difficult. Careful thought must be given to these techniques both preoperatively and during the eventual operation as these methods are Ex-vivo resection for liver tumors 71 widely thought to have a greater applicability than the exvivo technique. However, the only disadvantage of the ex-vivo method is the number of necessary vascular anastomoses and the associated thrombotic risk and in this author’s opinion this is outweighed by the advantages of superb exposure and adequate hypothermic protection in some cases. In-situ hypothermic perfusion the techniques involved in in-situ hypothermic perfusion (Fig. The aim is to provide a bloodless field combined with hypothermic cellular protection, allowing a prolonged and more precise dissection. Cooling can be achieved by portal vein or hepatic artery perfusion and a small dose of heparin is usually given before arterial and portal vein clamping. Liver cooling can be maintained by continuous slow perfusion during the resection or by repeated cooling by perfusion every 30 minutes. A practical point is to avoid rewarming by inadvertently allowing portal perfusion to continue: in a recent case we perfused and established veno-venous bypass through the cut end of the right portal vein and some blood flowed past the cannula from the main portal vein to the left liver. It is usual to ligate and divide the right suprarenal vein in order to gain adequate rotation of the organ. This should allow the whole upper part of the liver to be moved onto the abdominal wall in order to allow access to the cranial and posterior aspects of the liver. Hepatic perfusion is as for the in-situ technique, although the liver can be placed on a heat exchange plate to help keep it cool during the resection. Patient preparation Counselling Preoperative counselling is one of the most important aspects of modern medical practice. When considering ex-vivo liver resection, the patient must be warned that worldwide experience is small. It is appropriate to explain the reasons behind this option and the risks and results of alternative operative and chemotherapeutic strategies. It is our unit’s practice to give each patient being assessed for liver surgery a patient information booklet.
Furthermore fungus gnats thcfarmer order 200mg nizoral mastercard, the occurrence and predictors for esophageal varices and associated gastrointestinal bleeding were assessed fungus anatomy discount nizoral online mastercard, the relations between liver histology and clinical outcome variables evaluated antifungal essential oils nizoral 200mg generic, and noninvasive follow-up tools identified fungus zombie discount 200mg nizoral amex. After centralization, the clearance of jaundice rate improved significantly from 29% to 73%, p=0. A native liver biopsy taken from 23 patients with normal, or near normal, bilirubin levels (35 μmol/L) at a median of 4. The patients whose liver fibrosis progressed had higher serum bilirubin levels at follow-up [median 15 μmol/L (3-35) vs. The combination of normal serum bilirubin (<20 μmol/L) and galactose half-life under 12. Endoscopic surveillance could be allocated to patients with elevated serum bilirubin levels or clinical signs of portal hypertension like splenomegaly or thrombocytopenia. Multicenter collaboration would be desirable in order to further improve treatment results and to obtain adequate patient numbers in future studies. National centralization of biliary atresia care to an assigned multidisciplinary team provides high-quality outcomes. Endoscopic surveillance and primary prophylaxis sclerotherapy of esophageal varices in biliary atresia. Persistent cholangiocytic transformation may sustain progression of liver fibrosis after successful portoenterostomy in biliary atresia. Galactose half-life is a useful tool in assessing prognosis of chronic liver disease in children. These articles are reproduced with the kind permission of their copyright holders. According to the World Health Organization, over 5000 rare disorders exist and in Europe, over 30 million patients have a rare disease. Problems that affect patients with rare disorders, and medical professionals treating them, include limited information on rare diseases, limited availability of adequate treatments, and difficulties in obtaining research financing. Despite the fact that most European health care systems cover treatment costs for rare disorders, affected families report considerable burden of lost social and economical opportunities as well as delays in diagnostics and bad experiences of medical care (4). Most native liver survivors have a slowly progressive liver disease with a risk of portal hypertension, liver failure, and even malignancy (7). Besides lifelong dependency on immunosuppressive drugs, pediatric liver transplant recipients face the risks of allograft ageing and the adverse effects associated with long term immunosuppression (8). He wrote: “The jaundice of infants is a disease attendant with great danger, especially if it appears very soon after birth, and the stools evince a deficiency of bile; for we have then reason to apprehend some incurable state of the biliary apparatus. At 3 days however, it began to get yellow and at the end of three weeks was very yellow. Her motions at no time after the second day appeared natural on examination, but were white, like cream, and her urine was very high coloured. Patients were divided into an “uncorrectable” type with no extrahepatic ductular remnants of the biliary tract and a “correctable” type with a preserved, open part of the common hepatic duct where to suture the intestine. In Ladd’s later series, however, only 12 of 146 (8%) patients became jaundice-free whereas all the rest died (13). Potts, chief surgeon of Children’s Memorial Hospital in Chicago, to declare, in his book the Surgeon and the Child, in 1959: “Congenital atresia of the bile ducts is the darkest chapter in pediatric surgery. In the light of our present knowledge, unless bile can be shunted to the gastrointestinal tract, early death is inevitable. Their second similarly-treated patient also excreted some bile into stools, but eventually died. In the autopsy Kasai found a biliary fistula formed between the 11 intrahepatic bile ducts and the duodenum. Kasai first published the novel technique of excising the portal plate and suturing a jejunal loop to the liver hilum in Japanese in 1959, then in German in 1963, and in English in 1968 (16). In Kasai’s hands 70% of the patients cleared their jaundice but less than 20% survived jaundice-free more than two years (17). It took several years for the method to spread around the world and gain acceptance (20). The highest incidence, approximately 1:3000 live births, is in French Polynesia (38, 39) and Taiwan (40). Reports of gender distribution are conflicting: some centres report a slight majority of girls (54-69%) (30, 31, 33, 38), whereas a register study from Sweden showed female minority (40%) (29). An increasing amount of data exists, however, on a combined genetic susceptibility and an infectious, most likely viral, trigger followed by an autoimmune-type of inflammation in the biliary tree (1, 43, 44). Since June 2009, the World Health Organization has recommended rotavirus vaccination against diarrhoeal disease to be included in all national immunization programmes (49). Bile duct obstruction and abnormalities in organ symmetry were observed in mice with a mutation in the Inversin gene, which regulates laterality. The excess amount of water-soluble conjugated bilirubin in the blood is partly excreted by the kidneys making urine dark. If the early signs go unnoticed, liver failure develops presenting as failure to thrive due to catabolic metabolism, deficient absorption of lipids, liver and spleen enlargement, and ascites (1). Very rarely, the first alarm is a hemorrhage, either subcutaneous or intracranial, due to fat soluble vitamin K deficiency associated coagulopathy. Oral or absent neonatal vitamin K prophylaxis is a risk factor for hemorrhage, especially in infants with unrecognized cholestasis due to poor intestinal absorption of fat-soluble vitamins (1). In Finland, neonates have received intramuscular vitamin K prophylaxis since the 1950’s (55). At newborn discharge, the parents are given a stool color card (Figure 3) and advised to observe their baby’s stool color. The parents are asked to take the card to the baby’s one-month health check or mail it to the stool color registry centre. In the 1990s, a study from England measured bile acid concentrations from dried blood spots obtained from newborns at seven to ten days of age. A non-specific cyst may be observed in the upper right quadrant of the abdomen in the cystic variant in a second trimester ultrasound examination. A large proportion of newborns develop physiological jaundice and at two weeks up to 15% will still be jaundiced (59). In benign physiologic jaundice, the hyperbilirubinemia consists of unconjugated bilirubin (60). To reveal cholestatic jaundice, the serum conjugated bilirubin should also be measured. If the serum concentration of conjugated bilirubin exceeds 20 μmol/L, or the proportion of conjugated bilirubin exceeds 20%, the possibility of a severe cholestatic condition should be suspected and the patient timely evaluated in a pediatric unit (53, 61, 62). In infancy, the range of diagnoses underlying cholestasis is wider than ever later in life. The abnormal, acholic stool colors in three upper pictures and the normal infant stool colors in lowest four. Liver biochemical variables among 21 biliary atresia patients at first admission in Children’s Hospital after 2005. Item Median Range Interquartile range Reference Bilirubin, μmol/L 168 51-337 141-208 4-20 Conjugated bilirubin, μmol/L 116 35-224 91-147 0-5 Aspartate transferase, U/L 152 28-370 83-271 <50 Alanine transferase, U/L 86 9-276 38-175 <40 Alkaline phosphatase, U/L 626 170-2008 403-927 115-460 -glutamyl tranferase, U/L 496 175-1346 281-831 <50 Prothrombin ratio, % 82 6-136 60-93 70-130 Factor V, % 124 88-196 111-139 79-128 Prealbumin, mg/L 98 57-120 84-110 95-280 the evaluation of an infant with conjugated hyperbilirubinemia and pale stools usually proceeds with an imaging study in order to verify the patency of the bile ducts. The problem with all the imaging methods is the lack of complete specificity (63). In 20%, gallbladder and common bile duct are patent and visible by ultrasound despite obstruction in the common hepatic duct, looking misleadingly normal (1, 63). A triangular cord sign (reported sensitivity around 80%) may be observed by ultrasound: the sign represents the fibrous mass at the porta hepatis at the site of the former bile duct (59, 64). In cholescintigraphy, the liver uptakes the injected radioactive tracer (often technetium 99m) and normally excretes the tracer into the intestine. Percutaneous liver biopsy is used by most centres in the differential diagnostic path of a cholestatic infant. The liver histological assessment has approximately 90-100% sensitivity and 80-98% specificity for biliary obstruction (65). Considerable interobserver variability was observed: the percentage of agreement in the different features assessed varied from 43% to 93% (69).
Sequential changes in the metabolic response in severely septic patients during the first 23 days after the onset of peritonitis [see comments] antifungal yogurt quality nizoral 200 mg. Systematic review of prophylactic nasogastric decompression after abdominal operations fungus gnats tarantula order 200mg nizoral amex. A randomized clinical trial of total parenteral nutrition in malnourished surgical patients: the rationale and impact of previous clinical trials and pilot study on protocol design fungus gnats on orchids generic nizoral 200mg on-line. In this experiment anti fungal diet nizoral 200mg line, you will use a conductivity tester to determine whether substances are strong, weak, or non-electrolytes. A strong electrolyte will completely dissociate into ions in solution and will cause a strong or bright light. Only a small percentage of the compounds will dissociate into ions but most will stay together as intact molecules, and a weak light will be seen. Non-electrolytes will not dissociate into ions at all and will not conduct electricity. It is important to know the difference between ionic and covalent compounds in this lab. Background the best everyday example of an electrolyte is Gatorade™ or any similar sports drink. In order to maintain normal cell function, it is crucial that those electrolytes be replaced. Electrolytes are used by your body to regulate functions such as heartbeat, brain function, and muscle control. The most common electrolytes that must be kept in balance in your body are sodium, potassium, magnesium, calcium, chloride, and bicarbonate. Sodium is responsible for regulating the electrical signals to your brain, muscles, and nervous system. It is possible to have too much sodium (hypernatremia) or too little sodium (hyponatremia) in your system. One of the main roles of potassium is in the regulation of your heartbeat and muscle function. It is common for athletes who are experiencing muscle cramps to consume potassium (bananas are a great source). Like sodium, it is possible to have increased potassium levels (hyperkalemia) or decreased potassium levels (hypokalemia). Human body fluids have almost the same concentration of chloride ions as sea water. Bicarbonate acts as a buffer in the body to help control the pH of your blood and other fluids. Figure 1 to the right illustrates the difference between an electrolyte (left picture) and a non-electrolyte (right picture). The notation (aq) is used for the physical state and specifically means that substance will dissolve in water. If is will not break into ions then it is said to be largely insoluble (very few ions form. Strong electrolytes: A strong electrolyte will completely dissociate (break apart) into ions in solution and will cause a strong or bright light. If you check the solubility rules on your Periodic Table, potassium ions are always soluble. This means that potassium compounds will always break apart completely (100%) into ions in water. Insoluble ionic compounds are also weak electrolytes as they are very slightly soluble in water, and dissociate into a few ions. As you might guess, these will usually give a weak light when placed in a conductivity tester. The reason is that these substances will dissociate into ions to a small degree (1-5%). Since most of the compounds will stay together in molecular form, there aren’t as many ions floating around in solution. Therefore, they can only conduct electricity to a small degree, and that is why a weak light is seen. Notice in the drawing of hydrofluoric acid on the right how only one molecule out of five (or 20%) is dissociated into ions. Watch the animation at this link to see a strong acid versus a weak acid ionizing in water. These substances are usually covalently bonded molecules (non-metal + non-metal like C6H12O6). Water molecules are not strong enough to pull the compounds apart into ions and therefore they will not conduct electricity. Notice that each row on the well plate is labeled with letters and each column is labeled with numbers. This makes it possible to identify which substance is in which well (ex: A3 or C2). In your data table (on the next page), write which well you will place each substance in. For the solid salt (NaCl) and solid sugar (C12H22O11) use those bottles to carefully fill two wells about ½ full of each solid making sure no crystals spill over into a different well. Connect the 9-volt batter to the conductivity tester and make sure it is snapped into place (you should hear a click when it is fully connected). You might have to measure conductivities several times to determine the appropriate value on the scale. Describe what types of chemicals tend to be each of the following: Strong electrolytes: Weak electrolytes: Nonelectrolytes: 4. Electrolytes are salts, acids, bases, some – Imbalance in colloid osmotic pressures. All the following are acceptable managementthe following are acceptable management solutions except. Clonorchis Sinensis the night of surgery her urine output is 30The night of surgery her urine output is 30 ml/hr, her pulse is 114. Before discharge she complains of a bloody discharge /discharge she complains of a bloody discharge / drainage from her incision. Ascaris Lumbricoides Despite further hydration and colloid, her urine output is dismally lowDespite further hydration and colloid, her urine output is dismally low 10 ml/hour. Your nurse points out to you that her respiratorynurse points out to you that her respiratory rate is close to 40. Diphyllobothrium Latum What key electrolytes and vitamins areWhat key electrolytes and vitamins are being lost? Diphyllobothrium Latum How would you best manage her high outHow would you best manage her high out put? They are intended to serve as a general statement regarding appropriate patient care practices based upon the available medical literature at the time of development. They should not be considered to be accepted protocol or policy, nor are intended to replace clinical judgment or dictate care of individual patients. Crystalloids are water with electrolytes that form a solution that can pass through semi permeable membranes. Because of this, larger volumes than colloids are required for fluid resuscitation. Eventually, water from crystalloids diffuses through the intracellular fluid Crystalloids cont: Hypertonic. A hypertonic solution draws fluid into the intravascular compartment from the cells and the interstitial compartments. A hypotonic solution shifts fluid out of the intravascular compartment, hydrating the cells and the interstitial compartments. Because an isotonic solution stays in the intravascular space, it expands the intravascular compartment. Osmolarity is the same as serum osmolarity Common crystalloids Solution Type Uses Nursing considerations Dextrose 5% in water Isotonic Fluid loss Use cautiously in renal and cardiac patients (D5W) Dehydration Can cause fluid overload Hypernatraemia May cause hyperglycaemia or osmotic diuresis 0. Cryoprecipitate is a concentrated source of certain plasma proteins and is used to treat some bleeding problems Red blood cells Red Blood Cells carry oxygen from the lungs to other parts of the body and then carry carbon dioxide back to the lungs. Severe blood loss, either acute haemorrhagic or chronic blood loss, dietary deficit or erythropoetic issue of the bone marrow can result in a low red blood cell count – called anaemia.
Progress in genetic studies definition of fungus medical order 200 mg nizoral with mastercard, and the identiﬁcation of extracellular products and cell-wall components represent advances in knowledge about the virulence of group A streptococci fungus we eat cheap nizoral 200mg on line. These studies have also facilitated the genotypic and phenotypic characterization of group A streptococcal strains (3– 8 fungus gnats hydro purchase discount nizoral line, 11–19) lawn antifungal nizoral 200 mg lowest price. Pedigree studies suggested that this immune response is genetically controlled, with high respon siveness to the streptococcal cell-wall antigen being expressed through a single recessive gene, and low responsiveness through a single dominant gene. Subsequently, it was reported that a B-lymphocyte alloantigen, recog nized by the monoclonal antibody, D8/17, and another 70-kD mol ecule, may be genetically innate markers of an altered immune response to unidentiﬁed streptococcal antigens in susceptible sub jects. Host-pathogen interaction Infection by streptococci begins with the binding of bacterial surface ligands to speciﬁc receptors on host cells, and subsequently involves speciﬁc processes of adherence, colonization and invasion. The bind ing of bacterial surface ligands to host surface receptors is the most crucial event in the colonization of the host, and it is initiated by ﬁbronectin and by streptococcal ﬁbronectin-binding proteins (17). Streptococcal lipoteichoic acid and M-protein also play a major role in bacterial adherence (9). The host responses to streptococcal infec tion include type-speciﬁc antibody production, opsonization and phagocytosis. Crowded living conditions, with close interpersonal contacts, contribute to the rapid spread and persistence of virulent streptococ cal strains. These variations are particu larly pronounced in temperate climates, but are not signiﬁcant in the tropics. It is ironic that a rather innocuous “sore throat” should extract such a high price from the host. As scientiﬁc research evolves, it is hoped that the gaps in our understanding will be ﬁlled, and better 16 strategies for prophylaxis and treatment will become available. The following is a summary of our current understanding of the pathoge netic maze of rheumatic carditis. Initial streptococcal infection in a genetically predisposed host in a susceptible environment leads to the activation of T-cell and B-cell lymphocytes by streptococcal antigens and superantigens, which re sults in the production of cytokines and antibodies directed against streptococcal carbohydrate and myosin. A break in the endothelial continuity of a heart valve would expose subendothelial structures (vimentin, laminin and valvu lar interstitial cells) and lead to a “chain reaction” of valvular destruc tion. Once valve leaﬂets are inﬂamed through the valvular surface endothelium and new vascularization occurs, the newly formed mi crovasculature allows T-cells to inﬁltrate and perpetuate the cycle of valvular damage. The presence of T-cell inﬁltration, even in old min eralized lesions, is indicative of persistent and progressive disease in the valves. Valvular interstitial cells and other valvular constituents under the inﬂuence of inﬂammatory cytokines perpetuate aberrant repair. Although the foregoing offers a very feasible explanation of the ex perimental data, questions remain that have signiﬁcant implications for choosing streptococcal vaccines (22–24). For example, there is no direct and conclusive evidence for a pathogenetic role of cross-reac tive antibodies in vivo and there is no exact animal model of rheu matic fever for study. The need for a better understanding of the epidemiology of streptococci is underscored by a report that one group A streptococcal serotype can be rapidly and completely re placed by another serotype in a stable population with adequate access to health care (25). This serotype change still has not been adequately explained and it raises questions about the efﬁcacy of any type-speciﬁc streptococcal vaccine that is synthesized by combining M-protein sequences from virulent streptococcal serotypes. Identiﬁcation and characterization of novel superantigens from Streptococcus pyogenes. European Journal of Clinical Microbiology and Infectious Diseases, 1991, 10:55–57. VirR and Mry are homologous trans-acting regulators of M protein and C5a peptidase expression in group A streptococci. Interactions of ﬁbronectin with streptococci: the role of ﬁbronectin as a receptor for Streptococcus pyogenes. Genetic variability of the emm-related gene of the large vir regulon of group A streptococci: potential intra and intergenomic recombination events. Protection against a heterologous M serotype with shared C repeat region epitopes. Treatment of streptococcal pharyngotonsillitis: reports of penicillin’s demise are premature. Antibody-mediated autoimmune myocarditis depends on genetically determined target organ sensitivity. Dynamic epidemiology of group A streptococcal serotypes associated with pharyngitis. Major manifestations were least likely to lead to an improper diagno sis and included carditis, joint symptoms, subcutaneous nodules, and chorea. Modified in part from reference (45) 20 two minor, manifestations offered reasonable clinical evidence of rheumatic activity. Although the Jones criteria have been revised repeatedly, the modi ﬁcations were often made without prospective studies and were based on the perceived effects of previous revision(s). The prophylactic and prognostic stakes clearly underscore the importance of correctly identifying carditis. A diagnosis of recurring carditis requires the demonstration of valvular damage or involvement, with or without pericardial or myocardial involvement (11). Such clinical ﬁndings include a documented change in a previous murmur to a new murmur or pericardial rub, or an obvious radiographic increase in cardiac size, respectively. Further, recurrences of the disease are common in developing coun tries, owing to gaps in the detection and secondary prevention of disease caused by a lack of health-care facilities. It is prudent to consider them as cases of “probable rheumatic fever” (once other diagnoses are excluded) and advise regular secondary prophylaxis. This cautious approach is particularly suitable for patients in vulnerable age groups in high incidence settings. However, an echo-Doppler examination should be per formed if the facilities are available. Subcutaneous nodules are almost always associated with cardiac involvement and are found more commonly in patients with severe carditis. The major noncarditic manifestations occur in varying combinations, with or without carditis, during the evolution of the disease. The presence of noncarditic manifestations facilitates the detec tion of rheumatic carditis and their identiﬁcation is particularly important in recurrences of disease, when the diagnosis of carditis is difﬁcult. Diagnosis of rheumatic carditis Although the endocardium, myocardium and pericardium are all affected to varying degrees, rheumatic carditis is almost always asso ciated with a murmur of valvulitis (Table 4. Accordingly, myocardi this and pericarditis, by themselves, should not be labeled rheumatic in origin, when not associated with a murmur and other etiologies must be considered. Simultaneous demonstration of valvular involvement generally considered essential. The strict application of diagnostic criteria is mandatory to demonstrate pathological valvular regurgitation. Currently, data do not allow subclinical valvular regurgitation detected by echocardiography to be included in the Jones criteria, as evidence of a major manifestation of carditis. Myocarditis Myocarditis (alone) in the absence of valvulitis is unlikely to be of rheumatic origin and by itself should not be used as a basis for such a diagnosis. If previous clinical ﬁndings are known, they can be compared with current data — myocardial involvement is likely to result in a sudden cardiac enlargement that will be detectable radiographically. At times, however, the friction rub can mask the mitral regurgitation murmur, which becomes evident only after the pericarditis subsides. Since isolated pericarditis is not good evidence of rheumatic carditis without supporting evidence of a valvular regurgitant murmur, it may be helpful to have Doppler echocardiography available in such circumstances to look for signs of mitral regurgitation. Echocardiography could also corroborate the mild-to-moderate pericardial effusion likely to be associated with pericarditis; large effusions and tamponade are rare (18). Patients with this form of pericarditis are usually treated as cases of severe carditis. Noncardiac manifes tations may be the best guide for a diagnosis of rheumatic carditis. Arthritis is often the only major manifestation in adolescents, as well as in adults, where carditis and chorea become less common in older age groups. Joint pain without objective ﬁndings does not qualify as a major disease manifestation because of its nonspeciﬁcity. Inﬂamed joints are characteristically warm, red and swollen, and an aspirated sample of synovial ﬂuid may reveal a high -3 -3 average leukocyte count (29000mm, range 2000–96000mm) (21).
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Metronidazole and risk of acute pancrea titis: a population-based case-control study. Clinical diﬃculties in the differentiation of autoimmune pancreatitis and pancreatic carcinoma. Mutations in the gene encoding the serine protease in hibitor, Kazal type 1 are associated with chronic pancreatitis. Apancreaticductalleakshouldbesoughttodirect treatment in patients with acute pancreatitis. Acutenecrotizingpancreatitisas ararecomplication of extracorporeal shock wave lithotripsy. Macroscopic and microscopic vasculature of the duodenal-biliary pancreatic complex. Atheromatous embolization resulting in acute pancreatitis after cardiac catheterization and angiographic studies. Autoimmune pancreatitis as the initial presen tation of systemic lupus erythematosus. Acute pancreatitis associated with systemic lupus erythematosus: successful treatment with plasmapharesis followed by aggressive immunosuppressive therapy. Acute pancreatitis with pseudocyst formation in a patient with polyarteritis nodosa. Two cases of acute necrotizing pancreatitis complicating after transcatheter arterial embolization for hepatocellular carcinoma. Acute clinical pancreatitis following selective transcatheter arterial chemoembolization of hepatocellular carcinoma. Cytomegalovirus-associated acute pancre atic disease in patients with acquired immunodeﬁciency syndrome: report of two patients. Study of prevalence, severity, and etiological factors associ ated with acute pancreatitis in patients infected with human immunodeﬁciency virus. Acute hypercalcemia causes acute pancreatitis and ectopic trypsinogen activation in the rat. The penetrating duodenal ulcer: operative technique and postoperative complications. Effect of puriﬁed scorpion toxin (tityustoxin) on the pancreatic secretion of the rat. Proposed nomenclature and classiﬁcation of the human pancreatic ducts and duodenal papillae: study based on 200 post mortems. Endoscopic therapy in patients with pancreas divisum and acute pancreatitis: a prospective, randomized, controlled clinical trial. Evaluation and treatment of the dominant dorsal duct syndrome (pancreas divisum redeﬁned). Does endoscopic therapy favorably affect the out come of patients who have recurrent acute pancreatitis and pancreas divisum? Frequency of abnormal sphincter of Oddi manometry compared with the clinical suspicion of sphincter of Oddi dysfunction. Eﬃcacy of nifedipine therapy in patients with sphinc ter of Oddi dysfunction: a prospective double-blind, randomized, placebo-controlled, cross over trial. Endoscopic pancreatic sphincterotomy: indications, outcome, and a safe stentless technique. Occult microlithiasis in ‘‘idiopathic’’ acute pancreatitis: pre vention of relapses by cholecystectomy or ursodeoxycholic acid therapy. Isovolemic hemodilution with dextran prevents contrast medium induced impairment of pancreatic microcirculation in necrotizing pancre atitis of the rat. Hypocalcemia inpatientswithacute pancreatitis: a putative role for systemic endotoxin exposure. Prospective, randomized trial of nasogastric suction in patients with acute pancreatitis. Current conservative treatment of acute pancreatitis: evidence from animal and human studies. Baseline hypoxemia as a prognostic marker for pulmonary complications and outcome in patients with acute pancreatitis. Frequency and risk factors of recurrent pain dur ing refeeding in patients with acute pancreatitis: a multivariate multicentre prospective study of 116 patients. Comparison of the safety of early enteral vs parenteral nutrition in mild acute pancreatitis. Prophylacticantibiotictreatmentinpatientswithpre dicted severe acute pancreatitis: a placebo-controlled, double-blind trial. Intra-abdominal Candidainfection during acute necrotizing pancreatitis has a high prevalence and is associated with increased mortality. Serum amylase and lipase activities in normal pregnancy: a prospective case-control study. The fetal safety and clinical eﬃcacy of gastrointestinal endoscopy during pregnancy. Christeas Laboratory of Experimental Surgery and Surgical Research, Medical School, National and Kapodistrian University of Athens, Athens, Greece Dimitrios Vardakostas and Christos Damaskos contributed equally to this study Abstract. Congenital Liver, Cyst, Minimally, Invasive, Laparoscopic, Percu cystic lesions include polycystic liver disease, taneous, Drainage, Fenestration. The infec tious cysts are the hydatid cyst, the amoebic ab Introduction scess, and the pyogenic abscess, whereas the non-infectious cysts are neoplastic cysts and Nowadays, technological advances, lower cost, false cysts. While modern medicine provides and increasing medical experience have led to a a lot of minimally invasive therapeutic modali widespread use of imaging modalities, especial ties, there has emerged a pressing need for un derstanding the various types of liver cysts, the ly of ultrasonography. Not only are they used possible minimal therapeutic options along with for abdominal symptoms screening but also for their indications and complications. As a result, clarify the role of minimally invasive techniques cystic lesions of the liver are diagnosed more fre in the management of hepatic cysts. Moreover, in the setting of modern imally invasive, laparoscopic, percutaneous, medicine where minimally invasive technics are drainage and fenestration. We reviewed 82 En evolving, the choice of the most effective manage glish language publications articles, published ment is much more in question. Yet, a consensus has not cutaneous aspiration of pyogenic abscesses to been achieved on the defnition and classifcation laparoscopic hepatectomy for hepatic cystade of hepatic cystic lesions, and considerable contro nomas. Percutaneous drainage is most patic cysts are further divided into infectious and ly used in simple cysts, hydatid cysts, pyogenic non-infectious. Laparoscopic fenestra cysts, the parasitic ones (hydatid cysts and amo tion is mostly used in simple cysts and polycys tic liver disease. Finally, laparoscopic hepatec ebic abscesses) and non-parasitic, in other words, tomy is mostly used in polycystic liver disease, pyogenic liver abscesses. The overall hepatic cy these treatments are demonstrated to be equally stic lesion classifcation can be seen in Figure 1. Recurrence is estimated from 0% to Simple Hepatic Cysts 20% with morbidity in 0% to 25%2-5,7. Only 15% of be patients without previous open surgical inter these cysts are symptomatic when they are predo vention in the abdomen and have large, sympto minantly large (>4 cm). Wound the right lobe and are more common in women and infection, bile leak, chest infection, subphrenic older patients (Figure 2). Asymptomatic simple hematoma and prolonged drainage have all been cysts do not require any treatment or follow-up.
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