Formation of Pancreatoduodenal Fistula in Intraductal Papillary Mucinous Neoplasm of the Pancreas Decreased the Frequency of Recurrent Pancreatitis

Intraductal papillary mucinous neoplasms (IPMN) of the pancreas are characterized by proliferation of mucin-secreting cells in the main pancreatic duct (PD) or its branches. The secreted thick mucin usually leads to PD obstruction and dilation. A common complication of IPMN is recurrent acute pancreatitis secondary to poor pancreatic fluid drainage, and rarely, pancreatobiliary and pancreatointestinal fistulae. We describe a unique case of IPMN in a 57-year-old male who was referred to our institution for evaluation of recurrent acute pancreatitis. After extensive evaluation, he was diagnosed with main duct IPMN. Intraductal PD biopsy revealed intestinal type IPMN with intermediate grade dysplasia. Patient was managed clinically by large caliber (10 French) PD stenting which eliminated his recurrent acute pancreatitis. The patient was initially referred for pancreatic resection; however, surgery was aborted and evaluated to be high risk with high morbidity secondary to the extensive adhesions between the pancreas and surrounding structures. Patient remained clinically stable for a few years except for an episode of acute pancreatitis that happened after a trial of stent removal. Subsequently, the patient did well after the PD stent was replaced. Recently, repeat abdominal imaging revealed a large pancreatoduodenal fistula which was confirmed on repeat endoscopic retrograde cholangiopancreatography. We were able to perform pancreatoscopy by advancing a regular upper scope through the fistula and into the PD. Interestingly, the fistula relieved the symptoms of obstruction and subsequently decreased the frequency of recurrent pancreatitis episodes with no further episodes at 6 months follow-up. This case highlights the importance of providing adequate PD drainage to reduce the frequency of recurrent acute pancreatitis in the setting of main duct IPMN, especially if the patient is not a surgical candidate. Also, physicians need to monitor for complications such as fistula formation between the pancreas and surrounding structures in the setting of chronic inflammation due to recurrent episodes of pancreatitis. Early identification of a fistula is important for surgical planning. Furthermore, since recent studies suggested a higher incidence of additional primary malignancies in patients with IPMN of the pancreas compared to the general population, patients may be considered for screening for other primary malignancies

Exploring end of life priorities in Saudi males: usefulness of Q-methodology

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MEASUREMENT OF CORTISOL AND CORTISONE IN HUMAN SALIVA BY UPLC-MS/MS

Objective: To develop and validate a simple and rapid assay for simultaneous measurement of cortisol and cortisone in human saliva by ultra-performance liquid chromatography-tandem mass spectrometry. Methods: Chromatographic analysis was performed on an Atlantis dC18 column (2.1 x 100 mm, 3 µm) using a mobile phase consisting of acetonitrile and 2 mmol ammonium-acetate (50:50, v; v) that was delivered at a flow rate of 0.3 ml/min. The eluents were monitored using electrospray ionization in the positive ion mode set at transition set of mass-to-charge (m/z): 363.11 → 121.00, 361.18 → 163.11, and 367.19 → 121.24 for cortisol, cortisone and internal standard (IS), respectively the method was validated for linearity, accuracy, precision, and recovery, according to international guidelines. Results: The retention times of cortisol, cortisone and internal were about 1.38, 1.43 and 1.38 min, respectively. Cortisol level and cortisone level relationship to the ratio of their respective peak-area to IS’s peak-area was linear (range of 0.5-100 ng/ml). Coefficients of variation and inaccuracy were, ≤9.9% and-0.3 to 6.9 for cortisol and ≤8.4 and-1.5 to 4.8 for cortisone, respectively. Extraction recoveries for cortisol, cortisone, and the IS were 90%, 94%, and 98%, respectively. Cortisol and cortisone stability was evaluated in processed saliva samples (stored at room temperature for 24 h) and unprocessed saliva samples (stored at room temperature for 24 h or at-20 °C for 10 w) and after 3 freeze-thaw cycles was ≥ 86%. Conclusion: The proposed method is simple, precise, and accurate for the rapid simultaneous measurement of cortisol and cortisone levels in saliva. The assay was successfully applied to determine levels of cortisol and cortisone in human saliva samples obtained from healthy volunteers

QUANTITATION OF AMLODIPINE IN HUMAN PLASMA BY LCMS/MS ASSAY

­­­­­­­­­­­­­­­­­Objective: To develop and validate a simple, precise, and rapid liquid chromatographic-tandem mass spectrometric (LC-MS/MS) method for quantification of amlodipine in human plasma.Methods: Chromatographic analysis was performed on Atlantis dC18 column (2.1 x 100 mm, 3 µm) with a mobile phase consisting of acetonitrile and 10 mM formic acid (80:20, v: v) that was delivered at a flow rate of 0.3 ml/min. The eluents were monitored using electrospray ionization in the positive ion mode set at transition 409 → 238.4 and 254.3 → 43.9 for amlodipine and tizanidine hydrochloride (IS), respectively. The method was validated for linearity, accuracy, precision, and recovery as per US-FDA guidelines.Results: The retention times of amlodipine and tizanidine (IS) were 1.26 and 1.22 respectively. The relationship between amlodipine concentration and peak height ratio of amlodipine to the IS was linear (R2³ 0.9868) in the range of 0.2–20 ng/ml, and the intra-and inter-day coefficient of variations and bias were ≤14.4% and ≤13.6% and ≤13.7% and ≤11.2%, respectively.Conclusion: The proposed method is simple, precise, and accurate for rapid measurement of amlodipine level using 0.5 ml human plasma. Further, the assay was successfully applied to determine amlodipine level in human plasma samples obtained from a healthy volunteer

Preliminary Study: The Benefit of BaPiA Insomnia (Anti- Insomnia Massage Kerchief) Tool

Objective: The purpose of this present study was to systematically review the existing literature and the effectiveness of Anti-Insomnia Massage Kerchief in treating insomnia.Materials and methods: Databases of scientific studies were screened through the pubmed, the Cochrane library, Hindawi, and British Medical Journal with keywords: insomnia, acupuncture, acupressure; insomnia, acupressure, Baihui; and Insomnia, Baihui, Si Shencong. In addition, published studies were excluded if they were not using English and not written in the last 10 years.Results: 75 studies showed effects of accupressure on Baihui and Si Shencong to treat insomnia.Conclusion: Some literature showed positive result about stimulation in Baihui and Si Shencong for treating insomnia. Keywords: Insomnia, Acupuncture, Acupressure, Baihui, Si Shencong

Evaluation of serum-derived bovine immunoglobulin protein isolate in subjects with decompensated cirrhosis with ascites

Background Bacterial translocation plays a pivotal role in the natural course of cirrhosis and its complications. Serum-derived bovine immunoglobulin (SBI) is an oral medical food that has been shown to both reduce inflammation in the intestines and neutralize bacteria. It represents a unique intervention that has not been studied in this population. Methodology We conducted a prospective open-label trial with an eight-week treatment phase of SBI. Individuals were assessed using lactulose breath testing, serum markers for enterocyte damage and bacterial translocation, and the Chronic Liver Disease Questionnaire (CLDQ) prior to and after completion of the treatment phase. Results We evaluated nine patients with a diagnosis of decompensated cirrhosis with ascites. Subjects had a mean Model for End-Stage Liver Disease (MELD) score of 11.6 ± 3.0 and were not taking lactulose or antibiotics. All subjects tolerated SBI well with no significant adverse events or changes to any of the six domains of the CLDQ. Laboratory tests including liver tests and MELD score remained stable over the course of treatment. There were no significant changes in the rates of small intestinal bacterial overgrowth (55.6% vs 55.6%, p = 1.00) or serum levels of lipopolysaccharide-binding protein, intestinal fatty acid-binding protein, or soluble CD14 (p-values 0.883, 0.765, and 0.748, respectively) when comparing values prior to and immediately after treatment. Conclusions No adverse events or significant changes to the quality of life were detected while on treatment. There were no statistically significant differences in our outcomes when comparing individuals before and after treatment in this small prospective proof-of-concept pilot study. Further prospective randomized studies could be beneficial

Interaction between drug and placebo effects: a cross-over balanced placebo design trial

<p>Abstract</p> <p>Background</p> <p>The total effect of a medication is the sum of its drug effect, placebo effect (meaning response), and their possible interaction. Current interpretation of clinical trials' results assumes no interaction. Demonstrating such an interaction has been difficult due to lack of an appropriate study design.</p> <p>Methods</p> <p>180 adults were randomized to caffeine (300 mg) or placebo groups. Each group received the assigned intervention described by the investigators as caffeine or placebo, in a randomized crossover design. 4-hour-area-under-the-curve of energy, sleepiness, nausea (on 100 mm visual analog scales), and systolic blood pressure levels as well as caffeine pharmacokinetics (in 22 volunteers nested in the caffeine group) were determined. Caffeine drug, placebo, placebo-plus-interaction, and total effects were estimated by comparing outcomes after, receiving caffeine described as placebo to receiving placebo described as placebo, receiving placebo described as caffeine or placebo, receiving caffeine described as caffeine or placebo, and receiving caffeine described as caffeine to receiving placebo described as placebo, respectively.</p> <p>Results</p> <p>The placebo effect on area-under-the-curve of energy (mean difference) and sleepiness (geometric mean ratio) was larger than placebo-plus-interaction effect (16.6 [95% CI, 4.1 to 29.0] vs. 8.4 [-4.2 to 21.0] mm*hr and 0.58 [0.39 to 0.86] vs. 0.69 [0.49 to 0.97], respectively), similar in size to drug effect (20.8 [3.8 to 37.8] mm*hr and 0.49 [0.30 to 0.91], respectively), and its combination with the later was larger than total caffeine effect (29.5 [11.9 to 47.1] mm*hr and 0.37 [0.22 to 0.64]). Placebo-plus-interaction effect increased caffeine terminal half-life by 0.40 [0.12 to 0.68] hr (P = 0.007).</p> <p>Conclusions</p> <p>Drug and placebo effects of a medication may be less than additive, which influences the interpretation of clinical trials. The placebo effect may increase active drug terminal half-life, a novel mechanism of placebo action.</p> <p>Trial Registration</p> <p>ClinicalTrials.gov identification number - NCT00426010.</p

Saudi views on consenting for research on medical records and leftover tissue samples

<p>Abstract</p> <p>Background</p> <p>Consenting for retrospective medical records-based research (MR) and leftover tissue-based research (TR) continues to be controversial. Our objective was to survey Saudis attending outpatient clinics at a tertiary care hospital on their personal preference and perceptions of norm and current practice in relation to consenting for MR and TR.</p> <p>Methods</p> <p>We surveyed 528 Saudis attending clinics at a tertiary care hospital in Saudi Arabia to explore their preferences and perceptions of norm and current practice. The respondents selected one of 7 options from each of 6 questionnaires.</p> <p>Results</p> <p>Respondents' mean (SD) age was 33 (11) years, 42% were males, 56% were patients, 84% had ≥ secondary school education, and 10% had previously volunteered for research. Respectively, 40% and 49% perceived that the norm is to conduct MR and TR without consent and 38% and 37% with general or proposal-specific consent; the rest objected to such research. There was significant difference in the distribution of choices according to health status (patients vs. companions) for MR (adjusted Kruskal-Wallis test P = 0.03) but not to age group, gender, education level, or previous participation in research (unadjusted P = 0.02 - 0.59). The distributions of perceptions of current practice and norm were similar (unadjusted Marginal Homogeneity test P = 0.44 for MR and P = 0.89 for TR), whereas the distributions of preferences and perceptions of norm were different (adjusted P = 0.09 for MR and P = 0.02 for TR). The distributions of perceptions of norm, preferences, and perceptions of current practice for MR were significantly different from those of TR (adjusted P < 0.009 for all).</p> <p>Conclusions</p> <p>We conclude that: 1) there is a considerable diversity among Saudi views regarding consenting for retrospective research which may be related to health status, 2) the distribution of perceptions of norm was similar to the distribution of perceptions of current practice but different from that of preferences, and 3) MR and TR are perceived differently in regard to consenting.</p