Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines

Diagnostic and therapeutic strategies for acute biliary inflammation/ infection (acute cholangitis and acute cholecystitis), according to severity grade, have not yet been established in the world. Therefore we formulated flowcharts for the management of acute biliary inflammation/ infection in accordance with severity grade. For mild (grade I) acute cholangitis, medical treatment may be sufficient/appropriate. For moderate (grade II) acute cholangitis, early biliary drainage should be performed. For severe (grade III) acute cholangitis, appropriate organ support such as ventilatory/circulatory management is required. After hemodynamic stabilization is achieved, urgent endoscopic or percutaneous transhepatic biliary drainage should be performed. For patients with acute cholangitis of any grade of severity, treatment for the underlying etiology, including endoscopic, percutaneous, or surgical treatment should be performed after the patient's general condition has improved. For patients with mild (grade I) cholecystitis, early laparoscopic cholecystectomy is the preferred treatment. For patients with moderate (grade II) acute cholecystitis, early laparoscopic or open cholecystectomy is preferred. In patients with extensive local inflammation, elective cholecystectomy is recommended after initial management with percutaneous gallbladder drainage and/or cholecystostomy. For the patient with severe (grade III) acute cholecystitis, multiorgan support is a critical part of management. Biliary peritonitis due to perforation of the gallbladder is an indication for urgent cholecystectomy and/or drainage. Delayed elective cholecystectomy may be performed after initial treatment with gallbladder drainage and improvement of the patient's general medical condition. © Springer-Verlag Tokyo 2007.published_or_final_versio

Effects of Stereotactic Pallidal Surgery on Regional Cerebral Glucose Metabolism in Advanced Parkinson\u27s Disease

開始ページ、終了ページ: 冊子体のページ付

Thyroid reference ranges in pregnancy utilizing an Abbott Alinity platform in a multi-ethnic population in the UK

BACKGROUND: Maternal thyroid function significantly affects fetal development. However, thyroid hormone concentrations change dynamically throughout pregnancy rendering non-pregnancy reference ranges inaccurate. We aimed to establish the trimester-, population-, and assay-specific reference ranges for thyroid hormones in pregnancy using the recently introduced Abbott Alinity thyroid function test, according to American Thyroid Association 2017 Guidelines for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum. METHODS: This study of 663, iodine-replete and thyroid peroxidase (TPO)-antibody negative female determined trimester-specific reference ranges for thyroid stimulating hormone (TSH), free thyroxine (fT4), and free tri-iodothyronine (fT3) using Abbott Alinity assays in accordance with ATA guidelines. Study participants were drawn from a multi-ethnic population with 49% non-white participants. RESULTS: First trimester reference ranges were TSH 0.06–2.73 mIU/l, fT4 9.9–15.3 pmol/l, and fT3 3.4–5.6 pmol/l. Second trimester reference ranges were TSH 0.02–2.47 mIU/l, fT4 8.5–14.4 pmol/l, and fT3 3.3–5.5 pmol/l. In the third trimester, TSH ranges were 0.41–2.80 mIU/l, fT4 7.6–12.3 pmol/l, and fT3 3.1–5.0 pmol/l. There were no significant differences in any trimester-specific analyte reference ranges when white and non-white populations were compared. CONCLUSIONS: These reference ranges support the clinical care of female from diverse backgrounds with thyroid dysfunction in pregnancy using the thyroid function tests available on the Abbott Alinity platform. STUDY REGISTRATION: These reference ranges support the clinical care of female from diverse backgrounds with thyroid dysfunction in pregnancy using the thyroid function tests available on the Abbott Alinity platform

Flowcharts for the management of biliary tract and ampullary carcinomas

No strategies for the diagnosis and treatment of biliary tract carcinoma have been clearly described. We developed flowcharts for the diagnosis and treatment of biliary tract carcinoma on the basis of the best clinical evidence. Risk factors for bile duct carcinoma are a dilated type of pancreaticobiliary maljunction (PBM) and primary sclerosing cholangitis. A nondilated type of PBM is a risk factor for gallbladder carcinoma. Symptoms that may indicate biliary tract carcinoma are jaundice and pain in the upper right area of the abdomen. The first step of diagnosis is to carry out blood biochemistry tests and ultrasonography (US) of the abdomen. The second step of diagnosis is to find the local extension of the carcinoma by means of computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), percutaneous transhepatic cholangiography (PTC), and endoscopic retrograde cholangiopancreatography (ERCP). Because resection is the only way to completely cure biliary tract carcinoma, the indications for resection are determined first. In patients with resectable disease, the indications for biliary drainage or portal vein embolization (PVE) are checked. In those with nonresectable disease, biliary stenting, chemotherapy, radiotherapy, and/or best supportive care is selected

Quality Improvement for Portal Vein Embolization

Fibrin sealant is used in many areas of surgery. We present a novel aspect of flap insetting in the ischial region using fibrin spray to seal the transferred tissue. We analyzed 10 patients suffering from decubital ulcers and assessed drainage output, time of drain removal, as well as complications following fasciocutaneous flap surgery. Patients were randomized to receive sprayed fibrin glue (study group) or not (control group) before wound closure. The mean drainage time was 4 +/- 1 days in the study group and 6 +/- 1 days in the control group ( P = 0.06). The mean drainage volume was 100 +/- 20 mL in the study group and 168 +/- 30 mL in the control group ( P < 0.01). Fibrin sealant led to reduced drainage volumes and duration of drainage, indicating a beneficial effect of the application of fibrin glue in fasciocutaneous flap surgery for pressure sore coverage

Physiological aspects of the determination of comprehensive arterial inflows in the lower abdomen assessed by Doppler ultrasound

Non-invasive measurement of splanchnic hemodynamics has been utilized in the clinical setting for diagnosis of gastro-intestinal disease, and for determining reserve blood flow (BF) distribution. However, previous studies that measured BF in a "single vessel with small size volume", such as the superior mesenteric and coeliac arteries, were concerned solely with the target organ in the gastrointestinal area, and therefore evaluation of alterations in these single arterial BFs under various states was sometimes limited to "small blood volumes", even though there was a relatively large change in flow. BF in the lower abdomen (BFAb) is potentially a useful indicator of the influence of comprehensive BF redistribution in cardiovascular and hepato-gastrointestinal disease, in the postprandial period, and in relation to physical exercise. BFAb can be determined theoretically using Doppler ultrasound by subtracting BF in the bilateral proximal femoral arteries (FAs) from BF in the upper abdominal aorta (Ao) above the coeliac trunk. Prior to acceptance of this method of determining a true BFAb value, it is necessary to obtain validated normal physiological data that represent the hemodynamic relationship between the three arteries. In determining BFAb, relative reliability was acceptably high (range in intra-class correlation coefficient: 0.85-0.97) for three arterial hemodynamic parameters (blood velocity, vessel diameter, and BF) in three repeated measurements obtained over three different days. Bland-Altman analysis of the three repeated measurements revealed that day-to-day physiological variation (potentially including measurement error) was within the acceptable minimum range (95% of confidence interval), calculated as the difference in hemodynamics between two measurements. Mean BF (ml/min) was 2951 ± 767 in Ao, 316 ± 97 in left FA, 313 ± 83 in right FA, and 2323 ± 703 in BFAb, which is in agreement with a previous study that measured the sum of BF in the major part of the coeliac, mesenteric, and renal arteries. This review presents the methodological concept that underlies BFAb, and aspects of its day-to-day relative reliability in terms of the hemodynamics of the three target arteries, relationship with body surface area, respiratory effects, and potential clinical usefulness and application, in relation to data previously reported in original dedicated research

Genetic polymorphisms of cytochrome P4501A1 and oesophageal squamous-cell carcinoma in Taiwan

Several in vitro studies have demonstrated that genetic polymorphisms result in functionally significant changes in cytochrome p4501A1 (either CYP1A1 MspI or exon 7) but the few epidemiologic studies of these polymorphisms in oesophageal squamous-cell carcinoma have been inconclusive. These inconclusive results motivated us to further examine the relationship between CYP1A1 MspI and exon 7 polymorphisms and risk of oesophageal cancer. In total, 146 cases of oesophageal squamous-cell-carcinoma and 324 control cases (a total of 470 cases) were genotyped from records at three Taiwan hospitals. No significant association was noted for the CYP1A1 MspI polymorphism variable between carcinoma and control cases. In contrast, the frequency of Ile/Ile, Ile/Val, and Val/Val in exon 7 was 68 (46.6%), 62 (42.5%), and 16 (11.0%) in carcinoma cases and 179 (55.3%), 127 (39.2%), and 18 (5.6%) in control cases, respectively. After factoring out other potential contributing factors, patients with Val/Val showed a 2.48 (95% CT=1.15–5.34) greater risk of developing oesophageal cancer than those with Ile/Ile. A slightly (albeit not significantly) greater risk was identified in subjects with Ile/Val (OR=1.34; 95% CI=0.86–2.07). These findings suggest that an exon 7 polymorphism, not a MspI polymorphism, in CYP1A1 may be pivotal in the development of oesophageal cancer