Poor General Condition Research Articles

The contribution of PET/CT to the differentiation of benign and malignant pleural effusion in patients with ovarian carcinoma

ObjectiveThe present study investigates the ability of non-invasive contribution of positron emission tomography (PET)/computed tomography (CT) to distinguish between benign pleural effusions (BPE) and malignant pleural effusions (MPE) in patients diagnosed with ovarian carcinoma (OC). Material and methodsIncluded in the study were 32 OC patients with a PE diagnosis. The cases with BPE and MPE were compared in terms of the PE maximum standardized uptake value (SUVmax), PE SUVmax/mean standardized uptake (SUVmean) value of the mediastinal blood pool (TBRp), the presence of pleural thickening, the presence of supradiaphragmatic lymph node, unilateral or bilateral PE, pleural effusion diameter, patient age and CA125 value. ResultsThe mean age of the 32 patients was 57±2.8 years. TBRp>1.1, pleural thickening and supradiaphragmatic lymph node were observed significantly more frequently in the MPE than the BPE cases. While no pleural nodules were detected in patients with BPE, they were present in 7 of the patients with MPE. The rates of distinction between the MPE and BPE cases were as follows: the sensitivity of the TBRp value was 95.2% and specificity was 72.7%; the sensitivity of pleural thickness was 80.9% and specificity was 81.8%; the sensitivity of supradiaphragmatic lymph node was 38% and specificity was 90.9%; and the sensitivity of the pleural nodule was 33.3% and specificity was 100%. There were no significant differences between two groups in any other factors. ConclusionsPleural thickening and TBRp values ascertained through PET/CT may aid the distinction between MPE-BPE, especially in patients with advanced stage OC with a poor general condition, or those who cannot undergo surgery.

Laparoscopic Hartmann Procedure-A Surgery That Still Saves Lives.

A Hartmann operation, which is the intervention by which the lower part of the sigmoid and the upper part of the rectum are resected with the closing of the rectal stump and end colostomy, has as its indications: advanced or complicated rectosigmoid neoplasm, moderate biological condition of the patient, peritoneal sepsis, intestinal occlusion and fragile colonic wall, especially in the context of inflammatory changes. The Hartmann procedure can save lives even at the cost of a stoma reversal failure. The cases operated with the Hartmann procedure by an open approach or laparoscopic approach in our clinic, between 1 January 2016 and 31 December 2020, were admitted in this study and their medical records were reviewed, also making a comparison between the two types of approach. Univariate statistical comparisons but also a multivariate analysis was performed. We performed 985 operations for intestinal and colonic occlusion (7.15% of the total operations in the clinic), 531 (54%) were non-tumor occlusions and 454 (46%) were occlusive tumors (88 Hartmann operations). Of these, 7.3% were laparoscopically performed (7 laparoscopic Hartmann operations and 23 diagnostic laparoscopies). A total of 11 cases (18%) also had colonic perforation. We compared laparoscopic Hartmann with open Hartmann and observed the benefits of laparoscopy for postoperative morbidity and mortality. The presence of pulmonary and cardiac morbidities is associated with the occurrence of general postoperative morbidities, while peritonitis is statistically significantly associated with the occurrence of local complications that are absent after the laparoscopic approach. The Hartmann procedure is still nowadays an operation widely used in emergency situations. Laparoscopy may become standard for the Hartmann procedure and reversal of the Hartmann procedure, but the percentage of laparoscopy remains low due to advanced or complicated colorectal cancer, poor general condition both at the first and second intervention, and the difficulties of reversal of the Hartmann procedure.

Usefulness Evaluation of Water as an Oral Contrast Medium and Virtual Monoenergetic Images in Liver CT

The usefulness of intake water as an oral contrast medium and MonoE(Virtual Monoenergetic Images) 50 keV of DECT(Dual Energy Computed Tomography) was evaluated in Liver CT. In order to compare water intake image and non-water intake image and MonoE 50 keV image of non-water intake data were obtained from 50 patients who underwent liver follow-up CT at our hospital from January 1, 2021 to June 31, 2022 at our hospital, using IQon Spectral CT (Philips Healthcare, Netherlands). In the same patient, compared to non-water intake image, both Water intake image and MonoE 50 keV image of non-water intake showed an increase in the average values of HU of portal vein, liver parenchyma, SNR, CNR. As a result of quantitative analysis using the paired-sample t-test of SPSS (Statistical Package For Social Science, IBM, US), showed a statistically significant increase in portal vein, liver parenchyma, SNR, CNR in all phases except for the liver parenchyma of Artery Phase. In particular, in the case of MonoE 50 keV, it was confirmed that SNR and CNR increased significantly. Both water intake as an oral contrast and MonoE 50 keV of DECT showed significant increases in SNR and CNR compared to when non-water intake. If MonoE 50 keV using DECT is applied to patients who are restricted water intake and difficult to intake due to poor general conditions, it is believed that the safety and convenience of patients will be increased, and the satisfaction of CT will be improved.

Femoral fracture fixation followed by ipsilateral amputation: A case report

Severe crushing injury of the lower limb presenting as a concomitant femoral subtrochanteric fracture, ipsilateral open knee dislocation, and associated popliteal artery injury is unusual. Due to poor general and local conditions, despite a vascular repair, we performed a femoral fracture fixation followed by transfemoral amputation of the lower limb. The report aimed to demonstrate the effectiveness of this definitive treatment as one of the options in these difficult cases. The knee dislocation reduction was performed in the emergency operating room and the lower limb was stabilized with an external fixator. Vascular surgeons performed revascularization of the extremity with a femoropopliteal vascular bypass. Leg fasciotomies were performed and broad-spectrum antibiotics were administered. Several attempts at fasciotomy revisions and necrotic tissue debridement were made by plastic surgeons. Ten days after hospitalization, concomitant local rhabdomyolysis and deep soft-tissue infection lead to life-threatening sepsis. An above-the-knee amputation was quickly required. We performed an emergency proximal nailing of the femoral fracture and, subsequently, a transfemoral amputation at the distal third. In this case, we described the successful use of intramedullary nailing as a good option for stabilizing acute subtrochanteric fracture of a limb that required an above-the-knee amputation. This strategy saved the patient’s life, and intramedullary fixation with a short nail provided reliable bone stability for rapid and better functional recovery.

Posterior-only approach in patients with poor general condition and spinal metastatic vertebral fracture

PurposeThe surgical treatment of spinal metastases is mostly palliative in nature and focuses on improving the quality of life of patients. The posterior transpedicular surgical approach provides circumferential 360° decompression, allows reconstruction and stabilisation to be achieved in a single session and can be performed using an open, mini-open or minimally invasive approach. We present and discuss the surgical techniques and outcomes for patients with single-level metastatic spinal disease and in poor general condition who underwent surgery via the posterior-only transpedicular corpectomy approach and reconstruction with expandable corpectomy cages. MethodsPatients with a single level thoracolumbar metastatic disease (T3-L5) and a Karnofsky score of ≤70, who underwent a complete posterior transpedicular corpectomy with expandable cage reconstruction of the anterior spinal column were retrospectively reviewed. Patients’ demographics, SINS, modified Tokuhashi scores as well as preoperative and postoperative ASIA scale, Karnofsky scores, VAS scores and vertebral height/Cobb angle values were analysed. ResultsA total of 44 patients (24 M/20 F) (mean age 53.25±21.26 years) met the inclusion criteria. The modified Tokuhashi scores were as follows: score 0–8, 5 (11.4%) patients; score 9–11, 14 (31.8%) patients; and score 12–15, 25 (56.8%) patients. There were significant improvements in the postoperative VAS scores (mean 7.7–2.9), Karnofsky scores (mean 63.3–79.6) as well as the Cobb angles (18.6–12.8°) and vertebral height. Thirtyfive patients showed improved neurological function by at least one ASIA grade, whereas 9 showed no improvement during the postoperative period. ConclusionsThis technique, which has a low complication rate and a short recovery time, can help achieve satisfactory results even in patients with poor metabolic profiles and Karnofsky scores in the preoperative period. Further clinical studies with large patient groups are warranted to confirm the results of this study.

A pseudo-outbreak of Cyberlindnera fabianii funguria: Implication from whole genome sequencing assay.

Although the yeast Cyberlindnera fabianii (C. fabianii) has been rarely reported in human infections, nosocomial outbreaks caused by this organism have been documented. Here we report a pseudo-outbreak of C. fabianii in a urology department of a Chinese hospital over a two-week period. Three patients were admitted to the urology department of a tertiary teaching hospital in Beijing, China, from Nov to Dec 2018, for different medical intervention demands. During the period Nov 28 to Dec 5, funguria occurred in these three patients, and two of them had positive urine cultures multiple times. Sequencing of rDNA internal transcribed spacer (ITS) region and MALDI-TOF MS were applied for strain identification. Further, sequencing of rDNA non-transcribed spacer (NTS) region and whole genome sequencing approaches were used for outbreak investigation purpose. All the cultured yeast strains were identified as C. fabianii by sequencing of ITS region, and were 100% identical to the C. fabianii type strain CBS 5640T. However, the MALDI-TOF MS system failed to correctly identify this yeast pathogen. Moreover, isolates from these three clustered cases shared 99.91%-100% identical NTS region sequences, which could not rule out the possibility of an outbreak. However, whole genome sequencing results revealed that only two of the C. fabianii cases were genetically-related with a pairwise SNP of 192 nt, whilst the third case had over 26,000 SNPs on its genome, suggesting a different origin. Furthermore, the genomes of the first three case strains were phylogenetically even more diverged when compared to a C. fabianii strain identified from another patient, who was admitted to a general surgical department of the same hospital 7 months later. One of the first three patients eventually passed away due to poor general conditions, one was asymptomatic, and other clinically improved. In conclusion, nosocomial outbreaks caused by emerging and uncommon fungal species are increasingly being reported, hence awareness must be raised. Genotyping with commonly used universal gene targets may have limited discriminatory power in tracing the sources of infection for these organisms, requiring use of whole genome sequencing to confirm outbreak events.

Prognostic factors among patients with Shiga toxin-producing Escherichia coli hemolytic uremic syndrome: A retrospective cohort study using a nationwide inpatient database in Japan

IntroductionShiga toxin-producing Escherichia coli (STEC) causes hemorrhagic colitis and hemolytic uremic syndrome (STEC-HUS). Understanding its prognostic factors is essential for immediate interventions. We examined early-phase unfavorable prognostic factors among patients with STEC-HUS using a nationwide database. Material and methodsThis is a retrospective cohort study to analyze practice patterns and identify prognostic factors among patients with STEC-HUS. We used the Diagnosis Procedure Combination Database, which includes approximately half of the acute-care hospitalized patients in Japan. We enrolled patients who were hospitalized for STEC-HUS from July 2010 to March 2020. The composite unfavorable outcome included in-hospital death, mechanical ventilation, dialysis, and rehabilitation at discharge. Unfavorable prognostic factors were assessed using a multivariable logistic regression model. ResultsWe included 615 patients with STEC-HUS (median age, 7 years). Of them, 30 (4.9%) patients had acute encephalopathy and 24 (3.9%) died within 3 months of admission. Unfavorable composite outcome was observed in 124 (20.2%) patients. Significant unfavorable prognostic factors were age of 18 years or older, methylprednisolone pulse therapy, antiepileptic drug administration, and respiratory support within 2 days of admission. DiscussionPatients requiring early steroid pulse therapy, antiepileptic drugs, and respiratory support were considered to be in poor general condition; such patients should receive aggressive intervention to avoid worse outcomes.

Income and Employment of Patients at the Start of and During Follow-up After Palliative Radiation Therapy for Bone Metastasis

The aim of this study was to understand the income and employment status of patients at the start of and during follow-up after palliative radiation therapy for bone metastasis. From December 2020 to March 2021, a prospective multi-institutional observational study was conducted to investigate income and employment of patients at the start of administration of radiation therapy for bone metastasis and at 2 and 6 months after treatment. Of 333 patients referred to radiation therapy for bone metastasis, 101 were not registered, mainly because of their poor general condition, and another 8 were excluded from the follow-up analysis owing to ineligibility. In 224 patients analyzed, 108 had retired for reasons unrelated to cancer, 43 had retired for reasons related to cancer, 31 were taking leave, and 2 had lost their jobs at the time of registration. The number of patients who were in the working group was 40 (30 with no change in income and 10 with decreased income) at registration, 35 at 2 months, and 24 at 6 months. Younger patients (P=0), patients with better performance status (P=0), patients who were ambulatory (P=.008), and patients with lower scores on a numerical rating scale of pain (P=0) were significantly more likely to be in the working group at registration. There were 9 patients who experienced improvements in their working status or income at least once in the follow-up after radiation therapy. The majority of patients with bone metastasis were not working at the start of or after radiation therapy, but the number of patients who were working was not negligible. Radiation oncologists should be aware of the working status of patients and provide appropriate support for each patient. The benefit of radiation therapy to support patients continuing their work and returning to work should be investigated further in prospective studies.

Evaluation of steroid therapy in COVID-19 patients; in the right dose at the right time to the right patients.

Although there is still no universally accepted treatment agent, steroids have been administered chronologically at every dose and at every stage of the COVID-19 pandemic. We aimed to evaluate the clinical efficacy of high-dose steroid therapy and its effect on mortality in COVID-19 patients with severe pneumonia, severe Acute Respiratory Distress Syndrome (ARDS), and septic shock. : Patients with severe pneumonia, septic shock, and ARDS due to COVID-19 who were followed up in the intensive care unit were retrospectively reviewed. The study population was divided into two groups; the methylprednisolone pulse group (MP) (n = 55) and the dexamethasone group (Dex) (n = 39). When the values before and after treatment were compared; there was a statistically significant increase in the neutrophil/lymphocyte ratio after treatment in the MP group (p = 0.006). Although it was not statistically significant in the MP group, There was a numerical increase in D-dimer levels (p = 0.28). Thromboembolic complications developed in 2 patients in the MP group. The mortality outcomes of the groups were statistically similar (p = 0.943). We recommend steroids use in the condition that it is indicated in the critically ill group with the poor general condition. Since there is no significant difference between high-dose pulse steroid treatment and standard treatment doses, we think that the risk of complications should not be taken into account and high doses should not be used.

Konservative Behandlung der distalen Radiusfraktur

Distal radius fractures are the third most frequent fractures in Germany. The decision for conservative treatment and the weighing up of surgical treatment need an exact consideration of the indications based on instability criteria and the extent of possible articular involvement. Indications for an emergency operation must be excluded. In cases of stable fractures or multimorbid patients in a poor general condition conservative treatment is indicated. The principles for asuccessful treatment are the precise reduction and stable retention in aplaster splint. In the further course, fractures are closely monitored by biplanar radiography. This is necessary to rule out asecondary displacement until the swelling of the soft tissues has subsided and the plaster splint is changed to acircular cast approximately 11days after the traumatic event. The total duration of immobilization is 4weeks. Physiotherapy and ergotherapy including adjacent joints, starts after 2weeks of treatment. This treatment is extended to the wrist after removal of the circular cast.

The Identification of Risk Factors for Symptomatic Spinal Metastasis Onset: A Prospective Cohort Study of 128 Asymptomatic Spinal Metastasis Patients.

Background: Symptomatic spinal metastasis (SSM) decreases the activities of daily living (ADL) and quality of life of cancer patients. However, the risk factors for SSM onset remain unclear. This prospective cohort study aimed to statistically analyze the significant risk factors. Methods: From 2016 to 2018, 210 consecutive patients with spinal metastases were prospectively registered. Patients with SSM at the first consultation and those who were unable to be followed-up owing to poor general condition were excluded. The demographic factors (age, sex, primary cancer, performance status, and ADL), clinical factors (radiation therapy, chemotherapy, molecularly targeted drugs, and bone-modifying agents (BMAs)), and Spinal Neoplastic Instability Score (SINS) were evaluated. Multivariate analysis was performed to identify the risk factors for SSM onset. Furthermore, the threshold was calculated from the receiver operating characteristic curve using the Youden index. Results: Thirty-nine patients who presented with SSM at the first consultation and 43 patients who were unable to be followed-up owing to poor general condition were excluded. Finally, 128 asymptomatic patients were included. Thirty-seven patients (28.9%) developed SSM during the follow-up period. The total SINS (OR: 1.739; 95% CI: 1.345-2.250) was identified as the most significant factor. The cut-off value of the SINS was 9.5 (sensitivity: 67.6%; specificity: 83.5%). Twenty-five (62.5%) of the forty patients with a SINS ≥ 10 developed SSM within a mean of 5.5 months (95% CI: 1.17-9.83). Furthermore, all patients with a SINS ≥ 13 developed SSM (n = 5) within a mean of 1.37 months (95% CI: 0.0-3.01). Conclusions: This study identified the significant risk factors for SSM onset and the threshold of the SINS. If long-term survival is expected, patients with a SINS ≥ 10 should be considered for intervention to prevent SSM.

Diagnostic challenge of dyspnea in the context of the COVID-19 pandemic wave: a case report

BackgroundSince its discovery, COVID-19 has often been the first diagnosis of dyspnea and asthenia, especially during the pandemic waves. However, it is not always COVID-19. We report a particular case of a late-diagnosed HIV-positive patient in Madagascar.Case presentationA 21-year-old male patient was admitted to a hospital center in Antananarivo for dyspnea and poor general condition. Physical examination revealed hypoxemia of 85% on room air. His chest X-ray showed bilateral reticular-micronodular opacities. He was suspected and treated for COVID-19. On the 15th day of hospitalization, HIV-1 infection complicated by probable pneumocystis was diagnosed. On the other hand, a multimetastatic testicular cancer was also suspected. The patient died after a few hours of hospitalization in the intensive care unit.ConclusionThis was a case of an HIV-positive patient belatedly diagnosed in the complications stage during the COVID-19 pandemic wave. The investigation of the differential diagnoses remains crucial to avoid serial misdiagnosis and to adjust therapeutic management.

Aspiration Prevention Surgery: Clinical Factors Associated With Improvements in Oral Status Intake and Suction Frequency.

In recent years, the use of aspiration prevention surgery (APS) for the treatment of severe dysphagia has been on the rise. However, relevant clinical studies have included small samples, and the frequency of, and risk factors for postoperative complications have not been clarified. We investigated the clinical features of patients undergoing APS and whether oral-intake status and suction frequency could be reduced. A case series. Single-institution academic center. We retrospectively evaluated medical charts generated from 2010 to 2021. The clinical characteristics of patients undergoing APS, changes in the oral-intake status (Functional Oral Intake Scale, FOIS), suction frequency before and after surgery, risk factors for postoperative complications, and factors contributing to improvements in postoperative oral-intake status were retrieved. We included the data of 100 patients (median age: 65 years, 72 men). Amyotrophic lateral sclerosis was the most common primary disease (28%), and glottis closure was the most common APS (69%). Postoperatively, 78% of patients showed improvements in the FOIS score, and suction frequency decreased in 85% of cases. Postoperative complications were observed in 10 patients (10%), wound infection in 6, and bleeding in 4; all improved. Higher preoperative FOIS scores were significantly associated with postoperative complications (p = 0.02). APS contributed to improving the FOIS score and helped reduce the suction frequency in most cases. APS can be performed safely with proper perioperative management, even in patients with poor preoperative general conditions and nutritional status.

Comparison of first-line treatments for elderly patients with diffuse large B-cell lymphoma: A systematic review and network meta-analysis.

The incidence of DLBCL in elderly patients has been gradually increased. Considering their comorbidities and performance status, the first-line standard treatment hasn't been determined for the elderly. We performed a systemic review and network meta-analysis to compare the efficacy and safety of all eligible regimens as first line treatment for elderly patients with DLBCL. We searched PubMed, Cochrane Library, and Embase Library proceedings up to March 2022. Our search yielded thirteen trials including 1839 patients. R2CHOP21 showed the best PFS with a statistical difference and the most favorable OS without a statistical difference. RCOMP showed the most clinical benefits in EFS, CR and OR with no significant difference. The point estimate was in favored improved DFS with RCHOP14 than RCHOP21, although this was not statistically significant. In a subgroup analysis concerning 3-4 grade AEs revealed R-COMP was associated with a decrease in grade III/IV neutropenia and cardiac toxic events; RminiCEOP was associated with the lower rates of 3-4 grade anemia, thrombocytopenia and infection; RCHOP21 had the lowest rate of 3-4 grade AE of neurotoxicity. The findings of our meta-analysis indicated that R2CHOP21 provided the best disease control in PFS and represented an optimal first-line treatment option in the elderly with DLBCL. Furthermore, RCOMP, RminiCEOP and RCHOP21 exhibited lower rates in different 3-4 grade AEs and might be reasonable treatment options in the elderly with poor general conditions.

Erythrodermic psoriasis eruption following COVID-19 vaccination

Sir, Psoriasis is a chronic inflammatory skin condition affecting roughly 2% of the population. Erythrodermic psoriasis (EP) is its rare and severe variant [1]. It is characterized by acute flare-ups induced by various factors, yet some reports have described the onset or flare-up of EP induced by vaccination. To our knowledge, only two such cases following COVID-19 vaccination have been reported. Herein, we report a case of an EP flare-up after COVID-19 vaccination. A 47-year-old male was referred by our emergency department with diffuse erythema, desquamation, fever, and a poor general condition, arising ten days after the reception of the first dose of the Sinopharm vaccine. He had a history of plaque psoriasis, yet used only topical treatments. He denied any past vaccination-related reaction, recent medication changes, or recent infection. A physical examination revealed diffuse erythema and desquamation on the entire body (Fig. 1a). Initial laboratory investigation revealed hyperglycemia and incidentally discovered diabetes. A COVID-19 PCR test was negative and the peripheral blood smear was normal. He had no history of malignancy and the tumor marker tests were negative. Histopathology was also compatible with erythrodermic psoriasis. He was, thus, diagnosed with the exacerbation of erythrodermic psoriasis associated with the administration of CoronaVac. We commended methotrexate and local treatment with very good improvement.

Percutaneous fixation of unstable proximal humeral fractures augmented with external Ilizarov cubes: a new simple technique

Abstract Purpose To present the management of unstable proximal humeral fractures with percutaneous pinning augmented by an external Ilizarov cubes in elderly patients with poor general condition. Patients and methods Between October 2021 and December 2021, 7 patients (mean age: 56.7, range 53–62) with three-part proximal humeral fracture with 2 or more co-morbidities were surgically managed by percutaneous pinning augmented by an external cube. Functional results were evaluated through measuring shoulder range of motion. Radiological evaluation was done by antero-posterior and lateral radiograms of the treated humerus. Results The patients were followed up for an average period of 6 months. The external cube and the pins were removed at about the 6 weeks mark. The average range of motion at the final follow up was Abduction 110°, forward flexion 140°, internal rotation 60°, external rotation 58°. All patients achieved full radiological union. Conclusion Percutaneous fixation of unstable humeral fractures is an effective method of treatment especially in elderly patients with multiple co-morbidities. Adding external Ilizarov cubes to the construct is an easy, affordable, and quick method of improving results and minimizing complications of early pin loosening that give the ability of early range of motion and rapid bone union.

Mycotic subclavian artery aneurysms: a scoping review.

Mycotic subclavian artery aneurysms (SAAs) are a very rare disorder. To provide an overview of current knowledge on clinical features, management strategies and outcome evaluations of mycotic SAAs. The study materials were based on comprehensive literature retrieval of publications of mycotic SAAs published between 2000 and 2023. Contaminated mechanical injuries and abscess erosions of the arterial walls are mechanisms of mycotic SAAs. The diagnosis relies on detection of pathogenic microorganisms by cultures or microbiological investigations of blood, other fluids and infected tissues as well as medical imaging visualization. The indications for an interventional therapy were poor general condition, high surgical risk, and rescue exclusion for a ruptured pseudoaneurysm. Three (9.1%) pre-treatment deaths were a result of sudden rupture of the mycotic SAAs and thus they lost the opportunity of treatment. All post-treatment deaths occurred in the interventional patient group, whereas the causes of death seemed to be unrelated to mycotic SAAs per se or to treatments of choice. Patient outcome evaluations revealed no significant difference between different treatments of choice. No significant predictive risk factors were responsible for patient outcomes. Once a diagnosis of mycotic SAA is made, sensitive antibacterial drugs are applied immediately to control the infection and control aneurysmal progression. Early treatment is conducted as soon as possible to avoid aneurysmal rupture. A decision on treatment of choice is made based on the patient's specific condition. Antibacterial drug use is continued for about 6 weeks after surgical or interventional therapy.

The effect of using nitroderm TTS in ERCP on precut, selective cannulation, and bleeding.

The aim of the study was to investigate the use of prophylactic nitroglycerin patch in patients who applied to our clinic with occlusion icter and underwent endoscopic retrograde cholangiopancreatography (ERCP) for complications such as pancreatitis, bleeding, perforation that may occur during and after the procedure, duration of the procedure, length of hospitalization, precut and selective cannulation rates, and mortality. Patients were searched retrospectively using the hospital database. Patients under the age of 18, patients with poor general condition and patients treated under emergency conditions were excluded from the study. The effects of the drug on morbidity, mortality, duration of procedure, length of hospital stay, and cannulation techniques were investigated in patient groups with and without nitroglycerin patch. It was observed that using nitroglycerin decreased the precut probability by 2.28 times (p<0.001), and decreased periop-erative bleeding by 3.4 times (p<0.001). 75.1% selective cannulation was observed in the group not administered nitroglycerin, this rate was determined as 87.3% in the group administered nitroderm(p<0.001). In the regression model, it was observed that the presence of nitroderm increased the probability of selective cannulation 2.21 times (p<0.001). The effects of nitroglycerin use on mortality, patient's history of malignancy, presence of stones and mud, gender, age, post-operative pancreatitis, and perioperative bleeding variables were evaluated by regression analysis, and age increased mortality by 1.09 (p=0.023). It has been shown that the use of prophylactic nitroglycerin patch in ERCP procedure increases the prophylactic selective cannulation rate, shortens the precut rate, pre-operative bleeding, hospital stay, and procedure time.

Rare Etiology of Reversible Hypokinetic Dilatated Heart Disease in Infants: Bland-White-Garland Syndrome (ALCAPA)

Bland-White-Garland syndrome or ALCAPA is an abnormality of birth of the left coronary artery from the pulmonary artery. It is a diagnostic and therapeutic emergency because it is a curable cause of hypokinetic dilated heart disease in infants. We report through this clinical case, the fourth case of infantile ALCAPA diagnosed in Senegal in a 7-month-old infant. The symptomatology began around the age of 2 months, with a grumpy state associated with more marked crying and moaning during feedings and bowel movements. The mother reported hospitalization for a severe lung infection when she was 6 months old. The examination noted an infant in poor general condition, retarded growth and weight, and a 3/6th holosystolic murmur at the apex. Troponinemia was positive at 43.90 ng/L. The electrocardiogram showed Q waves on the lower side, a sub endocardial lesion on the upper side and a ST segment elevation in aVR. Doppler echocardiography showed dilated cardiomyopathy with a mean alteration of systolic function of the left ventricle at 37%, a mean mitral insufficiency and a strong suspicion of a birth anomaly of the left coronary artery. The CT scan confirmed the diagnosis of ALCAPA. Surgicalreimplantation of the left coronary artery at the aortic level was performed at 10 months of life with a favourable outcome at D50 postoperative.

EUS-guided biliary drainage in a patient after postcholecystectomy complete biliary transection (with video).

Biliary injury occurs after cholecystectomy in 0.3%–2.7% of patients.[1] Minor injuries can be managed endoscopically, whereas major injuries generally require surgical reconstruction.[2] However, due to the development of EUS-guided biliary drainage (EUS-BD) techniques, endoscopic minimally invasive treatment may be applied even for major injuries. Here, we describe a case of postcholecystectomy complete biliary transection managed endoscopically using the EUS-BD technique. An 85-year-old man was referred to our hospital for the treatment of severe cholecystitis. He was a bedridden patient with a history of liver cirrhosis and normal-pressure hydrocephalus. We performed subtotal cholecystectomy instead of total cholecystectomy due to severe adhesions and intraoperative bleeding. After the surgery, continuous biliary leakage occurred. Computed tomography showed a small amount of perihepatic ascites. The hilar bile duct was obscured, but the intrahepatic bile ducts were not dilated [Figure 1a and b]. We attempted endoscopic biliary stenting via ERCP to relieve the biliary pressure. However, we abandoned this approach because cholangiography revealed common bile duct disruption [Figure 2]. Magnetic resonance cholangiopancreatography also revealed complete transection of the common bile duct [Figure 3]. We decided to try endoscopic biliary stenting via EUS-BD because we considered that reoperation for this patient might lead to a poor result [Video 1]. The transected hilar duct was punctured from the duodenum because the B2 and B3 branches were not dilated. Cholangiography showed biliary leakage from the B6 branch. A plastic stent (TYPE-IT stent; Gadelius Medical Co., Ltd., Tokyo, Japan) was placed from the hilar bile duct to the duodenum. No procedure-related complications occurred, and biliary leakage was resolved.Figure 1: Computed tomography showing a small amount of perihepatic ascites. The hilar bile duct is obscured (arrow). The intrahepatic bile ducts are not dilated. (a) Axial view. (b) Coronal viewFigure 2: Cholangiography showing common bile duct disruptionFigure 3: Magnetic resonance cholangiopancreatography showings complete transection of the common bile duct (arrows)Surgical reconstruction for biliary injury was associated with a high morbidity rate of 20%–31%.[2] Endoscopic biliary stenting via EUS-BD can serve as a minimally invasive treatment option for patients with poor general conditions. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.