Transjugular intrahepatic portosystemic shunts (TIPS) in children

The transjugular intrahepatic portosystemic shunt procedure is an accepted treatment for adults with complications of portal hypertension. We performed a retrospective review of all pediatric TIPS placements performed at the University of California, San Francisco between 1990 and 1996. Twelve procedures were attempted in nine children, with a mean age (+/- SD) of 9.4 +/- 3.9 years (range, 5 to 15 years) and a mean weight of 31 +/- 18 kg (range, 16 to 70 kg). The indications for TIPS placement were portal hypertension complicated by chronic variceal hemorrhage not controlled with sclerotherapy (n = 7) and hypersplenism with thrombocytopenia (n = 2). TIPS placement was successfully completed initially in seven of nine (78%) patients. Unfavorable vascular anatomy was the cause of failure in two cases. The seven patients who underwent successful TIPS placement were followed up for an average of 136 days (range, 1 to 800 days); two still have patent shunts, three underwent liver transplantation, one had a splenorenal shunt after stenosis, and one died of underlying liver disease. Variceal bleeding was controlled in four of five patients who successfully underwent TIPS placement. Shunt occlusion occurred in four patients; patency was restored by transjugular shunt revision in three, and a splenorenal shunt was performed in one.     

Neural basis for the genesis and control of digitalis arrhythmias

The author discussed the increase in the frequency of traumatic paralyses of the ocular muscles, and reported 6 cases of inferior oblique muscle paresis caused by local blunt or sharp traumas (haematoma, contusion, rupture, incarceration) and one case of traumatic Brownian pseudo-paralysis. The localisation of the injuries in 3 cases was on the inferior temporal part and in the other 3 cases on the superior part of the bulbar conjunctiva. Atypical horizontal deviation and characteristic vertical deviation, torsion and torticollis were observed in the majority of cases. One patient recovered spontaneously. 3 patients became asymptomatic after correction by prisms and one after recession of contralateral superior rectus muscle. The symptoms remained unchanged in the case of a "blow out" fracture (in spite of operation) and a Brown's syndrome (without treatment).     

Vacuum pack technique of temporary abdominal closure: a four-year experience

The purpose of this review is to present a 4-year experience with the vacuum pack technique of temporary abdominal closure. From April 1992 to December 1996, 171 vacuum packs were performed on 93 patients. Eighty-seven vacuum packs were performed on 38 general surgical patients, and 84 vacuum packs were performed on 55 trauma patients. Overall hospital mortality was 32 per cent. Methods of achieving permanent wound closure varied in 73 patients. Four patients (4.3%) developed enterocutaneous fistulae; four patients developed intra-abdominal abscesses (4.3%). There were no eviscerations. Management of the complicated intra-abdominal process is discussed: 1) the decision to manage the abdomen in an open fashion; 2) which method of temporary closure to use; 3) subsequent explorations; 4) when the abdomen should be closed; 5) which type of closure to use; and 6) when the abdominal wall should be revised (herniorrhaphy). The vacuum pack is the method of choice for open abdomen management and temporary abdominal closure at our institution. With careful subsequent management, good patient outcome can be achieved.     

KCNE1 mutations cause jervell and Lange-Nielsen syndrome

The third reported case of pelvic gliomatosis found within foci of endometriosis is documented 16 years after the removal of a benign cystic teratoma. Grossly at laparoscopy the lesions appear as typical deep fibrotic endometriotic implants.     

QT interval dispersion in healthy subjects and survivors of sudden cardiac death: circadian variation in a twenty-four-hour assessment

Twenty-four-hour acquisition of QT dispersion (QTd) from the Holter and the circadian variation of QTd were evaluated in 20 survivors of sudden cardiac death (SCD), in 20 healthy subjects, and in 14 control patients without a history of cardiac arrest who were age, sex, diagnosis and therapy matched to 14 SCD patients. Computer-assisted QT measurements were performed on 24-hour Holter recordings; each recording was divided into 288 5-minute segments and templates representing the average QRST were generated. QTd was calculated as the difference between QT intervals in leads V1 and V5 for each template on Holter. The 24-hour mean QTd was significantly greater in SCD patients (40 +/- 28 ms) than in healthy subjects (20 +/- 10 ms) and control patients (15 +/- 5 ms) (p <0.05). There was a circadian variation in QTd with greater values at night (0 to 6 A.M.) than at daytime (10 A.M. to 4 P.M.) in healthy subjects (25 +/- 13 vs 15 +/- 8 ms, p <0.001) and control patients (18 +/- 10 vs 12 +/- 4 ms p <0.05), whereas in SCD patients there was no significant difference between night and day values (45 +/- 31 vs 37 +/- 28 ms, p = NS). It is concluded that QTd measured by Holter was greater in SCD patients than in healthy subjects and matched control patients during the entire day. QTd has a clear circadian variation in normal subjects, whereas this variation is blunted in SCD patients. QTd measured on Holter differentiates survivors of cardiac arrest and may be a useful tool for risk stratification.     

The client's perspective: Ethical judgments and perceptions of therapist practices.

In response to a questionnaire, 96 adults, both with and without experience as clients in therapy, judged the ethical appropriateness of 60 therapist practices. In addition, those who had been clients indicated whether the practices had occurred in their own therapy. The practices were organized into 6 groups that corresponded to major areas of professional ethics in psychology: confidentiality, dual relationships, informed consent and business practices, competence, sensitivity to differences, and interventions. Clients and nonclients alike showed a general understanding of ethical principles but uncertainty about many specific points. Some uncertainty stemmed from a misunderstanding about the nature, and particularly the risks, of therapy. Practices judged clearly appropriate were not reported to have occurred universally by the clients in the sample, and practices judged clearly inappropriate were reported to have occurred with some, albeit low, frequency. The results are discussed with regard to implications for ethics research and ethical practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Creation of transjugular intrahepatic portosystemic shunts with the wallstent endoprosthesis: results in 100 patients

One hundred patients underwent transjugular intrahepatic portosystemic shunt (TIPS) creation for variceal bleeding (n = 94), intractable ascites (n = 3), hepatorenal syndrome (n = 2), and preoperative portal decompression (n = 1). Shunts were completed in 96 patients. Portal vein pressure was reduced from 34.5 mm Hg +/- 7.6 (standard deviation) to 24.5 mm Hg +/- 6.2; the residual portal vein-hepatic vein gradient was 10.4 mm Hg +/- 0.9. Acute variceal bleeding was controlled in 29 of 30 patients. Of the 96 patients who underwent successful TIPS creation, 26 have died and 22 have undergone liver transplantation; the remaining 48 patients have survived an average of 7.6 months. Variceal bleeding recurred in 10 patients. Fifteen patients developed shunt stenosis (n = 6) or occlusion (n = 9). Patency was reestablished in eight of the nine occluded shunts. Seventeen patients developed new or worsened encephalopathy. The authors conclude that TIPS creation is an effective and reliable means of lowering portal pressure and controlling variceal bleeding, particularly in patients with acute variceal bleeding unresponsive to sclerotherapy and patients with chronic variceal bleeding before liver transplantation.     

Functioning and nonfunctioning adrenocortical carcinoma: clinical presentation and therapeutic strategies

Adrenocortical cancers are relatively rare endocrine tumors that usually present when hormonally active or after they have become large and metastasis has occurred. Consequently, the 5-year survival rate is 20% to 35%. Surgical removal remains the only form of therapy proven to prolong survival. Mitotane is the most accepted form of chemotherapy. For the approximately 20% to 25% of patients whose tumors respond to mitotane, survival is prolonged.     

Tamoxifen in liver disease: potential exacerbation of hepatic dysfunction

Tamoxifen, a non-steroidal anti-estrogen, has been used successfully for a decade as post-operative adjuvant therapy for breast cancer. Tamoxifen is generally well tolerated with few side effects, especially at the typical dose of 10 mg twice daily. However, hepatic effects have been reported after tamoxifen administration and are usually found to be cholestatic in nature. Although previous reports concentrate on tamoxifen as a probable cause of drug-induced hepatotoxicity, very little attention has been focused on the use of tamoxifen in patients with pre-existing liver dysfunction and the possible need for dose adjustment. We present the case of a 48-year-old woman with an acute exacerbation of her pre-existing liver dysfunction and subsequent elevations of tamoxifen blood levels after approximately one year of tamoxifen therapy for adjuvant treatment of breast cancer. Tamoxifen dosing was adjusted based on serum levels.