Purpose: A 38 year old African American male with AIDS and cirrhosis due to chronic Hepatitis B and C was evaluated for cough, shortness of breath, and decreased oral intake for 1 week. The patient had no fevers, chills, sick contacts, chest pain, abdominal pain or distention. The patient's initial physical exam was remarkable only for decreased right chest breath sounds. The patient had laboratory values that showed mild hyponatremia, normal renal function, and pancytopenia. He had an initial chest x-ray which was remarkable for an isolated right pleural effusion. The patient became progressively short of breath necessitating intubation. The following chest films showed worsening of the effusion. Two-liter thoracentesis of right chest was done revealing a golden colored, transudative effusion. In 48 hours, the right pleural effusion recurred along with a new left sided effusion. Ultrasound of the abdomen showed a small amount of ascites not present on prior exam from six months earlier. A repeat thoracentesis for symptomatic relief removed two liters of transudative fluid. Several therapeutic options were considered in the management of this case of hepatohydrothorax including TIPS. However, worsening liver and renal function complicated the patient's hospital course. At that time, the family decided to pursue a non-aggressive, supportive care approach. The patient subsequently expired. While hepatohydrothorax occurs with a prevalence of 10% in decompensated end stage liver disease, it is relatively uncommon for these patients to have clinically undetectable ascites.
In this review, we aim to provide a concise yet comprehensive summation of the assessment and management of humeral shaft fractures. These are uncommon but prevalent enough that they are part of any trauma surgeon's scope of practice. They have historically been treated using non-operative methods, including braces and casts, supported by published excellent results in the rate of the bone union. However, recently published studies challenge these results and suggest the outcomes might be better with surgery, but the complications of an operation such as infection and nerve injury can not be overlooked. In summary, non-surgical treatment is still the gold standard in the treatment of these fractures, but the indications for surgical management are now clearer and include early signs of delayed union and patients who are unable to have a brace fitted or are uncompliant. It is likely that these new developments will start to change practice, and therefore the treatment of humeral shaft fractures should be a topic of interest of any clinician who deals with them.
ASiT President Srinivas Cheruvu discusses the value of surgical training, the significance of the recent industrial strikes and what the future of surgical training looks like.
s Submitted for the 68th Annual Scientific Meeting of the American College of Gastroenterology October 10-15, 2003, Baltimore, Maryland: ENDOSCOPY: PDF Only
Biliary endoprostheses continue to demonstrate their utility and simplicity in daily therapeutic endoscopy. However, the transient nature of these foreign bodies also underscores their potential detrimental effects even after successful deployment. Stent related factors, such as type, length and caliber offer potential avenues to minimize the risk of migration. However, a patient related factor such as the presence of prior abdominal surgeries makes it paramount for endoscopists to ascertain the location of a migrated stent. There is a ripe niche for continued research and development in biodegradable stents.
Purpose: Animal models suggest that the RAS promotes fibrogenesis in chronic hepatitis. Our aim was to determine if medications that affect the RAS, angiotensin converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB), can also modulate fibrosis in CHC. Methods: We retrospectively reviewed medical records of patients (n=187) with CHC during a ten-year period at two institutions. We abstracted demographic, medical, histological, and biochemical data. The primary outcomes were a lower grade of hepatic inflammation and stage of fibrosis in patients treated with ACE-I or ARB. Results: Among our patients, 53% were male. The mean age of all patients was 54 years (IQR 49-61), and 22% were African American, 6% were Caucasian, 44% were Hispanic, and in 27% ethnicity data were unavailable. In a multivariate model controlling for age, diabetes mellitus, and gender, ACE-I/ARB treatment was associated with reduced hepatic inflammation and fibrosis (inflammation: OR=0.436 [95% CI 0.197, 0.967]; fibrosis OR=0.376 [95% CI=0.183, 0.769]). These findings suggest a protective effect of these agents on fibrosis. This protective effect appears to be more profound when we conduct multivariate analysis controlling for age and gender only in patients who have diabetes (inflammation OR=0.174 [95% CI 0.042, 0.723]; fibrosis OR=0.077 [95% CI 0.018, 0.338]). Conclusion: ACE-I/ARB's may have a role in attenuating inflammation and fibrosis in CHC, in particular among those patients with co-existing diabetes. These findings justify additional investigation of these agents as modulators of hepatic fibrosis particularly among this patient subgroup, which could provide an additional indication for the use of these medications.
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