Background and aim Accurate diagnosis is essential in the appropriate management of biliary strictures. Our aim is to evaluate the efficacy of cholangioscopy-directed biopsies in differentiating biliary intraductal malignancies from benign lesions. Materials and methods Articles were searched in Medline, PubMed, and Ovid journals. Pooling was performed by both fixed-effects and random-effects models. Only studies from which a 2×2 table could be constructed for true-positive, false-negative, false-positive, and true-negative values were included. Results Initial search identified 2110 reference articles for peroral cholangioscopy; of these, 160 relevant articles were selected and reviewed. Data were extracted from 15 studies (N=539) that fulfilled the inclusion criteria. Pooled sensitivity of cholangioscopy-directed biopsies in diagnosing malignancy was 71.9% [95% confidence interval (CI): 66.1–77.1] and pooled specificity was 99.1% (95% CI: 96.9–99.9). The positive likelihood ratio of cholangioscopy-directed biopsies was 18.1 (95% CI: 9.1–35.8), whereas the negative likelihood ratio was 0.3 (95% CI: 0.2–0.4). The pooled diagnostic odds ratio was 71.6 (95% CI: 32.8–156.4). All the pooled estimates calculated by fixed-effects and random-effect models were similar. Summary receiver operating characteristic curves showed an area under the curve of 0.98. The χ 2 heterogeneity for all the pooled accuracy estimates was 5.62 (P=0.96). Conclusion Peroral cholangioscopy with cholangioscopy-directed biopsies has a high specificity in differentiating intraductal malignancies from benign lesions. Cholangioscopy-directed biopsies should be strongly considered for biliary stricture evaluation.
Thrombotic thrombocytopenic purpura (TTP) is a potentially reversible, life-threatening medical emergency. We present a case of a 21-year-old female with evidence of haemolytic anaemia based on the presence of positive markers of haemolysis. Negative Coomb's test, thrombocytopenia and placental infarcts raised suspicion for a thrombotic microangiopathy. She was diagnosed with TTP and managed with emergency plasma exchange. Her recovery was immediate.A presumptive diagnosis of TTP should be based on the presence of microangiopathic haemolytic anaemia with thrombocytopenia and plasma exchange should be initiated while complete work up is pending. Using the regular pentad solely for diagnosis of TTP will lead to underdiagnosis of many cases and should be avoided.Several microangiopathies can be seen during pregnancy including TTP/atypical haemolytic uraemic syndrome, HELLP syndrome, pre-eclampsia, disseminated intravascular coagulopathy and antiphospholipid antibody syndrome. Distinction between each type will be the focus of our discussion as treatment decisions differ accordingly.
Background: Early cholecystectomy is the recommended treatment for patients with acute cholecystitis. A subset of these patients are unfit for surgery due to late presentation and comorbidities. Prompt gallbladder drainage (GBD) with percutaneous or endoscopic approach remains a viable therapeutic option for non-operative candidates. Endoscopic ultrasound (EUS) guided transluminal gallbladder drainage (EUS-GBD) continues to evolve as a viable alternative approach to percutaneous drainage. Advanced endoscopic techniques along with refinement in lumen apposing self-expandable mental stents (LAMS) offer several advantages. Current literature on the efficacy of EUS-GBD has been varied. We performed a pooled analysis on the efficacy and safety of EUS-GBD with LAMS in non-operative candidates with acute cholecystitis. Methods: Extensive English language literature search was performed in Medline, Embase, Cochrane central and Google scholar using keywords "endoscopic ultrasound", "stent", "gallbladder", "acute cholecystitis" and "cholecystostomy" from Jan. 2000 to Nov. 2019. Fixed and random effects models were used to calculate the pooled proportions. Results: Data was extracted from 19 studies that met the inclusion criteria (nZ480). Pooled proportion of technical success was 95.92% (95% CI Z 94.01 to 97.48) and clinical success was 93.05% (95% CI Z 90.04 to 95.55). Overall complication rate was 16.92 % (95% CI Z 11.30 to 23.42) and stent related complication rate was 7.03% (95% CI Z 4.24 to 10.45) in the pooled percentage of patients. Pooled proportion for perforation was 4.77% (95% CI Z 2.77 to 7.28) and total deaths was noted in 18.44% (95% CI Z 8.48 to 31.18). Pooled proportion for obstruction was 4.23% (95% CI Z 2.10 to 7.05) and recurrent cholangitis/cholecystitis was noted in 3.75% (95% CI Z 2.16 to 5.76). Proportion of tissue overgrowth was 4.65% (95% CI Z 1.85 to 8.63) with stent removal noted in 9.21% (CI Z 3.38 to 17.51). Inability to remove the stent was noted in 5.10% (95% CI Z 0.13 to 16.60). Pooled estimates were similar using random and fixed models.
Polymorphicventriculartachycardia(PMVT)ischaracter-izedbyQRScomplexesofchangingamplitudethatappear to twist around the isoelectric line. Torsades de Pointes (Tdp)isavariantofPMVTinwhichthereisprolongation ofQTcinterval(generallyexceeding500milliseconds).A numberofmedicationshavebeennotedtoprolongtheQTc interval.Wedescribeaclinicalcaseinwhichtheculprits areAzithromycin and Fluoxetine.Azithromycin has been regardedasa"safer"macrolidewhenitcomestoproarrhythmiaascomparedtoerythromycinorclarithromycin. However, in certain clinical circumstances like combination drug usage, unique clinical features like underlying pancreatitisinthisparticularpatient,someofthemedicationsthataredeemedlowriskcancertainlybemoreproarrhythmic.Itisthereforeimportanttoreviewtheclinical andpharmaceuticalprofilesofeverypatientbeforechoosingwhichmedicationstoprescribe.
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