Background Despite advances in endoscopic drainage procedures, percutaneous transhepatic biliary drainage (PTBD) remains an essential interventional radiology (IR) procedure. Several factors may adversely affect the success of PTBD. We report the experience of our IR unit with PTBD in patients considered at higher risk for adverse events. Material Consecutive PTBDs performed between November 2017 and April 2019 were retrospectively reviewed. The patients at increased risk for adverse events from PTBD, defined by one or more of the following factors: non-dilated system, moderate amount of perihepatic fluid, coagulopathy, altered sensorium, and PTBD performed at bedside, were identified. Technical success, complications, and outcome at 3 months were recorded. Results During the study period, PTBDs were performed in 90 patients. PTBDs in 57 (63.3%) patients (mean age 47.6 years, 35 females) were identified as predisposing to higher risk for adverse events. Left and right PTBD were performed in 37 (64.9%) and 15 (26.3%) patients, respectively. Bilateral PTBDs were performed in three (5.2%) patients. In two (3.5%) cases, biliary access was obtained via percutaneous cholecystostomy. Overall technical success of 91.2% (n = 52) was achieved. Carcinoma gallbladder was the most common underlying cause. Non-dilated ductal system was the most common condition deemed to predispose to higher risk for adverse events (n = 32, 56.1%), followed by perihepatic fluid (n = 9, 15.8%), and deranged coagulation parameters (n = 9, 15.8%). PTBD was performed at bedside in intensive care unit in 5 (8.8%) patients. Two (3.5%) patients had altered sensorium. Major complications in the form of biliary peritonitis were observed in three (5.2%) patients. No procedure-related mortality was observed. Conclusion PTBD can be effectively and safely performed even in situations deemed to predispose patients to increased risk for adverse events. Thus, the mere presence of these conditions should not cause a denial of PTBD.
References Landiolol and peri-induction tachycardiaTo the Editor: We read with interest the recently published article by Yamazaki et al. 1 The authors describe the role of landiolol, a new β 1 selective antagonist in attenuating tachycardia in response to tracheal intubation. The authors conclude that landiolol [0.1 mg·kg -1 (L1 group) and 0.3 mg·kg -1 (L3 group)] prevents tachycardia without affecting blood pressure. However, the results indicate that there was no difference in heart rate (HR) values between the control group and L1 group. We believe that this may be related to the anesthetic induction technique, which comprised propofol (2 mg·kg -1 ) and succinylcholine (1 mg·kg -1 ). It is well known that propofol 2 as well as succinylcholine 3 are associated with a decrease in HR. Further, it is unclear as to when vecuronium was administered during the induction-intubation sequence: as this may have presented an additional confounding factor.Thus, it appears that a dose of 0.1 mg·kg -1 of landiolol was unable to attenuate the tachycardia in response to tracheal intubation independently from the effects of the anesthetic agents. Further, the mean HR values ranged between 70 to 90 beats·min -1 (SD ± 10) in all the groups at all stages. Although the increase in HR was statistically significant, the magnitude of change was clinically insignificant, barring perhaps one minute after intubation. Therefore, it seems that the conclusions drawn by the authors should be revised. The study does not demonstrate that a dose of 0.1 mg·kg -1 of landiolol produced any significant change in HR as compared with the control group. Perhaps the drug should be evaluated in combination with other anesthetic techniques. Although the authors suggest that studies should be performed in patients with heart disease to demonstrate beneficial effects of landiolol, most patients with coronary artery disease are usually receiving beta blockers preoperatively. Long acting drugs such as atenolol may confer an anti-ischemic benefit during the entire perioperative period 4 (up to one week after surgery) and not just following tracheal intubation. Thus, it seems that the utility of landiolol may be limited to those patients in whom the effect is required for brief periods without causing a decrease in arterial pressure. Rajiv Chawla
Background: Based on previous studies, vitamin D deficiency could lead to nerve stimulation. The purpose of the present study was to determine frequency and duration of seizures in children with idiopathic epilepsy in two groups; normal level of vitamin D versus decreased level of vitamin D. Methods: This pilot, comparative study was carried out in Zanjan University of Medical Sciences on total 40 children aging between 2 to 12 years old (23 male and 17 female) with the diagnosis of idiopathic epilepsy. All patients were receiving anti-epileptic drugs. The initial questionnaire was completed by each parent. Total 40 epileptic cases were examined in close follow-ups every three months, during total 9 months. Meanwhile, the frequency and duration of each seizure were recorded in questionnaire at every three-month period. Vitamin D blood samples were analyzed at the beginning of the study and after 9 months following the study. Serum levels of Vitamin D were analyzed by ELISA method (Elecsys2010, RocheCo, Germany; STAR FAX; 2100), simultaneously, Vitamin D level <30 ng/ml (nanogram per milliliter) was defined as Vitamin D deficiency. Cases were divided into two groups based on Vitamin D level. The frequency and duration of convulsions were compared in patients with normal level of vitamin D versus children with decreased level of vitamin D. Data were analyzed by Chi-square and t-test methods. Results: In all 40 patients, vitamin D level less than 30 ng/ml was detected in 32% (13 patients) at the beginning of study and 35% (14 patients) in 9 months later (13 patients were common between the two groups). There was no significant relationship between the frequency of seizures, the duration of seizures and vitamin D levels in patients. The relationship between positive family history of epilepsy and the number of seizures was reported significant. The frequency of vitamin D deficiency was higher in female cases in final evaluation. Conclusion: In the present study, a considerable correlation was detected between the frequency of seizures and positive history of seizure in the family. The frequency of vitamin D deficiency was higher in female cases in final analysis. No significant relationship was detected between the number of seizures, the mean duration of seizures and serum level of Vitamin D in children who received anticonvulsant drugs. However, vitamin D deficiency in patients was not overlooked in order to prevent known complications. We recommend a randomized clinical trial in the future with an adequate sample size. Moreover, a non-epileptic control group in study would be useful.
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