Emergency ERCP with or without endoscopic papillotomy is indicated in the treatment of patients with acute pancreatitis.

Purpose : Accurate lymph node (LN) status evaluation for intrahepatic cholangiocarcinoma (ICC) patients is essential for surgical planning. This study aimed to develop and validate a prediction model for preoperative LN status evaluation in ICC patients. Methods and Materials : A group of 106 ICC patients, who were diagnosed between April 2011 and February 2016, was used for prediction model training. Image features were extracted from T1-weighted contrast-enhanced MR images. A support vector machine (SVM) model was built by using the most LN status-related features, which were selected using the maximum relevance minimum redundancy (mRMR) algorithm. The mRMR method ranked each feature according to its relevance to the LN status and redundancy with other features. An SVM score was calculated for each patient to reflect the LN metastasis (LNM) probability from the SVM model. Finally, a combination nomogram was constructed by incorporating the SVM score and clinical features. An independent group of 42 patients who were diagnosed from March 2016 to November 2017 was used to validate the prediction models. The model performances were evaluated on discrimination, calibration, and clinical utility. Results : The SVM model was constructed based on five selected image features. Significant differences were found between patients with LNM and non-LNM in SVM scores in both groups (the training group: 0.5466 (interquartile range (IQR), 0.4059-0.6985) vs. 0.3226 (IQR, 0.0527-0.4659), P <0.0001; the validation group: 0.5831 (IQR, 0.3641-0.8162) vs. 0.3101 (IQR, 0.1029-0.4661), P =0.0015). The combination nomogram based on the SVM score, the CA 19-9 level, and the MR-reported LNM factor showed better discrimination in separating patients with LNM and non-LNM, comparing to the SVM model alone (AUC: the training group: 0.842 vs. 0.788; the validation group: 0.870 vs. 0.787). Favorable clinical utility was observed using the decision curve analysis for the nomogram. Conclusion : The nomogram, incorporating the SVM score, CA 19-9 level and the MR-reported LNM factor, provided an individualized LN status evaluation and helped clinicians guide the surgical decisions.

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An outbreak of 95 clinical infections with imipenem-resistant Acinetobacter baumannii in a Chinese hospital was investigated and the carbapenemase-encoding genes and their relationship with ISAba1 of these and a further 16 isolates recovered from the intensive care unit (ICU) environment were analysed. Almost all isolates were resistant to a wide range of antimicrobials; the lowest resistance rates were found for polymyxin E (17.1 %), cefoperazone/sulbactam (30.6 %) and ampicillin/sulbactam (67.6 %). Six pattern types defined by DNA macrorestriction patterns were distinguished among the clinical isolates with dissemination of pattern A (50 isolates) to patients in seven hospital units and pattern B (35 isolates) to eight units; the environmental isolates from ICUs were also of pattern A. All isolates were positive for the bla OXA-66 and bla OXA-23 genes. The OXA-23-encoding gene was located 34 bp downstream of ISAba1. No plasmids were detected and conjugal transfer of resistance was not demonstrated. The bla OXA-23 probe hybridized with 200 and 220 kb ApaI chromosomal fragments for type patterns A and B, respectively. INTRODUCTIONAcinetobacter baumannii is an increasingly important nosocomial pathogen (Bergogne-Bérézin & Towner, 1996), causing a wide range of infections, some serious, in patients in intensive care units (ICUs) (Chastre & Trouillet, 2000). The species can survive for long periods in the hospital environment and is a frequent cause of outbreaks of nosocomial infection, which are often difficult to control (Towner, 2000). Effective treatment is compromised by the high level of resistance to antimicrobials exhibited by hospital strains. Indeed, the emergence of carbapenem resistance in A. baumannii has become of global concern, as these b-lactams are often the only active agents against many multiresistant strains ( Over a 17-month period, we observed the dissemination of imipenem-resistant A. baumannii isolates in clinical infections in several units of a university hospital in China. We describe here the molecular epidemiology of the isolates and the identification of the genes encoding resistance to carbapenems. METHODSBacterial isolates. Ninety-five non-repetitive imipenem-resistant isolates of A. baumannii were recovered from clinical infections in hospitalized patients from August 2003 to December 2004 in the First Affiliated Hospital, College of Medicine, Zhejiang University, China. The patients were distributed among ten clinical units, with the majority in the transplant unit (35.6 %) and ICU (18.9 %) ( Table 1). An additional 16 A. baumannii isolates were recovered from the environment of the ICU (bed sheets, desks, floors, computer keyboards and mouse, and healthcare workers' hands) in December 2004. All isolates were assigned to the Acinetobacter calcoaceticus-A. baumannii complex using a Vitek GNI + card (bioMérieux) and species identification was confirmed by sequence analysis of the 16S-23S rRNA gene intergenic spacer region (Chang et al., 2005).Abbreviation: ICU, intensive care unit...

Rationale:Anatomical variations of the celiac trunk and the hepatic artery are of considerable importance in hepatopancreatobiliary surgery, liver transplants, and radiological abdominal interventions.Patient concerns:Here, we report a 57-year-old man with 2 weeks of painless progressive jaundice. Preoperative imaging and cytology brush results suggested an ampullary tumor and common hepatic artery anomaly (CTA) was reported. The patient underwent pancreaticoduodenectomy (PD). Intraoperatively, the CHA and gastroduodenal artery (GDA) were abnormal. The CHA emerged from the superior mesenteric artery (SMA). Computer tomography angiography (CTA) was performed postoperatively; surprisingly, the left gastric artery (LGA) and splenic artery (SA) arising from the anterior wall of the abdominal aorta replaced the normal structure of the celiac trunk, and an accessory left hepatic artery (LHA) emerged from the LGA.Diagnoses:The patient was diagnosed with cholangiocarcinoma and accompanying extremely rare variation of celiac trunk and hepatic artery.Interventions and outcomes:The patient underwent PD and had an uneventful postoperative evolution. There was no recurrence of the tumor and with normal liver function during the 10-month follow-up.Interventions:The patient underwent PD and had an uneventful postoperative evolution.Outcomes:There was no recurrence of the tumor and with normal liver function during the 10-month follow-up.Lessons:Surgeons must keep in mind that arterial variation may be present in the vascular structures intraoperatively, even if it was not revealed in preoperative imaging. The preoperative identification of arterial variation and its relationship with the tumor is necessary to avoid intraoperative vascular injury and complications after surgery.

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