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Biomedical subjects

D E Morgan

Publications and source records attributed to D E Morgan.

At least 19 recordsLinked to original sources

Advantages of in situ hybridisation over direct or indirect in situ reverse transcriptase-polymerase chain reaction for localisation of galanin mRNA expression in rat small intestine and pituitary.

In situ hybridisation (ISH) and direct or indirect in situ reverse transcriptase-polymerase chain reaction (RT-PCR) were used to detect galanin mRNA in paraffin sections of rat intestine and pituitary. With conventional ISH, a subset of intestinal neuronal ganglion cells and anterior pituitary endocrine cells were labelled. Direct in situ RT-PCR also labelled some cells in pituitary but not in intestine. Negative controls were unlabelled, but sections with 3' primer alone for RT-PCR appeared positive. No signal was apparent using the indirect in situ RT-PCR method. Investigation of the specificity of solution phase RT-PCR using RNA extracts from pituitary or intestine revealed that additional PCR products were detected under some conditions. The sequences of these PCR products suggested that one was the result of mispriming and single primer PCR, which could also have occurred in situ. Alternative galanin primers gave only the predicted RT-PCR product in solution phase yet still gave artefacts in tissue sections using direct in situ RT-PCR. ISH with probes transcribed from the correct PCR product gave identical labelling to the original galanin riboprobe. In conclusion, direct in situ RT-PCR is unreliable and requires validation, while indirect in situ RT-PCR may fail even though sufficient target exists for detection with conventional sensitive riboprobe ISH.

Animals↗

Placement of PEG tubes through previously placed self-expanding esophageal metal stents.

BACKGROUND: Self-expanding metal stents are frequently used to palliate patients with malignant dysphagia and close tracheoesophageal fistulae. Despite proper stent positioning and deployment, in a subset of patients there is no improvement in dysphagia, closure of tracheoesophageal fistulae, or resolution of anorexia. Such patients may require a PEG tube. It has been suggested that PEG placement through a preexisting esophageal stent is problematic because of the risks of gastrostomy tube impaction within the stent and resultant stent migration. METHODS: Case records were retrospectively reviewed of 9 consecutive patients with indwelling esophageal self-expanding metal stents undergoing attempted PEG. OBSERVATIONS: PEG tube placement was successful in all patients. In 1 patient, the stent migrated distally into the stomach during PEG placement. This was managed endoscopically without further complication. CONCLUSIONS: PEG placement in patients with previously placed esophageal self-expanding metal stents is a relatively safe and feasible procedure, although stent migration may occur.

Aged↗

Role of ERCP in asymptomatic orthotopic liver transplant patients with abnormal liver enzymes.

OBJECTIVE: The safety and efficacy of endoscopic retrograde cholangiopancreatography (ERCP) in the evaluation and management of biliary tract complications after orthotopic liver transplantation (OLT) have been previously demonstrated. However, the role of ERCP in evaluating asymptomatic OLT patients with abnormal liver enzymes with a previously normal biliary tree remains poorly defined. We sought to assess the utility of ERCP in this subset of patients. METHODS: A retrospective analysis of-asymptomatic OLT patients with abnormal liver enzymes evaluated by ERCP was undertaken. In addition to ERCP, all these patients had a diagnostic abdominal Doppler ultrasound, and a percutaneous liver biopsy. All patients had choledochocholedochostomy at the time of transplant and normal T-tube cholangiograms 3 months postoperatively. A radiologist, blinded to clinical findings, interpreted the ultrasound as normal, biliary dilation, or vascular abnormalities. The same radiologist interpreted ERCP findings. A pathologist, blinded to clinical findings, graded liver biopsies as normal, diagnostic, or abnormal but nondiagnostic. RESULTS: Twenty-two patients underwent 23 ERCPs. Twenty-two of the 23 ERCPs were normal (96%), and one abnormal ERCP finding did not explain the liver enzyme abnormality. Liver biopsy was diagnostic in 13 of 22 (57%) and in each case the ERCP was normal. The remaining 10 liver biopsies were abnormal but nondiagnostic. Ultrasound was abnormal in five of 22 cases, but in the three cases suggesting biliary dilation, the ERCP was interpreted as normal. CONCLUSION: Routine use of ERCP in evaluation of asymptomatic OLT patients with liver function test abnormalities and normal cholangiograms at 3 months was not diagnostically useful. In this subset of patients, liver biopsy was usually abnormal and frequently diagnostic and should be the initial invasive diagnostic procedure.

Adult↗

CT cystography: radiographic and clinical predictors of bladder rupture.

OBJECTIVE: Our goal was to identify radiographic and clinical variables that correlate with bladder rupture that may then be used as selection criteria for CT cystography in trauma patients. SUBJECTS AND METHODS: Hemodynamically stable trauma patients with hematuria were examined under standardized protocol with dynamic oral and i.v. contrast-enhanced CT of the abdomen and pelvis, followed immediately by CT cystography. CT cystography consisted of contiguous 5-mm axial scans of the pelvis after retrograde distention of bladder with 300-400 ml of 4% iodinated contrast material. Radiographic and clinical variables (pelvic fracture, pelvic fluid, intraabdominal visceral injury, degree of hematuria, hematocrit, units of blood transfused, base deficit, injury mechanism, seat belt use, sex, age) were assessed and statistically analyzed using the two-tailed Fisher's exact test and Wilcoxon's rank sum test. Positive and negative individual and multivariate predictors were analyzed. RESULTS: Of the 157 patients entered in our study, 12 (eight males and four females) had bladder rupture. One or more pelvic fractures were present in nine (75%) of the 12 patients (p < 0.001). Pubic symphysis diastasis, sacroiliac diastasis, and sacral, iliac, and pubic rami fractures were statistically associated with bladder rupture. Isolated acetabular fractures did not correlate with rupture. Eight (67%) of the 12 patients with bladder rupture revealed on CT cystography had gross hematuria (p < 0.001). No ruptures were seen in patients with <25 RBC/HPF (red blood cells per high-power field). All patients with rupture had pelvic fluid revealed on standard contrast-enhanced CT (p < 0.001). CONCLUSION: Gross hematuria, pelvic fluid, and specific pelvic fractures were highly correlated with bladder rupture; identification of these findings may help in selection of trauma patients for CT cystography.

Adolescent↗

Stenotrophomonas (Xanthomonas) maltophilia infection in necrotizing pancreatitis.

CONCLUSION: Although the therapy of infected pancreatic collections or organized pancreatic necrosis remains surgical, we have demonstrated that infected organized pancreatic necrosis can be treated endoscopically. BACKGROUND: Stenotrophomonas (Xanthomonas) maltophilia has been increasingly recognized as a nosocomial pathogen associated with meningitis, pneumonia, conjunctivitis, soft tissue infections, endocarditis, and urinary tract infections. This organism is consistently resistant to imipenem, a drug commonly employed in patients with necrotizing pancreatitis to prevent local and systemic infections. METHODS AND RESULTS: We report the first case of infected pancreatic necrosis by S. (X.) maltophilia. Our patient was treated successfully with endoscopic drainage of the pancreatic fluid collection and appropriate antibiogram-based antibiotic therapy. Endoscopic drainage has emerged as one of the treatment modalities for pancreatic fluid collections.

Bacterial Infections↗

Comparison of two barium suspensions for dedicated small-bowel series.

OBJECTIVE: The in vivo radiographic features of two commercially available formulations of barium used as contrast media in dedicated small-bowel series were compared. SUBJECTS AND METHODS: Fifty-six consecutive outpatients referred for a dedicated small-bowel series were randomly administered either E-Z-Paque or Entrobar. Representative survey radiographs from each examination were randomized and reviewed by six gastrointestinal radiologists from three institutions. Each observer assigned a numeric score (1 = poor, 2 = fair, 3 = good, and 4 = excellent) that rated the quality of the radiograph with respect to these characteristics: definition of fold pattern, translucency, distention, and integrity of the barium column. Statistical analysis was performed for each characteristic using Wilcoxon's two-sample rank sum test. RESULTS: All six observers found a statistically significant difference between the two barium formulations for mean scores for definition of fold pattern and translucency. Mean scores for fold pattern were 3.3, 3.0, 3.2, 3.6, 3.3, and 3.4 for Entrobar and 2.1, 2.3, 2.4, 3.2, 2.6, and 2.7 for E-Z-Paque. Mean scores for translucency were 2.5, 2.7, 2.8, 3.1, 2.7, and 3.3 for Entrobar and 1.6, 1.7, 2.1, 2.3, 1.9, and 2.7 for E-Z-Paque. No statistically significant difference was found for mean score for distention or integrity of the barium column. CONCLUSION: On radiographs, Entrobar was found to have superior characteristics for visualization of fold pattern and translucency but offered no advantages for distention or integrity of the barium column. Improved translucency and definition of fold pattern may translate into improved sensitivity and confidence in diagnosing small-bowel abnormality.

Barium Sulfate↗

Pancreas divisum: implications for diagnostic and therapeutic pancreatography.

OBJECTIVE: The purpose of our study was to determine the prevalence, distribution, and clinical significance of pancreatic ductal changes due to pancreatitis on ERCP in patients with pancreas divisum. MATERIALS AND METHODS: From January 1993 through December 1997, 1714 patients underwent 2469 ERCP studies. Ninety-four patients (5.5%) had pancreas divisum. Retrospective review of the spot radiographs was performed to establish the presence and location of pancreatitis. Clinical indications for and therapy during ERCP were correlated with radiographic findings. RESULTS: Of the 94 patients with pancreas divisum, 54 (57%) had radiographic evidence of pancreatitis. Of these 54 patients, 44 had at least one episode of clinically documented pancreatitis, seven had recurrent abdominal pain, and three underwent ERCP for biliary indications. In 76% of the 54 patients with radiographic evidence of pancreatitis, only the dorsal system showed irreversible inflammatory change (p < .0001). Acute recurrent pancreatitis was the most common indication for ERCP in divisum patients and was statistically more common than in pancreatitis patients with normal anatomy (p < .0001). Sixty-two (66%) of the 94 patients with pancreas divisum underwent endoscopic pancreatic intervention, most commonly minor papilla sphincterotomy or stenting or both. Eleven patients with clinically documented pancreatitis had no abnormalities revealed by ERCP. CONCLUSION: In our population of patients referred for ERCP and found to have pancreas divisum, the prevalence of pancreatitis was very high and usually was limited to a dorsal distribution.

Acute Disease↗

Transmural drainage of pancreatic fluid collections without electrocautery using the Seldinger technique.

BACKGROUND: Complications of endoscopic transmural drainage of pancreatic fluid collections arise from entry through the gastrointestinal wall. We describe transmural drainage of these collections using the Seldinger technique without electrocautery. METHODS: From January 1995 to September 1997, we attempted endoscopic transmural drainage of 94 consecutive pancreatic fluid collections without EUS guidance (needle-knife entry in 51, Seldinger entry technique in 43). Success of entry and complications were compared. RESULTS: Successful entry was achieved in 95.3% using the Seldinger technique and 92.1% using the needle-knife entry technique (p = NS). Complications of bleeding and perforation were seen in 4.6% of patients in the Seldinger group and 15.7% in the needle-knife entry group. CONCLUSIONS: The Seldinger technique of endoscopic transmural drainage of pancreatic fluid collections appears effective and safer than entry using the needle-knife. Collections as small as 3 cm in diameter can be entered using the Seldinger technique without EUS guidance.

Chi-Square Distribution↗

Hysterosalpingography with videofluoroscopy: effect on radiologic practice in an academic medical center.

RATIONALE AND OBJECTIVES: The authors attempted to determine whether videotaping the fluoroscopic portion of hysterosalpingography would result in changed diagnoses or an increase in diagnostic confidence. MATERIALS AND METHODS: Ninety-nine consecutive outpatients underwent routine hysterosalpingography. The fluoroscopic portion of the examination was captured on videotape. Two consecutive interpretations of each hysterosalpingogram were made by attending radiologists. First, spot radiographs were interpreted alone. Second, these images were viewed along with videofluoroscopy. Concordance of and confidence in findings for the two interpretations were assessed with the two-tailed Fisher exact test. RESULTS: Interpretations of spot radiographs alone and with videofluoroscopy were in agreement in 92 of 99 uterine examinations and 164 of 198 tubal examinations. For uterine examinations classified as normal, interpretations of spot radiographs and videofluoroscopy were in agreement in 56 of 57 cases; there was no change in confidence with review of videofluoroscopic images. For uterine examinations interpreted as abnormal, agreement was noted in 36 of 42 cases (P = .04), and confidence increased with videofluoroscopy in 10 of 42 cases (P = .00001). With normal tubal findings, interpretations agreed in 94 of 118 cases, and confidence increased in 56 of 118 cases (P = .002). With abnormal tubal findings, interpretations agreed in 70 of 80 cases, and confidence increased in 20 of 80 cases (P = .002). When findings with and without videofluoroscopy were discordant, confidence was always higher after review of video-fluoroscopic images. CONCLUSION: Review of videofluoroscopic images obtained during hysterosalpingography increases the accuracy and confidence of diagnoses compared with review of spot radiographs alone.

Academic Medical Centers↗

Palliation of malignant gastric and small intestinal strictures with self-expandable metal stents.

BACKGROUND: Malignant gastrointestinal obstruction is a common preterminal event that is often treated surgically. The use of self-expandable stents to treat malignant gastric and small intestinal strictures is limited. We evaluated the feasibility, effectiveness, safety and outcome of self-expandable metal stents in providing palliative care for patients with inoperable malignant strictures of the stomach and small intestine. METHODS: Eleven consecutive patients with complete or near complete gastric or small intestinal obstruction were treated palliatively with self-expandable metal stents. Contrast radiographs were taken before and after insertion in all patients to confirm patency. Nineteen stents were placed using biliary guidewires and catheters under endoscopic and fluoroscopic guidance. Diets were modified as needed. Success was defined both technically and clinically. RESULTS: Technical and clinical success with improvement in the patient's oral diet was achieved in ten patients (91%). The one failure was caused by severe anastomotic angulation and distal luminal obstruction. During the follow-up of 5 to 294 days (mean 77 days) there were no major complications except that the stents occluded in four patients. CONCLUSION: Palliation of malignant gastric and small intestinal strictures with self-expandable metal stents is a feasible, effective, and safe alternative to operation.

Aged↗

Hemodialysis access graft stenosis: US detection.

PURPOSE: To prospectively evaluate the sensitivity of ultrasonography (US) in diagnosing stenosis of hemodialysis access grafts and their drainage veins in patients clinically suspected of having graft dysfunction. MATERIALS AND METHODS: Thirty-eight patients in whom dysfunction of their hemodialysis access grafts was suspected underwent both Doppler US and angiography. Gray-scale and color US were combined with spectral analysis of the graft, anastomoses, and venous outflow. Flow velocity at anastomoses and suspected stenotic areas was measured. The volume of flow in the graft was also measured. The prospective US criterion for diagnosis of stenosis was a focal twofold or higher elevation of peak systolic velocity (PSV) compared with the PSV immediately upstream. A blinded angiographic evaluation of the graft and drainage veins followed US. Angiographic diagnosis of stenosis required at least 50% narrowing in luminal diameter. US and angiographic results were then compared. RESULTS: Angiography allowed diagnosis of 43 stenoses in 34 patients. US depicted 92% (37 of 40) of these stenoses, with a 94% positive predictive value for any individual patient. Focal 2- to 2.9-times PSV elevation was associated with 75% or greater stenosis. Graft flow volume and resistive index change did not correlate with stenosis. CONCLUSION: US reliably depicts stenoses of hemodialysis access grafts and drainage veins in a clinically selected population when PSV criteria are used.

Adult↗