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Biomedical subjects

P S Jowell

Publications and source records attributed to P S Jowell.

At least 19 recordsLinked to original sources
PubMed1999

Endoscopic nasobiliary drain placement facilitates subsequent percutaneous transhepatic cholangiography.

BACKGROUND: Percutaneous biliary drainage is an established alternative to ERCP for managing bile duct obstruction. Although generally safe and effective, percutaneous drainage has its risks and is technically more difficult in patients with nondilated bile ducts. We report the use of nasobiliary drains and subsequent nasobiliary drain cholangiography to facilitate percutaneous biliary drainage by providing a target for accessing intrahepatic bile ducts. METHODS/RESULTS: Nine patients who were identified as requiring percutaneous biliary drainage underwent nasobiliary tube placement at completion of ERCP. Five of 9 patients had generalized intrahepatic ductal dilatation; in 4 patients, dilatation was focal or absent. Following nasobiliary drain cholangiography, percutaneous needle puncture of a bile duct was successful in all patients, in most cases with only a single puncture of the liver capsule. No procedural complications were encountered. CONCLUSION: Nasobiliary drain placement with subsequent nasobiliary drain cholangiography facilitates percutaneous biliary drainage and may be especially helpful in patients with nondilated intrahepatic bile ducts.

Catheterization↗
PubMed1998

Relation between mutations of the cystic fibrosis gene and idiopathic pancreatitis.

BACKGROUND: It is unknown whether genetic factors predispose patients to idiopathic pancreatitis. In patients with cystic fibrosis, mutations of the cystic fibrosis transmembrane conductance regulator (CFTR) gene typically cause pulmonary and pancreatic insufficiency while rarely causing pancreatitis. We examined whether idiopathic pancreatitis is associated with CFTR mutations in persons who do not have lung disease of cystic fibrosis. METHODS: We studied 27 patients (mean age at diagnosis, 36 years), 22 of whom were female, who had been referred for an evaluation of idiopathic pancreatitis. DNA was tested for 17 CFTR mutations and for the 5T allele in intron 8 of the CFTR gene. The 5T allele reduces the level of functional CFTR and is associated with an inherited form of infertility in males. Patients with two abnormal CFTR alleles were further evaluated for unrecognized cystic fibrosis-related lung disease, and both base-line and CFTR-mediated ion transport were measured in the nasal mucosa. RESULTS: Ten patients with idiopathic chronic pancreatitis (37 percent) had at least one abnormal CFTR allele. Eight CFTR mutations were detected (prevalence ratio, 11:1; 95 percent confidence interval, 5 to 23; P<0.001). In three patients both alleles were affected (prevalence ratio, 80:1; 95 percent confidence interval, 17 to 379; P<0.001). These three patients did not have lung disease typical of cystic fibrosis on the basis of sweat testing, spirometry, or base-line nasal potential-difference measurements. Nonetheless, each had abnormal nasal cyclic AMP-mediated chloride transport. CONCLUSION: In a group of patients referred for evaluation of idiopathic pancreatitis, there was a strong association between mutations in the CFTR gene and pancreatitis. The abnormal CFTR genotypes in these patients with pancreatitis resemble those associated with male infertility.

Adolescent↗
PubMed1998

Endoscopic sphincterotomy for stones by experts is safe, even in younger patients with normal ducts.

OBJECTIVE: To provide current information on the risks of endoscopic sphincterotomy for stone. SUMMARY BACKGROUND DATA: In recent years (since the popularity of laparoscopic cholecystectomy), endoscopic sphincterotomy has been used increasingly for the management of bile duct stones in relatively young and healthy patients. The validity of this trend has been questioned using data on short-term complications derived from earlier decades that involved more elderly and high-risk patients. METHODS: Seven academic centers collected data prospectively using a common database. Complications within 30 days of the procedures were documented by standard criteria. RESULTS: Of 1921 patients, 112 (5.8%) developed complications; two thirds of these events were graded as mild (<3 days in hospital). There was no evidence of increased risk in younger patients or in those with smaller bile ducts. There was only one severe complication and there were no fatalities in 238 patients age <60, with bile duct diameters of <9 mm. CONCLUSION: Sphincterotomy for stones can be performed very safely by experienced endoscopists.

Age Factors↗
PubMed1996

Quantitative assessment of procedural competence. A prospective study of training in endoscopic retrograde cholangiopancreatography.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a technically demanding procedure that can cause substantial complications. Competence in performing ERCP and the learning curve for achieving competence are poorly understood. OBJECTIVE: To evaluate the number of supervised ERCPs that physicians must do to achieve procedural competence. Competence was defined as a 0.8 probability of successfully completing specific technical components of ERCP and an overall grading of competence as judged by the attending physician. DESIGN: Prospective study. SETTING: University training program for gastroenterologists. PARTICIPANTS: 17 gastroenterology fellows at various stages of training. MEASURES: Experienced therapeutic endoscopists prospectively graded gastroenterology fellows during 1796 consecutive ERCPs. Fellows were graded on their overall level of competence for the procedure and on specific technical components of ERCP. RESULTS: Grading data were available for 1450 ERCPs (81%). The number of ERCPs done before adequate skill was achieved was 160 for cholangiography, 140 for pancreatography, 160 for deep cannulation of the pancreatic duct, 120 for stone extraction, and 60 for stent insertion. Fellows achieved overall competence after completing 180 to 200 ERCPs. The predicted probability of overall competence was 0.8 after 137 ERCPs and 0.9 after 185 ERCPs. CONCLUSIONS: At least 180 ERCPs were required before these gastroenterology fellows could be considered competent in ERCP. This number is much greater than that previously recommended, and these findings have substantial implications for training guidelines and issues of competence and certification in ERCP. The methods used to define and evaluate competence in ERCP could also be used to assess competence in other medical procedures.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1996

Patient-controlled analgesia for conscious sedation during endoscopic retrograde cholangiopancreatography: a randomized controlled trial.

BACKGROUND: Adequate comfort is essential to patients undergoing invasive procedures. This study was designed to evaluate whether patient-controlled analgesia could improve sedation for ERCP. METHODS: Patients were randomized to receive standard sedation (n = 31) or patient-controlled analgesia (n = 31). The patients were blinded to the randomization. After the procedure the patient, physician, and nurse each rated their satisfaction with sedation using a verbal rating scale. RESULTS: There was no significant difference between the patient's mean satisfaction score for the conventional and patient-controlled analgesia groups (9.3 and 9.6, respectively, p = 0.5). The physicians rated sedation higher in the conventional group compared with the patient-controlled analgesia group (8.6 and 8.2, respectively, p = 0.02). Physicians and nurses' scores correlated (r = 0.53, p = 0.0001), but there was no correlation between scores reported by either physicians or nurses and the patients' scores (r = 0.2 and r = 0.05, respectively). Oxygen saturation less than 90% occurred for more than 1 minute in three patients who received standard sedation but in none who used patient-controlled analgesia. CONCLUSION: This trial demonstrates that patient-controlled analgesia during ERCP is as effective as standard sedation with respect to patient satisfaction. Physicians and nurses, however, are not good proxies for assessing patient satisfaction.

Adolescent↗
PubMed1995

Novel methods for endoscopic training.

The development of past, present, and future endoscopic training methods is described. A historical perspective of endoscopy training guidelines and devices is used to demonstrate support for the use of novel endoscopic training techniques. Computer simulation of endoscopy, interactive learning, and virtual reality applications in endoscopy and surgery are reviewed. The goals of endoscopic simulation and challenges facing investigators in this field are discussed, with an emphasis on current and future research.

Computer Simulation↗
PubMed1995

Assessment of pancreatic duct strictures.

It should be fairly clear that the evaluation of pancreatic duct strictures is complex. Short of surgical resection, there is no gold standard that will provide an etiological diagnosis unless cancer is found on a biopsy specimen. To complicate matters further, much of the literature was generated in reference to differentiating between pancreatic cancer and pancreatitis. Using the same data to evaluate the patient with a pancreatic duct stricture may not be appropriate because the clinical scenario may not be comparable. Bearing these shortcomings in mind, however, a thoughtful history combined with the judicious use of abdominal imaging, ERCP, and the biopsy techniques discussed will lead to a clinical diagnosis that usually will prove to be correct in most cases. The role of tumor markers in patients with pancreatic duct strictures is still being defined. Although no tumor marker has proved especially helpful so far, the potential exists that a more useful one is just over the horizon. In situations in which the diagnosis remains uncertain, exploratory laparotomy in an appropriate surgical candidate by an experienced pancreatic surgeon will provide a definitive diagnosis in almost all cases.

Biomarkers, Tumor↗
PubMed1994

Non-operative management of a common bile duct injury sustained during cholecystectomy in a morbidly obese patient. (Non-operative repair of CBD injury).

A 29 year old morbidly obese patient suffered injury to his common bile duct during cholecystectomy. Subsequent access to the biliary tree was obtained by using a long heavy gauge needle after first opacifying the system with contrast injection through a nasobiliary tube. It is now twenty six months after initial percutaneous biliary drainage placement and eighteen months after removal of all biliary access. The patient is asymptomatic and has normal liver function tests. This technique can be useful in morbidly obese patients who are at increased risk from surgical repair of biliary duct injuries.

Adult↗
PubMed1988

Alteration in osteoblast activity and nutritional vitamin-D deficiency in non-hypercalcemic malignancy.

The biochemical parameters of bone mineral metabolism in patients with nonhypercalcemic malignancy have not been extensively investigated. Therefore, a group of 29 such patients with different types of malignancy was studied. Ten patients received corticosteroids. In the entire group, serum ionized calcium (Ca2+), bone gla protein (BGP), 25-hydroxyvitamin D (25OHD), and 1,25-dihydroxyvitamin D (1,25(OH)2D) were all lower than in age-matched controls, and carboxy-terminal parathyroid hormone (CPTH) was higher. Although both corticosteroid- and noncorticosteroid-treated patients had decreased BGP values, the corticosteroid-treated patients had lower BGP levels than those not on steroids (4.24 +/- 0.70 SE vs. 11.50 +/- 2.20 ng/ml; P less than 0.005). Patients on corticosteroids had lower 1,25(OH)2D values than controls (18.81 +/- 2.71 vs. 27.83 +/- 1.17 pg/ml; P less than 0.01), whereas those not on corticosteroids had normal 1,25(OH)2D values. These results suggest that patients with nonhypercalcemic malignancy have nutritional vitamin-D deficiency and secondary hyperparathyroidism with perhaps corticosteroid-induced suppression of serum 1,25(OH)2D and BGP. The decreased levels of serum BGP in the nonsteroid-treated patients suggest, in addition, a defect in osteoblast function.

Aged↗
PubMed1988

The effect of chronic caffeine administration on serum markers of bone mineral metabolism and bone histomorphometry in the rat.

Caffeine has been cited as a risk factor for osteoporosis in humans. In rats, caffeine increases calcium absorption and excretion and raises parathyroid hormone (iPTH) levels. This study investigated the effect of chronic caffeine administration on bone histomorphometry and serum markers of bone mineral metabolism. Twenty-seven male Sprague Dawley rats weighing approximately 300 g were divided into three groups: Group A (n = 8) served as controls, Group B (n = 9) received 2.5 mg/100 g caffeine in their drinking water, and Group C (n = 10) received 10 mg/100 g body weight caffeine in their drinking water. Animals were bled serially for the 8 week study period: Ionized calcium was measured from tail vein blood and serum iPTH and osteocalcin (BGP) from orbital sinus blood. All three groups received two doses of tetracycline for bone histomorphometry which was performed on a right tibial section from each animal. Ionized calcium was not different among the three groups at any time point. No alteration in serum iPTH levels was demonstrated except for day 56 when the high-dose group (C) showed a raised level (mean = 59.1, SE = +/- 8.9 pg/ml (P less than 0.05). By week 8 Group C showed a failure to gain weight compared with Group A. Group C mean weight = 384.0 +/- 6.6 g, Group A 427.4 +/- 10.8 g (P less than 0.005). Serum BGP was significantly increased in Group C compared with control (P less than 0.001). No differences in bone histomorphometry were observed among the three groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Administration, Oral↗
PubMed1987

1,25-Dihydroxyvitamin D3 modulates glucocorticoid-induced alteration in serum bone Gla protein and bone histomorphometry.

Glucocorticoid excess is associated with alterations in the vitamin D endocrine system. The aim of this study was to assess change in serum bone Gla protein (BGP) after low and high dose cortisone acetate treatment and to assess whether these alterations are altered or attenuated by 1,25-dihydroxyvitamin D3 [1,25-(OH)2D3] administration. Five groups of rats were studied and compared to a control group [cortisone acetate in doses of 0.2, 3.3, and 5.0 mg/100 g BW; 1,25-(OH)2D3 in a dose of 100 ng/100 g BW; and a combination of 1,25-(OH)2D3 (100 ng/100 g BW) plus cortisone acetate (3.3 mg/100 g BW)]. Each animal received daily sc injections for 27 days. BGP decreased significantly by day 7 in the two groups receiving high doses of cortisone acetate compared to control group values (65.20 +/- 4.38 vs. 150.18 +/- 6.13 ng/ml in the intermediate dose group and 91.57 +/- 5.30 vs. 150.18 +/- 6.13 ng/ml in the high dose group; P less than 0.01); this effect persisted until day 28. Histomorphometry revealed decreased formation and resorption in the two high dose cortisone acetate groups, whereas low dose cortisone acetate produced no histological change. The combination therapy lessens any change in BGP until day 28 when BGP was lower than the control value (P less than 0.01); histomorphometry showed that combination therapy prevents the effect of cortisone acetate by increasing bone formation and resorption. The data demonstrate that high doses of cortisone acetate suppress bone formation and that this is reflected in the low serum BGP values. Thus, BGP may be a marker of glucocorticoid-induced bone disease. 1,25-(OH)2D3 protects against glucocorticoid-induced bone disease and the normal BGP level reflects this.

Animals↗