Abstract: On the 30th of April 1943 the waterlogged body of Major William Martin of the Royal Marines drifted toward the shores of the Spanish Atlantic-coast city of Huelva after having been floated from a British submarine. A train of events was set into motion, which helped to change the course of the war. Major Martin, although dead, played a key role in the allied deception operation code-named Mincemeat. Operation Mincemeat has been the subject of several books and a motion picture. The crucial postmortem examination of Major Martin conducted by the Spanish authorities has received surprisingly little attention in the general intelligence literature and details of the medical aspects have to our knowledge never been examined. This article is, in a manner of speaking, a postmortem itself. The events happened 65 years ago and although new material is presented, the interpretation of its significance in the context of the known facts may convince some readers but not others. Nevertheless, we hope that this literary postmortem will fascinate intelligence and medical professionals alike and contribute to the medical and intelligence history of World War II.

Abstract: Endoscopic and endobronchial ultrasound are complementary techniques. When combined, they allow for nearly complete mediastinal staging in lung cancer. Each technique has inherent strengths and weaknesses, but when used simultaneously they become far more powerful, to the extent that mediastinoscopy -a more expensive and invasive procedure- is expected to decline in use as the application of endoscopic and endobronchial ultrasound becomes more widespread. The incorporation of these ultrasound techniques has been shown to lead to fewer thoracotomies, benefiting patients and also society, given that costs are thereby reduced. We reflect on recent developments in the field, discuss current debates, and propose a view of what the future holds in store.

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Abstract: We describe a 64-year-old man with squamous cell carcinoma of the esophagus who presented with an obstruction of the esophagus following radiation therapy and chemotherapy. Initial upper gastrointestinal barium swallow studies showed a complete stoppage of the barium column, not unlike that of a congenital esophageal atresia. Therapeutic endoscopy was performed using a two-endoscope, two-operator system that reestablished patency of the esophagus. Repeated endoscopy was then used to continue esophageal dilation with eventual placement of a permanent stent. A video and a comprehensive review of the literature regarding combined antegrade-retrograde dilation techniques used to date are also provided.

Abstract: This is the first known report of a primary pancreatic lymphoma (PPL) coexisting with chronic lymphocytic leukemia (CLL). PPL is a rare tumor and accounts for less than 0.7% of all pancreatic malignancies.1 Diagnostic criteria include the following: mass predominantly in the pancreas with nodal involvement confined to the peripancreatic region, no palpable superficial lymphadenopathy, no hepatic or splenic involvement, no mediastinal nodal enlargement on chest radiograph, and normal white cell count. Symptoms of these malignancies can mimic pancreatic adenocarcinoma;however, treatment of PPL responds well to chemotherapy and may not require surgical resection. Therefore, it is importantto differentiate between the two. Histologic evidence is still required to confirm the diagnosis. EUS has proved to be a valuable tool in identifying and staging pancreatic tumors. EUS has been found to be more accurate than CT in local staging, identifies tumors that were missed on CT, and allows real-time guided biopsies.4 A search of the literature shows that there are only 3 prior publications with EUS images of pancreatic lymphoma.

Abstract: Chordomas are rare tumors which originate from the remnants of the notochord. These tumors are locally aggressive and have a predilection for the ends of the axial skeleton. An important prerequisite for optimal management of these tumors is a correct preoperative diagnosis. The present case is the first report of the use of endoscopic ultrasound to obtain transrectal fine needle aspiration biopsy of a presacral chordoma. A review of the prior computer tomography (CT) scans allowed us to calculate the tumor volume doubling time (18.3 mo). Transrectal biopsy of chordomas is controversial, however we believe that such concerns are not justified.

Abstract: Mediastinal ultrasound is currently being performed by a variety of different practioners but all need to be familiar with major pathology outside their narrow fields. We are reporting the first case where echocardiography led to the discovery of a mediastinal mass which upon endoscopic-ultrasound guided fine needle aspiration biopsy (EUS-FNA) was found to be a plasmacytoma. The differential diagnosis of mediastinal masses is briefly reviewed.

Abstract: Hemorrhoidal bleeding is common during pregnancy. Other preexisting anorectal conditions can also be exacerbated by the increased vascular volume and pelvic congestion. We present the case of a young woman who developed life-threatening rectal bleeding requiring early delivery. Through use of endorectal endoscopic ultrasonography (EUS), the condition was diagnosed as a diffuse cavernous rectal hemangioma. To our knowledge, this is the first report to present Doppler images of pulsatile flow through the cavernous hemangioma. The EUS findings are correlated with those of computed tomography (CT) and magnetic resonance imagining (MRI), and a brief discussion follows.

Abstract: Familial adenomatous polyposis is an archetypal disease illustrating the genetic basis of human cancer. The adenomatous polyposis coli gene functions as a tumor suppressor with hundreds of known mutations that result in a defective adenomatous polyposis coli protein. In addition to the certain fate of colon cancer without colectomy, patients with familial adenomatous polyposis are also at increased risk for other types of neoplasms, including those which affect the pancreas. This review focuses on periampullary and ampullary tumors, benign and malignant pancreatic neoplasms that are associated with familial adenomatous polyposis and Gardner syndrome and pancreatitis in these patients. An individualized surveillance regimen is suggested which for certain patients could include endoscopic ultrasound.

Abstract: CONTEXT: Cutaneous T-cell lymphomas such as mycosis fungoides are uncommon neoplasms with a long and often relatively indolent course. Some eventually metastasize to lymph nodes or visceral organs but there are to our knowledge only two prior reports which describe clinically relevant pancreas involvement. CASE REPORT: We present the case of a 52-year-old man with mycosis fungoides who developed abdominal pain and jaundice. Endoscopic ultrasound guided-fine needle aspiration biopsies of a peculiar infiltrative appearing mass in the head of the pancreas revealed T-cell lymphoma cells. CONCLUSION: There is an increased incidence of second primaries in cutaneous T-cell lymphomas and a biopsy diagnosis of new intra-abdominal masses is essential.

Abstract: This tutorial survey with images examines current and possible future applications of the recently introduced 360-degree Doppler capable echoendoscopes. The better gray-scale resolution together with flow, spectral and color Doppler can improve EUS investigations in the mediastinum, abdomen and pelvis. There is no or very little EUS literature covering such important fields a Budd-Chiari syndrome, anatomic variations of the celiac trunk and hepatic artery, mesenteric artery flow determinations in the evaluation of mesenteric ischemia and arterial compression syndromes (celiac, superior mesenteric artery and hepatic artery). Additional other areas of possible future research are suggested.

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Abstract: A 58-year-old woman from El Salvador had a change of bowel habits.A colonoscopy was performed, which showed a submucosal cystic-appearing lesion in the transverse colon. The lesion was later evaluated by endoscopic ultrasound (EUS), which showed the characteristic features of a cystic lymphangioma. In a recent review of colonic lymphangiomas,a total of 331 published reports were found.Reports that specifically address EUS imaging features are, however, scarce. In 2001, Irisawa and Bhutani reported a case using a throughthe-colonoscope EUS catheter. A MEDLINE and citation search revealed no other EUS focused reports regarding colonic lymphangiomas since.

Abstract: BACKGROUND: EUS-guided fine-needle aspiration is rapidly becoming the procedure of choice for the diagnostic evaluation of pancreatic masses. Acute pancreatitis has been reported after EUS-guided fine-needle aspiration of the pancreas. This study evaluated the effect of EUS-guided fine-needle aspiration on the pancreas by serial measurement of amylase and lipase levels and determining the frequency of acute pancreatitis after EUS-guided fine-needle aspiration of pancreatic masses. METHODS: In 100 consecutive patients referred for EUS-guided fine-needle aspiration of a pancreatic mass, amylase and lipase levels were determined immediately before and within 2 hours after the procedure. Additionally, patients were questioned as to the occurrence of symptoms of acute pancreatitis within 48 hours after EUS-guided fine-needle aspiration. RESULTS: For 2 of 100 patients (2%) there was clinical and biochemical evidence of acute pancreatitis after EUS-guided fine-needle aspiration. Both patients had a history of recent pancreatitis. In addition, there was a significant increase in postprocedure lipase levels (p = 0.40) compared with amylase levels in this patient subset. CONCLUSION: The frequency of acute pancreatitis after EUS-guided fine-needle aspiration of the pancreas was 2% in this study. A history of recent pancreatitis appears to be a potential risk factor. Amylase and lipase levels can be elevated after EUS-guided fine-needle aspiration and in most cases have no clinical significance.

Abstract: BACKGROUND: Endoscopic ultrasound (EUS)--guided fine-needle aspiration (FNA) is frequently performed for diagnostic evaluation of lesions in or near the gastrointestinal (GI) tract. Little data exist concerning possible infectious complications associated with EUS-guided FNA. This prospective evaluation was undertaken to determine the frequency of bacteremia and infectious complications associated with EUS-guided FNA. METHODS: All patients undergoing EUS-guided FNA for any indication were enrolled in this study. Patients who required antibiotic prophylaxis as per the American Heart Association or American Society for Gastrointestinal Endoscopy guidelines were excluded from the study as were patients with cystic lesions, patients with advanced liver disease/ascites and those with human immunodeficiency virus/acquired immune deficiency syndrome. Blood cultures were obtained 30 and 60 minutes after the EUS-FNA. Patients were monitored for evidence of infection after procedure including telephone follow-up of each subject 1 week after procedure. RESULTS: One hundred patients underwent EUS-FNA of 108 lesions. All blood cultures were negative except in 6 patients in whom 1 of 2 bottles were positive for coagulase negative Staphylococcus, which was considered a contaminant. There were no complications of acute febrile illness, abscess or other infections. CONCLUSION: EUS-guided FNA was not associated with bacteremia or infectious complications.

Abstract: BACKGROUND: In many institutions, computed tomography (CT)-guided percutaneous fine-needle aspiration (FNA) has become the procedure of choice for biopsies of pancreatic mass lesions. This method of biopsy and others, such as endoscopic retrograde cholangiopancreatography (ERCP) cytology, are problematic because of a substantial false-negative rate. OBJECTIVE: To investigate the yield of endoscopic ultrasonography-guided FNA biopsies in patients who had negative results on CT-guided biopsy or negative cytologic findings on ERCP sampling. DESIGN: Prospective cohort study. SETTING: Tertiary care university medical center. PATIENTS: 102 patients (median age, 65 years; 58 men and 44 women) with suspected pancreatic cancer who fulfilled the above criteria were prospectively identified and underwent endoscopic ultrasonography-guided FNA biopsy. MEASUREMENTS: The operating characteristics of endoscopic ultrasonography-guided FNA for diagnosing pancreatic masses were determined. Surgical pathology or long-term follow-up (median, 24 months) was used to identify false-positive or false-negative results. RESULTS: Median mass size was 3.5 cm x 2.7 cm. A median of 3.4 passes were performed. Cytologic results on endoscopic ultrasonography-guided FNA biopsy were positive in 57 patients, negative in 37, and inconclusive or nondiagnostic in 8. No false-positive results were observed. A diagnosis of pancreatic cancer was subsequently confirmed in 3 patients who had tested negative (false-negative results) and 1 of the 8 patients with nondiagnostic results. Of these 4 patients, 3 had cytologic evidence of chronic pancreatitis on endoscopic ultrasonography-guided FNA biopsy. The 95% CI for the likelihood ratio for a positive test result contained all values greater than or equal to 9.7. The likelihood ratio for a negative test result was 0.05 (CI, 0.02 to 0.15). The posterior probability of pancreatic cancer after a definitely positive result was at least 93.5% by a conservative lower 95% confidence limit; after a definitely negative test result, it was 6.9%. The prevalence of pancreatic cancer was 59.8% (61 of 102 patients). Self-limited complications occurred in 3 of the 102 patients (2.9% [CI, 0.6% to 8.4%]). CONCLUSION: Endoscopic ultrasonography-guided FNA biopsy may play a valuable role in the evaluation of a pancreatic mass when results on other biopsy methods are negative but pancreatic cancer is suspected.

Abstract: BACKGROUND: Procurement of cytologic samples by brushing is common practice at endoscopic retrograde cholangiopancreatography (ERCP) but has low sensitivity for cancer detection. Limited data are available on other techniques, including endoluminal fine-needle aspiration and forceps biopsy. This series reviews the yield of these three stricture sampling methods. METHODS: In this prospective study, patients with biliary obstruction with a clinical suspicion of malignancy underwent triple-tissue sampling at one ERCP session. Final cancer diagnosis was based on all sampling methods plus surgery, autopsy, and clinical follow-up. Tissue specimens were reported as normal, atypia, or malignant. RESULTS: A total of 133 patients were evaluated: 104 had cancer and 29 had benign strictures. Tissue sampling sensitivity varied according to the type of cancer; the highest yield was seen in ampullary cancers (62% to 85%). The cumulative sensitivity of triple-tissue sampling in the cancer patients was as follows: sensitivity was 52% if atypia was considered benign and 77% if it was considered malignant. The addition of a second or third technique increased sensitivity rates in most instances. No serious complications occurred from the tissue sampling methods. CONCLUSIONS: Tissue sampling sensitivity varied according to the type of cancer. Combining a second or third method increased sensitivity; general use of at least two sampling methods is therefore recommended.

Abstract: OBJECTIVE: Mucinous cystic neoplasms of the pancreas have a more favorable prognosis than ductal adenocarcinoma. Management of a subgroup, intraductal papillary-mucinous neoplasms, is controversial. Endoscopic ultrasound (EUS) with fine-needle aspiration biopsy may emerge as the imaging modality of choice. There are few studies describing the EUS features of these tumors. METHODS: A total of 35 consecutive cases of cystic tumors of the pancreas with an established pathological diagnosis were analyzed for characteristic EUS features. RESULTS: Mucinous cystadenocarcinomas (n = 14) were more likely to be characterized by hypoechoic cystic/solid mass or complex cyst and were frequently associated with a dilated main pancreatic duct. Benign mucinous duct ectasia (n = 6) were characterized by a dilated main pancreatic duct in conjunction with hyperechoic thickening of the duct wall. The two cases of intraductal mucinous hyperplasia additionally showed a hypoechoic mass. Intraductal papillary carcinoma (n = 11) had features in common with mucinous cystadenocarcinoma but also had echogenic foci in the mass and intraductal hyperechoic lesions. The two cases of microcystic cystadenoma showed either a mixed hypoechoic solid/cystic mass or a complex cyst without the additional features seen in mucinous cystadenocarcinoma. CONCLUSIONS: EUS features seem to exist that may help to differentiate cystic neoplasms from adenocarcinoma of the pancreas and, thus, to establish the preoperative diagnosis of cystic tumors of the pancreas.

Abstract: OBJECTIVE: This study was undertaken to identify clinical scenarios in which the lipase is significantly elevated (three times above the upper limit of normal) but the amylase is normal, and to examine whether or not pancreatitis is the likely cause for this seemingly unusual constellation of laboratory results. METHODS: Twenty-five patients were retrospectively identified over a 2-yr period, which fulfilled the above criteria. A thorough review of their charts was conducted. In addition, a critical review of the literature was performed. RESULTS: It appears that isolated elevation of lipase in this case series was either related to renal insufficiency (two patients), to nonpancreatic sources of lipolytic enzymes due to malignant tumors (two), to acute cholecystitis (two) or esophagitis (one), to delayed blood withdrawal (at least five patients), to hypertriglyceridemia (two), or to subclinical pancreatitis in patients without abdominal pain (three). CONCLUSIONS: 1. An elevated lipase should not be equated with evidence for pancreatitis if the amylase is normal. 2. A simultaneous determination of both amylase and lipase is recommended for the evaluation of patients with abdominal pain.

Abstract: The magnitude of post-ERCP pancreatitis as a clinical and economic problem has increased, and with it the need to find ways of decreasing its incidence and severity. Furthermore, the study of post-ERCP pancreatitis is interesting as a unique model for acute pancreatitis in general. Current thinking and results of recent promising studies are reviewed.

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Abstract: Intestinal angina may be caused by compression of the celiac artery by the median arcuate ligament of the diaphragm. Aortography can suggest the diagnosis, but the diaphragm cannot be visualized by this examination. We report a symptomatic woman in whom spiral computed tomography-guided angiography demonstrated stenosis of the celiac artery, superior mesenteric artery, and both renal arteries due to diaphragmatic compression. Surgery was beneficial.

Abstract: BACKGROUND & AIMS: Cost-effectiveness of colorectal cancer screening will be maximized by selecting the widest screening intervals that effectively prevent cancer mortality. However, data on the incidence of neoplasia in persons with no abnormal findings on initial examination are limited. The aim of this study was to describe the incidence of colonic neoplasia 5 years after negative screening colonoscopy in asymptomatic average-risk persons. METHODS: We previously reported the results of screening colonoscopy in 496 asymptomatic average-risk persons, 368 of whom had no neoplasia identified. Colonoscopy to the cecum was performed in 154 of these persons at a mean of 66 months after the initial negative colonoscopy. RESULTS: Forty-one (27%) had at least one adenoma, but only 1 person had an adenoma > or = 1 cm and none had cancer, severe dysplasia, or villous or tubulovillous histology. Hyperplastic polyps at the initial examination did not predict incident adenomas. Regular nonsteroidal anti-inflammatory drug use was associated with a decreased rate of incident adenomas. CONCLUSIONS: In average-risk persons, the interval between screening examinations can be safely expanded beyond 5 years, provided the initial examination is a carefully performed complete colonoscopy that is negative for colonic adenomas or cancer.

Abstract: BACKGROUND: Opioids are traditionally avoided during sphincter of Oddi manometry because of indirect evidence suggesting that these agents cause sphincter of Oddi spasm. This study was undertaken to determine the direct effects of meperidine on the biliary and pancreatic sphincter. METHODS: Forty-seven patients were prospectively evaluated by sphincter of Oddi manometry in the conventional retrograde fashion. Manometry was initially performed with intravenous diazepam sedation alone. The manometry was repeated 3 to 5 minutes after meperidine was administered. RESULTS: The basal sphincter pressure of the biliary sphincter, pancreatic sphincter, and the combined sphincter group were not significantly altered by meperidine. Concordance (normal versus abnormal) between the basal sphincter pressure before and after meperidine was seen in 44 of 47 patients (94%). Meperidine produced a significant increase in the pancreatic, biliary, and combined sphincter phasic frequency and a significant decrease in the phasic duration. The pancreatic and combined sphincter phasic pressures were significantly reduced following meperidine administration. Seventeen manometry tracings (36%) were believed to be qualitatively better after meperidine, while only four (8.5%; p < .001) were qualitatively better with diazepam alone. CONCLUSION: Meperidine can be used for additional analgesia during sphincter of Oddi manometry if the basal sphincter pressure is the parameter used to determine therapy.

Abstract: BACKGROUND: This study evaluates the relative value of clinical assessment and serum pancreatic enzymes in the discharge management of outpatients undergoing ERCP. METHODS: Two hundred thirty-one patients who underwent ERCP had a detailed clinical assessment performed 2 h after the procedure and blood drawn for amylase and lipase. RESULTS: One-third of the patients who later developed pancreatitis had no pain 2 h after the end of the procedure, whereas an equal number who had no pancreatitis did complain of pain. Values below 276 U/L for amylase and 1000 U/L for lipase were useful in ruling out pancreatitis with negative predictive values of 0.97 and 0.98, respectively. Based on the data of this study a discharge algorithm for outpatients undergoing ERCP is proposed. CONCLUSIONS: In contrast to clinical assessment, which is unreliable, it is possible to stratify patients according to their risk of developing pancreatitis according to their 2-h serum amylase and lipase values. This helps to rationalize the discharge management of outpatients undergoing ERCP at a time when careful utilization of resources, especially the avoidance of unnecessary hospital admissions, becomes increasingly more important.

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Abstract: In this study the frequency of rare causes of acute upper gastrointestinal bleeding was studied retrospectively using the case load of a large teaching hospital. Nine hundred and eighty patients with a clinical diagnosis of upper gastrointestinal bleeding were endoscoped between November 1987 and February 1993. Of these, 156 patients were found to be actively bleeding or had a visible vessel. Rare causes of bleeding were identified in 11 patients (7%). A Dieulafoy ulcer was found in five cases, and a mesenchymal tumor of the stomach in three patients. In the three remaining patients a bleeding gastric polyp, hemobilia and ischemic necrosis of the small bowel were identified as the source of bleeding. In three of these 11 patients the diagnosis was delayed and only made on repeat endoscopy the following day. Therapeutic endoscopy with circumlesional injection of epinephrine was successful in the majority of patients, and only three patients underwent emergency surgery. Two patients died during the acute bleeding episode, one of them had a Dieulafoy ulcer, the other suffered from ischemic bowel necrosis. Diagnosis of rare causes of acute upper gastrointestinal bleeding may be delayed, morbidity and mortality increased. Familiarity with these conditions may improve the outcome.

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Abstract: Continuous ambulatory peritoneal dialysis (CAPD) is an increasingly popular alternative to hemodialysis. Nutrition practitioners in the in- and outpatient setting must be knowledgeable about specific nutritional considerations in these patients. In this paper, we briefly review factors which play a role in the malnutrition often encountered in end-stage renal disease, and focus on metabolic abnormalities, nutritional requirements, and nutritional assessment of patients undergoing CAPD. Urea kinetic modeling as an adjunct to nutritional assessment is explained in detail.

Abstract: The lumen of gastrostomy tubes is frequently colonized with Candida. To investigate the source of this contamination, 20 consecutive malnourished patients undergoing placement of a percutaneous endoscopic gastrostomy tube and ten ambulatory controls having routine upper endoscopy performed had both their oral cavity and gastric antrum swabbed and cultured. Percutaneous endoscopic gastrostomy tube recipients who after several weeks were still under our care (9 of 20) had the lumen of their tubes cultured. Fungi were isolated from the stomach in 13 (65%) of 20 patients undergoing percutaneous endoscopic gastrostomy tube placement but in only 1 of 10 ambulatory patients (p < .01). The species isolated from the oral cavity, the stomach, and later the gastrostomy tube were identical in most cases. We conclude that gastrostomy tubes are probably colonized by oral organisms that have made their way into the stomach.

Abstract: Biliary stones can be removed in 85% to 90% of patients using endoscopic sphincterotomy; in the rest alternative methods are required. Thirty-eight consecutive patients in whom conventional methods had failed underwent laser lithotripsy with a new laser system. A flashlamp-pumped pulsed laser with rhodamine 6G as dye (594 nm) has a tissue-stone recognition system that can identify bile duct stones by analyzing backscattered light and interrupt the pulse in case of tissue contact (Lithognost, Telemit, Munich, Germany). Access of the 0.25- or 0.30-mm-diameter laser fiber to the stones was achieved perorally in 18 patients. In 13 of these cases, eccentrically located stones in the middle or proximal common bile duct were targeted with a 3.4-mm miniscope introduced through a standard duodenoscope. Fluoroscopically guided peroral lithotripsy was performed in 5 patients with stones in the distal common bile duct that could be approached with a standard ERCP catheter. Percutaneous cholangioscopic laser lithotripsy was carried out in 20 patients with stones not amenable to retrograde techniques. The mean number of bile duct stones per patient was 3.6, and the average diameter of the largest stone of each patient was 25 mm (range, 8 to 52 mm). The bile ducts were cleared in all but 1 patient in a mean number of 1.3 sessions lasting 15 to 115 minutes (mean, 60). No laser-related complications were observed. The Lithognost laser was successfully used in 37 of 38 patients referred for the removal of difficult bile duct stones.(ABSTRACT TRUNCATED AT 250 WORDS)

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Abstract: This review summarizes what is presently known about microbial colonization of silicone gastrostomy feeding tubes and their deterioration. Feeding tubes are frequently colonized by fungal and bacterial organisms. Candida organisms seem to originate from the oral cavity from where they colonize the stomach and the gastrostomy tubes. It appears that many microorganisms are able to metabolize certain polymer additives, and although this is well described for polyvinyl chloride, it is not for silicone elastomers. However, clinical evidence for a role of microorganisms in the deterioration of silicone feeding tubes is very strong. The clinical significance of gastrointestinal tract seeding from gastrostomy tubes, which act as incubators, is not fully understood and deserves further study. Likewise, deterioration of feeding tubes must be investigated systematically to address the safety and economical issues it presents.

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Abstract: Percutaneous endoscopic gastrostomy tubes are frequently colonized with fungal and bacterial organisms. This has not been previously reported. In our sample of 10 patients, nine percutaneous endoscopic gastrostomy tubes were colonized with fungi. This occurred as early as 1 week after placement. Candida tropicalis was isolated in five patients. It is hypothesized that a variety of fungi use components of the gastrostomy tube polymer, such as polymer additives, which contribute to the structural deterioration of the tube.

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Abstract: We previously showed that daily intake of beta-carotene, a nontoxic antioxidant, reduces lipid peroxidation as assessed by serum lipid peroxide levels. An alternative method to detect lipid peroxidation is the measurement of pentane in breath. Pentane is a five-carbon hydrocarbon that is released when an omega-6 unsaturated fatty acid undergoes peroxidation. The aim of this study was to see whether graded doses of beta-carotene would affect breath pentane excretion in normal subjects placed on a carotenoid-free liquid diet for two weeks. The subjects were then repleted with either 15 (n = 7) or 120 mg (n = 8) of beta-carotene daily for four weeks while continuing the same diet. Serum beta-carotene and breath pentane were measured before and after beta-carotene refeeding. Lipid peroxidation, as assessed by gas-chromatographic measurement of breath pentane, was significantly (p < 0.05) reduced by daily supplements of 120 mg beta-carotene (from 3.7 +/- 0.9 to 2.2 +/- 1.4 nmol/l). However, the decline in pentane exhalation observed with the 15-mg beta-carotene dose did not achieve statistical significance (p = 0.13).

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Abstract: Acutely stressed patients with chronic pulmonary disease have a particular need for accurate nutritional assessment and appropriate nutritional therapy. Loss of skeletal muscle, often extensive, can be paralleled by dramatic alterations in cellular function; inadvertent provision of excessive calories or of individual substrates may produce more harm than benefit. In the absence of a single "gold standard" for nutritional assessment and monitoring, no single value should take precedence over the entire clinical picture, which should be thoughtfully assessed and reassessed, with both the patient's nutritional needs and the consequences of their provision kept in mind. In the future, assessments of the impact of nutritional intervention will probably rely more heavily on functional tests of specific organs and of the immune system. Intervention will be based not only on provision of calories, individual substrates, vitamins, and minerals, but also on control of the inflammatory response in order that the nutrients may be properly utilized.

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Abstract: This 6-minute video describes a reliable technique to remove migrated esophageal stents. Migration of plastic stents used for benign disease is a frequent problem Most of the time they are easy to remove but difficult situations with prolonged procedure times and repeated failures to capture and remove stents do occur. Repeated unsuccessful removal attempts and the use of more force exert stress on weakened sections of the anatomy, for example when removing stents after anastomotic leaks and perforations. In our method the common problem of stent slippage during removal attempts is avoided by piercing an FNA needle through the front and back of a migrated plastic stent close to its end. Subsequently a guidewire is advanced through the FNA needle and received with a polypectomy snare, which is coming through the other working channel of a therapeutic gastroscope. Once both ends of the guidewire are outside the endoscope effective control of the withdrawal force is possible. This force can be so considerable that an overtube is being used to reconstrain or capture the stent rather than allowing it to be pulled expanded through potentially weakened and non-compliant tissue, such as a healed anastomotic leak.

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Abstract: We conduct approx. 400 EUS exams annually at Deaconess and Sacred Heart Medical Centers, two tertiary-care hospitals in Spokane, WA. Since July 2006 EUS images are being archived on the PACS servers using a back-integration solution with the TIMS-DICOM converter (tims.com) as core. A systematic survey of content management systems for the teaching file project was conducted in December 2006. The selection was narrowed down to a Wiki based solution. A Wiki enables documents to be written collaboratively in a simple markup language using a web browser. There are currently more than 90 different Wiki software implementations available (wikimatrix.org). The Mediawiki software which runs Wikepedia was chosen as platform because it fulfilled the following requirements: Ease of use, low cost, familiar to millions, wide developer base, scalable and customizable, robust, low risk of obsolescence. User rights and permissions can be customized to optimize security. Suitable EUS and other images and case histories were retrospectively identified, going back 6 months and then since January 2007 prospectively forwards using PACS and Meditech, an EMR system connecting 38 facilities in the Inland Northwest (inhs.org). Cases were written up, images selected and uploaded and the English case descriptions translated into Spanish. EUSWIKI.COM went live on 1 Dec 2007