Ian Fraser

BACKGROUND: Stent blockage is a multifactorial process in which stent design and materials, bacteria, proteins, and bile viscosity play a role. AIMS: To compare the patency of the 10 Fr Teflon Tannenbaum (TT) stent to that of the 10 Fr Cotton-Leung (CL) polyethylene stent with sideholes, in patients with malignant obstructive jaundice. METHODS: Patients were recruited to this prospective multicentre randomised study if they had a newly diagnosed malignant bile duct stricture below the hilum of the liver suitable for stenting with a 10 Fr stent. Data were collected and monitored by a professional monitoring company. Primary patency was the interval between stent placement and first exchange or death without recurrent jaundice. RESULTS: 134 consecutive patients were recruited between November 1994 and June 1997; 65 were randomised to the TT stent and 69 to the CL stent. Median patency and 95% confidence intervals were 181 (59, 303) days for the TT stent and 133 (92, 174) days for the CL stent, with no significant difference between the two stents (p=0.49). Median survival and 95% confidence intervals were 115 (71, 159) days for the TT stent and 151 (112, 190) days for the CL stent, with no significant difference between the two stents (p=0.765). CONCLUSION: Neither Teflon as a stent material nor the Tannenbaum design prolong the patency of plastic stents.

BACKGROUND: Cyclosporine-induced side-effects such as gum enlargement and hirsutism potentially limit its effectiveness as a calcineurin-antagonist if these effects contribute to a lack of compliance. Although the differences in incidence of these effects are widely recognized, few studies are available to show the extent of reduced gum enlargement and hirsutism in patients converted from cyclosporine to tacrolimus. This study aimed to determine the efficacy and safety and patient-reported outcomes of such conversions. METHODS: Twenty-one consecutive cyclosporine-treated renal-transplant recipients with evidence of gingival enlargement were randomized into two arms: 10 continued to receive cyclosporine, 11 were converted to tacrolimus. Mean differences (0-3, 0-6, 0-9 and 0-12 months) in periodontal indices (gingival inflammation, plaque, pocket depth, gingival enlargement), hirsutism, serum creatinine and glucose and subjective differences in the patient's rating of disfigurement due to hirsutism and gingival enlargement were recorded. RESULTS: There were no differences in baseline periodontal scores between the two groups. Tacrolimus-treated subjects had significantly reduced pocket depth and gingival enlargement measures (Pocket Depths: -0.40 +/- 0.58 vs 0.30 +/- 0.35, P < 0.01; Gingival Enlargement Index: -1.12 +/- 0.83 vs-0.10 +/- 0.89, P < 0.05; tacrolimus vs cyclosporine, respectively), and decreased subjective disfigurement compared with the cyclosporine-treated group over the 12 months. While there was no difference in objective hirsutism scores between the two groups, tacrolimus-treated patients reported a significant improvement and cyclosporine-treated patients a significant worsening in their degree of disfigurement at the end of 12 months. There were no differences in creatinine or glucose levels. CONCLUSION: Conversion from cyclosporine to tacrolimus in stable renal-transplant recipients with cyclosporine-induced gingival enlargement can be achieved safely and with measurably good effect.

SUMMARY: Colonoscopy is a useful tool in modern medicine and is increasingly employed for both diagnostic and treatment reasons. However, its effectiveness is highly reliant on the quality of bowel cleansing. Among different bowel-cleansing agents available, PEG (polyethylene glycol) is considered to be the safest cleansing agent, especially in relation to fluid and electrolyte problems. We present here a case of severe symptomatic hyponatremia that developed after the use of PEG for an elective colonoscopy. This case highlights that despite the use of PEG-based preparations, life-threatening fluid and electrolyte disturbances can still occur in patients with risk factors, such as old age, use of thiazide diuretics and SSRIs, chronic kidney disease, heart failure and a history of electrolyte problems. These patients should be closely monitored when undertaking bowel cleansing and should receive prompt care in the event of complications, to avoid permanent neurological sequelae and death. Rapid correction of sodium levels in patients requiring treatment of hyponatremia should be avoided to prevent complications such as osmotic demyelination syndrome. LEARNING POINTS: PEG is considered to be the safest bowel-cleansing agents among different options available, but it can still cause significant side effects in susceptible individuals.Those at risk of developing adverse events include elderly individuals, patients with chronic kidney disease, heart failure or previous history of electrolyte problems and those taking thiazide diuretics and SSRIs.All such patients should be closely monitored i.e. have their metabolic profile checked prior to the commencement of bowel cleansing and a low threshold should be kept for the initiation of investigations and treatment in case of development of symptoms.Medications with a potential of causing fluid and electrolytes such as thiazide diuretics and SSRIs should be withheld while patient is undertaking bowel preparation.Hyponatremia in a hospitalized patient can be multifactorial, and the treatment principles are based on duration of onset, presence of symptoms and patients volume status.Overzealous correction of sodium levels during treatment of hyponatremia can result in serious complications such as osmotic demyelination syndrome.

Australian Bird Names is aimed at anyone with an interest in birds, words, or the history of Australian biology and bird-watching. It discusses common and scientific names of every Australian bird, to tease out the meanings, which may be useful, useless or downright misleading! The authors examine every species: its often many-and-varied common names, its full scientific name, with derivation, translation and a guide to pronunciation. Stories behind the name are included, as well as relevant aspects of biology, conservation and history. Original descriptions, translated by the authors, have been sourced for many species. As well as being a book about names this is a book about the history of ever-developing understandings of birds, about the people who contributed and, most of all, about the birds themselves. 2013 Whitley Award Commendation for Zoological Resource.

Renal failure due to cholesterol embolisation is an uncommonly recognised condition. It is usually associated with severe aortic atherosclerosis and in most cases follows a vascular event, such as angiography, vascular surgery, or aneurysm rupture. We report nine patients, all males, who presented to our unit. Six patients survived the initial event, although two died six and eight weeks later. This report emphasises that, although this condition has a high mortality, long term survival is not a rare event.