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Paragangliomas are very rare tumors derived from neuroendocrine cells of autonomic nervous system. Extra-adrenal paragangliomas account for only 10 to 15% of all paragangliomas and may present incidentally as a mass. Typical triad of fluctuating hypertension, headache, and sweating is not always present which makes the diagnosis difficult sometimes. Definitive diagnosis is usually made with histologic findings and surgery is the treatment of choice. We report a case of a 53-year-old male who presented with chest pain and vomiting.

To assess the frequency of low serum sodium levels and to correlate it with the severity of liver disease and hepatic encephalopathy (HE) in patients coming to the tertiary care hospital.Observational study.Shifa International Hospital, Islamabad, from January 2011 to January 2012.A total of 202 patients with hepatic encephalopathy and chronic liver disease had serum sodium measured. The HE was graded according to the West Haven classification (4 grades). Relationship of hyponatremia was correlated with severity grade of encephalopathy using Spearman rank correlation test.Out of 202 patients, 62 (30.7%) patients had serum sodium less than 130 meq/l. Out of 202, HE was present in 69 (34.15%) patients and out of these, 38 had grade III-IV HE and 31 had grade I - II HE. Out of 69 patients with HE 57 had sodium less than 135 (p0.001).Hyponatremia was a common feature in patients with cirrhosis and its severity increased with the severity of liver disease. The existence of serum sodium concentration135 mmol/L was associated with greater frequency of hepatic encephalopathy compared with patients with serum sodium concentration135 mmol/L.

There are limited data on the outcome of emergency endoscopic retrograde cholangiopancreatography (ERCP) performed in the intensive care unit (ICU). We sought to assess the frequency, indications, and clinical outcomes of ERCPs performed in ICU patients who were too unstable to be transported to the endoscopy unit. An electronic endoscopy database was used to identify the patients (n = 22) and to assess procedural success, complications, and mortality. The indications for ERCP included suspected biliary sepsis, suspected gallstone pancreatitis, and known choledocholithiasis with cholangitis. Biliary cannulation, which was attempted in all patients, was successful in 19 patients (86 %), and of these 18 (95 %) underwent a technically successful endoscopic therapy. There were no apparent endoscopic complications. Therefore, emergency bedside ERCP in ICU patients, which is primarily performed for the management of suspected biliary sepsis and gallstone pancreatitis, can achieve high technical success rates when performed by experienced endoscopists, although the 30-day mortality rate remains high due to multiorgan dysfunction.

v Enteral stenting is a safe and effective treatment option for palliation of gastroduodenal obstruction. A myriad of complications can occur after self-expandable metal stent (SEMS) placement.1 Severe complications of bleeding and perforaion are uncommon, and early massive bleeding after duoenal stent placement has not been reported. We describe a ase of massive bleeding within 72 hours of duodenal SEMS lacement.

There are certain oceanographic events specifically El Nino, tsunami, and hurricanes that catalyze and intensify disease breakouts. The ocean creates the prime environments necessary for bacteria to thrive or ocean-borne diseases to spread. In order to model phenomena like El Nino and take preventative measures against them, it is necessary to use probability distribution and numerical models as well as early warning systems. Tsunami can catalyze disease outbreak by creating stagnant water pools, flooding, the breaking of sewage lines, and overpopulated refugee camps. Each of these factors harnesses infectious diseases such as cholera, typhoid fever, skin rashes, and of course malaria and dengue fever. Model and data assimilation can be used in order to construct predictions for the intensity of a tsunami after water has been displaced at a respective location in the ocean. The DART (Deep-ocean assessment and reporting of tsunami system) system, with assistance from surface buoys/BPR deployments, can accurately send out emergency signals to regions that will be affected by the generated tsunami. Although the natural phenomena such as El Nino, tsunami, and hurricanes have been studied to be causes of disease outbreak, the ocean's role has yet to be analyzed thoroughly. Future directions include the use Oceanographic principles to determine intensities of these phenomena and then warn and help salvage communities.

Background Hilar cholangiocarcinoma (CC) is unresectable in 80% to 90% of cases. Placement of side-by-side bilateral self-expandable metal stents (SEMSs) can be technically challenging in these patients because deployment of the first stent can preclude passage of the second stent. Methods Using a prototype large-diameter therapeutic channel (6-mm) duodenoscope, we positioned guidewires into the right and left intrahepatic systems. Two predeployed uncovered SEMSs with 7.5F delivery systems were passed side by side over each guidewire and deployed simultaneously. Design Observational clinical feasibility study. Setting Tertiary referral center. Results This technique was attempted in 6 patients with malignant hilar biliary obstruction. Successful placement was achieved in all, with significant improvement in symptoms and cholestasis. Limitations Small number of patients. Conclusion This simple technique using a prototype large-diameter therapeutic channel duodenoscope facilitates placement of bilateral side-by-side hilar SEMSs.

Pancreaticopleural fistula is a rare complication estimated to occur in 0.5% of the patients with pancreatitis and even extremely rare in surgically altered anatomy (e.g. Roux-en-Y anastomosis) patients. The conventional ERCP is difficult to treat pancreaticopleural fistula in a patient with complex upper GI anatomy because of long anatomical route.We represent a case of a 47-year-old female with remote subtotal gastrectomy with Roux-en-Y gastrojejunostomy admitted with recurrent left pleural effusion due to pancreaticopleural fistula. After failed ERCP through the anatomical route, pancreaticopleural fistula was treated successfully with laparoscopy-assisted transjejunal ERCP.Laparoscopy-assisted ERCP is a useful modality in patients with surgically altered anatomy.

Conventional distance protection relays used in transmission line protection are based on measurement of impedance at the relaying point. In the case of series compensated transmission lines, this impedance is not a reliable parameter to estimate the fault distance. Ultra high speed (UHS) protection can be the proper solution for the protection of series compensated transmission lines. UHS relays can help avoid electric brownouts and grid utility system rotating Blackouts like the one that spanned the north-eastern United States and eastern Canada in August 2003. In this paper, the authors have studied the performance of a novel scheme for detection of arcing nonlinear faults caused across the insulator string on an extra high voltage (EHV) transmission tower. A novel wavelet transform based unit protection relaying scheme for series compensated transmission line is presented. The authors have made novel improvements in UHS relaying using wavelet transforms.

Microscopic Colitis (MC) is characterized by chronic watery diarrhea, grossly normal appearing colonic mucosa during conventional white light endoscopy, and biopsy showing microscopic inflammation. We report a case of collagenous colitis with gross endoscopic findings.

The endoscopic approach to large bile duct stones may require the use of intraductal electrohydraulic lithotripsy (IEHL) performed under direct cholangioscopic visualization. In patients with Roux-en-Y biliary reconstruction after liver transplantation, endoscopic retrograde cholangiography is feasible using long-length endoscopes. We describe successful fragmentation of a large common hepatic duct stone by using cholangioscopy-guided IEHL delivered through a colonoscope in a patient with a Rouxen-Y hepaticojejunostomy.

We present a case of a young woman who was initially diagnosed with acute stroke with no obvious risk factors. Preliminary investigation with transthoracic echocardiography and subsequent advanced imaging with transoesophageal echocardiography suggested the diagnosis of a benign cardiac tumour on the anterior leaflet of mitral valve. The patient underwent urgent surgical resection. Histology confirmed the diagnosis of cardiac papillary fibroelastoma. She made complete clinical recovery with no recurrence of symptoms.

Background Self-expandable metal stents (SEMSs) are used for palliation of malignant biliary obstruction. Objective We performed a meta-analysis to compare stent patency and stent survival of covered SEMSs (CSEMSs) and uncovered SEMSs (USEMSs) in patients with unresectable distal malignant biliary obstruction. Design Meta-analysis. Setting Tertiary-care facility. Patients A comprehensive search of several databases (from each database's earliest inclusive dates to November 2010, any language, and any population) was conducted. The search identified 337 potential abstracts and titles, of which 16 were retrieved in full text. Review of references identified 17 additional studies. We found 5 multicenter, randomized trials involving 781 patients. Intervention Placement of covered and uncovered SEMSs for treatment of distal malignant biliary obstruction. Main Outcome Measurements Stent patency, stent survival, patient survival, and cause for stent dysfunction (ingrowth, overgrowth, migration, and sludge formation). Results The median length of follow-up was 212 days. Compared with USEMSs, CSEMSs were associated with significantly prolonged stent patency (weighted mean difference [WMD] 60.56 days; 95% confidence interval [CI], 25.96, 95.17; I 2 = 0%) and longer stent survival (WMD 68.87 days; 95% CI, 25.64, 112.11; I 2 = 79%). Stent migration, tumor overgrowth, and sludge formation were significantly higher with CSEMSs (relative risk [RR] 8.11; 95% CI, 1.47, 44.76; I 2 = 0%), (RR 2.02; 95% CI, 1.08, 3.78; I 2 = 0%), (RR 2.89; 95% CI, 1.27, 6.55; I 2 = 0%). Limitations Relatively low number of studies available and the fact that 2 of the 5 studies were from one institution. Also, the limited availability of some stents used in the trials may limit the applicability of these results. Conclusion CSEMSs have a significantly longer duration of patency compared with USEMSs in patients with distal malignant biliary obstruction. Stent dysfunction occurs at a similar rate, although there is a trend toward later obstruction with CSEMSs.

Efficacy and Safety of 2-Octyl-Cyanoacrylate Injection for the Treatment of Gastric Variceal Hemorrhage Atif Saleem, Navtej Buttar, Elizabeth Rajan, Christopher J. Gostout, Todd H. Baron, Louis-Michel Wong Kee Song Mayo Clinic, Rochester, MN Background: Endoscopic injection of cyanoacrylate (glue) is effective for the treatment of gastric variceal hemorrhage (GVH). Although n-butyl-2 cyanoacrylate (Histoacryl®) is the most commonly used agent worldwide, it is not readily available in the U.S. As an alternative, our group has utilized 2-octyl cyanoacrylate (Dermabond®), an FDA-approved agent for wound closure. The off-label, intravariceal injection of 2-octyl cyanoacrylate (OCA) for GVH has been a treatment option at our institution since 2000. Aim: To assess the efficacy and safety of OCA injection for the treatment of GVH. Methods: The medical records of patients treated with OCA injection for GVH from 1/2000 to 7/2010 were reviewed retrospectively. Data were extracted for patient demographics, type of gastric varices (GV) according to Sarin classification, bleeding stigmata, OCA dose and number of sites injected per treatment session, initial hemostasis and rebleeding rates, procedure-related complications, and mortality. Undiluted OCA was injected at a rate of 1 ml/15 sec until bleeding cessation and/or hardening of the varix. Repeat endoscopy was performed at 4 wks to assess for variceal obliteration and treatment of any residual GV. Follow-up endoscopy was performed at 6-12 months thereafter. Results: A total of 62 patients (40 men) were identified. Cirrhotic portal hypertension was the cause of GV in 70% of cases. GV were classified as GOV1 in 2%, GOV2 in 63% and IGV1 in 35% of cases. Active bleeding, stigmata of recent bleeding (e.g., fibrin plug) and presumed bleeding from large GV were noted in 24%, 53% and 23% of patients, respectively. The mean volume of OCA injected was 6.5 ml (range 2-16 ml) with a mean of 2 injection sites (range 1-6) per treatment session. In patients with actively bleeding GV (n 15), immediate hemostasis was achieved in 93% of cases following OCA injection. The overall rebleeding rate was 6%. In 2 patients, early ( 1 wk) recurrent massive GVH required rescue TIPS which failed to control bleeding in one patient who subsequently died. Late ( 1 wk) recurrent GVH occurred in 2 patients; one patient was successfully retreated with OCA injection and the other patient opted for comfort care in the setting of multiorgan failure. Glue-related pulmonary embolism occurred in 2 (3%) patients, which was fatal in one. The mean (SD) follow-up was 17 (15) months. Bleeding-related mortality was 6% and the overall mortality was 23%. Conclusions: Endoscopic injection of 2-octyl cyanoacrylate is a relatively safe and effective endoscopic treatment option for gastric variceal hemorrhage. The outcomes are comparable to those reported for endoscopic variceal injection using n-butyl-2 cyanoacrylate.

ObjectivePatient-reported outcomes including health-related quality of life are important in clinical care and research studies. The MacNew Heart Disease health-related quality of life questionnaire has been validated in English-speaking patients with myocardial infarction. The aim of this study was to validate the MacNew in English-speaking patients with angina or ischemic heart failure.MethodsCanadian and American patients with angina or ischemic heart failure completed the MacNew, the Short Form-36 Health Survey, and the Hospital Anxiety and Depression Scale.ResultsWe administered questionnaires to 276 patients with angina (mean age, 65.9 years) and 155 patients with ischemic heart failure (mean age, 70.3 years). The mean ± SD MacNew global score in patients with ischemic heart failure (5.1 ± 1.2) was statistically (P < 0.001), but not clinically, poorer than in patients with angina (5.3 ± 1.1). The three-factor measurement model explained 46.1% of the observed variance in the MacNew in patients with angina and 46.5% in patients with ischemic heart failure. Internal consistency was ≥0.90, and test-retest reliability was ≥0.70 for each MacNew scale and the a priori convergent and discriminative validity hypotheses were confirmed in both diagnoses. The MacNew was highly accepted by patients with little respondent or administrative burden.ConclusionsThe English version of the MacNew is reliable and valid in patients with angina or ischemic heart failure. This permits health-related quality of life outcome comparisons in patients with angina, ischemic heart failure, and myocardial infarction with the MacNew and provides a better understanding of the full range of health-related quality of life outcomes.

Purpose The purpose of this paper is to understand conflicts that develop between managers and their respective firms when a personal relationship is present between managers of buying and supplying firms in the Chinese logistics industry. Design/methodology/approach This research uses a case study methodology to allow for an assessment of the conflicts that emerge between managers and their respective firms when a personal relationship is present between them. Findings The findings reveal conflicts between managers and their respective firms as a result of personal relationship between managers buying and selling logistics services in China. Research limitations/implications This study uses semi-structured interviews with Chinese senior managers to explore intra-organizational conflicts, which develop as a result of personal relationships embedded within buyer–supplier relationships. The generalizability of the findings will have to be empirically examined in future research. Practical implications Chinese firms can use the findings to understand conflicts, which arise between managers and their respective firms when a personal relationship is present between managers engaged in the process of buying and selling logistics services. Originality/value A notable gap in buyer–supplier relationship literature, specifically in Chinese business culture, is an unfulfilled need for research examining intra-organizational conflicts, when a personal relationship is present between managers of buying and supplying firms in the logistics industry. This paper addresses this gap.