Indeterminate biliary strictures refer to biliary strictures without an identifiable cause on imaging. The endoscopist's role is to determine if the stricture is benign or malignant and offer treatment options. Available tools for evaluation include ERCP, cholangioscopy, intraductal ultrasound (IDUS), and endoscopic ultrasound (EUS). ERCP allows for tissue sampling but has limited sensitivity. Newer techniques like fluorescence in-situ hybridization and confocal endomicroscopy show promise to improve detection. Direct visualization with cholangioscopy may also improve detection over standard techniques. IDUS provides diagnostic accuracy without direct sampling. EUS allows for tissue acquisition with fine needle aspiration and evaluation of local
Benign Billiary Stricture By Dr Dhaval Mangukiya
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Benign Biliary Stricture is a common condition which we encounter during gastro practice. Here we discuss in detail about its diagnosis and management.
Benign Billiary Stricture By Dr Dhaval Mangukiya
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Benign Biliary Stricture is a common condition which we encounter during gastro practice. Here we discuss in detail about its diagnosis and management.
Pancreatic cystic lesions are encountered quite commonly nowadays. How to appraoch them is important as some are bnign and some having malignant potential. EUS helps in characterising them complementing with the CT or MRI
Il ruolo dell'ecoendoscopia nella diagnosi delle lesioni solide pancreatiche ...Gastrolearning
Gastrolearning II modulo/4a lezione
Il ruolo dell'ecoendoscopia nella diagnosi delle lesioni solide pancreatiche
Prof. A. Larghi - Università Cattolica Sacro Cuore (Roma).
Pancreatic cystic lesions are encountered quite commonly nowadays. How to appraoch them is important as some are bnign and some having malignant potential. EUS helps in characterising them complementing with the CT or MRI
Il ruolo dell'ecoendoscopia nella diagnosi delle lesioni solide pancreatiche ...Gastrolearning
Gastrolearning II modulo/4a lezione
Il ruolo dell'ecoendoscopia nella diagnosi delle lesioni solide pancreatiche
Prof. A. Larghi - Università Cattolica Sacro Cuore (Roma).
Co-relation of multidetector CT scan based preoperative staging with intra-op...Apollo Hospitals
To assess the accuracy of CT scan in preoperative staging, to correlate preoperative findings with operative findings and with post-operative histopathological findings of colorectal carcinoma.
New Predictors for Periampullary Resectabilityasclepiuspdfs
Background: Periampullary tumor involves ampullary, pancreatic, biliary and duodenal mucosa, and pancreaticoduodenectomy considered the curative option. Hence, imaging evaluation to describe the lesion is important. Furthermore, certain specific features could help in pre-operative prediction of resectability for periampullary cancers. The aim of this study is to find out any specific perioperative predictor of resectability on periampullary cancers. Patients and Methods: This is an observational cross-sectional hospital-based study done in tertiary hospital, a total of 79 patients were included in the study. Variables such as age, gender, symptoms (back pain, jaundice, etc.), investigations (bilirubin, alkaline phosphatase, etc.), and imaging (Triphasic computed tomography [CT], magnetic resonance cholangiopancreatography, endoscopic ultrasonography, etc.) were studied and the data collected and analyzed using SPSS 20. Results: Male was slightly predominant and male to female ratio was 1:0.9. The mean age was 50 years (SD ±6.54). Triphasic CT abdomen pancreatic protocol was the most effective modality of investigation. High bilirubin (>10 mg/dl) and back pain were statistically significant among patients with unresectable tumor. Conclusions: Back pain and high bilirubin could be helpful in pre-operative prediction of operability of periampullary cancers.
The presence of haematuria may be the sole symptom of an underlying disease, either benign or malignant. It is one of the most common presentations of patients with urinary tract diseases and of patients referred for urinary imaging. Painless visible haematuria (VH) is the commonest presentation of bladder cancer.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
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Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?
Biliary strictures.shah
1. Indeterminate Biliary Strictures:Indeterminate Biliary Strictures:
Diagnosis by ERCP, IDUS,Diagnosis by ERCP, IDUS,
Cholangioscopy, and Tissue SamplingCholangioscopy, and Tissue Sampling
Janak N. Shah, MD
Director of Pancreatic / Biliary Endoscopy
Interventional Endoscopy Services - California Pacific Medical Center
Director of Endoscopy- SFVAMC
Associate Clinical Professor of Medicine - UCSF
San Francisco, CA
2. What is an “indeterminate”
biliary stricture ?
Biliary stricture without an identifiable
cause (e.g. mass) on imaging (CT, MRI)
+/- prior negative tissue sampling
3. Endoscopist’s role in evaluatingEndoscopist’s role in evaluating
indeterminate strictures:indeterminate strictures:
Determine the cause:
Benign or Malignant?
Diff dx: cholangioCA, pancreatic CA, PSC, autoimmune (IGG4),
inflammatory (chronic pancreatitis), bile duct injury
Offer treatment options:
benign - candidate for endo therapy? stent?
malignant - resectable or unresectable? Stenting?
4. Available tools for evaluatingAvailable tools for evaluating
biliary strictures:biliary strictures:
ERCP
Cholangioscopy
Intraductal US (IDUS)
Endoscopic ultrasound (EUS)
5. ERCP in indeterminate stx:ERCP in indeterminate stx:
Assess presence /
extent
tissue sampling
6. ERCP tissue sampling techniquesERCP tissue sampling techniques
Technique Sensitivity Technical aspects
bile aspirate
cytology
27% (6-32%; 6 studies with n=351)* easy
retrieved biliary
stent cytology
32% (11-79%; 6 studies with n=197)*
easy; done at 2nd
procedure
brush cytology 42% (30-57%; 8 studies with n=578)* over-the-wire, easy
forceps biopsies 56% (43-81%; 6 studies with n=343)*
more difficult;
often requires
sphincterotomy
forceps + brushings
55% (in same study brush alone 30%; bx
alone 43%)**
more difficult;
often requires
sphincterotomy
* de Bellis M, GIE 2002
** Jailwala J, GIE 2000
7. Improving yield at ERCP?Improving yield at ERCP?
newer techniques in suspected malignancynewer techniques in suspected malignancy
Technique Method Utility
digital image analysis
(DIA)
spectrophotometry to quantify DNA content
14% sensitivity in cyto-
negative stx *
fluorescence in-situ
hybridization (FISH)
fluorescently labeled DNA probes to detect
loss / gain of chromosomes
62% sensitivity in cyto-
negative stx *
optical coherence
tomography (OCT)
catheter-based; cross-sectional, subsurface
imaging (2mm) based on measuring
backscattered infrared light
1-2 abnl findings in 53-
79% with cancer **
confocal
endomicroscopy
catheter-based, in-vivo microscopic imaging
abnl findings in 83%
with cancer ***
* Levy MJ, AJG 2008
** Arvanitakis M, Endosc 2009
*** Giovannini M, Surg Endosc 2011
8. Cholangioscopy for indeterminateCholangioscopy for indeterminate
stricturesstrictures
Visualization of stricture and ability for direct tissue
sampling
Some studies suggest improved detection of
malignancy over standard ERCP techniques (e.g.
brushings):
92% vs. 66% (p=0.25) tumor detection among 53 PSC
pts with dominant strictures *
89% tumor detection (16 of 18) among 62 pts with
“indeterminate strictures”, majority with prior neg
sampling **
* Tischendorf JJ, Endosc 2006
** Shah RJ, Clin Gastroenterol Hepatol 2006
9. Cholangioscopy for stricturesCholangioscopy for strictures
Technology Pros Cons
mother-baby
(fiberoptic / video)
allows biopsy
reasonable image quality
2 operators
2 processors
fragile, easily damaged
Single-operator fiberoptic
disposable
allows biopsy
4-way tip deflection
easier for proximal stx
inferior image quality
compared to others
Direct ductoscopy with
ultraslim gastroscopes
(+/- overtube, wire-guided,
anchoring balloon
assistance)
widely available
allows biopsy
best imaging quality
technically challenging
difficult for prox. Stx
Nguyen NQ, Binmoeller KF, Shah JN. Tech Review GIE 2009
14. IDUS for indeterminate stricturesIDUS for indeterminate strictures
Catheter-based US probe, over-the-wire, 12-30 MHz
Abnl features in suspected malignant stx:
hypoechoic, infiltrating mass
notching or irregular outer border
intraductal papillary growth
suspicious LN
Improved tumor detection -- no direct tissue sampling
malig dx accurately predicted in 89% among 34 PSC and 52 non-PSC
pts with indeterminate stx (higher in non-PSC); malign dx in 86% of 21
pts with negative cytology *
Retrospective blinded review of 30pts with indeterminate stx: benign
vs. malign dx correct in 90% with IDUS vs. 67% with ERCP/cyto **
Other uses: assessing tumor extension for operative
planning and resectability
* Levy MJ, AJG 2008
** Vasquez-Sequeiros, GIE 2002
16. EUS for indeterminate stricturesEUS for indeterminate strictures
Bile duct (from ampulla to hilum) well visualized from
duodenum
Abnl features in suspected malignant stx:
hypoechoic mass
focal, irregular wall thickening
intraductal papillary growth
suspicious LN
liver metastases and distant LN
Immediate tissue sampling / on-site analysis
17. Sensitivity of EUS-FNA for bile duct CA:Sensitivity of EUS-FNA for bile duct CA:
indeterminate stx with prior negative samplingindeterminate stx with prior negative sampling
Study N Sensitivity
DeWitt
GIE 2006
24 pts 77%
Eloubeidi
Clin Gast Hep 2004
28 pts 86%
Fritscher-Ravens
AJG 2004
44 pts 89%
What is an indeterminate stx? We can define this as a stx of cholangiography without an identifiable cause on imaging. This should be in the setting of no history to suspect a bile duct injury. This type of definition has been used in most studies on the topic of indeterminate biliary strictures, and I’ll use this definition for purposes of todays talk.
Endoscopist has a few roles in evaluating indeterminate stx. Of primary importance is to determine the cause… is the stx benign or malignant.
ERCP allows us to identify the presence of a stricture and determine the extent; also allows a platform for tissue sampling…
This slide summarizes the more commonly used ERCP tissue sampling techniques and their relative yields. Most of the data comes from a nice review published in 2002 from the Indiana group (“Tissue sampling at ERCP”).
OCT- 37 pts with biliary stx
Confocal- abnl findings- irregular vessels, black band, black clumps; 37 pts (stones and strictures)
caution- under CO2 insufflation or water immersion only- risk or air embolism
both are mayo clinic studies
both are mayo clinic studies
From Indiana group review “Tissue sampling at ERCP” 2002
