INTRODUCTIONRadiofrequency ablation (RFA) for unresectable primary or secondary hepatic malignancies have gained widespread availability and acceptance over the past 5 years. Complication rates have been reported to range from 0% to 27%.

CLINICAL PICTUREWe report a patient with symptomatic right pleural effusion due to a diaphragmatic fistula and another with biliptysis post-RFA, for recurrent hepatoma.

TREATMENTPercutaneous drainage of both the pleural effusion and biloma was performed. However, surgical repair of the diaphragmatic fistula was only required for the former for persistent drainage.

OUTCOMEBoth patients were successfully treated with minimal morbidity.

CONCLUSIONHigh index of suspicion is required for the early diagnosis and treatment of diaphragmatic fistulas. Simple catheter drainage can potentially obviate the need for surgery.

Adult ; Aged ; Carcinoma, Hepatocellular ; surgery ; Catheter Ablation ; adverse effects ; Diaphragm ; physiopathology ; Fistula ; etiology ; Humans ; Liver Neoplasms ; surgery ; Male ; Neoplasm Recurrence, Local ; surgery ; Pleural Effusion ; etiology

INTRODUCTIONOrthodeoxia is a rare clinical syndrome characterised by dyspnoea and arterial deoxygenation that accompanies a change from a supine to erect position.

CLINICAL PICTUREWe describe an unusual case of "paradoxical orthodeoxia" in a 70-year-old man with a thoracic aortic aneurysm: arterial desaturation when supine that improved when erect.

TREATMENT AND OUTCOMENon-invasive imaging revealed compression of the left pulmonary artery by the aneurysm (thoracic computed tomography) and patent foramen ovale (transesophageal echocardiography). Nuclear studies show decreased relative left lung perfusion attributable to the former, and right-to-left atrial shunt attributable to the latter. The degree of right-to-left shunt increases in the supine position: nuclear pulmonary shunt study shows shunt extent of 21% when supine versus 10% erect.

CONCLUSIONA physioanatomical explanation is proposed.

Aged ; Aortic Aneurysm, Thoracic ; epidemiology ; Dyspnea ; etiology ; Echocardiography, Transesophageal ; Female ; Heart Septal Defects, Atrial ; epidemiology ; Humans ; Oxygen ; blood ; Posture ; physiology ; Supine Position ; physiology

BACKGROUND: Over the last 10-20 years, international guidelines and consensus statements for the management of common allergic diseases (e.g. allergic rhinitis and asthma) have been developed and disseminated worldwide. However, their impact on knowledge and standard of clinical practice among primary care physicians and specialists is unknown. OBJECTIVE: To investigate need for an improvement in the dissemination of international guidelines for the diagnosis and management of allergic rhinitis. METHODS: Seven medical students who attended 3-day 1st International Basic Allergy Course (2010) took down all questions raised during the entire course. A systemic analysis of these questions was performed to identify areas for improvement in diagnosis and management of allergic diseases mainly in the Association of Southeast Asian Nations (ASEAN) region. RESULTS: 268 participants, 143 males and 125 females, comprising Ear, Nose and Throat (ENT) specialists (n = 106) and trainees (n = 34), general practitioners (n = 87), and other healthcare professionals (n = 41) attended the course. Of the 103 questions recorded, 59 were regarding treatment modalities in allergy practice such as immunotherapy (n = 38), pharmacologics (n = 15), nasal surgery (n = 2), and others (n = 4). 41 questions (39.8%) have answers based in the Allergic Rhinitis and its Impact on Asthma guidelines (2001 and 2008). Certain questions were selected for further analysis because they appeared to be (a) more commonly asked (e.g. immunotherapy) or (b) were deemed to be challenging or, even controversial (e.g. food allergy and differential diagnosis between vasovagal and anaphylaxis reaction), as the recommendations in current international guidelines were less well-defined. CONCLUSION: Our study identified several problems that, if tackled, could help minimize confusion and provide better care for patients suffering from allergic diseases especially in the ASEAN region.
Anaphylaxis ; Asian Continental Ancestry Group ; Asthma ; Consensus ; Delivery of Health Care ; Diagnosis ; Diagnosis, Differential ; Ear ; Female ; Food Hypersensitivity ; General Practitioners ; Humans ; Hypersensitivity ; Immunotherapy ; Male ; Nasal Surgical Procedures ; Nose ; Pharynx ; Physicians, Primary Care ; Rhinitis, Allergic ; Specialization ; Students, Medical

Aged ; Endovascular Procedures ; methods ; Heart Valve Prosthesis Implantation ; methods ; Humans ; Male ; Mitral Valve Insufficiency ; diagnosis ; surgery ; Reoperation ; Singapore

Aged ; Atherosclerosis ; Case-Control Studies ; Coronary Artery Bypass ; methods ; Coronary Artery Disease ; surgery ; Female ; Hemodynamics ; physiology ; Humans ; Male ; Mammary Arteries ; physiology ; transplantation ; Middle Aged ; Pulsatile Flow ; Radial Artery ; physiology ; transplantation ; Rheology ; Saphenous Vein ; physiology ; transplantation ; Shear Strength ; Stress, Mechanical ; Vascular Patency ; physiology

INTRODUCTIONPercutaneous transcatheter aortic valve implantation (TAVI) has become an established therapy for inoperable and high-surgical-risk patients with severe aortic stenosis. Although TAVI in patients with degenerated surgical aortic bioprostheses (i.e. valve-in-valve TAVI) is increasingly reported in Western studies, such data is lacking in Asian patients. We describe the initial experience of valve-in-valve TAVI in Asia.

METHODSEight patients who underwent valve-in-valve TAVI due to degenerated aortic bioprostheses were enrolled. The mechanism of bioprosthetic valve failure was stenotic, regurgitation or mixed. All procedures were performed via transfemoral arterial access, using the self-expanding CoreValve prosthesis or balloon-expandable SAPIEN XT prosthesis.

RESULTSThe mean age of the patients was 71.6 ± 13.2 years and five were male. Mean duration to surgical bioprosthesis degeneration was 10.2 ± 4.1 years. Valve-in-valve TAVI was successfully performed in all patients. CoreValve and SAPIEN XT prostheses were used in six and two patients, respectively. There were no deaths, strokes or permanent pacemaker requirement at 30 days, with one noncardiac mortality at one year. All patients experienced New York Heart Association functional class improvement. Post-procedure mean pressure gradients were 20 ± 11 mmHg and 22 ± 8 mmHg at 30 days and one year, respectively. Residual aortic regurgitation (AR) of more than mild severity occurred in one patient at 30 days. At one year, only one patient had mild residual AR.

CONCLUSIONIn our experience of valve-in-valve TAVI, procedural success was achieved in all patients without adverse events at 30 days. Good clinical and haemodynamic outcomes were sustained at one year.

Aged ; Aged, 80 and over ; Aortic Valve ; surgery ; Aortic Valve Insufficiency ; surgery ; Aortic Valve Stenosis ; surgery ; Arteries ; Bioprosthesis ; Cardiac Catheterization ; methods ; Female ; Fluoroscopy ; Follow-Up Studies ; Heart Valve Prosthesis ; Heart Valve Prosthesis Implantation ; Hemodynamics ; Humans ; Male ; Middle Aged ; Pacemaker, Artificial ; Prosthesis Failure ; Severity of Illness Index ; Transcatheter Aortic Valve Replacement