The significance of cystic adrenal lesions in multiple endocrine neoplasia IIB syndrome

Cystic adrenal lesions are common, but cystic pheochromocytomas are rare. In the setting of a cystic adrenal mass in a patient with multiple endocrine neoplasia syndrome (MEN) IIB, the diagnosis of pheochromocytoma must be considered. We report a 29-year-old woman with typical phenotype of MEN IIB (marfanoid habitus, thick blubbery lips, mucosal ganglioneuromas) and a history of medullary thyroid carcinoma. She presented with headaches, palpitations and tremors. Computed tomography revealed a left cystic adrenal mass. The likelihood of the lesion being a pheochromocytoma was thought to be low due to its cystic appearance. However, urine ephinephrine and metanephrine levels were elevated. She underwent a left adrenalectomy and histological examination revealed a cystic pheochromocytoma.

Littoral cell angioma of the spleen

INTRODUCTION

Littoral cell angioma is a recently described vascular tumour of the spleen with an unknown aetiology.

CLINICAL PICTURE

We present a case of a 36-year-old lady who had a successful living-related renal transplantation 13 years ago. On follow-up, she was investigated for pyrexia of unknown origin (PUO) and was found to have a large solitary hypodense splenic lesion.

TREATMENT

Splenectomy was carried out because an underlying infective or neoplastic cause for this patient on long-term immunosuppression could not be excluded. The operation and subsequent clinical course was uneventful and the patient's fever settled postoperatively. The histological and immunohistochemical features of the tumour were consistent with a littoral cell angioma.

CONCLUSION

Littoral cell angioma is a vascular tumour of the spleen. This case illustrates that it can be a cause of PUO and should be considered in the differential diagnosis of splenic hypodense lesions.

Appropriateness of colonoscopy in a university hospital

An open access endoscopy system allows for the direct scheduling of endoscopies by non-gastroenterologist physicians without prior gastroenterology consultation. The aim of our study was to examine our practice of open access endoscopy by evaluating the appropriateness of referrals for colonoscopy and to determine whether there were differences depending on the specialty of the referring clinician. The indication for colonoscopy was assessed in 499 consecutive outpatients referred for colonoscopy at University Hospital, Kuala Lumpur over a 12-month period. The American Society of Gastrointestinal Endoscopy (ASGE) guidelines were used to determine the appropriateness of referrals. 80.6% of colonoscopies requested by the gastroenterologist were performed for accepted indications compared to 50.6% of referrals by the primary care physician (p<0.001) and 67.0% of referrals by the surgeon (p=0.006). The rate of colonoscopies generally not indicated was 2.1% for the gastroenterologist, 25.0% for the internist (p=0.002) and 7.5% for the surgeon (p=0.04). The rate of indications not listed in the ASGE guidelines was significantly lower for requests made by gastroenterologists (17.3%) than those requested by primary care physicians (44.2%; p<0.001). Patients who have had prior consultation with the gastroenterologist were significantly more likely to undergo colonoscopy for appropriate indications than among patients who were referred through an open access system. The rate of inappropriate indications for colonoscopy was also significantly lower when the gastroenterologist made the referral. A substantial proportion of colonoscopies (25.4%) was performed for indications not listed in the ASGE guidelines.

A comparison of two surgical strategies for the emergency treatment of gallstone ileus

INTRODUCTION

Debate currently exists regarding the appropriate surgical strategy for emergency treatment of gallstone ileus. This relates to the need for definitive biliary tract surgery after relief of mechanical obstruction. Our study reviews treatment by enterolithotomy alone and enterolithotomy combined with definitive biliary tract surgery and fistula closure to determine if there is advantage of one treatment option over the other.

METHODS

The clinical, operative and follow-up data on 19 consecutive patients treated by emergency surgery for gallstone ileus from January 1992 to December 2000 was retrospectively reviewed.

RESULTS

There were 15 women and four men, with a mean age of 74.6 (range 62-91) years. Pre-operative diagnosis was made in only nine of 19 patients. Enterolithotomy alone (E group) was performed in seven patients and enterolithotomy with cholecystectomy and fistula closure (E+C group) in 12 patients. In the E group, more patients had significant co-morbidity as identified by poorer American Society of Anesthesiologists (ASA) status, poorer pre-operative status (shock at presentation) than in the E+C group. Operative time was significantly shorter in the E group. However, there were no significant differences in morbidity, and both groups had zero mortality.

CONCLUSION

Both procedures can be carried out safely and with zero mortality. Relief of obstruction remains the mainstay of treatment. The better surgical option in our series is enterolithotomy alone. It is safe in both low and high-risk patients, and requires a shorter operating time as it is technically less demanding. In the longer term, the remnant fistula also does not appear to lead to further complications.

Multiple giant duodenal gallstones causing gastric outlet obstruction: Bouveret's minefield revisited

Gastric outlet obstruction caused by a gallstone impacted in the duodenum is a rare entity known as Bouveret's syndrome. We report the unusual case of multiple large gallstones impacted in the duodenum from a cholecystoduodenal fistula in an 83-year-old lady. A high index of suspicion allowed for prompt diagnosis. Early surgical intervention was instituted because if the size and number of gallstones with an excellent outcome. The surgical strategies and underlying pitfalls underlying the management of this syndrome are critically reviewed and discussed.

Clinical experience and results of ESWL treatment for 3,093 urinary calculi with the Storz Modulith SL 20 lithotripter at the Singapore general hospital

We study the outcome of 2,700 patients treated for 3,093 urinary calculi over a period of 60 months. All patients underwent Extracorporeal Shock Wave Lithotripsy (ESWL) treatment using the Storz Modulith SL20, predominantly on an outpatient basis (99.9% using intravenous pethidine for analgesia). The treatment outcome of 1,666 renal calculi and 1,427 ureteric calculi were analysed and stratified according to size and site. Follow-up status at 3 months was available for 91.8% of patients. For renal calculi, the overall success rate was 81% (re-treatment rate 29.7%). The majority of failures were stones larger than 2 cm and those situated in the lower pole of the renal calyces. The overall success rate for ureteric calculi is 85% with similar clearance rates throughout the ureter (re-treatment rate 22.8%). Failures were predominantly with stones larger than 2 cm. For the entire series, the morbidity rate requiring hospital admission was 2.9%, there was no mortality. The commonest cause for admission was for pain control (1.8%). To our knowledge, our experience with this lithotriptor is the largest to date. We have demonstrated that ESWL with Storz Modulith SL20 is safe, well tolerated and highly effective for the treatment of urolithiasis.

Autosomal dominant hypocalcemia: a novel activating mutation (E604K) in the cysteine-rich domain of the calcium-sensing receptor

We report a novel activating mutation (E604K) of the calcium-sensing receptor in a family with autosomal dominant hypocalcemia. Whereas all affected individuals exhibited marked hypocalcemia, some cases with untreated hypocalcemia exhibited seizures in infancy, whereas others were largely asymptomatic from birth into adulthood. The missense mutation E604K (G2182A; GenBank accession no. U20759), which affects an amino acid residue in the C terminus of the cysteine-rich domain of the extracellular head, cosegregated with hypocalcemia in all seven individuals for whom DNA was available. Two unaffected, normocalcemic members of the family did not exhibit the mutation. The molecular impact of the mutation on two key components of the signaling response was assessed in HEK-293 cells transiently transfected with cDNA corresponding to either the wild-type calcium-sensing receptor or the E604K mutation derived by site-directed mutagenesis. There was a significant leftward shift in the concentration response curves for the effects of extracellular Ca(2+) on both intracellular Ca(2+) mobilization (determined by aequorin luminescence) and MAPK activity (determined by luciferase expression). The C terminus of the cysteine-rich domain of the extracellular head may normally act to suppress receptor activity in the presence of low extracellular Ca(2+) concentrations.

Gallstone embedded within a port site metastasis--report of a case

The occurrence of port site metastasis after laparoscopic cholecystectomy for an incidental gallbladder carcinoma is well-documented but the underlying aetiology is not clear. Several mechanisms including tumour implantation to the effects of carbon dioxide usage have been implicated. Here, we describe an unusual case of a late port site recurrence in a 60-year-old woman where a gallstone was found embedded within the heart of the recurrence. We critically review the basic and clinical evidence that contributes to the pathophysiology of this phenomenon and the surgical strategies employed.

Does laparoscopic fenestration provide long-term alleviation for symptomatic cystic disease of the liver?

BACKGROUND

The use of laparoscopic technique for management of symptomatic liver cysts is documented to be a feasible and safe procedure with good short-term symptomatic relief. However, it cannot be recommended as the standard of care as long-term results are scarce. The present study was initiated to review the long-term results of this approach in the management of symptomatic liver cysts.

METHODS

A retrospective review of all patients with symptomatic liver cysts that were treated by laparoscopic fenestration in our department over an 8-year period from 1993 to 2001. The clinical and radiographical data were analysed at follow-up to assess the -outcome.

RESULTS

Eleven patients were treated using a laparoscopic approach; 10 patients with solitary cysts and one with adult polycystic liver disease. All patients achieved short-term alleviation of symptoms and an uneventful postoperative course. The mean hospital stay was 3 days. Long-term follow up was available for 9 patients with a mean of 44 months. Histologically, one of the patients was diagnosed with a biliary cystadenoma and she had a symptomatic recurrence and a liver resection at 20 months. In the other seven patients, there was no clinical recurrence but a radiographical recurrence of 28.5%. The patient with adult polycystic liver disease had two symptomatic recurrences: at 26 months where he underwent a repeat laparoscopic fenestration and at 43 months where he underwent an open fenestration.

CONCLUSION

The present study confirms that with adequate patients election, long-term alleviation of symptoms can be achieved with the laparoscopic approach for solitary simple liver cysts but not for polycystic liver disease or cystic tumours of the liver.

Current status in the surgical management of adult polycystic liver disease

INTRODUCTION

In patients with adult polycystic liver disease (APLD), there is considerable debate surrounding the most effective way of managing symptomatic cysts. Conservative approaches like percutaneous aspiration or cyst fenestration are associated with low morbidity but high recurrence rates. Conversely, liver resection and hepatectomy with orthotopic liver transplantation is drastic and associated with high morbidity and mortality rates. Our aim is to review the current understanding of liver cystogenesis in these patients and the therapeutic options available in order to provide a rationale guide to management of this intriguing condition.

METHODS

This article summarises the findings of published papers in major international journals indexed on MEDLINE on APLD using the key words--adult polycystic liver disease, liver cysts, fenestration, liver resection, liver transplantation and polycystic kidney disease. The period of search includes papers between 1965 and 2000.

RESULTS

Published studies have suggested a 'two-hit' hypothesis to explain the development of liver cysts in patients with APLD. This will provide the rationale for future management. Meanwhile, the indications, pitfalls and results of the various therapeutic options are reviewed. Management of symptoms has to be tailored to the underlying severity of the liver cystic disease, co-morbidity and procedural risks and recurrence rates.

CONCLUSION

Good long-term relief of symptoms can be achieved with the correct procedure at acceptable morbidity and mortality rates. We have provided guidelines on the various options available to enable a structured approach to the management of APLD.

Breast abscess as the initial presentation of squamous cell carcinoma of the breast

Breast abscesses are common and rarely harbour an underlying malignancy. Antibiotics and drainage by aspiration are the mainstays of treatment. We encountered two post-menopausal patients aged 48 and 70 who presented with acute breast abscesses that had an underlying squamous cell carcinoma of the breast. Infective aetiology was considered in each case and pre-operative diagnosis is possible but requires a high level of suspicion to avoid a delay in diagnosis. Aspirate from the abscess should be sent for both culture and cytology and if drainage is done, then biopsy of the abscess cavity is essential. Clinicians should be aware of the association of this rare primary neoplasm of the breast.

Pyogenic liver abscess complicated by endogenous endophthalmitis

BACKGROUND

Endogenous endophthalmitis is an inflammation of ocular tissues that can lead to deterioration of and loss of vision. Rarely, this can complicate the course of a patient with pyogenic liver abscess.

METHODS

Over an 18-month period, 68 patients were treated for pyogenic liver abscesses. Three patients, all of whom were male and with diabetes, were diagnosed with a Klebsiella pneumoniae liver abscess complicated by endogenous endophthalmitis. Open surgical or percutaneous drainage of the liver abscess was undertaken and the symptomology and outcome of the endophthalmitis reviewed.

RESULTS

There was no mortality in our series. Two patients presented with simultaneous abdominal and ocular symptoms and one patient had ocular symptoms 3 days after surgical drainage of the liver abscess. Despite aggressive treatment, all patients had permanent deterioration of visual function with one patient becoming blind and requiring evisceration of the infected eye.

CONCLUSION

Ocular symptoms in patients treated for pyogenic abscesses must be dealt with urgently with an ophthalmologic consultation. Increased awareness of this complication and a high index of suspicion are paramount for salvage of visual function.

Experimental evaluation of a mathematical model for predicting transfer efficiency of a high volume-low pressure air spray gun

The transfer efficiency of a spray-painting gun is defined as the amount of coating applied to the workpiece divided by the amount sprayed. Characterizing this transfer process allows for accurate estimation of the overspray generation rate, which is important for determining a spray painter's exposure to airborne contaminants. This study presents an experimental evaluation of a mathematical model for predicting the transfer efficiency of a high volume-low pressure spray gun. The effects of gun-to-surface distance and nozzle pressure on the agreement between the transfer efficiency measurement and prediction were examined. Wind tunnel studies and non-volatile vacuum pump oil in place of commercial paint were used to determine transfer efficiency at nine gun-to-surface distances and four nozzle pressure levels. The mathematical model successfully predicts transfer efficiency within the uncertainty limits. The least squares regression between measured and predicted transfer efficiency has a slope of 0.83 and an intercept of 0.12 (R2 = 0.98). Two correction factors were determined to improve the mathematical model. At higher nozzle pressure settings, 6.5 psig and 5.5 psig, the correction factor is a function of both gun-to-surface distance and nozzle pressure level. At lower nozzle pressures, 4 psig and 2.75 psig, gun-to-surface distance slightly influences the correction factor, while nozzle pressure has no discernible effect.

Exposure assessment of laboratory students

The Massachusetts Institute of Technology (MIT) has two kinds of laboratories, teaching for undergraduate students and research laboratories for graduate students and research staff. The objective of this study is to determine chemical exposures during teaching and research activities. There are three hypotheses in this study: (1) Exposures in academic laboratories are well below health standards; (2) Students in undergraduate teaching laboratories have less chemical exposure compared to students in graduate research laboratories; and (3) Students in different disciplines are expected to have different exposures. From September 1996 to December 1996, 132 air samples were collected from both teaching and research laboratories in the departments of Material Sciences and Engineering, Chemical Engineering, and Biology. The most frequently sampled chemicals in these three departments were cobalt, styrene, and formaldehyde, respectively. A total of 23 different agents were measured. In this study, the American Conference of Governmental Industrial Hygienists (ACGIH) threshold limit value (TLV)-short-term exposure limit (STEL) is used as the health-effect standard for exposure time less than four hours. The ACGIH TLV-TWA (time-weighted average) is used as the standard for exposure times equal to or greater than four hours. The ratio of measured concentrations to the appropriate ACGIH standard was then calculated. The geometric mean of the ratio for the total samples was 0.34 percent of the standards. There were 70 samples from teaching laboratories (geometric mean = 0.38% of the standards), and 62 samples from research laboratories (geometric mean = 0.08% of the standards). The chemical exposures relative to the standards in teaching laboratories were statistically higher than in research laboratories (p-value < 0.001). Information about personal protective equipment and the use of laboratory chemical hoods was also collected. The differences in use of personal protective equipment (PPE) among these departments was not statistically significant. From the air sampling results, we concluded that (1) Chemical exposures in the academic laboratories in this study were all well below the health standards; (2) Undergraduate students in teaching laboratories had higher chemical exposures than graduate students in research laboratories; (3) Chemical exposures among departments were not significantly different; and (4) Hazard communication, safety training, and laboratory rules enforcement are important for protection and may be the reason that the results from this study indicate that chemical exposures in this academic institution are well below the health standards under normal operations.

Clinics in diagnostic imaging (36). Benign renal oncocytoma

A 50-year-old Indian man presented with non-specific right-sided abdominal pain. Ultrasound of the abdomen demonstrated a small right renal tumour. Computed tomography showed features suggestive of a benign renal oncocytoma. This was confirmed by frozen section during surgical exploration. A partial nephrectomy was carried out. The role and limitations of imaging in the management of solid renal masses is discussed.