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.

Founder mutation in the BRCA1 gene in Malay breast cancer patients from Singapore

The mutation spectrum of the BRCA1 gene among ethnic groups from Asia has not been well studied. We investigated the frequency of mutations in the BRCA1 gene among Malay breast cancer patients from Singapore, independent of family history. By using the protein truncation test (PTT) and direct sequencing, BRCA1 mutations were detected in 6 of 49 (12.2%) unrelated patients. Four novel missense mutations in exon 11, T557A (1788A>G), T582A (1863A>G), N656S (2086A>G) and P684S (2169C>T) were identified in one patient. Two patients had missense mutations in exon 23, V1809A (5545T>C), which has been previously detected in individuals from Central and Eastern Europe. Three unrelated patients had the deleterious 2846insA frameshift mutation in exon 11. Methylation specific PCR (MSP) of the promoter region of the BRCA1 gene detected hypermethylation of tumor DNA in an additional 2 patients. Haplotype analysis using the microsatellite markers D17S855, D17S1323 and D17S1325 revealed a common haplotype for the three unrelated patients and their three relatives with the 2846insA mutation. These findings strongly suggest that the 2846insA mutation, the most common deleterious mutation in this study, may possibly be a founder mutation in breast cancer patients of Malay ethnic background.

Single institution's initial experience with sentinel lymph node biopsy in breast cancer patients

BACKGROUND

The sentinel lymph node is the first draining node from a cancer-bearing area and is therefore the first to manifest metastasis. In breast cancer it has been shown to predict the axillary status. Axillary dissection provides information determining prognosis and need for adjuvant therapy but carries a certain morbidity. Our aim was to determine the feasibility of detecting the sentinel node in a teaching hospital and whether the sentinel node accurately predicts the axillary status.

METHODS

All patients with stage I and II breast cancer and non-palpable axillary nodes were eligible, including those with previous excision biopsy. We excluded pregnant women, those with previous axillary surgery and women with advanced breast cancer with enlarged axillary nodes. The sentinel node was detected with technetium-99m-labelled tin colloid and vital blue dye and removed, and axillary clearance was performed.

RESULTS

A total of 312 patients were examined from August 1996 to December 1998. The mean age was 53 years (range 28-83) and mean tumour size 2.6 cm (range 0.2-9.0). The detection rate of the sentinel node was 86%. The sentinel lymph node predicted the axillary status with a sensitivity of 83% and specificity of 100%. The false-negative rate was 16.7%.

CONCLUSIONS

Detection of the sentinel lymph node is feasible and it can accurately predict the nodal status of the axilla. However, the high false-negative rate precludes as yet the use of sentinel lymph node biopsy in replacing axillary clearance as the standard of care for breast cancer.

All that wheezes is not asthma

Asthma is a common disease. Wheezing is not pathognomonic of asthma, however. One must be alert when appropriate asthmatic treatment does not provide adequate control. Other causes of airway obstruction must be considered, especially when stridor is heard. This report describes an elderly patient who had been managed as having asthma but had an endotracheal tumour.

Cost-effectiveness of CT thorax and bronchoscopy in haemoptysis with normal CXR for exclusion of lung cancer

As fibre-optic bronchoscopy and CT thorax become more widely used, patients with haemoptysis who had normal CXR and sputum results are more commonly offered both CT and bronchoscopy to exclude lung cancer. Doctors who are under possible litigation pressure arising from missed diagnoses of lung cancer are often exhaustive in their investigations, even when the haemoptysis has been transient. The present study aims to investigate the number of cancer patients who can be detected with the two investigations, and compare recent similar study results with archive results. We found that despite the use of more efficient investigation tools, the yield is paradoxically much lower and, hence, less cost-effective than that of previous studies. The likely reason is that doctors tend to over-investigate, even for short-term, minimal blood-streaked sputum, which is common among simple bronchitis. In order to be more cost-effective, these investigations should be used more selectively and for high risk patients such as those with prolonged haemoptysis and those who are heavy smokers.

Changing patterns of strabismus: a decade of experience in Hong Kong

BACKGROUND/AIMS

Racial variation in the pattern of strabismus is known, but few large scale studies on non-white populations are available. Furthermore, longitudinal change in this pattern within a local setting has not been well documented in the past. This study aims to support the clinical impression that exotropia is more common in Chinese patients, and that the proportion of patients with exotropia has been increasing in the past decade.

METHODS

A total of 2704 consecutive patients with the diagnosis of primary horizontal strabismus, seen in the strabismus clinic of the Hong Kong Eye Hospital, were retrospectively analysed to determine the relative prevalence of esotropia and exotropia. Characteristics recorded include patient demographics, type of strabismus, and whether the nature of the squint was constant or intermittent.

RESULTS

742 (27.4%) patients were found to have esotropia, 548 (20.3%) had constant exotropia, 1213 (44.9%) had intermittent exotropia, and 201 (7.4%) had microtropia. The proportion of exotropic to esotropic patients was shown to increase steadily throughout the past decade (p<0.0001). This was mainly accounted for by an increase in the number of patients with intermittent exotropia, and a corresponding decrease in the number of patients with esotropia.

CONCLUSION

Exotropia was shown to be more prevalent than esotropia in a Hong Kong Chinese population. Furthermore, the proportion of patients with intermittent exotropia appears to be increasing, in contrast with esotropic patients. The exact nature of this trend, and possible aetiological factors will require further study.

A study on the prevalence of and risk factors for neck pain among university academic staff in Hong Kong

The 1-year prevalence of neck pain and possible risk factors among university academic staff were investigated. Self-administered questionnaires were distributed to all the full-time academic staff in one of the universities in Hong Kong. The 1-year prevalence of neck pain was investigated. The relationship between individual factors, job nature, psychosocial factors, and neck pain were also analyzed. The 1-year prevalence of neck pain among after being an academic staff was 46.7%. A significant association was found between gender and neck pain (p = 0.02). The percentage of female academic staff with neck pain (62%) was higher than that in male staff (38%). This matched the results of other studies, which demonstrated that neck pain was more prevalent in women. There was a significant association between head posture during computer processing and neck pain (p = 0.02). Among those with neck pain during computer processing, 60.5% had a forward head posture. However, a low correlation between psychosocial factors and neck pain was demonstrated (r = 0.343). Academic staff in tertiary institutions could be considered as a high-risk group of job-related neck pain.

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.

Patterns of abnormal FDG uptake by various histological types of non-small cell lung cancer at initial staging by PET

The aim of this study was to identify useful patterns of abnormal fluorine-18 fluorodeoxyglucose (FDG) uptake by different types of non-small cell (NSC) lung cancer and to assess their clinical implications. One hundred and three sequential patients with newly diagnosed, pathology-proven NSC lung cancer were included. FDG positron emission tomography (PET) images were acquired using a dedicated PET scanner. There were 35 squamous cell carcinomas (SQC), 17 large cell cancers (LGC), 38 adenocarcinomas (ADC), 1 bronchioloalveolar carcinoma (BAC) and 12 non-classified NSC cancers. PET images were categorized into detectable patterns of necrotic center in the primary tumor, satellite lesions (T4), hilar lymph nodes (N1), and N2, N3, and M1 lesions by visual interpretation of PET images for SQC, LGC, and ADC (n=90; BAC and non-classified NSC cancers were excluded). The PET lesions were correlated with surgical pathology and with CT findings in inoperable cases. Necrosis was more commonly present in the primary tumors of LGC (53%) and SQC (43%) than in those of ADC (26%) (P<0.0001 and <0.01, respectively). The frequencies of nodal uptake in ADC, SQC and LGC were similar (71%, 60%, and 59%, respectively). However, M1 lesions were present significantly more often in LGC (41%) and ADC (34%) than in SQC (3%) (both P<0.0001). Significantly more surgically inoperable cases were found by PET (T4, N3, M1) in ADC (50%) and LGC (41%) than in SQC (26%) (P<0.001 and <0.02, respectively). Our results suggest a wide variation of PET findings for different types of NSC lung cancer. Identification of these patterns is useful in clinical PET interpretation, in that knowledge of the most probable association between the PET patterns and the histological types will facilitate initial staging and planning of management.

Gender-related psychosocial and cultural factors associated with condom use among Chinese married women

The present study explored the interplay of psychosocial, gender, and cultural factors on Chinese married women's condom use. A total of 433 Chinese married women residing in Hong Kong participated in the study. Correlation results showed that participants' conservative gender attitudes toward sexuality and sexual decision making were related to less accurate HIV/AIDS knowledge and less concern about contacting the disease from their husbands. About 34.4% of the sexually active participants never used condoms in the past 6 months, and current condom use was associated with egalitarian gender attitudes, positive feelings about condom use, and concerns about contacting HIV/AIDS from their husbands. Among all participants, 32.5% reported that they would not use condoms in their future sexual encounters. Future condom use was related to shorter duration of marriage, accurate HIV/AIDS knowledge, egalitarian gender attitudes, current condom use, and positive feelings about condom use. Results from the logistic regression analyses showed that egalitarian gender attitudes toward sexuality and positive feelings about condom use were the most salient predictors for current and future condom use.

Treating pulmonary TB. Revisiting an old problem

BACKGROUND

There is a resurgence of pulmonary tuberculosis worldwide, due to increase in air travel, decrease in resources in health control, as well as the AIDS pandemic. As pulmonary tuberculosis was not common in Australia, family physicians are facing a new challenge. The following is to highlight some principles in tuberculosis treatment.

OBJECTIVE

This article revisits some of the basic principles of treatment of tuberculosis in order to maximise management.

DISCUSSION

The tubercle bacillus has been capable of developing resistance to antituberculosis drugs for some time, making multiple drug therapy mandatory. Antituberculosis drugs on the other hand can be toxic and commonly cause gastro-intestinal upset. The patient has to take many tablets a day for many months. By informing patients of the side effects, compliance, which is the key issue to successful therapy, is enhanced.

Soluble E-cadherin is a valid prognostic marker in gastric carcinoma

BACKGROUND

Gastric cancer remains a major cause of cancer mortality globally but no good prognostic tumour marker is available. Soluble fragment of E-cadherin protein has been reported to increase in the sera of patients with cancer and recently was found to be elevated in 67% of patients with gastric cancer.

AIMS

To investigate if serum soluble E-cadherin is a valid prognostic marker in gastric cancer.

METHODS

Concentrations of soluble E-cadherin from 116 patients with histologically confirmed gastric adenocarcinoma and 40 healthy subjects were measured using an immunoenzymometric method with a commercially available sandwich ELISA kit based on monoclonal antibodies.

RESULTS

The logarithm of the means of soluble E-cadherin concentration was significantly higher in patients with gastric cancers (mean 3.85 (SD 0.28)) than in healthy subjects (3.71 (0.18)) (p=0.001), and in palliative/conservatively treated cancers (3.91 (0.35)) than in operable cancers (3.78 (0.19)) (p=0.015). The logarithm of the concentrations correlated with tumour size (p=0.032) and carcinoembryonic antigen concentrations (p=0.001). The cut off value calculated from discriminant analysis on operability and inoperability/palliative treatment was 7025 ng/ml. Soluble E-cadherin concentrations higher than this cut off value predicted tumour (T4) depth invasion (p=0.020, confidence interval (CI) 1.008-1.668) and palliative/conservative treatment (p=0.023, CI 1.038-2.514). In contrast, the relative risks for lymph node (N2) metastasis, distant metastasis, and stage III/IV disease were 1.41, 1.33, and 1.55 respectively, despite not reaching statistical significance.

CONCLUSION

Serum soluble E-cadherin is a potential valid prognostic marker for gastric cancer. A high concentration predicts palliative/conservative treatment and T4 invasion.

Pulmonary haemorrhage in a patient with Kikuchi disease

Kikuchi disease is an immunologic disease and most commonly presents with cervical lymphadenopathy. It is usually self-limiting [1]. It is sometimes associated with systemic lupus erythematosus (SLE) [2], and can be associated with many complications including aseptic meningitis, neuropathy, brachial neuritis. It can also be associated with lymphoma, and may sometimes be misdiagnosed as such [3]. The following is the first reported case of Kikuchi disease associated with pulmonary haemorrhage. The patient died and no other cause of the pulmonary haemorrhage could be identified at post mortem.

Surgical treatment of tibial plateau fracture in elderly patients

This retrospective study involves 22 patients with displaced tibial plateau fractures who were treated surgically from July 1993 to April 1996. All the patients were over 60 years old (mean 66.3 years old, range 61-80 years). All of the patients were treated by open reduction and internal fixation with AO/ASIF buttress plates (Synthes, Bochum, Switzerland). Additional small fragment plate or inter-fragmental screws were used in some of them as indicated. Two patients died during follow-up of causes unrelated to the fractures. The average follow-up time was 49.8 months (range 36-68 months). The other 20 patients were interviewed at the outpatient clinic, and radiographs of bilateral standing knees were taken. By comparison with the uninjured side on radiographs, condylar joint space depression was noted in 6 patients. However, joint depression greater than 4 mm was not found. Malalignment with varus or valgus greater than 5 deg was not demonstrated in any case. Their range of motion was restored in all patients, with more than 120 deg of flexion and without extension lag except for the one who suffered a superficial wound infection. No complication required further surgical management. During the period of follow-up, no accelerated degenerative change in the operated knee joint resulted in total knee arthroplasty. Two patients needed occasional medical treatment for residual knee joint pain. Only two patients needed canes for assistance during walking due to old age and minor stroke. The results justify surgical treatment for displaced tibial plateau fractures in elderly patients.

Effects of knee joint angles and fatigue on the neuromuscular control of vastus medialis oblique and vastus lateralis muscle in humans

The effects of different knee joint angles and fatigue on the neuromuscular control of the vastus medialis oblique (VMO) and vastus lateralis (VL) muscles were investigated in 17 (11 men, 6 women) young subjects. The electromyogram (EMG) activities and the force generation capacities were monitored before and after a fatigue protocol at three different knee joint angles, 90 degrees, 150 degrees, 175 degrees of knee extension, on three occasions. In response to randomly triggered light signals, the subjects performed three isometric maximal voluntary contraction (IMVC) that lasted for 4 to 8 s. This was then followed by the fatigue protocol which consisted of six bursts of contractions fixed at 30 s on and 10 s off. Immediately after the exercise to fatigue, the subjects performed another three IMVC in response to the light signals. Repeated measures ANOVA were performed to examine the effects of fatigue at these three positions on the electromechanical delay (EMD), median frequency (fmed), peak force (Fpeak) and root mean square (rms)-EMG:Fpeak quotient of VMO and VL. The results revealed a significant effect of the three knee joint angles on the EMD before the fatigue (P < 0.05). The fatigue protocol induced a significant decrease in Fpeak at all the three positions (P < 0.01). However, the fatigue induced a significant decrease of fmed at only 90 degrees and 150 degrees of knee extension (P < 0.01). This occurred in parallel with the lengthening of EMD at these two joint angles (P < 0.01 and P < 0.05). The effects of fatigue on the fmed and EMD were not significant between VMO and VL at all three angles. The insignificant difference in fmed and EMD between VMO and VL at the three knee positions before and after fatigue indicated that no preferential onset activation between VMO and VL had occurred.

Comparison of myocardial oxygen consumption using 11C acetate positron emission tomography scanning in a working and non-working heart transplant model

OBJECTIVE

In acute cardiac rejection, changes in myocardial oxygen consumption occur; non-invasive detection of these metabolic changes would have obvious clinical utility. In the classic cervical, heterotopic, canine, transplant model, the heart is non-working. It has a low myocardial oxygen consumption. Creation of a working model with normal myocardial oxygen consumption would enhance validity of non-human studies.

METHODS

Clearance of 11C acetate was determined by positron emission tomography (PET) scanning and compared with myocardial oxygen consumption in normal and transplanted canine hearts. Donor hearts from mongrel dogs (2.5-3 kg; n=4) were transplanted into the neck of adult beagles (12-15 kg; n=4), no immunosuppression was given. Two non-working hearts were modified to eject only coronary flow via the right ventricle. In two hearts, a novel working model was created with aortic regurgitation to load the left ventricle. Working and non-working hearts underwent PET scanning on post-operative days 2 and 4. Normal dog hearts (n=2) and native hearts of transplanted dogs (n=3) were used to validate the scanning technique. Coronary sinus and aortic oxygen saturation data along with myocardial blood flow (radiolabeled microspheres) confirmed that clearance of 11C acetate in normal and transplanted hearts followed a bi-exponential model.

RESULTS

Myocardial oxygen consumption was correlated with the rate constant of 11C acetate rapid phase clearance (r=0.91) in normal and transplanted hearts. The working hearts had increased myocardial oxygen consumption compared to non-working hearts.

CONCLUSIONS

This study (1) introduces a model of a working heterotopic cardiac transplantation with near-normal oxygen consumption; and (2) demonstrates that regional myocardial oxygen consumption in transplanted hearts can be detected by 11C acetate PET.

Impact of inadequate fine-needle aspiration cytology on outcome of patients with palpable breast lesions

BACKGROUND

The purpose of the present study was to assess the impact of inadequate fine-needle aspiration cytology (FNAC) breast specimens on the outcome of patients with a palpable breast lesion.

METHODS

A retrospective review was carried out of inadequate FNAC specimens from the Department of General Surgery, Singapore General Hospital in 1997.

RESULTS

One hundred and thirty-eight (16.6%) of 831 FNAC specimens were reported inadequate, and these form the study group. Outcome analysis was divided into benign on excision biopsy (n = 38; 29.4%); benign on repeat FNAC or trucut biopsy (n = 6; 4.7%); benign on follow up (n = 46; 35.7%); malignant on histology (n = 11; 8.5%); and lost to follow up (n = 28; 21.7%). The 11 cases with breast cancer were further analysed. The mean time to treatment was 88.3 days for three patients whose tumours were not clinically suspicious of malignancy versus 20 days for six patients who were diagnosed with cancer clinically from the onset. One patient with cancer refused treatment and one absconded from treatment only to return 7 months later.

CONCLUSION

Breast cancer was present in 8.5% of the inadequate FNAC specimens. When clinical suspicion of malignancy is high, an excision biopsy is advised in patients with inadequate FNAC specimens. If properly managed with triple tests and good clinical judgement, the inadequate FNAC specimens do not delay treatment in patients with breast cancer.

Microdochectomy for single-duct nipple discharge

INTRODUCTION

Isolated single-duct nipple discharge is worrying and poses a surgical dilemma. Factors predicting malignancy are controversial.

MATERIALS AND METHODS

Retrospective review of 92 consecutive microdochectomies for single-duct nipple discharge in a tertiary referral centre over 8 years.

RESULTS

The commonest causes were ductal papilloma (52%) and fibrocystic diseases of the breast (21%). Five (5%) patients had breast carcinoma, of whom only 1 had an invasive component. The median age of these patients was 43 years (range 26 to 72 years) which was similar to median age of the whole cohort. Sixty-seven (73%) patients presented with blood-stained nipple discharge. The 5 patients with breast carcinoma had blood-stained discharge. Mammography was abnormal in 1 out of 4 patients in the carcinoma group.

CONCLUSIONS

The incidence of breast carcinoma in patients presenting with isolated single-duct nipple discharge was low (5%) among Singaporean women. There was no reliable predictors of malignancy, though all patients with carcinoma presented with blood-stained discharge. Microdochectomy still remains an effective treatment for nipple discharge both for cure and diagnosis.

Serotonin infusion in the SCN reduces casein ingestion in rats

To compare food and water intakes, adult male Wistar rats were infused during 7 days with serotonin (5-HT, 2.5 nmol/24 h) or artificial cerebrospinal fluid (CSF) in the suprachiasmatic nucleus (SCN) in a three-way selection of macronutrient-rich diets. Nocturnal energy intake from the casein-rich diet was significantly lower during infusion of 5-HT than before infusion. Decrease in nocturnal casein consumption was significant in the middle dark phase. Within the infusion period, water intake was reduced by 5-HT infusion during the early, middle and late light phase. The present results reinforce the hypothesis of a serotonergic control of water intake and provide evidence for SCN 5-HT involvement in casein-specific dietary selection.

Focused abdominal sonography for trauma (FAST)

This study aims to examine the feasibility of applying the focused ultrasound examination (FAST) in the initial assessment of the trauma patient. Its advantage over diagnostic peritoneal lavage lies in the speed in which it can be performed, its non-invasiveness and repeatability. Over the period January 1997 to July 1998, the FAST examination (Acuson 128XP/10, 3.5 MHz probe) was used to assess the presence of haemopericardium or haemoperitoneum in 38 multi-trauma patients admitted to the Singapore General Hospital. The sample comprises mainly males (82%) with a mean age of 34 years (range 17 to 77 years). The mechanism of injury was predominantly blunt (95%). Mean Injury Severity Score (ISS) was 22. Eleven patients presented in shock and 16 patients had abdominal tenderness on examination. A single surgeon did the examination, which was performed during the secondary survey phase of resuscitation. Time taken for the FAST examination averaged 2.3 +/- 1.3 minutes. The results of the examination were compared to diagnostic peritoneal lavage, CT scan, operative findings, serial examination and/or post-mortem findings. Overall sensitivity was 67% and specificity 97%. Although the FAST examination missed the small amount of free fluid seen in the CT scan of 2 patients, these patients did not have to undergo laparotomy as their abdominal examination was normal. We conclude that the FAST examination is feasible and should be part of a general surgeon's armamentarium in the initial assessment of trauma.