'Fracture' of the penis: a case series

OBJECTIVES

To examine the epidemiology of penile 'fracture' and its presenting characteristics in the local population.

DESIGN

Retrospective study.

SETTING

District hospital, Hong Kong.

PATIENTS

Patients with a discharge diagnosis of 'fractured' penis during a 7-year period from August 1998 to August 2005.

MAIN OUTCOME MEASURES

Age, time of attendance, cause, symptoms, signs, emergency department diagnosis, site of rupture, operative findings, and final outcome.

RESULTS

A total of 11 patients were identified. The mean age was 44 years (range, 30-63 years). The interval between time of injury and presentation ranged from 17 minutes to 7 days. Seven (64%) cases were attributed to sexual intercourse, three (27%) to penile manipulation, and one (9%) to rolling over the erect penis during sleep. Ten patients underwent surgery; all had primary suturing of the tunica tear, while two also required primary urethral repair. At follow-up, three (27%) patients had erectile dysfunction, one had mild penile deformity and one had a mild urethral stricture.

CONCLUSION

Emergency physicians and surgeons, as well as family physicians, should be familiar with the presentation of 'fractured' penis, as prompt diagnosis and early surgical repair are instrumental in ensuring a successful outcome with minimal complications. The public should also be educated to seek medical attention immediately, as delay or failure to report may result in permanent physical and psychological disabilities that could otherwise have been avoided.

Isomaltooligosaccharide increases cecal Bifidobacterium population in young broiler chickens

A newly developed compound derived by fermentation, isomaltooligosaccharide (IMO), was hypothesized to enrich cecal bifidobacterial populations and reduce colonization levels of Salmonella in the ceca of broiler chickens. Broiler starter diets were prepared with final IMO concentrations of 1% (wt/wt), 2% (wt/wt), and 4% (wt/wt) and a control diet without IMO supplementation. Chickens were divided into 4 groups and challenged with 10(8) cell of Salmonlella enterica ser. Typhimurium with 200 microg/mL nalidixic acid resistant (S. Typhimurium Nalr) after 7 d of placement. The experiment was done in 3 replications. IMO-supplemented diets resulted in significantly higher cecal bifidobacteria compared with the control diet (P < 0.05). However, there was no significant difference in bifidobacteria counts among the treatment groups. Chickens fed diets with 1% IMO had a significant 2-log reduction in the level of inoculated S. Typhimurium Nalr (P < 0.05) present in, the ceca compared with the control group, but no differences were found between the control group and the groups fed 2 or 4% IMO for S. Typhimurium Nalr. No differences in feed consumption, feed conversion, or feed efficiency compared with the control group were observed; however, the result showed a significant reduction in weight for birds fed 1% IMO diet compared with those fed the control diet.

Intrahepatic cholestasis as a paraneoplastic syndrome associated with pheochromocytoma

Pheochromocytoma is a rare tumor of chromaffin cells that secrete catecholamines and several cytokines. The clinical manifestations are protean and may include hypertension, weight loss, sweating, palpitation, headache, anxiety, tremor, nausea, vomiting, and hypercalcemia. The tumor can mimic many unrelated diseases, leading to significant delay and difficulty in diagnosis. We report a case of a 37-yr-old male admitted with jaundice, dark urine, fever, and signs of a systemic inflammatory response. Abdominal computed tomography revealed a heterogeneously enhancing tumor between the pancreatic tail and left kidney. There was no evidence of obstruction to bile flow, neoplastic involvement of the liver or bile ducts, or infectious etiology. The tumor was removed and found to be a pheochromocytoma. Immunohistochemical analysis revealed the presence of interleukin-1beta in the tumor cells. After surgery, the jaundice resolved without further treatment, leading us to the conclusion that it was a paraneoplastic phenomenon possibly related to interleukin-1beta production. We suggest that occult pheochromocytoma should be added to the differential diagnosis of unexplained intrahepatic cholestasis.

A case of focal segmental glomerulosclerosis associated with aplastic anemia

The pathogenic mechanism of focal segmental glomerulosclerosis (FSGS) and aplastic anemia are associated with immunologic events which lead to glomerular cell injury or hematopoietic cell destruction. We present an extremely rare case of FSGS with aplastic anemia in a 30-yr-old woman. The laboratory examination showed hemoglobin 7.2 g/dL, white blood count of 4,200/ microL, platelet count 70,900/microL. Proteinuria (2+, 3.6 g/day) and microscopic hematuria were detected in urinalysis. The diagnosis of FSGS and aplastic anemia were confirmed by renal and bone marrow biopsy. She was treated with immunosuppressive therapy of prednisone 60 mg/day orally for 8 weeks and cyclosporine A 15 mg/kg/day orally. She responded with gradually improving her clinical manifestation and increasing peripheral blood cell counts. Prednisone was maintained at the adequate doses with tapering after 8 weeks and cyclosporine was given to achieve trough serum levels of 100-200 ng/mL. At review ten month after diagnosis and initial therapy, the patient was feeling well and her blood cell counts increased to near normal (Hb 9.5 g/dL, Hct 32%, WBC 8,300/microL, platelet 123,000/microL) and renal function maintains stable with normal range proteinuria (0.25 g/day).

Efficacy of Leuconostoc mesenteroides (ATCC 13146) isomaltooligosaccharides as a poultry prebiotic

The complex dietary carbohydrates, called prebiotics, have been used to control Salmonella and improve intestinal bacterial balance in broilers. Leuconostoc mesenteroides (ATCC 13146) isomaltooligosaccharides (IMO) stimulate growth of Bifidobacterium and Lactobacillus and are not used by Salmonella or Escherichia coli. We tested the efficacy of these IMO as a prebiotic. IMO, compared with fructooligosaccharides (FOS) as sole carbon source, promoted growth of chicken cecal isolates and Bifidobacterium. Cecal isolates and Salmonella typhimurium grown in mixed culture on IMO reduced the Salmonella population. Cecal isolates grown on IMO showed higher viable counts and faster growth than Salmonella, indicating a potential value for these oligomers for poultry intestinal microflora modification.

Disseminated intravascular coagulation associated with aortic dissecting aneurysm

Disseminated intravascular coagulation (DIC) is an acquired coagulation disorder that occurs when the normal hemostatic balance is disturbed, primarily by excessive thrombin formation. Moreover, while DIC is a rare complication of aortic dissecting aneurysm, it is also a well-recognized one. We reported a case of DIC associated with aortic dissecting aneurysm in a 55-year-old woman who was transferred from another hospital because of chest pain radiating to her back and thrombocytopenia. Laboratory findings showed DIC with severe thrombocytopenia, and she was diagnosed as having an acute aortic dissection and DIC. After medical treatment on the aortic dissecting aneurysm, her DIC profile recovered.

Long-term synaptic plasticity in deep layer-originated associational projections to superficial layers of rat entorhinal cortex

Superficial layers of the entorhinal cortex (EC) relay the majority of cortical input projections to the hippocampus, whereas deep layers of the EC mediate a large portion of hippocampal output projections back to other cortical areas, suggesting a functional segregation between superficial and deep layers of the EC as input and output structures of the hippocampus, respectively. However, deep layers of the EC send associational projections to superficial layers, suggesting a potential interaction between neocortical input and hippocampus-processed output in superficial layers. This possibility was investigated by examining whether deep to superficial EC projections support long-term synaptic plasticity, and whether they interact with other pathways in superficial layers in rat medial EC slice preparations. Synaptic responses of the deep-to-superficial layer projections were verified based on field potential profiles, paired-pulse facilitation, physical separation between superficial and deep layers, and pharmacological manipulation. Long-term potentiation (LTP) was reliably induced in the deep-to-superficial layer projections by burst stimulations that emulated theta or sharp wave electroencephalogram (EEG),and it was blocked by an N-methyl-d-aspartate receptor antagonist (D-2-amino-5-phosphonopentanoic acid) and a calcium channel blocker (nifedipine). Prolonged low frequency stimulation induced long-term depression. A weak stimulation of deep layers, which induced a small degree of LTP by itself, generated a much larger degree of LTP when paired with a strong stimulation of superficial layers, indicating that the deep-to-superficial layer projections cooperate with other pathways in the superficial EC to enhance synaptic weights. Our results suggest that neocortical input and hippocampal output information are integrated in superficial layers of the EC.

Small bowel perforation after radiotherapy for cervical carcinoma

Radiotherapy is the treatment of choice for carcinoma of the uterine cervix. We report on a 62-year-old Chinese woman with cervical carcinoma, in whom a small bowel perforation developed 5 months after radiotherapy. Ten centimetres of small bowel, including the perforation site, were resected. No bowel adhesion was detected during the operation. The postoperative course was uneventful, and the patient was discharged home 7 days after surgery. Histological examination confirmed post-irradiation injury. The presenting complaints of patients with bowel perforation following radiotherapy vary, and signs of peritonitis may be absent. Emergency physicians must be alert for these complications in patients who have been treated with radiotherapy.

Subtle perforation of the oesophagus by a foreign body

A case of subtle oesophageal perforation caused by a foreign body is described. A 48-year-old woman had had a chicken bone impacted in the upper oesophagus for 4 days. At presentation, the bone was dislodged at endoscopy, and two small round depressions at opposite sides of the oesophageal wall were visible. The chest X-ray findings were normal. Computed tomography of the thorax detected a small amount of air in the mediastinum. The water-soluble contrast swallow test showed no evidence of leakage. The patient was successfully treated using conservative measures.

Transient hypotension after high-speed head-on motor vehicle collision

A 43-year-old woman was taken to the accident and emergency department after a high-speed motor vehicle collision. She had only minor external injuries, but developed an episode of hypotension, which rapidly responded to fluid infusion. Chest X-ray showed a widened superior mediastinum. Computed tomography confirmed thoracic aortic injury. In patients with high-speed deceleration injury, even transient hypotension should be taken seriously and a diligent search for the source of bleeding should be immediately undertaken.

Hip pain and childhood malignancy

In children, neuroblastoma can mimic various orthopaedic pathologies and this may create difficulties for doctors in reaching the correct diagnosis. Stage IV neuroblastoma was initially diagnosed as transient synovitis in this case report of a 7-year-old girl presenting with hip and low back pain.

A returned traveller with persistent fever due to murine typhus

Murine (endemic) typhus is a notifiable disease in Hong Kong, but its diagnosis can be difficult. We report a case of murine typhus in a middle-aged man who presented with persistent fever, headache, and skin rash 2 weeks after returning from a visit to China. The diagnosis of murine typhus requires a high index of suspicion for a febrile patient with a history of potential exposure to the disease vector (rat flea) in an endemic area. The importance of early recognition lies in the potential for early therapeutic intervention, leading to decreases in morbidity and duration of stay in hospital.

Corrosive oesophageal injury following vinegar ingestion

A 39-year-old woman drank one tablespoon of white vinegar in order to 'soften' crab shell stuck in her throat. Endoscopy revealed inflammation of the oropharynx and second-degree caustic injury of the oesophagus extending to the cardia. She had an uneventful recovery. This case report confirmed that vinegar could cause ulcerative injury to the oropharynx and oesophagus. The folklore application of vinegar 'dislodging' a foreign body in the throat should be strongly discouraged.

Adult acute epiglottitis and foreign body in the throat - chicken or egg?

A 53 year old man presented with the chief complaint of having a fish bone stuck in the throat for about 1 h. There was no dysphagia or respiratory symptoms. Plain lateral neck X-ray, direct laryngoscopy and oesophagogastroduodenoscopy showed a grossly swollen epiglottis with narrowing of the laryngeal lumen. No foreign body was found. His condition improved rapidly with intravenous antibiotic therapy. As acute epiglottitis may be a sudden life-threatening condition, a high index of suspicion should be maintained for patients who present with alleged foreign bodies in the throat.

Group A streptococcal infection in patients presenting with a sore throat at an accident and emergency department: prospective observational study

OBJECTIVES

To determine the prevalence of group A streptococcal infection and to evaluate the predictive value of clinical findings and rapid streptococcal antigen detection testing in patients presenting with a sore throat or suspected clinically to have acute pharyngitis.

DESIGN

Prospective observational study.

SETTING

Accident and emergency department of a public hospital, Hong Kong.

PATIENTS

All patients presenting with a sore throat as the chief complaint, or suspected clinically to have acute pharyngitis, from April to September 2000.

MAIN OUTCOME MEASURES

Demographic data, clinical features, microbiological throat culture results, and rapid streptococcal antigen detection (Accustrip) test results.

RESULTS

Of 1449 patients recruited during the 6-month study period, only 44 (3.0%) had positive throat cultures for group A beta-haemolytic streptococcus. The majority of group A beta-haemolytic streptococci were isolated from patients between the age of 3 and 60 years. Clinical findings other than an absence of cough were found to be unhelpful in predicting group A beta-haemolytic streptococcal throat infection. The sensitivity of the rapid group A streptococcal antigen detection test was 52.6% and the specificity was 98.2%.

CONCLUSIONS

The prevalence of group A beta-haemolytic streptococcus in patients presenting with a sore throat, or suspected clinically of having acute pharyngitis, was low. If empirical antibiotics were given to all such patients, 97% of them would be unnecessarily treated. Age and absence of cough were the only clinical findings helpful in predicting the presence of group A beta-haemolytic streptococcal throat infection. The rapid group A streptococcal antigen detection test can provide a quick guide to clinicians on the necessity of antibiotic therapy. However, a confirmatory throat culture backup is recommended for patients with a negative test result.

Patient absconding behaviour in a public general hospital: retrospective study

OBJECTIVE

To identify characteristics of patients who abscond from general hospital wards, and to determine patient outcomes.

DESIGN

Retrospective study.

SETTING

In-patient wards of a public general hospital, Hong Kong.

SUBJECTS AND METHODS

Incident reports of 116 absconding episodes over a 20-month period from 1 November 1998 to 30 June 2000 were reviewed. Clinical characteristics, time and reason for absconding, destination of patient, outcomes, and adverse events were recorded.

RESULTS

The majority of patients who absconded were middle-aged males admitted through the Accident and Emergency Department to the specialty of general medicine. Most incidences occurred within 24 hours of admission while in the emergency admission wards. Twelve percent of incidents were repeated episodes of absconding. The most common clinical diagnoses given to this patient group were drug overdose, intoxication, and soft tissue injury. Known drug addicts (29.3%) formed a substantial proportion of the patient group. Forty- seven patients returned to the ward within a few hours, while a further nine (7.8%) re-attended the Accident and Emergency Department of the hospital within 4 days. Several adverse outcomes were recorded: one patient died following a fall from height and two patients committed criminal offences.

CONCLUSION

Patient absconding incidents are an important issue in hospital risk management. They can delay the delivery of appropriate medical treatment and may lead to other adverse patient outcomes, in addition to potential medicolegal consequences.

Tumor necrosis factor-alpha supports the survival of osteoclasts through the activation of Akt and ERK

Differentiated osteoclasts have a short life span. We tested various cytokines and growth factors for the effects on the survival of purified mature osteoclasts. In the absence of any added factors, osteoclasts exhibited the survival rate of less than 25% after a 24-h incubation. Among the tested factors, tumor necrosis factor-alpha (TNF-alpha) was found to increase the survival rate to approximately 80%. The TNF-alpha-enhanced survival of osteoclasts appeared to be associated with reduction in apoptosis and suppression of caspase activation. The antiapoptotic signaling pathways involved in the TNF-alpha-induced osteoclast survival were investigated. TNF-alpha treatment increased the phosphorylation of Akt in osteoclasts, which was suppressed by a phosphatidylinositol 3-kinase inhibitor LY294002 and an Src family kinase-selective inhibitor PP1. These inhibitors also attenuated the TNF-alpha stimulation of osteoclast survival. In addition an increase in the phosphorylation of ERK was observed upon TNF-alpha stimulation. PD98059, a specific inhibitor of the ERK-activating kinase MEK-1, abolished the TNF-alpha-induced ERK phosphorylation and osteoclast survival, and in these responses the involvement of Grb2 and ceramide was observed. These results suggest that TNF-alpha promotes the survival of osteoclasts by engaging the phosphatidylinositol 3-kinase Akt and MEK/ERK signaling pathways.

Nucleotide-dependent conformational changes in a protease-associated ATPase HsIU

BACKGROUND

The bacterial heat shock locus ATPase HslU is an AAA(+) protein that has structures known in many nucleotide-free and -bound states. Nucleotide is required for the formation of the biologically active HslU hexameric assembly. The hexameric HslU ATPase binds the dodecameric HslV peptidase and forms an ATP-dependent HslVU protease.

RESULTS

We have characterized four distinct HslU conformational states, going sequentially from open to closed: the empty, SO(4), ATP, and ADP states. The nucleotide binds at a cleft formed by an alpha/beta domain and an alpha-helical domain in HslU. The four HslU states differ by a rotation of the alpha-helical domain. This classification leads to a correction of nucleotide identity in one structure and reveals the ATP hydrolysis-dependent structural changes in the HslVU complex, including a ring rotation and a conformational change of the HslU C terminus. This leads to an amended protein unfolding-coupled translocation mechanism.

CONCLUSIONS

The observed nucleotide-dependent conformational changes in HslU and their governing principles provide a framework for the mechanistic understanding of other AAA(+) proteins.

Basic fibroblast growth factor as a growth factor for SRV-2-infected simian retroperitoneal fibromatosis cells, an animal model for AIDS related Kaposi's sarcoma

Basic fibroblast growth factor (bFGF) and vascular endothelial cell growth factor (VEGF) were demonstrated to be important factors sustaining the growth of Kaposi's sarcoma. RF cells were used to provide a model to study the pathogenesis of Kaposi's sarcoma. In this paper, we demonstrated that bFGF is present in the RF cells, cultured media, and tissues from monkey. The biological activities of bFGF on RF cells were also studied in vitro with serum-free media. The bFGF from serum-free-conditioned media is biologically active to stimulate RF cells in certain media condition. The mitogenic effect was abrogated by sheep neutralizing anti-bFGF antibody. Furthermore, the effect of antibody was reversed by the addition of exogenous bFGF. ELISA measurements indicating the growth potency of conditioned media correlated with the amount of bFGF in the conditioned media. The data from flow cytometry demonstrated the co-existence of SRV-2 and bFGF among RF cells and RF tissues. Immunohistochemical staining of RF tissue blocks for bFGF revealed that bFGF was present in the tumor and the presence of bFGF was not caused by the artifact of tissue culture. These results indicate that bFGF is an important growth factor to promote RF cell growth in vitro and RF tumor in vivo. Further studies are required to determine the relationship between the interaction of bFGF, SRV-2, and VEGF. This model also provides an adequate alternative to the model induced by simian immunodeficiency virus (SIV) to study the Kaposi's sarcoma.

A deubiquitinating enzyme, UCH/CeUBP130, has an essential role in the formation of a functional microtubule-organizing centre (MTOC) during early cleavage in C. elegans

BACKGROUND

Deubiquitinating enzymes generate monomeric ubiquitin in protein degradation pathways and are known to be important for the early development in many organisms.

RESULTS

RNA interference experiments targeted for a UBP homologue, UCH/CeUBP130, in C. elegans resulted in cell division defective embryos. Immunostaining localized UCH/CeUBP130 in the sperm and at the microtubule-organizing centre (MTOC) during early cleavage. Furthermore, the embryonic lethal phenotype was rescued by mating with wild-type males.

CONCLUSIONS

Since it is known that the MTOC in the fertilized embryo is contributed by sperm asters in C. elegans, we suggest that UCH/CeUBP130 and ubiquitin protein degradation pathways may be involved in microtubule-based sperm aster formation. Therefore UCH/CeUBP130 is necessary for the formation of a functional MTOC in the fertilized embryo of C. elegans.

Effect of occlusal trauma on healing of periapical pathoses: report of two cases

AIM

To present two clinical cases and demonstrate that occlusal trauma may affect healing of periapical pathoses.

SUMMARY

Two teeth with periradicular disease did not respond successfully to conventional root canal treatment or endodontic surgery. Occlusal adjustment was finally performed on both cases. After occlusal adjustment, uncomplicated healing and periapical repair occurred in both cases. The findings in these two cases suggest that occlusal trauma may play a role in the healing of periapical pathoses.

KEY LEARNING POINTS

Occlusal trauma is positively correlated with changes in periodontal tissues. Although experiments in animals have shown that application of forces to teeth will not induce further periodontal destruction, we believe that some failures of root canal treatment may be due to the presence of occlusal trauma modulating the responses of inflamed periapical tissues or apical pathoses with persistent infection.

The effect of combined 5-fluorouracil and dexamethasone on cultured human retinal pigment epithelial cells

This study was designed to investigate the inhibitory effect of 5-fluorouracil (5-FU) and dexamethasone (DEX) on the proliferation of human retinal pigment epithelial (RPE) cells in vitro. The human RPE cells (R-50 cell line) were cultured and exposed to various concentrations of combined 5-FU (0, 250, 500, 1000, 2000 ng/ml) and DEX (0, 1, 10, 100, 200 micrograms/ml). The cells were incubated for 96 hr and the medium was changed every 48 hr to replenish the drug action. Cell viability was assessed using cell counting and trypan blue exclusion method. Tetrazolium salt, which can be metabolized by mitochondrial dehydrogenase to form a formazan dye, was used to assay cell proliferation. Treatment with 5-FU alone inhibited cell proliferation in a dose-dependent manner. The concentration of 5-FU that inhibited growth by 50% (IC50) was found to be 704.12 ng/ml. There was a bimodal effect of DEX on RPE cells--stimulation at low concentrations (1, 10 micrograms/ml) and inhibition at high concentrations (100, 200 micrograms/ml). When the two drugs were combined, there was additive inhibition in the concentration of 200 micrograms/ml of DEX. These results indicate that a combination of 5-FU and DEX is no more effective in the inhibition of human RPE cells, except in combination with high concentrations of DEX (> or = 200 micrograms/ml).

Arsenite induces oxidative DNA adducts and DNA-protein cross-links in mammalian cells

Arsenic is generally recognized as a nonmutagenic carcinogen because sodium arsenite induces DNA damage only at very high concentrations. In this study we demonstrate that arsenite concentrations above 0.25 microM induce DNA strand breaks in both human leukemia cells and Chinese hamster ovary cells. Therefore, DNA damage may be involved in arsenic-induced carcinogenesis. Formamidopyrimidine-DNA glycosylase and proteinase K greatly increased DNA strand breaks in arsenite-treated cells, providing evidence that a large portion of arsenite-induced DNA strand breaks come from excision of oxidative DNA adducts and DNA-protein cross-links. Because DNA strand breaks appear only temporarily during excision repair, the level of detectable DNA strand breaks will be low at any given time point. For this reason many previous studies have only detected low levels of DNA strand breaks. We also show that catalase, and inhibitors of calcium, nitric oxide synthase, superoxide dismutase, and myeloperoxidase, could modulate arsenite-induced DNA damage. We conclude that arsenite induces DNA adducts through calcium-mediated production of peroxynitrite, hypochlorous acid, and hydroxyl radicals.