Analyzing the most effective indicators of accountant professional ethics: the inevitable necessity for assessing the safe behavior of accountants

Introduction: Morality is very important in human life because human humanity is formed when moral values are crystallized in him. Every human being is evaluated to the extent of the emergence of moral values in thoughts, speech, and behavior, the first manifestation of a person in society is that person's morality. To increase the impact of professional ethics, it is necessary to have patterns that are consistent with culture and society, and by recognizing them, the dimensions of safe behavior by accountants can be explored. Materials and Methods: This research is based on a combined method. Because in this research, both quantitative and qualitative approaches have been used in data collection and analysis, a combination of findings and conclusions. In the present study, data collection has been done through library and field research methods. Statistics consists of theoretical texts related to accounting professional ethics. In this study, using a researcher-made questionnaire, effective criteria based on previous research were identified and finally, 25 sub-components in the form of 5 indicators were identified as the most important factors of professional ethics. In this study, NVIVO software (in the content analysis section) Used. Results: According to experts, the components of professionalism and organization are more important than other criteria and affect the sustainable development of safe behavior and professional ethics of the accountant. Conclusion: By understanding the professional ethics of accountants and identifying its basic components in different dimensions and determining the importance of each of them, a specific framework or format for accountants to observe or not to observe professional ethics and the desire to act based on Design and implement a code of professional conduct to reduce unsafe behaviors and, as a result, reduce the incidence of accidents in the country's industries.

Fixed-time terminal synergetic observer for synchronization of fractional-order chaotic systems

In this paper, a fixed-time terminal synergetic observer for synchronization of fractional-order nonlinear chaotic systems is proposed. First, fixed-time terminal attractors for fractional-order nonlinear systems are introduced on the basis of fixed-time stability of integer-order nonlinear differential equations and on defining particular fractional-order macro-variables. Second, a new synergetic observer dedicated to the synchronization of fractional-order chaotic systems is developed. The proposed observer converges in a predefined fixed-time uniformly bounded with respect to initial conditions. Thanks to the step-by-step procedure, only one communication channel is used to achieve the synchronization. Third, a fixed-time synergetic extended observer with unknown input is constructed to simultaneously estimate the state variables and to recover the unknown input. Finally, computer simulations are performed to illustrate the efficiency of the proposed synchronization method and its application in a secure communication scheme.

Comparative analysis of cellulose acetate hemoglobin electrophoresis and high performance liquid chromatography for quantitative determination of hemoglobin A2

Background

The present study is designed to evaluate the reliability and cost effectiveness of cellulose acetate Hb electrophoresis and high performance liquid chromatography (HPLC) in the determination of HbA2 levels.

Methods

The test population comprised 160 individuals divided into four groups: normal individuals, β-thalassemia trait (BTT) patients, iron deficiency anemia (IDA) patients, and co-morbid patients (BTT with IDA). HbA2 levels determined using cellulose acetate Hb electrophoresis and HPLC were compared.

Results

HbA2 levels were found to be diagnostic for classical BTT using either method. In co-morbid cases, both techniques failed to diagnose all cases of BTT. The sensitivity, specificity, and Youden's index for detection of the co-morbid condition was 69% and 66% for HPLC and cellulose acetate Hb electrophoresis, respectively.

Conclusion

This study revealed that semi-automated cellulose acetate Hb electrophoresis is more suitable for use in β-thalassemia prevention programs in low-income countries like Pakistan. This technique is easily available, simple and cost effective.

Frequency of JAK2 V617F mutation in patients with Philadelphia positive Chronic Myeloid Leukemia in Pakistan

Background and Objective: Co-existence of myeloproliferative disorders (MPD) and Janus associated kinase 2 mutation (JAK2 V617F) is a well-established fact. Only few case reports are available showing presence of JAK2 V617F mutation in chronic myeloid leukemia (CML). Purpose of this study was to determine the frequency of JAK2 V617F mutation in Philadelphia Chromosome positive (Ph ⁺) CML patients in Pakistan.

Methods: The study was conducted from August 2009 to July 2010 at Civil Hospital and Baqai Institute of Hematology (BIH) Karachi. Blood samples from 25 patients with CML were collected. Multiplex reverse transcription polymerase chain reaction (RT-PCR) was performed for Breakpoint Cluster Region – Abelson (BCR-ABL) rearrangement. Conventional PCR was performed for JAK2 V617F mutation on BCR-ABL positive samples.

Results: All 25 samples showed BCR-ABL rearrangement. Out of these 11 samples (44%) had JAK2 V617F mutation; the remaining 14 (56%) cases showed JAK2 617V wild type.

Conclusion: It is concluded that the co-existence of Ph ⁺CML and JAK2 V617F mutation is possible.

Heterogeneity of BCR-ABL rearrangement in patients with chronic myeloid leukemia in Pakistan

BACKGROUND AND OBJECTIVE

Breakpoint cluster region-Abelson (BCR-ABL) rearrangement or Philadelphia (Ph) chromosome in Chronic Myeloid Leukemia (CML) is derived from a reciprocal chromosomal translocation between ABL gene on chromosome 9 and BCR gene on chromosome 22. This chimeric protein has various sizes and therefore different clinical behaviour. The purpose of this study was to determine the heterogeneity of BCR-ABL rearrangement in patients with Ph(+)CML in Pakistan.

METHODS

The study was conducted at Civil Hospital and Baqai Institute of Hematology (BIH) Karachi. Blood samples from 25 patients with CML were collected. Multiplex reverse transcription polymerase chain reaction (RT-PCR) was performed to identify various BCR-ABL transcripts.

RESULTS

All 25 samples showed BCR-ABL rearrangements. Out of these, 24 (96%) patients expressed p210 BCR-ABL rearrangements i.e. 60% (n=15) had b3a2 and 32% (n=8) had b2a2 rearrangements. Co-expression of b3a2 /b2a2 rearrangement and p190 (e1a3) rearrangement was also identified in two patients.

CONCLUSION

It is apparent that majority of the patients had p210 BCR-ABL rearrangements. Frequency of co-expression and rare fusion transcripts was very low.

New horizons in platelets flow cytometry

Platelet flow cytometry is an emerging tool in diagnostic and therapeutic hematology. It is eminently suited to study the expression of platelet surface receptors both qualitatively as well as quantitatively. It can serve as a useful marker for the documentation of in vivo platelet activation, and thus, fore-warn the risk of thromboembolism in patients with diabetes mellitus, coronary syndromes, peripheral vascular diseases, and pre-eclampsia. This technique can also be extended to study and compare the effect of various antiplatelet drugs on the level of activation of platelets and to establish any dose-effect relationship of these drugs. Topographical localization of platelet granules and study of platelet-platelet and platelet-leukocyte interaction is also possible by this procedure. All these parameters serve as pointers towards the presence of activated platelets in the circulation with its thromboembolic consequences. This is a simple reliable and cost effective technique which has a wide application in the diagnosis of various inherited and acquired platelet disorders. Study of platelet cluster of differentiation (CD) markers in various inherited disorders i.e. Bernard Soulier's disease, von Willebrand disease, Glanzman's disease, and Grey platelet syndrome may help categories the molecular lesions in these oft under-studied disorders.

Role of iron deficiency anemia in the propagation of beta thalssemia gene

BACKGROUND

The diagnostic criterion for beta thalassemia trait (BTT) is elevated Hb-A(2) levels. Iron deficiency anemia (IDA) reduces the synthesis of Hb-A(2), resulting in reduced Hb-A(2) levels, so patients with co-pathological conditions BTT with IDA, may have a normal level of Hb-A(2). Many socio-economic factors like unawareness, poor diagnostic facilities, and cost of molecular diagnosis (for screening purposes) result in interpretation of these subjects as normal.

METHODS

Venous blood samples from 200 unmarried females having a family history of thalassemia were collected, and basic hematological parameters, hemoglobin electrophoresis, and molecular analysis for beta thalassemia were done. Patients with IDA and patients with co-pathological conditions BTT and IDA were treated with oral iron. These subjects were then followed for a period of 20 weeks.

RESULTS

Of the 200 females, 34 were found to be anemic. Hemoglobin electrophoresis identified 16 of these patients as BTT. Molecular analysis of all patients confirmed this diagnosis, but identified 8 additional patients with BTT. Eight patients that were not detected with hemoglobin electrophoresis were found to have co-pathology of BTT with IDA.

CONCLUSION

Patients with the co-pathological condition BTT with IDA may be interpreted as being normal, as they have normal Hb-A(2) levels. These misdiagnosed subjects when marry with BTT have the potential to produce beta thalassemia major in offspring. This is one of the factors playing a major role in the propagation of beta thalassemia gene in Pakistani population, and become a serious hindrance for the thalassemia prevention program in Pakistan.

Molecular genetics of beta-thalassaemia syndrome in Pakistan

This molecular genetics study was conducted in Karachi, Pakistan from 2004 to 2006 to provide guidelines for prenatal diagnosis programmes in the country. Blood samples of patients with beta-thalassaemia minor (n=200) and beta-thalassaemia major (n=150) were collected from hospitals, transfusion centres and diagnostic laboratories from different districts of Karachi, representing 5 major ethnic groups. Molecular analysis revealed 11 genetic mutations of the beta-thalassaemia gene, among which 5 mutations accounted for 88% of the total beta-thalassaemia genes identified [IVS-1-5 (G-C), Fr 8/9 (+G), Fr 41/42 (-TTCT), IVS-1-1 (G-T) and Del 619]. Other mutations identified were: CAP+1 IVS-II-1 (G-A), Cd 5 (-CT), Cd 15 (G-A). Cd 16 and Cd 30.

Cap +1 mutation; an unsuspected cause of beta thalassaemia transmission in Pakistan

OBJECTIVE

Thalassemia is one of the most common genetic disorders worldwide. Cap +1 mutation which causes 'silent beta thalassemia' is present around all ethnic groups of Pakistan. This study was designed to detect the frequency of Cap+1 mutation in Pakistani Population.

METHODS

Molecular genetic for Cap+1 beta thalassemic mutation was done by extracting DNA from whole blood by using Genomic DNA Purification Kit (Gentra system USA). Amplification Refractory Mutation System (ARMS) primers were designed for detection of normal and mutant DNA. Basic hematological parameters were performed by using automated analyzer (Sysmex KX-21). Cellulose acetate hemoglobin electrophoresis was done by using semi-automated technique (INTERLAB Roma Microtech Series Electrophoresis system 4.23).

RESULTS

The frequency of Cap+1 mutation was observed 5% (10/200) in targeted thalassemic families (having patients with beta-thalassemia intermedia) while its frequency was observed 2% (12/600) in total thalassemic genes in Pakistani population.

CONCLUSION

Cap+1 (A-C) is a silent mutation and it has very minimum effect on beta globin synthesis because of which it produces very less clinical severity and certain important laboratory diagnostic tests like basic hematological parameters and Hb A2 levels are also remain in normal range. Therefore individuals with Cap+1 mutation may produce children with beta-thalassemia intermedia if they marry an individual with beta-thalassemia minor. Cap+1 (A-C) mutation is an unsuspected cause of beta thalassemia transmission in Pakistani population. This mutation can identify at molecular level. As this molecular defect is difficult to diagnose in Laboratory with routine laboratory tests because of that it has become a serious hindrance for thalassemia prevention program in Pakistan.

Screening of Five Common Beta Thalassemia Mutations in the Pakistani Population: A basis for prenatal diagnosis

OBJECTIVES

Thalassemia is one of the most common autosomal single-gene disorder worldwide. The highest prevalence of the disease is in the "thalassemia belt" which includes the Mediterranean region, parts of the Middle East, the Indian subcontinent, the southern parts of the Far East, Pakistan and South-East Asia. This study aimed to detect the common molecular abnormalities of the beta thalassemia syndrome in Pakistan.

METHODS

The study was conducted at the Institute of Hematology, Baqai Medical University, Karachi, Pakistan from August 2004 to November 2007. Blood samples of patients with beta thalassemia major (n = 400) were collected from hospital transfusion centres and diagnostic laboratories in different districts of Karachi representing five major ethnic groups including Punjabi, Pathan, Sindhi, Baluchi and Urdu speaking. All the samples were analysed for five common mutations by using the polymerase chain reaction technique ARMS (amplification of refractory mutation system).

RESULTS

The data revealed five common mutations including IVS 1-5(G→C), Fr 41/42(-CTTT), Fr 8/9 (+G), IVS 1-1 and Del 619. These accounted for 90% of the total beta thalassemia genes in Pakistan. The IVS 1-5(G→C) was found to be the most common beta thalassemia gene in the Pakistani population with a frequency of 44.4% present in all major ethnic groups.

CONCLUSION

The results of this study will be helpful in the establishment of a large scale prenatal diagnosis programme in Pakistan.

Geographical distribution of cutaneous leishmaniasis and sand flies in Pakistan

Cutaneous leishmaniasis is found in all the four provinces of Pakistan; these are NWFP, Balochistan, Sindh and Punjab. In Balochistan the areas from where the patients came are Uthal, Quetta and Ormara. The highest number of patients came from Quetta and least from Ormara. The patients included in this study were from the Mangopir and Chakewara, areas of Karachi. The infection is endemic in this country and the recent epidemics in the Dadu District and Nawabshah indicate its importance in the locality. The sand fly vector is found in all four provinces of Pakistan that are listed here. It is quite obvious that presence of leishmaniasis indicates the presence of sand flies and cutaneous leishmaniasis is more common.

Early experience with transmyocardial laser revascularization

Conventional treatment of coronary artery disease consists of either Coronary Artery Bypass Grafting (CABG), medical therapy or percutaneous transluminal coronary angioplasty (PTCA) or a combination. However, certain group of patients do not even qualify for CABG. Transmyocardial Laser Revascularization (TMR) is a unique new surgical modality specially for that sub group of patient population who have small and diffuse coronary artery disease not suitable for grafting. King Fahad Heart Center initiated its TMR program in February, 1994 and until February, 1996, 100 patients under went the TMR procedure. Eighty-one were males and 19 females with a mean average age of 55 years. Seventy-nine patients had 3 vessel disease (VD) and 66 patients had non-graftable small vessels. Ten patients had left ventricular ejection fraction (LVEF) less than 30%. All the patients underwent a strict protocol of follow-up. The pre and post TMR assessment at six months and 12 months follow-up showed an increase in LVEF at six and 12 months as compared to pre TMR level. The exercise time also increased from a base line level at six months and showed further improvement at 12 months which was statistically significant (p < 0.05) along-with VO2 max, which also showed improvement. Clinically, haemodynamically and symptomatically these patients showed significant improvement and use of anti-anginal drugs (87%) was reduced to minimum. Isotope myocardial perfusion scan on 15 segment viability score showed an improvement from pre TMR level of 33.8 to 45.9 at post TMR 12 months follow up. The surgical mortality in this high risk TMR population was 10%. TMR was found to be a reasonable alternative to medical treatment in patients with angina due to diffuse and or small vessel disease or occluded previous grafts not amenable to CABG.

Thrombotic obstruction of bileaflet mechanical prosthetic heart valves: early diagnosis and management

BACKGROUND

Thrombosis of mechanical prosthetic heart valves (TMPHV) is one of the major complications that accounts for the highest morbidity and mortality related to Bileaflet Mechanical Prosthetic Heart Valves (BMPHV).

MATERIALS AND METHODS

During the last six years we had ten cases of bileaflet mechanical valve thrombosis. All patients had undergone emergency surgical interventions except one who developed systemic embolization and massive brain insult immediately after admission for surgery and died two months later. We divided the patients in two groups, first group includes five patients who came in acute pulmonary edema and emergency operation was done either to replace the thrombosed BMPHV (in two) or successful thrombectomy was achieved (in three) and all of them have survived. The second group (four patients) presented with cardiogenic shock and required emergency femoro-femoral bypass. Two patients survived after thrombectomy and the other two could not come off bypass after changing the TMPHV and in spite of Intra-aortic balloon pump, they died 24 and 48 hours after the procedure. All patients received intravenous heparin on admission. Preoperative i.v. Streptokinase was given in two cases, of which one required thrombectomy and the other had valve replacement and died 24 hours later.

RESULTS

Early diagnosis and operation still had the best results in TMPHV though thrombolytic therapy was successful in few reported early presented cases. All patients who had thrombectomy of the TMPHV have survived without any morbidity. Follow up of survived patients ranged between two months and six years with a mean of 24.1 months. It is worth attempting thrombectomy of the thrombosed BMPHV rather than re-replacement which carries higher morbidity and mortality, because of the longer ischemic arrest during operation which further depletes the energy of the myocardium.

CONCLUSIONS

Though this is a small number of patients to make a definite conclusion, thrombectomy was more feasible in CarboMedics Prosthetic Heart Valves, since its in situ rotation that allows reorientation of its leaflets and declotting of valve hinge to be performed.

Papillary thyroid carcinoma: demographics, treatment, and outcome in eleven pediatric patients treated at a single institution

We describe 11 cases (8 females, 3 males) of papillary thyroid carcinoma in children treated at St. Jude Children's Research Hospital over a 33-year period, and review the literature. Ages ranged from 7-25 years (median, 16 years). Six patients had primary papillary thyroid carcinoma. Five patients had secondary papillary thyroid carcinoma after treatment of Hodgkin's disease (n = 2), acute lymphoblastic leukemia (n = 2), and neuroblastoma (n = 1) with chemotherapy and cervical radiation. The typical presentation was either cervical lymphadenopathy or a thyroid mass of short duration. Treatment consisted of thyroidectomy, cervical lymph node dissection, and postoperative thyroid hormone replacement (n = 1), parathyroid reimplantation (n = 1), 131I ablation (n = 4), external-beam irradiation (n = 1), and chemotherapy with doxorubicin (n = 1) or carboplatin and topotecan (n = 1). Nine patients are alive without evidence of disease 3.0-22.4 years from diagnosis. One patient has persistent but stable disease 17.3 years after diagnosis. One patient relapsed with metastatic lung disease 0.3 years after the initial diagnosis. He continues to do well after a brief but unsustained complete radiographic remission of disease to combination chemotherapy with carboplatin and topotecan. Our review supports excellent long-term outcome for primary or secondary papillary thyroid carcinoma in pediatric patients although complications may require close follow-up in a multidisciplinary setting.

Ectopic parathyroid adenomas: multi-imaging modalities and its management

Advancements in imaging technology have led to better diagnoses of ectopic parathyroid adenomas. Although surgery is curative in the majority of patients with parathyroid adenomas in normal preoperative locations, imaging is definitely required in ectopic adenomas in the neck and more importantly in the chest. The various imaging modalities used in the diagnosis of parathyroid adenomas are isotopic techniques, MRI, CT, ultrasound, arteriography, and venous sampling for parathormone. This review presents four patients studied with different diagnostic techniques resulting in cures with surgery or arteriographic ablation. The literature survey suggests the sensitivity of Tc-99m MIBI scanning to be more than 90%, MRI 70-75%, and CT scanning slightly lower. On the basis of the authors' experience and a literature review, a combination of MIBI scanning and MRI appears to be the most logical approach. If these two tests do not provide sufficient diagnostic confidence, then CT or a contrast arteriogram should be considered. Recent advances in arteriography/catheters have made angiographic ablation with alcohol or contrast material possible in patients who cannot undergo surgery.

Treatment of calcinosis with diltiazem

OBJECTIVE

To test the hypothesis that the calcium antagonist diltiazem is effective in the treatment of calcinosis.

METHODS

Diltiazem, 240-480 mg/day, was given to 4 patients with idiopathic or CREST-related (calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, telangiectasias) calcinosis for 1-12 years. Serial radiographs of the affected areas, using identical technique, and clinical evaluations were obtained. A fifth patient, who did not tolerate diltiazem, received verapamil, 120 mg/day for 18 months.

RESULTS

All patients taking diltiazem had a reduction or disappearance of the calcific lesions, with striking clinical improvement. One patient's case was followed for 12 years. The response to diltiazem during the first 5 years of treatment has been previously reported in detail; however, over 7 years of additional treatment, there was further reduction of the lesions. One patient developed a large calcific lesion while receiving verapamil for hypertension, and after verapamil was replaced with diltiazem, there was a dramatic response. Verapamil was ineffective in the fifth patient, who did not tolerate diltiazem.

CONCLUSION

Long-term treatment with diltiazem, but not verapamil, is effective in calcinosis.

Scintigraphic manifestation of iliotibial band injury in an endurance athlete

The scintigraphic appearance of an overuse injury at the insertion of the iliotibial band is described. This injury was depicted on three-phase bone scintigraphy as focally increased radionuclide concentration in the anterolateral tibial condyle (lateral tibial tubercle) where the iliotibial band inserts. Overuse injuries involving the insertion of the iliotibial band are uncommon and are not to be confused with a stress fracture or other bony lesion involving the lateral tibial condyle.

Intravenous dipyridamole thallium-201 SPECT imaging in patients with left bundle branch block

Tl-201 exercise imaging in patients with left bundle branch block (LBBB) has proven to be indeterminate for significant left anterior descending (LAD) coronary artery stenosis because of the presence of immediate septal perfusion defects with redistribution on delayed images in almost all cases. Tl-201 redistribution occurs regardless of the presence or absence of LAD stenosis. Nineteen patients having LBBB were evaluated with dipyridamole Tl-201 SPECT. Fourteen of these subjects had normal dipyridamole Tl-201 SPECT imaging. Three patients had normal coronary angiograms. None of the remaining 11 patients with normal dipyridamole Tl-201 SPECT images was found to have clinical coronary artery disease in a 5-11 month follow-up period. Five patients had abnormal septal perfusion. Four underwent coronary angiography. One had a significant LAD stenosis. The single patient with septal redistribution who refused to undergo coronary angiography died shortly thereafter of clinical coronary artery disease. This preliminary work suggests that dipyridamole Tl-201 SPECT may be more useful for excluding LAD stenosis in patients with LBBB than Tl-201 exercise imaging.

Stratification of patients with metastatic prostate cancer based on extent of disease on initial bone scan

Most patients with metastatic prostate cancer will have metastasis to bone. Such patients are best monitored by serial radionuclide bone scans. One hundred sixty six men with bone metastasis from prostate cancer who received androgen deprivation therapy had their pretreatment bone scans reviewed using a semiquantitative grading system based upon the extent of disease (EOD) observed on the scan. The EOD on the scan correlated with survival. The 2-year survival rates for EOD I to IV were 94%, 74%, 68%, and 40%, respectively. The survival of patients in categories EOD I and IV significantly differed from the other categories. Men with metastatic prostate cancer entered into trials designed to evaluate the impact of treatment on survival should be stratified based upon the EOD on the bone scan. This analysis also indicates that patients in the EOD IV category have a particularly poor prognosis and may be candidates for alternative treatments.

The limitation of liver function tests in metastatic carcinoid tumors

To evaluate the utility of liver function tests (LFT) as indicators of metastatic carcinoid tumors, a retrospective study was performed. The LFT results of 17 patients with carcinoid tumors metastatic to the liver were compared with 17 patients with other malignant tumors. In the noncarcinoid group, 82.4% of the patients had elevated alkaline phosphatase (AP) or gamma glutamyl transpeptidase (GGTP), whereas only 28.6% of carcinoid patients had abnormal enzymes. The medians of all LFT values were significantly higher in noncarcinoid patients than in the carcinoid group, except for glutamic pyruvic transaminase (SGPT). Our data indicate that LFT are helpful in screening for liver metastases in patients with noncarcinoid tumors, but are unreliable in carcinoid tumors. Imaging tests should be used to rule out liver metastases in carcinoid tumors, irrespective of LFT results.

Pyogenic liver abscess

Liver abscess is an uncommon condition, with an incidence of one to four cases per year in most hospitals in the United States. It can affect persons of any age but is most commonly seen in patients 50 to 70 years old. Clinical findings are nonspecific in a large number of patients and, therefore, one should maintain a high clinical index of suspicion and be aware of abnormal laboratory data, particularly liver function tests. On the basis of these factors, one of the imaging techniques discussed earlier--particularly the ultrasound and the CT scan--should be ordered for the patient immediately. Once the diagnosis of liver abscess is made, the primary source of infection should be determined. Prompt antibiotic treatment and percutaneous drainage or open surgery, depending on the circumstances, should be used. This approach should minimize the morbidity and mortality in this disease that was otherwise always fatal just a few decades ago.

Appearance of metastatic meningioma on bone scintigraphy

Extracranial metastases of meningioma are very rare, with a reported incidence of less than one in 1000 cases of meningioma. Metastases have been reported in the lungs and pleura, in the liver, in the lymph nodes, and in bone. The appearance of osseous metastases in the bony pelvis from intracranial angioblastic meningioma is described.

Gallium scintigraphy in the detection of amiodarone lung toxicity

Fourteen gallium scans were obtained in 11 patients suspected of having amiodarone lung toxicity on the basis of clinical findings, pulmonary function tests, and chest radiographs. All 11 patients had abnormal scans. Gallium accumulates in various inflammatory and neoplastic lesions, but despite this nonspecificity, the findings suggest gallium scintigraphy is a useful procedure to detect amiodarone lung toxicity when used in the appropriate clinical setting.

Hyperimmunoglobulinemia E syndrome: pulmonary imaging considerations

The Hyper IgE syndrome is a rare disease consisting of recurrent sinusitis and pneumonia, pneumatoceles, chronic dermatitis, and elevated serum levels of IgE. The primary radiographic abnormalities are recurrent alveolar lung disease and pneumatoceles. Pneumothorax may occasionally occur as in one of our cases. Other causes of pneumatoceles are usually easily excluded by the history and other clinical data. Pulmonary scintigraphy and computed tomography may add information valuable to the management of these patients.

Pyogenic liver abscess: changing epidemiology and prognosis

We reviewed the clinical features, methods of diagnosis, and outcome of 31 patients with pyogenic liver abscess seen at a private community hospital between 1973 and 1980. Two patient groups emerged. Group 1 consisted of 25 patients who had classical signs and symptoms of primary liver abscess. Group 2 consisted of six patients, most with underlying malignancy, in whom liver abscess(es) occurred as part of a septicemic process involving multiple other sites. The mortality was 0% in group 1 and 100% in group 2. Further analysis of the patients in group 1 revealed that (1) in contrast to findings of older studies, pyogenic liver abscess in now largely a disease of older adults who often have no identifiable predisposing process; (2) newer noninvasive imaging techniques greatly facilitate a firm diagnosis; and (3) the prognosis for such patients has become remarkably good, perhaps because of earlier diagnosis.

Scintigraphic diagnosis of hepatic hemangioma: its role in the management of hepatic mass lesions

Hepatic cavernous hemangiomas are benign tumors of the liver that are often an incidental finding. They are usually asymptomatic but may cause symptoms when traumatized, may bleed spontaneously, or may produce pain by virtue of their large size and mass effect. A retrospective analysis of the clinical presentation, liver function tests, and diagnostic imaging procedures in 20 patients with hepatic hemangiomas is presented and the literature is reviewed. The 20 patients had 27 mass lesions as seen on liver scintigraphy, computed tomography, or sonography. Technetium-99m-labeled red blood cell flow studies and blood pool scintigrams showed delayed filling of the mass lesions, diagnostic of hemangiomas. This finding was not encountered in any other type of lesion. A new diagnostic algorithm is proposed in which blood-flow and blood-pool scintigraphy play a more prominent role in the diagnostic workup. According to this algorithm, if liver function tests in a patient with hepatic mass are either normal or abnormal and suggestive of hepatocellular dysfunction, the patient should undergo hepatic blood-flow and blood-pool studies.

Renal infarction after aerobics

Renal infarction is most frequently due to emboli from the heart or aorta. Other causes include atheromatous disease, renal artery aneurysm, vasculitis, hypotension, hypercoagulable states, aortic dissection, and major trauma. Most renal infarctions are segmental. The extent of disease is dependent upon the size and number of renal vessels involved, coexistent renal disease, and collateral circulation. Flank pain, fever, leukocytosis, hematuria, renal failure, or hypertension may suggest the diagnosis, but these findings are nonspecific and diagnosis will depend not only on history and physical examination, but also on the appropriate imaging tests. The type of treatment is dictated by the etiology of the infarction.

Total and nondialyzable hydroxyproline excretion in Stage D2 prostate cancer

Hydroxyproline is excreted in urine as a breakdown product of normal bone turnover: A dialyzable (D) fraction (90% of total) reflects active bone destruction and a nondialyzable (ND) fraction reflects bone growth/regrowth. In metastatic prostate cancer where blastic osseous metastases predominate, disease progression on bone scan correlated with elevation of both total hydroxyproline excretion (7.84 + 1.28, P less than 0.001) and the ND urinary level (0.94 +/- 0.20, P less than 0.01). In patients with a serially stable/improving scan, urinary excretion of each fraction (2.18 + 0.27 and 0.27 +/- 0.01) was similar to that of men with no evidence of disease. For Stage D2 prostate cancer, these two markers satisfactorily monitor osseous activity in the intervals between serial bone scintigraphy.

Acute calculous cholecystitis with patent cystic duct

In the diagnosis of acute cholecystitis, the interpretation of cholescintigraphy is usually not difficult. It is conceivable, however, that with unusual location of obstructing calculi atypical images could result. Three cases were studied with cholescintigraphy and one with cholecystography in which more distal locations of obstructing calculi resulted in partial visualization of the gallbladder and erroneous interpretations were possible. Nuclear medicine radiologists should, therefore, be aware that atypical gallbladder images may be the result of unexpected location of obstructing calculi. Clues for assisting in interpretation are offered.

Serial spot hydroxyproline/creatinine ratios in metastatic prostatic cancer

Analysis of urinary hydroxyproline levels offers a marker to monitor osseous involvement in patients with metastatic malignancies. Such a marker is needed in patients with prostatic cancer when bone metastases predominate. Thirty-two men with stage D2 prostatic cancer were monitored by bone scan, acid and alkaline phosphatase values, and urinary hydroxyproline, beginning from 4 to 36 months after initiation of hormonal manipulation and/or systemic chemotherapy. In patients with disease progression determined by bone scan serial urinary hydroxyproline values progressively increased and were significantly elevated compared to urinary values obtained from patients with a stable or improving scan (p less than 0.001). Simultaneous alkaline phosphatase determinations showed less significant differences between patient groups. Acid phosphatase did not reliably indicate osseous response to therapy. These data suggest that urinary hydroxyproline values are predictive as an early objective sign of osseous response in patients receiving therapy for stage D2 prostatic cancer.

Pulmonary artery occlusion due to histoplasmosis

Histoplasma mediastinitis with complete or partial pulmonary artery obstruction due to compression and/or intraluminal granuloma was diagnosed in five patients and surgically verified in two. The patients, ages 12-27 years, had cough, dyspnea (four cases), and hemoptysis (two cases). Radionuclide imaging showed unilateral absence of pulmonary perfusion and minimal diminution of ventilation. Differentiation of this inflammatory process from other causes of ventilation-perfusion mismatch, for example, congenital hypoplasia and certain acquired causes of arterial obstruction, especially thromboembolism, may be possible by correlating radiographs, laminograms, and clinical history. Angiography can delineate the extent of perfusion impairment and may suggest its cause.

Spontaneously healing pyogenic liver abscess

We have presented an unusual case of pyogenic liver abscess due to gamma streptococci group D, which remained undiagnosed for about seven months, and which ruptured spontaneously into subcutaneous tissue, resulting in self-cure. Despite the large hepatic abscess seen on liver scan and ultrasound, results of liver function tests remained normal. A mass seen on liver scan or ultrasound in patients with a malignancy does not necessarily indicate metastasis, and a more aggressive approach is required to treat a potentially curable disease.

Parathyroid storm

Primary hyperparathyroidism frequently has a chronic and relatively benign course. Occasionally, however, it may have a stormy presentation requiring prompt adequate diagnosis and urgent surgical treatment. We describe a 71-year-old woman who had severe hypercalcemia, seizures, and coma refractory to treatment with anticonvulsant drugs, intravenous infusion of normal saline, furosemide, glucocorticoids, calcitonin, and hemodialysis. Bone roentgenograms were normal, but a strikingly positive bone scan that also showed marked soft-tissue uptake prompted the diagnosis of primary hyperparathyroidism and the successful surgical removal of a large parathyroid adenoma. This was followed by a remarkable recovery and marked reduction in soft-tissue radioactive uptake on bone scan. The association of hypercalcemia and seizures and the diagnostic value of bone scanning are discussed. An up-to-date review of the literature is presented. We proposed this condition to be named "parathyroid storm" on the basis of the rapid and lethal course unless surgery is performed without delay.

High-density lipoprotein cholesterol concentration and other serum lipids in an isolated island community free of coronary heart disease

Fasting serum high-density lipoprotein (HDL) cholesterol, other lipid concentrations and related characteristics have been measured in 87% of 261 residents aged over 5 years on the small isolated island of Salt Cay, Turks and Caicos Isles. Only one subject, a hypertensive woman, had a major electrocardiographic Q wave abnormality, and none of the islanders had clinical coronary heart disease. These findings, together with local clinical experience indicated a low incidence of coronary heart disease in this community. Adult mean concentrations of HDL cholesterol (1.6 mmol/l) and serum total triglyceride (0.81 mmol/l) were relatively high and low respectively compared with those of men and women in North American communities. Unlike findings in North America, there was no significant sex difference in HDL cholesterol concentration apparent in adulthood and this was not explained by sex differences in alcohol consumption (positively correlated with HDL cholesterol in both sexes) or adiposity (negatively correlated with HDL cholesterol in men only). Residents who were recovering from an epidemic of mild upper respiratory infection had on average a 9% reduction in HDL cholesterol concentration compared with the remainder of the community. The lipoprotein lipid pattern in these people is consistent with a low cardiovascular risk status, and might account for the apparent absence of coronary heart disease on the island.

Immunoblastic lymphosarcoma: a light, immunofluorescence, and electron microscopic study

Immunoblastic lymphosarcoma (ILS) is a newly recognized malignant lymphoreticular neoplasm and is included in the recent W.H.O. classification of lymphomas. This report concerns six cases of ILS studied by light, immunofluorescence (IF), and electron microscopy (EM). Four patients were female and all except one were over 50 years of age. Four patients had some immunological abnormality. Light microscopy showed a monomorphic population of immunoblasts with pyroninophilic cytoplasm and variable plasmacytoid differentiation. Intracytoplasmic IgG was demonstrated by IF in four cases, and IgA in one. Large lymphoid cells with varying proportions of polysomes, rough endoplasmic reticulum, and Golgi apparatus were seen by EM in four cases. Mean survival was 4.8 months in five cases; death in four was due to disseminated ILS. We concluded that our cases of ILS are of B cell origin, are often associated with immunological abnormalities, and carry a poor prognosis. Immunofluorescence and EM are helpful in its diagnosis.