Should prostate cancer be considered as a differential diagnosis in patients with osteolytic bone lesions?

OBJECTIVE

Prostate cancer is the most frequently diagnosed cancer in men, as well as the second leading cause of death among cancers after lung cancer. In the United States, it is more prevalent in African-American men than in Caucasian men. Prostate cancer frequently metastasizes to the bone, with most of the reported lesions appearing to be osteoblastic on radiographs. Here, we describe an unusual presentation of metastatic prostate cancer with diffuse osteolytic bone lesions.

CASE PRESENTATION

An 80-year-old previously healthy Hispanic man presented with worsening back pain, difficulty with ambulation, and bladder outlet obstruction. Physical examination was significant for spinal tenderness in the thoracic and lumbar region. Digital rectal examination was remarkable for asymmetric enlargement of the prostate with nodularity and firmness. Imaging studies revealed diffuse osteolytic lesions. His prostate-specific antigen was 562.8 ng/mL (normal 0-4). Prostate biopsy and imaging studies confirmed a diagnosis of metastatic prostate cancer.

CONCLUSIONS

This case demonstrates that bone metastases of prostate cancer are not purely osteoblastic although most of the reported bone metastases in prostate cancer have been osteoblastic in nature. Therefore, clinicians are to consider metastatic prostate cancer as a differential diagnosis for patients with osteolytic bone lesions.

False-negative and false-positive errors in abdominal pain evaluation: failure to diagnose acute appendicitis and unnecessary surgery

OBJECTIVES

To test the hypothesis that physician errors (failure to diagnose appendicitis at initial evaluation) correlate with adverse outcome. The authors also postulated that physician errors would correlate with delays in surgery, delays in surgery would correlate with adverse outcomes, and physician errors would occur on patients with atypical presentations.

METHODS

This was a retrospective two-arm observational cohort study at 12 acute care hospitals: 1) consecutive patients who had an appendectomy for appendicitis and 2) consecutive emergency department abdominal pain patients. Outcome measures were adverse events (perforation, abscess) and physician diagnostic performance (false-positive decisions, false-negative decisions).

RESULTS

The appendectomy arm of the study included 1, 026 patients with 110 (10.5%) false-positive decisions (range by hospital 4.7% to 19.5%). Of the 916 patients with appendicitis, 170 (18.6%) false-negative decisions were made (range by hospital 10.6% to 27.8%). Patients who had false-negative decisions had increased risks of perforation (r = 0.59, p = 0.058) and of abscess formation (r = 0.81, p = 0.002). For admitted patients, when the inhospital delay before surgery was >20 hours, the risk of perforation was increased [2.9 odds ratio (OR) 95% CI = 1.8 to 4.8]. The amount of delay from initial physician evaluation until surgery varied with physician diagnostic performance: 7.0 hours (95% CI = 6.7 to 7.4) if the initial physician made the diagnosis, 72.4 hours (95% CI = 51.2 to 93.7) if the initial office physician missed the diagnosis, and 63.1 hours (95% CI = 47.9 to 78.4) if the initial emergency physician missed the diagnosis. Patients whose diagnosis was initially missed by the physician had fewer signs and symptoms of appendicitis than patients whose diagnosis was made initially [appendicitis score 2.0 (95% CI = 1.6 to 2.3) vs 6.5 (95% CI = 6.4 to 6.7)]. Older patients (>41 years old) had more false-negative decisions and a higher risk of perforation or abscess (3.5 OR 95% CI = 2.4 to 5.1). False-positive decisions were made for patients who had signs and symptoms similar to those of appendicitis patients [appendicitis score 5.7 (95% CI = 5.2 to 6.1) vs 6.5 (95% CI = 6.4 to 6.7)]. Female patients had an increased risk of false-positive surgery (2.3 OR 95% CI = 1.5 to 3.4). The abdominal pain arm of the study included 1,118 consecutive patients submitted by eight hospitals, with 44 patients having appendicitis. Hospitals with observation units compared with hospitals without observation units had a higher "rule out appendicitis" evaluation rate [33.7% (95% CI = 27 to 38) vs 24.7% (95% CI = 23 to 27)] and a similar hospital admission rate (27.6% vs 24.7%, p = NS). There was a lower miss-diagnosis rate (15.1% vs 19.4%, p = NS power 0.02), lower perforation rate (19.0% vs 20.6%, p = NS power 0.05), and lower abscess rate (5.6% vs 6.9%, p = NS power 0.06), but these did not reach statistical significance.

CONCLUSIONS

Errors in physician diagnostic decisions correlated with patient clinical findings, i.e., the missed diagnoses were on appendicitis patients with few clinical findings and unnecessary surgeries were on non-appendicitis patients with clinical findings similar to those of patients with appendicitis. Adverse events (perforation, abscess formation) correlated with physician false-negative decisions.

Infant apnea detection after herniorrhaphy

STUDY OBJECTIVE

To elucidate risk factors for apnea in preterm infants discharged from the hospital and in full-term healthy infants. To determine the efficacy of real-time cardiopulmonary monitoring versus computerized storage and retrieval for infants at risk.

STUDY DESIGN

Prospective study.

SETTING

Operating rooms and pediatric patient care units of university medical center.

PATIENTS

27 preterm infants and 20 full-term infants no more than 60 weeks' post-conceptional age, who were admitted for elective herniorrhaphy.

INTERVENTIONS

Infants were monitored before and after herniorrhaphy with general anesthesia using an infant apnea impedance monitor, pulse oximetry, and nursing observation.

MEASUREMENTS AND MAIN RESULTS

Demographic information and medical history were correlated with postoperative apnea. The sensitivity and specificity of nursing observation and oximetry were compared with computerized apnea monitors. Five patients (11%, four preterm, one full-term) were apneic postoperatively as recorded by computerized pneumocardiography. Previous apnea history, gestational age at birth, and postconceptional age at operation positively correlated with postoperative apnea. Nursing observation failed to detect 4 of 5 patients with documented apnea (sensitivity 20%, positive predictive value 50%). Pulse oximetry failed to detect 3 of 5 patients with apnea (sensitivity 40%, positive predictive value 66%).

CONCLUSIONS

Although it is easier to predict postoperative respiratory dysfunction in previously sick or very young infants, absolute predictability for all neonates remains elusive. Clinical monitors with both storage and retrieval capabilities and real-time monitoring increase our ability to detect significant events in children at risk for apnea after herniorrhaphy.

CT differentiation of benign and malignant lung nodules in children

The superiority of computed tomography (CT) for detection of lung nodules has been documented and attempts have been made to distinguish benign from malignant lesions in adults. We attempted to characterize lung nodules in 12 children with solid malignant tumors (aged 8 months to 17 years) in an effort to differentiate benign from metastatic disease. All scans were performed at 10-mm contiguous intervals on a GE 9800 CT scanner. The scans were retrospectively viewed by two pediatric radiologists independently and without knowledge of the pathological findings. All biopsies were done via open thoracotomy. The CT findings were correlated with pathology results. Twelve children had 13 nodules biopsied. Six of these showed malignancy, two showed inflammatory changes, and two had a reactive subpleural lymph node. In three children, no abnormality was found and a biopsy was not obtained. One child had a metastatic nodule in one lung, and a simultaneous inflammatory nodule in the other. The radiologists agreed with each other on the CT interpretation in 11 of 13 surgically explored areas. They correctly predicted malignancy in four cases and correctly excluded it in two cases. However, they were simultaneously incorrect in five instances. Our conclusion is that, contrary to reports in adults, a tiny nodule may be either benign or malignant. Malignancy cannot be separated from benign disease by CT established criteria.

Surgical management of tracheal stenosis in an infant with multiple congenital anomalies: when is baby inoperable?

Congenital tracheal stenosis is a rare disorder that carries a significant morbidity and mortality. It is an even greater challenge when present in combination with other life-threatening congenital anomalies. We present an infant with multiple congenital anomalies, including trisomy 21, who was diagnosed with congenital tracheal stenosis at 3 months of age. At age 5 months, the infant underwent tracheoplasty with costal cartilage graft and pulmonary artery banding. Bronchoscopy 3 weeks later revealed a patent airway. However, the patient died 2 months postoperatively of cardiac complications. At autopsy, whole organ and histologic specimens revealed excellent incorporation of the graft with no evidence of re-stenosis. Our documentation of graft incorporation in this patient is evidence that long segments of stenotic trachea can be successfully treated by tracheoplasty utilizing rib cartilage grafts.

Meckel's diverticulum in the pediatric surgical population

Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract. We reviewed our experience with 31 cases of Meckel's diverticulum in children from 1966 to 1987. Twenty-four patients presented with clinical manifestations: ten from bleeding, ten from obstruction, and four from diverticulitis. Seven Meckel's were incidental findings at laparotomy. Fifty percent of the patients with bleeding had abdominal pain and 100% had ectopic gastric mucosa in the Meckel's. In six cases the technetium scan identified the Meckel's; there was one false negative scan. Obstruction secondary to a Meckel's diverticulum was due to an internal hernia in five and to intussusception in five. Three patients with intussusception had concomitant bleeding. Diverticulitis was clinically similar to appendicitis. There were no complications and no deaths following surgical resection of Meckel's diverticulum.

Delayed gastric emptying in infants with gastroesophageal reflux

The purpose of this study was to investigate the rate of gastric emptying of a liquid meal in young children with symptomatic gastroesophageal reflux of varying intensity. Twenty-three infants (mean age 7.0 +/- 1.4 [SEM] months, range 2 to 14 months) were evaluated for reflux by esophageal manometry, a five-hour pH probe study, and barium swallow. The rate of gastric emptying was determined by using a liquid meal of 4 ounces of cow milk formula labeled with 99mTc sulfur colloid. In seven infants with failure to thrive and objective criteria for severe reflux, the mean gastric emptying was 21.3 +/- 6.4% at one hour. In six infants with reflux and recurrent pulmonary disease, the mean gastric emptying was 19.8 +/- 5.4%. Ten infants with mild reflux, adequate weight gain, and no pulmonary symptoms emptied 44.3 +/- 6.0% of formula at one hour, and six normal adults (mean age 28.3 +/- 2 years) emptied 56.2 +/- 6.5% of formula at one hour. These data suggest that infants with severe GER have significantly delayed gastric emptying, that gastric retention may contribute to the FTT and pulmonary symptoms in these infants, and that abnormal motor function of the gastric fundus may be a significant factor in the pathogenesis of gastroesophageal reflux of infancy.