[The effect of WT1 expression on the prognosis of allogeneic hematopoietic stem cell transplantation in acute leukemia]

Objective: To study the effect of WT1 expression on the prognosis of allogeneic hematopoietic stem cell transplantation (allo-HSCT) in acute leukemia (AL) and its significance as molecular marker to dynamically monitor minimal residual disease (MRD) . Methods: Retrospectively analyzed those AL patients who underwent allo-HSCT in the First Hospital Affiliated to Zhejiang University School of Medicine during Jan 2016 to Dec 2017, a total number of 314 cases, 163 males and 151 females, median age was 30 (9-64) years old. Comparing the difference of WT1 expression at diagnosed, pre-HSCT and after HSCT. Using the receiver operating characteristic (ROC) curve to determine the WT1 threshold at different time so as to predict relapse. The threshold of WT1 expression before transplantation was 1.010%, within 3 months after HSCT was 0.079% and 6 months after HSCT was 0.375%. According to these thresholds, WT1 positive patients were divided into low expression groups and high expression groups. Analyzed the relationship between overall survival (OS) , disease-free survival (DFS) , cumulative incidence of relapse (CIR) and WT1 expression. Results: The OS and DFS of high expression group pre-HSCT were lower than low expression group [69.2% (9/13) vs 89.1% (57/64) , χ(2)=4.086, P=0.043; 53.8% (7/13) vs 87.5% (56/64) , χ(2)=9.766, P=0.002], CIR was higher than low expression group [30.8% (4/13) vs 7.8% (5/64) , P=0.017]. There was no significant difference of OS and DFS between high expression and low expression group of 3 months after HSCT (P=0.558, P=0.269) . The OS and DFS of high expression group of 6 months after transplantation were both lower than low expression group (P=0.049, P=0.035) . Multivariate analysis showed that WT1>0.375% when 6 months after transplantation was the only independent prognostic factor for shorter DFS (P=0.022) . There was no statistically significant difference in CIR between the high-expression group and the low-expression group 3 months after transplantation and 6 months after transplantation (P=0.114, P=0.306) . Conclusion: High expression of WT1 before and after HSCT was an adverse prognosis factor. It is of clinical practical value to use WT1 as a transplant recommendation index for patients with acute leukemia and as a marker to monitor MRD dynamically.

Metabolomic Characterizations of Liver Injury Caused by Acute Arsenic Toxicity in Zebrafish

Arsenic is one of the most common metalloid contaminants in groundwater and it has both acute and chronic toxicity affecting multiple organs. Details of the mechanism of arsenic toxicity are still lacking and profile studies at metabolic level are very limited. Using gas chromatography coupled with mass spectroscopy (GC/MS), we first generated metabolomic profiles from the livers of arsenic-treated zebrafish and identified 34 significantly altered metabolite peaks as potential markers, including four prominent ones: cholic acid, glycylglycine, glycine and hypotaurine. Combined results from GC/MS, histological examination and pathway analyses suggested a series of alterations, including apoptosis, glycogenolysis, changes in amino acid metabolism and fatty acid composition, accumulation of bile acids and fats, and disturbance in glycolysis related energy metabolism. The alterations in glycolysis partially resemble Warburg effect commonly observed in many cancer cells. However, cellular damages were not reflected in two conventional liver function tests performed, Bilirubin assay and alanine aminotransferase (ALT) assay, probably because the short arsenate exposure was insufficient to induce detectable damage. This study demonstrated that metabolic changes could reflect mild liver impairments induced by arsenic exposure, which underscored their potential in reporting early liver injury.

Gastrointestinal Symptoms and Altered Intestinal Permeability Induced by Combat Training Are Associated with Distinct Metabotypic Changes

Physical and psychological stress have been shown to modulate multiple aspects of gastrointestinal (GI) physiology, but its molecular basis remains elusive. We therefore characterized the stress-induced metabolic phenotype (metabotype) in soldiers during high-intensity combat training and correlated the metabotype with changes in GI symptoms and permeability. In a prospective, longitudinal study, urinary metabotyping was conducted on 38 male healthy soldiers during combat training and a rest period using gas chromatography-mass spectrometry. The urinary metabotype during combat training was clearly distinct from the rest period (partial least-squares discriminant analysis (PLSDA) Q(2) = 0.581), confirming the presence of a unique stress-induced metabotype. Differential metabolites related to combat stress were further uncovered, including elevated pyroglutamate and fructose, and reduced gut microbial metabolites, namely, hippurate and m-hydroxyphenylacetate (p < 0.05). The extent of pyroglutamate upregulation exhibited a positive correlation with an increase in IBS-SSS in soldiers during combat training (r = 0.5, p < 0.05). Additionally, the rise in fructose levels was positively correlated with an increase in intestinal permeability (r = 0.6, p < 0.005). In summary, protracted and mixed psychological and physical combat-training stress yielded unique metabolic changes that corresponded with the incidence and severity of GI symptoms and alteration in intestinal permeability. Our study provided novel molecular insights into stress-induced GI perturbations, which could be exploited for future biomarker research or development of therapeutic strategies.

Adjuvant hepatic intra-arterial iodine-131-lipiodol following curative resection of hepatocellular carcinoma: a prospective randomized trial

BACKGROUND

The purpose of the present study was to determine whether intrahepatic injection of (131)I-lipiodol (Lipiodol) is effective against recurrence of surgically resected hepatocellular carcinoma (HCC).

METHODS

From June 2001 through March 2007, this nationwide multi-center prospective randomized controlled trial enrolled 103 patients 4-6 weeks after curative resection of HCC with complete recovery (52: Lipiodol, 51: Control). Follow-up was every 3 months for 1 year, then every 6 months. Primary and secondary endpoints were recurrence-free survival (RFS) and overall survival (OS), respectively, both of which were evaluated by the Kaplan-Meier technique and summarized by the hazard ratio (HR). The design was based on information obtained from a similar trial that had been conducted in Hong Kong.

RESULTS

The Lipiodol group showed a small, and nonsignificant, improvement over control in RFS (HR = 0.75; 95 % confidence interval [95 % CI] 0.46-1.23; p = 0.25) and OS (HR = 0.88; 95 % CI 0.51-1.51; p = 0.64). Only two serious adverse events were reported, both with hypothyroidism caused by (131)I-lipiodol and hepatic artery dissection during angiography.

CONCLUSIONS

The randomized trial provides insufficient evidence to recommend the routine use of (131)I-lipiodol in these patients.

Development of a consumer product ingredient database for chemical exposure screening and prioritization

Consumer products are a primary source of chemical exposures, yet little structured information is available on the chemical ingredients of these products and the concentrations at which ingredients are present. To address this data gap, we created a database of chemicals in consumer products using product Material Safety Data Sheets (MSDSs) publicly provided by a large retailer. The resulting database represents 1797 unique chemicals mapped to 8921 consumer products and a hierarchy of 353 consumer product "use categories" within a total of 15 top-level categories. We examine the utility of this database and discuss ways in which it will support (i) exposure screening and prioritization, (ii) generic or framework formulations for several indoor/consumer product exposure modeling initiatives, (iii) candidate chemical selection for monitoring near field exposure from proximal sources, and (iv) as activity tracers or ubiquitous exposure sources using "chemical space" map analyses. Chemicals present at high concentrations and across multiple consumer products and use categories that hold high exposure potential are identified. Our database is publicly available to serve regulators, retailers, manufacturers, and the public for predictive screening of chemicals in new and existing consumer products on the basis of exposure and risk.

Combined heart-liver transplantation with extended cardiopulmonary bypass

We report a case of combined heart and liver transplantation for familial amyloid polyneuropathy. This is the first such combined transplant performed in Asia, and differs from previously described cases, in that cardiopulmonary bypass was continued at partial flow during liver transplantation in our case. This was done in order to provide haemodynamic support to the cardiac graft and to protect it from the impending reperfusion insult that frequently accompanies liver transplantation. The utility of this management course is discussed, along with its actual and potential complications. We also describe the impact of a lung-protective ventilation strategy employed during cardiac transplantation.

Surgery for the palliation of intestinal obstruction in advanced abdominal malignancy

INTRODUCTION

Intestinal obstruction commonly occurs in advanced abdominal and pelvic malignancy. Management of these patients is difficult, as it is uncertain which patients benefit from palliative surgery and which benefit from medical management.

METHODS

Clinical records for patients who underwent surgery for palliation of bowel obstruction were reviewed retrospectively. All had metastatic malignant disease and were seen by the general surgical department for intestinal obstruction. The following factors were examined: preoperative albumin, APACHE II score, age, site of metastases, presence of ascites, operative findings and type of operative procedure performed, length of postoperative stay and mortality.

RESULTS

27 palliative operations for intestinal obstruction for metastatic malignancy were performed during this period. This included two patients who were re-operated on for recurrence of intestinal obstruction after recovering from the first operation. All patients had radiological evidence of intestinal obstruction preoperatively. All patients who survived were discharged from hospital without requiring parenteral nutrition or hydration, and were able to tolerate oral medication and feeds. In this small series, site of metastases, presence of ascites, APACHE II score and gender were not predictive of mortality. An albumin level of 21 g/L or less was predictive of mortality. Almost 50 percent of these patients would require a stoma. Our series had a 30-day mortality rate of 20 percent.

CONCLUSION

Surgery does have a role in palliation of symptoms of intestinal obstruction in carefully selected patients with advanced abdominal and pelvic malignancy. Patients should be counselled on the likelihood of a stoma and the 30-day mortality risk.

Spleen-preserving distal pancreatectomy

INTRODUCTION

Splenectomy is routinely performed in conventional distal pancreatectomies. Spleen removal with its possible sequelae of infections and haematological complications has prompted the development of spleen-preserving techniques. This study aimed to evaluate the safety and clinical outcomes of distal pancreatectomy with preservation of the spleen.

METHODS

A retrospective review of 24 consecutive patients who underwent spleen-preserving distal pancreatectomy in a tertiary care hospital was conducted.

RESULTS

There were 17 female and seven male patients, and the mean age was 47 (range 14-77) years. Median American Society of Anesthesiologists score was II (range I-III) . The indications were as follows : mucinous cystadenoma (n = 7), serous cystadenoma (n = 6), insulinoma (n = 3), intraductal papillary mucinous tumour (n = 2), pseudocyst (n = 3), papillary cystic adenoma (n = 1), neuroendocrine neoplasm (n = 1), and metastatic carcinoma of the thyroid (n = 1). Two patients developed postoperative pancreatic fistula and another two patients developed postoperative ileus with spontaneous resolution. Mean operative time was 172 (range 105-250) minutes. Mean length of postoperative hospital stay was 6.7 (range 5-11) days. There was no perioperative mortality in this series.

CONCLUSION

Spleen-preserving distal pancreatectomy can be safely performed with low morbidity, and should be considered in the surgical management of distal pancreatic disease.

Late-onset post-transplant lymphoproliferative disease presenting as massive occult gastrointestinal haemorrhage

Post-transplant lymphoproliferative disease (PTLD) is a widely-recognised complication of solid organ transplants with a myriad of clinical presentations. We report a 56-year-old Chinese woman who developed PTLD 17 years after a renal transplant. She initially presented with constitutional symptoms, and a diagnosis of diffuse large B-cell lymphoma was confirmed on liver biopsy. Staging computed tomography demonstrated widespread adenopathy. Initial treatment consisted of reduction of immunosuppression and Rituximab. Prior to institution of chemotherapy, she presented with life-threatening melaena. Laparotomy revealed a mid-jejunal ulcerating tumour which was resected. Histology confirmed necrotic diffuse large B-cell lymphoma and the cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) chemotherapy regime was subsequently commenced. The aim of this case report is to highlight the unique challenges in the management of PTLD in the context of an acute abdomen.

Management of pyogenic liver abscesses - percutaneous or open drainage?

This pictorial essay aims to review the literature on the management of pyogenic liver abscess, focusing on the choice of drainage. Articles on the treatment of pyogenic liver abscess, accessed through a MEDLINE search using PubMed, were reviewed. A case series of the authors' experience with clinicopathological correlation is presented to highlight the indication and outcome of each modality of drainage. Intravenous antibiotic is the first line, and mainstay, of treatment. Drainage is necessary for large abscesses, equal to or larger than 5 cm in size, to facilitate resolution. While percutaneous drainage is appropriate as first-line surgical treatment in most cases, open surgical drainage is prudent in cases of rupture, multiloculation, associated biliary or intra-abdominal pathology. Percutaneous drainage may help to optimise clinical condition prior to surgery. Laparoscopic drainage is a feasible surgical option with promising results in the future. Liver resection is reserved for concomitant localised intrahepatic disease and tumour, after control of sepsis. The final verdict on the outcome of percutaneous versus open surgical drainage of pyogenic liver abscesses requires further studies in a controlled trial setting. Nevertheless, in current good clinical practices, the choice of therapy needs to be individualised according to patient's clinical status and abscess factors. They are complementary in the management of liver abscesses.

Endometriosis of the inguinal canal mimicking a hernia

We report a 37-year-old Chinese woman who presented with a groin lump associated with constant and non-catamenial pain. Ultrasonography was suggestive of an inguinal hernia. Intraoperatively, an endometriotic lump with no laparoscopical evidence of endometriosis in the abdominopelvic region was found. Isolated endometriotic lesions in the inguinal canal is a rare occurrence. Surgeons, however, should consider this diagnosis in women of reproductive age who present with a painful groin lump.

Clinical spectrum and surgical management of acute mesenteric ischaemia in Singapore

INTRODUCTION

Acute mesenteric ischaemia (AMI) is a surgical emergency with a dismal prognosis. Much of the literature concerning this condition is from the West. This study aims to present a single-centre Asian experience of management of patients with AMI and the immediate outcome following surgical treatment.

METHODS

This is a retrospective study of patients managed for AMI in our department between 1990 and 2003. The data was obtained from a prospectively-collected surgical data base as well as from clinical case records.

RESULTS

65 patients were managed by our department for AMI over 14 years. The median age of this patient group was 69 years, with a high prevalence of cardiovascular diseases. The majority of patients presented with abdominal pain, distension and vomiting. The commonest subtype of AMI was caused by mesenteric arterial occlusion; this subtype also had the highest in-hospital mortality. Our overall in-hospital mortality for all 65 patients was 55.4 percent.

CONCLUSION

Clinical suspicion, especially in a patient with the relevant risk factors, remains the mainstay of appropriate early management of AMI. Our patient demographics, coexistent diseases and commonest subtype of AMI were similar to that reported in the Western literature. In this paper, we also suggest a management algorithm for patients with suspected AMI.

Pedunculated HCC or adrenal metastasis: a diagnostic conundrum

Hepatocellular carcinoma (HCC) is the commonest primary liver tumour. Recurrences are common in the liver although extrahepatic metastases can occur and frequently involve the adrenals. When this occurs in the right adrenal gland, it can be confused with an exophytic HCC arising from the posterior surface of the liver. The distinction between a primary HCC and a metastasis is important but can be difficult in this clinical setting. We report a 52-year-old man with recurrent HCC presenting as an "exophytic" posterior liver surface lesion that was actually a right adrenal metastasis. Although right-sided adrenal metastases of HCC can be difficult to distinguish from intrahepatic recurrences, even with modern diagnostic imaging, management either way involves surgical exploration and resection whenever possible.

An audit of fusion CT-PET in the management of colorectal liver metastases

AIM

To assess the use of positron emission tomography combined with computerized tomography (CT-PET) with fluoro-18-2-deoxy-d-glucose ((18)F-FDG) to identify hyper-metabolic tumours, especially colorectal metastases (CRM).

METHODS

Patient particulars, diagnoses and clinical outcome for each patient were studied. Twenty-three patients underwent CT-PET, 10 males and 13 females, median age 59 (range 34-72). Fourteen patients presented with primary liver CRM and nine had undergone previous liver resections. Indications for CT-PET included; suspected extrahepatic disease in 13/23 patients, possible hepatic recurrence 5/23 and clinical suspicion in 8/23 patients.

RESULTS

Seven patients had a major impact on their management. Unexpected (not seen on CT) findings in the CRM group included, 7/23 (30%) patients with extrahepatic disease, 3/23 with hepatic metastases, 8/23 suspected of having liver or distant metastases on CT had a negative study. A clinical decision, based on the CT-PET report, could be undertaken in 21/23 patients.

CONCLUSION

CT-PET is useful in patients with CRM where conventional imaging presents dilemmas such as: assessment of suspected extrahepatic disease, recurrence in liver, patients with advanced or perforated initial tumours.

Clinico-pathological features of cystic pancreatic endocrine neoplasms and a comparison with their solid counterparts

AIM

Pancreatic endocrine neoplasms (PENs) may occasionally manifest as cystic lesions of the pancreas. The aim of this study is to report our experience with cystic PENs and to compare their clinico-pathological features with their solid counterparts.

MATERIALS AND METHODS

From 1990 to 2004, 38 patients with PENs were reviewed. Six of these tumours appeared on radiological imaging as a cystic lesion of the pancreas.

RESULTS

Of the 38 patients with a PEN, 21 of the patients were female and with a median age of 54.5 (range, 33-83) years. Sixteen patients had functional endocrine tumours of which insulinoma was the most common. The six patients with cystic PEN had a median age of 55.5 (range, 41-70) years and half were female. Cystic PENs were significantly larger [48 (range, 25-170) mm vs 19 (range, 3-120) mm, P = 0.013] and were less likely to be benign (0 vs 50%, P = 0.017) compared to their solid counterparts. There was no difference between cystic and solid PENs in terms of age, sex, presence of symptoms, proportion of functioning tumours and location of tumours within the pancreas.

CONCLUSION

Cystic PENs share many clinico-pathological features with solid PENs. These differ only in the cystic appearance and tend to be of a larger size. Hence, these findings suggest that cystic and solid PENs are unlikely to be distinct pathological entities but are likely to be morphological variants of the same entity.

Crohn’s disease in adults: Observations in a multiracial Asian population

AIM: To determine the demography and clinical presentation of CD and secondly to determine any differences in the prevalence between the different ethnic groups in a multiracial Asian population.

METHODS: Patients with CD who were seen in 2001–2003 in the University of Malaya Medical Centre (UMMC) were enrolled in this study. Prevalence of disease was calculated for the group as a whole and by race with hospital admissions per ethnic group as the denominator.

RESULTS: Thirty-four patients were diagnosed to have CD. Basic demographic data of patients; male:female 17:17; mean age 29.1 years (±13.5 years); ethnic group: Malays 5 (14.7%), Chinese 12 (35.3%) and Indians 17 (50%). Twenty-six (76.5%) were diagnosed under the age of 40 and 8 (23.5%) were diagnosed over the age of 40. Location of the disease was as follows: ileocolonic 13 (38.2%), terminal ileum only 9 (26.5%), colon only 8 (23.5%), and upper gastrointestinal 4 (11.8%). Sixteen (47.1%) had penetrating disease, 9 (26.5%) had stricturing disease and 9 (26.5%) had non-penetrating and non-stricturing disease. The hospital admission prevalence of CD was 26.0 overall, Indians 52.6, Chinese 6.9, and Malays 9.3 per 10⁵ admissions per ethnic group. The difference between Indians and Malays: [OR 5.67 (1.97, 17.53) P < 0.001] was statistically significant but not between the Indians and the Chinese [OR 1.95 (0.89, 4.35) P = 0.700]. The difference between the Chinese and the Malays was also not statistically significant. [OR 2.90 (0.95, 9.42) P = 0.063].

CONCLUSION: The clinical presentation of CD is similar to the Western experience. Although the overall prevalence is low, there appears to be a clear racial predominance among the Indians.

Cystic neoplasms of the pancreas with mucin-production

AIM

To compare the clinico-pathological features of intraductal papillary mucinous cystic tumours (IPMT) and mucinous cystic tumours (MCT) of the pancreas.

METHODS

Eighteen patients with IPMT and 18 with MCT who underwent surgical resection between 1990 and 2004 were retrospectively reviewed. Their clinico-pathological features were compared using univariate analysis. Statistical analyses of potential predictive factors of malignancy for each of these two groups were also conducted.

RESULTS

Patients with IPMT were found to be older (64+/-10 vs 43+/-18 years, p<0.001) and were predominantly male (male:female ratio, 5:4 vs 1:17, p=0.003) as compared to patients with MCT. MCTs were found in the body-tail region (100%) whereas IPMTs were more evenly distributed (50% in the head) (p=0.001). Pathologically, IPMT was distinct from MCT in terms of size (3.8+/-3.2 vs 9.1+/-4.4 cm, p=0.001), association with secondary pancreatitis (50 vs 0%, p=0.011), communication with the pancreatic duct (94 vs 0%, p<0.001), presence of a dilated main pancreatic duct (61 vs 0%, p<0.001) and the presence of ovarian-type stroma (0 vs 44%, p=0.003).

CONCLUSION

IPMT and MCT are distinct clinico-pathological entities. This distinction is important as management and outcome of these entities may differ.

Atypical presentations of emphysematous cystitis

Emphysematous cystitis is an uncommon infection of the bladder with the formation of carbon dioxide either within the bladder or within its wall. It is commonly seen in women and those with poorly controlled diabetes mellitus, in association with some form of urinary stasis and obstruction. The clinical features are very varied and the outcome is often unpredictable. Radiography may reveal a radiolucent line around the bladder wall or gas within the bladder. Occasionally, computed tomography scans are required to help in the diagnosis due to their atypical presentation with acute abdominal pain. Herein, we report three patients with such a condition who were treated with favourable outcomes. Of the three patients, two had to undergo exploratory laparotomy due to their initial presentations with acute abdomens.

Clinical mimicry of hepatocellular carcinoma: imaging-pathological correlation

This pictorial essay aims to show the clinical mimicry of hepatocellular carcinoma (HCC) and its diagnostic difficulty, and to create awareness among clinicians and radiologists of potential diagnostic pitfalls. A selected consecutive series of hepatectomies with proven HCC over a three-year period, identifying clinical presentation, blood results and imaging of patients with difficult preoperative diagnosis, was reviewed. The imaging of the focal liver lesions is presented pictorially with pathological correlation. Six patients out of 34 cases of resected HCC were diagnosed to have benign (three liver abscesses) and neoplastic (one Klatskin tumour, one colorectal liver metastasis, one gallbladder cancer) conditions. Compared to the rest in the series, all six patients had normal serum alpha fetoprotein levels. On computed tomography, the mosaic appearance of HCC mimicked locules of liver abscess while HCC with pseudocapsule (rim enhancement) was misdiagnosed as unilocular abscess or metastatic lesion. Arterial enhancement on contrast-enhanced triphasic computed tomography was useful in diagnosis of HCC. In summary, HCC can mimic benign and neoplastic clinical syndromes. The diagnosis of liver abscess can delay subsequent diagnosis of HCC and potentially complicate the treatment plan. Contrast-enhanced triphasic computed tomography or magnetic resonance imaging is useful to resolve difficult diagnosis, especially when the serum alpha fetoprotein level is not raised.

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

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

Littoral cell angioma of the spleen

INTRODUCTION

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

CLINICAL PICTURE

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

TREATMENT

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

CONCLUSION

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

Appropriateness of colonoscopy in a university hospital

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

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

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

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Current status in the surgical management of adult polycystic liver disease

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Pyogenic liver abscess complicated by endogenous endophthalmitis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Exposure assessment of laboratory students

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

Clinics in diagnostic imaging (36). Benign renal oncocytoma

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