Computed tomography scan can be misleading in the lateralisation of aldosterone excess

Primary aldosteronism (PA) is characterised by aldosterone hypersecretion and represents a common cause of secondary hypertension. During diagnostic evaluation, it is essential to determine the aetiology of PA since the treatment of unilateral and bilateral disease differs significantly. Adrenal vein sampling (AVS) has been implemented as a gold standard test for the diagnosis of PA subtype. However, due to the AVS complexity, costs and limited availability, many patients with PA are being treated based on the computed tomography (CT) findings. In this article, we present two patients with discrepant CT and AVS results, demonstrating that AVS is the only reliable method for localising the source of aldosterone excess.

Learning points:

CT is an unreliable method for distinguishing aldosterone-producing adenoma (APA) from bilateral adrenal hyperplasia (BAH).

CT can be misleading in defining lateralisation of the aldosterone excess in case of unilateral disease (APA).

AVS is the gold standard test for defining the PA subtype.

Small carcinomas involving less than one-quarter of the rectal circumference: local excision is still associated with a high risk of nodal positivity

AIM

A study was carried out to determine the relationship between mesorectal lymph nodal involvement and T stage in a group of patients with a rectal cancer involving less than one-quarter of the rectal circumference, such as might be selected for local excision.

METHOD

The data of patients having rectal resection between 2010 and 2014 were prospectively entered in a rectal carcinoma registry. A model for describing tumours involving less than one quadrant of the rectal circumference was created to facilitate the evaluation process.

RESULTS

In all, 304 patients were included in the study. In 68 (22.4%) a small tumour (< 1 quadrant involved) was found. Of these, 26.5% had positive mesorectal lymph nodes (N+). In lesions of Stage ypT0 cancer 12.5% patients were node positive, in Stage Tis and T1 tumours there was no case of node positivity, but in Stage T2 and Stage T3 cancers the incidence of node positivity was 27.5% and 64%.

CONCLUSION

The study demonstrated that, even for small tumours involving only one rectal quadrant, the risk of lymph nodal involvement was about 25%. Had the patients undergone local excision the treatment would have been incomplete.

Clinical features and therapeutic outcomes of patients with acromegaly: single-center experience

The aim of this study was to review the outcome of acromegaly treatment, as well as co-morbidity and mortality in a series of patients with acromegaly attending a single center in the last 10 yr. In that period, 53 patients were treated for acromegaly. Transsphenoidal operation was applied as the first-line therapy in 94.3% of patients and it led to disease remission in 59.2% of them. The remission criteria included a nadir GH<1 μg/l after glucose load, and normal age-related IGF-I levels. The remission rate after transsphenoidal surgery was significantly higher in the group of patients with microadenoma (76.9%), than in the group of patients with macroadenoma (52.8%). Patients with invasive tumors had remission rate of 16.7% after transsphenoidal surgery. There were no perioperative deaths. As the second-line treatment somatostatin analogues, radiotherapy, and dopaminergic agonists were used. Hypertension and diabetes were the most frequent co-morbidities in the group of patients. After successful treatment, 30% of patients with diabetes or impaired glucose tolerance had significant improvement of glycemic control. Transsphenoidal surgery is the appropriate firstline therapy in patients with somatotropinoma. Medical and radio-therapy should be reserved as the second-line therapy after surgery failure.

[Numbers of lymph nodes in large intestinal resections for colorectal carcinoma]

INTRODUCTION

Precise evaluation of lymph nodes in the surgical specimen is crucial for the staging and subsequent decision about the adjuvant therapy in colorectal cancer. Prognosis of the patients can be assessed only in cases when at least 12 lymph nodes in the surgical specimen are examined.

AIM OF THE WORK

To evaluate the radicalism of resections for colorectal carcinoma after introducing laparoscopic approach.

METHODS

We compared all resections for primary colorectal cancer and rectal cancer (C 18-C20) performed in the Department of Surgery in University Hospital Hradec Králové in the years 2005 and 2008 and we evaluated numbers of examined lymph nodes in the surgical specimens. The patients with recurrent tumours and the patients with complete pathological response (negative histology) after neoadjuvant therapy were excluded from the study.

RESULTS

117 patients were included in the study in 2005, 2 of them were operated laparoscopically. 155 patients (more by 32.5%) were included in the study in 2008, 53 of them (34.2%) were operated laparoscopically. In tumours of the right part of the colon (C180-C184) treated by right hemicolectomy: on an average 7.9 (+/- 5.3) lymph nodes were examined in the specimens in 2005, and 15.3 (+/- 7.0) lymph nodes in 2008. In tumours of the left part of the colon (C185-C186) treated by left hemicolectomy: 6.5 (+/- 5.1) lymph nodes were examined in 2005, and 19.6 (+/- 15.6) in 2008. In tumours of the sigmoid colon (C187) 9.1 (+/- 6.9) lymph nodes were examined in 2005,and 15.4 (+/- 7.9) in 2008. In tumours of the rectosigmoid junction (C19) 8.0 (+/- 6.9) lymph nodes were examined in 2005, and 17.8 (+/- 11.2) in 2008. In rectal cancer (C20) 5.2 (+/- 4.5) lymph nodes were examined in 2005, and 13.6 (+/- 12.5) in 2008. There is a significant difference in a number of examined lymph nodes in patients without neodadjuvant treatment compared to those with neoadjuvant chemoradiotherapy and neoadjuvant radiotherapy. In 2005, in an average 3.7 (+/- 3.3) lymph nodes were removed in rectal resections after neoadjuvant chemoradiotherapy, in 2008 in an average 7.6 (+/- 6.1) lymph nodes were removed. In 2005, in an average 5.1 (+/- 3.7) lymph nodes in rectal resections after neoadjuvant radiotherapy were removed, in 2008 6.3 (+/- 4.3) lymph nodes were removed. In 2005, in an average 7.0 (+/- 5.5) lymph nodes in rectal resections without neoadjuvant therapy were removed, in 2008 20.9 (+/- 14.1) lymph nodes were removed. Laparoscopic resections were comparable with open resections regarding the number of examined lymph nodes in our group of patients.

CONCLUSION

Introducing the laparoscopic approach to resections of colorectal carcinomas did not decrease radicalism of the operation as to the number of removed lymph nodes.

[Transgastric and transrectal hybrid NOTES cholecystectomy--experimental study]

INTRODUCTION

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a dynamically developing branch of miniinvasive surgery, whose aim is a minimazing abdominal wall injury. Many experimental studies describe the wide spectrum of the NOTES techniques in the animal model. The NOTES experiment begun in the porcine model for acquiring experience at the Surgical Departement in the University Hospital in Hradec Králové.

MATERIAL AND METHODS

Hybrid NOTES cholecystectomy with transgastric and transrectal approaches in the porcine model were performed there. Eight animals were operated and were observed for 7 to 14 days after operations. A post-operative morbidity and mortality was found as well as a post-mortal examination for intraperitoneal complications.

RESULTS

Three transgastric and five transrectal hybrid cholecystectomies were performed. One animal died immediately after operation due to an anaesthesiological complication. There were two transrectal operations that converted to open surgery due to massive rectum wall injury. Seven surviving animals were without complications in the post-operative period. No post-operative complication in post-mortal exploration were found, gastrotomy and colotomy were healed primarily, there were no signs for peritonitis.

CONCLUSION

The experimental study showed the posibility of futher continuing development of the hybrid NOTES technique in the porcine model, also its safety, pitfalls and complications were presented.

[Peroperative diagnostics of acute bowel ischemia using ultraviolet light and fluorescein dye]

Acute bowel ischemia continues to have a high mortality rate. The main factor related to this poor outcome is considered to be the delay in diagnosis. The ability to detect ischemia early and to assess the extent of bowel involvement, are the most important aspects of successful treatment. The combination of ultraviolet (UV) light and fluorescein dye would be considered a simple, reliable and technically easy procedure for diagnosis of intestinal ischemia. The method can be used both for laparotomy when the source of UV light is a Wood's lamp as well for laparoscopy when the optical filters are placed to the light source of laparoscopic set to produce UV light. Present clinical experience shows that the method is precise, objective and accessible and that it gives a greater amount of independence to the surgeon allowing him to make the diagnosis of intestinal ischemia without having to rely on the assistance of other specialists.

[Sacral nerve stimulation in the treatment of anal incontinence]

Anal incontinence is defined as the loss of control of defecation. An estimated prevalence is about 20%, it increases with age and women are affected more frequently. Sacral nerve stimulation is a new treatment method with success rate nearly of 80%. It consists of two phases, temporary percutaneous nerve evaluation and permanent stimulation. The best results may be achieved in patients with anatomically intact sphincters, although indication criteria are still not uniform. Mechanism of action remains also unclear. Authors summarise aetiology of anal incontinence, describe the method of sacral nerve stimulation, indications and bring present published results of this method. The aim of this paper is to inform about the new treatment option which has not been yet used in the Czech Republic.

Decreased peak bone mass is associated with a 3-bp deletion/insertion of the CYP19 intron 4 polymorphism: preliminary data from the GOOS study

Finding that estrogen plays an important role in bone homeostasis in men prompted research on relationship of polymorphism at the CYP19 gene and the bone mass. Therefore, influence of 3-bp deletion/insertion polymorphism of CYP19 (TTTA)7 allele on the peak bone mass attainment in males was studied. Fifty-eight unrelated male participants, aged 21-35, were selected depending on the presence of (TTTA)7 (no.=19) or (TTTA)7-3 (no.=39) alleles from the initial cohort of 92 young males. Heterozygotes (TTTA)7/(TTTA)7-3 (no.=13) were not included in the analysis. Serum levels of estradiol, free testosterone, 25-hydroxyvitamin D, bone alkaline phosphatase, osteocalcin, and beta-crosslaps were measured. Bone mass was measured by DXA at the hip and at the spine. (TTTA)7-3 allele was associated with significantly lower femoral neck bone mineral density (BMD) (p=0.02). Logistic regression model indicated strong association of (TTTA)7-3 allele with low BMD in the range of osteopenia/osteoporosis (p=0.014, odds ratio 12.36, confidence intervals 1.65-92.46). In the present study association of 3-bp deletion polymorphism of the (TTTA)7 allele with decreased peak bone mass in males is reported for the first time. However, further studies are necessary to elucidate the functional relevance of this polymorphism.

Multiple stress fractures in a young female runner

The effect of exercise on female's bone metabolism has received much attention in recent years. We report on unusual case of a female runner with low body mass and amenorrhea, who suffered 4 stress fractures. Three of the stress fractures occurred during her sports career, and the fourth occurred 7 years after the cessation of sports activities. It seems that exercise-induced amenorrhea together with food restriction in the young age may cause long-term consequences on bone metabolism.

Influence of high intensity training on menstrual cycle disorders in athletes

AIM

To estimate the influence of intensive training on menstrual cycles in female athletes.

METHOD

The questionnaire was used to determine the time of menarche, and the prevalence of primary and secondary amenorrhea and dysmenorrhea in 72 active female athletes from Zagreb (10 volleyball players, 18 basketball players, 10 ballet dancers, and 34 runners) aged between 15 and 21. The control group comprised 96 girls of the same age not engaged in any sports activity.

RESULTS

The prevalence of secondary amenorrhea was three times higher in athletes than in the control group (p=0.037). The prevalence of primary amenorrhea was substantially higher in athletes than in the control group (6/72 vs. 0/96, p=0.014), whereas the prevalence of dysmenorrhea was twofold lower in athletes than in the control group (p<0.001). The highest prevalence of secondary amenorrhea was recorded in runners (14/31), particularly long-distance runners (11/17), whereas there was only one case of secondary amenorrhea among basketball players. Menarche was significantly delayed in the athletes who started physical activities before the onset of menstruation (13.8+1.4 vs. 12.6+1.0 years, p<0.001).

CONCLUSION

High-intensity training before menarche postpones its onset. Type of training may be related to a significantly higher prevalence of secondary amenorrhea in runners than in basketball players.

Neuropsychologic correlates of MRI white matter hyperintensities: a study of 150 normal volunteers

To determine the effects of MRI white matter hyperintensities (WMH) on cognitive functioning, we used neuropsychologic tests and MRI to study 150 elderly volunteers free of neuropsychiatric or general disease. There were 76 (50.3%) individuals without and 74 (49.7%) with WMH. The latter subset was older (61.3 +/- 6.6 years versus 58.5 +/- 5.8 years, p = 0.005), had a higher mean arterial blood pressure (103.7 +/- 11.4 mm Hg versus 99.9 +/- 10.3 mm Hg, p = 0.03), and a larger ventricular-to-intracranial-cavity ratio (6.3 +/- 5.6% versus 4.7 +/- 1.6%, p = 0.02). Individuals with WMH performed worse than their counterparts without such abnormalities on all tests administered. After adjusting for the group differences in age, arterial blood pressure, and ventricular size, we noted statistically significant results on form B of the Trail Making Test (121.8 +/- 37.8 msec versus 100.3 +/- 47.9 msec, p = 0.04), a complex reaction time task (680.8 +/- 104.9 msec versus 607.1 +/- 93.9 msec, p = 0.001), and the assembly procedure of the Purdue Peg-board Test (27.5 +/- 5.8 versus 30.6 +/- 5.9, p = 0.02). Partial correlations did not reveal any relationship between test scores and the semiautomatically assessed total area of WMH. Our data suggest that the presence of WMH exerts a subtle effect on neuropsychologic performance of normal elderly individuals, which becomes particularly evident on tasks measuring the speed of more complex mental processing.