Looking Across the Drape: A Novel Quality Improvement Approach to Understanding Surgeon and Anesthesiologist Burnout

OBJECTIVE

To identify well-being threats for surgeons and anesthesiologists and develop interventions using the Quality of Life Improvement (QOLI) approach.

BACKGROUND

Developing feasible perioperative well-being interventions requires identifying shared and specialty-specific well-being needs. The QOLI framework integrates human-centered design, implementation science, and quality improvement to address well-being needs.

METHODS

Anesthesia and surgery faculty in eight perioperative departments at an academic medical center completed cross-sectional surveys containing validated measures of well-being and workplace satisfaction, and open-ended questions about professional motivations, pain points, strategies for improvement, and well-being priorities. Using template analysis, we analyzed open-ended survey data and presented resulting themes at a joint-specialty town hall for live-voting to identify well-being priorities.

RESULTS

104 perioperative faculty completed the survey. Across specialties, higher MHC-SF scores (representative of individual global well-being) were associated with higher satisfaction with workplace control, values, decision latitude, and social support. Anesthesiologists reported lower satisfaction and control than surgeons across multiple domains. Template analysis yielded five areas for intervention: (1) Work culture, (2) Work environment/resources, (3) Sources of fulfillment, (4) Work/life harmony, (5) Financial compensation. Surgeons and anesthesiologists both prioritized high-quality patient care but differed in their other top priorities. The most frequently cited well-being threats for surgeons were OR inefficiencies/delays and excessive workload, while anesthesiologists cited understaffing and unpredictable work hours.

CONCLUSIONS

Surgeons and anesthesiologists share many needs and priorities, with pain points that are often negatively synergistic. Applying the QOLI approach across specialties allows for well-being interventions that honor complexity and promote the development of feasible solutions.

Patient Safety and Clinician Well-Being

Clinician well-being and patient safety are intricately linked. We propose that organizational factors (ie, elements of the perioperative work environment and culture) affect both, as opposed to a bidirectional causal relationship. Threats to patient safety and clinician well-being include clinician mental health issues, negative work environments, poor teamwork and communication, and staffing shortages. Opportunities to mitigate these threats include the normalization of mental health care, peer support, psychological safety, just culture, teamwork and communication training, and creative staffing approaches.

Drivers of Well-Being and Burnout in Anesthesiology Residents

Background

With more than 50% of anesthesiology residents reporting burnout, many residency programs have begun creating wellness programs to address burnout and promote well-being. However, to date, many wellness initiatives have focused on individual strategies rather than systems approaches to improve the learning environment. Individual-focused interventions in the absence of systematic efforts can lead to resentment, resistance, and worsening burnout and precipitate a loss of trust in leadership and the organization. Here, we describe a process to engage anesthesiology residents, who are key stakeholders, by exploring their perspectives on burnout and well-being to better inform systematic interventions to improve the clinical work and learning environments.

Methods

We conducted semistructured interviews with second- and third-year clinical anesthesia residents at the University of California, San Francisco, using the areas of worklife model as sensitizing concepts. We conducted a thematic analysis on transcribed interviews grounded in constructivist orientation.

Results

We identified the following 3 major categories of themes based on interviews with 10 residents: (1) definition of well-being, (2) challenges to well-being, and (3) strategies for coping with challenges and burnout. Challenges described by anesthesiology residents align with the areas of the worklife model, with the coronavirus disease 2019 pandemic precipitating additional threats in the domains of workload and community.

Conclusions

Anesthesiology residents' definition of well-being includes both individual (resilience) and systemic (meaning in work, job autonomy, and control) factors, reaffirming that positive work and learning environments are critical to professional well-being.

Quality of Life Improvement: A Novel Framework and Approach to Well-Being

Physician burnout is a complex problem that requires creative solutions. Despite increasing awareness of the importance of systems approaches to address physician well-being, few tools exist for organizations to bridge the gap between well-being theory and practice. As demonstrated during the COVID-19 pandemic, new threats to well-being can arise at any time, necessitating an iterative approach. Here we outline the quality of life improvement (QOLI) approach, a novel framework and approach that incorporates principles of human-centered design (HCD), quality improvement (QI), and implementation science (IS) to address clinician well-being. Additionally, we share our experience using this approach in a large academic anesthesiology department.

Awake spinal surgery: simplifying the learning curve with a patient selection algorithm

OBJECTIVE

There is a learning curve for surgeons performing "awake" spinal surgery. No comprehensive guidelines have been proposed for the selection of ideal candidates for awake spinal fusion or decompression. The authors sought to formulate an algorithm to aid in patient selection for surgeons who are in the startup phase of awake spinal surgery.

METHODS

The authors developed an algorithm for selecting patients appropriate for awake spinal fusion or decompression using spinal anesthesia supplemented with mild sedation and local analgesia. The anesthetic protocol that was used has previously been reported in the literature. This algorithm was formulated based on a multidisciplinary team meeting and used in the first 15 patients who underwent awake lumbar surgery at a single institution.

RESULTS

A total of 15 patients who underwent decompression or lumbar fusion using the awake protocol were reviewed. The mean patient age was 61 ± 12 years, with a median BMI of 25.3 (IQR 2.7) and a mean Charlson Comorbidity Index of 2.1 ± 1.7; 7 patients (47%) were female. Key patient inclusion criteria were no history of anxiety, 1 to 2 levels of lumbar pathology, moderate stenosis and/or grade I spondylolisthesis, and no prior lumbar surgery at the level where the needle is introduced for anesthesia. Key exclusion criteria included severe and critical central canal stenosis or patients who did not meet the inclusion criteria. Using the novel algorithm, 14 patients (93%) successfully underwent awake spinal surgery without conversion to general anesthesia. One patient (7%) was converted to general anesthesia due to insufficient analgesia from spinal anesthesia. Overall, 93% (n = 14) of the patients were assessed as American Society of Anesthesiologists class II, with 1 patient (7%) as class III. The mean operative time was 115 minutes (± 60 minutes) with a mean estimated blood loss of 46 ± 39 mL. The median hospital length of stay was 1.3 days (IQR 0.1 days). No patients developed postoperative complications and only 1 patient (7%) required reoperation. The mean Oswestry Disability Index score decreased following operative intervention by 5.1 ± 10.8.

CONCLUSIONS

The authors propose an easy-to-use patient selection algorithm with the aim of assisting surgeons with patient selection for awake spinal surgery while considering BMI, patient anxiety, levels of surgery, and the extent of stenosis. The algorithm is specifically intended to assist surgeons who are in the learning curve of their first awake spinal surgery cases.

Conflict Management Education for Anesthesiology Residents: Bridging the Gap in Interpersonal and Communication Skills Competency

Effective communication and conflict management are important skills for anesthesiologists and are designated by the Accreditation Council for Graduate Medical Education (ACGME) as elements of the "interpersonal and communication skill" competency (ACGME Anesthesiology Milestone Project 2020). However, structured conflict management education for anesthesiology residents remains limited. To address this gap, we developed and implemented a conflict management session incorporating didactics and application exercises using role-play and high-fidelity simulation (SIM) for anesthesiology residents (postgraduate years 3 and 4) at a tertiary academic medical institution. These sessions were well-received, and both role-play and SIM appear to help residents learn conflict management skills.

Increasing the use of multimodal analgesia during adult surgery in a tertiary academic anaesthesia department

Objective

Multimodal analgesia pathways have been shown to reduce opioid use and side effects in surgical patients. A quality improvement initiative was implemented to increase the use of multimodal analgesia in adult patients presenting for general anaesthesia at an academic tertiary care centre. The aim of this study was to increase adoption of a perioperative multimodal analgesia protocol across a broad population of surgical patients. The use of multimodal analgesia was tracked as a process metric. Our primary outcome was opioid use normalised to oral morphine equivalents (OME) intraoperatively, in the postanaesthesia care unit (PACU), and 48 hours postoperatively. Pain scores and use of antiemetics were measured as balancing metrics.

Methods

We conducted a quality improvement study of a multimodal analgesia protocol implemented for adult (≥18 and≤70) non-transplant patients undergoing general anaesthesia (≥180 min). Components of multimodal analgesia were defined as (1) preoperative analgesic medication (acetaminophen, celecoxib, diclofenac, gabapentin), (2) regional anaesthesia (peripheral nerve block or catheter, epidural catheter or spinal) or (3) intraoperative analgesic medication (ketamine, ketorolac, lidocaine infusion, magnesium, acetaminophen, dexamethasone ≥8 mg, dexmedetomidine). We compared opioid use, pain scores and antiemetic use for patients 1 year before (baseline group—1 July 2018 to 30 June 2019) and 1 year after (implementation group—1 July 2019 to 30 June 2020) project implementation.

Results

Use of multimodal analgesia improved from 53.9% in the baseline group to 67.5% in the implementation group (p<0.001). There was no significant difference in intraoperative OME use before and after implementation (β₀=44.0, β₂=0.52, p=0.875). OME decreased after the project implementation in the PACU (β₀=34.4, β₂=−3.88, p<0.001) and 48 hours postoperatively (β₀=184.9, β₂=−22.59, p<0.001), while pain scores during those time points were similar.

Conclusion

A perioperative pragmatic multimodal analgesic intervention was associated with reduced OME use in the PACU and 48 hours postoperatively.

Applying Conflict Management Strategies to the Pediatric Operating Room

Effective communication is essential in today's health care environment, and poor communication can lead to conflict among health care providers. Differences in cultures and beliefs can further incite conflict among health care team members, families, and patients. Pediatric patient care has a higher potential for conflict because decision-making responsibilities are shared among patients, parents/guardians, and clinicians. It is important to understand the phases and types of conflict because each conflict situation requires a different approach to optimize management. Equally important is an understanding of styles used by individuals to manage conflict. The Thomas-Kilmann Conflict Mode Instrument and the Dutch Test for Conflict Handling are 2 validated tools used to assess conflict management styles. The different styles include competing/forcing, collaborating/problem solving, compromising, avoiding, and yielding/accommodating. A successful physician should be able to identify the phases and types of conflict to use the conflict management approach most suitable for the given conflict.There are several techniques for managing conflict in the pediatric operating room. Acknowledging and managing one's own emotions during conflict is a pivotal first step toward diffusing the situation. Active listening is an important communication skill that improves team dynamics. Aligning the interests of the parties involved in conflict will encourage collaborative problem solving. Cultural competency training can improve communication and conflict management skills. Effective conflict management through formal education of all perioperative team members can lead to improved communication and teamwork and better patient outcomes.

[Frequency and clinical features of ASXL2 gene mutation in acute myeloid leukemia patients with AML1- ETO fusion gene positive]

目的

探讨伴AML1-ETO融合基因的急性髓系白血病（AML）患者ASXL2基因突变情况、突变阳性患者临床特征及ASXL2基因突变与c-kit基因突变的关系。

方法

采用PCR扩增产物片段直接测序分析法，检测59例伴AML1-ETO融合基因初发AML患者ASXL2基因第11、12外显子编码区突变情况，比较ASXL2基因突变阳性和阴性组患者的临床特征、生存及c-kit基因突变情况。

结果

59例患者中7例存在ASXL2突变，突变率为11.9%。ASXL2基因突变阳性组患者初诊时外周血红蛋白浓度中位数为56.2（38.0~72.0）g/L，显著低于ASXL2突变阴性组患者的69.0（37.2~154.0）g/L，差异有统计学意义（P=0.038）；外周血WBC、PLT、嗜酸粒细胞比例、骨髓原始细胞比例与ASXL2突变阴性组相比，差异均无统计学意义（P值均>0.05）。两组均未见肝、脾、中枢神经系统浸润；淋巴结不同程度肿大，但ASXL2基因突变阳性、阴性两组间差异无统计学意义（P=0.859）。免疫表型分析显示：ASXL2基因突变阳性组CD33表达显著低于阴性组（P=0.033）；两组患者均未表达cCD3，CD117、cMPO、HLA-DR、CD34、CD38、CD13、CD44、CD15、CD64、CD11b、CD56、CD19、cCD79a、CD7两组表达差异均无统计学意义（P值均>0.05）。ASXL2基因突变阳性与阴性组患者总缓解率、总生存时间差异均无统计学意义（P值分别为0.577、0.631）。两组c-kit基因突变检出率分别为14.3％和29.4%，差异无统计学意义（P=0.697）。

结论

该组伴AML1-ETO融合基因AML患者ASXL2基因突变率为11.9%。ASXL2突变阳性患者外周血红蛋白浓度、CD33表达方面呈现一定的临床特征。ASXL2基因突变与c-kit基因变突可能没有特定的关联性。

[Discovery of a novel spliceosome of ABL gene (ABL(Δexon7+35INS)) and its association with TKIs resistance in chronic myeloid leukemia]

OBJECTIVE

To explore whether the ABL(Δexon7) and ABL(35INS) spliceosome contributed to TKIs resistance.

METHODS

Screening ABL(Δexon7) and ABL(35INS) in 74 normal people and 76 CML patients (53 patients in remission and 23 patients with TKIs resistance) by using polyacrylamide gel electrophoresis combined with cloning sequencing.

RESULTS

A novel spliceosome ABL(Δexon7+ 35INS) (ABL(Δexon7) and ABL(3)5INS existed at the same time) was identified and the mutation was detected in 8 (10.8%) of 74 normal people, 4 (7.5%) of 53 remission patients and 2 (8.7%) of 23 resistant patients. While 47 (63.5%) cases expressed ABL(Δexon7) and 8 (10.8% ) cases expressed ABL(35INS) in 74 healthy people, 30 (56.6%) cases expressed ABL(Δexon7) and 5 (9.4% ) cases expressed ABL(35INS) in 53 remission patients, 12 (52.2%) cases expressed ABL(Δexon7) and 3(13.0%) cases expressed ABL(35INS) in 23 resistant patients. Three kinds of spliceosome in all groups had no statistical difference.

CONCLUSION

ABL(Δexon7+ 35INS), ABL(Δexon7) and ABL(35INS) may be not uncommon in ABL gene and were unrelated to resistance in CML with TKIs treatment. ABL(35INS) were often accompanying with exon 7 deletion.

P2-09-13: The Value of FDG PET/CT in Screening Detected Breast Cancer Patients

Background. To evaluate the diagnostic value of FDG PET/CT for initial staging of screening detected breast cancer.

Methods. Between January 2008 and June 2010, a total of 77 women (mean age 54 years, range 31–77 years) with screening detected primary breast cancer (mean invasive tumor size 1.65cm, range 1–70mm) underwent whole body fluorine-18 fluorodeoxyglucose (FDG) PET/CT for initial staging and were included in this retrospective study. Two patients had bilateral breast cancer. The sensitivity of FDG PET/CT for the detection of primary tumor and the sensitivity, specificity, PPV and NPV for the detection of axillary lymph node metastases were determined. Systemic staging with whole body FDG PET/CT was also performed. For analysis of diagnostic performance of FDG PET/CT, quantitative measurement of the maximum standardized uptake value (SUVmax) criteria 1.0 was used. The final histopathology following surgery served as the gold standard.

Results. The primary tumor was FDG PET/CT positive in 65 of 79 lesions (82%). Depending on the tumor size, there was a variation in diagnostic sensitivity (63% in ≤ 1cm tumor, n=19 vs. 88% in &gt; 1cm tumor, n=60) and the uptake of FDG was significantly higher in &gt; 1cm tumor than in ≤ 1cm tumor (mean SUVmax 2.85 vs. 1.11, p&lt;0.05). The uptake of FDG was significantly higher in ductal carcinomas compared to lobular carcinomas (median SUVmax 2.0, n=72 vs. 1.3, n=7, p&lt;0.05). Of the 77 patients included in this study, 16 patients were found to have axillary node metastasis. The sensitivity, specificity, PPV and NPV of FDG PET/CT for detection of LN metastasis were 63% (10/16), 89% (54/61), 59% (10/17) and 90% (54/60), respectively. FDG PET/CT showed distant uptake in 9 patients and 8 of 9 were false positive results. 4 lesions were confirmed histopathologically as benign and 4 lesions were evaluated with radiologic methods. One of nine was true positive result. Distant involvement was skeletal and visible on the conventional bone scintigraphy. The patient staged as cT1N3M1.

Conclusion. FDG PET/CT has limited value for the initial staging of screening detected breast cancer patients. Considering high costs, radiation exposure and false positivity, FDG PET-CT is not recommended for the preoperative evaluation of screening detected breast cancer patients.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-09-13.

Pictorial review: Unusual tumours involving the prostate: radiological-pathological findings

The appearance of several unusual tumours in the prostate has resulted in questions being raised concerning their histogenesis; moreover, some of these tumours have prognoses that are quite unlike those of prostatic adenocarcinoma. Unusual neoplasms involving the prostate have been described in recent years, including mucinous cystadenocarcinoma, neuroendocrine cancer, lymphoma, spindle cell neoplasm, squamous cell carcinoma and transitional cell carcinoma. Radiological findings can overlap, and play limited roles in the diagnoses of these entities. However, knowledge of the radiological findings in these conditions can be helpful in making differential diagnoses. Images of prostate lesions using several imaging modalities, including transrectal ultrasound, MRI and CT, as well as available pathological images of such lesions, are presented in this article.

Endothelin-1 regulates parathyroid hormone expression of human parathyroid cells

OBJECTIVE

Parathyroid cells synthesize and release endothelin-1 (ET-1). ET-1 displays an in vitro inhibitory effect on basal parathyroid hormone (PTH) secretion and also counteracts PTH hypersecretion stimulated by low calcium. Such effects are further demonstrated in vivo, independent of the changes in calcitonin. We propose that ET-1 may regulate the pathogenesis of uremic hyperparathyroidism. However, this was not directly demonstrated in human parathyroid glands.

DESIGN

Hyperplastic parathyroid glands are obtained from the surgical operation for uremic hyperparathyroidism. Cells are isolated by enzyme digestion and treated with ET-1, and are assessed for PTH mRNA expression. PTH in the plasma and the medium is measured by a newly developed method to detect the whole PTH (1-84).

PATIENTS

Uremic patients with severe secondary hyperparathyroidism and ultrasonography-proved hypertrophy of parathyroid glands received elective surgical approaches under general anesthesia. The resected glands were immediately taken to the laboratory for fresh isolation.

MEASUREMENTS

Following ET-1 treatment, PTH mRNA expression is evaluated by RT-PCR method. ET-1 is detected with radioimmunoassay kit and PTH is measured by a new commercially available Duo PTH kit.

RESULTS

ET-1 exhibited a dose-dependent inhibitory effect (from 10(-12) - 10(-7) M) on PTH mRNA expression of parathyroid cells, either in the basal or in the low-calcium-stimulated states. Release of PTH into the medium is also gradually inhibited by the increase in ET-1 concentrations.

CONCLUSIONS

Our results demonstrate that ET-1 attenuates PTH mRNA expression in freshly isolated human parathyroid cells, and PTH release is also decreased. This result is consistent with our previously reported in vitro and in vivo experiments.

Decreased B cells and IgA-secreting B cells partially explain the high prevalence of IgA deficiency in dialysis patients

AIMS

We previously reported 2 hemodialysis (HD) patients with recurrent infections and selective immunoglobulin A deficiency (IgAD). We further demonstrated that serum IgA levels were lower and the prevalence of IgAD was higher in uremic patients. The exact mechanisms of IgAD in uremic patients largely remained unclear. In some patients, it was caused by anti-IgA antibody neutralization and subsequent destruction. We performed the present study to survey if there is any defect in IgA production.

MATERIALS AND METHODS

288 patients were initially included for examination of serum immunoglobulins. 16 normal persons, 16 dialysis patients without IgAD, and 12 dialysis patients with IgAD were enrolled after the initial examination. Blood was drawn into heparinized tubes. WBC counts and lymphocyte percentage were examined by a CBC counter. Lymphocytes were separated by the Ficoll-Paque method. Flow cytometry was utilized to isolate the B cell and IgA-secreting B cell after staining with CD 19 phycoerythrin and FITC-conjugated rabbit anti-human IgA antibody.

RESULTS

There is no significant difference between WBC counts or total lymphocyte counts of these 3 groups. However, we found a lower percentage of total lymphocyte counts in dialysis patients, either with or without IgAD. The total B cell numbers were lower in dialysis patients with IgAD. In addition, there were fewer IgA-secreting B cells in dialysis patients with IgAD.

CONCLUSION

Decreased B cell and IgA-secreting B cell counts are seen in uremic patients with IgAD. This, in turn, indicates that there might be a defect of IgA production in some patients, rather than IgA destruction by anti-IgA antibodies as seen in some other patients. Further study is needed to investigate the mechanisms of decreased B cells and IgA-secreting B cells.

Radiofrequency ablation in pig lungs: in vivo comparison of internally cooled, perfusion and multitined expandable electrodes

The purpose of this study was to compare the amounts of in vivo coagulation obtained by radiofrequency (RF) ablation in porcine lung, using three types of electrodes. 15 in vivo ablation procedures were performed in the lungs of five pigs using three kinds of currently available RF devices under CT guidance. After placing an electrode in the lung, three ablation zones were created at each of three different regimens: Group A: RF ablation with an internally cooled electrode; Group B: RF ablation with a perfusion electrode, with instillation of 0.9% NaCl solution at a rate of 1.5 ml min(-1); Group C: RF ablation with a multitined expandable electrode. According to the manufacturer's recommendations, RF application times were 12 min in group A and 20 min in group B. In group C, RF energy was delivered for 7 min after a mean temperature of 110 degrees C was reached at 5 cm deployment. 36 min after the procedures, contrast-enhanced CT scans were obtained to evaluate the volume of zone of coagulation, and lungs were harvested for gross measurements. After macroscopic and histopathological analyses of 5 mm-thick lung sections, diameters, volumes and variation coefficients of regions of central coagulation were assessed. During RF ablation, the perfusion electrode allowed a larger energy delivery than the internally cooled or the multitined expandable electrodes, i.e. 33.6+/-4.7 kJ in group A, 40.0+/-8.2 kJ in group B and 23.5+/-6.1 kJ in group C (p<0.05). On gross observation, the cut surface of the gross specimen containing RF-induced coagulation showed that the ablated tissue appeared to be a central, firm, dark-brown area surrounded by an irregular outer margin (approximately 3-10 mm thick) of bright red tissue. In vivo studies showed that RF ablation using the perfusion electrode achieved larger coagulation volume than RF ablation using the other electrodes (p<0.05): 7.2+/-4.1 cm3 in group A; 16.9+/-5.5 cm3 in group B; 7.5+/-3.3 cm3 in group C. The corresponding variation coefficients were 0.55, 0.31, and 0.45, respectively. Our study shows that RF ablation using a perfusion electrode achieves a larger coagulation volume with an irregular margin than RF ablation using internally cooled or multitined expandable electrodes in the porcine lung.

Kaposiform hemangioendothelioma arising from the internal auditory canal

Kaposiform hemangioendothelioma is a rare vascular tumor and locally aggressive endothelial-derived spindle cell neoplasm, which occurs almost exclusively in infants and adolescents. Radiologically, hemangioendothelioma, including Kaposiform hemangioendothelioma, is seen as a highly vascularized well-enhancing tumor, but no characteristic findings differentiate Kaposiform hemangioendothelioma from other soft-tissue tumors, particularly when the tumor is too small to have any locally aggressive features or identifiable large vessels. We present a case of Kaposiform hemangioendothelioma in the internal auditory canal that had no differential features on initial MR images and rapidly grew into a huge mass in a few months.

7-84 parathyroid hormone fragments are proportionally increased with the severity of uremic hyperparathyroidism

AIMS

Recent progress in PTH assay has revealed that the intact PTH assay kit in current use does not differentiate between the truncated 7-84 PTH molecule and the 1-84 PTH molecule. In our series, we examined the effectiveness of a new PTH assay as a noninvasive method of evaluating severity of uremic hyperparathyroidism.

METHODS AND MATERIALS

Two hundred and seventy hemodialysis (HD) patients recruited from three HD centers were included and divided into subgroups according to the conventional iPTH assay results. Pre-dialysis blood samples were collected and subjected to two different PTH assays: "intact" PTH assay (iPTH) and "whole" PTH (wPTH) assay. Two biochemical markers of bone remodeling were also examined.

RESULTS

In all cases, PTH levels determined by the wPTH assay were in the average 32.3% lower than those determined by the iPTH assay. The difference of the results of the two PTH assay methods, which indicated the portion of 7-84 PTH fragments of the total PTH molecules measured with the iPTH assay, was gradually increased while the severity of uremic hyperparathyroidism increased. Biochemical markers of bone formation/resorption showed a similar change.

CONCLUSION

The portion of the 7-84 PTH fragments and markers of increased bone turnover increased in proportion to the severity of uremic hyperparathyroidism. This finding disproves the hypothetical role of 7-84 PTH fragments alone as the noninvasive marker of low-turnover bone disease in HD patients.

Malignant mesothelioma of the tunica vaginalis testis

Malignant mesothelioma of the tunica vaginalis is rare, and is usually not diagnosed until surgery is undertaken. Reports on the ultrasound features of this tumour are limited. We present an unusual case with ultrasound features mimicking an adenomatoid tumour.

CT of small bowel ischemia

We evaluated the computed tomographic (CT) features of small bowel (SB) ischemia and necrosis and correlated the findings with clinical outcome or patient prognosis. Sixty-eight surgically or angiographically proved cases of SB ischemia were retrospectively reviewed. The CT features of intestinal ischemia were divided into three groups: (A) thinned bowel wall with poor enhancement, intramural gas, or portal venous gas; (B) thickened SB wall without superior mesenteric vein thrombosis; and (C) thickened SB wall with superior mesenteric vein thrombosis or intussusception. The evaluated factors included bowel wall or mucosal enhancement pattern, SB dilatation, mesenteric edema, and CT evidence of narrowing or occlusion of the superior mesenteric artery or vein. The bowel necrosis rates and mortalities were compared with chi-square test. Oral contrast material was not administered. Intramural gas and SB dilatation were associated with a higher bowel necrosis rate (eight of eight, 100%, and 17 of 21, 81%, respectively) in group A. Poor mucosal enhancement of the thickened bowel wall indicated a higher bowel necrosis rate in groups B (six of seven, 86%) and C (12 of 12, 100%) than did normal mucosal enhancement. Only intramural gas was accompanied with a higher mortality (six of eight, 75%). Intramural gas of a thinned bowel wall and poor mucosal enhancement of a thickened small bowel wall are useful signs of bowel necrosis. Intramural gas would indicate poor patient prognosis.

Ultrasound diagnosis of paratesticular rhabdomyosarcoma

Rhabdomyosarcoma is the most common tumour of the lower genitourinary tract in children in the first two decades. Paratesticular rhabdomyosarcoma is associated with a significantly better outcome than lesions elsewhere in the genitourinary tract. Although ultrasound is considered the imaging modality of choice for evaluating intrascrotal pathology, the ultrasound appearance of paratesticular rhabdomyosarcoma has rarely been reported and may be confused with other disease entities such as epididymitis, adenomatoid tumour and leiomyoma. We present the ultrasound features of a paratesticular rhabdomyosarcoma, discussing the clinical features and differential diagnosis.

Undifferentiated sarcoma of the mitral valve with unique clinicopathologic presentation

We report a case of undifferentiated sarcoma originating from the mitral valve in a 3-year-old boy who presented with embolic symptoms of the lower extremity. The tumor was demonstrated by echocardiography. The mass was removed under a mild hypothermic cardiopulmonary bypass with cold blood cardioplegia. Grossly, the mass was composed of multiple small nodules, and the histopathologic findings were compatible with an undifferentiated sarcoma. Postoperative chemotherapy was added. The patient remains without evidence of recurrence 18 months after surgery.

Case report: diabetic mastopathy

Diabetic mastopathy is a source of confusion with breast carcinoma. The association between mastopathy and Type I diabetes of long duration has been reported, but this clinical condition is poorly recognized since breast examination is not routinely performed in young diabetic patients. Radiologists' awareness of the constellation of findings in diabetic mastopathy may spare patients from undergoing unwarranted surgical biopsies.

Edema due to protein-losing enteropathy--a disorder rarely considered by nephrologists

In the differential diagnosis, protein-losing enteropathy (PLE) is a rarely considered explanation of edema. Three such cases are reported in this article. Clinical presentations varied from severe generalized anasarca and respiratory distress to mild pitting edema on the pretibial surface. Hypoalbuminemia (< 35 g/l) was another common finding in addition to edema. The patients were carefully examined to exclude other causes of hypoalbuminemia. Two patients experienced diarrhea. Endoscopic studies (plus biopsies) for any mucosal lesion in the stomach and colon were also performed. PLE was confirmed by the positive radionuclide scanning results after infusing intravenous 99mTc human serum albumin (USA). Investigation for the etiologies showed intestinal lymphangiectasia in 1 patient, Menetrier's disease in another, and no recognizable cause in the third. The severe anasarca of the patient with intestinal lymphangiectasia didn't respond to corticosteroids and albumin supplement plus large doses of furosemide. She died of overwhelming pulmonary infection despite the use of powerful antibiotics (ceftriaxone and amikacin). We planned to treat the Menetrier's disease patient with somatostatin to decrease the exocrine activities of the intestinal tract. The patient with presumable idiopathic PLE had the least severe edema and was not treated with any medication. In addition to the above patients, another 3 patients with hypoalbuminemia and edema were also noted to have positive HSA scan results. However, 2 of these patients had systemic lupus erythromatosus and the third pulmonary tuberculosis and biopsy-proven membranous nephropathy. Treatment of their underlying diseases showed satisfactory remission of edema.

Unilateral renal cystic disease--report of one case and review of literature

Clinical presentation of unilateral renal cystic disease (URCD) is characterized by multiple simple cysts in only 1 kidney. Involvement of other intra-abdominal organs is not found. Renal function is usually preserved despite the existence of multiple cysts. No genetic background can be delineated up to the present. We present 1 patient with URCD, who was evaluated for his right flank pain. Urinalysis and biochemical tests showed normal renal function (BUN 5.03 mmol/l, creatinine 110.5 micromol/l). Ultrasonographic examination was done and it revealed 2 right renal stones. Furthermore, multiple renal cysts over the juxta-medullary area were noted. His left kidney was intact. Computed tomography (CT) of both kidneys confirmed this finding. 99mTc-DTPA renal scan showed that the glomerular filtration rate of both kidneys was not significantly different. There was no family history of renal diseases. His parents, grandparents and siblings were examined for possible kidney lesions, but none of them had any renal cystic lesion. This patient was followed for only a relatively short period of time (3 years) and his renal function did not deteriorate. Follow-up image studies with sonography and CT were not different from the previous ones.

Differential effects of FMLP-activated neutrophils from patients with IgA nephropathy enhanced endothelin 1 production of glomerular mesangial cells

BACKGROUND

Neutrophil infiltration in the glomeruli is common in patients with IgA nephropathy (IgAN). The pathogenetic roles of the infiltrated neutrophils and their relationship with glomerular mesangial cells, however, are not clear.

METHODS

We examined the effects of coculture with N-formyl-methionyl-leucyl-phenylalanine (FMLP) activated neutrophils on the viability, endothelin 1 (ET-1) production, and ET-1 mRNA expression of rat glomerular mesangial cells. Neutrophils were isolated from 15 IgAN patients, from 13 patients with non-IgA mesangial proliferative glomerulonephritis (MsPGN), and from 10 normal controls.

RESULTS

The ET-1 production by mesangial cells was significantly higher after stimulation with FMLP-activated neutrophils from IgAN patients than that of MsPGN patients and normal controls, and this effect was significantly abolished by pretreating mesangial cells with superoxide dismutase and partly abolished by catalase. The ET-I mRNA expression of mesangial cells showed a parallel increase with ET-1 protein. The trypan blue exclusion test showed significant mesangial cell death after stimulation with FMLP-activated neutrophils as compared with quiescent neutrophils, and the cell death was also prevented by superoxide dismutase but not catalase. The FMLP-activated neutrophils from IgAN patients produced more superoxide than those of MsPGN patients and normal controls.

CONCLUSION

The FMLP-activated neutrophils from patients with IgAN have differential effects in enhancing the cell death and the ET-1 production of glomerular mesangial cells through the release of superoxide.

Expression of NF-kappaB and cytokines in chronic rejection of transplanted murine heart

The heart transplantation-associated accelerated graft arteriosclerosis (AGAS) is one of the major causes of cardiac allograft failure. We investigated the early time-course of expresssion patterns of cytokines, transcription factor, and its inhibitor in the intraabdominally transplanted mice hearts that differed only in the D locus of class I histocompatibility antigen. The allograft hearts were harvested at 1-3, 5, 7, 14, 28, and 42 days after the transplantation, and the expressions of NF-kappaB/I-kappaB and cytokines (TNF-alpha, INF-gamma) were examined in these specimens. The expressions of TNF-alpha and INF-gamma were observed on day 1, peaking on day 5 and 7, respectively. Activated NF-kappaB (p65) expression was present on the cytoplasm and perinuclear area in the endothelial cells of coronary arteries on day 1. The peak of translocation of NF-B from cytoplasm to nucleus appeared on day 5 in the endothelial cells, myocytes, and leukocytes within the vessels, and remained elevated until day 42. The I-kappaB expression gradually increased from day 1 until day 5, but a remarkable decrease was detected on day 7. Our data suggest that the increased expressions of NF-kappaB/I-kappaB and cytokines (TNF-alpha, INF-gamma) play an important role in inducing immune responses in the donor allograft heart and hence the blockage of the expressions might be mandatory to avoid a potential graft failure.

Differential effects of circulating IgA isolated from patients with IgA nephropathy on superoxide and fibronectin production of mesangial cells

BACKGROUND

IgA nephropathy (IgAN) is characterized by predominant deposition of IgA in the glomerular mesangium. Serum IgA is often elevated in patients with IgAN, and it has been postulated that it is responsible for the mesangial lesions. However, the direct effect of circulating IgA on mesangial cells is not clear.

METHODS

We investigated the effects of sera and IgA which were isolated from patients with IgAN on thymidine uptake, superoxide and fibronectin production and fibronectin mRNA expression of cultured rat mesangial cells, and we compared the findings to the effects of IgA isolated from patients with non-IgA mesangial proliferative glomerulonephritis (MsPGN) and normal controls. IgA was isolated with affinity chromatography using cyanogen bromide activated Sepharose 4B coupled to sheep antihuman IgA antiserum.

RESULTS

Our results demonstrated that both sera and IgA from patients with IgAN dose-dependently increased mitogenesis of mesangial cells as measured by (3)H-labeled thymidine uptake. The thymidine uptake by sera and IgA isolated from patients with IgAN was significantly higher than that of sera and IgA isolated from patients with MsPGN and normal controls. Sera and IgA from patients with IgAN significantly enhanced superoxide and fibronectin production and fibronectin mRNA expression of mesangial cells. The superoxide and fibronectin production was also significantly higher as compared with patients with MsPGN and normal controls.

CONCLUSIONS

Our results indicate that circulating IgA isolated from patients with IgAN is different from that of patients with MsPGN and normal controls and may potentially induce oxidative injury and production of extracellular matrix of glomerular mesangial cells in IgAN.

Protein-losing enteropathy: diagnosis with (99m)Tc-labeled human serum albumin scintigraphy

PURPOSE

To investigate the diagnostic value of technetium 99m-labeled human serum albumin (HSA) scintigraphy in a group of patients suspected of having protein-losing enteropathy (PLE).

MATERIALS AND METHODS

After intravenous injection of 740 MBq of freshly prepared (99m)Tc HSA, serial images of the abdomen were obtained from 10 minutes until 24 hours after injection. A (99m)Tc HSA scan was considered positive for PLE if there was visible tracer exudation in the gut. The diagnosis was established on the basis of standard clinical and biopsy findings.

RESULTS

Thirty-nine scans were obtained: 27 scans in 26 suspected cases of PLE and 12 scans in control subjects with no known gastrointestinal disease. Twenty-five of the 26 studies in patients suspected of having PLE showed (99m)Tc HSA activity in the bowel. Among the 25 studies with positive findings, seven demonstrated PLE only on images obtained 24 hours after injection. In the control subjects, no activity was seen in the bowel.

CONCLUSION

(99m)Tc HSA with serial scanning for up to 24 hours is reliable and useful for imaging PLE. Sites of protein loss may also be demonstrated. This imaging method is convenient, easy to perform, and yields results within 24 hours.

Plasma and urinary endothelin-1 in focal segmental glomerulosclerosis

The kidney is an important site of endothelin-1 (ET-1) production and is particularly susceptible to ET-1 action. Infusion of ET-1 in rats induces both functional and morphological alterations in the kidneys. Increased plasma level of ET-1 has been reported in patients with chronic renal failure. However, there are still no reports on the plasma and urinary ET-1 levels in patients with focal segmental glomerulosclerosis (FSGS). In the present study, we have measured the plasma concentration and urinary excretion rate of ET-1 in 15 patients with nephrotic syndrome due to FSGS, and observed the serial changes of plasma and urinary ET-1 in nephrotic rats with FSGS, induced by repeated injection with puromycin aminonucleoside (PAN). ET-1 was measured with radioimmunoassay. The results showed that plasma ET-1 concentration in FSGS patients was significantly higher than in normal controls (P < 0.05), and that urinary ET-1 excretion rate was also significantly higher in FSGS patients than in normal controls (P < 0.01). In FSGS patients, the plasma and urinary ET-1 was significantly correlated (P < 0.05), and the urinary ET-1 excretion rate was significantly correlated with the amount of proteinuria (P < 0.05) and the glomerular sclerosing score (P < 0.01). In the ten rats with PAN-induced FSGS, serial examination showed a significant increase in plasma ET-1 after 8 weeks of injections, while the urinary ET-1 excretion rate showed a biphasic increase that showed a peak after 4 to 6 weeks. The same changes in plasma and urinary ET-1 levels were not observed in control rats injected with normal saline at the same frequency. Our results suggest that ET-1 may be involved in the pathogenesis of FSGS in both humans and rats.

High prevalence of selective immunoglobulin A deficiency in peritoneal dialysis patients

We encountered two hemodialysis (HD) patients with recurrent infections and complete immunoglobulin A deficiency (IgAD). To survey the possibility of a similar occurrence in other populations, we conducted the present study. We used nephelometry to examine the levels of immunoglobulins G (IgG), A (IgA), and M (IgM) in 42 continuous ambulatory peritoneal dialysis (CAPD) patients, 246 HD patients, 56 chronic renal failure (CRF) patients, and 250 normal adults. Four CAPD patients (9.5%) and five HD patients (2.0%) were found to be completely IgA deficient (IgA < 6.67 mg/dL). Peritoneal dialysis patients therefore had a significantly higher prevalence of IgAD compared with HD and CRF patients. The underlying diseases leading to dialysis therapy in the IgAD patients varied. Their dialysis durations also varied. The occurrence rate of peritonitis in CAPD patients with IgAD was no higher than in patients without IgAD. The clinical significance of IgAD was focused on mucosal immunity, but the exact prevalence of infection was difficult to define. However, these patients' medical records did suggest more frequent respiratory tract infections and cellulitis events than did the records of patients without IgAD. Two PD patients with IgAD died of pneumonia. Immunodiffusion and indirect ELISA methods were used to detect the presence of auto-antibodies, successfully identifying them in three patients. Further research is needed to study other mechanisms of IgAD.

Altering expression of alpha3beta1 integrin on podocytes of human and rats with diabetes

The adhesion molecule integrin alpha3beta1 is the major receptor of podocyte to the glomerular capillary basement membrane (GBM). Since progressive alteration of the glomerular extracellular matrix (ECM) compartment leading to GBM thickening is common in diabetic nephropathy, we investigated the cellular distribution of alpha3beta1 integrin in podocytes of patients with diabetic nephropathy and streptozotocin-induced diabetic rats, and we evaluated the effects of high glucose on the cultured rat podocytes. Both human and rat kidneys were stained using the immunoelectron microscopy and immunoperoxidase technique with mouse monoclonal antibodies to human integrin alpha3 subunit. The results showed that both the number of immunogold particles and the staining of integrin alpha3 subunit on podocytes were weaker in patients with diabetic nephropathy than those of control kidneys. The staining of alpha3 on podocytes in the poorly-controlled diabetic rats was also weaker after one and three months of hyperglycemia. However, the staining was identical to controls in rats with only one week of hyperglycemia. High glucose (25 mM) but not streptozotocin in vitro suppressed the alpha3 expression of cultured rat podocytes. Our results demonstrated that the expression of integrin alpha3beta1 on podocytes was suppressed in both human and rats with diabetes, possibly due to the effects of hyperglycemia, and the suppression became more severe with the duration of diabetes.

Differentiation of obstructive from non-obstructive small bowel dilatation on CT

PURPOSE

to find a useful decision procedure for the differentiation of obstructive from non-obstructive small bowel (SB) dilatation on the computed tomography (CT).

MATERIALS AND METHODS

four criteria were divided into different degrees and evaluated. These include: (A): continuity (non-continuous, continuous); (B): transition zone (absent, gradual, abrupt); (C): prestenotic SB fluid (minimal, about one-fourth, one-half, and three-fourths, nearly complete); and (D): colonic contents (minimal, moderate, considerable). One hundred fifty-three examinations, 86 obstructive and 67 non-obstructive, were analyzed using chi(2)-square tests to determine the relationship of each criterion to the presence of small bowel obstruction (SBO), whether the proportions of various degrees of these criteria differed significantly among the obstructive and non-obstructive subgroups, and to classify the criteria with a tree-based model (calculated by the computer) for the development of a useful decision procedure.

RESULTS

in each of the four criteria, the trend of probability of obstruction was statistically significant (P=0.0000). The proportions of most, except two, of the various degrees of different criteria in the obstructive and non-obstructive subgroups differed significantly (P<0.01). The obstruction tends to have a continuou dilatation, an abrupt transition, more prestenotic SB fluids, and less colonic contents. The results of classification by a tree-based model were 76 true-positive, ten false-negative, six false-positive, and 61 true-negative. The sensitivity was 88%; specificity was 91%; positive predictive value was 93%; negative predictive value was 86%; and the overall accuracy was 90%.

CONCLUSION

by analyzing the above four criteria together, a useful tree-based model can be developed and utilized as a supplemental decision procedure for the differentiation of obstructive from non-obstructive SB dilatation. The accuracy can be further promoted if the factor of a recognized pathologic condition is taken into consideration.

In vivo effect of endothelin-1 on plasma calcium and parathyroid hormone concentrations

We have previously reported an in vitro inhibitory effect of endothelin-1 (ET-1) on parathyroid hormone (PTH) secretion. In the present experiment, ET-1 was infused into rabbits to study the in vivo effect of ET-1 on the changes in calcium, magnesium, PTH and calcitonin concentrations. Femoral arteries and veins of anesthetized male rabbits were cannulated to monitor vital signs, blood sampling and infusion of the agents being studied. Infusion of ET-1 (1, 5, 10 and 20 ng/kg per min) induced a dose-dependent decline in plasma ionized calcium concentrations from 6.68+/-0.26 to 5.50+/-0.46 mg/dl (P<0.05) and a decrease in calcitonin concentrations from 48.6+/-6.5 to 32.5+/-4.7 pg/ml. PTH concentrations increased from 58.3+/-10.2 to 159.4+/-22.1 pg/ml. In a separate experiment, calcium gluconate solution was simultaneously infused to keep calcium concentrations steady, thereby proving a calcium 'clamp'. In normal calcium concentration, ET-1 infusion gradually decreased PTH concentrations from 71.4+/-8.6 to 38.0+/-6.2 pg/ml. We further infused sodium citrate solution to decrease the calcium concentration (2.0 mg/dl less) and calcium gluconate solution was infused to keep calcium concentrations steadily less than normal. PTH concentrations were initially stimulated by the induction of hypocalcemia (68.1+/-11.2 to 135.6+/-8.5 pg/ml), but decreased by ET-1 infusion (135.6+/-8.5 to 85.1+/-15.2 pg/ml). Plasma magnesium concentrations did not change significantly throughout the entire study and calcitonin concentrations were not significantly changed during the calcium clamp studies. Serum phosphate and 1,25-(OH)(2) vitamin D(3) concentrations were also measured, but they also did not change significantly. In conclusion, ET-1 exhibited an in vivo acute hypocalcemic action, independent of calcitonin. It also directly decreased PTH secretion if serum calcium concentrations were kept steady. The above findings are consistent with the results of our previous in vitro experiment.

Fatal outcome after ingestion of star fruit (Averrhoa carambola) in uremic patients

Clinical outcome of dialysis patients after eating star fruit (Averrhoa carambola) varies, but it may be fatal. In the past 10 years, 20 such patients were treated in our hospital when they developed clinical symptoms after eating the fruit or drinking star fruit juice. Their initial presentations included sudden-onset limb numbness, muscle weakness, intractable hiccups, consciousness disturbance of various degrees, and seizure. No other major events that might be responsible for these symptoms could be identified. Eight patients died, including one patient with a serum creatinine level of 6.4 mg/dL who had not yet begun dialysis. The clinical manifestations of the survivors were similar to those who died except for consciousness disturbance and seizure. Death occurred within 5 days despite emergent hemodialysis and intensive medical care. The survivors' symptoms usually became less severe after supportive treatment, and these patients subsequently recovered without obvious sequelae. The purpose of this article is to report that patients with renal failure who ingest star fruit may develop neurological symptoms and also run the risk for death in severe cases. Mortality may also occur in patients with chronic renal failure not yet undergoing dialysis.

The peptide ligands mediating positive selection in the thymus control T cell survival and homeostatic proliferation in the periphery

Positive selection to self-MHC/peptide complexes has long been viewed as a device for skewing the T cell repertoire toward recognition of foreign peptides presented by self-MHC molecules. Here, we provide evidence for an alternative possibility, namely, that the self-peptides controlling positive selection in the thymus serve to maintain the longevity of mature T cells in the periphery. Surprisingly, when total T cell numbers are reduced, these self-ligands become overtly stimulatory and cause naive T cells to proliferate and undergo homeostatic expansion.

Short- and long-term uses of calcium acetate do not change hair and serum zinc concentrations in hemodialysis patients

Calcium acetate (CaAc) acutely decreases absorption of concomitantly administered zinc gluconate (Hwang et al., AJKD 1992), but its long-term effect on zinc metabolism has not been studied. This study is intended to elucidate whether use of CaAc as phosphate binder on a daily basis affects zinc status in hemodialysis (HD) patients. Effects of CaAc on serum zinc were studied in 44 HD patients for 8 weeks (short-term). In 10 of these patients, the changes of serum and hair zinc were followed for 8 months (long-term). The daily dose of CaAc contained 25.35 mmol elemental calcium. Serum and hair zinc concentrations were measured by atomic absorptiometry. Our results were as follows: (i) in the short-term study, serum zinc concentrations did not show a significant difference compared to the baseline; (ii) in the long-term study, serum zinc concentrations showed no significant difference between different time points (11.0+/-0.5 in the beginning, 11.9+/-0.4 after 2 months, 11.4+/-0.4 after 4 months and 11.3+/-0.5 micromol/L after 8 months, n=10). However, these values were all significantly lower than in the normal controls (15.7+/-0.5 micromol/L, n=16); (iii) hair zinc content was not significantly different from the baseline level (2.7+/-0.1 in the beginning, 2.4+/-0.1 after 2 months, 2.6+/-0.2 after 4 months, 3.1+/-0.1 micromol/g hair, and from that of normal controls, 2.7+/-0.2 micromol/g hair). In conclusion, daily application of CaAc does not significantly interfere with zinc absorption and storage in HD patients. However, the comparable hair zinc content in the presence of decreased serum zinc concentrations indicates that the metabolic processing of zinc in HD patients is different from that of normal individuals.

CT of agenesis and atrophy of the right hepatic lobe

BACKGROUND

To identify and differentiate agenesis and severe atrophy of the right hepatic lobe on computed tomography (CT).

METHODS

The CT examinations of three cases of agenesis and 11 cases of severe atrophy of the right hepatic lobe were reviewed. We evaluated visibility of the three hepatic veins, the two main portal veins (including their branches if necessary), the dilated intrahepatic ducts, enlargement of the medial and lateral segments of the left lobe and caudate lobe of the liver, presence of a retrohepatic gallbladder, hyperattenuation of the atrophic liver parenchyma, posterolateral interposition of the hepatic flexure of the colon, and upward migration of the right kidney.

RESULTS

In the three cases of agenesis, no structure can be recognized as the right hepatic vein, right portal vein, or dilated right intrahepatic ducts. In the 11 cases of severe lobar atrophy, the right portal vein (or its branches) was recognized in eight cases, the right hepatic vein in four cases, and the dilated right intrahepatic ducts in 11 cases. The degree of enlargement of the lateral segment does not necessarily change inversely with the size of the medial segment and the caudate lobe. The retrohepatic gallbladder is present in eight cases (two in agenesis and six in atrophy). The phenomenon of hyperattenuation of the atrophic liver parenchyma was noted in six cases.

CONCLUSION

Even though a retrohepatic gallbladder and a severely distorted hepatic morphology due to compensatory hypertrophy of the left and caudate lobes may raise a suspicion of agenesis of the right lobe of the liver, absence of visualization of all of the right hepatic vein, right portal vein and its branches, and dilated right intrahepatic ducts is a prerequisite of the diagnosis of agenesis of the right hepatic lobe on CT. In severe lobar atrophy, at least one of these structures is recognizable.

A patient of primary hyperparathyroidism with full-blown bone changes simulating malignancy

The two most common causes of hypercalcemia are malignancy and primary hyperparathyroidism (1 degree HPT). The radiographic presentations and the histological findings on bone biopsy are important for differential diagnosis of underlying diseases. We report a patient with hypercalcemia who presented unusual bone manifestations. A 43 y/o woman was admitted due to right femoral fracture. X-ray on the right tibia revealed several osteolytic cystic lesions with sclerotic rims. Blood biochemistry showed anemia, impaired renal function and hypercalcemia. Multiple osteolytic lesions on the skull and bilateral forearms were also noted. Malignancy, such as multiple myeloma or metastatic cancer was suspected. However, this was excluded because of the absence of M-component on serum protein electrophoresis and the negative finding of plasma cells or other malignant cell on bone biopsy examination. Abdominal sonography demonstrated bilateral medullary nephrocalcinosis. The final diagnosis of 1 degree HPT was made, based on the findings of classic pathological pictures (brown tumor) and the markedly elevated intact parathyroid hormone (1267.4 pg/ml) level. Sonography on the neck and 201Tl/99mTc parathyroid subtraction scan localized a left lower parathyroid tumor and fine needle aspiration confirmed the parathyroid origin. Diagnosis of 1 degree HPT could only be made from recurrent urolithiasis and X-ray picture of osteitis fibrosa cystica in the past. This patient presented the full-blown skeletal changes which are uncommonly seen nowadays. The characteristic sclerotic rims suggesting increased bone formation provides a further important clue for differential diagnosis of 1 degree HPT from other malignancies with osteolytic bone lesions.

CT of large small-bowel diverticulum

The previous reports concerning the computed tomographic (CT) appearances of small bowel diverticulum are usually limited to those of diverticulitis. We present the CT findings of uncomplicated, large small bowel diverticulum in five patients. An interesting coexistence of large small bowel diverticulum and small bowel volvulus will be mentioned. Four patients had recurrent abdominal pain in the past 2 years.

Medullary cystic disease: a family study

Medullary cystic disease of the kidney is characterized by progressive tubulointerstitial disease with medullary cyst formation and secondary glomerular sclerosis. We treated a patient with chronic renal failure and investigated the family history of renal disease. The patient, an 18-year-old woman, was admitted due to poor appetite and fatigue for several months. Findings on physical examination were normal except for a pale conjunctiva. Urinalysis revealed only mild proteinuria with clear sediment. The hemogram showed normocytic normochromic anemia with hemoglobin 86 g/L. The patient was azotemic and her creatinine clearance rate was 10.7 mL/min. Renal sonography showed contraction of both kidneys with a marked increase in cortical echogenicity. One small cyst was found in the medullary area. Computed tomography (CT) and magnetic resonance imaging revealed several medullary cysts. Percutaneous renal biopsy showed focal and periglomerular sclerosis, marked tubular atrophy, and interstitial fibrosis. Ten of her family members were examined for renal function, and by sonography and CT. Five had medullary cysts, and three of the five showed abnormal renal function. Medullary cystic disease should be considered in the differential diagnosis of patients with renal disease and a positive family history.

Peritoneoscintigraphy using Tc-99m MAA for diagnosis of diaphragmatic disruption in a peritoneal dialysis patient

Massive hydrothorax is an infrequent but well-recognized complication of continuous ambulatory peritoneal dialysis (CAPD), and is often regarded as a contraindication to its use. We describe here a patient with massive hydrothorax that appeared during CAPD. Peritoneoscintigraphy was performed to demonstrate the clinical suspicion of a pleuroperitoneal communication and the pleurodesis using tetracycline was commenced and this allowed the successful continuance of CAPD.

CT of the mesenteric vascular anatomy

BACKGROUND

To evaluate the appearance of the arrangement of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) on computed tomography (CT) in normal patients and in patients with abdominal masses.

METHODS

One hundred seventy-seven consecutive abdominal CT examinations of 143 adults and two children were reviewed. The relationship of the SMV to the SMA was recorded at four locations: the beginning of the mesenteric vessels and levels 3 cm, 6 cm, and 9 cm caudad to the beginning. The relationship of the SMV to the SMA was divided into four quadrants in relation to the SMA: I, ventral right or directly ventral; II, dorsal right or directly right; III, dorsal left or directly dorsal; and IV, ventral left or directly left.

RESULTS

In the beginning of the SMV-SMA complex and levels 3 cm, 6 cm, and 9 cm caudal to the beginning, the SMV was located in quadrant I in 146, 84, 69, and 43 examinations, in quadrant II in 31, 93, 71, and 27 examinations, in quadrant III in zero, zero, five, and three examinations, and in quadrant IV in zero, zero, nine, and 15 examinations, respectively. The cases with SMV inversion had neither malrotation nor adjacent tumor compression. All the cases with an adjacent tumor-induced compression of the SMV-SMA complex had a normal SMV-SMA relationship.

CONCLUSION

In the first 3 cm, the SMV is always to the right of the SMA. Caudal to the level of 6 cm, the SMV may be located to the left of the SMA without evidence of malrotation. A midgut nonrotation is more likely to be present when a proximal SMV inversion is coexistent with a rightward direction of the proximal jejunal vessels. A hypothetical depiction of the step-by-step change of the SMV-SMA relationship during embryologic development may explain the arrangement patterns of the mesenteric vessels in normal rotation and midgut nonrotation.