Pancreatic neuroendocrine tumor with splenic vein tumor thrombus: A case report

INTRODUCTION

Pancreatic neuroendocrine tumors (PNET) are rare, often indolent malignancies. PNET are classified as functional or nonfunctional based on the secretion of hormones without a negative feedback loop; the latter account for up to 60% of PNET. Although PNET are associated with a better prognosis compared to pancreatic adenocarcinomas, they are often diagnosed in advanced stages, making them a significant source of morbidity for patients. Here we present a rare case of venous tumor thrombus arising from a nonfunctional PNET.

PRESENTATION OF CASE

A 44-year-old woman was referred for evaluation and treatment of a possible tail of pancreas PNET discovered during work-up for a 9 year history of intermittent subcostal pain. Previous endoscopic ultrasound with fine needle aspiration revealed a 3.5 cm × 3 cm mass, with cytological diagnosis of neuroendocrine tumor. Patient was scheduled for laparoscopic distal pancreatectomy. During surgery the mass was found to encase the splenic vein leading the surgeon to perform an en bloc distal pancreatectomy and splenectomy. Pathologic analysis revealed a 1.8 cm × 5 cm tumor thrombus lodged in the splenic vein.

DISCUSSION

Nonfunctional PNET usually present in advanced stages and can be associated with venous tumor thrombi. Preoperative imaging may not accurately predict the presence of venous tumor thrombi.

CONCLUSION

En bloc resection of primary tumor, involved organs and thrombus is the recommended treatment option and often results in long term survival. New multi-modality strategies are needed for detection of venous involvement in nonfunctional PNET to better assist with preoperative planning and counseling.     

Adult respiratory distress syndrome. Strategies to provide support and enhance oxygen delivery.

Respiratory failure itself is rarely the cause of death in patients with adult respiratory distress syndrome (ARDS). The multiple-organ failure that often accompanies the syndrome or the underlying disease or trauma that leads to ARDS is more frequently the cause. Thus, care of these patients consists of providing life-sustaining support until they respond to therapy. The authors explain what happens in respiratory failure and how gas exchange can be enhanced in these critically ill patients.     

Race, ethnicity, socioeconomic position, and quality of care for adults with diabetes enrolled in managed care: the Translating Research Into Action for Diabetes (TRIAD) study

OBJECTIVE: To examine racial/ethnic and socioeconomic variation in diabetes care in managed-care settings. RESEARCH DESIGN AND METHODS: We studied 7,456 adults enrolled in health plans participating in the Translating Research Into Action for Diabetes study, a six-center cohort study of diabetes in managed care. Cross-sectional analyses using hierarchical regression models assessed processes of care (HbA(1c) [A1C], lipid, and proteinuria assessment; foot and dilated eye examinations; use or advice to use aspirin; and influenza vaccination) and intermediate health outcomes (A1C, LDL, and blood pressure control). RESULTS: Most quality indicators and intermediate outcomes were comparable across race/ethnicity and socioeconomic position (SEP). Latinos and Asians/Pacific Islanders had similar or better processes and intermediate outcomes than whites with the exception of slightly higher A1C levels. Compared with whites, African Americans had lower rates of A1C and LDL measurement and influenza vaccination, higher rates of foot and dilated eye examinations, and the poorest blood pressure and lipid control. The main SEP difference was lower rates of dilated eye examinations among poorer and less educated individuals. In almost all instances, racial/ethnic minorities or low SEP participants with poor glycemic, blood pressure, and lipid control received similar or more appropriate intensification of therapy relative to whites or those with higher SEP. CONCLUSIONS: In these managed-care settings, minority race/ethnicity was not consistently associated with worse processes or outcomes, and not all differences favored whites. The only notable SEP disparity was in rates of dilated eye examinations. Social disparities in health may be reduced in managed-care settings.     

Plasma alkaline phosphodiesterase I in intrahepatic cholestasis induced by alpha-naphthylisothiocyanate in rats

1. Administration of alpha-naphthylisothiocyanate (ANIT) to rats produced dose-dependent increases in plasma bile acid and bilirubin concentrations. Similar increases in plasma bile acid and bilirubin concentrations were evident in bile duct ligated rats, indicating that the severity of cholestasis is almost identical in both models. 2. Plasma alkaline phosphodiesterase I was increased by only 50-80% while alkaline phosphatase was increased more than threefold after ANIT administration. This is in contrast to an earlier study [S. R. Simpson, K. Rahman & D. Billington (1984) Clinical Science 67, 647-652] where, after bile duct ligation, serum alkaline phosphodiesterase I was elevated sixfold before any increase in alkaline phosphatase activity became apparent. Thus, plasma alkaline phosphodiesterase I does not offer as sensitive a marker of intrahepatic cholestasis (induced by ANIT) as it does of extrahepatic cholestasis (induced by bile duct ligation). 3. Hepatic alkaline phosphodiesterase I was unaffected by ANIT pretreatment while hepatic alkaline phosphatase was increased up to seven times. It is suggested that raised plasma alkaline phosphodiesterase I is due to regurgitation of the biliary enzyme rather than overspill of the enzyme from liver into blood. 4. Gel filtration showed that 24 h and 96 h after ANIT administration, rat serum contained a high molecular weight form of alkaline phosphodiesterase I, suggesting a different isoenzyme profile.     

Sulfate homeostasis. I. Effect of salicylic acid and its metabolites on inorganic sulfate in rats

Homeostasis of inorganic sulfate, a physiologic anion necessary for both detoxification and biosynthetic reactions, involves predominantly capacity-limited renal clearance mechanisms. The objective of this investigation was to examine the effect of salicylic acid (SA) and its major metabolites, salicyluric acid and salicyl phenolic glucuronide, on the serum concentrations and renal clearance of inorganic sulfate in rats. Animals were studied using a crossover design in which they received a bolus i.v. injection (75 mg/kg) and infusion (approximately 0.26 mg/min/kg) of SA or the same volume of saline (the vehicle). Blood samples were collected at 2, 3 and 4 hr after administration and urine between 2 and 4 hr. The renal clearance of sulfate and creatinine were examined at mean steady-state SA serum concentrations of 249 micrograms/ml. Although no changes in the serum concentrations and renal clearance of creatinine were observed, the renal clearance of inorganic sulfate was increased significantly (2.13 +/- 0.74 vs. 1.09 +/- 0.54 ml/min/kg in controls, mean +/- S.D., n = 7) and its serum concentration decreased (0.55 +/- 0.12 vs. 1.04 +/- 0.23 mM in controls). These changes were not due to alterations in uric acid concentrations as uric acid serum concentrations and renal clearance were unchanged when examined at similar steady-state SA serum concentrations in a subsequent study. The effects on sulfate disposition also were probably not due to the major metabolites of SA: no changes in the serum concentrations or renal clearance of sulfate were observed at mean steady-state concentrations of 52 micrograms/ml of salicyluric acid or 73.7 micrograms/ml of salicyl phenolic glucuronide after their direct administration.(ABSTRACT TRUNCATED AT 250 WORDS)     

Patient preference for time-saving telehealth postoperative visits after routine surgery in an urban setting

Background

Focusing on high-value delivery of health care, we describe our implementation of telephone postoperative visits as alternatives to in-person follow-up after routine, low-risk surgery in an urban setting. Our pilot program assessed telephone postoperative visit feasibility as well as patient satisfaction and clinical outcomes.