Carcinosarcoma of esophagus—a case report and review of literature

Carcinosarcoma of esophagus contains both the carcinomatous and sarcomatous elements. These are rare polypoidal malignancies of esophagus. One such case is presented and available literature is reviewed.     

Orbital and extraorbital giant cell angiofibroma: a giant cell-rich variant of solitary fibrous tumor? Clinicopathologic and immunohistochemical analysis of a series in favor of a unifying concept

The clinicopathologic and immunohistochemical features of one orbital and nine extraorbital soft tissue lesions, the morphology of which overlaps with giant cell angiofibroma and solitary fibrous tumor, are presented. There were 3 male and 7 female patients. Age at diagnosis ranged from 18 to 81 years (median: 45 yrs). Development of a mass was the main presenting symptom. For two patients, the lesion had been evident for several years before excision. Extraorbital tumors were located in the head and neck area (3), back (3), retroperitoneum (1), hip (1), and vulva (1). Tumor size ranged from 1.3 cm to 11 cm (median: 4.5 cm). The lesions presented grossly as well-demarcated, unencapsulated soft tissue masses. Histologically, they were characterized by the presence of alternating cellular and sclerosing areas, keloidal collagen deposition, round- to staghorn-shaped, thick-walled vessels and multinucleated giant stromal cells often lining pseudovascular spaces. Cellular areas were composed of non-atypical spindle to round cells set in a variably collagenous background. Mitotic activity ranged from 1 to 3 mitoses/10 high-power fields. Immunohistochemical studies showed positive staining of the spindle/round cells and multinucleated stromal cells invariably for vimentin, CD34, CD99, and mostly for bcl-2 but negative for muscle specific actin, desmin, CD31, CD117 (c-kit), and inhibin. Occasionally, focal reactivity was observed for smooth muscle actin, S-100 protein, epithelial membrane antigen, and keratin. Treatment consisted of simple tumorectomy in eight patients and wide excision in two. Follow-up information for eight patients (range: 7-32 mos; median: 14 mos), including four with microscopically positive surgical margins, showed no recurrence. These lesions share the clinical, pathologic, and immunohistochemical features of giant cell angiofibroma and solitary fibrous tumor, supporting the view that these tumors are closely related. In addition, it shows that giant cell angiofibroma occurs equally in both sexes and has a wider distribution than initially thought, developing even more often in extraorbital locations than in the orbit.     

An unusual tumor of rib diaphysis—report of a giant cell tumor and a brief review of literature

Giant Cell Tumor of bone (GCT) is a benign but aggressive tumor, which forms about 4?C5% of primary bone tumors and 1?C2% of all chest wall tumors. It arises in the epiphysis of bones. The epiphysis of a rib is in its head and tubercle posteriorly and hence a GCT arising in a rib??s anterior aspect, its diaphysis, is rare. In this unusual position, it can be mistaken for other more common diaphyseal pathologies. Radiological images are often diagnostic. A needle biopsy is best avoided and a wide excision biopsy is the treatment of choice. Microscopically, multinucleated giant cells are seen amidst stromal cells. Giant cells like these are also seen in other diseases like the brown tumor of primary hyperparathyroidism. Giant cell lesions are never caused by secondary hyperparathyroidism. We present a case of a diaphyseal GCT of rib in a patient with secondary hyperparathyroidism who was successfully treated.     

Concurrent rhinoplasty and endoscopic sinus surgery: a review of the pros and cons and a template for success

Historically concurrent FESS/rhinoplasty was avoided due to concerns of increased risk of complication. Recent studies have shown that FESS/rhinoplasty can be performed simultaneously with good outcomes and no significant increase in complications. A thorough and effective approach to the patient with sinonasal obstruction requires attention to aesthetic, functional, and inflammatory issues. Medical treatment is an important adjuvant to surgery in order to optimize outcomes by improving patient symptoms long-term. Surgery for these patients should be performed in a careful, stepwise approach to address the nasal septum, inferior turbinates, paranasal sinuses, and external nasal structures.     

Hypoalbuminaemia—a marker of malnutrition and predictor of postoperative complications and mortality after hip fractures

ObjectiveOur aim was to determine the effect of hypoalbuminaemia as a marker of malnutrition on the 30-day postoperative complication rate and mortality in patients receiving surgical treatment for hip fractures using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.MethodsWe analyzed all patients admitted with hip fractures receiving surgical treatment from 2011 to 2013. Patients were dichotomized based on their albumin levels; hypoalbuminaemia (albumin <3.5 g/dL), and nonhypoalbuminaemia (albumin >3.5 g/dL). Patient demographics, postoperative complications, and length of stay were analysed. Logistic regression analysis was conducted to assess the ability of albumin level for predicting postoperative complications, length of stay, and mortality.ResultsA total of 10,117 patients with hip fractures were identified with 5414 patients with normal albumin levels, and 4703 with low albumin. Multivariate analysis showed that when controlling for comorbidities; hypoalbuminaemia alone was a predictor of postoperative complications (death, unplanned intubation, being on a ventilator >48 h, sepsis, and blood transfusion), and increased length of stay (6.90 ± 7.23 versus 8.44 ± 8.70, CI 0.64–1.20, P < 0.001).ConclusionHypoalbuminaemia alone can predict postoperative outcomes in patients with hip fractures. Furthermore, patients with hypoalbuminaemia had a longer hospital length of stay. Further studies are needed to assess whether nutritional support can improve postoperative complications in patients with hypoalbuminaemia.     

What makes a competent surgeon?: Experts' and trainees' perceptions of the roles of a surgeon

Background

Assessment of surgical competence is a priority; however little is known about surgeons' perceptions of competence. We investigated components of competence and adequacy of training in achieving them.

Methods

Using questionnaires, Surgical Attendings and trainees rated the importance of 7 CanMEDS roles that define a competent surgeon (Medical Expert; Communicator; Collaborator; Manager; Health Advocate; Scholar; Professional) and whether training enabled them to achieve competency in each role.

Results

Ninety-two of 125 questionnaires (74%) were completed. Junior trainees attributed lower importance to the roles of Manager, Communicator, Collaborator, and Professional than senior trainees or Attendings. No surgeon stated that they had achieved competency in every role.

Conclusion

Trainee surgeons do not appreciate the importance of all the roles required of a competent surgeon and current training does not ensure competence in all roles. These gaps must be addressed to develop surgeons able to provide the highest quality of care.     

Case report of ovary and fallopian tube as content of a Spigelian hernia – a rare entity

IntroductionSpigelian hernia is a rare entity, comprising 1–2% of all hernias. Various abdominopelvic viscera herniate through the defect in the Spigelian fascia and become incarcerated. Specifically in females, the ovary and/or the fallopian tube can herniate through this defect. This is the third reported case of such a hernia.Presentation of caseWe report here a young lady aged 30 years with right-sided ovarian Spigelian hernia. She presented with a painful lump in the right lower quadrant of abdomen for 2 weeks. On examination, she had a tender irreducible lump below and to the right lateral to the umblilicus. CECT revealed a right-sided ovarian Spigelian hernia. The finding was confirmed at exploration and herniorrhaphy performed. She was discharged on the 3rd postoperative day.DiscussionDiagnosing Spigelian hernia clinically is challenging but radiologic investigations like computed tomography help establish the diagnosis and clarify the contents.ConclusionSpigelian hernia itself is a rare entity and to add to that, herniation of ovary and fallopian tube through Spigelian fascial defect is very rare and a possibility in females.     

Awareness of and attitudes towards infertility and its treatment： a cross-sectional survey of men in a United States primary care population

Previous studies have described racial and socioeconomic disparities in the treatment of infertility. Patient factors such as attitudes and awareness may be contributing factors. Since primary care is often the setting that serves as an entry into other areas of medicine, we sought to evaluate men＇s attitudes and awareness of male infertility in the primary care setting. To do this, we performed a cross-sectional survey of men＇s attitudes toward men＇s health issues in 210 men from two primary care clinic waiting rooms in Atlanta, Georgia. The survey was self-administered with closed-ended question items and was approximately 20 min in length. Of the 310 men approached, 210 agreed to participate and returned completed surveys. Overall, 52% of men said they were ＂very＂ or ＂somewhat＂ familiar with infertility and 25% were familiar with treatments for infertility. Some men had heard of surgery （21%） and medication （35%） as treatments for male infertility. Awareness and familiarity with the condition was greater in high socioeconomic status men （i.e. college graduates or those with income 〉$100 k per year） but did not differ by race on multivariate analysis. Attitudes toward infertility varied by race with non-Caucasian men being more likely to indicate that infertility is a serious condition, to be concerned about infertility, and to believe it decreases a man＇s quality-of-life. Therefore, a lack of awareness, but not negative attitudes, may contribute to previously-described disparities in the treatment of infertility.     

Relief of epilepsy and headache and quality of life after microsurgical treatment of unruptured brain AVM—audit of a single-center series and comprehensive review of the literature

Although the benefit of intervention for unruptured arteriovenous malformation (AVM) with regard to stroke rates and long-term disability remains unclear, most patients present with symptoms, such as epilepsy, headache, or neurological deficits, compromising their quality of life. Detailed analysis of the long-term effects of microsurgical treatment on quality of life, epilepsy, and headache was the purpose of this audit. A series of 25 microsurgically treated patients were interviewed on average 7?±?5 years after treatment. Detailed information was obtained regarding frequency and severity of seizures and headaches. Outcome data was compared with the initial complaints and neurological findings. The Short Form (SF)-36 was used to assess health-related quality of life. On average, the SF-36 scores did not differ significantly from the age-matched German norm values. Patients suffering from chronic headache prior to treatment scored worse in most SF-36 subscales than patients without headache at the time of treatment, and the difference was significant in the SF-36 dimensions physical role functioning and emotional role functioning (P?=?0.04). In contrast, there was a trend for patients treated for incidental AVM to score somewhat better than the age norm. Twelve patients had been admitted with epilepsy. At the time of follow-up, all patients were seizure free (Engel class I), although 7 of them continued to take antiepileptic medication. Two of 13 patients without epilepsy at the time of treatment experienced seizures sometime during the post treatment course and were under medication at the time of long-term follow-up interview. At the time of the audit, 7 of 11 patients admitted with chronic headache necessitating regular use of pain medication indicated not to use pain medication any longer. Our data suggest that initial symptoms leading to diagnosis and treatment of unruptured AVM may influence long-term quality of life following treatment. Patients admitted with headache as the chief complaint appear to fare worse than patients with epileptogenic or incidental AVMs.     

Are infundibular dilatations at risk of further transformation? Ten-year progression of a prior documented infundibulum into a saccular aneurysm and rupture: Case report and a review of the literature

Infundibular dilatations (IFDs) are conical, triangular, or funnel-shaped enlargements at the origin of cerebral arteries, and they are primarily located (7–25%) on the posterior communicating artery (PComA). Progression over time into a saccular aneurysm with a risk of rupture of a previously demonstrated IFD has rarely been reported. We report the case of a 60-year-old female who presented 10 years earlier with a subarachnoid hemorrhage caused by a left internal carotid artery aneurysm rupture. At that time, the carotid angiography showed the left internal carotid artery aneurysm and a right posterior communicating artery infundibular dilatation. Neck clipping for the left internal carotid artery aneurysm was performed and the patient was discharged with no neurological deficit. Ten years later, the patient suffered a second fatal subarachnoid hemorrhage; carotid angiography revealed a right posterior communicating artery aneurysm developed from the previously documented infundibular dilatation with a de novo right anterior choroidal artery aneurysm. This case is another proof of the small but growing number of examples of infundibular transformation over time, as well as their risk of progression into saccular aneurysms and subsequent rupture.     

Cystic lesions of the jaws—a review and analysis of 269 cases

Two hundred and sixty-nine patients (160 males and 109 females) with cystic lesions of the jaw were successfully diagnosed and treated. One hundred and twenty-nine (48%) were radicular cysts, 67 (25%) were dentigerous cysts, 19 (7%) were primordial cysts, 16 (6%) were eruption cysts, 14 (5%) were traumatic bone cysts, and 17 (9%) were nonodontogenic cysts. There were 79 in the pediatric age group (1 month to 16 years) and 190 in the adult age group (17 years and older). Male to female ratio was 1 in the pediatric age group and 1.7 in the adult age group. The treatment modalities were marsupialization, enucleation, or enucleation with bone grafting. The findings demonstrate that the distribution and characteristics of jaw cysts in children are different from those in adults. In children, there is a relatively high rate of developmental cysts, whereas in adults, the inflammatory cysts are more common.     

How do you stretch a bladder? A survey of UK practice,a literature review,and a recommendation of a standard approach

AIMS: To assess how and why hydrodistension of the bladder is performed by UK urologists and to compare this practise with the published literature on distension. To suggest a standardised technique for hydrodistension to allow comparison of diagnostic and therapeutic studies. METHODS: A questionnaire was sent to all UK consultant urologists. Questions addressed the indications for short bladder distension (SBD), details of technique, evaluation of outcome, and awareness of evidence base. The literature on bladder distension was reviewed. RESULTS: The majority of respondents perform SBD, principally in the diagnosis and therapy of interstitial cystitis (IC). There was considerable variation in the duration of distension, repetition of distension, the pressure used for distension, and the measurement of bladder capacity. The literature on the technique of hydrodistension is imprecise and no respondent was able to cite literature to support his or her practice. We suggest a simple, more objective technique for performing hydrodistension. CONCLUSIONS: SBD is widely used. There is marked variability in technique and little more than anecdotal evidence to support any particular approach. Research into the evaluation and treatment of painful bladder syndrome in general and IC in particular would be facilitated by the adoption of a standardised technique.     

Trends in the incidence of cryptorchidism and hypospadias of registry-based data in Korea： a comparison between industrialized areas of petrochemical estates and a non-industrialized area

This study aimed to represent the recent trends in the nationwide incidence of cryptorchidism and hypospadias in Korea, and to determine whether there is evidence of spatial heterogeneity in the incidence. The incidence was calculated as the number of newly diagnosed patients (males) during the first 4 years after a live birth in a population, nationally and regionally (a non-industrialized area (Chuncheon) and petrochemical estates (Yeocheon and Ulsan)), between 2000 and 2005. The data (numerator) for new patients were acquired from the National Health Insurance Review Agency, and the data (denominator) for the resident registration population were from the National Statistical Office. Between 2000 and 2005, the national incidence of cryptorchidism and hypospadias had an increased tendency from 5.01 to 17.43 per 10 000 persons and from 1.40 to 3.28 per 10 000 persons, respectively. The incidence of cryptorchidism was significantly higher in Yeocheon (throughout the study period) and in Ulsan (2001, 2002, 2004 and 2005) than the national incidence, whereas the incidence in Chuncheon was significantly lower in 2001 and 2002. It was difficult to compare the rates of hypospadias yearly and regionally because of the small number of cases. In conclusion, the incidence of cryptorchidism has recently increased in Korea. The petrochemical estates, Yeocheon and Ulsan, had a significantly higher incidence of cyptorchidism than the national incidence, which suggests that further study is needed to obtain a more precise estimation of the trends in the incidence of the anomalies and to confirm the association between petrochemicals and the anomalies.     

Proposal to establish a National Institute of Kidney and Urologic Diseases — a report of the National Kidney and Urologic Diseases Advisory Board

Summary In 1990, the National Kidney and Urologic Diseases Advisory Board published a long-range plan entitled Window on the 21st Century. In that plan, the board recommended that Congress establish a new National Institute of Kidney and Urologic Diseases (NIKUD). This recommendation stemmed from the board's appreciation that patient morbidity and mortality from kidney and urologic diseases continue to increase and that a focused, well-funded research endeavor is the only real hope for reversing this trend.In 1992, the board established a special subcommittee to further consider the establishment of a NIKUD. The subcommittee sought input from a wide variety of extramural and intramural sources.American Urologic Association — a new devoted institute would provide coordination and expansion of basic research into kidney and urologic diseases, now fragmented and underfunded within multiple institutes. The research areas of kidney and urologic diseases are not currently receiving adequate or appropriate attention proportionate to their prevalence and their adverse impact upon society.The American Society of Nephrology (ASN) supports the establishment of a separate kidney and urology institute. First and foremost, our primary interest is to obtain more support for kidney and urologic diseases. Such research does not receive the emphasis and prominence that it deserves at the National Institutes of Health. ASN believes that a separate institute would provide increased focus for these diseases.National Kidney Foundation (NKF) — the creation of such an institute is the highest priority of the medical and lay constituencies of the NKF.American Foundation for Urological Disease — the creation of a new (kidney and urology) institute within the National Institutes of Health is by far the most expeditious way to centralize and advance the research efforts in this critical field.Scope of a new NIKUD — NIKUD should develop an intramural and extramural research program that focuses on all aspects of kidney and urology diseases. NIKUD should be organized so that its activities address issues in both pediatric and adult kidney and urologic diseases, including renal failure, transplantation, hypertension, diabetes, cancer, incontinence, sexual dysfunction, and male reproduction. NIKUD must foster research training and career development.The integrated scientific programs of the new institute will enhance the treatment and cure of kidney and urologic diseases. The development of this new institute will improve the communication between the multiple disciplines involved in kidney and urologic diseases. The establishment of an integrated relationship between kidney and urologic diseases research will lead to the development of a unique scientific culture.A new institute for kidney and urologic diseases will greatly enhance the recruitment of bright, young physicians into kidney and urologic research.The initial budget for the new institute is proposed to be US $ 202.6 million (in 1992 dollars) of which US $ 180 million represents the extramural program, US $ 14 million represents the intramural program, and US $ 8.6 million (of which only US $ 2.2 million is new money) represents the research management and support. The new administrative costs are minimal and will not significantly impact the new institutes ability to support research and training programs.The board approved the report and unanimously recommended the establishment of a NIKUD.Special subcommittee of the National Institute for Kidney and Urologic Diseases: Ira Greifer, M. D.; Harry Jacobson, M. D.; Louis H. Diamond, M. B., Ch. B.; Diana H. Marver, Ph. D.; Mary Lou O'Brien Jackson; Michael J. Manyak, M. D.; Mani Menon, M. D., Co-chair; Franklyn Knox, M. D., Ph. D., Co-chair.     

Classification and diagnosis of prostatitis: a gold standard?

The National Institutes of Health Classification System for prostatitis has now been accepted by the North American and International urology community. This categorization system consists of category I (acute bacterial prostatitis), category II (chronic bacterial prostatitis), category III (chronic prostatitis/chronic pelvic pain syndrome - CP/CPPS) and category IV asymptomatic inflammatory prostatitis. The evaluation of a patient with category I and category II bacterial prostatitis consists of history and physical examination and urine culture for lower urinary tract localization cultures, respectively. The clinical tests for the evaluation of CP/CPPS can be classified as mandatory, recommended and optional. Mandatory evaluations include history and physical examination, urinalysis and urine culture. Recommended evaluations include lower urinary tract localization tests, symptom index, flow rate, residual urine determination and urine cytology. Optional evaluations include semen analysis and culture, urethral swab, urodynamics, cystoscopy, imaging, and prostate specific antigen determination. The physician must individualize a rational diagnostic strategy for each patient. There is no 'gold standard' for the diagnosis and evaluation of patients presenting with prostatitis.     

Are bone bruises a possible cause of osteochondritis dissecans of the capitellum? a case report and review of the literature

A 17-year old soccer-player sustained a fracture and dislocation of the ulnar epicondyle combined with a bone bruises at the radial head and the capitellum. An open reduction and internal fixation was performed using two K-wires. Initial recovery was uneventful. After the operation he was discharged home and reviewed on a regular basis. When bony union had occurred the two K-wires were removed. However, on follow up he continued to complain of pain on the radial aspect of the joint and did not regain his normal range of movement. A further MRI was performed. Now a grade II osteochondritis dissecans not visible on the previous MRI taken 12 weeks earlier was clearly visualised. Treatment was continued conservatively with physiotherapy but avoiding aggressive mobilisation. On final review 6 months later he was able to move painfree with residual limitation of movement (ROM 0–5–130°). Another MRI taken now was assessed as normal.This study was carried out at the Dept of MRI, Klinik für Radiologische Diagnostik, Klinikum Saarbrücken, Winterberg 1, D- 66119 Saarbrücken.     

Efficacy and safety of a combination of Sabal and Urtica extract in lower urinary tract symptoms—long-term follow-up of a placebo-controlled,double-blind,multicenter trial

In an open-label extension of a randomized, double-blind clinical trial, the long-term efficacy and tolerability of a fixed combination of 160 mg Sabal fruit extract WS 1473 and 120 mg Urtica root extract WS 1031 per capsule (PRO 160/120) were investigated in elderly men with moderate or severe lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH). Two hundred and fifty-seven patients were randomly treated with 2 x 1 capsule/day PRO 160/120 or placebo for 24 weeks, followed by a 24-week control period and a 48-week follow-up period in which all patients received PRO 160/120. Efficacy measures included the assessment of LUTS [International Prostate Symptom Score ((I-PSS) self-rating questionnaire] and uroflow and sonographic parameters. Two hundred and nineteen subjects participated in the follow-up. Between baseline and end of observation (week 96) the I-PSS total score was reduced by 53% (P < 0.001), peak and average urinary flow increased by 19% (P < 0.001), and residual urine volume decreased by 44% (P = 0.03). The incidence of adverse events during follow-up was one in 1,181 treatment days; in only one event a causal relationship with intake of PRO 160/120 could not be excluded. Treatment with PRO 160/120 thus provides a clinically relevant benefit over a period of 96 weeks.     

Mesenteric cystic lymphangioma: a congenital and an acquired anomaly? Two cases and a review of the literature

Mesenteric cystic lymphangioma is an uncommon benign abdominal mass. Two cases of mesenteric cystic lymphangioma are presented, both in combination with malrotation and intermittent volvulus. Both mesenteric cystic lymphangiomas were located near the duodenojejunal junction, the usual area of torsion in case of a volvulus. These findings suggest that mesenteric cystic lymphangioma could have evolved as a consequence of chronic intermittent volvulus. We hypothesize that in patients with malrotation and volvulus, mesenteric cystic lymphangioma may be regarded as an acquired anomaly.