Is a digital rectal examination necessary in the diagnosis and clinical staging of early prostate cancer?

OBJECTIVE: To assess the role of a digital rectal examination (DRE) in the clinical diagnosis of prostate cancer and in predicting the pathological stage, as the diagnosis of early prostate cancer usually comprises prostate-specific antigen (PSA) testing, a DRE and transrectal ultrasonography (TRUS)-guided biopsies. PATIENTS AND METHODS: Over the 4 years between 2000 and 2004, 408 consecutive patients (mean age 63.8 years) referred with age-specific PSA levels of 2.5-10.0 ng/mL and who had a TRUS-guided 12-core prostate biopsy were included in the study. They had a DRE by either of two experienced consultant urologists. The results of the DRE and core biopsy histology were compared with the histology and the radical prostatectomy specimen in a subset (82 men) of the study population. RESULTS: Cancer was detected on biopsy in 152 patients; of the 196 with an abnormal DRE, 47% had cancer on biopsy. In the patients with a normal DRE, 59 cancers were detected. Men with cancer were older and had a higher median PSA level. There was no correlation between the DRE and biopsy findings, and none between an abnormal DRE and histological diagnosis of cancer. Of the patients who had a radical prostatectomy, 38% had a normal DRE. CONCLUSION: There was no correlation between the DRE, biopsy findings and pathological staging. The DRE did not contribute to managing patients with prostate cancer, but this does not mean that there is no longer a place for the DRE in assessing the urological patient. If patients are appropriately counselled before PSA testing, a DRE may not be essential for patients with a PSA level of 2.5-10 ng/mL.     

Protracted fever of unknown origin as the presenting symptom of Behçet's disease. Report of a case

We report a case of Beh?et's disease that presented as protracted fever of unknown origin. The diagnosis was established when a thromboembolic event and ora3l aphthous ulcers occurred simultaneously. Antibiotics had no effect on the fever, which resolved when glucocorticoid and anticoagulant therapy was given. Among causes of protracted fever of unknown origin, Beh?et's disease is exceedingly rare but should be considered together with the other vasculitides. Above all, the presence of a fever should prompt a search for a thromboembolic complication.     

Is the presence of venous reflux really significant in the diagnosis of varicocele?

Objectives  We have attempted to determine the incidence of venous reflux detected by color Doppler in varicoceles of various grades evaluated during a physical examination. Patients and methods  The data of patients referred to our outpatient clinic between 1997 and 2007 with the diagnosis of varicocele due to complaints of scrotal pain, palpable swelling or infertility were retrospectively reviewed. The presence of venous reflux was compared with the grade of varicoceles during a physical examination. Results  A total of 802 male patients with a mean age of 27.1 years (range 16–52 years) were included in this study. Of these, physical examination reviewed that ten (1.2%), 72 (9.0%), 433 (54.0%) and 287 (35.8%) patients had grade 0, 1, 2 or 3 varicoceles, respectively, on the left side and that 607 (75.7%), 73 (9.1%), 108 (13.5%) and 14 (1.7%) patients had grade 0, 1, 2 or 3 varicoceles, respectively, on the right side. Color Doppler examination revealed venous reflux in three (30.0%) grade 0 testicular units, 63 (87.5%) grade 1 testicular units, 400 (92.4%) grade 2 testicular units and 273 (95.1%) grade 3 testicular units on the left side and venous reflux in 99 (16.3%) grade 0 testicular units, 54 (73.6%) grade 1 testicular units, 88 (81.5%) grade 2 testicular units and 12 (85.7%) grade 3 testicular units on the right side. Physical examination did not reveal any statistically significant correlation between the incidence of venous reflux and the grade of the clinically evident varicoceles for both sides. Conclusions  For assessing the severity of clinically evident varicoceles, the clinician should not use venous reflux as the sole predictor because of its high incidence in all grades of varicoceles. Additional measurements, such as flow volume, duration and velocity of reflux, are recommended as diagnostic tools for assessing the severity of varicocele more accurately.     

Is ethanol the unknown toxin in smoke inhalation injury?

Of the 12,000 fire-related deaths occurring annually in the United States, it is estimated that 60 to 80 per cent are due to smoke inhalation. Plastic and synthetic materials which have been introduced in home construction and furnishings produce a more toxic smoke when burned. Efforts to identify a "supertoxin" in this smoke have been unsuccessful to date. An alternative approach is to examine why victims are unable to escape, and become exposed to smoke for lethal periods of time. The authors examined the circumstances of death in 39 fire victims (27 adults, 12 children) over a 25-month period. Detailed examination of the fire scene, autopsy studies, and toxicologic analysis were carried out. Position of the victim, and escape efforts were noted. Carbon monoxide was elevated in all victims, with "lethal" levels (= greater than 50%) in 21/39 victims. Cyanide was detected in 24/29 victims, but none had lethal (3 mg/L) levels present. Ethanol was detected in 21/26 adults (80%) and 0/12 children (0%). 18/26 adult victims had ethanol levels above the statutory level of intoxication (10 mg%). Victims found in bed (no escape attempt) had a mean blood ethanol level of 268 mg%, compared with a mean level of 88 mg% in those victims found near an exit (P = .006). Ethanol intoxication significantly impairs the ability to escape from fire and smoke and is a contributory factor in smoke-related mortality.     

Is intraabdominal drainage necessary after laparotomy for typhoid intestinal perforation?

PurposeThis study was designed to compare the safety and effectiveness of routine drainage and nondrainage after emergency laparotomy for typhoid intestinal perforation (TIP).MethodsA retrospective review of children 15 years or younger who underwent surgery for TIP from 2002 to 2009 was performed. All children underwent resuscitation and laparotomy and were given antibiotics but were then divided into 2 groups: group I (n = 81), postoperative peritoneal drainage, and group II, (n = 66) no drainage.ResultsThere was no demographic difference between the groups (e.g., mean age 9.6 vs 9.0 years; P = .21). There was no significant difference in mean time for return of bowel function (3.8 vs 4.0 days; P = .6), rate of surgical site infection (63% vs 70%; P = .39), wound dehiscence (36% vs 27%; P = .27), anastomotic leak (2.5% vs 1.5%; P = .27), enterocutaneous fistula formation (10% vs 6.1%; P = .40), intraabdominal abscess formation (4% vs 9%; P = .18), or mean length of hospital stay (22 vs 19 days; P = .26).ConclusionThe results of this study clearly show that routine peritoneal drain placement after laparotomy for TIP is unnecessary, and such drains are not effective in reducing the rate of postoperative complications.     

Is bilateral protected specimen brush sampling necessary for the accurate diagnosis of ventilator-associated pneumonia?

BACKGROUND: Clinical acumen alone is unreliable in establishing a diagnosis of ventilator-associated pneumonia (VAP) and controversy exists over which diagnostic tools should be utilized to confirm a clinical suspicion of VAP. The purpose of this study was to determine the reliability of blind protected specimen brush (PSB) sampling in the diagnosis of VAP and if bilateral PSB sampling is necessary. METHODS: Prospective study comparing blind PSB sampling with bronchoscopic directed PSB sampling in thirty-four consecutive SICU patients with a clinical suspicion of VAP. All patients underwent blind PSB sampling followed by bronchoscopic directed contralateral PSB sampling. RESULTS: Twenty-four of 34 patients (71%) were diagnosed to have VAP. The concordance rate between blind and directed PSB samples was 53% (18/34). When blind PSB was positive (15/34), the contralateral sample yielded a different microorganism in three patients (9%). When blind PSB was negative (19/34), infection was present in the contralateral lung in nine patients (26%). Blind PSB sampling alone was inaccurate in 35% of patients. CONCLUSIONS: The low concordance between blind and directed PSB suggests the need to sample both lung fields. Bilateral PSB sampling can identify unsuspected pathogenic microorganisms in the contralateral lung.     

Is excision of a choledochal cyst in the neonatal period necessary?

Purpose

Although the incidence of choledochal cyst (CC) diagnosed in the prenatal or neonatal period is increasing, excision of CC in early infancy is not universally recommended. To validate the rationale of excision of CC in the neonatal period, operative complications and the histologic grade of liver fibrosis at the time of excision of CC were compared in three age groups.

Methods

198 patients who underwent excision of CC, were divided into three age groups, i.e., within 30 days old (group 1, n = 11), 1 to 12 month-old (group 2, n = 40) and over 12 month-old (group 2, n = 147). Retrospective review of their medical records was performed.

Results

The overall operative complications were 12 (7 cholangitis, 4 bleeding, 1 ileus). No complication occurred in the group 1. The grade of liver fibrosis had statistically significant positive correlation among groups.

Conclusion

Excision of CC in the neonatal period is a safe procedure. The grade of liver fibrosis increased with age. These results support the rationale of early excision of CC.     

Is pre-hospital thoracotomy necessary in the military environment?

Introduction

Exsanguination from penetrating torso injury is a major source of mortality on the battlefield. Advanced Life Support guidelines suggest ‘on-scene’ thoracotomy for patients in cardiac arrest following penetrating chest trauma. This requires significant resourcing and training. Experience from published series (31 pre-hospital thoracotomies with 3 survivors) suggests that when this manoeuvre is applied to a well selected group it is a significant and life-saving procedure. Can this be applied to military injuries?

Methods

Over a 12 month period on Operation Herrick all patients who sustained significant thoracic trauma were retrospectively reviewed. Parameters were recorded to allow detailed analysis of injury pattern and operative management. Our main objective was to determine if an early (pre-hospital) thoracotomy would have influenced the outcome.

Results

Over the period, 81 patients required operative intervention following thoracic trauma: 8 patients underwent emergency thoracotomy (performed as part of the resuscitation) and 14 underwent urgent thoracotomy (performed after physiology partly restored). There were 9 fatalities—7 undergoing emergency thoracotomy and 2 post-operatively from multi-organ failure. Of the 7 intra-operative deaths 4/7 patients had thoracic injury and 6/7 had additional abdominal injuries. The median predicted survival of fatalities was 2.0% using Trauma Injury Severity Scoring.

Discussion

Emergency thoracotomy should be performed in cardiac arrest following penetrating trauma as soon as possible. Highest survival rates in both in-hospital and pre-hospital thoracotomy are found in isolated cardiac stab wounds (19.4%). Poorest survival is found in multiply, ballistic injured patients (0.7%). The latter best reflects the injury pattern of military patients who have cardiac arrest following penetrating torso injury.

Conclusion

As our injury pattern suggests, any pre-hospital thoracotomy on military patients is likely to require complex intervention in very challenging environments. Our evidence does not support the notion that earlier thoracotomy could improve survival.     

Is routine preoperative aortoiliac arteriography necessary in the treatment of lower extremity ischemia?

Purpose: To determine whether preoperative aortoiliac arteriography can be replaced with noninvasive evaluation in the management of some patients with chronic lower extremity ischemia. Methods: Preoperative evaluation was performed on 184 ischemic limbs (119 patients) over 19 months by means of aortoiliac arteriography with runoff and noninvasive studies, which included common femoral artery duplex scanning, waveform and acceleration time (normal <140 msec), and aortoiliac duplex scanning. An algorithm was proposed for combining indirect (common femoral artery evaluation) and direct (aortoiliac evaluation) noninvasive studies to decrease the need for aortoiliac arteriography when possible. Results: Aortoiliac occlusive disease (≥50% stenosis to occlusion) was present at arteriography in 48 limbs (30%), and there was no inflow disease in 114 (70%). Aortoiliac lesions were identified by means of noninvasive studies. The accuracies of femoral waveform, acceleration time, and aortoiliac duplex studies were 85%, 89% and 87%. The negative predictive values were 92%, 94% and 100%. The acceleration time results were not affected by runoff status but were significantly different for various categories of stenosis (p < 0.05). The algorithm was applied to the data obtained. When acceleration time and waveform were normal, 84 of 86 patients (98%) had no stenosis at arteriography. When aortoiliac duplex findings were normal, the arteriographic findings were normal in all examinations. Conclusion: A combination of indirect and direct noninvasive studies can be used reliably to rule out clinically significant inflow occlusive disease and allows selective use of aortoiliac arteriography in patients with lower extremity ischemia. (J Vasc Surg 1998;28:28-36.)