Comparative evaluation of skin tests in surgical patients

A comparative estimation of the prognostic value of skin tests was made with tuberculin, coli-bacillus antigens, Candida, blue pus bacillus and more complete set of microbic allergens (hemolytic staphylococcus, white streptococcus, blue pus bacillus, coli-bacillus, group pneumococcus, Candida, Proteus Mirabilis). High prognostic information value was noted by results of skin tests in patients examined with the help of a set consisting of 7 antigens.     

Laboratory tests in the evaluation of renal hypertension.

Renal hypertension is better understood now as a result of the development of new laboratory techniques which permit the identification of the surgically curable forms of renovascular and renal parenchymal hypertension. The rationale for and efficacy of these new advances are discussed and a practical approach to the diagnosis of renal hypertension is offered.     

Role of diagnostic tests in esophageal evaluation

In the evaluation of esophageal disease, the appropriate question must be asked before the correct tests can be selected. Reflux can be demonstrated by radiologic methods, pH testing or radioisotopic techniques. Esophageal mucosal damage is best evaluated by x-ray, endoscopy or biopsy. Chest pain is demonstrated by acid infusion or by manometry. Two algorithms are presented for the evaluation of chest pain and reflux symptoms.     

Pitfalls in the surgical treatment of insulinoma

BACKGROUND: In the 75 years since an insulinoma was first described, the challenge for the surgeon has been one of localization. The combination of endoscopic ultrasound (EUS) or intraoperative ultrasound and operative palpation has led to nearly 100% success rate at primary operation in experienced institutions. However, 13% of patients at referral centers undergo reexploration, which has an increased morbidity. With more successful localization modalities, the operative failures have become more challenging than ever. METHODS: During the past 35 years, we have treated 118 cases of sporadic insulinoma. Technical advances in EUS have led to preoperative identification of more than 90% of insulinomas. Despite this success we have become increasingly aware of the limitations of EUS in the surgical treatment of insulinoma. We present the pitfalls of 6 recent cases. RESULTS: The limitations of EUS include the assessment of malignancy, the identification of pedunculated or adjacent lesions, the evaluation of distal pancreatic lesions, and the differentiation of larger homogeneous tumors from surrounding parenchyma. CONCLUSIONS: The surgical challenge in the treatment of insulinomas has transformed from one of localization to one of recognizing the limitations of our current localization modalities. By sharing our experience with recent difficult cases, we guide the surgeon to greater success and the patient to decreased morbidity.     

CT和MRI对胰岛素瘤的诊断价值

目的　探讨胰岛素瘤的多层螺旋CT(MSCT)和磁共振成像(MRI)的影像学特征。方法　回顾性分析18例经手术病理证实的胰岛素瘤的MSCT及MRI表现。结果　18例胰岛素瘤除1例为多发外其余均为单发,最大径0.3～2.0 cm。MSCT平扫多呈等密度或稍低密度结节,MRI平扫病灶呈T1WI为低或稍低信号,T2WI为高或稍高信号。MSCT及MRI动态增强扫描动脉期明显强化,实质期和门脉期强化降为等密度。 结论 胰岛素瘤的影像学表现具有一定的特征性,反映了胰岛素瘤的病理特点。MSCT动态增强应作为胰岛素瘤首选筛查手段,合理使用MSCT动态增强与MRI检查能显著提高诊断胰岛素瘤的检出率。     

Pharmacogenetics of tolbutamide metabolism in humans

This study was designed to focus on the genetic control of tolbutamide dispositon in humans and to provide insight into the potential for high accrued blood levels in individuals receiving fixed dosage regimens. Tolbutamide was administered intravenously to 42 nondiabetic subjects, eight of their relatives, and to five sets of twins. A ninefold variation in the rate of tolbutamide disappearance from plasms (Kd) was found. This variation was characterized by a trimodal frequency distribution, suggestive of monogenic inheritance and consistent with pedigree analysis, indicating autosomal transmission of rapid and slow inactivation of tolbutamide. A heritability value of 0.995 for Kd indicated little influence of environmental factors on variation of this rate. Interindividual differences in the binding of 35S-tolbutamide to serum proteins were also assessed. No correlation was found between tolbutamide serum protein binding affinity and Kd. Analysis of the metabolites of tolbutamide in urine samples provided evidence for the microsomal oxidation of the drug to hydroxytolbutamide as the primary site of genetic control. In conclusion, this study provides evidence for monogenic control of tolbutamide metabolism in man. The results suggest that fixed dosage regimens of this drug, as were prescribed in the controversial University Group Diabetes Program study, might lead to higher accrued blood levels in slow inactivators.     

Surgical treatment and outcome in insulinoma

In the therapy of organic hyperinsulinism, interest is mainly focussed on the surgical removal of the hyperactive tissue. In spite of these progresses, the surgical treatment is not devoid of problems. These comprise the primary untraceable insulinoma, multiple insulinomas, nesidioblastosis and reoperation. The development of laparoscopic surgery leads to new opportunities the rating of which must be defined. Solitary adenomas are causal for primary hyperinsulinism in 80% to 90% of cases. Intraoperative 87.5% of the tumors are palpable and 83% are detectable by ultrasound. By combination of both methods it is possible to remove 97% of the solitary tumors. Occult adenomas, which cannot be represented by preoperative imaging diagnostics are detectable through intraoperative methods in over 80% of cases by palpation or ultrasound respectively. By combination of both methods, 97% of these occult adenomas can be removed. This reliability of the intraoperative detection makes the preoperative localizing diagnostics unnecessary if no MEN-syndrome is present. If a MEN-syndrome is present, multiple adenomas are common. In 60% of cases multiple adenomas are responsible for the persistency of the syndrome after an unsuccessful primary operation. Therefore a preoperative localizing diagnostics is advisable in case of a MEN-syndrome. Multiple adenomas are treated by left-pancreatic resection with enucleation of remaining adenomas in the pancreatic head region. In case of an untraceable adenoma, the possibility of the rare nesidioblastosis should be considered. This rare occurrence can be detected by fresh frozen sectioning. The resection of 75% to 80% of the pancreas is recommended. The attempt of a laparoscopic removal of solitary adenomas may be indicated, taking into account all contraindications. The preliminary requisite for this is an experienced center in endocrine surgery as well as an experienced laparoscopic surgeon. Contraindications for the laparoscopic procedure are: a tumor localized in the head of the pancreas or in the dorsal parts of the organ, multiple adenomas and nesidioblastosis. In case of occult adenomas, laparoscopic therapy is problematic, as they are also difficult to detect intraoperatively through laparoscopy. The incidence of postoperative complications is still high with 30% and a mortality of 2%. Most often pancreatic fistulas (10%) and septic complications were seen.     

胰岛素瘤的诊断和治疗

目的 探讨胰岛素瘤诊断方法和治疗效果. 方法 回顾性分析胰岛素瘤诊治资料. 结果 23例中男9例,女14例.年龄19~69岁,40~50岁居多.病史最长10年,最短8个月.肿瘤位于胰头6例,胰体5例,胰尾8例,多发性3例,异位于十二指肠降部旁1例.肿瘤直径最小1 cm,最大10cm.良性20例,恶变3例.行肿瘤摘除术19例,肿瘤加部分胰腺组织切除术2例,胰体尾切除术2例.术后发生胰漏3例,全部治愈. 结论 胰岛素瘤诊断一旦成立,早期手术效果良好.     

胰岛素瘤的治疗进展

胰岛素瘤是来源于胰岛B细胞的一种罕见肿瘤,病因不明,起病隐匿.其临床表现多样化,再加上胰腺解剖的复杂及缺乏有效的定位诊断及良恶性判断方法,误诊率高,治愈率低,考虑到部分患者无法耐受手术或不愿手术治疗,胰岛素瘤的治疗始终是临床中的难题之一.除手术治疗外,近年来出现了一些新的治疗手段,本文将胰岛素瘤的各种治疗方法作一综述.     

Comparative value of tests for the diagnosis of venous thrombosis

The clinical diagnosis of venous thrombosis lacks sensitivity and specificity. Venography is recognized as the diagnostic reference standard but is invasive and associated with patient morbidity.¹²⁵I-fibrinogen leg scanning is sensitive to calf vein thrombosis but is relatively insensitive to femoral vein thrombosis and does not detect iliac vein thrombosis. This test is most useful as a screening test in high-risk medical and surgical patients. The test may be falsely positive at the site of hematoma, and because of this, it has serious limitations in patients undergoing knee and hip surgery. Leg scanning also has limitations when used to diagnose patients with suspected venous thrombosis because it may take up to 72 hours to obtain a positive result. Impedance plethysmography (IPG), a noninvasive technique, is sensitive and specific for thrombosis involving the popliteal, femoral, and iliac veins. Combined with¹²⁵Ifibrinogen leg scanning, this test has considerable potential as a screening test in patients undergoing hip surgery. The combined use of IPG and leg scanning has also been shown to be highly accurate for the diagnosis of clinically suspected venous thrombosis, and this approach offers a less invasive alternative to venography in these patients. The Doppler ultrasound flowmeter, like the IPG, is sensitive to popliteal and more proximal vein thrombosis but is relatively insensitive to calf vein thrombosis. The interpretation of the results of this test is more subjective and much more dependent upon the expertise of the examiner than is the IPG. A number of other techniques, including image scanning, and themography, are under investigation but require further evaluation before they can be recommended in the management of patients with venous thromboembolism.

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Résumé Le diagnostic clinique de la thrombose veineuse manque de sensibilité et de spécificité. La phlébographie est le meilleur moyen de diagnostic, mais peutêtre cause de complications. Le test au fibrinogène marqué à l'Iode 125 détecte bien les thromboses au mollet, mais est moins efficace pour les thromboses fémorales et ne diagnostique pas les thromboses iliaques. Ce test est surtout utile pour la détection en série des cas médicaux et chirurgicaux à haut risque. Il peut-être faussement positif à l'endroit d'un hématome et ses indications sont donc très limitées après chirurgie du genou et de la hanche. Une autre limitation vient de son temps de latence: il faut parfois 72 heures avant d'obtenir un résultat positif. La pléthysmographie par impédance (PGI) est une technique non-invasive qui est sensible et spécifique pour les thromboses des veines poplitée, fémorale et iliaque. L'utilisation combinée de la PGI et du scintigramme jambier au fibrinogène I₁₂₅ est une excellente méthode de détection des thromboses après chirurgie de la hanche. Elle est également très bonne pour le diagnostic des thromboses veineuses suspectées par la clinique. Ces techniques sont moins agressives que la phlébographie. De même que la PGI, la vélocimétrie ultrasonique (Doppler) détecte les thromboses de la veine poplitée ou des troncs plus proximaux, mais est peu utile pour les thromboses au mollet. L'interprétation des résultats est cependant assez subjective et dépend de l'expérience de l'examinateur. D'autres techniques, telles que la scintigraphie avec image veineuse et la thermographie, sont en cours d'étude. Mais elles ne pourront entrer dans la pratique qu'après une meilleure définition de leur valeur.

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Dr. Hull is a Research Fellow for the Ontario Heart Foundation.     

Diagnosis and management of insulinoma

Surgery for insulinoma represents one of the best examples of the application of the principles of physiology and pathology in therapeutics. Seven new cases of insulinoma are presented. New diagnostic tests including radioimmunoassay double antibody insulin levels and a diagnostic trial of diazoxide, an anti-insulin agent, were used. Six lesions were benign; four were treated by enucleation and two by distal pancreatectomy. The remaining patient had palliative cholecystojejunostomy for malignant insulinoma followed by chemotherapy with streptozotocin.Selective celiac angiography can now demonstrate the majority of insulinomas. With refinements in technic more nonpalpable lesions will be demonstrated, thus simplifiying the operative approach.Since 1958, 527 cases have been reported in the literature. Tabulation of nonpalpable lesions reveals that 53 per cent were located in the head of the pancreas, the remainder in the body and tail. These figures suggest that if no lesion can be located by arteriography or palpation, blind distal pancreatectomy should be performed. At this point, if no hyperglycemic response is obtained and serial frozen sections give negative results, subtotal pancreatectomy (95 per cent) will remove 90 per cent of these occult tumors.     

胰岛素瘤的诊断与治疗

目的 探讨胰岛素瘤的诊断治疗经验.方法 对本院2008年3月至2012年12月收治的10例胰岛素瘤资料进行回顾性研究.其中男2例,女8例;年龄11 ～ 52岁,平均（32±15）岁.通过对患者进行定性、定位检查确诊,并进行手术干预和随访观察.结果 7例为单纯性胰岛素瘤,3例为多发性内分泌肿瘤-1型（MEN-1）相关的胰岛素瘤;9例为良性肿瘤,1例为交界性肿瘤.10例均有典型的Whipp1e三联征.肿瘤直径＜2 cm者占79.5％.手术切除肿瘤16个,其中12.5％位于胰头部,6.25％位于胰颈部,25％位于胰体部,56.25％位于胰尾部.术前定位检查发现的胰岛素瘤敏感性：经腹超声检查30.5％,多排螺旋增强CT 68.9％,薄层CT灌注扫描79.5％.术中定位诊断方法的敏感性：术中多普勒超声检查100％.81.25％的病例可行肿瘤的局部摘除术.随访6个月～5年,10例病情稳定,血糖均在正常范围之内.结论 手术切除是胰岛素瘤的最佳治疗方式.薄层CT多期动态增强扫描是目前胰岛素瘤术前定位诊断的首选方法,术中多普勒超声显著提高手术切除率.加强对胰岛素瘤的认识,早期诊断并合理积极的手术治疗,能够改善患者生活质量.     

Clinical tests and indirect MR-arthrography in the evaluation of tears of the glenoid labrum

Purpose: Clinical and radiological evaluation of labral tears remains challenging. It has been shown that intravenous administration of contrast agents produces an MR arthrographic effect without the need for intraarticular injection. This is the first study evaluating this new technique of indirect MR arthrography in diagnosis of glenoid labrum tears. Methods: 28 patients with clinically suspected labral injuries were prospectively investigated (1.5 Tesla, flexible surface coil). A native MR exam of the shoulder (transverse and oblique-coronar orientation, T1-weighted spin-, proton density- and T2^*-weighted gradient echo sequences) and indirect MR arthrography (transverse and oblique-coronar orientation, fat-suppressed T1-weighted spin-echo sequences, intravenous injection of gadopentetate dimeglumine [0.1 mmol/kg], followed by 10–15 min of joint movement) were performed. Results were confirmed by arthroscopy and/or open surgery. Additionally sensitivity evaluation of clinical tests for investigation of labral tears were performed. Results: Indirect MR-Arthrography improved delineation of the glenoid labrum and hyaline cartilage significantly (p < 0.05). Sensitivity and specificity of indirect MR arthrography in diagnosis of labral injuries were 90 % and 89 % respectively, compared to 79 % and 67 % of the native MR exam. The reliability of the checked clinical tests is not sufficient enough to determine labral lesions (predictive value between 50 and 70 %). Conclusion: Indirect MR-arthrography is a promising non-invasive technique in the evaluation of the glenoid labrum.