Metastases to the breast

Metastases to the breast are uncommon, with about 250 cases reported from clinical and autopsy series. The mammographic findings in 16 new cases revealed a spectrum of changes that included solitary or multiple lesions, well demarcated or poorly marginated masses, and diffuse involvement of skin or parenchyma or both. Diffuse disease was seen more frequently in this series (4/16), at times simulating inflammatory breast cancer. Although diagnosis of a primary malignancy usually preceded detection of the breast lesion, 40% (6/16) had no history of malignancy. Prognosis remains poor; however, it has improved in the lymphoma-leukemia group due to improved immunotherapeutic and chemotherapeutic regimens. The clinical, radiologic, and pathologic features are discussed. Some of the lesions encountered can be confused with a primary breast malignancy or a benign lesion, necessitating prompt and accurate biopsy to preclude unnecessary major surgery and to improve survival in cancers amenable to current therapy.     

Adults with knee osteoarthritis use different coordinative strategies to transition from swing to stance compared to young asymptomatic adults

BackgroundNeuromuscular changes that occur with aging or joint pathology likely alter the coordinative strategies that adults use to walk and to recover from perturbations during gait. Differences in coordination patterns or in how coordination changes in response to a challenge may provide insight into neuromuscular targets for falls prevention interventions.Research questionDo young asymptomatic adults, older asymptomatic adults, and older adults with knee OA alter their lower extremity segment coordination differently in response to an increase in walking speed?.MethodsWe captured lower extremity kinematics using inertial measurement units as 29 participants (10 young, 10 older, 9 older with knee osteoarthritis) walked on a treadmill at self-selected preferred and faster speeds. We calculated lower extremity segment coordination and coordination variability using vector coding. We compared coordination and its variability among groups and speeds.ResultsThere were no significant interactions between group and speed. Overall group or speed differences in coordination or variability occurred mostly during terminal swing or early stance. Coordination patterns differed between young adults and adults with knee osteoarthritis in all segment couples during terminal swing and at the foot vs. shank during early stance. During these same gait cycle phases for the foot vs. shank and shank vs. thigh segment couples, coordination patterns shifted towards those of young adults when participants walked faster. Where coordination variability differed by group or speed, it was lower in the young adults than in the older adults with or without knee osteoarthritis and at faster walking speed.SignificanceOur results identified that older adults with knee osteoarthritis have a different strategy for transitioning from swing to stance compared to young adults, especially at distal limb segments. These results may help target fall prevention interventions to specific gait cycle phases or strategies.     

Wandering spleen associated to inflammatory pseudotumor

Wandering spleen is an uncommon clinical entity accounting for less than 0.5% of all splenectomies performed. It can be an incidental finding in asymptomatic patients or it can be found in patients with acute or chronic clinical presentation due to compression (urinary retention, constipation), alterations in splenic function (thrombocytopenia or hypersplenism), or torsion of a vascular pedicle. Wandering spleen is diagnosed by imaging techniques, usually ultrasound, CT, or MRI. scintigraphy or arteriography can also be useful in cases with inconclusive findings. Although cases of wandering spleen associated to diverse masses (epidermoid cysts, simple cysts, cystic lymphangiomas, and lymphomas) have been reported in the literature, to our knowledge there are no reports of this entity associated to inflammatory pseudotumor. We present the case of a patient with wandering spleen associated to inflammatory pseudotumor.     

The right not to be treated or to refuse treatment

The corollary to the right to refuse treatment is the requirement that, in general, informed consent be obtained before treatment. The Declaration of Lisbon recognises this: "The patient has the right to accept or to refuse treatment after receiving adequate information." The information to be given to the patient is of three kinds, but a special problem in relation to the doctrine of informed refusal places a special duty on the doctor to inform the patient about the possible consequences of refusing treatment. Related topics, such as refusal in part, refusal by a parent or guardian, the novus actus interveniens, the living will, and contributory negligence are touched upon.     

Failure to induce hypersensitivity reactions to opaque contrast media analogs in guinea pigs.

In a further exploration of idiosyncratic reactions to injections of contrast media, a systematic study of immediate or delayed hypersensitivity in guinea pigs injected with contrast media analogs was performed. No evidence of immediate or delayed hypersensitivity could be ascertained to either contrast media analogs alone, or analogs bound to protein carriers. This does not represent conclusive evidence against the notion of antibody formation as a factor in the production of some adverse reactions, but makes such a pathogenesis less likely.     

Urinomas secondary to pyelosinus backflow

Pyelosinus backflow of urine usually occurs through infractions of the calyceal fornices from obstruction or retrograde study. The primary cause appears to be a rapid rise in intrapelvic pressure with the backflow representing a physiologic release mechanism which returns the intrapelvic pressure to normal. Pyelosinus backflow is a benign process. However, complications can occur. In some persons whose urine transport cannot accommodate periodic increased urine flow or pressure, repeated pyelosinus backflow may lead to pseudocyst (urinomas) or retroperitoneal fibrosis. Several mechanisms produce these complications in children and adults. The authors present cases of urinomas related to upper tract obstruction from posterior urethral valves as well as ureteral obstruction by tumor, post-treatment scarring, retroperitoneal fibrosis, or calculus. Intrarenal urinomas are illustrated presumably in kidneys with firm capsular attachments to the renal pelvis which do not allow retroperitoneal extravasation.     

Trauma to the foot

Minor trauma to the foot may cause stress fracture, avulsion fracture or ligamentous and tendon injury. Plain radiographs are frequently normal. Radionuclide bone scan is a sensitive detector of early bone injury. A stress fracture may develop focal uptake or diffuse uptake throughout the bone involved. MR imaging is the most sensitive means of evaluating injury to the soft tissues. Acute edema, partial tear, complete tear, and chronic tendinitis have distinct features on T1- and T2-weighted images. Major trauma occurs most commonly as a result of falls from heights and from motor-vehicle accidents. Plain films are useful in the initial evaluation of the extent of trauma. CT is particularly useful in evaluating calcaneal fractures that involve the subtalar joint. Both MR imaging and CT scans are useful in detecting injured or entrapped tendons associated with fracture-dislocations.     

The responsibility to protect

The decision whether, if ever, to intervene in the affairs of a sovereign state with military force has become a critical issue of the post Cold War era. In 2000 the Canadian government launched the International Commission on Intervention and State Sovereignty (ICISS), which in 2001 published its findings in The Responsibility to Protect. The Commission found broad support for the notion of sovereignty not only as a right, but also a responsibility, the responsibility of a state to provide protection for its people. The primary responsibility for protecting citizens rests with states. But when states are unable or unwilling to provide this protection, or are themselves the perpetrators of atrocities, the Commission argues that the international community has a responsibility temporarily to step in, forcefully if necessary. The Commission resisted the temptation to identify human rights violations falling short of outright killing or ethnic cleansing. This eliminates the possibility of intervening on the basis of systematic oppression of human rights or intervening to remove a military dictatorship. The intention of the report was to provoke debate; to strengthen the role of the United Nations and ensure that such interventions were multilateral and meeting the wider needs of a region and not the interests of major powers. There is an ongoing need to ensure that the Security Council is effective and that resources match the political will. These debates must continue within a UN framework.     

Problems especially for nuclear medicine: better to prevent than to treat

Problems in nuclear medicine are as follows: There is a unique problem of intense and continuous education regarding new regimens in nuclear medicine, more than in many other clinical specialties. When attending two lectures of 45 min each we usually remember only the first 15-20 min of each lecture. There are countries where the subject of nuclear medicine is either not taught in the medical schools or is taught as part of radiology or imaging or as an optional subject. Research is very important for a fast growing new specialty like nuclear medicine. It was suggested to have in every medical school one professorship for clinical nuclear medicine and another one for research nuclear medicine. There is need for wider availability of modern equipment like PET or PET/CT in many countries. The EANM in cooperation with the International Atomic Energy Agency (IAEA) may propose to the EU measures that will help nuclear medicine. If research finds a way ro label glucose analogs with technetium-99m and this radiopharmaceutical becomes available, PET studies will be largely substituted by the use of SPET cameras. About nuclear cardiology and radiology: are we giving up the best part of our specialty to cardiologists and radiologists for no return? Some colleagues have proposed that nuclear medicine be divided into subspecialties. Following the example of diagnostic radiology and radiotherapy, we could have diagnostic nuclear medicine including nuclear cardiology and therapeutic nuclear medicine. According to Hippocrates: "It's better to prevent than to treat".     

Shoulder instability: return to play

Shoulder instability in the competitive athlete is a relatively common problem. The etiology of glenohumeral instability that can affect the athlete runs a wide spectrum, from an isolated traumatic dislocation to repeated microtrauma or congenital laxity. Although many athletes are able to adapt to a mild laxity that might only occasionally affect them, it can be much more difficult to adapt or return to play after a dislocation or repeated subluxation episodes. This article focuses on the return to play for competitive individuals after a glenohumeral dislocation or reconstructive surgery for shoulder instability.     

Injuries to runners: a study of entrants to a 10,000 meter race

As the number of runners has increased dramatically, so has the incidence of running-related injuries. In order to determine what training factors are associated with running-related injuries, as well as what percentage of injured runners seeks professional medical attention, a random sample of entrants to a 10 kilometer race was asked to complete a questionnaire. There were 451 respondents, 355 men and 96 women, with a nonresponse rate of 12.7%. Nonrespondents did not differ from respondents with regard to age or sex. Forty-seven percent of respondents indicated that they had sustained a running-related injury in the last 2 years. Injured runners differed significantly from noninjured runners in that they were more likely to have run more miles per week, run more days per week, run a faster pace, run more races in the last year, stretched before running, and not participated regularly in other sports. Associated with injury, but not statistically significant, were those who had run marathons and had done muscle-strengthening exercises. No association was found with regard to the length of time running, running surfaces, part of the foot first contacting the ground, or running intervals, sprints, or hills. Seventy percent of those injured sought professional medical care, with 76% of these having a good or excellent recovery from their injuries. Compliance with medical advice correlated well with treatment success.     

Breast cancer metastasis to intramammary lymph nodes

Metastatic disease to the intramammary lymph nodes from breast cancer may be seen mammographically. In the four cases reviewed, the affected intramammary lymph nodes were enlarged (1 cm or greater in diameter), homogeneous, and well circumscribed. All lacked the lucent center or hilar notch characteristic of benign intramammary nodes. Differentiation of malignant from benign causes of intramammary lymph node enlargement, such as inflammation or hyperplasia, is impossible by mammography. Biopsy is recommended for all intramammary lymph nodes of 1 cm or greater that are not fat infiltrated unless the patient clearly has an associated dermatitis or mastitis. Metastatic disease to the intramammary lymph nodes may be the first clinical and/or mammographic sign of breast cancer and may significantly affect prognosis.     

Injuries to neck structures in deaths due to constriction of neck, with a special reference to hanging

This prospective study aimed at examining various injuries to the neck structures in deaths due to constriction of neck. Neck dissection technique, as advocated by Prinsloo and Gordon was undertaken to study the injuries to the thyro-hyoid complex, strap muscles, carotid vessels, etc. Of the 1746 medico-legal autopsies, conducted during the study period, 5% were deaths due asphyxia of which 82% were those of constriction of neck. The 21-30 years age group accounted for the maximum number of cases (57%). Male:female ratio was 2:1. Hanging (69%) outnumbered other asphyxial deaths--ligature and/or manual strangulation, smothering, etc. Injury to the sternocleido-mastoid muscle (54%) was the commonest injury to the neck structures. The hyoid bone was fractured in 21% cases, while the thyroid cartilage was fractured in 17% cases. Complete hanging was noted in 68% of cases while the hanging was atypical in 88%. Fixed knot was found to have been used in 71%. A single loop round the neck was observed in 80% of the cases and it was above the level of thyroid in 58% cases. Most cases of the fracture of the laryngo-hyoid complex were in the 41-60 year age group, 72% and the fracture was on the same side as the knot in 52% cases. Majority used soft daily wear articles of clothing like a sari (32%) or chunni (24%). Asphyxial deaths due to constriction of neck being common in all parts of the world, prospective studies in different setups to examine the profile of neck structure injuries are needed so as to differentiate the suicidal or homicidal nature of such deaths with a greater certainty.     

Pre-exposure of human squamous carcinoma cells to low-doses of gamma-rays leads to an increased resistance to subsequent low-dose cisplatin treatment

Purpose: To investigate low-dose hypersensitivity to cisplatin and increased resistance at higher doses of cisplatin for the human squamous carcinoma cell line SCC-25 and its cisplatin-resistant derivative SCC-25/CP, and to examine the effects of pre- and post-treatment of SCC-25 cells with low-doses of gamma-rays on their resistance to cisplatin. Materials and methods: SCC-25 and SCC-25/CP cells were treated with various cisplatin concentrations (0.1 to 20 mu m for 1h) and assayed for survival using a conventional colony assay. For SCC-25, various doses of gamma-rays (5cGy to 2.5Gy) were given either 10 or 60min before the cisplatin challenge dose as well as either 10 or 60min after the cisplatin challenge dose. Results: Low-dose (0.5, 0.75 and 1 mu m for 1h) hypersensitivity to cisplatin and increased resistance at higher doses was detected for the SCC-25 cell line, but not for its cisplatin-resistant derivative, SCC-25/CP. Pretreatment of SCC-25 cells with an acute low-dose of 5, 25cGy or 1Gy gamma -rays given 60min before a low-dose cisplatin challenge (0.1 and 1 mu m for 1h) resulted in a significant increase in resistance (p=0.2, 0.01 and < 0.001 respectively). For pretreatment of SCC-25 cells with similar lowdoses of gamma-rays 10min before the challenge cisplatin dose, the increased resistance was reduced or absent and was only significantly increased for pretreatment with 25cGy and a challenge cisplatin dose of 0.1 mu m for 1h (p=0.02). Similar acute low-doses of gamma-rays given either 10 or 60min after the challenge cisplatin dose did not increase resistance. Conclusions: The human squamous carcinoma cell line SCC-25 showed a low-dose hypersensitivity to cisplatin followed by increased resistance at higher doses. Treatment of SCC-25 cells with low-doses of gamma-rays can induce a protective effect to a subsequent low-dose cisplatin challenge.     

Lens dose to standing patients treated with electrons to the hand

Patients receiving radiotherapy to the hand are sometimes treated standing, with their heads beside and potentially facing an electron applicator. This raises the possibility of consequential lens dose from scattered electrons, which this study investigates. This study measures the dose beside an applicator at a depth of 3 mm in a phantom as an estimate of lens dose for such patients. The lens dose is investigated as a function of height, distance, beam energy, applicator size, and cutout fill on a Varian Trilogy linear accelerator. The effect of the potential mitigation strategies of turning the head or shielding with lead sheets is also investigated. Measurement found that a typical hand setup may result in the lens receiving 0.15% of the treatment dose, which would deliver a cumulative dose above the demonstrated threshold dose for cataract risk for some courses. Large applicators and close facial proximity to the applicator separately enhance dose by factors of 3 and 5 respectively, raising the possibility of multiple gray to the lens for patients in unfavorable setups. Simple and effective mitigation strategies are available: Turning the patient's head to the side or placing 1–2 mm of lead on glasses reduced lens dose by a factor of 3–4, and covering the side of the applicator with 1 mm of lead or turning the head completely away effectively eliminated lens dose. The lens dose can be consequential but is readily mitigated.     

Failure of metoclopramide to control emesis or nausea due to stressful angular or linear acceleration

Orally administered metoclopramide (REGLAN) at doses of 10 or 20 mg, 75 min prior to either stressful linear acceleration (parabolic flight) or cross-coupled accelerative semicircular canal stimulation in a rotating chair was evaluated for its ability to prevent emesis or nausea II, respectively. Although metoclopramide is an effective antiemetic agent that enhances gastric emptying and prevents cancer chemotherapy-induced emesis, we were unable to demonstrate any significant (p less than 0.05) effects of this drug on motion sickness.     

Fit to be interviewed by the police--an aid to assessment

The assessment of a suspect's fitness to be interviewed by the police is becoming an increasingly important part of a police surgeon's workload. This paper discusses the assessment in terms of the various factors that may render a person prone to providing an involuntary or false confession and proposes an aide memoire to assist the examining doctor.     

A to Z of desmoid tumors

OBJECTIVE: The purpose of this article is to illustrate the common locations of desmoid tumors (deep fibromatosis), complications of intra- and extraabdominal desmoids, and treatment-related changes in their imaging appearance. CONCLUSION: Desmoids are locally aggressive fibrous tumors with a tendency to recur. Desmoids can be intraabdominal, in the abdominal wall, or extraabdominal. Complications, such as compression or invasion of adjacent structures, and abscess formation can occur. Treatment options include observation, local treatment (surgery, radiotherapy), or systemic therapy (conventional chemotherapy, molecular targeted agents).     

Adverse reactions to non-ionic contrast media with special regard to high-risk patients

Non-ionic contrast media (CM) are proven to be significantly safer than the high osmolar ionic contrast media (HOCM). Nevertheless deaths are reported after administration of non-ionic agents. The aim of the study was to investigate the rate of adverse reactions to non-ionic CM with special regard to high-risk patients and the effects of premedication with H1-and H2-receptor antagonists.In a prospective study conducted over about 2 years 12 995 examinations with intravenous or intra-arterial non-ionic CM were evaluated. Premedication with H1-and H2-antagonists was used in 1276 high-risk patients with known adverse reaction to CM, history of allergy or severe cardiac or pulmonary disease. 229 patients received no premedication inspite of known risk factors. In total, there were 143 (1.10%) adverse reactions (mild in 0.58%, moderate in 0.41% and severe in 0.05%). In high-risk patients there were adverse reactions in 4.37% without and in 1.57% with premedication. There were no severe adverse reactions in the high-risk patients after premedication. The age of the patient, CM dosage and CM concentration were not shown to be risk factors in the present study. In conclusion, the additional premedication with H1- and H2-antagonists could be an effective agent to reduce the risk of mild and moderate adverse reactions and to avoid severe adverse reactions in high-risk patients. Correspondence to: U. Fink     

Cardiovascular adaptation to weightlessness

Exposure to actual and simulated O g causes a significant central or cephalad shift of intravascular and interstitial fluid that triggers a complex set of cardiovascular and systemic adaptations. These adaptations are, in turn, directly responsible for the cardiovascular dysfunction that is apparent after return to normal gravity. However, critical information on several important adaptive mechanisms is incomplete or lacking. An attempt will be made to resolve these problems during a future dedicated Life Sciences Space Shuttle flight. A series of cardiovascular experiments will utilize direct measurements of central venous pressures, cross-sectional echocardiography, and noninvasive measurements of systemic and peripheral blood flow at rest and during stress. Autonomic control mechanisms will be studies in detail.