Granulocytic sarcoma: An atypical presentation in the oral cavity

Acute myelogenous leukemia (AMU is a hematologic disorder that is characterized by an abnormal proliferation of immature myeloid cells. Granulocytic sarcomas are clusters of leukemic myeloid cells that may develop as a result of AML. Oral manifestations of AML are common and often involve enlargements of the gingiva and/or mucosal tissue from direct leukemia cell infiltration. We describe the case history of a 50-year-old man who had an ulcera-tive lesion of the oral mucosa that was determined to be a granulocytic sarcoma of AML-M0 subtype. The combination of both the subtype and clinical presentation of the leukemia makes this presentation unusual, and to the best of our knowledge, of a type that has not been previously reported in the literature.     

Computed tomography of midline cysts of the prostate

Midline cysts in the male pelvis are a confusing entity due to their relatively infrequent presentation and the uncertainty as to their origin and classification. We report on CT appearance of four cases of midline prostatic cysts. Ultrasound correlation was available in one case. Two patients presented with lower urinary tract symptoms (hematospermia and/or hematuria), and two were asymptomatic, with one case detected on physical examination and one found incidentally on CT. Computed tomography demonstrated a characteristic sharply marginated, low density, homogeneous midline cyst within the prostate. On ultrasound a well defined midline anechoic cystic mass was seen. These cases are illustrated and a discussion of cystic masses in the male pelvis is included.     

Haemorrhagic complications of pancreaticoduodenectomy

BACKGROUND: Haemorrhagic complication occurs in 5-16% of patients following pancreaticoduodenectomy (PD). We report an analysis of patients with post-PD bleed, to identify predictors of bleed, predictors of survival following bleed and the management of post-PD bleed. METHODS: Two hundred and eighteen patients with periampullary cancers underwent PD from 1989 to 2002. Forty-four (20.2%) patients had a bleeding complication. Of these, 25 patients had an intra-abdominal (IA) bleed and 21 had gastrointestinal (GI) bleed (two had both IA and GI bleed). Clinical, biochemical and tumour characteristics were analysed to identify factors influencing bleeding complications. RESULTS: The median time to presentation was 4.5 days (0-21 days). Serum bilirubin (P = 0.000, OR: 1.090) and pancreaticojejunostomy (PJ) leak (P = 0.009, OR: 3.174) were significant independent factors predicting bleeding complications. Forty-three per cent of patients each had early bleed (<48 h after PD) or delayed bleed (7 days after PD). Comparison of early and late bleeds showed that IA bleed (P = 0.02) presented as early bleeds. Male sex (P = 0.00) longer duration of jaundice (P = 0.02), PJ leak (P = 0.001), HJ leak (P = 0.001), duct to mucosa type of PJ anastomosis (P = 0.03) and IA abscess (P = 0.00) were associated with a significantly higher incidence of late bleeds. Overall mortality after PD was 9.6% with 34% and 3% in bleeders and non-bleeders, respectively. Septicaemia (P = 0.01, OR: 5.49), and acute renal failure (P = 0.01) were associated with increased mortality. CONCLUSIONS: Bleeding complications following PD were seen in one-fifth of patients and were associated with high mortality. Serum bilirubin levels and PJ leak were significant factors associated with bleeding complications. Septicaemia and acute renal failure were significant factors associated with mortality in the bleeders.     

Prospective evaluation of the impact of [18F]fluoro-2-deoxy-D-glucose positron emission tomography of resectable colorectal liver metastases

BACKGROUND: The aim of this study was to assess the additional value of information provided by positron emission tomography (PET) with [(18)F]fluoro-2-deoxy-D-glucose (FDG) over that provided by computed tomography (CT) in patients with resectable liver metastases from colorectal cancer. METHODS: Between October 2001 and November 2002, a prospective double-blind comparison of preoperative FDG-PET and thoracoabdominal CT was performed in 53 patients with potentially resectable liver metastases from colorectal cancer. All resected metastases were subjected to histological examination. RESULTS: Histological examination confirmed the presence of malignant or benign lesions detected by PET and/or CT in 95 per cent of instances. Overall sensitivity (78 per cent) and accuracy (88 per cent) of PET were equivalent to those of CT (76 and 86 per cent respectively). The sensitivity of PET was equivalent to that of CT for hepatic sites (both 79 per cent), but was superior for extrahepatic abdominal sites (63 and 25 per cent respectively). PET provided additional information in five patients, mainly by revealing abdominal extrahepatic metastases, but falsely upstaged three patients. CONCLUSION: Whole-body FDG-PET may identify unrecognized extrahepatic metastases in patients with potentially resectable liver metastases imaged by CT. However, additional information provided by PET is not as reliable as suggested by earlier retrospective studies.     

Seizure Frequency Can Alter Brain Connectivity: Evidence from Resting-State fMRI

BACKGROUND AND PURPOSE:The frequency of seizures is an important factor that can alter functional brain connectivity. Analysis of this factor in patients with epilepsy is complex because of disease- and medication-induced confounders. Because patients with hot-water epilepsy generally are not on long-term drug therapy, we used seed-based connectivity analysis in these patients to assess connectivity changes associated with seizure frequency without confounding from antiepileptic drugs.MATERIALS AND METHODS:Resting-state fMRI data from 36 patients with hot-water epilepsy (18 with frequent seizures [>2 per month] and 18 with infrequent seizures [≤2 per month]) and 18 healthy age- and sex-matched controls were analyzed for seed-to-voxel connectivity by using 106 seeds. Voxel wise paired t-test analysis (P < .005, corrected for false-discovery rate) was used to identify significant intergroup differences between these groups.RESULTS:Connectivity analysis revealed significant differences between the 2 groups (P < .001). Patients in the frequent-seizure group had increased connectivity within the medial temporal structures and widespread areas of poor connectivity, even involving the default mode network, in comparison with those in the infrequent-seizure group. Patients in the infrequent-seizure group had focal abnormalities with increased default mode network connectivity and decreased left entorhinal cortex connectivity.CONCLUSIONS:The results of this study suggest that seizure frequency can alter functional brain connectivity, which can be visualized by using resting-state fMRI. Imaging features such as diffuse network abnormalities, involvement of the default mode network, and recruitment of medial temporal lobe structures were seen only in patients with frequent seizures. Future studies in more common epilepsy groups, however, will be required to further establish this finding.

Behind the unquestionable clinical and electroencephalographic manifestations of an epileptic seizure, there lie several molecular, metabolic, cellular, and hemodynamic events that alter the function of the brain in a complex manner. These alterations may be transient, but many such events can have a cumulative effect, resulting in psychological and memory deficits, personality changes, and reduced functioning in patients with epilepsy. Advances in neurophysiology, functional imaging, and computational neurosciences have made it possible to derive models mathematically to describe such complex diseases.Disease-state network analysis with resting-state fMRI is becoming increasingly popular because of its superior spatial resolution, nondependence on task, ease of acquisition, and ability to visualize whole-brain functional networks, which are amenable to long-term changes related to disease states.¹ Application of connectivity principles to these data has promoted research in various aspects of epileptic seizures, and there has been overwhelming report of decreased connectivity around the seizure-onset zone^2–6 and the default mode network (DMN) by several groups.^7,8 In 2012, Jehi⁷ and Morgan et al⁹ reported that connectivity patterns were different in patients with right and left mesial temporal sclerosis and that there was decreased connectivity between the regions of the DMN and the hippocampus and amygdala in patients with mesial temporal sclerosis. Similarly, hemispheric connectivity analysis in patients with unilateral mesial temporal sclerosis revealed decreased local and intrahemispheric connectivity and increased interhemispheric connectivity.¹⁰ In contradistinction to the aforementioned results, there have been reports on increased hippocampal connectivity that was presumed to be a compensatory mechanism because it linearly correlated with a disease duration of >10 years.^1–4,6 Graph-theory analysis of resting-state fMRI data from patients with epilepsy also revealed decreased functional nodal topologic properties of the DMN that were positively correlated with disease duration.^8,11–14 Regional homogeneity analysis of resting-state fMRI data was even used as a presurgical tool for seizure identification in patients with MR-negative focal epilepsy.¹⁵ Thus, various models of data analysis have helped in understanding epilepsy further, and now there is increasing interest in using these models to reclassify epilepsy as a focal epileptogenic area^10,15 or as a network of seizure-generating areas.^16–18Gower''s clinical observation that “seizures beget seizures” in 1881 triggered several studies, especially animal models that addressed the genesis of epilepsy. Kindling is a phenomenon in which the repetition of subconvulsive electrical stimuli results in a progressive epileptic state and an increased frequency of seizures.^19,20 Kindling is a continuous temporal process that remodels the mechanisms and circuits in the brain. Early changes, beginning with modulation of presynaptic and postsynaptic functioning in glutamate, N-methyl-d-aspartate, and α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors, and late changes, including mossy fiber sprouting, synaptogenesis/neurogenesis, and neurotrophic factor regulation, are known to occur as a result of kindling.^20–22 The increased risk for seizure recurrence with increasing numbers of seizures was first demonstrated clinically by Hauser and Lee.²³ The effects of seizure frequency and chronic epilepsy have been studied sparsely by using imaging techniques.¹ For example, Widjaja et al²⁴ found no significant correlation with seizure frequency, age of seizure onset, or duration of epilepsy in a group of children with medically refractory epilepsy.Apart from other disease-related confounders such as type of seizure, duration of epilepsy, age of onset, family history of epilepsy, etc, each of which can induce connectivity differences independently, a major limitation of interpreting the results of functional connectivity in patients with epilepsy is the use of antiepileptic drugs. Patients with hot-water epilepsy (HWE) present with a history of complex partial seizures clinically suggestive of temporal lobe onset with or without secondary generalization. Most patients are drug naive at their first evaluation, which provided us an opportunity to study networks that were affected by seizure frequency and matched for other disease-related confounders but not antiepileptic drugs. On the basis of the phenomenon of kindling, we hypothesized that seizures can alter brain connectivity and that the frequency of seizures can influence the magnitude of this alteration. We predicted that patients with a higher seizure frequency would have widespread changes in comparison with patients with a lower seizure frequency. We used seed-to-voxel–based resting-state fMRI connectivity in 36 drug-naive patients with HWE who were comparable in terms of various factors such as age, sex, education, and epilepsy-related confounders. We hope that such quantifiable noninvasive in vivo evidence further enhances knowledge of the etiopathogenesis of HWE and, if applicable to refractory epilepsy, can identify such patients early to avoid time-consuming trial-and-error methods of pharmacotherapy and facilitate early intervention to minimize cognitive deficits.     

Correlation of CT and ultrasound in the evaluation of renal lymphoma

In a series of 225 patients with lymphoma studied by computed tomography, involvement of the kidney(s) was found in 11 (4.9%). These cases were then also studied by ultrasound. Because of the characteristic findings of computed tomography and sonography in renal lymphoma, a reliable diagnosis was possible along with an accurate assessment of the incidence and types of renal involvement. Illustration of this material along with a discussion of the clinical implications of these findings is presented.     

Correlation of CT and ultrasound in the evaluation of renal lymphoma

In a series of 225 patients with lymphoma studied by computed tomography, involvement of the kidney(s) was found in 11 (4.9%). These cases were then also studied by ultrasound. Because of the characteristic findings of computed tomography and sonography in renal lymphoma, a reliable diagnosis was possible along with an accurate assessment of the incidence and types of renal involvement. Illustration of this material along with a discussion of the clinical implications of these findings is presented.     

Cytidinediphosphocholine treatment to decrease traumatic brain injury-induced hippocampal neuronal death,cortical contusion volume,and neurological dysfunction in rats

OBJECT: In previous studies at their laboratory the authors showed that cytidinediphosphocholine (CDP-choline), an intermediate of phosphatidylcholine synthesis, decreases edema formation and blood-brain barrier disruption following traumatic brain injury (TBI). In the present study the authors investigate whether CDP-choline protects hippocampal neurons after controlled cortical impact (CCI)-induced TBI in adult rats. METHODS: After adult male Sprague-Dawley rats had been anesthetized with halothane, a moderate-grade TBI was induced with the aid of a CCI device set at a velocity of 3 m/second, creating a 2-mm deformation. Sham-operated rats, which underwent craniectomy without impact served as controls. The CDP-choline (100, 200, and 400 mg/kg body weight) or saline was injected into the animals twice (once immediately postinjury and once 6 hours postinjury). Seven days after the injury, the rats were neurologically evaluated and killed, and the number of hippocampal neurons was estimated by examining thionine-stained brain sections. By 7 days postinjury, there was a significant amount of neuronal death in the ipsilateral hippocampus in the CA2 (by 53 +/- 7%, p < 0.05) and CA3 (by 59 +/- 9%, p < 0.05) regions and a contusion (volume 34 +/- 8 mm3) in the ipsilateral cortex compared with sham-operated control animals. Rats subjected to TBI also displayed severe neurological deficit at 7 days postinjury. Treating rats with CDP-choline (200 and 400 mg/kg, intraperitoneally) significantly prevented TBI-induced neuronal loss in the hippocampus, decreased cortical contusion volume, and improved neurological recovery. CONCLUSIONS: Treatment with CDP-choline decreased brain damage following TBI.     

Granulomatous mastitis — a diagnostic dilemma

Granulomatous lobular mastitis is a rare benign breast disease. It is characterized by chronic, non-caseating granulomatous lobulitis. It may be misdiagnosed as a carcinoma of the breast and may lead to mastectomy. Diagnostic criteria include-A) Granulomatous infl ammation with multinucleated giant cells, epithelioid histiocytes. B) It is centered on lobules with minor ductal and periductal infl ammation. C) It nearly always follows the pregnancy. A case of GLM, which was treated with local excision and postoperative steroid therapy is being reported to increase awareness amongst surgeons and pathologist.