Adrenal incidentalomas -- a continuing management dilemma

Adrenal incidentalomas (AI), adrenal tumors detected through an imaging procedure done for reasons unrelated to adrenal dysfunction, is becoming a common clinical problem with the more frequent utilization of different imaging techniques. Most such tumors are benign and hormonally inactive. A variety of diagnostic strategies have been developed to distinguish the latter; however, they are still controversial. Even after a commissioned systematic review of the literature and a state of the science conference sponsored by the National Institutes of Health, the optimal strategy for hormonal screening of a patient with AI is unknown, but we anticipate further refinements and major advances in the field. Surgery is the ultimate solution for the diagnostic-therapeutic dilemma of AI. Careful planning is required, and the learning curve which influences clinical decision making is especially relevant to immediate outcomes. The benefit of making a diagnosis of a clinically significant AI must be considered in the context of the patient's overall condition and preferences.     

Endoscopic ultrasonography guided biliary drainage: Summary of consortium meeting,May 7^th , 2011, Chicago

Endoscopic retrograde cholangiopancreatography (ERCP) has become the preferred procedure for biliary or pancreatic drainage in various pancreatico-biliary disorders. With a success rate of more than 90%, ERCP may not achieve biliary or pancreatic drainage in cases with altered anatomy or with tumors obstructing access to the duodenum. In the past those failures were typically managed exclusively by percutaneous approaches by interventional radiologists or surgical intervention. The morbidity associated was significant especially in those patients with advanced malignancy, seeking minimally invasive interventions and improved quality of life. With the advent of biliary drainage via endoscopic ultrasound (EUS) guidance, EUS guided biliary drainage has been used more frequently within the last decade in different countries. As with any novel advanced endoscopic procedure that encompasses various approaches, advanced endoscopists all over the world have innovated and adopted diverse EUS guided biliary and pancreatic drainage techniques. This diversity has resulted in variations and improvements in EUS Guided biliary and pancreatic drainage; and over the years has led to an extensive nomenclature. The diversity of techniques, nomenclature and recent progress in our intrumentation has led to a dedicated meeting on May 7 th , 2011 during Digestive Disease Week 2011. More than 40 advanced endoscopists from United States, Brazil, Mexico, Venezuela, Colombia, Italy, France, Austria, Germany, Spain, Japan, China, South Korea and India attended this pivotal meeting. The meeting covered improved EUS guided biliary access and drainage procedures, terminology, nomenclature, training and credentialing; as well as emerging devices for EUS guided biliary drainage. This paper summarizes the meeting’s agenda and the conclusions generated by the creation of this consortium group.     

Defect of epidermal 12(S)-hydroxyeicosatetraenoic acid receptors in psoriasis

12-hydroxyeicosatetraenoic acid (12-HETE) is assumed to play a central role in the pathophysiology of psoriasis. Since its effects in skin are mediated by specific high-affinity receptors, we studied the receptor characteristics in cultured epidermal cells from involved and apparently healthy skin of psoriasis patients by radioligand binding assay. Involved and uninvolved psoriatic epidermal cells showed a fourfold decrease in the number of 12-HETE binding sites as compared with normal healthy individuals and patients with atopic dermatitis, while receptor affinity remained unchanged. The decrease in receptor number was evident in psoriatic cells even in long-term culture and was not due to receptor down-regulation, defective response to interferon gamma or to protease degradation of receptor protein. The decrease in the number of 12-HETE receptors detectable even in clinically normal psoriatic skin functionally leads to diminished 12-HETE uptake and may thus represent a primary central molecular defect in the pathophysiology of the disease.     

Some effects of Naja nigricollis envenomation on developing fetal tissue

The effects of maternal envenomation with N. nigricollis venom on developing fetal tissue were studied in mice. The venom passed the placental barrier and injured the kidney nephrons. In the liver, it produced disorganization of lobules with cellular degeneration and congestion of the liver sinusoids. The hepatic erythropoietic tissue seemed not affected. In the heart, subendocardial hemorrhages together with fragmentation of the myocardium were observed. Edematous changes were noticed in the wall of the aorta and the large blood vessels. The endothelial lining of some of the vessels ruptured and extravasated blood was noticed in the lumen of the gut and respiratory passages.     

Testicular aging: vascularization and gametogenesis modifications in the Wistar rat

A light microscopic study was carried out on testicular aging in the Wistar rat at the ages of 7, 12, 24, 40, 56, 72, 104, and 124 weeks. The following tissular modifications were observed: a progressive decrease in capillary density, a gradually reduced spermatogenic production, and a progressive increase of degenerating tubular areas. The following two questions were raised: (1) Are the vascular modifications responsible for the other alterations? (2) Do the anomalies inducing a decreased number of spermatozoa simultaneously lead to genetic alterations in the morphologically normal spermatozoa with fertilizing ability? This question is particularly interesting owing to our current knowledge of the consequences of the father's age on offspring.     

National Hospital Ambulatory Medical Care Survey: 2004 emergency department summary

OBJECTIVES: This report describes ambulatory care visits to hospital emergency departments (EDs) in the United States in 2004. Statistics are presented on selected hospital, patient, and visit characteristics. Selected trends in ED utilization from 1994 through 2004 are also presented. METHODS: The data presented in this report were collected in the 2004 National Hospital Ambulatory Medical Care Survey (NHAMCS), a national probability sample survey of visits to emergency and outpatient departments of non-Federal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual national estimates. RESULTS: During 2004, an estimated 110.2 million visits were made to hospital EDs, about 38.2 visits per 100 persons. Visit rates have shown an increasing trend since 1994 for persons aged 22-49 years, 50-64 years, and 65 years and over. In 2004, more than 16 million patients arrived by ambulance (15.1 percent). At approximately 3 percent of visits, the patient had been seen in the ED within the last 72 hours. Abdominal pain, chest pain, fever, and back symptoms were the leading patient complaints, accounting for nearly one-fifth of all visits. Abdominal pain was the leading illness-related diagnosis at ED visits. There were an estimated 41.4 million injury-related visits or 14.4 visits per 100 persons. Diagnostic and screening services were provided at 89.9 percent of ED visits. Procedures were performed at 47.7 percent, and medications were prescribed at 78.4 percent of ED visits. Approximately 13 percent of ED visits resulted in hospital admission. On average, patients spent 3.3 hours in the ED, of which 47.4 minutes were spent waiting to see a physician.     

Non-hormonal drugs for the treatment of diabetes insipidus

Patients with diabetes insipidus may be successfully controlled with drugs other than vasopressin. These have the advantage of being effective when administered orally. The most important are the diuretics and the hypoglycemic agent chlorpropamide. The mode of action, indications and side effects of these drugs are reviewed. A third potentially useful agent is clofibrate. Recent experience with this drug has been described but more observations are needed before its possible role in the management of diabetes insipidus can be established.