Primary Gastrointestinal Lymphoma Complicated by Common Bile Duct Obstruction: Report of Two Cases

This report describes two cases, a case of primary small intestinal lymphoma and a case of gastroduodenal lymphoma both producing obstructive jaundice due to invasion of the common bile duct. Oesophagogastroduodenoscopy revealed the lesions and the endoscopic biopsies confirmed the diagnosis of lymphoma in both the cases. Ultrasound examination of the biliary system, followed by percutaneous transhepatic cholangiography, delineated the dilated biliary tree with distal obstruction of the common bile ducts. While radiotherapy alone was sufficient in the case of primary small intestinal lymphoma; drainage procedures were required in the case of gastroduodenal lymphoma to relieve the obstruction of the common bile duct.     

Intravenous alfacalcidol once weekly suppresses parathyroid hormone in hemodialysis patients

Management of secondary hyperparathyroidism is difficult because of the interrelationship of parathyroid hormone, calcium and phosphorus. This study was carried out to assess the efficacy of intravenous administration of alfacalcidol once weekly versus twice weekly in patients with severe hyperparathyroidism. Twenty-one hemodialysis patients with intact parathyroid hormone >88 pmol/L were divided into two groups. Eleven patients (Group 1) were given a once-weekly alfacalcidol intravenously for 12 weeks. The starting dose was 4 microg which was increased or decreased by 1 microg per week. Ten patients (Group 2) were given twice-weekly alfacalcidol intravenously for 12 weeks. The starting dose was 2 microg twice weekly which was increased or decreased by 0.5 microg/dose. The dose was increased or decreased according to serum calcium and phosphorus levels. Serum calcium, phosphorus and alkaline phosphatase levels were measured weekly and intact parathyroid hormone every 4 weeks. Intact parathyroid hormone reduced significantly (P = 0.0001) from 128.12 +/- 35.42 pmol/L to 82.93 +/- 65.20 pmol/L and from 113.74 +/- 40.83 pmol/L to 64.24 +/- 35.17 pmol/L after 4 weeks in Groups 1 and 2, respectively. After 4 weeks alkaline phosphatase declined significantly (P = 0.0001) from 146.0 +/- 57.3 IU/L to 116.0 +/- 45.6 IU/L in Group 1 and from 139.0 +/- 45.1 IU/L to 116.6 +/- 38 IU/L in Group 2. There were no significant differences in serum levels of calcium, phosphorous or their product. Interestingly, an adenoma disappeared in one patient from Group 1, and out of two adenomas, one disappeared from another patient in the same group. These results indicate that intravenous alfacalcidol once weekly is safe and effective in suppressing high parathyroid hormone in hemodialysis patients.     

Frequency spectra of the first heart sound and of the aortic component of the second heart sound in patients with degenerated porcine bioprosthetic valves

To determine the usefulness of the frequency of heart sounds in the assessment of porcine bioprosthetic valve degeneration, frequency spectra of phonocardiograms of the first heart sound and the aortic component of the second sound were analyzed in 31 patients with degenerated porcine bioprosthetic valves. Comparisons were made with 35 control patients whose valves were inserted 1 month or less. Among 23 patients with degenerated porcine bioprosthetic valves in the mitral position, the dominant frequency of the first heart sound was 95 ± 11 Hz, which exceeded the first sound in 18 controls (51 ± 3 Hz) (p < 0.01). The degenerated mitral porcine bioprosthetic valves of 14 patients showed calcification or fibrosis and the first heart sound in these patients was 115 ± 16 Hz, which exceeded that of control subjects (p < 0.001). The degenerated mitral porcine bioprosthetic valves of 9 patients showed torn leaflets only, and the first heart sound in these patients was 64 ± 9 Hz, which did not differ from that of control subjects. In the aortic position, 8 valves were degenerated and the aortic component of the second sound was 109 ± 12 Hz, which was higher than that in 17 control subjects (63 ± 4 Hz) (p < 0.001). Only 2 of these degenerated valves showed tears unaccompanied by calcific deposits or fibrosis, and the frequencies were comparable to that of control subjects. These observations indicate that the frequency of heart sounds in patients with degenerated porcine bioprosthetic valves becomes abnormally elevated when degeneration is accompanied by calcification or fibrosis, which causes the cusps to stiffen.     

Calcitonin pump improves nerve regeneration after transection injury and repair

Introduction: After nerve injury, excessive calcium impedes nerve regeneration. We previously showed that calcitonin improved nerve regeneration in crush injury. We aimed to validate the direct effect of calcitonin on transected and repaired nerve. Methods: Two rat groups (n = 8) underwent sciatic nerve transection followed by direct repair. In the calcitonin group, a calcitonin‐filled mini‐osmotic pump was implanted subcutaneously, with a catheter parallel to the repaired nerve. The control group underwent repair only, without a pump. Evaluation and comparison between the groups included: (1) compound muscle action potential recording of the extensor digitorum longus (EDL) muscle; (2) tetanic muscle force test of EDL; (3) nerve calcium concentration; and (4) nerve fiber count and calcified spot count. Results: The calcitonin pump group showed superior recovery. Conclusions: Calcitonin affects injured and repaired peripheral nerve directly. The calcitonin‐filled mini‐osmotic pump improved nerve functional recovery by accelerating calcium absorption from the repaired nerve. This finding has potential clinical applications. Muscle Nerve 51 : 229–234, 2015     

Comparison of alemtuzumab vs. antithymocyte globulin induction therapy in primary non‐sensitized renal transplant patients treated with rapid steroid withdrawal

Alemtuzumab and rabbit antithymocyte globulin (rATG) are commonly used for induction therapy in renal transplantation. This retrospective, single‐center, cohort study evaluated cumulative incidence of one‐yr biopsy‐proven acute rejection (BPAR) among 200 consecutive primary non‐sensitized kidney transplant recipients who received either alemtuzumab (n = 100) or rATG (n = 100) induction followed by rapid steroid taper, tacrolimus, and mycophenolate mofetil. Protocol biopsies, plasma and urine BK virus PCR, serum creatinine and iothalamate glomerular filtration rate (iGFR), were obtained at 1, 4, and 12 months from transplantation. The one‐yr BPAR rates were similar between the alemtuzumab and rATG groups; however, rejection Banff IA and higher was more common in the alemtuzumab arm (18% vs. 5%, p = 0.047). After adjusting for confounding variables, alemtuzumab was still associated with Banff IA and higher rejection (adjusted OR: 3.7, CI: 1.2–10.5, p = 0.02). Despite similar rates of BK viremia, more patients in the alemtuzumab arm developed BK nephropathy (16% vs. 3%, p = 0.046). One‐year iGFR (53.4 ± 20.2 vs. 71.9 ± 27.2 mL/min/1.73 m², p = 0.002) and three‐yr graft survival (89.5% vs. 95%, p = 0.05) were lower in the alemtuzumab group. In low immunological risk kidney transplant recipients on steroid‐free immunosuppression, alemtuzumab was associated with more severe rejection and BK nephropathy compared to rATG.     

Epidemiology of pediatric hand fractures presenting to a university hospital in Central Saudi Arabia

Objectives:

To investigate the epidemiology of pediatric hand fractures and to provide recommendations regarding prevention.

Methods:

Medical records and x-rays were retrospectively reviewed for age at the time of injury, gender, fracture pattern, place where the injury occurred, and mechanism of injury. The study was conducted at King Khalid University Hospital, Riyadh, Saudi Arabia between January 2005 and December 2011.

Results:

Of 361 cases reviewed, there were 291 (80.6%) male and 70 (19.4%) female patients. Most (46.2%) were in the age group of 13-18 years. For age group 1-4 years, the most common place of occurrence was at home (81.3%) and for the group 13-18 years, outdoors was the place of occurrence (64.7%). Females were mostly injured at home while males had similar distribution of indoor and outdoor injuries. The most common causes of fractures were: door slams in the 1-8 years age group; falls at home, in the 9-12 years age group; and both falls at home and sports in the oldest age group (13-18 years). The little finger ray are the most frequently injured part of the hand followed by the middle finger.

Conclusion:

Our series showed that most hand fractures in children occurred at home, which requires reevaluation of home settings. Implementation of safety measures during sports activities are relevant in the oldest age group.Childhood is the most important period in the development of healthy individuals. Among 1-18 year olds, 12% of 5.1 million global deaths from injuries in 2010 were due to unintentional injuries. For this pediatric age group, approximately 627,741 deaths were due to unintentional injuries in 2010.1 For unintentional injuries, falls rank second as a leading cause of mortality and account for 11% of worldwide, unintentional injury deaths.2 One study conducted at a hand center in England showed 663 hand fractures per 100,000 children aged 10-16 years.3 Injuries of the hand (including fractures) were among the most common injuries in the pediatric emergency departments in the United States of America.4 Severe hand fractures among children can lead to permanent loss of function and psychological trauma.5 Although there are several studies on pediatric upper limb fractures from different countries,6-26 little research has been conducted on primary prevention. Our literature search did not reveal any research on the prevention of hand fractures in Saudi children. A better understanding of the epidemiology of hand fractures in the pediatric age group is essential for effective preventive strategies development. In addition, there may be epidemiological variations in hand fractures among different populations, as some of these injuries depend on the environment, such as sports activities among local children. Various safety measures, such as compulsory use of protection during contact sports and implementation of playground safety, have been used in Western countries.3 We conducted a retrospective case series study to investigate the epidemiology of pediatric hand fractures among cases presenting to King Khalid University Hospital (KKUH) between 2005-2011. We aimed to describe the pattern of hand fractures in this age group and compare such fractures epidemiologically according to cause and place of injury. Finally, recommendations will be made regarding prevention.