Lace-like enhancement pattern of osteosarcoma of rib and liver metastasis in CT scans

The rib is an uncommon site of osteosarcoma. With the use of adjuvant chemotherapy and aggressive surgical resection of the metastatic pulmonary lesions, extrapulmonary metastases are becoming more clinically evident. Primary rib osteosarcoma with extrapulmonary metastasis is exceedingly rare. A case is reported, showing that the pattern of metastasis of rib osteosarcoma is similar to that of primary bone osteosarcoma. The liver metastasis occurred after resection of the metastatic pulmonary lesions. A CT scan of the primary rib lesion and liver metastasis both showed a lace-like enhancement pattern, its histological appearance corresponding with neoplastic osteoid. With the increasing use of CT abdomen for localization of extrapulmonary metastases, lace-like enhancement may be seen more readily in the future.     

The cytokine response to physical activity and training

Cytokines are soluble glycoproteins that are produced by and mediate communication between and within immune and nonimmune cells, organs and organ systems throughout the body. Pro- and anti-inflammatory mediators constitute the inflammatory cytokines, which are modulated by various stimuli, including physical activity, trauma and infection. Physical activity affects local and systemic cytokine production at different levels, often exhibiting striking similarity to the cytokine response to trauma and infection. The present review examines the cytokine response to short term exercise stress, with an emphasis on the balance between pro- and anti-inflammatory mechanisms and modulation of both innate and specific immune parameters through cytokine regulation. The effects of long term exercise on cytokine responses and the possible impact on various facets of the immune system are also discussed, with reference to both cross-sectional and longitudinal studies of exercise training. Finally, the validity of using exercise as a model for trauma and sepsis is scruti- nised in the light of physiological changes, symptomatology and outcome, and limitations of the model are addressed. Further studies, examining the effect of exercise, trauma and infection on novel cytokines and cytokine systems are needed to elucidate the significance of cytokine regulation by physical activity and, more importantly, to clarify the health implications of short and long term physical activity with respect to overall immune function and resistance to infection.     

Acute myeloid leukemia relapsing as gynecomastia

Granulocytic sarcoma (GS) is an increasingly common relapse feature of acute myeloid leukemia (AML), late in the disease course or post bone marrow transplantation (BMT). Any solid organ can be affected, and there have been a number of reports of GS in breast tissue in female patients. We present a unique case of GS in a male AML patient, presenting as painless gynecomastia immediately before BMT at advanced disease. Aberrant expression of CD56 was found in the relapsed GS tissue but not in the original AML clone. Twelve months after allogeneic BMT, leukemia relapsed again in the same breast, with normal marrow morphology and full donor chimerism. The lesion failed to respond to donor lymphocyte infusion, chemotherapy and radiotherapy, and disseminated to other subcutaneous tissues.     

Treatment outcome of rhabdomyosarcoma in Hong Kong Chinese children.

OBJECTIVES: To review the treatment outcome of rhabdomyosarcoma in Hong Kong Chinese children. DESIGN: Retrospective review. SETTING: University teaching hospital, Hong Kong. PATIENTS: Consecutive cases of rhabdomyosarcoma diagnosed and treated by the Department of Paediatrics and Adolescent Medicine of Queen Mary Hospital between 1989 and 2005. Each patient was staged and treated according to the Intergroup Rhabdomyosarcoma Study guidelines. MAIN OUTCOME MEASURES: Overall and event-free survival rates, and toxicity data. RESULTS: Of 19 patients (8 males and 11 females), 14 (74%) were younger than 10 years old. The median age at diagnosis was 6 (range, 0.5-17) years. Primary sites of rhabdomyosarcoma included: the head and neck (n=8; 6 classified as cranial parameningeal), genitourinary (3), extremity (3), pelvis (3), and trunk (2). Thirteen (68%) had embryonal and six (32%) had alveolar histology. Two, 2, 9, and 6 were classified as belonging to Intergroup Rhabdomyosarcoma Study groups 1, 2, 3, and 4, respectively. Respective 5-year overall and event-free survival rates of the entire cohort were 49% (95% confidence interval, 26-73%) and 32% (10-55%), with a median follow-up of 3.4 (range, 0.2-16.7) years. In non-metastatic cases (Intergroup Rhabdomyosarcoma Study groups 1-3), the 5-year overall survival rate was 66% (95% confidence interval, 39-93%) and in metastatic cases (group 4) it was 17% (0-46%). The 5-year overall survival rate for patients aged less than 10 years was 60% (95% confidence interval, 33-87%) compared to 20% (0-55%) in those aged 10 years and over. Significant treatment-related toxicities including myelosuppression, infections, peripheral neuropathy, and second cancers were encountered. CONCLUSIONS: Treatment outcome of rhabdomyosarcoma in this cohort of Chinese children was less favourable than that reported in international studies. Whilst the main reason could have been related to the high proportion of metastatic cases, also non-metastatic cases faired worse. Improved outcomes may be achieved by advances in multidisciplinary (paediatric oncology, pathology, radiotherapy, and surgery) management and supportive care.     

Levator avulsion and grading of pelvic floor muscle strength

In a retrospective study investigating the relationship between levator avulsion and clinical grading of levator ani muscle strength, we analyzed the 3D/4D translabial ultrasound and digital assessment data of 1,112 women seen in a tertiary Urogynecological clinic. Levator avulsion was diagnosed whenever the examiner was unable to palpate the insertion of the pubovisceral muscle on the inferior pubic ramus and/or whenever a discontinuity between bone and muscle was detected on ultrasound. For clinical grading of levator muscle strength, we used the modified Oxford grading. Avulsion defects were found in 252 women (23%), and this was associated with a highly significant reduction in the overall Oxford grading (2.07 vs 2.81, P < 0.001). The prevalence of avulsion increased depending on the side differences in the modified Oxford grading: from 16% when there was no difference to 76% when the side difference was 1.5 or higher (P < 0.001). Avulsion of the puborectalis muscle seems to have a marked effect on pelvic floor muscle strength, which may help in diagnosing trauma.     

New imaging method for assessing pelvic floor biomechanics.

OBJECTIVES: The investigation of female pelvic floor biomechanics is attracting attention due to its importance in pelvic floor dysfunction and childbirth. To date, there are no established means of assessing pelvic floor elasticity. We propose the use of translabial ultrasound to estimate strain, one element of pubovisceral muscle elasticity. METHODS: Ultrasound datasets of 98 women seen at a tertiary urogynecology clinic were reviewed using proprietary software. Data were processed to estimate muscle fiber strain during Valsalva and contraction by measuring hiatal circumference and deducting bony arc length. Clinical assessment included levator palpation during maximal contraction (modified Oxford grading scale) and at rest, with tone recorded on a new six-point scale. Analysis of imaging data was performed without knowledge of clinical data. RESULTS: Mean age was 52.2 (range, 19-87) years and mean parity was 2.4 (range, 0-8). Mean (SD) hiatal area during contraction, rest and Valsalva was 15.4 (3.8) cm(2), 18.9 (5.0) cm(2) and 27.3 (8.9) cm(2), respectively. There was a moderate association between strain during contraction and Oxford grade (r = 0.439, P < 0.0001), and a weak but significant association between strain during Valsalva and resting tone (r = - 0.224, P = 0.033). CONCLUSIONS: Translabial ultrasound can be used to measure strain, a component of pubovisceral muscle elasticity, and we have validated the technique against clinical assessment. Pubovisceral strain during contraction correlates positively with Oxford grade. Pubovisceral strain during Valsalva correlates negatively with resting tone grade. This new non-invasive ultrasound technique may be of value for assessing patients with pelvic floor dysfunction.     

The quantification of levator muscle resting tone by digital assessment

The biomechanical properties of the puborectalis muscle are likely to be important for pelvic organ support. However, neither elasticity nor its clinical correlate, muscle resting tone, have received much attention to date. We therefore conducted a prospective study to test a newly developed resting tone scale for validity and reproducibility. Ninety-eight patients underwent a physical examination including prolapse staging and palpation of the levator ani. They were also assessed by 4D translabial ultrasound for levator hiatal dimensions and prolapse assessment. Resting tone was negatively associated with anterior and posterior compartment prolapse. An independent test–retest series yielded a weighted kappa of 0.55 (CI 0.44–0.66), implying “moderate” repeatability. Resting tone of the puborectalis muscle can be determined by digital palpation. It is moderately repeatable and associated with pelvic organ prolapse. Palpation of resting tone may be a useful new tool for assessing women with pelvic floor dysfunction.     

Warfarin-acetaminophen drug interaction revisited.

Physicians and pharmacists routinely advise patients receiving warfarin to take acetaminophen for pain or fever because of its relative safety; however, a recent study questioned the safety of such practice. A comprehensive search of MEDLINE and IPA for human studies and case reports from 1966-1999 revealed evidence that acetaminophen may potentiate the effect of warfarin by a mechanism that has yet to be elucidated. Due to lack of a safer alternative, acetaminophen still should be the analgesic and antipyretic of choice in patients taking warfarin, as long as excessive amounts and prolonged administration (> 1.3 g acetaminophen/day for > 2 wks) are avoided. With the high degree of interpatient variability and the unpredictability of various drug-drug interactions with warfarin, close and frequent monitoring of international normalized ratios is the key for safe oral anticoagulation therapy.     

Incidence, causes and mechanism of hypercalcaemia in a hospital population in Hong Kong

To determine the incidence and causes of hypercalcaemia in a hospital population in Hong Kong, all 29,107 samples received in the laboratory in one year were analysed for plasma calcium and albumin, and samples with a plasma calcium concentration adjusted for albumin greater than 2.55 mmol/l were investigated. Plasma calcium greater than 2.55 mmol/l was found in 462 patients. Repeat samples were received from 302 of these and hypercalcaemia was confirmed in 183. The main causes of hypercalcaemia were malignancy (72.1 per cent), tuberculosis (6.0 per cent), and primary hyperparathyroidism (5.5 per cent). In the malignant hypercalcaemia group, carcinoma of lung was the most common (31.8 per cent) and carcinoma of breast was uncommon (3.0 per cent). Secondary deposits in bone were detected in 35 of the 122 solid tumours. In order to identify the mechanism of hypercalcaemia the contributions of renal tubular reabsorption and increased bone resorption to the plasma calcium concentration were calculated. Increased tubular reabsorption was the main contributor to hypercalcaemia in primary hyperparathyroidism and carcinoma of liver (none of whom had bony metastases) and it contributed significantly to hypercalcaemia in carcinoma of lung without bony metastases and carcinoma of oesophagus. We conclude that in Hong Kong (a) primary hyperparathyroidism is uncommon, (b) tuberculosis is an important cause and (c) humoral factors may be responsible for a relatively high proportion of cases of malignant hypercalcaemia.