Value of Routine Renal and Abdominal Ultrasonography in Patients Undergoing Prostatectomy

Objective: To evaluate the frequency of urological and non-urological abnormalities detected on routine renal and abdominal ultrasonography in patients undergoing surgery for benign prostatic hyperplasia (BPH) and to see if they affected the intended decision for prostate surgery. Methods: Medical records of 250 patients who underwent open or endoscopic surgery for BPH at Nishtar Hospital, Multan, Pakistan between May 2003 and December 2004 were studied. All patients had abdominal ultrasonography performed during routine preoperative workup. The frequency of urological and non-urological conditions detected on ultrasonography was calculated and the effect of these conditions on the intended decision for prostate surgery was observed. Results: In 102 patients (40.8%) urological and in 8 patients (3.2%) non-urological abnormalities were detected by ultrasonography. Urological conditions detected included uni/bilateral hydronephrosis (34 pts), vesical stones (34 pts), renal cysts (15 pts), renal stones (6 pts), small shrunken kidneys (2 pts), renal tumour (1 pt) and bladder carcinoma (1 pt). Non-urological conditions included gall stones (4 pts), liver abscess (2 pts), hydatid cyst (1 pt) and liver carcinoma (1 pt). Conclusion: The study shows that a sizeable number of patients (44%) had urological and non-urological conditions detected by renal and abdominal ultrasonography. Most patients had benign conditions but three of these patients had potentially life threatening conditions (renal, bladder and hepatic carcinoma) detected by sonography that were unrelated to the prostate. However, in only one patient (0.4%) with bladder carcinoma, surgery for prostate was postponed and bladder tumour was dealt with prior to transurethral resection of prostate (TURP). Various conditions detected by ultrasonography would have been missed if it had not been performed. As ultrasonography is a non-invasive, cost-effective and quite a safe imaging technique, in author’s opinion abdominal and renal tract evaluation by ultrasonography should be routinely performed in patients undergoing surgery for BPH.     

Developing a prognostic model for 90-day mortality after liver transplantation based on pretransplant recipient factors

BACKGROUND: Current statistical prognostic models for mortality after liver transplantation do not have good discriminatory ability. Furthermore, the methodology used to develop these models is often flawed. The objective of this paper is to develop a prognostic model for 90-day mortality after liver transplantation based on pretransplant recipient factors, employing a rigorous model development method. METHODS: We used data on 4,829 patient that were prospectively collected for the UK & Ireland Liver Transplant Audit. Switching regression was employed to impute missing values combined with a bootstrapping approach for variable selection. RESULTS: In all, 452 patients (9.4%) died within 90 days of their transplantation. The final prognostic model was well calibrated and discriminated moderately well between patients who did and who did not die (c-statistic 0.65, 95% CI [0.63, 0.68]). Although discrimination was not excellent overall, the results showed that those patients with a "low" chance of dying within 90 days of their transplant and those with a "high" chance of dying could be differentiated from patients with a "intermediate" chance. CONCLUSIONS: Our model can provide transplant candidates with predictions of their early posttransplantation prospects before any donor information is known, which is essential information for patients with end-stage liver disease for whom liver transplantation is a treatment option.     

Subcutaneous panniculitis-like T-cell lymphoma with hemophagocytic syndrome successfully treated with cyclosporin A

A 17-year-old girl previously in good health presented with a 2-month history of recurrent, high-grade fever; general fatigue; anorexia; a 10-kg weight loss; and multiple, painful, reddish skin lesions on the lower abdomen. Some lesions were ulcerated, with an oily yellowish brown discharge. A systemic review was unremarkable other than bleeding from the nose. Her medical and family histories were unremarkable. On examination, the patient was pale, jaundiced, and febrile (temperature of 39 degrees C). She had enlarged lymph nodes in the axillary and inguinal areas. There was moderate hepatosplenomegaly. Local skin examination revealed multiple erythematous, tender, and firm subcutaneous nodules of variable size (1-2 cm) on the lower abdomen. Some nodules were ulcerated, with oily yellowish brown discharge and overlying ecchymosis (Figures 1 and 2). Mucous membranes were free of lesions. Laboratory investigations showed pancytopenia, an elevated erythrocyte sedimentation rate (>80 mm/h), normal renal function tests, abnormal hepatic function tests (alanine aminotransferase 172 U/L, aspartate aminotransferase 229 U/L, alkaline phosphatase 725 U/L, and total bilirubin 100 mmol/L [normal range 0-18 mmol/L]), conjugated bilirubin 45 mmol/L (normal range 0-5 mmol/L), and high triglycerides 855 mg/dL (normal range 20-200 mg/dL). Prolonged prothrombin time, 26 seconds (normal range 13-16 seconds); prolonged activated partial thromboplastin time, 61 seconds (normal range 26-38 seconds); positive disseminated intravascular coagulation studies evidenced by low fibrinogen, 74 mg/dL (normal range 160-350 mg/dL); and positive fibrinogen degradation products were also noted. Throat, midstream urine, and blood culture results were negative. Serologic tests for syphilis, HIV, and hepatitis B and C viruses were negative. Epstein-Barr virus and cytomegalovirus serologic values revealed evidence of past infection. Tuberculin and Coombs tests were negative. The alpha1-antitrypsin level was normal. Antinuclear and anti-smith antibodies, rheumatoid factor, and cryoglobulins were negative. CT showed enlarged lymph nodes in the axillary and inguinal areas, bilateral small pleural effusion, moderate hepatosplenomegaly, severe fatty infiltration of the liver, and thickening of lower abdominal subcutaneous tissue. A liver biopsy showed steatohepatitis. Bone marrow aspirate and trephine were normal. A deep punch biopsy of a nodule from the right lower abdomen revealed lobular panniculitis with atypical lymphocytes and large macrophages with cytophagocytosis ("beanbag" cells) (Figures 3 and 4). Immunohistochemistry showed that these atypical cells were positive for CD3, CD8, granzyme B, and perforin, and negative for CD56. T-cell gene rearrangement studies on skin lesions revealed a monoclonal T-cell receptor (gamma-chain) gene rearrangement, supporting the diagnosis of subcutaneous panniculitis-like T-cell lymphoma. On presentation, the initial treatment included 6 U of fresh frozen plasma, 2 U of packed red blood cells, and 2 g IV fibrinogen for 3 consecutive days. The patient was started on prednisolone 60 mg orally once daily and cyclosporine A 5 mg/kg/d orally in two divided doses. The fever and other systemic symptoms and skin lesions resolved within 2 weeks after the treatment. The prednisolone dose was tapered gradually, and a maintenance dose of cyclosporine A was continued. The patient's condition remained in remission at 12-month follow-up; there was no evidence of clinical relapse.     

Accessory soleus muscle as a cause of congenital talipes equino varus. A case report

The authors report a case of congenital clubfoot in a one-year-old male child, in which an accessory soleus muscle was noted intraoperatively, running anteromedially to the Achilles tendon and with a distinct insertion on the postero-medial aspect of the calcaneus. Correction of the varus and equinus of the hindfoot could only be achieved after cutting the tendon of the accessory soleus muscle at its insertion on the calcaneus.     

Total aortic arch replacement for thoracic aneurysm involving an isolated left vertebral artery

We conducted 4 total aortic arch replacements in patients with an isolated left vertebral artery. In all 4, surgery was done using 4-branched arch grafts with moderately hypothermic selective cerebral perfusion and systemic circulatory arrest. All reconstructed isolated left vertebral arteries anastomosed to the native left subclavian artery or to the graft branch for this artery showed good patency. None of our patients had cerebral complications and all were discharged in good condition.     

Comparative in vivo toxicity of topical JP-8 jet fuel and its individual hydrocarbon components: identification of tridecane and tetradecane as key constituents responsible for dermal irritation

Despite widespread exposure to military jet fuels, there remains a knowledge gap concerning the actual toxic entities responsible for irritation observed after topical fuel exposure. The present studies with individual hydrocarbon (HC) constituents of JP-8 jet fuel shed light on this issue. To mimic occupational scenarios, JP-8, 8 aliphatic HC (nonane, decane, undecane, dodecane, tridecane, tetradecane, pentadecane, hexadecane) and 6 aromatic HC (ethyl benzene, o-xylene, trimethyl benzene, cyclohexyl benzene, naphthalene, dimethyl naphthalene) soaked cotton fabrics were topically exposed to pigs for 1 day and with repeated daily exposures for 4 days. Erythema, epidermal thickness, and epidermal cell layers were quantitated. No erythema was noted in 1-day in vivo HC exposures but significant erythema was observed in 4-day tridecane, tetradecane, pentadecane, and JP-8 exposed sites. The aromatic HCs did not produce any macroscopic lesions in 1 or 4 days of in vivo exposures. Morphological observations revealed slight intercellular and intracellular epidermal edema in 4-day exposures with the aliphatic HCs. Epidermal thickness and number of cell layers significantly increased (p < 0.05) in tridecane, tetradecane, pentadecane, and JP-8-treated sites. No significant differences were observed in the aromatic HC-exposed sites. Subcorneal microabscesses containing inflammatory cells were observed with most of the long-chain aliphatic HCs and JP-8 in 4-day exposures. Ultrastructural studies depicted that jet fuel HC-induced cleft formation within intercellular lipid lamellar bilayers of the stratum corneum. The degree of damage to the skin was proportional to the length of in vivo HC exposures. These data coupled with absorption and toxicity studies of jet fuel HC revealed that specific HCs (tridecane and tetradecane) might be the key constituents responsible for jet fuel-induced skin irritation.