Rectus sheath haematoma requiring laparotomy

Rectus sheath haematoma is a well‐documented but unusual cause of acute abdomen. Combination of clinical features and appropriate radiological investigations can make for a prompt diagnosis. Most authors advocate conservative management and it has been reported that patients were directly discharged from the emergency department. We report a case of rectus sheath haematoma which progressed with clinical deterioration and necessitated surgical intervention for clot evacuation. Causes, physical signs, radiological features and classification of rectus sheath haematoma are discussed. It may be necessary to continue close clinical monitoring after diagnosis of rectus sheath haematoma.     

A Study of Grid Artifacts Formation and Elimination in Computed Radiographic Images

Computed radiography (CR) has many advantages such as filmless operations, efficiency, and convenience. Furthermore, it is easier to integrate with the picture archiving and communication systems. Another important advantage is that CR images generally have a wider dynamic range than conventional screen film. Unfortunately, grid artifacts and moiré pattern artifacts may be present in CR images. These artifacts become a more serious problem when viewing CR images on a computer monitor when a clinic grade monitor is not available. Images produced using a grid with higher frequency or a Potter–Bucky grid (i.e., a moving grid, Bucky for short) can reduce occurrence but cannot guarantee elimination of these artifacts [CR & PACS (2000); Detrick F (2001), pp 7–8]. In this paper, the formation of the artifacts is studied. We show that the grid artifacts occur in a narrow band of frequency in the frequency domain. The frequency can be determined, accurately located, and thus removed from the frequency domain. When comparing the results obtained from the proposed method against the results obtained using previous computer methods, we show that our method can achieve better image quality.     

Hwa-byung. A community study of Korean Americans.

One hundred nine Korean American community subjects were interviewed regarding their experiences with hwa-byung (HB), a Korean folk illness label commonly used by Koreans with a myriad of physiological and psychological complaints. During these interviews, standard instruments were also used to assess their depressive and somatic symptoms. The results indicated that a relatively high proportion (12%) of the subjects labeled themselves as having suffered from HB. While no apparent sociodemographic differences were found between HB and non-HB subjects, significantly more HB subjects fulfilled the diagnosis of DSM-III major depression and also had previous diagnoses of depression. The HB subjects also had significantly higher scores for the total, depressive, and somatic subscales and 16 of the 20 individual items of the Center for Epidemiologic Studies-Depression Scale. These data confirm previous observations of substantial overlap between HB and DSM-III major depression among Koreans and Korean Americans, and suggest that HB may be a culturally patterned way of expression for Koreans experiencing major depression and related conditions. The clinical and theoretical implications of these findings are also discussed.     

The role of surgery in the management of unusual complications of transcatheter arterial embolization for hepatocellular carcinoma

Transcatheter arterial embolization (TAE) is accepted to be an effective treatment in both resectable and nonresectable hepatoma, which is very prevalent in Taiwan. Two hundred and twenty-five embolizations of TAE were performed in 137 patients in a 3-year period. Postembolization syndrome developed in the majority of patients. We analyzed these patients to study the nature and incidence of unusual complications and the surgical role in their managment. In our series, unusual complications, which were rarely reported in the literature, included 13 cases (5.8%) of gastroduodenal bleeding, 2 cases (0.9%) of duodenal perforation, 9 cases (4.0%) of acute pancreatitis with 1 case of gangrenous change, 24 cases (10.7%) of gallbladder infarction with 1 case of perforation, 4 cases (1.8%) of delayed formation of gallstones, 3 cases (1.3%) of hyperuricemia, and 2 cases (0.9%) of hepatoma rupture. Ischemic necrosis of the organs may be attributed to the inadvertent blockade of the gastroduodenal artery, gastric artery, cystic artery, and important collaterals. Inadequate superselectivity, the size of the tumor, regurgitation of embolus, anatomical variations, injury of vessel intima, or pseudoaneurysm formation resulting from previous embolization attempts made the avoidance of complications difficult with this technique. Most of the unusual complications could be managed by conservative treatment, but urgent operation was indicated in the cases of organ perforation. Elective operation was also needed for the delayed formation of gallstones with prominent symptoms. Awareness of the occurrence of these untoward sequelae makes us more careful in the evaluation and long-term follow-up of patients following TAE. Surgical intervention plays a selective but important role in the management of these unusual complications.

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Resumen La embolización arterial por cateterismo (EAC) es aceptada como tratamiento efectivo tanto en los hepatomas resecables como en los no resecables, tumores de alta incidencia en Taiwan. Doscientos veinticinco embolizaciones por EAC fueron realizadas en 137 pacientes en un período de 3 años; el síndrome de postembolización se desarrolló en la mayoría de los pacientes. Hemos analizado estos pacientes para estudiar la naturaleza y la incidencia de las complicaciones poco usuales y el papel de la cirugía en su manejo. Las complicaciones poco usuales observadas en nuestra serie, las cuales son raramente informadas en la literatura, incluyen 13 casos (5.8%) de hemorragia gastroduodenal, 2 casos (0.9%) de perforación duodenal, 9 casos (4.0%) de pancreatitis aguda con 1 caso de necrosis gangrenosa, 24 casos (10.7%) de infarto de la vesícula biliar con 1 caso de perforación, 4 casos (1.8%) de formación tardía de cálculos, 3 casos (1.3%) de hiperuricemia, y 2 casos (0.9%) de ruptura del hepatoma. La necrosis isquémica de los órganos puede ser atribuida a la oclusión inadvertida de la arteria gastroduodenal, la arteria gástrica, la arteria cística, y colaterales importantes. Superselectividad inadecuada, tamaño del tumor, regurgitación del émbolo, variaciones anatómicas, lesión de la íntima de la pared vascular, o formación de pseudoaneurismas como consecuencia de intentos previos de embolización hicieron difícil evitar las complicaciones con esta técnica. La mayoría de estas complicaciones poco usuales pudieron ser manejadas con tratamiento conservador, pero la operación de urgencia fue necesaria en casos de perforación de un órgano. La operación electiva también fue necesaria en los casos con formación tardía de cálculos biliares y síntomas prominentes. La toma de conciencia sobre la posibilidad de este tipo de secuelas nos ha hecho aún más cuidadosos en la evaluación y el seguimiento a largo plazo de los pacientes sometidos a EAC. La intervención quirúrgica juega un papel selectivo pero importante en el manejo de estas complicaciones poco usuales.

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Résumé L'embolisation par cathétérisme artériel occupe à Taiwan une place fiable dans le traitement de l'hépatome opérable ou de l'hépatome inopérable. Au cours d'une période de 3 ans 225 embolisations intra-artérielle ont été pratiquées chez 137 malades. Dans la majorité des cas l'embolisation a entrainé des phénomènes secondaires anormaux. Les auteurs font état de complications inhabituelles qui ont été rarement relatées dans la littérature: 13 cas (5.8%) d'hémorragie gastro-duodénale, 2 cas (0.9%) de perforation duodénale, 9 cas (4.0%) de pancréatite aigue dont une avec altérations gangréneuses, 24 cas (10.7%) d'infarcissement de la vésicule dont un avec perforation, 4 cas (1.8%) de formation retardée de calculs vésiculaires, 3 cas (1.3%) d'hyperuricémie, 2 cas (0.9%) de rupture de l'hématome. La nécrose ischémique des organes peut être attribuée à l'obstruction imprévue de l'artère gastro-duodénale, de l'artère gastrique, de l'artère cystique, et d'importantes collatérales. De multiples facteurs peuvent être invoqués pour expliquer les complications indésirables de l'embolisation: cathétérisme hypersélectif inadéquat, volume de la tumeur, régurgitation de l'embolus, blessure de l'intima artérielle, formation pseudoanévrysmale résultant de tentatives antérieures de cathétérisme artériel. La majorité d'entre elles peuvent être traitées médicalement mais l'intervention d'urgence s'impose quand une perforation viscérale est en cause. Il convient également de procéder à la cholécystectomie lorsque la lithiase vésiculaire entraîne des troubles importants. Connaître l'existence possible de ces accidents fâcheux doit rendre circonspect dans l'évaluation exacte de la valeur et le suivi à long terme de l'embolisation. De toute façon l'intervention chirurgicale est indispensable pour traiter certaines complications de l'embolisation.

     

Serum intact parathyroid hormone levels in elderly Chinese females with hip fracture

Summary Serum intact parathyroid hormone (PTH), 25 hydroxyvitamin D(25OHD), 1,25 dihydroxyvitamin D (1,25(OH)₂D), albumin, and ionized calcium were measured in 61 Chinese female patients with hip fracture and 61 control subjects. Hip fracture patients had low albumin, ionized calcium, and 250HD levels. Serum PTH and 1,25 (OH)₂D values were not different between the two groups. We conclude that although 250HD level in hip fracture patients is low, there is no evidence of secondary hyperparathyroidism, suggesting that the low 250HD levels may be a secondary phenomenon in response to the fracture.     

Immunology: High fecundity rates following in- vitro fertilization and embryo transfer in antiphospholipid antibody seropositive women treated with heparin and aspirin

This study was undertaken to explore whether intervention withheparin and aspirin (H/A) in selected patients undergoing in-vitrofertilization (TVF) and embryo transfer could improve fecundityrates. Specifically, it explored the possibility that womendiagnosed with organic pelvic disease who demonstrated antiphospholipidantibodies (APA) could benefit from H/A administration in asimilar manner to that used in patients with recurrent pregnancyloss. We used an enzyme–linked immunosorbent assay forsix different phospholipids to identify patients who expressedAPA before they underwent IVF/embryo transfer. This study wasconfined to the first IVF/embryo transfer cycle that followedassessment of APA status and accordingly, the number of IVF/embryotransfer cycles corresponds with the number of patients treated.APA seropositive patients were treated with aspirin, 81 mg orallyq.d., and heparin 5000 IU s.c. b.i.d., beginning on day 1 ofcontrolled ovarian stimulation. The endpoint for success wasa live birth or an ultrasound confirming fetal cardiac activity(a viable pregnancy). The prevalence of APA in patients diagnosedwith organic pelvic disease (53%) was much higher than in thosewithout female pathology (14%). The administration of H/A toAPA seropositive patients significantly (P < 0.05) improvedthe viable pregnancy rate (49%) compared to the untreated APAseropositive group (16%). The viable pregnancy rate for APAseropositive women treated with H/A was also significantly (P< 0.001) higher than for untreated APA seronegative patients(27%). We conclude that all women undergoing IVF/embryo transfershould be tested for APA prior to initiating ovarian stimulation,and those with APA seropositivity should be treated with H/A.     

D2-40 immunohistochemistry in the differential diagnosis of seminoma and embryonal carcinoma: a comparative immunohistochemical study with KIT (CD117) and CD30.

The distinction between seminoma and embryonal carcinoma based on morphology alone can sometimes be problematic, requiring the use of immunohistochemistry to facilitate diagnosis. D2-40 is a monoclonal antibody that reacts with an oncofetal antigen expressed by fetal germ cells and testicular germ cell tumors. The diagnostic value of D2-40 immunohistochemistry in distinguishing seminoma from embryonal carcinoma has not been determined. D2-40 immunoreactivity was evaluated in a series of testicular germ cell tumors and compared with that of KIT (CD117) and CD30, to assess the relative utility of this marker in discriminating between seminoma and embryonal carcinoma. Forty testicular germ cell neoplasms were examined, which included 19 seminomas, three embryonal carcinomas, three teratomas, one yolk sac tumor, and 14 mixed germ cell tumors. The 14 cases of mixed germ cell tumors contained components of seminoma (n=7), embryonal carcinoma (n=11), teratoma (n=10), yolk sac tumor (n=2), and choriocarcinoma (n=1). All cases of pure seminoma and the seminomatous components of mixed germ cell tumors exhibited positive immunoreactivity for D2-40. Focal positivity for D2-40 was also observed in 29% of the embryonal carcinoma samples. D2-40 immunoreactivity in seminomas was characterized by diffuse membrane staining, whereas for embryonal carcinomas, staining was focal and distributed along the apical surfaces of the neoplastic cells. Immunohistochemical staining for KIT was observed in 92% of the seminoma samples and in none of the embryonal carcinomas. Conversely, CD30 expression was identified in 93% of the embryonal carcinoma samples and in none of the seminomas. Other germ cell components showed no immunoreactivity for D2-40, KIT, or CD30. KIT and CD30 are effective immunohistochemical markers in separating seminoma from embryonal carcinoma. Although a highly sensitive marker for seminomas, D2-40 positivity was also observed in a subset of embryonal carcinomas, thus limiting the utility of this antibody for discriminating between these two malignancies.     

B-cell and T-regulatory cell dysfunction in six Chinese children with hypogammaglobulinaemia

We report six Chinese boys with hypogammaglobulinaemia. All but one had very low or undetectable circulating B-lymphocytes, two had reversed CD4/CD8 ratios (in one of whom this later became normal), one had reduced lymphocyte proliferative responses to concanavalin A and pokeweed mitogen and three had deficient responses to OKT3. Generation of antibody-secreting cells in response to pokeweed mitogen was markedly defective in all patients. Co-cultures of purified lymphocyte subsets from the patients with those of normal donors revealed that in addition to B-cell deficiency seen in all patients, two had T-helper cell deficiency and two had T-suppressor cell hyperactivity. One of the latter patients was treated with cimetidine in an attempt to ablate histamine type 2 receptor-bearing suppressor cells: the absolute number of such cells was temporarily reduced but there was no concurrent correction of the functional hyperactivity. These studies point to the variable nature of T-regulatory cell deficiencies in hypogammaglobulinaemia.     

Single-dose pharmacokinetics of paracetamol and its conjugates in Chinese non-insulin-dependent diabetic patients with renal impairment

Objective: A single oral dose of paracetamol (20 mg · kg⁻¹) was given to 38 Chinese patients with non-insulin-dependent diabetes mellitus (NIDDM) who had either normal renal function or varying degrees of renal impairment, with creatinine clearances ranging from 4 to 123 ml · min⁻¹ · 1.73 m⁻². The plasma and urinary concentrations of paracetamol and its major metabolites were measured by high-performance liquid chromatography (HPLC). Results: The absorption and elimination of paracetamol were unaffected by renal impairment. However, the area under the plasma concentration time curve and the elimination half-life of paracetamol metabolites increased significantly with worsening renal insufficiency. Mean renal clearances of paracetamol and its conjugates were significantly reduced in these subjects. There was no evidence of altered metabolic activation with renal impairment. Conclusion: The results demonstrate that paracetamol disposition is minimally affected by diabetic nephropathy; however, extensive accumulation of conjugates may occur. Received: 2 September 1996 / Accepted in revised form: 11 December 1996     

Unifocal origin of advanced human epithelial ovarian cancers.

Ovarian cancers are often diagnosed at a late stage, after the cancer cells have spread to extraovarian sites. Failure to diagnose these tumors earlier may reflect the lack of symptoms and the need for a sensitive, reliable screening test. Alternatively, this can be explained by the hypothesis that some of the extraovarian tumor implants do not represent metastatic spread from the primary cancer but instead are multiple primary tumors developing simultaneously in the peritoneal epithelium. If this is the case, some patients with advanced ovarian cancer may never have had a stage I disease, making early detection theoretically impossible. In this study, we examined the mutational pattern of the p53 gene in 9 patients with epithelial ovarian cancers using tissue collected from different sites within the same patient. In all 9 cases, the mutational pattern of the p53 gene was identical in cancer cells from different sites within the same patient, strongly suggesting that these ovarian tumors were of unifocal origin and that cancer tissues collected from different sites are derived from a single origin.