Evaluation of the clinical signs of anterior cruciate ligament and meniscal injuries

Background:

The diagnostic accuracy of anterior drawer (AD) sign, Lachman test and the pivot shift test for anterior cruciate ligament injury and McMurray test for medial and lateral meniscus is varied with sensitivity and specificity ranging from 2 to 100%. Generally, it is accepted that the pivot shift test is the most specific test to diagnose anterior cruciate ligament (ACL) tears and that the Lachman test is more sensitive than AD sign. This study was undertaken to calculate the sensitivity, specificity, positive predictive value, negative predictive value, and efficiency for the above-mentioned diagnostic tests.

Materials and Methods:

Twenty-eight male patients with clinical ACL injury were examined in the outpatient department and under anaesthesia, the findings were compared with arthroscopy.

Result:

The sensitivity and specificity for the Lachman test, AD sign and pivot shift test performed in the outpatient setting are 78.6 and 100%, 89.3 and 100%, and 75 and 100%, respectively. The sensitivity and specificity for the Lachman test, AD sign, and pivot shift test performed under anesthesia are 92.9 and 100%, 92.9 and 100%, and 100 and 100%, respectively. The sensitivity and specificity of the McMurray test for medial and lateral meniscus were 35.7 and 85.7% and 22.2 and 100%, respectively.

Conclusion:

The Lachman test, AD sign and pivot shift test are highly specific tests to diagnose ACL laxity in a non-acute setting; pivot shift test under anesthesia is the most sensitive and specific test for diagnosing ACL laxity in a non-acute setting and the McMurray test is not a sensitive test to diagnose meniscal injury in the presence of ACL injury.     

Laparoscopic repair of recurrent groin hernia: results of a prospective study

Background  Recurrences continue to be seen after repair of inguinal hernias. The repair of these recurrent hernias is a more complex and demanding procedure, with a high re-recurrence rate. Definite advantage has been demonstrated with endoscopic repair of these hernias. Methods  The results for this prospective study from January 2003 to December 2006 were evaluated after laparoscopic repair of 65 recurrent hernias in 61 patients. The patients were followed up for 1 year. Longer follow-up evaluation was performed for the patients who underwent surgery in the initial 3 years. Results  In this study, 37 recurrent hernias were managed using the transabdominal preperitoneal technique (TAPP) technique and 28 using the totally extraperitoneal (TEP) technique. There was no conversion and no cases of postoperative wound infection. Of the 12 metachronous hernias repaired simultaneously, 3 were occult. Seroma developed in five patients. At a follow-up assessment after 1 year, one patient had groin pain, and there was one re-recurrence. A longer follow-up period with a mean of 35.11 months failed to show any new re-recurrence. Conclusions  Laparoscopic repair of recurrent inguinal hernia is safe and effective. The morbidity and recurrence rates for the procedure are as low as for laparoscopic repair of primary hernias. Laparoscopic repair should be the gold standard for these hernias.     

Abdominal Cocoon: Clinical Presentation, Diagnosis, and Management

A 15-year-old girl presented with features suggestive of sub-acute intestinal obstruction (SAIO) with a palpable abdominal lump. Contrast-enhanced computed tomogram (CECT) abdomen revealed congregated small gut loops confined to a single area and encased in a thick membrane suggestive of abdominal cocoon. On laparotomy, a thick white membrane was found encasing most of the small gut. The cocoon was excised releasing the encased small bowel. The patient was relieved of her symptoms following surgery. Histopathology of excised cocoon membrane revealed granulomatous inflammation consistent with tuberculosis. The patient was discharged on ninth postoperative day with advice to take anti-tuberculosis drugs for 6 months. The possibility of abdominal cocoon should be considered in patients with SAIO and abdominal lump. Abdominal cocoon being a rare condition, CECT is useful in clinching the diagnosis and planning elective surgery in experienced hands.     

Comparative Analysis of Outcomes in Living and Deceased Donor Liver Transplants for Primary Sclerosing Cholangitis

Introduction  Primary sclerosing cholangitits (PSC) is a progressive fibrosing cholangiopathy eventually leading to end-stage liver disease (ESLD). While literature for deceased donor liver transplantation (DDLT) for PSC abounds, only a few reports describe live donor liver transplant (LDLT) in the setting of PSC. We present a single-center experience on survival outcomes and disease recurrence for LDLT and DDLT for ESLD secondary to PSC. Aim  The aim of this study was to analyze survival outcomes and disease recurrence for LDLT and DDLT for ESLD secondary to PSC. Patients and Methods  A retrospective review of 58 primary liver transplants for PSC-associated ESLD, performed between May 1995 and January 2007, was done. Patients were divided into two groups based on donor status. Group 1 (n = 14) patients received grafts from living donors, while group 2 (n = 44) patients received grafts from deceased donors. An analysis of survival outcomes and disease recurrence was performed. Recurrence was confirmed based on radiological and histological criteria. Results  Recurrence of PSC was observed in four patients in LDLT group and seven in DDLT group. Retransplantation was required in one patient in LDLT group and nine patients in DDLT group. One patient (7%) among LDLT and six patients (14%) among DDLT died. The difference in patient and graft survival was not statistically significant between the two groups (patient survival, p = 0.60; graft survival, p = 0.24). Conclusion  This study demonstrates equivalent survival outcomes between LDLT and DDLT for PSC; however, the rate of recurrence may be higher in patients undergoing LDLT.     

The Val432Leu polymorphism of the CYP1B1 gene is associated with differences in estrogen metabolism and bone density

Polymorphisms of the CYP450 genes that encode for the enzymes that metabolize estrogen are linked to hormone-related cancers. We investigated the impact of two polymorphisms of the CYP1B1 gene previously reported to be associated with hormone-related disorders on estrogen metabolism and bone mineral density (BMD), another hormone-dependent condition, in women from different ethnic backgrounds. Four hundred sixty-eight postmenopausal Caucasian women, 220 from St. Louis, MO, USA (mean age=63.5+/-0.53 years) and 248 from Palermo, Italy (mean age=72.9+/-0.44 years) participated in the study. Measurements of urinary estrogen metabolites by enzyme-linked immunoassay, serum estradiol by ultrasensitive radioimmnunoassay, and serum sex hormone-binding globulin by immunoradiometric assay were performed only in the American women, while BMD by dual energy X-ray absorptiometry and genotyping by pyrosequencing were performed in both American and Italian women. Differences in the levels of metabolites, free estradiol index and BMD were analyzed by analysis of covariance. Analysis among the American participants for the Valine432Leucine polymorphism showed that, compared to women with the Val/Val genotype, women with the Leu allele (Val/Leu and Leu/Leu) had significantly higher log-transformed values of total urinary estrogen metabolite (ng/mg-creatinine) levels (1.23+/-0.04, 1.35+/-0.02, and 1.34+/-0.03; p=0.03), and significantly lower BMD (gm/cm(2)) in the lumbar spine (1.009+/-0.02, 0.955+/-0.01 and 0.931+/-0.02; p=0.03) and the femoral neck (0.748+/-0.02, 0.717+/-0.01 and 0.693+/-001, p=0.03) for the Val/Val, Val/Leu and Leu/Leu genotypes respectively. There were no significant differences in the urinary metabolites and BMD in the different genotypes for the Alanine119Serine polymorphism among the American women. Meanwhile, a separate analysis among the Italian women revealed no significant differences in BMD among the different genotypes for the two polymorphisms investigated. In conclusion, women with the Leu allele for the CYP1B1 Val432polymorphism have increased estrogen catabolism, as indicated by higher urinary estrogen metabolites, compared to those with Val/Val genotype. This may lead to relative hypoestrogenism and lower BMD in the lumbar spine and femoral neck in these women. Our data suggest that through its effect on the rate of estrogen catabolism, the Val432Leu polymorphism of the CYP1B1 gene may represent as a possible genetic risk factor for osteoporosis in American women.     

Bone metastases as the initial presentation of carcinoma of gall bladder: a rarity

Distant metastases are rare form of presentation of carcinoma gall bladder. Bony pain as initial presentation is quite unusual. A 50-year-old woman presented with the pain in right shoulder. Investigation showed metastatic adenocarcinoma in the head of humerus and the primary was found in the gall bladder. She received local radiotherapy for bone metastases and undergoing systemic chemotherapy. Carcinoma gall bladder is a common abdominal malignancy, mostly presenting in advanced stage with abdominal symptoms and obstructive jaundice. In presence of metastasis, the management is palliative and role of chemotherapy is limited for palliation symptoms.     

Superior mesenteric artery syndrome

Opinion statement Superior mesenteric artery (SMA) syndrome (also known as Wilkie’s syndrome, chronic duodenal ileus, or cast syndrome) occurs when the third portion of the duodenum is compressed between the SMA and the aorta. The major risk factors for development of SMA syndrome are rapid weight loss and surgical correction of spinal deformities. The clinical presentation of SMA syndrome is variable and nonspecific, including nausea, vomiting, abdominal pain, and weight loss. The diagnosis is based on radiographic findings of duodenal compression by the SMA. The treatment of SMA syndrome is aimed at the precipitating factor, which usually is related to weight loss. Therefore, conservative therapy with nutritional supplementation is the initial approach, and surgery is reserved for those who do not respond to hyperalimentation.     

A case of acute infectious mononucleosis presenting with very high ferritin

Hepatitis is an important but uncommon manifestation of acute Epstein Barr infection. Infectious mononucleosis is usually a disease of young adults. We report a case of infectious mononucleosis in a 72-year old jaundiced gentleman with ferritin level of 2438 that normalised on clinical improvement.