Unusual presentation of perirenal lung metastases

Lung cancer is not commonly known to metastasise to the perirenal space, with only five such cases previously published. We present an unusual case of perirenal lung metastases manifesting as diffuse perinephric stranding which to our knowledge has not been described before.     

Breast cancer cell lines: friend or foe?

The majority of breast cancer research is conducted using established breast cancer cell lines as in vitro models. An alternative is to use cultures established from primary breast tumours. Here, we discuss the pros and cons of using both of these models in translational breast cancer research.     

Hypermobility of the first ray

Hypermobility of the first ray is one of the causative components in common foot problems (such as hallux valgus) with a large intermetatarsal angle and metatarsus primus varus. Although not always associated with hallux valgus, hypermobility is a predisposing factor for this deformity, especially in conjunction with extrinsic factors, such as disruption of the plantar first metatarsal cuneiform ligament and tendon-muscle imbalance. Hypermobility is also frequently found in adolescents with hallux valgus, especially when associated with a large intermetatarsal angle. Motion at the first metatarsocuneiform joint occurs in the sagittal and transverse planes. Most studies agree that greater than 4 degrees and greater than 8 degrees, respectively, constitutes excessive motion. Clinically, hypermobility is evaluated by determining sagittal motion (the grasping test) and transverse motion (the clinical squeeze test) and by identifying signs such as the presence of a dorsal bunion, intractable plantar keratosis beneath the second metatarsal head, and arthritis of the first and second metatarsocuneiform joint. Radiographically, hypermobility is evaluated by measurements from the modified Coleman block test (for sagittal motion) and the radiographic squeeze test (for transverse motion) and by the identification of signs, such as cortical hypertrophy along the medial border of the second metatarsal shaft, a cuneiform split, the presence of os intermetatarseum, and the round shape and increased medial slope of the first metatarsocuneiform joint. Usually, treatment for hypermobility of the first ray is operative, but surgery is contraindicated for patients less than 20 years of age (especially when the epiphysis is not closed) and for patients with generalized ligamentous laxity, short first metatarsal, and arthritis of the hallux MTP joint. The authors' surgical treatment of choice is arthrodesis of the tarsometatarsal joint (as part of the hallux valgus correction), exostectomy, capsulorraphy, and distal soft tissue release to correct and stabilize the first metatarsal at the apex of the deformity. The authors have found it unnecessary to include the base of the second metatarsal. The main complications associated with the Lapidus procedure and its modifications are nonunion, malunion, and dorsal elevation of the first metatarsal. Although radiographic nonunion is the most frequent complication, only 25% of the patients with this condition have associated clinical findings; the results have been defined as good or excellent in two series. These results closely equal those in rheumatoid or sedentary patients managed with newer, modified, less traumatic techniques that stabilize the first metatarsocuneiform joint with screws rather than with arthrodesis.     

Conservative alternatives to radical surgery for favorable rectal cancers

Selected cases of favorable rectal cancer can be treated with less than radical surgery. The literature demonstrates that excellent local control can be achieved using either local excision or carefully confined high dose radiation to treat the primary tumor site. Two treatments to the tumor site appear equally effective: local excision (usually a full thickness en bloc procedure) or low energy (50 kVp) endocavitary radiation. For many patients treated conservatively there is also a role for external beam radiation to the pelvis-this treats subclinical disease in regional nodes and around the tumor bed. The locoregional control for T1 lesions is excellent. For T2 lesions about 15% of patients can experience recurrence after conservative treatment. Close follow up of these patients is important, since local failures after conservative treatment are more amenable to salvage surgery than failures after standard radical surgery. Careful selection of cases, using endorectal ultrasound or MRI whenever possible, is important. The incidence of unexpected T3 disease or tumor at the margin of resection has been reported as high as 40% in series that do not utilize endorectal T staging.     

Paracetamol use, availability, and knowledge of toxicity among British and American adolescents

Paracetamol is the commonest agent employed in self poisoning, however it is not clear whether adolescents possess insight into the serious complications associated with its misuse. Using a one page questionnaire, the availability, usage, and knowledge of toxicity of paracetamol among 1147 American and British adolescents was assessed. Although 90% of all students recognised that paracetamol could kill, the great majority of students overestimated the lethal dose. In addition, while knowledge regarding side effects of paracetamol was poor the drug was widely available to, and used by, the study population. It is proposed that gross overestimation of the number of tablets required to kill, poor understanding of paracetamol side effects, and wide availability of the drug contribute to its frequent use in adolescent suicidal behaviour. The inclusion of some over-the-counter medications in school drug education programs in addition to tighter control of the availability of paracetamol may help reduce the problem of adolescent self poisoning.     

Screening for a raised rectal temperature in Africa

The main purpose of this study was to compare rectal and axillary temperature measurements in African children. Altogether 573 sick children were seen in an outpatient setting in rural West Africa. Rectal and axillary temperatures were measured and the parent or guardian was asked if they thought that the child had a raised body temperature. Normal ranges were defined from an age matched population of 203 healthy children. A raised axillary temperature predicted a raised rectal temperature with a sensitivity of 98% and a specificity of 88%. The parents' impression that their child had a fever was a less sensitive (89%) and less specific (59%) indicator of raised rectal temperature. A raised axillary temperature is a good screening test for a raised rectal temperature in African children.     

Right heart pressure determination by Doppler in infants with tricuspid regurgitation

Doppler and direct measurements of right ventricle to right atrial pressure drop were made during cardiac catheterisation on 28 occasions in 26 infants with congenital heart disease. Age was 10 days to 12 months (median 4.5 months), and weight was 3.1 to 9.0 kg (median 4.7 kg). We measured peak velocity of tricuspid regurgitation by continuous wave Doppler, and the pressure drop was calculated using the modified Bernoulli equation (delta p = 4v2). There was a high correlation (r = 0.95) between direct and Doppler measurements. Doppler values tended to underestimate the right ventricle to right atrial pressure drop, but this was not of clinical significance (mean 2 mm Hg). The 95% confidence interval for the Doppler velocity was -0.41 to +0.26 m/sec, and was consistent across the range of pressures studied. Variability between observers was tested, by two observers performing sequential paired examinations on 16 newborn babies with tricuspid regurgitation. The coefficient of repeatability was 6.3 mm Hg (95% confidence interval 4.7 to 9.5 mm Hg) or 0.26 m/sec (0.18 to 0.50 m/sec). This method of right ventricular pressure estimation, validated previously only in older children and adults, is a reproducible and accurate technique in infants with tricuspid regurgitation.     

Interpretation of random urinary catecholamines and their metabolites in neuroblastoma

O'Meara A, Tormey W, Fitz Gerald RJ, Fitzgibbon M, Kenny D. Interpretation of random urinary catecholamines and their metabolites in neuroblastoma. Acta Paediatr 1994;83:88–92. Stockholm. ISSN 0803–5253
This study reports experience in the estimation of urinary catecholamines (uCATs) and their metabolites in the diagnosis and follow-up of neuroblastoma. Random urine samples were assayed for dopamine, noradrenaline and adrenaline, together with their metabolites 4-hydroxy 3-methoxyman-delic acid (HMMA) and homovanillic acid (HVA), using HPLC with electrochemical detection. Twenty of 21 patients had elevation of one or more uCATs metabolites at diagnosis. Patients were monitored serially from diagnosis and, in those patients who had delayed resection of primary tumour (n=13), particular attention was paid to levels at the pre-surgical evaluation as an indicator of persistence of viable disease at the time of surgery; dopamine proved to be the most accurate indicator of persistent disease at this time. Five of these patients developed recurrent disease, 4 of whom had elevation of two or more uCATs metabolites at the time of relapse. Several conclusions can be drawn from this study: (a) results for HMMA, HVA and dopamine in random urine samples will detect all but the most biochemically immature or inert tumours; (b) dopamine may be the most reliable indicator of persistent disease and (c) noradrenaline and adrenaline measurements were of little benefit. As results are Expressed in relation to urinary creatinine, excretion of which may be affected by dietary protein and is therefore not constant, borderline results should be repeated.     

Liposomal amphotericin B in hepatic candidosis

A 4 year old girl treated with a standard chemotherapy protocol for acute lymphoblastic leukaemia developed hepatic candidosis during the consolidation phase. This relapsed after a prolonged course of amphotericin B and flucytosine. An eight week course of liposomal amphotericin produced a marked clinical improvement which was sustained for one year. A subsequent relapse was associated with transformation to myelodysplastic leukaemia.