Primary anorectal malignant melanoma: A clinical, radiology and pathology correlation.

INTRODUCTION: Primary gastrointestinal melanomas are mucosal malignancies that arise from melanocytes in the oropharynx, rectum, and anus. Anorectal malignant melanoma (ARMM) are exceedingly rare, accounting for less than 1% of all melanomas, 0.1% of all rectal malignancies and 4% of anal malignancies. Diagnosis is frequently delayed as these lesions are often mistaken for haemorrhoids. Histological evaluation with special immunohistochemical stains is often necessary for definitive diagnosis. Due to the aggressive nature, 61% of patients with ARMM would already have lymph node involvement or distant metastases, by the time of diagnosis. Prognosis is usually poor with 5-year survival rate of <20%. We report a case of metastatic ARMM in an elderly lady who presented with symptoms and signs mimicking a haemorrhoid. CASE REPORT: A 69-year-old lady presented with one year history of intermittent rectal bleed and an anorectal mass that was initially treated as haemorrhoid. Colonoscopy showed a hyperpigmented mass in the anorectal region which was confirmed as malignant melanoma on histopathological examination. Imaging with CT and MRI demonstrated locally advanced tumour with distant metastases to the liver and lung. Patient was referred for palliative management. CONCLUSION: ARMM is a rare malignancy and often presented with non-specific clinical signs. Diagnosis is frequently delayed without high index of suspicion. MRI pelvis is the imaging of choice to assess local extent of disease. Histologic evaluation with special immunohistochemical stains is often necessary for definitive diagnosis. Prognosis is poor despite surgical and chemotherapeutic interventions.

Fatal spontaneous rupture of splenic artery aneurysm in third trimester pregnancy.

INTRODUCTION: Unforeseen emergency in late pregnancy can be catastrophic and cause unexpected maternal and foetal demise. Moreover, lack of awareness and failure of prompt treatment raise mortality rate. Such fatalities warrant a forensic autopsy as it may raise redundant medico-legal concerns. CASE REPORT: We report a case that revealed significant intra-abdominal haemorrhage at autopsy. The source of haemorrhage was at the spleen hilum and histology established rupture of splenic artery aneurysm. There was no associated obstetric cause found. CONCLUSION: Knowledge of spontaneous rupture of splenic artery aneurysm in late pregnancy is essential for monitoring maternal and foetal, morbidity and mortality. However, in the eventuality of death a comprehensive forensic autopsy is the only investigation to recognise such calamity and clear clinical confusion.

Acute injuries in cross-country and downhill off-road bicycle racing.

This study was conducted to investigate injury patterns at three major off-road bicycle races in the Western United States in 1995. All cyclists forced out of the cross-country (CC) and downhill (DH) competitions due to injury were examined and interviewed. The overall injury rates were 0.49% (20/4074) for the CC and 0.51% (11/2158) for the DH event. In the CC there were 0.37 injured cyclists for every 100 h of racing time versus 4.34 injured cyclists/100 h in the DH (P = 0.01). Injury rates in the CC were higher for women than for men (1.05% vs 0.40%, P = 0.04; 0.75/100 h vs 0.31/100 h, P = 0.01). Injured CC cyclists who fell forward over their handlebars had higher mean injury severity scores (3.0 vs 1.3, P = 0.01) and required more emergency room visits (6/100 vs 1/10, P = 0.02) than cyclists who fell off their bicycles (5/6 vs 5/14, P = 0.05) and were taken to the hospital (4/6 vs 3/14, P = 0.05) more often than men. These data suggest that 1) the risk of being injured during a race is similar in the CC And DH events, 2) the long-term risk may be greater to DH racers than to CC competitors, 3) the severity of injury is greater when a CC cyclists falls forward off the bicycle, and 4) women CC competitors are more likely to fall forward off their bicycles and be injured than men.

Acute injuries in off-road bicycle racing.

A descriptive study was conducted to investigate injuries sustained at a major off-road bicycling race at Mammoth Mountain, California, July 6 to 10, 1994. A total of 4027 individual starts in five events during the race were reported. Overall, the total number of competitors in the 5 events was 3624, with some cyclists participating in multiple events. Injuries were considered significant if they occurred during competition and prevented the rider from completing the event. Sixteen cyclists had injuries that met these criteria for an overall injury rate of 0.40%. These 16 cyclists had 44 injuries. Abrasions were the most common injury, followed by contusions, lacerations, fractures, and concussions. The mean injury severity score was 3.0 (range, 1 to 5) with 81.2% of the injuries resulting from cyclists going downhill. Injuries were more severe when the riders were thrown from the bicycles (P = 0.03). We observed different mechanisms of injury in various events, suggesting that the risk factors for sustaining a traumatic injury may vary according to the type of competition involved.

Lymphoepithelioma-like carcinoma of oral cavity: report of three cases and literature review.

Lymphoepithelioma-like carcinoma is a rare tumour in the oral cavity and is characterized histologically by non-keratinizing, undifferentiated squamous cell carcinoma with lymphocytic infiltration. Three consecutive cases of intraoral lymphoepithelioma-like carcinoma are reported. A review of the literature reveals a similar biological behaviour to that of nasopharyngeal lymphoepithelioma: a high incidence of cervical nodal spread and remarkable radiosensitivity. Chemotherapy should be considered when nodal or distant metastases are present. The association of the Epstein-Barr virus with this tumour remains unclear but our experience suggests a positive correlation in Chinese individuals.

Intra-operative blood loss and operating time in orthognathic surgery using induced hypotensive general anaesthesia: prospective study.

We investigated the average operating time and extent of intra-operative blood loss in orthognathic surgeries performed using induced hypotensive general anaesthesia, with the intention of devising a practical guideline for blood unit preparation for these procedures. We prospectively studied 32 Chinese patients undergoing surgery to correct dentofacial deformities at a public hospital in Hong Kong from 1 December 1997 to 1 December 1998. Most patients (72. 4%) needed double-jaw surgery. The mean estimated blood loss was approximately 617.6 mL. The blood loss during simple Le Fort I osteotomies was about half that of multiple segmentalised osteotomies. For mandibular ramus osteotomies, the mean blood loss and operating time for were approximately 280 mL and 2 hours, respectively; for anterior mandibular osteotomies, the corresponding values were 171.3 mL and 1 hour 13 minutes. The average drop in the haematocrit value was 15.4%, and the crossmatch to transfusion ratio was 29. A bivariate correlation test between the blood loss and operating time gave a strong correlation (P<0.01), as did blood loss with a drop in haematocrit value (P<0.01). Orthognathic surgeries are thus safe and predictable in terms of intra-operative blood loss and operating time, and a 'type, screen, and save' policy for blood unit preparation is more appropriate than a 'crossmatch' policy.

Analysis of functional results and quality of life following free jejunal flaps for reconstruction after upper aerodigestive neoplastic resection: the St James's experience.

Surgical treatment of hypopharyngeal cancers with extension to the postcricoid region generally requires a circumferential pharyngolaryngoesphagectomy followed by reconstruction of the upper aerodigestive tract. Many techniques have been described in order to achieve a safe and functional reconstruction. Interposition of the jejunal free flap (JFF) is a well-established technique and is the flap of choice in our unit. This is a retrospective review of all patients who required a JFF following pharyngolaryngoesphagectomy over an 9-year period. We studied medical charts, histological reports, and speech and language therapy assessments. Eight of the nine surviving patients completed a quality of life questionnaire. Analysis was carried out on patient demographics, flap survival, patient survival and quality of life including swallow function and speech restoration. A total of 23 patients had 24 jejunal free flaps. There were four perioperative deaths. Two flaps failed, and were salvaged with a second JFF in one case and a gastric pull-up in the second. Functioning swallow was established in 74% of patients with four patients complaining of dysphagia. Speech was restored using an electrolarynx or Blom Singer valve in 70% of patients. Most patients required radiotherapy as part of their adjuvant treatment. In our hands the JFF for reconstruction following pharyngolaryngoesophageal resection allows restoration of function following major ablative surgery.

Antibacterial activity of snake, scorpion and bee venoms: a comparison with purified venom phospholipase A2 enzymes.

AIMS: Venoms of snakes, scorpions, bees and purified venom phospholipase A(2) (PLA(2)) enzymes were examined to evaluate the antibacterial activity of purified venom enzymes as compared with that of the crude venoms. METHODS AND RESULTS: Thirty-four crude venoms, nine purified PLA(2)s and two L-amino acid oxidases (LAAO) were studied for antibacterial activity by disc-diffusion assay (100 microg ml(-1)). Several snake venoms (Daboia russelli russelli, Crotalus adamanteus, Naja sumatrana, Pseudechis guttata, Agkistrodon halys, Acanthophis praelongus and Daboia russelli siamensis) showed activity against two to four different pathogenic bacteria. Daboia russelli russelli and Pseudechis australis venoms exhibited the most potent activity against Staphylococcus aureus, while the rest showed only a moderate activity against one or more bacteria. The order of susceptibility of the bacteria against viperidae venoms was -S. aureus > Proteus mirabilis > Proteus vulgaris > Enterobacter aerogenes > Pseudomonas aeruginosa and Escherichia coli. The minimum inhibitory concentrations (MIC) against S. aureus was studied by dilution method (160-1.25 microg ml(-1)). A stronger effect was noted with the viperidae venoms (20 microg ml(-11)) as compared with elapidae venoms (40 microg ml(-1)). The MIC were comparable with those of the standard drugs (chloramphenicol, streptomycin and penicillin). CONCLUSION: The present findings indicate that viperidae (D. russelli russelli) and elapidae (P. australis) venoms have significant antibacterial effects against gram (+) and gram (-) bacteria, which may be the result of the primary antibacterial components of laao, and in particular, the PLA(2) enzymes. The results would be useful for further purification and characterization of antibacterial agents from snake venoms. SIGNIFICANCE AND IMPACT OF THE STUDY: The activity of LAAO and PLA(2) enzymes may be associated with the antibacterial activity of snake venoms.

Survey of 300 Chinese cleft palate patients presenting for recall to a dental department in Hong Kong.

Three hundred Chinese patients with cleft lip and/or palate were reviewed in the Dentofacial Deformities Clinic of the Department of Dentistry at the United Christian Hospital between January 1990 and January 1992. A survey was taken of patients' age, sex, type of cleft, and cleft location. The findings from this survey are compared to an original sample of 2800 cleft patients surveyed earlier.

Acute injuries from mountain biking.

We questioned members of 2 southern California off-road bicycling organizations about injuries associated with the use of all-terrain bicycles. Cyclists were asked about riding and safety habits, the kind(s) of injury sustained with their most recent accident and whether they sought medical treatment, and the circumstances of the accident. Of 459 mailed surveys, 268 (58.4%) were returned. Respondents (82.8% of whom were male) ranged in age from 14 to 68 years. Of these, 225 (84%) had been injured while riding all-terrain bicycles, 51% in the past year. Although most injuries were characterized as minor, 26% required professional medical care, and 4.4% of those injured were admitted to hospital. Extremity injuries--abrasions, lacerations, contusions--occurred in 201 (90%) cyclists with 27 (12%) sustaining a fracture or dislocation. High levels of helmet use (88%) may explain the low occurrence of head and neck trauma (12%). Frequent riding and riding on paved terrain were associated with increased severity of injury, although most accidents--197 (87.6%)--occurred off paved roads. These results suggest that, compared with regular bicyclists, all-terrain cyclists have more, but not necessarily more severe, injuries. Clinicians and emergency medical personnel should be aware that the increasing popularity of off-road cycling may change the frequency and nature of bicycling injuries.

Spectrum of injuries from snowboarding.

OBJECTIVE: To examine and compare the types, frequency, and associated risk factors of injuries sustained in snowboarders with downhill skiers. DESIGN: Prospectively administered survey. MATERIALS AND METHODS: All snowboarders and skiers who presented to a rural hospital emergency department in California during one winter season were asked to answer a survey eliciting information regarding participants' demographics, previous experience, equipment use and circumstances surrounding their injury. MEASUREMENTS AND MAIN RESULTS: An overall response rate of 87.4% yielded examination of 355 injured snowboarders. Victims tended to be male (81%) with a mean age of 19.8. Snowboarders were more likely to injure the upper limb than skiers (58% vs. 32%, respectively, p < 0.001) but less likely to injure the lower extremities (16% vs. 35%, p < 0.001). Wrist injuries were most common. Nonorthopedic injuries were less common but potentially life threatening. The data also suggest that aerial maneuvers are associated with increased risk of injury to the head, face, spine, and abdomen and that collisions are associated with more severe injury. Snow conditions had no apparent effect on the type, location, or severity of injury and the reported use of alcohol and drugs was low (7%). It was estimated that snowboarders comprised 20 to 25% of participants on the slope but represented 45% of emergency department visits. CONCLUSIONS: There exists a wide spectrum of injuries from snowboarding, ranging from common extremity injuries to potentially life-threatening nonorthopedic trauma.

Helicobacter pylori in Melbourne Chinese immigrants: evidence for oral-oral transmission via chopsticks.

The Helicobacter pylori seroprevalence in a representative population of 328 Melbourne Chinese immigrants (162 men and 166 women) aged 25 years and older were studied. The population consisted of Chinese people born in China/Hong Kong (n = 110, 33.5%), Vietnam (n = 79, 24.1%), Malaysia/Singapore (n = 102, 31.1%), and elsewhere (n = 37, 11.3%). The overall seroprevalence of H. pylori was 59.5%; 60.5% in men and 58.4% in women. Gender specific analysis showed associations between higher seroprevalence and several socio-demographic factors; in men, age (P < 0.0001), lower education level (P < 0.002), cigarette smoking (P < 0.042), the use of antibiotics (P < 0.015) and chopsticks (P < 0.047), and in women, lower socioeconomical status [education level (P < 0.030), gross household income (P < 0.0001) and occupational status (P < 0.0001)] and use of chopsticks (P < 0.002). Seroprevalence differed between immigrants of various birthplaces (P < 0.001); those born in Malaysia/Singapore (43.1%) were lower than those born in China/Hong Kong (68.2%), Vietnam (68.4%), and elsewhere (59.5%). Immigrants of various birthplaces also differed in their pattern of socio-demographics. Multivariate analyses showed that risk factors for H. pylori infection within the Melbourne Chinese immigrants were, in men, age (B = 1.081) and birthplace (B = 1.769) and, in women, household income (B = 0.541) and use of chopsticks (B = 1.654). This study suggests person-to-person transmission of H. pylori via the oral-oral route with ethno-specific food practices an important risk factor.

Bilateral ankylosis of temporomandibular joint secondary to ankylosing spondylitis in a male Chinese.

A case of bilateral temporomandibular joint (TMJ) ankylosis in a Chinese male patient with ankylosing spondylitis is presented. A review of the literature emphasizes the rarity of this arthro-pathology in ankylosing spondylitis. The importance in the recognition of this complication by clinical examination supplemented by computed tomography is stressed.