[Lashing out in the A&E department]. / Slaande bewegingen op de SEH.

BACKGROUND: Subacute hemichorea-hemiballismus in an older patient can be induced by non-ketotic hyperglycaemia. The triad of onset of subacute hemichorea-hemiballismus, hyperglycaemia and hyperdensity in the contralateral putamen on a CT scan or hyperintensity on a T1-weighted MRI scan is pathognomic for this diagnosis. Close observation of the motor restlessness and knowledge of this triad are important for making this diagnosis. CASE DESCRIPTION: A 92-year-old female patient was admitted to the accident and emergency department with a history of motor restlessness for the past few days, confused speech and a glucose level of 20.5 mmol/l. Delirium was initially suspected. Abnormalities on the CT scan were indicative of hemichorea-hemiballismus caused by hyperglycaemia. The patient recovered fully once euglycaemic levels were restored. CONCLUSION: Hemichorea-hemiballismus is a rare motor disorder, often due to an infarct in the contralateral basal ganglia. It can, however, be an expression of non-ketotic hyperglycaemia. The condition is sometimes confused with the motor restlessness of delirium.

Periodic follow-up after breast cancer and the effect on survival.

OBJECTIVE: To assess the role of routine follow-up in current management of breast cancer. DESIGN: Retrospective review. SETTING: Teaching hospital, The Netherlands. SUBJECTS: 270 patients who presented with recurrent breast cancer, 1974-90. MAIN OUTCOME MEASURE: Recurrence was coded as asymptomatic or symptomatic and related to survival. RESULTS: 170 (63%) of the recurrences were detected when they were symptomatic and 100 (37%) when they were not. The groups differed significantly according to the site of recurrence; 45/100 recurrences were local in the asymptomatic group compared with 23/170 (14%) in the symptomatic group. There was no significant difference in disease-free survival between the two groups. Overall 5-year survival after primary treatment for all recurrences (locoregional and distant) was significantly better (p=0.0003) in the asymptomatic group (62/100) than in the symptomatic group 79/170 (46%). However, when locoregional and distant recurrences were analysed separately no significant differences were found between both groups in overall survival after primary treatment or survival after detection of recurrence. The 5-year overall survival after primary treatment for distant recurrence was 26/47 (55%) in the asymptomatic group compared with 62/134 (46%) in the symptomatic group (p=0.13). For locoregional recurrence these figures were 35/45 (78%) and 14/23 (61%), respectively (p=0.34). Routine follow-up hardly affected the course of locoregional recurrence. Only five of 75 patients with local recurrence (7%) developed uncontrolled local disease, 2 of whom were initially detected during routine follow-up. CONCLUSIONS: We conclude that in the current management of breast cancer the medical impact of follow-up is low, so follow-up visits after treatment for breast cancer are hardly warranted.

Granular cell tumor at the hepatic duct confluence mimicking Klatskin tumor. A report of two cases and a review of the literature.

BACKGROUND: Granular cell tumors are rare tumors most often located in the oral cavity, skin or subcutaneous tissue. The occurrence of this tumor in the biliary tree is extremely rare. METHODS: Two patients are described presenting with biliary obstruction due to a tumor at the hepatic duct confluence. One patient is a 38-year-old white male with concomitant cutaneous granular cell tumors, and the other a 50-year-old white female. RESULTS: Hilar excision was performed in both patients. Histopathology of the tumors revealed a proliferation of cells with granular cytoplasm, diagnosed as granular cell tumor. CONCLUSION: At preoperative examination, hilar granular cell tumors are difficult to differentiate from cholangiocarcinoma, sclerosing cholangitis or more common benign biliary tumors. Treatment consists of surgical excision after which prognosis is favorable.