Enteroenteric intussusception caused by a small bowel metastatic cutaneous melanoma.

Unlike in children, intussusception is very rare in adults and accounts for only 1% of ileus in that population. While intussusception in children is most often idiopathic, in adults the cause of intussusception in most cases is tumor and most often metastatic adenocarcinoma. It is an extremely rare phenomenon for intestinal melanoma metastasis to be the cause of intussusception and has been described in the literature so far only in a limited number of case reports. 41-year-old female patient was admitted to the emergency department with a clinical picture of ileus. The patient had a melanoma excision on her back five years ago, for which chemotherapy and radiotherapy were carried out. An MSCT of the abdomen was performed, which indicated an obstructive ileus of the small intestine with a typical sign of intussusception (target sign). Upon explorative laparotomy enteroenteric intussusception was found with an invaginated segment of the ileum in a length of about 20 cm. When the intussuscepted segment was reduced, a black tumor the size of a plum was verified as a leading point. Histological analysis indicated metastatic cutaneous melanoma with foci of melanocytes underneath normal intestinal epithelium.

AMIODARONE AND THYROID DYSFUNCTION.

Thyroid gland has a key role in maintaining the body homeostasis. Thyroxine is the main hormone secreted from the thyroid gland, its effect being predominantly achieved after the intracellular conversion of thyroxine to triiodothyronine, which exhibits a higher affinity for the receptor complex, thus modifying gene expression of the target cells. Amiodarone is one of the most commonly used antiarrhythmics in the treatment of a broad spectrum of arrhythmias, usually tachyarrhythmias. Amiodarone contains a large proportion of iodine, which is, in addition to the intrinsic effect of the medication, the basis of the impact on thyroid function. It is believed that 15%-20% of patients treated with amiodarone develop some form of thyroid dysfunction. Amiodarone may cause amiodarone-induced hypothyroidism (AIH) or amiodarone-induced thyrotoxicosis (AIT). AIT is usually developed in the areas with too low uptake of iodine, while AIH is developed in the areas where there is a sufficient iodine uptake. Type 1 AIT is more common among patients with an underlying thyroid pathology, such as nodular goiter or Graves' (Basedow's) disease, while type 2 mostly develops in a previously healthy thyroid. AIH is more common in patients with previously diagnosed Hashimoto's thyroiditis. Combined types of the diseases have also been described. Patients treated with amiodarone should be monitored regularly, including laboratory testing and clinical examinations, to early detect any deviations in the functioning of the thyroid gland. Supplementary levothyroxine therapy is the basis of AIH treatment. In such cases, amiodarone therapy quite often need not be discontinued. Type 1 AIT is treated with thyrostatic agents, like any other type of thyrotoxicosis. If possible, the underlying amiodarone therapy should be discontinued. In contrast to type 1 AIT, the basic pathophysiological substrate of which is the increased synthesis and release of thyroid hormones, the basis of type 2 AIT is destructive thyroiditis caused by amiodarone, desethylamiodarone as its main metabolite, and an increased iodine uptake. Glucocorticoid therapy is the basis of treatment for this type of disease.

The diagnostic accuracy of clinical and laboratory parameters in the diagnosis of acute appendicitis in the adult emergency department population - a case control pilot study.

INTRODUCTION: The evaluation of patients with suspected appendicitis strives to identify all patients with presenting symptoms while minimizing negative appendectomy rate. The aim of the study was to identify the optimal combination of clinical and laboratory parameters that should facilitate the emergency department surgeon's definite decision. MATERIALS AND METHODS: The study group comprised 120 patients with suspicion of acute appendicitis (AA). In 60 patients the AA diagnosis was confirmed intraoperatively and by histological analysis. Clinical parameters included: appetite, vomiting, diarrhea, dysuria, signs of localized peritonitis and pain migration. Measured laboratory parameters were: C-reactive protein (CRP), complete blood count (CBC) and the urine test strip. RESULTS: The control group of patients were more likely to present following symptoms: no changes in appetite (P < 0.001), diarrhea (P = 0.009) and dysuria (P = 0.047). CRP and white blood cell count (WBC) were significantly higher in the group with confirmed AA compared to the control group (44.7 vs. 6.6, and 13.6 ± 3.9 vs. 9.0 ± 3.4, respectively; P < 0.001). The multivariate logistic regression analysis identified lack of appetite (P = 0.013), absence of diarrhea (P = 0.004), and positive finding of signs of localized peritonitis (P = 0.013), as well as WBCs (P < 0.001) and negative urine test strip results (P = 0.009) as statistically significant predictors of AA. The highest percentage of correctly classified cases (82%) was achieved by combination of common clinical exam and basic inexpensive laboratory parameters (WBCs and urine test strip). CONCLUSIONS: Acute appendicitis in the emergency setting may be successfully ruled in based on elevated WBCs and negative urine test strip in combination with signs of localized peritonitis, lack of appetite and absence of diarrhea. Since CRP did not contribute to the overall diagnostic accuracy, its use in AA diagnostic protocols is of no value.

Kinetics of Ischemia-Modified Albumin Following Exercise-Induced Myocardial Ischemia.

BACKGROUND: Ischemia-modified albumin (IMA) is a potentially valuable biochemical marker of myocardial ischemia. The aim of our study was to define the kinetics and to determine the diagnostic value of IMA in detection of myocardial ischemia by using a model of exercise-stress induced transitory ischemia. METHODS: The study included 43 consecutive patients with positive exercise stress test and coronary artery disease confirmed by coronary angiography (ischemic group) and 22 healthy volunteers with negative exercise stress test (control group). IMA plasma levels were measured before and at nine time points after exercise over a 6-hour period. RESULTS: IMA kinetics was significantly different between the ischemic and control group (p = 0.03). In the ischemic group, IMA plasma levels peaked between the 3rd and 4th hour after exercise. However, due to large interindividual differences in the time-to-peak IMA values, a standard IMA kinetics curve could not be defined for the patients with transitory myocardial ischemia. On the other hand, with the cutoff value of a 10.6% relative increase, sensitivity and specificity of IMA for the detection of myocardial ischemia were sufficiently high at 81% and 82%, respectively. CONCLUSIONS: Although an optimum time for the detection of recent myocardial ischemia by a single IMA sampling could not be defined, serial measurements of IMA can be a useful biochemical tool for the detection of myocardial ischemia in patients with doubtful exercise stress test results.

Obstruction of left ventricular outflow tract by a calcified mass at mitral valve.

A case of an unusual left ventricular outflow tract obstruction by mitral valve pathology in a 35-year old female with diabetes and end-stage renal disease is presented in the study. The patient suffered from fever of an unknown origin after lower-leg amputation. Although the wound healed well, fever persisted for three weeks despite a triple antibiotic treatment until the infection was resolved with vancomycin. Three months later echocardiography displayed a floating mass attached to mitral valve, producing a newly developed systolic murmur and a mild haemodynamic obstruction of the left ventricular outflow tract. The calcified vegetation was probably formed during an unrecognized subacute infective endocarditis.