Is chronic rhinosinusitis related to allergic rhinitis in adults and children? Applying epidemiological guidelines for causation.

The relationship between allergic rhinitis and chronic rhinosinusitis has been assessed in a number of observational and experimental studies. In this review, we attempt their synthesis and evaluation using the modified Bradford Hill guidelines for causation. Although there is no proof of causation, especially in the pediatric literature, an evaluation of underlying allergies is recommended at least as an initial measure of symptoms relief.

Tacrolimus-induced thrombotic microangiopathy in orthotopic liver transplant patients: case series of four patients.

Thrombotic microangiopathy (TMA) is a potentially fatal complication in solid organ and bone marrow transplant patients, with reported incidence of 0.5-3% and mortality of about 75%. To emphasise the importance of early diagnosis and prompt commencement of therapy results in improved clinical outcomes. A retrospective study of all patients who underwent orthotopic liver transplantation (OLTX) at the Western Australian Liver Transplantation Service from May 1994 to December 2010 was conducted to identify patients who developed tacrolimus-induced TMA. We identified four patients with tacrolimus-induced TMA post-OLTX, derived from a cohort of 104 patients treated with tacrolimus in our institution. The mean age at diagnosis was 40 years, and the mean time of onset was 63 ± 7.5 weeks after OLTX. The indications for OLTX in the four patients were fulminant hepatic failure in three (Wilson disease, paracetamol overdose and post-partum thrombotic thrombocytopenic purpura) and hepatitis C virus-related cirrhosis. All patients had tacrolimus post-OLTX. At diagnosis, tacrolimus was discontinued in all patients, and three of the four patients underwent plasma exchange and all patients improved clinically. Mean duration of follow up was 15 ± 7.5 months. There was no mortality 6 months post-TMA. Early diagnosis with immediate discontinuation or conversion of calcineurin inhibitors and plasma exchange should be offered to OLTX patients with TMA as it results in good outcomes.

A rare cause of diplopia: Solitary extramedullary plasmacytoma of the skull base.

Diplopia is a common presenting complaint with a broad spectrum of differential diagnoses. Causative pathologies may affect the eye, extraocular muscles, neuromuscular junction, cranial nerves and central nervous system. Tumours, inflammatory and autoimmune conditions, vasculopathies and atypical infections are the most common underlying pathologies. Solitary extramedullary plasmacytoma is a rare cause of diplopia. This case emphasises the importance of submucosal biopsies for diagnosis and early involvement of the multidisciplinary team. Moreover, we advocate a low threshold for a second opinion and further immunohistochemistry, particularly when there is diagnostic uncertainty with histological discordance.

Robotics in cardiac surgery.

A summary of its uses in mitral valve surgery and coronary artery revascularisation.

Urgent liver transplantation for acute liver failure due to parvovirus B19 infection complicated by primary Epstein-Barr virus and cytomegalovirus infections and aplastic anaemia.

An 11-year-old boy presented with hepatic failure secondary to parvovirus B19 infection, requiring urgent liver transplantation. His recovery was complicated by primary Epstein-Barr virus and cytomegalovirus infections. He subsequently developed aplastic anaemia that has been refractory to antithymocyte globulin and cyclosporine therapy and may now require bone marrow transplantation. We present this case to emphasize parvovirus as a rare cause of hepatic failure and of aplastic anaemia as a complication of the virus.

Radiological considerations and surgical planning in the treatment of giant parathyroid adenomas.

Giant parathyroid adenomas constitute a rare clinical entity, particularly in the developed world. We report the case of a 53-year-old woman where the initial ultrasonography significantly underestimated the size of the lesion. The subsequent size and weight of the adenoma (7 cm diameter, 27 g) combined with the severity of the hypercalcaemia raised the suspicion for the presence of a parathyroid carcinoma. This was later disproven by the surgical and histological findings. Giant parathyroid adenomas are encountered infrequently among patients with primary hyperparathyroidism, and appear to have distinct clinical and biochemical features related to specific genomic alterations. Cross-sectional imaging is mandated in the investigation of parathyroid adenomas presenting with severe hypercalcaemia as ultrasonography alone can underestimate their size and extent. This is important since it can impact on preoperative preparation and planning as well as the consent process as a thoracic approach may prove necessary for certain cases.

Intralaboratory variations in the grading of breast carcinoma.

To assess the reliability of the World Health Organization's grading system for breast carcinomas, six observers independently graded 158 tumors. Five of the observers had been simultaneously trained in the same institution. The sixth was one of their tutors. There was agreement in the grading of only 23 cases, most of which were either well or poorly differentiated tumors. If the prognosis breast carcinoma is predicated by the who method, it should be restricted to the two extreme groups. It seems that there is no need to apply the who grading method because these groups could be easily distinguished by the overall impression of the examining pathologists.

The psychosocial impact of hearing aids in children with otitis media with effusion.

BACKGROUND: In children, otitis media with effusion is treated using grommets or hearing aids. Parents considering treatment options express concerns regarding the psychosocial impact of hearing aids in terms of self-esteem and bullying. This study assessed the psychosocial impact of hearing aid use. METHODS: A cross-sectional study was undertaken comparing hearing aid users to non hearing aid users with regard to their attitudes towards hearing aids. All subjects, who had been diagnosed with otitis media with effusion, were aged less than 16 years, were without disability and attended mainstream schools. A questionnaire was designed and utilised. RESULTS: The study comprised 47 children with hearing aids and 50 with grommets. Significant between-group differences (p < 0.05) were noted with regard to perceptions related to bullying, feelings of inadequacy and embarrassment. The overall negative perceptions of non hearing aid users were not reported by hearing aid users. CONCLUSION: Children with hearing aids do not suffer from bullying or low self-esteem to the extent perceived by parents. This information is useful for informed decisions regarding treatment of otitis media with effusion.

A two-cycle prospective audit of temporal bone computed tomography scan requests: improving the clinical applicability of radiology reports.

BACKGROUND: Radiologists require accurate clinical information to formulate reports. This is particularly relevant to computed tomography of the temporal bone, in which previous surgery can mimic disease. OBJECTIVES: The information provided with temporal bone computed tomography scan requests was evaluated. The study aimed to minimise inappropriate requests and improve the clinical value of reports. METHOD: A two-cycle prospective audit was undertaken using a proforma designed on the basis of national guidelines. Following the first cycle (in which the requests and reports of 100 scans were evaluated), new guidelines and training were implemented. A follow-up audit (of 50 scans) was then performed. RESULTS: Following intervention, the percentage of clinically relevant reports increased from 52 to 94 (p < 0.01), whilst unnecessary or inappropriate scan requests decreased from 11 to 2 per cent (p < 0.05). CONCLUSION: Optimising the clinical value of temporal bone computed tomography scan requests will have positive implications for patient care, time management and cost. The quality of the clinical information provided can have a significant impact on the clinical value of radiology reports, and can mean that unnecessary irradiation is avoided.

Assessment of obstruction level and selection of patients for obstructive sleep apnoea surgery: an evidence-based approach.

INTRODUCTION: Obstructive sleep apnoea has long been recognised as a clinical syndrome; however, high quality evidence on the effects of surgery for this condition is still missing. Despite this, a consensus seems to be evolving, albeit based on limited evidence, that surgery should be offered as a second line treatment to suitable patients with obstructive sleep apnoea. AIMS: This article aims to assess the different methods of investigating upper airway obstruction in patients with obstructive sleep apnoea, in respect to these methods' relevance to surgical treatment, via a systematic review of the literature. METHODS: The Cochrane Controlled Trials Register, Medline and EMBASE were searched from 1966 onwards. The search was performed in August 2008. A total of 2001 citations were retrieved. RESULTS AND CONCLUSION: There is not yet a generally accepted way to assess surgical candidacy based on the level of obstruction. Better organised clinical studies with well defined endpoints are needed. In the meanwhile, it appears that sleep nasendoscopy, acoustic reflectometry and pressure catheters can all provide useful information, and their use may be decided upon based on the experience and resources available in individual departments.

Melioidosis and the vacuum-assisted closure device: a rare cause of a discharging neck wound, and a new approach to management.

OBJECTIVE: We report a case of melioidosis presenting as a discharging neck abscess, and we describe the use of a vacuum-assisted closure device in its management. METHOD: We report the case of a 44-year-old, Afro-Caribbean woman with melioidosis. We also present the results of a literature search using the search terms 'melioidosis', 'Burkholderia pseudomallei' and 'vacuum-assisted closure device'. RESULTS: Microbiological analysis identified the causative organism as being the bacterium Burkholderia pseudomallei, and its antimicrobial sensitivities to imipenem and ciprofloxacin. A vacuum-assisted closure device was used to manage the patient's melioidosis of the neck; we believe this is the first report of such treatment. CONCLUSIONS: Melioidosis is rare in the UK and western world; however, exposure can occur during travel to endemic areas. We therefore draw attention to this infection as part of the differential diagnosis of a neck abscess. We propose the use of vacuum-assisted closure devices as useful adjuncts to the management of discharging neck wounds.

Somatostatin receptor expression, tumour response, and quality of life in patients with advanced hepatocellular carcinoma treated with long-acting octreotide.

Octreotide may extend survival in hepatocellular carcinoma (HCC). Forty-one per cent of HCCs have high-affinity somatostatin receptors. We aimed to determine the feasibility, safety, and activity of long-acting octreotide in advanced HCC; to identify the best method for assessing somatostatin receptor expression; to relate receptor expression to clinical outcomes; and to evaluate toxicity. Sixty-three patients with advanced HCC received intramuscular long-acting octreotide 20 mg monthly until progression or toxicity. Median age was 67 years (range 28-81 years), male 81%, Child-Pugh A 83%, and B 17%. The aetiologies of chronic liver disease were alcohol (22%), viral hepatitis (44%), and haemochromatosis (6%). Prior treatments for HCC included surgery (8%), chemotherapy (2%), local ablation (11%), and chemoembolisation (6%). One patient had an objective partial tumour response (2%, 95% CI 0-9%). Serum alpha-fetoprotein levels decreased more than 50% in four (6%). Median survival was 8 months. Thirty four of 61 patients (56%) had receptor expression detected by scintigraphy; no clear relationship with clinical outcomes was identified. There were few grade 3 or 4 toxicities: hyperglycaemia (8%), hypoglycaemia (2%), diarrhoea (5%), and anorexia (2%). Patients reported improvements in some symptoms, but no major changes in quality of life were detected. Long-acting octreotide is safe in advanced HCC. We found little evidence of anticancer activity. A definitive randomised trial would identify whether patients benefit from this treatment in other ways.

Hydatid disease of the tarsal bones. A case report.

Hydatid disease is caused by the larval form of the tapeworm Echinococcus. Osseous cysts are rare and very few cases of foot infestation have been reported. We present the case of a 51-year-old woman who developed a palpable mass at the medial dorsal aspect of the right midfoot. Radiological examination showed cystic lesions in the cuneiforms and the navicular. The lesion was explored and several small cysts containing clear fluid were found. They were evacuated and the bone was curetted. The diagnosis of E. granulosus infestation was made histologically. After 15 years' follow-up there were no signs of recurrence. Osseous echinococcosis is a rare disease that may present as infective or neoplastic pathology. A high index of suspicion is necessary for its diagnosis, especially in patients who live in or travel to sheep-raising areas where hydatid disease is endemic.

Sex cord nests with annular tubules. The incidence of identifying them in normal ovaries.

Sections from 588 ovaries removed during various operations and reported as being within normal size limits were reviewed. In seven cases structures with the characteristic appearances of sex cord "tumours" with annular tubules (SCTAT) were found. We called the lesions sex cord nests with annular tubules (SCNAT). Their mean diameter was 0.17 mm. If ovaries were cut in serial sections the probabilities of identifying such lesions should increase very much.

The nonsteroidal anti-inflammatory drugs controversy.

The relationship between NSAIDs and H. pylori as risk factors for the development of peptic ulcer is complex and controversial. In the case of duodenal ulcers in NSAID users, there now is enough information to suggest that eradication of H. pylori usually is worthwhile. In the stomach, however, there is some evidence that ulcers heal faster and are no more likely to reappear if the infection is left alone, provided that patients continue to take an NSAID. Why this situation should be so is unclear. Possibilities include greater efficacy of antisecretory agents, a smaller inhibition of prostaglandin production, and a blunted apoptotic response in patients who are infected with H. pylori and take NSAIDs.

Malignant melanoma metastatic to the common bile duct.

Metastatic melanoma is renowned for its propensity to spread to almost every organ of the body; however, symptomatic metastases within the biliary tree are very rare. We report two cases of bile duct obstruction from metastatic melanoma. The first case was caused by an intraluminal metastatic melanoma to the common bile duct, while the second case was caused by extraluminal involvement. The unique aspects of these cases include clinical presentations masquerading as biliary colic, cholangitis and obstructive jaundice. Management and follow up for 3 years is presented. Aspects of medical and surgical management, as well as a review of the world's literature are discussed.