Ureterocolic fistula diagnosed on the basis of diuretic renogram and direct radionuclide cystography.

Ureterocolic fistulae are a rare phenomenon and are most commonly seen secondary to obstructive ureteric calculi. These are usually diagnosed on barium enema or intravenous urography. Most of the times, more than one investigation is needed to confirm the findings. We present a case of iatrogenically-induced ureterocolic fistula, diagnosed on renogram and direct radionuclide cystography. This case showcases the possibility of using a renogram study as a diagnostic tool for a suspected ureterocolic fistula. A renogram study also enables to asess the renal function, which is essential in deciding the management.

Satisfactory outcomes following combined unicompartmental knee replacement and anterior cruciate ligament reconstruction.

PURPOSE: There exist limited options for treatment of patients with combined medial compartment arthritis and anterior cruciate ligament (ACL) deficiency. Ideal treatment is one that offers lasting relief of symptoms not compromising any future surgery. Unicompartmental knee replacement has shown consistently good results in the relatively young and active population, but there is a high reported incidence of failure up to 20%, if performed in ACL-deficient knees. One of the recognized treatment modality is combined ACL reconstruction and unicompartmental arthroplasty. A systematic review was conducted looking at the demographics, techniques, complications and outcome of combined ACL reconstruction with unicompartmental knee arthroplasty. METHODS: A systematic literature search within the online Medline, PubMed Database, EMBASE, Web of Science, Cochrane and Google Scholar was carried out until October 2016 to identify relevant articles. A study was defined eligible if it met the following inclusion criteria: the surgical procedure combined unicompartmental knee arthroplasty and anterior cruciate ligament reconstruction; patient's clinical and/or functional outcomes were reported; any complications intra-operatively and post-operatively were reported; and the full-text articles, written in English, German, Italian, Dutch or Spanish, were available. Quality and risk of bias assessments were done using standardized criteria set. RESULTS: A total of 8 studies met the inclusion criteria encompassing 186 patients who were treated with simultaneous ACL reconstruction and unicompartmental knee arthroplasty. The mean age was 50.5 years (range from 44 to 56) with a mean follow-up of 37.6 months (range from 24 to 60). There was an improvement in mean Oxford Score from 27.5 to 36.8. Complications reported included tibial inlay dislocation (n = 3), conversion to a total knee arthroplasty (n = 1), infection requiring two-stage revision (n = 2), deep-vein thrombosis (n = 1), stiffness requiring manipulation under anaesthesia (n = 1), retropatellar pain requiring arthroscopic adhesiolysis (n = 1). CONCLUSION: Unicompartmental knee arthroplasty combined with ACL reconstruction can be a valid treatment option for selected patients, with combined medial unicompartmental knee osteoarthritis and ACL deficiency. LEVEL OF EVIDENCE: Systematic Review of Level IV Studies, Level IV.

Use of tantalum cones in primary arthroplasty of acute proximal tibial fractures.

Metaphyseal tantalum cones in primary total knee arthroplasty and their functional outcome is described using 3 case reports over 6 years. 3 knees in 3 elderly individuals (mean age of 70.4 years), with pre-existing osteoarthritis and complex proximal tibial fractures, were operated on. Ambulation with walking frame was achieved from post-operation day 1, with weight-bearing as tolerated. Mean range of motion was 122° and Mean Knee Society Score was 88. All showed improvement in pre-operative limb alignment. Radiological fracture union was achieved on an average of 3 months. All were independent ambulators and pain-free at the latest follow-up. Our case series shows that tantalum cones are associated with significant improvements in clinical scores, patient symptoms, range of movement, early weight-bearing and low rates of complications in complex proximal tibial fractures with poor bone stock.

Clomifene citrate and intrauterine insemination as first-line treatments for unexplained infertility: are they cost-effective?

BACKGROUND: First-line treatments for unexplained infertility traditionally include clomifene citrate (CC) or unstimulated intrauterine insemination (IUI). A recently published randomized controlled trial considered the effectiveness of CC and IUI in patients with unexplained infertility and found that neither treatment offered a superior live birth rate when compared with expectant management (EM). This paper reports the economic evaluation conducted alongside this trial in order to assess whether health care providers are gaining value for money in this clinical area. METHODS: Five hundred and eighty women across five Scottish hospitals were randomized to either EM, CC or IUI for 6 months. The primary outcome measure was live births. Resource-use data were collected during the trial and costs were calculated from a UK National Health Service (NHS) perspective. Incremental cost-effectiveness ratios were calculated, expressed as cost per live birth, in order to compare the cost-effectiveness of CC and IUI with that of EM to treat unexplained infertility. RESULTS: Live birth rates in the three randomized groups were: EM = 32/193 (17%), CC = 26/194 (13%) and IUI = 43/193 (22%). The mean (standard deviation) costs per treatment cycle were £0 for EM, £83 (£17) for CC and £98 (£31) for IUI. The mean treatment costs per patient for EM, CC and IUI were £12 (£117), £350 (£220) and £331 (£222), respectively. The cost per live birth for EM, CC and IUI was £72 (95% confidence interval £0-£206), £2611 (£1870-£4166) and £1487 (£1116-£2155), respectively. The incremental cost-effectiveness ratio for IUI versus EM was £5604 (-£12204 to £2227), with CC dominated by IUI. CONCLUSIONS: Despite being more expensive, existing treatments such as empirical CC and unstimulated IUI do not offer superior live birth rates compared with EM of unexplained infertility. They are unlikely to be a cost-effective use of limited NHS resources. The study's main limitation is that it did not consider the psychological effects on couples. ISRCT Number: 71762042.

Evaluation of clinical skills for first-year surgical residents using orientation programme and objective structured clinical evaluation as a tool of assessment.

BACKGROUND: Postgraduate specialities require a combination of knowledge and clinical skills. The internship year is less structured. Clinical and practical skills that are picked up during training are not well regulated and the impact is not assessed. In this study, we assessed knowledge and skills using objective structured clinical examination (OSCE). AIM: To evaluate the clinical skills of new first-year surgical residents using orientation programme and OSCE as a tool for assessment. SETTINGS AND DESIGN: Observational study. MATERIALS AND METHODS: Twenty new first-year surgical residents (10 each in 2008 and 2009) participated in a detailed structured orientation programme conducted over a period of 7 days. Clinically important topics and skills expected at this level (e.g., suturing, wound care etc.) were covered. The programme was preceded by an OSCE to test pre-programme knowledge (the "pre-test"). The questions were validated by senior department staff. A post-programme OSCE (the "post-test") helped to evaluate the change in clinical skill level brought about by the orientation programme. STATISTICAL ANALYSIS: Wilcoxson matched-pairs signed-ranks test. RESULTS: Passing performance was achieved by all participants in both pre- and post-tests. Following the orientation programme, significant improvement was seen in tasks testing the psychomotor and cognitive domains. (P = 0.0001 and P = 0.0401, respectively). Overall reliability of the OSCE was found to be 0.7026 (Cronbach's coefficient alpha). CONCLUSIONS: This study highlighted the lacunae in current internship training, especially for skill-based tasks. There is a need for universal inclusion of structured orientation programmes in the training of first-year residents. OSCE is a reliable, valid and effective method for the assessment of clinical skills.

Kikuchi fujimoto disease and systemic lupus erythematosus--a rare association.

Kikuchi-Fujimoto disease is rarely associated with systemic lupus erythematosus (SLE). Kikuchi Fujimoto disease may precede, follow or coincide with the diagnosis of SLE. We report a case who was initially diagnosed as Kikuchi Fujimoto disease with SLE. She is presently in remission after treatment of SLE.

Lack of impact of semen quality on fertilization in assisted conception.

BACKGROUND: Defective semen quality is one of the commonest causes of infertility. The diagnosis of male fertility depends upon a descriptive evaluation of human semen, however a normal semen analysis does not necessarily indicate satisfactory fertility potential. AIMS: (i) to examine the semen quality of patients undergoing treatment by assisted conception, (ii) to explore relationships between semen quality and treatment outcomes, and (iii) to look at inter-laboratory variation in the assessment of semen quality. METHODS: Semen quality in patients undergoing assisted conception treatment between 2001 and 2004 was reviewed. Data on female age, egg numbers and fertilization outcomes was obtained by case note review. RESULTS: The thresholds used to direct patients towards IVF or ICSI treatment were comparable with the normal values promulgated by WHO, with the exception of morphology. Semen quality was not predictive of fertilization rates. When the results of independent measurements of the same sample were compared, there was diagnostic disagreement in between 10%-29% of samples. CONCLUSIONS: The conventional criteria of semen quality are used to determine treatment strategy for couples undergoing assisted conception but are not reflected in fertilization rates, emphasising the limited utility of the conventional criteria of semen quality in the assessment of sperm function. There remains significant inter-laboratory variation in the results of semen analysis.

Irreversible dilated cardiomyopathy due to thyrotoxicosis.

Irreversible dilated cardiomyopathy due to thyrotoxicosis is an unusual clinical entity. We report this case of a young female who presented with congestive cardiac failure and was diagnosed as dilated cardiomyopathy due to thyrotoxicosis. Restoration of euthyroid levels did not revert the cardiomyopathy.

Creatine kinase-MB elevation after coronary intervention correlates with diffuse atherosclerosis, and low-to-medium level elevation has a benign clinical course: implications for early discharge after coronary intervention.

OBJECTIVES: The study evaluated the incidence and predictors of creatine kinase-MB isoenzyme (CK-MB) elevation after successful coronary intervention using current devices, and assessed the influence on in-hospital course and midterm survival. BACKGROUND: The CK-MB elevation after coronary intervention predominantly using balloon angioplasty correlates with late cardiac events of myocardial infarction (MI) and death. Whether CK-MB elevation after nonballoon devices is associated with an adverse short and midterm prognosis is unknown. METHODS: The incidence and predictors of CK-MB elevation after coronary intervention were prospectively studied in 1,675 consecutive patients and were followed for in-hospital events and survival. RESULTS: CK-MB elevation was detected in 313 patients (18.7%), with 1-3x in 12.8%, 3-5x in 3.5% and >5x normal in 2.4% of patients. Procedural complications or electrocardiogram changes occurred in only 49% of the CK-MB-elevation cases; CK-MB elevation was more common after nonballoon devices (19.5% vs. 11.5% after percutaneous transluminal coronary angioplasty; p < 0.01). Predictors of CK-MB elevation on multivariate analysis were diffuse coronary disease (p = 0.02), systemic atherosclerosis (p = 0.002), stent use (p = 0.04) and absence of beta-blocker therapy (p = 0.001). Adverse in-hospital cardiac events were more frequent in patients with >5x CK-MB elevation, with no significant difference between 1-5x CK-MB elevation versus normal CK-MB group. During a mean follow-up of 13 +/- 3 months, the incidence of death in the CK-MB-elevation group was 1.6% versus 1.3% in the normal CK-MB group (p = NS). CONCLUSIONS: The CK-MB elevation after coronary intervention was observed even in the absence of discernible procedural complications and was more common in patients with diffuse atherosclerosis. In-hospital clinical events requiring prolonged monitoring were higher in >5x CK-MB-elevation patients only. Midterm survival of CK-MB-elevation patients was similar to those with normal CK-MB. Our prospective analysis shows a lack of adverse in-hospital cardiac events and suggests that early discharge of stable 1-5x normal CK-MB-elevation patients after successful coronary intervention is safe.

Differential cellular and subcellular localization of protein phosphatase 1 isoforms in brain.

Protein phosphatase 1 (PP1) is a gene family with a number of important functions in brain. Association with a wide variety of regulatory/targeting subunits is thought to be instrumental in directing the phosphatase to specific subcellular locations and substrates. By using antibodies directed against specific PP1 isoforms, we asked whether PP1 isoforms are differentially distributed in brain. Immunoblotting detects in brain the PP1gamma2 isoform, which had previously been thought to be testis specific, in addition to alpha, beta, and gamma1 isoforms. PP1 isoform expression varies modestly in extracts from different subdissected brain regions and is relatively constant during postnatal development, except for an about twofold increase in PP1gamma2. By immunohistochemical analyses of rat brain, PP1beta and PP1gamma1 cellular expression is widespread but quite distinct from one another. Subcellular fractionation studies demonstrate that PP1beta and PP1gamma1 are selectively associated with different cytoskeletal elements: PP1beta with microtubules, PP1gamma1 with the actin cytoskeleton. Double-immunofluorescence labeling of cultured cortical neurons further reveals a strikingly different and nonoverlapping localization of PP1beta and PP1gamma1: whereas PP1beta localizes to a discrete area of the soma, PP1gamma1 is highly enriched in dendritic spines and presynaptic terminals of cultured neurons. These results show that PP1 isoforms are targeted to different neuronal cytoskeletal compartments with a high degree of specificity, presumably by isoform-specific association with regulatory/targeting proteins. Furthermore, the synaptic localization of PP1gamma1 indicates that it is this isoform that is involved in the regulation of synaptic phosphoproteins such as neurotransmitter receptors and ion channels implicated in synaptic plasticity.

Signet ring cell lymphoma of the thyroid: a case report.

The first case of extranodal signet ring cell lymphoma involving the thyroid gland is reported in a 53-year-old woman with Hashimoto's thyroiditis. Since 1978, 24 cases of signet ring cell lymphoma, all involving primarily nodal tissue, have been documented in the literature. This rare neoplasm is believed to be a variant of non-Hodgkin's follicular lymphoma, which may be mistaken for metastatic poorly differentiated adenocarcinoma.

Diagnostic accuracy in lung cancer; comparison of techniques used in association with flexible fiberoptic bronchoscopy.

Flexible fiberoptic bronchoscopic examination was performed 254 times in 228 patients in a prospective study to determine what specimens would give the greatest yield in the diagnosis of lung cancer. In addition, we questioned whether postbronchoscopic sputum specimens were still the most accurate method of diagnosing lung cancer, as they had been when only the rigid bronchoscope was available. Material for cytopathologic examination was obtained from bronchial brushings, bronchial biopsy, bronchial brushings in saline solution, bronchial washings, and three postbronchoscopie sputum specimens. In the latter part of the study, patients with peripheral tumors were studied with the aid of biplane fluoroscopic techniques. Bronchial brushings and bronchial biopsy each yielded the highest percentage of positive specimens (65 percent); postbronchoscopic sputum specimens were less frequently positive (40 percent). The combination of bronchial brushings and bronchial biopsies gave the optimum overall accuracy (79 percent). Bronchial washings and postbronchoscopic sputum specimens did not add significantly to diagnostic yield, and we conclude that they should no longer be part of the diagnostic procedures routinely ordered. In peripheral lesions, diagnostic accuracy was greatly enhanced in the cases where biplane fluoroscopic techniques were employed.

A biodegradeable membrane from porcine intestinal submucosa to reinforce the gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass: preliminary report.

BACKGROUND: A Silastic ring has been used to prevent dilation of the gastrojejunostomy in Roux-en-Y gastric bypass (RYGBP). The use of a bio-membrane may prevent dilation of the anastomosis without the risks associated with prostheses. The aim of this study was to evaluate the feasibility and safety of applying such a bio-membrane around the gastrojejunostomy in Laparoscopic RYGBP (LRYGBP). METHODS: We used a new bio-membrane, that is derived from porcine small intestinal submucosa (SIS) and acts as a scaffolding for the ingrowth of connective tissue. Over a 4-month period, 14 LRYGBP patients had their proximal anastomosis wrapped with 10 x 2.5 cm SIS by a single surgeon. We compared these patients to a control group of LRYGBP patients matched for BMI. RESULTS: The average age of the patients was 35.0 years (control group: 45.1 years). The patients had a mean initial BMI of 44.7 kg/m2 (+/- 5.9) standard error, and the control subjects had a mean initial BMI of 46.7 kg/m2 (+/- 6.5). SIS application took a mean time of 11 (+/- 3) minutes without any intraoperative complication. The median hospital stay was 3.5 days in the experimental group and 3.7 days in controls. Three patients developed a symptomatic stenosis at the gastrojejunostomy following surgery. In the control group there were two stenoses. At an average follow-up of 87 days (controls: 95 days), the mean reduction in BMI was 7.8 (+/- 0.8) kg/m2 [controls 8.6 kg/m2 (+/- 1.5)]. CONCLUSION: Application of SIS around the gastrojejunostomy in patients undergoing LRYGBP is feasible and safe. Further follow-up is required, however, to evaluate the effectiveness in preventing dilation of the anastomosis.

Orbital metastasis from prostatic carcinoma. Identification by immunocytology.

We report a case in which the diagnosis of prostatic carcinoma, metastatic to the orbit, was confirmed using an immunoperoxidase technique on cytologic specimens obtained by fine-needle aspiration. Computed tomography was valuable in localizing the tumor for biopsy and subsequent radiation therapy. The results of these studies correlated with the clinical history and other evidence of widespread metastatic disease. Ironically, the first evidence of malignancy in this patient was possibly also ophthalmologic, manifesting 14 months earlier with hemorrhagic retinopathy associated with thrombocytopenia. To our knowledge, this is the first report describing the combination of an immunoperoxidase technique with the fine-needle aspiration biopsy of an orbital tumor.

A continuous quality improvement project to improve the quality of cervical Papanicolaou smears.

OBJECTIVE: To improve the quality of cervical Papanicolaou smears by continuous quality improvement techniques. METHODS: The study used a Papanicolaou smear data base of over 200,000 specimens collected between June 1988 and December 1992. A team approach employing techniques such as process flow-charting, cause and effect diagrams, run charts, and a randomized trial of collection methods was used to evaluate potential causes of Papanicolaou smear reports with the notation "inadequate" or "less than optimal" due to too few or absent endocervical cells. Once a key process variable (method of collection) was identified, the proportion of Papanicolaou smears with inadequate or absent endocervical cells was determined before and after employment of a collection technique using a spatula and Cytobrush. We measured the rate of less than optimal Papanicolaou smears due to too few or absent endocervical cells. RESULTS: Before implementing the new collection technique fully by June 1990, the overall rate of less than optimal cervical Papanicolaou smears ranged from 20-25%; by December 1993, it had stabilized at about 10%. CONCLUSION: Continuous quality improvement can be used successfully to study a clinical process and implement change that will lead to improvement.

Evidence-based medicine: open and laparoscopic bariatric surgery.

BACKGROUND: The aim of this study was to perform an evidence-based analysis of the literature on open and laparoscopic surgery for morbid obesity. METHODS: Human studies on surgery for morbid obesity were conducted. Multiple publications of the same studies, abstracts, and case reports were reviewed. Current Contents, MEDLINE, EMBASE, and Cochrane Library databases were investigated. RESULTS: Open Roux-en-Y gastric by pass (RYGB) for morbidly obese patients and long-limb RYGB for superobese patients are highly effective procedures. Randomized controlled trials comparing malabsorptive procedures with other bariatric operations are needed. The long-term efficacy of adjustable silicone gastric banding (ASGB) still is undetermined because of poor evidence. Laparoscopic RYGB is as safe as its open counterpart, although its long-term results are lacking. Laparoscopic ASGB is less invasive than open ASGB, although its efficacy cannot be determined because of poor evidence. Laparoscopic vertical banded gastroplasty (VBG) is becoming unpopular since the decreasing trend of open VBG. Laparoscopic biliopancreatic diversion with duodenal switch is feasible, but needs further studies. CONCLUSIONS: Randomized controlled trials comparing the various laparoscopic operations are strongly needed.

Cytopathologic features of medullary carcinoma of the thyroid.

Medullary carcinoma of the thyroid (MCT) presents a varied but characteristic cytologic pattern in cellular samples obtained by fine-needle aspiration (FNA) biopsy. In our experience with 17 cases of MCT, ten were identified by cytologic examination. One was acellular. The remaining six were typed as undifferentiated carcinoma (three cases), follicular variant of papillary carcinoma (one case), and cellular adenoma (two cases). Four Hürthle cell tumors and four papillary carcinomas were incorrectly typed as MCT. There was one false positive. Careful consideration of the listed cytologic features should make the FNA biopsy diagnosis of MCT of satisfactory sensitivity for the evaluation of "cold" thyroid nodules. Specificity may be considerably improved by using immunoperoxidase stain for calcitonin granules and/or by large-needle biopsy.

Malignant lymphoma in transplanted renal pelvis.

A middle-aged man with chronic renal failure received a renal transplant from his healthy daughter. Two years later, malignant lymphoma developed in the transplanted renal pelvis. The lymphoma was found to be B-cell immunoblastic lymphoma bearing monoclonal IgG and kappa immunoglobulin, and it was of recipient origin.

Post-fine-needle biopsy infarction of thyroid neoplasms: a review of 28 cases.

This report describes 28 cases of thyroids which had undergone infarction following fine-needle aspiration (FNA) biopsy procedure. Their cytologic diagnoses included 15 Hürthle cell tumors, eight papillary carcinomas, and five follicular neoplasms. Nine patients also had large-needle biopsy performed within 3 wk of FNA biopsy, three of which showed infarction and one had no surgical follow-up. Surgery was performed on 27 patients within 7 to 90 days. All 27 cases showed partial to total infarction. Histological and cytologic diagnoses were not in accordance in 12 cases, either due to complete fibrosis (two cases), obscuring of histologic details (four cases), or failure to recognize the thin rim of neoplastic tissue at the periphery, by pathologists unaware of the cytologic diagnoses (six cases). Fine-needle biopsy results should be made available to the surgical pathologists handling the surgically excised thyroid specimen. Also, partial or complete infarction must initiate careful examination, so as not to miss any neoplasms.