A trout fisherman with hypercalcaemia and skin lesions.

A 67-year-old trout fisherman presented with a six-week history of polyuria, polydipsia, dyspnoea on exertion and the development of subcutaneous extensor surface skin nodules. He was hypercalcaemic with acute renal impairment. Parathyroid hormone was suppressed and vitamin D levels were within normal limits. The patient had a past history of hypothyroidism, but thyroid replacement was adequate. Hypoadrenalism, myeloma and metastatic malignancy were excluded. Biopsy of a subcutaneous nodule revealed dermally based non-caseating granulomata, consistent with sarcoidosis. Serum angiotensin-converting enzyme was elevated, and computerized tomography scanning of the chest and abdomen revealed widespread lymphadenopathy with multiple lung nodules and splenomegaly. Prednisolone therapy produced rapid resolution of his skin lesions and normalization of his bone and renal biochemistry. The mechanism of hypercalcaemia in sarcoidosis is poorly understood but is thought to involve parathyroid hormone-independent 1-hydroxylation of 25-hydroxyvitamin D within sarcoid lesions. This process may be exacerbated by exposure to UV light and it is of interest that this patient developed symptoms after a period of intense trout fishing in the good weather of April and May 2007.

Amyand's hernia and peri-appendicular abscess in primary care.

We report an unusual case of peri-appendicular abscess occurring in an irreducible Amyand's hernia, managed in a primary care setting. An 84-year-old gentleman, with severe chronic obstructive airways disease, was assessed in a Primary Care surgical clinic and found to have a moderate-sized, tender, irreducible right inguinal hernia. He underwent immediate surgery under local anaesthetic. He was found to have a peri-appendicular abscess and perforated appendix within a right indirect inguinal hernia sac. Appendicectomy and sutured hernia repair were performed under local anaesthesia.

Interdigitating dendritic cell sarcoma of salivary gland associated lymphoid tissue not associated with HHV-8 or EBV infection.

Interdigitating dendritic cell sarcoma (IDCS) is an extremely rare malignancy derived from professional antigen presenting cells. This report describes a case of IDCS arising in the salivary gland associated lymphoid tissue of the parotid gland of a 51 year woman, presenting with a painless neck swelling. Histologically, sheets of S100(+)/Ccd68(+)/CD45(+)/CD34(-)/CD1a(-) spindle cells were surrounded with an inflammatory infiltrate with no evidence of B or T cell clonal proliferations. No evidence of either human herpesvirus 8 or Epstein-Barr virus could be detected by quantitative polymerase chain reaction in the tumour cells with serological evidence of previous Epstein-Barr virus infection. The patient remains well and disease free 24 months after presentation without specific treatment.

The effects of early tourniquet release during total knee arthroplasty: a prospective randomized double-blind study.

We studied the effects of the timing of tourniquet release in 88 patients randomly allocated for release after wound closure and bandaging (group A), or before the quadriceps layer had been closed allowing control of bleeding before suture (group B). The groups were similar in mean age, weight, gender, preoperative knee score, radiographic grading, and prosthesis implanted. Patients in group B had less postoperative pain, achieved earlier straight-leg raising, and had fewer wound complications. Five patients in group A had to return to theatre, three for manipulation under anaesthesia, one for secondary closure of wound dehiscence, and one for drainage of a haematoma. The last patient later developed a deep infection, which was treated by a two-stage revision. There were no significant differences between the two groups in operating time, or the decrease in haemoglobin concentration at 48 hours postoperatively. Some of the adverse effects of the use of a tourniquet for knee surgery can be significantly reduced by early tourniquet release, with haemostasis before the quadriceps mechanism and the wound are closed.

Over a thousand ambulatory hernia repairs in a primary care setting.

INTRODUCTION: This paper outlines the development and feasibility of a dedicated ambulatory primary care hernia service and examines the outcomes achieved during the period 1 March 2005 to 31 December 2008. PATIENTS AND METHODS: A prospective analysis of 1164 patients who underwent abdominal wall hernia repair at Probus Surgical Centre during the study period. The operations were carried out by two GPs with a special interest (GPwSI) and one retired surgeon. The techniques used were a Lichtenstein mesh repair or modified Shouldice repair for inguinal hernias and a primary sutured repair for ventral hernias. All procedures were performed as day-cases under local anaesthesia without sedation. All patients were reviewed routinely at 6 weeks. The primary outcomes of the study were recurrence and patient satisfaction levels, and complications such as infection, haematoma and chronic pain. RESULTS: No patient required conversion to general anaesthesia. There were three (0.3%) recurrences. Complication rates were low and similar to those obtained in other specialist hernia units. More than 90% of patients were satisfied with the service and would recommend it to a friend. CONCLUSIONS: Routine elective abdominal wall hernia repairs can be performed in a primary care setting, safely and with excellent outcomes.

Exercise training has greater effects on insulin sensitivity in daughters of patients with type 2 diabetes than in women with no family history of diabetes.

AIMS/HYPOTHESIS: Sedentary offspring of patients with type 2 diabetes are often more insulin-resistant than persons with no family history of diabetes, but when active or fit offspring of type 2 diabetic patients are compared with non-diabetic persons, differences in insulin resistance are less evident. This study aimed to determine the effects of an exercise training intervention on insulin sensitivity in both groups. METHODS: Women offspring (n = 34) of type 2 diabetic patients (offspring age 35.6 +/- 7.0 years, BMI 28.1 +/- 5.1 kg/m(2)) and 36 matched female controls (age 33.6 +/- 6.1 years, BMI 27.3 +/- 4.7 kg/m(2)) participated. Body composition, fitness and metabolic measurements were made at baseline and after a controlled 7 week exercise intervention. RESULTS: At baseline, insulin sensitivity index (ISI) was 22% lower in offspring than controls (p < 0.05), despite similar body fat and maximal oxygen uptake (.VO(2max)) values in the two groups. ISI increased by 23% (p < 0.05) in offspring following the exercise intervention, compared with 7% (NS) in the controls. Increases in .VO(2max) were similar in both groups (controls 12%, offspring 15%, p < 0.05 for both). Plasma leptin concentrations decreased significantly in the offspring (-24%, p < 0.01) but not in controls (0%, NS). Change in ISI correlated significantly with baseline ISI (r = -0.47, p < 0.0005) and change in leptin (r = -0.43, p < 0.0005). The latter relationship was not attenuated by adjustment for changes in body fat. CONCLUSIONS/INTERPRETATION: Offspring, but not controls, significantly increased ISI in response to an exercise intervention, indicating that insulin sensitivity is more highly modulated by physical activity in daughters of patients with type 2 diabetes than in women with no family history of the disease.