Critical limb ischaemia in a diabetic population from an Asian Centre: angiographic pattern of disease and 3-year limb salvage rate with percutaneous angioplasty as first line of treatment.

PURPOSE: Lower extremity amputation prevention (LEAP) is an ongoing program in our institution aimed at salvaging limbs in patients with critical limb ischemia (CLI). Patients in the LEAP program with reconstructible anatomy on initial Doppler imaging received either bypass surgery or percutaneous transluminal balloon angioplasty (PTA). We present the 3 year limb salvage rate and angiographic disease patterns in 42 consecutive diabetic patients with CLI who received PTA in 2005. METHODS AND MATERIAL: 26 women and 16 men with diabetes between the ages of 45 and 91 years old (mean age, 70.8 years) received PTA in 2005. Presenting symptoms were rest pain (n = 22), pre-existing gangrene (n = 17), non-healing ulcer (n = 16) and cellulitis (n = 2). The aim of the PTA was to achieve straight-line flow from the abdominal aorta down to the patent dorsalis pedis or plantar arch, with limb salvage as the ultimate outcome. Failure of treatment was defined as any amputation above the level of a Syme's amputation or the need for further surgical bypass. Technical success was achieved in 90% (38 out of 42 patients). RESULTS: Limb salvage rates were 93% at 1 month, 87% at 3 months, 82% at 6 months, 78% at 1 year, 69% at 2 years and 66% at 3 years. Mortality was 17% (n = 7) at 3 years. Of the 13 patients with failed therapy, 3 underwent bypass, 9 had amputations and 1 had bypass followed by amputation. Four of the cases required further intervention due to worsening gangrene and infection, while the remaining was due to persistent rest pain. The rest of the 32 patients had no lower limb related issues at the end of 3 years, with improvement of the presenting symptoms. Patterns of treated segments were aortoiliac occlusions (n = 3), pure infrapopliteal disease (n = 3), femoropopliteal with at least 1 good infrapopliteal run-off vessel (n = 14) and combined femoropopliteal and infrapopliteal disease (n = 25). CONCLUSION: Involvement of infrapopliteal vessels that needs to be treated is common in Asian diabetics. While early limb salvage rates up to 1 year are similar, the 3 year limb salvage rates in Asian diabetics are lower than the western population.

Transarterial embolisation of spontaneous adrenal pheochromocytoma rupture using polyvinyl alcohol particles.

The spontaneous rupture of a phaeochromocytoma is a rare and potentially fatal complication. Prompt diagnosis, patient stabilisation and adrenectomy are crucial for survival. However, it is known that adrenectomy performed in the emergency setting is associated with a high mortality rate, in contrast to the negligible mortality rate with elective surgery. We describe transcatheter arterial embolisation (TAE) using polyvinyl alcohol particles (PVA) in restoring haemodynamic stability during an acute phaeochromocytoma rupture in a 67-year-old man to avoid the risks of performing an emergency adrenectomy. TAE improves the prognosis significantly by prolonging treatment time for patient optimisation and to enable the possibility of elective adrenectomy. To the best of our knowledge, TAE using PVA in an acute phaeochromocytoma rupture has not been previously reported in the English literature.

Clinical utility of selective intra-arterial calcium-stimulated hepatic venous sampling in regionalisation of insulinomas--the Singapore experience.

INTRODUCTION: To evaluate the efficacy and safety of selective intra-arterial calcium-stimulated hepatic venous sampling (ASVS) as a preoperative regionalisation modality for insulinomas. DESIGN AND METHODS: Four patients with biochemically-proven endogenous hyperinsulinism and negative spiral computed tomographic (CT) pancreas were subjected to ASVS between October 1999 to May 2001. Results obtained from ASVS were compared with localisation studies using either magnetic resonance imaging (MRI) or endoscopic ultrasonography (EUS); and these were confirmed surgically whenever possible. RESULTS: ASVS led to a definitive regionalisation in all 4 patients evaluated; the predicted location of the insulinoma matched the findings intraoperatively in all 3 patients who were operated upon. These were all proven to be insulinoma histologically. However, 1 patient showed a positive ASVS result in samples obtained from the left hepatic vein only. In the patient who was unable to undergo surgical resection due to other co-morbid factors, his ASVS findings were corroborated by localisation obtained from the MRI study. Conversely, EUS was found to give an incorrect localisation of insulinoma in 1 patient. Adverse effects were encountered in 3 patients (2 with mild hypotension and 1 with transient atrial fibrillation); however, premature termination of the procedure was not necessary in any of the patients. CONCLUSION: ASVS is accurate and reliable for regionalisation of insulinoma, especially in patients who do not have an obvious, unequivocal tumour using high quality current-generation MRI scans.

Seabather's eruption. Clinical, histologic, and immunologic features.

BACKGROUND: Seabather's eruption (SE) is a highly pruritic eruption under swimwear that occurs after bathing in the ocean. Its cause has been unknown. Few data have been collected since the classic description by Sams in 1949. OBJECTIVE: Our purpose was to describe the clinical and histopathologic findings in SE and to confirm the cause. METHODS: Patients with a pruritic eruption that developed after swimming were seen within 1 week of onset. Skin biopsy specimens and sera were obtained in selected cases. Water samples taken from areas of active SE outbreaks were examined for a causative organism. Sera were tested by enzyme-linked immunosorbent assay for reactivity to this organism. RESULTS: In southeast Florida, during a 4-month period, 70 patients with SE were seen. Inflammatory papules and pruritus were noted within hours of exposure. Eruptions were maximal in areas covered by a bathing suit. Children were more likely than adults to have systemic symptoms. The average duration of the eruption and pruritus was 12.5 days, with recurrences in 4.3% of patients. Histopathologic examination revealed a superficial and deep perivascular and interstitial infiltrate consisting of lymphocytes, neutrophils, and eosinophils. Water samples contained many cnidarian larvae, later grown to maturity and identified as Linuche unguiculata (thimble jellyfish). Enzyme-linked immunosorbent assay demonstrated in patients' sera high IgG levels specific for L. unguiculata. CONCLUSION: SE is a severely pruritic marine dermatosis that resolves spontaneously within 2 weeks. Therapy is symptomatic but often ineffective. Sera from affected persons showed specific reactivity to L. unguiculata.

Preliminary report on ultrasound guided transrectal prostatic biopsy.

Transrectal ultrasound (TRUS)-guided transrectal biopsy was performed on 15 patients. Histological findings were carcinoma in three cases (20%), prostatitis in three cases (20%) and glandular atypia in two cases (13%). All lesions were located in the peripheral zone. Hyperechoic lesions on TRUS were seen in two of the three cases of prostatic carcinoma while hypoechoic lesions were seen in all three cases of prostatitis. Directed biopsies established the diagnosis in six cases. However, random biopsies revealed that the extent of involvement was underestimated in five of these six cases. In addition, random biopsies established the diagnosis in two cases where the directed specimen was negative. Where both digital rectal examination (DRE) and TRUS were positive for nodules and the prostatic specific antigen (PSA) was elevated, the histology was positive in 100%. Where both the DRE and TRUS were negative, the histology was negative irrespective of the PSA level. Patient acceptance of the procedure was high. Complications to the procedure were haematuria, passing blood per rectum and fever.

The long-term stability of recombinant (serine-17) human interferon-beta.

Escherichia coli-derived (Serine 17) human interferon-beta (HuIFN-beta SER) was formulated with SDS and placed at multiple isothermal temperatures (-70 degrees C to 37 degrees C). Three stability-indicating test methods (bioassay, SDS-PAGE, RP-HPLC) were used to evaluate the long-term stability of this preparation. No change was observed when stored for nearly a year at either -70 degrees C or 4 degrees C. At the elevated temperatures, proteolytic cleavage, noncovalent oligomer formation, and loss of antiviral activity were observed. The absence of a carrier protein makes this stable IFN-beta frozen reference preparation useful as a standard in both biological assays and protein chemical methods of analysis.

Parameters for the evaluation of long-term stability of tumour necrosis factor preparations.

Escherichia coli-derived Tumour Necrosis Factor (TNF) was formulated in the absence of a protein-carrier, both as a solution and as a lyophilized preparation. By means of three stability-indicating test methods (bioassay, SDS-PAGE, IEF), the long-term stability of these TNF preparations was evaluated. Both preparations showed no change upon storage for 9 months at -70 degrees C and -20 degrees C. Depending upon the test method, different rates of change were detected at elevated temperature. The analysis presented will assist in the design of future TNF reference standards.