PLASMAPHERESIS IN RAYNAUD'S DISEASE

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/22629/1/0000179.pd

MEN I pancreas: A histological and immunohistochemical study

The spectrum and extent of islet cell histopathological findings in patients with multiple endocrine neoplasia, type I (MEN I) syndrome has never been clearly defined. Although some patients have discreet tumors causing clinically evident syndromes, others may have no symptoms until metastatic islet cell carcinoma is apparent. Whether diffuse islet cell disease occurs in all patients with grossly apparent tumors is not known. This study is an attempt to define both the functional and anatomical extent of islet cell disease and its relationship with the clinical course of patients with MEN I syndrome. The resected specimens of pancreas from 14 patients with MEN I syndrome were evaluated for hyperplasia, nesidioblastosis, multiple tumors, and evidence of malignancy. In 12 cases, specimens consisted of distal pancreas and, in 2 cases, the entire pancreas was available. Multiple sections were taken from each specimen. Immunoperoxidase staining was done for gastrin, pancreatic polypeptide, glucagon, serotonin, VIP, somatostatin, and neuron-specific enolase in sections of 24 tumors from 10 patients. Five of the 10 patients with Zollinger-Ellison syndrome underwent total gastrectomy and 3 others underwent only pancreatic procedures to control their acid hypersecretion. The following is concluded. All MEN I patients with pancreatic neoplasms have diffuse islet cell involvement consisting of nesidioblastosis, micro- and macronodular hyperplasia. Some tumors produce multiple hormones and these patients are at risk to develop new tumors, but complete excision of grossly apparent tumors may result in long-term control of the endocrinopathy present. This is particularly true for patients with insulinoma and hypoglycemia. Selected patients with gastrinoma may also be considered for excision of their islet cell tumor(s) without concomitant gastrectomy, especially if transhepatic venous sampling demonstrates a single site of excess gastrin production. However, if transhepatic venous sampling demonstrates diffuse sources of hypergastrinemia, a local pancreatic procedure will invariably be unsuccessful. Total pancreatectomy in MEN I patients with disease localized to the pancreas is the only curative surgical procedure but is rarely indicated. L'histopathologie des cellules insulaires pancréatiques des malades qui présentent un syndrome MEN I n'a jamais été parfaitement définie. Si certains parmi eux sont porteurs de petites tumeurs qui se manifestent par des syndromes cliniques patents, d'autres n'accusent aucun symptôme avant que des métastases néoplasiques ne se manifestent. En particulier, on ne sait pas si les altérations des cellules insulaires sont diffuses quand les malades présentent des tumeurs évidentes. Cette étude a pour but de définir à la fois l'importance anatomique et l'importance fonctionnelle de la maladie insulaire par rapport à son expression clinique chez les sujets concernés par ce syndrome. Pour ce faire, des spécimens provenant de 14 malades atteints du syndrome MEN I ont été étudiés eu égard à l'hyperplasie, à la nésidioblastose, à la multiplicité des îlots tumoraux, à la malignité. Dans 12 cas, les spécimens répondaient au pancréas distal, dans 2 cas à la totalité du pancréas. De multiples coupes furent pratiquées au niveau de chaque pièce soumise à l'examen. L'imprégnation à l'immunoperoxidase concerna les coupes de 24 tumeurs provenant de 10 patients. Cinq des 10 malades qui présentaient un syndrome de Zollinger-Ellison avaient subi une gastrectomie totale et 3 une intervention pancréatique pour contrôler leur hypersécrétion acide. Les conclusions tirées de cette étude furent les suivantes: tous les malades accusant un syndrome MEN I et porteurs d'un néopolasme pancréatique présentaient des lésions insulaires diffuses répondant à une nésidioblastose, à une hyperplasie micronodulaire et macronodulaire. Quelques tumeurs produisaient de multiples hormones: gastrine, polypeptide pancréatique, glucagon, sérotonine, V.I.P., somatostatine, testées par la méthode. Il résulte de ces constatations que les risques de récidive tumorale après exérèse complète des tumeurs évidentes ne sont pas à écarter, encore que l'exérèse permette de contrôler longtemps l'endocrinopathie. Ceci est particulièrement vrai pour les insulinomes hypoglycémiants. En ce qui concerne les gastrinomes, leur exérèse peut être suffisante, en particulier lorsque les prélèvements veineux étagés montrent qu'ils sont uniques; la gastrectomie concomitante est alors inutile. En revanche, lorsque la gastrine est trouvée en excès au niveau de multiples échantillons veineux, l'exérèse tumorale est insuffisante et la pancréatectomie totale représente l'intervention indispensable; en fait, son indication est rare. La variedad del espectro de la histopatología de las células insulares en pacientes con sindrome de neoplasias endocrinas múltiples tipo I (NEM I) todavía no ha sido claramente definido. Aún cuando algunos pacientes poseen tumores discretos que causan síndromes clínicamente evidentes, otros pueden no exhibir sintomatología alguna hasta cuando se hace evidente un carcinoma metastásico de células insulares. No se sabe si hay enfermedad difusa de las células insulares en todo paciente con tumores macroscópicamente aparentes, ni además se conoce con qué frecuencia se desarrollan nuevos tumores en pacientes con síndrome NEM I después de resección local o de pancreatectomía parcial para tumores primarios de células insulares. El presente estudio intenta definir la extensión funcional y anatómica de la enfermedad de las células insulares y su relación con la evolución clínica en pacientes con el síndrome NEM I.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/41313/1/268_2005_Article_BF01654938.pd

Inguinal Hernia in Athletes: Role of Dynamic Ultrasound

BACKGROUND: Inguinal hernia is a commonly encountered cause of pain in athletes. Because of the anatomic complexity, lack of standard imaging, and the dynamic condition, there is no unified opinion explaining its underlying pathology. HYPOTHESIS: Athletes with persistent groin pain would have a high prevalence of inguinal hernia with dynamic ultrasound, and herniorrhaphy would successfully return athletes to activity. STUDY DESIGN: Case-control study. LEVEL OF EVIDENCE: Level 3. METHODS: Forty-seven amateur and professional athletes with sports-related groin pain who underwent ultrasound were selected based on history and examination. Patients with prior groin surgery or hip pathology were excluded. Clinical and surgical documentation were correlated with imaging. The study group was compared with 41 age-matched asymptomatic athletes. RESULTS: Ultrasound was positive for hernia with movement of bowel, bladder, or omental tissue anterior to the inferior epigastric vessels during Valsalva maneuver. The 47-patient symptomatic study group included 41 patients with direct inguinal hernias, 1 with indirect inguinal hernia, and 5 with negative ultrasound. Of 42 patients with hernia, 39 significantly improved with herniorrhaphy, 2 failed to improve after surgery and were diagnosed with adductor longus tears, and 1 improved with physical therapy. Five patients with negative ultrasound underwent magnetic resonance imaging and were diagnosed with hip labral tear or osteitis pubis. The 41-patient asymptomatic control group included 3 patients with direct inguinal hernias, 2 with indirect inguinal hernias, and 3 with femoral hernias. CONCLUSION: Inguinal hernias are a major component of groin pain in athletes. Prevalence of direct inguinal hernia in symptomatic athletes was greater than that for controls ( P \u3c 0.001). Surgery was successful in returning these athletes to sport: 39 of 42 (93%) athletes with groin pain and inguinal hernia became asymptomatic. CLINICAL RELEVANCE: Persistent groin pain in the athlete may relate to inguinal hernia, which can be diagnosed with dynamic ultrasound imaging. Herniorrhaphy is successful at returning athletes to sports activity

Clinical Value of Calcitonin and Carcinoembryonic Antigen Doubling Times in Medullary Thyroid Carcinoma

Doubling times of basal and stimulated calcitonin (CT) levels and of random carcinoembryonic antigen (CEA) levels were compared over time in 11 patients with residual medullary thyroid carcinoma (MTC)—five with the sporadic MTC and six with the hereditary MTC. Four patients with an indolent form of the disease showed little change in CT levels over three to eight years and little change in CEA doubling times (42 to 70+ months). Seven patients showing rapid progression of disease had CT doubling times of three to 11 months and CEA doubling times of two to 12 months (however, one patient showed no change in CEA). A twelfth patient had a marked increase in CT doubling during two separate periods of pregnancy and lactation. We conclude that both CT and CEA levels may be helpful prognostically in patients with residual MTC, and each should be determined at intervals. Doubling time calculations provide practical estimations whereby the effects of therapeutic approaches, pregnancy, and various environmental influences on the growth of MTC can be evaluated

Inguinal Hernia in Athletes: Role of Dynamic Ultrasound

BACKGROUND: Inguinal hernia is a commonly encountered cause of pain in athletes. Because of the anatomic complexity, lack of standard imaging, and the dynamic condition, there is no unified opinion explaining its underlying pathology. HYPOTHESIS: Athletes with persistent groin pain would have a high prevalence of inguinal hernia with dynamic ultrasound, and herniorrhaphy would successfully return athletes to activity. STUDY DESIGN: Case-control study. LEVEL OF EVIDENCE: Level 3. METHODS: Forty-seven amateur and professional athletes with sports-related groin pain who underwent ultrasound were selected based on history and examination. Patients with prior groin surgery or hip pathology were excluded. Clinical and surgical documentation were correlated with imaging. The study group was compared with 41 age-matched asymptomatic athletes. RESULTS: Ultrasound was positive for hernia with movement of bowel, bladder, or omental tissue anterior to the inferior epigastric vessels during Valsalva maneuver. The 47-patient symptomatic study group included 41 patients with direct inguinal hernias, 1 with indirect inguinal hernia, and 5 with negative ultrasound. Of 42 patients with hernia, 39 significantly improved with herniorrhaphy, 2 failed to improve after surgery and were diagnosed with adductor longus tears, and 1 improved with physical therapy. Five patients with negative ultrasound underwent magnetic resonance imaging and were diagnosed with hip labral tear or osteitis pubis. The 41-patient asymptomatic control group included 3 patients with direct inguinal hernias, 2 with indirect inguinal hernias, and 3 with femoral hernias. CONCLUSION: Inguinal hernias are a major component of groin pain in athletes. Prevalence of direct inguinal hernia in symptomatic athletes was greater than that for controls ( P \u3c 0.001). Surgery was successful in returning these athletes to sport: 39 of 42 (93%) athletes with groin pain and inguinal hernia became asymptomatic. CLINICAL RELEVANCE: Persistent groin pain in the athlete may relate to inguinal hernia, which can be diagnosed with dynamic ultrasound imaging. Herniorrhaphy is successful at returning athletes to sports activity

Inguinal Hernia in Athletes: Role of Dynamic Ultrasound.

BACKGROUND: Inguinal hernia is a commonly encountered cause of pain in athletes. Because of the anatomic complexity, lack of standard imaging, and the dynamic condition, there is no unified opinion explaining its underlying pathology. HYPOTHESIS: Athletes with persistent groin pain would have a high prevalence of inguinal hernia with dynamic ultrasound, and herniorrhaphy would successfully return athletes to activity. STUDY DESIGN: Case-control study. LEVEL OF EVIDENCE: Level 3. METHODS: Forty-seven amateur and professional athletes with sports-related groin pain who underwent ultrasound were selected based on history and examination. Patients with prior groin surgery or hip pathology were excluded. Clinical and surgical documentation were correlated with imaging. The study group was compared with 41 age-matched asymptomatic athletes. RESULTS: Ultrasound was positive for hernia with movement of bowel, bladder, or omental tissue anterior to the inferior epigastric vessels during Valsalva maneuver. The 47-patient symptomatic study group included 41 patients with direct inguinal hernias, 1 with indirect inguinal hernia, and 5 with negative ultrasound. Of 42 patients with hernia, 39 significantly improved with herniorrhaphy, 2 failed to improve after surgery and were diagnosed with adductor longus tears, and 1 improved with physical therapy. Five patients with negative ultrasound underwent magnetic resonance imaging and were diagnosed with hip labral tear or osteitis pubis. The 41-patient asymptomatic control group included 3 patients with direct inguinal hernias, 2 with indirect inguinal hernias, and 3 with femoral hernias. CONCLUSION: Inguinal hernias are a major component of groin pain in athletes. Prevalence of direct inguinal hernia in symptomatic athletes was greater than that for controls ( P \u3c 0.001). Surgery was successful in returning these athletes to sport: 39 of 42 (93%) athletes with groin pain and inguinal hernia became asymptomatic. CLINICAL RELEVANCE: Persistent groin pain in the athlete may relate to inguinal hernia, which can be diagnosed with dynamic ultrasound imaging. Herniorrhaphy is successful at returning athletes to sports activity

Value of Preoperative Ultrasonography in the Surgical Management of Initial and Reoperative Papillary Thyroid Cancer

Background: Cervical recurrences, predominantly in lymph nodes, occur in 14% to 30% of patients with papillary thyroid cancer (PTC). Postoperative surveillance for recurrent PTC increasingly includes thyrotropin-stimulated thyroglobulin and high-resolution ultrasonography (US). This combination commonly can detect recurrent disease as small as 5 mm. Hypothesis: Preoperative US will increase detection and assessment of the extent of lymph node metastasis (LNM) in patients with PTC. Design: Retrospective cohort study. Setting: Tertiary care academic center. Patients: From January 1, 1999, to December 31, 2004, a total of 770 patients were seen, 551 (381 female and 170 male; median age, 47 years; age range, 9-89 years) who underwent initial surgical management and 219 (154 female and 65 male; median age, 44 years; age range, 5-90 years) who underwent cervical reoperation for PTC. The US images were obtained preoperatively for 486 initial and 216 reoperative patients. Therapeutic radioactive iodine was administered to 151 (68.9%) of the reoperative patients before the subsequent operation (median dose, 5.6 × 109 Bq; range, 7.4 × 108-3.7 × 1010 Bq). Results: Ultrasonography identified nonpalpable lateral jugular LNMs in 70 (14.4%) of the patients undergoing initial exploration. Similarly, in reoperative patients, nonpalpable lateral LNMs were detected via US in 106 (64.2%), and 61 (28.2%) had LNMs detected in the central neck. Even when nodes were palpable preoperatively (37 [6.7%] of the initial and 56 [25.6%] of the reoperative patients), US assessment of the extent of LNM involvement altered the operation in 15 (40.5%) of the initial and 24 (42.9%) of the reoperative patients. The sensitivity, specificity, and positive predictive value for US were 83.5%, 97.7%, and 88.8% in initial patients, and 90.4%, 78.9%, and 93.9% in reoperative patients. Conclusions: Overall, preoperative US detected nonpalpable LNMs in 231 (32.9%) of the 702 patients with PTC who underwent US, thereby altering the operative procedure performed. In addition, even in patients with palpable LNs, US helped to guide the extent of lymphadenectomy