Diagnostic values of ultrasound and the Modified Alvarado Scoring System in acute appendicitis

BACKGROUND: Making the diagnosis of acute appendicitis is difficult, and is important for preventing perforation of the appendix and negative appendectomy results. Ultrasound and clinical scoring systems are very helpful in making the diagnosis. Ultrasound is non-invasive, available and cost-effective, and can accomplish more than CT scans. However, there is no certainty about its effect on the clinical outcomes of patients, and it is operator dependent. Counting the neutrophils as a parameter of the Alvarado Scale is not routine in many laboratories, so we decided to evaluate the diagnostic value of the Modified Alvarado Scaling System (MASS) by omitting the neutrophil count and ultrasonography. METHODS: After ethical approval of methodology in Tehran University of Medical Sciences ethical committee, we collected the data. During 9 months, 75 patients with right lower quadrant pain were enrolled in the study, and underwent abdominal ultrasonography and appendectomy, with pathological evaluation of the appendix. The MASS score was calculated for these patients and compared with pathology results. RESULTS: Fifty-five male and 20 female patients were assessed. Of these patients 89.3% had acute appendicitis. The sensitivity, specificity, PPV, NPV and accuracy rate of ultrasonography was 71.2%, 83.3%, 97.4%, 25% and 72.4%, respectively. By taking a cutoff point of 7 for the MASS score, a sensitivity of 65.7%, specificity of 37.5%, PPV of 89.8%, NPV of 11.5% and accuracy of 62.7% were calculated. Using the cutoff point of 6, a sensitivity of 85.1%, specificity of 25%, PPV of 90.5%, NPV of 16.7% and accuracy of 78.7% were obtained. CONCLUSION: Ultrasound provides reliable findings for helping to diagnose acute appendicitis in our hospital. A cutoff point of 6 for the MASS score will yield more sensitivity and a better diagnosis of appendicitis, though with an increase in negative appendectomy

Malignant Schwannoma of Anterior Abdominal Wall: Report of a Case

Malignant schwannoma of the anterior abdominal wall nerves is extremely rare. Malignant peripheral nerve sheath tumors (MPNST) represent approximately 10% of all soft tissue sarcomas and it is found in 4% of patients with neurofibromatosis 1. We present a case of malignant schwannoma in a 28-year-old female patient with neurofibromatosis 1. She presented with a painful mass in the right upper quadrant of her abdomen. The tumor location was in the abdominal wall in explorative laparatomy and malignant schwannoma was diagnosed in pathologic assessment. The tumor recurred in 3 months and computed tomography showed two masses in the right side of abdominopelvic cavity. Thereafter, second complete surgical resection was performed and pathologic finding was the same. In spite of administering chemotherapy after second surgery,the tumor recurred and magnetic resonance imaging finding showed a huge heterogeneously enhancing mass with adhesion to the inner side of the abdominal wall. The patient died because of acute respiratory failure due to multiple bilateral pulmonary metastases. Tumor location and rapid recurrence was unique in our patient

Comparison of Methoxyisobutylisonitrile Scintigraphy and Ultrasonography in Preoperative Localization of Secondary Hyperparathyroidism

Background: In patients with secondary hyperparathyroidism, the four glands are not uniformly enlarged; therefore, preoperative localization is difficult in comparison with primary hyperparathyroidism. The aim of this study was to compare the usefulness of 99mTc-sestamibi scintigraphy versus ultrasonography in the preoperative assessment of patients with secondary hyperparathyroidism.Methods: Between October 2008 and March 2012, 25 uremic patients with secondary hyperparathyroidism underwent 99mTc-sestamibi scintigraphy and high resolution ultrasonography before total or subtotal parathyroidectomy. We measured plasma concentration of intact parathyroid hormone (PTH), calcium, phosphorus, and alkaline phosphatase (ALP) before parathyroidectomy.Results: Sensitivity and positive predictive value (PPV), respectively, were 47.3% and 97.8% for MIBI scintigraphy, and 69.5% and 96.9% for ultrasonography. The sensitivity of combined techniques was 84.2%. There was a positive correlation between the parathyroid glands’ weight and serum calcium level, and positive MIBI scintigraphy and ultrasonography results. However, there was no correlation between the preoperative serum PTH, phosphorus, alkaline phosphatase (ALP), dialysis duration, and parathyroid glands’ weight.Conclusions: Ultrasonography is a reliable non-invasive localization tool. It has greater sensitivity in localizing parathyroid glands in secondary hyperparathyroidism than scintigraphy

Pancreas Transplantation: A Review of Literature

Pancreas transplantation has emerged as an effective treatment for patients with diabetes mellitus, especially those with established end-stage renal disease. Surgical and immunosuppressive advances have significantly improved allograft survival. The procedure reduces mortality compared with diabetic kidney transplant recipients and waitlisted patients. Improvements in diabetic nephropathy and retinopathy have also been demonstrated. Pancreas transplantation can improve cardiovascular risk profiles, improve cardiac function, and decrease cardiovascular events. Finally, improvements in diabetic neuropathy and quality of life can result from pancreas transplantation. Pancreas transplantation remains the most effective method to establish durable euglycemia for patients with diabetes mellitus

The Effect of Ticlopidine on Early Arteriovenous Fistula Thrombosis: A Randomized Clinical Trial

Background: Arteriovenous (AV) fistula is the first choice of a long-term vascular access for hemodialysis, but there is a 20-30% probability of thrombosis in the 1st month after its creation. Ticlopidine is a potent drug, which inhibits both primary and secondary platelet aggregation. This study is performed to evaluate the effect of ticlopidine in the prevention of AV fistula.Methods: Totally 124 patients in need of an AV fistula were divided into two groups after creation of their fistula. In the first group, we prescribed ticlopidine for 62 patients, and in the second group, 62 patients received placebo. The two groups were compared to see if their fistulas are patent or thrombotic after 1 and 3 months.Results: Of the 62 patients who received ticlopidine, four had fistula thrombosis, while in 62 patients who received placebo, 16 had fistula thrombosis (P = 0.003). This shows the significant effect of ticlopidine in the prevention of thrombosis in AV fistulas. Also, we compared age, sex, and the fistula location in the ticlopidine and placebo groups, and these attributes had no significant difference between the two groups (P > 0.050).Conclusions: Considering the significant value of ticlopidine in the prevention of AV fistula thrombosis, it can be recommended after the surgery if there is no contraindication for its use

Single Incision Laparoscopic Surgery: Review of Pros and Cons

Despite huge advances in minimally invasive surgeries, efforts still continue for finding less invasive methods of surgery. Patients desire less postoperative pain as well as better cosmetic outcomes. This may be achieved by decreasing the number of laparoscopic ports in which all the surgical maneuvers are performed through a single incision. However, surgeons should be also equipped to act well while avoiding adverse events of the new practicing approach. Along with increasing trends in performing of single incision laparoscopic surgery (SILS) in routine practice, the number of assessing the pros and cons of this new modality is also on the rise. Although it has been claimed that SILS is able to make the dream of invisible laparoscopy true for patients and surgeons, consecutive studies regarding postoperative outcomes questioned the benefits of the new evolved technique. Subsequent meta-analysis also revealed equal outcomes for SILS in comparison to the standard laparoscopy. Our review aimed to outline the pros and cons of SILS

Adenoma Weight and Biochemical Parameters in Primary Hyperparathyroidism

Background: Primary hyperparathyroidism is autonomous production of parathyroid hormone. After removal of adenoma, one of the surgeons concern is postoperative hypocalcaemia. There is no precise method to determine if patients have hypocalcaemia postoperatively. The purpose of this study was to determine the relation between parathyroid adenoma weights, postoperative serum calcium and serum biochemical parameters in patients with primary hyperparathyroidism. Methods: In a prospective study, eighty patients with single parathyroid adenoma were enrolled. Preoperative serum levels of calcium, phosphate, PTH, as well as Postoperative serum calcium and weight of adenomas were recorded. The level of significance was set to be p < 0.05. Results: There was no significant correlation between postoperative serum calcium, parathyroid adenoma weight (r= -0.17, p= 0.1), and parathyroid hormone level (r = -0.11, p = 0.3). However, a weak correlation between postoperative and preoperative serum calcium levels (r = 0.23, p = 0.03) was observed. Moreover, Serum calcium decline after adenoma resection was statistically correlated with adenoma weight (r = 0.36, p= 0.001), preoperative serum calcium (r = 0.92, p= 0.0007), PTH (r= 0.54, p= 0.0005) and ALP levels (r = 0.3, p= 0.006). Conclusion: Although preoperative serum markers and adenoma weight are unreliable in predicting postoperative serum calcium level, it is possible to estimate postoperative calcium decline by considering adenoma weight and preoperative serum biochemical parameters

Association of vitamin D levels and receptor gene polymorphisms with medullary thyroid cancer

Background: Thyroid cancer is the most common endocrine malignancy. Accounting for approximately 1-2% of all cancers. Thyroid cancers have been divided into four main types: papillary, follicular, medullary and anaplastic. The active form of vitamin D (1,25- (OH) 2-vitamin D3) by binding to its receptor, using genomic and non-genomic mechanisms inhibits the proliferative effect of TSH on thyroid cells. Therefore, vitamin D may have a role in regulating of thyroid gland cell proliferation. Many studies have shown anti-cancer effects of vitamin D in cancers. Polymorphisms of Vitamin D receptor can influence the prevalence to various cancers. In the present study, serum level of vitamin D and FokI, BsmI and Tru9I polymorphism of vitamin D receptor was investigated. Methods: This case-control study was performed in the summer of 2015 in Endocrinology and Metabolism Center of Shahid Beheshti University of Medical Sciences, Tehran, Iran. Forty medullary thyroid cancer patients and 40 healthy controls were investigated. Genomic DNA of subjects was extracted with saturated salt/proteinase K and polymorphisms of vitamin D receptor gene investigated by polymerase chain reaction-sequencing. Serum level of vitamin D evaluated by ELISA technique. The results were analyzed by SPSS, ver. 20 (Chicago, IL, USA) and GraphPad Prism, ver. 5 (GraphPad, Inc., CA, USA) softwares. Results: Genotypic and allelic abundance of FokI and BsmI polymorphisms between test and control groups have not shown significant different. In Tru9I polymorphism, Tt genotype abundance in test group were 45 percent and in control group were 17.5 percent and t allelic abundance in test group were 25 percent and in control group were 8.7 percent which this different were significant. Average serum level of vitamin D in test group was 23.32 ng/ml and in control group was 18.95 ng/ml which was statistically significant. Conclusion: Unexpectedly, serum levels of vitamin D in test group were higher than control group. Tru9I polymorphism is significantly correlated to medullary thyroid carcinoma prevalence

Parathyroid Adenoma Localization

Abstract Background: Bilateral neck exploration is the gold standard for parathyroid adenoma localization in primary hyperparathyroidism. But surgeons do not have adequate experience for accurate surgical exploration and new methods are developed for surgery like unilateral exploration and minimally invasive surgery, thus, preoperative localization could reduces time and stress in surgical performance. Method: 80 patients with documented primary hyperparathyroidism and with raised serum calcium and parathyroid hormone (PTH) were selected. The results of ultrasonographic localization for each patient were compared with findings of surgery and 99m technetium sestamibi scintigraphy. Also variables such as preoperative serum calcium, PTH level and adenoma weight were compared between patients who had localized and nonlocalized adenoma with ultrasonography or Sestamibi scan. The data was compared with student’s t-test. Results: In a prospective diagnostic tests’ accuracy, 80 patients with primary hyperparathyroidism were enrolled. Ultrasonography images detected enlarged parathyroid glands in 61 of 80 patients (76.3%) with sensitivity of 83.5% and positive predictive value (PPV) of 89.7%. Sestamibi scintigraphy detected adenoma in 63 patients (78.8%) with sensitivity of 85% and PPV of 91.3%. There was no significant deference between ultrasonography and scintigraphy in localization of adenomas. Both ultrasonography and scintigraphy used for determining localization, and they located 73 adenomas (91.3%) with sensitivity of 97.3% and PPV of 93.5%. Conclusion: Ultrasonography as an accurate method for localization of enlarged parathyroid glands in primary hyperparathyroidism, is comparable in overall utility with sestamibi scintigraphy. This study suggests a strategy for initial testing with one method, followed by the alternate imaging test if the first test happen to be negative