Giant peritoneal loose body: an instance of incidentaloma or warranted concern?

SUMMARY: In non-specific abdominal pain, cross-sectional imaging, often valued more than clinical examination in today's technologically advanced age, may reveal a large incidentaloma, posing questions regarding its relation to symptoms and the need for surgical removal. This is a situation that highlights the potential for early detection and treatment yet raises the question as to whether surgery is indeed indicated. This report relates the case of a 79-year-old male, with a longstanding history of abdominal pain, who had a giant loose peritoneal body removed. We discuss the reasons for removal and its pathogenesis.

Trabecular bone density in premenopausal rheumatoid arthritis patients.

OBJECTIVE: This study was undertaken to compare trabecular bone mineral density (BMD) in premenopausal rheumatoid arthritis (RA) patients and normal age-matched controls. METHOD: A protocol was designed to record age, duration of disease, use of corticosteroids (CS) and/or slow-acting antirheumatic drug (SAARD) therapy together with duration of such therapy. BMD was measured using the Hologic QDR 1,000 dual energy X-ray absorptiometer. The first four lumbar vertebrae and the left femur were measured in 56 RA patients and 165 controls. Height and weight were measured. Comparisons were made between RA patients and controls, as well as between subgroups of RA patients based on CS therapy. RESULTS: Patients with RA had significantly lower BMD (P < 0.05) at all the sites than the normal controls. The mean duration of RA at the time of study was 60 months (standard deviation 58 months). Thirteen RA patients had used CS in doses less than 10 mg daily for 6 months or longer (mean 19 months), while 25 patients had been on SAARD for an excess of 6 months (mean 23 months). The CS-treated patients had significantly lower BMD than untreated subjects at the femoral neck and inter-trochanteric region (P < 0.05), but not at the lumbar spine. However, when compared with normal controls, the CS-treated subgroups had significantly lower BMD at the lumbar spine and all femoral areas. Trochanteric BMD was the best determinant of the RA group, with a sensitivity of 65% and specificity of 77%. The positive predictive value was 16%, while the negative predictive value was 10%. Using Bayes' theorem, the prevalence of osteopenia in RA was found to be 6%. CONCLUSION: We conclude that generalised bone loss is a systemic feature of RA and that loss at the spine and femur may be aggravated by CS therapy.

Assessing the use of nuclear medicine technology in sub-Saharan Africa: the essential equipment list.

OBJECTIVE: The primary aim of the survey was to determine the core equipment required in a nuclear medicine department in public hospitals in Kenya and South Africa, and evaluate the capital investment requirements. METHODS: Physical site audits of equipment and direct interviews of medical and clinical engineering professionals were performed, as well as examination of tender and purchase documents, maintenance payment receipts, and other relevant documents. Originally, 10 public hospitals were selected: 6 referral and 4 teaching hospitals. The 6 referral hospitals were excluded from the survey due to lack of essential documents and records on equipment. The medical and technical staff from these hospitals were, however, interviewed on equipment usage and technical constraints. Data collection was done on-site and counter-checked against documents provided by the hospital administration. RESULTS: A list of essential equipment for a nuclear medicine department in sub-Saharan Africa was identified. Quotations for equipment were provided by all major equipment suppliers, local and international. CONCLUSION: A nuclear medicine department requires eight essential pieces of equipment to operate in sub-Saharan Africa. Two additional items are desirable but not essential.

Long-term restoration of deficits in bone mineral density is inadequate in premenopausal women with prior menstrual irregularity.

OBJECTIVE: To investigate change in bone mineral density (BMD) in premenopausal women (age, 29-46 years), some of whom were marathon runners with a history of menstrual irregularity. DESIGN: Longitudinal follow-up. SETTING: University medical school. PARTICIPANTS: We investigated 8 sedentary controls (SC) and 19 marathon runners (12 with regular menses (R) and 7 with a history of irregularity (OA) 11.7 +/- 7.9 years before follow-up). MAIN OUTCOME MEASURES: BMD (g/cm2) of lumbar spine (LS) and proximal femur were determined at baseline and follow-up (3-5 years later). We calculated a menstrual history index (MHI) (estimated periods/year since age 13). RESULTS: Body mass, age at menarche, and femoral BMD were not statistically different. Follow-up LS BMD (g/cm2) was lower (p < 0.01) in OA (0.936 +/- 0.060) than in R (1.043 +/- 0.103) and SC (1.094 +/- 0.077), even when covarying for age or both age and mass. No group changed BMD significantly with time. Current MHI was lower (p < 0.001) in OA (9.7 +/- 1.4) than in R (11.3 +/- 0.5) and SC (11.8 +/- 0.4). MHI for the teenage years was lower in OA than in SC but not in R. OA had significantly lower MHI than did R and SC for the third and fourth decades. Only MHI during the third decade correlated significantly with LS BMD for all subjects. CONCLUSIONS: Restoration of LS BMD deficit in women with prior menstrual irregularity aged over 30 is slow and may never reach the same level as age-related controls; secondly, this may be the result of both bone loss in the third decade of life and reduced acquisition during adolescence.

Technetium-99m-sestamibi uptake in myeloma.

A number of reports describe how 99mTc-sestamibi detects benign and malignant primary and metastatic tumors. We report abnormal 99mTc-sestamibi uptake in nine sites in a 53-yr-old patient with histologically and biochemically proven IgG kappa-secreting myeloma. The 99mTc-sestamibi study was undertaken for an unrelated hyperparathyroidism.

Bone mineral density in mature, premenopausal ultramarathon runners.

We measured bone mineral density (BMD) in 25 premenopausal ultramarathon (56 km) runners aged 29-39 yr and related risk factors for decreased BMD with actual BMD. Fifteen runners who had never had oligo/amenorrhea (R) were compared with 10 runners (OA): 4 oligomenorrheic, 2 amenorrheic, and 4 with prior oligo/amenorrhea. Menstrual, dietary and training data were obtained. BMD of the lumbar spine (LS) and proximal femur (F) were measured by dual energy x-ray densitometry. Both groups had similar body mass (58 +/- 8 vs 57 +/- 8 kg), running and dietary histories. F BMD was not different (P = 0.07) and correlated only with BMI (P < 0.05; r = 0.43). LS BMD was lower in OA (0.946 +/- 0.098 g.cm-2) than R (1.088 +/- 0.069 g.cm-2; P < 0.001). Menstrual History Index (MHI), (estimated periods.yr-1 since age 13), was higher in R (11.6 +/- 0.6) than OA (9.4 +/- 2.1; P < 0.01). LS BMD correlated with MHI (P < 0.0005; r = 0.67) and years oligomenorrheic (P < 0.01; r = -0.58) but not years amenorrheic, parity, breastfeeding, diet, or training. In conclusion, in mature women distance runners low LS BMD is related to a history of oligo/amenorrhea regardless of resumption of regular menstrual cycles in some subjects. Not only amenorrhea, but also prolonged oligomenorrhea may negatively influence peak adult bone mass.

Assessment of age-related bone loss in normal South African women by means of the Hologic QDR 1000 system.

The aim of this study was to evaluate age-related changes in cortical and trabecular bone mineral density (BMD) in South African subjects, and to develop a local reference database for dual energy X-ray absorptiometry with the QDR 1000 densitometer. A questionnaire was used to recruit volunteers. Age, years since menopause, use of medications and medical diseases were recorded. Men were excluded. Only whites and coloureds were studied. Three hundred and eleven women had single measurements over a 2-year period. Seven sets of subjects were defined according to age (18-44; 45-49; 50-54; 55-59; 60-64; 65-69; > 70 years) (N = 163; 32; 35; 23; 25; 16; 17 respectively). Height and weight did not change significantly with age. There were significant differences in lumbar and femoral BMD (Ward's) compared with those of American subjects in the different age categories. Both the lumbar and total femoral BMD began to fall significantly between the ages of 60 and 65 years (P < 0.01). Ward's triangle showed a significant fall in BMD between 45 and 50 years of age (P < 0.01). Ward's BMD predicted 36% of the variation in lumbar BMD at 45 years but 10% at 70 years. Ward's triangle is a useful predictor of femoral bone loss in later years. The fracture threshold at the lumbar vertebrae was 0.822 g/cm2; at Ward's triangle it was 0.443 g/cm2. This gave a 16% prevalence of osteopenia in the lumbar region and a prevalence of 24% at Ward's area.

Loss of trabecular bone mineral density in systemic lupus erythematosus.

OBJECTIVE: To evaluate trabecular bone mineral density (BMD) in young ambulatory female patients with systemic lupus erythematosus (SLE). METHODS: Bone mineral density (gm/cm2) at the lumbar vertebrae (L1-L4) and at the left femur (neck, trochanter, intertrochanter, and Ward's triangle) was measured by dual x-ray absorptiometry in 46 SLE patients (mean age 31 years, mean disease duration 76 months) and in 108 healthy female controls (mean age 32 years). Twenty-two of the SLE patients were receiving corticosteroids (CS) at the time of the study. RESULTS: Lumbar BMD in the SLE patients was less severely reduced than was BMD at the femoral sites, but the SLE group was closer to the lumbar fracture threshold of 0.812 gm/cm2 than was the control group (P = 0.0009). There were no significant differences between the SLE patients currently being treated with corticosteroids and those who were not (P > 0.3). BMD at Ward's triangle and at the femoral neck was not significantly reduced in the SLE patients. Total femoral BMD had a sensitivity of 76% and specificity of 62% in differentiating the SLE group from the controls. The positive predictive value was 61% and the negative predictive value was 89%. The prevalence of osteopenia in the SLE patients was 25%. CONCLUSION: SLE causes significant trabecular bone loss, which is not due to corticosteroid therapy.

Low bone density is an etiologic factor for stress fractures in athletes.

OBJECTIVE: To determine whether low bone density and other risk factors for osteoporosis are associated with stress fractures in athletes. DESIGN: Case-control study. SETTING: Institutional sports injury clinic with primary and secondary care. PARTICIPANTS: Twenty-five athletes (nineteen women) with scintigraphically confirmed stress fractures matched for sex, age, weight, height, and exercise history with 25 control athletes with no history of bone injury. MEASUREMENTS AND MAIN RESULTS: Bone mineral density measured by dual-energy x-ray absorptiometry was significantly lower in athletes with fractures than in control athletes: In the spine, bone mineral density was 1.01 +/- 0.14 g/cm2 in athletes with fractures and 1.11 +/- 0.13 g/cm2 in control athletes (P = 0.02). In the femoral neck, it was 0.84 +/- 0.09 g/cm2 in athletes with fractures and 0.90 +/- 0.11 g/cm2 in control athletes (P = 0.005). It was also significantly lower in the Ward triangle (P = 0.01) and the greater trochanter (P = 0.01). Eight athletes with fractures and no control athletes had less than 90% of predicted age-related spine density (P = 0.01), and three athletes with fractures had bone mineral densities that were 2 SDs or more below this predicted level. More athletes with fractures than control athletes had current menstrual irregularity (amenorrhea or oligomenorrhea) (P less than 0.005). Fewer athletes with fractures were using oral contraceptives (P less than 0.05). Seven-day diet records indicated similar energy and nutrient intakes, except athletes with fractures had lower calcium intakes (697 +/- 242 mg/d compared with 832 +/- 309 mg/d; P = 0.02). Dairy product intake was lower in athletes with fractures since leaving high school (P less than 0.05). The incidence of a family history of osteoporosis was similar in both groups. CONCLUSIONS: In athletes with similar training habits, those with stress fractures are more likely to have lower bone density, lower dietary calcium intake, current menstrual irregularity, and lower oral contraceptive use.

Pentavalent technetium-99m (V)-DMSA uptake in a pheochromocytoma in a patient with Sipple's syndrome.

This case report describes 99mTc(V)-dimercaptosuccinic acid (DMSA) accumulation in a pheochromocytoma in a patient with Sipple's syndrome. Scintigraphy with 99mTc(V)-DMSA demonstrated uptake in medullary carcinoma of the thyroid gland (MCT). Iodine-131 metaiodobenzylguanidine (MIBG) scintigraphy showed the bilateral pheochromocytomas but did not demonstrate uptake in the MCT.

A feasibility study of a new approach to clinical radiosensitisation: hypothermia and hyperbaric oxygen in combination with pharmacological vasodilatation.

It is proposed that hyperbaric oxygen fails in the clinical situation due to a high proportion (greater than 33%) of hypoxic cells in human tumours. The means of overcoming this problem are reviewed. Additional to hyperbaric oxygenation, moderate hypothermia (30 degrees C) to allow redistribution of oxygen in the tumour is proposed. A system of externally controlled intravenous anaesthesia has been developed for the single-subject hyperbaric cylinder. Pharmacological vasodilatation is induced in the anaesthetised patient who is then fluid loaded and cooled. Initial single-sensitising treatments are advocated. Twenty-nine patients with advanced mouth cancer have completed a course of this treatment, of whom five of nine were free of disease after 2 years and 10 of 21 at 1 year, with three intercurrent deaths. Fifteen have experienced local failure. This approach would appear to be practical, safe and promising.