Paradoxical embolism secondary to ovarian carcinoma resulting in stroke.

A middle aged woman presented with a posterior fossa stroke after an elective ear nose and throat procedure. The occurrence of a paradoxical embolism was suspected. The evidence for this and a discussion about this condition are presented.

Corticotroph pituitary carcinoma: case report and literature review.

Pituitary carcinomas, currently defined as primary adenohypophyseal neoplasms with evidence of either brain invasion or metastatic spread, are exceptionally rare. A case of corticotroph pituitary carcinoma is reported. A 17-year-old female first presented with an invasive and clinically non-functioning pituitary macroadenoma. The primary pituitary lesion lacked atypical histological features and retrospective immunohistochemical studies confirmed its corticotrophic nature. Repeated episodes of local recurrence followed together with the acquisition of severe Cushing's disease. Local disease control was not obtained despite repeated surgical decompression and courses of radiation therapy. Systemic dissemination with multiple bone metastases became manifest eleven years after the first presentation. Atypical histological features and Crooke's hyaline change were evident in both the recurrent and metastatic disease. She remains alive at last follow-up with severe complications relating to persisting sellar and metastatic disease and ongoing endocrine dysfunction. A further 32 cases of pituitary corticotroph carcinoma reported in English are reviewed to highlight the clinicopathological features of this rare form of pituitary neoplasm. Difficulties associated with the diagnosis and management of pituitary carcinoma are also discussed.

Choroid plexus carcinoma in an adult.

Choroid plexus carcinomas are rare in adults. They can behave aggressively and their optimal management is uncertain. An adult patient with choroid plexus carcinoma who was treated with an incomplete surgical resection and postoperative radiotherapy is reported. Despite an identifiable local response to radiotherapy, disease progression resulted in death 4 years after presentation. This report reviews the current literature and discusses the management issues regarding this uncommon adult malignancy.

Talc serodesis--report of four cases.

Talc is a known stimulator of fibrosis in biological systems. We present four cases in which instillation of talc in to serous cavities have produced obliteration of these cavities. No side-effects were noted.

Chronic subdural hematoma in a 50-year-old man with polycystic kidney disease.

The following case describes two spontaneous chronic subdural hematomas in one patient. The hematomas occurred on opposite sides. The patient had good blood pressure control and a normal creatinine. He was not receiving any anticoagulants or antiplatelet drugs. An angiogram was done after the second subdural collection was drained. There was no evidence of a vascular lesion. The possibility remains that patients with adult polycystic disease may be predisposed to develop spontaneous subdural hematomas in light of another report of five other cases.

Acute spontaneous spinal subdural haematoma: MRI features.

We present MRI findings in three patients with acute spontaneous subdural haematomas of the spine. Acute haematomas (1-3 days) were isointense or gave slightly high signal on T1-and heterogeneous signal on T2-weighted images. MRI precisely defined the level and extent of the haematoma preoperatively. The MRI was prospectively correctly interpreted as acute subdural haematomas in all patients. As a specific, noninvasive modality, MRI is the preferred imaging technique in this rare clinical entity.

Deep cervical fasciitis in a child.

Deep cervical infections in children are relatively uncommon and often require prolonged antibiotic therapy. The organism may not be isolated, in which case it is necessary to cover Gram-negative and Gram-positive organisms as well as anaerobes. During treatment continued vigilance is required to detect abscess formation, with ultrasound providing a useful tool for this purpose.

Cystosarcoma phyllodes: the Western Australian experience.

BACKGROUND: Cystosarcoma phyllodes is a rare breast tumour whose behaviour is not well understood by many clinicians. METHODS: In 1998 a retrospective study was undertaken of women diagnosed with phyllodes tumour of the breast who had their initial surgery between 1983 and 1994 in Western Australian public hospitals. RESULTS: Forty women were diagnosed and treated over this period; however, only 28 received ongoing follow-up (70%). Follow-up was obtained on 26 of these. The median age at diagnosis in this group was 46 years. Cases were predominantly Caucasian (85.5%). Postmenopausal women were affected in 26.9% of cases. Four patients had recurrences after surgery (one malignant and three benign). No patient had a recurrence with primary tumours with a diameter of < or = 2 cm. Mean time to recurrence was 35.8 months. CONCLUSIONS: Breast-conserving surgery was used in almost all cases (96.2% of first operations).

Cardiac reoperations in octogenerians.

OBJECTIVE: In recent years, satisfactory outcome of primary cardiac operation in octogenerians and increased ageing of cardiac surgical population in western hospitals have led to increased expectations and referrals for reoperation. Outcome of reoperation in this aged subset was analysed. METHODS: Consecutive 18 octogenerians (mean age 81.2 years, 10 men, eight women) undergoing cardiac reoperations from November 1989 through August 1998 were retrospectively reviewed. RESULTS: They represented 6.2% of all octogenerian cardiac surgical patients and 2.7% of all reoperations during the same period. Mean preoperative NYHA class was 3.4 and Parsonnet score was 29.4. The interval to reoperation was 114.5+/-11.96 (4-188) months. Priority was urgent in 11 and elective in seven patients. The procedures included four AVRs, five MVRs (including two associated TVAs), six CABGs and one each of MVR with CABG, AVR with CABG and AVR, MVR and CABG. Average graft/patient was 2.3. Mean ICU stay was 4.6+/-1.5 (1-28) days. There was one hospital death (5.5%) on 18 pod after MVR in an 83-year-old woman. Mean postoperative stay was 20.2+/-5.13 (8-93) days. There were three late deaths (17.6%)--at 32 months after MVR, at 44 and 63 months after CABG. Long-term survivors were 90% among men and 50% among women who were followed up for 42.7+/-6.9 (9-93) months. Mean Karnofsky score in survivors at 1 year of follow-up was 78.5+/-2.9. Despite continued medication in all survivors, mean current NYHA is 1.9 and most have improved lifestyle. CONCLUSIONS: Satisfactory outcome may be expected after cardiac reoperations in highly selected octogenerians. However, increased procedural risks, complications, hospital stay and slower convalescence during early follow-up may be anticipated, and will indicate very careful screening. These results indicate a need to reconsider the treatment policy in primary operation with regard to choice of graft conduits and prosthetic valves in other elderly patients.

Non-toxigenic Corynebacterium diphtheriae: two cases and review of the literature.

Non-toxigenic Corynebacterium diphtheriae infections are being reported with increasing frequency. We present two cases of C. diphtheriae endocarditis requiring early valve replacement. Both cases were complicated by cerebral embolic phenomena and pseudoaneurysm formation in lower limb arterial vessels. Non-toxigenic C. diphtheriae septicaemia must be excluded when 'diphtheroids' are isolated from blood cultures.

Effects of triacylglycerol-saturated acyl chains on the clearance of chylomicron-like emulsions from the plasma of the rat.

We previously found that a single saturated acyl chain at the glycerol 2-position affected the metabolism of chylomicrons. The explanation for the effect is not clear, but could be reproduced by saturated monoacylglycerols. In the present work we have extended our measurements to several different triacylglycerols containing one or two saturated chains in specific locations in an attempt to define structural features that affect chylomicron clearance. Lipid emulsions containing triacylglycerol, egg yolk phosphatidylcholine, free cholesterol, cholesteryl oleate (CO) and labelled with 3H-CO and [14C]triolein (OOO) were prepared as models of lymph chylomicrons. When injected intravenously into rats, the metabolism of the emulsions was influenced by the acyl chains of the constituent triacylglycerols. Compared with emulsions containing OOO as the only triacylglycerol, plasma clearances of emulsion [3H]CO were extremely slow in emulsions containing either 1,2-dioleoyl-3-stearoylglycerol (OOS) or 1-stearoyl-2,3-dioleoylglycerol (SOO). As little as 10% of SOO in mixture with OOO slowed the clearance, and increasing proportions of SOO in OOO emulsions progressively slowed the removal of OOO and CO labels from plasma. With 50% and 100% SOO in the emulsions clearance was negligible. In emulsions containing the triacyl-sn-glycerols, 1,3-dimyristoyl-2-oleoylglycerol (MOM), 1,3-dipalmitoyl-2-oleoylglycerol (POP), 1-oleoyl-2,3-distearoylglycerol (OSS) or 1-palmitoyl-2-oleoyl-3-stearoylglycerol (POS), clearance rates of CO and OOO labels from plasma were significantly decreased compared with control OOO emulsions. With emulsions prepared with the triacylglycerols, 1-oleoyl-2,3-dimyristoylglycerol (OMM) and 1-oleoyl-2,3-dipalmitoylglycerol (OPP), clearances of CO label were significantly slower than with control OOO emulsions, while the removal of OOO label was not significantly affected. The uptake of CO label in the liver was decreased in conjunction with the lower rates of clearance of emulsion CO from the plasma. The clearance from plasma of 1,3-distearoyl-2-oleoylglycerol (SOS) emulsions was similar to the control OOO emulsions, but significantly more emulsion OOO label was taken up by the liver. Emulsions made with the triacylglycerols extracted from natural cocoa butter, which contained a high proportion of saturated acyl chains, were cleared similarly to the control OOO emulsions. Our findings indicate that the plasma clearance of triacylglycerol-rich lipoprotein particles depends upon the specific arrangements of the acyl chains of the constituent triacylglycerols, and not necessarily on the overall saturation of the triacylglycerols.(ABSTRACT TRUNCATED AT 400 WORDS)

Plasma clearance of model lipoproteins containing saturated and polyunsaturated monoacylglycerols injected intravenously in the rat.

Triacylglycerols, with a saturated long-chain fatty acid at the glycerol-2-position, slow the clearance from plasma of remnants derived from injected chylomicrons and chylomicron-like emulsions. Slowing of remnant clearance also occurs when about 1% of monostearoylglycerol is added to a triolein chylomicron-like emulsion. We have now found that addition of monoacylglycerols, containing a saturated acyl chain from 12 to 20 carbons, slowed the plasma clearance and decreased the liver uptake of the remnants. In contrast, monoacylglycerols with unsaturated acyl chains were inconsistent in their effects on the remnant clearance. Monoarachidonin (M20:4) slowed remnant clearance comparable to that of saturated monoacylglycerols, monolinolenin (M18:3) and monolinolein (M18:2) were less effective, while monoolein had the least effect on remnant clearance. We have confirmed the defective remnant clearance in rats of injected emulsions containing saturated acyl chain by the using the diester-2-ether analogues of triolein and 1,3-dioleoyl-2-stearoylglycerol (OSO). Chylomicron-like lipid emulsions made with the ether analogues had clearance rates similar to their triester counterparts. Preformed remnants derived from emulsions of OSO, its ether analogue, and triolein emulsions or emulsions of triolein with approximately 1% saturated monoacylglycerols were prepared in hepatectomized rats. After intravenous injection into conscious recipient rats, these remnants were cleared from plasma similar to remnants traced in situ by lipolysis of injected chylomicron-like emulsions.