Rectal Foreign Body Removal in the Emergency Department: A Case Report.

INTRODUCTION: Rectal foreign bodies (RFB) pose a challenge to emergency physicians. Patients are not often forthcoming, which can lead to delays to intervention. Thus, RFBs require a heightened clinical suspicion. In the emergency department (ED), extraction may require creative methods to prevent need for surgical intervention. CASE REPORT: The authors present a case of a successful extraction of a RFB in the ED and review of the literature. CONCLUSION: Retained RFBs are an unusually problematic reason for an ED visit. Thus, it is important for emergency physicians to be comfortable managing such cases appropriately.

Removal of Migrating Lumbar Spine Bullet: Case Report and Surgical Video.

BACKGROUND: Gunshot wounds to the spine are devastating injuries. Rarely, the bullet has been reported to migrate. Migration is associated with progressive neurologic deficits that often improve with bullet removal. The authors report a case of removal of a migrating lumbar spine bullet. This is supplemented by an operative video and a review of the literature. CASE DESCRIPTION: A 31-year-old man presented to the emergency department with multiple gunshot wounds and lower-extremity paresthesia. A ballistic injury occurred with an entry wound in the right posterior soft tissues, traversing the right paraspinal muscle and fracturing the left lumbar 5 pedicle and left lumbar 4 transverse process. The bullet was positioned within the spinal canal at the lumbar 3/4 interspace. His spinal injury was managed nonoperatively due to his traumatic injuries and findings of minimal neurologic deficit without cerebrospinal fluid leak. The patient returned to the neurosurgery clinic a year later and was found to have worsening low back pain, decreased sensation throughout the left leg, and radiating pain throughout the right leg. Imaging demonstrated the bullet had migrated caudally to the midlumbar 5 vertebral body. Given the patient's progressive symptoms and migration of the bullet fragment, informed consent was obtained for a laminectomy and removal of the intradural bullet fragment. CONCLUSIONS: Neurosurgical treatment for gunshot wounds remains controversial. Cauda equina or lumbosacral level wounds are often incomplete and may improve with surgical decompression and bullet removal. Migrating bullet fragments throughout the spine and brain lead to worsened neurologic function, which can be reversed by removal. Movement of the bullet during surgery should be expected, and intraoperative fluoroscopy and patient positioning can help to properly localize the bullet and aid in its removal.

Robot-Assisted Pedicle Screw Placement: Learning Curve Experience.

OBJECTIVES: To describe the learning curve of pedicle screw placement using robot-assisted spine surgery of an experienced neurosurgeon and 2 supervised neurosurgical fellows. METHODS: The first 120 cases of robot-assisted spine surgery at our institution were assessed. Patient variables included age, body mass index, and indication for surgery. Intraoperative variables included the vertebral level of screw placement, number of screws placed by each operator, intraoperative blood loss, and operative time. Postoperative variables included length of stay, discharge disposition, 30-day readmissions, wound complications, and hardware revisions. Screw accuracy was determined with image overlay analysis comparing planned screw trajectory on the navigation software with the intraoperative computed tomography scan with final screw placement. Two-dimensional accuracy was determined for the tip of the screw, tail of the screw, and angle at the screw was placed. The supervising physician and first fellow began utilizing the robot concurrently upon its arrival, and the second fellow began using the robot after the system had been in place for 7 months. RESULTS: Both experienced surgeon and first fellow displayed a learning curve and achieved statistically significant improvement of accuracy after 30 screws. The second fellow had significantly better accuracy than the experienced surgeon in his first 30 screws. There were no complications from hardware placement in either group. There were no returns to the operating room for hardware issues. CONCLUSIONS: Robot-assisted spine surgery is a safe, accurate method of pedicle screw instrumentation. Our data show similar learning adaptation rates for the first fellow and the experienced surgeon. Techniques learned by the attending surgeon were immediately transferable to a new learner, who was able to achieve a faster learning curve than both the first fellow and the experienced surgeon.

External auditory canal as an unusual site for metastasis of breast cancer: A case report.

Metastatic breast cancer is one of most common cause of death in women worldwide. The estimated incidence of breast cancer to be metastatic at diagnosis is 6%, with a five year survival rate of about 21%. There are three types of breast cancer recurrence: local, regional and distant metastasis mainly to the lung, liver, bone or brain. Review of literature indicate a relatively few reported cases about metastatic breast cancer to soft tissue. We present a case of metastatic breast cancer to left external auditory canal.

Breast cancer molecular subtypes in oman: correlation with age, histology, and stage distribution - analysis of 542 cases.

BACKGROUND: Breast cancer (BC) is one of the most common malignancies and a foremost health issue throughout world. BC accounted for 23.1% of cancer cases diagnosed in Oman in 2009. BC is a heterogeneous disease, and immuno-histochemical (IHC) markers are used to further classify it into distinct subtypes, which are biologically discrete and display different behaviors. IHC testing of the estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor-2 (Her-2); can sub-classify BC into 4 principal molecular subtypes. These subtypes are luminal A (ER+ and/or PR+, HER2-), luminal B (ER+ and/or PR+, HER2+), basal like (BCL - ER-, PR-, HER2-), and Her2/neu (ER-, PR-, HER2+). Previous studies have shown preliminary evidence and high probabilities of molecular differences across ethnic and geographic groups which may be responsible for disparities in presentation, biological behavior, treatment response and outcome. PATIENTS AND METHODS: BC data from 2006-2010 at the National Oncology Center - The Royal Hospital, Oman were retrospectively retrieved from the electronic patient record system (Al-Shifa). Data were analyzed with respect to ER, PR, and Her-2 status and tumours were classified on molecular basis. Molecular subtypes were correlated with age, histology and treatment outcome. The results were compared with published regional and international data. RESULTS: There were 542 cases of BC accessible for evaluation. Luminal A subtype was the most common and the BCL subtype was highest among Omani females. Age was a significant factor in basal-like (63.8% younger than 50 years vs. 36.2% older than 50 years) and Her2 +ve tumours (60.9% vs. 39.1%). High grade tumors were mostly observed (41%) in basal tumors and were lowest in luminal A (19%). A higher stage at presentation (Stage III and IV) was observed in Her2+ tumours (59%), and a higher (22.4%) mortality was detected in basal like/TN tumours. CONCLUSIONS: The molecular classification and sub-typing of BC have revealed ethnic and geographic variation. Luminal A subtype is the most common among Omani female breast cancers but it is less common than in Western females. BCL subtype is highest among Omani females compared with Western females. These differences may have diagnostic, therapeutic and prognostic implications. Large scale and multi-centre studies may confirm these findings and can be translated and incorporated to pertinent management strategies. Key Words: Molecular subtypes, breast cancer, Oman, Royal Hospital.

Rapid rituximab infusion, local center experience.

UNLABELLED: Rituximab, a chimeric monoclonal antibody (MoAb) targeting CD20 has been widely used in the management of B-cell lympho-proliferative disorders.(1-3) The usual recommended schedule of regular administration over 3 to 4 hours requires considerable healthcare resources and oftentimes inconvenient for patients. Literature shows the availability of published reports proving the safety and feasibility of rapid infusion of rituximab. This study explored the safety and tolerability of rituximab infusion over a shorter total infusion time. A total of 24 patients diagnosed with CD20+ Non-Hodgkin's lymphoma and planned to receive rituximab at a dose of 375mg/m2 in combination with standard chemotherapy regimens were included in the study from January 2009 to December 2009. The administration of first rituximab dose was unaltered and given as per standard practice of 3-4 hours infusion. The second and subsequent doses were delivered over a total infusion time of only 90 minutes (20% of dose in the first 30 minutes, remaining 80% over the next 60 minutes). These patients, aged between 15 and 79 years, received a total of 152 rituximab infusions with an average of 6.33 (+/-2.37) infusions per patient. Grade 1 infusion related toxicity was reported in 5 infusions (3.2%), and there were no acute reactions or G3/4 toxicity in any infusion episode. A rapid infusion of rituximab is well tolerated, feasible and safe when administered as second and subsequent infusions in the course of therapy for those who tolerate the first dose without significant infusion related toxicity. This shortened infusion method results in a substantial reduction in resource utilization. Our institution has now adopted this as a routine practice. KEYWORDS: Rituximab, Short infusion, Oman.

Renal Cell Carcinoma metastasizing to larynx: a case report.

Renal Cell Carcinoma (RCC) is a malignant tumor occurring in 5th-6th decade of life with an increasing incidence reported in the US but stable in Europe. The metastasis of RCC to head and neck region is infrequent and very rarely seen in larynx. Very few cases of RCC metastasizing to larynx are reported in literature. We report a case of RCC in a middle aged male with metastasis to larynx, 7 years after initial diagnosis and nephrectomy. These unusual tumor metastases have unique pathobiology and route of metastasis, and there can be a long interval from initial diagnosis of primary tumor. The diagnosis of metastatic RCC in unusual locations is often not easy. Treatment options include metastasectomy, radiotherapy and systemic chemotherapy but with a poor outcome. A differential diagnosis should always be considered in metastatic head and neck tumors. The need for prompt accurate diagnosis, risk stratification at initial primary diagnosis, surveillance, and long term regular follow up is emphasized.

Early discharge of patients with pulmonary embolism: a two-phase observational study.

The aim of the present study was to assess whether patients with pulmonary embolism (PE) could be managed as outpatients after early discharge from hospital using low molecular weight heparin instead of remaining as in-patients until effective oral anticoagulation was achieved. Phase 1 of the study identified criteria for the safe discharge of selected patients; phase 2 treated a cohort of low-risk patients with PE as outpatients with tinzaparin using existing deep venous thrombosis services. In phase 1, 127 (56.4%) of 225 patients were considered unsuitable for outpatient management. Reasons included: admission for another medical reason; additional monitoring or requirement for oxygen; bleeding disorders; previous PE/further PE while on warfarin; co-existing major deep venous thrombosis; likelihood of poor compliance; significant immobility; and pregnancy. In phase 2, 157 patients with PE received outpatient anticoagulation therapy. There were no deaths, bleeding or recurrent thromboembolic events during acute treatment with low molecular weight heparin. The median (range) length of hospital stay was 1.0 (1-4) day, with a median saving of 5.0 (1-42) bed-days per patient. Patients were highly satisfied with outpatient management; 144 (96.6%) indicated that they would prefer treatment as outpatients for a subsequent pulmonary embolism. Early discharge and outpatient management of pulmonary embolism appears safe and acceptable in selected low-risk patients, and can be implemented using existing outpatient deep venous thrombosis services.

Value of routine duodenal biopsy in diagnosing coeliac disease in patients with iron deficiency anaemia.

BACKGROUND: Iron deficiency anaemia (IDA) is a recognised feature of coeliac disease in adults and can be its only presentation. OBJECTIVE: To determine the yield of routine distal duodenal biopsies in diagnosing coeliac disease in adult and elderly patients with IDA whose endoscopy revealed no upper gastrointestinal cause of iron deficiency. STUDY DESIGN: Prospective study in a teaching hospital endoscopy unit. METHOD: Altogether 504 consecutive patients with IDA, aged 16-80 years, attending for endoscopy were included in this study. At least two distal duodenal biopsies were taken if endoscopy revealed no cause of iron deficiency. RESULT: In nine (1.8%) patients duodenal biopsies revealed typical histological features of coeliac disease. Of these, five patients were above 65 years old. CONCLUSION: In adult and elderly patients undergoing endoscopy for IDA, the endoscopist should take distal duodenal biopsies to exclude coeliac disease if no upper gastrointestinal cause of anaemia is found. Coeliac disease is not an uncommon cause of IDA in patients >65 years of age and a history of chronic diarrhoea increases diagnostic yield in this age group.

Diagnostic efficacy of stool antigen test (HPSA), CLO test and serology for the detection of Helicobacter pylori infection.

BACKGROUND: The diagnosis of Helicobacter pylori infection was initially being made through invasive methods but now non invasive methods have been developed to make the diagnosis easier. The present study was done to evaluate the diagnostic efficacy of a two non invasive tests i.e. Helicobacter pylori Stool antigen test (HpSA) and Helicobacter pylori IgG serology with an invasive method i.e. Campylobacter like organism (CLO) gel test. METHODS: The study was conducted in the gastroenterology unit of Pakistan Medical Research Council Research Centre Karachi. Adult patients with gastroduodenal disease were selected for study and their medical history was recorded. Endoscopy was done on all patients and the antral biopsy sample was tested for H. pylori using CLO test. Serology (IgG) was done elsewhere using ELISA and titers of over 50 units were recorded as positive. HpSA was done to determine the presence of H. pylori antigen in stool. RESULTS: Out of 43 patients 34 (79%) were males and 9 (21%) females. The main presenting symptom was epigastric pain in 74% cases. Although H. pylori IgG antibody titers of over 50 were taken as positive but for this study titres of over 100 were taken as significant for comparison with other tests. CLO test was positive in 26 (60.5%) cases, H. Pylori antibody titers of over 100 IU were present in 33 (76.7%) cases and HpSA in 21 (48.8%). Using CLO test as the gold standard the sensitivity of serology was 81% and that of HpSA 65% with a 29% and 76% specificity respectively. CONCLUSION: In our setting CLO test is still the best diagnostic test for H. Pylori detection. Both non invasive tests i.e. serology and stool HpSA are less sensitive than CLO but amongst each other both are equally sensitive.

Diabetes mellitus is equally frequent in chronic HCV and HBV infection.

OBJECTIVE: To see the association of type 2 diabetes mellitus (Type 2 DM) in patients suffering from chronic HBV or HCV related liver disease. SETTING: Patients were selected from the gastroenterology OPD of the medical research centre, diabetic controls from private diabetes clinic and healthy controls from the blood bank of the hospital. METHODS: Patients with chronic liver disease had HBV, HCV tested using ELISA and blood sugar using a glucometer mostly as a 2 hour post prandial sample. Healthy controls had their sugar and ALT checked while donating blood and HBV, HCV were checked routinely. In diabetic controls, blood sample was taken as sera stored for HBV,HCV and ALT and later tested in batches. A random sugar of > or = 200 mg/dl was taken as diabetes. RESULTS: Of 400 patient with chronic liver disease 302 had HCV and 98 HBV infection. Diabetes was found in 24.5% HCV and 19.4% HBV related cases (not significant). Out of 410 healthy controls 18 were HCV and 17 HBV positive. Diabetes was found in only 1 (5.6%) HCV positive control and none of the HBV positive controls. Of 196 diabetics 10 (5.1%) were HCV positive and none HBV positive. Diabetes was more frequent in patients having liver cirrhosis than in those having chronic hepatitis (P < 0.01). CONCLUSION: Diabetes is equally frequent in both HBV and HCV related disease but is significantly more in those with chronic liver disease than in controls. The pancreatic damage secondary to extrahepatic viral replication appears to be the major cause but genetic factors also need to be explored.

Two weeks triple therapy with lansoprazole, amoxycillin and roxythromycin is better than dual therapy with lansoprazole and amoxycillin for H. pylori infection: a randomised, clinical trial.

AIMS: To compare the efficacy of 2 weeks of dual therapy of Lansoprazole and Amoxycilline with triple therapy of Lansoprazole, Amoxycilline and Roxythromycin for H. pylori eradication. SUBJECTS: Twenty-five suffering from dyspepsia and found H. pylori positive (CLO) during upper GI endoscopy. METHODS: Patients were divided into 2 groups, one group received Lansoprazole (30 mg) once a day, and amoxycilline (500 mg) three times a day (group I), while the second group received Lansoparazole and amoxycillin in similar dosage with the addition of Roxythromycin (150 mg) twice a day (group II). H. pylori status was confirmed on endoscopy using CLO test at entry to the protocol and then at 4 weeks. RESULTS: H. pylori eradication was 57% in group I and 86% in group II with healing of lesions in all cases. CONCLUSION: Better response with triple therapy (group II) indicates enhanced eradication of the pathogens with triple therapy while using roxythromycin (JPMA 50:157, 2000).