Spontaneous gastro-pancreatic fistula - a hitherto unknown natural history of IPMN?

Intraductal papillary mucinous neoplasm (IPMN) is a distinct group of benign pancreatic neoplasms often discovered incidentally on imaging. Apart from their malignant potential, little is known about their natural history as most are surgically resected. We report an unusual presentation and possible natural history of IPMN in a patient who refused surgery and hence was on regular follow up.

Investigation of the interleukin 1 gene cluster and its association with acute pancreatitis.

The interleukin 1 (IL-1) gene cluster has been implicated in acute pancreatitis. Penta-allelic and bi-allelic polymorphisms exist in the IL-1RN and IL-1B genes, respectively. The aim of the study was to investigate these polymorphisms in acute pancreatitis. Genotype and allele frequencies were determined in patients (n = 116) and healthy controls (n = 170) using the polymerase chain reaction. PCR products from the IL-1B study were further digested with Taq I restriction endonuclease. Patients were categorised according to aetiology, severity, and organ-failure scores. Allele 1 of the IL-1RN polymorphism was significantly increased in patients compared with controls (72.0 vs. 63.0%; p = 0.029, Pc = 0.029), in severe cases compared with controls (81.9 vs. 63.0%; p = 0.002, Pc = 0.004), in idiopathics compared with controls (82.4 vs. 63.0%; p = 0.002, Pc = 0.006), and in severe cases compared with mild cases (81.9 vs. 67.5%; p = 0.023, Pc = 0.046). Allele 2 was significantly decreased in severe cases compared with controls (18.1 vs. 33.0%; p = 0.013, Pc = 0.026), in idiopathics compared with controls (17.6 vs. 33%; p = 0.013, Pc = 0.039), and in severe cases compared with mild cases (18.1 vs. 32.5%; p = 0.023, Pc = 0.046). No significant differences were found for the Taq I allele or genotype frequencies between controls and patients/subgroups of patients. IL-1RN appears to determine severity of acute pancreatitis and susceptibility to idiopathic acute pancreatitis. No association was found between IL-1B and the disease.

An epidemiological needs assessment of carotid endarterectomy in an English health region. Is the need being met?

OBJECTIVE: To compare the level of provision of carotid endarterectomy (an intervention of proved efficacy for prevention of stroke in patients with symptomatic high grade carotid artery stenosis) with estimates of need. DESIGN: Comparison of regional, district, and age-sex specific operation rates derived from hospital episode statistics with estimates of need based on demographic and epidemiological data; interviews with regional vascular surgeons and a joint provider-purchaser workshop to discuss implications. SETTING: Former Wessex Regional Health Authority, 1991-2 to 1995-6. SUBJECTS: All residents covered by Wessex region treated for carotid artery reconstruction. MAIN OUTCOME MEASURES: Regional, district, and age-sex operation rates as three year average 1993-6 (use) compared with respective estimates of need for carotid endarterectomy among those who presented with symptomatic carotid disease-transient ischaemic attack or minor stroke. RESULTS: The operation rate more than doubled between 1991-2 and 1995-6, from 35 to 89 per million population, compared with an estimated level of need in the region's general population of 153 per million population (transient ischaemic attack 77, minor stroke 76). The ratio of use to need was 0.47 (95% confidence interval 0.4 to 0.54); district ratios were 0.28 (0.19-0.38) to 0.81 (0.62 to 1.06). The annual use:need ratio rose over the three years 1993-6 from 0.38 to 0.59. Use:need ratios were lower in elderly and female patients. Providers were keen to develop guidelines for referral and to increase access to diagnostic facilities; purchasers were more reluctant, given the limited impact of this intervention on the incidence of stroke and the relatively high cost of the operation. CONCLUSION: Although treatment rates increased in Wessex there is still unmet need. Further research is needed to determine the referral pathways of patients with symptomatic carotid disease for diagnosis and operation and to evaluate strategies to improve access to diagnostic facilities.

The Lundh test: a review of its clinical use in the diagnosis of pancreatic disease.

The clinical value of the Lundh test in the diagnosis of pancreatic disorders was reviewed retrospectively for 139 patients with proven pancreatic disease (15 acute and 72 chronic pancreatitis, 51 carcinoma of the pancreas and one partial pancreatectomy). There was a good separation between patients with pancreatic disease and those with other gastrointestinal disorders who presented with similar symptoms. The test was most helpful in patients with chronic pancreatitis (diagnostic rate 89%, mean tryptic activity (MTA) less than 7 U), more particularly in those presenting with jaundice or steatorrhoea (100%) than pain (86%), but less successful (diagnostic rate 68%) in carcinoma of the pancreas (steatorrhoea 100%; jaundice 64%; pain 55%). Complete absence of bile from duodenal juice in jaundiced patients usually indicated pancreatic or hepatobiliary carcinoma. An abnormal but not diagnostic MTA (7 to less than 10 U) was seen in 7% of patients with chronic pancreatitis, 13% with carcinoma of the pancreas and 11% with non-pancreatic disorders and suggested the need for further pancreatic investigation. Cytological examination of duodenal juice increased the usefulness of the test. Although malignant cells were rarely seen, characteristic (degenerate) cells were found in 22 of 44 (50%) patients with, but only five of 85 (6%) without pancreatic disease, even when the MTA was normal. The Lundh test can be conveniently combined with a jejunal biopsy at the same intubation for the investigation of diarrhoea or steatorrhoea.

Tuberculosis of the cervix: cytology as an aid to diagnosis.

Two cases of tuberculous cervicitis are presented. The presence in cervical smears of both epithelioid and Langhans' giant cells, which are described, should raise a strong suspicion of tuberculosis.

The Prader-Willi syndrome with a 15/15 translocation. Case report and review of the literature.

A case, diagnosed clinically as the Prader-Willi syndrome, was shown by Giemsa banding, to have a 15/15 chromosome translocation. A review of the literature indicates that such a translocation has only been described once before, in a normal woman, but that chromosme abnormalities in the Prader-Willi syndrome most commonly involve the D group. The significance of this would be clarified by specific chromosome identification in these patients.

Cytology in the diagnosis of oesophageal cancer.

The value of brush cytology under direct vision in the diagnosis of oesophageal cancer was evaluated and compared with other diagnostic procedures in a prospective study of 33 patients suspected of having an oesophageal lesion. Barium swallow correctly diagnosed cancer in 19 out of 20 patients, the remaining patient was diagnosed by both histology and cytology. In all, cytology was correct in 18 cases (90%), whereas histology confirmed the diagnosis in 10 (50%). In the 13 patients with benign lesions, barium swallow was correct in 12; cytology was benign in all 13; biopsy was only possible in 9, although the results of this procedure were always correct. Thus barium swallow is still the ideal screening procedure for patients with oesophageal symptoms, but per-endoscopic brush cytology seems to be the method of choice for confirmation of the diagnosis.

Assessment of endoscopic retrograde cholangio-pancreatography (ERCP) and pure pancreatic juice cytology in patients with pancreatic disease.

Pure pancreatic juice has been collected from 61 patients at the time of endoscopic retrograde cholangio-pancreatography (ERCP) for the purpose of cytodiagnosis. The ERCP and cytological findings are discussed. Pure pancreatic juice cytology may help in the interpretation of the pancreatogram in both pancreatitis and pancreatic carcinoma. In patients with pancreatic carcinoma, ERCP alone was diagnostic in 65%, cytology alone in 54%. By combining these two approaches, a diagnostic result was obtained in 92% of patients.