Proximal esophageal adenocarcinoma presenting as a thyroid mass: case report and review of the literature.

Metastatic disease to the thyroid is not an unusual finding at autopsies, but it is rare to be found in clinical situations. We present the first case of adenocarcinoma of the proximal esophagus presenting as a thyroid mass in a young healthy patient without any previous history of malignancy. This case highlights the importance of thorough work-up when addressing a thyroid mass. A high index of suspicion should be maintained in order to be able to detect unusual etiologies of thyroid conditions, especially when histopathology is not characteristic for primary thyroidal malignancies.

Percutaneous interventions for lower extremity peripheral vascular disease.

Peripheral vascular disease of the lower extremities is an important cause of morbidity that affects up to 10 million people in the United States. The primary care physician can easily identify patients who are at risk for the disease with a questionnaire and a relatively simple test-the ankle brachial index. More than 70 percent of patients diagnosed with the disease remain stable or improve with conservative management. Those who do not improve may undergo contrast angiography or magnetic resonance angiography, which may be used in planning for surgery or percutaneous intervention. Surgical bypass is the gold standard for extensive vascular occlusive disease, but endovascular interventions, including percutaneous transluminal angioplasty and stent placement, are being used more frequently, particularly in patients with significant comorbid conditions.

Effect of patient position on sonographically measured renal length in neonates, infants, and children.

OBJECTIVE: Renal length as measured on sonography is fundamental in the evaluation of renal disease in children. Understanding the effect of patient position and imaging plane on measured renal length is important for the appropriate use of the standards for interpretation. The goal of this study was to determine how measurement of renal length on sonograms is affected by changes in patient position and imaging plane. SUBJECTS AND METHODS: One hundred seventy-six neonates, infants, and children who were 2 days to 17 years old underwent sonography froin October 1995 through June 1996. The largest long-axis renal dimension in sagittal, coronal, and prone planes was obtained for each kidney. Data were analyzed separately for each kidney to determine the individual variation of renal length. RESULTS: The correlation between maximum renal length on coronal, sagittal, and prone sonograms was greater than .95 for both right and left kidneys. The coronal plane yielded the largest measured renal length and the prone view, the smallest. The median of the absolute value of the differences between individual renal lengths as measured on sonograms in the different imaging planes was 2-3 mm for both left and right kidneys (mean difference, left kidney = 3.34-3.62 mm; mean difference, right kidney = 3.22-3.68 mm). CONCLUSION: The coronal and sagittal views yield the longest measurements and prone views, the shortest. Therefore, initial measurements should be made in coronal or sagittal planes. Prone views should be reserved for situations in which the suspicion exists that the kidney was foreshortened on other views. Reference standards done in a particular plane should be applicable in most situations regardless of the patient position necessary to obtain optimum length.

Prognostic indicators in acute pancreatitis: CT vs APACHE II.

PURPOSE: To investigate the correlation between established contrast-enhanced computed tomography (CECT) criteria of disease severity in acute pancreatitis and the APACHE (Acute Physiology and Chronic Health Evaluation) II score and to assess the utility of each as prognostic indicators in acute pancreatitis. MATERIALS AND METHODS: Over a 1-year period, prospective, consensus interpretation of the CECTs of 35 consecutive inpatients was performed with determination of the CECT grade, degree of necrosis, and severity index. The APACHE II score was calculated within 24 h of CECT. Multiple clinical endpoints were recorded: local complications (pseudocyst, abscess, or acute fluid collections requiring urgent surgical or radiological intervention), systemic disease (intensive care unit admission), and duration of hospitalization. Statistical analysis was performed to determine correlations. RESULTS: No statistically significant correlation existed between the APACHE II score and CECT grade, the degree of necrosis, or the CECT severity index. Only the CECT grade and severity index correlated significantly with the occurrence of local complications (P = 0.0035 and 0.0048, respectively). The APACHE II score was superior to the CECT grade as a predictor of the need for ICU admission (P = 0.022 vs P = 0.035), and no other CECT criteria was a significant predictor of ICU admission. CONCLUSION: The preferred clinical and imaging prognostic measures in acute pancreatitis, the APACHE II score and CECT criteria, do not correlate with one another in the commonly encountered, mixed primary and tertiary care population. The mathematical integration of CECT criteria and the APACHE II score fails to yield a predictor of outcome superior to the use of any one measure alone. CECT criteria best define local anatomic abnormality, and are superior to the APACHE II score as predictors of local complications. The APACHE II score is superior to all CECT criteria as an indicator of systemic disease severity (reflected in the need for ICU admission). The most effective initial triage would be immediate APACHE II calculation. Further use of imaging vs clinical assessment can then be individualized.

Can clinical parameters help reliably predict the onset of acute intracranial hemorrhage in infants receiving extracorporeal membrane oxygenation?

PURPOSE: To determine whether clinical parameters can be used to help predict the onset of acute intracranial hemorrhage (ICH) in infants receiving extracorporeal membrane oxygenation (ECMO). MATERIALS AND METHODS: The authors retrospectively reviewed cranial sonograms and intensive care unit data for 53 neonates treated with ECMO for intractable cardiorespiratory insufficiency. Thirty-nine boys and 14 girls were treated between February 1988 and June 1993. Gestational age ranged from 34 to 43.5 weeks (mean, 39.2 weeks). Birth weights ranged from 2,200 to 4,650 g (mean, 3,310 g). Multiple clinical variables were subjected to statistical analysis. RESULTS: There were 38 patients without ICH, 10 with early ICH (within 72 hours after cannulation), and five with late ICH (more than 72 hours after cannulation). Analysis with bivariate scatterplots revealed almost complete overlap in the clinical parameters for patients in these three categories. Thus, use of individual variables to predict acute ICH was impractical. CONCLUSION: No clinical parameters helped adequately distinguish patients who developed ICH from those who did not.