The spotty sign

BACKGROUND: This report details our experience in 13 patients with a technical modification of the standard central shunt. METHODS: The study was performed using a retrospective chart review approach. In our operation, the aorto-Gore-Tex (W.L. Gore & Assoc, Flagstaff, AZ) anastomosis is created in a side-to-side fashion with the free end of the Gore-Tex shunt being oversewn. RESULTS: All patients had echocardiographic evidence of shunt patency in the immediate postoperative period, and there have been no cases of late shunt occlusion at a mean follow-up period of 10 months. CONCLUSIONS: We believe this approach will yield patency rates equivalent to or better than those of the standard central shunt. The technique has the advantage of creating a short, straight-lying shunt that is less likely to kink or be injured on repeated sternotomy and in which flow may be more reliable.     

The Hawkins sign

A 77-year-old man with type II diabetes taking a stable dose of subcutaneous, twice daily human insulin developed symmetrical, inflammatory, rheumatoid factor positive polyarthritis. Within 2 weeks of starting therapy with prednisone 5 mg daily and hydroxychloroquine 400 mg daily he had 2 episodes of severe hypoglycemic coma requiring emergency care. His blood glucose became controlled again when his insulin was decreased by 37%. There are no reported cases of hypoglycemia in diabetic or nondiabetic patients treated with hydroxychloroquine. Hydroxychloroquine has been reported to reduce insulin requirements in refractory type II diabetes by an average of 30%. When hydroxychloroquine is initiated for the treatment of polyarthritis in a type II diabetic requiring insulin or sulfonylurea treatment, blood glucose levels should be monitored closely and the insulin dose may need to be reduced.     

The caput medusae sign

Isolated endobronchial secondaries are reported usually as single cases or in series from either specialist surgical or cancer units. The latter two are selected populations and are not a good guide to the true frequency of occurrence of such isolated endobronchial secondaries. The incidence of such endobronchial secondaries in a 15 yr prospective series is reported. Results of all fibre-optic bronchoscopies carried out in the Blackburn, Hyndburn and Ribble Valley districts from 1981 to 1995 together with histology were recorded prospectively throughout the period. These had been audited yearly throughout, the data were collated, and the individual records of cases of endobronchial secondaries examined. A total of 3353 bronchoscopies were carried out in the years 1981-1995 inclusive. Of these, 1391 had visible endobronchial abnormalities, from which 1059 had positive endobronchial histology. Sixteen of the 1059 (1.5%) were with endobronchial secondaries. Over the same period eight bronchial carcinoids (none biopsied, but later surgically resected) were encountered. Isolated endobronchial secondaries made up a higher proportion of endobronchial histology than expected at 1.5% and were twice as frequently found as bronchial carcinoids. The possibility of endobronchial secondaries should always be considered in those with a history of previous carcinomas at other sites.     

The nonspecific inflammatory response to injury

PURPOSE: The role of the nonspecific inflammatory response in causing injury related to surgery has become better understood over the last decade. There are complex interactions between neutrophils, cytokines and nitric oxide metabolites that may cause organ injury following surgery. The purpose of this review is to summarize some of the processes causing injury through these nonspecific pathways. METHODS: A review of the medical and anaesthetic literature related to inflammation, neutrophils and pro-inflammatory cytokines were performed using Medline. Bibliographies of relevant articles were searched and additional articles were then selected and reviewed. RESULTS: Pro-inflammatory cytokines, such as tumour necrosis factor, are released in response to a variety of noxious stimuli (e.g. burns, sepsis, or CABG surgery). These cytokines cause activation of neutrophils with increased upregulation of adhesion complexes on neutrophils and vascular endothelium. Nitric oxide synthase activity is also increased with a resultant increased production of nitric oxide. The increased nitric oxide concentration in the presence of superoxide free radicals secreted by activated neutrophils forms peroxynitrite, a more reactive and toxic molecule. Once this process is initiated, diffuse organ injury can result. Although some information related to specific anaesthetics is available, firm recommendations related to clinical practice cannot be made. CONCLUSIONS: There is a complex interplay of inflammatory mediators that can cause injury. Although specific clinical applications for manipulating these pathways are not yet generally available, this area holds promise to develop new techniques to improve outcomes following surgery.     

The hot rectus abdominis muscle sign

We report a 2.5-year-old child who presented with an acute abdomen caused by the perforation of a sewing pin through her appendix that had started to penetrate the wall of the bladder.     

The mechanism for nonspecific lipase from rat pancreas

Purified nonspecific lipase from rat pancreas appears to mediate the followin reaction sequence: (2) HE +nB in equilibrium HEBn; (2) HEBn + S inequilibrium HEBnS; (3) HEBnS IN EQUILIBRIUM EBnS' + ROH; (4) EBnS' + h2o vector HEBn + R'COO- + H+, where E equils enzyme, B equils bile salt, and S equils R'COOR. Evidence is presented for the occurrence, sequence and reversibility or irreversibility of the above four reactions. Also discussed are the activation energies for both a "good" and a "poor" substrate, the correlation between V and subsitituent function (o-) for a series of substituted benzoic acid esters, and the effects of steric hindrance. Studies of the incorporation of label from H2(18)O further detail the hydrolytic mechanism, and the effects of the physical state in which substrate is presented to the enzyme (micelles, emulsion, crude bulk phase, etc.) are discussed.     

Chronic nonspecific endometritis

To assess the proliferative activity of glands and stroma in nonspecific chronic endometritis (NCE), we evaluated the plasma and morphologic features. We examined 25 endometrial sections that were coded as inactive for the morphologic features of NCE other than plasma cells and 25 proliferative endometria (PE) as controls. Furthermore, the sections were stained with methyl green pyronin (MGP) to demonstrate plasma cells and proliferative cell nuclear antigen (PCNA) for proliferative activity. The number of plasma cells and the grade of proliferative activity were determined by a semiquantitative scale. The results were compared by using the Mann-Whitney-U-test. Of the 25 inactive endometria cases, 11 were NCE and 14 were either early proliferative endometria (seven cases), lower uterine segments (five cases), or under hormone effect (two cases). The number of plasma cells in NCE was significantly higher than in PE. However, there were cases of NCE without plasma cells and cases of PE containing plasma cells. Proliferative activity was significantly lower in NCE cases than in the PE group (p < 0.05). The diagnosis of NCE should rely more on morphologic abnormalities than on plasma cell criteria. Identification of plasma cells may be useful for diagnosis.     

The supinator notch sign in rheumatoid arthritis

Unconcentrated CSF and 200 times diluted serum samples from 192 patients were examined by agar electrophoresis; their albumin and transferrin content were determined simultaneously by radial immunodiffusion. Using the data on transferrin and albumin concentrations in serum and cerebrospinal fluid, the transferrin/albumin index was calculated in a similar way to the IgG/albumin index. Normally the transferrin/albumin index is 1.68 (n = 77; S.D. = 0.22). If the permeability of the blood-CSF barrier increases, the transferrin/albumin index gradually decreases to 1. If the tau-globulin fraction is increased on the agar pherogram, the transferrin/albumin index will be greater than 2.34 (mean + 3 S.D.).     

The sign of Leser-Trelat associated with esophageal carcinoma

A 79-year-old woman was admitted to our hospital with complaints of dysphagia and multiple verrucous papules that had developed over the previous year. The diagnosis of esophageal carcinoma was based on upper gastrointestinal radiography and endoscopic examination with biopsy. The clinical syndrome was consistent with the sign of Leser-Trelat associated with esophageal carcinoma. Although radiation therapy and chemotherapy were undertaken, the patient died 8 months later because of the sign of Leser-Trelat in association with squamous cell esophageal carcinoma.     

The "harlequin" sign and congenital Horner''s syndrome

When trying to establish the likely anatomical site (preganglionic or postganglionic) of a lesion causing congenital Horner's syndrome, the distribution of facial flushing (the "harlequin" sign), may be seen. In babies and young children, facial flushing is a relatively simple clinical sign to demonstrate, compared with facial sweating. In unilateral facial flushing the areas that do not flush are almost always identical to the anhidrotic areas. However, neither facial flushing nor testing the pupil reactions with pholedrine or hydroxyamphetamine can be relied on to predict the probable site of any lesion causing congenital Horner's syndrome. Two patients with congenital Horner's syndrome are presented which demonstrated the "harlequin" sign and in whom clinical examination and pharmacological testing gave conflicting evidence for localisation of the site of the causative lesion. The presentation of congenital Horner's syndrome should be investigated and include MRI or CT to exclude a serious underlying cause.     

The rim sign in epidural hematoma: case report

A case of epidural hematoma of 7 days' duration showed a rim sign in the dynamic and static brain images. The significance and value of a rim sign are discussed.