A 23-year-old woman was diagnosed with coeliac disease with positive serology and typical duodenal histology. A gluten-free diet was instituted. About 9 months later, she presented with bipedal oedema that developed overnight, associated with a fall in …

Sir,We present a case of mucinous variant of minimally invasive follicular carcinoma of the thyroid gland. The production of mucin‐like substances by primary thyroid neoplasms1 has been increasingl...

Introduction: We sought to evaluate the utility of a phased-array intracardiac echocardiography (ICE) device to identify left atrial (LA) and pulmonary vein (PV) anatomy; accurately guide radiofrequency ablation (RFA) to the right or left PV ostium and LA appendage (LAA); and evaluate PV blood flow before and after RFA using Doppler parameters.Methods and Results: Twelve adult sheep were anesthetized and an Acuson 10-French, 7-MHz ICE transducer introduced via the internal jugular vein into the right atrium, The LA was imaged and PV anatomy and blood flow documented using two-dimensional and pulsed-wave Doppler, Mean LA dimensions were 4.6 +/- 0.4 x 3.5 +/- 0.5 cm; mean single right and left main PV ostium diameters were 1.5 +/- 0.2 and 1.3 +/- 0.3 cm; and mean right and left PV first-order branch diameters were 0.8 +/- 0.2 and 0.6 +/- 0.1 cm. Mean PV maximum inflow velocity for the right PV were 0.30 +/- 0.05 m/sec and for the left PV were 0.35 +/- 0.04 m/sec, The PV ostia and LAA could be targeted accurately for RFA using ICE guidance. At pathologic evaluation, the mean distance of the lesion center to the right or left PV-LA junction was 3.0 +/- 2.0 mm, The mean distance of the lesion center to the posterior margin of the LAA was <4 mm in all cases. There was no significant increase in PV maximum inflow velocity or decrease in PV diameter following RFA at the PV ostium, Absence of PV obstruction was confirmed at pathology.Conclusion: Phased-array ICE allows detailed assessment of LA and PV anatomy when imaged from the right atrium; accurate guidance of RFA to the PV ostium and LAA; and immediate evaluation of PV patency after RFA.

We report on the rare finding of pituitary tissue, including both adenohypophysis and neurohypophsis, in a mature cystic teratoma of the ovary removed from a 26 year old female at the time of cesarean section. Immunocytochemistry of the ectopic anterior pituitary component showed pregnancy-related changes that have previously only been described in pituitaries obtained at autopsy.

Thirty-two patients underwent 38 arthroplasties for advanced rheumatoid arthritis and marked soft tissue losses. Seven wrists required repair or transfer of at least one tendon for rebalancing. All patients were improved by the implants. Thirty-four of the 38 patients were improved beyond the functional level of a painless wrist arthrodesis. Overall, there were 23 excellent, 10 good, 3 fair, and 2 poor results. The average wrist score was 90.3 points, and the average arc of motion was 38 degrees. There were three cases of migration of the third metacarpal stem and nine cases of lucency about the stems, three of which were progressive or greater than 1 mm. There were no deep infections. There was one reoperation for persistent pain and one for component loosening. There were no cases of implant failure. These results indicate that this total wrist arthroplasty is a safe, reproducible procedure for radiographic class III and IV rheumatoid disease and should be considered a first line of therapy for that group.

Fifty-six elbows were evaluated for correlation between implant alignment and functional results following total elbow arthroplasty. Accurate reconstruction of the anatomic center of rotation of the humerus and ulna and accurate placement of the implant stem were correlated with improved durability and decreased complications.

Thirty elbows were critically reviewed for quantitative evidence of bone remodeling, with demonstrable bone remodeling noted in more than one half of the ulnae and humerii. Bone remodeling was analyzed statistically with independent variables of age, sex, handedness, diagnosis, implant design considerations, and implant alignment. Only implant design and alignment had a statistically significant impact on bone remodeling. Periarticular (zone 1) bone loss was statistically significantly correlated with a high percentage of diaphyseal medullary canal occupied by prosthesis, the presence of assymetric stem cortical contact, and lack of metaphyseal (zone 1) load transfer. Diaphyseal bone hypertrophy (zone 4) was statistically significantly correlated with a high percentage of diaphyseal medullary canal occupied by prosthesis (zone 4) and assymetric stem tip-to-cortical wall contact. Periarticular bone hypertrophy and diaphyseal bone atrophy did not occur. Fractures through the humeral condyles occurred in three elbows undergoing bone atrophy, but no implant loosening or failure could be correlated with bone remodeling. Bone remodeling does occur in a high percentage of stemmed elbow implants but to date has not been a factor in clinical failure.

There is a class of patients with severe bone stock or soft tissue losses who remain an unsolved problem in elbow reconstruction. The authors report the results of 16 such patients who underwent 16 total elbow replacements. Follow-up averaged 4.0 years (range, 2.0–9.6 years). Fourteen patients had previous surgery on their elbows and three had been previously infected. Fourteen of the 16 patients had a good or excellent result, and overall elbow scores averaged 90 (range, 53–100). There were three reoperations and one case of nonprogressive circumferential lucent lines about a humeral component with clinical symptoms. There were no other cases of clinical or radiographic implant loosening and no implant fractures. The preliminary results of this study indicate that custom-fit total elbow arthroplasty offers acceptable functional results in a devastated elbow when normal methods of reconstruction are not suitable.