Study Design: Retrospective cohort. Objectives: To validate the 11-item modified Frailty Index (mFI) as a perioperative risk stratification tool in elderly patients undergoing spine surgery. Methods: All consecutive cases of spine surgery in patients aged 65 years or older between July 2016 and June 2018 at a state-wide trauma center were retrospectively reviewed. The primary outcome was post-operative major complication rate (Clavien-Dindo Classification ≥ III). Secondary outcome measures included the rate of all complications, 6-month mortality and surgical site infection. Results: A total of 348 cases were identified. The major complication rate was significantly lower in patients with an mFI of 0 compared to ≥ 0.45 (18.3% versus 42.5%, P = .049). As the mFI increased from 0 to ≥ 0.45 there was a stepwise increase in risk of major complications ( P < .001). Additionally, 6-month mortality rate was considerably lower when the mFI was 0 rather than ≥ 0.27 (4.2% versus 20.4%, P = .007). Multivariate analysis demonstrated an mFI ≥ 0.27 was significantly associated with an increased incidence of major complication (OR 2.80, 95% CI 1.46-5.35, P = .002), all complication (OR 2.93, 95% CI 1.70-15.11, P < .001), 6-month mortality (OR 7.39, 95% CI 2.55-21.43, P < .001) and surgical site infection (OR 4.43, 95% CI 1.71-11.51, P = .002). The American Society of Anesthesiologists’ (ASA) index did not share a stepwise relationship with any outcome. Conclusion: The mFI is significantly associated in a gradated fashion with increased morbidity and mortality. Patients with an mFI ≥ 0.27 are at greater risk of major complications, all-complications, 6-monthy mortality, and surgical site infection.

Acute subdural hematoma (aSDH) is among the most common injury types encountered by neurosurgeons, and carries a poor prognosis, particularly in the elderly. As the incidence of aSDH in the elderly population rises, identifying those patients who may benefit from operative intervention is crucial. This systematic review aimed to identify data on prognostic factors or indices, such as the modified frailty index, that may help predict outcome, and hence guide management. A comprehensive search of online databases was conducted by two independent authors, and data on prognostic factors and outcomes were extracted. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Of 769 studies identified in the initial search, 7 satisfied inclusion and exclusion criteria. Mortality and morbidity varied considerably among studies. Initial Glasgow Coma Scale (GCS) of 3-8 was the most consistently reported negative prognostic feature. Several studies evaluated the impact of medical comorbidities and premorbid frailty, but were limited by small sample size. A previous history of pneumonia was shown to increase the risk of Glasgow Outcome Score (GOS) 1-3 (odds ratio [OR] 6.4 [95% CI 1.6-25.2], p = 0.04) in a single study, which also reported a greater increase in GOS at 3 months in those with fewer than five comorbidities (56% vs. 19%, p < 0.01). There are limited data describing prognostic factors or the use of frailty indices within the specific group of elderly patients with aSDH. Prospective research is needed to evaluate the utility of accurate and validated assessments of frailty to enhance the neurosurgeon's ability to appropriately manage this complex and expanding patient group.

Topical protoporphyrin (PpIX)-induced photodynamic therapy (PDT) relies on the penetration of the prodrug into the skin lesion and subsequent accumulation of the photosensitizer. Methyl aminolevulinate (MAL)-PDT is an established treatment for thinner and superficial non-melanoma skin cancers (NMSCs) but for the treatment of the thicker nodular basal cell carcinoma (nBCC) enhanced penetration of the prodrug is required. This study employed a new higher pressure, oxygen pressure injection (OPI) device, at the time of Metvix® application with a view to enhancing the penetration of MAL into the tumors. Each patient had Metvix® applied to a single nBCC followed by application of a higher pressure OPI device. Following different time intervals (0, 30, 60, 120 or 180 min) the tumors were excised. The maximum depth and area of MAL penetration achieved in each lesion was measured using PpIX fluorescence microscopy. As expected, an increase in the depth of MAL-induced PpIX accumulation and area of tumor sensitized was observed over time; when the Metvix® cream was applied for 0, 30, 60, 120 and 180 min the median depth of PpIX fluorescence was 0%, 21%, 26.5%, 75.5% and 90%, respectively and the median area of tumor sensitized was 0%, 4%, 6%, 19% and 60%, respectively. As the investigation presented here did not include a control arm, the relative depths of fluorescence observed in this study were statistically compared (using the non-parametric Mann Whitney U test) with the results of our previous study where patients had Metvix® cream applied either with or without the standard pressure OPI device. When the higher pressure OPI device was employed compared to without OPI this increase was observed to be greater following 30, 120, and 180 min although overall not significantly (p = 0.835). In addition, no significant difference between the higher pressure OPI device employed here and the previously investigated standard pressure OPI device was observed (p = 0.403). However, when the results for both OPI devices were combined and compared to the standard treatment (no OPI employed) group, although the difference did not reach significance (p = 0.531) a consistent and substantial increase in the depth of PpIX fluorescence was observed, therefore employment of an OPI device during topical MAL-PDT protocols warrants further investigation as a technique for enhancing MAL penetration.

Medical Journal of AustraliaVolume 190, Issue 11 p. 649-649 Letter Primary osteosarcoma of the sternum after coronary artery bypass grafting Laurence Weinberg, Corresponding Author Laurence Weinberg Anaesthetist Laurence.Weinberg@austin.org.au Department of Anaesthesia, Austin Hospital, Melbourne, VIC.Correspondence: Laurence.Weinberg@austin.org.auSearch for more papers by this authorJoseph Mathew, Joseph Mathew Pathologist Department of Diagnostic and Molecular Pathology, Royal Cornwall Hospital, Truro, UK.Search for more papers by this author Laurence Weinberg, Corresponding Author Laurence Weinberg Anaesthetist Laurence.Weinberg@austin.org.au Department of Anaesthesia, Austin Hospital, Melbourne, VIC.Correspondence: Laurence.Weinberg@austin.org.auSearch for more papers by this authorJoseph Mathew, Joseph Mathew Pathologist Department of Diagnostic and Molecular Pathology, Royal Cornwall Hospital, Truro, UK.Search for more papers by this author First published: 01 June 2009 https://doi.org/10.5694/j.1326-5377.2009.tb02599.xCitations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume190, Issue11June 2009Pages 649-649 RelatedInformation

INTRODUCTION:Scrotal leiomyomas are rare tumours which are essentially benign. Recurrence and malignant transformation to leiomyosarcoma have been reported. However, a specific subgroup with increased bizarre nuclei showing increased mitosis raises the need for a closer follow-up. We report on such a case.CASE PRESENTATION:We report the case of a 65-year-old man who underwent a scrotal lump excision. Histology showed a well defined leiomyoma. The presence of nuclear pleomorphism and mitoses, just falling short of the criteria for malignancy, made prediction of biological behaviour difficult. The patient remains well on 4-year follow-up.CONCLUSION:Histological evidence of increased mitosis raises the need for sustained follow-up in view of the malignant potential from the extent of mitosis. Immunohistochemistry helps in identifying those patients warranting close follow-up.

Intrahepatic nerves serve important metabolic, sensory and motor functions. Their ontogeny in human liver has not been elucidated. We aimed to characterise the ontogeny of human intrahepatic innervation, to assess its relationship with biliary structures and to examine the distribution and nature of peptidergic nerves during development. We used immunohistochemistry on archival normal human liver tissue from 63 fetuses [8-40 gestational weeks (gw)] and 10 adults with antibodies to pan-neural markers and neuropeptides. Few nerve fibers appeared in portal tracts at 8 gw. Their density increased gradually from 12 gw and reached adult levels at 32-33 gw. Rare intra-acinar nerves, restricted to periportal areas, appeared at 40 gw. Galanin-, somatostatin- and calcitonin-gene-related peptide-positive nerve fibers were noted only in portal tracts from 22, 26 and 32 gw, respectively. In human adult liver, dense portal and intra-acinar neural supply was observed. Human fetal liver contains a neural network distributed mainly in portal tracts with a density that increases progressively towards term. Intra-acinar innervation appears at term, suggesting that is not required for normal liver function during development, while peptidergic nerves are important for intrauterine liver functions. Developmentally regulated expression of galanin and somatostatin may play a role in liver morphogenesis.

BACKGROUND:To determine the causes of cardiac tamponade (CT), focussing especially on haemopericardium (HP), as a terminal mode of death, within a 430,000 rural English population.METHODS:Our hospital mortuary register and, all postmortem reports between 1995 and 2004 inclusive, were interrogated for patients dying of CT or HP. The causes of CT/HP and selected morphological characteristics were then determined.RESULTS:14,368 postmortems were performed in this period: of these, 461 patients died of CT. Three cases were due to non-haemorrhagic pericardial effusion. HP accounted for the remaining 458 cases of which, five were post-traumatic, 311 followed rupture of an acute myocardial infarction (RAMI), 138 after intra-pericardial rupture of dissecting ascending aortic aneurysms (RD3A) and four were due to miscellaneous causes.HP was more commonly due to RAMI. Men tended to die from RAMI or RD3A earlier than women. RAMI or RD3A were commoner in men <70 yrs, but more frequent in women after this.Two thirds of RAMI were associated with coronary artery thrombosis. Anterior free wall rupture was commonest overall, and in women, but posterior free wall rupture was commoner in men.The volume of intrapericardial blood in RAMI (mean = 440 ml) and RD3A (mean = 498 ml) varied between 150 and 1000 ml: intrapericardial blood volume was greater in men than in women dying from either RAMI or RD3A.CONCLUSION:At postmortem, CT is most often related to HP, attributable to either RAMI or intrapericardial RD3A. Post-traumatic and other causes of CT are infrequent.

Background This pilot study was carried out to determine whether Helicobacter pylori can be detected in normal colon or in association with colorectal neoplasia. Methods Paraffin processed colonic tissue blocks of normal colonic mucosa (n = 60), and patients diagnosed as adenoma (n = 60), and adenocarcinoma (n = 60) were retrieved from our archive; the adenoma group included tubular (n = 20), tubulovillous (n = 20) and villous adenomas (n = 20). 4 μm sections were stained by immunohistochemical methods using anti- Helicobacter pylori antibodies (polyclonal NCL-HPp and monoclonal NCL-C-jejuni). Results Significant numbers of Helicobacter pylori were identified in tubular adenomas (OR = 11.13; 95%CI = 1.62–76.70), tubulovillous adenomas (OR = 10.45; 95%CI = 1.52–71.52) and adenocarcinomas (OR = 8.13; 95%CI = 1.40–46.99) compared to controls: there was no association in numbers of Helicobacter pylori and villous adenomas (OR = 2.95; 95%CI = 0.29–9.96). Conclusion We conclude that although, in this pilot study, there appears to be an association in the prevalence of Helicobacter pylori with some, but not all, colorectal neoplasms, we can not infer causality from these results. These findings need to be further substantiated with a prospective study and the use of molecular biological techniques to determine a causal association.

Stomal varices secondary to portal hypertension are a rare but potentially fatal cause of hemorrhage. Management, determined by, the site of the bleeding, centers on preventing additional bleeds and may include providing local pressure, applying silver nitrate, injection sclerotherapy, suture ligation of the bleeding point, and/or the placement of transjugular intrahepatic portosystemic shunts and refashioning the stoma. Two patients (60- and 69-year-old women) had panproctocolectomy for inflammatory bowel disease and presented at the authors' hospital with bleeding from the ileostomy 1 and 19 years, respectively, following the creation of their stomas. A third patient (a 72-year-old man) bled from an end colostomy following an abdominoperineal resection for Duke's C rectal adenocarcinoma performed 3 years previous. All three patients had recurrent admissions for stomal bleeding and stomal varices secondary to portal hypertension and were initially treated with local measures (pressure, silver nitrate, and suture ligation). Two had undergone revision of their stomas prior to current treatment One patient responded to local treatment but later died due to liver failure, one stopped bleeding after transjugular portosystemic shunt placement, and one died from metastatic cancer. Clinicians should maintain a high index of suspicion of stomal varices in patients with underlying liver disease who present with recurrent stomal bleeds and provide appropriate treatment to stop active bleeding and reduce portal venous pressure.

Background Prostatic carcinoma is the second most common cause of cancer-related deaths in males in the West. Approximately 20% of patients present with metastatic disease. We describe the case of a patient with metastatic prostate cancer to the bowel presenting clinically and radiologically as a primary caecal cancer. Case presentation A 72 year-old man presented with abdominal discomfort and a clinically palpable caecal mass and a firm nodule on his thigh, the latter behaving clinically and radiologically as a lipoma. Computed tomographic (CT) scan showed a luminally protuberant caecal mass with regional nodal involvement. The patient was being treated (Zoladex ® ) for prostatic cancer diagnosed 6 years previously and was known to have bony metastases. On admission his PSA was 245.4 nmol/ml. The patient underwent a right hemicolectomy. Histology showed a poorly differentiated adenocarcinoma which was PSA positive, confirming metastatic prostatic adenocarcinoma to the caecum. The patient underwent adjuvant chemotherapy and is free from recurrence a year later. Conclusion Metastasis of prostatic carcinoma to the bowel is a very rare occurrence and presents a challenging diagnosis. The diagnosis is supported by immunohistochemistry for PSA. The treatment for metastatic prostate cancer is mainly palliative.

BACKGROUND Psammoma bodies (PBs) are an unusual finding in cervical cytology preparations. They have been identified in association with a wide range of benign and malignant conditions within the female genital tract. Portents of a significant underlying pathology include their occurrence in postmenopausal patients, the presence of unexplained vaginal bleeding and their occurrence in association with atypical cells. CASE PBs associated with atypical cells were detected in repeated cervical cytology smears of an asymptomatic, 55-year-old postmenopausal woman over a 4-year period. She was extensively investigated, and, in the absence of a bleeding) have definitive cause, she underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. Histologic examination of the specimen demonstrated the presence of bilateral benign ovarian serous cystadenofibromas with large numbers of PBs. Focally the PBs were closely apposed to the serosal surface and invested in a blanket of mesothelial cells. CONCLUSION Caution is required when assessing the significance of PBs associated with atypical cells in a cervical cytology specimen. Our case demonstrates the presence of ovarian mesothelial cells mimicking atypical glandular cells.

Background: Dermatologists, or pathologists, occasionally need to decide whether or not to continue methotrexate therapy in a patient with an identifiable risk factor for liver fibrosis, in this instance heterozygous α1-antitrypsin deficiency. Case Presentation: We relate our experience with an elderly male patient, diagnosed as having α1-antitrypsin deficiency on a liver biopsy, genotypically confirmed as PiMZ. He had been receiving methotrexate for psoriasis for 17 years with a cumulative dose of 7,200 mg. He was monitored by biochemical profiling and interval (10) liver biopsies. Non-specific changes were seen on liver histology although grade 1 liver fibrosis was seen in his last 2 biopsies. Conclusion: We suggest that methotrexate therapy is relatively safe in patients with heterozygous α1-antitrypsin deficiency, with no other risk factor. We however advise that the risk of fibrosis should be monitored and that the patient receives appropriate counselling.

This report describes the case of a patient with clinically antepartum hemorrhage and a colposcopic lesion resembling invasive cervical cancer. A 28-year-old patient sought treatment at 28 weeks of pregnancy with significant antepartum hemorrhage, clinically thought to be a result of placenta previa or abruptio placenta. Colposcopy showed a lesion resembling an invasive cervical cancer for which a biopsy was taken. Abnormal placentation was ruled out by ultrasound examination of the uterus. Histologic analysis showed a cervical decidual reaction with focal surface ulceration accounting for the cervical growth and hemorrhage. We describe an unusual cause of significant intrapartum hemorrhage attributable to cervical decidual reaction, mimicking abnormal placentation clinically and invasive cervical cancer colposcopically.

BACKGROUND:Pathologists are often faced with the dilemma of whether to recommend continuation of methotrexate therapy for psoriasis within the context of an existing pro-fibrogenic risk factor, in this instance, patients with genetic hemochromatosis.CASE PRESENTATIONS:We describe our experience with two male psoriatic patients (A and B) on long term methotrexate therapy (cumulative dose A = 1.56 gms and B = 7.88 gms) with hetero- (A) and homozygous (B) genetic hemochromatosis. These patients liver function were monitored with routine biochemical profiling; apart from mild perivenular fibrosis in one patient (B), significant liver fibrosis was not identified in either patient with multiple interval percutaneous liver biopsies; in the latter instance this patient (B) had an additional risk factor of partiality to alcohol.CONCLUSION:We conclude that methotrexate therapy is relatively safe in patients with genetic hemochromatosis, with no other risk factor, but caution that the risk of fibrosis be monitored, preferably by non-invasive techniques, or by liver biopsy.

A patient was admitted to the emergency department with a reduced level of consciousness and deteriorating vision. Her pupils became fixed and dilated and she developed a third nerve palsy with extensor posturing of her limbs. Biochemistry profile showed an increased serum osmolar gap with a raised anion gap metabolic acidosis. Supportive treatment was instituted, but she made no recovery and brainstem death was later confirmed. Post mortem examination and toxicology screen confirmed the cause of death as methanol poisoning leading to cerebral oedema and transtentorial herniation. We highlight some of the diagnostic difficulties associated with treating a patient with a reduced level of consciousness. The clinical and biochemical findings that are critical in establishing a diagnosis of methanol intoxication are discussed. The definitive management of methanol poisoning is reviewed.

BACKGROUND: Carcinoma of the prostate metastasising to the penis is rare. These patients have a poor prognosis receiving various treatment modalities. CASE PRESENTATION: Two such patients are discussed here having received differing therapeutic regimes, pointing out the necessity for standardised palliative treatment rather than radical therapy. CONCLUSION: Management of patients with penile metastases from carcinoma of the prostate should emphasise improving quality of life with palliative treatment rather than radical therapy

ABSTRACTThe aim of the study was to assess the monocyte/macrophage and hepatic stellate cell responses during experimental diethylnitrosamine (DEN)‐induced hepatocarcinogenesis. Diethylnitrosamine (50mg/L) was administered to 39 rats for 10 weeks; liver tissue was obtained at weeks 10, 16 and 19. In this model, necroinflammatory damage occurs during the period of DEN administration but thereafter subsides; dysplastic nodules and carcinomas subsequently develop. Monocytes/macrophages were detected immunohistochemically using ED1 and ED2 monoclonal antibodies; hepatic stellate cells (HSC) were detected using antibodies to α‐smooth muscle actin (α‐SMA) (activated HSC) and glial fibrillary acidic protein (GFAP). Parenchymal ED1‐ and ED2‐positive monocytes/macrophages and α‐SMA‐positive HSC increased at week 10 when there was ongoing DEN‐induced necroinflammatory activity. ED1‐ and ED2‐positive cells were also prominent at weeks 16 and 19, particularly around the periphery of dysplastic and carcinomatous nodules, with occasional macrophages between dysplastic hepatocytes. α‐SMA‐positive HSC were present within sinusoids between dysplastic cells and were more abundant at weeks 16 and 19 than in control or week 10 animals. Activated HSC were prominent in fibrous septa around and within dysplastic and carcinomatous nodules at weeks 16 and 19. In contrast, GFAP‐positive HSC did not accumulate in developing septa or within dysplastic and carcinomatous nodules. We have demonstrated changes in the monocyte/macrophage and HSC populations during the development of hepatocellular dysplasia and carcinoma at time points when there is little necroinflammatory activity; this may therefore represent a host response to hepatocyte dysplasia. The HSC activation may be mediated, in part, by monocyte/macrophage‐derived factors, but we speculate that it may also result from direct stimulation by factors released from dysplastic hepatocytes.

The aim of this study was to determine the prevalence of infection with the newly described hepatitis G virus (HGV) in a liver transplant cohort, and to establish the frequency and nature of hepatitis in those with and without HGV infection. A reverse transcriptase-polymerase chain reaction technique was employed to determine viraemia in the patients, and liver biopsies taken at different times after transplantation were assessed histologically, Hepatitis G virus RNA was detected in 47% of the liver transplant recipients investigated. Those positive for HGV had received significantly more blood or blood products than the HGV-negative patients. The frequency of abnormal liver function tests was similar in HGV-positive and HGV-negative recipients. Bile duct epithelial cell damage was more frequently seen in those with HGV viraemia. This study indicates that almost half of the liver transplant recipients in Northern England are positive for HGV, and that infection is associated with exposure to blood and blood products. It appears that, in the immunosuppressed patient, HGV does not cause clinically significant liver disease, at least up to 2 years after transplantation. If HGV infection is associated with hepatitis outside this clinical setting, it is likely that the liver damage is immunopathologically mediated rather than as a result of direct viral cytotoxicity.