  A financial how-to book that doesn't mentally tax its readers

	How many of us are guilty of reading only the first couple of pages of the latest financial best seller and then leaving it sheepishly on our nightstand for another evening when our minds are a bit more focused? Financial how-to books have the tendency to leave their readers feeling like they need the Cliffs Notes version to truly understand their meaning. Now an easy-to-digest translation of finance is available to anyone who ever wanted to know what a contango was, but was too embarrassed to ask. In 

The Wall Street Journal Complete Money & Investing Guidebook

 (Three Rivers Press; 2006), Dave Kansas does not simply supply a map, compass, and a half-hearted "good luck," but instead leads the reader through the world of finance by the hand. Part history book and part financial text, each chapter covers a topic simply and thoroughly, as if the reader were a visitor from a foreign land. Economics, Wall Street, stocks, bonds, mutual funds, retirement, real estate, and nontraditional investments?Kansas skillfully covers these subjects by drawing on his knowledge as an editor of The Wall Street Journal's Money & Investing section. Illustrations break down how to read the distinguishing marks on paper money, and graphs show you how the Dow has fared through past presidential administrations. Kansas even explains how to read those intimidating charts in the back of financial publications. As complete as its title proclaims, Kansas' 200-page guidebook is a must-have crash course on money and investing. Although beginners will benefit the most, experienced surgeon investors can also discover new financial facts with Kansas' exploration.

	With slowing profit margins due to fierce competition among credit card issuing banks, companies are now offering rewards programs for debit cards in an attempt to attract customers to use their plastic rather than cash or check. According to the 

, 36% of banks that issue debit cards offer rewards programs, up 12% from 2 years ago. While some carry annual fees, many offer a reward for purchases made only with a signature and not PIN-based transactions. Yet debit rewards programs, which allow card users to redeem points for such items as gift cards or even trips, remain a struggle for banks, and a winning strategy for rewarding customers for loyalty has yet to emerge. One of the problems is linked to the very nature of debit cards. Whereas credit cards allow a grace period for repayment, debit cards are linked directly to the consumer's bank ac?count, a direct payment that does not allow for reliance on America's greatest standby?debt. The fact that institutions earn more money from credit card transactions than debit card transactions compounds the issue. Not only do card issuers receive finance charges and late fees for using credit cards, but merchants pay on average 1.6% for every credit card transaction, compared with 1.3% for signature-required debit transactions and 0.8% for PIN-based transactions. These fees fund the rewards programs, and the 0.8% difference between debit and credit card fees could explain the less-than-stellar debit rewards programs.

 Learn to shop around for the best prices on college textbooks 

	As a medical school graduate, you know how outrageously expensive textbooks can be. According to the

, these pricey primers aren't getting any cheaper, with costs going up an average of 6% a year since 1986. But if you have children in college, there are ways they can cut down on textbook spending. On?line shopping is the easiest way for students to find the books they need and compare prices among different sites. Web sites such as AddAll.com and BestBookBuys.com search doz?ens of online stores at once to find the low-est price. Students with similar course loads can also swap textbooks through SwitchTextbooks.com. But keep in mind that although a site may have the best price for one book, it may not be the lowest for another, so you should shop around for each textbook needed. One drawback to online book buying is that students have to wait several days for the book to be shipped, so they have to know exactly what they need long be-fore classes begin, which isn't always possible. College scholars can try to locate used textbooks at local bookstores, but most of the time professors require the latest editions, which come out frequently. When it comes time to sell the books back, eBay is a better bet to get maximum value than the campus bookstore, which usually offers a refund of roughly 50% of the purchase price.

Small shops struggle with high-tech car tools

If you have ever brought your vehicle to a local repair shop and have been turned away because your mechanic does not have the necessary equipment to fix it, you are not alone. As vehicles have become increasingly more computerized and complicated over the past 10 years, many manufacturers require expensive and often unaffordable diagnostic tools simply to figure out what is wrong with your car. Small, independent garages that work on several different brands are hit the hardest because they do not have the money to invest in each manufacturer's tool, according to the 

. For example, Ford Motor Company charges independent repair shops $11,000 for a Volvo scanning tool and the accompanying software. A study by the research firm Tarrance Group of Alexandria, VA, found that 59% of independent auto technicians had problems acquiring necessary equipment or information from manufacturers, and 67% of shops had to divert business to a dealership. This epidemic of lost business may explain why parts and service comprise 44% of dealer profit, while only 28% stems from new car sales, according to the Wall Street Journal. After years of problems, the concerns of drivers and mechanics are finally getting heard. This past November, Rep. Joe Barton (R-Tex) spoke to a House Energy and Commerce subcommittee about the "Motor Vehicle Owners' Right to Re?pair Act," which he introduced in March 2005. If passed, the bill would direct the Federal Trade Commission to institute rules that would ensure independent repair shops and dealers have equal access to repair information.

	$36 billion?Net earnings last year for Exxon Mobil, up 42% from 2004. (

	1?Number of new blogs created every second. (

	1 in 7?Proportion of dollars that will be spent on ethnic food over the next decade. (

	70%?Percentage of divorces initiated by women. (

	60%?Percentage of Americans aged 75 and older who depend on Social Security for at least 50% of their in?come. (

	52%?Percentage of college students who say it is okay to download and swap copyrighted files. (

	3%?Percentage of Americans who walk to work. (

	Today's grandparents give more than just $20 in a birthday card to their grandchildren. With 70% of the country's wealth controlled by the 50-plus generation, grandparents are in a better position than ever before to contribute to expensive upbringing necessities such as braces and college. According to 

, unless parents are savvy and work together with grand?parents, financial aid problems and tax issues may arise. For items such as braces, generous grandparents should pay orthodontists directly. If they wish to contribute to a future college education, grandparents should open a 529 savings plan in their grandchild's name. An?nual gift-giving al?lows grandparents to move money out of their estate without paying a gift tax. What is more, grandparents can contribute 5 years' worth of contributions in a single year without alerting the gift-tax po?lice, but they should check the cap on their state's 529 plan. Keep in mind that if the grandchild is of college age and applying for financial aid, his or her chances of receiving help could be hurt if significant funds are found in the grandchild's name. Stud?ents should wait to receive their financial package, and then ask Grandma to write a check directly to the school to make up the difference.

If you're a surgeon who has paid a bill late at one time or another, you're not alone. Bill-paying tardiness is becoming a national epidemic. Increasing numbers of Americans are paying their bills more than 30 days late, according to the Association of Independent Consumer Credit Counseling Agencies (AICCCA). A report by the American Bankers Association revealed that credit card payments made over a

	month late rose to a record high of 4.81% for the April to June 2005 period. If you're having trouble with late payments, the AICCCA recommends that you take steps to correct the problem. Figure out precisely what you owe, so you know where you stand. Then, take a close look at your daily spending habits to determine where you can cut back to save money to pay your bill.Most importantly, stop charging altogether so you do not make the problem worse. If you find that you're still ringing up charges and your payments are out of control, seek help from a certified credit counselor. Visit 

 or call (800) 450-1794 to find a credit counselor near you.

 Earn free miles when you fly with your pet 

	Pooches and kitties can now earn frequent flier miles just like their human companions. Midwest Airlines' Premier Pet Program offers your pet one free flight for every three paid roundtrip tickets or six one-way flights. An added bonus is that any person or animal that resides within the same residence can combine trip rewards. Owners can also redeem their 15,000 Midwest Miles for free roundtrip pet tickets. Some conditions do apply. Pets must fly with owners, and service animals or pets shipped as cargo are excluded. When looking for flights, keep in mind that pets are accepted on Boeing 717, MD-80, and Beech 1900 aircraft only. All pets must be in an approved carrier and are held in the forward compartment, which is temperature-controlled and pressurized. Pets and owners have 3 years to accumulate miles for free travel. For more information on how to earn free flights for your pet, contact Midwest Airlines at (800) 452-2022 or visit 

Finding child care in a competitive market 

	The hottest market around may not be real estate anymore?it's baby-sitting. That's right, finding in-home child care on a part-time basis is not easy these days, and the demand has pushed part-time rates to full-time levels, according to the

. Changing work schedules and a growing emphasis on preschool education are fueling the need for part-time help. Instead of hiring a full-time nanny for a 3 year old, more parents split a child's care between part-time preschool and a part-time nanny. But it's not only dual-income households that are looking for help. With ever-increasing extracurricular demands, many at-home parents employ part-time help to manage children's daily activities. So how much are parents willing to invest in their child's daily care? If you live in an affluent area, expect to pay a part-time nanny as much as $20 to $25 per hour for a highly qualified individual, in addition to offering paid vacation and flexible hours to attract the right person. Recruiting fees range from $450 to $2,400, if you utilize a nanny placement agency that carefully screens candidates for you. The 

 offers some strategies for hiring part-time child care:

	?Set regular work hours, offering at least 20 hours per week.

	?Help nannies find a second part-time job, if necessary.

	A British man was sentenced to 4 years in jail for leading a six-man Internet gang that stole nearly $360,000 through a sophisticated fraud that took place over a 12-month period. According to the Associated Press, David Levi, 29, of Latham, England, orchestrated a high-level scheme that employed phishing e-mails to defraud unsuspecting eBay customers. The e-mails pretended to be from the online auction Web site and directed customers to bogus URLs, where victims were asked to input credit card or bank account information and passwords. The gang then used this in?formation to gain access to the financial records of more than 160 individuals. Other gang members' sentences ranged from 6 months to 2 years. The ring-leader's brother, Guy Levi, 22, was sentenced to 21 months.

 What is the appropriate tip at a buffet restaurant?

	Depending on the class of the establishment and the service you receive, you likely tip 15% to 20% of your check total at a restaurant, a reasonable compensation to a member of the wait staff working hard to serve you. But what if you have to do all the food serving yourself? In other words, what should you tip at a buffet, where service is minimal? The Wall Street Journal posed this question to Peter Post, a director of the Emily Post Institute, who says a suitable tip in a buffet restaurant is 10%. Although the servers may not be going through the rigors of a normal sit-down eating establishment, they're still catering to you by taking your drink orders, refilling them, clearing your plates, etc. Post also says to keep in mind that you should calculate your tip off of the pretax amount of the meal no matter what type of restaurant it is, because it's senseless to pay a tip on the tax.

Has the time come for your child to move out?

Naturally, you want your children to be financially comfortable, and as a result, you allow your children to live at home after college to save money. But what happens when the time comes to let your adult child go out into the world? According to the Wall Street Journal, if a child stays at home for an extended period of time, they may become overly dependent. They may lose the desire to move out and start careers because they feel they have a good, inexpensive living situation. While you are helping your children out by letting them stay in your home, the added cost can hold back your own retirement plans. The Journal article recommends that you set up a financial strategy with your child to prepare them for life on their own. Start by charging them rent, which will get them adjusted to making such a monthly payment and will alleviate some of your financial burden. Also, try to set a tentative move-out date. If your child is living at home while going to grad school, have them pay part or all of their tuition costs, so that putting off starting their career has a financial price. Remember: The point is not only to ease your financial situation but to prepare your child for adulthood.

Articles

Surgical Rounds

Surgeon's Bulletin Board

Abdominal pain in patients with ac?quired immunodeficiency syndrome (AIDS)

 can present a diagnostic challenge for clinicians. A small but significant number of patients will require op?er?ative intervention. In addition to the more common surgical problems such as acute appendicitis, AIDS pa?tients may present with atypical conditions related to their infection. The authors report an 

scess and diffuse fibropurulent peritonitis in a 37-year-old man with AIDS. 

									Rosalind Franklin University of Medicine and Science

									Mount Sinai Hospital Medical Center

	Abdominal pain requiring evaluation by a surgeon is common in patients with acquired immuno-deficiency syndrome (AIDS).

 Although most patients have relatively benign conditions such as gastroenteritis, a smaller subset of patients have severe intra-abdominal problems that may require surgical intervention. The most common of these are cytomegalovirus (CMV)-in?duced enterocolitis with perforation and acute appendicitis.

 complex (MAC) is common in patients with advanced AIDS and usually presents as disseminated disease.

 The gastrointestinal (GI) manifestation of MAC in patients with AIDS is generally limited to mesenteric lymphadenopathy or, less commonly, peritonitis in patients with ascites or those undergoing peritoneal dialysis.

 We describe an unusual case of MAC resulting in fibropurulent peritonitis and intra-abdominal abscess in an AIDS patient. Exploratory laparotomy was re?quired to rule out GI perforation.

	A 37-year-old African American man came to the emergency department reporting abdominal pain, fever, and tachypnea of 24 hours' duration. He had tested positive for the human immunodeficiency virus (HIV) 5 years earlier, at which time he had already developed AIDS. The patient had been noncompliant in treating his infection for the first 4 years following the diagnosis. He also had been treated previously for MAC (diagnosed by blood culture), toxoplasmosis, and pneumocytis. Three months earlier, the patient was evaluated for abdominal pain and underwent a computed tomography (CT) scan of the abdomen, which was reported as normal. The patient's compliance with his antiviral regimen and MAC treatment was reported as excellent 6 months be?fore his current presentation to the hospital. His weight had increased from 93 lb to 132 lb and he was doing well, but he had discontinued his two-drug treatment for MAC on his own, after following the regimen for approximately 1 year.

	During physical examination, the patient was in moderate distress and had a temperature of 101?F, blood pressure of 125/80 mm Hg, pulse of 102 beats per minute, and a respiratory rate of 25 breaths per minute. The abdomen had hypoactive bowel sounds, mild distention, and diffuse, moderate tenderness to palpation, but no peritoneal signs or masses.

	His initial white blood cell count was 24,500/mm

 with 93% neutrophils. The patient's CD4 count was 33 cells/mm

. The patient's viral load was 5,200 copies/mL. A chest radiograph showed no acute changes.

	The patient was admitted to the hospital and underwent an abdominal CT scan, which showed an 8 x 10-cm fluid collection abutting the left psoas muscle, with fat stranding around the mesentery consistent with an abscess (Figure 1). There was no evidence of free air or free fluid within the abdominal cavity.

	Blood cultures were obtained, and the patient was started on broad-spectrum antibiotics. The patient underwent CT-guided drainage of the fluid collection. The aspirate was described as consistent with abscess; however, gram stain and initial cultures were negative for bacteria and acid-fast bacilli. On hospital day 4, the patient developed loose stools. An assay for Clostridium difficile was positive, and the patient was started on metronidazole. A flexible sigmoidoscopy was performed to 60 cm and was negative for inflammation or other signs consistent with colitis.

	Over the next 5 days, the patient continued to have increasingly severe ab?dominal pain and fevers. Repeat CT scans showed persistence of the psoas fluid collection, additional intra-abdominal fluid collections, and inflammatory changes consistent with peritonitis (Figure 2). Since the patient's abdominal pain continued to worsen and the physical findings progressed to frank peritonitis, the decision was made to perform an ex?ploratory laparotomy to rule out GI perforation.

	Upon entering the abdomen, several hundred cubic centimeters of free turbid fluid were encountered. This fluid was aspirated and sent to microbiology. Examination of the small bowel revealed numerous fi?bropurulent adhesions and exudate, which separated easily. At the base of the small bowel mesentery, a necrotic ab?scess cavity was seen, which measured approximately 6 x 6 cm. Numerous biopsies were taken of the fibropurulent exudates on the bowel serosa and of the tissue around the abscess cavity. Careful examination of the entire length of bowel re?vealed no evidence of perforation or ischemia. Drains were placed in the nec?ro?tic cavity at the base of the mesentery, and the abdomen was extensively irrigated.

	Postoperatively, the patient was continued on broad-spectrum antibiotics and remained on total parenteral nutrition, taking nothing by mouth, until bowel function resumed on postoperative day 5. Because of the negative bacterial cultures, the patient was empirically placed on ethambutol, pyrazinamide, and isoniazid for broad coverage of atypical pathogens. The patient's pain markedly decreased by postoperative day 2, and drainage was minimal. The drains were removed on postoperative day 3. All oper?ative specimens were negative for bacterial growth. Sub?sequently, the fi?brous biopsies and intra-abdominal fluid were positive for MAC. The patient was discharged to home on postoperative day 7, tolerating a regular diet with minimal discomfort. At subsequent follow-up, he reported no further abdominal symptoms.

	Although the incidence of opportunistic infections in patients with HIV has decreased with current antiviral regimens, the incidence of HIV infection is increasing, resulting in a growing number of patients requiring evaluation by general surgeons for AIDS-related problems.

 While most AIDS patients with abdominal pain do not require operative intervention, there are a significant number of patients with abdominal symptoms requiring more extensive investigation.

 The most commonly reported intra-ab??dominal conditions that require lapa-rotomy to alleviate abdominal symptoms are CMV enterocolitis with or without perforation, acute appendicitis, complications from non-Hodgkin's lymphoma, and mesenteric adenopathy from MAC infections.

	While CMV can be detected in more than 80% of individuals over the age of 35, it is generally of no consequence un?less significant immunosuppression is present.

 In AIDS patients, CMV most commonly affects the colon but can cause significant infection in any portion of the GI tract. In those with CMV colitis, sigmoidoscopy frequently reveals geographic ulcers, friability, mucosal edema, and erythema.

 Biopsy usually demonstrates the typical intranuclear inclusion bodies characteristic of CMV and can be confirmed by polymerase chain reaction. Al?though generally treated medically when diagnosed, suspicion of perforation with peritonitis warrants laparotomy with resection of the involved segment. Pri?mary anastomosis is rarely recommended because the risk of anastomotic disruption is high.

	Disseminated infections with MAC are fairly common in patients with advanced AIDS.

 MAC is acquired from the environment and enters the body through the GI tract. In immunodeficient patients, the organism's adherence to the mucosal surface is rapidly followed by invasion of the gut wall. Organisms multiply within the macrophages and are released with cell rupture.

 Infection spreads through local lymphatics to the mesenteric lymph nodes, where multiplication again occurs in macrophages, and eventually the organism breaks out, resulting in hem?atogenous dissemination. When the disease progresses to include the entire gut, patients generally experience nausea, diarrhea, and weight loss.

 Hemato?gen?ous dissemination is thought to be re?sponsible for the fever and night sweats observed in some patients.

	With regard to conditions requiring sur?gical evaluation, MAC has been associated with a variety of conditions, in?cluding abdominal pain with enlarged mesenteric or retroperitoneal lympha?denopathy and peritonitis in patients with ascites or on continuous peritoneal dialysis.

 Al?though abscess formation is rare, there have been individual reports of isolated abscesses involving the psoas muscles, kidneys, spinal epidural space, and liver.

	Our patient's initial presentation ap?peared to be an isolated abscess in the ret-r?operitoneum. Initial percutaneous drain-age was significant for the absence of any bacterial pathogens, suggesting an atypical infection. Given MAC's pre?dilection for affecting lymph nodes in the bowel mesentery and retroperitoneum, it is possible that the etiology of this collection resulted from a MAC infection and necrosis of lymph nodes in the small bowel mesentery. This finding would be consistent with the findings at laparotomy. In addition, Dworkin has described a MAC-induced abscess in the axillary lymph node of an AIDS patient on an?tiretroviral therapy.

	After percutaneous drainage, our pa?tient's condition deteriorated. There was increasing evidence of peritonitis, and he eventually required laparotomy to ex?clude GI perforation. Findings at laparotomy included diffuse fibropurulent exudates on the bowel surface and a necrotic ab?scess cavity within the small bowel mesentery. No perforation was identified within the GI tract. It is possible that intra-abdominal con?tamination occurred at the time of attempted percutaneous drainage, resulting in a more diffuse in?fection. The combination of lavage, drain?age, and broad antimicrobial coverage for atypical path?ogens in addition to antiretroviral therapy resulted in an uneventful recovery.

	Abdominal pain in an AIDS patient can present a diagnostic challenge. While most serious conditions requiring operative intervention (such as CMV enterocolitis with perforation or appendicitis) can be relatively straightforward, the susceptibility of AIDS patients to a variety of unusual pathogens can result in clinical presentations that necessitate laparot?omy to rule out conditions requiring bowel resection.

	1. Parente F, Cernuschi M, Antinori S, et al. Severe abdominal pain in patients with AIDS: frequency, clinical aspects, causes, and outcome. Scand J Gastroenterol. 1994;29(6):511-515.

	2. Mueller GP, Williams RA. Surgical infections in AIDS pa?tients. Am J Surg. 1995;169(suppl 5A):S34-S38.

	3. Horsburgh CR Jr. The pathophysiology of disseminated Mycobacterium avium complex disease in AIDS. J Infect Dis. 1999;179(suppl 3):S461-S465.

 complex peritonitis in an AIDS patient. 

	5. Potter DA, Danforth DN Jr, Macher AM, et al. Evaluation of abdominal pain in the AIDS patient. 

	6. Davidson T, Allen-Mersh TG, Miles AJ, et al. Emergency laparotomy in patients with AIDS. Br J Surg. 1991;78(8):924-926.

	7. Lowy AM, Barie PS. Laparotomy in patients infected with human immunodeficiency virus: indications and outcome. Br J Surg. 1994;81(7): 942-945.

	8. Ferguson CM. Surgical complications of human immuno-deficiency virus infection. Am Surg. 1988;54(1):4-9.

	9. Wilson SE, Robinson G, Williams RA, et al. Acquired im?mune deficiency syndrome (AIDS). Indications for abdominal surgery, pathology, and outcome. Ann Surg. 1989;210(4):428-433.

	10. Ho M. Epidemiology of CMV infection in man. In: Greenbough WB, Merigan TC, eds. Cytomegalovirus. New York, NY: Kluwer Academic Publishers; 1982:79-104.

	11. Cappell MS, Friedel D. The role of sigmoidoscopy and colonoscopy in the diagnosis and management of lower gastrointestinal disorders: endoscopic findings, therapy, and complications. Med Clin North Am. 2002;86(6):1253-1288.

	12. Robinson G, Wilson SE, Williams RA. Surgery in patients with acquired immunodeficiency syndrome. Arch Surg. 1987;122(2): 170-175.

	13. Gray JR, Rabeneck L. Atypical mycobacterial infection of the gastrointestinal tract in AIDS patients. Am J Gastroenterol. 1989;84(12):1521-1524.

	14. Perazella M, Eisen T, Brown E. Peritonitis associated with disseminated Mycobacterium avium complex in an acquired immunodeficiency syndrome patient on chronic ambulatory peritoneal dialysis. Am J Kidney Dis. 1993;21(3):319-321.

	15. Fernandez-Miranda C, Medina J, Palenque E, et al. Peri?tonitis with Mycobacterium avium in a patient with hepatic cirrhosis. Am J Gastroenterol. 1993;88(4):615.

	16. Boyd AE, Brettle RP. Localized Mycobacterium avium-intracellulare psoas abscess in patients with AIDS after anti?retroviral therapy. AIDS. 1999;13(15):2185-2186.

	17. Colebunders R, Kint I, Bastian I, et al. Renal abscess due to Mycobacterium avium complex in a human immunodeficiency virus-positive patient. Int J Infect Dis. 2002;6(3):238-239.

Mark A. Mueller, Senior Resident; Michael Zdon, Professor and Vice Chairman, Department of Surgery, Chicago Medical School at Rosalind Franklin University of Medicine and Science, Mount Sinai Hospital Medical Center, Chicago, IL

Mycobacterium Avium Complex Causing Intra-abdominal Abscess and Fibropurulent Peritonitis in an Aids Patient

completely understood. Different mech?anisms have been postulated, most of which point to various anatomical ab?normalities of the pelvic floor. Schisto?somiasis, caused by parasitic trematode worms and common in many parts of the world, has been associated with rectal prolapse but is rarely reported in the United States. The authors report a case of rectal prolapse associated with schistosomiasis in a nulliparous Filipino woman. The patient underwent an un?eventful perineal rectosigmoidectomy.

									Department of Colorectal Surgery

	Rectal prolapse is full-thickness protrusion of the rectum through the anal sphincters. This condition can affect people of all ages. Children may present with partial prolapse, a condition more common in boys younger than 5 years.

 In adults, women are affected more often than men and commonly present with full-thickness rectal prolapse.

	Several causes of rectal prolapse have been described in the literature, most of which point to various anatomical abnormalities of the pelvic floor.

 Childbirth is a primary cause of rectal prolapse in women, but we could immediately rule this out in our patient because she was nulliparous. During perineal rectosigmoidectomy for her rectal prolapse, we discovered she had schistosomiasis. Along with this case report, we review the literature regarding schistosomiasis-induced rectal prolapse.

	A 62-year-old Filipino woman presented with rectal prolapse, intermittent bright red bleeding from her rectum, and urinary incontinence. She had immigrated to the United States 30 years earlier and was married but had no children. Her medical history was significant for anxiety, chronic abdominal and back pain, hypertension, and diabetes mellitus. She had visited the Philippines within the past year.

Physical examination was normal except for full-thickness rectal prolapse. The patient underwent colonoscopy and an upper gastrointestinal endoscopy, both of which were normal. She had a thorough urological examination, and it was recommended that she receive conservative treatment for urinary incontinence. The patient subsequently underwent perineal rectosigmoidectomy for rectal prolapse.

	The rectosigmoidectomy specimen consisted of a 16-cm length of bowel. The mucosal surface was smooth, glistening, tan, and intact; the wall appeared slightly thickened. Many irregular areas of yellow discoloration measuring up to 2 cm in diameter were seen throughout the bowel wall of the cut section. A microscopic examination showed numerous parasitic eggs measuring 65 to 75 microns in length, many of which were calcified, consistent with 

 (Figure 1). The eggs were non?operculate and lacked both birefringence and lateral or prominent terminal spines (Figure 2), found in other species of 

	In 1851, Theodor Bilharz described a parasitic infection (

), currently referred to as schistosomiasis, caused by the presence of trematode worms (

) in the venous system of the intestines.

 Man is the principal definitive host for this parasite. The adult worms of 

 inhabit the portal and mesenteric veins. The female worms occupy a groove in the lateral edge of the male worm's body and produce approximately 3,000 eggs each day.

 Egg production begins 4 to 6 weeks after infection and continues for the life of the worm, which is usually 3 to 5 years. Schis?tosome eggs find their way into the lumen of the bowel and bladder and are excreted in the feces (

	The eggs hatch in fresh water and release motile ciliated miracidia, which penetrate the body of an intermediate host snail (

). The miracidia multiply asexually in the body of the snail, and within a few weeks hundreds of motile cercaria emerge. Cercaria enter humans by penetrating the skin, after which they lose their tails and evolve into schistosomula before migrating to the lungs and liver. Approximately 6 weeks after infection, they mature into adult worms, mate, and then pass through the venous system to their final habitat.

	It is estimated that 200 million people throughout 74 countries have schistosomiasis. Of these, 120 million experience symptoms, 20 million of whom suffer severe illness. Three species are primarily responsible for human infections: 

. Despite major advances in controlling the parasite and decreases in morbidity and mortality, schistosomiasis continues to spread in humans with increasing frequency. Praziquantel is the mainstay of treatment and reliably cures 60% to 90% of patients; for those who are not cured, praziquantel substantially decreases the worm burden and egg production. After nearly 20 years of intensive use, resistance to praziquantel may be emerging.

 Despite substantial and successful control measures, 

 infection still occurs in China, Indonesia, and the Philippines.

	Schistosomiasis is the principal cause of rectal prolapse in certain parts of the world.

 In Egypt, the disease occurs almost exclusively in rural populations among young men, who are exposed to the parasite while cultivating and irrigating fields with water from the Nile, which is infested with 

	El Sebai reported that schistosomiasis of the rectum and colon can cause rectal prolapse due to frequent severe attacks of dysentery, passage of mucus and blood in the stool, and dragging tension of schistosomal polyps on the mucosa of the rectum.

 Hammam also reported a relationship between schistosomiasis of the colon and rectum and the development of rectal prolapse.

	Several mechanisms have been proposed for schistosomiasis-induced rectal prolapse. Chronic straining due to dysentery, along with the passage of blood and mucus in the stools, may weaken the pelvic floor, muscles, and sphincters. Repeated prolapse of schistosomal polyps with resulting venous congestion and secondary infection may greatly increase the bulk of the polyps. This, and the constant dragging effect of these polyps when present with lax ampullary mucosa of the rectum, may lead to prolapse. Continuous and repeated passage of mucus and blood in the stools can render these patients severely anemic and hypoproteinemic, resulting in weakness and hypotonia of the pelvic muscles and sphincters. This results in a lack of fixation of the rectum and can lead to rectal prolapse.

 Our patient presented with bleeding but no dysentery or anemia.

	The presence of schistosomal polyps is not a constant finding in patients with schistosomiasis presenting with rectal prolapse; in these patients, myopathy may be a major contributory factor.

 In addition, positive immune fluorescence reaction for 

 egg antigen along the sarcolemmal membrane of human myocardial fibers suggests a role for im?mune complexes in the pathogenesis of the muscle lesions in

	Schistosomiasis results from the host's immune response to schistosome eggs and the granulomatous reaction caused by secreted antigens. Most granulomas develop at the sites of maximal egg accumulation: the intestine, genitourinary tract, and liver. Eggs retained in the bowel wall cause inflammation, hyperplasia, ulceration, and polyposis. As was the case with our patient, rectal prolapse may result. Chronic granulomatous le?sions may lead to portal hypertension, massive splenomegaly, and gastrointestinal bleeding. Patients experience fatigue, abdominal pain, and diarrhea; in severe cases, they may suffer from jaundice and liver failure.

	Schistosomiasis is diagnosed when evidence of schistosome eggs is found in the feces, urine, or a biopsy specimen (usually of the rectal mucosa). The extent of egg shedding may fluctuate, and as many as three specimens may be re?quired in some patients to make the diagnosis.

 We made our diagnosis after examining the rectosigmoidectomy specimen taken to repair the rectal prolapse. Since our patient had never borne children, we were able to eliminate one of the primary causes of rectal prolapse from consideration. The possibility of schistosomiasis should be considered for patients who present with rectal prolapse and have a history of living or traveling in an endemic region.

	1. Wright AD, Hughes ES, et al. Discussion on prolapse of the rectum. Proc R Soc Med. 1949;42(12):1005-1016.

	2. Goligher JC. Surgery of Anus, Rectum and Colon. 2nd ed. London, England; Bailliere Tindall:1967;289.

Mirza Khurrum Baig, Research Fellow, Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL; Sherry Woodhouse, Chairman, Department of Pathology, Cleveland Clinic Florida, Weston, FL; Bruno Dipasquale, Staff, Department of Pathology, Cleveland Clinic Florida, Naples, FL; Anthony M. Vernava III, Staff, Department of Colorectal Surgery, Cleveland Clinic Florida, Naples, FL; Jonathan Efron, Staff, Department of Colorectal Surgery, Cleveland Clinic Florida, Naples, FL

Rectal Prolapse Associated With Schistosomiasis

	Adenocystic carcinoma accounts for fewer than 1% of all primary carcinomas of the breast.

 Most of the knowledge regarding these tumors is derived from case reports or retrospective case series. Adenoid cystic carcinoma of the breast is mainly diagnosed based on morphologic features.

 It is considered a benign disease, and its treatment is still a topic of debate. We report a case of adenocystic carcinoma of the breast in a patient who was referred to a community-based hospital and review the literature regarding this rare entity.

	A 65-year-old woman (gravida 5, para 3) presented with a painful lump in her left breast, which she had discovered by self-examination a few weeks earlier. She had observed no change in the size of the recently palpated lump. The patient had no history of taking hormone replacement therapy or of breast disease, breast discoloration, or breast discharge. She had a medical history of hypertension, which was controlled with amlodipine. Her surgical history included cervical fusion and total abdominal hysterectomy with bilateral oophorectomy. Her only significant family history was throat cancer, which afflicted her father at age 58. The patient was a nonsmoker and only drank alcohol socially. Physical examination revealed a hard, mobile, 3-cm lump located in the left breast at the 5 to 6 o'clock position. The rest of the breast examination was normal. No axillary or supraclavicular lymph nodes were palpable on either side.

	At this time, ultrasonography of the breast showed a 2.5-cm mass, solid and noncystic, located at the 6 o'clock position on the left breast, which was consistent with our physical assessment. Op?tions were discussed with the patient, and the decision to do an excisional bi?opsy of the left breast mass was made. The patient underwent this procedure a month later. Frozen section at the time of the operation was read as suspicious of malignancy pending the permanent path?o?logy report. Pathologic slides were sent to New York Presbyterian Hospital for consultation. The result was an adenocystic carcinoma, predominantly low-grade, with a high-grade component secondary to the foci of near solid architecture in the tumor (Figure). The specimen ob?tained was 6.7 x 6.5 x 3.0 cm, with the hard mass measuring 2.7 x 2.5 x 1.4 cm. Adeno?cystic carcinoma was present within 0.1 cm of the posterior resection margin. The tumor staining for HER2/

 was classified as 1  (faint/barely perceptible membrane staining in >10% of tumor cells). The tumor was focally positive for estrogen and progesterone receptors. After an extensive literature review, and because of the close resection margins, the decision was made to do a lumpectomy without lymph node dissection. The patient underwent breast-conserving surgery (lumpectomy), with wide surgical margins reaching a small portion of the pectoralis major muscle in order to achieve a good posterior margin around the cancer. The permanent pathology report confirmed the results of the fine-needle aspiration and described the tumor as 5.5 cm with fibrocystic changes, patchy moderate ductal epithelial hyperplasia, fibro?adenoma, and adenosis, with no residual tumor focus.

	Adenocystic carcinoma is a rare form of invasive breast carcinoma and ac?counts for fewer than 1% of all primary carcinomas of the breast.

 A report by Arpino and colleagues identified 28 cases of adenocystic breast cancer among 50,000 patients with breast mali?g?nancies.

 A report by Sumpio and colleagues identified 37 cases of adenocystic cancer out of 40,350 invasive breast tumors.

 Ad?eno?cystic carcinoma of the breast usually presents in postmeno?pausal women during the sixth and seventh decades of life.

 There are also re?ports of adenocystic carcinoma of the breast in men.

	The most frequent clinical presentation of this neoplasm is a palpable mass in the breast, usually detected by self-examination.

 The mean tumor size in Arpino and colleagues' review was 1.9 cm (range, 0.5 cm?7.0 cm),

 which is com?parable with the 20-mm size reported by McClenathan and de la Roza in patients from the Northern California Cancer Registry.

 A subareolar location was re?ported in 50% of cases (10 of 20) evaluated at the University of Michigan Medical Center.

 Adenocystic carcinoma has the same incidence in both breasts.

	Adenocystic carcinoma of the breast is mainly diagnosed by its morphologic features. The overall histologic pattern is analogous to that of adenocystic carci-nomas in other locations.

 Adenocystic carcinoma is characterized by the presence of cribriform structures that are formed by multiple pseudocysts filled with amorphous substance. Clusters of small, monomorphic, cubic cells with round or oval nuclei form abundant islets with a characteristic sieve-pattern. Myo?epithelial cells are frequently detected in the tumor.

 Diagnosis of the tumor should be based on strict criteria, because it carries a very good prognosis; moreover, adenocystic cancer requires special treatment. Estrogen receptor positivity has been assessed in several reports and was found to range between 24% and 46%.

 Progesterone receptors were de?tected in 35% of cases in one series of 28 patients.

 The grading of adenocystic carcinoma of the breast is similar to that of adenocystic carcinomas in other locations: grade I is completely glandular, grade II has fewer than 30% solid areas, and grade III has a more than 30% solid pattern. Shin and Rosen reported a correlation between histologic grade and prognosis

; however, an earlier report from the University of Michigan showed no such correlation.

 In Shin and Rosen's study, the solid variant with basaloid features was more capable of axillary metastasis than the conventional adenoid cystic carcinoma of the breast.

	Adenoid cystic carcinoma of the breast is considered a benign disease, and its treatment is still an area of debate. Treatment includes lumpectomy, modified radical mastectomy, or total mastectomy with or without axillary lymph node dissection.

Several reports show that the incidence of axillary lymph node metastasis is almost nil (0%?5%),

 and the value of axillary lymph node sampling is not as great as it is for invasive ductal carcinoma of the breast. Despite the minimal incidence of axillary lymph node metastasis, adenoid cystic carcinoma of the breast can result in distant metastasis.

	The outcome of treatment for this tumor is excellent, with a 5-year overall survival rate of 85% to 90% and a 5-year disease-free rate of almost 100% for survivors.

 The prognosis was independent of histologic grade, nuclear grade, or proliferative activity. The outcome was independent of the type of procedure performed, whether lumpectomy, modified radical mastectomy, or total mastectomy with or without axillary lymph node dissection.

 The role of radiotherapy after breast conserving surgery needs further evaluation, with long-term follow-up.

	Adenoid cystic carcinoma of the breast is a rare finding. This tumor has a favorable prognosis, and treatment should consist of lumpectomy with wide margins, avoiding the need for axillary node dissection.

	1. Cavanzo FJ, Taylor HB. Adenoid cystic carcinoma of the breast. An analysis of 21 cases. Cancer. 1969;24(4):740-745.

	2. Kleer CG, Oberman HA. Adenoid cystic carcinoma of the breast: value of histologic grading and proliferative activity. Am J Surg Pathol. 1998;22(5):569-575.

	3. Arpino G, Clark GM, Mohsin S, et al. Adenoid cystic carcinoma of the breast: molecular markers, treatment, and clinical outcome. Cancer. 2002;94(8):2119-2127.

	4. Sumpio BE, Jennings TA, Merino MJ, et al. Adenoid cystic carcinoma of the breast. Data from the Connecticut Tumor Registry and a review of the literature. Ann Surg. 1987;205(3):295-301.

	5. McClenathan JH, de la Roza G. Adenoid cystic breast cancer. Am J Surg. 2002;183(6):646-649.

	6. Ferlito A, Di Bonito L. Adenoid cystic carcinoma of the male breast: report of a case. Am Surg. 1974;40(1):72-76.

	7. Lamovec J, Us-Krasovec M, Zidar A, et al. Adenoid cystic carcinoma of the breast: a histologic, cytologic, and immunohistochemical study. Semin Diagn Pathol. 1989;6(2):153-164.

	8. Pastolero G, Hanna W, Zbieranowski I, et al. Proliferative activity and p53 expression in adenoid cystic carcinoma of the breast. Mod Pathol. 1996;9(3):215-219.

	9. Chababy M, Daou R, Aftimos G. Adenoid cystic carcinoma of the breast: case report [in French]. J Med Liban. 2002;50(1-2):70-73.

	10. Ermilova VD, Krylova MO. Adenocystic cancer of the breast (clinico-morphologic characteristics) [in Russian]. Arkh Patol. 1989;51(6):72-75.

	11. Shin SJ, Rosen PP. Solid variant of mammary adenoid cystic carcinoma with basaloid features: a study of nine cases. Am J Surg Pathol. 2002;26(4):413-420.

	12. Kontos M, Fentiman IS. Adenoid cystic carcinoma of the breast. Int J Clin Pract. 2003;57(8):669-672.

	13. Herzberg AJ, Bossen EH, Walther PJ. Adenoid cystic carcinoma of the breast metastatic to the kidney. A clinically symptomatic lesion requiring surgical management. Cancer. 1991;68(5): 1015-1020.

Melhem Solh, First-Year Resident, Department of General Surgery; Mubashir Sabir, Chief Resident, Department of General Surgery; Linda Dubay, Associate Professor, Department of General Surgery; Farooq Minhas, Clinical Pathologist, Department of Pathology, Providence Hospital and Clinics, Southfield, MI

Adenocystic Breast Cancer

									Department of Surgery College of Physicians and Surgeons Columbia University

									Chief of Laparoscopic and Endoscopic Surgery

	Mirizzi's syndrome is an un?common complication of longstanding gallstone disease, re?sulting in obstructive jaundice. The syn?drome occurs in 0.7% to 1.1% of all patients undergoing cholecystectomy.

 McSherry and colleagues classified Mi?rizzi's syndrome into two types based on endoscopic retrograde cholangiopancreatography (ERCP) findings.

 Type I involves external compression of the com?mon hepatic duct by a large stone impacted at the cystic duct or Hartmann's pouch. Type II involves the presence of a cholecystocholedochal fistula, which is caused by the stone partially or completely eroding into the common bile duct. We report the case of a 36-year-old woman who presented with obstructive jaundice and was found to have type II Mirizzi's syndrome based on the ERCP findings. Open partial cholecystectomy, common bile duct exploration, removal of the stone, and cholecystoduodenostomy were performed to treat this patient.

	A 36-year-old woman was admitted to a community hospital because of a 6-day history of right upper quadrant abdominal pain, jaundice, and nausea. The pa?tient had experienced a few similar episodes over the previous year, which resolved spontaneously. Abdominal examination elicited mild tenderness in the right upper quadrant with no signs of peritonitis on palpation. The patient had no other comorbidities. Per?tinent laboratory results revealed a white blood cell count of 9.0 x 10

L, total bilirubin of 8.9 mg/dL, direct bilirubin of 6.2 mg/dL, and alkaline phospha?tase of 235 U/L. All other laboratory values were within normal limits. The pa?tient underwent abdominal ultrasonography, which showed a 1-cm gallstone in the neck of the gallbladder, a gallbladder wall thickness of 2.7 mm, and a common bile duct that was dilated to 1.6 cm. Be?cause ERCP was unsuccessful at the community hospital, she was referred to our institution.

	Before undergoing ERCP at our hospital, the patient received prophylactic antibiotics. ERCP revealed a dilated com?mon bile duct with a stone at the distal end and compression of the common hepatic duct by a large stone impacted in the Hartmann's pouch (Figures 1 and 2). Type II Mirizzi's syndrome was diagnosed by passage of a guidewire into the gallbladder via the fistula (Figure 3). Re?moval of the stones after sphincterotomy was not successful using Dormia baskets and balloon catheters. A biliary stent was placed to drain the common hepatic duct (Figure 4), and the decision was made to do an open cholecystectomy followed by exploration of the common bile duct. Two days later, a laparotomy was performed through a right subcostal incision. The gallbladder was found to be contracted and thickened. Dense fibrosis, inflammation, and adhesions were noted near Calot's triangle and the hepatoduodenal ligament. Cholecystectomy was performed using the fundus-first technique, which spared part of the Hartmann's pouch. Upon reaching the neck of the gallbladder, a type II Mirizzi's fistula was identified between the Hartmann's pouch and common bile duct. A 1.5-cm, im?pacted gallstone that eroded into the common bile duct was gently removed via the open Hartmann's pouch. The distal common bile duct was explored, but removal of the distal impacted stone was not successful. A cholecystoduodenostomy was performed using 3.0 poliglecaprone continuous sutures. Two closed-suction drains were placed in the Morrison's pouch and the abdomen was closed.

	The patient had an uneventful postoperative recovery and her direct bilirubin dropped to 0.9 mg/dL a few days after the operation. She was discharged from the hospital on postoperative day 5 with one drain in situ, which was removed on postoperative day 8.

	Mirizzi's syndrome is caused by longstanding impacted stones at the cystic duct or Hartmann's pouch, which result in partial or complete obstruction of the common bile duct, leading to obstructive jaundice.

 Mirizzi's syndrome is diagnosed in 0.7% to 1.1% of all patients undergoing cholecystectomy.

 In 1982, McSherry and colleagues divided Mirizzi's syndrome into two types based on the ERCP findings.

 Type I involves external compression of the common hepatic duct by a large stone impacted at the cystic duct or Hartmann's pouch. Type II involves a cholecystocholedochal fistula, which is caused by the stone partially or completely eroding into the common bile duct.

	Preoperative diagnosis of Mirizzi's syndrome is invaluable in devising a man?agement strategy. Ultrasonography of the biliary system and ERCP (with or without computed tomography scanning) are sensitive and specific enough to establish a preoperative diagnosis.

 Dur?ing ERCP, clinicians should have a high index of suspicion for Mirizzi's syndrome in any patient with obstructive jaundice whose ultrasound shows stones in the cystic duct and evidence of cholecystitis. Because ERCP allows drainage to relieve cholangitis, some studies indicate it may improve the surgical results.

	Patients with Mirizzi's syndrome usually have a shrunken gallbladder with dense adhesions and severe inflammatory changes in Calot's triangle and along the hepatoduodenal ligament.

 Re?moval of the entire gallbladder increases the risk of bile duct injury and the morbidity associated with bile duct repair.

 During the operation, the general principle is to avoid dissection of Calot's triangle and to do a partial cholecystectomy using a fundus-first technique.

 This strategy should be sufficient for treating type I Mirizzi's syndrome because it removes the gallstone, allowing the obstructive jaundice to re?solve, and prevents late stricture formation.

 Common bile duct exploration is not necessary if the operative cholangiogram shows no stones in this duct.

	Management of type II Mirizzi's syndrome is more challenging. The choice of operation depends on the size of the fistula and the quality of the surrounding tissue. If primary suture closure (with or without a flap from the remnant gallbladder wall) is possible to repair the fistula, a T-tube is inserted into the common bile duct to protect the repair.

 If primary suture closure cannot be performed safely, a bilioenteric anastomosis should be undertaken.

 A cholecystocholedochoduodenostomy was required to treat our patient because the defect was large and there was an impacted stone in the distal common bile duct.

	ERCP is extremely useful in diagnosing Mirizzi's syndrome and assessing the anatomy. Partial cholecystectomy and removal of gallstones is the treatment of choice for type I Mirizzi's syndrome. Primary suture repair with a T-tube or a bilioenteric anastomosis are the treatment options for patients with type II Mirizzi's syndrome. If there is obstruction of the distal common bile duct, the latter option is used.

Henry Talus, Chief Resident, Department of Surgery, Harlem Hospital Center, New York, NY; Sitaram Pillarisetty, Assistant Clinical Professor, Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY, Chief of Laparoscopic and Endoscopic Surgery, Department of Surgery, Harlem Hospital Center, New York, NY

April 2006

Surgeon's Bulletin Board

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Rectal Prolapse Associated With Schistosomiasis

Adenocystic Breast Cancer

ERCP findings of Mirizzi's type II Syndrome

Simple Pitfalls for Today's Thoracic Surgeon to Avoid

Ruptured Renal Artery Aneurysm

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