Vasculitis is a known cause of pancreatitis and other gastrointestinal symptoms; however, most of these patients have medium vessel vasculitis like polyarteritis nodosa and often there are other associated conditions like hepatitis B or clinical manifestations that suggest the diagnosis. Wegener's granulomatosis is predominantly a reno-pulmonary disorder, rarely having gastrointestinal manifestations. We report a case of Wegener's granulomatosis initially presenting as acute pancreatitis and then rapidly progressing to severe multi-organ involvement over the next few months. Pancreatic association as an initial presentation of Wegener's granulomatosis is limited to only a few reports. This extremely rare initial presentation makes the diagnostic process challenging. Two different pancreatic manifestations have been reported: as a pancreatic mass mimicking a tumor or as acute pancreatitis. The patients who presented as pancreatic head masses underwent extensive surgical procedures before the diagnosis was established. Acute pancreatitis as the initial presentation is usually associated with an aggressive course of the vasculitis and often results in a fatal outcome. This case illustrates Wegener's granulomatosis as a rare cause of acute pancreatitis. It emphasizes the need for thorough continued systemic clinical evaluation of patients when the etiology is not readily evident. Also, since most patients with pancreatitis due to Wegener's granulomatosis rapidly progress to severe multiorgan involvement, knowledge of a broad differential of potential etiologies and a low index of suspicion is required for timely diagnosis and treatment.

A prototype version of the ImmersiveTouch® virtual reality simulator was applied to capsulorhexis, the creation of circular tear or "rhexis" in the lens capsule of the eye during cataract surgery. Virtual and live surgery scores by residents were compared. The same three metrics are used in each mode: circularity of the rhexis, duration of surgery (sec), and number of forceps grabs of the capsule per completed rhexis (fewer is better). The average simulator circularity score correlated closely with the average live score (P = 0.0002; N = 4), establishing "concurrent validity" for this metric. Individuals performed similarly to each other in both modes, as shown by the low standard deviations for average circularity (virtual 0.92 ± 0.04; live 0.88 ± 0.04). By contrast, the standard deviations are high for the other two metrics, capsulorhexis duration (virtual 96.91 ± 44.23 sec; live 94.42 ± 65.74 sec, N = 8) and number of forceps grabs (virtual 10.66 ± 4.81; live 10.31 ± 5.23, N = 8). Nevertheless, the simulator was able to demonstrate that the surgeons with wide variations in total duration and number of capsular grabs in 2 to 4 trials of simulated surgery also had similar variations in live surgery, so that the simulator retains some realism or "face validity."

In the dying days of the first half of the last century, when ward sisters wore starched veils and hospital walls were painted green, an intern 10 days out of medical schoolwas summoned in the middle of the night to restart a clogged intravenous drip. This was done in those days by injecting 3.8% of sodium citrate, a procedure that doctors but notnurses were allowed to undertake. Sleepily the intern made his way to the medical floor. A …

I was flying across the ocean in a big metal box, quietly dozing in business class by courtesy of accumulated frequent flyer points and one of those wine glasses that automatically refill themselves, when my Oslerian aequanimitas was rudely shattered by a voice over the loudspeaker calling for a doctor. Making my way through countless cabins of fellow travellers sleeping in various distorted positions, I reached a small lounge at the back of the plane bustling with agitated people, …

Dr Mumps, a primary care physician, has a patient who fell off the roof and was taken to the University of Excellence Hospital, the one that advertises every morning on the radio. In a capricious mood, Dr Mumps decides to find out how his patient is doing. He is greeted by a friendly recording: “If you speak Spanish press one, if you speak Swahili press two, to speak to the laundry press three, for the kitchen four, for …

Patients with postlaminectomy pseudomeningoceles may present to pain management centers without having been diagnosed previously. Practitioners treating chronic low back pain need to be aware of this potential hazard. Retrospective analyses of six such cases was made including: clinical signs and symptoms, radiological findings, and possible therapeutic modalities. In every case, there was a palpable fluctuating mass under the surgical scar, sensory loss in both lower extremities, and limited leg raising; moreover, heel tapping produced pain. Also, every patient had a history of long standing cigarette smoking and multiple spinal surgeries. Radiologically dural saccular or tubular structures were noted at myelograms, magnetic resonance imaging, or computed axial tomography scan, usually at the site of the surgery. In one patient with metallic devices, diagnosis was made by ultrasound. The need for a complete examination by the pain specialist is emphasized since instrumentation in attempts to perform invasive procedures, i.e., inserting needles in the patients, may result in unintentional puncture of the pseudomeningocele and cerebrospinal fluid leaks. The clinical features accompanying the surgical complications ought to be recognized as a warning signal.