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Results: It was noted that there was a delay of more than three days in taking the patients to theatre if wait and watch policy was adopted and the INR fell to levels below 2.0 in patients who were given vitamin K on admission within 12-24 h hence expediting their operation.Discussion: We propose that in discussion with local haematologists, every trust should have a policy for reversing warfarisation in semi emergencies like fracture neck of femur and that vitamin K should be considered in patients with atrial fibrillation without other risk factors on admission.Introduction: Fracture classification systems help in communication, treatment planning, assessing prognosis and form standards to report treatment results. The ideal classification system should be reliable, reproducible, all-inclusive, mutually exclusive, logical and clinically useful. The aim of our study was to assess the inter-observer reliability and intra-observer variability for the AO, Schatzker and Hohl and Moore classification systems.Materials and methods: We randomly selected fifty sets of radiographs of tibial plateau fractures occurred between 2000 and 2005.Exclusion criteria: Only one available view, inadequate films. Four orthopaedic surgeons at various level of experience, i.e. one senior house officer, two registrars and a trauma consultant classified the fractures. Radiographs were blinded and each time the radiographs were presented to the observers in a different order. Radiographs were viewed at two separate sittings 8 weeks apart. The data was analysed using kappa statistics through SPSS version 14. The kappa coefficients were interpreted according to Landis and Koch grading. (<0.00 = poor; 0.0-0.2 = slight; 0.21-0.4 = fair; 0.41-0.60 = moderate; 0.61-0.8 = substantial; >0.8 = excellent).Results: For the AO classification the mean kappa coefficients for inter-observer and intra-observer reliability were 0.36 (0.33-0.39) and 0.83(0.61-1.00), respectively. For the Schatzker classification the mean kappa coefficients for inter-observer and intra-observer reliability were 0.47(0.45-0.49) and 0.90 (0.75-1.00), respectively. For the Hohl and Moore classification mean kappa values for interobserver and intra-observer variability were 0.14 and 0.81 (0.59-1.00), respectively. According to Landis and Koch grading, AO classification is fair in terms of inter-observer reliability, the Schatzker classification is moderate and the Hohl and Moore is slight.Conclusions: None of the three systems fulfils the criteria for an ideal classification system. However, the Schatzker classification system was found to be superior. The Hohl and Moore system was least reliable of all. Hence, we rec-

The present study reports satisfactory outcome with the usage of the Synthes plate for extra-articular fracture management. It has become the technique of choice in our centre because it provides excellent results.

Introduction Renal cell carcinoma (RCC) constitutes 3% of all adult malignancies and often presents insidiously. Consequently, 25-30% of patients have metastases at the time of diagnosis. Discussion Gastrointestinal (GI) bleeding from RCC metastases is an uncommon and underrecognized manifestation of this disease. We hereby report a rare case of RCC with stomach metastasis which heralded the primary manifestation of the disease. This case highlights the importance of maintaining vigilance for unusual causes during endoscopy in cases of upper GI hemorrhage.Keywords renal cell carcinoma . upper gastrointestinal bleeding . stomach metastasis . initial presentation Case ReportA 53-year-old male presented to the emergency room with 1 week history of melena, generalized fatigue, and dizziness. Other significant medical problems included coronary artery disease, type 2 diabetes, hypertension, dyslipidemia, and chronic obstructive pulmonary disease. He was an ex-smoker with a 40-pack yearcigarette smoking history. Medications included aspirin, metoprolol, simvastatin, and metformin. He denied recent use of over-the-counter or nonsteroidal antiinflammatory medications. Physical examination revealed a cachectic pale gentleman who was in moderate distress. Blood pressure was 70/50 mm Hg and heart rate was 130 beats/min. Heart and lungs were normal. Abdominal examination revealed mild epigastric tenderness to deep palpation. There was no rebound tenderness or guarding or palpable masses. Laboratory tests revealed hemoglobin of 6.3 g/dl (13.8-17.2 g/dl) with microcytic picture, hematocrit of 19.5% (41-50%), blood urea nitrogen of 74 mg/dl (3-29 mg/dl), creatinine of 3.0 mg/dl (0.5-1.4 mg/dl), and calcium of 14.6 mg/dl (8.5-10.4 mg/dl). Urinalysis did not reveal any red blood cells. White blood count, platelets, and coagulation studies were all normal. After initial resuscitation, an emergent esophagogastroduodenoscopy was performed. A 1.5-cm vascular polypoid mass was noted in the fundus of the stomach (Fig. 1a, b), which was biopsied. No other lesions were noted in the esophagus and the duodenum. Histology from the stomach mass revealed small, vacuolated, clear cells highlighted by immunostaining with AE 1/3, CA 9, and CD 10 and showed strong reactivity with Vimentin ( Fig. 2a-c). These findings confirmed the diagnosis of clear cell subtype metastatic renal cell carcinoma (RCC). Subsequent computed tomography (CT) of the abdomen revealed a 5×7.4-cm ill-defined mass in the inferior pole of the right kidney, multiple pulmonary nodules, and osteolytic lesions involving multiple vertebrae and sternum suggestive of primary renal cancer with metastatic disease (Fig. 3a, b). Because of the extensive metastatic disease, palliative therapy options were discussed with the patient but he declined any further interventions and opted for

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13. McIntosh GG, Lodge AJ, Watson P et al. NCL-CD10-270: a new monoclonal antibody recognising CD10 in paraffin-embedded tissue. Am. J. Pathol. 1999; 154; 77-82. 14. Kesse-Adu R, Shousha S. Myoepithelial markers are expressed in at least 29% of oestrogen receptor negative breast carcinoma. Mod. Pathol. 2004; 17; 646-652. 15. Tse GMK, Tsang AKH, Putti TC. et al. Stromal CD10 expression in mammary fibroadenoma and phyllodes tumours. J. Clin. Pathol. 2005; 58; 185-189. 16. Makretsov NA, Hayes M, Carter BA, Dabiri S, Gilks CB, Huntsman DG. Stromal CD10 expression in invasive breast carcinoma correlates with poor prognosis, estrogen receptor negativity, and high grade. Mod. Pathol. 2007; 20; 84-89. 17. Khanafshar E, Phillipson J, Schammel DP, Minobe L, Cymerman J, Weidner N. Inflammatory myofibroblastic tumor of the breast. Ann Diagn. Pathol. 2005; 9; 123-129. 18. Magro G, Caltabiano R, Di Cataldo A, Puzzo L. CD10 is expressed by mammary myofibroblastoma and spindle cell lipoma of soft tissue: an additional evidence of their histogenetic linking. Virchows Arch. 2007; 450; 727-728. 19. Leibl S, Moinfar F. Mammary NOS-type sarcoma with CD10 expression. A rare entity with features of myoepithelial differentiation. Am. J. Surg. Pathol. 2006; 30; 450-456.

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