An unusual cause of renal impairment: a latex glove

Male genital self-mutilation is thought to be increasing in incidence and is underreported in the literature. We therefore have no clear and uniform treatment programmes. We present a case of genital self-mutilation involving a 16-year-old male. The case highlights an important complication and the multidisciplinary approach to its management.

Recurrent familial neonatal deaths: hereditary surfactant protein B deficiency

Hereditary surfactant protein B (SP-B) deficiency is an uncommon autosomal recessive lung disorder that causes hypoxemic respiratory failure in mature, morphologically normal infants. Recognition and diagnosis of this condition is of paramount importance, as it has significant implications for future pregnancies with a recurrence risk of 25%. In a family with three neonatal deaths over 20 years, SP-B deficiency was diagnosed following the death of the fourth affected infant. Previous deaths were mistakenly attributed to hyaline membrane disease (HMD), congenital Mycoplasma hominis infection, and pulmonary hypertension, however, following the diagnosis in the proposita, SP-B deficiency was also confirmed in her deceased siblings by immunohistochemical staining of autopsy specimens. This case highlights the presentation, postnatal course, diagnosis, and therapeutic options of SP-B deficiency in addition to the mode of inheritance and the possibility of antenatal diagnosis. Genetic consultation is imperative in the investigations of recurrent neonatal deaths, especially in cases of remote events. The recent enormous advances in human genetics have shown that many conditions previously ascribed to environmental agents have a genetic basis.

Craniovertebral junction tuberculosis: a review of 29 cases

PURPOSE

The purpose of this work was to describe the various imaging findings in craniovertebral tuberculosis and the importance of imaging in treatment in these patients.

METHOD

A retrospective review of MR and CT scans in 29 patients with craniovertebral tuberculosis was performed. The images were reviewed, paying special attention to both bony (skull base, atlas, and axis) and soft tissue involvement in addition to atlantoaxial dislocation, lateral subluxation of the dens, and compression of the spinal cord.

RESULTS

Suboccipital pain with neck stiffness was the most common presenting symptom in our patients. The skull was involved in 19 of the 29 cases, clivus involvement was seen in 11 patients, and occipital condyle involvement was present in 14 patients. Detailed analysis of atlas involvement due to tuberculosis showed the lateral masses to be predominantly affected. The dens was involved in 18 cases (62%). Soft tissue masses in the prevertebral area were seen in 22 patients, paravertebral in 27 patients, and epidural involvement in 25 patients was identified. Atlantoaxial displacement was present in seven cases, lateral mass-dens subluxation in five, and superior subluxation of the dens through the foramen magnum compressing the medulla was seen in two cases. Spinal cord compression with intrinsic cord changes was noted in 12 cases. All patients received multidrug antituberculous therapy for 1 year. The presence of neurologic deficit and instability of the atlantoaxial complex was pivotal in further management in these patients.

CONCLUSION

A high degree of clinical suspicion is necessary when confronted with patients with neck stiffness and tenderness over the upper cervical vertebrae. MRI in these patients provides a sensitive method for the diagnosis of craniovertebral tuberculosis.

Midazolam reduces the dose of propofol required for induction of anaesthesia and laryngeal mask airway insertion

BACKGROUND AND OBJECTIVE

Insertion of the laryngeal mask airway in the anaesthetized patient can sometimes be difficult and propofol has been advocated as the anaesthetic induction agent of choice because of its depressant effect on laryngeal reflexes compared with other intravenous anaesthetics. However, when used as the sole induction agent, relatively large doses of propofol are required to achieve successful laryngeal mask insertion. This has cost implications and may produce unwanted cardiorespiratory depression.

METHODS

One hundred and forty-two patients were randomized to receive either: fentanyl 1 microg kg(-1) and lidocaine 1.5 mg kg(-1) (group 1), or fentanyl 1 microg kg(-1) and midazolam 0.04 mg kg(-1) (group 2), or fentanyl 1 microg kg(-1), midazolam 0.04 mg kg(-1) and lidocaine 1.5 mg kg(-1) (group 3) or fentanyl 1 microg kg(-1) (group 4) 2 min before induction of anaesthesia. Anaesthesia was established with propofol infused at 33.3 mg min(-1).

RESULTS

Patients who were given midazolam required significantly less propofol to achieve satisfactory laryngeal mask insertion, median propofol doses: group 1, 1.63 mg kg(-1); group 2, 1.16 mg kg(-1); group 3, 1.01 mg kg(-1); group 4, 1.9 mg kg(-1), P < 0.0001 (analysis of variance). Patients given midazolam reported less pain on injection with propofol 13% and 3% groups (2 and 3) compared with 37.5% and 77% (groups 1 and 4) P = 0.002 (chi(2)).

CONCLUSIONS

Midazolam reduces the dose of propofol required for induction of anaesthesia and successful insertion of the laryngeal mask airway. There was no clinical benefit to be gained from the addition of lidocaine.

Role of fine-needle aspiration biopsy and frozen section analysis in the surgical management of thyroid tumors

INTRODUCTION

The role of fine-needle aspiration (FNA) and frozen section (FS) in the management of thyroid neoplasms continues to generate considerable controversy. We reviewed our recent experience to determine the clinical utility of FNA and FS in our surgical management and intraoperative decision-making.

METHODS

All patients who had operations for thyroid disease between January 1996 and June 1999 were identified in our prospective database. Completion and incidental thyroidectomies were excluded. Data obtained from the pathology files included FNA, FS, and the final histologic diagnosis.

RESULTS

Five hundred sixty-four patients, including 409 women (73%), with a median age of 50 years (range, 6-94) were identified, of whom 293 (52%) had cancer diagnosed on permanent sections. Three hundred twenty-nine patients (58%) had evaluable FNA, of which 91 (28%) were benign, 94 were malignant (28%), and 144 (44%) were suspicious (46% of these were malignant on final). Frozen section was performed in 397 (70%) patients; of these samples, 170 (43%) were found to be benign, 106 (27%) were malignant, and 121 (30%) were deferred (46% malignant on final). Fine-needle aspiration positively identified 51% of confirmed malignancies; 13% of patients with malignancy had a benign FNA result. Total thyroidectomy was performed in 64% of malignant tumors and 29% of benign thyroid disease (P < .001). Logistic regression revealed no association of extent of surgery with FNA results. A frozen section positive for malignancy was associated with total thyroidectomy (P < .001, RR 6 [CI 3-10]), and a negative frozen section report was associated with lobectomy (P < .05, RR 0.5 [CI 0.3-0.96]). Frozen sections results altered the preoperative plan in only 29 patients (5%).

CONCLUSION

Results of preoperative FNA had no direct impact on the selection of the surgical procedure in this selected cohort. Intraoperative FS added very little to surgical management. The majority of thyroid operations at this institution are planned and performed based on known prognostic factors and intraoperative findings.

Evaluation of pre-emptive intramuscular phenylephrine and ephedrine for reduction of spinal anaesthesia-induced hypotension during Caesarean section

Pre-emptive intramuscular (i.m.) vasopressors were evaluated in 108 patients undergoing elective Caesarean section under spinal anaesthesia, assigned to four groups in a randomized, double-blind, placebo-controlled study. Group 1 received pre-emptive phenylephrine 4 mg i.m., group 2 received phenylephrine 2 mg i.m., group 3 received ephedrine 45 mg i.m., while controls received an i.m. injection of saline, all given immediately after induction of spinal anaesthesia. Hypotension was defined as a 25% decrease in mean arterial pressure (MAP). Rescue intravenous (i.v.) boluses of ephedrine were given if the patient was hypotensive or reported nausea, vomiting or dizziness. The incidence of hypotension was 33% in the phenylephrine 4 mg group compared with 70% in the control and phenylephrine 2 mg groups (P=0.03), and 48% in the ephedrine 45 mg group. The phenylephrine 4 mg and ephedrine 45 mg groups had a significantly lower percentage reduction in MAP (-21 (SD 14)% and -22 (14)%) compared with controls (-32 (18)%, P=0.04). They also had a lower total dose of rescue i.v. ephedrine (15.7 (15.7) mg and 15.8 (15.6) mg) compared with controls (28.8 (20.6) mg, P=0.02). We conclude that pre-emptive i.m. phenylephrine 4 mg and ephedrine 45 mg reduce the severity of hypotension and the total dose of rescue i.v. ephedrine during spinal anaesthesia for Caesarean section.

A recessive mutation in the Arabidopsis SSI2 gene confers SA- and NPR1-independent expression of PR genes and resistance against bacterial and oomycete pathogens

The Arabidopsis thaliana NPR1 gene is required for salicylic acid (SA)-induced expression of pathogenesis-related (PR) genes and systemic acquired resistance. However, loss-of-function mutations in NPR1 do not confer complete loss of PR gene expression or disease resistance. Thus these responses also can be activated via an NPR1-independent pathway that currently remain to be elucidated. The ssi2-1 mutant, identified in a genetic screen for suppressors of npr1-5, affects signaling through the NPR1-independent defense pathway(s). In comparison with the wild-type (SSI2 NPR1) plants and the npr1-5 mutant (SSI2 npr1-5), the ssi2-1 npr1-5 double mutant and the ssi2-1 NPR1 single mutant constitutively express PR genes [PR-1, BGL2 (PR-2) and PR-5]; accumulate elevated levels of SA; spontaneously develop lesions; and possess enhanced resistance to a virulent strain of Peronospora parasitica. The ssi2-1 mutation also confers enhanced resistance to Pseudomonas syringae pv. tomato (Pst); however, this is accomplished primarily via an NPR1-dependent pathway. Analysis of ssi2-1 NPR1 nahG and ssi2-1 npr1-5 nahG plants revealed that elevated SA levels were not essential for the ssi2-1-conferred phenotypes. However, expression of the nahG transgene did reduce the intensity of some ssi2-1-conferred phenotypes, including PR-1 expression, and disease resistance. Based on these results, SSI2 or an SSI2-generated signal appears to modulate signaling of an SA-dependent, NPR1-independent defense pathway, or an SA- and NPR1-independent defense pathway.

Necrotising fasciitis of the breast

Necrotising fasciitis is a rare condition and to the best of our knowledge has never been reported in the breast. We report the first case in the literature of necrotising fasciitis involving the breast.

Intramedullary tuberculomas. MR findings in seven patients

PURPOSE

To describe the MR findings in intramedullary tuberculomas and to discuss the usefulness of MR in the management of this pathology.

MATERIAL AND METHODS

A retrospective study of 7 patients from 21 to 60 years of age with clinical and radiological evidence of intramedullary tuberculomas was undertaken. Both T1- and T2-weighted images (WI) were obtained along with postcontrast T1WI. Signal intensities (SIs) of the granulomas were compared with SIs of the normal spinal cord.

RESULTS

Six patients showed focus of tuberculosis elsewhere in the body. Six out of 7 showed fusiform swelling of the cord. Ill-defined iso-intensity (in 4 patients) to hyperintensity (in 3 patients) was seen at the site of granuloma on T1WI. On T2WI, 2 patients revealed a hypointense area (with disc enhancement). An iso-hypointense rim was seen surrounding a hyperintense centre in 5 patients (with rim enhancement). Adjacent oedema was seen in all patients. In 2 patients meningeal enhancement was also seen. In 2 patients the histopathology following surgical biopsy confirmed the diagnosis. In the remaining 5 patients, another known focus of tuberculosis elsewhere in the body and a marked response to antitubercular treatment was considered confirmatory for tuberculomas.

CONCLUSION

Hypo- or iso-intensity on T2WI within the spinal cord with surrounding hyperintense oedema is suggestive of intramedullary tuberculomas. Central hyperintensities are also detected at times due to a variable amount of caseous necrosis with liquefaction. On T1WI, fusiform swelling of the cord is seen along with iso- to hyperintense foci, surrounded by hypointense oedema of the cord. Such findings should prompt a contrast-enhanced study, which may show single or conglomerate disc- or ring-enhancing lesions. MR thus plays an important role not only in detection and diagnosis, but also in deciding the treatment options and in the follow-up of those patients.

Pigmented villonodular synovitis: magnetic resonance features of an unusual case of bilateral hip joint involvement

Pigmented villonodular synovitis (PVNS) is usually a mono-articular disorder. Bilateral symmetrical affection of this disease process is exceptional. A case is reported of a patient with PVNS with bilateral, symmetrical hip joint involvement.

Dominance of radiative coupling over disorder in resonance Rayleigh scattering in semiconductor multiple quantum-well structures

Resonance Rayleigh scattering by periodic semiconductor multiple quantum-well structures is studied experimentally and theoretically. Polaritonic effects are found to dominate disorder in the secondary emission dynamics. The coexistence of several radiant polaritonic modes with different radiative decay times leads to polarization beating between modes, strongly influences the rise times, and determines the fast decay times of the resonance Rayleigh scattered signals.

Electroclinical correlates of flumazenil and fluorodeoxyglucose PET abnormalities in lesional epilepsy

OBJECTIVE

To analyze the clinical utility of [11C]flumazenil (FMZ) PET to detect perilesional and remote cortical areas of abnormal benzodiazepine receptor binding in relation to MRI, 2-deoxy-2-[18F]fluoro-d-glucose (FDG) PET, and electrocorticographic (ECoG) findings as well as clinical characteristics of the epilepsy in epileptic patients with brain lesion.

BACKGROUND

The success of resective surgery in patients with medically intractable epilepsy and brain lesion depends not only on removal of the lesion itself but also on the reliable presurgical delineation of the epileptic cortex that commonly extends beyond it. PET could provide a noninvasive identification of such epileptogenic areas.

METHODS

Seventeen patients underwent high resolution MRI, FDG and FMZ PET, and presurgical EEG evaluation, including chronic intracranial ECoG monitoring or intraoperative ECoG. Regional cortical FDG/FMZ PET abnormalities were defined on partial volume-corrected PET images using an objective method based on a semiautomated definition of areas with abnormal asymmetry. Structural lesions were defined on coregistered MRI. The marked PET abnormalities visualized on three-dimensional cortical surface were compared with each other, to the extent of MRI-defined lesion, as well as to ECoG findings.

RESULTS

The mean surface extent of FMZ PET abnormalities was significantly larger than the corresponding structural lesions, but it was significantly smaller than areas of glucose hypometabolism. The size of perilesional FDG PET abnormalities showed a correlation with the lifetime number of seizures (r = 0.93, p = 0.001). The extent of perilesional FMZ PET abnormalities was independent of the seizure number and showed an excellent correspondence with spiking cortex, the resection of which resulted in seizure-free outcome in all but one operated patient. Remote FMZ PET abnormalities (n = 6) were associated with early age at seizure onset (p = 0.048) and appeared in ipsilateral synaptically connected regions from the lesion area.

CONCLUSIONS

Three-dimensional surface-rendered FMZ PET is able to delineate perilesional epileptic cortex, and it may be especially useful to localize such areas in patients with extensive perilesional glucose hypometabolism associated with a large number of seizures. Remote FMZ PET abnormalities in patients with early onset and long duration of epilepsy might represent secondary epileptogenesis, but this requires further study.

Motor block during patient-controlled epidural analgesia with ropivacaine or ropivacaine/fentanyl after intrathecal bupivacaine for caesarean section

We compared patient-controlled epidural analgesia (PCEA) with ropivacaine alone or combined with fentanyl in terms of analgesic efficacy, motor weakness and side-effects in patients who had received spinal anaesthesia for elective Caesarean section. ASA I patients received combined spinal-epidural anaesthesia and were randomly assigned, in a double-blind study, into two groups after operation: group R (n = 23) received PCEA ropivacaine 0.1%, bolus 5 mg, lock-out 15 min, 3 mg h-1 background infusion, and group RF (n = 24) received PCEA 0.1% ropivacaine/fentanyl 2 micrograms ml-1 at identical settings. Pain and satisfaction on a 100 mm visual analogue scale (VAS) and side-effects were noted. Incidence of motor weakness (Bromage grade 1 or higher) was 48% (11/23) at 8 h in group R compared with 13% (3/24) in group RF (P = 0.025). Pain scores on movement were lower in group RF at 8 and 12 h and at rest at 6 and 8 h (P < 0.05 for each comparison). Analgesic consumption was less in RF (P = 0.041), but there was no difference in time to first request for supplementary analgesia. Patient satisfaction with postoperative analgesia (mean (SD)) was higher in RF (79 (23) vs 57 (29) mm, P = 0.045). Caution should be exercised using ropivacaine PCEA after spinal bupivacaine for Caesarean section, because its reputed motor-sparing property may be unreliable.

Giant hypothalamic hamartoma with cystic change: report of two cases and review of the literature

We describe the MRI findings in two patients with giant hypothalamic hamartomas with cystic areas. Cystic change within hypothalamic hamartomas is rarely reported in the literature.

Use of 'locked-in' antibiotic to treat an unusual gram-negative hemodialysis catheter infection

A 37-year-old woman on maintenance hemodialysis for 3 years had multiple vascular access failures due to antiphospholipid syndrome. She was dialyzed via a tunneled left subclavian catheter, but after 1 year developed chills and fever during each dialysis session. Blood cultures grew out Xanthomonas maltophilia sensitive to ceftazidime and ciprofloxacin. Intravenous administration of both antibiotics failed to eradicate infection. We added 'locked-in' ceftazidime, instilling it daily into the catheter along with heparinized saline for 3 weeks. Within 24 h the patient was dialyzed uneventfully, and all subsequent blood cultures have been negative. This case shows the successful use of a 'locked-in' antibiotic to treat an unusual gram-negative catheter infection. Two prior series have reported similar good results in infections with more common organisms. Such treatment may permit continued use of tunneled hemodialysis catheters for longer periods.

Nitric oxide and salicylic acid signaling in plant defense

Salicylic acid (SA) plays a critical signaling role in the activation of plant defense responses after pathogen attack. We have identified several potential components of the SA signaling pathway, including (i) the H(2)O(2)-scavenging enzymes catalase and ascorbate peroxidase, (ii) a high affinity SA-binding protein (SABP2), (iii) a SA-inducible protein kinase (SIPK), (iv) NPR1, an ankyrin repeat-containing protein that exhibits limited homology to IkappaBalpha and is required for SA signaling, and (v) members of the TGA/OBF family of bZIP transcription factors. These bZIP factors physically interact with NPR1 and bind the SA-responsive element in promoters of several defense genes, such as the pathogenesis-related 1 gene (PR-1). Recent studies have demonstrated that nitric oxide (NO) is another signal that activates defense responses after pathogen attack. NO has been shown to play a critical role in the activation of innate immune and inflammatory responses in animals. Increases in NO synthase (NOS)-like activity occurred in resistant but not susceptible tobacco after infection with tobacco mosaic virus. Here we demonstrate that this increase in activity participates in PR-1 gene induction. Two signaling molecules, cGMP and cyclic ADP ribose (cADPR), which function downstream of NO in animals, also appear to mediate plant defense gene activation (e.g., PR-1). Additionally, NO may activate PR-1 expression via an NO-dependent, cADPR-independent pathway. Several targets of NO in animals, including guanylate cyclase, aconitase, and mitogen-activated protein kinases (e.g., SIPK), are also modulated by NO in plants. Thus, at least portions of NO signaling pathways appear to be shared between plants and animals.

Cytochalasin E, an epoxide containing Aspergillus-derived fungal metabolite, inhibits angiogenesis and tumor growth

Several previously identified inhibitors of angiogenesis have been epoxide-containing fungus-derived metabolites. We therefore hypothesized that novel epoxide-containing low molecular weight compounds structurally resembling known antiangiogenic agents may also exhibit antiangiogenic activity. Cytochalasin E was found to be a potent and selective inhibitor of bovine capillary endothelial (BCE) cell proliferation. Cytochalasin E differed from other cytochalasins by the presence of an epoxide. The epoxide was required for activity, because acid-catalyzed hydrolysis of the epoxide abrogated the specificity and potency of cytochalasin E. Phalloidin staining indicated that disruption of actin stress fibers by cytochalasin E occurred only at relatively high concentrations. Lower concentrations of cytochalasin E preferentially inhibited BCE cell proliferation without disrupting actin stress fibers. In vivo, cytochalasin E inhibited angiogenesis induced by basic fibroblast growth factor by 40% to 50% in the mouse cornea assay and inhibited the growth of Lewis lung tumors by approximately 72%. Cytochalasin E is a potent antiangiogenic agent that may hold promise for the treatment of cancer and other types of pathologic angiogenesis.

Effects of age, sex, race, diagnosis-related group, and hospital setting on lipid management in patients with coronary artery disease

Among 1,211 patients hospitalized with documented CAD at either a university hospital or a large suburban community hospital, 36% failed to receive appropriate evaluation and treatment for dyslipidemia. Younger patients, those admitted to a university hospital, and those undergoing percutaneous coronary intervention were substantially more likely to receive appropriate lipid management than other subgroups.

Tuberculosis of the sternum and clavicle: imaging findings in 15 patients

OBJECTIVE

To describe the imaging findings in sterno-clavicular tubercular involvement.

DESIGN AND PATIENTS

Fifteen patients with pathologically proven tuberculosis of the sternum and clavicle were retrospectively evaluated. Routine radiography, computed tomography (CT) and magnetic resonance imaging (MRI) were used in some or all of the patients. Clinical information and imaging features were evaluated in each case.

RESULTS

Eight patients had sternoclavicular joint (SCJ) involvement, five had isolated sternal involvement and two had isolated clavicular involvement. Seven patients were evaluated with only CT, six with only MRI and two with both. There were eight male and seven female patients, varying in age between 16 and 78 years. Fever, swelling and pain were common presenting symptoms. Two patients were HIV positive. Radiographs were positive in only eight patients. Destruction and signal intensity (SI) changes of the sternum and clavicle, destruction of the cartilage, soft tissue changes representing granulation tissue/abscess, displacement of the adjacent structures (vessels, trachea, etc.) and inflammatory changes in the adjacent structures in the form of cellulitis and myositis were common imaging features.

CONCLUSIONS

All imaging methods can provide complementary information regarding sterno-clavicular tubercular involvement that is helpful for determination of the therapy. MRI is useful in determining the extent of the lesion, particularly marrow involvement and soft tissue extent.

Is epileptogenic cortex truly hypometabolic on interictal positron emission tomography?

Positron emission tomography (PET) of glucose metabolism is often applied for the localization of epileptogenic brain regions, but hypometabolic areas are often larger than or can miss epileptogenic cortex in nonlesional neocortical epilepsy. The present study is a three-dimensional brain surface analysis designed to demonstrate the functional relation between glucose PET abnormalities and epileptogenic cortical regions. Twelve young patients (mean age, 10.8 years) with intractable epilepsy of neocortical origin underwent chronic intracranial electroencephalographic monitoring. The exact location of the subdural electrodes was determined on high-resolution three-dimensional reconstructed magnetic resonance imaging scan volumes. The electrodes were classified according to their locations over cortical areas, which were defined as hypometabolic, normometabolic, or at the border between hypometabolic and normal cortex (metabolic "border zones") based on interictal glucose PET. Electrodes with seizure onset were located over metabolic border zones significantly more frequently than over hypometabolic or normometabolic regions. Seizure spread electrodes also more frequently overlay metabolic border zones than hypometabolic regions. These findings suggest that cortical areas with hypometabolism should be interpreted as regions mostly not involved in seizure activity, although epileptic activity commonly occurs in the surrounding cortex. This feature of hypometabolic cortex is remarkably similar to that of structural brain lesions surrounded by epileptogenic cortex. Cortical areas bordering hypometabolic regions can be highly epileptogenic and should be carefully assessed in presurgical evaluations.

Imaging in isolated sacral tuberculosis: a review of 15 cases

OBJECTIVE

To review imaging studies of isolated involvement of the sacrum due to tuberculosis and determine the role of imaging in the diagnosis and management of these patients.

DESIGN AND PATIENTS

A retrospective analysis of 15 cases of isolated sacral tuberculosis imaged with MR imaging was performed. The CT images were also reviewed where available, and the various lesion characteristics were identified. We also reviewed the medical records in an attempt to determine the impact of the imaging studies on the management of these patients.

RESULTS

Fifteen patients (5 male, 10 female) presented with symptoms of 3-15 months' duration. Chronic localized backache with muscle spasm was the commonest presenting symptom; discharging sinuses with abscess formation was found in six patients, five of whom were children. MR imaging of the sacrum revealed a hypointense marrow signal on T1-weighted images and hyperintense signal on T2-weighted images in 14 of 15 patients, the S2 vertebra being always involved. CT revealed osteolytic changes in the sacrum in all the five patients in whom CT was performed. All patients showed marked clinical improvement within 1 year of anti-tuberculous chemotherapy.

CONCLUSION

Isolated tuberculosis of the sacrum is uncommon but should be suspected in patients presenting with chronic low backache or children with discharging sinuses/abscesses and showing sacral destruction on CT or MR imaging. MR imaging can identify cases and enables early institution of antituberculous chemotherapy.

Placenta accreta and methotrexate therapy: three case reports

Placenta accreta is a complication that is rising in incidence. The reported experience of methotrexate treatment in the conservative management of placenta accreta is scant. Three cases of placenta accreta managed with methotrexate are presented. Case 1: A woman had an antenatal diagnosis of placenta percreta. A successful manual placental removal occurred on post-cesarean day 16. Case 2: A woman had retention of a placenta accreta after a term vaginal delivery. Successful dilation and curettage were performed on postpartum day 37. Case 3: A woman had an antenatal diagnosis of placenta previa-percreta with bladder invasion. A simple hysterectomy was performed on post-cesarean day 46. Conservative management and methotrexate treatment resulted in uterine preservation in two of our three patients; however, this treatment did not prevent significant delayed hemorrhage. In view of the rapid resolution of vascular invasion of the bladder, methotrexate may have an important role in the management of placenta percreta with bladder invasion. The utility of methotrexate treatment with the conservative management of placenta accreta requires further evaluation.

Objective method for localization of cortical asymmetries using positron emission tomography to aid surgical resection of epileptic foci

We designed a semiautomated method for the objective detection of abnormal regions of tracer accumulation in the brain. The purpose of the present study was to examine the diagnostic performance of this method by applying it to patients with clinically intractable epilepsy of unilateral origin; they underwent [F-18] deoxyglucose positron emission tomography (PET) prior to surgical resection of epileptic foci. A semiautomated method for assessment of asymmetries in the brain cortex was developed that compares activity concentrations in homotopic cortical areas. When these differences exceeded a predefined threshold, the areas with lower activity were marked and 3-dimensional surface rendered images were created to guide placement of intracranial electrodes (ECoG) followed by surgical resection. The normal amount of asymmetry between small (0.5-0.7 cm2) homotopic cortical regions was determined as 5.9 +/- 4.0% (mean +/- SD). The false-positive fraction was determined for cutoff thresholds of 1 SD (10%), 1.5 SD (12%), and 2 SD (15%) outside the mean and was found to be 89, 44, and 0%, respectively. The obtained sensitivity-specificity pairs for correct localization of epileptogenic lobes based on the ECoG results were best for the 15% threshold (80/94%, accuracy 0.90). This objective PET method allows the accurate determination of cortical asymmetries, and it proved to be highly efficient in guiding epilepsy surgery.