Analysis of cover of the femoral head in normal and dysplastic hips: new CT-based technique

We present a new CT-based method which measures cover of the femoral head in both normal and dysplastic hips and allows assessment of acetabular inclination and anteversion. A clear topographical image of the head with its covered area is generated. We studied 36 normal and 39 dysplastic hips. In the normal hips the mean cover was 73% (66% to 81%), whereas in the dysplastic group it was 51% (38% to 64%). The significant advantage of this technique is that it allows the measurements to be standardised with reference to a specific anatomical plane. When this is applied to assessing cover in surgery for dysplasia of the hip it gives a clearer understanding of where the corrected hip stands in relation to normal and allows accurate assessment of inclination and anteversion.

Guidelines for the use of imaging in the management of myeloma

In 2001, reference to the use of imaging in the British Committee for Standards in Haematology guidelines for the diagnosis and management of myeloma was confined to the standard use of plain X-rays in the diagnostic skeletal survey and emergency use of computed tomography (CT) and magnetic resonance (MR) imaging in the setting of cord compression. Since then, there has been a steady rise in interest in the use of various imaging techniques in the management of myeloma. The purpose of imaging in the management of myeloma includes the assessment of the extent and severity of the disease at presentation, the identification and characterisation of complications, and the assessment of response to therapy. Plain radiography, CT, and MR imaging are generally established examination techniques in myeloma whilst positron emission tomography (PET) and (99)Technetium sestamibi (MIBI) imaging are promising newer scanning techniques under current evaluation. These stand-alone imaging guidelines discuss recommendations for the use of each modality of imaging at diagnosis and in the follow up of patients with myeloma.

Bone bruises: definition, classification and significance

The increasing use of magnetic resonance imaging in the diagnosis of musculoskeletal injuries has alerted clinicians to the phenomenon of bone bruising. This article will outline the current knowledge and treatment implications of these interesting radiological findings.

A test of performance of breast MRI interpretation in a multicentre screening study

OBJECTIVES

The aim of this study was to assess the consistency and performance of radiologists interpreting breast magnetic resonance imaging (MRI) examinations.

MATERIALS AND METHODS

Two test sets of eight cases comprising cancers, benign disease, technical problems and parenchymal enhancement were prepared from two manufacturers' equipment (X and Y) and reported by 15 radiologists using the recording form and scoring system of the UK MRI breast screening study [(MAgnetic Resonance Imaging in Breast Screening (MARIBS)]. Variations in assessments of morphology, kinetic scores and diagnosis were measured by assessing intraobserver and interobserver variability and agreement. The sensitivity and specificity of reporting performances was determined using receiver operating characteristic (ROC) curve analysis.

RESULTS

Intraobserver variation was seen in 13 (27.7%) of 47 of the radiologists' conclusions (four technical and seven pathological differences). Substantial interobserver variation was observed in the scores recorded for morphology, pattern of enhancement, quantification of enhancement and washout pattern. The overall sensitivity of breast MRI was high [88.6%, 95% confidence interval (CI) 77.4-94.7%], combined with a specificity of 69.2% (95% CI 60.5-76.7%). The sensitivities were similar for the two test sets (P=.3), but the specificity was significantly higher for the Manufacturer X dataset (P<.001). ROC curve analysis gave an area under the curve of 0.85 (95% CI 0.79-0.92)

CONCLUSIONS

Substantial variation in all elements of the scoring system and in the overall diagnostic conclusions was observed between radiologists participating in MARIBS. High overall sensitivity was achieved with moderate specificity. Manufacturer-related differences in specificities possibly occurred because the numerical thresholds set for the scoring system were not optimised for both equipment manufacturers. Scoring systems developed on one equipment software may not be transferable to other manufacturers.

Cerebral CD8+ lymphocytosis in HIV-1 infected patients with immune restoration induced by HAART

In HIV infected persons, highly active antiretroviral therapy (HAART) has reduced both the morbidity and incidence of several disorders. Its effects on direct HIV-induced damage to the CNS remain controversial. In addition, HAART may provoke an "immune reconstitution inflammatory syndrome" (IRIS). Herein we report two patients who, despite HAART, developed a diffuse encephalopathy. Their clinical, radiological and neuropathological features are described. Immunohistochemical and PCR analyses were used to detect HIV and to exclude other viruses in brain tissue. The unusual inflammatory reaction in the brain tissue was defined by immunohistochemistry. Both patients had advanced HIV disease with low CD4 counts and high HIV "viral loads" before starting HAART. In both, HAART induced an increase in CD4 count and a marked reduction in HIV viral load, which was accompanied, in patient one, by worsening of pre-existing, and, in patient two, by development of, acute encephalopathy. At post-mortem examination, the brain of patient one showed HIV encephalitis. In addition, the brains of both patients revealed HIV-DNA by PCR, diffuse microglial hyperplasia and massive and diffuse perivascular and intraparenchymal infiltration by CD8+/CD4- lymphocytes. We suggest that the rapid immune reconstitution induced by HAART in these two patients led to a redistribution of lymphocytes into peripheral blood. This was followed by recruitment of CD8+ lymphocytes into the brain, which resulted in the diffuse infiltration described. The appearances in patient two further suggest that HIV brain infection, even without encephalitis, is sufficient to trigger this response.

Single center experience of a new intensive induction therapy for ewing's family of tumors: feasibility, toxicity, and stem cell mobilization properties

PURPOSE

To examine the feasibility, tolerability, and toxicity of an intensified induction regimen (vincristine, ifosfamide, doxorubicin, and etoposide [VIDE]) in patients with newly diagnosed Ewing's family of tumors (EFT); to assess ability to maintain dose-intensity, and predictability of peripheral-blood stem cell mobilization.

PATIENTS AND METHODS

Thirty patients were treated with vincristine 1.4 mg/m2 (maximum 2 mg) on day 1, doxorubicin 20 mg/m2, ifosfamide 3 g/m2 plus mesna and etoposide 150 mg/m2 on days 1 to 3. Cycles were given every 21 days for up to six cycles.

RESULTS

One-hundred and seventy cycles of VIDE were given. The median treatment interval was 21 days (21 to 42) and nadir count: hemoglobin 8.3 (6.3 to 11.9), neutrophils 0.045 (0.0 to 2.1), and platelets 45 (3 to 343). There were 96 episodes of infection requiring hospitalization (56%). Growth factor support reduced infectious complications by 34%. Etoposide dose was reduced, or omitted, in 24% of cycles. Four patients did not complete six cycles due to unacceptable toxicity and one patient progressed on treatment. Twenty patients underwent peripheral-blood stem cell harvesting, 15 after cycle 3, and five after cycle 4. Median CD34+ yield was 4.6 x 106/kg per patient (1.8 to 14.5). Overall response to treatment, measured in 24 patients, was 88%. Seven of 11 patients undergoing surgery achieved greater than 90% necrosis of tumor (64%).

CONCLUSION

VIDE is an effective induction regimen with substantial but acceptable toxicity that allows predictable mobilization of stem cells. Maintenance of dose-intensity is feasible in the majority of patients. Growth factors play a role in maintaining dose-intensity and reduce infectious complications.

The use of ultrasound imaging to demonstrate reduced movement of the median nerve during wrist flexion in patients with non-specific arm pain

Following clinical screening, we examined movement of the median nerve at the wrist using high-resolution (10-22 MHz) ultrasound in 16 controls and 12 patients with non-specific arm pain (also referred to as repetitive strain injury). Imaging was performed just proximal to the carpal tunnel with the wrist in neutral, 30 degrees of extension and 30 degrees of flexion. In control subjects the position of the median nerve was 4.8 (SE=0.4) mm more radial with the wrist flexed than with the wrist extended. In the twelve arm pain patients the average change was only 1.2 (SE=0.5) mm. It appears that ultrasound imaging may be helpful in diagnosing non-specific arm pain, a condition for which there are no well-defined diagnostic tests at present. The reduced nerve movement seen with ultrasound imaging confirms previous work with magnetic resonance imaging.

Magnetic resonance imaging in the assessment of complex Müllerian anomalies

OBJECTIVE

To evaluate the accuracy of magnetic resonance imaging in assessment of adolescent patients with complex Müllerian anomalies and its contribution towards operative management.

DESIGN

A retrospective review of magnetic resonance imaging and operative findings.

SETTING

A London teaching hospital that is a tertiary referral centre for complex reproductive tract disorders.

SAMPLE

All adolescents referred for assessment of complex Müllerian anomalies, from 1996 to 1999, and undergoing both magnetic resonance imaging and surgical assessment.

METHOD

In the nine suitable patients magnetic resonance imaging and surgical findings were compared and the role of magnetic resonance imaging in determining the route and type of surgery was evaluated.

MAIN OUTCOME MEASURES

Magnetic resonance imaging data on reproductive tract anatomy and surgical findings detailing reproductive tract anatomy.

RESULTS

There was good correlation of magnetic resonance imaging and operative findings in all cases. The best correlation was with uterine structure. In four cases the magnetic resonance imaging findings were essential for the appropriate choice of the surgical approach and type of procedure.

CONCLUSIONS

Magnetic resonance imaging is a valuable tool in the management of this particular complex group of patients.

Reduced movement of median nerve in carpal tunnel during wrist flexion in patients with non-specific arm pain

Magnetic resonance scans on patients with non-specific arm pain (repetitive strain injury) show reduced median-nerve movement in the carpal tunnel, suggesting that this common condition may involve nerve entrapment.

Function of the nasal muscles in normal subjects assessed by dynamic MRI and EMG: its relevance to rhinoplasty surgery

The external nose is generally considered to have a relatively static shape. Movement of the nose and the potential for change of external shape and the internal airway have been assessed by (1) cadaver dissection and (2) dynamic studies during a standardized series of facial expressions in 13 subjects; video recording of the movement of skin markers, electromyography, and moving magnetic resonance images. A standard description of muscle anatomy is presented. The dynamic investigations indicated the following. Video analysis showed the components of muscle action: dilatation, constriction of the nostril, depression of the tip, vertical contraction in the bridge, and elevation of the alar, in different expressions. Electromyography confirmed muscle actions during expression and phonation. Magnetic resonance imaging demonstrated large changes in the external shape of the nose and nasal aperture due to muscle actions. Muscle function should be given greater consideration in aesthetic and cleft rhinoplasty.

Organ-limited autopsies. Obtaining permission for postmortem examination of the urinary tract

OBJECTIVE

To develop a systematic pre- and postmortem program for obtaining permission for autopsies limited to the urinary tract.

DESIGN

Comparison versus historical control of autopsy permission using a new process comprising premortem education, modification of the permission process, and autopsy limited to the urinary tract.

PARTICIPANTS AND SETTING

Patients, family members, and healthcare providers associated with a nursing home.

INTERVENTION

Education of healthcare providers and family members and modification of autopsy consent and performance.

MAIN OUTCOME MEASURE

Permission rate and demographic characteristics of patients and family members giving permission.

RESULTS

Of the 361 patients who died during the study, we received permission for postmortem examination of the urinary tract for 129 (36%). This was substantially better than the autopsy rate in the year prior to the study, 0.6%. A significantly higher permission rate was associated with patients and contact persons of white race, a higher level of education of the contact person, a nonrelative contact person, and two or fewer individuals making the decision.

CONCLUSION

Permission for organ-limited autopsies can be obtained with a systematic approach.

Long-term urethral catheterization increases risk of chronic pyelonephritis and renal inflammation

OBJECTIVE

To determine the prevalences of chronic pyelonephritis and chronic renal inflammation in elderly nursing home patients at the time of death and to assess correlation with urethral catheterization and other putative risk factors.

DESIGN

Prospective assessment of risk factors with the prevalences of chronic pyelonephritis and renal inflammation at autopsy.

SETTING

A 240-bed long-term care facility.

PARTICIPANTS

All residents > or = 65 years old who died and were autopsied during a 2-year period.

MEASUREMENTS

Antemortem assessment of risk factors for renal inflammation, including a search for any urethral catheterization in the person's life. Prospective assessment of urethral catheterization, catheter obstruction, and use of anti-inflammatory medications and urine cultures. Urinary tract pathology was assessed for gross and microscopic evidence of inflammation and urinary tract stones.

RESULTS

The duration of catheterization was significantly associated with increasing prevalence of bacteriuria, polymicrobial bacteriuria, chronic pyelonephritis, and chronic renal inflammation. The prevalence of chronic pyelonephritis at death was 10 percent (5/52) for patients catheterized > 90 days during their last year of life and zero (0/65) when catheterized < or = 90 days (P < 0.02; Fisher's exact test). Chronic pyelonephritis was significantly associated with renal stones and hydronephrosis. The prevalence of chronic renal inflammation without chronic pyelonephritis was significantly greater than that of chronic pyelonephritis: the prevalence was 43 percent (20/47) when catheterized > 90 days and 18 percent (12/65) when < or = 90 days (P < 0.05). Chronic renal inflammation was associated with hydronephrosis, ureteral dilatation, acute pyelonephritis and diastolic hypertension.

CONCLUSION

Chronic pyelonephritis and chronic renal inflammation are associated with long-term catheterization.

Mouse models of short- and long-term foreign body in the urinary bladder: analogies to the bladder segment of urinary catheters

Catheter-associated bacteriuria is the most common infection occurring in hospitals, where urethral catheters are generally in place for a few days, and in nursing homes, where catheters may be in place for months or years. We developed murine models with intrabladder urinary catheters for studying complications of bacteriuria in short- and long-term catheterization. In the short-term model, a catheter segment was inserted transurethrally and lay free within the bladder lumen. Half of the animals expelled segments during a 2-to-7-day period, durations similar to catheterizations in hospitalized patients. For studies of long-term catheter use, the catheter segment was secured within the bladder by a single suture for up to 12 months. Antibiotics administered for 7 days after catheter placement and housing mice in cages with wire screen floors reduced spontaneous bacteriuria to an acceptably low incidence rate of only 7%. Proteus mirabilis bacteriuria of high concentration provoked the same complications that are common in patients with long-term catheters: acute pyelonephritis, chronic renal inflammation, and struvite stone formation. These models allow inoculation of the bacteria of interest and are suitable for studies of short- and long-term foreign body-associated bacteriuria and its complications.

Acute pyelonephritis associated with bacteriuria during long-term catheterization: a prospective clinicopathological study

Bacteriuria is virtually universal in long-term catheterized patients. This blinded autopsy study of 75 aged nursing home patients demonstrated that acute inflammation of the renal parenchyma was present in 38% of patients with a urinary catheter in place at death versus 5% of noncatheterized patients (P = .004). Of a number of clinical and demographic variables studied, only catheterization was significantly related to acute renal inflammation. Acute cystitis was uncommon, but each case was associated with inflammation of at least one kidney. The majority of kidneys showing acute inflammation (21 [68%] of 31) were not accompanied by acute pyelitis. Acute renal inflammation with or without pelvic inflammation is a common finding in nursing home patients dying with urethral catheters in place. This finding provides additional support for the development of alternatives to the indwelling urethral catheter.

Polyarteritis nodosa involving only the main renal arteries

A unique case of accelerated hypertension and acute anuria in a 24-year-old man is presented. Clinically, the patient was found to have obstruction of both main renal arteries caused by extensive bilateral thrombosis. Microscopically, a healing panarteritis involving only the main renal arteries was found. This was associated with acute renal infarction and tubular atrophy in the left kidney. This appears to be an unusual variant of polyarteritis nodosa limited to both main renal arteries.

Acute renal failure, hemolytic anemia, and thrombocytopenia in poststreptococcal glomerulonephritis

We have presented the case of a 13-year-old boy who had an apparent hemolytic-uremic syndrome, with hemolytic anemia, thrombocytopenia, and acute renal failure. Subsequent laboratory investigations indicated poststreptococcal glomerulonephritis as the cause of renal failure. The triad of hemolytic anemia, thrombocytopenia, and renal failure has not been previously reported in a case of proven poststreptococcal glomerulonephritis.