Neurosonographic identification of ventricular asymmetry in premature infants

Routine head ultrasound scans have been performed on 185 consecutive infants weighing under 1500 g at birth. In 40 of these infants a significant difference in the size of the lateral ventricles was observed on one or more occasions. In 38 of these infants the left ventricle was larger than the right. The aetiology of this ventricular asymmetry is unknown. It is not believed to be due to germinal matrix or ventricular haemorrhage, hydrocephalus or the position of the infant at the time of scanning.

Cauda equina syndrome secondary to long-standing ankylosing spondylitis

Fourteen patients with cauda equina syndrome secondary to long-standing ankylosing spondylitis are described. The roughly symmetrical neurological deficits were very slowly progressive and began long after the onset of the spondylitis, usually well after the rheumatological symptoms had stopped. Eventually every patient had cutaneous sensory loss in the fifth lumbar and sacral dermatomes. All patients developed urinary sphincter disturbances of a lower motor neuron type. There was prominent loss of rectal sphincter tone, and all but 2 patients had bowel complaints, including incontinence and severe constipation. Seven patients had mild to moderate weakness in the lumbosacral myotomes. Seven patients had pain in the rectum or lower limbs. Electromyographic abnormalities were consistent with multiple lumbosacral radiculopathies. Myelography and computed tomographic scanning of the lumbosacral spine showed characteristic enlargement of the caudal sac and dorsal arachnoid diverticula that had eroded the laminae and spinous processes. Recognition of this syndrome, coupled with computed tomographic scanning of the lower spinal canal, allows one to omit myelography, a procedure that is difficult because of the associated spine abnormalities. Surgical intervention should be avoided.

The role of computerized tomography in the diagnosis and management of patients with bilateral Wilms tumor

We report 2 cases of bilateral Wilms tumor. In both cases computerized tomography provided accurate data for the diagnosis of bilateral tumors and predicted surgical resectability, without nephrectomy, of the smaller tumor. In 1 patient computerized tomography demonstrated tumor growth while on chemotherapy and radiotherapy. The role of angiography in the management of these patients is discussed.

Immunohistologic and cytochemical studies of temporal arteritis

Arteritic lesions from 14 patients with temporal arteritis were studied by cytochemical and immunohistochemical methods to identify the nature of the inflammatory cell infiltrate and to demonstrate immunoglobulin deposition. The infiltrating cells typically seen were histiocytes, giant cells, monocytes, and lymphocytes. The lymphocytes were mainly T cells and the majority of them were of the helper/inducer (Leu-3a) T cell subset, as indicated by monoclonal antibody reactivity. Immunoglobulin deposits on the internal elastica were identified in only 6 patients and neutrophils were either very sparse or absent. These findings are consistent with the hypothesis that cell-mediated immunity may be important in the pathogenesis of temporal arteritis.

Peripheral arthritis in ankylosing spondylitis. A review of 209 patients followed up for more than 20 years

Charts of 209 patients with ankylosing spondylitis were reviewed with regard to the occurrence of seronegative peripheral arthritis. Peripheral arthritis, excluding hip and shoulder involvement, occurred in 67 of the 209 patients (32%). No relationship was found between the age at onset of spondylitis and the onset of the peripheral arthritis. Among the 67 patients with peripheral arthritis, 19 (28%) had recurrent flares. X-ray findings similar to those of rheumatoid arthritis were seen in 22 patients (33%) with peripheral arthritis. Confusion about the cause of the peripheral arthritis frequently arose in patients who had the onset of the disease when the spondylitis was in remission.

A new look at the neonatal bowel-contrast studies with metrizamide (Amipaque)

Metrizamide is the first water-soluble radiographic contrast agent which, because it is nonionic, can be used in isotonic solution and gives good visualization of the desired body structure. Its only major disadvantage is that it is very expensive. Metrizamide can be used to study the neonatal bowel in clinical situations where all the other existing contrast agents are contraindicated. The results of 55 metrizamide studies of the bowel in infants are reviewed. In necrotizing enterocolitis metrizamide aids in confirming or rejecting the diagnosis, identifying patients for surgery, and in evaluating the response to surgery. Metrizamide can identify the etiology in unusual cases of bowel obstruction. Metrizamide correctly identified a thoracic origin of free peritoneal air in four cases and a bowel origin in two cases. It identified bowel perforation in two patients in the absence of pneumoperitoneum. In six patients, the metrizamide study identified the cause for a gasless abdomen. It is concluded that metrizamide has a valuable role to play in evaluating a variety of neonatal bowel disorders.

Ultrasound diagnosis of liquid-filled lesions in children

The ultrasound studies and clinical records of 93 children with cystic lesions have been reviewed. Ultrasound is extremely accurate in identifying the cystic nature of the lesions. Where precise anatomical localisation is possible the prediction of pathology is most accurate. Where anatomical localisation (e.g., in soft tissues, some abdominal sites) is more difficult the ultrasound will generate a good differential diagnosis and aid in planning additional investigations. Review of other investigations done showed that CT in 16 cases rarely yielded new information.

Primary pulmonary hypertension: an unusual case associated with extrahepatic portal hypertension

A patient with both extrahepatic portal hypertension and primary pulmonary hypertension is reported. The pulmonary hypertension developed without a surgical portal-systemic shunt, and at autopsy there was no evidence of a large spontaneous shunt. This association of pulmonary arterial hypertension and portal venous hypertension without either intrinsic liver disease or a large portal-systemic anastomosis has not been reported previously. Our case supports the concept that portal hypertension with its attendant portal-systemic collateral circulation may be the major predisposing cause of pulmonary hypertension both in intrinsic liver disease and extrahepatic portal vein obstruction.

Radiographic and scintigraphic skeletal imaging in patients with neuroblastoma: concise communication

Bone scans, bone-marrow scans, and radiographic skeletal surveys have been reviewed in 40 children with neuroblastoma. Bone scans are the most sensitive method for detecting metastases and should be used first. The additional yield from a skeletal survey is very small, so it should be done only if the bone scan is negative and major therapeutic decisions are to be made. Bone-marrow scans provide a sensitive method of identifying metastases, and may help in staging a patient as stage IV when the bone scan is negative.

The diagnostic dilemma of the posterior mediastinal thymus: CT manifestations

Extension of the normal thymus into the posterior mediastinum is rare. The CT appearance of this anomaly in an infant is presented. A mass of soft-tissue density extended from the anterior mediastinum to the posterior chest wall. The absence of any tissue-cleavage plane in the lesion and a smooth continuous lateral margin are signs of posterior extension of the thymus, and they help to distinguish this from a normal anterior thymus being present with a posterior tumor.

Elevation of creatine kinase in amyotrophic lateral sclerosis. Potential confusion with polymyositis

Serum creatine kinase (CK) levels were recorded in 100 patients with amyotrophic lateral sclerosis (ALS). CK concentrations were elevated in 43% of the patients, with a mean level of 240 U/liter and a range of 59-1,327 U/liter (male normal less than 95 U/liter, female normal less than 59 U/liter). All patients with elevated CK had muscle weakness. Seven patients were initially misdiagnosed as having polymyositis and given high dose corticosteroids without clinical benefit, prior to the diagnosis of ALS. Such diagnostic confusion can be avoided by an awareness that CK levels cannot be used to reliably differentiate between ALS and primary muscle disease such as polymyositis.

Osteoid osteoma: 95 cases and a review of the literature

Osteoid osteoma is a benign bone tumor occurring primarily in patients under the age of 30 yr. Bone pain at night and relief by aspirin or other nonsteroidal antiinflammatory agents is a common symptom complex. The proximal femur and spine are frequent sites of involvement, but almost any bone can be involved. If plain roentgenograms do not demonstrate the lesion, tomography or a bone scan may be helpful. Complete surgical excision is the therapy of choice with a low recurrence rate. Osteoid osteoma may present initially with symptoms suggestive of inflammatory arthritis, degenerative joint disease, neoplasm, or infection. This lesion can therefore be a difficult diagnostic problem, especially if routine roentgenograms are normal. A high index of suspicion is necessary to make the diagnosis.

Lung nodules after whole lung radiation

It is essential to recognize radiation pneumonitis after whole lung irradiation, or nodular changes in response to chemotherapy, so that such conditions are not mistaken for tumor metastases, causing grave error in patient management and the possibility of further lung damage.

Neonatal small left colon syndrome in twins

There are no previous reports of small left colon syndrome in twins. Small left colon syndrome is reported in 2 sets of twins. In 1 set 1 twin had clinical and radiographic signs of small left colon syndrome. The sib was clinically normal and had no radiographic studies. In the other set, both twins had identical clinical and radiographic findings of hyperplastic left colon. This suggests a genetic and/or environmental intrauterine, rather than a postpartum etiology for the small left colon syndrome.

Late-onset peripheral joint disease in ankylosing spondylitis

We reviewed the records of 150 patients with definite ankylosing spondylitis who had significant peripheral arthritis and were seronegative and found 7 patients who had the onset of peripheral arthritis after their spinal disease became inactive. This late-onset peripheral arthritis may lead to significant joint deformity, and aggressive therapy may be warranted.

Clinical, radiographic and pathologic effects of Amipaque on rabbit lung. Comparison with barium and Gastrografin

The effects of saline and 3 contrast media, Amipaque, Gastrografin and barium, were evaluated for 24 hours following intratracheal instillation in rabbits. Respiratory rates, serial chest films, and pathologic examination of the lungs demonstrated that Amipaque induced significantly less respiratory distress than the other 2 contrast media whereas inflammatory reactions were comparable for all of the media. Significant pulmonary edema occurred with both Amipaque and Gastrografin but was greater with Gastrografin. Both of these media were cleared from the lung within 24 hours, however barium continued to obstruct bronchi and fill alveolar air spaces. It is concluded that in comparison to Gastrografin and barium, Amipaque is relatively innocuous in the lung.

Metrizamide in neonatal and childhood small bowel obstruction

Metrizamide (Amipaque) has been used to image the bowel of four neonates and one older child with possible bowel obstruction. In each case, barium and hypertonic water-soluble agents, such as Gastrografin and Hypaque, were contraindicated. In each case, the metrizamide study provided unique formation altering the management of the patient. Metrizamide provides a new method of evaluating selected difficult cases of suspected bowel obstruction in the newborn, and in older children it may help to distinguish between postoperative ileus and mechanical obstruction.

Liver metastases in Wilms' tumour

Fifty patients with Wilms' tumour have been reviewed to evaluate the incidence of liver metastasis in order to identify the optimum time and frequency for radiological investigation. Liver involvement occurred in 12% of our cases. The most rewarding periods for the diagnosis of liver metastasis are the first few months of the illness, the period immediately after stopping chemotherapy, or any time that lung metastases are identified. Liver scintigraphy is recommended as the initial investigation, and abnormal cases should proceed to ultrasound or computed tomography.

Prolonged visualization of the gastrointestinal tract with metrizamide

Excellent images of the bowel can be obtained for many days, and sometimes weeks, after oral administration of metrizamide unless it is evacuated via the rectum or a bowel perforation; the quality of images obtained with barium or hypertonic contrast agents (such as diatrizoate meglumine and diatrizoate sodium) begins to deteriorate after several hours. The reasons for prolonged visualization of the bowel with metrizamide and its clinical applications are discussed.

Absorption of intraperitoneally injected amipaque in the rabbit

The appearances of intraperitoneally injected Amipaque and the absorption rate are described. At 30 min after injection the peritoneal concentration was decreased and the urinary tract began to fill. At one hour, almost all Amipaque had disappeared from the peritoneal cavity and the urinary tract was well demonstrated. As absorption of Amipaque from the gastrointestinal tract is minimal, bowel perforation is thus indicated if, after oral administration, it appears in either the peritoneal cavity or the urinary tract.

Neonatal pneumoperitoneum without significant adventitious pulmonary air: use of metrizamide to rule out perforation of the bowel

Pneumoperitoneum in the neonate may be due to air that has dissected from the chest. Four infants, in whom pneumoperitoneum, from thoracic air dissection, occurred in the absence of pneumothorax or pneumomediastinum are reported. The absence of abnormal collections of air in the chest is of no value in deciding whether a pneumoperitoneum is due to bowel perforation or air dissecting from the chest. Contrast bowel studies are needed in all cases of pneumoperitoneum in the infant to distinguish bowel perforation from intrathoracic origin of the air.

Facial swelling and giant cell arteritis

A 62-year-old white woman presented with severe facial swelling, glossitis, and odynophagia. Giant cell arteritis (GCA) was diagnosed on the basis of temporal artery biopsy, and the patient responded to corticosteroids. GCA may rarely involve vessels of the mouth and face, resulting in unusual clinical manifestations. Early recognition and treatment are important.

Tubes wires and the neonate

The structure and function of the various tubes and wires that may be seen on radiography of neonates undergoing intensive care are described. The desired position for these and some examples of the consequences of malposition are considered and illustrated; practical conclusions are made.

Hiatus hernia: a complication of postero-lateral diaphragmatic herniation (Bochdalek hernia) in infants

During the six years from January 1973 to Februrary 1979, 23 infants with postero-lateral diaphragmatic (Bochdalek) hernias have been treated in the Paediatric Surgical Unit of the General Infirmary at Leeds. Surgical repair was performed in all cases. Ten patients died. Severe vomiting occurred in seven (54%) of the 13 survivors. Barium meal demonstrated large hiatus hernias in four (31%) of the 13 survivors. This previously unreported complication of Bochdalek hernia repair should be consideredin all patients with vomiting following surgical repair of a Bochdalek hernia.

Intravenous urography in neonates and infants. What dose of contrast should be used?

The dose of contrast to be used for IV urography in neonates and infants is discussed. Toxic levels are only just above the currently accepted doses of 2-4.4 ml contrast medium per kg bodyweight. The dangers of expressing the dose of contrast medium as a volume of contrast related to the patient's age are discussed. A case is presented who had a severe reaction following an acceptable dose expressed as volume for age, but probably excessive when expressed as ml per kg bodyweight. It is concluded that for IV urography in neonates and infants the dose of contrast must be related to weight of patient and not its age; no dehydration should be used; and the injection should be slow, taking about three minutes.

Transient small bowel intussusception in adult coeliac disease

Considerable disagreement exists in the literature concerning the occurrence and incidence of transient non-obstructive intussusception in adult coeliac disease. Only a few case reports have been published and several standard texts do not mention the association at all. We report six adult patients, all with coeliac disease, who demonstrated transient non-obstructive intussusception on small bowel meal examination. The technique of the small bowel meal and the radiological signs of malabsorption are briefly described. The literature is reviewed and reasons for the disagreement herein are discussed. We conclude that the incidence of finding intussusception in adult coeliac disease is related to the intensity of searching and in our series this association was seen in at least 20% of cases. It is considered to be an additional radiological sign of coeliac disease although in no case did it occur in the absence of other prominent radiological evidence of malabsorption.

New approaches in the therapy of the peripheral vascular ulcer

It can readily be seen that Debrisan represents a more effective mode of therapy for several groups of patients which tend to have chronic disabling ulcers of limbs of various etiologies, including venous stasis ulcers, chronic sickle-cell ulcers, decubiti, etc. The more effective treatment of this patient populations, which is provided by Debrisan, would provide a very significant decrease in the total cost of health care in the United States, approximating half a billion dollars per year.

Pharmacology of some oral penicillins in the newborn infant

Serum and urine concentrations of ampicillin, amoxycillin, and flucloxacillin achieved after oral administration have been measured in 27 newborn infants. Compared with adults and children, newborn infants show a delay in achieving adequate blood concentrations, presumably due to delayed absorption. However most infants achieve therapeutic concentrations in the serum. Infected newborn infants should be given these antibiotics by intramuscular injection for the first dose, but thereafter oral therapy (25 mg/lg every 6 hours begun concomitantly) should be satisfactory. The better absorption of amoxycillin compared with ampicillin reported in adults has not been confirmed in the newborn infant.