Clinics in diagnostic imaging (29). Thalassaemia major with iron overload

A 5-year-old girl presented with lethargy, anaemia and facial distortion. Both parents had beta-thalassaemia minor. Radiographs confirmed the characteristic features of thalassaemia major. A treatment regime comprising regular blood transfusions was commenced. The basis of the radiographic changes and the current role of magnetic resonance imaging, particularly with respect to assessing iron overload, are emphasized.

Clinics in diagnostic imaging (25). Aggressive vertebral haemangioma

A 30-year-old female presented with a three month history of back pain. Radiographs and computed tomography indicated an aggressive haemangioma of T12 which was confirmed on red cell scintigraphy. The varying imaging appearances of non-aggressive and aggressive vertebral haemangiomas are described, emphasizing the ability of aggressive haemangiomas to mimic metastases on magnetic resonance imaging. The therapeutic role of embolisation as an adjunct ro surgery is stressed.

Uncommon features of abdominal aortoiliac disease

This pictorial review illustrates the cross-sectional imaging of several less common manifestations of aortoiliac disease. Despite their varying clinical features, the imaging appearances with ultrasound, CT and MRI will allow a correct assessment in most cases.

Radiological intervention in Budd-Chiari syndrome: techniques and outcome in 18 patients

We reviewed our experience of the therapeutic role of radiology in Budd-Chiari syndrome. Patients with stenosis and/or occlusion of the main hepatic veins and/or inferior vena cava (IVC) are suitable for radiological intervention (35% in our series). Eighteen patients (mean age 37.4 years) have undergone radiological intervention over the past 8 years. The site of obstruction was the hepatic veins in 12/18 patients while 6/18 patients had both hepatic vein and IVC obstruction, which in two was due to tumour thrombus. One patient had repeated dilatations of a mesocaval shunt; 49 angiographic venous dilatations were performed (18 during initial intervention, 31 on review) including 10 recanalizations of occlusions. A combined transhepatic-transjugular approach was used for 10/49 procedures. Thrombolysis was performed in 5/18 and stent insertion in 6/18 patients. Three serious complications occurred (IVC stent migration, hepatic artery pseudoaneurysm, myocardial puncture). Follow-up, after initial intervention, has continued for a mean of 24.2 months (range 4 days-92 months). Symptoms related to hepatic venous outflow obstruction were fully relieved in 10/18 (56%) patients and partially relieved in 4/18 (22%) patients. Close monitoring (and re-intervention) during the early post-intervention period is needed because 28% of initial venous dilatations failed to provide adequate venous return in the first instance. Once the patient is stabilized regular review is mandatory as HV restenosis is common after 10 months or more follow-up. The efficacy and safety of radiological intervention make it the preferred first line of treatment in selected patients with Budd-Chiari syndrome.

Multiple rice body formation in chronic subacromial/subdeltoid bursitis: MR appearances

Multiple rice body formation is an unusual complication of chronic bursitis. Clinically and macroscopically, it can resemble synovial osteochondromatosis. Radiographic and MR appearances, however, may allow an accurate pre-operative diagnosis. The imaging features of two middle-aged women with multiple subacromial/subdeltoid bursa rice bodies are described.

Imaging of biliary complications following paediatric liver transplantation

Biliary complications (BC) are well recognised following paediatric liver transplantation. We reviewed retrospectively 169 consecutive liver transplants performed in 139 children. BC occurred in 36/169 grafts (21 %) in 35/139 patients (25 %). Biliary obstruction was present in 18/169 grafts (11 %), biliary leakage in 14/169 grafts (8 %) and a combination of obstruction and leakage was present in 4/169 (2 %) grafts. BC were as likely to present radiologically as they were with either clinical and/or biochemical abnormalities. Most BC (26/36, i. e. 72 %) occurred in the first 2 weeks following transplantation. Ultrasound and cholangiography were the principle imaging modalities used for detection of these complications. False negative ultrasound examinations occurred in three patients with biliary obstruction and in three patients with biliary leakage. False negative cholangiograms occurred in two patients with biliary leakage. Ultrasound is important in the post-operative surveillance of paediatric liver transplants, with cholangiography having a complementary role in those with BC.

A comparison of different imaging modalities and direct inspection after periosteal stripping in predicting the invasion of the mandible by oral squamous cell carcinoma

OBJECTIVE

To compare the predictability of orthopantomograms (OPG), bone scans, computerised tomography (CT), magnetic resonance imaging (MRI) and periosteal stripping with direct inspection in predicting both the presence and extent of tumor invasion of the mandible.

DESIGN

Prospective study.

SETTING

Queen Elizabeth Hospital, Birmingham; Wordsley Hospital, Stourbridge; North Staffordshire Royal Infirmary, Stroke-on-Trent.

SUBJECTS

35 consecutive patients requiring a mandibular resection as part of their treatment for oral squamous cell carcinoma.

MAIN OUTCOME MEASURES

The prediction of the extent of bone invasion for each of the investigations and direct inspection after periosteal stripping. The actual extent of invasion of the mandible from a detailed histological assessment.

RESULTS

The OPG underpredicted the width and depth of invasion by on average 13 mm and 2 mm. There were 5 false negative reports. Bone scans overpredicted the width and depth by 14 mm and 15 mm with 1 false negative. CT scans underpredicted the width of invasion by 5 mm and overpredicted depth by 3 mm, but 7 false negatives were returned. MRI scans overpredicted width and depth of invasion by 19 mm and 10 mm with 1 false negative. Direct inspection after periosteal stripping underpredicted the width and depth of invasion by 5 mm and 3 mm with 1 false negative.

CONCLUSION

OPG's and bone scans are useful for the initial assessment of all tumours in the region of the mandible. MRI is a more useful investigation than CT in the assessment of mandibular invasion by oral squamous cell carcinomas. Exploratory periosteal stripping at the time of resection can accurately predict the presence of tumour invading the mandible.

Evaluation of modified methods for determining skin irritation

The premarket testing of household cleaning products for dermal irritancy is best achieved via human testing. Animal dermal irritation testing is generally limited to screening for possible dermal hazard of totally new or unique products or ingredients prior to human testing or to meeting regulatory requirements of government bodies. Alternatives to animal tests are being sought; however, until such time that these alternatives are identified, validated, and accepted by government bodies, the judicious use of animal testing remains a necessity. Modifications to standard animal skin irritation test procedures have been evaluated against human skin irritation results with the objective of defining one method that could be used in place of current standard procedures that differ slightly from one another, and thereby avoid excessive and redundant use of animals. Hill Top Chambers (19 mm) and standard gauze patches (U.S. Department of Transportation procedure) were used to obtain comparative irritation responses for 24 cleaning products, common caustics, and acids in rabbits and humans. Exposure times were 1 or 4 hr, and responses were graded over a 72-hr period. Results indicate that use of the Chamber offers the potential to (1) reduce the number of animals used for skin irritation screening (smaller group size and up to eight test substances/concentrations per animal); (2) eliminate the need for conducting multiple tests to satisfy different governmental requirements; and (3) reduce animal stress by reducing exposure times without compromising the value of the irritancy patch test as a screening tool. When animal data are required, it is suggested that the use of a Chamber and other modifications of traditional test procedures offers advantages that could result in using fewer animals and/or have less potential for producing unnecessarily severe responses in animals.

Human and rabbit eye responses to chemical insult

Groups of eight human volunteers and eight albino rabbits, under controlled laboratory conditions, were exposed in one eye without subsequent rinsing to the same concentrations and volumes of four prototype consumer products: fabric softener, shampoo, hand soap, and laundry detergent. Dose volume was 0.10 or 0.01 ml. The dose concentrations were selected to produce moderate effects with recovery within 24 to 48 hr. Two irritation scales were employed with both human and animal subjects: the Draize scale by a technician and a medical scale used with slit lamp examination by an ophthalmologist. Eyes were examined by both graders before and after dosing at specified intervals until recovery. Mean and maximum irritation scores are presented for each grading time, method, and exposure, as are the mean hours to recovery (clearing) for each exposure. Recovery times for human eyes were consistent with those reported previously for accidental human exposures to similar materials. Correlation coefficients for time to clear, comparing human vs rabbit for each dose volume-species combination across the four test products, were 0.72, 0.1 ml-human vs 0.01 ml-rabbit; 0.66, 0.01 ml-human vs 0.01 ml-rabbit; 0.40, 0.01 ml-human vs 0.1 ml-rabbit; 0.35, 0.1 ml-human vs 0.1 ml-rabbit. Thus, recovery time obtained under conditions of the "Low-Volume" test (0.01 ml-rabbit) better correlates with human eye recovery time (either dose volume) than does recovery time under Draize test conditions (0.10 ml-rabbit).(ABSTRACT TRUNCATED AT 250 WORDS)

Myoclonus epilepsy in two brothers. Clinical features and neuropathology of a unique syndrome

We report 2 brothers with progressive ataxia, seizures, myoclonus, supranuclear ophthalmoplegia, progressive visual loss and embolic strokes. The epilepsy and myoclonus came on many years after the onset of the ataxia. In the more severely affected brother the myoclonus was often unilateral and focal but ultimately involved both sides of the body. His sibling had only unilateral myoclonus after a contralateral middle cerebral artery stroke. When focal, persistent and unilateral, the myoclonus in both brothers was clinically similar to epilepsia partialis continua except that muscles of the trunk and proximal limbs were the most affected. It was exacerbated by movement of the affected part but was otherwise not stimulus sensitive. The more severely affected brother had a pigmentary retinopathy and a cardiac fibromyxoid valvulopathy. In his sibling, visual loss was not fully investigated and the heart was not examined at autopsy though he had a longstanding heart murmur. Neuropathological studies showed pancerebellar cortical atrophy, cell loss in the inferior olivary nuclei and old right middle cerebral artery infarctions in both brothers. Biochemical assays for known metabolic diseases were negative. We suggest that this syndrome represents a unique autosomal recessive form of progressive myoclonus epilepsy of unclear aetiology. It is distinguished from other familial myoclonus epilepsies by the presence of early onset cerebellar ataxia, supranuclear ophthalmoplegia, pigmentary retinopathy and possibly cardiac valvulopathy with subsequent cerebral emboli.

Development of encephalopathic features similar to Reye syndrome in rabbits

The progression of neurological abnormalities through four or five clinically distinguishable levels of deepening coma and the development of a fatty liver are the hallmarks of Reye syndrome. A number of animal models have been described that result in fatty liver formation with minimal, static, or catastrophic neurological changes. In this study, we attempted to produce neurological features in rabbits that reflected a rostral-caudal progression of abnormalities that could be categorized into clinically distinguishable levels reminiscent of Reye syndrome. This was accomplished by the intracisternal administration of 0.5-25 mg of 11,14-icosadienoic acid (20:2 omega 6) suspended in a mixture of rabbit serum and isotonic saline solution. A reproducible, dose-titratable spectrum of at least four levels of deepening coma could be produced at will. Increases in serum glutamate-oxaloacetate transaminase and creatine kinase and changes in serum glucose resulted 1-2 hr after the neurological abnormalities were evoked. Other unsaturated fatty acids produced similar responses. Those tested included 18:1 omega 9, 18:2 omega 6, 18:3 omega 3, 20:3 omega 6, 20:4 omega 6, and 22:4 omega 6 fatty acids. Saturated fatty acids, including 6:0, 8:0, 16:0, 18:0, and 20:0, failed to elicit these effects. The abnormalities were sustained for 30-120 min after a single dose. Full recovery was observed in some animals that had not reached the fourth level of our grading system for coma. Pretreatment of the rabbits with aspirin modulated the neurological abnormalities. Twenty micrograms of bee venom melittin, which activates endogenous phospholipase A2, administered intracisternally into rabbits also produced signs of level 3 (our grading system) coma for several hours. These findings suggest a possible role for polyunsaturated fatty acids in the development of Reye syndrome and offer a means of producing the neurological components of that syndrome in a laboratory animal.

Herpes simplex virus encephalitis. Diagnostic and treatment considerations

The patient with meningoencephalitis should be evaluated carefully for the presence of focal signs referable to involvement of the frontotemporal regions of the brain. A significant percentage of cases of encephalitis with discrete focal features are caused by infection with herpes simplex virus. If focal signs are not present, the patient should be managed conservatively but examined regularly because focal neurologic dysfunction may present at any time in the course of disease. If there is clinical and electrographic evidence of involvement of the frontotemporal lobes, radiographic imaging is indicated as well as studies of the serum and cerebrospinal fluid for antibodies indicative of a recent infection with herpes simplex virus. Assuming that the radiographic scans identify the characteristic changes of a focal encephalitis and that the antibody responses are indicative of a recent herpes simplex virus infection, brain biopsy should be done in order to confirm the diagnosis. With positive evidence for HSE, treatment with ara-A should be initiated and continued for 10 days. If the biopsy proves negative for virus, ara-A should be discontinued and the patient managed conservatively (Fig. 3). Although the NIAID study of ara-A treatment of HSE is encouraging, the numbers are small and the evidence is, at best, only suggestive. It is reasonable to use this drug until a better one becomes available for the treatment of known HSE, and treatment should be instituted early before cellular injury is extensive. In centers familiar with this problem, biopsy confirmation of the diagnosis is a simple and informative procedure and can be defended. If patients cannot be moved to a center of this type, physicians familiar with the many facets of this problem should be consulted, and a decision regarding biopsy and treatment should be individualized in light of the circumstances. Biopsy should only be undertaken when the procedure can be done with minimal risk to the patient and the assurance that the maximum amount of information can be gained.

Research on the effectiveness of denatonium benzoate as a deterrent to liquid detergent ingestion by children

Research was conducted among young children to determine whether or not the bitter tasting substance denatonium benzoate added to liquid detergents would effectively reduce the risk that large quantities of such products might be ingested. The research design involved essentially no risk to the young subjects and was approved by an Institutional Review Board prior to initiation. The value of an effective deterrent material is apparent based on the number of reported ingestions of detergent products each year. Denatonium benzoate was chosen as a potential deterrent based on its existing uses in alcohol as a denaturant and in thumb-sucking and nail-biting deterrent products. In the present research, 108 children ranging in age from 18 to 47 months were offered a drink of either a dilute soapy tasting solution or that same solution with denatonium benzoate added. The results showed that for the liquid containing denatonium benzoate, significantly less liquid was ingested, significantly fewer subjects accepted a second taste, and significantly more subjects displayed behavior indicating immediate and intense aversion to the taste of denatonium benzoate. The data indicate that the addition of denatonium benzoate to a liquid detergent would be expected to significantly reduce, but most likely not eliminate, the probability of an accidental ingestion involving multiple swallows by a young child.

Persistent and fatal central-nervous-system ECHOvirus infections in patients with agammaglobulinemia

We observed persistent ECHOvirus infection of the central nervous system, as defined by continued presence of isolatable virus in cerebrospinal fluid, in five patients with agammaglobulinemia. The immunologic deficit in each was characterized by absence of surface-immunoglobulin-bearing B lymphocytes and of lymph-node cortical follicles, but normal T-cell function. ECHOviruses 30, 19, 9 and 33 were recovered from cerebrospinal fluid for periods varying from two months to three years. The patients had few signs of acute central-nervous-system infection. Three of the five patients had a dermatomyositis-like syndrome, with peripheral lymphocytes that reacted with anti-human leukemia-specific primate and rabbit serums in a cytotoxicity assay. These data suggest that intact B-cell function is essential for eradication of ECHOvirus infection of the central nervous system.

Perceptuo-motor dysfunction in the child with hemiplegia

Eighteen children with hemiplegia were examined by means of standard neurological and other, specialized, sub-tests to define the extent of their perceptuo-motor dysfunction. Particular attention was paid to auditory language function, praxis, visuo-spatial skills, body schema, tactile defensiveness and inattention. The side of the hemiplegia was not found to predispose to any specific dysfunction, with the exception of inattention which was seen only in those with left-sided hemiplegia. Children with a history of familial sinistrality had a higher incidence of speech problems, particularly in the area of auditory language and speech delay. The results are discussed in the light of therories of plasticity and cerebral organization.

Experimental encephalitis caused by herpes simplex virus: comparison of treatment with tilorone hydrochloride and phosphonoacetic acid

A mouse model of encephalitis caused by herpes simplex virus was used to compare the antiviral activity of tilorone hydrochloride with that of phosphonoacetic acid. These compounds were also administered simultaneously to determine whether the combination had a synergistic effect. Rates of survival and concentrations of virus in brain were used as criteria for judging the effectiveness of treatment. The fatal course of encephalitis was not altered by any treatment protocols in which tilorone hydrochloride was used alone. Four days of treatment with phosphonoacetic acid resulted in a long-term survival rate of about 15% of the infected, treated animals, and extension of this therapy for an additional three days resulted in an overall survival rate of about 35%. No increase in survival rate was obtained by use of phosphonoacetic acid and tilorone hydrochloride in combination. The concentration of virus in the brains of tilorone hydrochloride treated animals did not differ significantly from that in the untreated, infected control animals. Treatment with phosphonoacetic acid resulted in a reduction in titer of virus in brain and in an increased rate of survival.

Inclusion bodies in brain cell cultures from Creutzfeldt-Jakob disease

Brain cell cultures were established from 20 patients with various forms of dementia and studied for evidence of virus induced alterations. Changes were detected in the cultured cells from 1 patient (L.C.) with the clinical and pathological diagnosis of Creutzfeldt-Jakob disease. These changes were present in the early passages of the brain tissue and were not seen in the cultures from the other cases.