Macrocerebellum in Achondroplasia: A Further CNS Manifestation of FGFR3 Mutations?

Achondroplasia is the result of a mutation in the fibroblast growth factor receptor 3 gene (FGFR3). Appearances suggestive of macrocerebellum have not been described in this patient group. We retrospectively reviewed MR imaging studies of the brain in 23 children with achondroplasia. A constellation of imaging findings that are recognized in macrocerebellum was observed, including cerebellar hemisphere enlargement (inferior and superior extension, wrapping around the brainstem); an effaced retro- and infravermian cerebellar subarachnoid CSF space; a shortened midbrain; distortion of the tectal plate; and mass effect on the brainstem. All MR imaging studies exhibited some of these findings. Quantitative analysis confirmed an increased cerebellar volume compared with age- and sex-matched controls. We hypothesized that this may be due to direct effects of the FGFR3 mutation on cerebellar morphogenesis.

Temporal Lobe Malformations in Achondroplasia: Expanding the Brain Imaging Phenotype Associated with FGFR3-Related Skeletal Dysplasias

Thanatophoric dysplasia, achondroplasia, and hypochondroplasia belong to the fibroblast growth factor receptor 3 (FGFR3) group of genetic skeletal disorders. Temporal lobe abnormalities have been documented in thanatophoric dysplasia and hypochondroplasia, and in 1 case of achondroplasia. We retrospectively identified 13 children with achondroplasia who underwent MR imaging of the brain between 2002 and 2015. All children demonstrated a deep transverse temporal sulcus on MR imaging. Further common neuroimaging findings were incomplete hippocampal rotation (12 children), oversulcation of the mesial temporal lobe (11 children), loss of gray-white matter differentiation of the mesial temporal lobe (5 children), and a triangular shape of the temporal horn (6 children). These appearances are very similar to those described in hypochondroplasia, strengthening the association of temporal lobe malformations in FGFR3-associated skeletal dysplasias.

Effect of first-line treatment on second primary malignancies and Richter's transformation in patients with CLL

This study aimed to assess the frequency of and the contributing factors for second primary malignancies (SPMs) and Richter's transformations (RTs) following first-line treatment of chronic lymphocytic leukemia within four phase II/III trials of the GCLLSG evaluating fludarabine (F) vs F+cyclophosphamide (FC), chlorambucil vs F, FC without or with rituximab, and bendamustine+R (BR). Among 1458 patients, 239 (16.4%) experienced either an SPM (N=191) or a RT (N=75). Solid tumors (N=115; 43.2% of all second neoplasias) appeared most frequently, followed by RTs (N=75; 28.2%). Patients showed a 1.23-fold increased risk of solid tumors in comparison to the age-matched general population from the German cancer registry. Age>65 (hazard ratio (HR) 2.1; P<0.001), male sex (HR 1.7; P=0.01), co-morbidities (HR 1.6; P=0.01) and number of subsequent treatments⩾1 (HR 12.1; P<0.001) showed an independent adverse prognostic impact on SPM-free survival. Serum thymidine kinase>10 U/l at trial enrollment (HR 3.9; P=0.02), non-response to first-line treatment (HR 3.6; P<0.001) and number of subsequent treatments⩾1 (HR 30.2; P<0.001) were independently associated with increased risk for RT.

Accuracy of the non-sentinel node risk score (N-SNORE) in patients with cutaneous melanoma and positive sentinel lymph nodes: a retrospective study

BACKGROUND

Sentinel node (SLN) biopsy in patients with melanoma permits identification of those at risk for further metastases in non-sentinel lymph nodes (NSLN). However, a mere 20% of SLN-positive patients have metastases in NSLN. Therefore we need criteria to predict NSLN-positivity. A new score system known as the non-sentinel risk score, (N-SNORE) based on five clinical and pathological characteristics (gender, regression in primary melanoma, proportion of SNs containing melanoma, perinodal lymphatic invasion, and SN tumor burden), was first published in 2010. In this study, the accuracy of N-SNORE was validated in melanoma patients with positive SLN.

METHODS

A total of 106 melanoma patients with positive SLN, who had undergone complete lymph node dissection (CLND) subsequently, were included in the study. The N-SNORE was calculated in all patients, and the risk was compared to the frequency of NSLN metastases. Statistical analysis of the data was performed.

RESULTS

Thirteen patients were at very low risk for NSN metastasis (score 0), 63 patients at low risk (score 1-3), 19 at intermediate risk (score 4-5), 6 at high risk (score 6-7), and 5 at very high risk (score >8). NSLN positivity rates for these 5 risk groups were 7.7%, 18.2%, 21.1%, 33.3%, and 80%, respectively. According to Fisher's exact test, the contingency coefficient was .322; the p-value was .025.

CONCLUSION

An increasing N-SNORE was clearly correlated with a higher risk of NSLN positivity. Based on the p-value and the contingency coefficient, the overall accuracy of the N-SNORE was proven on statistical calculation.

Addition of rituximab to fludarabine and cyclophosphamide in patients with chronic lymphocytic leukaemia: a randomised, open-label, phase 3 trial

BACKGROUND

On the basis of promising results that were reported in several phase 2 trials, we investigated whether the addition of the monoclonal antibody rituximab to first-line chemotherapy with fludarabine and cyclophosphamide would improve the outcome of patients with chronic lymphocytic leukaemia.

METHODS

Treatment-naive, physically fit patients (aged 30-81 years) with CD20-positive chronic lymphocytic leukaemia were randomly assigned in a one-to-one ratio to receive six courses of intravenous fludarabine (25 mg/m(2) per day) and cyclophosphamide (250 mg/m(2) per day) for the first 3 days of each 28-day treatment course with or without rituximab (375 mg/m(2) on day 0 of first course, and 500 mg/m(2) on day 1 of second to sixth courses) in 190 centres in 11 countries. Investigators and patients were not masked to the computer-generated treatment assignment. The primary endpoint was progression-free survival (PFS). Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00281918.

FINDINGS

408 patients were assigned to fludarabine, cyclophosphamide, and rituximab (chemoimmunotherapy group) and 409 to fludarabine and cyclophosphamide (chemotherapy group); all patients were analysed. At 3 years after randomisation, 65% of patients in the chemoimmunotherapy group were free of progression compared with 45% in the chemotherapy group (hazard ratio 0·56 [95% CI 0·46-0·69], p<0·0001); 87% were alive versus 83%, respectively (0·67 [0·48-0·92]; p=0·01). Chemoimmunotherapy was more frequently associated with grade 3 and 4 neutropenia (136 [34%] of 404 vs 83 [21%] of 396; p<0·0001) and leucocytopenia (97 [24%] vs 48 [12%]; p<0·0001). Other side-effects, including severe infections, were not increased. There were eight (2%) treatment-related deaths in the chemoimmunotherapy group compared with ten (3%) in the chemotherapy group.

INTERPRETATION

Chemoimmunotherapy with fludarabine, cyclophosphamide, and rituximab improves progression-free survival and overall survival in patients with chronic lymphocytic leukaemia. Moreover, the results suggest that the choice of a specific first-line treatment changes the natural course of chronic lymphocytic leukaemia.

FUNDING

F Hoffmann-La Roche.

Seborrhoeic keratoses in patients with internal malignancies: a case-control study with prospective accrual of patients

BACKGROUND

The association between the eruption of numerous seborrhoeic keratoses as a result of an underlying malignancy is controversially discussed. The aim of this case-control study with prospective accrual of patients was to determine whether a direct association exists between the number seborrhoeic keratoses and internal malignancies.

METHODS

The numbers and sites of seborrhoeic keratoses were counted in 150 oncological patients and 150 matched controls. Additionally, the presence or absence of pruritus, acanthosis nigricans, and the sudden appearance of seborrhoeic keratoses were assessed.

RESULTS

Seborrhoeic keratoses did not differ significantly between patients with internal malignancies and controls. Only two patients fulfilled the criteria of the Leser-Trélat sign, defined as the eruption of numerous seborrhoeic keratoses as a cutaneous marker of an underlying internal malignancy.

CONCLUSION

No association was found between seborrhoeic keratoses and cancer. Furthermore, our data did not provide support to the validity of the Leser-Trélat sign in patients with internal malignancies.

Vascular endothelial growth factor in patients with psoriatic arthritis

OBJECTIVE

To determine the levels of vascular endothelial growth factor (VEGF) in patients with active psoriatic arthritis, patients with inactive psoriatic arthritis, and healthy controls. Serum VEGF levels were correlated with clinical and laboratory features in patients with active psoriasis arthritis.

METHODS

Serum samples from 14 patients with active psoriatic arthritis, 14 patients with inactive psoriatic arthritis, and 9 healthy controls were investigated. VEGF levels in the serum were measured using a sensitive sandwich ELISA.

RESULTS

The mean serum VEGF concentration in patients with active PA was 394.4 pg/ml (394 +/- 171.8), in patients with inactive PA 200.4 pg/ml (200.4 +/- 115.7), and in healthy subjects 214.3 pg/ml (214.3 +/- 162.1). Patients with active psoriasis arthritis had significantly higher levels of VEGF compared to patients with inactive psoriasis arthritis and healthy individuals (p > 0.001). In contrast, VEGF levels were comparable in patients with inactive psoriatic arthritis and controls (p =0.659). Furthermore, in patients with psoriatic arthritis, VEGF levels were positively correlated with ESR, HAQ, PASI and VAS.

CONCLUSION

VEGF levels may be regarded as a good indicator of active psoriasis arthritis.

Enlarged parietal foramina: MR imaging features in the fetus and neonate

Enlarged parietal foramina are believed to be benign and familial and due to a variable degree of defective intramembranous ossification of the parietal bones. We report 2 patients with this condition in whom fetal and neonatal MR imaging studies illustrate the antenatal and perinatal evolution of this condition and the associated persistence of a falcine sinus. We discuss its relationship to the spectrum of cephalocoeles.

Long-term Mortality in Patients with Thrombosis of the Inferior Vena Cava, Iliac and Femoral Veins

OBJECTIVES

To assess the long-term mortality in patients with thrombosis of the vena cava, iliac and femoral veins.

DESIGN

Registry study.

MATERIALS

Between 1992 and 2000, 212 consecutive patients with acute pelvic vein thrombosis diagnosed by duplex sonography were examined by magnetic resonance imaging (MRI) to determine the most proximal extent of the thrombus. MRI revealed a thrombosis in the inferior vena cava in 46 patients (22%), in the iliac vein in 142 patients (67%), and in the femoral vein in 24 patients (11%).

METHODS

The vital status of the patients was investigated in April 2004 using the Austrian National Registry and the Cause of Death Register.

RESULTS

A total of 211 patients of the original 212 patients were monitored over a mean follow-up period of 91 months. Seventy-two of 211 patients (34%) had died. There was no significant difference in the long-term mortality, the survival period or the occurrence of fatal pulmonary embolism (PE) between previously diagnosed vena cava, iliac vein, or femoral vein thrombosis.

CONCLUSIONS

Extension of a thrombus into the inferior caval vein in patients considered to have a pelvic vein thrombosis has no impact on long-term mortality or the development of fatal PE compared to those patients with thrombus limited to more distal veins.

Age-related pituitary volumes in prepubertal children with normal endocrine function: volumetric magnetic resonance data

BACKGROUND

Evaluation of the size of the pituitary gland on magnetic resonance imaging (MRI) may be difficult, considering the wide variation in normal gland morphology. Given the paucity of age-related biometric data, our purpose was to obtain standard normal reference values for pituitary volumes in prepubertal children using three-dimensional MRI data.

METHODS

Children under the age of 10 yr undergoing brain MRI for seizures or idiopathic developmental delay and who had no endocrine abnormality were recruited prospectively over 2 yr. All MRI studies included a three-dimensional sequence. Only subjects with normal studies were included. One hundred thirty-nine children were eligible (mean age, 5.2 yr). Direct pituitary volumes were measured from contiguous 1-mm thick reconstructed coronal and sagittal images. Estimated pituitary volumes were calculated using pituitary height, width, and length.

RESULTS

Volumes obtained from reconstructions in either plane were essentially identical. There was a linear increase in log-transformed pituitary volume with age, but relatively weak correlations with height or body mass index. There was no gender difference and only weak correlations between pituitary height and pituitary volume and between estimated pituitary volume calculation and measured pituitary volume. We provide age-related reference ranges for pituitary volumes in graphical and tabular forms.

Serum level of VEGF-D in patients with primary lymphedema

Recent studies have indicated that vascular endothelial growth factor-D (VEGF-D) stimulates lymphangiogenesis in humans. Furthermore, mutations of vascular endothelial growth factor receptor 3 (VEGFR-3) have been observed in families with hereditary lymphedema. The lack of stimulation of lymphangiogenesis could lead to production of even more VEGF-D to obtain stimulation of lymphangiogenesis resulting in a high serum level of VEGF-D. The aim of the present study was to compare the serum level of VEGF-D in patients with primary lymphedema with healthy controls. In a prospective study, the serum level of VEGF-D was determined by a solid phase ELISA in patients with primary lymphedema and compared with healthy controls. In the group of patients with primary lymphedema the serum level of VEGF-D was significantly higher compared with controls (p=0.0047). The increased levels of VEGF-D observed in the present study suggest that primary lymphedema may be based on defective stimulation of VEGFR-3.

Lupus anticoagulant and venous leg ulceration

BACKGROUND

Most leg ulcers occur in patients with venous insufficiency. However, not all patients with venous insufficiency develop leg ulcers. Recent studies have found that factors causing clotting abnormalities, e.g. anticardiolipin antibody (ACA), are associated with leg ulcers. Although lupus anticoagulant, like ACA, belongs to the group of antiphospholipid antibodies, its presence in patients with venous leg ulceration has not been previously reported.

OBJECTIVES

To determine the presence of lupus anticoagulant in patients with venous leg ulceration.

METHODS

We investigated the presence of lupus anticoagulant in 27 patients with venous leg ulcers and compared these data with controls. Lupus anticoagulant was evaluated in all subjects by the Russell's viper venom test.

RESULTS

Of 27 patients with venous leg ulceration, 16 (59%) were shown to have lupus anticoagulant, while only one of 32 controls (3%) was found to have lupus anticoagulant. Thus, lupus anticoagulant was significantly more frequent in patients with venous leg ulcers than in controls (P < 0.001).

CONCLUSIONS

We suggest that lupus anticoagulant could be a hitherto unknown factor contributing to the development of venous leg ulcers.

[Mondor phlebitis associated with hepatitis C]

Mondor's disease in association with hepatitis C. We report a case of a 40 years old patient suffering from Mondor's disease. Neither a malignancy nor a disturbance of the clotting system was found. This case is remarkable for the association with hepatitis C.

Seasonal pattern of the excision rate of melanoma and naevi

Based on available information that melanocytic skin lesions presenting a junctional component are more susceptible to the influence of ultraviolet radiation, this study compares the seasonal differences between the excision rates of melanocytic skin lesions with a junctional component to those without. The histological diagnoses of 1230 patients with melanocytic skin lesions were retrospectively analysed. Depending on the histological diagnosis four groups were formed: melanomas, dysplastic naevi, common naevi (junctional and compound naevi), and dermal naevi. All dates of operations were allocated to summer or winter halves of the year. The collected data were computer analysed for statistical description. The number of excisions of melanocytic lesions with a junctional component (melanoma, dysplastic naevi, common naevi) showed an impressive seasonal variation, with a peak during the summer months, while the excision frequency of dermal naevi was approximately constant during the year. In conclusion, we suggest that ultraviolet radiation may contribute to the seasonal pattern of excision of melanoma and naevi only when a junctional component is present.

Delayed presentation of an ingested foreign body causing gastric perforation

Ingested foreign bodies may lead to perforation of the gastrointestinal tract. We present a case of a 14-month-old boy who presented with an unusual abdominal mass secondary to ingesting a foreign body 4 months previously. Abdominal computerized tomography scan was valuable in making this diagnosis.

Refractive lensectomy for hyperopia

PURPOSE

The purpose of this study was to evaluate refractive lensectomy as a surgical procedure for the treatment of hyperopia.

DESIGN

A retrospective noncomparative case series.

PARTICIPANTS

Twenty-nine patients were included in the study. Fifty eyes underwent extraction of the crystalline lens and intraocular lens implantation.

METHODS

Operations were performed by the same surgeon with the patient under general anesthetic. All lenses were removed by phacoemulsification with insertion of lens implants singly or as piggyback lenses. The Holladay2 formula was used to calculate lens powers. Results are compared with other methods of treating hyperopia.

MAIN OUTCOME MEASURES

The main parameters assessed were safety, efficacy, predictability, stability, and complications.

RESULTS

Eyes were divided into group A (n = 26), with an average preoperative spherical equivalent (SE) of +2.26 +/- 0.94, and group B (n = 24), with an average preoperative SE of +6.32 +/- 1.32. In group A, after refractive lensectomy, 80.7% had no change in best-corrected visual acuity (BCVA) or gained a line, whereas 11.5% lost one line; 88.5% had an uncorrected visual acuity (UCVA) of 20/40 or better, and 88.5% were within 1 diopter (D) of intended postoperative SE. In group B, 70.9% of eyes had no change or gained a line in BCVA, whereas 29.2% lost a line of BCVA; 62.5% had UCVA of 20/40 or better postoperatively, and 58.3% were within 1 D of the intended SE. In one eye the posterior capsule was breached intraoperatively. One eye had a symptomatic episode of cystoid macula edema that settled spontaneously. To date, seven eyes have required secondary refractive procedures, and three eyes have required yttrium-aluminum-garnet capsulotomy.

CONCLUSIONS

In the presbyopic age group refractive lensectomy may be a realistic alternative to photorefractive keratectomy or laser in situ keratomileusis, with certain potential advantages.

Overcorrected radial keratotomy treated with posterior chamber phakic intraocular lens and laser thermal keratoplasty

PURPOSE

Modern refractive surgery is effective in a large majority of cases in achieving a good first time result. Some attempts at correction, however, are less successful and require subsequent revision.

METHODS

A case of secondary hyperopic astigmatism (+0.75 +1.50 x 45 degrees) is reported in a patient who had undergone radial keratotomy for myopia of -6.00 +0.75 x 90 degrees, 8 years previously. Preoperative uncorrected visual acuity was 20/120 improving to 20/20 with correction. Further refractive procedures were performed including arcuate keratotomy, posterior chamber phakic intraocular lens implantation and laser thermal keratoplasty to improve the uncorrected visual result.

RESULTS

Final uncorrected visual acuity was 20/40, spectacle-corrected visual acuity was 20/20 with a manifest refraction of +0.50 +1.00 x 40 degrees.

CONCLUSIONS

This case demonstrates how the consecutive application of several procedures can successfully refine an initially unsatisfactory refractive result. The potential for reduced predictability and additional complications with each procedure should not be forgotten.

Cataract development after implantation of the Staar Collamer posterior chamber phakic lens

Implantation of a posterior chamber phakic intraocular lens is an effective refractive procedure with a good safety record in the short-term follow-ups reported in the literature. Cataract formation is a potential complication of the procedure. Two patients developed lens opacities in 3 eyes after the procedure was performed for myopic astigmatism. The possible causes are discussed. This is not a dangerous complication as cataract extraction is easily achieved if necessary. However, it is undesirable and further research is required to assess the long-term incidence, causes, and ways to prevent its occurrence.

A follow-up study of the learning transfer process in further training of nursing staff

The purpose of the study was to investigate whether the human and economic investment of resources in the further training of nursing and nursing assistants is justified. The study focused in particular on the transfer of knowledge from training course to working practice. It was carried out as a case study in Ringkøbing County, Denmark, during 1993/94. The population consisted of 49 nurses and 49 nursing assistants. The study showed that the participants took a keen interest in the courses. The learning process was found relevant by the nurses, but not by the nursing assistants. Neither group found that their expectations of getting more knowledge were satisfied. With respect to job-behaviour, the study confirmed the hypothesis that the practising of the content of the course will depend on the support and interest of the head of the department towards a goal-oriented development of competence and structure. If such support and interest is lacking, the course-participant will only change her own working practices, independent of the organizational structure.

Totally implantable venous access devices in children with cystic fibrosis: incidence and type of complications

BACKGROUND

Totally implantable vascular access devices (TIVADs) are accepted as a safe and effective method of facilitating long term intravenous therapy. We report our experience of the use of these devices in children with cystic fibrosis with a particular focus on the incidence and type of complications.

METHODS

The medical records of patients with cystic fibrosis who underwent placement of a TIVAD at the Royal Children's Hospital, Melbourne, Australia from January 1987 to October 1996 were reviewed. Venous ultrasonography with Doppler was performed in surviving patients with a TIVAD in situ from November 1996 to April 1997 to detect occult thrombotic complications.

RESULTS

A total of 57 TIVADs were implanted in 44 children with a median functional duration of 700 days (range 27-3347 days). Twenty one children had devices inserted without complications. Forty eight complications (30 mechanical, 18 infectious) occurred in 36 devices in 23 children during a total functional duration of 53,057 catheter days. Mechanical complications occurred in 53% of devices (one per 1712 catheter days). Symptomatic venous thrombosis occurred five times in four patients (9%). Infectious complications occurred in 32% (one per 2948 catheter days) while sepsis occurred in five devices (9%). Doppler ultrasonography detected unsuspected thrombosis in two of 10 patients examined.

CONCLUSIONS

While TIVADs provided effective long term intravenous access, septic and thrombotic complications caused significant morbidity in this population. Careful patient selection, adherence to aseptic technique for access and blood sampling, and periodic ultrasonography with Doppler to detect early thrombosis may help reduce these risks.

B mode ultrasonography--spectrum of paediatric ocular disease

BACKGROUND

Despite having appropriate sonographic equipment available many radiologists remain unfamiliar with B mode sonography of the eye.

OBJECTIVE

This article reviews the advantages and disadvantages of B mode sonography of the paediatric eye. We illustrate the spectrum of eye abnormalities occurring in paediatric practice and the sonographic appearance of clinical entities for which sonography is appropriate.

MATERIALS AND METHOD

We reviewed our experience of eye sonography within a paediatric radiology department over 8 years. A total of 212 sonographic examinations were performed on 206 eyes in 103 children, aged from 3 days to 16 years (mean 4.6 years).

RESULTS

Sonography was well tolerated by the children, was a very useful imaging modality and was the only diagnostic imaging modality required in 94%. Supplementary computed tomography (CT) was performed in ten of 206 eyes (5%) and magnetic resonance imaging (MR) was performed in two of 206 eyes (1%).

CONCLUSIONS

B mode sonography is a very useful imaging modality for suspected ocular or orbital pathology in children and is often the appropriate first line investigation following clinical evaluation. Radiologists familiar with sonography of the eye can provide valuable support to their ophthalmology colleagues.

Wall enhancement of leaking polytetrafluoroethylene grafts: a new CT sign

Perigraft seroma is a rare complication of synthetic vascular grafts. We describe a new sign observed in two children who underwent computed tomography of the chest for further evaluation of seromas complicating modified Blalock-Taussig procedures in which a polytetrafluoroethylene graft was used. In both patients contrast enhancement of the wall of the leaking graft was demonstrated on delayed imaging. One patient had bilateral grafts, and the enhancement was only demonstrated in the wall of the leaking graft. We discuss the possible mechanism of this finding and propose that this sign may be further evidence of abnormal graft permeability.

Survival after aortic dissection in giant cell arteritis

Images

Technical note: identifying and aspirating hip effusions

Ultrasound has become a routine investigation in the investigation of the painful hip in children. It has been recommended that all effusions demonstrated by sonography be drained. Based on the experience of 800 hip aspirations, the authors describe an approach to the demonstration and aspiration of hip effusions with some of the pitfalls that result in false positive and false negative diagnoses.

Buscopan and glaucoma: a survey of current practice

Hyoscine butylbromide (Buscopan) is commonly used by radiologists in the UK as a hypotonic agent in double-contract gastrointestinal studies. A history of glaucoma is still taught to be the prime contraindication to its use, although the only individuals at risk are those with undiagnosed and therefore untreated angle closure glaucoma (ACG), who will not give a positive history. We conducted a postal survey of all members and fellows of the Royal College of Radiologists in the UK to establish current practice.

RESULTS

Of the 1045 respondents who use Buscopan, 724 (81.6%) withhold it if the patient gives a history of glaucoma, and 631 (87.2%) of this group substitute glucagon. Of the 51 respondents who state that they understand that the patient who gives the positive history is not the one at risk, 22 continue to withhold Buscopan because of the established teaching. Only 429 (52.4%) substitute glucagon for Buscopan if the patient gives a history of heart disease. Eight respondents (0.8%) have seen an attack of glaucoma thought to have been precipitated by Buscopan, and 20 (1.9%) have seen cardiac complications.

CONCLUSION

There are still widespread misconceptions about the contraindications to the use of Buscopan among radiologists in the UK. We recommend abandoning the practice of enquiring about a history of glaucoma, and substituting advice to seek urgent medical advice should eye pain and visual loss develop. Caution in the patient with heart disease appears to be of greater importance.

The irritable hip: immediate ultrasound guided aspiration and prevention of hospital admission

A protocol for the management of irritable hip was assessed; this protocol avoids hospital admission while detecting all other serious causes of hip pain, in particular septic arthritis, at the earliest possible opportunity. Fifty children with painful hips were studied prospectively with immediate ultrasound guided aspiration and Gram stain of all hip effusions. Bone scintigraphy performed at an early stage was reserved for patients with unremitting symptoms. Thirty six hips were aspirated. Only two patients were admitted. The final diagnoses were transient synovitis (45 cases), Perthes' disease (three cases), fracture (one case), and septic arthritis (one case). The single case of hip sepsis was diagnosed on presentation. The traditional approach to management is questioned and the advantages of the protocol highlighted, including earliest diagnosis of sepsis and other serious pathology, avoidance of hospital admission, and the relief of pain by joint decompression.

Bleeding Meckel's diverticulum in infancy: unusual scintigraphic and ultrasound appearances

We report a case of a bleeding Meckel's diverticulum where scintigraphic and sonographic findings were thought to suggest an ileal duplication. We are not aware of previous reports of sonographic imaging of an uncomplicated Meckel's diverticulum.

Indium-111 labelled leucocyte uptake in aortitis

Inflammatory conditions of the aorta may present with non-specific clinical features, including unexplained fever. Indium-111 labelled leucocyte imaging may be performed in such patients to look for the presence of occult sepsis or to assess the activity of a known vasculitis. Of approximately 1100 patients to undergo leucocyte scintigraphy for these indications over a 5 year period, three had focal leucocyte uptake in the aorta. The final diagnoses were: (1) periaortitis in Wegener's granulomatosis; (2) aortic dissection in giant cell arteritis; and (3) streptococcal aortitis with impending rupture. In all three cases the uptake was initially not thought to be in the aorta, but in bowel, a paravertebral abscess and in the lumbar spine respectively. Further imaging with CT and MRI led to the correct diagnoses. As the aorta is a rare site of focal leucocyte uptake, errors in image interpretation are likely. The rapid diagnosis of inflammatory conditions of the aorta is essential, however, as they may be life-threatening if unrecognized; therefore awareness of the aorta as a potential site of uptake is important. Urgent referral for further imaging is imperative in these cases as a false or delayed diagnosis may lead to avoidable morbidity and mortality.

Periorbital necrobiosis lipoidica

Necrobiosis lipoidica is a granulomatous skin condition typically occurring on the legs. A patient with this condition presented with gross bilateral induration of the eyelids sufficient to close both eyes.