Conventional and advanced imaging in neuromyelitis optica

Myelitis and optic neuritis are prototypic clinical presentations of both multiple sclerosis and neuromyelitis optica. Once considered a subtype of multiple sclerosis, neuromyelitis optica, is now known to have a discrete pathogenesis in which antibodies to the water channel, aquaporin 4, play a critical role. Timely differentiation of neuromyelitis optica from MS is imperative, determining both prognosis and treatment strategy. Early, aggressive immunosuppression is required to prevent the accrual of severe disability in neuromyelitis optica; conversely, MS-specific therapies may exacerbate the disease. The diagnosis of neuromyelitis optica requires the integration of clinical, MR imaging, and laboratory data, but current criteria are insensitive and exclude patients with limited clinical syndromes. Failure to recognize the expanding spectrum of cerebral MR imaging patterns associated with aquaporin 4 antibody seropositivity adds to diagnostic uncertainty in some patients. We present the state of the art in conventional and nonconventional MR imaging in neuromyelitis optica and review the place of neuroimaging in the diagnosis, management, and research of the condition.

Relative risk of conversion from normoglycaemia to impaired glucose tolerance or non-insulin dependent diabetes mellitus in polycystic ovarian syndrome

BACKGROUND

Cross-sectional studies have shown a high frequency of impaired glucose tolerance (IGT) and non-insulin dependent diabetes mellitus (NIDDM) in women with polycystic ovarian syndrome (PCOS). However, little is known about the change in glucose tolerance that occurs over a period of several years in women with PCOS.

METHODS

Sixty-seven women with PCOS received a 75 g glucose tolerance test and measurement of lipids at baseline and at follow-up after an average time of 6.2 years. All women followed prospectively had normal glucose tolerance (n = 54) or IGT (n = 13) at the start of the study.

RESULTS

Change in glycaemic control from baseline was frequent, with 5/54 (9%) of normoglycaemic women at baseline developing IGT and a further 4/54 (8%) moving directly from normoglycaemic to NIDDM. For women with IGT at baseline, 7/13 (54%) had NIDDM at follow-up. Body mass index (BMI) at baseline was an independent significant predictor of adverse change in glycaemic control.

CONCLUSIONS

Women with PCOS, particularly those with a high BMI, should be reviewed regularly with respect to IGT or NIDDM, as the frequency of impaired glycaemic control is high, and that the rate of conversion from normal glucose tolerance to IGT or NIDDM, or from IGT to NIDDM is substantial.

Management of a ruptured basilar artery aneurysm during pregnancy

A 36 year old woman who ruptured a basilar artery aneurysm at 38 weeks gestation in her second pregnancy was managed successfully by endovascular embolisation 36 hours after an emergency Caesarean section. The timing of treatment along with the obstetric, neurosurgical and anaesthetic aspects of this complex problem are discussed along with a review of the current literature on the subject.

The role of laparoscopy in the diagnosis and treatment of peritoneal carcinomatosis: a case report

A patient presented with deep venous thrombosis and an elevated CA-125 level, but normal pelvic ultrasound and abdominal and pelvic CT scans. Laparoscopy revealed diffuse carcinomatosis and a diagnosis of stage IIIc, poorly differentiated epithelial ovarian carcinoma was made. Laparoscopy may provide an alternative means of diagnosis when conventional imaging fails, and may facilitate the placement of catheters for subsequent intraperitoneal therapy.

The role of chemotherapy and prophylactic bilateral oophorectomy in a case of colorectal adenocarcinoma with ovarian metastases

A 66-year-old female presented with a large abdominal mass and accompanying systemic complaints of abdominal pain, constipation. and fever. On exploratory laparotomy, the mass was found to be a moderately differentiated adenocarcinoma of the sigmoid colon with metastasis to the left ovary. A primary colorectal carcinoma that has metastasized to the ovaries can be difficult to distinguish clinically from an advanced primary ovarian tumor. Histology and tumor markers are currently the most useful tools available in making an accurate diagnosis. If the nature of the primary tumor is uncertain and the initial response to chemotherapy is poor, the patient's prognosis will also he poor. Though controversy exists regarding the role of prophylactic bilateral oophorectomy during resection for primary colorectal cancer, later confusion can be avoided by performing this procedure when the colorectal carcinoma is first diagnosed. However the possibility of a concurrent primary ovarian tumor must not be overlooked.

Spontaneous rupture of a splenic artery aneurysm in pregnancy: report of two cases

The spontaneous rupture of a splenic artery aneurysm during pregnancy is a rare but catastrophic event. Two cases are reported, both involving fetal death and one maternal death as well. A review of the literature covering this condition shows that mortality amongst pregnant women remains high at 75% with 95% fetal loss, which compares with a 25% mortality rate amongst non-pregnant women. Clinical presentation is often non-specific, with good haemodynamic compensation, followed by a rapid deterioration. The best investigation appears to be a diagnostic laparotomy. The discussion stresses the importance of early diagnosis faced with this serious condition, as well as the potential benefits of a prompt lower mid-line incision in terms of statistical survival for both mother and fetus.

What appears to be cancer

We describe a case of multiple hepatic pyogenic abscesses with an unusual presentation. The typical signs and symptoms of fever and pain in the right upper quadrant were absent. Instead, the chief complaint was muscle weakness and myalgias accompanied by weight loss. Findings from an ultrasonogram of the abdomen revealed multiple hepatic lesions consistent with metastases. Hence, the initial presumptive diagnosis was metastatic malignancy with unknown primary tumor. It was only when purulent material was unexpectedly encountered when a needle biopsy was performed that the true diagnosis of pyogenic liver abscess was recognized. While liver abscess is rare, it should not be forgotten in the differential diagnosis for multiple hepatic lesions seen on imaging studies.

Consumption of different alcoholic beverages as predictors of local rates of night-time assault and acute alcohol-related morbidity

OBJECTIVE

To determine whether population levels of consumption of some alcoholic beverages are more closely associated with levels of harm than others, particularly if consumption of cask wine is more strongly related to rates of acute alcohol problems than consumption of bottled wine as a consequence of the extremely low rates of federal tax levied on the former.

METHOD

A database of alcohol consumption and related problems was established for 130 areas of Western Australia. Demographic and economic data for these areas were included from the 1991 census. Empirically derived assumptions regarding the mean wholesale price of cask and bottled wine were utilised. Regression analyses examined the extent to which the consumption of different alcoholic beverages predicted levels of major varieties of harm.

RESULTS

Only cask wine and high-strength beer consumption were significantly associated with rates of night-time assault; consumption of all beverage varieties except bottled wine was significantly associated with rates of acute alcohol-related morbidity. Further analyses, which included controls for an effect of total alcohol consumption, confirmed the pronounced contributions of cask wine and high-strength beer to rates of night assaults and acute alcohol-related morbidity. The proportion of all alcohol consumed as low-alcohol beer was significantly negatively associated with these harms.

CONCLUSIONS

The beverages most associated with rates of night-time assaults and acute alcohol-related morbidity are those with the lowest federal taxation per standard drink, i.e. cask not bottled wine and regular-strength not low-alcohol beer.

Gadolinium-enhanced 3D MRA of the aortic arch vessels in the detection of atherosclerotic cerebrovascular occlusive disease

PURPOSE

Our goal was to evaluate non-breath-hold Gd-enhanced 3D MR angiography (MRA) for the detection of atherosclerotic occlusive disease of the aortic arch vessels and to compare image quality with two breath-hold techniques.

METHOD

One hundred sixty consecutive patients with known or clinically suspected atherosclerotic cerebrovascular occlusive disease underwent Gd-enhanced 3D MRA of the aortic arch and great vessels. One hundred twenty-six examinations were performed with the body coil after infusion of 40 ml of Gd-DTPA; 89 of these were performed without breath-holding and 37 were acquired during suspended respiration. Thirty-four examinations were performed in a body phased-array coil with breath-holding, a timing examination, and 20 ml of contrast agent by manual (n = 17) or power (n = 17) injection. Images were evaluated for the presence of blurring and ghosting artifacts and venous enhancement. Of the 27 patients who underwent non-breath-hold MRI and digital subtraction angiography (DSA), two readers blinded to the DSA results retrospectively evaluated the MRA examinations for the presence of occlusive disease of the innominate, carotid, subclavian, and vertebral arteries. DSA correlation was not evaluated for the 71 breath-hold studies.

RESULTS

Sensitivity and specificity for arch vessel occlusive disease with non-breath-hold MRA were 38 and 94% for Reader A and 38 and 95% for Reader B. Breath-holding significantly reduced blurring and ghosting artifacts (p < 0.001) when compared with non-breath-hold imaging, and use of 20 ml of contrast medium, with a timing examination, resulted in significantly less venous enhancement than seen with 40 ml (p < 0.001).

CONCLUSION

Non-breath-hold Gd-enhanced 3D MRA is insensitive for detecting arch vessel occlusive disease. Breath-hold imaging, in conjunction with a timing examination and a lower dose of contrast agent, improves image quality, but further studies are needed to assess diagnostic accuracy.

Alcohol consumption and injury in Western Australia: a spatial correlation analysis using geographic information systems

Geographic information systems technology was used to describe, in geographical terms, the nature and strength of the relationship in Western Australia between alcohol consumption and the rates of related injury: night-time assaults (10 p.m. to 6 a.m.); minor night-time road crashes (10 p.m. to 6 a.m.), weighted by traffic density; and hospital E-code (external-cause) morbidity, weighted by alcohol aetiologic fractions. The data were aggregated by five conventional state regions: northern, central, western, southern and Perth metropolitan. There was a general association, of equal significance for males and females, between estimated per capita alcohol consumption and the selected rates of injury in the five regions. However, the nature and strength of association between alcohol consumption and individual injury measures varied. Night-time assaults and hospital E-code morbidity were strongly, associated with consumption. Minor night-time crashes had only a weak association. The variation in the relationship between alcohol consumption and injury suggests that prevention strategies need to take into account the particular drinking patterns and associated harm that occur in different regions of the state, and to develop a range of targeted responses. High rates of consumption and injury in most country areas support the need for greater regional prevention efforts.

Complete hydatidiform mole and coexisting normal fetuses. A report of two cases with contrasting outcomes

BACKGROUND

Multiple pregnancies consisting of a complete hydatidiform mole and coexisting fetuses are relatively rare but may become more common due to the increasing use of ovulation-induction agents.

CASES

We report on a twin and a triplet pregnancy, conceived using clomiphene citrate, with contrasting outcomes. The twin pregnancy resulted in a term delivery of a healthy singleton and the triplet pregnancy in a termination at 17 weeks followed by the development of choriocarcinoma.

CONCLUSION

The few cases available suggest that a subgroup of complete moles follows a more benign course and can be managed conservatively, allowing the pregnancy to go to term with appropriate follow-up, whereas other cases follow a more aggressive course. Larger case series are needed to develop definitive protocols.

Selective feticide by embolization in twin-twin transfusion syndrome. A report of two cases

BACKGROUND

The early development of complications in twin-twin transfusion syndrome is a poor prognostic sign. For this reason, new techniques for intrauterine therapy are being developed: invasive options, such as selective feticide of one of the twins, have been reported.

CASES

Two cases of twin-twin transfusion syndrome in the late second trimester were treated by selective feticide using vascular embolization to the more severely damaged fetus. In one case the embolized fetus was a hydropic recipient with a normal cotwin; in the other, the donor fetus was affected by bilateral hydrocephalus. These fetuses underwent ultrasound-guided embolization using a bolus of histoacryl injected into the umbilical vein and fetal heart. Both patients went on to deliver healthy singletons in the third trimester.

CONCLUSION

In twin-twin transfusion syndrome of early onset, embolization may help one of the twins survive. This technique is neither time-consuming nor expensive and does not require a general anesthetic.

Family planning in genitourinary medicine: an opportunistic service?

OBJECTIVE

To evaluate and serve the need for contraception in those not using conventional sources of family planning services.

SETTING

South London outpatient genitourinary medicine department at King's College Hospital.

DESIGN AND SUBJECTS

Prospective study of 200 women seen consecutively in the clinic by the same doctor (LM) during 1993. Women at risk of unwanted pregnancy were identified, and offered immediate contraceptive provision or referral.

RESULTS

15 women (7.5%) were using no contraception, despite being sexually active and not wishing to conceive; of these two presented with an unwanted pregnancy. A further 23 women (11.5%) were not using their chosen contraception effectively, and another 20 women were unclear about contraceptive methods and wanted advice. Young women were most at risk; 14% of those aged 25 years and under were using no contraception. Eight women wished to defer contraceptive advice; of these four defaulted from follow up. Eighteen women (9%) wanted immediate contraceptive supplies. Ten of 18 returned a follow up questionnaire; all these women were satisfied with the contraceptive advice service received.

CONCLUSIONS

Absent or ineffective contraception is common in women attending an inner city genitourinary medicine clinic. Immediate provision of contraceptive education, advice and supplies is welcomed by patients.