Multiple subpial lipomas with dumb-bell extradural extension through the intervertebral foramen without spinal dysraphism

BACKGROUND: Intradural subpial lipomas not associated with spinal dysraphism, account for less than 1% of spinal cord tumors. The simultaneous existence of multiple intradural subpial lipomas with dumb-bell extradural extension through the intervertebral foramen in the same patient without any evidence of spinal dysraphism has not been previously reported. CASE DESCRIPTION: A 38-year-old man presented with progressive spastic paraparesis, and weakness of right elbow extension and opposition of the medial three fingers. He also had ascending paraesthesia from the C6 dermatome to the saddle region and loss of joint and position sense of both lower limbs with hesitancy and precipitancy of micturition. There was no spinal tenderness, deformity, neurocutaneous markers, or spinal dysraphism. The total duration of illness was 11 years.The oblique views of the plain radiographs of the cervical spine revealed an enlarged right C7-D1 intervertebral foramen. The T1- and T2-weighted magnetic resonance (MR) images showed two intradural, hyperintense lesions (with extensive loss of signal on fat suppression sequences), one extending from C5 to D2 and the other opposite the C3-4 disc space. The parasagittal and axial images showed the extradural component of the lesion emerging from the right C7-D1 intervertebral foramen.At surgery, a C2 to D2 laminectomy was performed. The lipoma, enclosed in a fine pial membrane, was situated on the right posterolateral aspect of the cord. The right-sided nerve roots from the C6 to D1 levels were completely enmeshed by the lipoma. There was a separate superficial subpial lipoma adherent to the posterior aspect of the cord at the C3-4 level. A distinct area of normal cord was present between the two lesions. A subtotal decompression of the lesions including the component emerging through the right C7-D1 intervertebral foramen and a duraplasty were performed.At follow-up after 18 months, the posterior column impairment, lower limb hypoaesthesia, and right upper limb paraesthesia had improved. However, residual elbow extension and lower limb weakness, mild lower limb spasticity and sphincteric dysfunction persisted. CONCLUSIONS: The multiplicity of intradural subpial lipomas without spinal dysraphism points to a dysembryogenetic basis similar to that seen in patients with spinal dysraphism that results in lipomas, but in which the defect is not severe enough to give rise to coexisting vertebral and soft tissue anomalies. The dumb-bell extradural extension through the intervertebral foramen is extremely rare. The magnetic resonance imaging and surgical principles are discussed.     

Radiology curriculum for medical students: Clinicians’ perspectives

This study was conducted to establish clinicians’ perspectives of a set of radiology curriculum topics for medical student teaching, which were held to be important by radiologists. A questionnaire was sent to clinicians in all specialties. Forty‐six clinicians (51.1%) out of 90 returned the questionnaires. All curriculum topics were scored above an average of 4 (agree). The five highest ranking curriculum topics in order of importance were: developing a system for viewing chest radiographs (5.59), developing a system for viewing abdominal radiographs (5.56), developing a system for viewing bone and joint radiographs (5.33), distinguishing normal structures from abnormal in chest and abdominal radiographs (5.33) and identifying gross bone or joint abnormalities in skeletal radiographs (5.22). Correlative analysis between speciality groups showed surgical and medical specialities were significantly different in their responses of two learning outcomes: basic knowledge about the contrast media benefits and risks (P= 0.01) and ability to select the most appropriate and the most cost‐effective methods of radiological investigations for clinical situations (P= 0.03). Acute specialities were not significantly different from the other two groups for these two learning outcomes. There was no statistically significant difference for other learning outcomes between the three speciality groups.     

Experience with video-assisted thoracoscopic surgery in the management of complicated pneumonia in children

PURPOSE: The aim of this study was to assess the impact of video assisted thoracoscopic surgery (VATS) in the management of empyema in children. METHODS: This report involves cases of complicated pneumonia in children requiring surgical intervention after failure of medical treatment with antibiotics, with or without drainage from November 1997 to October 1999. The impact of VATS has been studied prospectively from October 1998 when VATS was introduced. The results have been compared with the previous year when similar cases were dealt with open thoracotomy. These 2 groups of patients with VATS (V) or without VATS (O) were studied for their progress in hospital and the final outcome. RESULTS: A total of 39 immunocompetent children with community-acquired pneumonia were studied. There were 17 cases in O and 22 in V. There were 2 conversions to open thoracotomy in V. Both of these cases required resection of the lung parenchyma for severe necrosis and bronchopleural fistula. The mean age in years was 5.3 (O) and 4.9 (V). Parameters that were significantly less in V compared with O include timing of referral (O, 13.6 days; V, 5.3 days), number of lung resections (O, 8; V, 2), blood transfusion (O, 14; V, 2), analgesia requirements (O, 7.8 days; V, 2.9 days), postoperative length of stay in hospital (O, 10.4 days; V, 4.6 days), time to become normothermic (O, 5.6 days; V, 1.7 days); and time to removal of chest drains (O, 6.0 days; V, 2.7 days). Cosmesis is superior in cases of VATS compared with open thoracotomy. All the children recovered well on follow-up with resolution of symptoms and no recurrences. CONCLUSIONS: (1) VATS has ushered in a new era of hope for patients with complicated pneumonia. (2) Thoracotomy, lung resections, and the attending morbidity rate have decreased. (3) Patients are being referred earlier by the physicians because the management protocol is changing.     

The cost-effectiveness of opportunistic salpingectomy versus standard tubal ligation at the time of cesarean delivery for ovarian cancer risk reduction

Objectives

Opportunistic salpingectomy is a cost-effective strategy recommended for ovarian cancer (OvCa) risk reduction at the time of gynecologic surgery in women who have completed childbearing. We aimed to evaluate the cost-effectiveness of opportunistic salpingectomy compared to standard tubal ligation (TL) during cesarean delivery.

HEPARIN-REBOUND IN THE EARLY POSTOPERATIVE PHASE FOLLOWING CARDIOPULMONARY BYPASS

The incidence of the ‘heparin-rebound’ phenomenon after protamine neutralization of systemic heparinization required for cardiopulmonary bypass (CPB) was investigated. Heparin-effect was detected in 43% of patients studied at 2h, 31% at 4h, and 37% at 8h after reversal of circuit heparin on CPB. Heparin-rebound was shown to be associated with a small but significant increase in postoperative bleeding which was not of clinical importance.     

Utilizing prognostic and predictive factors in breast cancer

Opinion statement In order to make optimal treatment recommendations for patients with early-stage breast cancer, it is essential to accurately determine the patient’s underlying risk of disease recurrence and choose a therapy to which the individual is most likely to respond. Lymph node status, tumor size, histopathologic features including tumor type and grade, and hormone receptor status are well-accepted prognostic factors related to breast cancer. In addition, hormone receptor status is a very strong predictor of response to hormonal therapy. However, our currently accepted prognostic and predictive factors fall short and there is a critical need to more accurately identify those most likely to require or benefit from particular therapies. Attention has therefore focused on the determination of novel prognostic and predictive factors. The most promising new factor is the level of urokinase plasminogen activator and its inhibitor plasminogen activator inhibitor. Other putative factors include proliferative rate, the presence of lymphatic or vascular invasion, human epidermal growth factor receptor 2 (HER-2/neu or erbB-2) positivity, the presence of micrometastases in lymph nodes or bone marrow, and gene expression profile by microarray analysis, and by RNA-based methodology. Data regarding potential new prognostic factors are constantly emerging. These studies are frequently challenging to interpret as they are often retrospective, based on relatively small numbers of patients, include a mix of treated and untreated women, and often do not control for other known prognostic factors. Therefore, new data must be interpreted with caution.