Pheochromocytoma and paraganglioma: comparison of MR imaging with CT and I-131 MIBG scintigraphy

To ascertain the magnetic resonance (MR) imaging characteristics of pheochromocytomas and paragangliomas and to compare MR with computed tomography (CT) and iodine-131 metaiodobenzylguanidine (I-131 MIBG), 19 patients (18 with pheochromocytomas, one with a paraganglioma) were studied. The 18 patients with pheochromocytomas had had positive findings with I-131 MIBG scintigraphy. Abdominal pheochromocytomas were generally hypointense compared with normal liver on T1-weighted MR images and extremely hyperintense on T2-weighted MR images. MR imaging was preferable to CT in the evaluation of primary pheochromocytomas due to superior tissue characterization, particularly in the patient with hypertension and borderline catecholamine levels. For patients with recurrent or metastatic disease, the data suggest that I-131 MIBG scintigraphy is the examination of choice.     

In situ saphenous vein bypass grafts: angiographic evaluation and interventional repair of complications

In situ saphenous vein grafts are being used with increasing frequency for bypass procedures involving the femoral and popliteal arteries. Complications of these procedures include anastomotic stenoses and persistent arteriovenous fistulae that may result in failure of the graft. Balloon angioplasty and embolotherapy with detachable balloons were employed successfully in three or four recent cases of patients with complications from in situ grafts. Tailored angiography is essential for evaluating in situ grafts, and interventional techniques are extremely useful for managing complications.     

Evolution in the management of Hirschsprung��s disease in the UK and Ireland: a national survey of practice revisited

INTRODUCTION

The management of Hirschsprung’s disease continues to evolve. This questionnaire survey aimed to determine current surgical management strategies for Hirschsprung’s disease in Britain.

SUBJECTS AND METHODS

The survey was sent electronically to all British paediatric surgeons. Initial questions explored individual experience and regional service provision. Additional questions, reserved for surgeons who perform definitive Hirschsprung’s disease surgery, addressed specific clinical scenarios.

RESULTS

Surveys were sent to 142 surgeons yielding 85 responses. After exclusions, 64 surveys from 21 centres were analysed. Forty-seven respondents worked in centres with designated ‘Hirschsprung’s disease surgeons’. Forty respondents perform definitive Hirschsprung’s disease surgery. In a well neonate with left-sided Hirschsprung’s disease, 34 of 40 surgeons favour primary pull-through following bowel decompression with rectal washouts; 35 of 40 surgeons aim to perform definitive surgery at less than 3 months of age, with 17 favouring laparoscopic-assisted Soave–Boley and 15 favouring an open Duhamel pull-through. Of the 40 surgeons, 36 use a staged approach to right-sided/total colonic Hirschsprung’s disease with 23 favouring a Duhamel or Long Duhamel pull-through.

CONCLUSIONS

The primary pull-through, using an open Duhamel or laparoscopic-assisted Soave–Boley technique, during the first 3 months of life, has become the operative strategy of choice in rectosigmoid Hirschsprung’s disease in Britain. Marked variation in practice remains for right-sided Hirschsprung’s disease.     

Central pontine myelinolysis and its imitators: MR findings

The clinical, radiologic, and neuropathologic findings in 13 patients with central pontine myelinolysis were reviewed. Antemortem computed tomography (CT) had been performed in nine, and ante- or postmortem magnetic resonance (MR) imaging in 11. Chronic alcoholism or rapid correction of hyponatremia was present in over 75% of cases. One CT scan was positive, but only on retrospective review. In all but one patient, MR imaging eventually revealed an abnormality within the pons; in two patients the initial study was normal. The lesions varied in shape, with peripheral involvement in two patients and extrapontine involvement in four. The abnormality was smaller at 6-month follow-up in one patient and unchanged at 1 year in another. One patient never had a demonstrable pontine lesion but did have symmetric basal ganglia abnormalities, which were consistent with extrapontine myelinolysis. MR imaging disclosed similar central pontine alterations resulting from infarct, metastasis, glioma, multiple sclerosis, encephalitis, and radiation or chemotherapy; thus, such changes are not unique.     

Complicated vs uncomplicated mild traumatic brain injury: acute neuropsychological outcome

PRIMARY OBJECTIVE: The purpose of this study was to carefully examine the effects of a complicated vs uncomplicated mild traumatic brain injury (MTBI) on acute neuropsychological outcome. RESEARCH DESIGN: Participants were derived from an archival trauma database. This is a retrospective matched groups design. METHODS AND PROCEDURES: All patients were seen through a Head Injury Trauma Service clinical pathway. To be included, all patients must have undergone a day-of-injury CT scan and completed a small battery of neuropsychological tests within 2 weeks of injury. Patients were sorted into two groups on the basis of having a normal or abnormal CT scan. Patients were then carefully matched on age, education, gender and mode of injury (e.g. car accident, fall or assault). The final sample consisted of 100 patients, with 50 in each group. Main outcomes and results: The patients with complicated MTBIs performed significantly more poorly on some of the neuropsychological tests. However, the effect sizes were small or medium and the two groups could not be differentiated using logistic regression analysis. CONCLUSIONS: The reasons why people recover slowly or fail to recover fully from MTBIs remain poorly understood. Visible structural brain damage carries increased risk for slow and incomplete recovery, but certainly does not provide an explanation for good or poor outcome in the majority of patients.     

The effect of lengthening the gastrocnemius muscle in chronic therapy resistant plantar fasciitis

BackgroundThe aetiology of chronic therapy resistant plantar fasciitis (CTRPF) is multifactorial with more focus in recent times on the gastroc-soleus complex. This study evaluates the effect of lengthening the gastrocnemius muscle in CTRPF.MethodsAll patients with CRTPF complaints for at least one year underwent the same standard conservative treatment prior to surgery. 32 patients failed this treatment and underwent gastrocnemius recession. Silfverskiöld test, questionnaires and plantar pressure measurements were obtained at 5 visits.ResultsOne year follow up showed a significantly increase in dorsiflexion of the ankle (16 degrees), a decrease in VAS; 78 (SD: 19) to 20 (SD: 24) and significant improved functional scores. Plantar pressure measurements showed an increase of pressure under the medial proximal part of the midfoot and the 1 st metatarsal and a decrease under the hallux.ConclusionsA gastrocnemius recession results in a significant gain in dorsiflexion, altered loading of the foot and good clinical outcome in patients with CTRPF.Level of EvidenceLevel 2     

The spectrum of MR detectable cortical microinfarcts: a classification study with 7-tesla postmortem MRI and histopathology

Cerebral microinfarcts (CMIs) are common neuropathologic findings in aging and dementia. We explored the spectrum of cortical CMIs that can be visualized with 7T magnetic resonance imaging (MRI). Thirty-three coronal brain slices of 11 individuals with neuropathologically confirmed dementia were subjected to a high-resolution postmortem 7T MRI protocol. First, we identified all visible small (⩽5 mm) intracortical and juxtacortical lesions on postmortem MRI. Lesions were classified as CMI or nonCMI based on histology, and their MR features were recorded. Thirty lesions were identified on the initial MRI evaluation, of which twenty-three could be matched with histology. Histopathology classified 12 lesions as CMIs, all of which were located intracortically. On the basis of their MR features, they could be classified as chronic gliotic CMIs—with or without cavitation or hemorrhagic components—and acute CMIs. Eleven MRI identified lesions were not of ischemic nature and most commonly enlarged or atypically shaped perivascular spaces. Their MRI features were similar to gliotic CMIs with or without cavitation, but these ‘CMI mimics'' were always located juxtacortically. 7T postmortem MRI distinguishes different histopathologic types of cortical CMIs, with distinctive MR characteristics. On the basis of our findings, we propose in vivo rating criteria for the detection of intracortical CMIs.     

“Good Old Days” Bias Following Mild Traumatic Brain Injury

A small percentage of people with a mild traumatic brain injury (MTBI) report persistent symptoms and problems many months or even years following injury. Preliminary research suggests that people who sustain an injury often underestimate past problems (i.e., “good old days” bias), which can impact their perceived level of current problems and recovery. The purpose of this study was to examine the influence of the good old bays bias on symptom reporting following MTBI. The MTBI sample consisted of 90 referrals to a concussion clinic (mean time from injury to evaluation = 2.1 months, SD = 1.5, range = 0.8–8.1). All were considered temporarily fully disabled from an MTBI and they were receiving financial compensation through the Worker's Compensation system. Patients provided post-injury and pre-injury retrospective ratings on the 16-item British Columbia Post-concussion Symptom Inventory (BC-PSI). Ratings were compared to 177 healthy controls recruited from the community and a local university. Consistent with the good old bays bias, MTBI patients retrospectively endorsed the presence of fewer pre-injury symptoms compared to the control group. Individuals who failed effort testing tended to retrospectively report fewer symptoms pre-injury compared to those patients who passed effort testing. Many MTBI patients report their pre-injury functioning as better than the average person. This can negatively impact their perception of current problems, recovery from injury, and return to work.     

Conceptual issues specifically related to health-related quality of life in critically ill patients

During recent years increasing attention has been given to the quality of survival in critical care. Health-related quality of life (HRQOL) is an important issue both for patients and their families. Furthermore, admission to the intensive care unit can have adverse psychological effects in critically ill patients. Recent studies conducted in critically ill patients have measured HRQOL. However, usually absent from such reports are evaluations of conceptual issues, addressing factors such as why HRQOL should be measured in critically ill patients, how to define and standardize domains of HRQOL, whether proxies can provide useful information about HRQOL in critically ill patients, whether response shift occurs in critically ill patients, and whether post-traumatic stress disorder (PTSD) occurs in critically ill patients. Some studies reported moderate agreement between patients and their proxies, although lower levels of agreement may be reported for psychosocial or physical functioning. Response shift (adaptation and change in perception) appears to be an important phenomenon and likely to be present, but it is seldom measured when estimating HRQOL in critically ill patients. Furthermore, vigilance for symptoms of PTSD and early interventions to prevent PTSD are needed.