Prognostic value of dynamic MRI in assessing post-traumatic femoral head vascularity

Objective  The vascular status of femoral heads in the post-traumatic period of intracapsular femoral neck fracture (ICFNF) remains uncertain until the patient actually develops avascular necrosis (AVN). Several methods for predicting the viability of femoral head have been reported, that are not effective or widely used because of unreliability, potential complications, and technical difficulties. The present study involved the use of Dynamic MRI (DMRI) in assessing femoral head vascularity to predict AVN. Materials and methods  The role of DMRI was studied prospectively in 30 patients with 31 ICFNF. Fractures were divided in to three types (Type A, B, or C) based on the femoral head vascularity shown by dynamic curve patterns on MRI evaluation. Type A was preserved vascularity, Type B was some decrease in vascularity but still viable while Type C was significantly reduced vascularity. These were followed-up for 6 months to 2 years to observe the final outcome in terms of union, non-union, or AVN. Results  We found that Type A curves correlate well with vascular status and Type C curves correlate well with poor vascularity of the femoral heads. No AVN was seen in any of Type A (13/31) or Type B (eight out of 31). Five cases showed AVN and all of them were of Type C dynamic curves. Conclusion  Dynamic MRI is a reliable tool to evaluate vascularity of femoral heads and thus reduces the uncertainty of outcome of treatment of ICFNFs. DMRI can be a useful tool to formulate a treatment algorithm in management of ICFNF.     

Lung lesions in children with Crohn's disease presenting as nonresolving pneumonias and response to infliximab therapy

Lung lesions in children with Crohn's disease are often difficult to diagnose and treat. We report here 3 children (aged 13, 14, and 17 years) on immunosuppressive therapy for previously diagnosed Crohn's disease who presented with nonresolving pneumonias. All 3 had unfavorable response to empiric antibiotics and had progression of lesions. Cultures of sputum and blood did not yield any organisms. Subsequent lung biopsies revealed noncaseating granulomas with giant cells in 2 subjects and bronchiolitis obliterans with organizing pneumonia in the third. All patients were treated with infliximab, a novel anti-tumor necrosis factor monoclonal antibody, and showed rapid clinical and radiologic response. We emphasize that a high index of suspicion for noninfectious etiologies needs to be maintained in patients with Crohn's disease who present with lung lesions to ensure timely intervention. Infliximab therapy seems to be effective and well tolerated in such patients.     

Cancellation of elective oral and maxillofacial operations

Our aim was to assess whether the Commission for Health Improvement Performance Indicator value of 0.5% of cancellations on the day of operation or less had been achieved. We reviewed 912 consecutive elective operations, both day case and inpatient over an 8-month period (January–August 2003). A total of 117 procedures (13%) were cancelled for non-clinical or logistical reasons, of which 39 (4%) were cancelled on the day of the operation. Only 3 of the 39 patients who wanted a new admission date within 28 days of cancellation could not be accommodated. The performance indicator value of 0.3% was below the target threshold. An additional 60 (7%) patients had their admissions cancelled the day before operation and 18 (2%) had their operations deferred for a day before they were cancelled. However, these patients have been specifically excluded from the performance indictor.     

Irreversible inhibition by acetaldehyde of cholecystokinin-induced amylase secretion from isolated rat pancreatic acini

Acetaldehyde inhibited both amylase secretion induced by maximal concentrations (300 pM) of cholecystokinin octapeptide and the binding of radioiodinated cholecystokinin to receptors on isolated rat pancreatic acini. This inhibition was concentration dependent (10 mM to 1 M for amylase secretion and 100 mM to 1 M for binding). However, a correlation between the two inhibitory effects could not be obtained. Furthermore, the inhibitory effects were not reversible. Acetaldehyde did not alter the basal amylase secretion between 6 and 45 mM concentrations. However, 60, 100 and 300 mM acetaldehyde significantly decreased basal amylase secretion; no significant change in amylase secretion was observed at 600 mM and 1 M. Higher concentrations of acetaldehyde produced a 2- to 10-fold increase in basal amylase secretion. 51Cr release from prelabeled acini revealed no significant cell membrane damage between 10 and 600 mM acetaldehyde. These data suggest that acetaldehyde inhibition of cholecystokinin-induced amylase secretion is intracellularly mediated.     

Reversal by glucose of pancreatic amylase insufficiency in chronic alcoholic rats

Carbohydrate consumption regulates pancreatic amylase synthesis in rats. The Lieber-DeCarli 36% alcohol diet employed in chronic alcohol studies and the isocaloric control diet contain 11 and 47% of total calories from carbohydrates, respectively. Young rats fed ad libitum the 36% ethanol diet for 2 weeks obtained 1.2 g/day of carbohydrate, whereas those pair-fed with control diet received 5.8 g/day. Rats fed the 36% ethanol diet and given an intramuscular injection of a solution of 1.5 g of glucose daily for 2 weeks received twofold greater amounts of carbohydrate than saline-injected controls (2.7 versus 1.2 g). These changes in carbohydrate intake produced proportionate changes in pancreatic amylase levels. The secretory responses to cholecystokinin-octapeptide (CCK8) of acini from control and glucose-injected rats were significantly higher compared with those in the saline-injected or noninjected alcohol groups. The blood alcohol levels in glucose-injected rats were markedly reduced compared with other alcohol groups (71.7 versus 274.9 mg/dl) despite similar amounts of ethanol ingestion daily (2.4 g) in the three groups. In vitro experiments with acini from rats fed a nutritionally optimal diet revealed that high pharmacologic concentrations of ethanol, while inducing basal secretion, inhibited CCK8-stimulated amylase secretion. These results indicate that: (a) the amount of alcohol consumption does not correlate with either the levels of blood alcohol or of pancreatic amylase; (b) the carbohydrate availability in rats regulates pancreatic amylase levels despite significant levels of alcohol in blood; (c) blood alcohol levels observed in vivo may not affect synthetic and secretory processes of amylase in pancreatic acini.     

Bacterial tracheitis in children.

We examined the records of 14 patients aged 7 months to 10 1/4 years who were treated for bacterial tracheitis from May 1982 to December 1987; the management protocol for 13 of the patients included the use of nasotracheal intubation. The infection was caused by Staphylococcus aureus in seven, Haemophilus influenzae in three, Branhamella catarrhalis in one and Streptococcus pneumoniae in one. Both H. influenzae and B. catarrhalis were isolated in another patient, and no organism was found in the remaining patient. In addition to the bacteria, viruses were cultured from the tracheal secretions of two patients. The mean duration of intubation was 7.6 days and of hospital stay 9.2 days. Twelve of the cases occurred during the cold months of the year (October to March). Of the three deaths only one occurred in the pediatric intensive care unit and was due to severe bronchospasm and an air leak that caused bilateral pneumothorax and pneumomediastinum. In one patient subglottic stenosis developed that necessitated tracheostomy. Healing began 5 to 9 days after the onset of symptoms, as demonstrated with the use of repeated fibreoptic bronchoscopy. We found that the airway could be safely managed with the use of a nasotracheal tube. Bronchoscopy helped to confirm the diagnosis, to remove adherent secretions and to monitor the course of the disease. The ventilation tube can be removed after the patient's temperature returns to normal, if there is an air leak around the tube, if the quantity and viscosity of the secretions decrease and if healing is observed at bronchoscopy.     

Giant broad ligament leiomyoma.

Giant fibroids are known to arise from the uterus, but occasionally from the broad ligament also. A case of giant broad ligament fibroid is reported for its rarity, and the diagnostic difficulties it posed are discussed.