Alpha-adrenergic agents in urinary disorders of the proximal urethra. Part II. Urethral obstruction due to "sympathetic dyssynergia".

Lower urinary tract obstruction in patients with neurological lesions can be due to "sympathetic dyssynergia". The obstruction can be at the level of the external sphincter. Phentolamine (i.v.) used during the voiding cystourethrogram helps to make the diagnosis. Phenoxybenzamine therapy produced improvement in 10 of 18 patients. As a rule, patients had to continue on the drug to maintain their response.     

Therapeutic management of sexual abuse allegations in custody and visitation disputes

Our experience is that in many cases, trying to assess the "truthfulness" or "falseness" of sexual abuse allegations that occur in the midst of custody and access disputes may not be possible. Instead therapeutic management of such cases is advocated. A case is presented in which sexual abuse was suspected because the recanting child displayed sexualized symptoms. Following a thorough assessment, which indicated that the child was abused, but could not confirm who the offender was, both the child and the mother were seen in psychotherapy on a regular basis. The father used counselling to achieve rights for visitations. The building of a therapeutic relationship allowed us to experiment with the situation to where we felt we could identify the potential offender who had to be kept away from the child. In addition, the therapeutic relationship enables this family to come to us to resolve their disputes rather than use the judicial system.     

Intravenous digital subtraction angiography: an index of collateral cerebral blood flow in internal carotid artery occlusion

The objective of this investigation was to correlate Xenon-133 inhalation rCBF measurements with the pattern of cortical arterial filling on intravenous DSA in 18 patients with unilateral internal carotid artery occlusion. Of 9 patients showing symmetrical filling of hemispheric cortical arteries, none showed an inter-hemispheric difference in rCBF ( delta Fg) greater than 10ml/100gm/min. Of 9 patients showing delayed cortical opacification ipsilateral to the internal artery occlusion, 3 showed a delta Fg greater than 10ml/100gm/min, 3 showed a delta Fg in the 7-10ml/100gm/min range, and 3 had a delta Fg less than 7ml/100gm/min. All patients with asymmetric abnormalities in the rCBF profile had the delayed pattern of cortical filling on DSA. The presence of symmetrical hemispheric opacification of cortical arteries on DSA indicates adequate interhemispheric redistribution of rCBF and patent inter-hemispheric collateral channels, but not necessarily normal cerebral blood flow. The presence of delayed cortical arterial opacification on the side of internal carotid artery occlusion does not necessarily imply significant inter-hemispheric rCBF differences, nor does it rule out a normal rCBF. The presence of bilateral reduction of rCBF and symmetrical cortical artery filling on DSA may represent an "interhemispheric steal".     

Someone should write a letter

Correspondence

Someone should write a letter     

Panniculitis in childhood and adolescence

Background: The purpose of the present paper was to describe the clinical manifestations and treatment of patients with panniculitis. Methods: From January 1983 to December 2002, 4294 patients were treated for pediatric rheumatological diseases at Pediatric Rheumatology Unit, University of São Paulo, Brazil. Of these, 35 children and adolescents (0.8%) presented with panniculitis: erythema nodosum (EN) or Weber–Christian disease (WCD). Clinical characteristics, laboratory exams, biopsy of the lesion, treatment and clinical course were studied. Results: Of the 35 patients, 29 presented with EN and six with WCD, one of these with cytophagic histiocytic panniculitis. Mean age at symptom onset was 85 months (6–204 months) and the mean duration of follow up was 55 months (1–144 months). All the patients presented with inflammatory subcutaneous nodules. The patients with WCD presented with systemic manifestations and cutaneous atrophy. The principal etiologies of EN were streptococcal infection (42%), undetermined (13.5%), pulmonary tuberculosis (10%), and acute rheumatic fever (10%). Biopsy of the nodules indicated septal panniculitis in 14 patients with EN and lobular panniculitis without vasculitis in the patients with WCD, one of which had cytophagic histiocytic panniculitis. There was recurrence in 11 patients (38%) with EN and in all those with WCD. Non‐steroidal anti‐inflammatory drugs were used in 15 patients with EN and corticosteroids and/or immunosuppressive drugs in the six patients with WCD. Three patients died. Conclusions: EN is the most frequent panniculitis, with a benign course and is mainly associated with infections. WCD is a severe disease, with systemic involvement, that proceeds with cutaneous atrophy and requires the use of corticosteroids and or immunosuppressive drugs.     

Diagnosis of pulmonary embolism: Ventilation perfusion scintigraphy versus helical computed tomography pulmonary angiography

The present study compared the accuracy of ventilation perfusion scintigraphy (VQS) and CT pulmonary angiography (CTPA) for the diagnosis of pulmonary embolism. This was a prospective observational study of 112 patients with suspected pulmonary embolism (PE) who could be studied with both investigations within 24 h. Results were compared to final diagnosis at completion of 6-month follow up, using receiver operating characteristic (ROC) analysis. Pulmonary embolism was diagnosed in 27 referred patients (24%). The sensitivity and specificity of VQS and CTPA were similar to that reported from the literature. A normal VQ scan had the highest negative predictive value (100%), while a high-probability VQ scan had the highest positive predictive value (92%). There was no overall difference (area under the ROC curve (AUC)) between VQS (AUC (95% CI) = 0.82 (0.75,0.89)) and CTPA (AUC = 0.88 (0.81,0.94)) for the diagnosis of PE. Among patients with abnormal chest X-rays, CTPA (AUC 0.90 (0.83,0.97)) appeared somewhat better than VQS (AUC 0.78 (0.68,0.88)) but this difference did not reach statistical significance. In this instance, CTPA is at least as accurate as VQS and may provide an opportunity to make alternative diagnoses.