Sensitivity of Gd-DTPA-enhanced MR imaging of benign extraaxial tumors

The effect of gadolinium diethylenetriaminepentaacetic acid (DTPA) on the sensitivity of cranial magnetic resonance (MR) imaging was measured in a prospective blinded study. Twenty-two consecutive patients with benign extraaxial tumors underwent MR imaging on a 1.5-T system without and with intravenous administration of Gd-DTPA. Readers independently interpreted the unenhanced and enhanced images without clinical information. The interpretations were compared with the anatomically verified diagnoses. Gd-DTPA improved the sensitivity of MR imaging for benign extraaxial tumors, especially in cases of residual or recurrent acoustic neuromas, multiple tumors (e.g., neurofibromatosis), or inconclusive unenhanced MR images. Enhancement with Gd-DTPA impaired the identification of a skull base tumor.     

Philadelphia chromosome positive childhood acute lymphoblastic leukemia

In a 3-yr period, the Philadelphia chromosome (Ph1) was found in 4 of 43 children with acute lymphoblastic leukemia (ALL) in whom chromosomes were studied at diagnosis. The clinical, morphological, cytochemical, and immunologic findings in the Ph1-positive (PH1+) CASES WERE CONsistent with typical childhood ALL, indicating that identification of cases requires chromosome studies. A review of all reported cases of Ph1 + childhood ALL shows that Ph1 + patients are older and have higher initial platelet and white blood cell counts (WBC) than most children with ALL. However, a life table comparison between the reported cases of Ph1 + ALL in children and randomly selected age-, sex-, and WBC- matched controls with ALL shows the duration of first marrow remission to be significantly shorter (p less than 0.02) for the Ph1 + cases Ph1 + ALL is a distinct subtype of childhood ALL that is not rare and can be identified only by cytogenetic studies. The prognosis is poor. Cytogenetic studies should be done prospectively in a large group of children with ALL to define further the subgroup of patients and to confirm the findings of this retrospective analysis.     

Fatal airway obstruction caused by a mucous ball from a transtracheal oxygen catheter

A 50-year-old man with pulmonary fibrosis and COPD presented with worsening cough, dyspnea, chest pain, and hypoxemia of no readily apparent etiology, approximately four weeks after insertion of a transtracheal oxygen therapy catheter. Despite vigorous bronchial hygiene therapy, the patient died. Autopsy revealed obstruction of the trachea by a large mucous ball. We point out the nonspecificity of physical and radiologic findings associated with this condition and suggest that serial flow-volume loop analysis or earlier use of fiberoptic bronchoscopy might have been of assistance in premortem diagnosis of the mucous plug.     

Improving the Efficiency of Medical Respiratory Referrals in a District General Hospital

The British Thoracic Society's guidelines for the management of chronic obstructive pulmonary disease (COPD) state that there are few data to support or refute the use of chest physiotherapy in acute exacerbations of COPD. They suggest that pulmonary rehabilitation, inhaler education with technique assessment, nebuliser assessment and provision and intermittent positive pressure nasal ventilation in the acutely unwell should be available to patients within this classification. This paper presents the results of two audits performed to see if the efficiency of an in-patient chest clearance service could be improved to make time available for some of these developments.

Methods

Data of the numbers of referrals and treatment are routinely recorded by the respiratory physiotherapy team. These data were analysed retrospectively to compare oral referral with a request card system, and the origins and rate of inappropriate referrals.

Results

Changing the referral mechanism to one of request card from one of oral referral did not affect the referral rate. Forty per cent of all referrals were inappropriate. Doctors referred less often than their nursing colleagues but more accurately, 21 referrals compared to 56, with 90% appropriateness compared to 48% for nursing staff. A structure of senior-only assessment for new referrals decreased the number of treatments delivered per referral by 26%.

Conclusions

Structured referral and senior assessment improved the efficiency of the service and permitted extra servies to be developed.     

Inverted Y ureter anomaly and associated distal yo-yo phenomenon

Duplication of the distal ureter is a very rare anomaly. A case is reported here in which the lower ectopic limb of the duplicated distal ureter presents with a ureterocele, and shows a different pattern of backflow.     

Survey of difficult to contain and treat children and adolescents

Child psychiatrists and paediatricians are faced by a number of disturbed children and adolescents who become a major treatment challenge due to a combination of their dangerous and/or disruptive behaviour and the unavailability of resources. Paediatricians and psychiatrists in one regional health area were questioned about the number of such children and adolescents under 18 years of age seen over a 20 month period. The response rate was 44% (86/194 specialists approached). A total of 72 children and adolescents were identified. For a health district with a total population of 200,000, this represents nearly five children (about one of these identified by paediatricians and one with associated learning disability). The majority of cases were adolescents with chronic problems (over one month's duration) but most cases reported by paediatricians were acute in preadolescents. Conduct disorders, autistic spectrum, and psychotic disorders were the most common clinical problems. Seriously disruptive behaviour had been present in two thirds and marked problems with behaviour that was a physical risk to others and to the self were present in over half and nearly a third of cases respectively. Services had been universally stretched by these children's difficulties. Clinicians thought the needs of these children would have been best met either through psychiatric day hospital type facilities or in combined paediatric/child psychiatric inpatient units.