Magnetic resonance imaging of the femoral head after acute intracapsular fracture of the femoral neck

In fifteen patients who had a subcapital fracture of the femoral neck (twelve displaced fractures and three non-displaced fractures), magnetic resonance imaging of the femoral head was done with two-dimensional Fourier transform spin-echo technique within forty-eight hours of injury. The magnetic resonance image did not show avascular necrosis of the femoral head in any of the patients. In eleven patients, there was a decreased signal at the base of the femoral head, immediately adjacent to the fracture. This decreased signal corresponded to a recognized band of necrosis and hemorrhage next to the site of the fracture and was not related to the viability of the femoral head. No other changes were seen on the images. We concluded that this type of magnetic resonance imaging is inadequate to determine the viability of the femoral head within forty-eight hours after a patient sustains an acute intracapsular fracture of the femoral neck.     

Assessment of instability of the long head of the biceps tendon by MRI

Objective. To determine whether MRI can identify instability of the long head of the biceps tendon (LBT) in the rotator interval. Design and patients . A retrospective review was carried out of 19 patients, all arthroscopically examined, nine of whom had surgically confirmed instability of the LBT. Results. A LBT perched on the lesser tuberosity correctly indicated all nine cases of instability with one false positive. In six of seven cases where the LBT was oval in shape, no instability of the biceps tendon existed, whereas LBT instability was present in eight of 12 patients with a flat long head of the biceps tendon. In seven of eight acutely angled intertubercular sulci there was no instability of the LBT while eight of 11 obtusely angled sulci were associated with LBT instability. By consensus impression, instability of the LBT could be determined with 67% sensitivity, 90% specificity, 86% positive predictive value, and 75% negative predictive value. Conclusions. A flat LBT perched on the lesser tuberosity with an obtusely angled intertubercular sulcus suggests the diagnosis of instability of the LBT in the correct clinical setting. Received for publication: 3 May 2000 Revision requested: 2 July 2000 Revision received: 27 September 2000 Accepted: 27 November 2000     

Spironolactone as a single agent for long-term therapy of hirsute patients

OBJECTIVE: To assess the androgen-suppressing effect of spironolactone, and the use of this drug as a single agent in the long-term therapy of hirsute patients with either polycystic ovary syndrome (PCOS) or idiopathic hirsutism (IH). Standard cyproterone acetate (CPA) treatment was used to evaluate the results obtained with spironolactone. DESIGN: Prospective randomized study. PATIENTS: Forty-six hirsute women were separated randomly into two groups, stratified for polycystic ovary syndrome. For 12 months, Group 1 (21 patients, 10 PCOS) received spironolactone only (200 mg/day). Group 2 (23 patients, nine PCOS) received CPA (50 mg/day) with ethinyl oestradiol (35 microgram/day). MEASUREMENTS: Ferriman-Gallwey clinical score for hirsutism and serum testosterone, androstenedione, and LH levels. RESULTS: In IH patients, hirsutism regressed equally with spironolactone (21 +/- 2-14.5 +/- 2) and CPA (23 +/- 2-13 +/- 2). In PCOS patients, the mean score for hirsutism after 12 months was significantly lower with CPA (12 +/- 1) than with spironolactone (16 +/- 1). Testosterone levels did not change with spironolactone; with CPA there was a decrease from baseline in PCOS (47% and 51%, 6 and 12 months) and IH patients (31% and 30%). Androstenedione levels also declined from baseline in CPA-treated PCOS patients (38% and 39%, 6 and 12 months). Androgen levels were significantly different between the groups after 6 and 12 months. LH levels decreased with CPA (72%) but not with spironolactone. CONCLUSION: Our results suggest that spironolactone used as a single agent is as effective as cyproterone acetate combined with oestradiol for long-term treatment of patients with idiopathic hirsutism. In PCOS patients, spironolactone is still effective for reducing hirsutism; however, for treatment of the hormonal or metabolic manifestations associated with PCOS, it may be necessary to combine spironolactone with either an antigonadotrophic agent or a drug that improves peripheral insulin sensitivity.     

Prostatic disorders: MR imaging at 1.5 T

Pelvic magnetic resonance (MR) images obtained at 1.5 T of 31 men with known genitourinary disease were reviewed retrospectively. In most, peripheral and central prostatic zones could be seen on axial images obtained with long repetition times/echo times (TRs/TEs). The prostate had no specific signal intensity that enabled differentiation between benign and malignant changes. Each patient with known extracapsular prostatic carcinoma had a peripheral zone defect--1 cm or greater in diameter with ill-defined borders and relatively lower signal intensity than that of the remainder of the peripheral zone--that correlated with the site of clinical-pathologic involvement. Correlation of a peripheral zone defect on long TR/TE images as a sign for extracapsular spread of prostatic cancer was 100% sensitive, yet 54% specific, with excellent interobserver agreement. Stage A2 and B1 prostatic carcinoma was not detected. Benign prostatic hyperplasia was seen as centrally located proliferation and nodularity, usually with discrete margins and a wide spectrum of low- to high-signal-intensity features. MR imaging may have a role in differentiating between intracapsular and extracapsular prostatic carcinoma.     

MR imaging of marrow changes adjacent to end plates in degenerative lumbar disk disease

MR studies of the lumbar spine in 41 patients were analyzed at 203 disk interspaces to assess the appearance and frequency of bone marrow signal changes in the vertebral bodies adjacent to normal and degenerated disks. Degenerative changes were found at 58 interspaces; an abnormal bone marrow signal was identified in 29 (50%) of these. On spin-echo pulse sequences with short and long repetition times (TRs) and echo times (TEs), an area of relative increased signal intensity was seen in the vertebral body adjacent to the disk in 24 cases (17 were bandlike on both sides of the disk, four were focal on one side of the disk, and three were bandlike and focal on one or both sides of the disk). In one patient decreased signal was noted on both short and long TR/TE imaging. In the other four patients decreased signal was noted on short TR/TE pulse sequences and increased signal was evident on long TR/TE. These marrow changes were not present adjacent to normal disks. The relatively high signal intensity on both short and long TR/TE pulse sequences suggests that the increased signal resulted from the conversion of normal hemopoietic bone marrow to fatty marrow. We conclude that bandlike or focal areas of high signal intensity in the bone marrow adjacent to degenerated intervertebral disks occur commonly on MR images of the spine and must not be confused with signal changes from tumors or infections involving the disk space and adjacent vertebral end plates.     

Imaging of the renal arteries: value of MR angiography

We compared the efficacy of MR angiography with that of conventional angiography for visualizing the renal arteries and detecting renovascular disease. Thirty-three MR angiographic studies, consisting of axial two-dimensional (2-D) phase-contrast, coronal 2-D phase-contrast, and coronal 2-D time-of-flight acquisitions, were performed within 48 hr of conventional arteriography. The studies were done to evaluate possible renovascular hypertension (n = 25) or potential donor nephrectomy (n = 8). The three MR image sets were interpreted independently, in random order by three observers, with regard to the number of renal arteries, degree of vessel visualization, arteriovenous overlap, and presence of renovascular disease. A fourth interpretation was based on the combined axial and coronal phase-contrast image sets. Evaluation was limited to the proximal 35 mm of each renal artery. Renal artery visualization and detection of renovascular disease were more complete with coronal phase-contrast (80% sensitivity, 91% specificity) than with time-of-flight (53% sensitivity, 97% specificity) images. Combined axial and coronal phase-contrast images permitted visualization of the proximal 35 mm of all dominant renal arteries and detection of 13 of 15 stenoses (87% sensitivity, 97% specificity). Our data suggest that biplanar MR angiography has considerable potential as a noninvasive screening technique for the evaluation of renovascular disease.     

Five years of cefotaxime use in a neonatal intensive care unit

In 1983 our antibiotic regimen for suspected neonatal septicemia was changed from amoxicillin-gentamicin to cefotaxime-amoxicillin. During the subsequent 5-year period we studied the effect of this change in regimen on the bacterial flora of the infants in the unit and the occurrence of serious infections. This was done with bacteriologic surveillance and analysis of the positive blood cultures from 1978 through 1987. A change in the relative numbers of isolated pathogens was observed; Klebsiella sp. and Escherichia coli decreased whereas Enterobacter sp. increased. The susceptibility of the Enterobacter isolates to cefamandole decreased from 85.3% in 1982 to 52.9% in 1983. The susceptibility of these bacteria to cefotaxime was 55.2% in 1983 and 55.0% in 1987. No change in susceptibilities to cefotaxime, amoxicillin or gentamicin was found in other pathogens. Although colonization with Enterobacter strains has increased and the susceptibility of these bacteria to the cephalosporins has decreased, the incidence of serious infections with Gram-negative bacteria decreased.     

Development of physical and mental health summary scores from the patient-reported outcomes measurement information system (PROMIS) global items

Background  The use of global health items permits an efficient way of gathering general perceptions of health. These items provide useful summary information about health and are predictive of health care utilization and subsequent mortality. Methods  Analyses of 10 self-reported global health items obtained from an internet survey as part of the Patient-Reported Outcome Measurement Information System (PROMIS) project. We derived summary scores from the global health items. We estimated the associations of the summary scores with the EQ-5D index score and the PROMIS physical function, pain, fatigue, emotional distress, and social health domain scores. Results  Exploratory and confirmatory factor analyses supported a two-factor model. Global physical health (GPH; 4 items on overall physical health, physical function, pain, and fatigue) and global mental health (GMH; 4 items on quality of life, mental health, satisfaction with social activities, and emotional problems) scales were created. The scales had internal consistency reliability coefficients of 0.81 and 0.86, respectively. GPH correlated more strongly with the EQ-5D than did GMH (r = 0.76 vs. 0.59). GPH correlated most strongly with pain impact (r = −0.75) whereas GMH correlated most strongly with depressive symptoms (r = −0.71). Conclusions  Two dimensions representing physical and mental health underlie the global health items in PROMIS. These global health scales can be used to efficiently summarize physical and mental health in patient-reported outcome studies.