Dynamic gadolinium-enhanced MRI in the detection of spinal arteriovenous malformations

Arteriovenous fistulae and malformations (AVFs and AVMs) of the spinal cord are rare, potentially treatable causes of progressive disability. Although a variety of MRI abnormalities has been described, the diagnosis rests on the findings on selective spinal angiography.Collecting T2^*-weighted MR images during the passage of a gadolinium bolus gives information about perfusion and blood volume. We carried out dynamic MRI in seven patients with vascular abnormalities (5 dural AVFs, 1 intramedullary AVM, 1 cryptic angioma) and in two patients without an AVM. High resolution T1- and T2-weighted sagittal images of the whole spinal cord were first obtained using a multiarray receiver coil. Sagittal radiofrequency spoilt gradient echo images (GE34/25, flip angle 10⁰) were then obtained during bolus injection of gadolinium-DTPA. Abnormalities were seen in all seven patients with AVFs or AVMs. In the patient with an intramedullary AVM and four of the five with dural AVFs transient signal reduction was seen within the perimedullary venous plexus during passage of the bolus. The findings correlated well with those from selective spinal angiography. We conclude that dynamic MRI offers a useful adjunct to angiography and may localise an arteriovenous shunt when conventional MRI fails to do so. In combination with high-resolution imaging of the entire spinal cord the technique may make myelography redundant; it is simple, well tolerated and can be carried out without significant time penalty.     

Septic discitis resulting from Escherichia coli urosepsis.

Septic discitis refers to a primary suppurative process involving the intervertebral disc space and occurs as a result of hematogenous invasion or contamination by pyogenic organisms. A case of septic discitis is described in a 77-year-old woman following an episode of Escherichia coli urosepsis. Despite bed rest, an orthosis, and appropriate antibiotics, the patient ultimately had to undergo surgical disc removal. The diagnosis of septic discitis is often made in the context of other diseases that share common clinical and laboratory findings. Magnetic resonance imaging appears well suited for diagnostic confirmation of septic discitis. Needle biopsy and aspiration results should be used to determine the appropriate choice of antibiotic for this disease process.     

Experience with the endorectal ileal pullthrough with lateral reservoir for ulcerative colitis and polyposis

Since 1977, 184 patients with colitis or polyposis underwent colectomy with endorectal ileal pullthrough in two stages with a temporary ileostomy. Five had an S reservoir, three had a J reservoir, and 15 had no reservoir; 97 patients had a lateral reservoir constructed at the second operation and 64 had one constructed at the first operation. Ten patients with no reservoir and one with a J reservoir underwent conversion to a lateral reservoir because of stool frequency. Three patients with an S reservoir and six (3.5%) of 172 patients with a lateral reservoir underwent a permanent ileostomy. Over 65% of complications occurred in the first 50 patients. Late reservoir shortening was necessary in 34 patients. Of the last 110 patients, 107 are functioning well with a mean of six bowel movements per day. A short lateral reservoir (less than 15 cm) constructed at the first operation produces the fewest complications and best results.     

Evaluating podiatry services: Testing a treatment specific measure of health status

This study reports on the preliminary testing of a new measure designed for use alongside EQ-5D in evaluating outcomes in podiatry: the Podiatry Health Questionnaire (PHQ). Individuals aged 18 years or more, receiving podiatry services in clinic or domicilliary locations across four NHS Trusts in Yorkshire and Humberside UK took part in a questionnaire survey. Respondents reported high levels of problems on all six PHQ dimensions. Correlations suggested that the PHQ and EQ-5D were measuring distinct constructs. The levels on each dimension were well defined in terms of self-rated morbidity on the PHQ visual analogue scale (PHQ_vas) and the EQ-5D_vas, although PHQ_vas appeared to be slightly more sensitive to changes in health on the dimensions. There was a strong relationship between clinicians' Podiatry Clinical Score rating and reported symptoms for four out of six PHQ dimensions and PHQ_vas. The PHQ was able to distinguish respondents in terms of their self-reported morbidity in EQ-5D and in terms of their morbidity as assessed by clinicians. It is suggested that the respondent completed PHQ appears to be a useful new measure for assessing foot-related health. However, further investigation of the psychometric properties of the measure is required.     

Controlled investigation of the amobarbital interview for catatonic mutism.

OBJECTIVE: Clinical reports over the last 60 years suggest that the amobarbital interview is effective in relieving catatonic symptoms. This has never been substantiated with methodologically sound trials. The authors postulated that a randomized blind comparison of intravenous amobarbital and saline would demonstrate the superiority of amobarbital in relieving catatonic mutism. METHOD: The subjects were 20 inpatients with catatonic mutism. They were randomly assigned to either saline (N = 10) or a 5% amobarbital solution (N = 10), and the infusions were administered intravenously at a rate of 1 cc/min or less over 10 minutes by a blinded physician. A second blinded physician administered a semistructured interview during the infusion to control for the effect of suggestion. A third blinded physician rated patient responsiveness, reactivity, and arousal. Any patient who was unresponsive to the initial infusion was crossed over to the other infusion. Interviews were videotaped for determination of interrater reliability. RESULTS: In the initial infusions, six of 10 patients responded to amobarbital and zero of 10 responded to saline. Four of the saline nonresponders responded when given amobarbital. Response was evident by the 4th minute of the amobarbital infusion. Interrater reliability was high. The responders and nonresponders differed significantly in the variance of the weight-adjusted amobarbital dose, and the responders tended to be older and female. CONCLUSIONS: Intravenous amobarbital is superior to saline in relieving catatonic mutism, although only 50% of these patients responded. The nonresponders were distinguished from the responders by a greater variance in the weight-adjusted dose of amobarbital.     

Coexisting Endogenous and Exogenous Llpold Pneumonia and Pulmonary Alveolar Proteinosis in a Patient with Neurodevelopmental Disease

We report a unique case of coexistingexogenous lipoid pneumonia, endogenous lipoid pneumonia (EU), and pulmonary alveolar proteinosis (PAP) in a 5-year-old patient with severe neurodevelop mental disease. The patient presented with gastroesophageal reflux and presumed chronic lung disease resulting from recurrent aspiration pneumonias and succumbed to respiratory failure. The autopsy showed lipid-laden macrophages and periodic acid-SchiJf9ositive granular matm'al i n alveolar spaces and multilamellated structures within both alveolar macrophages and extracellular debris.

These findings were similar to those in previous reports of coexisting E I P and PAP in the setting of gastroesophageal refux [I] . However, the present case diJfered by the presence of scattered large osmiophilic extracellular lipid vacuob. Besides strengthening the association between EIP and PAP and their relationship to gastroesophageal refux, this case suggests that t h q may arise together with exogenous lipoid pneumonia, through related mechanisms, in the setting of neurodevelopmental disease.