Primary uretero-iliac fistula: the unusual source of haematuria

Uretero-iliac fistula is a rare cause of frank haematuria. The aetiology of such fistula is commonly iatrogenic. We present a unique case of a primary aorto-iliac fistula in the absence of an aneurysm or arteriovenous malformation. The diagnosis was demonstrated by ureteroscopy and real-time retrograde ureterogram. Multiple arterial embolisation of the fistula had failed, and the patient underwent a successful ureterolysis and ligation of fistula. We demonstrate the diagnostic difficulties and treatment dilemma of such rare cause of haematuria.     

Is there a GP in the hospital?

Modern health care is increasingly complex with a progression to specialisation and super specialisation in the primary and tertiary settings. Traditional models of health such as the biomedical model are often inadequate. The value of a more holistic approach to patients' health problems has been long accepted by the medical profession. As health care becomes more fragmented we are overlooking the potential benefits of a generalist approach in improving the care of patients in our hospitals. This article examines the potential benefits of involving general practitioners in the tertiary care setting.     

MR Quantitative Susceptibility Imaging for the Evaluation of Iron Loading in the Brains of Patients with β-Thalassemia Major

BACKGROUND AND PURPOSE:Patients with β-thalassemia require blood transfusion to prolong their survival, which could cause iron overload in multiple organs, including the heart, liver, and brain. In this study, we aimed to quantify iron loading in the brains of patients with β-thalassemia major through the use of MR quantitative susceptibility imaging.MATERIALS AND METHODS:Thirty-one patients with thalassemia with a mean (± standard deviation) age of 25.3 (±5.9) years and 33 age-matched healthy volunteers were recruited and underwent MR imaging at 3T. Quantitative susceptibility images were reconstructed from a 3D gradient-echo sequence. Susceptibility values were measured in the caudate nucleus, putamen, globus pallidus, red nucleus, substantia nigra, dentate nucleus, and choroid plexus. General linear model analyses were performed to compare susceptibility values of different ROIs between the patients with thalassemia and healthy volunteers.RESULTS:Of the 31 patients, 27 (87.1%) had abnormal iron deposition in one of the ROIs examined. Significant positive age effect on susceptibility value was found in the putamen, dentate nucleus, substantia nigra, and red nucleus (P = .002, P = .017, P = .044, and P = .014, respectively) in the control subjects. Compared with healthy control subjects, patients with thalassemia showed significantly lower susceptibility value in the globus pallidus (P < .001) and substantia nigra (P = .003) and significantly higher susceptibility value in the red nucleus (P = .021) and choroid plexus (P < .001).CONCLUSIONS:A wide range of abnormal susceptibility values, indicating iron overloading or low iron content, was found in patients with thalassemia. MR susceptibility imaging is a sensitive method for quantifying iron concentration in the brain and can be used as a potentially valuable tool for brain iron assessment.

Beta-thalassemia major is a disease caused by genetic defects that lead to reduced production of hemoglobin. The patients require blood transfusion to prolong their survival, which could cause iron overload in multiple organs, including the heart, liver, and brain.¹ Iron chelation therapy is administrated to clear the excess iron. Whereas iron overload in the heart and liver may cause death, alterations of iron content in the brain may contribute to cognitive impairment, as observed in some patients with thalassemia,^2,3 which has not been found to correlate with age and blood ferritin levels. Accurate assessment of iron content in the brains of patients with thalassemia could provide valuable information for individualized patient treatment. Conventionally, MR relaxometry on the basis of methods that use T2 and T2* mapping has been used to quantify iron in the brain.⁴ Recently, the application of measuring brain iron by use of phase value of MR imaging with SWI^5,6 and quantitative susceptibility mapping (QSM)^7–12 has been evaluated for the quantification of iron content in patients with Parkinson disease.¹³ QSM is an MR imaging technique that measures the magnetic susceptibility of tissues, such as blood or iron content, through mathematically modeling their induced effects on the phase of signal. Although the derivation of a magnetic susceptibility image from the phase information obtained from MR imaging is an ill-posed problem, techniques have been established to overcome this by imposing smoothness or sparseness constraints on the susceptibility images.^9–11 QSM has been successfully applied in multiple sclerosis, Parkinson disease, and so forth. A recent study¹⁴ has also established positive correlation between magnetic susceptibility values measured by use of QSM and iron content measured by x-ray fluorescence imaging and inductively coupled plasma mass spectrometry. In the present study, we quantified the brain iron content in a cohort of patients with β-thalassemia major and compared this with healthy age-matched subjects. We hypothesize that there are significant differences in iron loading between patients with thalassemia and healthy control subjects as measured by QSM.     

Oestrogen-soaked vaginal packing for decubitus ulcer in advanced pelvic organ prolapse: a case series

Introduction

Cervicovaginal decubitus ulceration is a well-known complication of advanced pelvic organ prolapse (POP). There is no consensus for its management. This case series describes the outcome of using repeated vaginal packs soaked with oestrogen cream to reduce POP and promote decubitus ulcer healing. We aimed to investigate the speed of ulcer healing and endometrial safety with this regimen.

Methods

This was a retrospective study of patients with stage 3 or 4 POP and intact uterus with decubitus ulcer who were planned for surgery that included hysterectomy after ulcer healing. Vaginal packs are replaced at least biweekly—or more frequently if extruded—until ulcer resolution.

Results

Thirteen patients were studied. Mean age was 69?±?6 years and mean duration of menopause was 19?±?6 years. Nine patients had a single ulcer and four had multiple ulcers. Mean ulcer diameter was 2.8?±?1.5 cm and mean duration for ulcer healing was 26?±?14 days. Hysterectomy and pelvic floor reconstruction was performed a median of 5 (range 0–153) days after ulcer healing was first noted. Histopathological examination of the endometrium following hysterectomy showed three specimens with endocervical hyperplasia; one had concurrent proliferative endometrium, two had simple endometrial hyperplasia and another two had proliferative endometrium.

Conclusion

Oestrogen-soaked vaginal packing is a viable option for managing a decubitus ulcer in advanced POP. We document a measurable impact on the endometrium with this short-term preoperative regimen. Further research is needed to evaluate its efficacy in promoting ulcer healing and endometrial safety.

     

Excess risk of hip fractures attributable to the use of antidepressants in five European countries and the USA

Summary

The association between antidepressant use and hip fracture remains unclear. We conducted a systematic review to estimate Population Attributable Risks (PAR) for France, Germany, Italy, Spain, UK, and the USA. We report a heterogeneous prevalence of antidepressant use and related PARs, both lowest for Italy and highest for the USA.

Introduction

Antidepressant use has been associated with an increased hip fracture risk in observational studies. However, the potential contribution of antidepressant consumption on the population rate of hip fractures has not been described. Our aim was to estimate the impact of the use of different classes of antidepressants on the rate of hip fracture at a population-level in France, Germany, Italy, Spain, the UK, and the USA.

Methods

We conducted a systematic literature review to estimate the pooled relative risk (RR) of hip fracture according to use of antidepressants. Prevalence rates of antidepressant use (Pe) in 2009 were calculated for each country using the The Intercontinental Medical Statistics database and three public databases from Denmark, the Netherlands, and Norway. Both the RR and Pe were used to calculate PAR of hip fractures associated with antidepressant use.

Results

The literature review showed an increased risk of hip fractures in antidepressant users (RR, 1.7; 95 % confidence interval (CI), 1.5–2.0). Rates of antidepressant use showed considerable differences between countries, ranging from 4.4 % (Italy) to 11.2 % (USA) in the year 2009. The estimated PAR of antidepressants on hip fracture rates were 3.0 % (95 % CI, 2.0–4.1; Italy), 3.1 % (95 % CI, 2.1–4.3; Germany), 3.8 % (95 % CI, 2.6–5.3; France), 4.8 % (95 % CI, 3.3–6.5; Spain), 4.9 % (95 % CI, 3.4–6.8; UK), and 7.2 % (95 % CI, 5.0–9.9; USA). PARs differed for different types of antidepressants, with highest attributable risks for selective serotonin reuptake inhibitors.

Conclusions

These findings suggest that the potential contribution of antidepressant use to the population rate of hip fractures in the five large EU countries and the USA varies between 3 and 7 %.