Percutaneous drainage access: a simplified coaxial technique

We describe an access technique that we have used in 150 nephrostomy and biliary drainage procedures and for access to some abscesses and viscera. The system provides safe coaxial access with a 22-gauge removable hub needle, which then acts as a guide wire and is replaced by an 18-gauge cannula. A major advantage is that only one guide wire is used (0.038-inch) for the entire drainage procedure. No significant complications have occurred to date with this method.     

Percutaneous cholecystography in children

Percutaneous cholecystography was performed on 13 children who had biliary system abnormalities: two had biliary hypoplasia, five had sclerosing cholangitis, three had cirrhosis, two had distal choledochal obstruction, and one had an obstructed portoenterostomy. In 12 patients transcholecystic cholangiography showed, without significant complications, the intra-and extrahepatic bile ducts. In one patient with primary sclerosing cholangitis, the intrahepatic bile ducts were not opacified satisfactorily; dilatation of the gallbladder required surgical drainage. The transcholecystic technique is indicated when the intrahepatic bile ducts are either mildly dilated or not dilated.     

The effects of manual therapy and exercise directed at the cervical spine on pain and pressure pain sensitivity in patients with myofascial temporomandibular disorders

Summary No studies have investigated the effects of the treatments directed at the cervical spine in patients with temporomandibular disorders (TMD). Our aim was to investigate the effects of joint mobilization and exercise directed at the cervical spine on pain intensity and pressure pain sensitivity in the muscles of mastication in patients with TMD. Nineteen patients (14 females), aged 19–57 years, with myofascial TMD were included. All patients received a total of 10 treatment session over a 5‐week period (twice per week). Treatment included manual therapy techniques and exercise directed at the cervical spine. Outcome measures included bilateral pressure pain threshold (PPT) levels over the masseter and temporalis muscles, active pain‐free mouth opening (mm) and pain (Visual Analogue Scale) and were all assessed pre‐intervention, 48 h after the last treatment (post‐intervention) and at 12‐week follow‐up period. Mixed‐model anovas were used to examine the effects of the intervention on each outcome measure. Within‐group effect sizes were calculated in order to assess clinical effect. The 2 × 3 mixed model anova revealed significant effect for time (F = 77·8; P < 0·001) but not for side (F = 0·2; P = 0·7) for changes in PPT over the masseter muscle and over the temporalis muscle (time: F = 66·8; P < 0·001; side: F = 0·07; P = 0·8). Post hoc revealed significant differences between pre‐intervention and both post‐intervention and follow‐up periods (P < 0·001) but not between post‐intervention and follow‐up period (P = 0·9) for both muscles. Within‐group effect sizes were large (d > 1·0) for both follow‐up periods in both muscles. The anova found a significant effect for time (F = 78·6; P < 0·001) for changes in pain intensity and active pain‐free mouth opening (F = 17·1; P < 0·001). Significant differences were found between pre‐intervention and both post‐intervention and follow‐up periods (P < 0·001) but not between the post‐intervention and follow‐up period (P > 0·7). Within‐group effect sizes were large (d > 0·8) for both post‐intervention and follow‐up periods. The application of treatment directed at the cervical spine may be beneficial in decreasing pain intensity, increasing PPTs over the masticatory muscles and an increasing pain‐free mouth opening in patients with myofascial TMD.     

White-matter lesions in MR imaging of clinically healthy brains of elderly subjects: possible pathologic basis

Patchy white-matter lesions occur in the magnetic resonance (MR) imaging brain studies of 20%-30% of neurologically healthy elderly subjects. To determine the frequency of histologically verifiable white-matter lesions at autopsy in such subjects the authors examined serial, microscopic, whole brain sections from 15 clinically healthy subjects aged 52-72 years. Small white-matter lesions were found in 12. In these 12, zones of atrophic perivascular demyelination were present in eight brains. These are not the familiar thrombotic, embolic, or ischemic vascular lesions that produce acute necrosis. This mild vascular insufficiency produces atrophy, which has been recognized in the pathology literature but whose clinical significance remains unknown. Other lesions seen were small vascular malformations in the centrum ovale in four brains, diverticula of the lateral ventricle extending into the white matter in three, and an isolated central white-matter infarction in one. All of these lesions are probably the basis of the patchy white-matter lesions seen on MR imaging studies in the neurologically healthy elderly population.     

Tongue and oropharynx: findings on MR imaging

Ten healthy subjects and 44 patients with diseases of the tongue or oropharynx were studied with magnetic resonance (MR) imaging. Axial, coronal, and sagittal images with a thickness of 4 mm were obtained with a pixel size of 0.75 X 0.75 mm on a 256 matrix. Nineteen of the patients underwent computed tomography (CT). Nine of those patients later had surgery, and the specimens were obtained for organ sectioning. These three studies as well as clinical history and physical examination findings were correlated. MR imaging was equal to or better than CT in those patients having both examinations. However, neither CT nor MR allowed recognition of histologic features or detection of microscopic spread of disease. Direct coronal and sagittal imaging planes on MR imaging allowed visualization of intrinsic tongue musculature, not possible with CT; this was important in recognizing subtle tumor extension. For these reasons, MR is the imaging method of choice for studying diseases of the tongue and oropharynx.     

Rotator cuff lesions of the shoulder: evaluation by direct sagittal CT arthrography

Direct sagittal computed tomographic scanning (DSCT) of the shoulder was performed in 42 symptomatic patients, six healthy volunteers, and two cadaver shoulders. Axial CT scanning and double-contrast arthrography with plain radiographs were performed in 41 patients for comparison. DSCT enabled correct identification of 27 of 29 lesions in 24 patients. Seventeen patients had normal shoulders. Axial CT scanning and DSCT together enabled correct identification of all lesions and were markedly superior to plain-film arthrography. DSCT enabled diagnosis of all cases of complete rotator cuff tear plus three cases of incomplete tear and three of rotator cuff atrophy not identified by the other techniques. Axial CT scanning was better than DSCT for diagnosis of Bankart lesions.     

International Headache Society classification: interobserver reliability in the diagnosis of primary headaches

We assessed interobserver reliability of the International Headache Society (IBIS) classification for diagnosis of primary headaches. The study was performed on 103 patients consecutively seen at two Headache Centres. Each patient was given a structured interview recorded on videotape. Four experienced clinicians then reviewed the interviews separately and made a diagnosis of headache according to IHS criteria at the one- and two-digit levels. At both the one- and the two-digit level the agreement was substantial (Kappa = 0.74 and 0.65, respectively). The analysis of reliability for each of nine items necessary for diagnosis showed an agreement ranging from substantial (Kappa = 0.69) to almost perfect (Kappa = 0.89). Our results indicate that the IHS classification has a good reliability for the diagnosis of primary headaches at the one- and two-digit levels.     

Baroreflex Sensitivity as a Cardiac and Arrhythmia Mortality Risk Stratifier

The last two decades have provided clear evidence for the tight and casual relation existing between arrhythmic mortality and the autonomic nervous system, particularly with imbalances characterized by decreases in vagal and/or increases in sympathetic activity. A series of compelling experimental results has represented the driving force for the clinical evaluation of the potential prognostic value of baroreflex sensitivity (BBS), a measure that can provide information on the capability to augment vagal activity. This article reviews the methodology more commonly used to quantify the clinical evaluation of this parameter, and then focuses on the key clinical studies highlighting those performed in postmyocardial infarction patients. Among them the most informative is ATRAMI, a multicenter prospective study involving almost 1300 patients. The main conclusion is that both heart rate variability and BRS are strong and independent risk factors for post-infarction mortality, thus demonstrating the clinical usefulness of autonomic markers.