Life-threatening, localized angio-oedema associated with streptokinase

We report what we believe to be the first documented case of localized angio-oedema of the upper airway secondary to streptokinase.     

Anatomic evidence for a neurotoxic effect of (±)-fenfluramine upon serotonergic projections in the rat

Immunocytochemistry was used to determine whether (±)-fenfluramine causes structural damage to serotonergic (5-HT) neurons. Sections from rat forebrain were examined 4 h, 36 h and 2 weeks after various dose regimens of fenfluramine. At all time points there was a reduction of fine 5-HT axon terminals in the forebrain, while beaded axons were spared. The presence of markedly swollen, fragmented 5-HT axons 36 h after injection is indicative of axonal degeneration, and provides morphologic evidence for a neurotoxic effect of (±)-fenfluramine upon 5-HT axon terminals.     

Cytomegalovirus infection and colonic perforation in renal transplant patients

Cytomegalovirus (CMV) infection in immunocompromised patients is a major cause of morbidity and mortality. A well-documented manifestation of gastrointestinal CMV infection is gastrointestinal haemorrhage. In contrast, CMV-associated intestinal perforation has rarely been reported after transplantation, although it is well documented in AIDS patients. Three patients are reported who received their first cadaveric renal transplant in 1994 and subsequently developed CMV disease. During the course of their CMV illness, which was treated with ganciclovir, each presented with clinical suspicion of peritonitis and proceeded to laparotomy. All three were found to have sigmoid colon perforations with histological evidence of CMV infection. Following bowel resection and defunctioning, two patients made an uneventful recovery and have had the continuity of their bowel restored, but one died of overwhelming sepsis within hours of surgery. The explanation for the apparent clustering of this rare condition in transplant patients is uncertain.     

Bronchodilator response with use of optivent versus aerosol cloud enhancer metered-dose inhaler spacers in patients receiving ventilatory assistance

OBJECTIVE: This study compared the clinical effectiveness of the OptiVent (HealthScan Products, Inc, Cedar Grove, NJ) and the ACE (DHD, Inc. Canastota, NY) metered dose inhaler (MDI) in-line spacers.DESIGN: Two-group, split-plot design with subjects serving as their own controlsSETTING: Data were collected in a 1000-bed urban hospital.PATIENTS: A convenience sample of 7 intubated patients receiving mechanical ventilation.INTERVENTION: Patients received 4 and 8 puffs of albuterol with use of both the OptiVent and ACE devices.RESULTS: Changes in expiratory airway resistance (Raw), passive peak expiratory flow rate (PEFR), and total work-of-breathing (WOB_TOT) were determined using a Bicore monitor (Bicore Monitoring System; Irvine, Calif). With the ACE, Raw decreased an average of 20.2% and 8.8% in patients receiving 4 and 8 puffs, respectively. With the OptiVent, Raw decreased an average of 34.6% and 10.8% in patients receiving 4 and 8 puffs, respectively. Improvements in WOB_TOT, were less than those seen in Raw, and PEFR did not trend with the other 2 variables. The performances of the 2 spacer brands were comparable, with no statistical difference (P values > 0.05) for all 3 variables with use of the nonparametric Kolmogorov-Smirnov test.CONCLUSIONS: These data suggest that use of the OptiVent spacer yields comparable clinical results with the ACE spacer in patients receiving mechanical ventilation and merits further evaluation. (Heart Lung® 1998; 27:418-23)     

The effect of intensity windowing on the detection of simulated masses embedded in dense portions of digitized mammograms in a laboratory setting

The purpose of this study was to determine whether intensity windowing (IW) improves detection of simulated masses in dense mammograms. Simulated masses were embedded in dense mammograms digitized at 50 microns/pixel, 12 bits deep. Images were printed with no windowing applied and with nine window width and level combinations applied. A simulated mass was embedded in a realistic background of dense breast tissue, with the position of the mass (against the background) varied. The key variables involved in each trial included the position of the mass, the contrast levels and the IW setting applied to the image. Combining the 10 image processing conditions, 4 contrast levels, and 4 quadrant positions gave 160 combinations. The trials were constructed by pairing 160 combinations of key variables with 160 backgrounds. The entire experiment consisted of 800 trials. Twenty observers were asked to detect the quadrant of the image into which the mass was located. There was a statistically significant improvement in detection performance for masses when the window width was set at 1024 with a level of 3328. IW should be tested in the clinic to determine whether mass detection performance in real mammograms is improved.     

New or worsening lumbar spine vertebral fractures increase lumbar spine bone mineral density and falsely suggest improved skeletal status.

Changes in lumbar spine bone mineral density (BMD) are determined by follow-up dual-energy x-ray absorptiometry (DXA) assessments. Inclusion of new or worsening vertebral fractures in follow-up measurements may increase BMD. To test this hypothesis, we examined pooled data from the placebo groups of two clinical trials that involved postmenopausal women with osteoporosis. DXA measurements of lumbar spine BMD, bone mineral content (BMC), and area were obtained at baseline and at two years in the Multiple Outcomes of Raloxifene Evaluation (MORE) Trial and at baseline and study endpoint in the Fracture Prevention Trial. In these trials, fractured vertebrae identified by expert radiologists during posterioranterior (PA) spine DXA assessment were excluded from the BMD assessment. Lateral spine radiographs were graded using a semi-quantitative (SQ) scale. Most new or worsening vertebral fractures (84%) diagnosed from lateral spine radiographs were not identified by PA spine DXA. While the follow-up BMD of vertebrae without new or worsening fractures did not change significantly, each unit increase in SQ grade was associated with an approximate 7.0% increase in the BMD of affected vertebrae (p < 0.001). Increases in BMD were highly correlated with increases in BMC (r = 0.87, p < 0.001). Inclusion of new or worsening vertebral fractures increased PA spine BMD measurements at follow-up, with the impact being related to the magnitude of change in SQ score. It is difficult to reliably identify vertebral fractures from PA spine DXA assessments. Inclusion of new or worsening vertebral fractures in follow-up DXA measurements may falsely suggest an improvement in spine BMD. Our suggestion is to perform lateral spine imaging concurrently with any assessment of PA spine BMD in patients who, in the opinion of the health care provider, may have vertebral fractures.     

Vertebral morphometry by DXA: a comparison of supine lateral and decubitus lateral densitometers.

Identification of vertebral fracture has become increasingly important in the diagnosis and management of osteoporosis. This study compares the morphometric techniques on a fan beam dual-energy X-ray absorptiometry (DXA) GE-Lunar Expert system (Expert) using a supine lateral position and a narrow fan beam GE-Lunar Prodigy system (Prodigy; GE Lunar, Madison, WI) that requires lateral decubitus positioning. Patient acceptability, image quality, observer, and equipment variability were determined. Study subjects were recruited from clinical referrals sent for a routine DXA study that included vertebral morphometry. Twenty-five patients underwent lateral vertebral assessment on both machines and completed a questionnaire on comfort and tolerability. Analysis was undertaken by two trained observers. Vertebral height, anterior/posterior height (A/P) and mid/posterior height (M/P) ratios, image quality, and prevalent fractures were assessed. There were no significant differences in patient comfort or image quality scores. More upper thoracic vertebrae could be assessed on the Expert, and good radiographic positioning was easier to achieve on the Expert. Inter-observer coefficients of variance percentage (CV%) of vertebral height was lower on the Prodigy (3.5% in the lumbar spine rising to 12.8% in the thoracic spine) than the Expert (4.2% to 16.9%). Inter-observer CV% for A/P and M/P ratios varied from 2.5% to 10.5% on the Prodigy compared with 3.5% to 12.3% on the Expert, depending on vertebral level. The variation between instruments was similar to the inter-observer CV% (anterior height: -0.11+/-1.65 mm; mid height: 0.54+/-1.51 mm; posterior height: 0.43+/-1.46 mm). There was good agreement between observers and between the Expert and Prodigy in identifying severe fractures, but lack of agreement in identifying moderate fractures. In conclusion, there was no clinically significant difference in patient comfort and image quality between the Expert and the Prodigy. The inter-observer variations in vertebral height and A/P and M/P ratios are similar to the variations between instruments. In making the change from the supine lateral to the decubitus lateral positioning, measurements of vertebral height are reproducible and patient comfort is not compromised.