Sarcoid Myelopathy

A 45-year-old woman with history of iritis, uveitis, and sarcoidosis of the skin presented with a subacute cervical myelopathy. Magnetic resonance imaging (MRI) ;howed patchy, multifocal, gadoliniumenhancing intramedullary lesions of the spinal cord, and extramedullary lesions of the basal cisterns and fourth ventricle. Symptoms and MRI abnormalities were improved within 1 month of corticosteroid therapy.     

REHABILITATION OF LOWER LIMB AMPUTEES AND SOME IMPLICATIONS FOR SURGICAL MANAGEMENT

Aspects of peri-operative management, amputation level and rehabilitation of the lower limb amputee are reported in the context of a review of a rehabilitation service for amputees which includes an integrated prosthetic service. Two hundred admissions were reviewed and some complex cases described. It is concluded that: a very close liaison between the surgeon and the rehabilitation team (ideally with pre-operative consultation) is in the patient's best interests; any person previously walking (or a potential walker) should be considered for a trial of prosthetic walking; an integrated prosthetic service enhances the efficiency of the rehabilitation service; and that modification of the current Artificial Limb Scheme to allow manufacture of first definitive limbs in prosthetic rehabilitation units would further enhance service to patients.     

Solitary necrotic nodule of the liver: A riddle that is difficult to answer

Solitary necrotic nodule of the liver is an unusual lesion that is often an incidental finding on abdominal imaging, intraoperative examination, or post mortem. Most reported cases of solitary necrotic nodule have been in males, and over three quarters of these lesions have occurred in the right lobe of the liver. Pathologically, solitary necrotic nodule is a benign lesion characterized by a completely necrotic core that is often partly calcified, surrounded by a dense hyalinized fibrous capsule containing elastin fibres. The ultrasound appearance of solitary necrotic nodule is usually of a “target” lesion with a hyperechoic center, while on CT scan they appear as non-enhancing hypodense lesions that are typical of metastatic adenocarcinoma or peripheral cholangiocarcinoma. The impression of malignancy is further enforced with the finding of necrotic cellular material on biopsy and the macroscopically hard and “gritty” nature of the nodules. Currently, permanent histopathology of solitary necrotic nodules is the only accurate method of diagnosis. However, solitary necrotic nodules are usually of a bilobed or lobulated shape that is unusual for malignant liver lesions, and they often lie in close proximity to hepatic inflow structures. Solitary necrotic nodule should be suspected in liver lesions with this configuration, location, and on a biopsy showing a large amount of necrosis.     

MANAGEMENT OF SEMINOMA OF THE TESTIS: RECOMMENDATIONS BASED ON TREATMENT RESULTS

Background : The results of management of seminoma of the testis at the Department of Radiation Oncology St Vincent's Hospital, Sydney were evaluated retrospectively to: (i) establish that outcomes were in keeping with published results from centres in Australia and overseas; (ii) assess the impact of chemotherapy on management; and (iii) to determine ‘best practice’ management protocols based on our results and a review of the relevant literature. Methods : (i) Assessment of treatment results for stage I and II seminoma of the testis treated by post-orchidectomy radiotherapy and/or chemotherapy at St Vincent's Hospital between 1979 and 1993; (ii) literature review of published data from Australian and overseas centres on the management of seminoma of the testis, and in particular the use of surveillance or chemotherapy either alone, at time of relapse or combined with radiotherapy; and (iii) development of recommendations for use as management protocols in our department. Results : Our data and a review of the literature suggest that post-orchidectomy radiotherapy with chemotherapy for relapse in stage I and IIA disease results in long-term cure rates approaching 100%. Treatment with chemotherapy either routinely or selectively or using a surveillance policy is unlikely to show any improvement in outcome and may be less cost-effective and/or produce increased morbidity and the risk of secondary leukaemia. For stage IIB disease (5–10 cm) the use of initial combination chemotherapy with or without subsequent radiotherapy did not appear to give better outcomes than initial radical radiotherapy alone, reserving chemotherapy or further radiotherapy for relapse. For bulkier stage IIB disease (> 10cm). the use of initial chemotherapy plus consolidation radiotherapy appeared to be an appropriate treatment. Conclusions : Management protocols for seminoma of the testis at St Vincent's Hospital, Sydney Department of Radiation Oncology currently are (i) stage I, IA and IIB (5–10 cm): post-orchidectomy radiotherapy alone with chemotherapy or further radiotherapy for relapse; and (ii) stage IIB (> 10 cm) disease: initial chemotherapy post-orchidectomy followed by radiotherapy to sites of initial disease involvement.     

Postnatal maturation of mast cell subpopulations in the rat respiratory tract.

The distribution and enumeration of mast cell subpopulations within the respiratory tract of a high- and low-Ige responder rat strain was determined during postnatal development. Mast cells were identified in adjacent sections by the alcian blue (AB)/safranin (SAF) staining sequence, or using immunoperoxidase to detect the rat mast cell proteinases I (RMCPI) or II (RMCPII). At birth both mucosal mast cells (MMC) and connective tissue mast cells (CTMC) were represented in very low numbers at distinct locations throughout the respiratory tract. The total number of mast cells increased with age. MMC (AB+/RMCPII+ mast cells) were the predominant phenotype in the epithelium and lamina propria of the trachea and the major conducting airways of the lung in all age groups. In contrast, CTMC (AB+/RPMCPI+ and SAF+/RMCPI+ mast cells) predominated in the submucosa of the trachea and major conducting airways as well as in the parenchyma and visceral pleura of the peripheral lung. Both phenotypes co-exist in similar proportions in peribronchial adventitial tissue and adventitia surrounding large blood vessels in neonates as well as adults. In rats the tracheal epithelium is densely populated by MMC from around the time of weaning (3 weeks) and a small but generalized increase in the number of MMC at all sites within the respiratory tract is noted from this time. This increase in MMC frequency in tissue sections with increasing age is mirrored by the levels of circulating serum RMCPII. The number of bone marrow-derived MMC also increased with increasing age prior to weaning, with a significant drop (P less than 0.01) at 4 weeks of age before returning to the peak numbers in 3-week-old rats. The high-IgE responder Brown Norwegian (BN) rat strain constitutively produces significantly more IgE than the low-IgE responder White albino Glaxo (WAG) strain (P less than 0.001) at all ages studied. In contrast, only minor differences between the number and distribution of mast cells in the two strains were observed.     

Bring me home: Renal dialysis in the Kimberley

SUMMARY:   The incidence of end-stage renal failure (ESRF) in the Kimberley region at the top end of Western Australia far exceeds known national rates and trend analysis demonstrates a close parallel to what is occurring in the Northern Territory. Dialysis prevalence in the Kimberley has nearly tripled in the last decade and has increased at a much faster rate than the rest of Western Australia. Almost all of these people with ESRF are Aboriginal Australians living in remote communities.
In January 2004, the Western Australia Country Health Service and Kimberley Aboriginal Medical Services' Council, under the auspices of the Kimberley Aboriginal Health Planning Forum, embarked upon a review of renal disease in the Kimberley funded by the Western Australia Department of Health. The main purpose of the review was to identify the scope of the problem and make projections upon which to base programme and service development over the next 10 years.
This paper outlines the findings of the Review of Renal Disease in the Kimberley and presents, for the first time, regional data analysis and comparisons. In addition, future projections on the impact of ESRF and recommendations for improving current service delivery are discussed. Given the challenges of remoteness and individuals' desire to return home, this review recommends development of locally-based expertise capable of providing training and support to patients and their families, reinvigoration of community-based dialysis modalities, and the initiation of planning for a second satellite service in the Kimberley.     

Human imaging of phosphorus in cortical and trabecular bone in vivo.

Phosphorus was imaged in vivo in human cortical and trabecular bone and the T(1) and T(2) (*) were measured. An ultrashort TE (UTE) pulse sequence (TE = 70 microm) was used with half pulse excitation and radial mapping of k-space from the center out. T(2) (*) was measured using multiple echo times and T(1) was measured both by saturation recovery and by a method using different RF pulse amplitudes. Seven normal subjects (32-85 years) were examined. Phosphorus was imaged, with a true in-plane resolution of 2.9 x 2.9 mm and a signal-to-noise ratio (SNR) of 19:1, in both cortical and trabecular bone. The mean T(2) (*) value was 207 +/- 12 micros, and the mean T(1) value was 8.6 +/- 3.0 sec. Images and measurements were obtained in realistic times on a clinical MR system. This may provide a new approach to characterizing disease of bone.     

Genetic diversity among community methicillin-resistant Staphylococcus aureus strains causing outpatient infections in Australia

Increasing reports of the appearance of novel nonmultiresistant methicillin-resistant Staphylococcus aureus MRSA (MRSA) strains in the community and of the spread of hospital MRSA strains into the community are cause for public health concern. We conducted two national surveys of unique isolates of S. aureus from clinical specimens collected from nonhospitalized patients commencing in 2000 and 2002, respectively. A total of 11.7% of 2,498 isolates from 2000 and 15.4% of 2,486 isolates from 2002 were MRSA. Approximately 54% of the MRSA isolates were nonmultiresistant (resistant to less than three of nine antibiotics) in both surveys. The majority of multiresistant MRSA isolates in both surveys belonged to two strains (strains AUS-2 and AUS-3), as determined by pulsed-field gel electrophoresis (PFGE) and resistogram typing. The 3 AUS-2 isolates and 10 of the 11 AUS-3 isolates selected for multilocus sequence typing (MLST) and staphylococcal chromosomal cassette mec (SCCmec) analysis were ST239-MRSA-III (where ST is the sequence type) and thus belonged to the same clone as the eastern Australian MRSA strain of the 1980s, which spread internationally. Four predominant clones of novel nonmultiresistant MRSA were identified by PFGE, MLST, and SCCmec analysis: ST22-MRSA-IV (strain EMRSA-15), ST1-MRSA-IV (strain WA-1), ST30-MRSA-IV (strain SWP), and ST93-MRSA-IV (strain Queensland). The last three clones are associated with community acquisition. A total of 14 STs were identified in the surveys, including six unique clones of novel nonmultiresistant MRSA, namely, STs 73, 93, 129, 75, and 80slv and a new ST. SCCmec types IV and V were present in diverse genetic backgrounds. These findings provide support for the acquisition of SCCmec by multiple lineages of S. aureus. They also confirm that both hospital and community strains of MRSA are now common in nonhospitalized patients throughout Australia.