Interventional computed tomography

Due to the development and refinement of computed tomography (CT), sonography, and interventional techniques, the field of interventional radiology has seen tremendous growth in recent years. In particular, the precise anatomic detail provided by CT and sonography has allowed percutaneous biopsies and abscess drainages to be performed safely and effectively. Percutaneous biopsies are now becoming the most common interventional radiographic procedures in many institutions. The usual indications for a biopsy are to determine the etiology of a mass, neoplasm, or inflammation, and to determine whether masses in known oncologic patients represent scarring or residual viable tumor. Accuracy rates for most percutaneous CT-directed biopsies are well over 90%, and the complication rate is very low. CT-directed percutaneous abscess drainages are also safe and effective and, in most cases, will be preferable to surgical drainage. The initial indications for percutaneous drainage (single, unilocular fluid collections) have been greatly expanded to include multiloculated collections, interloop abscesses, periappendiceal abscesses, and even percutaneous cholecystotomies. Biopsy and drainage procedures, together with their accuracy rates, indications and complications, are reviewed in this monograph.     

Apparent lack of synergism between heparin and dihydroergotamine in prevention of deep vein thrombosis after elective hip replacement: a randomised double-blind trial reported in conjunction with an overview of previous results.

We report the results of a double-blind, randomised trial of venous thrombosis (VT) prevention in 117 patients having elective hip replacement where low dose heparin alone (5,000 IU sodium heparin given subcutaneously [sc] 8 hourly until the seventh postoperative day) was compared with low dose heparin plus dihydroergotamine (DHE; 0.5 mg, given 8 hourly by sc injection). The trial end point consisted of VT discovered through bilateral ascending venography done routinely on the seventh postoperative day. VT developed in 34% of patients given heparin/DHE (95% confidence interval = 22% - 47%) compared with 24% in those given low dose heparin alone (95% confidence interval = 14% - 37%; p = 0.34), difference = 10% (95% confidence interval = -7% to +26%). Corresponding figures for the incidence of proximal (above-knee) thrombosis were 17% and 14% (95% confidence intervals = 8% - 29% and 6% - 25% respectively). These results are discussed in the context of a detailed overview of published evidence concerning VT prevention with heparin/DHE after hip replacement and we conclude it is unlikely that heparin/DHE is markedly superior to low dose heparin alone in this clinical setting.     

Parity and bone mineral density in middle-aged women

A retrospective study was carried out to determine the relationship between parity and bone mineral density (BMD) in middle-aged women. Eight hundred and twenty-five woman aged 41–76 years were recruited from four general practice registers in Cambridge. Subjects were unselected as to their health status. Each subject completed a detailed health questionnaire. Participation rate was 50%. The main outcome measure was BMD measured at the spine (L2–4,n=825) and hip (neck, intertrochanter and Ward's triangle;n=817) by dual-energy X-ray absorptiometry (DXA) using the Hologic QDR-1000 densitometer. It was found that the unadjusted mean BMD was significantly higher at all sites among the parous women (p=0.031 to <0.00001), and remained significantly higher at the femoral neck (p=0.025), intertrochanter (p=0.001) and Ward's triangle (p=0.045) after adjusting for age and body mass index (BMI). Similar findings were seen after stratifying for potential confounding variables. There was a consistent upward trend of BMD with increasing parity at all sites. Parity remained a significant independent predictor of BMD at all sites after controlling for age, BMI, menopausal status, oral contraceptive and hormone replacement therapy use, smoking status and breast-feeding status in multiple linear regression analyses. There was, on average, a 1.0% increase in BMD per live birth. Our findings therefore suggest a positive relationship between parity and bone mass.     

Case report 487

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official nor as reflecting the views of the United States Air Force     

Pulsed dye laser (577 nm) treatment of portwine stains: ultrastructural evidence of neovascularization and mast cell degranulation in healed lesions

Portwine stains were examined before, immediately after, and 1 yr after successful clearance by a pulsed dye laser (577 nm) using ultrastructural techniques. Dilated vascular channels and mast cell hypoplasia characterized lesional skin before treatment. Immediately after treatment, widespread selective vessel necrosis, similar to changes previously described, was observed. One year after laser irradiation, the abnormally ectatic portwine stain vessels had been replaced by small venules and arterioles, similar in number and diameter to blood vessels in normal skin; the only difference noted was that these new vessels were surrounded by easily identifiable mast cells. Many of these mast cells exhibited evidence of activation and degranulation. We conclude that mast cells may play an important role in the neovascularization of portwine stains treated by 577-nm dye laser irradiation.     

The impact of HIV disease on an Irish prison population.

Between January 1987 and January 1991, 168 known HIV-infected prisoners have been incarcerated in Dublin's Mountjoy prison. This figure constitutes 16.6% of the total HIV-infected population in the Republic of Ireland over the same period. One hundred and forty-one (84%) of these prisoners have attended the Department of Genitourinary Medicine, St James's Hospital, Dublin. This group displayed considerable morbidity from HIV-related disease. Respiratory tract infection was the most frequent complication seen. Much additional morbidity was directly attributable to intravenous drug use. A survey of a representative group of inmates revealed that 64.7% were diagnosed HIV-positive in prison. The mean length of time spent incarcerated since the diagnosis of HIV infection was 38.9 months. Twenty-nine of 34 individuals who answered a questionnaire were imprisoned for drug-related crimes and 32 of 34 prisoners admitted to parenteral drug use within the prison. As the HIV epidemic unfolds in Dublin, increasing numbers of prisoners with symptomatic HIV disease will spend time incarcerated in Mountjoy prison. This will pose a considerable burden on prison and hospital medical services alike.     

Binding and retrograde transport of leukemia inhibitory factor by the sensory nervous system.

Leukemia inhibitory factor (LIF), a peptide growth factor with multiple activities, has recently been shown to support the generation and survival of sensory neurons in cultures of mouse neural crest and dorsal root ganglia (DRG). We have conducted binding experiments with 125I-LIF on cultures of DRG to determine the receptor distribution for LIF on these cells and found that at least 60% of the sensory neurons in the cultures bound 125I-LIF, all of which could be eliminated by the addition of unlabeled LIF. The other cells in the culture, which morphologically appeared to be Schwann cells, did not bind appreciable quantities of 125I-LIF. In order to investigate whether LIF is retrogradely transported to sensory neurons in vivo, 125I-LIF was injected into the footpads and gastrocnemius muscles of newborn and adult mice, following sciatic nerve ligation. Radioactivity accumulated in the distal portion of the sciatic nerve, indicating retrograde transport of LIF. Subsequent experiments on mice with unligated sciatic nerves showed that 125I-LIF is specifically transported into the sensory neurons of the DRG. There was no apparent transport of 125I-LIF into motor neurons in the spinal cord. These experiments demonstrate that LIF can specifically bind to and be transported by sensory neurons and further support the idea that LIF acts as a target-derived neurotrophic factor, analogous to NGF.     

Acute impairment of regional myocardial glucose uptake in the apical ballooning (takotsubo) syndrome

BACKGROUND: Apical ballooning syndrome (ABS) is a poorly understood clinical entity characterized by acute, transient systolic dysfunction of the left ventricular (LV) apex in the absence of epicardial coronary artery disease and commonly associated with acute emotional stress. We report abnormal regional myocardial perfusion and glucose uptake in 4 consecutive ABS patients studied using positron emission tomography with 13N-ammonia and 18F-fluorodeoxyglucose within 72 hours of presentation with ABS. METHODS: All patients were postmenopausal females, 3 of whom had a major recent life stress event. Coronary angiography revealed no or minimal obstructive epicardial coronary artery disease. All patients exhibited reduced glucose uptake in the mid-LV and apical myocardial segments, which was out of proportion to perfusion abnormalities in half of the cases. CONCLUSION: In all 4 patients, affected regions subsequently recovered regional LV systolic function within 6 weeks.     

Squamous and adenocarcinoma of the uterine cervix: a comparison using routine data

We studied the clinical, demographic and survival characteristics of more than 5,000 women registered with either squamous or adenocarcinoma of the uterine cervix in South Thames Cancer Registry over the period 1968-81. There were similarities with respect to social class, smoking habit, oestrogen/oral contraceptive use and time trends in incidence but differences between the two cancers were found with respect to age distribution, parity, method of detection and survival. Some of the data are of limited value, having been obtained only from case notes, so the results need some caution in their interpretation. However the results are broadly consistent with those of studies performed in other countries on smaller samples. A methodological issue is also raised, viz. the appropriateness of a disease with well-known characteristics as a comparison group. From our results the likely size of various associations can be judged and used in the design of future studies to clarify the epidemiology of cervical adenocarcinoma.     

Genetic construction, expression, and melanoma-selective cytotoxicity of a diphtheria toxin-related alpha-melanocyte-stimulating hormone fusion protein.

The structural gene for diphtheria toxin, tox, has been modified at its Sph I site by the introduction of an oligonucleotide linker encoding a unique Pst I restriction endonuclease site and a synthetic oligonucleotide encoding alpha-melanocyte-stimulating hormone (alpha-MSH). The resulting fusion gene directs the expression of a diphtheria toxin-related alpha-MSH hybrid protein in which the diphtheria toxin receptor-binding domain has been replaced with alpha-MSH sequences. The chimeric toxin has been partially purified from periplasmic extracts of recombinant Escherichia coli K-12 and has been found to be selectively toxic for alpha-MSH receptor-positive human malignant melanoma NEL-M1 cells in vitro.