Search

Careful analysis of over 400 patients radiologically diagnosed with arachnoiditis showed a subgroup of eight patients with a specific set of imaging signs that suggest a pre-existing developmental abnormality mimicking the appearance of arachnoiditis. These cases have been collected over a 15-year period. No autopsy or surgical proof is available. All patients have (i) the presence of a well-defined midline septum in the sagittal plane that splits the thecal sac, usually symmetrically, in the lower lumbar or sacral region, below the level of the spinal cord; (ii) the absence of adjacent epidural fibrosis that one would expect if the septation had been caused by surgical intervention or trauma; (iii) the preservation of cerebrospinal fluid within the nerve root sheaths and around the nerve roots at the level of the septation; and in four cases (iv) the presence of either calcification or bone in this midline septum, yet nowhere else in the theca or epidural space. These cases suggest a developmental variant called, for want of a better term, 'split lumbo-sacral thecal sac' analogous to diastematomyelia but not involving the spinal cord. This variant is potentially confused with arachnoiditis or thecal scarring in the lumbo-sacral sac.

Background: More than 80% of hepatocellular carcinoma tumours (HCC) are unresectable at presentation because of the multicentric nature of the disease or the severity of liver disease. Arterially administered lipiodol is preferentially retained by HCC and has been used as a vehicle for delivery of therapeutic agents to the tumour. The aim of this phase I study is to present the experience with 1 3 1 I-labelled lipiodol in the treatment of unresectable HCC. Methods: 1 3 1 Iodine lipiodol treatment was administered to 12 patients with unresectable HCC between 1994 and 1999. The outcome of treatment in these patients was evaluated for survival, clinical tolerance, liver function tests, α-fetoprotein (AFP) levels and changes in tumour size on computed tomography (CT) scans. Results: Ten of the 12 patients received more than one 1 3 1 I treatment. Five patients had treatment for post-resection recurrence. Serum AFP levels dropped initially in five of the seven patients with elevated values. Tumour size, evaluated by CT scans at 3 months, decreased in six patients and remained stable in the rest, except one patient in whom both the AFP level and tumour size had increased. Using life table analysis, the 50% survival was 19 months. Conclusions: Intra-arterial 1 3 1 I treatment was very well tolerated. A reduction in AFP levels and tumour size occurred in half of the patients and resulted in a 50% probability of survival of 19 months. Further examination of the value of this treatment in phase II and III studies is required.

Cholesterol granuloma and cholesteatoma are the two most common destructive lesions of the petrous apex. Arachnoid cyst is less common. These three expansile lesions are often indistinguishable on clinical grounds. Cholesterol granulomas can be treated effectively through internal drainage into the mastoid cavity or middle ear. Cholesteatomas, however, are managed by more aggressive and complicated removal, which often mandates the sacrifice of hearing. Symptomatic arachnoid cysts are amenable to simple surgical drainage. Therefore, accurate preoperative recognition on computed tomography (CT) and magnetic resonance imaging (MRI) is important in planning proper treatment. Thirteen cases of destructive lesions of the petrous apex are analyzed. The authors' experience illustrates that the "typical" CT and MRI radiographic features are diagnostic in some cases, but not in all. In this study the pathologic findings have been correlated with the radiologic features on both MRI and CT.

SUMMARY There have been several methods, both surgical and radiological, to attempt to treat ilio-femoral thrombosis secondary to the iliac compression syndrome. A case is reported here which was managed by a combination of surgical thrombectomy and radiological stenting of the left common iliac vein.

Between 12% and 37% of people will die in the year after a hip fracture, and 10% to 20% of survivors will move into a more dependent residence.We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of surgical interventions in people with hip fracture? What are the effects of perisurgical medical interventions on surgical outcome and prevention of complications in people with hip fracture? What are the effects of rehabilitation interventions and programmes after hip fracture? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).We found 55 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.In this systematic review we present information relating to the effectiveness and safety of the following interventions: anaesthesia (general, regional); antibiotic regimens; arthroplasty; choice of implant for internal fixation; conservative treatment; co-ordinated multidisciplinary approaches for inpatient rehabilitation of older people; cyclical compression of the foot or calf; early supported discharge followed by home-based rehabilitation; extramedullary devices; fixation (external, internal); graduated elastic compression; intramedullary devices; mobilisation strategies; nerve blocks for pain control; nutritional supplementation (oral multinutrient feeds, nasogastric feeds); perioperative prophylaxis with antibiotics, with antiplatelet agents, or with heparin (low molecular weight or unfractionated); preoperative traction to the injured limb; and systematic multicomponent home-based rehabilitation.

SUMMARY Three cases of basilar artery territory infarction, in which a dense basilar artery was noted, are described. The dense basilar artery was recognized on computed tomography (CT) by comparing its density with that of other unaffected intracranial vessels. This sign is thought to represent basilar thrombosis or embolism and has similarities to the dense middle cerebral artery sign. The dense basilar artery is an early sign suggesting basilar territory infarction and its use improves the CT detection of basilar territory infarction.

Vocal granulomas are uncommon benign tumors that may not respond readily to medical treatment or surgical removal. Gastroesophageal reflux is said to be a causative factor. Osteosclerosis of the arytenoid cartilage was found on computed tomographic scan in a series of 21 consecutive patients. The relationship of vocal granuloma to so-called contact ulcer (better called contact pachydermia) is discussed. Imaging of the granuloma and the arytenoid has little, if any, place in management, but should be recognized in the differential diagnosis of a vocal cord mass if the mass lies immediately adjacent to a sclerotic arytenoid.

A disk array is a set of disk drives (and controller) which can automatically recover data when one or more disk drives in the set fail. One method used by disk arrays to achieve high availability at lower cost than mirroring is a parity technique. This paper considers disk arrays that use the parity technique. The main drawback of such arrays is that they need four disk accesses to update a data block-two to read old data and parity, and two to write new data and parity. We describe four new methods to improve the update performance of disk arrays that use the parity technique from four accesses to three and, in some cases, to two. All our schemes sacrifice disk storage efficiency for improved update performance by relaxing the requirement that the modified data and parity blocks be written back into their original locations. Our best technique, called floating parity track, achieves much improved update performance while using only 1% more disk space than traditional arrays.

1. An unusual clinical case is described in which renal artery stenosis (RAS) was found to coexist with adrenocortical hyperplasia, resulting in hypertension. 2. Partial relief of the hypertension was achieved by correction of RAS, and then further relief by extirpation of one adrenal gland affected by unilateral hyperplasia, in interventions 8 months apart. 3. Biochemical features typical of primary hyperaldosteronism were observed both before and after RAS repair but were not present after unilateral adrenalectomy. 4. The association of these two lesions could have occurred by chance, through genetic linkage, or by progression from RAS to tertiary aldosteronism.

Between 12% and 37% of people will die in the year after a hip fracture, and 10-20% of survivors will move into a more dependent residence.We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of surgical interventions in people with hip fracture? What are the effects of perisurgical medical interventions on surgical outcome and prevention of complications in people with hip fracture? What are the effects of rehabilitation interventions and programmes after hip fracture? We searched: Medline, Embase, The Cochrane Library and other important databases up to January 2007 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).We found 52 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.In this systematic review we present information relating to the effectiveness and safety of the following interventions: anaesthesia (general, regional), antibiotic regimens, arthroplasty, choice of implant for internal fixation, conservative treatment, coordinated multidisciplinary approaches for inpatient rehabilitation of older people, cyclical compression of the foot or calf, early supported discharge followed by home-based rehabilitation, extramedullary devices, fixation (external, internal), graduated elastic compression, intramedullary devices, mobilisation strategies, nerve blocks for pain control, nutritional supplementation (oral multinutrient feeds, nasogastric feeds), perioperative prophylaxis with antibiotics, antiplatelet agents, or heparin (low molecular weight or unfractionated), preoperative traction to the injured limb, surgery, and systematic multicomponent home-based rehabilitation.

A single degree of freedom simulator has been developed to analyse the influence of athlete physique on descent time in the bob skeleton. A model of human proportions is used to predict frontal and total surface area of an athlete for a given weight and height. Empirical relationships are then used to estimate the viscous and pressure form components of drag as functions of sled speed. A parametric variation of athlete height and mass is used to evaluate the influence on descent time excluding the influence of the initial sprint time. The actual descent times for the top 15 male competitors at the 2007 St Moritz world championships are compared to the simulated descent time for each athlete based on their mass and height. The results demonstrate gains in aerodynamic performance are made from being taller for a given weight and also for increased overall weight. A final analysis shows the influence of the rule that attempts to equalise overall mass show an advantage for an athlete being lighter for a given height. A normalisation of the world championship race times so that start time is not taken into account shows a correlation between athlete experience and descent time.

Audited cost data from two public hospital installations participating in a trial of the utilisation and efficacy of magnetic resonance imaging are presented. The data cover the period July 1987 to June 1988 when both installations had attained stable patterns of operation. One hospital operated a superconductive system and the other a resistive magnetic resonance imaging unit. Depreciation and salaries represented the major components of cost.

Four cases of occipital bone pneumatization and subsequent complications are described, which include a pathological fracture of C1 and the occipital bone, spontaneous subcutaneous emphysema and pneumatocele formation. Reviews of the published literature and possible aetiological factors have been discussed.

This case report describes a 24-year-old female who presented with sudden onset of painless diplopia and ptosis in her left eye. Examination identified an isolated incomplete pupil-sparing left oculomotor nerve palsy. Magnetic resonance imaging demonstrated focal hyperintensity in the left midbrain with infarction suggested by diffusion-weighted imaging. A diagnosis of primary antiphospholipid syndrome was made with the demonstration of a positive lupus anticoagulant. Other autoimmune markers were present on initial assessment, but did not fulfil diagnostic criteria for systemic lupus erythematosus. Anticoagulation with warfarin was commenced, with gradual resolution of neurological deficits. This case illustrates an unusual initial manifestation of primary antiphospholipid syndrome causing midbrain stroke in a young woman.

More than 80% of hepatocellular carcinoma tumours (HCC) are unresectable at presentation because of the multicentric nature of the disease or the severity of liver disease. Arterially administered lipiodol is preferentially retained by HCC and has been used as a vehicle for delivery of therapeutic agents to the tumour. The aim of this phase I study is to present the experience with 131I-labelled lipiodol in the treatment of unresectable HCC.131Iodine lipiodol treatment was administered to 12 patients with unresectable HCC between 1994 and 1999. The outcome of treatment in these patients was evaluated for survival, clinical tolerance, liver function tests, alpha-fetoprotein (AFP) levels and changes in tumour size on computed tomography (CT) scans.Ten of the 12 patients received more than one 131I treatment. Five patients had treatment for post-resection recurrence. Serum AFP levels dropped initially in five of the seven patients with elevated values. Tumour size, evaluated by CT scans at 3 months, decreased in six patients and remained stable in the rest, except one patient in whom both the AFP level and tumour size had increased. Using life table analysis, the 50% survival was 19 months.Intra-arterial 131I treatment was very well tolerated. A reduction in AFP levels and tumour size occurred in half of the patients and resulted in a 50% probability of survival of 19 months. Further examination of the value of this treatment in phase II and III studies is required.

A 23 year old man presented with classical hypothyroidism of 9 years duration. This was associated with pituitary enlargement, documented on magnetic resonance imaging (MRI), and abnormal half-field visual evoked responses (VERs). Following the initiation of thyroxine therapy the pituitary enlargement and the VER abnormalities resolved. The final diagnosis was of primary hypothyroidism with secondary pituitary hyperplasia.

A double-blinded trial was performed comparing Doppler interrogation of intra-renal arteries with findings at renal angiography in the assessment of renal artery stenosis. Fifty-three consecutive patients were studied. Previously reported parameters and cut-off values were used for predicting the presence of renal artery stenosis with Doppler. Doppler wave-form analysis proved relatively specific (91%) but insensitive (68%) to the presence of renal artery stenosis (of greater than 60%) if acceleration parameters were used alone. The technique of using a difference in mean resistive indices was found to be both insensitive (61%) and non-specific (54%). Patients with fibromuscular dysplasia, branch vessel stenoses, multiple renal arteries and chronic renal impairment proved to cause the most false negatives. Young patients with normal arteries were the source of the few false positive results. The interrogation of intra-renal arteries does not have appropriate sensitivity to be useful as a screening test for renal artery stenosis.

Enteroaggregative Escherichia coli (EAEC) is a recognized cause of enteric disease in diverse clinical settings. Mucosal immunity towards EAEC infections is poorly understood. To better characterize immunoregulatory mechanisms underlying EAEC infections we constructed a computational model mimicking host responses to EAEC at the gut mucosa. Preliminary model calibration efforts demonstrated remarkable fitting to experimental data. Nuclear receptor peroxisome proliferator-activated receptor gamma (PPARγ) has been targeted to modulate mucosal immune responses to EAEC. Wild type and conditional knockout mice lacking PPARγ in T cells were fed protein-deficient diets at weaning and challenged with 5x109cfu EAEC strain JM221. Quantitative RT-PCR data reveal that administration of GW9662, a potent PPARγ antagonist, for 7 days post infection or the deletion of PPARγ in T cells results in upregulation of pro-inflammatory cytokines including IL-6, TNF-α, and IL-1β when compared to non-treated infected animals. Histological analysis of colons divulges lower leukocyte infiltration and decreased mucosal thickness 14 days following EAEC infection after pharmacological blockade of PPARγ or deletion of PPARγ in T cells. These findings were accompanied by faster clearance of colonic EAEC in tissue-specific PPARγ null mice. In conclusion, we present a fully integrated approach to study host responses to EAEC that provides new insights on the pathogenesis and treatment of enteric infections.

Clostridium difficile is typically a harmless anaerobic bacterium but has recently re-emerged as a pathogen that can cause nosocomial diarrhea, colitis and death. To investigate the role of peroxisome proliferator-activated receptor (PPAR) γ in modulating immune responses to C. difficile we have performed several studies using a mouse model of antibiotic-induced C. difficile-associated disease (CDAD). The loss of PPARγ in T cells increased disease activity, body weight loss, and colonic inflammatory lesions after infection. It also resulted in upregulated IL-17 and MCP-1, and downregulated IL-10 expression, suggesting that a Th17 phenotype predominates during CDAD in mice lacking T cell PPARγ. Treatment of C. difficile-infected mice with PPAR γ agonists ameliorates disease severity and colonic lesions. RNA-seq results in colonic specimens indicated that three miRNAs were significantly overexpressed in infected mice: mmu-miR-146b, mmu-miR-1940, and mmu-miR-1298 (FDR P < 0.05). Real-time PCR results validated that infection results in overexpression of miR-146b, a molecule involved in regulating immunity and inflammation. Furthermore, NCOA4, a co-activator of PPARγ and target of miR-146b, was down-regulated in colons of infected mice. We provide novel evidence supporting a role for PPARγ in regulating C. difficile-related inflammation and immunopathology and explore the potential role of miRNA in modulating host responses to C. difficile.

Purpose: Duplex examination is today the principal initial method of assessing extracranial carotid or vertebral artery disease. However, varying haemodynamic criteria have been described to categorize the degree of internal carotid artery stenosis, and similarly the degree of stenosis detected with angiography has been assessed with different methods as highlighted in studies performed by the North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial. This study looks at the correlation between two commonly used methods of assessing carotid artery stenosis with duplex criteria and the two methods of angiographic interpretation used in these trials. Duplex parameters are also identified to determine the greater than 70% stenosis group identified as at risk in these studies. Methods: A total of 120 carotid bifurcations were studied in patients who underwent both carotid duplex and angiography. Correlations of duplex with angiography were assessed with duplex criteria described by Zwiebel and by Strandness and the angiographic methods used in studies performed by the North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial. Receiver operator curves were constructed from the duplex data for the detection of stenosis greater than 70% based on the angiographic assessment used in the study performed by the North American Symptomatic Carotid Endarterectomy Trial. Results: The duplex criteria described by Zwiebel and Strandness differed in their accuracy depending on which of the two methods was used to report the angiograms. Zwiebel's criteria agreed more with the angiographic method used in the study performed by the European Carotid Surgery Trial (sensitivity 98%, specificity 81%, accuracy 88%), whereas Strandness' criteria agreed more with the angiographic method used in the study performed by the North American Symptomatic Carotid Endarterectomy Trial (sensitivity 96%, specificity 85%, accuracy 89%). For the detection of a stenosis greater than 70%, a peak systolic velocity greater than 270 cm/sec and end diastolic velocity greater than 110 cm/sec provided a sensitivity of 96%, specificity of 91%, and accuracy of 93%. Conclusions: The accuracy of duplex studies compared with angiography in the assessment of extracranial vascular disease depends on the method of angiographic determination of carotid stenosis. Vascular laboratories should validate the duplex criteria they use against a standard method of angiographic assessment of carotid artery stenosis, with special reference to the recently reported studies noting the significance of a stenosis greater than 70% in patients with symptoms. (J VASC SURG 1994;20:642-9.)

OBJECTIVE This study was undertaken to see if patients who had a radiological diagnosis of arachnoiditis attributed to methylprednisolone acetate (Depo-Medrol, Upjohn Pty Limited) had the clinical syndrome of arachnoiditis. DESIGN An attempt was made to review all patients, reported by Roche in 1984 with a radiological diagnosis of corticosteroid-induced arachnoiditis, by taking a detailed history and performing a physical examination. SETTING The Department of Orthopaedics and Traumatic Surgery, The University of Sydney, The Royal North Shore Hospital, Sydney. RESULTS Of the 18 patients reported by Roche 15 were located and participated in this study. The clinical syndrome of arachnoiditis was defined as a constant burning pain in the back and legs, impotence, marked limitation of spinal motion, alteration of sensation and power in the legs, and a need for regular analgesia. Three of the 15 patients had the clinical syndrome of arachnoiditis. The grade of radiological change was unrelated to the severity of symptoms. The details of doses and precise sites of administration were unavailable for the severely affected individuals. CONCLUSIONS The absence of any other apparent cause for their symptoms implies that Depo-Medrol should not be used in or about the thecal sac.

Two cases of recurrent bleeding from the gastro-intestinal tract are described. The initial diagnosis and the identification of the lesions at laparotomy were difficult problems. In both cases the bleeding was due to a vascular lesion of the small bowel, referred to as angiodysplasia. The lesions were detected before operation by selective angiography and identified at laparotomy by a preoperative and an intraoperative injection of a vital stain through the catheter into the feeding vessels.

Computed tomography detected intra-abdominal abscess with 97% accuracy in 111 patients who underwent 135 separate scans. A true negative ratio of 0.98, and a true positive ratio of 0.96 was obtained. Further important findings, unrelated to the presence of abscesses, were detected in 41 of the 135 scans. The information given by computed tomography significantly modified clinical management in over 55% of studies performed.

Eighteen cases are reported in which the myelographic appearances of adhesive arachnoiditis were found. These patients have had intrathecal steroid injections as either the only procedure or the most likely procedure that could have induced such changes. Adhesive arachnoiditis has not been found at this hospital in the absence of some type of intervention. Other possible iatrogenic causes of arachnoiditis have been excluded in this group. The literature on the aetiology and symptomatology of steroid-induced arachnoiditis is reviewed.

Obstructive jaundice due to growth within bile ducts of hepatocellular carcinoma is uncommon and usually a manifestation of advanced, lethal tumour. We report a case of fibrolamellar carcinoma of the liver presenting with obstructive jaundice, caused by tumorous permeation of the left hepatic duct with migration of tumour fragments into the common bile duct. Immunocytochemical and ultrastructural features are described. Two and a half years after complete surgical resection the patient is free of tumour. The importance of accurate diagnosis of such tumours is emphasized.

In order to evaluate forearm osteodensitometry for its potential to detect subjects with a low spinal mineral content and/or vertebral fractures, single-photon absorptiometry of the forearm and estimations of spinal mineral content by computed tomography were performed in 124 normal and abnormal subjects. Eighty-one per cent (22/27) of patients with vertebral crush fractures had a low spinal mineral content. In contrast, among 64 apparently normal individuals, six patients (four women, two men; 9.4%) had a low spinal mineral content. Forearm osteodensitometry showed a significant positive correlation with spinal mineral content. A forearm value in women in excess of 35 arbitrary units was associated with a spinal value of 75.1-mg equivalent dipotassium phosphate (K2HPO4) or above in 29/31 cases. A forearm value in women of 28.5 arbitrary units or lower was associated with a spinal value of 75-mg equivalent K2HPO4 or less in 20/24 subjects. While of no predictive value for the spine in patients with intermediate readings, forearm osteodensitometry is nevertheless considered a useful screening procedure for spinal osteoporosis.

The standard radiological reports of 50 carotid angiograms were reviewed with regard to the presence of ulceration at the carotid bifurcation. The angiograms were then specifically re-examined retrospectively by a radiologist and the presence or absence of ulceration commented on. The macroscopic features of the carotid endarterectomy specimens of the same patients undergoing carotid endarterectomy were then examined by an independent observer. The results of these three examinations were then compared. There were 28 ulcers in 23 of the 50 specimens with 12 large ulcers (greater than three mm diameter) and 16 small ulcers (less than three mm). In the diagnosis of ulcers, the initial radiological report showed a sensitivity of 32% and a specificity of 97.2%, with an accuracy of 79%, whilst on the retrospective search for ulcers the sensitivity rose to 67.8% whilst the specificity fell to 55.5%, with an accuracy of 59%. The factors affecting the accuracy of the detection of carotid ulcers by angiography are discussed. Angiography in its present form has limitations in diagnosing carotid ulceration.

Acoustic neuromata (AN) account for nearly 90 per cent of internal auditory canal (IAC) and cerebello-pontine angle (CPA) tumours. The second most common tumour is meningioma. Rare lesions include primary cholesteatoma, facial neuroma, lipoma, angioma and various cysts.Two cases of IAC tumour are presented, one of hamartoma in which smooth muscle was prominent and the other of lymphangioma. Of interest are the specific clinical and radiological features associated with these lesions.