Search

Objectives Subjective loss of response immediately prior to routine TNFi therapy can occur in axial spondyloarthritis (axSpA). We investigated clinical outcomes in patients taking the first three licenced TNFis and correlated this with recurrence of MRI bone marrow oedema (MRI-BMO). Methods Proof-of-concept study including axSpA patients established on etanercept (ETA), adalimumab (ADA) or infliximab (IFX) reporting symptom deterioration prior to next dose. MRI/clinical data were collected prior to scheduled dose (v1), 4 days post-dose (v2) and at the time of patient-reported symptom return (v3). MRI spine/sacroiliac joints utilizing 3 T were scored using the semi-quantitative Leeds MRI scoring system. Results A total of 113 clinical assessments and MRIs were performed in 38 participants (ADA = 16, ETA = 12, IFX = 10), mean age 42.1 years ± 24.4(2SD, n = 38), 71.1% male (n = 27/38), 69.7% HLA-B27 positive (n = 23/33). At v1, all patients had high disease activity [ASDAS-CRP = 3 (2.7–3.7)] and 57.9% had MRI-BMO (number of MRI-BMO: ETA = 26, ADA = 59, IFX = 28). Improved clinical responses were seen at v2 [ASDAS-CRP −0.41(−0.81 − 0.30), P =0.018; BASDAI −0.58(−2.2 − 0.52), P =0.024]. Despite just a 4-day interval between v1 and v2, a numerical reduction in MRI-BMO lesions between v1/v2 was observed (ETA = −6, ADA = −10, IFX = −3). By v3, comparatively fewer new BMO lesions were detected in the ETA and ADA groups compared with IFX (ETA = −1, ADA = +3, IFX = +8), although the numbers were too small to enable testing for statistical significance. Conclusions Short-lived fluctuations in MRI-BMO were commoner with longer-acting agents and corresponded with subjective loss of clinical response before next scheduled TNFi dose. Larger studies are needed to confirm the possible pathogenic implications of this phenomenon.

This report describes a set of neonatal electroencephalogram (EEG) recordings graded according to the severity of abnormalities in the background pattern. The dataset consists of 169 hours of multichannel EEG from 53 neonates recorded in a neonatal intensive care unit. All neonates received a diagnosis of hypoxic-ischaemic encephalopathy (HIE), the most common cause of brain injury in full term infants. For each neonate, multiple 1-hour epochs of good quality EEG were selected and then graded for background abnormalities. The grading system assesses EEG attributes such as amplitude, continuity, sleep–wake cycling, symmetry and synchrony, and abnormal waveforms. Background severity was then categorised into 4 grades: normal or mildly abnormal EEG, moderately abnormal EEG, majorly abnormal EEG, and inactive EEG. The data can be used as a reference set of multi-channel EEG for neonates with HIE, for EEG training purposes, or for developing and evaluating automated grading algorithms.

Sleep supports neurodevelopment and sleep architecture reflects brain maturation. This prospective observational study describes the nocturnal sleep architecture of healthy moderate to late preterm (MLP) infants in the neonatal unit at 36 weeks post menstrual age (PMA).MLP infants, in the neonatal unit of a tertiary hospital in Ireland from 2017 to 2018, had overnight continuous electroencephalography (cEEG) with video for a minimum 12 h at 36 weeks PMA. The total sleep time (TST) including periods of active sleep (AS), quiet sleep (QS), indeterminate sleep (IS), wakefulness and feeding were identified, annotated and quantified.A total of 98 infants had cEEG with video monitoring suitable for analysis. The median (IQR) of TST in the 12 h period was 7.09 h (IQR 6.61-7.76 h), 4.58 h (3.69-5.09 h) in AS, 2.02 h (1.76-2.36 h) in QS and 0.65 h (0.48-0.89 h) in IS. The total duration of AS was significantly lower in infants born at lower GA (p = 0.007) whilst the duration of individual QS periods was significantly higher (p = 0.001).Overnight cEEG with video at 36 weeks PMA showed that sleep state architecture is dependent on birth GA. Infants with a lower birth GA have less AS and more QS that may have implications for later neurodevelopment.EEG provides objective information about the sleep organisation of the moderate to late preterm (MLP) infant. Quantitative changes in sleep states occur with each week of advancing gestational age (GA). Active sleep (AS) is the dominant sleep state that was significantly lower in infants born at lower GA. MLP infants who were exclusively fed orally had a shorter total sleep time and less AS compared to infants who were fed via nasogastric tube.

Understanding the evolution of the nuclear charge radius is one of the long-standing challenges for nuclear theory. Recently, density functional theory calculations utilizing Fayans functionals have successfully reproduced the charge radii of a variety of exotic isotopes. However, difficulties in the isotope production have hindered testing these models in the immediate region of the nuclear chart below the heaviest self-conjugate doubly-magic nucleus 100Sn, where the near-equal number of protons (Z) and neutrons (N) lead to enhanced neutron-proton pairing. Here, we present an optical excursion into this region by crossing the N = 50 magic neutron number in the silver isotopic chain with the measurement of the charge radius of 96Ag (N = 49). The results provide a challenge for nuclear theory: calculations are unable to reproduce the pronounced discontinuity in the charge radii as one moves below N = 50. The technical advancements in this work open the N = Z region below 100Sn for further optical studies, which will lead to more comprehensive input for nuclear theory development., Laser spectroscopic measurements of isotopes near the doubly-magic 100-Sn are challenging due to difficulties in their production. Here the authors measure the ground state charge radius of the proton-rich 96-Ag isotope and find a discontinuity in the nuclear size when crossing the neutron number N equal to 50.

Pallister Killian Syndrome (PKS) is a rare genetic disorder caused by a mosaic tetrasomy of the short arm of chromosome 12. The syndrome is characterised by typical craniofacial dysmorphism, congenital anomalies and intellectual disability. Epilepsy is a known complication, with onset usually occurring in early childhood and characterised most commonly by spasms and myoclonic seizures. To the best of our knowledge, there have been no cases describing the early neonatal EEG in PKS and electrographic seizures, to date. Here, we report two cases of PKS presenting in the neonatal period with distinctive EEG features and seizures.

Seizures are more common in the neonatal period than at any other time of life, partly due to the relative hyperexcitability of the neonatal brain. Brain monitoring of sick neonates in the NICU using either conventional electroencephalography or amplitude integrated EEG is essential to accurately detect seizures. Treatment of seizures is important, as evidence increasingly indicates that seizures damage the brain in addition to that caused by the underlying etiology. Prompt treatment has been shown to reduce seizure burden with the potential to ameliorate seizure-mediated damage. Neonatal encephalopathy most commonly caused by a hypoxia-ischemia results in an alteration of mental status and problems such as seizures, hypotonia, apnea, and feeding difficulties. Confirmation of encephalopathy with EEG monitoring can act as an important adjunct to other investigations and the clinical examination, particularly when considering treatment strategies such as therapeutic hypothermia. Brain monitoring also provides useful early prognostic indicators to clinicians. Recent use of machine learning in algorithms to continuously monitor the neonatal EEG, detect seizures, and grade encephalopathy offers the exciting prospect of real-time decision support in the NICU in the very near future.

ObjectivesThe Canadian Stroke Best Practice Recommendations suggests that patients suspected of transient ischemic attack (TIA)/minor stroke receive urgent brain imaging, preferably computed tomography angiography (CTA). Yet, high requisition rates for non-cerebrovascular patients overburden limited radiological resources, putting patients at risk. We hypothesize that our clinical decision support tool (CDST) developed for risk stratification of TIA in the emergency department (ED), and which incorporates Canadian guidelines, could improve CTA utilization.MethodsRetrospective study design with clinical information gathered from ED patient referrals to an outpatient TIA unit in Victoria, BC, from 2015-2016. Actual CTA orders by ED and TIA unit staff were compared to hypothetical CTA ordering if our CDST had been used in the ED upon patient arrival.ResultsFor 1,679 referrals, clinicians ordered 954 CTAs. Our CDST would have ordered a total of 977 CTAs for these patients. Overall, this would have increased the number of imaged-TIA patients by 89 (10.1%) while imaging 98 (16.1%) fewer non-cerebrovascular patients over the 2-year period. Our CDST would have ordered CTA for 18 (78.3%) of the recurrent stroke patients in the sample.ConclusionsOur CDST could enhance CTA utilization in the ED for suspected TIA patients, and facilitate guideline-based stroke care. Use of our CDST would increase the number of TIA patients receiving CTA before ED discharge (rather than later at TIA units) and reduce the burden of imaging stroke mimics in radiological departments.

An animal’s survival depends on finding food, and the memory of food and contexts are often linked. Given that the hippocampus is required for spatial and contextual memory, it is reasonable to expect related coding of space and food stimuli in hippocampal neurons. However, relatively little is known about how the hippocampus responds to tastes, the most central sensory property of food. In this study, we examined the taste-evoked responses and spatial firing properties of single units in the dorsal CA1 hippocampal region as male rats received a battery of taste stimuli differing in both chemical composition and palatability within a specific spatial context. We identified a subset of hippocampal neurons that responded to tastes, some of which were place cells. These taste and place responses had a distinct interaction: taste-responsive cells tended to have less spatially specific firing fields, and place cells only responded to tastes delivered inside their place field. Like neurons in the amygdala and lateral hypothalamus, hippocampal neurons discriminated between tastes predominantly on the basis of palatability, with taste-selectivity emerging concurrently with palatability-relatedness; these responses did not reflect movement or arousal. However, hippocampal taste responses emerged several hundred msec later than responses in other parts of the taste system, suggesting that the hippocampus does not influence real-time taste decisions, instead associating the hedonic value of tastes with a particular context. This incorporation of taste responses into existing hippocampal maps could be one way that animals use past experience to locate food sources.Significance statementFinding food is essential for animals’ survival, and taste and context memory are often linked. While hippocampal responses to space and contexts have been well characterized, little is known about how the hippocampus responds to tastes. Here, we identified a subset of hippocampal neurons that discriminated between tastes based on palatability. Cells with stronger taste responses typically had weaker spatial responses, and taste responses were confined to place cells’ firing fields. Hippocampal taste responses emerged later than in other parts of the taste system, suggesting that the hippocampus does not influence taste decisions, but rather, associates the hedonic value of tastes consumed within a particular context. This could be one way that animals use past experience to locate food sources.

Background: Many patients with psoriasis have undiagnosed psoriatic arthritis. Low specificity is found with many PsA screening tools. A new instrument, the CONTEST questionnaire, was developed utilizing the most discriminative items from existing instruments.Objective: The aim of this study was to compare the CONTEST and PEST screening tools.Methods: People attending secondary care clinics with psoriasis, but not PsA, completed the questionnaires, were assessed for function and quality of life, and had a physical examination. Patients thought to have PsA were compared to those without. The performance of CONTEST and PEST was compared using area under the receiver operating curve (AUC), and sensitivity and specificity at the previously published cut‐offs.Results: A total of 451 dermatology patients were approached, 35% were reviewed and 27 (17%, 95% CI 12.3–21.7) had unidentified psoriatic arthritis. The sensitivity and specificity (95% CI) of PEST were 0.60 (0.42–0.78)/0.76 (0.69–0.83) and for CONTEST 0.53 (0.34–0.72)/0.71 (0.63–0.79). The confidence limits for the AUC overlapped (AUC for PEST 0.72 (0.61–0.84), for CONTEST 0.66 (0.54–0.77).Conclusions: PEST and CONTEST questionnaires performed equally well, with no superiority of the new CONTEST tool.

Background Tumour necrosis factor inhibitors (TNFi) are highly efficacious in axial spondyloarthritis (axSpA) with significant clinical responses mirrored in resolution of MRI determined bone marrow oedema (BMO) lesions representative of active inflammation in the sacroiliac joints (SIJ) and spine. However, symptom flare suggesting loss of response is common with many patients reporting deterioration days or weeks prior to the next dose. We hypothesised that intermittent suppression of inflammation with longer acting TNFis such as adalimumab or infliximab may be associated with a greater likelihood of recurrence of MRI determined BMO lesions than shorter acting agents such as etanercept. Objectives To explore the relationship between symptom flare immediately prior to next treatment dose and recurrence of MRI determined BMO lesions with different TNFi in axSpA. Methods Proof-of-concept, single centre study. Eligible participants were adults with axSpA established on adalimumab, etanercept or infliximab describing loss of response immediately prior to next treatment dose. Loss of response was defined as subjective “flare” or “wearing off” of drug effect before the expected duration of treatment effect. Participants attended at three points: Baseline: first day of treatment cycle (day of drug dose); Endpoint 1: 3–4 days after dose; and Endpoint 2: within 48 hours of next dose. ASDAS-CRP and whole spine and SIJ MR imaging utilising 3T MRI scanner were performed at each visit. Images were scored according to the semi-quantitative Leeds MRI scoring system by two observers blinded to participant identity and date of scan. Results 38 participants (16 adalimumab; 12 etanercept; 10 infliximab) with a total 113 MRI scans were analysed. 71% (n=27) male; 60% (n=23) HLA-B27+ with no differences between the groups; 73.7% (n=28) fulfilled mNYC for AS; the remainder were classified as nr-axSpA. 58% (n=22) had at least 1 Grade 1 BMO lesion at baseline with lesions more commonly seen with longer acting drugs (5/12 in etanercept group; 9/16 in adalimumab group; 8/10 in infliximab group) and 11 (50%) had at least 1 Grade ≥2 lesion (Table 2). There was a trend towards number and severity of BMO lesions fluctuating through the treatment cycle (Figure 1) mimicking subjective loss of response, also reflected on the ASDAS-CRP (Table 1) but this did not reach statistical significance. Conclusions This small proof-of-concept study shows subtle fluctuations on MRI changes of BMO and ASDAS-CRP corresponding to time of subjective “flare” before next scheduled TNFi dose in subjects with axSpA. Although these changes may be more common with the longer acting TNFi our data are not confirmatory. Larger studies are required to explore this concept further as these observations are potentially relevant for disease progression since cycles of inflammation and its subsequent suppression could theoretically increase the risk of new bone formation. Acknowledgements This study was sponsored by Pfizer. Disclosure of Interest R. Ansell Grant/research support from: Pfizer, H. Mathieson: None declared, M. Merashli: None declared, N. Busquets-Perez: None declared, D. McGonagle Grant/research support from: Celgene, Janssen & Pfizer, Consultant for: AbbVie, Celgene, Janssen, Novartis, UCB, Speakers bureau: Abbvie, Celgene, Janssen, UCB., H. Marzo-Ortega Grant/research support from: Janssen & Pfizer., Consultant for: AbbVie, Celgene, Janssen, Novartis, UCB. S, Speakers bureau: Abbvie, Celgene, Janssen, UCB.

Background Circadian variation of joint stiffness (morning stiffness) and its impact on functional ability are widely recognised in rheumatoid arthritis. Subsequent within-day variation of walking ability is important due to the increased availability of instrumented gait analysis. This study aimed to quantify diurnal variation of gait in patients with rheumatoid arthritis, and explore associations with disease characteristics. Methods Thirty one inpatients with rheumatoid arthritis walked at a self-selected speed along a GAITRite instrumented walkway 5 times during a single day. Findings Participants showed marked diurnal variation in gait, leading to a systematic variation throughout the day (F = 19.56, P =, Highlights • Patients with rheumatoid arthritis exhibited a systematic change in walking ability throughout the day. • The magnitude of within day change appeared independent of disease characteristics. • In future, repeat measures should be conducted at the same time of day to exclude the effects of diurnal variation.

Highlights • Phenobarbital reduces both amplitude and propagation of neonatal seizures. • These changes may help to explain electroclinical uncoupling. • The performance of our seizure detection algorithm was unaffected., Objective Phenobarbital increases electroclinical uncoupling and our preliminary observations suggest it may also affect electrographic seizure morphology. This may alter the performance of a novel seizure detection algorithm (SDA) developed by our group. The objectives of this study were to compare the morphology of seizures before and after phenobarbital administration in neonates and to determine the effect of any changes on automated seizure detection rates. Methods The EEGs of 18 term neonates with seizures both pre- and post-phenobarbital (524 seizures) administration were studied. Ten features of seizures were manually quantified and summary measures for each neonate were statistically compared between pre- and post-phenobarbital seizures. SDA seizure detection rates were also compared. Results Post-phenobarbital seizures showed significantly lower amplitude (p

Highlights ► Kv3.1b and Kv3.3 expression was studied in dorsal horn GABAergic interneurones. ► Kv3.1b or Kv3.3 was most abundantly expressed in laminae I–III. ► Kv3.1b but not Kv3.3 was associated with GAD65 and GAD67 neurones. ► Capsaicin-induced c-fos expression was localized mainly to GAD65-GFP interneurones., GABAergic interneurones, including those within spinal dorsal horn, contain one of the two isoforms of the synthesizing enzyme glutamate decarboxylase (GAD), either GAD65 or GAD67. The physiological significance of these two GABAergic phenotypes is unknown but a more detailed anatomical and functional characterization may help resolve this issue. In this study, two transgenic Green Fluorescent Protein (GFP) knock-in murine lines, namely GAD65-GFP and GAD67-GFP (Δneo) mice, were used to profile expression of Shaw-related Kv3.1b and Kv3.3 K+-channel subunits in dorsal horn interneurones. Neuronal expression of these subunits confers specific biophysical characteristic referred to as ‘fast-spiking’. Immuno-labelling for Kv3.1b or Kv3.3 revealed the presence of both of these subunits across the dorsal horn, most abundantly in laminae I–III. Co-localization studies in transgenic mice indicated that Kv3.1b but not Kv3.3 was associated with GAD65-GFP and GAD67-GFP immunopositive neurones. For comparison the distributions of Kv4.2 and Kv4.3 K+-channel subunits which are linked to an excitatory neuronal phenotype were characterized. No co-localization was found between GAD-GFP +ve neurones and Kv4.2 or Kv4.3. In functional studies to evaluate whether either GABAergic population is activated by noxious stimulation, hindpaw intradermal injection of capsaicin followed by c-fos quantification in dorsal horn revealed co-expression c-fos and GAD65-GFP (quantified as 20–30% of GFP +ve population). Co-expression was also detected for GAD67-GFP +ve neurones and capsaicin-induced c-fos but at a much reduced level of 4–5%. These data suggest that whilst both GAD65-GFP and GAD67-GFP +ve neurones express Kv3.1b and therefore may share certain biophysical traits, their responses to peripheral noxious stimulation are distinct.

While plain abdominal radiographs retain an essential place in acute abdominal emergencies, the dramatic advances in ultrasound, computed tomography and magnetic resonance imaging witnessed over the past two decades have revolutionized the practice of emergency medicine. Crosssectional imaging techniques now play a key role in evaluating patients with abdominal emergencies, and allow confident diagnoses to be made in an ever increasing proportion of these patients. Unnecessary laparotomies are now uncommon, and a wide array of interventional radiological techniques can be used to treat abdominal emergencies without surgery.

The authors studied the prevalence of abnormalities at abdominal ultrasonography (US) in patients with acquired immunodeficiency syndrome (AIDS), the temporal change in prevalence, and the use of US to correlate clinical indications with these abnormalities.From 1983 to 1991, 899 AIDS patients were seen, representing 89.36% of the 1,006 AIDS patients in the province during that time. Of these, 414 underwent 684 US studies, 399 of which were able to be reviewed.US results showed abnormalities in 264 of the 399 studies, including splenomegaly (n = 124), lymphadenopathy (n = 83]), gallbladder and bile duct abnormalities (n = 80), hepatomegaly (n = 77), and ascites (n = 54). Clinical indications with the highest frequency of abnormal findings included hepatosplenomegaly (n = 337) and abnormal liver function tests (n = 270). Lymph nodes more than 3 cm in diameter (in 10 of 83 patients with enlarged nodes) always represented an abnormality other than reactive hyperplasia. The percentage of abnormal results went from 25% in 1984 (two of nine studies) to 81% in 1990 (77 of 95 studies).The prevalence of abdominal abnormalities depicted at US in AIDS patients has increased since 1983.

To determine how long Gianturco-Rosch metal stents remain patent when used as the initial treatment for malignant obstruction of the common bile duct.The patency of Gianturco-Rosch metal stents was prospectively studied in 26 patients with malignant obstructive jaundice. Biliary obstruction was caused by pancreatic carcinoma (n = 15), cholangiocarcinoma (n = 10), or metastatic lymphadenopathy (n = 1). Follow-up information was obtained every 3-4 months until death.Stent insertion was successful in all patients. Stent occlusion occurred in nine patients (35%). The overall mean patency period was 39.9 weeks. Adequate biliary drainage for a minimum of 80 weeks or until death was achieved in 19 patients (73%). Life-table analysis predicted stent patency rates of 86%, 75%, and 69% at 12, 24, and 48 weeks, respectively.These results are better than those previously reported in patients with plastic endoprostheses. The authors believe that insertion of the metal stent is the procedure of choice in patients with inoperable malignant biliary obstruction.

The impact of AIDS has included a fundamental reappraisal of methods of disease transmission, and the type of risks posed not only to health care professionals, but also to the public seeking medical care.

Small catheters containing 20 MHz transducers have recently become available for high resolution endoluminal ultrasound. We report our early use of this technique to image and stage esophageal carcinoma. Fifteen patients undergoing high resolution endoluminal ultrasonography for suspected esophageal carcinoma were studied. Twelve of these patients also underwent computed tomography and pathologic correlation was available in seven. Satisfactory esophageal examination was possible in 14 of 15 patients. Of those with pathologic correlation, the depth of tumor invasion was correctly staged by high resolution endoluminal ultrasonography in six of seven patients and by computed tomography in only three of seven patients. Lymph node assessment correlated poorly with pathologic findings for both high resolution endoluminal ultrasound and computed tomography. With the increasing use of preoperative radiation therapy, we believe these early results predict a potential role for high resolution endoluminal ultrasonography in the staging of esophageal carcinoma.

The dimensions of the infrarenal inferior vena cava during quiet respiration, single leg lifting, and breath-holding were assessed using sonography in 156 patients. Sonographic assessment of infrarenal inferior vena caval dimensions was feasible in 69% of patients. Measurements during breath-holding were significantly greater than during quiet respiration (P < 0.001) and leg lifting (P < 0.005), although in approximately one quarter of the patients the mean calculated diameter was greatest during quiet respiration. we conclude that sonographic assessment of infrarenal inferior vena caval dimensions is feasible, but it should be performed during quiet respiration and breath-holding to allow for variation with different respiratory maneuvers.

Purpose To determine the effect of extent of peritoneal contamination in enteric abscesses on final outcome and duration of percutaneous drainage. Patients and Methods Results were retrospectively reviewed for 11 patients with varying degrees of peritoneal contamination secondary to subacute bowel perforation who were primarily treated with percutaneous drainage. Stepwise linear regression analysis of duration of drainage was performed with use of patient age and immune status, the site of bowel perforation, and the number of peritoneal compartments involved in the resultant contamination as independent variables. Results In 10 of 11 patients (91%) treatment of the resultant intraperitoneal collections with percutaneous drainage was successful irrespective of the extent of peritoneal contamination. There was no correlation between duration of drainage and extext of peritoneal contamination but good correlation with patient age and site of bowel perforation ( r =0.82, P =.02). Conclusion In patients with enteric abscesses due to subacute bowel perforation, the duration of drainage and final outcome after percutaneous drainage are independent of the extent of peritoneal contamination.

While plain abdominal radiographs retain an essential place in acute abdominal emergencies, the dramatic advances in ultrasound, computed tomography and magnetic resonance imaging witnessed over the past two decades have revolutionized the practice of emergency medicine. Cross-sectional imaging techniques now play a key role in evaluating patients with abdominal emergencies, and allow confident diagnoses to be made in an ever increasing proportion of these patients. Unnecessary laparotomies are now uncommon, and a wide array of interventional radiological techniques can be used to treat abdominal emergencies without surgery.

To assess the long-term outcome in patients with acute cholecystitis treated initially by percutaneous cholecystostomy, the authors reviewed the medical and radiology records of all such patients treated at their hospital from January 1990 to September 1993. Of the 50 patients, 29 had calculous and 21 had acalculous cholecystitis. In the group with calculous cholecystitis, 1 of the patients required no further treatment, 3 subsequently underwent percutaneous stone removal, 14 underwent elective cholecystectomy, 6 underwent emergency cholecystectomy and 5 died of the underlying condition shortly after cholecystostomy. In the group with acalculous cholecystitis, 12 of the patients needed no further treatment after a mean follow-up period of 12 months; 8 of these underwent follow-up ultrasound examination, which revealed gallbladder calculi in only 1 patient. Four patients underwent elective cholecystectomy, 1 underwent emergency cholecystectomy, and 4 died of the underlying condition shortly after cholecystostomy. Over the long term, 23 (79%) of the 29 patients with calculous cholecystitis underwent surgery or removal of calculi. In the other group surgery was required in only 5 (24%) of the 21 patients. The authors conclude that percutaneous cholecystostomy is a useful temporizing measure, which allows patients with calculous cholecystitis to undergo elective cholecystectomy. In most cases of acalculous cholecystitis the procedure is curative, obviating the need for cholecystectomy.

Hyoscine butylbromide (Buscopan) is an intravenously administered hypotonic agent that significantly reduces pressure in the lower esophageal sphincter and may therefore artificially induce gastroesophageal reflux during barium examination of the upper gastrointestinal tract. This study was performed to test this hypothesis. The presence or absence and severity of gastroesophageal reflux before and after intravenous injection of 20 mg Buscopan were evaluated in 112 consecutive patients undergoing biphasic upper gastrointestinal examination. Gastroesophageal reflux was seen in 49 (44%) of the patients. Reflux was evident both before and after the injection of Buscopan in 35 (31%) of the patients, before injection only in 10 (9%) and after injection only in 4 (4%). The magnitude of reflux after injection of Buscopan was reduced or the same in 108 of the patients (96%) and increased in 4 (4%). There was no significant difference in the overall occurrence (p = 0.41) or degree (p = 0.81) of gastroesophageal reflux before and after injection of Buscopan (chi 2 test). The authors conclude that the routine use of Buscopan is unlikely to spuriously increase the frequency or degree of gastroesophageal reflux observed on upper gastrointestinal barium studies.

This study was undertaken to confirm the utility of systematic transrectal ultrasound-guided prostate biopsy in diagnosing cancer in patients with abnormal findings on digital rectal examination or abnormal levels of prostate-specific antigen (or both). The authors also wanted to determine the diagnostic advantage of taking six sextant biopsy samples rather than four quadrant samples. In a prospective study of 669 men examined between July 1992 and April 1993 at a tertiary-care hospital, core samples were obtained from any visualized or palpated abnormalities, the three other "normal" quadrants (apices and bases) and the two parasagittal midzones. The glands of 403 of the patients (60%) had an abnormality detectable by ultrasonography, and 233 of the patients (35%) had adenocarcinoma, proven by histologic examination. Of the 169 cases of adenocarcinoma initially indicated by ultrasonography, the suspected lesion was histologically benign in 66 (39%), but malignancy was found in another portion of the gland. In 18 (8%) of the 233 patients with adenocarcinoma, the only positive result was obtained from the additional core biopsy samples from the midzone. This study confirms that the ultrasonographic characteristics of cancer are variable, that many tumours (130 [56%] in this study) are detected in areas that are normal on ultrasonography and digital rectal examination, and that the detection sensitivity is increased (by 8% in this study) when two midlobe parasagittal plane biopsy samples are added to the four standard quadrant samples.