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A 43-year-old woman who was 12 weeks pregnant presented with a one-month history of visual loss in the right eye. Neuroimaging studies revealed multiple intracranial aneurysms, one of which compressed the right optic nerve. Her pregnancy raised many issues concerning her management. Evidence of aneurysm enlargement and the increased risk of aneurysm rupture as gestation progressed led to early, successful surgical intervention.
Congenital vascular anomalies have been and remain poorly understood. Since 1982 haemangiomas and vascular malformations have been recognised as distinct entities that exhibit unique characteristics and demand appropriately tailored treatment plans. However, "haemangioma" still continues to be used as a clinical and pathological description of many different types of vascular anomalies, which complicates both the care of patients and the interpretation of reports in journals. In this review we summarise the current classification, terminology, and the pathological basis of these lesions and discuss their management. The various therapeutic options available and their outcome will be discussed in addition to the recent advances in the psychosocial aspects of care, interventional radiology, laser and pharmacological therapy.
Gadolinium chelates have been recently proposed and preliminarily tested as contrast agents for diagnostic and interventional angiography in alternative to iodinated media. However, in most studies low-osmolarity agents were employed and digital subtraction was required for satisfactory images. In this article, we report for the first time in the literature two cases of successful percutaneous renal artery stenting in which gadobutrol, a high-osmolar (1 mmol/ml) gadolinium chelate, was employed as contrast agent because of chronic renal failure and substantial risk for iodinated contrast-associated nephrotoxicity. In both patients gadobutrol yielded high-quality images without digital subtraction and was well tolerated with no ensuing renal dysfunction.
A 46-year-old woman with Darier's disease was referred suffering from severe nail involvement. The patient suffered constant nail infections and an intolerable cycle of progressively more deformity. On examination the patient's nails and nail folds were badly deformed. Initially, as a test, a procedure was undertaken on the thumb alone. The operation was performed under tourniquet control with a digital nerve block. An eponychial flap was raised and nail complex excised. A full thickness skin graft was obtained from the groin. This was sutured into place with the proximal border of graft tucked under the eponychial fold. The results were excellent both surgically and cosmetically. Subsequently, procedures were performed on the remaining nine digits. Darier's disease is extremely variable in its degree of nail involvement. This case highlights a surgical intervention that may help people with intractable associated nail disease.
STUDY OBJECTIVE: To assess the feasibility and potential usefulness of quantitative measurement of end-tidal carbon dioxide pressure (PETCO2) during out-of-hospital cardiac arrest. DESIGN: Emergency medical technician-paramedics (EMT-Ps) were instructed in the operation of a portable battery-powered capnograph, the sensor for which was attached to the endotracheal tube following intubation. This was a preliminary pilot study limited to defining feasibility and potential utility in a small group of patients. SETTING: City with population of 70,745 served by an advanced life support emergency medical services system. PARTICIPANTS: Initial group of four patients who experienced out-of-hospital cardiac arrest and who were treated by EMT-Ps trained in operation of the capnograph. INTERVENTIONS: As soon as possible following endotracheal intubation a mainstream sensor was connected to the endotracheal tube and digital and capnographic waveform data obtained for the remainder of the resuscitation. Data were stored in memory and subsequently retrieved for the entire event, with digital readings at eight-second intervals. RESULTS: Capnographic measurements were obtained immediately after endotracheal intubation in all four patients. The capnograph was operated without difficulty throughout the resuscitations. Changes in performance of chest compression or changes in cardiac rhythm were reflected immediately in changes in (PETCO2). Persistent excretion of carbon dioxide during pulselessness was observed in two patients, consistent with "pseudo-electromechanical dissociation." CONCLUSION: These preliminary pilot observations confirm the feasibility of quantitative capnography during out-of-hospital cardiac arrest and indicate that early institution of this noninvasive procedure may provide insight into pathophysiologic mechanisms such as pseudo-electromechanical dissociation and may also track changes in pulmonary blood flow during chest compressions or during spontaneous circulation.
OBJECTIVE: To test the validity of a colour food photography atlas for quantifying portion size eaten compared with weighed foods. DESIGN: The colour food photography atlas was prepared by cooking, weighing and taking digital photographs of three portion sizes of 434 foods and beverages typical of the Italian diet. SUBJECTS AND INTERVENTIONS: In all, 448 male and female volunteers aged 6-60 y from a wide variety of social backgrounds completed 9075 assessments of food portions eaten at lunch and dinner in relation to a set of colour food photographs during 8 weeks of investigation. The amounts of foods eaten by individuals in five different cafeterias in Pavia, Northern Italy, were weighed by trained investigators at the time of serving and, within 5-10 min of the end of the meal, each subject was asked to quantify all foods consumed with reference to one of the three food photographs or in terms of virtual portions among those shown in the photographs. RESULTS: Multiple regression analysis shows that weights of portion sizes chosen from the set of photographs are significantly associated (P<0.05) to weights of eaten portions (beta=0.81; R(2)=0.70) and are independent of age, gender and BMI. The differences between mean weights of the portions chosen by individuals from photographs and mean weights of eaten foods are significant for all food categories (P<0.05), except for bread. However, because of the very large number of observations, the mean differences are very small (range: from +23.2 g (+11.2%) for first courses to -1.3 g (-2.7%) for bread). Bland-Altman plots show that first courses limits of agreement are wide because the dispersion is increasing while weights are rising. CONCLUSIONS: The use of a series of three photographs and virtual portion sizes being associated with relatively small errors, our findings support the validity of using this colour food photography atlas as a tool for quantifying food portion size in epidemiological dietary surveys on different age groups of Italian subjects.
AIM: The aim of this study is to retrospectively assess the complications and result of cases that underwent open surgery or endoscopic releasing for carpel tunnel syndrome. METHOD: A total of 50 cases of carpel tunnel syndrome, 30 of whom underwent endoscopic release using the biportal extrabursal technique described by Chow, and the other 20 that underwent open surgery were included in the study. Average age of the cases was 41 (24 - 62), 44 of them were females and 6 males. RESULTS: Follow-up examinations of the patients at the first and third month after operation revealed no limitation of activity in 40 (80 %) cases, minimal limitation in 4 (8 %), moderate limitation in 5 (10 %) and significant limitation in 1 (2 %). Among the group that underwent endoscopic release, as a major complication, the median nerve was almost totally cut in a patient undergoing endoscopic release. During the same operation setting perifascicular neurorrhaphy was done. Fourth and fifth digital nerve lesions occurred in three cases. Among the group that underwent open surgery fourth and fifth digital nerve injury occurred in one case, and in another case severe inflammation requiring reoperation occurred. CONCLUSION: Before intervention, cases of carpal tunnel syndrome should be examined well as regards which technique to use. Experience of the surgeon with the technique to be used should also be taken into consideration. Endoscopic carpal tunnel releasing, though a relatively easier procedure, leads to neurovascular injuries more frequently than open surgery; thus open surgery appears to be safer.
In cases of severe bleeding of the nose, besides sufficient packings further steps like surgical exploration and closure of vessels like maxillary or ethmoidal arteries or even the external carotid artery are described in most textbooks. Superselective angiographical embolisation is also mentioned, mostly as an alternative method, while often pointing out the danger of severe thromboembolic complications. In the last two years, we had excellent experiences with this method in 15 cases, without any of the complications mentioned above. We do feel that attempts at superselective angiological embolisation should be made prior to surgical intervention. Of course, technical and personal prerequisites must be adequately met besides excellent individual experience in interventional angiography.
STUDY OBJECTIVES: While there is general agreement on the age changes in non-rapid eye movement sleep, there is conflicting evidence on whether eye movement density (EMD) in rapid eye movement sleep is affected by aging. We therefore performed computer measurement of EMD in young and elderly normal subjects. DESIGN: Sleep electroencephalogram and electrooculogram were recorded in each subject on 4 nonconsecutive baseline nights. Eye movement density in the elderly subjects was compared to that in young adults. SETTING: A sleep research laboratory with 4 separate bedrooms. INTERVENTIONS: Not applicable. PARTICIPANTS: Subjects were 19 young normal adults and 19 elderly normal adults. MEASUREMENTS AND RESULTS: Digitized electrooculograms were analyzed with the extensively validated zero-cross period-amplitude module of PASS PLUS software. The EMD was measured as 0.3 to 2 Hz integrated amplitude per 20-second stage of rapid eye movement sleep. Eye-movement incidence was the number of half waves. Eye-movement amplitude was the sum of peak-trough excursions (curve length) in the average half wave. We also counted visually the number of 2-second epochs with eye movements for 1 baseline night in both groups. The EMD in the elderly subjects was substantially and significantly lower than in the young subjects. Visual scoring of EMD on 1 baseline night confirmed the statistically significant difference between age groups. Period-amplitude analysis revealed that a lower eye-movement incidence rather than reduced amplitude caused the lower EMD in the elderly. The EMD was significantly correlated within subjects across the nonconsecutive baseline nights in both groups; in both, subjects' EMD average across 2 nights provided a correlation greater than .90 with the 4-night mean. CONCLUSIONS: The incidence of eye movements during rapid eye movement sleep is substantially reduced in the elderly. We hypothesize that this reduction is due to degenerative (aging) rather than developmental brain changes. The correlation analysis indicates that EMD is a reasonably stable individual trait in both young and elderly adults. These results encourage normative studies of EMD over a wider age span and continued exploration of the relation of EMD to cognitive function in the elderly.
BACKGROUND: Experts call for stronger safety cultures and transparent reporting practices to increase medication safety in today's strained healthcare environments. The field of ecological restoration is concerned with the effective, efficient, and sustainable repair and recovery of ecosystems that have been degraded, damaged, or destroyed. A study was undertaken to determine whether the lessons of restoration science can be adapted to the study of medication safety issues. METHODS: Working with 26 practitioners, the principles of good restoration were used to design and pilot an innovative multifaceted medication safety intervention. The intervention included focus groups with practitioners, the construction and administration of a research based medication safety inventory, repeat digital photography of environmental safety issues, and targeted environmental modifications. RESULTS: Participants were most concerned about staff education and the physical environment for medication administration. Ward staff used the research to build a healthy reporting culture, introduce regular discussions of near misses, develop education strategies, redesign delivery and storage processes, and renovate the environment. CONCLUSIONS: Members of a busy hospital ward successfully adapted methods of restoration science to study, redesign, and strengthen medication safety practices and ward safety culture within existing resources. Further research will be conducted to test the merits of restoration science for health care.
To reduce radiation exposure to patients and staff during neurointerventional procedures, region-of-interest (ROI) techniques were used with fluoroscopy, road mapping, and digital subtraction angiography in 19 patients. ROI filters, made of multiple layers of gadolinium, were attached to the collimators. Patient skin exposure was reduced by a factor of 3.3-10.0 across 85% of the field of view, and exposures were reduced to below thresholds for skin effects.
We studied the use of digital angiography for the quantification of regional myocardial perfusion in the dog using selective left coronary arterial injection of radiographic contrast material as a flow dilution indicator. We developed algorithms for generating time-intensity curves from regions of interest over the proximal coronary artery and the myocardium and for densitometric error correction by subtraction of the intensity curve over a small lead blocker before logarithmic transformation. The resultant myocardial time-density curves were analyzed for time from injection to peak concentration (TPC) and for exponential washout rate (k). A linear correlation was found between absolute coronary arterial blood flow and both k (slope = 0.13, r = .85) and 1/TPC (slope = 0.18, r = .85). Reproducibility of TPC and k for repeated studies was 11% and 16%. Induced hyperemia significantly improved the sensitivity to stenosis by increasing the average difference in TPC and k between regions served by normal and stenotic coronary arteries to 65% and 80%, respectively. By combining selective coronary arterial injection with the left lateral x-ray projection it was possible to avoid most overlap of regional perfusion beds in the dog. This study suggests that contrast dilution measurements made during digital coronary angiography provide a means for assessing the hemodynamic significance of stenoses and the efficacy of therapeutic interventions.
Fluoroscopic nonsurgical placement of an expandable polyurethane stent is less invasive than surgery for the treatment of epiphora due to obstruction of the nasolacrimal duct. It needs to be performed with the collaboration of an ophthalmologist, using a high resolution digital subtraction imaging unit.
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The medicinal effect of carbostimulin was studied under conditions of anemia in pregnant women. A group of pregnant women (n-54) who were given carbostimulin in addition to the ordinary antianemic therapy showed a 2.5-fold increase of erythrocytes and 1.6-fold rise of hemoglobin as compared to the control group. The number of labour complications decreased: a 5-fold decrease was observed for the intrauterine hypoxia of the fetus and the amount of delayed labour. The percentage of labour with surgical intervention lowered from 40.0 down to 18.5. The frequency of the instrumental examination of the womb cavity and digital removal of the placenta were 6 and 3.4 times as low, respectively. The number of children of small weight became more than twice as low (from 27 up to 12.2%). There were less newborns in the state of light and heavy asphyxia (1.5 and 3.7 times, respectively). No cases of perinatal mortality were observed. Parameters of the newborns peripheral blood improved.
Radiologists' interpretation of mammograms can differ, sometimes substantially. Advances in interventional radiology emphasize the use of stents in the treatment of vascular lesions. It is now possible to digitize any radiographic image and allow it to be stored electronically.
OBJECTIVE: To determine the prevalence of occult prostate cancer in men with low serum total testosterone or free testosterone levels. DESIGN: Retrospective analysis of a consecutive series of men. SETTING: Academic teaching hospital. PATIENTS: Seventy-seven men with low total testosterone or free testosterone levels, with normal results of digital rectal examination and prostate-specific antigen (PSA) levels of 4.0 ng/mL or less. The mean age was 58 years. INTERVENTIONS: Sextant prostate needle biopsies with ultrasound guidance. MAIN OUTCOME MEASURES: Results of prostate needle biopsies, transrectal ultrasound, prostate volume, PSA level, PSA density, total and free testosterone levels. RESULTS: Prostate cancer was identified in 14% (11/77) of the entire group and in 10 men (29%) aged 60 years or older. The median age for men with cancer was 64 years. Histologic examination showed Gleason scores of 6 or 7 for all cancers. No significant differences were noted between the cancer and benign groups with regard to PSA level, PSA density, prostate volume, total testosterone level, or free testosterone level. CONCLUSIONS: A high prevalence of biopsy-detectable prostate cancer was identified in men with low total or free testosterone levels despite normal PSA levels and results of digital rectal examination. These data suggest that (1) digital rectal examination and PSA levels are insensitive indicators of prostate cancer in men with low total or free testosterone levels, and (2) PSA levels may be altered by naturally occurring reductions in serum androgen levels.
Computerized techniques (CT and MRI) allow precise delineation of orbital anatomy and abnormalities. Orbital tumors are nicely depicted by these methods; various examples are illustrated in this article, with discussion of the respective impact of CT and MRI. Orbital inflammation and foreign bodies usually represent radiologic emergencies, prompting use of CT (frequently) or MRI (occasionally). Digital subtraction angiography (DSA) is indicated for diagnosis of vascular changes (mainly carotid-cavernous fistula, aneurysms, angiomas, Rendu-Osler disease). Angiography is usually done to ascertain the possibility of an interventional procedure. Orbital vascular interventions include re-canalization of occluded vessels, and embolization of pathologic (tumorous or post-traumatic) vessels.