Review of external referrals to a regional stroke centre: it is not just about thrombectomy.

AIMS: To determine the experience of a regional stroke referral centre of external referrals for endovascular thrombectomy (EVT) in patients with symptoms of acute ischaemic stroke (AIS) and large vessel occlusion (LVO). MATERIALS AND METHODS: Data were collected prospectively over two 4-month periods (2017-2018) on consecutive external referrals for EVT. Baseline demographics, imaging findings, and key time parameters were recorded. Reasons for not transferring patients and for not performing EVT were recorded. Key time intervals were calculated and compared between the transferred and non-transferred group with and without intracranial occlusion and between the transferred patients who underwent thrombectomy and those who did not. RESULTS: Two hundred and sixty-two patients were referred. Sixty-one percent (n=159) were accepted and transferred for treatment. Of those transferred, 86% (n=136) had EVT. Fourteen percent (n=23) were unsuitable for EVT on arrival due to no vessel occlusion (48% n=11), poor Alberta Stroke Program Early CT Score (ASPECTS)/established infarct (30%, n=7) haemorrhage (9%, n=2), and clinical recovery (13% n=3). One hundred and three patients (39%) were ineligible for EVT following phone discussion due to absence of intracranial occlusion (59%, n=61), low ASPECTS (22%, n=23), distal occlusion (4%, n=4), low/improving National Institutes of Health Stroke Scale (NIHSS; 10.7%, n=11), and poor modified Rankin Scale (mRS) at baseline (3%, n=3). Patients with LVO but not transferred had longer onset to hospital arrival time compared with those transferred 151.5 versus 91 minutes (p<0.005), with a trend also toward a longer door to CT/CTA 40 minutes versus 30 minutes (p=0.142). CONCLUSION: These data provide valuable insights into the service provision of a comprehensive stroke network. The present rates of EVT and futile transfers are modest compared to published data. Access to neuroradiology and specialised stroke assessment is crucial to optimise time to treatment.

Identification of a new diarrhoetic toxin in shellfish using liquid chromatography with fluorimetric and mass spectrometric detection.

A new toxin, dinophysistoxin-2B (DTX-2B) was isolated from Irish mussels using silica chromatography, gel permeation, octadecylsilane solid-phase extraction and repeated preparative high-performance liquid chromatography (HPLC). Dinophysistoxin-2 (DTX-2) was also isolated from shellfish using the same procedures. The separation of these toxins in chromatographic fractions was monitored using fluorimetric HPLC following derivatization with 9-anthrylmethyldiazomethane or 1-bromoacetylpyrene. Flow-injection analysis-mass spectrometry (FIA-MS) with an atmospheric pressure ionization (API) and an ionspray (ISP) interface showed a mass spectrum dominated by the protonated molecule, [M+H]+, at m/z 805 for DTX-2B, thus indicating that this new toxin has the same mol.wt as okadaic acid and DTX-2. The low-energy fragment ion spectrum, as produced in FIA-MS experiments by up-front collision-induced dissociation of the protonated molecule of DTX-2B, showed fragment ions corresponding to successive losses of water molecules from the [M+H]+ ion. This low collision energy fragmentation pattern is typical of marine polyether toxins such as okadaic acid, DTX-2 and DTX-1. These results provide strong evidence that DTX-2B is another okadaic acid isomer.

Isolation of dinophysistoxin-2 and the high-performance liquid chromatographic analysis of diarrhetic shellfish toxins using derivatisation with 1-bromoacetylpyrene.

The rare diarrhetic shellfish toxin, dinophysistoxin-2 (DTX-2), was isolated from the digestive glands of mussels (Mytilus edulis). This was achieved by chromatography on silica and Sephadex LH-20 followed by reversed-phase solid phase extraction and semi-preparative high-performance liquid chromatography (HPLC) with an Ultremex C18 column. Using 1-bromoacetylpyrene (BAP), as a precolumn derivatisation reagent, the diarrhetic shellfish toxins, okadaic acid (OA), dinophysistoxin-1 (DTX-1) and DTX-2, were determined by HPLC with fluorimetric detection. Derivatisation using BAP was compared with 9-anthryldiazomethane (ADAM) and, although the latter exhibited a four-fold better sensitivity, the BAP method gave fewer artefact peaks from reagent decomposition. The limits of detection of OA and DTX-2 were 0.4 ng on-column using BAP, which permits this method to be used for the regulatory control of these toxins in shellfish.

Dinophysistoxin-2: the predominant diarrhoetic shellfish toxin in Ireland.

Diarrhoetic shellfish poisoning (DSP) in Europe is due mainly to the presence of the dinoflagellate toxin, okadaic acid (OA). However, analysis of cultivated mussels (Mytilus edulis) from southwest Ireland revealed that an isomer of OA, dinophysistoxin-2, was the major toxin present during DSP episodes. Using fluorimetric HPLC, following derivatisation with 9-anthryldiazomethane, both OA and DTX-2 were found in shellfish during a prolonged toxic episode in 1991. However, examination of similar mussel cultivation locations in 1994 showed that DTX-2 was even more predominant. During this DSP period, OA levels were less than 0.7 microgram/g, whereas maximum DTX-2 levels of 6.3 micrograms/g hepatopancreas were recorded. This toxicity in shellfish occurred soon after high cell counts of Dinophysis acuta were observed. As well as large seasonal variability in toxin levels in rope cultured mussels, substantial variations were also observed, both horizontally and vertically, within the water column.

Percutaneous gastrostomy and gastrojejunostomy: additional experience in 519 procedures.

PURPOSE: To assess the efficacy and safety of radiologically guided percutaneous placement of gastrostomy and gastrojejunostomy catheters. MATERIALS AND METHODS: Over 6 years, 562 referred patients were considered for gastrojejunostomy or gastrostomy procedures. In 43 cases (7.7%), the procedure was not performed because of overlying viscera, high position of the stomach, or massive ascites. In 478 patients, 519 procedures were performed. RESULTS: Of 507 attempted gastrojejunostomy procedures, 482 (95.1%) were successful, 14 (2.8%) catheters could not be advanced through the pylorus and necessitated gastrostomies, and 11 (2.2%) were technical failures. Twelve gastrostomy tubes were placed for decompression, with a 100% success rate. Thirty-day follow-up data were available for 457 procedures: The 30-day mortality rate was 17.1% (71 of 416 patients). There were two gastrostomy-related deaths. The overall major and minor complication rates were 1.3% and 2.9%, respectively. CONCLUSION: Percutaneous gastrostomy and gastrojejunostomy are safe and effective methods of providing short- or long-term enteral nutrition or upper gastrointestinal tract decompression.

Cytomegalovirus cholangitis after renal transplantation.

Clinically significant cytomegalovirus cholangitis is well recognized in patients with AIDS but is less common in other groups of immunocompromised patients. The authors describe a 59-year-old man who had undergone renal transplantation in whom this condition developed, and they emphasize that this diagnosis should be considered in renal transplant patients presenting with biliary obstruction. Careful examination of biopsy material for cytomegalovirus inclusion bodies is necessary.

Angiomyolipomas of the liver in tuberous sclerosis.

Although the association of tuberous sclerosis and renal angiomyolipomas is well established, the occurrence of hepatic hamartomatous lesions in this disease is less well documented. We describe two cases of tuberous sclerosis with associated multiple intrahepatic angiomyolipomas, and we review the literature on this subject. Radiologically, angiomyolipomas can range from entirely lipomatous to completely solid, features which are present in our cases. A characteristic finding of the hepatic involvement in this disease appears to be the multiplicity of the lesions. We suggest that in the setting of tuberous sclerosis it is reasonable to assume that intrahepatic lesions represent angiomyolipomas. However, in nontuberous sclerosis patients with similar findings malignancy cannot be excluded.

Failed or difficult laparoscopic cholecystectomy: can preoperative ultrasonography identify potential problems?

A prospective study was performed to assess the role of preoperative ultrasonography in predicting failed or difficult laparoscopic cholecystectomy. Fifty patients underwent detailed preoperative ultrasound examinations. The number and size of calculi, evidence of acute or chronic cholecystitis, gallbladder morphology, and the presence or absence of aberrant anatomy were documented. A comparison was made of the surgical outcome and the ultrasound findings in each patient. Six patients were converted to open cholecystectomy because of inflammatory changes in the gallbladder. The preoperative ultrasound studies in 5 of these patients demonstrated evidence of cholecystitis and cholelithiasis. Gallbladder wall thickening and contraction were also seen. Five gallbladder resections had intraoperative difficulties; preoperative ultrasonography demonstrated a thickened gallbladder wall in 2. Of 31 uneventful cases, 7 had evidence of gallbladder wall thickening and/or contraction. There were no ultrasound features that identified between the unsuccessful, difficult, or uneventful laparoscopic cholecystectomies. We conclude that detailed preoperative ultrasound evaluation of the gallbladder in patients destined for laparoscopic cholecystectomy is of little value in screening for difficult or unsuitable cases.

Percutaneous fluoroscopically guided removal of dysfunctioning ureteral stents.

PURPOSE: To present the authors' experience with fluoroscopically guided percutaneous removal of dysfunctioning ureteral stents and to discuss the technique and instrumentation used. MATERIALS AND METHODS: Over 6 years, stent or stent fragment extraction procedures were performed in 20 patients. Indications included stent misplacement or migration, stent fracture, difficult retrograde exchange, stent occlusion, and removal prior to percutaneous ureteroscopy. Twelve extractions were performed as two-stage procedures and eight as one-stage procedures. A rigid forceps passed through a 12-F sheath was the preferred instrument for extraction. Other instruments used successfully included snares and flexible forceps. RESULTS: Seventeen procedures were successful: Eight stents were removed with rigid forceps, seven with flexible forceps, and two with snares. Three procedures were unsuccessful: In two, the stent could not be grasped because there was intervening renal pelvic mucosa, and in one, clotted blood surrounded the stent. There were no undue complications. CONCLUSION: This procedure is highly successful when appropriate technique and instruments are used.

Transrectal drainage of deep pelvic collections under fluoroscopic guidance.

Although transrectal drainage of pelvic fluid collections, guided by fluoroscopy, computed tomography (CT) and ultrasonography (US), has been reported, the cumulative experience is small. The authors describe a technique for fluoroscopically guided transrectal drainage and present the results obtained for 13 patients. Each patient underwent diagnostic CT and then fluoroscopically guided drainage. A barium enema tube assembly, consisting of an enema tube, a Lunderquist PTC (percutaneous transhepatic cholangiogram) needle and a small portion of a red rubber catheter, was used to facilitate insertion of the drainage catheter. The procedure was defined as successful if complete clearance occurred after drainage, as temporizing if partial drainage was achieved and clinical improvement occurred, and as failed if the collection showed no response to drainage. Twelve of the patients had abscesses, 9 of which were successfully treated by drainage alone; one drainage was temporizing and two failed. The collection in the last patient represented a hematoma, which did not respond to drainage. The authors conclude that the technique they describe is suitable for draining moderate to large pelvic abscesses. The procedure is safe and can easily be performed in both male and female patients.

Sequential Tc 99m mercaptoacetyl-triglycine (MAG3) renography as an evaluator of early renal transplant function.

A prospective study was carried out to evaluate the role of sequential Tc 99m MAG3 renography in assessing transplant function in the early post-operative period. Twenty patients were included in the study. Studies were performed on all patients at intervals of 48-72 hours until discharge. There were 11 clinically diagnosed episodes of rejection, 9 of which were correctly diagnosed using MAG3 renography. Six episodes of rejection were diagnosed prior to the onset of clinical symptoms. Two patients with graft infarction were correctly diagnosed. Six patients had evidence of transient renographic abnormalities in the immediate post-operative phase which were not associated with clinical symptoms, all of these resolved spontaneously on subsequent examinations and were presumed to be related to resolving acute tubular necrosis (ATN). The perfusion index was of no discriminatory value in this study. Sequential Tc 99m MAG3 renography is highly sensitive but entirely nonspecific in the evaluation of pathology in the transplant kidney. Rejection in an uncomplicated transplant can be readily detected in many cases well in advance of clinical manifestations. This study demonstrates that Tc 99m MAG3 renography is certainly equal to Tc 99m DTPA renography or Iodine 131 renography in assessing early transplant function. However, Tc 9m MAG3 exposes the patient to considerably less radiation and the images are of superior quality.

Bilateral retrovesical testes: an unusual location for impalpable undescended testes.

Although the majority of impalpable undescended testes lie in an intracanalicular location, a significant number are also found to be intraabdominal. The expected location of intraabdominal testes is a line joining the renal hilum and the internal inguinal ring. We describe a case of an adult patient in whom impalpable undescended testes were located in a retrovesical location. This case highlights the importance of performing a thorough inspection of the entire abdomen and pelvis if the impalpable testis is not found in an expected location.

Acute renal failure and non-Hodgkins lymphoma in a patient with minimal change glomerulonephritis.

Two rare features of minimal change glomerulonephritis occurring together in an adult patient are described. A 70-year-old man presented with acute renal failure and the nephrotic syndrome. Investigation revealed minimal change glomerulonephritis and non-Hodgkins lymphoma. Anti-lymphoma treatment reversed both the renal failure and the nephrotic syndrome. Minimal change glomerulonephritis, as a cause of acute renal failure and as a manifestation of malignancy, is briefly reviewed.