Gluteus medius calcific tendonitis as a cause of severe anterior hip pain.

Calcific tendinopathy in the gluteus medius is uncommon and sporadically reported. It may be asymptomatic or present with acute or chronic pain. Pain is usually isolated to the lateral hip overlying the gluteal muscles or greater trochanter. We present a rare case of gluteus medius calcific tendonitis as a cause of severe anterior hip pain. Given the atypical local and clinical presentation these can be often misdiagnosed as septic arthritis or fracture which may lead to overtreatment and even unnecessary surgery. This article will detail the clinical presentation, imaging findings, and clinical course following treatment. This will facilitate the clinician in making a timely diagnosis and establishing an effective treatment course.

Radiological evaluation before and after treatment with an osseointegrated bone-anchor following major limb amputation-a guide for radiologists.

Osseointegrated implants have been developed to allow direct skeletal fixation of a prosthesis as an alternative to traditional socket-fitted prostheses for patients who have suffered from a major limb amputation. The implants contribute to improvements in functional outcome and quality of life and radiological evaluation plays a crucial role in pre- and post-operative assessment. This article acts as a guide for radiologists who may be tasked with providing the radiological information required by surgeons and prosthetists. We also look at the radiological appearances of complications that may arise in patients treated with an osseointegrated implant. Plain X-rays are used to screen patients who wish to undergo treatment. Limb-length X-rays are then used to measure the length of any residual bone, and comparisons can be made with the normal side (if present). From this, decisions about the likely size of the implant and the need for further amputation can be made. CT scans enable accurate assessment of the medullary cavity and cortical thickness. Post-operatively, plain X-rays form the mainstay of the routine monitoring of the bone-implant interface. Potential complications include infection, aseptic loosening, mechanical fracture of the implant and periprosthetic fracture. Infection and aseptic loosening can be seen as a lucency at the bone-implant interface which (if left untreated) can lead to loss of the implant. Implant and periprosthetic fractures are radiographically obvious. Radiologists involved in the care of patients undergoing treatment with an osseointegrated implant should become familiar with the imaging requirements so they can contribute to optimal patient outcomes.

Nasogastric tube knotting: a rare and potentially overlooked complication among healthcare professionals.

Nasogastric tube placement is a common procedure performed in surgical and medical specialities. The occurrence of knot formation is perhaps one of the least well-recognised complications associated with its usage. We present a case of nasogastric tube knotting to remind colleagues of this rare but important complication. A 75-year-old woman with adhesional bowel obstruction was admitted under the general surgery team. A wide bore nasogastric tube was inserted for drainage and decompression. Although placement of the tube was deemed to be successful, there was no drainage of gastric content evident. On removal of the 'non-functioning' tube a simple knot was seen at its proximal end. A further nasogastric tube was placed and the patient's symptoms resolved with conservative management. Nasogastric tube knotting is a rare and often overlooked complication with the potential to cause significant trauma on tube removal if unrecognised.

An 81 Year Old with Back Pain.

You see an 81-year-old man in the emergency department. He has been troubled by abdominal and back pain that has been worsening over the last two days. He has smoked 20 cigarettes a day for the last 60 years. On examination his heart rate is 110 beats per minute and his blood pressure is 130/80 mmhg. He is tender over the central abdomen and you feel a pulsatile mass above the umbilicus. You request a CT scan of the abdomen.

68-Year-Old Man with PR Bleed.

A 68-year-old man is referred to the colorectal clinic by his GP. He has lost 10 kg in weight over the last two months. He also noticed that his bowel motions have been loose and sometimes contain blood. You review the full blood count and faecal occult blood test the GP requested. What should you do next?

Postpartum pneumoperitoneum: an important clinical lesson.

A 23-year-old primigravida presented to accident and emergency department with a 4-day history of generalised abdominal pain associated with vomiting and diarrhoea. She had previously given birth to her first child by vaginal delivery 6 days previously at another hospital and suffered a third-degree vaginal tear following prolonged labour. Shortly after birth, the patient had described the unusual symptom of soft tissue crepitations in the neck, but had been reassured and discharged without further investigation by her obstetrics team and reassured by a visiting general practitioner. At representation, the patient had obvious pneumoperitoneum, which was missed by the admitting team and underwent laparotomy for perforated duodenal ulcer.

Haemophilia imaging: a review.

Haemophilia disorders are characterised by a blood coagulation anomaly leading to prolonged and excessive bleeding. Imaging provides an essential role in the investigation of both the musculoskeletal and the non-musculoskeletal complications of haemophilia. Our institution is home to a large tertiary referral centre for haemophilia treatment. Using our broad experience, we present a multi-modality pictorial review of the musculoskeletal manifestations of haemophilia, including haemophilic arthropathy, intra-muscular haemorrhage and haemophilic pseudotumour. The main imaging features of haemophilic arthropathy are described, including synovial hypertrophy, haemosiderin deposition, sub-chondral cyst formation and loss of joint space.

Ultrasound and MRI findings in appendicular and truncal fat necrosis.

OBJECTIVE: The objective was to evaluate ultrasound and MRI in clinical appendicular and truncal fat necrosis. MATERIALS AND METHODS: Thirty-three patients (14 men, 19 women, median age 55, range 29-95) were retrospectively evaluated. Histologically, three groups were seen: Group 1 (n = 18) consisted of patients with subcutaneous masses with septal and extrinsic oedema; in Group 2 (n = 11) necrosis occurred within lipomatous tumours and little oedema; and in Group 3 (n = 4) there were large complex masses consistent with Morel-Lavallée lesions. Two experienced radiologists reviewed MR (n = 30) and ultrasound (n = 32) images with consensus agreement. MRI was performed on a 1.5T system with T1-weighted, T2-weighted fat-suppressed and T1-weighted fat-suppressed post-intravenous gadolinium sequences obtained in two orthogonal planes. Ultrasound (linear 5- to 13.5-MHz probe) was performed in the longitudinal and short axis. Anatomical position, size, shape (oval, linear, ill-defined), internal architecture (lobules, septi or stranding), intrinsic signal characteristics, presence of surrounding pseudocapsule, extrinsic linear stranding and vascularity (gadolinium enhancement or power Doppler) were recorded. RESULTS: Anatomical locations were buttock/thigh (n = 17), leg (n = 6), upper limb (n = 5) and thoracic/abdominal wall (n = 5) with the majority of lesions (30 out of 33) oval/linear in shape. On ultrasound and MRI most lesions showed internal fat lobules, intervening septi and a surrounding pseudocapsule. CONCLUSION: Fat necrosis can usually be identified as containing multiple fat lobules on ultrasound and MRI despite a varying degree of inflammatory change surrounding and within the mass.

Statins inhibit the dimerization of beta-secretase via both isoprenoid- and cholesterol-mediated mechanisms.

We have previously reported that protein lipidation in the form of palmitoylation and farnesylation is critical for the production of Abeta (amyloid beta-peptide), the dimerization of beta-secretase and its trafficking into cholesterol-rich microdomains. As statins influence these lipid modifications in addition to their effects on cholesterol biosynthesis, we have investigated the effects of lovastatin and SIMVA (simvastatin) at a range of concentrations chosen to distinguish different cellular effects on Abeta production and beta-secretase structure and its localization in bHEK cells [HEK-293 cells (human embryonic kidney cells) transfected with the Asp-2 gene plus a polyhistidine coding tag] cells. We have compared the changes brought about by statins with those brought about by the palmitoylation inhibitor cerulenin and the farnesyltransferase inhibitor CVFM (Cys-Val-Phe-Met). The statin-mediated reduction in Abeta production correlated with an inhibition of beta-secretase dimerization into its more active form at all concentrations of statin investigated. These effects were reversed by the administration of mevalonate, showing that these effects were mediated via 3-hydroxy-3-methylglutaryl-CoA-dependent pathways. At low (1 microM) statin concentrations, reduction in Abeta production and inhibition of beta-secretase dimerization were mediated by inhibition of isoprenoid synthesis. At high (>10 microM) concentrations of statins, inhibition of beta-secretase palmitoylation occurred, which we demonstrated to be regulated by intracellular cholesterol levels. There was also a concomitant concentration-dependent change in beta-secretase subcellular trafficking. Significantly, Abeta release from cells was markedly higher at 50 microM SIMVA than at 1 microM, whereas these concentrations resulted in similar reductions in total Abeta production, suggesting that low-dose statins may be more beneficial than high doses for the therapeutic treatment of Alzheimer's disease.