Severe occlusive carotid artery disease: hemodynamic assessment by MR perfusion imaging in symptomatic patients.

BACKGROUND AND PURPOSE: Cerebral hemodynamic status has been reported to influence the occurrence and outcome of acute stroke. The purpose of this study was to assess hemodynamic compromise in symptomatic patients with severe occlusive disease of the carotid artery by the use of echo-planar perfusion imaging. METHODS: Spin-echo echo-planar perfusion imaging was performed in 11 patients (two had bilateral disease) with severe stenosis or occlusion of the carotid artery who had experienced either a recent transient ischemic attack or minor stroke. Relative cerebral blood volume (rCBV) maps and relative mean transit time (rMTT) maps were generated from the time-concentration curve. Findings on T2-weighted images, angiograms, rCBV maps, and rMTT maps were compared and assessed qualitatively and quantitatively. RESULTS: Although the abnormalities on T2-weighted images were absent, minimal, and/or unrelated to the degree of stenosis or collateral circulation, rMTT maps showed much larger and more distinct perfusion abnormalities along the vascular distribution of the affected vessels in all 13 vascular territories of the 11 patients. Despite obvious abnormalities on rMTT maps, none of the patients had evidence of decreased rCBV in the affected brain tissue (increased in three, normal in eight). A statistically significant difference in rMTT values was found between the affected and unaffected brain tissue, whereas no significant difference was seen in rCBV values. CONCLUSION: Echo-planar perfusion imaging is a noninvasive and rapid method for evaluating the hemodynamics in severe occlusive carotid artery disease and the compensatory vascular changes, and it may be useful in patient management.

Senior surgeons and radiologists should assess emergency patients on presentation: a prospective randomized controlled trial.

The objective of this study was to determine whether abdominal ultrasound and plain film radiography (evaluated by senior radiologists) substantially enhances senior surgical assessment in reducing surgical admissions. A randomized controlled trial was carried out in a teaching hospital; ninety-five emergency referrals to general surgery (mean age 51 years, 37% males), presenting with intrabdominal disturbances not requiring immediate surgery, were selected for study. The major outcome measure was the number of patients not admitted as in-patients. Thirty per cent of the intervention group and 10% of the controls did not need admission (95% confidence interval on this 29% difference, 12-38%). There were no important differences in the mean waiting time in casualty (26 min vs. 25 min), length of admission (4.1-5.9 days), surgical intervention (seven vs. 11 patients), readmission with similar pathology within 3 months (seven vs. three patients), and mortality as an in-patient or within 3 months of discharge. Abdominal ultrasound and plain film radiography, assessed by senior radiologists, enhances senior surgical assessment in reducing unnecessary surgical admissions.

Periorbital edema as an initial presentation of rosacea.

Rosacea is a common dermatosis with a variety of clinical manifestations. The eyes are often affected. The most frequent ocular findings are blepharitis and conjunctivitis. We describe three patients with rosacea in whom periorbital edema was the initial presentation. This symptom may be confused with other dermatoses and may be refractory to conventional treatments for rosacea.

Application of contrast agents in the evaluation of stroke: conventional MR and echo-planar MR imaging.

The availability of new therapeutic interventions, including neuroprotective agents and endovascular thrombolysis, has given new hope to patients suffering an acute stroke. Early intervention remains a key factor in the effectiveness of these new and traditional treatments. More importantly, the capability to assess the viability and reversibility of the ischemic tissue became essential for better delineation and differentiation of infarcted versus ischemic tissue and patient management. Abnormal MR imaging (MRI) findings during acute stroke usually reflect the underlying pathophysiologic changes, which can be classified into three sequential stages: (a) hypoperfusion, (b) cellular dysfunction and (c) breakdown of the blood-brain barrier. The first stage is a kinetic phenomenon (not biologic) and, therefore, can be detected immediately. Contrast agents accentuate the abnormal flow kinetics and facilitate the early diagnosis of ischemia using either conventional MRI or newly developed echo-planar perfusion imaging (EPPI). The demonstration of abnormal arterial or parenchymal enhancement on conventional MRI during acute stroke provides the earliest sign of vascular occlusion/stenosis. EPPI, in contrast, provides information related to microcirculation (< 100 microns) and tissue reserve (cerebral blood volume) that cannot be obtained by conventional angiography and is directly related to the target end-organ. Further information obtained from both contrast MRI and EPPI may have a predictive value in the clinical outcome of acute stroke patients.

Inguinal hernia and a single strenuous event.

A study of 129 consecutive patients, who had a total of 145 inguinal hernias, showed that in only 7% of the patients was the hernia subjectively attributable to a single muscular strain. Guidelines are suggested to assist in assessing 'cause' in claims for industrial injury in such patients.

Echo-planar FLAIR imaging in evaluation of intracranial lesions.

Fluid-attenuated inversion-recovery (FLAIR) imaging is a magnetic resonance imaging technique that improves lesion detection in the brain. This technique suppresses signal from free water in cerebrospinal fluid and maintains the hyperintense lesion contrast of T2-weighted spin-echo imaging. Unfortunately, conventional FLAIR imaging requires a long acquisition time and provides a limited number of sections. A combination of echo-planar imaging and FLAIR imaging offers the image contrast effects of FLAIR imaging and the speed of echo-planar imaging. Clinically, the echo-planar FLAIR technique is most helpful in detecting subtle, early lesions that do not enhance, such as early infarct, demyelinating disease, early infection, and trauma. The increased magnetic susceptibility effect associated with the echo-planar technique can be clinically useful in detecting subtle hemorrhage and cavernous angioma. Echo-planar FLAIR imaging is a practical and efficient means of screening the entire brain in a short time.

Improving the primary management of emergency surgical admissions: a controlled trial.

The initial screening by senior surgical staff of surgical patients referred for emergency hospital admission should result in improved patient management. The present study was undertaken to determine the effects of this policy. The primary outcome measure was hospital admission rates. The number of operations, diagnostic investigations, initial treatments, deaths, length of stay and bed days per 100 referrals were also measured. The results suggest a 20 per cent reduction in emergency surgical admissions, an important potential benefit to the health service, and to individual patients.

Aspects of hernia surgery in Wales.

The management of elective inguinal herniorrhaphy in Wales was assessed by means of a postal survey of consultant general surgeons. This included technique of repair, length of inpatient stay, follow-up, use of heparin thromboprophylaxis and advice regarding driving, strenuous activities and work. In all, 54 replies (77%) were received. The views of patients on their surgery was assessed by a questionnaire sent to 80 patients treated on a single surgical unit; 60 replies (75%) were received. Waiting times were relatively short among this group, 67.5% of patients being treated within 6 months of seeking medical advice; 16.25% suffered a complication. All wound infections occurred after discharge and 15% of patients had some groin discomfort 6 months after operation. Accuracy of clinical examination of 50 inguinal hernias by different grades of surgeon was assessed. Consultants were significantly more accurate when compared with house officers (P < 0.001). There is a wide range of repair techniques and postoperative advice practised by consultant general surgeons in Wales. Patients' main complaint was that of a sparsity of postoperative advice, although there also appears to be an appreciable postoperative morbidity. Clinical experience plays a significant role in assessment of the suitability of hernias for surgery.

Reversal of vasectomy and the general surgeon.

Reversal of vasectomy is a difficult procedure. Most surgeons still perform a macroscopic vasovasostomy. However, there is a little guidance in the current literature on the results that can be expected from such procedures. Patients may therefore be given unrealistic expectations preoperatively. Our study shows the results of macroscopic reversals of vasectomy performed over a 9-year period. A survey of Welsh surgeons is also presented concerning their preferred techniques and estimated success rates for reversals. The study clearly shows that a macroscopic vasovasostomy is the commonest method employed, with a wide variation in estimated success rates. Patients considering a macroscopic reversal of vasectomy should be warned of a less than 20% success rate.

PIP: 33 patients over a 9 year period had undergone macroscopic vasovasostomies (a single layer anastomosis) at a surgical unit at the University Hospital of Wales in Cardiff. 4 patients were lost to follow-up. The partners of 5 (17%) of the remaining 29 vasectomy reversal patients had become pregnant. The interval between vasectomy and reversal for these 5 men was shorter than that for those who did not have a successful vasectomy reversal (6.2 years vs. 8.9 years). After the reversal, 13 men had a normal sperm count (20,000,000/ml) and 12 had no sperm at all. 77% of the Welsh surgeons responding to a questionnaire had performed vasectomy reversals. All these surgeons had used a one-layer anastomosis. 54% used low power magnification, 43% used no magnification, and 3% used an operating microscope. 64% did not use a stent. The remaining 46% did use a stent. General surgeons and urologists generally used the same techniques. There was a wide variation in the estimates of patients who fathered children after vasectomy reversal among the 31 surgeons. Most surgeons (11) reported a pregnancy rate of 21-30%. 2 surgeons said that 60-70% of their vasectomy reversal patients fathered children. The authors recommend that surgeons tell patients undergoing a macroscopic reversal of vasectomy of a less than 20% success rate.

Provision of postoperative care in UK hospitals.

Surveys have been undertaken of the clinical dependency of surgical patients in eight United Kingdom acute general hospitals. The findings indicate that patients' needs are not always matched by appropriate levels of clinical care. In particular, it appears that a significant number of surgical patients need high-dependency care. Currently most of these patients are admitted to ITU beds, or are at risk on surgical wards.

Bullous diseases. Introduction.

The bullous diseases have a history as old as that of medicine. Although blisters have drawn the attention of medical caregivers throughout written history, only modern times have seen the origin of a clear classification of these disorders, based initially upon clinical and histologic criteria. Recent work has allowed clear delineation between similar diseases based upon localization of immune reactants and, more recently, molecular targets of autoimmune response or defects of inherited diseases. With a clear understanding of the clinical findings, histologic alterations, immune deposits, and metabolic defects, a clinician can arrive at a correct diagnosis in almost all cases of cutaneous blistering. The application of molecular biology to the study of bullous diseases has led to a more detailed understanding of the pathogenesis of the disorders. New horizons in the bullous diseases include further understanding of the molecular and immunologic mechanisms that lead to blisters. It is hoped that this understanding will lead to exciting new therapies and hope for patients suffering with blistering diseases.