MRI analysis of simple and aneurysmal bone cysts in the proximal humerus: what actually matters in clinical routine.

OBJECTIVE: To evaluate magnetic resonance imaging (MRI) characteristics of simple and aneurysmal bone cysts (SBC/ABC) of the proximal humerus and the intermittent difficulty in the imaging differentiation between the two in daily clinical routine. MATERIALS AND METHODS: MR images of 26 patients with suspected SBC/ABC in the proximal humerus were retrospectively assessed by two independent radiologists blinded to the final histological result. Based on a standard MRI protocol, different morphologic features and signal intensities of the lesion on non-enhanced and enhanced sequences were documented. The radiological diagnosis was correlated with histology. RESULTS: Eighteen patients had the image-based diagnosis of an SBC, yet the histology confirmed only 12, the residual 6 were identified as an ABC, despite the imaging criteria corresponding unambiguously to the former. One of the main reasons was the unicameral morphology of lesions, found in 9/14 (64.3%) cases of all ABCs, i.e., in 19/26 cases in total. Therefore, the sensitivity of the radiological diagnosis was moderate (57.14%), yet specificity very high (100%). In total, 69.2% (18/26) presented with a pathological fracture at admission, which correlated strongly with both circumferential (MCC = 0.65, p = 0.01) and septal (MCC = 0.42, p = 0.06) enhancement patterns. Circumferential enhancement was also found to correlate strongly with the histological diagnosis, being recognized in all cases of ABC (MCC = 0.44, p = 0.06). CONCLUSION: MRI characteristics of ABCs/SBCs in the proximal humerus are indifferent and ABCs may morphologically present as SBCs. Radiologists should be aware of the different, often confusing presentation of both entities in daily clinical routine.

Impact of symptomatic skeletal events on health-care resource utilization and quality of life among patients with castration-resistant prostate cancer and bone metastases.

BACKGROUND: Data regarding the impact of symptomatic skeletal events (SSEs) on health economics and patient-reported outcomes in men with castration-resistant prostate cancer (CRPC) and bone metastases from a clinical setting are lacking. Hence, this study aimed to quantify the effects of SSEs on health-care resource utilization (HRU), health-related quality of life (HRQoL) and pain in men with CRPC metastasized to bone. METHODS: This cohort study included men with CRPC and bone metastasis treated at a tertiary center during December 1996-July 2015. SSEs, including pathological fracture, radiation to bone, spinal cord compression and bone surgery, as well as HRU were identified retrospectively through medical records and clinical database. A subset of surviving patients completed Functional Assessment of Cancer Therapy-Prostate (FACT-P) and Brief Pain Inventory-Short Form (BPI-SF) questionnaires. The incremental effect of SSEs on HRU was evaluated using multivariable generalized linear regression. Questionnaire scores were compared using effect sizes (ES); ES⩾0.33 indicated meaningful differences between SSE and non-SSE cohorts. Lower scores suggest lower HRQoL and pain. RESULTS: Of the 832 patients, 207 developed ⩾1 SSE (mean 1.5±0.8) during follow-up (median 2.1 years). Radiation to bone was the most common SSE (84.1%). SSE cohort had significantly higher emergency room (incidence rate ratio (IRR)=1.48; P=0.006), outpatient (IRR=1.17; P=0.005) and inpatient (IRR=1.74; P<0.001) visits. Of the 107 eligible survey patients, 103 (96.3%) responded. SSE cohort had lower mean FACT-P functional well-being (17.5 vs 19.8; P=0.158; ES=0.36), higher mean pain severity (2.5 vs 1.6; P=0.048; ES=0.47) and worst pain scores (3.6 vs 2.3; P=0.033; ES=0.50) compared with the non-SSE cohort, indicating meaningful differences between cohorts. CONCLUSIONS: This study demonstrated high economic and HRQoL burden of SSEs. The findings underscore the need for better supportive and disease-modifying treatments for these patients.

Routine stress testing after percutaneous coronary interventions.

Percutaneous coronary intervention (PCI) is the most frequently performed cardiovascular procedure. Many physicians caring for post-PCI patients have routinely subjected patients to periodic stress testing. In the recent years, due to widespread use of drug eluting stents the combined rates of major adverse cardiac events (MACE) and in-stent restenosis (ISR) dropped <10% in the initial 12 months post-PCI, with only half of these patients bearing symptoms. This has translated into reduced pre-test probability of post-PCI ischemia. Consequently, the beneficial effect of this practice came into question. Moreover, in addition to its financial implications, routine post-PCI stress testing may carry potential harm: medication or exercise induced arrhythmia, infarction and/or death, patient irradiation exposure, false-positive tests resulting in excessive invasive testing or interventions, and the illusion of "wellness" in the face of a somewhat unpredictable disease. This review addresses the role stress testing post-PCI: it is concluded that routine stress testing in clinically stable asymptomatic post-PCI patients should be discouraged. Selective utilization of stress testing in patients with exceptionally high risk of ISR or MACE can be utilized to answer important clinical questions or guide and refine clinical care.

Clinical applicability of coronary atherosclerotic lesion characterization.

Native coronary atherosclerosis (CAS) is a diffuse and progressive disease process that is occasionally associated with either clinical atherothrombosis and/or major adverse cardiac events (MACE) including: ST elevation myocardial infarction (STEMI), acute coronary syndromes without ST elevation (ACSWSTE), heart failure, cardiac arrest and sudden cardiac death. Both, the timing and coronary site responsible for the MACE are currently unpredictable. Cardiovascular investigators have engaged in the task of characterizing CAS lesions in order to enhance our knowledge of CAS pathophysiology. It was expected that the knowledge acquired will allow scientists and clinicians to develop effective strategies to detect and treat "vulnerable plaque" (VP) prior to the evolution of MACE. This review discusses the emerging data regarding the pathology and natural history of the VP and vulnerable patient and the progress made in characterizing atherosclerotic plaque instability and vulnerability. Future directions in the field of plaque characterization and their potential clinical and research applications are discussed.

Aspirin for the prevention of cardiovascular morbidity.

Aspirin (ASA) use for secondary prevention in patients with cardiovascular (CV) disease is well established through its beneficial effects on the reduction of myocardial infarction, ischemic stroke and CV mortality. This beneficial effect of ASA seems to consistently outweigh the risk in most patient subsets. Current guidelines endorse ASA for primary prevention of CV events in adults who are at moderate-high risk of CV morbidity. Recent emerging data on the efficacy and safety of ASA conflicts with former randomized clinical trials and raises concerns regarding the validity of these recommendations. The following manuscript describes the data emerging from contemporary trials regarding the efficacy and safety of ASA in various patient subsets. The authors propose certain strategies to enhance safety and efficacy in order to augment the beneficial effects of ASA along with other modalities of primary prevention for suitable candidates. When contemplating ASA prescription for primary prevention of CV events, physicians should carefully weigh the potential benefits of risk reduction versus likelihood of harm, mostly related to bleeding complications.

Prescribing of psychotropic medication to the intellectually disabled by community paediatricians - a survey.

BACKGROUND: Children with intellectual disability are often managed by community paediatricians and have a high prevalence of mental disorder. We do not know whether community paediatricians feel adequately trained to treat this group although we know that paediatricians contribute significantly to psychotropic prescribing for children. METHODS: Psychotropic medication prescribing by community paediatricians to the intellectually disabled in the north-west and northern regions, community paediatricians' perceived training needs in this area and the availability of specialized psychiatric services were surveyed. Postal questionnaires were sent to all members of the British Association of Community Child Health in the north and north western regions (n= 155), between summer 2004 and autumn 2005. RESULTS: A total of 70.1% (n= 110) of questionnaires were returned of which 66 were completed. The most common reason for non-completion was that the respondent did not look after the intellectually disabled. A total of 54.5% of respondents did not have access to specialist psychiatry services for children and adolescents with an intellectual disability. Community paediatricians were most likely to prescribe for sleep disorders and attention deficit hyperactivity disorder (ADHD). There was a significant relationship between perceived adequacy of training and paediatrics prescribing for ADHD, but there was no such relationship for sleep disorders. The vast majority of community paediatricians did not feel adequately trained to prescribe for challenging behaviour or depression, although a small minority did prescribe. CONCLUSIONS: Community paediatricians play a substantial role in prescribing psychotropic medications for this group. A substantial minority of community paediatricians do not feel that they have enough training to prescribe for ADHD and sleep disorders, and perceived competency is more likely to inform prescribing for ADHD than for sleep disorders. This may have implications for training. Although these children pose complex difficulties, access to specialist mental health services for children and adolescents with intellectual disability remains patchy, especially in the north-west, and further development of these services is needed.

Labial reduction in adolescent population--a case series study.

STUDY OBJECTIVE: To find the primary referral reasons for labial reduction in adolescent girls. DESIGN: A retrospective review of six case notes of patients from July 2003 to January 2007. SETTING: Pediatric and adolescent gynecology clinic. INTERVENTIONS AND OUTCOME: Unilateral or bilateral labial reduction. The procedure was done by standard trimming of the protuberant edge of the labia minora and over-sewing the edge with 3-0 vicryl rapide. RESULTS: The age ranged from 11 to 16 years old. The reasons for requesting labial reduction were labia getting caught in underwear, being prominent under swimwear, causing vulval irritation, and its appearance causing embarrassment. All the patients were satisfied with the outcome. CONCLUSIONS: Two groups requested labial reduction. In the first group the enlarged labia caused physical discomfort. In the other group the procedure was carried out for cosmetic reasons. It is important to carefully choose the patients in the later group, because it can otherwise lead to dissatisfaction and regret later on in life. The child can give consent if Gillick competent, but it is a good practice to involve person with parental responsibility in the process of making a decision.

Multiple-micronutrient supplementation for women during pregnancy.

BACKGROUND: Multiple-micronutrient deficiencies often coexist in low- to middle-income countries. They are exacerbated in pregnancy due to the increased demands, leading to potentially adverse effects on the mother. Substantive evidence regarding the effectiveness of multiple-micronutrient supplements (MMS) during pregnancy is not available. OBJECTIVES: To evaluate the benefits to mother and infant of multiple-micronutrient supplements in pregnancy and assess the risk of excess supplementation and potential adverse interactions between micronutrients. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 December 2005). SELECTION CRITERIA: All prospective randomised controlled trials evaluating micronutrient supplementation during pregnancy and its effects on the pregnancy outcome. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted the data. MAIN RESULTS: Nine trials (15,378 women) are included. When compared with supplementation of two or less micronutrients or no supplementation or a placebo, multiple-micronutrient supplementation resulted in a statistically significant decrease in the number of low birthweight babies (relative risk (RR) 0.83; 95% confidence interval (CI) 0.76 to 0.91), small-for-gestational-age babies (RR 0.92; 95% CI 0.86 to 0.99) and in maternal anaemia (RR 0.61; CI 0.52 to 0.71). However, these differences lost statistical significance when multiple-micronutrient supplementation was compared with iron folic acid supplementation alone. No statistically significant differences were shown for the outcomes of preterm births and perinatal mortality in any of the comparisons. A number of prespecified clinically important outcomes could not be assessed due to insufficient or non-available data from the included trials. These include placental abruption, congenital anomalies including neural tube defects, premature rupture of membranes, pre-eclampsia, miscarriage, maternal mortality, neurodevelopmental delay, very preterm births, cost of supplementation, side-effects of supplements, maternal wellbeing or satisfaction and nutritional status of children. AUTHORS' CONCLUSIONS: The evidence provided in this review is insufficient to suggest replacement of iron and folate supplementation with a multiple-micronutrient supplement. A reduction in the number of low birthweight and small-for-gestational-age babies and maternal anaemia has been found with a multiple-micronutrient supplement against supplementation with two or less micronutrients or none or a placebo, but analyses revealed no added benefit of multiple-micronutrient supplements compared with iron folic acid supplementation. These results are limited by the small number of studies available. There is also insufficient evidence to identify adverse effects and to say that excess multiple-micronutrient supplementation during pregnancy is harmful to the mother or the fetus. Further research is needed to find out the beneficial maternal or fetal effects and to assess the risk of excess supplementation and potential adverse interactions between the micronutrients.

Atosiban and nifedipine in acute tocolysis: a comparative study.

OBJECTIVE: The objective was to compare the effectiveness, efficacy, and safety of atosiban and nifedipine in preventing or delaying premature labor. DESIGN: An interventional, randomized, controlled trial of 63 women experiencing preterm labor varying from 24 to 35 completed weeks of gestation. The women were randomized to receive either atosiban intravenously (group I, n=31), or nifedipine orally (group II, n=32). RESULTS: There were no significant differences in effectiveness and efficacy of tocolysis between the two groups. Women with a history of preterm labor responded significantly better to atosiban than those with no such history. Those at 28 weeks or less responded significantly better to nifedipine, while those at more than 28 weeks' gestation showed an equal response in the two groups. Nifedipine achieved uterine quiescence in a significantly shorter time than atosiban. The maternal side effects were higher with nifedipine. Neonatal complications were comparable in both groups. CONCLUSIONS: Both drugs are equally effective and efficacious in acute tocolysis. Subgrouping of patients according to gestational age and history of preterm labor may be applied in selecting the line of treatment. The maternal side effects were higher with nifedipine.

Dietary vitamin B12 deficiency in an adolescent white boy.

Dietary deficiency of cobalamin resulting in tissue deficiency in white individuals is unusual. However, several patients with dietary deficiency who were neither vegan nor Hindu have been described. This report describes the case of a 14 year old boy who was a white non-Hindu with a very low intake of cobalamin, which was not apparent until a detailed dietary assessment was performed. The patient responded rapidly to a combination of oral and parenteral B12. This case illustrates the fact that severe dietary vitamin B12 deficiency can occur in non-Hindu white individuals. Inadequate dietary content of B12 may not be apparent until a detailed dietary assessment is performed. This patient is likely to have had subclinical vitamin B12 deficiency for several years. Increased vitamin B12 requirements associated with the adolescent growth spurt may have provoked overt tissue deficiency.

Neurofibrosarcoma in the nasal cavity.

A nine month old male child presented with a swelling protruding from the right nasal cavity for two months. Other symptoms were mild breathlessness during suckling and blood stained nasal discharge. CT Scan sshowed a mass arising from the lasteral wall of the right nasal cavity with mild erosion of the adjacent bones. The tumor was excised with wide margin through a lateral rhinotomy approach under general anaesthesia. In histopathological examination it was found to be a low grade neurofibrosarcoma. The child recovered well and is free from any recurrence till the time of reporting.

Pulse elongation and deconvolution filtering for medical ultrasonic imaging.

Range sidelobe artifacts which are associated with pulse compression methods can be reduced with a new method composed of pulse elongation and deconvolution (PED). While pulse compression and PED yield similar signal-to-noise ratio (SNR) improvements, PED inherently minimizes the range sidelobe artifacts. The deconvolution is implemented as a stabilized inverse filter. With proper selection of the excitation waveform an exact inverse filter can be implemented. The excitation waveform is optimized in a minimum mean square error (MMSE) sense. An analytical expression for the power spectrum of the optimal pulse is presented and several techniques to numerically optimize the excitation pulse are shown. The effects of PED are demonstrated in computer simulations as well as ultrasonic images.

Myocardial infarction postpartum in patients taking bromocriptine for the prevention of breast engorgement.

Three cases of myocardial infarction (MI) in women taking bromocriptine for milk suppression are presented. The incidents occurred in 1993 and 1994, the last only two weeks before the withdrawal of the drug from the American market as a drug suitable for ablactation. In one patient, the MI presented on the 12 day postpartum and was accompanied by signs and symptoms reminiscent to ergotism. Another mother suffered MI, accompanied by hypertension, six days after a vaginal delivery complicated by postpartum haemorrhage. The third patient began to take bromocriptine more than 2 weeks postpartum and died suddenly 24 days after her childbirth. To the knowledge of the authors, these are the 12th to 14th literary reports describing an apparent association between the use of bromocriptine for ablactation and the occurrence of MI in the puerperium.

Simultaneous choriocarcinoma in mother and newborn infant.

A male infant, born following an uncomplicated pregnancy, was severely anaemic at birth following significant foeto-maternal haemorrhage. At three weeks of age a tumour was found in the liver with evidence of metastatic disease in the lungs. The infant died before treatment could be started. Postmortem revealed choriocarcinoma which led to subsequent diagnosis in the mother who also had pulmonary metastases. The mother has been successfully treated. The case is described in detail and followed by a discussion and a literature review of reported cases of simultaneous choriocarcinoma in infant and mother.

A double chamber system for producing constant radon concentration.

An experimental arrangement of a radon chamber with an intrinsic constancy of the relative radon concentration is described. The system consists of a reference chamber and an auxiliary storage chamber. The only active device is a timer-controlled pump or valve which feeds radon gas from the storage into the reference chamber. The switching pattern of the timer is extracted from model calculations and theoretically performs an exact compensation of the radon loss by radioactive decay. If the calculations are done in real time and online, every known external event influencing the radon concentration can be compensated. This paper presents a simple timer circuit and a computer code which generates the timer program. The influence of the air flow stability and the leakage of the chambers are discussed. It is planned to apply this theoretical approach to provide a constant radon gas concentration for an actual chamber.

Diabetic cardiomyopathy: experimental and clinical observations.

Heart failure, arrhythmia, or chest pain can be a consequence of diabetes independent of coronary disease or hypertension. Diastolic myocardial dysfunction is common, contributing to the high mortality during acute infarction. The authors discuss diabetic cardiomyopathy and its management.

Efficacy and safety of combinations of nitrendipine, atenolol, and hydrochlorothiazide in black hypertensive patients.

Twenty-four black hypertensive patients were studied in a randomized, double-blind trial of combinations of nitrendipine, atenolol, and hydrochlorothiazide. After six weeks, blood pressure was normalized in all three treatment groups, i.e. diastolic blood pressure less than 95 mmHg and a decline in diastolic blood pressure of at least 5 mmHg from baseline. The drug combinations containing hydrochlorothiazide were associated with higher incidence of metabolic abnormalities, especially hypokalaemia and hyperuricaemia.

Effects of diabetes on myocardial perfusion in the atherosclerotic monkey.

We examined the influence of diabetes on the severity of coronary atherosclerosis, as judged by coronary morphometric and blood flow studies. Cynomolgus monkeys were fed a coconut-peanut oil mixture plus cholesterol to induce the plaque lesions of atherosclerosis in nondiabetic (group 2) and diabetic monkeys (group 3). Group 1 consisted of chow-fed controls. After 18 months of hypercholesterolemia, the animals were anesthetized to assess myocardial blood flow, by use of radioactive microspheres. Transmural and inner/outer wall flow ratios were normal in the two lipid-fed groups in the basal state. Vasodilation after adenosine (0.45 mg/kg/min IV) elicited a more than threefold rise of transmural blood flow in group 1, and a significantly reduced increment in groups 2 and 3. The blood flow ratio was not different from unity in group 1 but declined to 0.69 +/- 0.03 in group 2 and 0.69 +/- 0.06 in group 3, with similar decrements of heart rate and aortic pressure. In contrast to results in group 1, left ventricular filling pressure rose and velocity of contractile elements declined to a similar extent in groups 2 and 3 after adenosine, consistent with myocardial ischemia. Morphometric measurements as well as chemical analyses were performed on the three major coronary arteries. The degree of intimal thickening and increase of cholesterol and collagen content were comparable in groups 2 and 3. Thus, in this model the plaque lesions of atherosclerosis did not appear to be intensified by diabetes. Moreover, the responses to adenosine in terms of myocardial underperfusion and mechanical dysfunction were comparable in the two experimental groups.

Metabolic fate of inhaled Co aerosols in beagle dogs.

Lung retention of 57Co in dogs after the inhalation of physically and chemically uniform particles of Co compounds was similar, indicating little biological variability. The retention of Co oxide particles ranging from 0.3 micron to 2.7 micron geometric diameter, however, depended markedly on their physicochemical parameters. Measuring the retention by a gamma camera, and analyzing excreta and blood samples enabled the distinction of different clearance pathways from the lungs particularly with the use of results of some metabolic studies. Particle dissolution was the predominant clearance pathway. Particle dissolution half-times ranged from 6 to 80 d proportional to the size of the particles. Organ analysis yielded information on the fate of the long-term burden of Co in the lungs and other organs. A fraction less than 10% of the initial lung burden was retained in the lungs of all dogs with a biological half-time of 400 d presumably after being transformed into a nonparticulate state. There were cellular structures in the tracheobronchial tree which accumulated Co significantly. These studies on dogs suggest the dose after human exposure to well-defined Co aerosols can be accurately estimated. Whereas risk assessment after the exposure to undefined aerosols containing radionuclides of Co will mostly be impossible because retention varies widely with the varying physicochemical properties of the aerosol particles.