Spinal CSF-Venous Fistulas in Morbidly and Super Obese Patients with Spontaneous Intracranial Hypotension.

BACKGROUND AND PURPOSE: Spinal CSF-venous fistulas are increasingly recognized as the cause of spontaneous intracranial hypotension. Here, we describe the challenges in the care of patients with CSF-venous fistulas who are morbidly or super obese. MATERIALS AND METHODS: A review was undertaken of all patients with spontaneous intracranial hypotension and a body mass index of >40 who underwent digital subtraction myelography in the lateral decubitus position to look for CSF-venous fistulas. RESULTS: Eight patients with spontaneous intracranial hypotension with a body mass index of >40 underwent lateral decubitus digital subtraction myelography. The mean age of these 5 women and 3 men was 53 years (range, 45 to 68 years). Six patients were morbidly obese (body mass indexes = 40.2, 40.6, 41, 41.8, 45.4, and 46.9), and 2 were super obese (body mass indexes = 53.7 and 56.3). Lumbar puncture showed an elevated opening pressure in 5 patients (26.5-47 cm H2O). The combination of an elevated opening pressure and normal conventional spine imaging findings resulted in a misdiagnosis (midbrain glioma and demyelinating disease, respectively) in 2 patients. Prior treatment included surgical nerve root ligation for suspected CSF-venous fistula in 3 patients. Digital subtraction myelography demonstrated a CSF-venous fistula in 6 patients (75%). Rebound high-pressure headache occurred in all 6 patients following surgical ligation of the fistula, and papilledema developed in 3. CONCLUSIONS: In our series, opening pressure was generally elevated in patients with morbid or super obesity. The yield of identifying CSF-venous fistulas with digital subtraction myelography in this patient population can approach that of the nonobese patient population. These patients may be at higher risk of developing rebound high-pressure headaches and papilledema.

Parotid lymphoepithelial cysts in human immunodeficiency virus: a review.

BACKGROUND: Many patients with human immunodeficiency virus present with atypical features. Early indicators of human immunodeficiency virus are scarce and hence most affected patients are diagnosed in the later stages of the disease, which is associated with poor prognosis. Salivary gland disease usually develops before acquired immunodeficiency syndrome, and is sometimes the first manifestation of human immunodeficiency virus infection. Salivary gland lesions include benign lymphoepithelial cysts of the parotid gland, which are seen in 3-6 per cent of patients. Many of the reported lesions are diagnosed on routine examination. OBJECTIVE: This review aimed to highlight the association between parotid gland benign lymphoepithelial cyst and human immunodeficiency virus infection, in order to aid early diagnosis and management of the disease. CONCLUSION: Human immunodeficiency virus testing is recommended for patients with benign lymphoepithelial cysts, as this can often be the first indication of human immunodeficiency virus infection. Benign lymphoepithelial cysts are important diagnostic and prognostic indicators in human immunodeficiency virus infection.

Driving experiences of disabled drivers.

OBJECTIVE: To study the influence of non-standard controls on return to driving after disability, including prevalence of accidents/retraining difficulties. DESIGN: Postal questionnaires sent within two years of assessment to 972 disabled drivers seen over a three-year period. SETTING: Scottish Driving Assessment Service. SUBJECTS: All patients considered capable of driving after assessment during the study period. RESULTS: Five hundred and eighty-nine people (61 %) replied who were representative of the total population (mean age 55 years, range 19-87); 73% were male and 70% were disabled for up to two years. Overall 79% respondents had returned to driving (highest reported success with standard manual car (86%) and lowest using left foot to accelerate and brake (66%) (chi2 = 16.6, P = 0.005)). A significantly higher proportion of the 30 patients (6.5%) admitting to accidents and 25 (5.4%) to problems with retraining were using non-standard driving techniques, especially the use of hand controls. CONCLUSION: Disabled drivers returning to drive using non-familiar controls had lower success and a higher proportion of accidents and/or problems with retraining than people using conventional controls. If confirmed in larger studies this may have implications for policy-makers as well as specialist practitioners.

Rupture of tuberculous spinal abscess resulting in tuberculous empyema and chylothorax.

STUDY DESIGN: Case report with a review of scientific literature. OBJECTIVE: To describe the course of tuberculous spinal disease (Pott's disease) complicated by pyogenic and tuberculous empyema, and chylothorax as there has been an increase in the numbers of notified cases of tuberculosis in the UK(1). To the best of our knowledge, a similar case has not been reported previously in the UK, although there has been a report of bilateral chylothorax associated with Pott's disease. SETTING: A national spinal injuries unit in a Scottish university teaching hospital. METHODS: Review of literature on the chemotherapy of spinal tuberculosis and the role of streptokinase in the treatment of empyema and the relation between spinal tuberculosis, empyema and chylothorax. RESULTS: Although spinal tuberculosis was recognised and treated appropriately with chemotherapy, the patient sustained pleural involvement with later development of both empyema and chylothorax. CONCLUSION: The case highlights the difficulties in the treatment of tuberculosis of the spine inspite of the presence of fully sensitive organisms and early institution of appropriate chemotherapy. In the absence of surgical debridement, the duration and dosage of chemotherapy as practised in the initial period may have to be prolonged into the continuation phase. The thoracic duct can be damaged either because of extension of the tuberculosis itself or because of instillation of intrapleural streptokinase for treatment of pleural empyema leading to chylothorax. There is a need for randomised trials of intrapleural streptokinase treatment in tuberculous empyema.

Lower abdominal pressure versus external bladder stimulation to aid bladder emptying in multiple sclerosis: a randomized controlled study.

OBJECTIVE: To investigate the change in post-void residual bladder volumes (PVR) with 'abdominal vibration' using a percutaneous bladder stimulator in multiple sclerosis (MS) patients compared with either 'no treatment' or 'abdominal pressure'. DESIGN: Randomized controlled cross-over study. SETTING: Regional neurorehabilitation clinics. SUBJECTS: Twenty-eight MS patients with urinary symptoms and PVR > 100 ml. Twelve patients had urinary incontinence. METHODS: MS patients with voiding dysfunction and elevated PVR of 100-500 ml on BVI-3000 Ultrasound Scanner were randomized to either 'abdominal pressure' or 'vibration' by a portable, percutaneous, vibrating device (Queen Square Bladder Stimulator; Malem Medical) or to 'no treatment'. PVR was assessed at the end of each two-week phase. OUTCOME MEASURE: PVR reduction by greater than 100 ml. RESULTS: The 28 patients ranged in age from 29 to 71 years with a mean age of 49 years and a mean duration of MS of 12 years (range 1-37 years). The PVR decreased from 231 (SD 119) ml during no treatment to 191 (SD 132) ml with abdominal pressure (p = 0.242). Using suprapubic vibration the PVR reduced further to 126 (SD 121) ml, which was highly significant (p = 0.002) compared with no treatment. The difference between abdominal pressure and vibration just failed to reach significance (p = 0.059). There was no significant reduction in either the frequency of micturition or episodes of incontinence. The device was well-tolerated by patients. CONCLUSION: Abdominal vibration is an effective method of reducing PVR in MS patients and appears more effective than abdominal pressure alone.

Artifical Blood.

Elimination of unwanted side-effects, especially transfusion-transmitted diseases (HIV and hepatitis) and leucocyte-mediated allosensitisation, is an important goal of modern transfusion medicine. The problems and high cost factor involved in collecting and storing human blood and the pending world-wide shortages are the other driving forces contributing towards the development of blood substitutes. Two major areas of research in this endeavour are haemoglobin-based oxygen carriers (HBOCs) and perfluorochemicals. Even though they do not qualify as perfect red blood cell substitutes, these 'oxygen carrying solutions' have many potential clinical and non clinical usages. These can reach tissues more easily than normal red cells and can deliver oxygen directly. These are not without adverse effects, and extensive clinical trials are being conducted to test their safety and efficacy. New understandings on the mode of action of these products will help to define their utility and application. Only after successful clinical trials can they be used for patient management, after approval by the FDA.

FINE NEEDLE ASPIRATION CYTOLOGY OF LYMPH NODES IN HIV INFECTED PATIENTS.

Lymphadenopathy is the commonest presentation in HIV positive individuals. Fine needle aspiration cytology of 196 HIV positive patients was studied during six monthly review. 75% paients in this study who were asymptomatic were detected to have lymphadenopathy during the surveillance. 82% had lymph nodes smaller than 1cm size. Lymphadenopathy at more than one site was observed in 46.8% cases. Commonest opportunistic infection noticed was tuberculosis (TB) in 34.2%. Cyto-morphologically reactive pattern with Add fast bacilli (AFB) positivity was observed in 16.4% of TB cases. In 2.9% cases AFB were detected even in the tissue fluid. Negative images of AFB were observed in the macrophages in 3 cases. TB was detected with equal frequency in both asymptomatic and symptomatic groups. Axillary nodes pose problem due to deeper location. False positives were a case of dermatopathic lymphadenopathy and a case of Kimura's disease. False negatives include two cases of TB lymphadenitis. Pathogens should be looked for irrespective of cyto-morphology. Biopsy should be done to confirm cases of lymphomas. Fine needle aspiration cytology should be included in the protocol of six monthly review of HIV infected cases.

Development of the HIV/AIDS Q-sort instrument to measure physician attitudes.

BACKGROUND: Providers'attitudes about HIV/AIDS are an important dimension in the delivery of quality care to persons with HIV/AIDS. It is believed that education can alter attitudes, but there is a needfor a user-friendly instrument to measure the effect that HIV/AIDS educational programs have on attitudes. METHODS: A pool of HIV/AIDS attitude descriptors was collected through literature review and from individuals working in the HIV/AIDS field. Out of this pool of 90 descriptors, 48 descriptors with the highest face validity were selected through expert consensus ranking to create a preliminary survey instrument. Twenty-six physicians completed a pilot Q-Sort instrument with 48 descriptors. A variance analysis was conducted, and the top 28 descriptors with the most variability were selected for the final Q-Sort instrument, which was then completed by 191 physicians. A factor analysis was conducted to identify a small number of factors that explained the 28 descriptors. A subsample of 22 physicians repeated the test to establish test-retest reliability. RESULTS: Factor analysis revealed three factors: (1) emotionality, (2) ability, and (3) reluctance. The Q-Sort instrument demonstrated good test-retest reliability, with reliability for the three factors of .82, .80, and .88, respectively. CONCLUSIONS: This Q-sort instrument is a reliable method for measuring physician attitudes toward HIV/AIDS patients. Further studies can test its use for evaluating the effect of educational programs on changing provider attitudes.

Etretinate in the management of harlequin siblings.

Harlequin fetus is the severe form of congenital ichthyosis. There are very few reports of babies with this condition surviving the first few weeks of life. We treated two siblings who lived for 22 months and six weeks respectively. We started treatment with oral etretinate every early in their lives and achieved good improvement in the skin condition of these babies.

A controlled trial of high-intensity double-surface phototherapy on a fluid bed versus conventional phototherapy in neonatal jaundice.

OBJECTIVE: To evaluate a simple, relatively inexpensive method using the fluid bed to provide high-intensity double-surface (HIDS) phototherapy and to confirm that the method described is more effective than conventional phototherapy (CPT) in the treatment of neonatal hyperbilirubinemia. DESIGN: Prospective controlled study. METHOD: HIDS phototherapy (26 to 30 microW/cm2 per nanometer) on the fluid bed (n = 22) versus conventional (7 to 10 microW/cm2 per nanometer) phototherapy (n = 28) was used to treat neonates weighing more than 1500 g with hyperbilirubinemia. RESULTS: After 24 hours of therapy, the bilirubin in the group receiving HIDS phototherapy was significantly lower. The mean rate of fall of bilirubin was 5.34 mumol/L per hour in the group receiving HIDS phototherapy versus 0.7 mumol/L per hour in the group receiving CPT. HIDS phototherapy on a fluid bed was well tolerated. CONCLUSION: HIDS phototherapy on the fluid bed is significantly more effective in reducing bilirubin than CPT. It can be easily and economically provided using equipment currently available in most neonatal units.

Management and follow-up of harlequin siblings.

Harlequin fetus is a rare clinical entity, and survival of affected infants beyond the first year of life is uncommon. Management involves intensive care of the skin and eyes, close monitoring of fluid and electrolyte status, constant support and counselling of parents, and surveillance against infection and side-effects of medication. A well-coordinated multidisciplinary approach can prolong survival beyond the neonatal period. We report our experiences in the management and follow-up of two successive harlequin siblings.

A laboratory study on the life cycle and feeding behaviour of Arrenurus madaraszi (Acari: Arrenuridae) parasitizing Anopheles mosquitoes.

Although mosquitoes of several genera were collected from one locality in Thiruvananthapuram, Kerala State, India, only Anopheles spp. carried larval Arrenurus madaraszi; 21.5% of the An. hyrcanus and 19.0% of the An. vagus were infested. However, the whole life cycle of Arr. madaraszi could be replicated in the laboratory using Aedes albopictus, Ae. vittatus or Armigeres subalbatus as foster hosts. The host specificity observed in the field is therefore ecological, not physiological. In the laboratory, the nymphs and adult mites were free-living and when offered ostracods, copepods and larvae of Ae. albopictus, Ae. vittatus, An. hyrcanus, An. vagus and Arm. subalbatus as food, they showed a preference for first instar mosquito larvae, particularly those of Ae. albopictus.

A new non-hormonal antifertility drug DL-204: II. Effect on testicular hyaluronidase and gamma-glutamyl transpeptidase in male rats.

Effects of DL-204, 2-(3-ethoxyphenyl)-5,6-dihydro (5,1-a)-isoquinoline, a non-hormonal antifertility drug on testicular hyaluronidase and gamma-glutamyl transpeptidase levels, biochemical markers for testicular function, were evaluated in male rats. Treatment of 21-day-old rats with DL-204 for 7 or 15 days produced cryptorchid condition. Testicular hyaluronidase and gamma-glutamyl transpeptidase levels reveal that DL-204 acts on the testes, possibly in two ways; one, by reducing the gonadotropin levels thereby reducing the levels of androgens as reflected by reduced accessory reproductive organ weights and, secondly, by a direct action on the testes. Thus, we conclude that DL-204 is acting as an antispermatogenic agent, possibly acting in more than one way on the testes.

A new non-hormonal antifertility drug DL-204: I. Effects on testes and accessory glands of reproduction in male rats.

The effect of DL-204, 2-(3-ethoxyphenyl)-5,6-dihydro-5-triazole (5,1a)-isoquinoline, a non-hormonal post-implantational anti-fertility drug, on tissue weights, nucleic acids and total protein concentrations in the testes, ventral prostate and seminal vesicles were evaluated in immature and sexually mature rats, while changes in DNA synthesis were studied only in the immature rats. Treatment of 21-day-old rats at doses of 5mg and 10mg/kg bw once daily for 15 days had no effect on body weight but reduced the weights of testes and accessory glands of reproduction. The concentration of DNA increased while RNA and protein decreased significantly. Treatment of adult rats with DL-204 at a dose of 10mg/kg bw had no effect on body and testes weights but reduced ventral prostate and seminal vesicle weights. The concentration of RNA and protein decreased significantly, while DNA concentration was not altered. DL-204 treatment resulted in drastic decrease of RNA/DNA ratio, reflecting ribosomal loss and cytoplasmic shrinkage. The effects observed after DL-204 treatment are comparable to post-castration changes. DL-204 may be acting on testes and accessory reproductive organs by blocking androgen biosynthesis and/or by antagonizing the action of androgens. It may be acting directly on the normal function of the hypothalamo-pituitary-gonadal axis.

A new non-hormonal antifertility drug DL 111-IT: I. Effects on testes and accessory glands of reproduction in male rats.

Effect of DL-111, 3-(2-ethylphenyl)-5-(3-methoxyphenyl-1H-1,2,4-triazole, a non-hormonal postimplantational antifertility agent, on testicular and accessory reproductive organ weights and total protein, RNA and DNA concentrations were evaluated in immature and adult rats. Treatment of 21-day-old rats at doses of 2.5 mg and 5 mg/kg body weight decreased body weight, weights of testes and accessory glands of reproduction. RNA and protein concentrations decreased significantly with significant increase increase in DNA concentration in testes, epididymis, ventral prostate and seminal vesicles. DL-111 treatment of adult rats at doses of 5 mg and 10 mg/kg body weight had no effect on body weight, but significantly decreased weights of testes and accessory glands of reproduction. RNA and protein concentrations decreased significantly in all tissues studied while DNA concentration was not altered. RNA/DNA ratio decreased significantly, reflecting ribosomal loss and cytoplasmic shrinkage. These effects of DL-111 are comparable to post-castrational changes in accessory glands of reproduction. We presume that these changes are mediated by blocking the androgen biosynthesis and/or by interfering with normal function of hypothalamo-pituitary-gonadal axis.

A new non-hormonal antifertility drug DL 111-IT: II. Effects on testicular hyaluronidase activity in male rats.

Effects of DL-111, [3-(2-ethylphenyl)-5-(3-methoxyphenyl-1H-1,2,4-triazole] a non-hormonal antifertility agent, on testicular hyaluronidase activity, an accurate biochemical marker for testicular function, were evaluated in male rats. Treatment of 21-day-old rats with DL-111 sc for 7 or 15 days resulted in a significant fall in testicular weight and complete suppression of hyaluronidase activity. During the 30-day post-treatment the enzyme activity was restored to normal levels. Treatment of 40-day-old rats for 7 or 15 days also produced a significant decrease in testicular weight and hyaluronidase activity. Simultaneous administration of LH, PMSG or T with DL-111 to 21-day-old rats blocked the inhibitory activity of the drug as the enzyme activity was restored to untreated control levels. Administration of FSH along with DL-111 had no effect on suppressive action of the drug. These results suggest that in male rats DL-111 inhibits testicular activity by reducing LH levels, thereby reducing T levels as observed by reduced weights of testes and accessory glands of reproduction and hyaluronidase activity.