Coronal oblique imaging of the knee: can it increase radiologists' confidence in diagnosing posterior root meniscal tears?

AIM: To investigate the utility of the coronal oblique sequence in the interrogation of posterior root meniscal lesions. MATERIALS AND METHODS: Following international review board approval, 62 consecutive knee arthroscopy cases were referred to the musculoskeletal (MSK) radiologists from the same orthopaedic surgeon for imaging/surgical correlation of the posterior meniscal roots. Of 62 cases, 45 lateral and 46 medial menisci met the inclusion criteria. Imaging evaluation was performed with standard magnetic resonance imaging (MRI) sequences, including a coronal oblique proton density sequence. Two blinded fellowship-trained MSK radiologists independently evaluated the menisci on standard sequences indicating whether a tear was identified and then specifying a confidence score using a scale of 1-3 on each study interpreted. Immediately thereafter, the coronal oblique sequence was evaluated using the same method. Statistics were performed on meniscal lesions involving the posterior horn/root junction or isolated root tears comparing confidence scores. RESULTS: Reader A identified nine posterior horn/root junction tears and 14 isolated root tears. Following the addition of the coronal oblique sequence, confidence scores increased in three of 14 (21.4%) isolated root tears. All three final reads were concordant with arthroscopy. Reader B identified 10 posterior horn/root junction tears and 19 isolated root tears. The confidence score increased in six cases: five of 19 (26.3%) isolated root tears and one of 10 (10%) posterior horn/root junction tears. All six final reads were concordant with arthroscopy. Kappa coefficients indicated near perfect agreement. CONCLUSION: The coronal oblique sequence increased reader confidence in nearly 24% of the posterior root cases identified in this series.

Severe aortic regurgitation as a late complication of temporal arteritis.

Two patients with a remote history of pathologically documented giant cell arteritis developed severe regurgitation. The first patient developed severe aortic regurgitation five years after the pathologic documentation of giant cell arteritis of the temporal arteries. Giant cell arteritis involvement of the aortic root was confirmed. The second patient developed aortic regurgitation seven years after pathologic documentation of giant cell arteries of the temporal arteries. Although pathologic confirmation of the aortic root process was not obtained, this case strengthens the clinical association between giant cell arteritis of the temporal arteries and subsequent aortic root dilatation and severe aortic regurgitation. Observation for signs of de novo severe aortic regurgitation is indicated in follow-up of patients with temporal arteritis.

Dipyridamole thallium imaging: use in preoperative cardiac risk assessment in vascular surgical patients.

BACKGROUND: The objective of this study was to determine whether routine performance of dipyridamole thallium imaging adds to the power of a careful clinical evaluation in the risk stratification of patients undergoing major vascular surgery. METHODS: In this retrospective study, 115 cases evaluated by dipyridamole thallium imaging before major vascular surgery were reviewed. Patients were assigned to a high-risk cohort if they had a history of congestive heart failure or evidence of previous myocardial infarction. RESULTS: Six (8%) patients from the high-risk cohort developed major cardiovascular complications. Reversible perfusion defects, present in 67% of the high-risk patients, did not predict complications. None of the patients in the low-risk cohort developed complications despite the presence of reversible perfusion defects in 33%. Patients in the high-risk cohort who underwent cardiac catheterization and selective coronary bypass grafting were uniformly free of perioperative complications. The extent and severity of fixed or reversible thallium perfusion did not predict the occurrence of cardiovascular complications. However, three patients were denied surgery following an unacceptable cardiovascular risk assessment based on clinical findings and multiple reversible thallium perfusion defects. CONCLUSION: In low-risk patients, screening with dipyridamole thallium can identify patients with redistribution defects whose risk of perioperative ischemic events can be reduced by intensifying perioperative anti-ischemic management. If the patient is in the high-clinical-risk subgroup, screening with dipyridamole thallium does not identify a cohort with negligible perioperative risk; thus, further evaluation of these patients by cardiac catheterization should be considered.

Forearm compartment syndrome following thrombolytic therapy for acute myocardial infarction.

Thrombolytic therapy for myocardial infarction may contribute to bleeding complications when central venous or arterial access is required, but peripheral venous access is usually uncomplicated. We report a patient in whom tissue plasminogen activator and subsequent intravenous heparin exacerbated bleeding from a disrupted intravenous access site, leading to acute compartment syndrome requiring surgical decompression. This case emphasizes the risks associated with iatrogenic trauma during thrombolytic therapy.

Echocardiographic detection of pulmonary valve papillary fibroelastoma.

Papillary fibroelastomas of the heart are rare lesions usually discovered at autopsy or incidentally at surgery. Although these lesions are benign and generally asymptomatic, they can cause valvular dysfunction or embolize to vital structures. In this case report, we describe a pulmonary valve papillary fibroelastoma detected by echocardiography in an adult. Most of the 12 cases of pulmonary valve papillary fibroelastoma reported in the literature were discovered incidentally at autopsy or during surgery. To our knowledge, this is the first reported case of pulmonary valve papillary fibroelastoma detected by echocardiography. Rest imaging before exercise echocardiography for evaluation of atypical chest pain in a 42-year-old white female demonstrated a mass on the pulmonary valve. The mass was further characterized by transesophageal echocardiography and excised during open heart surgery. Pulmonary valve papillary fibroelastoma was diagnosed histopathologically. This case illustrates the additional diagnostic value of comprehensive 2D imaging in the rest phase before doing exercise echocardiography.

Drug reaction simulating malignant lymphoma: a case due to pyrimethamine.

A 9 1/2-year-old boy who had been treated with pyrimethamine and sulphadimidine presented with generalised lymphadenopathy, fever, and an unusual sun-tanning. He was found to have mild anaemia, severe leucopenia and thrombocytopenia. The bone marrow was megaloblastic. Lymph node biopsy was initially interpreted as showing malignant lymphoma. No treatment for neoplasia was given and he was well 4 1/2 years later. We consider that the seemingly malignant changes were due to pyrimethamine.

The response to treatment with pituitary growth hormone: the New Zealand experience.

Ninety-four growth hormone deficient New Zealand children were treated with thrice weekly intramuscular injections of human pituitary growth hormone (GH) from 1979 to 1985 and the results from 43 children were analysed in detail. Their height velocity was mean (SD) 4.0 (1.9) cm/yr immediately prior to treatment and 8.5 (3.1) cm/yr in the first year of treatment. In each of the first three years of treatment the height velocity was significantly increased (p less than 0.001), but there was a significant decline in height velocity between the first and second, and second and third years. Nevertheless each year of treatment gave a highly significant gain in relative height. Bone age did not advance more rapidly than chronological age during the first two years of treatment, but did so subsequently. The response to GH, as assessed by the increase in relative height, was negatively correlated with the relative height at the start of treatment and with the maximum pretreatment plasma GH response to insulin hypoglycaemia. There was no correlation with pretreatment relative height velocity or aetiology of GH deficiency. Height velocity improved in five of 14 children treated with thyroxine after starting GH. Discontinuation of GH for one year in 34 children resulted in a highly significant reduction in growth rate from 7.5 (2.4) cm/yr to 2.5 (2.0) cm/yr, however four prepubertal children continued to grow at a rate exceeding 4 cm/yr.

Programmed instruction.

This report presents a description of the principles of programmed instruction and an explanation of all major components of a program. No attempt is made to review or critique all available speech and language programs, but certain programs are discussed in some detail in order to illustrate adequate application of programming principles.

Neonatal hypopituitarism: a neurological perspective.

Twelve patients presented with evidence of hypopituitarism in the neonatal period, but only four were correctly diagnosed at that time. Craniofacial, optic and neurological features were common. Optic hypoplasia occurred in six cases, large anterior and posterior fontanelles in four, wide sutures in four, depressed nasal bridge in three, facial palsy in three, and one infant had an asymmetrical, crying facies. Seizures occurred in three during the neonatal period and in eight at a later age. All 12 had hyperbilirubinaemia, 11 had hypoglycaemia, and micropenis occurred in five of the seven boys. This survey suggests that the incidence of neonatal hypopituitarism may have increased.

An analysis of the relationship among stuttering behaviors.

The purpose of this study was to determine whether different topographies of disfluent behavior form a response class. A within-subject, repeated reversals (ABAB) design was used to analyze the stuttering behavior of three adult stuttering speakers. A single type of stuttering behavior was punished for each subject while frequencies of occurrence of other types were concurrently measured. The results showed that: (1) stuttering behaviors displayed direct behavioral covariation for all subjects, illustrating the existence of a response class; and (2) the response classes observed included both kernel and accessory features of stuttering. The results are discussed in terms of the literature on response classes and two-factor learning theory of stuttering with special emphasis on the implications of these results for our understanding of the development of stuttering.

Treatable chondral injuries in the knee: frequency of associated focal subchondral edema.

OBJECTIVE: In the knee, chondral flaps and fractures are radiographically occult articular cartilage injuries that can mimic meniscal tears clinically; once correctly diagnosed, these injuries can be treated surgically. We investigated an associated MR imaging finding--focal subchondral bone edema--in a series of surgically proven lesions. MATERIALS AND METHODS: Two musculoskeletal radiologists retrospectively reviewed the MR studies of 18 knees with arthroscopically proven treatable cartilage infractions, noting articular surface defects and associated subchondral bone edema; subchondral edema was defined as focal regions of high signal intensity in the bone immediately underlying an articular surface defect on a T2-weighted or short inversion time inversion recovery (STIR) image. RESULTS: The first observer saw focal subchondral edema deep relative to a cartilage surface defect in 15 (83%) of the 18 cases; in two additional cases a surface defect was seen without underlying edema. The second observer identified 13 knees (72%) with surface defects and associated subchondral edema and three with chondral surface defects and no associated edema. Subchondral edema was seen more frequently on fat-suppressed images and on STIR images than non-fat-suppressed images. CONCLUSION: Focal subchondral edema is commonly visible on MR images of treatable, traumatic cartilage defects in the knee; this MR finding may prove to be an important clue to assist in the detection of these traumatic chondral lesions.

Stuttering and speech naturalness: some additional data.

Thirty listeners used the 9-point speech naturalness rating scale described by Martin, Haroldson, and Triden (1984) to score 1-minute spontaneous speaking samples from 15 normally fluent speakers and 15 stutterers who had completed the initial phases of a prolonged speech treatment program. The same listeners were later asked to judge whether each sample was from a stutterer or from a normal speaker. Reliable listeners identified almost identical numbers of samples from both speaker groups as "normal speakers," but the stutterers received significantly higher scores on the rating scale, indicating that their speech was judged more unnatural sounding. The speech samples incorporated those used in a related study by Ingham and Packman (1978), thus permitting a reevaluation of the findings of that study.

46, X,X-X terminal rearrangement/45, X mosaicism in a child with short stature.

A phenotypically female child, investigated because of short stature, had abnormally large, often bipartite Barr bodies and a mosaicism of 45, X cells and cells with 46 chromosomes which included an exceptionally large metacentric chromosome (Xp+). G- and C-banding established that the chromosome was derived from two substantially entire X chromosomes joined short arm-to-short arm, and was likely to be an isodicentric X with functional inactivation of one centromere.

Identification of a genetic region in mice that specifies sensitivity to propofol.

BACKGROUND: Long-sleep (LS) and short-sleep (SS) mice, initially selected for differential sensitivity to ethanol, also exhibit differential sensitivity to propofol. By interbreeding LS and SS mice to obtain progeny whose chromosomes are a patchwork of the LS and SS chromosomes, the authors determined whether differential propofol sensitivity cosegregates with any particular chromosomal region(s). Such cosegregation is the essence of genetic linkage mapping and a first step toward isolating a gene that can modulate propofol sensitivity in mammals. A gene underlying a quantitative trait such as anesthetic sensitivity is commonly called a quantitative trait locus (QTL). METHODS: The propofol dose was 20 mg/kg injected retroorbitally. Sensitivity was measured as the duration of the loss of righting reflex (LORR). The LORR and propofol brain levels at awakening were determined for 24 LSXSS recombinant-inbred (RI) strains, derived by intercrossing LS and SS for two generations followed by >20 generations of inbreeding. A genetic linkage between LORR and an albino mutation on chromosome 7 was investigated further using 164 second-generation progeny (F2s) from intercrossing inbred LS and inbred SS mice, similar to the LSXSS RIs except F2s are not inbred. The linkage between propofol sensitivity and the albino locus also was investigated using additional genetic markers on chromosome 7. Statistical significance was assessed by interval mapping using a regression method for RIs and Mapmaker/QTL (Whitehead Institute, Cambridge, MA) for F2s. RESULTS: Genetic mapping in the LSXSS RIs revealed a QTL tightly linked to the Tyr (albino) locus that accounts for nearly all of the genetic difference in propofol sensitivity between LS and SS mice. Analysis of propofol brain levels at awakening indicated that this QTL results from differential neurosensitivity. Mapping in F2s confirmed the genetic linkage to Tyr. Mice (ISS c/c x C57BL/6 c2j/C) that differed only by an albino mutation at Tyr were not differentially sensitive to propofol. CONCLUSIONS: A single QTL, called Lorp1, underlies most of the genetic difference in propofol neurosensitivity between LS and SS mice. Although this QTL is tightly linked to Tyr, propofol sensitivity is not modulated by albinism. For mapping this QTL, the LSXSS RIs proved to be an especially powerful resource, localizing the candidate-gene region to a 99% confidence interval of only 2.5 centimorgans.

Interstitial deletion of the long arm of chromosome no. 5 in two unrelated children with congenital anomalies and mental retardation.

Two unrelated children with partial deletion of the long arm of a chromosome no. 5 are reported. The boy presented with severe hypotonia, developmental delay, and a few minor defects of the face including frontal bossing, antimongoloid slant of the palpebral fissures, depressed nasal bridge and bilateral epicanthal folds. With age, his hypotonia has improved. The parents have normal chromosomes; the mother has a 9qh+ variant. The second patient, a girl, presented at birth with multiple congenital anomalies including cleft palate, epicanthal folds, anteverted nostrils, horseshoe kidneys and club feet. At 4 years of age, she was small and severely retarded. The normal parents and the normal sister showed no chromosomal abnormalities. Gene mapping studies in both patients failed to define a specific gene locus to the deleted chromosome regions. Including these two patients, there appear to be only three reported cases of patients with 5q deletion. A comparative description of the third patient is included in this report. There are some clinical similarities but these are inadequate to identify a clinical syndrome. This perhaps is explained by some quantitative and qualitative differences in the deletions.