Imaging of spindle cell lipoma.

AIM: To review the evaluation, diagnosis, and treatment of spindle cell lipoma (SCL) with emphasis on the location of these tumours and the spectrum of magnetic resonance imaging (MRI) and computed tomography (CT) appearances. MATERIALS AND METHODS: The MRI and CT findings of 27 histopathologically proven SCLs were evaluated retrospectively. Imaging features evaluated included margins, percentage visible fat, MRI signal characteristics, oedema, and contrast enhancement patterns. RESULTS: Patient ages ranged from 18 to 80 years with an average age of 56.5 years. Men were affected twice as frequently as women (M=18, F=9). SCLs ranged in size from 2 to 10 cm, with an average greatest dimension of 5.5 cm. Five lesions (19%) contained no visible fat on CT or MRI, and the leading differential diagnosis of high-grade soft-tissue sarcoma diagnosis was suggested by referring surgeons. Five lesions (19%) had <50% fatty areas, nine lesions (52%) demonstrated >50% but <90% fat at MRI or CT. Only three of 25 lesions (12%) had an appearance of a typical lipoma on unenhanced MRI sequences. All SCLs that were imaged with contrast medium (n = 18) demonstrated some degree of enhancement, with eight (44%) showing marked enhancement, four (22%) showing moderate, and six (33%) minimal enhancement. CONCLUSION: SCLs have considerably variable imaging appearances and may have minimal or no visible fat at MRI or CT. Imaging features may make it difficult to distinguish this benign tumour from a potentially higher-grade malignant tumour.

Peripheral thermoregulation: foot temperature in two Arctic canines.

Arctic foxes and gray wolves maintain their foot temperature just above the tissue freezing point (about -1 degrees C)when standing on extremely cold snow, or when the foot is immersed in a -35 degrees C bath in the laboratory. Proportional thermoregulation stabilized the subcutaneous temperature of the foot pad to a precision of +/- 0.7 degrees C (largest deviations). Selective shunting of blood-borne body heat through a cutaneous vascular plexus in the foot pad accounted for more than 99 percent of measured heat loss from the pad surface. Maximum energetic efficiency is achieved because the unit of heat exchange is located in the pad surface which contacts the cold substrate rather than throughout the pad.

Cross-talk among ROR alpha 1 and the Rev-erb family of orphan nuclear receptors.

We have cloned Rev-erb beta, a novel isoform of the Rev-erb alpha orphan nuclear receptor. The DNA binding domains of Rev-erb alpha and beta are highly related to each other and to the retinoic acid related orphan receptor (ROR)/RZR subfamily of nuclear receptors. Indeed, we find that all three receptors bind as monomers to the sequence AATGT-AGGTCA. Whereas ROR alpha 1 constitutively activates transcription through this sequence, both isoforms of Rev-erb are inactive. When coexpressed, both Rev-erb isoforms suppress the transcriptional activity of ROR alpha 1. Our data define Rev-erb and ROR/RZR as a family of related receptors with opposing activities on overlapping regulatory networks.

Basic fibroblast growth factor protects against excitotoxicity and chemical hypoxia in both neonatal and adult rats.

Basic fibroblast growth factor (bFGF) is a polypeptide growth factor that promotes neuronal survival. We recently found that systemic administration of bFGF protects against both excitotoxicity and hypoxia-ischemia in neonatal animals. In the present study, we examined whether systemically administered bFGF could prevent neuronal death induced by intrastriatal injection of N-methyl-D-aspartate (NMDA) or chemical hypoxia induced by intrastriatal injection of malonate in adult rats and 1-methyl-4-phenylpyridinium (MPP+) in neonatal rats. Systemic administration of bFGF (100 micrograms/kg) for three doses both before and after intrastriatal injection of either NMDA or malonate in adult rats produced a significant neuroprotective effect. In neonatal rats, bFGF produced dose-dependent significant neuroprotective effects against MPP+ neurotoxicity, with a maximal protection of approximately 50% seen with either a single dose of bFGF of 300 micrograms/kg or three doses of 100 micrograms/kg. These results show that systemic administration of bFGF is effective in preventing neuronal injury under circumstances in which the blood-brain barrier may be compromised, raising the possibility that this strategy could be effective in stroke.

Malonate produces striatal lesions by indirect NMDA receptor activation.

We previously showed that local striatal injections of malonate produce age-dependent excitotoxic lesions. In the present study volumetric analysis confirmed that malonate produces age-dependent striatal lesions. Pretreatment with the non-competitive and competitive NMDA receptor antagonists, MK-801 and LY274614, and with lamotrigine resulted in significant protection in 4-month-old animals. In vivo magnetic resonance imaging of lesion area showed a significant correlation of increasing lesion size and lactate production in rats ranging from 1 to 12 months of age. Histological evaluation showed NADPH-diaphorase neurons were spared. The results provide further evidence that a subtle impairment of energy metabolism may play a role in neurodegenerative diseases.

Fit of the uncemented femoral component and the use of cement influence the strain transfer the femoral cortex.

To determine whether the strain patterns produced in the femoral cortex after uncemented femoral arthroplasty are influenced by the fit of the component and whether these patterns are different from those of cemented components, cortical surface strains of cadaveric femurs subjected to loads simulating single-limb stance were measured before and after the insertion of uncemented, collared, straight-stemmed femoral components. The effects of press fit, loose fit, and precise fit of the components were evaluated and were contrasted to the strain patterns occurring after insertion of cemented femoral components. Strains varied markedly, depending on the fit of the stem of the uncemented femoral component within the isthmus. Nearly normal patterns of femoral strain were produced when the femoral stem was fit precisely at the isthmus, and the proximal femoral strains were similar to those of the intact state. In contrast, press fit and loose fit at the isthmus altered the strain patterns. The proximal medial axial strains were significantly reduced with press fit, to a mean of 39% of normal (p < 0.05), and increased with loose fit, to a mean of 141% of normal (p < 0.05). The prostheses fixed with cement showed a mean reduction in proximal medial axial strains to 33% of normal, which was comparable with press fit uncemented components even though the collar was well seated. Thus, our findings indicated that, in the immediate postoperative period, femoral strain patterns can be influenced by the fit of an uncemented component within the isthmus and by the use of cement.

Extraspinal bone and soft-tissue tumors as a cause of sciatica. Clinical diagnosis and recommendations: analysis of 32 cases.

STUDY DESIGN: Between 1982 and 1997, the authors treated 32 patients with sciatica who subsequently were found to have a tumor along the extraspinal course of the sciatic nerve. SUMMARY OF BACKGROUND DATA: Extraspinal compression of the sciatic nerve by a tumor is a rare cause of sciatica. Signs and symptoms overlap those of the more common causes of sciatica (i.e., herniated disc and spinal stenosis). OBJECTIVE: To characterize the unique clinical presentation of these patients and to formulate guidelines that may lead to early diagnosis. METHODS: All pertinent clinical data and studies were reviewed retrospectively, and standard demographic data were collected for analysis. RESULTS: These patients typically sought treatment for an insidious onset of sciatic pain that was constant, progressive, and unresponsive to change in position or bed rest. The mean time to final diagnosis was 11.9 months (median, 6 months). Seventeen patients were able to locate their pain to a specific point along the extraspinal course of the sciatic pain, and a mass was noted in 13 patients. Eighteen of these tumors were in the pelvis, 10 in the thigh, and 4 in the popliteal fossa and calf. CONCLUSIONS: A high index of clinical suspicion is the key to early diagnosis of bone or soft-tissue tumors as a cause of sciatica; special attention should be given to pain pattern, physical examination of the entire course of the sciatic nerve, and selection of proper imaging studies. Routine anteroposterior plain radiography of the pelvis as part of the initial imaging screening process is recommended.

Medical management of missed abortion and anembryonic pregnancy.

PIP: Mifepristone (an antiprogesterone) and misoprostol (a synthetic analogue of prostaglandin E1) were administered to 60 women diagnosed with missed abortion or anembryonic pregnancy (gestation sac present but no developing embryo) equivalent to 13 weeks' gestation or less who were recruited after counselling. The median age was 227 (range 15-44), and the median duration of amenorrhoea was 71 (42-110) days. 25 of the women had been referred for ultrasound scanning because of bleeding in early pregnancy, while the rest were diagnosed by routine scanning. 29 patients had anembryonic pregnancies, and 31 had a missed abortion. Each patient received a 600 mg single oral dose of mifepristone, and 36-48 hours later misoprostol 600 mcg was given orally (400 mcg and, 2 hours later, 200 mcg). If the products of conception were not expelled within 4 hours, vaginal ultrasonography was performed. 8 patients aborted with mifepristone alone, 43 aborted after taking 600 mcg of misoprostol, and 5 more aborted after receiving a 2nd divided dose of 600 mcg misoprostol. In 3 patients the treatment failed, and they underwent evacuation of the uterus under general anaesthesia. Exploratory curettage was performed in 2 other patients at 14 and 22 days after treatment with misoprostol, but no products of conception were obtained. The median time from administration of misoprostol to abortion was 4 (1-11) hours. The median duration of bleeding after abortion was 10 (2-22) days. Side effects included nausea, vomiting (5 patients received antiemetic drugs), and diarrhoea (7 patients) from misoprostol treatment. 39 women did not want any pain relief, 13 asked for oral analgesia, and 7 obtained parenteral analgesia.^ieng

Comparison of medical abortion with surgical vacuum aspiration: women's preferences and acceptability of treatment.

OBJECTIVES: To assess women's preferences for, and the acceptability of, medical abortion and vacuum aspiration in the early first trimester. DESIGN: Patient centred, partially randomised trial. Medical abortion was performed with mifepristone 600 mg followed 48 hours later by gemeprost 1 mg vaginal pessary. Vacuum aspiration was performed under general anaesthesia. SETTING: Teaching hospital in Scotland. PATIENTS: 363 women undergoing legal induced abortion at less than nine weeks' gestation. MAIN OUTCOME MEASURES: Women's preferences for method of abortion before abortion; acceptability judged two weeks after abortion by recording the method women would opt to undergo in future and by semantic differential rating technique. RESULTS: 73 (20%) women preferred to undergo medical abortion, and 95 (26%) vacuum aspiration; 195 (54%) were willing to undergo either method, and were allocated at random. Both procedures were highly acceptable to women with preferences. Gestation had a definite effect on acceptability in randomised women; at less than 50 days there were no differences, but between 50 and 63 days vacuum aspiration was significantly more acceptable. CONCLUSIONS: Women who wish to use a particular method should be allowed their choice, regardless of gestation. Women of 50-63 days' gestation without preferences for a particular method are likely to find vacuum aspiration more acceptable. A patient centred, partially randomised trial design may be a useful tool in pragmatic research.

PIP: In Scotland, physicians compared women's preferences for and acceptability of medical abortion and vacuum aspiration in the early 1st trimester of pregnancy among 363 patients at the Maternity Hospital in Aberdeen. They measured acceptability 2 weeks after the abortion. The 4 groups included 73 women who chose a medical abortion (600 mg RU-486 followed 48 hours later by a vaginal pessary of 1 mg gemeprost), 95 women who chose vacuum aspiration, 99 women randomly allocated to medical abortion, and 96 women randomly allocated to vacuum aspiration. 23% had had a previous legal abortion. Almost all the women who had a preference for an abortion method accepted their chosen method (95% for medical abortion and 90% for vacuum aspiration). Just 4% from either group would choose another method if the need would arise in the future. Women randomized to medical abortion were significantly more likely to choose vacuum aspiration in the future than were those randomized to vacuum aspiration who would choose medical abortion in the future (22% vs. 2%; p .001). The only predictor of acceptability before the abortion among women randomly allocated to medical abortion was gestational age. Specifically, 95% of the women who considered medical abortion to be unacceptable underwent medical abortion at 50 or more days gestation. At gestations under 50 days, acceptability between the 2 randomly allocated groups was the same. The 2 groups did not differ in pain rating scores, indicating that preferences were likely to be more significant than pain. All 4 groups rated the quality of nursing care to be positive in 11 of the 12 bipolar adjectives. Women who preferred medical abortion rated treatment considerably higher on 4 scores (p .05). These 4 bipolar adjectives were relaxed-stressed, soft-hard, sympathetic-unsympathetic, and gentle-harsh.

Intractable pelvic pain following Filshie clip application.

PIP: Presented is the case of a 37-year-old South Australian woman who experienced intractable pelvic pain following laparoscopic sterilization with Filshie clips. The pelvic anatomy was normal and one Filshie clip was applied to each Fallopian tube. The patient stated she had experienced right-sided lower abdominal pain that radiated down the anterior part of her right thigh since regaining consciousness after general anesthesia. The pain had failed to resolve seven days after the procedure and the patient was unable to perform even simple tasks. Analgesics provided only temporary, partial relief. There were no signs of infection or any other exacerbating condition. At diagnostic laparoscopy, instillation of bupivacaine around the clip provided transient relief, but the pain returned the next day at the same level of severity. After one month of intractable pain, laparoscopic bilateral salpingectomy was performed to remove the clips and the pain disappeared. Although back pain has been reported in up to 14% of women undergoing laparoscopic sterilization, this is the first published case of long-term abdominal pain associated with the Filshie clip.^ieng

Pre-operative cervical preparation before first trimester vacuum aspiration: a randomized controlled comparison between gemeprost and mifepristone (RU 486).

OBJECTIVE: To compare the effectiveness of 200 mg mifepristone with 1 mg gemeprost vaginal pessary in achieving cervical dilatation and softening ('priming') before late first trimester pregnancy vacuum aspiration. DESIGN: A randomized, operator blind, placebo controlled trial. SETTING: UK teaching hospital. SUBJECTS: 90 primigravid women with 63-91 days amenorrhoea and ultrasonically confirmed single living fetus of correct size for gestational age. INTERVENTIONS: The women were allocated to receive 200 mg mifepristone orally or an identical oral placebo 36 h before operation or 1 mg gemeprost vaginal pessary 3-4 h preoperatively. MAIN OUTCOME MEASURES: Onset of new symptoms following drug administration, a proven objective measure of the force required to dilate the cervix, and estimated intraoperative blood loss. RESULTS: There were no significant differences in the baseline cervical dilatation, the force required to dilate the cervix or the volume of intraoperative blood loss between the active treatment groups. Both drugs were significantly more effective than placebo. Significantly fewer women in the mifepristone group had adverse side effects than in the gemeprost group. CONCLUSIONS: Mifepristone is a highly effective cervical priming agent, and has the advantages of being an oral preparation associated with few side effects.

PIP: This study compared the effectiveness of 200 mg mifepristone with 1 mg gemeprost vaginal pessary in achieving cervical dilatation and softening (priming) before late 1st trimester pregnancy vacuum aspiration. A UK teaching hospital was the setting for this randomized, operator blind, placebo controlled trial. 90 primigravid women with 63-91 days of amenorrhea and ultrasonically confirmed single living fetus of correct size for gestational age were included; women were allocated to receive 200 mg mifepristone orally or an identical oral placebo 36 hours before their operation of 1 mg gemeprost vaginal pessary 3-4 hours preoperatively. Investigation focused on the onset of new symptoms following drug administration, a proven objective measure of the force required to dilate the cervix, as well as estimated intraoperative blood loss. There were no significant differences in the baseline cervical dilatation, the force required to dilate the cervix, or the volume of intraoperative blood loss between the active treatment groups. Both drugs were significantly more effective than the placebo. Significantly fewer women in the mifepristone group had adverse effects than in the gemeprost group. Mifepristone is a highly effective cervical priming agent and has the advantages of being an oral preparation and resulting in few side effects.

Is evacuation of the uterus necessary after middle trimester abortion?

PIP: To assess the importance of uterine evacuation after prostaglandin- induced mid-trimester abortion, the results of management with and without this procedure were compared. The gestational age of study participants was 15 weeks (range, 12-18 weeks). The procedure involved insertion of a Foley catheter through the cervical canal and infusion of a solution of prostaglandin E2 into the extra-amniotic space. Complete abortion was considered to have occurred if the placenta and products appeared intact, the uterus was well contracted, and there was no excessive bleeding. If complete abortion has occurred, the patients were randomly assigned to have uterine evacuation under general anesthesia (9 patients) or no uterine evacuation (22 patients). The 37 patients who were diagnosed clinically has having incomplete abortion also underwent uterine evacuation. Women who had evacuation of the uterus performed after clinically complete abortion were more likely to visit their general practitioner (4.9 cases) and to require antibiotics (4 cases) than those who did not undergo evacuation (4/22 and 4 cases, respectively). In 1 of the 9 cases where complete abortion was judged to have occurred, a moderate amount of retained placental tissue was found. However, the possible complications of uterine evacuation after an apparently complete abortion--the need for general anesthesia, and the danger of introducing infection into the uterine cavity--suggest that this procedure is not a advisable component of the management of prostaglandin-induced mid-trimester abortions.^ieng

Assessing strength of preference for abortion method using 'willingness to pay': a useful research technique for measuring values.

Policy makers and practitioners need to differentiate between patient preferences which are strongly held, and those which are not. This study measured not only women's preferences for medical abortion versus surgical vacuum aspiration, but also the strength of these preferences, using a 'willingness to pay' (WTP) technique. Fifty women were recruited and interviewed prior to and following termination of early pregnancy. Due to the sensitivity of the situation, the WTP approach was administered by interview. Results revealed that 34 (64%) preferred to have the medical method. The amounts offered for each method were similar; however, a minority gave higher values for the medical method, thus for those women their strength of preference for that method was more intense. Validity of the technique was supported by the finding of a positive association with social class and the importance women attached to having choice. It is argued that WTP is an acceptable method for the elicitation of strength of treatment preferences. Its further use by nurses and midwives to assess health care preferences should be explored, particularly when considering aspects of care which are traditionally difficult to identify and measure.

Psychological responses following medical abortion (using mifepristone and gemeprost) and surgical vacuum aspiration. A patient-centered, partially randomised prospective study.

BACKGROUND: A substantial body of objective data now exists to support the consensus view that induced abortion results in a low incidence of psychiatric morbidity. However, these data do not include more recent advances in abortion technology. Medical abortion entails a participatory role on the part of the woman, who may perceive more pain or see products of conception. The physical and psychological events experienced by women undergoing this procedure may lead to differences in psychopathology. METHODS: 363 women undergoing legal induced abortion up to 63 days gestation were allocated by a prospective partially randomised design to undergo medical abortion (using mifepristone 600 mg followed 48 h later by gemeprost 1 mg vaginal pessary) or vacuum aspiration performed under general anesthesia. This study design allowed women with a preference for a particular method to undergo that method; women without preferences were allocated at random. Women completed sensitive and reliable psychometric instruments (the Hospital Anxiety and Depression Scale and a semantic differential rating scale designed to measure self-esteem) prior to abortion and 16 days later. RESULTS: There were no significant differences between women allocated at random to medical abortion or vacuum aspiration in post-abortal anxiety, depression or low self-esteem. Women with high levels of mood disturbance prior to abortion, who were smokers or who had medical complications following abortion were at highest risk of post-abortal mood disorder. CONCLUSIONS: Medical abortion is a psychologically safe as surgical vacuum aspiration. The quantitative findings of the study support the consensus view that abortion is associated with high incidence of psychological benefit, whichever method is used.

PIP: A prospective study of 363 abortion patients failed to provide evidence that women who receive a mifepristone/gemeprost medical abortion are at any greater risk of subsequent psychiatric morbidity than those who undergo the traditional vacuum aspiration procedure. Since women who undergo medical abortions are exposed to more pain, may see the products of conception, and generally play a more participatory role in the process, they were hypothesized to experience more psychological trauma than other abortion patients. The 168 women in the medical abortion subgroup received 600 mg of mifepristone followed 48 hours later by a vaginal pessary containing 1 mg of gemeprost. All subjects completed the Hospital Anxiety and Depression Scale and a self-esteem measure before and an average of 16 days after abortion. Overall, 165 women (45.5%) were significantly anxious and 67 (18,5%) were clinically depressed at baseline; after abortion, these rates had dropped to 37 (10.2%) and 9 (2.5%), respectively. Only 4 women who were non-anxious at baseline were anxious at follow up, while post-abortion depression developed in just 2 women. 190 women (55%) reported an improvement in self-esteem at follow up compared to baseline, 25 (7%) experienced no change, and 130 (38%) reported a decrease in self-esteem--a finding that is considered temporary and an integral part of the post-abortion grieving process. There was a significant correlation between anxiety and depression subscale scores before and after abortion and a significant negative correlation with self-esteem scores. There were no significant differences in any of these scores, however, between women who received medical versus vacuum aspiration procedures. Depression subscale scores at follow up were significantly related to postabortal medical complications, while anxiety scores after abortion were correlated with the number of physician consultations and the time required to resume normal activities. Baseline characteristics significantly associated with high anxiety and depression scores included cigarette smoking and a pre-existing mood disorder.