Effectiveness of triglycyl vasopressin in persistent hematuria associated with sickle cell hemoglobin.

Two cases of persistent hematuria associated with the presence of sickle cell hemoglobin were treated intravenously with triglycyl vasopressin, a drug not previously used for this condition. One patient, a 16-year-old boy, had hemoglobin AS. Both patients had a history of severe hematuria persisting over several months, resistant to the usual forms of therapy, and requiring numerous transfusions. In each patient, the condition responded to intravenous triglycyl vasopression therapy, with cessation of hematuria. Experimental studies in dogs indicate that triglycyl vasopressin reduces renal blood flow substantially. Further trial of triglycyl vasopressin in severe hematuria associated with the presence of sickle cell hemoglobin appears to be indicated.

Effect of plasma proteins and temperature on echogenicity of blood.

An explanation is proposed for the echogenicity to ultrasound scanning at 5 mHz and above of unclotted blood under conditions of stasis. In vitro experiments using blood from normal subjects and from patients with myeloma revealed that: 1) lysis of red cells prevented echogenicity, 2) echogenicity increased with increasing hematocrit, fibrinogen and other macromolecules, and temperature, and 3) blood from myeloma patients showed increased echogenicity and rouleau formation, a form of aggregation seen on peripheral smears. From these experiments it was concluded that red cell aggregation is a major cause of echogenicity of unclotted blood, requiring both intact red cells and conditions which are known to enhance red cell aggregation, such as the presence of macromolecules and increased temperature.

Arterial digital angiography in the evaluation of potential renal donors.

Twenty-two potential renal donors were examined by both arterial digital and conventional aortography. The digital studies accurately identified all of the renal arteries. Digital subtraction angiography may be a suitable alternative to conventional aortographic evaluation of the renal arterial supply of potential renal donors.

Ultrasonography of blood during stasis and coagulation.

A series of in vitro and animal experiments were performed to determine ultrasonic features of blood during stasis and coagulation. Liquid whole blood became echogenic within a few seconds to 3 minutes following the onset of stasis. This occurred in citrated human blood allowed to stand and in occluded segments of vena cava and aorta of dogs. Mechanical agitation of the blood in stasis caused a disappearance of echoes. This echogenicity occurred with gray-scale and real-time ultrasonography using 7.5-mHz transducers, but was not observed with 3.5-mHz transducer used in real-time scanning. Whole blood clot was echogenic both with 7.5- and 3.5-mHz scanning. Fibrin clot was sonolucent. Echogenicity with stasis did not occur with plasma, serum, or packed erythrocytes. The development of echogenicity required the presence of fibrinogen or its products plus erythrocytes. The echogenicity of blood during stasis detectable by high-frequency ultrasonography probably was related to physical layering of blood products. The disappearance of reflective echoes following agitation suggested that the layering could be readily disrupted.

Detection of experimental arterial defects by portable and serial biplanar operative arteriography.

The accuracy of arteriography in detecting vascular defects similar to those encountered during vascular surgery was evaluated experimentally. Intimal flaps, thrombi, and strictures were created in dog aortas and studied under circumstances resembling operating room conditions by single-view portable and serial biplanar contrast arteriography. The specificity of both types of arteriography was comparable and high for detecting vascular defects. The sensitivity for diagnosing strictures was also comparable and high. However, both radiographic techniques were relatively insensitive in the detection of small intimal flaps and thrombi. In the detection of these two types of defects, serial biplanar arteriography was significantly more sensitive than portable arteriography. The degree of the superiority of serial bi-plane and the possible clinical insignificance of small defects indicates that portable arteriography in the operating room may still be an adequate methodology.

Magnetic resonance imaging and intraocular foreign bodies.

We conducted in vitro and in vivo experiments to study magnetic resonance imaging of intraocular foreign bodies. Diamagnetic and paramagnetic foreign bodies were imaged without artifact and without movement during the imaging process, while ferromagnetic foreign bodies produced large amounts of artifact that prevented meaningful images. All fetromagnetic foreign bodies moved during in vitro imaging. During in vivo imaging, three of four ferromagnetic bodies moved, producing substantial retinal injury. We concluded that magnetic resonance imaging is contraindicated in traumatized eyes with suspected ferromagnetic foreign bodies.

Partial splenic embolization, an alternative to splenectomy--results of a prospective, randomized study.

UNLABELLED: We conducted a prospective, randomized study comparing transcatheter partial splenic embolization (PSE) with splenectomy (SX) in 53 renal transplant candidates. An additional 112 PSE procedures were performed for various indications in 101 patients. STUDY RESULTS: A mean +/- SD of 65% +/- 16% of splenic mass was ablated in the PSE group. The early postoperative morbidity rate was similar in the two study groups, as was the duration of hospital stay. Abscess or rupture of the spleen were not encountered. Severe pancreatitis occurred only in the SX group. Renal transplantation was carried out in equivalent numbers in both groups, with a similar long-term (2.5 to 4.0 years) graft survival (60% versus 66%). No difference in long-term patient mortality was noted. Splenic "regeneration" occurred frequently after PSE. PSE experience exclusive of study: Embolization attempts failed in nine patients. Repeat PSE was performed in 11 of the 101 patients. Where hypersplenism was the primary indication, PSE resulted in significant improvement in the hematologic parameters. The incidence of serious complications was acceptably low. There were two late procedure-related deaths. Our conclusion from the study and the total experience of 137 PSE procedures is that PSE offers an acceptably safe alternative to SX in selected high-risk patients in whom both the surgical intervention and the resulting asplenic state carry a prohibitive risk.

Computed tomography-guided pudendal block for treatment of pelvic pain due to pudendal neuropathy.

BACKGROUND: Severe pelvic pain secondary to pudendal neuropathy can be treated with repeated local anesthetic nerve blocks or with surgical decompression of the nerve. Computed tomographic (CT) needle guidance to identified reliable anatomic points might be useful for improved success rates. TECHNIQUE: A CT scan is used to determine baseline anatomy and identify the sacrospinous process. A metallic marker is used to create a perpendicular pathway from the sacrospinous process upward to the skin surface, where a local anesthetic is injected. A 22-gauge, 5-inch needle is inserted downward in a perpendicular direction to the target. Deep penetration and direction are confirmed by serial CT scans. Medication is injected and the needle is removed. EXPERIENCE: Twenty-six women with diagnoses of pudendal neuropathy were treated with injection therapy once per month, for five total treatments each. About three-quarters experienced improvement. There were no complications in this series. Outcomes were gratifying considering the complex patient population, all having failed multiple therapeutic trials. CONCLUSION: We believe this technique warrants further evaluation and application in instances where noninvasive therapy of pudendal neuropathy is indicated.

Ultrasonic imaging during vascular surgery.

Real-time B-mode ultrasound scanning was used during arterial reconstruction surgery to supplement the information of preoperative arteriography and to detect vascular defects immediately after restoration of blood flow. At 55 operations, 100 sites were examined. At three operations, ultrasound provided new information that, in two patients, directly affected the choice of operation. Intraoperative postreconstruction scanning detected vascular defects in over 20% of the patients. Intimal flaps were the commonest defects observed. In most instances in which defects were seen, the vessels were not reentered because the defects were considered to be too small or located in a nonstrategic site or both. One relatively large intimal flap in a common carotid artery prompted reentry. Ultrasound during vascular operations proved to be a highly sensitive diagnostic tool to supplement preoperative arteriography and to detect vascular defects resulting from reconstructive surgery.

Detection of pancreatic tumors by ultrasound during surgery.

Real-time B-mode ultrasonic scanning was performed during 14 operations for pancreatic tumors. All operations were for adenocarcinoma, except in one patient with a Zollinger-Ellison tumor. The ultrasonic tissue appearance of pancreatic carcinoma was not specific. However, ultrasonic signs of pancreatic duct dilation, striction or invasion of the superior mesenteric veins, and common bile duct involvement may help to establish the diagnosis of malignancy. A triad of ultrasound signs indicative of malignant obstruction of the common bile duct consisted of (1) dilation, (2) absence of biliary stones, and (3) a distinctive termination pattern of the duct. Operative ultrasound was used to guide a biopsy needle to obtain pancreatic tissue samples. The Zollinger-Ellison tumor of the pancreas produced a sonolucent appearance that clearly distinguished it from the surrounding tissue.

Identification of a parathyroid adenoma by operative ultrasonography.

During surgery, real-time ultrasound scanning accurately localized a parathyroid adenoma posterior to be the superior pole of the right thyroid lobe. This was made feasible because of the ultrasound features of parathyroid tissue and current developments in ultrasound instrumentation.

Emergency transumbilical embolization of bleeding esophageal varices.

Eight patients had major hemorrhage from esophageal varices; in seven, one or two embolizations of the coronary and short gastric veins resulted in cessation of hemorrhage. This procedure can be used in patients with massive ascites, severe coagulopathy, or profound liver failure, as the access route through the dilated umbilical vein can be reached via a supraumbilical incision done with the patient under local anesthesia. All patients died; two deaths were attributable to complications of the procedure, the other six to the severity of the cirrhosis. Sclerotherapy may be combined with coronary vein embolization, but the risk of esophageal perforation may be greater than with sclerotherapy alone.

Ultrasonic assistance during surgery for pancreatic inflammatory disease.

Real-time B-mode ultrasound scanning was used during 35 operations for inflammatory disease of the pancreas. In 21, ultrasonography was considered helpful in operative management of pancreatic pseudocysts, abscesses, and chronic pancreatitis. Assistance consisted of establishing a diagnosis not made during preoperative testing, more precisely localizing pancreatic abnormalities, and excluding the presence of pseudocyst, abscess cavities, and dilated ducts. Operative ultrasound is a safe and simple technique that may reduce the use of tissue dissection, contrast material injections, and radiation.

Nonoperative control of retroperitoneal hemorrhage secondary to placement of an inferior vena cava occluding device in a patient with recurrent pulmonary emboli.

A woman with multiple recurrent pulmonary emboli and iatrogenic inferior vena cava perforation caused by the Hunter-Sessions introducer was treated successfully by placement of a Hunter-Sessions balloon to control the ensuing retroperitoneal hemorrhage and interrupt the inferior vena cava. Full anticoagulation therapy was continued throughout the operation and postoperatively.

Computed air myelography of the lumbosacral spine.

Plain computed tomography (CT) of the lumbosacral spine may be a reliable method for diagnosing herniated disk when abundant epidural fat is present. When epidural fat is not sufficient, CT after the administration of nonionic contrast medium (170 mg I/ml) and/or regular metrizamide myelography have been used. Ten patients were studied by CT enhanced with air injected as a negative contrast agent. The findings were correlated with plain and contrast-enhanced (metrizamide) CT as well as conventional myelography. The technique is described and advantages and disadvantages of the method are discussed. Air-contrast CT is useful in the evaluation of herniated disk in cases with equivocal findings on plain CT and in patients with a history of allergic reaction to iodinated contrast media.

MRI of the normal orbit and optic pathway.

In recent years MRI has made increasingly important contributions to the evaluation of the orbit and optic pathway. The unique ability of MRI to demonstrate soft tissue contrast allows exquisite demonstration of anatomic detail. MRI technique and normal anatomy are reviewed. Today, optimal ophthalmologic work-up is often incomplete without the critical input of the radiologist.

Ultrasonic imaging during biliary and pancreatic surgery.

Real-time ultrasound scanning was used during operations on the biliary tract and pancreas. The principal application in biliary surgery was to evaluate the common bile duct for presence of calculi. Our initial experience indicates that operative ultrasonography compares favorably with operative cholangiography. In pancreatic operations, ultrasound has been helpful in the management of pseudocysts and chronic pancreatitis. For pseudocysts, ultrasonography has indicated cyst wall thickness and the presence of adjacent anatomic structures. Ultrasound has distinguished the fluid loculations of the pseudocyst from swelling due to inflammatory edema. In surgery for chronic pancreatitis, ultrasonography has revealed the size and location of pancreatic ducts. This information has been useful in helping select sites for internal drainage of pseudocysts and in chronic pancreatitis with ductal dilatation. Operative ultrasonography is a relatively simple procedure which has the potential for providing the surgeon with early information and decreasing the need for dissection and radiographic imaging.

Diagnosis of sacroiliac joint infection in pregnancy by magnetic resonance imaging.

MR imaging was used to diagnose sacroiliac joint infection as the source of persistent back and hip pain in a pregnant woman with bacterial endocarditis and fever who refused diagnostic exposure to any ionizing radiation.

High resolution proton magnetic resonance spectroscopy of human brain and liver.

Water-suppressed and slice-selective proton spectra of live human brain exhibited several resonances that were tentatively assigned to metabolites such as N-acetylaspartate, glutamate, phosphocreatine and creatine, choline derivatives, and taurine. In the liver spectrum of a healthy volunteer, the major resonance was tentatively assigned to a fatty acyl methylene and the minor resonances to protons in carnitine, taurine, glutamate, and glutamine. In the spectrum of a cancerous liver, resonances in addition to those present in the normal liver were seen. Protein degradation in the liver with cancer was indicated by resonances from urea and from the ring protons in tryptophan, tyrosine, and phenylalanine. Furthermore, increased nucleic acid synthesis was indicated by resonances from nucleotide protons.

Intraosseous pressure in the lumbar spine.

Intraosseus pressure in the lumbar spine is defined as the hydrostatic pressure of venous blood in the trabecular sinusoids of cancellous bone. Measurements of it in the lumbar vertebrae and the inferior vena cava confirm that the intraosseus pressure in the lumbar spine is identical to, and dependent upon, the pressure in the inferior vena cava. With Valsalva maneuver in the decubitus position, the pressure reaches levels of 90 mm Hg in the inferior vena cava and intraosseus space of lumbar spine.