Alternative diagnoses at paediatric appendicitis MRI.

As the utilization of MRI in the assessment for paediatric appendicitis increases in clinical practice, it is important to recognize alternative diagnoses as the cause of abdominal pain. The purpose of this review is to share our institution's experience using MRI in the evaluation of 510 paediatric patients presenting with suspected appendicitis over a 30 month interval (July 2011 to December 2013). An alternative diagnosis was documented in 98/510 (19.2%) patients; adnexal pathology (6.3%, n = 32), enteritis-colitis (6.3%, n = 32), and mesenteric adenitis (2.2%, n = 11) comprised the majority of cases. These common entities and other less frequent illustrative cases obtained during our overall institutional experience with MRI for suspected appendicitis are reviewed.

[Frequency-specific analysis of the hVOR Prior of Cochlear Implant Operation]. / Frequenzspezifische Untersuchung des hVOR im Vorfeld einer CI-Operation.

Dizziness is one of the most common postoperative complications after a cochlear-implant (CI) surgery. With our prospective, matched-paired controlled study, we could demonstrate that patients with distinctive sensorineural hearing loss--even without any complaints of dizziness--already have a reduced horizontal vestibular-ocular-reflex (hVOR). Compared to controls, CI patients presented with a significantly reduced gain. 9 out of 17 CI patients showed physiological results in rotatory testing and video head thrust testing. One patient presented with pathological results in both tests. Remarkably, there were 2 patients who presented with pathological head impulse testing but normal values in rotatory testing and 5 patients who showed normal gains in video head impulse testing but abnormal rotatory tests. These findings clearly show the importance of a differentiated, frequency-dependent pre-operative vestibular assessment including rotatory testing and video-head impulse testing. Additionally, only an accurate pre-operative vestibular testing allows evaluating possible post-operative dizziness related complications and should be documented precisely, also for forensic reasons. This is the key to differentiate post-operative dizziness from an pre-operatively existing vestibular disorder that possibly might not be clinically apparent by the time of testing.

A field-test battery for elite, young soccer players.

The validity and reliability of a battery of field-based performance tests was examined. The opinions of coaches, fitness professionals and players (n=170, 172 and 101 respectively) on the importance of performance testing were established using a questionnaire. On 2 occasions, separated by 7 days, 80 elite, young soccer players (mean±SD [and range]: age 13.2±2.6 [8.9-19.1] years; stature 1.59±0.18 m [1.32-1.91]; body mass 50.6±17.1 [26.5-88.7] kg) completed a battery of field-based tests comprised of heart rate response to a submaximal Multi-stage fitness test, 3 types of vertical jump, sprints over 10 and 20 m, and an agility test. Physical performance testing was considered important by coaches (97%), fitness professionals (94%) and players (83%). The systematic bias ratio and the random error components of the 95% ratio limits of agreement for the first and second tests, for the U9-U11 vs. U12-U14 vs. U15-U18 age groups, were [Systematic bias (*/÷ ratio limits)]: Heart rate (Level 5): 0.983 (*/÷ 1.044) vs. 0.969 (*/÷ 1.056) vs. 0.983 (*/÷ 1.055); Rocket jump: 0998 (*/÷ 1.112) vs. 0.999 (*/÷ 1.106) vs. 0.996 (*/÷ 1.093); 10 m sprint: 0.997 (*/÷ 1.038) vs. 0.994 (*/÷ 1.033) vs. 0.994 (*/÷ 1.038); Agility test: 1.010 (*/÷1.050) vs. 1.014 (*/÷1.050) vs. 1.002 (*/÷1.053). All tests, except heart rate recovery from the Multi-stage fitness test, were able to distinguish between different ability and age groups of players (p<0.05). Thus, the field-test battery demonstrated logical and construct validity, and was shown to be a reliable and objective tool for assessing elite, young soccer players.

[Temporomandibular joint dysfunction. A consequence of whiplash-injury]. / Die kraniomandibuläre Dysfunktion. Ein Folgezustand nach erlittenem HWS-Trauma.

BACKGROUND: In 10-20% of patients with a simple whiplash-injury without severe structural lesions, a chronification of the complaints occurs. The question is whether some unidentified pathogenic factors exist. SCIENTIFIC QUESTION: Investigations have demonstrated that mandibular and head-neck movements are coordinated and centrally controlled and that a craniocervical dysfunction (CCD) can lead to a temporomandibular dysfunction (TMD) by reflex action and vice versa. This study investigated whether a whiplash-injury can lead to a TMD. METHODS AND RESULTS: IA total of 187 patients with whiplash-associated disorders (WAD) were examined for TMD. Simple tests with and without loading of the mandible were used to initially diagnose TMD and the diagnosis was confirmed electrophysiologically. TMD could be verified in all patients with WAD. According to these investigations a CMD was regularly found in patients with WAD and relief from suffering can often not be achieved without treatment of the CMD.

Serum lipid changes during contraceptive administration in obese women: relation to serum insulin levels.

Previous reports agree that estrogen and estrogen-containing contraceptives increase serum triglyceride levels of normal women, but disagree on their effect on serum cholesterol levels. Since obesity is often accompanied by hyperinsulinemia and since hyperinsulinemia may participate in production of hypertriglyceridemia, we investigated the effect of oral contraceptives on the serum lipids of obese women. Serum triglycerides and cholesterol were measured before and after 3 months administration of the contraceptives. The mean triglyceride level increased 23% in the obese and 21% in the normal women. The mean cholesterol level increased 6% (P less than 0.05) in the obese and did not change in the normal women. The increase in cholesterol occurred mostly in those with initial levels less than 225 mg/100 ml; in those with initial levels above 250 mg/100 ml the level usually decreased with treatment. The serum lipid changes were not related to the serum insulin levels.

Metabolism and storage of catecholamines in rats with pheochromocytoma implants.

New England Deaconess Hospital rats implanted with a pheochromocytoma P259 became hypertensive and showed high concentrations of plasma dopamine (42.0 +/- 14.6 ng/ml) and norepinephrine (45.7 +/- 8.4 ng/ml). However, the norepinephrine content of several peripheral tissues of these rats did not differ from those of the New England Deaconess Hospital control rats, and their dopamine content, although slightly higher, was much lower than would have been expected from the plasma dopamine levels. Methylation by catechol-O-methyltransferase did not appear to play a major role in the inactivation of tissue catecholamines since there were no noticeable increases of normetanephrine or 3-methoxytyramine in the tissues of the rats with pheochromocytoma. There was also no increase in conjugated dopamine, in either the sulfate or glucuronide form, in the plasma or tissue of the hypertensive rats, although injection of L-dopa induced a large increase in dopamine sulfate in the plasma and urine of these rats. This finding indicated that, although their sulfoconjugation mechanism was intact and not affected by the pheochromocytoma, it did not participate in the metabolism of dopamine released by the tumor into the blood. On the other hand, plasma and urine of tumor-bearing rats exhibited abnormally high concentrations of homovanillic acid, the main metabolite of dopamine resulting from monoamine oxidase action. In contrast to the control rats, intravenous infusion of free dopamine in rats with pheochromocytoma had no effect on plasma free dopamine levels but increased homovanillic acid levels considerably. The present data underline the important role of monoamine oxidase in the removal of excessive quantities of catecholamines released by the tumor in New England Deaconess Hospital rats with the pheochromocytoma implant.

Effect of pheochromocytoma and hypophysectomy on blood pressure and catecholamines in NEDH rats.

The New England Deaconess Hospital (NEDH) rat provides a valuable model with which to study pheochromocytoma (P); 59% of male rats 700 to 900 days old and 81% of those 900 days or older developed spontaneous P. One transplantable P (P259), when implanted into other NEDH rats, markedly increased plasma norepinephrine and dopamine as well as blood pressure, and usually caused death within 4 weeks. Even without P, about 83% of NEDH rats became hypertensive by 131/2 weeks of age and remained moderately hypertensive until 2 years of age when some animals developed spontaneous P and hypertension became severe. Whether a common mechanism is responsible for early appearance of hypertension and later development of P remains to be determined. Hypophysectomized NEDH rats remained normotensive or slightly hypotensive despite marked elevations of plasma norepinephrine and dopamine caused by P259 implantation; furthermore, survival was prolonged to 3 months. Catecholamine concentrations in plasma and RBC were usually quite similar, indicating that red blood cells play a significant role in inactivating circulating catecholamines. Unlike the normal adrenal, P259 in NEDH rats contains mainly norepinephrine and dopamine with little epinephrine; it appears that P259 is deficient in the enzyme phenylethanolamine-N-methyltransferase (PNMT), which converts norepinephrine to epinephrine. Why hypophysectomy prevents hypertension and prolongs life in rats with P259 implants is unclear; adrenal cortical and thyroid deficiency may play a role. Preliminary observations indicate that hypophysectomy can prevent spontaneous development of P in NEDH rats.

Salicylate absorption from a bismuth subsalicylate preparation.

The active ingredient in Pepto-Bismol (PB) (Norwich-Eaton), a common antidiarrheal, is bismuth subsalicylate. The absorption of salicylate after oral PB was studied in six fasted men. Plasma concentrations of total salicylate and the urinary excretion profile of salicylate were determined as a function of time and dose. After 60 ml PB, 500.1 +/- 33.6 mg (mean +/- SD) salicylate were recovered in urine, representing 95.0 +/- 6.4% of salicylic acid equivalents in 60 ml of the formulation. Peak plasma salicylate levels were reached 0.5 to 3 hr after ingestion and averaged 40.1 +/- 17.3 micrograms/ml. Absorption of salicylate was also essentially complete after 15- and 30-ml doses of the antidiarrheal preparation, and a linear relationship between dose and recovery of salicylate in the urine was found. Salicylate kinetics was nonlinear after a multiple-dose regimen of 60 ml every 6 hr for five doses.

Pharmacokinetics of low- and high-dose intravenous diatrizoate contrast media administration.

The pharmacokinetics of diatrizoate contrast media were determined following low- (0.7 g I/kg) and high- (1.5 g I/kg) dose intravenous administration. The higher dose of contrast media produced plasma concentrations of iodine which remained approximately twice as high as conventional doses for one hour following infusion. This finding may explain the improved CT images obtained after infusion of higher doses of iodine contrast media. There was no significant long-term change in plasma osmolality noted in venous blood after either dose.

Hypertriglyceridemia during treatment with estrogen and oral contraceptives. An alteration in hepatic function?

PIP: Impaired glucose tolerance in 49 women taking Envoid (5 mg norethynodrel, .075 mg mestranol) is reported and evidence that mestranol is the disposing factor is presented. 23 of 38 (61%) women who had taken the drug for more than 10 months had triglyceride levels greater than 110 mg/100 ml. Generally, triglyceride levels increased with the duration of treatment. However, cholesterol levels were not markedly increased. Administration of mestranol alone resulted in a prompt increase in plasma triglyceride levels. Except for 1 woman who had been under long-term Enovid treatment, triglyceride levels returned to normal soon after discontinuation of treatment. The results suggest that hypertriglyceridemia resulting from oral contraceptives containing estrogens is due to an alteration in liver function.^ieng

Warfarin resistance: diagnosis and therapeutic alternatives.

Warfarin resistance is a rare phenomenon, and most of the related literature obtained in a MEDLINE search from 1964-1995 consists of case reports. Warfarin resistance may develop as a result of noncompliance, exogenous consumption of vitamin K, and concurrent ingestion of other agents known to decrease warfarin's effects. There are three documented cases of hereditary resistance and one case of loose documentation of hereditary resistance with confirmation of similar resistant patterns in family members. Data on two of the three cases may support the postulation that hereditary resistance may be caused by the presence of an abnormal receptor or enzyme that has an increased affinity for vitamin K. To date, this receptor or enzyme has not been identified. To assess a subtherapeutic dose response to oral anticoagulation, the clinician must consider many possible causes of resistance, such as noncompliance, drug interactions, laboratory error, or pharmacokinetic changes. Once these have been ruled out, it is possible to consider that a tissue resistance to warfarin may be responsible.

Metformin, a promising oral antihyperglycemic for the treatment of noninsulin-dependent diabetes mellitus.

Noninsulin-dependent diabetes mellitus has historically been treated with diet therapy alone or the addition of an oral hypoglycemic agent such as a sulfonylurea, or the two in combination with insulin. Although these medical interventions lower blood glucose concentrations, they may also potentiate hyperinsulinism through increased serum insulin concentrations. Insulin resistance and hyperinsulinism are associated with cardiovascular risk factors such as hypertriglyceridemia, decreased high-density lipoprotein cholesterol levels, hypertension, and hyperglycemia, among others. Therefore, a desirable therapeutic alternative would lower blood glucose, not result in hyperinsulinism, and have beneficial effects on lipid profiles. Metformin is a biguanide antihyperglycemic agent that provides these effects. When administered to carefully selected patients and monitored appropriately metformin may prove to be valuable in the treatment of diabetes mellitus and in altering its cardiovascular sequelae.

The Football Association medical research programme: an audit of injuries in academy youth football.

OBJECTIVES: To undertake a prospective epidemiological study of the injuries sustained in English youth academy football over two competitive seasons. METHODS: Player injuries were annotated by medical staff at 38 English football club youth academies. A specific injury audit questionnaire was used together with a weekly return form that documented each club's current injury status. RESULTS: A total of 3805 injuries were reported over two complete seasons (June to May) with an average injury rate of 0.40 per player per season. The mean (SD) number of days absent for each injury was 21.9 (33.63), with an average of 2.31 (3.66) games missed per injury. The total amount of time absent through injury equated to about 6% of the player's development time. Players in the higher age groups (17-19 years) were more likely to receive an injury than those in the younger age groups (9-16 years). Injury incidence varied throughout the season, with training injuries peaking in January (p<0.05) and competition injuries peaking in October (p<0.05). Competition injuries accounted for 50.4% of the total, with 36% of these occurring in the last third of each half. Strains (31%) and sprains (20%) were the main injury types, predominantly affecting the lower limb, with a similar proportion of injuries affecting the thigh (19%), ankle (19%), and knee (18%). Growth related conditions, including Sever's disease and Osgood-Schlatter's disease, accounted for 5% of total injuries, peaking in the under 13 age group for Osgood-Schlatter's disease and the under 11 age group for Sever's disease. The rate of re-injury of exactly the same anatomical structure was 3%. CONCLUSIONS: Footballers are at high risk of injury and there is a need to investigate ways of reducing this risk. Injury incidence at academy level is approximately half that of the professional game. Academy players probably have much less exposure to injury than their full time counterparts. Areas that warrant further attention include the link between musculoskeletal development and the onset of youth related conditions such as Sever's disease and Osgood-Schlatter's disease, the significant number of non-contact injuries that occur in academy football, and the increased rates of injury during preseason training and after the mid season break. This study has highlighted the nature and severity of injuries that occur at academy level, and the third part of the audit process now needs to be undertaken: the implementation of strategies to reduce the number of injuries encountered at this level.