Barium proctography vs magnetic resonance proctography for pelvic floor disorders: a comparative study.

AIM: Accurate and reliable imaging of pelvic floor dynamics is important for tailoring treatment in pelvic floor disorders; however, two imaging modalities are available. Barium proctography (BaP) is widely used, but involves a significant radiation dose. Magnetic resonance (MR) proctography allows visualization of all pelvic midline structures but patients are supine. This project investigates whether there are measurable differences between BaP and MR proctography. Patient preference for the tests was also investigated. METHODS: Consecutive patients referred for BaP were invited to participate (National Research Ethics Service approved). Participants underwent BaP in Poole and MR proctography in Dorchester. Proctograms were reported by a consultant radiologist with pelvic floor subspecialization. RESULTS: A total of 71 patients were recruited. Both tests were carried out on 42 patients. Complete rectal emptying was observed in 29% (12/42) on BaP and in 2% (1/42) on MR proctography. Anismus was reported in 29% (12/42) on BaP and 43% (18/42) on MR proctography. MR proctography missed 31% (11/35) of rectal intussusception detected on BaP. In 10 of these cases no rectal evacuation was achieved during MR proctography. The measure of agreement between grade of rectal intussusception was fair (κ=0.260) although MR proctography tended to underestimate the grade. Rectoceles were extremely common but clinically relevant differences in size were evident. Patients reported that they found MR proctography less embarrassing but harder to empty their bowel. CONCLUSIONS: The results demonstrate that MR proctography under-reports pelvic floor abnormalities especially where there has been poor rectal evacuation.

Pulmonary embolism. Is the clinical history a useful adjunct to aid the interpretation of the equivocal lung scan?

Pulmonary embolism is commonly fatal, yet notoriously difficult to detect. Diagnosis often relies on the ventilation-perfusion radionuclide scan, which itself is frequently equivocal. It has been suggested that if the equivocal ventilation-perfusion scan is interpreted in the light of clinical information, diagnostic accuracy can be improved. However, which features in the history should be considered? In this study of 197 patients undergoing ventilation-perfusion scanning, the clinical data of the 98 patients with either high-probability or normal scans were compared to the scan findings. The presence of a deep vein thrombosis was significantly associated with a high probability scan, whereas the presence of constant chest pain was significantly associated with a negative scan. Classical symptoms for pulmonary embolism, namely pleuritic chest pain and hemoptysis, were poor predictors of high-probability scans. Consequently, the authors advise considerable caution when using the clinical data to aid the interpretation of the equivocal lung scan in the individual case.

Case report: the effect of contrast density on computed tomographic arterial portography.

Artifacts associated with computed tomographic arterial tomography (CTAP) are well documented. We report a patient undergoing CTAP in whom laminar flow artifact occurred using Iopamidol 370 mg ml-1 but not when using Iopamidol 300 mg ml-1 under identical conditions. The denser Iopamidol 370 mg ml-1 mixed inadequately with unopacified blood in the portal vein. This was not a problem with the less dense Iopamidol 300 mg ml-1 which is likely to be a more reliable contrast agent for CTAP.

Traumatic pneumomyelogram. Implications for the anaesthetist.

A 70-year-old man sustained a severe head injury following a fall downstairs, which resulted in him being found in a head down position. In the accident and emergency department he was noted to have subarachnoid air on a lateral cervical spine radiograph. This drew attention to the presence of fractures in the middle cranial fossa and nitrous oxide was immediately discontinued. The presence of a traumatic pneumomylogram implies a base of skull or middle cranial fossa fracture, and is almost certainly associated with intracranial subarachnoid air. Early recognition of the condition, and cessation of nitrous oxide, is essential to prevent dangerous increases in intracranial pressure secondary to the diffusion of gas into the air filled cavity.

Enteroclysis--the influence of tube design.

The performance of three 10F enteroclysis tubes with different tip designs (E. Merck Ltd) was assessed using double-contrast, gravity infusion enteroclysis, with methylcellulose solution as negative contrast. Intubation times, screening times, patient tolerability and examination quality were compared. The results show that a streamlined tip design facilitated passage through the nose. None of the tubes provided consistently reliable results due to inadequate flow rates. The Corsafe tube transmits a higher flow rate of methylcellulose and produced satisfactory examinations more frequently. Mechanically assisted infusion of methylcellulose is recommended when using 10F enteroclysis tubes.

Case report: life-threatening hypercalcaemia secondary to pancreatic tumour secreting parathyroid hormone-related protein--successful control by hepatic arterial embolization.

Parathyroid hormone-related protein elaborated by pancreatic neuro-endocrine tumours can cause life-threatening hypercalcaemia. This is the first reported case where hypercalcaemia caused by such a tumour has been successfully controlled by hepatic arterial embolization.

Convergent validity of measures of PTSD in Vietnam combat veterans.

The authors evaluated the convergent validity of several widely used psychometric tests of posttraumatic stress disorder (PTSD) symptoms against DSM-III-R criteria for PTSD in 130 Vietnam combat veterans. Significant positive correlations were found between these instruments and the number of DSM-III-R symptoms endorsed, supporting the validity of psychometric instruments as continuous measures of PTSD symptom severity. The various psychometric measures also correlated moderately with one another, suggesting that they assess related but somewhat separate PTSD phenomena. Finally, predicted relationships between stressors and symptoms were supported by significant correlations between degree of traumatic combat exposure and DSM-III-R and psychometric indexes of PTSD.

Molecular genetic diagnosis of sickle cell disease using dried blood specimens on blotters used for newborn screening.

The protein-based technologies used to screen newborns for sickle cell disease require confirmation with a liquid blood specimen. We have developed a strategy for rapid and specific genotypic diagnosis using DNA extracted from a dried blood spot on the filter paper blotter used to screen newborns. DNA could be microextracted from a specimen as small as a 1/8 inch diameter punched disc representing the dried equivalent of approximately 3 microliters of whole blood. We utilized the DNA from a 1/4 inch diameter specimen (12 microliters equivalent) for polymerase chain reaction amplification of the beta-globin region spanning the sickle cell mutation with detection by allele-specific oligonucleotide probes. Molecular confirmation of genotype from the original blotter would reduce the personnel costs associated with obtaining follow-up liquid blood specimens and would provide information to the family in a more timely and less equivocal manner.