Gonadotropin, steroid, and inhibin levels in women with incipient ovarian failure during anovulatory and ovulatory rebound cycles.

We have identified a group of women with infertility and regular menses who have persistently raised FSH levels and probable incipient ovarian failure (IOF). Thirteen such women (19 cycles) had serum samples taken for RIA of LH, FSH, estradiol, and progesterone (P) 3 times a week over 1 menstrual cycle. Sixty infertile women with normal ovulatory cycles (as determined by hormones and ultrasound scan) served as controls. Overall, the FSH was higher (P less than 0.01) on all days of the cycle in the IOF group, serum LH was raised on days-14 to-5 before and days 5-11 after the LH surge. There was no difference between estradiol and P levels in the two groups. Ultrasound scanning showed failure of normal ovulation in the IOF group. Inhibin, measured by RIA in 9 cycles in the IOF group was lower (P less than 0.01) during the follicular phase than in 43 normal cycles. The highest inhibin level was seen in the luteal phase, as in normal cycles, but levels were still lower (P less than 0.01) in the IOF group. Inhibin was inversely correlated with FSH (P less than 0.05) during the follicular and luteal phases and was correlated with P during the luteal phase (P less than 0.05) in the IOF group. After 3 weeks of suppression (39 cycles) with an estrogen-progestogen preparation in the IOF group, LH and FSH fell to normal values. Ovulation occurred in 22 cycles on withdrawal of suppression in the presence of high FSH levels and low inhibin levels. No pregnancies occurred. These findings are consistent with the suggestion that diminished ovarian inhibin secretion may contribute to the elevated FSH levels of IOF and indicate that ovulation in the rebound cycle after suppression occurs in the presence of high FSH and low inhibin levels. Such cycles, however, still appear to be subfertile.

Evaluation of gastric antral motor performance in patients with dysmotility-like dyspepsia using real-time high-resolution ultrasound.

Although manometric antral hypomotility and delayed gastric emptying have been reported separately in patients with dyspepsia, relationships between symptoms, antral contractility and emptying rate have not been sought. The present study therefore aimed to evaluate, simultaneously, gastric antral excursion characteristics and emptying in a sub-group of patients with severe functional dyspepsia using high-resolution real-time ultrasound. The circumference of the relaxed and contracted antrum was measured at 15-min intervals after ingestion of a 360 mL mixed nutrient meal in 36 chronic dyspepsia patients with symptoms of post-prandial bloating and epigastric distension, and in 25 healthy volunteers. Antral emptying (measured as the rate of decrease in circumference of the relaxed antrum) was slower in patients than normals (P = 0.02). In both groups, the average values for antral excursion were similar but the range of excursion in patients was significantly wider than in controls (F < 0.001), with 11 patients showing values above, and 8 showing values below the normal range. There was no relationship between antral emptying and antral excursion in either patients or volunteers. In conclusion, patients with severe functional dyspepsia show a wide range of antral performance characteristics, suggesting not only that the mechanisms responsible for the control of antral motor function are disturbed but also that the cause of the symptoms and the disturbed antral motor function are probably not directly related.

A prospective evaluation of central venous blood flow using Doppler ultrasound in patients with a long-term central venous catheter.

Using Doppler ultrasound, we prospectively evaluated the relationship between central venous blood flow and the development of central venous thrombosis in ten patients with a long term central line. The presence of turbulent blood flow around the catheter was followed by the development of central venous thrombosis in two patients but neither had subsequent clinical sequelae. More surprisingly, however, normal blood flow was demonstrated in eight patients, two of whom subsequently developed intravascular thrombi.

The importance of associated extra-renal vascular disease on the outcome of patients with atherosclerotic renovascular disease.

Atherosclerotic renovascular disease (ARVD) is a disease of ageing. It is usually a manifestation of widespread vascular disease and although it may be symptomless, many patients with ARVD present with the effects of extra-renal vascular disease, such as peripheral vascular (PVD), coronary heart (CHD) and cerebrovascular disease. ARVD is a common cause of hypertension and chronic renal failure (CRF), and it is one of the most common renal diagnoses in elderly patients accepted on to dialysis programmes with end-stage renal failure (ESRF). The cause of renal impairment in these patients is still a matter of debate. Patients with ARVD have a high mortality, especially those with renal failure. In this review we examine the relationships between ARVD and co-morbid extra-renal vascular disease, and the impact of these associated vascular pathologies upon renal functional and mortality outcomes is considered. The latest evidence concerning the likely pathogenesis of renal dysfunction in patients with ARVD is also reviewed.

Transvaginal leak of peritoneal dialysate demonstrated by CT peritoneography.

CT peritoneography is the investigation of choice for suspected leaks or hernias in patients on continuous ambulatory peritoneal dialysis (CAPD). We report a case of transvaginal leak of peritoneal dialysate in a young woman, confirmed by CT peritoneography. CAPD has been successfully recommenced following the repair of a left vaginal vault erosion.

The role of abdominal computed tomography in lymphoma following treatment.

Two hundred and six patients with biopsy-proven lymphoma, 74 with Hodgkin's disease and 132 with non-Hodgkin's lymphoma had abdominal computed tomography for assessment of remission status (108 patients) or for investigation of relapse (98 patients). In 43 patients with diffuse large cell lymphomas scanned at a time of apparent complete remission CT was abnormal in 21. Sixteen of these patients have relapsed and died. Only one patient has relapsed in the group who have normal CT scans. This difference was significant (p=0.00001). This difference was not seen in nodular lymphomas. There were very few patients with Hodgkin's disease in whom the CT scan was abnormal and there is a suggestion that many abnormalities following treatment may represent inactive Hodgkin's disease or fibrosis only. CT played a major role in diagnosing the full extent of relapse in both non-Hodgkin's lymphoma and Hodgkin's disease. Over 50% of the abnormal sites detected by CT would not have been shown by any other non-invasive investigation. Five patients with treated Hodgkin's disease who had "B" symptoms only suggesting relapse were all shown by CT to have extensive intra-abdominal disease.

Increasing the diagnostic yield of renal angiography for the diagnosis of atheromatous renovascular disease.

Atheromatous renovascular disease (ARVD) is a common cause of hypertension and chronic renal failure (CRF). In this unit, intravenous digital subtraction angiography (DSA) (or intraarterial DSA if indicated) is used as a screening angiographic study when ARVD is suspected. However, increased use of these investigations has resulted in a longer waiting time for angiography. As the majority of studies are negative for ARVD, clinical features and results of investigations of patients undergoing angiography were reviewed to identify those having the greatest likelihood of ARVD. The clinical notes were reviewed for all 249 patients undergoing angiography over an 18-month period. Primary indications for investigation were: hypertension 71 (28.5%), CRF 156 (62.7%) and CRF with severe hypertension 22 (8.8%). 12 of the CRF patients had end-stage renal failure. 166 (66.7%) patients had no evidence of ARVD, while only 83 (33.3%) patients showed some degree of ARVD, 29 (35%) of which had bilateral renal artery disease. There was no significant difference between the ARVD group and the non-ARVD group for mean age (69.0 years vs 63.3 years), male to female ratio, history of smoking (68.7% vs 55.4%), severe hypertension (10.8% vs 9.0%), hypercholesterolaemia (61.4% vs 47.0%), diabetes mellitus (28.6% vs 25.3%) or angiotensin converting enzyme inhibitor-related renal dysfunction (9.6% vs 6.1%). More patients in the ARVD group were investigated for CRF than in the non-ARVD group, as reflected by the higher serum creatinine level and the lower creatinine clearance in the ARVD group. 55 (33.1%) of the non-ARVD patients had no comorbid vascular disease, vascular bruits or ultrasound discrepancy in the size of the two kidneys, whereas all ARVD patients had at least one of these features (negative predictive value 100%). All three features were present in 19.3% of ARVD patients but in only 3.0% of the non-ARVD patients (positive predictive value 76.2%, specificity 97%). We plan to rationalize the criteria for angiography in the light of these findings, anticipating an increase in the diagnostic yield of renal angiography from its current 33.3% to above 42%.

MR-derived renal morphology and renal function in patients with atherosclerotic renovascular disease.

Appropriate selection of patients with atherosclerotic renovascular disease (ARVD) for revascularization might be improved if accurate non-invasive investigations were used to assess severity of pre-existing parenchymal damage. The purpose of this study was to evaluate the associations between magnetic resonance imaging (MRI)-measured renal morphological parameters and single-kidney glomerular filtration rate (GFR) in ARVD. Three-dimensional (3D)-MRI was performed on 35 ARVD patients. Renal bipolar length (BL), parenchymal volume, parenchymal (PT), and cortical thicknesses (CT) were measured in 65 kidneys. Thirteen kidneys were supplied by normal vessels, 13 had insignificant (<50%) renal artery stenosis (RAS), 33 significant (>or=50%) RAS, and six complete vessel occlusion. All patients underwent radioisotopic measurement of single-kidney GFR (isoSK-GFR). Overall, 3D parameters such as parenchymal volume were better correlates of isoSK-GFR (r=0.86, P<0.001) than BL (r=0.78, P<0.001), PT (r=0.63, P<0.001) or CT (r=0.60, P<0.001). Kidneys with >or=50% RAS did show significant reduction in mean CT compared to those supplied by normal vessel (5.67+/-1.63 vs 7.28+/-1.80 mm, P=0.002; 22.1% reduction) and an even greater loss of parenchymal volume (120.65+/-47.15 vs 179.24+/-86.90 ml, P<0.001; 32.7% reduction) with no significant reduction in BL. In a proportion of >or=50% RAS kidneys, a disproportionately high parenchymal volume to isoSK-GFR was observed supporting a concept of 'hibernating parenchyma'. 3D parameters of parenchymal volume are stronger correlates of isoSK-GFR than two-dimensional measures of BL, PT or CT. 3D morphological evaluation together with isoSK-GFR might be useful in aiding patient selection for renal revascularization. Kidneys with increased parenchymal volume to SK-GFR might represent a subgroup with the potential to respond beneficially to angioplasty.

Computed tomography in ovarian carcinoma: patterns of disease and limitations.

Between June 1977 and July 1980, a mixed group of 46 patients with ovarian carcinoma was examined by computed tomography (CT). CT was useful for demonstration of extent of disease within the abdomen and pelvis and may be used to provide an objective means for assessing response to treatment. The limitations of CT include failure to detect peritoneal deposits less than 2-3 cm in diameter, bowel infiltration and minor residual or recurrent disease. The patterns of disease as seen on CT are illustrated and its potential role is discussed.

Fungal liver abscesses in acute leukaemia--a report of two cases.

The radiological findings in two cases of hepatic fungal microabscesses (one with concomitant splenic involvement) occurring in children with acute leukaemia are presented, and the previous literature is reviewed. Usually both liver and spleen are involved, though either organ may be affected in isolation. Typical ultrasound features include hepatosplenomegaly with multiple hypoechoic areas throughout the liver and spleen, often with a 'target' configuration. Computed tomography shows these as multiple non-enhancing low attenuation lesions. These findings in a patient with acute leukaemia are strongly suspicious of fungal infection, and percutaneous fine-needle aspiration under ultrasound or computed tomography-guidance is indicated.

Two patients with symptomatic renal metastases.

Two patients with symptoms referable to the urinary tract who were found to have renal metastatic disease are presented. The first case illustrates typical radiological features of metastatic malignancy affecting the kidney. In the second case angiographic features were suggestive of a grossly dilated renal collecting system conflicting with the sonographic appearances of a solid renal mass. At surgery the pelvicalyceal system and proximal ureter were found to be grossly distended with an intraluminal metastasis.

The relevance of parity to ureteric dilatation.

OBJECTIVE: To assess whether the mild dilatation of the right ureter in women that is sometimes seen on intravenous urography (IVU) represents persistent dilatation after a previous pregnancy. PATIENTS AND METHODS: The intravenous urograms of 71 men, 63 parous and 27 nulliparous women were evaluated prospectively. The two groups of women were divided into those with and without a confirmed history of urinary tract infection (UTI) as the indication for IVU. producing five groups in all. Measurements were taken on both the 5-min and the compressed or release films on each side. RESULTS: There were no significant differences in ureteric diameters among the five groups for the uncompressed right ureter (P=0.23), the left ureter uncompressed (P=0.32) or compressed (P=0.87). For the compressed right ureter, the difference was significant, with the diameters in the parous women with proven UTIs being larger than in the other groups (P=0.043). CONCLUSION: There is a significant increase in the diameter of the compressed right ureter in the group of parous women with a history of proven UTI. Infection or parity alone do not produce this effect: the combination of the two factors is required.

A case of necrobacillosis.

A case of empyema due to Fusobacterium necrophorum infection is described. A history of sore throat followed by metastatic abscesses may alert the clinician to the possibility of this unusual infection.

Macronodular congenital adrenal hyperplasia in an adult with female pseudohermaphroditism.

We report a case of previously undiagnosed congenital adrenal hyperplasia presenting with virilisation in a 59-year-old woman. Biochemical analysis revealed C-21 hydroxylase deficiency. CT demonstrated adrenal hyperplasia and a 3.8-cm adrenal nodule, raising the possibility of the development of an autonomous adrenal adenoma or carcinoma. The adrenal nodule regressed significantly with oral replacement steroid therapy over the next 30 months, indicating it to be an ACTH-dependent hyperplastic nodule and thus avoiding the need for biopsy or surgical excision. Macronodular adrenal hyperplasia should be considered in the differential diagnosis of a patient presenting with virilisation and an adrenal mass.