An aggressive case of pseudomyogenic haemangioendothelioma of bone with pathological fracture and rapidly progressive pulmonary metastatic disease: case report and review of the literature.

Pseudomyogenic haemangioendothelioma (PMH) is a rare recently described vascular tumour typically presenting with soft tissue disease in distal extremities of young adults. Multi-focal and multi-layered involvement is commonly recognised. The majority of cases described so far have shown an indolent clinical course and distant metastatic spread is rare. We report a case of PMH in an 82-year-old male diagnosed following a pathological fracture of the distal tibia. Further bone lesions were identified in the fibula, patella and distal femur. The patient was found to have multiple nodules suspicious for pulmonary metastases on a CT scan at the time of diagnosis that showed significant progression at a follow-up scan 4 weeks later. To our knowledge, this is the first reported case of PMH presenting with a pathological fracture. The rapid progression of bone and distant metastatic disease in this case is highly unusual given the typically indolent clinical course reported in the literature to date.

Fusion and subsidence rate of stand alone anterior lumbar interbody fusion using PEEK cage with recombinant human bone morphogenetic protein-2.

INTRODUCTION: Anterior lumbar interbody fusion (ALIF) is an established treatment for structural instability associated with symptomatic disk degeneration (SDD). Stand-alone ALIF offers many advantages, however, it may increase the risk of non-union. Recombinant human bone morphogenetic protein-2 (BMP-2) may enhance fusion rate but is associated with postoperative complication. The optimal dose of BMP-2 remains unclear. This study assessed the fusion and subsidence rates of stand-alone ALIF using the SynFix-LR interbody cage with 6 ml/level of BMP-2. METHODS: Thirty-two ALIF procedures were performed by a single surgeon in 25 patients. Twenty-five procedures were performed for SDD without spondylolisthesis (SDD group) and seven procedures were performed for SDD with grade-I olisthesis (SDD-olisthesis group). Patients were followed-up for a mean of 17 ± 6 months. RESULTS: Solid fusion was achieved in 29 cases (90.6 %) within 6 months postoperatively. Five cases of implant subsidence were observed (16 %). Four of these occurred in the SDD-olisthesis group and one occurred in the SDD group (57 % vs. 4 % respectively; p = 0.004). Three cases of subsidence failed to fuse and required revision. The body mass index of patients with olisthesis who developed subsidence was higher than those who did not develop subsidence (29 ± 2.6 vs. 22 ± 6.5 respectively; p = 0.04). No BMP-2 related complications occurred. CONCLUSION: The overall fusion rate of stand-alone ALIF using the SynFix-LR system with BMP-2 was 90.6 %, comparable with other published series. No BMP-2 related complication occurred at a dose of 6 mg/level. Degenerative spondylolisthesis and obesity seemed to increase the rate of implant subsidence, and thus we believe that adding posterior fusion for these cases should be considered.

Knowledge, attitudes and behaviours of health care workers towards clients of sexual health services in Fiji.

A cross-sectional survey was conducted to identify the attitudes and behaviours of health care workers (HCWs) in health care settings (HCS) in Fiji involving 369 participants. Self-rated knowledge of HIV and sexually transmissible infections (STIs) varied depending on whether the HCS was divisional or sub-divisional, and varied between the various national divisions. HCWs with experience in HIV, reproductive health and antenatal clinics had higher self-rated HIV knowledge. A high proportion had a fear of catching HIV from HIV-positive clients. This study found high levels of negative attitudes towards clients from vulnerable groups with regards to the transmission and spread of HIV. Study participants also reported observing differential treatment by their colleagues if a client was known to have or was suspected of having HIV. There is a need for further HIV education of HCWs, with training focussed on occupational risk, and on reducing stigma and discrimination of those living with or vulnerable to HIV in Fiji.

Ultrasound guided alcohol ablation of Morton's neuroma.

BACKGROUND: Morton's neuroma is a common cause of metatarsalgia. This study evaluated the efficacy of ultrasound guided alcohol injection as a treatment for this condition. METHOD: Data from 87 treatment courses were included in this study with a mean follow of 14.3 months. RESULTS: Technical success was 100%. One patient developed symptoms consistent with an allergic reaction to the injection and one patient declined further injection because of periprocedural pain. Partial or total treatment response was achieved in 66%, with 32% of patients having complete resolution of pain. The median visual analogue score (VAS) decreased from 8 pre-procedure to 4 post-procedure (p < 0.0001). Procedural success was greater in patients under 55 years old and in those with solitary neuromas. Seventeen patients (20%) went on to have surgery due to continuing pain. CONCLUSION: Ultrasound guided alcohol ablation for the treatment of Morton's neuroma was a safe procedure that significantly reduced pain and may offer an alternative therapy to surgery.

Gas patterns on plain abdominal radiographs: a pictorial review.

Abdominal radiographs are one of the most commonly performed radiological examinations and have an established role in the assessment of the acute abdomen. The main indication is for suspected bowel obstruction and in conjunction with an erect chest x-ray for suspected visceral perforation. Often, the pattern of gas points to a particular pathology, and accurate interpretation is important for prompt diagnosis. The diagnosis in most cases will be confirmed by further imaging studies such as ultrasound, contrast studies or, most commonly in contemporary practice, CT. This pictorial review summarises the various types of intraluminal and extraluminal gas patterns, illustrates some of the common clinical diagnoses made from plain films, describes some commonly encountered clinical problems with radiographs, and discusses the role of advanced imaging techniques.

Imaging in acute ischaemic stroke: essential for modern stroke care.

Stroke is the second most common cause of death worldwide and the third most common in the UK. 'Time is brain' in ischaemic stroke; early reperfusion has been shown to lead to improved clinical outcomes, yet the majority of patients with acute stroke do not attend in time for thrombolysis as it is currently licensed, hence the interest in trials extending the therapeutic window. Defining the ischaemic penumbra is of crucial importance in choosing the appropriate patients for thrombolytic therapy who attend outside the optimal therapeutic window. Integrated stroke imaging, including demonstration of potentially salvageable tissue with either MR perfusion/diffusion studies or CT perfusion, is increasingly likely to play a central role in future management strategies and widening of the potential therapeutic window. This review highlights the basic imaging findings of acute stroke and discusses the role of advanced CT and MR techniques as well as options for vascular imaging.

Imaging in childhood scoliosis: a pictorial review.

Childhood scoliosis is a common clinical entity with a number of different causes. In the majority of cases, the scoliosis is idiopathic, but it may be the manifestation of an occult spinal pathology. The clinical history and examination may elicit certain worrying features such as pain, neurological symptoms or an atypical curve pattern. These findings should prompt advanced imaging, as early and accurate detection of an underlying cause allows optimal planning and timing of surgery and helps reduce associated risks. The most common occult pathologies detected by advanced imaging are Arnold Chiari malformations, syringohydromyelia and closed spinal dysraphism such as diastematomyelia. Advanced imaging techniques, in particular multiplanar MRI, are also increasingly requested in children with known congenital scoliosis associated with spinal dysraphism and developmental causes of scoliosis such as neurofibromatosis and Klippel-Feil syndrome, as it allows superior delineation of the spinal column without the radiation risk. This review aims to examine the different imaging techniques currently used in the evaluation of scoliosis and provide a pictorial summary of the more common causes and associations.

Restricted diffusion in Wallerian degeneration of the middle cerebellar peduncles following pontine infarction.

BACKGROUND: Acute Wallerian degeneration following infarction has been show to result in areas of restricted diffusion within the brain. Very few reports describe this appearance in middle cerebellar peduncles. CASE REPORT: A 37 year old woman was admitted to hospital following sudden collapse and was subsequently found to have a pontine infarct. The complex clinical course resulted in MR imaging including DWI at day 4, 9 and 23 after the initial presentation. The cerebellar peduncles were normal when imaged on day 4 and 9. At day 23, symmetrical high T2 signal was seen in both cerebellar peduncles. The DWI illustrated high signal with corresponding low signal on the ADC map consistent with restricted diffusion. We discuss why this appearance is in keeping with Wallerian degeneration and also describe the fibre pathways involved. CONCLUSIONS: Symmetrical high signal with restricted diffusion in the middle cerebellar peduncles following a pontine lesion is almost certainly attributable to Wallerian degeneration and should not be mistaken for a new ischaemia.

HIV and AIDS responses of health care training institutions in the Pacific Islands--a literature review.

The purpose of this review paper is to provide information on the current roles of Pacific health care training institutions response to the HIV pandemic and to identify ways to scale up their response. The evidence presented here comes primarily from few published papers, unpublished literature and anecdotal evidence through interviews with health care training institute staff in the region. Studies from high prevalence countries in the Sub - Sahara African and Caribbean Countries reveal that higher tertiary institutions played an important role in the fight against HIV, through the development of HIV related policies, research, partnership networks, community awareness, treatment and care services and curriculum in response to the pandemic. While these responses were initiated at a time when incidence had seemed to reach an uncontrollable level the processes generated many important lessons. Very little is known about the response of health care training institutions in the Pacific. Detailed studies need to be implemented to assess and verify the level of responses in the health care training institutions. What is needed now is political will and resources to support and scale up HIV responses at Pacific health care training institutions.

Scaling up HIV treatment, care and support for injecting drug users in Vietnam.

BACKGROUND: People living with HIV/AIDS (PLWHA) in developing countries are rarely consulted about ways to promote their health and well-being. This study sought to identify and understand, from the perspective of PLWHA, challenges and opportunities for improving access to HIV treatment, care and support in Vietnam, a resource-limited setting with an epidemic driven by injecting drug use. METHODS: PLWHA trained in participatory research methods completed fieldwork and data collection and co-facilitated focus groups with injecting drug users (IDUs) in Ho Chi Minh City. Qualitative data were analysed in Vietnamese and English using an inductive approach to code and compare content and identify key themes. RESULTS: Results suggest considerable barriers to scaling up in this setting. Against a backdrop of punitive government policies, including mandatory detention of IDUs and sex workers, and widespread stigma and discrimination, many PLWHA lived with the fear of discovery and the threat of abandonment. Lack of confidentiality, limited financial resources and restricted access to essential medications provided powerful disincentives to health service utilisation. CONCLUSIONS: Opportunities for scaling up lie firstly in expanding access to confidential HIV counselling and testing. However, in the absence of affordable, quality care and access to anti-retroviral therapy, IDUs are unlikely to see testing as worthwhile. Efforts to scale up also need to address structural barriers including stigma and discrimination, poverty and institutional capacity. Finally, PLWHA in Vietnam are a significant but underutilised resource and consideration should be given to overcoming barriers to building confidence and capacity within affected communities.