Sonographic incidence of deep venous thrombosis contralateral to hip or knee replacement surgery.

PURPOSE: This study assesses the sonographic incidence of deep venous thrombosis (DVT) contralateral to and the venographic incidence ipsilateral to hip or knee replacement surgery and the role of sonography in routine surveillance. METHODS: We prospectively evaluated 178 consecutive patients with sonography of the femoropopliteal venous systems of the contralateral lower extremity and venography of the ipsilateral lower extremity on days 3 and 4, respectively, after total hip or knee replacement surgery. RESULTS: No cases of acute DVT and only 1 case of chronic DVT isolated to the popliteal system were identified by sonography in the contralateral extremity. In the ipsilateral extremity, venography identified 26 patients with acute DVT (3 femoropopliteal, 21 calf, and 2 concurrent femoropopliteal and calf). CONCLUSIONS: Routine sonographic evaluation of the lower extremity contralateral to hip or knee replacement surgery is not cost-effective because of the extremely low incidence of detectable acute thrombus.

The optimization of helical thoracic CT.

PURPOSE: Our purpose was to determine the optimal helical thoracic CT scanning protocol. METHOD: Three adult Suffolk sheep under general anesthesia were repeatedly scanned by a variety of variable thickness helical and conventional plus thin section high resolution (lung gold standard) CT sequences, reconstructed for mediastinal (standard interpolator and algorithm) and lung parenchymal (extrasharp interpolator, bone algorithm) detail. The images were evaluated in a random order by five separate blinded, experienced imagers utilizing a predetermined grading scale. RESULTS: At equivalent slice thicknesses, the mediastinal images showed no statistically significant differences between conventional and helical CT using pitches of 1.0, 1.5, and 2.0. However, the 5-mm-thick sections, regardless of technique, performed better than did either the 2- or the 10-mm-thick section images. For the lung interstitium, there was an obvious and marked advantage to reconstructing the lung images separately from the mediastinal images with edge-enhancing algorithms and interpolators. With 1-mm-high mA thin section, high resolution lung CT as the gold standard, 2 mm conventional and helical pitch 1.0, 1.5, and 2.0 images were all graded equivalent. Of the 5 mm images, the helical pitches of 1.0 and 1.5 were graded equivalent to the gold standard. All of the 10 mm lung sections using both conventional and helical CT were graded statistically worse than the gold standard (p < 0.05). CONCLUSION: The use of helical CT with a 5 mm beam collimation and a pitch of 1.0 or 1.5 reconstructed twice to maximize both the mediastinal and the lung parenchymal detail provides the optimal way to routinely evaluate the chest.

Experience with 100 consecutive central venous access arm ports placed by interventional radiologists.

PURPOSE: This study reports the authors' experience with long-term follow-up of 100 consecutive peripherally inserted, subcutaneous arm ports for central venous access. MATERIALS AND METHODS: One hundred patients with subcutaneous arm ports inserted by interventional radiologists were retrospectively studied. Data were collected from the patients' medical records and from telephone canvassing. Using each insertion period as an observation, the complication rates per 100 catheter days were determined with 95% confidence intervals (CIs). RESULTS: One hundred subcutaneously implanted ports were placed in 98 patients; three devices (three patients) were lost to follow-up, leaving 97 devices in 95 patients. Total exposure time was 23,842 days (mean, 246 days; range, 2-865 days). Seven infectious and two noninfectious complications occurred with seven (7.2%) devices in six patients (6.3%), yielding 0.038 complications per 100 catheter days at risk (95% CI; 0.011-0.069) and 0.029 infections per 100 catheter days at risk (95% CI; 0.008-0.058). A successful clinical outcome was defined as a functional port at removal, time of death, or at study closure (minimum of 6 months of follow-up), which was not removed because of a complication. This successful outcome was achieved in 91 ports (93.8%). Procedural-related complications, defined as those occurring up to 30 days after insertion, occurred in only one port (thrombophlebitis and catheter tip infection-day 9). All other patients received several months of service from their port. Fifteen devices were placed in 13 patients with HIV for 3,486 days, with a total complication rate of 0.11 per 100 catheter days (95% CI; 0.0-0.28), all of which were infections. Devices in HIV-positive patients were associated with higher total complication (20% vs 4.9%) and infection rates (20% vs 3.7%) than devices in patients without HIV infection. This gives a relative risk 8.17 x (P = .04) greater for infectious complications for devices placed in HIV-infected individuals. CONCLUSIONS: Subcutaneous arm ports placed by interventional radiologists are effective for central venous access with excellent functionality (93.8% achieved a successful long-term outcome) and a very low procedural complication rate. Although infections were more frequent in HIV-infected individuals, these devices are associated with a very low incidence of both immediate and long-term complications, including infection, for all patients.

Experimental nonsurgical transcervical sterilization with a custom-designed platinum microcoil.

PURPOSE: Investigation of a technique for nonsurgical female sterilization. MATERIALS AND METHODS: A custom designed platinum microcoil with Dacron fibers was placed unilaterally into a fallopian tube and uterine horn of 10 rabbits after transcervical selective tubal catheterization with use of fluoroscopic guidance. The contralateral uterus and fallopian tube served as controls. After the rabbits were bred, pregnancy was determined by palpation and confirmed at autopsy. Postmortem histopathologic evaluation of uteri and fallopian tubes was performed. RESULTS: Nine of the 10 rabbits became pregnant. None of the animals had embryos on the microcoil side. Nine rabbits had a total of 45 embryos on the control side. One animal failed to become pregnant on either side. The microcoil remained in good position in all 10 rabbits. There was a microcoil-associated, mild inflammatory tissue response in the uteri and fallopian tubes. CONCLUSION: A platinum occlusion microcoil placed in a utero-tubal location has potential as a means for nonsurgical female sterilization.

PIP: At Milton S. Hershey Medical Center in Hershey, Pennsylvania, researchers used fluoroscopy to guide transcervical selective tubal catheterization in order to correctly insert a custom-designed platinum microcoil with Dacron fibers 1.5-6 cm into a fallopian tube and 1.5-5.5 cm into a uterine horn of 10 rabbits. The fallopian tube and uterine horn on the opposite side were the controls. The researchers sacrificed the rabbits to conduct histopathologic examination of the uteri and fallopian tubes in order to determine the presence or absence of embryos. One rabbit had no embryos on either side, even after 4 breeding attempts. Among the remaining 9 rabbits, there were no embryos on the microcoil side and 45 embryos on the control side. The position of the microcoil did not change in any rabbit. The microcoil caused a mild inflammatory tissue response in the uteri and fallopian tubes. Longer-term studies in more animals are necessary to confirm the efficacy and safety of this sterilization method as well as to determine the potential for retrievability of the microcoil and reversibility of the sterilization effect. In conclusion, a uterotubal coil may someday be a safe, effective, minimally invasive means of female sterilization.

Intrasubject variability of objective voice measures.

Recent advances in the diagnosis and treatment of voice disorders necessitate the need for accurate and reliable objective voice measurements. There are many instruments commonly used to analyze voice data. Many, if not most, of these instruments have not been adequately tested for reliability or consistency. This study evaluates the intrasubject variability of the objective voice measurements from two commonly used voice analysis instruments. The study also presents data correlating subjective mood states, room temperatures, sleep times of the subject, time since last meal, and hydration levels to the various acoustic measures. Several weak but significant correlations were obtained and are discussed. Guidelines for the appropriate use of these instruments are described.

Gastroesophageal reflux laryngitis resistant to omeprazole therapy.

Gastroesophageal reflux disease (GERD) is known to cause a variety of symptoms that lead a patient to seek otolaryngologic care. New advances in the treatment of GERD have enabled otolaryngologists to eliminate most of the signs and symptoms caused by acid reflux. Omeprazole, the most recent pharmacologic advancement, has been reported to be universally successful in controlling acid release from the stomach of patients with GERD. This report describes a series of patients with GERD for whom high-dose omeprazole therapy was not successful in completely reducing gastric acid levels of GERD symptomatology.

Cervical epidural spinal infection: MR imaging characteristics.

OBJECTIVE: Cervical epidural spinal infection, which includes diskitis, osteomyelitis, and/or epidural space infection, is an uncommon disease, and the MR imaging features have not been fully described. Accordingly, the objective of this study was to determine the MR imaging findings in a large series of patients with this condition, with emphasis on patients with pyogenic infection. MATERIALS AND METHODS: During a 5-1/2-year interval, 12,695 MR examinations of the spine were performed in our department. A computer search retrospectively identified 60 patients with proved epidural spinal infection; 19 (32%) had involvement of the cervical spine. Pyogenic infection was present in approximately 90% of cases. One patient had an epidural abscess without an underlying osseous abnormality. The remaining 18 patients had cervical diskitis/osteomyelitis, as well as inflammation in the epidural space. All MR examinations were performed with a 1.5-T superconducting magnet by using a combination of spin-echo, fast spin-echo, and/or gradient-echo pulse sequences; 12 patients received IV gadopentetate dimeglumine. The MR examinations were retrospectively reviewed by a neuroradiologist for multiple imaging characteristics, including extent and location of osseous abnormalities, extent and location of inflammation in the epidural space, likelihood of abscess formation, and frequency of spinal cord compromise. RESULTS: On MR images, an average of three vertebral bodies showed abnormal signal of the bone marrow. Inflammation in the epidural space extended an average of four levels and was most frequently anterior in location; MR images in six (50%) of 12 patients who received contrast material showed a large, peripherally enhancing epidural abscess. Thirteen (72%) of the 18 infections with osseous involvement occurred at or below the level of C4; the C5 and C6 levels were affected most frequently. Cord compression was identified in 14 (74%) of 19 patients; cord hyperintensity was seen in 12 (63%) of 19 patients and was well defined on T2-weighted FSE images. CONCLUSION: The results of our study show that cervical epidural spinal infection is a more aggressive disease than previously recognized. MR findings are characterized by multilevel involvement, an anterior location, and frequent abscess formation. MR evidence of isolated involvement of the epidural space, without underlying osseous abnormality, is rare. There is a predilection for infection to affect the lower cervical segments. We observed a strong association between cervical epidural spinal infection and spinal cord compromise, which makes prompt diagnosis and treatment mandatory.

Myasthenia gravis: signs, symptoms, diagnosis, immunology, and current therapy.

Myasthenia gravis is a neuromuscular disease that presents clinically as fluctuating weakness of one or more skeletal muscle groups. Weakness becomes more severe with exercise and improves with rest. The disease is caused by an autoimmune reaction at or near the post-synaptic nicotinic acetylcholine receptor. The results of this immune reaction are the lytic destruction of the post-synaptic membrane and a reduction in the number of acetylcholine receptors. Myasthenia gravis can be diagnosed by repetitive exercise of the involved muscles, administration of edrophonium (Tensilon), electrophysiologic testing, or demonstration of anti-acetylcholine receptor antibodies. When the myasthenic weakness is mild or limited to the extraocular muscles, it may be treated with acetylcholinesterase inhibitors. When the weakness is more severe and/or more generalized, immunotherapy is most often indicated. Prednisone or prednisone plus thymectomy is the most frequently used form of immunotherapy. Azathioprine, 6-mercaptopurine, plasmapheresis, or gamma globulin injections are other immunotherapeutic options that may be useful in selected patients. A large number of drugs may precipitate or exacerbate myasthenic weakness.

Migraine headache: signs and symptoms, biochemistry, and current therapy.

The classification, biochemistry, precipitating factors, differential diagnosis, treatment of acute attacks, and prophylactic therapy of migraine headaches are reviewed. The biochemistry of both classic (prodromal symptoms) and common (no prodromal symptoms) migraines is poorly understood, but appears to involve serotonin. Although their clinical importance is not clear, common precipitating factors include coffee, tea, and cola beverages; chocolate, cheese, and alcohol; light stimulation, stress, fasting, lack of sleep, and fever; and reduced estrogen levels. The symptomatic treatment of acute attacks with ergot preparations, isometheptene, flufenamic acid, analgesics and sedatives is reviewed. Prophylactic therapy with methysergide maleate, tricyclic compounds, monoamine oxidase inhibitors, propranolol, and 5-hydroxytryptophan is also discussed.

Hypothalamic hypothyroidism causing spastic paraplegia: recovery following thyroid medication.

A 63-year-old woman with longstanding spastic paraplegia and neurological evidence of long tract disturbance was found to have hypothyroidism, partial diabetes insipidus, hyperprolactinemia, and gonadotropin deficiency of hypothalamic origin. Replacement therapy with thyroxine and prednisone induced complete remission of the neurological abnormalities. The association of spastic paraplegia with hypothalamic insufficiency has not been reported previously. The possibility of hypothalamic disease should be considered in cases of spastic paraplegia of unknown cause.