Congenital para-oesophageal hiatal hernia in infancy.

Congenital para-oesophageal hiatal hernia (PEHH) is a rare problem in infancy, however, it constitutes a clinical entity that mandates surgical repair once the diagnosis is made. In the paediatric age group, acquired PEHH has been described as a major complication in a number of patients who were treated surgically for gastro-oesophageal reflux (GER) by Nissen fundoplication. PEHH is a frequently encountered condition in elderly patients; it accounts for 5% of diaphragmatic hiatal hernias. In both paediatric and adult patients PEHH, whether congenital or acquired in origin, is usually associated with potentially lethal complications such as gastric volvulus, incarceration, and perforation. In clinical practice true PEHH is extremely rare. The term has been expanded to include large gastric hiatal hernias where most of the stomach and the gastro-oesophageal junction are in the chest. Six infants with congenital PEHH are presented, together with an attempt to understand its possible aetiology and a review of its current surgical management.

Comparing the sensitivities and specificities of two diagnostic procedures performed on the same group of patients.

Studies of diagnostic accuracy are the most commonly performed diagnostic tests. These are carried out by using Decision Matrix tables in which sensitivities, specificities, predictive values and other ratios are calculated and compared. Various recoverable pitfalls and limitations of this method have been reported. This study reports additional further limitations of using this method as a statistical analytical tool. Decision protocol and formulae are presented to show how the sensitivities and specificities of tests are compared in order to make a decision. The study also shows how special tables can be constructed for the four results of comparative diagnostic tests (true positive, true negative, false positive and false negative), and cautions against the use of some 2 x 2 contingency tables. The procedures of how to use these special tables and formulae for comparing sensitivity and specificity and deriving confidence intervals for their difference are presented. It is also shown how it is possible to make a single inference from diagnostic test performance which will permit the determination of which test is better.

Morphology and growth of the fetal stomach.

To assess the development of the fetal stomach, we performed 162 esophageal injections of contrast media into spontaneously aborted normal fetuses from 7.5 to 26 weeks of gestation. The length of esophagus and trunk, greater and lesser curvature, and vertical and oblique axis of stomach were measured, and the means and standard deviations at each gestational age were calculated. The most frequently encountered patterns of stomach shape were: the standard shape, 90%; steerhorn, 3%; and horizontal stomach, 2%. The final shape of the stomach is not assumed at least until the the age of 22 weeks. Regarding the growth of stomach, with age, the greater curvature grew at a much faster rate than the lesser curvature, and the distance between skin and outer border of the stomach increased. The oblique axis of the stomach did not rotate after eight weeks; gastric surface area showed the fastest growth after 14 weeks. The gastroesophageal junction cephalad relative to the trunk ascended through week 25, due to the differential growth of the trunk and esophagus.

Intrathoracic fat. A new CT feature of intrathoracic rib. Case report.

A case of intrathoracic rib in a 55-year-old woman is described. A plain chest film showed a rib forking and a pleural based opacity. Computed tomography (CT) showed the lower arm of the rib fork to be "intrathoracic" and the pleural based opacity to be due to pleural tent and intrathoracic fat. Twenty cases have so far been reported, only few were studied by CT scan. The presence of intrathoracic fat has not previously been described in these cases. The types of intrathoracic rib including pseudo intrathoracic rib of newborn infants are discussed.

Camel bites: report of severe osteolysis as late bone complications.

Four cases of severe osteolysis of bones subsequent to camel bite are described. The first had osteolysis of the ribs with traumatic diaphragmatic hernia. Two cases had similar appearances of gross osteolysis of the shafts of the radius and ulna, whilst one had osteolysis of the humeral shaft. The similarities in the radiological appearances especially of the gross osteolysis at the site of trauma are noted. The complications following mammal bites are discussed.

Clinical and radiological features of pseudomyxoma peritonei.

Pseudomyxoma peritonei is due to diffuse involvement of the peritoneal cavity with mucinous material. Four patients were found in two major general hospitals in Riyadh. All patients were male. Cardinal clinical features were abdominal distension, pain and weight loss. Computed tomography was helpful preoperatively. Laparoscopy or laparotomy were performed to arrive at a correct diagnosis.

Fetal necrogram: a new technique. Experience with 12,000 contrast examinations.

The authors describe a new technique "necrogram" for post-mortem fetal investigations that uses ionic contrast media and employs the principles of diffusion and osmosis for clearing the fetus from contrast injection. It was possible to perform subsequent contrast examinations without the problem of overlapping structures. The study was conducted on 1,500 fetuses with more than 12,000 contrast examinations performed, followed by autopsy. In a sample of 250 fetuses undergoing 2,135 contrast examinations, similar results were obtained from necrogram and autopsy in 79% of the fetuses examined. Details are given of the 21% of the studies in which discrepancies were noted between necrogram and autopsy. The result showed that necrogram was comparable to autopsy and that luminal anatomy can be best visualized by necrogram, a laborious and almost impossible task in autopsy. It was apparent that post-mortem diagnostic precision can only be obtained by employing both necrogram and autopsy, one for visualization of the inner and the other for the outer appearance of the organs.

Absence status epilepticus with computed tomographic brain changes following metrizamide myelography.

Absence status epilepticus following metrizamide myelography was associated with computed tomographic scan evidence of a high concentration of the dye in brain gray matter. We suggest that absence status epilepticus is due to the direct effect of metrizamide on the cortex and that this clinically treatable condition may have escaped diagnosis in previous reports.

Adult geophagia--report of three cases with review of the literature.

This is the first report of three cases of adult geophagia in Saudi Arabia, two with a history of eating mud, and the third of eating pebbles. The presentation in these patients were of abdominal pains, with the radiographs showing very dense opacities within the intestine, especially the colon. These opacities were of varying sizes, and of varying densities, some of them polygonal in shape. These opacities changed in position with time differentiating them from other densities such as renal calculi with which they are may be confused. A review of the clinical and pathological changes of geophagia is given. The association of iron-deficiency anaemia, hepatomegaly, dwarfism and hypogonadism with a geophagia syndrome is noted and its pathogenesis explained. The role of socio-cultural and other predisposing factors in the aetiology of geophagia is discussed.

Cranial and epidural mycetoma caused by streptomyces somaliensis.

The authors report a rare case of cranial and intracranial mycetoma which presented with occipital sinuses, extensive involvement of skull vault and base, an extradural granuloma and intracranial hypertension. Radiological appearances are reviewed. The computerized tomography findings are the first of their kind for this condition. The diagnosis and treatment of this disease are discussed.

Acro-osteolysis following snake and scorpion envenomation.

Three cases of acro-osteolysis are described following snake bite and three after scorpion stings. This effect is consistent with tissue necrosis secondary to the enzymatic actions of the venom.