Ergovaline and peramine production in endophyte-infected tall fescue: Independent regulation and effects of plant and endophyte genotype.

Peramine and ergovaline have ecological and economical significance because they possess insect and/or mammalian toxicity properties. The relationship between these endophytically derived alkaloids in tall fescue (Festuca arundinacea Schreb.) is unknown. Seasonal and plant tissue effects on the concentration of peramine and ergovaline was investigated in field and greenhouse experiments. The relationship between the alkaloids and the regulatory effects of endophyte and plant on their content were investigated among progeny of reciprocal crosses between high- and low-ergovaline and peramine plant-endophyte combinations. Variation in peramine concentration ranged from 750 to 1742 µg/kg in greenhouse-grown plants, and there was no seasonal trend in peramine content. There was a correlation (r=0.69) between peramine and ergovaline content among leaf tissues of field-grown plants, but there was no correlation between the alkaloids in the culm (r=0.20) or panicle (r=0.17) tissues. Mean leaf ergovaline concentration of progeny derived from the low-ergovaline parent (163 µg/kg) was less than the midparent value (228 µg/kg), but mean of progeny from the high-ergovaline parent was not different from the mid-parent value. Ranges within each progeny set were approximately double their mean. Mean leaf peramine concentrations of the progeny sets were similar to the mid-parent value (3354 µg/kg) but ranges were from 1716 to 8753 µg/kg. There was no correlation between leaf peramine and ergovaline (r=0.01). These data suggest that endophytically produced alkaloids are independently regulated and are controlled by both plant and endophyte genotype.

Compliance with the Royal College of Radiologists' guidelines on the use of pre-operative chest radiographs.

Clinical compliance with the Royal College of Radiologists' guidelines on the use of pre-operative chest radiology was examined in a random sample of patients in four hospitals in England and Wales. Pre-operative clinical data were abstracted from medical reports and, in one hospital, from special chest radiograph request forms completed by clinicians. Seventy-five per cent of patients had clinical indications warranting a pre-operative chest radiograph. This level of compliance is compatible with that found with other guidelines and would suggest that the pre-operative chest radiograph guidelines are suitable for wider implementation in the National Health Service.

Multicentre trial of four strategies to reduce use of a radiological test.

The Royal College of Radiologists' guidelines on the use of pre-operative chest X-rays were implemented for 1 year in four hospitals in England and Wales. The strategies adopted were: (1) the appointment of a utilisation review committee; (2) getting feedback on use to consultants; (3) the introduction of a new chest X-ray request form; or (4) the concurrent reviewing of chest X-ray requests by the radiology department. The lowest level of use (8.5 pre-operative chest X-rays per 100 elective operations) was achieved with the utilisation review committee after it displayed the guidelines in surgical wards. Information feedback produced a consistent reduction from 29.4 to 13.3 X-rays per 100 operations. Both the new request form and concurrent review had a moderate and intermittent effect. No change in practice occurred in a control hospital.

An unusual intraosseous lesion with fibroblastic, osteoclastic, osteoblastic, aneurysmal and fibromyxoid elements. "Solid" variant of aneurysmal bone cyst.

Four examples are reported of an unusual noncystic intraosseous lesion which does not conform to any hitherto recognized entity and which can be mistaken, not only by the general histopathologist but by the osteoarticular pathologist, for a variety of other conditions, including sarcoma and giant-cell tumor. They were in patients aged 5 to 13 years; three in the spine, one in the ethmoid. Local excision, supplemented by low-dose radiotherapy in cases with cord compression, produced a satisfactory outcome in all cases. At presentation the radiologic findings were nonspecific but, following treatment, an eggshell rim of bone developed in those lesions which had been incompletely excised. Histologically, they are characterised by florid fibroblastic or fibrohistiocytic proliferation, osteoblastic differentiation with osteoid production, areas rich in osteoclast-type giant cells, aneurysmal sinusoids, and occasional foci of degenerate calcifying fibromyxoid tissue. Because this combination of histologic features can be found in the solid parts of aneurysmal bone cyst and in no other condition, at this centre we have regarded this lesion as a variant of aneurysmal bone cyst devoid of any cystic component.

Diaphyseal osteosarcoma.

Fifteen cases of diaphyseal osteosarcomas were found in a review of 157 cases of long bone osteosarcoma (9.5%) and two further examples were added. The clinical and histological features of the diaphyseal osteosarcomas were indistinguishable from those of the commoner juxta metaphyseal osteosarcomas. The radiological features, however, fell into four distinct patterns: Group I had the classical appearance of a conventional osteosarcoma; Group II showed dense cortical sclerosis with bony expansion but no soft tissue swelling or break of the cortex at presentation; Group III presented with a pathological fracture through a purely osteolytic lesion; Group IV usually had the classical appearances of an osteosarcoma in the diaphysis but had, in addition, dense separate sclerotic lesions which were proximal to the tumour in the humerus and distal to it in the femur. The importance of these four groups lies in the quite distinct differential diagnosis which each presents.

Bone formation associated with osseous metastases from bladder carcinoma.

Twenty-four cases of carcinoma of the urinary bladder, involving bone, have been reviewed. Eighteen of these were distant metastases beyond the pelvis. The lesions were predominantly osteolytic. Ossification in the soft tissues adjacent to the bone metastasis was observed in three cases, all involving the left tibia. The reason for this site of predilection remains obscure.

Urinoma.

A urinoma is a mass formed by encapsulated extravasated urine. It may follow closed renal injury, surgical operation or arise spontaneously in the presence of obstruction. The essential factors are continued renal function, rupture of the collecting system and distal obstruction. The extravasating urine is localised within the perirenal fascia and stimulates an intense fibrous reaction which forms a thick wall. Early diagnosis is important for successful treatment. The clinical features include malaise, vague abdominal pain, weight loss and a palpable mass. Plain films usually reveal a mass with loss of the retroperitoneal landmarks. High-dose excretion urography usually shows renal displacement, hydronephrosis and extravasation of contrast medium into the urinoma. Should renal function be inadequate for diagnosis, renal puncture, preceded by ultrasound examination, is the investigation of choice.

The value of urography following lymphography in malignant diseases.

The need for urography following ascending pedal lymphography in malignant disease has been studied in 298 consecutive patients. Forty per cent of the urograms were abnormal. Urographic abnormalities due to the disease being investigated were heralded by abnormal lymphography except in four patients, three with carcinoma of the bladder and one with carcinoma of the cervix. The majority of abnormalities unrelated to the disease being investigated were of no significance. In a small number there was congenital malposition of the kidney so that it fell within the proposed field of treatment. It is concluded that it is unnecessary to do routine urography with every lymphogram. Indications for urography are abnormality or suspected abnormality of the lymphogram, failure to locate the kidneys on plain films and clinical indications such as carcinoma of the bladder or carcinoma of the cervix.

Transitional cell carcinoma of the kidney.

Transitional cell carcinoma is an uncommon disease of the renal pelvis, the diagnosis of which depends largely upon radiological investigation. Thirty-eight such tumours in 37 patients have been reviewed to establish the examination of choice. High-dose excretion urography, tailored to the presenting problems, is the primary investigation and the results fall into five main groups. Each presents different differential diagnostic problems. Discrete filling defects within the pyelogram (group I) may be overlooked, but, when seen, can be diagnosed on urography alone. Filling defects with dilated calyces (group II) are easily seen and readily diagnosed. Calyceal obliteration (group III) presents more difficulty in diagnosis and may require retrograde pyelography and selective renal angiography. Hydronephrosis with renal enlargement (group IV) is easily confused with uncomplicated primary pelvic hydronephrosis and will usually require antegrade pyelography for diagnosis. Reduced function without renal enlargement (group V) cannot be diagnosed on excretion urography and requires both retrograde pyeloureterography and selective renal angiography.

Pyonephrosis.

The clinical and radiological features of pyonephrosis are reviewed, based on a consecutive series of 40 cases. There were 32 female and eight male patients, with a peak incidence in the 50-59 year age group. In 63% of cases the right kidney was involved. Almost all patients complained of loin pain and 48% had lower urinary tract symptoms. In 58% of cases a renal mass was palpable. An anaemia, pyuria and elevated blood sedimentation rate were usual. Plain films of the abdomen revealed enlargement of the outline of the involved kidney in 75%, ipsilateral absence of the psoas shadow in 63% and urinary tract calculi in 60%. At high-dose excretion urography a nephrogram was obtained in 58% of cases and a pyelogram produced in 34%. No single clinical or radiological entity emerged, there being an unbroken spectrum of disease ranging from infected hydronephrosis to xanthogranulomatous pyelonephritis. There is an increasing incidence of calculi, loss of the renal and psoas outlines and reduced renal function with increasing chronicity of disease. High-dose excretion urography is the investigation of choice since not only may the diagnosis be established but also there precise pathological state of the involved kidney. Further radiological investigation is infrequently required.

The incidence and importance of renal duplication.

The excretory urograms performed on 1716 children and 3480 adults have been examined to find the incidence and complications of renal duplication. Ninety-five patients with duplication were found, unilateral in 79 and bilateral in 16 patients. It was equally common on each side and twice as common in females as in males. Non-duplex kidneys had a mean of 9.4 calyces and duplex kidneys had a mean 3.7 upper and 7-6 calyces in lower moieties. In patients without renal disease and with unilateral duplication the two kidneys were equal in size in 39%, and the duplex was smaller in 10%. Twenty-seven per cent of the duplex kidneys examined showed evidence of disease compared to 3% of the non-duplex kidneys-a significant difference (P less than 0-001). Saddle reflux is the only abnormality unique to duplication and was seen in one patient. Extravesical ectopic ureter and ureterocoeles are known to be associated with renal duplication, but in this series ureterocoeles were found only on the non-duplex side. The duplex kidney in children is more susceptible to reflux than is the non-duplex kidney, and this leads to both ureteric and pelvi-calyceal dilation, and to chronic pyelonephritis in the duplex side in those children who develop urinary tract infections. Chronic pyelonephritis was found in 22% of patients under 15, significantly more often than in adults (P less than 0-001), although the incidence of duplication was unchanged. It is concluded that there is no real increase in the number of children with duplex kidneys having urinary tract infections, and the vast majority of duplex kidneys do not become diseased.

Excretion urography in the investigation of prostatism.

The excretion urogram and urodynamic studies of 201 patients presenting with prostatism were reviewed. The urographic features of trabeculation and diverticula were found to be associated with bladder instability as shown on inflow cystometry but not to be associated with outflow obstruction as shown by the pressure-flow analysis of micturition. The bladder shadow on the preliminary film and the bladder size on the post-evacuation film were associated with the measured residual urine and with outflow obstruction. The basal prostatic filling defect was also associated with outflow obstruction.

Acute reactions to urographic contrast media.

A prospective study of 3509 consecutive patients examined by excretion urography has been conducted to assess the incidence and significance of the untoward effects of urographic contrast media. Four compounds were used in doses containing 160 to 500 mg iodine/kg body weight. Toxic effects, arm pain, and allegic reactions were assessed separately, while the remainder were classified according to the influence of each reaction on the investigation and the need for treatment. From the results and a review of the literature we conclude that when there is a clear clinical indication for excretion urography a dose of contrast medium containing up to 600 mg iodine/kg body weight should be injected rapidly. Prophylactic antihistamine treatment and pretesting should be abandoned. Special care is needed for small infants and the lederly and for patients with renal or hepatic failure, myeloma, heart disease, or a history of previous major reaction. Full resuscitation facilities must always be available.