Extensive vulval oedema secondary to severe pelvic infection.

A 17-year-old female developed a complex pelvic abscess a few weeks post-surgical abortion. Despite surgical drainage, a debilitating infection induced a low albumen. The resulting pelvic oedema caused gross vulval oedema that was difficult to manage. She had previously been treated for chlamydia.

Exercise training for claudicants: changes in blood flow, cardiorespiratory status, metabolic functions, blood rheology and lipid profile.

OBJECTIVE: Exercise training improves the walking distance of claudicants. The aim of this study was to investigate factors associated with the improvement in the maximum walking distance (MWD) in respect to cardiovascular, respiratory and metabolic adaptations. METHODS: Forty claudicants were studied. Common femoral artery blood flow (BF), heart rate (HR), oxygen consumption (VO(2)), respiratory exchange ratio (RER), lactate levels, blood rheology and lipid profiles were measured. Tests were repeated after 3 months of exercise training. RESULTS: Fifteen patients did not complete the exercise program. For patients who did complete the program, MWD improved by 82%. A significant reduction in HR and VO(2)during exercise was demonstrated. No significant changes occurred in BF or RER. Although MWD increased significantly, there was no increase in recovery VO(2)(oxygen debt). A significant reduction in post-exercise lactate levels occurred. Blood rheology was unchanged, but an improvement in HDL levels was noted. CONCLUSIONS: Many claudicants could not complete an exercise program, mainly due to osteoarthritis. Exercise training improved exercise tolerance significantly without any increase in BF. The HR and oxygen cost of similar exercise was reduced. An improved MWD did not correlate with a higher oxygen debt or lactate load. Favourable changes in lipid profiles occurred.

Cavernous haemangioma of the nasal bones: an alternative management option.

The authors present a case of bilateral cavernous haemangiomas affecting the posterior ends of both inferior turbinates of the nose. The condition was treated by angiographically controlled embolization. Review of the literature back to 1967 has revealed no other report of embolization being used specifically for this condition. All previous treatments have involved surgery; we describe an alternative therapeutic option.

The effect of pregnancy on the lower-limb venous system of women with varicose veins.

OBJECTIVES: to assess the effect of pregnancy on the lower-limb venous system of women with varicose veins. Design a longitudinal prospective study of 11 pregnant women, with varicose vein disease. METHODS: eleven pregnant women with varicose veins were recruited as part of a larger study. Veins were assessed in both lower limbs using colour-flow duplex scanning at a 75 degrees head-up tilt. The diameter and velocity and duration of reflux were measured in each vein at 12, 20, 26, 34, 38 weeks gestation and 6 weeks postpartum. RESULTS: eleven women had reflux and varicose veins demonstrated at first scan. All veins dilated with increasing gestation. This was maximal in the superficial system, reaching significance (p

Serial colour flow duplex scanning of the veins of the lower limb throughout pregnancy.

OBJECTIVE: To examine changes in diameter and reflux in normal veins of the lower limb throughout pregnancy. METHODS: Fifty-seven women were recruited into the study and 43 completed the full assessment to six weeks postpartum. Thirteen had pre-existing venous disease and are reported elsewhere. The veins were assessed in both lower limbs using colour flow duplex scanning. This was performed at a 75 degree tilt measuring vein diameter and the presence or absence of reflux. Measurements were made at 12, 20, 26, 34, 38 weeks of gestation and 6 weeks postpartum. RESULTS: No new reflux developed in any of the veins studied. In the superficial system the maximum change was seen in the long saphenous vein at 34 weeks, on the left side the vein diameter failed to return to baseline size. Significant change also occurred in the superficial femoral vein. Dilatation of the deep veins of the calf was observed being greater in the left posterior tibial and the left peroneal at the mid-calf point. CONCLUSION: Colour flow duplex scanning is an acceptable method of assessing the lower limb veins in pregnancy. Maximum diameter changes were seen in the long saphenous vein and in the deep veins at mid-calf. No new reflux developed during the gestation period in veins which were previously normal.

A case of intractable epistaxis.

The surgical management of intractable epistaxis by external carotid artery ligation may become complicated if there is a high bifurcation of the common carotid artery. Occlusion of the bleeding vessels by catheter embolization is described in a patient in whom exploration of the neck had failed to locate the external carotid artery.

Carotid artery duplex scanning: does plaque echogenicity correlate with patient symptoms?

In this study we have investigated the relationship between plaque sonolucency and ipsilateral hemispheric symptoms in 116 patients at risk of cerebrovascular disease (75 symptomatic patients, 41 asymptomatic patients). Our results indicate that plaque sonolucency is significantly associated with the incidence of patient symptoms at presentation. Twice as many symptomatic vessels contained the predominantly sonolucent plaque types (types 1 and 2) compared to contralateral asymptomatic vessels (p = 0.039, odds ratio = 2.9). Vessel stenosis also had a significant association with patient symptoms. No significant interaction was shown between vessel stenosis and plaque sonolucency (p = 0.15, odds ratio = 1.0). A model using vessel stenosis and plaque echogenicity as independent variables showed that degree of vessel stenosis had a closer association with incidence of symptoms (p = 0.03, odds ratio = 1.04) than plaque type (p = 0.13, odds ratio = 0.51).

Magnetic resonance imaging facilitates assessment of perianal Crohn's disease.

Three illustrative cases of magnetic resonance imaging (MRI) in patients with perianal Crohn's disease are presented. Modern MRI techniques provided excellent visualization of perineal anatomy, inflammatory tissues and an anorectal stricture. It also allowed detailed delineation of the patho-anatomy of fistulous abscess and any communication to more proximal bowel. This report illustrates the potential of modern MRI as an important investigative adjunct in evaluating the anorectal manifestations of Crohn's disease.

Pulmonary scintigraphy in suspected pulmonary embolism: how often does it change clinical management?

The effect of pulmonary scintigraphy on patient management in suspected pulmonary embolism has been assessed in 158 patients. A change in management occurred in 30% following scintigraphy. The major effect was a reduction in the total number of patients who were anticoagulated. Heparin was stopped in 42 of the 74 patients to whom it had been administered prior to the scintigram.

Transjugular intrahepatic portocaval shunt (TIPS) and hepatic vein-to-caval stenting as salvage treatment of portal hypertension secondary to neoplasm.

A percutaneous transjugular intrahepatic portocaval shunt (TIPS) was successfully performed using Wallstents in a 53-year-old man with neoplastic disease causing portal hypertension and life-threatening variceal hemorrhage. Shortly afterwards, recurrent hemorrhage was investigated by shunt venography which showed that extrinsic narrowing of the hepatic vein and hepatic vena cava was causing shunt thrombosis. Shunt thrombosis was cleared by balloon occlusion of the shunt and forceful retrograde flushing of thrombus into the portal circulation. The compressed hepatic vein and vena cava were then dilated and stented using Gianturco "Z" stents. Bleeding recurred 3 months later due to focal narrowing within the shunt which possibly was due to intimal proliferation. Repeat dilatation and placement of a coaxial Palmaz stent again relieved portal hypertension. Creation of a TIPS for portal hypertension secondary to neoplasm can produce valuable palliation. Complete assessment of hepatic vein and vena cava patency is required to ensure shunt function.

Iodixanol in femoral arteriography (phase III): a comparative double-blind parallel trial between iodixanol and iopromide.

Iodixanol is a new non-ionic, dimeric contrast medium (CM) which is formulated to be isotonic with blood in all clinically relevant concentrations. This is a report of a parallel, double-blind study comparing the safety and efficacy of iodixanol with iopromide (Ultravist) in aortofemoral arteriography. One hundred consecutive, eligible patients scheduled to undergo peripheral arteriography were entered into the study and randomly allocated to receive one or other CM. Radiographic quality, discomfort, adverse events, femoral blood flow and renal function were examined. Ninety-five patients were successfully included in the study. Radiographic quality (efficacy) was found to be similar in both groups. Three patients (6%) in the iodixanol group and five patients (11%) in the iopromide group reported adverse events. In this respect there was no statistically significant difference between the two groups (P = 0.48), and all adverse events were mild and transient. Forty-six (97%) patients in the iodixanol group and 45 (100%) patients in the iopromide group experienced a sensation of warmth (discomfort) in connection with one or more of the injections. There was no statistically significant difference in the frequency of discomfort in the two groups. However, the intensity of warmth was significantly milder following iodixanol than after iopromide (P = 0.003, two-sided Mantel-Haenszel test). The mean percentage increase in femoral blood flow was found to be less with iodixanol (43.4%) than with iopromide (96.3%) (P < 0.05, Student's t-test). Renal function was affected slightly after administration of both CM. Serum creatinine and creatinine clearance were affected more by iodixanol than by iopromide, while the excretion of tubular enzymes was more affected by iopromide. In conclusion, this comparison between iodixanol and iopromide showed both contrast media to be safe, effective and well tolerated and the only major difference between them was in their effect on femoral blood flow.

Can serum prostate-specific antigen replace bone scintigraphy in the follow-up of metastatic prostatic cancer?

Bone scintigraphy is the most sensitive imaging technique for the initial detection of bone metastases and is widely used in the staging of prostatic cancer. This study was performed to assess whether the development of further bone metastases can be detected by serial measurements of the serum glycoprotein prostate-specific antigen (PSA) as an alternative to follow-up scintigraphy. The bone scintigrams and PSA levels of 101 patients with metastatic prostate cancer entered into two therapeutic trials have been reviewed. Serial results of both investigations were available in 59 cases. In three cases new bone deposits were observed without a corresponding rise in PSA. In two other cases the scintigrams were considered to be suspicious of progression with no change in PSA levels; however, further follow-up indicated that these changes were not due to metastases. In 13 cases PSA levels were rising in advance of new deposits on the scintigrams. In the remaining 41 cases the PSA levels and scintigraphic findings paralleled each other. We conclude that serial estimation of PSA levels is a simpler marker for disease progression than bone scintigraphy in metastatic prostatic cancer, but that neither technique in isolation gives complete accuracy.

Accidental subdural catheterization: radiological evidence of a possible mechanism for spinal cord damage.

We describe the inadvertent subdural insertion of a lumbar extradural catheter in a primiparous woman in labour. A small quantity of local anaesthetic resulted in extensive motor and sensory block. Computed tomography performed after contrast injection demonstrated unequivocally that the catheter was in the subdural space. The catheter and injected fluid produced considerable displacement of the arachnoid within the thecal sac. We postulate that this could result in arterial compression or direct damage to the spinal nerve roots. Such a mechanism might explain some of the cases of permanent neurological damage associated with extradural analgesia.

The radiological imaging of bronchial atresia.

The clinical and radiological findings in three cases of bronchial atresia are presented. Bronchial atresia has a characteristic plain radiographic appearance in the majority of cases. Computed tomography may be required to confirm the diagnosis. The condition often presents to the radiologist as an incidental finding on the chest radiograph in a patient undergoing investigation for an unrelated problem.

The effect of iodixanol, a new isotonic contrast agent, on femoral blood flow in man.

Both ionic and non-ionic contrast media (CM) injected intra-arterially produce peripheral vasodilatation and a sensation of heat or even pain. This effect has been considered to be predominantly related to the osmolality of the CM used. Iodixanol is a non-ionic dimeric CM which can be made isotonic with blood at iodine concentrations up to 400 mg/ml. To assess the degree of peripheral vasodilatation following aortic injection of iodixanol, the change in femoral artery blood flow has been assessed non-invasively. Dupex ultrasound flow-velocity records were taken from the contralateral femoral artery in 10 patients undergoing transfemoral aortography. Volume flow, mean velocity, pulsatility index and peak systolic velocity were continuously recorded before and up to 2 min after injection of 60 ml of iodixanol at an iodine concentration of 320 mg/ml (iodixanol 320). Transient changes consistent with vasodilatation were observed in all patients. The greatest changes were observed during the time period 18-24 s after injection. Volume flow, mean velocity and pulsatility index all changed significantly from baseline (mean changes of 80.6%, 73% and -42.7% respectively). Peak systolic velocity did not change significantly. Intra-arterial injections of isotonic iodixanol 320 produces a significant increase in femoral blood flow in man. Factors other than hypertonicity must therefore be implicated in the vasodilatory effect of contrast media.