Ultrasound as the first line investigation for midgut malrotation: a UK tertiary centre experience.

AIM: To present the first 22-months experience of transitioning to an ultrasound-first pathway for suspected midgut malrotation. MATERIALS AND METHODS: An "ultrasound-first" imaging pathway was initiated in October 2021. Twenty-two-months later, a search was undertaken of all <1-year-old patients with "bilious", "malrotation," or "volvulus" as the imaging indication. Reports and images from upper gastrointestinal fluoroscopy (UGI) and ultrasound were reviewed, and diagnoses and outcomes were documented. RESULTS: The search yielded 101 eligible cases between October 2021 and July 2023. Of the patients, 63/101 (62%) had both ultrasound and UGI: 47/63 (75%) ultrasound first, 16/63 (25%) UGI first. Thirty-one per cent (31/101) had ultrasound only and 7/70 (10%) UGI only. The pathway diagnosed 7/8 (88%) infants with midgut malrotation with or without volvulus and one infant who had an inconclusive ultrasound examination with a suspected an internal hernia and who was found to have malrotation volvulus at surgery. Twenty-one infants who had confidently normal ultrasound examinations and who also had UGI all had a normal duodenojejunal flexure position. Ultrasound detected alternative pathology in eight children. Duodenal visualisation improved with time: 6/15 (40%) in the first 6 months to 23/34 (68%) after the first year. CONCLUSION: The transition to ultrasound as the first diagnostic test for midgut malrotation can be done safely and effectively in a UK centre, which previously relied solely on UGI.

Early onset inflammatory bowel disease - What the radiologist needs to know.

Approximately 25% of Inflammatory Bowel Disease (IBD) patients present before the age of 18 years; early-onset IBD is defined as disease presenting before 10 years of age. Although early-onset disease is rare, it presents a particular challenge both in terms of treatment and diagnosis. There is a strong genetic component to these diseases and it is now possible to identify specific genetic mutations associated with certain patterns of early-onset IBD. All of these children require specific clinical work-up that is often performed at specialist centres. Young children with IBD, present a particular challenge to the radiologist because conventional bowel imaging techniques such as MR Enterography require general anaesthetic and other techniques such as CT or fluoroscopy must be carefully considered given the increased susceptibility to radiation in this young patient population. In this paper, we present a review of the aetiology, clinical work-up, differential diagnosis, and latest theories on the genetics of early-onset and very-early onset (<6 years) IBD. We also present our experience in the imaging of these children with particular focus on the difficulties and nuances that this group present to the radiologist.

Abnormalities of the craniovertebral junction in the paediatric population: a novel biomechanical approach.

The craniovertebral junction (CVJ) is the bony transition between the cranium and cervical spine. It is a biomechanically complex articulation comprising the occipital condyles (Oc) the atlas (C1) and axis (C2). Pathologies affecting the CVJ in children are myriad with clinical features resulting from biomechanical instability, deformity, or neuraxial compression. Establishing the natural history and clinical burden of a condition is challenging in infants and young children, often complicated by co-existing neuromuscular and cognitive impairment. This makes investigation and treatment planning difficult. Each disease entity has a predilection for a particular biomechanical abnormality. Investigation using dynamic imaging is most appropriate in instability, computed tomography examination in abnormalities of deformity and magnetic resonance imaging examination in neuraxial compression. Treatment comprises reduction and immobilisation of instability, re-alignment of deformity, or decompression of the neuraxis. We present a review of disease entities affecting the CVJ in children categorised according to a simple mechanistic approach to aid investigation and treatment planning.

Hay fever: pharmacotherapy or immunotherapy?

The total management of the patient with hay fever involves a multifaceted approach including environmental control, pharmacotherapy, and immunotherapy. Pharmacotherapy and immunotherapy are complementary methods which the allergist may utilize as appropriate to each individual patient's needs.

Ablation of luteal phase symptoms of Menière's disease with leuprolide.

Symptoms of Menière's disease in women may be exacerbated during the luteal phase of the menstrual cycle. This suggests a role for progesterone production and subsequent fluid redistribution as a predisposing factor for Menière's symptoms. We report the use of leuprolide acetate, a gonadotropin-releasing hormone agonist, in a woman with cyclic Menière's symptoms. This drug, which abolishes gonadotropin-dependent ovarian sex steroid production, alleviated the patient's symptoms during therapy. This observation offers further support to the hypothesis of sex hormone-related exacerbations of Menière's symptoms and provides a possible future treatment option for this debilitating disease.

Effects of pH and feeding regime on methylmercury accumulation within aquatic microcosms.

The effect of pH (pH 5, 6 or 7) on accumulation of radiolabelled methylmercury was examined using a laboratory microcosm system. Accumulation of labelled mercury at three trophic levels, primary consumers (Daphnia magna), secondary consumers (rainbow trout, Salmo gairdneri) and tertiary consumers (walleye, Stizostedion vitreum) was not significantly affected by pH. Our results are in direct contrast with field observations of elevated methylmercury concentrations in fish from low pH water and indicate that the elevated mercury residues observed in the field result from factors other than the direct effects of pH on accumulation of methylmercury by aquatic organisms. Both water and diet were important as sources of the labelled mercury which was accumulated by walleye. Walleye which were fed rainbow trout, that had accumulated labelled mercury from within the experimental microcosms, accumulated almost twice as much labelled mercury as walleye fed non-labelled prey, or walleye which were not fed. Walleye fed non-labelled rainbow trout accumulated slightly more labelled mercury than walleye which were not fed, presumably as a result of the higher metabolic rate of the fish which were fed.

In vitro effects of acephate on carbonic anhydrase activity in the blood and gills of rainbow trout, Salmo gairdneri.

Acephate, a water-soluble organophosphate pesticide used to control terrestrial insect pests, may enter aquatic ecosystems in the course of its use and adversely affect fish populations. The in vitro effects of this insecticide on gill and red blood cell (RBC) carbonic anyhdrase (CA) activity in rainbow trout were investigated over a range of 100 mg/1 (0.55 mM) to 50,000 mg/l (273 mM) to assess the manner in which acephate might affect respiratory capacity in exposed fish. Concentrations required to produce 50% inhibition of CA activity in the gill and RBC preparations were 38,000 mg/l (207 mM) and 8,900 mg/l (48 mM) respectively. The toxic action of acephate may be related to inhibition of CA activity in the blood and gills with resultant disturbances of respiratory capacity and salt balance.

The effect of radiotherapy in the treatment of adenoid cystic carcinoma of the head and neck arising in minor salivary glands.

Eighteen cases of adenoid cystic carcinoma of the minor salivary glands are reviewed. Noteworthy in the history is the report of pain at the site of the lesion which radiates elsewhere, or of numbers or tingling in its area. Radiation therapy is as able to control the primary as local surgery. Involvement of a much wider field than is required to treat the primary may control the perineural spread common to this tumor and avoid the massive procedures necessary to cure it by surgical means. Metastases to the lung, bone, and brain by venous spread can probably be avoided only by early diagnosis.

The activity of delta 5-3 beta hydroxysteroid dehydrogenase enzyme in the interrenal tissue of rainbow trout (Salmo gairdneri Richardson) exposed to sublethal concentrations of zinc.

The effects of exposure of rainbow trout (Salmo gairdneri Richardson) to three sublethal concentrations of zinc (0.248, 0.528 and 1.14 ppm) on delta 5-3 beta-hydroxysteroid dehydrogenase (delta 5-3 beta HSDH) enzyme activity in the head kidney tissue was investigated. The activity of this enzyme was localized by the reduction of a tetrazolium salt to formazan at the site of activity. Using subjective methods to indicate the degree of activity and indirectly assess the degree of corticosteroid production, the zinc-exposed rainbow trout showed a greater degree of delta 5-3 beta HSDH activity compared to the control fish. This increase in enzyme activity has been associated with the stimulation of the pituitary-interrenal axis by the noxious stress of zinc.

The effect of sublethal concentrations of zinc on growth and plasma glucose levels in rainbow trout, Salmo gairdneri (Richardson).

The long term effects of three sublethal concentrations of zinc (0.214, 0.52 and 1.12 ppm) on growth and plasma glucose concentration in yearling rainbow trout Salmo gairdneri (Richardson) were investigated. Analysis of covariance of percent weight increase revealed that a significant inhibition of growth (P less than 0.05) in the 1.12 ppm zinc-exposed fish had occurred. Plasma glucose showed a significant hyperglycemia (P less than 0.05) in all three zinc-exposed groups of fish after 7 days exposure and in the 1.12 ppm zinc-exposed group after 63 days. The hyperglycemia observed has been explained as possibly resulting from activation of the pituitary-interrenal axis by the stress of zinc causing mobilization of tissue glycogen.

The 1974 Gordon Richards Memorial Lecture: trends in the organization of cancer services.

The development of cancer programs and organizations in Canada is traced from their beginnings until the present time, and tribute is paid to our pioneers, of whom Dr. Richards was an outstanding example in this field. Although provinical cancer control measures vary, there is a marked similarity among some, so that they can be categorized into two or three patterns. The desirable requirements for the establishment and progressive development of cancer centres is described together with their relationship to increasing integration of teaching and research activities. An attempt is made to predict the future pattern of our "cancer clinic" system in which there will be increasing reliance on an interdisciplinary approach.