Gastric duplication presenting as a double esophagus

Duplications of the stomach are infrequent and, when present, usually become clinically manifest as an abdominal mass. Other clinical presentations have rarely been described. This report illustrates the case of a patient who presented with occult blood loss and radiographic evidence of esophageal duplication. A technetium scan demonstrated gastric duplication with mediastinal extension. Operative management and a review of the literature are described.

The fatty liver: pitfalls of the CT and angiographic evaluation of metastatic disease

Five patients with known primary malignancy demonstrated fatty infiltration of the liver on routine computed tomography (CT) examination. Within the diffuse fatty infiltration were focal areas of relatively increased beam attenuation in four cases. These areas of increased beam attenuation are nonspecific as to etiology. Their differential diagnosis is discussed. Since the true extent of the neoplastic process may be underestimated by conventional CT and celiac angiography, superselective angiography, computed angiotomography, or biopsy is required to accurately assess the etiology and the extent of the disease.

CT detection of hepatic metastases with Ethiodized Oil Emulsion 13

The use of an experimental liposoluble contrast agent-Ethiodized Oil Emulsion 13 (EOE 13)--is described in hepatic computed tomography (CT) of 23 oncologic patients. Without exception, all the hepatic metastases were better delineated in the EOE 13 enhanced scans. The postcontrast scans also detected an increased number of lesions but not all were malignant. There is no specificity to the increased lesion detection. Various splenic abnormalities were detected. Very few minor side effects and no major side effects were caused by the contrast media. We feel that with time, hepatic specific agents such as EOE 13 will become the contrast media of choice in hepatic CT examinations. Also, CT with hepatic specific agents may become the preoperative examination of choice in candidates for partial hepatectomy.

Imaging hepatic neoplasms

The various radiologic methods used in the detection of hepatic lesions in the oncologic patient are discussed. The advantages and disadvantages of each imaging technique as well as a new diagnostic approach are also discussed. With the rapid technological advances made in cross-sectional imaging, the authors believe that ultrasound and, whenever possible, computed tomography, should be used as the screening method.

Real-time ultrasonographic evaluation of normal fetal adrenal glands

Using real-time ultrasonography, the normal fetal adrenal glands can be consistently imaged after 30 weeks of gestational life. It was found that the normal fetal adrenals had specific size, shape, and echogenicity and could be consistently separated from the adjacent kidneys. The long axis of the adrenal gland had a range of 14 to 22 mm, compared with a range of renal lengths of 27 to 42 mm, with a ratio of the long axes of fetal adrenal to fetal kidney of .48 to .66. These figures compare favorably with dimensions of the adrenals and kidneys found in newborn autopsies. Since certain in utero abnormalities change the size and shape of normal fetal adrenal glands, these data should serve as a reference to evaluate adrenal disturbances. In addition, it would be expected that failure to image either the kidney or adrenal gland after 30 weeks would strongly imply abnormality in that gland.

Computed tomography and routine chest radiography in oat cell carcinoma of the lung

Computed tomography (CT) scans of the chest and routine postero-anterior and lateral chest films were compared in 32 patients with pathologically proven oat cell carcinoma of the lung. Nineteen of the 32 patients were examined prior to any form of therapy. Overall, CT gave more information about the extent of disease. The significance of this information may be of little value because the routine chest films also demonstrated mediastinal involvement, although to a lesser degree. Computed tomography of the chest should not be the initial diagnostic staging procedure in oat cell carcinoma, but used selectively. It can be quite useful in patients who have a partially opacified lung, possibly for the evaluation of mediastinum after therapy, and for the evaluation of possible abdominal metastases.

Post-therapy CT-detected mass in lymphoma patients: is it viable tissue?

The demonstration by computed tomography (CT) of enlarged nodes and/or masses in lymphoma patients has been interpreted as indicating that active disease is present. Four cases are presented in which either biopsy or laparotomy of a CT-detected mass after therapy revealed fibrous tissue with no evidence of viable neoplasm. These four cases demonstrate the possible pitfall of diagnosing viable lymphoma in masses detected by CT after therapy.

Thymic cyst of the neck

The diagnosis of a thymic cyst of the neck must be considered particularly in a male child with a mass that is lateral, soft, asymptomatic, and closely related to the carotid sheath. Although rare in the literature, this entity is probably more common than usually appreciated. A patient with this condition has been reported along with a review of previous publications on this subject.

Herbal remedies of the Maritime indians: sterols and triterpenes of Tanacetum vulgare L. (Tansy)

Plant sterols and triterpenes exhibit a wide range of pharmacological activities. As part of our ongoing studies of the medicinal aspects of Maritime flora, particularly the herbal remedies of the Micmac and Malecite Indians, we determined the nature of the sterols and triterpenes of Tanacetum vulgare L. (Compositae)-a widely used herbal remedy usually referred to as tansy. By using thin layer and gas chromatographics, nuclear magnetic resonance (NMR) spectroscopy and combined gas chromatography-mass spectrometry, we were able to identify beta-sitosterol as the major sterol and alpha-amyrin as the major triterpene of tansy. We also identified the sterols stigmasterol, campesterol and cholesterol, and the triterpenes beta-amyrin and taraxasterol. A fourth triterpene was tentatively identified as pseudo-taraxasterol. The successful therapeutic application of this herb may be due partly to the presence of one or more of these compounds. The sterols and triterpenes of tansy have not been previously reported; neither, to our knowledge, have the NMR spectra of the amyrins and the NMR and mass spectra of taraxasterol.

A simple ultrasonic method for assessing renal size

The relation between renal length (L) and the distance between the first four lumbar transverse processes, (4TP) as measured by sonography and intravenous urography, has been studied in 20 adults with normal urograms. The ratio of L/4TP (Mean +/- 2.S.D.) was 1.04 +/- 0.22 for sonograms and 1.25 +/- 0.26 for urograms. The possible reasons for these differences are discussed. It is suggested that measurement of the distance between the 4TP is a simple method for estimating expected normal renal size in patients referred for renal ultrasonography.

Porter training: the key is 'keep it practical'

Just over two years ago, Edward Lewis, personnel officer, Mid Glamorgan HA, described in the Journal how a training programme for head and deputy head porters was received in Wales. At that stage only the first module had been devised. Now with Nigel Bryant, lecturer in the department of management studies, Polytechnic of Wales, and William Brown, Welsh Office advisor, he reports on further progress.

Impaired sexual maturation associated with sleep apnea syndrome during puberty: a case study

A 20-year-old hypogonadal man was discovered to have had obstructive sleep apnea syndrome--secondary to hypertrophied tonsils, adenoids, and uvula--spanning the years of puberty. All-night polysomnographic recordings and 24 hr measurements of plasma luteinizing hormone (LH) concentrations (sampling at 20 min intervals) were performed before and after combined tonsillectomy, adenoidectomy, and uvulectomy. Two weeks preoperatively, nocturnal sleep was markedly disturbed by 407 apneic episodes, and the patient was found to be hypogonadotropic. Daytime LH concentrations were in the low-normal range for an adult male, and concentrations fell dramatically during nocturnal sleep. This contrasts with both the sleep-related elevation of LH normally seen in puberty and the adult pattern, where no difference is observed in mean concentrations during waking and sleep. Two week and 6 month postoperative evaluations revealed complete alleviation of the sleep apnea syndrome and normalization of the 24 hr pattern of plasma LH, although LH values remained in the low-normal range. Plasma testosterone concentrations were in the low to low-normal range both pre- and postoperatively. No evidence of continued sexual development, beyond that achieved preoperatively, was observed 20 months after surgery, despite continued relief from apnea. These data suggest that sleep apnea during puberty may impair sexual development by preventing the sleep-related elevation in LH secretion normally observed during a critical period spanning puberty.

Nonvisualization of the left lobe of the liver due to atrophy or aplasia

Aplasia or atrophy of the left lobe of the liver may result in a liver scan appearance easily misinterpreted as showing evidence of tumor involvement. Three illustrative cases of the phenomenon are presented.

Inhibition of mourning by pregnancy: psychopathology and management

A bereavement during pregnancy is difficult to mourn: a pregnant woman is so increasingly preoccupied with the new life that mourning is interrupted and often impossible to resume later. This may lead to idealisation of the child as a reincarnation of the dead person or child abuse. A bereaved woman should be helped to mourn at the time of death and to keep alive the expectation of future mourning once her baby is thriving.

Mourning by the family after a stillbirth or neonatal death

Failure of the parents to mourn after the sorrow of a stillbirth or neonatal death can result in dire consequences for the well-being of the family. Doctors and nurses should learn how to facilitate mourning and should accept the strange and sometimes bizarre forms this may take. When mourning is facilitated, the family is likely to adjust better to its bereavement.

Violence: outside the safety of the hospital

The DHSS has issued guidelines on how to deal with violent and potentially violent patients in hospital. Author argues that it fails to give effective advice to ancillary staff dealing with patients in casualty departments and outside the hospital.

Failure to mourn a stillbirth: an overlooked catastrophe

The reasons for the difficulty of mourning a stillbirth and the therapeutic management of this mourning process are outlined. A case is described of failed mourning of a stillbirth which gave rise to a profound disturbance in mothering of a subsequent live baby. A psychotherapeutic technique is discussed which facilitates the failed mourning of a stillbirth.

The management of stillbirth: coping with an unreality

With about 1 stillbirth occurring in every 80 deliveries, stillbirth is a common tragedy. Yet it is an event which, by common consent, is cloaked in secrecy, and which by its very nature seems unreal. There are thus strong forces operating on the bereaved mother and her family, and on the professionals who care for them, to keep the crisis of stillbirth hidden away, therby in fact hindering the mourning and healing process. Bourne has produced statistical evidence to show that family docotrs are astonishingly reluctant to know or remember anything about the patient who has had a stillbirth. I would like to put forward some suggestions for helping doctors to overcome their reluctance to face the problem of stillbirth.

Loss of low-level antibiotic resistance in Neisseria gonorrhoeae due to env mutations

Mutations (env) which resulted in increased sensitivity of gonococci to diverse compounds were studied by transformation. Strains carrying an env mutation were more sensitive than wild-type strains to several antibiotics, dyes, and detergents. The env mutations resulted in complete phenotypic suppression of low-level resistance to these same drugs determined by mutation at ery. Recombination was observed in transformation crosses between various env mutants. The env locus was not linked to the cluster of antibiotic resistance genes near str and spc.

Public health and the urban gray squirrel: mycology

From 180 gray squirrels (Sciurus c. carolinesis), 942 isolates of fungi representing 19 genera were recovered upon culture of hair-skin scrapings and toenails. Of the isolates, 170 represented known human pathogens and 142, squirrel pathogens. A human infection of Trichophyton mentagrophytes was derived from handling the squirrels. Skin lesions of seven squirrels were attributable to T. mentagrophytes and Mucor sp.

Variation in the properties of a strain of Staphylococcus aureus isolated over three months from a single hospital

A strain of Staphylococcus aureus has been isolated from a hospital environment over 3 months. Every isolate was lysed by phage 77, had high-level resistance to streptomycin, and was resistant to about 250 pg per ml of both tetracycline and sulphonamide; a combination of sulphamethoxazole and trimethoprim produced little bacteristatic synergy towards each isolate. All These organisms were thus considered to be "the same"; the variation in other properties was probably due to rapid evolutionary change in vivo. the variation in senxitivity to methicillin and neomycin, and the absence of penicillinase production in some isolates, probably indicated loss of the relevant genes. Several isolates had probably acquired resistance to lincomycin by a one-step mutatuon in vivo. The usefulness of lincomycin and analogues in treating staphylococcal infections seems limited.

Comparison of the effect of various antisera and cobra venom factor on inflammatory reactions in guinea-pig skin. II. The Arthus reaction and the local Shwartzman reaction

The ability of antisera to guinea-pig C3 to inhibit the Arthus and local Shwartzman reactions was studied. They were found to reduce the non-haemorrhagic component of the active and reversed passive Arthus reactions and to delay the appearance of the haemorrhage in the active Arthus reaction. Cobra venom factor, however, had no effect on the non-haemorrhagic components of these reactions and only delayed the appearance of the haemorrhage of the active Arthus reaction. There appeared to be a correlation between the serum complement level and the time taken for the haemorrhage to appear, and between the circulating platelet count and the extent of the non-haemorrhagic, oedematous component of the reaction. The haemorrhagic component of the local Shwartzman reaction was not affected by decomplementation with cobra venom factor. The ability of the antisera to inhibit the haemorrhage of the Shwartzman reaction was not dependent on lowering the serum complement titre. However, the haemorrhage was inhibited if the circulating platelet count was also reduced to very low numbers. Antiserum to zymosan alone had the same effect as anti-beta1C/beta1A globulin (zymosan) in blocking the reaction, although it did not alter the complement levels or the platelet counts. The possibility of an immunological cross-reactivity between zymosan and endotoxin in this action is discussed.

Comparison of the effect of various antisera and cobra venom factor on inflammatory reactions in guinea-pig skin. I. Non-specific inflammation due to the intradermal injection of turpentine

Guinea-pigs were treated with agents which lowered the serum complement levels and the effect on the inflammatory reaction to intradermal turpentine was studied. A comparison was made between two antisera to beta1C/beta1A globulin which had been prepared in different ways. One was made using C3 fixed to zymosan particles as the antigen, and the other using chemically extracted beta 1C/beta1A globulin. The antisera to beta1C/beta1A globulin (zymosan) was found to have the greater anti-inflammatory activity. The effect of each on the parameters of complement studied, and on the circulating platelet count, was much the same. An antiserum to serum factors fixed to zymosan during C3 activication was prepared free of anti-beta1C/beta1A globulin antibodies. This was found to have some of the anti-inflammatory activity of the anti-beta1C/beta1A globulin (zymosan), as well as lowering total complement levels. Anti-gamma globulin andheterologous immune complexes also lowered serum complement levels and were antiinflammatory. However, all the above agents were also found to reduce the number of circulating platelets. This was in contrast to CVF which reduced complement levels by 90 per cent. but had no effect on platelet numbers. CVF also reduced the inflammatory response but was no more effective than the other agents. In view of these findings a role for the participation of the complement system, possibly involving the alternate pathway of activation of C3, is discussed as well as the participation of platelets in the reaction.