Cardiac pseudotumor: tissue characterization by cardiovascular magnetic resonance

We present serial cardiovascular magnetic resonance (CMR) in a case of cardiac pseudotumor (inflammatory myofibroblastic tumor). The diagnosis proved difficult and was helped by myocardial tissue characterization using CMR. Intrinsic contrast and extrinsic contrast (using gadolinium-DTPA perfusion, early and late imaging) differentiated between normal and pathological tissues and demonstrated the changes in properties of cardiac pseudotumor over time. The case illustrates the versatility of CMR in tissue characterization, which is unavailable by other cardiac imaging modalities.

Perimortem surgical intervention in cardiorespiratory arrest secondary to ruptured ovarian neoplasm

Perimortem caesarean section is the intervention of choice for unresponsive cardiorespiratory arrest during the third trimester of pregnancy. We present a case of emergent surgical intervention in an arrested patient with an abdominopelvic mass, which revealed a ruptured granulosa cell ovarian neoplasm with haemoperitoneum.

How to get on a SpR rotation in emergency medicine (and make the most of it)

Emergency medicine is now proving a popular specialty in the United Kingdom. A recent report ranks emergency medicine second in specialties attracting the most applications for specialist registrar (SpR) interview. Numbered posts are becoming increasingly competitive as a result. This paper offers advice to aspiring emergency department SpRs. It identifies areas in which a curriculum vitae may be improved. It should also enable emergency department trainees to set objectives for their early SpR years.

Meeting National Service Framework goals for patients presenting with acute myocardial infarction

BACKGROUND

The National Service Framework for coronary heart disease established clear standards for the management of patients with acute myocardial infarction in March 2000. This study evaluates an emergency department's thrombolysis performance in light of these standards.

SETTING

Inner city teaching hospital emergency department.

METHODS

The data were prospectively collected using a formal clinical pathway for all patients receiving thrombolysis in the emergency department between February 2000 and January 2001. Cases were reviewed at monthly multidisciplinary audit meetings. Regular feedback complemented routine teaching for both nursing and medical staff.

RESULTS

127 patients were thrombolysed, of whom 92 (72%) were immediately eligible. Some 77% of these had a door to needle time of less than 30 minutes and 38% less than 20 minutes. Twenty per cent of patients had a call to door time of less than 30 minutes. Some 84% of patients managed by the emergency department team had a door to needle time of less than 30 minutes compared with 53% of those patients seen by duty physicians.

CONCLUSIONS

The thrombolysis target set by the National Service Framework for April 2002 is achievable. The target set for April 2003 remains an ambitious goal. Overall call to needle times are undermined by call to door times. Emergency department teams may be more efficient than duty physicians in processing patients needing thrombolysis.

Activation and repression of transcription initiation in bacteria

Transcription initiation is the principal step at which bacterial gene expression is regulated. Bacterial transcription is due to a single multisubunit RNA polymerase. The potential transcription initiation rate of any promoter is set by the efficiency with which RNA polymerase recognizes the different promoter sequence elements. The sigma subunit plays the major role in the process of promoter recognition. Different RNA polymerase sigma subunits can guide RNA polymerase to different promoters. The E. coli genome encodes seven different sigma subunits, each of which allows the cell to respond to different environmental stimuli. A large number of transcription factors up-regulate and down-regulate expression from different promoters in response to environmental signals. Many transcription activators function by making a direct interaction with RNA polymerase. Some activators function by altering the conformation of promoter DNA. Most transcription repressors function by blocking access of RNA polymerase to their target promoter. In some cases, optimal repression depends on multiply bound repressor molecules that interact in complex ways. Many promoters are regulated by more than one transcription factor. A variety of mechanisms whereby a promoter can be regulated by a repressor and an activator, or by two activators, is known.

Recurrence and its avoidance in juvenile angiofibroma

OBJECTIVE

Angiofibroma is a highly vascular lesion for which a wide range of surgical approaches has been recommended. Irrespective of the approach, a significant and often rapid recurrence rate is reported in all major series.

AIM

To consider the impact of lessons learned from imaging on the recurrence rate of angiofibroma.

MATERIAL AND METHODS

From a cohort of 90 male patients with histologically proven angiofibroma, 40 individuals were studied. The recurrence rate in 20 cases treated before March 1998 was compared with that in 19 cases treated thereafter. In the latter group, an additional exploration of the basisphenoid had been undertaken.

RESULTS

The two cohorts were comparable in age range (7-27 y and 11-24 years, respectively), and all had been treated by midfacial degloving. In the first group, 8 recurrences occurred which were multiple in 1 patient. In the next 19 patients, the area of the pterygoid canal was meticulously explored and the basisphenoid drilled to remove all residual tumor. No recurrences have occurred in this group during a follow-up of between 6 months to 3 years.

CONCLUSION

Meticulous removal of angiofibroma infiltrating the pterygoid canal and basisphenoid is paramount to avoid "recurrence."

Serological evidence for the continued presence of human rickettsioses in southern India

Rickettsiosis is generally believed to have disappeared from many parts of India. However, the serological testing of 37 residents of southern India who presented with fever of unknown aetiology in 1996-1998 confirmed that spotted fever, epidemic/endemic typhus and scrub typhus continue to occur in southern India. The epidemiology and magnitude of the problem need to be evaluated.

Murray Valley encephalitis virus surveillance and control initiatives in Australia. National Arbovirus Advisory Committee of the Communicable Diseases Network Australia

Mechanisms for monitoring Murray Valley encephalitis (MVE) virus activity include surveillance of human cases, surveillance for activity in sentinel animals, monitoring of mosquito vectors and monitoring of weather conditions. The monitoring of human cases is only one possible trigger for public health action and the additional surveillance systems are used in concert to signal the risk of human disease, often before the appearance of human cases. Mosquito vector surveillance includes mosquito trapping for speciation and enumeration of mosquitoes to monitor population sizes and relative composition. Virus isolation from mosquitoes can also be undertaken. Monitoring of weather conditions and vector surveillance determines whether there is a potential for MVE activity to occur. Virus isolation from trapped mosquitoes is necessary to define whether MVE is actually present, but is difficult to deliver in a timely fashion in some jurisdictions. Monitoring of sentinel animals indicates whether MVE transmission to vertebrates is actually occurring. Meteorological surveillance can assist in the prediction of potential MVE virus activity by signalling conditions that have been associated with outbreaks of Murray Valley encephalitis in humans in the past. Predictive models of MVE virus activity for south-eastern Australia have been developed, but due to the infrequency of outbreaks, are yet to be demonstrated as useful for the forecasting of major outbreaks. Surveillance mechanisms vary across the jurisdictions. Surveillance of human disease occurs in all States and Territories by reporting of cases to health authorities. Sentinel flocks of chickens are maintained in 4 jurisdictions (Western Australia, the Northern Territory, Victoria and New South Wales) with collaborations between Western Australia and the Northern Territory. Mosquito monitoring complements the surveillance of sentinel animals in these jurisdictions. In addition, other mosquito monitoring programs exist in other States (including South Australia and Queensland). Public health control measures may include advice to the general public and mosquito management programs to reduce the numbers of both mosquito larvae and adult vectors. Strategic plans for public health action in the event of MVE virus activity are currently developed or being developed in New South Wales, the Northern Territory, South Australia, Western Australia and Victoria. A southern tri-State agreement exists between health departments of New South Wales, Victoria and South Australia and the Commonwealth Department of Health and Aged Care. All partners have agreed to co-operate and provide assistance in predicting and combatting outbreaks of mosquito-borne disease in south-eastern Australia. The newly formed National Arbovirus Advisory Committee is a working party providing advice to the Communicable Diseases Network Australia on arbovirus surveillance and control. Recommendations for further enhancement of national surveillance for Murray Valley encephalitis are described.

Hemodynamic responses to cold stress in blacks: effect of application site

Black Americans have been shown to exhibit increased blood pressure responses to a variety of physical stressors. However, few investigators have examined hemodynamic responses to cold stress. Additionally, no studies have compared blood pressure responses to forehead and foot stress in blacks. Therefore, in this study, hemodynamic responses to cold pressor tests were compared in 30 blacks (15 males, 15 females) utilizing two application sites. Baseline comparisons of systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), forearm blood flow (FBF) and forearm vascular resistance (FVR) were not different prior to forehead and foot cold stress. Following baseline measurements, ice was applied separately to the forehead and foot for 90 seconds with hemodynamic measurements being recorded at 45 and 90 seconds. During application of ice to the forehead, FVR-90 was significantly higher (P < .002, 97.0 units vs. 66.4 units) compared to the foot. The application of ice to the foot resulted in significantly greater SBP-45 responses (P < .0001, 147 mmHg vs. 139 mmHg), HR-45 responses (P < .0043, 80, b.min-1 vs. 69 b.min-1). HR-90 responses (P < .0001, 78 b.min-1 vs. 64 b.min-1), and FBF-45 responses (P < .05, 2.74 ml.min-1.100ml-1 vs. 1.98 ml.min-1.100ml-1). These findings suggest that blacks exhibit disparate patterns of reactivity in response to cold stress as a function of application site. Therefore, investigators should consider the application site when interpreting studies examining a biracial cohort.

Origin and spread of allergic fungal disease of the nose and paranasal sinuses

Although expansion of bony walls occurs in allergic fungal disease of the nose and paranasal sinuses by increased mucus secretion and fungal growth, the latter is apparently confined to the lumen and does not invade the tissues. Nevertheless, spread of the disease process from paranasal sinuses to orbit, cheek and intracranial cavity is well described. An imaging and histopathological study was carried out in 16 cases to determine how the disease originates and spreads. The infection starts in the nasal cavity, the lumen of a sinus or in a seromucinous gland or duct. A thin vascular zone of intense allergic inflammation surrounds the infected mucin. Erosion of bone takes place focally, probably by substances produced by the inflammatory tissue, allowing intromission by the thin vascular layer together with its underlying fungus-containing mucus and so extension of the disease process through the eroded bone.

Optimum imaging and diagnosis of cerebrospinal fluid rhinorrhoea

Imaging is an important component in the investigation of unilateral watery rhinorrhoea suspicious of cerebrospinal fluid (CSF). Whilst the demonstration of the presence of beta 2 transferrin confirms that CSF is present it may prove difficult to demonstrate the exact site of origin. Fine detail coronal computed tomography (CT) with sections of 1-2 mm thickness through the anterior skull base may show small dehiscences and fractures. The commonest site for congenital dehiscences is the cribriform niche adjacent to the vertical attachment of the middle turbinate anteriorly and the superior and lateral walls of the sphenoid posteriorly. In the presence of frequent or constant CSF rhinorrhoea a CT cisternogram can be helpful in defining the exact site of the leak. Magnetic resonance imaging (MRI) is reserved for defining the nature of soft tissue i.e. inflammatory tissue, meningoencephalocele or tumour. Finally, per-operative intrathecal fluorescein is helpful when imaging does not prove positive. A management algorithm for CSF rhinorrhoea is presented.

Transoesophageal echocardiography: its role in the management of patients in a district general hospital

The aim of this study was to assess the value of a transoesophageal echocardiography (TOE) service in a district general hospital (DGH). A series of 151 consecutive cases was analysed retrospectively to determine the relative additional benefit of TOE over transthoracic echocardiography (TTE) in establishing diagnoses and making therapeutic decisions. Of the 151 cases, 140 were suitable for the two procedures to be compared. In 56%, TOE provided useful information for patient management. This consisted of the detection of new major findings (33%) and the exclusion of significant abnormalities (23%), suspected either clinically or by TTE. TOE made a minor clinical contribution in 8% of cases, while in 30% there was concordance between the two studies. Finally, in 6% both examinations were inconclusive. We conclude that TOE has a significant complementary role to TTE in terms of clinical diagnosis and patient management in the DGH setting.

An audit of clinical nurse practitioner led thrombolysis to improve the treatment of acute myocardial infarction

BACKGROUND

The aim of the study was to audit the impact of cardiac nurse practitioner led thrombolysis as a method of reducing call to needle times for acute myocardial infarction (AMI) in a single district hospital.

METHODS

This was a prospectively planned, observational study, comparing time delay between arrival at hospital and the administration of thrombolysis ('door to needle' time) in patients presenting with AMI in a district general hospital serving a population of 270000. The 6 months before and 6 months after initiation of the scheme were compared.

RESULTS

There were 151 consecutive patients (undergoing 163 thrombolysis episodes). The median door to needle time fell from 60 min (range 42-110 min) to 30 min (range 20-61 min) (p<0.01). In those patients eligible for immediate thrombolysis the number of cases treated within 30 min of arrival rose from 10/58 (17 per cent) to 48/64 (75 per cent) (p<0.01). The proportion of cases where there was an initial delay as a result of non-diagnostic ECG or possible contra-indication to therapy remained constant, 20/78 (25 per cent) cases before and 21/85 (25 per cent) cases after initiation of the scheme. The number of cases of inappropriate thrombolysis fell from 73 per cent to 30 per cent.

CONCLUSION

The provision of i.v. thrombolysis by cardiac nurse practitioners is safe and should be considered as a method for achieving acceptable door to needle times in the management of acute myocardial infarction.

Optimum imaging for inverted papilloma

Inverted papilloma is the most common benign tumour of the nose and paranasal sinuses, and usually arises in the lateral wall of the nasal cavity and the middle meatus. The diagnosis is suggested on computed tomography (CT) when there is a mass continuous from the middle meatus into the adjacent maxillary antrum, through an expanded maxillary ostium. The mass may contain areas of high density or calcification, and there may be sclerosis of the wall of the affected sinus. The main advantage of magnetic resonance imaging (MRI) is in defining the extent of the tumour, and in differentiating it from adjacent inflammatory tissue, but there are no certain signal intensity or enhancement characteristics to help differentiate inverted papilloma from sinus malignancy. In the differential diagnosis, antro-choanal polyp, malignant sinus tumours and chronic rhinosinusitis and fungal disease need to be excluded. The combination of bone deformity and sclerosis with the typical antro-meatal mass suggests a slow-growing tumour such as inverted papilloma.

Chikungunya fever as a risk factor for endemic Burkitt's lymphoma in Malawi

The geographical and age distributions of endemic Burkitt's lymphoma (eBL), in Africa, parallel those of certain arboviruses, which include chikungunya fever. Increased incidences of antibodies to assorted arboviruses, including chikungunya, have been found in eBL sera compared to controls. An increased incidence and space-time case-clusters of eBL occurred during a chikungunya fever epidemic which were confirmed by serology and clinical observation. The present study, conducted in 1987-89, involved 108 eBL patients, and 97 local and 111 hospital controls. We examined, as hospital controls, patients with afebrile, non-malignant conditions admitted to Kamuzu Central Hospital, Malawi, during the eBL patients' first admission there. Analyses were for hospital controls and eBL patients at the end of their first admission and for local controls and eBL patients at the beginning of their third admission, about 8 weeks after the day of first admission, because of the local controls' temporal bias. Patients in case-clusters were among those seropositive for chikungunya virus, with a history compatible with arbovirus infection preceding the lymphoma, suggesting involvement of chikungunya virus in the case-clusters and a possible association between recent infection with this virus and development of the lymphoma. eBL patients were significantly more likely to be seropositive for chikungunya virus antibody (68x5%) than either hospital controls (46.8%) or local controls (50x5%) (P = 0x002 and 0x009, respectively), raising the possibility of an association between infection with an arbovirus and developing eBL in children already primed by holoendemic malaria and Epstein-Barr virus infection.

Imaging for juvenile angiofibroma

Juvenile angiofibroma presents characteristic imaging signs, may of which allow diagnosis and accurate estimation of extent without recourse to the dangers of biopsy. The diagnosis by computed tomography (CT) is based upon the site of origin of the lesion in the pterygopalatine fossa. There are two constant features: (1) a mass in the posterior nasal cavity and pterygopalatine fossa; (2) erosion of bone behind the sphenopalatine foramen with extension to the upper medial pterygoid plate. Good bone imaging on CT is essential to show invasion of the cancellous bone of the sphenoid. This is the main predictor of recurrence: the deeper the extension, the larger the potential tumour remnant likely to be left following surgery. The characteristic features on magnetic resonance imaging (MRI) are due to the high vascularity of the tumour causing signal voids and strong post-contrast enhancement. MRI shows the pre-operative soft tissue extent of angiofibroma optimally, but its more important application is to provide post-operative surveillance: to show any residual or recurrent tumour, record tumour growth or natural involution and monitor the effects of radiotherapy.

Communication skills training for emergency department senior house officers--a qualitative study

OBJECTIVE

To identify common weaknesses in senior house officer-patient consultation skills, and evaluate direct observation with feedback and negotiation of educational contracts, as a teaching tool in an emergency department setting.

METHOD

Common weaknesses were identified through review of feedback charts by three trained observers. Alteration in clinical and learning behaviour, as well as senior house officer and observer perceptions of the teaching were evaluated qualitatively by a combination of semistructured interviews and focus groups.

RESULTS

Several common weaknesses were identified, notably the use of closed questions, and poor negotiation and explanation of treatment plan and follow up. The senior house officers perceived improvement in their clinical practice, welcomed feedback, and subsequently set, though did not complete educational contracts. While comfortable with this style of teaching, the observers felt that it did not make efficient use of teaching time.

CONCLUSIONS

This study identifies common weaknesses in the consultation skills of emergency department senior house officers and confirms the need for training in this area. Direct observation is effective in changing behaviour to this end, though self directed learning is not necessarily stimulated. Video recorded consultations with group feedback may be a more effective teaching tool.

Optimum imaging for sinonasal malignancy

A combination of computed tomography (CT) and magnetic resonance imaging (MRI) is now established as the optimum assessment of sinonasal malignancy. CT and MRI are of particular value in assessing the skull base, orbit and pteryo-palatine and infratemporal fossae. Although MRI offers better differentiation of tumour from surrounding tissue and fluid, coronal CT is still required for the demonstration of bone erosion particularly in the region of the cribriform plate. Thus the extent of local tumour spread may be determined with a degree of accuracy in excess of 98 per cent. However, the final determinant of penetration of the dura and orbital periosteum requires per-operative frozen section assessment. A knowledge of the tissue characteristics and site of origin can be of value in distinguishing some of the commoner sinonasal malignancies such as squamous cell carcinoma, adenocarcinoma, adenoid cystic carcinoma, olfactory neuroblastoma and chondrosarcoma. Imaging, particularly MRI also plays an important role in the post-therapeutic follow-up of patients, indicating areas of residual or recurrent disease, defining suspicious areas for biopsy. Post-operative surveillance is best achieved with three planar T1-weighted MRI, with, and without, gadolinium and axial T2-weighted sequences. The subtraction of the T1 pre- and post gadolinium T1 sequences can be of particular value in delineating recurrence.

Imaging for endoscopic sinus surgery in adults

Computerized tomography (CT) offers the gold standard in terms of imaging the extent of disease and the fine detailed anatomy, both pre-requisites to the safe practice of endoscopic sinus surgery. Neither plain X-rays nor magnetic resonance imaging (MRI) offer optimal information in this respect. A variety of protocols minimizing radiation dose to the lens whilst providing high quality images are presented together with a menu of anatomical features that require careful evaluation pre-operatively.