HIV and Pneumocystis Jiroveci Pneumonia (PJP) Managed With Extracorporeal Membrane Oxygenation (ECMO)

Presentation A 40-year-old Irish female presented with a new diagnosis of HIV, advanced immunosuppression and severe respiratory failure. Diagnosis Patient was subsequently diagnosed with Pneumocystis jiroveci Pneumonia (PJP). Treatment The patient was treated for HIV and PJP and required mechanical ventilation. She continued to deteriorate and veno-venous Extracorporeal Membrane Oxygenation (V-V ECMO) was deployed in her management after 18 days of mechanical ventilation. Conclusion HIV presenting with extensive pneumonia secondary to PJP and advanced immunosuppression is still a treatable condition. All available respiratory support including ECMO should be considered for patients even if they have been on mechanical ventilation for more than 7 days.

Medium term review of the ASR implant system: A single surgeon series

INTRODUCTION

Both ASR hip resurfacings and stemmed ASR XL arthroplasties have failed at high rates in several published series. We assessed a single surgeon series of these arthroplasties looking to identify factors associated with their failure.

METHODS

All surgeries were performed by one surgeon. Patients were evaluated clinically, radiologically and with serial cobalt and chromium ion analysis.

RESULTS

274 implants were analysed - 152 ASR resurfacings and 122 ASR XL implants. Thirty revisions were performed.

CONCLUSION

The failure rate of the ASR implant in our series is unacceptably high - its use in routine hip arthroplasty cannot be supported.

Role of vascular channels as a novel mechanism for subchondral bone damage at cruciate ligament entheses in osteoarthritis and inflammatory arthritis

OBJECTIVES

The purpose of this work was to test whether normal peri-entheseal vascular anatomy at anterior and posterior cruciate ligaments (ACL and PCL) was associated with distribution of peri-entheseal bone erosion/bone marrow lesions (BMLs) in inflammatory arthritis (IA) and osteoarthritis (OA).

METHODS

Normal microanatomy was defined histologically in mice and by 3 T MRI and histology in 21 cadaveric knees. MRI of 89 patients from the Osteoarthritis Initiative and 27 patients with IA was evaluated for BMLs at ACL and PCL entheses. Antigen-induced arthritis (AIA) in mice was evaluated to ascertain whether putative peri-entheseal vascular regions influenced osteitis and bone erosion.

RESULTS

Vascular channels penetrating cortical bone were identified in knees of non-arthritic mice adjacent to the cruciate ligaments. On MRI of normal cadavers, vascular channels adjacent to the ACL (64% of cases) and PCL (71%) entheses were observed. Histology of 10 macroscopically normal cadaveric specimens confirmed the location of vascular channels and associated subclinical changes including subchondral bone damage (80% of cases) and micro-cyst formation (50%). In the AIA model, vascular channels clearly provided a site for inflammatory tissue entry and osteoclast activation. MRI showed BMLs in the same topographic locations in both patients with early OA (41% ACL, 59% PCL) and IA (44%, 33%).

CONCLUSION

The findings show that normal ACL and PCL entheses have immediately adjacent vascular channels which are common sites of subtle bone marrow pathology in non-arthritic joints. These channels appear to be key determinants in bone damage in inflammatory and degenerative arthritis.

Potential role of the posterior cruciate ligament synovio-entheseal complex in joint effusion in early osteoarthritis: a magnetic resonance imaging and histological evaluation of cadaveric tissue and data from the Osteoarthritis Initiative

OBJECTIVE

This study explored posterior cruciate ligament (PCL) synovio-entheseal complex (SEC) microanatomy to determine whether it may participate in the early osteoarthritis (OA) disease process.

METHODS

SEC microanatomy and OA features were evaluated in 14 non-arthritic cadaveric knees (mean age = 69.9) using magnetic resonance imaging (MRI) and histology. MRI images of 49 subjects selected from the progression cohort of the Osteoarthritis Initiative (OAI) were evaluated by a musculoskeletal radiologist using an original semi-quantitative method for features associated with OA at the PCL tibial enthesis. Statistical analysis was performed using chi-square and Wilcoxon signed-rank tests to evaluate associations between SEC configuration and OA features.

RESULTS

The PCL formed a SEC-like structure encompassing bone- and ligament-lining intra-articular cartilages to which the posterior root of the medial meniscus contributed. Degenerative features at the PCL-SEC included: neovascularisation (44%), enthesis chondrocyte clustering (44%), collagen matrix fissuring at the enthesis (56%) and in the PCL itself (67%), tidemark duplication (44%), bone remodelling (44%) and microscopic inflammatory changes (33%). In the OAI cohort, SEC-related pathology included bone marrow lesions (BMLs) (69%) and osteophytosis (94%) at locations that corresponded to SEC-related cartilages. Posterior joint recess effusion (49%) was linked to MRI abnormalities at PCL-SEC cartilages (χ2 = 7.27, P = 0.007).

CONCLUSIONS

The PCL has a prominent SEC configuration that is associated with microscopic OA changes in aged clinically non-diseased joints. MRI determined knee OA commonly exhibited pathological features at this site which was associated with adjacent joint effusion. Thus, the PCL-SEC could play a hitherto unappreciated role in the early OA disease process.

'Ready-access' CT imaging for an orthopaedic trauma clinic

'Ready-Access' to CT imaging facilities in Orthopaedic Trauma Clinics is not a standard facility. This facility has been available at the regional trauma unit, in Merlin Park Hospital, Galway for the past four years. We reviewed the use of this facility over a 2-year period when 100 patients had CT scans as part of their trauma clinic assessment. The rate of CT scan per clinic was 0.6. The mean waiting time for a CT scan was 30 minutes. 20 (20%) new fractures were confirmed, 33 (33%) fractures were out-ruled, 25 (25%) fractures demonstrated additional information and 8 (8%) had additional fractures. 20 (20%) patients were discharged and 12 (12%) patients were admitted as a result of the CT scan. It adds little time and cost to CT scanning lists.

MRI detection of a female pelvic arteriovenous fistula after hysterectomy: treatment with superselective coil embolisation

We present a rare case of acquired pelvic arteriovenous fistula of the uterine vessels in a woman with a remote history of hysterectomy who presented with chronic pelvic and left limb pain. It was successfully treated by coil embolisation of the left uterine artery. The MRI and angiographic features are described, together with the current management and a review of literature.

A meta-analysis study of the effect of chilling on prevalence of Salmonella on pig carcasses

In the field of food safety, meta-analysis can be used to combine results of prevalence studies of pathogens at critical stages within the food processing chain so that policy makers can access reliable and concise information on the effectiveness of interventions for controlling and preventing foodborne illnesses in humans. The objective of this work was to demonstrate the applicability of a parametric approach of meta-analysis to the specific case of determining the overall effect of chilling on Salmonella prevalence on pig carcasses. A meta-analysis was performed on each of two parameters measuring effect size for binary outcomes (relative risk and risk difference). Both meta-analyses confirmed that the chilling operation has a significant beneficial effect (P < 0.001) on the reduction of Salmonella prevalence on pig carcasses. Because risk difference is a parameter sensitive to the differences across studies in carcass swab areas and Salmonella detection methods, its meta-analysis highly reflected this heterogeneity (P < 0.001). However, parameterization of relative risk, not being biased by the above sources of variability, did not give rise to heterogeneity among studies and produced a fixed-effects meta-analysis solution, which is deemed more suitable for compilations based on a small number of individual studies (n = 9). Because of the systematic approach of meta-analysis (i.e., individual studies are weighed according to precision) and its reliance for actual data, the output distribution of the relative risk effect size (approximately eN(-0.868,0.166)) merits consideration for inclusion in the chilling stage of quantitative risk assessments modeling the prevalence of this pathogen along the pork production chain.

Paraovarian adrenal rest with MRI features characteristic of an adrenal adenoma

We report MR and sonographic imaging features of an incidentally detected paraovarian adrenal rest in a 44-year-old woman who was being evaluated for menorrhagia. This is the first report of chemical shift imaging identifying the presence of lipid within an adrenal rest as well as rapid washout of contrast. Both of these MR characteristics are typically seen with an adrenal adenoma.

Indirect magnetic resonance arthrography

Indirect MR arthrography is useful for evaluation of joints such as the elbow, wrist, ankle and shoulder where there is a large synovial surface area relative to joint volume. It allows simultaneous assessment of both intra-articular and extra-articular soft tissues with the added advantage of minimal invasiveness. The established and potential uses of this imaging technique are reviewed below and the pathology that is demonstrated by this technique is discussed.

The "dependent viscera" sign in CT diagnosis of blunt traumatic diaphragmatic rupture

OBJECTIVE

The objective of our study was to describe the "dependent viscera" sign and determine its usefulness at CT in the diagnosis of diaphragmatic rupture after blunt abdominal trauma.

MATERIALS AND METHODS

The study sample consisted of 28 consecutive patients (19 men, nine women) between 17 and 74 years old (mean age, 31 years) who had undergone abdominal CT and subsequent emergency laparotomy after a blunt trauma. Ten patients had a diaphragmatic rupture (six, right-sided; four, left-sided) at laparotomy. An experienced radiologist unaware of the surgical findings retrospectively reviewed the CT scans, and then a second radiologist reviewed the scans to provide interobserver agreement. Note was made of discontinuity of the diaphragm, intrathoracic herniation of abdominal contents, and waistlike constriction of bowel (the collar sign). Also noted was whether the upper one third of the liver abutted the posterior right ribs or whether the bowel or stomach lay in contact with the posterior left ribs. Either of these findings was termed the "dependent viscera" sign. The radiologists' detection rate of diaphragmatic rupture on the CT scans via observance of the dependent viscera sign was determined. Interobserver agreement was assessed using Cohen's kappa statistic.

RESULTS

The dependent viscera sign was observed on the CT scans of 100% of the patients with a left-sided diaphragmatic rupture and of 83% of the patients with right-sided diaphragmatic rupture. Both observers missed one case of right-sided diaphragmatic rupture. The radiologists' overall rate of detecting diaphragmatic rupture was 90% using the dependent viscera sign. We found excellent interobserver agreement (kappa = 1) for detection of the dependent viscera sign and for the diagnosis of diaphragmatic tear on CT scans.

CONCLUSION

The dependent viscera sign increases the detection at CT of acute diaphragmatic rupture after blunt trauma.

Power Doppler ultrasound assessment of rheumatoid hand synovitis

OBJECTIVE

To evaluate power Doppler ultrasound (PD) as a technique in assessing response to treatment with steroids in rheumatoid hand synovitis.

METHODS

Twelve patients with rheumatoid hand synovitis were assessed before and after treatment with steroids. Variables used to assess synovitis activity in each patient included patient visual analog scale (VAS) score for pain, physician assessment score (PAS), erythrocyte sedimentation rate (ESR), and PD of the metacarpophalangeal joints.

RESULTS

Nine female and 3 male patients were studied; mean age was 53.3+/-6.5 yrs and mean disease duration 6.5+/-4.5 yrs. All patients had a good clinical response to steroid treatment and there was a significant improvement in the synovitis activity assessments. Wilcoxon signed-rank test using the exact method was applied to the change in disease activity variables. For PD signal, p < 0.002; VAS, p < 0.0016; ESR, p < 0.031; PAS, p < 0.008.

CONCLUSION

PD quantifies synovitis and may be a useful adjunct to disease assessment and the response to treatment in RA.

MR imaging of bone tumors of the cervical spine

MR Imaging has altered radically the detection, characterization, and the staging of bone tumors. This article reviews MR imaging techniques and appearances of benign and malignant bone tumors that are encountered in the cervical spine.

An immunohistochemical study of papillary tumors in the central nervous system

An immunohistochemical study was performed on the paraffin sections of 25 tumors in the central nervous system (CNS) with prominent papillary configurations. These tumors included seven metastatic papillary carcinomas, six choroid plexus tumors, four papillary ependymomas, two myxopapillary ependymomas, two papillary pituitary adenomas, two astroblastomas, one papillary meningioma, and one anaplastic astrocytoma with significant papillary changes. The panel of antibodies applied included anti-glial fibrillary acidic protein (GFAP), anti-carcinoembryonic antigen (CEA), anti-vimentin (VM), anti-S-100 protein (S-100 P), anti-cytokeratin, and anti-prealbumin antisera. All ependymomas and astroblastomas examined expressed both VM and GFAP, which were either absent or focally expressed in choroid plexus tumors. In contrast, all choroid plexus tumors showed anti-cytokeratin immunoreactivity that was absent in the ependymomas and astroblastomas. Five choroid plexus tumors also expressed S-100 P, thus differentiating them from metastatic carcinoma that showed negative immunostaining. Anti-CEA antisera immunoreactivity was seen in six metastatic tumors, whereas none of the primary CNS tumors expressed CEA. Prealbumin was expressed in four choroid plexus tumors and two metastatic tumors. Immunohistochemical typing using a panel of antibodies has allowed the differentiation of most of the papillary tumors in the CNS examined in this study.

An immunohistochemical study of papillary tumors in the central nervous system

An immunohistochemical study was performed on the paraffin sections of 25 tumors in the central nervous system (CNS) with prominent papillary configurations. These tumors included seven metastatic papillary carcinomas, six choroid plexus tumors, four papillary ependymomas, two myxopapillary ependymomas, two papillary pituitary adenomas, two astroblastomas, one papillary meningioma, and one anaplastic astrocytoma with significant papillary changes. The panel of antibodies applied included anti-glial fibrillary acidic protein (GFAP), anti-carcinoembryonic antigen (CEA), anti-vimentin (VM), anti-S-100 protein (S-100 P), anti-cytokeratin, and anti-prealbumin antisera. All ependymomas and astroblastomas examined expressed both VM and GFAP, which were either absent or focally expressed in choroid plexus tumors. In contrast, all choroid plexus tumors showed anti-cytokeratin immunoreactivity that was absent in the ependymomas and astroblastomas. Five choroid plexus tumors also expressed S-100 P, thus differentiating them from metastatic carcinoma that showed negative immunostaining. Anti-CEA antisera immunoreactivity was seen in six metastatic tumors, whereas none of the primary CNS tumors expressed CEA. Prealbumin was expressed in four choroid plexus tumors and two metastatic tumors. Immunohistochemical typing using a panel of antibodies has allowed the differentiation of most of the papillary tumors in the CNS examined in this study.

The use of propoxyphene napsylate in the treatment of heroin and methadone addiction

The use of methadone in the treatment of heroin addiction continues to be controversial. Propoxyphene napsylate (Darvon N(R)) is a possible alternative and a pilot study was conducted to test its acceptability, safety and clinical efficacy in treating long term, "multi-relapse" heroin addicts. Findings indicate that propoxyphene napsylate suppresses many of the symptoms associated with opioid withdrawal phenomena. It should be viewed as a very promising therapeutic tool to be used in conjunction with psychological counseling and socio-vocational rehabilitation in detoxification and maintenance therapy for heroin or methadone addiction.