The European Rare Disease Network for HHT Frameworks for management of hereditary haemorrhagic telangiectasia in general and speciality care

Hereditary haemorrhagic telangiectasia (HHT) is a complex, multisystemic vascular dysplasia affecting approximately 85,000 European Citizens. In 2016, eight founding centres operating within 6 countries, set up a working group dedicated to HHT within what became the European Reference Network on Rare Multisystemic Vascular Diseases. By launch, combined experience exceeded 10,000 HHT patients, and Chairs representing 7 separate specialties provided a median of 24 years' experience in HHT. Integrated were expert patients who focused discussions on the patient experience. Following a 2016-2017 survey to capture priorities, and underpinned by more than 40 monthly meetings, and new data acquisitions, VASCERN HHT generated position statements that distinguish expert HHT care from non-expert HHT practice. Leadership was by specialists in the relevant sub-discipline(s), and 100% consensus was required amongst all clinicians before statements were published or disseminated. One major set of outputs targeted all healthcare professionals and their HHT patients, and include the new Orphanet definition; Do's and Don'ts for common situations; Outcome Measures suitable for all consultations; COVID-19; and anticoagulation. The second output set span aspects of vascular pathophysiology where greater understanding will assist organ-specific specialist clinicians to provide more informed care to HHT patients. These cover cerebral vascular malformations and screening; mucocutaneous telangiectasia and differential diagnosis; anti-angiogenic therapies; circulatory interplays between anaemia and arteriovenous malformations; and microbiological strategies to counteract loss of normal pulmonary capillary function. Overall, the integrated outputs, and documented current practices, provide frameworks for approaches that augment the health and safety of HHT patients in diverse health-care settings.

Development of gynecomastia following initiation of bictegravir/emtricitabine/tenofovir alafenamide

Bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) is a recently approved single-tablet antiretroviral regimen and is recommended as a first-line agent. No cases of gynecomastia were reported in clinical trials. We report development of ultrasound-confirmed gynecomastia in a previously antiretroviral-naïve patient approximately two months after starting BIC/FTC/TAF, which resolved ten weeks after discontinuing bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) based therapy.

Diffusion tensor imaging reveals changes in microstructural integrity along compressed nerve roots that correlate with chronic pain symptoms and motor deficiencies in elderly stenosis patients

Age-related degenerative changes in the lumbar spine frequently result in nerve root compression causing severe pain and disability. Given the increasing incidence of lumbar spinal disorders in the aging population and the discrepancies between the use of current diagnostic imaging tools and clinical symptoms, novel methods of nerve root assessment are needed. We investigated elderly patients with stenosis at L4-L5 or L5-S1 levels. Diffusion tensor imaging (DTI) was used to quantify microstructure in compressed L5 nerve roots and investigate relationships to clinical symptoms and motor neurophysiology. DTI metrics (i.e. FA, MD, AD and RD) were measured at proximal, mid and distal segments along compressed (i.e. L5) and intact (i.e. L4 or S1) nerve roots. FA was significantly reduced in compressed nerve roots and MD, AD and RD were significantly elevated in the most proximal segment of the nerve root studied. FA was significantly correlated with electrophysiological measures of root function: minimum F-wave latency and peripheral motor conduction time (PMCT). In addition, FA along the compressed root also correlated with leg pain and depression score. There was also a relationship between RD and anxiety, leg pain and disability score and AD correlated with depression score. Taken together, these data show that DTI metrics are sensitive to nerve root compression in patients with stenosis as a result of age-related lumbar degeneration. Critically, they show that the changes in microstructural integrity along compressed L5 nerve roots are closely related to a number of clinical symptoms associated with the development of chronic pain as well as neurophysiological assessments of motor function. These inherent relationships between nerve root damage and phenotype suggest that the use DTI is a promising method as a way to stratify treatment selection and predict outcomes.

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DTI can be used to quantify lumbar spinal nerve root compression in elderly patients.

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Diffusion parameters correlate with functional neurophysiology and clinical symptoms.

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DTI has the potential to be used to predict treatment outcomes.

Relationships between the integrity and function of lumbar nerve roots as assessed by diffusion tensor imaging and neurophysiology

Purpose

Diffusion tensor imaging (DTI) has shown promise in the measurement of peripheral nerve integrity, although the optimal way to apply the technique for the study of lumbar spinal nerves is unclear. The aims of this study are to use an improved DTI acquisition to investigate lumbar nerve root integrity and correlate this with functional measures using neurophysiology.

Methods

Twenty healthy volunteers underwent 3 T DTI of the L5/S1 area. Regions of interest were applied to L5 and S1 nerve roots, and DTI metrics (fractional anisotropy, mean, axial and radial diffusivity) were derived. Neurophysiological measures were obtained from muscles innervated by L5/S1 nerves; these included the slope of motor-evoked potential input-output curves, F-wave latency, maximal motor response, and central and peripheral motor conduction times.

Results

DTI metrics were similar between the left and right sides and between vertebral levels. Conversely, significant differences in DTI measures were seen along the course of the nerves. Regression analyses revealed that DTI metrics of the L5 nerve correlated with neurophysiological measures from the muscle innervated by it.

Conclusion

The current findings suggest that DTI has the potential to be used for assessing lumbar spinal nerve integrity and that parameters derived from DTI provide quantitative information which reflects their function.

Acute neuromedical and neurosurgical admissions: Standard and ultrafast MR imaging of the brain compared with cranial CT

Purpose: To evaluate the role of standard and ultrafast MR brain imaging and compare the information with CT.

Material and Methods: This was a prospective study of 114 patients with acute neurological symptoms and signs. CT brain examinations consisted of axial non-enhanced images. MR imaging consisted of standard spin-echo/fast spin-echo sequences and a series of rapid techniques including echoplanar and single shot fast spin-echo sequences.

Results: Using standard MR methods, 41% of the patients had all five sequences of good technical quality, while using ultrafast methods 81% of the patients had good technical quality examinations in all five sequences. In 3% of the cases, ischaemic stroke was incorrectly reported on CT. In 24% of the cases, MR gave extra diagnostic information not reported on CT and in a further 8%, one neuroradiologist reported the abnormality in agreement with the MR, whilst the other neuroradiologist reported the CT as normal. In 2 cases, subarachnoid haemorrhage was missed on MR. Subarachnoid haemorrhage was not shown on the ultrafast sequences.

Conclusion: MR can be used to image acute neurological admissions with a high success rate, particularly using ultrafast methods. In many cases, MR provided extra information of direct clinical relevance not shown on CT.

3-(2-Chloro-3-hy-droxy-4-meth-oxy-phen-yl)-1-(4,5-dimeth-oxy-2-methyl-phen-yl)prop-2-en-1-one

The title compound, C(19)H(19)ClO(5), is a chloro derivative of a biologically significant chalcone family. The mean plane of the two substituted benzene rings are twisted by 55.33 (8)° with respect to each other. An intra-molecular C-H⋯Cl hydrogen bond generates an S(5) graph-set motif. In the crystal, a bifurcated O-H⋯(O,O) hydrogen bond leads to an R(1) (2)(5) graph-set motif and to the formation of zigzag chains propagating along the c-axis direction. A weak π-π inter-action involving the methyl-phenyl rings [centroid-centroid distance = 3.8185 (10) Å] and C-H⋯π inter-actions also occur.

The prevalence of traumatic dental injuries to permanent anterior teeth and its relation with predisposing risk factors among 8-13 years school children of Vadodara city: an epidemiological study

BACKGROUND AND OBJECTIVE

dental trauma is an irreversible pathology that after occurrence is characterized by life-long debilitating effects. The objectives of this study were to measure the prevalence of anterior teeth fracture and their association with predisposing factors such as lip coverage, molar relationship, overjet, and variables such as age, sex, cause, and place of trauma.

MATERIALS AND METHODS

an epidemiological cross-sectional study was carried out among 3708 school children aged 8-13 years in the Vadodara city. All children completed a questionnaire related to history of trauma to their anterior teeth after which they were examined for lip competence, Angle's molar relationship amount of overjet and nature of trauma sustained. The results were statistically analyzed using the prevalence test, Chi-square test, and Mantel-Haenszel Common Odds Ratio.

RESULTS

the prevalence of traumatic injuries was 8.79% and the ratio of boys: girl's was 1.28:1. Inadequate lip coverage group sustained about five times more injuries than the adequate lip coverage group (P = 0.000, OR= 5.407). The maximum traumatic injuries were seen in children having Angle Class II Div 1 molar relationship and/or overjet greater than 5.5 mm and was statistically significant (P<0.05). Maximum number of injuries occurred at 9 years of age. The most predominant injuries were enamel fractures, the most common place for occurrence was home and fall against object, the most frequent cause.

CONCLUSION

the prevalence of dental injuries in the Vadodara city is high and it has a great potential to be considered as an emerging public health problem.

Making a jigsaw puzzle in 10 minutes: is case management feasible in general practice?

Background Case management has been advocated as a method of optimising the care of patients with complex problems and reducing inappropriate use of hospital services, but its impact to date has been limited. It is not known whether case management earlier in the development of complex problems will be more effective. Aim To develop a case management protocol usable in general practice. Design Co-designed by practitioners using a technology development approach. Setting General practices and community nursing teams in one primary care trust (PCT). Method Nominal group techniques applied to six multidisciplinary workshops held over nine months, in order to design and refine a case management protocol. Then field testing of the protocol with selected patients in four practices. Results A modular case management protocol has been designed that can be used in routine practice and completed over successive consultations. The protocol asks the practitioner and patient about their different perspectives on need, and about mental health, social care needs, nutritional status, vision and hearing, bone fragility, pain, continence and where appropriate end-of-life plans. An electronic version can be partially populated automatically, from the existing medical record. Field testing suggests that a paper version can also be used as a patient-held record for other professionals to use. Conclusion This study has created a model of case management for general practice that appears to be useable in general practice. A wider feasibility study is now needed to test uptake of the protocol by practices.

Trimethoprim related Hyperkalaemia in a patient with Renal Tubular Acidosis Type 4

Hyperkalaemia is a common, treatable, medical emergency, often with an iatrogenic cause. This case illustrates the vulnerability of patients with pre-existing renal tubular acidosis type 4 to medications that further inhibit renin-aldosterone action. The case also illustrates the danger of keeping entirely separate case notes between different hospital disciplines.

Erythrodermic syringotropic cutaneous T-cell lymphoma

Syringotropic cutaneous T-cell lymphoma (CTCL) is a rare localized variant of CTCL, characterized histologically by eccrine gland and ductal hyperplasia surrounded by a dense syringotropic lymphocytic infiltrate. Previously reported only in men, we describe the first woman with syringotropic CTCL. Unusually, she presented with erythroderma, cutaneous nodules, poikilodermatous patches, widespread alopecia and lymphadenopathy.

Rhodium-catalyzed regioselective olefin hydrophosphorylation

Parameters influencing the selectivity of the (PPh(3))(3)RhCl-catalyzed hydrophosphorylation of olefins and enynes are described. The reaction between differentiated dienes was shown to be highly responsive to olefin substitution. The trimethylsilyl group effectively reversed the normal preference for hydrophosphorylation of an alkyne over an alkene. [reaction: see text]

Phase I trial of lobradimil (RMP-7) and carboplatin in children with brain tumors

PURPOSE

To determine the maximum tolerated dose (MTD), the incidence and severity of toxicities, and the pharmacokinetics of lobradimil administered intravenously over 10 min in combination with carboplatin in children with refractory brain tumors.

METHODS

A group of 25 children with primary brain tumors received carboplatin and lobradimil on two consecutive days every 28 days. The 10-min lobradimil infusion began 5 min before the end of the carboplatin infusion. Four lobradimil dose levels (100, 300, 450 and 600 ng/kg ideal body weight, IBW) were studied in cohorts of 4 to 13 patients. Carboplatin was adaptively dosed based on the glomerular filtration rate to achieve a target plasma area under the concentration-time curve (AUC) of 7.0 mg min/ml per course (5.0 mg min/ml for patients who had previously received craniospinal radiation or myeloablative chemotherapy).

RESULTS

Lobradimil toxicity was immediate, tolerable and rapidly reversible. The most frequent toxicities were hypotension, flushing, headache and gastrointestinal complaints. One patient on the 600 ng/kg dose level had a seizure during the lobradimil infusion. The incidence and severity of lobradimil toxicities were not dose-related and the lobradimil dose was not escalated beyond the 600 ng/kg IBW dose level. Two patients had partial responses and ten patients had stable disease. Myelosuppression (thrombocytopenia more prominent than neutropenia) was the primary toxicity attributed to carboplatin. Lobradimil pharmacokinetics were characterized by rapid clearance from the plasma compartment and substantial interpatient variability.

CONCLUSIONS

The combination of carboplatin and lobradimil is safe and tolerable. An MTD for lobradimil was not defined because toxicity was not dose-related. The recommended pediatric phase II dose of lobradimil is 600 ng/kg IBW.

Multimodality MR imaging depiction of hemodynamic changes and cerebral ischemia in subarachnoid hemorrhage

BACKGROUND AND PURPOSE

Subarachnoid hemorrhage (SAH) is a common and serious neurologic emergent condition. We tested the hypothesis that multimodality MR imaging depicts changes in cerebral blood flow SAH, before any surgical or endovascular intervention, and that the frequency of these changes increases with time after ictus.

METHODS

We prospectively examined 37 patients with suspected SAH and three with symptoms of acute stroke but who subsequently had SAH. Routine CT and multimodality MR imaging were performed within 18 h of presentation. Standard MR imaging, diffusion-weighted MR imaging, time-of-flight MR angiography, and dynamic first-pass gadolinium-enhanced MR perfusion imaging were performed. Images were reviewed for abnormalities in cerebral blood flow, ischemia, and infarction. Nine patients did not have SAH at CT and CSF investigations. Of 31 patients with proved SAH, 13 were examined during the acute stage (within 4 d of ictus) and 18, during the subacute stage (4-14 d after ictus).

RESULTS

MR imaging showed alteration in cerebral blood flow parameters in 16 of 31 patients before surgery or endovascular treatment. The frequency of blood flow changes and associated complications increased with worsening clinical grade and increasing time after ictus.

CONCLUSION

Multimodality MR imaging provides information not available from CT in patients with SAH. MR imaging shows oligemic and ischemic areas in SAH before surgery or endovascular treatment. MR imaging is a simple noninvasive method of assessing cerebral blood flow and its complications in SAH. It can be performed in a clinical environment.

Imaging infection with LeuTech

LeuTech is a 99Tcm labelled, anti-CD15, IgM, murine monoclonal antibody shown to have high affinity (Kd = 10(-11) M) for CD15 receptors (5.1 x 10(5)/cell) expressed on human neutrophils. LeuTech was injected directly, intravenously, and its efficacy in imaging infection in 46 consecutive patients was determined. Human anti-mouse antibody (HAMA) response was examined in 30 normal volunteers using a standard LeuTech dose reconstituted with decayed 99Tcm solution. There were 38 true positive, six true negative, and two false negative scans. Of the 38 positive images, 33 (92%) were positive within 10 min after injection of LeuTech. LeuTech accuracy in this group of patients was 96%, sensitivity 95%, specificity 100%, positive predictive value (PPV) 100%, and negative predictive value (NPV) 75%. No elevation of the HAMA titre was observed in any of the 30 normal volunteers and no adverse reaction was noted in any patient. LeuTech is a highly promising agent for rapid imaging of infectious foci.

Spontaneous obliteration of pial arteriovenous malformations: a review of 27 cases

BACKGROUND AND PURPOSE

Brain arteriovenous malformations (AVMs) occur in approximately 0.14% of the population. The most common presentations are hemorrhage (50%) and seizures (25%). Although they are congenital abnormalities, their angioarchitecture may vary over time. A rare but well-recognized phenomenon of AVMs is that of spontaneous obliteration. It is not known what factors predispose to spontaneous obliteration. The purpose of our study was to determine whether spontaneous thrombosis of AVMs can be predicted by their angioarchitecture and whether there is any risk of recurrence once obliteration has occurred.

METHODS

We retrospectively reviewed the angiographic and cross-sectional imaging data amassed over an 18-year period, including follow-up imaging studies and mail surveys of referring and family physicians. A control group was obtained from contemporaneous AVMs of a similar size.

RESULTS

We identified 28 cases of spontaneous obliteration in a series of 2162 patients. The mean time between initial diagnostic angiography and angiographic obliteration was 10 months, during which time there was no intervention and no history of repeat hemorrhage; nor had hemorrhage recurred during the follow-up period (mean, 53 months). Most of the AVMs were deep (22/27) with only one draining vein (21/27) and few feeding arteries. In more than half the cases (15/27) drainage was exclusively into the superficial venous system.

CONCLUSION

Spontaneous obliteration is rare (1.3%). Common features include hemorrhagic presentation and few arterial feeding vessels. Although we found no instance of repeat hemorrhage during the follow-up period, AVMs can recanalize, and follow-up is therefore recommended.

Muscle paralysis produced by botulinum toxin type A injection in treated torticollis patients compared with toxin naive individuals

We sought to determine whether the response to varying doses of botulinum toxin type A (BTX-A) injected in BTX-A-treated torticollis patients differed from the same injections given in toxin-naive individuals. We have developed a technique to objectively measure muscle weakness resulting from BTX injections in humans and have validated the technique in those not previously treated with BTX. We now examine BTX-A-treated torticollis patients to see if their response to BTX-A injection is similar to that of toxin-naive individuals. We injected 11 torticollis patients who had been receiving BTX-A injections with a standard 5-mouse unit (mu) dose into one extensor digitorum brevis (EDB) muscle and a varying dose into the other EDB, measuring muscle paralysis 2 weeks after the injection. Nine of the 11 patients were clinical and electrophysiologic responders. Two patients were non-responders. In the 9 responding patients the dose response curve to increasing doses of BTX-A was very similar to that seen in toxin-naive individuals. The mean muscle paralysis from the standard 5 mu dose was also similar to that previously reported in toxin-naive individuals. Torticollis patients who continue to respond clinically to BTX-A injections demonstrate essentially the same degree of muscle paralysis from the EDB injections as do subjects who have never been exposed to BTX-A.

Riedel's lobe of the liver: fact or fiction?

Riedel's lobe should be considered in all patients undergoing cross-sectional imaging. It may harbor a lesion that might not be demonstrated unless the most inferior aspect of the liver is imaged. We have tried to identify the prevalence of Riedel's lobe in a series of patients with normal abdominopelvic computed tomographic (CT) findings. We reviewed the digital CT data of 105 patients, ages 20-89 years, to define the position of the liver in relation to the costal margin and the iliac crest. There were no significant differences in the prevalence of Riedel's lobe between sexes. The proportion of individuals in whom the most caudal margin of the liver was inferior to the most caudal costal margin was age-dependent and increased to 65% in the 50-59 age group. The craniocaudal dimension of the liver decreased with age (P < 0.02). Riedel's lobe appears to be a common variant of normal anatomy, its prevalence being dependent on age-related changes in liver size and skeletal shape.

Effect of P-glycoprotein modulation with cyclosporin A on cerebrospinal fluid penetration of doxorubicin in non-human primates

PURPOSE

P-glycoprotein (Pgp) is a transmembrane drug efflux pump that is expressed in multidrug-resistant cancer cells and in a variety of normal tissues, including brain capillary endothelial cells which comprise the blood-brain barrier. We studied the effects of the Pgp inhibitor, cyclosporin A (CsA), on the cerebrospinal fluid (CSF) penetration of the Pgp substrate, doxorubicin, in non-human primates.

METHODS

The animals received doxorubicin alone (2.0 mg/kg i.v. over 60 min) or doxorubicin (1 mg/kg i.v. over 60 min) and CsA (loading dose 4.0 mg/kg i.v. over 2 h, followed by continuous infusion of 12 mg/kg per day over 48 h). Plasma and CSF were collected over 48 h and the doxorubicin concentration was measured by reverse-phase high-pressure liquid chromatography (HPLC) with fluorescence detection (detection limit 5 nM). A two-compartment model was fitted to the plasma concentration-time data.

RESULTS

Pgp was demonstrated to be present in the epithelium of the choroid plexus by immunohistochemical methods, indicating that CSF drug penetration could be used as a surrogate for blood-brain barrier penetration. Steady state whole blood CsA concentrations, which were measured with a fluorescence-polarization immunoassay (TDX) that detects both CsA and its metabolites, ranged from 551-1315 microg/l at 24 h. The clearance of doxorubicin in four animals was reduced by 34%, 38%, 45% and 49% when given with CsA. The doxorubicin concentration in the CSF was <5 nM in all animals, both after doxorubicin alone and doxorubicin with CsA.

CONCLUSIONS

The Pgp inhibitor, CsA, at a concentration that alters systemic clearance of doxorubicin, does not appear to significantly increase the CSF penetration of doxorubicin.

Endarterectomy of an Occluded ICA: Short Segment Occlusion with Distal Patency Maintained by an Aberrant Ascending Pharyngeal Artery

SUMMARY

The authors report a case in which an anomalous ascending pharyngeal artery maintained patency of the internal carotid artery beyond an occlusion. The patient presented with ipsilateral transient ischaemic attacks and was found to have an internal carotid artery occlusion on Doppler ultrasound. Subsequent angiography demonstrated retrograde flow in the ipsilateral APA, perfused by pharyngeal anastomoses from the contralateral APA with slow antegrade flow in the ipsilateral ICA distal to the occlusion. Carotid endarterectomy resulted in abolition of the TIA's.

Subclavian and internal jugular veins at Doppler US: abnormal cardiac pulsatility and respiratory phasicity as a predictor of complete central occlusion

In 21 consecutive patients, the authors analyzed changes in venous Doppler waveforms of damped or diminished cardiac pulsatility and respiratory phasicity. Each patient was suspected of having upper limb venous thrombosis, but thrombus was not visible at gray-scale ultrasonography (US) in the subclavian and brachiocephalic veins. US findings were compared with phlebographic findings. The results show that US can be used to establish the presence or absence of thrombosis in the distal portion of the brachiocephalic or subclavian veins, which are inaccessible to direct insonation.

Technique for reduction of bile peritonitis after T-tube removal in liver transplant patients

PURPOSE

The purpose of this work was to evaluate the incidence of bile peritonitis following T-tube removal in liver transplant patients as a function of the method of T-tube removal. Removal at the bedside was compared to removal in the interventional radiology department with subsequent placement of a temporary drainage catheter.

MATERIALS AND METHODS

From June 1987 through July 1993, 1,105 patients underwent orthotopic liver transplantation at the UCLA Medical Center. Three hundred patients were randomly selected from this group and their charts were reviewed. Two hundred sixty-three patients who had choledocho-choledochostomies over a T tube, and adequate documentation of the method of T-tube removal and subsequent clinical course were included in the study. Forty-one patients had their drainage catheter removed at the bedside, and 222 patients had their T-tube removed over a wire in the interventional radiology department with subsequent placement of a temporary drainage catheter.

RESULTS

Among all patients included in this study, 10.3% had bile peritonitis. Of the patients who had their T-tube removed at the bedside, 19.5% had bile peritonitis, whereas only 8.6% of the patients who had their T-tube removed in the interventional radiology department had bile peritonitis. This result is statistically significant (P < .05).

CONCLUSION

Placing a temporary drain at the time of T-tube removal in the interventional radiology department results in a significant reduction in the incidence of bile peritonitis in liver transplant patients. The procedure is relatively simple, quickly mastered, and well tolerated by patients.

Riedel's lobe of the liver: fact or fiction?

Riedel's lobe should be considered in all patients undergoing cross-sectional imaging. It may harbor a lesion that might not be demonstrated unless the most inferior aspect of the liver is imaged. We have tried to identify the prevalence of Riedel's lobe in a series of patients with normal abdominopelvic computed tomographic (CT) findings. We reviewed the digital CT data of 105 patients, ages 20-89 years, to define the position of the liver in relation to the costal margin and the iliac crest. There were no significant differences in the prevalence of Riedel's lobe between sexes. The proportion of individuals in whom the most caudal margin of the liver was inferior to the most caudal costal margin was age-dependent and increased to 65% in the 50-59 age group. The craniocaudal dimension of the liver decreased with age (P < 0.02). Riedel's lobe appears to be a common variant of normal anatomy, its prevalence being dependent on age-related changes in liver size and skeletal shape.

Riedel's lobe of the liver: fact or fiction?

Riedel's lobe should be considered in all patients undergoing cross-sectional imaging. It may harbor a lesion that might not be demonstrated unless the most inferior aspect of the liver is imaged. We have tried to identify the prevalence of Riedel's lobe in a series of patients with normal abdominopelvic computed tomographic (CT) findings. We reviewed the digital CT data of 105 patients, ages 20-89 years, to define the position of the liver in relation to the costal margin and the iliac crest. There were no significant differences in the prevalence of Riedel's lobe between sexes. The proportion of individuals in whom the most caudal margin of the liver was inferior to the most caudal costal margin was age-dependent and increased to 65% in the 50-59 age group. The craniocaudal dimension of the liver decreased with age (P < 0.02). Riedel's lobe appears to be a common variant of normal anatomy, its prevalence being dependent on age-related changes in liver size and skeletal shape.

Radiology in the management of pleural disease

This is a review of the role of radiological intervention in the pleural space. It discusses the radiological management of effusions, empyemas (including the use of fibrinolytic agents), pneumothoraces and pleural thickening.

Peripartum hypopituitarism and lymphocytic hypophysitis

The classical cause of postpartum hypopituitarism is Sheehan's syndrome, in which an obstetric catastrophe is associated with hypotension. However, with improvements in obstetric care, the most common cause now may be lymphocytic hypophysitis. Five women with postpartum hypopituitarism, whose symptoms occurred during or immediately after pregnancy, had detailed endocrine and pituitary imaging for the duration of follow-up. Two presented with visual symptoms, and three with non-specific illnesses related to varying deficiencies of anterior pituitary hormones. Four were unable to lactate, and four were initially amenorrhoeic. Initially, four of the five women had enlarged pituitary glands on magnetic resonance imaging. Four have to some extent recovered pituitary function. One patient had associated thyroiditis: in two cases antinuclear antibodies became positive during follow-up, and in one of these dsDNA antibody was also detected. In no case were pituitary antibodies detected. None had complicated pregnancies or deliveries, and the two who had caesarean sections had no episodes of hypotension. The presentation of secondary hypothyroidism combined with ACTH deficiency in four of the five women strongly suggests lymphocytic hypophysitis. This diagnosis should be considered in postpartum women with general malaise and persistent amenorrhoea, as well as in women who develop visual impairment in the last trimester of pregnancy without antecedent pituitary disease. A conservative policy of management of the pituitary enlargement should be pursued as this resolves.

Regional distribution study of brain perfusion and metabolic agents in normal and tumour bearing rat brains using autoradiographic technique

Regional distribution of brain perfusion imaging agents, [131I]N,N,N'-trimethyl-N'-[2-hydroxy-3-methyl-5-iodobenzyl]1,3 propanediamine (HIPDM) and [131I]-N-isopropyl-p-iodoamphetamine (IMP), was compared with the distribution of patterns of [14C]L-methionine and [14C]D-glucose in normal and tumour bearing rat brains using autoradiographic technique. There was higher concentration of the radiopharmaceutical in grey than white matter in normal rat brain. Autoradiographs of brain tumour sections showed very low uptake of [131I]HIPDM and [131I]IMP as compared to normal brain tissue. There was moderate concentration of [14C]D-glucose and avid uptake of [14C]L-methionine in tumours. Autoradiographic study is useful for evaluating distribution patterns of radiopharmaceuticals.

An online technique for estimating cerebral carbon dioxide reactivity

A technique for measuring cerebral reactivity using transcranial pulsed Doppler ultrasound is described; the system includes a spectrum analyser and capnometer. Data acquisition and manipulation is under software control. Main stem middle cerebral artery blood velocity is monitored continuously using the transcranial Doppler technique, whilst the operator initiates data collection and controls the inspired gas composition. The calculation of cerebral CO2 reactivity is based upon linear regression analysis of normalized, time-averaged middle cerebral velocity on end-tidal pCO2 and is displayed graphically. Measurement of middle cerebral CO2 reactivities can be completed within 15 min. Results from two subjects, a healthy volunteer and a patient with occlusive disease, are shown to illustrate the technique.

Clinical evaluation of 99mTc(V)-dimercapto succinic acid (DMSA) for imaging medullary carcinoma of thyroid and its metastasis

99mTc(V)-DMSA kits developed by the Radiopharmaceutical Division, Bhabha Atomic Research Centre, have been evaluated for potential use in scanning medullary carcinoma of the thyroid and its metastases. There were 15 patients with proved medullary carcinoma and 6 patients with other differentiated thyroid carcinoma. Amongst the 15 patients with medullary carcinoma, 12 (80%) showed positive localisation either in the primary or one or more metastatic sites. None of the six patients with carcinoma other than medullary showed increased concentration of 99mTc(V)-DMSA. Of the 37 known metastatic sites in 15 patients with medullary carcinoma, 24 showed concentration of 99mTc(V)-DMSA (64.9%). In addition, 99mTc(V)-DMSA concentration was seen in 14 sites where no evidence of metastasis was revealed. The incidence of 99mTc(V)-DMSA concentration in soft tissue and bone metastasis was similar.

Preparation and evaluation of 99mTc(V)-DMSA complex: studies in medullary carcinoma of thyroid

Consequent to the promising results reported with 99mTc(V)-DMSA for imaging certain types of soft tissue tumors, we have developed methods to prepare this radiopharmaceutical in three ways: from freshly prepared reagents, through the use of a two component kit and use of the standard renal DMSA kit by a modified recipe. The 99mTc(V)-DMSA complex has been subjected to paper electrophoretic and chromatographic procedures and also biodistribution studies. The distinctly different behaviour of this new product compared to that of the well known renal DMSA complex has been clearly established. Scintiimaging in a preliminary clinical trial in patients with medullary carcinoma of the thyroid has been encouraging.

Thyroid function and thyrotropin levels in rabbits immunized to produce antibodies against thyroid hormones

Various parameters of thyroid function were studied in 27 rabbits, out of which 10 were immunized to produce antibodies against triiodothyronine (T3), 9 against thyroxine (T4) and 8 were normals. Estimations of T3, T4, Free T4 (FT4) and thyrotropin (TSH) in blood, qualitative and quantitative analysis of iodoamino acids in serum, protein bound iodine-131 (PB131I), butanol extractable iodine-125 (BE125I) and measurement of the disappearance rates of 125I-labelled T3 and T4 from plasma were done. In addition, glandular changes were also studied by measurement of 131I uptake, thyroid scanning and chromatographic analysis of hydrolysate of soluble iodoproteins. In T3 immunized animals, levels of T3 in serum increased by 38 to 125 times, levels of TSH also showed a significant rise (7.4 +/- 1.2 vs 28 +/- 9 ng/mL). Chromatographic analysis of iodoamino acids in serum as well as in the hydrolysate of the thyroid gland demonstrated a selective increase in synthesis of T3. Rate of disappearance of T3 from blood showed a significant decline. Thyroid glands in the immunized rabbits showed signs of hypertrophy and hyperplasia. Identical studies done in rabbits immunized to produce antibodies against T4 showed a similar pattern though of variable degree. Our studies indicate that the thyroid glands of the immunized rabbits undergo marked alterations resulting in selective increase in the synthesis and secretion of the particular thyroid hormone against which they were immunized. They do so under the influence of increased levels of TSH.

Increased sensitivity of triiodothyronine antibodies for radioimmunoassay after removal of endogenous antigen by simple laboratory procedures

Conventionally produced antibodies against triiodothyronine (T3) are known to possess high amounts of endogenously produced T3 associated with them. We felt that such antibodies would work better for T3 radioimmunoassay (RIA) after prior removal of the antigen. With this in view, we attempted dissociation and subsequent removal of T3 from antisera by two different methods, viz. dialysis and alcohol extraction. It was possible to remove T3 to an extent of 77% by alcohol extraction and 60% by dialysis. Resultant antisera fail to demonstrate any increase in the titre. However, when standard curves were generated using these antisera, the assays became more sensitive and it was possible to detect T3 in concentrations as low as 6.25 pg. The affinity constants of these antisera calculated from the respective Scatchard plots were found to have increased after both dialysis treatment was well as alcohol extraction. This was thought to be due to rendering some of the high affinity binding sites on the antibodies free of antigen after treatment. Serum T3 levels were measured in 68 patients with various thyroid status using both treated as well as untreated antiserum. The difference between the average values of serum T3 concentration estimated using various antisera before and after the treatment was not statistically significant. Our results suggested that a simple procedure like stripping of antigen from antibodies could be of help for acquiring high affinity and high sensitivity antibodies for this purpose.

Hepatobiliary kinetics of 113mIn-phenolphthalexon

Phenolphthalexon, a compound with iminodiacetic acid as a functional group, has been labelled with 113mIn to high chemical purity and its usefulness in studies of biliary excretion patency has been studied. Organ distribution of 113mInphenolphthalexon in mice was characterized by high liver uptake (50.8% of the administered dose after 5 min) and rapid clearance through the gall bladder. An animal model for studying obstruction of biliary excretion has been developed. Data on the kinetics of the radiopharmaceutical were obtained by collecting in-vivo data through an on-line computer.

Hepatobiliary Kinetics of 113mIn-Phenolphthalexon

Phenolphthalexon, a compound with iminodiacetic acid as a functional group, has been labelled with 113mIn to high chemical purity and its usefulness in studies of biliary excretion patency has been studied. Organ distribution of 113mIn-phenolphthalexon in mice was characterized by high liver uptake (50.8% of the administered dose after 5 min) and rapid clearance through the gall bladder. An animal model for studying obstruction of biliary excretion has been developed. Data on the kinetics of the radiopharmaceutical were obtained by collecting in-vivo data through an on-line computer.

Labeling of red blood cells with Tc-99m after oral administration of SnCl2: concise communication

In vivo labeling of red blood cells with Tc-99m was possible after prior oral administration of SnCl2, both in rats and human volunteers. Absorption of oral SnCl2 was low but sufficient for more than 95% labeling efficiency. Prior i.v. administration of stannous chloride is known to induce in vivo labeling of red blood cells with pertechnetate. We have observed that such labeling is possible even after oral administration of stannous chloride. Nearly 95% of the circulating radioactivity and 93.7% of the administered radioactivity was in RBCs 30 min after i.v. injection of 99mTcO4- in rats that were fed 5 mg of stannous chloride (3.13 mg Sn2+ ion) 2 hr before injection. Red blood cells from four human volunteers could bind pertechnetate, both in vitro and in vivo, after oral administration of 100 mg of SnCl2. We have obtained a blood-pool image of the human heart by labeling the RBCs in vivo by this method. We have also studied various parameters affecting the in vivo binding of RBCs with Tc-99m--such as the amount of orally administered SnCl2, the time of injection of radionuclide after oral SnCl2, and the optimum time for the imaging.