F.L. Chan

Treatment of acute cerebral hemorrhage with intravenous glycerol. A double-blind, placebo-controlled, randomized trial.

Background and Purpose Hitherto, treatment of acute cerebral hemorrhage with intravenous glycerol has not been evaluated in rigorous clinical studies with sufficient patient numbers. Methods We undertook a double-blind, stratified and randomized, placebo-controlled clinical trial. Only patients with a first stroke admitted to the hospital within 24 hours after onset of symptoms were recruited, provided computed tomography confirmed hemorrhage and informed consent was obtained. After stratification into alert, semicoma, and coma subgroups using the Glasgow Coma Scale, 107 patients received active treatment (500 ml of 10% glycerol in saline by intravenous infusion over 4 hours on 6 consecutive days) and 109 were given corresponding saline treatment. Using a variety of objective scoring systems, patients were followed up for up to 6 months. Results At follow-up, all measures of outcome in the treated and control groups were very similar. At 6 months, respective mortality rates were 37 of 107 and 33 of 109. Corresponding mean±SD improvements in Scandinavian Stroke Study Group scores were 8.35±16.9 versus 11.55±15.6 (long-term) and 0.64±7.3 versus 2.40±6.9 (prognostic), and improvements in the Barthel Index ratings were 10.72±24.7 versus 13.95±23.3, respectively. Glasgow Coma Scale score improvements in the survivors were 0.81±1.5 and 1.16±1.7 in the treated and control groups, respectively. Hemolysis (generally subclinical) was the only adverse effect of glycerol noted. Conclusions In the absence of any clinically or statistically significant difference in outcome between the treated and control groups, this trial provides no justification for glycerol therapy following acute cerebral hemorrhage.s

Early and late results of excision of choledochal cysts

BACKGROUND/PURPOSE Reports on the late results of choledochal cyst excision with hepaticojejunostomy in children are relatively few. METHODS Of the 84 patients who had choledochal cyst who came under our care, 79 have had definitive surgery, three are awaiting surgery, one is being observed with Carolis disease, and the parents of one child have refused surgery. Thirty-eight patients treated decades ago had internal drainage procedures. Since 1972, 41 patients have had cyst excision with hepaticojejunostomy using a 40-cm Roux loop without an antireflux procedure. Early complications in those who underwent cyst excision with hepaticojejunostomy included anastomotic leak in three patients who required reoperation, cholangitis in two, and fluid collection in the gall-bladder bed that required no intervention in one. RESULTS During a follow-up period ranging from 4 months to 17 years (mean, 8.5 years), anastomotic stricture, cholangitis, and intrahepatic stone formation developed in two children after being well for 8 years and over 11 years. These children required additional surgical procedures to overcome their problems. Asymptomatic intrahepatic stones 2 years after cyst excision with hepaticojejunostomy developed in a third child. There was no mortality in the entire group that underwent cyst excision and they are all enjoying a good quality of life. CONCLUSIONS Careful, long-term follow-up is important in children who have choledochal cyst excision with hepaticojejunostomy.

Cranial nerve involvement and base of the skull erosion in nasopharyngeal carcinoma

In a prospective study of 262 consecutive patients with nasopharyngeal carcinoma (NPC), using computed tomography (CT) as their baseline evaluation, erosion of the base of the skull and intracranial extension into the middle cranial fossa were found in 31.3% and 12.2% of patients, respectively. Thirty‐four of these patients had cranial nerve involvement at presentation; 30 of them had involvement of one or more of the third to sixth cranial nerves. Most cases of intracranial extension of tumor were accompanied by erosion of the base of the skull, but the reverse was not true. All patients with cranial nerve palsy involving the third to sixth cranial nerves had associated erosion of the ipsilateral base of the skull. The CT evaluation of patients with cranial nerve involvement who are believed to harbor NPC should include thin cuts of the base of the skull for detection of subtle bone erosion. This may be the only clue to the presence of a small NPC. The prognostic significance of cranial nerve involvement, base of the skull erosion, and intracranial extension of the tumor on the survival of the group of 84 patients who had T4 tumors was evaluated with regression analysis using the Cox model. Only cranial nerve involvement was found to be a significant factor influencing survival.

Cerebrovascular disease in Hong Kong Chinese.

Our prospective study of cerebrovascular disease in Hong Kong confirms a previous clinical impression that stroke in the Chinese has a pattern different from that in Caucasians. We studied 540 patients (aged 20-70 years) with stroke. Computed tomography or autopsy was obtained in 86.1% and showed an increase in the proportion with lacunar infarction, striatocapsular infarction, and parenchymal hemorrhage relative to the frequencies in Caucasians. This increase in the incidence of cerebral hemorrhage occurs not only in semicomatose and comatose patients but also in alert patients (16.9%) and those with a lacunar syndrome (12.5%). Our findings suggest that cerebrovascular disease in the Chinese selectively affects small vessels, causing lacunes and hemorrhages. In future community studies on stroke prevalence, researchers should be cautious about interpreting similar prevalence rates as reflecting similar risk factors or pathologies.

Necrotizing enterocolitis in neonates with symptomatic congenital heart disease

10. Mollitt DL, Golladay ES. Postoperative neonatal necrotizing enterocolitis. J Pediatr Surg 1982;17:757-63. 11. Raziuddin K, Kim MH, Yao AC. Peripheral circulatory response to feeding in newborn low birthweight infants. J Pediatr Gastroenterol Nutr 1984;3:89-94. 12. Cooperstock MS. C. difficile, enterocolitis, and Hirschsprungs disease [Letter]. Lancet 1982;1:800. 13. Merkler RG, Solish SB, Scherzer AL. Meningomyelocele and Hirschsprungs disease: theoretical and clinical significance. Pediatrics 1985;76:299-300.

Transverse testicular ectopia detected by MR imaging and MR venography

Abstract. Crossed testicular ectopia is a rare anomaly, characterised by migration of one testis towards the opposite inguinal canal. In most reported cases, the correct diagnosis was not made pre-operatively. We report a case of transverse testicular ectopia diagnosed pre-operatively with MRI. MRI and MR venography demonstrated unilateral location of both testes in the right inguinal canal, which was confirmed by surgery. We provide a brief literature review of transverse testicular ectopia and the imaging of undescended testis.

CT in acute mesenteric ischaemia.

Enhanced computed tomography (CT) is frequently performed for possible bowel ischaemia. It has the distinct advantage of possible detection of the causes of ischaemia. Radiologists therefore need to be familiar with the spectrum of diagnostic CT signs. We present the CT imaging findings in surgically proven cases of small bowel ischaemia. In addition to signs pertaining to the underlying aetiological pathology, bowel dilatation, bowel wall thickening, mural gas, occlusion of mesenteric vessels, ascites and infarct of other abdominal organs were observed.

Nasopharyngeal carcinoma: pattern of skeletal metastases

The records of 153 nasopharyngeal carcinoma patients with skeletal metastases were reviewed. The skeletal system was the most common site of distant metastases. The patients who developed skeletal metastases were significantly younger than those without skeletal metastases, although there was no difference between sexes. The pattern of skeletal involvement conforms to the general pattern, the spine and pelvis being the common sites. The first region of involvement was lumbar spine (28.4%), then dorsal spine (27.7%), sacrum and pelvis (16.3%), femur (9.9%), rib and sternum (7.8%), humerus (5.0%), cervical spine (3.5%) and skull vault (1.4%). Radiologically, the lesions were lytic in 66.0%, mixed lytic and sclerotic in 12.8% and sclerotic in 21.2%. The time to development of symptomatic skeletal metastases of mixed or sclerotic nature was significantly longer than lytic lesions, and patients with mixed or sclerotic metastases also had better survival.

Computed tomography evaluation of neck node metastases from nasopharyngeal carcinoma

PURPOSE To study the role of computed tomography in the pre-therapy evaluation of nasopharyngeal carcinoma. METHODS AND MATERIALS The computed tomography of 119 new patients of nasopharyngeal carcinoma were evaluated independent of clinical findings for neck node metastases, and then compared with clinical findings. Contrast enhanced axial scans were obtained at 5 mm intervals with the infraorbitomeatal line parallel to the gantry. Scans were obtained from the supra-sellar cistern to the C5 or C6 vertebra for the evaluation of the base of skull, nasopharynx, paranasopharyngeal space and the upper and mid neck. RESULT The present study confirmed the disparity of nodal extent documented by clinical palpation and computed tomography. Of the 37 patients who have no clinically palpable node (N0), computed tomography showed nodal involvement in 11 (29.7%) of them, and they were up-staged from N0 to N1. Computed tomography showed multiple or bilateral nodes in seven (58.3%) of the 12 patients with AJC N1 disease and they were hence up-staged to N2. All together, there were 28 (23.5%) patients who have no computed tomography evidence of nodal involvement by tumor. In agreement with clinical experience, the most commonly involved nodal groups were the upper internal jugular and upper spinoaccessary, followed by the lateral retropharyngeal. The percentage of nodes which were not clinically palpable was roughly the same for different regions (15-30%), except, as expected, that all the retropharyngeal nodes were not palpable. The risk of harboring retropharyngeal node was proportional to the size of the largest node in the ipsilateral neck. CONCLUSION A significant proportion of patients with clinically negative neck (N0) or AJC N1 disease will be upstaged by computed tomography, thus supporting its routine use in pre-therapy evaluation of nasopharyngeal carcinoma.

Surfactant Tracheobronchial Lavage for the Management of a Rabbit Model of Meconium Aspiration Syndrome

We evaluated the effect of tracheobronchial lavage with diluted surfactant solution (bovine lipid extract surfactant, bLES) in a rabbit model of meconium aspiration. All animals were anaesthetized, tracheotomized and given 3–4 ml/kg of 25% slurry of human meconium into the endotracheal tube and mechanically ventilated for 1 h. The animals were then randomly assigned to surfactant lavage (n = 12) with 15 ml/kg of diluted surfactant at a concentration of 5.4 mg phospholipid/ml administered in aliquots of 2 ml; or simple endotracheal suction (control n = 12) when the oxygenation index (OI) was ≥15. Changes in the arterial blood gases and the histomorphological and radiological appearances of the lungs were recorded. The OI and arterial/alveolar oxygen tension (a/A PO2) of the surfactant lavage group improved significantly at 5 min post-treatment, and these improvements were observed throughout the ensuing 4 h of ventilation. There was significantly more solid content recovered by surfactant lavage compared with the control group (p = 0.0001). Radiologically, the post-treatment air space opacification scores of the lavage group were significantly lower compared with the control (p = 0.002). The post-treatment radiographs of the lavage-treated rabbits were rated by the radiologist, who was blinded to the treatment groups, as much improved in 5 and improved in 4, whereas the control rabbits were rated as much worse in 3 and worse in 4. Histological examination showed the lungs of the lavaged rabbits had significantly more normal airway (p < 0.0001), more fields showing completely normal airspace (p = 0.0001) and less fields showing severe overdistension with meconium (p = 0.0005). We concluded that lavage with diluted surfactant solution effectively washed out the meconium, improved gases exchanges, and improved the histological and radiological appearances in the rabbit model of MAS.