CT of the extraperitoneal space: normal anatomy and fluid collections

Knowledge of the appearance and location of the normal fascial structures surrounding the kidneys and the bladder is the key to proper CT analysis of extraperitoneal fluid collections. Recent studies have shown that the renal fascia and the perirenal space are more complex than previously recognized. An extracapsular renal hematoma, confined against the kidney by the posterior renorenal septum within the perirenal space, can entirely simulate a subcapsular hematoma. Pancreatitis fluid can dissect between the discrete layers that constitute the posterior renal fascia, allowing fluid in the anterior pararenal space to extend posterior to the kidney without directly involving the posterior pararenal space. The umbilicovesical fascia separates the small perivesical space from the potential large reservoir of the prevesical space in the extraperitoneal portion of the pelvis. Fluid in the prevesical space can communicate directly with the retroperitoneal spaces surrounding the kidney. In addition to compartmental localization, CT features of the fluid itself or the presence of ancillary findings such as aortic aneurysm, enlarged pancreas, renal mass, or hydronephrosis will frequently indicate the cause and the extent of most extraperitoneal fluid collections.     

Evidence that cellular immune responses to soluble and membrane associated antigens are independently regulated during human schistosomiasis mansoni

The glucagonoma syndrome is a rare disorder characterized by weight loss, necrolytic migratory erythema (NME), diabetes, stomatitis, and diarrhea. We identified 21 patients with the glucagonoma syndrome evaluated at the Mayo Clinic from 1975 to 1991. Although NME and diabetes help identify patients with glucagonomas, other manifestations of malignant disease often lead to the diagnosis. If the diagnosis is made after the tumor is metastatic, the potential for cure is limited. The most common presenting symptoms of the glucagonoma syndrome were weight loss (71%), NME (67%), diabetes mellitus (38%), cheilosis or stomatitis (29%), and diarrhea (29%). Although only 8 of the 21 patients had diabetes at presentation, diabetes eventually developed in 16 patients, 75% of whom required insulin therapy. Symptoms other than NME or diabetes mellitus led to the diagnosis of an islet cell tumor in 7 patients. The combination of NME and diabetes mellitus led to a more rapid diagnosis (7 months) than either symptom alone (4 years). Ten patients had diabetes mellitus before the onset of NME. No patients had NME clearly preceding diabetes mellitus. Increased levels of secondary hormones, such as gastrin (4 patients), vasoactive intestinal peptide (1 patient), serotonin (5 patients), insulin (6 patients, clinically significant in 1 only), human pancreatic polypeptide (2 patients), calcitonin (2 patients) and adrenocorticotropic hormone (2 patients), contributed to clinical symptoms leading to the diagnosis of an islet cell tumor before the onset of the full glucagonoma syndrome in 2 patients. All patients had metastatic disease at presentation. Surgical debulking, chemotherapy, somatostatin, and hepatic artery embolization offered palliation of NME, diabetes, weight loss, and diarrhea. Despite the malignant potential of the glucagonomas, only 9 of 21 patients had tumor-related deaths, occurring an average of 4.91 years after diagnosis. Twelve patients were still alive, with an average age follow-up of 3.67 years.     

The diversity of lipases from psychrotrophic strains of Pseudomonas: a novel lipase from a highly lipolytic strain of Pseudomonas fluorescens

Strains of Pseudomonas fluorescens and Ps. fragi are the predominant psychrotrophs found in raw milk and may cause spoilage due to the secretion of hydrolytic enzymes such as lipase and protease. The diversity of lipases has been examined in Pseudomonas isolates from raw milk which represent different taxonomic groups (phenons). Significant diversity was found using both DNA hybridization and immunoblotting techniques, which has implications for the development of a diagnostic test. The lipase-encoding gene (lipA) was cloned from one strain, C9, of Ps. fluorescens biovar V. In contrast to previously reported lipase sequences from Ps. fluorescens, the gene encodes a lipase of M(r) 33 kDa. Alignment of all known Pseudomonas and Burkholderia lipase amino acid sequences indicates the existence of two major groups, one of M(r) approximately 30 kDa comprising sequences from Ps. fragi, Ps. aeruginosa, Ps. fluorescens C9 and Burkholderia, and one of approximately 50 kDa comprising Ps. fluorescens lipases. The lipase from C9 does not contain a signal peptide and is presumed to be secreted via a signal peptide-independent pathway. The lipA gene of strain C9 was disrupted by insertional mutagenesis. The mutant retained its lipolytic phenotype, strongly suggesting the presence of a second lipase in this strain.     

Pheochromocytomas that do not accumulate metaiodobenzylguanidine: localization with PET and administration of FDG

Many imaging methods can be used to detect pheochromocytoma, but some tumors are not detected with conventional modalities. To explore the possible usefulness of positron emission tomography (PET) after administration of 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) to localize pheochromocytoma in patients with false-negative scintigrams obtained after administration of metaiodobenzylguanidine (MIBG), FDG was administered and PET was performed in two adult patients with pheochromocytomas that had never been localized despite administration of MIBG. In both patients, images were obtained dynamically for 50 minutes; then a limited truncal sequence was performed. PET enabled correct localization of the tumors. In patient 1, a tumor that had not been detected for 21 years was localized in the middle mediastinum; in patient 2, a pheochromocytoma was detected in the right adrenal gland. PET performed after administration of FDG may be useful for localization of pheochromocytomas that do not accumulate MIBG.     

Efficacy of itraconazole in the prevention of fungal infections among neutropenic patients with hematologic malignancies and intensive chemotherapy. A double blind, placebo controlled study

We studied the efficacy and safety of itraconazole for the prevention of fungal infection in neutropenic patients given cytotoxic chemotherapy for hematologic malignancies. Patients were randomly allocated to receive either itraconazole (200 mg bd) or placebo in addition to oral amphotericin B until the patient either developed fungal infection or had completed antileukemic treatment. Forty six patients (83 neutropenic episodes) treated with itraconazole and 46 placebo treated patients (84 neutropenic episodes) were evaluable. No specific toxicity was noted. Nine fungal infections developed in the itraconazole group, of which four were histologically or microbiologically proven and 15 in the patients given placebo (eight proven) (p < 0.12). All these patients received IV amphotericin B. The incidence of Candida albicans infections tended to be lower in the itraconazole group, but overall, there was no measurable improvement in the prevention of fungal infections and mortality by itraconazole.     

Validity and reliability of the MTI photoscreener

OBJECTIVES: The prevalence and necessity for early detection of vision problems illustrate the need for improved methods of vision screening in preschool children. This study assessed the validity and reliability of a new device, the MTI photoscreener in a cross-sectional field study. METHODS: An appropriate sample size (> 140) was calculated and recruited for the study. All children (N = 161) in a migrant workers summer education program were screened with the MTI Photoscreener. Simultaneously and in a masked design, disease status was determined by the Modified Clinic Technique, a well established method for diagnosing the conditions which the MTI screener was designed to detect. RESULTS: Validity measures revealed a sensitivity of 54%, specificity of 87%, phi coefficient of 0.40, and positive predictive value of 52%. Repeatability was assessed by the kappa coefficient, by a test for effect modification by examiner, and by comparison of sensitivity and specificity across 12 masked examiners. The kappa coefficient was 0.38. A test for effect modification suggested that differences existed among the examiners. Variability of sensitivity was high, but variability of specificity was low. CONCLUSIONS: Methods for vision screening in preschool children are limited. The MTI Photoscreener is an easy and efficient method, but the validity and reliability is a concern. Comparison of our results with other studies suggests future potential for this instrument provided protocols are refined and further field studies reveal efficacy.     

Ten-year trends of heart disease risk factors in the Halifax County MONICA population. MONItoring of trends and determinants in CArdiovascular disease

OBJECTIVE: To investigate trends in heart disease risk factors (RFs) in the general population of Halifax County, Nova Scotia during a 10-year period. DESIGN: Two independent random samples of the population of Halifax County were surveyed in 1985 and 1995; age ranges were 25-64 years and 25-74 years. Blood pressure, cholesterol and body weight were measured. Smoking and health history were obtained by questionnaire. MAIN RESULTS: Participation rate was 66.3% in 1985 and 1995. All RFs were negatively correlated with education attainment. RF changes from 1985 to 1995 were related to education level. Among survey participants, mean body mass index increased from 26.7 kg/m2 to 27.6 kg/m2 (P + 0.005) for men, and from 25.5 kg/m2 to 27.3 kg/m2 (P < 0.00001) for women. Average smoking rate increased from 32.0% to 34.6% (not significant) in men and from 27.7% to 29.1% (not significant) in women. Age-specific smoking rate increased by 13% (P = 0.14) in younger women and decreased by 10% in older women. (P = 0.00). Mean levels of blood cholesterol decreased by 0.2 mmol/L (P = 0.002) in men and 0.1 mmol/L (P = 0.20) in women. Systolic blood pressure increased by 6.3 mmHg (P < 0.0001) in men and by 7.9 mmHg (P < 0.0001) in women, being steepest in the lower education group. Mortality predicted from RFs declined between the survey years, but less than the observed mortality. This discrepancy may result from the effect of medical care or the delayed effect of RF changes. CONCLUSIONS: Some risk factors show a disturbing trend, indicating that an increased effort or a change in strategy is needed to combat the risk of ischemic heart disease.     

Early intervention for schizophrenic disorders. Implementing optimal treatment strategies in routine clinical services. OTP Collaborative Group

BACKGROUND: Early detection and intervention in schizophrenic disorders is an important challenge for psychiatry. METHOD: Review of literature on effective biomedical and psychosocial intervention strategies. RESULTS: Comprehensive programmes of drug and psychosocial interventions with adults who show early signs and symptoms of schizophrenic disorders may contribute to a lower incidence and prevalence of major episodes of schizophrenia. These programmes combine early detection of psychotic features by primary care services, with close liaison with mental health professionals. Long-term monitoring of signs of recurrence, with further intervention, appears essential to maintain these benefits. CONCLUSIONS: Field trials demonstrate that effective early treatment strategies can be routinely applied in clinical practice.     

The structure of depression among elderly institution residents: affective and somatic correlates of physical frailty

BACKGROUND: Confounding of depression with somatic illness and anxiety, a problem in any age group, may be especially troublesome in frail older persons. This paper examined this problem in a factor analytic study of the structure of depressive symptomatology, identifying affective and somatic symptom clusters and relating those clusters to health and functional variables cross-sectionally and prospectively over a 1-year interval. METHODS: The factor structure of a DSM-IV symptom checklist was examined among 1,245 elderly long-term care residents. Regression analyses examined the association of resulting factors with cognition, functional disability, self- and physician-rated health, and pain at baseline and a year later. One-year mortality was also examined. RESULTS: Factor analysis revealed three unique symptom clusters: depressed mood, somatic symptoms, and psychic anxiety. Depressed mood and somatic symptoms were associated cross-sectionally with all functional health variables, but psychic anxiety was associated only with pain. Longitudinally, depressed mood was the only independent predictor of decline in cognition, functional ability, physician-rated health, and mortality; the last effect, however, did not withstand control for baseline health and functioning. Somatic symptoms at baseline predicted decrement in self-rated health a year later. Effects varied as a function of cognitive status. CONCLUSIONS: These data suggest that concerns about the confounding role of somatic symptoms in the association of depression with physical health are unfounded. Although somatic symptoms of depression and anxiety were associated with health and functional status cross-sectionally, depressed mood was by far the stronger predictor of health declines over time.