PURPOSE: The aim of this study was to describe the MR findings in extraspinal musculoskeletal tuberculosis (EMT). METHOD: A retrospective review was conducted of the MR findings of 18 patients with microbiologically and/or pathologically proven EMT. All MR studies were performed using T1-and T2-weighted spin echo sequences. T1-weighted spin echo sequences after Gd-DTPA injection were obtained for 12 patients. The MR images were evaluated for abnormalities in joints, bones, and soft tissues, and the results were grouped by anatomic localization, frequency distribution of structures affected, and morphologic patterns of involvement. RESULTS: Isolated soft tissue tuberculosis was found in 10 (55.5%) patients and involvement of more than one structure in 8 (44.4%). Pyomyositis (n = 6) and arthritis with involvement of adjacent soft tissues (n = 7) were the most common forms of presentation. One patient presented with isolated fascial superficial tissue involvement in one leg. Isolated pyomyositis involving one (n = 3) or two (n = 3) muscles was homogeneous in six cases and showed intermediate (n = 6), low (n = 2), or high (n = 1) signal intensity on T1-weighted images and a high and very hyperintense signal on T2-weighted images. The tenosynovitis synovial fluid was homogeneous (n = 1) or heterogeneous with multiple tiny hypointense nodules (n = 1) on T2-weighted images. The subdeltoid bursitis fluid was characterized by homogeneous low signal intensity with a hyperintense rim (n = 2) on T1-weighted images and homogeneous (n = 1) or heterogeneous hyperintense signals with areas of low signal intensity (n = 1) on T2-weighted images. In tuberculous arthritis, the synovial joint fluid (n = 7) showed heterogeneous (n = 4) or homogeneous (n = 3) low signal intensity on T1-weighted images and high or very high signal intensity on T2-weighted images. Where involved, the adjacent muscle(s) (n = 8) were usually hypointense on T1-weighted images and very hyperintense on T2-weighted images. Associated cellulitis was found in arthritis with involvement of neighboring soft tissues (n = 5), pyomyositis (n = 2), and tenosynovitis (n = 1). The images obtained after Gd-DTPA showed peripheral (n = 10) or heterogeneous (n = 1) enhancement or no enhancement (n = 1). CONCLUSION: The MR findings for EMT are variable. Although diagnosis is dependent largely on prior presumption and clinical context, MRI provides valuable guidelines in defining the extent of the lesions to select the appropriate treatment and for follow-up of abnormalities.

Adolescent↗

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Cardiopulmonary and analgesic effects of epidural lidocaine, alfentanil, and xylazine in pigs anesthetized with isoflurane.

To determine cardiopulmonary and analgesic effects of lidocaine, alfentanil, and xylazine in pigs anesthetized with isoflurane, 18 healthy Landrace-Large White pigs were studied (six for each drug). General anesthesia was induced with isoflurane in O2 and maintained with 1% to 1.2% end-tidal ISO, ensuring presence of a pain response before epidural drug administration. Heart rate (HR), arterial blood pressures (AP), cardiac output (CO), pulmonary arterial pressure, pulmonary capillary wedge pressure (PCWP), central venous pressure, respiratory rate (RR), tidal volume (TV), minute volume (MV), arterial blood gas data, core temperature (CT), and analgesic effects (by picking the lumbar area and the abdominal wall) were determined at various times (2, 5, 15, 30, 45, 60, and 90 minutes) after epidural administration of lidocaine (5 mg/kg), alfentanil (5 micrograms/kg), or xylazine (0.2 mg/kg), all diluted in NaCl 0.9% to 0.5 mL/kg. Statistical analysis included two-way analysis of variance for repeated measures and the least significant difference test for determining differences among means. A probability level of P < .05 was used. The following results were statistically significant decreases in systolic AP, HR, TV, RR, MV, CT, pH, PaO2, and TCO2 and increases in PCWP, PaCO2, and HCO3 after LID. After ALF, only CT and HCO3 decreased. Core temperature and TV decreased after XYL. Lidocaine provided 45 to 60 minutes of analgesia. Alfentanil had no analgesic effects, and xylazine provided 90 minutes of analgesia. The authors conclude that xylazine, when injected epidurally, provides suitable analgesia in isoflurane-anesthetized pigs.

Alfentanil↗

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Anesthetic potency of desflurane in the horse: determination of the minimum alveolar concentration.

OBJECTIVE: To determine the minimum alveolar concentration (MAC) of desflurane (DES) in the horse. STUDY DESIGN: Prospective study. ANIMALS: Six healthy adult horses (three males and three females) weighing 370 +/- 16 kg and aged 9 +/- 2 years old. METHODS: Anesthesia was induced with DES vaporized in oxygen via a face mask connected to a large-animal, semiclosed anesthetic circle system. The horses were endotracheally intubated and positioned in right lateral recumbency. Inspired and end-tidal DES were monitored using a calibrated Ohmeda RGM 5250 multigas analyzer (Ohmeda-BOC, Spain). The MAC of desflurane that prevented gross purposeful movement in response to 60 seconds of noxious electrical stimulation of oral mucous membranes was determined. RESULTS: The time from the start of DES administration to lateral recumbency was 6.1 +/- 0.9 min. The MAC of DES in these horses was 7.6 +/- 0.4%. Time required for the animal to regain sternal recumbency after 98 +/- 4 minutes of anesthesia was 6.6 +/- 0.5 minutes and the time to standing was 14.3 +/- 2.7 minutes. CONCLUSIONS: The MAC of desflurane in these horses was 7.6 +/- 0.4%. DES provided a rapid induction to, and recovery from, anesthesia. CLINICAL RELEVANCE: Desflurane offers the potential for more precise control during anesthesia, and may allow a faster and uneventful recovery. It is important to know the MAC of an inhalant to use it clinically.

Administration, Inhalation↗

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Epidural injection of ketamine for perineal analgesia in the horse.

OBJECTIVE: To determine the analgesic, sedative, and cardiopulmonary effects of epidural ketamine in the horse. ANIMAL POPULATION: Six healthy horses (three males and three females) weighing between 350 and 450 kg. METHODS: Three doses of ketamine were selected (0.5, 1, 2 mg/kg). Two months before the beginning of experiments, the carotid artery was exteriorized, and 1 week before experiments began, an epidural catheter was placed percutaneously in all animals with the tip located 12 cm cranially in the midsacrum. One week later, either saline (control) or one of three doses of ketamine was injected epidurally. Each animal received each ketamine dose and saline in random order at 1-week intervals. Ketamine was diluted in saline 0.9% before the experiment, and the volume used was adjusted to horse size and correlated to clinically used volumes. All the animals received a standard noxious stimulus consisting of needle insertion into the skin and deep muscle using a 3-point scale for scoring the response. A second scale was used to score the degree of sedation. The response to a noxious stimulus, the degree of sedation, and arterial blood pressure were assessed at previously determined intervals: before drug and 2, 5, 10, and 15 minutes and every 15 minutes to 210 minutes after ketamine or saline administration. Arterial blood samples were drawn for blood gas analysis before drug and at 15, 30, 60, and 90 minutes. RESULTS: All the tested doses of ketamine were effective in producing analgesia of the tail, perineum, and upper hindlimb. Total tail and perineal analgesia times were similar depending on dosage (30 minutes for 0.5 and 1.0 mg/kg and 75 minutes for 2.0 mg/kg). A sedative effect of ketamine was also observed in a dose-response manner with a peak effect between 15 and 30 minutes postadministration. No cardiopulmonary effects were observed with any dose of ketamine. CONCLUSIONS: Results indicate that epidurally administered ketamine in the horse produces local spinal and central nervous system effects with analgesia and sedation but minimal cardiopulmonary effects. CLINICAL RELEVANCE: Further studies are required to determine whether the analgesia is sufficient for surgery.

Analgesia, Epidural↗

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Phenylketonuria in Costa Rica: preliminary spectrum of PAH mutations and their associations with highly polymorphic haplotypes.

A preliminary evaluation of the molecular basis of phenylketonuria (PKU) in Costa Rica was made by performing mutational analyses in the six PKU families identified to date. These studies revealed the presence of the previously reported European mutations IVS1nt5, L48S, E221G and IVS12ntl as well as the novel mutation IVS7nt3. The combined use of the STR, VNTR and XmnI polymorphic systems for the PAH gene resulted in a discriminant distribution of haplotypes among normal and mutant chromosomes and suggests its potential usefulness for future diagnostic applications in Costa Rican PKU kindreds. This is the first report of a genetic analysis in a Central American PKU population.

Child↗

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[Fragile X Syndrome: case report in two brothers].

OBJECTIVE: To alert the pediatricians about the phenotype of the patients with Fragile X Syndrome, because of it's high incidence and the variable degrees of incapacity that may occur. METHODS: Case report of two brothers with the classical findings of the Fragile X Syndrome (mental retardation, "Dumbo-like" ears, macroorchidism, among others), confirmed by cytogenetic studies. RESULTS: The diagnosis of the syndrome is based on the presence of a variable number of cells with fragile sites on the X chromosome at Xq 27.3. The DNA analysis revealed Fragile X locus in 14% of the brothers' metaphases and in 1% of the mother's. It was also observed that two cousins on the mother's side had the syndrome, confirmed by genetic studies. CONCLUSIONS: The recognition of this syndrome by the pediatrician is of extreme importance to an early multidisciplinary approach.

English Abstract↗

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[Brain stem ischemia in a boy with resistance to C activated protein and elevated lipoprotein A].

INTRODUCTION: Activated protein C resistance is the most common hereditary coagulation abnormality. In the majority of cases it results from a point mutation Arg506-->Gln of the factor V gene, and characterized by a poor anticoagulant response to activated protein C. CLINICAL CASE: We report the clinical case of a 6-year-old obese boy, who presented with acute hemiparesis. A cerebral MRI revealed an area of infarction in the left hemiprotuberance. Further investigation identified activated protein C resistance (heterozygosity for factor V Leiden) and elevation in lipoprotein (a). His mother also had factor V Leiden mutation. Prophylaxis with acetylsalicylic acid was instituted with favorable evolution. CONCLUSIONS: This mutation, isolated, is usually asymptomatic, unless other risk factors coexist. Although venous thromboembolism seems to be the main clinical manifestation, recent reports consider that activated protein C resistance is also a risk factor for arterial thrombosis and stroke in children. We reinforce the need for systematic and thorough evaluation of etiology and risk factors in cases of stroke in children.

Activated Protein C Resistance↗

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[Intraoperative radiotherapy with accelerated electrons for urinary bladder carcinoma: principles and results].

OBJECTIVE: To describe intraoperative radiotherapy with accelerated electrons, a highly selective method of administering irradiation for radical treatment of bladder cancer. METHODS: We reviewed the experience reported in the literature since this treatment modality was utilized in Japan and its application extended to the western countries. RESULTS: Animal experiments have shown an acceptable clinicopathological tolerance to 20 Gy intraoperative irradiation of partial bladder volume. The local recurrence rate was 9% for early solitary tumor (> T2) and 27% for early multicentric tumor, according to the Japanese clinical experience. In the western countries, intraoperative radiotherapy plus external irradiation with or without systemic chemotherapy achieves a pT0 of about 65% (in total cystectomy specimens) and an intravesical tumor control rate of 88% in organ-sparing protocols. CONCLUSIONS: The results achieved by the groups with wider experience demonstrate that highly selective intraoperative radiotherapy is feasible, well-tolerated and effective in terms of inducing complete pathological remissions and definitive control of intravesical tumor. These selected clinical experiences must be corroborated by multicenter studies.

Electrons↗

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Innovative techniques in modern radiation oncology: the economic and organizational impact.

An overview of the impact of innovative techniques in modern radiotherapy on economic and organizational issues is proposed. The analyzed innovative procedures are: intraoperative radiotherapy, stereotactic radiosurgery, conformal radiotherapy and high dose rate brachytherapy. They are approached separately in terms of cost-benefit analysis, optimized management and estimated productivity. The introduction of these innovative techniques in the daily practice of radiation oncology departments is vital in the quest for excellence. The strictly monetary implications of programs for the implementation of innovative radiotherapy techniques are hindered by the present planned containment of public health care expenditure in western European countries.

Cost-Benefit Analysis↗

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[The importance of TTR met 30 in the diagnosis of familial amyloidotic polyneuropathy in the absence of a positive family history].

INTRODUCTION: Familial amyloidotic polyneuropathy type I is an hereditary autosomal dominant disease, characterized by having a mutant transthyretin (TTR met 30). For this reason there is a deposition of amyloid in several organs with their subsequent malfunction. The most characteristic clinical presentation is peripheral, sensomotor and autonomic neuropathy. The dysautonomic component is seen early and often dominates the clinical picture. Subsequently, there is cardiac, ocular or renal involvement and death generally occurs 10 to 15 years after onset of the disorder. In Portugal one thought the gene was fully penetrant and, thus, a positive family history was an important criterion for the diagnosis. However an increasing number of patients without a positive family history have been identified. CLINICAL CASES: We present the cases of three men and a woman, aged between 36 and 48 years, with clinical sensomotor and autonomic polyneuropathy. There was no known family history of the condition in any case. Nerve biopsy in three of the patients, and biopsy of abdominal fat in the other patient, showed amyloid to be present. Similarly, TTR met 30 analysis was positive in all cases, and allowed the diagnosis to be established. CONCLUSION: It is essential to do TTR met 30 analysis in all patients with peripheral polyneuropathy in whom there is obviously a dysautonomic component and no known family history.

Abdomen↗

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[Kingella kingae in a 10-year-old girl].

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Child↗

PubMedDate not supplied

[Necrotizing fasciitis after varicella].

Necrotizing fasciitis is a rare and severe infection characterised by extremely rapid progressive involvement of the superficial fascias and deep dermal layers of the skin, with resultant vasculitis and necrosis. The authors present three clinical cases of necrotizing fasciitis; all three patients previously had varicella rash, rapid progressive spreading erythema with severe pain and toxic shock syndrome. Two patients had positive cultures of b-haemolytic streptococcus. Early stage differential diagnosis with celulitis, aggressive antibiotic treatment and pediatric intensive care support are essential. However, the main therapy is early extensive surgical approach involving all indurate areas, down to and including the muscle fascia.

Chickenpox↗