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No current neuroimaging modality offers mechanistic or prognostic information to guide management in paediatric dystonia. We assessed F-fluorodeoxyglucose (¹⁸F-FDG) PET/computed tomography (CT) brain imaging in childhood primary dystonia (PDS) and neurodegeneration with brain iron accumulation (NBIA) to determine whether it would identify altered metabolism and hence constitute a potentially useful 'biomarker' indicating functional disturbances associated with dystonia and severity of the disease.A total of 27 children (15 PDS and 12 NBIA) underwent brain ¹⁸F-FDG PET/CT imaging under anaesthesia during acquisition. The images were assessed visually and the two groups were compared quantitatively with statistical parametric mapping. PET/CT images were spatially transformed to Montreal Neurological Institute standard space. Voxelwise ¹⁸F-FDG uptake was normalized to whole-brain uptake. Data of both groups were correlated separately with duration and severity of dystonia as assessed using the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS).Visual inspection did not identify any abnormalities in ¹⁸F-FDG uptake within the cerebral cortex, basal ganglia, or thalami in either group. Quantitative analysis identified higher uptake in the posterior cingulate and bilateral posterior putamina but decreased uptake in the occipital cortex and cerebellum in NBIA compared with PDS. The NBIA group had more severe dystonia scores compared with the PDS group. BFMDRS was negatively correlated with age but not with duration of dystonia.Compared with PDS, NBIA is dominated by relative overactivity in the putamen and by cerebellar underactivity, patterns that may reflect the increased severity of dystonia in NBIA cases. Hence, there is a potential role for ¹⁸F-FDG PET/CT imaging in paediatric dystonia, particularly in the NBIA group.

A common problem encountered in clinical medicine is the classification of a lung lesion (nodule/opacity) on conventional imaging. Often attempts at biopsy are unsuccessful or are falsely reassuring, and the decision to send the patient for more invasive and potentially morbid procedures can be difficult. Our aim was to investigate the role of fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) in helping to identify more accurately those patients with malignant lesions. Sixty-three patients underwent FDG-PET scans following unsuccessful biopsy of a lung lesion or, in a lesser number of cases, when an attempt at biopsy was considered too dangerous. Follow-up was by histology or, if this was unavailable, by clinical progress to death or a minimum of 18 months post scan. Visual and quantitative analysis was performed. On visual analysis, positive and negative predictive values were 90% and 100%, respectively. On quantitative (SUV2.5) analysis, positive and negative predictive values were 90% and 85%, respectively. We interpret these results as showing that the use of FDG-PET scans in patients in this circumstance is non-invasive and highly sensitive in diagnosing malignancy. The high positive predictive value suggests that those with a positive scan must undergo further investigation, while the 100% negative predictive value means those with no FDG uptake can safely be spared further invasive investigations

Objectif : Etudier les hospitalisations chez les autochtones et les non-autochtones pour des soins psychiatriques aigus dans le nord-ouest de l'Ontario, en 1992. Methode : Reprendre en 1992 une etude qui a eu lieu en 1986-1987 visant a comparer les hospitalisations chez les autochtones et les non-autochtones pour des soins psychiatriques aigus dans le nord-ouest de l'Ontario et examiner les inscriptions des autochtones aupres des organismes de sante mentale communautaires au cours des 6 premiers mois de 1993. Resultats : L'analyse comparative des hospitalisations a revele les suivantes : le nombre d'autochtones hospitalises depasse de 33 % le taux moyen de la population generale ; la depression semble sous-diagnostiquee chez les autochtones ; ceux-ci continuent d'etre hospitalises principalement pour des raisons autres que des troubles psychiatriques graves ; la toxicomanie et les problemes avec la loi ont souvent un role a jouer ; leur sejour a l'hopital est 2 fois plus long que celui du groupe temoin de non-autochtones ; ils sont souvent issus de milieux ruraux ; ils sont moins souvent pris en main par un service aux malades externes et plus souvent par le systeme de justice criminel. L'examen des inscriptions aupres des organismes de sante mentale communautaires a revele les suivantes : une surrepresentation similaire des autochtones ; les troubles de l'humeur et les perturbations de la pensee des autochtones de ce secteur etaient semblables a ceux des non-autochtones ; et la longueur de leur sejour etait semblable. L'hopital psychiatrique semble offrir un traitement de soins aigus non pas pour des troubles psychiatriques graves (ce qui constitue son mandat), mais pour les hospitalisations atypiques qui resultent de problemes economiques, sociaux et culturels. On soupconne un sous-diagnostic de la depression atypique chez la population autochtone hospitalisee. Lorsqu'on pose des questions sur l'origine du traitement, on apprend que le profil de diagnostic des autochtones et des non-autochtones est identique en ce qui a trait aux aspects humeur et pensee. Conclusion : Il n 'y a pas eu de changements considerables au cours de 5 dernieres annees quant au recours aux services psychiatriques hospitaliers chez les autochtones. Il se peut que les stereotypes culturels influencent le diagnostic des autochtones de facon negative. L'amelioration des programmes de controle de traitement chez les autochtones ainsi que le developpement communautaire peuvent resoudre en partie le probleme. Le redressement des mandats et des responsabilites des organismes communautaires (generiques et specifiques a une culture) permettra de reduire le nombre d'hospitalisations inutiles.

Australia's rapidly aging population has a high prevalence of chronic disease and disability, leading to an increased social and economic burden. The Enhanced Primary Care program seeks to reduce this burden by promoting preventive and coordinated care. This study aimed to identify unmet needs in community dwelling general practice patients aged 75 years and over through annual health assessments performed by a general practitioner-nurse team.Community dwelling patients of a large suburban general practice aged 75 years and over were invited to participate. Five hundred and forty-six consecutive, eligible patients were recruited. Data were collected by GP-nurse teams on physical and psychosocial variables using a combination of physical examination, self reporting, and rating scales.Fifty percent of the women and 25% of the men lived alone. Over 90% of participants reported one or more health problems, with musculoskeletal issues being most common. Men rated their health more poorly than women. Incontinence affected one-third of patients, mainly women. Women reported more psychological distress. There were age and gender differences in activities of daily living (ADL). Mobility, ADL, visual impairment, bowel problems, use of sleep medications and psychological wellbeing were strongly associated to self reported health.Health assessments were effective in identifying significant physical and psychosocial problems in older adults. The importance of such assessments is underscored by strong associations between various domains and perceived general health. Collaboration between a GP and a practice based community nurse represents a potential solution to identifying (and responding to) unmet physical and psychosocial needs to improve quality of life in community dwelling older adults.

We have undertaken a retrospective analysis of all positron emission tomography (PET) scans carried out at St Thomas' Hospital, London, since 1994 to establish the sensitivity and specificity of this radiologic technique in cutaneous malignant melanoma. In particular, we have identified those patients with primary cutaneous malignant melanoma in whom PET scanning revealed in-transit or regional spread to nodes and those patients with known regional spread in whom PET scanning revealed distant metastases. We defined our false-negative results as a negative scan result with positive histology or subsequent clinical progression of disease. False-positive results were defined as a suspect scan with negative histology or no subsequent progression of disease. PET scanning had an overall sensitivity of 78% and specificity of 87%; however, subset analysis (M. D. Anderson staging system) showed a sensitivity of 50% for stage I disease (34 patients and 35 scans) and 33% for stage II disease (9 patients and 9 scans) with specificities of 87% and 100%, respectively. For stage III disease (16 patients and 17 scans), PET showed a sensitivity of 93% and specificity of 50%. Overall, 35% of patients with true-positive scans had their disease restaged. We can conclude therefore that PET is valuable as a staging procedure in patients with known regional spread but is suboptimal in the prediction of outcome in stage I or stage II disease.

The problem of residual masses on post-treatment CT scans is a continuing dilemma for the oncologist treating malignant lymphomas. These masses may contain active disease or represent only necrotic tumour which continues to shrink without further treatment or post-treatment fibrosis which remains stable on continued follow-up. 18-FDG-PET offers a novel metabolic imaging modality, which can differentiate malignant from benign tissue on the basis of increased glycolytic activity.Thirty-two patients (15 with Hodgkin's disease (HD) and 17 with aggressive histology non-Hodgkin's lymphoma (NHL)) who had residual masses on their post-treatment CT scans underwent 18-FDG-PET. The post-treatment CT and PET scans were compared and the accuracy of the 18-FDG-PET in assessing residual masses was evaluated using clinical and pathological follow-up data.Nine patients had positive post-treatment 18-FDG-PET, eight (89%) of whom have relapsed. Twenty-three patients had negative post-treatment PET with only two relapses in this group. The 2 patients who relapsed had aggressive NHL while none of the 11 HD patients with negative PET relapsed. The median follow-up of patients in continued complete remission is 38 months.18-FDG-PET can differentiate between residual masses containing viable lymphoma where further treatment will be required to achieve cure and those representing ablated disease, where unnecessary treatment and additional morbidity may be avoided.

Needle localizations of radiologically suspicious but clinically impalpable breast lesions are being carried out with increasing frequency as a result of the National Breast Screening Programme. At our institution, the Nottingham Lesion Location Set (Mediplus Ltd, Bourne End, Bucks) has been used, without complication, for at least 50 such procedures (Fig. 1). It comprises an 18 gauge (G), or 21 G cannula, a fine needle localization wire which is fed through the cannula during initial positioning and a 20 G bluntended cannula which is introduced over the wire by the surgeon in theatre to facilitate identification of the wire tip. The following case report, undocumented to date, describes an unusual hazard of breast localization.

We performed a retrospective analysis to evaluate the ability of whole-body F-fluorodeoxyglucose positron emission tomography (FDG PET) to identify local recurrence and pulmonary metastases in patients with soft-tissue tumours after treatment. We compared the results of FDG PET with those of MRI for the detection of local recurrence, and with CT of the chest for pulmonary metastases. We assessed 62 patients of mean age 51 years, who had 15 types of soft-tissue sarcoma, after a mean follow-up of 3 years 2 months. For the detection of local disease, 71 comparisons showed that the sensitivity and specificity of FDG PET were 73.7% and 94.3%, respectively; there were 14 true-positive and five false-negative results. MRI had a sensitivity and specificity of 88.2% and 96.0% respectively. For the identification of lung metastases, 70 comparisons showed that the sensitivity and specificity of FDG PET were 86.7% and 100%, with 13 true-positive results and two false-negative results. CT of the chest had a sensitivity and specificity of 100% and 96.4%. Thirteen other sites of metastases were identified by FDG PET. FDG PET can identify both local and distant recurrence of tumour as a one-step procedure and will detect other metastases. It seems that all three methods of imaging are needed to define accurately the extent of disease, both at initial staging and during follow-up.

This paper presents the short term results of an ongoing prospective randomized trial comparing a cemented unipolar with a cemented bipolar hemiarthroplasty for the treatment of displaced femoral neck fractures in the elderly. Forty-seven patients with an average age of 77 years completed 6-month followup. Outcomes at 6 weeks, 3 months and 6 months were assessed by completion of a patient oriented hip outcome instrument and by functional tests of walking speed and endurance. No differences in the postoperative complication rates or lengths of hospitalization were seen between the two groups. Patients treated with a bipolar hemiarthroplasty had greater range of hip motion in rotation and abduction and had faster walking speeds. However, no differences in hip rating outcomes were found. These early results suggest that use of the less expensive unipolar prosthesis for hemiarthroplasty after femoral neck fracture may be justified in the elderly.

The use of PET scanning in patients with human immunodeficiency virus infection and fever of unknown origin, confusion and/or weight loss was investigated.Eighty patients were examined using PET. Fifty-seven patients had half-body scans with [18F]fluorodeoxyglucose (FDG), and 23 patients had brain studies performed with FDG. Fourteen patients also had [11C]methionine studies (2 chest, 1 abdomen and 11 brain) performed.Thirteen patients with lymphoma had the extent of the disease clearly identified in both nodal and extranodal sites. Patients with a variety of infections (Cryptococcus neoformans, Pseudomonas aeruginosa, Mycobacterium tuberculosis and Mycobacterium avium intracellulare) had disease localized for appropriate biopsy or sampling procedures. A half-body FDG-PET scan had a sensitivity of 92% and a specificity of 94% for localization of focal pathology that needed treatment. High uptake of FDG (greater than liver) had a positive predictive value for pathology needing treatment of 95%. FDG brain studies showed that 16 patients with CD4 T-lymphocyte counts less than 200 cells/ml had reduced cortical uptake compared with that in basal ganglia. FDG scans were abnormal in all 19 patients with focal space occupying lesions identified by magnetic resonance scans. The standardized uptake values (SUVs) over cerebral lesions due to toxoplasma were in the range of 0.14-3.7 (13 patients) and due to lymphoma were in the range of 3.9-8.7 (6 patients). Three more patients with progressive multifocal leukoencephalopathy had SUVs in the range of 1.0-1.5 over the lesions. Another patient had a low-grade oligodendroglioma (SUV = 2.9). Carbon-11-methionine uptake also was high in patients with cerebral lymphoma but did not add to the discrimination between toxoplasmosis and lymphoma in these patients obtained with the FDG scan.In hospitals with access to PET facilities, FDG scanning allows the rapid evaluation of the whole body, including the brain, of patients with human immunodeficiency virus infection, with a report potentially available within 4 hr of injection. Sites of infection and tumor were identified, and discrimination between cerebral pathologies was possible.

Radionuclide gastric emptying studies were carried out on 20 patients with end-stage renal failure (ESRF) undergoing continuous ambulatory peritoneal dialysis (CAPD). Nine of the patients had diabetes mellitus. Eight normal volunteers were also studied to establish normal ranges. Solid and liquid emptying patterns were investigated simultaneously using a meal made up of a solid phase labelled with 99mTechnetium and a liquid phase labelled with 111Indium. The solid emptying fitted a model with a lag phase followed by a linear emptying phase and the liquid emptying fitted a single exponential. Nine of the 20 patients (four diabetic, five non-diabetic) were found to have delayed solid emptying, and four of these (two diabetic, two non-diabetic) also had delayed liquid emptying. No correlation was found between any of the parameters studied and the clinical symptoms of the patients. It is concluded that almost half of the patients studied had abnormal gastric emptying, but that many of these did not suffer from severe symptoms.

The National Breast Screening Programme is an ongoing public health programme. Women between 50 and 64 years are being invited to attend for screening at three yearly intervals. The results of the first 5,000 women screened in the Eastern Health and Social Services Board's unit are presented. The breast cancer detection rate was 7.8 per thousand women screened. The malignant to benign biopsy rate was greater than 1:1.

In a prospective study of 72 human immunodeficiency virus (HIV) positive patients presenting with fever and breathlessness, a non-invasive management protocol, incorporating a scanning technique using radioactively labelled diethylenetriamine penta acetate (DTPA) and sputum induction, was found to be highly sensitive and specific in the early detection of Pneumocystis carinii pneumonia (PCP). At presentation, the DTPA scan was abnormal in 34 of 36 cases of PCP, irrespective of smoking history, whilst the chest radiograph was diffusely abnormal in 21 cases. Sputum induction identified 7 of 14 patients with PCP in the first six months of its use and 7 of 10 patients over the last six months. The DTPA lung scan and induced sputum examination are non-invasive techniques which can be used to investigate out-patients. In combination they detected all cases of PCP at presentation, reduced the need for bronchoscopy, resulted in a low case fatality (5.4%) and reduced the need for admission.

Technetium-99m-HM-PAO [( 99mTc]HM-PAO) leukocyte and indium-111-oxine (111In-oxine) leukocyte scanning were carried out simultaneously in 41 patients at 4 hr and 24 hr after reinjection to determine whether the 4-hr 99mTc scan could replace the 24-hr 111In scan for detecting intraabdominal sepsis. Abdominal infection was confirmed in 12 cases. The 4-hr 99Tc-leukocyte scan, the 4-hr 111In-leukocyte scan, and the 24-hr 111In-leukocyte scan yielded a sensitivity of 100%, 67%, and 100%, respectively, and a specificity of 62%, 90%, and 86%, respectively. The 24-hr 99mTc-leukocyte scan also produced a sensitivity of 100%, but it was falsely positive in all 29 cases without infection due to physiologic bowel uptake. False-positive 4-hr 99mTc-leukocyte scans were also produced by physiologic bowel uptake in seven cases all of whom had true-negative 4-hr and 24-hr 111In-leukocyte scans. Because of the high incidence of false-positive 4-hr [99mTc]HM-PAO leukocyte scans, it was concluded that they could not replace 24-hr 111In-leukocyte scans for detecting intraabdominal sepsis, and that serial 99mTc leukocyte scans starting earlier than 4 hr after reinjection must be evaluated.

Na+-selective and Ca2+-selective microelectrodes were used to examine the ionic mechanisms regulating acetylcholine (ACh) stimulation of pancreatic secretion. The cytosolic concentrations of free ionized Na+ and Ca2+ ([Na]i, [Ca]i) were determined in unstimulated acinar cells to be 10.5 +/- 0.4 mM and 0.43 +/- 0.03 microM, respectively. By measuring the induced changes in intracellular Ca2+, Na+, and membrane potentials (ECa, ENa, Em), we were able to demonstrate that 5 X 10(-8) M ACh depolarized Em by 4.3 +/- 0.2 mV and increased [Na]i and [ca]i to 12.2 +/- 0.3 mM and 0.58 +/- 0.02 microM, respectively. Stimulation with ACh at concentrations ranging from 10(-8) to 10(-5) M increased [Ca]i from 0.4 microM to between 0.5 and 1.0 microM. Amylase release reached a maximum at 10(-7) M ACh stimulation and progressively decreased at higher concentrations of stimulus. Increasing the stimulus above an optimal concentration appears to reduce or inhibit enzyme release. These experiments provide direct evidence supporting the concept that acinar cell secretion is triggered by increases in [Ca]i and of calcium's ability to act as primary intracellular mediator. Stimulation after removal of extracellular Ca2+ eliminated the increase in [ca]i that is usually observed in secreting cells, while producing the normal depolarization of Em and increase in [Na]i. These studies demonstrate the increases in [Ca]i are derived from an increase in membrane permeability to Ca2+ and the ability of ACh to depolarize the Em by a transmembrane movement of Na+ that is independent of the change in intracellular Ca2+.

A multicentre case-control study of 216 patients with palmoplantar pustulosis and 626 controls with miscellaneous dermatoses showed a considerably higher prevalence of smoking in the group with palmoplantar pustulosis. This was the first indication that smoking may be an important factor in this skin disease, possibly by affecting the inflammatory responses of the skin.

The palatability of three bulk additives was studied in volunteers under 40 and over 60 years of age. Women highly significantly preferred Normaeol Special® (Norgine) to Fybogel® (Reckitt & Colman) and Celevac Granules® (W.B.P.). On both preference and palatability score Normacol Special was significantly preferred to Celevac Granules, as it was in the under 40's on palatability; score and in the over 60's on preference, but in the latter, sex may have accounted for the difference observed. Volunteers under the age of 40 gave Celevac a significantly higher palatability score than Fybogel; the reverse occurred in the over 60's. These results have therapeutic implications in patients with different gastrointestinal disorders.

Ion-selective microelectrodes were employed to determine the electrochemical driving forces involved in the transepithelial transport of Na+ and Cl- during acetylcholine (ACh) stimulation of pancreatic acinar cells. In HCO-3-free Ringer solution, the mean values of intracellular Cl and Na activities (aiCl and aiNa) were 68.9 +/- 1.1 and 8.3 +/- 0.3 mM, respectively. The mean value of aiCl is above the calculated equilibrium value, indicating that Cl entry into the cell is an energy-requiring process. Continuous measurement of intracellular electrode potentials during stimulation of the cells with concentrations of ACh ranging from 10(-7) to 10(-5) M demonstrated the neurotransmitter's influence on transmembrane Na+ and Cl- movement in secreting cells. The mean values of the induced changes in aiCl and aiNa at every concentration of ACh measured were not significantly different (P greater than 0.5), although the mean changes in either aiNa or aiCl determined with every decade change in ACh concentration were significant (P less than 0.05). The transmembrane Na+ electrochemical gradient dissipated with the induced increases in aiCl. These results suggest that, during stimulus-secretion coupling of pancreatic acinar cells, there is a transcellular route for NaCl secretion, and the energy for NaCl entry into the cell may be derived from the Na+ electrochemical gradient that exists across the basolateral epithelial membrane. They also suggest that the ACh-induced changes in ionic permeability of the plasma membrane may be the coupling mechanism by which the simultaneous events enzyme release and electrolyte secretion are controlled in stimulated cells.

In a study of risk factors for the development of melanocytic naevi in relation to the pathogenesis of malignant melanoma 197 white adults were examined by four dermatologists and naevus counts correlated with several other features. Highly significant associations were found between large numbers of banal acquired melanocytic naevi and the ability to tan easily without burning (skin types 3 and 4; relative risk 4.6), brown or hazel eyes (relative risk 3.5), green or grey eyes (relative risk 3.5) and brown or black hair (relative risk 3.7). No significant associations with numbers of naevi were shown for parity or use of oral contraceptives or other steroid hormones. This is the first study to find any relation between melanocytic naevi and phenotypic factors in a white population.

The term ermine phenotype has been chosen to describe patients with white hair with black tufts. The patients also have sensorineural hearing loss. This rare phenotype may come about either by failure of migration of melanocytes or by an autoimmune mechanism. Examples of each are cited. The authors describe a possible third type. Comparison with other pigment loss-sensorineural hearing loss syndromes is made.

A case of hepatopulmonary hydatid disease in a Cypriot who presented with pyogenic infection with Streptococcus milleri is described. Although hydatid disease and pyogenic liver abscess are both rare in the UK, an underlying echinococcal pathology should be suspected in any patient from an area endemic for hydatid who presents with a pyogenic hepatic or hepatopulmonary abscess.

SUMMARY The clinical features of two female infants with incontinentia pigmenti and evidence of neurological abnormality are described. In one infant a neuropathological examination revealed a prenatal malformation of the cerebral cortex (micropolygyria) and unilateral pyramidal hypoplasia. There were also signs of a destructive process which had occurred later in development and which was characterised by some small cavities in the central white matter, sclerotic atrophy of a few cerebral gyri and patchy foci of neuronal loss in the cerebellum. RESUME Les auteurs decrivent les caracteristiques cliniques de deux nouveaux nes du sexe feminin avec incontinentia pigmenti et evidence de malformation neurologique. Chez un des nouveaux nes un examen neuropathologique a revele une malformation prenatale du cortex cerebral (micropolygyrie) et une hypoplasie pyramidale unilaterale. Il y avait aussi des signes d'un processus de destruction qui etait survenu a un stade plus tardif du developpement et qui etait caracterise par de petites cavites dans la matiere blanche centrale, l'atrophie sclerotique de quelques circonvolutions cerebrales et des foyers irreguliers de perte des neurones dans le cervelet. ZUSAMMENFASSUNG Die klinischen Merkmale zweier weiblicher Kleinkinder mit incontinentia pigmenti und neurologischen Anomalien werden beschrieben. Bei einem der Kleinkinder ergab die neuropathologische Untersuchung eine praenatale Anlagestorung der Hirnrinde (Micropolygyrie) mit einseitiger Hypoplasie der Pyramiden. Es fanden sich auch Anzeichen eines destruktiven Vorganges, der wahrend eines spateren Entwicklungsstadiums aufgetreten war mit kleinen Hohlraumbildungen in der weissen Substanz, mit sklerotischer Atrophie einiger Hirnwindungen und mit herdformigem Untergang von Neuronen im Kleinhirn. RESUMEN Se describe el cuadro clinico de dos lactantes afectas de incontinentia pigmenti con evidencia de anormalidad neurologica. En una de las lactantes un examen neuropatologico revelo una malformacion cerebral (micropoligira) e hipopoplasia piramidal unilateral. Habia tambien signos de un proceso destructwo que habia ocurrido mas tarde en el desarrollo y que caracterizaban unas cavidades pequenas en la materia blanca central, atrofia esclerorica de algunas de las circunvoluviones cerebrales, y focos esparcidos de dano neuronal en el cerebelo.