Experimental Neurology By Prof Paul Glees Pp xii + 532 (Oxford: Clarendon Press; London: Oxford University Press, 1961) 75s net

The Nervous System

Viruses and bivalve shellfish

The publication of this book is timely. Although diffusion-weighted imaging is routinely available on most modern clinical MRI machines there are few resources that even approach a comprehensive evaluation in clinical practice. Whilst it was generally accepted that a diffusion-weighted abnormality represented irreversible ischaemia in the setting of acute stroke, subsequent work has shown that this tissue may be pathologically heterogenous and can even be reversible. This understanding is slowly filtering into books describing imaging in stroke. This book introduces the principles of diffusionweighted imaging, normal findings and, importantly, pitfalls and artefacts, the latter chapter being extremely helpful. There is then a chapter dedicated to the differentiation between cytotoxic and vasogenic oedema. The book then sequentially discusses infarction, haemorrhage, vasculopathies, epilepsy, demyelination, metabolic diseases, infection, trauma, neoplasia and paediatrics. All of these discussions are comprehensive and very well illustrated with numerous examples. One of the novelties of the book is the final section entitled ‘how to use this book’. This basically does the reverse of the previous chapters in that it is based primarily on the differences seen with the diffusionweighted image, the apparent diffusion coefficient (ADC) image and the T2 image, i.e., it discusses the differential diagnosis of an image, e.g., with increased diffusion weighting, low ADC and increased T2. This section is likely to be of great assistance to individuals seeing a combination of signal changes for the first time. There are very few negative points associated with the book, areas such as mislabelling of some of the figures in Chapter 14 which should have been picked up by the publisher. Overall the authors should be complimented for putting together such a rich resource of cases in such a balanced manner. The book is very accessible and will mainly be of interest to radiologists involved in reporting diffusion-weighted studies and should be a welcome addition to the reading room area for reference. There will be other individuals within clinical neuroscience who will also find the book of interest.

Diffusion-weighted MR Imaging of the brain

Background and aim Pancreatitis is the most common and serious complication of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Prevention strategies targeting risk factors could be important to reduce the rate of post-ERCP pancreatitis. However, the risk factors for post-ERCP pancreatitis (PEP) are still debated. This systematic review and meta-analysis was performed to identify risk factors for PEP. Methods Medline (PubMed and Ovid), Cochrane Central Register of Controlled trials & Database of Systematic Reviews, Embase, Scopus, ScienceDirect, Springer links and WEB OF SCIENCE were searched for published studies in all languages. Inclusion and exclusion criteria were defined a priori. Eighteen probable risk factors were evaluated, and outcomes were expressed in the case of dichotomous variables, as an odds ratio (OR) (with a 95% confidence interval, (CI)). Results When patient-related risk factors were analyzed, the ORs for female gender was 1.46 (95%CI: 1.30–1.64); for previous pancreatitis 2.03 (95%CI: 1.31–3.14); for previous PEP was 2.90 (95%CI: 1.87–4.48); for Sphincter of Oddi dysfunction (SOD) was 2.04 (95%CI: 1.73–2.33) and for Intraductal papillary mucinous neoplasm (IPMN) was 3.01 (95%CI: 1.34–6.77). Four endoscopy-related factors were confirmed: the OR for difficult cannulation was 3.49 (95%CI: 1.364–8.925); for endoscopic sphincterotomy (EST) it was 1.39 (95%CI: 1.09–1.79); for precut sphincterotomy it was 2.25 (95%CI: 1.70_2.96); and for main pancreatic duct injection it was 1.58 (95%CI: 1.21–2.08). Conclusions Female gender, previous pancreatitis, previous PEP, SOD, IPMN, difficult cannulation, EST, precut sphincterotomy and main pancreatic duct injection are risk factors for post-ERCP pancreatitis.

Risk factors for post-ERCP pancreatitis: A systematic review and meta-analysis

Study Objective. To compare the reported occurrence of liver failure in subjects in prospective trials with that in patients in retrospective reports after repeated use of therapeutic dosages of acetaminophen.

Design. Systematic review of the medical literature.

Data Source. MEDLINE and EMBASE biomedical and pharmacologic databases.

Subjects. Adults who received repeated dosing of acetaminophen 4 g/day or lower for at least 24 hours.

Measurements and Main Results. Articles written in several languages were abstracted by trained personnel using a structured abstraction form. Data were categorized by methodology (prospective vs retrospective), acetaminophen dosage, and type of liver effect. A total of 791 articles were identified, which included 30,865 subjects in prospective studies and 9337 patients in retrospective reports. The prospective studies reported no cases of fulminant hepatic injury, liver transplantation, or death due to acetaminophen. Of the 30,865 subjects in these studies, 129 (0.4%) were identified who had a serum aminotransferase level that exceeded the upper limit of normal, including 61 subjects in randomized trials in which the proportion of serum aminotransferase level increase was the same as or less than that in the placebo group and 68 subjects in trials without a placebo group. In addition, 4263 (13.8%) received the maximum recommended therapeutic dosage (3.9-4 g/day). In the retrospective reports, 96 patients (1.0%) had a serum alanine aminotransferase level that exceeded the upper limit of normal, one (0.01%) underwent liver transplantation, and six (0.06%) died. Causality relationship of acetaminophen for each retrospective case was assessed with the Naranjo adverse drug reaction probability scale. The mean ± SD Naranjo score for all 103 retrospective cases was 3.2 ± 1.9, indicating a possible relationship between the increased aminotransferase levels and acetaminophen use. Some retrospective reports contained information suggesting that the patient had ingested an overdose despite a history of therapeutic use.

Conclusion. Prospective studies indicated that repeated use of a true therapeutic acetaminophen dosage may slightly increase the level of serum aminotransferase activity, but hepatic failure or death was not reported. Retrospective reports indicated a higher rate of increased serum aminotransferase levels, and several reported associated liver injury and death. The differing results and presence of evidence indicating inaccurate acetaminophen dosage information in some case reports suggests that these cases may be inadvertent overdoses, rather than true therapeutic dosages.

Does Therapeutic Use of Acetaminophen Cause Acute Liver Failure

A 71-year-old man with characteristic clinical and pathological pictures of Cronkhite-Canada syndrome associated with gastric cancer is presented Histological examinations of gastric and colonie polyps which resembled juvenile type revealed no malignant cells The patient slowly recovered after subtotal gastrectomy and elemental diet supplement with antiplasmin agents As for as is known to the authors, a total of 69 cases with this syndrome were reported in Japan including our patient Of these cases 8 had cancer of the gastrointestinal tract Two of them, including our case, had gastric cancer Another one was associated with gastric cancer but not intestinal polyposis The remaining 5 cases were associated with colonic cancer Caution must be paid to the fact that cachexia or malabsorption in some patients with this syndrome results from gastrointestinal malignancy The prognosis of this syndrome consisted of 20 deaths including 2 postoperative deaths, 33 of improvement including 4 of natural remission and 4 of remission after gastrectomy or colectomy, 7 unchanged and the remainder not described

Cronkhite-canada syndrome associated with gastric cancer: report of a case.

In order to study the clinical significance of cholylglycine (CG), CG in both fasting levels and after oral loading of 300 mg ursodeoxycholic acid (UDCA) were determined by radioimmunoassay in 313 patients with various liver diseases. Elevated fasting CG levels were found in 66.6% of patients with acute hepatitis (AH), 34.8% chronic inactive hepatitis (CIH), 79.3% chronic active hepatitis (CAH), 97.1% liver cirrhosis (LC), 94.7% hepatocellular carcinoma (HCC), and 80% of gall stones (GS). Changes of fasting CG during the course of AH were found to be parallel with values of transaminases. On oral loading of UDCA, different CG responses were found in CIH and CAH, and in compensated and decompensated LC. From these results we concluded that the determinations of serum CG gave additional informations of various liver diseases.

Clinical usefulness of serum cholylglycine determination in various liver diseases.

We have often encountered high signal intensity (SI) of the cingulate gyrus and insula during diffusion-weighted magnetic resonance imaging (DW-MRI) on neurologically healthy adults. To date, cortical signal heterogeneity on DW images has not been investigated systematically. The purpose of our study was to determine whether there is regional signal variation in the brain cortices of neurologically healthy adults on DW-MR images. The SI of the cerebral cortices on DW-MR images at 1.5 T was evaluated in 50 neurologically healthy subjects (34 men, 16 women; age range 33–84 years; mean age 57.6 years). The cortical SI in the cingulate gyrus, insula, and temporal, occipital, and parietal lobes was graded relative to the SI of the frontal lobe. Contrast-to-noise ratios (CNRs) on DW-MR images were compared for each cortical area. Diffusion changes were analyzed by visually assessment of the differences in appearance among the cortices on apparent diffusion coefficient (ADC) maps. Increased SI was frequently seen in the cingulate gyrus and insula regardless of patient age. There were no significant gender- or laterality-related differences. The CNR was significantly higher in the cingulate gyrus and insula than in the other cortices (p < .01) , and significant differences existed among the cortical regions (p < .001). There were no apparent ADC differences among the cortices on ADC maps. Regional signal variation of the brain cortices was observed on DW-MR images of healthy subjects, and the cingulate gyrus and insula frequently manifested high SI. These findings may help in the recognition of cortical signal abnormalities as visualized on DW-MR images.

Human cerebral cortices: signal variation on diffusion-weighted MR imaging

An epidemic of hepatitis A occurred around Hondo City, Kumamoto Prefecture in Japan during the first six months of 1982. Clinical, immunological and epidemiological studies were carried out in 225 cases. Cases were distributed over a relatively wide area, and in small numbers of young children and school children. More than half of the patients were in their twenties or thirties. The clinical course was generally favorable with rapid resolution. No episode lasted more than six months. There was only one fatality in a cure which was a carrier of HBs antigen with liver cirrhosis. Titers of IgM anti-HAV measured by radioimmunoassay (RIA) or enzyme immunoassay (EIA) reached a peak during the second week after onset, followed by a gradual decrease. Conversion to negative results was never experienced within two months. We found a good correlation between RIA and EIA in terms of detecting IgM anti-HAV. The route of infection was thought to be fecal-oral in nature, with ingestion of raw oysters the major etiologic factor.

An epidemic of hepatitis A related to ingestion of raw oysters.

A 44-year-old man with Borrmann type III gastric carcinoma initially presenting bone metastasis and later transverse myelopathy is reported. Chest and skull roentgenograms showed multiple punched-out lesions. A bone scintigram showed multiple abnormal uptake. Histological examinations of biopsy and autopsy materials revealed signet-ring cell carcinoma of the stomach. Disseminated carcinomatosis of the bone marrow was ruled out histologically and neither microangiopathic hemolytic anemia nor disseminated intravascular coagulopathy was observed. Because this patient with bone metastasis did not have metastasis to the liver and lungs we propose that a nonportal route through the vertebral venous plexus might be an alternative to the portal route of bone metastasis from gastric carcinoma. During the last 20 years, only 10 such cases including this one have been reported in Japan. Their prognosis was quite poor and in most of them the malignancy was either undifferentiated adenocarcinoma or signet-ring cell carcinoma. If a bone metastasis is found as the initial sign, physicians should keep in mind that the primary lesion might be in the stomach, or in the thyroid, kidney, lung or prostate as another point of search.

An unusual case of gastric carcinoma initially presenting bone metastasis and later transverse myelopathy.

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