ISSN:0004-8461    

DOI:10.1111/j.1440-1673.1967.tb01541.x

出版商:Blackwell Publishing Ltd    

年代:1967

数据来源: WILEY

ISSN:0004-8461    

DOI:10.1111/j.1440-1673.1967.tb01542.x

出版商:Blackwell Publishing Ltd    

年代:1967

数据来源: WILEY

摘要:

SUMMARYTwo notable “firsts” are described: the opening of the Department of Medical History in the University of Melbourne, the first such department in an Australian medical school and coinciding with this event there was arranged the first seminar on Medical History to be held in this coun

ISSN:0004-8461    

DOI:10.1111/j.1440-1673.1967.tb01543.x

出版商:Blackwell Publishing Ltd    

年代:1967

数据来源: WILEY

ISSN:0004-8461    

DOI:10.1111/j.1440-1673.1967.tb01544.x

出版商:Blackwell Publishing Ltd    

年代:1967

数据来源: WILEY

摘要:

SUMMARY1On initiating micturition in urinary bladders associated with reflux, there appears to be a normal descent of the bladder neck and pelvic floor. Except in cases of neuro‐muscular incoordination and uncommon urethral lesions, the intravesical pressures and urethra appear normal. The ureters also show peristaltic activity. The primary fault appears to lie in the distal 2 cm. of the ureter, that is, where it passes obliquely through the bladder wall. Because of the variation in the time and quantity of reflux, there may be some secondary, as yet undefined, factor involved.2This review confirms previously held impressions that the cause of reflux in the vast majority of otherwise normal children is in the faulty insertion of the ureter into the bladder. The ureters associated with reflux pass straight through the bladder wall and the ureteric orifice “gapes” when seen on cystoscopy. There is no oblique passage of the ureter through the bladder wall. The mechanisms of micturition and the pressure relationships are perfectly normal in these children.3It is impossible to exclude even gross reflux on an excretory pyelogram. This fact is not yet fully appreciated. Reflux was also present in a much larger number of patients than is at present appreciated by the medical profession. Thirty‐seven per cent, of patients examined showed reflux on cinecystography. Ten per cent, of patients examined showed reflux on cinecystography, despite a normalIf intravenous pyelography is used as a screening test for reflux, 10% of cases will be missed. In other words, this review shows the indications for cinecystography to be clinical–not radiological. It would appear to be medical negligence to reserve cinecystography for those patients showing pathological changes on the intravenous pyelogram in the presence of infection.The total error of prediction of vesico‐ureteric reflux on the intravenous pyelogram is 20%. This emphasizes the errors made if one relies on static appearances for diagnosing dynamic phenomena.4There is no relationship between infection and the aetiology of reflux. Only 28% of cases with reflux showed infection at the time of the cinecystogram, and some of these were cases of unilateral reflux.5This review shows that it is infection and not reflux which causes destruction of renal cortex, i.e., chronic pyelonephritis. Cases of reflux in meningomyelocele with an ileal loop bladder did not show renal cortical destruction despite gross reflux. In fact, as the ileal loop bladder facilitated control of urinary infection, renal function improved post‐operatively in 50%, and renal deterioration was arrested in a further 40% of cases for periods of up to 36 months. These findings negate the views of Hodson and Edwards (1960) that reflux causes renal cortical destruction. In fact, renal function is improving despite reflux. It is seen that all the cases of renal cortical destruction showed vesico‐ureteric reflux into the associated ureter.It is seen that all the cases of renal cortical destruction–23 or 6% of patients–had been subject to recurrent urinary tract infections with a variety of organisms. The correlation of these findings strongly points to infection as being the cause of the renal damage.6In those cases showing renal cortical destruction reflux was marked. In 88% of kidneys showing scars, the reflux reached the renal pelvis and calyces, and in 72% of kidneys showing scars the reflux occurred not only on micturition but also on filling the bladder.7This review shows that the intravenous pyelogram may demonstrate abnormalities previously considered sufficient cause for renal infection or cortical destruction, e.g., pelvi‐ureteric obstruction. However, reflux can occur into these ureters, with the result that curing the proximal pathology removes an “in‐built protection” against ascending infection. Thus no matter what the intravenous pyelogram findings all patients with a proven urinary tract infection must be fully investigated by an intravenous pyelogram and a cinecystogram.8Reflux must predispose to renal cortical destruction in some way. This is demonstrated by those cases showing renal cortical loss localized to that area drained by the half of a double‐collecting system into which reflux occurs. At the same time the area of renal cortex drained by that half of the double‐collecting system into which no reflux occurs is normal.9This review shows that bladder neck obstruction is a myth.10Double or triple micturition, assiduously applied, will empty the bladder even if there is a large post‐micturition residue on the intravenous pyelogram.11Urinary infection is commoner in female children, reflux is commoner in female children, and destruction of renal cortical tissue is commoner in female children. Destruction of renal cortex can be present from birth onwards. Reflux diagnosed under two years of age has a particularly bad prognosis.12Reflux tends to diminish in some patients as puberty approaches, but it may increase with age in others.13As a result of this review, the author feels the medical treatment of these children must be modified. For medical treatment to succeed, it must either(a) control infection, or(b) control the reflux, or(c) preferably control both.(a) ontrol of the infection can only be obtained with full parental co‐operation associated with three‐monthly analyses of fresh specimens of urine. Urine in patients with reflux can be kept sterile.(b) Control of the reflux. Double or triple micturition is, of course, not a control of the reflux, but it is an effort to negate the effects of the reflux.(c) Preferably control both. A combination of “laboratory‐controlled” long‐term chemotherapy and triple micturition.Some intelligence is required of the parents for this treatment to be undertaken satisfactorily.(b) Recurrent infection.14This review shows that destruction of renal cortex may occur in less than twelve months. In order to prevent this, surgical correction of the anatomy of the lower ureter must be undertaken, but the main indications are considered by the author to be:(a) Marked reflux, i.e. reflux occurring as the bladder fills and reflux that reaches the calyces.It istoo lateto wait until renal scars are present to perform surgery for correction of the reflux. Surgery will offer an 80–85% chance of complete cure of the reflux, and this cure rate may rise as more experience is obtained.15This review shows that with the equipment at present available the cinecystogram is the only adequate method of demonstrating vesico‐ureteric reflux. Contrary to some current opinions, the author firmly believes that in paediatrics all other methods of investigation will cause misdiagnosis and mismanagement, with regrettable and irreversible consequences.Any additional radiation to the patient is insignificant when compared to the irretrievable damage that may be caused by allowing reflux to go undetected.In order to perform the examination competently, a dynamic recording is required. The cine camera is the only adequate means at present available.16Under no circumstances must vesico‐ureteric reflux be ignored, and no urinary infection should be left uninvestigated or, worse, half‐investigated.

ISSN:0004-8461    

DOI:10.1111/j.1440-1673.1967.tb01545.x

出版商:Blackwell Publishing Ltd    

年代:1967

数据来源: WILEY

摘要:

SUMMARYTwenty‐nine cases of arterial embolus of the lower limbs over an eight‐year period are reviewed from the case records of this hospital. Of these, 18 patients were in atrial fibrillation and 19 finally died. Of the total, five were subjected to arteriography. All five presented an appearance of block in the arterial tree, a block which in each case presented a crescentic upper margin, with convexity proximal which it is considered may be characteristic of embolus. The sites of block were in four the popliteal artery and in one the external iliac artery. Of the five patients, three underwent embolectomy and in the other two there was little clinical doubt that the obstruction was in fact due to embolus. It is suggested that this arterio‐graphic picture may in some cases be useful in differentiating embolic from thrombotic arterial obstru

ISSN:0004-8461    

DOI:10.1111/j.1440-1673.1967.tb01546.x

出版商:Blackwell Publishing Ltd    

年代:1967

数据来源: WILEY

摘要:

SUMMARYAttention is confined to injuries to catheters and guide wires as complications of arteriography, as opposed to mechanical damage to the arterial system, or effects attributable to the contrast medium, although it is acknowledged that not infrequently damage to an equipment part will also involve arterial injury. Two illustrative cases are reported, one of knotting of a transfemoral catheter in the distal aortic arch, and one of breakage of the flexible tip of the guide wire in attempting to negotiate a tortuous innominate bifurcation with a right transaxillary catheter. Possible technical factors underlying the equipment injury in each case are analysed critically, and refinements of technique and equipment suggested to avoid such injury. Reports of other forms of arterial equipment damage and of injury to similar equipment in other parts of the vascular system are briefly reviewed.

ISSN:0004-8461    

DOI:10.1111/j.1440-1673.1967.tb01547.x

出版商:Blackwell Publishing Ltd    

年代:1967

数据来源: WILEY

摘要:

SUMMARYPercutaneous transfemoral catheterization with selective carotid and vertebral angiography was employed in the investigation of 100 consecutive patients with subarachnoid haemorrhage. The method, which is described in detail, has many advantages and is considered the technique of choice in patients under 60 years of age. The carotid and vertebral systems are studied at the one examination with minimal discomfort to the patient. Haematomata in the neck are avoided and cross‐compression tests are performed with ease. In addition, renal arteriography, often significant because of the frequency of hypertension, may be performed at the same time. Of the 63 patients who were less than 50 years of age, it was possible to selectively catheterize both carotid arteries and obtain satisfactory vertebral angiograms in all but five cases. Over 50 years, because of arterial degeneration, the frequency with which it was necessary to supplement the method with other techniques increase

ISSN:0004-8461    

DOI:10.1111/j.1440-1673.1967.tb01548.x

出版商:Blackwell Publishing Ltd    

年代:1967

数据来源: WILEY

ISSN:0004-8461    

DOI:10.1111/j.1440-1673.1967.tb01549.x

出版商:Blackwell Publishing Ltd    

年代:1967

数据来源: WILEY

摘要:

SUMMARYAlthough scanning is performed for purposes other than the detection of cold tumours, it was felt that this was a logical basis for a method of investigating and comparing the image‐producing properties of various radioisotopes. The method involves the measurement of the contrast for a cold sphere in a tank of radioisotope. Contrast is denned as the percentage change in the counting rate of the tank when the sphere is placed in it, in the field of view of the detector. It depends, to a varying extent, on a number of factors:1The size of the sphere2the depth of the sphere below the surface3the depth of the tank4the spatial resolution of the collimator at the position occupied by the sphere5the collimator‐tank distance6the amount of scattered radiation included in the counting rate7the energy of the primary gamma rays.The contrast for a cold sphere in the surface of a tank, at the required distance from a particular collimator, is measured directly, but its value at other depths is most easily and accurately found by an indirect method. The variation of contrast with depth is due to the variation with depth of the response of the sphere of activity displaced by the cold sphere. This response is obtained from the response of a hot sphere in air–which will be the same for all radioisotopes for which septum penetration is negligible–by correcting for attenuation in water. The latter corrections are easily obtained from the response of a plane source containing the radioisotope being studied. The contrast for a sphere at any depth is then obtained by multiplying its value in the surface by the ratio of the response for a hot sphere at the required depth to that in the surface.This method was used to determine the contrast for a 3 cm. sphere under various conditions using three broad‐focus medium‐energy collimators with essentially the same resolution (1–5 cm.). Radioisotopes emitting primary photons in the range 77 to 364 KeV. were used. It was shown that the contrast for the sphere in the surface was greater for a radioisotope emittinglow‐energy photons butfor positions deep in the phantom it was greater for one emitting photons of higher energy, while at some intermediate depth it was the same for both. The result is that, in practice, over a wide range of depths there is no significant difference between the contrast for the radioisotopes emitting photons in the energy range studied.Due to the variations in the spatial resolution with depth of all collimators, contrast is very dependent on collimator‐organ distance. It has been shown in one instance that the change in contrast due to a change of 2 cm. in this distance produces a greater variation in the contrast than would be obtained by substituting131I for197Hg. In practice the distance chosen will depend on the thickness of the organ and the depth at which maximum contrast and detail are required. When scanning a large organ for maximum detail, this effect will necessitate frequent adjustment, during scanning, of the height of the detector above the patient.Since, for geometrical reasons, the spatial resolution varies more widely for a collimator used with a 5 in. detector than for one used with a 3 in. detector, the variation of contrast with collimator‐organ distance varies more widely with the former, especially when the sphere is situated between the collimator and the focus.In spite of the very considerable contribution of scattered photons to the counting rate when low energies (77 KeV.) are used, the results of contrast measurements, using the methods described, have shown that there should be no significant difference in the quality of scans obtained using radioisotopes emitting gamma rays in the range considered. These conclusions have been confirmed by phantom studies. In cases where the dose to the patient depends primarily on gamma‐ray absorption, emitters of photons with energy as low as 77 KeV. May therefore be used, with reduced dose to the patient, without significantly pre

ISSN:0004-8461    

DOI:10.1111/j.1440-1673.1967.tb01550.x

出版商:Blackwell Publishing Ltd    

年代:1967

数据来源: WILEY