Delayed Parkinsonism after CO Intoxication: Evaluation of the Substantia Nigra with Inversion-Recovery MR Imaging

Purpose: To quantitatively investigate signal alterations of the substantia nigra in patients with delayed parkinsonism following CO intoxication, as seen on gray matter (GM)-suppressed inversion-recovery (IR) magnetic resonance (MR) images. Materials and Methods: This prospective study was approved by the local institutional review board, and written informed consent was obtained from all subjects. Thirteen patients with delayed onset of CO-induced parkinsonism (nine men and four women; mean age, 40.3 years), 13 age-matched CO-intoxicated patients without parkinsonism, and 13 age-matched healthy volunteers were examined with GM-suppressed IR MR imaging. The signal intensity of the substantia nigra was normalized to the adjacent normal-appearing white matter in the temporal lobe, followed by semiautomatic segmentation into medial, middle, and lateral parts by using a skeleton-based algorithm. Multivariate and univariate analyses and Spearman rank correlation test were performed to examine the relationships between variables. Clinical severity was assessed with the modified Hoehn and Yahr rating scale. Results: The normalized signal ratios in the middle and lateral segments of the substantia nigra were significantly higher in those with CO-induced parkinsonism, compared with those with CO intoxication without parkinsonism or normal volunteers (P = .02). For the medial segments, the ratios showed no significant differences among the groups. The normalized signal ratios of substantia nigra were correlated with the severity of parkinsonism, particularly in the lateral segments (ρ = 0.927, P < .001). Conclusion: CO toxicity to the substantia nigra plays a role in pathophysiologic mechanisms of CO-induced parkinsonism. GM-suppressed IR MR imaging is a useful tool in depicting substantia nigra injury following CO intoxication. ? RSNA, 2012.     

Randomized trial of vitamin D3 to prevent worsening of musculoskeletal symptoms in women with breast cancer receiving adjuvant letrozole. The VITAL trial

Purpose

Aromatase inhibitor-associated musculoskeletal symptoms (AIMSS) frequently occur in women being treated for breast cancer. Prior studies suggest high prevalence of vitamin D deficiency in breast cancer patients with musculoskeletal (MS) pain. We conducted a randomized, placebo-controlled trial to determine if 30,000 IU vitamin D3 per week (VitD3) would prevent worsening of AIMSS in women starting adjuvant letrozole for breast cancer.

Methods

Women with stage I–III breast cancer starting adjuvant letrozole and 25(OH)D level ≤40 ng/ml were eligible. All subjects received standard daily supplement of 1200 mg calcium and 600 IU vitamin D3 and were randomized to 30,000 IU oral VitD3/week or placebo. Pain, disability, fatigue, quality of life, 25(OH)D levels, and hand grip strength were assessed at baseline, 12, and 24 weeks. The primary endpoint was incidence of an AIMSS event.

Results

Median age of the 160 subjects (80/arm) was 61. Median 25OHD (ng/ml) was 25 at baseline, 32 at 12 weeks, and 31 at 24 weeks in the placebo arm and 22, 53, and 57 in the VitD3 arm. There were no serious adverse events. At week 24, 51% of women assigned to placebo had a protocol defined AIMSS event (worsening of joint pain using a categorical pain intensity scale (CPIS), disability from joint pain using HAQ-II, or discontinuation of letrozole due to MS symptoms) vs. 37% of women assigned to VitD3 (p = 0.069). When the brief pain inventory (BPI) was used instead of CPIS, the difference was statistically significant: 56 vs. 39% (p = 0.024).

Conclusions

Although 30,000 IU/week of oral vitamin D3 is safe and effective in achieving adequate vitamin D levels, it was not associated with a decrease in AIMSS events based on the primary endpoint. Post-hoc analysis using a different tool suggests potential benefit of vitamin D3 in reducing AIMSS.

     

Risk reduction of long-term major adverse cardiovascular events after endoscopic thoracic sympathectomy in palmar hyperhidrosis

Purpose

Palmar hyperhidrosis (PH) is excessive sweating of the palms resulting from sympathetic overactivity, and patients who undergo endoscopic thoracic sympathectomy (ETS) show reduced cardiac demand after 1 year and improved cerebral perfusion within 2–4 weeks. However, the long-term risks of major adverse cardiovascular events (MACE) following ETS remain unclear.

Methods

We searched the Longitudinal National Health Insurance Database in Taiwan and identified PH patients (International Classification of Disease, Ninth Revision, Clinical Modification diagnostic code 708.8) from the outpatient database and patients who underwent ETS (procedure code 05.29) from the inpatient database between 2000 and 2010; furthermore, we excluded patients younger than 18 years of age or older than 65 years of age. We defined MACE as stroke (diagnostic codes 430–437), myocardial infarction (diagnostic code 410), or death. Patients followed until the first cardiac event or December 31, 2010. Risk factors were identified using a multivariable Cox proportional hazards regression.

Results

The incidence of MACE was significantly lower in patients with ETS (0.76%) than without (1.67%). In PH patients, ETS significantly reduced the risk of MACE (adjusted hazard ratio 0.473; 95% confidence interval 0.277–0.808).

Conclusion

PH patients who underwent ETS showed a reduced risk of MACE over a long-term follow-up period. This result could provide support for patients with PH who are considering undergoing ETS because of its additional cardiovascular benefits.

     

Incidence of hip replacement among national health insurance enrollees in Taiwan

Background  

There is no national joint replacement registry in the country of Asia and reports of national outcomes of joint replacement in Asia as yet. Therefore, this study was then to report a national data of the number of hip replacements, incidence rate, demographic characteristics of hip replacement patients, and short-time survival rate after hip replacement of Han Chinese in Taiwan.     

A nanoscale drug-entrapment strategy for hydrogel-based systems for the delivery of poorly soluble drugs

The hydrophilic nature of hydrogel matrices makes them disadvantageous to entrap poorly soluble therapeutic agents and greatly restricts their applications as drug-delivery systems. In this study, we demonstrated that sustained delivery of lipophilic drugs in hydrogel-based devices can be readily achieved by enhancing retention of drugs within micelles. This nanoscale drug-entrapment strategy was applied to develop a polymeric drug-eluting stent. Sirolimus, a lipophilic anti-proliferative/immunosuppressive drug, was entrapped into the hydrophobic core of Pluronic L121 micelles and then blended in a chitosan-based strip and crosslinked by an epoxy compound to fabricate test stents. It was found that the use of such a nanoscale drug-entrapment strategy was able to significantly increase the loading efficiency of lipophilic drugs, prevent the drug from aggregation and beneficially reduce its initial burst release; thus, the duration of drug release was extended considerably. When implanting the stent in rabbit infrarenal abdominal aortas, in-stent restenosis was markedly reduced and less inflammatory reaction was observed, while unfavorable effects such as delayed endothelial healing caused by the overdose of sirolimus could be significantly evaded.     

Intravascular Pyogenic Granuloma Arising in an Acquired Arteriovenous Malformation: Report of a Case and Review of the Literature

BACKGROUND: Pyogenic granuloma, also known as lobular capillary hemangioma, is a benign vascular skin tumor. Intravascular variant of this vascular tumor is rare and such a variant arising in another hemangioma is extremely unusual. OBJECTIVE: The objective was to present a patient with an intravascular pyogenic granuloma arising in an acquired arteriovenous malformation of the palm. METHODS: We report a case and review the literature. RESULT: A 44-year-old woman presented with an easy-bleeding and ulcerative nodule with a hyperkeratotic collaret on her right palm for 3-4 months. The nodule measured 6 x 6 mm in size and was tender. Under the clinical impression of pyogenic granuloma, the lesion was totally excised and the microscopic examination revealed an intravascular pyogenic granuloma in the papillary dermis with an underlying arteriovenous malformation. CONCLUSION: A rare composite vascular tumor is reported, and our case presented as a red eroded nodule surrounded by a keratotic collaret, which was easily misdiagnosed as pyogenic granuloma clinically. We suggest that any pyogenic granuloma-like lesion should be palpated carefully, and if a nodule is present, surgical excision rather than cryotherapy or laser ablation should be considered.     

Treatment for axillary osmidrosis with suction-assisted cartilage shaver.

Axillary osmidrosis is a common and distressing social problem for many. Topical astringents are temporary and inadequate. Permanent solutions often involve invasive surgical treatment. This study is to evaluate the effectiveness and advantages of treating axillary osmidrosis with suction-assisted cartilage shaver. Eighty-nine patients with osmidrosis were treated with suction-assisted cartilage shaver under local anesthesia on an outpatient basis. Patients were followed-up and surveyed for satisfaction with surgery by completing a questionnaire. Of the 89 patients, 82 patients (92.1%) expressed positive satisfaction with the procedure. In the elimination of odour, a total of 81 patients (91.0%) ranked good to excellent, and seven patients (7.9%) expressed fair results. All of the 89 patients (100%) detected the clearing of wound induration within 3 months. Eighty patients (89.9%) felt their arms were back in full range of movement within 1 month, and all had such hindrance resolved within 2 months. Thus, the procedure proved itself a promising treatment for the removal of sweat glands with advantages of a short operation time, inconspicuous scar, and a rapid recovery for returning to daily activities.