Raynaud's phenomenon secondary to erenumab in a patient with chronic migraine

Raynaud''s phenomenon is a rare side effect of CGRP monoclonal antibodies. These molecular treatments are a relatively new class of drugs for the prevention of migraine. It is likely that we will see this side effect more often in the future. Patients with a background of Raynaud''s phenomenon may experience worsening of their symptoms if started on these treatments.     

影像技术在雷诺现象中的应用进展

雷诺现象是由于血管神经功能紊乱导致血管痉挛收缩、微循环障碍引起供血不足的一系列临床表现,是多种疾病的伴发症状,与疾病的进展及并发症有密切关系,是影响疾病预后及疗效的重要因素。随着技术的进步发展,越来越多的方法和技术被应用于雷诺现象的诊断及鉴别诊断。本文将影像技术在雷诺现象中的应用进展进行综述。     

Neurologic conditions: assessing medical fitness to drive

Clinicians are often asked to make an assessment on whether a patient is medically fit to drive, even though few have been formally trained in this area. Driving is a complex task that requires having adequate operational, cognitive and higher executive functions that work together. These functions can be compromised to a greater or lesser extent in neurological disorders, such as stroke, traumatic brain injury, peripheral neuropathy, dementia, Parkinson's disease and epilepsy. There is insufficient standardized information relating to impaired function at this time. Because of this, state laws vary in their assessment of medical conditions as they relate to driver licensing. Wisconsin laws are reviewed as an example. There are numerous assessment tests for various functions, but they lack a validated correlation with actual driving performance. These and other factors, as well as practical recommendations for the practicing physicians, are the subjects of this review.     

Ultrasound-guided injection of platelet-rich plasma in chronic Achilles and patellar tendinopathy

PurposeThe efficacy of platelet-rich plasma (PRP) in the treatment and healing of chronic tendinopathy through stimulation of cell proliferation and total collagen production has been demonstrated by both in vitro and in vivo studies. The aim of this study is to evaluate the effectiveness of ultrasound (US)-guided autologous PRP injections in patellar and Achilles tendinopathy.Materials and methodsAutologous PRP was injected under US-guidance into the Achilles and patellar tendons (30 Achilles tendons, 28 patellar tendons) in 48 prospectively selected patients (30 males, 18 females, mean age 38 ± 16 years, range 20–61 years). All patients were previously evaluated according to the Victoria Institute of Sport Assessment (VISA) scale, which assessed pain and activity level, and they all underwent US of the tendon before treatment and at follow-up after 20 days and 6 months. Statistical analysis was performed with Chi-square and Wilcoxon tests.Results20 days after PRP injection the patients presented a non-significant improvement of clinical symptoms. At the 6-month follow-up VISA score increased from a mean value of 57–75.5 (p < .01). US evaluation revealed a reduction of hypoechoic areas in 26 tendons (p < .01) associated with a widespread improvement of fibrillar echotexture of the tendon and reduced hypervascularity at power Doppler.ConclusionPRP injection in patellar and Achilles tendinopathy results in a significant and lasting improvement of clinical symptoms and leads to recovery of the tendon matrix potentially helping to prevent degenerative lesions. US-guidance allows PRP injection into the tendon with great accuracy.     

A case of acute exacerbation of chronic hepatitis C during the course of adrenal Cushing's syndrome

A 50‐year‐old woman with adrenal Cushing''s syndrome and chronic hepatitis C developed an acute exacerbation of chronic hepatitis C before adrenectomy. After administration of glecaprevir/pibrentasvir was started, her transaminase levels normalized promptly and a rapid virological response also was achieved. Laparoscopic left adrenectomy was then performed safely.     

Highly selective escape from KSHV-mediated host mRNA shutoff and its implications for viral pathogenesis

During Kaposi's sarcoma (KS)-associated herpesvirus (KSHV) lytic infection, many virus-encoded signaling molecules (e.g., viral G protein-coupled receptor [vGPCR]) are produced that can induce host gene expression in transiently transfected cells, and roles for such induced host genes have been posited in KS pathogenesis. However, we have recently found that host gene expression is strongly inhibited by 10-12 h after lytic reactivation of KSHV, raising the question of whether and to what extent de novo host gene expression induced by viral signaling molecules can proceed during the lytic cycle. Here, we show by microarray analysis that expression of most vGPCR target genes is drastically curtailed by this host shutoff. However, rare cellular genes can escape the host shutoff and are potently up-regulated during lytic KSHV growth. Prominent among these is human interleukin-6, whose striking induction may contribute to the overexpression of this cytokine in several disease states linked to KSHV infection.     

The effect of sympathetic blockade and cooling in Raynaud's phenomenon

Summary. Nineteen patients with Raynaud's phenomenon (12 suffering from generalized scleroderma [GS] and seven from primary Raynaud's phenomenon [PR] and seven cold-tolerant healthy women underwent a cooling challenge with combined body and finger cooling. Finger systolic blood pressure was measured at 30 and 15°C, before and after nervous blockade at the finger-base with lidocain. Finger/arm blood pressure ratio (FBP/armBP) at 30°C was significantly lower in GS as compared to controls and PR, and it did not change after nervous blockade in any group. FBP/armBP at 15°C, decreased to zero in all patients with Raynaud's phenomenon and to median 0–67 in controls, prior to nervous blockade. After nervous blockade, in response to cooling, FBP/armBP at 15°C decreased significantly and was comparable in all groups. We conclude that the sympathetic nervous system seems to play an important part in provoking Raynaud's phenomenon in PR and most GS.     

Kaposi’s sarcoma associated with chronic myeloid leukemia and imatinib mesylate therapy

Kaposi''s sarcoma is associated with immunosuppression and human herpesvirus 8 infection, while rarely described in myeloid malignancies. Here, we illustrate a rare case of chronic myeloid leukemia treated with imatinib, a tyrosine kinase inhibitor, who developed a human herpesvirus 8‐related Kaposi''s sarcoma.     

肠道超声检查在克罗恩病及其黏膜愈合的随访监测中的应用

克罗恩病（Crohn''s disease,CD）是炎症性肠病的一种,肠道超声检查（intestinal ultrasound,IUS）在CD患者初诊及随访中具有重要作用。相比于胃肠镜、磁共振肠道成像（magnetic resonance enterography,MRE）以及计算机断层扫描肠道成像（Computed tomography enterography,CTE）等检查方式,IUS具有无辐射、价格低廉、患者耐受好、重复性高等优点。实现和维持CD患者的黏膜愈合（Mucosal healing,MH）对维持临床缓解和无手术生存率有重要的临床意义。本文综述了IUS在CD及其MH中的应用现状     

脑深部电刺激术治疗帕金森病的进展与展望

脑深部电刺激术(deep brain stimulation,DBS)目前已成为国内外认可的帕金森病重要治疗方案。随着脑科学、手术方法、磁共振成像技术的不断发展,以及大量临床循证医学证据的逐渐完善,DBS治疗帕金森病在手术时机、靶点选择、症状控制、治疗机制、设备改进等方面均取得了较大的进展。但是,其在中轴运动症状和非运动症状的控制方面尚存在一些不足,设备、程控设置等方面也有待改进。     

Complement-dependent Proinflammatory Properties of the Alzheimer's Disease β-Peptide

Large numbers of neuritic plaques (NP), largely composed of a fibrillar insoluble form of the β-amyloid peptide (Aβ), are found in the hippocampus and neocortex of Alzheimer''s disease (AD) patients in association with damaged neuronal processes, increased numbers of activated astrocytes and microglia, and several proteins including the components of the proinflammatory complement system. These studies address the hypothesis that the activated complement system mediates the cellular changes that surround fibrillar Aβ deposits in NP. We report that Aβ peptides directly and independently activate the alternative complement pathway as well as the classical complement pathway; trigger the formation of covalent, ester-linked complexes of Aβ with activation products of the third complement component (C3); generate the cytokine-like C5a complement-activation fragment; and mediate formation of the proinflammatory C5b-9 membrane attack complex, in functionally active form able to insert into and permeabilize the membrane of neuronal precursor cells. These findings provide inflammation-based mechanisms to account for the presence of complement components in NP in association with damaged neurons and increased numbers of activated glial cells, and they have potential implications for the therapy of AD.     

Case of the month: rivastigmine (Exelon) toxicity with evidence of respiratory depression

Rivastigmine, which has been approved by the US Food and Drugs Administration for the treatment of Alzheimer's disease, is a non-competitive reversible inhibitor of acetylcholinesterase. We present a case of rivastigmine toxicity at a dose of 90 mg, with evidence of respiratory depression. To our knowledge, this case report provides evidence of the highest rivastigmine ingestion recorded (90 mg) that caused respiratory depression but requiring only supportive intervention without the need for ralidoxime. Emergency physicians should strongly consider cholinesterase inhibitor (rivastigmine, galantamine, and tacrine) ingestion in patients who present with short and temporary organophosphate-like toxidromes.     

Gait profile score and movement analysis profile in patients with Parkinson's disease during concurrent cognitive load

Background:

Gait disorders are common in individuals with Parkinson''s Disease (PD) and the concurrent performance of motor and cognitive tasks can have marked effects on gait. The Gait Profile Score (GPS) and the Movement Analysis Profile (MAP) were developed in order to summarize the data of kinematics and facilitate understanding of the results of gait analysis.

Objective:

To investigate the effectiveness of the GPS and MAP in the quantification of changes in gait during a concurrent cognitive load while walking in adults with and without PD.

Method:

Fourteen patients with idiopathic PD and nine healthy subjects participated in the study. All subjects performed single and dual walking tasks. The GPS/MAP was computed from three-dimensional gait analysis data.

Results:

Differences were found between tasks for GPS (P<0.05) and Gait Variable Score (GVS) (pelvic rotation, knee flexion-extension and ankle dorsiflexion-plantarflexion) (P<0.05) in the PD group. An interaction between task and group was observed for GPS (P<0.01) for the right side (Cohen''s ¯d=0.99), left side (Cohen''s ¯d=0.91), and overall (Cohen''s ¯d=0.88). No interaction was observed only for hip internal-external rotation and foot internal-external progression GVS variables in the PD group.

Conclusions:

The results showed gait impairment during the dual task and suggest that GPS/MAP may be used to evaluate the effects of concurrent cognitive load while walking in patients with PD.     

KSHV vFLIP is essential for the survival of infected lymphoma cells

Primary effusion lymphomas (PELs) associated with infection by the Kaposi's sarcoma-associated herpesvirus (KSHV/HHV-8) have constitutive nuclear factor (NF)-kappaB activity that is essential for their survival, but the source of this activity is unknown. We report that viral FADD-like interleukin-1-beta-converting enzyme [FLICE/caspase 8]-inhibitory protein (FLIP) activates NF-kappaB more potently than cellular FLIP in B cells and that it is largely responsible for NF-kappaB activation in latently infected PEL cells. Elimination of vFLIP production in PEL cells by RNA interference results in significantly decreased NF-kappaB activity, down-regulation of essential NF-kappaB-regulated cellular prosurvival factors, induction of apoptosis, and enhanced sensitivity to external apoptotic stimuli. vFLIP is the first virally encoded gene shown to be essential for the survival of naturally infected tumor cells.     

复发库欣病患者二次手术治疗后缓解影响因素分析

目的:分析接受再次手术的复发性库欣病患者的缓解率及其影响因素。方法:回顾性分析2003年1月至2018年12月行第2次经蝶手术的22例复发性库欣病患者(随访超过6个月)的临床资料。分析患者第2次术前生化指标、双侧岩下窦静脉采血结果、MRI结果。同时评估术后血清皮质醇、24 h尿游离皮质醇(urinary free cortisol, UFC)和病理结果。术后缓解定义为术后血皮质醇小于50μg/L或者24 h UFC值处于正常范围。分析两次术前MRI结果、促肾上腺皮质激素(ACTH)水平、24 h UFC、肿瘤大小等因素与第2次术后缓解的相关性。结果:16例(72.7%)患者在第2次术后获得缓解,平均随访时间为64.5个月。22例患者初次术前均有明显库欣病影像学证据,其中有8例(36.4%)再次手术前无复发的明显影像学证据。MRI显示存在垂体占位的14例患者中10例(71.4%)再手术后缓解;8例MRI未显示明显肿瘤的患者中6例于再次手术后缓解。微腺瘤患者(75.0%,15/20)的再手术后缓解率略优于大腺瘤患者(50.0%,1/2),但差异无统计学意义。缓解患者二次术前ACTH和UFC水平均低于术后未缓解组,但差异无统计学意义。二次术后,病理结果显示有ACTH阳性腺瘤证据的患者有更高的缓解率(86.7%vs 42.9%,P0.05),而复发时的年龄较大非手术结果的不利因素。结论:二次手术对于初次手术后复发的库欣病患者是一个较好的选择,而其远期效果须延长随访时间进一步验证,缓解相关因素须增加病例进一步筛选。     

Effect of educational outreach on general practice prescribing of antibiotics and antidepressants: A two-year randomised controlled trial

Objective

Prescribing of broad spectrum antibiotics and antidepressants in general practice often does not accord with guidelines. The aim was to determine the effectiveness of educational outreach in improving the prescribing of selected antibiotics and antidepressants, and whether the effect is sustained for two years.

Design

Single blind randomized trial.

Setting

Twenty-eight general practices in Leicestershire, England.

Intervention

Educational outreach visits were undertaken, tailored to barriers to change, 14 practices receiving visits for reducing selected antibiotics and 14 for improving antidepressant prescribing.

Main outcome measures

Number of items prescribed per 1000 registered patients for amoxicillin with clavulanic acid (co-amoxiclav) and quinolone antibiotics, and average daily quantities per 1000 patients for lofepramine and fluoxetine antidepressants, measured at the practice level for six-month periods over two years.

Results

There was no effect on the prescribing of co-amoxiclav, quinolones, or fluoxetine, but prescribing of lofepramine increased in accordance with the guidelines. The increase persisted throughout two years of follow-up.

Conclusion

A simple, group-level educational outreach intervention, designed to take account of identified barriers to change, can have a modest but sustained effect on prescribing levels. However, outreach is not always effective. The context in which change in prescribing practice is being sought, the views of prescribers concerning the value of the drug, or other unrecognised barriers to change may influence the effectiveness of outreach.     

乳腺外佩吉特病的超声特征

目的 探讨乳腺外佩吉特病（EMPD）的超声声像图特征。方法 回顾性分析经病理证实的41例EMPD患者的超声资料及声像图特征。结果 41例中,病灶位于外阴33例,腹股沟2例,肛周2例,上胸壁1例,下腹壁1例,额部1例,拇指1例。超声检出病变36例,根据形态可分为弥漫型和肿块型。弥漫型31例,均表现为形态不规则、边缘不清的弥漫性病变,超声显示皮肤增厚30例,无增厚1例;病灶呈低回声8例,稍低回声23例;CDFI血流分级0级2例,1级6例,2级11例,3级12例;腹股沟淋巴结异常9例。肿块型5例,均表现为边缘清晰的肿块样病变,超声显示皮肤增厚1例,无增厚4例;肿块内部呈低回声3例,稍低回声2例;形态规则4例,不规则1例;CDFI血流分级0级1例,1级2例,2级1例,3级1例;腹股沟淋巴结异常3例。5例（5/41,12.20%）超声未见明显异常。结论 超声可敏感识别EMPD病变区回声异常及血流异常,诊断EMPD需结合临床表现。     

Management of lytic bone disease in lymphoplasmacytic lymphoma: A case report and review of the literature

Waldenström macroglobulinemia (WM)/lymphoplasmacytic lymphoma (LPL) is often differentiated from myeloma based on the presence of lytic bone lesions (LBL). However, WM/LPL can present with LBL, and management is poorly understood. We describe a case of an 81‐year‐old woman with LPL who presented with LBL and was successfully treated with chemoimmunotherapy.