The effect of high-dose steroids on MRI gadolinium enhancement in acute demyelinating lesions

Gadolinium (Gd) enhancement of brain lesions by MRI is a marker of active blood-brain barrier damage secondary to an inflammatory process. We studied the effects of high-dose (1,000 mg/d) intravenous (IV) methylprednisolone (Mp) for 4 to 8 days on Gd-enhancing lesions in seven patients with acute demyelinating diseases and compared pretreatment brain MRIs with studies obtained 1 to 4 days after treatment. Five patients had complete suppression, and two had significant suppression of Gd enhancement following treatment. In addition, six of seven patients had Gd-enhancing lesions that explained their clinical signs; in five of six of these patients, suppression of the Gd-enhanced lesions temporally correlated with clinical improvement. Thus, short courses of high-dose IV Mp suppress Gd enhancement in acute demyelinating lesions, and this correlates with clinical improvement.     

Effects of sevelamer and calcium on coronary artery calcification in patients new to hemodialysis

BACKGROUND: Hemodialysis patients are at increased risk for progressive coronary artery calcification; however, the development and progression of this disease process in patients new to hemodialysis is unknown. METHOD: One hundred and twenty-nine patients new to hemodialysis were randomized to receive calcium containing phosphate binders or the noncalcium phosphate binder sevelamer hydrochloride. Subjects underwent electron beam computed tomography scanning (EBCT) at entry into the study and again at 6, 12, and 18 months. RESULTS: One hundred and nine patients underwent baseline and at least one additional assessment of coronary calcification. At baseline, 37% of sevelamer treated and 31% of calcium treated patients had no evidence of coronary calcification. No subject with a zero coronary artery calcium score (CACS) at baseline progressed to a CACS >30 over 18 months. Subjects with a CACS > 30 at baseline showed progressive increases in CACS in both treatment arms (P < 0.05 for each time point in both groups). Subjects treated with calcium containing phosphate binders showed more rapid and more severe increases in CACS when compared with those receiving sevelamer hydrochloride (P= 0.056 at 12 months, P= 0.01 at 18 months). CONCLUSION: New hemodialysis patients with no evidence of coronary calcification showed little evidence of disease development over 18 months independent of phosphate binder therapy. However, subjects with evidence of at least mild coronary calcification had significant progression at 6, 12, and 18 months. Use of calcium containing phosphate binders resulted in more rapid progression of coronary calcification than did use of sevelamer hydrochloride.     

Prevalence and risk indicators of oral mucosal lesions in an urban population from South Brazil

Oral Diseases (2011) 17 , 171–179 Objective: The objective of the study was to assess the prevalence of oral mucosal lesions (OML) and to perform a multivariable risk assessment of demographic, socioeconomic, behavioral, and oral risk indicators for its occurrence in an urban population in South Brazil. Methods: This cross‐sectional study selected 1586 subjects (719M/867F, age: 14–104 years) using a multistage probability sampling strategy (65.1% response rate). Prevalence, odds ratios (OR), and confidence intervals (95% CI) were calculated accounting for the survey design. Results: Leukoplakia and lichen planus were observed in 1.01% and 1.02% of subjects, respectively. In the multivariable analysis, these lesions were significantly associated with moderate/heavy smoking (OR = 9.0, 95% CI = 2.1–39.1) and heavy drinking (OR = 2.0, 95% CI = 1.1–3.7). Candidiasis and proliferative lesions were observed in 14.09% and 3.80% of the subjects, respectively. These lesions were significantly associated with female gender (OR = 2.2, 95% CI = 1.5–3.2 and OR = 1.7, 95% CI = 1.0–2.8), older age (OR = 22, 95% CI = 8.0–60.8 and OR = 8.9, 95% CI = 3.4–23.7), and low socioeconomic status (OR = 1.9, 95% CI = 1.0–3.5 and OR = 3.0, 95% CI = 1.2–7.2). Conclusions: This population is in need of OML prevention and treatment. Future studies should validate the findings that premalignant lesions are causally related to smoking and alcohol consumption, and that other OML are associated with socioeconomic‐demographic disparities in this and similar populations.     

An anatomical study of the palmar cutaneous branch of the median nerve

We present an anatomical study of the palmar cutaneous branch of the median nerve emphasizing its frequency, origin, perforation point at the transverse carpal ligament, point of emergence in the palm, width, length, divisions and innervation territory. For this purpose, fifty cadaver hands were dissected under a stereomicroscope and/or magnifying glass. The origin of the palmar cutaneous branch (PCB) was on the average 4.56 cm proximal to conventionally named "zero point" on the most distal transverse volar wrist crease. Perforation of the aponeurosis occurred on average 0.79 cm from the mentioned point and its emergence in the palm at 0.76 cm. The nerve had an average length of 5.24 cm. PCB's divisions in the palm resulted in a medial branch in 42%, a lateral branch in 92% and an intermediate branch in 100% of the hands studied. In six specimens PCB presented a deep branch which was directed toward the thenar eminence or made communication with the superficial branch of the palmar digital nerve or still penetrated between the first or second metacarpal. In 4% of the cases there was a communicating branch between the superficial branch of the radial nerve and the PCB. These anatomical results should be considered in the evaluation of the best surgical techniques for decompression of the median nerve in the carpal tunnel.     

Clearance kinetics of parasites and pigment-containing leukocytes in severe malaria

In tropical areas, where unsupervised use of antimalarial drugs is common, patients with an illness consistent clinically with severe malaria but with negative blood smears pose a management dilemma. Malaria pigment is evident in peripheral blood leukocytes in greater than 90% of patients with severe malaria. To characterize the clearance kinetics of parasitized erythrocytes and malaria pigment-containing leukocytes, sequential peripheral blood and intradermal smears were assessed in 27 adult Vietnamese patients with severe falciparum malaria. The clearance of parasitized erythrocytes and pigment- containing monocytes (PCMs) followed first order kinetics. The elimination of pigment-containing neutrophils (PCNs) was first order initially, but deviated from this when counts were low. Clearance of peripheral blood PCMs (median clearance time, 216 hours; range, 84 to 492 hours) was significantly slower than that of parasitized erythrocytes (median, 96 hours; range, 36 to 168 hours) or PCNs (median, 72 hours; range, 0 to 168 hours; P < .0001). Intradermal PCM clearance times were the longest of all (median, 12 days; range, 6 to 23 days; significantly longer than peripheral blood PCM clearance, P < .001). Twenty-one (88%) patients still had signs, symptoms, or laboratory features of severe malaria after parasite clearance but before phagocyte pigment clearance. Sixteen of the 23 surviving patients (70%; 95% confidence interval, 50% to 87%) still had intraleukocytic malaria pigment on peripheral blood films 72 hours after parasite clearance. Thus, by determining the distribution of malaria pigment in peripheral blood and intradermal phagocytes, the time since effective antimalarial treatment started can be estimated. Microscopy for intraleukocytic pigment is valuable in the differential diagnosis of severe febrile illnesses in malarious areas where uncontrolled use of antimalarial drugs is widespread.     

Correlates of sleep and pediatric bipolar disorder

STUDY OBJECTIVE: To determine, based on a large community sample, the prevalence and associated sleep characteristics of children with a bipolar mood disturbance behavioral profile. METHODS: Participants who fit the pediatric bipolar disorder profile as derived from the Child Behavior Checklist were matched to control participants for age, sex, ethnicity, parentally reported attention-deficit/hyperactivity disorder, psychotropic medication usage, and apnea-hypopnea indexes. Paired comparisons were made between the groups to examine differences on polysomnographic data and parentally reported sleep characteristics. RESULTS: Thirteen (approximately 3%) of 438 participants fit the pediatric bipolar disorder profile. These children demonstrated significant sleep-continuity disturbances with poorer sleep efficiency and more awakenings after sleep onset, less rapid eye movement sleep, and longer periods of slow-wave sleep than their matched counterparts during overnight polysomnography. In addition, responses to a parental-report questionnaire about child sleep behavior suggest these children have significant sleep problems, including more difficulty initiating sleep, restless sleep, nightmares, and morning headaches relative to the control group. CONCLUSIONS: Children with a pediatric bipolar disorder profile display consistent quantitative differences in sleep relative to matched controls. Prevalence rates of pediatric bipolar disorder, as assessed by the Child Behavior Checklist, are consistent with those found in the adult bipolar population.     

Fatal Bacillus cereus endocarditis masquerading as an anthrax-like infection in a patient with acute lymphoblastic leukemia: case report

A 38-year-old male farm worker with relapsing acute lymphoblastic leukemia spontaneously developed an ulcerating ulcer on his anterior thigh which was surrounded by a non-tender area of erythema. Bacillus cereus was isolated from the ulcer and blood, and the patient received intravenous penicillin and vancomycin for one week. When sensitivity studies were returned he was treated with gatifloxacin orally. After two weeks of combined antimicrobial therapy and negative blood cultures, the patient received combination chemotherapy with vincristine, prednisone, doxorubicin and cyclophosphamide. He was hospitalized a day after completing chemotherapy with neutropenic sepsis due to B. cereus. He received similar antimicrobial therapy as previously, but died three days later. At autopsy, the patient was found to have acute mitral valve endocarditis and bilateral brain abscesses. This was the first case of B. cereus endocarditis reported in a patient with acute lymphoblastic leukemia.     

Rhabdomyolysis and acute renal failure in a cardiac transplant recipient due to multiple drug interactions

BACKGROUND: The 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitors lovastatin and simvastatin have been associated with rhabdomyolysis in cardiac transplant recipients. Herein, we report a case of a 52-year-old male recipient of a cardiac transplant who developed rhabdomyolysis and acute renal failure caused by simvastatin precipitated by multiple drug interactions. METHODS: The patient had a history of cardiac transplantation (5 years before) and presented with a 2-day history of dark urine preceded by 2 weeks of diffuse myalgias. He had been maintained on cyclosporine throughout the entire post-transplant period. Simvastatin was added and pravastatin was discontinued 2 months before admission. Two weeks before the onset of muscle symptoms, digoxin and verapamil were started for new-onset atrial fibrillation. Creatinine phosphokinase levels peaked at 950,000 IU with serum creatinine of 3.3 mg/dL (baseline, 1.8 mg/dL). RESULTS: Review of the medication history indicates a temporal association between the addition of 3 drugs (simvastatin, verapamil, and digoxin) to the medication regimen already containing cyclosporine and the episode of rhabdomyolysis. All of these drugs are cytochrome P450 3A4 and/or P-glycoprotein substrates that are known from previous pharmacokinetic studies to individually produce substantial increases in levels of simvastatin. CONCLUSION: We believe this case illustrates that avoiding the use of drugs that are cytochrome P450 3A4 and/or P-glycoprotein substrates reduces the risk of rhabdomyolysis caused by 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitors.