Cerebral infarction secondary to vasospasm after perimesencephalic subarachnoid hemorrhage

Perimesencephalic subarachnoid hemorrhage (pSAH) has been described as a distinct form of subarachnoid hemorrhage (SAH) associated with good outcomes. We report a 48-year-old female who developed cerebral infarction due to severe diffuse vasospasm following pSAH. The patient presented with non-aneurysmal pSAH and was discharged home on day 5. However, one week later she developed an acute onset of right hemiparesis. A brain MRI showed acute infarctions on diffusion weighted imaging and her cerebral angiogram showed diffuse vasospasm. The patient received intra-arterial diltiazem and hypervolemic-hypertensive-hemodilution therapy with resulting resolution of the vasospasm and hemiparesis. While not as common as in SAH, there is a potential for the occurrence of cerebral infarction due to vasospasm after pSAH.     

Effect of third ventricle injection of GABA to feeding responses and blood sugar in intact and ovariectomized female rats

Injections into third ventricle of brain of either 4 m Molar or 8 m Molar of GABA were given to intact and ovariectomized female rats to evaluate the effects of these dosages on body weight, food intake, water intake and blood glucose levels. Statistically significant reduction in food and water intake with 8 m Molar GABA was observed in intact female rats. Very precise alterations seen in ovariectomized female rats suggested that GABA could demonstrate more profound effects on body weight, food intake and water intake. Blood glucose level was elevated in both the groups with 4 m Molar GABA, while inhibition was seen with 8 m Molar GABA. These observations have been correlated with trophic hormonal profiles, which are modulated by third ventricle GABA injection or it might have had some intervention on hypothalamic mechanisms regulating these functions.     

Effect of sustained-release long-acting intravitreal dexamethasone implant in patients of non-proliferative diabetic retinopathy undergoing phacoemulsification: A randomized controlled trial

Purpose:Cataract and diabetes, both being a major health care problem, an intervention evaluated for the combination of the two attains paramount importance. The purpose of the study was to determine the role of intraoperative intravitreal dexamethasone implant in patients with diabetic retinopathy with/without macula edema undergoing phacoemulsification.Methods:The study was a two-arm, single-center, randomized, assessor-blinded trial of 151 patients with type-2 diabetes mellitus and cataract. It had two groups: dexamethasone group (DEX) versus standard of care (SOC) group, i.e. phacoemulsification and intraocular lens (IOL) implantation without injection of dexamethasone drug delivery system (DDS). The number of rescue interventions required, central macular thickness by optical coherence tomography (OCT), Early Treatment Diabetic Retinopathy Study (ETDRS) score, laser flare meter (LFM) values, intraocular pressure (IOP), and grade of diabetic retinopathy (DR) were recorded until three months follow up. Macular thickness and number of rescue medications between the treatment groups were the co-primary outcomes.Results:A statistically significant interaction was present between treatment and time on OCT score (P < 0.001). The requirement of rescue interventions in the dexamethasone DDS group [40.2% (33/82)] was lesser as compared to the SOC group [49.3% (34/69)] at the end of 12 weeks [odds ratio (OR), 0.70 (0.36–1.33)] follow up although not statistically significant (P = 0.343). A statistically significant interaction was present between treatment and time on LFM score (P = 0.003). No statistically significant interaction was present between the treatment and time on visual acuity score (P = 0.08) and IOP score (P = 0.375).Conclusion:Dexamethasone implant may have potential as a valuable therapy for patients undergoing cataract surgery with DR with/without macular edema with effects lasting for at least three months.     

Endogenous endophthalmitis due to Staphylococcus aureus in a lactating woman

Endogenous endophthalmitis (EE) is a rare but fulminant intraocular infection that needs prompt recognition and management. Bacteria are the commonest causative organisms and they may colonize the eye secondary to hematogenous spread from a focus anywhere in the body. EE in the peripartum period is an infrequent occurrence with no cases reported to occur secondary to a peurperal mastitis. We report a case of EE due to Staphylococcus aureous in a lactating female and describe its clinical presentation and management.     

A novel pacing manoeuvre to diagnose atrial tachycardia

Aims: Currently used diagnostic manoeuvres at the electrophysiologystudy do not always allow for consistent identification of atrialtachycardia (AT), either because of inapplicability of the techniqueor because of low predictive value and specificity. The aimof this study was to determine whether overdrive atrial pacingduring paroxysmal supraventricular tachycardia (SVT) with thesame cycle length from both the high right atrium and the coronarysinus can accurately identify or exclude AT by examining thedifference between the V–A intervals of the first returningbeat of tachycardia between the two pacing sites. Methods and results: Fifty-two patients were included; 24 patients with atrioventricularnodal re-entry tachycardia (AVNRT), 13 patients with atrioventricularre-entry tachycardia (AVRT), and 15 patients with AT. Comparingthe 37 non-AT patients with the 15 AT patients, there was ahighly significant difference between the mean V–A intervaldifference, (delta V–A) 2.1 ± 1.8 ms (range 0–9ms) vs. 79.1 ± 42 (range 22–267 ms) (P < 0.001),respectively. None of the patients in the non-AT group had adelta V–A > 10 ms. In contrast, all 15 patients withAT had a delta V–A interval >10 ms. Thus, the diagnosticaccuracy of the delta V–A interval cut-off of >10 mswas 100%, with a 95% confidence interval of 93.1–100%for AT. In 11 (73%) of the 15 AT patients, the standard ventricularoverdrive pacing manoeuvre was not possible. In 14 of the 15patients (93%) in the AT group, standard atrial overdrive pacingshowed variable V–A intervals, correctly diagnosing AT.In all 52 patients, this measurement was repeated during pacingfrom the other location. In five patients from the AT group,the result of the second attempt was different from the resultof the first attempt. Conclusion: We found that atrial differential pacing during paroxysmal SVTwithout termination of tachycardia and the finding of variablereturning V–A interval was highly sensitive and specificfor the diagnosis of AT. The manoeuvre can be easily performedin all patients with SVT and is highly reproducible. It is auseful adjunct to the currently available ventricular and atrialpacing manoeuvres.     

Calcium hydroxyapatite fillers

Calcium hydroxyapatite fillers have unique advantages over other fillers in regards to duration of action and volume of product required for augmentation, especially in the midface and lower face. In this article, we describe our experience with calcium hydroxyapatite fillers and compare them with other available filler products.     

A case of longitudinally extensive transverse myelitis (LETM): neuromyelitis optica

Neuromyelitis optica (NMO), characterised by longitudinally extensive transverse myelitis (LETM), was previously thought to be a variant of multiple sclerosis. Transverse myelitis may be a manifestation of autoimmune connective tissue diseases and NMO is now recognised to be a humorally mediated autoimmune disease. We present a case of NMO associated with non-organ-specific autoantibodies and the absence of the characteristic NMO-IgG antibody. Our case provides an opportunity to review the diagnostic criteria of NMO and its distinction from other autoimmune and demyelinating conditions. We report successful treatment with plasmapheresis and rituximab in NMO-IgG-negative relapsing disease.     

Improved Accuracy of Percutaneous Biopsy Using “Cross and Push” Technique for Patients Suspected with Malignant Biliary Strictures

Purpose

Various methods have been used to sample biliary strictures, including percutaneous fine-needle aspiration biopsy, intraluminal biliary washings, and cytological analysis of drained bile. However, none of these methods has proven to be particularly sensitive in the diagnosis of biliary tract malignancy. We report improved diagnostic accuracy using a modified technique for percutaneous transluminal biopsy in patients with this disease.

Materials and Methods

Fifty-two patients with obstructive jaundice due to a biliary stricture underwent transluminal forceps biopsy with a modified “cross and push” technique with the use of a flexible biopsy forceps kit commonly used for cardiac biopsies. The modification entailed crossing the stricture with a 0.038-in. wire leading all the way down into the duodenum. A standard or long sheath was subsequently advanced up to the stricture over the wire. A Cook 5.2-Fr biopsy forceps was introduced alongside the wire and the cup was opened upon exiting the sheath. With the biopsy forceps open, within the stricture the sheath was used to push and advance the biopsy cup into the stricture before the cup was closed and the sample obtained. The data were analysed retrospectively.

Results

We report the outcomes of this modified technique used on 52 consecutive patients with obstructive jaundice secondary to a biliary stricture. The sensitivity and accuracy were 93.3 and 94.2 %, respectively. There was one procedure-related late complication.

Conclusion

We propose that the modified “cross and push” technique is a feasible, safe, and more accurate option over the standard technique for sampling strictures of the biliary tree.

     

Gender differences and quality of life in atrial fibrillation: the mediating role of depression

OBJECTIVE: This study investigated gender differences, depression, and health-related quality of life (QoL) in a cross-sectional sample of patients with atrial fibrillation (AF). METHODS: This cross-sectional study involved a convenience sample of AF patients from two tertiary-care clinics in Toronto, Canada. Ninety-three AF patients completed psychometrically validated measures of generic QoL and depression. Mediation analyses evaluated the relationship between gender and QoL using depression as mediating variable. RESULTS: Relative to male patients, female patients reported lower physical, but not mental, QoL. Gender was associated with both depression and physical QoL, while depression was correlated with poorer physical QoL. Path analyses demonstrated that depression significantly mediated the relationship between gender and physical QoL. CONCLUSION: Among AF patients, female patients report lower physical QoL relative to male patients, and this relationship may be mediated by self-reported symptoms of depression. Albeit correlational, the findings underscore the need to develop a better understanding of the role of depression in physical QoL, especially when considering the burden of AF in women.