Lemierre's syndrome: a report of six cases

OBJECTIVE: Lemierre's syndrome is a rare but severe condition combining pyrexia, cervical pain and pulmonary signs following a pharyngeal infection, usually tonsillitis. This infectious disease is still present in our country despite wide use of antibiotic therapy in pharyngeal infections. METHODS: In a retrospective study conducted between 1995 and 2000 in two departments (infectious diseases and critical care unit) of Nice university hospital (Nice, France), we collected and analysed six cases of Lemierre's syndrome. RESULTS: We describe a serie of 6 cases, all of them female patients of mean age 27. We enrolled healthy patients whose initial symptom was tonsillitis. Most of these patients showed signs of severe sepsis and one died of septic shock. All the others recovered with treatment. The mean time between tonsillitis and first sign of sepsis was seven days. In four cases, patients received a beta- lactam antimicrobial agent with metronidazole. In two cases, patients were treated with amoxicillin-clavulanate. All patients were investigated for the presence of internal jugular vein thrombosis and were treated by anticoagulants when research was positive. CONCLUSIONS: A strong presumptive diagnosis can be made on the basis of clinical presentation, secondarily confirmed by para-clinical data. The prognosis depends on the speed and quality of management. We therefore wished to raise awareness of this condition among our colleagues by reporting our personal experience.     

Steroid regulation of the synthesis and secretion of retinol-binding protein by the uterus of the pig.

The endometrium of the pig secretes retinol-binding protein (RBP) under the influence of progesterone (P4). The objective of this study was to determine how conceptus-derived estrogen might modulate this production of RBP around days 11-13 of pregnancy when conceptuses elongate from spheres to long thread-like forms. Concentrations of retinol and RBP were low (35 +/- 7 ng/ml) in uterine flushings obtained on days 10-12 of the estrous cycle or from pregnant gilts in which conceptuses had not elongated. Concentrations of retinol and RBP increased 7- to 8-fold (P less than 0.01) in flushings where filamentous conceptuses were present. Size exclusion and ion exchange chromatography demonstrated that virtually all retinol assayed in uterine flushings was associated with RBP. Northern blot analysis with a cDNA representing uterine RBP revealed a single endometrial mRNA 1.1 kilobases in length. Expression of RBP mRNA in uterine endometrium was measured in ovariectomized prepubertal gilts after the administration of steroids according to the following regimens: I, corn oil (days 0-16; n = 10); II, estradiol benzoate (EB; days 13-14; n = 11); III, EB (days 1-2; n = 12); IV, EB (days 1-2) plus P4 (days 3-16; n = 12); and V, EB (days 1-2) plus P4 (days 3-16) plus EB (days 13-14; n = 12). EB (200 micrograms) and P4 (100 mg) were administered twice daily. Treatment IV was designed to stimulate the estrous cycle, and treatment V simulated early pregnancy. All gilts were hysterectomized on day 16, and total uterine mRNA (3 micrograms) was analyzed by Northern blotting. No RBP mRNA was detected in groups I, II, or III. In group IV, 5 of 12 gilts had detectable RBP mRNA, as measured by densitometric scanning (OD = 0.35 +/- 0.14). RNA isolated from all gilts in group V (12 of 12) gave a strong hybridization signal (OD = 1.58 +/- 0.22) for RBP. Finally, RBP mRNA was examined in the uterine endometrium of mature gilts on day 13 of the estrous cycle (n = 4), day 13 of pseudopregnancy (2.5 mg EB given on days 11-12; n = 4), or day 13 of pregnancy after conceptuses had elongated (n = 4). RBP mRNA was present in all groups, but was enhanced approximately 12-fold (P less than 0.01) in pregnant and pseudopregnant gilts compared to that in control gilts.(ABSTRACT TRUNCATED AT 400 WORDS)     

Mauling of the “Celtic Tiger”: Clinical characteristics and outcome of first-episode depression secondary to the economic recession in Ireland

Background

There is a dearth of studies describing clinical characteristics and outcome of patients who present with mood disorders related to economic recession.

Aims

To describe a cohort of patients admitted with first-episode depression related to the Irish economic recession and compare this cohort with all other first-episode depressives admitted during the same time period (2009–2010).

Methods

A cohort of 137 patients admitted with first-episode depression to an independent university teaching hospital was prospectively identified and followed up from admission over 2 years (mean follow-up 430 days, s.d. 176 days). The cohort was divided into “Celtic Tiger” (patients with first-episode depression secondary to the economic recession) and non-Celtic Tiger control patients (other first-episode depressed patients). Both groups were compared in terms of clinical characteristics at baseline and outcome over follow-up.

Results

The number of admissions due to first depressive episodes were higher in recession years 2009/10 than in pre-recession years 2008/9. Celtic Tiger patients were predominantly male and more severely depressed with more marked suicidal ideation (χ², p<0.001) than control patients. They were more likely to recover (χ², p=0.013), less likely to recur (χ², p<0.001) and had faster time to recovery (log rank, p<0.001) and slower time to full recurrence (log rank, p=0.001). The Celtic Tiger patients spent more time asymptomatic and less time at full and subthreshold depression levels over follow-up.

Limitations

Study setting of centre specializing in affective disorders treatment, retrospective nature of follow-up after initial prospective interview and lack of patient follow-up interview.

Conclusion

The study describes a subgroup of patients with severe depression associated with economic recession with likely high suicide risk but very favourable outcome.     

Mutations in protein N-arginine methyltransferases are not the cause of FTLD-FUS

The nuclear protein fused in sarcoma (FUS) is found in cytoplasmic inclusions in a subset of patients with the neurodegenerative disorder frontotemporal lobar degeneration (FTLD-FUS). FUS contains a methylated arginine–glycine–glycine domain that is required for transport into the nucleus. Recent findings have shown that this domain is hypomethylated in patients with FTLD-FUS. To determine whether the cause of hypomethylation is the result of mutations in protein N-arginine methyltransferases (PRMTs), we selected 3 candidate genes (PRMT1, PRMT3, and PRMT8) and performed complete sequencing analysis and real-time polymerase chain reaction mRNA expression analysis in 20 FTLD-FUS cases. No mutations or statistically significant changes in expression were observed in our patient samples, suggesting that defects in PRMTs are not the cause of FTLD-FUS.     

The subjective–objective mismatch in sleep perception among those with insomnia and sleep apnea

The diagnosis and management of insomnia relies primarily on clinical history. However, patient self‐report of sleep–wake times may not agree with objective measurements. We hypothesized that those with shallow or fragmented sleep would under‐report sleep quantity, and that this might account for some of the mismatch. We compared objective and subjective sleep–wake times for 277 patients who underwent diagnostic polysomnography. The group included those with insomnia symptoms (n = 92), obstructive sleep apnea (n = 66) or both (n = 119). Mismatch of wake duration was context dependent: all three groups overestimated sleep latency but underestimated wakefulness after sleep onset. The insomnia group underestimated total sleep time by a median of 81 min. However, contrary to our hypothesis, measures of fragmentation (N1, arousal index, sleep efficiency, etc.) did not correlate with the subjective sleep duration estimates. To unmask a potential relationship between sleep architecture and subjective duration, we tested three hypotheses: N1 is perceived as wake; sleep bouts under 10 min are perceived as wake; or N1 and N2 are perceived in a weighted fashion. None of these hypotheses exposed a match between subjective and objective sleep duration. We show only modest performance of a Naïve Bayes Classifier algorithm for predicting mismatch using clinical and polysomnographic variables. Subjective–objective mismatch is common in patients reporting insomnia symptoms. We conclude that mismatch was not attributable to commonly measured polysomnographic measures of fragmentation. Further insight is needed into the complex relationships between subjective perception of sleep and conventional, objective measurements.     

Ablation of porcine ligamentum flavum with Ho:YAG,q‐switched Ho:YAG,and quadrupled Nd:YAG lasers

Background and Objectives

Ligamentum flavum (LF) is a tough, rubbery connective tissue providing a portion of the ligamentous stability to the spinal column, and in its hypertrophied state forms a significant compressive pathology in degenerative spinal stenosis. The interaction of lasers and this biological tissue have not been thoroughly studied. Technological advances improving endoscopic surgical access to the spinal canal makes selective removal of LF using small, flexible tools such as laser‐coupled fiber optics increasingly attractive for treatment of debilitating spinal stenosis. Testing was performed to assess the effect of Ho:YAG, Q‐switched Ho:YAG, and frequency quadrupled Nd:YAG lasers on samples of porcine LF. The objective was to evaluate the suitability of these lasers for surgical removal of LF.

Study Design/Materials and Methods

LF was resected from porcine spine within 2 hours of sacrifice and stored in saline until immediately prior to laser irradiation, which occurred within an additional 2 hours. The optical absorbance of a sample was measured over the spectral band from 190 to 2,360 nm both before and after dehydration. For the experiments using the Ho:YAG (λ = 2,080 nm, t_p = 140 µs, FWHM) and Q‐Switched Ho:YAG (λ = 2,080 nm, t_p = 260 ns, FWHM) lasers, energy was delivered to the LF through a laser‐fiber optic with 600 µm core and NA = 0.39. For the experiment using the frequency quadrupled Nd:YAG laser (λ = 266 nm, t_p = 5 ns FWHM), rather than applying the laser energy through a laser‐fiber, the energy was focused through an aperture and lens directly onto the LF. Five experiments were conducted to evaluate the effect of the given lasers on LF. First, using the Ho:YAG laser, the single‐pulse laser‐hole depth versus laser fluence was measured with the laser‐fiber in direct contact with the LF (1 g force) and with a standoff distance of 1 mm between the laser‐fiber face and the LF. Second, with the LF remaining in situ and the spine bisected along the coronal plane, the surface temperature of the LF was measured with an IR camera during irradiation with the Ho:YAG laser, with and without constant saline flush. Third, the mass loss was measured over the course of 450 Ho:YAG pulses. Fourth, hole depth and temperature were measured over 30 pulses of fixed fluence from the Ho:YAG and Q‐Switched Ho:YAG lasers. Fifth, the ablation rate and surface temperature were measured as a function of fluence from the Nd:YAG laser. Several LF staining and hole‐depth measurement techniques were also explored.

Results

Aside from the expected absorbance peaks corresponding to the water in the LF, the most significant peaks in absorbance were located in the spectral band from 190 to 290 nm and persisted after the tissue was dehydrated. In the first experiment, using the Ho:YAG laser and with the laser‐fiber in direct contact with the LF, the lowest single‐pulse fluence for which LF was visibly removed was 35 J/cm². Testing was conducted at 6 fluences between 35 and 354 J/cm². Over this range the single‐pulse hole depth was shown to be near linear (R² = 0.9374, M = 1.6), ranging from 40 to 639 µm (N = 3). For the case where the laser‐fiber face was displaced 1 mm from the LF surface, the lowest single‐pulse fluence for which tissue was visibly removed was 72 J/cm². Testing was conducted at 4 energy densities between 72 and 180 J/cm². Over this range the single‐pulse hole depth was shown to be near linear (R² = 0.8951, M = 1.4), ranging from 31 to 220 µm (N = 3). In the second experiment, with LF in situ, constant flushing with room temperature saline was shown to drastically reduce surface temperature during exposure to Ho:YAG at 5 Hz with the laser‐fiber in direct contact with the LF. Without saline, over 1 minute of treatment with a per‐pulse fluence of 141 mJ/cm², the average maximum surface temperature measured 110°C. With 10 cc's of saline flushed over 1 minute and a per‐pulse laser fluence of 212 mJ/cm², the average maximum surface temperature was 35°C. In the third experiment, mass loss was shown to be linear over 450 pulses of 600 mJ from the Ho:YAG laser (212 J/cm², direct contact, N = 4; 108 J/cm², 1 mm standoff, N = 4). With the laser‐fiber in direct contact, an average of 53 mg was removed (R² = 0.996, M = 0.117) and with 1 mm laser‐fiber standoff, an average of 44 mg was removed (R² = 0.9988, M = 0.097). In the fourth experiment, 30 pulses of the Ho:YAG and Q‐Switched Ho:YAG lasers at 1 mm standoff, and 5 Hz produced similar hole depths for the tested fluences of 9 J/cm² (151 and 154 µm, respectively) and 18 J/cm² (470 and 442 µm, respectively), though the Ho:YAG laser produced significantly more carbonization around the rim of the laser‐hole. The increased carbonization was corroborated by higher measured LF temperature. In all tests with the Ho:YAG and Q‐Switched Ho:YAG, an audible photo‐acoustic affect coincided with the laser pulse. In the fifth experiment, with the frequency quadrupled Nd:YAG laser at 15 Hz for 450 pulses, ablation depth per pulse was shown to be linear for the fluence range of 0.18 – 0.73 J/cm² (R² = 0.989, M = 2.4). There was no noticeable photo‐acoustic effect nor charring around the rim of the laser‐hole.

Conclusion

The Ho:YAG, Q‐Switched Ho:YAG, and frequency quadrupled Nd:YAG lasers were shown to remove ligamentum flavum (LF). A single pulse of the Ho:YAG laser was shown to cause tearing of the tissue and a large zone of necrosis surrounding the laser‐hole. Multiple pulses of the Ho:YAG and Q‐Switched Ho:YAG lasers caused charring around the rim of the laser‐hole, though the extent of charring was more extensive with the Ho:YAG laser. Charring caused by the Ho:YAG laser was shown to be mitigated by continuously flushing the affected LF with saline during irradiation. The Nd:YAG laser was shown to ablate LF with no gross visible indication of thermal damage to surrounding LF. Lasers Surg. Med. 47:839–851, 2015. © 2015 The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc.     

Posterior shoulder instability following anatomic total shoulder arthroplasty: A case report and review of management

We report a case of posterior shoulder instability following anatomic total shoulder arthroplasty (TSA). In addition, we present guidelines to aid in the management of posterior instability after TSA. A 50-year-old male underwent anatomic TSA for glenohumeral osteoarthritis. Postoperatively, the patient developed posterior instability secondary to glenoid retroversion. He did not improve despite conservative treatment. He underwent an arthroscopic posterior bone block procedure, 4-month after his index arthroplasty. At 14-month follow-up, the patient had regained near full motion and strength, and radiographs demonstrated osseous integration with no evidence of component loosening. Posterior instability following TSA is a relatively rare complication and challenging to manage. The posterior, arthroscopic iliac crest bone block grafting procedure represents a treatment option for posterior instability in the setting of a stable glenoid prosthesis following TSA.