A case of dengue‐related osteonecrosis of the maxillary dentoalveolar bone

Dengue is a mosquito transmitted flaviviral infection which can give rise to severe haemorrhage (dengue haemorrhagic fever) and with capillary leakage induces hypovolaemic shock (dengue shock syndrome). Although dengue symptoms and complications have been known for many decades, there has only been one documented case of osteonecrosis of the maxilla which was treated by excision of the necrotic bone. In this case of dengue infection, extensive maxillary osteonecrosis and minimal root resorption appeared to follow factitious injury with a toothpick but resolved with non‐surgical management.     

Ischemia-Mediated Dysfunction in Subpapillary Myocardium as a Marker of Functional Mitral Regurgitation

ObjectivesThe goal of this study was to test whether ischemia-mediated contractile dysfunction underlying the mitral valve affects functional mitral regurgitation (FMR) and the prognostic impact of FMR.BackgroundFMR results from left ventricular (LV) remodeling, which can stem from myocardial tissue alterations. Stress cardiac magnetic resonance can assess ischemia and infarction in the left ventricle and papillary muscles; relative impact on FMR is uncertain.MethodsVasodilator stress cardiac magnetic resonance was performed in patients with known or suspected coronary artery disease at 7 sites. Images were centrally analyzed for MR etiology/severity, mitral apparatus remodeling, and papillary ischemia.ResultsA total of 8,631 patients (mean age 60.0 ± 14.1 years; 55% male) were studied. FMR was present in 27%, among whom 16% (n = 372) had advanced (moderate or severe) FMR. Patients with ischemia localized to subpapillary regions were more likely to have advanced FMR (p = 0.003); those with ischemia localized to other areas were not (p = 0.17). Ischemic/dysfunctional subpapillary myocardium (odds ratio: 1.24/10% subpapillary myocardium; confidence interval: 1.17 to 1.31; p < 0.001) was associated with advanced FMR controlling for infarction. Among a subgroup with (n = 372) and without (n = 744) advanced FMR matched (1:2) on infarct size/distribution, patients with advanced FMR had increased adverse mitral apparatus remodeling, paralleled by greater ischemic/dysfunctional subpapillary myocardium (p < 0.001). Although posteromedial papillary ischemia was more common with advanced FMR (p = 0.006), subpapillary ischemia with dysfunction remained associated (p < 0.001), adjusting for posteromedial papillary ischemia (p = 0.074). During follow-up (median 5.1 years), 1,473 deaths occurred in the overall cohort; advanced FMR conferred increased mortality risk (hazard ratio: 1.52; 95% confidence interval: 1.25 to 1.86; p < 0.001) controlling for left ventricular ejection fraction, infarction, and ischemia.ConclusionsIschemic and dysfunctional subpapillary myocardium provides a substrate for FMR, which predicts mortality independent of key mechanistic substrates.     

Prosthetic valve endocarditis in a patient with Marfan's syndrome following acupuncture

Active prosthetic valve endocarditis (PVE) as a complication of acupuncture requiring valve surgery has not been reported previously. We report a case of PVE in a patient with Marfan's syndrome as a complication of acupuncture, who underwent emergency redo aortic root and valve replacement with a homograft. This report highlights the need for prophylactic antibiotics before acupuncture in patients with prosthetic valves, and also describes the use of a homograft as an effective surgical strategy.     

Transmission of a newly characterized strain of varicella-zoster virus from a patient with herpes zoster in a long-term-care facility, West Virginia, 2004

We investigated a small outbreak of varicella in a long-term-care facility after a case of herpes zoster. Clinical specimens and environmental samples were collected from all case patients and from surfaces in the case patients' rooms and other common-use areas. Wild-type varicella-zoster virus (VZV) DNA was identified in all 3 varicella case patients, and high concentrations of VZV DNA were detected in environmental samples from the room of the herpes zoster case patient. Genotypic analysis showed that the identical VZV strain was present in all samples; moreover, the strain was a unique Mosaic genotype isolate that included a stable Oka vaccine marker that had hitherto never been observed in a wild-type strain of VZV. This study provides evidence for the value of including environmental sampling during the investigation of varicella outbreaks and illustrates the importance of evaluating multiple vaccine-associated markers for the discrimination of vaccine virus from wild-type VZV.     

Concurrent responses elicited by isolated activation of platelet Gq-coupled receptors,in vitro: a novel approach for their separation and analysis

This study tested the hypothesis that aggregation mediated by activation of a single G(q)-coupled receptor can be studied quantitatively if four concurrent but distinct components of the observed platelet response, autocrine stimulation, shape change (SC), aggregation and deaggregation, are separately measured. Responses mediated by two G(q)-coupled receptors, the TXA(2) and the P2Y(1), were assayed by a novel, kinetics-based turbidimetric approach. Blocking the autocrine stimulation with a cocktail of receptor antagonists revealed rapid and sustained SC that largely masked the aggregation. Mathematical removal of the SC contribution from the changes in optical density indicated that selective activation of either the TXA(2) or the P2Y(1) receptor was sufficient to induce a small aggregation (DeltaOD = 0.1-0.2) that was reversed rapidly by a concurrent deaggregation. Model-derived rate constants of SC, aggregation and deaggregation described the observed complex time course of their concurrency well. Laser light scattering aggregometry confirmed the rapid deaggregation of platelet aggregates following TXA(2) or P2Y(1) receptor-mediated formation. Saturable concentration response curves of net aggregation were elicited at EC(50) values 6-15 higher than those of SC. The utility of this approach was further demonstrated by the separation of the four components of the response mediated by concurrent 5-HT(2A) and alpha(2A)-adrenoceptor activation, as well as the P2Y(1) and alpha(2A)-adrenoceptor, and the autocrine stimulation and SC mediated by the 5-HT(2A) receptor. We propose that the novel approach described here is necessary to study the receptor pharmacology and the kinetics of concurrent platelet responses in vitro as demonstrated by platelet aggregation elicited by selective activation of the TXA(2) or the P2Y(1) receptors.     

Analysis of baseline parameters in the HALT polycystic kidney disease trials

HALT PKD consists of two ongoing randomized trials with the largest cohort of systematically studied patients with autosomal dominant polycystic kidney disease to date. Study A will compare combined treatment with an angiotensin-converting inhibitor and receptor blocker to inhibitor alone and standard compared with low blood pressure targets in 558 early-stage disease patients with an eGFR over 60 ml/min per 1.73 m(2). Study B will compare inhibitor-blocker treatment to the inhibitor alone in 486 late-stage patients with eGFR 25-60 ml/min per 1.73 m(2). We used correlation and multiple regression cross-sectional analyses to determine associations of baseline parameters with total kidney, liver, or liver cyst volumes measured by MRI in Study A and eGFR in both studies. Lower eGFR and higher natural log-transformed urine albumin excretion were independently associated with a larger natural log-transformed total kidney volume adjusted for height (ln(HtTKV)). Higher body surface area was independently associated with a higher ln(HtTKV) and lower eGFR. Men had larger height-adjusted total kidney volume and smaller liver cyst volumes than women. A weak correlation was found between the ln(HtTKV) and natural log-transformed total liver volume adjusted for height or natural log liver cyst volume in women only. Women had higher urine aldosterone excretion and lower plasma potassium. Thus, our analysis (1) confirms a strong association between renal volume and functional parameters, (2) shows that gender and other factors differentially affect the development of polycystic disease in the kidney and liver, and (3) suggests an association between anthropomorphic measures reflecting prenatal and/or postnatal growth and disease severity.     

EAU Guidelines on Assessment and Nonsurgical Management of Urinary Incontinence

Context

The previous European Association of Urology (EAU) guidelines on urinary incontinence comprised a summary of sections of the 2009 International Consultation on Incontinence. A decision was made in 2010 to rewrite these guidelines based on an independent systematic review carried out by the EAU guidelines panel, using a sustainable methodology.

Objective

We present a short version of the full guidelines on assessment, diagnosis, and nonsurgical treatment of urinary incontinence, with the aim of increasing their dissemination.

Evidence acquisition

Evidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches, based on Population, Intervention, Comparator, Outcome questions. Appraisal of papers was carried out by an international panel of experts, who also collaborated on a series of consensus discussions, to develop concise structured evidence summaries and action-based recommendations using a modified Oxford system.

Evidence summary

The full version of the guidelines is available online (http://www.uroweb.org/guidelines/online-guidelines/). The guidelines include algorithms that refer the reader back to the supporting evidence, and they are more immediately useable in daily clinical practice.

Conclusions

These new guidelines present an up-to-date summary of the available evidence, together with clear clinical algorithms and action-based recommendations based on the best available evidence. Where such evidence does not exist, they present a consensus of expert opinion.     

Agonist concentration-dependent differential responsivity of a human platelet purinergic receptor: pharmacological and kinetic studies of aggregation,deaggregation and shape change responses mediated by the purinergic P2Y1 receptor in vitro

Platelet shape change (SC), aggregation and deaggregation responses are integral components of hemostasis that are elicited and modulated in vivo by the simultaneous activation of several membrane receptors. Selective activation of the purinergic P2Y₁ receptor in vitro elicits a sustained SC and a small, transient aggregation response that is reversed rapidly by a robust deaggregation response (Platelets 2003; 14: 89). Using a kinetics-based turbidimetric approach to study the modulation of these concurrent components of human platelet responses, we demonstrate that these P2Y₁ receptor-related responses and a number of their kinetic and steady-state characteristics are differentially elicited and modulated. P2Y₁ receptor agonist concentrations that elicited aggregation (pEC₅₀ for ADP, 2-MeSADP; 5.88, 6.69) were 10-fold greater than those that elicited SC (7.33, 7.67). The magnitude of the aggregation response was agonist concentration-dependent, saturable and was associated with an agonist concentration-dependent deceleration of the deaggregation response. G_i-coupled receptor (α_2A-adrenoceptor, EP3 and P2Y₁₂ receptors) agonists also enhanced aggregation through deceleration of the deaggregation response, and an inhibitor of PI3K activity (wortmannin) inhibited aggregation through acceleration of the deaggregation response. Neither treatment affected the extent or the kinetics of the SC response. The aggregation but not the SC response was rapidly desensitized by P2Y₁ receptor activation by ADP. The affinity of the selective P2Y₁ receptor antagonist, A3P5P, was independent of the response measured and is consistent with the presence of a single P2Y₁ receptor subtype. The differential characteristics and modulation of the SC and aggregation responses by a single receptor support the idea that different signaling pathways activated at different occupancy states of the same receptor underlie the two responses. P2Y₁ receptor-mediated platelet aggregation and SC responses provide a convenient model for studying the phenomenon of agonist-directed signaling by differential occupancy of the same membrane receptor.     

A case of myasthenia gravis with thyrotoxicosis treated by combined subtotal thyroidectomy and total thymectomy

Thyrotoxicosis occurring in conjunction with myasthenia gravis is rare. The usual treatment consists of medical control of the thyrotoxicosis, then thymectomy and later subtotal thyroidectomy. The case reported here concerns a 19-year-old girl who had surgical treatment for both lesions on the same occasion. With proper medical preparation, modern anaesthesia and respiratory care, the surgical treatment of both lesions can be accomplished in one stage.