Primary Ewing's sarcoma of the sphenoid bone with unusual imaging features: a case report

Ewing's sarcomas (ES) account for approximately 10% of primary malignant bone tumors. Primary Ewing's sarcoma of the skull is a very rare entity. We report a case of Ewing's sarcoma of the sphenoid bone in a 5-year-old boy. CT scan showed heterogeneously enhancing mass with associated spiculated new bone formation along the posterolateral wall of the orbit. Magnetic resonance (MR) imaging showed markedly heterogeneously signal intensity mass lesion containing areas of hemorrhage and fluid–fluid levels. Spiculated new bone formation and fluid–fluid levels had not been reported previously in skull Ewing's sarcomas and may be helpful features for preoperative diagnosis.     

Is more frequent hemodialysis beneficial and what is the evidence?

PURPOSE OF REVIEW: The HEMO study results have shown that increasing dialysis dose in conventional thrice weekly hemodialysis does not improve patient outcomes. Interest has therefore turned to more frequent (daily) hemodialysis treatments. This review covers the rationale for such an approach together with a current review of the published study data. RECENT FINDINGS: Recent studies have suggested improvements in a number of intermediate patient outcomes such as cardiovascular (blood pressure control, left ventricular hypertrophy), anemia, phosphate control, nutritional status and quality of life. Some of these outcomes are associated with increased survival in the dialysis population. SUMMARY: The inference from these studies is that more frequent hemodialysis will indeed reduce mortality and morbidity. To date, however, the studies have all been small and underpowered to detect such primary outcomes. No randomized controlled trials are yet reported. The US National Institutes of Health have sponsored larger scale North American based studies and an International Registry of Daily Dialysis patients has been created to attain further information of the possible benefits of such therapy. In spite of the paucity of hard evidence the studies to date have been enough to convince some jurisdictions to recognize and fund daily hemodialysis treatments.     

The use of a modified sphygmomanometer to detect atrial fibrillation in outpatients

This study was designed to assess the accuracy of a modified sphygmomanometer, that measures pulse irregularity, to detect atrial fibrillation (AF). An irregularity index, defined as the standard deviation of the time intervals between beats divided by the mean of the time intervals, was used to analyze standard 12-lead ECGs from hospitalized patients. A threshold irregularity index was selected such that all ECGs with AF exceeded this irregularity index value. A modified automatic blood pressure monitor was designed to detect AF by calculating the irregularity index of the pulse. The device was used to calculate the irregularity index in an unselected group of outpatients during scheduled office visits in which a standard 12-lead ECG was performed. A total of 125 ECGs, 53 with AF, were analyzed. Using a threshold irregularity index of 0.066, the sensitivity for detecting AF was 100%, the specificity was 92% and diagnostic accuracy 95%. A modified sphygmomanometer was used to analyze the pulse of 450 outpatients, 54 of whom were documented by ECG to be in AF. When paired readings were analyzed, the rhythm was considered to be irregular if both readings were greater than the threshold index. Using a threshold index of 0.06, all the AF patients were correctly identified while 37 non-AF patients also exceeded the threshold irregularity index. In this analysis, the sensitivity was 100%, the specificity 91%, and the diagnostic accuracy 92% for detecting AF. The irregularity index determined using a modified sphygmomanometer can accurately identify AF.     

Predicting response to rhDNase and hypertonic saline in children with cystic fibrosis

Daily recombinant human deoxyribonuclease (rhDNase) is an established but expensive treatment in cystic fibrosis (CF). Alternate-day rhDNase and hypertonic saline (HS) represent potential cheaper alternative therapies. However, not all patients improve on treatment. To assess response, many CF centers have developed formal n-of-1 trials of treatment to find out who benefits. Response to daily rhDNase at 3 months has been shown to be a good predictor of response at 1 year. There are no data correlating individual response at a shorter time period with 3-month response. We assessed whether individual responses to daily rhDNase, alternate-day rhDNase, and HS could be predicted from lung function response at 6 weeks, thus shortening the n-of-1 trial, or from baseline patient characteristics, therefore avoiding the need for an n-of-1 trial. In a randomized crossover trial, 48 CF children were allocated consecutively to 12 weeks of once-daily 2.5-mg rhDNase, alternate-day 2.5-mg rhDNase, and twice-daily 5 ml of 7% HS. Forced expiratory volume in 1 sec (FEV1) and forced vital capacity (FVC) were measured at baseline and then at 6 and 12 weeks into each treatment period. Lung function response to the drugs at 6 weeks was highly predictive of response at 3 months. There was some evidence that response to HS was worse in patients with lower baseline lung function. However, there was no association between response to alternate-day or daily rhDNase and baseline characteristics. In conclusion, response to rhDNase and HS at 6 weeks was highly predictive of response at 3 months. For daily and alternate-day rhDNase, at least, the drug needs to be administered for at most 6 weeks initially to assess long-term response to treatment. Response to treatment could not be reliably predicted from baseline characteristics.     

Peripheral thyroid hormones and response to selective serotonin reuptake inhibitors

OBJECTIVE: To examine the relation between baseline measurements of thyroid function and response to selective serotonin reuptake inhibitors (SSRIs) and to consider the effect of these antidepressants on thyroid hormone levels. METHODS: Nineteen subjects with major depression, but without a history of thyroid treatment or lithium treatment, were treated openly with either sertraline or fluoxetine in a university- affiliated tertiary care hospital. Hamilton Depression Rating Scale (Ham-D) scores were measured before and after treatment. Clinical Global Impressions (CGI) scores were measured at study end. Thyroid data, consisting of values for thyroid-stimulating hormone (TSH), triiodothyronine (T(3), measured by radioimmunoassay [RIA]), thyroxine (T(4), measured by RIA) and free T(4), were collected before and after treatment. Complete thyroid data were available for 17 subjects. Data were collected during 1997-1999. RESULTS: Baseline TSH correlated strongly with response to treatment as measured by change in Ham-D scores (r = 0.64, p = 0.003). Low TSH values correlated with greater improvement in depressive symptoms. Thyroid hormone levels decreased with treatment, but these decreases did not correlate with clinical improvement. CONCLUSION: Baseline thyroid function, as measured by serum TSH, may predict a patient's response to antidepressant treatment with SSRIs. Optimal thyroid function, beyond simply being within the normal laboratory values, may be necessary for an optimal response to antidepressants.     

Birth outcomes after prenatal exposure to antidepressant medication

OBJECTIVE: The purpose of this study was to examine prospectively the incidence of congenital anomalies and neonatal complications after prenatal exposure to antidepressant medication. STUDY DESIGN: Birth outcomes were obtained from a review of obstetric and neonatal records of 138 women who were treated with selective serotonin reuptake inhibitor antidepressant medications (SSRIs) during pregnancy. RESULTS: The incidence of congenital anomalies in this study was 1.4%, comparable to general population rates. Rates of low birth weight and preterm births were low, occurring in 2.9% and 6.5% of births, respectively. The low birth weight infants had been exposed to relatively high doses of fluoxetine (40-80 mg/d) throughout pregnancy. Average maternal weight gain in pregnancy was comparable across the three major medication categories (fluoxetine, paroxetine, sertraline). CONCLUSION: After prenatal use of selective serotonin reuptake inhibitor antidepressant medications, neonatal complications and congenital anomalies appear to occur within general population rates. However, maternal use of high doses of fluoxetine throughout pregnancy may be associated with a risk for low birth weight.