Angiographically documented coronary vasospasm as a cause of myocardial infarction during the acute phase of aortic dissection

Summary We angiographically documented coronary vasospasm which resulted in myocardial infarction during the acute phase of aortic dissection (Stanford A). Coronary and aortic angiography performed at admission of the patient revealed complete occlusion of the right coronary artery and dissection of the aorta. Intracoronary injection of isosorbide dinitrate and intravenous administration of verapamil opened the occluded right coronary artery and blood flow was fully restored. We conclude that, in this case of aortic dissection, the severe stimulation by the aortic dissection brought about vasospasm of the right coronary artery which was the major cause of myocardial infarction. This is the first case report showing clear evidence that myocardial infarction is brought about by vasospasm associated with aortic dissection.     

High prevalence of non-leprotic hypochromic patches among children in a rural area of Mali, West Africa

The identification of one or several hypochromic patches (HP) on the skin is a key stage in the diagnosis of leprosy on dark skin. However, HP are often caused by other disorder than leprosy. A study to determine the prevalence and causes of HP among children was carried out in a rural area of Mali in November 2001. All children under 15 years of age in two villages in an endemic area were screened by two dermatologists. Among the 1729 children seen, HP were identified in 71 patients, with a prevalence of 4.1%. The most common cause of HP was tinea versicolor, which was present in 39.4% of children with HP, followed by pityriasis alba in 31%, naevus achromicus in 24% and vitiligo in 5.6%. No case of leprosy was detected. Our study raises several points with practical consequences for the detection of leprosy cases: the high prevalence of non-leprous HP compared to leprosy, the reliability of the clinical diagnosis of leprosy, and the role of general health care workers in the detection of leprosy cases. Helping those who should be involved in that detection in distinguishing true cases from other hypochromic disorders appears to be a priority.     

Case report: penetrating cardiac injury secondary to a terrorism-related nail bomb explosion

Penetrating cardiac injuries commonly occur secondary to gunshot or stab wounds. This is a report an unusual case of a patient who sustained a penetrating cardiac injury due to a nail from a terrorism-related, nail-bomb explosion. Associated problems included pericardial tamponade, penetrating cardiac injuries, acute, traumatic, myocardial infarction, and a penetrating lung injury. Prompt diagnosis and aggressive surgical intervention resulted in full recovery of the patient.     

Real-world evidence of the safety and efficacy profile of suvorexant in elderly patients with insomnia: a sub-analysis of the post-marketing drug-use results survey in Japan

Abstract

Objective: Global Phase III trials of suvorexant showed no obvious differences in the safety and efficacy profile of suvorexant between elderly and non-elderly patients. However, the clinical profile of suvorexant in elderly patients with comorbidities in a real-world setting was not evaluated. To further understand the safety and efficacy profile of suvorexant in elderly patients with insomnia in a daily clinical practice setting, we conducted a sub-group analysis of the post-marketing drug-use results survey.

Methods: Patients with insomnia who were treated with suvorexant for the first time were divided into three groups: group-1 (<65?years, N?=?1490), group-2 (≥65?years and <75?years, N?=?730), and group-3 (≥75?years, N?=?1028).

Results: The incidence of overall adverse drug reactions (ADRs) were 11.28% (N?=?168), 8.63% (N?=?63), and 8.17% (N?=?84) in group-1, -2, and -3, respectively. The ADRs most commonly observed in this survey were somnolence, insomnia, and dizziness, with no new safety concerns or differences in safety issues found. The numbers of patients in group-1, -2, and -3 who visited internal medicine departments were: 690 patients (46.3%), 521 patients (71.4%), and 793 patients (77.1%), respectively. The percentage of patients who were deemed to have “improved”, based on the patient’s self-assessment and their physician’s assessment, was 70–75% of patients in all groups.

Conclusion: These results reveal the safety and efficacy profile of suvorexant in elderly patients who often have various and multiple comorbidities and were treated in a daily clinical practice setting.     

Predictive Factors for Restenosis Following Stent-Supported Endovascular Therapy with Intravascular Ultrasound Evaluation for Femoropopliteal Chronic Total Occlusion

PurposeTo determine the predictive factors for in-stent restenosis (ISR) following stent-supported endovascular therapy (EVT) with intravascular ultrasound (US) evaluation for femoropopliteal chronic total occlusion.Materials and MethodsThis was a single-center, retrospective, observational study. The study included 276 lesions in 251 patients who underwent stent-supported EVT with intravascular ultrasound evaluation for femoropopliteal chronic total occlusion from July 2012 to June 2019. The wire passage route was assessed using intravascular US, and lesions were classified accordingly into 2 groups: intraluminal and subintimal passage. In this study, the intraluminal group was further divided into 3 subgroups by severity of calcification: none, <180°, and ≥180° circumferential. The subintimal group was further divided into 2 subgroups: subintimal passage without or with calcification. The primary outcome measure was ISR. Cox proportional hazards regression was used to determine the association of clinical characteristics with ISR rates.ResultsThe mean follow-up period was 19 months ±16, during which time ISR was observed in 31% of lesions. After multivariate analysis, an increased degree of plaque burden (hazard ratio [HR] = 1.101) and subintimal passage with calcification (HR = 3.408) were associated with an increased risk of ISR; a larger distal external elastic membrane area (HR = 0.898) and use of a stent graft (HR = 0.130) were significantly associated with a reduced risk of ISR.ConclusionsThis study revealed that factors associated with ISR after stent-supported EVT with intravascular US evaluation were distal external elastic membrane area, plaque burden, subintimal passage with calcification, and use of a stent graft.     

Adverse reactions after large-scale treatment of onchocerciasis with ivermectin: combined results from eight community trials

Eight community trials were carried out by the Onchocerciasis Control Programme in West Africa to determine the safety of the new microfilaricide ivermectin during large-scale treatment of onchocerciasis. The trial areas were located in eight different countries and varied greatly in endemicity level; a total of 50,929 persons were treated and monitored for 72 hours. Overall treatment coverage was 60% of the census population, the main reasons for non-treatment being the exclusion criteria. Of those treated, 9% reported with adverse reactions, 2.4% with moderate reactions, and 0.24% with severe reactions. Most reactions were reported during the first day of follow-up, the most frequent severe reaction being severe symptomatic postural hypotension (in 49 cases). Three cases of severe dyspnoea were life-threatening but their relationship with ivermectin treatment is uncertain. The incidence of adverse reactions was directly related to skin microfilarial load and was highest in the foci with the highest endemicity levels. Treatment resulted in 98% reductions in mean microfilarial loads at all endemicity levels. The benefit of treatment largely compensated for the discomfort due to adverse reactions, which were all transient and managed successfully. Ivermectin thus appears to be sufficiently safe for large-scale treatment but monitoring by resident nurses for at least 36 hours is recommended.     

Electro-ophthalmological analysis of Beh?et's disease

Six patients with complete type Beh?et's disease were studied electro-retinographically and electro-oculographically. The electrical responses tested include the hyperosmolarity response in the EOG, the oscillatory potentials and the rapid off-response in the ERG. The oscillatory potentials diminished in five eyes of four cases. In all except one of these eyes the rapid off-response and the hyperosmolarity response were within normal ranges. The hyperosmolarity response was suppressed in one eye which suffered from severe diffuse uveitis and iridocyclitis accompanied with hypopyon. The a-wave, the b-wave, the oscillatory potentials and the rapid off-response were also abnormal in this eye. The hyperosmolarity response was abnormal in an eye with severe ocular lesions of Beh?et's disease, while the oscillatory potentials were frequently abnormal even in the earlier stages of the disease. The hyperosmolarity response originates in the retinal pigment epithelial layer. The oscillatory potentials originate in the inner retinal layer. Our findings are compatible with the hypothesis that the initial retinal lesions take place in the inner retinal layer in Beh?et's disease.     

Traumatic cervical tracheal disruption: Report of two cases

We report herein the cases of two patients who suffered traumatic tracheal disruption, both of whom under-went successful surgical treatment. The first patient was a 48-year-old truck driver who suffered severe dyspnea after jamming his neck in a truck door. An endotracheal tube was unable to be inserted due to bleeding and thus, an emergency tracheostomy was performed. On admission massive subcutaneous emphysema was noted in the neck and anterior chest, and tracheal disruption was confirmed by a lateral neck X-ray, computed tomography (CT), and fiberscopy. An emergency end-to-end anastomosis of the trachea with insertion of a T-type silicon tube into the lower trachea was performed. The second patient was a 36-year-old man who suffered severe dyspnea after having his neck caught in a chain while driving a motorcycle. On admission, marked subcutaneous emphysema in the neck and paradoxical movement of the trachea were noted. Tracheal disruption was confirmed by a lateral neck X-ray and CT, and a similar operation to that of the first patient was performed. This type of injury is rare; however, lateral neck X-ray, CT, and fiberscopy proved extremely useful for making an accurate diagnosis following which successful emergency surgery was able to be performed, achieving good long-term results.