Shunt Devices for Neurointensivists: Complications and Management

Cerebrospinal fluid diversion has become the mainstay treatment in hydrocephalus for over 50 years. As the number of patients with ventricular shunt systems increases, neurointensivists are becoming the first-line physicians for many of these patients. When symptoms of a shunt malfunction are suspected and access to a neurosurgeon is limited or delayed, workup and temporizing measures must be initiated. The article highlights the functional nuances, complications, and management of current programmable shunt valves and their MRI sensitivity.     

New and Low-Cost Auto-Algometry for Screening Hypertension-Associated Hypoalgesia

Objective:   The aim of the present work was to measure the pain threshold in hypertensive patients with a new auto-algometry method.
Design and Setting:   Auto-algometry consists of asking the subjects to push their fingers against a fixed round-tip needle until they feel a pain sensation. An electronic force transducer permits the measurement of the force applied by the subjects and storage of the data on a personal computer. Eight tests are performed twice on each subject on the tip and back of four fingers. For each test, the maximal applied force (grams) is defined as pain threshold. The overall discomfort during the entire procedure is reported by the subjects on a 0 (no discomfort) to 10 (intolerable pain) scale.
Patients and Interventions:   A group of hypertensive patients ( n  = 22) and a group of normotensive subjects ( n  = 22) underwent the auto-algometry examination.
Results:   The pain threshold was higher in hypertensive patients compared with normotensive subjects. All discomfort scores referred by the subjects fell within the 4–6 range.
Conclusion:   The data obtained from this study indicate that the auto-algometer as described here can detect hypoalgesia associated with hypertension.     

E‐PTFE (Gore‐Tex®) implant with or without low‐dosage mitomycin‐C as an adjuvant in penetrating glaucoma surgery: 2 year randomized clinical trial

Purpose: To test the expanded polytetrafluoroethylene (ePTFE) as a new adjuvant in trabeculectomy. Methods: Consecutive glaucoma surgical inpatients were observed at the Department of Ophthalmology of Palermo University. Sixty patients (60 eyes) were randomly assigned to undergo trabeculectomy (T), trabeculectomy with mitomycin‐C (TMMC), with ePTFE (TG) or with mitomycin‐C and ePTFE (TGMMC). Postoperative visits were scheduled at 24 hr, 7 days, 1, 3, 6, 12, 18 and 24 months. Complete success and qualified success were assessed at two target intraocular pressure (IOP) levels –≤21 and ≤17 mmHg – by Kaplan–Meier curves. Results: The postoperative IOP reduction was significant (P < 0.01) at the endpoint in all groups, with a mean IOP of 16.9 (±2.9), 16.2 (±2.7), 15.3 (±3.4) and 15.2 (±4.3) mmHg in T, TMMC, TG and TGMMC eyes, respectively. No intergroup difference was found at either IOP targets. The Kaplan–Meier curves relating to either the ≤21 mmHg or the ≤17 mmHg target IOP did not show significant intergroup differences for complete and qualified success rate. When ePTFE was used, a trend favouring the medium‐term survival rate was noted. No adverse reaction to the ePTFE was present, and no membrane extrusion or conjuctival erosion were noted in any cases. Hypotony was significantly more frequent (P = 0.035) in groups without ePTFE. Moreover, the late MMC‐related complications were more frequent when MMC was applied. Conclusion: Expanded polytetrafluoroethylene implant in trabeculectomy is well tolerated and could act as a filtration modulating device. Therefore, it is useful in reducing early hypotony‐related complications and contributes to attaining medium‐term IOP control that is comparable to the low‐dosage MMC.     

Tamoxifen and aromatase inhibitors differentially affect vascular endothelial growth factor and endostatin levels in women with breast cancer.

PURPOSE: Circulating and cellular proangiogenic and antiangiogenic proteins such as vascular endothelial growth factor (VEGF) and endostatin contribute to the local angiogenic balance. We explored the effects of tamoxifen and aromatase inhibitors on concentrations of VEGF and endostatin in plasma, serum, and platelet releasate (induced by platelet activation). EXPERIMENTAL DESIGN: VEGF and endostatin concentrations were measured with a quantitative immunoassay before and after 1 to 5 weeks of treatment in 30 women with breast cancer treated with either tamoxifen (n = 14) or aromatase inhibitors (n = 16). Platelet activation was induced by a thrombin receptor agonist. RESULTS: Tamoxifen therapy resulted in an increase in platelet releasate concentrations of VEGF (P = 0.01) but no change in plasma VEGF. In contrast, aromatase inhibitor therapy did not affect serum, plasma, or platelet releasate VEGF. In univariate analysis, aspirin use attenuated the tamoxifen-associated increase in VEGF in the platelet releasate and decreased serum levels of VEGF (P = 0.03). Aromatase inhibitor therapy resulted in a decrease in serum endostatin concentrations (P = 0.04), whereas plasma concentrations of endostatin tended to be higher during treatment with aromatase inhibitors (P = 0.06). Tamoxifen therapy resulted in no change in serum or plasma endostatin concentrations. Platelet releasate concentrations of endostatin did not change with either treatment. Interindividual variability was noted among both aromatase inhibitor--and tamoxifen-treated patients. CONCLUSIONS: Tamoxifen and aromatase inhibitor therapy affect VEGF and endostatin levels and likely contribute to the angiogenic balance in breast cancer patients. Aspirin decreased the proangiogenic effects of tamoxifen, suggesting that antiplatelet and/or antiangiogenic therapy might improve the effectiveness of tamoxifen in women with breast cancer.     

Severe primary malnutrition in US children

We studied 16 children aged 18 months or less who had severe primary protein-calorie malnutrition. All were admitted to one urban pediatric teaching hospital for treatment of failure to thrive between Jan 1, 1980, and Aug 30, 1984. The definitions of malnutrition were based on those of the Wellcome Trust. The patients had no evidence of medical causes for their conditions and grew rapidly when they were refed in the hospital. Eight were products of teenage pregnancies. Eleven patients were receiving public aid, and four had no third-party coverage. All were markedly below the fifth percentile in weight for length; their mean percentage of expected weight for age was 0.55. The mean hospital stay was 18.5 days. Severe primary protein-calorie malnutrition does exist in the United States. Thorough nutritional evaluation in children with failure to thrive is indicated, and malnutrition should be a reportable condition in the United States.     

Munchausen syndrome presenting as gross hematuria in two women

Munchausen syndrome is an uncommon disorder in which patients present with fictitious disorders and a self-destructive urge to undergo invasive procedures. We present 2 cases of nurses who presented with recurrent urinary tract infections, flank pain, and gross hematuria. One patient had such severe hematuria as to require transfusions of more than 1000 U of packed red cells during a 30-year period. Both patients underwent extensive investigations--all of which were normal. One patient even underwent nephrectomy, which showed normal pathologic findings. Both were found to be phlebotomizing themselves and infusing blood into their bladders.     

Gleason score predicts androgen independent progression after androgen deprivation therapy

OBJECTIVE: The Gleason system is the most widely utilized histologic grading system for prostate cancer and a powerful predictor of cancer behavior. In this study, we evaluated the prognostic value of the Gleason grading system in predicting progression to androgen independent prostate cancer (AIPC). METHODS: Records from 150 patients with advanced or metastatic prostate cancer treated with androgen deprivation therapy (ADT) were retrospectively reviewed. Androgen independent progression was defined as two consecutive elevations of serum prostate specific antigen (PSA) above the nadir value. Kaplan-Meier and the Cox proportional hazards methods were used to assess potential predictors of progression to AIPC. RESULTS: Patients with low and moderate Gleason scores experienced significantly longer remissions compared to those with Gleason score of 8-10 (p=0.0006, Log-Rank test). The cumulative hazard of progressing to AIPC increased by almost 70% for each unit increase in total Gleason score. CONCLUSION: In this patient cohort the Gleason score was the only independent predictor of progression to AIPC.