Migrainous Infarction in a Patient With Sporadic Hemiplegic Migraine and Cystic Fibrosis: A 99mTc-HMPAO Brain SPECT Study

Genetic mutations of sporadic hemiplegic migraine (SHM) are mostly unknown. SHM pathophysiology relies on cortical spreading depression (CSD), which might be responsible for ischemic brain infarction. Cystic fibrosis (CF) is caused by a monogenic mutation of the chlorine transmembrane conductance regulator (CFTR), possibly altering brain excitability. We describe the case of a patient with CF, who had a migrainous stroke during an SHM attack. A 32-year-old Caucasian male was diagnosed with CF, with heterozygotic delta F508/unknown CFTR mutation. The patient experiences bouts of coughing sometimes triggering SHM attacks with visual phosphenes, aphasia, right-sided paresthesia, and hemiparesis. He had a 48-hour hemiparesis triggered by a bout of coughing with hemoptysis, loss of consciousness, and severe hypoxia-hypercapnia. MRI demonstrated transient diffusion hyperintensity in the left frontal-parietal-occipital regions resulting in a permanent infarction in the primary motor area. Later, a brain perfusion SPECT showed persistent diffuse hypoperfusion in the territories involved in diffusion-weighted imaging alteration. Migrainous infarction, depending on the co-occurrence of 2 strictly related phenomena, CSD and hypoxia, appears to be the most plausible explanation. Brain SPECT hypoperfusion suggests a more extensive permanent neuronal loss in territories affected by aura. CF may be then a risk factor for hemiplegic migraine and stroke since bouts of coughing can facilitate brain hypoxia, triggering auras.     

Potential causes of insufficient bladder contrast opacification and premature microbubble destruction during contrast-enhanced voiding urosonography in children

Contrast-enhanced voiding urosonography (ceVUS) has been recognized as a child-friendly examination with high diagnostic accuracy for vesicoureteric reflux detection. A single bolus and the infusion techniques of ceVUS are described. Insufficient bladder contrast opacification during the filling phase and premature destruction of SonoVue microbubbles might occur. Data regarding SonoVue's features, doses, bladder contrast opacification, US bladder parameters, urine catheter, antibiotic prophylaxis, and childrens behaviors were collected to discover the possible causes of the contrast vanishing observed during bladder filling in 10% of examinations and in the later phase of ceVUS in 5% of examinations. An updated ceVUS examination protocol is suggested.     

Cover Image,Volume 20, Issue 6

The cover image, by Sara Charleer et al., is based on the Brief Report A vitamin Accuracy and precision of flash glucose monitoring sensors inserted into the abdomen and upper thigh compared with the upper arm, DOI: 10.1111/dom.13239 . Design Credit: Mr. Joren Polfliet.

     

Clinical characteristics and prognostic factors of sinonasal undifferentiated carcinoma: a multicenter study

Background

Sinonasal undifferentiated carcinoma (SNUC) is a very rare entity with a poor prognosis. Due to the lack of studies on the subject, evidence is lacking concerning its management.

Methods

A multicenter collaborative study was conducted to assess treatment strategy, oncological outcome, and prognostic factors.

Results

Definitive analyses focused on 54 patients with a majority of advanced stage; the 3‐year overall survival (OS) and 3‐year recurrence‐free survival (RFS) rates were, respectively, 62.4% and 47.8%. During the follow‐up, 18 patients (33.3%) died, 10 (18.5%) developed metastases, 7 had lymph‐node involvement (13%), and 12 (22.2%) showed recurrence or local progression. In univariate analyses, treatment modalities associated with improved RFS were induction chemotherapy (p = 0.02) and intensity‐modulated radiotherapy (p = 0.007). In the multivariate analyses, only induction chemotherapy (p = 0.047, hazard ratio [HR] = 0.39) was significantly associated with improved RFS.

Conclusion

Multimodal therapies including induction chemotherapy and intensity‐modulated radiotherapy may improve the prognosis of SNUC; surgery might improve local control. Further multicenter studies are required.

     

Survival Estimates for Patients with Abnormal Swallowing Studies

OBJECTIVE: To better understand the life expectancy of patients who have an abnormal videofluoroscopic swallowing study. DESIGN: Retrospective cohort study. The common starting point was the time of the severely abnormal swallowing study. Hospital charts were reviewed for clinical variables of potential prognostic significance by reviewers blinded to the outcome of interest, survival time. SETTING: A university-affiliated, community teaching hospital. PATIENTS: One hundred forty-nine hospitalized patients who were deemed nonoral feeders based on their swallowing study. Patients excluded were those with head, neck, or esophageal cancer, or those undergoing a thoracotomy procedure. MEASUREMENTS AND MAIN RESULTS: Clinical and demographic variables and time until death or censoring were measured. Overall 1-year mortality was 62%. Multivariable Cox proportional hazards analyses identified four variables that independently predicted death: advanced age, reduced serum albumin concentration, disorientation to person, and higher Charlson comorbidity score. Eighty patients (54%) subsequently underwent placement of a percutaneous endoscopic gastrostomy (PEG) tube after their swallowing study. CONCLUSIONS: Mortality is high in patients with severely abnormal swallowing studies. Common clinical variables can be used to identify groups of patients with particularly poor prognoses. This information may help guide discussions regarding possible PEG placement.     

Triage decisions for emergency department patients with chest pain

OBJECTIVE: To determine whether physicians’ risk attitudes correlate with their triage decisions for emergency department patients with acute chest pain. DESIGN: Cohort. SETTING: The emergency department of a university teaching hospital. PATIENTS: Patients presenting to the emergency department with a chief complaint of acute chest pain. PHYSICIANS: All physicians who were primarily responsible for the emergency department triage of at least one patient with acute chest pain from July 1990 to July 1991. METHODS: The physicians’ risk attitudes were assessed by two methods: 1) a new, six-question risk-taking scale adapted from the Jackson Personality Index (JPI), and 2) the Stress from Uncertainty Scale (SUS). RESULTS: The physicians who had high risk-taking scores (“risk seekers”) admitted only 31% of the patients they evaluated, compared with admission rates of 44% for the medium scorers and 53% for the physicians who had low risk-taking scores (“risk avoiders”), p<0.001. After adjustment for clinical factors, the patients triaged by the risk-seeking physicians had half the odds of admission [odds ratio (OR) 0.51, 95% confidence interval (95% CI) 0.27 to 0.97], and the patients triaged by the risk-avoiding physicians had nearly twice the odds of admission (OR 1.83, 95% CI 1.10 to 3.03) of the patients triaged by the medium-risk scoring physicians. The SUS did not correlate significantly with admission rates. Of the 92 patients released home by the risk-seeking physicians, 91 (99%) were known to be alive four to six weeks afterwards and one was lost to follow-up; among the 66 patients released by the risk-avoiding physicians, 64 (97%) were known to be alive at four to six weeks, one was lost to follow-up, and one died of ischemic heart disease during a subsequent hospitalization (p=NS). CONCLUSIONS: The physicians’ risk attitudes as measured by a brief risk-taking scale correlated significantly with then-rates of admission for emergency department patients with acute chest pain. These data do not suggest that the risk-seeking physicians achieved lower admission rates by releasing more patients who needed to be in the hospital, but an adequate evaluation of the appropriateness of triage decisions of risk-seeking and risk-avoiding physicians will require further study.     

Acute Sildenafil Use Reduces 24‐Hour Blood Pressure Levels in Patients With Resistant Hypertension: A Placebo‐Controlled,Crossover Trial

The authors previously demonstrated that acute administration of sildenafil—a phosphodiesterase 5 (PDE5) inhibitor—improves hemodynamic parameters in patients with resistant hypertensive (RH), but its effect on ambulatory blood pressure monitoring (ABPM) is unknown. This interventional, nonrandomized, single‐blinded, placebo‐controlled, crossover trial included 26 patients with RH. A dose of sildenafil (187.5mg) was given, and after a washout period of 14 days the patients received a single oral dose of placebo and the protocol was repeated. The patients underwent 24‐hour ABPM recordings the day before and immediately after the protocols. The reduction of systolic (−8.8±1.4 vs 1.3±1.2 mm Hg, P=.02), diastolic (−5.3±3.3 vs 1.8±1.1 mm Hg, P=.03), and mean (−7.9±3.6 vs 0.8±0.9 mm Hg, P=.01) 24‐hour BP were found after the use of sildenafil compared with placebo. Improvement in daytime BP levels was also observed (systolic −6.0±4.7 vs 4.4±1.5 mm Hg [P=.02] and mean −4.8±3.9 vs 3.5±1.4 mm Hg [P=.02] for sildenafil vs placebo, respectively). Considering its antihypertensive effect, sildenafil may represent a therapeutic option for RH treatment.

The pathogenesis of resistant hypertension (RH) is multifactorial,¹ impacting a worse prognosis when compared with controlled hypertension.² The mechanisms of resistance to antihypertensive therapy are not completely understood and can be modulated by several interrelated factors such as (1) hyperactivation of the sympathetic nervous and renin‐angiotensin‐aldosterone system,³, ⁴ (2) volume expansion,⁵ (3) endothelial dysfunction,⁶, ⁷ (4) inflammatory processes,⁸ and (5) increased peripheral vascular resistance.⁹ Although there is little evidence related to populations with RH, effective blood pressure (BP) control reduces the risk of cardiovascular events in general hypertensive patients and should be targeted.¹⁰ New drug therapies have been proposed, but BP control remains a challenge for patients with RH.¹¹ Phosphodiesterase type 5 (PDE5) inhibitors are safe and effective drugs presenting vasodilatory effects that provide office BP reductions in untreated¹² and resistant hypertensive patients.¹³ Recently, our group has shown an improvement in hemodynamic parameters after acute administration of sildenafil in patients with RH.¹⁴ Although ambulatory BP monitoring (ABPM) is superior to casual BP for predicting organ damage in hypertensive patients,¹⁵, ¹⁶ the influence of sildenafil on ABPM was never assessed in patients with RH.The present study sought to evaluate the effects of sildenafil on ABPM in patients with RH. We hypothesized that acute administration of sildenafil—a PDE5 inhibitor—compared with placebo improves 24‐hour BP levels in patients with resistance to antihypertensive therapy.