Neuromyopathy of cyanide intoxication due to "laetrile" (amygdalin). A clinicopathologic study

A 67-year-old woman with lymphoma presented with a neuromyopathy following "laetrile" (amygdalin) treatment. She had significant elevation of blood and urinary thiocyanate and cyanide levels. Sural nerve biopsy specimen revealed a mixed pattern of demyelination and axonal degeneration, the latter being prominent. Gastrocnemius muscle biopsy specimen showed histochemically a mixed pattern of denervation and myopathy with Type II atrophy. It is concluded that cyanide toxicity secondary to laetrile therapy and nutritional deficiency caused the neuromyopathy, as the changes in peripheral nerve are similar to changes described in ataxic polyneuropathy occurring in Nigeria attributed to high cyanide content in the diet and nutritional deficiency. Although this patient received vincristine initially, the development of the neuromyopathy had no temporal relationship to its administration. The clinical profile, as well as peripheral nerve and muscle changes were not similar to either vincristine neuromyopathy or neuromyopathy due to paraneoplastic manifestation of lymphoma. Clinical improvement following discontinuation of "laetrile" by the patient further supports the toxic etiologic results for the neuromyopathy in this patient.     

Anaesthetic management of acute blunt thoracic trauma

Sunnybrook Health Science Centre is an adult regional trauma unit serving metropolitan Toronto and environs. We undertook a nvo-year retrospective review of patients admitted to our institution with blunt thoracic trauma. Three hundred and thirty-three patients with blunt trauma and an injury severity score (ISS) greater than 17 required emergency surgery. Of these, 208 had blunt thoracic injuries while 125 did not have chest injuries. Both groups were similar with respect to age but patients with thoracic trauma had a greater ISS. (P < 0.05) and greater intraoperative mortality (P < 0.01). The aetiology of the intraoperative deaths with one exception was exsanguination. Emergency thoracotomy or sternotomy indicated a poor prognosis with a mortality rate of 80%. The most common intraoperative problem was an elevated airway pressure. Awake intubation was undertaken in 77.5% of patients requiring anaesthesia and surgery because of the potentially compromised airways and difficult intubations due to the nature of the associated injuries. Finally, 74% of patients undergoing urgent surgery required mechanical postoperative ventilation. The presence of blunt chest trauma should be considered a marker of the severity of injury sustained by the patient.     

Ischemic heart disease in black South African stroke patients

BACKGROUND AND PURPOSE: Stroke patients in western countries frequently have coronary artery disease (CAD). In black Africans, CAD has been reported as being rare in both stroke patients and the general population. In this study, an attempt has been made to determine the prevalence of CAD in a black South African stroke population. METHODS: The prevalence of CAD was determined by indicators identified through a series of 5 observational studies in black patients diagnosed with stroke. CAD indicators included (1) bedside diagnosis in 741 patients; (2) resting ECG in 555 consecutively admitted patients; (3) a combination of clinical examination, cardiac ultrasound, radionuclide scintigraphy, and multigated blood pool studies in 102 consecutively admitted patients; (4) thallium scintigraphy in 60 patients; and (5) necropsy in 23 patients. RESULTS: On bedside questioning, only 0.7% complained of previous angina. There was no history given of myocardial infarction (MI), but documentation of this was found in the clinical notes of 0.7% of the patients. In the resting ECG study, evidence of myocardial ischemia was present in 14.6% and MI in 2.1%. In the combined study, cardiac ischemia was documented on ECG in 12.7% of patients and evidence of previous MI in 5.8%. Cardiac scintigraphic studies revealed changes of myocardial ischemia in 31.7% and MI in 13.3% of the 60 patients studied. Four (17.4%) of 23 patients in the necropsy study had histological evidence of previous MI, and 50% of all patients had evidence of >50% atherosclerotic stenosis in 1, 2, or 3 coronary arteries. CONCLUSIONS: The prevalence of CAD in black African stroke patients is significantly higher than has been documented in the general nonstroke black population as well as in stroke patients. Black stroke patients may have a risk for CAD similar to that of their white counterparts.     

Accumulation of insoluble alpha-synuclein in dementia with Lewy bodies

The alpha-synuclein (alpha SN) protein is thought to play a central role in the pathogenesis of neurodegenerative diseases where it aggregates to form intracellular inclusions. We have used Western blotting to examine the expression levels and solubility of alpha SN in brain homogenates from dementia with Lewy bodies (DLB), Parkinson's disease (PD), Alzheimer's disease (AD), and normal controls using samples from the parahippocampus/transentorhinal cortex. Compared to controls, DLB brains accumulate significantly greater amounts of sodium dodecyl sulfate (SDS)-soluble and SDS-insoluble alpha SN but levels of TBS-soluble alpha SN did not change. Levels of synaptophysin, a marker of synaptic integrity, were significantly lower in DLB cases than in normal aged controls regardless of whether concurrent changes of AD were present. This limbic synaptic dysfunction may contribute to cognitive impairment in DLB. Whether aggregated alpha SN is a cause or effect of the disease process in DLB and PD remains to be determined, but the presence of aggregated alpha SN is consistent with a pathogenesis similar to that associated with aggregates of Abeta amyloid in AD.     

Elderly cohort study subjects unable to return for follow-up have lower bone mass than those who can return

Longitudinal studies of osteoporosis in older persons may underestimate bone loss because of a lack of follow-up measurements on subjects too frail to return. The authors addressed this possible bias as part of the population-based Framingham Study; in 1996-1997, they used quantitative ultrasound to assess the bone status of elderly subjects regardless of their ability to return to the clinic. Broadband ultrasound attenuation (BUA) and speed of sound of the calcaneus (heel) were measured in 433 subjects at the Framingham, Massachusetts, clinic and in 167 subjects at their homes or nursing homes. All ultrasound parameters were measured with intramachine coefficients of variation of <6.0%. The mean BUA for those subjects evaluated at the clinic was higher than for those measured at home (9.2% higher for men, p = 0.081; 8.6% higher for women, p = 0.034). After adjustment for age and weight, the differences in BUA were no longer significant. Among the elderly subjects participating in this longitudinal cohort study, those who were unable to return for follow-up were older, weighed less, and had a lower BUA than those who did return, suggesting that longitudinal studies of changes in bone mass with aging may underestimate the true population values.