The Role of C-Reactive Protein as a Risk Predictor of Coronary Atherosclerosis: Implications from the JUPITER Trial

Much controversy surrounds the use of high-sensitivity C-reactive protein (hs-CRP) as a marker of cardiovascular (CV) risk. Although data regarding the association of hs-CRP with CV disease is extensive and consistent, its role in clinical practice remains unclear. The American Heart Association (AHA) recently published a scientific statement regarding criteria for evaluation of novel markers of CV risk. This article provides a comprehensive review of data regarding hs-CRP as a risk marker for CV disease in the context of these AHA criteria. The impact of the JUPITER trial on the utility of hs-CRP as a risk marker is emphasized. The review concludes with an evidence-based statement regarding the current role of hs-CRP in CV risk prediction.     

Co-existence of Parkinson’s disease and progressive supranuclear palsy: case report and a review of the literature

Idiopathic Parkinson’s disease (PD) and progressive supranuclear palsy (PSP) are distinct clinicopathological entities characterized by α-synuclein and tau pathology, respectively. They have occasionally been reported to co-exist in the same patient. We describe a rare case of a 73-year-old Caucasian woman diagnosed as idiopathic PD 5 years before her death yet at autopsy had not only PD, but also PSP. Although this patient fulfilled clinical criteria for idiopathic PD and did not have supranuclear ophthalmoplegia, she had several atypical features, including early postural instability with falls, early dysphagia, and a relatively rapid course. In conclusion, this case and a literature review highlight the co-existence of synuclein and tau pathology in the same patient and demonstrate that multiple diagnoses may exist in patients presenting with parkinsonism. The clinical heterogeneity seen in parkinsonism may reflect the occurrence of combined pathology.     

Baastrup’s disease: The kissing spine

A 67-year-old male presented with a gradually progressive low back pain of 2 years duration. The patient was leading a retired life and there was no history of chronic fever or significant trauma. There was no radiation of pain or any features suggestive of claudication. There was no history of any comorbidity. The pain was aggravated with extension of the spine and relieved with flexion. There was no swelling or neurological deficit, but muscle spasm was present. Radiographs of the spine revealed degenerative changes in the lumbosacral spine, along with articulation of spinous processes at in lumbar spine at all levels level suggestive of Baastrup’s disease, commonly known as “kissing spine”. Routine blood investigations were within normal limits. The patient was managed conservatively. He was given a week’s course of analgesics and muscle relaxants and then started on spinal flexion exercises, with significant improvement being noted at 6 months follow up.     

Epidemiology and outcome of chronic high Epstein‐Barr viral load carriage in pediatric kidney transplant recipients

The development of EBV infection and PTLD is normally associated with a high EBV viral load in peripheral blood. Observations have previously identified existence of a CHL carrier state that demonstrated variable outcomes based upon the organ which was transplanted. Data defining the incidence and outcome of CHL in pediatric KTx are not well described. The charts of children undergoing isolated KTx at Children's Hospital of Pittsburgh between January 2000 and December 2014 were retrospectively reviewed. EBV loads in the peripheral blood were routinely measured as part of surveillance protocols at our center. CHL was defined as the presence of high load for >50% of samples for ≥6 months. PTLD was defined histologically using WHO definitions. Of 188 isolated KTx recipients, we identified a total of 16 (8%) children who developed CHL carrier state. No patient developed EBV‐driven late‐onset PTLD. Age at the time of KTx was significantly lower in the CHL group (median 3.9 years, interquartile range: IQR 2.9‐6.6, P = .0004). Children in the CHL group were more likely to be EBV‐seronegative prior to KTx (94%, 15/16), compared to the UVL and LVL groups (55% and 50%, respectively, P < .002). The median duration of CHL carrier state was 20 months (IQR 10.7‐35.8). Fifteen of the 16 CHL carriers experienced spontaneous resolution of CHL carrier state. Children in the CHL group were younger at the time of primary EBV infection (P = .023). Finally, antiviral medication was not effective in either preventing or decreasing the EBV viral load in blood (P = .84). Overall incidence of late‐onset PTLD is very low compared to heart and intestinal transplant, even though KTx recipients can develop CHL carrier state. The CHL carriers in KTx recipients were EBV‐seronegative prior to transplant and were younger both at the time of KTx and at the time of primary EBV infection compared to those in the UVL and HVL groups. Antivirals did not prevent EBV infection or decrease EBV viral loads.     

Extracardiac manifestations of atrial myxomas

Primary cardiac tumors are extremely rare and constitute only about 5% of all cardiac tumors. Cardiac myxomas are noncancerous primary tumors of the heart and constitute about of 50% of all primary heart tumors. Left-sided atrial myxomas are more common than right-sided atrial myxomas. Atrial myxomas can lead to a triad of complications. The most common symptoms are associated with obstruction due to the size and location of the tumor. The next most common symptoms are associated with pulmonary and systemic embolization. Patients may also present with constitutional symptoms. Diagnosis is made via means of transesophageal echocardiography and magnetic resonance imaging. Early diagnosis and surgical resection remain the treatment of choice to prevent complications. Patients usually have a good prognosis after resection.     

Differential diagnosis of parkinsonian syndromes using F-18 fluorodeoxyglucose positron emission tomography

Introduction

Positron emission tomography (PET) imaging with F-18 fluorodeoxyglucose (FDG) has been used to identify characteristic patterns of regional glucose metabolism in patients with idiopathic Parkinson's disease (IPD) and the atypical parkinsonian syndromes of progressive supranuclear palsy (PSP), multiple system atrophy (MSA), and corticobasal syndrome (CBS). We undertook this study to assess the utility of fluorodeoxyglucose-PET in the differential diagnosis of individual patients with clinical parkinsonism. “Visual” and “computer-supported” reading of the fluorodeoxyglucose-PET scans were used for image interpretation and compared with each other.

Methods

One hundred thirty-six parkinsonian patients were referred from movement disorder clinics in specialty neurology centers for the fluorodeoxyglucose-PET study. Imaging-based diagnosis was obtained by visual assessment of individual scans by a PET physician blinded to the clinical diagnosis and also by computer-assisted interpretation using statistical parametric mapping (SPM) analysis. The results were compared with a 2-year follow-up clinical assessment made by a movement disorder specialist.

Results

Concordance of visual evaluation of fluorodeoxyglucose-PET with clinical diagnosis was achieved in 91.7 % of patients scanned, 97.6 % IPD, 80 % MSA, 76.6 % PSP, and 100 % CBS. Blinded computer assessment using SPM was concordant with the clinical diagnosis in 91 % of cases evaluated (90.4 % IPD, 80 % MSA, 93.3 % PSP, and 100 % CBS).

Conclusions

Fluorodeoxyglucose-PET performed at the time of initial referral for parkinsonism is useful for the differential diagnosis of IPD, PSP, MSA, and CBS. Computer-assisted methods can be used for objective evaluation especially when expert readers are not available.     

Complete mesocolic excision and extended lymphadenectomy: Where should we stand?

Debate regarding the risks and merits of complete mesocolic excision and extended lymphadenectomy is ongoing, particularly for right-sided colon cancers. In this article, we hope to provide a succinct yet encompassing review of the relevant literature. We posit that complete mesocolic excision with D3 dissection is indicated in select patients with colon cancers, particularly those distal to the cecum.