Recurrent rhabdomyolysis and mild acute renal failure associated with acute Brucella infection.

Sir, Various infectious agents have been reported to cause rhabdomyolysis[1–5]. We present a case of acute Brucella infection,complicated with recurrent rhabdomyolysis and mild renal failure. A 39-year old man was admitted to hospital because of muscularpain and dark urine. Ciprofloxacine was begun 1 day before hisreferral with the possible diagnosis of urinary infection. Hereported consumption of unpasteurized milk     

Dosimetric evaluation of the effect of dental implants in head and neck radiotherapy.

OBJECTIVE: The aim of the study was to examine the dose enhancement from scattered radiation at bone-dental implant interfaces during simulated head and neck radiotherapy. STUDY DESIGN: Four cylindrical titanium dental implants with 3 different sizes and lengths were implanted into a human mandible in 4 different positions. Ionization measurements for 6 MV X, 25 MV X, and Co-60 gamma rays were done. Thermoluminescent dosimeter (TLD 100 ) chips were used to measure radiation dose enhancement due to the scattered electrons from titanium and electronic disequilibrium at the tissue-metal interface. RESULTS: The results showed that for Co-60, there is a 21% maximum increase in dose to alveolar mandibular bone at the close proximity to the titanium. For 6-MV x-rays the dose enhancement increase was almost the same or slightly lower than for Co-60, while for 25-MV high-energy x-rays, dose enhancement was lower than that of others. This increase in dose enhancement fell off rapidly and became insignificant at 2 mm from the interface. CONCLUSION: Total dose that may lead to osteoradionecrosis risk of the mandible is slightly but not significantly affected by the scattered dose of the dental implants of lower jaw in the radiation field exposed to 3 different radiation beams.     

Painful neuroma requiring surgical excision after lower limb amputation caused by landmine explosions

This article reports an analysis of 75 consecutive lower limb amputees who developed painful neuroma requiring surgical excision after lower limb amputation following landmine explosions. This retrospective study analyses the results of 75 patients who were treated for painful neuroma after lower limb amputation following landmine explosions between the years 2000 and 2006. The average time period from use of prosthesis to start of symptoms suggesting neuroma was 9.6 months. The average time period from start of pain symptoms to neuroma surgery was 7.8 months. All clinically proven neuromas were surgically resected. In the mean follow-up of 2.8 years, all patients were satisfied with the end results and all were free of any pain symptoms. Painful stump with clinical diagnostic findings of neuroma described above may be regarded as neuroma without requiring any further imaging modalities and is an indication for surgery if conservative measures fail.     

The natural history of renal function following orthotopic heart transplant

BACKGROUND: The outcome of solid organ transplantation has dramatically improved after the introduction of the calcineurin inhibitor cyclosporine. With the increasing longevity of heart transplant recipients, the long-term effects of cyclosporine on renal function have become more evident. The natural history of kidney function following orthotopic heart transplant is not well defined and long-term follow up studies are scant. METHODS: We conducted an observational study on patients who received a heart transplant at Saint Louis University Hospital between January 1, 1983 and December 31, 1988. Patients were followed up for 15 yr or until death whichever occurred first. In order to assess the effect of heart transplantation and cyclosporine exposure on long-term renal function we restricted the statistical analysis to patients who survived the first year post-transplantation. RESULTS: A total of 68 patients received orthotopic heart transplants at Saint Louis University Hospital between 1983 and 1988. Forty-eight (71%) patients survived for more than 1 yr. All patients were treated with cyclosporine based triple immunosuppressive regimen, with gradual cyclosporine dose reduction over time. The mean duration of follow-up was 8 yr. The estimated GFR at 5 and 10 yr post-transplant were significantly lower than estimated GFR at baseline and 1 yr post-transplant. There was no significant difference between estimated GFR at 15 yr and estimated GFR at baseline or 1 yr post-transplant. The cumulative incidence of chronic renal failure (GFR < or = 29 mL/min/1.73 m2) at 5, 10 and 15 yr was 4.2, 10.4 and 12.5%, respectively (p < 0.05). The cumulative incidence of severe chronic renal failure (GFR < or = 15 mL/min/1.73 m2) at 5, 10 and 15 yr was 2.1, 8.3 and 8.3%, respectively. The mortality rate was 8, 37, and 52% at 5, 10, and 15 yr, respectively. The 10 and 15 yr survivors had an estimated GFR at 1 yr post-transplant that was significantly higher than the non-survivors. Age, pre-transplantation estimated GFR, pre-transplantation diabetes and pre-transplantation hypertension are risk factors associated with > or = 10 mL/min/1.73 m2 decrement in estimated GFR. CONCLUSION: Heart transplant survivors beyond the first year post-transplant have a significant decrease in renal function and significant mortality observed over time. Age, pre-transplant GFR, pre-transplant diabetes and pre-transplant hypertension are important risk factors for decrement in renal function.     

Axillary Recurrence after Negative Sentinel Lymph Node Biopsy: Frequency and Factors Influencing Recurrence on the Long Term

Abstract:  Sentinel lymph node (SLN) biopsy is a less invasive method for determining tumor stage. Purpose of this study was to determine the frequency of axillary recurrence after negative SLN biopsy for women with breast cancer. A total of 121 patients with a negative SLN biopsy, from January 1, 2000 to December 31, 2004, were identified from a maintained pathology database. Retrospective chart review and data analysis were performed until September 1, 2006, to determine frequency of axillary recurrence and identify variables predictive of recurrence. Two hundred and sixty eight patients had undergone SLN biopsy in the researched period, of which 121 were SLN negative and had no further axillary treatment. The median follow-up was 44 months (range, 15–76 months). Three patients (2.5%) developed isolated axillary recurrence. Five patients (4.1%) developed distant disease recurrence. Grade 3 tumor differentiation was significantly associated with tumor recurrence. Tumor size, hormone receptor state, and mitotic activity/2 mm² were not significantly associated with disease recurrence. Patients with a negative SLN biopsy with no further axillary treatment, show a low rate of axillary recurrence. SLN biopsy is a less invasive and accurate method for determining tumor stage and a negative SLN biopsy provides good regional control of the axilla on the long term.     

The relationship between the MEFV genotype, clinical features, and cytokine-inflammatory activities in patients with familial mediterranean fever

Familial Mediterranean Fever (FMF) is an autosomal recessive disease characterized by periodic attacks of fever and polyserositis. The effects of the MEFV genotype differences on clinical picture and inflammatory activity have not been well documented. The aim of this study was to investigate levels of conventional inflammation markers, procalcitonin, interleukin levels, TNF-alpha, and C5a levels in patients with FMF who had different MEFV genotypes and compare them with those of healthy subjects. The study consisted of 41 patients with FMF (F/M: 23/18), and 31 healthy subjects (F/M: 18/13). Tests were performed during the attack-free period. White-blood cell count, CRP and IL-8 levels were higher in patients with FMF than in healthy subjects (p < 0.05) and also higher in M680I carriers than in the patients with M694V allele carriers. However, ESR, fibrinogen, procalcitonin, IL-6, C5a, TNF-alpha, and IgD levels were not significantly different between patients and healthy subjects (p > 0.05). Arthralgia or arthritis was significantly higher in M694V carriers than in non-M694V carriers (p < 0.05). It is concluded that the clinical features and inflammatory-cytokine activities were higher in patients with FMF during the attack-free period than in healthy subjects, and the different genotype might be related to different clinical pictures.     

The expression of MMP-2, MMP-7, MMP-9, and TIMP-1 in chronic rhinosinusitis and nasal polyposis

OBJECTIVES: To investigate the expression and clinical significance of MMP-2, MMP-7, MMP-9, and TIMP-1 in patients with nasal polyposis (NP) and chronic rhinosinusitis (CRS). STUDY DESIGN: Prospective study. SUBJECTS AND METHODS: This study involved 54 patients. There were three groups: nasal polyposis group, chronic rhinosinusitis group, and control group. Specimens were collected during endoscopic sinus surgery. Each sample was immunohistochemically examined. RESULTS: Expression of MMP-2 was found significantly increased in NP, whereas MMP-7 expression was found significantly increased in CRS (P < 0.001). TIMP-1 was significantly high in control group compared to CRS and NP (P < 0.001 and P = 0.002, respectively). CONCLUSIONS: Different regulation type of activation of MMPs has been found in these two diseases. If MMP-2 expression is intense in the mucosa, then this ends with polyp formation; if MMP-7 expression is intense, it ends with CRS or stays as CRS.     

Persistent posttraumatic wrist pain: complex regional pain syndrome? Mycobacterium tuberculosis infection should be in the differential diagnosis

It is a common algorithm for hand surgeons to diagnose and treat persistent post-traumatic wrist pain as complex regional pain syndrome (CRPS). Although it works for many patients, some conditions that affect the wrist don’t fall in this category and worsen with this treatment practice. We present a single-handed patient who had had a non-displaced distal radius fracture and was treated as CRPS for the next three months. He was eventually diagnosed with late tuberculous tenosynovitis of the wrist and a total wrist arthrodesis was performed. We believe that Mycobacterium tuberculosis infection should be in the differential diagnosis of persistent post-traumatic joint pain. This is especially important as Mycobacterium infections are becoming more common due to an increase in patients with chronic immunosuppression and definitive diagnosis and treatment of tuberculous tenosynovitis needs a high index of clinical suspicion.     

The effect of preoperative atrial fibrillation on survival following mitral valve repair for degenerative mitral regurgitation.

OBJECTIVE: There is conflicting evidence with regard to the impact of preoperative atrial fibrillation (AF) on the post mitral valve (MV) repair on the early and late outcome. METHODS: A total of 349 patients undergoing various MV repair procedures for degenerative mitral regurgitation (MR) between 1997 and 2003 were studied. Preoperatively, 152 (44%) of these patients were in AF and 197 (56%) patients were in sinus rhythm (SR). The clinical features and the outcome in these two cohorts of patients were compared. RESULTS: The patients in the AF group were older than their counterparts in the SR group (66+/-7 vs 62+/-9 years) (p=0.01), had a higher mean NYHA class score (2.4+/-0.6 vs 2.2+/-0.7) (p=0.04) and were more likely to have impaired left ventricular function (60% vs 36%) (p<0.0001). A similar proportion of patients in the AF (38%) and SR (30%) groups had additional cardiac surgical procedures (p=0.12). Operative mortality was 3.9% in AF group versus 0.5% in SR group (p=0.04), and operative morbidity was 27% versus 17%, respectively (p=0.03). At latest follow up, 4% of patients that were in SR preoperatively developed AF; conversely, 2% of the patients in the AF group converted to SR. The rates of recurrent grade II or III MR (4% vs 5%) (p=0.8) and MV re-operation (2.6% vs 2.5%) (p=1.0) were similar in the AF and SR groups. Kaplan-Meier survival at 7 years was 75+/-6% versus 90+/-3% (p=0.005). On Cox proportional hazards regression model, impaired LV function [(p=0.02), hazard ratio 0.25 (95% confidence intervals (C.I.) 0.078-0.84)] and AF [(p=0.03), hazard ratio 2.70 (95% C.I. 1.09-6.68)] were significant adverse predictors of survival. CONCLUSIONS: This study shows that in patients undergoing MV repair for degenerative MR, preoperative AF has a major negative impact on the early and late survival.     

Fetal programming of polycystic ovary syndrome

Polycystic ovary syndrome(PCOS) is a common endocrine disorder that affects up to 6.8% of reproductive age women.Experimental research and clinical observations suggest that PCOS may originate in the very early stages of development,possibly even during intrauterine life.This suggests that PCOS is either genetically-transmittedor is due to epigenetic alterations that develop in the intrauterine microenvironment.Although familial cases support the role of genetic factors,no specific genetic pattern has been defined in PCOS.Several candidate genes have been implicated in its pathogenesis,but none can specifically be implicated in PCOS development.Hypotheses based on the impact of the intrauterine environment on PCOS development can be grouped into two categories.The first is the "thrifty" phenotype hypothesis,which states that intrauterine nutritional restriction in fetuses causes decreased insulin secretion and,as a compensatory mechanism,insulin resistance.Additionally,an impaired nutritional environment can affect the methylation of some specific genes,which can also trigger PCOS.The second hypothesis postulates that fetal exposure to excess androgen can induce changes in differentiating tissues,causing the PCOS phenotype to develop in adult life.This review aimed to examine the role of fetal programming in development of PCOS.