Refractory Intracranial Hypertension in Posterior Reversible Encephalopathy Syndrome

Introduction

Posterior reversible encephalopathy syndrome (PRES) is a largely reversible disease with long-term favorable outcome. A minority of patients, however, may develop progressive cerebral edema and ischemia resulting in severe disability or death. We report a case of severe intracranial hypertension associated with PRES that was successfully treated according to intracranial pressure (ICP)- and cerebral perfusion pressure (CPP)-driven therapy.

Methods

Case report.

Results

A 42-year-old woman underwent bilateral lung transplantation for severe bronchiectasis. Her immunosuppressive regimen consisted of azathioprine, prednisone, and tacrolimus. She acutely developed an aggressive form of PRES that rapidly resulted in severe refractory intracranial hypertension despite discontinuation of potentially causative medications and adequate supportive therapy. Accordingly, second-tier therapies, including barbiturate infusion, were instituted and immunosuppression was switched to anti-thymocyte globulin followed by mycophenolate mofetil. Within 10 h of barbiturate administration, ICP dropped to 20 mmHg. Thiopental was administered for two days and then rapidly tapered because of severe urosepsis. Six months after discharge from the intensive care unit the patient returned to near-normal life, her only complaint being short-term amnesia.

Conclusions

The decision to undertake ICP monitoring in medical conditions in which no clear recommendations exist greatly relies on physicians’ judgment. This case suggests that ICP monitoring may be considered in the setting of acute PRES among selected patients, when severe intracranial hypertension is suspected, provided that a multidisciplinary team of neurocritical care specialists is readily available.     

A practical definition of minor stroke

It is generally assumed that minor stroke (MS) is an ischemic stroke with a short-term, good functional outcome. However, no clear definition of MS exists. Modified Rankin Scale (mRS) and National Institute of Health Stroke Scale (NIHSS) are still the most accredited standards, but scores and timing of the assessment are not homogeneous. As suggested by a qualified sample of Italian neurologists, the index parameter chosen in our analysis was mRS at the time of hospital discharge. The database of the SIRIO study (a large observational study of 2,573 patients with stroke admitted in Italian hospitals in 2005) was used to identify an mRS threshold to define MS. Reference was made to outcome markers such as rate of discharge to home, 1-year disability and 1-year mortality. The rate of discharge progressively decreased with increase in mRS, while the rates of 1-year mortality and disability progressively increased. Our proposal is one of defining a stroke “minor” when the rate of discharge to home is above the SIRIO database overall value and the 1-year mortality and disability is below the respective overall values. This definition is consistent with a score ≤2 on the mRS.     

Ultrasound revealing subclinical enthesopathy at the greater trochanter level in patients with spondyloarthritis

This study was conducted to determine the prevalence of subclinical entheseal involvement at the greater trochanter level by ultrasound in patients with spondyloarthritis. Forty-six patients with spondyloarthritis and 46 healthy age- and sex-matched controls were studied. All patients with no clinical evidence of enthesopathy at the greater trochanter underwent an ultrasound examination. The following three entheses were scanned bilaterally: anterior insertion of gluteus minimus, anterior insertion of gluteus medius, and posterior insertion of gluteus medius. Ultrasound findings of enthesopathy were thickening, calcifications, bone erosions, enthesophytes, bursitis, and power Doppler signal. A total of 276 entheses were evaluated in spondyloarthritis patients. In 112 out of 276 (40.5%), grayscale ultrasound found enthesopathy. The enthesis with the highest number of signs of enthesopathy was the anterior insertion of gluteus medius (46/276) (16%), followed by posterior insertion of gluteus medius (37/276) (13.4%) and anterior insertion of gluteus minimus (29/276) (10.5%). In the healthy population, ultrasound found entesopathy in 80 out of 276 (29%) entheseal sites (p < 0.0001). Posterior insertion of gluteus medius enthesis was the more frequently involved (34/276) (12.3%), followed by anterior insertion of gluteus medius (24/276) (8.6%) and anterior insertion of gluteus minimus (22/276) (7.9%). Power Doppler was found more frequently in patients with spondyloarthritis compared with healthy controls (1% vs 0%). Our results show a higher prevalence of subclinical enthesopathy at the greater trochanter level in patients with spondyloarthritis than in age- and sex-matched healthy controls.     

Bioenergetics of T cell activation and death in HIV type 1 infection

Regressive morphological lesions, found in peripheral lymphocytes from HIV(+) patients, clearly conflict with normal cycle progression and with the execution of basic housekeeping and immune functions. With these lesions, circulating lymphocytes are destined to spontaneous and energy-independent cell lysis. By means of confocal microscopy and morphometry, we have quantified the rate of circulating T cells that are probably destined to emocatheresis in vivo. This rate includes lymphocytes in which nucleolin fragments have been scattered out of the nuclear region as a result of prelethal alterations in the nuclear membrane permeability. In terms of bioenergetics, these cells show evident anomalies in the energy production machinery that make them unable to carry out ATP-requiring functions. The extent of damaged cell fraction in peripheral blood reflects the frequency with which T lymphocytes leave lymphoid tissue to be cleared in hemocatheretic processes.     

Risk factors for dislocation arthropathy after Latarjet procedure: a long-term study

Purpose

The purpose of this study was to analyse the long-term incidence of dislocation arthropathy after a modified Latarjet procedure for glenohumeral instability.

Methods

Long-term follow-up information was obtained from a consecutive series of patients who had undergone a modified Latarjet procedure by one surgeon between 1986 and 1999. Multivariable regression analysis was performed to examine the relation between the development of a dislocation arthropathy and patients and surgery-related factors.

Results

There were 117 patients (117 shoulders) for evaluation, (35 women and 82 men) with a mean age 28.4 ± 8.5 (range, 16–55). The mean follow-up was 16.2 years (range, ten to 22.2 years). Signs of dislocation arthropathy were found in 36 % of patients, graded as Samilson 1 in 30 %, Samilson 2 in 3 %, and 3 % Samilson 3 in 3 % of patients. Risk factors for dislocation arthropathy included surgery in patients older than 40 years of age (64.3 vs. 34.4 %; adjusted RR 2.2, 95 % CI 1.7–2.9) and lateral positioning of the transferred coracoid process in relation to the glenoid rim (82.4 vs. 30.4 %; adjusted RR 2.3, 95 % CI 1.7–3.2). Patients with hyperlaxity developed less dislocation arthropathy (15 vs. 42.5 %; adjusted RR 0.4, 95 % CI 0.1–0.95).

Conclusion

The development of dislocation arthropathy after the Latarjet procedure remains a source of concern in the long term. It correlates with surgery after the age of 40 and lateral coracoid transfer in relation to the glenoid rim. On the other hand, hyperlaxity seems to have a protective effect on the development of dislocation arthropathy.     

Associations of Frequency and Duration of Patient-Doctor Contact in Hemodialysis Facilities with Mortality

It is unknown whether regular patient-doctor contact (PDC) contributes to better outcomes for patients undergoing hemodialysis. Here, we analyzed the associations between frequency and duration of PDC during hemodialysis treatments with clinical outcomes among 24,498 patients from 778 facilities in the international Dialysis Outcomes and Practice Patterns Study (DOPPS). The typical facility PDC frequency, estimated by facility personnel, was high (more than once per week) for 55% of facilities, intermediate (once per week) for 24%, and low (less than once per week) for 21%. The mean ± SD estimated duration of a typical interaction between patient and physician was 7.7±5.6 minutes. PDC frequency and duration varied across DOPPS phases and countries; the proportion of facilities with high PDC frequency was 17% in the United States and 73% across the other countries. Compared with high PDC frequency, the adjusted hazard ratio (HR) for all-cause mortality was 1.06 (95% confidence interval [CI], 0.96 to 1.17) for intermediate PDC frequency and 1.11 (95% CI, 1.01 to 1.23) for low PDC frequency (P=0.03 for trend). Furthermore, each 5-minutes-shorter duration of PDC was associated with a 5% higher risk for death, on average (HR, 1.05; 95% CI, 1.01 to 1.09), adjusted for PDC frequency and other covariates. Multivariable analyses also suggested modest inverse associations between both PDC frequency and duration with hospitalization but not with kidney transplantation. Taken together, these results suggest that policies supporting more frequent and longer duration of PDC may improve patient outcomes in hemodialysis.Although maintenance hemodialysis (HD) saves lives, survival of patients with ESRD remains poor and is much worse than for the general population.¹ HD facilities differ with respect to provision of important clinical practices;^2,3 among these, differences in patterns of dialysis unit staffing might influence mortality.^4,5 HD patients usually receive thrice-weekly dialysis provided by a multidisciplinary team of health care professionals (doctors, nurses, technicians, dietitians, and social workers). As part of this team, the physician’s role in improving the quality of chronic disease care is considered crucial.^6,7Many health care providers and researchers believe that more frequent and longer patient-doctor contact (PDC) in HD care may improve patient outcomes because it provides physicians with greater opportunity to monitor treatments; enhance communication and build trust with the patient; and detect, prevent, and treat new medical problems.^2,5,8 However, the actual frequency and duration of PDC for HD care have not been reported in many countries, and there is little direct evidence that more frequent and longer PDC contributes to better patient health outcomes. Previous studies from the United States showed that less frequent PDC was associated with lower patient satisfaction, lower patient adherence, lower patient achievement of clinical performance targets, and higher hospitalization, but more frequent PDC was not necessarily related to longer patient survival.^8–10 A recent study based on data from the U.S. Renal Data System (USRDS) also reported no difference in survival for PDC frequency of <4 times per month compared with 4 times per month.¹⁰ However, the study was limited to one country and was unable to evaluate differences in outcomes between 4 times per month and >4 times per month because of limitations of the billing codes and relatively low proportion of high PDC frequency in the United States.This study examined the estimated typical frequency and duration of PDC that occurs at the time of HD treatments and its associations with all-cause mortality as a primary outcome among participants in the Dialysis Outcomes and Practice Patterns Study (DOPPS), an international prospective cohort study of HD patients and facilities. PDC was studied at the facility level, reducing the opportunity for patient-level confounding by indication in this international cohort. Among such patients, a high PDC frequency (>4 times per month) is much more common outside of than in the United States. We also examined the associations of PDC frequency and duration with first hospitalization and kidney transplantation as secondary outcomes. A better understanding of the effect of PDC intensity could have implications for health policy in addition to improving health care delivery and HD patient outcomes.     

Parry Romberg Syndrome associated with chronic facial pain

Parry Romberg Syndrome (PRS) is a rare condition of unknown cause and pathophysiology. It is characterized by progressive facial hemiatrophy, and neurological abnormalities are found in 20% of cases. We describe a 50-year-old woman with PRS and severe neurological involvement (lateralised epileptic seizure activity and facial pain refractory to medication). Pain intensity and frequency was reduced and control of epileptic crises was improved using levetiracetam as an additional therapy. In previous published cases associated with facial pain, the most frequent diagnoses were migraine and trigeminal neuralgia. Our findings suggest that in this patient PRS-related persistent pain has peculiar features possibly attributed to the underlying musculoskeletal abnormalities.