Spontaneous cholesterol crystal embolization to bone marrow

Cholesterol crystal embolization is a well-established complication of arterial trauma and anticoagulation which may involve multiple organs including the skin and muscle, producing clinical features such as livedo reticularis, cyanosis and gangrene of the toes and intense myalgias. Cholesterol crystal embolization to bone marrow has been described in postmortem studies, but has been previously reported premortem in only two patients, both of whom had characteristic risk factors and clinical features. We report herein a case of spontaneous cholesterol crystal embolization to bone marrow in a patient with atypical clinical manifestations.     

Predictors of a positive response to biventricular pacing in patients with severe heart failure and ventricular conduction delay

BACKGROUND: Cardiac resynchronization therapy (CRT) is recommended in patients with ejection fraction <35%, QRS width> 120 ms, and New York Heart Association (NYHA) functional class III or IV despite optimal medical therapy. We aimed to define demographic, clinical, and electrocardiographic predictors of positive clinical response to CRT. METHODS AND RESULTS: Hundred consecutive patients fulfilling the recommended criteria were implanted with a CRT device. Demographic, clinical, two-dimensional echocardiographic and electrographic parameters were measured at baseline and after 6 months of simultaneous biventricular pacing. A positive response to CRT included an improvement of at least one NYHA functional class associated with an absence of hospitalization for worsening heart failure. At the end of follow-up, 12 patients were dead and 71% of the patients were classified as responders. After 6 months of CRT, the ejection fraction was significantly higher (P = 0.035) in responders versus nonresponders. Multivariate analysis identified three independent predictors of positive response to CRT: an idiopathic origin of the cardiomyopathy (P = 0.043), a wider QRS before implantation (P = 0.017), and a narrowing of the QRS after implantation (P = 0.037). CONCLUSION: An idiopathic origin of the cardiomyopathy, a wider QRS before implantation, and a narrowing of the QRS width after implantation were identified as independent predictors of clinical positive response to CRT.     

Availability of Paracetamol Sold Over the Counter in Europe: A Descriptive Cross‐Sectional International Survey of Pack Size Restriction

Due to the risk of hepatotoxicity when excessive amounts of paracetamol are consumed, Poisons Information Centers (PICs) frequently receive paracetamol‐related enquiries. This study examined how widely pack size restrictions of paracetamol sold over the counter have been implemented in Europe and also availability of paracetamol through non‐pharmacy outlets and their possible associations with frequency of poisoning enquiries. A cross‐sectional European multi‐centre questionnaire study was performed using a questionnaire to identify the extent and nature of paracetamol pack size restrictions, non‐pharmacy outlet sales and the frequency of paracetamol‐related enquiries to PICs. In total, 21 European countries participated. All PICs provided telephone hotline services. In 14 (67%) countries, pack size restrictions had been implemented in pharmacies (range: 8–30 g). No significant difference (median difference 0.7%, p‐value = 0.36) was found when comparing median frequencies of paracetamol‐related enquiries in countries with pack size restriction to countries without restrictions. A significantly lower median frequency of paracetamol‐related enquiries was found in countries without non‐pharmacy outlet sales compared to those with such sales (median difference 2.2%, p = 0.02). Pack size restrictions on pharmacy sales of paracetamol have been implemented in two‐thirds of examined countries. There was no difference in the proportion of paracetamol‐related enquiries to PICs among countries with and without pack size restrictions. However, a lower rate of paracetamol‐related enquiries was noted in countries where paracetamol was not available in non‐pharmacy outlets.     

International survey of neurosurgical anesthesia (iSonata)

Die Anaesthesiologie - No standardized recommendations have been currently defined for anesthesia management of patients undergoing elective intracranial surgery. It can therefore be assumed that...     

Constellation of lipoproteins in patients with hyperlipoproteinemia and in rabbits fed a cholesterol diet with reference to vascular permeability]

By feeding of rabbits with cholesterol a hyperlipoproteinaemia (HLP) was created and the changes of the cholesterol and triglyceride (TGL) level were compared with the changes of the portions of the pre-beta- and beta-lipoproteins. The electrophoresis with a gel of agar-agarose are more suitable for the densitometric evaluation than electrophoresis with cellulose acetate films. Tests with Evan's blue of the angiopermeability of rabbits feeded with cholesterol showed that the permeability of the cutaneous vessels decreased strikingly during test period, while a change of the permeability of the aorta was not to be proved under the conditions of our tests. HLP patients had been treated with clofibrinic acid, nicotinic acid derivatives and metabolism basic diet for 3 years. The cholesterol and TGL values as well as the pre-beta-/beta-lipoprotein quotients have been determined before and after treatment. The pre-beta-/beta-lipoprotein quotient has proved as suitable complementary parameter for pursuit of the therapeutic result with HLP patients. The changes of the quotients corresponded well with the found changes of the HLP types. The decrease of the TGL content of HLP patients of the type IV or IIb being treated with metabolism basic diet or clofibrinic acid may be estimated (with nearly constant cholesterol level) from the per cent decrease of the pre-beta-/beta-quotient.     

Changes in Neuron-Specific Enolase are More Suitable Than Its Absolute Serum Levels for the Prediction of Neurologic Outcome in Hypothermia-Treated Patients with Out-of-Hospital Cardiac Arrest

Background

To determine neurologic outcome in patients with out-of-hospital cardiac arrest (OHCA) and treatment with mild therapeutic hypothermia (MTH).

Methods

Seventy-three consecutive OHCA patients treated with MTH were retrospectively analyzed. Serum neuron-specific enolase (NSE) was measured 24, 48, and 72 h after admission. In patients with no motor response 48 h after termination of analgosedation (n = 40), clinical neurological examination and evoked potentials (EPs) were determined. Neurological outcome was assessed after 2 months based on the cerebral performance categories (CPC), and categorized as good (CPC 1–3) or poor (CPC 4 and 5).

Results

Forty-three patients had a CPC score of 1–3 and 30 patients had a CPC 4–5. The best predictive value for poor neurologic outcome was an increase of NSE by ≥4.3 ng/mL between day 1 and day 2 (sensitivity 80 %, specificity 100 %, positive predictive value (PPV) 100 %, negative predictive value 86 %). Absolute NSE values were less reliable in the prediction of poor outcome with the highest sensitivity (88 %) and specificity (95 %) if values reached ≥36.3 ng/mL on day 3. Somatosensory EPs (SSEPs) showed a specificity of 100 % and PPV of 100 %; however, sensitivity for evoked potentials was low (29 %). Intriguingly, two initially comatose patients with excessive NSE values (24 h NSE: 101 and 256 ng/mL, and 48 h NSE: 93 and 110 ng/mL, respectively) had physiological SSEPs and regained a CPC score of 1.

Conclusion

In patients treated with MTH after OHCA changes in NSE are more suitable than its absolute serum levels for the prediction of poor neurologic outcome. Since unequivocal prediction of poor neurologic outcome is of utmost importance in these patients the decision to limit therapy must be based on several prediction tools with the highest PPV and specificity including SSEPs.