Isolated translocation of Wernicke's area to the right hemisphere in a 62-year-man with a temporo-parietal glioma

We describe a case of translocation of temporo-parietal language function (Wernicke's area) to the contralateral hemisphere in a right-handed patient with a left temporo-parietal glioma. This translocation was identified by functional MR imaging (fMRI) and validated by direct cortical stimulation during gross-total resection. The current case exemplifies how preoperative fMRI can identify unexpected language organization as a result of tumor growth, affording surgery to patients who may otherwise be deemed inoperable.     

Whole body magnetic resonance imaging in the diagnosis of Parsonage Turner syndrome

Purpose: To describe magnetic resonance imaging (MRI) findings in patients with suspected Parsonage Turner syndrome and to emphasize the value of an additional whole body MR scan to improve specificity of this diagnosis.

Material and Methods: Three patients with proven Parsonage Turner syndrome referred for conventional MRI of the shoulder girdle and additional whole body turboSTIR MRI were included for study.

Results: In each case, imaging revealed edema in the muscles of the shoulder girdle. Whole body turboSTIR MRI scan confirmed localized unilateral changes in each case improving specificity and confidence in the diagnosis of Parsonage Turner syndrome in each case.

Conclusion: Whole body turboSTIR MR imaging is a useful diagnostic tool in the evaluation of patients with suspected Parsonage Turner syndrome. Inclusion of the brain, neck, brachial plexus, and extremity musculature at whole body imaging allows differentiation from polymyositis and elimination of additional causes of shoulder girdle pain and weakness including gross lesions in the brain, neck, and brachial plexus by a single non-invasive study.     

Hypofibrinogenaemia associated with a novel heterozygous gamma289 Ala -->Val substitution (fibrinogen Dorfen)

The molecular basis of hypofibrinogenaemia was investigated in a 34-year-old woman and her 10-year-old daughter. DNA sequencing revealed a single heterozygous GCC-->GTC transition in exon 8 of the fibrinogen gamma ?gene in both subjects, predicting a novel gamma289 Ala-->Val substitution. Examination of fibrinogen gamma ?chains by electrospray ionization mass spectrometry failed to detect the variant chain in plasma fibrinogen. Further evidence for its non-expression came from tryptic peptide mapping. The mutation predicts a mass increase of 28 Da in peptide T32, but only the normal (M + 2H) ion was detected at 1418 m/z in the proposita. Our finding that gamma289 is an important determinant of plasma fibrinogen levels highlights the role of mutational analysis in defining structurally important regions of the fibrinogen molecule. This case suggests that the highly conserved Ala(289) is important in maintaining structure of the "a" polymerization site via hydrogen bonding to Thr(371).     

Changes in tissue pH and temperature after incision indicate acidosis may contribute to postoperative pain

BACKGROUND: Incisional pain is a common form of acute pain. Previously, the authors studied persistent pain behaviors caused by incisions, using animal models for postoperative pain. In this study, the authors measured tissue pH and hind paw temperature before and after incision to understand factors that may activate and sensitize nociceptors in the incision. METHODS: Rats underwent a plantar incision, a gastrocnemius muscle incision, or a cutaneous paraspinal incision. For the hind paw incision, pain behaviors were measured. Tissue pH was measured using a pH-sensitive needle electrode in halothane-anesthetized rats. The pH in the incision was compared to a corresponding control site on the contralateral side of the rat or to the sham-operated group. RESULTS: Plantar tissue pH was 7.16 +/- 0.04 in sham-operated rats. Ten minutes after plantar incision, tissue pH was decreased to 6.91 +/- 0.20 (P < 0.05), and this decrease was sustained through 60 min after incision, when pH was 6.99 +/- 0.06 (P < 0.05). Tissue pH values were 6.95, 6.90, 6.89, and 6.95 (P < 0.05 vs. sham) 4 h and 1, 2, and 4 days after incision, respectively. On postoperative day 7, when plantar pH was same as for the control side (7.13 +/- 0.05), guarding behavior, heat responses, and responses to mechanical stimuli recovered. Outside the incised area in the hind paw, tissue pH was normal. Tissue pH was significantly correlated with all pain behaviors. In the gastrocnemius muscle, tissue pH was 7.14 +/- 0.7 in the sham-operated side. Ten minutes after incision, tissue pH was 6.54 +/- 0.12 (P < 0.05), and muscle pH remained decreased through 60 min after gastrocnemius incision when pH was 6.76 +/- 0.17 (P < 0.05). Tissue pH was also significantly decreased (P < 0.05) on day 1 (6.96 vs. 7.20) and day 4 (7.06 vs. 7.18) after gastrocnemius incision but was not reduced on postoperative day 8 (7.11 vs. 7.15). A paraspinal incision also decreased tissue pH in the hairy skin of the rat compared with the preincision value. Hind paw skin temperature did not change after incision. CONCLUSION: A decrease in pH occurs immediately after incision and is sustained for at least 4 days. During the period of decreased tissue pH, pain behaviors are evident. When the tissue pH returns to normal, pain behaviors are diminished. The decreased pH is localized at the incision site and not to areas surrounding the incision. Decreased pH likely contributes to nociceptor sensitization and pain related behaviors after incision. The magnitude of the pH change varies among tissues. An increase in hind paw skin temperature does not play a role in these pain-related behaviors.     

Prognostic nomogram for patients undergoing resection for adenocarcinoma of the pancreas

BACKGROUND: Predictive nomograms are becoming increasingly used to define and predict outcome. They can be developed at presentation or following treatment and include variables not conventionally used in standard staging systems. METHODS: We use a predictive nomogram based on prospectively collected data from 555 pancreatic resections for adenocarcinoma at a single institution. At last follow-up, 481 (87%) had died, defining a mature and comprehensive database. We used a 1-, 2-, and 3-year follow-up, as the number of patients alive beyond 3 years is sufficiently limited to provide insufficient events. RESULTS: Based on a Cox model, we then developed a nomogram that predicts the probability that a patient will survive pancreatic cancer for 1, 2, and 3 years from the time of the initial resection, assuming that there is not death from an alternate cause. Calibration between observed and corrected is good, and variables not conventionally associated with standard staging systems improved the predictivity of the model. CONCLUSIONS: This nomogram can serve as a basis for investigating other potentially predictive variables that are proposed of prognostic importance for patients undergoing resection for adenocarcinoma of the pancreas.     

Late complications after ligation and bypass for popliteal aneurysm

BACKGROUND: Ligation and bypass is standard treatment for popliteal aneurysm. This technique does not abolish collateral circulation to the aneurysm, which may continue to expand and/or rupture. This study assessed whether complete thrombosis of the aneurysm sac occurs after operation and examined the long-term clinical outcome. METHODS: The records of all patients who underwent popliteal aneurysm repair in a university hospital over 10 years were reviewed. Patients who had undergone ligation and bypass were recalled for clinical and ultrasonographic examination to determine the fate of the aneurysm sac. RESULTS: Persistent blood flow in the aneurysm sac was present in 12 of 36 legs a median of 48 months after operation. This was associated with symptomatic enlargement of the aneurysm in six patients. The incidence of sac enlargement was lower in bypassed aneurysms with no intrasac flow on duplex examination. CONCLUSION: Ligation and bypass does not always abolish blood flow in the sac of a popliteal aneurysm. It may be associated with continued expansion and late complications.     

Patient safety and medical malpractice: a case study

The system of tort liability for medical malpractice is frequently criticized for poorly performing its theoretical functions of compensating injured patients, deterring negligence, and dispensing corrective justice. Working from an actual malpractice case involving serious injury but no apparent negligence, the authors explore these criticisms from the perspectives of both the plaintiff-patient and the defendant-physician. They then examine the tort system through the lens of patient safety and conclude that the tensions between the system and patient safety initiatives suggest a need to reexamine our attachment to adversarial dispute resolution in health care. They propose targeted reforms that could improve the functioning of the system and create incentives to improve safety and quality.