Sublingual immunotherapy: from safety to mechanism of action

Allergen specific immunotherapy is an important option for the treatment of respiratory allergy and its clinical efficacy has been clearly demonstrated by several studies. However, the injective route of administration and the possibility of severe side effects has limited its use in children and led to the introduction of new forms of administration. Sublingual immunotherapy (SLIT) has proven to be an effective and safe treatment for respiratory allergy. However, its mechanism of action is still debated. Pharmacokinetic studies showed that, differently from nasal mucosa, allergen extracts administered by SLIT are not immediately adsorbed but are long retained before being drained to local lymph nodes. This difference may be responsible of the absence of severe side effects and instead of short-lasting local symptoms. Studies by biopsies of the oral mucosa should greatly help in defining the presence and the role of cells involved in the mechanisms of oral tolerance.     

Women with epilepsy: hormonal issues from menarche through menopause

Epilepsy is a multilayered disorder complicated by numerous comorbid conditions and hormonal changes. More than 1.5 million girls and women with epilepsy face side effects that are compounded at different ages by menstruation, fertility, pregnancy, fetal health, bone health, and other health issues. Changes in hormonal balance during maturation, from menarche through menopause, affect seizure thresholds and antiepileptic drugs, and vice versa. This overview provides physicians with a background on the multiple issues relevant to women of all ages in the reproductive years, including those planning to conceive and those who are pregnant, and beyond the childbearing years.     

The impact of seizures and adverse effects on global health ratings

This study was undertaken to explore the perceived impact of having a seizure (SZ) compared with having an adverse effect (AE). Patients (N=201) with partial-onset epilepsy taking two or more antiepileptic drugs (AEDs) rated their health state from 0 to100 based on their health today, hypothetical health if experiencing a SZ today, and hypothetical health if experiencing an AE today. Overall health status ratings (HLTH) declined as SZ frequency increased (P=0.01). Perceived decrements in HLTH with SZs were greatest for patients with the least frequent SZs (P=0.001) and the most recent SZs (P=0.004). Perceived decrements in HLTH with SZs compared with AEs (SZ-AE) differed across SZ recency groups (P<0.05 except for muscle incoordination and weakness). Patients with the more remote SZs were most concerned with SZ control; patients with more recent SZs were more sensitive to AED side effects. These data provide insight into the risk-benefit concerns of patients at equipoise when addressing the efficacy and AEs of AEDs.     

Multidisciplinary design and implementation of a day program specialized for the frontotemporal dementias

To supervise activities for patients with frontotemporal dementias presents major challenges to day programs typically equipped to care for more elderly, frail patients. In this article, we present the development and immediate outcomes of integrating a day program specialized for patients with frontal lobe disturbances into an already established day program. Planning required new collaborations between the ambulatory memory clinic and the day program staff. Immediate outcomes have included relief of burden for an under-served group of caregivers and behavioral management that more seamlessly combines strategies for medication titration, environmental adjustments, and activity participation.     

Postnatal concerns in children born to women with epilepsy

Infants born to mothers with epilepsy are at substantial risk for neurocognitive and behavioral disorders. Although exposure of the child to antiepileptic drugs (AEDs) during pregnancy and postnatally through breast milk has been implicated in disorders of higher cortical function, there have been relatively few clinical or animal studies examining the long-term effects of AEDs on cognition in the developing brain. In the limited animal studies done thus far, drug-specific effects on cognitive function have been identified. Phenobarbital, in particular, has been found to lead to adverse cognitive outcomes, whereas the newer AEDs have generally had more favorable outcomes. Although the pathophysiological mechanisms responsible for these deficits remain largely unknown, there is evidence that AEDs can adversely effect neuronal proliferation and migration, and increase apoptosis. While animal studies can provide valuable information regarding mechanism of AED-induced developmental pathology, they do not provide insight into cortical functions unique to humans, such as speech and language. Understanding the full spectrum of AED-induced effects on the developing brain will require both rigorous basic science and clinical studies.     

Unenhanced multidetector CT (CT KUB) in the initial imaging of suspected acute renal colic: evaluating a new service

AIM: To evaluate a new imaging pathway for the investigation of patients presenting with suspected acute renal colic. MATERIALS AND METHODS: A retrospective review of 500 consecutive cases of suspected acute renal colic was undertaken to evaluate the initial results of a new imaging pathway introduced at our institution, which completely replaced the intravenous urogram (IVU) with unenhanced multidetector CT (CT KUB). RESULTS: The positive rate for urolithiasis was 44% (221/500), the negative rate 46% (229/500) and the rate of other significant findings was 12% (59/500). Female patients had a low positive rate compared with male patients (27.5 versus 57.5%; p<0.001). Urological intervention was required in 28% (61/221) and these patients had a larger average stone size (6.6 versus 3.7 mm; p<0.001) and the stone was located more proximally. Out-of-hours imaging was performed in 37% (186/500), and these patients had a higher positive rate (52 versus 40%; p<0.001). Other findings included a wide range of acute non-urological conditions. CONCLUSION: The feasibility of replacing the acute IVU with CT KUB in the initial assessment of suspected acute renal colic was demonstrated in the present study. The technique enables rapid diagnosis of urolithiasis, stratification of patients likely to proceed to urological intervention, and prompt diagnosis of a variety of other acute pathological conditions.     

Pyogenic liver abscesses caused by Klebsiella pneumoniae: US appearance and aspiration findings

PURPOSE: To retrospectively compare the ultrasonographic (US) appearance and amount of pus obtained at initial aspiration for liver abscesses caused by Klebsiella pneumoniae with those for liver abscesses caused by other bacterial pathogens. MATERIALS AND METHODS: This study had medical ethics committee approval; informed consent was not required. Asian patients with pyogenic liver abscesses in a 5-year period were included. Abscess clinical, laboratory, and microbiologic characteristics and treatment and outcome were analyzed. US images were classified according to the size of the largest liver abscess, the echogenic pattern of the lesion, the presence of any echogenic debris within the lesion, increased through transmission in the posterior aspect of the lesion, and the lesion margin. Clinical and US characteristics of patients with K pneumoniae monomicrobial liver abscesses and those with non-K pneumoniae monomicrobial or polymicrobial liver abscesses were compared. The chi(2) or Fisher exact test was used for categorical variables; the Student t test was used for continuous variables. RESULTS: There were 120 patients with pyogenic liver abscesses. Median patient age was 69 years (range, 13-94 years). Fifty-nine patients were male, and 61 were female. Fifty patients with K pneumoniae monomicrobial and 33 patients with non-K pneumoniae monomicrobial or polymicrobial liver abscesses underwent US. K pneumoniae monomicrobial liver abscesses were associated with diabetes mellitus (P < .001), higher blood glucose levels at admission (P < .05), predominantly solid US appearances (P < .001), irregular or indistinct lesion margins (P < .05), less than 2 mL of pus aspirated (P < .001), and longer duration of antibiotic treatment (P < .05). CONCLUSION: A predominantly solid appearance at US is associated with K pneumoniae monomicrobial liver abscess. K pneumoniae liver abscess is associated with a much smaller quantity of pus at initial aspiration.     

Radiation protection

One of radiologic technologists' most important professional obligations is protecting patients, other members of the health care team, the public and themselves from as much radiation-related harm as possible while also maximizing the screening, diagnostic and therapeutic potential of ionizing radiation. This article reviews the different types of radiation dose and how radiation affects the body. Patient shielding, personnel dosimeters and area monitors are discussed, along with beam collimation and filtration. The author also describes protocols to protect pregnant patients and pregnant technologists.     

Exact moment of tendon of pectoralis major muscle rupture captured on video

A powerlifting athlete ruptured his left tendon of the pectoralis major muscle while attempting to lift 160 kg in a Brazilian bench press championship. The injury seemed to occur in the concentric phase of exercise; however, the more common mechanism of rupture is during the eccentric phase. The tendon was reinserted to the humerus 3 weeks later with screws and washers. The athlete returned to competitive activities after 5 months. One year later he lifted 170 kg and won the national championship.