Inflationary oscillometric blood pressure monitoring: validation of the OMRON-MIT

BACKGROUND: To evaluate the accuracy of the OMRON-MIT, (an automated inflationary oscillometric blood pressure monitoring device) for use in the general population by direct comparison to standard auscultatory mercury sphygmomanometry. DESIGN: Two trained, blinded observers taking simultaneous blood pressure measurements alternating between a mercury sphygmomanometer and the OMRON-MIT. METHODS: The evaluation was carried out according to the revised British Hypertension Society protocol. The validation data was also classified by the American Association for the Advancement of Medical Instrumentation (AAMI). RESULTS: The OMRON-MIT device achieved a BHS grade A for both systolic blood pressure (SBP) and diastolic blood pressure (DBP). It also met the criteria for the AAMI protocol, the mean difference between the MIT and standard was -2.0 +/- 7 mmHg for SBP and -2.0 +/- 6 mmHg for DBP. CONCLUSIONS: Inflationary oscillometry is a valid technique for the measurement of blood pressure. The OMRON-MIT, which uses this technique, is accurate and can be recommended for clinical use in the adult population.     

Characterization of events preceding the release of malaria parasite from the host red blood cell

The process of merozoite release involves proteolysis of both the parasitophorous vacuole membrane (PVM) and red blood cell membrane (RBCM), but the precise temporal sequence remains controversial. Using immunofluorescence microscopy and Western blotting of parasite-infected RBCs, we observed that the intraerythrocytic parasite was enclosed in a continuous ring of PVM at early stages of parasite development while at the segmented schizont stage, the PVM appeared to be integrated in the cluster of newly formed merozoites. Subsequently, such clusters were detected extraerythrocytically together with single merozoites devoid of the PVM at low frequency, suggesting a primary rupture of RBCM, followed by PVM rupture and release of invasive merozoites. Secondly, since cysteine proteases are implicated in the process of parasite release, antimalarial effects of 4 cysteine protease inhibitors (leupeptin, E64, E64d, and MDL) were tested at the late schizont stage and correlated with the integrity of PVM and RBCM. We observed that leupeptin and E64 treatment produced extraerythrocytic clusters of merozoites associated with PVM suggesting inhibition of PVM lysis but not RBCM lysis. Merozoites in these clusters developed into rings upon removal of the inhibitors. In contrast, E64d and MDL caused an irreversible parasite death blocking further development. Future characterization of the mechanism(s) of inhibition may facilitate the design of novel antimalarial inhibitors.     

Lymphadenectomy for Adenocarcinoma of the Gastroesophageal Junction (GEJ): Impact of Adequate Staging on Outcome

Introduction Adequate staging of gastric cancer requires examination of at least 15 lymph nodes. Most resected patients are inadequately staged potentially confounding the interpretation of clinical data. The aim of this study was to determine whether adequate staging revealed different prognostic factors or improved survival compared with patients with <15 nodes examined after R0 resection for GEJ cancer. Methods A prospectively maintained database identified 366 patients with Siewert types II and III adenocarcinoma of the GEJ who underwent R0 resection without neoadjuvant therapy at a single institution. Patients were grouped into adequately (≥15 nodes examined) or inadequately staged (<15 nodes examined). Median follow up was 51 months. Results From 1985 through 2003, 250/366 (68%) patients were adequately staged and 116/366 (32%) were inadequately staged. There was no difference in operative mortality between adequately staged (5.2%) and inadequately staged patients (4.3%, P = NS). Adequately staged patients had more positive lymph nodes (median 2) compared with inadequately staged patients (median 1, P < 0.01). Multivariable analysis of adequately staged patients found the number of positive lymph nodes, T stage, and lymphovascular invasion to be independent prognostic factors for overall survival (OS). For inadequately staged patients only the number of positive lymph nodes and T stage were independent prognostic factors. Adequate staging was an independent prognostic factor for patients with advanced (T ≥ 2 Nany) tumors. For T1 tumors adequate staging was not associated with improved survival. Conclusions Patients with GEJ cancer should undergo adequate lymphadenectomy to permit examination of ≥15 lymph nodes allowing the accurate identification of prognostic variables. Removal of ≥15 lymph nodes is associated with more accurate survival estimates for patients with advanced disease.     

Dengue has a benign presentation in renal transplant patients: a case series

AIM: Dengue fever and its complications are a poorly described entity in the renal transplant population. Previous reports in renal transplant patients suggest a high mortality rate. METHODS: We undertook a retrospective study of six cases of dengue fever in renal transplant patients during a dengue outbreak in Singapore in 2005 which involved a total of 1400 cases in the city state. RESULTS: Mean thrombocytopenia was 130,000/microL on presentation and 80,000/microL at deffervescence. No dengue haemorrhagic fever, dengue shock syndrome, deaths or abnormal graft function were observed. Mean hospital stay was 8.6 days. Four of six patients also had simultaneous CMV reactivation. CONCLUSION: In common with the majority of adults, dengue fever follows a benign course in the renal transplant population and dengue haemorrhagic fever is rare. This may be related to the relative immunosuppression reducing the risk for antibody-enhanced complications.     

Functional and structural neuroimaging in trigeminal autonomic cephalalgias

Abastract The trigeminal autonomic cephalalgias (TACs) are a group of primary headache disorders characterized by unilateral trigeminal distribution pain that occurs in association with ipsilateral cranial autonomic features. They include cluster headache, paroxysmal hemicrania, and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing. Until recently, primary headache disorders, including the TACs, were widely considered to be caused by peripheral mechanisms such as vascular changes or neurogenic inflammation. Developments in neuroimaging are revolutionizing our understanding of the pathophysiology of primary headache syndromes. Functional imaging studies have demonstrated hypothalamic activation in all the TACs. Furthermore, neuroimaging studies using voxel-based morphometry and magnetic resonance spectroscopy techniques have demonstrated structural and biochemical alterations, respectively, in the hypothalamus of patients with cluster headache. These studies suggest that the hypothalamus plays a crucial role in the pathophysiology of TACs, thereby supporting the notion that these disorders are primarily due to central rather than peripheral mechanisms.     

New insights into migraine: application of functional and structural imaging

PURPOSE OF REVIEW: Functional neuroimaging in headache patients has revolutionized our understanding of these syndromes. Further insights into the pathophysiology of headache syndromes have been provided by innovative neuroimaging analysis using structural data. This review highlights the recent advances made in studying migraine using neuroimaging techniques. RECENT FINDINGS: Several independent studies have reinforced the crucial role for the brainstem in acute and probably also chronic migraine. Recently described structural abnormalities in the visual network of motion-processing areas could account for, or be caused by, the cortical hyperexcitability observed in migraineurs. Although data from morphometric studies are heterogeneous, a recent study suggests an increased density of brainstem structures and decreased grey matter in pain-transmitting areas in migraine patients. SUMMARY: Given the rapid advances in functional neuroimaging, in particular newer techniques such as voxel-based morphometry and magnetic resonance spectrometry, functional imaging continues to play a significant role and opens new avenues in targeting the neural substrates in individual primary headache syndromes.     

Trigeminal autonomic cephalalgias: Diagnosis and treatment

The trigeminal autonomic cephalalgias (TACs) are a group of primary headache disorders characterized by unilateral head pain that occurs in association with ipsilateral cranial autonomic features. The TACs include cluster headache, paroxysmal hemicrania, and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and its close relative short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA). These syndromes cause patients considerable disability and certainly very significant suffering. They are distinguished by the frequency of attacks of pain, the length of the attacks, and very characteristic responses to medical therapy, such that the diagnosis can usually be made clinically, which is important because it completely dictates therapy. The management of TACs can be very rewarding for physicians and highly beneficial to patients.     

Peripheral neurostimulation in primary headaches

Peripheral neurostimulation techniques have emerged as promising treatments for patients with medically intractable, highly disabling chronic daily headaches including chronic migraine (CM) and chronic cluster headache (CCH) besides other less common headache syndromes. Encouraging controlled and open label data in medically intractable CM and trigeminal autonomic cephalalgias (TACs) have suggested a meaningful therapeutic role for occipital nerve stimulation (ONS). In view of the frequent occurrence of pain in the first branch of trigeminal nerve, percutaneous supraorbital nerve stimulation alone or in combination with ONS has been used successfully in open label series of CM and CCH patients. In view of its connections with the trigeminovascular system, the stimulation of the sphenopalatine ganglion has been used as a therapeutic target for the treatment of acute cluster headache attacks, with promising results. Preliminary data in patients with epilepsy and migraine have suggested a potential efficacy of vagus nerve stimulation in the treatment of primary headaches. Non-invasive devices targeting peripheral nerves have been developed and initial experience is emerging for the acute and preventive treatments of primary headache disorders. This review analyses the available evidence on the efficacy and safety of the different peripheral neurostimulation techniques.     

Cutaneous Atrophy and Alopecia After Greater Occipital Nerve Injection Using Triamcinolone

Greater occipital nerve (GON) infiltration is widely used for the treatment of primary and secondary headache disorders mainly on the basis of open‐label evidence, although recent double‐blinded placebo‐controlled trials have demonstrated its efficacy in cluster headache. The procedure is generally well tolerated although corticosteroid‐related side effects, including Cushing's syndrome and local cutaneous changes, can occur. We report the occurrence of cutaneous atrophy and alopecia in 4 patients who underwent GON blockade with triamcinolone and lidocaine. Triamcinolone injection is associated with cutaneous atrophy, especially in superficial injection sites; therefore, alternative steroid preparations like methylprednisolone and betamethasone might be more appropriate for GON blockade.