Comparison between true and partial hemifacial hypertrophy.

Hemifacial hypertrophy (HFH) is rare and characterized by unilateral enlargement of the head and teeth. Hemifacial hypertrophy is classified as true HFH (THFH) with unilateral enlargement of the viscerocranium, and partial HFH (PHFH) in which not all structures are enlarged. We present a case of THFH and compare and contrast it with a case of PHFH. Hemifacial hypertrophy may cover a wide spectrum of defects or may involve only muscle or bone. Myohyperplasia, reported previously as a separate syndrome, may actually represent a forme fruste of PHFH or THFH. The PHFH patient lead a healthy, normal life without significant psychosocial problems and was reluctant to accept his deformity. Contrastingly, the THFH patient had significant social stigma and compromised health together with major aesthetic morbidity. Treatment planning in THFH is arduous and involves multiple modalities. Therefore, it is imperative to differentiate THFH and PHFH for better understanding and management of the condition.     

Effects of the novel antidepressant S-adenosyl-methionine on alpha 1- and beta-adrenoceptors in rat brain

alpha 1- and beta-adrenoceptors were studied ex vivo in the brains of rats receiving repeated daily treatment with the standard antidepressant imipramine or the atypical antidepressant S-adenosyl-L-methionine (SAM), which has minimal effects on monoamine reuptake or turnover. Consistent with past studies, a decrease in the density of beta receptors at three weeks and an increase in the affinity of alpha 1 receptors for the agonist phenylephrine at one week of treatment was observed with imipramine. By comparison, an increase in the density of beta receptors and a decrease in the affinity of alpha 1 receptors for phenylephrine was observed at one week of treatment with SAM. These changes were no longer apparent at three weeks of treatment. The results suggest that treatment with SAM does lead to changes in adrenergic neurotransmission, but that down regulation of beta receptors or increased agonist affinity of alpha 1 receptors may not be necessary for the production of antidepressant effects.     

Subungual malignant melanoma

An early accurate diagnosis of subungual melanoma depends upon an alert podiatric physician. Clinically, the lesion is often easily misdiagnosed and mistreated because of its resemblance to benign nail conditions. This paper discusses the incidence, histology, clinical findings, diagnosis, and treatment of this malignant lesion. An illustrative case report is presented.     

BK Virus-Specific Antibodies and BKV DNA in Renal Transplant Recipients with BKV Nephritis

We evaluated twenty renal transplant subjects at various stages of BKV nephritis (BKVN) for BKV-specific IgG and IgM antibodies using ELISA technique and BKV-DNA using PCR. They were divided as early onset (n = 7), stabilizing (n = 3), resolved (n = 8) and late onset (n = 2) BKVN. BKV-specific antibodies and BKV-DNA were simultaneously determined. The mean BKV-specific IgG level in early onset and stabilizing BKVN were 64 and 39 EIA units, and were significantly lower than 138 EIA units seen in resolved BKVN, P = 0.007, P = 0.008. The mean BKV-specific IgM levels in stabilizing BKVN was higher than resolved BKVN (130 vs 51 EIA units), P = 0.006. Mean plasma BKV loads for each group were 955,925, 5642 and 42 copies/mL of plasma, respectively. Prospective study in six BKVN cases revealed mean IgG, IgM levels and BKV-DNA at the time of diagnosis of BKVN as 39, 110 EIA units and 586,758 copies/mL of plasma, respectively. After a mean period of 5.2 months, IgG level increased to 120 EIA units (p = 0.0058) and had no detectable viral copies in circulation. Recovery from BKVN and elimination of BKV is associated with the development of BKV-specific IgG antibodies and this provides insight into the role of humoral immunity to BKV in the pathogenesis of BKVN.     

Anticholinergic sensitivity in patients with dementia of the Alzheimer type and age-matched controls. A dose-response study

We compared the cognitive and behavioral responses to three intravenous doses of scopolamine (0.1, 0.25, and 0.5 mg) and placebo of ten patients with dementia of the Alzheimer type (DAT) and ten age- and sex-matched elderly control subjects. The patients with DAT showed significant behavioral and cognitive but not physiologic changes at a lower scopolamine dose (0.25 mg) than did the normal elderly controls. Cognitive tests of new learning and semantic knowledge revealed significant impairments at the 0.25-mg scopolamine dose in the patients with DAT, while the responses of the control population were essentially unchanged. Behaviorally, mild euphoria, motor incoordination, and hostility occurred in the patients with DAT but not the controls at the 0.25-mg dose. These differences were unrelated to peripheral physiologic changes produced by the different scopolamine doses. These results indicate that central nervous system functions such as cognition and certain elements of behavior are more sensitive to temporary cholinergic blockade in patients with DAT than in normal age-matched controls. We review implications concerning the status of central cholinergic function in patients with DAT in light of neuropathologically demonstrated cholinergic system lesions in DAT.     

COMPARISON OF REFLEX MODIFICATION PROCEDURES AND AUDITORY BRAINSTEM RESPONSE IN HIGH-RISK NEONATES

This study compared the results of reflex modification (RM)--an objective technique for assessing brainstem sensorineural processing--with those of auditory brainstem response (ABR) for a group of high-risk infants at comparable postconceptional ages. For the RM procedure, an eyeblink-eliciting tap to the glabella was presented either alone or accompanied by a brief 90dB SPL tone. 37 high-risk infants were tested with both RM and ABR at a mean postconceptional age of 37.3 weeks. Seven had an increased brainstem conduction time ('failed ABR') and eight did not exhibit significant reflex augmentation ('failed RM'), seven of whom also failed the ABR. These data provide evidence that sensory stimuli which affect the neural mechanisms responsible for the organization of the startle response and auditory processing share essential neural components.     

Technology assessment of anaesthesia monitors: problems and future directions

Specific factors have limited the interpretation of studies regarding the efficacy, effectiveness and efficiency of technology in anaesthesia. Some of these problems are reviewed, including the lack of specific outcomes necessitating the use of intermediate measures (e.g., hypoxaemia, myocardial ischaemia), which are not necessarily related to ultimate patient outcomes. This emphasizes the need for anaesthesia investigators to define fundamental issues specifically and design studies accordingly. With respect to anaesthesia monitors, the “lead time” or early warning provided by a monitor relative to that required to alter therapy effectively needs to be defined better and compared with the “lead time” without the monitor. After defining the benefit of a monitor, investigators should analyze the cost relative to alternatives (cost-benefit and cost-effectiveness). A hierarchical model to guide technology assessment is presented that addresses in order, the scientific basis of the technology, and the influence on the patient followed by societal issues. Anaesthetists have relied on traditional methods of technology assessment adopted from other disciplines. These methodologies do not address specific issues related to anaesthesia practice (such as “lead time”). In defining problems specific to the specialty of anaesthesia, new outcome measures that focus on the human factors related to decision-making in the operating room need to be developed. Future evaluations of anaesthesia technology require innovative approaches that address specific anaesthesia-related problems. One such approach is the use of simulation-based studies of response patterns to critical incidents.