Right aortic arch with aberrant subclavian arteries: a cause of esophageal compression

We report a case of symptomatic partial vascular ring that to our knowledge has not been previously described. This anomaly includes a right aortic arch with an aberrant left subclavian artery and an atypical origin of the right subclavian artery.     

Defective slow inactivation of sodium channels contributes to familial periodic paralysis

OBJECTIVE: To evaluate the effects of missense mutations within the skeletal muscle sodium (Na) channel on slow inactivation (SI) in periodic paralysis and related myotonic disorders. BACKGROUND: Na channel mutations in hyperkalemic periodic paralysis and the nondystrophic myotonias interfere with the normally rapid inactivation of muscle Na currents following an action potential. This defect causes persistent inward Na currents that produce muscle depolarization, myotonia, or onset of weakness. Distinct from fast inactivation is the process called SI, which limits availability of Na channels on a time scale of seconds to minutes, thereby influencing muscle excitability. METHODS: Human Na channel cDNAs containing mutations associated with paralytic and nonparalytic phenotypes were transiently expressed in human embryonic kidney cells for whole-cell Na current recording. Extent of SI over a range of conditioning voltages (-120 to +20 mV) was defined as the fraction of Na current that failed to recover within 20 ms at - 100 mV. The time course of entry to SI at -30 mV was measured using a conditioning pulse duration of 20 ms to 60 seconds. Recovery from SI at -100 mV was assessed over 20 ms to 10 seconds. RESULTS: The two most common hyperkalemic periodic paralysis (HyperPP) mutations responsible for episodic attacks of weakness or paralysis, T704M and M1592V, showed clearly impaired SI, as we and others have observed previously for the rat homologs of these mutations. In addition, a new paralysis-associated mutant, I693T, with cold-induced weakness, exhibited a comparable defect in SI. However, SI remained intact for both the HyperPP/paramyotonia congenita (PMC) mutant, A1156T, and the nonparalytic potassium-aggravated myotonia (PAM) mutant, V1589M. CONCLUSIONS: SI is defective in a subset of mutant Na channels associated with episodic weakness (HyperPP or PMC) but remains intact for mutants studied so far that cause myotonia without weakness (PAM).     

Clinical governance. Thin on the ground

Clinical governance is being led by two people, usually a GP and a nurse, in most of the PCGs that responded to the survey. A fifth of the leads for clinical governance had no experience of working on quality issues. Nearly a third of respondents felt that their health authority had provided poor support or none at all. Only 10 PCGs had identified a clinical governance budget. No PCG was working with a finance manager to develop clinical governance and only five were working with an information manager.     

Neuropsychological functioning and sleep patterns in the elderly.

OBJECTIVE: To discover whether reported sleep-wake disturbances in the elderly (more frequent nocturnal awakenings, earlier waking and more day time naps) are associated with neuropsychological dysfunction. DESIGN AND SETTING: A sample of 124 residents of a retirement village complex were interviewed about their sleep patterns and given neuropsychological assessments. Reported sleep-wake difficulties were combined to form two variables, "night sleep" and "day sleep". Additional sleep variables analysed were reported sleep duration and time of wakening. Principal components analysis of the neuropsychological test scores yielded four factors: "general ability", "memory", "motor", and "cerebral efficiency". MAIN OUTCOME MEASURES: A correlation analysis was performed for sleep variables, neuropsychological factors and age, mood scale and scores on indices of participation in physical and passive activities. RESULTS: There was no correlation between "night sleep" and the factor scores derived from the neuropsychological tests. "Day sleep" was correlated with "cerebral efficiency" only. Age was correlated with the "memory" and "motor" factors, the latter also being associated with participation in physical activities. CONCLUSION: Night sleep problems are not associated with neuropsychological deficits in a non-clinic population.     

Foetal cystic abdominal masses

Foetal abdominal cysts are frequently found on routine antenatal ultrasound. Various sonographic features might help in their differential diagnosis. However, a definitive diagnosis is often not made until postnatal life, and detection of an intra‐abdominal cyst antenatally rarely alters obstetric management. A review of possible causes of a foetal abdominal cyst is presented.     

Cost-utility analysis of screening intervals for diabetic retinopathy in patients with type 2 diabetes mellitus

CONTEXT: Annual eye screening for patients with diabetes mellitus is frequently proposed as a measure of quality of care. However, the benefit of annual vs less frequent screening intervals has not been well evaluated, especially for low-risk patients. OBJECTIVE: To examine the marginal cost-effectiveness of various screening intervals for eye disease in patients with type 2 diabetes, stratified by age and level of glycemic control. DESIGN: Markov cost-effectiveness model. SETTING AND PARTICIPANTS: Hypothetical patients based on the US population of diabetic patients older than 40 years from the Third National Health and Nutrition Examination Survey. MAIN OUTCOME MEASURES: Patient time spent blind, quality-adjusted life-years (QALYs), and costs of annual vs less frequent screening compared by age and level of hemoglobin A1c. RESULTS: Retinal screening in patients with type 2 diabetes is an effective intervention; however, the risk reduction varies dramatically by age and level of glycemic control. On average, a high-risk patient who is aged 45 years and has a hemoglobin A1c level of 11% gains 21 days of sight when screened annually as opposed to every third year, while a low-risk patient who is aged 65 years and has a hemoglobin A1c level of 7% gains an average of 3 days of sight. The marginal cost-effectiveness of screening annually vs every other year also varies; patients in the high-risk group cost an additional $40530 per QALY gained, while those in the low-risk group cost an additional $211570 per QALY gained. In the US population, retinal screening annually vs every other year for patients with type 2 diabetes costs $107510 per QALY gained, while screening every other year vs every third year costs $49760 per QALY gained. CONCLUSIONS: Annual retinal screening for all patients with type 2 diabetes without previously detected retinopathy may not be warranted on the basis of cost-effectiveness, and tailoring recommendations to individual circumstances may be preferable. Organizations evaluating quality of care should consider costs and benefits carefully before setting universal standards.     

The Impact of Diabetes on Workforce Participation: Results from a National Household Sample

Objective. Diabetes is a highly prevalent condition that results in substantial morbidity and premature mortality. We investigated how diabetes-associated mortality, disability, early retirement, and work absenteeism impacts workforce participation.
Data Source. We used the Health and Retirement Study (HRS), a national household sample of adults aged 51–61 in 1992, as a data source.
Study Design. We conducted cross-sectional analyses on the baseline HRS data, and longitudinal analyses using data from eight years of follow-up. We used two-part regression models to estimate the adjusted impact of diabetes on workforce participation, and then estimated the economic impact of diabetes-related losses in productivity.
Principal Findings. Diabetes is a significant predictor of lost productivity. The incremental lost income due to diabetes by 1992 was $60.0 billion over an average diabetes duration of 9.7 years. From 1992 to 2000, diabetes was responsible for $4.4 billion in lost income due to early retirement, $0.5 billion due to increased sick days, $31.7 billion due to disability, and $22.0 billion in lost income due to premature mortality, for a total of $58.6 billion dollars in lost productivity, or $7.3 billion per year.
Conclusions. In the U.S. population of adults born between 1931 and 1941, diabetes is associated with a profound negative impact on economic productivity. By 1992, an estimated $60 billion in lost productivity was associated with diabetes; additional annual losses averaged $7.3 billion over the next eight years, totaling about $120 billion by the year 2000. Given the rising prevalence of diabetes, these costs are likely to increase substantially unless countered by better public health or medical interventions.     

Voice Hearing in Borderline Personality Disorder Across Perceptual,Subjective, and Neural Dimensions

BackgroundAuditory verbal hallucinations (AVH) commonly occur in the context of borderline personality disorder (BPD) yet remain poorly understood. AVH are often perceived by patients with BPD as originating from inside the head and hence viewed clinically as “pseudohallucinations,” but they nevertheless have a detrimental impact on well-being.MethodsThe current study characterized perceptual, subjective, and neural expressions of AVH by using an auditory detection task, experience sampling and questionnaires, and functional neuroimaging, respectively.ResultsPerceptually, reported AVH correlated with a bias for reporting the presence of a voice in white noise. Subjectively, questionnaire measures indicated that AVH were significantly distressing and persecutory. In addition, AVH intensity, but not perceived origin (i.e., inside vs outside the head), was associated with greater concurrent anxiety. Neurally, fMRI of BPD participants demonstrated that, relative to imagining or listening to voices, periods of reported AVH induced greater blood oxygenation level–dependent activity in anterior cingulate and bilateral temporal cortices (regional substrates for language processing). AVH symptom severity was associated with weaker functional connectivity between anterior cingulate and bilateral insular cortices.ConclusionIn summary, our results indicate that AVH in participants with BPD are (1) underpinned by aberrant perceptual-cognitive mechanisms for signal detection, (2) experienced subjectively as persecutory and distressing, and (3) associated with distinct patterns of neural activity that inform proximal mechanistic understanding. Our findings are like analogous observations in patients with schizophrenia and validate the clinical significance of the AVH experience in BPD, often dismissed as “pseudohallucinations.” These highlight a need to reconsider this experience as a treatment priority.     

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