Algodystrophy of the knee anatomo-radiological study of a case

Summary Presentation of a case of algodystrophy (i.e., Sudeck's dystrophy) of the left knee, affecting the femur, tibia and patella. It was brought on by a simple movement made while playing tennis and it recurred subsequently accompanied by algodystrophy of the corresponding foot. Histological study of the biopsy material showed the classical image of cortical and cancellous bone atrophy with non-specific remodelling which explained the increased uptake on the scintigraph as well as the repairing of the bone tissue observed on the X-rays. Reasons are given for the choice of the term algodystrophy to describe the condition.     

The safety and feasibility of continuous intravenous magnesium sulfate for prevention of cerebral vasospasm in aneurysmal subarachnoid hemorrhage

Introduction: Cerebral vasospasm in aneurysmal subarachnoid hemorrhage (SAH) is associated with poor outcome. The safety and feasibility of continuous high-dose intravenous magnesium sulfate (MgSO₄) for the prevention of cerebral vasospasm and ischemic cerebral injury has not been well studied. Methods: Patients presenting to our center within 72 hours of aneurysmal SAH (confirmed by computed tomography [CT] scanning and cerebral angiography) between June 2001 and October 2002 were enrolled in a prospective pilot study in which they received MgSO₄ as an adjunct to standard SAH management. Study patients received an intravenous infusion of 12 g of MgSO₄ in a 500-mL solution of 0.9% NaCl administered at a rate of 4.06 mM (or 0.5 g) every hour over a 24-hour period for 10 days to achieve a target predetermined serum Mg range of more than 1.5 to less than 4.0 mM/L. The effect of MgSO₄ on clinical examination, heart rate, and blood pressure was measured every 2 hours; serum glucose and phenytoin levels were monitored daily. Outcome measures included evidence of vasospasm on clinical examination, transcranial Doppler study ((TCD); velocity ≥100 cm/s), or repeat cerebral angiogram obtained within 10 days of SAH; and Glasgow Outcome Scale (GOS) score assessment and CT scan evidence of ischemic infarction at 30 days. Results: Nineteen patients (mean age: 55 years; range: 39–84 years; 11 males, 8 females) were enrolled in the study. Presenting Hunt & Hess grade was II or higher; mean Fisher grade was 3. Vasospasm was observed in nine patients (by clinical examination in two, TCD in five, and angiogram in nine). The mean serum Mg level was 2.7 mM/L (standard deviation: ±0.37) and was maintained during the infusion period. No clinical adverse effects, hemodynamic changes, or fluctuations in serum glucose or phenytoin levels were observed. None of the patients died; no CT evidence of ischemic infarction was present; and most had good outcomes (GOS 5 in 10 patients; GOS 4 in 8 patients). Conclusion: Our study confirmed the safety and feasibility of a continuous infusion of high-dose intravenous MgSO₄ in patients with aneurysmal SAH. Randomized controlled trials are required to confirm the promising results.     

Viable Myocardium: How Much Is Enough?

Left ventricular systolic dysfunction is mainly a result of coronary artery disease (CAD). Decrease in myocardial contractility results as a response to a chronic hypoperfusion state that produces a change in cardiac myocyte metabolism, resulting in a perfusion-contraction mismatch in which function is sacrificed for survival. If revascularization is performed in a timely fashion, metabolism can be restored leading to recovery of function. Through the use of noninvasive imaging modalities, assessing myocardial viability can be easily performed and will aid in selecting those patients who will benefit from revascularization. Viable myocardium can be identified by nuclear modalities that have a high sensitivity but a lower specificity, such as thallium-201 single photon emission computed tomography and positron emission tomography (PET); or by the use of dobutamine stress echocardiogram (DSE), which has a decreased sensitivity but a better specificity. A modality that is increasingly being used with an overall good sensitivity and specificity is contrast-enhanced magnetic resonance imaging. The purpose of this review is to explore the amount of myocardial viability that is relevant to pursue revascularization, since as myocardial function improves there is a decrease in morbidity and mortality from heart failure and arrhythmias.     

Lacunar stroke in patients with intermittent claudication

OBJECTIVES: To compare the characteristics of lacunar stroke (LS) in patients with and without intermittent claudication. MATERIAL AND METHODS: Data of 484 consecutive patients with LS were collected from a prospective hospital-based stroke registry in which 2500 patients are included. RESULTS: Of the 142 patients with ischemic stroke and intermittent claudication, 39 (27.5%) had LS (8% of all lacunes). In the multivariate analysis, small centrum ovale topography (odds ratio 7.35), carotid stenosis >50% (odds ratio 3.17), and absence of limitation at discharge (odds ratio 2.01) were independent variables significantly associated with LS in patients with intermittent claudication. CONCLUSION: Only 8% of patients with LS had intermittent claudication. The short-term prognosis is good with a spontaneous early neurological recovery at discharge in 51.3% of patients. LS patients with intermittent claudication showed a striking similarity in risk factors and clinical syndromes in comparison with the LS patients without intermittent claudication.     

Reversed operation of glutamate transporter GLT-1 is crucial to the development of preconditioning-induced ischemic tolerance of neurons in neuron/astrocyte co-cultures

Sublethal ischemia leads to increased tolerance against subsequent prolonged cerebral ischemia in vivo. In the present study, we investigated the roles of the astrocytic glutamate (Glu) transporter GLT-1 in preconditioning (PC)-induced neuronal ischemic tolerance in cortical neuron/astrocyte co-cultures. Ischemia in vitro was simulated by subjecting cultures to both oxygen and glucose deprivation (OGD). A sublethal OGD (PC) increased the survival rate of neurons significantly when cultures were exposed to a lethal OGD 24 h later. The extracellular concentration of Glu increased significantly during PC, and treatment with an inhibitor of N-methyl-D-actetate (NMDA) receptors significantly reversed the PC-induced ischemic tolerance of neurons, suggesting that the increase in extracellular concentration of Glu during PC was critical to the development of PC-induced neuronal ischemic tolerance via the activation of NMDA receptors. Treatment with a GLT-1 blocker during PC suppressed this increase in Glu significantly, and antagonized the PC-induced neuronal ischemic tolerance. This study suggested that the reversed operation of GLT-1 was crucial to the development of neuronal ischemic tolerance.     

X-linked Emery-Dreifuss muscular dystrophy and vacuoles: an immunohistochemical characterization

We report a striking abundance of rimmed vacuoles in two brothers with X-linked Emery-Dreifuss muscular dystrophy (X-EDMD) confirmed by the absence of emerin at the muscular nuclear envelope and by genetic analysis showing a new 2-bp deletion in exon 6 of the STA gene at the Xq28 region. Immunohistochemical analysis of the vacuoles revealed expression of dystrophin but not of merosin in the sarcolemma of rimmed vacuoles and absence of amyloid and membrane attack complex (MAC) deposition either in vacuoles or muscle fibers. The presence of rimmed vacuoles can be a histopathological finding in X-EDMD, and the diagnosis should not be excluded in clinically well-defined EDMD patients because of this finding.     

The relationship between coronary artery calcification detected by non-gated multi-detector CT in patients with suspected ischemic heart disease and myocardial ischemia detected by thallium exercise stress testing

OBJECTIVE: To examine whether we could predict myocardial ischemia when coronary artery calcification is detected by non-gated multidetector CT in patients with suspected ischemic heart disease. METHODS: Eighty-three patients suspected of having ischemic heart disease (55 men, 28 women; age range 36-83 years; mean age 68 years) underwent multidetector CT and T1-201 single photon emission computed tomography. Prediction of myocardial ischemia by coronary arterial calcification detected on CT was evaluated by comparing the coronary artery territories that showed calcification with the area of myocardial ischemia determined by SPECT. The sensitivity, specificity, positive predictive value, and negative predictive value of multidetector CT for predicting myocardial ischemia were calculated. Coronary angiography was also examined and compared with multidetector CT. Risk factors, including hypertension, smoking, hyperlipidemia, diabetes, and family history, were compared for evidence of coronary artery calcification detected by multidetector CT and myocardial ischemia detected by thallium nuclear scans. RESULTS: For analysis by patients, the sensitivity, specificity, positive predictive value, and negative predictive value of coronary artery calcification for myocardial ischemia detection were 65, 63, 56, and 71%, respectively. Similarly, for analysis by coronary arterial territories, those values were 56, 77, 41 and 86%, respectively. Coronary stenosis on CAG was also related to the ischemia determined by SPECT and calcification on multidetector CT. Ischemia was better influenced by risk factors than was coronary arterial calcification. CONCLUSIONS: For analysis by coronary arterial territories, the specificity and negative predictive value of coronary arterial calcification seen by multidetector CT are relatively high.     

STUDY AND PREPARATION ON “PAIN TAN NING” AND ITS CLINICAL APPLICATION AND STUDY ON BRAIN ATLAS

Objective:To observe clinical effect of combined mixture of traditional chineses and western medicine " PIAN TAN NING" in treatment of ischemic cerebrovascular diseases and change of brain atlas. Methods: In 6660 patients with ischemic cerebrovascular disease, the curative effect of "PIAN TAN NING" and brain atlas were observed and other 30 cases were compared with treatment of Dextran. Results: After treatment,patient's clinical symptoms and recovered degree of myodynamia and brain atlas improved significantly. Total effective rate was 96.7%. But the contral group was 80.0%. There was a significant difference between them ( p < 0. 05). Conclusion: The " PIAN TAN NING" produced a good clinical curative effect in treatment of ischemic cerebrovascular diseases and the side effect was only a few. So it can be applied very well in patients with ischemic cerebrovascular disease. The applied value of brain atlas was very good.     

Severe Transient Left Ventricular Hypertrophy in an Infant with Acute Myocarditis and Heart Failure

A case of rare acute myocarditis with heart failure and transient left ventricular hypertrophy in a 4.5-month-old male infant is described. Initial echocardiogram demonstrated severe concentric left ventricular hypertrophy with depressed left ventricular systolic function and reduced left ventricular cavity. Left ventricular hypertrophy was transient; it decreased significantly within a couple of weeks concomitantly with the improvement of ejection fraction. The myocarditis resolved without sequelae. The natural course of this rare mode of presentation of myocarditis and its relationship to immunosuppressive and immunomodulatory treatment are discussed.     

Severe transient hyperinsulinaemic hypoglycaemia: two neonates without predisposing factors and a review of the literature

We report on transient hyperinsulinism (HI), presenting as severe congenital HI, in two neonates born without intrauterine growth restriction, maternal diabetes, perinatal asphyxia or Rhesus/platelet isoimmunisation. The neonates developed early (<6 h of life), symptomatic, non-ketotic hypoglycaemia (0–0.66 mmol/l), associated with elevated insulin levels (40–200 mU/l), and required high glucose infusion rates (22–24 mg/kg per min) to maintain normoglycaemia. However, both babies were diazoxide-sensitive and did not require glucose infusions beyond 2 weeks of life. Neither neonate had elevated serum ammonia levels or evidence of a metabolic disorder. Conclusion:transient hyperinsulinism can occur in newborns delivered uneventfully without significant perinatal complications. The unusual sensitivity to medical treatment in these cases of neonatal-onset hyperinsulinaemic hypoglycaemia underscores the importance of careful medical management of severe congenital hyperinsulinism. Careful consideration of the indication and if necessary, timing and extent of pancreatectomy is required, while maintaining euglycaemia to protect the developing brain.Abbreviations AGA appropriate for gestational age - BGL blood glucose level - BWS Beckwith-Wiedemann syndrome - HI hyperinsulinism - HI/HA hyperinsulinism/hyperammonaemia - IUGR intrauterine growth restriction - PHHI persistent hyperinsulinaemic hypoglycaemia of infancy - SGA small for gestational age - SUR sulphonylurea receptor - TNHI transient neonatal hyperinsulinism - UVC umbilical venous catheter