Slowly Recovering Isolated Bilateral Abducens Nerve Palsy after Embolization of Ruptured Anterior Communicating Artery Aneurysm

Bilateral abducens nerve palsy related to ruptured aneurysm of the anterior communicating artery (ACoA) has only been reported in four patients. Three cases were treated by surgical clipping. No report has described the clinical course of the isolated bilateral abducens nerve palsy following ruptured ACoA aneurysm obliterated with coil. A 32-year-old man was transferred to our institution after three days of diplopia, dizziness and headache after the onset of a 5-minute generalized tonic-clonic seizure. Computed tomographic angiography revealed an aneurysm of the ACoA. Magnetic resonance imaging showed focal intraventricular hemorrhage without brain stem abnormalities including infarction or space-occupying lesion. Endovascular coil embolization was conducted to obliterate an aneurysmal sac followed by lumbar cerebrospinal fluid (CSF) drainage. Bilateral paresis of abducens nerve completely recovered 9 weeks after ictus. In conclusion, isolated bilateral abducens nerve palsy associated with ruptured ACoA aneurysm may be resolved successfully by coil embolization and lumbar CSF drainage without directly relieving cerebrospinal fluid pressure by opening Lillequist''s membrane and prepontine cistern.     

Evidence for a social function of the anterior temporal lobes: Low-frequency rTMS reduces implicit gender stereotypes

By nature, stereotypes require processes of categorization or semantic association, including social information about groups of people. There is empirical evidence that the anterior temporal lobe (ATL) processes domain‐general semantic information, and supports social knowledge. A recent study showed that inhibitory repetitive transcranial magnetic stimulation (rTMS) to the ATL reduced racial stereotypes on an implicit association test (IAT). However, it was not determined whether this was caused by changes to specific social, or general semantic processing, or both. The current study addresses these theoretical issues. The design investigated the effect of rTMS to the left or right ATL, or a sham stimulation, on a social IAT (gender stereotypes), a non-social IAT (living versus non-living associations), and a non-semantic control (Stroop) task. The results showed that low-frequency rTMS to both left and right ATL significantly reduced D-scores on the gender IAT compared to the sham group; however, there were no differences on the non-social IAT or the Stroop. The findings show the ATL has a role in mediating stereotypes, and the decrease of bias after stimulation could be due to weakening of social stereotypical associations either within the ATL or via a network of brain regions connected with the ATL.     

Internal Herniation after Roux-en-Y Gastric Bypass: Case Reports and a Review of the Literature

Internal herniation, defined as a protrusion of the bowel through a peritoneal or mesenteric aperture into a compartment of the abdominal cavity, is a potentially serious complication following Roux-en-Y gastric bypass. In view of the high risk of strangulation and volvulus with possible progression to necrotic bowel, sepsis and multiple organ failure, early diagnosis and prompt surgical intervention are crucial to minimise morbidity and mortality rates. As little is known about internal herniation, pathogenesis, consequences, clinical presentation and diagnostic approach are discussed in this article. A review of the literature and the consideration of three cases make it clear that diagnosis is often delayed due to a vague, non-specific clinical presentation and the frequently negative radiological investigations. Displacement of the superior mesenteric artery (SmA) with crowding, stretching and engorgement of its visceral branches, mesenteric swirl and a clustered appearance of small bowel loops are CT findings with a high specificity but low sensitivity. A high degree of vigilance, communication between radiologists and surgeons and a low threshold for surgical exploration is therefore necessary.     

Contemporary role of medical genetics in internal medicine

Molecular biology and medical genetics, one of the most dynamically developing fields of medicine, nowadays is also a base for development of basic and clinical research in internal medicine. Understanding of crucial genetic pathomechanisms of many common diseases was possible due to the newest and modern molecular methods and tools. Moreover, development of genetics also made possible the discovery and understanding of the pathogenesis of many different diseases. However, not so long ago, we discovered precise pathomechanisms leading from damage of a single gene to a related pathological phenotype. Now, we have just started to explain molecular mechanisms of complex, multifactorial diseases. To achieve these goals, we need permanent development of genetic tests, genomics and proteomics. After fulfilling these conditions, we will get a chance to implement all molecular and genetic hopes, particularly their practical application in the clinic.     

Oral/sublingual Phleum pretense grass tablet (Grazax/Grastek) to treat allergic rhinitis in the USA

With the approval of two grass tablets and one ragweed tablet for sublingual immunotherapy (SLIT) by the US FDA in April 2014, the practice of allergy immunotherapy (AIT) in the USA has dramatically changed. Until this time, there were no approved allergen extracts for sublingual administration and physicians who prescribed SLIT for their patients did so without full knowledge of proper dosing or assurance of its safety. Now sublingual allergen tablets are available that have proven safe and effective doses. This article describes, in detail, the studies that have been conducted with a timothy grass SLIT tablet and draws some comparisons to the alternative 5-grass SLIT tablet. It also attempts to predict what will be the impact of the introduction of these tablets on the practice of AIT in the USA over the next few years.     

An update on treatment strategies for common variable immunodeficiency

Common variable immunodeficiency (CVID) is a primary immunological disease with variable severity, ranging from mild forms of infections to chronic progressive complications. The hallmark of this disorder is hypogammaglobulinemia due to an unknown molecular defect in immune regulation. The primary clinical manifestations are recurrent infections that may lead to structural damage of affected organs. Adequate intravenous immunoglobulin (Ig) therapy has dramatically changed the prognosis of this disorder, and the advent of home subcutaneous Ig therapy has further improved the quality of life of these patients. Aberrant T-cell functions predispose to autoimmune, inflammatory and lymphoproliferative complications, as well as malignancies in a variable percentage of CVID patients. Immunosuppressive anti-inflammatory therapies and chemotherapy are used, although always in conjunction with adequate replacement Ig therapy and adjunct antimicrobial prophylaxis. Any organ can be involved and therefore a multidisciplinary approach to the management of this disorder is essential.     

Ragweed allergy immunotherapy tablet MK-3641 (Ragwitek®) for the treatment of allergic rhinitis

ABSTRACT

Introduction: Allergic rhinitis (AR) is among the most common chronic conditions affecting both children and adults. It is the cause of significant morbidity from the symptoms and interference with sleep. It results in major impairment of performance both at school and at work. In the U.S. and certain parts of Europe, ragweed pollen is a major cause of seasonal AR. In 2014, the U.S. Food and Drug Administration (FDA) approved a sublingual ragweed tablet (MK-3641) for use in adults with ragweed-induced AR.

Areas covered: This paper will review the impact of ragweed-induced AR and available treatments including subcutaneous immunotherapy and studies with MK-3641. The principal search method was PubMed.

Expert commentary: One dosing finding, two 28-day safety and two 52-week safety and efficacy studies have been conducted with MK-3641. The 12-U (12μg Amb a 1) tablet was the most effective. Local application site reactions were common but usually not serious. Only one, non-serious systemic reaction was reported in four safety studies. MK-3641 is a safe and effective treatment for ragweed-pollen-induced AR when treatment is initiated ≥ 12 weeks prior to the onset of the ragweed pollen season.     

Golimumab in the treatment of psoriatic arthritis

ABSTRACT

Introduction: Psoriatic arthritis (PsA) is an inflammatory arthritis that can be aggressive and destructive, resulting in significant morbidity. While many new agents have been approved for the treatment of PsA over the past decade, TNF inhibitors (TNFi)remain an anchor treatment, in part based on extensive clinical experience. Recently, the TNFi golimumab was approved for intravenous use in PsA.

Areas covered: This expert review presents an overview of the currently available treatment options for PsA with a focus on the evidence from clinical trials supporting the use of golimumab in PsA. This information is placed in context with recent advances in the understanding of PsA pathogenesis and treatment.

Expert commentary: The rapid growth of treatment options available for PsA has brought the prospect of personalized treatment selection closer to reality but improved understanding of the domains of PsA and new biomarkers may be needed before such changes reach the clinic. Until patients who are most likely to benefit from a given agent can be identified and then treated accordingly, TNFi will likely remain a central option and their further development, such as the introduction of an intravenous form of golimumab, remains an important part of treatment improvement.     

Right ventricular involvement in anterior myocardial infarction: a tissue Doppler-derived strain and strain rate study

OBJECTIVE:

Strain and strain rate imaging is currently the most popular echocardiographic technique that reveals subclinical myocardial damage. There are currently no available data on this imaging method with regard to assessing right ventricular involvement in anterior myocardial infarction. Therefore, we aimed to evaluate right ventricular regional functions using a derived strain and strain rate imaging tissue Doppler method in patients who were successfully treated for their first anterior myocardial infarction.

METHODS:

The patient group was composed of 44 patients who had experienced their first anterior myocardial infarction and had undergone successful percutaneous coronary intervention. Twenty patients were selected for the control group. The right ventricular myocardial samplings were performed in three regions: the basal, mid, and apical segments of the lateral wall. The individual myocardial velocity, strain, and strain rate values of each basal, mid, and apical segment were obtained.

RESULTS:

The right ventricular myocardial velocities of the patient group were significantly decreased with respect to all three velocities in the control group. The strain and strain rate values of the right mid and apical ventricular segments in the patient group were significantly lower than those of the control group (excluding the right ventricular basal strain and strain rate). In addition, changes in the right ventricular mean strain and strain rate values were significant.

CONCLUSION:

Right ventricular involvement following anterior myocardial infarction can be assessed using tissue Doppler based strain and strain rate