Early non-convulsive seizures are associated with the development of acute encephalopathy with biphasic seizures and late reduced diffusion

IntroductionChildren with either febrile seizure or acute encephalopathy exhibit seizures and/or impaired consciousness accompanied by fever of unknown etiology (SICF). Among children with SICF, we previously reported those who have refractory status epilepticus or prolonged neurological abnormalities with normal AST levels are at a high risk for the development of acute encephalopathy with biphasic seizures and late reduced diffusion (AESD), considered to be caused by excitotoxicity. Non-convulsive seizures (NCS) are common in critically ill children and cause excitotoxic neuronal injury. The aim of this study was to elucidate the prevalence of NCS in the acute phase of children at a high risk for developing AESD and the relationship between NCS in the acute phase and neurological outcomes.MethodsWe studied 137 children with SICF at a high risk for developing AESD and who underwent continuous electroencephalogram monitoring (cEEG) upon admission to a tertiary pediatric care center at Hyogo Prefectural Kobe Children’s Hospital between October 2007 and August 2018. Patient characteristics and outcomes were compared between patients with NCS and without NCS.ResultsOf the 137 children, NCS occurred in 30 children; the first NCS were detected in cEEG at the beginning in 63.3%, during the first hour in 90%, and within 12 h in 96.7%. Neurological sequelae were more common in NCS patients (20.0%) than in non-NCS patients (1.9%; p = 0.001). Five in 30 NCS patients (16.7%) and 3 in 107 non-NCS patients (2.8%) developed AESD (p = 0.013).ConclusionThe occurrence of NCS is associated with subsequent neurological sequelae, especially the development of AESD.     

急性高眼压大鼠视网膜胶质细胞水通道蛋白-4的内化

目的:观察急性高眼压时大鼠视网膜胶质细胞水通道蛋白-4(AQP4)内化的时空变化及其规律,并探讨其与视网膜水肿的关系.方法:建模并分组;应用免疫荧光双标鉴定视网膜AQP4阳性细胞;观察AQP4与早期内涵体抗原1(EEA1)及晚期内涵体标记物甘露糖-6-磷酸受体(MPR)的共表达规律.结果:在正常视网膜内,表达AQP4的星形胶质细胞胞体位于节细胞层,Müller细胞的胞体位于内核层.正常及假手术组未见AQP4与EEA-1、MPR的共表达;高眼压作用不同时间,AQP4与EEA1共表达细胞的分布部位及其占AQP4阳性细胞比例都有改变,在高眼压作用60 min,AQP4与EEA1共表达细胞的比例达到最高值,AQP4与MPR共表达细胞分布的部位也有变化.结论:高眼压可诱导视网膜胶质细胞AQP4的内化,即AQP4经过内吞进入早期内涵体,再转运至晚期内涵体.AQP4的内化可能对肿胀的胶质细胞起保护作用.     

Association of QRS-T angle and Late Gadolinium Enhancement in patients with a Clinical Suspicion of Myocarditis

Objective: To investigate the association of a wide QRS-T angle on the surface ECG and late gadolinium enhancement on contrast-enhanced cardiovascular magnetic (CMR) imaging in patients with clinically suspected myocarditis.Background: Diagnosis and risk stratification in patients with suspected myocarditis is particularly challenging due to a great spectrum of clinical presentations. Late gadolinium enhancement (LGE) visualizes myocardial necrosis and fibrosis in patients with biopsy-proven myocarditis. The presence or absence of late gadolinium enhancements in these patients is prognostically meaningful. The QRS-T angle from the surface ECG, on the other hand, may serve as a simple and easily available risk marker in suspected myocarditis.Methods: We enrolled 97 consecutive patients that were referred to CMR imaging for a clinical suspicion of myocarditis. All patients obtained a standardized digital 12-lead ECG for the calculation of the QRS-T angle and underwent contrast-enhanced CMR imaging. Patients were divided into two groups according to the absence or presence of LGE on CMR.Results: 78 of 97 patients with suspected myocarditis had LGE on CMR. Patients with LGE had wider QRS-T angles as compared to the patient group without LGE (53.95-47.5 vs. 26.2-21.2; p<0.001). The sensivity, specificity, negative predictive value and positive predictive value for a QRS-T angle above 90 degrees for LGE positive myocarditis were 16.5%, 100%, 24.7%, and 100%, respectively.Conclusion: A wide QRS-T angle of 90 degrees or more is linked to myocardial fibrosis or necrosis (late gadolinium enhancement) in patients with suspected myocarditis.     

Ethical Analysis as a Tool for Addressing Treatment Controversies: Radiotherapy Timing in Children With Orbital Rhabdomyosarcoma as a Case Example

PurposeThe treatment of orbital rhabdomyosarcoma is a topic of debate between North American and European clinicians, with the utility of radiation therapy as part of initial management in question. Despite differences in philosophy, the dominant North American approach of upfront radiation and the dominant European approach of radiation only in the event of recurrence yield a similar rate of overall survival. We sought to identify the ethical arguments for each approach.MethodsEstablished moral principles and appeals in contemporary medical ethics were utilized to identify the ethical arguments supporting each treatment approach. The potential for technologic advances to alter the analysis was considered.ResultsEmphasizing the principle of beneficence, the North American approach seeks to reduce recurrence rates. In contrast, the European approach seeks to avoid radiation-induced sequelae, emphasizing the principle of nonmaleficence. Both approaches are based on well-established ethical principles, evidence, and clinical experience. Thus, both approaches currently appear to have legitimacy and should be included in the informed consent process. However, if treatment-related toxicity is reduced through improvements in radiation delivery, the North American approach could emerge as ethically superior.ConclusionsEthical analysis can aid in addressing challenges that arise when professional practices and perspectives differ in the management of cancer patients.     

The causes of total knee arthroplasty failure: Avoiding your next revision

This article is a personal retrospective of the author׳s more than 35 years of experience as an arthroplasty surgeon and specifically addresses how to avoid revision total knee arthroplasty.

• 1.Avoid revision surgery if the patient is satisfied, unless imminent danger of prosthetic failure appears.
• 2.Use proper technique at the primary arthroplasty to avoid the problems of aseptic loosening, instability, malalignment, and infection that force most revisions. Scrupulous attention to detail in patient selection and operative technique at the primary surgery will help avert revision surgery.
• 3.Remember that surgical technique is prosthesis specific. Understanding the design and insertion philosophy of each implant is crucial to success; every implant system is different.
• 4.Strive to understand the underlying reason that an arthroplasty has failed to make a patient satisfied and fix the problem at revision. If the reason for revision is unclear, it is unlikely that surgery will make the patient better.
• 5.Avoid revision surgery if the problem is pain with no identifiable, surgically correctable problem.
• 6.Maintain strict selection criteria for obese patients, who have higher prevalence of problems that can lead to total knee revision. Surgeons who operate on obese patients likely will have more revision cases. Often, however, obese patients have gratifying results in terms of pain relief and improved function.

     

Comparison of estimates of left ventricular ejection fraction obtained from gated blood pool imaging,different software packages and cameras

Serial measurement of LVEF using gated blood pool (GBP) imaging is an established technique for monitoring LVEF in patients undergoing chemotherapy with cardiotoxic medication and in patients after heart transplants.11,2 The nuclear medicine department at Groote Schuur Hospital performs up to a thousand GBP studies annually. The majority of these studies are for patients receiving cardiotoxic chemotherapy and have a significant impact on patient management.In our hospital, the radiation oncologists consider not starting cardiotoxic chemotherapy if the LVEF is below 50% and terminating chemotherapy if there is a 10% decrease. In patients who have had heart transplants, the cardiologists start patients on glucocorticosteroids if a patient’s LVEF decreases by10%. It is therefore imperative that serial studies on an individual patient are comparable.Two software systems are used in our nuclear medicine department. The Siemens system (Siemens Medical Solutions, Chicago, USA) was introduced in February 2006 and the Hermes system (Hermes Medical Solutions, Stockholm Sweden) in September 2007. After the introduction of the Hermes system, we found large differences between the LVEFs calculated by the two systems. This was confirmed by a pilot study and is consistent with the literature that different software programs for processing equilibrium gated radionuclide studies cannot be used interchangeably.3-7The department also uses two different cameras, a General Electric (GE) Starcam 400 AC single-head and a Siemens Signature Series e.cam dual-head camera to acquire the raw data. These are then transferred to the Siemens and Hermes processing systems.This study was done to determine how the software packages used for processing GBP studies should be integrated into our department and if the use of different cameras for acquisition influences results. The study had two components. The first examined the values and reproducibility of estimates of LVEF from two software packages using data acquired on the GE gamma camera and processed independently by three operators. The second component examined the values and reproducibility of estimates of LVEF calculated with the same software packages using matched pairs of raw data acquired on both gamma cameras (GE and Siemens) processed by one operator.