Long-term intrathecal S(+)-ketamine in a patient with cancer-related neuropathic pain

Neuropathic pain sometimes needs invasive pain therapy. We presentthe case of a patient with cancer-related neuropathic pain untreatablewith conventional pain therapy after tumour-embolization. Thepatient was treated successfully with intrathecal (i.t.) administrationof S(+)-ketamine, in addition to morphine. Plasma concentrationsof S(+)-ketamine were measured regularly throughout the treatment.Continuous i.t. administration of S(+)-ketamine over a periodof 3 months demonstrated low plasma levels and no unwanted side-effects.     

A rare involvement of Romberg’s disease: frontal region

Progressive hemifacial atrophy is characterized by slow progressive atrophy of the subcutaneous tissue. Although, in the majority of sufferers, half of the face and the chin are the most severely-affected areas, we present the case of a patient with a 2-year history of local atrophy in the forehead, a very rare involvement. Reconstruction was done using bilateral subcutaneous flaps. There was no recurrence of the atrophy at the 12th-month postoperative check.     

Absence of muscle capillary basement membrane thickening and retinopathy in patients with myocardial infarction and impaired I.V. glucose tolerance

Summary We have investigated the possible contribution of an early capillaropathy to the increased incidence of myocardial infarction (MI) in patients who had impaired glucose tolerence (IGT) during an i.v. glucose tolerance test (IVGTT). In lieu of the myocardium, biopsies from the quadriceps femoris muscle were studied for muscle capillary basement membrane (MCBM) thickening. Fluorescence angiography was performed to detect capillary retinopathy. Plasma growth hormone (GH) concentrations were determined during IGT. Data were obtained from 14 male patients with MI and IGT on IVGTT. Nine healthy subjects served as controls. MCBM thickness was similar in patients and controls (1,107±55vs 1,067±88 ?). None of the patients had signs of capillary retinopathy, and plasma GH concentrations were not higher in the patients as compared to control subjects. It is concluded that, in patients with IGT on IVGTT, MCBM thickening is probably not a factor for the development of MI.     

Neuronal intranuclear inclusions are ultrastructurally and immunologically distinct from cytoplasmic inclusions of neuronal intermediate filament inclusion disease

Abnormal neuronal cytoplasmic inclusions (NCIs) containing aggregates of -internexin and the neurofilament (NF) subunits, NF-H, NF-M, and NF-L, are the signature lesions of neuronal intermediate filament (IF) inclusion disease (NIFID). The disease has a clinically heterogeneous phenotype, including frontotemporal dementia, pyramidal and extrapyramidal signs presenting at a young age. NCIs are variably ubiquitinated and about half of cases also have neuronal intranuclear inclusions (NIIs), which are also ubiquitinated. NIIs have been described in polyglutamine-repeat expansion diseases, where they are strongly ubiquitin immunoreactive. The fine structure of NIIs of NIFID has not previously been described. Therefore, to determine the ultrastructure of NIIs, immunoelectron microscopy was undertaken on NIFID cases and normal aged control brains. Our results indicate that the NIIs of NIFID are strongly ubiquitin immunoreactive. However, unlike NCIs which contain ubiquitin, -internexin and NF epitopes, NIIs contain neither epitopes of -internexin nor NF subunits. Neither NIIs nor NCIs were recognised by antibodies to expanded polyglutamine repeats. The NII of NIFID lacks a limiting membrane and contains straight filaments of 20 nm mean width (range 11–35 nm), while NCIs contain filaments with a mean width of 10 nm (range 5–18 nm; t-test, P<0.001). Biochemistry revealed no differences in neuronal IF protein mobilities between NIFID and normal brain tissue. Therefore, NIIs of NIFID contain filaments morphologically and immunologically distinct from those of NCIs, and both types of inclusion lack expanded polyglutamine tracts of the triplet-repeat expansion diseases. These observations indicate that abnormal protein aggregation follows separate pathways in different neuronal compartments of NIFID.     

Giant fatty Schmorl’s nodes: CT findings in four patients

Objective To describe the CT features of an unusual type of lumbar Schmorls node (SN) appearing as giant fatty lesion of the vertebral bodies.Design and patients >Four patients (4 men; mean age 48.5 years) collected during a 9-month period were examined with MDCT for unremarkable lumbar symptoms; none had relevant history of specific trauma during the last years preceding the CT.Results and conclusions The CT findings had a similar showing: a central or para-central osteolytic lesion in contact with the upper end plate of the vertebra, occupying about two-thirds to three-quarters of the body height and being surrounded by a thin and well-delineated bony rim. There was a clear interruption of the superior vertebral end plate above the lesion and an almost normal height of the adjacent vertebral disk. The CT appearance suggested a uniform fat content which was confirmed by density measurements ranging from –20 to –30 HU. The origin remains unknown, but a parallel is drawn between giant fatty SNs and giant cystic SNs. Intravertebral disk herniation is likely to be the initial phenomenon, with a preponderant responsibility of the secondary induced intramedullar tissular disorders to constitute the final size of the lesion. One hypothesis could be a fracture of trabecular bone with secondary hemorrhage and cystic or fatty degeneration. Alternatively, intramedullary vascular disturbances may lead to foci of bone necrosis that heal by fibroblastic proliferation followed by mucoid or fatty degeneration. It is also possible that giant fatty SNs could represent end stage of giant cystic SNs.     

Meconium plug obstruction

We reviewed the final diagnosis and incidence of bowel pathology in neonates presenting with large bowel obstruction that was relieved by the passage of meconium plugs. A retrospective case-note review was undertaken of all patients with a discharge diagnosis of meconium plug syndrome (MPS), meconium ileus (MI), Hirschsprungs disease (HD), or small left colon syndrome (SLCS) from January 1996 to April 2002. Of 21 patients with meconium plug obstruction, eight (38%) had HD, nine had MPS, four had SLCS, and none had MI. However, there was considerable clinical and radiological overlap between MPS and SLCS, suggesting that these terms are imprecise. We found a much higher incidence of HD in babies presenting with meconium plug obstruction than has previously been reported. Overlap between MPS and SLCS suggests that these are not specific diagnoses and that current terminology needs to be changed. All babies with meconium plug obstruction should have HD and cystic fibrosis (CF) excluded.     

The use of in-line intravenous filters in sick newborn infants

AIM: This study assesses the improvement in outcome for newborn infants by decreasing major complications associated with intravenous fluid therapy by using an in-line filter, and evaluates the economical impact this might have in relation to daily changing of i.v. lines. METHODS: In a prospective controlled study, 88 infants were randomly assigned to receive either filtered (except for lipids, blood and blood products) or non-filtered infusions via a central catheter. Main outcome measures such as bacteraemia, phlebitis, extravasation, thrombosis, septicaemia and necrosis were all scored. The costs attributable to patients during a standard 8-day stay were also recorded. RESULTS: Significant reductions were found in major complications such as thrombi and clinical sepsis (control group (21), filter group (8); p < 0.05). Bacterial cultures of the filters showed a contamination rate on the upstream surface of 15/109 filters (14%). The mean costs of disposables were less in the filter group, showing a reduction from 31.17 euros to 23.79 euros. CONCLUSIONS: The use of this in-line filter leads to a significant decrease in major complications and substantial cost savings.     

Osteopontin expression and microvascular injury in cyclosporine nephrotoxicity

The aim of this study was to evaluate the role of osteopontin (OPN) in cyclosporine (CsA) nephrotoxicity of the human kidney. Renal biopsy samples obtained before and after 1–2 years of CsA treatment were evaluated in 18 children (2.2–13.0 years, 14 males, 4 females) diagnosed with minimal change nephrotic syndrome. The changes in tubular OPN expression between pre- and post-treatment samples were correlated with interstitial macrophage infiltration, transforming growth factor- (TGF-) expression, interstitial fibrosis, and microvascular density. OPN, TGF-, CD68, and CD34 positivity were quantitatively assessed by immunohistochemical staining. Light microscopy showed that interstitial fibrosis developed in two-thirds of patients after CsA treatment. However, CD68-positive macrophages infiltrated minimally in fibrotic areas and were found in only one-third of patients. OPN expression was significantly increased in the glomerular mesangium (P=0.001) and tubules (P=0.025) after CsA treatment, whereas the number of CD34-positive peritubular capillaries decreased (P=0.022). An inverse relationship was observed between tubular OPN expression and microvascular density (r=–0.644). However, tubular OPN expression was not related to proteinuria, interstitial fibrosis, or interstitial or tubular TGF- expression. This study indicates that increased OPN expression may be related to microvascular injury in human CsA nephrotoxicity. It also shows that OPN expression may be used as an early but non-specific marker of CsA toxicity before the manifestation of interstitial fibrosis.