Giant cell arteritis presenting as a stroke in the internal carotid artery territory: a case-based review

Giant cell arteritis (GCA) is a large-vessel vasculitis, typically affecting the aorta and its branches. The involvement of vertebral and internal carotid arteries occurs in a limited number of cases, and stroke as a presenting symptom of GCA is extremely unusual: this subset of the disease has a poor prognosis and rarely responds to immunosuppression.We report the case of a 70-year-old woman, who presented to the Emergency Department for ischemic stroke, which appeared to be the first and only symptom of GCA. The prompt administration of steroids and tocilizumab (TCZ) led to clinical and radiological resolution, with no residual disability at 6-month follow-up.Our case-based review, highlighting the rarity of a large vessel vasculitis presenting only with a cerebrovascular accident, provides new evidence for the efficacy of TCZ even in more unusual varieties of GCA: in these cases, TCZ should be immediately prescribed, in order to prevent mortality and severe long-term morbidity.     

The effects of somatostatin in the polycystic ovary syndrome.

Eighteen obese women (body mass index 30 +/- 6.1 kg/m2) with hyperinsulinaemia and with the polycystic ovary syndrome took octreotide at the dose of 100 mug s.c. The effect of the drug was assessed on plasma levels of gonadotropins luteinising hormone (LH), follicle stimulating hormone (FSH), of insulin, insulin-like growth factor-1 (IGF-1), androstenedione, testosterone, dehydroepiandrosterone sulphate (DHEAS), sex hormone binding globulin (SHBG) and insulin-like growth factor-binding protein-3 (IGFBP-3). Octreotide significantly reduced LH (31.8%), insulin (52%), IGF-1 (14%), androstenedione (22.6%) and testosterone (20%) and increased IGFBP-3 (25%).     

Total and regional myocardial blood flow in aortic regurgitation.

Total, phasic, and regional flow were studied in 12 open-chest dogs with aortic regurgitation. An adjustable catheter device was used to produce aortic regurgitation. Four differently labeled 7 to 9μ microspheres were injected into the left atrium during control, mild (5 to 25 per cent), moderate (25 to 50 per cent), and severe (50 to 80 per cent) regurgitation. Aortic regurgitation (AR) and the ratio of diastolic coronary blood flow to systolic coronary blood flow ($\text{DIAS}\text{SYS}$ RATIO) were measured from the electromagnetic flow tracings. The simultaneous left ventricular and aortic pressures were used to calculate $\text{DPTI}\text{SPTI}$ (diastolic pressure time index to systolic time index). Myocardial flow, flow to major subgroups, and endocardial/epicardial ratios were determined from radioisotope analysis of the left ventricle.Mean absolute control values and mean changes of key variables from control were:

3.

	Control	Mild AR	Mod AR	Severe AR
Heart rate (beats/min.)	163.42	?5.00	?4.831	?8.56
$\text{DPTI}\text{SPTI}$	1.18	?0.121	?0.241	?0.561
Dias/Sys ratio	4.23	?0.28	?1.641	?3.311
Myo. flow (ml./100g./min.)	99.90	?5.63	11.18	21.63
Endocardium (ml./100 g./min.)	97.27	?5.28	10.26	7.39
Epicardium (ml./100 g./min.)	100.15	?7.38	7.88	21.58
$\text{ENDO}\text{EPI}$ ratio	0.99	0.01	0.01	?0.11

1

Denotes significant change from control state (P = 0.05).

The phasic coronary blood flow results in this study are similar to those reported in chronic, intact anesthetized dogs; when the degree of aortic regurgitation increased, there was a significant decrease in diastolic coronary blood flow with an increase in systolic coronary blood flow. Not previously reported are the changes in the distribution of myocardial perfusion. Total myocardial flow increased slightly. There were minimal changes in blood flow to the endocardium which resulted in a slight decrease in the $\text{ENDO}\text{EPI}$ ratio and a decrease in the per cent of flow to the endocardium. These results indicate that, although acute aortic regurgitation produces significant changes in phasic coronary flow, there are much smaller effects on total and regional myocardial blood flow.     

Sonographic study of calcaneal entheses in erosive osteoarthritis, nodal osteoarthritis, rheumatoid arthritis and psoriatic arthritis

OBJECTIVE: To establish by ultrasonography (US) the frequency of calcaneal entheses involvement in erosive osteoarthritis (EOA), nodal osteoarthritis (NOA), RA and PsA, and to compare these results in order to aid clinicians in the differential diagnosis among these diseases. A comparison between US results and radiography was also made. METHODS: The heels of 56 consecutive outpatients with EOA, 209 with NOA, 158 with RA and 125 with PsA were studied by US and radiography. A control group of 50 subjects was examined by US. RESULTS: US showed no significant difference in inferior calcaneal enthesophytosis among the four diseases. The frequency of posterioinferior enthesophytosis was lower in RA (34%) in comparison with the other diseases (57% in EOA, 47% in NOA, 49% in PsA). Achilles enthesitis was found in 8% of PsA and in 2% of RA. Retrocalcaneal bursitis was found in 18% of RA and in 6% of PsA. Posterior erosions were present in 12% of RA and 5% of PsA. Inferior erosions were present in 6% of RA and in 1% of PsA. Plantar fasciitis was found in 26% of RA, in 37% of PsA, and in 15% of NOA and 12% of EOA. Subcalcaneal panniculitis was observed in 10% of RA and in 1% of PsA. In the control group, only posterioinferior and inferior enthesophytosis (22% and 18% respectively) were found. Kappa statistics show excellent agreement between US and radiography in detecting posterioinferior (kappa = 0.89) and inferior enthesophytosis (kappa = 0.83), and entheseal erosions (kappa = 0.86). CONCLUSIONS: The calcaneal lesions that could be found in EOA are similar to those observed in NOA. The frequency of calcaneal enthesophytosis is similar in EOA, NOA, and PsA, but inflammatory lesions of calcaneal entheses and of the adjacent bursae are more frequent in RA and in PsA. In terms of heel involvement, EOA seems to be similar to NOA. US shows an excellent concordance with radiography in detecting entheseal cortical bone abnormalities.     

Vasoactive intestinal polypeptide (VIP) selectively stimulates prolactin release in healthy women

The neuropeptide, vasoactive intestinal polypeptide (VIP), is released from the hypothalamus to the portal circulation, and experiments on animals provide evidence that it might modulate hormone secretion from the pituitary. Here we report the effects of VIP on the release of different pituitary hormones, including prolactin (PRL), luteinizing hormone (LH), follicle-stimulating hormone (FSH) and thyrotropin-releasing hormone (TSH), in normal women. Seven healthy women (aged 27-32; body weight 53-60 kg), with normal menses and receiving no medication, were tested on days 20-23 of their cycle. Porcine VIP was injected i.v. as a bolus dose of 1 mcg/kg body weight. Blood samples were collected 10 minutes prior to VIP administration and 5, 15, 30, 45, 60 and 90 minutes after VIP injection. Blood pressure and heart rate were continuously monitored. Hormone levels were determined by RIA. Stress, which can stimulate PRL release, was assayed by measuring the effect of placebo on hormone release (5 controls). VIP injection induced a significant (p less than 0.01) increase in plasma PRL levels. Basal PRL was 20.25 +/- 9.14 ng/ml; 5 minutes after VIP injection PRL levels rose to 45.0 +/- 14.9 ng/ml (p less than 0.01). At 15 minutes a plateau was reached (46.0 +/- 14.5 ng/ml), then the levels slowly decreased. VIP administration did not modify the plasma concentration of LH, FSH or TSH at any time during the observation period. The present study indicates that VIP might play a physiological role as a RPL-releasing factor in human beings.     

The effect of acute aortic regurgitation on the transthoracic impedance cardiogram

In nine anesthetized dogs, recordings of the first derivative of the transthoracic impedance cardiogram (ICG) were made during varying grades of acute aortic regurgitation. Acute aortic regurgitation was induced using a specially designed umbrella catheter, passed retrograde across the aortic valve into the left ventricle. The RF_A (representing the fraction of the aortic reverse flow to the aortic forward flow) was computed using an electromagnetic flow probe implanted around the ascending aorta. Both the peak of the scalar ICG, dz/dt_max, which occurs at peak systolic ejection, and the nadir of the scalar ICG, X, which marks the closing of the aortic valve, increased with aortic regurgitation. The planimetered areas of the ICG during systole (S?), and in early-diastole (X?) increased during aortic regurgitation. These areas, S? and X?, correlated with the electromagnetic normalized aortic stroke volume (r = 0.90) and the regurgitant volume (r = 0.78), respectively. The ICG ratio X?/S? was correlated directly with the electromagnetic aortic regurgitant fraction (r = 0.86). This study demonstrates that the ICG waveform is consistently modified by experimental aortic regurgitation. Furthermore, these changes can be quantitatively related to the degree of aortic regurgitation.     

Patients with generalized anxiety disorder and a history of trauma: somatic symptom endorsement

The authors investigated the types and rates of trauma exposure and differences in symptom endorsement in a clinical sample of patients diagnosed with generalized anxiety disorder (GAD). Fifty-eight patients with GAD were assessed using the Structured Clinical Interview (SCID) and Trauma Assessment for Adults. In order to explore the relationship between specific traumatic event(s) and clinical presentation, the presence of somatic symptoms associated with GAD, including muscle tension, autonomic hyperactivity, and vigilance/scanning clusters (using DSM-III-R criteria), were examined. Patients with a history of sexual assault before 18 years (25.9%) endorsed fewer somatic symptoms, specifically fewer motor tension and autonomic GAD symptoms, than patients with other types of trauma. These findings indicate that early exposure to serious trauma, specifically childhood sexual assault, may lead to a different clinical presentation in GAD patients.