Schizophrenia following new-onset refractory status epilepticus secondary to antiphospholipid syndrome

New-onset refractory status epilepticus (NORSE) is a drug-resistant status epilepticus that often has a catastrophic outcome. Our patient was diagnosed with NORSE and had an EEG reading that showed status epilepticus persisting for 8 months in general anesthesia. After autoimmune workup showed positive antiphospholipid antibodies, his seizure was controlled, and he was discharged with good condition apart from moderate cognitive impairment. However, he later developed schizophrenia. Although psychiatric disorders have been associated with antiphospholipid syndrome, to the best of our knowledge, it has not been reported to be associated with status epilepticus. We recommend vigilance of psychological complications of refractory status epilepticus’ patients for early psychiatric referral, diagnosis, and treatment.

New-onset refractory status epilepticus (NORSE) is a syndrome of new-onset drug-resistant status epilepticus that often has a catastrophic outcome. Epilepsy is usually associated with psychiatric disorders of different manifestations of which psychosis is an example.1 However, not much is found in the literature review regarding psychiatric disorders following NORSE although a recent study concluded 32% of NORSE patients ended up with altered behavioral states like aggression.2 Schizophrenia following NORSE like in the rare presentation of this case has not been reported in the literature review before, although an association between schizophrenia and autoimmune disorders like APS has been reported.3     

Closed versus open mitral commissurotomy in pure noncalcific mitral stenosis: hemodynamic studies before and after operation

Controversy persists regarding whether the efficacy of closed instrumental mitral commissurotomy compares well enough with that of open commissurotomy to warrant its continued use. The purpose of this study was to compare the results of operation as determined by catheterization studies in 63 patients with pure, severe, and noncalcified mitral stenosis. The patients were randomly assigned to one of two groups: thirty-two patients were operated on by the closed technique (group I) and 31 by the open technique (group II). All patients underwent left-sided and right-sided catheterization before and 4 months after operation. Preoperatively the two groups were statistically similar with regard to major clinical data and hemodynamic findings. There were no deaths at operation or systemic embolism in the two groups. The prevalence of surgically induced mitral regurgitation was similar in the two groups (12.4% versus 12.9%). Pulmonary arterial pressure and arteriolar and total pulmonary vascular resistance decreased significantly in the two groups. Pulmonary capillary wedge pressure decreased from 23.3 +/- 8.5 to 15.8 +/- 7 mm Hg in group I (p less than 0.001) and from 23.7 +/- 6 to 14 +/- 5.8 mm Hg in group II (p less than 0.001). Cardiac index increased from 2.86 +/- 0.84 to 3.14 +/- 0.78 L/min/m2 in group I, but this increase did not reach statistical significance. In group II cardiac index increased from 2.89 +/- 0.6 to 3.6 +/- 0.6 L/min/m2 (p less than 0.005). The mean and end-diastolic transmitral pressure gradients decreased significantly in the two groups, but the decrease was statistically greater in the open mitral commissurotomy group (p less than 0.001). Mitral valve area increased from 0.82 +/- 0.18 to 1.4 +/- 0.40 cm2 in group I (p less than 0.01) and from 0.84 +/- 0.15 to 2.14 +/- 0.53 cm2 in group II (p less than 0.001). The mean increase in mitral valve area was 0.61 cm2 in group I and 1.34 cm2 in group II (p less than 0.001). At exercise, in patients with resting pulmonary capillary wedge pressures of 18 mm Hg or less, cardiac index increased by 36% in group I (23 patients) and 48% in group II (24 patients), because of a smaller mitral valve area in group I (1.61 +/- 0.39 cm2) than in group II (2.45 +/- 0.65 cm2). Thus open commissurotomy improved hemodynamic values to a greater extent than closed commissurotomy at both rest and exercise.(ABSTRACT TRUNCATED AT 400 WORDS)     

Follicular thyroid lesions coexisting with Hashimoto's thyroiditis: incidence and possible sources of diagnostic errors

Our objectives were to study the types and incidence of thyroid follicular lesions coexisting with Hashimoto's thyroiditis (HT), the pitfalls in their cytodiagnosis, and the effect on management. All cases of HT diagnosed by fine-needle aspiration (FNA) and/or histology over a 7-yr period were retrospectively studied. HT coexisted with follicular adenoma (FA) in 6 cases, follicular variant of papillary carcinoma (FVPC) in 1 case, and goitrous nodule (GN) in 2 cases. The overall incidence rates of thyroid neoplasm and goitrous nodules coexistent with HT were 15% and 3.5%, respectively. A preoperative FNA diagnosis was available in 10 histologically proven cases of HT. A false-positive diagnosis of follicular neoplasm (FN) that led to unnecessary thyroidectomies was given in 3 cases. In 2 of these, the cytological diagnosis was HT with the possibility of coexisting FN, and in the third case, the cytological finding of HT was misinterpreted as FN. The main causes of these diagnostic pitfalls were the presence of hyperplastic follicular cells with nuclear pleomorphism, a paucity of lymphoid cells in burned-out HT, and lack of ones exposure. Nuclear pleomorphism was observed in none of the follicular adenomas. FNA diagnosed accurately the coexisting lesions in 6 cases; 3 FA, 1 FVPC, and 2 GN, but it did not sample HT. In one case, FNA diagnosed correctly both HT and the coexisting FA. Therefore, the presence of a coexistent neoplasm or goitrous nodule reduced the chances of sampling HT by 85.7%, with no false-negative results. Indeed, aspiration on and around the thyroid nodule helps in sampling HT. However, HT may dominate the smear and obscure neoplasia. This can be avoided if the procedure is performed by the pathologist and the aspiration is done on the nodule only. The overlapping cytological features of FN and HT were the main causes of false-positive results. This can be reduced by avoiding the diagnosis of FN in the presence of follicular-cell pleomorphism and/or moderate to excessive numbers of lymphoid cells, provided proper aspiration technique is maintained.     

Schistosomiasis of the spinal cord in a Yemeni boy. A report of a case with brief review of literature

A 13-year old Yemeni boy who presented with flaccid paraplegia was thought to have a spinal cord tumor on myelography. Microscopic examination of surgically excised material revealed bilharzial granulomas. Brief review of relevant literature on schistosomiasis of the spinal cord, with particular reference to the Middle East, is presented.     

A Novel technique of ureteroneocystostomy (extravesical seromuscular tunnel): An experimental study in dogs. II. Optimization of surgical technique

Objectives

To optimize the surgical technique of the new extravesical seromuscular tunnel ureteroneocystostomy and to study the optimal relation between the length and width of the tunnel and the diameter of the normal and dilated ureters.

Methods

The optimized technique was applied to the left ureters of 20 dogs; 10 with normal ureters and 10 after induction of ureteral dilation. The new technique was performed to maintain a ratio of 3:1 between the width of the tunnel and the diameter of the ureter and a ratio of 1:1 between the length of the tunnel and the ureteral diameter. The results were compared with those for 5 dogs in which unilateral direct ureterovesical reimplantation was performed without an antireflux procedure. All the dogs were evaluated by intravenous urography, radioisotope renography, and ascending cystography before and at 1, 3, and 6 months after ureteroneocystostomy.

Results

All the dogs of the control group showed low-pressure vesicoureteral reflux and 3 demonstrated mild hydronephrosis and significant deterioration of the corresponding kidney. At 6-month follow-up, none of the 20 dogs subjected to the new technique showed deterioration of the function or configuration of the corresponding kidney. Moreover, the new technique was sufficient to prevent reflux in all but two dilated ureters that showed high-pressure vesicoureteral reflux.

Conclusions

For the extravesical seromuscular tunnel to be effective in reflux prevention without obstruction, the width of the tunnel must be triple the diameter of the ureter, and the length of the tunnel covering the intact (nonspatulated) part of the ureter should be equal to its diameter.     

Anti-HIV-1 protease activity of lanostane triterpenes from the vietnamese mushroom Ganoderma colossum

Four new lanostane triterpenes, colossolactone V (1), colossolactone VI (2), colossolactone VII (3), and colossolactone VIII (4), were isolated from the fruiting bodies of the Vietnamese mushroom Ganoderma colossum, together with the known compound colossolactone E (5). The structures of 1- 4 were assigned on the basis of spectroscopic evidence, and their absolute configurations were determined by CD spectroscopy and the Mosher ester method. Compounds 1- 5, as well as two previously isolated compounds [schisanlactone A (6) and colossolactone G (7)] from the same mushroom, were evaluated for inhibition of HIV-1 protease, with IC 50 values for the most potent compounds ranging from 5 to 13 microg/mL.     

Pyogenic abscess of the breast: clinical and therapeutic aspects

OBJECTIVE: The goal of this retrospective work was to study the clinical aspects and the principles of management of the abscess of the breast in order to determine a convenient and recent therapeutic attitude. PATIENTS AND METHODS: Our retrospective survey concerns 114 cases of breast abscess collected in a surgery department over a period of 14 years, from 1990 to 2003. All patients have been operated and the diagnosis confirmed through the operation. The puerperal abscesses have been noted in 31 cases. RESULTS: One hundred and four women and ten men were concerned, with a sex-ratio of 0.1. The medium age was 33 years old for the women and 42 years for the men. The diagnosis was based on the clinical criteria, confirmed by the ultrasonography in 11 cases out of 16 and by the mammary puncture in 15 cases out of 22. Two non-puerperal abscesses have revealed an infiltrating canal carcinoma. The Staphylococcus aureus was the germ the most frequently met, concerning 8 cases out of 16. The surgical biopsies carried out in 52 cases revealed a fibrocystic mastopathy in six cases, a canalar ectasia in two cases and an infiltrating canalar carcinoma in two cases. The surgical treatment, performed in any case, was associated to an anti-staphylococcus antibiotherapy. The recurrence of the abscess has been observed in four cases. DISCUSSION AND CONCLUSION: The frequency of pyogenic abscess of the breast, particularly the puerperal abscesses, has considerably decreased. The non-puerperal abscesses often pose a differential diagnosis problem with the very aggressive inflammatory cancers. The percutaneous ultrasonography guided drainage must be proposed in first intention to treat the abscesses of the breast. However, surgical treatment is still valid with an abscess either relapsing or chronic, or else the failure of the non-operative processes.     

Pulmonary metastatectomy for soft tissue sarcomas: is it valuable?

BACKGROUND: A retrospective study and analysis was performed to determine the value and benefit of pulmonary metastatectomy for soft tissue sarcomas, and which factors predict prognosis following resection. METHODS: Twenty-three patients underwent resections for pulmonary metastases from a soft tissue sarcoma (STS) at King Faisal Specialist Hospital and Research Center (KFSH&RC), between January 1985 and December 1998. There were 11 male and 12 female patients. Thirteen of 23 patients (57%) had one to three metastases, and 10 (43%) had four or more metastases. A total of 41 thoracic explorations was performed for the 23 evaluable patients. Median sternotomy was used only for three patients and lateral thoracotomy was used for 20 patients as an initial surgical approach. Pulmonary resections performed included one or more wedge resections (n=16), segmentectomy (n=5), and lobectomy (n=2). No one in this series underwent pneumonectomy. The number of resected metastatic nodules ranged from one-six with average three. Eight patients (35%) received various kinds of postoperative adjuvant chemotherapy. RESULTS: The overall and disease-free survival rate post-metastatectomy at five years was 24% and 21%, respectively. Various prognostic indicators were examined to evaluate their association with improved survival. Age, sex localization of the primary site and histologic type, tumor grade, size of the resected nodules, laterality (unilateral or bilateral), types of resection, adjuvant chemotherapy, and local recurrence did not significantly affect survival. However, patient with disease free interval >6 months, and those with three or fewer metastases showed a trend toward a higher five-year overall survival (p=0.06, 0.07, respectively). CONCLUSIONS: Surgical excision of lung metastases from soft tissue sarcomas is well accepted and should be considered as a first line of treatment if preoperative evaluation indicated that complete resection of the metastases is possible. Further investigation is needed before chemotherapy can be recommended as additional therapy.     

Percutaneous suprapubic cystolithotripsy for pediatric bladder stones in a developing country

OBJECTIVE: To evaluate our experience with percutaneous suprapubic cystolithotripsy (PCCL) in Yemeni children with endemic urinary bladder stones. PATIENTS AND METHODS: Between January 1993 and December 1998, 117 children underwent percutaneous suprapubic lithotripsy in Arabia Felix Modern Hospital, Sana'a Republic of Yemen. The patients' ages ranged from 8 months to 14 years (average 3.7 years). Ninety patients (77%) were under 5 years old; 20 patients (16%) were between 6 and 10 years old, and 7 patients (6%) were between 11 and 14 years old. There were 116 boys and 1 girl. The stone size ranged from 0.7 to 4 (average 2.3) cm. Five patients had coexisting urinary bilharziasis and another 5 patients had coexisting renal stone. In 10 patients, the stone was in the urethra. The procedure was done under general anesthesia. Dilation of the tract was made under fluoroscopy. The instrument was an adult 26-french nephroscope, the same as that used for percutaneous nephrolithotripsy. Ultrasound disintegration was needed for stones of > 1 cm. A suprapubic catheter was left for 24 h, and a urethral catheter was kept for 48 h. RESULTS: All patients became stone free. The average operating time was 15 (5-50) min. The average hospital stay was 2.7 (2-5) days. No severe intra- or postoperative complication was observed. The nucleus and/or the main component of the stones were ammonium acid urate in 109 patients (93%). CONCLUSION: Based on our experience we can conclude that percutaneous suprapubic lithotripsy is a safe and effective method for the treatment of bladder stones in children. It reduces morbidity and hospital stay and thus the cost of treatment. Our series proves the nutritional etiology of endemic pediatric bladder stones. To our knowledge, this is the largest series reported on percutaneous suprapubic management of endemic bladder stones in children.