Giant fusiform aneurysm of the vertebro-basilar artery presenting with stroke

The authors describe a case of giant fusiform aneurysm of the basilar artery presenting with ischemic symptoms. Angiography and CT revealed vertebro-basilar fusiform aneurysmal dilatation. Fusiform vertebro-basilar ancurysm is associated with various complications particularly brain stem infarction. Similar lesions in the literature are reviewed and the relationship between this clinical entity and cerebral ischemia, particularly brainstem infarction are discussed.     

Blood Cultures Positive for Coagulase-Negative Staphylococci: Antisepsis,Pseudobacteremia, and Therapy of Patients

A blood culture cohort study investigating issues related to isolation of coagulase-negative staphylococci (CoNS) and other skin microflora is reported. Data were collected over 12 weeks to determine the incidence of significant CoNS bacteremia versus that of pseudobacteremia (contaminants) and to evaluate drug therapy in patients with cultures positive for CoNS. In addition, the effectiveness of 0.2% chlorine peroxide as a bactericidal disinfectant was compared to that of 10% providone iodine. A total of 3,276 cultures of blood from 1,433 patients were evaluated in the study. Eighty-nine cultures were positive for skin flora, with 81 of 89 (91%) involving CoNS. The incidence of significant CoNS bacteremia was 20 of 81 (24.7%), that of indeterminate bacteremia was 10 of 81 (12.3%), and that of contamination was 59 of 81 (72.8%). The incidence of significant bacteremia involving CoNS was double the 10 to 12% rate based on previous estimations at our institutions. In tests with the two bactericidal disinfectants, 22 of 1,639 cultures (1.3%) in the chlorine peroxide group versus 37 of 1,637 (2.3%) in the providone iodine group were considered contaminated (P = 0.065). Rates of contamination for venipuncture versus catheter collection were not significantly different (P = 0.46). The overall contamination rate was 59 of 3,276 (1.8%), which is consistent with the lower end of published quality assurance benchmark standards. The low rate was believed to be due to the professional phlebotomy staff in our institutions. There was excellent agreement between retrospective analysis by reviewers, when formal criteria were used, and the attending physicians’ intuitive clinical impressions in the classification of significant bloodstream infections (100% agreement) or contamination (95% agreement). However, physicians still used antimicrobial agents to treat nearly one-half of the patients with contaminated blood cultures, with vancomycin being misused in 34% of patients. In addition, 10% of patients with significant bacteremia were treated with inappropriate agents. There were no significant adverse events or prolonged hospital stays due to the unnecessary use of vancomycin; however, the additional costs of treating patients whose cultures contained CoNS contaminants was estimated to be $1,000 per patient. Measures to limit the unnecessary use of vancomycin (and other agents) are important.Coagulase-negative staphylococci (CoNS), the most frequent blood culture isolates, are predominantly blood culture contaminants, but they are also a significant cause of bacteremia (2–5, 7, 9, 13). Institution-specific contamination rates vary from 2 to more than 6% (3, 5, 23, 26, 27). In the past 5 years, estimated contamination rates at our hospitals ranged from 2.5 to 3.5%. During this period, CoNS accounted for 45 to 60% of total blood isolates, and we estimated, using laboratory criteria, that 10 to 12% of CoNS isolates from blood were implicated in significant bloodstream infections. A relatively large proportion of the patient population with presumed false-positive blood cultures due to contaminants (pseudobacteremia) were treated with antimicrobial agents, in particular, vancomycin.Clinical and microbiologic guidelines for the differentiation of true bacteremia from pseudobacteremia or contamination have been published (5, 13, 15). Suggested laboratory criteria for true bacteremia include growth within 48 h and multiple blood cultures positive for the same organism. In contrast, increased duration of time before positivity, polymicrobial growth of skin organisms, or growth during antibiotic treatment suggest contamination. Others recommended that the addition of clinical guidelines is essential for the appropriate classification of bacteremia (4, 8, 9, 15, 18).We conducted a cohort study to evaluate clinical and laboratory data for adult patients with blood cultures positive for CoNS. The study was done at two tertiary-care teaching centers, Deaconess Medical Center (DMC) and Sacred Heart Medical Center (SHMC), with a combined capacity of 900 beds. We examined problems associated with false-positive bacteremia and determined the incidence of significant bacteremia. Our goal was to make recommendations to improve clinicians’ ability to recognize the significance of potentially contaminating organisms and to evaluate treatment given to patients with CoNS-positive blood cultures. To attempt to minimize contamination, we evaluated the nontoxic, antiseptic and disinfectant chlorine peroxide in comparison to a standard disinfectant.(This work was previously presented in abstract form at the 96th General Meeting of the American Society for Microbiology, New Orleans, La., 19 to 23 May 1996 [24a].)     

Acquired lobar emphysema (overinflation): clinical and pathological evaluation of infants requiring lobectomy.

Acquired lobar "emphysema" (overinflation) (ALE) is an increasingly recognized complication of advanced bronchopulmonary dysplasia (BPD). To refine current concepts regarding patient management and pathogenesis, we examined clinical and pathological features of six infants with ALE who did not have obstructing intraluminal lesions and who underwent lobectomy after failing nonoperative management. All had severe neonatal respiratory distress and required prolonged ventilatory support (average, 2 months) with peak inspiratory pressures greater than 30 mm Hg and 100% oxygen. ALE developed between 3 weeks and 20 months of age (median, 5 months), with lobar hyperinflation, atelectasis, and mediastinal shift. Selective bronchial intubation provided only transient benefit. Videobronchoscopy demonstrated no intraluminal obstructing lesions in five patients. In one child, ALE became clinically apparent only after laser excision of an endobronchial cicatrix. All infants had bronchomalacia with the involved lobar bronchus being most severely affected. Ventilation-perfusion scans demonstrated severe impairment of both ventilation and perfusion in the involved lobes. The decision to perform lobectomy was based on clinical parameters and failure of non-operative management. After lobectomy, all children dramatically improved. However, only three of six were alive 2 to 3 years later; one infant died of unrelated causes at 6 weeks; and two died of progressive respiratory insufficiency 13 and 24 months postlobectomy. Microscopic evaluation of the lung demonstrated findings of late-stage BPD with peribronchial and interstitial fibrosis, parenchymal overinflation, and alveolar septal disruption.(ABSTRACT TRUNCATED AT 250 WORDS)     

HMB-45 immunohistochemical staining of sentinel lymph nodes: a specific method for enhancing detection of micrometastases in patients with melanoma

Despite the profound therapeutic and prognostic implications of nodal metastases in patients with melanoma, there is no consensus strategy for the optimal detection of metastases in sentinel lymph node biopsies. Traditional microscopic examination may be too crude to detect scattered, individual tumor cells. Conversely, molecular genetic techniques are prone to false-positive results. The authors evaluated the ability of HMB-45 immunohistochemistry to enhance detection of melanoma cells in histologically negative sentinel lymph nodes. Ninety-six sentinel lymph nodes, collected over a 25-month period from 66 consecutive patients with melanoma, were processed routinely and sectioned serially. Slides 1, 3, and 5 were stained with hematoxylin and eosin. HMB-45 staining was performed on an intervening slide in histologically negative nodes. To assess the background incidence of HMB-45-positive cells in lymph nodes draining the skin, the authors stained 244 cervical and axillary lymph nodes from patients without melanoma. Metastases were apparent microscopically in 12 (18%) of the 66 patients with melanoma. Of the remaining 54 patients, four patients (7%) had lymph nodes harboring individual, scattered HMB-45-positive cells. Benign nevocellular aggregates were present in four of the 96 sentinel lymph nodes (4% nodal incidence), but they were HMB-45-negative. The authors did not observe a single HMB-45-positive cell in the 244 lymph nodes from patients without melanoma. Immunohistochemistry appears to represent a specific means of enhancing tumor detection in sentinel lymph nodes from patients with melanoma.     

High-Sensitivity Cardiac Troponin T levels in prehypertensive patients

Background: High-sensitivity cardiac troponin T (hs-cTNT) is an important non-invasive laboratory-based marker of subclinical myocardial injury. Prehypertension, which may be a precursor of hypertension, is a major public health issue. Our aim was to evaluate the importance of serum hs-cTnT as a marker predicting prehypertension.

Methods: A total of 100 subjects (45 women and 55 men) consisting of 50 consecutive prehypertensive patients with blood pressures between 120/80 and 139/89 mmHg and 50 normotensive patients with blood pressures < 120/80 mmHg were enrolled prospectively. The hs-cTNT level was calculated and compared between the two groups. Echocardiographic examinations were performed in all patients.

Results: The hs-cTnT level was significantly higher in the prehypertensive group (p < 0.001) and was positively correlated with prehypertension (r = 0.625, p < 0.001). Hs-cTnT was an independent predictor of prehypertension (odds ratio = 1.043, 95% confidence interval [CI] 1.019–1.067, p < 0.001). An Hs-cTnT level of 0.55 ng/L was predictive of prehypertension with a sensitivity of 86% and specificity of 60% (area under the curve = 0.861; 95% CI, 0.787–0.935; p < 0.001).

Conclusion: hs-cTnT may complement other diagnostic biomarkers in predicting prehypertension.

Abbrevations: high-sensitivity cardiac troponin T, prehypertension, subclinical myocardial injury     

Clinical characteristics of pulmonary artery involvement in patients with Behçet’s syndrome: single-centre experience of 61 patients

Clinical Rheumatology - To report the clinical characteristics of pulmonary artery involvement (PAI) in patients with Behçet’s syndrome (BS) and to define the predictors of relapses. We...     

The efficacy of phonophoresis on electrophysiological studies of the patients with carpal tunnel syndrome

To investigate the efficacy of phonophoresis with nonsteroid anti-inflammatory drugs (P-NSAID) and corticosteroids (P-CS) in the treatment for carpal tunnel syndrome (CTS) and to compare the efficacy of phonophoresis with local CS injection (LCSI) and splinting with a 3-month follow-up. 84 hands of 51 patients with CTS were treated by applying LCSI, P-CS, P-NSAID, and wrist splinting. Electrophysiological studies, grip strength, hand dexterity, and sensory recovery of the first three digits were assessed. Duru?z hand index (DHI) was used to assess the functional hand disability. For clinical evaluation, we used Phalen and Tinnel signs. Pain intensity was evaluated by visual analog scale. The LCIS group showed a significant improvement in pain relief and DHI, but this group had significant deterioration in the results of monofilament and pegboard tests. The P-CS group showed improvement in sensory nerve conduction velocity, distal latency, grip strength, and DHI parameters. There was a significant improvement in grip strength, pegboard test, and pain intensity in the P-NSAID group. There was improvement only in pain intensity in the splinting group. We identified marked improvement in the electrophysiological studies in the P-CS group. Splinting had no effect on hand functions, disability, and electrophysiological studies.     

Unusual Traumatic Midthoracic Spondyloptosis and Its Surgical Management: Case Report

Posttraumatic spondyloptosis develops as a result of complete subluxation of the vertebral bodies and causes complete transection of the spinal cord. Severe trauma-related spondyloptosis of the upper-mid thoracic region is a rare form of spinal trauma. Traumatic midthoracic spondyloptosis is quite rare, and radiology plays an important role in the diagnosis and treatment of this condition. Surgical reconstruction and stabilization are required for early mobilization and rehabilitation of patients with this injury. Here, we report the clinical features, radiographic findings, and management of an unusual case of traumatic midthoracic spondyloptosis that showed complete spinal cord transection and was operated.