Congenital central hypoventilation syndrome

Congenital central hypoventilation syndrome (CCHS) is characterized by hypoventilation during sleep and impaired ventilatory responses to hypercapnia and hypoxemia. Most cases are sporadic and caused by de novo PHOX2B gene mutations, which are usually polyalanine repeat expansions. Physiological and neuroanatomical studies of genetically engineered mice and analyses of cellular responses to mutated Phox2b have shed light on the pathophysiological mechanisms of CCHS. Findings in Phox2b(27Ala/+) knock-in mice consisted of unstable breathing with apneas, absence of the ventilatory response to hypercapnia, death within a few hours after birth, and absence of the retrotrapezoid nucleus (RTN). Conditional mouse mutants in which Phox2b(27Ala) was targeted to the RTN also lacked the ventilatory response to hypercapnia at birth but survived to adulthood and developed a partial hypercapnia response. The therapeutic effects of desogestrel are being evaluated in clinical trials, and recent analyses of cellular responses to polyAla Phox2b aggregates have suggested new pharmacological approaches designed to counteract the toxic effects of mutated Phox2b.

[Clomipramine hypersensitivity with predominantly pulmonary involvement]

Drug hypersensitivity (DRESS syndrome) is a rare disorder with diverse systemic and visceral manifestations. Pulmonary involvement is uncommon and is mainly characterized by eosinophilic infiltration. We report a case of DRESS syndrome induced by clomipramine with predominant pulmonary involvement.

Stripping in hot mix asphalt produced by aggregates from construction and demolition waste

This paper analyses the effect of water on the durability of hot asphalt mixtures made with recycled aggregates from construction and demolition debris. Indirect tensile stress tests were carried out to evaluate stripping behaviour. The mixtures tested were fabricated with 0, 20, 40 and 60% recycled aggregates. Two types of natural aggregates were used: schist and calcite dolomite. An increase in the percentage of recycled aggregates was found to produce a decrease in the tensile stress ratio of the hot asphalt mixtures. To study this phenomenon, two and three factor analyses of variance (ANOVA) were performed with indirect tensile stress being used as the dependent variable. The factors studied were the percentage of recycled aggregates (0, 20, 40 and 60%), the moisture state (dry, wet) and the type of natural aggregate (schist, calcite). On the basis of the ANOVA results, it was found that the most important factor affecting resistance was the moisture state (dry, wet) of the specimens. The percentage of recycled aggregate also affected indirect tensile stress, especially in the dry state. The type of natural aggregate did not have a significant effect on indirect tensile stress. The hot asphalt mixture specimens made with different percentages of recycled aggregates from construction and demolition debris and of natural quarry aggregates showed poor stripping behaviour. This stripping behaviour can be related to both the poor adhesion of the recycled aggregates and the high absorption of the mortar of cement adhered to them.

A 4-year dopamine transporter (DAT) imaging study in neuroleptic-naive first episode schizophrenia patients

Alterations in the dopaminergic system have long been implicated in schizophrenia. A key component in dopaminergic neurotransmission is the striatal dopamine transporter (DAT). To date, there have been no longitudinal studies evaluating the course of DAT in schizophrenia. A 4-year follow-up study was therefore conducted in which single photon emission computed tomography was used to measure DAT binding in 14 patients and 7 controls. We compared the difference over time in [(123)I] FP-CIT striatal/occipital uptake ratios (SOUR) between patients and controls and the relationship between this difference and both symptomatology and functional outcome at follow-up. We also calculated the relationship between baseline SOUR, symptoms and functional outcome at follow-up. There were no statistically significant differences between patients' SOUR changes over time and those of controls. A significant negative correlation was observed between patients' SOUR changes over time and negative symptomatology at follow-up. A significant negative correlation was also found between baseline SOUR in patients and negative symptomatology, and there was a significant association between lower SOUR at baseline and poor outcome. Although the study found no overall differences in DAT binding during follow-up between schizophrenia patients and controls, it demonstrated that differences in DAT binding relate to patients' characteristics at follow-up.

[Left ventricle free wall rupture - a 10-year experience]

The left ventricle free wall rupture is one of the most serious and lethal complications associated to myocardial infarction.The most common treatment in our days consists in direct closure of the rupture with pericardium or synthetic material, applied with the help of histoacryl glue, without extracorporeal circulation.Between January 2000 and September 2010, 35 consecutive patients underwent operation for left ventricle free wall rupture at our hospital.The mean age was 69,5 years and most of the patients were male ( 65,7 % ). 2,9 days was the mean time for rupture after infarction and the anterior and lateral wall were most frequently involved. 94,7 % of the patients were in shock. Surgery was performed without extracorporeal circulation using a patch of pericardium and/or Dacron Sauvage, with histoacryl glue in 85,7 % of cases.Mean time of ICU stay was 7,9 days, in-hospital global mortality 28,6 %. At 2,5 years follow-up, 86 % of the patients were alive.Despite the high morbidity and mortality associated to surgery, the procedure is now safer, simpler and quick allowing the treatment of a situation that conducted to a most certain death without management.

Decreased striatal dopamine transporter uptake and substantia nigra hyperechogenicity as risk markers of synucleinopathy in patients with idiopathic rapid-eye-movement sleep behaviour disorder: a prospective study [corrected]

BACKGROUND

Patients with idiopathic rapid-eye-movement sleep behaviour disorder (IRBD) may develop neurodegenerative conditions associated with substantia nigra dysfunction such as Parkinson's disease. In patients with Parkinson's disease, ¹²³I-2β-carbomethoxy-3β-(4-iodophenyl)-N-(3-fluoropropyl)-nortropane (¹²³I-FP-CIT) SPECT detects striatal dopamine dysfunction resulting from nigral pathology whereas transcranial sonography (TCS) shows increased substantia nigra echogenic size, even before parkinsonism is clinically evident. We postulated that these neuroimaging changes could occur in a proportion of IRBD individuals who might then be at increased risk for development of a neurodegenerative disorder associated with substantia nigra dysfunction.

METHODS

In our prospective study, we identified patients with IRBD from individuals referred to our sleep disorders centre in Barcelona, Spain. At baseline, we assessed dopamine transporter [corrected] uptake by use of ¹²³I-FP-CIT SPECT, and estimated echogenicity of the substantia nigra by use of TCS. After a follow-up of 2·5 years, participants were clinically assessed to establish whether they had developed neurodegenerative syndromes. Data were compared with those of matched healthy controls.

FINDINGS

43 individuals with IRBD agreed to participate in the study. We found reduced ¹²³I-FP-CIT binding in the striatum (p=0·045) in 17 (40%) of 43 participants compared with 18 controls, and substantia nigra hyperechogenicity in 14 (36%) of 39 participants with IRBD, compared with 16 (11%) of 149 controls (p=0·0002). Tracer uptake reduction was more pronounced in the putamen than it was in the caudate nucleus. 27 (63%) participants had reduced ¹²³I-FP-CIT binding or substantia nigra hyperechogenicity at baseline. Eight (30%) of these participants developed a neurodegenerative disorder (five Parkinson's disease, two dementia with Lewy bodies, and one multiple system atrophy). Individuals with normal neuroimaging results remained disease-free. Sensitivity of combined ¹²³I-FP-CIT SPECT and TCS to predict conversion to synucleinopathy after 2·5 years was 100% and specificity was 55%.

INTERPRETATION

In patients with IRBD, ¹²³I-FP-CIT SPECT and TCS can detect subclinical changes much the same as those typically seen in patients with early Parkinson's disease. Decreased striatal ¹²³I-FP-CIT binding and substantia nigra hyperechogenicity might be useful markers to identify individuals at increased risk for development of synucleinopathies.

FUNDING

None.

[Myocardial abscess of the right ventricle anterior wall]

The authors report the clinical case of a 63 old male, with a previous history of aortic mechanical replacement valve, who was admitted with fever, neutrophilic leukocytosis and c-reactive protein elevation. During admission Escherichia coli was cultured from blood, and the patient underwent repeated transthoracic and transesophageal echocardiograms, that did not reveal any abnormalities. Three weeks after admission, a new transesophageal echocardiogram showed an image suggestive of an aortic annular abscess. The patient was transferred to the Cardiothoracic Department of Santa Maria Hospital, in order to be submitted to surgical treatment. During the procedure an abscess in the anterior wall of right ventricle was diagnosed. The microbiological cultures of pus were negative. It was assumed the diagnosis of E. coli myocardial abscess. The diagnostic approach to patients with febrile syndrome and mechanical replacement valve should consider the hypothesis of infectious endocarditis and myocardial abscess, despite the rarity of its occurrence.

[Minimally invasive thoracic surgery: a fifteen-years experience]

The evolution of surgical techniques has rendering possible for thoracic surgery to be performed efficiently and safely, with less aggressive approaches. Being less traumatic, minimally invasive surgery allows a faster post-operative recovery, less complications and reduces in patient days and morbidity. The authors consider as minimally invasive approaches the video-assisted thoracic surgery, as well as the minithoractomy and the ministernotomy. The present paper reviews thoracic surgeries performed for the last 15 years in a cardiothoracic surgical unit using a minimally invasive surgical approach.

[Intra-thoracic goiter: analysis of the Department's experience]

A review of all clinical files with pre-operative diagnosis of intra-thoracic goiter operated in our Department from 2001-2009 was made. We identified 30 patients, of which 66% were females. 63% of the patients were asymptomatic, 46% had clinical or radiological findings of mediastinal structures compression and 2 patients were ventilated prior to surgery. 50% of the patients were operated on through an inferior transverse cervicotomy, the remaining were operated on through partial or complete sternotomy, with cervical approach. 6,6% of patients (n=2) had an intra-operative diagnosis of invasive thymoma, 3,3% (n=1) had a very invasive mediastinal tumor and 3,3% (n=1) had an ectopic thyroid. Average surgical length of time was of 83 minutes. In 10% of patients (n=3) post-operative invasive ventilation was required, one of which for unilateral permanent lesion of the recurrent laryngeal nerve. In the long term follow-up we assessed 18 patients. The median follow up was 53 months. One patient died at the 15th post-operatory day of pneumonia, one expired at the 30th day for anaplasic thyroid carcinoma progression and one died at the 18 month from invasive thymoma progression. One patient currently reveals evidence of local recurrence 3 patients are currently taking levothyroxine and one is taking propiltiouracil. Pathological studies revealed that 66% of cases were multinodular goiter and neoplasia was present in 13% of the patients. Other results were thymic pathology in 13% of cases (n=4), parathyroid cyst in 3,3% (n=1), and ectopic thyroid in 3,3% (n=1(.

Neural control of breathing: insights from genetic mouse models

Recent studies described the in vivo ventilatory phenotype of mutant newborn mice with targeted deletions of genes involved in the organization and development of the respiratory-neuron network. Whole body flow barometric plethysmography is the noninvasive method of choice for studying unrestrained newborn mice. Breathing-pattern abnormalities with apneas occur in mutant newborn mice that lack genes involved in the development and modulation of rhythmogenesis. Studies of deficits in ventilatory responses to hypercapnia and/or hypoxia helped to identify genes involved in chemosensitivity to oxygen and carbon dioxide. Combined studies in mutant newborn mice and in humans have shed light on the pathogenesis of genetically determined respiratory-control abnormalities such as congenital central hypoventilation syndrome, Rett syndrome, and Prader-Willi syndrome. The development of mouse models has opened up the field of research into new treatments for respiratory-control disorders in humans.

[New perspectives on intracerebral haemorrhage]

Intracerebral haemorrhage (ICH) results from the spontaneous rupture of an intracranial vessel. It comprises about 15% of all cerebrovascular diseases, and carries the highest risk of mortality and morbidity. ICH volume is the strongest single predictor of a bad outcome. Recent evidence shows that haematoma expansion is associated with early neurological deterioration and it occurs in 38% of patients. Ultra-early haemostatic agents such as recombinant factor VII (rfVII) may have a role in ICH management; although further clinical trials are required for it to be used in routine management. This article reviews its pathophysiology and natural history, and the evidence supporting recent advances in medical and chirurgical management for spontaneous ICH.