Stroke disclosing primary aldosteronism: Report on three cases and review of the literature

OBJECTIVES

There is a growing evidence of increased risk of cerebrovascular events in primary aldosteronism (PA). Nevertheless, acute neurologic ailment as presenting feature of PA is uncommon. Our aim is to highlight the diagnosis challenges in stroke unmasking PA and to discuss the underlying physiopathology and management dilemmas.

MATERIALS AND METHODS

We hereby describe three consecutive rare cases of stroke revealing PA. All patients had brain imaging and thorough biological and morphological assessment to rule out other etiologies of stroke. The diagnosis of primary aldosteronism was established according to the Endocrine Society Clinical Practice Guideline, with a review of the literature on the spectrum of neurologic manifestations in PA.

RESULTS

We report on three cases, two women and a man, presenting with ischemic or hemorrhagic stroke, of early onset in two of them. All of the reported patients had hypertension and hypokaliemia. This association prompted the assessment of renin angiotensin aldosterone system (RAAS) disclosing PA, which was due to bilateral adenomas in the first one or bilateral adrenal hyperplasia in the two others. All patients refused the surgical option and received spironolactone with recurrence of stroke in one of them due to treatment incompliance.

CONCLUSION

Although cerebrovascular events are quite common in PA, their occurrence as initial feature can be misleading. The association of hypokaliemia and refractory hypertension in ischemic or hemorrhagic strokes should prompt an assessment of the RAAS to rule out PA and initiate adequate management as soon as possible in order to avoid further complications.

119 ASSESSMENT OF OVARIAN FOLLICULAR DYSPLASIA UTILIZING ULTRASOUND AND HISTOLOGIC EXAMINATION

A slaughterhouse study commissioned by Florida Cattleman’s Association in 2007 identified ovarian follicular dysplasia (OFD) as a primary cause of infertility in Florida beef cows. Ovaries with OFD have progressive bilateral development of solid clustered follicles containing multiple Call-Exner bodies that originate in the rete ovarii and the hilar region, and progress into the cortex to eventually form bilateral Sertoli-type granulosa theca cell tumours (GTCT). The objectives of this study were to assess the distribution of OFD in cull animals and to evaluate utilisation of ultrasound for diagnosis of OFD in cattle. Ultrasound images of the right and left ovaries from 390 cull cows and heifers representing 4 Florida ranches were made with 5-MHz linear probes (Aloka, Ibex). Then, 10 to 12 females per ranch were followed to slaughter the proceeding day for collection of reproductive tracts. The fixed ovaries were measured, sectioned para-sagittally through the hilus, photographed, and arranged in histology cassettes for complete examination of the cut surface. Large ovarian structures including corpus luteum, Graafian follicles, atretic follicles, dysplastic follicles, rete ovarii, dysplastic follicles, and tumours were counted and measured for each ovary. Ovaries with OFD were graded I to IV. Grade I OFD contained small individual dysplastic follicles with diameter less than 200 µm mostly limited to the rete ovarii and medulla. Grade II OFD possessed dysplastic follicles greater than 200 µm diameter that were present in the medulla and cortex. Grade III OFD had extensive multi-sized dysplastic follicles scattered throughout the entire cortex of the ovary and Grade IV OFD had Sertoli-type GTCT. Grade II–IV often had dystrophic mineralization of dysplastic follicles. Gross morphology of fixed sagittal sections and ultrasound images were blindly compared against OFD grade in 40 individual ovaries. The OFD was identified at slaughter in 29/41 cows and in 1/5 of heifers. The distribution of OFD for 30 affected females was Gr I 16/30, Gr II 9/30, Gr III 4/30, and Gr IV 1/30. Characteristics that could be detected by routine ultrasound included increased size and length, increased hyperechogenicity and decreased number of fluid-filled follicles. Hyperechogenic shadows were evident in higher grade OFD. The study demonstrated that Grade III and IV OFD can be observed by routine ultrasound but Grade I and II may require higher resolution ultrasound probes, imaging analysis software, or Doppler ultrasound.

International Nosocomial Infection Control Consortium report, data summary of 50 countries for 2010-2015: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2010-December 2015 in 703 intensive care units (ICUs) in Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, using Centers for Disease Control and Prevention National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI), we collected prospective data from 861,284 patients hospitalized in INICC hospital ICUs for an aggregate of 3,506,562 days.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the INICC medical-surgical ICUs, the pooled rate of central line-associated bloodstream infection, 4.1 per 1,000 central line-days, was nearly 5-fold higher than the 0.8 per 1,000 central line-days reported from comparable US ICUs, the overall rate of ventilator-associated pneumonia was also higher, 13.1 versus 0.9 per 1,000 ventilator-days, as was the rate of catheter-associated urinary tract infection, 5.07 versus 1.7 per 1,000 catheter-days. From blood cultures samples, frequencies of resistance of Pseudomonas isolates to amikacin (29.87% vs 10%) and to imipenem (44.3% vs 26.1%), and of Klebsiella pneumoniae isolates to ceftazidime (73.2% vs 28.8%) and to imipenem (43.27% vs 12.8%) were also higher in the INICC ICUs compared with CDC-NHSN ICUs.

CONCLUSIONS

Although DA-HAIs in INICC ICU patients continue to be higher than the rates reported in CDC-NSHN ICUs representing the developed world, we have observed a significant trend toward the reduction of DA-HAI rates in INICC ICUs as shown in each international report. It is INICC's main goal to continue facilitating education, training, and basic and cost-effective tools and resources, such as standardized forms and an online platform, to tackle this problem effectively and systematically.

Recurrent status epilepticus in posterior reversible encephalopathy syndrome as initial feature of pediatric lupus: A newly diagnosed case and literature review

INTRODUCTION

Posterior reversible encephalopathy syndrome (PRES) is a recently described clinico-neuroradiological syndrome with several predisposing conditions. Systemic lupus erythematosus (SLE), beginning in 15-20% in childhood, is considered as a potential underlying etiology of PRES. In children, status epilepticus (SE) rarely complicates PRES, and exceptionally occurs in SLE.

METHODS

We report on an illustrative case of PRES complicating pediatric lupus revealed by recurrent SE, and we further review through a Pubmed search the previously reported cases of pediatric SLE, PRES and SE.

RESULTS

We describe the case of a 12-year old girl who presented with recurrent status epilepticus associated to high blood pressure and renal involvement. Brain imaging showed classical aspects of PRES. Immunological tests including antinuclear, anti-DNA, and anticardiolipin antibodies were positive. The diagnosis of SLE was established. The Pubmed search identified a total number of 9 children with SE in SLE, and 26 with PRES, including our patient.

CONCLUSIONS

We discussed the clinical and paraclinical features of PRES in SLE with epilepsy, their underlying pathophysiological aspects, and their management challenges. PRES should be considered in initial recurrent SE in children, justifying a battery of tests comprising immunological testing. Anticardiolipin antibodies seem to play a crucial role in epilepsy, PRES and renal involvement in pediatric SLE. Further studies are needed to clarify whether PRES should be considered one of the neuropsychiatric manifestations of SLE or a consequence of active disease in other organ systems or its treatment.

[Neurologic manifestations of sarcoidosis: A study of 18 cases]

INTRODUCTION

Sarcoidosis is a multisystemic granulomatous disease of unknown aetiology. Neurologic manifestations are found in 5 to 10% of cases.

PATIENTS AND METHODS

We conducted a retrospective study over 6-year period including 18 patients diagnosed with neurosarcoidosis in the Neurologic department of the Military Hospital of Instruction of Tunis. Clinical, radiological, therapeutic features and outcome were studied.

RESULTS

The mean age was 43.44 years. Neurologic signs were the first symptom in 10 cases. Peripheral nervous system impairment was often found. Meningitis was noted in 8 cases. Biological tests are not contributive for the diagnosis. The brain magnetic resonance imaging was pathologic in 10 cases. Corticosteroids were administrated in the majority of cases. Eight patients did not show any sign of improvement. Ten cases improved with treatment.

DISCUSSION AND CONCLUSION

Diagnosis of neurosarcoidosis is difficult because of its clinical and radiological polymorphism. It is based on a clinical history suggestive of neurosarcoidosis, laboratory, imaging and histological studies.

Lapatinib-based therapy for women with advanced/metastatic HER2 positive breast cancer

BACKGROUND

Lapatinib alone or in combination with other agents, mostly capecitabine is used for patients with advanced/metastatic HER2 positive breast cancer (HER2(+)BC) after progression on trastuzumab based therapy. Here we report our experience with lapatinib based therapy in this setting.

MATERIAL AND METHODS

67 consecutive patients received lapatinib based therapy. 58 (86.6%) received lapatinib + capecitabine (LC), 7 (10.4%) with other agents and 2 (3.0%) as single agent lapatinib. Data was collected from patients' records retrospectively.

RESULTS

Objective response to lapatinib based therapy in 64 evaluable patients was 64.0% in all patients and 64.0% in patients who received LC. Median progression free survival and overall survival were 10 and 27 months in all patients and 10 and 17 months in patients who received LC, respectively. 16 (24.0%) patients had dose delay > 1 week and/or dose reduction.

CONCLUSION

Lapatinib based therapy is an effective treatment for women with advanced/metastatic HER2(+)BC after prior exposure to trastuzumab. It yields meaningful response rates, progression free and overall survival. Some patients require dose adjustments.

Cerebral venous thrombosis: clinical features, risk factors, and long-term outcome in a Tunisian cohort

BACKGROUND

Data from African countries regarding diagnosis, prognosis, management, and outcome of patients with cerebral venous thrombosis (CVT) are limited. The aim of the present study is to characterize clinical presentation, predisposing factors, neuroimaging findings, and outcomes of the disease in the Tunisian population.

METHODS

This is a prospective study including patients referred to the Neurology Department of the Military Hospital of Tunis between January 2009 and December 2012. The diagnosis of CVT was confirmed in all patients using magnetic resonance imaging and magnetic resonance venography. The demographic, clinical, radiological, and outcome data were recorded and analyzed. Median follow-up was 16 months (range 6 months to 4 years). Primary outcome was death or dependency as assessed by modified Rankin score more than 2 at the end of follow-up.

RESULTS

This study included 41 patients with CVT. Mean age was 41.24 years, predominantly women (68%). The mode of onset was acute in 10 patients (24%), subacute in 26 (64%), and chronic in 5 (12%). The most common presenting features were headache, observed in 83% of the patients, followed by seizures, focal motor deficits, papilledema, and mental status changes. Lateral (56%) and superior longitudinal (51%) sinuses were the most commonly involved. Multiple sinuses were involved in 46% of cases. Nineteen patients (46%) had a D-dimer level more than 500 ng/mL. Major causes of CVT were thrombophilia (56%), either genetic or acquired, obstetric and gynecological (50%), and septic (34%). Outcome was favorable in 83% of patients. At the end of follow-up, 32 patients (78%) had complete recovery (modified Rankin Scale [mRs] score 0-1), 2 (5%) had partial recovery (mRs score 2), and 4 (10%) were dependent (mRs score 3-5). One patient (2.5%) had a recurrent sinus thrombosis.

CONCLUSIONS

Our Tunisian population presented distinct risk factors profile with high frequency of thrombophilia, infections, and postpartum state. Oral contraceptive use is not a major risk factor in our population. The overall prognosis was good.

Methylenetetrahydrofolate reductase (C677T and A1298C) polymorphisms, hyperhomocysteinemia, and ischemic stroke in Tunisian patients

OBJECTIVE

The present study evaluated the role of the methylenetetrahydrofolate reductase (MTHFR) C677T and A1298C gene polymorphisms and correlated these results with plasma homocysteine (Hcy) levels in Tunisian ischemic stroke (IS) patients.

METHODS

Overall, 84 patients with IS were included and compared with 100 healthy controls. The most common stroke risk factors were investigated. Fasting plasma Hcy levels were measured. Genotyping of the MTHFR C677T and A1298 polymorphisms was studied by polymerase chain reaction.

RESULTS

Aside from tobacco and alcohol use, the other studied factors were significant risk factors for IS. Mean plasma Hcy levels were significantly higher in IS patients than in controls (16.1 ± 8.28 μmol/L versus 8.76 ± 3.48 μmol/L, P < 10(-3)). Significant associations were found with both the MTHFR 677(CT + TT) and 1298 (AC + CC) genotypes in comparison with controls (P < 10(-3)). A significant synergistic interaction was also found with the double heterozygote MTHFR 677CT/1298AC (P < 10(-3)). Homocysteine levels were significantly higher in IS patients with the MTHFR C677T variant (CT and TT genotypes) (P < 10(-3)); however, the difference was not significant with the MTHFR A1298C variant (AC and CC genotypes) (P = .31).

CONCLUSION

The MTHFR C677T and A1298 polymorphisms (individually or in concert) and hyperhomocysteinemia represent important risk factors for IS. Elevated Hcy levels were found to be associated with the MTHFR C677T variant; however, no significant association was found with the MTHFR A1298C variant.

Apolipoprotein E genotypes associated with Alzheimer disease and concomitant stroke

BACKGROUND

The ɛ4 allele of the apolipoprotein E (APOE) gene is a well-characterized genetic risk factor for Alzheimer disease (AD). The association between stroke and a higher risk for AD has also been reported. Our study sought to determine the relationship between the APOE gene and AD and the comorbid risk of stroke.

METHODS

The subjects of this study consisted of 48 patients with AD and 48 members of a control group. All subjects were genotyped for APOE.

RESULTS

The results clearly show a significant increased risk of AD in carriers of the APOE ε3/ε4 genotype (P = .003, odds ratio [OR] = 4.1) or ε4 allele (P = .001, OR = 4.2). The risk for stroke in AD patients was also increased for carriers of the APOE ε3/ε4 genotype (P = .02, OR = 9.0) and for carriers of the APOE ε4 allele (P = .004, OR = 5.5).

CONCLUSIONS

The present study is the first to establish a relationship between APOE ε4 and concomitant AD and stroke in the Tunisian population.

Association of methylenetetrahydrofolate reductase polymorphisms with susceptibility to Alzheimer's disease

BACKGROUND

Genetic risk factors play an important role in the pathogenesis of Alzheimer's disease (AD). In this case-control study, we examined the C677T and A1298C polymorphisms in the methylenetetrahydrofolate reductase (MTHFR) gene and their correlation with this pathology.

OBJECTIVE

To verify the association between MTHFR C677T and A1298C polymorphisms and Alzheimer's disease.

METHOD

This work was conducted as a case-control study. Cases consisted of thirty-eight patients and 100 individuals without dementia constituted the control group. Genotyping of MTHFR polymorphisms was performed on patients and controls.

RESULT

Genetic analyses did not indicate a significant association between the MTHFR C677T mutation and AD (C/T: 63.15% versus 39%, p=0.087). However, the genotype prevalence of the missense variant MTHFR A1298C was significantly different between patients and controls (A/C: 55% versus 7%, p<10(-3)). Our data suggest an association between the MTHFR A1298C mutation and AD; however, the MTHFR C677T mutation did not contribute to susceptibility for AD.

CONCLUSION

The MTHFR A1298C polymorphism is a possible risk factor for Alzheimer's disease.

High temperature fast response pressure probe for use in liquid metal droplet dispensers

A miniature fast response high temperature pressure probe, with demonstrated use in liquid metals up to 255 °C (528 K), has been developed. Innovative packaging technologies have been applied to integrate a conventional piezoresistive silicon pressure sensor into the probe, without the need of an auxiliary water-cooling system. In situ static calibrations are used to verify the linearity of the pressure signal and the stability of the pressure sensitivity (0.5% standard deviation over 70 min at 255 °C). Dynamic calibration, completed in an air shock tube facility, yields the probe's natural frequency. This frequency, when corrected for probe operation in liquid tin, is found to be 100 kHz. The reliability and accuracy of the probe is assessed by mounting it in a tin droplet dispenser for use in an extreme ultraviolet light source. Droplet dispensers typically include an excitation mechanism, which can be based on the generation of acoustic pressure waves to impose a desired droplet frequency. The probe accuracy is verified by the comparison of pressure measurements with laser Doppler vibrometry measurements of the pressure generating structure. A reference pressure measurement, conducted at representative conditions, shows a complex frequency response, with peaks distributed over three orders of magnitude and maximum amplitude of 440 mbar. Time variance of the excitation mechanism due to thermal transients is studied by monitoring the pressure response during operation. Finally, the linearity of the excitation system, with respect to the excitation amplitude, is verified by response measurements. In conclusion, the developed probe is capable of characterizing the excitation mechanism of a liquid metal droplet dispenser. Additionally, real-time monitoring of the performance of the excitation system during long-term operation is possible.

Gastric marginal zone B cell lymphoma of the duodenum

Small bowel lymphomas of the extranodal type occur in the young and are characteristically associated with malabsorption syndrome. We present the case of an elderly in whom there was no malabsorption and the duodenal tumor was a gastric type marginal zone B cell lymphoma also known as gastric mucosa-associated lymphoid tissue (MALT) lymphoma. A 73-year-old woman presented to the emergency room with 2 weeks of general weakness, recurrent vomiting containing food particles and abdominal distension. She had been diagnosed with diabetic gastroparesis 4 years prior. CT of the abdomen and pelvis was suggestive of gastric outlet obstruction but no evidence of pancreatic or duodenal mass. Endoscopy and biopsy of the tumor obstructing the distal first part of the duodenum confirmed a gastric marginal MALT lymphoma. The patient's symptoms improved with radiotherapy. Gastric MALT lymphoma, an extranodal lymphoma primarily described in the stomach, can also present in the small bowel and is not associated with malabsorption.

Sperm chromatin structure, semen quality and lead in blood and seminal fluid of infertile men

BACKGROUND

Exposures to lead above the threshold value of 50-60 μg/dL have been linked to diminished semen quality parameters. Worldwide, the lead exposure has been diminished during the last years. Therefore, it has become of a great concern to examine the effects of lead exposures on semen quality at low levels of exposure.

OBJECTIVE

To evaluate the effect of low level (<20 μg/dL) blood lead on semen quality and sperm chromatin structure.

METHODS

A cross-sectional study was conducted on 29 men with primary infertility attending the outpatient clinic of infertility in Mansoura University Hospital, Egypt, from March to May 2010. Semen quality parameters and sperm flow-cytometry analysis were compared between two groups of infertile men with blood lead level (BLL) above, and below 20 μg/dL, respectively.

RESULTS

The mean BLL in the studied subjects was 20.08 μg/dL. 45% of the studied men had BLL ≥ 20 μg/dL. Non-significant reduction in sperm count, impaired sperm motility and altered sperm morphology were observed in those with BLL ≥ 20 μg/dL compared to those with BLL <20 μg/dL. Concerning semen flow-cytometry analysis, percentage of haploid sperms was significantly lower among men with BLL ≥ 20 μg/dL (78%) compared to that among those with BLL <20 μg/dL (87%). A positive significant correlation was observed between BLL and percentage of diploid sperms. The chromatin condensation was however, negatively correlated with BLL (p<0.05).

CONCLUSION

Semen quality of men with primary infertility does not have any correlation with BLL at the cutoff value of 20 μg/dL. However, even at this low level, a significant decrease in haploid sperm counts and chromatin condensation was observed.

Axial rotation in the lumbar spine following axial force wrench

The report presents measurements of axial rotation of lumbar motion segments (L1/L2, L3/L4, L4/L5), particularly with small angles of rotation (in the range of +/-1 degrees) following axial force wrenches. The investigation focussed on determining the influence of geometrically varying configurations in axial wrench (consisting of axial torque and axial force) applied on the kinematics (as defined by the migrating instantaneous helical axis, IHA) of lumbar motion segments under constant resulting axial force, and relating IHA-migration to anatomical structures. In all segments, IHA migrated over several centimetres (up to 6 cm). The main portion of IHA-migration was linked to the angle of rotation interval of +/-1 degrees. 3. The shape of the IHA-migration was greatly dependent upon the position of the force line F(z). The-force-wrench-dependent wide IHA-migration found for the rotational angle interval of +/-1 degrees suggests that joint guidance predominates in segment kinematics. The segment kinematics can be adjusted by means of the geometrical configuration of the force wrenches. The design of non-fusion spine implants and FE calculations have to take into consideration joint guidance and muscular force distributions with small intervals of axial rotation.

How do spinal segments move?

PURPOSE

To study and clarify the kinematics of spinal segments following cyclic torques causing axial rotation (T(z) (t)), lateral-flexion (T(x) (t)), flexion/extension (T(y) (t)).

METHODS

A 6D--Measurement of location, alignment, and migration of the instantaneous helical axis (IHA) as a function of rotational angle in cervical, thoracic, and lumbar segments subjected to axially directed preloads.

RESULTS

IHA retained an almost constant alignment, but migrated along distinct centrodes. THORACIC SEGMENTS: IHA was almost parallel to T(z) (t), T(x) (t), or T(y) (t), stationary for T(x) (t) or T(y) (t), and migrating for T(z) (t) along dorsally opened bows. IHA locations hardly depended on the position or size of axial preload. LUMBAR SEGMENTS: IHA was also almost parallel to T(z) (t), T(x) (t), or T(y) (t). In axial rotation IHA-migration along wide, ventrally or dorsally bent bows depending on segmental flexional/extensional status. Distances covered: 20-60mm. In lateral-flexion: IHA-migration to the left/right joint and vice versa. In flexion/extension IHA-migration from the facets to the centre of the disc. CERVICAL SEGMENTS: In flexion/flexion IHA was almost stationary for and parallel to T(y) (t). In axial rotation or lateral-flexion IHA intersected T(z) (t)/T(x) (t) under approximately -30 degrees /+30 degrees.

CONCLUSIONS

Generally joints alternate in guidance. Lumbar segments: in axial rotation and lateral-flexion parametrical control of IHA-position and IHA-migration by axial preload position. Cervical segments: kinematical coupling between axial rotation and lateral-flexion. The IHA-migration guided by the joints should be taken into account in the design of non-fusion implants. FE-calculations of spinal mechanics and kinematics should be based on detailed data of curvature morphology of the articulating surfaces of the joint facets.

Influence of the implantation profiles of Si(+) on the dielectric function and optical transitions in silicon nanocrystals

We report optical characterization of silicon nanocrystals embedded in silica thin films by spectroscopic ellipsometry (SE). Silicon nanocrystals (nc-Si) are produced by single energy ion implantation and multienergy Si(+) ion implantation into 250 nm of thermal oxide (SiO(2)) layers on silicon substrate. After thermal annealing, the obtained nc-Si have a Gaussian and uniform profiles for single and multienergy implantation, respectively. SE measurements are performed at room temperature at spectral range from 0.6 to 6.5 eV using the photoelastic modulated spectroscopic ellipsometer. Physical models based on the Maxwell-Garnet approximation combined with Forouhi-Bloomer dispersion formulas and wavelength by wavelength inversion are developed to extract the optical parameters of the layers. The complex dielectric function epsilon(E)=epsilon(r)(E)-iepsilon(i)(E) of nc-Si is determined and analyzed. The obtained epsilon(E) spectra of both uniform and Gaussian profiles are given and compared with those of bulk Si. The nc-Si exhibit a significant reduction of the dielectric function in comparison with bulk Si. We have determined the optical transitions E(1) and E(2) corresponding to Van Hove singularities in the joint density of states. A reduction of the amplitude of E(1) peak with a very weak shift of its energy position is observed. The transition E(2) is characterized by a rather broad peak; the amplitude of this peak is more important than that of E(1). The extended Forouhi-Bloomer model to semiconductor is also used to determine the dielectric functions of nc-Si and optical transitions. In epsilon(i)(E) spectra of nc-Si we have observed that not only the optical transition E(1) peak reduced but it tends to disappear and to form with E(2) only a single broad peak centered at around 4.3 eV. The influence of the distribution profile on the sample's structural and optical characteristics is also investigated. Defects caused by implantation are identified by analyzing the dielectric function behavior. For more reliability, photoluminescence analysis are used to obtain direct optical responses of nc-Si.