SALVAGE OF A FAILED SAUVÉ-KAPANDJI PROCEDURE USING A TOTAL DISTAL RADIO-ULNAR JOINT REPLACEMENT

This is the first report in the literature of a patient treated with a DRUJ replacement after Sauvé-Kapandji procedure failed due to pain and instability. The DRUJ replacement is an unconstrained, biomechanically more advantageous implant which can confer stability in cases where soft tissues are inadequate. We describe the treatment and outcome of persistent ulnar instability with a distal radio-ulnar joint replacement following failed salvage procedures for a malunion of a distal radius fracture.

EXTENSOR CARPI RADIALIS LONGUS AVULSION: A LITERATURE REVIEW AND CASE REPORT

Extensor Carpi Radialis Longus (ECRL) avulsion is a rare injury which follows resisted wrist hyperflexion. Treatment of this condition with open reduction and internal fixation is not previously described in the literature, and treatment with plaster immobilisation or k-wire fixation requires a prolonged period of immobilisation. We believe that open reduction and internal fixation of these fractures with early mobilisation will result in the best possible wrist function. We describe a sign to raise the index of suspicion for this injury: a palpable bone lump on the dorsum of the hand in the presence of wrist extensor pain or weakness after wrist hyperflexion injury is a sign of wrist extensor avulsion.

Reversible delayed neuropsychiatric syndrome following acute carbon monoxide exposure

A 40-year-old male presented with acutely oncoming neuropsychiatric symptoms in the form of extrapyramidal disturbances, personality change, behavior changes and urinary incontinence. One month prior to this symptomatology, he had been found unconscious in his closed room where a coal fire was burning overnight. He recovered completely in two days with supportive therapy. Magnetic resonance imaging during this presentation showed bilateral white matter changes suggestive of demyelination. Tc99m-ECD SPECT study revealed hypoperfusion in bilateral frontal region. He was managed conservatively and eventually made a nearly complete recovery. Repeat SPECT study revealed marked improvement in tracer uptake correlating with his improvement. Delayed neuropsychiatric syndrome after acute carbonmonoxide poisoning is a rare and distinct entity. This case report discusses the various aspects of this disease entity.

Regional leptomeningeal score on CT angiography predicts clinical and imaging outcomes in patients with acute anterior circulation occlusions

BACKGROUND AND PURPOSE

The regional leptomeningeal score is a strong and reliable imaging predictor of good clinical outcomes in acute anterior circulation ischemic strokes and can therefore be used for imaging based patient selection. Efforts to determine biological determinants of collateral status are needed if techniques to alter collateral behavior and extend time windows are to succeed.

MATERIALS AND METHODS

This was a retrospective Institutional Review Board-approved study of patients with acute ischemic stroke and M1 middle cerebral artery+/- intracranial internal carotid artery occlusion at our center from 2003 to 2009. The rLMC score is based on scoring pial and lenticulostriate arteries (0, no; 1, less; 2, equal or more prominent compared with matching region in opposite hemisphere) in 6 ASPECTS regions (M1-6) plus anterior cerebral artery region and basal ganglia. Pial arteries in the Sylvian sulcus are scored 0, 2, or 4. Good clinical outcome was defined as mRS ≤ 2 at 90 days.

RESULTS

The analysis included 138 patients: 37.6% had a good (17-20), 40.5% a medium (11-16), and 21.7% a poor (0-10) rLMC score. Interrater reliability was high, with an intraclass correlation coefficient of 0.87 (95% CI, 0.77%-0.95%). On univariate analysis, no single vascular risk factor was associated with the presence of poor rLMCs (P ≥ .20 for all comparisons). In multivariable analysis, the rLMC score (good versus poor: OR, 16.7; 95% CI, 2.9%-97.4%; medium versus poor: OR, 9.2, 95% CI, 1.7%-50.6%), age (< 80 years), baseline ASPECTS (≥ 8), and clot burden score (≥ 8) were independent predictors of good clinical outcome.

CONCLUSIONS

The rLMC score is a strong imaging parameter on CT angiography for predicting clinical outcomes in patients with acute ischemic strokes.

Normobaric oxygen therapy in acute ischemic stroke: A pilot study in Indian patients

Purpose:

Clinical and radiological assessment of effects of normobaric high-flow oxygen therapy in patients with acute ischemic stroke (AIS).

Materials and Methods:

Patients with anterior circulation ischemic strokes presenting within 12 h of onset, ineligible for intravenous thrombolysis, an National Institute of Health Stroke Scale (NIHSS) score of >4, a mean transit time (MTT) lesion larger than diffusion-weighted image (DWI) (perfusiondiffusion mismatch), and an evidence of cortical hypoperfusion on magnetic resonance imaging (MRI) were included into the trial. Active chronic obstructive pulmonary disease (COPD), requirement of >3/L min oxygen delivery to maintain SaO2 > 95%, rapidly improving neurological deficits, pregnancy, contraindications to MRI, or unstable medical conditions were excluded. The experimental group received humidified oxygen at flow rates of 10 L/min for 12 h. The NIHSS, modified Rankin Score (mRS), Barthel Index (BI) were measured at 0, 1, 7 day of admission and at 3 months follow-up. MRI with DWI/PWI was performed at admission, 24 h later and at 3 months follow-up.

Results:

Of 40 patients (mean age = 55.8 years ± 13.2) (range, 26–82), 20 patients were randomized to normobaric oxygen (NBO). The mean NIHSS in NBO and control groups were 14.25 and 12.7 at admission which decreased to 11.6 and 9.5 on the seventh day, and 9.4 and 9.05 at 3 months, respectively. The mean mRS (3.7/3.7) and BI (58.2/53.9) in NBO and control groups improved to 2/2.2 and 73.05/73.8 at the end of 3 months, respectively.

Conclusions:

NBO did not improve the clinical scores of stroke outcome in Indian patients with AIS.

Identification of pneumothorax in very preterm infants

OBJECTIVE

To compare respiratory and other morbidities between very preterm infants with and without a pneumothorax and to determine whether infants at higher risk of pneumothorax can be identified early in their course.

STUDY DESIGN

Preterm infants at 23 to 28 weeks' gestation with pneumothorax were compared with matched control subjects. Demographic and clinical data from birth through the first 72 hours were compared.

RESULTS

Sixty-two (9.2%) of 675 infants had pneumothorax. There were no significant differences in the baseline maternal and infant characteristics. Mortality was significantly higher in the pneumothorax group (43%) versus control subjects (13%). There was no significant difference in continuous positive airway pressure or surfactant treatment or rates of intraventricular hemorrhage or bronchopulmonary dysplasia. Infants treated with early continuous positive airway pressure in the delivery room typically had pneumothorax on day 2 of life. Those who had pneumothorax had higher inspired fraction of oxygen before its diagnosis and over the first 12 hours of life than did control subjects.

CONCLUSIONS

Pneumothorax is associated with increased mortality and with severity of lung disease in the first day of life. It may be possible to identify babies at highest risk of pneumothorax on the basis of inspired fraction of oxygen in the first 12 hours of life.

Chlamydia pneumoniae seropositivity in adults with acute ischemic stroke: A case-control study

BACKGROUND

Causative role of Chlamydia pneumoniae infection in patients with acute ischemic stroke (AIS) remains unresolved till date.

AIM

To investigate the role of C. pneumoniae antibodies in AIS.

MATERIALS AND METHODS

Patients with AIS and sex- and environment-matched controls were enrolled. Antibodies to C. pneumoniae (IgA, IgG and IgM) were measured using enzyme-linked immunosorbent assay (ELISA).

RESULTS

A total of 51 patients and 48 controls were enrolled. The IgA seropositivity was significantly associated with AIS (unadjusted odds ratio 3.1; 95% CI 1.38, 6.96; P = 0.005), whereas IgG (unadjusted OR 0.44; 95% CI 0.18, 1.09; P = 0.07) and IgM (unadjusted OR 1.1; 95% CI 0.36, 3.3; P = 0.88) were not. There was no difference in IgA or IgG positivity in different stroke subtypes. On multivariate analysis after adjusting for sex, hypertension, diabetes mellitus, smoking and alcohol, the IgA seropositivity yielded an adjusted OR for stroke (4.72; 95% CI 1.61, 13.83; P = 0.005), while IgG seropositivity did not (OR 0.25; 95% CI 0.08, 0.83; P = 0.23).

CONCLUSIONS

An increased risk of AIS was demonstrated in patients seropositive for C. pneumoniae for IgA antibodies.

Autonomic and metabolic effects of OSA in childhood obesity

This study investigates the effects of exposure to intermittent hypoxia on cardiovascular autonomic control and metabolic function in obese children with obstructive sleep apnea (OSA). Each subject underwent: (1) a polysomnography; (2) morning fasting blood samples and a subsequent FSIVGTT; (3) noninvasive measurement of respiration, arterial blood pressure, and heart rate during supine and standing postures. Assessment of adiposity was performed using a DEXA scan. From these measurements, we deduced the pertinent sleep parameters, Bergman minimal model parameters and the parameters characterizing a minimal model of cardiovascular variability. Results suggest that intermittent hypoxia in OSA contributes independently to insulin resistance and autonomic dysfunction in overweight children.

Detection of the membrane attack complex as a diagnostic tool in dermatomyositis

BACKGROUND

Currently there is no reliable diagnostic marker to distinguish between the subgroups of idiopathic inflammatory myopathies (IIMs), i.e. dermatomyositis (DM), polymyositis (PM) and inclusion body myositis (IBM). Membrane attack complex (MAC) has been shown to be involved in the pathogenesis of dermatomyositis but its role as a diagnostic marker has not been evaluated.

AIM

To assess the diagnostic utility of MAC deposition in distinguishing dermatomyositis from other neuromuscular disorders.

MATERIAL AND METHODS

Immunohistochemical detection of MAC deposition on endomysial microvessels was carried out on 127 muscle biopsies comprising of 21 cases of dermatomyositis, 42 other IIMs and 64 non-IIM neuromuscular diseases.

RESULTS

MAC deposition showed a high sensitivity (80.9%) and specificity (85%) to differentiate DM from other IIMs. Its specificity was higher (98.4%) in discriminating DM from non-IIM muscular diseases and IIM from non-IIMs.

CONCLUSION

MAC deposition can serve as a reliable marker to distinguish DM from other IIMs (i.e. PM and IBM) as well as from non-IIM diseases. It can also serve as a useful adjunct in diagnosis of IIMs when there is diagnostic dilemma with their morphologic similarities. These results provide further credence to the long-standing view that MAC-mediated capillary destruction is involved in the immunopathogenesis of DM.

Inhibition of Grb2 expression demonstrates an important role in BCR-ABL-mediated MAPK activation and transformation of primary human hematopoietic cells

Chronic myeloid leukemia (CML) results from the expression of the BCR/ABL oncogene in a primitive hematopoietic cell. However, BCR/ABL-activated signaling mechanisms are dependent on the cellular context in which it is expressed, and mechanisms underlying primitive human hematopoietic cell transformation by BCR-ABL are not well understood. Our previous studies have shown that BCR/ABL-Y177 has an essential role in Ras activation and human hematopoietic progenitor transformation in CML. The adapter protein growth factor receptor-binding protein-2 (Grb2) can bind phosphorylated BCR/ABL-Y177, induce Grb2-SoS complex formation and activate Ras signaling. We investigated the role of Grb2 in CML progenitor transformation by cotransducing human CD34+ cells with lentivirus vectors expressing short hairpin RNA to Grb2 and retrovirus vectors expressing BCR/ABL. We show that Grb2 knockdown significantly inhibits proliferation and survival of BCR-ABL-expressing CD34+ cells, but not control CD34+ cells. Grb2 knockdown reduced mitogen-activated protein kinase (MAPK) activity in BCR-ABL-expressing hematopoietic cells. We conclude that inhibition of Grb2 expression demonstrates an important role in BCR-ABL-mediated MAPK activation and transformation of primary human hematopoietic cells.These results support further investigation of downstream effectors of Grb2-mediated signals and targeting of Grb2 interactions in the treatment of CML.

The volar anatomy of the distal radius--an MRI study of the FCR approach

INTRODUCTION

Fractures of the distal radius are one the commonest orthopaedic injuries. Recent advances in implant technology have seen a dramatic rise in the number of fractures treated with volar locked plates, as they permit accurate peri-articular reconstruction. The surgical approach along the bed of flexor carpii radialis (FCR) tendon encounters a number of key soft tissue and neurovascular structures during the dissection to the fracture plane. The aim of this study was to describe the exact position of such structures involved (and hence at risk) during the FCR approach.

METHODS

100 adult MRI scans were reviewed. The relationships between the brachioradialis tendon (BR), flexor carpi radialis (FCR) tendon, flexor pollicis longus (FPL) tendon, median nerve (MN) and radial artery (RA) were measured.

RESULTS

The male to female ratio was 35:65. Average age was 39. FCR tendon was 7.4 mm (SD 1.46) from the RA and 7.01 mm (SD 2.37) from the MN. The distance between BR and RA was significantly different between male and female (5.06 mm vs. 4.1 mm, p=0.034).

CONCLUSION

This study highlights the precise nature of the surgical anatomy involved in dissection to the fracture site. Vigilance is needed during the initial steps of the FCR-bed approach to avoid damage to the radial artery and median nerve which lie in close proximity. If the approach is extended to include a brachioradialis tenotomy, we suggest this should be made under direct vision, given its relationship with the radial artery.

Oxygen delivery using neonatal self-inflating resuscitation bags without a reservoir

BACKGROUND

Guidelines recommend avoidance of excessive oxygen administration during neonatal resuscitation. Blenders are used in some but not all hospitals. It has been suggested that self-inflating bags without a reservoir deliver around 40% oxygen and could be used to provide an inexpensive and effective technique of avoiding oxygen toxicity.

OBJECTIVE

To explore how much oxygen is delivered when using two different brands of neonatal self-inflating resuscitation bags without a reservoir.

METHODS

In a benchtop setting, the smallest non-disposable self-inflating bags from the Laerdal and Ambu ranges were tested. Oxygen concentration delivered by these devices under a variety of conditions was measured. 108 combinations of oxygen flow rates (10; 5 to 1 litre/min), ventilation rates (30, 60, 100 inflations/min) and peak inspiratory pressure ranges (20 to 25 cm H(2)O, 35 to 40 cm H(2)O or pop-off valve range, 55 to 60 cm H(2)O) were tested.

RESULTS

Delivered oxygen concentration varied depending on three parameters: gas flow rate, ventilatory rate and pressure. At a pressure of 20 to 25 cm H(2)O, mean oxygen concentration delivered by both bags exceeded 70% at any gas flow rate except for 1 litre/min (where delivered oxygen concentration was 60% to 70%). When the pop-off valve was opened at 35 to 40 cm H(2)0, oxygen concentrations fell to 30% to 45% at gas flow rates < or =2 litres/min. The Ambu bag delivered a lower oxygen concentration than the Laerdal bag but this difference was not clinically important.

CONCLUSION

When using the Laerdal and Ambu infant resuscitation self-inflating bags without a reservoir, delivered oxygen concentration is >70% for currently recommended flow and pressure settings.

Elimination of neglected tropical diseases in the South-East Asia Region of the World Health Organization

The neglected tropical diseases (NTDs), which affect the very poor, pose a major public health problem in the South-East Asia Region of the World Health Organization (WHO). Although more than a dozen NTDs affect the region, over the past five years four of them in particular - leprosy, lymphatic filariasis, visceral leishmaniasis (kala-azar) and yaws - have been targeted for elimination. These four were selected for a number of reasons. First, they affect the WHO South-East Asia Region disproportionately. For example, every year around 67% of all new leprosy cases and 60% of all new cases of visceral leishmaniasis worldwide occur in countries of the region, where as many as 850 million inhabitants are at risk of contracting lymphatic filariasis. In addition, several epidemiological, technological and historical factors that are unique to the region make each of these four diseases amenable to elimination. Safe and effective tools and interventions to achieve these targets are available and concerted efforts to scale them up, singly or in an integrated manner, are likely to lead to success. The World Health Assembly and the WHO Regional Committee, through a series of resolutions, have already expressed regional and global commitments for the elimination of these diseases as public health problems. Such action is expected to have a quick and dramatic impact on poverty reduction and to contribute to the achievement of the Millennium Development Goals. This paper reviews the policy rationale for disease control in the WHO South-East Asia Region, the progress made so far, the lessons learnt along the way, and the remaining challenges and opportunities.

Electrophysiological characteristics of seizure clusters

The phenomenon of temporal clustering of seizures is well known, but its effect on seizure localization has not been rigorously analyzed. The aim of our study was to assess electrophysiological localization during Video EEG (VEEG) monitoring in patients with intractable epilepsy demonstrating a cluster of seizures. The study was conducted on 203 intractable epilepsy patients, aged 2 to 60 years (19.96 +/- 10.87). Patients with unilateral temporal lobe epilepsy having clusters were compared with patients not having clusters, and the effect of clustering on concordance was addressed. Fully consistent localization was observed in 116 patients, partially consistent localization in 18 patients, and inconsistent localization in 19 patients. ANOVA did not reveal any significant difference in these groups (p=0.65). A total of 770 seizures recorded from 149 patients was analyzed for clustering effect. Clustering was present in 603/770 seizures pairs (78.31%). In the cluster group, 483 (80.09%) seizure pairs were concordant for seizure onset, while 98 (16.25%) were discordant and 22 (3.65%) were indeterminate. In the noncluster group, 134 (80.24%) seizure pairs were concordant for seizure onset, while 23 (13.77%) were discordant and 10 (5.98%) were indeterminate. The study found that cluster seizures occurring within an interseizure interval (ISI) less than 8 hours are independent and have the same localizing value as those seizures with longer ISIs.

Undisplaced scaphoid waist fractures: is 4 weeks' immobilisation in a below-elbow cast sufficient if a week 4 CT scan suggests fracture union?

This prospective study investigated a cohort of 59 scaphoid waist fractures which were treated nonoperatively in a below-elbow plaster cast for 4 weeks and then underwent a Week 4 CT scan to assess displacement and progress to union. Forty-three were classed as undisplaced and 37 of these 43 were also classed as 'united'. All the 37 undisplaced and 'united' fractures united with up to 8 weeks' cast immobilisation, including 26 which were taken out of plaster at 4 weeks and mobilised. We conclude that scaphoid waist fractures which appear to be undisplaced and united on a week 4 CT scan will unite, and may not need to be immobilised in a plaster cast for more than 4 weeks. Such a treatment policy may reduce the period of disability and time off work associated with nonoperative treatment.

Intra-arterial thrombolysis in basilar artery occlusions combination of intra-arterial thrombolytics and Gp IIb/IIIa inhibitors in basilar artery thrombosis

Basilar artery thrombosis has high morbidity and mortality. Though intra-arterial thrombolytics have proven efficacy in the treatment of acute basilar artery occlusion, the elevation of procoagulant factors in the blood after intra-arterial thrombolysis could result in subsequent thrombus formation and clinical deterioration. Glycoprotein IIb/IIIa inhibitors have been shown to reduce this elevation in procoagulants. We present a pilot study of three cases of acute basilar artery occlusion treated with a combination of intra-arterial thrombolytics and Gp IIb/IIIa inhibitor with remarkable clinical recovery seen in all the patients.

Herpes simplex keratitis -- an unusual clinical presentation

A case of posterior corneal abscess with extension into the anterior chamber, in the presence of an intact corneal epithelium and clear anterior corneal stroma, occurring in a young patient is described. The patient responded to treatment with systemic and topical acyclovir. The diagnosis of presumed herpes simplex keratitis was made. We report this unusual presentation of ocular herpes manifesting as a posterior corneal and anterior chamber abscess.

Idiopathic hypertrophic cranial pachymeningitis and dural sinus occlusion: two patients with long-term follow up

Idiopathic hypertrophic cranial pachymeningitis (IHPM) is a clinicopathological entity characterized by thickening and fibrosis of the dura mater with resultant clinical symptoms. It is generally steroid responsive and has a tendency to remit and relapse. We present here two patients with IHPM with associated dural sinus occlusion and describe their clinicoradiological features and long-term course and outcome.

Sea urchin spine injuries of the hand

Sea urchin spine injuries are common. They usually cause local pain and swelling that subsides. Chronic granulation is rare. We report two cases of sea urchin granulomata involving finger metacarpophalangeal joints. Both resolved following surgery.

Can visceral leishmaniasis be eliminated from Asia?

Data on the burden of visceral leishmaniasis (VL) in Indian sub-continent are vital for elimination programme planners for estimating resource requirements, effective implementation and monitoring of elimination programme. In Indian sub-continent, about 200 million population is at risk of VL. Nearly 25,000-40,000 cases and 200-300 deaths are reported every year, but these are grossly underestimates. Recent well-designed multicentric studies identified VL burden of 21 cases/10,000 among sampled population in Indian sub-continent (Bangladesh, India and Nepal). This estimates 4,20,000 cases per 200 million risk population clearly indicating that the disease is highly under-reported. Chemical and environmental vector control studies show that the indoor residual spraying (IRS) and long-lasting insecticidal nets (LLINs) are effective and significantly reduce sandfly densities. The findings documented from different sources revealed that some gaps and weakness in existing policies for introducing VL vector control interventions. Our studies emphasize the need of integrated vector management with both IRS and LLIN vector control interventions. Active case detection with rK39 strip test as diagnostic tool is the key element for detection of VL cases. The use of oral drug miltefosine for the treatment after assessing feasibility at community level is important. Kala-azar elimination in Indian sub-continent is possible if elimination programmes ensure access to health care and prevention of kala-azar for people at risk with particular attention to the poorest and marginalized groups. The evidence-based policy should be designed that motivates to implement the programmes, which will be cost-effective. Maintaining the acceptable level of incidence requires public awareness, vector control, appropriate diagnosis and treatment. The five pillars of VL elimination strategies identified are: early diagnosis and complete treatment; integrated vector management and vector surveillance; effective disease surveillance through passive and active case detection; social mobilization and building partnerships; and clinical and operational research which need to be re-enforced to effective implementation.

Fatal subacute necrotising brainstem encephalitis in a young man due to a rare parasitic (Balamuthia) infection

We describe a case of brainstem inflammation in a young man which at first defied diagnosis. However, after his death, and notwithstanding our inability to find a cause at autopsy, we did not give up. After sending paraffin blocks to the Centers for Disease Control in Atlanta, Georgia, USA, they suggested the diagnosis of Balamuthia (amoebic) infection.

Role of temporalis muscle over activity in chronic tension type headache: effect of yoga based management

The role of central versus peripheral mechanisms has always been questioned while explaining the etiopathogenesis of chronic tension type headache (CTTH). The following study was done to study the role of muscle spasm in CTTH. 15 patients of CTTH and 7 age matched controls were included in the study and their m. temporalis EMG was recorded for one minute each during rest, mental activity and maximal voluntary contraction and subjective pain scoring was done by visual analogue scale. The results revealed significant overactivity of m.temporalis in CTTH patients at rest when compared with control subjects (P = 0.01 and 0.03 left and right side respectively). After respective interventions namely non steroidal anti inflammatory drugs, botulinum toxin injections and yogic life style course, the EMG records revealed decrease in the mean EMG amplitude of m. temporalis during rest and mental activity more significantly after yoga based interventions (P = 0.03) and subjective pain scores decreased from 7.00 +/- 2.10 to 2.00 +/- 1.26 (P = 0.02) supporting the beneficial effect of such non invasive techniques.

Reduced-intensity conditioning for allogeneic hematopoietic stem cell transplantation with fludarabine and melphalan is associated with durable disease control in myelodysplastic syndrome

We retrospectively evaluated the outcome of reduced-intensity conditioning (RIC) followed by allogeneic hematopoietic stem cell transplantation (HCT) in 43 patients with myelodysplastic syndrome (MDS) or AML arising from MDS. All patients received fludarabine plus melphalan followed by an allogeneic HCT from an HLA-identical sibling (SIB: n=19) or unrelated donor (MUD: n=24). Median age was 58 years (range: 30-71). Diagnoses at transplantation were RA (n=8), RARS (n=1), RAEB (n=13), RAEB-T (n=6), or AML arising from MDS (n=15). Of 28 patients with MDS, two patients had low, 10 had intermediate-1, nine had intermediate-2 and seven had high-risk MDS by IPSS criteria. All patients initially engrafted with the median neutrophil recovery of 15 days (range: 9-27). The 2-year overall survival, disease-free survival, relapse and transplant-related mortality were 53.5% (CI 45.2-61.1), 51.2% (CI 43.3-58.5), 16.3% (CI 7.9-30.7) and 35.2% (26.4-45.7), respectively. Grade II-IV acute graft-versus-host disease occurred in 27 (63%) patients. There was no significant survival difference between SIB and MUD-HCT, but the relapse rate was higher among SIB donor recipients when compared to MUD (38.5 versus 7%, P=0.02). RIC with fludarabine plus melphalan was associated with durable disease control and acceptable toxicity in this high-risk cohort.

Hyperacute thrombolysis with IV rtPA of acute ischemic stroke: Efficacy and safety profile of 54 patients at a tertiary referral center in a developing country

BACKGROUND

Given the constraints of resources, thrombolysis for acute ischemic stroke (AIS) is under evaluation in developing countries. Prothrombin time (PT), platelet count and activated partial thromboplastin time (aPTT) may not be feasible within the time window.

AIM

To evaluate the safety and efficacy of thrombolysis in selected patients without the coagulation profile.

DESIGN

Open, nonrandomized, observational study.

MATERIALS AND METHODS

Fifty-four stroke patients were classified using TOAST criteria (large artery atherosclerotic = 13; cardioembolic = 12; small vessel occlusion = 22; other determined etiology =three; undetermined etiology = four). The mean time to reach emergency was 2.4h (1.15-3.4), the mean door to CT, 24 min (10-47) and the door to recombinant tissue plasminogen activator (r-tPA) injection, 26.8 min (25-67). The NIHSS scores ranged from 11 to 22 (mean = 15.5 +/- 2.7). Patients with history of liver or renal disease or those on anticoagulants were excluded. The PT, aPTT and platelet count were not done. Recombinant tissue plasminogen activator was administered at a dosage of 0.9 mg/Kg.

RESULTS

Thirty-five patients (65%) significantly improved on NIHSS at 48 h (> or =4 points) (mean change = 10; range= 4-17). At one month, 43 (79%) improved on Barthel Index (mean change = 45%). One each developed small frontal lobe hemorrhage and recurrent stroke; one died of aspiration; and eight showed no improvement.

CONCLUSIONS

Hyperacute thrombolysis was found useful and safe in selected patients with AIS even without the coagulation studies.

Aneurysmal subarachnoid haemorrhage in a patient with thyrotoxicosis

A case of subarachnoid haemorrhage secondary to rupture of an intracranial aneurysm occurring in a patient with new-onset, frank thyrotoxicosis is described. This unusual case highlights the dilemma of whether to continue beta-blockers such as propanolol for frank thyrotoxicosis, or whether to assign higher priority to maintaining adequate cerebral perfusion pressure in established ischaemic deficit due to vasospasm. In a complicated case such as this, the Maudsley Mentation Test score and perfusion CT scanning are two useful adjuncts for the early detection and evaluation of the course of ischaemic deficit.

An unusual case of bowel perforation due to fish fin ingestion

We reported the case of an 85-year-old woman who presented with an acutely tender abdomen and underwent abdominal computed tomography (CT) scanning initially reported as showing diverticulitis. After failed conservative management, this patient was taken to theatre, and laparotomy revealed a punctate perforation of the ileum due to a 4 x 3 cm fish fin, which was removed through enterotomy. Retrospective analysis of the initial CT scans showed a foreign body consistent with that removed. This is the first case documented in the literature of perforation of bowel due to fish fin ingestion, as opposed to fish bone. It highlights firstly how common presentations may have an uncommon cause and secondly, how easily a small foreign body can be missed on CT scan. It also highlights and the importance of (i) eliciting a full history of eating habits in those presenting with abdominal pain and (ii) basing intervention on clinical findings. In this case report, we review the wider medical literature on perforation due to foreign body ingestion.

Nonproliferating CML CD34+ progenitors are resistant to apoptosis induced by a wide range of proapoptotic stimuli

Imatinib mesylate, a Bcr-Abl kinase inhibitor, has been very successful in the treatment of chronic myelogenous leukemia (CML). However, the majority of patients achieving cytogenetic remissions with imatinib treatment have molecular evidence of persistent disease, and residual BCR/ABL(+) progenitors can be detected. There is a need to develop new approaches that enhance elimination of malignant progenitors in imatinib-treated patients. Here we show that CML CD34(+) progenitors are sensitive to several apoptosis-inducing stimuli including the chemotherapeutic agents Ara-C and VP-16, radiation, arsenic trioxide, ceramide, growth factor withdrawal, and the death receptor activators TNFalpha and TRAIL. Bcr-Abl kinase inhibition by imatinib did not enhance sensitivity of CML progenitors to Ara-C, VP-16, ceramide, radiation or TRAIL-induced apoptosis but did enhance arsenic and TNFalpha-induced apoptosis. We further demonstrate that apoptosis was restricted to dividing cells, whereas nonproliferating BCR/ABL(+) CD34(+) cells were resistant to apoptosis induced by imatinib, Ara-C or arsenic, either alone or in combination. Resistance of quiescent CML progenitors to imatinib-induced apoptosis could contribute to persistence of residual malignant progenitors in imatinib-treated patients. Combination treatment with Ara-C or arsenic may not enhance targeting of nonproliferating CML progenitors. The assay described here may be useful for identifying agents targeting quiescent CML progenitors.

Elasticity and adhesion force mapping reveals real-time clustering of growth factor receptors and associated changes in local cellular rheological properties

Cell surface macromolecules such as receptors and ion channels serve as the interface link between the cytoplasm and the extracellular region. Their density, distribution, and clustering are key spatial features influencing effective and proper physical and biochemical cellular responses to many regulatory signals. In this study, the effect of plasma-membrane receptor clustering on local cell mechanics was obtained from maps of interaction forces between antibody-conjugated atomic force microscope tips and a specific receptor, a vascular endothelial growth factor (VEGF) receptor. The technique allows simultaneous measurement of the real-time motion of specific macromolecules and their effect on local rheological properties like elasticity. The clustering was stimulated by online additions of VEGF, or antibody against VEGF receptors. VEGF receptors are found to concentrate toward the cell boundaries and cluster rapidly after the online additions commence. Elasticity of regions under the clusters is found to change remarkably, with order-of-magnitude stiffness reductions and fluidity increases. The local stiffness reductions are nearly proportional to receptor density and, being concentrated near the cell edges, provide a mechanism for cell growth and angiogenesis.

A long-term follow-up report on allogeneic stem cell transplantation for patients with primary refractory acute myelogenous leukemia: impact of cytogenetic characteristics on transplantation outcome

The prognosis of patients with primary refractory acute myelogenous leukemia (AML) is poor. Our initial report suggested that some patients could achieve durable remission after allogeneic stem cell transplantation (SCT). Herein, we update our initial experience and report further analysis of this group of patients to determine whether there are pre-SCT prognostic factors predictive of posttransplantation relapse and survival. We reviewed the records of 68 patients who consecutively underwent transplantation at the City of Hope Cancer Center with allogeneic SCT for primary refractory AML between July 1978 and August 2000. Potential factors associated with overall survival and disease-free survival were examined. With a median follow-up of 3 years, the 3-year cumulative probabilities of disease-free survival (DFS), overall survival (OS), and relapse rate for all 68 patients were 31% (95% confidence interval [CI], 20%-42%), 30% (95% CI, 18%-41%), and 51% (95% CI, 38%-65%), respectively. In multivariate analysis, the only variables associated with shortened OS and DFS included the use of an unrelated donor as the stem cell source (relative risk, 2.23 [OS] and 2.05 [DFS]; P =.0005 and.0014, respectively) and unfavorable cytogenetics before SCT (relative risk: 1.68 [OS] and 1.58 [DFS]; P =.0107 and.0038, respectively). Allogeneic SCT can cure approximately one third of patients with primary refractory AML. Cytogenetic characteristics before SCT correlate with transplantation outcome and posttransplantation relapse.

Cold chain monitoring of OPV at transit levels in India: correlation of VVM and potency status

We have conducted a study to analyze monitoring of the cold chain of 674 OPV field samples collected at four different levels of vaccine distribution viz., immunization clinics, district stores, hospitals and Primary Health Centers (PHC) from states of Uttar Pradesh, Madhya Pradesh, and Delhi. The study design included: collection and scoring of vaccine vial monitor (VVM) status of the samples and testing for total oral polio virus concentration (TOPV) by standard WHO protocol. Ten samples each were exposed to 25 degrees C and 37 degrees C, and 10 samples as controls were kept at -20 degrees C. VVM were scored daily till they attained grade 4 and each sample was subsequently subjected to potency testing for individual polio serotypes 1, 2 and 3, and TOPV. Of the 674 samples tested it was observed that: samples from immunization clinics and district stores had an acceptable VVM score of grade 1 and 2; however the probable risk that a sub potent vaccine could have been administered was 2.15%. In 2.5% samples received from district stores vaccine had a VVM score of grade 3 (i.e., discard point), although vaccine when tested was found to be potent (i.e., leading to the vaccine wastage). With exposure to higher temperatures, VVM changed score to grade 2 and 3 when the vaccine was kept at 25 degrees C/37 degrees C, and the titres of individual serotypes 1, 2 and 3 and TOPV were beyond the acceptable limits. Important observations at the different levels of vaccine distribution network and correlation of VVM and potency status of OPV are discussed in the paper which will be of help to the EPI program managers at different transit levels.

Drug-eluting stents: new era and new concerns

At present there is much excitement about drug-eluting stents, which hold promise for the treatment of coronary artery disease. This ingenious therapy involves coating the outside of a standard coronary stent with a thin polymer containing medication that can prevent scarring at the site of coronary intervention. Early trials with sirolimus coated stents showed that they might prevent coronary artery restenosis, but later studies, involving more complex coronary lesions, did not show a complete absence of restenosis. Recent studies have demonstrated the long term cost effectiveness of drug-eluting stents as they have reduced the need for revascularisation procedures. At present there are few data on the safety and effectiveness of stents over follow up periods exceeding two years, and data obtained from animal models of stenting might not be completely applicable to humans. There are concerns that drug-eluting stents might delay, rather than inhibit, restenosis. Also there is concern regarding the inflammation caused by the polymer substrate. This article reviews the present data on drug-eluting stents and their benefits, shortcomings, and concerns.