Imaging abnormalities in sporadic hemiplegic migraine on conventional MRI, diffusion and perfusion MRI and MRS

Prolonged hemiparetic migraine aura can cause diagnostic confusion and be mistaken for ischaemic stroke occurring during the course of a migraine--'migrainous infarction'. We report a case of prolonged hemiparesis occurring during the course of a migraine attack. Though initially confused with migrainous infarction, we suggest with sequential magnetic resonance imaging, magnetic resonance angiography, diffusion, perfusion images and magnetic resonance spectroscopy that the hemiplegia was not of vascular origin and that the patient had sporadic hemiplegic migraine. We hypothesize that the mechanisms of sporadic hemiplegic migraine probably lie at a cellular level, similiar to familial hemiplegic migraine.

Dietary intake of choline and plasma choline concentrations in pregnant women in Jamaica

Choline is an essential nutrient for humans and its availability during pregnancy is important for optimal fetal development. The Food and Nutrition Board of the Institute of Medicine in the United States of America has set the adequate choline intake during pregnancy at 450 mg/day. There is limited data available on normal plasma choline concentrations in pregnancy. Moreover, there are neither documented studies of choline intake among pregnant women in the Jamaican population nor of free plasma choline concentrations during pregnancy. Sixteen women presenting to the antenatal clinic of the University Hospital of the West Indies (UHWI) at 10-15 weeks of gestation were selected for this pilot study. A food frequency questionnaire was administered to estimate frequency of consumption of foods rich in choline. Fasting blood samples were collected by venepuncture and plasma assayed for choline using liquid chromatography electrospray ionization isotopic dilution mass spectrometry. Most of the women reported consumption of diets that delivered less than the recommended choline intake (mean +/- SEM, 278.5 +/- 28.9 mg). Mean plasma choline concentration was 8.4 +/- 0.4 micromol/L. This falls below the normal concentration (10 micromol/L) reported for individuals that are not pregnant and pregnant (14.5 micromol/L). The results of this study may be an indication that the choline included in the diet of pregnant women in Jamaica may not be adequate to meet both the needs of the mother and fetus and that further studies are warranted to determine clinical implications.

Validation of laser Doppler fluxmetry as a method of assessing neo-angiogenesis in laryngeal tumours

Our intention was to validate the hypothesis that laser Doppler fluxmetry would give a valid representation of underlying tissue blood flow and would provide a reliable tool for measuring blood flow in human laryngeal cancers. This was an experimental prospective study. We performed laser Doppler fluxmetry on 20 patients with laryngeal cancer and compared the values obtained through this method with manual counting of microvessel density from biopsies, the accepted gold standard. We demonstrated good inter- and intraobserver variability in our estimation of microvessel density. We then compared microvessel density with laser Doppler fluxmetry, and using Spearman's test to assess nonparametric correlation, we obtained a correlation coefficient of 0.4 (P value: 0.15). To our knowledge, this study is the first of its kind to demonstrate a positive trend between angiogenesis measured conventionally when compared with laser Doppler fluxmetry.

Contemporary management of acute coronary syndromes: does the practice match the evidence? The global registry of acute coronary events (GRACE)

OBJECTIVE

To determine to what extent evidence based guidelines are followed in the management of acute coronary syndromes (ACS) in the UK, elsewhere in Europe, and multinationally, and what the outcomes are.

DESIGN

Multinational, prospective, observational registry (GRACE, global registry of acute coronary events) with six months' follow up.

SETTING

Patients presenting to a cluster of hospitals. The study was designed to collect data representative of the full spectrum of ACS in specific geographic populations.

PATIENTS

Patients admitted with a working diagnosis of unstable angina or suspected myocardial infarction (MI).

MAIN OUTCOME MEASURES

Death during hospitalisation and at six months' follow up (adjusted for baseline risks).

RESULTS

In ST elevation MI, reperfusion was applied more often in the UK (71%) than in Europe (65%) and multinationally (59%) (p < 0.01). However, this was almost entirely by lytic treatment, in contrast with elsewhere (primary percutaneous coronary intervention 1%, 29%, 16%, respectively). Statins were applied more frequently in the UK for all classes of patients with ACS (p < 0.0001). In contrast there was lower use of revascularisation procedures in non-ST MI (20% v 37% v 28%, respectively) and glycoprotein IIb/IIIa antagonists (6% v 25% v 26%, respectively). In-hospital death rates, adjusted for baseline risk, were not significantly different but six month death rates were higher in the UK for ST elevation MI (7.2% UK, 4.3% Europe, 5.3% multinationally; p < 0.0001) and non-ST elevation MI (7.5%, 6.2%, and 6.7%, respectively; p = 0.012, UK v Europe).

CONCLUSIONS

Current management of ACS in the UK more closely follows the recommendations of the National Service Framework than British or European guidelines. Differences in practice may account for the observed higher event rates in the UK after hospital discharge.

Surveillance ophtalmologique des patients sous APS au long cours : analyse d’une population de 925 patients

PURPOSE

The aim of this 4-Year study was to analyze the population referred to our laboratory for the visual follow-up of hydroxychloroquine or chloroquine treatment.

MATERIAL AND METHODS

We received 925 patients: 78% female, 22% male. For each patient, a 13-item criteria was filled out and regular exams were performed. The pathologies were divided in to 4 groups: rheumatoid polyarthritis (P), lupus (L), sarcoidosis (S), others (O).

RESULTS

The pathologies were distributed as follows: 48% "P", 29% "L", 3% "S", 1% "P + L", 19% "O". Of these patients, 19% had less than 1 Year of treatment, 73% 1-10 Years and 8% more than 10 Years. The screening exposed no retinal intoxications but 3% presented pre-clinical intoxication (PCI) and 80% were allowed to continue their treatment. The most important statistical results were: 1) a significant relation between the PCI and the duration of the treatment (p<0.001); 2) a non-significant relation between the PCI and the daily dose (p=0.417); and 3) a significant relation between PCI and the cumulative dose (p=0.003).

CONCLUSION

The results shows the advantage of the ERG in screening to prevent anti-malarial retinal toxicity. This study confirms that the cumulative dose seems to be more important than the daily dose, but we agree with the international consensus to respect a daily dose under 6.5 mg/kg/d. The results also demonstrated that, with this large and diversified population, there is a need for prospective and multi-centric studies. With the above results, international standards should be established in order to obtain the most efficient screening for each category of patient.

[Granular cell tumor of the cervical esophagus: a case report]

BACKGROUND

Granular cell tumor of the cervical esophagus is a rare and benign tumor. We present a case of constricting granular cell tumor of the cervical esophagus and discuss esophageal reconstruction.

CASE REPORT

Constricting granular cell tumor of the cervical esophagus was diagnosed in a patient who experienced aphagia for two years. Endoscopy demonstrated complete stricture of the cervical esophagus and computed tomography and magnetic resonance imaging confirmed the presence of a tumor formation in the cervical esophagus. Total esophagectomy with preservation of the larynx was performed.

DISCUSSION

Surgical treatment raises the problem of esophageal reconstruction (gastric pull up, free flap reconstruction). We used the gastric pull up technique and fashioned a piriform sinus anastomosis. There was no postoperative complication and functional outcome was excellent.

CONCLUSION

Computed tomography and magnetic resonance imaging provide essential data on the spread and location of granular cell tumor. Surgery provides excellent functional results.

Laser Doppler flux-metry as an experimental tool in laryngology

Angiogenesis is a cascade-like mechanism, essential for the progression of solid tumours. Quantifying microvessel density is considered the gold standard for measuring baseline angiogenesis and indeed "the response to intervention". Applying immunohistochemical techniques to biopsies conventionally does this; however, it would be very helpful to have a less invasive, reliable method of quantifying blood flux, and hence angiogenesis. The aim of the study was to validate the use of a laser Doppler flux meter as an experimental tool in laryngology. The principle and technique of laser Doppler flux-metry is described. A validation study designed to estimate the reproducibility and ability to measure change was performed in the human larynx and in an animal model. Statistical advice was sought and analysis was performed using SPSS software. Our experiments show good reproducibility of laser Doppler measurements in the human and animal model (correlation coefficient 0.956 and 0.947, respectively, P=0.01). We have also shown that the laser Doppler flux meter is capable of detecting change when it is expected ( P<0.01). Utilising a standardised technique, laser Doppler flux-metry appears to be a reliable and reproducible method of estimating blood flux in the larynx.

Two siblings with Allgrove's syndrome and extrapyramidal features

We report two siblings with Allgrove's syndrome and extrapyramidal features. Though various neurological abnormalities have been described in this disorder, we report the first patient of Allgrove's syndrome associated with dystonia and chorea.

The oral health of a group of prison inmates

The oral health of prison inmates in England has come under increased scrutiny with the arrival of joint responsibility between the Home Office and the NHS for prison healthcare. This brief study indicates very high levels of oral disease amongst a group of prisoners attending for treatment in an English prison. Further study of the oral health of prisoners seems timely, as does the exploration of effective oral health promotion for this group of people.

Five year risk of progression of primary angle closure suspects to primary angle closure: a population based study

AIM

To report progression of primary angle closure suspects (PACS) to primary angle closure (PAC) at the 5 year follow up of a population based sample.

METHODS

82 of 118 PACS who could be contacted and 110 randomly selected normals from a population based survey in 1995 were invited for a follow up examination in 2000. Progression to PAC was based on the development of raised IOP or synechiae in a PACS.

RESULTS

50 of the 82 PACS contacted were examined. 11 (22%; 95% CI 9.8 to 34.2) developed PAC (seven synechial and four appositional); all were bilateral PACS. Two of 50 people previously diagnosed as PACS were reclassified as normal. One person among the 110 normals progressed to PAC. The relative risk of progression among PACS was 24 (95% CI 3.2 to 182.4). There was no significant difference in axial length, anterior chamber depth, or lens thickness between those who progressed and those who did not. None of the patients developed optic disc or field damage attributable to angle closure. One angle closure suspect was diagnosed to have normotensive glaucoma.

CONCLUSION

In this population based study of PACS the 5 year incidence of PAC was 22%; none developed functional damage. Bilateral PACS was a clinical risk factor for progression.