Megacolon, hypoganglionosis, and cerebrovascular disease

INTRODUCTION

Gastrointestinal dysmotility has recently been recognized as a sequela of cerebrovascular accident.

CASE REPORT

This paper reports the case of a 58-year-old man who presented to an emergency department with severe abdominal pain and distention. He had no prior history of constipation or other symptom of gastrointestinal dysmotility, but did suffer a cerebrovascular accident ten years previously. A diagnosis of colonic volvulus was made. Following partial mechanical decompression, sigmoid colectomy was performed, revealing a severely distended colon with marked wall thickening. Pathology revealed hypogangliosis and disrupted crypt architecture, establishing the diagnosis of idiopathic megacolon with hypogangliosis.

DISCUSSION

Chronic gastrointestinal dysmotility has recently been recognized as a sequela of cerebrovascular accident, but is also commonly found following other forms of central nervous system injury. This association likely follows disrupted communication between central autonomic regulatory pathways and intestinal enteric pacemakers.

CONCLUSIONS

Gastrointestinal dysmotility is a consequence of neurologic injury, and must be addressed in recommendations for long-term care following a cerebrovascular accident. Current recommendations focus on acute treatment, but do not recommend measures to promote colonic health and gastrointestinal motility.

Combined mycophenolate mofetil and prednisone therapy in tamoxifen- and prednisone-resistant Reidel's thyroiditis

BACKGROUND

Mycophenolate mofetil is a recently identified therapy for disorders associated with systemic fibrosis, but has never been reported in the treatment of Reidel's thyroiditis. We report the first case of Reidel's thyroiditis that became resectable after treatment with mycophenolate and prednisone.

SUMMARY

A 27-year-old woman presented to an outside hospital with thyromegaly associated with compressive symptoms. The patient underwent a neck exploration with thyroid biopsy that revealed evidence of fibrosing variant Hashimoto's thyroiditis. The patient was then treated with tamoxifen and prednisone at an outside hospital without resolution. After initial evaluation she underwent an open thyroid wedge biopsy that revealed Reidel's thyroiditis. She was subsequently treated with both 1 g mycophenolate twice daily and 100 mg prednisone daily. The patient experienced immediate subjective improvement of compressive symptoms and objective decrease in mass size at 30 days, as seen by serial computed tomography examination. By 90 days of therapy the mass had decreased to a size small enough to allow subtotal thyroidectomy, which was completed over two staged procedures.

CONCLUSIONS

Reidel's thyroiditis remains a primarily surgical disease. Patients who are not surgical candidates have been treated with tamoxifen and prednisone with equivocal results. Our report is the first to suggest the combination of mycophenolate and prednisone as a viable treatment option for patients with Reidel's thyroiditis.

The Organellular Chloride Channel Protein CLIC4/mtCLIC Translocates to the Nucleus in Response to Cellular Stress and Accelerates Apoptosis

CLIC4/mtCLIC, a chloride intracellular channel protein, localizes to the mitochondria and cytoplasm of keratinocytes and participates in the apoptotic response to stress. We now show that multiple stress inducers cause the translocation of cytoplasmic CLIC4 to the nucleus. Immunogold electron microscopy and confocal analyses indicate that nuclear CLIC4 is detected prior to the apoptotic phenotype. CLIC4 associates with the Ran, NTF2, and Importin-alpha nuclear import complexes in immunoprecipitates of lysates from cells treated with apoptotic/stress-inducing agents. Deletion or mutation of the nuclear localization signal in the C terminus of CLIC4 eliminates nuclear translocation, whereas N terminus deletion enhances nuclear localization. Targeting CLIC4 to the nucleus via adenoviral transduction accelerates apoptosis when compared with cytoplasmic CLIC4, and only nuclear-targeted CLIC4 causes apoptosis in Apaf null mouse fibroblasts or in Bcl-2-overexpressing keratinocytes. These results indicate that CLIC4 nuclear translocation is an integral part of the cellular response to stress and may contribute to the initiation of nuclear alterations that are associated with apoptosis.

mtCLIC/CLIC4, an organellular chloride channel protein, is increased by DNA damage and participates in the apoptotic response to p53

mtCLIC/CLIC4 (referred to here as mtCLIC) is a p53- and tumor necrosis factor alpha-regulated cytoplasmic and mitochondrial protein that belongs to the CLIC family of intracellular chloride channels. mtCLIC associates with the inner mitochondrial membrane. Dual regulation of mtCLIC by two stress response pathways suggested that this chloride channel protein might contribute to the cellular response to cytotoxic stimuli. DNA damage or overexpression of p53 upregulates mtCLIC and induces apoptosis. Overexpression of mtCLIC by transient transfection reduces mitochondrial membrane potential, releases cytochrome c into the cytoplasm, activates caspases, and induces apoptosis. mtCLIC is additive with Bax in inducing apoptosis without a physical association of the two proteins. Antisense mtCLIC prevents the increase in mtCLIC levels and reduces apoptosis induced by p53 but not apoptosis induced by Bax, suggesting that the two proapoptotic proteins function through independent pathways. Our studies indicate that mtCLIC, like Bax, Noxa, p53AIP1, and PUMA, participates in a stress-induced death pathway converging on mitochondria and should be considered a target for cancer therapy through genetic or pharmacologic approaches.

Favorable selection in the Medicare+Choice program: new evidence

Historically, studying the Medicare managed care favorable-selection issue has been difficult because direct data on managed care enrollees have been unavailable. In this study, we analyzed the first year of Balanced Budget Act (BBA)-mandated inpatient encounter data. Based on this comparison of actual managed care and fee-for-service (FFS) beneficiaries, it appears that there are significant differences between these populations. The most striking differences are found in the comparison of average risk factors, indicating a clear bias in the managed care populations toward beneficiaries predicted to be less costly.

Risk Adjustment for the Medicare program: lessons learned from research and demonstrations

The Balanced Budget Act (BBA) of 1997 requires numerous changes in Medicare. Medicare's managed care program has been reinvented as "Medicare + Choice," offering an expanded range of delivery system options for beneficiaries and a schedule of payment changes that will dramatically affect managed care plans. Preceding some of these BBA-legislated changes to Medicare were years of research and demonstrations. Risk-adjusted payment in the Medicare + Choice program, which is mandated for implementation in 2000, is one example of a longstanding developmental initiative. This paper provides a brief overview of risk adjustment-related research and demonstration activities carried out by the Health Care Financing Administration (HCFA) since the 1980s, and describes a possible technical approach for the implementation of risk-adjusted Medicare managed care payments in 2000.

Delivering home-based case management to families with children with mental retardation and developmental disabilities

To meet the needs of individuals with mental retardation and developmental disabilities (MR/DD) and their families living in urban setting, a noncenter-based model of case management was implemented. In contrast to traditional case management in which families and consumers come to the case manager and most service coordination is done by telephone or in meetings at the case manager/social worker's worksite, the case manager in a noncenter-based model is mobile and able to meet the consumer and family in their domains. In this model, case management is provided in conjunction with in-home residential habilitation and funded by Medicaid under the Home and Community Based Services Waiver. This funding stream provides monies for nontraditional services delivered in noncertified settings. Case managers used the Family Resource Scale to get an immediate indication of the resources and needs of each family. The scale highlights the adequacy of a person's basic and caregiving resources, as well as financial needs. The findings from this study suggest that an understanding of both disability and entitlements is essential for case managers who may have to help advocate for consumers around services and benefits. Moreover, to build and maintain an egalitarian and supportive relationship with families, the importance of caregiver-specified resources and needs must be recognized by case managers. Access to resource information and the ability to engage the family in problem-solving depends on a well-trained staff with the ability to respond to individuals with different needs and from a variety of circumstances. These essential skills prepare a case manager to assist families with their immediate requirements as well as to mobilize them to plan for future needs.

Tuberculoma presenting as an en plaque meningioma. Case report

Intracranial tuberculomas generally present as either solitary or multiple lesions in the brain parenchyma. They are characterized by a ring-enhancing area on either computerized tomography scans or magnetic resonance images. A case is presented in which an intracranial tuberculoma was dural based and had an appearance similar to an en plaque meningioma.

Employers' attitudes towards persons with disabilities: a comparison of national and New York State data

This paper compares the results of two large-scale studies conducted as part of an ongoing research programme on employers' attitudes towards the employability of persons with severe disabilities--a study of Fortune 500 corporations and a study of employers doing business in New York State. The results indicated that both groups of employers were favourable towards the employability of persons with disabilities. Executives from large national corporations were more favourable than those from the predominantly small companies doing business in New York State. Prior contact with persons with disabilities that was positively evaluated appeared to differentiate those more and less favourable in both study groups, especially in the smaller companies of the New York State study group. Employers' characteristics associated with differences in attitudes in the literature (e.g. education, work experience) also appeared to be confirmed by data from New York State companies more than from the corporations of the Fortune 500.

Differences in job placements between men and women with mental retardation

Thirty-three men and women with mental retardation living in the New York metropolitan area (USA), who entered a supported employment programme were followed during their first 9 months in competitive employment. Differences in placement outcomes were consistently associated with gender differences. The implications of these findings are discussed in terms of providing employment services to men and women with mental retardation and developmental disabilities.

[Retroperitoneal teratomas in the perinatal period. Review of the literature concerning a neonatal, immature, aggressive teratoma]

A neonate with an immature, poorly demarcated retroperitoneal teratoma invading the aorta-vena cava space died immediately after surgery. Among 34 cases of retroperitoneal teratoma discovered during the first postnatal month, including one renal case and ours, eight can be considered malignant on the basis of histology in two cases and clinical course in six. Five of these tumors exhibited a significant immature component. In neonates, the proportion of malignant teratomas is greater for retroperitoneal tumors than for other sites: sacrum and coccyx, heart, neck, mediastinum, and abdomen. Evaluation of chemotherapy in teratomas with significant immature components is difficult because few of the patients of this small sample received such treatment. As in other sites, regardless of the degree of maturity, exeresis must be as complete as possible.