Cerebral degeneration predicts survival in amyotrophic lateral sclerosis

OBJECTIVE

To determine the relationship of cerebral degeneration with survival in amyotrophic lateral sclerosis (ALS).

METHODS

Patients with probable or definite ALS underwent magnetic resonance spectroscopic imaging (MRSI) of the brain between July 1996 and May 2002, and were followed prospectively until March 2004. Creatine (Cr), choline (Cho) and the neuronal marker N-acetylaspartate (NAA) were quantified as ratios in the motor cortex.

RESULTS

In 63 patients compared with 18 healthy people, NAA/Cho was reduced by 13% (p<0.001), NAA/Cr was reduced by 5% (p = 0.01) and Cho/Cr was increased by 8% (p = 0.01). NAA/Cho was used for survival analysis, given its larger effect size and superior test accuracy (a sensitivity of 67% and a specificity of 83%). Median survival after MRSI was 24 months. Multivariate analysis showed reduced survival for lower NAA/Cho (hazard ratio (HR) 0.24, 95% confidence interval (CI) 0.08 to 0.72, p = 0.01), older age (HR 1.03, 95% CI 1.00 to 1.06, p = 0.04) and shorter symptom duration (HR 0.96, 95% CI 0.93 to 0.99, p = 0.01). Patients with NAA/Cho <2.11 had a reduced survival of 19.4 v 31.9 months (HR 2.05, 95% CI 1.12 to 4.03, p = 0.02).

CONCLUSIONS

Cerebral degeneration is predictive of reduced survival in ALS.

A custom-made prosthesis attached to an existing femoral component for the treatment of peri- and sub-prosthetic fracture

Peri- and sub-prosthetic fractures, or pathological fractures below an existing well-fixed femoral component, with or without an ipsilateral knee replacement, present a difficult surgical challenge.

We describe a simple solution, in which a custom-made prosthesis with a cylindrical design is cemented proximally to the stem of an existing, well-fixed femoral component. This effectively treats the fracture without sacrificing the good hip. We describe five patients with a mean age of 73 years (60 to 81) and a mean follow-up of 47 months (6 to 108).

The mean overlap of the prosthesis over the femoral component was 7.5 cm (5.5 to 10). There have been no mechanical failures, no new infections and no re-operations. We suggest that in highly selected cases, in which conventional fixation is not feasible, this technique offers a durable option and avoids the morbidity of a total femoral replacement.

Intracapsular hip fractures in end-stage renal failure

Patients with end-stage renal failure (ESRF) have metabolic bone disease. This increases the risk of femoral neck fracture and increases the risk of complications associated with fracture fixation such as non-union and avascular necrosis (AVN). We report the results of treatment in a consecutive series of 15 intracapsular fractures of the hip occurring in 13 patients with ESRF over a 5-year period. Six intracapsular hip fractures (of which five were undisplaced) were treated by internal fixation. Five out of these six (mean=83.3%) required conversion to total hip arthroplasty because of non-union or AVN. In all six of these patients, internal fixation was considered adequate post operatively. Of the remaining nine intracapsular hip fractures treated by hemiarthroplasty, only one required conversion to total hip arthroplasty because of stem subsidence (mean=11%). The difference in the revision rate for the two groups i.e. primary fixation versus primary hemiarthroplasty was statistically significant (p-value=0.01). The six patients with undisplaced intracapsular fractures treated by internal fixation required a total of 14 major operations, at an average rate (including initial fracture fixation and revision surgery) of 2.3 per patient. The 9 displaced fractures treated by hemiarthroplasty required just 10 operations in total, at an average rate of 1.1 per patient. (The difference was significant; p-value=0.006.) The 1-year mortality in the whole group (13 patients with 15 fractures) was 44.4%. We suggest that patients with ESRF with an intracapsular fracture of the neck of femur should be treated by replacement arthroplasty irrespective of femoral head displacement because of the high risk of revision surgery associated with internal fixation.

Unusual features associated with cranial openings of optic canal in dry adult human skulls

One hundred and eighty six dry adult human skulls (372 sides) were studied in order to reveal the presence of unusual features--such as recess, fissure and notch--in the cranial opening of the optic canal. Recess, an extension of the lateral wall, was found in 229 (61.5%) sides. Fissure, an irregular discontinuity above the lateral recess, was observed in 158 (42.4%) sides. Notch, a gap in the posterior-most limit of the roof, was seen in 66 (17.7%) sides. These were commonly seen bilaterally. The etiology of these was attributed to the development of the optic canal. During intrauterine life the optic canal is in the form of a large keyhole shaped foramen, which slowly transforms into the adult canal. A developmental arrest at an early stage may lead to the formation of recesses and fissures.

Designer insulins regimens in clinical practice--pilot multicenter Indian study

BACKGROUND

Newer insulin analogues viz., premix insulin analogue (biphasic insulin aspart) and insulin glargine are now available in India. A multicenter all-India study was done to document the patient profile and responses to these analogues in routine clinical practice.

METHODS

The study was conducted prospectively at 4 diabetes care clinics in different regions of India and collected data on the use of either of the two regimens A. Premix insulin analogue given twice-daily B. Basal-bolus analogue regimen (insulin aspart with every meal and insulin glargine once-a-day at bedtime). The centers collected all data at 3 time-points--baseline, 4 weeks later and end of 12 weeks. The study measures were FPG (fasting plasma glucose), PPPG (postprandial plasma glucose), HbA1c and insulin dose. FPG and PPPG were recorded at each of the three time points. HbA1c was recorded at baseline and end of study. Safety was assessed based on reported adverse drug reactions and occurrence of hypoglycaemias.

RESULTS

Data of 145 patients was available for analysis (n=114 on premix insulin analogue and n=31 on basal-bolus analogue regimen). Baseline demography was comparable in the two groups. Both the regimens lowered all blood glucose parameters including HbA1c significantly as compared to baseline. However, the premix insulin analogue fared better than the basal-bolus regimen in lowering HbA1c (1.58 vs. 1.16% respectively; p<0.05). Also 41% more patients in the premix group could achieve target HbA1c of < 7% at the end of study. The mean insulin dose was lower with the premix analogue group at the end of 12 weeks. There was no significant difference between the two groups in terms of change in body weight. No major hypoglycaemias were reported and the percentage of patients experiencing a minor episode was lower with the premix analogue than the basal-bolus regimen both at 4 and 12 weeks (11.4 vs. 35.48%; 16.7 vs. 58.06% respectively). No adverse drug reactions were reported throughout the study.

CONCLUSION

We conclude that both premix analogue administered twice a day and four times a day basal bolus regimen appear to be a convenient, safe and effective way of initiating insulin therapy in people with type-2 diabetes. The premix analogues achieves target better than the basal bolus regimen as has better compliance.

Taking antidepressants during late pregnancy. How should we advise women?

QUESTION

In light of recent negative media attention to antidepressant use during late pregnancy, several of my patients have either discontinued or are considering discontinuing their antidepressant medications. How can I best counsel these patients on taking antidepressants during late pregnancy?

ANSWER

Antidepressant use during the third trimester has been associated occasionally with a transient neonatal withdrawal-like syndrome characterized by jitteriness, self-limiting respiratory difficulties, and problems with feeding. When counseling patients, the risk of these adverse effects must be weighed against the risks associated with untreated depression during late pregnancy. Abrupt discontinuation of psychotropic medications has been associated with both physical (eg, withdrawal) and psychological (eg, suicidal thoughts) symptoms.

ALS surrogate markers. MRS

Magnetic resonance spectroscopy (MRS) allows the quantitative assessment of neuronal integrity in vivo based on the resonance intensity of N-acetylaspartate (NAA). A simple approach to quantitation that is commonly used is to quantify the resonance intensity of NAA with respect to creatine (Cr). In patients with ALS, NAA/Cr density is decreased in areas of the brain that contribute significantly to the corticospinal tract. Since MRS is non-invasive, it can be easily used to monitor the evolution of regional changes in NAA/Cr over time. The changes in NAA/Cr over a period of months are small, however, and challenge the precision of the method.

Bone mineral parameters in healthy young Indian adults with optimal vitamin D availability

BACKGROUND

Several recent studies indicate a marked prevalence of vitamin D deficiency in asymptomatic, apparently healthy urban subjects from different socioeconomic groups in north India.

METHODS

To further examine this trend, we studied 40 men and 50 women, 20-30 years of age, from the Indian paramilitary forces. These individuals consume a nutritious, high-protein diet, have optimal exposure to sunlight and undertake strenuous outdoor physical exercise.

RESULTS

The mean serum calcium, phosphorus and alkaline phosphatase levels were normal in both men and women. The mean (SD) serum intact parathyroid hormone and 25-hydroxyvitamin D3 levels were 19.3 (8.2) pg/ml and 18.4 (5.3) ng/ml in men, and 11.9 (6.6) pg/ml and 25.3 (7.4) ng/ml in women. Bone mineral density estimated in 20 men and 22 women revealed that in comparison with white Caucasians, 35%-50% of men and 14%-32% of women were osteopenic at different sites, while an additional 10% of men had osteoporosis of the lumbar spine.

CONCLUSION

We found that with optimal nutrition, good sunlight exposure and regular physical exercise, healthy young individuals have normal bone and mineral biochemical values. The reasons for the abnormalities detected in bone mineral density in them needs further study. The impact of childhood nutrition on accumulation of peak bone mass may contribute to our findings. There is a need for establishing normative bone mineral density data for Indians.

Intracystic papillary carcinoma; solid variant in a male breast - case report and review of the literature

A rare case of the solid variant of pure intracystic papillary carcinoma (IPC) in a 72-year-old male is described with a review of the literature. Currently, there is no clear consensus as to how this condition is best managed. Literature review demonstrates that this is an excellent prognosis tumour. Careful pathological examination should exclude the presence of coexistent conventional ductal carcinoma in situ (DCIS) or invasive carcinoma. In the male, simple mastectomy should be the treatment of choice for pure IPC. Local recurrence is rare.

The significance of intramammary nodes in primary breast cancer

The use of sentinel node biopsy in primary breast cancer raises many new controversies with regard to extra-axillary nodes. Three cases with intramammary nodes are discussed in relation to sentinel node biopsy.

External-beam radiation therapy in the treatment of diffuse tracheobronchial amyloidosis

Tracheobronchial amyloidosis is characterized by deposits of amyloid in airway walls. No effective treatment is known. We describe a 59-year-old woman who presented with increasing symptoms of airway obstruction due to diffuse deposition of amyloid throughout her tracheobronchial tree. She was treated with external-beam radiation therapy (20 Gy) with marked improvement in her symptoms, effort tolerance, bronchoscopic appearance, and forced expiratory volume in 1 second (1.39 L to 1.97 L [42%]). This improvement was maintained during 21 months of follow-up.

Alveolar hemorrhage as a complication of treatment with abciximab

STUDY OBJECTIVE

The use of abciximab, a chimeric monoclonal antibody Fab fragment specific for platelet glycoprotein IIb/IIIa receptors, is associated with improved outcome after angioplasty and stent placement. Major complications include bleeding, but pulmonary hemorrhage has been reported rarely. This study was done to identify patients with pulmonary hemorrhage following abciximab infusion and to define, if possible, any specific risk factors.

DESIGN

Retrospective review of institutional coronary angiography and bronchoscopy databases to identify patients who received abciximab and developed pulmonary hemorrhage.

SETTING

Tertiary-care teaching hospital.

PATIENTS

All patients who underwent coronary angiography and received abciximab between June 1995 and March 2000.

INTERVENTION

None.

MEASUREMENTS AND RESULTS

Seven of 2,553 patients (0.27%) had documented severe pulmonary hemorrhage associated with chest radiographic abnormalities, impaired oxygenation, and the need for blood product transfusions. The initial symptom was hemoptysis in four of the seven patients. There were two early deaths and one late death. No cases of pulmonary hemorrhage were identified in 5,412 patients who underwent coronary procedures without abciximab infusion. No other risk factors predicting hemorrhage were identified.

CONCLUSIONS

Severe pulmonary hemorrhage is a complication of abciximab use. Although hemoptysis is an important alerting symptom, it may not be present initially and the diagnosis may be missed or considered late, with the potential for inappropriate treatment until the diagnosis is established. Lesser degrees of bleeding are potentially easily missed, and this report should alert physicians to this complication so that it can be considered early in the evaluation of patients presenting with pulmonary events after abciximab use.

Chemical composition and nutritional characteristics of some hull less and hulled barley cultivars grown in India

Three hull less and nine hulled barley cultivars were grown during 1995-96 at Research Farm, CCS Haryana Agricultural University, Hisar, India and were used for chemical analysis such as nutritional and antinutritional parameters. Dolma, a hull less barley cultivar had higher contents of protein, fat, starch, in vitro digestibility of protein and starch, in vitro availability of Ca, Fe and Zn. Hulled cultivar BH-331 showed higher values of phytic acid (925 mg/100 g), polyphenols (625 mg/100 g) and amylase inhibitor activity (169 AIU) which might have contributed towards poor in vitro digestibility of Ca, Fe and Zn. Phytic acid and polyphenols manifested significantly negative correlation with in vitro availability of Ca, Fe and Zn and protein digestibility. Whereas amylase inhibitor activity showed significant and negative correlation (-0.992) only with starch digestibility.