Energy expenditure in acute pancreatitis evaluated by the Harris-Benedict equation compared with indirect calorimetry

OBJECTIVES

Enteral nutrition (EN) is recommended for severe acute pancreatitis (AP) and for biliary AP if cholecystectomy is delayed. Energy expenditure (EE) is calculated using the Harris-Benedict equation (HBE), but indirect calorimetry (IC) can also be employed. We wished to compare EE evaluated by the HBE equation, modified HBE (mHBE) and IC at study inclusion and 1 month after AP resolution.

METHODS

We undertook a single-center prospective study in Paris, France.

RESULTS

Among 35 patients, 19 had biliary AP and 11 alcoholic-related AP. Eleven cases had severe AP. There was no significant difference between EE calculated by the HBE and that using IC at study inclusion. However, the EE calculated by the mHBE was significantly higher than that calculated using IC. For severe AP, the HBE underestimated EE whereas the mHBE overestimated it. No difference was found based on the cause of AP. There was no difference between methods for EE at 30 days.

CONCLUSIONS

The HBE underestimated EE for severe AP, whereas the mHBE overestimated it. IC seems to be the best means of EE evaluation for AP.

Association of brain natriuretic peptide and adrenomedullin plasma levels with left ventricular filling pressures in end-stage renal disease patients on hemodialysis

OBJECTIVE

Adrenomedullin (ADM) and brain natriuretic peptide (BNP) are known to be associated with elevated left ventricular filling pressures. However, little is known about this association in hemodialysis (HD) patients with preserved left ventricular ejection fraction (LVEF). Our objective was to evaluate the potential association between E/e' ratio and plasma levels of BNP and ADM in end-stage renal disease (ESRD) patients with preserved LVEF undergoing chronic hemodialysis.

PATIENTS AND METHODS

The study group enrolled 62 ESRD patients treated with hemodialysis three times weekly. BNP and ADM plasma concentration measurements and echocardiographic examination were performed 30 minutes after hemodialysis. E/e' ratio, evaluated by Tissue Doppler imaging and measured at the basal septum, was used as a surrogate marker for assessing left ventricular filling pressures.

RESULTS

The mean age of patients was 62 ± 25 years. The mean BNP and ADM values after hemodialysis were 0.40 ± 6.73 ng/ml and 0.06 ± 2.12 ng/ml, respectively. Elderly patients with hypertrophied left ventricles and larger left atria displayed higher E/e' values. BNP (r = 0.324. p = 0.018) and ADM (r = 0.319, p = 0.042) plasma levels were positively and significantly associated with E/e΄. Multivariate regression analysis including BNP, ADM, age, hemodialysis duration, left ventricular end-systolic volume index, LVEF, left ventricular mass index and left atrium volume index, revealed that ADM (p-value 0.025) but not BNP levels, were independently associated with the E/e' ratio.

CONCLUSIONS

ADM, but not BNP, was independently associated with septal E/e' in HD patients with preserved LVEF. ADM plasma levels can be used as a surrogate index to assess left ventricular filling pressures in HD patients.

Association of brain natriuretic peptide and adrenomedullin plasma levels with left ventricular filling pressures in end-stage renal disease patients on hemodialysis

OBJECTIVE

Adrenomedullin (ADM) and brain natriuretic peptide (BNP) are known to be associated with elevated left ventricular filling pressures. However, little is known about this association in hemodialysis (HD) patients with preserved left ventricular ejection fraction (LVEF). Our objective was to evaluate the potential association between E/e' ratio and plasma levels of BNP and ADM in end-stage renal disease (ESRD) patients with preserved LVEF undergoing chronic hemodialysis.

PATIENTS AND METHODS

The study group enrolled 62 ESRD patients treated with hemodialysis three times weekly. BNP and ADM plasma concentration measurements and echocardiographic examination were performed 30 minutes after hemodialysis. E/e' ratio, evaluated by Tissue Doppler imaging and measured at the basal septum, was used as a surrogate marker for assessing left ventricular filling pressures.

RESULTS

The mean age of patients was 62 ± 25 years. The mean BNP and ADM values after hemodialysis were 0.40 ± 6.73 ng/ml and 0.06 ± 2.12 ng/ml, respectively. Elderly patients with hypertrophied left ventricles and larger left atria displayed higher E/e' values. BNP (r = 0.324. p = 0.018) and ADM (r = 0.319, p = 0.042) plasma levels were positively and significantly associated with E/e΄. Multivariate regression analysis including BNP, ADM, age, hemodialysis duration, left ventricular end-systolic volume index, LVEF, left ventricular mass index and left atrium volume index, revealed that ADM (p-value 0.025) but not BNP levels, were independently associated with the E/e' ratio.

CONCLUSIONS

ADM, but not BNP, was independently associated with septal E/e' in HD patients with preserved LVEF. ADM plasma levels can be used as a surrogate index to assess left ventricular filling pressures in HD patients.

A patient with pleuritic chest pain and abnormal blood clotting tests

We present the case of a 58 year old man who developed pleuritic chest while an in-patient; investigations revealed pulmonary embolism, despite a significantly raised Activated Partial Thromboplastin Time (APTT), which was subsequently attributed to Antiphospholipid syndrome (APS). The diagnosis and initial management of APS in the acute setting is discussed.

Minimal extracorporeal circulation reduces the incidence of postoperative major adverse events after elective coronary artery bypass grafting in high-risk patients. A single-institutional prospective randomized study

Coronary artery bypass grafting (CABG) using minimal extracorporeal circulation (MECC) has been associated with an improved short-term clinical outcome compared to conventional extracorporeal circulation (CECC). The aim of this study was to evaluate the impact of MECC compared to CECC on postoperative major adverse events in high-risk patients undergoing elective coronary revascularization procedures. Two hundred patients undergoing elective CABG were randomized into two groups. In Group A (n=100), MECC was used while Group B (n=100) included patients who were operated on CECC. The incidence of postoperative major adverse events (myocardial infarction, renal failure, stroke, death) was the primary end-point of the study. MECC was associated with a 77% relative risk reduction in the incidence of major adverse events compared to CECC (p=0.004). The rate of major adverse events occurring in the high-risk patient subgroup (preoperative left ventricular ejection fraction ≤40%, age >65 years, EuroSCORE II >5) operated on with MECC was significantly lower in comparison to their CECC counterparts. Based on our results, cardiac centres should be encouraged to use MECC as the standard circuit when performing elective coronary procedures, even in a high-risk population.

Posterior mediastinal Castleman's disease presented as hypervascular lipomatous tumor

Castleman's disease (CD) is a rare lymphoproliferative disorder most often found in the chest. Herein we describe the imaging findings of a histologically proven case of CD involving the posterior mediastinum in a 41-year-old asymptomatic man presented as a well-defined hypervascular lipomatous tumor. To our knowledge less than 10 cases of posterior mediastinal CD have been reported so far and this is the first case of CD mimicking mediastinal lipomatous tumor.

Cerebellar hemorrhage after supratentorial burr hole drainage of a chronic subdural hematoma

Cerebellar hemorrhage is an unusual, but increasingly recognized complication after supratentorial surgery. Even rarer are the cases of cerebellar hemorrhage after supratentorial burr-hole drainage of a chronic subdural hematoma (CSDH). The pathophysiology of this rare complication still remains unclear. Hypertension and overdrainage of cerebrospinal fluid seem to be causative factors of postoperative cerebellar hemorrhage. The most important key to minimize this hazardous sequel is to be aware of this potential complication and its pathogenetic mechanisms. We report our case of a 43-year old man who developed cerebellar hemorrhage after burr hole trephination for supratentorial CSDH.

Tuberculous orchitis US and MRI findings. Correlation with histopathological findings

Tuberculosis of the testis is a rare disease. Although Ultrasound (US) findings of tuberculous epididymo-orchitis have been well described, there are only few reported cases describing the Magnetic Resonance Imaging (MR) findings of this disease. Herein, we describe the US and MR findings in a patient with tuberculous orchitis of the left testis and correlate them with the histopathological findings. In our case, the MR findings differ from previous studies because granulomatous areas in the testis had intermediate to high signal intensity on T2WI, while in all studies granulomatous areas in tuberculous epididymo-orchitis demonstrated invariably low signal intensity.

A double-blind, randomized clinical trial of the effect of omega-3 fatty acids on the oxidative stress of preterm neonates fed through parenteral nutrition

BACKGROUND/OBJECTIVES

The aim of this study was to research and draw conclusions about the effect of a parenteral nutrition (PN) fat emulsion, rich in omega-3 fatty acids, on the antioxidant markers of preterm infants, when compared with a standard fat emulsion. This was a double-blind, parallel-group study conducted in Athens, Greece, using an equal randomization method.

SUBJECTS/METHODS

Thirty-eight infants were selected using a double-blind method and a computer-generated randomization list. Both groups received PN, based on the same protocols. Group A received SMOFlipid fat emulsion, while group B received the standard fat emulsion (Intralipid). Serum levels of vitamin A, E and total antioxidant potential (TAP) were measured on days 0, 7 and 14 of PN support. Clinical and biochemical data were collected on days 0, 14 and on the day of discharge.

RESULTS

Serum levels of vitamin E and A were significantly increased in group A, while only vitamin A serum level was increased in group B on the fourteenth day (group A: vitamin E: P-value=0.002, vitamin A: P-value=0.000, group B: vitamin E: P-value=0.065, vitamin A: P-value=0.000). TAP was increased only in the intervention group (group A: P-value=0.000, group B: P-value=0.287). Mild anemia was developed in both groups, while no differences were detected in the infection rate, days of hospitalization, days of ventilator support and days of phototherapy.

CONCLUSIONS

Oxidative stress was significantly reduced in those neonates fed with omega-3 fatty acids, whereas no effect was observed in the neonates fed with standard lipids. Intervention had no effect on infants' growth and clinical outcome.

Magnetic Resonance Imaging and Ultrasonographic Evaluation of Retinal Detachment in Orbital Uveal Melanomas

We assess the role of ultrasonography (US) in the evaluation of retinal detachment in patients with uveal melanomas, in correlation with magnetic resonance imaging (MRI) findings. Twenty-six patients (13♂ and 13♀) with uveal melanomas underwent MRI and US examination. The signal intensity of the tumors and retinal detachments were depicted using MRI. The position of retinal detachment in correlation with the position of intraocular tumor was also evaluated performing ultrasound examination. MRI and US identified uveal melanoma in all 26 patients. In 11 of the 26 patients (42.3%) uveal melanoma was accompanied by retinal detachment. MRI demonstrated retinal detachment in nine patients. US disclosed retinal detachment in two more cases. US has an important role in the depiction of uveal melanomas and associated retinal detachment. It also appears to be more sensitive than MRI in detecting retinal detachment in patients with orbital uveal melanomas.

Craniosynostosis : correlation with cranial vault shape and osseous defects

This study assessed the value of three-dimensional CT (3D CT) in the diagnosis of craniosynostosis, and correlated the cranial deformity with the presence of osseous defects in cranial vault's bones. One hundred and two children (55♀ and 47♂) with a clinical suspicion of craniosynostosis, underwent spiral computed tomography with 3D reconstruction using the shaded surface display (SSD) and volume rendering (VR) algorithms. We evaluated the presence of osseous defects in cranial bones in correlation with the type of craniosynostosis and the shape of the cranial vault. 3D CT allowed the evaluation of craniosynostosis in all patients. All patients had combined forms of craniosynostosis. Osseous defects in the bones of cranial vault were found in 56 patients of whom nine had scaphocephaly, eight plagiocephaly and one trigonocephaly. CT of the skull with three-dimensional reconstruction can safely and reliably identify craniosynostoses in children and could be used for the identification of osseous defects in the cranial vault.

Co-occurrence of brain tumours and demyelination of the central nervous system: coincidence or interrelation?

The co-occurrence of a brain tumour and demyelinating disease of the central nervous system (CNS) constitutes a rare clinical entity. We herein report the incidence of meningioma and CNS non-specific demyelination in a patient with a 6-year history of operated brain tumour (meningioma). Our case bolsters the argument that in at least some cases, the occurrence of a brain tumour could predispose to CNS non-specific demyelination.

Solitary plasmacytoma of the upper cervical spine: therapeutic considerations

Solitary plasmacytomas are localized plasma cell malignancies involving bone marrow (solitary bone plasmacytoma, SBP) or extramedullary tissues (solitary extramedullary plasmacytoma, SEP). The upper cervical spine involvement by SBP is a rare and more challenging condition. The authors describe a patient with solitary plasmacytoma involving all the elements of C2 vertebra. Severe neck pain was the only manifestation of disease. The patient underwent an occipito-cervical stabilization with a partial decompression through a single posterior approach. The authors stress the importance of early diagnosis followed by appropriate multidisciplinary treatment strategies, including surgery and discuss the management dilemmas concerning the timing and management consequence, in scope to prevent a major neurological damage and allow the patient to be ambulatory.

Cardio-renal anemia syndrome

The interaction between chronic heart failure, chronic kidney insufficiency and anemia, form a vicious cycle, termed as the cardio-renal anemia syndrome. The interaction between these three conditions causes deterioration of the cardiac and renal function and increases anemia. Each of the three can cause or be caused by the others.We herein analyze and speculate the mechanisms involved in the pathophysiology of this new syndrome highlighting the main points of interest that seem to expand upon more than one specialty. The cardio-renal anemia syndrome is emerging in the area of clinical investigation with progressively elevated significance. Additionaly we report the data related to anemia treatment as part of therapeutic perspective concerning the management of patients manifesting the profile of this syndrome.

Resection of giant meningiomas of the anterior cranial fossa using orbital osteotomies

AIM

The challenge in large cranial base meningiomas is total resection of the tumor with the least possible mortality and morbidity. During the last two decades the technical approaches for anterior skull base tumors have shown a considerable progress, providing a wide exposure with minimal brain retraction. The purpose of this study is to present our experience with these approaches for treatment of giant anterior cranial fossa meningiomas.

METHODS

A retrospective analysis was performed in 20 patients with giant meningiomas (diameter >4.5 cm) of the anterior cranial fossa, which were treated surgically in our department, between January 1992 and January 2002. There were 5 men and 15 women with an average age of 48,3 years. Mental and visual disturbances were the most common presenting symptoms. We used the extended subfrontal approach for 16 patients and the fronto-orbito-zygomatic approach for 4 patients. The follow-up period ranged from 3 to 10 years.

RESULTS

In all patients, total resection of the tumor (Simpson grade I, 12 patients, Simpson grade II, 8 patients) was accomplished. Significant improvement occurred by the time of follow-up examination in all but three patients. No evidence of recurrence was observed in 19 of the 20 patients.

CONCLUSIONS

The extended anterior skull base approaches, using orbital osteotomies, for giant meningiomas of the anterior cranial fossa have improved the extent of radical tumor removal with minimal neurological morbidity. Furthermore a long term prevention of recurrence was achieved.

The predictive value of external continuous lumbar drainage, with cerebrospinal fluid outflow controlled by medium pressure valve, in normal pressure hydrocephalus

BACKGROUND

Although sporadic studies have described temporary external cerebrospinal fluid (CSF) lumbar drainage as a highly accurate test for predicting the outcome after ventricular shunting in normal pressure hydrocephalus (NPH) patients, a more recent study reports that the positive predictive value of external lumbar drainage (ELD) is high but the negative predictive value is deceptively low. Therefore, we conducted a prospective study in order to evaluate the predictive value of a continuous ELD, with CSF outflow controlled by medium pressure valve, in NPH patients.

METHOD

Twenty-seven patients with presumed NPH were admitted to our department and CSF drainage was carried out by a temporary (ELD) with CSF outflow controlled by a medium pressure valve for five days. All patients received a ventriculoperitoneal shunt using a medium pressure valve based upon preoperative clinical and radiographic criteria of NPH, regardless of ELD outcome. Clinical evaluation of gait disturbances, urinary incontinence and mental status, and radiological evaluation with brain CT was performed prior to and after ELD test, as well as three months after shunting.

FINDINGS

Twenty-two patients were finally shunted and included in this study. In a three-month follow-up, using a previously validated score system, overall improvement after permanent shunting correlated well to improvement after ELD test (Spearman's rho = 0.462, p = 0.03). When considering any degree of improvement as a positive response, ELD test yielded high positive predictive values for all individual parameters (gait disturbances 94%, 95% CI 71%-100%, urinary incontinence 100%, 95% CI 66%-100%, and mental status 100%, 95% CI 66%-100%) but negative predictive values were low (< 50%) except for cognitive impairment (85%, 95% CI 55%-98%).

CONCLUSION

This study suggests that a positive ELD-valve system test should be considered a reliable criterion for preoperative selection of shunt-responsive NPH patients. In case of a negative ELD-valve system test, further investigation of the presumed NPH patients with additional tests should be performed.

Multiple spinal epidural abscesses extending to the whole spinal canal

Spinal epidural abscess (SEA) is a rare life-threatening disease mostly affecting patients with an altered immune system. It presents as a sequela of adjacent infection or hematogenous spread. MRI is the method of choice in evaluating patients with suspected SEAs and should always include the whole spinal canal, excluding the exceedingly rare possibility of multiple epidural collections. We present a rare case of a patient with no predisposing factors suffering from multiple SEAs, extending to the whole spinal canal.

Vascular injury complicating lumbar disc surgery. A systematic review

OBJECTIVES

to review the literature concerning the early and late vascular complications of lumbar disc surgery.

METHODS

using the MEDLINE database, we reviewed all reports of vascular complications associated with surgical excision of a prolapsed disc via a posterior approach reported in the English literature since 1965.

RESULTS

we identified 98 cases of vascular complications for an incidence of 1-5 in 10000 disc operations. Early presentation is shock due to rupture of a large retroperitoneal vessel. Late complications include development of pseudoaneurysms and arteriovenous fistulas. Treatment of a vascular tear consisted mainly of primary suturing of the injured vessel. The preferred method for arteriovenous fistula and pseudoaneurysm repair was suturing from within the arterial lumen along with interposition grafting. Recently, endovascular techniques have been recommended, lowering the high morbidity and mortality related to conventional repair.

CONCLUSION

iatrogenic vascular injury during lumbar disc surgery, although rare, should be suspected if signs of circulatory instability are noted or if lumbar pain, leg oedema or high output cardiac failure develop months to years following such surgical procedures. However, these symptoms may arise during or immediately after surgery, requiring immediate intervention.

Two episodes of leukoencephalitis associated with recombinant hepatitis B vaccination in a single patient

Cases of central nervous system demyelination have been reported after recombinant hepatitis B vaccination, but no causal link has been clearly demonstrated. We present the first case report involving the occurrence of 2 episodes of leukoencephalitis in a previously healthy patient after vaccination and rechallenge with hepatitis B vaccine.

Segmental myoclonus as the sole manifestation of a choroid plexus papilloma in the posterior fossa. Case report

The authors describe the case of a 22-year-old woman with involuntary contractions of the sternocleidomastoid and trapezius muscles that resulted in turning movements of the head. The jerks displayed the clinical and neurophysiological characteristics of segmental myoclonus (SM) restricted to muscles supplied bilaterally by the first four cervical segments. Magnetic resonance imaging disclosed a tumor in the midline above the cisterna magna that was later histologically proven to be a choroid plexus papilloma. The patient's involuntary movements did not extend to other muscle groups or, in particular, to the palate, as one might have expected in the case of brainstem lesions. Myoclonus was the sole clinical manifestation of the tumor in this patient; other signs and symptoms invariably reported in other cases of posterior fossa papilloma, such as increased intracranial pressure or cranial nerve palsies, were absent. Release from suprasegmental control is suggested as a possible pathophysiological mechanism in this case of SM.

Spinal bone mineral density changes following halo vest immobilization for cervical trauma

In this prospective study we followed the bone mineral density (BMD) changes of the injured cervical spine immobilized with the halo vest. In order to define the natural history of cancellous vertebral bone loss and restoration, dual-energy densitometry was used on each of ten selected cervical spines in the lateral view (1) immediately after the application of the device, (2) at the end of the treatment and (3) 3 months after the removal of the halo vest. The halo vest produces local osteoporosis in the immobilized cervical spine with an overall reduction of BMD averaging 2.83% (P < 0.05). The response of the cervical spine to immobilization was only slightly different from patient to patient and between different vertebral bodies in each particular spine. The type and the level of injury of the cervical spine were not related to the changes of BMD, age or gender of the patient, whereas the local osteoporosis was mostly reversible in the follow-up evaluation of 5-6 months.

IgG and IgM concentration in the prolapsed human intervertebral disc and sciatica etiology

STUDY DESIGN

A prospective study was conducted in patients who underwent surgeries for sciatica. The results were compared to those of control subjects.

OBJECTIVES

This study expanded knowledge about the pathogenesis of back pain and sciatica in disc herniation.

METHODS

Nucleus pulposus, retrieved from 10 patients who underwent surgeries for sciatica caused by disc herniation and from 8 patients used as control subjects, was homogenized and together with serum and cerebrospinal fluid was examined for local production of IgG and IgM by rate nephelometry.

SUMMARY OF THE BACKGROUND DATA

Experimental data have shown an inflammatory reaction in the nucleus pulposus of animal models.

RESULTS AND CONCLUSIONS

An increased ratio IgGNP/IgGs x 10(3) and IgMNP/IgMs x 10(3) was found in all patient samples, whereas only the IgMNP/IgMs x 10(3) ratio was significantly higher (P < 0.005) when compared with those of the control values. These findings may be secondary to an inflammatory reaction close to the nerve root and prolapsed nucleus pulposus. Therefore, they may contribute in some way to the inflammatory origin of sciatica.

Pattern reversal visual evoked potentials in minor head injury

Pattern reversal visual evoked potentials (PR-VEPs) have been recorded in 50 patients with minor head injury (MHI) on days 1 and 30 after trauma and the data compared to 20 normals. None of the patients had visual complaints. The aim was to investigate a possible visual pathway affection in MHI and test the usefulness of PR-VEPs as an objective noninvasive tool in the detection of a possible subclinical affection of the visual system in MHI. P100 latency and amplitude had no significant difference compared to normals. Comparison of patient data on days 1 and 30 after trauma showed a significant latency decrease and amplitude increase on day 30, compared to day 1. These alterations were not age dependent. Our data suggest affection of the human visual pathway in MHI. PR-VEP recording seems to be a useful, objective, noninvasive tool, helping to identify possible subclinical affections of the visual pathway in MHI.