ATP1A3 related disease manifesting as rapid onset dystonia-parkinsonism with prominent myoclonus and exaggerated startle

We report ATP1A3-associated rapid-onset dystonia-parkinsonism with an atypical presentation including myoclonus and exaggerated startle in four patients. Their prominence over parkinsonism prompted consideration of a syndromic diagnosis of myoclonus dystonia. ATP1α3 dysfunction in GABAergic neurons could explain these examination findings. The spectrum of ATP1A3-associated movement disorders includes myoclonus-dystonia.

Ticagrelor or prasugrel versus clopidogrel in patients undergoing percutaneous coronary intervention for chronic coronary syndromes

BACKGROUND

Potent P2Y12 inhibitors such as ticagrelor and prasugrel are superior to clopidogrel in acute coronary syndrome (ACS) patients treated with percutaneous coronary intervention (PCI). Whether this benefit extends to a patient population with chronic coronary syndromes (CCS) is unclear.

AIMS

We sought to compare the safety and efficacy of prasugrel and ticagrelor versus clopidogrel in patients undergoing PCI for CCS.

METHODS

Consecutive patients undergoing PCI for CCS at a tertiary centre between 2014 and 2019 who were discharged on prasugrel or ticagrelor were compared with those on clopidogrel. The primary endpoint was the composite of death and myocardial infarction (MI), with secondary outcomes including rates of bleeding, stroke, and target vessel revascularisation at 1 year.

RESULTS

Overall, 11,508 patients were included in the study (ticagrelor/prasugrel n=2,860 [24.9%], clopidogrel n=8,648 [75.1%]) with an increasing frequency of potent P2Y12 inhibitor use over the study period (ptrend<0.001). Clopidogrel was used more frequently in patients with multimorbid risk factors, whereas anatomical or procedural complexity was associated with ticagrelor/prasugrel use (left main PCI, bifurcation PCI, number of lesions, rotational atherectomy). No difference in the incidence of death or MI was noted across the groups (ticagrelor/prasugrel vs clopidogrel: 2.7% vs 3.1%, adjusted hazard ratio [adjHR] 0.86, 95% confidence interval [CI]: 0.62-1.17; p=0.33) or secondary outcomes including bleeding (adjHR 0.75, 95% CI: 0.46-1.21; p=0.23) on propensity score stratification analysis. Additionally, no difference in the primary outcome was observed across subgroups, including those undergoing complex PCI.

CONCLUSIONS

Ticagrelor and prasugrel are increasingly used in patients with CCS undergoing PCI with similar 1-year efficacy and safety when compared to clopidogrel. Whether use of these agents can be beneficial in patients undergoing PCI for CCS with a high thrombotic and low bleeding risk warrants further study.

Efficacy and Safety of an Upfront RotaTripsy Strategy in the Treatment of De Novo and In-Stent Restenosis Cases

BACKGROUND

Use of both rotational atherectomy (RA) and intravascular lithotripsy (IVL)-the "RotaTripsy" technique-offers a potentially synergistic calcium-modification strategy that can treat both luminal and abluminal calcification. An upfront RotaTripsy strategy using an undersized burr in large-caliber coronaries also offers the advantage of facilitating IVL catheter passage while being able to undertake the procedure with a 6-Fr system.

METHODS

Consecutive patients with heavily calcified lesions on angiographic or intravascular imaging and large target-vessel caliber (≥3 mm) who underwent an upfront RA followed by IVL between July 2021 and January 2022 were included in this study. Study aims were to evaluate periprocedural efficacy and safety.

RESULTS

Of the 21 patients included, RotaTripsy was used for treatment of de novo lesions in 12 patients (57%) and for in-stent-restenosis in 9 patients (43%). Seven cases of in-stent restenosis (ISR) involved 2 layers of stents. Mean reference vessel diameter was 3.67 ± 0.46 mm and baseline diameter stenosis was 77.4 ± 11.3%. Average RA burr-to-artery ratio was 0.43 ± 0.05 and IVL balloon-to-artery ratio was 0.93 ± 0.06, with IVL balloon crossing the lesion in all cases following RA. Procedural success was attained in 20 of 21 cases; 1 periprocedural complication (a death related to coronary perforation following stent postdilation) was recorded.

CONCLUSIONS

An upfront RotaTripsy strategy is associated with a high degree of procedural success in de novo lesions and ISR cases by facilitating the use of a smaller burr-to-artery ratio and smaller-bore vascular access. Larger studies are required to further evaluate the potential benefits of an upfront RotaTripsy strategy from a safety and cost-benefit perspective.

Comparative safety profile of chloral hydrate versus other sedatives for procedural sedation in hospitalized infants

BACKGROUND

Given the limited available evidence on chloral hydrate safety in neonatal populations and the discrepancy in chloral hydrate acceptance between the US and other countries, we sought to clarify the safety profile of chloral hydrate compared to other sedatives in hospitalized infants.

METHODS

We included all infants <120 days of life who underwent a minor procedure and were administered chloral hydrate, clonidine, clonazepam, dexmedetomidine, diazepam, ketamine, lorazepam, midazolam, propofol, or pentobarbital on the day of the procedure. We characterized the distribution of infant characteristics and evaluated the relationship between drug administration and any adverse event. We performed propensity score matching, regression adjustment (RA), and inverse probability weighting (IPW) to ensure comparison of similar infants and to account for confounding by indication and residual bias. Results were assessed for robustness to analytical technique by reanalyzing the main outcomes with multivariate logistic regression, a doubly robust IPW with RA model, and a doubly robust augmented IPW model with bias-correction.

RESULTS

Of 650 infants, 497 (76%) received chloral hydrate, 79 (12%) received midazolam, 54 (8%) received lorazepam, and 15 (2%) received pentobarbital. Adverse events occurred in 41 (6%) infants. Using propensity score matching, chloral hydrate was associated with a decreased risk of an adverse event compared to other sedatives, risk difference (95% confidence interval) of -12.79 (-18.61, -6.98), p <  0.001. All other statistical methods resulted in similar findings.

CONCLUSION

Administration of chloral hydrate to hospitalized infants undergoing minor procedures is associated with a lower risk for adverse events compared to other sedatives.

Single Coil Implantable Cardioverter Defibrillator Leads in Patients With Hypertrophic Cardiomyopathy

Patients with hypertrophic cardiomyopathy (HC) may require higher energies to terminate ventricular fibrillation (VF); thus, dual coil defibrillation leads are often implanted. However, single coil leads may be preferred in young patients. All patients with HCM implanted with a transvenous ICD from years 2000 to 2014 were included. Of 249 patients, 223 underwent VF testing including 150 with a dual coil lead and 73 a single coil. Patients tested with dual coil compared with single coil had lower successful VF energies (15.7 ± 6.1 joule to 20.2 ± 7.9 joule (p <0.0001)). Adequate safety margin for defibrillation was noted in 97.3% of patients. Notably, 6 (4 with single coil leads) had inadequate safety margins (defined as ≥10 joule). Three of these 6 patients required replacement of a single coil lead with a dual coil lead. The remaining 3 underwent waveform tilt alteration, higher energy ICD, or removal of the can from the shock vector. There were no clinical or implant predictors of inadequate safety margins. In follow-up of 16 ± 30 months (range 0 to 170), there were 24 arrhythmias including 13 VF, all successfully terminated. In conclusion, in HC patients undergoing ICD implantation, single coil leads can provide adequate safety margins. In conclusion, defibrillation testing should be considered in all HC patients undergoing ICD implantation, and should be performed in those undergoing implantation with a single coil lead.

Cardiac rehabilitation in older adults: New options

Cardiac rehabilitation (CR) is an important component in the continuum of care for patients with cardiovascular diseases, including the older population. Benefits of CR which include mortality benefit, decreased hospitalizations, increased functional capacity all extend to an older population. In Medicare beneficiaries which represent an older population, utilization of CR continues to remain low despite evidence that suggests lower hospitalization rates, Medicare costs, and improved symptoms. Given poor referral rates, enrollment rates, and completion rates, a call for new strategies has been made by all major societies. However, several barriers exist. Newer models of CR constructed to overcome these barriers are reviewed below. Some of these new strategies include alternative site CR or home‐based CR and the utilization of technology.

Right-sided endocarditis: eustachian valve and coronary sinus involvement

Infective endocarditis in patients with intravenous drug use commonly involves right-sided heart valves. Eustachian valve (EV) endocarditis is not commonly seen given the valve's infrequent presence. Involvement of the coronary sinus (CS) with endocarditis is also an unusual finding. We present a case with echocardiographic findings consistent with EV endocarditis along with CS involvement, which appropriately responded to antibiotics.

Atrial and ventricular arrhythmias in hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is an autosomal dominant disease caused by mutations in genes coding for cardiac sarcomeres. HCM is the most common inherited heart disease, with a prevalence of 0.2%. There are multiple genetic variants that cause pleomorphic clinical attributes and disease characterized by myocardial disarray and myocardial hypertrophy. Patients are at an increased risk of atrial and ventricular arrhythmias. Management of these arrhythmias is complex. Atrial fibrillation is associated with increased mortality and thromboembolism. Ventricular arrhythmias are life threatening and best treated with an implantable defibrillator.

Cortical excitability changes distinguish the motor neuron disease phenotypes from hereditary spastic paraplegia

BACKGROUND AND PURPOSE

Cortical hyperexcitability has been identified as an important pathogenic mechanism in motor neuron disease (MND). The issue as to whether cortical hyperexcitability is a common process across the MND phenotypes, including amyotrophic lateral sclerosis (ALS) and primary lateral sclerosis (PLS), remains unresolved. Separately, the clinical distinction between PLS and 'mimic disorders' such as hereditary spastic paraparesis (HSP) may be difficult, potentially delaying diagnosis. Consequently, the aim of the present study was to determine the nature and spectrum of cortical excitability changes across the MND phenotypes, and to determine whether the presence of cortical dysfunction distinguishes PLS from HSP.

METHODS

Cortical excitability studies were undertaken on a cohort of 14 PLS, 82 ALS and 13 HSP patients with mutations in the spastin gene.

RESULTS

Cortical hyperexcitability, as heralded by reduction of short interval intracortical inhibition (PLS 0.26%, -3.8% to 1.4%; ALS -0.15%, -3.6% to 7.0%; P < 0.01) and cortical silent period duration (CSPPLS 172.2 ± 5.4 ms; CSPALS 178.1 ± 5.1 ms; P < 0.001), along with an increase in intracortical facilitation was evident in ALS and PLS phenotypes, although appeared more frequently in ALS. Inexcitability of the motor cortex was more frequent in PLS (PLS 71%, ALS 24%, P < 0.0001). Cortical excitability was preserved in HSP.

CONCLUSIONS

Cortical dysfunction appears to be an intrinsic process across the MND phenotypes, with cortical inexcitability predominating in PLS and cortical hyperexcitability predominating in ALS. Importantly, cortical excitability was preserved in HSP, thereby suggesting that the presence of cortical dysfunction could help differentiate PLS from HSP in a clinical setting.

Erosive potential of cola and orange fruit juice on tooth colored restorative materials

BACKGROUND

Erosion is a common condition which manifests due to consumption of high caloric and low pH acidic food stuffs such as carbonated drinks and fruit juices which cause irreversible damage to dental hard tissues and early deterioration of the dental restorations.

AIM

The main aim of this study is to evaluate and to compare the erosive potential of carbonated drink (cola) and fruit juice (orange fruit juice) by measuring the surface roughness (Ra) values on two commonly used dental restorative materials.

MATERIALS AND METHODS

A total of 36 specimens each were prepared using both testing materials, compomer (Group I) and giomer (Group II). Six specimens in each group were discarded due to wide variation in pre exposed Ra values and the remaining 30 specimens in each group were further sub divided into 10 samples each according to the testing media used. Immersion regime was followed according to Von Fraunhofer and Rogers. The pre and post immersion surface roughness values were recorded using a profilometer.

RESULTS

Both tested materials showed statistically-significant surface erosion (P < 0.01) when exposed to cola and orange fruit juice than the control group (water).

DISCUSSION

Compomer showed more surface roughness when compared to giomer when exposed to the three tested media which can be attributed to the variation in filler content, decomposition of resin matrix and fallout of the fillers in composites when exposed to acidic drinks. Other factors responsible for this significant erosion were also discussed.

CONCLUSIONS

Significant surface changes of the dental restorative materials can take place when exposed to low pH drinks for a prolonged period.

Glucocerebrosidase mutations in a Serbian Parkinson's disease population

BACKGROUND AND PURPOSE

To screen for glucocerebrosidase (GBA) mutations in a Serbian Parkinson's disease (PD) population.

METHODS

Glucocerebrosidase exons 8-11 harbouring the most common mutations were sequenced in 360 patients with PD and 348 controls from Serbia. Haplotype analysis was performed for the N370S mutation and compared with German and Ashkenazi Jewish carriers.

RESULTS

Glucocerebrosidase mutations were significantly more frequent in patients with PD (21/360; 5.8%) vs. controls (5/348; 1.4%; OR = 4.25; CI, 1.58-11.40; P = 0.0041). Two patients with PD carried homozygous or compound heterozygous mutations in GBA. The N370S mutation accounted for about half of the mutated alleles in patients (10/23) but was absent amongst controls. Three novel variants were detected including two non-synonymous variants (D380V, N392S) in the patient group and one synonymous change (V459V) in a control. Carriers of the D409H mutation were also sequenced for H255Q, and all were found to carry the [D409H; H255Q] double-mutant allele. Genotyping suggested a common haplotype for all N370S carriers.

CONCLUSION

Glucocerebrosidase mutations represent a PD risk factor in the Serbian population.

Delivering low-bandwidth telemedicine services over hybrid networks in developing countries

The results of medical specialist consultations sampled from several rural clinics located throughout India indicate that remote expert opinions can improve the speed and accuracy of diagnosis. Central to this presentation is a description of how real-time and store & forward telemedicine services can be provided to rural populations over hybrid networks made up of ISDN, POTS, VSAT, cellular, and Cable Internet connections. A model for meeting the specialized medical needs of developing countries will be highlighted. Descriptions, examples, and benefits of how Browser-based client-server architectures are being used in over 20 locations in India and Mexico for triaging real-time vital signs, DICOM images, audio & video, and clinical text information will be highlighted.

Chemical characterization of bovine urine with special reference to oestrus

Cows' urine was analysed by gas chromatography mass spectrometry (GC-MS). The profiles from preovulatory, ovulatory and postovulatory samples were compared to establish any qualitative and quantitative differences that might have potential value in olfactory communication. Dichloromethane was used as the solvent for extraction of the compounds. Seven different compounds were detected, of which only two were common to all the chromatograms. The chemical profile of oestrous urine was distinguished by the presence of two specific compounds, viz. di-n-propyl phthalate and 1-iodoundecane, that were not found in the other samples. As oestrous urine has been shown to elicit sexual behaviour in cattle, these two characteristic peaks may represent important chemical compounds that elicit signals that allow the bull to detect 'oestrous odours'.

Effects of case-load size on the process of care of patients with severe psychotic illness. Report from the UK700 trial

BACKGROUND

Studies of intensive case management (ICM) for patients with psychotic illnesses have produced conflicting results in terms of outcome. Negative results have sometimes been attributed to a failure to deliver differing patterns of care.

AIMS

To test whether the actual care delivered in a randomised clinical trial of ICM v. standard case management (the UK700 trial) differed significantly.

METHOD

Data on 545 patients' care were collected over 2 years. All patient contacts and all other patient-centred interventions (e.g. telephone calls, carer contacts) of over 15 minutes were prospectively recorded. Rates and distributions of these interventions were compared.

RESULTS

Contact frequency was more than doubled in the ICM group. There were proportionately more failed contacts and carer contacts but there was no difference in the average length of individual contacts or the proportion of contacts in the patients' homes.

CONCLUSIONS

The failure to demonstrate outcome differences in the UK700 study is not due to a failure to vary the treatment process. UK standard care contains many of the characteristics of assertive outreach services and differences in outcome may require that greater attention be paid to delivering evidence-based interventions.

Influence of the stage of the cycle on olfactory sensitivity in laboratory mice

Females in estrus showed maximum olfactory sensitivity as judged by their ability in locating the buried bait. The results suggest that olfactory sensitivity in females varies during the stages of the estrous cycle. The findings further indicate that gonadal steroids play an important role in the expression of olfactory sensitivity in females.

Electrophysiologic study of spraymen exposed to insecticide Lambda-cyhalothrin

Lambda-cyhalothrin ia a potent insecticide which acts by producing prolonging the duration of opening of sodium channels in neurons. While it is being used in several countries, no extensive neurophysiologic study of toxic effects in humans is available. We performed multimodality electro-physiologic studies in 15 spraymen in the age range of 19-48 years, before and after the exposure to this insecticide, with a view to detect any neurotoxic manifestation. Facial nerve conduction, blink response, repetitive stimulation test and visual, auditory and somatosensory evoked potentials were normal. Six subjects had mild changes in peripheral nerve conduction parameters. Comparison of mean values of the various nerve conduction studies in three subjects showed normal findings. We conclude that Lambda-cyhalothrin may produce transient, subclinical, electrophysiologic changes in the nerves of upper limb, possibly as a local toxic manifestation.

Exocrine pancreatic and beta-cell function in malnutrition-related diabetes among north Indians

OBJECTIVE

To compare the pancreatic exocrine and beta-cell function in the two variants of malnutrition-related diabetes mellitus (MRDM): fibrocalculous pancreatic diabetes (FCPD) and protein-deficient pancreatic diabetes (PDPD).

RESEARCH DESIGN AND METHODS

Fecal chymotrypsin (FCT) and fasting C-peptide levels were measured in 20 consecutive patients with FCPD and 19 with PDPD. FCPD was diagnosed by pancreatic calcification on ultrasonography, while the diagnosis of PDPD was made on the basis of low body mass index, severe diabetes requiring insulin therapy, and ketosis resistance on interruption of insulin. Twenty patients with type I diabetes and 32 healthy subjects served as control subjects.

RESULTS

Both FCPD and PDPD patients had diminished levels of FCT when compared with those of control subjects and patients with type I diabetes. However, FCT levels were significantly lower in subjects with FCPD (median 0.4 U/g, range 0-8.9 U/g), in comparison with those with PDPD (4.7 U/g, 0.6-40.5 U/g; P < 0.001). Of the FCPD patients, 13 of 20 (65%) had severe exocrine pancreatic deficiency (FCT < 1 U/g) vs. 3 of 19 (15.8%) PDPD subjects (P < 0.01). In comparison with control subjects, fasting serum C-peptide levels were significantly diminished in both MRDM groups. However, C-peptide levels in subjects with FCPD (mean +/- SE, 0.22 +/- 0.04 nmol/l) and PDPD (0.26 +/- 0.04 nmol/l) were comparable.

CONCLUSIONS

Among the two variants of MRDM, subjects with FCPD have severe pancreatic exocrine deficiency in comparison with those with PDPD, even though their C-peptide levels are comparably diminished. This suggests that the pathogenesis of these two entities may differ or that the genetic and/or environmental factors leading to exocrine damage are different.

Secondary mania following stroke

Stroke is rarely reported as one of the organic brain disorders which could give rise to secondary mania. This report describes a case of secondary mania following right fronto-parietal infarction.

Cushingoid adrenal hyperplasia in infancy

Cushing's syndrome, a characteristic pattern of obesity with hypertension due to the hyperfunction of the adrenal cortex, is relatively rare in infancy. Thirty-six infants have been reported in world literature, most of whom have had adrenal tumours. There are only eight reported cases of infants under the age of 1 year with adrenal hyperplasia responsible for Cushing's syndrome. This is a report of an 8 month old child with bilateral nodular adrenal hyperplasia.