Tick Paralysis: A Thorough Examination May Prevent Unnecessary Harm

Tick paralysis is a relatively uncommon tick-borne illness that is often overlooked and misdiagnosed. Therefore, it is not unusual for cases to undergo unnecessary work-up and interventions that may delay correct diagnosis and treatment, placing the patient at risk for catastrophic consequences. We present the case of a four-year-old female who developed ascending flaccid paralysis, initially misdiagnosed with Guillain-Barré syndrome (GBS). She was placed in the pediatric intensive care unit (PICU) for mechanical ventilation after failing to respond to intravenous immunoglobulin (IVIG) administration and plasmapheresis. Later in her hospital course, she was correctly diagnosed to have tick paralysis.

“Neurodevelopmental disorder with microcephaly, epilepsy, and brain atrophy” with a novel mutation

“Neurodevelopmental disorder with microcephaly, epilepsy, and brain atrophy” is a newly described disorder related to homozygous mutations in TRAPPC6B gene. Although nonspecific, the features of this disorder appear to have a characteristic course of postnatal progressive microcephaly that should raise the suspicion of this disorder. To the best of our knowledge, only eight cases were published in the literature. Here, we report a new case with a novel mutation and compare the clinical findings to the published cases. This case was not picked up by whole-exome sequencing but rather by whole-genome sequencing, emphasizing the importance of pursuing an etiological diagnosis in patients with otherwise unexplained progressive neurological disorders.

Effect of acute maximal exercise on lymphocyte subgroups in type 1 diabetes

The essential therapy of diabetes mellitus includes medical nutrition therapy (MNT), exercise and medical therapy. Exercise, besides its metabolic effects, has positive influence on the immune system, but some forms of exercise may cause trauma for muscle and skeletal systems, they may also support negative effects on the immune system. Nineteen type 1 diabetic patients (mean age 22.1 +/- 2.8 yrs), followed by Diabetes Outpatient Clinic and twenty age matched male control subjects were included into the study, to demonstrate the effects of maximal, acute exercise on the immune system. The exercise test was performed according to Bruce protocol on treadmill. In diabetic subjects, increased CD19 and CD23 expressions were observed before exercise. In both groups (diabetic/control) CD3, CD4 expressions and CD4/CD8 ratio were decreased following the exercise, however expression of natural killer (NK) cells increased. Compared to type 1 diabetic patients healthy subjects had longer acute exercise that caused the increased level of CD8 expression, however type 1 diabetic patients did not show any difference. These results indicate that submaximal aerobic exercise might be recommended for type 1 diabetics without any complications because of its positive reflection on metabolic control and no negative effects on the immune system.

Intracytoplasmic cytokine levels and neutrophil functions in early clinical stage of type 1 diabetes

Studies indicate that both CD4(+) and CD8(+) T lymphocytes and their cytokines play a critical role in different clinical stages of type 1 diabetes (T1D). Disturbances of oxidative burst and phagocytic activities in neutrophils of diabetic patients compared to uncontrolled disease support the importance of neutrophil functions in the treatment and follow up of diabetic patients. This study is designed in order to investigate Th1 and Th2 cytokine profiles and neutrophil functions in early clinical stage of T1D. Patients diagnosed as T1D but not yet under insulin therapy (Group 1; n=15) and T1D patients with disease duration of <3 months (Group 2; n=20) were compared to healthy subjects (Group 3; n=15). All subjects with T1D were positive for islet cell antibody (ICA) and glutamic acid decarboxylase antibody (GADA), their fasting glucose levels were >126 mg/dl and A1(c) levels were >8. Intracytoplasmic interleukin (IL)-2, IL-10, interferon (IFN)-gamma and tumour necrosis factor (TNF)-alpha levels of isolated CD4(+) and CD8(+) T cells, and neutrophil functions were determined by flow cytometry. Intracellular TNF-alpha level of CD4(+) T lymphocytes was significantly decreased in Group 1 compared to Group 2 and healthy subjects. In contrast, TNF-alpha in CD8(+) T lymphocytes was higher in Group 1 compared to Group 2. Increased TNF-alpha content of CD8(+) T lymphocytes was also obtained in Groups 1 and 2 compared to healthy subjects. Increased TNF-alpha secretion of CD8(+) T cells might reflect the role of CD8(+) T cells in beta cell destruction. Similar to cytokine content, phagocytic and oxidative burst activities in Group 1 were significantly lower compared to Group 2 and healthy subjects. Impaired neutrophil functions could be recovered by the treatment of the disease.

Prenatal anger effects on the fetus and neonate

One hundred and sixty-six women were classified as experiencing high or low anger during the second trimester of pregnancy. The high-anger women also had high scores on depression and anxiety scales. In a follow-up across pregnancy, the fetuses of the high-anger women were noted to be more active and to experience growth delays. The high-anger mothers' high prenatal cortisol and adrenaline and low dopamine and serotonin levels were mimicked by their neonates' high cortisol and low dopamine levels. The high-anger mothers and infants were also similar on their relative right frontal EEG activation and their low vagal tone. Finally, the newborns of high-anger mothers had disorganised sleep patterns (greater indeterminate sleep and more state changes) and less optimal performance on the Brazelton Neonatal Behavior Assessment Scale (orientation, motor maturity and depression). These data highlight the need for prenatal intervention for elevated angry mood during pregnancy.

Comparison of acarbose and gliclazide as first-line agents in patients with type 2 diabetes

AIM

To compare the effect of acarbose and gliclazide on clinical findings, biochemical parameters and safety in type 2 diabetic patients insufficiently controlled with medical nutrition therapy (MNT).

METHODS

Seventy-two patients (age 35-70 years, BMI < or = 35 kg/m2), who had not taken any oral antidiabetic drug previously, were randomised into two groups after a four-week placebo period, and treated for 24 weeks with acarbose (100 mg two to three times daily) and gliclazide (40-80 mg twice daily). The study was open and 57 patients (33 males and 24 females) completed it. MNT was provided for each patient based on personal requirements as defined by a dietitian. The effect of treatment was evaluated by fasting and postprandial (PP) metabolic parameters (blood glucose, insulin and C peptide levels), HbA1c and plasma lipid levels. In addition, side-effects were recorded and clinical examinations performed.

RESULTS

Both drugs were effective in reducing of HbA1c, fasting and PP blood glucose levels. However, PP serum insulin levels in the gliclazide group increased more than those in the group treated with acarbose (p = 0.007). Moreover, a small weight reduction was obtained with acarbose treatment but not with gliclazide. Lipid levels were favourably affected by both drugs. Total cholesterol levels decreased in both groups, the decrease only reaching significance in the acarbose group (p = 0.013). However, serum levels of LDL cholesterol decreased in both groups (acarbose and gliclazide, p = 0.033 and p = 0.023, respectively), but the ratio of HDL to LDL cholesterol increased in the acarbose group only (p = 0.045). Both treatments were generally well tolerated. Common complaints in the acarbose group were flatulence and meteorism (29.6%). However, 10.0% of the patients in the gliclazide group reported at least one mild hypoglycaemic episode.

CONCLUSIONS

The results of the study demonstrate that acarbose and gliclazide were reasonably effective in improving metabolic control in patients insufficiently controlled with diet alone, and both treatments were well tolerated. Because of its effects on weight reduction and PP hyperinsulinaemia, acarbose may be preferred as a first-line drug, particularly in the treatment of overweight type 2 diabetic patients.

Caudal regression syndrome: etiopathogenesis, prenatal diagnosis, and perinatal management

Caudal regression syndrome represents a continuum of congenital malformations ranging from agenesis of the lumbosacral spine to the most severe cases of sirenomelia with lower extremities fusion and major visceral anomalies. The etiology of this syndrome is not well known. Maternal diabetes, genetic predisposition, and vascular hypoperfusion have been suggested as possible causative factors. The degree of associated anomalies usually parallels the severity of the primary defect. Ultrasonography is the diagnostic tool of choice revealing the absent distal vertebrae of the fetal spine. Amnioinfusion and magnetic resonance imaging (MRI) are of help in better evaluation of the fetal anatomy in cases with oligohydramnios. Perinatal management depends mainly on gestational age at diagnosis and severity of the lesion. It should include genetic counseling and serial sonography to assess interval growth and amniotic fluid volume. Surviving infants have usually a normal mental function and they require extensive urologic and orthopedic assistance. Their long-term morbidity consists mostly of neurogenic bladder dysfunction resulting in progressive renal damage and disabling neuromuscular deficits of the lower extremities. Neurosurgical and orthopedic intervention with physical rehabilitation is indicated to improve the quality of their lives.

Removal of indwelling ureteral catheters with ultrasound guidance

Indwelling ureteral catheters are commonly used to splint injured ureters or to relieve obstruction. This study evaluated the possibility of using ultrasound guidance in the removal of internal ureteral catheters in women. During the 12-month period from August 1990 to August 1991, patients who desired the removal of indwelling ureteral catheters were sent to the outpatient ultrasound division instead of the urology clinic. They were instructed to come with a full bladder, or a saline infusion was required. Abdominal or vaginal ultrasound was first performed to locate the ureteral catheter. Blunt-tipped alligator forceps were used to remove the catheters under direct, real-time ultrasound guidance. A total of six catheters was removed from five patients. The average removal time was 12 +/- 4 (SD) minutes, with good patient acceptance. Further studies are required to establish the safety and efficacy of the procedure.

The Goldston syndrome: report of a case

We present a case of the Goldston syndrome--that is, cystic renal dysplasia and the Dandy-Walker malformation. The condition was diagnosed by ultrasound in a 635 g fetus in the seventeenth week of gestation. Ultrasound studies showed the fetal head to be somewhat enlarged with slight dilatation of the lateral ventricles and marked dilatation of the fourth ventricle. The kidneys were symmetrically enlarged and multicystic. Autopsy revealed evidence of the oligohydramnios syndrome. The kidneys were typical of the Goldston syndrome as were the microscopic lesions in the liver. To our knowledge this is the first reported case in which this diagnosis was made during intrauterine life.