Imaging manifestations of IgG4-related disease

IgG4-related disease is a multisystem immune-mediated disorder associated with lesions manifesting an IgG4-rich plasma cell infiltrate and often raised serum IgG4 concentrations. The disease can mimic neoplastic, infective, and inflammatory processes due to features such as development of masses or organ enlargement. Prompt consideration of this diagnosis is essential to avoid unnecessary investigations and offer appropriate treatments, which can include steroids and other immunosuppressive agents. Although histology is typically diagnostic, imaging is critical to assess disease burden, determine biopsy targets, and evaluate response to treatment. Characteristic imaging features can also point towards the diagnosis in the absence of biopsy. This review highlights these features, as well as more atypical findings, grouped by organ or system. Differential diagnoses are emphasised. The full spectrum of imaging methods is discussed. Whole-body imaging with integrated 2-[18F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET)/computed tomography (CT) has an evolving role in the detection of multi-organ involvement and subsequent follow-up.

Imaging of transcatheter aortic valve replacement complications

Aortic stenosis is increasing in incidence and is now commonly managed with transcatheter aortic valve replacement (TAVR) in intermediate and high-risk patients. Radiologists are likely to encounter patients undergoing this procedure both pre- and postoperatively, and therefore, an understanding of procedural complications is essential. Complications may relate to the access site or approach, or the valve itself. This article will review the most common complications described in literature and focuses on the role of multidetector computed tomography (CT) in their evaluation either exclusively, or complementary to other imaging methods.

Identifying patients at risk of acute symptomatic seizure after ischemic stroke

BACKGROUND

Contributors to post-stroke seizure research have advocated the need for prospective studies of acute symptomatic seizures after stroke. Identification of the patient at risk of seizure and the impact of the event on outcome is a prerequisite for this kind of research. The aim of this study was to identify risk factors, make an outline for a risk score, and look at consequences of seizure on short-time clinical outcomes.

METHODS

This registry-based study included patients with ischemic stroke admitted between 2007 and 2013. We identified variables associated with the presence of acute symptomatic seizures and made a risk score. Clinical outcome measures were modified Rankin scale, National Institute of Health Stroke Scale (NIHSS), and death at discharge or at day seven.

RESULTS

A total of 2598 ischemic stroke patients were included, 66 experiencing seizure within seven days of stroke. We found diabetes mellitus, NIHSS on admission, and cortical lesion to be associated with the risk of seizure. The risk score had a sensitivity of 58%, specificity of 85%, and a positive predictive value of 9% with a three-point cutoff. We found a negative effect of seizure on survival in mild-to-moderate strokes after adjusting for infections and stroke severity.

CONCLUSIONS

Because of low incidence and the lack of specific risk factors, acute symptomatic seizure after ischemic stroke is hard to predict. The negative effect of seizure on stroke outcome is uncertain, and more thorough studies are needed because of possible subtle or non-overt seizures.

WIN OVER study: Efficacy and safety of olmesartan in Indian hypertensive patients: results of an open label, non-comparative, multi-centric, post marketing observational study

BACKGROUND

Hypertension is a global health problem. Multiple classes of drugs including angiotensin receptor blockers (ARBs) are available for the treatment of hypertension. Olmesartan is a relatively newer ARB used in hypertension management.

OBJECTIVE

To assess the efficacy and safety of WIN-BP (Olmesartan 20 mg/40 mg) tablet in Indian patients with hypertension.

MATERIAL AND METHODS

An open label, non-comparative, multi-centric, real world post marketing observational study included Indian adult hypertensive patients who were treated with olmesartan 20 mg/40 mg tablet once daily for six months. The primary outcome was reduction of systolic blood pressure (SBP) to <140 mmHg and diastolic BP (DBP) to <90 mmHg at 3 and 6 months after initiation of treatment with olmesartan. All reported adverse events were recorded.

RESULTS

A total of 8940 patients were enrolled in this study. Baseline SBP of 164 mmHg was reduced to 153, 145, 134 and 130 mmHg at the end of 15 days, 1, 3 and 6 months respectively. Similarly, baseline DBP of 100 mmHg was reduced to 93, 89, 84 and 82 mmHg at the end of 15 days, 1, 3 and 6 months respectively. The reduction in both systolic and diastolic blood pressure from day 15 to month 6 was statistically significant (p < 0.0001) with olmesartan treatment. The percentage of responders for both systolic and diastolic blood pressure increased consistently from day 15 to month 6. Only 0.08% patients reported the adverse events. No serious adverse event was reported in the study.

CONCLUSION

Olmesartan 20 mg/40 mg is effective and well tolerated without any serious adverse events in patients with hypertension.

[Amputation of the hand due to necrotising fasciitis: a case report]

We report the case of an 81-year-old woman who fell at home on her left hand and suffered a laceration of her forehead. Within days a fulminant necrotizing fasciitis of the hand from group A β-haemolytic streptococcus developed. Lacking an apparent local germ entry point at the hand, the infection was initially misinterpreted as compartment syndrome. The patient's life was saved by amputation of the hand.

[Fused little finger in the palm after operation for recurrent Dupuytren's contracture]

A 72-year-old woman suffered from Dupuytren's contracture of her right little finger, which was treated operatively 3 times in 4 years. However, the finger bent back into the palm. Over time she hid her little finger in the fist. In 2010, she presented with the hand in our office. Surprisingly a fused finger in the palm was observed. The woman reported that she had ignored her little finger and that it was no longer present in her conscious mind.

Intramedullary nailing for pathological femoral fractures

PURPOSE

To evaluate whether the operating time correlates with the survival and outcome in patients who underwent intramedullary nailing for metastatic femoral fractures.

METHODS

Records of 10 men and 11 women aged 43 to 86 (mean, 66) years who underwent intramedullary nailing (4 bilaterally) for metastatic femoral fractures between 1999 and 2003 were reviewed. The patients were followed up for at least 2 years or until their death. The main outcome measure was the correlation between operating time and survival. Operating time was categorised into 5 groups from 60 to 210 minutes, with 30-minute increments.

RESULTS

Operating time does not correlate with survival and outcome. The mean survival period was 9.4 months. Pain relief was achieved in 90% of the patients. There was no implant failure, but one loss of reduction.

CONCLUSION

Intramedullary nailing appears safe and effective for treatment of metastatic bone disease, and confers good functional results, pain relief, and mobility.

Retinal nerve fibre layer imaging compared with histological measurements in a human eye

PURPOSE

A feasibility study comparing retinal nerve fibre layer (RNFL) thickness values obtained with imaging devices against RNFL thickness measurements obtained histologically in a human eye.

DESIGN

A single patient scheduled for orbital exenteration, who still possessed a healthy functioning eye.

METHODS

Before surgery, the eye was imaged using optical coherence tomography (OCT) and scanning laser polarimetry (SLP). After orbital exenteration, the globe was sectioned, and 100 equidistant RNFL thickness measurements were obtained for each of four concentric rings centred on the optic disc, with diameters of 3.0, 3.5, 4.0, and 4.5 mm.

RESULTS

RNFL thickness was found to be inversely related to the distance from the centre of the optic disc along each radial meridian. Peripapillary RNFL thickness was found comparable for histology, OCT, and SLP. RNFL thickness measured histologically confirmed a 'double hump' pattern, peaking at the superior and inferior poles. Histologically derived RNFL thickness (microm), at 3.0 and 3.5 mm diameter ring ranged between 30-135 and 25-115 respectively. In comparison, the 3.0 mm diameter GDx data ranged between 25 and 100, and the 3.4 mm diameter OCT data between 40 and 175.

CONCLUSIONS

Imaging data appear qualitatively similar when compared to the histologically derived data. Quantitative differences may be partly due to scaling differences and histological artefacts. The histological analysis approach demonstrated in this study can potentially serve to validate imaging-derived data, as well as help improve our understanding of RNFL loss in glaucoma.

N-Alkyl-N-arylmethylpiperidin-4-amines: Novel dual inhibitors of serotonin and norepinephrine reuptake

A series of N-alkyl-N-arylmethylpiperidin-4-amines have been prepared and are demonstrated to be inhibitors of both serotonin and norepinephrine reuptake.

Clinico-radiological profile of stroke in eastern Nepal: a computed tomographic study

AIM

Stroke is a frequent cause of death and disability in elderly patients. This study was carried out to establish the pattern of various types of cerebrovascular accident (CVA) in eastern Nepal and to correlate the clinical data and radiological findings in cases of stroke.

MATERIALS AND METHODS

All the patients clinically diagnosed as stroke and referred to the radiology department for Computed tomography (CT) of the brain over a period of 1 year were included.

RESULTS

There were 150 patients with stroke (104 males and 46 females), aged 7 to 91 years in which infarction (58%) was more common than haemorrhage (42%) in both group of age (< or = 40 years and > 40 years). Smoking was the commonest risk factor noted in 40.66% cases followed by hypertension (40%). Excessive meat consumption (more than 4 times a week) was seen in 69.1% cases. In early Middle Cerebral Artery (MCA) territory infarction presenting within six hours of onset, positive CT findings were seen in 40% cases among which, obscuration of the lentiform nuclei was diagnostic.

CONCLUSION

In this part of Nepal, infarction is more common than haemorrhage as the cause of stroke and in contrary to western population; hemorrhagic stroke constitutes a significantly higher proportion of stroke. Smoking is the commonest risk factor followed by hypertension and it is also seen in combination with alcohol in many cases. Excessive meat consumption could be an additional risk factor for stroke in this part of Nepal. In younger age group (< or = 40 years), haemorrhage is more common than infarction and alcohol consumption is the commonest risk factor.

Multiple hemangiomas involving the vertebral column

Hemangiomas are benign, slow-growing skeletal and soft tissue tumors that commonly involve the bony spine. When found in the spine, they are usually asymptomatic, but can sometimes be associated with local pain and/or neurological deficits. We report the case of a middle-aged Indian male with multiple hemangiomas involving almost all the vertebrae contiguously from C2 to S1 vertebral levels. These were discovered incidentally when a magnetic resonance scan was performed for backache. To the best of our knowledge, such extensive involvement of the spine has not been reported previously.

A single blind, prospective, randomized trial comparing n-butyl 2-cyanoacrylate tissue adhesive (Indermil) and sutures for skin closure in hand surgery

Fifty patients underwent a variety of hand operations and were randomized for wound closure either with tissue adhesive (Indermil) or sutures. The two treatment groups had similar demographic characteristics and similar outcomes at the 2 and 6 week postoperative assessments which were performed by a designated tissue viability nurse blinded to the method of closure. Five minor wound dehiscences occurred: three in the adhesive group and two in the suture group. No infection occurred in either group. In conclusion, the study demonstrates tissue adhesive is as effective as suture in this type of hand surgery.

Giant coronary aneurysms with multiple vascular aneurysms: a rare manifestation of hyperhomocysteinemia

Hyperhomocysteinemia is associated with accelerated atherosclerosis, which leads to an increased incidence of premature vascular disease. Although multiple vascular aneurysms have been linked to hyperhomocysteinemia, coronary artery aneurysms have not. We report a case of giant coronary artery aneurysm associated with multiple peripheral vascular aneurysms in a patient with hyperhomocysteinemia.

[Mental impairment in nursing home residents]

BACKGROUND

Nursing homes are the corner stones in long-term institutional care for frail elderly people. Expansion and strengthening of community-based services during the last decade has enabled frail elderly who earlier would have moved into a nursing home to stay in their own home or in service apartments.

MATERIAL AND METHODS

In a cross-sectional, anonymised study, changes in nursing homes in the city of Bergen between 1985 and 1996/97 were analysed with regard to prevalence of mentally impaired residents. The following items were assessed by nurses who were in daily contact with the residents: mental capacity by means of Clinical Dementia Rating (CDR), activities of daily living (ADL), and behaviour. The study population consisted of 1,296 residents from 21 institutions in 1985 and 1,141 residents from 16 institutions i 1996/97.

RESULTS

The percentage of mentally impaired residents increased significantly, from 75 to 82, and the percentage of residents who were in need of extended nursing care rose from 87 to 91. The median duration of stay did not change significantly, but was reduced for residents with slight mental impairments (CDR 1), from 871 to 721 days.

INTERPRETATION

Today, predominately mentally impaired and physically disabled elderly are cared for in general nursing homes. These are patients in need of continuous medical care and supervision, and do not fit into an ideology which "demedicalizes" severe medical conditions in old people. Both nursing homes and sheltered livings are needed.

Drug use in homes for the aged. A comparison between mentally intact and mentally impaired residents

The aim of this study was to analyze drug use in 347 residents in homes for the aged in Bergen, Norway. All drugs prescribed on a regular schedule were assessed, the prevalence of potentially harmful drug combinations, and inappropriately prescribed drugs were studied and related to mental capacity of the residents. Mental capacity was assessed by means of the Clinical Dementia Rating scale (CDR). The median number of drugs used was 4.0 (range 0-11, 95% CI 3.0-4.0). Mentally impaired residents consumed fewer drugs than mentally intact ones. In a logistic regression analysis the use of NSAIDS, beta-blockers and anxiolytics was significantly lower in mentally impaired residents (OR 0.37, 95% CI 0.17-0.80, OR 0.35, 95% CI 0.13-0.95, and OR 0.45, 95% CI 0.21-0.94, respectively), and the use of laxatives and vitamin B-12 higher (OR 2.19, 95% CI 1.04-4.62, and OR 5.08, 95% CI 1.11-23.25, respectively). Twenty percent of mentally intact and 21% of mentally impaired residents have potentially harmful two-by-two drug combinations, and drugs augmenting sedating properties were dominating. The prevalence of inappropriately used drugs was significantly lower in mentally impaired residents (20%) than in mentally intact ones (33%). Antidepressants with anticholinergic properties, benzodiazepines with long half-life and phenothiazines were the most frequent.

Xanthogranulomatous oophoritis--a case report

This is a case of a 25 year old unmarried women who presented with intermittent fever and lower abdominal pain. Laparotomy revealed a large cystic left sided tuboovarian mass adherent to surrounding structures and containing foul smelling fluid. Microscopy showed extensive replacement of the ovary by a chronic inflammatory exudate composed predominantly of foamy macrophages.

[Changes among residents in homes for the aged in Bergen between 1985-96]

Homes for the aged are intended for elderly people who, by and large, are able to perform basic activities of daily living (ADL) on their own, but who, in spite of this, need or wish to live in an institutional setting, where only minor nursing facilities are available. The present study focuses on the changes in mental capacity and in the altered need for nursing assistance with ADL functions which developed among residents at 13 homes for the aged in the city of Bergen, between 1985 and 1996. In 1985, the average age for residents was 84 years; and in 1996 it was 87 years. The average duration of stay was 30 and 38 months, respectively. There was a significant increase in the proportion of mentally impaired residents (28% and 35%). There was also an increase in the percentage in need of intensive nursing care (34% and 41%). The changes in residents living in the homes were not caused by dementia. It is concluded that homes for the aged are used increasingly for elderly in need of nursing care. There is an obvious mismatch between tasks and resources.

Sequential respiratory, psychologic, and immunologic studies in relation to methyl isocyanate exposure over two years with model development

Of 113 methyl isocyanate (MIC)-exposed subjects studied initially at Bhopal, India, 79, 56, 68, and 87 were followed with clinical, lung function, radiographic, and immunologic tests at 3, 6, 12, 18, and 24 months. Though our cohort consisted of subjects at all ages showing a varied severity of initial illness, fewer females and young subjects were seen. Initially all had eye problems, but dominant symptoms were exertional dyspnea, cough, chest pain, sputum, and muscle weakness. A large number showed persistent depression mixed with anxiety, with disturbances of personality parameters. The early radiographic changes were lung edema, overinflation, enlarged heart, pleural scars, and consolidation. The persistent changes seen were interstitial deposits. Lung functions showed mainly restrictive changes with small airway obstruction; there was impairment of oxygen exchange. Oxygen exchange improved at 3-6 months, and spirometry improved at 12 months, only to decline later. The expiratory flow rates pertaining to large and medium airway function improved, but those for small airways remained low. There were changes of alveolitis in bronchoalveolar lavage fluid on fiber optic bronchoscopy, and in 11 cases positive MIC-specific antibodies to IgM, IgG, and IgE were demonstrated. On follow up, only 48% of the subjects were clinically stable, while 50% showed fluctuations. Thirty-two percent of the subjects had lung function fluctuations. Detailed sequential behavior over 2-4 years was predicted for dyspnea, forced vital capacity, maximum expiratory flow rate (0.25-0.75), peak expiratory flow rate, VO2, and depression score. A model for clinical behavior explained a total variance of 52.4% by using the factors of cough, PCO2 and X-ray zones in addition to above five parameters. The behavior of the railway colony group (1640 patients) revealed a similar pattern of illness. When this observed pattern of changes was transferred to the affected Bhopal city sections (with an equitable age-sex distribution), our model results were again validated. Thus the picture of MIC-induced disease seems similar despite the differences for age-sex and initial severity of illness in our cohort and in the population of Bhopal city as predicted by our model.

A comparison of the effects of dietary cadmium on heart and kidney antioxidant enzymes: evidence for the greater vulnerability of the heart to cadmium toxicity

This study demonstrates the greater susceptibility of the heart as compared to the kidney to cadmium in the presence of high dietary selenium. Male weanling rats were fed an adequate-copper low-selenium feed supplemented with 0, 10 or 50 ppm copper with or without 50 ppm dietary cadmium for 7 weeks. All rats received 0.5 ppm selenium in their drinking water. Cadmium treatment resulted in histopathological lesions in the heart, but not in the kidney. Although cadmium treatment resulted in more extensive effects on glutathione peroxidase and superoxide dismutase in the heart as compared to the kidney, no increase in peroxidation was noted in either organ, suggesting that cadmium cardiotoxicity can be dissociated from tissue peroxidation. Mean cadmium concentrations in the heart ranged from 0.55 to 1.22 micrograms cadmium g-1 tissue, wet weight, and in the kidney from 11.53 to 21.04 micrograms cadmium g-1 tissue, wet weight. In both tissues examined, cadmium levels were influenced by dietary copper and heart cadmium concentrations did not correlate with either the biochemical or histological lesions observed. Thus, tissue cadmium levels alone may not be adequate for predicting cadmium toxicity.

P-glycoprotein expression in multidrug-resistant human ovarian carcinoma cell lines

Multiple selections with either vinblastine or vincristine in the human ovarian carcinoma cell line SKOV3 resulted in variants with increasing degrees of multidrug resistance. SKOV3 derivatives that span a wide range in resistance (4- to 2000-fold) were obtained and analyzed for P-glycoprotein expression. In general, we observed a progressive increase in P-glycoprotein level (detected by Western blot) that paralleled the increase in multidrug resistance. However, a more detailed analysis of the P-glycoprotein mRNA and gene level indicated that the amount of P-glycoprotein expressed may be under complex control. At low levels of resistance, only an increase in P-glycoprotein mRNA and protein was observed. At intermediate to high levels of resistance P-glycoprotein gene amplification became evident. At the high level of resistance, an example was observed where only the amount of P-glycoprotein was increased without a concomitant increase in mRNA or gene copy. The mechanisms through which the content of P-glycoprotein in the plasma membrane is mediated are not understood; it is possible that the resistant variants identified here represent perturbations at different levels of regulation.

Resistance of multidrug-resistant lines to natural killer-like cell-mediated cytotoxicity

Multidrug resistance (MDR) refers to a complex phenotype that describes a number of features characterized primarily by resistance to a wide range of structurally unrelated drugs. In this paper we investigated the relationship between drug resistance and resistance to NK-mediated cytotoxicity. Studies with two independently selected multidrug-resistant cell lines indicated that increased drug resistance was associated with both an increased resistance to NK-mediated cytotoxicity and increased levels of membrane P-glycoprotein expression. This resistance to cytotoxicity appears to result partly from an alteration in the membrane structure of the target cells inasmuch as there was a reduction in effector:target cell recognition. Resistance to NK-mediated cytotoxicity should be included with the numerous pleiotropic changes associated with the multidrug resistance phenotype.

Expression of hamster P-glycoprotein and multidrug resistance in DNA-mediated transformants of mouse LTA cells

The overexpression of a plasma membrane glycoprotein, P-glycoprotein, is strongly correlated with the expression of multidrug resistance. This phenotype (frequently observed in cell lines selected for resistance to a single drug) is characterized by cross resistance to many drugs, some of which are used in cancer chemotherapy. In the present study we showed that DNA-mediated transformants of mouse LTA cells with DNA from multidrug-resistant hamster cells acquired the multidrug resistance phenotype, that the transformants contained hamster P-glycoprotein DNA sequences, that these sequences were amplified whereas the recipient mouse P-glycoprotein sequences remained at wild-type levels, and that the overexpressed P-glycoprotein in these cells was of hamster origin. Furthermore, we showed that the hamster P-glycoprotein sequences were transfected independently of a group of genes that were originally coamplified and linked within a 1-megabase-pair region in the donor hamster genome. These data indicate that the high expression of P-glycoprotein is the only alteration required to mediate multidrug resistance.

Leukocyte and neutrophil counts in healthy Puerto Rican children and children with acute appendicitis

Blood counts were performed on 107 healthy Puerto Rican children aged 1 to 5 years to establish normal ranges of leukocyte and neutrophil counts and were compared with preoperative counts in 30 Puerto Rican children with acute appendicitis and also with values published in healthy black and white children of the same age. In healthy Puerto Rican patients and in patients with acute appendicitis, the mean leukocyte and neutrophil counts were significantly higher than in blacks.