Lyme neuro-borreliosis in a 66-year old women. Differential diagnosis of cerebral metastases and cerebral infarction]

A 66-year-old woman with medically treated hypertension and a recent operation for breast cancer was admitted because of burning pain localized between her shoulder blades and a paretic, dysaesthetic right arm. CSF examination revealed lymphocytic pleocytosis and specific IgM Borrelia burgdorferi antibodies. CT was normal. The patient was treated intravenously with high doses of penicillin for 14 days, and within one month of admission she had recovered completely neurologically. During the first days of treatment a drop in blood pressure, ECG changes, and further neurological changes were observed, but disappeared spontaneously within three days. The patient did not recall a tick bite, and the case illustrates that neuroborreliosis may be a differential diagnosis to stroke or cerebral neoplasms in elderly patients.     

Diffusion-weighted MR of acute cerebral infarction: comparison of data processing methods

BACKGROUND AND PURPOSE: Some investigators have proposed that either calculated diffusion trace images or apparent diffusion coefficient (ADC) maps, which require imaging with multiple diffusion sensitivities and/or postacquisition image processing, are essential for the accurate interpretation of diffusion-weighted images in acute stroke because of the possible pitfalls of regional diffusion anisotropy, magnetic susceptibility artifacts, and confounding T2 effects, all of which alter signal on diffusion-weighted MR images. The purpose of our study was to compare the sensitivity, specificity, and accuracy of simple, orthogonal-axis diffusion-weighted imaging for the diagnosis of early cerebral infarction with three other sets of postacquisition-processed images: isotropic diffusion-weighted, diffusion trace-weighted, and diffusion trace images. METHODS: Twenty-six consecutive adult patients with signs and symptoms consistent with a clinical diagnosis of early cortical and/or subcortical cerebral infarction and 17 control subjects were studied with multisection, single-shot, spin-echo echo-planar diffusion-weighted imaging at 1.5 T to generate a set of three orthogonal-axis diffusion-weighted images. Isotropic diffusion-weighted, diffusion trace-weighted, and diffusion trace (mean ADC) images were then generated off-line and all four sets of images were interpreted blindly by two neuroradiologists. RESULTS: The average sensitivity, specificity, and accuracy for the orthogonal-axis diffusion-weighted images were 98.1%, 97.1%, and 97.7%, respectively. The average sensitivity, specificity, and accuracy for isotropic diffusion-weighted images were 88.5%, 100%, and 93% respectively. The average sensitivity, specificity, and accuracy for diffusion trace-weighted images were 82.7%, 73.6%, and 79.1%, respectively. The average sensitivity, specificity, and accuracy for diffusion trace images were 50.0%, 85.3%, and 64.0%, respectively. CONCLUSION: Orthogonal-axis diffusion-weighted images have the highest sensitivity and accuracy and very high specificity for early cerebral infarction. Our data contradict the contention that quantitative diffusion maps, requiring imaging with multiple diffusion sensitivities and/or subsequent image processing, are necessary for clinical stroke imaging.     

Diffusion-weighted MRI detectability of acute cerebral ischemia: comparison with eventual infarction]

OBJECTIVE: To evaluate the seasonal influence, signalment, type of hay consumed, clinical examination findings, and outcome after surgery for horses with ileal impaction. STUDY DESIGN: A retrospective study. RESULTS: Between 1988 and 1993, 28 horses had surgical correction of ileal impaction. There was a significantly higher rate of ileal impaction during the Fall (September-November, P = .0041 ). Mean duration of clinical signs of abdominal pain before referral was 15 hours. Transrectal palpation was used to localize the impaction in 11 horses. The ileal impaction was reduced by extraluminal massage aided by admixing of intestinal fluid oral to the impaction or injection of fluids intraluminally and then movement of the ingesta into the cecum alone in 24 horses. A total of 26 horses recovered from surgery; 24 horses were discharged from the hospital and eventually returned to previous use. Two horses had fatal postoperative complications: jejunocecostomy dehiscence and development of extensive small intestine adhesions after manual reduction of the impaction. One horse initially treated by manual reduction required jejunocecostomy twice for management of recurrent ileal impaction. Follow-up information was obtained for 21 horses, of which 20 were alive 1 year or longer after surgery. A total of 27 of 28 horses were fed Coastal Bermudagrass hay as the primary type of hay consumed. A total of 9 horses continued to be fed Coastal Bermudagrass hay as the only roughage source, whereas 6 horses were fed Coastal Bermudagrass with at least 50% other hay, and in 6 horses, Coastal Bermudagrass hay was entirely eliminated from the diet. CONCLUSION AND CLINICAL RELEVANCE: Ileal impactions can be successfully reduced by celiotomy and extraluminal massage and injection techniques to soften the ingesta for passage into the cecum without enterotomy or bypass techniques in most horses. Changes in weather and feeding practices in the Fall may account for an increased risk of ileal impaction in horses in the southeastern United States at that time of year.     

Age-related trends in short- and long-term survival after acute myocardial infarction: a 20-year population-based perspective (1975-1995)

This study examines age-related differences and temporal trends in hospital and long-term survival after acute myocardial infarction (AMI) over a 2-decade-long (1975 to 1995) experience. A total of 8,070 patients with validated AMI hospitalized in all acute care hospitals in the Worcester, Massachusetts, metropolitan area (1990 census population 437,000) were studied over 10 one-year periods between 1975 and 1995. This population included 1,326 patients aged <55 years (16.4%), 1,768 patients aged 55 to 64 years (21.9%), 2,325 patients aged 65 to 74 years (28.8%), 1,880 patients aged 75 to 84 years (23.3%), and 771 patients aged > or = 85 years (9.6%). Compared with patients <55 years, patients 55 to 64 years were 2.2 times more likely to die during hospitalization for AMI, whereas patients 65 to 74, 75 to 84, and > or = 85 years were at 4.2, 7.8, and 10.2 times greater risk of dying, respectively. Similar age disparities in the risk of dying were seen when controlling for additional prognostic factors. Despite the adverse impact of increasing age on hospital survival after AMI, declining in-hospital death rates were seen in each of the age groups under study, with declining magnitude of these trends with advancing age. Among discharged hospital patients, increasing age was related to a significantly poorer long-term prognosis. Trends toward improving long-term prognosis were seen in patients discharged in the mid-1990s compared with those discharged in the mid- to late 1970s for patients aged <85 years. The present results demonstrate the marked impact of advancing age on survival after AMI. Despite the adverse impact of age on prognosis, encouraging trends in prognosis were observed in all age groups, although to a lesser extent in the oldest elderly patients. These findings emphasize the low death rates in middle-aged patients with AMI and the need for targeted secondary prevention efforts in elderly patients with AMI.     

Decreased rejection and improved survival of first and second marrow transplants for severe aplastic anemia (a 26-year retrospective analysis)

Between 1970 and 1996, 333 patients with severe aplastic anemia underwent HLA-matched related marrow transplant after conditioning with cyclophosphamide (CY). Thirty-five percent of patients transplanted between 1970 and 1976 (group 1), 12% of those transplanted between 1977 and 1981 (group 2), and 9% of patients transplanted between 1982 and 1997 (group 3) had graft rejection. Graft rejection occurred later among group 3 patients (median, 180 days) than among those in groups 1 and 2 (medians, 28 and 47 days, respectively; P < .001 group 3 v 2). In group 3, 92% of rejecting patients underwent a second transplant, compared with 78% and 77% in groups 1 and 2, respectively. Group 1 patients received various conditioning regimens before second transplant, whereas most patients of groups 2 and 3 received CY combined with antithymocyte globulin (ATG). Graft-versus-host disease (GVHD) prophylaxis after second transplant consisted of methotrexate (MTX) for all group 1 and 2 patients, whereas group 3 patients received MTX combined with cyclosporine (CSP). Over the three time periods studied, first graft rejection decreased from 35% to 9%, and the proportion of rejecting patients undergoing second transplants increased from 77% to 92%. The 10-year probability of survival after second transplants increased from 5% to 83%. Multivariate analysis showed MTX/CSP GVHD prophylaxis to be a significant factor accounting for the increase in patient survival after second transplant.     

Advanced endocrine cell carcinoma of the gallbladder: a patient with 12-year survival

Gallbladder carcinoid is a rare disease. In previous reports, classical carcinoid, an entity with a good prognosis, has not been distinguished from endocrine cell carcinoma, a tumor associated with marked cell atypia and mitosis, and a poor prognosis. The patient was a 66 year old woman who presented to our hospital with a chief complaint of jaundice. Pre-operatively, she was diagnosed as having advanced gallbladder carcinoma invading the liver and the hepatic hilus. The patient underwent right hepatic trisegmentectomy with en bloc resection of the caudate lobe and extrahepatic bile ducts, extended lymph node clearance and left hepaticojejunostomy. Histopathological examination showed positive Grimelius staining, marked mitosis, and intense atypism, hence, the tumor was diagnosed as an endocrine cell carcinoma. Twelve years after surgery, the patient is healthy, without any sign of recurrence. We present this novel case of long-term survival and review the literature.     

The cost of treatment of psychiatric emergencies: a comparison of hospital and community services

This study aimed to compare the costs of treatment by community-based and hospital-based psychiatric services. The design entailed random allocation of patients presenting with psychiatric emergencies over a subsequent 3-month period to one of two services, followed by retrospective quantification of service use and its cost for each group. One hundred patients with emergency presentations to the psychiatric service via the Accident and Emergency Department, liaison psychiatrist and approved social worker were included in the study. Their use of a range of terms of service was recorded and disaggregated costings of these items of service was calculated. The use of non-psychiatric services was similar for both groups, but the use of psychiatric services differed, with the hospital group making greater use of in-patient beds and the community group employing more frequent home-based interventions. The total cost of treatment for the community group (pound 56,000) was much lower than for the hospital group (pound 130,000), although the median patient cost was 50% higher in the community group (pound 938 v. pound 610), and a greater proportion of the community service expenditure (10% v. 2%) was due to failed contacts. Taken together with clinical outcome, which showed no advantages for the hospital-based service over the community-based service, our findings suggest that this form of community psychiatric service is a cost-efficient alternative to hospital-based care for this group of patients.     

Phototherapy: clinical and therapeutic evaluation of a 2-year experience

Cationic lipids are widely used for in vitro gene transfer due to their efficiency. The major challenges for the improvement of in vivo cationic lipid-mediated gene delivery reside in the design of more biocompatible lipoplexes mimicking viral-mediated gene delivery and in understanding the fate of the lipoplexes within the cells.     

Lacunar infarct and deep cerebral hemorrhage: a comparison of the risk factors

INTRODUCTION: Lacunar infarcts (LI) and deep cerebral hemorrhages (DCH) have the same localization and a vasculopathy which appears to be similar, at the level of the small perforating arteries, classically attributed to arterial hypertension (AHT). OBJECTIVES: To compare the vascular risk factors of patients with lacunar ictus (LIc) and those with DCH, to try to determine how these may affect the appearance of one type of stroke or another. PATIENTS AND METHODS: We analyzed a prospective consecutive series of patients with cerebral vascular accidents (CVA), selecting 1,540 patients in the first 1,155 with a first CVA. We recorded demographic data and the following risk factors: previous transient ischemic accident (TIA), AHT, diabetes mellitus (DM), hypercholesterolemia, ischemic cardiopathy, atrial fibrillation and the presence of silent infarcts on CT. RESULTS: Two hundred and four patients had LIc and 163 had DCH. There was a significant dissociation between LIc and a history of TIA, DM, hypercholesterolemia and the presence of silent lacunar-type infarcts on CT. However, after multivariant analysis, DM did not continue to be an independent variable. Arterial blood pressure was found to be greater in the DCH group. CONCLUSIONS: The presence of different risk factors for LIc and DCH may be the key to understanding the mechanism which leads to one type or other of CVA.     

Age of onset for binge eating and purging during late adolescence: a 4-year survival analysis

Protection of the vein of Labbé is a significant concern during surgery that involves retraction of the temporal lobe. A cranial base surgical approach, especially one via the presigmoid-petrosal route, carries considerable risk to this venous complex. A case is presented in which a large dominant vein of Labbé was injured during resection of a petroclival meningioma. This vein drained all the sylvian venous circulation as well as the lateral temporal surface; no connection to another venous system was noted. The vein was successfully reconstructed using a short saphenous vein bypass graft. Significant complications could have occurred without this reconstruction. The technique and benefits of this type of reconstruction are discussed.     

Cytogenetic and molecular biology for acute leukemias at diagnosis: a cost/effectiveness comparison

This article presents a cost-effectiveness study comparing cytogenetic and molecular analyses for detection of chromosomal abnormalities which are prognostic factors in acute leukemia. The aim of the study was to determine how these two techniques could substitute or complement one another. The study sample consisted of 107 adult patients with de novo myeloid or lymphoid acute leukemias, tested by both techniques in 1994 and 1995, for identification of translocations t(9;22), t(8;21), t(15;17), t(4;11), t(1;19), the inversion of chromosome 16 and for monosomy 5 or 7 (or deletion of their long arms) and trisomy 8. The criterion for diagnostic effectiveness of these strategies was the rate of detection of true positive anomalies which are clinically relevant, according to the current state of knowledge. On the basis of these observations six alternative strategies at diagnosis were compared (each technique alone or different combinations of the two techniques). The study shows that:-for ALL, PCR alone appears the most cost-effective strategy;-for AML, cytogenetic analysis alone is the best strategy;-sequential strategies are more cost effective than simultaneous use of both techniques for minimising risk of false negatives.     

Prolonged survival by 'early' salvage treatment of breast cancer patients: a retrospective 6-year study

Between 1977 and 1993, 384 breast cancer patients were followed up post-operatively every 4 or 6 months with a serum tumour marker panel (CEA-TPA-CA15-3) and the usual imaging techniques. Twenty-eight patients were treated 13.5 +/- 10 months (mean +/- s.d.) before the clinical and/or radiological occurrence of distant metastases that were suspected because of an increase in the tumour markers (patients treated 'early'). Their outcome was compared with that of 22 similar patients who were treated only after a definite radiological diagnosis was achieved (patients treated 'not early'). The median survivals from mastectomy and salvage treatment were also compared for the two groups. The groups were similar for all the major prognostic factors (menopause, staging, hormone dependency). In the group treated 'early', the lead time from the tumour marker increase to the clinical and radiological signs of metastases was significantly longer than that of the group not treated 'early' (13.5 +/- 10 vs 3.4 +/- 2.8 months respectively; P < 0.001 by unpaired t-test). For patients treated 'early', the survival curves up to 30 months after salvage treatment and up to 72 months after mastectomy showed greater survival than those for the patients treated later (42.9% vs 13.6% and 42.9% vs 22.7% respectively; P = 0.04 in both instances). These data suggest that treatment triggered by rising tumour markers before clinical and/or radiological appearance of distant metastases can be useful in prolonging both the asymptomatic interval and the duration of response of some relapsed patients. Randomized prospective trials must be encouraged to confirm these data and to better evaluate the effect on the disease-free survival (DFS) and overall survival (OS) of 'early' salvage treatment protocols.     

Multidisciplinary evaluation of preschool children in a military psychiatry clinic: a 10-year comparison and a brief outcome study

A little over a decade ago, the Child and Adolescent Psychiatry Service at Tripler Army Medical Center opened the Child Study Group (CSG), a multidisciplinary diagnostic team clinic for preschool children. The methods and results of the clinic were reported previously (Lee, 1987). The current study is a comparison of the cohort of children seen from January through December 1984 with the parallel group seen from January through June 1994. The paper also presents a brief follow-up study of the children seen in 1994.     

Role of carotid sonography as a first examination in the evaluation of patients with transient ischemic attacks and strokes: benefit in relation to age

PURPOSE: We studied the influence of age on the utility of carotid sonography in patients with transient ischemic attacks and strokes. METHODS: The results of Doppler ultrasound examinations of the carotid arteries in 613 consecutive patients with transient ischemic attacks (n = 450) or strokes (n = 163) were analyzed for different age groups. For each patient, the grade of stenosis was scored for the ipsilateral internal carotid artery. The results of the ultrasound examinations were correlated with angiographic findings and findings at endarterectomy. The extent of atherosclerosis for each age group was expressed as the ratio between the number of grade II-IV stenoses (> or = 50%) in the carotid arteries and the number of patients in that group ("atherosclerosis ratio"). RESULTS: Under the age of 40 years, high-grade atherosclerotic stenoses were not found. However, 3 relatively young patients had dissections of the internal carotid arteries. The atherosclerosis ratio exceeded 0.5 for age groups 65-69 years through 80+ years. Among the patients with high-grade stenoses, ischemic heart disease prevented endarterectomy in 63% of patients in age group 80+ years, 44% in age group 75-79 years, and 26% in age group 70-74 years. CONCLUSIONS: Carotid sonography did not detect any significant atherosclerotic changes in young patients but was useful for diagnosing other etiologies of ischemic cerebral disease, eg, carotid dissection. At the other end of the spectrum, the impact of carotid sonography on patient management appears to be limited in patients over the age of 70 years. Carotid sonography seems to be most useful for patients 40-69 years old.     

Cancer rate differentials between blacks and whites in three metropolitan areas: a 10-year comparison

This article compares cancer rate differentials for 1989-1993 and 1979-1981 between black and whites in Los Angeles, Nashville, and Atlanta, In Los Angeles and Atlanta, the black/white relative risk of lung cancer incidence has increased. While the relative risk for prostate cancer has decreased, blacks still show an excess incidence. White women still show a higher incidence of breast cancer, but the risk is closer to one. In all three cities, the excesses of black male lung cancer and female breast cancer mortalities have increased. The excess of black prostate cancer mortality increased in Atlanta and Nashville but decreased in Los Angeles. The excess of black cervical cancer mortality fell in Los Angeles and Atlanta but rose in Nashville. These results indicate a continuing need to develop and implement culturally sensitive interventions targeted at the black population.     

Reversible segmental cerebral arterial vasospasm and cerebral infarction: possible association with excessive use of sumatriptan and Midrin

OBJECTIVE: To describe a patient who developed reversible segmental cerebral arterial vasospasm and cerebral infarction while taking excessive amounts of sumatriptan succinate and a combination drug (Midrin) consisting of isometheptene mucate, 65 mg, dichloralphenazone, 100 mg, and acetaminophen, 325 mg. DESIGN: Case report. SETTING: Tertiary care center. PATIENT: A 43-year-old man who developed a left occipital infarct after taking a total of 23 sumatriptan succinate tablets (25 mg per tablet) and 32 Midrin tablets during a 7-day period and who on digital subtraction angiography was shown to have segmental cerebral arterial narrowing in multiple vessels. An extensive evaluation for other possible risk factors for cerebral infarction was unrevealing. MAIN OUTCOME AND RESULTS: Discontinuation of sumatriptan and Midrin regimens and administration of nicardipine hydrochloride led to nearly total resolution of the angiographic findings, and the patient had no recurrent strokes. CONCLUSIONS: One should consider the diagnosis of drug-induced vasospasm in patients with cerebral infarction and a history of excessive use of sumatriptan and Midrin. The initial angiographic abnormalities may resemble those found in patients with primary angiitis of the central nervous system.     

Effect of reperfusion on biventricular function and survival after right ventricular infarction

BACKGROUND: Although the salutary effects of reperfusion in patients with left ventricular infarction are well documented, the benefits in patients with acute right ventricular infarction are less clear. METHODS: To determine whether primary angioplasty improves right ventricular function and the clinical outcome in patients with right ventricular infarction, we performed echocardiographic studies before and after angioplasty in 53 patients with acute right ventricular infarction. RESULTS: Complete reperfusion, defined as normal flow in the right main coronary artery and its major right ventricular branches, was achieved in 41 patients (77 percent), leading to prompt and striking recovery of right ventricular function (mean [+/-SE] score for free-wall motion, 3.0+/-0.1 at base line and 1.4+/-0.1 at three days; P<0.001). Twelve patients (23 percent) had unsuccessful reperfusion, defined as the failure to restore right ventricular branch flow, with or without patency of the right main coronary artery. Unsuccessful reperfusion was associated with lack of recovery of right ventricular function (score for free-wall motion, 3.2+/-0.2 at base line and 3.0+/-0.9 at three days; P= 0.55), as well as persistent hypotension and low cardiac output (in 83 percent of the patients, vs. 12 percent of those with successful reperfusion; P=0.002) and a high mortality rate (58 percent, vs. 2 percent for those with successful reperfusion; P=0.001). CONCLUSIONS: In patients with right ventricular infarction, complete reperfusion of the right coronary artery by angioplasty results in the dramatic recovery of right ventricular performance and an excellent clinical outcome. In contrast, unsuccessful reperfusion is associated with impaired recovery of right ventricular function, persistent hemodynamic compromise, and a high mortality rate.     

Stability and change in needs of patients with schizophrenic disorders: a 15- and 17-year follow-up from first onset of psychosis, and a comparison between ''objective'' and ''subjective'' assessments of needs for care

The flow cytofluorimetric method allowed to show that intact liver nucleus population of adult (6 months) rats consists of discrete ploidy classes (2c, 4c, 8c and 16c+), from which the diploid class was approximately a half of the total nuclei. Thirty days after the wholebody X-ray irradiation with a dose of 2 Gy, the percentage frequency of each nuclear class was statistically unchanged. However, the polyploidization level of the total nuclear population increased. Partial hepatectomy induces an entering into mitotic cycle (maximum S-phase; 22 h after operation) of the most of the hepatocyte nuclei in both irradiated and unirradiated animals. With that the relative number of nuclei in S-phase decreases in geometric progression according to increasing of ploidy class. In regenerating liver of irradiated rats in comparison with that of unirradiated ones, the greater part of nuclei enters into the mitotic cycle at the expense of di- and especially tetraploid nuclei.     

Chronic daily headache in children and adolescents: a 2-year prospective study

The newer generation of antifungal agents such as itraconazole and terbinafine are more effective than the older therapies, griseofulvin and ketoconazole, in the treatment of dermatophyte pedal onychomycosis. Itraconazole can be administered as continuous dosing, 200 mg per day for 3 months, or in the form of pulse therapy, 200 mg twice a day for 1 week per month for 3 consecutive months. Terbinafine is given as continuous dosing, 250 mg per day for 3 months.     

The favorable effect of topical betaxolol and timolol on glaucomatous visual fields: a 2-year follow-up study

BACKGROUND: It has been suggested that beta-adrenergic antagonists might have mechanisms of action other than ocular hypotensive effects affecting the visual function in glaucoma patients and that betaxolol might protect the visual field better than others. A randomized, double-blind study was conducted to compare the effects of betaxolol and timolol on visual fields of glaucoma patients. METHODS: Sixty-four glaucoma patients were treated with either 0.5% betaxolol or 0.25% timolol eyedrops twice daily. The Octopus visual field performance was followed up for 2 years and analyzed to find diffuse and localized changes. We analyzed the change in the mean sensitivity (MS) and performed a cluster analysis and clinical assessment of the visual fields in both treatment groups. RESULTS: The mean sensitivity (MS) improved significantly and equally in both treatment groups. There was a tendency towards more improved clusters in the betaxolol group than in the timolol group and more worsened cluster in the timolol group than in the betaxolol group, but the difference was not statistically significant. The clinical assessment also showed no statistically significant difference between the two groups. CONCLUSION: In the present study both betaxolol and timolol had a favorable effect on the visual fields of glaucoma patients. There was no statistically significant difference between betaxolol- and timolol-treated patients either in the change in mean retinal sensitivity or in the change in localized scotomatous areas.