Lambl's excrescence: an uncommon cause of cerebral embolism

A 31 year old right handed woman presented with acute onset of aphasia which cleared over two days. CT-scan showed a left middle cerebral artery infarct within Wernicke area. Initial transesophageal two-dimensional echocardiography disclosed a mitral valve lesion suggesting a thrombus. She was discharged on oral anticoagulant treatment. A second stroke occurred ten months later involving left lenticulo-striate arteries area. Echocardiography remain unchanged. Subsequently, giant Lambl's excrescences of mitral valve was confirmed by operation and pathologic examination. The majority of patients with Lambl's excrescences are asymptomatic. However surface thrombus is common with this tumors which reposant a potential us for cerebral embolization. These tumors should be operated since complete excision is the only definitive means of eliminating the source of recurrent embolization.     

Severe encephalopathy in a child: an uncommon cause

We report the unusual fixed cutaneous variety of sporotrichosis in a patient hailing from Uttarkashi (Uttar Pradesh) in the north-western part of India.     

Arteriovenous malformations of the uterus: an uncommon cause of vaginal bleeding

Arteriovenous malformations (AVM) are rare entities in gynecology, with only 73 cases reported in the literature. Most commonly they present with vaginal hemorrhage, but other presentations such as congestive heart failure, postmenopausal bleeding, and an asymptomatic mass have been described. These lesions may be congenital or acquired. Acquired lesions are believed to follow trauma or may arise after choriocarcinoma or other gynecologic malignancies. Diagnosis can rapidly be made with color flow Doppler ultrasound or angiography. Additionally, they have been detected using hysteroscopy, hysterosalpingogram, and computerized tomography. Acute management consists of hemodynamic stabilization and possibly placement of a Foley bulb in the uterus or methylergonovine injection. Ultimate treatment depends on the patients desire for fertility. Embolization therapy is variably successful and may allow the preservation of reproductive capacity. To date, five pregnancies after embolization have been reported with varying outcomes. If pregnancy is not desired or embolization fails, hysterectomy remains the treatment of choice.     

Rupture of pectoralis major muscle: operative treatment of an uncommon sport injury

Rupture of the pectoralis major muscle in an athlete is rare, but is said to be common in weight lifters. The muscle usually ruptures at the musculotendinous junction during forceful contraction of the muscle in adduction, forward flexion and internal rotation of the arm. We describe an athlete who suffered such a major tear during a rugby game. It was treated surgically and after adequate rehabilitation, athletic activities were resumed.     

Ewing's tumour: uncommon presentation of an uncommon tumour

A case of Ewing's sarcoma presenting with high cervical cord compression is described and disseminated disease was present at the time of diagnosis. A combination of radiotherapy and chemotherapy did not result in a cure. The current treatment of Ewing's sarcoma is briefly reviewed.     

Aortopulmonary fistula in an infected Dacron graft for coarctation of the aorta: an uncommon cause of hemoptysis

Hemoptysis secondary to an aortobronchial fistula is rare and uniformly fatal when left untreated. The authors describe a case of massive hemoptysis caused by an aortopulmonary fistula in an infected Dacron graft used successfully to repair a coarctation of the aorta.     

Serious traumatic brain injury: an evaluation of functional outcomes

OBJECTIVES: Evaluate independent living, productivity, and social outcomes of patients with serious traumatic brain injury (TBI) after inpatient rehabilitation. METHODS: Fifty-five adults with serious TBI (Abbreviated Injury Scale score > or = 3) were admitted to a Level I trauma center and subsequently transferred to a comprehensive inpatient rehabilitation hospital (Walton Rehabilitation Hospital). Functional Independence Measures were obtained at admission (Adm), discharge (D/C), and at 3- (n = 52) and 1-year (n = 51) follow-up. RESULTS: At 1 year, 90% of the patients were living at home. Eight (16%) required full-time supervision, while 41 (82%) were independent of supervision throughout most of the day. Thirteen (25%) patients had returned to work, eight full time and five with reduced responsibility and fewer hours than before injury. Nineteen shared household duties, while eight (16%) had primary responsibility. Fourteen (27%) patients demonstrated socially inappropriate or disruptive behavior at least weekly. [table: see text] CONCLUSION: Although cognitive skills were diminished for the majority of patients, many achieved a substantial reduction in disability within 18 months after TBI.     

Cerebral venous thrombosis and acquired protein S deficiency: an uncommon cause of headache in systemic lupus erythematosus

A 42-yr-old woman with hypertension and renal involvement due to systemic lupus erythematosus (SLE) developed unilateral headache followed by the sudden onset of confusion and a grand mal convulsion. Cerebral computed tomography was normal. A magnetic resonance imaging angiogram revealed cerebral venous thrombosis and a venous infarct. Nephrotic syndrome had resulted in an acquired protein S deficiency. A review of previous cases suggests that either renal disease with proteinuria or features of the antiphospholipid syndrome are prerequisites for the development of cerebral venous thrombosis in SLE. Low free-protein S levels may be an additional risk factor. Furthermore it is likely that this condition is underdiagnosed.     

Segmental neurofibromatosis: an uncommon variant of neurofibromatosis

It was reported that sodium thiosulfate (STS) was contributed to antivomiting effect in 20 transarterial chemotherapic patients. The antitumor sensitivity of STS (< 500 micrograms/ml) adjuncting to the ADM, MMC, CDDP and other four agens (1 x PPC/ml) individually on two tumor cells studied by MTT test in vitro and no antitumor activity of adjuvant of STS were obviously obliterated (P > 0.05) except for CDDP clinically, to comparing the adjuncting effects of STS (iv. 30 min ahead) or metochlopramidum (im. 30 min ahead) to ADM, MMC and CDDP on HCC (40 cases), the degrees of vomiting in hepatoma patient after transcatheter arterial chemoem bolization with ADM, MMC and CDDP were statisticaly analysec. It have been proven that STS was contributed to the low incidence of vomiting and superior to metocloe pramidum, without worsening of the chemotherapy of HCC. It is worth futher studying adjuvant STS to other antitumor drugs and exploring potential application of chematherapy in cancer.     

Splenic lymphoma with villus lymphocytes--an uncommon cause for lymphocytosis

We describe the clinical and laboratory features of four patients who presented with mild to moderate lymphocytosis but with no peripheral lymphadenopathy. These patients in the past, would have been classified as chronic lymphocytic leukaemia (CLL). However, it is now realised that chronic lymphoproliferative disorders are very heterogeneous and the clinical and laboratory features of our patients would support a diagnosis of splenic lymphoma with villus lymphocytes (SLVL) with characteristic morphological features. SLVL usually runs a benign clinical course but symptoms related a benign clinical course but symptoms related to splenomegaly or hypersplenism may be a problem. Splenectomy is considered the treatment of choice in these patients. Two of our patients had splenectomy and the other two patients are on regular follow-up without any specific treatment. It is therefore important to recognise this uncommon condition and also to differentiate it from CLL.     

Positive talk training in an adult with traumatic brain injury

Social skills often create a barrier to placement in less restrictive environments for persons with TBI. This case study illustrated the use of a positive talk program in the treatment of a person with long-standing social skill deficits. Occupational therapy intervention with speech-language consultation began with an evaluation of the cognitive barriers that influenced the client's social behavior. Work with the client's concrete concept formation, decreased memory, and poor generalization skills led to the development of the positive talk training program described. Through an understanding of the underlying cognitive deficits that influenced the client's behavior, the clinical team was able to develop an individual treatment plan. The intervention resulted in modification of behavior that would have required placing the client in a restricted environment. In the final analysis, the client's social skills improved to a level where he could be discharged to a less restrictive environment.     

Motor performance following a mild traumatic brain injury in children: an exploratory study

Mild Traumatic Brain Injury (TBI) is a common occurrence in the paediatric population and, as the concept of motor performance has not been assessed specifically in this population, the purpose of this study was to determine if motor performance deficits are present and can be objectively identified in a sample of children having sustained a mild TBI (Glasgow Coma Scale score 13-15). Twenty-eight children aged between 5 and 15 years were recruited immediately post-trauma. Subjects were considered normal on standard neurological exam at the time of discharge. They were assessed 13-18 days post-trauma using the Bruininks-Oseretsky Test of Motor Proficiency, a norm referenced clinical standardized assessment tool. Compared to published norms, motor performance was significantly lower in domains of balance, response speed and running speed an agility (t-test p < 0.01), and significantly higher in domains of upper extremity coordination and visual motor control (t-test p < 0.01). Although excellent performance can be observed in domains requiring upper limb coordination, motor planning and execution of motor tasks, deficits in balance and response speed can be identified in a significant number of children even after mild TBI. More specific and sensitive evaluations are necessary to identify the exact nature of the problems and evaluate their functional impact on daily activities.     

Attentional factors in response time variability after traumatic brain injury: an ERP study

The activities of 21 enzymes (belonging to four classes of enzymes) involved in different metabolic pathways were assayed in blood sera of healthy young and adult/elderly groups of humans, rats and pigs, to determine whether activity changes coinciding with changes in age and aging could be detected. In all three species analysed, measurable activities (performed by highly specific and sensitive techniques, generally spectrofluorimetric procedures) were found, usually following a decreasing order of: among glycosidases, beta-N-acetylglucosaminidase (NAG) > alpha-L-fucosidase > alpha-mannosidase > beta-glucuronidase > beta-galactosidase > alpha-galactosidase. In addition, among esterases very high values were found for arylesterase and acid phosphatase. By contrast, no measurable activity was found for the remaining enzymes assayed (8 hydrolases, 1 oxidoreductase, 3 transferases and 1 lyase). In the elderly group of humans, significantly higher activities (P < or = 0.05) were found for NAG, alpha-mannosidase and beta-glucuronidase in comparison to the adult and young groups. However, several activities in rats and all activities in pigs decreased with age. In conclusion, differences in the activities of 6 lysosomal glycosidases and 2 esterases (but no significant differences for another 13 enzymes belonging to several enzyme classes) are found in the sera of healthy humans, rats and pigs. These differences coincide with changes observed in aging.     

Construct validity of an attention rating scale for traumatic brain injury.

Attention deficits are nearly ubiquitous after traumatic brain injury (TBI). In the subacute phase of moderate to severe TBI, these deficits may be difficult to measure with the precision needed to predict outcomes, assess degree of recovery, and monitor treatment response. This article reports the findings of four studies, three observational and one a randomized, controlled treatment trial of methylphenidate (MP), designed to provide construct validation of the Moss Attention Rating Scale (MARS), an observational measure of attention dysfunction following TBI. One hundred seven participants with moderate to severe TBI were enrolled during treatment on an inpatient rehabilitation unit. MARS scores were provided independently by four rehabilitation disciplines (Physical, Occupational and Speech Therapies and Nursing). Results indicated that the MARS: (1) is more strongly related to concurrent measures of cognitive versus physical disability, supporting its validity as a measure of cognition, (2) is more strongly related to concurrent psychometric measures of attention versus measures thought to rely less on attention, supporting its validity as a measure of attention; and (3) predicts 1-year outcomes of TBI better than psychometric measures of attention. However, the MARS (4) was not differentially affected by MP versus placebo treatment. Results support the construct validity and utility of the MARS, with further research needed to clarify its role in treatment outcome assessment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Paraplegia from traumatic spinal injury

Acute spinal injury with paresis or paralysis is an increasing problem in modern communities. The corrdinated efforts of many are necessary for its management. The expertise developed by various disciplines through work with nonparaplegic patients should be coupled with the specific expertise of those responsible for total care. Generally, operative techniques have only a limited application, whereas basic medical and nursing techniques give good results.     

Adaptive functioning following traumatic brain injury and orthopedic injury: a controlled study

BACKGROUND: In an effort to intensify osteosarcoma therapy, systemic ifosfamide was added pre- and postoperatively to an already aggressive three-drug regimen. In a subgroup of patients, loco-regional treatment intensification was attempted by using the intraarterial route to give cisplatin. PATIENTS AND METHODS: Patients < or = 40 years at diagnosis of a localised, de novo high-grade central extremity osteosarcoma were eligible for inclusion into study COSS-86 if registered within three weeks from biopsy. Doxorubicin, high-dose methotrexate, and cisplatin were given to all patients. Patients who fulfilled one or more of three defined high-risk criteria received early systemic treatment intensification by adding ifosfamide as the fourth agent. Preoperatively, these high-risk patients received cisplatin either intraarterially or intravenously. RESULTS: 171 eligible patients were entered, of which 128 were stratified into the high-risk group. When all 171 were analysed by intention-to-treat, actuarial overall and event-free survival rates at ten years were 72% and 66%, respectively. No benefit of intraarterial cisplatin application was detected. Cumulative treatment toxicity was considerable. CONCLUSIONS: In a multicenter setting, intensive treatment of osteosarcoma according to protocol COSS-86 led to long-term disease-free survival for two thirds of patients. We saw no benefit of using the intraarterial route to administer cisplatin.     

Sympathetic reflex dystrophy: an uncommon illness in childhood]

We measured activities of dynorphin-converting enzyme (DCE), substance P endopeptidase (SPE) and angiotensin-converting enzyme (ACE) in cerebrospinal fluid (CSF) in 13 patients with rhizopathic pain from an herniated lumbar disc, in 9 patients with pain from coxarthrosis and in 11 control patients without pain. In the patients with disc hernia and coxarthrosis, another sample of CSF was analyzed 3-12 months after treatment, when pain had subsided. The DCE activity in the patients was higher than that in both the control patients and the patients with pain from coxarthrosis (nociceptive pain). Similarly, the activity of SPE was lower in the patients with herniated lumbar disc than in controls and in the patients with coxarthrosis. After treatment, the difference in activity compared to controls was lower, but still significant in patients with herniated discs. The ACE activity did not differ from controls in patients with ischialgia, while it was increased in patients with coxarthrosis. This increase also remained after arthroplasty with pain relief. In conclusion, measurements of neuropeptides may be useful for evaluating neuropathic pain.