Assessment of cardiovascular impairment in obese patients: Limitations and troubleshooting of available imaging tools.

The prevalence and severity of obesity have increased over recent decades, reaching worldwide epidemics. Obesity is associated to coronary artery disease and other risk factors, including hypertension, heart failure and atrial fibrillation, which are all increased in the setting of obesity. Several noninvasive cardiac imaging modalities, such as echocardiography, cardiac computed tomography, magnetic resonance and cardiac gated single-photon emission computed tomography, are available in assessing coronary artery disease and myocardial dysfunction. Yet, in patients with excess adiposity the diagnostic accuracy of these techniques may be limited due to some issues. In this review, we analyze challenges and possibilities to find the optimal cardiac imaging approach to obese population.

Reclassification of cardiovascular risk by myocardial perfusion imaging in diabetic patients with abnormal resting electrocardiogram.

BACKGROUND AND AIMS: Despite an extensive use of stress myocardial perfusion single-photon emission computed tomography (MPS), no study addressed the role of perfusion imaging in diabetic patients with abnormal resting electrocardiogram (ECG). We compared analytical approaches to assess the added value of stress MPS variables in estimating coronary heart disease outcomes in diabetic patients with abnormal resting ECG. METHODS AND RESULTS: A total of 416 patients with diabetes and abnormal resting ECG who underwent stress MPS were prospectively followed up after the index study. The end point was the occurrence of a major cardiac event, including cardiac death and nonfatal myocardial infarction. At the end of follow-up (median 58 months), 42 patients experienced events. MPS data increased the predictive value of a model including traditional cardiovascular risk factors and left ventricular (LV) ejection fraction (likelihood ratio χ² from 17.54 to 24.15, p < 0.05, with a C statistic of 0.72, 95% confidence interval: 0.65-0.79). The addition of MPS data resulted in reclassification of 25% of the sample with a net reclassification improvement of 0.20 (95% confidence interval: 0.05-0.36). Overall, 63 patients were reclassified to a lower risk category, with a 5-year event rate of 3.5%, and 40 patients were reclassified to a higher risk category, with a 5-year event rate of 20%. CONCLUSION: The addition of MPS findings to a model based on traditional cardiovascular risk factors and LV ejection fraction improves risk classification for incident cardiac events in diabetic patients with abnormal resting ECG.

Screening for mutations in the ISL1 gene in patients with thyroid dysgenesis.

CONTEXT: Congenital hypothyroidism (CH) is a common endocrine disorder with an incidence of 1:3000- 4000 newborns. In 80-85% of cases, CH is caused by defects in thyroid organogenesis, resulting in absent, ectopically located, and/or severely reduced gland, all conditions indicated as "thyroid dysgenesis" (TD). A higher prevalence of congenital heart diseases has been documented in children with CH compared to the general population. This association suggests a possible pathogenic role of genes involved in both heart and thyroid development. Among these, it can be included Isl1, a transcription factor containing a LIM homeodomain that is expressed in both thyroid and heart during morphogenesis. OBJECTIVE: In the present study, we investigate the role of ISL1 in the pathogenesis of TD. SETTINGS AND PATIENTS: By single stranded conformational polymorphism, we screened for mutations the entire ISL1 coding sequence in 96 patients with TD and in 96 normal controls. RESULTS: No mutations have been found in patients and controls. CONCLUSION: Our data indicate that, despite the relevant role of ISL1 in thyroid and heart morphogenesis, mutations in its coding region are not associated with TD in our group of patients.

Mutations in TAZ/WWTR1, a co-activator of NKX2.1 and PAX8 are not a frequent cause of thyroid dysgenesis.

AIM: In 80-85% of cases, congenital hypothyroidism is associated with thyroid dysgenesis (TD), but only in a small percentage of cases mutations in thyroid transcription factors (NKX2.1, PAX8, FOXE1, and NKX2.5) have been associated with the disease. Several studies demonstrated that the activity of the transcription factors can be modulated by the interaction with other proteins, such as coactivators and co-repressors, and TAZ (transcriptional co-activator with PDZ-binding motif or WWTR1) is a co-activator interacting with both NKX2.1 and PAX8. In the present study we investigate the role of TAZ in the pathogenesis of TD. MATERIAL AND METHODS: By Single Stranded Conformational Polymorphism, we screened the entire TAZ coding sequence for mutations in 96 patients with TD and in 96 normal controls. RESULTS: No mutations were found in patients and controls, but we found several polymorphisms in both groups. No significant differences could be demonstrated in the prevalence of the mutations between patients and controls. CONCLUSIONS: Our data indicate that TAZ mutations are not a cause of TD in the series of patients studied.

Haemochromatosis gene (HFE) polymorphisms and migraine: an association study.

Several studies have suggested that iron metabolism may be involved in the pathogenesis of migraine. Using a case-control design, we performed an association study in a cohort of Italian migraine patients to evaluate whether a particular allele or genotype of the haemochromatosis gene (HFE) would modify the occurrence and clinical features of the disease. We genotyped 256 migraine patients and 237 healthy age-, sex- and ethnicity-matched controls for the C282Y and H63D polymorphisms of the HFE gene. Phenotype and allele frequencies of both polymorphisms were similarly distributed in migraine patients and controls. The patients carrying the DD genotype of the H63D polymorphism showed a later age at onset of the disease and an increased number of migraine attacks. Our data suggest that the HFE gene is not a major disease gene for migraine. However, the H63D polymorphism of the HFE gene may be considered a modifying genetic factor in migraine.

Vagal nerve stimulator: a new approach to medically refractory epilepsy.

Repetitive vagal nerve stimulation (VNS) is a new, FDA-approved treatment for medically refractory epilepsy. The device is implanted subcutaneously in the left chest and sends intermittent impulses to the left vagus nerve through communicating leads. Twelve patients have been implanted to date. The ages of the patients range from 8 to 36 years and the average followup at this point is five months. Five patients have achieved a greater than 50 percent reduction in seizure frequency with no serious adverse effects.

Psychopharmacologic treatment of acquired attention disorders in children with brain injury.

This investigation examined the efficacy of psychostimulant therapy in alleviating neurobehavioral dysfunction attendant to pediatric brain injury. The most commonly reported neurobehavioral sequelae associated with head injury in the pediatric population involve deficits along the attentional matrix. This is also the most common objectively documented neurobehavioral finding among children as well as adults. There are several investigations in the adult literature which have employed the use of psychostimulants in treating both psychiatric and neuropsychological residua associated with head injury. Overall, the results of these studies are equivocal, but suggest a beneficial impact on general functioning. The present prospective investigation utilized a double-blind, placebo-controlled, cross-over experimental design to examine the efficacy of methylphenidate in treating children with acquired attentional disorders secondary to brain injury. A cohort of 14 children with varying degrees of head injury were recruited for participation. As expected, differences between drug and placebo conditions uniformly achieved statistical significance. Additionally, there were no differences in performance between baseline and placebo conditions on neurobehavioral tasks of attention and concentration. Current findings suggest that methylphenidate (and probably other psychostimulants such as Cylert, Adderal, Wellbutrin and dextroamphetamine sulfate) is an extremely effective agent in treating attentional disorders secondary to brain injury in children.

The importance of cerebral ischemia during carotid endarterectomy.

The importance of cerebral ischemia produced by carotid clamping during carotid endarterectomy remains controversial. In an effort to determine the importance of cerebral ischemia during carotid endarterectomy, 369 patients undergoing 431 consecutive carotid endarterectomies were studied by Xenon-133 (133Xe) clearance and electroencephalogram (EEG) monitoring. None of the patients was shunted during the procedures. The severity of ischemia as indicated by 133Xe clearance from the ipsilateral hemisphere during 20 to 30 minutes of carotid occlusion did not predict the appearance of complications in this group of patients (chi 2 = 1.417; P = 0.841). There was a highly significant relationship between the depth of cerebral ischemia as demonstrated by 133Xe clearance and the appearance of abnormalities on the EEG (chi 2 = 42.043, P less than 0.0001). In the subgroup of patients developing abnormalities as shown by EEG, there was a negative correlation (chi 2 = 17.495; P less than 0.002) between reduction in blood flow and the appearance of complications, in that the higher the blood flow during occlusion the more likely the patient developing EEG changes would develop complications.

Computed tomography and magnetic resonance imaging in traumatic locked-in syndrome.

The first reported case of traumatic locked-in syndrome with computed tomographic and magnetic resonance scan confirmation of the brain stem lesion is presented. The lesion responsible for the patient's condition consisted of a hemorrhage in the ventral pontomedullary junction. The pathophysiology of the production of such lesions is discussed.

Conservative management of thrombosed vein of Galen malformations. Report of two cases and a review of the literature.

Spontaneously thrombosed vein of Galen malformations are rare congenital vascular malformations. Surgical treatment of these lesions based on experience with the management of patent malformations has yielded less than satisfactory results. This report reviews the literature concerning these lesions and details our experience with nonoperative management in 2 patients.

Symptomatic spinal epidural lipomatosis as a complication of steroid immunosuppression in cardiac transplant patients. Report of two cases.

Patients with Cushing's syndrome may develop spinal epidural lipomatosis, an abnormal accumulation of fat in the spinal epidural space. This accumulation of fat may cause compression of the spinal cord or cauda equina with resulting neurological deficit. Two cases of symptomatic spinal lipomatosis are reported in cardiac transplant patients receiving chronic corticosteroid treatment. The literature is reviewed, and diagnostic and therapeutic considerations are discussed.

A prospective analysis of 142 carotid endarterectomies for occlusive vascular disease, 1979-1985.

Carotid endarterectomy may carry a substantial risk of morbidity and mortality from major stroke, thus offsetting any statistical benefit in reduction of future stroke. Because of the disturbing ranges in the incidence of stroke morbidity and mortality reported from the several institutional series studying carotid endarterectomy, the authors undertook a prospective review of 142 consecutive carotid endarterectomies performed for symptomatic atherosclerotic occlusive vascular disease on the neurosurgical service. The University of Alabama Hospital. Preoperative risk assessment was performed in each case according to the Mayo Clinic classification system. The overall mortality rate was 1.4% and the major stroke morbidity rate was 0.7%, for a combined major morbidity and mortality rate of 2.1%. The incidence of minor neurological morbidity was 1.4%. There was no morbidity or mortality in the Grade I and II (low-risk) patient groups. This low combined major morbidity and mortality rate of 2.1% for carotid endarterectomy causes the surgical stroke-free survival curve to intersect the medical stroke-free survival curve at an earlier point in time, and thus demonstrates the greater reduction in risk of stroke which accrues over time for the surgically treated patient.

Intervertebral disc infection after lumbar chemonucleolysis: report of a case.

Intervertebral disc space infection can be a serious and disabling complication of any procedure that affords entry for bacteria into the susceptible disc space. Most disc space infections occur after cervical or lumbar laminectomies. Discitis has been reported after myelography, lumbar puncture, paravertebral injection, and obstetrical epidural anesthesia. A case of septic discitis occurring after intradiscal therapy with chymopapain is presented. Patients who return for evaluation of recurrent spinal pain after chemonucleolysis, especially those with paravertebral muscle spasm, should be evaluated for the possibility of disc space infection by obtaining an erythrocyte sedimentation rate, peripheral white count, differential cell count, and plain roentgenograms. Radionuclide bone scans, although not specific, may provide further objective evidence leading to the diagnosis of an intervertebral disc space infection.

Glucose-6-phosphate dehydrogenase: a possible clinical indicator for prostatic carcinoma.

Any system of biochemical analysis that can be used to detect chemical differences between normal and malignant cells may add potentially valuable information to complement the histologic data which provide the practical definition of human prostatic carcinoma. A difference (P less than 0.0001) was observed in the levels of glucose-6-phosphate dehydrogenase (G-6-PD) activity in prostatic tissue with benign hyperplasia and prostatic carcinoma. Measured as a function of the amount of protein extracted from whole-tissue homogenates, the values for G-6-PD activity in prostatic carcinoma are almost four times those measured for benign prostatic hyperplasia. The degree of elevation of the activity of this enzyme suggests a correlation between enzymatic activity and clinical prognosticators, ie., histologic differentiation and clinical stage.