A patient with pleuritic chest pain and abnormal blood clotting tests.

We present the case of a 58 year old man who developed pleuritic chest while an in-patient; investigations revealed pulmonary embolism, despite a significantly raised Activated Partial Thromboplastin Time (APTT), which was subsequently attributed to Antiphospholipid syndrome (APS). The diagnosis and initial management of APS in the acute setting is discussed.

Dermoscopy of discoid lupus erythematosus.

BACKGROUND: Dermoscopy is useful in evaluating skin tumours, but its applicability also extends into the field of inflammatory skin disorders. Discoid lupus erythematosus (DLE) represents the most common subtype of cutaneous lupus erythematosus. While dermoscopy and videodermoscopy have been shown to aid the differentiation of scalp DLE from other causes of scarring alopecia, limited data exist concerning dermoscopic criteria of DLE in other locations, such as the face, trunk and extremities. OBJECTIVE: To describe the dermoscopic criteria observed in a series of patients with DLE located on areas other than the scalp, and to correlate them to the underlying histopathological alterations. METHODS: DLE lesions located on the face, trunk and extremities were dermoscopically and histopathologically examined. Selection of the dermoscopic variables included in the evaluation process was based on data in the available literature on DLE of the scalp and on our preliminary observations. Analysis of data was done with SPSS analysis software. RESULTS: Fifty-five lesions from 37 patients with DLE were included in the study. Perifollicular whitish halo, follicular keratotic plugs and telangiectasias were the most common dermoscopic criteria. Statistical analysis revealed excellent correlation between dermoscopic and histopathological findings. Notably, a time-related alteration of dermoscopic features was observed. CONCLUSIONS: The present study provides new insights into the dermoscopic variability of DLE located on the face, trunk and extremities.

Minimal extracorporeal circulation reduces the incidence of postoperative major adverse events after elective coronary artery bypass grafting in high-risk patients. A single-institutional prospective randomized study.

Coronary artery bypass grafting (CABG) using minimal extracorporeal circulation (MECC) has been associated with an improved short-term clinical outcome compared to conventional extracorporeal circulation (CECC). The aim of this study was to evaluate the impact of MECC compared to CECC on postoperative major adverse events in high-risk patients undergoing elective coronary revascularization procedures. Two hundred patients undergoing elective CABG were randomized into two groups. In Group A (n=100), MECC was used while Group B (n=100) included patients who were operated on CECC. The incidence of postoperative major adverse events (myocardial infarction, renal failure, stroke, death) was the primary end-point of the study. MECC was associated with a 77% relative risk reduction in the incidence of major adverse events compared to CECC (p=0.004). The rate of major adverse events occurring in the high-risk patient subgroup (preoperative left ventricular ejection fraction ≤40%, age >65 years, EuroSCORE II >5) operated on with MECC was significantly lower in comparison to their CECC counterparts. Based on our results, cardiac centres should be encouraged to use MECC as the standard circuit when performing elective coronary procedures, even in a high-risk population.

Cholesterol embolization syndrome following thrombolysis during acute myocardial infarction.

BACKGROUND: Cholesterol embolization syndrome (CES) is the result of atherosclerotic plaque erosion and subsequent dislodgement of cholesterol crystals from the core of the plaque to the peripheral arteries. The source of emboli is usually located in the aorta, whereas the most commonly affected organs are the skin and the kidneys. CASE REPORT: The case of a 69-year-old male with cyanotic painful discoloration of his toes following thrombolysis for acute myocardial infarction 1 month previously is presented. Both transesophageal echocardiography and magnetic resonance aortography showed a diffuse ulcerated atherosclerotic plaque in the course of descending thoracic aorta, while a skin biopsy of the cyanotic toes revealed cholesterol crystals in the lumen of the small diameter arteries. CONCLUSION: Cholesterol embolizations from the aorta are difficult to treat and may end in renal failure. Since treatment options are limited without proven efficacy, increased awareness by the clinicians is needed.

Energy expenditure in acute pancreatitis evaluated by the Harris-Benedict equation compared with indirect calorimetry.

OBJECTIVES: Enteral nutrition (EN) is recommended for severe acute pancreatitis (AP) and for biliary AP if cholecystectomy is delayed. Energy expenditure (EE) is calculated using the Harris-Benedict equation (HBE), but indirect calorimetry (IC) can also be employed. We wished to compare EE evaluated by the HBE equation, modified HBE (mHBE) and IC at study inclusion and 1 month after AP resolution. METHODS: We undertook a single-center prospective study in Paris, France. RESULTS: Among 35 patients, 19 had biliary AP and 11 alcoholic-related AP. Eleven cases had severe AP. There was no significant difference between EE calculated by the HBE and that using IC at study inclusion. However, the EE calculated by the mHBE was significantly higher than that calculated using IC. For severe AP, the HBE underestimated EE whereas the mHBE overestimated it. No difference was found based on the cause of AP. There was no difference between methods for EE at 30 days. CONCLUSIONS: The HBE underestimated EE for severe AP, whereas the mHBE overestimated it. IC seems to be the best means of EE evaluation for AP.

Solitary plasmacytoma of the upper cervical spine: therapeutic considerations.

Solitary plasmacytomas are localized plasma cell malignancies involving bone marrow (solitary bone plasmacytoma, SBP) or extramedullary tissues (solitary extramedullary plasmacytoma, SEP). The upper cervical spine involvement by SBP is a rare and more challenging condition. The authors describe a patient with solitary plasmacytoma involving all the elements of C2 vertebra. Severe neck pain was the only manifestation of disease. The patient underwent an occipito-cervical stabilization with a partial decompression through a single posterior approach. The authors stress the importance of early diagnosis followed by appropriate multidisciplinary treatment strategies, including surgery and discuss the management dilemmas concerning the timing and management consequence, in scope to prevent a major neurological damage and allow the patient to be ambulatory.

Co-occurrence of brain tumours and demyelination of the central nervous system: coincidence or interrelation?

The co-occurrence of a brain tumour and demyelinating disease of the central nervous system (CNS) constitutes a rare clinical entity. We herein report the incidence of meningioma and CNS non-specific demyelination in a patient with a 6-year history of operated brain tumour (meningioma). Our case bolsters the argument that in at least some cases, the occurrence of a brain tumour could predispose to CNS non-specific demyelination.

Association of brain natriuretic peptide and adrenomedullin plasma levels with left ventricular filling pressures in end-stage renal disease patients on hemodialysis.

OBJECTIVE: Adrenomedullin (ADM) and brain natriuretic peptide (BNP) are known to be associated with elevated left ventricular filling pressures. However, little is known about this association in hemodialysis (HD) patients with preserved left ventricular ejection fraction (LVEF). Our objective was to evaluate the potential association between E/e' ratio and plasma levels of BNP and ADM in end-stage renal disease (ESRD) patients with preserved LVEF undergoing chronic hemodialysis. PATIENTS AND METHODS: The study group enrolled 62 ESRD patients treated with hemodialysis three times weekly. BNP and ADM plasma concentration measurements and echocardiographic examination were performed 30 minutes after hemodialysis. E/e' ratio, evaluated by Tissue Doppler imaging and measured at the basal septum, was used as a surrogate marker for assessing left ventricular filling pressures. RESULTS: The mean age of patients was 62 ± 25 years. The mean BNP and ADM values after hemodialysis were 0.40 ± 6.73 ng/ml and 0.06 ± 2.12 ng/ml, respectively. Elderly patients with hypertrophied left ventricles and larger left atria displayed higher E/e' values. BNP (r = 0.324. p = 0.018) and ADM (r = 0.319, p = 0.042) plasma levels were positively and significantly associated with E/e΄. Multivariate regression analysis including BNP, ADM, age, hemodialysis duration, left ventricular end-systolic volume index, LVEF, left ventricular mass index and left atrium volume index, revealed that ADM (p-value 0.025) but not BNP levels, were independently associated with the E/e' ratio. CONCLUSIONS: ADM, but not BNP, was independently associated with septal E/e' in HD patients with preserved LVEF. ADM plasma levels can be used as a surrogate index to assess left ventricular filling pressures in HD patients.

Resection of giant meningiomas of the anterior cranial fossa using orbital osteotomies.

AIM: The challenge in large cranial base meningiomas is total resection of the tumor with the least possible mortality and morbidity. During the last two decades the technical approaches for anterior skull base tumors have shown a considerable progress, providing a wide exposure with minimal brain retraction. The purpose of this study is to present our experience with these approaches for treatment of giant anterior cranial fossa meningiomas. METHODS: A retrospective analysis was performed in 20 patients with giant meningiomas (diameter >4.5 cm) of the anterior cranial fossa, which were treated surgically in our department, between January 1992 and January 2002. There were 5 men and 15 women with an average age of 48,3 years. Mental and visual disturbances were the most common presenting symptoms. We used the extended subfrontal approach for 16 patients and the fronto-orbito-zygomatic approach for 4 patients. The follow-up period ranged from 3 to 10 years. RESULTS: In all patients, total resection of the tumor (Simpson grade I, 12 patients, Simpson grade II, 8 patients) was accomplished. Significant improvement occurred by the time of follow-up examination in all but three patients. No evidence of recurrence was observed in 19 of the 20 patients. CONCLUSIONS: The extended anterior skull base approaches, using orbital osteotomies, for giant meningiomas of the anterior cranial fossa have improved the extent of radical tumor removal with minimal neurological morbidity. Furthermore a long term prevention of recurrence was achieved.

Segmental myoclonus as the sole manifestation of a choroid plexus papilloma in the posterior fossa. Case report.

The authors describe the case of a 22-year-old woman with involuntary contractions of the sternocleidomastoid and trapezius muscles that resulted in turning movements of the head. The jerks displayed the clinical and neurophysiological characteristics of segmental myoclonus (SM) restricted to muscles supplied bilaterally by the first four cervical segments. Magnetic resonance imaging disclosed a tumor in the midline above the cisterna magna that was later histologically proven to be a choroid plexus papilloma. The patient's involuntary movements did not extend to other muscle groups or, in particular, to the palate, as one might have expected in the case of brainstem lesions. Myoclonus was the sole clinical manifestation of the tumor in this patient; other signs and symptoms invariably reported in other cases of posterior fossa papilloma, such as increased intracranial pressure or cranial nerve palsies, were absent. Release from suprasegmental control is suggested as a possible pathophysiological mechanism in this case of SM.

Multiple spinal epidural abscesses extending to the whole spinal canal.

Spinal epidural abscess (SEA) is a rare life-threatening disease mostly affecting patients with an altered immune system. It presents as a sequela of adjacent infection or hematogenous spread. MRI is the method of choice in evaluating patients with suspected SEAs and should always include the whole spinal canal, excluding the exceedingly rare possibility of multiple epidural collections. We present a rare case of a patient with no predisposing factors suffering from multiple SEAs, extending to the whole spinal canal.

IgG and IgM concentration in the prolapsed human intervertebral disc and sciatica etiology.

STUDY DESIGN: A prospective study was conducted in patients who underwent surgeries for sciatica. The results were compared to those of control subjects. OBJECTIVES: This study expanded knowledge about the pathogenesis of back pain and sciatica in disc herniation. METHODS: Nucleus pulposus, retrieved from 10 patients who underwent surgeries for sciatica caused by disc herniation and from 8 patients used as control subjects, was homogenized and together with serum and cerebrospinal fluid was examined for local production of IgG and IgM by rate nephelometry. SUMMARY OF THE BACKGROUND DATA: Experimental data have shown an inflammatory reaction in the nucleus pulposus of animal models. RESULTS AND CONCLUSIONS: An increased ratio IgGNP/IgGs x 10(3) and IgMNP/IgMs x 10(3) was found in all patient samples, whereas only the IgMNP/IgMs x 10(3) ratio was significantly higher (P < 0.005) when compared with those of the control values. These findings may be secondary to an inflammatory reaction close to the nerve root and prolapsed nucleus pulposus. Therefore, they may contribute in some way to the inflammatory origin of sciatica.

The impact of age on clinical outcomes following cardiac resynchronisation therapy.

BACKGROUND: Cardiac resynchronisation therapy (CRT) is an established treatment for selected patients with symptomatic left ventricular (LV) systolic dysfunction. Heart failure (HF) is primarily a disease of the elderly; however, these patients are underrepresented in CRT trials. Our aim was to evaluate the impact of age on clinical outcomes following CRT. METHODS: A consecutive series of 177 patients was identified and divided into those aged ≤ 7 5 years (n = 131, mean ± SD 62.1 ± 11.2 years) and those aged >75 years (n = 46, mean ± SD 80.7 ± 4.1 years). The primary end point was a composite of all-cause mortality or HF hospitalisation. RESULTS: During a median ± IQR follow up of 28.5 ± 33.7 months, the event rate for the primary end point was significantly higher in the elderly compared to younger patients (20.1 vs. 11.1 %, respectively, logrank p = 0.020). This was mainly driven by an excess mortality rate among those aged >75 years (10 vs. 4.7%, respectively, logrank p = 0.018) whereas HF hospitalisation rates were similar between groups (10 vs. 6.4%, respectively, logrank p = 0.301). After adjusting for comorbidities and ICD status, the difference in the composite end point rates was attenuated and no longer significant (HR 1.580, 95% CI 0.899-2.778; p = 0.112 for >75 vs. ≤ 75 years). Notably, both groups demonstrated similar response rates to CRT in terms of symptomatic improvement, reverse LV remodelling and neurohormonal activation. CONCLUSIONS: CRT is equally effective in the elderly as in younger patients to reduce adverse clinical outcomes. For those who fulfil the prerequisite selection criteria, it should be considered as a valid therapeutic option.

Posterior mediastinal Castleman's disease presented as hypervascular lipomatous tumor.

Castleman's disease (CD) is a rare lymphoproliferative disorder most often found in the chest. Herein we describe the imaging findings of a histologically proven case of CD involving the posterior mediastinum in a 41-year-old asymptomatic man presented as a well-defined hypervascular lipomatous tumor. To our knowledge less than 10 cases of posterior mediastinal CD have been reported so far and this is the first case of CD mimicking mediastinal lipomatous tumor.

Cerebellar hemorrhage after supratentorial burr hole drainage of a chronic subdural hematoma.

Cerebellar hemorrhage is an unusual, but increasingly recognized complication after supratentorial surgery. Even rarer are the cases of cerebellar hemorrhage after supratentorial burr-hole drainage of a chronic subdural hematoma (CSDH). The pathophysiology of this rare complication still remains unclear. Hypertension and overdrainage of cerebrospinal fluid seem to be causative factors of postoperative cerebellar hemorrhage. The most important key to minimize this hazardous sequel is to be aware of this potential complication and its pathogenetic mechanisms. We report our case of a 43-year old man who developed cerebellar hemorrhage after burr hole trephination for supratentorial CSDH.

Tuberculous orchitis US and MRI findings. Correlation with histopathological findings.

Tuberculosis of the testis is a rare disease. Although Ultrasound (US) findings of tuberculous epididymo-orchitis have been well described, there are only few reported cases describing the Magnetic Resonance Imaging (MR) findings of this disease. Herein, we describe the US and MR findings in a patient with tuberculous orchitis of the left testis and correlate them with the histopathological findings. In our case, the MR findings differ from previous studies because granulomatous areas in the testis had intermediate to high signal intensity on T2WI, while in all studies granulomatous areas in tuberculous epididymo-orchitis demonstrated invariably low signal intensity.

Magnetic resonance imaging and ultrasonographic evaluation of retinal detachment in orbital uveal melanomas.

We assess the role of ultrasonography (US) in the evaluation of retinal detachment in patients with uveal melanomas, in correlation with magnetic resonance imaging (MRI) findings. Twenty-six patients (13♂ and 13♀) with uveal melanomas underwent MRI and US examination. The signal intensity of the tumors and retinal detachments were depicted using MRI. The position of retinal detachment in correlation with the position of intraocular tumor was also evaluated performing ultrasound examination. MRI and US identified uveal melanoma in all 26 patients. In 11 of the 26 patients (42.3%) uveal melanoma was accompanied by retinal detachment. MRI demonstrated retinal detachment in nine patients. US disclosed retinal detachment in two more cases. US has an important role in the depiction of uveal melanomas and associated retinal detachment. It also appears to be more sensitive than MRI in detecting retinal detachment in patients with orbital uveal melanomas.

Non-diabetic hyperglycaemia correlates with angiographic coronary artery disease prevalence and severity.

AIM: The role of glycaemia as a coronary artery disease (CAD) risk factor is controversial, and the optimal glucose level is still a matter of debate. For this reason, we assessed the prevalence and severity of angiographic CAD across hyperglycaemia categories and in relation to haemoglobin A(1c) (HbA(1c)) levels. METHODS: We studied 273 consecutive patients without prior revascularization undergoing coronary angiography for suspected ischaemic pain. CAD severity was assessed using three angiographic scores: the Gensini's score; extent score; and arbitrary index. Patients were grouped, according to 2003 American Diabetes Association criteria, into those with normal fasting glucose (NFG), impaired fasting glucose (IFG) and diabetes mellitus (DM). RESULTS: CAD prevalence was 2.5-fold higher in both the IFG and DM groups compared with the NFG group. Deterioration of glycaemic profile was a multivariate predictor of angiographic CAD severity (extent score: P=0.027; arbitrary index: P=0.007). HbA(1c) levels were significantly higher among CAD patients (P=0.016) and in those with two or more diseased vessels (P=0.023) compared with the non-CAD group. HbA(1c) levels remained predictive of CAD prevalence even after adjusting for conventional risk factors, including DM (adjusted OR: 1.853; 95% CI: 1.269-2.704). CONCLUSION: Non-diabetic hyperglycaemia, assessed either categorically by fasting glucose categories or continuously by HbA(1c) levels, correlates with the poorest angiographic outcomes.