A case of neglect.

In 1875 William Andrew Johnson, who had been formerly enslaved by Andrew Johnson and who subsequently served as his valet after being emancipated, was present when the former president suffered his fatal stroke. William's description of his deficits, as told decades later to journalist Ernie Pyle, appears to represent one of the earliest known cases of asomatognosia. The limited description of the symptoms provides a backdrop for a discussion of the evolution of knowledge regarding disorders of body awareness. This case also highlights the importance of caregivers as sources of clinical information and serves as a cautionary tale regarding the risk of marginalizing them due to cultural bias.

Delayed diagnosis of foreign body aspiration in children.

AIMS: To assess the diagnostic and therapeutic difficulties as well as the long-term complications of prolonged endobronchial foreign body retention. METHOD: Between January 2000 and May 2021, 794 patients with suspected foreign body aspiration (FBA) were hospitalized in our department. A total of 12 patients with a delayed diagnosis of over 1 month were included. FBAs were confirmed by flexible or rigid endoscopy. A retrospective analysis of medical records was performed. RESULTS: Six male patients and six female patients were hospitalized due to prolonged FBA. The average age was 6.90 years (range: 1-13 years). The average duration of the foreign body retention was 2.60 years (2 months to 9 years). A choking event was found in eight cases. Coughing and wheezing were the main symptoms and signs. A misdiagnosis of asthma was made for five patients. Two atypical clinical presentations led to diagnosis of endobronchial foreign body, unilateral pleurisy, and hemoptysis. We report one case of an occult foreign body externalized spontaneously through a pneumo-pleuro-cutaneous fistula. The most common clinical and radiological findings were of pneumonia and atelectasis. Computed tomography showed localized bronchiectasis in three patients. FBAs were removed with a rigid bronchoscope in eight cases. Other extractions were carried out with a flexible endoscope. The foreign bodies were most frequently of vegetable origin, such as seeds and peanuts. A granulation tissue was observed in seven cases. Bronchial stenosis and bronchiectasis are the most common late complications. Only one patient needed a surgical intervention. CONCLUSIONS: FBA should always be considered in the differential diagnosis of chronic or recurrent respiratory diseases, even in the absence of a previous choking event. Clinical and radiological findings should be carefully evaluated for a possible FBA. Delay in diagnosis and treatment of FBA should be avoided in order to prevent complications. Open surgery may be required when lung abscess has occurred.

Retrolaminar Migration of Intraocular Silicone Oil.

BACKGROUND: Migration of intravitreal silicone to the retrolaminar optic nerve was detected pathologically in 1983, symptomatic migration to the subarachnoid space of the optic nerve was reported in 1994, and asymptomatic intraventricular silicone was first seen radiographically in 1999. Since then, little advance has been made in understanding this phenomenon despite numerous case reports. Although some authors have restricted their attention to cases of intraventricular silicone, we believe that these represent part of a clinical spectrum and that all cases with retrolaminar silicone should be considered. The pathophysiology of silicone migration may have significant implications for the management of patients after vitrectomy. EVIDENCE ACQUISITION: Two patients were evaluated by the authors. An internet-based literature review was conducted, beginning with the key search terms "intraventricular, intracranial, subarachnoid, or optic nerve silicone," and "complications of vitrectomy or intravitreal silicone." Further searches cascaded from the initial search results. An additional 24 cases of retrolaminar migration of silicone oil were found and summarized. The relevant anatomy and pathophysiology were reviewed, with attention to additional information from enucleation studies, as well as to gaps in the current understanding of this process. RESULTS: Retrolaminar migration of silicone oil may be more common than previously thought, especially in at-risk patient groups, and may be associated with visual and neurologic symptoms. Some impressions regarding the cause and significance of this syndrome seem incorrect. Although this process is likely linked to postoperative elevations of intraocular pressure, the exact mechanisms of silicone entry into the subarachnoid space remain undefined. A number of anatomic factors may influence the movement of silicone from the orbit and in the various compartments of the subarachnoid space and ventricular system, resulting in variability of clinical presentations and radiologic findings. Implications for clinical decision making and directions for further research are discussed. CONCLUSION: Greater awareness on the part of treating physicians, systematic study of at-risk populations, and advances in imaging technology will allow further insight into this phenomenon.

The role of B-mode ultrasonography and electron beam computed tomography in evaluation of Takayasu's arteritis: a study of 43 patients.

OBJECTIVES: To evaluate the capacity of B-Mode ultrasonography (B-Mode US) and electron-beam computed tomography (EBCT) to detect arterial changes in Takayasu's arteritis. METHODS: EBCT angiography of the thoracoabdominal aorta and pulmonary artery, and B-mode US of large superficial arteries (common carotid, subclavian, and common femoral arteries) were performed prospectively in 43 consecutive patients with established Takayasu's arteritis. The arterial wall thickness was measured, and lumen changes (stenosis, aneurysm) were noted. RESULTS: The combined results of B-Mode US and EBCT examinations showed that every patient had at least one abnormality at the studied sites. The median score of abnormal sites was 7. The most frequent lesion was a characteristic long, homogeneous, circumferential thickening, visualized in 52% of examined sites and in all patients but one (98%). Stenosis was detected by US and by EBCT, respectively, in 44% and 32% of patients, and aneurysm in 0.4% and 68%. CONCLUSIONS: In Takayasu's arteritis, B-Mode US and EBCT was able to visualize the classical caliber abnormalities (stenosis, aneurysm) and, in contrast to angiography, to depict vessel wall thickening, a major pathologic feature of the disease. Both these safe techniques seem more useful than angiography to characterize and map the vascular lesions of Takayasu's arteritis.

Brain involvement in scleroderma: two autopsy cases.

BACKGROUND: Neuropathological data are very scarce in systemic sclerosis and fail to demonstrate primary changes in the brains of such patients. CASE DESCRIPTIONS: A 41-year-old woman with CREST syndrome developed signs of dementia after an episode of severe dehydration and died two months later of septic shock. A 63-year-old woman with CREST syndrome and a history of two unexplained transient ischemic attacks had had balance disorders since age 62. She died of severe pulmonary hypertension. In both cases, the autopsy showed extensive wall calcification of small arteries and arterioles in the brain, primarily in the basal ganglia, and also in the frontal lobes and the cerebellar area in the second case. No known cause of cerebrovascular calcification was found in either patient. CONCLUSION: The neuropathological findings in these two patients suggest that systemic sclerosis may induce primary vascular changes in the brain, of which calcification may be a marker.

[Evaluation of a test for rapid detection of D-dimers for the exclusion of the diagnosis of venous thrombosis]. / Evaluation d'un test de détection rapide des D-dimères pour l'exclusion du diagnostic de thrombose veineuse.

OBJECTIVES: The SimpliRED whole blood D-dimer assay for exclusion of deep venous thrombosis in symptomatic outpatient appears to be a simple and rapid method; we wanted to confirm its reliability. METHODS: Fifty consecutive outpatients (mean age 57, range 20 to 89) referred to our department between September and December 1996, for clinically suspected deep venous thrombosis (DVT) were included. Hospitalized patients were excluded as well as patients under anticoagulant and pregnant women. DVT was diagnosed with our usual strategy of compression ultrasonography at the levels of the common femoral, the superficial femoral and the popliteal veins including the exploration of sural and saphenous veins. The D-dimer assay was performed, according to the manufacturer recommendation, blindly by a physician unaware of the results of ultrasonography within one hour. RESULTS: Eight of nineteen patients with DVT had a normal D-dimer test result Four had a sural DVT, but four had a proximal DVT. Furthermore four patients with normal D-dimers had superficial venous thrombosis. CONCLUSIONS: Our series does not confirm the high sensitivity and negative predictive value reported previously. To date it is premature to propose this assay as a first line test in the therapeutic management of patients with suspected DVT.

[Venous thromboembolic disease and occult cancers: what investigations should be done? Apropos of 204 patients]. / Maladie thrombo-embolique veineuse et cancers occultes: quel bilan réaliser? A propos de 204 patients.

There is no consensus about the investigations which should be performed to detect occult malignancy after an episode of venous thromboembolism. The authors studied 204 patients (167 in-patients and 37 day hospital patients) with deep venous thrombosis or pulmonary embolism to determine the incidence of cancers detected during or after the thrombosis and the diagnostic value of abdomino-pelvic ultrasonography. Of the 167 in-patients, 18 (10.7%) had a known malignancy. After the initial investigations, 7 tumours were detected (4.6%). In all cases, clinical history and examination or chest X-ray were suggestive of neoplasia. Abdomino-pelvic ultrasonography did not detect any cases of occult malignancy. Of the 37 patients seen in the day hospital, only one had known malignant disease and no other cases were detected. After exclusion of the 26 patients with known malignancies or tumours discovered after the initial investigations, the remaining 178 patients were followed up for an average of 27 months. Four cancers (2.5%) were detected in this period. The authors conclude that the occurrence of deep venous thrombosis should lead to investigation for malignant disease: clinical examination, chest X-ray and laboratory tests are sufficient to orientate this investigation. Systematic abdominopelvic ultrasonography does not seem to be worthwhile in this indication.

Bridging the theory--practice gap in the ITU with in-service education.

The use of an education programme within a busy intensive therapy unit has proved to be highly successful in providing a framework for learning for those taking up an appointment in the unit with no previous experience of intensive therapy. The creation of a supportive learning environment was vital for it to work, promoted by enthusiastic and motivated staff and led by a full-time education coordinator. New course members were allocated to teams and provided with a 4-week supernumerary status to work alongside the education coordinator or mentors who acted as role models. This provided an opportunity for junior nurses to build confidence in newly acquired skills and knowledge. Resources for learning included a room designated for teaching equipped with visual teaching and learning aids. It has been shown that a large percentage of the nurses who have completed the education programme have gone on to undertake the English National Board Course 100 or other related courses. The education programme has been effective in bridging the theory-practice gap and ultimately achieving excellence in patient care.

Characterisation of ovine mast cells derived from in vitro culture of haemopoietic tissue.

Ovine mast cells generated in vitro from bone marrow (BMMC) were compared with mucosal mast cells (MMC) isolated from parasitised abomasum. Ultrastructurally, the granules of BMMC were partially developed and immature. Both cells types contained beta-hexosaminidase, arylsulfatase, histamine, dopamine and sheep mast cell proteinase (SMCP). Greater amounts of beta-hexosaminidase, but less SMCP, histamine and arylsulfatase were present in BMMC. Stimulation with calcium ionophore A23187 caused the secretion of granule constituents and generation of leukotriene C4 by BMMC in a dose-dependent manner. An additional [3H]diisopropylfluorophosphate-binding 31,500 mol. wt. serine esterase, antigenically related to SMCP (27,000 mol. wt.) was present in cultures of BMMC but was not detected in isolated MMC. Both enzymes were detected in BMMC by Day 7 of culture and were secreted concomitantly following stimulation of BMMC with ionophore.

tpr homologues activate met and raf.

We have previously described the primary structure of the entire met domain and part of the tpr domain present in the human tpr-met oncogene. The isolation and sequencing of an additional cDNA clone now enables us to present the complete primary sequence of the tpr domain. A computer search has unearthed a remarkable identity between tpr and a rat sequence found at the 5-prime end of the activated raf oncogene. The occurrence of tpr-like sequences in combination with two oncogenes suggests that tpr contributes a domain(s) relevant to the observed activation of met and raf.

Activation of the met oncogene in the human MNNG-HOS cell line involves a chromosomal rearrangement.

In this study it is demonstrated that the activated met gene, which was originally detected in the MNNG-HOS chemically transformed human cell line, is a chimeric gene formed by the joining together of two distinct regions of DNA. Rearrangement of cellular DNA in MNNG-HOS cells was demonstrated by Southern analyses, which showed that the MNNG-HOS cell line contained unique met-related DNA fragments that were not detected in the parental cell line, HOS. Chromosomal localization using a series of rodent-human hybrid cell lines showed that the 5' end of the activated met gene is derived from human chromosome 1, in contrast to the 3' end of met which has been previously localized to human chromosome 7. The chimeric gene is transcribed to produce a 5-kb mRNA that is encoded both by regions of the gene derived from chromosome 1 and by regions of the gene derived from chromosome 7. Karyotype analysis of HOS and MNNG-HOS cells has identified several marker chromosomes that involve translocations of chromosomes 1 and 7. The possible location of the activated met locus within these rearranged chromosomes is discussed.

Ribosomal protein S6 phosphorylation and morphological changes in response to the tumour promoter 12-O-tetradecanoylphorbol 13-acetate in primary human tumour cells, established and transformed cell lines.

The phosphorylation of ribosomal protein S6 in fibroblasts, primary human tumour cells, established and SV40-transformed human cell lines was compared after the addition of 12-O-tetradecanoylphorbol 13-acetate (TPA). In fibroblasts and primary tumour cell cultures, stimulation of S6 phosphorylation was about 4-6-fold. Established and transformed cell lines showed enhanced S6 phosphorylation which was not further stimulated by the addition of TPA. These findings indicated that the influence of TPA on the metabolic pathway, that finally leads to the phosphorylation of protein S6 in cells with a limited lifespan (fibroblasts, primary human tumour cells) can be mimicked by unknown steps also associated with immortalization (establishment function) and the transformed state of the tumour cells. Another interesting observation were morphological changes of the established and SV40-transformed cells which were visible as early as 20 min after the addition of TPA. In fibroblasts and primary tumour cells no changes in morphology were observed, even after 8h incubation.

Spectral Transmittance Characteristics of Holmium Oxide in Perchloric Acid Solution.

The work describes the methods and procedures used to determine the wavelengths of minimum transmittance of holmium oxide in perchloric acid solution. Measurements of spectral transmittance of the solutions were made by means of a high precision spectrophotometer over the wavelength range 200 nm to 680 nm. The wavelength scale accuracy of this instrument was verified by extensive measurements of mercury and deuterium emission lines. The measurements of spectral transmittance of the holmium oxide solutions were made as a function of temperature, purity, concentration, and spectral bandwidth. Analysis of the uncertainties associated with these parameters and the uncertainties associated with the calibration of the instrument wavelength scale and the data analysis have resulted in an estimated uncertainty of ±0.1 nm for the determination of the wavelengths of minimum transmittance of the holmium oxide solution.