A case of catastrophic antiphospholipid syndrome: first report with advanced cardiac imaging using MRI.

This present case pertains to a 48-year-old woman with a history of antiphospholipid syndrome, who presented with progressive fatigue, generalized weakness, and orthopnea acutely. She had a prior diagnosis of antiphospholipid syndrome with recurrent deep vein thromboses (DVTs) and repeated demonstration of lupus anticoagulants. She presented in cardiogenic shock with markedly elevated troponin and global myocardial dysfunction on echocardiography, and cardiac catheterization revealed minimal disease. Cardiac magnetic resonance imaging was performed, which revealed findings of perfusion defects and microvascular obstruction, consistent with the pathophysiology of catastrophic antiphospholipid syndrome (CAPS). Diagnosis was made based on supportive imaging, including head magnetic resonance imaging (MRI) revealing multifocal, acute strokes; microvascular thrombosis in the dermis; and subacute renal infarctions. The patient was anticoagulated with intravenous unfractionated heparin and received high-dose methylprednisolone, plasmapheresis, intravenous immunoglobulin, and one dose each of rituximab and cyclophosphamide. She convalesced with eventual myocardial recovery after a complicated course. The diagnosis of CAPS relies on the presence of (1) antiphospholipid antibodies and (2) involvement of multiple organs in a microangiopathic thrombotic process with a close temporal association. The myocardium is frequently affected, and heart failure, either as the presenting symptom or cause of death, is common. Despite echocardiographic evidence of myocardial dysfunction in such patients, MRIs of CAPS have not previously been reported. This case highlights the utility in assessing the involvement of the myocardium by the microangiopathic process with MRI. Because the diagnosis of CAPS requires involvement in multiple organ systems, cardiac MRI is likely an underused tool that not only reaffirms the pathophysiology of CAPS, but could also clue clinicians in to the possibility of a diffuse thrombotic process.

Effects of age on dopamine and serotonin receptors measured by positron tomography in the living human brain.

D2 dopamine and S2 serotonin receptors were imaged and measured in healthy human subjects by positron emission tomography after intravenous injection of 11C-labeled 3-N-methylspiperone. Levels of receptor in the caudate nucleus, putamen, and frontal cerebral cortex declined over the age span studied (19 to 73 years). The decline in D2 receptor in males was different from that in females.

Sedation with propofol for interventional endoscopy by trained nurses in high-risk octogenarians: a prospective, randomized, controlled study.

BACKGROUND AND STUDY AIMS: Sedation with the short-acting anesthetic agent propofol has shown several advantages, particularly in interventional endoscopy. So far, however, there are no valid data on the safety of nurse-administered propofol sedation (NAPS) during interventional endoscopy in elderly high-risk patients. PATIENTS AND METHODS: A total of 150 patients aged > 80 years with high comorbidity were randomized to receive midazolam plus meperidine (n = 75) or propofol alone (n = 76) for sedation during endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), or double-balloon endoscopy (DBE). Sedation was supervised by a trained nurse and a trained physician both of whom were not involved in the endoscopic procedure. Vital signs were continuously monitored as well as patient cooperation and tolerance. Mortality and morbidity at 30 days was analyzed. RESULTS: The overall cardiopulmonary complication rate was 16 % in the midazolam group and 23.7 % in the propofol group ( P > 0.05). The mean decline in oxygen saturation (initial vs. lowest O (2) saturation) and the mean decline of blood pressure (initial vs. lowest blood pressure) were significantly greater with propofol (7 % +/- 3 % vs. 4 % +/- 2 % [ P < 0.05] and 10 % +/- 2 % vs. 8 % +/- 2 %, respectively [ P < 0.05]). No procedure had to be interrupted due to serious adverse events. Patient cooperation was statistically significantly better in the propofol group (7 +/- 2 vs. 5 +/- 2 points). Patients sedated with propofol showed a significantly lower oxygen saturation rate during recovery time (8 % vs. 28 %; P < or = 0.01). CONCLUSION: NAPS during interventional endoscopy is as safe as midazolam/pethidine sedation even in high-risk patients aged > 80 years.

Polymer surface and thin film vibrational dynamics of poly(methyl methacrylate), polybutadiene, and polystyrene.

Inelastic helium atom scattering has been used to investigate the vibrational dynamics at the polymer vacuum interface of poly(methyl methacrylate), polystyrene, and polybutadiene thin films on SiO(x)Si(100). Experiments were performed for a large range of surface temperatures below and above the glass transition of these three polymers. The broad multiphonon feature that arises in the inelastic scattering spectra at surface temperatures between 175 and 500 K is indicative of the excitation of a continuum of surface vibrational modes. Similarities exist in the line shapes of the scattering spectra, indicating that helium atoms scatter from groups of similar mass on the surface of these polymer thin films. The line shapes obtained were further analyzed using a semiclassical scattering model. This study has shown that quite different polymer thin films can have similar interfacial dynamics at the topmost molecular layer.

Importance of sagittal orbital imaging in evaluating extraocular muscle trauma following endoscopic sinus surgery.

BACKGROUND/AIMS: Orbital trauma may result in severe restrictive, paralytic, or combined strabismus. Clinical diagnosis may be extremely challenging. Orbital imaging is helpful in determining the exact site of injury, functionality, and integrity of the extraocular muscles. A typical study now includes coronal and axial views of the muscles. This study aimed to emphasise the importance of sagittal imaging of the orbit when evaluating extraocular muscle injury or entrapment. METHODS: A retrospective review of two subjects who underwent endoscopic sinus surgery procedures that resulted in trauma to the medial rectus muscle. High resolution orbital imaging studies were performed. RESULTS: High resolution magnetic resonance imaging (MRI) scans with coronal and axial views suggested a large section of the muscle was not present and was probably destroyed. In both cases there was a displacement of the mid-portion of the medial rectus muscle into an area of bony defect not seen on the axial and coronal views. Sagittal images demonstrated continuity between the anterior and posterior segments of the medial rectus muscle in each case. CONCLUSION: Surgical strategies are dependent on accurate interpretation of MRI scans. Muscle displacement may result in axial and coronal orbital imaging misinterpretation. Sagittal views were essential to determine muscle integrity.

beta-Endorphin/beta-lipotropin immunoreactivity in endogenous depression. Effect of dexamethasone.

This study addresses the question of whether pituitary peptides (ie, beta-endorphin) show regulatory disruption in endogenous depression and, if so, does it co-occur in the same subjects who show cortisol dysregulation. Endogenously depressed patients and psychiatric controls from three centers were evaluated, when not taking medications, and studied for plasma cortisol and beta-endorphin levels. Plasma samples were taken at four time points over one hour, on the basal day, and 16 hours after 1 mg of dexamethasone. From 33% to 69% of the endogenous patients were abnormal in their postdexamethasone cortisol levels, and from 50% to 69% were abnormal on postdexamethasone beta-endorphin values (vs 0% and 8%, respectively, for controls). When endogenous subjects were evaluated for abnormality on both cortisol and beta-endorphin, after dexamethasone, it was found that the two measures of hypothalamic-pituitary-adrenal dysfunction did not necessarily co-vary. In fact when having either abnormal beta-endorphin or cortisol levels (or both) was used as a biological marker a larger number of the endogenous patients were detected than with either measure alone. Our conclusions are as follows: Plasma beta-endorphin shows a circadian rhythm similar to that seen with corticotropin (ACTH) and is suppressable by dexamethasone. In many endogenous patients plasma beta-endorphin levels escape from dexamethasone suppression. Many of these subjects are not cortisol escapers. When abnormality of either the beta-endorphin or cortisol is considered it is clear that both levels of the hypothalamic-pituitary-adrenal axis can be dysregulated in endogenous depression.

Slaughterhouse survey of pyelonephritis in dairy cows.

Twenty-one rejected kidneys from 2426 slaughtered dairy cows (0.87 per cent) had gross signs of pyelonephritis that were confirmed by histopathology. In all the kidneys the findings were consistent with a chronic rather than an acute infection. One species of bacteria was cultured from 12 of the kidneys and two species of bacteria were cultured from six. The most commonly isolated bacteria were Escherichia coli, from eight kidneys, Arcanobacterium pyogenes, from seven kidneys and Corynebacterium renale, from five kidneys. The other bacteria cultured were Corynebacterium cystitidis, Corynebacterium species, Streptococcus species group G and Enterococcus faecalis. E. coli was cultured from all the kidneys from which two species were isolated; the accompanying bacteria were A. pyogenes in three kidneys, C. renale in two and C. cystitidis in one. No bacteria were cultured from two of the kidneys and no significant bacteria were cultured from another. The kidneys with pyelonephritis were slightly larger than a comparison group of 72 kidneys without nephritis.

Positive therapeutic response to lithium in hypomania secondary to organic brain syndrome.

A 57-year-old man with no personal or family history of manic-depressive disease developed symptoms of hypomania after a cerebrovascular accident and surgical trauma to the brain. The patient responded well to lithium carbonate treatment over a 2-year period. Although this therapy is contraindicated in cases of organic brain syndrome, the authors suggest that it should be considered in the management of hypomanic behavior following organic brain dysfunction.

Head injury and marital aggression.

Of 31 consecutive male patients referred for evaluation of marital violence, 19 (61.3%) had histories of severe head injury. Although the relationship between child abuse and head injury did not reach an acceptable level of significance, it did indicate a trend toward a positive relationship. Alcohol abuse, reported by 48.4% of the sample, was significantly associated with head injury. Confirmation of biological etiologies in marital aggression would have implications for prevention and treatment.

Prolactin in psychiatry.

Prolactin is a protein hormone synthesized and secreted by the anterior pituitary gland. Because the monoamines dopamine and serotonin are important in the control of its secretion, prolactin has been the subject of much psychoendocrine research in recent years. The authors review some of the implications of the main findings of such research as they relate to schizophrenia, affective disorders, premenstrual syndrome, and alcoholism and discuss its possible usefulness to clinicians. As a research strategy, prolactin studies have a good potential for identifying specific neurotransmitters involved in discrete psychopathologic entities.

Toward a biochemical classification of depressive disorders, VII: urinary free cortisol and urinary MHPG in depressions.

The authors measured urinary free cortisol and urinary 3-methoxy-4-hydroxyphenylglycol (MHPG) levels in 24 severely depressed patients and 22 normal control subjects. Urinary free cortisol levels were significantly higher in the depressed patients than in the control subjects, but mean urinary MHPG levels were not significantly different in these two groups. A very high positive correlation between urinary MHPG levels and urinary free cortisol levels was found in the depressed patients but not in the control subjects.

MHPG as a predictor of antidepressant response to imipramine and maprotiline.

To explore the hypothesis that depressed patients with low pretreatment levels of urinary 3-methoxy-4-hydroxyphenylglycol (MHPG) respond more favorably to antidepressant drugs which act on noradrenergic neuronal systems than do patients with high MHPG levels, the authors administered 150--200 mg/day of imipramine or maprotiline to 13 depressed patients. All of the 5 patients with low pretreatment MHPG levels responded to treatment compared with 1 of the 14 patients with high MHPG levels; 4 patients dropped out of the study.

Toward a biochemical classification of depressive disorders, V: Heterogeneity of unipolar depressions.

The authors found that the mean urinary level of 3-methoxy-4-hydroxyphenylglycol (MHPG) was significantly lower in 20 patients with bipolar manic-depressive or schizoaffective depressions than in either 50 patients with unipolar depressions or 26 age- and sex-matched control subjects. In contrast, the mean MHPG levels in the total group of patients with unipolar depressions and in any subgroup defined by Research Diagnostic Criteria (RDC) were not significantly different from control values. However, examination of the distribution of urinary MHPG levels in patients with unipolar depressions in relation to other recent findings by the authors' collaborative research group suggested the existence of at least three biochemical subtypes of unipolar depressions that may, in part, be differentiated on the basis of urinary MHPG levels.

The dexamethasone suppression test in normal control subjects: comparison of two assays and effect of age.

he authors used competitive protein binding assay and radioimmunoassay to measure cortisol levels in 38 normal control subjects three times before and three times after administration of 1 mg of dexamethasone. They found significant interassay differences at 11:00 p.m. before dexamethasone and at all three postdexamethasone times. Analysis of variance revealed significant overall positive relationships between age and cortisol levels measured by both techniques. Age correlated significantly with postdexamethasone cortisol levels measured by radioimmunoassay but not when measured by competitive protein binding assay. Clinicians should obtain data from their laboratories as to appropriate cutoffs for cortisol suppression on the specific assay used.

The dexamethasone suppression test: identification of subtypes of depression.

In this study mean 4 p.m. cortisol levels were significantly higher in patients with major depression than in control subjects or in patients with bipolar depression or dysthymic-related disorders. Moreover, the distribution of values differed significantly among groups. Eighteen of 45 patients with major depression had cortisol levels of 10 micrograms/dl or more, compared with 2 of 20 bipolar depressed patients and 0 of 31 controls. Patients with very high cortisol levels (15 micrograms/dl or more) tended to fulfill criteria for major depression with mood-congruent psychosis. The distribution of values in the major depression group also suggested the existence of three major subgroups. The authors discuss the implications of these data.

Pediatric metrizamide CT cisternography: cerebrospinal fluid circulation and hydrocephalus.

The technique of intrathecal enhancement using metrizamide (Amipaque) combined with CT imaging enables both the morphologic and dynamic (serial) evaluation of the intracranial cerebrospinal fluid pathways. Three distinct metrizamide CT cisternographic patterns (delayed, intermediate, and normal) emerge in pediatric patients with hydrocephalus. The findings correlate well with radionuclide cisternographic patterns; however, CT also provides excellent morphologic definition.

Diagnostic approaches to pituitary adenomas.

The utility of diagnostic tests for pituitary adenoma was compared in 12 patients. Endocrine and radiologic studies were always abnormal, even when neuro-ophthalmologic tests were normal. In most cases, both tomography of the sella turcica and CT scan revealed a mass in the region of the sella turcica. For more precise definition of suprasellar extension of the mass, metrizamide CT cisternography or tomographic pneumoencephalography with metrizamide provided similar details, although CT cisternography was much more easily done. Angiography provides a means to exclude an aneurysm or vascular malformation, a vascular tumor, or an aberrant course of the internal carotid artery.

Anti-Ro(SS-A) autoantibodies in central nervous system disease associated with Sjögren's syndrome (CNS-SS): clinical, neuroimaging, and angiographic correlates.

OBJECTIVE: To examine in Sjögren's syndrome (SS) the interrelationship between the presence of the anti-Ro(SS-A) antibody response and (1) concomitant presence and type (ie, focal or nonfocal) of CNS disease (CNS-SS), (2) cross-sectional brain MRI or CT, and (3) abnormal cerebral angiography. METHODS: Neurologic, neuroimaging, and angiographic features of CNS-SS patients were correlated with the presence of precipitating anti-Ro(SS-A) autoantibodies detected by gel double-immunodiffusion or quantitative ELISA, which detects antibodies directed against the 60-kd peptide. Statistical analyses were performed using Fisher's exact test (two-tailed) with Haldane's adjustment and odds ratio with Cornfield 95% confidence intervals. RESULTS: Precipitating antibodies against the Ro(SS-A) antigen, determined by gel double-immunodiffusion, were present in an increased frequency in CNS-SS patients with (1) documented clinical CNS disease, (2) focal clinical CNS manifestations and serious complications, (3) large regions of increased signal intensity, consistent with ischemia/infarcts on brain MRI scans or regions of decreased attenuation consistent with infarcts on CT, and (4) abnormal cerebral angiograms consistent with small-vessel angiitis. Finally, the anti-Ro(SS-A) antibody response in CNS was directed against the 60-kd peptide specificity, determined by ELISA. CONCLUSIONS: Clinical, neuroimaging (cerebral CT), and angiographic observation suggest that a subset of anti-Ro(SS-A) antibody-positive, in contrast with -negative, CNS-SS patients have more serious and extensive CNS disease, some with frank cerebral angiopathy. Anti-Ro(SS-A) antibodies are postulated to play a role in mediating or potentiating vascular injury in CNS-SS.

Effects of marginal hypoxemia on recovery from oxygen-induced retinopathy in the kitten model.

Prolonged oxygen administration in premature infants is the most predictive variable for severe retinopathy of prematurity, after degree of prematurity itself. It was noted that infants receiving prolonged oxygen supplementation are probably hypoxemic relative to their healthy counterparts. Therefore, hypoxemia during recovery from a hyperoxic-induced retinal vascular injury was tested in the kitten model of oxygen-induced retinopathy. Twelve litters were exposed to 80% inspired O2 for 65 hours on day 3, and recovered in room air, 13% or 17% oxygen. The retinas were scored at 4 weeks, and 13% oxygen recovery (PO2 = 39 +/- 18 torr) was found to worsen significantly the retinopathy compared with that in room air-recovered littermates (P less than .01). Hemorrhages occurred more frequently in the retinas from the hypoxemic-recovered kittens. Clinical trials of this hypothesis are indicated in humans.

The role of tocopherol in oxygen-induced retinopathy: kitten model.

The effect of tocopherol (vitamin E) on oxygen-induced retinopathy was studied in 75 kittens following the development of a 12-point scoring system to quantitate the degree of retinopathy seen at three weeks. The tocopherol was found to be beneficial when given daily from the day of birth (P less than .0001) with oxygen exposures of two to three days (79% FiO2) beginning on day 3. Caution is urged in applying these data to humans because (1) hepatosplenomegaly was noted in the treated animals, and (2) the kitten model for oxygen-induced retinopathy is not entirely satisfactory, Pediatrics, 59:998-1005 1977, RETROLENTAL FIBROPLASIA, OXYGEN TOXICITY, VITAMIN E, RETINOPATHY, KITTEN.