Two year followup of anterior and vertical atlantoaxial subluxation in ankylosing spondylitis

OBJECTIVE: To describe the clinical and radiological 2-yr followup of 22 patients with anterior atlantoaxial subluxation (AAS) from a prospective cohort of patients with ankylosing spondylitis. METHODS: The 2-yr assessment included a structured questionnaire for rheumatologic and neurologic complaints and lateral cervical radiographs in maximal flexion view. Initial and 2-yr radiographs were assessed blind to patient data. The course of anterior AAS was classified as unchanged (< 1 mm), progression (> or = 1 mm) or regression (> or = 1 mm) at 2 yrs compared with baseline. Vertical AAS was classified using the Sakaguchi-Kauppi method. Magnification factor was corrected using the ratio of C3 width. RESULTS: Anterior AAS was detected in 22 patients at baseline examination. Two patients also had vertical AAS; 86% were male. Mean age was 33 +/- 9 yrs and mean disease duration was 12 +/- 7 yrs. At followup, one patient had died of acquired immunodeficiency syndrome, 3 could not be reached, and 2 had undergone surgical fusion due to severe myelopathy and now showed complete neurological recovery. Of the remaining 16 patients, 7 (32%) showed progression and 9 (41%) showed no change in the C1-odontoid distance. Vertical AAS developed in one patient. After the 2-yr assessment, 3 additional patients had surgical fusion because of notable progression of AAS, despite absence of neurological signs. CONCLUSION: Anterior AAS progressed in a number of these patients in the 2 yrs following its detection, and with or without neurological signs, surgical management was thought appropriate in a considerable number of them.     

Electron transfer kinetics at a biotin/avidin patterned glassy carbon electrode

STUDY DESIGN: Comparison of findings in plain radiography and conventional tomography with findings in plain radiography and magnetic resonance imaging of the upper cervical spine in consecutive patients with rheumatoid arthritis and with known or suspected abnormalities of the cervical spine. OBJECTIVES: To determine whether plain radiography and magnetic resonance imaging provide enough information to dispense with tomography in investigations of cervical spine involvement in rheumatoid arthritis. SUMMARY OF BACKGROUND DATA: With the recent advances in magnetic resonance imaging technology and the proliferation of magnetic resonance imaging techniques for specific clinical conditions. METHODS: Twenty-eight patients with rheumatoid arthritis and with known or suspected abnormalities of the cervical spine underwent a clinical neurologic examination; plain radiography, including full flexion lateral radiography; anteroposterior and lateral tomography at C1-C2; and magnetic resonance imaging at the same level in neutral position and in flexion. Two radiologists evaluated one image set consisting of plain radiography and conventional tomographic images and another image set consisting of plain radiography and magnetic resonance images, for each patient. RESULTS: Compared with conventional tomography and plain radiography, magnetic resonance imaging and plain radiography showed cystic lesions and erosions of the odontoid process and vertical atlantoaxial subluxation more often, showed anterior subluxation as often, and showed lateral atlantoaxial subluxation less often. CONCLUSION: Magnetic resonance imaging produces sufficiently distinct images of destruction of the odontoid and subluxations for it to replace conventional tomography in investigations of upper cervical spine involvement in rheumatoid arthritis.     

Use of the thoracic aorta for renal revascularization

OBJECTIVE: The primary role of the anterior cruciate ligament is to resist anterior subluxation of the tibia. When the ligament is torn, the tibia is free to sublux anteriorly when the leg is pulled forward. In addition to visualizing the anterior cruciate ligament directly, MR imaging can show joint alignment. The purpose of this study was to test the efficacy of MR images of anterior subluxation of the tibia for diagnosing complete tears of the anterior cruciate ligament. MATERIALS AND METHODS: We evaluated the records of 120 consecutive patients who underwent MR imaging of the knee and subsequently had arthroscopy. Arthroscopy showed a complete tear of the anterior cruciate ligament in 21 patients, a partial tear in eight patients, and an intact anterior cruciate ligament in 91 patients. Two radiologists together reviewed the MR images, and interpretation of anterior cruciate ligament integrity was reached by consensus. The anterior cruciate ligament was categorized as intact, completely torn, or partially torn on the basis of conventional MR imaging criteria. The degree of anterior subluxation of the tibia was measured on a separate occasion in random order by a radiologist who used a sagittal section through the middle of the lateral femoral condyle. On the selected image, two vertical lines parallel to the left and right margins of the image frame were drawn tangent to the posterior cortical margins of the lateral femoral and tibial condyles. Anterior subluxation of the tibia was determined by the distance in millimeters between these two lines and measured with calipers by using the 5-cm scale on the images. Measurements were considered reliable only to one half of the smallest increment of this scale (i.e., 5 mm). Accordingly, tibial subluxation (x) was measured in 5-mm increments, with x < or = 0 mm designated grade 0, 0 mm < x < or = 5 mm designated grade 1, 5 mm < x < or = 10 mm designated grade 2, and so forth. RESULTS: Conventional MR imaging criteria had 90% sensitivity and 94% specificity for diagnosing complete tears of the anterior cruciate ligament. According to the receiver-operating-characteristic (ROC) curve, anterior subluxation of the tibia greater than 5 mm (grade 2 or greater) was considered to be the optimal threshold (sensitivity, 86%; specificity, 99%) for diagnosing complete tears of the anterior cruciate ligament. Notably, none of the six false-positive diagnoses of complete tears by conventional criteria (three partial tears and three intact ligaments at arthroscopy) were misdiagnosed when tibial subluxation was used as the diagnostic criterion. Subluxation greater than 5 mm can be falsely negative with chronic tears of the anterior cruciate ligament (n = 2) or when a displaced bucket-handle tear of the lateral meniscus blocks anterior subluxation of the tibia (n = 1). CONCLUSION: An anterior tibial subluxation greater than 5 mm (grade 2 or greater) is a simple objective measurement that serves as a helpful adjunctive sign in the diagnosis of complete tears of the anterior cruciate ligament. This sign also offers improved discrimination of complete from partial tears of the anterior cruciate ligament.     

Second cancers following in situ carcinoma of the breast

Most reports of midbrain infarction have described clinicoanatomical correlations rather than associations and aetiologies. Thirty nine patients with midbrain infarction (9.4%) are described out of a series of 415 patients with vertebrobasilar ischaemic lesions in the New England Medical Center Posterior Circulation Registry. Patients were categorised according to the rostral-caudal extent of infarction. The "proximal" vertebrobasilar territory includes the medulla and posterior inferior cerebellar artery territory. The "middle" territory includes the pons and anterior inferior cerebellar artery territory. The "distal" territory includes the rostral midbrain, thalami, superior cerebellum, and medial temporal and occipital lobes. Midbrain infarction was accompanied by "proximal" territory infarcts in four patients, and by "middle" territory infarction in 19 patients. Thirteen patients had associated "distal" territory infarcts, three of whom had occipital or temporal lobe infarcts. Only three patients had isolated midbrain infarcts. Cardioembolism (n=11), in situ thrombosis (n=9), large artery to artery embolism (n=7), and intrinsic branch penetrator disease (n=5) were the most common aetiologies. Bilateral infarction and accompanying pontine infarction were associated with the most extensive vertebrobasilar occlusive disease. Midbrain infarction was 10-fold more likely to be accompanied by ischaemia of neighbouring structures than it was to occur in isolation. Recognition of the different patterns of infarction may act as a guide to the underlying aetiology and vascular lesions.     

Cerebellar infarction with hydrocephalus caused by spontaneous extracranial vertebral artery dissection--case report

A 38-year-old male suffered sudden onset of rotational vertigo without headache. Consciousness disturbance developed on the 3rd day after the onset. Computed tomography showed cerebellar infarction with obstructive hydrocephalus. External ventricular drainage was performed. Angiography showed bilateral extracranial vertebral artery dissection. Antiplatelet therapy was given. Repeat angiography showed improvement of the dissection. His neurological deficits completely resolved. Vertebral artery dissections may cause both lateral medullary or cerebellar infarction and hydrocephalus due to the cerebellar infarction manifesting as various symptoms so careful evaluation and treatment are required.     

Cerebral infarction associated with nephrotic syndrome in a young adult: a case report

We report a 19-year-old man who developed a cerebral infarction in the territory of the anterior choroidal artery and showed a hypercoagulable state and nephrotic syndrome after diarrhea and appetite loss. He had suffered from nephrotic syndrome from the age of three and had been treated for five years. MR-angiography showed an occlusion originating in the right internal carotid artery. The right anterior and middle cerebral arteries were imaged from the left internal carotid artery via the anterior communication artery. He showed symptoms of left hemiparesis, agnosia, loss of activity, anasarca and left hypacusis following his clinical course, but had recovered from all but left hemiparesis following medical treatments including steroid therapy. The histologic finding by a renal biopsy revealed focal glomerulosclerosis. In this case, we considered that when he was in a hypercoagulable state and had a second attack of nephrotic syndrome because of inflammation and dehydration due to diarrhea and appetite loss, his hypercoagulable state grew worse, and he then developed a cerebral infarction. When one see a patient with nephrotic syndrome, one should be attentive to the possibility of a complication of cerebral infarction.     

Voluntary subluxation of the shoulder in children. A long-term follow-up study of 36 shoulders

We reviewed 25 children who presented consecutively with voluntary (habitual) subluxation of the shoulder. Thirty-six shoulders were involved and symptoms had been present for an average period of 12 years. Eighteen children were managed by 'skillful neglect': all these had become fully active in the profession of their choice and were satisfied with the outcome. Two of them had required shoulder surgery in adult life but only after trauma. Seven children (ten shoulders) had undergone stabilising operations during childhood with the aim of preventing later degenerative arthritis. These patients were also active in their selected professions, but only three (five of the ten shoulders) had good results: two shoulders had recurrent instability, two were painful and one was stiff. None of the shoulders in either group had developed osteoarthritic changes. There was no association with emotional or psychiatric problems. We conclude that voluntary subluxation of the shoulder in children has a favourable prognosis and that there is no indication for surgical intervention during childhood.     

Meditation in palliative care--a practical tool for self-management

A thirty four-year-old-white man in good health developed an acute anterior wall myocardial infarction (AMI), Killip II with normal coronary arteries. No thrombolytic therapy was given. Selective angiography revealed multiple aneurysms in mesenteric and renal arteries. The diagnosis of polyarteritis nodosa (PAN) was performed. AMI in PAN is secondary to arteritis with thrombosis, or to atherosclerosis due to steroid therapy. This case, having multiorgan vascular aneurysms involvement without previous cardiac symptomatology nor steroid therapy, presented as his first cardiac complication an AMI with normal coronary arteries probably due to selective arteritis.     

Small retinal, cochlear, and cerebral infarctions in the young patient, "SICRET" syndrome of Susac syndrome

We report on two children who developed a fixed rotatory subluxation of the atlantoaxial joint due to torticollis being attributed to a fractured clavicle. Appropriate treatment was delayed for weeks to months; only after the fractured clavicle had healed and the torticollis persisted was the problem identified. Persisting rotatory subluxation also predisposes to further anterior displacement of C-1 due to an increased moment arm created by the forward displacement of the center of gravity of the head. The association of atlantoaxial subluxation should always be considered in children presenting with a clavicular fracture and an acute torticollis.     

Physiological changes in insulin resistance in human pregnancy: longitudinal study with the hyperinsulinaemic euglycaemic clamp technique

Twenty-six patients with rheumatoid disease affecting the cervical spine underwent surgical treatment for neck pain, neurological deficit, or both. Atlantoaxial subluxation (n=13), subaxial subluxation (n=7) and vertical migration of the odontoid (n=6) were treated. Arthrodesis with autologous bone was augmented with wire, Ransford loop, Hartshill rectangle or Magerl technique. Pain relief occurred in 92% of patients. Neurological deficit improved in 89% and was unchanged in the remainder. Radiographic stability was achieved in all but one patient. Posterior surgery effectively relieved pain and neurological deficit, and the complications encountered did not jeopardize the outcome.     

Catamnestic studies on the prodomal phase of myocardial infarct

In a retrospective study by means of a half-standardized method of interview in 154 patients with acute myocardial infarction and in a control group of the same age (n = 100) anamnestic data were established, particularly taking into consideration the preinfarction phase. 27% of the patients were surprised by an acute myocardial infarction without prodromal symptoms, in 32% the first occurrence of complaints of angina pectoris was during the last two months before the infarction. 41% had a preexisting angina pectoris which usually showed a crescendo-course with increasing approximation to the infarction. More than half of the patients reported on physical activity or/and emotional stress as causal factors of the preinfarction complaints. The correlation with the localisation of the infarction showed above all an occurrence of the prodromal symptoms in infarctions of the anterior wall and in lesions of the myocardium which in most cases could be ascertained only enzymatically. A greater accumulation of the prodromi was furthermore found in younger patients, in hypertension and preexisting restriction of the heart function. 70% of the patients with warning symptoms consulted a physician because of their heart complaints. In the control group 22% of the persons reported on heart complaints.     

A randomized phase II trial of interleukin 2 and interleukin 2-interferon alpha in advanced renal cancer

An 81 year old right handed woman developed a left alien hand syndrome characterised by involuntary movements of choking and hitting the face, neck, and shoulder. The patient showed multiple disorders of primary sensation, sensory processing, hemispatial attention, and visual association, as well as a combination of sensory, optic, and cerebellar ataxia (triple ataxia) of the left arm in the absence of motor neglect or hemiparesis. Imaging studies disclosed subacute infarction in the right thalamus, hippocampus, inferior temporal lobes, splenium of corpus callosum, and occipital lobe due to right posterior cerebral artery occlusion. This rare syndrome should be considered as a "sensory" or "posterior" form of the alien hand syndrome, to be distinguished from the "motor" or "anterior" form described more commonly.     

Characteristics of patients hospitalized for myocardial infarction in France with respect to left ventricular dysfunction. Results of the USIK study

Patients admitted in coronary care units, in november 1995, for confirmed acute myocardial infarction within 48 hours of symptoms onset were included in this study. The choice of measurement of left ventricular ejection fraction (LVEF) was left to the physician in charge. Only investigations performed within the first 8 days were taken into consideration. In cases with multiple investigations, the following order of preference was applied: a) angiographic LVEF, b) isotopic LVEF, c) echocardiographic ejection fraction by Simpson's method, d) echocardiographic ejection fraction by Berning's method, e) semi-quantitative visual echocardiographic evaluation. 2563 patients were included (1827 males and 736 females, mean age 67 years). A quantitative evaluation of LVEF was obtained in 1477 patients (57%) whereas 2 053 patients (80%) underwent at least a semi-quantitative evaluation. The average LVEF was 50% and 17% of patients had an ejection fraction < or = 35%. Patients with LVEF < or = 35% were older, less likely males, non smokers and diabetics. Prior heart failure, previous myocardial infarction and anterior location in infarction were more frequent. Heart failure was more frequent in patients with LVEF < or = 35% (75 vs 23%, p < 0.001). One hundred and ninety-seven patients (7.7%) died in the five first days following the onset of symptoms. A left ventricular ejection fraction < or = 35% multiplied the risk of death by 8.1 (Confidence interval: 5.7-11.4, p < 0.001). The presence of clinical heart failure increased the risk even more.     

Experimental study on biological characteristics of tenocyte and fibroblast in rabbit]

In this clinical study the presentation, electromyography and nerve conduction studies were described in different types of motor neurone disease in 28 Sudanese patients seen at El Shaab and Khartoum Teaching Hospitals. The three major clinical subtypes encountered were amyotrophic lateral sclerosis (n = 19), progressive bulbar palsy (n = 7) and progressive muscular atrophy (n = 2). Family history of the disease was found in four patients and those mainly presented with bulbar symptoms. Sudanese patients were found to have an earlier age of onset and a better prognosis of the disease than their caucasian counterparts.     

Relationship between lateral subluxation and widening of medial joint space in Legg-Calvé-Perthes disease

Fifty-five patients (61 affected hips and 49 unaffected hips) with Perthes disease were reviewed to evaluate the relationship between widening of medial joint space and lateral subluxation of the femoral head in radiographs. The components of the medial joint space were evaluated by using T1, T2, proton, and Gd-enhanced T1WI magnetic resonance images (MRI). The widened medial joint space in radiographs was filled with overgrown cartilage at the initial stage (27 hips) in MRI, with both overgrown cartilage and widened true medial joint space at the fragmentation stage (23 hips) and widened true medial joint space at the healing stage (11 hips). Between affected hips and unaffected hips, the mean difference of medial joint space in radiographs between hips at the initial stage and at the fragmentation stage was 2 and 4.5 mm, respectively; the mean difference in percentage of lack of coverage of the femoral head between hips at the initial stage and at the fragmentation stage was 3 and 15%, respectively. During the healing stage, widening of the medial joint space decreased or normalized because of ossification of overgrown cartilage despite the existence of lateral subluxation because of coxa magna. We concluded that widening of the medial joint space may be used as an index of lateral subluxation at only the fragmentation stage in Perthes disease.     

Regulation of human mast cell and basophil function by cAMP

BACKGROUND: Ischemic optic neuropathy (ION) is an infarction of the anterior or, less frequently, posterior part of the optic nerve, usually due to a disease of small arteries supplying the optic nerve. Carotid stenosis or occlusions are rare causes, and among them, carotid dissections have been so far reported in only 5 cases. METHODS: We describe 4 patients with ION (2 anterior and 2 posterior) due to internal carotid artery dissection of a consecutive series of 110 patients with internal carotid artery dissection (3.6%). RESULTS: None of the patients had signs of central retinal artery occlusion or ischemic ocular syndrome. Ischemic optic neuropathy occurred after a mean of 5.3 days (range, 3-8 days) following the first symptom, which was headache in 1 patient, transient monocular blindness in 2, and hemispheric transient ischemic attack in 1. One patient had associated Homer syndrome, and 2 had severe ipsilateral headache and orbital pain. None of the patients developed a cerebral infarction. These features differ from those observed in "classic" nonarteritic anterior ION and might therefore point to carotid dissection. CONCLUSION: Ischemic optic neuropathy may occur as an early sign of carotid dissection: young age, previous transient monocular blindness, an association with pain, Horner syndrome, or hemispheric transient ischemic attacks are suggestive of this cause and should prompt confirmatory investigations.     

Influence of cigarette smoking on rate of reopening of the infarct-related coronary artery after myocardial infarction: a multivariate analysis

OBJECTIVES: This study sought to determine whether the reopening of the infarct-related vessel is related to clinical characteristics or cardiovascular risk factors, or both. BACKGROUND: In acute myocardial infarction, thrombolytic therapy reduces mortality by restoring the patency of the infarct-related vessel. However, despite the use of thrombolytic agents, the infarct-related vessel remains occluded in up to 40% of patients. METHODS: We studied 295 consecutive patients with an acute myocardial infarction who underwent coronary angiography within 15 days (mean [+/- SD] 6.7 +/- 3.2 days) of the onset of symptoms. Infarct-related artery patency was defined by Thrombolysis in Myocardial Infarction trial flow grade > or = 2. Four cardiovascular risk factors--smoking, hypertension, hypercholesterolemia and diabetes mellitus--and eight different variables-age, gender, in-hospital death, history of previous myocardial infarction, location of current myocardial infarction, use of thrombolytic agents, time interval between onset of symptoms, thrombolytic therapy and coronary angiography--were recorded in all patients. RESULTS: Thrombolysis in current smokers and anterior infard location on admission were the three independent factors highly correlated with the patency of the infarct-related vessel (odds ratios 3.2, 3.0 and 1.9, respectively). In smokers, thrombolytic therapy was associated with a higher reopening rate of the infard vessel, from 35% to 77% (p < 0.001). Nonsmokers did not benefit from thrombolytic therapy, regardless of infarct location. CONCLUSIONS: These observational data, if replicated, suggest that in patients with acute myocardial infarction, thrombolytic therapy may be most effective in current smokers, whereas nonsmokers and ex-smokers may require other management strategies, such as emergency percutaneous transluminal coronary angioplasty.     

Three-dimensional motion of the upper cervical spine in rheumatoid arthritis

Rheumatoid arthritis frequently contributes to instability of the upper cervical spine. Rotational instability of the upper cervical spine was evaluated in rheumatoid arthritis patients using biplanar x-ray photogrammetry. Three-dimensional cervical motion and the instantaneous axis of rotation of the atlas relative to the axis were evaluated in normal and rheumatoid arthritis patients during axial rotation in the horizontal plane. Anterior atlantoaxial subluxation did not increase during axial head rotation in either the atlantoaxial subluxation or the vertical subluxation groups, while the instantaneous axes of rotation were distributed posteriorly in the dens in the RA-normal group, but were widely scattered in the atlantoaxial subluxation group.     

Growth and congenital heart disease

PURPOSE: To assess the efficacy of heparin in preventing the abrupt closure after coronary angioplasty in low risk patients for this phenomenon. METHODS: In the last 4 years, 525 patients successfully dilated were randomized to receive intravenous heparin (n = 264) or not (n = 261) after the angioplasty. The excluding criteria were contraindications for heparin and risk for abrupt closure (refractory unstable angina, primary coronary angioplasty in acute myocardial infarction, evidence of intracoronary thrombus, intimal tear after the procedure and cases of chronic total occlusions). Both heparin and non heparin groups were similar in respect to female sex (15% x 17%; p = NS), age over 70 years old (7% x 9%; p = NS), previous myocardial infarction (26% x 24%; p = NS), multi-vessel procedures (4% x 7%; p = NS, stable angina (40% x 46%; p = NS), unstable angina (52% x 48%; p = NS) and angioplasty after thrombolytic therapy (8% x 6%; p = NS). RESULTS: The overall incidence of abrupt closure was 2/525 (0.4%), with one case (0.4%) in each group. The in-hospital mortality was 1/525 (0.2%), which occurred in a non-heparin patient, due to a anterior myocardial infarction. Major complications occurred similarly in heparin and non-heparin groups (0.4%). Bleeding complications were observed more frequently in the heparin group (7% x 2%; p = 0.002). All of them were in the catheterization site and none required blood transfusion. Severe systemic bleeding were not observed. CONCLUSION: In patients regarded as low risk for abrupt closure, the incidence of this complication was really low (0.4%) and heparin probably do not prevent it.     

Antiphospholipid syndrome associated with progressive systemic sclerosis

Hemifacial spasm is a neurological disorder due to abnormal hyperactivity of the facial nerve. The most common cause of hemifacial spasm is a neuro-vascular conflict in the cerebellopontine angle between a vascular loop and the root of the facial nerve (96% of cases). Tumors are the cause of hemifacial spasm in only 1% of cases). The authors present their results in 100 patients who underwent microvascular decompression for essential hemifacial spasm between 1990 and 1995. They used microsurgical and endoscopic procedures by a minimal retrosigmoid approach in all cases. The most common offending vessels were the posterior inferior cerebellar artery (70%), the vertebral artery (41%) and the anterior inferior cerebellar artery (28%). An aberrant vein was found in 2 cases. There were 38% of multiple artery-nerve conflicts. Physiopathology of hemifacial spasm is explained by two principal theories: in the ephaptic theory, hyperactivity and an abnormal nervous impulse pathway are due to a short demyelinated area on the nerve trunk caused by the offending vessel, inducing short circuiting between adjacent nerve fibers. In the nuclear theory, hyperactivity of the facial nerve is due to an abnormal and automatic activity of the facial nerve nucleus itself, induced by the vessel. The authors used pre and postoperative electromyographic tests and intraoperative electromyographic tests. Their results tend to prove the nuclear theory. Ninety per cent of the patients had a good result, with a mean follow-up time of 30 months in 60 cases. In 82% of the cases, there was a total recovery after a single procedure. There was no mortality and no facial palsy. Hearing loss occurred in less than 5%.