A 12-year-old girl with absent radial pulse: arterial thoracic outlet syndrome with subclavian artery aneurysm and thrombosis of the brachial artery

Brachial arterial occlusion is rare in children and adolescents. Once a traumatic cause is excluded, the differential diagnosis consists of a variety of rare conditions. We report the case of a 12-year-old girl whose presenting symptoms--an absent radial pulse and Raynaud's phenomenon of the right hand--could be easily mistaken for a vasculitis. She was found to have arterial thoracic outlet syndrome with right subclavian artery compression and aneurysm formation caused by an anomalous first rib and consecutive thromboembolic occlusion of the brachial artery. The diagnosis and differential diagnosis of this condition are reviewed.

Observing signs of pain in relation to self-injurious behaviour among individuals with intellectual and developmental disabilities

BACKGROUND

Self-injurious behaviour is a chronic condition among people with intellectual and developmental disabilities for which there is no known cure. The pain hypothesis suggests that individuals who engage in self-injury have altered or diminished pain perception. The purpose of the present study was to assess how frequently individuals diagnosed with an intellectual and developmental disability who engage in chronic self-injury displayed non-verbal signs of pain in relation to their self-injury.

METHODS

We videotaped four participants (aged 28-50 years) in their homes during times when they were likely to engage in self-injury. Using continuous recording measures, we coded videotapes for the frequency and duration of self-injury and expressions of non-verbal pain-related behaviours. Sequential analyses were conducted to identify temporal relations between pain-related behaviours and self-injury.

RESULTS

Our data suggest that the existing measures of pain may be systematically related to instances of self-injury. The relationships, however, appear to vary depending on the person who engages in self-injury, the environmental contexts in which the self-injury occurs, and perhaps, the type of self-injury in which the person engages.

CONCLUSIONS

These results support some of the findings of Symons et al. and they raise questions about the blunted nociception hypothesis of self-injury.

Creep Study for Fatigue Life Assessment of Two Lead-Free High Temperature Solder Alloys

Creep of two lead-free high temperature solder alloys, 95Sn-5Ag and 99Sn-1.0Cu was studied in this investigation. Room and high temperature creep tests were performed to examine deformation mechanisms and to establish mathematical models of creep deformation for the alloys. A state variable creep model was introduced to model both primary and secondary creep deformation of these two alloys which show a very significant primary creep. Fatigue life models of the alloys were established based on an energy-based failure criteria, which was deduced from variable strain amplitude tests at a constant strain rate of 0.003/sec, and from variable strain rates tests with two constant strain amplitudes of 0.005 and 0.01. Applications of the creep model includes determination of peak loads and hysteresis strain energy density in strain-controlled fatigue tests. It is demonstrated that the creep model can be very helpful to establish fatigue failure criteria and to assess fatigue lives of these two alloys.

[Pain perception of adolescents with chronic functional pain : adaptation and psychometric validation of the Pain Perception Scale (SES) by Geissner]

BACKGROUND

Pain perception is a central aspect of the multidimensional model of chronic pain. Up to now, validated measurement tools are lacking in the German language for measuring pain perception in adolescents. The aim of this study was to examine and adapt the well-established Pain Perception Scale for Adults by Geissner (SES) for use in adolescents with chronic pain to provide a measure for clinical diagnosis and evaluation of treatment effects.

MATERIAL AND METHODS

Principal component, reliability and item analyses were conducted on a sample with 139 adolescents. To test validity, age and sex effects, correlations with pain-related constructs, differences between treatment groups (inpatients vs outpatients) and concordance between adolescents and their parents were analysed.

RESULTS

Findings support a two-factor solution with one affective and one sensory factor; three additional sensory items were included in the final version. The scales show good internal consistency. Consistent with hypotheses, we found significant correlations with pain characteristics, emotional and cognitive variables as well as pain-related disability. Inpatients and outpatients show a significant difference in affective pain perception. Concordance between parents and adolescents was high.

CONCLUSION

With this questionnaire there is now a validated German assessment tool to measure pain perception in adolescents with chronic pain (Pain Perception Scale for Adolescents, SES-J). Due to its practicability it is suitable for clinical application.

Antioxidant capacity of potato chips and snapshot trends in acrylamide content in potato chips and cereals on the Canadian market

The concentration of acrylamide was measured in selected varieties of five brands of potato chips and breakfast cereals over a 5-year period. Most of the products were purchased in one locality in Canada. Samples were analysed by an isotope dilution ((13)C(3)) acrylamide method. They were extracted with water, partitioned with dichloromethane, filtered through a 5 kDa centrifuge filter, cleaned-up on HLB Oasis polymeric and Accucat mixed mode anion and cation exchange SPE columns, and analysed by liquid chromatography-tandem mass spectrometry (LC-MS/MS). The acrylamide concentration in potato chips varied from 106 to 4630 ng g(-1), while values in cereals varied from 50 to 347 ng g(-1). Wide variations were observed between brands, within brands over time, and between lots of the same brand. A subset of potato chip samples was analysed for in vitro antioxidant activity. No relationship was found between antioxidative capacity of potato chips and their acrylamide content.

Cardiac CT in 2009

Multislice computed tomography is an emerging diagnostic modality in cardiology practice. Within the last decade a rapid technical evolution from 4-slice scanners to 64-slice and meanwhile 320-slice scanners which faster gantry rotation time has taken place. These advances as well as improved post-processing tools account for a stabilization of image quality and allow assessing cardiac structures with high spatial and temporal resolution. Moreover, dedicated acquisition techniques have been employed to reduce radiation exposure to a minimum. Today cardiac computed tomography is not only able to depict the coronary arteries, but to get reliable information about cardiac function and cardiac structure. This review focuses on present clinical indications and future application of multi-slice computed tomography in clinical cardiology.

Differences in plaque composition and distribution in stable coronary artery disease versus acute coronary syndromes; non‐invasive evaluation with multi‐slice computed tomography

BACKGROUND

Plaque composition rather than degree of luminal narrowing may be predictive of acute coronary syndromes (ACS). The purpose of the study was to compare plaque composition and distribution with multi-slice computed tomography (MSCT) between patients presenting with either stable coronary artery disease (CAD) or ACS.

METHODS

MSCT was performed in 22 and 24 patients presenting with ACS or stable CAD, respectively. Coronary lesions were classified as calcified, non-calcified or mixed while signal intensity (SI) was measured.

RESULTS

In patients with stable CAD, the majority of lesions were calcified (89%). In patients with ACS, less calcifications were observed with a greater proportion of non-calcified (18%) or mixed (36%) lesions (P<0.001). Accordingly, mean SI of plaques was significantly less in ACS (320+/-201 HU versus 620+/-256 HU in stable CAD, P<0.001). Dividing lesions in the ACS group according to culprit versus non-culprit vessel location resulted in no significant difference in average SI between these two groups while still lower as compared to stable CAD (P<0.001).

CONCLUSIONS

In patients with ACS, significantly less calcifications were present as compared to stable CAD. Moreover, even in non-culprit vessels, multiple non-calcified plaques were detected, indicating diffuse rather than focal atherosclerosis in ACS.

Experience with multiple stent implantations in primary antiphospholipid syndrome in childhood: a case report

The antiphospholipid syndrome (APS) is an autoimmune condition characterized by the persisting presence of antiphospholipid antibodies in association with thrombosis and/or pregnancy morbidity. Primary APS is quite rare in childhood and exact prevalence is not known. However, substantial proportion of thrombotic events in children is being attributed to APS. We herein present a 9-year-old boy presented with impending pericardial tamponade and large pleural effusions likely secondary to transudation of fluid from his gradually developed collateral circulation which was resulted from almost completely occluded vena caval system due to primary APS. He was treated with multiple angioplasty-stenting which offered symptomatic relief and better quality of life. To our knowledge, this is the first reported paediatric case of primary APS presented with extensive occlusive lesions in both caval systems and treated with repeated endovascular stent placements.

Accuracy of dual-source CT in the characterisation of non-calcified plaque: use of a colour-coded analysis compared with virtual histology intravascular ultrasound

Non-invasive assessment of plaque volume and composition is important for risk stratification and long-term studies of plaque stabilisation. Our aim was to evaluate dual-source computed tomography (DSCT) and colour-coded analysis in the quantification and classification of coronary atheroma. DSCT and virtual histology intravascular ultrasound (IVUS-VH) were prospectively performed in 14 patients. 22 lesions were compared in terms of plaque volume, maximal per cent vessel stenosis and percentages of fatty, fibrous or calcified components. Plaque characterisation was performed with software that automatically segments luminal or outer vessel boundaries and uses CT attenuation for a colour-coded plaque analysis. Good correlation was found for per cent vessel stenosis in DSCT (53+/-13%) and IVUS (51+/-14%; r(2) = 0.70). Mean volumes for entire plaque and non-calcified atheroma were 68.5+/-33 mm(3) and 56.7+/-30 mm(3), respectively, in DSCT and 60.8+/-29 mm(3) and 55.8+/-26 mm(3), respectively, in IVUS. Mean percentages of fatty, fibrous or calcified components were 28.2+/-6%, 53.2+/-9% and 18.7+/-13%, respectively, in DSCT and 29.9+/-5%, 55.3+/-12% and 14.4+/-9%, respectively, in IVUS-VH. Significant overestimation was present for the entire plaque and the volume of calcified plaque (p = 0.03; p = 0.0004). Although good correlation with IVUS was obtained for the entire plaque (r(2) = 0.76) and non-calcified plaque volume (r(2) = 0.84), correlation proved very poor and insignificant for percentage plaque composition. Interclass correlation coefficients for non-calcified plaque volume and percentages of fatty, fibrous or calcified components were 0.99, 0.99, 0.95 and 0.98, respectively, and intraclass coefficients were 0.98, 0.93, 0.98 and 0.99, respectively. We found that using Hounsfield unit-based analysis, DSCT allows for accurate quantification of non-calcified plaque. Although percentage plaque composition proves highly reproducible, it is not correlated with IVUS-VH.

Procalcitonin (PCT)-guided algorithm reduces length of antibiotic treatment in surgical intensive care patients with severe sepsis: results of a prospective randomized study

BACKGROUND

Adequate indication and duration of administration are central issues of modern antibiotic treatment in intensive care medicine. The biochemical variable procalcitonin (PCT) is known to indicate systemically relevant bacterial infections with high accuracy. In the present study, we aimed to investigate the clinical usefulness of PCT for guiding antibiotic treatment in surgical intensive care patients with severe sepsis.

PATIENTS AND METHODS

Patients were randomly assigned to a PCT-guided or a control group requiring antibiotic treatment. All patients received a calculated antibiotic regimen according to the presumed microbiological spectrum. In the PCT-guided group, antibiotic treatment was discontinued if clinical signs of infection improved and the PCT value was either <1 ng/ml or decreased to <35% of the initial concentration within three consecutive days. In the control group, antibiotic treatment was directed by empirical rules.

RESULTS

The PCT-guided group (n = 14 patients) and the control group (n = 13 patients) did not differ in terms of biological variables, underlying diseases, and overall disease severity. PCT guidance led to a significant reduction of antibiotic treatment from 6.6 +/- 1.1 days (mean +/- SD) compared with 8.3 +/- 0.7 days in control patients (p < 0.001) along with a reduction of antibiotic treatment costs of 17.8% (p < 0.01) without any adverse effects on outcome.

CONCLUSIONS

Monitoring of PCT is a helpful tool for guiding antibiotic treatment in surgical intensive care patients with severe sepsis. This may contribute to an optimized antibiotic regimen with beneficial effects on microbial resistances and costs in intensive care medicine.

Noninvasive coronary angiography using 64-slice spiral computed tomography in an unselected patient collective: Effect of heart rate, heart rate variability and coronary calcifications on image quality and diagnostic accuracy

OBJECTIVE

The aim of this study was to assess the impact of heart rate, heart rate variability and calcification on image quality and diagnostic accuracy in an unselected patient collective.

SUBJECTS AND METHODS

One hundred and two consecutive patients with known or suspected coronary artery disease underwent both 64-MSCT and invasive coronary angiography. Image quality (IQ) was assessed by independent observers using a 4-point scale from excellent (1) to non-diagnostic (4). Accuracy of MSCT regarding detection or exclusion of significant stenosis (>50%) was evaluated on a per segment basis in a modified AHA 13-segment model. Effects of heart rate, heart rate variability, calcification and body mass index (BMI) on IQ and accuracy were evaluated by multivariate regression. IQ and accuracy were further analysed in subgroups of significant predictor variables and simple regression performed to calculate thresholds for adequate IQ.

RESULTS

Mean heart rate was 68.2+/-13.3 bpm, mean heart rate variability 11.5+/-16.0 beats per CT-examination (bpct) and median Agatston score 226.5. Average IQ score was 2+/-0.6 whilst diagnostic quality was obtained in 89% of segments. Overall sensitivity, specificity, PPV or NPV was 91.2%, 99.2%, 95.3% or 98.3%. According to multivariate regression, overall IQ was significantly related to heart rate and calcification (P=0.0038; P<0.0001). The effect of heart rate variability was limited to IQ of RCA segments (P=0.018); BMI was not related to IQ (P=0.52). Calcification was the only predictor variable with significant effect on the number of non-diagnostic segments (P<0.0001). In a multivariate regression, calcification was also the single factor with impact on diagnostic accuracy (P=0.0049).

CONCLUSION

Whilst heart rate, heart rate variability and calcification all show an inverse correlation to IQ, severe calcium burden remains the single factor with translation of such effect into decrease of diagnostic accuracy.

[Chronic recurrent multifocal osteomyelitis and tumoral calcinosis--is there an association?]

BACKGROUND

Idiopathic tumorous calcinosis is a rare benign disease of the periarticular tissue near large joints. Deposits of hydroxyapatite in single or multiple pseudocysts lead to consecutive pain or complaints by attaching the surrounding tissues. The etiology of this disease is not definitively clear.

CASE REPORT

We describe the case of an 11-year-old turkish girl with a well known chronic recurrent multifocal osteomyelitis (CRMO) and hyperphosphataemia. Furthermore, she developed a tumorous calcinosis around the left hip, which recurred after surgery, and around the ankle joint.

CONCLUSIONS

CRMO and tumorous calcinosis can be associated diseases. The development of tumorous calcinosis in patients with CRMO and hyperphosphataemia should be excluded.

Interleukin-6 enhancement after direct autologous retransfusion of shed thoracic blood does not influence haemodynamic stability following coronary artery bypass grafting

BACKGROUND

Direct autologous retransfusion of shed thoracic blood is carried out to reduce homologous transfusion after cardiac surgery, but it contains high concentrations of inflammatory mediators. The purpose of the study was to investigate whether retransfusion of shed thoracic blood induces plasma interleukin-6 (IL-6) expression and influences haemodynamics.

METHODS

Following uncomplicated coronary artery bypass graft surgery, forty-four patients were randomised in case postoperative blood loss via thoracic drains exceeded 350 ml. The course of plasma IL-6 levels and haemodynamics including cardiac output, extravascular lung water and intrathoracic blood volume were investigated prior to (T0), 30 minutes (T1), 1 (T2), 3 (T3) and 12 hours (T4) after retransfusion of 350 ml shed blood in comparison to 350 ml saline.

RESULTS

Plasma IL-6 levels at T1 (1892 +/- 202 vs. 485 +/- 30 pg/ml) and T2 (1059 +/- 119 vs. 413 +/- 30 pg/ml) were significantly higher in the verum group (n = 20) compared to controls (n = 24) ( P < 0.01). Severe haemodynamic side effects were not detected.

CONCLUSION

This study found significantly elevated plasma IL-6 levels following direct autologous retransfusion of shed thoracic blood but failed to show severe adverse effects affecting haemodynamic stability.