Paraneoplastic/autoimmune myelopathies

Paraneoplastic myelopathies are a rare but important category of myelopathy. They usually present with an insidious or subacute progressive neurologic syndrome. Risk factors include tobacco use and family history of cancer. Cerebrospinal fluid analysis usually shows lymphocytic pleocytosis with elevated protein. MRI findings suggest that paraneoplastic myelopathies include longitudinally extensive T2 hyperintensities that are tract-specific and accompanied by enhancement, but spinal MRIs can also be normal. The most commonly associated neural antibodies include amphiphysin and collapsin-response-mediator-protein-5 (CRMP5/anti-CV2) antibodies with lung and breast cancers being the most frequent oncologic accompaniments. The differential diagnosis of paraneoplastic myelopathies includes nutritional deficiency myelopathy (B12, copper) as well as autoimmune/inflammatory conditions such as primary progressive multiple sclerosis or spinal cord sarcoidosis. Patients treated with immune checkpoint inhibitors for cancer may develop myelitis, that can be considered along the spectrum of paraneoplastic myelopathies. Management of paraneoplastic myelopathy includes oncologic treatment and immunotherapy. Despite these treatments, the prognosis is poor and the majority of patients eventually become wheelchair-dependent.

H - 29 Delivering Culturally Sensitive Neuropsychological Assessment Feedback: a Case Study of Atypical Neurosyphilis

OBJECTIVE

To demonstrate the neuropsychological correlates of atypical neurosyphilis and the importance of delivering assessment results in a culturally sensitive manner.

METHOD

The patient was a 52-year-old African American male with 12 years of education who was raised in a rural, southern town and worked as a delivery driver. He was hospitalized after three weeks of altered mental status, memory loss, and seizures. Electroencephalography (EEG) showed left lateralized periodic discharges. Magnetic resonance imaging (MRI) showed hyperintensities in the left hippocampus and amygdala consistent with limbic encephalitis. Cerebrospinal fluid studies revealed lymphocytic pleocytosis and hypoglycorrhachia. Rapid plasma regain and venereal disease tests were positive for syphilis in serum and CSF. He was initially treated with empiric antibiotics and antiseizures medications with modest improvement. His mental status improved after penicillin treatment, and he was discharged after 14 days. Repeat MRI showed cortical atrophy in the left medial frontal lobe and left hippocampus.

RESULTS

The patient demonstrated executive dysfunction (e.g., set-loss and source memory errors) and poor performance across verbal and visual memory tasks. He also demonstrated an inaccurate understanding of the possible causes of his illness. Feedback was delivered across two sessions: one session to discuss test results and a second session with the patient and his wife to discuss syphilis as a sexually transmitted infection and address the historical context of syphilis among African American men.

CONCLUSIONS

Neurosyphilis can present as limbic encephalitis and can mimic autoimmune encephalitis and other infectious diseases. Tailoring assessment feedback to a patient's sociocultural context is vital for encouraging continued treatment.

Progressive multifocal leukoencephalopathy without overt immunosuppression

Progressive multifocal leukoencephalopathy (PML) is a central nervous system disease caused by the human polyomavirus 2 that usually occurs in a setting of immunodeficiency. PML without overt immunosuppression is considered a rare occurrence but has been described in multiple previous case reports and series. Its prevalence, overall frequency, and prognosis are largely unknown. This is a single-center retrospective review of all University of Florida cases with the ICD10 PML diagnosis code (A81.2). PML without overt immunosuppression was defined as absence of human immunodeficiency virus (HIV) infection, hematological malignancy, immunomodulatory/-suppressive medications, autoimmune conditions with a propensity for PML (sarcoidosis, systemic lupus erythematosus). Cases that did not fulfill criteria for clinically or histologically definite PML were excluded. Of 52 patients with the ICD10 code A 81.2, 17 fulfilled definite diagnostic criteria for PML. Overt immunosuppression was identified in 15/17 (88.2%) cases (10/17 (58.8%): human immunodeficiency virus; 5/17 (29.4%): immunomodulatory/-suppressive medication). Two/seventeen (11.8%) cases were consistent with PML without overt immunosuppression. Possible contributing factors were a preceding dog bite and mild hypogammaglobulinemia M (39 mg/dL) in case 1 and significant alcohol use without evidence for liver disease in case 2. Both cases were fatal within 6 (case 1) and 2 (case 2) months. The results suggest that PML without overt immunosuppression may be more common than previously described. Therefore, PML should be considered even in the absence of overt immunosuppression if clinical and radiographic findings are suggestive of the diagnosis.

Cerebral Cortical Encephalitis in Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease

Cerebral cortical encephalitis (CCE) is a recently described myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) phenotype. In this observational retrospective study, we characterized 19 CCE patients (6.7% of our MOGAD cohort). Headache (n = 15, 79%), seizures (n = 13, 68%), and encephalopathy (n = 12, 63%) were frequent. Magnetic resonance imaging revealed unilateral (n = 12, 63%) or bilateral (n = 7, 37%) cortical T2 hyperintensity and leptomeningeal enhancement (n = 17, 89%). N-Methyl-D-aspartate receptor autoantibodies coexisted in 2 of 15 tested (13%). CCE pathology (n = 2) showed extensive subpial cortical demyelination (n = 2), microglial reactivity (n = 2), and inflammatory infiltrates (perivascular, n = 1; meningeal, n = 1). Most received high-dose steroids (n = 17, 89%), and all improved, but 3 had CCE relapses. This study highlights the CCE spectrum and provides insight into its pathogenesis. ANN NEUROL 2023;93:297-302.

Acute symptomatic seizures secondary to myelin oligodendrocyte glycoprotein antibody-associated disease

OBJECTIVE

To report the clinical presentations and outcomes of patients with seizure and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD).

METHODS

We retrospectively reviewed the electronic medical records for clinical and paraclinical features among patients with seizures and MOG-IgG (immunoglobulin G) seropositivity.

RESULTS

We identified 213 patients with MOG-IgG seropositivity who fulfilled criteria for MOGAD. Seizures attributed to central nervous system (CNS) autoimmunity were observed in 10% of patients (n = 23: 19 children, 4 adults). The majority (n = 19, 83%) had pediatric disease onset. Focal motor seizures were the most common seizure semiology (16/23; 70%). Focal to bilateral tonic-clonic seizures were present in 12 patients (53%), and 3 patients (13%) developed status epilepticus. All patients had features of encephalitis at onset of seizures. Cerebral cortical encephalitis (CCE) was the most common radiological finding (10 unilateral and 5 bilateral cases). Eight of 23 patients (35%) had only CCE, six of 23 patients (26%) had only acute disseminated encephalomyelitis (ADEM), and seven of 23 patients (30%) had features of both. Fifteen patients (65%) had leptomeningeal enhancement. Three patients (13%) had coexistence of N-methyl-d-aspartate receptor (NMDAR) IgG. Only 3 of 23 patients (13%) developed drug- resistant epilepsy. Although the majority had MOGAD relapses (14/23, 60%) had only 5 of 23 patients had recurrence of episodes of encephalitis with associated seizures. Twenty-one of 23 patients (91%) had seizure freedom at last follow-up.

SIGNIFICANCE

MOG-IgG evaluation should be considered in patients who present with encephalitis and focal motor and/or focal to bilateral tonic-clonic seizures, especially pediatric patients with magnetic resonance imaging (MRI) brain findings consistent with CCE, ADEM, or other MOGAD presentations. The majority of these seizures are self-limited and do not require maintenance/chronic antiseizure medications. Although seizure recurrence is uncommon, many patients have MOGAD relapses in the form of encephalitis and optic neuritis.

Septin-5 and -7-IgGs: Neurologic, Serologic, and Pathophysiologic Characteristics

BACKGROUND AND OBJECTIVES

We sought to determine clinical significance of neuronal septin autoimmunity and evaluate for potential IgG effects.

METHODS

Septin-IgGs were detected by indirect immunofluorescence assays (IFAs; mouse tissue and cell based) or Western blot. IgG binding to (and internalization of) extracellular septin epitopes were evaluated for by live rat hippocampal neuron assay. The impact of purified patient IgGs on murine cortical neuron function was determined by recording extracellular field potentials in a multielectrode array platform.

RESULTS

Septin-IgGs were identified in 23 patients. All 8 patients with septin-5-IgG detected had cerebellar ataxia, and 7 had prominent eye movement disorders. One of 2 patients with co-existing septin-7-IgG had additional psychiatric phenotype (apathy, emotional blunting, and poor insight). Fifteen patients had septin-7 autoimmunity, without septin-5-IgG detected. Disorders included encephalopathy (11; 2 patients with accompanying myelopathy, and 2 were relapsing), myelopathy (3), and episodic ataxia (1). Psychiatric symptoms (≥1 of agitation, apathy, catatonia, disorganized thinking, and paranoia) were prominent in 6 of 11 patients with encephalopathic symptoms. Eight of 10 patients with data available (from 23 total) improved after immunotherapy, and a further 2 patients improved spontaneously. Staining of plasma membranes of live hippocampal neurons produced by patient IgGs (subclasses 1 and 2) colocalized with pre- and post-synaptic markers. Decreased spiking and bursting behavior in mixed cultures of murine glutamatergic and GABAergic cortical neurons produced by patient IgGs were attributable to neither antigenic crosslinking and internalization nor complement activation.

INTERPRETATION

Septin-IgGs are predictive of distinct treatment-responsive autoimmune central nervous system (CNS) disorders. Live neuron binding and induced electrophysiologic effects by patient IgGs may support septin-specific pathophysiology. ANN NEUROL 2022;92:1090-1101.

Autoimmune gastrointestinal dysmotility following SARS-CoV-2 infection successfully treated with intravenous immunoglobulin

BACKGROUND

Autoimmune gastrointestinal dysmotility (AGID) is a limited form of dysautonomia that can be paraneoplastic or idiopathic. Some presentations can be preceded by a viral infection.

METHODS

We report a case of a 17-year-old girl that developed intractable nausea and early satiety after SARS-CoV-2 infection.

KEY RESULTS

Over ten months, she required nasogastric and nasoduodenal tube feedings and finally was advanced to total parenteral nutrition to meet her caloric needs. Her α3 nicotinic ganglionic acetylcholine and anti-striational antibodies were mildly elevated. Gastrointestinal transit scintigraphy studies showed delayed gastric emptying and slowed small bowel transit. Thermoregulatory sweat test showed areas of anhidrosis consistent with autonomic sudomotor impairment. After IVIG treatment the patient's symptoms improved dramatically and she was able to tolerate full oral diet. This was reflected by improvement of her baseline transit studies and the thermoregulatory sweat test.

CONCLUSIONS AND INFERENCES

This is the first report of AGID occurring after SARS-CoV-2 infection. The dramatic response to IVIG emphasizes the importance of early recognition and the reversible and treatable nature of this condition.

Diagnostic value of aquaporin-4-IgG live cell based assay in neuromyelitis optica spectrum disorders

Objective

Determine the utility of aquaporin 4 IgG (AQP4-IgG) testing (live cell-based assay) for Neuromyelitis Optica Spectrum Disorders (NMOSD).

Methods

We included Mayo Clinic patients (1/1/2018-12/31/2019) tested for serum AQP4-IgG by live cell-based flow-cytometric assay. Medical records were reviewed to assess if patients fulfilled 2015 NMOSD criteria.

Results

Of 1371 patients tested, 41 were positive (3%) and all fulfilled NMOSD criteria with AQP4-IgG (specificity = 100%). Only 10/1330 testing negative met NMOSD criteria without AQP4-IgG (sensitivity = 80%) and seven of these 10 were MOG-IgG positive.

Conclusions

AQP4-IgG by live cell-based assay was highly specific and without false positives in a high throughput setting.

Eastern Equine Encephalitis: Case Series in Southern New England and Review of the Literature

Purpose of Review

To describe the clinical presentation, diagnosis, management, and outcomes of 4 confirmed Eastern equine encephalitis (EEE) cases and a review of the literature.

Recent Findings

There was a sharp rise in the number of EEE cases in the United States in 2019, with 38 confirmed cases and 15 deaths. Our institution cared for 10% of patients with neuroinvasive EEE nationwide. These were the first cases seen locally since 2010.

Summary

EEE virus causes one of the most lethal types of arboviral encephalitis in the United States with a mortality of 30%-40%. Manifestations of EEE infections can range from mild encephalopathy to coma. Common findings include CSF pleocytosis and involvement of the basal ganglia on MRI. Given the rarity of this disease and nonspecific findings, diagnosis can be challenging, and a high clinical suspicion is important. Management is mainly supportive, and the use of IV immunoglobulin remains controversial. Two of our 4 patients died; these patients had coma within 48 hours, hyponatremia, involvement of bilateral thalami and brainstem, status epilepticus, and severe brain dysfunction in EEG.

La conversión retrospectiva en las bibliotecas del CSIC

El artículo describe el proceso de conversión de los ficheros manuales existentes en las bibliotecas del CSIC a soporte informático para su integración en el catálogo colectivo de la Red . Se explican los diferentes métodos empleados, haciendo una valoración exhaustiva de cada uno de ellos y proporcionando conclusiones relevantes sobre sus ventajas e inconvenientes, como resultado de la práctica desarrollada. En las conclusiones generales, se dan las pautas imprescindibles que hay que tener en cuenta a la hora de abordar la conversión retrospectiva, y se describen las características que hoy predominan en el sector.

Abstract 116: Predicting Symptomatic Intracranial Hemorrhage After Mechanical Thrombectomy: The TAG Score

Background: There is limited data on predictors of sICH in patients who underwent mechanical thrombectomy. In this study, we aim to determine those predictors with external validation.

Methods: We evaluated mechanical thrombectomy in a derivation cohort of patients at a comprehensive stroke center over a 30-month period. sICH was defined using the European Cooperative Acute Stroke Study III. We compared clinical and radiographic characteristics between patients with and without sICH to identify independent predictors of sICH with p<0.1. We then derived an sICH prediction score and validated it using the Blood Pressure After Endovascular Treatment (BEST) multicenter prospective registry.

Results: We identified 578 patients with acute ischemic stroke who received thrombectomy, 19 had sICH (3.3%). Predictive factors of sICH were: Thrombolysis in cerebral ischemia score, Alberta stroke program early computed tomography score (ASPECTS), and Glucose level, and using these predictors, we derived the weighted TAG score which was associated with sICH in the derivation (OR per unit increase 1.98, 95% CI 1.48-2.66, AUC=0.79) and validation (OR per unit increase 1.48, 95% CI 1.22-1.79, AUC=0.69) cohorts.

Conclusion: High TAG scores are associated with sICH in patients receiving mechanical thrombectomy. Larger studies are needed to validate this scoring system and test strategies to reduce sICH risk and make thrombectomy safer in patients with elevated TAG scores.

Predicting symptomatic intracranial haemorrhage after mechanical thrombectomy: the TAG score

BACKGROUND

There is limited data on predictors of symptomatic intracranial haemorrhage (sICH) in patients who underwent mechanical thrombectomy. In this study, we aim to determine those predictors with external validation.

METHODS

We evaluated mechanical thrombectomy in a derivation cohort of patients at a comprehensive stroke centre over a 30-month period. Clinical and radiographic data on these patients were obtained from the prospective quality improvement database. sICH was defined using the European Cooperative Acute Stroke Study III. We compared clinical and radiographic characteristics between patients with and without sICH using χ² and t tests to identify independent predictors of sICH with p<0.1. Significant variables were then combined in a multivariate logistic regression model to derive an sICH prediction score. This score was then validated using data from the Blood Pressure After Endovascular Treatment multicentre prospective registry.

RESULTS

We identified 578 patients with acute ischaemic stroke who received thrombectomy, 19 had sICH (3.3%). Predictive factors of sICH were: thrombolysis in cerebral ischaemia (TICI) score, Alberta stroke program early CT score (ASPECTS), and glucose level, and from these predictors, we derived the weighted TICI-ASPECTS-glucose (TAG) score, which was associated with sICH in the derivation (OR per unit increase 1.98, 95% CI 1.48 to 2.66, p<0.001, area under curve ((AUC)=0.79) and validation (OR per unit increase 1.48, 95% CI 1.22 to 1.79, p<0.001, AUC=0.69) cohorts.

CONCLUSION

High TAG scores are associated with sICH in patients receiving mechanical thrombectomy. Larger studies are needed to validate this scoring system and test strategies to reduce sICH risk and make thrombectomy safer in patients with elevated TAG scores.

Infectious Myelopathies

Infectious diseases are an important cause of spinal cord dysfunction. Infectious myelopathies are of growing concern given increasing global travel and migration and expanding prevention and treatment with vaccinations, antibiotics, and antiretrovirals. Clinicians must recognize these pathologies because outcomes can dramatically improve with prompt diagnosis and management. We provide a complete review of the most frequent infectious agents that can affect the spinal cord. For each pathogen we describe epidemiology, pathophysiology, anatomic location, characteristic clinical syndromes, diagnostic approach, treatment, and prognosis. The review includes spinal imaging from selected cases.

Abstract TP98: Diabetes Mellitus Predicts Symptomatic Intracerebral Hemorrhage Following Thrombectomy in Acute Ischemic Stroke

Introduction: Diabetes mellitus has deleterious effects on blood vessel integrity via several mechanisms including blood brain barrier injury, excitatory chemokines, acidosis, and edema. It has been associated with symptomatic intracerebral hemorrhage (sICH) after alteplase administration for ischemic stroke. We aim to determine the association between diabetes and sICH in patients undergoing thrombectomy.

Methods: Data was abstracted from the Rhode Island Hospital prospective stroke registry and included consecutive patients who were selected for thrombectomy at our institution over a period of 24 months with the goal of identifying risk factors for sICH. The primary predictor was history of diabetes and the primary outcome was sICH defined based on the modified SITS-MOST criteria (parenchymal hematoma along with increase in NIHSS by 4 points or more). We compared baseline characteristics between patients with and without sICH using univariate and multivariable analyses. Statistical analysis was performed using SPSS version 20.0 and a p value of <0.05 was statistically significant.

Results: Out of 307 patients, 12 (3.9%) experienced sICH. The mean age was 73 years; 49.2% were men. On univariate analyses, diabetes mellitus was associated with sICH (50.0% vs. 17.3%, p= 0.012). This association persisted on multivariable models adjusting for age, NIHSS score, ASPECTS score, time to reperfusion, and TICI score (Odds Ratio 6.0, 95% CI 1.5-23.3, p=0.011). We performed sensitivity analyses excluding patients who received intravenous tPA (n = 189) and the results remained unchanged (OR 8.5, 95% CI 0.84-83.3, p = 0.071).

Conclusion: Diabetes mellitus is an independent predictors of sICH in patients with acute ischemic stroke undergoing mechanical thrombectomy, with or without IV tPA. More studies are needed to confirm our findings and to determine blood sugar control in the post-thrombectomy reduces this risk.

PR Interval Prolongation and Cryptogenic Stroke: A Multicenter Retrospective Study

BACKGROUND

Atrial dysfunction or "cardiopathy" has been recently proposed as a mechanism in cryptogenic stroke. A prolonged PR interval may reflect impaired atrial conduction and thus may be a biomarker of atrial cardiopathy. We aim to compare the prevalence of PR interval prolongation in patients with cryptogenic stroke (CS) when compared with known non-cryptogenic non-cardioembolic stroke (NCNCS) subtypes.

METHODS

We used prospective ischemic stroke databases of 3 comprehensive stroke centers to identify patients 18 years or older with a discharge diagnosis of ischemic non-cardioembolic stroke between December 1, 2013 and August 31, 2015. The main outcome was ischemic stroke subtype (CS versus NCNCS). We compared PR intervals as a continuous and categorical variable (<200 milliseconds; ≥200 milliseconds) and other clinical and demographic factors between the 2 groups and used multivariate regression analyses to determine the association between PR interval prolongation and CS.

RESULTS

We identified 644 patients with ischemic non-cardioembolic stroke (224 CS and 420 NCNCS). Patients with CS were more likely to have a PR of 200 milliseconds or greater when compared with those with NCNCS (23.2% versus 13.8%, P = .009). After adjusting for factors that were significant in univariate analyses, a PR of 200 milliseconds or greater was independently associated with CS (odds ratio [OR] 1.70, 95% CI 1.08-2.70). The association was more pronounced when excluding patients on atrioventricular nodal blocking agents (OR 2.64, 95% CI 1.44-4.83).

CONCLUSIONS

A PR of 200 milliseconds or greater is associated with CS and may be a biomarker of atrial cardiopathy in the absence of atrial fibrillation. Prospective studies are needed to confirm this association.

Long-term Arrhythmia Monitoring in Cryptogenic Stroke: Who, How, and for How Long?

Cryptogenic stroke and transient ischemic attack (TIA) account for approximately one-third of stroke patients [1]. Paroxys-mal atrial fibrillation (PAF) has been suggested as a major etiology of these cryptogenic strokes [2, 3]. PAF can be difficult to diagnose because it is intermittent, often brief, and asymptomatic. PAF might be more prevalent than persistent atrial fibrillation in stroke and TIA patients, especially in younger populations [4, 5]. In patients with atrial fibrillation, anticoagulation provides significant risk reduction [6]. A new generation of oral anticoagulants has been approved for non-valvular atrial fibrillation, providing a variety of therapeutic options for patients with atrial fibrillation and risk of stroke [7]. Prior practice included an admission electrocardiogram (ECG) and continuous telemetry monitoring while in hospital [8]. However, this approach can lead to under-detection of brief asymptomatic events, which can occur at variable intervals, often outside of the hospital setting. Technological advancements have led to devices that can monitor cardiac rhythms outside of the hospital for longer durations resulting in higher yield of detection of atrial fibrillation events. Moreover, recent studies show that the normal monitoring time for arrhythmias may be shorter than ideal in order to detect atrial fibrillation, and increasing this interval could significantly improve detection of atrial fibrillation in these patients [9, 10]. The aim of this study is to review the literature in order to define what subgroup of patients, with what methodologies, and for how long monitoring for atrial fibrillation should occur in patients presenting with cryptogenic stroke.

Noninvasive mechanical ventilation with average volume assured pressure support (AVAPS) in patients with chronic obstructive pulmonary disease and hypercapnic encephalopathy

BACKGROUND

Non-invasive mechanical ventilation (NIV) in patients with acute respiratory failure has been traditionally determined based on clinical assessment and changes in blood gases, with NIV support pressures manually adjusted by an operator. Bilevel positive airway pressure-spontaneous/timed (BiPAP S/T) with average volume assured pressure support (AVAPS) uses a fixed tidal volume that automatically adjusts to a patient's needs. Our study assessed the use of BiPAP S/T with AVAPS in patients with chronic obstructive pulmonary disease (COPD) and hypercapnic encephalopathy as compared to BiPAP S/T alone, upon immediate arrival in the Emergency-ICU.

METHODS

We carried out a prospective interventional match-controlled study in Guayaquil, Ecuador. A total of 22 patients were analyzed. Eleven with COPD exacerbations and hypercapnic encephalopathy with a Glasgow Coma Scale (GCS) <10 and a pH of 7.25-7.35 were assigned to receive NIV via BiPAP S/T with AVAPS. Eleven patients were selected as paired controls for the initial group by physicians who were unfamiliar with our study, and these patients were administered BiPAP S/T. Arterial blood gases, GCS, vital signs, and ventilatory parameters were then measured and compared between the two groups.

RESULTS

We observed statistically significant differences in favor of the BiPAP S/T + AVAPS group in GCS (P = .00001), pCO(2) (P = .03) and maximum inspiratory positive airway pressure (IPAP) (P = .005), among others. However, no significant differences in terms of length of stay or days on NIV were observed.

CONCLUSIONS

BiPAP S/T with AVAPS facilitates rapid recovery of consciousness when compared to traditional BiPAP S/T in patients with chronic obstructive pulmonary disease and hypercapnic encephalopathy.

TRIAL REGISTRATION

Current Controlled Trials application ref is ISRCTN05135218.

Crop row detection in maize fields inspired on the human visual perception

This paper proposes a new method, oriented to image real-time processing, for identifying crop rows in maize fields in the images. The vision system is designed to be installed onboard a mobile agricultural vehicle, that is, submitted to gyros, vibrations, and undesired movements. The images are captured under image perspective, being affected by the above undesired effects. The image processing consists of two main processes: image segmentation and crop row detection. The first one applies a threshold to separate green plants or pixels (crops and weeds) from the rest (soil, stones, and others). It is based on a fuzzy clustering process, which allows obtaining the threshold to be applied during the normal operation process. The crop row detection applies a method based on image perspective projection that searches for maximum accumulation of segmented green pixels along straight alignments. They determine the expected crop lines in the images. The method is robust enough to work under the above-mentioned undesired effects. It is favorably compared against the well-tested Hough transformation for line detection.

Total parenteral nutrition in the surgical patient: a meta-analysis

OBJECTIVE

To examine the relationship between total parenteral nutrition(TPN) and complication and death rates in surgical patients.

DATA SOURCES

A computer search of published research on MEDLINE, personal files and a review of relevant reference lists.

STUDY SELECTION

A review of 237 titles, abstracts or papers. Primary studies were included if they were randomized clinical trials of surgical patients that evaluated the effect of TPN (compared to no TPN or standard care) on complication and death rates. Studies comparing TPN to enteral nutrition (EN) were excluded.

DATA EXTRACTION

Relevant data were abstracted on the methodology and outcomes of primary studies. Data were independently abstracted in duplicate.

DATA SYNTHESIS

There were 27 randomized trials in surgical patients that compared the use of TPN to standard care (usual oral diet plus intravenous dextrose). When the results of these trials were aggregated, there was no effect on mortality (risk ratio = 0.97, 95% confidence intervals, 0.76 to 1.24). There were fewer major complications in patients who received TPN, although there was significant heterogeneity in the overall estimate (risk ratio = 0.81, 95% CI, 0.65 to 1.01). Because of this significant heterogeneity, several a priori hypotheses were examined. Studies that included only malnourished patients demonstrated a trend to a reduction in complication rates but no difference in death rate when compared with studies of patients who were not malnourished. Studies published in 1988 or earlier and studies with a lower methods score were associated with a significant reduction in complication rates and a trend to a reduction in death rate when compared with studies published after 1988 and studies with a higher methods score. There was no difference in studies that provided lipids as a component of TPN when compared with studies that did not. Studies that initiated TPN preoperatively demonstrated a trend to a reduction in complication rates but no difference in death rate when compared with studies that initiated TPN postoperatively.

CONCLUSIONS

TPN does not influence the death rate of surgical patients. It may reduce the complication rate, especially in malnourished patients, but study results are influenced by methodologic quality and year of publication.

[Biodistribution of 99mTC-HMPAO in healthy rats and B16 melanoma carriers]

Scintigraphic studies carried out in melanoma patients have demonstrated that the 99mTc-HMPAO complex makes it possible to locate the lesion. A biodistribution and pharmacokinetic study of the 99mTc-HMPAO complex was carried out in B16-melanoma tumor healthy and carrier mice after an intravenous injection. Radioactivity was measured in the liver, kidneys, spleen, stomach, brain, blood and tumor. It was seen that at 15 minutes of the injections, 40% of the total activity distributed in the animal body was recorded in the tumor. An interesting effect observed is an increase in the tissue distribution curves in both experimental groups at 1-2 hours post-injection. According to the seriated imaging study results with 99mTc-HMPAO in B16 melanoma bearing mice, the best image is obtained 10-30 minutes after the injection.

Endogenous catecholamines suppress thyrotropin secretion during the early follicular phase of the menstrual cycle

The physiological role of hypothalamic catecholamines in the regulation of TSH secretion in humans has not been studied extensively. We administered the catecholamine synthesis inhibitor alpha-methyl-p-tyrosine (AMPT) to five women in the early follicular phase (one of menstrual cycle days 2-5) of the menstrual cycle and compared TSH secretion patterns to those in five women at the same time in the cycle who did not receive AMPT. From 0800-1600 h, volunteers had an i.v. line placed, through which blood was withdrawn every 15 min for TSH and PRL determinations. AMPT (500 mg) was administered to the study group at 0800 h and again at 1000 h. Baseline TSH concentrations at 0800 h were not significantly different between the control and treatment groups. In keeping with its characteristic circadian secretion pattern, TSH in the control group was 1.72 +/- 0.23 mIU/L at 0800 h, declined to 1.02 +/- 0.11 mIU/L by 1600 h, and was significantly less than the 0800 h value at all time points beyond 1115 h. The decline in TSH was observed in all five controls. By contrast, TSH in the AMPT group rose from an 0800 h value of 1.99 +/- 0.09 mIU/L to a peak of 3.30 +/- 0.86 IU/L by 1245 h, and was significantly higher than that at 0800 h in the treated group from 1130-1315 h. The increase in TSH was observed in all five women who received AMPT. There were significant differences between the mean TSH concentrations in the AMPT-treated (2.51 +/- 0.09 mIU/L) vs. the control group (1.28 +/- 0.09 mIU/L; P < 0.0001) for the entire study. The effectiveness of AMPT was demonstrated by an elevation of mean PRL concentrations from a baseline of 16.67 +/- 2.55 micrograms/L to a peak of 138.7 +/- 21.6 micrograms/L. We conclude that endogenous catecholamines tonically inhibit TSH secretion in the early follicular phase. These data suggest modulation of TRH by tuberoinfundibular dopamine at the hypothalamic and/or pituitary level.

Oral cefixime versus intramuscular ceftriaxone in patients with uncomplicated gonococcal infections

A randomized trial was conducted to compare cefixime (400 mg or 800 mg single oral dose) with ceftriaxone (250 mg single intramuscular dose) in terms of efficacy and safety for the treatment of uncomplicated Neisseria gonorrhoeae urethritis or cervicitis. Of 75 men and 150 women screened, 187 had positive culture results for N. gonorrhoeae. The course of treatment was evaluable in 155 cases (59 men, 96 women). Bacteriologic eradication was evident in 97% (105 out of 108) of the patients treated with cefixime and in 100% (47 out of 47) of the patients treated with ceftriaxone. N. gonorrhoeae was eliminated at 98% (143 out of 146) and 100% (72 out of 72) of the infection sites in the respective treatment groups. Of the 187 isolates, 8 were penicillinase-producing (PPNG) and 20 had high-level tetracycline resistance (TRNG). The cefixime and ceftriaxone MIC90 for all 187 study isolates was 0.008 micrograms/ml. The adverse clinical experiences reported by the patients treated with cefixime (10%) were self-limiting; no adverse experiences occurred in the patients treated with ceftriaxone. Cefixime was as well tolerated and efficacious as ceftriaxone in the treatment of the patients with uncomplicated N. gonorrhoeae urethritis or cervicitis reported here.

Neurocysticercosis. Short course of treatment with albendazole

Eighteen patients with nonenhancing parenchymal brain cysts were treated with albendazole; 9 patients were treated for 3 days and 9 patients for 1 month at daily doses of 15 mg/kg of body weight. Three months after starting therapy, results showed that in both groups the treatment was highly effective. Control studies carried out in the same group before the trial did not show any significant improvement. Five patients were controls and were treated only with symptomatic drugs. The total diameter of the lesions was reduced from 220.1 mm to 52.1 mm, which signifies a reduction of 76.3% in patients treated for a period of 3 days, and from 278.5 mm to 82.1 mm, which is 70.5%, in patients treated for 30 days. We conclude that albendazole administered according to the 3-day therapeutic scheme proposed above is as highly effective for the treatment of parenchymal brain cysticercosis as the 30-day scheme.