Prognostic value of serum albumin to creatinine ratio in patients undergoing carotid artery stenting

BACKGROUND

We aimed to investigate the prognostic value of serum albumin-to-creatinine ratio (sACR) in carotid artery stenting (CAS) patients regarding in-hospital and 5-year outcomes.

METHODS

This is a retrospective study. Baseline characteristics were compared between patients by admission albumin to creatinine ratio and categorized accordingly: T1, T2 and T3. 609 patients were included in the study. Serum albumin and creatinine levels at hospital admission were used to calculate the sACR. The primary endpoint was all-cause mortality. MACE consisted of stroke, transient ischemic attack (TIA), myocardial infarction (MI) and death. All follow-up data were obtained from electronic medical records or by interview. The study was terminated after 60 months of follow-up.

RESULTS

Serum albumin levels were found to be significantly lower in T1, while creatinine was found to be significantly higher in T1. T1 has the lowest sACR while T3 has the highest. In hospital, ipsilateral stroke, major stroke, MI and death were significantly higher in T1. In long-term outcomes, ipsilateral stroke, major stroke, and death were significantly higher in T1.

CONCLUSIONS

Low sACR values at hospital admission was independently associated with in-hospital and long-term mortality and major stroke in patients underwent CAS.

High AST/ALT Ratio Is Associated with Cardiac Involvement in Acute COVID-19 Patients

Background and Objectives: We aimed to assess the effect of AST/ALT ratio on echocardiographic and cardiac magnetic resonance imaging (CMRI) parameters after COVID-19 patients recover. Materials and Methods: 87 patients with COVID-19 were included in the study. The patients were hospitalized with COVID-19 pneumonia, but the patients did not need intensive care unit follow-up or non-invasive mechanical ventilation support. After a discharge and two weeks following the positive swab test result, patients were considered eligible if they had any symptoms. Transthoracic echocardiography (TTE) was performed within 24 h prior to CMRI. The median value of AST/ALT ratio was found, and the study population was divided into two subgroups based on the median AST/ALT ratio value. The clinical features, blood test, TTE and CMRI results were compared between subgroups. Results: C-reactive protein, D-dimer and fibrinogen were found to be significantly higher in patients with high AST/ALT ratio. LVEF, TAPSE, S', and FAC were significantly lower in patients with high AST/ALT ratio. LV-GLS were significantly lower in patients with high AST/ALT ratio. In CMRI, native T1 mapping signal, native T2 mapping signal and extracellular volume raised significantly in patients with high AST/ALT ratio. Right ventricle stroke volume and right ventricle ejection fraction were significantly lower in patients with high AST/ALT ratio, but right ventricle end systolic volume was significantly higher in patients with high AST/ALT ratio. Conclusion: High AST/ALT ratio is related to impaired right ventricular function parameters with CMRI and echocardiography after recovery from acute COVID-19. Assessment of AST/ALT ratio at hospital admission may be used to assess the risk of cardiac involvement in COVID-19 disease, and these patients may require closer follow-up during and after the course of COVID-19.

Echocardiographic assessment of pulmonary capillary wedge pressure in patients with frequent premature ventricular complexes

BACKGROUND

Premature ventricular complex (PVC) is seen in most individuals. It has been shown that the kinetics-tracking index or Kawasaki-Tanaka index (KT index) strongly predicts pulmonary capillary wedge pressure (PCWP) by noninvasively. KT index was defined as log10 (active LAEF/minimum LAV index). We goaled to assess PCWP non-invasively in patients with frequent PVCs with normal left ventricular systolic functions and to evaluate whether there is an increase in PCWP before systolic and diastolic functions are impaired.

METHODS

About 55 patients with frequent PVCs as a patient group and 54 healthy volunteers as a control group were involved to the study. After the conventional echocardiographic examination, the vendor-independent software system (EchoPAC version 202) was used to obtain the time-left atrial volume (LAV) curve. total left atrial emptying function (LAEF), passive LAEF, and active LAEF were calculated to evaluate phasic left atrial (LA) function. In this study, ePCWP was calculated using the KT index, and KT index results and other echocardiographic parameters were compared between study groups.

RESULTS

LA anterior-posterior dimension, LA maximum volume index, and LA minimum volume index were significantly larger in the patient group (all p values < .001). Total LAEF were significantly reduced in patients with frequent PVC (p < .001). Estimated pulmonary capillary wedge pressure (ePCWP) by KT index was significantly higher in patients with frequent PVCs (p < .001).

CONCLUSIONS

Patients with frequent PVC had increased ePCWP as assessed by KT index.

May myocardial work predict the risk of cardiomyopathy in patients with premature ventricular complex?

BACKGROUND

An increased premature ventricular complex (PVC) frequency is related to an increased risk of cardiomyopathy. Changes in myocardial work (MW) parameters in patients with PVC may be a predictor of the development of cardiomyopathy.

METHODS

The study included 56 patients with PVC and 50 healthy volunteers as a control group. A comprehensive echocardiographic examination was done. A speckle tracking echocardiography was used to obtain the left ventricle (LV) global longitudinal strain (GLS). A bull's eye plot of the global MW index and the global work efficiency of 17 left ventricle segments with MW component values were generated.

RESULTS

Global work index (GWI), global constructive work (GCW), and global work efficiency (GWE) were significantly lower in the patient group (2377.84 ± 216.52 vs.1818.30 ± 283.73, 2734.00 ± 208.90 vs. 2283.73 ± 321.65, 92.48 ± 2.85 vs. 87.75 ± 3.87, respectively, all p values <0.001). Global wasted work (GWW) was significantly higher in the patient group (216.80 ± 26.86 vs. 302.13 ± 41.81, p < 0.001) Patients were compared according to the origin of PVCs. GWI, GCW, GWE were significantly lower and GWW was significantly higher in patients with PVC originating from the right ventricle or the epicardial region (p < 0.001).

CONCLUSIONS

Compared to healthy individuals, patients with PVC had lower GCW, GWI, GWE values and a higher GWW value than healthy individuals, similar to cardiomyopathy patients. Therefore, the detoriation in MW parameter in patients with PVC may be a predictor of cardiomyopathy development.

Evaluation of the performance of simple laboratory parameters used in the diagnosis of acute appendicitis

Background

Acute appendicitis (AA) is one of the most common emergency surgery.

Aim

To evaluate the performance of laboratory parameters used in the diagnosis of AA.

Subjects and Methods

There were two groups. In both groups, leukocyte (WBC), neutrophil, lymphocyte count, neutrophil/lymphocyte ratio (NLR), mean platelet volume (MPV), red cell distribution width (RDW), and platelet distribution width (PDW) values were examined in complete blood count (CBC). In addition, serum bilirubin (total bilirubin and direct bilirubin) values were examined. All laboratory parameters studied were compared to evaluate their diagnostic performance.

Results

A total of 128 people were in the AA group and 122 people were in the healthy group (control). WBC count, neutrophil count, NLR, total bilirubin, direct bilirubin, and PDW values were significantly higher in the AA group than in the control group (P value <0.05). Lymphocyte counts and MPV values in the AA group were significantly lower than in the control group (P value <0.05). The sensitivity and selectivity of the WBC and neutrophil counts in AA were 95.13%, 89.34%, 94.53%, and 93.44%, respectively. The sensitivity and selectivity of the total bilirubin values were 59.38% and 73.77%, respectively. Area under the ROC curve (AUC) values within 95% confidence interval were over 0.900 for neutrophil count, WBC count, direct bilirubin, NLR, and PDW values. AUC values for total bilirubin, lymphocyte count, RDW, and MPV values were below 0.700.

Conclusions

Diagnostic performances of the laboratory parameters were determined as follows: neutrophil count > WBC count > direct bilirubin = NLR = PDW > total bilirubin = lymphocyte count = RDW = MPV.

Assessment of atrial conduction times in patients with frequent premature ventricular complex

Background

Premature ventricular complex (PVC) is a frequent finding in the general population. The atrial conduction time (ACT) is the period between the electrocardiographic P wave and the atrial mechanical contraction, and its prolongation indicates an atrial electromechanical delay (EMD). In our study, we compared atrial conduction parameters by echocardiographic methods between patients with frequent PVC and healthy control subjects.

Methods

The study included 54 patients with PVC and 54 healthy volunteers. Atrial conduction parameters were measured with echocardiographic examination. The time difference between the p wave and the Am wave was measured in the septal, lateral, and tricuspid annulus regions. The interatrial EMD, left atrial intra-atrial delay, and the right atrial intra-atrial delay were calculated from these measurements. The groups were compared for demographic and electrocardiographic features and echocardiographic parameters.

Results

Left intra-atrial EMD, right intra-atrial EMD, and interatrial EMD were significantly longer in the patient group (p = .001, p < .001, p < .001, respectively). PA lateral, PA septal, and PA tricuspid durations were significantly prolonged in the patient group (all p < .001). All ACT parameters were significantly prolonged in patients with PVC QRS duration of 150 ms and above (all p < .001). All ACT parameters were prolonged in PVCs of right ventricular origin than those of left ventricular origin (all p < .001). ACT parameters were prolonged in patients with a coupling interval time below 485 ms (all p < .001).

Conclusions

Atrial conduction times are prolonged in patients with frequent PVC.

Cardiac magnetic resonance T2* mapping in patients with COVID-19 pneumonia is associated with serum ferritin level?

The coronavirus disease of 2019 (COVID-19)-related myocardial injury is an increasingly recognized complication and cardiac magnetic resonance imaging (MRI) has become the most commonly used non-invasive imaging technique for myocardial involvement. This study aims to assess myocardial structure by T2*-mapping which is a non-invasive gold-standard imaging tool for the assessment of cardiac iron deposition in patients with COVID-19 pneumonia without significant cardiac symptoms. Twenty-five patients with COVID-19 pneumonia and 20 healthy subjects were prospectively enrolled.Cardiac volume and function parameters, myocardial native-T1, and T2*-mapping were measured. The association of serum ferritin level and myocardial mapping was analyzed. There was no difference in terms of cardiac volume and function parameters. The T2*-mapping values were lower in patients with COVID-19 compared to controls (35.37 [IQR 31.67-41.20] ms vs. 43.98 [IQR 41.97-46.88] ms; p < 0.0001), while no significant difference was found in terms of native-T1 mapping value(p = 0.701). There was a positive correlation with T2*mapping and native-T1 mapping values (r = 0.522, p = 0.007) and negative correlation with serum ferritin values (r = - 0.653, p = 0.000), while no correlation between cardiac native-T1 mapping and serum ferritin level. Negative correlation between serum ferritin level and T2*-mapping values in COVID-19 patients may provide a non-contrast-enhanced alternative to assess tissue structural changes in patients with COVID-19. T2*-mapping may provide a non-contrast-enhanced alternative to assess tissue alterations in patients with COVID-19. Adding T2*-mapping cardiac MRI in patients with myocardial pathologies would improve the revealing of underlying mechanisms. Further in vivo and ex vivo animal or human studies designed with larger patient cohorts should be planned.

Could premature ventricular contractions lead to atrial remodeling?

BACKGROUND

Premature ventricular contraction (PVC) is a frequent kind of arrhythmia that affects around 1% of the general population. While PVC most frequently impairs ventricular function in structurally normal heart, retrograde ventriculo-atrial conduction can occur in people with PVC. These retrograde atrial activations may mimic pulmonary vein-derived atrial ectopies. As a result, PVC may raise the risk of atrial fibrillation (AF) by retrograde ventriculo-atrial conduction. The Four-Dimensional Automated Left Atrial Quantification (4D Auto LAQ) tool is a left atrial analytical approach that utilizes three-dimensional volume data to quantify the volume, as well as LA longitudinal and circumferential strains. The purpose of this study was to determine if clinical diagnosis of PVC is connected with abnormal LA function as determined by LA strain evaluation utilizing a 4D Auto LAQ compared to the healthy population.

METHODS

The 58 patients with frequent PVCs and 53 healthy volunteers as a control group were enrolled in the study. Imaging was performed using the GE Vivid E95 echocardiography equipment (GE Healthcare; Vingmed Ultrasound, Horten, Norway) equipped with an M5S probe (frequency range: 1.5-4.6 MHz) and a 4V probe (frequency range: 1.5-4.0 MHz). Images were imported into and were selected for analysis using the EchoPAC203 software (GE Healthcare). The analysis mode was selected, followed by the volume and 4D Auto LAQ submodes. Following that, the sample point was positioned in the center of the mitral orifice in each of the three planes. The review function was used to acquire the LA parameters measured by 4D Auto LAQ, including volume and strain parameters.

RESULTS

The maximum left atrial volume (LAVmax) and minimal left atrial volume (LAVmin) were significantly higher in the patient group (38.91 ± 9.72 vs. 46.31 ± 10.22, 17.75 ± 4.52 vs. 23.10 ± 7.13, respectively, all p values <.001). On the other hand left atrial reservoir longitudinal strain (LASr), conduit longitudinal strain (LAScd), contraction longitudinal strain (LASct), reservoir circumferential strain (LASr-c), conduit circumferential strain (LAScd-c), and contraction circumferential strain (LASct-c) were significantly lower in patient group (26.64 ± 5.64 vs.19.16 ± 4.58, -19.53 ± 3.72 vs. -11.28 ± 3.47, -10.34 ± 1.56 vs. -4.59 ± 1.49, 30.72 ± 4.04 vs. 19.31 ± 2.60, -19.91 ± 1.78 vs. -13.38 ± 2.85, -15.89 ± 6.37 vs. -9.24 ± 1.63, respectively, all p values <.001).

CONCLUSIONS

The present study found that premature ventricular complexes can lead to atrial remodeling as well as ventricular remodeling in patients with PVC and 4D LAQ technology can quantitatively examine left atrial function and determine these alterations early.

Assessment of atrial conduction times in patients with frequent premature venticular complex

Background

Premature ventricular complex (PVC) is common in general population. The atrial conduction time (ACT) represents the interval between electrocardiographic P wave and atrial mechanical contraction, and the prolongation of ACT called atrial electromechanical delay (EMD). In the present study, we investigated atrial conduction parameters through echocardiography in patients with frequent PVC.

Methods

The study involved 54 patients with PVC and 54 healthy volunteers as a control group. A comprehensive echocardiographic examination was done. The time difference between the onset of the p wave and septal Am wave was the PA septal, the time difference between the onset of the p wave and the lateral Am wave was the PA lateral, and the time difference between the onset of the p wave and the tricuspid annulus Am wave was the PA tricuspid. The interatrial EMD was the time difference between the PA lateral and the PA tricuspid, the left atrial (LA) intraatrial delay was the time difference between the PA lateral and the PA septal and the right atrial (RA) intraatrial delay was the time difference between the PA septal and the PA tricuspid.

Results

LA anterior-posterior dimension and LA maximum volume were significantly larger in the patient group. Left intraatrial EMD, right intraatrial EMD, and interatrial EMD were significantly longer in the patient group. PA lateral, PA septal, PA tricuspid durations were significantly prolonged in the patient group.

Conclusions

Atrial conduction times were prolonged in patients with frequent PVC.

Funding Acknowledgement

Type of funding sources: None.

Could premature ventricular contractions lead to atrial remodeling?

Background

Premature ventricular contraction (PVC) is a frequent kind of arrhythmia that affects around 1% of the general population. While PVC most frequently impairs ventricular function in structurally normal hearts, retrograde ventriculo-atrial conduction can occur in people with PVC. These retrograde atrial activations may mimic pulmonary vein-derived atrial ectopies. As a result, PVC may raise the risk of AF by retrograde ventriculo-atrial conduction.

The Four-Dimensional Automated Left Atrial Quantification (4D Auto LAQ) tool is a left atrial analytical approach that utilizes three-dimensional volume data to quantify the volume, as well as LA longitudinal and circumferential strain. The purpose of this study was to determine if clinical diagnosis of PVC is connected with abnormal LA functions as determined by LA strain evaluation utilizing a 4D Auto LAQ compared to the normal population.

Methods

58 patients with frequent PVCs were enrolled in the research, along with 53 healthy volunteers as a control group. Imaging was performed using the GEvivid E95 ultrasonic diagnostic instrument (GE Healthcare; Vingmed Ultrasound, Horten, Norway) equipped with an M5S probe (frequency range: 1.5–4.6 MHz) and a 4V probe (frequency range: 1.5–4.0 MHz). Images were imported into and selected for analysis using the EchoPAC203 software (GE Healthcare). The analysis mode was selected, followed by the volume and 4D Auto LAQ submodes. Following that, the sample point was positioned in the center of the mitral orifice in each of the three planes. The'review' function was used to acquire the LA parameters measured by 4D Auto LAQ, including volume and strain parameters.

Results

The maximum left atrial volume (LAVmax) and minimal left atrial volume (LAVmin) were signifcantly higher in patient group (38.91±9.72 vs. 46.31±10.22, 17.75±4.52 vs. 23.10±7.13 respectively, all p values &lt;0.001).On the other hand left atrial reservoir longitudinal strain (LASr), conduit longitudinal strain (LAScd), contraction longitudinal strain (LASct), reservoir circumferential strain (LASr-c), conduit circumferential strain (LAScd-c), and contraction circumferential strain (LASct-c) were signifcantly lower in patient group (26.64±5.64 vs. 19.16±4.58, −19.53±3.72 vs. −11.28±3.47, −10.34±1.56 vs. −4.59±1.49, 30.72±4.04 vs. 19.31±2.60, −19.91±1.78 vs. −13.38±2.85, −15.89±6.37 vs. −9.24±1.63, respectively all p values &lt;0.001).

Conclusion

The present study found that premature ventricular contractions can lead to atrial remodeling as well as ventricular remodeling in patients with PVC and 4D LAQ technology can quantitatively evaluate atrial myocardial function and detect these changes early.

Funding Acknowledgement

Type of funding sources: None.

Randomisierte Studien zum Einsatz von Rekonvaleszentenplasma bei COVID-19: eine Standortbestimmung

Plasma von genesenen Spendern mit COVID-19 (COVID-19 Convalescent Plasma, CCP) wurde als Behandlungsoption für Patienten mit COVID-19 in Betracht gezogen. In der ersten Phase der Pandemie wurden mehrere Fallberichte und Fallkontrollstudien mit Hinweisen auf eine therapeutische Wirkung veröffentlicht. Inzwischen liegen die Ergebnisse zahlreicher randomisierter Studien vor. Die Studien unterscheiden sich in vielen Aspekten, u. a. in den Patientenpopulationen, die von ambulanten Patienten mit mildem COVID-19 bis zu kritisch Kranken reichten, wie auch den Endpunkten. Ebenso war der Behandlungsstandard innerhalb der klinischen Studien sehr unterschiedlich. Vor allem aber unterschied sich das Prüfpräparat CCP erheblich in Bezug auf das Behandlungsschema, das Volumen und den Gehalt an Antikörpern. Im Folgenden werden wir die Ergebnisse der bisher publizierten randomisierten Studien diskutieren. Aus den bisher veröffentlichten Ergebnissen lässt sich eine Wirksamkeit von CCP ableiten, sofern es sehr hohe Titer neutralisierender Antikörper enthält und früh im Krankheitsverlauf verabreicht wird. COVID-19-Rekonvaleszenten-Plasma ist noch keine Routinebehandlung und sollte möglichst weiter in klinischen Studien untersucht werden. Neu konzipierte Studien sollten sich auf die frühe Anwendung von CCP mit einem hohen Gehalt an neutralisierenden Antikörpern bei Patienten mit hohem Risiko für eine Progression zu einer schweren COVID-19-Erkrankung konzentrieren und wichtige Begleitmedikationen kontrollieren.

Short and Midterm Outcomes in Patients With Acute Myocardial Infarction: Results of the Nationwide TURKMI Registry

This recent Turkish Myocardial Infarction registry reported that guidelines are largely implemented in patients with acute myocardial infarction (MI) in Turkey. We aimed to obtain up-to-date information for short- and midterm outcomes of acute MI. Fifty centers were selected using probability sampling, and all consecutive patients with acute MI admitted to these centers (between November 1 and 16, 2018) were enrolled. Among 1930 (mean age 62 ± 13 years, 26% female) patients, 1195 (62%) had non-ST segment elevation myocardial infarction (NSTEMI) and 735 (38%) had ST segment elevation myocardial infarction (STEMI). Percutaneous coronary intervention (PCI) was performed in 94.4% of patients with STEMI and 60.2% of those with NSTEMI. Periprocedural mortality occurred in 4 (0.3%) patients. In-hospital mortality was significantly higher in STEMI than in patients with NSTEMI (5.4% vs 2.9%, respectively; P = .006). However, the risk became slightly higher in the NSTEMI group at 1 year. Women with STEMI had a significantly higher in-hospital mortality compared with men (11.2% vs 3.8%; P < .001); this persisted at follow-up. In conclusion, PCI is performed in Turkey with a low risk of complications in patients with acute MI. Compared with a previous registry, in-hospital mortality decreased by 50% within 20 years; however, the risk remains too high for women with STEMI.

Enzyme kinetics and inhibition parameters of human leukocyte glucosylceramidase

Glucosylceramidase (GCase) is a lysosomal enzyme that catalyzes the cleavage of β-glucosidic linkage of glucocerebroside (GC) into glucose and ceramide; thereby, plays an essential function in the degradation of complex lipids and the turnover of cellular membranes. The growing list of 460 mutations in the gene coding for it-glucosylceramidase beta acid 1 (GBA1)-is reported to abolish its catalytic activity and decrease its enzyme stability, associating it with severe health conditions such as Gaucher disease (GD), Parkinson Disease (PD) and Dementia with Lewy bodies (DLB). Although the three-dimensional structure of wild type glucosylceramidase is elucidated, little is known about its features in human cells. Moreover, alternative sources of GCase that prove to be effective in the treatment of diseases with enzyme treatment therapies, impose the need for a simple and cost-effective procedure to study the enzyme behavior. This work, for the first time, shows a well-established, yet simple, cost- and time-efficient protocol for the study of GCase enzyme in human leukocytes by the artificial substrate p-Nitrophenyl-β-D-glucopyranoside (PNPG). Characterization of the enzyme in human leukocytes for activation parameters (optimal pH, Km, and Vmax) and enzyme inhibition was done. The results indicate that the optimum pH of GCase enzyme with PNPG is 5.0. The Km and Vmax values are 12.6mM and 333 U/mg, respectively. Gluconolactone competitively inhibits GCase, with a Ki value of 0.023 mM and IC50 of 0.047 mM. Glucose inhibition is uncompetitive with a Ki of 1.94 mM and IC50 of 55.3 mM. This is the first report for the inhibitory effect of glucose, δ-gluconolactone on human leukocyte GCase activity.

Features of serial cranial ultrasound detected neuropathology in very preterm infants

BACKGROUND

The purpose of this study was to identify the pattern and factors associated with changes in cranial ultrasound (CUS) -detected findings in infants born at or less than 28 weeks of gestation.

METHODS

We compared readings of CUS performed at the end of the first week of life and at 4-5 weeks of age. Alteration of CUS findings was classified as: (i) unchanged, if no deviation was detected (Group 1); (ii) worsening, if there were new findings (Group 2); and (iii) improvement, if there was normalization or reduction in severity (Group 3). Descriptive statistics, multivariate controlled logistic regression, and kappa (k) statistics with 95% Confidence Interval (95% CI) were reported.

RESULTS

Among 510 studied infants, 82.3% (95% CI 78.8-85.4) were in Group 1, 10.0% (95% CI 7.7-12.9) in Group 2, and 7.7% (95% CI 5.7-10.3) in Group 3. Overall agreement between the two scans was moderate (k 0.62; 95% CI 0.55-0.69). Worsening of CUS findings was associated with neonatal morbidities independently from gestational age and birth weight. The probability for worsening of CUS findings was higher in infants with an initial diagnosis of intraventricular hemorrhage (IVH) grade 2, than in those reported as no pathology/IVH grade 1 (Odds Ratio 5.79; 95% CI 2.42-13.91) or IVH grade 3-4 (Odds Ratio 3.81; 95% CI 1.10-13.21).

CONCLUSIONS

In very preterm born infants, the initial CUS findings in combination with neonatal morbidities can help predict the brain lesions that are seen at the end of the first month of life and could be useful in their clinical management.

Bilateral capitellum humeri fracture; a case report

This is the report of a 33-year-old female patient who was admitted to the Emergency Department with bilateral capitellum humerus fracture after a fall from a height. The patient was surgically treated with open reduction and internal fixation for both elbows, with 3 Kirschner wires on the right elbow and one mini-fragment screw on the left. Surgical intervention was carried out in emergency conditions. Following an early physical rehabilitation programme at the end of the 1st week, the roentgenograms in the 9th week showed acceptable bone union. However, in the 2nd year of follow-up the patient had consistent pain and 35 degrees of flexion loss in her right elbow due to degenerative change. The literature reveals only two reports of such cases. Thus, this rare case of bilateral capitellum humerus showed that early mobilisation after anatomic reduction and stable fixation with a mini-screw provided the optimal outcome.

Internuclear and supranuclear disorders of eye movements: clinical features and causes

Eye movements bring visual stimuli to the fovea and also maintain foveal fixation on a moving target and during head movements. These movements are performed by the ocular motor system that consists of ocular motor nerves and nuclei in the brainstem originating in the cerebral cortex, cerebellum, vestibular structures, and the extraocular muscles. The ocular motor system is divided according to anatomic location into infranuclear, nuclear, internuclear, and supranuclear components. It is important to distinguish supranuclear and internuclear from nuclear and infranuclear disturbances affecting cranial nerves III, IV, and VI, because the disturbances are of highly varied causes and present different clinical pictures. Internuclear ophthalmoplegia is due to a lesion of the medial longitudinal fasciculus, caused by multiple sclerosis in younger patients, particularly when the ophthalmoplegia is bilateral, and usually of vascular origin in the elderly. Eye movement abnormalities of supranuclear origin are characterized by gaze palsies, tonic gaze deviation, saccadic and smooth pursuit disorders, vergence abnormalities, nystagmus, and ocular oscillations. Supranuclear disorders result from lesions above the level of the ocular motor nerve nuclei. If oculocephalic maneuvers move the eyes appropriately, the lesion causing the gaze palsy is supranuclear. Supranuclear disorders account for almost 10% of all patients with disorders of eye movements.

Atypical MRI Findings of Synchronous Cerebral Metastasis

Intracranial metastases represent 7% to 17% of all brain tumors. Metastases may appear before, after or synchronously with the primary tumor. Synchronous tumor presentation means that that metastasis is found within two months of primary tumor diagnosis. A 60-year-old man was seen 15 days after the acute onset of confusion and gait disturbance. Results of a neurologic examination revealed disorientation, dysarthria, and left-sided ataxia. Results of nonenhanced computed tomography scanning of the brain were unremarkable. Cerebral magnetic resonance imaging showed multiple miliary, round, small (maximum diameter, 1 cm) lesions located infra- and supratentorially. Gradient-echo magnetic resonance images of these lesions were compatible with hemorrhage and were more pronounced compared with other sequences. Hemorrhagic cerebral metastases were suspected, and the patient was examined for primary tumors. Chest computerized tomography revealed a tumor in the posterior, superior lobe of the right lung; a cervical lymph node biopsy suggested a metastatic carcinoma. Our case illustrates that magnetic resonance imaging findings of synchronous cerebral multiple metastases presenting with neurologic symptoms may be atypical while the results of cerebral computerized tomography are normal. Contrast-enhanced cerebral magnetic resonance imaging, especially gradient-echo magnetic resonance sequences, should always be considered for diagnosing hemorrhagic metastases in patients presenting neurologic findings with a known or unknown cancer.

High prevalence of neuropathy in patients with impaired 60-minute oral glucose tolerance test but normal fasting and 120-minute glucose levels

AIM

The aim of this study was to define the prevalence of neuropathy in patients with impaired 60-min oral glucose tolerance test (OGTT) but normal fasting and 120-min glucose levels and to evaluate risk factors for polyneuropathy and glucose intolerance.

METHODS

The hospital files of 320 patients (56.5+/-11.9 years, 73.1% female), who had both electrodiagnostic test for sensory symptoms (nerve conduction studies and needle electromyography) and OGTT in maximum 6 months apart, were studied in this retrospective design study. Serum glucose levels at fasting and 0-, 30-, 60-, 90- and 120-min of OGTT and some biochemical parameters were recorded.

RESULTS

Fifteen percent of patients had diabetes mellitus (DM) and 10.9% and 5.6% had impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). Twenty-one patients (6.6%) had only impaired 60-min blood glucose levels. Polyneuropathy was found in 44.4%, 28.5%, and 50.0% of patients with IGT, IFG and DM respectively. The prevalence of polyneuropathy was significantly higher in patients with impaired 60-min than OGTT normal subjects (52.4% vs 21.7% p=0.003). Fasting blood glucose, HDL, LDL and TSH levels, age, glucose intolerance low serum folic acid and significantly increased polyneuropathy risk. Age, weight, body mass index, high fasting, 30, 60-, 90-, 120-min serum glucose, insulin and HgA1c levels were risk factors for glucose intolerance.

CONCLUSION

Since the prevalence of neuropathy in patients with impaired 60-min glucose levels is high, it would be valuable to look at 60-min glucose levels to detect abnormal glucose metabolism and the neuropathy earlier in the course.

Levetiracetam in Meige's syndrome

The spontaneous occurrence of blepharospasm and dystonic movements in face muscles, particularly those of the perioral and mandibular regions, has been named as Meige's disease which was first described by Henry Meige in 1910. We report the case of a woman with Meige's syndrome whose symptoms improved with the use of levetiracetam.

Protection of the conjunctival flap from contact with mitomycin C during tunnel-trabeculectomy

AIM

The mid-term appearance of the filtering bleb and surgical outcome following tunnel-trabeculectomy, in which protective measures were carried out to avoid contact between the mitomycin C (MMC) and the conjunctival flap, are presented.

METHODS

In a retrospective study the records of 20 consecutive patients who had undergone tunnel-trabeculectomy >/=24 months earlier, using fornix-based conjunctival flap and MMC (0.4 mg/ml) application were evaluated. Inclusion criteria were patients in whom: (I) the MMC-socked sponge was applied without contact with the conjunctival flap; (II) during MMC washout, a second Weck cell sponge was held anterior to the conjunctival flap, to protect the flap from mitomycin contact during its back-flow. Excluded were five patients who either did not complete 24 months of follow-up (n=4) or underwent an intraocular surgery during that period (n=1).

RESULTS

After 24-32 (26.9+/-2.2) months, the filtering bleb was completely vascularized and thick in 13/15 patients (86.7%), mostly vascularized with some para-limbal thick cysts in one and avascular and cystic in another. Mean intraocular pressure (IOP) dropped from a preoperative level of 25.3+/-7.0 mmHg with 3.5+/-0.9 hypotensive medications to 13.9+/-2.9 mmHg with 0.9+/-1.1 medications (P<0.0001, Wilcoxon test). Of the five excluded patients, the IOP ranged between 10 and 16 mmHg with 0-1 medications at the last examination, 1-15 months postoperatively.

CONCLUSION

In this pilot study, an intraoperative protection of the conjunctival flap from mitomycin contact was mostly associated with a vascularized and thick filtering bleb after mid-term follow-up. Further controlled prospective studies are required to confirm these observations.

Bilateral Drop-Foot After Orthotopic Liver Transplant

Patients may demonstrate various neuromuscular abnormalities after liver transplantation. We report a patient who developed bilateral drop foot after orthotopic liver transplantation. He was diagnosed with critical illness polyneuropathy. During follow-up, his complaints gradually recovered and his electrodiagnostic findings improved.

Mucormycosis presenting with painful ophthalmoplegia

Mucormycosis is a rare fungal infection that can involve the sino-orbito-cerebral region. Sino-orbito-cerebral mucormycosis is most common in patients who are immunocompromised or have diabetes mellitus, severe malnutrition or burns. This condition can be fatal if it is not diagnosed early and treated aggressively. This article presents 4 cases of mucormycosis, including 2 with orbital apex syndrome, 1 with cavernous sinus syndrome, and 1 with multiple cranial nerve involvement. All of the patients were presented with painful ophthalmoplegia. The predisposing factors for mucormycosis included diabetes mellitus (three patients) and chronic leukemia (one patient). In all cases, mucormycosis was diagnosed by examining endoscopic sinus drainage material and was treated with surgical debridement and amphotericin B. Two patients with central nervous system involvement died. The others have survived, but still exhibiting various neurologic abnormalities after aggressive treatment. Patients with mucormycosis rarely present with orbital apex syndrome. The possibility of mucormycosis should be investigated in any patient with painful ophthalmoplegia, and prompt otorhinolaryngologic examination is recommended to ensure rapid diagnosis and treatment.

Nickel adsorption on the modified pine tree materials

Removal of nickel ions from aqueous solutions containing 1-100 mg l(-1), using pine tree (Pinus nigra) materials modified with HCl, was investigated on a laboratory scale. For this purpose, two natural adsorbents such as the modified pine bark (MPB) and the modified pine cone (MPC) materials with HCl solution were studied. At first, the required concentration level of the HCl solution for the modification was observed, and then this was followed by the determinations of optimum levels of adsorbent amount, stirring rate, contact time and pH values. Various adsorption isotherms were also obtained by using different concentrations of the heavy metal cations tested in the experiment. As a result, the maximum removal efficiency levels obtained were as follows; 97% for the modified pine bark at pH 8 and 80% for the modified pine cone at pH 8.

Effect of MnSO4 on the chromium removal from the leather industry wastewater

Chromium (VI) is one of the heavy metals in water and wastewater that has the most toxic characteristic. Consequently, it is dangerous for human and environmental health. Various methods are used for removal of the chromium from wastewater, and new methods have been developed in recent years. Recent studies and investigations on the removal of environmental pollution selected methods that were economical, of optimum efficiently and could be carried out easily. In this study, the removal of Cr6+ in the leather industry wastewater is investigated using MnSO4 that was used easily and economically. Experimental studies are performed in two phases. In the first phase, the optimum MnSO4 dose for removal of Cr6+ was determined. In the second phase, the optimum pH was studied. About 96% removal of chromium was launched with 530 mg l(-1) MnSO4 dose at pH value 9 in the wastewater sample.

Diabetic vitreopapillary traction and macular oedema

PURPOSE

To describe an association between optic disc traction and diabetic macular oedema (DME) unresponsive to laser treatment.

METHODS

A retrospective review of all patients with DME who attended our clinic between September 2001 and November 2003 was undertaken. The patients had undergone ophthalmic history and examination, fluorescein angiography, and optical coherence tomography (OCT) of the macular area and optic nerve head (ONH). A total of 10 nonvitrectomized eyes that were found to have an elevation of the ONH secondary to vitreopapillary traction were included in the analysis. Eyes with additional traction at the posterior pole were excluded.

RESULTS

Out of the 10 eyes (seven patients, aged 47-79 years) with vitreo-papillary traction, nine had previously undergone argon laser photocoagulation(s) for DME. In seven eyes (seven patients), OCT verified the vitreopapillary traction as the sole traction, whereas in the fellow eyes of three patients vitreomacular traction was evident as well. In the seven eyes with only vitreopapillary traction, OCT demonstrated parapapillary serous retinal detachment in two eyes and a diffuse DME in all eyes (mean foveal thickness, 396+/-144 microm). Maximal thickness of the papillo-macular bundle site was adjoining the elevated ONH in three eyes, and was maximal at the central macula in the other four eyes. Ultrasonography (n=5) revealed an incomplete detachment of the posterior hyaloid in each, adherent only at the ONH.

CONCLUSIONS

Diffuse DME unresponsive to laser treatment may be associated with vitreopapillary traction. Further studies should indicate whether these two phenomena could suggest a cause and effect in such eyes.

Assessment of spasticity using isokinetic dynamometry in patients with spinal cord injury

OBJECTIVES

To determine the value of isokinetic dynamometric measurement of passive resistance in quantifying spasticity.

SETTING

Turkey.

METHODS

Thirty-three spastic spinal cord-injured patients and 14 age-matched normal individuals were studied. Five consecutive flexion-extensions of the knee, abduction-adductions of the hip, and dorsal-plantar flexions of the ankle were performed at specific velocities (15, 30, 60, 90 and 120 degrees /s) using a computerized isokinetic dynamometer set at the continuous passive motion mode. We recorded maximum torque and the sum of torque amplitudes for five repetitions of each type of joint motion at all velocities.

RESULTS

Maximum torque values and the sum of torque amplitudes were both significantly higher in spastic patients than in controls, and there was a positive correlation between torque values and Ashworth scores. There was no significant linear increase in torque values associated with increasing velocity for any of the motions in either controls or patients.

CONCLUSION

Isokinetic dynamometric measurement of passive resistance appeared to be a valuable tool for assessing and quantifying spasticity, as well as other types of hypertonus.

Double spinal cord injury in a patient with ankylosing spondylitis

Ankylosing spondylitis patients are more prone to spinal fractures and these fractures commonly result in mobile nonunion. We report a patient with a 30-year history of ankylosing spondylitis who sustained double spinal cord injuries following minor trauma. The first injury occurred at the lumbar level due to pseudoarthrosis of an old fracture, and the second at the thoracic level following cardiopulmonary arrest and an episode of hypotension. The possible mechanisms of the injuries are discussed and maintaining normal blood pressure in these patients is emphasized.

Cerebral responses elicited by stimulation of the vesico-urethral junction (VUJ) in diabetics

To investigate the involvement of the visceral afferent nerves in diabetes mellitus, we enrolled 46 male patients in a study, examining the cerebral potentials evoked by stimulation of the vesico-urethral junction (VUJ CEP) and the pudendal (penile CEP) and posterior tibial nerves (tibial CEP). The age range was 23-67 (mean 45.8) years. The epithelial surface of the vesico-urethral junction was stimulated bipolarly with an electrode attached to a specially produced Foley catheter. Cerebral responses were recorded bipolarly at vertex. VUJ CEPs were absent (27 patients) or protracted and/or of low amplitude (4 patients) (total 31 patients; 67.8%). Penile CEP and/or tibial CEP could be obtained in all cases; however, protracted P1 peak latencies were detected in 15 (32.8%). The abnormalities of VUJ CEP did not correlate with the presence of peripheral neuropathy, while the abnormalities of penile CEP and/or tibial CEP invariably coincided with the presence of peripheral neuropathy. Although neither age nor the duration of diabetes correlated with abnormal CEPs as determined by any of the tests, insulin dependence correlated with abnormal penile CEP and to a lesser extent with VUJ CEP. We conclude that VUJ CEP is informative in evaluating the physiological condition of visceral afferents, and can be used in diagnosis of the early involvement of visceral afferents in diabetes mellitus.

Erectile dysfunction in sleep apnea and response to CPAP

This study assessed characteristics of sexual dysfunction in sleep apnea and the efficacy of treatment with continuous positive airway pressure (CPAP). Twenty-two men with sleep apnea syndrome and also sexual dysfunction served as subjects in this study. Tests included physical, psychological, neurological, and penile vascular examinations, along with polysomnography, nocturnal penile tumescence (NPT), and penile rigidity. All patients clinically had a history of snoring and difficulty getting and maintaining erections. Results indicate that erectile dysfunction in patients with sleep apnea could be related to patient's age and chronic cerebral hypoxia due to apnea. Treatment with CPAP relieved erectile dysfunction in one-third of these patients.