Zoster neuritis of lumbar nerves: A clinical, magnetic resonance imaging, and electrodiagnostic evaluation

Human herpesviruses, particularly the varicella-zoster virus, are notorious for affecting the central nervous system, especially when secondarily reactivated from a latent state. We present one such case of zoster radiculitis with an ensemble of typical dermatological and neurological features diagnosed on imaging and cerebrospinal fluid (CSF) studies and encourage the consideration of viral (zoster) neuritis as a differential in patients presenting with radicular pain.

Budd-Chiari syndrome has different presentations and disease severity during adolescence

There are limited data on clinical profile of adolescent patients with Budd-Chiari syndrome (BCS). We studied clinical, radiological, thrombophilia profile and treatment outcomes in adolescent patients with BCS.

METHODS

Forty-three consecutive patients of BCS with onset of symptoms during adolescence (10-19 years) were enrolled in the study. 129 randomly selected adult patients with BCS and 36 children with BCS formed the two control groups. The clinical history, physical examination, laboratory tests, thrombophilic disorders, radiological features and treatment outcomes of adolescents were compared to adults and children.

RESULTS

In adolescents, ascites (25/43 vs. 110/129, p = 0.0004) and thrombophilic disorders (16/43 vs. 93/129 p < 0.0001) were less frequent than adults. More adolescents (14/43) presented with hepatomegaly alone without ascites than adults (9/129, p < 0.001) or children (1/36, p = 0.005). Adolescents had lower Clichy scores [3.75 (1.2)] than adults [4.72 (1.3), p < 0.0001) or children [4.43 (1.7), p = 0.041]. JAK-2 V617F mutation was the most common thrombophilic disorder in adolescents (5/43) and more common than children (0/36, p = 0.043). Response to therapy was better in adolescents (74.4%) than children (52.8%, p = 0.038), but similar to adults (63.56%, p = 0.13).

CONCLUSION

During adolescence, patients with BCS present less commonly with ascites and may present with hepatomegaly alone. JAK-2 V617F mutation is the most common thrombophilic disorder during adolescence; though thrombophilic disorders are less common in adolescents than adults. Response to therapy is similar to adults, but better than children.

Pregnancy outcomes in women with Budd Chiari Syndrome before onset of symptoms and after treatment

BACKGROUND & AIMS

Pregnancy is known to have poor outcomes in women with Budd Chiari syndrome. There are no data on fertility and pregnancy outcomes prior to onset of symptoms or the effect of therapy on these parameters. We therefore evaluated reproductive profile of women with Budd Chiari Syndrome before the onset of symptoms and after therapy.

PATIENTS AND METHODS

Eighty women with Budd Chiari Syndrome (29 years [20-45]) were enrolled over 8 years. Baseline demographic characteristics, disease severity, thrombophilic disorders and treatment were reviewed. Their obstetric history before symptoms and after therapy was noted and compared.

RESULTS

Sixty women conceived at least once (150 pregnancies) before symptom onset and 20 had primary infertility. Eighty-one pregnancies resulted in live births and remaining 69 pregnancies had adverse pregnancy outcomes. Post-intervention, 28 women (15 with primary infertility) attempted conception. Thirteen patients conceived 15 times. More women had live births after successful therapy as compared to presymptomatic period (0/28 vs 5/28 P = .000, Odds ratio5.6; 95% CI: 2.16-14.5). In women with primary infertility, conception (0/15 vs 3/15 P = .007, Odds ratio 5, 95% CI: 1.44-17.27) and proportion of live births (0/15 vs 2/15 P = .002, Odds ratio 7.5, 95% CI: 1.71-32.79) was higher as compared to presymptomatic period.

CONCLUSION

Primary infertility is common and pregnancy outcomes are poor before the onset of symptoms in women with Budd-Chiari syndrome. Effective therapy of Budd-Chiari syndrome may improve fertility and pregnancy outcomes.

Cirrhotic cardiomyopathy is less prevalent in patients with Budd-Chiari syndrome than cirrhosis of liver

BACKGROUND AND AIM

Cirrhotic cardiomyopathy (CCM) is associated with high mortality after transjugular intrahepatic portosystemic shunt (TIPS) and liver transplantation in patients with cirrhosis. There is no data about the prevalence or impact of CCM in Budd-Chiari syndrome (BCS). We assessed the prevalence of CCM in patients with BCS and its impact on outcome after radiological intervention.

METHODS

Thirty-three consecutive patients with BCS (15 men) and 33 controls with hepatitis B-related cirrhosis (18 men, matched for Child-Pugh score) were evaluated with baseline electrocardiography (ECG), echocardiography (ECHO) and dobutamine stress ECHO, and ECG (DSE). The two groups were compared for prevalence of CCM. Patients with BCS with and without CCM were assessed for development of heart failure, duration of intensive care unit (ICU) stay, and in-hospital mortality immediately after radiological intervention.

RESULTS

Fewer patients with BCS had CCM (7/21 vs. 21/33; p = 0.001, OR-0.16, CI [0.05-0.5]), diastolic dysfunction (DD) (0/33 vs. 6/33; p = 0.01, OR-0.06, CI [0.00-1.1]), and prolonged QTc interval (5/33 vs.17/33; p = 0.001, OR-0.16, CI [0.05-0.5]) despite correction for age. Patients with BCS had lower end-systolic and end-diastolic volumes of left and right ventricles. None of the 19 patients (five with CCM) with BCS undergoing radiological intervention (12 TIPS, 4 inferior vena cava, and 3 hepatic vein stenting) developed heart failure or had prolonged ICU stay. There was no in-hospital mortality.

CONCLUSION

Patients with BCS have lower frequency of CCM as compared to patients with cirrhosis. CCM may not adversely affect outcomes after radiological interventions.

The Role of Red Cell Distribution Width as a Predictor of Mortality for Critically Ill Patients in an Inner-city Hospital

Background:

Red cell distribution width (RDW) is a measure of the variation in the red blood cell volume that is usually recorded as a part of the standard complete blood cell count. Recent studies have demonstrated the prognostic value of RDW in many different clinical settings. The objective of this research study is to investigate the independent association of RDW with 30-day mortality in Intensive Care Unit (ICU) patients.

Methods:

One hundred and fifty-six patients admitted to the ICU of our hospital between July 2009 and June 2011 were included in our study. Out of 156 patients, 124 survived the hospital stay. The data on patient's demographics, interventions done in ICU, and their comorbidities were collected. Baseline variables and the RDW value were compared between survivors and nonsurvivors. The cutoff point for RDW used for the comparison was 15.75. Both univariable and multivariable analyses were done. P < 0.05 was considered statistically significant.

Results:

In the univariable analysis of the study between survivors and nonsurvivors, the median RDW was 17.20 for nonsurvivors, implying statistical significance (P = 0.007). In multivariable analysis, RDW remained significantly associated with inpatient mortality. The receiver operating characteristic is 0.656 (P = 0.007), with an optimal cutoff of 15.75 for RDW. At the cutoff of RDW, i.e., 15.75, the sensitivity and specificity for inpatient mortality was 71% and 89%, respectively.

Conclusion:

In critically ill ICU patients, RDW is an independent predictor of 30-day mortality. Taking into consideration the fact that RDW is routinely measured in complete blood count with no additional cost, this can serve as an “inexpensive prognostic marker” in critically ill patients.

A rare case report of bilateral testicular masses as an initial manifestation of systemic sarcoidosis

Sarcoidosis is an idiopathic, systemic disease that rarely involves the genitourinary tract. Here, we present a case of a 40-year-old male presented with bilateral scrotal swelling. The scrotal ultrasound showed multiple echogenic masses bilaterally ranging between 3 mm and 15 mm involving both testicles. Enlarged retroperitoneal lymph nodes were detected on the abdominal computed tomography (CT). Surgical exploration of the testes with a frozen section analysis of the left testicular mass was carried out, and it revealed noncaseating granulomas. CT scan of the chest revealed the classic bilateral hilar and mediastinal lymphadenopathy with reticulonodular infiltrates. The final pathological diagnosis was systemic sarcoidosis with bilateral testicular involvement. Treatment with high-dose corticosteroids resulted in complete resolution of the testicular mass and a significant decrease in the size of the hilar, mediastinal, and retroperitoneal lymphadenopathy.

Hairy Cell Leukemia Presenting with Duodenal Involvement Duodenum: A Case Report

Context:

A rare case of adult hairy cell leukemia (HCL) with duodenal involvement is presented.

Case Report:

The patient was a 48-year-old man, who had a history of hairy cell leukemia. Three days after completion of 2-chlorodeoxyadenosine (CDA) chemotherapy, the patient started experiencing abdominal pain. An extensive gastroenterological workup culminated in the patient getting an esophagogastroduodenoscopy (EGD) that revealed duodenal inflammation and biopsies were taken. The duodenal biopsy was positive for chronic inflammatory infiltrate, primarily consisting of atypical lymphocytes and plasma cells with tartrate-resistant acid phosphatase (TRAP) positivity, and hence a diagnosis of duodenal involvement with HCL was made. Repeat bone marrow biopsy done 2 weeks after finishing chemotherapy revealed residual disease. At the 3-month follow-up, the patient was asymptomatic with a normocellular marrow and no residual disease. Repeat abdomen computerized tomography (CT) scan at completion of therapy showed resolution of duodenal thickening and spleen size of 12 cm. Currently, patient is in clinical remission for 6 years with 4-6 monthly follow-up visits and continues to do well.

Conclusion:

This case is presented to highlight the first case report of HCL with duodenal involvement that was successfully treated with CDA.

Statistical mechanics of DNA rupture: theory and simulations

We study the effects of the shear force on the rupture mechanism on a double stranded DNA. Motivated by recent experiments, we perform the atomistic simulations with explicit solvent to obtain the distributions of extension in hydrogen and covalent bonds below the rupture force. We obtain a significant difference between the atomistic simulations and the existing results in the literature based on the coarse-grained models (theory and simulations). We discuss the possible reasons and improve the coarse-grained model by incorporating the consequences of semi-microscopic details of the nucleotides in its description. The distributions obtained by the modified model (simulations and theoretical) are qualitatively similar to the one obtained using atomistic simulations.

Application of rapid read-out cleaning indicators for improved process control in hospital sterile services departments

BACKGROUND

Heightened awareness of the importance of cleaning has led to an emphasis on automated systems for the decontamination of re-usable medical devices. The authors have previously described an enzymatic indicator system, based on thermostable adenylate kinases (tAK), for quantitative monitoring of automated cleaning processes within hospital sterile services departments (SSDs).

AIM

To evaluate tAK indicators for routine process monitoring across a range of SSDs with different cleaning chemistries and different automated washer disinfectors (AWDs).

METHODS

tAK indicator devices and alternative industry test indicators were included in five independent cleaning cycles in each of eight different AWDs. Residual tAK post wash was determined by a coupled luciferase assay using a modified hygiene monitoring system.

FINDINGS

In all cases, with the exception of a single test, the alternative indicators showed that cleaning had been adequate. They were not able to discriminate between the performance of different processes. In contrast, the tAK indicators were able to resolve differences in the performance of processes across the different SSDs. Where the tAK indicators identified cleaning to the limits of detection of the assay, this demonstrated a log10 enzyme removal factor of >5.69.

CONCLUSION

The results suggest that tAK indicators are suitable for providing improved process control for automated cleaning processes, being able to distinguish between wash performance in different hospital settings and between individual process runs. This technology is believed to be a useful addition to routine AWD performance qualification when used as a daily or weekly test.

Clinical characteristics of triple-negative breast cancer in the African American population: A retrospective cohort analysis

e12025

Background: Triple-negative breast cancer (TNBC) is defined by a lack of expression of estrogen receptor (ER), progesterone receptor (PR), and HER2/neu. It is a very heterogeneous group of which a subset is clinically associated with an aggressive behavior and poor prognosis. They typically have a high relapse rate despite standard therapy. This study aimed to characterize the clinicopathologic findings and outcomes of these patients in an urban, predominantly African American (AA) population. Methods: Patients diagnosed with TNBC at the Regional Cancer Center at St Michael’s Medical Center in Newark, NJ between 2000 and 2008 were identified from the tumor registry databases. The clinical data was reviewed as a retrospective cohort for demographic information, clinical stage at presentation, recurrence rates and outcomes. Results: 42 pts were identified (median age 56) of which 28 (67%) were AA, 7 (16.7%) Hispanic (H) and 7 (16.7%) Caucasian. 22 patients (52.4%) presented with advanced disease (Stage 3, 4) and 18 of these patients were AA. At mean follow-up of 28 months, 12 (28.5%) pts had progressive disease with pulmonary metastases most common followed by brain metastases. The AA group displayed a trend towards shorter time to progression (TTP) (AA: 10.7 months vs. others: 14.7 months) and the younger patients less than 50 had a shorter TTP (12.3 months vs. 14.1 months). Tumor size was described > than 2 cm in 60%, < than 2 cm in 40%. Lymph nodes were positive in 43% and negative in 57%. Nuclear grade was 1 in 7%, 2 in 8.5% and 3 in 84.5%, respectively. A total of 8 (19%) patients died during the follow-up period. Conclusions: In the cohort we studied, we observed a trend that patients with TNBC in our urban city cancer center were more likely to be AA. These patients were more likely to present with advanced disease. AA and younger patients (less than 50) were more likely to have a more aggressive disease. Whether this could be attributed to non-compliance with mammogram screenings and healthcare disparities in the underserved AA inner city population is not clear but more research is needed to identify germline markers associated with TNBC which could potentiate effective therapies for women with TNBC.