Multimodality approach to treat calciphylaxis in end-stage kidney disease patients

A multimodality approach has been proposed as an effective treatment for calciphylaxis in patients with end-stage kidney disease. In this retrospective study, we report the cases of 12 end-stage kidney disease patients from l'Hôtel-Dieu de Québec hospital (Canada) who were diagnosed with calciphylaxis between 2004 and 2012 and treated with a multimodality clinical approach including sodium thiosulfate (STS). Statistical analyses were performed to evaluate the impacts of patients characteristics, the different interventions as well as therapy regimen on the therapeutic response. The majority of patients (n = 9) were hemodialyzed. The patients-associated comorbidities were consistent with previously reported risk factors for calciphylaxis: Diabetes (n = 11), calcium-based phosphate binders use (n = 10), warfarin use (n = 9), obesity (n = 7), female gender (n = 8) and intravenous iron use (n = 8). STS was given for a median duration of 81 days. 75% of the patients had a response (total or partial) including a complete response in 42% of patients. One-year mortality rate was low (25%). STS was used during a mean duration of 83.33 ± 41.52 days and with a total cumulating dose of 1129.00 ± 490.58 g. The recorded mean time before a complete response was 102.20 days (51-143). Pain improvement occurred after a mean time of 8.67 ± 10.06 days. None of the studied factors was statistically associated with a complete or a partial response to the multimodality approach. Although our data have a limited statistical power, they support treating calciphylaxis with a multimodality approach including STS as its effects are independent from important clinical variables.

Trigeminal Neuralgia from an Arteriovenous Malformation of the Trigeminal Root Entry Zone with a Flow-Related Feeding Artery Aneurysm: The Role of a Combined Endovascular and "Tailored" Surgical Treatment

Idiopathic trigeminal neuralgia (TN) due to an embedded arteriovenous malformation (AVM) on the trigeminal root entry zone (REZ) is rare but a potentially challenging condition to manage. Herein, we report such a case with an additional unruptured aneurysm on the feeding artery and highlight the role of a multimodality approach to their management. A 50-year-old female presented with drug-resistant right-sided trigeminal neuralgia for one year. The magnetic resonance imaging (MRI) suggested a possibility of AVM, the angiographic study showed an AVM nidus with feeders from the right anterior inferior cerebellar artery (AICA) and a dilated right intrinsic pontine artery, the latter showing a flow-related aneurysm towards its brainstem end. The flow-related aneurysm, as well as the dilated intrinsic pontine artery feeder, was embolized at first. During surgery, the AVM was found embedded inside the root entry zone. Parts of the AVM and its draining vein were partially coagulated followed by microvascular decompression of the AICA loop as well as a feeder emanating from it following which the patient recovered completely. She subsequently received gamma knife surgery (GKS) for the residual AVM and remained asymptomatic after 3.5 years of GKS. AVM-related TN are rare, and the additional presence of a feeding artery aneurysm increases the management complexity. Endovascular management of the aneurysm followed by microvascular decompression (MVD) and tailored AVM coagulation represent a prompt and effective means of pain control. Subsequent GKS is necessary to obliterate the AVM nidus.

Hydrocephalic Dementia: Revisited with Multimodality Imaging and toward a Unified Imaging Approach

Objective  Overlap of normal pressure hydrocephalus (NPH) and pathology proven cases of dementia is known. The objective of this paper is to correlate both the clinical and multimodality imaging findings in patients with imaging diagnosis NPH and give a hypothesis for association of clinical findings.

Methods  This is a retrospective observational analysis of 13 cases patients who were referred to molecular imaging center for imaging in 2016 to 2019, and they were divided into four groups based on structural imaging findings. Group 1 had magnetic resonance imaging (MRI) findings of diffuse effacement of sulcal spaces (DESH) and flow void, whereas Group 4 had none of these two. Group 3 had MRI findings of DESH but no flow void, and Group 2 had flow void but no DESH. Clinical presentation, MRI-PET findings of four groups are assessed.

Results  Groups with presence of flow void showed hypometabolism in the medial frontal and medial temporal lobe. Groups with presence of DESH has effacement of parietal sulci showed parietal hypo metabolism with clinical presentation AD/mixed dementia and absence of parietal effacement showed FTD-like presentation. Groups without flow void or DESH showed only mild medial temporal hypometabolism and presented with classical signs of NPH. ASL perfusion changes are in correlation with metabolism on positron emission tomography (PET)-MRI.

Conclusion  This study has led us to hypothesize the lack of outflow of brain protein and their deposition in parenchyma based on pressure gradient would be easier explanation to go with cluster of findings. MR-PET and other investigations each had different specificity and sensitivity and different pattern of presentation.

Early Detection of Myocardial Damage: A Multimodality Approach

Cardiovascular diseases are possible complications of antineoplastic treatment and may lead to premature morbidity and mortality among cancer survivors. A symptom-based follow-up is ineffective, and there are growing evidences that early detection of myocardial damage in patients treated with antineoplastic drugs is the key point to prevent the occurrence of damage and improve the prognosis of these patients. Different techniques have been proposed to monitor cardiac function in oncologic patients such as cardiac imaging (echocardiography, nuclear imaging, and cardiac magnetic resonance) and biomarkers (troponin and natriuretic peptides). The European Association of Cardiovascular Imaging/American Society of Echocardiography consensus document encourages an integrated approach to early detect cardiotoxicity.

Malignant Mesothelioma - Report of Two Cases with Different Presentations

Malignant pleural mesothelioma (MPM) is a rare and aggressive neoplasm that stems from the mesothelial cells lining the visceral cavities, namely, the pleura, peritoneum, pericardium, and tunica vaginalis of the testes. MPM is the most common variant of these and constitutes up to 80% of all malignant mesotheliomas. It is usually associated with asbestos exposure and is a locally invasive neoplasm that spreads along pleura and can involve lungs with locoregional metastasis. Diagnosis remains challenging due to the latency between asbestos exposure and clinical presentation and the variable clinicoradiological manifestations. Meticulous history taking, high index of, suspicion and multimodality approach toward diagnosis are the keys to better prognosis. We hereby present two interesting cases of MPM with different presentations.

An epidemiological study of traumatic brain injury cases in a trauma centre of New Delhi (India)

BACKGROUND

Trauma is one of the leading causes of death and disability in Indian population.

AIM

To correlate various variables like epidemiology, clinical status, severity of TBI & associated co-morbid conditions and its outcome.

SETTINGS AND DESIGN

This study involved retrospective collection, prospective management and follow up of 796 cases of TBI admitted to the neurosurgery department of a tertiary care hospital in New Delhi during one year study duration.

MATERIALS AND METHODS

All the relevant variables recorded and analyzed with Glasgow Outcome Scale (GOS) in 6 months into 3 groups i.e. group 1 (GOS-1/Dead), group 2 (GOS-2&3/Bad) and group 3- (GOS-3&4/good).

STATISTICAL ANALYSIS

Compiled data collected, analyzed and difference between two proportions was analyzed using Chi Square test.

RESULTS

This study included 791 cases with 569 (72%) males and 222 (28%) females with average age of 24 years. Fall from height was the main cause of TBI (56%) followed by road traffic injury (RTI) (36%). Majority (61%) patients reached the hospital within 6 hours of injury out of which 27% patients were unconscious. As per Glasgow coma scale mild, moderate & severe grade of TBI was seen in 62%, 22% &16% cases respectively. Radiological examination of other body parts revealed injuries in 11% cases. Only 11% cases required surgical management, rest was managed conservatively. Good outcome noted in 80% cases and 20% cases expired. Average duration of hospital stay was 5 days. According to multivariate analysis, the factors which correlated with poor prognosis are presence of radiological injuries to other body parts, GCS, abnormal cranial nerve examination, abnormal plantar and abnormal pupillary reflex. (P < 0.05).

CONCLUSION

TBI predominantly affects young male population and most of these are preventable. Early transportation to the hospital and first aid results in good outcome. Mortality increases with the severity of TBI and associated injuries therefore multimodality approach in polytrauma is essential.

Neoadjuvant therapy for locally advanced breast cancer: Focus on chemotherapy and biological targeted treatments' armamentarium

Despite progress achieved in diagnosis and therapy in recent years, locally advanced breast cancer (LABC) remains a major clinical issue. Biological characteristics and clinical behavior varies widely, ranging from indolent to locally aggressive or generalized disease. In depth knowledge of biology of cancer progression and cancer could lead to the identification of tumor characteristics associated with outcome. Neoadjuvant chemotherapy (NCT) integrated into a multimodality program is nowadays the established treatment in LABC. Although our efforts in this research task are ongoing, of special clinical interest is the integration of anti-HER2 and other biological therapies, as anti-angiogenesis targeted treatments, that may further improve the long term control of LABC. Clinical management of LABC could be modified based on molecular biology and an approach tailored to each patient will optimize therapy.