Question What is the most likely diagnosis? Cat scratch disease

Question
What is the most likely
diagnosis?
Cat scratch disease
Mumps
Sarcoidosis
Sjogren's syndrome
Tuberculosis
The image shows right submandibular lymphadenopathy with cutaneous extension and
drainage. Following skin testing and culture, a diagnosis of tuberculous lymphadenitis with
cutaneous extension (scrofuloderma) was made, and the patient was started on
antituberculous therapy. Scrofuloderma should be considered in cases of persistent
lymphadenitis, particularly when there is cutaneous extension.
Die Katzenkratzkrankheit (KKK) ist eine Krankheit des Menschen, die durch Kratzverletzungen von
Katzen übertragen wird. Es ist eine Infektionskrankheit, die meist anhand von
Lymphknotenschwellungen an der Achsel oder am Hals erkannt wird und in der Regel gutartig
verläuft. Die Katzen sind nur Überträger der Krankheit, zeigen aber nach derzeitigem
Kenntnisstand keine Krankheitszeichen. Auch im Katzenfloh sind die Erreger der
Katzenkratzkrankheit nachweisbar. Über ihn wird die Krankheit wahrscheinlich von Katze zu Katze
übertragen. Der Erreger der Krankheit ist Bartonella henselae, ein gramnegatives,
stäbchenförmiges Bakterium. Als weiterer Erreger wird Afipia felis genannt. Der Erreger wird durch
das Kratzen von Katzen oder auch deren Biss übertragen. Bei einer Reihe von Patienten ist aber
keinerlei Katzenkontakt nachweisbar. Auch Katzenflöhe können die Erreger der
Katzenkratzkrankheit übertragen.
Protein C ist ein Vitamin K-abhängiges Protein im (menschlichen) Blutplasma. Es wird in der
Leber als inaktive Vorstufe synthetisiert und wirkt nach Aktivierung als Serinproteinase. Die
Wirkung dieses Proteins wurde 1960 vom deutschen Mediziner Eberhard Mammen entdeckt. In
den folgenden zehn Jahren erforschten eine Reihe von Hämostaseologen (Fachleute für
Blutgerinnung) die weiteren Zusammenhänge von Protein C als Bestandteil eines komplexen
Regulationssystems, das für den physiologischen Ablauf der Blutgerinnung (Hämostase), also
der gesunden Funktion, von entscheidender Bedeutung ist.
Dem Protein C werden grundsätzlich drei physiologische Funktionen zugeschrieben:
Antikoagulatorische Wirkung (blutgerinnungshemmend),
Profibrinolytische Wirkung (Blutgerinnsel auflösend),
Antiinflammatorische Wirkung (entzündungshemmend).
Drotrecogin Alfa (Activated) in Adults with Septic Shock
There have been conflicting reports on the efficacy of recombinant human activated protein C, or
drotrecogin alfa (activated) (DrotAA), for the treatment of patients with septic shock. In this
randomized, double-blind, placebo-controlled, multicenter trial, we assigned 1697 patients with
infection, systemic inflammation, and shock who were receiving fluids and vasopressors above a
threshold dose for 4 hours to receive either DrotAA (at a dose of 24 µg per kilogram of body
weight per hour) or placebo for 96 hours. The primary outcome was death from any cause 28 days
after randomization.
In this large international study involving critically
ill adults with septic shock, DrotAA did not
reduce mortality at either 28 or 90 days, as
compared with placebo. The lack of benefit was
consistent across predefined subgroups.
Salmonellen gehören zu den stäbchenförmigen Bakterien, Durchmesser etwa 0,7 bis 1,5 µm,
Länge etwa 2 bis 5 µm, gramnegativ, vorwiegend aktiv beweglich, peritrich begeißelt, fakultativ
anaerob, chemoorganotroph mit oxidativem und fermentativem Energiestoffwechsel und nicht
sporenbildend. Sie werden in der Gattung Salmonella zusammengefasst und der Familie der
Enterobacteriaceae zugeordnet. Sie sind eng verwandt mit der Gattung Escherichia. Sie kommen
weltweit in kalt- und warmblütigen Tieren, in Menschen und in Habitaten außerhalb von
Lebewesen vor. Sie verursachen bei Menschen und vielen Tieren Krankheiten. Joseph Lignières
benannte die Gattung im Jahr 1900 nach dem US-amerikanischen Tierarzt Daniel Elmer Salmon.
Enteritis-Salmonellen, beispielsweise Salmonella enterica subsp. enterica Serovar Enteritidis
(Kurzbezeichnung Salmonella enteritidis) und Salmonella typhimurium, verursachen beim
Menschen meist spontan ausheilende Durchfallerkrankungen, die in der Regel nicht antibiotisch
behandelt werden müssen. Allerdings können bei Risikogruppen, wie Säuglingen, Kleinkindern,
alten Menschen, HIV-Patienten und immungeschwächten Patienten schwere Erkrankungen
(Allgemeininfektionen) hervorgerufen werden. In Deutschland gehören Salmonellosen zu den
sogenannten meldepflichtigen Erkrankungen (§ 6 bzw. § 7) des Infektionsschutzgesetzes. Die
amtlichen Meldungen sind seit 1990 von etwa 200 000 auf rund 55 000 Fälle im Jahr 2005
zurückgegangen. Deutschlandweit ist schätzungsweise jeder fünfte Mensch Salmonellenträger.
Pulsed-Field-Gelelektrophorese (PFGE) oder nur Pulsed-Field-Elektrophorese ist eine Methode
zur schnellen und genauen Längenbestimmung von DNA-Stücken, z. B. zur Bestimmung des
Genetischen Fingerabdruckes. Der Unterschied zur normalen Agarose-Gelelektrophorese
besteht darin, dass kein zeitlich homogenes Feld angelegt wird, sondern gelegentlich für kurze
Zeit umgepolt wird. Bei normaler Elektrophorese wandern große DNA-Stränge (ca 30-50 kbp)
etwa gleich schnell, unabhängig von ihrer Größe. Durch Umpolen kann die Auflösung in diesem
Bereich erheblich verbessert werden. Die theoretischen Grundlagen sind nicht genau erforscht,
jedoch macht sich dieses Verfahren die größere „Trägheit“ der größeren Stücke zu eigen, die
sich dem wechselnden Feld nur langsam anpassen können. Man kann sich das so vorstellen:
Die verschiedenen Stränge „verhaken“ sich in den Verstrebungen des Geles, durch die kurzen
Umpolphasen lösen sich die kürzeren Stränge, für die längeren reicht die Zeit nicht - im Mittel
beschleunigt man also relativ kürzere Stränge im Vergleich zu ganz langen. Auf kurze Stücke
hat das Verfahren keine Auswirkung; hier ist die Auflösung ohnehin gut genug. Die PFGE stellt
eine wichtige Möglichkeit zur Typisierung von bakteriellen Erregern dar, die der Erfassung der
Epidemiologie des Erregers dienen kann.
Outbreak of Salmonellosis Linked to Live Poultry from a Mail-Order
Hatchery
Outbreaks of human salmonella infections are increasingly associated with contact with live
poultry, but effective control measures are elusive. In 2005, a cluster of human salmonella
Montevideo infections with a rare pattern on pulsed-field gel electrophoresis (the outbreak
strain) was identified by PulseNet, a national subtyping network. In cooperation with public
health and animal health agencies, we conducted multistate investigations involving patient
interviews, trace-back investigations, and environmental testing at a mail-order hatchery
linked to the outbreak in order to identify the source of infections and prevent additional
illnesses. A case was defined as an infection with the outbreak strain between 2004 and 2011.
In April 2005, the Colorado Department of Public Health and Environment identified three
Salmonella enterica serotype Montevideo isolates with identical patterns on pulsed-field gel
electrophoresis (PFGE) (XbaI pattern JIXX01.0049, the outbreak strain). State and local
public health agencies in Colorado interviewed the patients; all three reported exposure to
chicks or ducklings purchased from agricultural feed stores in the week preceding the onset
of illness.
Between 2005 and 2011, trace-back investigations
were conducted for live poultry found in the households
of 59 case patients to determine the hatchery origin. In
48 of these households (81%), the origin was Hatchery
C. In 2006, poultry experts and veterinary consultants
began providing technical assistance to the owners of
Hatchery C for the prevention and control of
salmonella.
In this report, we describe a prolonged and ongoing multistate outbreak of human salmonella
Montevideo infections primarily affecting young children and linked to contact with live young
poultry from a single mail-order hatchery. Trace-back investigations of poultry to which ill
persons were exposed identified Hatchery C, a mail-order hatchery in the western United
States, as the source of the birds. During the 8-year period from 2004 through 2011, we
identified 316 cases in 43 states as part of the outbreak. Because only a portion of salmonella
infections are laboratory-confirmed, it is likely that thousands of additional unreported
infections occurred in association with this outbreak.
Preoperative Chemoradiotherapy for Esophageal or Junctional Cancer
The role of neoadjuvant chemoradiotherapy in the treatment of patients with esophageal or
esophagogastric-junction cancer is not well established. We compared chemoradiotherapy
followed by surgery with surgery alone in this patient population. We randomly assigned
patients with resectable tumors to receive surgery alone or weekly administration of
carboplatin (doses titrated to achieve an area under the curve of 2 mg per milliliter per minute)
and paclitaxel (50 mg per square meter of body-surface area) for 5 weeks and concurrent
radiotherapy (41.4 Gy in 23 fractions, 5 days per week), followed by surgery.
adenocarcinoma (AC)
squamous-cell carcinoma (SCC)
Preoperative chemoradiotherapy improved survival among patients with potentially curable
esophageal or esophagogastric-junction cancer. The regimen was associated with acceptable
adverse-event rates.
The term 'birth asphyxia' has been traditionally used to describe infants who present 'flat' at delivery
(eg delayed onset of breathing, bradycardia, impaired muscle tone and reflexes) where a period of
foetal hypoxia is likely. However, the clinical presentation is not specific to perinatal asphyxia (see
differential diagnosis) and the preferred term is 'neonatal encephalopathy' (NE), where the precise
cause is not implied. Hypoxic-ischaemic encephalopathy (HIE) is reserved for the subgroup of term
NE who have convincing evidence of intrapartum hypoxia; the criteria of which have been outlined
by the International Cerebral Palsy Taskforce.
Criteria
- Metabolic acidosis (pH<7, base deficit=12 mmol/L in foetal, cord or early neonatal samples)<7,
base deficit=12 mmol/L in foetal, cord or early neonatal samples) <7, base deficit=12 mmol/L in
foetal, cord or early neonatal samples) </div/>
-Early onset moderate or severe encephalopathy in infants born at 34 or more weeks of gestation
-Exclusion of other identifiable etiologies such as trauma, coagulation disorders, infectious
conditions, or genetic disorders
Suggestive
-Sentinel (signal) hypoxic event occurring immediately before or during labor
-Sudden and sustained fetal bradycardia or the absence of fetal heart rate variability in the
presence of persistent, late, or variable decelerations, usually after a hypoxic sentinel event when
the pattern was previously normal
-Apgar score 0-3 for longer than 5 minutes
-Onset of multisystem involvement within 72 hours of birth
-Early imaging study showing evidence of acute nonfocal cerebral abnormality
Antecedents
Perinatal hypoxia-ischaemia (19-52%), Infection, Cerebral infarction, Intracranial haemorrhage,
Congenital brain malformations, Inborn errors of metabolism, Genetic syndromes
Der Apgar-Score ist ein Punkteschema,
mit dem sich der klinische Zustand von
Neugeborenen standardisiert
beurteilen lässt. Mit Hilfe dieses Scores
gelingt es, die Anpassung an das
Leben außerhalb der Gebärmutter und
die Überführung des fetalen in den
neonatalen Zustand zu beschreiben.
Childhood Outcomes after Hypothermia for Neonatal Encephalopathy
We previously reported early results of a randomized trial of whole-body hypothermia for neonatal
hypoxic–ischemic encephalopathy showing a significant reduction in the rate of death or moderate
or severe disability at 18 to 22 months of age. Long-term outcomes are now available. In the
original trial, we assigned infants with moderate or severe encephalopathy to usual care (the
control group) or whole-body cooling to an esophageal temperature of 33.5°C for 72 hours,
followed by slow rewarming (the hypothermia group). We evaluated cognitive, attention and
executive, and visuospatial function; neurologic outcomes; and physical and psychosocial health
among participants at 6 to 7 years of age. The primary outcome of the present analyses was death
or an IQ score below 70.
Moderate or severe neonatal hypoxic–ischemic
encephalopathy is associated with a high incidence of
death or motor and sensory disability in children.
Hypothermia to 33 to 34°C for 72 hours, when initiated
within 6 hours after birth among infants of more than
35 weeks' gestational age with hypoxic–ischemic
encephalopathy, has been shown to reduce the risk of
death or disability-
The rate of the combined end point of death or an IQ score of less than 70 at 6 to 7 years of age
was lower among children undergoing whole-body hypothermia than among those undergoing
usual care, but the differences were not significant. However, hypothermia resulted in lower
death rates and did not increase rates of severe disability among survivors.
Where has cancer been, where is it now, and where is it going!!
In the 200 years since the New England Journal of Medicine was founded, cancer has gone from
a black box to a blueprint. During the first century of the Journal's publication, medical
practitioners could observe tumors, weigh them, and measure them but had few tools to examine
the workings within the cancer cell. A few astute observers were ahead of their time, including
Rudolf Virchow, who with the benefit of a microscope deduced the cellular origin of cancer in
1863,1 and Stephen Paget, who in 1889 wisely mused about the seed-and-soil hypothesis of
metastatic disease,2 a theory that is coming into its own today. Other key advances were the
discovery of a viral cause of avian cancer by Peyton Rous in 1911 and the proposal by Theodor
Boveri in 1914 that cancer can be triggered by chromosomal mutations.
Fisher hypothesis of breast cancer.
Figure 1 and Figure 2 show changes in cancer incidence and mortality, with notations in the
charts when the rates of death from a specific cancer began to fall. Soon after the
development of successful treatments in the 1970s, disease-specific death rates began to fall
dramatically for childhood leukemia and Hodgkin's disease.
The Emperor of All Maladies: A Biography of Cancer
Siddhartha Mukherjee
Ertrinken
According to the World Health Organization (WHO), 0.7% of all deaths worldwide — or more than
500,000 deaths each year — are due to unintentional drowning. Since some cases of fatal
drowning are not classified as such according to the codes of the International Classification of
Disease, this number underestimates the real figures, even for high-income countries, and does
not include drownings that occur as a result of floods, tsunamis, and boating accidents.
Drowning is a leading cause of death worldwide among boys 5 to 14 years of age. In the United
States, drowning is the second leading cause of injury-related death among children 1 to 4 years
of age, with a death rate of 3 per 100,000, and in some countries, such as Thailand, the death rate
among 2-year-old children is 107 per 100,000. In many countries in Africa and in Central America,
the incidence of drowning is 10 to 20 times as high as the incidence in the United States. Key risk
factors for drowning are male sex, age of less than 14 years, alcohol use, low income, poor
education, rural residency, aquatic exposure, risky behavior, and lack of supervision.
The clinical picture of the damage caused to the alveolar–capillary membrane is a massive, often
bloodstained, pulmonary edema that decreases the exchange of oxygen and carbon dioxide. The
combined effects of fluids in the lungs, loss of surfactant, and increased permeability of the
alveolar–capillary membrane result in decreased lung compliance, increased regions of very low
or zero ventilation to perfusion in the lungs, atelectasis, and bronchospasm.
Ertrinken – echt !?!
Acro-osteolysis (A) Photo of the patient's hands; (B) radiography of the patient's hands
showing acro-osteolysis of almost all terminal phalanges.
A 71-year-old man hospitalised with tracheobronchitis, complained of hand discolouration. His
hands showed the three-phases of skin colour changes (white, blue, and red) and a diagnosis
of Raynaud's syndrome was established. He had relatively short fingers, particularly of the
thumbs, and no bone was palpable in most of the distal phalanges (figure A). Radiography of
his hands showed bone resorption of almost all terminal phalanges of both hands, so-called
acro-osteolysis (figure B). The most common causes of acro-osteolysis include scleroderma,
psoriatic arthritis, occupational causes, injury (eg, thermal burn), and hereditary syndromes
(eg, Hadju-Cheney syndrome). In patients with long-standing primary Raynaud's syndrome,
chronic vascular deficiency may lead to acro-osteolysis.
Pleomorphic glial tumor with vascular
proliferation (arrow) and necrosis (arrowhead).
The patient had been well until 3 weeks before
admission, when loss of vision in the right eye,
associated with diplopia, developed while he
was jogging; it resolved spontaneously after
several minutes. Four days before admission,
the symptoms recurred transiently, and he
bumped into a tree while running. On the
morning of admission, dizziness and loss of
vision in the right lower visual field in both eyes
developed, which did not resolve and resulted in
difficulty driving. He went to the emergency
department at another hospital. On examination,
nystagmus was present in both eyes on left and
right gaze. The vital signs and the remainder of
the examination were normal, as were the
results of laboratory tests, including a complete
blood count; blood levels of electrolytes,
calcium, and glucose; and tests of coagulation
and renal and hepatic function. Magnetic
resonance imaging (MRI) of the brain, after the
administration of gadolinium, revealed two
adjacent masses (2 cm by 2 cm and 1 cm by 1.5
cm) in the left occipital and posterior parietal
regions.
Panel B shows abnormal T2-weighted signal surrounding the foci of enhancement and extending across
the splenium of the corpus callosum. Within the enhancing masses are small areas of very short T2weighted signal, which appear as dark areas on this susceptibility-weighted image (Panel C).
Since drugs that target the vascular endothelial
growth factor (VEGF) signal-transduction
pathway and consequently inhibit angiogenesis
have shown some benefit in patients with
recurrent glioblastoma, this patient was enrolled
in a phase 1 clinical trial in which vatalanib, an
oral, pan-VEGF tyrosine kinase inhibitor, was
added to concurrent radiation and
temozolomide.
The patient received this regimen with no
adverse effects. Four weeks after completion of
the 6-week course, a routine follow-up cranial
MRI was performed, at which time, the patient
was asymptomatic, physically active, and
managing all his activities of daily living.
Panel C, hematoxylin and eosin) shows necrosis with
microcalcifications, which is characteristic of treatmentrelated necrosis.
Temozolomid (Handelsname Temodal®) ist ein oral
verabreichtes alkylierendes Zytostatikum.
A T2-weighted fluid-attenuated inversion recovery (FLAIR) image
(Panel B) shows extensive edema around the surgical site. A
biopsy specimen of the left occipital lobe. An axial T1-weighted
image of the brain obtained after the administration of gadolinium
(Panel D) shows much less enhancement in the left occipital
lobe 18 months after surgery.
This regimen is now considered the standard of care for patients with newly diagnosed
glioblastoma, regardless of the methylation status of MGMT. However, in patients with
glioblastoma who are treated with this regimen, the methylation status of the MGMT promoter
has prognostic implications. In one study, patients with glioblastoma whose tumors were
positive for MGMT methylation, as this patient's was, had a median survival of 21.7 months and
2-year survival of 46%, as compared with patients whose tumors were negative for MGMT
methylation, who had a median survival of 12.7 months and 2-year survival of 13.8%.
MGMT-Status:
Das O6-Methylguanin-DNS-Methyltransferase
(MGMT)-Gen codiert für ein gleichnamiges
DNS-Reparaturprotein, welches Alkylgruppen
von der Position O6 des Guanins der DNS
entfernt. Die Wirkung einiger
Chemotherapeutika (wie z.B. Temozolomid)
beruht auf Anfügen von Alkylgruppen an diese
Position O6 - Zytotoxität und Apoptose der
Tumorzellen sind die Folge.
Die Untersuchung des MGMT-PromotorMethylierungsstatus wird mittels methylierungsspezifischer PCR (MSP), sowie Sequenzierung
bzw. Pyrosequenzierung durchgeführt und
erfolgt am ZNP bereits seit 2006 im Rahmen der
Gliomdiagnostik routinemäßig
The changes observed on the first postradiation cranial MRI could represent either tumor
progression or tumor pseudoprogression, which is a reaction of the tumor and tumor
microenvironment to the radiation and chemotherapy. Tumor pseudoprogression usually
occurs within 3 months after completion of radiation and chemotherapy. Since no imaging
studies are specific for distinguishing pseudoprogression from actual tumor progression, we
were concerned that the changes could represent tumor progression in this patient. Therefore,
we performed a stereotactic biopsy of the enhancing abnormalities in the left occipital lobe.
The specimens also contained viable brain tissue with some atypical glial cells and marked
hyalinization of small blood vessels that had plump endothelial cells with prominent nuclei.
These features are characteristic effects of radiation and other therapies. No areas of solid,
mitotically active tumor were present. The pathological findings were consistent with
pseudoprogression.
An MRI scan obtained after the
administration of gadolinium 19
months after surgery (Panel A)
shows a mass in the right temporal
lobe, midline shift, sulcal
effacement, and compression of
the right temporal ventricular horn.
A T2-weighted FLAIR image
(Panel B) shows marked edema
surrounding the mass. A biopsy
specimen (Panel C, hematoxylin
and eosin) shows highly cellular
recurrent glioblastoma with mitotic
figure (arrow) and necrosis
(arrowhead).
This patient had a relapse at 19 months, outside the radiation field; the timing and location are
characteristic of MGMT-methylated tumors that have been treated with temozolomide and
radiation.
Figure 4. Imaging Studies
Performed before and after the
Administration of Bevacizumab.
Images obtained before the initiation of bevacizumab therapy show areas of enhancement in
the right temporal lobe (Figure 4A) tat are surrounded by extensive edema (Figure 4B),
confirmed on maps of the apparent diffusion coefficient (Figure 4C). The effects of surgery in
the right temporal lobe are evident: the enhancing region has been removed (Figure 4D), and
the edema has been reduced (Figure 4E). Of note, however, is a focus of markedly restricted
diffusion (Figure 4F), consistent with more cellular tissue and suggestive of active tumor.
Figure 4. Imaging Studies
Performed before and after the
Administration of Bevacizumab.
Images obtained before the initiation of bevacizumab therapy show areas of enhancement in
the right temporal lobe (Figure 4A) tat are surrounded by extensive edema (Figure 4B),
confirmed on maps of the apparent diffusion coefficient (Figure 4C). The effects of surgery in
the right temporal lobe are evident: the enhancing region has been removed (Figure 4D), and
the edema has been reduced (Figure 4E). Of note, however, is a focus of markedly restricted
diffusion (Figure 4F), consistent with more cellular tissue and suggestive of active tumor.
A 2-year-old boy underwent abdominal magnetic resonance imaging (MRI) after liver
transplantation. The patient had been born prematurely at a gestational age of 24 weeks 5 days. At
18 months of age, abdominal fullness developed. At that time, an ultrasound examination showed a
hepatic mass, and laboratory-test results showed an elevated alpha-fetoprotein level. Further
evaluation confirmed a diagnosis of hepatoblastoma, for which he received chemotherapy and
subsequently underwent liver transplantation. MRI scans obtained 1 month after the liver
transplantation highlight the two pathways of splenic perfusion. Three sequential images obtained
after the administration of intravenous contrast material show the contrast material mostly in the
arterial system first (Panel A), then most intensely in the portal veins (Panel B), and finally in the
hepatic veins (Panel C). When imaging is performed rapidly, the regions of fast and slow circulation
in the spleen can be differentiated. Before the contrast material distributes fully within the spleen,
the regions of fast circulation transiently show higher signal (arrow) than do the regions of slow
circulation (dark spirals, dashed arrow). The primary purpose of the imaging was to assess the
patient after transplantation, but these images also allow us to appreciate normal physiology. Two
years after transplantation, the patient is doing well.
Carotid intima-media thickness (cIMT) is a non-invasive ultrasound biomarker of early
atherosclerosis. A positive association exists between it and the risk of subsequent
cardiovascular events in general populations, independent of all major risk factors. This
relation has promoted the use of cIMT in pathophysiological studies and clinical trials, in which
the perception of cIMT has shifted from a secondary endpoint to a surrogate of risk of
cardiovascular event.
Repeated cIMT measurements are a plausible way to test the effects of interventions on cIMT
progression. However, whether change of cIMT affects the risk of cardiovascular events should
be systematically investigated. The results of the Multi-Ethnic Study of Atherosclerosis6 show a
positive association between cIMT progression and stroke. The aim of the first stage of the
PROG-IMT project (individual progression of carotid intima media thickness as a surrogate of
vascular risk) is to assemble a large cIMT progression dataset from general populations and to
analyse the association of cIMT progression with the risk of cardiovascular events, the results
of which we present here.
Intima-media thickness (IMT), also called intimal
medial thickness, is a measurement of the
thickness of tunica intima and tunica media the
innermost two layers of the arterial wall. The
measurement is usually made by external
ultrasound, occasionally by internal, invasive
ultrasound catheters, see IVUS, measurements
of the thickness of the wall of blood vessels can
also be using other imaging modalities.
Carotid intima-media thickness progression to predict cardiovascular events in
the general population (the PROG-IMT collaborative project): a meta-analysis
of individual participant data
Carotid intima-media thickness (cIMT) is related to the risk of cardiovascular events in the
general population. An association between changes in cIMT and cardiovascular risk is frequently
assumed but has rarely been reported. Our aim was to test this association. We identified
general population studies that assessed cIMT at least twice and followed up participants for
myocardial infarction, stroke, or death. The study teams collaborated in an individual participant
data meta-analysis. Excluding individuals with previous myocardial infarction or stroke, we
assessed the association between cIMT progression and the risk of cardiovascular events
(myocardial infarction, stroke, vascular death, or a combination of these) for each study with Cox
regression. The log hazard ratios (HRs) per SD difference were pooled by random effects metaanalysis.
Overall hazard ratio (HR) of the combined endpoint by
quintile
Data shown for mean common carotid artery intimamedia thickness progression (A) and mean common
carotid artery intima-media thickness (B), relative to the
lowest quintile. Although we detected no associations
with cIMT progression in sensitivity analyses, the mean
cIMT of the two ultrasound scans was positively and
robustly associated with cardiovascular risk (HR for the
combined endpoint, 1.16.
In conclusion, the association between individual cIMT progression and cardiovascular risk
in the general population is still unproven, despite the strong association between single
cIMT measurement and cardiovascular disease, as shown again in this study. We strongly
advocate further validations and improvements of ultrasound protocols. Although efforts
have been made to develop standardised ultrasound protocols for single and repeated
cIMT assessments, methodological issues have only begun to be addressed.
Antipsychotic drugs versus placebo for relapse prevention in schizophrenia: a
systematic review and meta-analysis
Relapse prevention with antipsychotic drugs compared with placebo in patients with
schizophrenia has not been sufficiently addressed by previous systematic reviews. We aimed to
assess the association between such drugs and various outcomes in patients with schizophrenia
to resolve controversial issues. We searched the Cochrane Schizophrenia Group's specialised
register for reports published before Nov 11, 2008; and PubMed, Embase, and ClinicalTrials.gov
for those before June 8, 2011. We also contacted pharmaceutical companies and searched the
reference lists of included studies and previous reviews. Randomised trials of patients with
schizophrenia continued on or withdrawn from any antipsychotic drug regimen after stabilisation
were eligible. Our primary outcome was relapse between 7 and 12 months. We also examined
safety and various functional outcomes. We used the random effects model and verified results
for the primary outcome with a fixed effects model. Heterogeneity was investigated with
subgroup and meta-regression analyses.
Sensitivity analysis of subsequent relapse risk
after specific lengths of time without a patient
relapsing
We have established that antipsychotic
maintenance treatment substantially
reduces relapse risk in all patients with
schizophrenia for up to 2 years of followup. The effect was robust in important
subgroups such as patients who had had
only one episode and those in remission,
but seemed to decrease in size with time.
Zink ist ein chemisches Element mit dem Elementsymbol Zn und der Ordnungszahl 30
(Atommasse 65). Zink wird zu den Übergangsmetallen gezählt, nimmt aber darin eine
Sonderstellung ein, da es wegen der abgeschlossenen d-Schale in seinen Eigenschaften eher
den Erdalkalimetallen ähnelt.
ink zählt zu den unentbehrlichen (essentiellen) Spurenelementen für den Stoffwechsel. Es ist
Bestandteil einer Vielzahl von Enzymen, beispielsweise der RNA-Polymerase und der
Glutathionperoxidase. Die empfohlene Tagesmenge für Zink liegt laut
Weltgesundheitsorganisation für erwachsene Männer bei 15 mg, für Frauen bei 12 mg, für
präpubertäre Kinder bei 10 mg und für Säuglinge bei 5 mg. In den Vereinigten Staaten beträgt die
Aufnahme durch Nahrung gegenwärtig 9 mg/Tag für Frauen und 14 mg/Tag für Männer.
Acrodermatitis enteropathica is an autosomal recessive metabolic disorder affecting the uptake of
zinc, characterized by periorificial (around the natural orifices) and acral (in the limbs) dermatitis,
alopecia (loss of hair), and diarrhea. Similar features may be present in acquired zinc deficiency.
This disease also is related to deficiency of zinc due to congenital causes. The SLC39A4 gene
encodes a transmembrane protein that serves as a zinc uptake protein.
Zinc as adjunct treatment in infants aged between 7 and 120 days with
probable serious bacterial infection: a randomised, double-blind, placebocontrolled trial
Serious bacterial infections are a major cause of death in early infancy in developing countries.
Inexpensive and accessible interventions that can add to the effect of standard antibiotic
treatment could reduce infant mortality. We measured the effect of zinc as an adjunct to
antibiotics in infants with probable serious bacterial infection. In this randomised, double-blind,
placebo-controlled trial, we enrolled infants aged 7—120 days with probable serious bacterial
infection at three hospitals in New Delhi, India, between July 6, 2005, and Dec 3, 2008. With
computer-generated sequences, we randomly assigned infants in permuted blocks of six,
stratified by whether patients were underweight or had diarrhoea at enrolment, to receive either
10 mg of zinc or placebo orally every day in addition to standard antibiotic treatment. The
primary outcome was treatment failure, which was defined as a need to change antibiotics
within 7 days of randomisation, or a need for intensive care, or death at any time within 21 days.
In our investigation, adjunct treatment with 10 mg of elemental zinc daily in addition to standard
treatment with antibiotics led to a significant reduction in the risk of treatment failure in infants
aged 7—120 days with probable serious bacterial infection. Zinc could become an accessible
and inexpensive intervention to improve treatment outcomes of such infections and thereby
reduce infant mortality.
Zinc is important for mucosal barrier function and components of innate and adaptive immunity,
such as lytic activity of phagocytes and natural killer cells, and expression of cytokines. Oral zinc
supplementation increases serum thymulin and CD4 counts and decreases the occurrence of
opportunistic infections in clinical immunosuppressive disorders. Reduced incidence of
infections has also been reported in patients with sickle cell disease, in whom zinc
supplementation increased interleukin 2 production. Heightened activity of complement C3 and
phagocytes and the ratio of naive to memory T cells in children with diarrhoea caused by
enterotoxigenic Escherichia coli given zinc indicates that this supplement enhances innate
immunity. In a murine polymicrobial sepsis model, short-term zinc supplementation decreased
the bacterial load and reduced the NF-κB activity in vital organs. The researchers postulated that
zinc modulates innate immune responses to polymicrobial sepsis through the regulation of NFκB
50-year-old man was referred to our physiotherapy clinic with an extension movement of his
right index finger and simultaneous contraction of the corresponding flexor muscles. He was a
guitar player and had seen various medical specialists (rheumatologist, orthopaedic surgeon,
neurologist, psychiatrist) and alternative healers. On presentation, he had an uncontrolled
movement of the right index finger that interfered with the highly skilled coordination required for
playing the guitar. The extension movement of his right index finger was prevented by a
simultaneous co-contraction of the flexor muscles, and the strong contraction bent the finger into
the palm.
We suspected a focal dystonia and used electromyography to study the contractions of the
involved muscles. Electromyography of the right hand showed overflow into muscles not
normally involved in the provoking activity. On the basis of these findings and the clinical
presentation, we diagnosed a focal dystonia. We gave our patient levocarnitine (3 g daily for 3
months) to decrease cramps1 and botulinum toxin injected into the superficial (20 IU) and deep
flexor (20 IU) muscles of the right index finger under electromyographic and ultrasonographic
guidance (figure A). The contractions diminished 5 days later and he was able to play the guitar
again (figure B).
Oppenheim described dystonias 100 years ago,
as a heterogeneous group of hyperkinetic
movement disorders characterised by
involuntary sustained muscle contractions that
lead to abnormal repetitive movements. Other
characteristic features included sensory tics
(gestes antagonists), abnormal postures with or
without tremor, depression, anxiety, mirror
movements, and overflow dystonia.