Serum and urine Blastomyces antigen concentrations as markers of clinical remission in dogs treated for systemic blastomycosis.

BACKGROUND: Serum and urine Blastomyces antigen concentrations can be used to diagnose blastomycosis in dogs. OBJECTIVES: Blastomyces antigen concentrations correlate with clinical remission in dogs during antifungal treatment, and detect disease relapse after treatment discontinuation. ANIMALS: 21 dogs with newly diagnosed blastomycosis monitored until clinical remission (Treatment Phase), and 27 dogs monitored over 1 year from the time of antifungal discontinuation or until clinical relapse (After Treatment Phase). METHODS: Prospective study. Dogs were monitored monthly during treatment and every 3 months after treatment discontinuation, with a complete history, physical exam, chest radiographs, and ocular exam. Urine and serum Blastomyces antigen concentrations were measured at each visit using a quantitative enzyme immunoassay. RESULTS: At enrollment in the Treatment Phase, Blastomyces antigen was positive in all 21 urine samples (100% sensitivity; 95% CI 85-100%), and in 18 of 20 serum samples (90% sensitivity; 95% CI 70-97%). At 2-4 months of treatment, urine antigen was more sensitive for clinically detectable disease (82%; CI 60-94%) than serum antigen (18%; CI 6-41%). The sensitivity of the urine test for clinical relapse was 71% (CI 36-92%), with close to 100% specificity (CI 84-100%) during after treatment surveillance in this population. CONCLUSIONS: Urine Blastomyces antigen testing has high sensitivity for active disease at the time of diagnosis and during treatment, and moderate sensitivity but high specificity for clinical relapse. Urine testing should be useful at the time of diagnosis, when treatment discontinuation is being considered, and anytime there is poor clinical response or suspicion of relapse.

Sensitivity and specificity of a blood and urine galactomannan antigen assay for diagnosis of systemic aspergillosis in dogs.

BACKGROUND: Diagnosis of canine systemic aspergillosis requires fungal culture from a sterile site, or confirmatory histopathology from a nonsterile site. Invasive specimen collection techniques may be necessary. OBJECTIVE: To evaluate the sensitivity and specificity of a serum and urine Aspergillus galactomannan antigen (GMA) ELISA assay for diagnosis of systemic aspergillosis in dogs. DESIGN: Multicenter study. ANIMALS: Thirteen dogs with systemic aspergillosis and 89 dogs with other diseases. Thirty-seven of the 89 dogs had signs that resembled those of systemic aspergillosis and 52 dogs were not suspected to have aspergillosis. PROCEDURE: The GMA ELISA was performed on serum specimens from all dogs and urine specimens from 67 dogs. Galactomannan indices (GMI) ≥ 0.5 were considered positive. Results for dogs in each group were compared. RESULTS AND CONCLUSIONS: The sensitivity and specificity of the assay for serum were 92 and 86%, respectively, and for urine were 88 and 92%, respectively. False negatives were seen only in dogs with localized pulmonary aspergillosis. Use of a cutoff GMI of 1.5 increased specificity to 93% for both serum and urine without loss of sensitivity for diagnosis of disseminated infection. High-level false positives (> 1.5) occurred in dogs with other systemic mycoses and those treated with Plasmalyte. CLINICAL RELEVANCE: Serum and urine Aspergillus GMA ELISA is a noninvasive, sensitive, and specific test for the diagnosis of disseminated aspergillosis in dogs when a cutoff GMI of ≥ 1.5 is used.

Diffusion-weighted MR imaging of intramedullary spinal cord abscess.

Early diagnosis and prompt initiation of adequate treatment are essential for clinical outcome in ISCA. We report a case in which DWI provided a more specific diagnosis than conventional MR imaging and allowed differentiation of a ring-enhancing lesion from intramedullary tumor. Diagnosis was proved by PCR from CSF (Streptococcus intermedius). Adequate antibiotic treatment was immediately initiated, and the patient recovered completely.

[Preoperative accuracy of selective laser sintering (SLS) in craniofacial 3D modeling: comparison with patient CT data]. / Präoperative Genauigkeit von kraniofazialen, in selektiver Lasersinterung-Technik gefertigten 3-D-Modellen, im Vergleich zum primären CT-Datensatz.

PURPOSE: To evaluate the accuracy of craniofacial 3D models produced in the standardized selective laser sintering (SLS) technique from multislice computed tomography (MSCT) data sets in comparison with patient data and to investigate the effect of potential causes of inaccuracies. MATERIALS AND METHODS: 19 models were considered and examined by MSCT. The patient CT data used for 3D modeling was analyzed and compared to the 3D model data. 15 anatomical landmarks were defined and 20 distances were digitally measured. The digital measurements of both CT data sets were compared to manually measured distances of the SLS model. RESULTS: There was not a statistically significant difference (p < 0.05) between the measurements of the distances concerning all three groups (patient CT data, model CT data, manual measurement of the model). The mean values of the differences were between 0.5455 and -0.3214 mm. CONCLUSION: We found a high accuracy of SLS 3D models, which is due to a high precision in the modeling process and to the small voxel size of patient CT data achieved by MSCT. Anatomical landmarks in patient and model CT data sets and on the 3D model were able to be accurately reproduced, which is important for preoperative planning.

Embolic and bleeding events after modified Bentall procedure in selected patients.

AIM: As valve-sparing procedures gain increasing popularity, the long-term results of the total aortic root replacement (TARR) were evaluated using mechanical valve grafts in selected patients. METHODS AND RESULTS: From January 1993 to December 2003, 100 patients (87 men), aged >65 years (mean 51 (SD 10.4 years), presenting with isolated aortic root dilatation with or without aortic valve insufficiency, undergoing elective root replacement using a mechanical valve graft were reviewed. The aetiology of aortic root disease was degenerative in 69 patients and related to the bicuspid aortic valve in 31 patients. In 11 patients, concomitant coronary artery bypass graft was performed. Hospital mortality was 4%. Overall survival was 93.9% (2.4%), 89.1% (3.5%) and 83.2% (5.2%) at 1, 5 and 7 years, respectively. 14 patients experienced 45 embolic events (3.21 (2.64) events/patient; range: 1-10 events). Thus, the linearised rate of embolic events was 10.3 per 100 patient-years (95% confidence interval (CI) 7.29 to 13.31). The actuarial embolism-free survival was 96.6% (1.9%), 77.1% (6%) and 74.3% (6.4%) at 1, 5 and 7 years, respectively. The linearised rate of bleeding events was 2.2 per 100 patient-years (95% CI 0.87 to 3.71). Actuarial bleeding free survival was 95.6% (2.1%), 93.2% (2.6%) and 87.7% (5.8%) at 1, 5 and 7 years. respectively. None of the patients required reoperation and no cases of structural or non-structural valve dysfunction were observed. CONCLUSIONS: TARR using mechanical valve grafts yields excellent survival results in selected patients. However, a high rate of minor thromboembolic events was recorded. Aspirin in combination with oral anticoagulants might be of potential interest in these patients.

Heterogeneity in the remodeling of aneurysms of the ascending aorta with tricuspid aortic valves.

OBJECTIVES: The study addresses mechanisms driving the formation of ascending aortic aneurysms by comparing the maximal dilatation area with the transition area immediately adjacent to the normal aortic tissue left in place during surgical repair. METHODS: Aortic wall specimens were taken from the maximal dilatation area and transition area in 10 patients undergoing surgery for ascending aortic aneurysms and fixed for histology and immunohistochemistry for vascular smooth muscle cells (alpha-actin), endothelial cells (CD31), and macrophages (CD68). Tissue concentrations of vascular endothelial growth factor, matrix metalloproteinase-2, and matrix metalloproteinase-9 were determined by enzyme-linked immunosorbent assay. The results are expressed as medians with their 25th and 75th centiles. RESULTS: Vascular smooth muscle cells were significantly more abundant in the maximal dilatation area than in the transition area (20.3 [14.8-24.4]/10(-2) mm2 vs 8.0 [6.4-9.3]/10(-2) mm2, respectively, P = .002). In the maximal dilatation area, vascular smooth muscle cells had lost their typical lamellar organization, whereas it was preserved in the transition area. Microvessels were significantly more abundant in the media of transition area than in the maximal dilatation area (7.5 [2.9-10.1]/mm2 vs 1.75 [1.5-2.0]/mm2, respectively, P = .008) and were associated with an inflammatory cell infiltration that predominated in their immediate vicinity. There were no significant differences in vascular endothelial growth factor, matrix metalloproteinase-2, and matrix metalloproteinase-9 between both areas. CONCLUSIONS: The transition area appears as a disease progression front characterized by microvessel formation and inflammatory cell infiltration. In contrast, increased vascular smooth muscle cell density in the maximal dilatation area suggests a healing process, although inefficient to prevent aortic dilatation.

Pathobiology of idiopathic ascending aortic aneurysms.

The majority of ascending aortic aneurysms cannot be related to any specific etiology and should be qualified as idiopathic. The pathobiology of ascending aortic aneurysms remains incompletely understood. Data from direct study are still scarce and often limited because of patient heterogenicity. Currently available information suggests that destructive remodeling of the aortic wall, inflammation and angiogenesis, biomechanical wall stress, and molecular genetics are relevant mechanisms of idiopathic ascending aortic aneurysm formation and progression. Further understanding of these mechanisms will likely provide novel diagnostic, prognostic, and therapeutical tools for the clinician.

Aortic root replacement after previous surgical intervention on the aortic valve, aortic root, or ascending aorta.

BACKGROUND: Aortic root replacement after a previous operation on the aortic valve, aortic root, or ascending aorta remains a major challenge. METHODS: Records of 56 consecutive patients (44 men; mean age, 56.4 +/- 13.6 years) undergoing reoperative aortic root replacement between June 1994 and June 2005 were reviewed retrospectively. RESULTS: Reoperation was performed 9.4 +/- 6.7 years after the last cardiac operation. Indications for reoperation were true aneurysm (n = 14 [25%]), false aneurysm (n = 10 [18%]), dissection or redissection (n = 9 [16%]), structural or nonstructural valve dysfunction (n = 10 [18%]), prosthetic valve-graft infection (n = 12 [21%]), and miscellaneous (n = 1 [2%]). Procedures performed were aortic root replacement (n = 47 [84%]), aortic root replacement plus mitral valve procedure (n = 5 [9%]), and aortic root replacement plus arch replacement (n = 4 [7%]). In 14 (25%) patients coronary artery bypass grafting had to be performed unexpectedly during the same procedure or immediately after the procedure to re-establish coronary perfusion. Hospital mortality reached 17.9% (n = 10). Multivariate logistic regression analysis revealed the need for unplanned perioperative coronary artery bypass grafting as the sole independent risk factor for hospital death (P = .005). Actuarial survival was 83.8% +/- 4.9% at 1 month, 73.0% +/- 6.3% at 1 year, and 65.7% +/- 9.0% at 5 years after the operation. One patient had recurrence of endocarditis 6.7 months after the operation and required repeated homograft aortic root replacement. CONCLUSION: Reoperative aortic root replacement remains associated with a high postoperative mortality. The need to perform unplanned coronary artery bypass grafting during reoperative aortic root replacement is a major risk factor for hospital death. The optimal technique for coronary reconstruction in this setting remains to be debated.

Dynamics of Saturn's magnetosphere from MIMI during Cassini's orbital insertion.

The Magnetospheric Imaging Instrument (MIMI) onboard the Cassini spacecraft observed the saturnian magnetosphere from January 2004 until Saturn orbit insertion (SOI) on 1 July 2004. The MIMI sensors observed frequent energetic particle activity in interplanetary space for several months before SOI. When the imaging sensor was switched to its energetic neutral atom (ENA) operating mode on 20 February 2004, at approximately 10(3) times Saturn's radius RS (0.43 astronomical units), a weak but persistent signal was observed from the magnetosphere. About 10 days before SOI, the magnetosphere exhibited a day-night asymmetry that varied with an approximately 11-hour periodicity. Once Cassini entered the magnetosphere, in situ measurements showed high concentrations of H+, H2+, O+, OH+, and H2O+ and low concentrations of N+. The radial dependence of ion intensity profiles implies neutral gas densities sufficient to produce high loss rates of trapped ions from the middle and inner magnetosphere. ENA imaging has revealed a radiation belt that resides inward of the D ring and is probably the result of double charge exchange between the main radiation belt and the upper layers of Saturn's exosphere.

Migraine and asthma in childhood: evidence for specific asymmetric parent-child interactions in migraine and asthma families.

In spite of the fact that migraine often manifests as a familial disorder, the role of the family in migraine has not been adequately explored. In this study parent-child interactions in 20 families with a child suffering from migraine were analysed and compared with 20 healthy families and 20 families with an asthma child. The families had to solve a puzzle within a limited time. Parent-child interactions within migraine and asthma families were asymmetric, revealing a disease-specific interpersonal context in the family. Communication with the affected child in migraine families was significantly more directive, with more specific instructions and less help, towards migraineurs than with the healthy siblings. Dominance of parents and submissive behaviour of children were the main features of interactions. In asthma families interactions were more conflicting and less cooperative. This study demonstrated a specific, asymmetric, pattern of family interactions predisposing children either to migraine or asthma.

Disappearance of an intracerebral arteriovenous malformation in an HIV-infected patient after initiation of HAART.

HIV infection or complications of HIV-induced immunodeficiency may affect the central nervous system (CNS). However, vascular cerebral pathologies are very rare, in particular intracerebral arteriovenous malformations (AVM). We report the case of an HIV-infected patient who had a cerebral AVM leading to symptoms such as recurring focal seizures. Only after initiation of potent antiretroviral combination therapy, but not antiretroviral monotherapy or bitherapy, could the viral load be suppressed and immunodeficiency resolved. Two years after the start of highly active antiretroviraL therapy (HAART) total occlusion of the AVM could be demonstrated. Taken together, this case report may demonstrate the potent angiogenic activity of HIV for AVM. Also, this case report might show that inhibition of such a cofactor may lead to resolution of an AVM.

Carotid arterial stent placement: results and follow-up in 53 patients.

PURPOSE: To describe the results, complications, and follow-up data after stent placement for occlusive internal carotid arterial disease and to compare the results with those in the literature. MATERIALS AND METHODS: Carotid arterial stent placement was attempted in 57 arteries in 53 patients. Thirty-six (68%) of 53 patients were symptomatic. Forty-two (79%) of 53 patients had one to three clinically important comorbidities and were considered at high risk. All patients underwent pre- and postprocedural independent neurologic examinations. Follow-up consisted of serial duplex ultrasonography and clinical assessment. RESULTS: The immediate technical success rate of stent deployment was 97%. Periprocedurally, three (three [5%] of 57 interventions) transient ischemic attacks and three (three [5%] of 57 interventions) minor strokes occurred. Two deaths occurred in the first 30 days (one myocardial infarction, one renal failure). One ipsilateral major stroke occurred 3 weeks after the procedure. The 30-day ipsilateral major stroke and death rate was 5% (three of 57 interventions). At 30 days, one of three patients with minor stroke had mild residual dysphasia. Treatment remained clinically successful in 48 (96%) of 50 patients. The restenosis rate was 4% (two patients). CONCLUSION: Carotid arterial stent placement in a high-risk population has morbidity and mortality rates comparable to those of carotid endarterectomy in a lower risk population. Carotid arterial stent placement can be performed with a low restenosis rate.

Coagulopathy induced spinal intradural extramedullary haematoma: report of three cases and review of the literature.

In a retrospective review of patients operated for coagulopathy induced spinal intradural-extramedullary haematoma the literature regarding coagulopathy induced spinal haemorrhage is reviewed and the etiology of these rare spinal subdural and subarachnoid haemorrhages is discussed. Spinal intradural haematomas are usually related to trauma or a previous lumbar puncture. A review of the literature revealed only a handful cases of spinal intradural haemorrhages occurring secondary to an underlying haematological disorder or an iatrogenic coagulopathy. Coagulopathy induced spinal haemorrhage should be included in the differential diagnosis of acute paraparesis in patients with co-existent haematological disorders or undergoing anticoagulation therapy. Due to the often mixed subdural and subarachnoid bleeding patterns we have termed this entity spinal intradural-extramedullary haematoma.

Intramedullary spinal cord tumours: a clinical outcome and radiological follow-up study.

PRINCIPLES: Intramedullary spinal cord tumours are rare. The long-term results depend on their varying natural histories and the surgical approach. Less extensive tumour resection avoids greater postoperative neurological impairment without a negative impact on postoperative outcome. METHODS: Twenty-seven patients who underwent a total of 34 surgical interventions (including 7 reoperations) were clinically and radiologically reinvestigated. Histology revealed 19 glial, 4 nonglial and 4 miscellaneous tumours. RESULTS: Postoperative long-term clinical follow-up (mean 62 months postoperatively) in 25 patients revealed functional improvement in 2 cases, stable conditions in 17 and deterioration in 6. Although there was residual tumour on MRI in 19 of the 22 patients reexamined, stable radiological studies were seen in 15 cases. Despite the high percentage of partial resections or biopsies, good long-term clinical results were found in 19 patients (70%). CONCLUSION: The long-term outcome depends on tumour biology and the type of surgery. For low-grade astrocytomas we propose partial resection without incurring the risk of major postoperative neurological deficits, with semi-annual and, after 5 years, annual follow-up. Despite the fact that ependymomas are amenable to complete surgical resection, this was achieved in only one of six cases in this series. Postoperative MRI follow-up of intramedullary tumours must be protracted, as most of these tumours are slow-growing. An increase in the extent and intensity of contrast enhancement of the tumours was defined as tumour recurrence or progressive tumour growth.

Long-term follow-up after extracranial internal carotid artery dissection.

OBJECTIVE: To evaluate long-term outcome after extracranial internal carotid artery dissection (eICAD) in consideration of the applied antithrombotic therapy. MATERIAL AND METHODS: Among 33 consecutive eICAD patients initially treated either with anticoagulation (n = 25) or with antiplatelets (n = 8), a standardized interview was performed after 28 +/- 22.1 months to analyze risks and benefits of both agents. Ischemic and hemorrhagic complications, occurrence of seizure and rates of arterial recanalization were compared and long-term clinical outcome was assessed using the modified Rankin Scale (mRS) and Barthel Index (BI). RESULTS: Among anticoagulated patients, 1 died due to brain herniation. In 3 patients stroke (n = 2) or TIA (n = 1) recurred. In the antiplatelet group, none died and no subsequent ischemic events happened. Hemorrhagic complications were noted in neither treatment group. Functional outcome among anticoagulated patients was BI 92 +/- 21.6 and mRS 1.48 +/- 1.50, which did not differ from patients initially treated with antiplatelets (BI 89 +/- 18.9, mRS 1.50 +/- 1.41, p > 0.05). Four anticoagulated patients developed seizures, compared to 2 patients with antiplatelets (p > 0.05). Arterial recanalization occurred in 16 of 22 antico- agulated patients with ultrasound follow-up, compared to 6 of 6 patients with antiplatelets (p > 0.05). CONCLUSION: In the absence of iatrogenic side effects, both anticoagulation and antiplatelets seem to be safe for eICAD. The rates for death and stroke were low and outcome ratings did not differ between both agents. These findings may indicate that a controlled randomized trial comparing anticoagulation and antiplatelets is ethically justified.