Posterior reversible encephalopathy syndrome with Lilliputian hallucinations secondary to Takayasu's arteritis.

Posterior Reversible Encephalopathy Syndrome (PRES) is a rare complication of Takayasu's Arteritis. A 54-year-old, right-handed woman presented with Lilliputian visual hallucinations, postprandial abdominal pain, blurred vision and headaches. She then had a tonic-clonic seizure. Neuroimaging revealed characteristic white matter oedema of the occipital lobes, in keeping with PRES. Renal infarcts and abnormalities of the abdominal aorta, subclavian, mesenteric, and internal carotid arteries were demonstrated on further imaging. The combination of hypertension, absent peripheral pulses, postprandial claudication, and imaging abnormalities of the aorta as well as its branches, lead to the diagnosis of PRES secondary to Takayasu's Arteritis. Treatment with oral steroids resulted in complete resolution of the patient's symptoms and abnormalities found on CT and MRI brain imaging. Takayasu's Arteritis is a rare vasculitis, more common in women and PRES is an unusual complication. Symptoms of PRES may include headache, seizures, hallucinations, confusion, and altered consciousness. Risk factors for PRES include; pregnancy, immunosuppression, renal disease, hypertension and rheumatological disorders. Vasogenic oedema in affected lobes, most often occipital, is characteristic of PRES on neuroimaging. Prompt treatment of PRES can avoid catastrophic consequences such as death and can achieve complete resolution of symptoms and imaging abnormalities.

The Role of Interventional Radiology in the Management of Obstetric and Gynaecological Haemorrhage

Aim We will review our experience of emergent arterial embolization used to treat haemodynamically unstable patients with obstetric and gynaecological haemorrhage. Methods This is a retrospective study of patients with haemodynamically unstable obstetric and gynaecological haemorrhage treated with emergent arterial embolization from 2010 to 2015. Results 22 patients (average age 41 (SD +/-9) years) had emergent arterial embolization. 63% had post-partum haemorrhage (PPH). 82% of cases were performed with conscious sedation and local anaesthesia. Embolization was technically successful in all cases. Embolization was clinically successful in 95% (21/22). In one case of PPH the patient represented six days later with recurrent bleeding and was treated with surgical suturing of the cervix. There were no complications or deaths. Conclusion Arterial embolization is a highly successful treatment of obstetric and gynaecological haemorrhage in unstable patients.

Hallazgos radiológicos de una pseudooclusión carotídea sintomática: signo del Guadiana / Radiological findings of a symptomatic carotid pseudocclusion:

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Evaluating hyperglycaemia in the hospitalised patient: towards an improved system for classification and treatment.

BACKGROUND: Hyperglycaemia is common amongst hospitalised patients. Some of this is due to pre-existing diabetes (either previously diagnosed or not), but a proportion is due to stress hyperglycaemia, a transient state of high blood sugars related to the underlying illness. AIMS: We aimed to estimate the prevalence of hyperglycaemia in an Irish hospital setting, including an assessment of what contribution is made by cases of stress hyperglycaemia. METHODS: Over a 9-day period, all bedside glucometer-measured point of care blood glucoses performed in medical and surgical wards in University Hospital Galway were examined. Medical case notes and our diabetes computerised database were analysed to identify individuals with pre-existing diabetes. Glycosylated haemoglobin (HbA1c) was measured on the remainder of patients, to differentiate between pre-existing diabetes (HbA1c ≥ 48 mmol/mol) and stress hyperglycaemia (HbA1c < 48 mmol/mol). RESULTS: A total of 1,637 glucose readings were performed on 262 in-patients, of which 164 (63 %) were in the hyperglycaemic range. Of the 126 eligible for study inclusion, 92 (73 %) had pre-existing diabetes and 11 (9 %) had previously undiagnosed diabetes. The remaining 20 patients (16 %) had stress hyperglycaemia. CONCLUSIONS: We report a high prevalence of hyperglycaemia (including stress hyperglycaemia) in an in-patient cohort in whom testing was undertaken at the discretion of the treating physician. Our data illustrate the utility of HbA1c measurement in this setting to help differentiate between pre-existing diabetes and stress hyperglycaemia. Much work remains to be done on how to best identify and treat in-patient hyperglycaemia.

Does long-term partial sodium channel blockade alter disease progression in MS? Evidence from a retrospective study.

BACKGROUND: There is accumulating evidence that long-term disability and disease progression in multiple sclerosis (MS) are due to prolonged sodium channel opening along demyelinated axons. Despite good evidence in animal models of MS that partial voltage-gated sodium channel (VGSC) blockade reduces disease progression, little is known about its effects in patients, despite widespread use of such agents in the symptomatic management of MS. OBJECTIVE: To determine if long-term exposure to the VGSC-blocking drug carbamazepine (CBZ) alters disease progression in MS. METHODS: Using a retrospective chart review of patients diagnosed with MS, we compared progression of disability between patients exposed the VGSC blocker CBZ with those who were not exposed to the drug. Both whole-group and matched case-control analyses were performed after correcting for the influence of age, gender, MS subtype, expanded disability status score at diagnosis, use of disease-modifying therapy, and year of initial therapy. The multiple sclerosis severity scale (MSSS) was used as a measure of disease severity. The primary outcome measure was MSSS score difference between groups. RESULTS: Four hundred patients were included; 51 received CBZ symptomatic therapy (average duration of therapy 27 months). There was no significant difference in mean MSSS between the two groups in either the whole group comparison (p = 0.63) or the matched analysis (p = 0.12). CONCLUSION: Despite preclinical evidence suggesting a neuroprotective role of VGSC blockers in animal models of MS, this retrospective study suggests that long-term exposure to the VGSC-blocking drug CBZ fails to alter long-term disability and disease progression in MS patients.

Three synchronous gastrointestinal tumours.

Mucinous cystadenomas of the appendix are rare, with significant malignant potential [Lo and Sarr in Hepatogastroenterology 50(50):432-437, 2003]. Carcinoid tumours are similarly uncommon, rarely occurring in Meckel's diverticula but are still the commonest tumour of Meckel's diverticulae [Nies et al. in Dis Colon Rectum 35(6):589-596, 1992; Modlin and Lye in Cancer 97(4):934-959, 2003; Sutter et al. in Schweiz Med Wochenschr Suppl 89:20S-24S, 1997; Weber and McFadden DW in J Clin Gastroenterol 11(6):682-686, 1989]. A 77-year-old woman presented to our clinic with a 6-week history of non-specific lower abdominal pain. A pelvic ultrasound showed an 8 × 3 × 2.5 cm mass in the right iliac fossa. Colonoscopy and CT confirmed this mass and also revealed a left colonic tumor. At laparotomy, three tumours were identified; in the appendix, a Meckel's diverticulum, and the descending colon. A subtotal colectomy and diverticulectomy were performed. Histology confirmed a T3N0 Dukes B colonic adenocarcinoma, a carcinoid of Meckel's diverticulum and a mucinous adenoma of the appendix. The patient is tumor free to date, 5 years after presentation. The presence of three synchronous tumours of different histological origin in the gastrointestinal tract has not previously been described in the literature.

A new antibiotic CJ-17,665 from Aspergillus ochraceus.

A new antibiotic, CJ-17,665 (I) was isolated from the fermentation broth of Aspergillus ochraceus, CL41582. It inhibits growth of multi-drug resistant Staphylococcus aureus, Streptococcus pyogenes, and Enterococcus faecalis, with MICs of 12.5, 12.5 and 25 microg/ml, respectively. The structure contains a diketopiperazine and an indole N-oxide moiety that is unusual in natural products.

New pyrrolizidinone antibiotics CJ-16,264 and CJ-16,367.

Two new antibiotics, CJ-16,264 (I) and CJ-16,367 (II), were isolated from the fermentation broth of an unidentified fungus CL39457. These antibiotics have a pyrrolizidinone skeleton, first discovered in fungi. Compounds I and II inhibit the growth of Gram-positive multi-drug resistant bacteria and some Gram-negative strains such as Moraxella catarrhalis and Escherichia coli with altered permeability (imp). Comparison of an antibacterial profile between the two compounds suggested that the gamma-lactone portion of I is important for the activity.

CJ-15,801, a novel antibiotic from a fungus, Seimatosporium sp.

A novel antibiotic, CJ-15,801 (I), was isolated from the fermentation broth of a fungus, Seimatosporium sp. CL28611. The structure was determined to be a pantothenic acid analog having an alpha,beta-unsaturated carboxylic acid moiety by spectroscopic analyses. The compound inhibits the growth of multi-drug resistant (MDR) Staphylococcus aureus strains with MIC ranging from 6.25 to 50 microg/ml.

Spatial redistribution of energy in a nanosecond laser pulse by an organic optical limiter.

The spatial redistribution of energy resulting from the interaction between a near-diffraction-limited nanosecond laser pulse and the nonlinear absorbing optical limiting dye silicon naphthalocyanine is described, for what is to our knowledge the first time, in an optical geometry that is likely to be found in practical applications. For input fluences above that required for nonlinear absorption but below that for bubble growth, a plane wave or Gaussian spatial input evolves unexpectedly to a sharp central spike and a well-defined outer ring. The observed energy redistribution is thought to rely on a combination of nonlinear processes, since a pure absorptive process alone cannot explain the profiles presented. A model involving nonlinear absorption and nonlinear refraction qualitatively reproduces the observed spatial profiles. It is clear from the results that the performance of optical limiting dyes in representative optical geometries, even at fluences well below that required for bubble growth, cannot be described solely by nonlinear absorption.

An association between hypocholesterolaemia and colorectal carcinoma in an Irish population.

A group of 114 Irish patients with primary adenocarcinoma of the large bowel had significantly lower serum cholesterol concentrations than an age and sex matched group drawn from the general population. The hypocholesterolaemiac trait was manifest in male and female patients. Rigorous control procedures established that it was neither an artefact of nutritional compromise nor of preoperative bowel preparatory protocols. The data suggested that the appreciable hypocholesterolaemia observed was not influenced by the pathological stage or degree of differentiation of the tumour.

2-Methoxyacetic acid dosimetry-teratogenicity relationships in CD-1 mice exposed to 2-methoxyethanol.

The teratogen 2-methoxyethanol (2-ME), an industrial solvent, was administered to pregnant CD-1 mice either as a single subcutaneous (sc) bolus dose (100-250 mg/kg) or via constant-rate infusion from sc implanted osmotic minipumps (34.7 or 69.4 mg/kg/hr for up to 12 hr) on gestation Day 11, when embryonic paw development is maximally sensitive to perturbation by this agent. The sc entry route most closely reflects likely human exposures via dermal penetration, while bolus and constant-rate infusion administrations were contrasted to mimic potential occupational exposure scenarios. The pharmacokinetic profiles of 2-methoxyacetic acid (2-MAA), the proximate toxic metabolite of 2-ME, were quantitated, generating peak concentration (Cmax) and total 2-MAA exposure values (24-hr area under the concentration-time curve; AUC) in the maternal plasma, extraembryonic fluid, and embryo. The total 2-ME dose (mg/kg) required to achieve similar 2-MAA levels (Cmax or AUC) in these compartments was 2- to 3-fold higher by constant-rate infusion than by bolus injection; therefore, no simple association existed between 2-MAA levels and the total 2-ME dose, when the dose rate was not considered. Similarly, there was no good correlation between the combined total 2-ME doses and the fetal malformation rate, although clear dose-response patterns for paw malformations were observed in litters and fetuses for each individual dosing regimen. However, the combined 2-MAA pharmacokinetic data from each of the dosing regimens demonstrated that during the phase of maximum susceptibility of paw morphogenesis to disruption by 2-MAA (from gd 11 to gd 11.5), a strong linear correlation existed between fetal malformation incidence and 2-MAA AUC levels in either maternal plasma or embryonic compartments (linear correlation coefficient, r2 0.91-0.92). The correlation with Cmax was less favorable (r2 0.74-0.81) over the dose range studied. In a further experiment designed to investigate the importance of AUC vs Cmax regarding 2-ME teratogenicity, infusion of 2-ME (34.7 mg/kg/hr for 8 hr) beginning 2.5 hr after bolus loading (175 mg/kg) provided an increased 24-hr 2-MAA AUC without increased Cmax. This resulted in greater than 70% of the fetuses having various digit malformations (micro-, syn-, ectro-, and polydactyly), compared to only 32-35% of fetuses with mostly stunted digits when either dose was applied singularly. These data support total 2-MAA exposure (AUC levels), rather than peak 2-MAA concentrations, as the principle determinant of teratogenesis following exposure to 2-ME.(ABSTRACT TRUNCATED AT 400 WORDS)

Prophylactic antibiotic use in four Dublin teaching hospitals.

A retrospective study of 266 surgical patients revealed that 55% received antibiotics. Of these, 71% had prophylactic and 29% therapeutic courses. Twenty-five per cent of prophylactic courses were started post-operatively, 65% were continued for more than 24 hours, 28% were administered by an inappropriate route and 10% were started more than two hours pre-operatively. Of all courses of antibiotics ordered, 67% had no record of intended duration on the prescription. In 4% of courses the surgeon's orders were not followed. This study demonstrates widespread suboptimal use of antibiotic prophylaxis in a variety of surgical specialties.

Overwhelming infection occurring in the immediate post-splenectomy period.

Overwhelming post-splenectomy infection (OPSI) is a serious condition associated with a high mortality rate. Occurring most often in the first two years after splenectomy, it has also been described up to 47 years after this operation. We report a further occurrence of this syndrome and stress the importance of early detection and aggressive treatment of this type of infection.

Surgical anatomy of the human spleen.

Post-splenectomy sequelae are now well recognized, and conservative splenic surgery is widely advocated. However, controversies exist regarding splenic surgical anatomy. We studied 127 human spleens using anatomical dissection and a sequential injection method involving both radiology and corrosion casting, with the primary aim of examining segmental splenic anatomy and blood supply. The existence of well-defined splenic segments was confirmed and these ranged in number from 3 to 7 with a mean of 4.3. Each segment had its own arterial supply and venous drainage. The segments were separated from each other by avascular planes. Subsegments with independent blood supply were also identified. The splenic artery was found to divide into two branches; in all cases these further divided into segmental arteries supplying the central segments of the spleen. The polar segments were supplied by segmental vessels of highly variable origin and size. This study aims to highlight the importance of identifying these segmental vessels at operation when splenic conservation is considered.