Etiologic Considerations Research Articles

AUTOSOMAL DOMINANT GTP CYCLOHYDROLASE I DEFICIENCY

Objective: Autosomal Dominant GTP cyclohydrolase I Deficiency (Segawa disease) is a postural dystonia with onset in childhood. This presentation describes the clinical characteristics, pathophysiology and etiological considerations.

Treatment of Nonaortic Aneurysms in the Endograft Era: Aneurysms of the Innominate and Subclavian Arteries

Although open aneurysm repair remains the standard of care, the advent of endoluminal techniques and stent grafts has significant potential to improve treatment of aneurysms of the innominate and subclavian arteries. Regardless of the modality chosen, therapy must be individualized and treatments tailored on the basis of anatomic and etiologic considerations. Occasionally, definitive treatment of an aneurysm with endoluminal stent-graft placement is possible for focal aneurysms or pseudoaneurysms of the innominate or subclavian arteries. In other situations, endoluminal grafting may be combined with open repair to allow for the benefits of both techniques. Ultimately long-term follow-up data are necessary to determine whether the durability of the endoluminal approach warrants more widespread use.

Treatment of Depression Following Traumatic Brain Injury

Depression is a common consequence of traumatic brain injury (TBI), and is a source of substantial distress and disability for persons with TBI and their families. This article offers a practical approach to the evaluation and treatment of this condition. Diagnostic and etiologic considerations relevant to this issue are reviewed first. Next, somatic therapies for posttraumatic depression, including antidepressant medications and electroconvulsive therapy, are discussed. Use of these therapies is also considered in the context of the common medical and neurological comorbidities among persons with TBI. Finally, psychosocial interventions relevant to the care of persons with posttraumatic depression are presented.

Strategic Planning: Establishing Need and Clarifying Motivation

Strategic Planning: Establishing Need and Clarifying Motivation

A primary aorto-duodenal fistula associated with an inflammatory abdominal aortic aneurysm: a case report.

Primary aorto-enteric fistula (PAEF)is a serious complication of abdominal aortic aneurysm(AAA). We report a patient with PAEF associated with inflammatory AAA who underwent emergent surgery. A 52-year-old male presented with recurrent hematemesis. A computer tomography scan showed a sealed rupture of the AAA adjacent to the duodenum. At surgery, a coin-sized PAEF was noted. The aorta was replaced with a Dacron graft in situ . Histological examination revealed the characteristics of an inflammatory AAA. The postoperative course was uneventful, and there has been no evidence of infection during a follow-up period of 3 years. We discuss the etiologic and surgical considerations regarding this unusual entity.

Treatment of nonvariceal upper gastrointestinal bleeding

The etiology, pathophysiology, prognostic factors, pharmacologic treatment, and pharmacoeconomic considerations of nonvariceal upper-gastrointestinal-tract bleeding (UGB) are reviewed. UGB is associated with substantial morbidity and mortality. While UGB can be caused by a wide variety of medical conditions, 50% of UGB cases are caused by peptic ulcers. Approximately 80% of all UGB episodes stop bleeding spontaneously. Recurrence of gastrointestinal hemorrhage is associated with an increased mortality rate, a greater need for surgery, blood transfusions, a prolonged length of hospital stay, and increased overall health care costs. All patients with UGB should be evaluated for signs and symptoms of hemodynamic instability and active hemorrhage. Endoscopy within the first 24 hours of a UGB episode is considered the standard of therapy for the management of the initial hemorrhage. However, approximately 20% of patients will experience a rebleeding episode. Acid-suppressive therapy with proton-pump inhibitors (PPIs) in addition to endoscopic hemostasis is effective in reducing the frequency of rebleeding, the need for surgery, transfusion requirements, and the length of hospital stay, but not mortality rates. There are multiple dosing options for administration of PPIs in this setting. More studies are necessary to elucidate the best therapeutic approach to manage UGB. Acid-suppressive therapy is beneficial in the management of UGB. It reduces the frequency of rebleeding, the need for surgery, transfusion requirements, and the length of hospital stay. To date, no pharmacologic intervention has demonstrated a reduction in the mortality rates of patients with UGB. An optimal acid-suppressive regimen has not yet been clearly established.

Non-neurological organ dysfunction in neurocritical care: impact on outcome and etiological considerations

Organ dysfunction is an important determinant of outcome in critical care medicine. Patients with life threatening neurologic injury represent a distinct subset of critically ill patients in whom non-neurologic organ dysfunction may develop. In this paper the incidence and impact of non-neurologic organ dysfunction in patients with major neurologic injury will be reviewed. Further, potential etiological considerations will be addressed and management strategies discussed. Non-neurologic organ dysfunction is extremely common in patients with brain injury occurring in 80-90% of patients admitted to intensive-care units. Several studies have now identified this dysfunction as an independent predictor of poor outcome in neurocritical care. This dysfunction may arise as a result of the neurologic injury or secondary to treatment. Massive catecholamine release continues to be the primary etiological theory of non-neurologic organ dysfunction due to brain injury. Currently employed therapies directed at intracranial hypertension such as maintenance of cerebral perfusion pressure and the use of hypothermia or barbiturates predispose non-neurologic organ dysfunction. Non-neurologic organ dysfunction is common. This dysfunction independently predicts poor outcome following brain injury and represents a potentially modifiable risk factor. Further study is required to develop optimal management strategies.

Erectile dysfunction after fracture of the pelvis

Male sexual dysfunction after fracture of the pelvis is more common than previously supposed with rates as high as 30% reported when the complaint is specifically sought. With the increase in survival from major injuries, the long-term consequences of trauma are being seen with increasing frequency

Uncommon complications of sacrospinous fixation for treatment of vaginal vault prolapse

The present study was undertaken to evaluate uncommon complications following transvaginal sacrospinous colpopexy for treatment of vaginal vault prolapse. A series of three patients who developed uncommon complications following sacrospinous fixation are reported. A 64-year-old patient undergoing bilateral sacrospinous colpopexy for the treatment of an ICS stage III vaginal vault prolapse developed a perineal necrotizing infection. Another patient, a 69-year-old woman with total vaginal vault prolapse and anterior vaginal wall defect (ICS stage II), underwent a right transvaginal sacrospinous colpopexy and anterior repair, presenting postoperatively with a perineal hernia. The third case consisted of a 71-year-old woman who underwent a right sacrospinous colpopexy with paravaginal repair, rectocele repair, and perineorrhaphy for treatment of an ICS stage III post-hysterectomy vaginal vault prolapse, stage II cystocele secondary to a bilateral paravaginal defect, and a stage II rectocele. Six months later the patient developed a left lateral enterocele, which was successfully repaired with a left sacrospinous ligament fixation. Etiological factors and treatment considerations for these uncommon complications of sacrospinous colpopexy are discussed in detail, and prophylactic measures, when applicable, are emphasized.

Diagnostic Issues in Penile and Vulvar Pathology

Diagnostic Issues in Penile and Vulvar Pathology

椎骨動脈圧迫による顔面痙攣 : 病因論と手術法(第24回日本脳神経外科コングレス「神経血管減圧術 : 困難例に対する手技)

神経血管減圧術を行った自験199例の顔面痙攣例のうち,椎骨動脈圧迫45例(22.6%)の病態を解析,手術手技について解説する.椎骨動脈圧迫は右側例の9.2%,左側例の32.4%.女性例の17.1%,男性例の30.5%であった.発症年齢45歳未満では20.6%,46歳以上では24.5%.高血圧合併例では22.7%,なしでは21.9%の割合であった.以上より椎骨動脈圧迫例は左側で,男性に多いが,動脈硬化のない非高血圧,若年症例にも生じうる.減圧操作は聴性誘発脳幹電位モニター下に血管を移動させる.顔面神経を圧迫する椎骨動脈(および分枝)をテフロン^<〔○!R〕>テープとテフロン^<〔○!R〕>ボールを用いて神経から移動し減圧する.時に椎骨動脈を錐体骨硬膜にglueで接着.椎骨脳底動脈の分枝を障害しないことが重要である.顔面神経,聴神経,外転神経,下部脳神経への愛護的な丁寧な手術操作が必要である.

The paradox of normal serum albumin in anorexia nervosa: A case report

Anorexia nervosa (AN) is associated with marked decreases in caloric intake and a corresponding reduction in body weight due to abnormal self body image. Although counterintuitive, hypoalbuminemia and vitamin deficiencies are not expected consequences of this disorder. Etiologic considerations for hypoalbuminemia are discussed. The case report of a patient with AN and marked hypoalbuminemia is presented and a focused literature review is reported. Hypoalbuminemia was initially attributed to starvation. However, occult infection was ultimately responsible. Serum albumin concentration normalized with antibiotic therapy despite minimal restoration of body weight. Hypoalbuminemia should not be considered a characteristic feature of AN even in the setting of progressive weight loss. The presence of other potentially life-threatening conditions should be sought, as reduced serum albumin concentration is a marker of inflammation in AN.

Management strategies for cardiogenic shock

Cardiogenic shock remains the most serious complication of acute MI, with an incidence of 6 to 8% and a 30-day mortality rate that remains close to 50%. While cardiogenic shock is due primarily to left ventricular failure, other causes such as acute mitral regurgitation and ventricular septal rupture must always be considered as emergency surgery may be life saving. The purpose of this review is to summarize recent advances in the care of these critically ill patients including the consideration of etiology and pathophysiology as well as the influence of age and adjunctive therapies. Early revascularization is now an American College of Cardiology/American Heart Association guideline class 1 indication for percutaneous coronary intervention (PCI) particularly for younger patients in cardiogenic shock. Recent studies suggest there may also be a benefit in elderly patients with cardiogenic shock. Prompt triage of all patients in cardiogenic shock for early angiography, intra-aortic balloon pump counterpulsation, and early revascularization with PCI or bypass surgery is now the preferred management strategy.

True Aneurysms in a Saphenous Vein Graft Placed for Repair of a Popliteal Aneurysm: Etiologic Considerations

Although vein graft aneurysms have been described to be atherosclerotic in nature, it has been hypothesized that vein graft aneurysms may be a part of a systemic dilating process. In the case reported here, histopathologic examination of vein graft aneurysms demonstrates aneurysmal degeneration with no atherosclerotic changes and do support the hypothesis that vein graft aneurysms may be a manifestation of a systemic dilating process.

Multiple Lung Nodules in a Hispanic Woman Shortly After Hysterectomy

INTRODUCTION: The differential diagnoses of multiple lung masses are diverse, with metastatic disease being the most common etiologic consideration. Other causes include Sarcoidosis, lung infections with Mycobacteria, Fungi, Nocardia or Septic emboli. In asymptomatic patients, other possibilities include amyloidosis, rheumatoid nodules, arteriovenous malformations, hamartomas and smooth muscle tumors.

Biliary atresia associated with hypoplastic left heart syndrome: A case report and review of the literature

Biliary atresia is a cholestatic disorder of infancy that is associated with other anatomic anomalies in approximately 20% of cases. These frequently are defects in situs determination and laterality, causing syndromes of heterotaxy and complex heart defects. The authors describe an infant with both biliary atresia and hypoplastic left heart syndrome (HLHS) in the absence of a laterality defect or evidence of any other morphologic defect. The presence of a hypoplastic left ventricle in a patient with biliary atresia has previously been reported only in the context of a heterotaxy syndrome. The coexistence of these 2 disorders raises etiologic considerations and represents a potential challenge for the surgical treatment of both conditions.

Canine brucellosis

This review discusses the prevalence, etiology, pathogenesis, clinical findings, diagnostic methods, therapy, management and public health considerations of Brucella canis infection in dogs. Canine brucellosis is a contagious infection produced by a gram-negative coccobacilus called Brucella canis. The main sources of infection are vaginal fluids of infected females and urine in males. Routes of entry are venereal, oronasal, conjunctivae mucosa and placenta. The most significant symptoms are late abortions in bitches, epididymitis in males and infertility in both sexes, as well as generalized lymphadenitis, discospondylitis and uveitis. Diagnosis is complex because serology can give false positive results and chronic cases can give negative results, needing to be complemented with bacteriological studies. No antibiotic treatment is 100% effective and the infection often recurs in animals apparently treated successfully. Infected animals must be removed from the kennels and no longer used for breeding. Preferably, males should be castrated and females spayed. Human contagion is not frequent, although it has been reported, and is easily treated.

Influence of etiology on ventilatory expired gas and prognosis in heart failure

Background: Mechanisms leading to heart failure (HF) are numerous. Etiology-based differences are, however, frequently not taken into account when assessing results of an exercise test. The purpose of this investigation is to: (1) compare subject characteristics and ventilatory expired gas measures demonstrating clinical value between subjects with ischemic and non-ischemic HF. (2) Examine the prognostic value of HF etiology. Methods: 71 subjects (44 male/27 female) diagnosed with compensated HF underwent exercise testing with ventilatory expired gas analysis. Mean age and ejection fraction (EF) were 51.3% (±12.8) and 27.0% (±12.5%) for the entire group. HF etiology was ischemic in 30 subjects (16 male/14 female) and non-ischemic in 41 (28 male/13 female). Results: Age (57.5±10.7 vs. 46.7±12.5, p<0.001), minute ventilation–carbon dioxide production (VE/VCO 2) slope (39.5±9.1 vs. 32.6±7.7, p=0.001), and duration of phase 1 kinetics in seconds (46.0±23.0 vs. 30.0±15.6, p=0.001) were significantly higher while peak oxygen consumption (VO 2) in ml O 2 kg −1 min −1 (12.5±4.7 vs. 16.0±5.2, p=0.006) and partial pressure of end-tidal CO 2 ( P ETCO 2) in mm Hg at rest (32.1±4.8 vs. 36.1±8.0, p=0.02) and peak exercise (31.7±4.3 vs. 36.2±5.9, p=0.001) were significantly lower in the ischemic group. Difference in EF did not reach statistical significance (28.4% ±12.5%—ischemic vs. 26.1%±12.5%—non-ischemic, p=0.44). Ischemic etiology was additionally a significant predictor of cardiac-related events ( p=0.04). Conclusions: These findings demonstrate noninvasive indicators of cardiac function and prognosis is poorer in subjects with ischemic HF etiology. Consideration of HF etiology may therefore be prudent, particularly when considering prognosis.

Acute Chagas’ Disease Presenting with a Suprasellar Mass and Panhypopituitarism

Although intrinsic pituitary lesions are the most common cause of hypopituitarism, suprasellar masses can produce similar symptoms. The differential diagnosis of a suprasellar mass includes cystic lesions, tumors, granulomatous disease, and infection. The etiology is not always obvious, and despite extensive work-up, may remain elusive. A 28-year-old Mexican man presented with complaints of headache and weakness for two weeks duration. He became increasingly lethargic and an MRI revealed a two centimeter suprasellar mass. Testing of the hypothalamic-pituitary axis suggested panhypopituitarism. He was prescribed treatment with hydrocortisone, DDAVP, and levothyroxine. Open craniotomy and biopsy of the hypothalamus revealed marked inflammation with plasma cells, histiocytes, and small lymphocytes. Light microscopy revealed macrophage-contained leishmania-like organisms although results were not immediately available. Pathological data was consistent with acute infection by Trypanasoma cruzi. Despite supportive efforts, the patient expired two months after presentation. This case illustrates the difficulty of diagnosing and the potential rapid mortality of a suprasellar mass. Because of the wide consideration of etiologies, a tissue diagnosis is needed. However, as this case illustrates, a definitive tissue diagnosis is not always possible, even following biopsy during open craniotomy.

Treating Patients Distressed Regarding Their Sexual Orientation: Clinical and Ethical Alternatives.

Homosexuality and bisexuality have not been considered psychopathologies for many years, and recent research has suggested a wide variety of etiological considerations, many biologically based, to account for same-sex desire. Nevertheless, many patients still present with questions and distress regarding their sexual orientation. The authors address the question of how practitioners may manage these situations. To this end, the authors briefly review the background of the relevant issues, make various assumptions, consider therapists' values, and present 4 alternatives available to practitioners who may be confronted with this situation. Each alternative is discussed with regard to its relevant ethical issues and clinical implications.