Temporary Improvement In Symptoms Research Articles

Directional Deep Brain Stimulation Programming: Is the Segment Clearly Identifiable and Stable Over Time?

In our early experience programming directional deep brain stimulation (d-DBS) in PD, we found the optimal directional segment changed over time in some patients. To determine the frequency/reasons for this we examined whether (1) different programmers would identify the same segment as "optimal"; and (2) the same programmer would select the same "optimal" segment over time. We hypothesized there would be a moderately high level of agreement on optimal electrode selection between different assessors and repeated assessments by the same evaluator. This was a prospective, double-blind investigation evaluating the reliability and stability of programming d-DBS. Each patient underwent a mono-polar survey four times (2 time points by 2 separate assessors). The primary aim was the inter-rater agreement of selecting the optimal electrode at 1 and 6 months. The secondary aim was to determine the intra-rater agreement of selecting the optimal electrode from 1 to 6 months. Twenty-one patients were enrolled. There was fair inter-rater agreement at 1 month and moderate at 6 months. There was minimal intra-rater agreement between 1 and 6 months. The data refuted our hypothesis. Potential reasons for low agreement include (1) the arduous/subjective nature of identifying the optimal electrode in d-DBS systems, especially in well-placed electrodes; and/or (2) acute changes to the location of stimulation delivery offering temporary improvement in symptoms. Key takeaways gathered were it may, (1) behoove the programmer to explore different electrode montages after a period of time; and (2) be more efficient to review the directional electrode montage only when dictated by clinical symptoms/disease progression.

Anterior Thoracic Discectomy and Fusion for Symptomatic Ventral Bone Spur Associated Type I Cerebrospinal Fluid Leak: A Technical Report and Operative Video.

Technical Report. Cerebrospinal fluid (CSF) leak secondary to anterior osteophytes at the cervico-thoracic junction is a rare cause of intracranial hypotension. In this article we describe a technique for anterior repair of spontaneous ventral cerebrospinal fluid leaks in the upper thoracic spine. In this technical report and operative video, we describe a 23-year-old male who presented with positional headaches and bilateral subdural hematoma. Dynamic CT myelography demonstrated a high flow ventral cerebrospinal fluid leak associated with a ventral osteophyte at the level of the T1-T2 disc space. Targeted blood patch provided only temporary improvement in symptoms. An anterior approach was chosen to remove the offending spur and micro-surgically repair the dural defect. The patient had complete resolution of his preoperative symptoms after primary repair. In select cases, an anterior approach to the upper thoracic spine is effective to repair Type 1 cerebrospinal fluid leaks.

Delayed‐type hypersensitivity gastrointestinal symptoms induced by food oral immunotherapy and efficiently treated by dupilumab: A case report

Delayed‐type hypersensitivity gastrointestinal symptoms induced by food oral immunotherapy and efficiently treated by dupilumab: A case report

Cannabinoid Hyperemesis Syndrome in a 23-Year-Old Woman with Uncontrolled Type 1 Diabetes Mellitus.

BACKGROUND Patients with type 1 diabetes mellitus may experience gastrointestinal symptoms, including those suggestive of diabetic gastroparesis. Cannabinoid hyperemesis syndrome (CHS) includes nausea, vomiting, and abdominal pain in the setting of chronic cannabinoid use. This report presents a case of CHS in a 23-year-old woman with uncontrolled type 1 diabetes mellitus. CASE REPORT A 23-year-old woman with chronically uncontrolled type 1 diabetes mellitus had been presenting monthly at the emergency department for the last 2 years, for acute bouts of intractable nausea and vomiting, occasionally with abdominal pain. Given her history of uncontrolled diabetes, she had been managed for diabetic gastroparesis with prokinetics. A gastric emptying study 6 months prior to admission was normal, and the patient had had multiple unremarkable abdominal computed tomography imaging scans. On this admission, she benefitted from supportive management with only temporary improvement of symptoms. On further questioning, she reported consistent use of cannabis for the last few years, and regression of acute vomiting with hot baths at home. With counseling, she ceased cannabis for 2 months and was symptom-free during this period. CONCLUSIONS This report has shown the importance of taking a comprehensive drug history in all patients, including in patients with type 1 diabetes, and is a reminder that cannabinoid use can cause severe nausea, vomiting, and abdominal pain in this patient group.

MOMMY RN DERMATITIS

<h3>Introduction</h3> The COVID-19 pandemic has highlighted the importance of hand hygiene and led to the increased use of sanitizing gels and wipes. Here we describe a case of contact dermatitis due to sanitizing gels and wipes which was misdiagnosed as eczema for 3 years. <h3>Case Description</h3> A 40-year-old Guyanese female presented for evaluation of pruritic rash. She has seen several dermatologists and diagnosed with eczematous dermatitis. She has been prescribed topical 0.1% triamcinolone and a course of oral steroids with temporary improvement in symptoms. She had tried oral antihistamines with no improvement. On interview, she reported a rash predominantly on her hands which began in early 2020 and had worsened in the past year. Social history is significant for working as a registered nurse and having a baby 9 months ago. She admitted to frequent use of Clorox wipes without gloves at home since her baby was born. On exam she had numerous small papules with flare on bilateral dorsal hand, forearm, right orbit, and upper back. Patch testing was done and positive for benzyl alcohol. We recommended she use soap and water to clean her hands, avoid alcohol gels, and use gloves when using antiseptic wipes. She had abrupt improvement in symptoms. <h3>Discussion</h3> This case emphasizes the importance of cleaning gels and wipes as a cause of contact dermatitis. It particularly important to remember in the context of healthcare workers who frequently clean their hands, new parents who may using sanitizing wipes more often, and people with darker colored skin.

Maintenance Laser Treatment for Vaginal Looseness and Sexual Dysfunction: A Double-blinded Randomized Controlled Trial

Vaginal looseness and decreased sensation during intercourse is prevalent in up to 30%-55% of premenopausal women. The efficacy and safety of CO2 laser have been demonstrated for these indications; however, the effect is temporary, up to 6-12 months. No studies regarding the efficacy and safety of adjuvant laser treatments have been conducted to date. To evaluate the efficacy and safety of a single maintenance CO2 laser treatment in women with vaginal looseness and a concurrent decline in sexual sensation during intercourse. This prospective double-blinded randomized controlled trial included premenopausal women who experienced significant temporary improvement in symptoms following previous treatment with CO2 laser due to the abovementioned indications. Participants were randomized to either a single CO2 laser treatment or a single sham treatment. Treatment efficacy evaluated with the female sexual function index (FSFI) and the vaginal health index (VHI). Overall, 119 women were included in the study. Mean VHI and FSFI scores were significantly higher in the study group compared to the control group at three months post-treatment (17.34±1.39 vs 12.86±2.23, P=.023 and 30.93±1.79 vs 25.78±1.87, P=.044, respectively). In the study group, both VHI and FSFI returned to baseline at six months post-treatment. The median rate of sexual intercourse per month was increased in the study group at three months post-treatment (8 vs 4, P=.011), and returned to baseline at six months post-treatment. Maintenance laser treatment provides a temporary non-surgical alternative for women with vaginal looseness and associated sexual dysfunction, though treatment effect seems to be limited to less than 6 months, requiring additional maintenance sessions. The strengths of the current study include a randomized-sham controlled design. Furthermore, VHI was used as an objective evaluation tool, in addition to the FSFI, and assessment of the rate of sexual intercourse. The homogeneity and the relatively small sample size of the cohort is a limitation, and calls for caution in interpretation of the results, and the use of CO2 laser treatment in different age groups and populations. A single maintenance laser treatment in women who previously underwent successful treatment with laser is an effective, well-tolerated, and safe procedure for treating symptoms of vaginal looseness and sexual dysfunction, though effects are temporary. Lauterbach R, Aharoni S, Farago N, et al. Maintenance Laser Treatment for Vaginal Looseness and Sexual Dysfunction: A Double-blinded Randomized Controlled Trial. J Sex Med 2022;19:1404-1411.

AB0648 REACTIVE ARTHRITIS IN SYPHILIS MIMICKING RHEUMATOID ARTHRITIS: A CASE REPORT

Background:Reactive arthritis is a form of spondyloarthritis with aseptic joint involvement occurring after a gastrointestinal or urogenital infection. Most commonly associated with Chlamydia trachomatis, Salmonella, Shigella, Campylobacter, and Yersinia. Syphilis is an infection caused by the spirochete Treponema pallidum and is not usually associated with reactive arthritis. Syphilis is a great imitator of other diseases due to its broad presentation including painless chancre, constitutional symptoms, adenopathy, rash, synovitis, neurological and ocular findings.Objectives:To discuss a patient who presented with symptoms of rheumatoid arthritis (RA) but was later diagnosed with syphilis.Methods:31 year old male, former tobacco smoker, referred to Rheumatology for sudden onset joint pains, elevated anti-cyclic citrullinated peptide (anti-CCP), and elevated inflammatory markers. He reported pain in bilateral wrists, fingers, and right elbow for 6 weeks. Associated with 45 minutes of morning stiffness and new onset lower back pain without stiffness. He denied trauma, fever, chills, skin rash, dysuria, or diarrhea. Initiated trial naproxen 500mg twice a day only to have minimal relief. Patient is sexually active with men and was recently diagnosed with oropharyngeal gonorrhea treated with azithromycin 4 months prior. All other STI screening including syphilis, gonorrhea, HIV were negative at that time. Patient is on emtricitabine and tenofovir disoproxil fumarate for HIV pre-exposure prophylaxis. He denied family history of immune mediated conditions. Exam was significant for mild synovitis of both wrists and bilateral 2nd metacarpophalangeal joints. Initial labs revealed weakly positive anti-CCP 21 (normal &lt;20), sedimentation rate 64 (normal ESR 0-15 mm/hr), C-reactive protein 24 (normal CRP 0-10 mg/L), and negative RF, ANA, HLA B27. During a short trial of prednisone taper, there was temporary improvement in symptoms, however synovitis recurred upon completion. Hydroxychloroquine (HCQ) 200mg twice a day was started for possible RA and he was referred to Ophthalmology for baseline retinopathy screening. Incidentally, he developed right sided blurry vision 2 weeks after initiation of HCQ. He was diagnosed with panuveitis of the right eye with inflammation of the optic nerve head and prednisone 40mg daily was initiated for presumed ocular manifestation of RA. However, further workup of panuveitis revealed reactive Treponema pallidum antibody and RPR quantity 1:32. Prednisone was immediately discontinued and he was referred to the emergency department for possible neurosyphilis.Results:Lumbar puncture showed cerebral spinal fluid with 260 red blood cells, 1 white blood cell, 27mg/dL protein, 60mg/dL glucose, non reactive VDRL, reactive pallidum IgG antibody, and negative cultures. Meningitis and encephalitis panels were negative. Patient completed a 14 day course of IV penicillin G with complete remission of joint pain, visual symptoms, and normalization of anti-CCP, ESR, and CRP.Conclusion:This case highlights how syphilis may mimic signs and symptoms of RA including symmetrical small joint pain, morning stiffness, elevated inflammatory markers, and positive anti-CCP. Anti-CCP is &gt;96% specific for RA but was a false positive in this patient. There have only been few reported cases noting positive anti-CCP with reactive arthritis. This is a rare case of reactive arthritis secondary to syphilis with resolution of symptoms upon treating the syphilis.

Unilateral spinal motion segment rotational deformity causing foraminal stenosis

The objective of this article is to describe for the first time a case of unilateral spinal motion segment rotational deformity causing foraminal stenosis. In this report we present the case of a 43 year old male with multilevel lumbar degeneration who progressively developed an isolated L3/4 rotational deformity leading to symptomatic neural compression from foraminal stenosis. He first presented to our clinic in 2015 and was followed up over the course of four years. The patient failed non-operative treatment and developed increasing L3 radiculopathy and neurological dysfunction for which he had temporary improvement of symptoms after a foraminal epidural steroid injection. He therefore underwent a decompression with no resolution of symptoms and subsequently a lateral interbody fusion that restored foraminal height but not antero-posterior (AP) compression. Subsequent derotation with pedicle screws resulted in an increase in the antero-posterior size and resolution of his symptoms. Unilateral mono-segmental rotational deformity is a cause of foraminal stenosis that should be considered when patients present with radiculopathy. Surgical management should involve restoration of the antero-posterior dimension, which can be achieved with derotation.

Severe Lymphatic Disorder Resolved With MEK Inhibition in a Patient With Noonan Syndrome and SOS1 Mutation.

Noonan syndrome is a multiorgan system disorder mediated by genetic defects along the RASknown as RASopathies. It is the second most common syndromic cause of congenital heart disease and, in ∼20% of the cases, is associated with severe lymphatic disorders, including chylothorax and protein-losing enteropathy. Recently, we reported on the use of mitogen-activated protein kinase inhibition in a patient with an ARAF mutation and severe lymphatic disorder leading to an abrupt improvement in symptoms and complete remodeling of the central lymphatic system. Here, we present a patient with Noonan syndrome and severe lymphatic abnormality, leading to transfusion-dependent upper gastrointestinal bleeding and protein-losing enteropathy. The patient stopped responding to medical therapy and underwent several lymphatic interventional procedures, which led only to a temporary improvement in symptoms. Because of a lack of other treatment options, an expanded access approval was obtained, and the patient initiated treatment by mitogen-activated protein kinase inhibition using trametinib. This led to resolution of her symptoms, with complete normalization of her electrolyte levels, hemoglobin, and albumin within 3 months of starting the drug. Similar to the previously reported case, she also had complete and generalized remodeling of her lymphatic system. In patients with RAS pathway defects complicated by a severe lymphatic disorder, inhibition of the RAS-MAPK pathway should be considered as a possible treatment option in patients who failed conventional treatment and might be a first-line treatment in the future.

Photobiomodulation Therapy in the Management of Burning Mouth Syndrome: Morphological Variations in the Capillary Bed.

Burning mouth syndrome (BMS) is an idiopathic condition that manifests itself primarily with the onset of a burning sensation. The aim of this research was to perform photobiomodulation therapy (PBM) using a diode laser on the oral mucosa of BMS patients, followed by an objective evaluation of the morphological changes in the vascular bed underlying the mucosa using polarized light videocapillaroscopy. A group of 40 patients were included in the study. The patients were randomly divided into two groups (using simple randomization) as follows: 20 patients were assigned to the laser group and 20 patients were assigned to the placebo group. Each patient of the laser group received eight irradiations (with 4 Watt of power, wavelength 800 nm, energy 1200 Joules, irradiation time of 300 s, energy density 50 J/cm2, 60 mW continuous wave laser, and irradiance 180 mW/cm2), twice a week, blinded to the type of irradiation administered, for four consecutive weeks. The patients in the placebo group underwent the same sessions as the other patients, the only difference was the non-emission of the laser. An initial check of the vascular bed was performed with a polarized light videocapillaroscope. This was followed by treatment with a therapeutic diode laser and a subsequent check with a videocapillaroscope. We observed that in the group of patients who underwent laser therapy, there was a lasting improvement in symptoms. The capillary oral bed of patients in the placebo group did not show any statistically significant difference (p > 0.05). In the laser group we observed the following: in the buccal mucosa the diameter of the capillary had a reduction of 3 μm; in the upper lip mucosa, there was a reduction of 3 μm; in the lower lip mucosa, there was a reduction of 3 μm; and in the dorsal lingual surface, there was a reduction of 2 μm. An increase in capillary length was also obtained in all irradiated regions in the laser group patients (p < 0.05). PBM induces microcirculatory changes that are still present over a long period of time, such as an improvement in the clinical picture. The improvement in the symptoms has been correlated to the reduction of the capillary diameter. The placebo effect only led to a temporary improvement in symptoms that were unrelated to changes in the microcirculatory pattern.

Mutations in Myosin 5B in Children With Early-onset Cholestasis.

Mutations in Myosin 5B (MYO5B) are known to be associated with microvillous inclusion disease (MVID) a genetic cause of neonatal intractable diarrhoea. More recently, they have been reported in children with cholestasis but without typical gastrointestinal symptoms of MVID. We describe our series of children with cholestasis and mutations in MYO5B. Clinical, laboratory, and histological data were collected from patients with cholestasis and pathogenic mutations in MYO5B, found by next generation sequencing (NGS) but with minimal gastrointestinal disease. Six patients (3 boys) were identified. Median age at presentation was 19 months (range, 3-92). Presenting features were jaundice, pale stools, pruritus, and failure to thrive. Patients 5 and 6 had intractable diarrhoea until the age of 3 and 7 years, respectively, but currently are on full enteral diet with no intestinal symptoms. Median values for serum total bilirubin were 55 μmol/L (2-500), alanine aminotransferase 73I IU/L (32-114), γ-glutamyltransferase 7 IU/L (7-10), and serum bile acids 134 μmol/L (18-274). Three patients underwent 1 or more types of biliary diversion for symptom control. Median follow-up was 5 years (2-22). At most recent follow-up, they all reported pruritus while on antipruritics. Patient 1 had a liver transplant. We identified 6 patients, with mutations in MYO5B, early-onset cholestasis and pruritus, with variable response to biliary diversion without typical MVID.

TRANSFORAMINAL CERVICAL NERVE ROOT BLOCK: OUTCOMES AND COMPLICATIONS

ABSTRACT Objectives: To investigate the effect and complications after transforaminal injection for cervicobrachialgia caused by cervical disc herniation. Methods: We retrospectively reviewed all patients undergoing fluoroscopy-guided transforaminal injection for radiculopathy caused by cervical disc herniation. During the last seven years, 57 patients (39 female, 18 male, mean age 45.6 years) experiencing cervical radiculopathy underwent cervical foraminal block guided by fluoroscopy by postero-lateral approach. The position of the needle was verified after injection of a small amount of contrast. A glucocorticosteroid was injected after 0.5 ml of 2% lidocaine. Results: The local with the highest prevalence of procedures was C6 root (31 procedures); 14 patients underwent C7 block, 7 had C5 block, and 5 in C4. Eight patients (14%) had complications (3 syncopes, 3 transient hoarseness, one patient had worsening of symptoms and one patient had soft tissue hematoma). In total, 42.1% were asymptomatic after the procedure and therefore did not require surgery after the procedure. Other 57.9% had transient improvement, became asymptomatic for at least 2 months but required surgery due to the recurrence of symptoms. Conclusion: Cervical foraminal block for cervical disc herniation is a safe way to avoid surgery. Some patients still need surgery after the procedure, but the temporary improvement in symptoms gives the patient some relief while awaiting surgery.

Possible coexisting autoimmunity in a variant case of familial amyotrophic lateral sclerosis associated with anti‐GM2 immunoglobulin M antibody

AbstractA 43‐year‐old man presented with bilateral facial palsy, and muscle weakness and numbness in the upper limbs after an episode of antecedent infection. He rapidly developed muscle weakness in all limbs and bulbar palsy, and subsequently required artificial ventilation. Serum samples were weakly positive for anti‐GM2 immunoglobulin M antibody. Plasmapheresis and intravenous immunoglobulin therapy resulted in partial and temporary improvement of symptoms. The patient subsequently developed complete tetraplegia. The patient's father and uncle had been previously diagnosed with amyotrophic lateral sclerosis. Mutational analysis of the patient's blood showed a Cys6Gly mutation in the Cu/Zn superoxide dismutase 1 gene. Here, we report a variant case of familial amyotrophic lateral sclerosis suggesting a possible coexisting autoimmunity.

Inferior Oblique Botulinum Toxin Injection: A Postoperative Diplopia Test for Secondary Inferior Oblique Muscle Overaction.

To evaluate the utility of botulinum toxin injection into the inferior oblique muscle for secondary inferior oblique muscle overaction. A retrospective review of 18 patients and 23 injections performed over a 9-year period. Indications and deviations in primary position and contralateral gaze before and after injection were recorded. Functional outcomes and further management (conservative vs surgical) were observed. In 14 patients, chemodenervation resulted in a temporary improvement in symptoms. Eleven of these patients went on to have inferior oblique myectomy with resolution of their diplopia. Two patients preferred to receive regular injections of botulinum toxin as a treatment. Botulinum toxin chemodenervation of the inferior oblique muscle in cases of secondary inferior oblique muscle overaction is useful where one needs to establish a risk of overcorrection following planned inferior oblique muscle weakening. This is particularly true in cases where the primary position deviation may be small but symptoms of diplopia exist on contralateral side gaze, giving rise to a narrowed field of binocular single vision.

Last Resort of Individuals with Dementia Threatened

A recent Wisconsin Supreme Court decision held that individuals with dementia cannot be placed involuntarily into “units for the acutely mentally ill.”1 This creates a treatment vacuum for people with dementia who develop behavioral disturbances too severe to be managed elsewhere. Ironically, one premise for the court's decision was that, under Wisconsin law, civil commitment required amenability to “treatment,” which was defined as “rehabilitation.” The court ruled that because individuals with dementia cannot be rehabilitated, they cannot be civilly committed. Can individuals with psychiatric or behavioral disturbances caused by dementia be cured? No. Can they be treated? Most certainly yes. In spite of recent data on the dangers and limitations of pharmacological therapies for behavioral disturbances due to dementia, there is much (including a safe environment and nonpharmacological therapy) that inpatient psychiatric facilities can offer to individuals with dementia.2-5 Many people experience improvement or resolution of their symptoms.4, 5 In Wisconsin, a fundamental misunderstanding about the care of individuals with dementia has resulted in the exclusion of individuals with dementia from the civil commitment process. That process is an unpleasant but necessary step on the path to stabilization for many people with psychiatric or behavioral symptoms of dementia. It is our hope that the misunderstanding in Wisconsin will be quickly corrected. Perhaps even more important, we hope that Wisconsin's mistake does not spread to other states. California and Florida are the two states with the greatest number of people aged 65 and older. There is a real possibility that both could follow Wisconsin. California's attorney general has concluded that individuals with Alzheimer's disease may be held for 72 hours in the first step toward civil commitment,6 but further detention must be for treatment.7 A California court could, as in Wisconsin, conclude that treatment is not possible for dementia. Indeed, one California court upheld a conservator's determination that an individual's “inability to care for himself [was] not a product of a mental disorder for which treatment [was] available in a state mental hospital, but a result of dementia.”8 The definition of “mental illness” in Florida is broad enough to include dementia and even specifies that etiology is irrelevant.9 The Florida Supreme Court has held that a person who is involuntarily committed has a right to treatment.10 Florida statutes codify and broaden this right to include “such medical, vocational, social, educational, and rehabilitative services as his or her condition requires in order to live successfully in the community.”9 This broad definition of treatment may appear encouraging, but a court could conclude that civil commitment is inappropriate for individuals with advanced dementia who will never be able “to live successfully in the community.” Success in treating individuals with dementia, as with other mental illnesses, often means modest and sometimes temporary improvement in symptoms. To twist that unfortunate reality into a reason to deny supportive care in what may be the best setting is a legal blunder of colossal proportions. We must educate policy-makers to reverse the Wisconsin error and to prevent its spread. Conflict of Interest: Neither author has any conflict of interest. Author Contributions: Fredrick Vars provided legal analysis. Caroline Harada provided medical expertise. Both contributed significantly to the drafting. Sponsor's Role: No sponsor.

Intracranial hypertension caused by a depressed skull fracture resulting in superior sagittal sinus thrombosis in a pediatric patient: treatment with ventriculoperitoneal shunt insertion

Intracranial hypertension resulting from compression of the superior sagittal sinus (SSS) by an overlying depressed calvarial fracture is a rare condition. Primary surgical treatment for the symptomatic patient in this setting traditionally involves elevation of the fracture, which often carries significant associated morbidity. The authors report a case involving a 6-year-old boy who suffered a closed, depressed, parietooccipital fracture as the result of an unhelmeted all-terrain vehicle accident. This fracture caused compression and subsequent thrombosis of the SSS, which resulted in CSF malabsorption and progressive intracranial hypertension. Initially headache free following the injury, he had developed severe and unremitting headaches by postinjury Day 7. A CT angiography study of the head obtained at this time exhibited thrombosis of the SSS underlying the depressed calvarial fracture. Subsequent lumbar puncture demonstrated markedly elevated intrathecal pressures. Large volumes of CSF were removed, with temporary improvement in symptoms. After medical management with anticoagulation failed, the decision was made to proceed with image-guided ventriculoperitoneal shunt insertion. The patient's headaches resolved immediately following the procedure, and anticoagulation therapy was reinstituted. Follow-up images obtained 4 months after the injury demonstrated evidence of resolution of the depressed fracture, with recanalization of the SSS. The anticoagulation therapy was then discontinued. To the authors' knowledge, this report is the first description of ventriculoperitoneal shunt insertion as the primary treatment of this infrequent condition. This report demonstrates that select patients with this presentation can undergo CSF diversion in lieu of elevation of the depressed skull fracture-a surgical procedure shown to be associated with increased risks when the depressed fracture overlies the posterior SSS. The literature on this topic is reviewed and management of this condition is discussed.

Progress in treatment of chronic heart failure in Western medicine and treatment strategies in traditional Chinese medicine

The concept of modern medicine in treating chronic heart failure (CHF) has changed markedly in recent years. To improve the quality of life and prolong life, the treatment goal is no longer just temporary improvement of symptoms, more importantly, is to prevent and delay the occurrence and development of ventricular remodeling. Long-term chronic over-activation of sympathetic system, renin-angiotensin-aldosterone system and other neuroendocrine factors promotes myocardial remodeling, increases myocardial injury and deteriorates cardiac function. Despite short-term use can significantly improve the blood flow dynamics, long-term use of beta-adrenergic receptor stimulators and phosphodiesterase inhibitors does not prolong life, but increases the rate of sudden death caused by cardiac arrhythmia. Angiotensin converting enzyme inhibitors and beta-blockers have become the preferred drugs in treating chronic heart failure. In fact, after long-term use, beta-blockers can significantly improve ventricular remodeling, enhance ventricular function and reduce the incidence of sudden death of patients with CHF. In traditional Chinese medicine practice, short-term use of drugs for warming yang and reinforcing qi can improve symptoms of CHF, but long-term use may have adverse effects, for these medicines can stimulate sympathetic system. Early treatment with medicines of cold and cool property may be more favorable to patients with CHF, except the advanced patients who need special intervention. Eliminating heat and nourishing yin may play more active role in controlling the occurrence and development of CHF. Drugs with good efficacy and value in treating CHF may be developed from the Chinese herbal medicines with eliminating heat and nourishing yin property.

Fibromuscular dysplasia in association with intrauterine cocaine exposure

Fibromuscular dysplasia (FMD) is an idiopathic disease of small- and medium-sized arteries, involving one or more vascular beds. Patients may present with a range of symptoms, which may not readily lead to a diagnosis of FMD. While maternal cocaine abuse during pregnancy has previously been associated with vascular alterations in the fetus, an association specifically with FMD has not previously been described. In this case report, a 21-month-old male presented with a 3-week history of daily vomiting, with temporary improvement of symptoms, then relapse followed by loss of consciousness. His medical history was significant only for maternal cocaine use. Clinical evaluation revealed dilated cardiomyopathy, and a presumptive diagnosis of myocarditis was rendered. Respiratory arrest and death occurred 2 days after admission. Postmortem examination demonstrated intimal-type multivessel FMD, which was determined to be the cause of the clinical presentation. Without a postmortem examination, it is unlikely that a diagnosis of intimal fibroplasia, a rare variant of FMD (5% of cases), would have been made. This case thus illustrates the continuing utility of the classic postmortem examination. More intriguingly, the case suggests a possible relationship between in utero cocaine exposure and the development of fibromuscular dysplasia in the child.

The inoperable valvular heart disease patient:the pluses and minuses of percutaneous valvular replacement.

The spectrum of potentially successful treatment options for inoperable valvular disease is limited. Aortic valvuloplasty may offer temporary improvement in symptoms and some survival benefit in select non-surgical patients with aortic stenosis, but it does not improve long-term outcome. Mitral valve incompetence often responds well to surgical repair, though patients with significantly reduced left ventricular function have worsened outcomes. The design of a percutaneous implantable prosthetic heart valve is a promising alternative to valvuloplasty. Although not yet an established interventional method, Percutaneous Aortic Valve Replacement (PAVR) will likely take a position among the innovative catheter-based techniques currently in development. The appropriate clinical scenario for Percutaneous Mitral Valve Intervention (PMVI), however, may be significantly narrower. As with many other minimally invasive operations or procedures, the ethical considerations of a novel approach must be considered.

Botulinum Neurotoxin Serotype A: A Clinical Update on Non-Cosmetic Uses

Clinical experience with botulinum toxin type A for non-cosmetic uses that are approved by the Food and Drug Administration (FDA) and various other non-cosmetic uses that are not approved by FDA, including some applications that are widely known and others that currently are emerging, is discussed. FDA-approved indications for botulinum toxin type A (Botox) include the temporary treatment of cervical dystonia (a neuromuscular disorder involving the head and neck), the oculomotor disorders strabismus (improperly aligned eyes) and blepharospasm (involuntary contraction of the eye muscles), and severe primary axillary hyperhidrosis (excessive sweating). Other uses of botulinum toxin type A that are widely known but not approved by FDA include spastic disorders associated with injury or disease of the central nervous system including trauma, stroke, multiple sclerosis, or cerebral palsy and focal dystonias affecting the limbs, face, jaw, or vocal cords. Treatment and prevention of chronic headache and chronic musculoskeletal pain are emerging uses for botulinum toxin type A. Many of the conditions for which botulinum toxin type A has been explored are common and difficult to treat. Temporary improvement in symptoms is associated with botulinum toxin type A injection, and repeat treatment often is required. The drug is well tolerated and has a wide margin of safety.