Isolated disturbance of written language-acquisition as an initial symptom of epileptic aphasia in a 7-year-old child - a 3-year follow-up-study

A 7-year-old right-handed girl developed partial complex seizures with a left-sided onset. A brief period of post-ictal aphasia of the conduction type was documented before seizure control and complete normalization of oral language were obtained. We also found that she had a history of previous unexplained difficulty with written language acquisition that had occurred prior to the clinically recognized epilepsy and a subsequent loss of this ability. This rapidly improved with control of the epilepsy. The evolution of written language were been followed for 3 years, and continued improvement has occurred with fluctuations related to her epilepsy. This observation adds support to the growing body of data indicating that specific cognitive disturbances can be due to epilepsy in young children. It shows the vulnerability of skills which are in a period of active development, and the possibility that oral/written language can be differentially involved by cerebral dysfunction in the young child.

Migrated foreign body liver abscess: illustrative case report, systematic review, and proposed diagnostic algorithm.

Pyogenic liver abscess is a severe condition and a therapeutic challenge. Treatment failure may be due to an unrecognized ingested foreign body that migrated from the gastrointestinal tract. There has recently been a marked increase in the number of reported cases of this condition, but initial misdiagnosis as cryptogenic liver abscess still occurs in the majority of cases. We conducted the current study to characterize this entity and provide a diagnostic strategy applicable worldwide. To this end, data were collected from our case and from a systematic review that identified 59 well-described cases. Another systematic review identified series of cryptogenic-and Asian Klebsiella-liver abscess; these data were pooled and compared with the data from the cases of migrated foreign body liver abscess. The review points out the low diagnostic accuracy of history taking, modern imaging, and even surgical exploration. A fistula found through imaging procedures or endoscopy warrants surgical exploration. Findings suggestive of foreign body migration are symptoms of gastrointestinal perforation, computed tomography demonstration of a thickened gastrointestinal wall in continuity with the abscess, and adhesions seen during surgery. Treatment failure, left lobe location, unique location (that is, only 1 abscess location within the liver), and absence of underlying conditions also point to the diagnosis, as shown by comparison with the cryptogenic liver abscess series. This study demonstrates that migrated foreign body liver abscess is a specific entity, increasingly reported. It usually is not cured when unrecognized, and diagnosis is mainly delayed. This study provides what we consider the best available evidence for timely diagnosis with worldwide applicability. Increased awareness is required to treat this underestimated condition effectively, and further studies are needed.

Report on initial experience with local anaesthesia for carotid artery endarterectomy.

PURPOSE OF THE STUDY: This prospective study reports our preliminary results with local anaesthesia (LA) for carotid endarterectomy (CEA). MATERIAL AND METHODS: Twenty CEA in nineteen patients were performed using a three-stage local infiltration technique. CEA were performed through a short Duplex-assisted skin incision (median length: 55 mm) using a retro-jugular approach and polyurethane patch closure (median length: 35 mm). RESULTS: There were 13 men and 6 women with a mean age of 71.2 years. The indications of CEA were asymptomatic lesions in 11 cases, stroke in 7 cases and transient ischaemic attack in 2 cases. The median degree of internal carotid artery stenosis was 90%. One patient (5%) required an intraluminal shunt. There were no peri-operative deaths, stroke or conversion to general anaesthesia (GA). The median length of stay was 3 days. CONCLUSIONS: LA is a good alternative to GA. It can be used after a feasibility study and a short teaching procedure. In our centre, it is a safe and effective procedure associated with low morbidity, high acceptance by patients and a short hospital stay.

Flow-targeted inversion-prepared b-TFE coronary MR angiography: initial results in patients.

PURPOSE: Visualization of coronary blood flow in the right and left coronary system in volunteers and patients by means of a modified inversion-prepared bright-blood coronary magnetic resonance angiography (cMRA) sequence. MATERIALS AND METHODS: cMRA was performed in 14 healthy volunteers and 19 patients on a 1.5 Tesla MR system using a free-breathing 3D balanced turbo field echo (b-TFE) sequence with radial k-space sampling. For magnetization preparation a slab selective and a 2D selective inversion pulse were used for the right and left coronary system, respectively. cMRA images were evaluated in terms of clinically relevant stenoses (< 50 %) and compared to conventional catheter angiography. Signal was measured in the coronary arteries (coro), the aorta (ao) and in the epicardial fat (fat) to determine SNR and CNR. In addition, maximal visible vessel length, and vessel border definition were analyzed. RESULTS: The use of a selective inversion pre-pulse allowed direct visualization of the coronary blood flow in the right and left coronary system. The measured SNR and CNR, vessel length, and vessel sharpness in volunteers (SNR coro: 28.3 +/- 5.0; SNR ao: 37.6 +/- 8.4; CNR coro-fat: 25.3 +/- 4.5; LAD: 128.0 cm +/- 8.8; RCA: 74.6 cm +/- 12.4; Sharpness: 66.6 % +/- 4.8) were slightly increased compared to those in patients (SNR coro: 24.1 +/- 3.8; SNR ao: 33.8 +/- 11.4; CNR coro-fat: 19.9 +/- 3.3; LAD: 112.5 cm +/- 13.8; RCA: 69.6 cm +/- 16.6; Sharpness: 58.9 % +/- 7.9; n.s.). In the patient study the assessment of 42 coronary segments lead to correct identification of 10 clinically relevant stenoses. CONCLUSION: The modification of a previously published inversion-prepared cMRA sequence allowed direct visualization of the coronary blood flow in the right as well as in the left coronary system. In addition, this sequence proved to be highly sensitive regarding the assessment of clinically relevant stenotic lesions.

Surgical outcomes of deep sclerectomy versus Baerveldt aqueous shunt implantation following initial failed deep sclerectomy

Purpose: To examine the efficacy and safety of repeat deep sclerectomy (DS) versus Baerveldt shunt (BS) implantation as second line surgery following failed primary DS. Methods: Fifty one patients were prospectively recruited to undergo BS implantation following failed DS and 51 patients underwent repeat DS, for which data was collected retrospectively. All eyes had at least one failed DS. Surgical success was defined as IOP≤21mmHg and 20% reduction in IOP from baseline. Success rates, number of glaucoma medications (GMs), IOP, and complication rates were compared between the two groups at year 1, post-operatively. Results: Mean age, sex and the proportion of glaucoma subtypes were similar between groups. Preoperatively IOP was significantly lower in DS group vs BS group (18.8mmHg vs 23.8mmHg, p<0.01, two sample t-test). Postoperatively IOP was significantly higher in DS group than BS group (14.6mmHg vs 12.0mmHg, p<0.01, two-sample t-test). In the DS group, 47% of eyes did not achieve 20% reduction in IOP from baseline, as a result the success rates were significantly lower in eyes with DS (51%) than in eyes with BS (88%) (p=0.02, log-rank test). Preoperatively the number of GMs used in DS and BS groups were similar (2.2 vs 2.7 p=0.02, two sample t-test). Postoperatively there remained no significant difference in GMs between groups (0.9 vs 1.1, p= 0.58, two sample t-test). Complication rates were similar between the two groups (12% vs 10%). Conclusions: Baerveldt tube implantation was more effective in lowering IOP than repeat deep sclerectomy in eyes with failed primary DS, at year one. Complications were minor and infrequent in both groups

Initial results on in vivo human coronary MR angiography at 7 T.

Seven tesla (T) MR imaging is potentially promising for the morphologic evaluation of coronary arteries because of the increased signal-to-noise ratio compared to lower field strengths, in turn allowing improved spatial resolution, improved temporal resolution, or reduced scanning times. However, there are a large number of technical challenges, including the commercial 7 T systems not being equipped with homogeneous body radiofrequency coils, conservative specific absorption rate constraints, and magnified sample-induced amplitude of radiofrequency field inhomogeneity. In the present study, an initial attempt was made to address these challenges and to implement coronary MR angiography at 7 T. A single-element radiofrequency transmit and receive coil was designed and a 7 T specific imaging protocol was implemented, including significant changes in scout scanning, contrast generation, and navigator geometry compared to current protocols at 3 T. With this methodology, the first human coronary MR images were successfully obtained at 7 T, with both qualitative and quantitative findings being presented.

Initial experience with hybrid surgery in congenital heart disease in a single center : P171

Introduction: A hybrid intervention is a joint procedure involving the interventional cardiologist and the cardiac surgeon. At our institution we have opted for this type of approach in congenital heart disease since 2005. We report here our initial experience. Cases: 1. A 3 year old boy with double aortic arch and multiple muscular ventricular septal defects (VSD),was readdressed for pulmonary band (PAB) removal and residual VSD closure after previous palliation. After surgical removal of the PAB, the surgeon provided a minimal transventricular access for placement of a 6mm Amplatzer® muscular VSD occluder by the cardiologist under transoesophageal guidance. The patient was extubated the same day and discharged after 5 days. 2. An 8 year old girl with Williams syndrome was followed for two large VSDs and severe peripheral pulmonary arteries (PA) stenosis. The membranous VSD was closed surgically, the muscular VSD during the same operation by direct placement of a 12 mm Amplatzer® muscular VSD occluder. During rewarming, balloon angioplasty of peripheral PA stenosis was achieved under fluoroscopy. Patient was extubated the following day and discharged after 8 days. 3. A 9 year old boy post tetralogy of Fallot repair had severe distal stenosis of the right ventricular to PA conduit.With patient on partial cardiopulmonary bypass, an incision was made on the conduit and a CP 8 Zig 16 stent placed on the stenosis. The child passed on full bypass and the definitive placement of the stent achieved. The child was extubated at the end of the intervention and discharged after 6 days. 4. A newborn presented at 2 days life with complex aortic arch anatomy: left aortic arch and right descending thoracic aorta perfused directly from a right arterial duct and left PA atresia. The arterial duct was stented with a Genesis XD stent dilated at 7mm. Two days later the cardiac surgeon made banded the right PA. The child was extubated after the operation and discharged a week later. Conclusion: Hybrid approach opens new ways of correction or palliation in congenital heart disease with encouraging results and less morbidity.

Free-breathing T2 mapping at 3T for the monitoring of cardiac allograft rejection: initial results

rejection can lead to loss of function. Histological reading of endomyocardial biopsy remains the "gold standard" for guiding immunosuppression, despite its methodological limitations (sampling error and interobserver variability). The measurement of the T2 relaxation time has been suggested for detection of allograft rejection, on the pathophysiological basis that the T2 relaxation time prolongs with local edema resulting from acute allograft rejection. Using breath-held cardiac magnetic resonance T2 mapping at 1.5 T, Usman et al. (CircCardiovascImaging2012) detected moderate allograft rejection (grade 2R, ISHLT 2004). With modern immunosuppression grade 2R rejection has become a rare event, but the need remains for a technique that permits the discrimination of absent (grade 0R) and mild rejection (grade 1R). We therefore investigated whether an increase of magnetic field strength to 3T and the use of real-time navigator-gated respiration compensation allow for an increase in the sensitivity of T2 relaxation time detection that is necessary to achieve this discrimination. Methods: Eighteen patients received EMB (Tan et al., ArchPatholLabMed2007) and cardiac T2 mapping on the same day. Reading of T2 maps was blinded to the histological results. For final analysis, 3 cases with known 2R rejection at the time of T2 mapping were added, yielding 21 T2 mapping sessions. A respiration-navigator-gated radial gradient-recalled-echo pulse sequence (resolution 1.17 mm2, matrix 2562, trigger time 3 heartbeats, T2 preparation duration TET2 Prep = 60/30/0 ms) was applied to obtain 3 short-axis T2 maps (van Heeswijk et al., JACCCardiovascImaging2012), which were segmented according to AHA guidelines (Cerqueira et al, Circulation2001). The highest segmental T2 values were grouped according to histological rejection grade and differences were analyzed by Student's t-test, except for the non-blinded cases with 2R rejection. The degree of discrimination was determined using the Spearman's ranked correlation test. Results: The high-quality T2 maps allowed for visual differentiation of the rejection degrees (Figure 1), and the correlation of T2 mapping with the histological grade of acute cellular rejection was significant (Spearman's r = 0.56, p = 0.007). The 0R (n = 15) and 1R (n = 3) degrees demonstrated significantly different T2 values (46.9 ± 5.0 and 54.3 ± 3.0 ms, p = 0.02, Figure 2). Cases with 2R rejection showed clear T2 elevation (T2 = 60.3 ± 16.2 ms). Conclusions: This pilot study demonstrates that non-invasive free-breathing cardiac T2 mapping at 3T discriminates between no and mild cardiac allograft rejection. Confirmation of these encouraging results in a larger cohort should consider a study able to show equivalency or superiority of T2 mapping.

Associations of baroreflex sensitivity, heart rate variability, and initial orthostatic hypotension with prenatal and recent postnatal methylmercury exposure in the Seychelles Child Development Study at age 19 years.

BACKGROUND: A few studies have suggested an association between prenatal exposure to methylmercury and decreased heart rate variability (HRV) related to autonomic heart function, but no study has examined this association using baroreflex sensitivity (BRS). In this study we assessed the distribution of BRS and immediate orthostatic hypotension (IOH) in young Seychellois adults and their associations with exposure to prenatal and recent postnatal methylmercury. METHODS: Subjects in the Seychelles Child Development Study (SCDS) main cohort were evaluated at age 19 years. Non-invasive beat-to-beat blood pressure (BP) monitoring (Finapres, Ohmeda) was performed at rest and during active standing in 95 consecutive subjects. Recent postnatal mercury exposure was measured in subjects' hair at the age of 19 years and prenatal exposure in maternal hair grown during pregnancy. BRS was estimated by sequence analysis to identify spontaneous ascending and descending BP ramps. HRV was estimated by the following markers: PNN50 (relative numbers of normal-to-normal intervals which are shorter by more than 50 ms than the immediately following normal-to-normal intervals); rMSSD (root mean of the squared sum of successive interval differences); LF/HF (low frequency/high frequency component ratio); ratio of the mean expiratory/inspiratory RR intervals (EI ratio); and the ratio between the longest RR interval 30 s after active standing and the shortest RR interval at 15 s (Max30/Min15). IOH was estimated by the deepest BP fall within the first 15 s after active standing up. RESULTS: Prenatal MeHg exposures were similar in boys and girls (6.7±4.3, 6.7±3.8 ng/g) but recent postnatal mercury levels were higher in males than females (11.2±5.8 vs 7.9±4.3 ng/g, p=0.003). Markers of autonomic heart rate control were within the normal range (BRS: 24.8±7 ms/mm Hg, PNN50: 24.9±6.8%, rMSSD: 68±22, LF/HF: 0.61±0.28) in both sexes. After standing, 51.4% of subjects had a transient systolic BP drop>40 mm Hg, but only 5.3% reported dizziness or had syncope. Prenatal and recent postnatal MeHg levels, overall, were not associated with BRS, E/I ratio, PNN50, rMSSD, LF/HF ratio, Max30/Min15 ratio, and IOH. CONCLUSIONS: This study provides no support for the hypothesis that prenatal or recent postnatal MeHg exposure from fish consumption is associated with impaired autonomic heart rate control.

Free-running 4D whole-heart self-navigated golden angle MRI: Initial results.

PURPOSE: To test the hypothesis that both coronary anatomy and ventricular function can be assessed simultaneously using a single four-dimensional (4D) acquisition. METHODS: A free-running 4D whole-heart self-navigated acquisition incorporating a golden angle radial trajectory was implemented and tested in vivo in nine healthy adult human subjects. Coronary magnetic resonance angiography (MRA) datasets with retrospective selection of acquisition window width and position were extracted and quantitatively compared with baseline self-navigated electrocardiography (ECG) -triggered coronary MRA. From the 4D datasets, the left-ventricular end-systolic, end-diastolic volumes (ESV & EDV) and ejection fraction (EF) were computed and compared with values obtained from conventional 2D cine images. RESULTS: The 4D datasets enabled dynamic assessment of the whole heart with isotropic spatial resolution of 1.15 mm(3) . Coronary artery image quality was very similar to that of the ECG-triggered baseline scan despite some SNR penalty. A good agreement between 4D and 2D cine imaging was found for EDV, ESV, and EF. CONCLUSION: The hypothesis that both coronary anatomy and ventricular function can be assessed simultaneously in vivo has been tested positive. Retrospective and flexible acquisition window selection allows to best visualize each coronary segment at its individual time point of quiescence. Magn Reson Med, 2014. © 2014 Wiley Periodicals, Inc.

Fingermark initial composition and aging using Fourier transform infrared microscopy (μ-FTIR)

This study investigated fingermark residues using Fourier transform infrared microscopy (μ- FTIR) in order to obtain fundamental information about the marks' initial composition and aging kinetics. This knowledge would be an asset for fundamental research on fingermarks, such as for dating purposes. Attenuated Total Reflection (ATR) and single-point reflection modes were tested on fresh fingermarks. ATR proved to be better suited and this mode was subsequently selected for further aging studies. Eccrine and sebaceous material was found in fresh and aged fingermarks and the spectral regions 1000-1850 cm-1 and 2700-3600 cm-1 were identified as the most informative. The impact of substrates (aluminium and glass slides) and storage conditions (storage in the light and in the dark) on fingermark aging was also studied. Chemometric analyses showed that fingermarks could be grouped according to their age regardless of the substrate when they were stored in an open box kept in an air-conditioned laboratory at around 20°C next to a window. On the contrary, when fingermarks were stored in the dark, only specimens deposited on the same substrate could be grouped by age. Thus, the substrate appeared to influence aging of fingermarks in the dark. Furthermore, PLS regression analyses were conducted in order to study the possibility of modelling fingermark aging for potential fingermark dating applications. The resulting models showed an overall precision of ±3 days and clearly demonstrated their capability to differentiate older fingermarks (20 and 34-days old) from newer ones (1, 3, 7 and 9-days old) regardless of the substrate and lighting conditions. These results are promising from a fingermark dating perspective. Further research is required to fully validate such models and assess their robustness and limitations in uncontrolled casework conditions.

Erratum of initial paper: Postmortem computed tomography angiography vs. conventional autopsy: advantages and inconveniences of each method.

PURPOSE: Postmortem computed tomography angiography (PMCTA) was introduced into forensic investigations a few years ago. It provides reliable images that can be consulted at any time. Conventional autopsy remains the reference standard for defining the cause of death, but provides only limited possibility of a second examination. This study compares these two procedures and discusses findings that can be detected exclusively using each method. MATERIALS AND METHODS: This retrospective study compared radiological reports from PMCTA to reports from conventional autopsy for 50 forensic autopsy cases. Reported findings from autopsy and PMCTA were extracted and compared to each other. PMCTA was performed using a modified heart-lung machine and the oily contrast agent Angiofil® (Fumedica AG, Muri, Switzerland). RESULTS: PMCTA and conventional autopsy would have drawn similar conclusions regarding causes of death. Nearly 60 % of all findings were visualized with both techniques. PMCTA demonstrates a higher sensitivity for identifying skeletal and vascular lesions. However, vascular occlusions due to postmortem blood clots could be falsely assumed to be vascular lesions. In contrast, conventional autopsy does not detect all bone fractures or the exact source of bleeding. Conventional autopsy provides important information about organ morphology and remains the only way to diagnose a vital vascular occlusion with certitude. CONCLUSION: Overall, PMCTA and conventional autopsy provide comparable findings. However, each technique presents advantages and disadvantages for detecting specific findings. To correctly interpret findings and clearly define the indications for PMCTA, these differences must be understood.