Citations

Purpose: Microsurgical anatomy of the corticospinal tract, its functional role and crucial points in differential diagnosis were evaluated. There is no consensus about its differences and cerebral origin of the corticospinal tract. Tractography and cadaver dissection can help to investigate the characteristics of the corticospinal tract. Also, amyotrophic lateral sclerosis is hard to diagnose as it has common symptoms and signs with other disorders. Methods: Three formalin-fixed human brains (six sides) were dissected by the Klingler technique in a stepwise manner from the lateral to medial and superior to inferior under 6x–40x magnification using a surgical microscope. All stages of the dissection were photographed using three-dimensional method. Lastly, we present a patient with the sign of drop foot who underwent electromyographical and radiological examination, diagnosed as atypic amyotrophic lateral sclerosis. Results: The connections of the corticospinal tract, in particular the travel in the in trajectories of stepwise in manner cerebral origin. We demonstrated a case report with anatomic correlation to define the damage of corticospinal tract in variable levels. Crucial landmarks, connections, eloquent brain areas that related to the corticospinal tract were emphasized. Conclusion: So that pointing the importance of such disorders to keep in mind as not to move forward with incorrect operation decision. Trajectory of one of the largest desending pathway, corticospinal tract and the relationship with different diagnosis should be considered.

ABSTRACT Background: Cannabis is widely used among patients with type 1 diabetes (T1D) in Colorado. Despite increasing use of cannabis among patients with T1D, the frequency and characteristics of unhealthy cannabis use are unknown. We investigated the differences in unhealthy cannabis use in recreational and medical cannabis users with T1D. Methods: Adult cannabis users with T1D completed an in-person questionnaire regarding their cannabis use patterns. They further divided into 2 categories; recreational and medical users. Cannabis Use Disorder Identification Test-Revised (CUDIT-R) was used to identify unhealthy cannabis use (CUDIT-R ≥ 8). Characteristics of cannabis users and unhealthy cannabis use between recreational and medical cannabis users were compared using unpaired t test. Results: Out of 117 patients, 85 patients reported recreational and 32 patients reported medical cannabis use. Based on CUDIT-R scores, 37.6% of adults with T1D had unhealthy cannabis use. Frequency of cannabis use ≥4 times a week was higher among medical users compared to recreational users (59.4% vs 28.2%, P < 0.01). There was no difference between the groups in duration of cannabis use. There was no difference in mean overall CUDIT-R score (7.14 vs 7.5, P = 0.76) between recreational and medical cannabis users. There were also no significant differences in mean CUDIT-R score between recreational and medical users within the nonhazardous use category (3.70 vs 4.4, P = 0.15) and unhealthy cannabis use category (12.84 vs 12.67, P = 0.92). Conclusions: Our study showed no difference in unhealthy cannabis use among recreational and medical cannabis users with T1D. Unhealthy cannabis use should be considered among users with T1D regardless of the reason for its use. Contexte: Le cannabis est largement utilisé chez les patients atteints de diabète de type 1 (DT1) au Colorado. Malgré l’augmentation de la consommation de cannabis chez les patients atteints de DT1, la fréquence et les caractéristiques d’une consommation de cannabis malsaine sont inconnues. Nous avons étudié les différences entre la consommation de cannabis malsaine chez les consommateurs de cannabis récréatifs et médicaux atteints de DT1. Méthodes: Les consommateurs de cannabis adultes atteints de DT1 ont rempli un questionnaire personnel sur leurs habitudes de consommation de cannabis. Ils ont été ensuite divisés en deux catégories; utilisateurs récréatifs et médicaux. Le Test d’identification des troubles liés à l’utilisation du cannabis révisé (CUDIT-R) a été utilisé pour identifier une utilisation malsaine du cannabis (CUDIT-R ≥8). Les caractéristiques des consommateurs de cannabis, ainsi que ceux d’une consommation de cannabis malsaine, entre les consommateurs de cannabis récréatifs et médicaux ont été comparées en utilisant un test t non apparié. Résultats: Sur 117 patients, 85 patients ont signalé des activités récréatives et 32 patients ont déclaré avoir utilisé du cannabis à des fins médicales. D’après les scores CUDIT-R, 37,6% des adultes atteints de DT1 avaient une consommation de cannabis malsaine. La fréquence de consommation de cannabis ≥ 4 fois par semaine était plus élevée chez les utilisateurs de médicaments que chez les utilisateurs récréatifs (59,4% contre 28,2%, p < 0,01). Il n’y avait pas de différence entre les groupes quant à la durée de consommation de cannabis. Il n’y avait pas de différence dans le score CUDIT-R global moyen (7,14 vs 7,5, p = 0,76) entre les utilisateurs de cannabis à des fins récréatives et médicales. Il n’existait pas non plus de différence significative entre le score CUDIT-R moyen entre les utilisateurs récréatifs et les utilisateurs à des fins médicales dans la catégorie d’usages non dangereux (3,70 contre 4,4, p = 0,15) et dans la catégorie d’abus de cannabis (12,84 contre 12,67, p = 0,92). Conclusions: Notre étude n’a montré aucune différence dans la consommation de cannabis malsaine chez les consommateurs de cannabis récréatifs et médicaux atteints de DT1. Une consommation de cannabis malsaine doit être envisagée chez les utilisateurs atteints de DT1, quelle que soit la raison de sa consommation.

Aim To conduct a systematic review and meta‐analysis to understand the timing and factors associated with anti‐programmed cell death protein‐1 ( PD ‐1)/anti‐programmed cell death protein‐1 ligand ( PD ‐L1) inhibitor‐induced Type 1 diabetes. Methods We searched MEDLINE , EMBASE , SCOPUS and Cochrane databases (August 2000–2018) for studies of any design on immune checkpoint inhibitors. A total of 71 cases were reviewed from 56 publications. Comparisons were made using Fisher's exact and Student's t ‐tests. Results The mean ± sd age at Type 1 diabetes presentation was 61.7±12.2 years, 55% of cases were in men, and melanoma (53.5%) was the most frequent cancer. The median time to Type 1 diabetes onset was 49 (5–448) days with ketoacidosis in 76% of cases. The average ± sd HbA 1c concentration was 62 ± 0.3 mmol/mol (7.84±1.0%) at presentation. All cases had insulin deficiency and required permanent exogenous insulin treatment. Half of the cases had Type 1 diabetes‐associated antibodies at presentation, and those with antibodies had a more rapid onset ( P =0.005) and higher incidence of diabetic ketoacidosis ( P =0.02) compared to people without antibodies. Conclusions Many people developed Type 1 diabetes within 3 months of initial PD ‐1/ PD ‐L1 inhibitor exposure. People presenting with Type 1 diabetes‐associated antibodies had a more rapid onset and higher incidence of ketoacidosis than those without antibodies. Healthcare providers caring for people receiving these state‐of‐the‐art therapies need to be aware of this potential severe adverse event.

Summary Objective Surgery is a stressor that can be categorized by duration and severity and induces a systemic stress response that includes increased adrenal cortisol production. However, the precise impact of surgical stress on the cortisol response remains to be defined. Design We performed a systematic review and meta‐analysis to assess the cortisol stress response induced by surgery and to stratify this response according to different parameters. Methods We conducted a comprehensive search in several databases from 1990 to 2016. Pairs of reviewers independently selected studies, extracted data and evaluated the risk of bias. Cortisol concentrations were standardized, pooled in meta‐analysis and plotted over time. Results We included 71 studies reporting peri‐operative serum cortisol measurements in 2953 patients. The cortisol response differed substantially between moderately/highly invasive and minimally invasive surgical procedures. Minimally invasive procedures did not show a peri‐operative cortisol peak, whereas more invasive surgeries caused a cortisol surge that was more pronounced in older subjects, women and patients undergoing open surgery and general anaesthesia. The duration of the procedure and the use of etomidate for induction of anaesthesia did not affect the cortisol response. Conclusions The peri‐operative cortisol stress response is dynamic and influenced by patient‐specific, surgical and anaesthetic features. However, the available evidence is derived from highly heterogeneous studies, with only two of 71 studies measuring cortisol by mass spectrometry, which currently prevents a precise and reproducible definition of this response.

Summary Nivolumab, a monoclonal antibody against programmed cell death-1 receptor, is increasingly used in advanced cancers. While nivolumab use enhances cancer therapy, it is associated with increased immune-related adverse events. We describe an elderly man who presented in ketoacidosis after receiving nivolumab for metastatic renal cell carcinoma. On presentation, he was hyperpneic and laboratory analyses showed hyperglycemia and anion-gapped metabolic acidosis consistent with diabetic ketoacidosis. No other precipitating factors, besides nivolumab, were identified. Pre-nivolumab blood glucose levels were normal. The patient responded to treatment with intravenous fluids, insulin and electrolyte replacement. He was diagnosed with insulin-dependent autoimmune diabetes mellitus secondary to nivolumab. Although nivolumab was stopped, he continued to require multiple insulin injection therapy till his last follow-up 7 months after presentation. Clinicians need to be alerted to the development of diabetes mellitus and diabetic ketoacidosis in patients receiving nivolumab. Learning points: Diabetic ketoacidosis should be considered in the differential of patients presenting with metabolic acidosis following treatment with antibodies to programmed cell death-1 receptor (anti-PD-1). Autoimmune islet cell damage is the presumed mechanism for how insulin requiring diabetes mellitus can develop de novo following administration of anti-PD-1. Because anti-PD-1 works by the activation of T-cells and reduction of ‘self-tolerance’, other autoimmune disorders are likely to be increasingly recognized with increased use of these agents.