The primitive trigeminal arteries appear in the 3-mm. human embryo, connecting the internal carotid arteries with the paired longitudinal arteries which eventually fuse to form the basilar artery (4). After the formation of the posterior communicating arteries, at the 14-mm. stage, the trigeminal arteries regress as a rule. Rarely, they persist in the adult. Reports of postmortem demonstration of persistent carotid-basilar anastomoses were reviewed by Sunderland (7, 8), who found 3 examples of this anomaly in 210 brains examined. In 2 instances, the vessel accompanied the trigeminal nerve in Meckel's cave; in the third it coursed through a separate foramen to reach the cavernous sinus, where it joined the carotid artery. Recognition of this congenital anomaly in cerebral angiograms has been reported by Sutton (9), Sugar (cited by Harrison and Luttrell, 2), Harrison and Luttrell (2) (3 cases), Murtagh et al. (3), Schaerer (6) and Poblete and Asenjo (5) (2 cases). Case Report A 29-year-old white female was admitted to Letterman Army Hospital, Dec. 14, 1955. In 1950, the patient began to drink heavily, averaging about a pint of rum daily during the two years prior to admission. About four months before admission, she began to have episodes of automatic behavior, with amnesia, lasting fifteen to thirty minutes. Episodes of rage also occurred, in which she would throw any object within reach. There was a history of occasional severe bifrontal headaches since childhood, which had recently shown a gradual decrease in frequency. Minor head injuries had occurred at the ages of three and eighteen years. Except for a small capillary angioma in the left temporal scalp area, no abnormalities were noted on physical examination. Neurological examination was within the limits of normal, as were a complete blood count, urinalysis, and spinal fluid examination. An electroencephalogram on Dec. 23, 1955, with the patient awake, was within normal limits. Repeat electroencephalograms on Jan. 4 and 12, 1956, with the patient asleep, demonstrated slowing and sharp waves in the right parietal and occipital areas. A pneumoencephalogram was within the limits of normal. Right carotid angiography, performed by the percutaneous technic, under local anesthesia, revealed a large vascular channel joining the proximal subclinoid portion of the internal carotid artery with the midportion of the basilar artery (Fig. 1). The portion of the basilar artery distal to this channel and both posterior cerebral arteries were well filled with the medium. No other abnormalities were noted. Therapy with Dilantin, 100 mg., and phenobarbital, 32 mg., each three times daily, was instituted. The patient remained free of seizures up to the time of writing. Discussion It appears that a persistent trigeminal artery does not, per se, have any pathological significance.
To determine whether the amount of physical activity (PA) is a determinant of joint space narrowing (JSN) worsening over 48 months in participants with knee osteoarthritis.Data were obtained from the Osteoarthritis Initiative. PA, measured using the Physical Activity Scale for the Elderly (PASE), was defined as the mean value of the annual measurements conducted prior to development of worsening JSN. Worsening JSN was defined as at least a partial grade increase in the Osteoarthritis Research Society International JSN score over 48 months, in comparison with baseline. Restricted cubic spline function was used to group participants based on the linear association between PA and JSN worsening. A pooled logistic regression model was used to evaluate the association between PA and JSN worsening adjusted for confounders.A total of 2,167 participants were included. In total, 625 participants (28.8%) had JSN worsening over 48 months. Compared with a PASE score of 141-180, PASE scores of 101-140 and >220 were associated with an increased risk of JSN worsening in men, with odds ratios (ORs) of 1.73 (95% confidence interval [95% CI] 1.07-2.81) and 1.83 (95% CI 1.14-2.93), respectively. Similarly, in participants with Kellgren/Lawrence (K/L) grade 2, compared with a PASE score of 141-180, PASE scores of ≤100 and >220 were associated with increased risks of JSN worsening, with an OR of 1.69 (95% CI 1.13-2.54) and 1.64 (95% CI 1.05-2.56), respectively.Compared to moderate PA, higher or lower amounts of PA are associated with an elevated risk for JSN worsening in men and in participants with K/L grade 2 knees.
—The recent letter of Dr. Morton F. Goldberg (Hazards of Mannitol,Arch Ophthal69:687, 1963) is a timely warning because of the increasing use of osmotic agents in ophthalmology, neurological surgery, urology, vascular surgery, etc. While Dr. Goldberg refers specifically to mannitol, the possible risk of "circulatory overloading" must be considered with the use of any osmotic agent. The studies of Barry and Berman (New Eng J Med264:1085-1088, 1961) demonstrated that while mannitol caused a transient increase in plasma and whole blood volume, the magnitude of the increase was inversely proportional to the magnitude of diuresis. In their experience, the intravenous infusion of 100 gm of mannitol solution had not caused clinical evidence of "cardiocirculatory overload" in 150 infusions, despite the presence of "severe heart disease" in some patients. In neurosurgical patients, we have not seen evidence of complications referable to rapid expansion of the extracellular
Valley fever or coccidioidomycosis is a pulmonary infection caused by species of Coccidioides fungi that are endemic to California and Arizona. Skeletal coccidioidomycosis accounts for about half of disseminated infections, with the vertebral spine being the preferred site of dissemination. Most cases of skeletal coccidioidomycosis progress to bone destruction or spread to adjacent structures such as joints, tendons, and other soft tissues, causing significant pain and restricting mobility. Manifestations of such cases are usually nonspecific, making diagnosis very challenging, especially in non-endemic areas. The lack of basic knowledge and research data on the mechanisms defining susceptibility to extrapulmonary infection, especially when it involves bones and joints, prompted us to survey available clinical and animal data to establish specific research questions that remain to be investigated. In this review, we explore published literature reviews, case reports, and case series on the dissemination of coccidioidomycosis to bones and/or joints. We highlight key differential features with other conditions and opportunities for mechanistic and basic research studies that can help develop novel diagnostic, prognostic, and treatment strategies.
We examined rheumatologists' approaches to and perceptions of depression in everyday practice.A questionnaire was mailed to 470 practicing rheumatologists in California; 226 were included in the final analyses. Respondents provided information on demographics, practice characteristics, and attitudes, perceptions, and practices related to depression. Logistic regression models were constructed to assess the relationship of rheumatologists' personal and practice characteristics with their depression-related practices.Fifty-one percent of respondents reported that at least half of their patients had depression. Nearly all providers (99%) reported addressing mental health issues during some visits. Rheumatologists were about equally likely to prescribe antidepressants, refer to a psychiatrist, or return the patient to the primary care physician, with roughly 60% often applying each of the 3 strategies. Respondents identified access to services and patients' resistance to mental health diagnoses as major barriers to effective depression management. In logistic regression models, greater number of patient visits per week, greater percentage of patients with fibromyalgia, and private practice setting were associated with more prescription of antidepressants (P < 0.05).Depression is common in rheumatologic practice, yet systems for identification, treatment, and referral of depressed patients are not universal. Rheumatologists' awareness of the need for mental health services is high, but they may lack the confidence, time, and/or referral networks to provide consistently effective care for depressed patients. Improving depression care in rheumatology may require a combination of clinician-level interventions (e.g., enhanced behavioral health training) and practice-level reforms (e.g., collaborative care).
