The early diagnosis of an acoustic neuroma

A study aiming to assess the clinical tolerance of a special follow-up soybean milk formula (Neo-Soyal 2) in children with cow's milk protein intolerance or allergy (CMPI/CMPA) has been conducted in 17 infants and children (9 girls and 8 boys) aged from 6 months to 3 years. All the patients had a past history suggestive of CMPI/CMPA and were fed a restricted hypoallergenic diet with a semi-elemental formula based on protein hydrolysates. At the time of initiation of the study, all the patients were asymptomatic with normal growth while on a semi-elemental diet. The formula with protein hydrolysates was substituted by the test milk (Neo-Soyal 2) and blood samples were taken before and after 2 months. The clinical tolerance to the follow-up soybean formula was considered excellent in 16 children who remained asymptomatic with normal growth velocity. Only one patient developed a severe diarrhoea within 72 hours after introduction of the soybean formula which was stopped. However, after one month he was able to tolerate a certain amount of the soybean milk (240 ml) without symptoms. For all the patients studied, there was no change in the nutritional parameters measured in the blood before and after 2 months of the trial. Likewise, the plasma amino acid levels determined in 2 patients remained unchanged before and after the experimental period. These data indicate that the soybean milk formula used here (Neo-Soyal 2) can be safely given as a substitute of semi-elemental diets during the follow-up of children with CMPI/CMPA after the age of 6 months.     

Quality of life after acoustic neuroma surgery

OBJECTIVE: To assess how surgery affected the quality of life of patients with acoustic neuromas and to investigate possible predictors of the functional outcome following surgery. STUDY DESIGN: A questionnaire based on the Glasgow Benefit Inventory was completed by patients randomly selected following acoustic neuroma surgery. SETTING: Skull base surgery unit of a university teaching hospital (tertiary referral center). PATIENTS: Fifty-three patients with acoustic tumors (follow-up, 1 to 3 y). RESULTS: With regard to overall quality of life, nine patients (17.4%) reported that it became better, 28 patients (53.8%) worse, and 15 patients (28.8%) that it remained the same. Four patients (7.8%) became better off financially, 15 patients (29.4%) worse, and 32 (62.8%) remained unchanged. Forty-one patients (78.8%) did not change their occupation, and 11 (21.2%) had to change their occupation, mainly because of the adverse effects of the operation. With regard to the age at operation, older patients were found to have better overall quality of life. Moreover, younger patients had worse postoperative financial status and they were more likely to change their occupation after the operation. The tumor size did not significantly affect the overall postoperative quality, but it did affect the postoperative financial status (patients with larger tumors were more likely to have worse postoperative financial status). CONCLUSION: Acoustic neuroma surgery has a significant impact on patients' overall quality of life. Surgeons proposing to operate on small tumors should not assume that the impact on patients' life will be necessarily less than that following the removal of larger tumors. All patients, especially in the younger age group, should be prepared and thoroughly informed about the consequences of the operation on their quality of life.     

Quality of hearing preservation in acoustic neuroma surgery

OBJECTIVE: This study aimed to investigate the factors affecting the quality of postoperative hearing in acoustic neuroma. STUDY DESIGN: The study was designed as a retrospective case review. SETTING: The study was performed at the Department of Otolaryngology, School of Medicine, Keio University, Tokyo, Japan. PATIENTS: The subjects were 94 patients with unilateral acoustic neuroma. INTERVENTION: Hearing preservation surgery was performed in the subjects via the extended cranial fossa approach or the middle cranial fossa approach. MAIN OUTCOME MEASURES: The outcome measures included patient's age and gender, hearing level, speech discrimination score, tumor size, and surgical approach. The relationship between the qualities of preoperative and postoperative hearing and the long-term prognosis of preserved hearing also was investigated. RESULTS: In 94 subjects, there were 47 patients whose hearing was preserved (HP group) and 47 patients whose hearing was not preserved (non-HP group). Overall, hearing preservation rate was 50%. There were no significant differences in age, gender, and tumor size between the two groups. The hearing preservation rate was significantly higher in patients with an intracanalicular tumor than that with a larger tumor. The better the preoperative quality of hearing was, the higher the postoperative one. Although the preserved hearing deteriorated after surgery in 4 patients, no significant hearing deterioration was observed in the other 43 patients. CONCLUSIONS: The results of this study indicated that the diagnosis for acoustic neuroma in the early stage with serviceable hearing is the most important to improve the quality of postoperative hearing.     

Incidence of normal hearing in acoustic neuroma]

In a 4 1/2 year period fetal, echocardiographic studies were performed on 1600 fetuses. In 55 with arrhythmia, 44 had supraventricular ectopic beats, resolved in all, and none had heart disease. Sustained arrhythmias occurred in 11 fetuses. Atrial flutter was present in 3 all with heart disease (Ebstein disease, right atrial tumour and WPW diagnosed after birth). Another 3 fetuses had supraventricular tachycardia (SVT), all with a normal heart. In the bradycardia group, 2 had complete heart block (CHB) associated with AVSD; 2 sinus bradycardia and one had non conducted atrial ectopic beats. Digoxin was the first choice drug for tachyarrhythmia therapy; association with Verapamil, Flecainide, Quinidine and Procainamide was used in 4 of the 6. One fetus with CHB received Orciprenaline with no results. Atrial flutter resolved or improved; in SVT 2 fetuses converted to sinus rhythm and one died in utero. All fetuses with CHB died in cardiac failure. Mortality was 27% (3 cases) in utero and global 36%. In our experience most fetal arrhythmias (90%) were transitory ectopic beats or non lasting bradycardia in normal heart and did not trigger other kinds of arrhythmias. In sustained arrhythmias, heart failure and heart disease had a negative effect on prognosis.     

Intraoperative monitoring of facial nerve antidromic potentials during acoustic neuroma surgery

The present paper presents monopolar recording of facial nerve antidromic potentials as an alternative technique to facial electromyography for the continuous monitoring of the facial nerve during acoustic neuroma surgery. The investigation involved 22 patients undergoing acoustic neuroma surgery via a retrosigmoid approach (tumour sizes ranging from 5 to 28 mm). Bipolar electrical stimulation of the marginalis mandibulae was performed to elicit facial nerve antidromic potentials. Stimulus intensity ranged from 2 to 6 mA with a delivery rate of 7/sec. A silver wire monopolar electrode positioned intracranially on the proximal portion of the acoustic facial bundle was used to record antidromic potentials. To define the specific origin of the action potentials and acquire normative data, monopolar and bipolar recordings of facial nerve antidromic potentials were performed in 15 subjects undergoing retrosigmoid vestibular neurectomy for Meniere's disease. The average facial nerve antidromic potential latency was 4.2 (+/- 0.6) msec in subjects with acoustic neuroma and 3.3 (+/- 0.2) msec in subjects with Meniere's disease. Facial nerve antidromic potentials furnished near real-time information about intraoperative facial nerve damage and postoperative facial nerve function during acoustic neuroma surgery. Facial nerve antidromic potentials may provide additional information to conventional EMG. They allow the use of endplate blockers, yield quantitative estimation of facial nerve conduction properties in terms of amplitude and latency, and allow actual continuous monitoring of the facial nerve.     

Costs and effects of microsurgery versus radiosurgery in treating acoustic neuroma

This study analyses costs and effects of treating acoustic neuroma patients by using microsurgery compared to radiosurgery. Radiosurgery is the stereotactic application of radiotherapy and an innovative medical technology. Cost and effect estimates of conventional treatment were based on a retrospective study in the Netherlands. Similar data for a comparable group of patients in Sweden were collected for radiosurgery, as this treatment option is currently not available in the Netherlands. Fifty-three acoustic neuroma patients who had been operated on the University Hospital Rotterdam between November 1990 and February 1995 were included. This group was compared with 92 acoustic neuroma patients treated with radiosurgery (Gamma Knife. Stockholm, Sweden) in the same period. Data on health care use were collected from patient files. To obtain data on production losses and quality of life, a questionnaire was sent by mail in February 1995. This booklet consisted of the Health and Labour-questionnaire (HLQ), the Short Form-36 (SF36) and the EuroQol. The response rate was 92%. Direct costs for microsurgery amounted to Dfl. 20.072,- and for radiosurgery to Dfl. 14.272,-. Indirect costs were respectively Dfl. 16.400,- and Dfl. 1.020,-. General health rating was better for radiosurgery than for microsurgery. On the whole, differences in clinical outcomes between the two patient groups were small. Assuming a reasonable occupancy rate of the expensive radiosurgery equipment, we demonstrated that for the short term treating patients with acoustic neuroma with an extra-meatal tumour diameter of less than 3 centimeters, radiosurgery is more cost-effective than microsurgery.     

The size of acoustic neuromas: CT and MRI

The growth rate of acoustic neuromas is very variable: some tumours grow rapidly, some do not grow and some even get smaller. When making treatment decisions, it may be important to have an idea of the growth rate of the individual tumour, and this is only possible when there are comparable examinations. We performed both CT and MRI on 15 patients. Two radiologists estimated the size of their acoustic neuromas. There was a significant difference between the two examiners' calculations of tumour volumes on CT and between the first examiner's CT and MRI volume calculations. No difference was found between the two MRI volume estimations or the second examiner's estimation of volumes on CT and MRI. Measurements of the maximal tumour diameter along the pyramid showed good concordance. We conclude that measurement the size of acoustic neuromas is reproducible with MRI and the measurement of the maximal tumour diameter is in practice a better parameter for comparison than calculation of real volume.     

Evaluation of quality of life and symptoms after translabyrinthine acoustic neuroma surgery

OBJECTIVE: This study aimed to describe the consequences of acoustic neuroma surgery in terms of symptoms and quality of life. STUDY DESIGN: This study was a retrospective case review. SETTING: The surgery was conducted in Uppsala, Sweden. PATIENTS: A consecutive sample of acoustic neuroma patients operated on between 1988 and 1994. INTERVENTION: All patients had been operated on with the translabyrinthine technique. MAIN OUTCOME MEASURES: A questionnaire was constructed including questions about the surgery and symptoms. The House and Brackmann scale was used for grading facial function and the Brackmann and Bars scale was used for self-assessment of facial function. RESULTS: Follow-up data were collected by a postal questionnaire sent out and returned by 141 patients, which yielded a 90% response rate. Normal to moderately impaired facial function (House I-III) was evident in 85.2% of patients, although residual facial problems were reported. Most considered hearing to be worse after surgery (80%), and tinnitus was found in 60% of the sample. Balance problems (45%), dizziness (19%), and headache/pain (22%) were also reported. Work ability was affected in 23%, and 37% reported a continued need for medical consultations, mainly because of facial problems and pain. Most (89%) were pleased with the preoperative information. CONCLUSIONS: This study showed that few patients with acoustic neuroma had experienced negative social consequences after surgery. Although not linked to the operation, residual symptoms were reported that may necessitate further rehabilitation.     

MRI of patellar articular cartilage: evaluation of an optimized gradient echo sequence (3D-DESS)

OBJECTIVES: This study sought to examine the influence of time to reperfusion on myocardial salvage. BACKGROUND: Major trials of reperfusion therapy for myocardial infarction (MI) have demonstrated improved outcome for patients achieving earlier reperfusion. However, some patients experience significant benefit despite delayed reperfusion. METHODS: Fifty-five patients with a first anterior MI underwent successful reperfusion therapy (angioplasty or thrombolysis). Technetium-99m (Tc-99m) sestamibi was injected before reperfusion therapy and again at hospital discharge to determine the myocardial salvage index for each patient. Residual flow to the infarct territory was assessed by the nadir of the Tc-99m sestamibi count-profile curve. RESULTS: The salvage index showed wide variability (range -0.04 to 1.0), and extreme values were seen in 34.5% of the group (<0.10 in 9%, >0.90 in 25%). A high salvage index was associated with reperfusion therapy before 2 h (p=0.02) or good residual blood flow (p < 0.01). For the 10 patients who received reperfusion therapy within 2 h, residual blood flow was not correlated with salvage (p=0.12). For the 45 patients treated after 2 h, residual blood flow correlated significantly with salvage (r=0.57, p < 0.0001). There was a significant interaction (p < 0.05) between residual blood flow and time to therapy, indicating that the effect of each variable on salvage depended on the value of the other. Multiple historic and hemodynamic variables were examined, but none demonstrated any association with residual flow or myocardial salvage. CONCLUSIONS: In patients with acute MI, successful reperfusion therapy within 2 h is associated with the greatest degree of myocardial salvage. For patients treated after 2 h, residual blood flow to the infarct-related territory appears to be the most important determinant of myocardial salvage.     

MRI gadolinium enhancement of bone marrow: age-related changes in normals and in diffuse neoplastic infiltration

OBJECTIVE: To quantify gadolinium-related enhancement in the bone marrow of the spine in normals and in patients with homogeneous diffuse malignant bone marrow infiltration. DESIGN AND PATIENTS: The patients consisted of two groups: group 1 comprised 94 healthy adults (18-86 years) without bone marrow disease and group 2 comprised 30 patients with homogeneous diffuse malignant bone marrow infiltration due to myeloma (n = 20) or breast carcinoma (n = 10). All patients received intravenous gadopentetate dimeglumine (Gd-DTPA), 0.1 mmol/kg body weight. Pre- and postcontrast signal intensity (SI) on T1-weighted spin-echo (SE) images (TR/TE: 572 ms/15 ms) was measured over a region of interest (ROI) and the percentage SI increase was calculated. The results were confirmed by bone marrow biopsy (n = 20) and clinical parameters (n = 10). Dynamic contrast-enhanced studies using a spoiled gradient-recalled-echo (GRE) sequence (TR/TE/alpha: 68 ms/6 ms 75 degrees) were performed in 10 controls with normal bone marrow. RESULTS AND CONCLUSION: Contrast material enhancement in healthy persons can vary greatly (range 3-59%, mean 21%, SD 11%). With increasing age there is a significant decrease in contrast enhancement (Pearson's correlation, P < 0.01). The percentage SI increase in patients with intermediate-grade (biopsy 20-50 vol%) and high-grade (biopsy > 50 vol%) diffuse malignant bone marrow infiltration was significantly higher than in normals (mean 67%, SD 34%, P < 0.001). Low-grade (biopsy < 20 vol%) diffuse malignant bone marrow infiltration can not be assessed by non-enhanced T1-weighted SE images or Gd-DTPA application. In conclusion, contrast material enhancement in healthy persons can vary greatly and is dependent on age, while intermediate-grade and high-grade diffuse malignant bone marrow infiltration can be objectively assessed with SI measurements.     

Sacral hydatidosis: value of MRI in the diagnosis

We present a case of primary hydatid disease of the sacrum. The diagnosis was made on MR imaging obtained to evaluate the spine for recurrent disc disease. The patient had previously undergone laminectomy elsewhere for L4-5 radiculopathy. Ultrasound-guided aspiration and visualisation of scolices confirmed the diagnosis. No other site of involvement was found.     

Posterior leukoencephalopathy without severe hypertension: utility of diffusion-weighted MRI

OBJECTIVE: Standard MRI confirms the diagnosis of posterior leukoencephalopathy syndrome (PLES), recently associated with an increasing number of medical conditions. In PLES, T2-weighted MRI demonstrates hyperintensity spreading out from posterior brain regions; the pathophysiology remains mysterious. In the acute setting, diffusion-weighted imaging (DWI), but not standard MR imaging, can distinguish ischemic injury from those conditions known to cause vasogenic brain edema. DWI is potentially valuable in understanding the pathophysiology of PLES and in diagnosing patients who do not have previously known risk factors. METHODS: Serial CT and MRI studies (including DWI, apparent diffusion coefficient [ADC] maps, and, in one instance, perfusion-weighted imaging) were performed in three female patients with a neurologic syndrome consistent with PLES while hospitalized for treatment of other conditions. RESULTS: None of the patients had previously described risk factors for PLES; all had only mild elevations in blood pressure. MRI showed large, abnormal, T2 hyperintense regions in the posterior cerebrum with corresponding hyperintensity on ADC maps-signal characteristics predominantly consistent with vasogenic edema. There were also smaller patchy posterior cortical regions with decreased ADC and bright DWI consistent with infarction in one, and dramatic conversion of a large region to an ischemic pattern in another. CONCLUSIONS: ADC maps and DWI can successfully differentiate PLES from early cerebral ischemia, thus playing a pivotal role in treatment decisions. PLES is associated with a wider variety of conditions than has been previously reported and is not always reversible. Hyperintense DWI signal in patients with the syndrome likely marks a tissue stage of permanent brain injury.     

Prognostic factors for hearing preservation following observation-only versus stereotactic irradiation (STI) in patients with acoustic neuroma

Prognostic factors for hearing preservation following observation-only versus STI were compared in patients with acoustic neuroma. There were 48 patients with acoustic neuroma treated by fractionated STI. Between 1991 and 1997, patients were given 36 Gy in 20 fractions over 5 weeks (36 Gy/20 Fr/5 wks) to 44 Gy/22 Fr/6 wks followed by a 4 Gy boost. A linear accelerator was used for irradiation. Twenty-three patients with acoustic neuroma who were followed without any treatment (observation-only group) were selected as matched controls. The largest hearing loss was observed at the frequency of 2 kHz in the observation-only group and at 1-2 kHz in the STI group. Hearing loss at 1 kHz was more frequent in the STI group (p < 0.01). There were no significant prognostic factors which predicted hearing preservation in the observation-only group. Stereotactic irradiation has been suggested to damage to cochlear nerve function in patients whose cochlear nerve had been impaired already. Tumor control rate of STI appeared to be as good as single fraction radiosurgery rates in the literature and better than in the observation-only group. Hearing preservation rate in the STI group was as good as in the observation-only group and appeared to be better than single fraction radiosurgery. In conclusion, because there were no factors predictive of hearing preservation in the observation-only group, it is difficult to select patients for observation only. Fractionated STI is potentially the treatment of choice, resulting in the same hearing preservation rate as achieved with observation only, although longer follow-up periods are needed.     

Cervico-mediastinal recurrences of differentiated thyroid cancers: value of MRI

AIM: The aim of this study was to evaluate the ability of MRI to detect recurrent differentiated thyroid carcinomas developed in the neck or the upper mediastinum. RESULTS: MRI was performed in 25 patients, and was compared in 5 cases with surgery. In 20 cases it was compared with I-131 scintigraphy (100 mCi in 14 cases and 5 mCi in 6 cases). The sensibility, specificity and overall accuracy of MRI was respectively: 100%, 66.6%, 82.6%. COMMENTARY: MRI is a good technique to detect recurrent thyroid carcinomas. It is specially interesting to investigate patients with a biological suspicion of recurrence and a negative scintigraphy. Mediastinal localisations that cannot be detected by US can be detected by MRI.     

The value of screening for psychiatric disorders in rheumatology referrals

BACKGROUND: Musculoskeletal complaints are common and often unexplained and often lead to rheumatology referrals. The prevalence of psychiatric disease in patients with musculoskeletal complaints is unknown. OBJECTIVES: To determine the prevalence of common psychiatric disorders among patients referred to a rheumatology clinic and the likelihood of establishing a rheumatic diagnosis if a psychiatric disorder is present. DESIGN: Prospective diagnostic survey. SETTING: Two hospital-based rheumatology clinics and a general medicine clinic. PARTICIPANTS: A consecutive sample of newly referred patients (n = 185) and their rheumatologists (n = 9). INTERVENTION: Before their visit, all patients filled out a self-administered version of PRIME-MD (Primary Care Evaluation of Mental Disorders), a questionnaire that makes Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: Primary Care Version, diagnoses of depressive, anxiety, and somatoform disorders. After the visit, the study rheumatologists, who were unaware of the PRIME-MD results, completed a questionnaire regarding their diagnostic assessment. These patients were compared with 210 patients with musculoskeletal complaints who were cared for in a general medicine clinic. MAIN OUTCOME MEASURES: Psychiatric and rheumatic disorders. RESULTS: Compared with patients with musculoskeletal complaints in a general medicine clinic, patients referred to a rheumatology clinic had a higher prevalence of psychiatric disease (40% vs 29%; P = .008), had an almost 2-fold higher prevalence of anxiety disorders, and were more likely to have multiple psychiatric disorders (odds ratio = 2.70, 95% confidence interval = 1.50-5.00). The likelihood of a psychiatric disorder differed among patients with connective tissue disease, nonsystemic articular or periarticular disorders, and nonarticular disorders (27%, 38%, 55%, respectively; P = .006). In a best-fitting logistic regression model, psychiatric disorders markedly decreased the likelihood of a connective tissue disease (odds ratio = 0.24, 95% confidence interval = 0.09-0.62). CONCLUSIONS: Forty percent of patients referred to a rheumatology clinic in this study had a psychiatric disorder, and its presence predicted a lower likelihood of a connective tissue disease. Prospective studies are needed to determine if screening for psychiatric disease before referring patients with unexplained musculoskeletal complaints would reduce costs or improve recognition of potentially treatable psychiatric disorders.     

The value of screening for psychiatric disorders prior to upper endoscopy

The small subunit of bacteriophages SPP1 and SF6 terminase, G1P, share 71% identity clustered in three conserved segments (I, II, and III). Within segment I the helix-turn-helix DNA-binding domain was mapped, whereas segment III was found to be nonessential. For terminase activity, chimeric G1Ps, obtained by domain swapping between gene 1 of SPP1 and the SF6 origin (Chi1 to Chi4), were purified. The chimeric proteins behave in all respects similarly to the G1P of SPP1 or SF6. The major determinant for G1P:G1P interactions was found to lie within segment II. We showed that a G1P derivative (G1P*) lacking the 62 N-terminal residues (segment I), and Chi1 lacking the 45 C-terminal residues (segment III) interact with G1P. The N-terminal domain of G1P is necessary for terminase subunit assembly, because the large subunit of the terminase (G2P) interacts only with G1P and Chi1, but fails to do so with G1P*. These results suggest that segment III and the extended C-terminal part of SPP1 G1P do not play a major role in DNA recognition and that G1P recognizes an extended nucleotide sequence and DNA structure.     

Thalamic deactivation during early implicit sequence learning: a functional MRI study

Previous research has implicated the striatum in implicit sequence learning. However, imaging findings have been inconsistent with regard to activity within the thalamus during performance of such tasks. Contemporary models of cortico-striato-thalamic circuitry suggest opposing influences on thalamic activity; suppression of thalamic activity is mediated by the indirect pathway and enhancement is mediated by the direct pathway. Using functional magnetic resonance imaging, we studied activity within human thalamus during early and late phases of an implicit sequence learning task known to reliably recruit the striatum. Significant deactivation (decreased signal relative to a baseline condition) was observed within the thalamus during early implicit learning. This finding is consistent with models of cortico-striato-thalamic function and specifically supports a profile of early 'thalamic gating' via the indirect pathway.