Budd-Chiari syndrome: a contribution to surgical therapy

The commonest cause of Budd-Chiari syndrome is stenosis of the inferior vena cava and hepatic veins. Improved venous draining can be achieved by resection of a dorso-cranial portion of the liver and the anterior aspect of the vena cava wall. A complex case is reported.     

Application of a semi-automatic ROI setting system for brain PET images to animal PET studies

ProASSIST, a semi-automatic ROI (region of interest) setting system for human brain PET images, has been modified for use with the canine brain, and the performance of the obtained system was evaluated by comparing the operational simplicity for ROI setting and the consistency of ROI values obtained with those by a conventional manual procedure. Namely, we created segment maps for the canine brain by making reference to the coronal section atlas of the canine brain by Lim et al., and incorporated them into the ProASSIST system. For the performance test, CBF (cerebral blood flow) and CMRglc (cerebral metabolic rate in glucose) images in dogs with or without focal cerebral ischemia were used. In ProASSIST, brain contours were defined semiautomatically. In the ROI analysis of the test image, manual modification of the contour was necessary in half cases examined (8/16). However, the operation was rather simple so that the operation time per one brain section was significantly shorter than that in the manual operation. The ROI values determined by the system were comparable with those by the manual procedure, confirming the applicability of the system to these animal studies. The use of the system like the present one would also merit the more objective data acquisition for the quantitative ROI analysis, because no manual procedure except for some specifications of the anatomical features is required for ROI setting.     

Idiopathic normal pressure hydrocephalus: analysis of factors related to cerebrospinal fluid dynamics determining functional prognosis

OBJECTIVE: To examine the effect of maternal smoking on the relationship between maternal hemoglobin levels and pregnancy outcome. DESIGN: A prospective study of healthy parous women from early pregnancy and of their infants. SETTING: Three Scandinavian university hospitals covering all deliveries from well defined geographical areas. SUBJECTS: Smoking (669) and non-smoking (368) mothers, para 1 and 2 and with > or = 37 weeks of gestational length. MAIN OUTCOME MEASURES: Birth weight and placental weight. Ponderal Index and Placental Index as measures of possible discordant fetal and placental growth. RESULTS: In non-smoking mothers the hemoglobin levels in the three trimesters had no relation to birth weight. In smoking mothers a significantly lower birth weight was seen with a high hemoglobin level in the third trimester, but hemoglobin levels in early or mid-pregnancy had no association to birth weight. Smoking mothers also had a significantly greater fall in hemoglobin concentration from first to second and third trimester as compared to non-smokers although ferritin levels were similar in smokers and non-smokers, implying similar iron stores. The ratio of placental weight to the weight of the newborn was significantly higher in smokers, but no association was found to different hemoglobin levels. CONCLUSIONS: Fetal growth impairment associated with maternal smoking is even more pronounced in smoking mothers with high hemoglobin levels in late pregnancy. Smoking mothers were also found to have disproportional fetal/placental growth with relatively high placental weights. In non-smoking mothers hemoglobin levels had no relation to birthweight.     

Qualitative approach: a contribution to nursing

This paper focus on some characteristics of the qualitative methodology. Some of these methods are explored such as: participatory research, phenomenology, grounded theory and ethnography critical theory Perspectives of their utilization in nursing research are examined.     

Cervical spondylotic myelopathy: surgical results and factors affecting prognosis

OBJECTIVE: A variety of factors may affect surgical outcome in patients with cervical spondylotic myelopathy. The aim of this study is to determine these factors on the basis of preoperative radiological and clinical data. METHODS: To assess the factors affecting postoperative outcome after surgery for cervical spondylotic myelopathy, the clinical and radiological data of 27 patients with cervical spondylotic myelopathy were reviewed. Functional and neurological statuses were assessed using the Japanese Orthopaedic Association (JOA) scale modified by Benzel. In all patients, the effect of age, symptom duration, cervical curvature, presence or absence of preoperative high signal intensity within the spinal cord as revealed by T2-weighted magnetic resonance imaging, and diameters of the spinal canal and vertebral body on pre- and postoperative neurological statuses were investigated. Plain radiographs were obtained for all patients, magnetic resonance images for 21 patients (77.8%), computed tomographic scans for 13 patients (48.1%), myelograms for 6 patients (22.2%), and computed tomographic myelograms for 4 patients (14.8%). There were five patients with a JOA score of 10, six patients with a JOA score of 11, six patients with a JOA score of 12, four patients with a JOA score of 13, four patients with a JOA score of 14, one patient with a JOA score of 15, and one patient with a JOA score of 16. All patients underwent cervical laminectomies. The mean follow-up period was 54.1 months. The final neurological examinations revealed improvement in the JOA scores of 85.1 % of the patients. RESULTS: Statistical analysis of all patients revealed mean JOA scores of 12.185 +/- 1.618 and 14.370 +/- 2.15 before surgery and at final examination, respectively. The difference between the preoperative JOA score and the final JOA score was determined to be statistically significant (P < 0.0001). Statistical analyses also showed better neurological improvement in patients younger than 60 years and in patients with normal preoperative cervical lordosis. Although patients without preoperative high signal intensity of the spinal cord showed a better improvement rate than did patients with preoperative high signal intensity, the determined difference was statistically insignificant. CONCLUSION: It can be concluded that age and abnormal cervical curvature predict less postoperative neurological improvement. The presence of preoperative high signal intensity within the spinal cord may also reflect less neurological improvement.     

Cure of recurrent medulloblastoma: the contribution of surgical resection at relapse

BACKGROUND: Recurrent medulloblastoma has long been considered universally fatal. In spite of attempts to improve its treatment, only rarely have long term survivors been documented in the world's medical literature. Although the treatment of primary medulloblastoma is well established and includes surgical excision, postsurgical irradiation, and, more recently, chemotherapy, there is no established treatment for its recurrence. Current guidelines dictate the experimental use of chemotherapy, and there have been some encouraging results; yet no increase in long term survival has been documented. METHODS: This article presents a case of cured recurrent medulloblastoma in which the only intervention at the time of recurrence was surgical excision. In addition, a review of the literature is presented, which evaluates chemotherapeutic trials involving cases of recurrent medulloblastoma. RESULTS: The authors were surprised to find that the longest survivors of multiple trials had undergone reoperation at the time of recurrence. The authors' case, as well as cases described in the literature, point to a valid treatment alternative largely ignored in the management of recurrent medulloblastoma. CONCLUSIONS: Reoperation of recurrent brain tumors has received surprisingly little attention in the medical literature. Yet, as this case and a review of the literature demonstrate, this is a useful intervention.     

Immunohistochemical studies of the adult human ovary: possible contribution of immune and epithelial factors to folliculogenesis

PROBLEM: Formation of primordial follicles in adult ovaries could be a cryptic process limited to relatively small areas of the ovarian cortex and occurring during a certain stage of the menstrual cycle. Such an event may require a specific milieu provided by factors involved in developmental processes, i.e., morphoregulatory molecules and macrophages. METHOD: Adult human ovaries were investigated by immunohistochemistry for surface epithelium and granulosa cell markers (cytokeratin 18 and MHC class I), immune system-related morphoregulatory molecules (Thy-1 glycoprotein and N-CAM), and macrophage phenotypes (CD14, CD68, and MHC class II). RESULTS: In some ovaries 300-500 microns areas of surface epithelium were overgrown by tunica albuginea, descended into the stroma, and apparently fragmented into individual small (20-40 microns) follicle-like cell nests. Differentiation of the surface epithelium was accompanied by macrophages and Thy-1 glycoprotein. Small segments of surface epithelium showed N-CAM and a lacked MHC class I expression. In such segments, clear spherical germ-like cells migrated into the deeper stroma, associated with the microvasculature, and eventually aggregated with follicle-like cell nests. CONCLUSIONS: Our data suggest that surface epithelium may be involved in the formation of some primordial follicles in adult ovaries. This process, and further follicular fate, may require a precise interplay of immune system related morphoregulatory molecules and macrophages.     

Technetium-94m-teboroxime: synthesis, dosimetry and initial PET imaging studies

Technetium-94m (T1/2 = 53 min) allows the in vivo study of technetium radiopharmaceuticals with positron emission tomography (PET). PET provides a quantitative assay of radioactivity with excellent temporal and spatial resolution, revealing biodistributions that were previously available only through in vitro assay methods. Technetium-94m, produced by the proton irradiation of natural molybdenum on an 11 MeV cyclotron, was extracted with an electrochemical etching technique. Technetium-94m-pertechnetate was prepared to make the myocardial perfusion agent teboroxime in an identical manner as 99mTcO4-. The increased absorbed radiation dose requires a sevenfold reduction in administered activity compared to 99mTc-teboroxime. Eleven clinical PET studies were performed and visually compared to 13N-ammonia. The clearance half-time for 94mTc-teboroxime was approximately 8 min, with a peak myocardial extraction of approximately 3% of the injected dose into a 400-g heart. These results confirm the potential of 94mTc PET for quantitatively studying the pharmacokinetics of new, and old, technetium agents in man.     

Blunt renal traumas: contribution of spiral CT with three dimensional reconstruction to the surgical decision process?

Spiral CT has proved to be a valuable tool by providing various kinds of three-dimensional (3D) images of the studied structures. Such 3D images, which offer a more realistic depiction of the lesions, could be of interest for surgeons who are attempting to treat conservatively blunt abdominal traumas and lead to less inappropriate triage between conservative and operative management particularly for renal trauma. A good working relationship between surgeons and radiologists allowed us to perform an early follow-up 3D spiral CT on a commercially available spiral CT scanner. In the first adult patient, the 3D CT demonstrated minor spleen injury associated with severe lacerations of the left kidney with complete separation of the kidney lower pole. A delayed partial lower nephrectomy was performed. For the second 12-year-old patient presenting with severe spleen trauma and macroscopic hematuria, the 3D CT accurately documented the spleen and renal lesions that were safely amenable to nonoperative treatment. For hemodynamically stable patients, 3D CT is a potentially helpful addition to conventional axial CT for quantifying blunt renal traumas and for making the strategic choice between nonoperative, emergency or delayed surgical treatment.     

Exercise and oxygen inhalation in relation to prognosis of chronic obstructive pulmonary disease

We examined the relationship between prognosis and arterial blood gases during exercise and 100 percent oxygen inhalation in 54 patients randomly selected from 119 background patients with chronic obstructive pulmonary disease (COPD). Light exercise was performed and 100 percent oxygen was inhaled during clinically stable stages. By four years after these tests, 19/54 patients had died from respiratory failure. All subjects had similar physical and clinical features. Survivors had significantly higher PaO2 during air breathing than nonsurvivors; in nonsurvivors, FEV1 and MVV were significantly lower, and heart rate and RV/TLC were significantly higher. Exercise PaO2 of nonsurvivors decreased by 6.7 mm Hg, whereas that of survivors did not change. The P(A--a)O2 did not change in survivors and nonsurvivors during exercise, but in survivors it was significantly smaller. Mean PaO2 after 100 percent oxygen was significantly lower, and PaCO2 was significantly higher in nonsurvivors than in survivors, and in nonsurvivors the increase in PaO2 during 100 percent oxygen correlated positively with the time between first admission and death. These results indicate that patients with combination of resting arterial hypoxemia, worsened hypoxemia during stepped-up exercise, and lesser degree of arterial oxygenation and increased PaCO2 during 100 percent oxygen inhalation may have a poor prognosis.     

The prognosis of a protracted course of pseudotuberculosis in chronic opisthorchiasis

Forty-five pseudotuberculosis patients with concomitant chronic opisthorchiasis were examined at the peak of infection and in early convalescence, as were 30 patients with chronic opisthorchiasis and 30 normal subjects. The immunologic status of pseudotuberculosis patients coursing in the presence of chronic opisthorchiasis was found changed. Reduction of B lymphocyte counts by 1.7 times, of absolute theophyllin-resistant counts by 1.6 times, and of the relative theophyllin-resistant lymphocyte counts by 2 times and elevated levels of circulating immune complexes (by 3 times) and of IgE (by 3.5 times) vs. the norm in the early periods of the disease predict a protracted course of pseudotuberculosis in the presence of chronic opisthorchiasis.     

Validation therapy: a review of its contribution to dementia care

There has been a great deal of interest in validation therapy (VT), an interactive technique and group therapy for people who are disoriented. This article reviews the strengths and development of VT and acknowledges Naomi Feil's contribution to the care of those with dementia. Techniques for communicating with people who are dysphasic are described, as are therapeutic interventions which address the devastating effects of memory loss on the sufferers' sense of self and identity.     

p53 expression in B-cell chronic lymphocytic leukemia: a marker of disease progression and poor prognosis

We have analyzed by immunocytochemistry (ICC) the frequency of p53 protein expression in 181 cases of B-cell chronic lymphocytic leukemia (CLL) followed at a single institution to assess the relationship between p53 and the clinical and morphological features of the disease, as well as the possible involvement of this protein in the pathogenesis of the more aggressive forms of CLL. The overall frequency of p53 protein positivity in CLL was 15% (27 of 181 cases). There were no significant differences in age, sex, absolute lymphocyte count, or lymphocyte doubling time between p53-positive and -negative patients. By contrast, p53-positive patients had a significantly higher percentage of prolymphocytes (P = .002) and a significantly lower percentage of residual CD3-positive T lymphocytes (P = .0001). No correlation was found between the percentage of p53-positive cells and the percentage of cells in cycle assessed by the monoclonal antibody Ki-67. When the percentage of p53 positivity was correlated with the clinical stage of the disease, the proportion of p53-positive cases increased significantly from Binet's stage A (8 of 108; 7.4%), to stage B (12 of 49; 24.4%) and C (7 of 24; 29.2%) (P = .002). p53 positivity correlated also with the phase of the disease, showing a low expression at diagnosis (8 of 112; 7.1%) and a significantly higher expression in patients studied during the course of the disease (7 of 35; 20%) and, to a further extent, with disease progression (12 of 34; 35.3%) (P = .0001). The association of p53 protein expression with mutations in the gene was confirmed by direct sequence of the entire cDNA in 15 of the 17 ICC positive cases tested (88%). A significantly shorter treatment-free interval from diagnosis (P = .003) and a poorer response to therapy (P = .007) was observed in p53-positive compared with p53-negative patients. Overall survival from the time of diagnosis, as well as from the time of p53 protein analysis, was significantly shorter in patients with p53 protein expression (P = .03 and .0001, respectively). Moreover, in multivariate analysis, p53 expression and stage C were independently associated with a short survival. The results of this study indicate that in CLL the expression of the p53 protein, analyzed by a simple and reliable immunocytochemical method, is strongly associated with p53 gene mutations, a morphological variant (CLL with >10% prolymphocytes), advanced clinical stage, progressive disease, poor response to therapy, and short survival.