Mitochondrial DNA variants as genetic risk factors for Parkinson disease

BACKGROUND AND PURPOSE

Investigation of the relationship between mitochondrial DNA (mtDNA) variants and Parkinson disease (PD) remains an issue awaiting more supportive evidence. Moreover, an affirming cellular model study is also lacking.

METHODS

The index mtDNA variants and their defining mitochondrial haplogroup were determined in 725 PD patients and 744 non-PD controls. Full-length mtDNA sequences were also conducted in 110 cases harboring various haplogroups. Cybrid cellular models, composed by fusion of mitochondria-depleted rho-zero cells and donor mitochondria, were used for a rotenone-induced PD simulation study.

RESULTS

Multivariate logistic regression analysis revealed that subjects harboring the mitochondrial haplogroup B5 have resistance against PD (odds ratio 0.50, 95% confidence interval 0.32-0.78; P = 0.002). Furthermore, a composite mtDNA variant group consisting of A10398G and G8584A at the coding region was found to have resistance against PD (odds ratio 0.50, 95% confidence interval 0.33-0.78; P = 0.001). In cellular studies, B4 and B5 cybrids were selected according to their higher resistance to rotenone, in comparison with cybrids harboring other haplogroups. The B5 cybrid, containing G8584A/A10398G variants, showed more resistance to rotenone than the B4 cybrid not harboring these variants. This is supported by findings of low reactive oxygen species generation and a low apoptosis rate in the B5 cybrid, whereas a higher expression of autophagy was observed in the B4 cybrid particularly under medium dosage and longer treatment time with rotenone.

CONCLUSIONS

Our studies, offering positive results from clinical investigations and cybrid experiments, provide data supporting the role of variant mtDNA in the risk of PD.

Expression of high-mobility group box protein 1 in diabetic foot atherogenesis

The role of high mobility group box 1 (HMGB1) has been demonstrated in stroke and coronary artery disease but not in peripheral arterial occlusive disease (PAOD). The pathogenesis of HMGB1 in acute and chronic vascular injury is also not well understood. We hypothesized that HMGB1 induces inflammatory markers in diabetic PAOD patients. We studied 36 diabetic patients, including 29 patients with PAOD, who had undergone amputation for diabetic foot and 7 nondiabetic patients who had undergone amputation after traumatic injury. Expression of HMGB1 and inflammatory markers were quantified using immunohistochemical staining. Mitochondrial DNA copy number was quantified using real-time polymerase chain reaction. Compared with that in the traumatic amputation group, HMGB1 expression in vessels was significantly higher in the diabetes and diabetic PAOD groups. In all subjects, arterial stenosis grade was positively correlated with the expression levels of HMGB1, 8-hydroxyguanosine, malondialdehyde, vascular cell adhesion molecule 1, and inflammatory markers CD3, and CD68 in both the intima and the media of vessels. Furthermore, HMGB1 expression level was positively correlated with 8-hydroxyguanosine, vascular cell adhesion molecule 1, nuclear factor-kB, CD3, and CD68 expression. Within the PAOD subgroup, subjects with HMGB1 expression had higher expression of the autophagy marker LC3A/B and higher mitochondrial DNA copy number. HMGB1 may be an inflammatory mediator with roles in oxidative damage and proinflammatory and inflammatory processes in diabetic atherogenesis. Moreover, it may have dual effects by compensating for increased mitochondrial DNA copy number and increased autophagy marker expression.

Voriconazole in the treatment of fungal eye infections: a review of current literature

BACKGROUND

Voriconazole has an important role to play in the prophylaxis and management of fungal endophthalmitis and keratitis. New-generation triazoles, including voriconazole, posaconazole and ravuconazole, have been shown in laboratory studies and clinical experience to have very good safety profiles with few side effects. Fungal eye infections, while not common in temperate climates, have been notoriously difficult to diagnose and treat, and generally result in protracted therapy with poor final outcomes. Current treatment options are far from optimal.

AIMS

This paper will review studies and clinical case reports published in the ophthalmic literature that address the safety of these drugs in the eye, penetration and concentration in ocular tissues and media, and efficacy in treating common pathogens implicated in fungal keratitis and endophthalmitis.

CONCLUSIONS

Over 40 clinical case reports of treatment with voriconazole suggest that it may be used safely and effectively against a broad range of fungal pathogens.

Upregulation of nitric oxide synthase II contributes to apoptotic cell death in the hippocampal CA3 subfield via a cytochrome c/caspase-3 signaling cascade following induction of experimental temporal lobe status epilepticus in the rat

Status epilepticus results in preferential neuronal cell loss in the hippocampus. We evaluated the hypothesis that the repertoire of intracellular events in the vulnerable hippocampal CA3 subfield after induction of experimental temporal lobe status epilepticus entails upregulation of nitric oxide synthase II (NOS II), followed by the release of mitochondrial cytochrome c that triggers the cytosolic caspase-3 cascade, leading to apoptotic cell death. In Sprague-Dawley rats, significant and temporally correlated upregulation of NOS II (3-24h), but not NOS I or II expression, enhanced cytosolic translocation of cytochrome c (days 1 and 3), augmented activated caspase-3 in cytosol (days 1, 3 and 7) and DNA fragmentation (days 1, 3 and 7) was detected bilaterally in the hippocampal CA3 subfield after elicitation of sustained seizure activity by microinjection of kainic acid into the unilateral CA3 subfield. Application bilaterally into the hippocampal CA3 subfield of a selective NOS II inhibitor, S-methylisothiourea, significantly blunted these apoptotic events; a selective NOS I inhibitor, N(omega)-propyl-l-arginine or a potent NOS III inhibitor, N(5)-(1-iminoethyl)-l-ornithine was ineffective. We conclude that upregulation of NOS II contributes to apoptotic cell death in the hippocampal CA3 subfield via a cytochrome c/caspase-3 signaling cascade following the induction of experimental temporal lobe status epilepticus.

Solitary intraventricular tuberculoma in adults

Intracranial tuberculoma is typically located in the parenchyma. Lesions limited to the ventricular system are uncommon. It is difficult to make a differential diagnosis from other lesions if no systemic tuberculosis is present. This study investigates a case of solitary intraventricular tuberculoma in a 19-year-old female patient with an initial clinical symptom of progressive headache. Cranial computed tomography revealed a strongly enhanced lesion in the lateral ventricle. Histopathology of the tumor demonstrated chronic inflammation, caseous necrosis, epithelioid cells and Langhans' giant cell. The culture study grew M. Tuberculosis. Solitary intraventricular tuberculoma in adults is extremely rare. Medical treatment is the preferred management method of this disease, and surgical intervention should be considered in certain situations.

Generalized argyria in two chronic hemodialysis patients

Silver can be absorbed through ingestion, topical administration, or inhalation. Generalized argyria results from deposition of silver in the skin, nails, mucous membranes, and internal organs and is characterized by a diffuse bluish-gray discoloration in sun-exposed areas. We report two cases of generalized argyria in patients on maintenance hemodialysis (HD) therapy for more than 15 years. They presented with diffuse hyperpigmentation of the face that was mistaken to be related to uremia and bluish-gray discoloration of all nails believed to be cyanosis. Histopathologic examination of skin biopsy specimens showed characteristic findings of argyria, which was further confirmed by radiograph microanalysis. Their serum silver levels were also elevated. No definite silver source could be determined. However, their argyria might be related to their long-term HD therapy because (1) they had been on HD therapy for more than 15 years and the discoloration appeared several years afterward, and (2) the water used for HD was not well processed in the early 1980s in TAIWAN: Argyria should be suspected in chronic HD patients presenting with a diffuse bluish-gray discoloration of the skin and nails and evaluated carefully by skin biopsy.

Prophylactic esmolol infusion for the control of cardiovascular responses to extubation after intracranial surgery

INTRODUCTION

Emergence from general anaesthesia and extubation are often accompanied by significant surges in heart rate and blood pressure. To document these changes and the efficacy of low-dose beta-blocker infusions in ameliorating these rises, we undertook a descriptive dose-ranging study comparing the use of esmolol to placebo in patients emerging from neuro-anaesthesia.

MATERIALS AND METHODS

Thirty-six patients undergoing intracranial surgery were randomised to receive saline, esmolol 100 micrograms/kg/min or 200 micrograms/kg/min infusions. The number of patients developing severe hypertension or tachycardia in each group was compared using Fisher's exact test.

RESULTS

Systolic blood pressure (SBP) and heart rate (HR) increased in all 3 groups during emergence and peaked at extubation. The proportion of patients with severe tachycardia or hypertension was reduced from 92% in the placebo group to 40% (P = 0.02) and 8% (P = 0.001) in the low and intermediate dose esmolol groups, respectively. Results were better in the intermediate dose group but the difference was not statistically significant. Two patients from the esmolol infusion groups required supplemental medication for bradycardia.

CONCLUSION

Severe hypertension or tachycardia occurs in 92% of patients during extubation following neuro-anaesthesia and warrants the consideration of routine prophylaxis. Prophylactic esmolol infusion for the control of haemodynamic disturbances during extubation is feasible and safe. A modest level of obtundation is evident at 100 micrograms/kg/min but a rate of 200 micrograms/kg/min may prove to be more effective.

Mitochondrially targeted antioxidants and thiol reagents

Mitochondrial oxidative damage and dysfunction contributes to a number of cell pathologies. To investigate how this damage affects cell function we have developed mitochondrially targeted antioxidants and thiol reagents by covalently linking them to lipophilic cations. The cation drives the selective accumulation of these reagents into mitochondria within cells where the antioxidants decrease oxidative damage and the thiol reagents enable measurement of the redox status of thiol proteins. In conjunction with cell and animal models of apoptosis, oxidative damage, and nitric oxide signaling, these molecules may provide new insights into the roles of mitochondria in human pathologies.

Unusual dilatation of Virchow-Robin spaces: case report

Virchow-Robin spaces normally surround the perforating arteries that enter the brain. These spaces are a well-defined sites where immunological reactions take place and they may have implications in the pathogenesis of a number of neuropathological conditions. We present the case of a 52-year-old woman who had a history of complex partial seizures for 30 years. Her routine neurological examinations and mini-mental tests had normal results. Magnetic resonance images of this patient revealed unusual widening of the Virchow-Robin spaces up to 1.5 cm in diameter along the perforating medullary arteries in the white matter, more so in the left hemisphere. Although it has been concluded that these large spaces are a phenomenon of the normal aging brain and are unrelated to neurological diseases, our patient had had epileptic seizures for 30 years. The large Virchow-Robin spaces of our patient might have been an incidental radiologic finding. Their pathogenesis remains unclear, and their possible clinical relationship to epilepsy deserves further pathological studies.

Hemodynamic abnormalities in sodium monofluoroacetate intoxication

Hypotension is one of the most important predictors of mortality in sodium monofluoroacetate (SMFA) intoxication. This paper reports the hemodynamic response in one fatal and another survival case of SMFA intoxication. Despite correction of hypovolemia and with inotropic support, the patients remained in shock. Hemodynamic observations have provided evidence that shock after SMFA intoxication is due to diminished systemic vascular resistance and increased cardiac output. This is the first report in which such an invasive hemodynamic investigation has been recorded in a clinical case of SMFA intoxication.

Osmotic demyelination syndrome with two-phase movement disorders: case report

Osmotic demyelination syndrome (ODS) is characterized by regions of demyelination throughout the brain, which are most prominent in the pons. This demyelinating disease is associated with electrolyte disturbances and typically occurs in patients who are alcoholic or malnourished. Movement disorders are not frequently recognized in patients with ODS. This report describes a 22-year-old woman with ODS after correction of profound hyponatremia. The main neurologic symptom was two-phase movement disorder. First, she had acute onset dystonia, then the movement disorder transformed to generalized rigidity and tremors in the delayed second phase. Magnetic resonance imaging in the first phase revealed demyelinating lesions in the central pons, bilateral thalami and basal ganglia. In the second phase, the previous myelinolysis had been partially resolved. The clinical course of the two-phase movement disorder did not correlate with the resolving feature of neuroradiologic findings. During the second-phase movement disorder, the patient had a good response to propranolol and trihexyphenidyl.

Lhermitte-Duclos disease: first report in Taiwan

We report a case of Lhermitte-Duclos disease (dysplastic gangliocytoma of the cerebellum), an uncommon disorder of uncertain pathogenesis characterized by disarrangement of the normal cerebellar laminar cytoarchitecture. A 40-year-old man was admitted because of vomiting and syncope of a few days' duration, and a 2-month history of intermittent headaches and unsteady gait. A computed tomographic scan of the patient's head showed obstructive hydrocephalus due to displacement of the fourth ventricle by a large, nonenhancing cerebellar mass. The magnetic resonance images of the brain also revealed a space-occupying lesion within the right cerebellum with unusual septation. After surgery, the histologic examination confirmed the diagnosis of Lhermitte-Duclos disease. This is the first report of Lhermitte-Duclos disease in Taiwan.

Effect of insulin-like growth factors (IGFs) and IGF-binding proteins on in vitro sperm motility

OBJECTIVE

Previous studies have shown that exogenous growth hormone (GH) produces increases in sperm motility when given to subfertile men. Previous studies have also demonstrated the presence of IGFs and IGFBPs in seminal plasma. We have therefore investigated the effects of insulin-like growth factor-I (IGF-I), IGF-II, IGF-binding protein 2 (IGFBP-2) and intact IGFBP-3 on in vitro sperm motility.

DESIGN AND METHODS

Using computer-aided sperm analysis, we investigated the effects of IGFs and IGFBPs on the in vitro sperm motility parameters: curvilinear velocity (CV), progressive velocity (PV), linearity (Ln), straightness (St), amplitude of lateral head movement (ALH), and beat frequency (BF). Washed motile sperm selected by the 'swim-up' method, from normozoospermic samples, were incubated at 37 degrees C in 5% CO2 in air with IGF-I, IGF-II, IGFBP-2, IGFBP-3, or control Earle's media, and were examined at time 0 and after 60 min incubation. Changes in motility parameters after 60 min incubation were compared with controls by analysis of variance (ANOVA).

RESULTS

Compared to controls, statistically significant changes occurred at time 60 min after incubation: IGF-I decreased CV and ALH significantly (P < 0.05), but IGFBP-3 increased Ln, St, BF, and decreased ALH significantly (P < 0.05). In contrast, IGF-II, IGFBP-2, and a combination of IGF-I/IGFBP-3, had no significant effects.

CONCLUSIONS

IGF-I and IGFBP-3 have differing and opposing effects on in vitro sperm motility parameters and thus may have a role in modulating in vivo sperm motility.

Enhanced cervical MRI in identifying intracranial dural arteriovenous fistulae with spinal perimedullary venous drainage

Diagnosis of an intracranial dural arteriovenous fistula (DAVF) with spinal perimedullary venous drainage is challenging because the presenting symptoms are usually related to dysfunction of the spine, not of the brain. Repeated spinal angiograms are usually performed before the diagnosis is finally made by cerebral angiography. We report two cases of intracranial DAVFs with spinal perimedullary venous drainage. In both cases contrast-enhanced cervical MRI demonstrated dilated lower brainstem and upper spinal veins, which, we believe, is a good indicator of the existence of such drainage. We suggest that, in cases with perimedullary serpentine enhancement on thoracic or lumbar MR images, additional Gd-enhanced cervical spinal MR imaging should be performed. The simple process of tracing the veins upwards may avoid a lot of unnecessary examinations and delay in the diagnosis.

Structuring a safer donor-replacement program

BACKGROUND

Replacement donors are more likely than volunteer donors to have positive or abnormal tests for transfusion-transmissible disease. In an effort to increase the donor pool, workers sought to identify a safer replacement-donor subgroup that may be acceptable for routine donations.

STUDY DESIGN AND METHODS

In a retrospective review and cohort study, the replacement-donor effect was separated from the new-donor effect. The relative effect the replacement donor has on the risk of transfusion-transmissible diseases, donor retention, and frequency of returning donations was then quantified by comparison against the effect of repeat volunteer donors.

RESULTS

The replacement donor had 3.1 times the risk and 0.72 times the donor retention rate and made 0.81 times as many returning donations as the repeat volunteer donor. The figures for the new-donor effect were similar. The two risks were additive, making a new replacement donor particularly hazardous. If replacement donations only from repeat replacement donors were considered, the donor risk and the number of donations per returning donor were made comparable to those for the general (combined) volunteer donor.

CONCLUSION

The negative effect of the replacement donor is similar in magnitude to that of the new volunteer donor. A replacement-donation program targeting repeat replacement donors has an acceptable risk profile and may be a valuable adjunct to the collection of blood from general volunteer donors.

Preoperative embolization of meningiomas: comparison of superselective and subselective techniques

We retrospectively compared the efficacy of preoperative superselective and subselective embolization for intracranial meningiomas. Between January and December 1996, 22 patients (7 men, 15 women, mean age 51 +/- 15.5 yr) underwent superselective embolization with 45 to 150 mm polyvinyl alcohol particles after superselective catheterization of the feeding vessels with a microcatheter system. Another 30 patients (12 men, 18 women, mean age 50 +/- 12.9 yr) underwent subselective embolization between January and December 1995 with 150 to 300 mm Gelfoam particles after catheterization of the terminal external carotid artery just proximal to the orifice of the maxillary artery with a 4- or 5-F angiocatheter. The mean intraoperative blood loss (918 versus 1450 mL, p < 0.05), amount of blood transfused (4.9 versus 7.5 units, p = 0.09), and surgical resection time (422 versus 529 min, p < 0.05) were all lower in the superselective group than in the subselective group, while the occurrence of fresh ischemic necrosis (59% versus 53%, p = 0.68), hemorrhage (77% versus 60%, p = 0.19), and embolic material (55% versus 13%, p < 0.05) on pathologic examination were higher in the superselective group. No procedure-related complications occurred in the superselective group, whereas two patients in the subselective group had postoperative scalp necrosis. Our findings show that superselective embolization is more effective than subselective embolization for preoperative endovascular devascularization of meningiomas, with significant reductions in intraoperative blood loss and surgery time. Preoperative embolization of meningiomas, if indicated, should be done with the superselective technique whenever feasible.

Reoperation for recurrent trigeminal neuralgia after microvascular decompression

BACKGROUND

Microvascular decompression (MVD) is an effective technique for those who have trigeminal neuralgia (TN) but cannot tolerate, or show no response to medicine. Though the initial success rate is high, some patients may develop severe recurrent neuralgia, especially after a longer period of follow-up. The efficacy of reoperation needs to be evaluated. To know the possible risk factors of recurrence after initial MVD is mandatory to the management of recurrent TN.

METHODS

Among the 80 cases of TN treated with MVD, five cases showed severe recurrent symptoms within a follow-up period from 9 months-4 years. The symptoms recurred on the same side of the face, and were unresponsive to medical treatment. Brain computed tomography (CT) and magnetic resonance imaging (MRI) may reveal the etiology of recurrence. Repeat decompression of the trigeminal nerve was the main goal of reoperation, which was done via a suboccipital approach.

RESULTS

Over the past 17 years, 80 MVDs for TN have been performed at Chang Gung Memorial Hospital. There were five cases of serious postoperative recurrence, which could not be relieved by medicine. Recurrence occurred 1 day-12 months after the initial surgery. Three cases were due to vascular compression, while two were caused by the local effect of Teflon felt. Reoperation produced complete remission in four patients, and partial remission in one.

CONCLUSIONS

An increasing number of patients may experience severe recurrent TN after initial MVD during a long period of follow-up. Reoperation is safe and beneficial for these patients, but the results are dependent on the etiology of the recurrence. Further vascular compression of the trigeminal nerve can be relieved by MVD. Otherwise, in cases of severe adhesion caused by Teflon, complete microneural lysis can achieve satisfactory results.

Thrombolytic therapy for mitral valve thrombosis

A 44-year-old man with a St. Jude mitral valve was admitted because of progressive pulmonary edema. He was diagnosed with prosthetic heart valve thrombosis (PHVT) based on the findings of "muffled" prosthetic valve clicks. Doppler echocardiographic evidence of severe mitral stenosis and transesophageal echocardiographic evidence of limited mitral valve motility. Because the patient hesitated to undergo our recommended surgical treatment, he was immediately treated with intravenous recombinant tissue plasminogen activator (100 mg over 3 h) followed by heparinization. Two hours after the thrombolytic therapy, the prosthetic valve clicks became clearly audible and his congestive symptoms were dramatically improved. Follow-up echocardiography no longer-showed significant mitral valve obstruction. A transient cerebral ischemic attack occurred at the end of thrombolytic therapy but there were no neurologic sequalae. The patient, on warfarin therapy, was well at follow-up 8 months after discharge. Surgical intervention has long been the standard therapy for patients with PHVT. Our case experience suggests that thrombolytic therapy may be considered as an effective alternative to surgical intervention for selected patients with PHVT. In this report, we also review the current literature regarding the indications, effectiveness and safety of thrombolytic therapy in PHVT.

The erythrocyte cell hemoglobin distribution width segregates thalassemia traits from other nonthalassemic conditions with microcytosis

Red cell heterogeneity, as represented by the red cell distribution width (RDW), can be used to distinguish thalassemia traits from iron deficiency. Two other indices of heterogeneity, the hemoglobin distribution width and the cell hemoglobin distribution width (CHDW), are also available. In addition, the CHDW may reflect the process of cell hemoglobinization more accurately than does the RDW. In this study, recursive partitioning methods were used to compare the ability of these three indices to discriminate between thalassemia traits and other nonthalassemic conditions among hospital patients who had microcytosis. The data indicate that the CHDW can segregate patients who have either iron replete or iron deficient nonthalassemic conditions from those who have thalassemia traits. A CHDW level of less than 3.05 correctly discriminated 78.4% of patients in a mixed hospital sample. A CHDW/RBC ratio of 0.57 improved the segregation further, with a sensitivity of 79.2% and a specificity of 88.5% for the identification of a thalassemia trait.

Effect of growth hormone therapy in men with severe idiopathic oligozoospermia

Some studies have suggested that growth hormone (GH) may enhance folliculogenesis in women, and similarly may enhance spermatogenesis in men with hypogonadotrophic hypogonadism. In this prospective open-controlled pilot study, we investigated the effect of daily subcutaneous GH for 5 months in 12 endocrinologically normal men with severe idiopathic oligozoospermia (< 10 million/ml). All the men had normal karyotype and endocrine tests, including a GH response of > 20,000 mU/l to insulin hypoglycaemia. Nine men with similar sperm counts acted as controls. During treatment, each patient was examined monthly, asked for side effects and had glycosylated haemoglobin, glucose and blood counts monitored. Five semen samples were obtained in the 4 months before treatment, two samples per month during treatment and three samples after stopping treatment. The mean insulin-like growth factor I (IGF-I) was normal before treatment and 1 month after ending treatment, at 206 and 182 micrograms/l, respectively, but increased significantly during treatment to 444 micrograms/l (p < 0.0001, ANOVA). The mean (SD) sperm counts were 2.6 (2.5), 2.5 (3.7) and 2.3 (2.1) million/ml before, during and after GH treatment, respectively, and did not show any statistically significant differences (ANOVA). We conclude that GH does not increase or decrease sperm counts in men with severe idiopathic oligozoospermia.

Laparoscopic ovariopexy before irradiation for medulloblastoma

Ovarian preservation before abdominal irradiation may be recommended for young patients with various types of invasive cancer. The most common site for ovarian transposition is just below the iliac crest or posterolateral to the uterus. Here, we demonstrate laparoscopic ovariopexy with an automatic stapling device to transpose the ovaries to an uncommon site, i.e. lower anterolateral abdomen, in a patient with medulloblastoma prior to her receiving irradiation of the craniospinal axis. The anterolateral transposition of the ovary not only kept it away from the irradiated field but allowed it also to be shielded by the uterus. Thus, ovarian function could be well preserved.

Delayed intracerebral hematoma caused by traumatic intracavernous aneurysm: case report

Although delayed intracerebral hematomas from head injury are not uncommon, they are extremely rare when they are caused by extradural (extracranial) pseudoaneurysms of the internal carotid artery in the cavernous sinus. The case of a 33-year-old man who sustained a delayed frontal intracerebral hematoma from a traumatic intracavernous aneurysm 32 days after a head injury is presented. Posterior frontal base fractures accounted for monocular blindness and injury over the anterior siphon of the intracavernous carotid artery, which resulted in the formation of a pseudoaneurysm inside the sphenoid sinus. Subsequently, the cranial base fractures with secondary defects provided a route for the pseudoaneurysm to rupture intracranially and also accounted for intractable cerebrospinal fluid rhinorrhea and pneumocephalus after surgical treatment for the pseudoaneurysm and the intracerebral hematoma.

Combination chemotherapy with carmustine and cisplatin before, during, and after radiotherapy for adult malignant gliomas

Twenty-two patients, aged 16 to 67, who had malignant gliomas after surgical resection were treated with carmustine and cisplatin intravenous infusion before, during, and after radiotherapy. All patients had subtotal or total resection, or biopsy as the initial procedure. Twenty-one patients who had at least 2 cycles of chemotherapy and finished the whole course of radiotherapy were considered to be evaluable for responses. Among them, 5 had glioblastoma multiforme, 16 had anaplastic astrocytoma. The median time to tumor progression was 35 weeks (range 12-130 weeks) and median survival time was 66 weeks (range 10-156 weeks). Early progression occurred more frequently in patients with biopsy only and subtotal resection, and in patients with glioblastoma than in those with anaplastic astrocytoma. This combined modality treatment program was associated with reversible hematologic toxicity which was severe in 2 patients, and with ototoxicity in 1 patient, nephrotoxicity in 2 patients. Combination of carmustine and cisplatin with cranial irradiation for malignant gliomas is moderately toxic and appears to offer no obvious survival advantage compared with radiation therapy plus BCNU alone.

Chylothorax after endoscopic sympathectomy: case report

Endoscopic sympathectomy is a new trend for the treatment of hyperhidrosis palmaris. It is a simple and effective technique; however, it carries some recognized risks such as Horner's syndrome and pneumohemothorax. We recently encountered a case complicated by the development of a chylothorax. The patient was a 23-year-old healthy women with profuse palmar sweating. She developed an intractable dry cough after a transthoracic endoscopic sympathectomy. A chest x-ray revealed a left pleural effusion. A chylous effusion was found after thoracentesis and fluid analysis. The pleural effusion resolved after chest tube drainage and diet control. Although endoscopic sympathectomy is a simple and quick procedure, unusual complications, such as chylothorax, may occur. Appropriate early recognition and treatment can prevent a disastrous result.

[Unspecified subarachnoid hemorrhage in Taiwan]

We report the epidemiological and clinical features of unspecified subarachnoid hemorrhage by reviewing the literature published in Taiwan. Data from stroke registry from January 1988 to June 1992 showed that 4.9% of 23910 acute strokes were diagnosed as subarachnoid hemorrhage; in about half of them the cause of hemorrhage was not specified due to lack of confirmatory diagnostic examinations or to rapid deterioration of consciousness subsequent to bleeding that made angiography unapplicable during hospitalization. The age distribution, sex ratio, clinical profiles and associated risk factors in this group of patients were similar to those in the group of aneurysmal rupture. Therefore, the majority of patients categorized in the group of unspecified subarachnoid hemorrhage very likely had aneurysmal ruptures. The causes of subarachnoid hemorrhage were more frequently undetermined in hospitals where neuroradiological as well as neurosurgical facilities and staff were not immediately available, and also in patients whose clinical condition was poor on arrival at the hospital or who deteriorated rapidly after the onset. These two facts may partly explain the higher case-fatality rate and poorer prognosis in patients whose causes of subarachnoid hemorrhage were undetermined and effective surgical treatment could not be done.

Surgical treatment for ossification of the posterior longitudinal ligament of the cervical spine

Ossification of the posterior longitudinal ligament (OPLL) is a degenerative disease of the spine, usually found in the cervical vertebrae. Most symptomatic patients present with a myelopathy or myeloradiculopathy. Surgical decompression is the preferred treatment. The choice of operative approach, anterior or posterior, is still controversial. From January 1986 to June 1992, 20 patients with this condition received operations at Chang Gung Memorial Hospital. The clinical manifestations and the results of treatment are analysed. The ideal surgery seems to be the anterior approach with bone fusion. If, however, the OPLL involves more than three segments, the posterior approach with an expansive laminoplasty would be the better alternative technique.

Analysing a mental health survey by chi-squared automatic interaction detection

Based on a mental health survey conducted in 1987 by the Singapore Association for Mental Health, an exploratory statistical technique CHAID (Chi-Squared Automatic Interaction Detection), which is an offshoot of AID (Automatic Interaction Detection) designed for a categorical dependent variable, was employed to establish the characteristics of people who were vulnerable to mental problems in Singapore. Of the sixteen predictors considered, five were found to play significant roles in identifying the various vulnerable groups. They were the respondent's perception of his or her own health, the number of problems encountered during the four weeks before the survey, whether experiencing a depression or not during the four weeks prior to the survey, the respondent's perception of family support and the number of life events in the past six months before the survey, summarised into a weighted score. The dendrogram obtained from CHAID was very useful in displaying the structure of the relationship of the predictors with mental health. Examining the dendrogram, one can easily classify the various vulnerable groups by tracing each of the terminal groups to the root of the tree.

The expectant treatment of "asymptomatic" supratentorial epidural hematomas

Seventy-four patients with a traumatic epidural hematoma (EDH) and a Glasgow Coma Scale score of more than 12 received expectant treatment; 14 subsequently underwent surgical evacuation of the EDH. A patient with initial brain computed tomograms (CT) showing an EDH volume of more than 30 ml, a thickness of more than 15 mm, and a midline shift beyond 5 mm tended to require surgery within 3 days of the injury when the brain had exhausted its compensatory mechanism and yielded to the expanding EDH. After the 3-day period, in the absence of neurological symptoms, the presence of the EDH may not be an indication for surgical evacuation or hospitalization beyond 7 days. In our patients, the presence of a skull fracture in the temporal bone, the heterogeneous density of the EDH in the CT scan, or the 6-hour period between the CT study and the injury did not significantly increase the failure rate of nonsurgical treatment. Although a zero mortality was achieved in this series, these guidelines may not be applicable to the management of an infratentorial EDH.

Effects of enhanced calling efforts on response rates, estimates of health behavior, and costs in a telephone health survey using random-digit dialing

Public health researchers frequently rely on random-digit dialing (RDD) telephone surveys in monitoring trends in health behavior and evaluating health promotion interventions. RDD response rates have declined during the past decade, and cost-effective methods to increase response rates are needed. The authors evaluated two levels of enhanced calling efforts in an RDD survey of cancer-related health behavior in the State of Washington. The first level of enhanced calling effort was 1 month after 11 original calling attempts to a household, when the authors attempted up to 11 recalls. The second level was 6 months after the first answered call, when the authors recalled those persons who could not be interviewed. Enhanced calling efforts increased the overall survey response rate by 11 percent. Nine percentage points of the increase were attributable to call backs. There were demographic differences among the participants reached at different levels of calling effort, but no consistent associations of level of calling effort with health behavior related to alcohol use, smoking, diet, or health screening. Marginal costs for interviews completed with enhanced calling efforts were about 50 percent higher than costs for interviews reached in the first 11 calls. The authors concluded that enhanced calling efforts may be justified, because they increase confidence in the generalizability of survey results. However, the authors found very little change in survey results by including interviews from persons who were difficult to reach and to interview.

Intraventricular neurocytoma: four cases report

Intraventricular neurocytoma, a newly identified disease entity with probably not so rare incidence, has several distinctive clinico-pathological characteristics. Four cases are presented. As in the other cases reported in the literature [1-7], the characteristic features are young age, location close to the junction of the septum pellucidum and foramen of Monro, and well-differentiated neuronal origin pathologically.

Spontaneous intracerebral hematoma from occult carotid-cavernous fistula during pregnancy and puerperium. Case report

In most cases, intracerebral hemorrhage during pregnancy or puerperium results from cerebral aneurysms or arteriovenous malformations. The authors present a case of a 30-year-old woman whose symptoms from a traumatic carotid-cavernous fistula had completely resolved 1 1/2 years after the event, but recurred 4 years later, causing two hemorrhages during pregnancy (33rd and 35th week of gestation) and one during the postpartum period (10 days after Caesarean section). Partial thrombosis of the cavernous sinus with obliteration of most of the drainage from the fistula accounted for the resolution of clinical symptoms, but also promoted back-flow to the preserved drainage of superficial cortical veins. The hemodynamic changes and the hormonal effects due to the patient's subsequent pregnancy further aggravated the venous engorgement and finally caused rupture. All three hematomas occurred in the vicinity of the extremely dilated veins, suggesting that back-flow with venous hypertension was the probable cause for the intracerebral hematomas. Spontaneous healing of the carotid-cavernous fistula should be confirmed with cerebral angiography.

Cerebral arteriovenous malformations: factors influencing the surgical difficulty and outcome

The outcomes of 151 patients with arteriovenous malformations (AVMs) treated either surgically or conservatively are presented. In terms of long-term survival rate and follow-up results, the patients who underwent total excision had more favorable results than did those treated conservatively. Patient age was the most important clinical factors, with the preoperative level of consciousness being the second most important. A grading system was formulated on the basis of the angiographical factors by using multiregression analysis; the size of the AVM influenced the surgical outcome twice as much as did the location and the pattern of arterial feeding. Thus, a large AVM (greater than or equal to 4 cm) was given 2 points; a small AVM (less than 4 cm) was given 0 points; a deep AVM was given 1 point; a superficial AVM was given 0 points; an AVM supplied by three of more artery systems was given 1 point; and an AVM supplied by one or two artery systems was given 0 points. AVMs were categorized into 5 grades from Grade 0 to 4 by the summation of these points. Predicted Karnofsky scale after surgery was calculated by this grading system and the following equation: predicted Karnofsky scale = 87.2 - 5.6 x Grade. Grade 0 and 1 AVMs showed high rates of total excision (Grade 0, 94%; Grade 1, 82%) and of satisfactory outcome (Grade 0, 90%; Grade 1, 82%) and were classified as "easy" lesions. Grade 2 AVMs are lesions classified as "moderate" and had a total excision rate of 76% and a satisfactory outcome rate of 71%.(ABSTRACT TRUNCATED AT 250 WORDS)

The pattern of diabetes in a primary health care setting in Singapore

This is a study of Diabetes mellitus and its treatment in a single doctor government primary health care clinic in Singapore. Data was collected on the entire 349 patients with diabetes attending this clinic over a three month period in 1987. We found there was an increasing number of diabetics with age and a substantial proportion was above 70 years of age. Only 7% had their diabetes treated with diet alone and 9.6% were treated with insulin. Most (61%) patients were on tolbutamide, with 17.6% on glibenclamide and 5.9% on chlorpropamide. Hypertension was found in 38% of the diabetic patients but was not associated with increase in age of the patient. The duration of diabetes, but not the age of the patient, was positively associated with the number of drugs taken by the patient (chi-squared, p less than 0.05).

The association of arteriovenous malformation and aneurysm within the posterior cranial fossa--report of a case

A relatively rare case of cerebellar arteriovenous malformation (AVM) associated with a saccular aneurysm fed by the left posterior inferior cerebellar artery (PICA) is described. The interpretation of angiograms and the appropriate surgical treatment for the coexistence of the intracranial AVM and aneurysm are discussed. It is a fact that the steal phenomenon existed in the flow of contrast medium during the angiography. The appropriate surgical treatment may be clipping of the aneurysmal neck first and then radical excision of the AVM.

Cysts of the pineal gland. A new clinical entity to be distinguished from tumors of the pineal region

Thirty-two cases of pineal cyst diagnosed by magnetic resonance imaging (MRI) were reviewed and are described. The pineal cyst was demonstrated to be an area with slightly less intensity than the surrounding tissue and with slightly greater intensity than the CSF on T1-weighted images. On the T2-weighted images this lesion was identified as a high-intensity area with smooth margins and was homogeneous in nature. In three cases presenting with headache, compression of the vein of Galen was identified, and compression of the quadrigeminal plate was demonstrated in five cases. No patients presented with both pineal and quadrigeminal lesions. Of the cases, 63% were not detected by CT scanning alone. There were two cases in which the cyst ruptured and collapsed spontaneously during follow-up. It is emphasized that the presence of this lesion, which was more frequent than previously expected, should be kept in mind when diagnosing pineal tumors and should not be misdiagnosed. Surgery should not be undertaken unless the lesion produces symptoms due to the compression of the quadrigeminal plate, aqueduct, or the vein of Galen.

Functional group contribution of bile salt molecules to partitioning of a quaternary ammonium N,N-dimethyl derivative of propranolol

A quaternary ammonium N,N-dimethyl derivative of propranolol was extracted from pH 7.4 phosphate buffer into 1-octanol as ion-pairs with 12 different bile salts. The binding number, n, and the extraction constant, Ke, were determined. To obtain group contribution values of the bile salt molecule from the ion-pair extraction data, multiple linear regression analysis by the Free-Wilson technique was applied. The results showed that the fundamental premise of the functional group's contribution to the ion-pair extraction is valid. The functional groups of counterions contribute to the partitioning of the ammonium compound independently and additively in this system.

Pericardial angiosarcoma simulating pericardial effusion by echocardiography

A fast-growing angiosarcoma caused incapacitation of a boy and death in a period of three months. The growth of the tumor was well documented by a series of echocardiograms. The heart was well encased by a thick layer of purplish vascular neoplasm enveloped mostly by thin pericardium, with some additional few foci of extracardiac metastasis. The heart weighed 2,000 gm. It is worthy to note that another cause of an echo-free space may be the presence of a pericardial tumor, rather than pericardial effusion.