Gut Microbiome Changes in Patients With Idiopathic Normal Pressure Hydrocephalus

BACKGROUND

The gut microbiome is a complex system within the human gastrointestinal tract. The bacteria play a significant role in human health, and some can promote inflammation and pathologic processes through chemical interactions or metabolites. Gut microbiome dysbiosis has been linked to some neurological and other diseases. Here we aimed to examine microbiome differences between patients with a progressive neurological disorder, idiopathic normal pressure hydrocephalus (iNPH), compared with healthy controls (CO).

METHODS

We recruited 37 neurologically healthy CO and 10 patients with shunted iNPH. We evaluated these participants' cognition using the CERAD-NB test battery and CDR test, and collected a variety of information, including about dietary habits and health. We also collected fecal samples, which were subjected to 16S amplicon sequencing to analyze differences in gut microbiome composition.

RESULTS

We found that the iNPH group exhibited significantly different abundances of 10 bacterial genera compared with the CO group. The Escherichia/Shigella and Anaeromassilibacillus genera were most remarkably increased. Other increased genera were Butyrivibrio , Duncaniella , and an unidentified genus. The decreased genera were Agathobaculum , Paramuribaculum , Catenibacterium , and 2 unidentified genera.

CONCLUSIONS

Here we report the first identified microbiome differences in iNPH patients compared with healthy controls.

Different Trajectories of Depressive Symptoms in Alzheimer's Disease Caregivers - 5-Year Follow-Up

OBJECTIVES

The care of individuals with Alzheimer's disease (AD) relies on family caregivers (FCs) who face increasing demands. This study aimed to identify trajectories of depressive symptoms in FCs.

METHODS

226 FCs and individuals with AD were followed up for 5 years as a part of the ALSOVA study. Depressive symptoms in FCs were measured with the Beck Depression Inventory from the time of the AD diagnosis to the 5-year follow-up. We compared the trajectory of groups regarding age, education, and sex of both FC distress and AD symptoms.

RESULTS

We identified three trajectories of FC depressive symptoms throughout follow-up: (1) declining (7.5% of FCs), (2) minor (59.7% of FCs), and (3) increased (32.7% of FCs). These groups exhibited differences in demographic variables, FC distress, and individuals with AD neuropsychiatric symptoms.

CONCLUSIONS

The present study showed that FC depressive symptoms existed, and one-third of caregivers experienced increasing depressive symptoms over five years.

CLINICAL IMPLICATIONS

Family caregivers' health should be followed in clinical practice, and those at risk of depression could be recognized early in caregiving.

Trends in Brain Research: A Bibliometric Analysis

BACKGROUND

Bibliometrics methods have allowed researchers to assess the popularity of brain research through the ever-growing number of brain-related research papers. While many topics of brain research have been covered by previous studies, there is no comprehensive overview of the evolution of brain research and its various specialties and funding practices over a long period of time.

OBJECTIVE

This paper aims to (1) determine how brain research has evolved over time in terms of number of papers, (2) countries' relative and absolute positioning in terms of papers and impact, and (3) how those various trends vary by area.

METHODS

Using a list of validated keywords, we extracted brain-related articles and journals indexed in the Web of Science over the 1991-2020 period, for a total of 2,467,708 papers. We used three indicators to perform: number of papers, specialization, and research impact.

RESULTS

Our results show that over the past 30 years, the number of brain-related papers has grown at a faster pace than science in general, with China being at the forefront of this growth. Different patterns of specialization among countries and funders were also underlined. Finally, the NIH, the European Commission, the National Natural Science Foundation of China, the UK Medical Research Council, and the German Research Foundation were found to be among the top funders.

CONCLUSION

Despite data-related limitations, our findings provide a large-scope snapshot of the evolution of brain research and its funding, which may be used as a baseline for future studies on these topics.

The Cognitive Function at Work Questionnaire in memory clinic setting: a validation study

INTRODUCTION

As there is a trend toward more people seeking medical help due to cognitive symptoms, validated and targeted questionnaires are increasingly important in the clinical evaluation process. The Cognitive Function at Work Questionnaire (CFWQ) was developed to identify and rate subjective cognitive symptoms of individuals active in working life. However, its psychometric characteristics have not been previously studied in a memory clinic setting.

METHOD

The factorial structure, internal consistency, test-retest reliability, and convergent validity of the CFWQ were studied in a memory clinic setting (N = 113). We also investigated the instrument's ability to identify cognitive symptoms in a cohort of early-onset dementia (EOD, N = 22), mild cognitive impairment-neurological (MCI-n, N = 18), MCI due to mood, sleep, or other physical health problems (MCI-o, N = 59), and subjective cognitive decline (SCD, N = 14) patients.

RESULTS

Based on factor analysis, eight cognitive subscales were identified covering main cognitive domains: Memory, Language, Executive Function, Speed of Processing, Cognitive Control, Name Memory, Visuospatial/Praxis and Attention. The internal consistency (α = .93) and the test-retest reliability (ICC = .91) were high. Several correlations (r = .19 - .33, p < .05) were documented between neuropsychological impairment level and CFWQ scores. EOD, MCI-n, MCI-o, and SCD groups did not differ statistically significantly in the levels of cognitive symptoms as measured by the CFWQ Total score. EOD group scored higher (p = .009) than other patient groups on the Visuospatial/Praxis subscale, but the difference between EOD and MCI-o groups turned insignificant after correcting for multiple testing.

CONCLUSIONS

The results of the study support the validity and reliability characteristics of the CFWQ in a memory clinic setting. The instrument is easy-to-use and has clinical utility in capturing the subjective cognitive symptoms of patients active in working life and who need a referral to a more detailed evaluation.

Shortening of Saccades as a Possible Easy-to-Use Biomarker to Detect Risk of Alzheimer's Disease

Background:

Wide-ranging functional defects in eye movements have been reported in Alzheimer’s disease (AD) dementia. The detection of abnormal eye movements and reading problems may identify persons at risk of AD when clear clinical symptoms are lacking.

Objective:

To examine whether computer-based eye-tracking (ET) analysis of King-Devick (KD) test results differentiates cognitively healthy persons from persons with minor problems in cognitive testing or diagnosed mild AD.

Methods:

We recruited 78 participants (57 non-demented, 21 with mild AD) who underwent neurological examination, the Consortium to Establish a Registry for Alzheimer’s Disease neuropsychological test battery (CERAD-NB), and a Clinical Dementia Rating (CDR) interview. The non-demented participants were further divided into control (normal CERAD subtests, mean MMSE = 28) and objective mild cognitive impairment (MCI; decline in at least one CERAD memory score, mean MMSE = 27) groups. The KD reading test was performed using computer-based ET. The total time used for the reading test, errors made, fixation and saccade durations, and saccade amplitudes were analyzed.

Results:

We found significant differences between the control, objective MCI, and AD groups in regard to the mean saccade amplitude (3.58, 3.33, and 3.21 ms, respectively, p < 0.03) and duration (27.1, 25.3, and 24.8 ms, respectively, p < 0.05). The KD error scores in the AD group differed significantly (p < 0.01) from the other groups.

Conclusion:

Computed ET analysis of the KD test may help detect persons with objective MCI early when clear clinical symptoms are lacking. The portable device for ET is easy to use in primary health care memory clinics.

Biometal Dyshomeostasis in Olfactory Mucosa of Alzheimer's Disease Patients

Olfactory function, orchestrated by the cells of the olfactory mucosa at the rooftop of the nasal cavity, is disturbed early in the pathogenesis of Alzheimer's disease (AD). Biometals including zinc and calcium are known to be important for sense of smell and to be altered in the brains of AD patients. Little is known about elemental homeostasis in the AD patient olfactory mucosa. Here we aimed to assess whether the disease-related alterations to biometal homeostasis observed in the brain are also reflected in the olfactory mucosa. We applied RNA sequencing to discover gene expression changes related to metals in olfactory mucosal cells of cognitively healthy controls, individuals with mild cognitive impairment and AD patients, and performed analysis of the elemental content to determine metal levels. Results demonstrate that the levels of zinc, calcium and sodium are increased in the AD olfactory mucosa concomitantly with alterations to 17 genes related to metal-ion binding or metal-related function of the protein product. A significant elevation in alpha-2-macroglobulin, a known metal-binding biomarker correlated with brain disease burden, was observed on the gene and protein levels in the olfactory mucosa cells of AD patients. These data demonstrate that the olfactory mucosa cells derived from AD patients recapitulate certain impairments of biometal homeostasis observed in the brains of patients.

Severe Obstructive Sleep Apnea and Increased Cortical Amyloid-β Deposition

BACKGROUND

The suggested association between severe obstructive sleep apnea (OSA) and risk of Alzheimer's disease (AD) needs further study. Only few recent reports exist on associations between brain amyloid-β (Aβ) burden and severe OSA in middle-aged patients.

OBJECTIVE

Examine the possible presence of cortical Aβ accumulation in middle-aged patients with severe OSA.

METHODS

We performed detailed multimodal neuroimaging in 19 cognitive intact patients (mean 44.2 years) with severe OSA (Apnea-Hypopnea Index >30 h-1). Known etiological factors for possible Aβ accumulation were used as exclusion criteria. Aβ uptake was studied with [11C]-PiB-PET, glucose metabolism with [18F]-FDG-PET, and structural imaging with 3.0T MRI.

RESULTS

When analyzed individually, in [11C]-PiB-PET a substantial number (∼32%) of the patients exhibited statistically significant evidence of increased cortical Aβ uptake based on elevated regional Z-score values, mostly seen bilaterally in the precuneus and posterior cingulum regions. Cortical glucose hypometabolism in [18F]-FDG-PET was seen in two patients. MRI did not show structural changes suggestive of AD-related pathology.

CONCLUSION

Increased [11C]-PiB uptake was seen in middle-aged cognitively intact patients with severe OSA. These findings are similar to those described in cognitive unimpaired older OSA patients. The changes in cortical Aβ uptake suggest that severe OSA itself may predispose to alterations related to AD already in middle-age. Aβ clearance may be compromised without simultaneous evidence of metabolic or structural alterations. The results emphasize the importance of early diagnostics and proper treatment of severe OSA in cognitively intact middle-aged subjects, possibly diminishing the individual risk for later cognitive dysfunction.

Food insecurity among Finnish private sector service workers and food pantry clients

Background

There is a paucity of comparable quantitative data on the prevalence and predictors of food insecurity in high-income countries. We applied the Household Food Insecurity Access Scale (HFIAS) to assess food insecurity among i) the Service Union United members; female-dominated, low-income employees of the Finnish private service sector, and ii) a convenience sample of Finnish food pantry clients.

Methods

The HFIAS classification was based on 9 validated questions capturing respondents' perceptions on food scarcity and behavioural responses to food insecurity due to lack of resources during the past month. The resulting indicator categorized respondents as food secure, and mildly, moderately and severely food insecure. We performed cross-tabulations and regression models to assess if education, housing, self-perceived health, income, and resource scarcity associated with levels of food insecurity. In addition, gender, age, and self-perceived disadvantage were assessed among the food pantry clients.

Results

Among the service workers (n = 6 573, 6% of those invited), 35% were food secure, 29% mildly or moderately food insecure, and 36% severely food insecure. The respective proportions were 28%, 26%, and 46% among the 129 food pantry clients. All assessed variables were associated to food insecurity status in the service workers (p &lt; 0.01 for all). Among the food pantry clients, men (OR 1.60; 95% CI 1.09 − 4.80) and homeless/tenants in community rental units (OR 7.12; 95% CI 2.42 − 20.95) were most likely to experience severe food insecurity.

Conclusions

Alongside the food pantry clients the majority of the service workers demonstrated some degree of food insecurity, with a considerable proportion being severely food-insecure. This predominantly low-income group is subject to rapid changes in the labour market and social security systems. The data demonstrated that well-known SES indicators and self-perceived health are linked to food insecurity.

Key messages

Severe food insecurity was common among predominantly low-income private sector service workers and food pantry clients. Food insecurity is linked to SES indicators and wellbeing.

Psychometric Properties of the Neuropsychiatric Inventory: A Review

Neuropsychiatric symptoms cause a significant burden to individuals with neurocognitive disorders and their families. Insights into the clinical associations, neurobiology, and treatment of these symptoms depend on informant questionnaires, such as the commonly used Neuropsychiatric Inventory (NPI). As with any scale, the utility of the NPI relies on its psychometric properties, but the NPI faces unique challenges related to its skip-question and scoring formats. In this narrative review, we examined the psychometric properties of the NPI in a framework including properties pertinent to construct validation, and health-related outcome measurement in general. We found that aspects such as test-retest and inter-rater reliability are major strengths of the NPI in addition to its flexible and relatively quick administration. These properties are desired in clinical trials. However, the reported properties appear to cover only some of the generally examined psychometric properties, representing perhaps necessary but insufficient reliability and validity evidence for the NPI. The psychometric data seem to have significant gaps, in part because small sample sizes in the relevant studies have precluded more comprehensive analyses. Regarding construct validity, only one study has examined structural validity with the NPI subquestions. Measurement error was not assessed in the reviewed studies. For future validation, we recommend using data from all subquestions, collecting larger samples, paying specific attention to construct validity and formulating hypotheses a priori. Because the NPI is an outcome measure of interest in clinical trials, examining measurement error could be of practical importance.

Relationships between Cognition and Activities of Daily Living in Alzheimer's Disease During a 5-Year Follow-Up: ALSOVA Study

BACKGROUND

Impaired cognition and activities of daily living (ADL) are core symptoms of Alzheimer's disease (AD), but their relationship is unclear.

OBJECTIVES

To explore relationships between cognitive domains and functional ability during 5-year follow-up in persons with AD.

METHODS

We analyzed ALSOVA study data from 236 individuals with very mild or mild AD at baseline. The CERAD Neuropsychological Battery (CERAD-NB) was used as a cognitive measure and Alzheimer's Disease Cooperative Study ADL (ADCS-ADL) as a functional measure, analyzing the IADL and BADL sub-scores separately. Annual regression models and linear mixed-effect models (LMMs) covering a 5-year follow-up period were used.

RESULTS

Annually, the CERAD-NB total and especially Verbal Fluency, Clock Drawing, and Constructional Praxis were associated with the total ADCS-ADL and IADL scores increasingly yet modestly, and to a lesser extent the BADL score. In the LMMs, the same measures and MMSE were associated with ADL.

CONCLUSION

Measures of executive function and visuoconstructive skills appear to be associated with caregiver-interview based ADL measure during the progression of AD.

Exercise training alters lipoprotein particles independent of brown adipose tissue metabolic activity

Introduction

New strategies for weight loss and weight maintenance in humans are needed. Human brown adipose tissue (BAT) can stimulate energy expenditure and may be a potential therapeutic target for obesity and type 2 diabetes. However, whether exercise training is an efficient stimulus to activate and recruit BAT remains to be explored. This study aimed to evaluate whether regular exercise training affects cold‐stimulated BAT metabolism and, if so, whether this was associated with changes in plasma metabolites.

Methods

Healthy sedentary men (n = 11; aged 31 [SD 7] years; body mass index 23 [0.9] kg m⁻²; VO_{2 max} 39 [7.6] mL min⁻¹ kg⁻¹) participated in a 6‐week exercise training intervention. Fasting BAT and neck muscle glucose uptake (GU) were measured using quantitative [¹⁸F]fluorodeoxyglucose positron emission tomography–magnetic resonance imaging three times: (1) before training at room temperature and (2) before and (3) after the training period during cold stimulation. Cervico‐thoracic BAT mass was measured using MRI signal fat fraction maps. Plasma metabolites were analysed using nuclear magnetic resonance spectroscopy.

Results

Cold exposure increased supraclavicular BAT GU by threefold (p < 0.001), energy expenditure by 59% (p < 0.001) and plasma fatty acids (p < 0.01). Exercise training had no effect on cold‐induced GU in BAT or neck muscles. Training increased aerobic capacity (p = 0.01) and decreased visceral fat (p = 0.02) and cervico‐thoracic BAT mass (p = 0.003). Additionally, training decreased very low‐density lipoprotein particle size (p = 0.04), triglycerides within chylomicrons (p = 0.04) and small high‐density lipoprotein (p = 0.04).

Conclusions

Although exercise training plays an important role for metabolic health, its beneficial effects on whole body metabolism through physiological adaptations seem to be independent of BAT activation in young, sedentary men.

Outcomes of early endovascular versus surgical treatment of ruptured cerebral aneurysms. A prospective randomized study

BACKGROUND AND PURPOSE

This prospective study was conducted to compare the outcomes of surgical clipping and endovascular treatment in acute (<72 hours) aneurysmal subarachnoid hemorrhage (SAH).

METHODS

One hundred nine consecutive patients were randomly assigned to either surgical (n=57) or endovascular (n=52) treatment. Clinical and neuropsychological outcome was assessed at 3 and 12 months after treatment; MRI of the brain was performed at 12 months. Follow-up angiography was scheduled after clipping and 3 and 12 months after endovascular treatment.

RESULTS

One year postoperatively, 43/41 (surgical/endovascular) patients had good or moderate recovery, 5/4 had severe disability or were in a vegetative state, and 9/7 had died (NS) according to intention to treat. Patients with good clinical recovery did not differ in their neuropsychological test scores. Symptomatic vasospasm (OR 2.47; 95% CI 1.45 to 4.19; P<0.001), poorer Hunt and Hess grade (OR 2.50; 95% CI 1.31 to 4.75; P=0.005), need for permanent shunt (OR 8.90; 95% CI 1.80 to 44.15; P=0.008), and larger size of the aneurysm (OR 1. 22; 95% CI 1.02 to 1.45; P=0.032) independently predicted worsened clinical outcome regardless of the treatment modality. In MRI, superficial brain retraction deficits (P<0.001) and ischemic lesions in the territory of the ruptured aneurysm (P=0.025) were more frequent in the surgical group. Kaplan-Meier analysis (mean+/-SD follow-up 39+/-18 months) revealed equal survival in both treatment groups. No late rebleedings have occurred.

CONCLUSIONS

One-year clinical and neuropsychological outcomes seem comparable after early surgical and endovascular treatment of ruptured intracranial aneurysms. The long-term efficacy of endovascular treatment in preventing rebleeding remains open.

Computed tomography findings 4 years after surgical management of lumbar spinal stenosis. No correlation with clinical outcome

STUDY DESIGN

A prospective, cross-sectional study of the correlation between postoperative computed tomography findings and patients' clinical outcomes approximately 4 years after laminectomy for lumbar spinal stenosis.

OBJECTIVES

To evaluate clinical and radiologic characteristics and their relation to each other.

SUMMARY OF BACKGROUND DATA

The goal of surgical management for lumbar spinal stenosis is to decompress the stenotic area determined in radiologic examinations to relieve pressure on the neurovascular structures. However, the success of this decompression very rarely has been confirmed by postoperative radiologic imaging or compared with clinical outcome.

METHODS

Postoperative computed tomography was performed on 191 patients. The findings were classified as "no stenosis," "central stenosis," "lateral stenosis," or "central-lateral stenosis." Postoperative instability of the lumbar spine was investigated by functional radiography. Clinical status was assessed by clinical examination. Subjective disability was assessing using the Oswestry questionnaire, and severity of pain using the visual analog scale. Walking capacity was evaluated by the tread-mill test.

RESULTS

Radiologic studies revealed postoperative stenosis in 123 patients (64%). Small differences between the computed tomography groups were shown for the Oswestry score, but not for walking distance. Clinical signs, severity of pain, and radiologic instability were very similar for all computed tomography groups.

CONCLUSIONS

Postoperative radiologic stenosis was very common in patients operated on for lumbar spinal stenosis, but this did not correlate with clinical outcome. The clinician must be cautious when reconciling clinical symptoms and signs with postoperative computed tomography findings in patients operated on for lumbar spinal stenosis.

The degree of decompressive relief and its relation to clinical outcome in patients undergoing surgery for lumbar spinal stenosis

STUDY DESIGN

A cross-sectional, clinical study to evaluate surgical decompression of the stenotic area monitored by computed tomographic scan and its relation to clinical variables in patients operated on for lumbar spinal stenosis.

OBJECTIVE

To study in patients with lumbar spinal stenosis the influence of the degree of compressive relief on the patients' clinical outcome.

SUMMARY OF BACKGROUND DATA

The goal of surgical treatment in lumbar spinal stenosis is to decompress the stenotic area. Although the decompression should be adequate, there are no clear guidelines to determine the extent of necessary decompression. In fact, there is clinical evidence that there is a discrepancy between the surgical outcome in the patient with lumbar spinal stenosis and postoperative radiologic findings.

METHODS

In 92 patients with lumbar spinal stenosis who had had no prior back surgery, preoperative and postoperative computed tomographic scans were obtained to determine the degree of decompression. The postoperative scan findings were classified according to the degree of decompression into a no-stenosis group (n = 35), an adjacent-stenosis group (n = 27), and a residual-stenosis group (n = 30). The postoperative instability of the lumbar spine was investigated by functional radiography. The subjective disability of the patients was assessed using the Oswestry score and the severity of pain using the visual analog scale. Walking capacity was evaluated by a treadmill test. The patients' estimations of the results of surgery were classified into groups of satisfied patients and dissatisfied patients.

RESULTS

The mean Oswestry score in all 92 patients was 27.1, and mean walking capacity was 630 m. In the satisfied patients, the Oswestry score was 18.8 and in the dissatisfied patients, 34.9 (P < 0.0000). Walking capacity was 690 m and 594 m, respectively. There were 30 patients with postoperative spinal instability, but it had no influence on surgical outcome. There were no differences in the Oswestry score, walking capacity, and patients' satisfaction among the postoperative CT groups. In the linear regression analysis, the satisfied patient corresponded significantly with the Oswestry score.

CONCLUSIONS

The satisfaction of the patients with the results of surgery was more important in surgical outcome than the degree of decompression detected on computed tomographic scan.

Ruptured intracranial aneurysms: acute endovascular treatment with electrolytically detachable coils--a prospective randomized study

PURPOSE

To compare the use of electrolytically detachable coils versus surgical ligation for the management of acutely ruptured intracranial aneurysm.

MATERIALS AND METHODS

A prospective randomized study included 109 patients with acute (< 72 hours) subarachnoid hemorrhage caused by a ruptured aneurysm (Hunt and Hess grade I-II [n = 67], grade III [n = 26], or grade IV-V [n = 16]). All patients were suitable candidates for both endovascular and surgical treatment and were randomly assigned to undergo coil embolization (n = 52) or surgical ligation (n = 57).

RESULTS

Significantly better primary angiographic results were achieved after surgery in patients with anterior cerebral artery aneurysm (n = 55, P = .005) and after endovascular treatment in those with posterior circulation aneurysm (n = 11, P = .045). No significant differences were seen in middle cerebral artery (n = 19) or internal carotid artery (n = 24) aneurysms. Early rebleeding occurred in one patient after incomplete coil embolization. The technique-related mortality rate was 4% in the surgical group and 2% in the endovascular group. Clinical outcome (Glasgow Outcome Scale score) at 3 months was not significantly different between treatment groups in terms of intended treatment modality. No late rebleedings had occurred at the time of this writing.

CONCLUSION

In selected patients with a recently ruptured intracranial aneurysm, favorable results were achieved by using endovascular treatment. Subsequent acute or late open surgery was sometimes required. The clinical outcome at 3 months was comparable in the endovascular and surgical treatment groups.

Mild carotid artery atherosclerosis: assessment by 3-dimensional time-of-flight magnetic resonance angiography, with reference to intravascular ultrasound imaging and contrast angiography

BACKGROUND AND PURPOSE

Our aim was to evaluate the usefulness of 3-dimensional time-of-flight magnetic resonance angiography (3-D TOF MRA) in detection and quantification of mild atherosclerotic changes of carotid arteries with reference to intravascular ultrasound (IVUS) and contrast angiography.

METHODS

TOF MRA at 1.5 T, IVUS, and selective digital subtraction angiography were performed on 31 extracranial carotid arteries of 27 patients (mean age, 52 years; age range, 17 to 75 years) undergoing neuroendovascular interventions. The atherosclerotic lesions were registered, and quantitative measurements of plaque thickness, luminal diameters, and diameter stenosis were independently performed for the imaging modalities.

RESULTS

Among 170 arterial segments analyzed, IVUS revealed a total of 48 atherosclerotic lesions (mean diameter stenosis, 17%; range, 4% to 40%), only 25 of which were depicted on digital subtraction angiography. Analysis of the axial source images of TOF MRA resulted in sensitivity of 77% to 83% and specificity of 71% to 80% in lesion depiction for the 2 readers with reference to IVUS. The values of diameter stenosis measured from MRA and IVUS were closely interrelated (r=0.53 to 0.61, P<0.001).

CONCLUSIONS

Three-dimensional TOF MRA is feasible and moderately accurate for evaluation of mild atherosclerotic changes of carotid arteries.

Regional cerebral blood flow in aneurysmal subarachnoid hemorrhage: single photon emission tomography evaluation of endovascular versus surgical treatment

Since February 1995, 59 patients with recent aneurysmal SAH have been randomised in our study program, either for surgical aneurysm clipping or for endovascular treatment with Guglielmi detachable coils, to compare the safety and long-term efficacy of these methods. Patients with expansive haematomas or those in a moribund state were excluded, as well as those with aneurysms unsuitable for treatment with both methods. We used single photon emission tomography (SPET) to compare regional cerebral blood flow (rCBF) in surgically and in endovascularly-treated patients. In a sub-study presented in this paper, we analysed the data of patients in Grade I-III (Hunt & Hess) with anterior circulation aneurysms (n = 21). When changes between the pre- and post-treatment rCBF were compared, the surgically treated group showed a tendency towards improved rCBF (change in different vascular territories varied from +4% to +12%) while the endovascularly-treated group showed no consistent change (changes varied from -3% to +6%). There was, however, no significant statistical difference between the changes in the groups. Our results are preliminary, but they suggest that endovascular treatment of anterior circulation aneurysms may not have any advantage over surgical treatment in respect to disturbances in the rCBF.

Human carotid arteries: correlation of intravascular US with angiographic and histopathologic findings

PURPOSE

To establish the intravascular ultrasound (US) morphology of the arterial wall in various segments of the carotid artery and to evaluate atherosclerotic changes correlated with angiographic and in vitro histopathologic findings.

MATERIALS AND METHODS

A total of 67 carotid arteries were imaged with a 3.5-F, 30-MHz intravascular US catheter: Twenty-four arteries were studied in vivo in 22 patients during neuroendovascular interventional procedures, in situ in 10 cadaveric arteries, and in vitro in 33 fresh excised arteries.

RESULTS

In vivo, none of 10 calcifications and five (29%) of 17 intimal thickenings detected at intravascular US were seen at contrast material-enhanced angiography. At intravascular US, the arterial wall morphology was consistently three layered in the internal carotid artery above the bulb, either vaguely three layered or homogeneous in the bulb and in the carotid bifurcation, and homogeneous in the majority of common carotid arteries. The medial-adventitial interface was distinct in 21 (88%) of 24 arteries in vivo. Histopathologic and intravascular US classifications of the plaque agreed for 31 (82%) of the 38 arterial specimens in vitro.

CONCLUSION

In vivo intravascular US was feasible in carotid arteries with mild atherosclerosis and often revealed intimal thickenings and concentric plaques in angiographically normal segments.

Surgical outcome of 438 patients treated surgically for lumbar spinal stenosis

STUDY DESIGN

A retrospective, follow-up study.

OBJECTIVES

To investigate the overall outcome of surgery for lumbar spinal stenosis and to investigate the preoperative factors affecting outcome.

SUMMARY OF BACKGROUND DATA

The success rates of surgical intervention for lumbar spinal stenosis vary, and few preoperative factors have been found to be significantly correlated to surgical outcome.

METHODS

A total of 438 patients (183 women, 255 men) who underwent decompressive surgery for lumbar spinal stenosis were re-examined and evaluated for outcome 4.3 years after surgery. Outcome was based on subjective disability, which was assessed using the Oswestry low back pain questionnaire. The preoperative data (clinical documentation, length of laminectomy, and radiographs) were collected from patient records that had been stored in the hospital. Preoperative factors affecting outcome were reported.

RESULTS

The mean value of the Oswestry disability score of these 438 patients was 34 +/- 18 (women, 36.3 +/- 17; men, 32.3 +/- 18; P < 0.05). Age did not influence general outcome. The proportion of good to excellent outcomes of all 438 patients was 62% (women, 57%; men, 65%). Diabetes, hip joint arthrosis, and preoperative fracture of the lumbar spine seemed to be associated with poor outcome. The ability to work before or after surgery and a history of no prior back surgery were predictive of good outcome.

CONCLUSION

The results suggest that clear myelographic stenosis and no prior surgical intervention, no comorbidity of diabetes, no hip joint arthrosis, and no preoperative fracture of the lumbar spine are factors associated with a good outcome in surgical management of lumbar spinal stenosis.

Dissecting aneurysms of all four cervicocranial arteries in fibromuscular dysplasia: treatment with self-expanding endovascular stents, coil embolization, and surgical ligation

A patient with cervicocranial fibromuscular dysplasia (FMD) presented with subarachnoid hemorrhage. A ruptured dissecting distal vertebral artery aneurysm required clip ligation of the parent artery; a contralateral dissecting proximal vertebral aneurysm was occluded with detachable coils. Progressive dissecting, extracranial aneurysms of the internal carotid artery were treated with self-expanding stents. Subsequent angiography and intravascular sonography revealed patent stents, a smooth luminal surface, and total occlusion of the aneurysm. Clinical outcome was excellent.

Microvascular permeability to the F(ab')2 fragment of IgG in the male rat reproductive tract at puberty

Development of contraceptive vaccines has recently raised much interest following the cloning of the sperm and oocyte components involved in the sperm-oocyte interaction. The main difficulty of immunocontraception in the male is the poor access of antibodies to the luminal compartment. As recent literature suggests that many substances are transported to the testis by receptor-mediated or fluid-phase transcytosis, the dependence of the transport of IgG on the Fc receptor was studied in the present investigation by comparing the penetration of whole IgG and the F(ab')2 fragment of IgG to the testis and epididymis. The maximum volume of distribution (Veq) for the F(ab')2 fragment was significantly higher than that for whole IgG in the testis of 30-60-day old rats, in the caput and cauda of 30- and 45-day old rats and the corpus of 45-day old rats. The speeds at which equilibrium between tissue extracellular fluid and serum was reached (K) for the F(ab')2 fragment and whole IgG were significantly different in the testicular capsule of the 60-day old, in the caput and corpus of the 45- and 60-day old and in the cauda of the 45-day old rats. The microvascular permeabilities (PE) to the F(ab')2 fragment were more than 2-fold higher than those to whole IgG in the testis of the 20-, 45- and 60-day old, in the testicular capsule of the 20- and 45-day old, in the caput of 20-, 30- and 60-day old and in the corpus of 20-day old rats. The PE to whole IgG was more than 2-fold higher than that to the F(ab')2 fragment in the cauda of the 45-day-old rats. The PE to the F(ab')2 fragment increased steadily from 20 to 60 days of age in the testis and caput, but in the corpus there was a more abrupt increase between 30 and 45 days of age. In the cauda, PE remained in the same range of magnitude throughout pubertal development. These results suggest that the F(ab')2 fragment reaches the lumen of the reproductive tract more easily than whole IgG from 30 days of age onwards in the testis, whereas in the caput, corpus and cauda epididymidis the rate at which F(ab')2 fragment reaches the lumen increases only temporarily at the time of appearance of spermatozoa in the lumen. Transport of IgG to the male reproductive tract is thus unlikely to be mediated by Fc receptors.

CD28-CD80/CD86 interactions in testicular immunoregulation

The expression of two accessory molecules on antigen-presenting cells (APC), the CD80/ B7-1 and CD86/B7-2 antigens, was studied in the testis of normal and non-obese diabetic (NOD) mice. In addition, the effect of CD28 stimulation on suppression of lymphocytes by testicular products was investigated. The testes of 4-week old NOD mice or normal BALB/c mice and the testis of 17-21-week old BALB/c mice contained no CD80 or CD86 expressing cells. In contrast, CD80+ and CD86+ cells were present in the testis of 14-22-week old NOD mice. The CD80+ cells and most of the CD86+ cells were CD11b/CD18 negative. There were some CD11b/CD18+ cells that expressed CD86 weakly. The CD80+ and CD86+ cells were often located adjacent to the vessel walls where a leukocyte not expressing CD80 or CD86 had attached to the endothelium. Some CD80+ and CD86+ cells were present among the interstitial cells. The CD80 and CD86 antigens could not be observed in the same cells as judged from stainings in parallel sections. Stimulation of ConA- or anti-CD3 epsilon-primed peripheral blood or spleen lymphocytes with anti-CD28 was able significantly to antagonize the growth-inhibitory effect of the M(r) > 5 K fraction of testis extracts, but could not abolish it with increasing concentrations of testis extract. The results suggest that T lymphocytes can not be activated locally in the testis of BALB/c and young NOD mice because of the absence of the necessary CD28 ligands, CD80 and CD86, from the APCs and because of the suppression of T lymphocytes by the testicular products. In the testis of older diabetic NOD mice lymphocyte activation may occur because the testes of these mice contain CD80+; CD11b/CD18-, CD86+; CD11b/CD18+ and CD86+; CD11b/CD18- cells and therefore, CD28 co-stimulation, which can antagonize the suppressive effect of testis extract, may occur. The possibilities for clonal anergy in testicular immunoregulation are discussed.

Pre- and postoperative factors associated with return to work following surgery for lumbar spinal stenosis

Low back disorders are an increasingly common and costly health problem in Western countries. It has been recommended that the return to work of patients should be the most important outcome measure of medical care. The aim of this study was to compare women's and men's working capacity after lumbar spinal stenosis (LSS) operations and to identify the factors related to it. The subjects of this study were 185 women (mean age 54 years, mean follow-up time 4.2 years) and 254 men (mean age 52 years, mean follow-up time 4.3 years). After the operation, 37% of the women and 41% of the men returned to work. None of the patients who had retired before the operation returned to work afterward. The variables that predicted postoperative ability to work for women were: being fit to work at the time of operation, age < 50 years at the time of operation, and duration of LSS symptoms < 2 years. For men, these variables were: being fit to work at the time of operation, age < 50 years at the time of operation, no prior surgery, and the extent of the surgical procedure equal to or less than 1 laminectomy. Women's and men's working capacity do not differ after LSS operation. If the aim is to maximize working capacity, then, when an LSS operation is indicated, it should be performed without delay. In LSS patients who are > 50 years old and on sick leave, it is unrealistic to expect that they will return to work. Therefore, after such an extensive surgical procedure, re-education of patients for lighter jobs could improve the chances of these patients returning to work.

Lumbar spinal stenosis: a matched-pair study of operated and non-operated patients

The prevailing opinion seems to accept that the natural course of lumbar spinal stenosis is one of progressive worsening, and that only surgery can check this development. In fact, the choice of treatment for lumbar spinal stenosis is still an open question. The aim of this study was to compare in the matched-pair format the outcome of surgically and non-surgically treated patients with lumbar spinal stenosis. The surgically treated group consisted of 496 patients who were operated on during the period 1974-1987 and 440 of whom were re-examined an average of 4.1 years after surgery. The non-surgically treated group consisted of 57 patients who were treated conservatively during the period 1980-1987 and were re-examined an average of 4.3 years after the start of treatment. The matching criteria were sex, age, myelographic findings, major symptom and duration of symptoms. We were able to form 54 similar matched-pairs from the surgically and non-surgically treated patients. Subjective disability was assessed using the Oswestry questionnaire and functional status was evaluated during the clinical examination. For statistical analysis the McNemar test and the paired Student's t-test were used. The overall results showed no statistical difference in outcome between the matched-pair groups, but the operated men fared significantly better than the non-operated men. The functional status was very good in both groups and for both sexes. In conclusion, conservative treatment of lumbar spinal stenosis should be considered for the patients with moderate stenosis. Controlled, prospective and randomized trials are needed to clarify better the choice of treatment in patients with lumbar stenosis.

Autoantigenicity of the basal compartment of seminiferous tubules in the rat

The expression of testicular autoantigens has been thought to be restricted to the luminal compartment of the seminiferous tubules. In the present study it was observed that germ cells in the basal compartment of seminiferous tubules and lamina propria of the seminiferous tubule bound antibodies in anti-testis immunosera in vivo after passive transfer of the sera by intra-peritoneal injection. The anti-testis immunosera were prepared in orchiectomised rats to avoid pre-collection adsorption of antibodies in the basal compartment of the seminiferous tubules. When testis-immune sera collected from non-orchiectomised rats or normal sera were transferred no such binding of antibodies to the basal germ cell surface or the lamina propria occurred. In Western blot analysis the anti-testis immune sera prepared in orchiectomised rats defined polypeptides from the adult rat testis with relative MWs of 19-23, 26-28, 30, 34, 38, 40-43, 45-47, 51-52, 56-57, 68, 78 and 97 kDa. The 40-43 kDa band was not detected by sera prepared in non-orchiectomised rats, suggesting that this autoantigen was expressed in the basal compartment of the seminiferous tubules. These observations suggest that the segregation of testicular autoantigens in the luminal compartment of seminiferous tubules is not complete for all of them in the rat and emphasize the role of more dynamic mechanisms in prevention of anti-germ cell autoimmune disease.

Density of lumbar muscles 4 years after decompressive spinal surgery

Results of decompressive surgery for lumbar spinal stenosis vary. We evaluated the density of lumbar muscles by computed tomography (CT) at the L2-L4 levels in patients 4 years after they had undergone surgery for lumbar spinal stenosis. Twenty of these patients had an excellent outcome clinically, and 16 patients had very poor outcome. The residual stenosis and density of lumbar muscles in Hounsfield units were measured on CT images. The clinical evaluation of outcome also included the Oswestry questionnaire and a walking test. The density of lumbar flexors was higher in the group with excellent results than in the group with poor results. The density of lumbar extensors showed a marked decrease in the operated area. These results suggest that the decrease of muscular density can be partially explained by disuse or inactivity. The decrease in the operated area probably reflects muscular atrophy caused by muscle denervation.

The effect of prior back surgery on surgical outcome in patients operated on for lumbar spinal stenosis. A matched-pair study

It has been widely observed that the outcome after repeat lumbar surgery is rarely comparable to that of primary surgery. In particular, the results of repeat surgery for lumbar spinal stenosis (LSS) have not been favourable. We used a matched-pair format in an attempt to decrease the confounding factors so as to determine as exactly as possible the effect of prior back surgery on the LSS patients' surgical outcome. The matching criteria were sex, age, myelographic findings, major symptom, and duration of symptoms. From one group of 251 patients without prior back surgery (SO patients) and another of fifty-three patients with one preceding back operation (RS patients), forty-one similar matched patients pairs (one SO and one RS-patient) were formed. There were 8 female and 33 male pairs. The mean age of the SO patients was 51.6 and of the RS patient 51.4 years, and the mean follow-up time was 4.6 and 4.4 years. The assessment of outcome was based on a subjective disability questionnaire. The SO patients fared significantly better than the RS patients (32.1 versus 41.3, P = 0.026). A short time interval between operations in the RS patients had a worsening effect on outcome, but this trend was not significant. We concluded that one preceding back operation had a worsening effect on the outcome of patients operated on for LSS. As a whole, the results of RS patients were unfavourable. The proper time for achieving good surgical results in LSS patients is the initial operation.

Dural arteriovenous fistulas of superior sagittal sinus: case report and review of literature

A case report and review of the literature of 16 dural arteriovenous fistulas (DAVFs) involving the superior sagittal sinus region are presented. In our case, magnetic resonance angiography detected the DAVF with multiple arterial feeding vessels from both external carotid arteries. The patient was successfully treated endovascularly, with complete occlusion of arterial feeders and a total resolution of symptoms.

Reactions of Leydig cells and blood vessels to lymphoblastic leukemia in the rat testis

The testis is the third common site of relapse in childhood acute lymphoblastic leukemia (ALL). Despite the apparent clinical importance of testicular relapse, its pathogenesis is still unknown. The studies with an animal model of ALL have shown that many testicular factors are able to control the intratesticular infiltration and proliferation of leukemic lymphoblasts during the untreated course of ALL. In the present study, the ultrastructure of rat testicular interstitium infiltrated by leukemic lymphoblasts was studied in two groups of rats transplanted with rat T cell leukemia in early and late puberty. In both groups most of the leukemic cells infiltrating testicular interstitium were totally or partly enveloped by one or more Leydig cells, and the endothelial cells of capillaries, arterioles and venules were hypertrophic. The Leydig cells of the younger experimental group were by nuclear and cytoplasmic ultrastructure similar to the undifferentiated Leydig cells normally seen on the third postnatal week. The results suggest that Leydig cells bind leukemic lymphoblasts on their surface in vivo as also previously observed in vitro, and that ALL may disturb the pubertal maturation of Leydig cells. The occlusion of arterial and capillary lumina by folds of hypertrophic endothelial cells together with adhered leukemic lymphoblasts may impair the circulation of leukemic testes.

Surgical results of lumbar spinal stenosis. A comparison of patients with or without previous back surgery

STUDY DESIGN

This retrospective study was designed to investigate the effects of previous back surgery in patients undergoing surgical procedure for lumbar spinal stenosis.

OBJECTIVES

The authors evaluated the results of singly operated and repeat surgery patients operated on for lumbar spinal stenosis, and compared prognostic factors correlated with the results for these two groups.

SUMMARY OF BACKGROUND DATA

Repeat back surgery is generally not as successful as a first operation, but few studies evaluate the effects of previous back surgery on the surgical outcome of patients with lumbar spinal stenosis.

METHODS

The subjective disability of singly operated and repeat surgery patients as assessed by the Oswestry questionnaire was compared with clinical data and myelographic findings to identify factors predictive of outcome.

RESULTS

The mean Oswestry score was 31.0 for singly operated patients and 40.9 for repeat surgery patients (P = 0.0001). The outcome was excellent-to-good in 67% of singly operated patients and in 46% of repeat surgery ones (P < 0.0017). Severe myelographic findings correlated significantly with good outcome in the singly operated group but not in the repeat surgery group. Coexisting disease contributed significantly to poor outcome in the repeat surgery group, but not in the singly operated group. The optimum time interval for achieving successful results from subsequent surgery is at least 18 months after previous surgery. In the regression analysis, the prognostic preoperative variables for good outcome was block stenosis on myelography in the singly operated patients and age over 50 years and no coexisting disease in the repeat surgery patients.

CONCLUSIONS

Previous back surgery had a highly significant worsening effect on the outcome of patients reoperated on for lumbar spinal stenosis. Not even a very well-established diagnosis of lumbar spinal stenosis, as confirmed by myelography and during surgery, could guarantee as successful a surgical outcome in the repeat surgery patients as that in the singly operated patients.

Effects of testicular cytokines on proliferation of rat T-leukaemic lymphoblasts in vitro

A rat acute lymphoblastic leukaemia (ALL) model was used to study the mechanisms involved in the tendency to testicular relapse of ALL in boys. Previous studies have indicated that the infiltration and growth of leukaemic lymphoblasts in the testis are influenced by the same endocrine and paracrine control systems that regulate normal testicular function. In the present study the effects of aqueous extracts of scrotal, abdominal and estrogen-treated postpubertal rat testes on rat-leukaemic lymphoblast proliferation were evaluated. The effects of recombinant cytokines analogous to those observed in the testis on leukaemic cell DNA-synthesis were also evaluated since changes in the levels of these factors have been observed in association with cryptorchidism and low levels of gonadotropins. Transforming growth factor-beta 1 (TGF-beta1), significantly inhibited the proliferation of leukaemic rat lymphoblasts after 24 h of culture, whereas TGF-beta 2, interleukin-1 alpha (IL-1 alpha), IL-1 beta, IL-6 or combinations of them were inactive. Extracts of estrogen-treated testes and abdominal testes of unilaterally cryptorchid animals inhibited leukaemic T-cell proliferation significantly more than extracts of normal testes. The inhibitory activity in abdominal testes could be neutralized by anti-TGF-beta 1 antibodies. These results suggest that testicular TGF-beta 1 may influence growth of leukaemic lymphoblasts in the testis but also that other as yet unknown, testicular factors are involved in the regulation of leukaemic cell function in the testis.

Regulation of the transport of immunoglobulin G into the male rat reproductive tract

The net movements of IgG in the rat testis and epididymis were studied using physiological techniques in conditions of anticipated subnormal organ concentrations of testosterone (T). The volume of extracellular fluid accessible to IgG per gram whole testis (Veq, microliter/g) did not change but that per gram interstitial tissue decreased in intact rats treated with T to suppress gonadotrophin secretion. Estimates of surface areas of the exchange vessels (S, cm2/g whole tissue) did not change in any of the organs studied. The speed at which equilibrium between tissue extracellular fluid and serum was reached (magnitude of K, min-1), lymph flow (QL, microliter/g/min) and estimates of microvascular permeability (P, nm/min) to IgG decreased in the testis of T-treated intact rats. In these animals, magnitude of K and P were higher than normal in the cauda. After castration, magnitude of K and P decreased to near zero in the caput and corpus regions. The changes in magnitude of K and P due to castration could partly be prevented by T supplementation in the caput, but not in the corpus, where Veq was supra-normal after T treatment. This difference in endothelial response between caput and corpus indicates differences in control of endothelium and epithelium along the length of the epididymal duct. In the testis of efferent duct-ligated (EDL) rats, P was lower than that in the intact rats, whereas in the corpus epididymidis of EDL rats, Veq and P were higher than normal. The supra-normal Veq values in the corpus epididymidis of EDL and castrated T-treated rats suggest that the epithelial barrier leaks in the corpus when luminal testosterone is low. It is concluded that during testosterone administration to normal rats, the testicular and epididymal epithelial barrier remains intact, that trans-endothelial transport of IgG and extracellular fluid volume decrease in the testicular interstitium and that in conditions of low serum T, the endothelium of microvessels in the caput and corpus epididymidis forms a barrier to IgG.

Multiple intracranial aneurysms in a defined population: prospective angiographic and clinical study

Multiple intracranial aneurysms (MIA) have been detected in up to one-third of patients with cerebral aneurysms. Three main external factors influence these figures as follows: the quality of angiographies, the quantity of vessels studied, and referral policy. In a 1-year prospective study, we determined the incidence of MIA in a defined catchment area in East Finland by investigating all of the patients with intracranial aneurysms with panangiography. In 114 unselected patients, a total of 170 intracranial aneurysms were detected, and, of these, 39 (34%) harbored MIA. In contrast to most other reports, there was a male predominance in patients with MIA, and half of these men had hypertension. Intracavernous carotid and pericallosal aneurysms were more frequent in patients with MIA. The number of asymptomatic vertebrobasilar aneurysms was extremely low, and most of the nonruptured aneurysms were found in bilateral carotid angiograms. In spite of the active search, the proportion of vertebrobasilar aneurysms remained at 6%. Although our surgical policy was most active, one-third of the asymptomatic aneurysms remained untreated, mainly because of the poor condition of the patient.

Surgical treatment of lumbar spinal stenosis: patients' postoperative disability and working capacity

A total of 439 patients operated on for lumbar spinal stenosis during the period 1974-1987 was re-examinated and evaluated for working and functional capacity approximately 4 years after the decompressive surgery. The assessment of subjective disability was based on the Oswestry low-back pain questionnaire. The proportion of excellent-to-good outcomes was 62% (women 57%, men 65%). The ability to work before or after the operation and a history of no prior back surgery were variables predictive of a good outcome. Before the operation 86 patients were working, 223 patients were on sick leave, and 130 patients were retired. After the operation 52 of the employed patients and 70 of the unemployed patients returned to work. None of the retired patients returned to work. In logistic regression analysis the ability to work preoperatively, age under 50 years at the time of operation and the absence of prior back surgery predicted a postoperative ability to work. Our results suggest that more attention should be focussed on the diagnosis of spinal stenosis and on the timing of the operative intervention.

Computed tomography after laminectomy for lumbar spinal stenosis. Patients' pain patterns, walking capacity, and subjective disability had no correlation with computed tomography findings

OBJECTIVES

The purpose of this study was to evaluate the relationship between postoperative computed tomography findings and patients' pain patterns, walking capacity, and subjective disability after laminectomy for lumbar spinal stenosis.

SUMMARY OF BACKGROUND DATA

Recent improvements in computed tomography have enabled this tool to reveal changes in a patient after an operation, but there is a paucity of comparative examinations regarding the lumbar spinal canal of asymptomatic and symptomatic patients after laminectomy for lumbar spinal stenosis.

METHODS

Ninety-two patients (42 women, and 50 men) with a mean age of 55 years were operated upon. Mean follow-up time was 3.5 years. Based on computed tomography findings of the operative area, three patient groups were formed: 1) no stenosis, 2) moderate stenosis, 3) and severe stenosis. During treadmill testing, each patient's pain was evaluated by visual analogue scale. The patients were divided into four pain pattern groups: 1) pain in the back and leg, 2) pain in the back only, 3) pain in the leg only, and 4) no pain in the back and leg. Subjective disability was measured by the Oswestry disability score.

RESULTS

The structural changes revealed by computed tomography, and the patients' pain patterns, walking capacity, and subjective disability did not correlate significantly with each other.

CONCLUSIONS

Postoperative computed tomography has only limited value because asymptomatic and symptomatic patients yield similar findings after surgery for lumbar spinal stenosis.

The predictive value of preoperative myelography in lumbar spinal stenosis

STUDY DESIGN

Retrospective follow-up study on the significance of myelographic findings on the postoperative results of patients with lumbar canal stenosis is not well defined.

OBJECTIVES

The authors studied the predictive influence of preoperative myelography on the outcome of patients with surgically treated lumbar spinal stenosis, defined by an upper limit of anteroposterior diameter of the dural sac on the lateral myelogram film of equal to or less than 12 mm.

SUMMARY OF BACKGROUND DATA

Patients with prior lumbar surgery were excluded. There were 251 patients (women 44% and men 56%) with a mean age of 55 years and a mean follow-up time of 4.2 years.

METHODS

Patients with complete block or subtotal block on myelography were included in the block stenosis group, patients with an anteroposterior diameter of less than 10 mm were included in the absolute stenosis group and patients with an anteroposterior diameter of 10-12 mm were included in the relative stenosis group.

RESULTS

The proportion of good-to-excellent outcomes was 76% in block stenosis, 56% in absolute stenosis, and 61% in relative stenosis. In the multivariate analysis, the pre-preoperative variables that correlated with good outcome were block stenosis and male sex.

CONCLUSIONS

The severity of myelographic findings is significantly related to the outcome of patients who underwent surgeries for lumbar canal stenosis.

Regulation of testicular infiltration in acute lymphoblastic leukaemia of the rat

The testis is a common site of relapse in childhood acute lymphoblastic leukaemia (ALL). In adults, testicular relapses of ALL are very rare. A similar age-difference in the frequency of the testicular infiltration exists also in the rat T-cell leukaemia. In the present investigation, the effect of various hormonal treatments and unilateral cryptorchidism on the form of testicular infiltrates by the rat T-cell leukaemia was studied. Inhibition of testicular activity by estradiol treatment (E2) of early pubertal rats injected i.p. with rat T-leukaemic lymphoblasts significantly decreased the proportion of the testis occupied by leukaemic infiltrates. The proportion of the testis occupied by leukaemic infiltrates was significantly higher in the abdominal testes of both early and late pubertal unilaterally cryptorchid rats, than in the scrotal testes of leukaemic control rats. Daily treatment of early pubertal rats with human chorionic gonadotrophin (hCG), or human menopausal gonadotrophin (hMG), did not have an effect on testicular leukaemic infiltration. These studies demonstrate that the leukaemic infiltration of the testis is influenced by the changes in the physiological activity of the testes.

The long-term prognosis after operation for lumbar spinal stenosis

The prognosis for patients treated surgically for lumbar spinal stenosis with a minimum follow-up time of 10 years was evaluated. The study group consisted of 102 patients (39 women and 63 men) with a mean age at operation of 52 years and with a mean follow-up time of 12.4 years. The antero-posterior (AP) diameter was equal to or less than 12 mm at the narrowest point on the preoperative lateral myelograms. The results were based on the Oswestry disability score, the severity of pain, the change in pain and the state of depression. According to this score the results were excellent-to-good in 69 patients (68%), the pain was mild in 64 patients (63%), the change in pain was slight in 78 patients (77%), and there was no depression in 55 patients (54%). The pain and the change in pain had a very high correlation in the Oswestry disability score. The pain led to depression more often in the men than in the women. The depression had a much stronger correlation to outcome in the men than in the women.

Value of computed tomography (CT) in the diagnosis of cochlear otosclerosis

The temporal bones of 40 patients with surgically confirmed otosclerosis were studied with high-resolution CT. The hearing of these patients was re-examined 5 years later. Foci of demineralization in the cochlear capsule were detected in 36% of operated ears and in 44% of otosclerotic ears not operated on. Mean bone conduction (BC) thresholds of ears with positive radiological findings did not differ significantly from those of otosclerotic ears with normal CT, either at the time of CT examination or 5 years later. Over 5 years, elevation of BC thresholds by 10 dB or more was observed significantly more often in operated ears with abnormal CT than in operated ears with normal CT, but in otosclerotic ears not operated on the corresponding difference was non-significant. It was concluded that CT examination is of little value in predicting sensorineural hearing loss in patients with otosclerosis.

Long-term results of surgical treatment of lumbar spinal stenosis

There are few data available regarding the long-term outcome of laminectomy for lumbar canal stenosis. Both in 1985 and in 1991 108 patients who had undergone surgery for lumbar spinal stenosis were reevaluated using the Oswestry disability questionnaire. There were 50 women and 58 men. The clinical diagnosis of stenosis was confirmed mainly by myelography. The mean follow-up time in 1985 was 6.8 years and in 1991 12.8 years, and the mean age of the patients at the time of surgery was 50.7 years. The mean Oswestry score in 1985 was 34.5 and in 1991 30.2 (P < 0.001). Men improved more than women. Laminectomy was performed on an average of 1.6 levels. Ten (9.3%) of the 108 patients underwent repeat decompression during the study period. The authors concluded that the results of the patients improved during the course of the longitudinal follow-up time of 7 and 13 years. The chances of a patient requiring reoperation after surgery for lumbar spinal stenosis were low.

Role of transforming growth factor beta in testicular immunosuppression

The potential role of transforming growth factor beta (TGF beta) in the regulation of the immunological milieu of the testis was investigated. Antibodies neutralizing TGF beta reversed the previously observed suppression of rat peripheral blood lymphocyte proliferation induced by rat abdominal testis extract. Recombinant TGF beta 1 dose-dependently inhibited testicular interleukin-1-like factor-driven proliferation of murine thymocytes and ConA-stimulated rat peripheral blood mononuclear cells. Extracts of seminiferous tubules contained a M(r) approximately 25 K TGF beta-like growth inhibitor of the CLL-64 mink lung epithelial cell line. The present findings suggest an important role for TGF beta in testicular immunosuppression.

One-year outcome in early aneurysm surgery: a 14 years experience

In a consecutive series of 1150 patients with cerebral aneurysms diagnosed in our department by angiography or autopsy between the years 1977-1990, 1007 patients underwent definitive operative treatment of their aneurysms mainly by early surgery. More than half (55%) were operated on during the first three days after subarachnoid haemorrhage (SAH), and more than three quarters (77%) during the first week. The surgical mortality at 30 days was 9%; at one-year follow-up 13% had died. The total management mortality was 22%. The 618 patients presenting in Hunt and Hess Grades I-II had a 4% mortality, and 90% had an independent life at follow-up; 270 Grade III patients had a 19% mortality and 68% were independent. There were 99 patients operated on in Grades IV-V with a 46% mortality and 30% were independent. Age of the patient and size of the aneurysm were strongly related to outcome; however, many of the giant aneurysms were operated on as an emergency because of large intracerebral haematomas. Best results were obtained in the anterior communicating artery (ACA) area; the lowest rate of useful recoveries was in the vertebro-basilar artery (VBA) area (71%). Early surgery did not prevent delayed ischaemic deficits. During the first 72 hours patients in Grades I-III can be operated on safely with good results. The results in Grades IV-V are poor, and we suggest that only cases with large haematomas or considerable hydrocephalus or those improving should be operated on in the first days after SAH, with limited hopes of functional recovery.

Pulmonary hypertension with coexisting portal hypertension

A 10-year-old boy who had portal hypertension secondary to portal fibrosis/intrahepatic biliary atresia developed syncopal episodes related to strenuous activity. A work-up excluded a metabolic or neurologic etiology and cardiac catheterization demonstrated significant pulmonary hypertension. Six months later he died and an autopsy revealed pulmonary plexogenic arteriopathy without microemboli. Previous reported cases of this symptom complex are reviewed. In addition, he had a history of nonspecific colitis, ulcerative stomatitis, and conjunctivitis responsive to steroid therapy. The possible relationship of these manifestations to the portal pulmonary pathology is discussed.