The oxysterol receptor LXRβ protects against DSS- and TNBS-induced colitis in mice

We examined the function of the oxysterol receptors (LXRs) in inflammatory bowel disease (IBD) through studying dextran sodium sulfate (DSS)- and 2,4,6-trinitrobenzene sulfonic acid (TNBS)-induced colitis in mice and by elucidating molecular mechanisms underlying their anti-inflammatory action. We observed that Lxr-deficient mice are more susceptible to colitis. Clinical indicators of colitis including weight loss, diarrhea and blood in feces appeared earlier and were more severe in Lxr-deficient mice and particularly LXRβ protected against symptoms of colitis. Addition of an LXR agonist led to faster recovery and increased survival. In contrast, Lxr-deficient mice showed slower recovery and decreased survival. In Lxr-deficient mice, inflammatory cytokines and chemokines were increased together with increased infiltration of immune cells in the colon epithelium. Activation of LXRs strongly suppressed expression of inflammatory mediators including TNFα. While LXRα had anti-inflammatory effects in CD11b(+) immune cell populations, LXRβ in addition had anti-inflammatory effects in colon epithelial cells. Lack of LXRβ also induced CD4(+)/CD3(+) immune cell recruitment to the inflamed colon. Expression of both LXRA and LXRB was significantly suppressed in inflamed colon from subjects with IBD compared with non-inflamed colon. Taken together, our observations suggest that the LXRs could provide interesting targets to reduce the inflammatory responses in IBD.

Abstract 2228: Folate-related genes polymorphism and risk of pediatric acute lymphoplastic leukemia

Background: Childhood acute lymphoblastic leukemia (ALL) is the most common malignancy affecting children, constituting about 30% of all cancers among children. It constitutes about 75% of pediatric acute leukemia with peak incidence between ages 3 and 4. The assertion that ALL may have a genetic basis has long been pursued through association studies based on candidate genes as folate metabolism. Polymorphisms in folate pathway genes may influence the susceptibility to acute lymphoblastic leukemia. Increased risk of ALL was observed in reduced folate carrier protein (RFC1) 80GA variant carriers. A 1.4-fold reduction in ALL risk was observed for carriers of the methyl tetrahydrofolate reductase (MTHFR) 677T allele. Objectives: this study was carried out to evaluate the contribution of MTHFR C677T and RFC1 80GA gene polymorphism and susciptability of childhood acute lymphoblastic leukemia. Materials &Methods: DNA was isolated from 200 children, divided into 2 groups, group I included 100 pediatric ALL patients and group II included 100 healthy donors as controls. Genotyping of MTHFR C677T and RFC1 G80A was performed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) using Hinf I and HhaI restriction endonuclease respectively. Results: MTHFR 677T allele carriers were significantly lower in ALL cases (46%) than healthy controls (56%). Reduction in ALL risk was observed for heterozygous (CT) or homozygous (TT) carriers of the MTHFR 677T allele (OR 0.8; 95% CI, 0.9-1.5; P < 0.002). RFC1 80A allelic carriers have an increased susceptibility to ALL. Risk was increased 2.0 times (OR 3.5; 95% CI, 1.5-4.8 ; P .02) for A-allelic carriers. Conclusion: our data suggested that the MTHFR gene variants are associated with decreased ALL rate and risk. the reduced risk associated with the MTHFR C677T polymorphisms may be the result of changed intracellular folate redistribution. the results of our study also supported the suggestion that RFC1 G80A RFC1 G80A single nucleotide polymorphism contributed to increase the susceptibility and the development of pediatric ALL.

Citation Format: Nermin Raafat, Amal Gharib, Usama Elsafy, Tamer Hassan. Folate-related genes polymorphism and risk of pediatric acute lymphoplastic leukemia. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 2228. doi:10.1158/1538-7445.AM2014-2228

Pattern of malignant solid tumors and lymphomas in children in the east delta of Egypt: A five-year study

Worldwide, the incidence and mortality rates of childhood cancers differ. The study of incidence patterns and survival rates in childhood malignancies is important in aiding in the planning of treatment centers and in obtaining further information with regard to the etiology. Few studies have investigated the survival in cases of childhood solid tumors in Egypt. The aim of the current study was to evaluate the patterns, frequency and outcome of solid tumors and lymphomas in children admitted to and followed up at the Pediatric Oncology Department of Zagazig University Hospital (Zagazig, Egypt) over a duration of 5 years (January 2004 to December 2008). A retrospective study was conducted, which included 155 children with solid tumors and lymphomas. The medical records were reviewed and the relevant data collected, in particular, those concerning demographic, clinical, histopathological, laboratory and imaging data as well as the treatment plans and outcomes. The mean age of patients was 5.6±3.04 years at diagnosis. The patients comprised 94 males and 61 females. Non-Hodgkin lymphoma (NHL) was the most common tumor type, followed by neuroblastoma (31.0 and 29.0%, respectively). When patients were stratified in terms of age (<5, ≥5 but <10, and ≥10 years), the <5-years-of-age group exhibited the greatest number of patients. Fever, pallor and pain were the most frequent initial clinical presentations among the patients and stage II was the most common stage (39.1%) followed by stage IV, III and I (35.0, 20.3 and 5.6% respectively). The overall 5-year survival rate in the study group was 66.7%. The survival rate was significantly higher in patients with Wilm’s tumor and Hodgkin lymphoma, followed by NHL (92.0, 88.0 and 72.0%, respectively; P<0.001), while the mortality rate was significantly higher in patients with neuroblastoma (P<0.001). In conclusion, NHL and neuroblastoma were the most common tumors; the survival rates were higher in patients with Wilm’s tumor and Hodgkin lymphoma and lower in patients with neuroblastoma. A larger multicenter study is required to further investigate the conclusions drawn from this study.

Management of spinal dural arterio-venous fistulas. Report of 12 cases and review of literature

INTRODUCTION

Spinal cord arteriovenous malformations and fistulae are rare vascular lesions than can lead to myelopathy that is at many instances overlooked during diagnosing the cause of progressive myelopathy and weakness. Treatment options involve either endovascular embolization, surgical disconnection or a combination of both. This study aims to evaluate various treatment methods for sDAVFs and the outcome of these methods.

METHODS

This study involved 12 patients suffering from symptoms attributed to spinal dural arteriovenous fistulas; 11 were male and one was a female patient, with ages ranging between 50 years and 71 years. All patients presented with progressive spastic paraparesis of varying grades, and 6 had sphincter disturbances prior to treatment. Patients were evaluated by Aminoff-Logue motor disability scale.

RESULTS

Three were managed by endovascular embolization and 9 by surgical disconnection. Three patients showed full recovery after treatment, 7 patients showed no change in their neurological status following treatment, and 2 patients showed partial recovery after treatment.

CONCLUSION

Spinal AVF is a rare curable cause of spinal myelopathy if managed promptly. Good angiographic studies prior to treatment decision are a must, in order to plan the best approach according to the angioarchitecture of the fistula whether it will allow endovascular embolization or will surgery be more feasible.

Carotid artery occlusion for the treatment of symptomatic giant carotid aneurysms: a proposal of classification and surgical protocol

Giant intracranial aneurysms are rare disorders that represent only 5% of all intracranial aneurysms; they have a wide variety of presentations including rupture, embolic effects, and mass effect symptoms that can mislead the diagnosis to tumors rather than aneurysms. Their treatment is difficult and carries higher morbidity and mortality than usual aneurysms due to their complex nature. This study involved retrospective analysis of data of 28 patients, managed between 2006 and 2012, suffering from giant internal carotid artery (ICA) aneurysms with various presenting symptoms, none of which was hemorrhage. They were all evaluated by BOT prior to any intervention; they were subjected to various treatment strategies including selective coiling, parent artery occlusion with or without bypass, aneurysm trapping with or without bypass, and patients were followed for a period ranging from 6 months to 5 years. Out of 26 patients with giant aneurysms with mass effects, 16 patients showed full recovery (61.5 %), 5 showed partial improvement (19.2 %), and 5 showed no change in mass effect symptoms (19.2 %). One patient died (3.5 %). Symptoms such as TIA or epistaxis showed complete recovery. This study shows that a well-designed protocol aiming at parent artery sacrifice will yield good to excellent results in managing ICA giant aneurysms, and it also shows that parent artery sacrifice is superior to other forms of treatment of these lesions regarding recurrence rates, morbidity, and mortality.

Identification of patients with low-risk pulmonary embolism suitable for outpatient treatment using the pulmonary embolism severity index (PESI)

BACKGROUND

There is increasing evidence that outpatient treatment of patients with low-risk stable pulmonary embolism (PE) is safe, effective and potentially reduces costs. It is not clear how many patients presenting to an Irish Emergency Department (ED) are potentially suitable for outpatient management.

AIMS

To identify how many patients presenting to our ED over a 1-year period who were diagnosed with acute PE are potentially suitable for outpatient treatment.

METHODS

A retrospective observational study was conducted over a 1-year period. Clinical notes for patients who had a positive computed tomographic pulmonary angiogram (CTPA) within 24 h of presentation to the ED were examined to risk stratify the patients according to the pulmonary embolism severity index (PESI).

RESULTS

Forty-seven patients who presented to our ED were diagnosed with a PE. Clinical notes were missing for 3 cases, and 44 cases were analysed further. The mean age was 64.3 (±16.8 SD) years and 24 (54.5 %, 95 % CI 40-68.3 %) were males. Six patients (13.6 %, 95 % CI 6.4-26.7 %) had a background of cancer. Fifteen cases (34.1 %, 95 % CI 21.9-48.7 %) were deemed to be low risk as they were categorised as PESI risk class I or II. Our study found that 61/420 (14.5 %, 95 % CI 11.5-18.2) of CTPAs done were positive for PE.

CONCLUSION

This study suggests that a significant percentage of patients diagnosed with acute PE are low risk as per PESI and therefore potentially suitable for outpatient management.

Acromegaly caused by growth hormone releasing hormone (GHRH) secreting tumor in multiple endocrine neoplasia (MEN-1)

We are presenting the clinical features, diagnostic work up and treatment of acromegaly caused by Growth hormone releasing hormone (GHRH) secreting neuroendocrine tumor (NECT) in a case of multiple endocrine neoplasia type 1 (MEN-1). A 36 year old man, known case of MEN-1 presented with acromegalic features. He has high IGF-1, GH and very high GHRH levels with a pancreatic head tumor and pituitary mass. He had high GHRH arteriovenous gradient across pancreatic tumor and underwent tumor resection, Post operative GHRH level fell dramatically. Tumor had high GHRH m-RNA level. Acromegalic patients with MEN-1 should be screened for ectopic GHRH secretion. Measurement of GHRH arteriovenous gradient across NECT or mRNA for GHRH in resected tumor can confirm the ectopic source. Treatment of choice is surgical resection of the tumor. Somatostatin analogue is an alternative because of its dual action in the pituitary gland and the NECT. Life long surveillance is needed as recurrence chance is high.

Evaluation of Balloon Occlusion Test for Giant Brain Aneurysms under Local Anaesthesia

We describe our experience in balloon test occlusion for giant carotid or basilar aneurysms under hypotension. Twenty-four patients underwent balloon test occlusion (BTO) during the year 2008. Only patients showed absence of any neurological deficits after 20 minutes under normal tension then another 20 minutes under hypotension were considered tolerable for occlusion of the parent artery. Of the 24 patients, four (16.67%) had deficits at normal tension and two (8.33%) had deficits at hypotensive phase. None of the 18 (75%) patients who clinically tolerated test occlusion and had parent artery sacrifice show any complication at follow-up period of two years. Two patients with clinical intolerability underwent carotid artery sacrifice after STA-MCA bypass without sequelae. Balloon test occlusion with hypotension is a useful, competent and simple technique in the evaluation of tolerance to parent artery occlusion in case of giant and complex intracranial aneurysms.

Prenatal diagnosis of chorionicity in twins

The aim of this audit was to assess the accuracy of transabdominal ultrasound scan in predicting chorionicity in twin pregnancies in our unit. The presence or absence of lambda sign, T-sign, dividing membrane thickness and number of placentae were used to determine chorionicity. We retrospectively analysed these antenatal markers in 268 sets of twins delivered over a 5 year period and compared it with the postpartum placental histology and neonatal gender. Of 268 twin deliveries, 204 (76%) had both chorionicity and placental histology to compare. 67 of 84 (80%) were correctly diagnosed antenatally as monochorionic and 137 of 151 (91%) as dichorionic. In 31 cases (15%) the ultrasound diagnosis of chorionicity didn't match placental histology. Seventeen were thought to be monochorionic antenatally but were confirmed dichorionic on placental histology. Overall chorionicity was correctly diagnosed in 171/204 (84%) using transabdominal ultrasound scan (USS) in all trimesters. However the sensitivity and specificity of USS was much higher for dichorionic twins when carried out before 14 weeks of gestation.

The adverse effects of flow-diverter stent-like devices on the flow pattern of saccular intracranial aneurysm models: computational fluid dynamics study

BACKGROUND

Stent deployment across the aneurysmal neck has been established as one of the endovascular methods to treat intracranial aneurysms with or without coils.

OBJECTIVE

The purpose is to study the possible adverse effects of deployment of the new flow-diverter stent-like devices (FD) on the flow characteristics of saccular aneurysm models.

METHODS

Numerical simulations of the blood flow patterns in the artificial models of three aneurysms were studied. One model was designed without an FD stent, the second model with one FD stent, and the third model with two stents. Numerical simulation for incompressible laminar blood flow was conducted in the three artificial cerebral aneurysm models by means of computational fluid dynamics.

RESULTS

There was a noticeable increase in the values of the circumferential pressure distributed on the walls of the aneurysm after stent deployment; this led to an increase the tension of the aneurysm surface and was considered to be an adverse effect. This pressure increase was further aggravated by the deployment of another stent. However, there is a beneficial effect of using FD stents, translating into the reduction of the flow velocity inside the aneurysm and wall shear stress at the inflow zone. This reduction decreases further with the deployment of another stent.

CONCLUSION

Aneurysms become tenser after the deployment of one flow-diverter stent and (more tense still) after after the deployment of another stent. This principle should be kept in mind when choosing which group of aneurysms is the best candidate for such a treatment strategy. This study recommends deploying several FD stents during endovascular procedures until complete arrest of the blood flow occurs during the procedure; otherwise, the aneurysm may become tenser and dangerous if a slow blood flow jet still exists inside it at the end of the procedure.

Influence of parent vessel dominancy on fluid dynamics of anterior communicating artery aneurysms

BACKGROUND

Parent vessel plays an important role in aneurysm formation and rupture. The diameter of either the A1 arteries is the peculiar key controlling the flow of the anterior communicating artery (ACOMA) aneurysms (ANs).

OBJECTIVE

The purpose is to study the effect of parent vessel dominancy, that is, the diameter of the A1 artery, on the flow characteristics of the ACOMA ANs.

METHODS

Numerical simulations for the flow patterns in six artificial models have been studied. Three models are designed with aneurysms and three models without. The two A1s were equal in two models. In the other two models, the nondominant A1 diameters were decreased by 50%. Again, the nondominant A1s were decreased by another 50% in the last two models. Each pair was designed with and without aneurysms in the ACOMA.

FINDINGS

The ACOMA shows lower velocity magnitudes and wall shear stresses when the two A1s are equal. However, if one A1 is dominant with a 50% difference from the other A1, there is higher shear stress on the ACOMA itself and in the inflow zone of the aneurysm that increases more with further reduction of the nondominant A1 by another 50%. An area of high corner pressure at the bifurcation of the dominant A1 into the ACOMA and A2 exists and increases in value with the decrease of diameter of the other nondominant A1.

CONCLUSION

Aneurysms located in the ACOMA with differences of 50% or more between the two A1s are subjected to more flow stresses.

Insulin-like growth factor-1 and childhood cancer risk

Overexpression of growth factors and/or their receptors is a common event in malignancy and provides the underlying mechanisms for one of the hallmarks of cancer, uncontrolled proliferation. Mounting evidence suggests that IGF-1 is involved in the pathogenesis and progression of different types of human cancer such as colon, breast, prostate and lung. However, only a few studies have investigated the association between IGF-1 levels and childhood cancer risk. We aimed to compare the IGF-1 serum level in children with de novo malignancies to healthy children, and to assess its relationship with cancer type, stage, metastasis and different disease characteristics. The study was carried out on 100 children; 50 children with de novo malignancies and 50 healthy children of matched age and gender as a control group. The patients were subjected to a routine work-up for their cancers according to our local standards. Estimation of the serum level of IGF-1 was carried out in the two groups using ELISA. Our results showed that children with cancer had significantly higher levels of IGF-1 than healthy controls of the same age and gender. No association was found between IGF-1 and tumor type, stage, metastasis and other disease characteristics. In conclusion, the IGF-1 serum level is an important indicator of risk for the most prevalent forms of childhood cancer. It may be used to identify children at the highest risk for these cancers and aid in determing who may benefit most from preventive strategies. Given the small number of children in our study, studies with larger populations are required to confirm these results.

Sclerosing mesenteritis presenting with complete small bowel obstruction, abdominal mass and hydronephrosis

Sclerosing mesenteritis is an uncommon and poorly understood inflammatory condition of the bowel mesentery which can often be confused with neoplasia, Crohn's disease and other inflammatory conditions. We describe a case of complete small bowel obstruction and right sided hydronephrosis due to sclerosing mesenteritis.

Vein of Galen aneurysms: presentation and endovascular management

BACKGROUND

We present our experience with managing 13 cases of vein of Galen aneurysm with a special focus on endovascular strategies. This clinical review deals with the multivariable clinical presentation of vein of Galen aneurysms and the role of transarterial endovascular treatment.

METHODS

Thirteen patients diagnosed with vein of Galen aneurysms have been reviewed. Clinical presentation, diagnostic modalities and treatment strategies are also documented for each. MRI and three-dimensional CT angiogram (3D CTA) were performed for all patients. Transarterial embolization with Histoacryl was performed in 8 patients proved to have true vein of Galen aneurysmal malformation (VGAM).

RESULTS

Clinical presentation was variable including hydrocephalus, headaches, heart failure, coma, epilepsy, and even left orbital swelling. MRI demonstrated large vein of Galen aneurysms in all the cases. 3D CTA demonstrated true VGAM in 10 patients. Two cases proved to have vein of Galen varices. Endovascular treatment was conducted successfully in 8 patients and resulted in arrest of head growth, resolution of headaches and improvement of cardiac condition.

CONCLUSION

The transarterial approach proved to be a successful way of management of true VGAM that yielded better outcomes.

The Immediate Management of the Patient with Rupture: Open Versus Endovascular repair (IMPROVE) aneurysm trial--ISRCTN 48334791 IMPROVE trialists

BACKGROUND

Systematic reviews have suggested a survival advantage for patients with ruptured abdominal aortic aneurysm (AAA), who are managed by endovascular repair. These reviews are based on single centre experiences of selected patients.

OBJECTIVE

To determine whether a policy of endovascular repair improves the survival of all patients with ruptured AAA.

METHODS

A randomized controlled trial, IMPROVE (ISRCTN 48334791) will randomize patients with a clinical diagnosis of rAAA, made in hospital, either to immediate CT scan and endovascular repair whenever anatomically suitable (endovascular first), or to open repair, with CT scan being optional (normal care), The trial is set on a background of guidelines for emergency care, CT scanning and anaesthesia, which incorporate the protocol of permissive hypotension. Recruitment started in October 2009 and 600 patients are required to show a 14% survival benefit at 30 days (primary outcome) for the endovascular first policy. Recruitment will be from the UK and Europe. Secondary outcomes include 24h, in-hospital and 1 year survival, complications, major morbidities, costs and quality of life.

DISCUSSION

This is a "real life" trial that will answer the fundamental relevant clinical dilemma, namely, do patients who present with ruptured AAA derive benefit from treatment in a system, which offers a preferential strategy of endovascular repair? The trial addresses whether the anticipated reduced mortality and morbidity associated with endovascular repair is offset by the relatively greater ease of access and speed to conventional surgery. This issue is pivotal to future patient care and provision of services.

Evaluation of the need for endoscopy to identify low-risk patients presenting with an acute upper gastrointestinal bleed suitable for early discharge

AIMS

To audit the safety of differing protocol-driven early-discharge policies, from two sites, for low-risk acute upper gastrointestinal (GI) bleeding and determine if default early (<24 h) in-patient endoscopy is necessary.

METHODS

All patients with low-risk acute upper GI bleeding presenting to two separate hospital sites in Leeds from August 2002 to March 2005 were identified. Both hospitals operate nurse-led process-driven protocols for discharge within 24 h, but only one includes default endoscopy. Relevant information was obtained from patients' notes, patient administration systems, discharge letters and endoscopy records.

RESULTS

120 patients were admitted to site A and 74 to site B. Median length of stay on the clinical decisions unit was 12.6 h at site A and 9.4 h at site B (p = 0.045). Oesophagogastroduodenoscopy was performed on 89/120 (74%) patients at site A compared with only 7/74 (9%) at site B (p<0.001). Six of 120 (5%) patients from site A were admitted to hospital for further observation compared with 6/74 (8%) from site B (p = 0.38). Of the remaining patients, all were discharged within 24 h, and 8/114 (7%) at site A vs 17/68 (25%) at site B were given hospital clinic follow-up (p<0.001). None of the 194 patients had further bleeding or complications within 30 days.

CONCLUSIONS

Patients admitted with a low-risk acute upper GI bleeding can be managed safely by a nurse-led process-driven protocol, based on readily available clinical and laboratory variables, with early discharge <24 h. Avoiding in-patient endoscopy appears to be safe but at the price of greater clinic follow-up.

An audit of referral practice for patients with impacted palatal canines and the impact of referral guidelines

OBJECTIVE

To assess referral practice for patients presenting with impacted palatal maxillary canines, and to develop and evaluate the effectiveness of referral guidelines.

DESIGN

Prospective clinical audit.

SETTING

Southend and Basildon district general hospitals.

SUBJECTS AND METHODS

The 'gold' standard was identified as regular dental attenders with unerupted palatal canines being referred by 12 years old, with a wait of no longer than 20 weeks from referral to assessment. Data were collected and compared to the defined standard. An algorithm outlining the correct management was developed and distributed to all local dentists. The cycle was repeated for a similar time period.

RESULTS

Ninety-eight per cent of patients were seen within 20 weeks during both cycles while the referrals increased from 85 to 109 patients. The percentage of patients referred by 12 years of age increased from 16.5% to 27% (p = 0.09). During the first cycle 82% of patients presented with retained deciduous maxillary canines. This was reduced to 76% during the second cycle (p = 0.29).

CONCLUSION

Referral practice was generally poor when compared to the recommended good practice. More patients were referred after distribution of the guidelines, but the percentage referred by the recommended age was not statistically significantly improved.

A proposed parent vessel geometry-based categorization of saccular intracranial aneurysms: computational flow dynamics analysis of the risk factors for lesion rupture

OBJECT

The authors created a simple, broadly applicable classification of saccular intracranial aneurysms into three categories: sidewall (SW), sidewall with branching vessel (SWBV), and endwall (EW) according to the angiographically documented patterns of their parent arteries. Using computational flow dynamics analysis (CFDA) of simple models representing the three aneurysm categories, the authors analyzed geometry-related risk factors such as neck width, parent artery curvature, and angulation of the branching vessels.

METHODS

The authors performed CFDAs of 68 aneurysmal geometric formations documented on angiograms that had been obtained in patients with 45 ruptured and 23 unruptured lesions. In successfully studied CFDA cases, the wall shear stress, blood velocity, and pressure maps were examined and correlated with aneurysm rupture points. Statistical analysis of the cases involving aneurysm rupture revealed a statistically significant correlation between aneurysm depth and both neck size (p < 0.0001) and caliber of draining arteries (p < 0.0001). Wider-necked aneurysms or those with wider-caliber draining vessels were found to be high-flow lesions that tended to rupture at larger sizes. Smaller-necked aneurysms or those with smaller-caliber draining vessels were found to be low-flow lesions that tended to rupture at smaller sizes. The incidence of ruptured aneurysms with an aspect ratio (depth/neck) exceeding 1.6 was 100% in the SW and SWBV categories, whereas the incidence was only 28.75% for the EW aneurysms.

CONCLUSIONS

The application of standardized categories enables the comparison of results for various aneurysms' geometric formations, thus assisting in their management. The proposed classification system may provide a promising means of understanding the natural history of saccular intracranial aneurysms.

Treatment of giant fusiform aneurysms of the basilar trunk with intra-aneurysmal and basilar artery coil embolization

OBJECTIVE

The authors report their experience in endovascular treatment of basilar artery (BA) trunk aneurysms by intra-aneurysmal and BA occlusion.

METHODS

Four patients were referred to our hospital from 1995 until 2002 with variable clinical presentations and radiologic appearances. All the patients were subjected for tolerability to balloon BA occlusion test to verify the collateral supply from the posterior communicating arteries. The patients were treated by intra-aneurysmal embolization together with basilar artery occlusion.

RESULTS

All the aneurysms were successfully isolated from the circulation. Transient postoperative neurologic deficits were constant findings in all the cases. Outcome was finally good for all the patients.

CONCLUSIONS

Endovascular treatment of complex BA trunk aneurysm by intra-aneurysmal embolization and BA occlusion method is a valuable alternative for management and successful isolation in patients with good collateral arterial flow.

Computational replicas: anatomic reconstructions of cerebral vessels as volume numerical grids at three-dimensional angiography

BACKGROUND AND PURPOSE

We present a relatively simple approach that physicians can use to reconstruct cerebral vessels as 3D numerical grids or computational replicas. The method accurately duplicates their geometry to provide computer simulations of their blood flow.

METHODS

Initial images were obtained by using any medical imaging technique, such as MR angiography, CT angiography, or 3D digital subtraction angiography. The data were collected in DICOM format and converted by a DICOM reader into a 3D gray-scale raster image. The image was then processed by using commercial visualization and mesh generation software, which allowed extraction of the luminal surface of the blood vessel (by using the isosurfacing technique). The subsequent final output was an unstructured tetrahedral grid that can be directly used for detailed analysis of cerebral vascular geometry for patient-specific simulations of blood flow.

RESULTS

Four examples of grid reconstruction and blood flow simulation for patients with ruptured aneurysms were validated with angiographic and operative findings. The ruptured areas were correlated with areas of high fluid-induced wall-shear stress.

CONCLUSION

This approach promises to be a practical tool for planning treatment and follow-up of patients after neurosurgical or endovascular interventions with 3D angiography. The proposed commercial packages or conceptually similar ones seem to be relatively simple and suitable for direct use by neurosurgeons or neuroradiologists.

Computational simulation of therapeutic parent artery occlusion to treat giant vertebrobasilar aneurysm

We applied computational fluid dynamics (CFD) analysis to assess 3D digital subtraction angiography findings in a patient with a giant vertebrobasilar aneurysm to simulate and compare the consequences of left and right vertebral artery occlusion. The balloon occlusion test suggested that occlusion of the right vertebral artery is the better way to treat this patient's aneurysm from the point of view of aneurysmal thrombosis and isolation from the circulation. The computer simulation supported this conclusion, at the same time indicating that from the point of view of pressure distribution on the wall of the aneurysm, the right vertebral occlusion may be also accompanied by an undesirable effect. A high-pressure area on the aneurysm wall in systole was revealed. This high pressure potentially could lead to subsequent aneurysmal growth, which indeed occurred, as was revealed by a follow-up examination 6 months later. This study is a good example of possible future applications of CFD in patients with cerebrovascular disease before therapeutic intervention.

Salmon roe-like amyloid deposition in a prolactinoma: a case report

An unusual case of prolactin-producing adenoma with extensive amyloid deposition is reported to clarify its radiological, intraoperative, and light- and electron-microscopic findings. A 41-year-old female patient complained of amenorrhea persisting for 20 years. Magnetic resonance imaging (MRI) revealed a pituitary adenoma, which included low-intensity spots on T1- and T2-weighted images. Intraoperative examination found multiple small, yellowish, spherical masses resembling salmon roe within the adenoma. Light and electron microscopy revealed the presence of immunoreactive cells for prolactin intermingled with concentric lamellar bodies of radially arranged amyloid fibrils originating from the endoplasmic reticulum in prolactinoma cells. The extracellular lamellar amyloid deposits were apparently due to degradation of prolactin-producing cells, but the reason for the production and radially arranged accumulation of amyloid remains to be identified.

Cervical cord compression with myelopathy caused by bilateral persistence of the first intersegmental arteries: case report

OBJECTIVE AND IMPORTANCE

Cervical myelopathy induced by vascular compression is rare. We report a case caused by bilateral persistence of the first intersegmental arteries (a vertebral artery anomaly). Myelopathy was successfully treated with vascular decompression.

CLINICAL PRESENTATION

A 66-year-old woman presented with gradually worsening paroxysmal neck and arm pain. Magnetic resonance imaging and angiography demonstrated anomalous intradural courses of both vertebral arteries, compressing the dorsal aspect of the cervical spinal cord.

INTERVENTION

Microvascular decompression was performed with transposition of the arteries, followed by anchoring of the arteries to the dorsolateral dura mater with Gore-Tex bands (W.L. Gore & Associates, Inc., Flagstaff, AZ).

CONCLUSION

The pain disappeared promptly after surgery. Surgical decompression, with anchoring of an anomalous vertebral artery to the dura, can relieve pain and other symptoms resulting from vascular cord compression.

Hemodynamic analysis of an adult vein of Galen aneurysm malformation by use of 3D image-based computational fluid dynamics

We applied computational fluid dynamic (CFD) analysis on the numerical grid of a 3D rotational digital subtraction angiogram obtained in a 22-year-old male patient, with an accidentally discovered vein of Galen malformation associated with single feeder aneurysm, to understand the flow pattern through the two aneurysms and improve our general understanding of hemodynamic characteristics of this variety of fusiform aneurysm. This technical note provides a good example of the application of CFD to 3D digital subtraction angiography for studying the flow pattern in patients with cerebrovascular disease.

Relationship of visceral fat distribution to angiographically assessed coronary artery disease: results in subjects with or without diabetes or impaired glucose tolerance

BACKGROUND AND AIM

To evaluate the relationship between the degree of coronary artery disease (CAD) and the amount of visceral fat deposition in a mixed population of CAD patients with or without diabetes or impaired glucose tolerance (IGT), and with different body weights.

METHODS AND RESULTS

A total of 55 patients undergoing coronary angiography (43 men and 12 women with a mean age of 58.9 +/- 1.1 years, range 37-70, and a mean body mass index [BMI] of 27.9 +/- 0.4, range 21.3-38.7) were studied in order to establish whether the coronary damage exclusively depends on intra-abdominal adipose tissue per se, or may be influenced by the coexistence of diabetes or IGT. Twenty-one subjects were non-diabetic, 13 had type 2 diabetes, and 21 IGT. Hypertension was found in 47% and dyslipidemia in 55%; 69% were smokers. The angiographic evaluation of CAD was made using the method of Gensini, and computed tomography (CT) was used to estimate the amount of visceral adipose tissue (VAT) based on a single scan at L4 level. Clinical, anthropometric, biochemical and hormonal variables, as well as smoking and alcohol consumption were determined. In the study population as a whole, the coronary score did not correlate with VAT, but only with smoking. However, both univariate and multivariate regression analysis showed that CAD significantly correlated with VAT in the non-diabetic patients, particularly in those with VAT of > 130 cm2. This correlation did not appear in the diabetic or IGT patients, nor when the group of patients with VAT > 130 cm2 was extended to include diabetic or IGT patients. No relationship was found between CAD and BMI or the other considered variables.

CONCLUSIONS

In a mixed population of CAD patients with or without diabetes, CAD correlates with VAT only in the absence of diabetes or IGT, and especially when VAT exceeds 130 cm2 at an L4 CT scan, regardless of weight or obesity. Diabetes or IGT therefore seem to contribute towards the development of CAD regardless of the amount of VAT.

Ulcerative terminal ileitis after BCG therapy for bladder carcinoma

AIM

We evaluated the aetiology of ulcerative ileitis in a 77-year-old patient receiving BCG therapy for recurring bladder carcinoma.

METHODS AND RESULTS

Histological examination, laboratory data and the clinical history allowed us to exclude a classical cause such as Crohn's disease, tuberculosis or ischaemia. The important locoregional reaction suggests a BCG ileitis of the terminal ileum. Intestinal BCG ileitis has been exceptionally described after BCG vaccination.

CONCLUSION

Our observation of ulcerative ileitis indicates that a digestive tract location is possible as a reaction to BCG therapy.

Microbubble retention and failed macular hole surgery

This case reports a possible new cause of failed macular hole surgery. Standard macular hole surgery with removal of epiretinal membranes, 16% C3F8, and strict postoperative prone positioning was performed on a patient with stage 4 macular hole. Macular hole surgery failed with retention of a microbubble of C3F8 within the macular hole during the follow-up period. Retention of a microbubble within a macular hole may prevent closure of the hole and be a previously unrecognized cause of failed macular hole surgery.

External versus internal approach to the removal of metallic intraocular foreign bodies

OBJECTIVE

To review the management of metallic intraocular foreign bodies (IOFB) at a single institution and to compare the use of internal and external approaches for their removal.

SUBJECTS AND METHODS

A retrospective review was conducted on 70 eyes from 70 patients who underwent surgical removal of a metallic IOFB with either an internal (vitrectomy followed by forceps or internal magnet use) or external approach (large electromagnet) by seven vitreoretinal surgeons at a single institution between 1973 and 1996. Visual acuity and complications occurring with the two approaches were the main outcome measures studied.

RESULTS

Overall, patients showed significant improvement in visual acuity following surgical intervention (P < 0.001) despite widely varying surgical techniques. When the authors compared patients treated with an external versus an internal approach they found no statistically significant difference with regard to visual outcome and a trend toward a higher rate of postoperative endophthalmitis in the external approach group.

CONCLUSION

Surgical removal of metallic IOFB results in significant visual improvement. The external approach to the removal of magnetic metallic IOFB remains a viable treatment option in select cases.

Revision hip arthroplasty activity in a single UK health region: an audit of 1265 cases

Revision hip arthroplasty is an operation which is steadily increasing in number and can often be technically challenging. We have utilised a regional hip register (the Trent Regional Arthroplasty Study) to analyse the epidemiology of revision hip arthroplasties in a single UK health region. The study shows that of the large number (1265) of procedures performed over a 7-year period (1991-1997), the majority were performed by general orthopaedic surgeons, with 91 different surgeons performing the operation and only two surgeons performing more than 20 procedures per year. Of more than 100 prosthetic combinations used for the procedure, the Charnley prosthesis was the most common (38.3% of acetabular revisions and 37.5% of femoral revisions). The same component was also the most commonly explanted (43%). There was an even geographical spread across the region with revision hip arthroplasty being performed in all hospitals with an orthopaedic in-patient facility. Prospective audit of this large and varied cohort is necessary to determine differences in outcome (if any) between 'specialist' hip surgeons and general orthopaedic surgeons.

The SCID mouse: an experimental model for endometriosis

The purpose of this study was to validate the suitability of the severe combined immunodeficient (SCID) mouse as an experimental model for endometriosis, by defining the morphological and histological features of induced endometrial implants, and characterizing specific biochemical properties of these implants. Human secretory endometrial tissues were injected into the peritoneal cavity of SCID/SCID CB17 mature female mice. Successful peritoneal implantation was observed in 55 of 57 (96.5%) SCID mice and consisted of circumscribed elevated nodules. Haematoxylin-eosin staining of implanting lesions demonstrated the presence of endometrial glandular tissue in a mixed background of stromal and inflammatory cells. When progesterone was administered to mice, epithelial glands underwent well-defined secretory changes. Immunohistochemical analysis using polyclonal human pan-cytokeratin antibodies demonstrated selective positive staining in the glandular epithelium of the human implants with none in the surrounding stroma. In-situ hybridization analysis using complement component 3 cDNA radiolabelled riboprobes yielded significantly more intense signals in glands compared to stroma. As human endometrial implants in SCID mice were shown to retain specific histological, functional and biochemical properties, we conclude that the SCID mouse is an attractive animal model for the study of endometriosis.