Intracranial aneurysms in twins: case report and review of the literature

Intracranial aneurysm in twins is a rare clinical disease entity. Only 15 cases have been described in the literature. We report on a pair of identical twins with intracranial aneurysms. One presented with subarachnoid haemorrhage; digital subtraction angiography showed a left posterior communicating artery aneurysm, which was treated by coiling. The patient's twin sister was called for screening, whereupon digital subtraction angiography revealed a right ophthalmic internal carotid artery aneurysm that was treated conservatively.

Impact of patterns of proteinuria on renal allograft function and survival: a prospective cohort study

BACKGROUND

Proteinuria is an important complication in renal transplant recipients. The aim of this prospective study was to evaluate the long-term impact of transplant proteinuria patterns on allograft function and survival.

METHODS

We analyzed urinary protein of a cohort of 83 renal transplants with proteinuria ≥0.5 g/d by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and radial immunogel diffusion assay. After initial stratification and analysis, the cohort was followed up for 16 yr. The graft outcome and survival were analyzed using Cox regression model to determine their association with different patterns of initial transplant proteinuria.

RESULTS

Group with predominantly glomerular (middle- and high-molecular-weight with or without low-molecular-weight) proteinuria (61%) had higher serum creatinine (p < 0.001) than the group with predominantly tubular (low-molecular-weight) proteinuria (39%). The incidences of chronic graft dysfunction and graft loss had increased in the glomerular proteinuria group (p < 0.001, hazard ratio 3.6, 95% confidence interval 1.7-7.5 and p < 0.001, hazard ratio 4.9, 95% confidence interval 1.9-12.1, respectively). Patient death did not differ (p = 0.434, hazard ratio 1.5, 95% confidence interval 0.5-4.5).

CONCLUSION

  Proteinuria in renal transplants can be differentiated into glomerular and tubular types based on molecular weight. Glomerular proteinuria is associated with significant increase in graft dysfunction and graft loss.

The validation and reproducibility of the pulmonary embolism severity index

SUMMARY BACKGROUND

Rapid, accurate risk stratification is paramount in managing patients with acute pulmonary embolism (PE). The PE Severity Index (PESI) is a simple tool that risk stratifies patients with acute PE.

OBJECTIVES

We sought to validate the PESI as a predictor of short- and intermediate-term mortality and to determine the inter-rater variability.

PATIENTS/METHODS

We retrospectively identified all patients with acute PE between October 2007 and February 2009. Two clinicians reviewed charts and independently scored PESI blinded to each other and to patient outcomes. Thirty- and 90-day mortality served as study endpoints and vital status was assessed via the Social Security Death Index. To facilitate analyses, raw PESI score was converted into risk class groups (I-V) and further dichotomized into low risk (I-II) vs. high risk (III-V) groups. Intraclass correlation and the kappa statistic were used to determine inter-rater variability.

RESULTS

The cohort included 302 subjects (mean age, 59.7 +/- 17.2 years; 44% male). All-cause 30- and 90-day mortalities were 3.0% and 4.0%, respectively. The mortality rate increased as raw PESI score increased. Risk of death correlated with risk class (P < 0.001). There were no deaths in risk classes I-III, but 30- and 90-day mortality for class V were 9.2% and 10.5%, respectively. Overall, mean PESI scores were similar between observers: 103.3 +/- 39.3 and 96.5 +/- 37.6 (P = NS). The inter-rater variability was good (kappa = 0.69; P < 0.0001).

CONCLUSIONS

The PESI correlates with 30- and 90-day mortality. It represents a reproducible scoring tool to risk stratify patients with acute PE.

Size, location, and multiplicity of ruptured intracranial aneurysms in the Hong Kong Chinese population with subarachnoid haemorrhage

OBJECTIVE

To review the pattern of ruptured intracranial aneurysms in terms of size, location, and the prevalence of multiple aneurysms in the Hong Kong Chinese population with subarachnoid haemorrhage.

DESIGN

Retrospective study.

SETTING

Three public hospitals in Hong Kong.

PATIENTS

A total of 267 Chinese patients with subarachnoid haemorrhage from ruptured intracranial aneurysms between July 1998 and June 2002 were reviewed retrospectively.

RESULTS

The patients had a mean age of 59 (range, 13-96) years, with a female-to-male ratio of 2:1. Concerning the age at presentation, males presented with ruptured intracranial aneurysms at a younger age (P=0.001) than females. Ruptured aneurysms were more commonly located in the anterior than posterior circulation (84% vs 16%). The posterior communicating artery (26%) and anterior communicating artery (22%) were the most common sites of rupture. As a whole, 64% of the aneurysms had a size of 5 mm or less. The anterior communicating artery had a higher proportion with a size of 5 mm or less compared to other locations (P<0.05). In this cohort, the prevalence of multiple aneurysms was 17%. There was no significant difference in the prevalence of multiple aneurysms between men and women (P=0.30). In patients with multiple aneurysms, the sizes of ruptured aneurysms were greater than those of the largest unruptured aneurysms (P<0.001). When compared with the group with single aneurysms, patients with multiple aneurysms had a smaller proportion of small aneurysms, sized 5 mm or less (P<0.05).

CONCLUSIONS

The pattern of ruptured intracranial aneurysms in the Hong Kong Chinese population was different from western and Japanese populations. Although the distribution of locations for ruptured aneurysms was similar, Hong Kong Chinese had a larger proportion of small aneurysms sized 5 mm or less. The prevalence of multiple aneurysms in Hong Kong is comparable to that in the Japanese population, but lower than that in the western populations.

Traumatic intracranial aneurysm in infancy

An anterior cerebral artery traumatic aneurysm in a 15-month-old infant is described. The diagnosis was confirmed by computed tomographic angiography. The patient recovered fully after successful clipping of the aneurysm. As the signs of traumatic intracranial aneurysm may be subtle especially in young children, a high degree of suspicion is essential in patients presenting with delayed neurological deterioration after head trauma.

Mycophenolate mofetil in the treatment of IgA nephropathy: a systematic review

INTRODUCTION

The aim of this study was to determine the effectiveness of mycophenolate mofetil (MMF) in IgA nephropathy (IgAN).

METHODS

A search through Cochrane Library, EMBASE and PubMed was carried out. Randomised controlled trials (RCTs), which compared MMF with conventional treatments, were identified. Patients' baseline, treatment strategies and study end-points were compared.

RESULTS

Four RCTs (168 patients) were selected. All patients had histologically-confirmed IgAN and proteinuria greater than 1 g/day. The follow-up duration ranged from 1.5 to 3.0 years. MMF was used at a titrated dose of 1-2 g/day. In the two trials with subjects having moderate to high risk for progressive disease, MMF did not demonstrate any significant difference in retarding the decline in renal function and proteinuria reduction. One trial concluded that there was a trend towards worse outcomes when MMF was used in moderately-advanced disease. Only one trial involving subjects with less advanced disease (reflected by a favourable histological grade) showed a significant decrease in proteinuria in the MMF-treated group. No serious adverse events occurred in all the four trials using MMF.

CONCLUSION

No benefit was seen in moderately-advanced IgAN treated with MMF. In a selected group of patients with less advanced disease, MMF was effective in proteinuria reduction. Larger randomised studies are needed to confirm or reject these results.

Molecular and genetic characterisation of the SARS coronavirus auxiliary protein X1 in Drosophila

1. We have generated monoclonal antibodies against the SARS coronavirus (SARS-CoV) X1/3a protein (3a), which are suitable for western blotting, immunocytochemistry, and immunohistochemistry. 2. We have established and characterised an in-vivo 3a transgenic Drosophila model, and demonstrated its usefulness in studying SARS-CoV 3a gene function. 3. We validated our in-vivo findings on 3a gene function in mammalian Vero E6 cells. 4. Our findings raise the possibility of using ion channel blockers as a novel approach to suppress SARS-CoV-induced cell death.

Pharmacological investigations of the anti-diabetic effect of Cortex Moutan and its active component paeonol

Cortex Moutan (CM, root bark of Paeonia suffruticosa Andr.) is one of the common herbs found in anti-diabetic traditional Chinese medicine formulae. To study the potential anti-diabetic mechanisms of CM, four in vitro models (intestinal brush border membrane vesicles (BBMV), rat hepatoma cell line H4IIE, human skin fibroblasts cell line Hs68 and mouse adipocytes 3T3-L1) were used. CM showed significant in vitro anti-diabetic effects by inhibiting glucose uptake of BBMV and enhancing glucose uptake into Hs68 and 3T3-L1 cells. Using bioassay-guided fractionation, paeonol was confirmed to be one of the active constituents for inhibiting BBMV glucose uptake. With neonatal-streptozotocin diabetic rats, paeonol (200 and 400mg/kgbody wt.) was found to improve oral glucose tolerance in vivo. To the best of our knowledge, this is the first report on the anti-diabetic effect of paeonol.

Effect of pattern topology on the self-cleaning properties of textured surfaces

The water contact angle and self-cleaning property of microfabricated surface textures possessing different topologies are compared. In one kind of surface textures, the protruded regions form a connected square network. In the other kind of surface textures, the protruded regions form a regular array of square posts. We find that the water apparent contact angle of the connected textures agrees with the Cassie equation [Discuss. Faraday Soc. 3, 11 (1948)], but that of the disconnected textures is much larger. Nevertheless, the disconnected textures exhibit inferior self-cleaning property, contrary to conventional conception. We discuss the possible reasons for these observations.

Mathematical modeling of guided neurite extension in an engineered conduit with multiple concentration gradients of nerve growth factor (NGF)

Neurotrophic factors such as nerve growth factor (NGF) provide essential cues to navigate growing axon toward their targets. Concentration and concentration gradient of NGF are key parameters affecting the growth rate and direction of neurites and axons. However, the maximum distance for guided nerve growth under stimulation of a single concentration gradient is limited and is thus unfavorable in nerve regeneration. Since the sensitivity of PC12 cells to NGF signals is restorable even after brief removal of the factors, exposure to multiple concentration gradients of the factor can achieve longer distances and greater rates of guided growth. In this study, a mathematical model simulating nerve growth in a virtually constructed nerve conduit incorporating multiple NGF concentration gradients is established. Using a genetic algorithm, optimized initial profiles of NGF able to achieve 4.5 cm of guided growth with a significantly improved growth rate has been obtained. The model also predicts an inverse relationship between the diffusion coefficient of the factor and the neurite growth rate. This model provides a useful tool for evaluating various conduit designs before fabrication and evaluation.

Opportunistic breast cancer screening in Hong Kong; a revisit of the Kwong Wah Hospital experience

OBJECTIVE

To analyse the performance of opportunistic breast screening in local Well Women Clinics during the 5-year period from 1998 to 2002, with reference to international as well as our own earlier experience (1991 to 1993 to 1995).

DESIGN

Prospective study.

SETTING

Well Women Clinics in regional Hong Kong hospitals.

PARTICIPANTS

Women attending the Well Women Clinics of the Tung Wah Group of Hospitals for breast cancer screening.

MAIN OUTCOME MEASURES

All screening-detected breast cancers.

RESULTS

After 46 637 screening mammograms and excluding palpable masses detected by the patients themselves, 232 women were detected with cancers, yielding a crude detection rate of 5.0 per 1000. Age range for cancer detection was 35 to 72 (median, 49) years. Clinic staff detected palpable lumps in 83 patients, constituting 36% of the detected cancers, of which 15 (6.5% of all detected cancers) were not identified by mammography. The cancer detection rate was 5.9 per 1000 in the age-group 40-49 years and 3.7 per 1000 in those 50 years or older. The cancer detection rate was 58.5 per 1000 in the high-risk group (aged <40 years with positive family history). The minimal cancer detection rate was 2.2 per 1000, representing 45% of all cancers whose pathology was available to us. Ductal carcinoma in situ comprised 28% of all such cancers. Our recall rates were 4.6% for additional views only, 3.3% for ultrasound only, and 2.3% for both. Positive predictive values for abnormal mammograms and biopsies were 4.9% and 26.0%, respectively.

CONCLUSION

Mammographic screening has been reported to reduce mortality up to 35% in western countries. However, data concerning Asian Chinese populations are meagre. Our Well Women Clinics pioneered large-scale self-referred breast screening in Hong Kong. Despite the lower incidence of breast cancers than in Occidental populations, our screening programme performed comparably to those in the West, and has improved over time. Our screening service for self-referred women detected breast cancers even at an early stage, which facilitated a better prognosis and more treatment options, whilst appearing to be highly acceptable to our community. Besides, it could provide training and expertise in breast radiology and mammography, which are essential prerequisites for establishing population screening.

Influence of an anti-diabetic foot ulcer formula and its component herbs on tissue and systemic glucose homeostasis

Complications of diabetes impose major public health burdens worldwide. The positive effect of a Radix Astragali-based herbal preparation on healing diabetic foot ulcers in patients has been reported. Formula 1 is also referred as the 'Herbal drink to strengthen muscle and control swelling'. This formula contains six Chinese medical herbs, including Radix Astragali, Radix Rehmanniae, Rhizoma Smilacis Chinensis, Rhizoma Atractylodis Macrocephalae, Radix Polygoni Multiflori Preparata, and Radix Stephania Tetrandrae. Three of these herbs (Radix Astragali, Radix Rehmanniae, Rhizoma Atractylodis Macrocephalae) are commonly used in different anti-diabetic formulae of Chinese medicine. The objective of the current study is to use an interdisciplinary approach to test the hypothesis that Formula 1 and its components influence tissue and systemic glucose homeostasis. In vitro and in vivo models have been established including: (1) glucose absorption into intestinal brush border membrane vesicles (BBMV); (2) gluconeogenesis by H4IIE hepatoma cells; (3) glucose uptake by 3T3-L1 adipocytes and Hs68 skin fibroblasts; (4) normalization of glycaemic control in a diabetic rat model. The results of in vitro studies indicated that all herbal extracts can modify cellular glucose homeostasis. Since Formula 1 and Rhizoma Smilacis Chinensis extracts demonstrated potent effects on modifying glucose homeostasis in multiple tissues in vitro, they were further studied for their anti-diabetic activities in vivo using a streptozotocin (STZ)-induced diabetic rat model. The results showed that Formula 1 and Rhizoma Smilacis Chinensis extracts did not significantly improve oral glucose tolerance or basal glycaemia in diabetic rats. In conclusion, the anti-diabetic foot ulcer Formula 1 contains ingredients active in modifying tissue glucose homeostasis in vitro but these biological activities could not be associated with improved glycaemic control of diabetes in vivo.

Investigation of the effects of Chinese medicine on fibroblast viability: implications in wound healing

Diabetes mellitus has been a clinical problem for hundreds of years. Over 194 million people suffer from this disease worldwide. Improper control of diabetes may result in diabetic foot ulcer or even amputation. Granulation formation is an important issue essential for ulcer healing. The CRL-7522 fibroblast cell line and primary fibroblasts from a diabetic foot ulcer patient were used to model the wound healing enhancing activities of two clinically efficacious Chinese herbal formulae, Formula 1 (F1) and Formula 2 (F2) and their component herbs. Results showed that the two formulae and four of their component herbs, Radix Astragali, Radix Rehmanniae, Rhizoma Alismatis and Rhizoma Atractylodis Macrocephalae significantly enhanced CRL-7522 cell viability. However, these component herbs showed compromised effects on the viability of primary fibroblasts cultured from the ulcerous tissue of a diabetic patient. Interestingly, F1 and F2 enhanced the viability of primary cultured fibroblasts from the diabetic patient even in the face of insulin resistance. These results further support the previously reported clinical efficacies of the two formulae on healing diabetic foot ulcers.

Photocatalytic degradation of di(2-ethylhexyl)phthalate adsorbed by chitin A

Di(2-ethylhexyl)phthalate (DEHP) is a ubiquitous environmental contaminant due to its extensive use as a plasticiser and its persistence. Currently, there is no cost-effective treatment method for its removal from industrial wastewater. In a previous study, DEHP was effectively adsorbed from aqueous solution by biosorption onto chitinous materials. Biosorption can pre-concentrate DEHP from the aqueous phase for further treatment. As biosorption cannot degrade DEHP, in this study the degradation (and detoxification) of DEHP adsorbed onto chitinous material by photocatalytic oxidation (PCO) is attempted. PCO relies on hydroxyl radical (.OH), which is a strong oxidising agent, for the oxidative degradation of pollutants. It is a non-selective process which can degrade DEHP adsorbed onto chitinous material. The first part of this study is the optimisation of the degradation of adsorbed DEHP by PCO. Adsorption was carried out in the physicochemical conditions optimised in the previous study, with 500 mg/L chitin A and 40 mg/L DEHP at initial pH 2, 22+/-2 degrees C and 150 rpm agitation for 5 min. After optimisation of PCO, a 61% removal efficiency of 10 mg/L of DEHP was achieved within 45 min under 0.65 mW/cm2 of UV-A with 100 mg/L TiO2, and 10 mM of H2O2 at initial pH 12. The optimisation study showed that UV-A and TiO(2) are essential for the degradation of DEHP by PCO. The degradation intermediates/products were identified by GC-MS analysis. GC-MS results showed that the di(2-ethylhexyl) side chain was first degraded, producing phthalates with shorter side chains. Further reaction produced phathalic anhydride and aliphatic compounds such as alkanol and ester. The toxicities of parental and degradation intermediates in the solution phase and on chitinous materials were followed by the Microtox test. Results indicated that toxicity can be removed after 4 h treatment by PCO. Thus the decontamination of DEHP by integrating biosorption and PCO is feasible.

A treatable case of dementia--intracranial dural arteriovenous fistula

Dementia is a common medical problem that affects elderly patients. We report on a 77-year-old man with an intracranial dural arteriovenous fistula who presented with dementia that was initially thought to be irreversible and degenerative. Subsequent neuroendovascular intervention resulted in significant functional and cognitive improvement.

Randomized clinical trial comparing blue dye with combined dye and isotope for sentinel lymph node biopsy in breast cancer

Background

Use of blue dye alone as a marker for sentinel lymph node (SLN) biopsy is effective, but combining it with isotope marking can improve the success rate. Use of the isotope adds extra cost and there are potential radiation hazards. The two techniques were compared in a randomized trial.

Methods

Women with early breast cancer (less than 3 cm) and no palpable axillary nodes were recruited. Women older than 70 years with multicentric cancers or previous surgery to the breast or axilla were excluded. Patients were randomized to either blue dye alone or combined mapping for SLN biopsy. All women had a level I and II axillary dissection after the SLN biopsy.

Results

A total of 123 patients were recruited, of whom five were excluded from analysis. Blue dye alone was used in 57 women and 61 had combined mapping. Baseline demographic data were similar in the two cohorts. The success rate of SLN biopsy was higher with combined mapping than with blue dye alone (100 versus 86 per cent; P = 0·002). The accuracy and false-negative rate were similar (accuracy 100 per cent for combined mapping versus 98 per cent for blue dye; false-negative rate 0 versus 5 per cent).

Conclusion

Combined mapping was superior to blue dye alone in identification of the SLN, but accuracy and false-negative rates were similar.

Hyperlipidaemia in chronic kidney disease

Cardiovascular disease is a major cause of mortality and morbidity in patients with chronic kidney disease (CKD). The prevalence of hyperlipidaemia or dyslipidaemias is much higher compared to the general population. Total or low-density lipoprotein (LDL) cholesterol is highest in patients with chronic renal impairment. The majority of patients with CKD do not develop renal failure; indeed, most of them die of cardiovascular causes before the development of renal failure. The K/DOQI (Kidney Disease Outcomes Quality Initiative) guidelines on dyslipidaemias in CKD suggest that all patients should therefore be evaluated for dyslipidaemias. They should have a complete fasting lipid profile with total, LDL and high-density lipoprotein cholesterol, and triglycerides measured to identify those at risk and those who require treatment. Generally, the treatment approach parallels that suggested by the National Cholesterol Education Program Adult Treatment Panel III guidelines, in which the main focus of treatment is the level of LDL cholesterol. Patients with CKD should be considered a "very high risk" category and aggressive therapeutic intervention initiated to reduce the risk of cardiovascular events.

ATRA therapy restores normal renal function and renal reserve and prevents renal failure

This article presents clinical data which suggest that the current dosage of losartan 50 to 100 mg/day may not be the optimum in many cases, especially if used as monotherapy in the treatment of proteinuria and we may have to increase to 200 mg/day. However, about 30% of patients cannot take angiotensin-converting enzyme inhibitor (ACEI) because of the side effect of cough. To potentiate the anti-proteinuric effect of losartan, especially for patients who do not adhere to a low salt diet, a 12.5-mg dose of hydro-chlorothiazide may further decrease proteinuria. The main message of this article is that we would have to, in many instances, increase the dose of losartan to a minimum of 100 mg/day or 100 mg twice a day for some patients for optimal therapy. The second message is to monitor the creatinine clearance test (CCT) and to start therapy when CCT is reduced and not wait for serum creatinine to rise to abnormal levels (renal impairment) before starting therapy. The first group involves half a dozen patients with hypertension but no proteinuria. Therapy with losartan is shown to improve the renal function. This data suggest that losartan, apart from its use in reduction of proteinuria, can be used in patients with mild renal impairment without proteinuria to reverse the mild renal impairment and preserve renal function. The second group deals with 3 patients with low creatinine clearance. After a followup period of an average of 3 years, they all developed renal impairment. In another 6 patients, the data suggest that we should perhaps treat patients with low CCT as soon as possible and with dose ranging from 100 to 200 mg/day if necessary, to derive maximum beneficial effect. The third group highlights 5 patients with high CCT due to glomerular hyperfiltration. With time, the high CCT decreases and renal impairment sets in. The data suggest that patients with high CCT should be treated early to prevent renal impairment. The fourth group illustrates 6 patients where their proteinuria was markedly reduced with the increase of losartan from 100 mg/day to 200 mg/day, suggesting that losartan 200 mg/day is probably the optimum dose. In conclusion, apart from its traditional usage in reduction of proteinuria to retard progression to renal failure, the data suggest that losartan is also indicated in patients with renal impairment in the absence of proteinuria; patients with low CCT, patients with high CCT and patients who do not respond to a dosage of 100 mg/day should have the dosage increased to 100 mg twice daily to increase efficacy of losartan. It is hoped that with these new and earlier indications as well as increased dosage of losartan starting with 100 mg, whenever possible, and increasing to 200 mg/day, if there is no response, we can prevent more patients from developing renal failure. Based on these observations, further randomised controlled trials should be designed to address these issues.

Beliefs about elderly people among social workers and the general public in Hong Kong

Social learning theory expects the social worker to hold more favorable beliefs about elderly people and scapegoat theory expects one having higher self-esteem to be so. The role of social work and self-esteem may be factors explaining ageism at the individual level. Because ageism seems to emerge in Hong Kong as well as other industrialized societies, the study surveyed the general public, social workers, students, elderly center members to (1) determine the relative extent of ageism in terms of beliefs about physical, social, and psychological dimensions of elderly people, and (2) test hypotheses deriving from social learning and scapegoat theories. Analysis of data from 902 respondents showed that people younger than 60 years were more favorable regarding the social dimension and less favorable regarding the psychological dimension of beliefs about elderly people. One with higher self-esteem tended to be more favorable in beliefs about social and psychological dimensions of elderly people but less favorable in the belief about the physical dimension. Although the gerontological social worker was more favorable in the belief regarding the social dimension of elderly people than others, this difference might be attributable to his or her higher self-esteem. Hence the role of social work did not necessarily improve one's image of elderly people in Hong Kong.

MR Detection of Dilated Deep Medullary Veins in Intracranial Dural Arteriovenous Fistulas with retrograde Leptomeningeal Venous Drainage

SUMMARY

Patients with dural arteriovenous fistula (DAVF) are at higher risk of developing neurological deficits when there is retrograde leptomeningeal venous drainage. Our aim is to demonstrate the presence of dilated deep medullary veins in the brain on magnetic resonance imaging (MR) in this group of patients, and to assess their clinical significance. Nine patients with angiographically proven DAVF associated with leptomeningeal venous drainage who had MR before treatment were studied.MR was performed in at least two orthogonal planes before and after gadolinium administration. The dural fistula was located at the cavernous sinus in five patients, at the transverse-sigmoid sinus in three and at the tentorium in one. Dilated deep medullary veins were noted in six patients. Of these, four showed parenchymal abnormalities which included intracerebral haematoma, venous infarction, brain oedema and T2 hyperintensity in brainstem. Venous varix was present in one patient. No neurological complication or parenchymal change was observed in the three patients without dilated deep medullary veins. Therefore, in patients with intracranial DAVF associated with leptomeningeal venous recruitment, the MR finding of dilated deep medullary veins suggests a more severe degree of venous hypertension and congestion in the brain. This subgroup of patients has a much higher chance of neurological complications and warrants urgent intervention.

Endovascular treatment of radiation-induced petrous internal carotid artery aneurysm presenting with acute haemorrhage. A report of two cases

Haemorrhage from rupture of petrous ICA aneurysm can be life threatening and emergency treatment is required. We report 2 cases of radiation-induced petrous internal carotid artery (ICA) aneurysm presenting with acute haemorrhage (epistaxis and otorrhagia) after radiotherapy (RT) for nasopharyngeal carcinoma (NPC). Both patients had a history of RT treatment for NPC. The first patient, a 54-year-old man, presented with sudden severe epistaxis and haemorrhagic shock. The second patient, a 35-year-old man, presented with episodes of severe otorrhagia. The first patient was immediately resuscitated. Obliteration of the aneurysm was performed by endovascular occlusion of the ICA with Guglielmi detachable coils and fibered platinum coils. For the second patient, the aneurysm was treated by deploying a self-expandable stent across the aneurysm neck. In an emergency situation, ruptured petrous ICA aneurysm can be treated with endovascular occlusion of the ICA with microcoils if there is a good collateral blood flow. Alternatively, the aneurysm can be treated by deployment of a stent, which can induce stasis and eventual thrombosis of the aneurysm.

Characterization of AFMP1: a novel target for serodiagnosis of aspergillosis

We cloned the AFMP1 gene, which encodes the first antigenic cell wall galactomannoprotein in Aspergillus fumigatus. AFMP1 codes for a protein, Afmp1p, of 284 amino acid residues, with a few sequence features that are present in Mp1p, the antigenic cell wall mannoprotein in Penicillium marneffei that we described previously, as well as several other cell wall proteins of Saccharomyces cerevisiae and Candida albicans. It contains a serine- and threonine-rich region for O glycosylation, a signal peptide, and a putative glycosylphosphatidyl inositol attachment signal sequence. Specific anti-Afmp1p antibody was generated with recombinant Afmp1p protein purified from Escherichia coli to allow further characterization of Afmp1p. Afmp1p has a high affinity for Galanthus nivalis agglutinin, a characteristic indicative of a mannoprotein. Furthermore, it was recognized by a rat monoclonal antibody against the galactofuran side chain of galactomannan, indicating that it is a galactomannoprotein. Ultrastructural analysis by immunogold staining indicated that Afmp1p is present in the cell walls of the hyphae and conidia of A. fumigatus. Finally, it was observed that patients with aspergilloma and invasive aspergillosis due to A. fumigatus develop a specific antibody response against Afmp1p. This suggested that the recombinant protein and its antibody may be useful for serodiagnosis in patients with aspergilloma or invasive aspergillosis, and the protein may represent a good cell surface target for host humoral immunity.

Diagnostic accuracy of vacuum-assisted biopsy device for image-detected breast lesions

BACKGROUND

Non-palpable breast lesions present diagnostic difficulties. Ultrasound-guided fine-needle aspiration cytology (FNAC) is a common method used to obtain a diagnosis, but FNAC is frequently inconclusive or insufficiently accurate. Recently a vacuum-assisted biopsy device (Mammotome, Ethicon, Endo-surgery, USA) has been introduced. The diagnostic accuracy of this biopsy device was assessed for lesions that were visible on ultrasound.

METHODS

Fifty ultrasound-guided mammotome biopsies were performed. All were small breast lesions primarily detected by ultrasound. All received FNAC as initial assessment. Mammotome biopsy was performed whenever the breast lesion was considered indeterminate or if it was considered benign and there were associated risk factors such as a family history of breast cancer.

RESULTS

Of 50 mammotome biopsies 45 had benign histology. Three of 45 lesions were excised at the patients' request and were confirmed to be benign. The remaining 42 patients received an ultrasound follow up at 6 months. The lesion size remained static in 39 patients. In three patients the lesion size increased and they were excised and histology was benign. For the four malignancies diagnosed with mammotome biopsy, three patients received definitive treatment and one patient defaulted. There was one failed mammotome biopsy in the present series.

CONCLUSIONS

Mammotome biopsy is an acceptable diagnostic method for small breast lesions seen on ultrasound. It reduces the need for open biopsy without compromising diagnostic accuracy.

Vascular patterns in pterygium and conjunctival autografting: a pilot study using indocyanine green anterior segment angiography

AIMS

To characterise the vasculature of pterygium using indocyanine green (ICG) anterior segment angiography and to demonstrate the pattern of revascularisation following conjunctival autografting.

METHODS

ICG anterior segment angiography was performed on nine patients with pterygium. Angiography was repeated at 1-2 weeks and 2 months following conjunctival autografting in these patients.

RESULTS

Angiography showed a single feeder vessel originating from the anterior conjunctival circulation in six cases (66.7%). This vessel branched to form the radial vessels of the pterygium. Following conjunctival autografting, reperfusion of the vessels in the conjunctival autograft was demonstrable as early as 1 week postoperatively from the episcleral bed. At 2 months postoperatively, the graft appeared well perfused with mild leakage demonstrable at the edges of the graft.

CONCLUSIONS

A single feeder vessel from the anterior conjunctival circulation branches to form the radial vessels in pterygium. Reperfusion of conjunctival autografts occurs as early as 1 week postoperatively from the episcleral bed.