Reappraisal of duplex criteria to assess significant carotid stenosis with special reference to reports from the North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial

PURPOSE

Duplex examination is today the principal initial method of assessing extracranial carotid or vertebral artery disease. However, varying haemodynamic criteria have been described to categorize the degree of internal carotid artery stenosis, and similarly the degree of stenosis detected with angiography has been assessed with different methods as highlighted in studies performed by the North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial. This study looks at the correlation between two commonly used methods of assessing carotid artery stenosis with duplex criteria and the two methods of angiographic interpretation used in these trials. Duplex parameters are also identified to determine the greater than 70% stenosis group identified as at risk in these studies.

METHODS

A total of 120 carotid bifurcations were studied in patients who underwent both carotid duplex and angiography. Correlations of duplex with angiography were assessed with duplex criteria described by Zwiebel and by Strandness and the angiographic methods used in studies performed by the North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial. Receiver operator curves were constructed from the duplex data for the detection of stenosis greater than 70% based on the angiographic assessment used in the study performed by the North American Symptomatic Carotid Endarterectomy Trial.

RESULTS

The duplex criteria described by Zwiebel and Strandness differed in their accuracy depending on which of the two methods was used to report the angiograms. Zwiebel's criteria agreed more with the angiographic method used in the study performed by the European Carotid Surgery Trial (sensitivity 98%, specificity 81%, accuracy 88%), whereas Strandness' criteria agreed more with the angiographic method used in the study performed by the North American Symptomatic Carotid Endarterectomy Trial (sensitivity 96%, specificity 85%, accuracy 89%). For the detection of a stenosis greater than 70%, a peak systolic velocity greater than 270 cm/sec and end diastolic velocity greater than 110 cm/sec provided a sensitivity of 96%, specificity of 91%, and accuracy of 93%.

CONCLUSIONS

The accuracy of duplex studies compared with angiography in the assessment of extracranial vascular disease depends on the method of angiographic determination of carotid stenosis. Vascular laboratories should validate the duplex criteria they use against a standard method of angiographic assessment of carotid artery stenosis, with special reference to the recently reported studies noting the significance of a stenosis greater than 70% in patients with symptoms.

The story: a primary spiritual tool. Stories can be a healing power in the dying process

Recounting the events of one's life is therapeutic, particularly if the storyteller has the opportunity to share feelings, as well as factual content. Inherent in each person's story is the key to healing. Sensitive listening and dialogue can help dying persons discover connections between their own stories and those in the Scripture. In addition, when a person is in denial regarding a life-threatening illness, dreams can often provide a means to unlocking the unconscious. As Jesus used images from nature and symbols from everyday life, so, too, can care givers use analogies to get to the heart of the matter. Another source of healing is the original story, which can help a patient and family see their situation in a new light. Humor, used appropriately, can be a redemptive gift. Finally, when unfinished business has been completed and issues of forgiveness resolved, there is little left but to celebrate the life of the dying person. The story can thus be therapeutic, diagnostic, a source of healing, a means of fostering reconciliation, and an occasion for celebration.

The dense basilar artery as a sign of basilar territory infarction

Three cases of basilar artery territory infarction, in which a dense basilar artery was noted, are described. The dense basilar artery was recognized on computed tomography (CT) by comparing its density with that of other unaffected intracranial vessels. This sign is thought to represent basilar thrombosis or embolism and has similarities to the dense middle cerebral artery sign. The dense basilar artery is an early sign suggesting basilar territory infarction and its use improves the CT detection of basilar territory infarction.

Resistance of Plasmodium falciparum to antimalarial drugs in Equatorial Guinea

One hundred and sixty-six children from Equatorial Guinea, all under 10 years of age and with acute uncomplicated falciparum malaria, were randomly allocated to four groups and treated with one of the following regimens: chloroquine or amodiaquine (25 mg base/kg body weight over 3 days), quinine (8 mg/kg every 8 h for 3 or 5 days), and sulphadoxine-pyrimethamine (25-1.25 mg/kg, in one dose). The parasite clearance rates up to day 14 were 28% with chloroquine, 74% with amodiaquine, and 95% with quinine or sulphadoxine-pyrimethamine. The times required to clear asexual blood forms of Plasmodium falciparum in sensitive cases were 64, 70, 73 and 65 h, respectively. Although quinine and sulphadoxine-pyrimethamine are equally effective, quinine is recommended for treatment of multidrug-resistant malaria in paediatric patients, essentially because of the risk of serious reactions to sulpha drugs. Health providers are, however, encouraged to keep supplies of sulphadoxine-pyrimethamine as an option and to refer patients quickly, if required.

Vocal granuloma, including sclerosis of the arytenoid cartilage: radiographic findings

Vocal granulomas are uncommon benign tumors that may not respond readily to medical treatment or surgical removal. Gastroesophageal reflux is said to be a causative factor. Osteosclerosis of the arytenoid cartilage was found on computed tomographic scan in a series of 21 consecutive patients. The relationship of vocal granuloma to so-called contact ulcer (better called contact pachydermia) is discussed. Imaging of the granuloma and the arytenoid has little, if any, place in management, but should be recognized in the differential diagnosis of a vocal cord mass if the mass lies immediately adjacent to a sclerotic arytenoid.

Rapid direct reversal photography

This is a description of a method which enables fast, direct-reversal photography of radiological images for slides and was designed to retain: (i) continued use of an existing small darkroom; (ii) use of Kodak Rapid Process copy film; and (iii) use of standard X-ray processors. By adaptation of a commercial photographic flash power pack, a flash head and a reflector it is possible to achieve a somewhat expensive but very successful system which enables the very rapid production of good quality image slides for lectures.

Baseline entomological data for a pilot malaria control program in Equatorial Guinea

Entomological studies conducted on the island of Bioko and the mainland province, Río Muni, in Equatorial Guinea provided baseline data for a pilot malaria control program. The main species collected resting in houses at low density were Anopheles gambiae s.l. Giles and Anopheles funestus Giles. An. gambiae s.l. density increased during the rainy season, whereas An. funestus populations remained stable during both dry and wet seasons. Both species tended to be endophilic and were not collected resting or biting outdoors. Overall, delayed sporozoite rates were about 10% for both species and were highest in the dry season. An. gambiae s.l. from the mainland showed resistance to 4% DDT, but the island population was still susceptible. All populations were completely susceptible to 5% malathion and 0.025% deltamethrin.

DNase activity of micrococcal endonuclease covalently immobilized on nylon and polystyrene

Water-insoluble nucleases were prepared by immobilizing the endonuclease from S. aureus onto the surface of nylon-66 and polystyrene spheres. The activation phase of the synthetic supports was optimized to define optimal conditions of pH, temperature, and Ca2+ concentration for using immobilized enzymes. The activity, evaluated by hydrolysis of high-molecular-weight and supercoiled DNA, indicates that both derivatives are highly stable for storage and further use. Immobilization of the enzyme is much more effective when the covalent binding is performed on polystyrene. By using different activation methods with these matrices, a set of immobilized nucleases with various levels of enzymatic activity can be prepared. The possibility of working in a wide range of enzymatic activity and at low temperature and Ca2+ concentrations in different buffers makes these immobilized nucleases very useful for investigating accessible DNA regions in chromatin structure.

Concurrence of primary aldosteronism and renal artery stenosis

1. An unusual clinical case is described in which renal artery stenosis (RAS) was found to coexist with adrenocortical hyperplasia, resulting in hypertension. 2. Partial relief of the hypertension was achieved by correction of RAS, and then further relief by extirpation of one adrenal gland affected by unilateral hyperplasia, in interventions 8 months apart. 3. Biochemical features typical of primary hyperaldosteronism were observed both before and after RAS repair but were not present after unilateral adrenalectomy. 4. The association of these two lesions could have occurred by chance, through genetic linkage, or by progression from RAS to tertiary aldosteronism.

Spiritual care of the person with AIDS. Literature and art can touch closed hearts

Spiritual ministers, challenged to find meaningful ways to heal the hearts of persons with AIDS, are turning to some untraditional sources for help. Poetry, art, and stories are among the creative instruments for healing that pastoral ministers are bringing to the bedsides of the terminally ill. The story is the primary tool of spiritual care. Spiritual ministers working with persons with AIDS and their families should elicit and listen to their stories, which serve multiple purposes. Telling the stories is therapeutic for the person with AIDS. For the minister, the stories identify areas that need reconciliation, as well as those which call for celebration. Finally, when the time is right, the minister can tell another story, one that offers consolation and hope to the afflicted. Ritual is another tool of spiritual care. Just as the concrete image symbolizes the spiritual reality, so, too, does ritual facilitate or help celebrate spiritual healing. The Bible is a rich source of ideas for creative ritual. Other effective tools are art, drama, poetry, guided meditations, and dreams. In the hands of sensitive care givers, they are instruments of spiritual healing.

Primary hypothyroidism with pituitary enlargement and a visual field abnormality

A 23 year old man presented with classical hypothyroidism of 9 years duration. This was associated with pituitary enlargement, documented on magnetic resonance imaging (MRI), and abnormal half-field visual evoked responses (VERs). Following the initiation of thyroxine therapy the pituitary enlargement and the VER abnormalities resolved. The final diagnosis was of primary hypothyroidism with secondary pituitary hyperplasia.

Identification of GATA-1 and NF-E2 binding sites in the flanking regions of the human alpha-globin genes

Some of the elements involved in the erythroid-specific transcriptional regulation of the human gamma- and beta-globin genes and located inside or in the immediate proximity of these genes have been identified as sequences which bind erythroid-specific factors. In the present study, we found two regions located within 1 kb in 5' to the alpha 2- and in 3' to the alpha 1-globin genes which contribute to the induction of human alpha-globin genes following erythroid differentiation in stable MEL transformants. By DNAse I footprinting and gel mobility shift assays, we identified several GATA-1 and one AP-1/NF-E2-binding sites located inside these regions. These results strengthen the idea that, like for all other globin genes, flanking regions contribute in vivo to the regulation of human alpha-globin gene expression.

An epidemiological study of malaria in Bioko and Annobón islands (Equatorial Guinea)

A seroparasitological study of malaria was carried out in two of the more important islands of Equatorial Guinea, Bioko (ex Fernando Poo) and Annobón. The study involved a randomly-chosen population of children aged from two to nine years. In Bioko 1130 children were chosen from 29 of the 51 villages on the island; in Annobón 185 children were chosen from the capital town, where all the population lived. Indirect immunofluorescence tests (IFAT) showed a prevalence of malaria infection of 29.8% in Bioko and 55.7% in Annobón. The parasitic prevalence (malaria index) was 26.6% and 55.1% respectively, and the splenic index was 57.0% and 54.6% respectively. The results indicate that this is an area of stable hyperendemic malaria, which may benefit from an antimalarial programme.

Depo-Medrol and myelographic arachnoiditis

OBJECTIVE

This study was undertaken to see if patients who had a radiological diagnosis of arachnoiditis attributed to methylprednisolone acetate (Depo-Medrol, Upjohn Pty Limited) had the clinical syndrome of arachnoiditis.

DESIGN

An attempt was made to review all patients, reported by Roche in 1984 with a radiological diagnosis of corticosteroid-induced arachnoiditis, by taking a detailed history and performing a physical examination.

SETTING

The Department of Orthopaedics and Traumatic Surgery, The University of Sydney, The Royal North Shore Hospital, Sydney.

RESULTS

Of the 18 patients reported by Roche 15 were located and participated in this study. The clinical syndrome of arachnoiditis was defined as a constant burning pain in the back and legs, impotence, marked limitation of spinal motion, alteration of sensation and power in the legs, and a need for regular analgesia. Three of the 15 patients had the clinical syndrome of arachnoiditis. The grade of radiological change was unrelated to the severity of symptoms. The details of doses and precise sites of administration were unavailable for the severely affected individuals.

CONCLUSIONS

The absence of any other apparent cause for their symptoms implies that Depo-Medrol should not be used in or about the thecal sac.

Endemic human paragonimiasis in Equatorial Guinea. Detection of the existence of endemic human paragonimiasis in Equatorial Guinea as a result of an integrated sanitary programme

Between February and April 1990 the first five cases of human paragonimiasis, tentatively due to Paragonimus africanus, have been detected in Equatorial Guinea, thanks to the normal activities of the National Schistosomiasis Project and its coordination with the National Tuberculosis Project.

Diabetes prevalence in Alaska, 1984-1986

The prevalence of diabetes in Alaska from 1984 to 1986 was determined through medical records review. Cases were identified from hospital and physician discharge forms and from financial abstracts. As of December 1986, 3,719 Alaskans met the criteria for physician diagnosis of diabetes. The overall age-adjusted prevalence of diagnosed diabetes mellitus, 1,357/100,000, was lower than the U.S. rate of 2,470/100,000. The overall age-adjusted prevalence rates of specific complications and pregnancy among Alaskans with diabetes were retinopathy--167.5/1,000; blindness--24.3/1,000; amputations--19.4/1,000; end stage renal disease--9.7/1,000; pregnancy--50.7/1,000. Limitations in available data sources such as death certificates, hospital records, and subspecialists' medical records provided serious problems in identifying persons with diabetes, especially those in the 30- to 69-year age group who have not yet developed complications requiring hospitalization or subspecialty care. This population perhaps is most in need of services to prevent future complications of diabetes.

Renal oncocytomas--an Australian experience

A review was made of 24 cases of renal oncocytoma seen between 1978 and 1989. There was considerable overlap between the clinical presentation of renal oncocytomas and renal carcinomas. Although pre-operative radiological, cytological and pathological investigations may suggest the presence of an oncocytoma, these studies cannot make a definitive diagnosis. We recommend that these tumours be treated as potential renal carcinomas until post-operative microscopic evaluation proves otherwise.