Targeted gene expression profiling predicts meningioma outcomes and radiotherapy responses

Surgery is the mainstay of treatment for meningioma, the most common primary intracranial tumor, but improvements in meningioma risk stratification are needed and indications for postoperative radiotherapy are controversial. Here we develop a targeted gene expression biomarker that predicts meningioma outcomes and radiotherapy responses. Using a discovery cohort of 173 meningiomas, we developed a 34-gene expression risk score and performed clinical and analytical validation of this biomarker on independent meningiomas from 12 institutions across 3 continents (N = 1,856), including 103 meningiomas from a prospective clinical trial. The gene expression biomarker improved discrimination of outcomes compared with all other systems tested (N = 9) in the clinical validation cohort for local recurrence (5-year area under the curve (AUC) 0.81) and overall survival (5-year AUC 0.80). The increase in AUC compared with the standard of care, World Health Organization 2021 grade, was 0.11 for local recurrence (95% confidence interval 0.07 to 0.17, P < 0.001). The gene expression biomarker identified meningiomas benefiting from postoperative radiotherapy (hazard ratio 0.54, 95% confidence interval 0.37 to 0.78, P = 0.0001) and suggested postoperative management could be refined for 29.8% of patients. In sum, our results identify a targeted gene expression biomarker that improves discrimination of meningioma outcomes, including prediction of postoperative radiotherapy responses.

Dual-Energy CT and Cinematic Rendering to Improve Assessment of Pelvic Fracture Instability

Background Grading of pelvic fracture instability is challenging in patients with pelvic binders. Dual-energy CT (DECT) and cinematic rendering can provide ancillary information regarding osteoligamentous integrity, but the utility of these tools remains unknown. Purpose To assess the added diagnostic value of DECT and cinematic rendering, with respect to single-energy CT (SECT), for discriminating any instability and translational instability in patients with pelvic binders. Materials and Methods In this retrospective analysis, consecutive adult patients (age ≥18 years) were stabilized with pelvic binders and scanned in dual-energy mode using a 128-section CT scanner at one level I trauma center between August 2016 and January 2019. Young-Burgess grading by orthopedists served as the reference standard. Two radiologists performed blinded consensus grading with the Young-Burgess system in three reading sessions (session 1, SECT; session 2, SECT plus DECT; session 3, SECT plus DECT and cinematic rendering). Lateral compression (LC) type 1 (LC-1) and anteroposterior compression (APC) type 1 (APC-1) injuries were considered stable; LC type 2 and APC type 2, rotationally unstable; and LC type 3, APC type 3, and vertical shear, translationally unstable. Diagnostic performance for any instability and translational instability was compared between reading sessions using the McNemar and DeLong tests. Radiologist agreement with the orthopedic reference standard was calculated with the weighted κ statistic. Results Fifty-four patients (mean age, 41 years ± 16 [SD]; 41 men) were analyzed. Diagnostic performance was greater with SECT plus DECT and cinematic rendering compared with SECT alone for any instability, with an area under the receiver operating characteristic curve (AUC) of 0.67 for SECT alone and 0.82 for SECT plus DECT and cinematic rendering (P = .04); for translational instability, the AUCs were 0.80 for SECT alone and 0.95 for SECT plus DECT and cinematic rendering (P = .01). For any instability, corresponding sensitivities were 61% (22 of 36 patients) for SECT alone and 86% (31 of 36 patients) for SECT plus DECT and cinematic rendering (P < .001). The corresponding specificities were 72% (13 of 18 patients) and 78% (14 of 18 patients), respectively (P > .99). Agreement (κ value) between radiologists and orthopedist reference standard improved from 0.44 to 0.76 for SECT versus the combination of SECT, DECT, and cinematic rendering. Conclusion Combined use of single-energy CT, dual-energy CT, and cinematic rendering improved instability assessment over that with single-energy CT alone. © RSNA, 2022 Online supplemental material is available for this article.

Centrally Reduced Diffusion Sign for Differentiation between Treatment-Related Lesions and Glioma Progression: A Validation Study

BACKGROUND AND PURPOSE

Differentiating between treatment-related lesions and tumor progression remains one of the greatest dilemmas in neuro-oncology. Diffusion MR imaging characteristics may provide useful information to help make this distinction. The aim of the study was to assess the diagnostic accuracy of the centrally reduced diffusion sign for differentiation of treatment-related lesions and true tumor progression in patients with suspected glioma recurrence.

MATERIALS AND METHODS

The images of 231 patients who underwent an operation for suspected glioma recurrence were reviewed. Patients with susceptibility artifacts or without central necrosis were excluded. The final diagnosis was established according to histopathology reports. Two neuroradiologists classified the diffusion patterns on preoperative MR imaging as the following: 1) reduced diffusion in the solid component only, 2) reduced diffusion mainly in the solid component, 3) no reduced diffusion, 4) reduced diffusion mainly in the central necrosis, and 5) reduced diffusion in the central necrosis only. Diagnostic accuracy metrics and the area under the receiver operating characteristic curve were estimated for the diffusion patterns.

RESULTS

One hundred three patients were included (22 with treatment-related lesions and 81 with tumor progression). The diagnostic accuracy results for the centrally reduced diffusion pattern as a predictor of treatment-related lesions ("mainly central" and "exclusively central" patterns versus all other patterns) were as follows: 64% sensitivity (95% CI, 41%-83%), 84% specificity (95% CI, 74%-91%), 52% positive predictive value (95% CI, 37%-66%), and 89% negative predictive value (95% CI, 83%-94%).

CONCLUSIONS

The centrally reduced diffusion sign is associated with the presence of treatment effect. The probability of a histologic diagnosis of a treatment-related lesion is low (11%) in the absence of centrally reduced diffusion.

Anisotropic dependence of light extraction behavior on propagation path in AlGaN-based deep-ultraviolet light-emitting diodes

The anisotropic extraction dependence of polarized light on propagation path in AlGaN-based deep-ultraviolet (DUV) light-emitting diodes (LEDs) is investigated by simulations and photoluminescence (PL) measurements. Theoretical calculations based on k⋅p approximation and Monte Carol ray tracing indicate that there are two kinds of polarized sources with different angular distributions in ~280 nm AlGaN-based LEDs, s-polarized (spherical-shaped) and p-polarized (dumbbell-shaped) sources, which have different extraction behaviors. It is found that the total light extraction intensities are improved with decreasing the propagation path, and the lateral surface extraction gradually becomes dominant. Moreover, the extraction intensity of s-polarized light improves more than that of p-polarized light when the propagation path decreases, leading to a greater polarization degree. Polarization-resolved PL measurements show that the polarization degree of extracted light from lateral facet of the AlGaN multiple quantum well sample can be enhanced from 1% to 17% as the average propagation path reduces by 0.6 mm, which is consistent with the simulation results of the anisotropic dependence of light extraction on propagation path. Our results are significant for understanding and modulating the anisotropic extraction behavior of polarized light to realize high efficiency AlGaN-based DUV LEDs.

CYP4A in tumor-associated macrophages promotes pre-metastatic niche formation and metastasis

Tumor-associated macrophages (TAMs) play an essential role in metastasis. However, what enables TAMs to have a superior capacity to establish pre-metastatic microenvironment in distant organs is unclear. Here we have begun to uncover the effects of cytochrome P450 (CYP) 4A in TAMs on lung pre-metastatic niche formation and metastasis. CYP4A⁺ TAM infiltration was positively associated with metastasis, pre-metastatic niche formation and poor prognosis in breast cancer patients. The pharmacological inhibition of CYP4A reduced lung pre-metastatic niche formation (evidenced by a decrease in vascular endothelial growth factor receptor 1 positive (VEGFR1⁺) myeloid cell recruitment and pro-metastatic protein expression) and metastatic burden, accompanied with TAM polarization away from the M2 phenotype in spontaneous metastasis models of 4T1 breast cancer and B16F10 melanoma. Co-implantation of 4T1 cells with CYP4A10^high macrophages promoted lung pre-metastatic niche formation and metastasis. Depletion of TAMs disrupted lung pre-metastatic niches and thereby prevented metastasis. Treatment with the CM from CYP4A10^high M2 macrophages (M2) increased pre-metastatic niche formation and metastatic burden in the lungs, whereas CYP4A inhibition attenuated these effects. In vitro TAM polarization away from the M2 phenotype induced by CYP4A inhibition decreased VEGFR1⁺ myeloid cell migration and fibronectin expression, accompanied with downregulation of STAT3 signaling. Conversely, overexpression of CYP4A or exogenous addition of 20-hydroxyeicosatetraenoic acid promoted M2 polarization and cytokine production of macrophages and thereby enhanced migration of VEGFR1⁺ myeloid cells, which were reversed by siRNA or pharmacological inhibition of STAT3. Importantly, a combined blocking M2 macrophage-derived factors TGF-β, VEGF and SDF-1 abolished VEGFR1⁺ myeloid cell migration and fibroblast activation induced by CYP4A. In summary, CYP4A in TAMs is crucial for lung pre-metastatic niche formation and metastasis, and may serve as a potential therapeutic target in human cancer.

Capability of GaN based micro-light emitting diodes operated at an injection level of kA/cm²

Different size InGaN/GaN based micro-LEDs (μLEDs) are fabricated. An extremely high injection level above 16 kA/cm2 is achieved for 10 μm-diameter LED. The lateral current density and carrier distributions of the μLEDs are simulated by APSYS software. Streak camera time resolved photoluminescence (TRPL) results show clear evidence that the band-gap renormalization (BGR) effect is weakened by strain relaxation in smaller size μLEDs. BGR affects the relaxation of free carriers on the conduction band bottom in multiple quantum wells (MQWs), and then indirectly affects the recombination rate of carriers. An energy band model based on BGR effect is made to explain the high-injection-level phenomenon for μLEDs.

Laser-driven proton acceleration enhancement by nanostructured foils

Nanostructured thin plastic foils have been used to enhance the mechanism of laser-driven proton beam acceleration. In particular, the presence of a monolayer of polystyrene nanospheres on the target front side has drastically enhanced the absorption of the incident 100 TW laser beam, leading to a consequent increase in the maximum proton energy and beam charge. The cutoff energy increased by about 60% for the optimal spheres' diameter of 535 nm in comparison to the planar foil. The total number of protons with energies higher than 1 MeV was increased approximately 5 times. To our knowledge this is the first experimental demonstration of such advanced target geometry. Experimental results are interpreted and discussed by means of 2(1/2)-dimensional particle-in-cell simulations.

Ion spectrometer composed of time-of-flight and Thomson parabola spectrometers for simultaneous characterization of laser-driven ions

An ion spectrometer, composed of a time-of-flight spectrometer (TOFS) and a Thomson parabola spectrometer (TPS), has been developed to measure energy spectra and to analyze species of laser-driven ions. Two spectrometers can be operated simultaneously, thereby facilitate to compare the independently measured data and to combine advantages of each spectrometer. Real-time and shot-to-shot characterizations have been possible with the TOFS, and species of ions can be analyzed with the TPS. The two spectrometers show very good agreement of maximum proton energy even for a single laser shot. The composite ion spectrometer can provide two complementary spectra measured by TOFS with a large solid angle and TPS with a small one for the same ion source, which are useful to estimate precise total ion number and to investigate fine structure of energy spectrum at high energy depending on the detection position and solid angle. Advantage and comparison to other online measurement system, such as the TPS equipped with microchannel plate, are discussed in terms of overlay of ion species, high-repetition rate operation, detection solid angle, and detector characteristics of imaging plate.

31-Year-old bladder diverticulocutaneous fistula with a giant stone as a complication of pelvic fracture

Pelvic fractures associated with urinary bladder rupture are not rare, however, bladder fistulae are a rare complication after primary repair of bladder rupture. To our knowledge, we present the first case of a vesical diverticulocutaneous fistula after pelvic fractures. Etiology, presentation. diagnosis, and management are discussed.

Improvement of sexual function in male patients after parathyroidectomy for secondary hyperparathyroidism

BACKGROUND

Clinically, the severity of uremia is known to be inversely proportional to sexual desire and activity in patients with chronic renal failure. We studied sexual function and sex hormones in male patients with symptomatic hyperparathyroidism before and 3 months after parathyroidectomy.

STUDY DESIGN

From October 1998 to December 2000, 20 male patients with symptomatic secondary hyperparathyroidism were enrolled in this study. They underwent total parathyridectomy and autotransplantation of 90 mg of tissue to the subcutaneous tissue of the forearm or thigh. They all had regular sexual partners and were sexually active. Preoperatively, hemoglobin, hematocrit, calcium, phosphorus, alkaline phosphatase, intact parathyroid hormone (iPTH), prolactin, testosterone, leutenizing hormone (LH), and follicle stimulation hormone (FSH) were checked routinely. Three months after operation those data were checked again. Sexual function was evaluated with the International Index of Erectile Function (IIEF). Monthly frequency of attempted sexual intercourse, satisfaction of attempted intercourse, and enjoyment of intercourse were individually analyzed preoperatively and 3 months postoperatively.

RESULTS

Hemoglobin, hematocrit, testosterone, and LH were noted to have not significantly changed 3 months after surgery. Serum levels of calcium, phosphorus, alkaline phosphatase, FSH, and iPTH were significantly reduced, as were the levels of prolactin. But preoperative and postoperative FSH levels were within normal limits, and 70% of the postoperative alkaline phosphatase levels were above normal. Sexual function increased significantly 3 months after parathyroidectomy, as did monthly frequency of attempted intercourse, satisfaction of attempted intercourse, and enjoyment of intercourse.

CONCLUSIONS

Sexual function of male patients with symptomatic hyperparathyroidism can possibly be improved by parathyroidectomy and autotransplantation. Decreases in the levels of prolactin, calcium, phosphorus, and iPTH are also noticed after parathyroidectomy.

Treatment guideline of enuresis in Taiwan

The treatment guideline of enuresis suggested by the study group of enuresis in Taiwan is reported. Medical consultation and treatment of enuresis are recommended at the age of 5 and 6 years respectively. Evaluation of the enuretic children includes history taking, physical examination and laboratory investigations. A checklist is provided for quick evaluation in busy clinics. Urinalysis, urine specific gravity and office ultrasonography are essential tests. An algorithm of treatment of monosymptomatic enuresis is constructed. The two main options of treatment are behavioral modification with alarm system and pharmacotherapy with desmopressin or imipramine. Imipramine is recommended as one of the treatment options because of its relative safety in Taiwan. However the potential toxicity and mortality of imipramine is highlighted and warned. The responses to treatment are evaluated after a period of treatment for 1 to 3 months. Further evaluation and individualized treatment is suggested for poor responders.

Ipsilateral renal dysplasia with hypertensive heart disease in an infant with cutaneous varicella lesions: an unusual presentation of congenital varicella syndrome

A child with congenital varicella syndrome including cutaneous lesions and ipsilateral renal dysplasia with hypertensive heart disease is described. Varicella was contracted during the tenth week of gestation. Typical congenital varicella bullae, high titer of anti-varicella-zoster virus IgM, and a small right kidney were noted after birth. Hypertensive heart disease resulting from renal dysplasia occurred at 1 year of age. The cutaneous lesions and the dysplastic kidney involved the same dermatomes. Nephrectomy proved to be the treatment of choice for hypertension and congestive heart failure.

Age related testosterone level changes and male andropause syndrome

BACKGROUND

Much like the menopause syndrome occurring among older women, a similar condition has been defined among men. Testosterone production increases rapidly at the onset of puberty, then dwindles quickly after age 50 to become 20 to 50% of the peak level by age 80. Many men older than age 50 have experienced frailty syndrome, which includes decrease of libido, easy fatigue, mood disturbance, accelerated osteoporosis, and decreased muscle strength. We investigated serum total testosterone levels and andropause syndrome in men.

METHODS

Serum total testosterone levels were measured in 53 symptomatic men older than age 50 and in 48 men younger than age 40 for a control group. We also analyzed andropause symptoms among the 53 men older than age 50.

RESULTS

The mean serum total testosterone level in the symptomatic men older than age 50 (mean: 2.68 +/- 0.51 ng/ml, range: 1.21 to 4.13 ng/ml) was significantly lower than that in the control group (mean: 7.01 +/- 0.82 ng/ml, range: 5.53 ng/ml to 8.14 ng/ml). Male frailty syndrome in these men older than 50 included: decreased libido (91%), lack of energy (89%), erection problems (79%), falling asleep after dinner (77%), memory impairment (77%), loss of pubic hair (70%), sad or grumpy mood changes (68%), decrease in endurance (66%), loss of axillary hair (55%), and deterioration in work performance (51%).

CONCLUSION

The serum total testosterone level showed a decline with aging, especially in the men older than age 50. Low serum testosterone levels were also associated with the symptoms of male andropause syndrome.

Surgical repair of postinfarction ventricular septal defect

BACKGROUND

Rupture of the interventricular septum complicates 1% to 2% of all acute myocardial infarction patients and its natural course is ominous. The purpose of this study is to present our experience with surgical ventricular septal defect (VSD) repair and examine the possible risk factors and explanations for surgical mortality.

METHODS

Fourteen patients underwent repair of postinfarction VSD from 1996 to 1998 at the Taipei Veterans General Hospital. Thirteen patients were in New York Heart Association (NYHA) Functional Class IV and one was in Functional Class III. Eleven patients were in cardiogenic shock with intra-aortic balloon pumps (IABPs) prior to surgery. The operative techniques for VSD repair range from extensive infarctectomy with reconstruction of the septum and the right and left ventricular free walls using single or double patches, to minimal or no infarctectomy with closure of the VSD by excluding the infarcted muscle from the left ventricular cavity and leaving the right ventricle intact.

RESULTS

Overall surgical mortality occurred in four patients. All deaths occurred in patients with cardiogenic shock, two with anterior VSD and two with posterior VSD. Three late survivors had limited exercise tolerance with NYHA Functional Class II to III. Left ventricular function was moderately impaired in most patients with a mean nuclear scan ejection fraction of 0.32. However, all patients were elderly and adapted to their residual symptoms without significant life-style changes.

CONCLUSIONS

The surgical mortality for treating patients with postinfarction VSD has decreased with improvements in surgical technique. Rapid diagnosis, appropriate preoperative management and delicate surgical repair improve the overall results and help to attain long-term survival.

Causes of venous thrombosis in fifty Chinese patients

In a whole year from July 1997 to June 1998, a total of 50 patients with sonogram-proved venous thrombosis who called on our hematology clinic consecutively entered into the study. Their mean age was 59.1 +/- 17.5 years, range 18-83 years, and 29 were male. A series of examinations were performed in order to find out the cause of venous thrombosis. These examinations included antithrombin, protein C, protein S, plasminogen, heparin cofactor II, activated protein C ratio, factor V Leiden mutation, fibrinogen, factors VIII and XII, euglobulin lysis time, 677 C-->T mutation of methylenetetrahydrofolate reductase (MTHFR), prothrombin 20210 (PT 20210) A allele mutation, lupus anticoagulant, anticardiolipin antibody, and complete blood count. Five patients (10%) were found to have malignancy; an inferior vena cava thrombosis in one patient was due to venous compression by hydronephrosis; two patients had lupus anticoagulant; two had varicose veins of legs; two had protein C deficiency; four had protein S deficiency; two had plasminogen deficiency; two had antithrombin deficiency. No activated protein C resistance, elevated factor VIII level, factor V Leiden, PT 20210 A allele or heparin cofactor II deficiency was found in the present study. Homozygous MTHFR 677 C-->T gene mutation was found in 7 patients (14%); one of them also had a plasminogen deficiency. No possible risk factor of venous thrombosis could be found in 24 patients (48%). In conclusion, malignancy and protein S deficiency were the most frequent acquired and congenital causes of venous thrombosis in the Chinese, respectively.

Transmyocardial holmium-YAG laser channels in an animal model: a preliminary morphologic and histologic study

BACKGROUND

Laser transmyocardial revascularization (TMR) appears to improve symptoms in patients with refractory angina. However, it remains a controversial treatment modality for relieving ischemia. We conducted our study in dogs and evaluated the changes in morphology and histology of the myocardium after laser TMR.

METHODS

The hearts of 10 mongrel dogs (20-30 kg each) were treated with a holmiumyttrium aluminum garnet (YAG) laser in vivo. After opening the pericardium, the 1-mm fiberoptic device was used to create an average of 30 transmyocardial channels per heart at approximate intervals of 0.5 to 1 cm through normal left ventricular myocardium. All dogs tested survived the procedure. The dogs were sacrificed on the first and 60th postoperative days.

RESULTS

In the day-1 postoperative group (n = 4), the transmyocardial channels were obliterated at both epicardial and endocardial ends. The channels were totally occupied by necrotic myocytes and did not appear patent under the microscope. In the day-60 postoperative group (n = 6), the epicardial and endocardial scars were identified at each original laser application site. On cross-section, the channels were invaded by fibrous tissue bands extending from the endocardium to the epicardium, without a prominent central passage. Trichrome stained specimens showed that the channels were replaced by collagen fibers, fat tissue and numerous well-developed capillaries or sinusoids in which plenty of red blood cells were found.

CONCLUSIONS

We concluded that laser TMR offers no help for acute myocardial ischemia, but results in neovascularization inside the channels by the 60th postoperative day. Angiogenesis induced by laser TMR could possibly play a role in relieving chronic ischemia.

Bladder rupture after inguinal herniotomy

An 18-month-old male sustained an extensive bladder injury during a routine right inguinal herniotomy. Primary closure of the remaining detrusor was performed. Three months postoperatively he could void spontaneously, but with a small, contracted bladder and bilateral vesicoureteral reflux. He was stable throughout a 6-month follow-up period. Further surgical options will depend upon the bladder capacity and the grade of reflux.

Minimally-invasive, direct coronary artery bypass grafting

BACKGROUND

Minimally-invasive, direct vision coronary artery bypass grafting (MIDCAB) is a new surgical technique performed via limited thoracotomy in a beating heart without cardiopulmonary bypass.

METHODS

From June 1996 to December 1996, MIDCAB was performed in 12 patients (all male, average age, 65.9 years). In 11 patients with left anterior descending coronary artery lesions, thoracotomy was performed via the left, fourth intercostal space and the pericardium was incised to identify the target site. About 8 cm of the left internal mammary artery was harvested. Bilateral anterolateral thoractomy was performed in one patient with left anterior descending and right coronary artery lesions. Anastomosis was performed under direct vision in the beating heart without cardiopulmonary bypass.

RESULTS

MIDCAB was performed successfully without morbidity. The patients' average stay in the intensive care unit was 1.8 days. No patient had any early cardiac event requiring additional surgery or percutaneous transluminal coronary angioplasty. Postoperatively, all patients were asymptomatic and their recovery was uneventful.

CONCLUSIONS

Our initial experience indicates that MIDCAB offers good results and is a treatment option for selected patients with left anterior descending and/or right coronary artery lesions.

Endoscopic vein harvest for coronary artery bypass surgery

BACKGROUND

Despite increased awareness of risk factors, wound complications continue to be a problem following coronary artery bypass graft (CABG) surgery. A minimally invasive alternative was therefore developed to reduce the risk of complications while providing the same benefits as the standard open vein harvest procedure.

METHODS

Video-assisted endoscopic technique for vein harvest was introduced in our medical center in October 1996. The procedure was evaluated and compared with the standard open vein harvest procedure. With the endoscopic technique, small incisions were made, each about 2-3 cm at the selected access sites (groin and above and below the knee). An endopath subcutaneous dissector was subsequently inserted along the anterior surface of the saphenous vein with the assistance of an endoscope and video monitor. The venous side branches were detected and positioned using a vessel dissector. A ligaclip was applied and the branches were divided using endopath-scissors. In some cases, the venous branches were divided directly using the endopath-scissors. Therefore, the distal and proximal ends of the saphenous vein were isolated, ligated and divided. The harvested veins were used for CABG. Each patient was evaluated for length of surgery, hospital stay and morbidity.

RESULTS

From October 1996 through May 1997, we performed 50 procedures using video-assisted endoscopic vein harvest. The results were compared with those from 106 patients who underwent standard open vein harvest during the same period. The rate of complications was 2% in the endoscopic group compared with 13.2% in the open group (p < 0.05). The average hospital stay was 7.2 days in the endoscopic group and 11.5 days in the open group (p < 0.05). Twelve weeks after the operation, all of the incisions healed with good cosmetic results in the endoscopic group. However, long visible scars were found in the patients in the open group.

CONCLUSIONS

Endoscopic saphenous vein harvest provides a minimally invasive alternative to open vein harvest. It provides good cosmetic results without a hypertrophic scar and enables the patient to regain early ambulation.

Extravesical detrusorrhaphy for vesicoureteral reflux in children

Extravesical detrusorrhaphy is a simple and safe approach to antireflux surgery; however, its use in Taiwan has seldom been reported. We report the outcomes of 15 patients (23 ureters) with primary vesicoureteral reflux who underwent extravesical detrusorrhaphy between January 1995 and April 1996, and describe the surgical technique. Overall, vesicoureteral reflux was cured in 22 of 23 ureters. Postoperative morbidity and complications were minimal. None of the patients had obstruction or significant hematuria. The discomfort related to bladder spasms during the postoperative period was subjectively decreased compared to the conventional transvesical technique. There was transient voiding inefficiency in three patients, as well as urinary retention in one, which resolved spontaneously after 4 weeks of Foley catheter drainage. Our experience showed that detrusorrhaphy is an effective way to correct vesicoureteral reflux with minimal morbidity and discomfort. Proper patient selection and strict adherence to the surgical principle are important for high success rates.

Renal squamous cell carcinoma: CT findings and clinical significance

BACKGROUND

To study the biological behavior of renal squamous cell carcinoma (RSCC).

METHODS

Fifteen cases of RSCC were retrospectively studied. These cases were classified as central (eight cases) and peripheral (seven cases) types by the tumor location. The clinical data and computed tomographic findings were analyzed and compared.

RESULTS

High incidence (87%) of urolithiasis was observed. The prognosis of RSCC was very poor, with a median survival time of 3.5 months. The infectious symptoms, central location, and modified stage IV of the tumor were the poor prognostic factors of RSCC. Two types of RSCC were different in the presenting symptoms, lymph node metastasis, modified tumor staging, and survival time.

CONCLUSION

The central and peripheral types of RSCC were different biologically. High index of suspicion should be maintained when identifying the subtle clues of malignancy in patients with urolithiasis.

Surgical repair of Ebstein's anomaly

BACKGROUND

Ebstein's anomaly represents a congenital structural deformity of the tricuspid valve associated with a wide spectrum of morphologic and physiologic abnormalities. Valvuloplasty and tricuspid valve replacement are the main surgical treatments. Plication of the atrialized right ventricle and valvuloplasty of the tricuspid valve can achieve satisfactory clinical results. Two surgical techniques, known as Danielson's and Quaegebeur's methods, are often used clinically. This study was conducted to compare the postoperative results between both methods in treatment of Ebstein's anomaly.

METHODS

Valvuloplasty of tricuspid valve and the plication of atrialized right ventricle were performed in 8 out of 17 patients with Ebstein's anomaly in our hospital from January 1986 to August 1996. Danielson's method was used in six of eight patients, and Quaegebeur's method was used in the remaining two patients. There were three males and five females, aged from 8 months to 61 years (mean: 14.1 years).

RESULTS

All patients achieved clinical improvement in cardiothoracic ratio and heart functional class. Cardiac arrhythmia was the likely cause of death in two patients treated by Danielson's method, and one patient developed complete atrioventricular (A-V) block postoperatively. By Quaegebeur's method, all patients survived, but a permanent pacemaker was implanted for both patients due to their preoperative complete A-V block.

CONCLUSIONS

Both methods achieved satisfactory postoperative results. However, Quaegebeur's method seems to be more effective because it provided a simultaneous reconstruction of both tricuspid valve and right ventricle without the need for additional excision of the right atrium.

Surgical management of grades III and IV primary vesicoureteral reflux in children with and without acute pyelonephritis as breakthrough infections: a comparative analysis

PURPOSE

Although high grade vesicoureteral reflux associated with breakthrough infection may be an indication for surgical intervention, it remains uncertain whether acute pyelonephritis as breakthrough infection is a risk for renal scar formation and whether surgery performed without it has any advantage. We assessed the results of antireflux surgery for high grade vesicoureteral reflux in children with and without acute pyelonephritis as breakthrough infections.

MATERIALS AND METHODS

A total of 33 boys and 27 girls (102 refluxing units) less than 3 years old with grades III and IV vesicoureteral reflux who underwent surgical management because of breakthrough infections were retrospectively studied in a 3-year period. Of the 60 patients 30 (group 1) presented with breakthrough infections of acute pyelonephritis, although they were maintained on prophylactic antibacterials. The remaining 30 patients (group 2) underwent surgery without acute pyelonephritis as the breakthrough infections. There was no renal scar formation at the diagnosis of vesicoureteral reflux in either group. Patients with renal scars were excluded from study. There was no significant difference in patient gender (p = 0.795) or distribution of bilateral vesicoureteral reflux (p = 0.781) in the groups. Group 1 patients were significantly younger at the diagnosis of vesicoureteral reflux (p = 0.006).

RESULTS

Although 55 patients presented with a febrile urinary tract infection at the diagnosis of vesicoureteral reflux, the infection was not significantly related to the development of renal scars (p = 0.066). Of the 55 patients 12 presented with acute pyelonephritis as the initial episode of urinary tract infection. The presence of acute pyelonephritis at the diagnosis of vesicoureteral reflux was also not significantly related to renal scar formation (p = 0.207). Postoperative urinary tract infections developed in 34 patients but there was no significant correlation between postoperative urinary tract infections and renal scar formation (p = 0.235). At followup 17 group 1 and 7 group 2 patients (29 renal units) were found to have renal scars.

CONCLUSIONS

Renal scars were significantly more common in younger children with than without acute pyelonephritis as breakthrough infections (p = 0.010). Although breakthrough infections in high grade reflux may be an indication for antireflux surgery, the most appropriate results were achieved when acute pyelonephritis was not a breakthrough infection.

Early versus late surgical management of fetal reflux nephropathy

PURPOSE

Considering that infants with reflux nephropathy may be susceptible to urinary tract infection or longer postnatal vesicoureteral reflux, an early antireflux procedure rather than chemoprophylaxis may be indicated after birth.

MATERIALS AND METHODS

In 15 male and 7 female neonates bilateral and unilateral primary high grade vesicoureteral reflux was detected prenatally in 15 and 7, respectively, on the basis of dilatation of the urinary tract. There was grade III or IV reflux in the 37 refluxing renal units and all patients received chemoprophylaxis after birth. In 11 neonates congenital reflux nephropathy was diagnosed during month 1 of life, including 5 (9 refluxing renal units) who underwent early antireflux surgery without evidence of urinary tract infection and 6 (11 refluxing renal units) who underwent late surgery with a history of urinary tract infection. All patients treated nonsurgically and surgically were monitored up to 2 years and for 2 years postoperatively, respectively.

RESULTS

Of the 11 patients (17 renal units) without congenital reflux nephropathy reflux improved in 53%, a documented urinary tract infection occurred in 2 and there was no development of new scars in a previously normal kidney. In the 11 patients (20 renal units) with congenital reflux nephropathy the parenchymal defect detected during month 1 of life was general or focal, that is at the mid zone as well as the poles. Surgery was performed at a mean of 8 weeks of life in 5 patients without a documented urinary tract infection, 24 weeks earlier than in the 6 with a history of urinary tract infections. Postoperative breakthrough infections occurred in all 6 infants who underwent late surgery and in none who underwent early surgery (p < 0.05). New scarring developed in previously scarred renal units but there was more new scarring in the renal units treated with late surgery (10 of 11, 90%) than in those treated with early surgery (2 of 9, 22%, p < 0.001). In both groups retardation of growth was identified in the renal units with general nephropathy.

CONCLUSIONS

Renal units with fetal reflux nephropathy were susceptible to urinary tract infections and new scar formation. Early antireflux surgery performed before a urinary tract infection develops offers a better prognosis than late surgery.

Antituberculosis drug resistance in Keelung area-1993 to 1994

Patterns of drug resistance of 176 isolates of Mycobacterium tuberculosis collected from 1993 to 1994 were reviewed retrospectively. The rates of resistance to isoniazid, rifampicin, ethambutol and streptomycin were 84.1%, 17.6%, 23.3% and 11.9% respectively and the incidence of multidrug-resistant M. tuberculosis was 17.0%. Comparisons between 1993 and 1994 showed decrease in rates of resistance to rifampicin (25% vs. 7.5%) and ethambutol (36.5% vs. 7.5%) and the incidence of multidrug-resistant tuberculosis (25% vs. 7.5%). In contrast, the rate of resistance to isoniazid increased from 79.2% to 84.1%. Due to the high frequency of resistance to multiple drugs in tuberculosis isolates at Chang Gung Memorial Hospital, Keelung, three-combined (isoniazid+rifampicin+ethambutol) regimen of antituberculosis drugs may be ineffective as initial therapy for one-fourth of patients in our hospital. Of epidemiological factors, previous treatment was found to influence the rates of drug resistance. Of roentgenographic features, stage of chest roentgenography was found to be a positive predictor of infection with multidrug-resistant tuberculosis. The information provided in this study may help us understanding the epidemiology of M. tuberculosis in Keelung and refining antituberculosis treatment for our patients.

Pulmonary actinomycosis appearing as a "ball-in-hole" on chest radiography and bronchoscopy

A 40 year old diabetic man with pulmonary actinomycosis was admitted to hospital with recurrent haemoptysis. The chest radiograph showed an air meniscus in the left upper lobe, a rare presentation of pulmonary actinomycosis. Bronchoscopic examination revealed a mass in a cavity which has never been reported previously. He underwent lobectomy and the surgical specimen revealed sulphur granules, the typical pathological finding of actinomycosis, without evidence of fungal or mycobacterial infection.

Early repair of traumatic ventricular septal defect and mitral valve regurgitation

Traumatic ventricular septal defect with valvular injury is an uncommon blunt trauma. It may develop either immediately or be delayed, but it should be corrected electively. With hemodynamic instability and cardiopulmonary deterioration, however, early repair is necessary as a lifesaving procedure. Two-dimensional echocardiography and Doppler color flow mapping are very important for rapid detection in patients who are critically injured. This is a case report of the successful repair of ventricular septal defect and posterior leaflet disruption of mitral valve right after blunt trauma.

Use of laparoscopy in intersex patients

PURPOSE

Management of impalpable gonads in intersex patients remains a challenging problem. Since laparoscopic gonadectomy or gonadal preservation has been used in the management of impalpable gonads in the normal male population, laparoscopy can be an alternative method in the treatment of intersex patients.

MATERIALS AND METHODS

Laparoscopic operations were performed on 6 patients with intersex conditions, including the testicular feminization syndrome in 2, 17 beta-hydroxysteroid dehydrogenase deficiency in 1, 5 alpha-reductase deficiency in 1 and mixed gonadal dysgenesis in 2.

RESULTS

Laparoscopic gonadal biopsy, gonadectomy and hysterosalpingectomy were done in select patients.

CONCLUSIONS

Although the initial diagnoses were made by phenotypic presentation, and biochemical and cytogenetic studies, laparoscopy had an important role in defining the internal ductal and gonadal structures to confirm the diagnosis, and served as an efficient method for gonadectomy and removing structures contrary to the assigned gender.

Two-stage orchiopexy with laparoscopic clip ligation of the spermatic vessels in prune-belly syndrome

A 1-year-old boy with prune-belly syndrome underwent unilateral laparoscopic clip ligation of the spermatic vessels with the hope of developing vasal collateral circulation. Six months later, the patient underwent ipsilateral second-stage orchiopexy on the right testis after division if the ligated spermatic vessels and contralateral Fowler-Stephens orchiopexy on the left testis in combination with major urinary tract reconstructions and abdominoplasty. For the following 1-year period, both testes were growing and comparable in size.

Budd-Chiari syndrome due to pacemaker-induced thrombosis

We report a unique case of Budd-Chiari syndrome caused by pacemaker leads-induced thrombosis. A 34 year old female patient was subjected to a permanent pacemaker insertion because of refractory paroxysmal supraventricular tachycardia attacks related to Wolff-Parkinson-White syndrome. Three years later, another pacemaker was re-implanted because of its dislodgement. Four episodes of skin infections at the implantation site were noted thereafter. The patient developed symptoms of abdominal pain and ascites 5 years after the second pacemaker implantation. Ultrasonography and computerized tomography of the abdomen revealed hepatomegaly with ascites and dilated inferior vena cava. An echocardiogram displayed thrombus formation in the superior vena cava, the right atrium and the inlet of the inferior vena cava into the right atrium. Inferior and superior venacavogram confirmed the above findings. With the impression that Budd-Chiari syndrome was caused by pacemaker-induced thrombus, we removed the pacemaker first and thoracotomy with thrombectomy was then performed. The clinical symptoms resolved after the operation. To our knowledge, this is the first case reported in the literature and this observation supported the thrombosis theory for membranous obstruction of inferior vena cava.

Spontaneous rupture of the bladder in childhood: report of one case

Perforation of the urinary bladder without history of antecedent trauma is a rare clinical occurrence in children, but should be considered in patients with voiding disorders, abdominal symptoms and unexplained metabolic disturbances. The present report concerns a young infant who presented with irritability, abdominal colic, decreased urine output; blood examinations showing mild leukocytosis, azotemia and metabolic acidosis. Further cystogram and cystoscopy confirmed rupture of the bladder. She had an uneventful recovery after a twelve days of conservative treatment with indwelling catheterization and nutritional support. A subsequent urogram revealed complete healing of the lesion.

Urethral prolapse--a case report

Urethral prolapse is an uncommon anomaly that involves primarily the distal female urethra. It occurs most commonly in black girls and in post-menopausal white patients. We report a case of urethral prolapse in an 8-year-old girl. She was treated by total excision of prolapsed mucosa. Postoperative course was smooth. No urinary incontinence or recurrence was found.

[Use of pediatric laparoscopy for nonpalpable testis]

Children with nonpalpable testes create a clinical dilemma because it is difficult to determine the location or absence of the testis by clinical examination. Twenty-two children with unilateral nonpalpable tests underwent successful laparoscopic management under general anesthesia. In 11 (50%) of the patients, the vas deferens and the spermatic vessels exited the internal inguinal ring via the normal anatomy. Either hypoplastic testes or inguinal vanishing testes were found during inguinal exploration in 8 children with normal anatomy but smaller spermatic vessels exiting the internal inguinal ring. Four patients (18%) with blind end of vas and vessels terminating proximal to the internal inguinal ring were considered to be cases of intra-abdominal vanishing testis and no further surgery was necessary. Laparoscopy revealed 7 intra-abdominal testes (32%) which were managed by laparoscopic orchiectomy, simple orchiopexy, trans-abdominal orchiopexy or laparoscopic staged orchiopexy depending on the patient's age and the gonadal intra-abdominal location.

Synchronous carotid endarterectomy and myocardial revascularization

BACKGROUND

The management of the coexisting extracranial carotid and coronary disease is still controversial. We reviewed our experience in synchronous operation for both diseases in Veterans General Hospital-Taipei.

METHODS

From Jan. 1988 to Nov. 1992, the synchronous carotid endarterectomy and myocardial revascularization were performed in nine patients with the mean age of 66.6 +/- 11 years. Five had symptomatic extracranial vascular disease or stabilized neurological deficits, and four had asymptomatic carotid bruits. Four had bilateral hemodynamically significant carotid stenosis. NYHA functional class III-IV was noted in three patients. Triple-vessel coronary disease was documented in 6 patients including one with left main lesion more than 50%. Eight had previous or recent myocardial infarction and four had moderate to severe left ventricular dysfunction noted on left ventriculography.

RESULTS

All nine patients received unilateral carotid endarterectomy and a mean number of 2.8 distal anastomosis. Operative number of 2.8 distal anastomosis. Operative mortality within 30 days was zero and morbidity was noted in two patients. One patient was CVA and the other one was perioperative myocardial infarction. Late mortality occurred in previous two patients with morbidity. Late morbidity was mainly due to cardiac rather than neurological problems.

CONCLUSIONS

If long-term natural history of coronary or carotid artery disease could be actually altered by surgery, a systemic evaluation for possible multifocal atherosclerosis is mandatory. By following a proposed guideline, synchronous operation is appropriate for a subgroup of patients with coexisting carotid and coronary artery disease.

Radiolucent ureterocele calculus. Case report

In a 30-year-old man a radiolucent stone in an orthoptic, nonobstructing ureterocele was detected by ultrasonography of the bladder. The stone was impacted in the ureteral orifice. Endoscopic ureteral meatotomy was performed in preference to endoscopic incision of the ureterocele, and the stone was disintegrated at ureterorenoscopy via the enlarged orifice.

Bicomponent vascular grafts consisting of synthetic absorbable fibers: Part II: In vivo healing response

The objectives of this research were (1) to determine whether the use of partially absorbable vascular grafts would improve their nonthrombogenic performance and whether they are more prone to aneurysmal dilation and subsequent failure in vivo, and (2) to find out the relationships, if any, between these in vivo and the previously reported in vitro data with an emphasis on how the in vitro changes in fabric structure and properties related to these in vivo data. Bicomponent vascular fabrics were made from Dacron and polyglycolic acid (PGA) yarns with a range of composition ratios of the PGA to Dacron. Both woven and single Jersey knit fabrics were made, and implanted in dogs for 4 months. The following findings and relationships were obtained. (1) The bicomponent vascular fabrics resulted in a full-wall healing in the thoracic aorta of dogs. All bicomponent vascular grafts in survived dogs exhibited 100% patency, no thrombus or aneurysmal formation, no hematoma or seroma around the grafts, and no fibrin coagula in the inner capsules. The gross morphology of the regenerated tissues was very similar visually to the adjacent original arterial tissue. Histologically, the luminal surface was lined with a layer of endothelial cells with myofibroblasts, fibroblasts, and collagens underneath. (2) The extent of the full-wall healing depended on the type of fabric structure, the concentration of absorbable yarns, the location of absorbable yarns (for the woven group only), and initial water permeability. It is believed that the concentration effect was related to the level of macrophage activation from the degradation products of the absorbable yarns, while the location effect was attributed to the various types of fabric structure change on the degradation of the absorbable yarns. (3) In general, the knitted group (K), was better than the woven group (W). K3 showed the best in vivo performance in the knitted group. (4) In the woven group, W3 was the best. The incorporation of absorbable yarns in the weft direction of the bicomponent fabrics (W3) resulted in a velourlike, loose and porous fabric surface for facilitating tissue ingrowth. The placement of absorbable yarns in the warp direction (W1), however, did not show this unique surface morphology. Calcification was, however, occasionally observed in the woven samples with low initial water permeability. These observed in vivo performances correlated well with our previously reported in vitro study.

Acute urinary retention in two patients with imperforate hymen

Acute urinary retention in two adolescent girls with hematometrocolpos caused by imperforate hymen are reported. The accumulation of the menstrual blood in the vagina and uterus may form a mechanical effect on the urethra and bladder and lead to the obstructive urinary symptoms. Hymenotomy created individually by CO2 laser and cruciate incision was performed. The two patients were discharged on the same day after operation and made an uneventful recovery.

Single unilateral vaginal ectopic ureter

Three cases of girls, aged three, four and five years, with a single unilateral ectopic ureter draining into the vagina are discussed. All of the children had urinary incontinence. Vaginoscopy demonstrated different findings of the ectopic ureteral orifice within the vaginal mucosal fold in each child. Of the three patients, two underwent nephroureterectomy and one underwent ureteral reimplantation. Complete cure of urinary incontinence was obtained in all three children after surgery.

Bicomponent vascular grafts consisting of synthetic absorbable fibers. I. In vitro study

The objective of this study is to determine the effects of the location and concentration of synthetic absorbable yarn components in bicomponent vascular graft fabrics on their structure and properties in a controlled in vitro hydrolytic environment. Bicomponent vascular fabrics were made from Dacron and polyglycolic acid (PGA) yarns with a range of composition ratios of PGA to Dacron and a range of locations of PGA. Both woven and single jersey knit fabrics were made. These fabrics were characterized by standard textile methods and subject to in vitro hydrolytic degradation study. In vitro hydrolytic degradation study showed that the most dramatic changes in the bicomponent fabric characteristics and properties occurred 30 and 60 days of hydrolysis. This schedule coincided with the hydrolytic degradation rate of PGA absorbable sutures. In the woven (W) group, the incorporation of absorbable yarns in the weft direction (W3) of the bicomponent fabrics resulted in the velour-like, loose, and porous surface morphology of the fabric for potential subsequent tissue ingrowth, while those woven fabrics with absorbable yarns in the warp direction (W1) did not have this unique velour-like surface. In the knitted (K) group, the concentration of absorbable yarns appeared to be closely related to the observed changes in fabric properties and structure. The incorporation of absorbable yarns into knitted fabrics did not result in the same level change in fabric structure and property as woven fabrics. In both W and K groups, a minimal level of mechanical strength of the fabrics was maintained due to the remaining Dacron yarns. Structural integrity of these fabrics was retained at the end of hydrolytic degradation study. The data obtained could be used to correlate with the subsequent in vivo performance of these bicomponent vascular grafts. If correlations exist, they could be used to improve the design of future bicomponent vascular grafts for improved performance.

Intrapelvic Wilms tumor: report of 2 cases and review of the literature

Wilms tumor arising from the renal parenchyma usually presents initially as an abdominal mass. A review of the literature revealed fewer than 10 cases manifesting as a renal pelvic mass occupying primarily the collecting system. We have treated 2 patients with this unusual presentation: 1) a 4-month-old male infant whose initial radiological investigation demonstrated a left renal neoplasm measuring 10 x 7 x 5 cm.; bisection of the kidney showed a tumor completely filling the collecting system to the proximal ureter with extreme attenuation of the renal parenchyma, and 2) a 9-year-old boy who was hospitalized due to hematuria; ultrasonography, computerized tomography and magnetic resonance imaging showed a mass in the right renal pelvis; gross pathology displayed a 7 x 6 x 5 cm. polypoid mass occupying the renal pelvis without parenchymal involvement. Microscopically, both lesions were typical Wilms tumors. We discuss the characteristic clinical manifestations, diagnosis and treatment, and review the literature.

A new autoperfusion technique for aortic reconstruction of suprarenal aortic aneurysm

Visceral ischemia is a serious factor in the postoperative morbidity and mortality of suprarenal aortic reconstruction. We reported two patients of suprarenal aortic aneurysm involving visceral arteries, who received successful Dacron graft replacement by using Pruitt-Inahara balloon catheters as an autoperfusion for preservation of the visceral organs. No visceral organ ischemia occurred postoperatively except in patient 2 who had preoperative chronic renal failure and persistent renal failure after the operation. The renal function recovered gradually during the follow-up period. Both patients are doing well at the present time. The new autoperfusion technique can directly deliver normothermic blood from the arterial cannula at proximal aorta to the individual visceral arteries by using the balloon perfusion catheters. It is simple, safe, easily instituted and the used products are readily obtainable. It allows the surgeon to provide an effective protection of visceral organs for the suprarenal aortic reconstruction.

Idiopathic portal hypertension: a case report

Clinically, idiopathic portal hypertension (IPH) is characterized by overt splenomegaly with pancytopenia, portal hypertension and relatively mild abnormalities in liver function tests. Although its etiology is still undetermined, the liver pathology is characterized by occlusive changes of the intrahepatic portal radicles, portal and periportal fibrosis, irregularly distributed parenchyma atrophies and absent of regeneration nodules. The disease is relatively benign and does not progress to cirrhosis. Differential diagnosis between IPH and liver cirrhosis is mandatory. We now report a case with histologically proven IPH, including clinical course, laboratory data, roentgenographic findings of hepatic venogram and celiac angiogram, hepatic hemodynamic features and intravariceal pressure of esophageal varix which has never been reported in Taiwan.

Methotrexate, vinblastine, adriamycin and cisplatin (M-VAC) for advanced TCC of urothelium

After the introduction of methotrexate, vinblastine, adriamycin and cisplatin combination (M-VAC) chemotherapy for transitional cell carcinoma (TCC) of the urothelium, the reported response and survival rates improved when compared with the previous regimens. From July 1989 to March 1991, 43 consecutive cases of invasive or metastatic TCC that had received at least one course of M-VAC treatment were collected by a computer-assisted search and analyzed. The overall response rate, including complete response (CR) and partial response (PR), was 44% (CR, 16%; PR, 28%). Tumors originating from the renal pelvis or bladder responded better than those from the ureter (kidney, 57%; bladder, 42%; and ureter 30%). Lymph node, soft tissue, lung metastases and local recurrent tumors had a greater chance of response than bone or liver metastases. Although patients from the blackfoot disease endemic area seemed to respond better than those from the nonendemic area, there was no statistically significant survival benefit. The duration of follow-up ranged from nine to 38 months. The length of survival of nonresponders ranged from one month to 19 months (median, eight months; mean, seven months). Ten of the 19 responders relapsed, and the others were still responding. Three patients (7%) survived two years, disease-free. Although the response rate improved, the chance of long-term survival was still unsatisfactory in our study.

Initial results of laser angioplasty under angioscopic guidance for salvage of an ischemic lower limb: preliminary report

From March to July 1989, nine patients at risk for peripheral artery disease underwent intraoperative Nd:YAG laser angioplasty using angioscopy at the Veterans General Hospital (Taipei, Taiwan, Republic of China). Following the laser angioplasty, balloon dilatation was performed in all cases. Eight men and one woman at an average age of 68 were included in the study (range: 58 to 78 years old). Ischemic symptoms included five patients with disabling claudication, four with pain at rest and one with gangrene on the toes. Eight of the nine patients had complete occlusions ranging from 2 to 19 cm in length. Two patients had high degree multiple segmental stenosis of the superficial femoral artery from 1 to 2 cm in length. Initial clinical success (indicated by relief of symptoms and increase in Doppler ankle pressure and index) and improvement in the angiographic luminal diameter was noted in 9 of 10 occluded vessels (90%) that underwent Nd:YAG laser treatment which was delivered at 10 to 12 watts through laser probes. Prelaser intraluminal diameter increased from 0.05 +/- 0.07 to 0.53 +/- 0.07 mm, Doppler ankle pressure index rose from 0.51 +/- 0.12 to 0.81 +/- 0.12, Doppler ankle pressure increased from 62.44 +/- 16.10 to 104 +/- 21.21 mmHg and the amplitude of pulse volume recorder at ankle level rose from 5.77 +/- 2.80 to 12.11 +/- 2.77 mm as compared with prelaser therapy (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Unusual presentations of angiomyolipoma]

Angiomyolipoma is an uncommon benign tumor of the kidney. The tumor is composed of fat, smooth muscle, and blood vessels. The same pathological entity can appear in two clinically different forms, with or without tuberous sclerosis. We present two cases of renal angiomyolipomas with unusual manifestations. One was associated with tuberous sclerosis and both had the presentation of acute abdomen. Case one presented with epilepsy, angiofibroma, subungual fibroma, periventricular calcification, and bilateral renal angiomyolipomas. Tuberous sclerosis is characterized by these findings. Both cases had spontaneous hemorrhage with hypovolemic shock. Massive hemorrhage resulting in shock is uncommon and the incidence has been estimated to be about 10 per cent. In fact, many angiomyolipomas are clinically occult. The size of the tumor correlates well with the presence or absence of symptoms which include microhematuria, flank pain, hypertension and urinary tract infection. Abdominal CT is the preferred modality for diagnosis of angiomyolipoma. The most important finding is the presence of an intrarenal tumor with fat component which is recognized as a relative low density on CT. Our patients were hospitalized under the impression of angiomyolipoma after the CT study. In addition, the CT defined either the size of the tumor or the extension of the hemorrhage. Although many believe that renal angiography is not sufficient by itself to establish the diagnosis of angiomyolipoma, occasionally it is mandatory in the management of the tumor. The management is decided by two factors, the size of tumor and the clinical presentation. The attitude of management should include conservative treatment with regular follow-up, selective arterial embolization, enucleation, and partial or total nephrectomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Radionuclide transit studies for esophageal function before and after esophageal transection and devascularization

Nonobstructive swallowing disturbance is a common complication following esophageal transection and devascularization to control bleeding from esophageal varices. From July 1983 to July 1984, 12 patients underwent both a radionuclide esophageal transit study (RETS) and a barium swallowing fluoroscopic study (BSFS) before and after surgery to evaluate esophageal function. Before surgery, 9 of the 12 patients had no swallowing disturbance and the RETS was normal in 8 cases, and the BSFS was normal in all cases. Three patients who received sclerotherapy on more than 3 occasions suffered from swallowing disturbances and both the RETS and BSFS detected their defective passage. The average distal 1/3 segmental and total esophagus transit times were 11.5 +/- 9.9 seconds and 13.0 +/- 10.6 seconds among symptom-free patients; and 24.8 +/- 11.8 seconds and 30.1 +/- 14.6 seconds among swallowing-disturbance patients. The time prolongation was significant (p less than 0.005). After surgery, 5 of 9 preoperative symptom-free patients suffered from swallowing disturbances for 10 days and then became symptom free. Their serial follow-up RETS and BSFS at 1 month, 3 months and 6 months all showed normal results. One preoperative symptom-free patient suffered from a mild swallowing disturbance for 2 months. However, only RETS, but not BSFS, demonstrated the prolonged proximal segmental esophageal transit time at 1 month postoperatively. The remaining 6 patients suffered from prominent swallowing disturbances and their initial postoperative RETS demonstrated prolonged defective transit or the presence of gastroesophageal (GE) reflux. All these events were confirmed by both tests.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic value of glycosylated hemoglobin in intravascular hemolysis after cardiac surgery

Glycosylated hemoglobin (GH), hemoglobin (Hb), hematocrit, LDH and serum bilirubin were measured pre-operatively, and 1-10 days and 11-42 d post-operatively in 42 patients undergoing cardiac surgery. Their mean age was 39.90 years, ranging from 4 to 68 yr. In the early post-operation days, Hb and hematocrit, but not GH percentage, were significantly decreased. This demonstrates that, at this stage, acute blood loss rather than hemolysis is more prominent. In the later post-operative days, GH, but not Hb or hematocrit, decreased significantly. This indicates the presence of chronic hemolysis with bone marrow compensation. In our study, the incidence of chronic mild hemolysis after cardiac surgery was very high (68.8%). We conclude that GH determination is a simple, easy and sensitive method to detect chronic hemolysis and we suggest measuring it in every case with suspicion of hemolysis.

[Results of vascular reconstruction in lower limbs ischemia: a six-year clinical experience]

During the period between Dec. 1982 to Nov. 1988, a total of 412 patients with 471 limbs at risk of peripheral arterial occlusive disease underwent vascular surgical treatment at the Veterans General Hospital. There were 382 men and 30 women, who ranged in age from 20 to 84 years (mean 63.17 +/- 11.85 years). 95 cases were isolated aortoiliac occlusive disease, 94 cases were combined aortoiliac and femoropopliteal disease, 169 cases were femoropopliteal occlusive disease and 54 cases were femorotibialperoneal occlusive disease. Various reconstructive procedures were performed in the these patients. The cumulative limb salvage rate (LSR) exceeded cumulative patency rate (CPR) in all categories and the result of LSR and CPR were 97.6% and 91% for aortoiliac reconstructive surgery in six years, 96% and 77% for above-knee femoropopliteal saphenous vein bypass (SVB) in six years, 79% and 74% for below-knee femoropopliteal SBV and 63% and 34% for femoro-distal SVB in five years. 88% and 76% for above-knee femoropopliteal human umbilical vein (HUV) bypass in four years. 67% and 45% for femoro-distal HUV bypass in three years follow-up period individually. The immediate good symptomatic results of the vascular reconstruction was 88% encountered in isolated aortoiliac disease, 63% in combined aortoiliac and femoropopliteal disease, 70.4% in isolated femoropopliteal disease and only 26% in femorotibial-peroneal disease (FTP). No change symptoms was still higher (33%) in FTP than the other vascular reconstruction due to poor distal runoff in this series. The early postoperative mortality rate was 1.6%, the late mortality rate was 2.7%, the incidence of postoperative complication rate was 13.6%. The major lower limb amputation rate was low as 7% in our series.(ABSTRACT TRUNCATED AT 250 WORDS)