Intracerebral hematomas caused by aneurysm rupture. Experience with 67 cases

During a six-year period (1986–1992) 334 patients with subarachnoid hemorrhage (SAH) were admitted to the Department of Neurosurgery, Medical University of Lübeck, Germany. In 281 patients the SAH was caused by rupture of an intracranial arterial aneurysm, verified by angiography, postmortem examination, or at emergency operation without angiography. In 67 (23.8 %) of the 281 aneurysmal SAH patients the initial computerized tomography (CT) demonstrated an intracerebral hematoma (ICH). An ICH localized in the temporal lobe due to the rupture of a middle cerebral artery (MCA) aneurysm was found in 47 patients (70.2 %). Forty-three patients were considered for surgery with a surgical mortality of 8 (18.6 %). In the group of 19 ICH patients not operated upon, 16 individuals died (84.2%).We therefore advocate active surgical management of ICH patients: hematoma evacuation and aneurysm clipping at the same operation. Emergency surgery in younger patients (grade V) with temporal ICH suggesting the rupture of a MCA or internal carotid artery (ICA) aneurysm can be done without angiography.     

Extended resection for locally advanced colorectal carcinoma

Background: The purpose of this study was to determine the therapeutic benefit of multivisceral resection (MVR) in patients with locally advanced colorectal carcinomas. Methods: The study population was composed of 118 patients whose resection of the primary lesion included one or more adhesed adjacent secondary organs or structures (ASOS). Tumors were staged as B3 (T4,N0) and as C3 (T4,N1–3). Adhesions were classified as invasive (B3+,C3+) or inflammatory (B3–,C3–). Results: Sixty-four patients were staged B3 and 54 C3. Eighty-one were classified B3+/C3+. Fifty-nine percent of patients had ASOS resected, 29% had two resected, and the remaining 12% had three or four resected. Actuarial 5-year survival rates were 62% and 38% (p=0.017) for B3 and C3 lesions, respectively. The 5-year survival rates were 78% for patients with B3– tumors and 58% for those with B3+ tumors (p=0.043), and 34% for patients with C3+ tumors and 64% for those with C3– tumors (p=NS). The 5-year survival rates were 71% for patients with B3–/C3– tumors and 47% for those with B3+/C3+ tumors (p=NS). The 5-year survival rates after resection of one ASOS, two ASOS, and three or four ASOS were 52%, 55%, and 38%, respectively (p=NS). Conclusion: There is no statistically significant difference in the 5-year survival rates when multiple ASOS are resected; therefore, an aggressive surgical approach is warranted.Presented at the 49th Annual Cancer Symposium of The Society of Surgical Oncology, Atlanta, Georgia, March 21–24, 1996.     

Intracerebral haematomas from aneurysm rupture: Their clinical significance

Summary Two series of patients (814 cases altogether) with ruptured intracranial aneurysms are analyzed in order to try to outline the clinical significance of space-occupying intracerebral haematomas (ICH) which may accompany SAH. In particular the question of whether intracerebral clots are or are not to be taken into account in planning emergency surgery is debated.From the reported series, it would appear that ICH after aneurysm rupture seldom lead to increasing intracranial hypertension warranting urgent surgery. This evolution was observed in approximately 5% of patients with expanding ICH. In 35% the intracerebral effusions were associated with irreversible lesions and in 20% the initial symptomatology definitely improved. Finally, in a relatively high percentage of cases (about 40%) ICH lacked of clinical significance.Brandtet al. [Brandt L, Sonesson B, Ljunggren B, Saveland H (1987), Ruptured middle cerebral artery aneurysm with intracerebral haemorrhage in younger patients appearing moribund: emergency operation, Neurosurgery 20, 925–929] have just reported 4 cases of huge ICH from ruptured MCA in young moribund patients successfully submitted to ultraemergency surgery, on the basis of CT alone without angiography. 3 patients survived with moderate disability. This report would indicate unsuspected therapeutic possibilities in some hyperacute cases. Unfortunately, the circumstances which had been given in the cases reported by Brandtet al. are seldom gathered.     

High concentrations of procoagulant microparticles in the cerebrospinal fluid and peripheral blood of patients with acute basal ganglia hemorrhage are associated with poor outcome

BackgroundApoptosis plays an important role in further brain injury after intracerebral hemorrhage (ICH). Procoagulant microparticles (MPs) are shed from the plasma membrane of apoptotic cells. The objective of this study was to determine plasma and cerebrospinal fluid (CSF) levels of MPs in patients with spontaneous ICH and to correlate MP levels with Glasgow Coma Scale (GCS) scores, ICH volumes, presence of intraventricular hemorrhage (IVH), and survival rate.MethodsTen patients with suspicion of subarachnoid hemorrhage and 36 patients with spontaneous basal ganglia hemorrhage were included. Plasma and CSF samples were collected. Circulating MPs were obtained by double centrifugation and captured with annexinV. Their procoagulant potential was measured with a prothrombinase assay.ResultsPlasma or CSF MP levels in the ICH group were significantly higher than those in the control group (8.2 ± 3.0 vs 3.2 ± 1.7 nmol/L phosphatidylserine [PS] equivalent; P < .001 or 9.8 ± 3.7 vs 1.4 ± 0.6 nmol/L PS equivalent; P < .001). The MP levels were highly associated with GCS scores, ICH volumes, presence of IVH, and survival rate (all P < .05) in ICH. A receiver operating characteristic curve identified CSF and plasma MP cutoff levels that predicted 1-week mortality of patients with the high sensitivity and specificity values. Areas under curves (AUCs) of GCS scores and ICH volumes were larger than those of CSF and plasma MP levels, but only the difference between AUC of GCS scores and that of plasma MPs levels reached statistical significance (P < .05).ConclusionsHigh levels of procoagulant MPs are present in the CSF and peripheral blood of patients with ICH and may contribute to the pathogenesis of ICH. The levels of CSF and plasma MPs after spontaneous onset of ICH seem to correlate with clinical outcome in these patients. Taking clinical complexity into account, only plasma MP levels can be served as useful clinical markers for evaluating the prognosis of ICH.     

Comparison of the effect of decompressive craniectomy on different neurosurgical diseases

Background  Many previous studies have reported that decompressive craniectomy has improved clinical outcomes in patients with intractable increased intracranial pressure (ICP) caused by various neurosurgical diseases. However there is no report that compares the effectiveness of the procedure in the different conditions. The authors performed decompressive craniectomy following a constant surgical indication and compared the clinical outcomes in different neurosurgical diseases. Materials and methods  Seventy five patients who underwent decompressive craniectomy were analysed retrospectively. There were 28 with severe traumatic brain injury (TBI), 24 cases with massive intracerebral haemorrhage (ICH), and 23 cases with major infarction (MI). The surgical indications were GCS score less than 8 and/or a midline shift more than 6 mm on CT. The clinical outcomes were assessed on the basis of mortality and Glasgow Outcome Scale (GOS) scores. The changes of ventricular pressure related to the surgical intervention were also compared between the different disease groups. Findings  Clinical outcomes were evaluated 6 months after decompressive craniectomy. The mortality was 21.4% in patients with TBI, 25% in those with ICH and 60.9% in MI. A favourable outcome, i.e. GOS 4–5 (moderate disability or better) was observed in 16 (57.1%) patients with TBI, 12 (50%) with ICH and 7 (30.4%) with MI. The change of ventricular pressure after craniectomy and was 53.2 (reductions of 17.4%) and further reduced by 14.9% (with dural opening) and (24.8%) after returning to its recovery room, regardless of the diseases group. Conclusions  According to the mortality and GOS scores, decompressive craniectomy with dural expansion was found to be more effective in patients with ICH or TBI than in the MI group. However, the ventricular pressure change during the decompressive craniectomy was similar in the different disease groups. The authors thought that decompressive craniectomy should be performed earlier for the major infarction patients.     

The Effect of Intravesical Mitomycin C on the Recurrence of Superficial (Ta–T1) Bladder Cancer. A Hungarian Multicenter Study

We evaluated the prophylactic efficacy of instillations of intravesical mitomycin C in 57 patients with primary superficial bladder cancer in a multicenter clinical trial. After complete transurethral resection of Ta–T1 G1–G2 transitional cell bladder carcinomas, patients were treated with mitomycin 40 mg/50 ml saline of 15 instillations for 12 months. Most of the complications were mild and transient but two patients dropped out of the trial because of moderate side effects. Fifty-one patients were evaluable. We observed tumour recurrences in six patients (11.8%) during a median follow-up of 44.5 months. The recurrences were treated by transurethral resection. There was no muscle invasive progression in the recurrences. Our investigations confirm the effectiveness of mitomycin C in the treatment of patients with superficial bladder cancer.     

Risk Factors for Sepsis and Endocarditis and Long-Term Survival Following Coronary Artery Bypass Grafting

We sought to determine risk factors for sepsis and/or endocarditis (S/E) and to identify their impact on long-term survival after coronary artery bypass grafting (CABG). We studied 3760 consecutive patients who underwent isolated CABG from 1992 to 2002. Patients with CABG without S/E were compared with those who developed S/E. Long-term survival data (mean follow-up 5.2 years) were obtained from the National Death Index. Groups were compared by Cox proportional hazard models and Kaplan-Meier survival plots. The propensity for S/E was determined by logistic regression analysis and each patient with S/E was matched to one patient without S/E. Thirty-six patients (0.96%) developed S/E. Independent predictors for S/E were increased age (odds ratio [OR] 1.05 per year, 95% Confidence interval [95% CI] 1.00–1.09; p = 0.040) and the development of other major complications after CABG such as deep sternal wound infection (OR 30.80, 95% CI 9.50–99.82; p < 0.001), gastrointestinal complications (OR 19.48, 95% CI 7.14–53.18; p < 0.001), renal failure (OR 15.18, 95% CI 4.42–52.06; p < 0.001), intraoperative stroke (OR 13.11, 95% CI 4.81–35.69; p < 0.001) and respiratory failure (OR 12.95, 95% CI 5.69–29.45; p < 0.001). After adjustment for pre-, intra- and postoperative factors, the adjusted hazard ratio of long-term mortality for patients with S/E was 3.33 (95% CI 2.17–5.10; p < 0.001). There was no difference in 30-day mortality between matched groups (25.0% vs. 19.4% in patients without S/E, p = 0.778), however patients without S/E had better 5-year survival rate (52.7 ± 8.7% vs. 16.2 ± 6.2%; p = 0.0004). We have identified risk factors for S/E following CABG and we found that there was increased mortality in patients with S/E during a 10-year follow-up period.     

Health-related quality of life measurements in elderly Canadians with osteoporosis compared to other chronic medical conditions: a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos)

The objective of this research was to determine the relative decrement in health-related quality of life, as measured by the health utilities index mark 3 (HUI3), in osteoporosis compared to other chronic medical conditions. The impact of chronic medical conditions other than osteoporosis on HUI3 measurements had been previously established in the 1996/1997 Canadian National Population Health Survey (NPHS). The Canadian Multicentre Osteoporosis Study (CaMos) is a national population-based study in which regional participants were randomly recruited, regardless of presence of osteoporosis. We analyzed data from participants aged 65 years who completed a baseline HUI3 questionnaire and provided information on their medical history (n=3,750). We determined the age- and gender-adjusted mean decrement in HUI3 for several chronic medical conditions, including osteoporosis. The mean changes in HUI3 adjusted for age and gender (with 95% confidence intervals) were as follows: arthritis –0.10 (–0.11, –0.09), chronic obstructive pulmonary disease (COPD) –0.07 (–0.09, -0.05), diabetes mellitus –0.05 (–0.08, –0.03), heart disease –0.06 (-0.08, –0.04), hypertension –0.02 (-0.03, –0.01), and osteoporosis –0.08 (–0.11, –0.06), respectively (model r²=0.17; P<0.0001). These findings were comparable to those observed in the NPHS, with the exception of osteoporosis, which had not been previously studied in this fashion. The decrement in HUI3 score seen in participants with osteoporosis was comparable to that observed in other chronic medical conditions, such as arthritis, COPD, diabetes mellitus or heart disease.This article was written with the participation of the CaMos Investigators: T. Anastassiades, L. Bissette, J.P. Brown, L. Joseph, R.G. Josse, C. Joyce, S. Kaiser, S. Kirkland, N. Kreiger, T.M. Murray, W.P. Olszynski, J. Prior, K. Siminoski, S. Poliquin, A. Tenenhouse     

Hybrid Assistive Limb (HAL) Rehabilitation in Patients with Acute Hemorrhagic Stroke

The efficacy of hybrid assistive limb (HAL) rehabilitation in the acute phase of stroke remains unclear. The purpose of this study was to evaluate the outcomes of patients with acute intracranial hemorrhage (ICH) who were treated with or without HAL rehabilitation. Among 270 patients with acute ICH from 2009 to 2014, 91 patients with supratentorial ICH were included in this retrospective study. Of these, 14 patients (HAL group) received HAL rehabilitation at approximately 1 week after ICH occurrence, while the remaining 77 patients received usual rehabilitation without HAL (N-HAL group). We obtained various patient data from the hospitals where the patients were moved to for further rehabilitation. Statistical comparisons were performed for the characteristics of the ICH patients, and outcomes between the HAL and N-HAL groups. There were no differences in outcomes between the HAL and N-HAL groups. However, patients with right ICH in the HAL group exhibited a significant association with a functional independence measure (FIM) score of ≥ 110 compared with patients in the N-HAL group (HAL group: 81.8%, N-HAL group: 43.9%, P = 0.04). In patients with right ICH, HAL rehabilitation was associated with improved outcomes as evaluated by the FIM score. Thus, HAL rehabilitation may improve outcomes of acute ICH in appropriately selected patients.     

The −1997 G/T Polymorphism in the COLIA1 Upstream Regulatory Region is Associated with Hip Bone Mineral Density (BMD) in Chinese Nuclear Families

Type I collagen is the most abundant protein of bone matrix, and the collagen type I alpha 1(COLIA1) gene has been considered one of the most important candidate genes for osteoporosis. In this study, we simultaneously tested linkage and/or association of the –1997 G/T polymorphism in the COLIA1 upstream regulatory region with the variation of bone mineral density (BMD) in 1263 subjects from 402 Chinese nuclear families, consisted of both parents and at least one healthy female offspring from 20 to 45 years of age. All the subjects were genotyped by using polymerase chain reaction–restriction fragment length polymorphism (PCR-RFLP). BMD of the lumbar spine (L1–L4) and hip (respective and combined phenotype of the femoral neck, trochanter, and intertrochanter) was measured by dual-energy X-ray absorptiometry (DXA). By using the tests implemented in program QTDT (quantitative transmission disequilibrium test), we found significant within-family association (via TDT) between the –1997 G/T polymorphism with BMD variation at all the hip sites (respective and combined phenotypes, P < 0.05). The amount of BMD variation explained by the –1997G/T polymorphism was 1.6%, 2.0%, 1.2%, and 1.3% at the total hip, femoral neck, trochanter, and intertrochanter, respectively. Because of the limited number of sib pairs in this sample, we did not find evidence of linkage. In summary, the –1997 G/T polymorphism in the COLIA1 gene is likely to be in linkage disequilibrium with a nearby functional polymorphism affecting hip BMD, or the -1997 G/T polymorphism itself may have an important effect on the variation of hip BMD in our Chinese sample.Y.- Y. Zhang, S.- F. Lei, X-Y Mo contributed equally to the article.     

多次给予羟乙基淀粉或高渗氯化钠溶液对实验性脑出血大鼠脑水肿的影响

目的 评价多次给予羟乙基淀粉或高渗氯化钠溶液对实验性脑出血(ICH)大鼠脑水肿的影响.方法 清洁级雄性SD大鼠167只,体重260～300 g,随机分为假手术组(S组,n=20)、ICH组(M组,n=38)、氯化钠组(N组,n=55)和羟乙基淀粉组(H组,n=54).采用立体定向技术向大鼠右侧尾状核注入自体血50μl建立ICH模型,S组仅刺入基底节,但不注血.N组分别于ICH后2、24、48、72 h前5～10 min静脉输注7.5%氯化钠溶液5 ml/kg,H组分别于ICH后2、24、48、72 h前45～50 min静脉输注6%羟乙基淀粉130/0.4 30 ml/kg,速率均为0.2 ml/min.S组和M组分别于ICH后2、24、48、72 h随机取5只大鼠断头处死,N组和H组则在上述各时点输液前、后随机取5只大鼠处死,采用干湿重法测定脑含水量;各组每天行行为学评分,观察大鼠生存情况.结果 与M组比较,N组和H组ICH后2、24、48、72 h输液后注血侧皮层和基底节脑含水量、ICH后24、48 h时行为学评分降低,ICH后24、48、72 h时生存率升高(P<0.05);与N组比较,H组ICH后72 h时生存率升高(P<0.05).结论 多次给予6%羟乙基淀粉130/0.4或7.5%氯化钠溶液可改善ICH后大鼠脑水肿.     

The Role of Stereotactic Radiosurgery in the Management of Benign, Atypical, and Malignant Meningiomas

Stereotactic radiosurgery and fractionated Stereotactic radiotherapy (SR) offer precise localization of radiation dose (Gy) for the treatment of meningioma (M). For the multimodal treatment with preservation of function, SR is complementary to both microsurgery (S) and conventional external beam radiotherapy (XRT). The role of SR in the management of atypical and malignant meningiomas, however, remains unexplored. Fifty consecutive patients with meningioma: 18 males (60.1 +/– 2.3 years) and 32 females (56.9 +/– 2.2 years) (p = NS) received SR. Thirty-one patients had surgery 69.6 +/– 13.9 months (95% CI: 53.3–98.0) prior to SR. For patients having S, the incidence of atypical or malignant versus benign meningiomas (14 versus 17 patients) increased with age (p = 0.03). Twenty patients had XRT approximately 18 months prior to SR. For antecedent XRT, the range of doses was 3600–6400 cGy (median: 5040 cGy). Following failure of S and/or XRT, patients had SR. Compared to other series, the mean tumor volumes for SR were comparatively large: 9.8 +/– 1.3 cm³ (range 0.3–37.1 cm³). The median SR dose was 3500 cGy (range 540–5400 cGy) administered in seven fractions (range 1–30). Linear regression analysis showed a consistent method for fractionation: the number of administered fractions increased (p = 0.053) and the total dose increased (p = 0.054) with tumor size. During the interval for follow–up (17.9 +/– 2.9 months), one patient with malignant meningioma required surgery for progression 8 months after SR. In the remaining patients, post-SR MRIs showed control (unchanged or smaller tumor volume) regardless of histology. These results show that SR may provide control of M regardless of grade.     

External fixation of intra-articular fracture of the distal radius in young and old adults

Forty patients (18–89 years old, mean 58 years) with comminuted intra-articular fractures of the distal radial end (AO-type C 2 or C 3) treated with external fixation could be followed for an average of 2.3 years. After 3 weeks, the distraction was released, and after another 3 weeks, the device was removed. Complications seen were one malunion, one radial shaft fracture caused by excentric drilling of a Schanz screw, one Sudeck atrophy, and one subcutaneous pin-track infection. Radial and ulnar deviations were reduced to 52% and 71% of the untreated wrist, whereas the range of motion in the other planes reached about 80% or more of the healthy side. In all, 82.5% of the patients showed good or excellent radiological and functional results. This study demonstrates that external fixation of distal radial C 2 and 3 fractures for 6 weeks results in good recovery for young patients and elderly patients with osteoporosis.Preliminary results of this study were presented at the German Congress of Surgeons, Munich, April 13–17, 1993, and at Eurosurgery, London, September 15–17, 1993.     

A short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12)

The aim of this study was to develop the short form of a condition-specific, reliable, validated and self-administered instrument to evaluate sexual function in women with pelvic organ prolapse and/or urinary incontinence. The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire –12 (PISQ-12) was developed from the data of 99 of 182 women surveyed to create the long form (PISQ-31). An additional 46 patients were recruited for further validation. All subsets regression analysis identified 12 items likely to predict PISQ-31 scores. Short form scores underwent correlation analysis with long form, Incontinence Impact Questionnaire – 7 (IIQ-7), Sexual History Form –12 (SHF-12) and Symptom Questionnaire (SQ) scores. Test–retest reliability was checked with a subset of 20 patients. All subsets regression analysis with R>0.92 identified 12 items that predicted PISQ-31 scores. Short form scores were highly correlated with long form scores (R=0.75–0.95). Correlations of the PISQ-12 with SHF-12 (R=–0.66 and –0.68) and IIQ-7 (R=–0.38 and –0.54) scores were similar to correlation of the PISQ-31 with these other measures. Reliability was moderate to high, with weighted values from 0.56 to 0.93. PISQ-12 scores were lower in patients with low sexual function as measured on the SHF-12 (P <0.001), and lower in women with depression as measured on the SQ (P <0.001). The PISQ-12 is a validated and reliable short form that evaluates sexual function in women with urinary incontinence and/or pelvic organ prolapse and predicts PISQ-31 scores. It is able to distinguish women with poor sexual function as measured on the SHF-12.Editorial Comment: For decades, clinicians and researchers have described treatment success in our field as resolution of either anatomic defects or of urinary of fecal leakage. We have all had patients with perfect anatomic support after a prolapse operation who were unhappy because of problems with pain, leakage, defecation or sexual function. Yet, considering these and other quality of life issues as part of the definition of treatment success is a recent development. The emphasis on the importance of assessing various quality of life indicators is snow-balling, yet our efforts to do so have been hampered by the absence of good, easy to administrate, reliable and valid tools. The short form of the PISQ is an eagerly awaited tool that fills this void. From a research prospective, information derived from responses to this questionnaire will allow us to understand the effect of various treatments on sexual function, arguably one of the most important and least investigated domains of quality of life. When completed by patients in a clinical setting, the PISQ-12 provides a template for clinicians to discuss sexuality with patients, and to suggest appropriate interventions. In developing the long and short forms of this instrument, the authors have set a high standard for others developing quality of life instruments to strive for.Study supported by NCRR-GCRC Grant # M01 RR00997Presented at American Urogynecologic Society annual meeting in Hilton Head, South Carolina, USA, 2000An erratum to this article can be found at     

Spine fractures caused by horse riding

Study Design: Retrospective study and review of literature. Objectives: Study of demographic data concerning spinal fractures caused by horse riding, classification of fractures according to the AO and Load Sharing classifications, evaluation of mid-term radiological results and long-term functional results. Methods: A review of medical reports and radiological examinations of patients presented to our hospital with horse riding-related spine fractures over a 13-year period; long-term functional follow-up is performed using the Roland Morris Disability Questionnaire (RMDQ-24). Results: Thirty-six spine fractures were found in 32 patients. Male to female ratio is 1:7. Average age is 33.7 years (8–58 years). The majority of the fractures (78%) are seen at the thoracolumbar junction Th11–L2. All but two patients have AO type A fractures. The average Load Sharing Classification score is 4.9 (range 3–9). Neurological examinations show ASIA/Frankel E status for all patients. Surgical treatment is performed on ten patients. Mean follow-up for radiological data is 15 months (range 3–63). Functional follow-up times range from 1 to 13 years with an average follow-up of 7.3 years. Mean RMDQ-24 score for all patients is 5.5 (range: 0–19), with significantly different scores for the non-operative and surgical group: 4.6 vs 8.1. Twenty-two percent of the patients have permanent occupational disabilities and there is a significant correlation between occupational disability and RMDQ-24 scores. Conclusions: Not only are short-term effects of spine fractures caused by horse riding substantial but these injuries can also lead to long-term disabilities.     

Cyclosporin A absorption profiles in children with nephrotic syndrome

A single blood concentration measurement of Neoral 2 h after administration (C2) is a new concept in therapeutic drug monitoring (TDM). In most adult patients, the concentration of cyclosporin A (CyA) peaks within 2 h after Neoral administration. Therefore, monitoring the area under the concentration-time curve over the first 4 h post-dose (AUC0–4) is considered to be the most reliable strategy for Neoral TDM. In addition, C2 is considered to be the most accurate predictor of AUC0–4, with which C2 correlates best. Thus, in adult patients, C2 monitoring is recommended as the best single-point TDM method for Neoral. However, in paediatric patients, the effectiveness of C2 monitoring is still unclear. We examined the trough concentration (C0), C1, C2, C3, and C4 of CyA in 60 patients (1 to 20 years old, mean age 7.42±0.67 years) who had nephrotic syndrome treated with Neoral. The peak concentration of C0-C4 was C1 or C2 in 38 patients (early peak group) and C3 or C4 in 22 patients (late peak group). C2 in the late peak group was significantly lower than that in the early peak group (422±50.1 vs. 665 ±53.8 ng/ml, P =0.0008), although the administered doses of Neoral and C0 were similar between these groups. Therefore, TDM by C2 using the same standard as in the early peak group might result in an overdose of CyA in the late peak group. As the concentration peaked at 3 h or more after Neoral administration in the late peak group, AUC0–4 does not necessarily reflect the Neoral absorption profile. As more than 33% of the paediatric patients were in the late peak group, TDM by AUC0–4 or C2 should be used carefully in paediatric patients treated with Neoral.     

Spinal anesthesia with 0.5% S(−)-bupivacaine for elective lower limb surgery

Background and Objectives. This study examines the clinical effects of the subarachnoid administration of levobupivacaine, the S(−)-enantiomer of racemic bupivacaine. Methods. An open, noncomparative study was performed on 20 patients undergoing elective lower limb surgery. Three milliliters of a plain solution of 0.5% S(−)-bupivacaine (15 mg) was administered via the L2 or L3 interspace with the patient in the sitting position. Following injection, the patients were immediately placed supine. Spread of sensory analgesia, degree of motor block, and hemodynamic parameters were recorded. Results. Satisfactory surgical anesthesia was achieved in 18 patients. The median time to onset of analgesia was 2 minutes (ranging 2–10 minutes) and the median duration of analgesia was 388 minutes (range, 295–478 minutes). This group of patients achieved complete motor block, with a median onset time of 5 minutes (2–10 minutes) and duration of 266 minutes (range, 170–415 minutes). Sensory block height was inadequate for surgery in 2 patients, who received supplemental anesthesia. Conclusions. The results suggest that S(−)-bupivacaine can provide satisfactory surgical anesthesia, but the spread of the plain solution is unpredictable.     

The natural history of amaurosis fugax with minor degrees of internal carotid artery stenosis

The natural history of amaurosis fugax with hemodynamically insignificant degrees of internal carotid artery stenosis is uncertain. Seventy-three patients over age 40 who presented with amaurosis fugax without obvious cause and had ipsilateral stenoses of 50% or less with carotid duplex scanning were followed for a mean period of 35.5 months (range 3–110) without surgical intervention. At the initial vascular laboratory duplex evaluation, 35 patients had normal arteries (47.9%), 29 had minor (0–19%) stenoses of the ipsilateral internal carotid arteries (39.7%), and 11 had 20–50% stenosis (15.1%). Four patients with 0–19% stenosis and one patient with 20–50% stenosis experienced a subsequent stroke or permanent ipsilateral blindness. When analyzed by life-table format, stroke, blindness, and early death were more frequent in patients with minor degrees of stenosis than in those with normal arteries. Investigations in all patients with amaurosis fugax should be aimed at identifying whether the symptoms are explained by arteriosclerotic, systemic, collagen, cardiac, hematologic, or ophthalmologic disease. When no other etiology is found, and localized carotid bifurcation atherosclerosis of even modest degrees is identified, an atheroembolic etiology should be considered.     

Inadvertent C2–C3 Union After C1–C2 Posterior Fusion in Adults

Introduction: Some authors pointed out that there were more than a few patients with inadvertent C2–C3 union after C1–C2 posterior fusion, although few detailed studies of C2–C3 union have been reported. The purpose of this study was to clarify whether C2–C3 union accelerated adjacent C3–C4 disc degeneration after C1–C2 posterior fusion and to investigate the related factors for C2–C3 union. Methods: Sixteen patients with rheumatoid arthritis (RA group) (4 males, 12 females, mean age 60 years, mean follow-up period 4 years and 3 months) and fifteen patients without RA (non-RA group) (11 males, 4 females, mean 52 years, mean follow-up period 3 years and 10 months) who underwent C1–C2 posterior fusion were radiologically assessed. The C2–C3 union was defined as trabecular bone formation at C2–C3 interlamina in lateral radiograph. C3–C4 disc height was measured to evaluate the disc degeneration. Results: C2–C3 union rate was 56% and 60% in RA group and non-RA group, respectively. In RA group, postoperative C3–C4 disc height was lower (Students t-test, P = 0.029) and the decrease rate of C3–C4 disc height was higher (Students t-test, P = 0.015) in patients with C2–C3 union than in patients without C2–C3 union. In non-RA group, the age at operation was older (Students t-test, P = 0.0007), and the C1–C2 fusion angle (Students t-test, P = 0.012) was smaller in patients with C2–C3 union than in patients without C2–C3 union. Conclusions: C2–C3 union after C1–C2 posterior fusion occurred in more than half of both groups. Inadvertent C2–C3 union should be considered a radiological complication and a potential risk factor due to acceleration of C3–C4 disc degeneration in RA.     

Bone mineral density in men with genetic hemochromatosis and HFE gene mutation

Genetic hemochromatosis (GH) is an iron overload disorder mainly due to the C282Y mutation of the HFE gene. The possibility of bone involvement was only recently recognized. The aims of this study were to assess bone mineral density (BMD) and bone remodeling in men with GH, and to examine the influence of iron overload. Thirty-eight men (mean age 47.2±9.4 years) with well-defined HFE-related GH were studied. They had an important iron overload with liver iron concentration to age ratio >2.5, no previous venesection therapy and were C282Y homozygotes ( n =37) or compound C282Y/H63D heterozygote ( n =1). BMD measured by DXA was 0.925±0.15 g/cm² at the lumbar spine (LS) and 0.778±0.13 g/cm² at the femoral neck (FN). Osteopenia (T-score <–1 SD) was observed in 78.9% of patients and osteoporosis (T-score <–2.5 SD) in 34.2%. Vitamin D levels were normal, and no 1–84 parathyroid hormone dysfunction was found. Hypogonadism was found in only 13.2% of patients. Patients with hypogonadism had lower LS BMD than eugonadal patients (0.788±0.16 and 0.954±0.14 g/cm²). Bone remodeling and parathyroid hormone levels were lower in patients with cirrhosis, but BMD values were similar to those in patients without cirrhosis. FN BMD appeared to fall with rising hepatic iron concentrations ( r =–0.399). We conclude that there is significant bone loss in HFE-related hemochromatosis that cannot solely be explained by hypogonadism or cirrhosis. Further investigations are needed to determine the role of iron overload itself.