Infrared/video ENG recording of eye movements to evaluate the inferior vestibular nerve using the minimal caloric test

The technique was originally developed to test the inferior vestibular nerve in tumor suspects whose high-frequency hearing loss exceeded the capabilities of the auditory brainstem response tests and whose electronystagmographic results showed no significantly reduced vestibular response. The test has subsequently been found effective to demonstrate persistent singular nerve fiber function in patients with persistent vertigo after retrolabyrinthine vestibular nerve section.     

Interlaboratory variability of rotational chair test results II: analysis of simulated data.

Standardization of rotational chair testing across laboratories has not been achieved because of differences in test protocol and analysis algorithms. The Interlaboratory Rotational Chair Study Group was formed to investigate these differences. Its first study demonstrated significant variability in calculated results using actual patient data files. No estimation of accuracy could be made, however, because the "true" values of response parameters were unknown. In this study we used simulated "patient" data files to further explore the differences among analysis algorithms. We found a high degree of agreement and accuracy across laboratories using automated analysis of high signal-to-noise/low-artifact data for gain, phase, and asymmetry. Variability increased significantly for the lower signal-to-noise ratio/higher artifact files. Operator intervention generally improved accuracy and decreased variability, but there were cases in which operator intervention reduced accuracy.     

Scaphoidectomy (instead of trapezectomy) in the treatment of rhizoarthrosis. Report of a case

IntroductionSurgery site errors and technical errors in hand surgery are rare and not often published.ObservationA 46-year-old patient with rhizoarthrosis of the left hand was initially treated by mistake in another center by a scaphoidectomy instead of a trapezectomy. She was seen in consultation 6 months later, still suffering from her rhizoarthrosis and with carpal instability, clinically symptomatic and radiologically confirmed. The instability of the wrist was treated by a hamatocapito-lunar arthrodesis and a trapeziometacarpal arthrodesis was performed to treat the rhizoarthrosis. The clinical and radiological results were acceptable.DiscussionBesides the paradigmatic error, this observation confirms that the excision of the scaphoid quickly leads to a destabilization of the wrist, the capitatum no longer maintaining its alignment under the lunatum, and leads to a limitation of the wrist mobility and a loss of strength. The hamato-capito-lunate arthrodesis described in 1997 can treat wrist instability and only the trapeziometacarpal arthrodesis can, in the absence of scaphoid, treat the problem of rhizoarthrosis.ConclusionThe authors recommend to always carry out a radiography of the wrist during trapezectomy surgery when there is doubt about the identification of the trapezium.     

The aldosterone/renin ratio as a screening test for primary aldosteronism.

OBJECTIVE: To investigate the utility of random outpatient plasma aldosterone and renin measurements in screening for primary aldosteronism (PA) in hypertensive patients. DESIGN: Clinical records of hypertensive patients who had aldosterone and renin determinations over a 3-year period were analysed retrospectively. The patients were arbitrarily classified into five groups defined according to the aldosterone level and the aldosterone/renin (A/R) ratio: PA (plasma aldosterone > 500, A/R ratio > or = 1,000; essential hypertension (EHT) (aldosterone < 1,000, A/R < 1000); secondary hyperaldosteronism (SHA) (aldosterone > or = 1,000, A/R < 400); low-renin hypertension (LRHT) (aldosterone < 500, A/R > or = 1,000); miscellaneous hyperaldosteronism (MHA) (aldosterone > or = 1,000, A/R 400-1000). SETTING: A hypertension clinic in a large teaching hospital. PATIENTS AND RESULTS: The sample of 216 hypertensives were classified as follows: EHT 51%, LRHT 8%, PA 32%, SHA 7%, and MHA 3%. Mean plasma potassium values were significantly lower (P < 0.0001) in the PA group compared with essential hypertensives, but plasma K+ was of little utility in identifying individual patients with PA, as 71% were normokalaemic. Adrenal computed tomography scans were performed on 38 of 69 patients with PA, and revealed definite unilateral or bilateral adrenal masses in 7 and probable unilateral masses in a further 4. Five patients underwent unilateral adrenalectomy, confirming adrenal adenomas in 4 and nodular hyperplasia in 1. The minimum prevalence of PA due to adrenal adenoma or hyperplasia was 3.3% of all hypertensives and 10.1% of patients with biochemical PA defined by A/R ratio. Patients with biochemical PA had more target organ damage, and in general responded more favourably to regimens with spironolactone than to conventional therapy. CONCLUSIONS: A random outpatient aldosterone and renin measurement identifies a group of hypertensives with biochemical PA in which there is a significant prevalence of adrenal adenomas, increased prevalence of target organ damage and a good response to spironolactone. These results have major implications for the investigation and management of patients with severe or resistant hypertension.     

Cochlear and vestibular gross and histologic anatomy (as seen from postauricular approach)

The otologic surgeon must have a clear understanding of the anatomy of the seventh and eighth cranial nerves from the labyrinth to the brain stem, as seen from the postauricular approach. The surgical anatomy of the seventh and eighth cranial nerves was studied in 64 transcochlear eighth-nerve sections and 33 retrolabyrinthine vestibular neurectomies. Analysis indicates the nerves rotate 90 degrees in their course from the ear to the brain. The key relationship is that the cochlear nerve is always the most inferior, rotating from anterior (medial) near the labyrinth to posterior (lateral) near the brain stem. The seventh (facial) nerve rotates from anterosuperior (medial superior) near the labyrinth to anteroinferior (medial inferior) near the brain stem. The seventh nerve is easily seen in the transcochlear approach and hidden from view in the retrolabyrinthine approach. Twenty-seven fixed nerve specimens were examined with an operating microscope before being prepared for sectioning. In 73% (19 of 26) a cleavage plane was seen on the lateral aspect of the eighth nerve (that portion of the nerve facing the surgeon in the retrolabyrinthine approach).     

Estimated creatinine clearance instead of plasma creatinine level as prognostic test for postoperative renal function in patients undergoing coronary artery bypass surgery.

BACKGROUND: Preoperative renal failure is a risk factor for adverse events in cardiac surgery. Serum creatinine (SCr) is the most used test for renal failure. However, patients can have significantly decreased glomerular filtration rates with normal SCr levels. More accurate approximation of renal function can be obtained using the Cockroft-Gault equation to calculate an estimated creatinine clearance (CrCl) rate from SCr. METHODS: This study included 627 patients undergoing an isolated CABG between January 2003 and September 2004. CrCl was calculated using the Cockroft-Gault formula. Patients were divided in group A-SCr, 576 patients (91.1%) with a good renal function, SCr < or =1.20 mg/dL for women and < or =1.40 mg/dL for men, and a group B-SCr, with impaired renal function, 51 patients (8.1%). CrCl < or = 50 mL/min was chosen to reflect renal impairment. Group A-CrCl (555 patients, 88.5%) had a normal renal function and group B-CrCl (72 patients,11.5%) an impaired renal function. The studied outcomes were hospital mortality, hospital morbidity, and postoperative renal failure. RESULTS: There was no statistical significant difference between A-SCr and B-SCr group according to the studied outcomes. On the contrary, using the CrCl there was a statistical significant difference between A-CrCl and B-CrCl for the percentage of postoperative renal failure 10 patients (1.8%) versus 5 patients (6.9%) (p=0.00), hospital morbidity 75 patients (13.5%) versus 16 patients (22.2%) (p=0.04). Hospital mortality, 11 patients (2%) versus 4 patients (5.6%), was not significantly (p=0.06) different. Postoperative dialysis, four patients (0.7%) versus three patients (4.2%) (p=0.00), stroke, three patients (0.5%) versus three patients (4.2%) (p=0.00), and hospital stay (7.6 days vs 11.0 days) (p=0.01) were significantly different. CONCLUSION: This study documents that the association between preoperative renal failure and adverse outcomes after CABG is stronger with the estimated CrCl than with the routinely used SCr. Routine estimation or measurement of glomerular filtration rate should be preferred to SCr as screening method for the detection of higher risk patients undergoing CABG.     

Microsurgical results with large vestibular schwannomas with preservation of facial and cochlear nerve function as the primary aim

Summary Objective. To evaluate our microsurgical results in dealing with vestibular schwannomas (VS) greater than or equal to 30 mm when preservation of cranial nerve function was considered more important than total tumour removal.Methods. Sixteen consecutive cases were operated on by the same neurosurgeon according to a prospective protocol using intraoperative neuro-monitoring (IONM) based on electromyographic and brain stem auditory evoked potential recordings. Facial nerve function was evaluated on the House-Brackmann Scale and cochlear nerve function on the Gardner-Robertson Scale. Someone not involved in the clinical management of our patients collected all data.Results. Fifteen patients showed facial nerve (FN) function of House-Brackmann grade (HBG) I or II at one year postoperatively and one kept the HBG IV she had preoperatively. Two patients of four maintained a cochlear nerve function of Gardner-Robertson grade (GRG) II. The tumour excision rates were: total, 68.7%; near total, 6.3%; subtotal, 18.7%, and partial, 6.3%. The average follow-up was 55 months (1–106). Three patients underwent radiotherapy later with growth stabilisation and no additional morbidity.Conclusion. When dealing with VS greater than or equal to 30 mm, microsurgery guided by IONM, with a rate of total or near-total tumour excision of about 75%, can retain socially acceptable facial nerve function (HBG I or II) in all cases and serviceable hearing (GRG I or II) in two cases out of four. Maintaining serviceable cranial nerve function should take precedence over total tumour excision.     

The angle velocity reproduction test (AVRT) as sensorimotor function of the glenohumeral complex

BACKGROUND: The purpose of the present study was to develop and evaluate the angle velocity reproduction test (AVRT) in the glenohumeral joint. METHODS: In 46 volunteers with healthy shoulders, a test was devised in order to record the angle velocity perception in the shoulder. One arm was moved passively by means of a Cybex 6000 unit. The subjects were asked to perform the same movement as precisely as possible with the contralateral arm without visual control. The movement was recorded with a contact-free motion analysis system with a digital infrared camera and evaluated by aid of a movement analysis program. Starting at -20 degrees, the movement was an anteversion (anterior flexion) of 110 degrees. The sector between 20 degrees and 90 degrees was analyzed in detail. Different parameters were documented which represented different aspects of the sensorimotor function. The predetermined angle velocity of the Cybex setting on the contralateral arm amounted to exactly 53 degrees /s. In order to observe validity and reliability, 10 additional measurements with visual control as well as 21 double measurements were performed. RESULTS: The comparison of the measurements with and without visual control yielded highly significantly better results for those courses with visual control with regard to all those parameters which represent the perception of velocity. The values which describe the evenness of the movements were weak and/or insignificant. CONCLUSION: The introduced AVRT appears suitable to test dynamic sensorimotor abilities.     

Feasibility of subrenal capsule assay as chemosensitivity test for primary esophageal cancer

Subrenal Capsule Assay (SRCA) as a chemosensitivity test was performed on 39 esophageal squamous cell carcinomas in order to select a more effective chemotherapy and assess the correspondence between the assay results and clinical results. The implant grew progressively for six days and decreased from day 7 in the group of control mice. Histologically, host cell infiltration and new vessel was observed from day 3 after transplantation. Tumor growth curve was not influenced by immunosuppression with cyclophosphamide for six days. As primary esophageal squamous cell carcinomas, two diameter method was more sufficient for evaluating the sensitivity than volume method. Macroscopically, the rate of remained implants was 88.2% and yielded an evaluable assay rate of 94.9%. As to sensitivity, the effective rate of CDDP was 24.3%, BLM was 5.9%, MTX was 8.6% and VDS was 20.7%. Histologically, the rate of tumor cells occupied in implant was decreased by grade of augmentation of effectiveness. Clinically, correspondence between the assay results and clinical result was obtained in 92.3%. SRCA is a new promising chemosensitivity test which is clinically useful, and the present results indicated the feasibility of its use in developing an effective chemotherapy for primary esophageal cancer.     

Evaluation of mutation screening as a first line test for the diagnosis of the primary hyperoxalurias

BACKGROUND: A definitive diagnosis of primary hyperoxaluria type 1 (PH1) and primary hyperoxaluria type 2 (PH2) requires the measurement of alanine:glyoxylate aminotransferase (AGT) and glyoxylate reductase (GR) activities, respectively, in a liver biopsy. We have evaluated a molecular genetic approach for the diagnosis of these autosomal-recessive diseases. METHODS: Polymerase chain reaction (PCR) was used to detect three common mutations in the AGXT gene (c.33_34insC, c.508G>A, and c.731T>C) and one, c.103delG, in the GRHPR gene in DNA samples from 365 unrelated individuals referred for diagnosis of PH1 and/or PH2 by liver enzyme analysis. RESULTS: One or more of these mutations was found in 183 (68.8%) biopsy proven cases of PH1 and PH2 with a test negative predictive value of 62% and 2%, respectively. 102 (34.1%) patients were homozygous or compound heterozygous, making a molecular diagnosis possible. Age of onset and presenting features were similar in patients homozygous for any of the four mutations. Of the AGXT homozygotes, only the c.508G>A mutant was associated with significant AGT catalytic activity and in two of these activity was in the low normal range, possibly reflecting variation in mitochondrial content of the biopsy as this particular mutation is associated with mitochondrial mistargeting. CONCLUSION: Limited mutation analysis can provide a useful first line test for PH1 and PH2 in patients in whom primary hyperoxaluria is suspected and in whom secondary causes have been excluded. Those patients in whom a single mutation, or no mutation, is found can then be selectively targeted for liver biopsy.     

Carcinoembryonic antigen (CEA) as a prognostic and monitoring test in clinically complete resection of colorectal carcinoma.

The prognostic and postoperative monitoring capabilities of the CEA assay were compared to pathological staging of the operative specimens, clinical followup including endoscopy, radiology and scanning techniques, as well as DNCB skin testing and laboratory enzyme determinations (alkaline phosphatase and transaminase). A total of 46 patients with curative resection for colorectal carcinoma were studied. This included 23 patients with recurrent tumors compared to 23 long-term survivors without signs of recurrence at the time of the study. Preoperative CEA determinations were a good prognostic tool comparable to pathological staging of the specimen. Post operative CEA monitoring was the earliest sign of recurrence in 14 of 23 patients and was positive at the time of recurrence determined by other methods in 20; it was negative in only three cases. The incidence of false positive results among the non recurrent group became a lesser problem when repeated elevated values were required before considering the patient as having a recurrence. From these data, it seems reasonable to propose the use of a second-look operation in patients with maintained elevation of circulating CEA and no clinical signs of tumor presence, if we are to treat recurrence at an early stage. Chemotherapy would be an alternative way to deal with this problem, since the absence of clinical signs in general correlate with small bulk of tumor which at this time may be more susceptible to chemotherapeutic agents.     

甲状腺乳头状癌为第三原发肿瘤1例

患者女,56岁.因发现颈部无痛性包块6d入院,无外伤史,体查:颈前左侧扪及1.5cm×1.5cm包块,随吞咽上下移动,质中,边界清楚,可推动,颈侧未扪及肿大淋巴结.颈部B超:左叶甲状腺1.0cm×0.9cm,异常低回声结节.右叶甲状腺2.0cm×1.0cm,异常低回声结节.颈侧区未探及肿大淋巴结.ECT:左叶甲状腺凉结节,有血供. 胸部正侧位摄片:双肺间质性炎变.术中发现左叶甲状腺中份1cm直径包块,质硬,胸骨上凹气管前有肿大淋巴结.