Anterior circulation aneurysms: surgical perspectives

Aneurysms arising from the internal carotid circulation represent 85% of all intracranial aneurysms. The intimate relationship of the internal carotid artery and its branches with the brain and cranial nerves, and the distribution of the internal carotid artery flow, make these aneurysms challenging, and potentially complicated in their surgical management. Great attention to detail, and clear understanding of the operative anatomy of the carotid system, facilitate the safe and successful treatment of these aneurysms. The surgical experience with 475 anterior circulation aneurysms treated from 1980 to 1992 is presented. The aneurysms arose from the internal carotid artery: 230(40%), middle cerebral artery: 152(32%), and anterior cerebral artery: 133(28%). Of aneurysms arising from the internal carotid artery, there were 142(30%) from the posterior communicating artery; internal carotid bifurcation: 29(6%), and anterior choroidal artery: 19(4%). There were 62(13%) giant aneurysms evenly distributed among the middle cerebral, internal carotid bifurcation and anterior cerebral artery. Serious neurological morbidity was observed in 13(3%) patients, who presented a combination of different neurological symptoms including: hemiplegia 3, hemiparesis 6, dysphasia 7, and loss of vision 4. Two patients developed a myocardial infarct and survived. Mortality occurred in 16(3%); these patients died from: a hemispheric infarction 7, severe vasospasm 6, myocardial infarction 2, and pulmonary emboli 1. All aneurysms appeared angiographically obliterated. Vasospasm was observed in 75(16%) patients of which nine were symptomatic, and six of them died. Six major arterial trunks were occluded in the post-operative angiogram, and three patients had occlusion of the internal carotid artery, not identified during surgery. Three of these patients with unexpected occlusions died from a major cerebral infarction, and three had lasting hemipareses and dysphasia. Surgical correction of internal carotid aneurysms can be conducted safely when the anatomical characteristics of the intracranial vessels is preserved, and when these patients are treated with appropriate medical support.     

Influence of pancreas transplantation on cardiorespiratory reflexes, nerve conduction, and mortality in diabetes mellitus

Cardiorespiratory reflexes (CRR) were studied by measuring heart-rate variation during 6 breaths/min respiration and a Valsalva maneuver in 232 insulin-dependent diabetic subjects. Abnormalities were found in 175 patients. During a 7-yr follow-up, 41 (23.4%) patients with abnormal and 2 (3.5%) with normal CRR tests died. The mortality rates of diabetic patients with abnormal autonomic function tests were 17% at 2.5 yr, 33% at 5 yr, and 40% at 7 yr, significantly higher (P less than 0.002) than in patients with normal tests (rates of 4.6, 4.6, and 13.8% at the respective intervals). Nerve conduction studies (NCS) were indicative of somatic neuropathy in 148 of 205 patients. Mortality rates were higher in patients with abnormal NCS than in those with normal results (P less than 0.025). Among patients with abnormal autonomic function, patients with a functioning pancreas transplantation (PTx) had better survival rates than patients with a failed PTx (P less than 0.005) and, on long-term follow-up, better rates than patients without PTx. Similar results were found comparing the same group of patients who had abnormal NCS.     

Lack of effect of cimetidine on cigarette smoking

Summary The efficacy of cimetidine as a treatment that could reduce smoking in heavily dependent smokers has been determined. In a randomised, double-blind, double-crossover experiment, 43 heavy smokers were divided into two groups, one receiving cimetidine 400 mg orally three times a day, and the other receiving placebo for two weeks followed by the alternative treatment (placebo or cimetidine).No significant difference in the mean alveolar carbon monoxide, nicotine or cotinine levels was found between the two treatment groups compared to baseline. Since the alveolar carbon monoxide level reflects the intensity of smoking behaviour, the results suggest that no change in smoking behaviour occurred in the subjects.Contrary to our previous findings that cimetidine decreased the total body clearance of nicotine by 30% in a population of non-smokers, in the heavily dependent smokers, cimetidine did not appear to alter nicotine elimination. One possible explanation for the discrepancy is that tobacco smoking is known to induce nicotine metabolism and the induction might have offset any effect of cimetidine on nicotine elimination.Cimetidine does not appear to be a useful treatment leading to a reduction or cessation of cigarette smoking.     

PULMONARY RESECTION FOR METASTATIC BREAST CANCER

Background : A patient with a solitary pulmonary metastasis who had breast cancer in the past may benefit from pulmonary resection. Methods : Between 1984 and 1996, 17 patients underwent metastatectomy for metastatic breast cancer. There were 15 females and two males whose average age was 59 (range: 40–74 years). The median tumour-free interval after the primary breast-cancer operation was 5.1 years (range: 8 months-18.2 years). Sixteen patients had complete resections, which included six lobectomies and 10 lesser resections. Results : The postoperative mortality was nil and the morbidity rate was 6%. Follow-up was complete in all patients. Recurrent disease developed in four patients and two patients died of their disease. The 5-year survival was 62%. Conclusion : An aggressive surgical approach is warranted in patients with isolated resectable pulmonary metastases from breast cancer.     

Effect of different questionnaire formats on reporting of occupational exposures

During an exposure monitoring study, 78 saw maintenance tradesmen were randomly assigned to be interviewed about their exposures using one of two questionnaire formats: open-ended and partly prompted questions about five categories of materials; and detailed prompting about 75 agents. The more open-ended questionnaire elicited fewer exposure responses overall, but more responses about agents not included on the detailed questionnaire. Composite materials and trade name products were more frequently cited as exposures than individual metals or compounds. Validity of responses was ascertained using air measurements (individual metals) or observations of the employees (composite materials). Sums of sensitivities and specificities were very low (near 1.0) for most of the metals for both types of questionnaire. For composite materials, validity improved substantially. Sensitivities with the partly prompted format (0.44–0.85) were always lower than with detailed prompting (0.80–1.00). Specificities were usually, but not always, higher with partial prompting (0.66–0.92) than with detailed prompting (0.18–0.86). Selection of questionnaire format for an epidemiologic study would depend on the likely prevalence of exposure in controls and the effects of trade-offs in sensitivity and specificity.