Spontaneous disappearance of an intracranial aneurysm after subarachnoid hemorrhage.

Spontaneous disappearance of an intracranial aneurysm after subarachnoid hemorrhage is an uncommon event and usually associated with severe cerebral vasospasm, giant aneurysms or the use of antifibrinolytics. We present a young woman who suffered a grade 5 subarachnoid hemorrhage with severe vasospasm caused by a small anterior communicating artery aneurysm. The patient underwent a slow recovery and two years later requested surgery. Angiography demonstrated complete disappearance of the aneurysm. The neurosurgeon should be aware that spontaneous thrombosis of cerebral aneurysms can occur and ensure that angiography is repeated when surgery is significantly delayed.     

Myofibroblasts and the progression of diabetic nephropathy

Background. The cellular mediators of progressive renal fibrosis in diabetic nephropathy remain unknown. Myofibroblasts have been implicated in the pathogenesis of experimental and clinical renal fibrosis. Their role in the progression of diabetic nephropathy is the subject of this study.Subjects and methods. We have studied by immunohistochemistry the expression of cytoskeletal proteins associated with the activation of myofibroblasts; &agr;-smooth-muscle actin (&agr;-SMA), vimentin (Vi) and desmin (D), in the kidneys of 25 patients with diabetic nephropathy (5 patients with diabetic nephropathy (5 patients had a superimposed glomerulonephritis). Comparisons were made with normal tissue for three kidneys removed for renal-cell carcinoma. Correlations were studied between clinical and biochemical parameters with the expression renal cytoskeletal proteins. Results. In normal kidneys, cells expressing &agr;-SMA were confined to the vascular media and adventia while immunoreactive Vi was detected in glomerular epithelial cells. In diabetic kidneys, cells expressing &agr;-SMA were detected primarily in the renal interstitium and to a lesser extent in some glomeruli in association with mesangial proliferation. Vimentin immunostain decreased in glomeruli displaying diabetic hyalinosis and sclerosis. By contrast, strong Vi immunoreactivity was noted in atrophic diabetic tubules and to a lesser extent in the interstitium. Desmin was not detected in either normal or diabetic kidneys. Close correlations were observed between the expression of renal cytoskeletal proteins and the progression of renal insufficiency. Interstitial &agr;-SMA proved to be a predictor of progressive diabetic nephropathy (R² for 1/serum Cr slope=0.608, P=0.00001). This predictive parameters; tubular atrophy (R²=0.477, P=0.00004) and interstitial fibrosis (R²=0.28, P=0.001). Conclusion. We have demonstrated in this study the neoexpression of cytoskeletal proteins within diabetic kidneys. This has allowed the identification of new predicting histological markers for the progression of diabetic nephropathy.     

Liver and Pancreatic Resection in the Elderly

Background: Liver resection, or pancreaticoduodenectomy, has traditionally been thought to have a high morbidity and. mortality rate among the elderly. Recent improvements in surgical and anesthetic techniques, an increasing number of elderly patients, and an increasing need to justify use of limited health care resources prompted an assessment of recent surgical outcomes.Methods: Five hundred seventy-seven liver resections (July 1985–July 1994) performed for metastatic colorectal cancer and 488 pancreatic resections (October 1983–July 1994) performed for pancreatic malignancies were identified in departmental data bases. Outcomes of patients younger than age 70 years were compared with those of patients age 70 years or older.Results: Liver resection for 128 patients age 70 years or older resulted in a 4% perioperative. mortality rate and a 42% complication rate. Median hospital stay was 13 days, and 8% of the patients required admission to the intensive care unit (ICU). Median survival was 40 months, and the 5-year survival rate was 35%. No difference were found between results for the elderly and those for younger patients who had undergone liver resection, except for a minimally shorter hospital stay fortheyoungerpatients (median, 12 days vs. 13 days p=0.003). Pancreatic resection for 138 elderly patients resulted in a mortality rate of 6% and a complication rate of 45%. Median stay was 20 days, and 19% of the patients required ICU admission, results identical to those for the younger cohort. Long-term survival was poorer for the elderly patients, with a 5-year survival rate of 21% compared with 29% for the younger cohort (p=0.03).Conclusions: Major liver or pancreatic resections can be performed for the elderly with acceptable morbidity and mortality rates and possible long-term survival. Chronologic age alone is not a contraindication to liver or pancreatic resection for malignancy.     

Influence of variation at the apolipoprotein E locus on lipid and lipoprotein levels in CAPD patients

Background. Variation at the apolipoprotein E (apo E) locus influence lipid and lipoprotein levels in the normal population, and is associated with premature coronary artery disease. Patients with end-stage kidney disease or undergoing dialysis treatment are particularly prone to develop accelerated atherosclerosis. Methods. To evaluate the influence of genetic variation at the apo E locus, apo E genotypes and serum lipid and lipoprotein levels were measured in 51 subjects undergoing continuous ambulatory peritoneal dialysis (CAPD). Results. The distribution of apo E phenotypes and apo E allelic frequency among the CAPD subjects (&egr;2 0.049; &egr;3 0.745; &egr;4 0.206) corresponded to the healthy Swedish population. In the CAPD subjects, total serum and LDL cholesterol levels were high (6.7±1.5 mmol/l and 4.2±1.3 mmol/l respectively) and HDL cholesterol levels were low (1.2±0.5 mmol/l). When directly comparing the two major apo E groups, E 3/3 subjects (n=30) and E4/3 and 4/4 subjects, &egr;4-carriers, (n=16), LDL cholesterol levels were significantly higher among &egr;4-carriers (4,8±1.1 vs 4.0±1.2 mmol/l, P<0.03), but total serum cholesterol levels was not higher among the &egr;4-carriers (7.3±1.3 vs 6.5±1.5 mmol/l, P<0.08). Serum triglycerides or HDL cholesterol levels did not differ significantly between &agr;3-homozygotes and &egr;4-carriers. Conclusions. The results demonstrate a strong effect of variation of the apo E locus on LDL cholesterol levels in CAPD subjects, suggesting that &egr;4-carriers may be more susceptible to accelerated development of atherosclerosis in this condition.     

Shoot First,Draw Later Peroneal Nerve Palsy: A Sonographic Study

A 32–year–old man had an unusual gunshot wound to the leg, causing a peroneal nerve palsy. Sonography provided useful complementary findings to the electrodiagnostic localization of the injury.     

Reproductive hormone levels after pituitary allograft in cyclosporin-treated monkeys

OBJECTIVE: To determine the course of events during the onset of hyperprolactinemic amenorrhea, a nonhuman primate model was sought that did not require suckling or interference with the in situ hypothalamic-pituitary axis. DESIGN: Because removal of the adenohypophysis from hypothalamic influence results in secretion of large quantities of prolactin (PRL) but little of the other adenohypophyseal hormones, we explored the possibility of establishing pituitary allografts in monkeys. Normally cycling female rhesus monkeys were immunosuppressed with a daily regimen of cyclosporin A (CyA; 10 to 15 mg/kg per day) and then subcutaneously grafted with a pituitary from another animal (allograft). Blood samples were obtained daily via saphenous vein puncture during control, only CyA-treatment, and allografted-plus CyA- menstrual cycles. SETTING: Oregon Regional Primate Research Center, Beaverton, Oregon. PARTICIPANTS: Female Macaca mulatta exhibiting regular menstruation. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Prolactin, luteinizing hormone (LH), estradiol (E2), and progesterone (P) levels were determined in harvested serum. RESULTS: Temporary survival of 5 of 11 (45%) allografts was assumed based on elevations in serum PRL. Of the viable grafts, 4 of 5 (80%) resulted in reproductive dysfunction, as first evidenced by delay or loss of the preovulatory rise in E2. When the peak of follicular E2 was delayed, then the LH surge occurred, but it was also delayed. If follicular E2 levels did not peak, then the LH surge was absent as was luteal P production. CONCLUSION: These data suggest that in the etiology of PRL-induced infertility in women, the first event is a suppression of follicular E2 production. In addition, the hypothalamus probably remains responsive to the positive feedback of E2 during early or moderate hyperprolactinemia.