Outcome in Children With Significantly Abnormal Cerebral Blood Flow Detected by Doppler Ultrasonography: Focus on the Survivors

BACKGROUND AND PURPOSE: The Doppler waveform patterns of loss of diastolic flow, appearance of retrograde diastolic flow, or no detectable flow in the cerebral arteries suggest significantly abnormal cerebral blood flow (CBF). A retrospective study was performed to show that significantly abnormal CBF alone, without clinical criteria, is not necessarily specific to brain death in the young pediatric population. PATIENTS AND METHODS: Forty-seven pediatric patients, from newborn to 4 years of age, were found to have significantly abnormal CBF, including 7 patients with loss of diastolic flow, 28 with retrograde diastolic flow, and 23 with no detectable cerebral flow on serial Doppler sonographic examinations. Their clinical data and sonographic results were collected and analyzed. RESULTS: Forty-two patients died, a few of whom had only transient improvement of cerebral flow. All of the patients with no detectable cerebral flow expired. Five patients survived with or without sequelae. Their underlying conditions that caused increased intracranial pressure were treated by medical and/or surgical intervention, and diastolic reversal of CBF corrected within 1 day in all 5. CONCLUSIONS: Although no detectable flow is a lethal sign, pediatric patients with loss or reversal of diastolic flow may survive with prompt and effective treatment. Using Doppler ultrasound to diagnose cerebral circulatory arrest should be done with caution in pediatric patients.     

Alterations of G-protein Coupling Function in Phosphoinositide Signalling Pathways of Rat Hippocampus by Ischaemic Brain Injury

The activation of membrane-associated phospholipase C is rapidly and transiently induced in the central nervous system by a variety of stimuli. Ischaemic brain injury is one of the situations that leads to a dramatic increase in polyphosphoinositide (PPI) turnover. In this study, stimulation of PPI hydrolysis by glutamate (500 μM) was measured in hippocampal slices from rats up to 21 days after an ischaemic insult of 30 min. Ischaemia was induced using the four-vessel occlusion method. PPI hydrolysis elicited by glutamate was significantly increased in the slices prepared from ischaemic rats 24 h after reperfusion, the accumulation of inositol phosphates (InsP_s) and inositol 1,4,5-trisphosphate (InsP₃) was 614±74% ( n = 8) and 182±11% ( n = 9) of the basal level respectively. This potentiation was also observed 21 days after ischaemia. Hyper-responsiveness to glutamate was also accompanied by an increase in AIF⁻₄-stimulated formation of [³H]inositol phosphates. In addition, global ischaemia did not change either high-affinity [³H]glutamate binding in hippocampal membranes or the stimulation of PPI hydrolysis by carbachol or noradrenaline in hippocampal slices. The present results suggest that the increased responsiveness to glutamate is the result, at least in part, of functional changes at the G-protein level, and may contribute to the pathophysiology of ischaemic brain injury or to the regenerative phenomena that accompany ischaemic damage.     

Mycotic aneurysm of the aorta: MRI and MRA features

Mycotic aneurysms of the abdominal aorta are potentially fatal but uncommon. We report the MRI and MRA features of an abdominal aortic mycotic aneurysm in a patient who presented with nonspecific low back pain. By delineating the saccular nature of the aneurysm and identifying the coexistence of vertebral enhancement, MRI was crucial for the final diagnosis. A potential pitfall of contrast-enhanced MRA is also demonstrated.     

Intensive chemotherapy for peripheral T-cell lymphomas.

Forty-two patients with previously untreated peripheral T-cell lymphomas (PTCL) were treated with an intensive chemotherapy protocol. Either the BACOP or the m-BACOD regimen was used for induction. Patients achieving complete clinical remission after three courses were given intensive consolidation and maintenance chemotherapy similar to the L10/L17M protocol designed by the Memorial Sloan-Kettering Group for acute lymphoblastic leukemia and lymphoblastic lymphoma. There were 27 (64 per cent) males and 15 (36 per cent) females. The median age was 54 years (mean 53, range 15 to 68). Seven of them (17 per cent) had stage I disease, four (10 per cent) stage II, seven (17 per cent) stage III and 24 (57 per cent) stage IV. Eighteen patients (43 per cent) had B symptoms and four (10 per cent) had bulky disease. According to the Working Formulation, the histology was diffuse mixed in 16 patients (38 per cent), diffuse large cell in 18 (43 per cent), diffuse immunoblastic in four (10 per cent) and unclassifiable in four (10 per cent). According to a modified Japanese Lymphoma Study Group's classification, the histology in 24 patients (57 per cent) was the pleomorphic type, in 13 (31 per cent) immunoblastic-lymphadenopathy-like (IBL-like), and in five (12 per cent) unclassifiable. The overall complete remission rate was 67 per cent. Twenty-five per cent of the complete responders relapsed and the DFS of the CR patients was 62 per cent at three years. The overall survival of all patients at three years was 52 per cent. Patients with stage I, II and III disease had significantly better CR rate (100 per cent versus 42 per cent, p = 0.001) and overall survival (82 per cent versus 35 per cent at three years, p = 0.01) than those with stage IV disease but the relapse rate and DFS of CR patients were similar. This study shows that the prognosis of patients with PTCL can be improved by intensive therapy.     

Restriction fragment length polymorphism analysis to study the genetic origin of complete hydatidiform mole.

To determine the genetic origin of the complete hydatidiform mole, 20 abnormal pregnancies were studied with restriction fragment length polymorphism with five genomic probes: EJ 6.6, beta-globin gene, 3'alpha-hypervariable region, J-Bir, and St14. In the 12 cases of molar pregnancy, pure paternal origin was proved in 11 cases, but both maternal and paternal inheritance were shown in only one case. In the cases with pure paternal origin, all of the restriction fragment length polymorphisms were homozygous, although those of the fathers were heterozygous at 15 loci. In the four cases that mimicked hydatidiform mole but were diagnosed as hydropic change of villi, both paternal and maternal inheritance were noted. In the four pregnancies with blighted ovum, both paternal and maternal inheritance were shown in three cases; and in one case with a balanced translocation between chromosomes 13 and 14, only paternal inheritance was noted. This study showed that most of the complete hydatidiform moles were caused by fertilization of an empty egg by a duplicated haploid sperm, but rare exceptions may exist.     

Modeling two dimensions of patient satisfaction: a panel study.

Measurement of patient satisfaction is an essential part of health outcome assessment. The purpose of this study is (a) to compare the stability of an aggregate summary measure and two separate summary measures of patient satisfaction; and, (b) to examine causal effects between two separate summary measures at two points in time. Data were collected from 1,451 Medicare HMO beneficiaries. In conclusion, (a) separate summary measures are recommended for constructing the measure of patient satisfaction and (b) moderate causal relationships and cross-lagged effects between the patient satisfaction measures of qualify of care and access to care were found.