Arteriovenous malformations that rupture during pregnancy: a management dilemma

Summary Intracranial haemorrhage due to rupture of an arteriovenous malformation (AVM) during pregnancy is a rare but serious condition that warrants prompt recognition. Once the diagnosis is made, the management is primarily based on neurosurgical rather than obstetric considerations. Due to its rarity, no definitive guidelines exist, and the best time to perform elective surgery (i.e., at presentation or at completion of the pregnancy) is ill-defined. This report describes three patients recently treated at our institution who had AVMs that ruptured during pregnancy. These cases well summarize the difficulties encountered in treating such patients. The diagnostic as well as the therapeutic implications of this condition are discussed.     

Comparison studies of HPV detection in areas at different risk for cervical cancer.

The hypothesis of a geographical correlation between HPV detection rates and incidence of cervical cancer has been investigated in studies of various types. However, results from these studies are equivocal, in contrast to findings concerning other suspected risk factors which seem to correlate well with the cervical cancer incidence. Possible explanations include (1) greater sensitivity of ecological studies to cumulative exposures such as lifetime number of sexual partners, lifetime smoking and seroprevalence of herpes simplex virus type 2, than to HPV DNA prevalence which does not reflect cumulative exposure to HPV and (2) misclassification in the HPV diagnosis leading to wrong prevalence estimates. In future research, it will be important to establish the sensitivity and specificity of the different methods and conduct intra- and interlaboratory validation studies in order to standardize methods. In spite of the limitations of cross-sectional studies, the measurement of HPV prevalence and its correlation with, for example, sexual behaviour is still valuable for our understanding and interpretation of the role of HPV infections.     

Nimodipine treatment of subarachnoid hemorrhage

In a pilot study of 6 patients with subarachnoid hemorrhage caused by a ruptured intracranial (grade IV (Hunt and Hess) aneurysm the hemodynamics and plasma-nimodipine concentrations have been observed during a 3-week period of treatment. We found that 3 patients developed reversible hypotension during the nimodipine treatment and that the hypotension tendency could be related to the plasmanimodipine level and not to a more or less severe sensitivity to nimodipine.

Repeated measurements of blood pressure, plasma-nimodipine and regional cerebral blood flow (rCBF) are necessary for the purpose of obtaining the optimum treatment and for evaluating the effect of treatment.     

Role of sucralfate in peptic disease.

Sucralfate, a basic aluminum salt of sucrose, was the first successful drug with a major cytoprotective mechanism of action. It binds bile acids and pepsin and adheres to both ulcerated and nonulcerated mucosa. Sucralfate stimulates the synthesis and release of gastric mucosal prostaglandins as well as bicarbonate and the epidermal growth factor which stimulates healing. Sucralfate is the safest drug available today in the treatment of dyspeptic symptoms and compared to ranitidine and cimetidine it has the following characteristics. (2) The short-term healing of duodenal ulcers is the same for sucralfate, cimetidine and ranitidine. (3) Sucralfate-treated patients have a lower recurrence rate of duodenal ulceration after healing when compared with cimetidine and the recurrence rate is not connected with the presence or absence of Campylobacter pylori.     

Prediction of severe postoperative complications in patients admitted to neuroanaesthesia

The purpose of this study was to identify factors which will predict the risk of severe postoperative complications in individual patients in a neurosurgical unit. Eleven risk factors were investigated in 363 neurosurgical patients, of whom 40 (11%) developed postoperative complications requiring mechanical ventilation for more than 24 h in an intensive care unit, 16 were found to be severely disabled or in a vegetative state at follow-up 1 month after admission, and 28 patients died. By applying stepwise, logistic regression analysis to the patient's data, we were able to select two significant risk variables, i.e. the Glasgow Coma Scale (GCS) 8 or less preoperatively and emergency anaesthesia. The presence of GCS 8 or less on the consciousness scale was associated with postoperative complications in approximately 40% of the cases. Emergency patients with severe neurological damage had the greatest risk of postoperative complications (93%). Fatal outcome for patients with postoperative complications was seen in 40% of the cases.     

Sympathetic preganglionic neurons projecting to the adrenal medulla and aorticorenal ganglion in the rabbit.

The distribution of sympathetic preganglionic neurons (SPN) projecting to the adrenal medulla and the aorticorenal ganglion in the rabbit was studied using a dual retrograde transport technique. The B subunit of cholera toxin (CTB) was injected into the left adrenal medulla and wheatgerm agglutinin-apo-horseradish peroxidase-7 nm gold (WGA-apo-HRP-gold) was injected into the left aorticorenal ganglion. Retrogradely transported CTB was detected by immunohistochemistry, while gold particles were detected by silver intensification. SPN projecting to the adrenal medulla were observed in segments T2-L2 of the spinal cord in 5 rabbits, with the majority of cells within segments T6-T11 (79%). SPN projecting to the aorticorenal ganglion were seen in segments T2-L1 of the spinal cord in 5 rabbits, with the greatest number of the cells within T6-T11 (81%). Only a small number of doubly labelled cells (1%) were found in two rabbits. The results suggest that despite their similar segmental distribution SPN projecting to the adrenal medulla or the aorticorenal ganglion belong to separate populations and few, if any, individual SPN have axonal projections to both locations.     

Obsessive-compulsive disorder: admission patterns and diagnostic stability

All first-time admissions from 1970 to 1986 with obsessive-compulsive neurosis (OCD) (ICD-8 diagnosis number 300.39) or obsessive-compulsive personality disorder (OCPD) (ICD-8 diagnosis number 301.49) were analyzed based on an extract from the nationwide Psychiatric Case Register in Denmark. All patients with secondary diagnoses other than neurotic disorders or personality disorders (including “neuroses characterogenes”) were excluded from the study. A total of 284 patients were first-time admitted with a main diagnosis of OCD during the period. The sex ratio was 0.67 (males/females). A total of 126 were first-time admitted with a diagnosis of OCPD, with a sex ratio of 1.18 (males/females). Seventy-seven percent of the readmitted patients with a first-time diagnosis of OCD kept a diagnosis within the “emotional spectrum” at the last admission. About half kept OCD as a main diagnosis, whereas only 15% shifted to a severe psychiatric diagnosis such as schizophrenia or manic-depressive psychosis. Of the readmitted patients with OCPD. 13% later developed a diagnosis of manic-depressive psychosis.