Treatment of dural sinus thrombosis using selective catheterization and urokinase

Thrombosis of the cerebral dural venous sinuses, cortical draining veins, and deep cerebral veins is a rare clinical finding. Because of its low incidence and multiple etiologies, the optimum therapy for this condition will only be elucidated by a multicenter, randomized prospective study. At our institution, we favor early and aggressive management of cerebral venous sinus thrombosis with transfemoral, venous intradural infusions of the fibrinolytic agent urokinase. To date, treatment of only 13 patients using this technique has been reported in the English literature. This report adds 12 more such treated patients. Despite the presence of preinfusion infarcts in 5 patients, four of which were hemorrhagic, we incurred no major therapeutic morbidity. Functional sinus patency was achieved in 11 of 12 patients, with our only true failure occurring in an individual with symptoms of at least 2 months' duration. Good to excellent clinical outcome was achieved in 10 of 11 patients (one newborn had inadequate follow-up).     

Y chromosome loss in esophageal carcinoma: An in situ hybridization study

Carcinoma of the esophagus shows a strong male predominance and other epidemiologic differences from cancers arising at other sites. In this study, the prevalence of Y chromosome loss in 29 carcinomas of the esophagus and 53 carcinomas arising elsewhere in the aerodigestive tract was assessed by in situ hybridization of formalin-fixed paraffin-embedded tissue sections. Absence of the Y chromosome was defined as (1) negative staining for Y in neoplastic cells with positive staining for Y in immediately adjacent nonneoplastic epithelial and stromal cells, (2) positive staining of neoplastic cells with control probes for chromosomes X and 17, and (3) similar results at different stringencies and levels of protein digestion. According to these criteria, absence of the Y chromosome was observed in 13 of 14 (93%) adenocarcinomas of the esophagus, 8 of 13 (62%) squamous cell carcinomas of the esophagus, and 5 of 53 (9%) carcinomas arising in other sites. For the neoplasms examined, Y chromosome deletion was strongly and selectively associated with carcinomas, particularly adenocarcinomas, of the esophagus (P < .0001). These findings suggest that Y chromosome loss may be pathogenetically significant in these neoplasms. © 1993 Wiley-Liss, Inc.     

Functional restoration in chronic low back pain

Conventional treatments have not slowed down the ever expanding low back pain (LBP) problem. Traditional treatment has most probably contributed to the growth of the problem. Therefore, in a search for new solutions, 'functional restoration' has been devised. In connection with chronic LBP the term has been associated with a full-day program lasting from 3 to 5 weeks. it includes multidisciplinary treatment of patients in groups with intensive physical and ergonomic training, psychological pain management, back school, as well as teaching in social/work related issues. The key concepts are 'acceptance of the pain', 'activity', 'self-responsibility', 'multidisciplinary' and 'quantitative functional evaluation (QFE)'. The latter is aimed so that the participants can feel the physical improvement, encouraging them to be able to go back to work, or at least to lead a more active life style. Several controlled studies suggest a lasting effect in terms of regaining their ability to work and improving pain behavior for a good part of disabled chronic LBP patients. However, it is noteworthy that randomized studies seemingly show poorer results than studies not employing randomized controls.     

On Gordian knots and nooses: aboriginal suicide in the Kimberley

Aboriginal suicide has become an issue receiving national attention because of the association with "deaths in custody". To date little systematic work has been directed to the investigation of suicide among a non-incarcerated Aboriginal population. This paper focuses on deaths by suicide within one geographical area. It identifies two factors, alcoholism and disruption of interpersonal attachments, which may play a causal role in male Aboriginal suicide. The sudden emergence of suicide in this partial descent population, in concert with suicides among incarcerated and non-incarcerated Aborigines elsewhere, suggests that socio-historical forces must be examined to further clarify the phenomenon.     

A comprehensive approach to managed care for mental health

Managing mental health and substance abuse utilization in a complex network health maintenance organization (HMO) can successfully be accomplished through a comprehensive approach. Prescreening of admissions, and preferred provider contracts are two of the key components of one HMO's managed care system described in this paper. Savings approaching $300,000 in the first year were documented and formulas for tracking savings are described. These savings were the result of averting unnecessary admissions. Additional savings resulted from contract discounts from preferred providers and utilization of short term facilities. Increased physician and patient satisfaction, coupled with meeting the HMO's goal of quality, appropriate, cost-effective and humane care have benefited patient and insurer alike.This paper was prepared for the American Public Health Association 115th Annual Meeting. Health Care for People or for Profit. Tuesday, October 20, 1987. New Orleans, Louisiana. The authors wish to acknowledge David Segal, M.M., Manager of Rates and Underwriting, Harvard Community Health Plan, for his contribution to the Financial models.Nancy Langman-Dorwart, M.S., M.P.H., Manager of Mental Health and Chemical Dependency, Private HealthCare Systems, LTD., 620 Maguire Rd., Lexington, MA 02173.Thomas Peebles, M.D., Medical Director, General Associates, Weston, MA.     

Opportunities and challenges for the clinical utilization of functional electrical stimulation

Clinical applications of electrical stimulation for effecting change in the damaged or disabled nervous system are in their infancy. This technique is extremely powerful, because any neural structure that is electrically excitable can potentially be affected. Although early attempts to apply electrical stimulation were limited by insufficient physiological knowledge and undeveloped technology, developments over the past two decades now provide a strong base for clinical applications. Clinical systems for bladder control and respiration have been in use for many years. Some applications of FES to restore hand function and walking are in multicenter testing, whereas many others are being studied for clinical feasibility at single sites. Applications are focusing on safety and efficacy, as well as on clinical outcome measures to address the issues posed by the regulatory and reimbursement processes. As clinical systems become more routine, issues of multiple system applications will need to be addressed. Present and future applications of functional electrical stimulation may be expected to significantly enhance independence and improve the quality of life for individuals with central nervous system dysfunction.     

Long-term clinical outcome of patients with tricuspid atresia. I. "Natural history"

The clinical course and outcome of 111 patients with tricuspid atresia, seen during 1972-1982, were reviewed. All clinical and investigation data, progress and management were analysed. The mean age at presentation was 21.9 +/- 8.8 days. Patients with reduced pulmonary blood flow presented earlier. Patients with normal or increased pulmonary blood flow usually presented in heart failure. "True" natural history was observed in 13 unoperated patients. Six of these died at the age of 7 days to 8 months (mean 32.2 days). Seven patients survived without surgery for 11 months to 24 years, the older ones developing pulmonary vascular obstructive disease. The overall mortality in the whole series was 32.4% (36/111), the mean age at death was 3.1 years (range 3 days-48 years). The mortality rate within the first year of life was 22.5%. The mean age of survivors at follow-up was 10.7 +/- 0.9 years (range 11 months-27 years).     

Comparison of hydrostatic weighing and bioelectric impedance measurements in determining body composition pre- and postdehydration

This study investigated the effect of dehydration on measurements of body composition by hydrostatic weighing (HW) and bioelectric impedance analysis (BIA). Ten endurance-trained male athletes between the ages of 18 and 42 years performed an endurance training session consisting of running until body weight was reduced by approximately 3%. Body composition was determined prior to exercise and immediately after exercise by HW and BIA techniques. A high correlation existed between pre- and postdehydration for both HW and BIA. Validity coefficients between HW and BIA were moderate (predehydration 0.85 and postdehydration 0.82). In addition, BIA percent fat was 3.5% higher than HW percent fat. The BIA revealed a mean loss of 2.1% fat BIA and only 0.9% fat HW after approximately 45 minutes of exercise. BIA also showed an increase in percent body water (mean = 2.6%) in all 10 subjects after dehydration. There are indications that BIA, with its present equational configuration, is measuring something other than lean body weight. J Orthop Sports Phys Ther 1989;10(11):451-455.     

Optic nerve pseudomeningioma secondary to localized amyloidosis

A 55-year-old woman presented with a mass of the optic nerve sheath suggestive of a meningioma. On excision, this proved to be amyloid. No systemic involvement could be found. Although amyloid may arise as a solitary lesion of the orbit or extraocular muscle, this "pseudomeningiomatous" pattern has not been previously noted. A magnetic resonance scan was helpful because the amyloid imaged at a density similar to vitreous and cerebral white matter, unlike meningiomas, which appear more like bone. The diagnosis of localized amyloidosis, however, still remains dependent on histopathology and cannot be made on a clinical basis.