Parkinsonism caused by cavernoma located in basal ganglion

Deep-seated cavernoma or cavernous angioma is a very rare clinical entity, as is basal ganglia cavernoma presenting with Parkinsonism. The authors demonstrate a 56-year-old man with a cavernoma located in basal ganglion, who subsequently developed Parkinsonism. The patient refused the surgical intervention, and received L-dopa trial; however, no change in the tremor and bradykinesia was observed in spite of high doses of L-dopa. Our case indicates that chronic compression and continuous hemorrhage could cause Parkinsonism, which is uncommon symptom of cavernous angioma.     

Intrahepatic arterioportal fistula and its treatment with detachable balloon and transcatheter embolization with coils and microspheres

BACKGROUND: Although intrahepatic arterioportal fistula (APF) due to acquired or congenital causes are infrequent, they are listed among the causes of portal hypertension. PURPOSE: The aim of this study was to present the results of intrahepatic APF treatment with embolotherapy in six cases. MATERIAL AND METHODS: Transarterial detachable balloon and coil embolization was used on six consecutive cases with traumatic intrahepatic APF from 1989 to 2003. Six-month follow-up angiography was obtained in every case. RESULTS: Successful disconnection of hepatic arterial and portal system was achieved in five cases. At least symptomatic improvement was achieved in one. CONCLUSION: Transcatheter embolization may be the first line of treatment for intrahepatic APF.     

Radial artery graft for bypass of the maxillary to proximal posterior cerebral artery: an anatomical and technical study

OBJECTIVE: To examine the use of a radial artery graft for bypass of the maxillary artery (MA) to proximal posterior cerebral artery (PCA) as an alternative to the external carotid artery (ECA) to PCA anastomosis used in posterior circulation bypass surgery. MATERIALS AND METHODS: The method was applied to five adult cadaver sides bilaterally. The MA was easily found 1-2 cm beneath the infratemporal crest after a frontotemporal craniotomy and a zygomatic arch osteotomy. Extradurally, 2-3 cm posterolateral to the foramen rotundum, a hole was drilled in the sphenoid bone with a 4-mm tipped drill. After sylvian fissure, the interpedincular and ambient cisternae were opened and the P2 segment of the PCA appeared. The graft was passed through the hole and dura to reach the P2 segment. Proximal to the infraorbital artery branch, the MA was freed from the surrounding tissue and transected. The proximal side of the radial artery graft was anastomosed end-to-end with the MA and the distal side was anastomosed end-to-side with the P2 segment of the PCA. RESULTS: The average diameter of the MA proximal to the infraorbital artery branch was 2.6+/-0.3 mm. The average diameter of the P2 was 2.2+/-0.2 mm. The average length of the graft was 47+/-5.2 mm. CONCLUSION: As MA to proximal PCA bypass uses a short radial graft and as the calibers of the MA and PCA are >2 mm such a bypass may provide sufficient blood flow and represents a reasonable alternative to "ECA to PCA" bypass.     

Routine Cyclosporine concentration - C2 level Monitoring. Is it helpful during the early post Transplant Period?

Background

Pre dose or trough blood cyclosporine (CSA) concentration is routinely monitored and the result is used to alter patient''s drug dosing. Patients with identical pre dose blood CSA may have very different systemic exposure to the drug. Recently CSA 2 hour post dose level [C2] has been reported to correlate better with drug exposure. We undertook this study to evaluate the influence of trough and C2, CSA concentration monitoring on short-term renal allograft outcomes.

Methods

25 patients of renal transplant receiving a triple drug regimen of CSA micro emulsion (Panacea Biotec) 8mg/kg, azathioprine 1mg/kg and prednisolone 0.5mg/kg were analyzed prospectively for graft outcomes. CSA levels were monitored in whole blood by radioimmunoassay using monoclonal antibodies, at 72 hours after the transplant.

Results

The mean age of patients was 37.08 + 9.1 years. There were 20 males and 5 females. The mean age of donors was 40.2 + 8.2 years. There were 11 related donors with at least a haplomatch, 4 spousal and 10 unrelated donors with a nil antigen match. The mean pre dose CSA concentration was 289.22 + 171.9ng/ml; range (98.8 + 783.41ng/ml). The CSA concentration at 2 hours after the CSA administration was 838 + 310.87ng/ml (range, 169 + 1268ng/ml). 3 (12%) patients had acute rejection. In these patients the mean pre dose CSA concentration was 328.67ng/ml and the mean C2, CSA concentration was 1006.26ng/ml. CSA induced hemolytic uraemic syndrome was diagnosed in one patient. The trough and C2, CSA concentration levels were 174 and 870.83ng/ml respectively in this patient.

Conclusion

In our study CSA levels, trough and peak showed significant inter patient variability. The trough and C2 concentration levels did not correlate with the episodes of acute rejection. We conclude that in a triple drug regimen with fixed dosing schedules routine trough CSA level monitoring is not helpful in the acute post renal transplant period.Key Words: Cyclosporine levels, Cyclosporine trough levels, C2 levels     

Sonovue improves endocardial border detection and variability in assessing wall motion score and ejection fraction during stress echocardiography

Background Stress echocardiography is useful for assessing patients with coronary artery disease unable to undergo formal exercise testing. Considerable skill is required to avoid large intra- and inter-observer variability due to poor endocardial definition. Intravenous ultrasound contrast agents are now available which may improve this variability. Aim To study intravenous Sonovue in assessing wall motion score and ejection fraction (EF) during stress echocardiography. Methods Thirty-eight patients undergoing arbutamine stress echocardiography for known or suspected coronary artery disease were studied. Echocardiographic analysis of wall motion score index, endocardial border detection (EBD) and EF was performed at rest and at peak stress before and after intravenous injection of Sonovue, by experienced and inexperienced observers. Results All three observers noted an improvement in endocardial border definition following Sonovue (p=<0.001). At baseline, there was a significant difference in wall motion score index between experienced and inexperienced observers at rest (p=0.01) and at peak stress (p=0.001). Following Sonovue administration this was no longer significant (p=0.07, p=0.114). Intra-observer variability of end diastolic, end systolic volumes (ESV) and EF improved following contrast (p<0.05) at rest and during stress. Conclusion Sonovue significantly improved EBD and reduced intra-observer variability of EF at rest and during peak arbutamine infusion.     

The effects of hormone replacement therapy on ocular surface and tear function tests in postmenopausal women

PURPOSE: To prospectively investigate the impact of various hormone replacement therapies (HRT) on ocular surface and tear function tests. METHODS: A total of 70 women in the postmenopausal period were enrolled in the study. The groups consisted of 16 women who were not on HRT (group 1), 29 women who were on HRT with tibolone (group 2) and 25 women who received estradiol plus medroxyprogesterone acetate treatment (group 3). All patients underwent tear film break-up time (TFBUT), Schirmer's test and conjunctiva cytology at the time of enrollment and at 6 months' follow-up. RESULTS: Patients in group 2 showed improved Schirmer's test and TFBUT results (p < 0.001); however, no significant changes occurred in group 1 and group 3 patients (p > 0.05). Conjunctival cytology scores did not differ at the time of enrollment and at 6 months' follow-up in all groups. CONCLUSIONS: This is the first comparative clinical study on the effects of tibolone and estradiol plus medroxyprogesterone acetate on ocular surface and tear function tests. HRT with tibolone seems to improve tear function tests in postmenopausal women.     

Reassessment of the CAGE questionnaire by ROC/Taguchi methods

OBJECTIVES: The clinical assessment efficiency of the CAGE questionnaire for alcohol abuse based on diagnostic accuracy has not been fully established to date because of the varied and inconclusive gold standards used as diagnostic criteria. CAGE has also been highlighted to miss almost half of the risk-drinkers due to the use of inadequetly set criteria for the positive recognition of alcohol abuse. This study aims to establish the diagnostic accuracy of CAGE at different treatment settings. METHODS: A hybrid of the receiver operating characteristic (ROC) and the Taguchi method was used, as this approach proved to evaluate the diagnostic performance and accuracy in hypothetical clinical settings. Data were used from three cross-clinical treatment settings, i.e., general medicine outpatients, medical inpatients, and psychiatric inpatients, and analyzed by means of a step-wise application of managable number of statistical indices such as the area under the ROC curve (AUC), leveling factor (p'), and signal-to-noise ratios (S/N; standardized S/N [SS/N]). RESULTS: The selected settings yielded similar AUCs but portrayed different trade-offs on the ROC curves signaling the presence of different critical CAGE scores. Analysis of the sensitivity and specificity data of i, ii, iii by p', S/N, SS/N and their dependent relation resulted in the critical CAGE scores of 1,1, and 2; and high diagnostic accuracy levels of 76.84 percent, 86 percent, and 76.84 percent, respectively. CONCLUSIONS: By setting these critical CAGE scores as the minimum detection levels of alcohol abuse, early intervention before the onset of serious alcohol-related problems is possible. This will decrease the health-care costs of the patient and, in addition, reduce the psychological and social burdens inherent to alcohol abuse both on the patient and society. Having its critical scores reliably identified and diagnostic accuracy fully determined, CAGE can now improve the detection rate of problem drinking individuals substantially.     

Nasomaxillary frame translocation in medial maxillectomy

Medial maxillectomy is the standard operation for en bloc resection of the lateral nasal wall with portions of the maxillary and ethmoid sinuses. Although most reports comment on good to excellent cosmetic results, nasal collapse is a possible complication of the procedure and is best explained by the loss of lateral nasal wall support. To overcome this problem, we describe a technique with temporary mobilization of a bone frame around the ipsilateral pyriform aperture, including one nasal bone, and fixing it to its original position at the end of the operation.