A method for the direct electrical stimulation of the auditory system in deaf subjects: a functional magnetic resonance imaging study

PURPOSE: To develop a safe functional magnetic resonance imaging (fMRI) procedure for auditory assessment of deaf subjects. MATERIALS AND METHODS: A gold-plated tungsten electrode has been developed which has zero magnetic susceptibility. Used with carbon leads and a carbon reference pad, it enables safe, distortion-free fMRI studies of deaf subjects following direct electrical stimulation of the acoustic nerve. Minor pickup of the radio frequency (RF) pulses by the electrode assembly is difficult to eliminate, and a SPARSE acquisition sequence is used to avoid any effects of unintentional auditory nerve stimulation. RESULTS: The procedure is demonstrated in a deaf volunteer. Activation is observed in the contralateral but not the ipsilateral primary auditory cortex. This is in sharp contrast to studies of auditory processing in hearing subjects, but consistent with the small number of previous positron emission tomography (PET) and MR studies on adult deaf subjects. CONCLUSION: The fMRI procedure is able to demonstrate whether the auditory pathway is fully intact, and may provide a useful method for preoperative assessment of candidates for cochlear implantation.     

A new score for the evaluation of palpable breast masses in women under age 40

BACKGROUND: The purpose of this study was to develop a rapid and accurate diagnostic test for palpable breast masses in women under age 40. METHODS: Masses were evaluated utilitzing a modified triple test score (MTTS), which assigned scores of 1 point for benign, 2 points for suspicious, or 3 points for malignant findings from physical examination, ultrasonography, and fine needle aspiration. The MTTS was the sum of the three scores and was correlated with biopsy or follow-up. RESULTS: Among 113 masses, 100 scored 3 points, 8 scored 4 points; all were benign. Three scored 5 points; 1 was malignant. Two scored >or=6 points: both were malignant. CONCLUSIONS: The MTTS has 100% diagnostic accuracy when other than 5 points. Masses scoring or=6 points may proceed to definitive therapy. Masses scoring 5 points (3%) require biopsy. This approach avoids open biopsy in the majority of cases, while capturing all malignancies.     

Radiotherapy for carcinoma in situ of the true vocal cords

PURPOSE: To report long-term rates of tumor control after radiotherapy (RT) for carcinoma in situ (CIS) of the true vocal cords (TVC). A comprehensive literature review was performed, and outcomes with other modalities of treatment for CIS of the TVC were compared. METHODS AND MATERIALS: Thirty patients with CIS of the TVC were treated between July 1967 and May 1998 with curative intent using megavoltage RT. Most patients (28 of 30) were treated with cobalt-60 through small (usually 5 x 5 cm) fields. Median RT dose was 56.25 Gy (range, 56.25-75 Gy; mean dose, 59.15 Gy) at 2.25 Gy per fraction. One patient was treated for a synchronous head and neck primary malignancy with large fields to a total dose of 75 Gy at 1.8 Gy per fraction. Approximately two thirds of the patients (19 of 30) were referred for RT because of recurrence after at least one stripping procedure. RESULTS: With a mean follow-up of 7.1 years (range, 2-17 years), the 5-year rates of local control, local control with larynx preservation, and ultimate local control (including salvage surgery) were the following: 88%, 88%, and 100%, respectively. Invasive squamous cell carcinoma developed in three (10%) of the patients. Time to failure was 14 months, 34 months, and 48 months, respectively. All three patients were surgically salvaged with a total laryngectomy. Cause-specific survival at 5 years was 100%. There were no late complications. CONCLUSIONS: RT to approximately 60 Gy at 2.25 Gy per fraction using small (5 x 5 cm) fields produces excellent results with CIS of the TVC.     

The urological complications of renal transplantation: a series of 1535 patients

OBJECTIVE: To determine the incidence of urological complications of renal transplantation at one institution, and relate this to donor and recipient factors. PATIENTS AND METHODS: A consecutive series of 1535 renal transplants were audited, and a database of donor and recipient characteristics created for risk-factor analysis. An unstented Leadbetter-Politano anastomosis was the preferred method of ureteric reimplantation. RESULTS: There were 45 urinary leaks, 54 primary ureteric obstructions, nine cases of ureteric calculi, three bladder stones and 19 cases of bladder outlet obstruction at some time after transplantation. The overall incidence of urological complications was 9.2%, with that for urinary leak or primary ureteric obstruction being 6.5%. One graft was lost because of complications, and there were three deaths associated directly or indirectly with urological complications. There was no association with recipient age, cadaveric vs living-donor transplants, or cold ischaemic times before organ reimplantation, although the donor age was slightly higher in cases of urinary leak. There was no association with kidneys imported via the UK national organ-sharing scheme vs the use of local kidneys. The management of these complications is discussed. CONCLUSION: The incidence of urological complications in this series has remained essentially unchanged for 20 years. The causes of these complications and techniques for their prevention are discussed.     

Epidemiology of perforated colonic diverticular disease

Perforated colonic diverticular disease results in considerable mortality and morbidity. This review appraises existing evidence on the epidemiology and mechanisms of perforation, highlights areas of further study, and suggests an epidemiological approach towards preventing the condition. Computerised searches were used to identify published articles relating to the epidemiology, pathophysiology, and clinical features of perforated colonic diverticular disease. Several drug and dietary exposures have potential biological mechanisms for causing perforation. Of these only non-steroidal anti-inflammatory drugs have been consistently identified as risk factors in aetiological studies. The causes of perforated colonic diverticular disease remain largely unknown. Further aetiological studies, looking specifically at perforation, are required to investigate whether cause-effect relationships exist for both drug and dietary exposures. The identification of risk factors for perforation would allow primary public health prevention, secondary risk factor modification, and early prophylactic surgery to be aimed at people at high risk.     

Anti-thrombotic efficacies of enoxaparin, dalteparin, and unfractionated heparin in venous thrombo-embolism

BACKGROUND: Few data exist by which the anti-thrombotic efficacy of different anticoagulants may be compared. We used a radiolabeled antibody specific for polymerizing fibrin to compare the in vivo anti-thrombotic potencies of different systemic anticoagulants (enoxaparin, dalteparin, and unfractionated heparin). METHODS AND RESULTS: Deep venous thrombi (DVTs) were induced in dogs' femoral veins. The dogs were then treated with one of the following subcutaneous regimens: enoxaparin 100 units/kg (1.0 mg/kg) every 12 hours (n=4), dalteparin 200 units/kg every 24 hours (n=4), or unfractionated heparin 240 units/kg every 8 hours with dose adjustment via aPTT (n=3). 111Indium-labeled anti-fibrin antibodies, specific for propagating thrombi, were given intravenously and nuclear scans of the legs were taken over the following 24 hours. Thrombus propagation was estimated by the ratio of gamma emissions from the legs containing DVTs divided by the emissions from the contralateral "control" legs. DVTs accumulated labeled anti-fibrin antibodies at the same rates in both the enoxaparin group and the dalteparin group (gamma emissions 171+/-6% and 168+/-36% of control by 24 hours, respectively). DVTs in the adjusted dose unfractionated heparin group tended to accumulate antibodies at a slower rate (129+/-19% of control by 24 hours). CONCLUSIONS: Enoxaparin and dalteparin inhibited propagation of pre-formed thrombi to the same degree. Subcutaneous unfractionated heparin, adjusted every 8 hours by aPTT, tended to suppress ongoing thrombosis more than either LMWH.     

Long-term clinical and neurophysiological follow-up of patients with peripheral, neuropathy associated with benign monoclonal gammopathy

The incidence of hematological malignancy in patients with monoclonal gammopathy of undetermined significance (MGUS) has been assessed as 17% to 25%. To ascertain whether this is true of neuropathy associated with MGUS, a long-term (5-42 years) retrospective clinical and neurophysiological follow-up was conducted in 50 cases (immunoglobulin M [IgM], n = 38; IgG, n = 11; IgA, n = 1). Only three patients developed hematological malignancy. Of 25 survivors with IgM paraproteinemia, 7 had myelin-associated glycoprotein antibodies with typical clinical features. Evoked distal muscle amplitudes were significantly smaller than for the other paraprotein classes. Preferential distal demyelination manifested by relative prolongation of distal motor latency was not apparent in the cases of long duration. Two patients with IgM antidisialosyl antibodies and cold agglutinating activity had a large fiber neuropathy with intermittent oculofacial involvement. Both responded to intravenous immunoglobulin. Findings in the remaining patients were varied. Recognition of IgM subgroups is important both for prognosis and possible response to treatment.     

慢性每日头痛

家庭医生经常遇到患有偏头痛或其他特发性头痛的患者。近年来,因头痛而进行咨询的患者数增加了1倍,并且数量还在持续上升。尽管多数患者的头痛是短暂的,但估计有4%~5%的成年患者患有慢性每日头痛。慢性每日头痛患者的生活质量低于短暂偏头痛患者。慢性每日头痛患者普遍有经短暂偏头痛发展为每日头痛(慢性偏头痛)的病史,除外原发头痛综合征,近1/3发展为每日头痛的患者有过量用药的情况。药物引起的头痛或药物反弹性头痛曾被认为是“尚未认识的流行症状”。在三期头痛治疗中心,50%~82%的慢性每日头痛患者曾有过量用药史。每日头痛分为特发性头…