A prospective evaluation of changes in neuropsychological and liver function tests following transjugular intrahepatic portosystemic stent-shunt

Background/Aims: This study was designed to assess changes in: (a) neuropsychological tests, measures of memory, quality of life and scores for anxiety and depression; (b) liver function tests; and (c) the relationship between these following transjugular intrahepatic portosystemic stent-shunt.Methods: Twenty-nine patients undergoing transjugular intrahepatic portosystemic stent-shunt for recurrent variceal haemorrhage, 12 matched patients with cirrhosis and variceal haemorrhage manage with variceal band ligation and 16 normal controls were studied. Patients in any of the groups who were clinically encephalopathic were excluded from the study. Serial changes in the conventional liver function tests and Indocyanine green clearance, and psychometric function (Hospital Anxiety Depression Scale, Rivermead Behavioral Memory Test, Quality of Life and the memory and reaction sub-tests of the Cambridge Automated Neuropsychological Test Assessment Battery) were measured prior to and 1, 3, 9 and 15 months following transjugular intrahepatic portosystemic stent-shunt.Results: Over a mean follow up of 9.1 months in the transjugular intrahepatic portosystemic stent-shunt group (range 3–28), one patient (3%) developed clinically detectable encephalopathy. Sixty-seven percent of patients with cirrhosis showed evidence of subclinical encephalopathy as compared with the control population. Significant deterioration occurred in the reaction sub-tests of the Cambridge Automated neuropsychological Test Assessment Battery in patients, both in the transjugular intrahepatic portosystemic stent-shunt group and the controls with cirrhosis, during follow up. Transjugular intrahepatic portosystemic stent-shunt was followed by significant deterioration in levels of anxiety and psychological component of the quality of life. The Rivermead Behavioural Memory Test and the memory sub-test of the Cambridge Automated Neurpsychological Test Assessment Battery did, however, improve significantly at 1 and 15 months after transjugular intrahepatic portosystemic stent-shunt, respectively. Serum alanine aminotransferase, bilirubin and indocyanine green clearance deteriorated significantly following transjugular intrahepatic portosystemic stent-shunt (p<0.001, p<0.001 and p<0.0001, respectively). Significant correlation was observed between changes in the indocyanine green clearance and changes in the complex and simple reaction time subtests of the Cambridge Automated Neuropsychological Test Assessment Battery (r=0.6 and r=0.66, respectively).Conclusions: The results of this study showed that about 67% of patients with cirrhosis were subclinically encephalopathic and that temporary deterioration occurred in the Cambridge Automated Neuropsychological Test Assessment Battery during follow up, both in patients having transjugular intrahepatic portosystemic stent-shunt and in the controls with cirrhosis. These parallel the changes in the liver function tests and indocyanine green clearance. Temporary deterioration was also observed in the Quality of Life and Hospital Anxiety Depression Scale in the transjugular intrahepatic portosystemic stent-shunt group, although the measures of memory improved. Further studies should address the biochemical mechanisms of these changes and the role of prophylactic measures.     

Choosing a career in general practice: the influence of medical schools

Summary. This paper reviews the literature on career choice to investigate the undergraduate influences on the preference of Australian graduates for a career in general practice. Although isolation of influencing factors is difficult, admission criteria and undergraduate curricula may influence career preference. As the institutional environment of medical schools is weighted towards scientific research and specialized medicine, medical students may be socialized into choosing non-generalist careers. Medical schools should consider broadening selection criteria and curriculum exposure to produce graduates with a broad range of career interests.     

123I-MIBG myocardial scintigraphy as a noninvasive screen for the diagnosis of coronary artery spasm

Background  It has been suggested that the sympathetic nervous system might play an important role in the development of coronary artery spasm. However, no cardiac imaging modality has been able to demonstrate abnormal sympathetic innervation in patients with coronary artery spasm. The purpose of this study was to assess the presence and location of abnormal sympathetic innervation using iodine 123-metaiodobenzylguanidine (¹²³I-MIBG) single photon emission computed tomography (SPECT) and to evaluate the clinical efficacy of ¹²³I-MIBG SPECT as a noninvasive screening test in patients with coronary artery spasm. Methods and Results  Coronary arteriography and a provocative test with intravenous administration of ergonovine maleate were performed in 26 patients (20 men, 6 women, mean age 48.2±12.0 years, range 20 to 67 years) who were suspected of having a coronary artery spasm. The subjects were divided into 2 groups: group 1 (n=18) comprised subjects with negative provocative provocative test result, and group 2 (n=8) comprised subjects with negative provocative test results. Ten healthy subjects served as controls. No abnormal MIBG uptake was observed in the control subjects. Abnormal sympathetic nervous innervation using ¹²³I-MIBG SPECT was observed either as a reduced uptake or a defective pattern in the perfused areas in 13 of the 18 regions supplied by vessels of ergonovine-induced vasospasm. Normal sympathetic innervation, as evidenced by normal ¹²³I-MIBG uptake, was noted in all of the 60 segments of normal vessel territories. Reduced uptake of ¹²³I-MIBG was not detected in the perfused areas of 5 vasospasm-induced vessels (perfusion territory of left anterior descending coronary artery [LAD] and the right coronary artery [RCA] in 2 and 3 patients, respectively). The sensitivity and specificity of ¹²³I-MIBG for detection of coronary artery spasm were 72.2% (95% confidence interval, [CI] 55% to 89%) and 100%, respectively. The positive predictive and negative predictive values were 100% and 92.3% (95% CI 91% to 93%), respectively. Conclusion   ¹²³I-MIBG SPECT is a feasible method to evaluate noninvasively and localize the territories of coronary arteries with spasm. Invasive diagnostic coronary arteriography with ergonovine provocation test may be unnecessary for diagnosis of coronary artery spasm in patients with typical resting pain, negative exercise test or normal thallium perfusion scan results, but showing abnormalities in ¹²³I-MIBG SPECT. Presented in part at the European Association of Nuclear Medicine Congress, September 1996, Copenhagen, Denmark.     

硬脑膜动脉海绵窦瘘的眼眶CT表现,DSA检查及栓塞治疗

笔者分析了５例硬脑膜动脉海绵窦瘘伴突眼，结膜充血的病例，全部经ＣＴ及ＤＳＡ检查，同时进行了栓塞治疗，经随访７－９个月未见复发，主要ＣＴ表现为：（１）眼球突出，结膜充血；（２）眼上静脉扩张；（３）海绵窦增大；（４）眼外肌增厚：（５）眶尖软组织肿胀。并讨论了诊断鉴别诊断，ＤＳＡ检查及有关治疗问题。     

完全性大动脉转位的外科治疗

对３３例完全性大动脉转位施行了手术治疗，其中全腔静脉肺动脉连接３例、改良Ｆｏｎｔａｎ手术２例、Ｍｕｓｔａｒｄ及大动脉调转术各１例，Ｒａｓｔｅｌｉ手术２６例，包括１５例心内隧道和心外管道，１１例心内、外双管道。这２６例心外管道中，除４例采用同种主动脉管道外，其余为经处理的猪肺动脉人工管道。全组手术死亡１０例，晚期死亡１例。结论：完全性大动脉转位病理解剖变异性大，应按不同类型的病理解剖特征选择手术方法     

综合因素与老年人心律失常(附200例病例分析)

通过对200例老年人心律失常的病因分析,明确了老年人心律失常的发生有其形态学基础,再加上疾病综合作用所致。其中缺血性心脏病占首位,再依次为高血压病、肺心病、脑血管病、糖尿病、颈椎病。同时患有两种以上疾病的心律失常发生率明显增高。另外还对心功能及烟酒对心律失常的影响进行了初步探讨,结果显示心功能异常及吸烟与心律失常的发生呈正相关,饮酒与心律失常的发生呈负相关。     

296例胎膜早破的临床分析

以２９６例胎膜早破（ＰＲＯＭ）作为研究对象，并以３５０例无ＰＲＯＭ作对照，探讨ＰＲＯＭ对母婴的影响。结果显示：ＰＲＯＭ组难产率为５６．０８％，产褥病率４．０５％，早产率为５．４０％，胎儿窘迫率为１３．００％，新生儿窒息率为４．３３％，新生儿肺炎发生率为３．６６％，均明显高于对照组，统计学处理后有显著或极显著性差异（Ｐ＜０．０５，Ｐ＜０．０１）。而且，ＰＲＯＭ隐惹期小于２４小时的产褥病率为２．２９％；大于２４小时的产褥病率则为８．９７％（Ｐ＜０．０５）。本文提示，应积极预防胎膜早破，一旦出现胎膜早破，宜在６小时内使用抗生素预防感染，并加强母儿监测。     

复方丹参注射液与维生素B6、C注射液配伍稳定性试验

本文观察了复方丹参注射液与维生素B6、维生素C注射液的配伍稳定性，结果表明复方丹参注射液与维生素B6注射液可以在4h内配伍使用，而不能与维生素C配伍。     

Indomethacin increases the effect of isosorbide dinitrate on cerebral hemodynamic in migraine patients: pathogenetic and therapeutic implications

Intracerebral vascular reactivity induced by the nitric oxide (NO) donor isosorbide dinitrate (IDN, 5 mg sublingually) is more major and longer-lasting in migraine patients who develop delayed headache in response to the drug. The headache is purportedly due to neuronally-mediated vascular mechanisms. Indomethacin inhibits prostaglandin synthesis, which is involved in NO generation. Indomethacin also decreases cerebral blood flow by constricting precapillary resistance vessels. In the present study, the hemodynamic effects of indomethacin were evaluated in migraine patients and healthy controls by means of transcranial Doppler monitoring. Indomethacin caused a significant decrease in mean flow velocity in the middle cerebral artery. This was an additional effect to the mean velocity decrease induced by IDN. The interactions between the two drugs suggest that their effects on cerebral hemodynamics (and pain) may be of relevance both in understanding the role of NO in migraine pathogenesis and in evaluating symptomatic treatments for migraine attacks.