Long-term results of simple and radical nephrectomy for renal cell carcinoma

From 1974 to 1983, simple and radical nephrectomies were performed at the Chaim Sheba Medical Center (Tel Hashomer, Israel) for renal cell carcinoma. The authors reviewed 109 cases that were followed for a period ranging from 5 to 14 years. Simple nephrectomy was performed in 55 patients, and 54 patients underwent radical nephrectomy. The selection of the surgical procedure was based on the surgeon's preference and not on the basis of clinical stage, age, or sex. The surgical results and survival rates were assessed according to the pathologic stage of the tumors. Among patients with Stage I tumor, radical nephrectomy produced better survival rates at 5 and 10 years (P = 0.03); however, when the non-cancer deaths were excluded, the difference in survival was not statistically significant. For Stage I tumors the survival free of disease at 5 years was better for the radical nephrectomy group, but this difference was not statistically significant. No difference was noticed in the local recurrence rate between the two groups. Nephrectomy in patients with Stage IV disease did not alter survival regardless of the type of operation.     

Quantification of perfusion fMRI using a numerical model of arterial spin labeling that accounts for dynamic transit time effects.

A new approach to modeling the signal observed in arterial spin labeling (ASL) experiments during changing perfusion conditions is presented in this article. The new model uses numerical methods to extend first-order kinetic principles to include the changes in arrival time of the arterial tag that occur during neuronal activation. Estimation of the perfusion function from the ASL signal using this model is also demonstrated. The estimation algorithm uses a roughness penalty as well as prior information. The approach is demonstrated in numerical simulations and human experiments. The approach presented here is particularly suitable for fast ASL acquisition schemes, such as turbo continuous ASL (Turbo-CASL), which allows subtraction pairs to be acquired in less than 3 s but is sensitive to arrival time changes. This modeling approach can also be extended to other acquisition schemes.     

Protein nutrition and amino acid metabolism after 4 weeks of total parenteral nutrition with a mixture of 14 dipeptides: serendipitous observations on effects of sepsis in baboons

We investigated parameters of nutrition, metabolism, and organ function after 4 wk of total parenteral nutrition (TPN) in baboons receiving either dipeptides or amino acids as the nitrogen source. The two groups showed no significant difference with respect to gain in body weight, nitrogen balance, plasma and muscle concentrations of amino acids, plasma concentrations of proteins, and leucine incorporation into muscle protein. All dipeptides were efficiently utilized as evidenced by trace concentrations of dipeptides in plasma and urine; they produced no deleterious effect on the function of liver, kidney, or immune system. Development of infection in several baboons increased urinary excretion of urea nitrogen but had no effect on urinary excretion of dipeptides and amino acids with the single exception of taurine, which was greatly increased. In conclusion, the data show long-term efficacy and safety of the dipeptide mixture as the sole nitrogen source for TPN.     

The effect of cyclophosphamide pulses on fertility in patients with lupus nephritis.

The effect of cyclophosphamide pulse therapy given in relatively small doses (10 mg/kg per pulse) in 17 females with lupus nephritis has been studied. Four females developed menopause; in one transient amenorrhea occurred. No changes in menstrual cycle were noted in the other 11 females, four of whom subsequently delivered five normal babies. These data suggest the relative safety of small doses of cyclophosphamide pulse therapy on gonadal function in females under age 40 years.     

Extent of ictal origin in mesial temporal sclerosis patients monitored with subdural intracranial electrodes predicts outcome.

In patients with mesiotemporal sclerosis, posterior hippocampal involvement at the ictal onset is not associated with an excellent outcome. A study confirmed that ictal onset in the posterior parahippocampal gyrus is associated with a less favorable outcome compared with ictal onset in the anterior parahippocampal gyrus in patients with mesiobasal temporal lobe epilepsy who are undergoing foramen ovale recording. The authors hypothesized that involvement of the two medial contact points of posterior basal temporal subdural (SD) strip at the ictal onset, representing ictal onset in the posterior parahippocampal gyrus, may also adversely influence the surgical outcome. With this objective, the authors assessed the incidence of posterior basal temporal SD strip (the two medial contact points) involvement at the ictal onset in patients with mesiotemporal sclerosis and determined whether presence of this finding influenced surgical outcome. Thirty-six patients with mesiotemporal sclerosis underwent a single SD grid (lateral frontotemporal) and strips (three basal temporal and one orbitosubfrontal) monitoring. Based on the earliest involvement of basal temporal strips (the two medial contact points) during the seizure, patients were classified into (1) anterior and/or middle basal temporal, or (2) posterior basal temporal (with or without involvement of anterior and/or middle basal temporal) ictal onset groups. A temporal lobectomy with adequate resection of the ictal onset zone was performed in all patients. Surgical outcome was based on Engel's classification. Six of 36 (17%) patients were classified into the posterior basal temporal ictal onset group. Only two patients from the posterior basal temporal ictal onset group experienced a good outcome compared with 26 of 30 patients from anterior and/or middle basal temporal ictal onset group (P = 0.01). In patients with mesiotemporal sclerosis who were monitored with SD electrodes, involvement of the two medial contact points of posterior basal temporal strip at the ictal onset (representing ictal onset in the posterior parahippocampal gyrus) occurred in 17% of the patients. These patients might not experience an excellent surgical outcome despite including the ictal onset zone in resection. These findings may be useful in presurgical counseling of patients with mesiotemporal sclerosis who undergo intracranial SD monitoring.     

Morbidity and mortality in Cushing's disease: an epidemiological approach

OBJECTIVE Although Cushing's disease is a well documented clinical entity, there is no epidemiological information about it. The present study tries to obtain this information. DESIGN AND PATIENTS Forty-nine patients affected by Cushing's disease living in Vizcaya (Spain) between 1975 and 1992 were considered for an epidemiological study. RESULTS The prevalence of known cases at the end of 1992 was 39.1 per million inhabitants. The average incidence of newly diagnosed cases was 2 4 cases per million people per year. Cushing's disease was more frequent in women (n= 46) than in men (n= 3), with a ratio of 15:1. Diabetes mellitus and hypertension were observed in 38.7 and 55.1% of patients, respectively. Remission of Cushing's disease was achieved in 36 out of 41 patients (87.5%). In general, the mortality was higher than that expected for the control population (standardized mortality ratio, SMR 3.8, 95% confidence interval, CI 2.5–17.9, P<0.03). Concerning the cause of death, the SMR of vascular disease was 5 (95% CI 3.4–48.6, P< 0.05). Higher age, persistence of hypertension and abnormalities of glucose metabolism after treatment, were independent predictors of mortality (multivariate analyses, P<0.01). CONCLUSIONS Prevalence of Cushing's disease was 39.1 cases/million inhabitants and average incidence was 2.4 cases/million per year. Mortality was elevated, due to vascular disease, associated with higher age, persistence of hypertension and impaired glucose metabolism.     

Balloon occlusion of the internal carotid artery in 40 cases of giant intracavernous aneurysm: technical aspects,cerebral monitoring,and results

Summary We have studied the results of carotid occlusion in the treatment of giant intracavernous carotid artery (ICA) aneurysms in 40 patients. Clinical, angiographic, Doppler and cerebral blood flow (CBF) criteria for tolerance of occlusion are discussed. The patients had headaches (47.5%), cranial nerve compression (87.5%), decreased visual acuity (20%), ruptured aneurysm (15%) and 5% were asymptomatic. Balloon occlusion tests were performed under light sedation anaesthesia: a successful test required perfect clinical tolerance and adequate angiographic collateral circulation in arterial, parenchymatous, and venous phases. Additional criteria include xenon 133 CBF measurements, and transcranial Doppler sonography of the middle cerebral artery. According to these criteria, 5 patients did not tolerate test occlusion and required an extra-intracranial (EC-IC) bypass. Mean follow-up was 4.7 years. All patients were radiologically cured of their ancurysm, and in 35 the symptoms resolved, although 3 had persistent ocular motor nerve palsies, and in 4 visual defects were unchanged. Complications were 1 permanent and 3 transient neurological deficits. Balloon occlusion of the ICA is an effective, reliable form of treatment for intracavernous giant aneurysm and should replace surgical ligation of the cervical carotid artery. With CBF or Doppler monitoring, the risk of neurological deficit is diminished. EC-IC bypass prior to ICA occlusion is indicated if test occlusion is not tolerated.