Repeated laser-assisted high-flow bypass for recurrent giant intracranial aneurysm

The treatment of intracranial aneurysms is changing as endovascular obliteration possibilities and long-term results are being published in regard to outcome. However, not all aneurysms are amenable to direct endovascular or surgical treatment. In such situations, a high flow bypass for flow preservation can be considered as indirect treatment alternative, enabling a trapping of the aneurysm or occlusion of the feeding artery. We present the case history of a 57 year-old patient suffering of a recurrent giant intracranial carotid aneurysm. The aneurysm could be excluded using a new cerebral high-flow bypass technique for which no temporary occlusion of any intracranial vessels is required. This technique reduces the risks of perioperative neurological complications.

Intracardiac devices for stroke prevention

Stroke is a significant cause of serious disability and death worldwide. A substantial proportion of strokes are related to an underlying cardiac embolic source, most commonly in association with atrial arrhythmias (fibrillation/flutter). Atrial fibrillation is considered a major risk factor for stroke. Although long-term prophylactic oral anticoagulation has been shown to be very effective in reducing stroke in patients with atrial fibrillation, it has a number of major limitations and is not feasible in all patients. In such cases, the use of percutaneously (transvenous) implanted left atrial appendage occlusive devices or surgical appendage obliteration is being explored. Similarly, the presence of a patent foramen ovale, especially in the presence of an atrial septal aneurysm, is now recognized as an important potential mediator of paradoxical cardiogenic embolism. Percutaneous patent foramen ovale closure is becoming increasingly established as a safe and effective means of preventing recurrent strokes in the presence of a patent foramen ovale. In this account, the authors discuss the intracardiac devices and techniques available and the relative merits of their use for stroke prevention.

ADAMTS13 activity in sickle cell disease

Sickle red blood cell (SRBC)-endothelial adhesion plays a central role in sickle cell disease (SCD)-related vaso-occlusion. As unusually large von Willebrand factor (ULVWF) multimers mediate SRBC-endothelial adhesion, we investigated the activity of ADAMTS13, the metalloprotease responsible for cleaving ULVWF multimers, in SCD. ADAMTS13 activity was determined using a quantitative immunoblotting assay. VWF:Ag and VWF:RCo were determined using commercial assays. The high-molecular-weight VWF multimer percentage was determined by employing gel electrophoresis. ADAMTS13 activity was similar among asymptomatic patients (n = 8), patients at presentation with a painful crisis (n = 23), and healthy controls. ADAMTS13/VWF:Ag ratios were lower in patients compared to healthy HbAA controls, with the lowest values at presentation with a painful crisis (P = 0.02). Division of samples in those with VWF:RCo/VWF:Ag ratios < 0.70 and those with ratios >or= 0.70 revealed significantly more samples with ratios >or= 0.70 (P = 0.01) collected during painful crises. ULVWF multimers were detected in 6 patient samples and in 1 control sample. ADAMTS13/VWF:Ag ratios were inversely related to the duration of symptoms at presentation with an acute vaso-occlusive event (r(s)-0.67, P = 0.002). Although SCD is characterized by elevated VWF:Ag levels, no severe ADAMTS13 deficiency was detected in our patients.

Subarachnoid hemorrhage and intracerebral hematoma: incidence, prognostic factors, and outcome

OBJECTIVE: To analyze the incidence and impact of an intracerebral hematoma (ICH) on treatment and outcome in patients with aneurysmal subarachnoid hemorrhage. METHODS: Data of 585 consecutive patients with subarachnoid hemorrhage from June 1999 to December 2005 were prospectively entered in a database. ICH was diagnosed and size was measured by computed tomographic scan before aneurysm occlusion. Fifty patients (8.5%) presented with an ICH larger than 50 cm3. The treatment decision (coil, clip, or hematoma evacuation) was based on an interdisciplinary approach. Patients were stratified into good (Hunt and Hess Grades I-III) versus poor (Hunt and Hess Grades IV and V) grade, and outcome was assessed according to the modified Rankin Scale at 6 months. RESULTS: Overall, 358 patients presented in good grade, with 4 of them having ICH (1.1%); and 227 patients presented in poor grade, with 46 of them having ICH (20.3%, P < 0.01). In good-grade patients with an ICH (n = 4), a favorable outcome (modified Rankin Scale score of 0-2) was achieved in 1 patient (25%), and in 246 patients (75%) without an ICH (P = 0.053; odds ratio, 0.11). A favorable outcome was achieved in 5 poor-grade patients (12.8%) with an ICH and in 40 patients (23.7%) without an ICH (P = 0.19; odds ratio, 0.47). Time to treatment was significantly shorter in patients with an ICH than without an ICH (median, 7 versus 26 h; P < 0.001) and shortest in patients with favorable outcome (3.5 hours; P < 0.01). CONCLUSION: The current data confirm that the presence of an ICH is a predictor of unfavorable outcome. However, despite large ICHs, a significant number of patients have a good outcome. To achieve a favorable outcome, ultra-early treatment with hematoma evacuation and aneurysm obliteration seems to be mandatory.

Decreased visual function after patchy loss of retinal pigment epithelium induced by low-dose sodium iodate

PURPOSE: To correlate damage to the retinal pigment epithelium (RPE) with decreased visual function after the systemic administration of sodium iodate (NaIO(3)). METHODS: Damage was produced in mice by injection of 15, 25, or 35 mg/kg NaIO(3). Visual function was assessed with the cued water maze (WM) behavioral test and the optokinetic reflex (OKR) measurement at different times after injection. Autofluorescence in whole eye flatmounts was quantified, and hematoxylin and eosin staining of paraffin sections was performed to assess changes in the outer retina. RESULTS: After 15 mg/kg NaIO(3), cued WM test results were normal, whereas OKR measurements were significantly decreased at all times. Focal RPE loss began on day 21, but no significant damage to the outer nuclear layer was observed. After 25 mg/kg NaIO(3), the cued WM test was transitionally reduced and the OKR measurement again decreased at all times. Large areas of RPE loss occurred on day 14 with a reduced outer nuclear layer on the same day. With 35 mg/kg NaIO(3), the cued WM test was reduced beginning on day 14 with complete obliteration of the OKR beginning on day 3, large areas of RPE loss on the same day, and a reduced outer nuclear layer on day 7. CONCLUSIONS: Stable, patchy RPE loss was observed with a low concentration of NaIO(3). The OKR measurement showed changes in visual function earlier than the cued WM test and before histologic findings were observed.

Early biochemical indicators of the obliterative bronchiolitis syndrome in lung transplantation

The diagnosis of the obliterative bronchiolitis syndrome in lung transplantation is presently best established by evaluation of postoperative lung function tests. Unfortunately the decline in lung function occurs only when obliteration has progressed significantly and is therefore not an early predictive indicator. To distinguish patients at increased risk for the development of obliterative bronchiolitis, we regularly assessed the chemiluminescence response of polymorphonuclear leukocytes, opsonic capacity, and plasma elastase/beta-N-acetylglucosaminidase in 52 outpatients (25 women and 27 men; mean age 45 +/- 12 years) who underwent transplantation between January 1991 and January 1992. Recent onset bronchiolitis within the described observation period occurred in 16 patients (group obliterative bronchiolitis). A matched cohort of 16 patients was formed according to type of procedure, age and follow-up (control) from the remaining 36 patients. Data obtained from a period 6 months before clinical onset of the syndrome showed a significant drop of the opsonic capacity (group obliterative bronchiolitis = 87% +/- 7%; control = 100% +/- 9%; p < 0.023) and rise of the N-acetyl-D-glucosaminidase (group obliterative bronchiolitis = 7.5 +/- 2 U/L; control = 5.8 +/- 1.8 U/L; p < 0.04). No correlation was found between the number of infectious events or rejection episodes and the incidence of obliterative bronchiolitis. According to these results, it can be concluded that a decrease in the plasma opsonic capacity and a rise in beta-N-acetylglucosaminidase may be early markers before clinical onset of obliterative bronchiolitis. The nonspecific immune system may therefore play an important role in the development of obliterative bronchiolitis.

Effects of Novel Growth Hormone Secretagogues on Growth Hormone Secretion in Farm Animals

The requirement for growth hormone (GH) secretion by the anterior pituitary gland in beef calves is demonstrated by a complete lack of long bone-growth and muscle accretion after hypophysectomy (surgical removal of the pituitary gland). When the connecting link (hypophyseal stalk) to the basal region (hypothalamus) of the brain is surgically severed, long bone growth and body weight gain are greatly limited compared with sham-operated controls. This limited growth results from obliteration of episodic GH secretion and reduced basal blood concentration of the hormone compared with sham-operated controls. Thus, the hypophyseal stalk-transected (HST) calf provides an appropriate model to determine mechanisms by which hypothalamic neuropeptides from the brain regulate GH secretion, and thereby growth in the young calf. Neuropeptides have been isolated and characterized in bovine hypothalamus that stimulate GH secretion (GH-releasing hormone [GHRH]) or factor [GHRF] and inhibit GH secretion (GH release-inhibiting hormone [GHRIH] or somatostatin [SRIH]). A dose of .067 micrograms of GHRF per kilogram of body weight injected intravenously in HST calves abruptly increased plasma GH concentration to 55 nanograms per milliliter from the control period mean of 5 nanograms per milliliter. HST calves then were infused intravenously with .033 and .067 microgram somatostatin per kilogram of body weight, during which a pulse injection of .067 microgram of GHRF was administered. GH increase was limited to 9 and 5 micrograms per kilogram body weight during the .033- and .067 microgram SRIH infusions after GHRF; no GH rebound was observed after the SRIH was discontinued. GHRF from humans contains 40 to 44 amino acids. Rat hypothalamic GHRF analogs containing 29 to 32 amino acids elicited dose-dependent GH peak release in these HST calves. In 1977, Bowers and Monomy isolated novel GH releasing peptides consisting of only six amino acids; they caused GH release by isolated pituitary cells in culture and acute GH release when administered intravenously. We recently have utilized a novel nonpeptidyl GH secretagogue of low molecular weight in the pig to determine its mechanisms of action within the central nervous system.

Microsurgical treatment of perimedullary spinal arteriovenous fistulas

Objective: Perimedullary arteriovenous fistulas (PMAVF) are exceptional spinal vascular malformations and their best therapeutic management remains controversial. Here the authors present their experience with PMAVF to characterize the clinical, neuroimaging and treatment data of patients operated on PMAVF and to analyse both incidence of complications and resurgery in the microsurgical therapy of PMAVF. Method: Fifteen patients (13 men, 2 women, mean age 51 years) with PMAVF identified by selective spinal angiography were microsurgically treated at our institution between 1992 and 2006. The presenting symptoms (duration 3 months to 5 years) were consistent with progressive myelopathy (13) or included isolated pain syndrome (2). Lumbar PMAVF location (6) was predominant followed by the sacral (5) and thoracic (4) site including 6 PMAVF of the filum terminale and 2 PMAVF associated with a glomerular AVM and dural arteriovenous fistula, respectively. Microsurgical PMAVF obliteration and postoperative angiography were routinely performed. All patients were available for follow-up evaluation within 6 months postoperatively. Results: Surgery with complete (12) or almost complete (3) PMAVF occlusion resulted in neurological improvement (10) or stabilization (1), 4 patients deteriorated postoperatively. Whereas no complications occured, a second operation because of residual or recanalized PMAVF was indicated in one case each. Two associated dual spinal vascular malformations could be observed and subsequently obliterated. Conclusions: Microsurgical occlusion of PMAVF appears to be a secure and adequate therapeutic option that prevents progressive neurological deterioration and results in good outcome in the majority of patients. Complications associated with surgery, recurrences and reoperations are infrequent. Therefore, in the authors experience microsurgery is the preferred therapy to treat PMAVF. Despite the rarity of PMAVF the possibility of the coincidence of associated second vascular malformations should be considered.

Sudden death in a case of sickle cell anemia: post-mortem computed tomography and autopsy correlation from a radiologist's perspective

Sickle cell anemia (SCA) is a hemolytic disease characterized by the production of abnormal hemoglobin chains and distorted red blood cell morphology or sickling. "Sickle cell crisis" includes vaso-occlusive crisis, a plastic crisis, sequestration crisis, haemolytic crisis and often culminating in serious complications, organ damage and even sudden death. Post-mortem computed tomography (PMCT) findings of sickle cell disease have never been reported in literature. This case of sudden death from acute hemolytic crisis in SCA where post-mortem computed tomography (PMCT) and autopsy findings complemented each other, both revealing findings invisible to the other and both crucial to the case.

William Osler: Original Papers 1898-1906

Part 1: 1898-1899 On Chronic Symmetrical Enlargement of the Salivary and Lachrymal Glands, 1898 Leprosy in the United States, with the Report of a Case, 1898 An Acute Myxaedematous Condition, with Tachycardia, Glycosuria, Melaena, Mania and Death, 1898 On some of the Intestinal Features of Typhoid Fever, 1898 Cerebro-Spinal Fever, 1898 The Arthritis of Cerebro-Spinal Fever, 1898 In Memoriam, William Pepper, 1899 After Twenty-Five Years, 1899 The Diagnosis of Typhoid Fever, 1899 Interstitial Processes in the Central Nervous System, 1899 Part 2: 1900 The Home Treatment of Consumption, 1900 On Splenic Anaemia, 1900 The Chronic Intermittent Fever of Endocarditis, 1900 A Case of Multiple Gangrene in Malarial Fever, 1900 Latent Cancer of the Stomach, 1900 On the Study of Tuberculosis, 1900 Fatal Angina Pectoris without Lesions of the Coronary Arteries of a Young Man, 1900 On the Advantages of a Trace of Albumin and a Few Casts in the Urine of Certain Men above Fifty Years of Age, 1900 Part 3: 1901-1902 Congenital Absence of the Abdominal Muscles with Distended Hypertrophied Urinary Bladder, 1901 Intermittent Claudication, 1902 On the Diagnosis of Bilateral Cystic Kidney, 1902 On Amebic Abscess of the Liver, 1902 Note on the Occurrence of Ascites in Solid Abdominal Tumors, 1902 Amebic Dysentery, 1902 Notes on Aneurism, 1902 William Beaumont; a Pioneer American Physiologist, 1902 Part 4: 1903 On the Educational Value of the Medical Society, 1903 On obliteration of the Superior Vena Cava,1903 Chronic Cyanosis, with Polycythemia and Enlarged Spleen: A New Clinical Entity, 1903 The Home and its Relation to the Tuberculosis Problem, 1903 Unity, Peace, and Concord, 1903 Typhoid Fever and Tuberculosis, 1903 Part 5: 1904-1906 Ochronosis, 1904 The “Phthisiologia” of Richard Morton, M.D., 1904 On the Surgical Importance of the Visceral Crises In the Erythema Group of Skin Diseases, 1904 Aneurysm of the Abdominal Aorta, 1905 Back Notes

La época de raleo como factor de rentabilidad en duraznos conserveros de maduración temprana

Del total de la superficie implantada con duraznos conserveros en la provincia de Mendoza, el 27% corresponde a cultivares de maduración temprana, en los que el raleo de frutos es un factor crítico de manejo. Para determinar la incidencia de diferentes épocas de raleo sobre la rentabilidad del cultivo se realizó un ensayo en un monte comercial de durazneros cvs. Fortuna y Carson. Se utilizaron árboles injertados sobre portainjerto Nemaguard, conducidos en vaso tipo californiano e implantados a 6 m entre hileras y a 5 m entre plantas, que fueron raleados en tres épocas diferentes: a los 40 días después de plena floración, en inicio de endurecimiento de carozo y 10 días después, en la fecha de referencia. Se realizaron evaluaciones de producción por planta y calidad de frutos. También se determinó el valor de la producción y la relación entre éste y las distintas fechas de raleo. En ambos cultivares, los árboles raleados en época temprana obtuvieron mayor peso de frutos, producción total y producción destinada a mitades. En el cv. Fortuna, este tratamiento produjo un aumento significativo del porcentaje de frutos con carozo partido.El raleo temprano de frutos aumentó significativamente el valor de la cosecha, logrando un incremento de $ 3636.ha-1 y $ 3441.ha-1en los cvs. Fortuna y Carson, respectivamente, en relación con el tratamiento en fecha de referencia.

Efectos de la carga frutal en durazneros

Para determinar el efecto de la carga frutal sobre el peso de frutos y la distribución de calibres se realizó un ensayo en durazneros variedades Bowen, Andross y Ross. Árboles en plena producción, conducidos en vaso tipo californiano e implantados a 6x5 m fueron raleados manualmente 20 días después de iniciado el endurecimiento de carozo. La carga frutal quedó establecida en el rango de 750 a 1 350 frutos/planta en Bowen y Ross y entre 850 y 1400 frutos/planta en Andross. Se realizaron evaluaciones de tamaño final de frutos, producción total y producción destinada a mitades. En las tres variedades se estableció un alto grado de correlación entre la carga frutal y los tres parámetros de evaluación y se observó una respuesta similar a diferentes niveles de carga frutal. A medida que se incrementó la carga frutal, se lograron aumentos en la producción total, aunque disminuyó el peso de frutos. La producción destinada a mitades aumentó en relación con la carga frutal, hasta alcanzar valores máximos con cargas de 1 150 frutos/planta. Luego se estabilizó y, superado un valor crítico en la carga frutal, empezó a disminuir. Para todo el rango de carga utilizado, el peso de frutos y la producción total fueron mayores en Ross. Esta variedad también logró los máximos valores de producción destinada a mitades. Andross superó a Bowen en los tres parámetros evaluados.

Manejo de la carga frutal y productividad de duraznos conserveros

Para determinar la relación entre la carga frutal y la productividad, medida en términos de producción destinada a mitades (PDM) y producción para pulpa, se realizó un ensayo en un monte comercial de duraznero variedad Bowen, Andross y Ross. Se utilizaron árboles injertados sobre patrón Nemaguard, conducidos en vaso tipo californiano e implantados a 6 m entre hileras y a 5 m entre plantas (333 árboles/ha), los que fueron raleados 20 días después del inicio de endurecimiento de carozo. La carga frutal quedó establecida en el rango de 750 a 1350 frutos/planta en Bowen y Ross y entre 850 y 1400 frutos/planta en Andross. A la cosecha se evaluó: tamaño de frutos; producción de los árboles, a través de las variables producción total, producción destinada a mitades (PDM) y producción para pulpa; y valor de la producción. La carga frutal se vinculó, con un alto grado de correlación, con todas las variables analizadas y se observó una respuesta a la carga de frutos muy similar en las tres variedades en estudio. A medida que se incrementó la carga frutal, aumentó la producción total, aunque disminuyó el peso medio de frutos. La PDM aumentó en función de la carga frutal, hasta alcanzar valores máximos con 1200 frutos/planta; por encima de un valor crítico en la carga frutal, la PDM empezó a disminuir. Los rendimientos de pulpa, en fábrica, no se relacionaron linealmente con los rendimientos totales del monte frutal y respondieron a una función similar a la que relaciona carga frutal y PDM. Los resultados indicaron que, con independencia del destino de la fruta, el raleo de frutos aseguró los rendimientos y la calidad de frutos que permitieron maximizar la rentabilidad del productor, convirtiéndose en una tarea cultural imprescindible, desde el punto de vista técnico y económico.

Influencia de la intercepción lumínica en el desarrollo vegetativo y productivo de durazneros cv. Elegant Lady

El presente ensayo fue establecido en el Alto Valle del Río Negro, Argentina (38°55´ Sur), sobre durazneros cv. Elegant Lady conducidos en vaso, de 5 m de altura, con un distanciamiento de 4 m entre plantas y 4,8 m entre filas. Se realizaron tres tratamientos en un diseño totalmente aleatorizado, simulando diferentes intensidades de luz: restricción lumínica con mallas de sombreo del 80%, poda en verde y un control sin intervención. En cada una de las plantas se diferenciaron 4 sectores orientados hacia los 4 puntos cardinales y 3 alturas distintas de la copa del árbol. La radiación fotosintéticamente activa (RFA) fue medida en cada sector 25, 15 y 6 días antes de la cosecha. La RFA interceptada estuvo influenciada por la restricción lumínica y por la altura. Las variables vegetativas y de producción se relacionaron entre sí linealmente, y ambas dependieron principalmente de la RFA interceptada. Los modelos que explican el comportamiento entre la RFA y las variables de calidad son de tipo asintóticos. A partir de los 25 días anteriores a la cosecha, la RFA necesaria para alcanzar frutos con un peso y color adecuados para su comercialización debe ser del 30%. En el rango de 0 a 15% de RFA interceptada, pequeñas variaciones de RFA dan como resultado grandes cambios en las variables de peso, color de cobertura e intensidad de color del fruto.

Modelación numérica de deslizamientos de ladera en embalses mediante el método de partículas y elementos finitos (PFEM)

Se presentan resultados obtenidos mediante la aplicación del MétododePartículasyElementosFinitos (PFEM) en la simulación dedeslizamientosdeladeraenembalses. Es un fenómeno complejo, por la interacción entre el material deslizado, la masa de agua del embalse, yel conjunto formado por el vaso y la presa. PFEM es un esquema numérico original con el que se ha afrontado con éxito la resolución de problemas de interacción fluido-estructura. Combina un enfoque Lagrangiano con la resolución de las ecuaciones deelementosfinitosmediante la generación de una malla, que se actualiza en cada paso de tiempo. Se presentan resultados de casos de validación en los que se han reproducido ensayos en laboratorio existentes en la bibliografía técnica. Se muestran también otros cálculos más complejos, sobre la cartografía a escala real de un embalse, donde se aprecia el fenómeno de generación de la ola, su propagación por el embalse y la afección a la presa. Por último, se ha modelado el deslizamiento ocurrido en 1958 en la bahía de Lituya (Alaska), enel que la caída de 90 millones de toneladas de roca produjo una ola que alcanzó una sobreelevación máxima de 524 m en la ladera opuesta. Los resultados permiten afirmar que PFEM puede ser una herramienta útil enel análisis de riesgos frente a este tipo de fenómenos, ofreciendo una buena aproximación de las afecciones potenciales