Early assessment of minimal residual disease in AML by flow cytometry during aplasia identifies patients at increased risk of relapse.

In acute myeloid leukemia (AML), assessment of minimal residual disease (MRD) by flow cytometry (flow MRD) after induction and consolidation therapy has been shown to provide independent prognostic information. However, data on the value of earlier flow MRD assessment are lacking. Therefore, the value of flow MRD detection was determined during aplasia in 178 patients achieving complete remission after treatment according to AMLCG (AML Cooperative Group) induction protocols. Flow MRD positivity during aplasia predicted poor outcome (5-year relapse-free survival (RFS) 16% vs 43%, P<0.001) independently from age and cytogenetic risk group (hazard ratio for MRD positivity 1.71; P=0.009). Importantly, the prognosis of patients without detectable MRD was neither impacted by morphological blast count during aplasia nor by MRD status postinduction. Early flow MRD was also evaluated in the context of existing risk factors. Flow MRD was prognostic within the intermediate cytogenetic risk group (5-year RFS 15% vs 37%, P=0.016) as well as for patients with normal karyotype and NPM1 mutations (5-year RFS 13% vs 49%, P=0.02) or FLT3-ITD (3-year RFS rates 9% vs 44%, P=0.016). Early flow MRD assessment can improve current risk stratification approaches by prediction of RFS in AML and might facilitate adaptation of postremission therapy for patients at high risk of relapse.

[Injury of ICA during endonasal sinus surgery and management by endovascular stent application]. / Verletzung der ACI bei Nasennebenhöhlenoperation und Management durch endovaskuläre Stentapplikation.

BACKGROUND: Injury of the internal carotid artery (ICA) during endonasal sinus surgery is rare but a life-threatening situation for the patient. For adequate treatment endovascular therapy as embolization or balloon occlusion is usually performed although there is a high risk of irreversible neurological deficits. CASE REPORT: We report on a twenty-five-year-old female patient with acute exacerbated chronic polyposis nasi suffering from an injury of the ICA during endonasal sinus surgery. After intraoperative identification of the site of hemorrhage the massive bleeding could temporarily be controlled by a nasal pack. The woman was immediately transferred to a neuroradiological department. After angiographic localization of the vessel defect the bleeding could be stopped by application of a vascular stent without any neurological deficits during or after the procedure. Anatomical characteristics of the ICA in the sphenoid sinus, and recommended emergency treatment and preventive measures are discussed. CONCLUSION: Although vascular stents are difficult to place in the intrasphenoidal course of the ICA, it provides an effective closure of the vascular injury and above all a sufficient cerebral perfusion, therefore, the risk of neurological defects can be reduced.

Ex vivo study of the physical effect of coils on pressure and flow dynamics in experimental aneurysms.

BACKGROUND AND PURPOSE: Recent experimental studies and a few case reports reveal that coiling may not lead to permanent occlusion of aneurysms by an organized thrombus. Therefore, biologic long-term prognosis seems to be doubtful, and the physical effect of coils may be important. The purpose of this study was to investigate the physical effect of coils on pressure and flow dynamics in aneurysms. METHODS: Bifurcation aneurysms were created in eight rabbits, explanted after 3 weeks, and tested in a model with pulsatile perfusion with 0.9% saline and heparinized blood. Before and after densely packing with coils, systemic and intraaneurysmal pressure, aneurysmal pulsation, and impact measurements were recorded. RESULTS: The peak and shape of the pressure waves in the aneurysm and in the delivery system were not significantly different before and after coiling. Under physiological intraaneurysmal pressure (while being perfused with saline), significant reduction (P = .022) of aneurysmal wall pulsation after coil embolization was noted. Overall, the aneurysmal impact on surrounding structures was statistically unchanged after coiling. However, in a few cases, after coil embolization, the observed increase of impact was more than doubled compared with the original values before coiling. CONCLUSION: Coils do not physically affect intraaneurysmal pressure. After coiling, there is no significant reduction of flow rates through the aneurysm and no reduction of aneurysmal impact, but aneurysmal wall pulsation may be decreased.

Isolated superior oblique palsies with brainstem lesions.

Isolated unilateral superior oblique palsies resulting from brainstem lesions occurred in three patients. MRI documented contralateral tegmental lesions of the trochlear nucleus and adjacent intraaxial trochlear nerve. Lacunar infarct was the cause in two patients and a small hemorrhage in a third.

Association of oligodendroglioma-like cell proliferation and angiomatous vasculature--coincidence or pathogenetically related lesions?

We report a case of an oligodendroglioma associated with a cavernous angioma. The patient, a 20-year-old man with an 8-year history of epileptic seizures, presented an acute onset of headache, nausea, and vomiting. Computerized tomographic scan and angiogram revealed multiple vascular malformations in both hemispheres including a cystic hemorraghic lesion with a perifocal edema attributing to a mass effect. Repeated puncture of the cyst failed to give improvement of elevated intracranial pressure. At surgery, the cyst and the underlying lesion were excised and found to be oligodendrocyte-rich tissue with malformed vascular tissue. Final histological examination revealed an oligodendroglioma associated with a cavernous angioma. As concurrence of oligodendroglioma and vascular malformation is rare, this case raises a broad range of differential diagnoses such as reactive oligodendroglial gliosis due to a vascular malformation, unusual vascularity of an oligodendroglioma as well as other kinds of cerebral tumors or malformations. The diagnostic difficulties as well as the pathogenetic and pathological significance of the concurrence of an oligodendroglioma and cavernous angioma are discussed.

The role of endoscopy in the treatment of acute traumatic anterior epidural hematoma of the cervical spine: case report.

OBJECTIVE AND IMPORTANCE: Epidural hematoma (EDH) of the spine represents an uncommon neurosurgical disorder that sometimes requires emergent surgical decompressive therapy. Traumatic EDH of the cervical spine is exceedingly rare. The hematoma is usually located dorsally in the epidural space. We present one case of acute EDH located ventrally in the cervical spine. Special emphasis is placed on the role of spinal endoscopy in surgical treatment. CLINICAL PRESENTATION: After a fall from a tree, a 69-year-old man with rapidly increasing tetraparesis was referred to our institution. Plain films of the cervical spine revealed nothing abnormal. The results of computed tomography were highly suspicious for EDH. A myelogram and a post-myelographic computed tomographic scan demonstrated the lesion and its extent craniocaudally. INTERVENTION: Emergency decompressive surgery and removal of the hematoma were performed via an anterior approach. Control for total removal of the EDH was achieved using a flexible neuroendoscope providing visualization of the anterior epidural space from the foramen magnum to the T1 level. Surgery was accomplished by vertebral body replacement and anterior plating. CONCLUSION: Spinal endoscopy seems to be a useful tool in the surgical treatment of spinal EDH, providing control of the adjacent levels and allowing the limitation of the extent of bony resection.

Isolated cranial nerve palsies in multiple sclerosis.

During a 10 year period 24 patients with definite multiple sclerosis with isolated cranial nerve palsies were studied (third and fourth nerve: one patient each, sixth nerve: 12 patients, seventh nerve: three patients, eighth nerve: seven patients), in whom cranial nerve palsies were the presenting sign in 14 and the only clinical sign of an exacerbation in 10 patients. MRI was carried out in 20 patients and substantiated corresponding brainstem lesions in seven patients (third nerve: one patient, sixth nerve: four patients, eighth nerve: two patients). Additional abnormal findings of electro-oculography, or masseter reflex, or blink reflex, or combinations of these were found in 20 patients and interpreted in favour of a brainstem lesion at the level of the respective cranial nerve. In 11 of 14 patients with isolated cranial nerve palsies as the presenting sign of multiple sclerosis, dissemination in space was documented by MRI, and in the remaining three by evoked potentials. In patients with multiple sclerosis with isolated cranial nerve palsies, MRI is the most sensitive method of documenting dissemination in space and electrophysiological testing the most sensitive at disclosing brainstem lesions.

[The role of color duplex ultrasound in diagnosis and differential diagnosis of carotid body tumors]. / Die Rolle der Farbduplex-sonographie bei Diagnose und Differentialdiagnose von Glomus-caroticum-Tumoren.

BACKGROUND: Currently the diagnosis of tumorous lesions of the carotid bifurcation is the domain of magnetic resonance imaging (MRI) and digital subtraction angiography (DSA). So far, colour Doppler imaging (CDI) has not been playing an important part in this field. The aim of this study was to define the diagnostic value of CDI in the evaluation of these tumours related to the big arteries and to compare the different imaging techniques. PATIENTS AND METHODS: 6 female patients with suspected tumours of the carotid bifurcation were examined with CDI. Additionally 5 MRI examinations and 3 preoperative diagnostic DSA examinations were performed in the same patients. Pathologically, there were 4 typical carotid body tumours, 1 neuroma of the sympathetic trunk and 1 multifocal paraganglioma of the neck. RESULTS: In carotid body tumours we found a characteristic broadening of the bifurcation with shifting of the internal carotid artery posteriorly and laterally and of the external carotid artery anteriorly and medially. The highly vascularized tumour is surrounded by the arteries. This combination of ultrasound findings was absent in cases of sympathetic neuroma and multifocal paraganglioma. No additional information was achieved with MRI and DSA. CONCLUSION: CDI and MRI evaluation revealed the same diagnostic value in cases of vascularised tumours of the carotid bifurcation. CDI proved to be as accurate as DSA in the imaging of the big arteries and their relationship to the tumour, as well as of the small tumour feeding vessels. Therefore DSA may be omitted as an invasive diagnostic tool in the diagnosis of carotid body tumours.

Stressors and stress management--1 month after myocardial infarction.

Stressors and stress management behaviors reported by 52 myocardial infarction (MI) patients were identified from a content analysis of transcriptions of nurse/patient/spouse interactions that took place 30 days postinfarction. Subjects defined stress primarily in terms of distress related to appraisals of harm, loss, or threat. Stressors and stress management behaviors varied, although subjects were similar in age and occupation and were in the same phase of recovery. Most stressors related to recent myocardial infarction and pertained to thoughts and feelings more than to external events. Others, related to family and/or work, were ongoing before the MI. Stress management behaviors comprised a continuum of physical, cognitive, and verbal behaviors ranging from active to passive. Avoidance of situations, ignoring situations, expressing feelings, and thinking things through were the four major modes of stress management behaviors. Implications for rehabilitation nursing practice are identified.

Marital functioning after cardiac surgery.

Using Barnhill's components of family health functioning, we examined the relationships of spouse anxiety, coping methods, couple responsibility for compliance, and reported compliance with marital couple functioning. Five psychosocial scales were returned by mail by 136 Mended Heart members and spouses from five geographic regions. By multiple regression analysis, confrontive coping strategies and spouse trait anxiety were the two factors predictive of couple marital functioning. When marital functioning scores were examined separately, spouses' confrontive behaviors and patient reported compliance for diet, stress, and smoking prescriptions were predictive of both spouse and patient marital functioning. In addition, spouse marital functioning was predicted by state anxiety and patient compliance, and patient marital functioning by compliance and shared responsibility for compliance. Further studies should evaluate spouse inclusion in rehabilitation programs during hospitalization and convalescence and examine interactional strategies that facilitate confrontive behaviors and patient compliance to promote couple marital functioning after the cardiac event.

Personal adjustments and regimen compliance 1 year after myocardial infarction.

The relationship of attitudes and perceived beliefs of others to regimen compliance and personal psychologic and social adjustments of patients with myocardial infarction was investigated 1 year after the infarction. Eighty-one patients (39 in the experimental group, 42 in the control group) who participated in a prior study on the effect of a nursing intervention on regimen compliance, completed scales that assessed attitudes toward regimen prescriptions (diet, medications, activity, smoking, and stress response), perceived beliefs of others concerning compliance, personal adjustments, and regimen compliance. At 1 year, no differences were found between experimental and control groups for regimen compliance or personal adjustments. There was a significant decrease in mean scores for all variables from the time the patient was in the hospital to 30 days afterward, but no change at 1 year from the 30- or 60-day visit. At 1 year, attitudes were predictive of compliance for all regimen prescriptions. Perceived beliefs of others were predictive of diet, activity, and medication prescriptions.

A double-blind study comparing the safety, tolerability, and efficacy of ioversol 320 and iopamidol-300 in cerebral angiography.

Ioversol is a new nonionic, triiodinated, water-soluble contrast medium. In a controlled double-blind study, ioversol 320 versus iopamidol-300 was tested on 60 patients in cerebral angiography. The safety of the contrast medium, the general and local tolerance, as well as the contrast quality were tested. In this study, ioversol 320 displayed no differences from iopamidol-300 in terms of contrast quality, neurologic status, and liver and kidney tolerance. In the local tolerance test, patients receiving ioversol 320 perceived significantly less heat than patients receiving iopamidol-300 when all injections were considered.

Iotrolan versus iopamidol: a controlled, multicenter, double-blind study of lumbar and direct cervical myelography.

Iotrolan is a new nonionic, dimeric contrast medium that is distinguished by its special physicochemical and low chemotoxic properties. It displays near isotonicity with blood and cerebrospinal fluid in all clinically used concentrations (190, 240, and 300 mg I/ml). The controlled, double-blind study of iotrolan versus iopamidol presented here shows that iotrolan is significantly superior to the monomeric contrast medium in lumbar and direct cervical myelography. Use of the dimeric contrast medium reduced not only the incidence of side effects, but also their severity and duration. The chemotoxicity of contrast media commonly used was significantly less with iotrolan in all neuroradiologic diagnostic studies of the spine. The diagnostic quality of lumbar and direct cervical myelography with iotrolan was high. In this randomized, double-blind study versus iopamidol, iotrolan proved to be the safer and better myelographic agent for contrast studies of the spinal canal.

[Cauda equina syndrome in ankylosing spondylitis]. / Cauda-equina-Syndrom bei Spondylitis ankylosans.

A 55-year-old man who has had ankylosing spondylitis for over 20 years developed gradually increasing pain and sensory disorders in the legs, as well as mild foot and toe elevator weakness. There was no evidence of inflammatory activity. Clinical, neurophysiological and neuroradiological examination revealed a cauda equina syndrome as a late complication of ankylosing spondylitis. There is no known causal treatment.

Influence of a nursing intervention on regimen adherence and societal adjustments postmyocardial infarction.

One hundred three first-time myocardial infarction (MI) patients were randomly assigned to either an experimental or a control condition. Patients completed a cardiac rehabilitation program during hospitalization and were interviewed to assess intentions to follow regimen prescriptions, attitudes toward the prescriptions, coping methods, and the perceived beliefs of others concerning their intentions. Patients were visited at home 30 days after discharge and reassessed on each of the above variables except that their behavior was substituted for intentions and societal adjustment was assessed. The experimental group was given an intervention program which included a discussion of assessment data, identification of problems, and establishment of goals. The assessment was repeated 60 days after discharge. No differences were found between experimental and control groups for either medical regimen adherence or societal adjustment. There was a significant decrease in mean scores for all variables from hospital to 30 days for both groups, but no change from 30 to 60 days. Attitudes and perceived beliefs of others were predictive of adherence, and it was concluded that these variables need to be included in any rehabilitation program.