How to reduce the complication rate of multiple burr holes surgery in moyamoya angiopathy.

PURPOSE: This study is aimed at analyzing clinical outcome, absence of stroke recurrence, revascularization, and complications and long-term follow-up in the surgical treatment of moyamoya angiopathy (MMA) using the multiple burr holes (MBH) technique with dura opening and arachnoid preservation as a single procedure. To the best of our knowledge, this is the first to describe an MBH technique with arachnoid preservation. METHOD: We retrospectively reviewed all patients operated from June 2001 to March 2021, for a symptomatic and progressive MMA operated with opening of the dura but arachnoid preservation. Clinical examinations were obtained in all patients, and radiological monitoring was performed by cerebral 3D-magnetic resonance angiography (MRA) with perfusion or single-photon emission computed tomography (SPECT) with acetazolamide. RESULTS: In total, 21 consecutive patients (6 children and 15 adults) were included with a mean age of 7.4 years in the pediatric group and 36.9 years in the adult group. Initial presentation was permanent ischemic stroke in 15 cases, transient ischemic attack (TIA) in 5 cases, and cerebral hemorrhage in one case. The MBH with dura opening and arachnoid preservation was performed bilaterally in 9 cases (43%) and unilaterally in 12 cases (57%). One patient died due to intraoperative bilateral ischemic stroke. Of the 20 other patients, 30% demonstrated clinical stability and 70% showed partial or complete recovery. Although one patient experienced a perioperative stroke, we did not observe any pseudomeningocele or postoperative ischemic stroke (IS) recurrence in all surviving cases during the average follow-up period of 55.5 months (range: 1-195). These outcomes emphasize the importance of preoperative monitoring to ensure the effectiveness and safety of the intervention. Postoperative angiography studies showed revascularization in 96.3% of treated hemispheres (100% in the adult group vs 80% in the pediatric group). CONCLUSIONS: Our results on this small cohort suggest that the MBH technique with opening of the dura and arachnoids preservation can prevent recurrent strokes and reduce the risk of pseudomeningocele.

Learning curve of medialization thyroplasty using a Montgomery™ implant.

UNLABELLED: Type I thyroplasty--also called medialization thyroplasty (MT)--is considered as an effective treatment for glottic incompetence in general and for abductor vocal fold palsy in particular. In the past there have been some concerns about the experience a laryngeal framework surgeon should have in order achieve an acceptable voice outcome. To assess the learning curve of MT performed using the Montgomery(®) hard silicone implant. A retrospective study involving 36 patients divided into three consecutive groups (1, 2, 3) of 12 MT patients or six consecutive groups (1a, 1b, 2a, 2b, 3a, 3b) of six MT patients. OUTCOME MEASURES: acoustic and aerodynamic outcome improvements (δ) compared to the duration of intervention [operative times (OT)]. Data were analysed by Anova, Kuskal Wallis and χ (2) statistical tests, according to data distributions. OT decreased significantly between groups 1, 2 and 3 with a mean OT of 90.5', 71.5' and 56' (p < 0.001), respectively. Objective δ such as maximum phonation time (MPT) (p 0.376), Estimated Sub-Glottic Pressure (ESPG) (p: 0.675) Shimmer (p: 0.543) and Jitter (p: 0.709) did not show significant improvement. Only the voice handicap index (VHI) δ of group 2 showed significant improvement (p 0.005) compared with the two other groups 1 and 3. Surgeon experience decreases the OT significantly. On the other hand, our study did not show a correlation between surgeon experience and voice outcome measures improvemnts (MPT, ESGP, Shimmer, Jitter).

An innovative approach to tracheotomy in patients with major obstruction of the upper airway.

BACKGROUND: Patients with severe dyspnea consecutive to locally advanced obstructive head and neck squamous cell carcinoma (HNSCC) or subglottic stenosis requiring definitive or temporary tracheotomy are frequently difficult to ventilate and intubate. MATERIALS AND METHODS: We describe a new procedure to perform tracheotomy easily and safely in patients with major obstruction of the upper airway. A catheter, specifically designed for cricothyroidotomy, was inserted into the trachea under local anesthesia. Then, general anesthesia was induced and the catheter was used as a guide for dilatation tracheotomy. From November 2009 to March 2013, the procedure was successfully used in 13 consecutive patients. Twelve out of 13 patients presented severe inspiratory dyspnea and stridor. RESULTS: During and after the procedure, no complications were reported. CONCLUSIONS: The reported technique is quickly performed and is a safe way to ensure short and long time ventilation of patients with major obstruction of the upper airway.

Massive postoperative pulmonary embolism in a young woman using oral contraceptives: the value of a preoperative anesthetic consult.

We describe the case of a woman with a history of active tabagism and on the oral contraceptive Yasmin, presenting in the Post-Anesthesia Care Unit (PACU) with a cardiac arrest due to massive pulmonary embolism following transforaminal lumbar interbody fusion surgery. The patient had preoperatively several risk factors for deep venous thrombosis. This case-report emphasizes the value of a preoperative anesthetic visit and eventual temporary cessation of certain oral contraceptives in specific cases.

Transient perioperative visual loss after an elective neurosurgical procedure.

OBJECTIVE: To describe a case of reversible visual loss after a neurosurgical intervention and to discuss the role of the prone position as a potential risk factor. OBSERVATION: A 63-year-old woman without significant medical previous history underwent elective resection of a left parieto-occipital meningioma. Preoperatively, the patient presented a right homonymous lower quadranopsia. The surgical procedure was not complicated. The patient was positioned in prone with a mild inclination of the table in reverse Trendelenburg position. The head was maintained in a Mayfield skull clamp, and ocular compression was excluded. There was no significant hypotension, hemodilution or vasopressors infusion during the procedure. Immediately after recovery from anesthesia, the patient experienced total blindness and flash visual evoked potentials confirmed the absence of retinal, primary or late occipital activities. A progressive, but finally complete recovery started after 24 hours. CONCLUSION: This case illustrates the individual risk for visual injury after the prone position during some neurosurgical interventions.

The role of backyard poultry flocks in the epidemic of highly pathogenic avian influenza virus (H7N7) in the Netherlands in 2003.

In recent years, outbreaks of highly pathogenic avian influenza (HPAI) viruses have caused the death of millions of poultry and of more than 200 humans worldwide. A proper understanding of the transmission dynamics and risk factors for epidemic spread of these viruses is key to devising effective control strategies. The aim of this study was to quantify the epidemiological contributions of backyard flocks using data from the H7N7 HPAI epidemic in the Netherlands in 2003. A dataset was constructed in which flocks in the affected area were classified as susceptible (S), infected but not yet infectious (E), infectious (I), and removed (R). The analyses were based on a two-type SEIR epidemic model, with the two types representing commercial poultry farms and backyard poultry flocks. The analyses were aimed at estimation of the susceptibility (g) and infectiousness (f) of backyard flocks relative to commercial farms. The results show that backyard flocks were considerably less susceptible to infection than commercial farms (g = 0.014; 95%CI = 0.0071-0.023), while estimates of the relative infectiousness of backyard flocks varied widely (0 < or = f < or =5). Our results indicate that, from an epidemiological perspective, backyard flocks played a marginal role in the outbreak of highly pathogenic avian influenza in the Netherlands in 2003.

Vaccinating children against influenza increases variability in epidemic size.

Seasonal influenza causes a high disease burden. Many influenza vaccination programmes target the elderly and persons at high risk of complications. Some countries have recommended or even implemented a paediatric vaccination programme. Such a programme is expected to reduce influenza transmission in the population, offering direct protection to the vaccinated children and indirect protection to the elderly. We study the impact of a child vaccination programme with an age- and risk-structured transmission model, calibrated to data of 11 influenza seasons in the Netherlands. The model tracks the build-up of immunes and susceptibles in each age cohort over time, and it allows for seasonal variation in vaccine match and antigenic drift. Different vaccination strategies are evaluated for three target age groups (2-3, 2-12 and 2-16 year olds) over the full range of vaccination coverages (0-100%). The results show that the paediatric vaccination programme has only a limited impact on the elderly age groups, which account for most influenza morbidity and mortality. This is due to two notable changes in infection dynamics. First, an age shift is observed: influenza infections are reduced in vaccinated children, but are increased in young adults with limited natural immunity after years of vaccination. These young adults assume the role of driving the epidemic. Second, a year with low influenza activity can be followed by a large epidemic due to build-up of susceptibles. This variation of the infection attack rate increases with increasing vaccination coverage. The increased variability in the infection attack rate implies that health care facilities should be prepared for rare but larger peaks in influenza patients. Moreover, vaccinating the group with the highest transmission potential, results in a larger dependency on a secure vaccine supply. These arguments should be taken into account in the decision to introduce mass vaccination of school-aged children against influenza.

The impact of influenza vaccination on infection, hospitalisation and mortality in the Netherlands between 2003 and 2015.

Influenza epidemics annually cause substantial morbidity and mortality. For this reason, vaccination is offered yearly to persons with an elevated risk for complications. Assessments of the impact of vaccination are, however, hampered by year-to-year variation in epidemic size and vaccine effectiveness. We estimate the impact of the current vaccination programme comparing simulations with vaccination to counterfactual simulations without vaccination. The simulations rely on an age- and risk-structured transmission model that tracks the build-up and loss of immunity over successive seasons, and that allows the vaccine match to vary between seasons. The model parameters are estimated with a particle Monte Carlo method and approximate Bayesian computation, using epidemiological data on vaccine effectiveness and epidemic size in the Netherlands over a period of 11 years. The number of infections, hospitalisations and deaths vary greatly between years because waning of immunity and vaccine match may differ every season, which is in line with observed variation in influenza epidemic sizes. At an overall coverage of 21%, vaccination has averted on average 13% (7.2-19%, 95% range) of infections, 24% (16-36%) of hospitalisations, and 35% (16-50%) of deaths. This suggests that vaccination is mainly effective in protecting vaccinees from infection rather than reducing transmission. As the Dutch population continues to grow and age, the vaccination programme is projected (up to 2025) to gain in impact, despite a decreasing infection attack rate.

Office-based anesthesia in Belgium?

For many years, office based anesthesia (OBA), has been considerably increasing in the US. This type of practice is starting to develop in Belgium. On the other side of the atlantic, legislation concerning this practice is becoming more and more precise, whereas the same isn't true in our country. It seems therefore opportune to try and define the different points of view. This article will define the position of the legislator, insurance companies and finally, of the professional organizations. OBA practice is developping insidiously here, and we should therefore ask ourselves serious questions regarding the legal repercussions that it could have. To conclude, we can say that if for a couple of years, the US have started to legislate and propose guidelines, as well as creating special accreditation organizations to inspect and advise the offices, the same is not the case in Belgium. The OBA phenomenon arrived much later here and is really at its very beginnings, but it seems however important to anticipate and clearly regulate this practice in our country.

PEGylated cholecystokinin prolongs satiation in rats: dose dependency and receptor involvement.

BACKGROUND AND PURPOSE: Acute intraperitoneal (i.p.) administration of cholecystokinin (CCK) is known to induce a significant, but short-lasting, reduction in food intake, followed by recovery within hours. Therefore, we had covalently coupled CCK to a 10 kDa polyethylene glycol and showed that this conjugate, PEG-CCK(9), produced a significantly longer anorectic effect than unmodified CCK(9). The present study assessed the dose-dependency of this response and the effect of two selective CCK(1) receptor antagonists, with different abilities to cross the blood-brain barrier (BBB), on PEG-CCK(9)-induced anorexia. EXPERIMENTAL APPROACH: Food intake was measured, for up to 23 h, after i.p. administration of different doses (2, 4, 8, 16 and 32 microg kg(-1)) of CCK(9) or PEG-CCK(9) in male Wistar rats. Devazepide (100 microg kg(-1)), which penetrates the BBB or 2-NAP (3 mg kg(-1)), which does not cross the BBB, were coadministered i.p. with PEG-CCK(9) (6 microg kg(-1)) and food intake was monitored. KEY RESULTS: In PEG-CCK(9)-treated rats, a clear dose-dependency was seen for both the duration and initial intensity of the anorexia whereas, for CCK(9), only the initial intensity was dose-dependent. Intraperitoneal administration of devazepide or 2-NAP, injected immediately prior to PEG-CCK(9), completely abolished the anorectic effect of PEG-CCK(9). CONCLUSIONS AND IMPLICATIONS: The duration of the anorexia for PEG-CCK(9) was dose-dependent, suggesting that PEGylation of CCK(9) increases its circulation time. Both devazepide and 2-NAP completely abolished the anorectic effect of i.p. PEG-CCK(9) indicating that its anorectic effect was solely due to stimulation of peripheral CCK(1) receptors.

Effect of vaccination on transmission of HPAI H5N1: the effect of a single vaccination dose on transmission of highly pathogenic avian influenza H5N1 in Peking ducks.

The highly pathogenic H5N1 avian influenza virus is widespread among domestic ducks throughout Southeast Asia. Many aspects of the poultry industry and social habits hinder the containment and eradication of AI. Vaccination is often put forward as a tool for the control of AI. However, vaccination will only lead to eradication when it reduces the virus spread to such an extent that herd immunity is obtained. To study the effect of a single vaccination dose on the transmission of H5N1 in domestic ducks we performed experiments in which infected and uninfected ducks were housed together and the infection chain was monitored by means of virus isolation and serology. Specifically, Peking ducks were vaccinated with A/Chicken/Mexico/232/94/ CPA H5N2 and challenged with A/Chicken/GxLA/1204/04 H5N1 one week after vaccination. In both the control and vaccinated groups all inoculated and contact animals were quickly infected. However, the disease signs and mortality differed between the control and treatment groups. This finding may have important implications for the control of H5N1 by means of vaccination.

The relationship between 8-methoxypsoralen skin and blood levels.

A method is described to determine the 8-methoxypsoralen (8-MOP) concentration in vivo in the skin by means of high-performance liquid chromatography (HPLC). Skin and blood samples were taken from 80 rats at specific intervals after oral administration of [3H]8-MOP. The pharmacokinetic results obtained for the skin levels were compared to the blood levels. In addition, liquid scintillation counting (LSC) was done on all the samples to compare the concentrations of 8-MOP plus metabolites to the concentrations of 8-MOP alone. There was a good correlation between the 8-MOP skin and blood levels. The values obtained with LSC were higher in function of time than the corresponding values obtained by HPLC, which indicates the presence of metabolites in both the skin and the blood. No statistically significant difference in the time of peaking was noted for the skin and blood levels. The blood levels seem to be a good parameter for the 8-MOP skin concentration.

Evolution at the mouse t complex: why is the t haplotype preserved as an integral unit?

Segregation distorters are selfish genetic elements that bias Mendelian segregation in their favor. All well-known segregation distortion systems consist of one or more "distorter" loci that act upon a "responder" locus. At the t complex of the house mouse, segregation distortion is brought about by the harmful effect of t alleles at a number of distorter loci on the wild-type variant of the responder locus. The responder and distorter alleles are closely linked by a number of inversions, thus forming a coherent t haplotype. It has been conjectured that the close integration of the various components into a "complete" t haplotype has been crucial for the evolutionary success of these selfish genetic elements. By means of a population genetical metapopulation model, we show that this intuition may be unfounded. In fact, under most circumstances an "insensitive" t haplotype retaining only the responder did invade and reach a high frequency, despite the fact that this haplotype has a strong segregation disadvantage. For certain population structures, the complete t haplotype was even competitively excluded by partial t haplotypes with lower segregation ratios. Moreover, t haplotypes carrying one or more recessive lethals only prevailed over their nonlethal counterparts if the product of local population size and migration rate (Nm) was not much smaller or larger than one. These phenomena occurred for rather realistic fitness, segregation, and recombination values. It is therefore quite puzzling that partial t haplotypes are absent from natural house mousepopulations, and that t haplotypes carrying recessive lethals prevail over nonlethal t haplotypes.

Devazepide reverses the anorexic effect of simmondsin in the rat.

Simmondsin, a glycoside extracted from jojoba meal (Simmondsia chinensis), causes a reduction in food intake after oral administration. To investigate the mechanism by which simmondsin reduces food intake, fasted and free-feeding rats were given simmondsin-supplemented food and simultaneously injected with devazepide, a specific antagonist of peripheral-type cholecystokinin receptors (CCKA receptors). In free-feeding rats, supplementation of food with 0.5% simmondsin caused a reduction in food intake of +/- 40% in the period of 4 h following food presentation. Intraperitoneal injection of 100 micrograms devazepide/kg body weight prevented this effect. In rats fasted for 20 h, the food intake in the 30 min after presentation of food supplemented with 0.15% or 0.50% simmondsin was reduced in a dose-related manner; this was also inhibited by simultaneous application of devazepide. It is suggested that peripheral CCKA receptors are involved in the effect of simmondsin on food intake. However, a direct effect of simmondsin on CCKA receptors has been excluded, since simmondsin was unable to cause contraction of the guinea-pig gallbladder in vitro.

Prospective analysis of aneurysm treatment in a series of 103 consecutive patients when endovascular embolization is considered the first option.

OBJECT: The aim of this study was to evaluate prospectively the results of treating cerebral aneurysms with coil embolization (CE) or with surgical clipping when CE was considered the first option. METHODS: Whenever an aneurysm was to be treated, CE was first considered by our neurovascular team. Surgical clipping was reserved for cases excluded from CE or cases in which CE failed. The study consisted of 103 consecutive patients with 132 aneurysms, of which 127 were treated. Coil embolization was performed using Guglielmi detachable coils, and surgery was performed using Zeppelin clips. Three groups were defined: Group A consisted of 64 aneurysms that were treated by CE (neck/sac ratio < 1:3); Group B, 63 aneurysms that were surgically clipped; and Group C, 12 aneurysms that failed to be satisfactorily (> or = 95%) embolized and were subsequently clipped. The percentages of residual aneurysm were 31.2% in Group A, 1.6% in Group B, and 0% in Group C. The percentages of patients with poor Glasgow Outcome Scale (GOS) scores (GOS Scores 1-3) were 13.3% in Group A, 6.1% in Group B, and 8.3% in Group C. The percentages of poor outcome (GOS Scores 1-3) in patients with good clinical status before treatment were 10.7% in Group A, 0% in Group B, and 8.3% in Group C. CONCLUSIONS: Even with preselection, CE remains associated with a significant number of treatment failures and poor outcomes, even in patients with good preoperative clinical status. Surgical clipping can offer better results than CE, even for more complex aneurysms of the anterior circulation, especially for those involving the middle cerebral artery cases. However, because CE can be effective and causes less stress and invasiveness for the patient, it should be considered first in aneurysms strictly selected by a neurovascular team.

Biotransformation and excretion of nitromethaqualone in rats and humans.

The metabolic disposition of 14C-labeled nitromethaqualone was investigated in rats. Unlabeled nitromethaqualone was used for studies on humans. nitromethaqualone was eliminated from the body after most of it had undergone biotransformation. Both humans and rats reduced the nitro group of nitromethaqualone to the corresponding amino derivative, which was partially transformed to the corresponding acetylated form. Cleavage of the quinazolinone nucleus resulting in 2-methoxyl-4-nitroaniline was also observed in humans. In rats additional major metabolites arose from the oxidation of the 2-methyl group into hydroxymethyl resulting in 2-hydroxymethyl-3-(2'-methoxy-4-nitrophenyl)-4(3H)-quinazolinone and concomitant in vivo reduction of the latter resulting in 2-hydroxymethyl-3-(2'-methoxy-4'-aminophenyl)-4(3H)-quinazolinone. Both metabolites were also excreted as glucuronides. In rats fecal excretion accounted for 55-60% of the administered dose, while 24-27% was excreted in the urine. Protracted excretion in both humans and rats indicated an extensive enterohepatic circulation.

Gas chromatographic analysis of simmondsins and simmondsin ferulates in jojoba meal.

A capillary gas chromatographic method was developed for the simultaneous determination of simmondsins and simmondsin ferulates in jojoba meal, in detoxified jojoba meal, in jojoba meal extracts, and in animal food mixtures.

Identification of 4,5-didemethyl-4-O-alpha-D-glucopyranosylsimmondsin and pinitol alpha-D-galactosides in jojoba seed meal (Simmondsia chinensis).

The isolation and identification of two pinitol alpha-D-galactosides from jojoba meal are described. The products were isolated by a combination of preparative HPLC on silica gel and TLC on amino silica gel and were identified by MS, NMR spectroscopy, and chemical derivatization as 5-O-(alpha-D-galactopyranosyl)-3-O-methyl-D-chiro-inositol or 5-alpha-D-galactopyranosyl-D-pinitol and 2-O-(alpha-D-galactopyranosyl)-3-O-methyl-D-chiro-inositol or 2-alpha-D-galactopyranosyl-D-pinitol. The same preparative HPLC method on silica gel allowed a new simmondsin derivative to be isolated and identified as 4,5-didemethyl-4-O-alpha-D-glucopyranosylsimmondsin mainly by NMR spectroscopy and high-resolution mass spectrometry.

Mechanism of simmondsin decomposition during sodium hydroxide treatment.

Jojoba seed meal shows appetite-suppressing activity due to the presence of simmondsin. This pharmacological activity disappears with treatment of the meal with sodium hydroxide. To elucidate this mechanism of inactivation, the reaction of simmondsin in 1 N NaOH at 20 degrees C was monitored as a function of time. The end products of the reaction as well as intermediates were isolated and identified. The half-life of simmondsin was approximately 60 min with d-glucose and 2-hydroxy-3-methoxyphenylacetonitrile as reaction end products. The reaction mechanism could be elucidated by the isolation of isosimmondsin and a simmondsin lactone derivative. Those compounds were isolated and purified by a combination of column chromatography and HPLC and identified mainly by HRMS and NMR spectroscopy.

Teratological studies in defatted jojoba meal-supplemented rats.

To look for possible developmental effects in the offspring of jojoba meal-treated Wistar rats, and to distinguish between the effects of reduced food intake and the specific developmental effects of jojoba meal itself, mated female rats were divided into three groups of 20 rats. They received during gestation: (a) normal rodent food (control group); (b) normal rodent food supplemented with 3% defatted jojoba meal (jojoba group); or (c) normal rodent food pair-fed with the jojoba group (pair-fed group). The jojoba meal group showed approximately 30% inhibition of food intake. Ten rats from each group were killed on gestation day 21. Compared to the control group, foetal body weight was reduced in both the jojoba and pair-fed groups, with a greater reduction in the jojoba group. Skeletal ossification was retarded to the same extent in both the jojoba and pair-fed groups. The other 10 rats from each group were left to produce litters. Compared with controls, the body weight of the pups was lower in both the jojoba and pair-fed groups; the reduction was slightly greater in the jojoba group, but this difference disappeared after 1 week. The offspring showed no other abnormalities and reproduced normally. We conclude that, at the dose used, the retardation in foetal skeletal ossification, induced by jojoba meal supplementation during gestation, is due to food intake inhibition. Moreover, the lower birth weight of the young of jojoba-treated dams compared with the pair-fed group is merely due to a lower body weight gain during gestation.