[Analysis of efficacy and safety of a new endoscopic anastomosis clip in the treatment of defects after endoscopic full-thickness resection].

Objective: To investigate the efficacy and safety of a new endoscopic anastomosis clip in the treatment of defects after endoscopic full-thickness resection (EFTR). Methods: Retrospective cohort study. Fourteen patients [4 males and 10 females, aged (55.9±8.2) years (45-69 years)] with gastric submucosal tumors underwent EFTR at the First Affiliated Hospital of Soochow University were included from December 2018 to January 2021. Patients were divided into new anastomotic clamp group (n=6) and nylon ring combined with metal clips group (n=8). Preoperative endoscopic ultrasound examinations were required to all patients to evaluate the wound condition. The size of the defect, operation time required for wound closure, success rate of closure, postoperative gastric tube placement time, postoperative hospital stay, incidence of complications, preoperative and postoperative serological indexes were compared between the two groups. All patients were followed up after the operation, among which the general endoscopy was reviewed in the first month after the operation, and the telephone and questionnaire follow-up were used in the second, third, sixth month and one year after the operation to evaluate the therapeutic effect of the new endoscopic anastomosis clip and nylon rope combined with metal clip after the EFTR operation. Results: Both groups successfully completed EFTR and were successfully closed. There was no significant difference between the age, tumor diameter and defect diameter of the two groups (all P>0.05). Compared with the nylon ring combined with metal clip group, the operation time of the new anastomotic clip group was shortened [(5.0±1.8) minutes vs (35.6±10.2) minutes, P<0.001]. The operation time was shortened [(62.2±12.5) minutes vs (92.5±0.2) minutes, P=0.007]. Postoperative fasting time decreased [(2.8±0.8) days vs (4.9±1.1) days, P=0.002]. The hospital stay after operation was also shortened [(5.2±0.8) days vs (6.9±1.5) days, P=0.023]. The total intraoperative bleeding volume decreased [(20.00±5.48) ml vs (35.63±14.75) ml, P=0.031]. The patients in both groups received endoscopic examination 1 month after operation, and there was no delayed perforation and bleeding after operation. There was no obvious symptoms of discomfort. Conclusion: The new anastomotic clamp is suitable for the treatment of full-thickness gastric wall defects after EFTR, and shows advantages of shorter operation, less bleeding, and fewer postoperative complications.

Association of Condylar Bone Quality with TMJ Osteoarthritis.

The etiology and treatment of temporomandibular joint (TMJ) osteoarthritis (TMJOA) remain complex and unclear. Based on clinical observations, we hypothesized that low condylar bone quality is significantly correlated with TMJOA and explored this association in a cross-sectional study with human patients. A total of 254 postmenopausal female participants were included in this study. Radiographic findings from cone beam computed tomography (CBCT) and clinical symptoms were used to classify each TMJ data sample as healthy control ( n = 124) or TMJOA ( n = 130). Condylar bone mineral density (BMD) (computed tomography Hounsfield unit [CT HU]) and bone volume fraction (BV/TV) were measured and modeled as predictors of healthy control versus TMJOA status in multilevel logistic regression analyses. Both CT HU (adjusted odds ratio [AOR] = 0.9989, interquartile odds ratio [IOR] = 0.4206) and BV/TV (AOR= 0.8096, IOR = 0.1769) were negatively associated with TMJOA ( P = 0.049, 0.011, respectively). To assess the diagnostic performance of CT HU and BV/TV for identification of TMJOA, receiver operating characteristic (ROC) curves were plotted. The estimated areas under the curve (AUC) were 0.6622 for BV/TV alone, 0.6074 for CT HU alone, and 0.7136 for CT HU and BV/TV together. The model incorporating CT HU and BV/TV together had a significantly higher AUC than the models using BV/TV alone ( P = 0.038) or HU alone ( P = 0.021). In conclusion, we found that low condylar bone quality was significantly correlated with TMJOA development and that condylar CT HU and BV/TV can be used together as a potential diagnostic tool for TMJOA. Careful clinical evaluation of the condyle coupled with appropriate radiographic interpretation would thus be critical for the early detection of TMJOA.

Molecular cloning, sequence analysis, prokaryotic expression, and function prediction of foot-specific peroxidase in Hydra magnipapillata Chinese strain.

The cDNA sequence of foot-specific peroxidase PPOD1 from the Chinese strain of Hydra magnipapillata was cloned by reverse transcription-polymerase chain reaction. The cDNA sequence contained a coding region with an 873-bp open reading frame, a 31-bp 5'-untranslated region, and a 36-bp 3'-untranslated region. The structure prediction results showed that PPOD1 contains 10.34% of α-helix, 38.62% of extended strand, 12.41% of ß-turn, and 38.62% of random coil. The structural core was α-helix at the N terminus. The GenBank protein blast server showed that PPOD1 contains 2 fascin-like domains. In addition, high-level PPOD1 activity was only present in the ectodermal epithelial cells located on the edge of the adhesive face of the basal disc, and that these cells extended lamellipodia and filopodia when the basal disc was tightly attached to a glass slide. The fascin-like domains of Hydra PPOD1 might contribute to the bundling of the actin filament of these cells, and hence, the formation of filopodia. In conclusion, these cells might play an important role in strengthening the adsorbability of the basal disc to substrates.

Scoring systems for 6-month mortality in critically ill cirrhotic patients: a prospective analysis of chronic liver failure - sequential organ failure assessment score (CLIF-SOFA).

BACKGROUND: Cirrhotic patients admitted to intensive care units (ICUs) have high mortality rates. The Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) score, a modified Sequential Organ Failure Assessment (SOFA) score, is a newly developed scoring system exclusively for patients with end-stage liver disease. AIM: To externally validate the efficacy of the CLIF-SOFA score and evaluate other scoring systems for 6-month mortality in critically ill cirrhotic patients. METHODS: This study prospectively recorded and analysed the data for 30 demographical parameters and some clinical characteristic variables on day 1 of 250 cirrhotic patients admitted to a 10-bed specialised hepatogastroenterology ICU in a 2000-bed tertiary care referral hospital during the period from September 2010 to August 2013. RESULTS: The overall in-hospital and 6-month mortality rate were 58.8% (147/250) and 78.0% (195/250), respectively. Liver diseases were mostly attributed to hepatitis B virus infection (32%). Multiple Cox logistic regression hazard analysis revealed that Glasgow coma scale, both the CLIF-SOFA and Acute Physiology and Chronic Health Evaluation III (ACPACHE III) scores determined on the first day of ICU admission were independent predictors of 6-month mortality. Analysis of the area under the receiver operating characteristic curve revealed that the CLIF-SOFA score had the best discriminatory power (0.900 ± 0.020). Moreover, the cumulative 6-month survival rates differed significantly for patients with a CLIF-SOFA score ≤11 and those with a CLIF-SOFA score >11 on the ICU admission day. CONCLUSION: Both CLIF-SOFA and APACHE III scores are excellent prognosis evaluation tools for critically ill cirrhotic patients.

Tegaserod, a small compound mimetic of polysialic acid, promotes functional recovery after spinal cord injury in mice.

In a previous study, we have shown that the small organic compound tegaserod, a drug approved for clinical application in an unrelated condition, is a mimic of the regeneration-beneficial glycan polysialic acid (PSA) in a mouse model of femoral nerve injury. Several independent observations have shown positive effects of PSA and its mimetic peptides in different paradigms of injury of the central and peripheral mammalian nervous systems. Since small organic compounds generally have advantages over metabolically rapidly degraded glycans and the proteolytically vulnerable mimetic peptides, a screen for a small PSA mimetic compound was successfully carried out, and the identified molecule proved to be beneficial in neurite outgrowth in vitro, independent of its originally described function as a 5-HT4 receptor agonist. In the present study, a mouse spinal cord compression device was used to elicit severe compression injury. We show that tegaserod promotes hindlimb motor function at 6 weeks after spinal cord injury compared to the control group receiving vehicle only. Immunohistology of the spinal cord rostral and caudal to the lesion site showed increased numbers of neurons, and a reduced area and intensity of glial fibrillary acidic protein immunoreactivity. Quantification of regrowth/sprouting of axons immunoreactive for tyrosine hydroxylase and serotonin showed increased axonal density rostral and caudal to the injury site in the ventral horns of mice treated with tegaserod. The combined observations suggest that tegaserod has the potential for treatment of spinal cord injuries in higher vertebrates.

Comparisons between different polychemotherapy regimens for early breast cancer: meta-analyses of long-term outcome among 100,000 women in 123 randomised trials.

BACKGROUND: Moderate differences in efficacy between adjuvant chemotherapy regimens for breast cancer are plausible, and could affect treatment choices. We sought any such differences. METHODS: We undertook individual-patient-data meta-analyses of the randomised trials comparing: any taxane-plus-anthracycline-based regimen versus the same, or more, non-taxane chemotherapy (n=44,000); one anthracycline-based regimen versus another (n=7000) or versus cyclophosphamide, methotrexate, and fluorouracil (CMF; n=18,000); and polychemotherapy versus no chemotherapy (n=32,000). The scheduled dosages of these three drugs and of the anthracyclines doxorubicin (A) and epirubicin (E) were used to define standard CMF, standard 4AC, and CAF and CEF. Log-rank breast cancer mortality rate ratios (RRs) are reported. FINDINGS: In trials adding four separate cycles of a taxane to a fixed anthracycline-based control regimen, extending treatment duration, breast cancer mortality was reduced (RR 0·86, SE 0·04, two-sided significance [2p]=0·0005). In trials with four such extra cycles of a taxane counterbalanced in controls by extra cycles of other cytotoxic drugs, roughly doubling non-taxane dosage, there was no significant difference (RR 0·94, SE 0·06, 2p=0·33). Trials with CMF-treated controls showed that standard 4AC and standard CMF were equivalent (RR 0·98, SE 0·05, 2p=0·67), but that anthracycline-based regimens with substantially higher cumulative dosage than standard 4AC (eg, CAF or CEF) were superior to standard CMF (RR 0·78, SE 0·06, 2p=0·0004). Trials versus no chemotherapy also suggested greater mortality reductions with CAF (RR 0·64, SE 0·09, 2p<0·0001) than with standard 4AC (RR 0·78, SE 0·09, 2p=0·01) or standard CMF (RR 0·76, SE 0·05, 2p<0·0001). In all meta-analyses involving taxane-based or anthracycline-based regimens, proportional risk reductions were little affected by age, nodal status, tumour diameter or differentiation (moderate or poor; few were well differentiated), oestrogen receptor status, or tamoxifen use. Hence, largely independently of age (up to at least 70 years) or the tumour characteristics currently available to us for the patients selected to be in these trials, some taxane-plus-anthracycline-based or higher-cumulative-dosage anthracycline-based regimens (not requiring stem cells) reduced breast cancer mortality by, on average, about one-third. 10-year overall mortality differences paralleled breast cancer mortality differences, despite taxane, anthracycline, and other toxicities. INTERPRETATION: 10-year gains from a one-third breast cancer mortality reduction depend on absolute risks without chemotherapy (which, for oestrogen-receptor-positive disease, are the risks remaining with appropriate endocrine therapy). Low absolute risk implies low absolute benefit, but information was lacking about tumour gene expression markers or quantitative immunohistochemistry that might help to predict risk, chemosensitivity, or both. FUNDING: Cancer Research UK; British Heart Foundation; UK Medical Research Council.

Relevance of breast cancer hormone receptors and other factors to the efficacy of adjuvant tamoxifen: patient-level meta-analysis of randomised trials.

BACKGROUND: As trials of 5 years of tamoxifen in early breast cancer mature, the relevance of hormone receptor measurements (and other patient characteristics) to long-term outcome can be assessed increasingly reliably. We report updated meta-analyses of the trials of 5 years of adjuvant tamoxifen. METHODS: We undertook a collaborative meta-analysis of individual patient data from 20 trials (n=21,457) in early breast cancer of about 5 years of tamoxifen versus no adjuvant tamoxifen, with about 80% compliance. Recurrence and death rate ratios (RRs) were from log-rank analyses by allocated treatment. FINDINGS: In oestrogen receptor (ER)-positive disease (n=10,645), allocation to about 5 years of tamoxifen substantially reduced recurrence rates throughout the first 10 years (RR 0·53 [SE 0·03] during years 0-4 and RR 0·68 [0·06] during years 5-9 [both 2p<0·00001]; but RR 0·97 [0·10] during years 10-14, suggesting no further gain or loss after year 10). Even in marginally ER-positive disease (10-19 fmol/mg cytosol protein) the recurrence reduction was substantial (RR 0·67 [0·08]). In ER-positive disease, the RR was approximately independent of progesterone receptor status (or level), age, nodal status, or use of chemotherapy. Breast cancer mortality was reduced by about a third throughout the first 15 years (RR 0·71 [0·05] during years 0-4, 0·66 [0·05] during years 5-9, and 0·68 [0·08] during years 10-14; p<0·0001 for extra mortality reduction during each separate time period). Overall non-breast-cancer mortality was little affected, despite small absolute increases in thromboembolic and uterine cancer mortality (both only in women older than 55 years), so all-cause mortality was substantially reduced. In ER-negative disease, tamoxifen had little or no effect on breast cancer recurrence or mortality. INTERPRETATION: 5 years of adjuvant tamoxifen safely reduces 15-year risks of breast cancer recurrence and death. ER status was the only recorded factor importantly predictive of the proportional reductions. Hence, the absolute risk reductions produced by tamoxifen depend on the absolute breast cancer risks (after any chemotherapy) without tamoxifen. FUNDING: Cancer Research UK, British Heart Foundation, and Medical Research Council.

Minimally invasive approaches to treating chemosis of the eyes from unusual dural arteriovenous fistulae.

Chemosis of the eyes is usually attributed to carotid cavernous sinus dural arteriovenous fistulae. Herein, we reviewed unusual cases in which chemosis of the eyes originated from dural ateriovenous fistulae (dAVFs) that were distinctly different from carotid cavernous sinus fistulae. Cases in which ocular symptoms were related to increased intracranial pressure either due to sinus thrombosis or cortical venous drainage without involvement of superior or inferior ophthalmic veins were excluded in this review. Several different types of dural AVFs were associated with chemosis, and these included dAVFs harboring a feeding artery from branches of the external carotid artery directly draining to the superior ophthalmic vein or cavernous sinus via the superior petrous sinus, posterior fossa dAVFs draining via the inferior petrous sinus and cavernous sinus to the ophthalmic vein, a fistula between the ophthalmic artery or branches of the internal carotid artery and inferior ophthalmic vein, or tentorial fistula with a drainage vein to the cavernous sinus via the vein of Galen. This study reviews the symptomatology, treatment options, and cerebrovascular abnormalities observed for these unusual dAVF's with chemosis.

The impact of arteriovenous malformation radiosurgery on the brain: From morphology and perfusion to neurocognition.

The therapeutic aims of brain arteriovenous malformation (AVM) radiosurgery are multiple. Protecting patients from rebleeding is the prime goal. Among the others, hemodynamics, perfusion and neurocognition recovery are interesting and important. Anatomically AVM contains an abnormal cluster of vascular networks (nidus) between arteries and veins. Hemodynamically the nidus contains a low resistance and causes high-flow transnidal shunts between both sides of the nidus. The shunts cause hypotension in the neighboring arteries and diversion of blood from the adjacent brain tissues. The diversion disturbs brain hemodynamics. Radiosurgery, by eliminating the nidus, reconstitutes normal brain hemodynamics. From the early stage after radiosurgery, the abnormal transnidal flows gradually decrease, and the adjacent hemodynamics recovers toward normal. For nonhemorrhagic AVM, improvement of seizure control and stable or improved neurological status are observed clinically. The radiosurgical effects are also reflected in the recovery of metabolism in the adjacent brain and neurocognitive function paralleling the hemodynamic normalization. Morphological cure of AVM and the associated recovery of brain hemodynamics, metabolism and neurocognitive function form the therapeutic rationale of AVM radiosurgery.

Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial.

BACKGROUND: Despite improvements in the emergency treatment of myocardial infarction (MI), early mortality and morbidity remain high. The antiplatelet agent clopidogrel adds to the benefit of aspirin in acute coronary syndromes without ST-segment elevation, but its effects in patients with ST-elevation MI were unclear. METHODS: 45,852 patients admitted to 1250 hospitals within 24 h of suspected acute MI onset were randomly allocated clopidogrel 75 mg daily (n=22,961) or matching placebo (n=22,891) in addition to aspirin 162 mg daily. 93% had ST-segment elevation or bundle branch block, and 7% had ST-segment depression. Treatment was to continue until discharge or up to 4 weeks in hospital (mean 15 days in survivors) and 93% of patients completed it. The two prespecified co-primary outcomes were: (1) the composite of death, reinfarction, or stroke; and (2) death from any cause during the scheduled treatment period. Comparisons were by intention to treat, and used the log-rank method. This trial is registered with ClinicalTrials.gov, number NCT00222573. FINDINGS: Allocation to clopidogrel produced a highly significant 9% (95% CI 3-14) proportional reduction in death, reinfarction, or stroke (2121 [9.2%] clopidogrel vs 2310 [10.1%] placebo; p=0.002), corresponding to nine (SE 3) fewer events per 1000 patients treated for about 2 weeks. There was also a significant 7% (1-13) proportional reduction in any death (1726 [7.5%] vs 1845 [8.1%]; p=0.03). These effects on death, reinfarction, and stroke seemed consistent across a wide range of patients and independent of other treatments being used. Considering all fatal, transfused, or cerebral bleeds together, no significant excess risk was noted with clopidogrel, either overall (134 [0.58%] vs 125 [0.55%]; p=0.59), or in patients aged older than 70 years or in those given fibrinolytic therapy. INTERPRETATION: In a wide range of patients with acute MI, adding clopidogrel 75 mg daily to aspirin and other standard treatments (such as fibrinolytic therapy) safely reduces mortality and major vascular events in hospital, and should be considered routinely.

Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial.

BACKGROUND: Despite previous randomised trials of early beta-blocker therapy in the emergency treatment of myocardial infarction (MI), uncertainty has persisted about the value of adding it to current standard interventions (eg, aspirin and fibrinolytic therapy), and the balance of potential benefits and hazards is still unclear in high-risk patients. METHODS: 45,852 patients admitted to 1250 hospitals within 24 h of suspected acute MI onset were randomly allocated metoprolol (up to 15 mg intravenous then 200 mg oral daily; n=22,929) or matching placebo (n=22,923). 93% had ST-segment elevation or bundle branch block, and 7% had ST-segment depression. Treatment was to continue until discharge or up to 4 weeks in hospital (mean 15 days in survivors) and 89% completed it. The two prespecified co-primary outcomes were: (1) composite of death, reinfarction, or cardiac arrest; and (2) death from any cause during the scheduled treatment period. Comparisons were by intention to treat, and used the log-rank method. This study is registered with ClinicalTrials.gov, number NCT 00222573. FINDINGS: Neither of the co-primary outcomes was significantly reduced by allocation to metoprolol. For death, reinfarction, or cardiac arrest, 2166 (9.4%) patients allocated metoprolol had at least one such event compared with 2261 (9.9%) allocated placebo (odds ratio [OR] 0.96, 95% CI 0.90-1.01; p=0.1). For death alone, there were 1774 (7.7%) deaths in the metoprolol group versus 1797 (7.8%) in the placebo group (OR 0.99, 0.92-1.05; p=0.69). Allocation to metoprolol was associated with five fewer people having reinfarction (464 [2.0%] metoprolol vs 568 [2.5%] placebo; OR 0.82, 0.72-0.92; p=0.001) and five fewer having ventricular fibrillation (581 [2.5%] vs 698 [3.0%]; OR 0.83, 0.75-0.93; p=0.001) per 1000 treated. Overall, these reductions were counterbalanced by 11 more per 1000 developing cardiogenic shock (1141 [5.0%] vs 885 [3.9%]; OR 1.30, 1.19-1.41; p<0.00001). This excess of cardiogenic shock was mainly during days 0-1 after admission, whereas the reductions in reinfarction and ventricular fibrillation emerged more gradually. Consequently, the overall effect on death, reinfarction, arrest, or shock was significantly adverse during days 0-1 and significantly beneficial thereafter. There was substantial net hazard in haemodynamically unstable patients, and moderate net benefit in those who were relatively stable (particularly after days 0-1). INTERPRETATION: The use of early beta-blocker therapy in acute MI reduces the risks of reinfarction and ventricular fibrillation, but increases the risk of cardiogenic shock, especially during the first day or so after admission. Consequently, it might generally be prudent to consider starting beta-blocker therapy in hospital only when the haemodynamic condition after MI has stabilised.

Indications for early aspirin use in acute ischemic stroke : A combined analysis of 40 000 randomized patients from the chinese acute stroke trial and the international stroke trial. On behalf of the CAST and IST collaborative groups.

BACKGROUND AND PURPOSE: Long-term daily aspirin is of benefit in the years after ischemic stroke, and 2 large randomized trials (the Chinese Acute Stroke Trial [CAST] and the International Stroke Trial [IST]), with 20 000 patients in each, have shown that starting daily aspirin promptly in patients with suspected acute ischemic stroke also reduces the immediate risk of further stroke or death in hospital and the overall risk of death or dependency. However, some uncertainty remains about the effects of early aspirin in particular categories of patient with acute stroke. METHODS: To assess the balance of benefits and risks of aspirin in particular categories of patient with acute stroke (eg, the elderly, those without a CT scan, or those with atrial fibrillation), a prospectively planned meta-analysis is presented of the data from 40 000 individual patients from both trials on events that occurred in the hospital during the scheduled treatment period (4 weeks in CAST, 2 weeks in IST), with 10 characteristics used to define 28 subgroups. This represents 99% of the worldwide evidence from randomized trials. RESULTS: There was a highly significant reduction of 7 per 1000 (SD 1) in recurrent ischemic stroke (320 [1.6%] aspirin versus 457 [2. 3%] control, 2P<0.000001) and a less clearly significant reduction of 4 (SD 2) per 1000 in death without further stroke (5.0% versus 5. 4%, 2P=0.05). Against these benefits, there was an increase of 2 (SD 1) per 1000 in hemorrhagic stroke or hemorrhagic transformation of the original infarct (1.0% versus 0.8%, 2P=0.07) and no apparent effect on further stroke of unknown cause (0.9% versus 0.9%). In total, therefore, there was a net decrease of 9 (SD 3) per 1000 in the overall risk of further stroke or death in hospital (8.2% versus 9.1%, 2P=0.001). For the reduction of one third in recurrent ischemic stroke, subgroup-specific analyses found no significant heterogeneity of the proportional benefit of aspirin (chi(2)(18)=20. 9, NS), even though the overall treatment effect (chi(2)(1)=24.8, 2P<0.000001) was sufficiently large for such subgroup analyses to be statistically informative. The absolute risk among control patients was similar in all 28 subgroups, so the absolute reduction of approximately 7 per 1000 in recurrent ischemic stroke does not differ substantially with respect to age, sex, level of consciousness, atrial fibrillation, CT findings, blood pressure, stroke subtype, or concomitant heparin use. There was no good evidence that the apparent decrease of approximately 4 per 1000 in death without further stroke was reversed in any subgroup or that in any subgroup the increase in hemorrhagic stroke was much larger than the overall average of approximately 2 per 1000. Finally, there was no significant heterogeneity between the reductions in the composite outcome of any further stroke or death (chi(2)(18)=16.5, NS). Among the 9000 patients (22%) randomized without a prior CT scan, aspirin appeared to be of net benefit with no unusual excess of hemorrhagic stroke; moreover, even among the 800 (2%) who had inadvertently been randomized after a hemorrhagic stroke, there was no evidence of net hazard (further stroke or death, 63 aspirin versus 67 control). CONCLUSIONS: Early aspirin is of benefit for a wide range of patients, and its prompt use should be routinely considered for all patients with suspected acute ischemic stroke, mainly to reduce the risk of early recurrence.

Pilocytic astrocytoma of the posterior fossa: a follow-up study in 15 patients.

BACKGROUND: The extent of resection in pilocytic astrocytoma of the posterior fossa remains undefined, as the problem of hydrocephalus has not yet been solved. We retrospectively reviewed the data from 15 patients with a pilocytic astrocytoma of the posterior fossa to evaluate the impact of surgical technique, in terms of resection extent, by serial magnetic resonance imaging (MRI) examinations. In addition, the issue of hydrocephalus was considered and related to the different treatment modalities. METHODS: Macroscopic, gross, total resection of the tumor was performed in all 15 patients. Follow-up was obtained in 14 patients for a period ranging between 11 and 119 months (median, 41.5 months). The ages of patients ranged from two to 13 years (mean, 7 +/- 3 years). All patients underwent serial MRI examinations in the first month, every six months for the first two years and then yearly. RESULTS: Outcome was good in 12 patients who had no neurologic deficit and fair in two patients who were slightly handicapped but had an independent life. There were four patients with an abnormally persistent enhancement on MRI, with a median follow-up of 30 months. One of these patients had progressively increasing size of the enhancement. Three of them had the same size of enhancement during the follow-up period. The MRI findings showed residual tumors in four patients. One of them had tumor regrowth one year after surgery. There were 11 cases with pilocytic astrocytoma and hydrocephalus. Five patients were treated with tumor removal and external CSF drainage. Six patients underwent tumor removal only, without perioperative cerebrospinal fluid (CSF) drainage. Only one patient had a permanent ventriculoperitoneal shunt. CONCLUSIONS: Our study illustrated that the extent of tumor resection of pilocytic astrocytoma can be defined by postoperative serial MRI examinations. Long-term follow-up with MRI seems mandatory in cases with abnormal enhancement. Hydrocephalus is a common finding in patients with a pilocytic astrocytoma. A permanent ventriculoperitoneal shunt is required only in patients with postoperative hydrocephalus.

Computerized tomography-guided stereotactic aspiration of brain abscesses: experience with 28 cases.

BACKGROUND: Computerized tomography (CT)-guided stereotactic techniques allow accurate identification of brain abscesses and provide promising results for the management of brain abscesses. METHODS: We reviewed the results of stereotactic aspiration of brain abscesses in 28 consecutive patients from 1984 to 1995. In all patients, the diagnosis of brain abscess was made by computerized tomography (CT). All patients underwent stereotactic aspiration of abscesses as the primary surgical therapy. Intravenous antibiotics were administered preoperatively and adjusted according to organism type and sensitivity to antibiotics. In patients with multiple lesions, aspirations were performed on abscesses larger than 2 cm in diameter or on those causing significant mass effects. CT was performed weekly to monitor abscess growth or failure to resolve. Patients were followed on an outpatient basis. This report is a retrospective review of clinical features, diagnostic methods, treatment and postoperative results. RESULTS: A total of 19 patients had good recoveries and six patients had mild neurologic sequelae. One patient had persistent conscious impairment. Intracranial hemorrhage occurred in one patient. Two deaths occurred during hospitalization. One patient with a fungal infection underwent additional surgical excision of the abscess. Most patients had resolution of abscesses after stereotactic treatment within two months. The cure rate was 92% in patients with bacterial brain abscesses treated with stereotactic aspiration and intravenous antibiotics for six weeks. CONCLUSIONS: Stereotactic surgery is a procedure with minimal morbidity and mortality, and can be the treatment of choice for brain abscesses when combined with appropriate antibiotic therapy.

Anterior cervical stabilization with the synthes cervical spine locking plate system.

BACKGROUND: The Synthes cervical spine locking plate (CSLP) was originally designed by Mörscher and colleagues, who refined it to prevent the migration and loosening of a locking screw by using a cross-split screw head that could be locked into the plate. This eliminated the requirement of the posterior cortex purchase and thereby decreased the risk of spinal cord injury. The purpose of this report is to review our experience using the cervical spine locking plate system and to evaluate its ability to stabilize the cervical spine. METHODS: Twenty patients with cervical trauma, cervical spondylosis of failed anterior interbody fusion underwent anterior cervical fusion with the Synthes CSLP system between August, 1993, and April, 1996. All patients were evaluated preoperatively and postoperatively by plain radiography and magnetic resonance imaging (MRI). RESULTS: All 20 patients achieved solid bone fusion and 19 of them had neurologic improvement, by a mean follow-up period of 36 months. No patients suffered from neurologic injury as a result of the locking device. No patient demonstrated radiologic evidence of implant failure. The postoperative MRI examination disclosed minimal implant artifacts and adequate spinal cord decompression. CONCLUSIONS: The Synthes CSLP system for anterior stabilization provides efficacy, safety and ease of use. It also caused less distortion and minimal artifacts on postoperative MRI.

Emerging tobacco hazards in China: 2. Early mortality results from a prospective study.

OBJECTIVE: To monitor the evolving epidemic of mortality from tobacco in China following the large increase in male cigarette use in recent decades. DESIGN: Prospective study of smoking and mortality starting with 224 500 interviewees who should eventually be followed for some decades. SETTING: 45 nationally representative small urban or rural areas distributed across China. SUBJECTS: Male population aged 40 or over in 1991, of whom about 80% were interviewed about smoking, drinking, and medical history. MAIN OUTCOME MEASURE: Cause specific mortality, initially to 1995 but later to continue, with smoker versus non-smoker risk ratios standardised for area, age, and use of alcohol. RESULTS: 74% were smokers (73% current, only 1% former), but few of this generation would have smoked substantial numbers of cigarettes since early adult life. Overall mortality is increased among smokers (risk ratio 1.19; 95% confidence interval 1.13 to 1.25, P<0.0001). Almost all the increased mortality involved neoplastic, respiratory, or vascular disease. The overall risk ratios currently associated with smoking are less extreme in rural areas (1.26, 1.12, or 1.02 respectively for smokers who started before age 20, at 20-24, or at older ages) than in urban areas (1.73, 1.40, or 1.16 respectively). CONCLUSION: This prospective study and the accompanying retrospective study show that by 1990 smoking was already causing about 12% of Chinese male mortality in middle age. This proportion is predicted to rise to about 33% by 2030. Long term continuation of the prospective study (with periodic resurveys) can monitor the evolution of this epidemic.

Protection of visual pathway in gamma knife radiosurgery for craniopharyngiomas.

Craniopharyngiomas present a major challenge to Gamma Knife radiosurgery (GKRS) due to their proximity to the optic apparatus. Based on observations of the evolving tumoral change on MRI and clinical results, an optimization of the treatment strategy and dose selection is possible. From March 1993 to September 1996, 21 patients with craniopharyngiomas were treated by GKRS. Every patient received stereotactic MRI exclusively for targeting and dose planning. The tumor and adjacent structures, including optic nerves, chiasm, and tracts were carefully identified and delineated on sagittal, coronal and axial films. The tumor volume ranged from 0.3 to 28 ml (average 9 ml). We purposefully apply multiple isocenters (average 9.1 shots) to create an isodose curve that covered the tumor optimally while sparing the optic pathway. The marginal dose prescribed was 9.5 to 16 Gy (50%). The maximal dose was 19 to 32 Gy. The maximal dose to the optic apparatus was 3.2 to 12.5 Gy. After GKRS, all patients were followed up clinically every month. MR studies were conducted every six months with the same techniques on the same scanner to investigate evolution of tumor volume and any adverse radiation effect. The follow-up period ranged from 6 to 40 months (mean: 18.4, median: 19). All patients were followed more than 6 months. Nineteen out of 21 cases (90.5%) achieved tumor control; that is, 18 tumor shrinkage (volume reduction: 15-95%) and 1 stabilized tumor growth. Among these 21 patients, 7 had improved visual acuity or visual field after GKRS, and the rest remained stable. Two patients developed mild T2 change on MRI without any endocrinological disturbance or visual impairment. Protection of the visual pathway can be secured by a sophisticated delineation on 3-dimensional stereotactic images with multiple-shot dose planning. Craniopharyngiomas with tumor volume up to 25 ml were treated safely and effectively, because the dose to the optic apparatus was kept as low as possiby this strategy. Further follow-up is needed to determine the highest tolerable dose to surrounding critical structures and the long-term outcome of tumor control.

Effects of gamma knife radiosurgery for brain tumors: clinical evaluation.

BACKGROUND: Gamma knife radiosurgery is a safe and effective alternative to microsurgery in the management of selected intracranial lesions. In our initial three-year experience with gamma knife radiosurgery, 431 patients were treated using this method. This report presents the treatment results for three different types of brain tumors: benign meningiomas, malignant metastases and gliomas. METHODS: A retrospective study was performed to analyze a consecutive series of 71 meningiomas, 31 metastatic tumors and 21 gliomas treated by gamma knife radiosurgery between March 1993 and May 1996. The treatment results were investigated using regular magnetic resonance examinations and tumor volume measurement at six-month intervals to observe sequential changes of the tumors. Patients with meningiomas were further divided into three groups according to the peripheral radiation doses: high-dose (20-17 Gy, n = 18), medium-dose (16-15 Gy, n = 33) and low-dose (14-12 Gy, n = 20). The Generalized Estimation Equation was applied to compare treatment results in these three groups with different doses and tumor volumes. RESULTS: Volume measurements of the 71 meningiomas showed that 76% decreased in size, 16% stabilized and 8% increased in size. The volumes increased most frequently in the early stage (6-12 months) after treatment and subsequently regressed after the twelfth month. The tumor control rate for meningiomas in our three-year follow-up was over 90%. For meningiomas, the statistical analysis showed that both the radiation dose and tumor volume were significantly related to the development of adverse radiation effects (p < 0.05). In metastatic tumors, rapid tumor regression after radiosurgery was found in 87% of the patients. In gliomas, radiosurgery effectively inhibited tumor growth in selected patients with small, circumscribed, less infiltrative tumors. Ependymomas and low-grade astrocytomas had more favorable outcomes than other gliomas. CONCLUSIONS: Gamma knife radiosurgery is effective for controlling tumor growth in benign meningiomas for up to three years after surgery. In selected cases of malignant metastasis and gliomas, most patients appeared to benefit from the treatment with symptomatic improvement and prolonged survival. Treatment strategy and dose selection in radiosurgery should be adjusted to optimize tumor control and avoid adverse radiation effects.

Hemichorea-hemiballism: an explanation for MR signal changes.

PURPOSE: Some cases of hemichorea-hemiballism (HCHB) are associated with a hyperintense putamen on T1-weighted MR images, the cause of which remains unclear. Our purpose was to determine the cause and significance of these MR signal changes. METHODS: We analyzed the clinical and neuroimaging findings in 10 patients with HCHB, focusing on locations of the hyperintense lesions on T1-weighted images, comparing them with those on CT scans, and evaluating their changes after years of follow-up. A biopsy was performed in one patient. RESULTS: Seven patients had hyperglycemia and two had cortical infarcts. HCHB recurred in four patients. A hyperintense putamen preceded the occurrence of HCHB in two patients. T1-weighted MR images revealed hyperintense lesions limited to the ventral striatum in six patients. Hyperintense lesions extended to the level of the midbrain in one patient and persisted for as long as 6 years in another patient. T2-weighted MR images revealed slit-shaped cystic lesions in the lateral part of the putamina 2 to 6 years after the onset of symptoms in two patients. A biopsy specimen from the hyperintense putamen in one patient revealed a fragment of gliotic brain tissue with abundant gemistocytes. Proton MR spectroscopy of the specimen showed an increase in lactic acid, acetate, and lipids, and a decrease in N-acetylaspartate and creatine, suggesting the presence of pronounced energy depletion and neuronal dysfunction. CONCLUSION: Gemistocytes are sufficient to explain the shortening of T1 relaxation time. Our investigation suggests that neurons in the ventral striatum and striatonigral pathway may play a critical role in generating ballism.

MRI-guided stereotatic aspiration for the treatment of deep-seated tentorial empyema: a case report.

Tentorial empyema is a rare intracranial infection. In the past, most authors treated the subdural empyema by craniotomy, craniectomy or burr hole drainage. In the case presented, magnetic resonance imaging (MRI)-guided stereotatic aspiration was used to treat deep-seated extensive tentorial empyema successfully, via a simple burr hole to avoid any brain resection and retraction. This operation method is relative simple and effective for treating deep-seated intracranial empyema, significantly reduces the risk of injury to the lateral temporal lobe cortex or transection of optic radiations. On the other hand, it must be emphasized that contrast-enhanced MRI scan may offer a more sensitive and better diagnostic procedure than contrast enhanced computed tomography (CT) scan.