Early prediction of cardiac allograft vasculopathy and heart transplant failure.

Early risk-prediction is essential to prevent cardiac allograft vasculopathy (CAV) and graft failure in heart transplant patients. We developed multivariate models to identify patients likely to experience CAV, severe CAV, and failure due to CAV, at 1, 5 and 10 years. A cohort of 172 patients was followed prospectively for 6.7 ± 3.9 years. Logistic regression models were developed and cross-validated using bootstrap resampling. Predictive markers of atherothrombosis (myocardial fibrin deposition, and loss of vascular antithrombin and tissue plasminogen activator) and arterial endothelial activation (intercellular adhesion molecule-1 expression) were measured in serial biopsies obtained within 3 months posttransplant. Most markers were univariately associated with outcome. Multivariate models showed that loss of tissue plasminogen activator was the dominant and, in most cases, only predictor of long-term CAV (p < 0.001), severe CAV (p < 0.001), and graft failure due to CAV (p < 0.001). The models discriminated patients having adverse outcomes, had particularly high negative predictive values (graft failure due to CAV: 99%, 99% and 95% at 1, 5 and 10 years) and predicted event incidence and time to event. Early absence of atherothrombotic risk identifies a patient subgroup that rarely develops CAV or graft failure, implying that this low-risk subgroup could possibly be followed with fewer invasive procedures.

Teflon granuloma with midbrain cysts after microvascular decompression of the trigeminal nerve.

Granuloma formation is a known complication after microvascular decompression using Teflon fibers. Such granulomas commonly present with recurrent neuralgia whereas other symptoms are exceedingly rare. We report the first case of a multicystic lesion due to a Teflon granuloma that is also uncommon for the lack of recurrent neuralgia.

Dreams in obsessive-compulsive disorder: an analysis of semantic and emotional content compared to controls.

OBJECTIVE: We sought to investigate the content of the dreams of obsessive-compulsive outpatients in the light of the following postulate: if dreams play a role in the processing of information and mental storage of events of the day, the dream recollections of obsessive-compulsive disorder (OCD) patients should present evidence of diurnal obsessive or ritual themes. METHOD: On seven successive mornings, immediately after awakening in their home environment, 10 nondepressed OCD patients and 11 controls recorded their recollections of the night's dreams on an audiotape. After randomization of dreams, two judges were asked to carry out a blind evaluation of the emotional characteristics perceptible in these dreams and the presence of obsessive or ritual themes. RESULTS: 47 dreams were collected in the OCD group and 55 in the control group. No differences were found between the two groups regarding anxiety, sadness, the theme of failure, or the presence of obsessive or ritual themes. About 60% of OCD patients and 73% of the control group recounted dreams expressing anxiety, sadness, or failure. Most surprisingly, in the control group as well as in the OCD group, about one-third of subjects presented obsessive or ritual themes in their dreams. CONCLUSION: These data suggest that there is no evident link between diurnal mental activity and the morning recollection of nocturnal dreams regarding anxiety, failure, sadness, and obsessive-compulsive themes.

Effects of hyperbaric oxygen therapy on hydroxyapatite orbital implant vascularization in rabbits.

PURPOSE: To deterrmine if hyperbaric oxygen therapy affects the rate of hydroxyapatite orbital implant vascularization in normal rabbit orbits. METHODS: We performed a randomized comparative experimental pilot study involving 6 rabbits. All rabbits were enucleated and implanted with hydroxyapatite orbital spheres. The animals were randomized for enucleation of the right or left eye and for treatment or nontreatment (control) with hyperbaric oxygen. The implants were removed after 3 weeks of treatment and histologically examined for fibrovascular ingrowth, inflammation, and multinucleated giant cells. Each parameter was graded on a numeric scale and analyzed. RESULTS: Hyperbaric oxygen therapy did not increase implant vascularization compared with nontreatment implants. Although treated implants had less central fibrovascular maturity compared with control implants, the difference was not statistically significant (p < 0.055). There was no significant difference in inflammation or the number of multinucleated giant cells between treated and control implants. CONCLUSIONS: In this pilot study, hyperbaric oxygen therapy did not increase hydroxyapatite vascular ingrowth and possibly delayed fibrovascular maturation in normal sockets. Further studies with more subject numbers are needed to confirm these conclusions. The effect of hyperbaric oxygen therapy in vascularly compromised sockets also needs to be determined.

[Predictive factors of suicide? an 8-year-long prospective longitudinal study of 200 psychiatric inpatients]. / Les facteurs prédictifs du suicide: étude prospective sur 8 ans de 200 patients hospitalisés en psychiatrie.

Suicide is the most dramatic complication of psychiatric disorders. Certain risk factors are generally accepted by practitioners. Mental disorders increase (tenfold) suicidal risk. However, this "statistically rare event" renders very difficult the definition of predictive factors. A personal prospective longitudinal study of 200 psychiatric inpatients followed up during an 8-year period found 5% of deaths by suicide. Amongst the various risk factors reputed predictive for suicide, only 2 were found statistically more frequent in the suicidal group: familial antecedents (1st degree relatives) of suicide and hospitalization in psychiatry. Impulsivity was also more frequent but could be imputed to the younger age of the suicide victims. Therefore, it was impossible to find determinants of suicide. This makes difficult preventive measures, excepted that psychiatric patients are at a much greater risk and should be diagnosed and correctly treated. There are also increasing legal aspects of responsibility for psychiatrists and psychiatric institutions in charge of these patients.

Polydiaxonon prevents adhesions in the rabbit model: a pilot report.

PURPOSE: Restrictive strabismus is a common and difficult problem confronted by strabismologists. Several materials have been used to minimize the formation of adhesions after strabismus surgery with varying degrees of success. Polydiaxonon (PDS, Ethicon) is an absorbable, nontoxic, nonporous material. We used it as 25 and 50 microm thick sleeves to study its effectiveness in the prevention of adhesions. METHOD: Eight eyes of four adult New Zealand White rabbits were used. To simulate the adhesions, a raw scleral bed was created under the superior rectus insertion in study animals and the muscle capsule facing the sclera was opened. Four study eyes had PDS sleeves inserted around the superior rectus; the other four served as controls. After 4 months the animals were killed. The surgical sites were inspected for adhesions. Light microscopy was also performed. RESULTS: Virtually no adhesion formation was noted in the study eyes. In the control group, however, dense adhesions were seen. Light microscopy confirmed these results. No significant amount of foreign material was found. There was no toxicity resulting from PDS. CONCLUSIONS: This demonstrated nearly complete prevention of adhesions in the rabbit model. PDS sleeves appear to have potential in surgery for restrictive strabismus.

Management of experimental globe perforation during strabismus surgery.

BACKGROUND: The incidence of potentially vision-threatening globe perforation during strabismus surgery is reportedly between less than 1% and 12% of cases. Optimal treatment of globe perforation is not known; however, traditionally it has been treated with cryotherapy at the time of surgery or observation without treatment. The indirect-ophthalmoscope-directed diode laser may provide a safe and effective alternative treatment. METHODS: We perforated the globes of six adult Dutch rabbits (12 eyes) and treated four eyes with cryotherapy and four with diode laser; the remaining four were not treated. RESULTS: Histologic examination of the untreated eyes revealed a cellular reaction around the polyglactin suture that formed a non-uniform chorioretinal adhesion. The cryotherapy eyes had a tenuous chorioretinal adhesion and retinal pigment epithelium (RPE) cells in the vitreous on several sections. The laser-treated eyes had a firm, wide chorioretinal adhesion, with minimal tissue disruption and no release of RPE cells. No complications occurred. CONCLUSION: We conclude that indirect-ophthalmoscope-directed diode laser retinopexy was safe and efficacious for globe perforation during strabismus surgery on rabbits and could be expected to be useful in humans.

Ethylene oxide neurotoxicity: a cluster of 12 nurses with peripheral and central nervous system toxicity.

Ethylene oxide (EO) is commonly used to sterilize heat-sensitive products used by hospital patients and personnel. Ethylene chlorohydrin (EC), a by-product, is considered highly toxic. We report a cluster of 12 operating-room nurses and technicians who developed symptoms after a 5-month exposure to high levels of EO and EC in disposable surgical gowns. All patients reported a rash on the wrist where contact was made with the gowns, headaches, and hand numbness with weakness. Ten of 12 patients complained of memory loss. Neurologic evaluation revealed neuropathy on examination in nine of the 12 patients, elevated vibration threshold in four of nine, abnormal pressure threshold in 10 of 11, atrophy on head MRI in three of 10, and neuropathy on conduction studies in four of 10. Neuropsychological testing demonstrated mild cognitive impairment in four of six patients. Sural nerve biopsy in the most severely affected patient showed findings of axonal injury. Several patients in this group display signs of peripheral and CNS dysfunction following exposure to EO. Possible mechanisms of neurotoxicity include direct exposure of peripheral nerves through cutaneous absorption and central involvement through inhalation and vascular dissemination. The frequency of central and peripheral nervous system symptoms, supported by objective testing in these EO-exposed patients, suggests other healthcare personnel may be at similar risk.

Effects of radiation on the use of hydroxyapatite for orbital reconstruction in the rabbit.

The gross and histopathologic effects of external beam radiation on host response to subperiosteal implantation of dense hydroxyapatite (HA) blocks along the superior orbital rim was investigated, using the rabbit as an experimental model. Three study groups were employed: those with no radiation, those receiving 500 cGy, and those receiving 1,500 cGy. The hydroxyapatite blocks were surgically implanted 2 weeks after administration of the radiation. The pathologic specimens, including the HA block and the neighboring bone segment, were harvested and examined at either the fourth or 12th postsurgical week. There was essentially no inflammatory reaction stimulated by the implanted HA blocks, nor was there any evidence of abnormal bone remodeling in the underlying orbital rim segments. The most secure bonding between the HA block and bone was found in the specimens having received either 500 cGy or 1,500 cGy and harvested at 12 weeks. We conclude that HA serves as an acceptable bone graft substitute in areas previously treated with radiation. The various properties of HA are also reviewed.

Exposure rate of hydroxyapatite spheres in the anophthalmic socket: histopathologic correlation and comparison with silicone sphere implants.

We retrospectively reviewed enucleations and secondary anophthalmic socket sphere implantations for a 3 year period. We compared the incidence of exposure of hydroxyapatite implants to the incidence of exposure of silicone implants. We found that the incidence of hydroxyapatite exposure following enucleation was 3 of 27 (11.1%), and following secondary anophthalmic socket implantation was 3 of 32 (9.4%). The incidence of silicone sphere exposure following enucleation was 0 of 48 (0%), and following secondary implantation was 1 of 30 (3.3%). The difference in exposure rate between hydroxyapatite and silicone reached statistical significance in the enucleation group (p = 0.043) and in the combined enucleation and secondary implantation group (p = 0.033), but not in the secondary implantation group when considered separately. Osteoinduction and fibrovascular infiltration were found in all hydroxyapatite specimens examined histopathologically. In the exposed implants, liquefaction necrosis of the implant occurred. In the nonexposed implant, complete fibrovascular ingrowth was noted at 7 months. We believe that the hydroxyapatite anophthalmic sphere is associated with a higher incidence of exposure and postoperative inflammation when compared to silicone anophthalmic spheres. Patient selection and technique modification may reduce the incidence of hydroxyapatite implant exposure.

Astroblastomas: a pathological study of 23 tumors, with a postoperative follow-up in 13 patients.

Astroblastomas are rare, usually circumscribed, supratentorial tumors of young subjects and are characterized by a perivascular arrangement of the tumor cells. Their clinical behavior is unpredictable and their prognosis has been regarded as intermediate between that of astrocytomas and glioblastomas. A personal series of 23 astroblastomas was reviewed, adequate postoperative follow-up being available in 13 patients. Two distinct histological types were encountered: low-grade and high-grade. The low-grade type comprised tumors with better differentiated and more benign-appearing microscopical features. Five of the 8 patients with tumors of this type who were available for follow-up have survived from 3 to 20 years after treatment; in 1 patient the tumor converted into a fatal glioblastoma after 4 1/2 years. The high-grade type consisted of tumors with more anaplastic features. Three of the 4 patients with tumors of this type available for follow-up died after 1 1/2 to 2 1/2 years, the astroblastomas in 2 of them having converted into a glioblastoma and a gliosarcoma, respectively. One patient, however, has had an unexpected length of postoperative survival of 11 1/2 years. The best clinical results were obtained after total or subtotal resection of the tumor, followed by radiotherapy. The role of chemotherapy is still uncertain. This form of glioma illustrates the discrepancies that may sometimes be apparent between histopathological features and length of postoperative survival. The prognosis is also further complicated by the potential of the astroblastoma to convert into a more malignant type of glioma.

Neuroendocrine differentiation in prostatic carcinomas. A retrospective autopsy study.

Neuroendocrine differentiation in prostatic neoplasms has in the past been considered extremely uncommon. The histologic neuroendocrine patterns reported previously vary from small cell to carcinoidlike to mixed adenocarcinoma--small cell or carcinoid. The majority of the tumors reported are of the mixed variety. We reviewed 2648 autopsies, revealing 69 prostatic carcinomas, eight with neuroendocrine differentiation (five mixed adenocarcinoma--small-cell carcinoma, two "pure" small cell, and one "pure" carcinoidlike). The mean patient age was 69.5 years. One patient presented with markedly elevated serum corticotropin and another was severely hypercalcemic with elevated serum parathyroid hormone level. Three neoplasms were incidental autopsy findings. The mean survival time, after diagnosis, was 19 months for the other patients. Three of the cases were examined ultrastructurally and showed cytoplasmic processes containing membrane-bound granules in the neuroendocrine component. The areas with neuroendocrine differentiation were positive for markers as follows: neuron-specific enolase, seven of eight; prostate-specific antigen (PSA), none of eight; chromogranin A, seven of eight; synaptophysin, four of eight; and calcitonin, four of eight. Those neoplasms mixed with an adenocarcinoma component showed well-defined PSA positivity in the glandular elements. This study suggests that neuroendocrine differentiation in prostatic neoplasms may be more common than previously thought. Often, the areas with neuroendocrine differentiation are considered to represent poorly differentiated adenocarcinoma. It is important to recognize neuroendocrine components in prostatic carcinomas owing to prognostic and potential therapeutic implications.

Retinal S-antigen immunoreactivity in medulloblastomas.

A series of 16 cerebellar medulloblastomas were studied immunohistochemically using a four-step immunoperoxidase (PAP) method and a monoclonal antibody (MAbA9-C6) which defines an epitope of the retinal S-antigen, a protein known to occur in retinal photoreceptor cells and pinealocytes of the pineal gland as well as in retinoblastomas, pineocytomas and pineoblastomas. Immunopositivity was demonstrated in a variable number of tumor cells in 50% of the cases. This finding may be an indication of a differentiation potential of medulloblastomas along the photoreceptor cell lineage. Alternatively, it may simply indicate the non-specificity of the retinal antigen in the neoplastic state.

Metastases of a spinal glioblastoma multiforme into an intracranial arachnoid cyst.

Spread of spinal cord glioblastoma multiforme to the intracranial compartment is uncommon. This report documents a case of metastatic spread of glioblastoma multiforme from the spinal cord to an intracranial arachnoid cyst. Seeding of the cyst cavity could have occurred by direct permeation of the cyst wall by the neoplastic glial cells spreading via the cerebrospinal fluid or by direct access of the cells through a defect in the arachnoid cyst wall and their subsequent entrapment by a ball valve type mechanism, leading to multiple implants.

Ectopic pituitary gland simulating a suprasellar tumor.

A case report of ectopic pituitary gland in the suprasellar region of a normal 39-year-old woman with persistent headaches is presented. The embryological development of the pituitary gland is briefly reviewed, with a discussion of the relevant literature. No previous report of normal pituitary tissue in a suprasellar location in the absence of tumor could be found.