CT angiography and CT perfusion improve prediction of infarct volume in patients with anterior circulation stroke.

INTRODUCTION: We investigated whether baseline CT angiography (CTA) and CT perfusion (CTP) in acute ischemic stroke could improve prediction of infarct presence and infarct volume on follow-up imaging. METHODS: We analyzed 906 patients with suspected anterior circulation stroke from the prospective multicenter Dutch acute stroke study (DUST). All patients underwent baseline non-contrast CT, CTA, and CTP and follow-up non-contrast CT/MRI after 3 days. Multivariable regression models were developed including patient characteristics and non-contrast CT, and subsequently, CTA and CTP measures were added. The increase in area under the curve (AUC) and R (2) was assessed to determine the additional value of CTA and CTP. RESULTS: At follow-up, 612 patients (67.5%) had a detectable infarct on CT/MRI; median infarct volume was 14.8 mL (interquartile range (IQR) 2.8-69.6). Regarding infarct presence, the AUC of 0.82 (95% confidence interval (CI) 0.79-0.85) for patient characteristics and non-contrast CT was improved with addition of CTA measures (AUC 0.85 (95% CI 0.82-0.87); p < 0.001) and was even higher after addition of CTP measures (AUC 0.89 (95% CI 0.87-0.91); p < 0.001) and combined CTA/CTP measures (AUC 0.89 (95% CI 0.87-0.91); p < 0.001). For infarct volume, adding combined CTA/CTP measures (R (2) = 0.58) was superior to patient characteristics and non-contrast CT alone (R (2) = 0.44) and to addition of CTA alone (R (2) = 0.55) or CTP alone (R (2) = 0.54; all p < 0.001). CONCLUSION: In the acute stage, CTA and CTP have additional value over patient characteristics and non-contrast CT for predicting infarct presence and infarct volume on follow-up imaging. These findings could be applied for patient selection in future trials on ischemic stroke treatment.

The Prognostic Value of CT Angiography and CT Perfusion in Acute Ischemic Stroke.

BACKGROUND: CT angiography (CTA) and CT perfusion (CTP) are important diagnostic tools in acute ischemic stroke. We investigated the prognostic value of CTA and CTP for clinical outcome and determined whether they have additional prognostic value over patient characteristics and non-contrast CT (NCCT). METHODS: We included 1,374 patients with suspected acute ischemic stroke in the prospective multicenter Dutch acute stroke study. Sixty percent of the cohort was used for deriving the predictors and the remaining 40% for validating them. We calculated the predictive values of CTA and CTP predictors for poor clinical outcome (modified Rankin Scale score 3-6). Associations between CTA and CTP predictors and poor clinical outcome were assessed with odds ratios (OR). Multivariable logistic regression models were developed based on patient characteristics and NCCT predictors, and subsequently CTA and CTP predictors were added. The increase in area under the curve (AUC) value was determined to assess the additional prognostic value of CTA and CTP. Model validation was performed by assessing discrimination and calibration. RESULTS: Poor outcome occurred in 501 patients (36.5%). Each of the evaluated CTA measures strongly predicted outcome in univariable analyses: the positive predictive value (PPV) was 59% for Alberta Stroke Program Early CT Score (ASPECTS) ≤7 on CTA source images (OR 3.3; 95% CI 2.3-4.8), 63% for presence of a proximal intracranial occlusion (OR 5.1; 95% CI 3.7-7.1), 66% for poor leptomeningeal collaterals (OR 4.3; 95% CI 2.8-6.6), and 58% for a >70% carotid or vertebrobasilar stenosis/occlusion (OR 3.2; 95% CI 2.2-4.6). The same applied to the CTP measures, as the PPVs were 65% for ASPECTS ≤7 on cerebral blood volume maps (OR 5.1; 95% CI 3.7-7.2) and 53% for ASPECTS ≤7 on mean transit time maps (OR 3.9; 95% CI 2.9-5.3). The prognostic model based on patient characteristics and NCCT measures was highly predictive for poor clinical outcome (AUC 0.84; 95% CI 0.81-0.86). Adding CTA and CTP predictors to this model did not improve the predictive value (AUC 0.85; 95% CI 0.83-0.88). In the validation cohort, the AUC values were 0.78 (95% CI 0.73-0.82) and 0.79 (95% CI 0.75-0.83), respectively. Calibration of the models was satisfactory. CONCLUSIONS: In patients with suspected acute ischemic stroke, admission CTA and CTP parameters are strong predictors of poor outcome and can be used to predict long-term clinical outcome. In multivariable prediction models, however, their additional prognostic value over patient characteristics and NCCT is limited in an unselected stroke population.

MR arthrography of traumatic anterior shoulder lesions showed modest reproducibility and accuracy when evaluated under clinical circumstances.

INTRODUCTION: We examined the reproducibility and accuracy of high-field MRA in traumatic anterior shoulder instability under conditions resembling clinical practice and assessed the influence of observer experience. MATERIALS AND METHODS: Two radiologists with different experience levels evaluated 61 MRAs. Assessment was independent, blinded and non-sequential. For 40 MRAs, surgical reports were available to assess diagnosis accuracy and influence of observer experience. The assessed lesions were cuff lesions, Hill-Sachs lesions, bony and classic Bankart lesions, greater humeral tuberosity fractures, SLAP lesions and joint capsule lesions. Reproducibility was quantified using kappa coefficients. Accuracy was evaluated with sensitivity and specificity rates, positive and negative predictive values. Differences in the percentage of correctly diagnosed MRAs between the radiologists were tested using McNemar's test for paired proportions. RESULTS: Inter-observer k-values ranged from 0.03 for joint capsule lesions to 0.45 for humeral head lesions. The overall kappa was 0.21 (95% CI; 0.12-0.30). We also observed markedly lower sensitivity and specificity rates than those reported in the literature for most lesions. The more experienced radiologist correctly diagnosed 78.9% of all lesions compared to 65.4% for the less experienced radiologist (P < 0.001; McNemar's test). CONCLUSION: MRA-interpretations of traumatic anterior shoulder instability should be regarded with caution in clinical practice. The experience level of radiologists can affect reproducibility and accuracy.

Grade 3 vulvar and anal intraepithelial neoplasia in a HIV seropositive child--therapeutic result: case report.

A case report of a HIV seropositive 8-year-old child with vulvar and anal border neoplasia, both grade 3, and the adopted therapeutic management are presented. The mother reported the history of a progressively growing verrucous lesion in the vulva since the age of three and a half years. On physical examination a pigmented and elevated lesion was observed in the whole vulvar region extending to the anal region and intergluteal sulcus. After biopsies and anatomic pathological examination, antiretroviral therapy, adequate for age, and topical application of podophyllotoxin associated with Thuya officinalis extract was started. Three months afterwards vaporization and CO2 laser excision were performed in five sequential sessions, thereafter associated with topical imiquimod application. After the first two sessions of laser therapy early relapses occurred. After four weeks of imiquimod use, already a significant improvement of the lesions was observed, making the following laser therapy sessions easier. We conclude that antiretroviral therapy associated with podophyllotoxin and Thuya was not effective regarding regression of the lesions. Laser therapy alone led to early relapses. The local use of imiquimod associated with laser was effective in decreasing and controling the lesions.

Low-dose 5-fluorouracil adjuvant in laser therapy for HPV lesions in immunosuppressed patients and cases of difficult control.

The authors established a protocol for the use of 5-fluorouracil (5FU) adjuvant in lasertherapy for clinical and subclinical HPV infection in immunosuppressed patients, persistent lesions and as reinforcement treatment in cases of poor progress. Sixty-four patients were evaluated, of whom 26 were immunosuppressed, 34 presented persistent lesions and four received intravaginal reinforcement treatment with 2.5 g 5% 5FU every two weeks, or biweekly vulvar reinforcement after lasertherapy. On average, five 5FU courses were used, but in the immunossuppressed patients its use was maintained indefinitely. The rate of complete response was 66%, but the immunossuppressed patients showed less response (46.2%) when compared with the persistent lesion/reinforcement treatment group (78.9%). The responses were positive in the two groups when compared to that with no response. We deem the use of low-dose 5FU an excellent alternative in cases of difficult HPV progress, presenting a low cost and minimal side-effects.

[Smoking prevalence at the Federal University of São Paulo, 1996--preliminary data of an institutional program]. / Prevalência de tabagismo na Universidade Federal de São Paulo, 1996--dados preliminares de um programa institucional.

PURPOSE: To evaluate the prevalence of tobacco smoking among health workers, professores, nurses and students of Federal University of São Paulo and the acceptance of an institutional program for quitting smoking. METHODS: We analized the answers of a questionnairy with 51 questions, distributed to people from different categories. RESULTS: The total percentage of answered questionnaires was 48.6% (2613). The answers obtained from health workers were 37.3%, professors 49.0%, nurses 52.7% and students 76.5% The total percentage of smokers at UNIFESP was 15.5%:23.7% for health workers, 18% for professors, 16% for nurses and 8.6% for students. There was no significant statistical difference between the prevalence of smoking among females (17.3%) and males (16.3%). The age of major prevalence of smoking was between 31 to 40 years (26.6%). For all ages, people who have university level smoked less, independent of sex. Eighty three percent (83%) of the UNIFESP workers and students are worried of being passive smokers. Between the smokers, 55% were thinking of quiting and 42% declared that need some help to quit. CONCLUSION: We concluded that educational programs and help for cessation at institutional level are necessary and well accepted at UNIFESP, and the completion of these programs will contribute to the obeying of the prohibitive laws of no smoking within the community.

Prevalência de tabagismo na Universidade Federal de Säo Paulo, 1996: dados preliminares de um programa institucional / Smoking prevalence at Universidade Federal de Säo Paulo, 1996: preliminary data of an institutional program

Objetivo. O conhecimento da prevalência do tabagismo é necessário para a realizaçao de programas institucionais adequados que visem a diminuiçao do número de fumantes. O objetivo do trabalho foi verificar a prevalência do tabagismo entre funcionários, docentes, enfermeiros e alunos da Universidade Federal de Sao Paulo e a aceitabilidade de um programa antifumo. Pacientes e Métodos. Foram analisadas as respostas obtidas a partir de um questionário contendo 51 questoes, distribuídos para as diferentes categorias. Resultados. A porcentagem total de questionários respondidos foi de 48,6 por cento (2.613) sendo 37,3 por cento para funcionários, 49,0 por cento para docentes, 52,7 por cento para enfermeiras e 76,5 por cento para alunos. Verificou-se que a porcentagem total de fumantes na UNIFESP foi de 15,5 por cento, sendo 23,7 por cento entre funcionários, 18 por cento entre docentes, 16 por cento entre enfermeiros e 8,6 por cento entre alunos. A faixa etária de maior prevalência de fumantes foi a de 31 a 40 anos (26,6 por cento). Nao houve diferença estatística entre a prevalência de fumantes entre homens e mulheres. Em ambos os sexos, para todas as faixas etárias, os indivíduos com maior nível de instruçao fumavam menos. Das pessoas que responderam o questionário, 82,5 por cento estavam preocupadas em serem fumantes passivas. Dos fumantes, 55 por cento estao pensando em largar de fumar e 42 por cento julgam precisar de algum tipo de ajuda. Conclusao. Programas educacionais e de cessaçao do tabagismo em nível institucional sao necessários e bem aceitos na UNIFESP, devendo ser realizados para que as leis de restriçao do fumo dentro da instituiçao sejam efetivamente cumpridas.

Changes in G protein pattern and in G protein-dependent signaling during erythropoietin- and dimethylsulfoxide-induced differentiation of murine erythroleukemia cells.

We have studied the expression of G protein subtypes and the role of G protein-dependent signaling in two subclones of RED-1 cells, an erythropoetin(Epo)-sensitive, murine erythroleukemia cell line. Clone 6C8 showed terminal erythroid differentiation in response to a combined treatment with Epo and dimethylsulfoxide. Clone G3 was resistant to these inducers, but responded to Epo with enhanced proliferation. We measured G protein alpha subunit levels by toxin-catalyzed adenosine diphosphate (ADP)-ribosylation with [32P]-nicotinamide adenine dinucleotide (NAD) and by semiquantitative immunoblotting with specific antisera. Native RED-1 cells expressed G alpha i2, alpha i3, alpha s, and alpha q/11, but not alpha i1 and alpha o. Terminal differentiation was associated with a selective loss (approximately 80%) of G alpha i3 and an increase in a truncated cytosolic form of G alpha i2, while the membrane levels of alpha i2, alpha q/11, and alpha s did not change significantly. Treatment of G3 cells with the inducers was without effect on G protein abundance. However, except for alpha s, G3 cells contained significantly higher levels of the different G protein alpha subunits tested. Stimulation of G protein-coupled receptors by thrombin and ADP caused a pertussis toxin (PTX)-inhibitable transient increase in intracellular Ca2+ that was markedly reduced in differentiated cells. In G3 cells, but not in 6C8 cells, thrombin also caused a PTX-sensitive inhibition of isoprenaline-stimulated cyclic 3',5'-adenosine monophosphate (cAMP) formation. Our results show that specific alterations in G protein expression and function are associated with erythroid differentiation of erythroleukemia cells but do not prove a causal relationship. The loss of G alpha i3 may affect cellular responses that are mediated via P2T purine or thrombin receptors.

[A surprising double tumor of the liver 60 years following thoratrast diagnosis]. / Een verrassende dubbeltumor van de lever 60 jaar na thorotrast-diagnostiek.

A 66-year-old man with thorotrastosis of the reticuloendothelial system is described. Post mortem two tumours were found in an enlarged liver: a cholangiocarcinoma and an angiosarcoma. Coincidentally, a hilar neurofibroma was found. The former two tumours most probably developed because of a lifelong endogenous alpha-irradiation by thorium disintegration. The exceptional latency period of 60 years' duration is emphasized.

[Medial necrosis of the pulmonary artery in ruptured aneurysm]. / Medianekrosen der Arteria pulmonalis bei Aneurysmaruptur.

Fifty years ago the first author of this paper described the entity known as idiopathic medial necrosis of the aorta. The present report describes two cases of ruptured aneurysm of the main pulmonary artery. The histologic alterations of the arterial wall were the same as in the much more common aneurysms of the aorta, viz. severe medial necrosis and mucoid degeneration. The findings are discussed and compared with 20 cases documented in the literature. Physical (hypertension) as well as biochemical factors appear to play an essential role in the pathogenesis of medial necrosis.