The influence of carotid artery catheterization technique on the incidence of thromboembolism during carotid artery stenting.

BACKGROUND AND PURPOSE: Thromboembolic events related to CAS continue to be the main limitation to the widespread use of this technique as a first-line treatment for carotid occlusive disease. Our aim was to evaluate thromboembolism during CAS using DWI for catheterization techniques of the carotid artery. MATERIALS AND METHODS: Thirty-two consecutive patients with symptomatic carotid stenosis underwent CAS involving 1 of 2 carotid artery catheterization techniques: One used a 7F or 8F catheter (group 1, n = 16) and the other used a coaxial system in which a 7F or 8F catheter was used in conjunction with a 4F or 5F catheter (group 2, n = 16). DWI was performed before and after CAS. Clinical variables, the number and location of NES on DWI after CAS, were compared between the 2 groups. RESULTS: NES on DWI occurred in 53% of all patients. The incidence of NES was significantly higher in patients 65 years of age and older versus those younger than 65 years of age (P = .013). All NESs were asymptomatic, and their rate of occurrence did not differ significantly between groups 1 and 2. The incidence of NES in the other territories that were outside that of the treated carotid artery (P = .004) and the incidence of multiple NESs (P = .04) were significantly higher in group 1. CONCLUSIONS: NES in the other territories mainly arises from the atherosclerotic aortic arch and arch vessels during the manipulation of endoluminal devices. The carotid artery catheterization technique using the coaxial system with a 7F or 8F catheter in conjunction with a 4F or 5F catheter reduced the incidence of NES in the other territories.

Prenatal diagnosis of cri-du-chat syndrome: importance of ultrasonographical markers.

Cri-du-chat syndrome is a chromosomal abnormality involving a 5p deletion and is characterised by a cat-like cry, mental retardation, microcephaly and abnormal facial features. We report a case of prenatally-diagnosed cri-du-chat syndrome. Although PAPP-A was low at first trimester screening (FTS), the combined risks of trisomies 21, 18 and 13 were low. Amniocentesis was, however, carried out following the ultrasonographical observation of a severely hypoplastic nasal bone, cerebellar hypoplasia, choroid plexus cyst and a single umbilical artery during the second trimester. This case report highlights the importance of careful examination of basic and extended foetal biometry and structures, as well as soft markers for the detection of rarer chromosomal abnormalities that may be missed at FTS.

Community-acquired Klebsiella pneumoniae complicated skin and soft-tissue infections of extremities: emphasis on cirrhotic patients and gas formation.

BACKGROUND: Klebsiella pneumoniae was rarely reported to cause complicated skin and soft tissue infections (cSSTIs). Our study was to delineate clinical characteristics and outcome of cSSTIs involving extremities caused by K. pneumoniae. PATIENTS AND METHODS: Adult patients aged 16 years or more with community-acquired cSSTIs, which involved the extremities and were caused by four common aerobic pathogens at a medical center in southern Taiwan during a 54-month period, were reviewed. RESULTS: Of 76 cases enrolled, Staphylococcus aureus was the most common pathogen (52 cases, 68%), followed by K. pneumoniae (16, 21%), beta-hemolytic streptococci (5, 7%), and Escherichia coli (3, 4%). Forty-six (61%) had underlying conditions, and diabetes mellitus was most common among K. pneumoniae and non-K. pneumoniae groups (63% and 45%, respectively). Compared to patients with cSSTIs caused by other bacteria, those with K. pneumoniae cSSTIs were predominantly male, more often had liver cirrhosis, malignant neoplasm and alcoholism. In addition, they were more likely to have fever, shock, bacteremia, gas formation, pyomyositis, metastatic infections, as well as longer durations of hospitalization. Using multivariate analysis, liver cirrhosis (adjusted odds ratio [aOR] 12.5, 95% confidence interval [CI] 2.0-79.1, p = 0.007) and male gender (aOR 11.5, 95% CI 1.1-116.8, p = 0.039) were significantly associated with K. pneumoniae cSSTIs. CONCLUSIONS: We highlight the role of K. pneumoniae in Taiwanese patients with cSSTIs involving extremities, and its potential for gas and pus formation, and metastatic infections. Empiric antimicrobial coverage of K. pneumoniae and close monitoring of metastatic infections are mandatory for patients with risk factors.

The relevance of oncogenes as prognostic markers in cervical cancer.

To study the prevalence of the oncogenes c-myc, IFN-alpha; c-erbB2; H-ras codon 12, 13, and 61; c-fos; and E6/E7 oncogenes of human papillomavirus (HPV) 16 in patients with invasive carcinoma of the cervix and their prognostic significance, genomic DNA and RNA were isolated from tissues of 275 patients in Singapore with nonmetastatic cervical cancer and 32 patients with normal cervix. The levels of expression of the various oncogenes were quantified by PCR using the respective primers. When the PCR data on the DNA were analyzed by the log-rank test, IFN gamma (P = 0.02) and H-ras codon 12 and 13 (P = 0.02) were found to be prognostic. In the multivariate analysis, a statistically significant trend for increasing risk with higher quartiles was found for c-myc (P = 0.007) and c-erbB2 (P = 0.03). After adjusting for age and stage, a correlation appears between the amplification of the oncogenes c-myc, c-erbB2, and H-ras codon 12, 13, and 61 and the development of recurrent cervical cancer. Further adjustment to include the parameters of treatment and histology type did not change the outcome of the correlation observed.

Intraventricular hemorrhage caused by lateral ventricular meningioma: a case report.

Meningiomas causing intracranial hemorrhage are rare, and hemorrhage from a lateral ventricular meningioma seems to be even rarer. We report a case of trigonal meningioma in a 43-year-old woman who presented with intraventricular hemorrhage, and describe the CT, MRI and angiographic findings.

Complications of eyelash and eyebrow tattooing: reports of 2 cases of pigment fanning.

Eyelash and eyebrow tattooing are commonly performed procedures that have a very low rate of reported complications. We describe one case of infraorbital pigmentation after eyelash tattooing and another of periorbital pigmentation after eyebrow tattooing. Although most complications related to eyelash and eyebrow tattooing, including pigment fanning, have been reported by ophthalmologists, pigment fanning is also of concern to dermatologists.

A comparative study of cervical cytology, colposcopy and PCR for HPV in female sex workers in Singapore.

This study examined the prevalence of human papillomavirus (HPV) infection in a cohort of female sex workers in Singapore. HPV infection was diagnosed by clinical examination, Papanicolaou (Pap) smears, histology and polymerase chain reaction (PCR). One hundred and eighty-seven female sex workers who came for their routine medical screening were enrolled into the study. PCR was positive for HPV in 27 (14.4%), 20 of these had a single HPV type detected, while 7 had multiple types of HPV detected. The most common HPV types identified were types 16, 58 and 18. In conclusion, HPV infection is moderately prevalent among sex workers as tested by PCR, but routine screening with Pap smears does not appear to be a sensitive method of diagnosis for HPV infection.

The living shunt: a tissue engineering approach in the treatment of hydrocephalus.

Tissue engineering is the use of cultured cells seeded into biodegradable polymers to create custom designed, living implantable devices. As a first approach to the use of this technique in the treatment of hydrocephalus, we have prepared chondrocyte-seeded polyglycolic acid (PGA) tubes coated with polylactic glycolic acid (PGLA), implanted initially with thin silastic stents removed four weeks after shunt insertion. The use of bovine xenograft cells in athymic (nude) rats resulted in more efficient seeding with chondrocytes, stiffer tube walls, and better patency. When implanted in 6-week-old rats made hydrocephalic by cisternal injection of kaolin at 4 weeks of age, six of eight 'living shunts' remained patent to radio-opaque contrast injection at two weeks after stent removal. At four weeks after stent removal, all four of the shunts had occluded at the ventricular end, three of the four apparently due to growth of the animal. We conclude that polymer type, cell type, and cell density will require considerable optimization, but a working tissue engineered shunt is feasible and may one day address some problems of interactions of living tissue and inert polymer.

Shunt-independent surgical treatment of middle cranial fossa arachnoid cysts in children.

The best operative intervention for children with arachnoid cysts remains the subject of controversy. Recent reports stress that craniotomy for cyst fenestration is associated with a low incidence of morbidity and mortality and may leave the child shunt-independent. Among a total of 66 intracranial arachnoid cysts operated on in the authors' department from 1985 to 1997, 44 cases (67%) were located in the middle cranial fossa. A higher incidence in the first decade of life (53 cases) and a marked male predominance (45 cases) were recognized. Headache, cranial deformities, symptoms of raised intracranial pressure, and seizures constituted the most frequent features of the clinical presentation. To determine which treatment provides the greatest benefit with the lowest incidence of complications, the records of the 44 patients with arachnoid cysts in the middle cranial fossa were reviewed. The mean age of these patients was 4.6 years (range 0-16 years). Different types of initial surgical procedures were performed. In 33 patients with middle cranial fossa arachnoid cysts (MCFAC) the initial surgery took the form of craniotomy with excision of the cyst walls and fenestration into the basal cisterns. Shunting procedures were performed in 9 patients: cysto-peritoneal shunts (CPS) were placed in 4 patients and ventriculo-peritoneal shunts (VPS), in 3 patients, and cyst excision was performed in addition to CPS in 2 patients. Excision of the cyst membrane alone without fenestration was performed in 2 patients. The initial treatment was successful in terms of reduced symptoms and decreased cyst size, with no additional treatment needed for the cyst, in 79% (26/33) of patients who had undergone excision of the cyst walls and fenestration into the basal cisterns, compared with 66% (6/9) of patients who had undergone shunting procedures. Cyst membrane excision was not successful in any of the patients who underwent this procedure alone. No significant difference in morbidity was noted between these different treatment options. On follow-up CT scan and MRI, cysts of types I and II (Galassi classification) exhibited a steady tendency to reduction or obliteration. These results confirm that radical excision of the outer and inner membranes of the cyst wall with fenestration into the basal cistern is a safe and effective shunt-independent procedure for MCFAC, especially for those of types I and II.

An unusual tumour metastasis to the cervix.

INTRODUCTION: The vast majority of tumours in the cervix are either primary carcinomas or direct extension of primary tumours from nearby sites such as the endometrium, myometrium, rectum and bladder. Patients usually present with abnormal bleeding, pain and dyspareunia. A smaller number of patients are asymptomatic and their tumours can be diagnosed early by PAP smears. CLINICAL PICTURE: We present an unusual case of an elderly lady with breast cancer that had metastasized to the cervix 4 years after primary treatment of the breast malignancy. Although the appearance of the cervix was "normal looking", it was firm and indurated on palpation. PATHOLOGY: A definite diagnosis of metastatic infiltration could only be made by colposcopic biopsy. Early PAP smears had shown some abnormal cells suggestive of metastatic lobular carcinoma but were not conclusive of metastasis from breast carcinoma. Subsequent bone scans and CT scans of the abdomen revealed metastatic lesions in the skull, spine, left femoral shaft and liver.

Optimization of resolution and color reproduction by controlling luminance and contrast levels of a liquid-crystal display monitor.

The image quality of a color liquid-crystal display monitor is studied by changing the contrast and the luminance levels. The resolution is assessed with modulation transfer function area (MTFA) that is measured at nine different combinations of the luminance and contrast. At these combinations, we measure the chromaticity coordinates and luminance of red-green-blue channels as a function of the digital-analog convert value. We analyze the relations among MTFA value, constant-channel chromaticity, color gamut, and maximum luminance of a white pattern. From the results, the combination of levels is found that provides both high resolution and good color reproduction.

Long-term follow-up of shunting therapy.

Ventricular CSF shunting surgery has changed the overall outcome figures for hydrocephalic patients over the past three decades. The factors that have improved the outcome are evolution of the shunt systems, improvement of the surgical environment and use of potent antibiotics, technological advances in brain imaging, and refinements in the assessment of cognitive and functional outcomes and of actuarial statistical techniques. But the recent large studies revealed that nearly half of all shunt placements were for revision, and there is a low but real percentage of cases in which death and neurological impairment are related to shunt surgery. The most frequent complication was shunt obstruction, followed by infection, disconnection, hematoma and slit ventricle syndrome. This clearly means that the shunt systems and the techniques in current use involve many problems that have yet to be solved. To solve these problems, new shunt systems should be developed and continuous efforts at reducing shunt infection should be made. The overall complication rate in the authors' series was 31.7%, but we have been able to reduce the complication rate from 37% to 25% by exercising special care focused on the surgical environment and techniques. Careful, long-term follow-up using various parameters and proper statistical analysis is another important factor in improving surgical outcome. Multicenter and international studies will be easier with the development of a network, and it will give us a strong background to treat hydrocephalus.

Leukemic macrocheilia associated with chronic lymphocytic leukemia.

Specific cutaneous infiltrates in chronic lymphocytic leukemia presenting as a tumor or a large nodule on the face, scalp, and upper trunk are rare; involvement of the oral mucosa is extremely rare. We report a case of leukemic macrocheilia that occurred three years before a diagnosis of chronic lymphocytic leukemia was made.

Radiotherapy for the treatment of metastatic granulosa cell tumor in the mediastinum: a case report.

OBJECTIVE: We report a case of metastatic ovarian granulosa cell tumor in the mediastinum with a 2-year disease-free interval after treatment with radiotherapy and review the literature regarding the use of radiotherapy in recurrent and metastatic granulosa cell tumor. METHODS: The patient's medical records, histological slides, and radiological films were reviewed. The pertinent references were obtained using a Medline search and cross-references. RESULTS: A patient with Stage 1A granulosa cell tumor developed a recurrence in the retroperitoneum 10 years after initial surgery. She was treated with chemotherapy followed by surgical resection. She subsequently developed metastatic tumor in the mediastinum which responded completely to radiotherapy. She has remained disease free for 2 years since the completion of radiotherapy. CONCLUSION: Radiotherapy is a treatment option that should be considered in localized recurrent or metastatic granulosa cell tumor that is not amenable to surgery as it can potentially control the disease for several years.

Complex modular cis-acting elements regulate expression of the cardiac specifying homeobox gene Csx/Nkx2.5.

The murine homeobox gene Csx/Nkx2.5 is an evolutionarily highly conserved gene related to the Drosophila tinman gene, which specifies cardiac and visceral mesoderm. Since Csx/Nkx2.5 plays an essential role in heart development, studying its regulation is essential for the better understanding of molecular mechanisms of cardiogenesis and the pathogenesis of congenital heart disease in humans. In this study, we characterized the murine Csx/Nkx2.5 gene and identified two novel untranslated exons, 1a, and 1b, resulting in three different Csx/Nkx2.5 transcripts. To examine the tissue-specific transcriptional regulation in vivo, we analyzed a total of 23 kb of Csx/Nkx2.5 upstream and downstream sequences by generating transgenic embryos carrying lacZ reporter constructs containing various lengths of flanking sequence. With 14 kb of 5' flanking sequence, lacZ expression was observed in the cardiac crescent at E7.5, and in the outflow tract, the interatrial groove, the atrioventricular canal and right and left ventricles, as well as in pharyngeal floor, thyroid primordia, and stomach at E10.5. In adult animals, lacZ expression of the transgene was limited to the atrioventricular junction and the subendocardium of the ventricular septum. Reducing the size of flanking sequence to 3.3 kb of intron 2 restricted lacZ expression to the outflow tract and the basal part of the right ventricle in E10.5 embryos. In contrast, the addition of 6 kb of 3' flanking sequence caused strong expression of the reporter gene in the entire right ventricle. Interestingly, Csx/Nkx2. 5 seems to be negatively regulated by its own gene product, because when lacZ was "knocked-in" to replace the entire coding exons, lacZ expression was much higher in the heart of homozygous embryos than that in the heterozygote. These results indicate that the transcriptional regulatory elements of Csx/Nkx 2.5 seems unexpectedly highly modular, and is temporally regulated in a dynamic manner by different enhancer regions. Since Csx/Nkx2.5-like genes are expressed in all species having a heart, their complex modular organization with multiple enhancers probably reflects progressive addition of regulatory elements during the evolution from a simple heart tube to a complex four-chambered organ.

Urticarial reaction following the inhalation of nicotine in tobacco smoke.

We report a patient with recurrent generalized itching and urticaria due to inhalation of nicotine in tobacco smoke. A skin prick test with nicotine base (1:10 w/v) was negative but an intradermal test with nicotine base (1:100 w/v) was strongly positive. Intradermal tests with nicotine base (1:100 w/v) performed on 10 healthy controls were negative. A provocation test with a nicotine patch showed the same symptoms and signs including generalized itching, weals and flares, and mild dyspnoea, which occurred when he was exposed to tobacco smoke. Nicotine in tobacco smoke can act as an inhalant allergen and induce urticaria in hypersensitive persons.

Experience with pineal region tumors.

The results are reported of a retrospective review of the presentation and outcome of 43 pineal region tumors treated from 1982 to 1996, including 20 identified tumors: 5 germinomas, 8 teratomas, 2 embryonal carcinomas, 1 endodermal sinus tumor, 2 pineocytomas and 2 pineoblastomas. Of the 43 tumors reviewed, 36 were located in the pineal region, 5 in the suprasellar, and 2 in both the pineal and suprasellar regions. Twenty patients underwent surgical resection: total in 6 and partial in 10, while only a biopsy was taken in 4 cases. Fifteen patients were managed on the basis of serum CSF tumor markers and radiation response. Twenty-three patients with germinomas received radiotherapy (RT) and had a 5-year survival rate of 87%. Fifteen patients with non-germinomatous germ cell tumors received RT and chemotherapy following direct surgery, and 5 died (mortality rate of 33.3%). The overall survival rate of the 43 patients with pineal tumors was 79.1% (34/43) and the death rate was 20.9% (9/43). It is now recognized that the wide variety of tumor types found in the pineal region necessitates different modes of treatment, and improved microsurgical and stereotactic surgical techniques have made mortality and morbidity rates acceptably low. Because the radiation response and CSF cytology are not enough to determine optimum treatment, a tissue diagnosis should be obtained in all patients.

Tumors of the orbit. Pitfalls of the surgical approach in 37 children with orbital tumor.

The authors review their experience with 37 children with orbital tumors, summarizing their surgical techniques, the indications applied, and the pitfalls of each surgical approach. Tumors located in the retro-ocular or intraorbital space were surgically excised through a transcranial approach (28 cases), while for tumors in other sites lateral orbitotomy (5 cases), medial orbitotomy (1 case) and biopsy (3 cases) were performed. A transcranial approach was used for tumors with intracranial extension and for those located in the orbital apex and deep medial orbital compartment. Lateral orbitotomy was used for tumors located in the superior, temporal or inferior compartment of the orbit and those in the lateral apex. A medial orbitotomy was used for tumors located medial to the optic nerve. Outcomes of the surgical intervention varied, depending on the pathology, location and extent of the individual tumors. To obtain optimal exposure and minimize functional deficits, the pitfalls of surgical approaches to orbital tumors are discussed.

Regulation of endothelin-1 gene expression by cell shape and the microfilament network in vascular endothelium.

Endothelial synthesis and release of endothelin-1 (ET-1) are exquisitely regulated by external shear and strain. We tested the hypothesis that manipulation of endothelial cell shape can regulate ET-1 gene expression. Treatment of bovine aortic endothelial cell (BAEC) monolayers with cytochalasin D disrupted F-actin and induced cell retraction and rounding, in parallel with time- and dose-dependent specific decreases in ET-1 mRNA levels. Treatments with forskolin, phorbol 12-myristate 13-acetate, staurosporine, and genistein also induced cell shape change and decreased F-actin staining and ET-1 mRNA levels. BAEC plated onto nonadhesive petri dishes coated with decreasing concentrations of synthetic RGD polymer showed RGD dose-dependent decreases in cell spreading and in F-actin microfilament elaboration. These changes were specifically accompanied by decreases in ET-1 peptide secretion (60%) and, via posttranscriptional mechanisms, ET-1 mRNA (94%) and were not due to decreased cell-cell contact. We conclude that the shape and microfilament network of endothelial cells are potent posttranscriptional regulators of ET-1 gene expression.