Body fat distribution and risk of diabetes among Chinese women.

OBJECTIVE: To assess the relationship between measures of central and overall obesity and risk of diabetes. DESIGN: Nested case-control study. SETTING: Shanghai, China. PARTICIPANTS: A total of 57 130 women were screened for diabetes at enrollment for the Shanghai Women's Health Study (SWHS), a population-based cohort study of Chinese women aged 40-70 y. In this study, 345 women diagnosed with diabetes and 2760 age-matched controls (eight controls per case), randomly selected from women who tested negative for urine glucose, were included. RESULTS: Risk of diabetes increased significantly with increasing levels of obesity, particularly with measures of central obesity. Compared to those in the lowest quartile, women in the highest quartile of body mass index (BMI) (>/=26.57) and waist to hip ratio (WHR) (>/=0.855) had a 2.57-fold (95% CI 1.75-3.77) and a 6.05-fold (95% CI 4.05-9.04) increased risk of diabetes, respectively. The risk of diabetes was elevated with increasing WHR at all levels of BMI, while the positive association between BMI and diabetes was observed primarily among women with a low WHR. However, test for multiplicative interaction was not statistically significant. CONCLUSIONS: Our data indicated that central obesity is a stronger risk factor for diabetes than overall obesity, suggesting that WHR may be a better indicator of risk of diabetes than BMI among Chinese women.

Methyl methacrylate cranioplasty in children: long-term results.

The long-term outcome of 75 children who underwent methyl methacrylate cranioplasty over a 15-year period is presented. Forty-two patients underwent cranioplasty for posttraumatic skull defects and 33 for nontraumatic causes. Within 8 years following initial cranioplasty procedure, a total of 17 (23%) complications occurred. Several factors correlated with the development of complications, including postoperative radiotherapy, the size of the defect, involvement of the frontal sinus, and the presence of prior infection. The authors currently recommend avoiding methyl methacrylate cranioplasty in selected patients who have received postoperative radiation therapy, in patients with large cranial defects, involvement of the frontal sinus, or any history of prior infection.

New techniques for guiding catheter management during directional coronary atherectomy.

Directional coronary atherectomy (DCA) is an important advance in the mechanical revascularization of stenotic coronary arteries. The bulky nature of the DCA device has necessitated the use of guiding catheter designs that are more cumbersome to use than balloon angioplasty guiding catheters. Because engagement of coronary artery ostia with the currently available DCA guiding catheters is often difficult and because DCA guiding catheters significantly "relax" and reshape during the atherectomy procedure, angiography using these guiding catheters before and after atherectomy can be suboptimal. A new technique for angiography during atherectomy using long Judkin's diagnostic catheters inserted through the existing DCA guiding catheters is described. This technique can be used for optimal visualization of the coronary arteries with minimal use of contrast before and after sessions of atherectomy and also can be used to help engage the DCA guiding catheters. Some improvements in the design of guiding catheters for DCA are suggested.

A preliminary report on the use of laser-Doppler flowmetry during tethered spinal cord release.

Neurological deterioration in the tethered cord syndrome has been postulated to result from a compromise of blood flow in the distal spinal cord. In order to evaluate vascular perfusion in human subjects, a new technique of laser-Doppler flowmetry was used to monitor continuously the microcirculation of the distal spinal cord during surgery for tethered cord release in 10 children. For further comparison, five children undergoing selective dorsal rhizotomy were also monitored. In the tethered cord syndrome group, spinal cord blood flow before untethering was a mean of 12.6 ml/min per 100 g of tissue and increased in all cases after release to a mean of 29.4 ml/min per 100 g of tissue. All patients improved neurologically. The selective dorsal rhizotomy group had a preoperative mean spinal cord blood flow of 30.8 ml/min per 100 g of tissue, which was not altered by the operative procedure. Significant improvement occurs in distal spinal cord blood flow after tethered cord release, which may be representative of an important mechanism in the pathophysiology of the tethered cord syndrome.

Coronary hemodynamic effects of atrial natriuretic peptide in humans.

Studies of the effects of atrial natriuretic peptide on the coronary circulation have yielded conflicting results in animals and have not been fully investigated in human subjects. To further characterize the direct coronary hemodynamic actions of atrial natriuretic peptide in humans and to assess the safety of its administration in patients with coronary artery disease, incremental doses of synthetic atrial natriuretic peptide and nitroglycerin were infused into the left coronary artery in 14 patients, 11 of whom had coronary artery disease. Both agents caused dose-related increases in total coronary sinus blood flow. The largest dose of atrial natriuretic peptide given to all patients (100 micrograms) increased mean coronary sinus blood flow from 127 +/- 7 to 149 +/- 9 ml/min (p less than 0.05) and decreased coronary vascular resistance from 0.93 +/- 0.07 to 0.81 +/- 0.05 mm Hg/ml per min (p less than 0.05); mean arterial blood pressure and heart rate were not affected by this dose of atrial natriuretic peptide. The greatest changes in coronary sinus blood flow (+25%) and coronary vascular resistance (-18%) after atrial natriuretic peptide administration occurred in the patients with coronary artery disease and no other associated cardiovascular disease. The maximal effects of atrial natriuretic peptide were similar to those of nitroglycerin, and no untoward effects were observed. Thus, atrial natriuretic peptide is a direct coronary vasodilator in humans. Its maximal dose effects are similar to those of nitroglycerin and were well tolerated in this small group of patients. The physiologic importance and therapeutic potential of atrial natriuretic peptide in patients with coronary artery disease merit further investigation.

Cardiovascular effects of intracoronary atrial natriuretic peptide administration in man.

An intracoronary drug infusion protocol was employed to assess the hemodynamic effects of synthetic atrial natriuretic peptide in normal subjects and to evaluate its actions on epicardial coronary artery dimensions. Increasing concentrations of synthetic atrial natriuretic peptide (1.75 to 84 micrograms/min) were infused at a constant rate directly into the left coronary artery in eight patients with normal left ventricular function and left coronary artery angiograms. Steady-state hemodynamic parameters and high-fidelity left ventricular pressure were recorded at each dose and indexes of left ventricular contractile and diastolic function were calculated. Coronary angiograms obtained at baseline and the highest dose of atrial natriuretic peptide were compared by quantitative image analysis techniques. At the highest dose administered, atrial natriuretic peptide decreased mean pulmonary artery pressure (-36%, p less than 0.01), pulmonary capillary wedge pressure (-80%, p less than 0.01), left ventricular end-diastolic pressure (-58%, p less than 0.01), left ventricular end-systolic pressure (-11%, p less than 0.01), mean arterial pressure (-8%, p less than 0.05), and pulmonary vascular resistance (-18%, p less than 0.05). Cardiac output and systemic vascular resistance were unchanged, and heart rate and peak positive dP/dt increased. Peak negative dP/dt and the time constant of early diastolic relaxation calculated by the logarithmic method both fell at the highest dose of atrial natriuretic peptide, although the time constants calculated by other less load-sensitive methods were unchanged. Doses of intracoronary atrial peptide that did not alter left ventricular load had no effect on indexes of left ventricular systolic or diastolic function despite a presumably high intramyocardial concentration of the agent.(ABSTRACT TRUNCATED AT 250 WORDS)

Extensive surgical excision of large hemispheric "malignant" astrocytoma in a 6-week-old infant.

A massive hemispheric "high"-grade astrocytoma, diagnosed in a 6-week-old infant, was totally excised by means of two craniotomies. The child is still alive and well with minimal neurological dysfunction 1.5 years after operation. This case report illustrates the benefit of aggressive surgical excision (without radiation or chemotherapy) of massive malignant neonatal astrocytomas. While surgical deficits may be minimized by the plasticity of the developing nervous system, extensive excision may yield occasional long-term palliation.

Cerebral metastasis from malignant pulmonary fibrous histiocytoma. A case report.

Within 3 months, a 13-year-old girl had two thoracotomies performed for resection of pulmonary primary and metastatic malignant fibrous histiocytoma (MFH). Seven months following the second operation, a right frontal cerebral metastasis was diagnosed as responsible for the sudden onset of a left hemiparesis. Although she recovered from the craniotomy, and tolerated radiation and chemotherapy, she succumbed 5 months later to recurrent pulmonary involvement. This case report uniquely records the spread of MFH to the brain in a child. The unusual appearance of this tumor in the pediatric age group and its rare presentation intracranially is explored within the context of the current pediatric literature.

Shunt placement and myelomeningocele repair: simultaneous vs sequential shunting. Review of 12 cases.

The optimal management of patients with myelomeningocele and hydrocephalus is facilitated by a constant review of the patients with the aid of the sonogram and CT scan. Six infants treated with simultaneous shunt placement and myelomeningocele repair were compared with six other neonates treated with conventional sequential myelomeningocele repairs requiring a second separate procedure for shunt placement. Infants operated upon simultaneously experienced no increase in morbidity or mortality and appeared to benefit substantially.

Lumbar intervertebral disk herniation in teenage children: recognition and management of associated anomalies.

Herniated disks in children and adolescents can be extremely disabling and difficult to diagnose because of the paucity of neurologic abnormalities and the consequent suspicions of hysteria. The Laségue sign is often the only consistent positive finding, and when persisting without remission, justifies early diagnostic studies such as CT scanning, and electromyography. Myelography may be avoided if these studies are definitively diagnostic. The almost uniformly good results that follow diskectomy do not justify prolonged conservative care. Management is facilitated by awareness of often unrecognized structural abnormalities found in these patients. These include spinal stenosis, lateral recess narrowing, and transitional vertebra. Spinal fusion, while rarely indicated, should be considered where motion segment instability contributes to persistent backache. The management of 25 patients is recorded. Twenty-one of these presented with an anomaly worthy of record requiring modifications in surgical technique to provide proper decompression and lasting relief of symptoms.

Congenital inclusion cysts of the subgaleal space.

Congenital inclusion cysts of the subgaleal space in 23 white children are reported. Twenty-two cysts were dermoid and one was epidermoid in nature. The lesions were extracranial and had no intracranial extension. Their location in the subgaleal space was median or paramedian. Their clinical, radiologic, biochemical, and histologic characteristics are detailed and compared with those from Africa. This series counters the motion that such cysts are extremely rare in whites and that the anterior fontanel is their only site of location, as claimed by various authors from Africa.

Moderate grade astrocytoma presenting in a 4-month-old child with a family history of von Recklinghausen's neurofibromatosis spanning four generations: a case report.

Intracranial gliomas are found in association with von Recklinghausen's neurofibromatosis. However, few truly neonatal lesions have been identified and studied. This case report concerns a 4-month-old child who was found to have a massive thalamic glioma of moderate grade. Four paternal generations had suffered from different manifestations of this transmissible autosomal-dominant (Ad) phakomatosis.

Cervical myeloradiculopathy caused by arthrotic hypertrophy of the posterior facets and laminae.

Five patients with typical cervical myeloradiculopathy caused by focal cervical spinal stenosis are presented. Dorsal intrusions into the spinal canal by hypertrophied apophyseal joints and thickened laminae resulted in cord and nerve root compression. Minor spondylotic changes were present in the floor of the spinal canal. Laminar decompression with formainotomy and facetectomy relieved the patients of their symptoms. An anterior approach should not be considered in the management of this disorder. Our findings of severe apophyseal arthrosis with lesser degrees of associated spondylosis are similar to those described in anatomical studies by other authors. While uncommon, myelopathy caused by dorsal compression of the spinal cord and nerve roots deserves specific mention so that therapy can be directed to the proper quadrants of the spinal canal wherein the significant pathology is located.

Naevoid basal cell carcinoma syndrome and Charcot-Marie-Tooth disease: two autosomal dominant disorders segregating in a family.

A family is described in which 16 individuals in 3 generations have Charcot-Marie-Tooth disease. At least 6 family members also have the naevoid basal cell carcinoma syndrome. In addition, 1 subject with both disorders has 2 young daughters with the naevoid basal cell carcinoma syndrome.

Obliterative arachnoiditis complicating lumbar spinal stenosis.

The authors report five patients with spinal stenosis who had a total myelographic block at the level of the obliterated subarachnoid space. Arachnoiditis had not been considered as a primary diagnosis until laminectomy revealed a non-pulsating, thickened dural sac that conformed to the internal configuration of the involved spinal canal. Two patients had stenosis complicated by spondyloarthrosis over multiple lumbar levels, one had a previous spinal fusion, another had degenerative spondylolisthesis, and the fifth had a large midline extruded disc at L2-3 that completely blocked the spinal canal. The dura was opened in two patients, confirming the lesion. Despite obliteration of the subarachnoid space, significant relief for approximately 1 year followed decompressive laminectomy, foraminotomy, and discectomy, with disappearance of neurogenic claudication in three patients. Postoperative erect films showed no caudad passage of contrast. While further observations are required, an awareness of this complication of spinal stenosis is important in the diagnosis and management of such patients and in evaluating their ultimate prognosis.

Degenerative lumbar spondylolisthesis with an intact neural arch (pseudospondylolisthesis).

Twenty patients treated for degenerative spondylolisthesis with an intact neural arch principally at the L4-5 interspace had neural compression caused by dislocation of the vertebral bodies and intrusions of lamina and enlarged, arthrotic facets into a stenotic spinal canal. The resulting "pincer" effect caused complete or partial block demonstrable on myelography, with nerve root and cauda equina compression. Most of the patients were women aged 45-84 years. Seven had neurogenic claudication. The majority had unrestricted straight-leg raising, and no signs of acute neural entrapment were seen as in patients with a herniated disc. Absent ankle reflexes, and weakness and atrophy of the anterior tibial muscle group were common, while sensation was relatively undisturbed. Treatment consisted of liberal laminar decompression including foraminotomy and medial or total facetectomy. Good-to-excellent results were obtained, and no patient was made worse by the procedure.