CM-Pf deep brain stimulation in polyneuromodulation for epilepsy.

OBJECTIVE: Neuromodulation is a viable option for patients with drug-resistant epilepsies. We reviewed the management of patients with two deep brain neurostimulators. In addition, patients implanted with a device targeting the centromedian-parafascicular (CM-Pf) nuclear complex supplements this report to provide an illustrative case to implantation and programming a patient with three active devices. METHODS: A narrative review using PubMed and Embase identified patients with drug-resistant epilepsy implanted with more than one neurostimulator was performed. Combinations of vagus nerve stimulation (VNS), deep brain stimulation (DBS), and responsive neurostimulation (RNS) were identified. We provide a background of a newly reported case of an adult with a triple implant eventually responding to CM-Pf DBS as the third implant following suboptimal benefit from VNS and RNS. RESULTS: In review of the literature, dual-device therapy is increasing in reports of use with combinations of VNS, RNS, and DBS to treat patients with drug-resistant epilepsy. We review dual-device implants with thalamic DBS device combinations, functional neural networks, and programming patients with dual devices. CM-Pf is a new target for DBS and has shown a variable response in focal epilepsy. We report the unique case of 28-year-old male with drug-resistant focal epilepsy who experienced a 75% seizure reduction with CM-Pf DBS as his third device after suboptimal responses to VNS and RNS. After 9 months, he also experienced seizure freedom from recurrent focal to bilateral tonic-clonic seizures. No medical or surgical complications or safety issues were encountered. CONCLUSION: We demonstrate safety and feasibility in an adult combining active VNS, RNS, and CM-Pf DBS. Patients with dual-device therapy who experience a suboptimal response to initial device use at optimized settings should not be considered a neuromodulation "failure." Strategies to combine devices require a working knowledge of brain networks.

Coenzyme Q10 administration increases antibody titer in hepatitis B vaccinated volunteers--a single blind placebo-controlled and randomized clinical study.

Persons involved in the study, 21 per treatment arm, were consuming ubiquinone (Q10), 90 mg/day, 180 mg/day or placebo, for two weeks prior to hepatitis B vaccination. After 30 days this vaccination was repeated. Q10 was given as soft gelatin capsules containing 30 mg each. The consumption was continued throughout the study conducted for 90 days. Clinical observations and laboratory tests were performed throughout the study and no adverse effects were observed in any of the groups. Already after 30 days the two groups receiving Q10 showed a slightly titer of antibodies to hepatitis B surface antigen then the placebo group. This difference escalated and the immunopotentiating effect of Q10 was even more clear-cut in the residual part of the study. In addition, a dose response did also seem to be present when comparing the 90 mg group with the 180 mg group. Statistics revealed that Q10 in the dose 180 mg/day is able to increase antibody response in vivo in humans vaccinated against hepatitis B with up to 57% (p = 0.011).

[Done is done--and gone is gone. Sex reassignment is presently the best cure for transsexuals]. / Bytt är bytt--kommer aldrig igen. Könsbyte för närvarande bästa hjälp för transsexuella.

Sweden was the first country to legislate on sex reassignment procedures in 1972. Patients with gender dysphoria are in Sweden referred to one of six university clinics specialised in the field; all surgery, however, is centralised to the Karolinska Hospital in Stockholm. The aetiological strivings regarding transsexualism have to date been inconclusive; however, several lines of evidence speak in favour of an early biological influence on gender identity. The vast majority of studies addressing outcome have provided convincing evidence for the benefit of sex reassignment surgery in carefully selected cases. The current article summarises the state of the art regarding work-up and treatment of transsexuals.

Angiography in epidemic nephropathy.

Nephroangiography has been performed in 35 patients with epidemic nephropathy during the course of the renal lesion phase. In addition to enlarged kidney with thickened cortex, generalized renal vasodilatation was demonstrated in the majority of the cases, frequently combined with rapid circulation. Thus, contrary to previous assumptions, acute oliguric renal insufficiency may also occur in cases with peripheral renal vasodilatation. The angiographic appearance of epidemic nephropathy was characteristic and most evident in the oliguric and anuric phases. Nephroangiography in acute oliguric renal failure may thus be of value for the differential diagnosis and thereby influence the clinical management of the patient.

Idiopathic retroperitoneal fibrosis and common bile duct stenosis. A case report.

The ordinary manifestations of idiopathic retroperitoneal fibrosis (IRF) with involvement of the ureters and urinary obstruction are well known. Quite a number of publications have made it clear that this disease process can often also affect organ systems other than the urinary tract--from the trachea and mediastinum to the rectum. The present case report calls attention to the fact that IRF may also be a surgically treatable cause of obstructive icterus.

Extrahepatic obstruction of the portal vein with bleeding from the gallbladder. Report of a case.

A case of extrahepatic obstruction of the common bile duct and the portal vein by a retroperitoneal neurolemmoma is described. In the initial stages portal hypertension with hepatofugal collaterals and bleeding from oesophageal varices existed. Then gradually, hepatopetal anastomoses developed, partly via veins in the wall of the gallbladder. Such venous collaterals tend to reduce the portal hypertension, but may cause bleeding from the gallbladder.

Serum activity of ornithine carbamoyl transferase in patients operated with jejunoileal bypass for extreme obesity after pretreatment with aminoacids.

Increased blood level of the liver specific enzyme ornithine carbamoyl transferase (OCT) is known to be a sensitive indicator of liver cell damage. The effect of preoperative aminoacid infusion to obese patients before jejunoileal bypass due to obesity was studied in 7 patients. They had a significantly lower rise on OCT than eight patients receiving only 5.5% glucose. The result seems to indicate that the liver in an obese patient undergoing abdominal surgery is protected against damage by an infusion of aminoacids.

Experimental and clinical evaluation of cholangiography with xeroradiography.

Conventional screen film radiography is compared with xeroradiography in an experimental model for cholangiography. The wider exposure latitude of the xerographic technique confers certain diagnostic advantages. However, the actual clinical application presents practical difficulties, which, combined with low sensitivity, are of such a nature that the method can hardly be considered suitable at the present time. If certain improvements can be made, xeroradiography could become a superior method for radiography of the bile ducts.

Bile duct diameter and diagnostic reliability at cholangiography.

Cases of exploratory choledochotomy with widened bile duct as the indication have been assessed with respect to missed bile duct concretion in a retrospective study covering a period of five years. During this period 2,000 cholecystectomies were performed. The 110 cases, in which (a) pre-exploratory cholangiography was completely normal apart from a diameter of more than 10 mm, (b) exploratory choledochotomy was performed, and (c) secondary cholangiography had been carried out, were studied in detail. No calculi were demonstrable either at exploratory surgery or secondary cholangiography. With a good radiographic technique it does not seem likely that bile duct concretions would be missed in widened ducts at otherwise normal operative cholangiography--at any rate not with bile duct diameters up to 20 mm.

Radiographic measurements on the radio-carpal joint in distal radial fractures.

Radiography of 40 wrists with fractures in the distal part of radius was performed. In the lateral view the inclination of the radial joint surface was analysed in different degrees of pronation and supination. The central ray was directed 15 degrees proximally and the results were compared with those obtained with a perpendicular central ray. In the perpendicular projections even moderate differences in pronation or supination between two examinations could seriously alter the measured inclination of the joint surface of the radius. The projection with the central ray directed 15 degrees proximally highly significantly decreased the errors between the measurements when compared to the perpendicular projection. The joint surface was depicted more dorsally inclined than in the perpendicular projection.

Early changes in the serum activity of ornithine carbamoyl transferase in patients operated on with a jejuno-ileal by-pass for extreme obesity.

In 13 patients operated on with jejuno-ileal shunting for extreme obesity the serum activity of ornithine-carbamoyl-transferase (S-OCT) was monitored. A rapid rise in the S-COT occurred and was observed at its peak between 2 and 8 hours after the operation. In 4 patients operated on for intestinal diseases much smaller rises in the S-OCT were noted. In a control group of 6 patients operated on for knee injuries, no changes of the S-OCT were noted after operation. The rise in the S-OCT is interpreted as a sign of liver cell damage of unknown cause in the patients with jejuno-ileal shunting.

Radiographic measurements of the radio-carpal joint in normal adults.

Radiography of 60 normal wrists was performed in 50 adults to determine the inclination of the distal joint surface of the radius. The central ray was directed 10 degrees proximally in postero-anterior projection and 15 degree proximally in lateral projection. The values obtained were compared with those from perpendicular projections. No dfferences were found between the two p.a. projections. In the lateral projection with the central ray directed proximally the measuring points were better defined, resulting in significantly increased exactness of the measurement. The mean value for the volar inclination was 9 degrees in the latter projection.

Assessment of deep venous insufficiency by ascending phlebography.

Retrograde femoral phlebography performed in the supine and erect positions are compared. In deep venous insufficiency, the contrast medium passes considerably farther down in the retrograde direction in examinations with the patient in the erect position. A comparison was made between ascending and retrograde techniques in order to find out what predictive value conventional ascending phlebography of the lower limb may have with regard to the function of the valves in the femoral vein. Layering of the contrast medium in the valvular sinus is a very reliable sign of valvular competence and was observed in two-thirds of the cases without deep venous insufficiency. This figure can be increased by a slight modification of the method of examination. Absence of layering does not necessarily indicate deep venous insufficiency.

Thyroid morphology and function after subtotal resection for hyperthyroidism.

Two main patterns of hyperplasia of the thyroid epithelium are seen in hyperthyroidism--toxic diffuse hyperplasia and toxic nodular hyperplasia. Toxic diffuse hyperplasia may affect the entire gland or it may arise in the extranodular tissue in a gland with nodular lesions. A series of patients treated by subtotal thyroidectomy for hyperthyroidism were classified into three morphological groups of goitre: 98 had a toxic diffuse goitre (TDG), 58 toxic nodular goiter with diffuse hyperplasia (TNGDH), and 105 toxic nodular goitre with nodular hyperplasia (TNGNH). The type of goitre was correlated to the development of disturbed thyroid function 1-6 years after surgery. Twenty-two patients with TDG and 18 (31 per cent) with TNGDH developed hypothyroidism; only 3 (3 per cent) with TNGNH showed hypofunction. Six patients with recurrent hyperthyroidism were found; all showed diffuse hyperplasia of the gland. It is concluded that the development of disturbed thyroid function after surgery is closely related to the histopathological type of goitre.

The importance of elevated TSH in serum after subtotal thyroidectomy for hyperthyroidism. A five-year follow-up study.

68 patients operated on for hyperthyroidism were observed regularly for 5 years after operation as regards the concentration of TSH in serum and the incidence of hypothyroidism and recurrent hyperthyroidism. 20 patients had elevated TSH 6 weeks after operation. 5 years later 9 of them had developed hypothyroidism, 6 had elevated TSH without clinical symptoms of hypothyroidism, while 5 were normal in all measured thyroid variables. 48 patients had normal TSH 6 weeks after operation. 5 years later 5 of them had developed a recurrence of hyperthyroidism, 4 had elevated TSH with no clinical symptoms of hypothyroidism, while the remaining 39 patients were euthyroid with normal thyroid variables. A scheme for follow-up of patients operated on for hyperthyroidism is proposed, with close follow-up of patients with elevated TSH soon after operation.

Clinical problems in relation to breast cancer screening with mammography. A preliminary report.

In the mammography screening in Ostergötland county, a shift to more favourable stages of breast tumours has been observed after five years of screening: stage I 71% and stage II 29% in the study group compared with stage I 40% and stage II 60% in the control group. 1 429 women were referred for clinical examination. 418 (29%) turned out to have breast carcinomas. 339 patients (23%) needed more than one clinical examination for definite diagnosis. 49% of the tumours were smaller than 11 mm, and only 32% of the small invasive cancers were suspected of malignancy at the clinical examination.

Renal blood flow in acute epidemic nephritis (nephropathia epidemica of Scandinavia).

Different haemodynamic and functional parameters were studied in 5 cases of acute epidemic nephritis with uraemia using nephroangiography and dye-dilution measurements combined with determination of extraction ratio and clearance for 51Cr-EDTA and PAH. In the acute phase, with greatly reduced renal function, increased vascular resistance was noted in spite of the vasodilatation observed in the renal artery out to and including the interlobular arteries. Moreover, angiography revealed enlarged kidneys with an increase in the thickness of the cortex and reduced cortical contrast accumulation. The renal blood flow, which was normal or slightly reduced initially, increased during convalescence, and renal function returned to normal. The investigation indicated that a primary vascular lesion in glomerular to postglomerular capillaries gives rise to pronounced interstitial oedema, which, probably as a result of secondary tubular compression, may be the cause of the rapidly developing renal failure.