[Effect of head elevation on intracranial pressure, cerebral perfusion pressure, and regional cerebral oxygen saturation in patients with cerebral hemorrhage]. / Influencia de la elevación de la cabeza sobre la presión intracraneal, presión de perfusión cerebral y saturación de oxígeno cerebral regional en pacientes con hemorragia cerebral.

OBJECTIVE: To study the effects on cerebral dynamics and regional oxygenation (rSO2) of the semi-sitting position, with the head at either 30 degrees or 45 degrees, in surgery for cerebral hemorrhage. PATIENTS AND METHODS: We performed a prospective study of 10 patients undergoing surgery for cerebral hemorrhage under sedation and analgesia and with mechanical ventilation. Intracranial pressure (ICP), mean arterial pressure (MAP), cerebral perfusion pressure (CPP), and rSO2 measured using near-infrared spectroscopy were recorded with the head in the supine position (0 degrees) and elevated to an angle of 30 degrees and then 45 degrees, following a stabilization period of 5 minutes. RESULTS: Mean (SD) ICP values were significantly lower in both semi-sitting positions than in the supine position: 2.8 (1.4) mm Hg lower at 30 degrees and 4.4 (1.4) mm Hg lower at 45 degrees. Mean CPP values were fell slightly when the head was elevated to 30 degrees (3.5 [3.1] mm Hg, P=.048); a greater reduction was achieved when the head was elevated 45 degrees (7.1 [4.8] mm Hg, P<.01). The greatest reduction in mean MAP values also occurred with the head elevated to 45 degrees (11.8 [4.6] mm Hg, P<.001). Mean rSO2 values fell when the head was elevated to 30 degrees and 45 degrees; the greatest reduction occurred when the head was elevated to 45 degrees (7% [2%], P<.001). There was a moderate correlation between CPP values and changes in rSO2 (r2=0.45, P<.001). CONCLUSION: Head elevation significantly reduces ICP and CPP in patients with cerebral hemorrhage. Head elevation also reduces rSO2, to a greater or lesser extent depending on the degree to which the head is elevated.

Non-surgical management of intracranial subdural hematoma complicating spinal anesthesia.

We report the case of a 29 year-old woman who presented a symptomatic intracranial subdural hematoma developing shortly after spinal anesthesia. The patient was fully conscious at clinical onset, and thus we treated her conservatively with an epidural autologous blood patch and close neurological observation. Given the clinical improvement the possibility of surgery was discauded in agreement with the neurosurgical team. Most cases of subdural hematoma appearing after spinal anesthesia are treated with surgery. In the present case the subdural hemorrhage was detected at our hospital 20 days after the anesthetic procedure, and given the excellent state of consciousness, we choosed a conservative management.

Effect of beta-carotene supplementation on indices of colonic cell proliferation.

BACKGROUND: Epidemiologic studies have shown that consuming foods containing beta-carotene is associated with a decreased incidence of colon cancer. The validity of this association has recently been questioned. It is not known if the rate of colonic cell proliferation differs among individuals with or without a history of colonic polyps or cancer and if proliferation changes in response to beta-carotene. PURPOSE: This study was intended to (a) determine whether differences exist in colonic cell proliferation in individuals with and without prior colonic polyps or tumors, (b) demonstrate that beta-carotene accumulates in colonic mucosa following dietary supplementation, and (c) determine whether mucosal beta-carotene accumulation influences colonic cell proliferation. METHODS: Subjects were enrolled in the phase I study from June 1991 until February 1994. The participants included 20 individuals (11 males and nine females, aged 62.3 +/- 8.9 years [means +/- SD]) with normal colons (as judged by recent colonoscopy), 40 (24 males and 16 females, aged 59.6 +/- 10.1 years) with a history of colonic polyp(s), and 41 (30 males and 11 females, aged 67.2 +/- 9.7 years) with prior colon cancer. The subjects in the last two groups consumed either 30 mg of beta-carotene or placebo each morning for 3 months. This dose of beta-carotene has no known toxic effects, but it can increase the serum level by approximately 10-fold. beta-carotene concentration in serum and colonic tissue was quantitated by high-pressure liquid chromatography in samples collected before and after supplementation with beta-carotene or placebo. Cellular proliferation was assessed on the basis of tissue ornithine decarboxylase activity, urinary polyamine excretion, and proliferating cell nuclear antigen expression. The differences in colonic cell proliferation parameters due to beta-carotene supplementation, within and among different groups, were evaluated by the Wilcoxon matched-pairs signed ranked test and the Mann-Whitney test, respectively. All statistical tests were two-sided. RESULTS: Colonic cell proliferation did not differ in samples obtained from individuals with and without prior colonic polyp(s) or cancer. beta-carotene concentrations in serum and colonic tissue were significantly increased in groups receiving beta-carotene (P < .001). However, cell proliferation did not differ, as judged by any of the three measures, among samples from all experimental groups collected before and after supplementation with beta-carotene. CONCLUSIONS: Dietary supplementation with beta-carotene for a period of 3 months does not alter colonic cell proliferation in individuals with a history of colonic polyps or cancer. IMPLICATIONS: The mechanism by which beta-carotene might reduce colon cancer incidence does not appear to involve or result in a change in cell proliferation in the normal colonic mucosa as studied in individuals with a history of colonic polyps or cancer.

Epidural Analgesia with Ropivacaine during Labour in a Patient with a SCN5A Gene Mutation.

SCN5A gene mutations can lead to ion channel defects which can cause cardiac conduction disturbances. In the presence of specific ECG characteristics, this mutation is called Brugada syndrome. Many drugs are associated with adverse events, making anesthesia in patients with SCN5A gene mutations or Brugada syndrome challenging. In this case report, we describe a pregnant patient with this mutation who received epidural analgesia using low dose ropivacaine and sufentanil during labour.

A binding event converted into a folding event.

We have designed a chimeric protein by connecting a circular permutant of the alpha-spectrin SH3 domain to the proline-rich decapeptide APSYSPPPPP with a three-residue link. Our aim was to obtain a single-chain protein with a tertiary fold that would mimic the binding between SH3 domains and proline-rich peptides. A comparison of the circular-dichroism and fluorescence spectra of the purified chimera and the SH3 circular permutant showed that the proline-rich sequence occupies the putative SH3 binding site in a similar conformation and with comparable interactions to those found in complexes between SH3 and proline-rich peptides. Differential scanning calorimetry indicated that the interactions in the binding motif interface are highly cooperative with the rest of the structure and thus the protein unfolds in a two-state process. The chimera is more stable than the circular permutant SH3 by 6-8 kJ mol(-1) at 25 degrees C and the difference in their unfolding enthalpy is approximately 32 kJ mol(-1), which coincides with the values found for the binding of proline-rich peptides to SH3 domains. This type of chimeric protein may be useful in designing SH3 peptide ligands with improved affinity and specificity.

Adenosquamous carcinoma of the prostate.

We describe a patient with adenosquamous carcinoma of the prostate. His history suggests a common histogenesis of the glandular and squamous elements of the tumor. A 60-year-old white man had adenocarcinoma of the prostate diagnosed by biopsy and then underwent radical prostatectomy, which showed adenosquamous carcinoma. Immunoperoxidase in the glandular component was positive for prostate-specific antigen (PSA), prostatic acid phosphatase (PAP), and low molecular weight keratin CAM 5.2 but was negative for high molecular weight keratin AE-3. The squamous component was negative for PSA, PAP, and CAM 5.2 but positive for AE-3. Previously reported patients with adenosquamous carcinoma of the prostate share a history of radiation or hormonal therapy followed much later by prostatectomy, suggesting that adenosquamous carcinoma consists of residual primary adenocarcinoma and metaplastic squamous epithelium caused by radiation or hormonal treatment. However, the present case lacks this history, suggesting that the two types of epithelia may have developed concurrently.

Fine-needle aspiration biopsy of adrenal masses in patients with extraadrenal malignancy.

BACKGROUND: Reports evaluating the efficacy of fine needle aspiration (FNA) of the adrenal gland have suggested a possible correlation between size of an adrenal mass and the presence of a primary or metastatic malignancy. These studies have focused on FNAs of all adrenal gland masses regardless of clinical history. This study investigates this relationship in a subpopulation of patients with a known history of primary extraadrenal malignancy. METHODS: All patients who have undergone computed tomographic-guided FNA biopsy of an adrenal mass at Loyola University Medical Center and Hines Veterans Administration Hospital, from 1985 to 1991, were reviewed. RESULTS: If size was assumed to be an independent predictor for presence of metastases, the highest efficiency was obtained with a cutoff value of 3 cm. This value divided the group into 15 (42%) "low-risk" (< or = 3 cm) and 21 (58%) "high-risk" (> 3 cm) subjects. In the "low-risk" group, 87% of the masses (13 of 15) were benign and 13% (2 of 15) were malignant. Within the "high-risk" group, more than 95% of the masses (20 of 21) were malignant, with a single (5%) benign case (p < 0.05). CONCLUSIONS: There is a significant correlation between the size of an adrenal nodule and the presence of metastases in patients with a known primary extraadrenal malignancy. Nodules greater than 3 cm have a very high probability of involvement by metastatic tumor. Nodules 3 cm or smaller are usually benign, but metastatic tumor can still be found in up to 13%. FNA biopsy is useful in evaluating adrenal masses in this setting.

New technique for producing uniform partial lacerations of tendons.

Previous experimental studies of partial flexor tendon lacerations have used tendons cut by hand with magnification and a scalpel. When we biomechanically tested chicken flexor tendons lacerated by hand through 75% of their cross-sectional area, the tensile strength of the residual tendons varied substantially among specimens from different chickens as well as between digit matched pairs of tendons from the same animal. A device was designed that uses standard scalpel blades to create a uniform tendon laceration by leaving a constant area of tendon intact regardless of original tendon size or shape. With the instrument we have called the "tenotome," a second group of chicken flexor tendons were lacerated through 75% of their cross-sectional area. Biomechanical testing of the tendons cut with the tenotome showed significantly less variation when compared with the tendons cut by hand. Use of the tenotome permits the establishment of a more uniform model for partial flexor tendon injuries, and potentially decreases the number of specimens needed to demonstrate statistical significance.

Fine-needle aspiration of supraclavicular lymph nodes.

Malignancies from many primary sites may metastasize to supraclavicular lymph nodes (SCLN). We reviewed 100 fine-needle aspirations (FNAs) of SCLNs. There were three major types of malignancy detected by this method: adenocarcinoma (n = 40), squamous cell carcinoma (n = 14), and other malignancies (n = 29). Adenocarcinomas and other malignancies from all sites tended to metastasize to the left SCLN. Squamous cell carcinomas from all sites, however, tended to appear on the right side. For 61 patients, a previous diagnosis of malignancy had been made within 1 yr of the clinical appearance of the abnormal SCLN. For 20 patients, the primary diagnosis antedated SCLN metastasis by more than 1 yr, particularly patients with adenocarcinoma of the breast, prostate, or thyroid papillary carcinoma.

Metastatic melanoma of the vulva identified by peritoneal fluid cytology.

Malignant melanoma of the vulva is an uncommon disease, with a significant portion of cases demonstrating metastasis to inguinal lymph nodes with potential distal spread. Identification of such metastases often requires fine-needle aspiration or biopsy. The cytologic diagnosis of metastatic vulvar melanoma from peritoneal effusions has not been previously described. We present the case of a 54-yr-old woman who underwent en bloc radical vulvectomy with bilateral inguinal lymphadenectomy for melanoma of the right labium minora. No evidence of metastatic disease was identified, and all surgical margins were free of tumor. Despite chemotherapy, the patient returned approximately 2 yr later with abdominal pain and distention. Computed tomography revealed marked ascites and three hepatic lesions. Cytologic examination of the ascites revealed recurrent, metastatic melanoma. Although very rare, metastatic melanoma of the vulva may present as a malignant effusion. In such an event, the diagnosis may be rendered by exfoliative cytology.

Is fine needle aspiration biopsy of salivary gland masses really necessary?

The use of fine needle aspirate biopsies (FNAB's) in the outpatient setting has progressively escalated, particularly in the area of head and neck pathology. An increasing percentage of these are for salivary gland masses. We present our experience with salivary gland FNAB's at our institution for four years, from 1988-1992. One thousand and twenty-two (1,022) FNAB's of superficial masses were performed by two pathologists. One hundred sixty-three (15.9%) were salivary gland biopsies. Of these 163 cases, 21 (12.9%) were normal tissue, 77 (47.2%) were inflammatory processes, 50 (30.7%) were benign tumors, and 15 (9.2%) were malignant tumors. None of the aspirates were unsatisfactory. Tissue correlation was possible in 47 (28.8%) cases. Two false negative cases (4.3%) were identified; these were a Warthin's tumor diagnosed as chronic sialoadenitis by FNAB; and a poorly differentiated squamous cell carcinoma diagnosed as adenocarcinoma by FNAB. There were no false positive cases. Overall sensitivity was 95.7% and specificity was 100%. Our experience indicates that FNAB of salivary glands is an effective screening procedure in evaluating salivary gland masses. The cytologic diagnosis may assist the clinician in allaying patients' anxieties, as well as in further collateral workup prior to definitive therapy.

The clinical context and utility of tongue biopsies.

Lesions of patients' tongue biopsies are described to determine whether certain patients had predilections to develop various lesions based on gender or age, and to determine whether there were significant correlations between the diagnoses, which could be clinically useful, and the various patients. Surgical pathology specimens of the tongue were reviewed. Patients' gender, age and diagnoses were recorded. Most of the 399 patients surveyed were elderly. Patients with epidermal inclusion cysts or granular cell tumors were significantly younger than others. Men were younger than women with squamous cell dysplasia and carcinoma. Benign diagnoses were nearly equally distributed between men and women. Premalignant and malignant conditions were significantly more common among men than women. Follow-up revealed a moderate degree of risk that a premalignant lesion may later develop frank malignancy.

[Special forms of analgesia: patient-controlled analgesia]. / Bijzondere vormen van pijnbehandeling: patient controlled analgesia.

Patient Controlled Analgesia (PCA) has been used by our Department since 1989 in the management of acute pain following major surgery. A total of 120 patients used the PCA pump in our hospital during the past 3 years. Ages varied from 5 to 20 years with an average of 10.5 years. Duration of administration was 1 day to 14 days with an average of 4 days. The morphine dosages fluctuated from 8 microgram/kg/hr to 37 microgram/kg/hr with an average of 17 microgram/kg/hr. During the first 24 hours postoperatively the average amount of morphine used with the PCAS was 36 microgram/kg/hr, which is higher than the usually prescribed dose of 25 microgram/kg/hr in the fixed rate infusions. No major complications occurred. Pain, sedation and other side effects were assessed by the ward nursing staff. Patient, parent and staff acceptance has been high. We conclude that PCA can be successfully managed by any child who understands the concept of pressing the button when there is pain and we feel that PCA has helped solve many of the problems of providing adequate analgesia in children. It is possible that patients on fixed rate morphine infusions were undermedicated during the first post-operative 24 hours.

Desorption of BTEX from activated charcoal using accelerated solvent extraction: evaluation of occupational exposures.

A procedure for the determination of benzene, toluene, ethylbenzene and o-xylene, m-xylene and p-xylene (BTEX) in occupational environments is proposed. These compounds are extracted from activated charcoal using accelerated solvent extraction. Operational parameters are optimized and quantitative recovery is obtained using acetonitrile as the extraction solvent and 1-mL extraction cells, a preheat time of 2 min, a temperature of 160 degrees C, a pressure of 1,500 psi, a static period of 5 min, a flush volume of 110%, two cycles and a purge time of 90 s. Determination of BTEX compounds is carried out by gas chromatography using a flame ionization detector. The recoveries, obtained for a confidence level of 95%, are 91 +/- 4, 100 +/- 3, 104 +/- 2, 93 +/- 4, 99 +/- 2 and 99 +/- 2% for benzene, toluene, ethylbenzene, o-xylene, m-xylene and p-xylene, respectively. The detection limits are 0.5 microg for benzene, 0.7 microg for toluene and 1.0 microg for the other compounds. The proposed procedure has been applied to real samples collected in several workplaces, like a microbiology laboratory, an analytical chemistry laboratory, a printer's, a car repair shop and a petrol station. From the results obtained, it can be concluded that the occupational exposures determined are always acceptable because they are lower than the tenth part of the recommended exposure limits (VLA-ED and VLA-EC).

Experimental retinochoroidal tissue vaporization with a CO2 laser probe.

The immediate and chronic effects of an intraocular carbon dioxide CO2 laser probe used for tissue vaporization were studied in cynomolgus monkeys' eyes. Acute lesions produced necrosis (from superficial to deep) of the retina and choroid, depending on the amount of energy used. Chronic lesions showed disorganization of the retina and choroid, with scar formation. Extensive tissue vaporization produced tractional retinal detachment in the chronic stage. Tractional detachment was prevented if the area of CO2 laser application was previously encircled with argon laser scars.

Immunohistochemical localization of cytokines in nevi.

Eight common nevi and 11 dysplastic nevi were evaluated for the presence of basic fibroblast growth factor, platelet-derived growth factor, transforming growth factor-alpha, interleukin-1-alpha, and interleukin-1-beta by immunohistochemical labelling with highly specific monoclonal antibodies. Basic fibroblast growth factor was abundant in the nevus cells and keratinocytes of nevi. Dysplastic nevus cells on average stained less intensely for basic fibroblast growth factor than did common nevus cells. In both types of nevi, basic fibroblast growth factor was identified in the basement membranes at the dermoepidermal junction and surrounding nevus cell nests and individual nevus cells. Labelling of nevus cells for transforming growth factor-alpha was variable, while there was moderate labelling for platelet-derived growth factor and light labelling for interleukin-1-alpha. Only two nevi, both dysplastic, stained (very faintly) for interleukin-1-beta. It is possible that these cytokines, especially basic fibroblast growth factor, act in autocrine fashion to maintain nevocellular growth and may also contribute to the epidermal hyperplasia and fibrosis frequently observed in nevi.