Surgical or Endovascular Treatment of MCA Aneurysms: An Agreement Study.

BACKGROUND AND PURPOSE: MCA aneurysms are still commonly clipped surgically despite the recent development of a number of endovascular tools and techniques. We measured clinical uncertainty by studying the reliability of decisions made for patients with middle cerebral artery (MCA) aneurysms. MATERIALS AND METHODS: A portfolio of 60 MCA aneurysms was presented to surgical and endovascular specialists who were asked whether they considered surgery or endovascular treatment to be an option, whether they would consider recruitment of the patient in a randomized trial, and whether they would provide their final management recommendation. Agreement was studied using κ statistics. Intrarater reliability was assessed with the same, permuted portfolio of cases of MCA aneurysm sent to the same specialists 1 month later. RESULTS: Surgical management was the preferred option for neurosurgeons (n = 844/1320; [64%] responses/22 raters), while endovascular treatment was more commonly chosen by interventional neuroradiologists (1149/1500 [76.6%] responses/25 raters). Interrater agreement was only "slight" for all cases and all judges (κ = 0.094; 95% CI, 0.068-0.130). Agreement was no better within specialties or with more experience. On delayed requestioning, 11 of 35 raters (31%) disagreed with themselves on at least 20% of cases. Surgical management and endovascular treatment were always judged to be a treatment option, for all patients. Trial participation was offered to patients 65% of the time. CONCLUSIONS: Individual clinicians did not agree regarding the best management of patients with MCA aneurysms. A randomized trial comparing endovascular with surgical management of patients with MCA aneurysms is in order.

The modified osteotome technique.

Patients who have been partially edentulous in the posterior segments for many years frequently present with reduced alveolar bone and/or enlarged sinuses. The choice of treatment for these patients will depend on the volume of residual bone, morphology of the alveolar crest, and amount of space available for the prosthesis. A new, minimally invasive surgical procedure using Summers osteotomes is described for the treatment of the edentulous posterior maxilla in which the bone thickness below the sinus is limited (> or = 5 mm). This suggested modified treatment is based on the use of a combination of osteotomes, drills, and screw-type implants with a rough surface texture.

Brief or new: two pronation splints.

For two years we have made pronation splints to assist quadriplegic patients who lack adequate forearm pronation but who have enough upper extremity strength to feed themselves and perform other self-care or functional activities. We have found the splints to be an appropriate alternative to the MAS. The first pronation splint fits underneath the arm, is simple in design and fabrication, and is hidden. However, occasionally the lever of the splint hangs up in the shirt, catches on the post of the wheelchair, or slips out from underneath the arm when the patient reaches away from the body. To eliminate these problems, we designed a second splint. But, this splint requires more time to make and adjust, has two parts to put on instead of one, and is more noticeable because it is worn on top of the arm rather than underneath it. When a patient uses either splint, the degree of pronation may be adjusted according to the activity by slightly rotating the splint either way when strapping it on. For example, full pronation may be required for feeding, but only half the range is necessary to operate the keyboard of a computer or typewriter. Once the Velcro straps are applied, the splints do not slip. The splints are not interchangeable from left to right and assistance is always needed to put them on. For patients with "weak" or "absent" wrist extensors, a wrist support and cuff splint may be used along with the pronation splint or a universal cuff, if wrist extension is adequate. The pronation splints are appropriate for those patients whose forearms supinate when they reach their hand to or near their mouth.

Renal biopsy in children in a developing country in 61 consecutive cases.

Percutaneous renal biopsy in children is a safe procedure. It is used for definitive diagnosis, prognosis and evaluation of the response to therapy. Repeated percutaneous biopsies are currently performed especially in allograft kidneys and in native kidneys as well. No major complications were noted in our series. The use of the new automated technique with small disposable needles in a well sedated child and experienced operator minimizes the complication rate. The important clinical benefit of the percutaneous renal biopsy overcomes the minimal risk of the procedure. Mesangiocapillary glomerulonephritis and focal segmental glomerulosclerosis are the predominant histological findings in our series. More data from other centers are necessary to evaluate the real incidence of the different entities of renal diseases in our country.

Spontaneous resolution of cholelithiasis in an infant.

Cholelithiasis is an extremely unusual finding in infancy. Hemolytic disease, bile duct abnormalities, intestinal malabsorption have been implicated. Recently, an association of prematurity, bronchopulmonary dysplasia, total parenteral nutrition and furosemide has been reported. Rarely, sonographic discovery of idiopathic gallstones and their subsequent spontaneous disappearance has been reported. We report a case of an 11-week-old infant whose initial sonogram displayed evidence of true gallstone, that later showed resolution on follow-up examinations. In the absence of clinical or imaging evidence of biliary tract disease, we suggest an initial conservative management and follow-up sonograms.

Genetics of autoimmune thyroid disease in the Lebanese population.

This study aims to investigate the association of human leukocyte antigen (HLA) class II genes and cytotoxic T lymphocyte-associated antigen-4 (CTLA-4) with autoimmune thyroid diseases in the Lebanese population. A total of 128 patients with autoimmune thyroid disease (55 with Graves' disease (GD) and 73 with Hashimoto's thyroiditis (HT)) were typed for HLA DQA1 (0301 and 0501) and DQB1 (0201, 0302, and 0303) and for 49A/G CTLA-4 using PCR-based sequence-specific priming methods. A total of 186 matched controls were typed for the same alleles and compared to the diseased population. Results showed no significant differences in HLA DQB1*0201 or DQB1*0301 allelic frequencies or CTLA-4 polymorphisms between patients and controls. For GD, there was a weak association with HLA DQB1*0302 [34.6% (19 of 55) vs. 21.5% (40 of 186), P = 0.048, odds ratio (OR) = 1.926, confidence interval (CI) = 0.999-3.715] and HLA DQB1*0302-DQA1*0501 haplotype [56.36% (31 of 55) vs. 40.8% (76 of 186), P = 0.042, OR = 1.870, CI = 1.018-3.433]. For HT, the frequencies of DQB1*0302-DQA1*0501 haplotype [28.8% (21of 73) vs. 14.5% (27 of 186), P = 0.008, OR = 2.378, CI = 1.241-4.558] and DQB1*0302-DQA1*0301 haplotype [60.2% (44 of 73) vs. 38.7% (72 of 186), P = 0.002, OR = 2.402, CI = 1.381-4.180] were significantly higher in patients. On the other hand, weak association was found between HT and DQA1*0301 allele [32.9% (24 of 73) vs. 20.9% (39 of 186), P = 0.044, OR = 1.846, CI = 1.011-3.373]. Findings show that DQB1*0302-DQA1*0501 and DQB1*0302-DQA1*0301 haplotypes may play a role in the pathogenesis of HT in the Lebanese population. For the 49A/G CTLA-4 polymorphism, no significant difference was found between patients and controls.

A double-blind, randomized, placebo-controlled trial of the effect of testosterone cream on the sexual motivation of menopausal hysterectomized women with hypoactive sexual desire disorder.

OBJECTIVES: To assess the safety and efficacy of 10 mg topical testosterone therapy daily (2 cm Andro-Feme cream) as a treatment for low sexual desire in postmenopausal hysterectomized women who were already on transdermal estrogen. METHODS: A double-blind, randomized, placebo-controlled, cross-over study (each period being of 3 months' duration) was performed in the research center of a tertiary referral women's hospital. Thirty-six menopausal healthy women were recruited who had undergone a hysterectomy, who were not depressed, were in a stable relationship and who fulfilled diagnostic criteria for low sexual desire, as measured by the Brief Index of Sexual Function for Women (BISF-W). MAIN OUTCOME MEASURES: The primary outcome measure was improvement in the sexuality score as measured by a validated tool (BISF-W); secondary measures were sub-scores of the BISF-W, effect on mood and energy, lipids and testosterone levels. RESULTS: Testosterone cream significantly improved sexual desire, frequency of sex, receptivity and initiation as measured by the BISF-W score. It did not change mood, energy, lipids, blood pressure or weight over the study period. CONCLUSIONS: Testosterone cream significantly improved sexual scores in menopausal women with low sexual desire. It was effective, easy to use and had no side-effects over the 3-month period of active treatment. It offers a novel and acceptable method of administering testosterone to menopausal women.

Effects of fasting on gluconeogenic enzymes in the ovine fetus.

Fetal and maternal sheep were studied to determine whether changes in gluconeogenic enzyme activities could be detected in the liver and/or kidney associated with maternal nutritional deprivation. Thirteen ewes and 16 fetuses were sacrificed in the fed state, while 13 ewes with 17 fetuses were sacrificed after 5 days of fasting, all at 125 days gestation (term = 147 days). Fetal weight was decreased in the fasted versus fed group (2.86 +/- 0.56 versus 3.61 +/- 0.58 kg, p less than 0.001). Tissues were analyzed for glucose-6-phosphatase, fructose-1,6-diphosphatase, pyruvate carboxylase, phosphoenolpyruvate carboxykinase, glutamate oxaloacetate aminotransferase, and glutamate pyruvate aminotransferase. In maternal liver, four of the six enzymes increased significantly during fasting, whereas none of the enzymes increased in maternal kidney. In fetal hepatic tissue, five of the six enzymes (with the exception of pyruvate carboxylase) increased during maternal fasting and three of the enzymes increased in renal tissue. These data are consistent with the potential for increased rates of gluconeogenesis in the ovine fetus during periods of compromised maternal nutrition.

Hyperthyroidism, diabetes mellitus and the congenital rubella syndrome.

A male patient born to a mother who developed rubella during the tenth week of gestation presented a typical congenital rubella syndrome with mental retardation, neuro-sensory deafness, hypoplasia of the dental enamel and chorioretinitis. Hyperthyroidism occurred at the age of 3 10/12 years and was treated successfully with propylthiouracil for 4 years. The course was complicated by premature craniosynostosis and a craniectomy was performed at the age of 7 years. Overt diabetes mellitus developed at 17 years and was well controlled by insulin therapy. Histocompatilibity (HLA) antigens were A2, B8, B40. Diabetes mellitus and thyroid disorders have previously been reported after congenital rubella, and recently after congenital cytomegalovirus infection. Our patient had both endocrinopaties. It is possible that HLA B8 antigens might be responsible for increased susceptibility to rubella infection.

[Bartter's syndrome: the long term effects of indomethacin on growth (author's transl)]. / Syndrome de Bartter: effets á long terme de l'indométacine sur la croissance.

Six children with Bartter's syndrome aged 6 years 4 months to 13 years 11 months were treated with indomethacin (1.7 to 4.3 mg/kg/day) during 7 to 27 months. A catch up growth was first observed, then growth curve was parallel to the normal. A catch up weight was also observed. The osseous maturation was the faster it was more delayed. These changes were observed despite a partial correction of potassium and plasma renine activity.

[Gastritis with hypoproteinemia in children. Relation to Menetrier's disease and cytomegalic inclusion disease]. / Gastrite avec hypoproteinemie chez l'enfant. Rapport avec la maladie de Menetrier et la maladie des inclusions cytomegaliques.

The case report concerns a 2 years old girl with hypoproteinemia associated with gastritis. The child recovered completely 8 weeks later. Cytomegalovirus was excreted in urine. The authors suggest that such a clinical picture should not be called Menetrier's disease. The role of cytomegalovirus is discussed.

Chronic alcoholism and endogenous gastrin.

Gastirn blood levels after the ingestion of a meat meal, either alone or associated with ethanol (1.0 gm./kg.), are higher and better sustained in dogs treated chronically with alcohol than in control animals. This greater gastrin-releasing capacity of the dog gastric antrum would be responsible for the increased parietal cell mass and gastric acid secretion shown by animals subjected to chronic alcohol intoxication.

Experimental lymphatic obstruction and fat absorption in the rabbit.

Using a previously published procedure of experimental abdominal lymphatic duct obstruction, we were unable to confirm increased faecal fat excretion after the operation. Nevertheless, the completeness of the obstruction and the huge dilatation of the lymph ducts of the villi have been verified. A spontaneous seasonal variation of faecal fat excretion has been observed in the rabbit with a maximum in October and November.