Therapeutic potential of amniotic fluid stem cells to treat bilateral ovarian dystrophy in dairy cows in a subtropical region.

Amniotic fluid is a rich source of multipotent mesenchymal stem cells (MSCs). Amniotic fluid stem cells (AFSCs) have become a new source of stem cells; they have low immunogenicity and are easily harvested. For this reason, they may be useful in clinical tissue engineering. Moreover, AFSCs have anti-inflammatory properties and can repair tissues. This study evaluated the utility of AFSC injection to treat bilateral ovarian dystrophy in Holstein-Friesian cows. Bovine AFSCs (BAFSCs) were collected at slaughter from Holstein-Friesian cows during the third or fourth month of pregnancy and cultured in vitro. The BAFSCs began to show a fibroblast-like morphology. They were positive for ß-integrin, CD44, CD73, CD106 and Oct4 and negative for CD34 and CD45. After induction, the cells differentiated into mesodermal lineages. Bilateral ovarian dystrophy was confirmed by ultrasonography in 16 lactating cows. The subsequent experiment lasted 15 weeks. Serum was collected weekly to analyse progesterone concentrations, and weekly ultrasonography recorded ovarian changes. Each cow was equipped with an automatic heat detection system to facilitate oestrus observation and breeding records. The progesterone concentration of two cows in the treatment group (25%) significantly increased during weeks 10-15. On ultrasonography, the treatment group demonstrated mature follicles after BAFSCs injection, and foetuses were visualized approximately 40 days after artificial insemination (AI). Oestrus rates in the control and treatment groups were 0% (0/8) and 50% (4/8), respectively; pregnancy rates were 0% (0/8) and 25% (2/8), respectively. Calves were successfully delivered in both cases of pregnancy. These results show that BAFSCs can alleviate bovine ovarian dystrophy and restore fertility.

Mitochondrial DNA variants as genetic risk factors for Parkinson disease.

BACKGROUND AND PURPOSE: Investigation of the relationship between mitochondrial DNA (mtDNA) variants and Parkinson disease (PD) remains an issue awaiting more supportive evidence. Moreover, an affirming cellular model study is also lacking. METHODS: The index mtDNA variants and their defining mitochondrial haplogroup were determined in 725 PD patients and 744 non-PD controls. Full-length mtDNA sequences were also conducted in 110 cases harboring various haplogroups. Cybrid cellular models, composed by fusion of mitochondria-depleted rho-zero cells and donor mitochondria, were used for a rotenone-induced PD simulation study. RESULTS: Multivariate logistic regression analysis revealed that subjects harboring the mitochondrial haplogroup B5 have resistance against PD (odds ratio 0.50, 95% confidence interval 0.32-0.78; P = 0.002). Furthermore, a composite mtDNA variant group consisting of A10398G and G8584A at the coding region was found to have resistance against PD (odds ratio 0.50, 95% confidence interval 0.33-0.78; P = 0.001). In cellular studies, B4 and B5 cybrids were selected according to their higher resistance to rotenone, in comparison with cybrids harboring other haplogroups. The B5 cybrid, containing G8584A/A10398G variants, showed more resistance to rotenone than the B4 cybrid not harboring these variants. This is supported by findings of low reactive oxygen species generation and a low apoptosis rate in the B5 cybrid, whereas a higher expression of autophagy was observed in the B4 cybrid particularly under medium dosage and longer treatment time with rotenone. CONCLUSIONS: Our studies, offering positive results from clinical investigations and cybrid experiments, provide data supporting the role of variant mtDNA in the risk of PD.

Expression of high-mobility group box protein 1 in diabetic foot atherogenesis.

The role of high mobility group box 1 (HMGB1) has been demonstrated in stroke and coronary artery disease but not in peripheral arterial occlusive disease (PAOD). The pathogenesis of HMGB1 in acute and chronic vascular injury is also not well understood. We hypothesized that HMGB1 induces inflammatory markers in diabetic PAOD patients. We studied 36 diabetic patients, including 29 patients with PAOD, who had undergone amputation for diabetic foot and 7 nondiabetic patients who had undergone amputation after traumatic injury. Expression of HMGB1 and inflammatory markers were quantified using immunohistochemical staining. Mitochondrial DNA copy number was quantified using real-time polymerase chain reaction. Compared with that in the traumatic amputation group, HMGB1 expression in vessels was significantly higher in the diabetes and diabetic PAOD groups. In all subjects, arterial stenosis grade was positively correlated with the expression levels of HMGB1, 8-hydroxyguanosine, malondialdehyde, vascular cell adhesion molecule 1, and inflammatory markers CD3, and CD68 in both the intima and the media of vessels. Furthermore, HMGB1 expression level was positively correlated with 8-hydroxyguanosine, vascular cell adhesion molecule 1, nuclear factor-kB, CD3, and CD68 expression. Within the PAOD subgroup, subjects with HMGB1 expression had higher expression of the autophagy marker LC3A/B and higher mitochondrial DNA copy number. HMGB1 may be an inflammatory mediator with roles in oxidative damage and proinflammatory and inflammatory processes in diabetic atherogenesis. Moreover, it may have dual effects by compensating for increased mitochondrial DNA copy number and increased autophagy marker expression.

Quality-Adjusted Life Year Proxies for Caries in Primary Dentition: A Discrete Choice Experiment.

INTRODUCTION: Cost-utility analysis (CUA)-a method to evaluate intervention cost-effectiveness-transforms benefits of alternatives into a measure of quantity and quality of life, such as quality-adjusted life year (QALY), to enable comparison across heterogeneous programs. Measurement challenges prevent directly estimating utilities and calculating QALYs for caries in primary dentition. Proxy disease QALYs are often used as a substitute; however, there lacks quantitative evidence that these proxy diseases are comparable to caries. OBJECTIVE: To employ a discrete choice experiment (DCE) to quantitatively determine the most comparable proxy disease for different levels of caries in primary dentition. METHODS: A cross-sectional DCE survey was administered to respondents (N = 461) who resided in California, were aged ≥18 y, and were primary caretakers for ≥1 child aged 3 to 12 y. Four attributes were included: pain level, disease duration, treatment cost, and family life impacts. Mixed effects logistic regression and conditional logistic regression were used to analyze the survey data. RESULTS: Respondents from the overall sample preferred no pain over mild (odds ratio [OR] = 0.50, P < 0.05), moderate (OR = 0.57, P < 0.05), and severe pain (OR = 0.48, P < 0.05). Acute gastritis (OR = 0.44, P < 0.05), chronic gastritis (OR = 0.31, P < 0.01), and cold sore (OR = 0.38, P < 0.05) were less preferred than stage 1 caries. Acute tonsilitis (OR = 0.43, P < 0.05), acute gastritis (OR = 0.38, P < 0.05), chronic gastritis (OR = 0.26, P < 0.01), and cold sore (OR = 0.33, P < 0.01) were less preferred than stage 2 caries. Chronic gastritis (OR = 0.42,P < 0.05) was less preferred than stage 4 caries. CONCLUSIONS: Parents viewed the characteristics of many diseases with similar QALYs differently. Findings suggest that otitis media and its QALY-as commonly used in CUAs-may be a suitable proxy disease and substitute. However, other disease states with slightly different QALYs may be suitable. As such, the recommendation is to consider a range of proxy diseases and their QALYs when conducting a CUA for child caries interventions. KNOWLEDGE TRANSFER STATEMENT: This study reviews and systematically compares pediatric diseases that are comparable to caries in primary dentition. The findings may inform future research using cost-utility analysis to examine the incremental cost-effectiveness ratio of interventions to prevent and treat caries as compared with an alternative.

Role of mitochondrial DNA variants and copy number in diabetic atherogenesis.

Hyperglycemia-induced reactive oxygen species production can cause diabetes and its complications, including atherosclerosis. The role of mitochondrial DNA variants and mitochondrial copy number in the pathogenesis of diabetic atherogenesis is not well understood. We examined 36 diabetic patients who had undergone amputation for diabetic foot and seven non-diabetic patients who had undergone amputation after traumatic injury. Mitochondrial DNA was extracted and used for sequencing. Single nucleotide polymorphisms (SNPs) relative to the Cambridge reference sequence were analyzed. Mitochondrial DNA copy number was quantified by real-time PCR. Twenty-one novel variants were detected in 29 diabetic patients with arterial stenosis; six of the variants were heteroplasmic, and most occurred in highly evolutionarily conserved residues. These variants were more prevalent in patients with arterial stenosis than in those without stenosis. The novel variants included four in complex I (ND1: C3477A/C, A3523A/G; ND5: C13028A/C, C13060A/C), one in complex IV (COX1: T6090A/T), and one in rRNA (12srRNA: G857G/T). Compared with non-diabetic patients, the diabetic patients had significantly less mitochondrial DNA. Furthermore, among diabetic patients with arterial stenosis, there was a significant positive correlation between mitochondrial DNA copy number and the number of total SNPs. In conclusion, we identified six novel heteroplasmic mitochondrial DNA variants among diabetic patients with arterial stenosis, and we found that diabetic atherogenesis is associated with decreased amounts of mitochondrial DNA.

Secondary prophylaxis treatment versus on-demand treatment for patients with severe haemophilia A: comparisons of cost and outcomes in Taiwan.

This study compared secondary prophylaxis treatment with on-demand treatment for severe haemophilia A in Taiwan. Fifty patients from one medical centre were evaluated over a 5-year period. Differences in annual bleed rates and factor VIII (FVIII) utilization were assessed between patients receiving secondary prophylaxis and patients receiving FVIII concentrates on-demand. Results were then used as inputs in a pharmacoeconomic model to predict outcomes of future haemophilia therapy strategies in Taiwan. The median annual number of total bleeding episodes was significantly lower in the 13 (26%) patients who received secondary prophylaxis than in the 37 patients who received FVIII on-demand (7.76 vs. 31.91, P < 0.0001). The between-group difference in median annual factor VIII utilization was statistically significant (1824.41 IU kg(-1) for the prophylaxis group and 1324.81 IU kg(-1) for the on-demand group, P < 0.01). It was estimated that approximately $2 million (USD) per year would be added to the cost of treatment by having all severe haemophilia A patients in Taiwan receive secondary prophylaxis instead of on-demand therapy while 12,566 bleeding will be prevented. It is recommended that National Health Insurance officials utilize these data to evaluate the benefits of enhanced treatment strategies and before making substantial policy changes to haemophilia care in Taiwan.

Association between a common mitochondrial DNA D-loop polycytosine variant and alteration of mitochondrial copy number in human peripheral blood cells.

BACKGROUND: A T-to-C transition at mitochondrial DNA (mtDNA) nucleotide position 16189 can generate a variable length polycytosine tract (poly-C). This tract variance has been associated with disease. A suggested pathogenesis is that it interferes with the replication process of mtDNA, which in turn decreases the mtDNA copy number and generates disease. METHODS: In this study, 837 healthy adults' blood samples were collected and determined for their mtDNA D-loop sequence. The mtDNA copy number in the leucocytes and serum levels of oxidative thiobarbituric acid reactive substance (TBARS) and antioxidative thiols were measured. All subjects were then categorised into three groups: wild type or variant mtDNA with presence of an interrupted/uninterrupted poly-C at 16180-16195 segment. RESULTS: A step-wise multiple linear regression analysis identified factors affecting expression of mtDNA copy number including TBARS, thiols, age, body mass index and the mtDNA poly-C variant. Subjects harbouring a variant uninterrupted poly-C showed lowest mean (SD) mtDNA copy number (330 (178)), whereas an increased copy number was noted in subjects harbouring variant, interrupted poly-C (420 (273)) in comparison with wild type (358 (215)). The difference between the three groups and between the uninterrupted poly-C and the composite data from the interrupted poly-C and wild type remained consistent after adjustment for TBARS, thiols, age and body mass index (p=0.001 and p=0.011, respectively). A trend for decreased mtDNA copy number in association with increased number of continuous cytosine within the 16180-16195 segment was noted (p(trend)<0.006). CONCLUSIONS: Our results substantiate a previous suggestion that the mtDNA 16189 variant can cause alteration of mtDNA copy number in human blood cells.

Factors associated with gender difference in the intima-media thickness of the common carotid artery.

AIM: To investigate the gender differences associated with a thinner intima-media thickness (IMT) of the common carotid artery (CCA) in women. MATERIALS AND METHODS: In a sample of 218 consecutive healthy volunteers comprising 110 men and 108 women, the IMT of the CCA was measured using B-mode ultrasonography. Blood pressure, fasting blood sugar, body mass index (BMI), blood lipid profile, homocysteine, folic acid, uric acid, high sensitive C-reactive protein, and thiobarbituric acid reactive substances (TBARS) levels were measured and compared with each other in both genders. RESULTS: The IMT of the CCA was significantly thinner in women than in men (p=0.012). Blood pressure, fasting plasma glucose, BMI, low-density lipoprotein cholesterol, triglycerides, homocysteine, uric acid, and TBARS were significantly (p<0.05) lower, folic acid and high-density lipoprotein cholesterol (HDL-C) were significantly (p<0.0001) higher in women compared with men. Multivariable logistic regression analysis revealed that higher serum levels of homocysteine, uric acid, and TBARS, and lower serum levels of HDL-C were significantly (p<0.05) associated with male sex. Multiple linear regression analysis further revealed that age, sex, and BMI were independently associated with CCA IMT. CONCLUSIONS: The IMT of the CCA was thinner in women than in men. Traditional vascular risk factors explain only a small amount of variance in multivariate regression models supporting the hypothesis that other behavioural, sex hormone-related or genetic factors, which have not been sufficiently explored so far, may play a role in the gender differences of IMT.

Metabolic syndrome and three of its components as risk factors for recurrent ischaemic stroke presenting as large-vessel infarction.

BACKGROUND AND PURPOSE: Although a clear protocol for reduction of recurrent ischaemic stroke (RIS) has been established, few studies have compared the stroke subtype distribution and risk factors between RIS and first-ever stroke (FES). METHODS: This one-year hospital-based study enrolled 587 FES and 475 RIS patients. Patients were categorized into four stroke subtypes according to a modified TOAST stroke subtype classification system. Risk factor profiles were compared between the two major stroke groups and between the corresponding four subtypes to discriminate the significant risk factors for RIS. RESULTS: A multivariate regression analysis identified hypertension (OR, 1.87; 95% CI, 1.34-2.62), diabetes mellitus (DM) (OR, 1.57; 95% CI, 1.22-2.02), low high-density lipoprotein (LHDL) (OR, 1.43; 95% CI, 1.08-1.88) and older age as significant RIS risk factors. The significance of the former three RIS factors was further recognized in its large-vessel subtype. Moreover, metabolic syndrome was significantly more common in the recurrent stroke group (P = 0.01), including its large-vessel subtype (P = 0.04). Progressively increasing odds ratios from 1.49 to 2.02, in accordance with increased number of diagnostic components of metabolic syndrome for recurrent large-vessel ischaemic stroke, were noted. CONCLUSIONS: Metabolic syndrome likely plays a crucial role in the development of RIS, including large-vessel infarction in modern-day Taiwan.

Total cardiovascular risk profile of Taiwanese vegetarians.

BACKGROUND: Although the health benefits of vegetarian diets have been well documented among Western population, there are geographic differences of vegetarian diets and the health benefits of the Taiwanese vegetarian diet have not been studied extensively. In addition to conventional risk factors, homocysteine and high-sensitivity C-reactive protein (hs-CRP) levels have been found to predict first atherothrombotic events. We undertook this study to examine the total risk profile of Taiwanese vegetarians. METHODS: A total of 198 healthy subjects (99 vegetarians and 99 omnivores) were recruited. Fasting blood samples were analyzed for glucose, cholesterol, triglyceride, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), white blood cell count, hs-CRP and homocysteine. RESULTS: There was no significant difference in age, body mass index, blood glucose, white blood cell count, triglyceride and HDL-C between the two groups. The vegetarian group had significantly more females (65.7 vs 46.5%); lower body weight (58.66+/-11.13 vs 62.88+/-12.24 kg); shorter height (159.14+/-7.88 vs 162.53 +/-8.14 cm); lower total cholesterol (184.74+/-33.23 vs 202.01+/-41.05 mg/dl); and lower LDL-C (119.63+/-31.59 vs 135.89+/-39.50 mg/dl). Hs-CRP was significantly lower (0.14+/-0.23 vs 0.23+/-0.44 mg/dl, P=0.025), whereas homocysteine was significantly higher (10.97+/-6.69 vs 8.44+/-2.50 micromol/l, P=0.001) in vegetarians than omnivores. CONCLUSIONS: Taiwanese vegetarians have lower total cholesterol, LDL-C and hs-CRP levels, and higher homocysteine levels than omnivores. Owing to different predictive value of each risk factor, the Taiwanese vegetarians had a better cardiovascular risk profile than omnivores. Whether the Taiwanese vegetarian diet should be supplemented with vitamin B(12) to lower serum homocysteine level remains to be addressed.

Upregulation of nitric oxide synthase II contributes to apoptotic cell death in the hippocampal CA3 subfield via a cytochrome c/caspase-3 signaling cascade following induction of experimental temporal lobe status epilepticus in the rat.

Status epilepticus results in preferential neuronal cell loss in the hippocampus. We evaluated the hypothesis that the repertoire of intracellular events in the vulnerable hippocampal CA3 subfield after induction of experimental temporal lobe status epilepticus entails upregulation of nitric oxide synthase II (NOS II), followed by the release of mitochondrial cytochrome c that triggers the cytosolic caspase-3 cascade, leading to apoptotic cell death. In Sprague-Dawley rats, significant and temporally correlated upregulation of NOS II (3-24h), but not NOS I or II expression, enhanced cytosolic translocation of cytochrome c (days 1 and 3), augmented activated caspase-3 in cytosol (days 1, 3 and 7) and DNA fragmentation (days 1, 3 and 7) was detected bilaterally in the hippocampal CA3 subfield after elicitation of sustained seizure activity by microinjection of kainic acid into the unilateral CA3 subfield. Application bilaterally into the hippocampal CA3 subfield of a selective NOS II inhibitor, S-methylisothiourea, significantly blunted these apoptotic events; a selective NOS I inhibitor, N(omega)-propyl-l-arginine or a potent NOS III inhibitor, N(5)-(1-iminoethyl)-l-ornithine was ineffective. We conclude that upregulation of NOS II contributes to apoptotic cell death in the hippocampal CA3 subfield via a cytochrome c/caspase-3 signaling cascade following the induction of experimental temporal lobe status epilepticus.

Mitochondrially targeted antioxidants and thiol reagents.

Mitochondrial oxidative damage and dysfunction contributes to a number of cell pathologies. To investigate how this damage affects cell function we have developed mitochondrially targeted antioxidants and thiol reagents by covalently linking them to lipophilic cations. The cation drives the selective accumulation of these reagents into mitochondria within cells where the antioxidants decrease oxidative damage and the thiol reagents enable measurement of the redox status of thiol proteins. In conjunction with cell and animal models of apoptosis, oxidative damage, and nitric oxide signaling, these molecules may provide new insights into the roles of mitochondria in human pathologies.

Generalized argyria in two chronic hemodialysis patients.

Silver can be absorbed through ingestion, topical administration, or inhalation. Generalized argyria results from deposition of silver in the skin, nails, mucous membranes, and internal organs and is characterized by a diffuse bluish-gray discoloration in sun-exposed areas. We report two cases of generalized argyria in patients on maintenance hemodialysis (HD) therapy for more than 15 years. They presented with diffuse hyperpigmentation of the face that was mistaken to be related to uremia and bluish-gray discoloration of all nails believed to be cyanosis. Histopathologic examination of skin biopsy specimens showed characteristic findings of argyria, which was further confirmed by radiograph microanalysis. Their serum silver levels were also elevated. No definite silver source could be determined. However, their argyria might be related to their long-term HD therapy because (1) they had been on HD therapy for more than 15 years and the discoloration appeared several years afterward, and (2) the water used for HD was not well processed in the early 1980s in TAIWAN: Argyria should be suspected in chronic HD patients presenting with a diffuse bluish-gray discoloration of the skin and nails and evaluated carefully by skin biopsy.

Effect of growth hormone therapy in men with severe idiopathic oligozoospermia.

Some studies have suggested that growth hormone (GH) may enhance folliculogenesis in women, and similarly may enhance spermatogenesis in men with hypogonadotrophic hypogonadism. In this prospective open-controlled pilot study, we investigated the effect of daily subcutaneous GH for 5 months in 12 endocrinologically normal men with severe idiopathic oligozoospermia (< 10 million/ml). All the men had normal karyotype and endocrine tests, including a GH response of > 20,000 mU/l to insulin hypoglycaemia. Nine men with similar sperm counts acted as controls. During treatment, each patient was examined monthly, asked for side effects and had glycosylated haemoglobin, glucose and blood counts monitored. Five semen samples were obtained in the 4 months before treatment, two samples per month during treatment and three samples after stopping treatment. The mean insulin-like growth factor I (IGF-I) was normal before treatment and 1 month after ending treatment, at 206 and 182 micrograms/l, respectively, but increased significantly during treatment to 444 micrograms/l (p < 0.0001, ANOVA). The mean (SD) sperm counts were 2.6 (2.5), 2.5 (3.7) and 2.3 (2.1) million/ml before, during and after GH treatment, respectively, and did not show any statistically significant differences (ANOVA). We conclude that GH does not increase or decrease sperm counts in men with severe idiopathic oligozoospermia.

Pericardial angiosarcoma simulating pericardial effusion by echocardiography.

A fast-growing angiosarcoma caused incapacitation of a boy and death in a period of three months. The growth of the tumor was well documented by a series of echocardiograms. The heart was well encased by a thick layer of purplish vascular neoplasm enveloped mostly by thin pericardium, with some additional few foci of extracardiac metastasis. The heart weighed 2,000 gm. It is worthy to note that another cause of an echo-free space may be the presence of a pericardial tumor, rather than pericardial effusion.

The erythrocyte cell hemoglobin distribution width segregates thalassemia traits from other nonthalassemic conditions with microcytosis.

Red cell heterogeneity, as represented by the red cell distribution width (RDW), can be used to distinguish thalassemia traits from iron deficiency. Two other indices of heterogeneity, the hemoglobin distribution width and the cell hemoglobin distribution width (CHDW), are also available. In addition, the CHDW may reflect the process of cell hemoglobinization more accurately than does the RDW. In this study, recursive partitioning methods were used to compare the ability of these three indices to discriminate between thalassemia traits and other nonthalassemic conditions among hospital patients who had microcytosis. The data indicate that the CHDW can segregate patients who have either iron replete or iron deficient nonthalassemic conditions from those who have thalassemia traits. A CHDW level of less than 3.05 correctly discriminated 78.4% of patients in a mixed hospital sample. A CHDW/RBC ratio of 0.57 improved the segregation further, with a sensitivity of 79.2% and a specificity of 88.5% for the identification of a thalassemia trait.

Delayed intracerebral hematoma caused by traumatic intracavernous aneurysm: case report.

Although delayed intracerebral hematomas from head injury are not uncommon, they are extremely rare when they are caused by extradural (extracranial) pseudoaneurysms of the internal carotid artery in the cavernous sinus. The case of a 33-year-old man who sustained a delayed frontal intracerebral hematoma from a traumatic intracavernous aneurysm 32 days after a head injury is presented. Posterior frontal base fractures accounted for monocular blindness and injury over the anterior siphon of the intracavernous carotid artery, which resulted in the formation of a pseudoaneurysm inside the sphenoid sinus. Subsequently, the cranial base fractures with secondary defects provided a route for the pseudoaneurysm to rupture intracranially and also accounted for intractable cerebrospinal fluid rhinorrhea and pneumocephalus after surgical treatment for the pseudoaneurysm and the intracerebral hematoma.

Chylothorax after endoscopic sympathectomy: case report.

Endoscopic sympathectomy is a new trend for the treatment of hyperhidrosis palmaris. It is a simple and effective technique; however, it carries some recognized risks such as Horner's syndrome and pneumohemothorax. We recently encountered a case complicated by the development of a chylothorax. The patient was a 23-year-old healthy women with profuse palmar sweating. She developed an intractable dry cough after a transthoracic endoscopic sympathectomy. A chest x-ray revealed a left pleural effusion. A chylous effusion was found after thoracentesis and fluid analysis. The pleural effusion resolved after chest tube drainage and diet control. Although endoscopic sympathectomy is a simple and quick procedure, unusual complications, such as chylothorax, may occur. Appropriate early recognition and treatment can prevent a disastrous result.

Cerebral arteriovenous malformations: factors influencing the surgical difficulty and outcome.

The outcomes of 151 patients with arteriovenous malformations (AVMs) treated either surgically or conservatively are presented. In terms of long-term survival rate and follow-up results, the patients who underwent total excision had more favorable results than did those treated conservatively. Patient age was the most important clinical factors, with the preoperative level of consciousness being the second most important. A grading system was formulated on the basis of the angiographical factors by using multiregression analysis; the size of the AVM influenced the surgical outcome twice as much as did the location and the pattern of arterial feeding. Thus, a large AVM (greater than or equal to 4 cm) was given 2 points; a small AVM (less than 4 cm) was given 0 points; a deep AVM was given 1 point; a superficial AVM was given 0 points; an AVM supplied by three of more artery systems was given 1 point; and an AVM supplied by one or two artery systems was given 0 points. AVMs were categorized into 5 grades from Grade 0 to 4 by the summation of these points. Predicted Karnofsky scale after surgery was calculated by this grading system and the following equation: predicted Karnofsky scale = 87.2 - 5.6 x Grade. Grade 0 and 1 AVMs showed high rates of total excision (Grade 0, 94%; Grade 1, 82%) and of satisfactory outcome (Grade 0, 90%; Grade 1, 82%) and were classified as "easy" lesions. Grade 2 AVMs are lesions classified as "moderate" and had a total excision rate of 76% and a satisfactory outcome rate of 71%.(ABSTRACT TRUNCATED AT 250 WORDS)

The expectant treatment of "asymptomatic" supratentorial epidural hematomas.

Seventy-four patients with a traumatic epidural hematoma (EDH) and a Glasgow Coma Scale score of more than 12 received expectant treatment; 14 subsequently underwent surgical evacuation of the EDH. A patient with initial brain computed tomograms (CT) showing an EDH volume of more than 30 ml, a thickness of more than 15 mm, and a midline shift beyond 5 mm tended to require surgery within 3 days of the injury when the brain had exhausted its compensatory mechanism and yielded to the expanding EDH. After the 3-day period, in the absence of neurological symptoms, the presence of the EDH may not be an indication for surgical evacuation or hospitalization beyond 7 days. In our patients, the presence of a skull fracture in the temporal bone, the heterogeneous density of the EDH in the CT scan, or the 6-hour period between the CT study and the injury did not significantly increase the failure rate of nonsurgical treatment. Although a zero mortality was achieved in this series, these guidelines may not be applicable to the management of an infratentorial EDH.