A retrospective chart review of 435 consecutive intracarotid amobarbital tests (IAT) was performed to determine the frequency of carotid artery dissection (CAD) associated with IAT. Three patients ...with a CAD were found (0.7%). Mean age of patients with dissection (51.3 years) was higher than the average age of 432 patients without dissection (31.7 years) (p < 0.05). All patients had clinical symptoms including face or neck pain. Patients undergoing the IAT are at risk of CAD. Age may be a risk factor.
Quantitative indexes of compute tomography were compared in 28 patients with Alzheimer dementia and in 30 elderly persons with no history of neurologic disease. Age-corrected ventricle-brain ratios ...were abnormal for half of the dementia patients, whereas only a single subject in the control group had ventricles outside the limits of normal variation. Measurement of the distance between the third ventricle and Sylvian fissure indicated that the dementia patients had significantly more atrophy in this area. Employment of quantitative indexes standardized for age may aid in differentiating cerebral atrophy associated with dementia from that associated with normal aging.
PURPOSE: To assess the ability of the urinary N-telopeptide of type I collagen (NTx) to monitor and predict therapeutic effects of hormone replacement therapy (HRT) in postmenopausal women.
PATIENTS ...AND METHODS: To assess the relationship between baseline or change in NTx (predictive variable), and change in lumbar and hip bone mineral density (BMD; outcome variable), we conducted a 2-year randomized controlled study at academic university and private practice medical centers in 236 healthy women 1 to 3 years postmenopausal; 227 women completed the study. Women received estrogen plus progesterone plus calcium (treated group) or calcium alone (control group).
RESULTS: In the treated group NTx significantly (P <0.0001) decreased, and spine and hip BMD significantly (P <0.00001 and P <0.005, respectively) increased; in the control group NTx did not change but BMD decreased significantly (P <0.01). Subjects in the highest quartiles for baseline NTx (67 to 188 units) or decreasing NTx (−66% to −87%) through 6 months demonstrated the greatest gain in BMD in response to HRT (P <0.05 and P <0.005). For every increase of 30 units in baseline NTx, the odds of gain in BMD in response to HRT increased by a factor of 5.0 (95% confidence interval CI 1.9 to 13.3); for every 30% decrease in NTx through 6 months, the odds of gaining BMD in response to HRT increased by a factor of 2.6 (95% CI 1.6 to 4.4). In the control group an increase of 30 units in mean NTx across the study indicated a higher odds of losing BMD by a factor of 3.2 (95% CI 1.6 to 6.5). A high baseline NTx (>67 units) indicated a 17.3 times higher risk of BMD loss if not treated with HRT.
CONCLUSION: These data support the clinical utility of NTx to monitor the antiresorptive effect of HRT in recently postmenopausal women, and to predict changes in BMD in response to HRT.
The clinical and EEG features of 11 patients with seizures arising in the supplementary motor area (SMA) were reviewed. All patients underwent prolonged EEG with simultaneous video recording. Three ...patients had recordings and electrical stimulation of the SMA using subdural electrode arrays. All patients had preservation of consciousness during the seizure unless it became secondarily generalized. Tonic posturing of the extremities was present in all patients, and in seven it was present bilaterally. Adversive movements were not seen unless the seizure became secondarily generalized. Interictal and/or ictal abnormalities were present at or adjacent to the midline in ten patients. Seizures arising from the supplementary motor region are clinically distinct, and the diagnosis can almost always be verified with prolonged EEG/video recording.
We describe 6 patients who demonstrated postoperative neurological deficits despite unchanged somatosensory evoked potentials during intraoperative monitoring. Although there is both experimental and ...clinical evidence that somatosensory evoked potentials are sensitive to some types of intraoperative mishap, the technique should be employed with an awareness of its possible limitations.
In evaluation for surgical treatment of intractable psychomotor seizures originating in the language-dominant left mesiotemporal region, subdural grid electrodes were placed in 29 patients over the ...temporoparietal cortex and over the basotemporal region. In 13 patients, cortical stimulation of the basotemporal region showed interference with language processing. The most anterior border of the basotemporal language area began 1.1 cm posterior to the anterotemporal tip, and the most posterior margin of the language region was located 6.1 cm posterior to the temporal tip. The most lateral and the most mesial border were located 1.4 and 5.9 cm, respectively, from the lateral edge of the temporal lobe. The region in which language disturbance could be elicited included the inferior temporal gyrus, the fusiform (lateral and medial occipitotemporal) gyrus, and the parahippocampal gyrus. The basotemporal area most consistently involved with language function was the fusiform gyrus (60% of affected electrodes), followed by the inferotemporal (30%), and the parahippocampal (10%) gyri.
To determine the technical success rate of sentinel lymph node biopsy in women with nonpalpable infiltrating breast cancer diagnosed by using percutaneous core biopsy and to determine the frequency ...with which sentinel lymph node biopsy obviated axillary dissection.
Retrospective review revealed 33 women who underwent sentinel node biopsy after percutaneous core biopsy diagnosis of nonpalpable infiltrating breast cancer. Sentinel nodes were identified with radioisotope and blue dye; the procedure was technically successful if sentinel nodes were found at surgery. All sentinel nodes were excised. Axillary dissection was performed if tumor was present in sentinel nodes.
Sentinel nodes were found at surgery in 30 women (91%). Sentinel nodes were identified with both radioisotope and blue dye in 22 (73%) of these women, with only radioisotope in six (20%), and with only blue dye in two (7%). Sentinel nodes were found in 12 (80%) of 15 women in the first half of the study versus all 18 (100%) women in the second half (P = .08). Sentinel nodes were free of tumor in 23 (77%) of 30 women. In six (86%) of seven women with tumor in sentinel nodes, the sentinel nodes were the only nodes with tumor.
Sentinel node biopsy was successful in 30 women (91%) with nonpalpable infiltrating carcinoma diagnosed with percutaneous core biopsy and obviated axillary dissection in 23 women (70%). Using both radioisotope and blue dye may increase the success rate. A learning curve exists, and success improves with experience.
Femoral component revisions with extensively coated stems have shown promising clinical results, although concerns over stress shielding still exist. We retrospectively reviewed 59 patients ...undergoing femoral component revision with an extensively hydroxyapatite (HA)-coated stem. The average length of follow-up was 3.3 years (range, 2–5 years). The average preoperative Harris Hip Score was 43 points, which improved to 86 points at the latest follow-up (
P<.01). The overall mechanical failure rate was 2%. No evidence of stress shielding was seen in 78% of patients. The clinical results of this series using an extensively HA-coated stem are similar to those using an extensively porous-coated stem. Long-term follow-up is required to determine if an extensively HA-coated implant will be superior to an extensively porous-coated implant with regard to stress shielding
Fifty-six (5.8%) patients with partial epilepsy secondary to central nervous system (CNS) infection (meningitis = 20 and encephalitis = 36) were identified from 963 patients studied with prolonged ...video-EEG monitoring. Twenty-seven (48.2%) patients had unilateral mesial temporal lobe epilepsy (UMTLE), 9 (16.1%) had bilateral mesial temporal lobe epilepsy (BMTLE), and 20 (35.7%) had neocortical epilepsy (NE). Younger age at infection and prolonged latency between the time of infection and development of epilepsy were predictive factors for UMTLE. Predictors for BMTLE were late age of infection and short latency between infection and epilepsy development. Development of NE was associated with short latency between infection and epilepsy, and younger age at infection. When outcome after temporal lobectomy was compared between the UMTLE group and a control group with UMTLE without history of CNS infection, no statistically significant differences were found.
Central nervous system infection may lead to epilepsy, which in many cases,3is generated by a single portion of the brain. In such cases, epilepsy surgery should be considered, as in patients without history of CNS infection.
Background. In patients with acute profound cardiogenic circulatory failure unresponsive to conventional resuscitation, we instituted immediate aggressive application of extracorporeal membrane ...oxygenation (ECMO) to restore circulatory stability. Long-term hemodynamic support was accomplished with an early “bridge” to ventricular assist device (VAD) before definitive treatment with cardiac transplantation.
Methods. A respective review of ECMO and VAD data registries was instituted.
Results. From May 1996 to July 2000, 23 patients were placed on ECMO support for profound cardiogenic circulatory failure. Eleven patients (47%) were withdrawn from support due to severe neurologic injury or multisystem organ failure. Three patients (13%) were weaned off ECMO with good outcome. Nine patients (39%) were transferred to a VAD. Two patients expired while on VAD support, and 7 of the VAD-supported patients (78%) survived to transplantation. Overall survival was 43%.
Conclusions. Emergent ECMO support is a salvage approach for cardiac resuscitation once conventional measures have failed. In neurologically intact patients, the early transfer to a VAD quickly stabilizes hemodynamics, avoids complications, and is essential for long-term circulatory support before definitive treatment with cardiac transplantation.
