Reappearance Of Symptoms Research Articles

Le devenir de l’adolescent allergique

Asthma remission is rarely observed in allergic adolescents. Indeed, allergy, along with bronchial hyperresponsiveness, is the principal risk factor for persistence of asthma from childhood to adulthood. Even when clinical remission is observed in allergic adolescents, the disappearance of symptoms is most often transitory, frequently being followed by the reappearance of symptoms in adulthood. This clinical pattern is commonly associated with more marked abnormal lung function, its origin probably being very early in childhood asthma.

Enfermedad de Still del adulto con desarrollo de insuficiencia hepática que precisa trasplante hepático

We present the case of a 23-year-old man with fever of unknown origin, who developed acute liver failure 2 months after symptom onset, requiring an urgent liver transplantation. The diagnosis of adult-onset Still's disease was established after the reappearance of symptoms after transplantation, and high doses of corticosteroids were used to control disease activity. Subsequently, given the impossibility of tapering the steroid dose, interleukin-1 receptor blocking treatment was started with satisfactory outcome. We also review the published literature.

Considerations in the treatment of multiple myeloma: a consensus statement from Italian experts

PURPOSE AND BASIC PROCEDURE OF THE STUDY: The availability of new targeted therapies has revolutionised the treatment of multiple myeloma (MM), for both the newly diagnosed and the relapsed and refractory settings. A panel of Italian experts provided guidelines for optimal clinical practice in the treatment of MM. The panel recommended that treatment should only be initiated in symptomatic patients. Autologous stem cell transplantation (ASCT) with melphalan is the treatment of choice in patients younger than 65 yr, and induction therapy including new drugs seems the most suitable preparatory regimen before ASCT. In patients who fail to achieve at least a very good partial response (VGPR) after transplant, a consolidation with a second transplant is of clinical benefit. Also, there is evidence that maintenance with thalidomide after ASCT in young patients failing to reach at least VGPR could prolong survival. In elderly patients, the combination of an alkylating drug with a novel agent should be considered as standard approach. Relapsed MM should be retreated after the reappearance of symptoms and signs of organ and tissue damage. Salvage regimens should include corticosteroids plus bortezomib, thalidomide or lenalidomide.

NIH State-of-the-Science Conference Statement on Manifestations and Management of Chronic Insomnia in Adults

NIH State-of-the-Science Conference Statement on Manifestations and Management of Chronic Insomnia in Adults

Contrast-enhanced ultrasound (CEUS) assessment of superselective uterine fibroid embolization (SUFE): Preliminary experience

Purpose The use of superselective uterine fibroid embolization (SUFE) requires imaging techniques that can be used to verify the success of the procedure. The purpose of our study was to analyze the potential value of pre- and post-treatment contrast-enhanced ultrasonography (CEUS) for assessing the outcome of SUFE and for posttreatment follow-up. Materials and methods We studied twelve women undergoing SUFE for uterine fibroids. In those with multiple fibroids, only the three largest were considered in this study. A total of 21 lesions (size range 3.5–9.0 cm, mean 5.2 cm) were examined. Each myoma was examined immediately before and after SUFE (while the patient was still in the angiography room) with transabdominal CEUS performed after intravenous administration of a single bolus of contrast agent. The follow-up protocol included CEUS evaluation one month after treatment and CEUS plus dynamic magnetic resonance (MR) studies six months after treatment. Results In 20/21 cases, postembolization CEUS revealed total fibroid devascularization. The remaining lesion (in a woman with multiple lesions) showed persistent vascularization after SUFE. These findings were all consistent with angiographic data. No recurrences were observed during the six-month follow-up. One patient reported the reappearance of symptoms 18 months after SUFE, and CEUS showed the persistence of intralesional vascularization. Conclusions CEUS is effective for assessing the completeness of vascular occlusion following SUFE for uterine fibroids. CEUS findings correlate with clinical results observed one and six months after treatment. Compared with dynamic MR, CEUS is reliable and cost-effective.

728 Dilation in Eosinophilic Esophagitis: Safety, Effectiveness and Impact On Mucosal Inflammation

Background: Eosinophilic esophagitis (EE) is a rapidly emerging, chronic inflammatory disorder of the esophagus. Anti-inflammatory therapy with topical corticosteroids is effective; however, relapses after cessation of therapy often occur. Clinical observation suggests that dilation is probably a safe alternative leading to long-lasting symptom improvement. However, the question remains whether esophageal dilation alters the underlying inflammation in EE. Aim: To evaluate the effectiveness and safety of dilation and the impact on underlying mucosal inflammation. Methods: Retrospective analysis of the Swiss Eosinophilic Esophagitis Database and the database of Gastroenterology at Northwestern University of Chicago . Adolescent and adult EE patients undergoing 1.) Baseline upper endoscopy with esophageal biopsies; 2.) Subsequent dilation for dysphagia; and 3.) Follow-up endoscopy with repeated histological examination were included. Any therapy with anti-eosinophilic medication had to be discontinued at least 6 weeks prior to dilation and until after the post-dilation EGD. Dysphagia was graded using a validated score (0=none, 1=able to eat solid foods, 2=semisolids only, 3=liquids only, 4=complete dysphagia). Eosinophilic peak infiltration was graded semiquantitatively (0 = 100 eos/high power field). Results: We identified 46 patients (38m/8f), mean age at symptom onset was 28±15years, the interval between symptom onset and EE diagnosis was 12±10years. The duration of symptoms prior to dilation was 13±10years. Mean duration between completed dilation therapy and reappearance of symptoms was 24±23months, whereas the time interval between dilation therapy and follow-up examination was 31±29 months. Mean dysphagia score before dilation was 1.9±0.4 compared with 1.05±0.6 after dilation (P<0.0001). Esophageal diameter before and after dilation was 11±2mm and 15±2mm, respectively (mean increase 4.3±2mm). A mean of 2.3±2.7 dilation endoscopies were performed until dilation therapy was considered effective. No major complications, defined as esophageal perforation or major bleeding, occurred. The grade of eosinophilic peak infiltration before dilation was 2.1±0.8 compared to 2±0.4 in the follow-up endoscopy (P=0.76). Conclusions: 1) In EE, esophageal dilation can be safely performed and is effective in providing long-lasting symptom relief and a highly significant reduction of the dysphagia score. 2) Underlying eosinophilic inflammation is not influenced by the dilation. 3) The impressive response of the symptoms to dilation is suggestive that esophageal remodeling contributes to the swallowing disturbances in EE.

Primary myxoedema with idiopathic thrombocytopenia

To the Editor: Graves' disease, Hashimoto's thyroiditis and primary hypothyroidism are considered chronic autoimmune thyroid disorders (1). All these three are relatively common, with primary hypothyroidism being even more prevalent than Graves' hyperthyroidism (1). Whereas very many cases of either Hashimoto's thyroiditis or particularly Graves' disease may co-exist with idiopathic thrombocytopenic purpura (ITP) (2, 3), ITP association with primary hypothyroidism has been limited to few cases and mostly with borderline subclinical hypothyroidism (3). The literature, in addition, lacks documented evidence of the concurrence of ITP and idiopathic myxoedema. This study describes the first case report of the clear association of ITP and idiopathic myxoedema. Besides, it presents ideas of why, in spite of having a higher prevalence than Grave's disease, primary hypothyroidism is still much less commonly associated with ITP. An 18-year-old woman presented with menorrhagia and facial puffiness. Her thyroid gland was not palpable and she had a nonpitting pretibial oedema. Her thyroid-stimulating hormone (TSH) levels were markedly elevated, whereas her thyroid hormone levels were very low. Antithyroglobulin and thyroid peroxidase antibodies were both negative. On sonography, her thyroid echogenicity was similar to that of her submandibular gland. In addition, there was no evidence of lymphocytic thyroiditis in thyroidal fine needle aspiration biopsy (FNAB) cytology. She was diagnosed as having idiopathic myxoedema and her symptoms and signs resolved with thyroid hormone replacement therapy. Shortly before, she had been found to be thrombocytopenic, with platelet counts of 70,000–80,000/mm3. Extensive investigations had failed to disclose a cause for her thrombocytopenia and she was under observation. Temporary discontinuation of thyroid hormone on several occasions resulted in a reappearance of symptoms and signs of hypothyroidism with elevated TSH and decreased T4 levels necessitating the resumption of hormone replacement therapy. At 21 years of age, while continuing her thyroid replacement therapy, she first experienced excessive menstrual bleedings and then tarry stools requiring hospital admission. Petechiae and ecchymoses had appeared on her lower extremities and there was a haemorrhagic bulla in her mouth. Her platelet count had fallen to 8000/mm3 (Figure 1, left panel). Levels of TSH and thyroid hormones remained normal. Extensive investigations disclosed no diseases, conditions or medicines to account for her low platelet count. She had had no transfusions or drug abuse. She did not drink alcohol and had no toxic substance exposure. She took no regular medication except thyroid hormone. Smear of bone marrow aspiration showed normocellular marrow with increased megakaryocytes (Figure 1, right panel). A peripheral blood smear confirming the decreased platelet count (left panel); smear of bone marrow aspirate showing normocellular marrow with increased megakaryocytes (right panel). Possible reasons for these seemingly marked differences in the rates of association of ITP with any of the three chronic autoimmune thyroid diseases can be the following. First is the fact that patients with goitrous Hashimoto's disease are often treated with thyroid hormone well before their disease even progresses to subclinical hypothyroidism. A subsequent ITP in such patients would still, most probably, be considered in association more with the initial Hashimoto's thyroiditis than with the consequent hypothyroidism masked by thyroid hormone therapy (1). Another reason could be related to differences in age-of-occurrence of these three thyroid diseases (1). Graves' hyperthyroidism is particularly common in the third and fourth decades of life when ITP also is most common. Hashimoto's thyroiditis occurs most frequently in middle age and is therefore in proximity to the life period when ITP has its usual occurrence. At the same time, primary hypothyroidism is mostly diagnosed after mid-fifties, the period of life deemed much less likely for ITP to occur. Several diagnostic procedures can now be used in combination in order to view chronic autoimmune thyroiditis and idiopathic (primary) myxoedema as separate entities (1, 4, 5). These are the measurements of antithyroid antibody levels (1, 4, 5), thyroidal FNAB cytology (4) and thyroidal ultrasonography (4, 5); on the basis of the same diagnostic modalities, the case presented in this study, a 21-year-old woman, is the first report of the concurrence of ITP and a documented idiopathic myxoedema. Then, this association could probably lend support to a still autoimmune nature of the latter.

Metal-on-Metal Bearings and Hypersensitivity in Patients with Artificial Hip Joints

Some patients who have a total hip replacement with a second-generation metal-on-metal articulation have persistent or early recurrence of preoperative symptoms. Characteristic histological changes in the periprosthetic tissues suggested the development of an immunological response. Therefore, in order to determine the relevance of these symptoms, we performed a study of the clinical data and periprosthetic tissues associated with endoprostheses with a metal-on metal articulation that had been retrieved at revision. Periprosthetic tissues as well as the clinical data on the patients were obtained from the first nineteen consecutive revisions performed at the treating hospitals. At the time of the revision, fourteen patients had the metal-on-metal articulation exchanged for either an alumina-ceramic or a metal-on-polyethylene articulation. Five patients received another second-generation metal-on-metal total joint replacement. Five-micrometer sections were prepared from the tissue samples, were stained with routine and immunohistochemical methods, and were examined histologically. Histological specimens from three groups of patients, two of which were treated with non-metal-on-metal implants, served as controls. The majority of patients had persistence of their preoperative pain or early recurrence of the pain after the original total hip replacement, and often a pronounced hip joint effusion had developed after the original replacement. Radiographic follow-up showed the development of radiolucent lines in five hips and of osteolysis in another seven hips. At the revision surgery, both the cup and the stem were found to be well fixed in nine patients. The characteristic histological features were diffuse and perivascular infiltrates of T and B lymphocytes and plasma cells, high endothelial venules, massive fibrin exudation, accumulation of macrophages with droplike inclusions, and infiltrates of eosinophilic granulocytes and necrosis. Only a few metal particles were detected. Immunohistochemical analysis demonstrated that the cellular reaction was still active. The patients who received another second-generation metal-on-metal articulation at the time of the revision had no decrease in symptoms. In the control group of tissues obtained at revisions of endoprostheses without cobalt, chromium, or nickel articulations, there were no similar signs of immune reactions. These histological findings support the possibility of a lymphocyte-dominated immunological response. Although the prevalence of this reaction is low, the persistence or early reappearance of symptoms, including a marked joint effusion and the development of osteolysis, after primary implantation may suggest the possibility of such a reaction.

The Position of Pranlukast, a Cysteinyl Leukotriene Receptor Antagonist, in the Long-Term Treatment of Asthma

Background: Adverse effects, tachyphylaxis, and the position of pranlukast, a cysteinyl leukotriene receptor antagonist, in asthma treatment have not been fully established. Objectives and Methods: To address these questions, adverse effects and long-term efficacy of pranlukast were evaluated in 82 patients [28 patients with moderate asthma (group I), 27 with severe persistent asthma not on oral corticosteroid (OCS; group II) and 27 with severe persistent asthma on OCS (group III)] at 4 and 16 weeks. In the following, pranlukast was either withdrawn 1 year after the start of therapy, or if that was not possible due to reappearance of symptoms, the dose of OCS or inhaled corticosteroid (ICS) was reduced. The efficacy of pranlukast was evaluated during 5 years by peak expiratory flow rate (PEFR), and symptom and treatment scores. Results: Adverse reactions appeared in 4 patients (4.9%; diarrhea, dizziness and leg edema). The mean improvement in PEFR on week 16 was 18.5 ± 2.3, 18.8 ± 3.2, and 15.2 ± 3.8% in groups I–III, respectively (p < 0.01, for all groups). However, increases in PEFR in 29 of 72 patients (40.3%) were less than 15%. Pranlukast could not be withdrawn in 28 of 42 responders (66.7%), but their dose of ICS was reduced by 363 ± 97 µg/day (group II) and that of OCS by 3.4 ± 0.7 mg/day (group III). Tachyphylaxis was not recognized during the 5-year period. Conclusion: Pranlukast is safe when taken for up to 5 years, and is effective irrespective of asthma severity. In the majority of patients with persistent asthma, pranlukast may help to control the disease in the long term.

Unraveling the Molecular Pathogenesis of Isolated Proximal Renal Tubular Acidosis

Proximal renal tubular acidosis (pRTA) results from an impairment of bicarbonate (HCO(3)(-)) reabsorption in the renal proximal tubules and is characterized by a decreased renal HCO(3)(-) threshold. Proximal RTA most commonly occurs in association with multiple defects of proximal tubular transport (renal Fanconi syndrome). Although much more rare, pRTA may occur without other functional defects in proximal tubules (isolated pRTA). The presenting clinical symptom of isolated pRTA is usually growth retardation in infancy or early childhood. Three categories of isolated pRTA have been identified: (1) autosomal dominant pRTA; (2) autosomal recessive pRTA with ocular abnormalities; and (3) sporadic isolated pRTA. Autosomal dominant and autosomal recessive pRTA are usually permanent; life-long alkali therapy is needed. In contrast, sporadic isolated pRTA is transient; alkali therapy can be discontinued after several years without reappearance of symptoms. Recent genetic studies have begun to elucidate the molecular pathogenesis of inherited isolated pRTA. Studies in knockout mice have identified a candidate gene for autosomal dominant pRTA, SLC9A3, a gene encoding one of the five plasma membrane Na(+)/H(+) exchangers (NHE3). Patients with autosomal recessive pRTA and ocular abnormalities have recently been found to have mutations in the kidney type Na(+)/HCO(3)(-) cotransporter gene (SLC4A4). Identification of these gene mutations provides new insights into the molecular pathogenesis of pRTA.

Postural restrictions in labyrintholithiasis.

Benign paroxysmal positional vertigo (BPPV) is the most frequent labyrinthopathy in humans. Treatment consists mainly of liberatory maneuvers aiming to remove otolithic debris and subsequent postural restrictions in order to prevent debris from returning into the canal. The reappearance of symptoms after an effective liberatory maneuver was studied in a group subjected to restrictions and in a second group free from restrictions. The effects of these restrictions were evaluated. No statistically significant difference was found between the groups. Accordingly, restrictions seem to have no effect upon symptom recurrence. The slight supremacy of the Semont maneuver and the prevalence of subsequent relapse compared with the Epley maneuver suggests that these maneuvers could operate on different disorders (cupulolithiasis versus canalolithiasis). Finally, late recognition of relapse in patients who undergo restrictions might even make the liberatory maneuver less effective.

Hypersensitivity reactions during therapy with the nucleoside reverse transcriptase inhibitor abacavir

Background: Hypersensitivity reactions consist of a variable group of clinical findings and have been described for a wide variety of chemical compounds. Objective: This review characterizes the clinical profile of hypersensitivity to the nucleoside reverse transcriptase inhibitor abacavir sulfate. Methods: We performed a retrospective medical review of pooled adverse events data from ∼200,000 patients who received abacavir in clinical trials, through expanded-access programs, or by prescription from 1996 through 2000. Screened cases of hypersensitivity were classified as either definitive or probable. Definitive cases were identified when initial symptoms resolved on interruption of abacavir therapy and returned on reintroduction of abacavir therapy. Results: A total of 1803 cases were identified, 1302 in the 30,595 patients participating in clinical trials or the expanded-access program and 501 in patients from the postmarketing experience. On review, 176 (9.8%) of these cases were considered definitive and the remainder probable. Based on the 1302 cases identified in clinical trials or the expanded-access program, the calculated incidence of hypersensitivity was 4.3%. Symptoms reported in ≥20% of cases of this multiorgan reaction included fever, rash, malaise/fatigue, and gastrointestinal symptoms such as nausea, vomiting, and diarrhea, among others. Respiratory symptoms occurred in 30% of cases and included dyspnea (12%), cough (10%), and pharyngitis (6%). In 90% of cases, hypersensitivity reactions occurred within the first 6 weeks after initiation of abacavir (median time, 11 days); after an initial reaction, rechallenge with abacavir resulted in the reappearance of symptoms within hours of reexposure. Hypotension was present in 25% of these rechallenge reactions. Among patients who received abacavir in clinical trials, the mortality rate was 0.03% (3 per 10,000 patients). Conclusions: Hypersensitivity to abacavir is an idiosyncratic reaction and a distinct clinical syndrome characterized predominantly by systemic involvement. It can be expected to appear as a treatment-limiting event in ∼5% of patients. The appearance of clinical symptoms consistent with this syndrome mandates immediate discontinuation of abacavir. Hypersensitivity to abacavir is an absolute contra-indication to subsequent treatment with any formulation that includes this agent.

Corticosteroid-Sparing Effect of Etanercept in Idiopathic Panuveitis Resistant to Immunosuppressive Therapy

Uveitis, an inflammatory eye disease with varying immunopathogenic mechanisms, may be associated with autoimmune disorders, may be secondary to infection, or may be idiopathic. Response to treatment of uveitis is inconsistent. In this report we describe an adult with idiopathic panuveitis who attempted to lower his oral corticosteroid dose from intolerable levels but was unable to do so because of the reappearance of symptoms. His 8-year course was managed with ocular and systemic corticosteroids, methotrexate, and cyclosporine, which allowed only partially successful control of his ocular inflammation. Complete control was not achieved until the addition of etanercept. With this case report we are the first to describe the complete response of idiopathic panuveitis to etanercept. Our success with this patient strongly supports the critical role of tumor necrosis factor in the immunopathogenesis of some cases of idiopathic panuveitis. Furthermore, etanercept offers a relatively nontoxic, safe option in cases of panuveitis that are unresponsive to traditional immunosuppressive therapy.

Endovascular therapy of arteriovenous fistulae with electrolytically detachable coils.

We report our experience in using Guglielmi electrolytically detachable coils (GDC) alone or in combination with other materials in the treatment of intracranial or cervical high-flow fistulae. We treated 14 patients with arteriovenous fistulae on brain-supplying vessels--three involving the external carotid or the vertebral artery, five the cavernous sinus and six the dural sinuses--by endovascular occlusion using electrolytically detachable platinum coils. The fistula was caused by trauma in six cases. In one case Ehlers-Danlos syndrome was the underlying disease, and in the remaining seven cases no aetiology could be found. Fistulae of the external carotid and vertebral arteries and caroticocavernous fistulae were reached via the transarterial route, while in all dural fistulae a combined transarterial-transvenous approach was chosen. All fistulae were treated using electrolytically detachable coils. While small fistulae could be occluded with electrolytically detachable coils alone, large fistulae were treated by using coils to build a stable basket for other types of coil or balloons. In 11 of the 14 patients, endovascular treatment resulted in complete occlusion of the fistula; in the remaining three occlusion was subtotal. Symptoms and signs were completely abolished by this treatment in 12 patients and reduced in 2. On clinical and neuroradiological follow-up (mean 16 months) no reappearance of symptoms was recorded.

Systemic inflammatory reaction after starting highly active antiretroviral therapy in AIDS patients treated for extrapulmonary tuberculosis

Patients with acquired immunodeficiency syndrome (AIDS) who have drug-susceptible tuberculosis usually respond well to antimycobacterial therapy. Reappearance of symptoms and signs, such as fever, malaise, and weight loss, during treatment suggests side effects of drugs, concomitant opportunistic infections or malignancy, or treatment failure due to poor compliance or drug resistance. A “paradoxical response,” with flare of symptoms early during antimycobacterial treatment has been well described, in particular among patients with tuberculosis of the central nervous system, lymph nodes or pleura ( 1 Dooley D.P Carpenter J.L Rademacher S Adjunctive corticosteroid therapy for tuberculosis a critical reappraisal of the literature. Clin Infect Dis. 1997; 25: 872-887 Crossref PubMed Scopus (202) Google Scholar ). We report 3 patients with AIDS who were treated for extrapulmonary tuberculosis, who shortly after introduction of combination antiretroviral treatment developed a systemic inflammatory reaction.

Role of immunosuppressive therapy in refractory sprue-like disease

Patients with malabsorption and histological findings consistent with celiac disease, who are unresponsive to gluten free diet, and in whom other causes of flat mucosa have been excluded, are considered to suffer from so called unclassified or refractory sprue. Although the true nature of this condition needs to be further elucidated, it is known to represent a difficult therapeutical problem with potentially fatal course. Herein, we report a patient with refractory sprue-like disease who after failing to respond to corticosteroids and TPN was in a critical condition. He responded promptly to cyclosporine and made a remarkable recovery. In contrast to previous reports, the cyclosporine treatment in this patient was pursued only for 1 month, whereupon the patient turned responsive to steroids. Subsequent treatment with azathioprine allowed corticosteroids to be reduced to a low maintenance dose and eventually all drugs could be discontinued without reappearance of symptoms. Cyclosporine therapy might be lifesaving in occasional patients with refractory sprue-like disease and it may result in reversal of steroid resistance. Moreover, azathioprine seems to have a steroid sparing effect in this setting. Short term immunosuppressive treatment may have an advantage of lower risk for drug related side effects.

Exercise technetium 99m sestamibi single-photon emission computed tomography late after coronary artery bypass surgery: long-term follow-up.

The prognostic value of exercise technetium 99m sestamibi single-photon emission computed tomography (SPECT) imaging in patients with previous bypass surgery is unknown. The aim of our study was to assess the prognostic information obtained with exercise scintigraphy performed for routine follow-up or reappearance of symptoms. We studied 75 patients referred to our Center at a mean of 38 +/- 53 months from the revascularization procedure and prospectively followed them for 38 +/- 24 months. Fifteen patients (20%) had events at follow-up: there were 4 cardiac deaths, 3 nonfatal acute myocardial infarctions, 8 late revascularization procedures (4 percutaneous transluminal angioplasty and 4 repeat bypass surgery). Univariate analysis identified a history of typical angina (p = 0.001), a clinically positive ergometric test (p = 0.009), peak exercise heart rate (p = 0.0003), percentage of maximal predicted heart rate (p = 0.0001), peak exercise double product (p = 0.048), therapy during exercise (p = 0.003), scintigraphic summed reversibility score (i.e., the summation of the segmental differences between stress and rest) (p = 0.014), as significant predictors of events. Three multivariate models were built, with clinical variables (Model 1, chi square 15.97), ergometric variables (Model 2, chi square 19.66), and with scintigraphic variables added to clinical/ergometric variables (Model 3, chi square 31.13). The scintigraphic variable selected in the model as significant predictor of events was the summed reversibility score (p = 0.008). Exercise sestamibi SPECT scintigraphy provides optimal prognostic information after clinical and ergometric parameters in patients with previous bypass surgery.

Endovascular treatment for acute thrombotic occlusion of the middle cerebral artery: local intra-arterial thrombolysis combined with percutaneous transluminal angioplasty

We report our experience in treating 15 patients with acute thrombotic occlusion of the M1 or M2 segment of the middle cerebral artery who underwent intra-arterial thrombolytic therapy alone or in combination with percutaneous transluminal angioplasty (PTA). The results were compared with those of 30 patients with acute embolic occlusion of the same artery. Intra-arterial thrombolysis was performed in 10 patients and thrombolysis combined with PTA in 5 in whom symptoms reappeared due to restenosis or reocclusion, or in whom recanalisation was not successfully accomplished by thrombolysis alone. In the patients with embolism recanalisation was observed in 28 (93 %) and there was no patient with reocclusion. In the patients with thrombosis recanalisation immediately after thrombolysis alone was observed in 9 of 15 (60%). Restenosis, with reappearance of symptoms, occurred in 2 of these (22 %). In the patients who also underwent PTA, angiography after 1 month did not demonstrate any restenosis or reocclusion. Thrombolysis combined with PTA for acute thrombotic stroke may provide an effective procedure for restoring patency and preventing reocclusion of the occluded artery.

Correction of central venous stenoses: Use of angioplasty and vascular Wallstents

Central venous stenoses are a frequent complication in hemodialysis patients. These lesions lead to fistula thromboses, arm swelling, and limit future vascular access. Stenoses are characterized by excellent initial response to transluminal angioplasty but rapid recurrence. Response to angioplasty allows classification of stenoses as elastic or nonelastic. The success of angioplasty alone in 30 patients with central venous stenoses was compared to angioplasty and Wallstent placement in 11 patients with recurrent stenoses. In those who had angioplasty alone, 7%+ failed angioplasty, 70% had > or = 50% improvement in the luminal diameter while 23% showed no improvement due to elastic lesions. Subsequently, 81% of those with a successful result restenosed at an average of 7.6 months while 100% of elastic lesions occluded in an average of 2.9 months. In the 10 patients who underwent angioplasty and Wallstent placement, 5 were due to elastic lesions with four recurrences at a mean of 8.6 months. Four of five patients (80%) stented with nonelastic lesions had reappearance of symptoms at a mean of 4.2 months. We conclude that vascular stents should be reserved for those lesions that show elastic recoil after standard angioplasty.

Stereotaxic Implantation of Autologous Adrenal Medulla Into Caudate Nucleus in Four Patients With Parkinsonism

Four patients with levodopa-responsive parkinsonism (aged 26, 35, 45, and 49 years) received autologous adrenal medullary implants into or near the left caudate nucleus by stereotaxic implantation after flank adrenalectomy. All patients had an immediate response to implantation lasting several days, during which parkinsonian signs and symptoms decreased. This period was followed by a gradual reappearance of symptoms in all but one patient. This patient had had a dramatic increase in "on" time without dyskinesias and a decrease in the severity and duration of "off" time. He died of multifocal glioblastoma 1 year after transplantation. Autopsy revealed no surviving adrenal cells. In one case, the stereotaxic implantation missed the basal ganglia, resulting in the placement of the adrenal medullary tissue into the medial thalamus and near the third ventricle; the patient did not improve. In the other two cases, a modest but definite increase in "on" time without dyskinesia and a reduction in the severity and duration of "off" time has been observed. The role of autologous adrenal medullary transplantation in patients with parkinsonism remains to be determined. Patients with a family history of cerebral malignancy may be at increased risk for the development of transplant-induced malignancy.