Optimal management of an aneurysmal subarachnoid hemorrhage in a patient with known factor XI deficiency: a case report.

The authors report a rare case of an acute cerebral aneurysm rupture in a patient with a known factor XI deficiency. Aneurysmal subarachnoid hemorrhage (SAH) accounts for a high mortality and morbidity rate. When SAH is associated with an inherited coagulation disorder such as hemophilia C, an unexpected and possible increase in hemorrhagic stroke and increase in bleeding during surgery and in the postoperative period could lead to an extremely bad outcome. Clinical management consists of rapid correction of the coagulation disorder before undergoing any invasive intracranial procedure. Such an optimal therapeutic strategy must be under the care of a multidisciplinary medical and surgical team. Human factor XI concentrate (Hemoleven, Laboratoire Français du Fractionnement et des Biotechnologies [LFB], Les Ulis, France) was used successfully in this case report. New treatment using recombinant factor VIIa is discussed.

Capnography monitoring during neurosurgery: reliability in relation to various intraoperative positions.

UNLABELLED: In neurosurgery, estimation of PaCO2 from PETCO2 has been questioned. The aim of this study was to reevaluate the accuracy of PETCO2 in estimating PaCO2 during neurosurgical procedures lasting >3 h and to measure the effect of surgical positioning on arterial to end-tidal CO2 gradient (P[a-ET]CO2) over time. One hundred four neurosurgical patients classified into four groups (supine [SP], lateral [LT], prone [PR], sitting [ST]) were included in a prospective study. PaCO2, PETCO2, and P(a-ET)CO2 were measured after induction of anesthesia (T0), after positioning (T1), each following hour (T2, T3, T4), and at the end of the procedure after return to the SP position (T5). Data are expressed as the mean +/- SD, and statistical analysis used linear regression, the Bland-Altman method, and analysis of variance. The mean durations of positioning and surgery were 4.1+/-1 h and 3.7+/-1.3 h, respectively. We performed 624 simultaneous measurements of PaCO2 (33+/-5 mm Hg) and PETCO2 (27+/-4 mm Hg), leading to a mean P(a-ET)CO2 of 6+/-4 mm Hg. P(a-ET)CO2 of the LT group (7+/-3 mm Hg) was larger (compared with the SP, PR, and ST groups) because of a lower PETCO2 (26+/-4 mm Hg). Negative P(a-ET)CO2 (PETCO2 > PaCO2) occurred 22 times, only in the SP (n = 9) and ST groups (n = 13). Changes in opposite directions of PETCO2 and PaCO2 between two successive measurements were found in 26% of the cases. Correlation coefficients in the four groups (PaCO2 versus PETCO2) were not in good agreement (0.46 to 0.62; P < 0.001). The mean bias was between 5 and 7 mm Hg. The superior (13-15 mm Hg) and inferior (-5 to 0 mm Hg) limits of agreement were too large to expect PETCO2 to replace PaCO2. In conclusion, during neurosurgical procedures of >3 h, capnography should be performed with regular analysis of arterial blood gases for optimal ventilator adjustment. IMPLICATIONS: This study, which aimed to reevaluate the ability of PETCO2 to estimate PaCO2 during neurosurgical procedures according to surgical position, indicates that PETCO2 cannot replace PaCO2 for the following reasons: scattering of individual values; occurrence of negative arterial to end-tidal CO2 gradient (P[a-ET]CO2; PaCO2 and PETCO2 variations in opposite directions; large changes in P(a-ET)CO2 between two samples; and instability of P(a-ET)CO2 over time.

Paediatric day case anaesthesia: estimate of its quality at home.

The aim of this clinical audit was to evaluate the home recovery and complications of 104 daycase anaesthetized children, as well as parent satisfaction. A questionnaire, explained at the time of preoperative visit, was given to parents at hospital discharge and returned by mail. Opioids were administered in 19% of the children whereas regional anaesthesia was performed in 28% of cases. In the recovery room, 8% of them suffered pain. At home, pain was the main problem (25%) and vomiting and agitation were found in 9% and 6% of the cases respectively. Parents reported anxiety in 45% of cases, and 14% called their general practitioner. Nevertheless, 94% were satisfied with the anaesthetic. A clinical audit is useful in detecting management deficiencies. Quality of home recovery may be improved by: wider use of perioperative analgesia, systematic prescription of take-home analgesia, designation of a hospital practitioner for advice, and closer collaboration with general practitioners.

A new device for the detection of sponges and other foreign objects left accidentally in the operative field.

A new cost-effective device for the detection of sponges and other instruments left accidentally in the surgical field is presented. This device has 100 per cent sensitivity rate in the initial tests. It is extremely simple and rapid and does not require the use of radiation or other harmful techniques.

The nude mouse as a model for the study of human pancreatic cancer.

The purpose of this study was to characterize an in vivo model of human pancreatic cancer suitable for chemotherapy and immunotherapy studies. In this study we report a 2-year experience in growing the MIA PaCa-2 (CRL 1420) human pancreatic cancer cell line in 92 adult (8 weeks old) and 256 young (3-6 weeks old) nude mice. Ten million tumor cells were transplanted into orthotopic (duodenal lobe of the pancreas) and/or heterotopic positions (hepatic and subcutaneous) and data on operative mortality, effect of total body irradiation (TBI), tumor growth kinetics, and survival are presented comparing the two age groups. Operative mortality was due to anesthetic intolerance which was higher in the young mouse population (13.4% versus 5.7%). Adult mice withstood TBI (500 rad) without mortality but young mice were highly sensitive to radiation damage and their maximum tolerated dose (LD50) was 425-450 rad. Subcutaneous tumors grew significantly more often in young compared to adult animals (97.9% versus 69%) and this finding was not affected by TBI (96.9% versus 75%), though tumors did appear more quickly after TBI. An average of 14.7 +/- 2.8 days was required for the subcutaneous tumors to become macroscopically apparent in the adult population compared with 3.1 +/- 0.8 days in the young mice. The largest subcutaneous tumor diameter 28 days following tumor implant averaged 9.3 +/- 0.6 mm in the young animals and 5.5 +/- 1.7 mm in the adult population (P less than 0.01). Treatment of young mice with human recombinant interleukin-2 (IL-2) (10,000 Units twice a day for 28 days) produced a 27% decrease in tumor growth. This effect was abolished by prior irradiation of the young mice with 375 rad TBI. Pancreatic tumor growth also occurred more consistently in young than in adult animals (91.2% versus 64.3%) and irradiation did not affect pancreatic tumor take in either group. Occasionally intrapancreatic tumor growth was associated with liver metastases in animals that were killed after 28 days (17.8% in young and 22.2% in adult animals). However, when more than 45 days elapsed before sacrificing the animals, the incidence of hepatic metastases increased to 57.1%. This was slightly less than the incidence of hepatic lesions found after direct injection of cancer cells into the liver by portal vein injection (71.4%). Direct extension of tumor into surrounding tissues was common with frequent involvement of the duodenum (83.7%), kidneys (30.6%), and other intraabdominal organs (43.9%). Survival was significantly longer in adult compared to young mice.(ABSTRACT TRUNCATED AT 400 WORDS)

The in vivo distribution of human peripheral blood lymphocytes and lymphokine-activated killer cells adoptively transferred in human pancreatic cancer-bearing nude mice.

In this study we evaluated human pancreatic cancer xenotransplanted into nude mice as a model suitable for adoptive immunotherapy studies. A pancreatic cancer cell line (MIA PaCa-2) was chosen and its growth in nude mice and sensitivity to lysis by human lymphokine-activated killer (LAK) cells were characterized. This line grew in 96% of the cases when young (4- to 6-week-old) Swiss/NIH nude mice were used. The line was highly sensitive to lysis by LAK cells in a standard chromium-51 release assay (67.8%), similarly to other cell lines known to be highly sensitive, such as K562 (75.6%) and the melanoma cell line SU.102 (53.1%). To assess their in vivo distribution, human peripheral blood lymphocytes (PBLs) and LAK cells were adoptively transferred into nude mice after labeling with indium-111 oxine. The results of this study show that adoptively transferred PBLs and LAK cells localize in this heterologous system as they do in autologous systems. PBLs are taken up mostly by the liver and spleen. The percentage of the administered dose of radioactivity taken up corrected by weight (percent dose per gram tissue) is 64.3 +/- 15.6%d/gm (liver) and 43.5 +/- 9.5%d/gm (spleen). LAK cells are taken up by liver (43.2 +/- 5.3%d/gm) and spleen (28.0 +/- 4.9%d/gm) but also localize significantly more than PBLs in other organs such as lungs (12.9 +/- 3.5%d/gm vs 1.4 +/- 0.3%d/gm, p less than 0.01), kidneys (19.1 +/- 2.1%d/gm vs 6.3 +/- 1.5%d/gm, p less than 0.001), and pancreatic tumors growing in orthotopic position (1.93 +/- 0.36%d/gm vs 0.56 +/- 0.06%d/gm, p less than 0.05). When the nude mice are pretreated with human recombinant tumor necrosis factor, localization of LAK cells compared with PBLs is even further enhanced both in tumors implanted in the pancreas (3.1 +/- 0.5%d/gm vs 0.56 +/- 0.06%d/gm, p less than 0.01) and in the subcutis (12.5 +/- 8.3%d/gm vs 0.95 +/- 0.29%d/gm, p less than 0.001).

A new human pancreatic carcinoma cell line developed for adoptive immunotherapy studies with lymphokine-activated killer cells in nude mice.

A human tumor cell line designated SU.86 has been established from a moderate-to-poorly differentiated pancreatic carcinoma of ductal origin specifically for adoptive immunotherapy studies. This line was characterized as to its ability to be lysed in vitro by autologous and allogeneic lymphokine-activated killer (LAK) and natural killer cells and to grow in nude mice. SU.86 has been growing continuously in cell culture for more than 100 passages since 22 September 1986. Transplantation orthotopically and heterotopically into athymic Swiss nude mice showed that tumor take was 100% in the orthotopic position when young (4 to 6 wk old) mice were used and 0% when adult (8 wk old) mice were used (P = 0.004). In the heterotopic position (subcutaneous), tumor take was 100% in neonate (2 to 3 wk old) and young mice and 50% in adults. The rate of tumor growth was inversely correlated with age (P less than 0.001). The histologic pattern is similar to that observed in most human pancreatic carcinomas with pseudoglandular structures and frequent mitotic figures. SU.86 has a doubling time of 77 h in vitro and produces carcinoembryonic antigen, 594 ng/10(6) cells in 3 d. Chromosomal analysis shows heterogeneity with two notable cell subpopulations. The cell line is moderately sensitive to lysis by LAK cells in a standard, 4-h chromium-51 release assay (35.4 +/- 4.0%). When grown together with LAK cells in vitro, it is lysed completely in culture in 8 to 15 d, depending on the serum concentration.

A discordant sibship analysis between beta-NGF and neurofibromatosis.

A new restriction fragment length polymorphism 5' to the beta-nerve growth factor (beta-NGF) gene has been found in proximity to the BglII polymorphism, and both polymorphisms are detectable with an EcoRI 7-kilobase (kb) subclone. Absence of the TaqI recognition site lengthens the 4.3-kb and 1.7-kb hybridizing fragments to 6 kb, and the alleles are in Hardy-Weinberg equilibrium with frequencies of 83% and 17%, respectively. Previous research has suggested that NGF is involved in disseminated neurofibromatosis (NF). We found four informative disseminated NF families with the two beta-NGF polymorphisms and have provided clearcut evidence against beta-NGF gene alteration in these families. If disseminated NF is found to be heterogeneous at a molecular level, more families should be tested to further rule out any role for beta-NGF in this syndrome.