Minimal invasive decompression of the orbit in Graves' orbitopathy

BACKGROUND

Surgical decompresssion of the orbit may be considered as a suitable form of therapy if, as a result of the increased volume inside the orbit, there are motility disorders such as diplopia or a progressive decrease in visual acuity. In view of the fact that this operation will not cure the underlying disease, the treatment should be as mild as possible.

METHODS

In five subjects with Graves' orbitopathy we managed to extend the volume of the intraconal orbit by microsurgical liposuction. We carried out a lateral canthotomy to approach the orbit behind the globe. After decompression of the soft tissue, the lateral palpebral ligaments were refixed. To assess the scale of the functional rehabilitation we compared preoperative parameters (visual acuity, Hertel's index, visual field, motility) with the postoperative results.

RESULTS

In all cases we found a significant improvement of position and motility without signs of diplopia. There was a postoperative increase in the visual field and visual acuity was 0.4 and the protusion of the globe could be decreased by 3-6 mm (Hertel's index). Furthermore, the ocular hypertension we found preoperatively could no longer be detected after the operation.

CONCLUSIONS

Microsurgical decompression of the soft tissue via an approach from behind the globe proved to be a very gentle alternative to conventional methods of orbital decompression because of the satisfying functional and esthetic rehabilitation in selected cases.

RhD genotyping by quantitative fluorescent polymerase chain reaction: a new approach

OBJECTIVE

To develop a new method of RhD/d genotype determination using a quantitative fluorescent PCR (QF-PCR) assay.

METHODS

Polymerase chain reaction amplification (PCR) of fragments of exon 7 of both the RHD and RHCE genes was performed from 32 amniotic fluid and 26 chorionic villus samples known to be heterozygous for the RHD gene, 74 peripheral blood samples of RhD-positive blood donors (homozygous or heterozygous) estimated by serologic typing and 24 RhD-negative fetal samples. The number of copies of the RHD gene in RhD-positive samples was determined by comparing the fluorescent intensities of the amplification products specific for the RHD and the RHCE genes.

RESULTS

A ratio of fluorescent intensities of 1:1 clearly indicated D/D homozygous individuals whereas a ratio of 1:2 was demonstrated in samples from D/d heterozygous individuals. The mean fluorescent intensity ratio of the peak areas of homozygous samples was 1.12 (SD 0.128), the mean ratio of the peak areas of heterozygous samples was 0.51 (SD 0.060). Complete agreement was obtained between RhD/d typing by QF-PCR and RhD genotypes assessed by family studies and serological methods.

CONCLUSIONS

The fluorescent PCR-based DNA test allows easy, rapid and accurate determination of the zygosity for the RHD gene. This new technique provides useful information for the clinical management of pregnancies of sensitised RhD-negative mothers.

Impact of transportation on short-term preserved corneas preserved in Optisol-GS, Likorol, Likorol-DX, and MK-medium

PURPOSE

To investigate the impact of transportation, simulated under laboratory conditions, on the corneal endothelium preserved by Optisol-GS, Likorol-DX, Likorol, and MK-Medium.

METHODS

Three hundred twenty corneas from freshly slaughtered pigs were stored in Optisol-GS. Likorol-DX, Likorol. and MK-Medium for 1, 3, 6, or 10 days. After short-term preservation, the transportation was simulated on a laboratory shaker at 4 degrees C with an acceleration of 0-100 km/h in 16 seconds for 5 hours. Mate corneas served as the control. Corneal endothelial cell density was determined at the time of dissection, directly before the experiment, and after subsequent organ culture.

RESULTS

A significant cell loss induced by transportation simulation was not observed in any experimental group. Preservation in MK-Medium starting at 3 days of short-term preservation resulted in a significant cell loss. Storage for up to 6 days in Optisol-GS, Likorol-DX, and Likorol did not result in a significant decrease in cell density.

CONCLUSION

Short-term preserved corneas can be routinely distributed without a reevaluation, if the tissue is preserved for a shorter time as recommended by the manufacturers.

[Cervical cancer in pregnancy--practical recommendations]

Five-year survival did not differ between 20 pregnant women and 541 patients with invasive cervical cancer treated with radical surgery at the Department of Obstetrics and Gynecology of the University of Graz. Therapeutic recommendations are given. In stage Ib to IIb disease, surgery is recommended postpartum following the induction of fetal lung maturity if fertility should be preserved and if the cancer is diagnosed after the 20th week of pregnancy. The same is recommended in stage Ia independent of the duration of gestation. In advanced disease (stage IIIb to IVb) definite therapy should be applied immediately after diagnosis. If cervical intraepithelial neoplasia grade III is suspected, colposcopy, cytology and biopsy are mandatory. Definite therapy should be performed 6 weeks postpartum.

Elevated plasma concentrations of lipoprotein(a) in medicated epileptic patients

Lipoprotein(a) [Lp(a)] has been identified as an independent risk factor for vascular diseases. There are no data on Lp(a) levels in patients on long-term medication with carbamazepine, phenytoin, phenobarbital, or valproate. To investigate the effects of such treatment on Lp(a) levels and common carotid artery intima media thickness we studied 51 epileptic outpatients on long-term antiepileptic medication and 51 age-and sex-matched controls. Lp(a) levels above 45 mg/dl were found in 11 of 50 patients, but in only 4 of 51 controls (P < 0.05). The mean serum concentration of Lp(a) was 33.0+/-7.0 mg/dl in patients and 16.9+/-2.7 mg/dl in controls (P < 0.05). Epileptic patients also had a thicker intima media of the common carotid artery (0.79+/-0.04 mm) than controls (0.69+/-0.02 mm, P < 0.05) as measured by B-mode ultrasonography. Our results suggest an untoward effect of long-term antiepileptic medication on Lp(a) serum concentrations. Elevated Lp(a) levels might be a risk factor for arteriosclerosis in epileptic patients.

Preoperative thrombocytosis is an independent prognostic factor in stage III and IV endometrial cancer

BACKGROUND

To identify prognostic factors in stage III and IV endometrial cancer with special attention to pretreatment platelet count.

MATERIALS AND METHODS

59 patients with FIGO stage III or IV disease operated on between 1983 and 1993 were analyzed. Patients with preoperative thrombocytosis were compared with those without thrombocytosis. Prognostic factors were analyzed with a Cox proportional hazard model.

RESULTS

With the exception of age, there were no significant differences between patients with or without thrombocytosis. At multivariate analysis, five-year disease-free survival was influenced significantly by FIGO stage (stage III vs stage IV; p = 0.009), thrombocytosis (p = 0.02) and cervical involvement (p = 0.024). Similarly, overall five-year survival was significantly influenced by stage (p < 0.001), cervical involvement (p = 0.005) and thrombocytosis (p = 0.01). Age, histology, grade, myometrial invasion, lymph-vascular space involvement or spread to adnexae were not significantly associated with survival.

CONCLUSION

Thrombocytosis is an independent prognostic factor in stage III and IV endometrial cancer.

[Past, present and future of oncology]

The past, present and future of oncology are presented using the example of cervical cancer. In 1908, Walter Schauenstein described the histology of atypical squamous epithelium at the uterine cervix. This was one of the first descriptions of what today is called carcinoma in situ. In the 1950s, Ernst Navratil initiated the concept of the early diagnosis of cervical cancer based on colposcopy and cytology. Erich Burghardt's studies on the morphogenesis of cervical cancer in the 1970s led to a reduction of radicality in the treatment of early invasive types of cervical carcinoma. Conization only and simple total hysterectomy have all but replaced radical procedures for patients with microcarcinomas. Today the treatment of cervical cancer is individualized according to tumor size as determined by preoperative MRI. The lymph node status is determined intraoperatively by frozen section histology and influences the extent of the procedure. Molecular methods and genetic techniques are the future of oncology. However, inherited factors do not seem to play an important role in the development of cervical cancer. Surgery is still the basis of the treatment of this disease.

Phenotypic variability and asymmetry of Rieger syndrome associated with PITX2 mutations

PURPOSE

Rieger syndrome is an autosomal dominant condition characterized by a variable combination of anterior segment dysgenesis, dental anomalies, and umbilical hernia. To date, reports have shown mutations within the PITX2 gene associated with Rieger syndrome, iridogoniodysgenesis, and iris hypoplasia. The purposes of this study were to determine the range of expression and intrafamilial variability of PITX2 mutations in patients with anterior segment dysgenesis.

METHODS

Seventy-six patients with different forms of anterior segment dysgenesis were classified clinically. DNA was obtained and screened by means of polymerase chain reaction (PCR)-single-stranded conformation polymorphism (SSCP) and heteroduplex analysis followed by direct sequencing.

RESULTS

Eight of 76 patients had mutations within the PITX2 gene. Anterior segment phenotypes show wide variability and include a phenocopy of aniridia and Peters', Rieger, and Axenfeld anomalies. Mutations include premature terminations and splice-site and homeobox mutations, confirming that haploinsufficiency the likely pathogenic mechanism in the majority of cases.

CONCLUSIONS

There is significant phenotypic variability in patients with PITX2 mutations, both within and between families. Developmental glaucoma is common. The umbilical and dental abnormalities are highly penetrant, define those at risk of carrying mutations in this gene, and guide mutation analysis. In addition, there is a range of other extraocular manifestations.

Benign müllerian inclusions in pelvic and paraaortic lymph nodes

OBJECTIVE

This study was undertaken to determine the incidence and distribution of the location of benign müllerian inclusions in pelvic and paraaortic lymph nodes.

METHODS

A total of 114 patients operated on for gynecologic malignancy between 1995 and 1998 underwent surgery including systematic pelvic (n = 114) or pelvic and paraaortic (n = 70) lymphadenectomy. The lymph node material was labeled according to anatomic origin, immediately fixed en bloc, embedded in paraffin, and processed as step-serial sections at intervals of 400 microm. The 5-microm-thick sections were stained with hematoxylin and eosin.

RESULTS

Overall, 26 of 114 patients (23%) had benign müllerian inclusions. Inclusions were most common in the paraarotic (34%), external iliac (12%), and common iliac (9%) regions (P > 0.05). Multiple anatomic sites were involved in 14 of 26 patients (54%). Two women had paraaortic inclusions and negative pelvic nodes. Benign müllerian inclusions were seen in 13 of 51 patients (24%) with ovarian carcinoma, 11 of 47 (23%) with cervical carcinoma, 1 of 9 (11%) with endometrial carcinoma, and 1 of 2 with ovarian serous borderline tumor, (P > 0.05).

CONCLUSIONS

Benign müllerian inclusions occur in approximately one-fifth of patients with gynecologic malignancies in all anatomic regions of pelvic and paraaortic lymph nodes. They must be distinguished from metastatic deposits.

Relating structure and translational dynamics in aqueous dispersions of monoolein

The temperature dependence of the molecular diffusion in monoolein/water systems is investigated at several levels of hydration. Using the proton/deuteron selectivity, field gradient NMR allows the simultaneous determination of the diffusion constants of both, lipid and water molecules in the various lamellar and non-lamellar phases. Due to the mesoscopic structure of the monoolein/water phases, the diffusion coefficients are interpreted as 'reduced' or 'effective' diffusion coefficients, and are related to the microscopic molecular displacements by a so-called 'obstruction factor'. Changes in the microscopic structure at the phase transition from the bicontinuous cubic phases to the inverse hexagonal phase are reflected in the obstruction factor of the monoolein diffusion coefficients. The reduction of the water diffusion coefficients is too high to be explained by an obstruction factor only, implying a mechanism of molecular motion, which strongly differs from that of bulk water. Experiments on samples prepared with isotopic labeled water (2H(2)O and H(2)(17)O) indicate a chemical exchange of protons between the water molecules and the lipid headgroups on a millisecond timescale.

Effects of psoroptes ovis infection and its control with an ivermectin controlled-release capsule on growing sheep. 1. Evaluation of weight gain, feed consumption and carcass value

To evaluate the prophylactic and therapeutic effects of an ivermectin controlled-release capsule (IVM-CRC) on the productivity of growing sheep infested with Psoroptes ovis 24 male and 24 female Merino landrace lambs, 5-6 months old and weighing 21.2-35.0 kg, were used. Sixteen replicates of three animals were formed based on sex and Day 0 body weight. Within each replicate animals were randomly allocated to one of three groups: untreated control; IVM-CRC on Day 0; IVM-CRC on Day 84. For treatment an IVM-CRC for sheep weighing 20-45 kg was used which is designed to deliver ivermectin at a minimum dose of 20 microg/kg per day for 100 days. The lambs were infested with 50-60 P. ovis mites each on Days 14 and 21. Mites in skin scrapings were counted on Days 70, 84, 98, 112 and 126. Body weight and feed consumption were measured every 2 weeks from Day 0 to 126. The animals were slaughtered on Day 127 and their carcasses evaluated. The IVM-CRC treatment on Day 0 prevented the establishment of P. ovis. All untreated lambs became infested. The lambs treated with an IVM-CRC on Day 84 became mite-free from Day 112 onwards. The lambs treated on Day 0 had significantly (p<0.05) greater body weight gain from Day 0 to 84 (13.9 kg) and Day 0 to 126 (20.9 kg) than the untreated controls (9.6 and 12.8 kg, respectively) and the sheep treated on Day 84 (8.4 and 14.9 kg, respectively). Feed consumption (Days 0-126) for sheep treated with the IVM-CRC on Day 0 was higher than for sheep treated on Day 84 (p<0.05) and for the untreated controls (p<0.1). The carcasses of sheep treated with the IVM-CRC on Day 0 had significantly (p<0.05) higher warm and cold weights, carcass yield, rib eye area and back fat thickness than the untreated control group and the sheep treated with the IVM-CRC on Day 84. The sheep treated with the ivermectin CRC on either Day 0 or 84 had significantly (p<0.05) better muscle scores and lower muscle pH 1h post-slaughter than the untreated controls. There was no significant (p>0.1) difference between warm and cold carcass weights, carcass yield and rib eye area between sheep treated on Day 84 and untreated controls.

Effects of Psoroptes ovis infection and its control with an ivermectin controlled-release capsule on growing sheep. 2. Evaluation of wool production and leather value

To evaluate the prophylactic and therapeutic effects of an ivermectin controlled-release capsule (IVM-CRC) on the productivity of growing sheep infested with Psoroptes ovis 24 male and 24 female Merino landrace lambs, 5-6 months old and weighing 21.2-35.0 kg, were used. Sixteen replicates of three animals were formed based on sex and Day 0 body weight. Within each replicate animals were randomly allocated to one of three groups: untreated control; IVM-CRC on Day 0; IVM-CRC on Day 84. For treatment an IVM-CRC for sheep weighing 20-45 kg was used which is designed to deliver ivermectin at a minimum dose of 20 microg/kg/day for 100 days. The lambs were infested with 50-60 P. ovis mites each on days 14 and 21. The animals were shorn on Day 126. After slaughter on Day 127 the quality of the leather produced from their skins was evaluated. The IVM-CRC treatment on Day 0 prevented the establishment of P. ovis. All untreated lambs became infested. The lambs treated with an IVM-CRC on Day 84 became mite-free from Day 112 onwards. The lambs which were treated on Day 0 had significantly (p<0.05) greater clean fleece weight (1.5 kg) and fleece yield (52.1%) than the untreated controls (0.9 kg and 34.1%, respectively) or than lambs treated on Day 84 (1.0 kg and 47.8%, respectively). Clean fleece weight and fleece yield were in the tendency (p=0.055) or significantly (p<0. 001) greater, respectively, for lambs treated on Day 84 than for the untreated controls. The chrome tanned dried crust leather of all untreated controls and six of the 16 lambs treated on Day 84 showed grain surface defects such as discolourations, indurations and coarse, pitted grain. The useful (defect-free) leather size was significantly (p<0.01) higher for the lambs treated on Day 0 (100%) than for the lambs treated on Day 84 (82.7%) and the untreated controls (7.8%). The physical testing revealed that the leather of sheep treated on Day 0 had significantly (p<0.05) higher thickness, elongation break and tear resistance than the leather of both untreated controls and sheep treated on Day 84. There were no significant differences in the physical characteristics of the leather of the untreated controls and the sheep treated on Day 84.

Parametrial spread in patients with endometrial carcinoma undergoing radical hysterectomy

The objective of this paper is to study parametrial involvement in patients with endometrial carcinoma undergoing radical hysterectomy. We reviewed indications for surgery, pathology findings, and outcome of a series of 24 patients with endometrial carcinoma who underwent radical hysterectomy. The uterus, cervix and parametrial tissue were processed as step-serial sections. Histologically, 16 patients (67%) had carcinoma involving the cervix. Two of these patients (8%) had frank histologic parametrial involvement and four (17%) had disease extending to the transitional zone of the cervix. Parametrial involvement was continuous and seen only in patients with involvement of the cervical stroma. Six patients (25%) had pelvic node metastases. With a median follow-up of 53 months (range 2-140), four patients (17%) developed recurrences (all within 24 months). Twelve patients (50%), including one of the two with parametrial invasion, were free of disease for 5 years or longer. We conclude that direct parametrial extension can occur in locally advanced endometrial cancer. Radical hysterectomy with lymphadenectomy can be an adequate operation for such patients.

Pnictides as symmetrically bridging ligands in novel neutral complexes

The reaction of [LWCl] (3) [L = N(CH2CH2NiPr)3] with LiE(SiMe3)2 (E = P, As, Sb) yields the novel, neutral pnictido-bridged complexes [LW = E = WL] (5-7). By following the reaction, which starts from the LiP-(SiMe3)2 derivative, by 31P NMR spectroscopy, the formation of an intermediate with a terminal pnictido ligand can be ruled out. The paramagnetic complexes 5-7 are comprehensively spectroscopically characterised. The X-ray structure analysis of the heterocumulenes 5-7 reveals a linear structure in which the two W-"tren" units bind to the central pnictido atom in a staggered conformation ["tren" = tren-based ligand; tren = tris(2-aminoethyl)-amine. When N2 is used as the inert gas in the synthesis of the starting material [N(CH2CH2NNp)3WCl] [Np = CH2C-(CH3)3], the complex [[N(CH2CH2NNp)3]W2(mu, eta 1: eta 1-N2)] (4) is formed as a side product. Complex 4 possesses a hydrazido(4-) (N2(4-)) ligand connected by two tungsten-"tren" moieties.

Compensating plaintiffs and punishing defendants: is bifurcation necessary?

Critics of the civil jury have proposed several procedural reforms to address the concern that damage awards are capricious and unpredictable. One such reform is the bifurcation or separation of various phases of a trial that involves multiple claims for damages. The purpose of this study was to assess the effects of bifurcating the compensatory and punitive damages phases of a civil tort trial. We manipulated the wealth of the defendant and the reprehensibility of the defendant's conduct (both sets of evidence theoretically related to punitive but not to compensatory damages) across three cases in a jury analog study. We wondered whether jurors would misuse the punitive damages evidence in fixing compensatory damages and whether bifurcation would effectively undo this practice. Our findings indicated that mock jurors did not improperly consider punitive damages evidence in their decisions about compensation. Moreover, bifurcation had the unexpected effect of augmenting punitive damage awards. These findings raise questions about the merits of bifurcation in cases that involve multiple claims for damages.

[How much preoperative information? - How can it be documented?]

Preoperative information for patients and documentation of this information are becoming increasingly significant. Opinions diverge especially on how to document the information provided, the information protocol being only an ancillary element. The patient must be in a position to make an informed decision without suffering any prejudice. Information protocols relating to treatment, that is to the operation, aim at ensuring the quality of the treatment and at documenting the information provided. A scheme of the operation is an important element of this information. Twenty-one presurgical information protocols have been tested in a pilot phase and are still being evaluated by a patients' association. Information and documentation concepts need to be set up by professional societies before insurance companies and governmental offices start getting involved.

Expression of oestrogen and progesterone receptors in low-grade endometrial stromal sarcomas

We analysed oestrogen receptor (ER) and progesterone receptor (PR) expression in a retrospective series of 21 low-grade endometrial stromal sarcomas (LGSSs). Archival formalin-fixed and paraffin-embedded material was analysed by immunohistochemistry. ER and PR were measured with monoclonal antibodies and the peroxidase-antiperoxidase method and a score was calculated as for breast carcinoma based on both the percentage of positive tumour cell nuclei and the staining intensity. ER were seen in 15 (71%) and PR in 20 (95%) of tumours respectively. ER expression was scored as high in three (14%), moderate in four (19%), and low in eight (38%) tumours. Six (29%) tumours did not stain for ER and all of these were positive for PR. PR expression was scored as high in eight (38%), moderate in ten (47%) and weak in two (10%) LGSSs. Only one (5%) LGSS did not stain for PR (this tumour was positive for ER). ER and PR expression in LGSS is heterogeneous. This may have implications for hormone therapy in the management of these tumours. These results suggest that ER and PR should be routinely quantified in LGSSs by immunohistochemical methods.

Efficacy of an ivermectin controlled-release capsule against some rarer nematode parasites of sheep

A controlled trial was conducted to evaluate the efficacy of the intraruminal ivermectin controlled-release capsule (CRC) (IVOMEC Maximizer CR Capsule for Sheep, Merial Ltd.) against induced incoming third-stage larvae and established adult infections with some rarer gastrointestinal nematode parasites of sheep. Twenty-one worm-free lambs were allocated by restricted randomisation based on body weight within sex to one of the following treatments: unmedicated control, ivermectin CRC given on Day 0 prior to induced infection, and ivermectin CRC given on Day 70 after establishment of induced infection. The ivermectin CRC delivers ivermectin at a minimum dose rate of 20 microg/kg/day for 100 days. Infections were induced by daily administration of third-stage larvae for five consecutive days. Nematodes were counted on Day 84, 14 days after treatment of established infection. The treatment with the ivermectin CRC prevented the establishment of Ostertagia leptospicularis, O. ostertagi, Bunostomum trigonocephalum, Cooperia oncophora, C. punctata, C. surnabada, Nematodirus helvetianus, N. roscidus and Strongyloides papillosus by >99% as compared with the untreated controls (p < 0.01). The administration of the ivermectin CRC reduced established adult infections of O. ostertagi, B. trigonocephalum, C. oncophora, C. punctata, C. surnabada, N. roscidus and S. papillosus by >99% (p < 0.01), and reduced established adult infections of O. leptospicularis and N. helvetianus by 96.5 and 98.4% (p < 0.01), respectively.