Improved laparoscopic operating techniques using a digital enhancement video system

We conducted a prospective, randomized trial in a piglet model to assess the advantages of a digital enhancement video system during difficult endoscopic procedures. Laparoscopic pelvic lymphadenectomy was performed with either conventional two-dimensional or digitally enhanced videoendoscopy. With equal amounts of extirpated lymph nodes, the operations performed with digitally enhanced videoendoscopy were significantly shorter (left lymphadenectomy p = 0.0001, right lymphadenectomy p = 0.001), had less blood loss and fewer false movements, and were associated with no complications, compared with those performed with a two-dimensional videosystem. Thus the accuracy of difficult laparoscopic techniques can be improved by three-dimensional visual perception.

The fast-reacting fetal fibronectin test: a screening method for better prediction of the time of delivery

OBJECTIVE

Our aim was to determine from what time onward fetal fibronectin is consistently detectable in the cervicovaginal secretions before delivery and to what extent the actual time of delivery can be better determined by this procedure than by the sole use of the Bishop score.

STUDY DESIGN

A fast-reacting fetal fibronectin test was performed on 206 women on their expected date of confinement. In addition, the cervical status was evaluated with use of a modified Bishop score. Follow-up evaluations were subsequently carried out in the course of the routine examinations.

RESULTS

Women with a positive fetal fibronectin test result and a high Bishop score were delivered after a median of 1.7 days. Conversely, women with a negative fetal fibronectin test result and a low Bishop score were delivered after a median of 7.1 days.

CONCLUSION

Determination of fetal fibronectin in combination with the Bishop score makes it possible to predict the actual time of delivery with a greater degree of accuracy.

Caroverine in tinnitus treatment. A placebo-controlled blind study

This study was performed to examine whether a single infusion of caroverine, a quinoxaline-derivative, can be used successfully in the treatment of inner ear tinnitus. Microiontophoretical experiments in guinea-pigs have shown that caroverine acted as a potent competitive alpha-amino-3-hydroxy-5-methyl-4-isoxazone-proprionic acid (AMPA) receptor antagonist and, in higher dosages, a non-competitive N-methyl-d-aspartate (NMDA) antagonist. According to our working hypothesis of the pathophysiology of inner ear tinnitus (cochlear-synaptic tinnitus), these forms of tinnitus occur when the physiological activity of the NMDA and AMPA receptors at the subsynaptic membranes of inner hair cell afferents is disturbed. In total, 60 patients with inner ear tinnitus of assumed cochlear-synaptic pathophysiology were included in the study: after computerized randomization, 30 were treated with caroverine and 30 with placebo. For a response to have occurred, tinnitus had to show a reduction in both subjective rating and psychoacoustic measurement (tinnitus matching). In the caroverine group, 63.3% responded to therapy immediately after the infusion. In the placebo group, none of the patients treated showed a significant response according to the defined success criteria. The results confirm our working hypothesis on the genesis of cochlear-synaptic tinnitus.

Gaining more flexibility in Cox proportional hazards regression models with cubic spline functions

The Cox proportional hazards model is the most popular model for the analysis of survival data. The use of cubic spline functions allows investigation of non-linear effects of continuous covariates and flexible assessment of time-by-covariate interactions. Two main advantages are provided--no particular functional form has to be specified and standard computer software packages like SAS or BMDP can be used. A SAS macro which implements the method is presented.

Endothelial eicosanoid metabolism and signal transduction during exposure to oxygen radicals injury

Several physiological agonists that induce elevation of cytosolic free calcium (Ca2+)-levels act via receptor coupled G-proteins, involving activation of phospholipase C (PLC) and hydrolysis of phosphatidylinositol 4,5-bisphosphate. Activation of the inositol signal transduction pathway that precedes Ca2+ ion mobilization is a well accepted signaling pathway in endothelial cell eicosanoid synthesis. This study was designed to examine possible involvement of phosphoinositides in the effects of oxygen free radicals on Ca2+ liberation and eicosanoid synthesis in human umbilical venous endothelial cells (HUVEC). Hydrogen peroxide (H2O2) was chosen as oxygen radicals generating agent. Stimulation of HUVEC with H2O2 (0.1 mmol/l) led to significant rises in inositol phosphate and diacylglycerol (DAG) levels within 300 seconds and an inhibition of Ca2+ release from internal stores. Eicosanoid formation was detectable despite unchanged levels of cytosolic free Ca2+ and no detectable activation of membrane associated phospholipase A2 (PLA2). This suggests that eicosanoid formation may be mediated through the activation of a Ca2+ independent, cytosolic 40 kDa PLA2 isoenzyme and that DAG could serve as an alternative source for arachidonic acid and seems to sensitize a cytosolic PLA2.

Immunohistochemical detection of CD44 splice variant expression in premalignant lesions of the cervix and benign cervical epithelium

The expression of specific CD44 splice variants in malignant tumors has been shown to be associated with metastasis and poor prognosis. In previous studies we have detected aberrant expression of the transmembranous cell adhesion molecule CD44 in cervical cancer. Therefore, we now focus on its role in intraepithelial dysplastic lesions of the cervix. Forty-five cervical intraepithelial neoplasias (CIN), grades I to III, were investigated immunohistochemically for three different splice variants of CD44 (v5, v6, and v7-8). A negative correlation of CD44v5 (Kendall correlation coefficient r = -0.25, P < 0.05) expression with the grade of CIN was found. In normal squamous epithelium of the cervix, the staining reaction of CD44v5 was confined to the basal and the parabasal cell layers. In dysplastic lesions a diffuse and weaker staining pattern of the entire epithelium was observed. Our data suggest a loss of CD44v5 epitope during dysplastic transformation. It seems that expression of CD44 splice variants is not a continuous process in the natural history of cervical cancer, and the pattern of CD44 splice variant expression is changed during carcinogenesis.

Effect of successful parathyroidectomy on hematopoietic progenitor cells and parameters of red blood cells in patients with primary hyperparathyroidism

Elevated levels of parathyroid hormone (PTH) in primary and secondary hyperparathyroidism inhibit hematopoiesis at the level of hematopoietic progenitor cells, mainly the burst forming units-erythroid (BFUe). Removal of parathyroid adenomas is associated with an increase in hematopoietic progenitor cells. In contrast, a certain amount of PTH and calcium is needed to correct anemia after bleeding demonstrating that PTH has also a stimulatory effect on the bone marrow. We examined the effect of parathyroidectomy (PTX) in 10 patients with histologically proven primary hyperparathyroidism on hematopoietic progenitor cells and several parameters of red blood cells before and at 5, 30 and 90 days after PTX. After successful surgery serum levels of iPTH (p < 0.01) and calcium (p < 0.001) decreased significantly. Subsequently a steady increase in all hematopoietic progenitor cell classes was observed reaching significance for BFUe only (p < 0.05). Red blood cells and hemoglobin reached nearly pretreatment values within 90 days after PTX after they had decreased due to surgery associated blood loss. 8 patients undergoing hemithyroidectomy without PTX showed a similar decrease in red blood cells and hemoglobin followed by a rise after the operation. The changes of these parameters did not differ significantly from the patients with pHPT. In contrast to the patients with pHPT, no changes in hematopoietic progenitor cells during the 90 days were observed. The presented data provide further evidence that increased PTH concentrations might inhibit hematopoiesis in humans in vivo. The inhibition can be reversed following PTX by normalisation of PTH concentrations.

Forensic autopsies from 1984 to 1993 in Vienna, Austria

In Austria every death is subject to an examination by a medical doctor authorized by the local health authority. If death is suspected to be natural and/or perpetrated by another person, this doctor has to report it to the police. Depending on the investigation results, the examining magistrate in charge demands a judicial autopsy at the Institute of Forensic Medicine. In 1989, 41 murders of old patients by nursing assistants in a Viennese public hospital were disclosed. The main aim of this retrospective study was to determine any change in the demand for forensic autopsies by the Viennese health authority, as well as by the criminal court, after 1989. Furthermore, it was of interest to analyze the reporting practices of medical doctors examining corpses, as well as thr reaction of the criminal court during the study period. After 1989, there was a significant increase of non-judicial and judicial autopsies, performed by Viennese forensic pathologists. In addition, there was a significant increase of reports to the police by coroners as well as by forensic pathologists, paralleled by a higher rate of forensic autopsies demanded by the examining magistrate. This increase of forensic autopsies took place even though the overall rate of deaths in Vienna significantly decreased during the 10-year study period. Thus, the disclosure of 41 murders in the Viennese hospital in 1989 can be assumed as a turning point in the reporting practices of Viennese coroners, as well as the autopsy rate handled by Viennese forensic pathologists.

Preliminary toxicokinetic study with different crystal forms of S (+)-ibuprofen (dexibuprofen) and R,S-ibuprofen in rats

The aim of the study was to gain information on the plasma concentration-time profiles of both ibuprofen (CAS 15687-27-1) enantiomers in the rat after single oral application of two different crystal forms of S (+)-ibuprofen (dexibrufen, CAS 51146-56-6) and racemic ibuprofen in order to optimize blood-sampling times in a subsequent subchronic toxicity study. The application of either commercial racemic ibuprofen or recrystallised S (+)-ibuprofen (60 mg/kg) to two groups of 4 rats per blood sampling term was carried out in order to define Cmax and tmax and AUC of the plasma-concentrations of the ibuprofen enantiomers. The crystals of commercial (manufactured according to an usual manufacturing procedure) and recrystallised (S(+)- and racemic ibuprofen were different in respect to their shape and size. The recrystallised crystal species of S (+)- and racemic ibuprofen has better galenic (tabletting-) properties and tablets containing the modified S (+)-ibuprofen species showed favorable clinical results. The toxicokinetic behaviour of the recrystallised species was investigated in comparison to the commercial crystal species because of its slightly but significantly slower dissolution rate in simulated gastric and enteric juice. As the AUC0-24 h S-(+)-ibuprofen and the AUC0-24 h, R-(-)-ibuprofen after application of commercial and recrystallised crystal species were not different, the crystal form apparently did not exert an influence on the extent of absorption of S-(+)-ibuprofen and racemic ibuprofen in the rat. The rat has a high inversion capacity and the inversion of R-(-)-ibuprofen after application of commercial and recrystallised racemic ibuprofen was nearly complete in this study. The effects of crystallinity on solubility in simulated media in vitro did not correlate to the findings on the extent of absorption in the rat in vivo.

EGFR and steroid receptors in ovarian carcinoma: comparison with prognostic parameters and outcome of patients

Epidermal growth factor receptor (EGFR), progesterone receptor (PR) and estrogen receptor (ER) status were analyzed in 108 primary ovarian epithelial carcinoma specimens. Receptor concentration was determined with radioligand binding assays. 61% of the carcinomas investigated were positive for EGFR, 29% for PR and 57% for ER. EGFR status was not correlated with histological grading of tumors and no difference in EGFR positivity was found between subgroups of ovarian carcinomas. On the other hand, 50% of the tumors with FIGO stage III and IV and tumors which could not be operated to be free of residual tumor mass were EGFR positive, whereas only 30% were positive within the group of tumors with FIGO stage I and II and no residual tumor mass. The outcome of the carcinoma patients was followed up for a maximum of 100 months. A significant correlation between EGFR positivity and a shorter progressive-free period as well as shorter overall survival was found. For PR and ER status no relation to patient survival became evident. The response to chemotherapy was significantly correlated to EGFR status. After 5 years 63% of the patients with negative versus 25% with positive EGFR were still alive indicating the impaired response of EGFR positive carcinomas to chemotherapy containing platinum compounds.

Menstrual phase and breast cancer surgery: influence on clinical outcome or pitfall of statistical analysis?

The influence of menstrual status at the time of surgery on the prognosis of women suffering from breast cancer is still discussed controversially. In our patient collective, including 149 patients, we obtained statistically significant results for six different time intervals, indicating that patients who underwent surgery between 11 and 22 days after the last menstrual period (LMP) have a poorer outcome. Focusing on the effect of statistical data evaluation strategy we designed a simulation study to evaluate the amount of type I error (error of a false positive test result) in a multiple testing situation involving a cyclical covariate. Accordingly, we corrected the minimum P-values for the occurring type I error rates. After that correction all six previously significant P-values failed to achieve statistical significance. The impact of different statistical data evaluation strategies in a multiple testing situation is discussed.

Assessing interactions of binary time-dependent covariates with time in cox proportional hazards regression models using cubic spline functions

The Cox proportional hazards model is the most popular model for the analysis of survival data. Time-dependent covariates can be included in a straightforward manner. In most cases such covariates will be binary, indicating some form of changing group membership, with individuals starting in group 0, and changing into group 1 after the occurrence of a specific event. If there is evidence that the hazard ratio between these two groups depends on the sojourn time in group 1, then the use of cubic spline functions will allow investigation of the shape of the supposed effect and provide two main advantages-no particular functional form has to be specified and standard computer software packages like SAS or BMDP can be used.

A note on testing areas under the curve when using destructive measurement techniques

The area under the curve of drug concentration over time is considered important in many toxicological, pharmacological, and medical investigations. In case that only one measurement for each experimental unit has been recorded, the area under the curve has to be estimated on the basis of the mean concentration values at the measurement times. Defining an estimator by using a linear combination of these mean values enables the straightforward estimation of the corresponding variance. For testing the null hypothesis of equality between two areas under the curve the use of Welch's test for nonpairwise contrasts is recommended; the previously suggested normal approximation of the test statistic is not an adequate choice since it exceeds the nominal alpha-level; this is illustrated by simulation studies.

Prognostic value of immunohistochemically detected CD44 isoforms CD44v5, CD44v6 and CD44v7-8 in human breast cancer

We investigated the expression of CD44 isoforms containing variant exons v5, v6 and v7-8 in 115 human breast cancer specimens by means of immunohistochemistry. CD44 isoforms CD44v5, CD44v6 and CD44v7-8 were detected in 56% (n = 64), 24% (n = 28) and 15% (n = 17), respectively. In 36 specimens of axillary lymph node metastasis, expression of CD44v5, CD44v6 and CD44v7-8 was found in 94% (n = 34), 92% (n = 33) and 89% (n = 32), respectively. Five year survival rates with or without CD44v5 and CD44v6 expression were 71% versus 86% (log-rank test, P = 0.02) and 62% versus 81% (log-rank test, P = 0.001), respectively. For disease-free survival, expression of CD44v5, CD44v6 and CD44v7-8 showed a prognostic impact (log-rank test, P = 0.004, P = 0.0001 and P = 0.0001, respectively). However, multivariate analysis revealed that all investigated CD44 isoforms failed to be independent predictors of the patient's outcome.

[Value of prognostic factors in the Austrian A-NB87 Neuroblastoma Study]

AIMS

A multivariate analysis was performed to evaluate the impact of various prospectively evaluated risk factors.

PATIENTS AND METHODS

From January 1987 to December 1993, 120 patients were registered in the study. 108/120 patients were eligible. There were 49 girls and 59 boys with a median age at diagnosis of 14 months (range, 0 to 224 months). Patients were classified according to the Evans classification system. LDH, NSE, Ferritin, N-myc amplification, 1p-deletion and ploidy were evaluated at diagnosis. Treatment intensity was based on the results of primary surgery: surgery only for 22 (20%) stage I and IIA patients (macroscopic residue without lymph node involvement), the 9 IIB patients (8,5%) (macroscopic residue with lymph node involvement) had mild chemotherapy in addition (6 x VCR/CYC) and elective radiation (Rx). Stage III patients were divided into 2 groups: IIIA patients (n = 17/16%) had to have ferritin levels under 300 micrograms/ml, NSE lower than 100 ng/ml and age below 2 years at diagnosis and received 6 alternating cycles of DAMO/ MVDOC. If one of these three criteria was not fulfilled, patients were assigned to the more intensive treatment arm stage IIIB (n = 12/11%), i.e. 9 alternating cycles of DAMO/MVDOC/IPE. Stage IV pts (n = 35/32.5%) received 8 MVDOC/IPE cycles and 20 patients received megatherapy followed by stem cell reinfusion in addition. 13 stage IVs patients (12%) were registered and had elective VCR/CYC and/or liver radiation in case of poor clinical condition. The median observation time is 4.2 years (range, 1 to 7.5).

RESULTS

The survival rate at 3 years was excellent for localized disease and stage IVs with survival rates of 100% for stage I/IIA and 92% for stage IVs. Stage IIIA patients had an EFS rate of 81% whereas stage IIB patients achieved only 69%. Stage IV patients reached 51%, however outcome was especially poor for stage IIIB patients (20%) due to treatment related toxicities. The toxic death rate in the study was 13% (2 surgical deaths, 8 infections, 4 multiple organ failures). Univariate analysis demonstrated the following significant unfavorable risk factors: age over 1 year at diagnosis (58/108 pts, p = 0.006), NSE > 100 ng/ml (26/95 pts, p < 0.0001), Ferritin > 300 ng/ml (19/98 pts, p = 0.007), LDH > 300 (400) U/L, 51/87 pts, p = 0.004), presence of N-myc amplification (17/59 pts, p = 0.001), deletion of the short arm of chromosome 1 (19/74 pts, p < 0.0001) and di/tetraploidy (32/72 pts, p = 0.008). The power of these factors was even stronger in patients with localized disease whereas no significant prediction was observed for stage IV patients. Furthermore a significant correlation of the serological (NSE, ferritin, LDH) and biological factors (N-myc, deletion 1p, di/tetraploidy) was detected in this study. Only NSE was identified as an independent prognostic factor (p = 0.018) whereas no independent factor could be identified within the 3 biological parameters due to their high correlations (Kendall's tau for N-myc and deletion 1p:0.7). However, N-myc (p = 0.005) as well as deletion 1p (p = 0.01) were found significantly more important than di/tetraploidy.

CONCLUSIONS

Biological classification of neuroblastomas should be mandatory and be the prerequisite for any risk adapted treatment. One serological and 2 biological factors could be a good standard evaluation to identify neuroblastoma patients at risk.

Quantitative immunohistochemistry of factor VIII-related antigen in breast carcinoma: a comparison of computer-assisted image analysis with established counting methods

Microvessel density in the area of the most intense neovascularization in invasive breast carcinoma is reported to be an independent prognostic factor. The established method of enumeration of microvessel density is to count the vessels using an ocular raster (counted microvessel density [CMVD]). The vessels were detected by staining endothelial cells using Factor VIII-related antigen. The aim of the study was to compare the CMVD results with the percentage of factor VIII-related antigen-stained area using computer-assisted image analysis. A true color red-green-blue (RGB) image analyzer based on a morphologically reduced instruction set computer processor was used to evaluate the area of stained endothelial cells. Sixty invasive breast carcinomas were included in the analysis. There was no significant correlation between the CMVD and the percentage of factor VIII-related antigen-stained area (Spearman correlation coefficient = 0.24, confidence interval = 0.02-0.46). Although high CMVD was significantly correlated with poorer recurrence free survival (P = .024), percentage of factor VIII-related antigen-stained area showed no prognostic value. Counted microvessel density and percentage of factor VIII-related antigen-stained area showed a highly significant correlation with vessel invasion (P = .0001 and P = .02, respectively). There was no correlation between CMVD and percentage of factor VIII-related antigen-stained area with other prognostic factors. In contrast to the CMVD within malignant tissue, the percentage of factor VIII-related antigen-stained area is not suitable as an indicator of prognosis in breast cancer patients.

[Plasminogen activator inhibitor 1 and prognosis in breast carcinoma]

The proteolytic enzyme urokinase-type plasminogen activator (uPA) plays an important role in degrading extracellular matrix. This seems to be an important step in cancer invasion and metastasis. uPA antigen levels correlate significantly with disease recurrence and death in breast cancer. To build up tumour stroma in primary tumours as well as in metastases, inhibition of proteolytic activity is necessary. In this study we investigated the correlation of the Plasminogen Activator Inhibitor 1 (PAI-1), which is the specific inhibitor of uPA and which seems to be important for tumour formation, with prognosis in breast cancer. PAI-1 antigen levels were measured in cytosols of 268 primary breast cancers. In 205 cases we correlated the PAI-1 status (cut-off value: 1 ng/mg) with the clinical outcome. Furthermore we investigated PAI-1 antigen levels in 10 benign breast tumours and 33 metastases. PAI-1 levels were significantly higher in primary carcinomas (median value: 0.62 ng/mg, range: 0 to 30.7) than in benign tumours (median value: 0 ng/mg, range: 0 to 0.1) and metastases showed elevated levels (median value: 1.05 ng/mg, range: 0 to 7.8) in comparison to the primary tumours (Kruskal-Wallis test: p < 0.05). We found that the PAI-1 status correlated significantly with early disease recurrence (Mantel-Test p = 0.0069) and overall survival (Mantel-Test p = 0.0121). After a median follow-up of 32 months (range 2-58), 36% of patients with PAI-1 antigen levels > or = 1 ng/mg (n = 72) showed an early relapse and 24% died, whereas only 19% of patients with PAI-1 antigen levels < 1 ng/mg (n = 133) relapsed and 9% died within the study period. A multivariate analysis revealed that in our study population PAI-1 is not an independent prognostic factor. According to our findings PAI-1 seems to be involved in the formation of extracellular matrix in primary carcinomas and metastases and is related to poor prognosis in breast cancer.

Recorticalization after bifocal internal bone transport in the double-plated sheep femur

Distraction osteogenesis and bone remodelling after the end of bone transport were investigated in one femur each of six adult male sheep. A newly designed internal distraction device was used. A custom-made osteosynthesis plate was fixed on the lateral side of the femur, and two transporting plates driven by a transcutaneously inserted screwdriver moved two bone cylinders simultaneously over a 40 mm defect. An additional plate was applied ventrally to stabilize the device. Bone transport was begun 2 weeks postoperatively at 1 mm/day at each transporting plate until they came into contact. New bone formation within the distraction gaps was evaluated by computed tomography scans and was quantified at 4 and 6 months by dual energy x-ray absorptiometry as well as histomorphometry on polyfluorochrome-labelled undecalcified ground sections and microradiographs. At 4 months, all distraction gaps were bridged by abundant newly formed bone trabeculae, which were reduced and condensed to cortex-like layers of new bone at 6 months. Less new bone was always found under the lateral device than in the unplated medical and dorsal segments, but the amount of new bone under the ventral plate was comparable with that in the unplated regions. The results of this pilot study show that distraction osteogenesis can be achieved with an internal device such as this one and that recorticalization and restoration of a medullary canal occur despite the relatively rigid internal stabilization by the plates.

Incidence of cervical smears indicating dysplasia among Austrian women during the 1980s

OBJECTIVE

To determine the incidence of cervical smears indicating cervical intraepithelial neoplasia during the 1980s and to compare two quinquennia.

DESIGN

A retrospective epidemiologic analysis was performed, based on a large collection of 238,261 cervical smears obtained from Austrian women screened between 1980 and 1989. After application of strict epidemiologic criteria to avoid bias of changes in socio-economic status and methodological changes in cytology, 12,604 women were eligible for further analysis. We calculated incidences and relative risks of cytologically indicated cervical intraepithelial neoplasia, comparing the time periods of 1980 to 1984 and 1985 to 1989 for different age cohorts.

RESULTS

We found a statistically significant increase in the incidence of cervical cytology indicating cervical intraepithelial neoplasia in the second time period for patients between 21 and 40 years of age. Women older than 40 years showed a significant decrease of this incidence.

CONCLUSIONS

In Austrian women between the ages of 21 and 40 years an unidentified risk factor or a pattern of risk factors during the period prior to 1985 resulted in an increase of cervical intraepithelial neoplasia during the last years studied. This increasing incidence of cervical intraepithelial neoplasia indicates the importance of regular cytological screening. The significant decrease of the cervical intraepithelial neoplasia incidence in women older than 40 years provides an argument for increasing screening intervals in these women.

Splice variants of CD44 in human cervical cancer stage IB to IIB

Aberrant expression of the cell adhesion molecule CD44 has been detected in human tumors and the expression of specific CD44 isoforms (splice variants) has been shown to be associated with metastasis and poor prognosis in human malignancies. We used three different variant exon sequence-specific murine monoclonal antibodies to epitopes encoded by exon v5, exon v6, or exon v7-v8 of human variant CD44 to study the expression of CD44 splice variants by immunohistochemistry in human cervical cancer. One-hundred five patients with surgically treated squamous cell carcinomas of the cervix stages IB to IIB were included in the study. CD44 splice variants CD44v5, CD44v6, and CD44v7-8 were detected in 70, 67, and 26%, respectively. Tumors expressing exon v6 had significantly more often metastasized to the pelvic nodes (58 vs 79%, P = 0.04). Expression of exon v6 was significantly correlated with a greater probability of vascular space invasion (73 vs 50%, P = 0.04) and a significantly lower rate of inflammatory stromal reaction (48 vs 78%, P = 0.004). Patients suffering from tumors expressing splice variant CD44v6 showed poorer overall survival (P = 0.03). In cases with negative pelvic lymph nodes we found a poorer prognosis when tumors expressed CD44v6 (P = 0.01) or CD44v7-8 (P = 0.02). Among the investigated CD44 splice variants expression of exon v6 is the most promising prognostic marker in surgically treated cervical cancer.

Influence of age and human papillomavirus-infection on reliability of cervical cytopathology

The aim of the present study was to evaluate the effect of age and human papillomavirus (HPV) infection associated cellular changes on the predictive value of cervical cytology. In a group of 671 women with Papanicolaou smears suggesting low grade squamous intraepithelial lesion (LSIL), a high grade squamous intraepithelial lesion (HSIL) or invasive cervical cancer, cervical cytology was correlated with the histological finding. Predictive values were calculated and related to severity of the lesion, age and HPV associated changes. The predictive values of Papanicolaou (cervical) smears suggesting LSIL, HSIL and invasive carcinoma were 40%, 86%, and 78%, respectively. A poor predictive value of smears suggesting LSIL was found among older women. HPV associated changes were diagnosed in 80% of women < or = 25 years of age, 66% in the age group 26 to 35 years, 51% in the age group 36 to 45 years and 38% in women aged > or = 46 years (P = 0.03). The presence of HPV associated cellular changes led to a significantly higher number of overdiagnoses (9% with HPV infection compared to 4% without HPV infection) and HPV negative cases were more frequently associated with underdiagnosis (15% without HPV infection compared to 8% with HPV infection, P = 0.0011). This result remained significant after adjustment for age (P = 0.004). Cellular changes associated with HPV infection most frequently occurred in young women. HPV infection should therefore be acknowledged as source of overdiagnosis in the cytological evaluation of SIL especially in young women.

Number and distribution of neuromuscular spindles in human extraocular muscles

PURPOSE

To examine the number and distribution of muscle spindles in all extraocular muscles (EOMs) in humans.

METHODS

Thirty-six EOMs were obtained after death from three persons 67, 72, and 83 years of age. Serial sections were made throughout the length of these muscles. Consecutive sections were stained with different methods. To discriminate true spindles from false spindles, light microscopic criteria were defined and were subject to ultrastructural investigation. A distal portion of a single EOM was gained from a multiorgan donor 17 years of age, processed for electron microscopy, and analyzed.

RESULTS

Spindles were observed in all muscles studied, with the medial rectus exhibiting a mean of 18.8 spindles +/- 3.0 (+/- standard deviation), the lateral rectus 19.3 +/- 1.9, the superior rectus 15.8 +/- 2.5, the inferior rectus 34.0 +/- 4.4, , the superior oblique 27.3 +/- 8.2, and the inferior oblique 4.3 +/- 1.8 per muscle [corrected]. For each different human EOM, a typical distribution of spindles was observed in the persons examined. The ultrastructural investigation revealed sensory endings in structures primarily identified as spindles.

CONCLUSIONS

By comparing 1 g of tissue, spindles are found to be at least as frequent in human EOM as in skeletal muscles known to have a high density of spindles. This fact and the peculiar distribution of spindles in human EOMs suggest that spindles are functionally important proprioceptors in EOM.

Reactive oxygen product formation by human neutrophils as an early marker for biocompatibility of dialysis membranes

Production of reactive oxygen intermediates (ROI) by neutrophils (PMN) in vivo was examined by a whole blood assay using dichlorofluorescein-diacetate (DCFH-DA) in 10 patients each dialysed consecutively with two different dialyser membranes. Haemodialysis (HD) with cuprophan membrane (CM) led to a significantly (P < 0.001) more pronounced ROI production by PMN (2.4 +/- 0.5-fold increase in intracellular oxidation of DCFH-DA) compared with HD with polysulfone membranes (PM; 1.5 +/- 0.2-fold). HD with CM induced a decrease in PMN count by about 90%, whereas PM induced a decrease by only 25% (P < 0.001). In CM patients maximal ROI production coincided with the nadir in PMN count. All patients dialysed with CM showed a clear increase in serum levels of Bb fragments, whereas PM-dialysed patients did not. In this respect, however, no clear time relationship was seen to the kinetics of ROI production, nor to the disappearance of neutrophils from the circulation. Evaluating a direct effect of the dialysis membranes on PMN demonstrated that incubation of neutrophils with hollow fibres of the CM but not of the PM in the absence of plasma induces significant ROI production by PMN. Our study thus indicates that ROI production by PMN during HD correlates to membrane biocompatibility. Furthermore, one might speculate that also independently from but perhaps in addition to complement activation, reactive oxygen products are critically involved in the generation of haemodialysis-associated neutrophil emigration.

pS2 protein status fails to be an independent prognostic factor in an average breast cancer population

In this study we analysed the cytosolic concentrations of the estrogen-regulated protein pS2 in tumors of 462 breast cancer patients, 16 benign breast tumors and 58 metastases. The median pS2 values were highest in breast cancer, followed by benign tumors and metastases (Kruskal-Wallis Test: p < 0.05). Information on other prognostic factors and clinical outcome was available for 354 patients (median follow-up, 35 months). We found a pS2 value of 2 ng/mg protein to be the best cut-off level to discriminate between pS2+ (63%) and pS2- (37%) tumors with respect to relapse-free survival (RFS) and overall survival (OS). The pS2 status was significantly correlated with age, estrogen receptor (ER) and progesterone receptor (PR) status. pS2 was negatively correlated with grading and was more often positive in invasive lobular than in invasive ductal carcinomas. ER, pS2 and grading were highly significantly correlated with each other. In univariate analysis pS2- patients showed a significantly shorter RFS (p = 0.0001) and OS (p = 0.0005). However, multiple regression analysis revealed that in our series of patients the pS2 status provides no independent prognostic information.

Vascular space invasion and inflammatory stromal reaction as prognostic factors in patients with surgically treated cervical cancer stage IB to IIB

We assessed the prognostic value of the local tumor characteristics inflammatory stromal reaction (ISR) and vascular space invasion (VSI) together with established prognostic criteria, in cervical cancer patients. One hundred and forty-two patients with carcinoma of the cervix stage IB to IIB undergoing radical hysterectomy and lymphadenectomy between October 1980 and September 1990 were included in the study. Pelvic lymph node involvement, stage, parametrial involvement, age and histological tumor type were analysed together with VSI and ISR as prognostic factors. The most important prognostic parameters for recurrence-free interval and overall survival in the univariate analysis were pelvic lymph node involvement (P-value < 0.0001/0.0001) and stage (P-value < 0.0001/0.0005). ISR and VSI showed a significant prognostic value for recurrence-free interval (both P-values = 0.0014) and overall survival (ISR: P-value < 0.0001; VSI: P-value = 0.0018). In the multivariate analysis ISR showed an independent prognostic value for overall survival (P-value = 0.03, Relative Risk = 5.4, 95%-confidence interval 1.2-24.5). ISR, reflecting the biological behavior of the tumor, should be considered in the evaluation of prognosis in surgically treated squamous cell carcinoma of the cervix.

HLA class-I and -II antigens in chronic idiopathic autoimmune thrombocytopenia

We studied MHC class-I and -II phenotypes in adult Caucasian patients with chronic idiopathic autoimmune thrombocytopenia (cAITP). Forty-five patients (median age 51 years, range 21-78 years) with a median disease duration of 7 years (range 2-26 years) were phenotyped for HLA-A, -B, -C by the standard lymphocytotoxicity test, HLA-DR and -DQ by restriction fragment-length polymorphism (RFLP), and -DP by oligonucleotide typing. Antiplatelet antibodies directed against glycoproteins Ib/IX and IIb/IIIa were determined by monoclonal antibody-specific immobilization of platelet antigens (MAIPA). The comparison of antigen frequencies of the whole group of patients with healthy controls revealed no significant difference for any of the MHC class-I or class-II specificities (p > 0.05). Patients were then divided into groups based on (a) their response to therapy, and (b) on whether they did or did not have detectable anti-platelet antibodies (n = 16 versus n = 29). All patients with a poor response to splenectomy carried the HLA-DPB1*0402 phenotype. The HLA-DPB1*1501 allele was found only among patients with detectable antiplatelet antibodies. These differences were not significant after correction for the number of tested antigens, however. Our data suggest that there is no association between MHC class-I/II alleles and adult cAITP or subgroups thereof.

Prognostic value of cytokeratins and carcinoembryonic antigen expression in primary surgically treated cervical cancer

In a previous study we have shown the prognostic value of expression of cytokeratins and carcinoembryonic antigen (CEA) in cervical cancer FIGO stage III. The present study was performed to evaluate the prognostic value of cytokeratins and CEA in patients with cervical primary cancer stage IB to IIB, surgically treated by radical hysterectomy and lymphadenectomy. Seventy-six patients were included in the study. By application of immunohistochemistry we found AE1/AE3 (cytokeratins) expression in 27 (35.5%) cases and CEA expression in 56 (73.7%) cases. Multivariate analysis for the end points of relapse-free survival and overall survival showed that neither AE1/AE3 expression nor CEA expression had a prognostic value in the studied population. In contrast to patients with primary irradiated cervical carcinoma FIGO stage III, patients with primary surgically treated tumors stage IB to IIB showed no significant prognostic value of cytokeratin or CEA expression of the tumor.

Prognostic significance of cell DNA content in early-stage ovarian cancer (FIGO stages I and II/A) by means of automatic image cytometry

Paraffin-embedded material from 69 patients with epithelial ovarian cancer FIGO stages I and II/A (including 21 patients with borderline carcinoma) was studied with automatic DNA image cytometry. Univariate analysis indicated a significant difference in survival based on the presence of nuclei with high DNA content (higher than 5 C). A group of patients with less than 0.2% cells with high DNA content had a 6-year survival of 87%, whereas in a group of patients with more than 0.2% of such cells, 6-year survival was 49%. This parameter remained significant when used in a group of stage I/a and I/b patients. Statistical analysis of diploid vs. non-diploid tumors also showed significant difference in survival. Separate analysis of 48 invasive ovarian cancers indicated that ploidy, the percentage of cells with high DNA content and tumor stage (stage I/a + b vs. stages I/c + II/a) reached significance for survival, whereas grading did not. In addition, comparison of clinical stage, grading, ploidy and the percentage of cells exceeding 5 C with a threshold at 0.2% by means of a multivariate analysis (Cox regression model) showed that only the percentage of cells exceeding 5 C remained statistically significant.

Regenerative potential of abdominal vagal nerves in rats

After truncal vagotomy, impaired gastric emptying may represent a serious complication. This led us to study the feasibility of a reinnervation of the antrum by microsurgical vagorrhaphy and vagoplasty. Sixty-four rats were randomly assigned to undergo either 1) no operation (control), 2) laparotomy and vagal dissection (sham operation), 3) truncal abdominal vagotomy with nerve segment resection, 4) truncal vagotomy followed by vagorrhaphy, or 5) vagal resection extending to the nerve of Latarjet followed by grafting of the gap using the resected vagal segment (vagoplasty). Six months after surgery, vagal regeneration was assessed by morphometry of the anterior vagus and the antral wall and by recording the gastric emptying of a radiolabeled meal, the contractile response to electrical stimulation of the cervical vagi, and basal and insulin-stimulated acid secretion. After truncal vagotomy, there was a marked degeneration of vagal fibers and no evidence of spontaneous reinnervation. After vagorrhaphy, a recovery of gastric secretory and motor functions as well as morphological data indicated vagal regeneration. After vagoplasty, a partial recovery of gastric motor functions and the morphological appearance suggested a partial vagal reinnervation.

Differences in anti-Fab antibodies in adult and late onset rheumatoid arthritis

In the present study the ratio of antigen-bound anti-IgG-Fab antibodies (hidden aFab) to free aFab was found to be significantly increased in patients with adult onset rheumatoid arthritis (AORA) as compared to late onset rheumatoid arthritis (LORA). The overall amount of aFab was similar in both groups. The difference was only seen in seropositive patients. Within the seropositive AORA group, the aFab ratio was correlated with the duration and the stage of disease but not with the patients' age at investigation. This might reflect a higher affinity of anti-Fab antibodies and/or a greater diversity of the idiotypic repertoire in adult onset disease resulting in the formation of immune complexes, the stability of which might be enhanced further by the presence of rheumatoid factors. Although a pathophysiological involvement of aFab cannot be concluded from our observations, it is conceivable that different immunoregulatory mechanisms could be operative in RA with onset at different ages.

[Comparison of the effectiveness of triazolam (Halcion) and flunitrazepam (Rohypnol) in the preoperative period. A double blind crossover study]

The hypnotic effects of triazolam (Halcion) 0.25 mg and flunitrazepam (Rohypnol) 2 mg were compared in a randomized double-blind crossover study of 55 surgical patients in the preoperative stage. At these doses there was no significant difference between the two benzodiazepines regarding duration of sleep, depth of sleep and interruption of sleep. Sleep induction time was significantly shorter with Rohypnol, whereas waking was far pleasanter for patients after Halcion. The absence of hangover after Halcion is significant.