3D endoscopic approach for endonasal sinus surgery

Functional endoscopic sinus surgery (FESS) is a minimal invasive approach adopted in case of chronic sinusitis (inflammation of the paranasal sinuses). The paranasal sinuses are hollow structures within the bones surrounding the nasal cavity. During FESS the surgeon moves the endoscope and other surgical instruments within the nasal cavity following specific paths to approach each one of the paranasal sinuses. The purpose of this study was to reconstruct these paths to access the paranasal sinuses using volumetric CT data. The results will be used for Finite Element modeling and simulations for Robot Assisted Endonasal Surgery.

Sympatric diploid and hexaploid cytotypes of Senecio carniolicus (Asteraceae) in the Eastern Alps are separated along an altitudinal gradient

We explored the fine-scale distribution of cytotypes of the mountain plant Senecio carniolicus along an altitudinal transect in the Eastern Alps. Cytotypes showed a statistically significant altitudinal segregation with diploids exclusively found in the upper part of the transect, whereas diploids and hexaploids co-occurred in the lower range. Analysis of accompanying plant assemblages revealed significant differences between cytotypes along the entire transect but not within the lower part only, where both cytotypes co-occur. This suggests the presence of ecological differentiation between cytotypes with the diploid possessing the broader ecological niche. No tetraploids were detected, indicating the presence of strong crossing barriers.

[Orbital aneurysmal bone cyst in a 2-year-old child]

An aneurysmal bone cyst is a rare tumor-like lesion which can affect any part of the skeleton. It is a disease of childhood and adolescence. Reports of its occurrence on the skull base in children are rare. A 22-month-old male patient was admitted to our ENT department with a sudden protrusion of the right eyeball. Radiologically, a cystic, well-defined and contrast enhanced mass on the medial-cranial orbital wall with beginning destruction of the frontal skull base was detected. Histological assessment of a biopsy, which was taken by medial orbitotomy, showed giant-cellular and fibrohistiocytic changes. Definitive histological diagnosis after removal showed an aneurysmal bone cyst. If there is evidence for aggressive, expansive growth, an aneurysmal bone cyst should be included into the ENT-differential diagnosis of orbital tumors. It is not possible to confirm diagnosis from clinical or radiological data. Early biopsy is essential for a reliable diagnosis even if histological assessment is challenging.

Hemodynamic performance and incidence of patient-prosthesis mismatch of the complete supraannular perimount magna bioprosthesis in the aortic position

BACKGROUND

Complete supraannular placement and smaller stent design allow the implantation of a Perimount Magna bioprosthesis with a larger inner diameter than that of a standard Perimount. This study compares the hemodynamic performance and the incidence of patient-prosthesis mismatch (PPM) of both prostheses.

METHODS

128 patients underwent aortic valve replacement, receiving either a Magna (n = 57) or a standard (n = 71) prosthesis. Inner aortic annulus diameter was measured intraoperatively by a hegar dilator to match echocardiographically obtained results to the annulus diameter instead of matching them to labelled valve size.

RESULTS

The Magna was significantly superior with respect to mean pressure gradient and effective orifice area in patients with an annulus diameter of 22-23 mm. In patients with an annulus diameter < 22 mm or > 23 mm, there was a non-significant trend towards superior hemodynamics in the Magna group. Severe PPM (effective orifice area index < or = 0.65 cm (2)/m (2)) was present in 11.1% (Magna) vs. 42.1% (Standard) of patients with an annulus diameter < 22 mm; in 0% (Magna) vs. 13.8% (Standard) with an annulus diameter of 22-23 mm; no PPM was seen in patients with annulus diameter > 23 mm in both groups.

CONCLUSIONS

The Perimount Magna had a significantly reduced incidence of patient-prosthesis mismatch and superior hemodynamics compared to the standard Perimount.

Thawing of cryopreserved mobilized peripheral blood--comparison between waterbath and dry warming device

BACKGROUND

Thawing of cryopreserved mobilized peripheral blood (MPB) is routinely performed for autologous and allogeneic MPB transplantation. Usually thawing is achieved by submerging the cell bag in a waterbath (37 degrees C temperature). We compared the effectiveness of thawing cryopreserved MPB in a waterbath with an electric dry-warming device containing warmed gel pads (Sahara, Transmed).

METHODS

Two cryopreserved bags from each of 31 apheresis procedures were thawed in a waterbath and under dry conditions in parallel. Viability (dye exclusion), apoptosis/necrosis (annexin/propidiumiodide staining) and clonogenic potential (CFU-E plus BFU-E, CFU-GM) of the cells were tested after thawing.

RESULTS

Statistical analysis by Wilcoxon matched-pair test showed no significant difference between the thawing procedures in terms of the in vitro parameters tested.

DISCUSSION

Our results indicate that thawing of cryopreserved MPB using dry warming and water bath give similar viability, apoptosis/necrosis rate and clonogenic potential. Both procedures take about the same amount of time and are easy to perform. Nevertheless, the potentially decreased risk of bacterial contamination of either the cell product or the patient room, and guidelines of good clinical practice (GCP), favor the use of the dry warming procedure.

A qualitative study of Australian GPs' attitudes and practices in the diagnosis and management of attention-deficit/hyperactivity disorder (ADHD)

BACKGROUND

The importance of general practice involvement in the care of attention-deficit/ hyperactivity disorder (ADHD) is increasing due to the rising numbers of patients who present with the disorder. It has been suggested by consensus bodies that GPs should be identifying and referring patients at the severe end of the ADHD spectrum and managing those with less severe symptoms. However, GPs' views of their role in ADHD care are unknown.

OBJECTIVE

Our aim was to explore the attitudes and practices of Australian GPs towards the diagnosis and management of ADHD.

METHODS

We conducted a series of focus groups to explore GPs' beliefs regarding the causes of ADHD, their perceived role in ADHD diagnosis and management and their views on the role of behaviour therapies and pharmacotherapies in ADHD management. The subjects were 28 GPs in six focus groups.

RESULTS

GPs in this study did not want to be the primary providers of care for patients with ADHD. Participants indicated a preference to refer the patient to medical specialists for diagnosis and treatment of ADHD, and expressed low levels of interest in becoming highly involved in ADHD care. Concerns about overdiagnosis and misdiagnosis of the disorder, diagnostic complexity, time constraints, insufficient education and training about the disorder, and concerns regarding misuse and diversion of stimulant medications were the reasons cited for their lack of willingness.

CONCLUSIONS

The Australian GPs in this study identify a role for themselves in ADHD care which is largely supportive in nature, and involves close liaison with specialist services.

Genetic variation in the endangered wild apple (Malus sylvestris (L.) Mill.) in Belgium as revealed by amplified fragment length polymorphism and microsatellite markers

The genetic variation within and between wild apple samples (Malus sylvestris) and cultivated apple trees was investigated with amplified fragment length polymorphisms (AFLP) and microsatellite markers to develop a conservation genetics programme for the endangered wild apple in Belgium. In total, 76 putative wild apples (originating from Belgium and Germany), six presumed hybrids and 39 cultivars were typed at 12 simple sequence repeats (SSR) and 139 amplified fragment length polymorphism (AFLP) loci. Principal co-ordinate analysis and a model-based clustering method classified the apples into three major gene pools: wild Malus sylvestris genotypes, edible cultivars and ornamental cultivars. All presumed hybrids and two individuals (one Belgian, one German) sampled as M. sylvestris were assigned completely to the edible cultivar gene pool, revealing that cultivated genotypes are present in the wild. However, gene flow between wild and cultivated gene pools is shown to be almost absent, with only three genotypes that showed evidence of admixture between the wild and edible cultivar gene pools. Wild apples sampled in Belgium and Germany constitute gene pools that are clearly differentiated from cultivars and although some geographical pattern of genetic differentiation among wild apple populations exists, most variation is concentrated within samples. Concordant conclusions were obtained from AFLP and SSR markers, which showed highly significant correlations in both among-genotypes and among-samples genetic distances.

Morphometric analyses of endometriotic tissues to determine their grade of activity

The last revised classification of endometriosis of the American Fertility Society takes the extension of endometriotic lesions and the three macroscopic appearances of this disease into consideration. The aim of this study was to determine whether morphometric analyses are able to describe the grade of activity of endometriotic lesions according to their macroscopic-morphological appearances. Endometriotic samples of 45 patients were analyzed morphometrically using a semiautomatical planimeter. Six different parameters were investigated: the cytoplasmic surface of epithelial cells, the nucleus surface of epithelial cells, the nucleus surface of stromal cells, the gland surface, the gland circumference and the gland diameter. No statistically significant differences (p > 0.05) between the macroscopic appearances of the endometriotic lesions and the six analyzed morphometric parameters were found. The majority of the endometriotic lesions showed median values for the cytoplasmic surface of epithelial cells, the nucleus surface of epithelial cells and the gland surface that did not differ from the median values of all tissues, independently of the macroscopic appearances of these lesions and of the corresponding serum hormonal levels of 17 beta-estradiol and progesterone that were measured at the time of biopsy (p > 0.05). Our morphometric data showed that the red and so-called 'active' endometriotic lesions did not exhibit different morphometric characteristics from the so-called 'inactive' black or white lesions. We found that white and black lesions showed in some cases higher morphometric values than the mean values, so that these macroscopic appearances of endometriotic lesions cannot be considered as 'burned-out' endometriotic tissues. Therefore, black or white endometriotic lesions also have to be considered as therapeutically relevant, as they cannot be defined as 'inactive' endometriosis.

[Inverted papilloma: endoscopic versus external surgery. Apropos of 28 cases]

To evaluate the role of endoscopic versus external surgery in the treatment of inverted papillomas, the clinical courses of 35 patients over a period of 10 years were reviewed. 13 patients were treated endoscopically whereas 15 were treated with an external approach. 7 patients with a post operative follow up of less than 12 months were excluded from the study. Recurrences occurred in 4 patients, 2 patients had been treated by endoscopic surgery and 2 by medial maxillectomy by lateral rhinotomy. 3 patients were diagnosed with squamous cell carcinoma. Salvage surgery was performed by an external procedure or endoscopically depending on the extension of the recurrence. Late complications occurred in both groups: cosmetic complaints and epiphora were more frequently encountered after external treatment. Functional complaints were noted after endoscopic treatment. If there is no evidence of associated malignancy, if complete exposure of the tumor is possible and long term follow up is feasible, the authors propose endoscopic surgery as first line treatment to excise the body of the tumor, assess it's extension, and remove the root of the tumor. If this is not the case, medial maxillectomy by external approach should be performed.

[Cranialization of the frontal sinus]

In the surgery of frontal sinus exclusion, the place of cranialization is still controversial. Our aims were to describe the operative technique, report our results and discuss its indications.

PATIENTS AND METHODS

Nineteen patients were operated according to this technique between 1984 and 1997. Cranialization was performed in the first place for tumors, osteitis, traumatisms and benign tumors or mucoceles with a special location. In patients with chronic sinusitis or mucocele, it was performed in the second place when functional surgery was considered as failure and because sinus obliteration seemed to be inappropriate.

RESULTS

There was no mortality nor anosmia linked to the procedure. Postoperative sequelae were related to the disease or to the surgical approach. After a median follow-up of 29 months, no disease recurrence was observed.

CONCLUSION

Cranialization of frontal sinus gives good results in selected patients, with low morbidity. Even though its indications are infrequent, this technique has its place in the surgical exclusion of frontal sinus.

Numerical simulation of the casting process of titanium tooth crowns and bridges

The objectives of this paper were to simulate the casting process of titanium tooth crowns and bridges; to predict and control porosity defect. A casting simulation software, MAGMASOFT, was used. The geometry of the crowns with fine details of the occlusal surface were digitized by means of laser measuring technique, then converted and read in the simulation software. Both mold filling and solidification were simulated, the shrinkage porosity was predicted by a "feeding criterion", and the gas pore sensitivity was studied based on the mold filling and solidification simulations. Two types of dental prostheses (a single-crown casting and a three-unit-bridge) with various sprue designs were numerically "poured", and only one optimal design for each prosthesis was recommended for real casting trial. With the numerically optimized design, real titanium dental prostheses (five replicas for each) were made on a centrifugal casting machine. All the castings endured radiographic examination, and no porosity was detected in the cast prostheses. It indicates that the numerical simulation is an efficient tool for dental casting design and porosity control.

[Laryngeal immobility after thyroidectomy]

One of the most common complications of surgery of the thyroid gland is vocal folds immobility. New advances in its management have been achieved over the last few years. Laryngeal electromyography, stroboscopy, and computerized analysis of the voice help guide diagnosis, allowing differentiation between recurrent nerve paralysis and glottis traumatism due to intubation, and further follow-up of recovery with relevant therapeutic decisions. In case of unilateral vocal fold paralysis, intrafold silicone or injection of autologous fat is more and more routinely used to obtain vocal rehabilitation. In case of bilateral vocal fold paralysis, to avoid tracheotomy, partial posterior cordectomy using laser surgery restores sufficient laryngeal airflow, with minimal vocal sequelae. Early management of these complications by teams of specialists should allow appropriate and less invasive surgery.

Application of laser measuring, numerical simulation and rapid prototyping to titanium dental castings

OBJECTIVES

This paper describes a method of making titanium dental crowns by means of integrating laser measuring, numerical simulation and rapid prototype (RP) manufacture of wax patterns for the investment casting process.

METHODS

Four real tooth crowns (FDI No. 24, 25, 26, 27) were measured by means of 3D laser scanning. The laser digitized geometry of the crowns was processed and converted into standard CAD models in STL format, which is used by RP systems and numerical simulation software. Commercial software (MAGMASOFT) was used to simulate the casting process and optimize the runner and gating system (sprue) design. RP crowns were 'printed' directly on a ModelMaker II 3D Plotting System. A silicone negative mold (soft tool) was made from the RP crowns, then more than hundreds wax crowns were duplicated. The duplicated crowns were joined to the optimized runner and gating system. By using the investment casting process 20-25 replicas of each crown were made on a centrifugal casting machine. All castings were examined for porosity by X-ray radiographs.

RESULTS

By using the integrated scanning, simulation, RP pattern and casting procedure, cast crowns, free of porosity, with excellent functional contour and a smooth surface finish, were obtained from the first casting trial.

SIGNIFICANCE

The coupling of laser digitizing and RP indicates a potential to replace the traditional 'impression taking and waxing' procedure in dental laboratory, with the quality of the cast titanium prostheses also being improved by using the numerically optimized runner and gating system design.

Use of the carbon dioxide laser for tracheobronchial pathology in children

The carbon dioxide (CO2) laser has been used to treat tracheobronchial pathology for more than 20 years. It was initially employed in adults and now has been found to be useful in the treatment of certain lesions in children. We present our experience with this technique in 30 patients treated with a CO2 bronchoscopic laser from 1987 to 1995 in the Ear, Nose, and Throat Department of Armand Trousseau Hospital. Four different types of pathologies have been successfully treated with the laser: selective cases of tracheobronchial stenosis following trauma and/or secondary to neonatal ventilation, posttraumatic tracheobronchial granuloma (due to foreign bodies or tracheotomies), tracheobronchial granulomas of infectious origin (tuberculosis), and selective cases of tracheobronchial tumor.

[Treatment of snoring with controlled temperature radiofrequency: short- and mid-term tolerance and efficacy]

Uvulopalatopharyngoplasty and laser pharyngotomy can provide effective and definitive cure of snoring. These methods are however very painful. The ideal treatment would be not only effective but also pain free.

MATERIAL AND METHODS

We assessed prospectively the efficacy and tolerance to temperature controlled radiofrequency (somnoplasty). This technique was applied to the velar palate in 15 snoring patients. Self assessment was used to evaluate outcome. The patients daily recorded: uneasiness, pain, drug use, and food intake. Their spouse scored snoring for 6 to 8 weeks after the end of treatment and more than 6 months after the last treatment session.

RESULTS

We achieved 80% success after 2.1 sessions. Pain was minimal. A sensation of uneasiness was frequent and led to minimal drug use. After a mean 13 months, half of the patients experienced a recurrence or an aggravation of their snoring level. Overall satisfaction rate was 69%.

CONCLUSION

These preliminary results suggest that radiofrequency is well tolerated and effective in the short- and mid-term for the treatment of snoring.

[Retrospective cephalometric analysis for surgically treated obstructive sleep apnea: therapeutic deductions]

PURPOSE OF THE STUDY

The goal of surgical treatment for severe sleep apnea syndrome is to alleviate the upper airway obstruction. The narrowing site must be precisely determined during the preoperative evaluation to ensure success. We suggest that cephalometric analysis using a lateral cephalic radiograph to evaluate bony structures combined with magnetic resonance imaging (MRI) to study soft tissues may achieve this goal. The purpose of this study was to determine the role of two different cephalometric analysis systems for determining surgical strategy and to underline factors predictive of success for different surgical procedures.

MATERIALS AND METHOD

We prospectively studied 73 sleep apnea patients. The preoperative evaluation included MRI and two different cephalometric analyses on a lateral cephalic radiograph: Tweed's and Delaire's analyses. Three surgical techniques were performed: mandibular osteotomy and geni tubercule advancement, maxillo-mandibular advancement and tongue base reduction with hypoepiglottoplasty via a cervical approach.

RESULTS

Tweed's analysis appeared to underestimate maxillo-mandibular deficiencies compared with Delaire's analysis; the later seemed to be more sensitive. MRI did not prove to be useful in predicting surgical outcome. MRI was non-contributive in our preoperative evaluation.

DISCUSSION

We suggest a new surgical strategy using two procedures: maxillo-mandibular advancement and tongue base reduction. Indications are based on the results of two cephalometric analyses (Tweed and Delaire) and the measurement of the oropharyngeal surface.

[Surgical treatment of severe sleep apnea syndrome by maxillomandibular advancing or mental tranposition]

Surgery of the facial skeleton or the tongue may be envisaged in case of failure of continuous positive pressure ventilation for severe sleep apnea syndrome defined by a apnea-hyponea index greater than 30/h. We present here our results in patients treated by maxillo-mandibular advancing and mental transposition. We define the surgical indications. Between January 1993 and June 1997, 41 patients, mean age 49 years, with severe sleep apnea syndrome (mean apnea-hyponea index =58.5/h) were treated by maxillo-mandibular advancing (21 cases) or mental transposition (20 cases) depending on the cephalometric work-up including lateral teleradiography and sagittal magnetic resonance imaging of the tongue. Functional outcome was good in both groups. Objective success (postoperative apnea-hyponea index <20) was 70.5 % after bimaxillary advancing (mean apnea-hypopnea index =17), but only 25 % after mental transposition (mean apnea-hyponea index =44.5). Maxillomandibular advancing is a major procedure which can be effective in sleep apnea patients with severe craniofacial skeletal anomalies. Its applications in apneic patients with no skeletal anomaly remains a subject of debate. Conversely, there would appear to be very few indications for mental transposition.

Inter-organellar crosstalk in higher plants: impaired chloroplast development affects mitochondrial gene and transcript levels

Co-ordination of gene expression between the three genomes present in plastids, mitochondria and nucleus is of crucial importance for plant cells. Previous studies revealed that in white leaves of the albostrians (Hordeum vulgare cv. Haisa) mutant, photosynthesis-related plastid and nuclear genes are expressed only at an extremely low level. The plastids of this mutant lack ribosomes, photosynthetic activity and have only rudimentary membrane systems. Here we report on the expression of mitochondrial genes in albostrians barley. Steady-state RNA levels of the mitochondrial genes encoding cytochrome oxidase or ATPase subunits, coxII, coxIII, atpA, atp6, atp9 and cob, were observed to be consistently elevated in the white leaves but not in roots. Investigation of mitochondrial DNA revealed an about three-fold enhanced mitochondrial gene copy number in white compared to green leaf cells, but no differential amplification of mitochondrial genes. Analysis of plants in which the white albostrians plastids were combined with a new nuclear background showed that the enhanced transcript levels were a consequence of the impaired plastids and not of the nuclear albostrians allele. Furthermore, plants bleached by the carotenoid biosynthesis inhibitor norflurazon also showed an enhanced mitochondrial transcript level. These findings allow the conclusion that lack of chloroplast activity in an otherwise fully differentiated leaf leads to an increase in mitochondrial gene copy number and an elevated level of mitochondrial transcripts. Our results indicate an influence of plastids on the genetic apparatus of mitochondria in leaves but not in roots.

[Hypoglossal nerve in its intralingual trajectory: anatomy and clinical implications]

There is little literature on the intralingual trajectory of the hypoglosal nerve. We performed an anatomical dissection on 6 cadavers and completed our study with histological examinations. The 12th cranial nerve enters the lower part of the tongue laterally, reaching the anterior border of the hypoglossal muscle where it follows the ascending lingual artery medially to terminate anteriorly to the lingual V. Its terminal branches spread out horizontally in each half of the tongue. There is a paramedial branch, found in all cases, which projects downwardly, posteriorly and medially at the basilingual portion of the genioglossal muscle. These anatomic findings indicate that basiglossectomy removing the entire base of the tongue can be performed without functional sequelae. A certain degree of somatotopy is also found with specific fibers reaching the protractor and retractor muscles. This nerve distribution supports attempts at selective electrical stimulation of the hypoglossal nerve with the aim of dilating the upper airways in patients with sleep apnea syndrome.

Tongue base reduction with hyoepiglottoplasty: a treatment for severe obstructive sleep apnea

OBJECTIVE

To describe a surgical procedure for the treatment of severe obstructive sleep apnea syndrome (OSAS), the procedure's indications, and its results.

STUDY DESIGN

A retrospective study of 10 male patients with OSAS treated by tongue base reduction with hyoepiglottoplasty (TBRHE) at the Foch Hospital (Suresnes, France) between 1994 and 1997. Patients had a mean body mass index (BMI) of 32 kg/m2, a mean respiratory disturbance index (RDI) of 70 events/h, and a mean minimal oxygen saturation of 78%. They had refused positive airway pressure therapy or wished to discontinue it.

METHODS

Subtotal tongue base reduction preceded by lingual neurovascular bundle identification and derouting, epiglottal verticalization, mouth floor horizontalization, and hyoid bone repositioning was performed, associated in some cases to uvulopalatopharyngoplasty (UPPP). Indications were based on a site-related obstruction, on the absence of craniofacial deficiencies, and on the presence of hyolingual abnormalities determined by cephalometry and magnetic resonance imaging.

RESULTS

TBRHE associated to UPPP in most cases had an 80% success rate, based on a postoperative RDI below 20 events/h and a reduction of the preoperative RDI of more than 50%. Snoring and excessive daytime sleepiness decreased or disappeared, respectively, in 100% and 90% of the cases. No neurovascular complications occurred.

CONCLUSION

TBRHE is a safe procedure for the neurovascular bundle. Associated to a pharyngotomy, it is an effective treatment for severe OSAS attributable to tongue base obstruction. These results require confirmation in a larger series of patients.

[Tongue base reduction with hyoid-epiglottoplasty. A surgical alternative in severe sleep apnea syndromes]

We present preliminary results and indications of tongue base reduction with hyo-epiglottoplasty for the treatment of severe obstructive sleep apnea syndrome (OSAS) due to isolated hyolingual abnormalities. The procedure consists in a subtotal resection of the tongue base after identification and derouting of the lingual neurovascular bundle. Hypopharyngeal enlargement, epiglottis verticalization, floor of the mouth tension and hyoid bone repositioning are also performed during the procedure. 14 severe OSAS male patients (mean apnea-hypopnea index of 71) were treated in our institution from November 1992 to February 1996. Indications were determined after a cephalometric analysis and a magnetic resonance imaging evaluation. Results were evaluated on clinical and polysomnographic criteria. No neurovascular complications occurred. Clinical results were excellent but success rate based on polysomnography was 50%. These preliminary results led us to change some of the steps in the technique. We also identified a predictive factor of success on the cephalometrics: an oropharyngeal area greater than 25 cm2.

Autocatalytic processing of the ATP-dependent PIM1 protease: crucial function of a pro-region for sorting to mitochondria

The biogenesis of the ATP-dependent PIM1 protease of mitochondria was studied by mutational analysis. The ATPase and proteolytic activities of PIM1 were shown to be essential for mitochondrial function. A proteolytically inactive mutant form of PIM1 protease accumulated as a pro-form in mitochondria, revealing a two-step processing of PIM1: the matrix targeting signal is removed by the mitochondrial processing peptidase and then a pro-region of 61 amino acids is cleaved off in an autocatalytic reaction. This latter process depended on the ATP-dependent assembly of PIM1 protease subunits and can occur by an intermolecular and, most probably, also an intramolecular pathway. The respiratory competence of cells harboring mutant PIM1 protease lacking the pro-region was strongly impaired. Subcellular fractionation revealed a cytosolic localization of mutant PIM1 protease. This demonstrates the requirement for the propeptide for efficient sorting of PIM1 protease to mitochondria.

[Treatment by CO2 broncho-laser for acquired tracheobronchial stenosis in children with bronchopulmonary dysplasia]

OBJECTIVE

Evaluation of carbon dioxide (CO2) broncholaser for treating acquired proximal tracheo-bronchial stenosis in children with bronchopulmonary dysplasia.

DESIGN

Retrospective study from June 1987 through August 1995, with 39 months follow-up.

PATIENTS AND METHODS

During the study, 65 children were treated for bronchopulmonary dysplasia. Eight of those (average age: 42.6 months) had symptomatic tracheo-bronchial stenosis; they were treated with CO2 broncholaser and represented 23.5% of all broncholaser applications. All patients presented multiple lesions. Ten symptomatic well-organized lesions (obstructive bridles or diaphragms), all accessible to broncholaser, were treated. Broncholaser was the primary treatment used, except in one case where it was used following balloon dilatation failure. An adaptable rigid fibroscope combined with a CO2 Sharplan laser was used. All interventions were performed under general anesthesia.

RESULTS

Lesions not reaching the trachea's bifurcation (eight cases) disappeared following one laser session with significant clinical improvement. Lesions extending to the trachea's bifurcation (two cases) only showed partial improvement despite three laser sessions. The results remained stable throughout the follow-up period. There were no major complications.

CONCLUSIONS

Broncholaser is a safe and efficient method of treating stenoses occurring in patients with bronchopulmonary dysplasias. Obstructive lesions (such as bridles or diaphragms) and those which do not reach the trachea's bifurcation, give the best results.

Sperm chromatin anomalies can influence decondensation after intracytoplasmic sperm injection

In this study we investigated whether morphology and chromatin anomalies in human spermatozoa can influence fertilization after intracytoplasmic sperm injection (ICSI). We examined unfertilized oocytes, using the fluorochrome Hoechst 33342, to determine whether a relationship exists between failure of fertilization and sperm chromatin quality. Sperm chromatin packaging quality was assessed using the chromomycin A3 (CMA3) fluorochrome, and the presence of DNA damage in spermatozoa, using in-situ nick translation, Normal males present sperm parameters with a normal morphology of > 20%, CMA3 fluorescence of < 30% and exhibit endogenous nicks in < 10% of their spermatozoa. When patients were separated according to these values no difference was observed in their fertilization rates after ICSI. When the unfertilized ICSI oocytes were examined, we found that patients with CMA3 fluorescence of <30% and nicks in < 10% of their spermatozoa had only 17.5 and 21.6% respectively of their unfertilized oocytes containing spermatozoa that remained condensed. In contrast, patients with higher CMA3 and nick values had a significantly higher number, 41.2 and 48.9%, of their unfertilized oocytes containing condensed spermatozoa. sperm morphology did not show any such pattern. The percentage of spermatozoa which had initiated decondensation in unfertilized oocytes was not influenced by morphology, CMA3 fluorescence or nicks. In light of these results we postulate that poor chromatin packaging and/or damaged DNA may contribute to failure of sperm decondensation after ICSI and result in failure of fertilization.

[Surgery of primary malignant melanomas of the mucosa of the nasal fossa and facial sinuses]

A retrospective analysis of 22 patients with primary malignant melanoma of the nasal fossa and/or paranasal sinuses consecutively managed with surgery at our department from 1975 to 1993 was conducted. Fifteen patients had negative margins of resection. Neoadjuvant chemotherapy and post-operative radiation therapy was associated in 4 and 5 of these 15 patients, respectively. Four patients had positive margins. Adjunctive treatment was chemotherapy and postoperative radiation therapy in 2 and 3 of these 4 patients, respectively. The remaining 3 patients were managed with palliative treatment (debulking surgery and chemotherapy). No patients were lost to follow up. A 3-year follow-up was always achieved. In patients in whom surgical resection achieved negative margins, the 5-year actuarial survival, and local control estimate was 17.9%, and 26.9%, respectively. None of the variables under analysis were statistically related to local recurrence or survival. Death always occurred within 24 months from initial diagnosis in all 7 patients but one in whom surgical resection with negative margins was not achieved or debulking surgery was performed.

Cardiac troponin I release correlates with myocardial infarction size

Cardiac troponin I, creatine kinase, and creatine kinase MB activity were tested in serial blood samples from 15 patients with first-time Q wave acute myocardial infarction (2 anterior and 13 inferior wall infarctions). All patients received intravenous thrombolytic therapy. Cardiac troponin I and creatine kinase MB activity were compared with scintigraphic estimates of myocardial scar (single photon emission computed tomography [SPECT] with 99mTechnetium-isonitrile [Tc-sestamibi]) on late images at rest about 5 weeks after myocardial infarction. Scintigraphic defect sizes ranged from 3.2 to 41.2% (median: 27.3%) of left ventricle. Cardiac troponin I increased and peaked in parallel with creatine kinase MB activity, and the peak values correlated with each other (r = 0.76, p = 0.002). Troponin I stayed increased for several days longer than creatine kinase and creatine kinase MB activity. It could be detected at least until the 4th day after admission. Significant correlation coefficients were found between 99mTc-isonitrile defect sizes and areas under cardiac troponin I curves (r = 0.53, p = 0.042) and between 99mTc-isonitrile defect sizes and cumulative creatine kinase MB activity release (r = 0.64, p = 0.01). Animal studies have already shown a very close correlation between histologic infarct size and SPECT 99mTc-isonitrile defect size. Therefore, our results indicate that cardiac troponin I release in patients with acute myocardial infarction is also correlated with infarct size.

Different time courses of cardiac contractile proteins after acute myocardial infarction

For the first time we have compared time courses of cardiac myosin light chain-1 (MLC-1), beta-type myosin heavy chain (MHC), troponin T (TnT), myoglobin, creatine kinase (CK) and CKMB in the same patients with acute myocardial infarction (AMI). Blood samples were serially collected in 23 patients with first-time AMI. All but 3 patients received intravenous thrombolytic treatment. TnT and MLC-1 time courses were biphasic in most patients and showed two distinct peaks in 13 and 8 patients, respectively. MHC time courses were usually monophasic. Only 1 patient showed a biphasic MHC time course with two distinct peak values. Although MHC and MLC were lower by about the fourth day after onset of AMI in early reperfused patients, reperfusion did not qualitatively alter MLC and MHC release (no significant influence on the first appearance in blood or on time to peak). MLC and MHC peaks correlated closely (r = 0.75, P = 0.0001), whereas TnT peaks were correlated less closely with MLC or MHC peaks (r = 0.58 each, P < 0.007). Peak values of all cardiac contractile proteins correlated closely and significantly with CKMB peaks (0.75 < or = r < or = 0.81, P < or = 0.0006). Myoglobin was the first marker to increase in blood after AMI and showed the earliest peaks, whereas MHC increased latest showing the latest peaks. TnT increased significantly (P = 0.0001) earlier than MLC and MHC. These results can be explained by the impact of the intracellular compartmentation of a cardiac protein on the rapidity with which it is released after AMI.

Molecular chaperones cooperate with PIM1 protease in the degradation of misfolded proteins in mitochondria

ATP dependent proteolytic degradation of misfolded proteins in the mitochondrial matrix is mediated by the PIM1 protease and depends on the molecular chaperone proteins mt-hsp70 and Mdj1p. Chaperone function is essential to maintain misfolded proteins in a soluble state, a prerequisite for their degradation by PIM1 protease. In the absence of functional mt-hsp70 or Mdj1p misfolded proteins either remain associated with mt-hsp70 or form aggregates and thereby are no longer substrates for PIM1 protease. Mdj1p is shown to regulate the ATP dependent association of an unfolded polypeptide chain with mt-hsp70 affecting binding to as well as release from mt-hsp70. These findings establish a central role of molecular chaperone proteins in the degradation of misfolded proteins by PIM1 protease and thereby demonstrate a functional interrelation between components of the folding machinery and the proteolytic system within mitochondria.

Concentration time courses of troponin and myosin subunits after acute myocardial infarction

BACKGROUND

As a result of the limited sensitivity and specificity of creatine kinase and lactate dehydrogenase (LDH) as well as their isoenzymes, there is increasing interest in the use of cardiac contractile proteins for the diagnosis of acute myocardial infarction (AMI) and myocardial damage.

METHODS

This study compared the release of creatine kinase, creatine kinase MB, myoglobin, cardiac troponin I (cTnI), cardiac troponin T (cTnT), cardiac myosin light chain-1 (cMLC-1), and beta-type myosin heavy chains (bMHC) in serial blood samples from 13 patients (10 men, three women; median age 54 years, range 40-74 years) with first-time AMI (11 Q-wave, two non-Q-wave AMI; three anterior and 10 inferior wall AMI). All but one patient received intravenous thrombolytic treatment.

RESULTS

Myoglobin was the first marker to increase in blood after AMI and showed the earliest peak levels, whereas bMHC increased latest, showing the latest peak levels. cTnI and cTnT increased significantly earlier than cMLC-1 and bMHC. cTnI and cTnT increased and reached peak levels parallel to each other, but the latter tended to stay increased longer. cTnT time courses were biphasic in the majority of AMI patients, unlike cTnI time courses. cMLC-1 release was mostly biphasic. cMLC-1 allows diagnosis during the acute phase as well as several days after the onset of AMI. The time courses of bMHC were usually monophasic. Its delayed appearance makes it useful for the diagnosis of remote infarction. In contrast to cTnI and cTnT, cMLC-1 and bMHC time courses were not significantly influenced by early reperfusion.

CONCLUSION

Our results demonstrate the impact of the intracellular compartmentation of an intramyocardial protein (cytosolic, structurally bound, or structurally bound with soluble pool) on its concentration time course after AMI, particularly on the rapidity of its release.

[Loudness scaling. A procedure for quantitative recruitment detection]

Direct loudness scaling has been known as an audiological tool for about four decades. Although numerous publications have shown its clinical importance, loudness scaling has not been used in audiology and hearing aid fitting until now. This might be due to the lack of audiometers equipped with loudness scaling devices as well as missing evidence for its clinical applicability. In this study normal data for a single-step direct scaling procedure were established and loudness determinations of 105 patients with sensorineural hearing losses collected. The results show that normal level loudness functions exhibit very similar shapes for narrow band stimulation in the frequency range of 500 to 4000 Hz. However, loudness scaling is affected by the gender of the subjects: females scale systematically louder than do males. In hearing-impaired subjects the slopes of the level loudness functions tend to decrease with increasing hearing loss, indicating negative recruitment. This holds particularly true in the high-frequency range, e.g. at 4000 Hz. Our long-term experience with single-step direct loudness scaling has proven its clinical feasibility in typical patients of an audiology unit. Loudness scaling will prove useful for the localization of hearing impairments, as it can be employed as a quantitative indicator of recruitment without any restrictive preconditions. In addition, it allows the evaluation of hearing aids and cochlear implants by frequency-specific gain measurement.

Cardiac troponin T release in acute myocardial infarction is associated with scintigraphic estimates of myocardial scar

BACKGROUND

This study compared clinical-chemical estimates of infarct size with scintigraphic estimates of myocardial scar in patients with first-time acute myocardial infarction (AMI).

METHODS

Levels of the cardiac isoform of the contractile protein troponin T (TnT), of creatine kinase (CK), and of the isoenzyme MB of CK (CK MB) were tested in serially drawn blood samples from 21 patients (two females and 19 males; median age, 55 years). Of these 21 patients, five had anterior- and 16 had inferior-wall AMI; all patients received intravenous thrombolytic therapy. Single-photon emission computed tomography (SPECT) with technetium-99m-isonitrile (Tc-sestamibi) was performed at rest after the onset of AMI (median time, 5 weeks). Scintigraphic defects were calculated using "bull's-eye" polar coordinate maps. All patients had an uncomplicated course between discharge and myocardial scintigraphy.

RESULTS

Scintigraphic defect sizes ranged from 3.2% to 47.8% of the left ventricle (median, 27.3%). Cardiac TnT and CK MB release correlated closely with each other and with scintigraphic estimates of myocardial scar. Significant correlates were found between cardiac TnT and CK MB peak values (r = 0.87, P = 0.0001), CK MB peaks and Tc-sestamibi defect sizes (r = 0.73, P = 0.0014), and TnT peaks and scintigraphic defect sizes (r = 0.73, P = 0.0011).

CONCLUSIONS

Because animal studies have already shown a very close correlation between histologic infarct size and SPECT Tc-sestamibi defect size, our results indicate that cardiac TnT is a useful marker to assess infarct size noninvasively in man.

IVF treatment of moderate male factor infertility: a comparison of mini-Percoll, partial zona dissection and sub-zonal sperm insertion techniques

In this study we examined various techniques of in-vitro fertilization (IVF) for treating couples in whom the male had subnormal semen parameters. We compared two sperm preparation methods (mini-Percoll and conventional swim-up) for efficiency of recovery after preparation and for fertilization rates after IVF, and compared the suitability of partial zona dissection (PZD) and sub-zonal sperm insertion (SUZI) to patients with different types of male factor infertility. The mini-Percoll technique allowed the recovery of significantly more motile spermatozoa from the same semen sample compared to the swim-up method. More oocytes were fertilized after spermatozoa were prepared by the mini-Percoll technique. An increased number of spermatozoa recovered from an ejaculate led to an improvement in the quality of spermatozoa in the insemination droplet. Subsequently, when using the PZD technique, the fertilization rate increased when there was a higher number of spermatozoa in the patient's ejaculate. When comparing the two micromanipulation techniques, SUZI provided patients with oligoasthenzoospermia (i.e. < 10 x 10(6) spermatozoa/ml and 40% motility) with a higher chance of obtaining 2-pronculeate eggs.

Pleural liposarcoma presenting with respiratory distress and suspected diaphragmatic hernia

A young woman with a history of diaphragmatic hernia presented to the hospital in respiratory distress and in premature labor. Her admission chest roentgenogram showed opacification of the left hemithorax, and her arterial blood gas analysis revealed hypoxemia. Emergency cesarean section and exploratory left thoracotomy were carried out; a large tumor occupied the left side of the chest, and pneumonectomy was performed. No diaphragmatic hernia was present. A pathologic diagnosis of primary liposarcoma was made.

Early diagnosis of acute myocardial infarction by a newly developed rapid immunoturbidimetric assay for myoglobin

OBJECTIVE

To evaluate a rapid immunoturbidimetric assay for myoglobin and to investigate its clinical usefulness in the early detection of acute myocardial infarction.

DESIGN

Prospective study. Immunoturbidimetrically determined myoglobin concentrations were compared with radioimmunoassay results obtained with the same blood samples. The diagnostic performance of myoglobin determination was compared with creatine kinase and creatine kinase MB activity (current standard of routine diagnosis).

SETTINGS

Part 1: coronary care unit. Part 2: emergency room in a university hospital.

PATIENTS

Part 1:30 patients with acute myocardial infarction admitted not later than four hours (median two hours) after the onset of symptoms. Part 2: 126 patients admitted to the emergency room with chest pain not caused by trauma (51 cases of acute myocardial infarction, 51 cases of angina pectoris, and 24 cases of chest pain not related to coronary artery disease).

INTERVENTIONS

Part 1: routine treatment including intravenous thrombolytic treatment (28 patients). Part 2: routine emergency treatment without thrombolytic treatment.

MAIN OUTCOME MEASURES

The analytical quality of the immunoturbidimetric myoglobin assay and a comparison between the myoglobin assay and creatine kinase and creatine kinase MB for diagnostic sensitivity and performance.

RESULTS

The immunoturbidimetric myoglobin assay was fast and convenient and gave myoglobin determinations of high analytical quality. The concentration of myoglobin increased, peaked, and returned to the reference range significantly earlier than creatine kinase (p < or = 0.0001) and creatine kinase MB (p < or = 0.0002). Before thrombolytic therapy was started the diagnostic sensitivity of myoglobin was significantly higher than that of creatine kinase MB activity 0-6 h after the onset of chest pain and significantly higher (0.82 v 0.29) than creatine kinase 2-4 h after the onset of chest pain. In almost all patients (92%) plasma myoglobin concentrations were increased 4-6 h after the onset of chest pain.

CONCLUSION

Myoglobin was more sensitive in detecting early myocardial infarction than creatine kinase and creatine kinase MB activity. Immunoturbidimetric myoglobin measurements could be useful in the early evaluation of patients with suspected myocardial infarction because this assay takes less than two minutes.