Indication and technique of transnasal microscopic orbital decompression for endocrine ophthalmopathy

If endocrine ophthalmopathy progresses despite conservative treatment then indications for surgical decompression are: loss of visual acuity, increasing strabism, and severe keratopathy. Endonasal microsurgery ensures a binocular view onto the intranasal landmarks of the orbital walls and allows simultaneous decompression of the medial and inferior wall as well as a good relief of pressure at the orbital apex. Surgical decompressions were performed on 29 orbits in 19 patients, 16 by using the endonasal microsurgical, 3 via external approach. The microscopic approach was entirely comparable with regard to the reduction of proptosis with a mean improvement of 4.2 mm against a mean of 4.7 mm by external approach and a mean 0.2 of better visual acuity in both procedures. The microsurgical technique is considered superior to an external approach avoiding external scars, neural pain, and reportedly less diplopia. The healing phase and the hospitalization time are shorter.

Identification, purification, and molecular cloning of a putative plastidic glucose translocator

During photosynthesis, part of the fixed carbon is directed into the synthesis of transitory starch, which serves as an intermediate carbon storage facility in chloroplasts. This transitory starch is mobilized during the night. Increasing evidence indicates that the main route of starch breakdown proceeds by way of hydrolytic enzymes and results in glucose formation. This pathway requires a glucose translocator to mediate the export of glucose from the chloroplasts. We have reexamined the kinetic properties of the plastidic glucose translocator and, using a differential labeling procedure, have identified the glucose translocator as a component of the inner envelope membrane. Peptide sequence information derived from this protein was used to isolate cDNA clones encoding a putative plastidic glucose translocator from spinach, potato, tobacco, Arabidopsis, and maize. We also present the molecular characterization of a candidate for a hexose transporter of the plastid envelope membrane. This transporter, initially characterized more than 20 years ago, is closely related to the mammalian glucose transporter GLUT family and differs from all other plant hexose transporters that have been characterized to date.

[Medical habilitation. Accepted academic qualifications or outdated formalism?]

BACKGROUND

With the changes in the structure of education and society, in recent years also the medical habilitation (German postdoctoral lecturing qualification) has been called into question as an academic qualification. With this in mind, the aim of our study was to discover the current opinion of those who had successfully completed a habilitation on the prerequisites for a habilitation, the habilitation procedure and the status of a habilitation, and to document potential wishes for reform. COLLECTIVE AND METHODS: The target group of our survey were the 616 persons (female: 77, male 539) who successfully completed their habilitation in 1997 at one of the 36 German medical faculties. The database was formed by an anonymous questionnaire (23 items), which included questions on sociodemographic factors and occupational history (general part), and subjective opinions (specific part). Recruitment of the participants in the survey and passing on of the questionnaire were carried out by the office of the medical dean of the various universities, as the names of those who had completed a habilitation were not available to the investigators for reasons of protecting the individual's rights and identity. Evaluation of the returned questionnaires was carried out using descriptive statistics. Subgroups were formed according to sex, age and subject groups.

RESULTS

The questionnaire was answered in a useable form by 389 persons (female: 46, male 343) from 35 medical faculties (return quota 63%). 95% of those who took part in the survey were registered doctors; 79% of these came from clinics, 16% from the field of theoretical medicine. 81% were specialist physicians. 5% had studied the natural sciences or humanities. The median age at the time of completing the habilitation was 38 years (minimum 30, maximum 54 years old). At present 93% were assistant professors, 5% were professors. The median interval between the doctoral thesis and habilitation was 10 years. 58% had carried out a period of research abroad. In 90% of cases the persons had written a postdoctoral thesis for their habilitation, 10% qualified cumulatively. 47% had improved their occupational rank within a period of 2 years after completing the habilitation, about 2/3 of these reached senior positions. Among the prerequisites for habilitation, "Humboldt's trias" (research, teaching and caring for patients) was accepted by the great majority. Other prerequisites regarded as important for habilitation were publications, holding talks, specialist status and experience abroad. Impact factors, however, should be regarded as important conditions for habilitation only in combination with other criteria. The value of a habilitation was not called into question; 89% would recommend completing one. 80% of those questioned, however, thought the procedure for completing a habilitation should be optimized. The general abolition of the medical habilitation was, however, not desired by the vast majority.

CONCLUSION

The value of completing a medical habilitation is not a point for debate for most of those who successfully completed one. It remains the springboard for occupational advancement. The vast majority do not wish to see it abolished. Also the usual prerequisites for habilitation are accepted by the majority of persons. The procedure for completing a habilitation is, however, regarded as in need of improvement. There is a wide consensus of opinion regarding potential aims for reform.

A comparison of intrathecal analgesia with fentanyl or sufentanil after total hip replacement

We designed this study to compare the postoperative analgesic effects of intrathecal fentanyl and sufentanil, the end points being onset, quality, and duration of action. A total of 42 geriatric patients, scheduled for elective total hip replacement under continuous spinal anesthesia, were randomized in two double-blinded groups as soon as they experienced a pain score higher than 3 of 10 on the visual analog scale in the recovery room. Either 7.5 microg sufentanil or 40 microg fentanyl in 2 mL normal saline were intrathecally administered. Pain scores, rescue analgesia (ketorolac and morphine), and adverse effects (respiratory depression, postoperative nausea and vomiting, and itching) were recorded for 24 h after surgery. In both groups, comparing sufentanil to fentanyl, the time to a pain score <3 (9 +/- 9 vs 11 +/- 8 min), the time to the lowest pain score (18 +/- 6 vs 20 +/- 15 min), and the time to the first systemic analgesic intervention for a pain score >3 (241 +/- 102 vs 214 +/- 120 min) were comparable as were the analgesic requirements during the first 24 h. We conclude that, after total hip replacement, both lipid soluble opioids produce excellent analgesia with comparable onset, duration of action, and low incidence of minor adverse effects.

IMPLICATIONS

We compared the postoperative analgesic properties of 40 microg intrathecal fentanyl and 7.5 microg sufentanil after total hip replacement. Both opioids provided satisfactory analgesia, with comparable onset (11 +/- 8 vs 9 +/- 9 min) and duration of action (214 +/- 120 vs 241 +/- 102 min), as well as low incidence of minor side effects.

Microsurgical endonasal decompression in dysthyroid orbitopathy

Diagnosis of thyroid eye disease can be established by its history, signs, symptoms, clinical and laboratory findings of an autoimmune thyroid disease. Therapy for this disease is limited to a few options, which should be administered depending on its stage and inflammatory activity. When medication and radiation therapy fail indications for decompression are: loss of visual acuity or visual field defects, increasing strabism and severe keratopathy due to eyelid retraction. Numerous surgical decompression techniques have been described in endocrine orbitopathy. We have adopted endonasal microsurgery, because this technique gives the freedom to work bimanually, ensures a stereomicoscopic view of the intranasal landmarks of orbital walls and allows simultaneous decompression of the medial and inferior orbital wall as well as a good relief of pressure at the orbital apex. Decompressions were performed on 27 orbits in 17 patients, via the endonasal microsurgical, 3 via external approach. The microscopic approach was entirely comparable with regard to reduction of proptosis with a mean improvement of 4.1 mm against a mean of 4.7 mm by external approach and a mean 0.2 of better visual acuity in both procedures. The microsurgical technique is considered superior to an external approach avoiding external scars, neural pains and reportedly less diplopia. Also, trauma to the nalolacrimal and nasofrontal ducts are avoided. The healing phase and the hospitalization time is shorter.

Cyclooxygenase-independent inhibition of smooth muscle cell mitogenesis by ibuprofen

The aryl-propionic acid derivative, ketoprofen, has been shown to inhibit fibroblast growth by a cylooxygenase-dependent mechanism [Sánchez, T., Moreno, J.J., 1999. S(+) enantiomer inhibits prostaglandin production and cell growth in 3T6 fibroblast cultures. Eur. J. Pharmacol. 370, 63-67]. The present study demonstrates that ibuprofen, another aryl-propionic acid derivative, inhibited platelet-derived growth factor-BB (20 ng/ml)-induced mitogenesis of cultured bovine coronary artery smooth muscle cells in a stereo-independent manner. In addition, pretreatment of the cells with indomethacin (3 microM) did not affect the inhibitory effects of ibuprofen enantiomers on smooth muscle cell mitogenesis. Thus, aryl-propionic acid-type cyclooxygenase inhibitors can inhibit cell proliferation by both, cyclooxygenase-dependent and -independent ways.

[Effect of portal branch ligation on liver regeneration in the rat]

GOAL

The aim of this study was to assess liver regeneration after partial portal ligation.

METHODS

70% partial portal occlusion was obtained by ligation of the left portal vein branch. Total liver weight ratio were measured 96 hours after partial portal occlusion and in sham operated animals. The kinetics of hepatocytes division was evaluated by measuring the incorporation of 5-bromo-21-deoxyuridine into replicating cells at various time points by immunohistochemistry.

RESULTS

Partial portal occlusion did not alter the total liver weight 96 hours after surgery. It resulted in atrophy of the ligated lobes and hypertrophy of the lobes with preserved portal flow. Hypertrophy was associated to an increase of the percentage of replicating hepatocytes. The replication rate was maximum at 28 hours with a peak at 12.5% and was prolonged beyond the 48th hour.

CONCLUSIONS

Partial portal occlusion results in major and prolonged regeneration process in the liver lobes with preserved portal flow.

'Microsmatic' primates revisited: olfactory sensitivity in the squirrel monkey

Using a conditioning paradigm, the olfactory sensitivity of three squirrel monkeys to nine odorants representing different chemical classes as well as members of a homologous series of substances was investigated. The animals significantly discriminated dilutions as low as 1:10,000 n-propionic acid, 1:30,000 n-butanoic acid and n-pentanoic acid, 1:100,000 n-hexanoic acid, 1:1Mio n-heptanoic acid, 1:30, 000 1-pentanol, 1:300,000 1,8-cineole, 1:1Mio n-heptanal and 1:30Mio amyl acetate from the near-odorless solvent, with single individuals scoring even slightly better. The results showed (i) the squirrel monkey to have an unexpectedly high olfactory sensitivity, which for some substances matches or even is better than that of species such as the rat or the dog, and (ii) a significant negative correlation between perceptibility in terms of olfactory detection thresholds and carbon chain length of carboxylic acids. These findings support the assumptions that olfaction may play a significant and hitherto underestimated role in the regulation of primate behavior, and that the concept of primates as primarily visual and 'microsmatic' animals needs to be revised.

Tropomodulin increases the critical concentration of barbed end-capped actin filaments by converting ADP.P(i)-actin to ADP-actin at all pointed filament ends

The pointed end capping protein, tropomodulin, increases the critical concentration of barbed end capped actin, i.e. it lowers the apparent affinity of pointed ends for actin monomers. We show here that this is due to the conversion of pointed end ADP. P(i)-actin (low critical concentration) to ADP-actin (high critical concentration) when 70-98% of the ends are capped by tropomodulin. We propose that this is due to the low affinity of tropomodulin for pointed ends (K(d) approximately 0.3 microM), which allows tropomodulin to rapidly exchange binding sites and transiently block access of actin monomers to all pointed ends. This leaves time for ATP hydrolysis and phosphate release to go to completion between successive monomer additions to the pointed end. When the affinity of tropomodulin for pointed ends was increased about 1000-fold by the presence of tropomyosin (K(d) < 0.05 nM), capping of 95% of the ends by tropomodulin did not alter the critical concentration. However, the critical concentration did increase when the tropomodulin concentration was raised to the high values effective in the absence of tropomyosin. This may reflect transient tropomodulin binding to tropomyosin-free actin molecules at the pointed ends of the tropomyosin-actin filaments without a high affinity tropomodulin cap, i.e. the ends that determine the value of the actin critical concentration.

New telemetric system for daily pulmonary function surveillance of lung transplant recipients

BACKGROUND

Following lung transplantation, prompt diagnosis and therapy of acute pulmonary rejection and infection episodes relies primarily upon changes in pulmonary function and determines long-term outcome. We tested a new system that allows daily monitoring of the patient's pulmonary status even after discharge from the hospital.

METHODS

Seven lung transplant recipients from our center were equipped with a telemetric monitoring device consisting of a portable flowmeter and a special modem unit. The flowmeter measures forced vital capacity (FVC), forced expiratory volume per second (FEV1), and mid expiratory flows (MEFs), encodes information like fever, cough, and dyspnea in a binary code form, and stores all values in a 32 kB memory unit. After its use, the patient positions the flowmeter onto the modem unit which automatically connects to a central computer at our center to transfer all saved data. The whole set can be used via any regular phone jack. The patient's file in the computer can be checked every day.

RESULTS

All patients learned to use the unit during their postoperative stay or during later follow-up, and were able to apply the system at home. In a mean follow-up period of 10.3+/-2.2 months, 15 episodes of significant deterioration in home pulmonary function tests (PFTs) (>10%) were registered in 6 patients, which were all confirmed by in-hospital body plethysmography. They resulted in diagnoses of 4 episodes of acute rejection, 6 cases of beginning bacterial pneumonia, and 5 cases of, most likely, viral tracheobronchitis. Only 1 patient had to be admitted to the hospital. All patients PFTs returned to previous values after treatment.

CONCLUSIONS

Telemetric monitoring of graft function in lung transplant recipients allows reliable early diagnosis and treatment of infection or rejection, which might help to prevent exacerbation of the pathology and reduce quantity of amounting graft dysfunction.

[Use of open MRI in head-neck surgery]

The vertical open MRI (Signa SP, 0, 5 Tesla) is ideal for interventional diagnosis and therapy. From our point of view indications in Otorhinolaryngology are biopsies of tumours which are difficult to access such as the petrous apex and the petroclival region, the parapharyngeal space and neck and the orbit. Furthermore the open MRI is useful in the surgery of paranasal sinuses, in the evaluation of tissue-resection and helpful in detection of the anatomy of delicate structures as the internal carotid artery, the skull-base and the orbit. Also navigation in open MRI is possible for example with a flash-point-system. The advantage to conventional navigation systems is the possibility of real-time-imaging, which allows detection of tissue shift occurring during the procedure. We report about our experience with ten biopsies of the petrous apex and the petroclival junction and two biopsy of the parapharyngeal space and the neck. Further experience was gained with MR guided placement of afterloading tubes into large neck metastases in three cases and microscopic surgery of paranasal sinuses in five cases. In all operative procedures an excellent resolution was found especially for soft tissue structures as for example blood vessels. With the aid of special pointer systems or artefacts by surgical instruments all relevant anatomical structures could be detected intraoperatively, concerning normal and pathologic tissue. Thus open MRI proved to be a helpful instrument in these operative procedures.

Spinach hexokinase I is located in the outer envelope membrane of plastids

The subcellular localization of hexokinase activities in plant cells has been a matter of debate for a long time. We have isolated a hexokinase cDNA fragment from glucose-fed spinach leaves using a differential display reverse transcription-PCR approach. The corresponding cDNA was expressed in Escherichia coli and an antiserum, raised against the recombinant protein, was used in subcellular localization studies. The spinach hexokinase could be localized primarily to the outer envelope membrane of chloroplasts where it is inserted via its N-terminal membrane anchor. We suggest that the chloroplast envelope hexokinase is involved in the energization of glucose export from plastids rather than in the sugar-sensing pathway of the plant cell.

Immunoglobulin deficiency and determination of pneumococcal antibody titers in patients with therapy-refractory recurrent rhinosinusitis

We examined 245 patients with chronic rhinosinusitis not responding to prolonged antibiotic treatment and tested each patient for humoral antibody deficiencies. Low immunoglobulin levels were found in 22 patients. Five of them had defects of two or more immunoglobulin isotypes that were diagnosed as common variable immunodeficiency (CVI). Seventeen had an IgG-subclass deficiency. Before and after immunization with pneumococcal vaccine, serotype-specific pneumococcal antibody levels were determined to further evaluate the relevance of the underlying deficiency. Significantly reduced antibody titers of pneumococcal serotypes were found in CVI patients (n = 5), while immunization of 17 patients with IgG-subclass deficiency gave different results. Three of the 17 patients responded poorly to pneumococcal immunization and were prone to a polysaccharide specific immunodeficiency. Patients with CVI or IgG-subclass deficiency failing to produce protective antibody levels in more than five serotypes were chosen for antibiotic and/or immunoglobulin substitution therapy. Since recurrent sinusitis in these patients did not resolve with adequate conservative therapy, endonasal microsurgery was then performed and was seen to be a valuable therapeutic option. Our study suggests that an IgG-subclass deficiency may be the first sign of a basic immunological change, resulting in persisting sinus infections.

[Medical rehabilitation in long-term disability]

Based on data from a prospective observational cohort study the following article attempts to answer two key questions of rehabilitation research in Germany: (1) What are the utilization rates of rehabilitation measures in patients with long-term work-incapacity due to low-back pain? (2) In this group of patients: does participation in rehabilitation programs correlate with return to work? Patients with long-term work-incapacity due to low-back pain report a severely impaired health status (measured by FFbH, SF-36, numeric rating scale for pain intensity) which calls for comprehensive medical treatment and rehabilitation. 40.5% of study patients received first time medical rehabilitation between three months and one year after the beginning of long-term work-incapacity, 20.5% between one year and two years after the beginning of long-term work-incapacity. These figures were not influenced by age. Considering the severity of impairment we judge these rates as being quite low. There was no positive correlation found between utilization of medical rehabilitation measures or any other medical treatment and return to work. A positive correlation was observed for utilization of first time medical rehabilitation between three months to one year after the beginning of long-term work-incapacity and functional capacity. This effect was demonstrable for patients 50 years of age or younger.

CONCLUSIONS

(1) In our cohort utilization of medical rehabilitation measures in patients with low-back pain and long-term work-incapacity is quite low. This suggests a considerable amount of underutilization. (2) In order to avoid underutilization the process of accessing medical rehabilitation within the German health care system should be critically reviewed. (3) In the given context of high unemployment rates and the German early pensioning system the use of "return to work" as the main criterion to judge effectiveness of rehabilitation measures remains debatable.

Means of increasing sensitivity of an in vitro diagnostic test for aspirin intolerance

BACKGROUND

Pseudo-allergic reactions caused by aspirin (acetyl salicylic acid; ASA) often resemble immediate-type hypersensitivity reactions consisting of urticaria and angioedema or rhinoconjunctivitis, asthma and nasal polyps. In the last few years, a new in vitro assay based on determination of sulfidoleucotrienes from isolated leucocytes (cellular allergen stimulation test - CAST) has been introduced for type I allergies and pseudoallergic reactions. In ASA intolerance, there is only limited experience using this assay with - in some studies - only moderate sensitivity. Furthermore, the necessity to use freshly isolated leucocytes from untreated patients is inconvenient for routine settings.

OBJECTIVE

The purpose of our study was to search for possibilities of increasing the sensitivity of the test and to use stored blood samples which would permit shipping, two requirements for the clinical suitability of this test.

PATIENTS AND METHODS

Leucotriene release in response to ASA and other non-steroidal anti-inflammatory drugs (NSAIDs) was analysed in 38 ASA-intolerant patients (predominantly airway-related symptoms n = 22; predominantly cutaneous symptoms n = 16) and 50 controls. The diagnosis of ASA intolerance was established by history and placebo-controlled oral challenge tests.

RESULTS

Using 24 h-stored leucocytes obtained from 10 ASA-intolerant patients and 10 healthy controls there were no significant differences of leucotriene release by resting, ionomycin-, and anti FcepsilonRIalpha-stimulated leucocytes compared with freshly isolated leucocytes. Analysis of ASA + C5a-mediated leucotriene release by stored blood samples in combination with indomethacin- and diclofenac-mediated leucotriene release in ASA-intolerant patients (n = 38) resulted in an increased sensitivity (from 50 to 72.7% in ASA-intolerant patients with predominantly airway-related symptoms and from 81 to 100% in ASA-intolerant patients with predominantly skin symptoms) compared with assays in which only ASA + C5a-mediated leucotriene release has been determined. Moreover, the specificity of the assay remained high (96.7% when analysing different NSAIDs compared with > 99% when analysing only ASA + C5a-mediated leucotriene release).

CONCLUSION

In vitro stimulation with ASA + C5a leucocyte stimulation with other NSAIDs should be performed to achieve a higher sensitivity. This finding can be explained by the clinical observation of a high ratio of cross-reactivities between the mentioned NSAIDs.

Eosinophilic cationic protein as a marker of nasal inflammation in patients with cystic fibrosis

OBJECTIVES

Evaluation was made of eosinophilic cationic protein (ECP) in nasal secretion for measuring the degree of nasal inflammation and monitoring response to therapy in cystic fibrosis (CF) patients with chronic rhinosinusitis. Symptoms and findings in regard to ECP levels before and after treatment were described.

STUDY DESIGN

Study was prospective, with 21 CF patients aged 4 to 19 years; 20 healthy volunteers served as controls. Collection of nasal secretion by a sponge was performed, and blood samples were obtained for serum. Cystic fibrosis (CF) patients were classified according to nasal symptoms and findings.

METHODS

ECP was measured by fluoroimmunoassay. Age, sex, nasal symptoms, and endoscopic and histological findings were obtained, and examinations were conducted before and after treatment; recurrences were recorded.

RESULTS

In CF patients with chronic nasal inflammation, increased nasal levels of ECP were detected when compared with asymptomatic CF patients or healthy nonatopic subjects. ECP concentrations were strongly related to the extent of nasal disease; patients with nasal polyps had higher levels than those without. Checked at 1 and 4 months after treatment, ECP levels declined with regression of symptoms, and in patients with exacerbation of nasal disease, ECP levels rose.

CONCLUSIONS

According to our study, there is a relationship between levels of ECP in nasal secretions and the degrees of nasal inflammation. In addition, the measurement of ECP could be useful in monitoring nasal disease in CF patients.

The phosphoenolpyruvate/phosphate translocator is required for phenolic metabolism, palisade cell development, and plastid-dependent nuclear gene expression

The Arabidopsis chlorophyll a/b binding protein (CAB) gene underexpressed 1 (cue1) mutant underexpresses light-regulated nuclear genes encoding chloroplast-localized proteins. cue1 also exhibits mesophyll-specific chloroplast and cellular defects, resulting in reticulate leaves. Both the gene underexpression and the leaf cell morphology phenotypes are dependent on light intensity. In this study, we determine that CUE1 encodes the plastid inner envelope phosphoenolpyruvate/phosphate translocator (PPT) and define amino acid residues that are critical for translocator function. The biosynthesis of aromatics is compromised in cue1, and the reticulate phenotype can be rescued by feeding aromatic amino acids. Determining that CUE1 encodes PPT indicates the in vivo role of the translocator in metabolic partitioning and reveals a mesophyll cell-specific requirement for the translocator in Arabidopsis leaves. The nuclear gene expression defects in cue1 suggest that a light intensity-dependent interorganellar signal is modulated through metabolites dependent on a plastid supply of phosphoenolpyruvate.

The phosphoenolpyruvate/phosphate translocator is required for phenolic metabolism, palisade cell development, and plastid-dependent nuclear gene expression

The Arabidopsis chlorophyll a/b binding protein (CAB) gene underexpressed 1 (cue1) mutant underexpresses light-regulated nuclear genes encoding chloroplast-localized proteins. cue1 also exhibits mesophyll-specific chloroplast and cellular defects, resulting in reticulate leaves. Both the gene underexpression and the leaf cell morphology phenotypes are dependent on light intensity. In this study, we determine that CUE1 encodes the plastid inner envelope phosphoenolpyruvate/phosphate translocator (PPT) and define amino acid residues that are critical for translocator function. The biosynthesis of aromatics is compromised in cue1, and the reticulate phenotype can be rescued by feeding aromatic amino acids. Determining that CUE1 encodes PPT indicates the in vivo role of the translocator in metabolic partitioning and reveals a mesophyll cell-specific requirement for the translocator in Arabidopsis leaves. The nuclear gene expression defects in cue1 suggest that a light intensity-dependent interorganellar signal is modulated through metabolites dependent on a plastid supply of phosphoenolpyruvate.