[Antenatal diagnosis and management of vein of Galen aneurysm: review illustrated by a case report]

Vein of Galen aneurysm is a rare vascular congenital malformation. We report an antenatal diagnosis with duplex Doppler at 26 weeks gestation. Magnetic resonance imaging was used before and after delivery in order to determine neurological prognosis. The neonatal prognosis is poor if fetal cardiac insufficiency or cerebral lesions are present antenatally. Premature delivery does not improve the neonatal outcome. When the aneurysm is not life threatening, embolization of the malformation is at best delayed five months after birth.

The role of surgery in recurrent ovarian cancer

The role of cytoreductive surgery (CS) in recurrent ovarian cancer (ROC) has not been clearly defined. We performed a retrospective study evaluating criteria for CS in ROC. Twenty-five institutions documented their patients with CS for invasive epithelial ROC performed 2000-2003. Two hundred sixty-seven patients were included. Complete tumor removal was achieved in 133 patients (50%). Complete resection was associated with prolonged survival compared to surgeries with residual tumor. Median survival of patients without residual tumor was 45.3 months and of patients with residual tumor, irrespective of its size, 19.0 months (HR 4.33; 95% CI 2.53-7.43; P < 0.0001). In a multivariate analysis, the following factors showed a significant influence on the probability to achieve a postoperative residual tumor of 0 mm: absence of ascites (<500 vs > or =500 mL: HR 4.63; 95% CI: 1.81-11.76; P= 0.0001), good performance status Eastern Cooperative Oncology Group (ECOG) 0 vs >0: HR: 2.41; 95% CI: 1.41-4.08; P= 0.001, and low FIGO stage at primary diagnosis (FIGO I/II vs III/IV: HR 1.87; 95% CI: 1.04-3.37; P= 0.036). Significant factors for survival after surgery for recurrence in a multivariate analysis were achievement of complete resection (residual tumor at surgery for recurrence 0 vs >0 mm: HR 2.86; 95% CI: 1.66-4.93; P < 0.001), absence of ascites (<500 vs > or =500 mL: HR 2.09; 95% CI: 1.18-3.71; P= 0.012), and application of a platinum-containing chemotherapy (platinum-containing chemotherapy vs others: HR 1.83; 95% CI: 1.16-2.88; P= 0.009). Only patients with complete resection seem to benefit from CS. This new panel of selection criteria will be evaluated in a prospective study.

Hepatic carbohydrate metabolism in rats after laparotomy and laparoscopy

BACKGROUND

Portal venous and mesenteric blood flow are reduced by 40-60% in humans and animals during laparoscopic surgery compared to laparotomy. Little is known about whether these intraabdominal micro- and macrocirculatory changes are associated with alterations in the hepatic energy metabolism.

METHODS

We operated on male Sprague-Dawley rats, performing either laparoscopy (CO2, 6 mmHg; n = 27) or laparotomy (n = 28), and compared the results with two control groups: intraperitoneal (i.p.) endotoxin administration (n = 28, positive control) and anesthesia only (n = 28, negative control). We investigated the impact of the two different surgical techniques on daily food intake, body weight gain, glycogen content in the liver, levels of blood glucose, and liver function tests (LFTs) on postoperative days 1, 2, 4, and 8. Local (hepatic) and systemic inflammatory responses (interleukin-6 and tumor necrosis factor-alpha) during the postoperative time course were also determined. Data were analyzed using the Kruskal-Wallis test or univariate analysis of variance.

RESULTS

Body weight gain, food intake, liver and spleen weights, as well as LFTs [except aspartate aminotransferase (AST)] did not differ among the four groups. The significant increase in the AST level following laparoscopy compared to the anesthesia-only group was found on postoperative days 1 and 2; however, a similar difference was not detected after laparotomy or i.p. endotoxin injection. Laparoscopy showed no alterations in the hepatic glycogen stores compared to anesthesia only, whereas laparotomy and endotoxinemia significantly reduced the hepatic glycogen stores on postoperative days 2 and 4. The systemic postoperative inflammatory response did not differ between laparotomy and laparoscopy, but it was higher in both groups than in anesthesia only. In rats treated with endotoxin, the systemic inflammatory response was even higher than in the two surgical groups. The hepatic inflammatory response did not differ between the four groups.

CONCLUSION

This study shows a significant postoperative decrease in the hepatic glycogen content after laparotomy and i.p. endotoxin injection but not after laparoscopy. Food intake and inflammatory response cannot explain this difference between the two surgical groups, which suggests that alterations in the postsurgical hormonal stress response are the most likely explanation for these findings.

Neuroprotection with amifostine in the first-line treatment of advanced ovarian cancer with carboplatin/paclitaxel-based chemotherapy--a double-blind, placebo-controlled, randomized phase II study from the Arbeitsgemeinschaft Gynäkologische Onkologoie (AGO) Ovarian Cancer Study Group

GOALS OF WORK

Neurotoxicity is a common side effect of platinum/taxane-based therapy of ovarian cancer. We performed a double-blind randomized placebo-controlled trial to evaluate the influence of the cytoprotectant amifostine on the neurotoxicity of first-line therapy of ovarian cancer with paclitaxel/carboplatin with or without epirubicin.

PATIENTS AND METHODS

Of 72 patients randomized, 71 were treated with paclitaxel 175 mg/m2 and carboplatin AUC5 with or without epirubicin 60 mg/m2 (q21 x 6) and randomized for i.v. premedication with amifostine 740 mg/m2 or placebo. Assessment included a questionnaire, NCI-CTC, tendon reflex activity (TRA), two-point discrimination (2-PD), measurement of vibration perception threshold (VPT) and vibration disappearance threshold (VDT), and quality of life.

RESULTS

The majority of neurotoxicity criteria showed a significant impairment during therapy in both treatment arms. A significant protective effect of amifostine was observed for 2-PD, TRA, VPT and VDT. Amifostine failed to improve the 'global health status quality of life' score significantly. Toxicities according to NCI-CTC showed improved sensory neuropathy (P = 0.0046) but a worsening in terms of nausea (P = 0.0005) and vomiting (P = 0.0083). No significant differences were observed for single sensory and motor symptoms, except for a better skilfulness in the amifostine group (P = 0.0404).

CONCLUSION

Amifostine improved sensory neuropathy according to NCI-CTC and with regard to objective neurological assessment, but there were almost no differences in self-estimated specific sensory or motor symptoms. Disadvantages with regard to non-neurological toxicities and inconsistent results for quality of life demand further evaluation of neuroprotection with amifostine as well as alternative approaches to prevent platinum-taxane induced neurotoxicity.

Navigationsgeführtes Operieren beim subtemporalen Zugang von intrameatalen Kleinhirnbrückenwinkeltumoren?

BACKGROUND

Computer assisted surgery (CAS) permits the visualization of hidden bony covered structures invisible for the human eye with radiological 3d data sets. The surgeon might be able to orientate anatomically during surgery without having to prepare the according landmarks. This would mean less surgical traumatization and a shorter and smaller operation corridor.

METHOD

We determined the use of CAS in a quality assurance analysis with the subtemporal approach in 8 patients with supra-meatal tumors type A of the cerebellopontine angle. Various navigation systems and methods for referencing for the registration of the patients' heads were used. The question was whether it is possible intraoperatively without preparation of known anatomical landmarks to define the borders of an optimal positioned temporary bone cap and to identify the bony covered inner auditory canal and its neuronal structures without orienting neurostimulation.

RESULT

It was possible with CAS to assess intraoperatively the borders of a temporary bone cap above the cranially positioned mastoid cell. However, the objective inaccuracy of 2 to 28 mm observed during surgery did not allow a secure identification of the inner auditory canal.

CONCLUSIONS

CAS with the subtemporal approach cannot replace the conventional preparation of known anatomical landmarks nor neurostimulation to identify neural structures, due to the expected high inaccuracy with the non-invasive referencing systems that are available today.

A phase II study of paclitaxel, carboplatin, and gemcitabine in previously untreated patients with epithelial ovarian cancer FIGO stage IC-IV (AGO-OVAR protocol OVAR-8)

PURPOSE

A multicenter, nonrandomized, phase II study was initiated to evaluate the tolerability, toxicity, and activity of paclitaxel, carboplatin, and gemcitabine combination in previously untreated ovarian cancer.

PATIENTS AND METHODS

Chemonaive patients who had radical debulking surgery for primary epithelial ovarian cancer International Federation of Gynecology and Obstetrics (FIGO) IC-IV received sequentially paclitaxel 175 mg/m(2), carboplatin AUC 5, and gemcitabine 800 mg/m(2) on day 1 and gemcitabine 800 mg/m(2) on day 8, every 3 weeks.

RESULTS

From October 2001 to July 2002, 55 patients were treated and evaluated. Main toxicities were hematological with NCI-CTC grade 3/4 anemia 12.7%, leukopenia 70.9%, neutropenia 76.3%, and thrombocytopenia 45.5. However, febrile neutropenia occurred only in 1.8%. Grade 3/4 nonhematological toxicities were rare and occurred in less than 10% of patients. Toxicity-induced treatment delays occurred in 3.1% of cycles and resulted in early treatment cessation in four patients. Dose intensity reached 90.8% for carboplatin and paclitaxel, and 73.3% for gemcitabine. Objective response was observed in 10 of 14 patients with measurable disease.

CONCLUSIONS

The triplet combination of paclitaxel-carboplatin-gemcitabine is feasible and active, with manageable hematological toxicity and no unexpected nonhematological toxicity. This regimen has proceeded to phase III evaluation.

'Human' insulin versus animal insulin in people with diabetes mellitus

BACKGROUND

Human insulin was introduced for the routine treatment of diabetes mellitus in the early 1980s without adequate comparison of efficacy to animal insulin preparations. First reports of altered hypoglycaemia awareness after transfer to human insulin made physicians and especially patients uncertain about potential adverse effects of human insulin.

OBJECTIVES

To assess the effects of different insulin species by evaluating their efficacy (in particular glycaemic control) and adverse effects profile (mainly hypoglycaemia).

SEARCH STRATEGY

A highly sensitive search for randomised controlled trials combined with key terms for identifying studies on human versus animal insulin was performed using The Cochrane Library, MEDLINE and EMBASE. We also searched reference lists and databases of ongoing trials. Date of latest search: July 2004.

SELECTION CRITERIA

We included randomised controlled clinical trials with diabetic patients of all ages that compared human to animal (for the most part purified porcine) insulin. Trial duration had to be at least one month in order to achieve reliable results on the main outcome parameter glycated haemoglobin.

DATA COLLECTION AND ANALYSIS

Trial selection as well as evaluation of study quality was performed by two independent reviewers. The quality of reporting of each trial was assessed according to a modification of the quality criteria as specified by Schulz and by Jadad.

MAIN RESULTS

Altogether 2156 participants took part in the 45 randomised controlled studies that were discovered through extensive search efforts. Though many studies had a randomised, double-blind design, most studies were of poor methodological quality. Purified porcine and semi-synthetic insulin were most often investigated. No significant differences in metabolic control or hypoglycaemic episodes between various insulin species could be elucidated. Insulin dose and insulin antibodies did not show relevant dissimilarities.

AUTHORS' CONCLUSIONS

A comparison of the effects of human and animal insulin as well as of the adverse reaction profile did not show clinically relevant differences. Many patient-oriented outcomes like health-related quality of life or diabetes complications and mortality were never investigated in high-quality randomised clinical trials. The story of the introduction of human insulin might be repeated by contemporary launching campaigns to introduce pharmaceutical and technological innovations that are not backed up by sufficient proof of their advantages and safety.

Methodik der Evaluation perimodiolärer CI-Elektrodenträger im Felsenbeinmodell

BACKGROUND

Cochlear implants (CI) are the established treatment for cochlear deafness. Recently, indications for cochlear implantation have been expanded to include severely hearing-impaired patients. The use of bilateral implants seems to provide additional benefit. Moreover, new electrode designs, i. e. perimodiolar electrode arrays, aim at improving benefit for patients. However, in addition to providing functional improvements, modern electrode array development must also address safety aspects, because damage to the cochlear morphology (especially the osseous spiral lamina) may lead to degeneration of residual neuronal structures and bony obliteration or scarring within the cochlear ducts.

METHODS

Therefore, insertion trauma of the newly developed electrode arrays in human temporal bones must be evaluated before applied to patients. Several methods for testing electrode location and intracochlear trauma are described.

RESULTS

Combining cross-sectional imaging, histological analysis and elements of risk-assessment valid information about trauma and possible consequences for use in patients can be determined, based on our experience in 57 temporal bones.

CONCLUSIONS

Following our results, safety studies with prototype electrode arrays should, in addition to radiological examination, always include careful histomorphological evaluation.

Evaluation des Insertionstraumas des Nucleus® Contour Advance™-Elektrodenträgers im humanen Felsenbeinmodell

BACKGROUND

The development of intracochlear electrode arrays is aiming at a placement close to the modiolus with an insertion as atraumatic as possible. A new perimodiolar electrode model the Nucleus Contour Advance was to be evaluated regarding the possible intracochlear trauma.

METHODS

The implantation of the Contour Advance electrode was performed in 11 frozen native temporal bones. Beneath a regular insertion in 5 temporal bones in 6 cases the insertion was carried out using the "advance-off-stylett" technique with a fixed stylett. The temporal bones were embedded in metacrylate based resin for histomorphological evaluation. The evaluation was performed regarding to the intracochlear placement close to the modiolus and the damage to intracochlear fine structures (basilar membrane, osseus spiral lamina).

RESULTS

In 2 out of 11 cases we found a perforation from the scala tympani to the scala vestibuli independent of the insertion-technique. A severe intracochlear trauma was observed in one case with fracture of osseus spiral lamina using the AOS-technique. A close position to the modiolus could be achieved by insertion the scala tympani without perforation of the basilar membrane.

CONCLUSIONS

The Nucleus Contour Advance electrode array showed minimal trauma in human temporal bones by using a standard insertion technique. By using the freehand AOS-technique a severe cochlear trauma is possible. Therefore further development in electrode design and the use of an insertion-tool is recommended.

National Bioterrorism Syndromic Surveillance Demonstration Program

The National Bioterrorism Syndromic Surveillance Demonstration Program identifies new cases of illness from electronic ambulatory patient records. Its goals are to use data from health plans and practice groups to detect localized outbreaks and to facilitate rapid public health follow-up. Data are extracted nightly on patient encounters occurring during the previous 24 hours. Visits or calls with diagnostic codes corresponding to syndromes of interest are counted; repeat encounters are excluded. Daily counts of syndromes by zip code are sent to a central data repository, where they are statistically analyzed for unusual clustering by using a model-adjusted SaTScan approach. The results and raw data are displayed on a restricted website. Patient-level information stays at the originating health-care organization unless required by public health authorities. If a cluster surpasses a threshold of statistical aberration chosen by the corresponding public health department, an electronic alert can be sent to that department. The health department might then call a clinical responder, who has electronic access to records of cases contributing to clusters. The system is flexible, allowing for changes in participating organizations, syndrome definitions, and alert thresholds. It is transparent to clinicians and has been accepted by the health-care organizations that provide the data. The system's data are usable by local and national health agencies. Its software is compatible with commonly used systems and software and is mostly open-source. Ongoing activities include evaluating the system's ability to detect naturally occurring outbreaks and simulated terrorism events, automating and testing alerts and response capability, and evaluating alternative data sources.

Cluster core-level binding-energy shifts: the role of lattice strain

Our combined experimental and theoretical analysis of the shifts, with particle size, of core-level binding energies (BE's) of metal nanoparticles on insulating supports, shows that these shifts have an important initial state contribution arising, in large part, because of lattice strain. This contribution of BE shifts has not been recognized previously. Lattice strain changes the chemical bonding between the metal atoms and this change induces BE shifts.

Outcome of critical foot ischaemia in longstanding diabetic patients: a retrospective cohort study in a specialised tertiary care centre

Background: We sought to establish risk factors predicting the outcome of foot lesions in longstanding diabetic patients with critical foot ischaemia (CFI). Patients and methods: We investigated retrospectively 98 consecutive diabetic patients with ischaemic foot lesions. The patients (mean age 70 years, duration of diabetes 21 years) were jointly cared for by specialised diabetologists and vascular surgeons; 75 patients were treated by arterial revascularisation. Results: Good outcome (lesions healing) was observed in 53 patients (54%). Bad outcome was observed in 45 patients: not healing lesions (n = 5), major amputation(n = 19), and death in relation to the foot lesion (n = 21). Patients with good and bad outcome did not differ regarding age, sex, smoking status, type, duration and treatment of diabetes mellitus, presence of neuropathy, coronary heart disease, stroke, previous amputations, current revascularization, and localization of the foot lesion. The risk of bad outcome was increased 8.9 times in patients on dialysis for end-stage renal disease; 7.0 times if surgical complications were present; and 5.4 times with C-reactive protein (CRP) above the second quintile (cut-off value 8 mg/dl). Conclusion: Management of longstanding diabetic patients with ischaemic foot lesions leaves room for improvement. Dialysis treatment, elevated CRP levels and surgical complications were strongly predictive of non-healing lesions, major amputation and death.

'Human' insulin versus animal insulin in people with diabetes mellitus

BACKGROUND

Human insulin was introduced for the routine treatment of diabetes mellitus in the early 1980s without adequate comparison of efficacy to animal insulin preparations. First reports of altered hypoglycaemia awareness after transfer to human insulin made physicians and especially patients uncertain about potential adverse effects of human insulin.

OBJECTIVES

To assess the effects of different insulin species by evaluating their efficacy (in particular glycaemic control) and adverse effects profile (mainly hypoglycaemia).

SEARCH STRATEGY

A highly sensitive search for randomised controlled trials combined with key terms for identifying studies on human versus animal insulin was performed using the Cochrane Library (issue 2, 2002), Medline (1966 to May, 2002) and Embase (1974 to February, 2002). We also searched reference lists and databases of ongoing trials. Date of latest search: May 2002.

SELECTION CRITERIA

We included randomised controlled clinical trials with diabetic patients of all ages that compared human to animal (for the most part purified porcine) insulin. Trial duration had to be at least one month in order to achieve reliable results on the main outcome parameter glycated haemoglobin.

DATA COLLECTION AND ANALYSIS

Trial selection as well as evaluation of study quality was performed by two independent reviewers. The quality of reporting of each trial was assessed according to a modification of the quality criteria as specified by Schulz and by Jadad.

MAIN RESULTS

Altogether 2156 participants took part in the 45 randomised controlled studies that were discovered through extensive search efforts. Though many studies had a randomised, double-blind design, most studies were of poor methodological quality. Purified porcine and semi-synthetic insulin were most often investigated. No significant differences in metabolic control or hypoglycaemic episodes between various insulin species could be elucidated. Insulin dose and insulin antibodies did not show relevant dissimilarities.

REVIEWER'S CONCLUSIONS

A comparison of the effects of human and animal insulin as well as of the adverse reaction profile did not show clinically relevant differences. Many patient-oriented outcomes like health-related quality of life or diabetes complications and mortality were never investigated in high-quality randomised clinical trials. The story of the introduction of human insulin might be repeated by contemporary launching campaigns to introduce pharmaceutical and technological innovations that are not backed up by sufficient proof of their advantages and safety.

Reliability of causes of death in persons with Type I diabetes

AIMS/HYPOTHESIS

To compare causes of death assessed by a clinical review committee, the information given on death certificates, and ICD-codes provided by the State Documentation Office in deceased persons with Type 1 (insulin-dependent) diabetes mellitus.

METHODS

A cohort of 3674 patients were monitored for 10+/-3 (mean +/- SD) years. Vital status and end-stage diabetic complications were documented for 97%; 251 patients had died. Causes of death were assessed by a clinical review committee and compared to the information provided by death certificates and ICD-9 codes.

RESULTS

The review committee defined a leading cause of death in 94% of cases, whereas death certificates were available for 73% and ICD-codes for 79% of patients; 10% of death certificates could not be evaluated due to insufficient information. Diabetes was mentioned on 71% of death certificates, and renal disease in 75% of cases with renal replacement therapy. There was acceptable agreement between the committee, death certificates and ICD-codes only for deaths due to neoplasma, and between the committee and death certificates for deaths due to acute myocardial infarction, cerebrovascular events and accidents. In only one out of four deaths due to hypoglycaemia and in four of seven deaths due to ketoacidosis was this diagnosis mentioned on the death certificate. No death due to hypoglycaemia or ketoacidosis and 41% due to suicide were identifiable by ICD-codes.

CONCLUSION/INTERPRETATION

Reliance on death certificates or ICD-codes as the only sources of information on the cause of specific mortality does not provide data of sufficient reliability for evaluation of clinical outcome in Type I diabetes.

Chemotherapy versus hormonal treatment in platinum- and paclitaxel-refractory ovarian cancer: a randomised trial of the German Arbeitsgemeinschaft Gynaekologische Onkologie (AGO) Study Group Ovarian Cancer

BACKGROUND

The majority of patients with ovarian cancer are not cured by first-line treatment. Until now, no study could demonstrate any substantial benefit when exposing ovarian cancer patients to second-line chemotherapy. However, most treatment regimens induce toxicity, thus negatively influencing the quality of rather limited life spans. Here we evaluate whether a second-line chemotherapy can offer any benefit compared with a less toxic hormonal treatment.

PATIENTS AND METHODS

Patients with ovarian cancer progressing during platinum-paclitaxel containing first-line therapy or experiencing relapse within 6 months were eligible. Patients were stratified for response to primary treatment (progression versus no change/response), and measurable versus non-measurable disease. Treatment consisted of either treosulfan 7 g/m5 infused over 30 min or leuprorelin 3.75 mg injected subcutaneously or intramuscularly. Both regimens were repeated every 4 weeks.

RESULTS

This study began in late 1996, and after 2.5 years accrual an interim analysis was performed when several investigators reported their concern about a suspected lack of efficacy. Following this analysis the recruitment was stopped early and the 78 patients already enrolled were followed up. The majority of patients received treatment until progressive disease was diagnosed or death occurred. Treatment delay was observed rarely and dose reduction was performed only in the treosulfan arm in 5% of 150 courses. Overall, both treatment arms were well tolerated. No objective responses were observed. The median survival time was 36 and 30 weeks in the treosulfan and leuprorelin arms, respectively. Overall survival did not differ between patients with relapse 3-6 months after first-line chemotherapy compared with patients with progressive disease within 3 months.

CONCLUSIONS

The selected patient population represents a subgroup with extremely poor prognosis. Accordingly, results were not impressive. Both treatment arms showed favourable toxicity data, but failed to show remarkable activity, thus adding only limited evidence to the issue of whether patients with refractory ovarian cancer might benefit from second-line chemotherapy. Even stratified analysis did not identify any subgroup of patients in whom the administration of second-line chemotherapy could demonstrate a clinically relevant survival benefit.

cAMP-dependent phosphorylation of CYP2B1 as a functional switch for cyclophosphamide activation and its hormonal control in vitro and in vivo

An important feature of cytochrome P450 (CYP) 2B1 is its high ability to convert the prodrug cyclophosphamide (CPA) to therapeutically cytotoxic metabolites, resulting in interstrand DNA-cross-linking and cell death. We have examined whether and how the phosphorylation of CYP2B1 influences CPA metabolic activation in vitro and in vivo. We found first that only part of the total CYP2B1 pool undergoes phosphorylation. This part is fully inactivated. Second, phosphorylation of CYP2B1 in intact hepatocytes reduced by up to 75% toxification of CPA to mutagenic metabolites (totally dependent on the same preferentially CYP2B-catalyzed 4-hydroxylation of CPA as is the generation of highly cytotoxic species). Third, the phosphoacceptor-serine 128 of CYP2B1 in the consensus sequence for interaction with the protein kinase A represents an on/off switch for the activation of CPA depending on the phosphorylation conditions in the cell. Fourth, evidence is presented that the above-described events also occur in vivo. In conclusion, a successful therapy with CPA, helped by forced expression of CYP2B1 in tumor cells (as recently proposed) will, in addition, be profoundly modified by its phosphorylation status.

The integration of anthracyclines in the treatment of advanced ovarian cancer

Since the publication of the Gynecologic Oncology Group (GOG) protocol 111 in 1996, and the results of the Arbeitgemeinschaft Gyna kologische Onkologie (AGO) trial Ovar-3 and the GOG protocol 158, the combination of platinum and paclitaxel has been adopted as the standard therapy in advanced ovarian cancer. One option for achieving further progress in the first-line treatment of advanced ovarian cancer might be the addition of noncross-resistant drugs to the two-drug regimen. Meta-analysis showed a survival benefit for platinum-anthracycline based combinations as compared to platinum-based combinations without anthracyclines. An AGO phase I/II trial compared epirubicin in combination with carboplatin and paclitaxel in untreated patients with gynecological malignancies. Based on the results of this study a randomized phase III trial together with the French GINECO group was conducted. The trial started 11/97 and was closed 11/99. All 1281 patients were randomized. Currently, 1132 end-of-therapy reports have been issued. Nine hundred eighty nine (87%) patients completed six cycles of treatment. Treatment and toxicity data are available for these patients. Three hundred thirty five patients had a measurable residual tumor after initial debulking surgery. Response data of 228 patients (111 ET-Carbo, 117 Carbo-T) are available.

Saliva testing after single and chronic administration of dihydrocodeine

In the present study, concentrations of dihydrocodeine and its metabolites in saliva and serum were compared after single low-dose and chronic high-dosage administration of the drug. In the first investigation, blood and saliva were collected periodically from six subjects after oral administration of 60 mg dihydrocodeine. In the second study, 20 subjects on oral dihydrocodeine maintenance provided single samples of blood and saliva simultaneously. Serum protein binding of salivary analytes and their recovery from the adsorbing material of the collection device as well as pH values of saliva samples were determined. The fluids were analyzed for dihydrocodeine and the major metabolites by high-performance liquid chromatography. In the single dose study dihydrocodeine was the only analyte found in saliva for up to 12-24 h post-dose. The half-life of dihydrocodeine in saliva was about twice that found in blood. The ratios of saliva/serum concentrations ranged from 1.2 to 17.0. After chronic high-dosage use, dihydrocodeine was the main salivary analyte and N-nordihydrocodeine was present in a few samples. Saliva/serum concentration ratios of dihydrocodeine were strongly dependent on the pH value of saliva and, to a lesser extent, on serum-protein binding. The saliva/serum ratios were more similar after chronic administration. The data suggest a passive diffusion process as the underlying mechanism for the transport of dihydrocodeine into saliva. After both single and chronic use, the presence of the drug in saliva can be used as evidence of recent substance administration.

Cochlear structures after implantation of a perimodiolar electrode array

OBJECTIVE

A perimodiolar prototype electrode array has been evaluated on 12 human temporal bone specimens. To achieve modiolar proximity, a fine Teflon positioner is attached to the tip and base of a conventional Nucleus 22 electrode array.

METHODS

Intracochlear electrode position was examined by macroscopic preparation and confirmed by a cochlear view x-ray after insertion into human temporal bones. The temporal bones were examined with light microscopy for intracochlear trauma after insertion, explantation, and re-implantation of the perimodiolar array.

RESULTS

Macroscopic preparation and x-ray confirmed close proximity of the intracochlear electrodes to the modiolar wall. In some bones, electrode insertion and positioning was performed without significant damage to intracochlear structures, but explantation caused varying degrees of trauma depending on the explantation technique used. Re-implantation and repeat explantation appeared to destroy most of the intracochlear architecture.

CONCLUSIONS

The perimodiolar electrode array prototype with Teflon positioner cannot be recommended for clinical use, especially in children in whom the possibility for re-implantation is high.

Interaction of folate and homocysteine pathway genotypes evaluated in susceptibility to neural tube defects (NTD) in a German population

Neural tube defects (NTD) are likely to result from an interaction of several genes and environmental factors. Because periconceptional folate intake reduces the NTD risk in the fetus, and because mothers of children with NTD showed elevated plasma homocysteine levels, gene polymorphisms of the folate and homocysteine pathway, such as 5,10-methylenetetrahydrofolate reductase (MTHFR) 677C-->T, MTHFR 1298A-->C and cystathionine beta-synthase (CBS) 844ins68, have been implicated in the etiology of NTD. Several studies have demonstrated that these polymorphisms may indeed be associated with NTD in some populations. In order to evaluate the role of these polymorphisms and their interaction in NTD, we genotyped 417 individuals for case-control studies and 129 families for transmission disequilibrium tests. We are the first to present detailed data on MTHFR haploid genotypes in combination with CBS 844ins68. The MTHFR risk genotype 677CT/1298AC, known to be associated with decreased enzyme activity and increased homocysteine, was found significantly more often in patients than in controls (P = 0.02). A CBS insertion allele in addition to MTHFR 677CT/ 1298AC heterozygosity or MTHFR 677TT/1298AA homozygosity did not result in an increased risk for NTD. This is in agreement with the recently reported homocysteine-lowering effect of the CBS 844ins68 allele in carriers of MTHFR variants.

A screen for mutations in human homologues of mice exencephaly genes Tfap2alpha and Msx2 in patients with neural tube defects

BACKGROUND

Very little is known about the identity of genetic factors involved in the complex etiology of nonsyndromic neural tube defects (NTD). Potential susceptibility genes have emerged from the vast number of mutant mouse strains displaying NTD. Reasonable candidates are the human homologues of mice exencephaly genes Tfap2alpha and Msx2, which are expressed in the developing neural tube.

METHODS

A single-strand conformation analysis (SSCA) mutation screen of the coding sequences of TFAP2alpha and MSX2 was performed for 204 nonsyndromic NTD patients including cases of anencephaly (n = 10), encephalocele (n = 8), and spina bifida aperta, SBA (n = 183). A selected number of SBA patients was additionally tested for specific mutations in MTHFD, FRalpha, and PAX1 already shown to be related to NTD.

RESULTS

Two TFAP2alpha point mutations in individual SBA patients were silent on the amino acid level (C308C, T396T). On nucleic acid level, these mutations change evolutionary conserved codons and thus may influence mRNA processing and translation efficiency. One SBA patient displayed an exonic 9-bp deletion in MSX2 leading to a shortened and possibly less functional protein. None of these mutations was found in 222 controls. Seven polymorphisms detected in TFAP2alpha and MSX2 were equally distributed in patients and controls. Patients with combined heterozygosity of an exonic MSX2 and an intronic TFAP2alpha polymorphism were at a slightly increased risk of NTD (OR 1.71; 95% CI 0.57-5.39).

CONCLUSIONS

Although several new genetic variants were found in TFAP2 and MSX2, no statistically significant association was found between NTD cases and the new alleles or their combinations. Further studies are necessary to finally decide if these gene variants may have acted as susceptibility factors in our individual cases.

Gray-scale sonographic evaluation of cervical lymphadenopathy in cat-scratch disease

PURPOSE

The aim of this study was to characterize the gray-scale sonographic findings in the lymph nodes of patients with cat-scratch disease (CSD).

METHODS

We analyzed the sonograms of cervical lymph nodes in 41 patients with proven CSD between January 1997 and October 1999.

RESULTS

A total of 222 involved lymph nodes were detected. Involved nodes were most commonly found in the middle cervical (58%), parotid (37%), upper cervical (37%), and submandibular (17%) regions. We found acute, chronic, or abscessed lymphadenopathy in 63%, 12%, and 24% of patients, respectively. The size of involved lymph nodes ranged from 12 x 4 mm to 35 x 26 mm. The largest involved node had a short axis/long axis ratio of 0.5 or more in 61% of patients. Useful features for the differential diagnosis included markedly decreased echogenicity (100%), normal surrounding tissues (100%), and the presence of an echogenic hilum (76%). Posterior sound enhancement was significantly associated with larger and abscessed lymph nodes.

CONCLUSIONS

Despite the absence of a specific sonographic finding for CSD, gray-scale sonography can provide clues to the diagnosis of CSD in the proper clinical setting.

The Nucleus Contour electrode array: a radiological and histological study

OBJECTIVES

To evaluate the handling and insertion trauma of the recently developed Nucleus perimodiolar Contour electrode array (Cochlear Ltd., Pty, Lane Cove, New South Wales, Australia) in human temporal bones compared with the Nucleus standard straight electrode array.

STUDY DESIGN

E-perimental control group.

METHODS

Twenty-nine fresh-frozen bones were implanted with different electrode arrays by an experienced cochlear implant surgeon, and evaluated both radiologically and histologically.

RESULTS

Intracochlear insertion of the standard Nucleus straight electrode array was found to be atraumatic, confirming previous findings in the literature. Insertion of the Nucleus Contour electrode array resulted in instances of localized basilar membrane penetration causing the electrode array to move from the scala tympani into the scala vestibuli. However, this trauma did not result in any observable damage to the osseous spiral lamina or the modiolus. Basilar membrane penetration was observed in six of eight cochlear bones when a standard cochleostomy size (approximately 0.8 mm) and site (anterior and superior to the round window) were used. However, when the surgical technique was modified to use a slightly larger cochleostomy ( approximately 1.8 mm) situated closer to the round window and employ a partial stylet withdrawal technique during electrode insertion, the frequency of penetrations was restricted to two of seven bones. This trauma rate is comparable to that observed with other cochlear implants designs.

CONCLUSIONS

Following our results, the design of the Nucleus Contour electrode appears to fulfill the safety requirements for an intracochlear electrode array, provided that the surgical insertion technique is modified in the manner outlined.

Working conditions on stage: climatic considerations

Singers and actors frequently complain about dusty and dry theater environments, which they believe induce respiratory tract indispositions and decrements in vocal performance. In the literature to date, extremely few quantitative data exist about actual climatic conditions on stage. A previous study by our group in an unhumidified theater found that it had too high temperatures, too dry and too dusty air, based on German occupational guidelines for the generic workplace. In the present study, humidification units were installed in the same theater, and the environmental measures were repeated. The primary findings indicated that, following the activation of the humidification units, temperatures, humidities and fine dust concentrations were improved and generally within acceptable ranges for the generic workplace, although not always optimal. Where unacceptable performance environments exist, special care should be taken to counsel performers with regard to possible prophylactic measures such as individual steam inhalation and fluid intake.

Probiotics--compensation for lactase insufficiency

Yogurt and other conventional starter cultures and probiotic bacteria in fermented and unfermented milk products improve lactose digestion and eliminate symptoms of intolerance in lactose maldigesters. These beneficial effects are due to microbial beta-galactosidase in the (fermented) milk product, delayed gastrointestinal transit, positive effects on intestinal functions and colonic microflora, and reduced sensitivity to symptoms. Intact bacterial cell walls, which act as a mechanical protection of lactase during gastric transit, and the release of the enzyme into the small intestine are determinants of efficiency. There is a poor correlation between lactose maldigestion and intolerance; in some studies, low hydrogen exhalation without significant improvement of clinical symptoms was observed. Probiotic bacteria, which by definition target the colon, normally promote lactose digestion in the small intestine less efficiently than do yogurt cultures. They may, however, alleviate clinical symptoms brought about by undigested lactose or other reasons.

[Evaluation of a structured education program for adult outpatient asthmatics]

BACKGROUND AND METHODS

The efficacy of a structured education programme (AFAS) unter outpatient conditions was evaluated in a pilot study including 25 mild to severely ill adult asthmatics (age 41 +/- 2 yrs.) over a period of two and a half years. The main teaching items of the programme are: self-control of the disease with regular peak flow measurements, monitoring of symptoms with a patient diary, effects and side effects of the treatment, correct inhalation technique of asthma medication and the ability of self-management with regard to the actual degree of airflow limitation by the patients.

RESULTS

After AFAS the knowledge of the patients regarding the disease as well as the medication increased significantly. There was an improvement of drug therapy: before AFAS only 52% of the patients used inhaled steroids on a regular basis with regard to 96% one and two years after participation of AFAS (p < 0.01). The self-control of the disease was improved: before AFAS no patient measured peak flow during acute dyspnoea, compared with 88% (p < 0.001) and 75% (p < 0.001) one and two years after AFAS, respectively. The number of severe asthma-attacks decreased significantly from 10.7 +/- 2.5 per patient and year before education to 1.3 +/- 0.2 (p < 0.001) after the first year and to 2.0 +/- 0.3 (p < 0.05) after the second year. The total number of hospital days due to asthma decreased from 219 days in the year before the participation in AFAS to zero (p < 0.001) in the first year after the education and to 17 days (p < 0.001) after the second year.

CONCLUSIONS

The efficacy of patient education with AFAS is still evident two years after the course, but a reduction of self-control of the disease was observed during the follow-up period. In conclusion, structured education programmes for adult asthmatics can be effective even under outpatient conditions.

Epiglottic tuberculosis: differential diagnosis and treatment. Case report and review of the literature

A case of a 40-year-old man with tuberculous involvement of the epiglottis suffering from unsuspected pulmonary tuberculosis is described. The laryngeal lesions were primarily considered to be highly suspicious for a neoplastic process rather than an infectious one. After diagnosis, the patient was treated according a standard protocol and followed up for a period of 2 years. He is still free of disease. The clinical presentation, diagnosis, pathological findings, and therapy of the condition are described. The differential diagnosis and management of epiglottic tuberculosis are reviewed and discussed. Even though these cases are rare, otorhinolaryngologists should keep in mind the possibility of tuberculosis in the differential diagnosis of laryngeal tumors, as the incidence of tuberculosis in developed countries is steadily increasing.

The need for psychosocial support in parents with cochlear implanted children

OBJECTIVE

The aim of the study was to assess the need of parents with Cochlear implanted children for psychosocial support, based on psychic symptoms reported by these parents and their motivation to make use of psychosocial interventions.

METHODS

Fifty seven mothers and 46 fathers of 57 Cochlear implanted children were evaluated separately, employing validated questionnaires (Symptom Checklist-90-R and Questionnaire on Psychosocial Support).

RESULTS

26% of the mothers and 25% of the fathers showed severe psychic symptoms as reflected in the Symptom Checklist-90-R. Fifty nine percent of the mothers and 60% of the fathers were highly motivated to participate in psychosocial interventions--especially in the form of further information on their children's ailment and in parents' groups.

CONCLUSIONS

The data presented suggest that there is a need for psychosocial support in 18% of the parents; 8% of the parents show high psychic stress, but low motivation. The rest of the parents are not in need of support; nevertheless, 42% of the parents are highly motivated in favor of psychosocial interventions.

[Psychological stress, knowledge and treatment expectation of parents with a child managed by cochlear implant]

ESTABLISHED KNOWLEDGE: It is known that parents of hard-of-hearing children suffer from an increase in psychosocial stress.

SCIENTIFIC QUESTION

How does the psychosocial situation of parents with children who have cochlear implants change during rehabilitation?

AIM OF STUDY

It was the aim of this study to demonstrate how parents evaluate retrospectively their own psychological well-being during the process of rehabilitation.

METHODS AND RESULTS

We interviewed 87 parents by questionnaires which were mailed to them. Fifty-seven mothers and 46 fathers responded (59% return rate). Parents reported a significant increase in stress, as perceived by themselves, after the time of diagnosis. Of the parents, 25% continued to suffer from psychic stress during rehabilitation as could be demonstrated by the SCL-90-R questionnaire criteria. The expectations by parents were realistic prior to implantation but thereafter increased significantly with time.

CONCLUSIONS

The psychological state of parents during the critical phase, after a diagnosis of deafness has been made for their child, has to be considered. Even after an initial phase of shock, parents seemed to be stressed to an extent that required therapeutic intervention.

Chemiluminometric determination of tissue polypeptide antigen (TPA), cancer antigen 15-3 (CA 15-3), carcinoembryonic antigen (CEA) in comparison with vascular endothelial growth factor (VEGF) in follow-up of breast cancer

Vascular endothelial growth factor (VEGF), tissue polypeptide antigen (TPA), cancer antigen 15-3 (CA 15-3) and carcinoembryonic antigen (CEA) were measured in 314 sera of breast cancer patients and in 58 sera of women without breast cancer. VEGF was determined using a sandwich enzyme immunoassay technique (ELISA) and the tumour markers TPA, CA 15-3 and CEA with an immunoluminometric assay (ILMA). The breast cancer patients were staged according to the TNM classification stages 0-IV (by UICC) in patient groups with a compatible prognosis. Median and range of each stage were investigated. The cut-off values (95th and 97.5th percentile of control group) of VEGF, TPA, CA15-3 and CEA were determined; sensitivities for each parameter and for all combinations of two parameters were investigated for these cut-offs and the receiver operating characteristic (ROC) curves were calculated. The differences between the control group and stages 0-3 were shown to be non-significant for CA 15-3 and CEA but significant for VEGF and TPA. Significant differences were found in stage 4 for VEGF and all three markers. The increase in sensitivity of VEGF from stage 0 to stage 3 and the decrease from stage 3 to stage 4 can be interpreted based on the role of VEGF in the angiogenesis. The quantification of VEGF could give additional information for selecting patients for systemic adjuvant therapy.

[Parotid involvement in cat scratch disease: a differential diagnosis with increased significance]

BACKGROUND

Bartonella henselae is the causative agent of cat-scratch disease (CSD), an inflammatory infection of the lymph nodes. So far, only few cases of atypical manifestations in the head and neck, especially manifestations in the parotid gland have been reported.

PATIENTS AND METHODS

Between January 1997 and June 1999 seven patients with manifestations of CSD in the parotid gland were observed at the ENT-department Freiburg. The positive diagnosis was confirmed serologically by an indirect immunofluorescence assay and by detection of Bartonella henselae-DNA with PCR-amplification and subsequent hybridization or sequencing.

RESULTS

An intraglandular abscessed lymphadenitis was found in five patients, two of these cases were based on a Parinaud's oculoglandular syndrome. A diffuse affection of the parotid gland, initially misinterpreted as a parotid tumor, was seen in two patients.

CONCLUSIONS

Antibiotic treatment is recommended in order to reduce the duration of the disease, in cases of pain and lymph node abscesses. In uncommon manifestations of CSD, the nosological assignment can be difficult on the basis of the heterogeneous symptomatic in the individual patient and the CSD diagnosis can only be confirmed by serology or PCR-based techniques. CSD should be considered in the differential diagnosis of all equivocal masses in the head and neck, even in unusual localisations like the parotid gland.

Effects of on-demand beta2-agonist inhalation in moderate-to-severe asthma. A randomized controlled trial

BACKGROUND

The appropriate use of short-acting beta2-agonist inhalation in asthma has been the subject of controversy in recent years. Limited information is available for the group of moderate to severe asthmatics with high intake of bronchodilator inhalants and continuous anti-inflammatory protection.

OBJECTIVE

To investigate the effects of beta2-agonist reduction in marked asthma treated with multiple asthma medications.

DESIGN

Randomized, controlled single-blind, cross-over trial.

SETTING

Outpatient clinic at a university medical centre.

SUBJECTS

A total of 80 adult patients with moderate-to-severe asthma.

INTERVENTIONS

In a 1-year study patients were assigned to on-demand vs. regular beta2-agonist inhalation treatment.

MAIN OUTCOME MEASURES

Asthmatic episodes (primary outcome), symptoms, peak expiratory flow rates (PEF) and drug use were recorded daily. Bronchodilator and airway responsiveness, lung function indices and quality of life were assessed during five clinic visits. Also, practicability of beta2-agonist tapering in multimedicated asthmatics was analysed.

RESULTS

More than 80% of moderate-to-severe asthmatics were able to reduce their beta2-agonist intake by >/=50%. Puffs per day of active therapy decreased from 7.9 in regular to 3.3 in on-demand treated patients (P = 0.0001). The type of beta2-agonist used (salbutamol/fenoterol) had no significant impact on the study findings. Almost all parameters of control of asthma improved during the on-demand treatment period.

CONCLUSION

On-demand inhalation of short-acting beta2-agonists in moderate-to-severe asthma is safe, and even in severe asthma a reduction from regular to on-demand beta2-agonist inhalation is possible, with improved asthma control.