Short- and long-term results of abciximab versus aspirin in conjunction with thrombolysis for patients with peripheral occlusive arterial disease and arterial thrombosis

Acute peripheral occlusive arterial disease is an important cause of morbidity and mortality, particularly among older persons. Catheter-directed thrombolytic therapy is the treatment of choice but has limitations: long lytic times, occlusions refractory to thrombolysis, and a high rate of restenosis. We conducted a pilot study to evaluate the use of the platelet GP IIb/IIIa receptor antagonist abciximab versus aspirin in conjunction with thrombolysis in patients with acute peripheral occlusive arterial disease associated with arterial thrombosis. A total of 84 patients were randomized into two equal groups to receive 5 mg recombinant tissue plasminogen activator intravenously and 500 IU heparin/hour along with either 500 mg acetylsalicylic acid or a bolus of 0.25 mg/kg abciximab followed by 10 microg/min abciximab over 12 hours (heparin reduced to 250 IU/hour). Primary efficacy criteria included the number of rehospitalizations, reinterventions, and amputations during the following 6 months. Secondary endpoints were the changes in the Fontaine stage, Bollinger index (vessel occlusion), ankle-to-brachial ratios, distance to claudication after 6 months, and the duration of the initial local lysis treatment. Adjunctive use of abciximab reduced the rates of rehospitalization, reinterventions, and amputations versus results with the use of aspirin (10 vs 14 occurrences, respectively; 9 vs 11; 3 vs 5; when summed, intergroup difference p < 0.05). Secondary peripheral occlusive arterial disease variables became highly significant versus aspirin (p < 0.001 or greater) at 3 and 6 months after treatment. The duration of lysis was markedly shorter upon addition of abciximab versus aspirin (75 vs 110 min; p < 0.001). No major bleeding complications or embolisms occurred. These preliminary results indicate that abciximab may have a useful role when used adjunctively with a thrombolytic agent in older persons with acute peripheral occlusive arterial disease and arterial thrombosis.

Targeting of the pro-apoptotic VDAC-like porin (PorB) of Neisseria gonorrhoeae to mitochondria of infected cells

Infection of cell cultures with Neisseria gonorrhoeae results in apoptosis that is mediated by the PorB porin. During the infection process porin translocates from the outer bacterial membrane into host cell membranes where its channel activity is regulated by nucleotide binding and voltage-dependent gating, features that are shared by the mitochondrial voltage-dependent anion channel (VDAC). Here we show that porin is selectively and efficiently transported to mitochondria of infected cells. Prevention of porin translocation also blocked the induction of apoptosis. Mitochondria of cells treated with porin both in vitro and in vivo were depleted of cytochrome c and underwent permeability transition. Overexpression of Bcl-2 blocked porin-induced apoptosis. The release of cytochrome c occurred independently of active caspases but was completely prevented by Bcl-2. Our data suggest that the Neisseria porin can, like its eukaryotic homologue, function at the mitochondrial checkpoint to mediate apoptosis.

[Diagnosis and therapy of anorectal diseases (excluding constipation and venereal diseases)]

In the last couple of years, the anorectum has been of great interest to gastroenterologists. With new diagnostic tools and a refinement of technique, together with new therapeutic modalities, interesting research results have been obtained. These results may be beneficial to patients therapy. The patients history, inspection and palpation of the anorectum remain the basic, essential features of diagnosis. Based on the symptoms and possible differential diagnosis, further investigation is necessary: Anorectal physiology and anal endosonography are also regarded as essential investigative techniques in a colorectal laboratory. Great progress has been made in the medical treatment in proctology in two areas: Biofeedback techniques and botulinum toxin injection. In the following article, definitions, symptoms, diagnosis and therapeutic modalities of common anorectal disorders are described.

Eradication of cryptosporidia and microsporidia following successful antiretroviral therapy

OBJECTIVES

Incidence of opportunistic protozoal infections causing diarrheal illnesses in patients with HIV has decreased since the introduction of highly active antiretroviral therapy (HAART). The objective of this study was to determine whether the parasites, cryptosporidia, and microsporidia were effectively eradicated or only suppressed following treatment.

DESIGN

Six HIV-positive patients with diarrheal symptoms caused by cryptosporidia or microsporidia were prospectively followed up with stool samples and duodenal biopsies. Samples were taken before HAART, between 1 to 3 months, and 6 months post-HAART.

METHODS

Duodenal samples were analyzed using routine histology and transmission electron microscopy. Stool samples were analyzed by both light microscopy and polymerase chain reaction (PCR) techniques.

RESULTS

Patients who responded successfully to HAART eradicated both cryptosporidial and microsporidial organisms. Symptoms improved within 1 month of therapy but complete eradication of the organisms was only observed after 6 months of treatment.

CONCLUSIONS

AIDs-related cryptosporidiosis and microsporidiosis can be cured following successful antiretroviral therapy.

An animal model for anaplastic large cell lymphoma in the immunocompetent syngeneic C57Bl/6 mouse

We report on the analysis of a murine anaplastic lymphoid cell line TS1G6, established recently by interleukin (IL)-9 transfection. TS1G6 revealed a highly characteristic pattern of large anaplastic cells with mononuclear, binuclear, or multinuclear cells resembling Hodgkin (H) or Sternberg-Reed (SR) cells. This cell line is tumorigenous after injection of as few as 10(4) lymphoma cells into nude or immunocompetent C57Bl/6 mice and leads to death from progressive disease of all treated animals within a few weeks. The histological analysis of these tumors revealed a diffuse large cell malignant lymphoma that is morphologically almost identical to human anaplastic large cell lymphoma (ALCL). The lymphoma cells did not show overexpression of the anaplastic lymphoma kinase (ALK) gene, which is found in about 50% of the cases of human ALCL. Thus, this model may be an animal model for an important subset of human ALCL. The cytokine profile, which is of the T helper 2 type, showed strong parallels to the human lymphoma counterpart. Mice suffering from such lymphomas could not be cured with a regimen using high dose cyclophosphamide similar to many ALCL patients. Such an animal model for ALCL has not yet been recognized, but may provide the basis for investigating new antitumor immunotherapies in a fully immunocompetent host.

Identity testing in cervical carcinoma in case of suspected mix-up

The histopathologic diagnosis is the cornerstone of modern oncology. But mix-ups of specimens can occur at any stage. The resection of a 1.2 cm polypoid cervical mass in a 25-year-old woman showed a poorly differentiated adenocarcinoma prospectively staged as T1b1 (International Federation of Gynecology and Obstetrics IB1). Even after complete embedding and serial sectioning of the whole cervix of the hysterectomy specimen after radical hysterectomy, only adenocarcinoma in situ, but no invasive tumor, was seen. To exclude a mix-up of the specimens, identity testing of the paraffin-embedded material was performed by microsatellite analysis. For both materials, we established identical results after testing the microsatellite loci HumTH01, HumVWA, HumFGA, HumACTBP2, HumF13B, and HumD8S1132. The resulting probability of identity came to 99.9999%, excluding a mix-up of the specimens. Archival paraffin-embedded specimens can be used to establish identity and can prevent the wrong patient from having major surgery.

[How reliable is the measurement of tracheal stenosis by means of computed tomography?]

BACKGROUND

A reliable preoperative appraisal of laryngotracheal stenoses is necessary for airway surgery as well as stent implantation. Through progress of modern radiological modalities, particularly the computer tomography (CT), sectional image data and three dimensional airway reconstruction gain increasingly in meaning in Otorhinolaryngology.

METHODS

The aim of this study was to evaluate the reliability of this modern CT data in comparison to laser scan data. For this purpose deep frozen pig tracheal segments were prepared and examined by means of helical CT at different CT sets. Subsequently the measurement of the tracheal lumen employing a highly precise laser scanner was performed.

RESULTS

As a result we found that a CT slice thickness of 3 mm, a maximal pitch of 1.5 as well as the application of the so-called: edge enhancing modus seems to be the best compromise between the precision of CT airway measurement on one hand and breath-hold time for patient and total X-ray dose on the other hand.

CONCLUSIONS

The ENT specialist requires a good cooperation with the radiologist for the measurement of laryngotracheal stenoses using CT scans. We recommend the working out of standard parameters for respiratory tract-CTs.

Experimental liver preservation with Celsior: a novel alternative to University of Wisconsin and histidine-tryptophan-alpha-ketoglutarate solutions?

Celsior, a low viscosity and low potassium preservation solution, has recently been tested successfully in the cold preservation of heart, lung, kidney and small intestine. The purpose of the present study was to evaluate the potential of Celsior in the cold preservation of the liver. Livers were harvested from male Wistar rats and then flushed with either Celsior (CE), University of Wisconsin solution (UW) or histidine-tryptophan-alpha-ketoglutarate solution (HTK) and stored for 24 h at 4 degrees C in the respective solution. The reperfusion was performed in vitro using a recirculating model with oxygenated (95% O(2), 5% CO(2)) Krebs-Henseleit buffer at 37 degrees C. To simulate the slow rewarming during the surgical implantation in vivo, all livers were stored for 30 min at room temperature prior to reperfusion. After ischemic storage and also after reperfusion some samples were freeze-clamped for analysis of tissue metabolites while others were tested for structural and functional integrity by the isolated perfusion. CE vs. UW vs. HTK: Metabolic preservation of tissue ATP (micromol/g dry weight) during cold storage was best with Celsior (0. 46 +/- 0.17 vs. 0.26 +/- 0.03 vs. 0.35 +/- 0.07; p < 0.05 CE vs. UW), but upon reperfusion energetic recovery was comparable in the three groups (3.45 +/- 0.66 vs. 4.27 +/- 0.41 vs. 3.63 +/- 0.64 micromol/g/dry weight). There appeared to be structural integrity during reoxygenation irrespective of the used preservation solution with comparable values of parenchymal enzyme release (ALT: 575 +/- 82 vs. 547 +/- 106 vs. 593 +/- 38 mU/g/l), bile production (18.0 +/- 1.0 vs. 18.5 +/- 2.5 vs. 18.7 +/- 1.4 microl/g/ min), and the release of acid phosphatase, an indicator for activated Kupffer cells (89 +/- 13 vs. 90 +/- 5 vs. 123 +/- 21 mU/g/l) in this in vitro model. Vascular flow characteristics were approximated by the portal perfusion pressure, which tended to be elevated upon initial reperfusion in the UW group (8.4 +/- 0.6 mm Hg) compared to 6.6 +/- 1.0 and 7.3 +/- 0.4 mm Hg in Celsior and HTK, respectively. However, the pressure values decreased to the normal range even in the UW group with ongoing perfusion. The sensitivity of our model in detecting protective effects of the tested solution was confirmed by a negative control group of livers stored in Ringer's solution at 4 degrees C, yielding an impaired recovery which differed by one magnitude from the three other groups. Within the limits of an in vitro study it is concluded from these results that Celsior may become a suitable alternative for liver preservation and further studies including a transplantation in vivo are strongly encouraged.

Localized Wegener's granulomatosis: predominance of CD26 and IFN-gamma expression

The immune response in Wegener's granulomatosis (WG) has been characterized as a predominant, potentially pathogenic Th1-like reaction by blood T cells and T-cell clones from diseased tissues. To elucidate further the immunopathogenic mechanisms, this study analysed the phenotypes of inflammatory infiltrates in frozen nasal biopsies with involvement of the upper respiratory tract only (localized or 'initial phase' WG) and with multi-organ involvement, including systemic vasculitis (generalized WG). The expression and production of Th1 and Th2 cytokines were examined in tissue specimens and peripheral blood mononuclear cells (PBMCs) of localized and generalized WG. The number of CD3+ T cells in inflammatory infiltrates ranged from 50 to 70%, together with approximately 30% CD14+ monocytes/macrophages. An average of 40% of T cells expressed CD26 in nasal biopsies of localized WG, compared with about 16% in specimens of generalized WG. In parallel, a higher number of interferon-gamma (IFN-gamma)-positive cells were detected in nasal tissue of localized than in generalized WG. PBMCs from localized WG similarly exhibited higher spontaneous IFN-gamma production in contrast to generalized WG (207 vs. 3 pg/ml, p<0.05). Interleukin-4 (IL-4) mRNA was found in higher amounts in generalized than in localized WG. IL-4 production was negligible in both disease and controls. In addition, both IL-10 mRNA and IL-10 protein levels of activated PBMCs from localized WG were elevated when compared with generalized disease (574 vs. 154 pg/ml, p<0.05) or healthy controls (574 vs. 246 pg/ml, p<0.05). It is conluded that in nasal tissues, mainly CD4+/CD26+ T cells as well as IFN-gamma-positive cells may support a polarized Th1-like immune response. Furthermore, the data suggest that this in situ immune response is already initiated and established in localized WG, accompanied by increased peripheral IFN-gamma and IL-10 production.

Taxonomic position of the human intestinal protozoan parasite Isospora belli as based on ribosomal RNA sequences

The taxonomic positions of Isospora belli and other members of the genus Isospora are controversial. We determined the small-subunit ribosomal RNA of I. belli and used this sequence in combination with other coccidian RNA sequences for analysis of the taxonomic position of I. belli. The phylogenetic trees we obtained provide molecular evidence for three clades within a monophyletic group that represents the suborder Eimeriina. The clade containing I. belli consists of tissue-cyst-forming coccidia (Toxoplasma and Neospora) and members of the genus Isospora (I. ohioensis, I. suis, I. belli). The second clade, representing a sister clade of that containing the Isospora species, contains members of the genus Sarcocystis. The third one consists of members of the family Eimeriidae, including Eimeria and Cyclospora species. This shows that although I. belli as well as other members of the genus Isospora belong to the suborder Eimeriina, the family to which they belong is not Eimeriidae but rather Sarcocystidae. We suggest that the genus Isospora should be removed from the family Eimeriidae and placed into the family Sarcocystidae within the suborder Eimeriina.

Detection of Isospora belli by polymerase chain reaction using primers based on small-subunit ribosomal RNA sequences

The aim of the present study was to use small-subunit (SSU)-rRNA sequences of Isospora belli to design specific primer pairs and a hybridization probe for the detection of Isospora belli in human samples by PCR and Southern blot hybridization. PCR amplification with the primer pairs produced correct DNA fragments with target DNA from samples of Isospora belli-infected patients and from cloned SSU-rRNA of Isospora belli. The nature of the PCR products was confirmed by Southern blot hybridization. No amplification was seen with template DNA extracted from other parasites. Although Isospora belli infections can be easily diagnosed using light microscopy, molecular-based techniques may prove useful as an additional diagnostic tool.

IAA-synthase, an enzyme complex from Arabidopsis thaliana catalyzing the formation of indole-3-acetic acid from (S)-tryptophan

An enzyme complex was isolated from Arabidopsis thaliana that catalyzes the entire pathway of biosynthesis of the major plant growth hormone, indole-3-acetic acid (IAA), from (S)-tryptophan. The 160-180 kDa, soluble complex catalyzes a strictly O2-dependent reaction which requires no further added factors and is stereospecific for the substrate (S)-tryptophan (app. Km = 120 microM). H2(18)O labeling proved that both oxygen atoms of IAA were delivered via H2O. This, as well as immunological evidence for the presence of a nitrilase-like protein in the complex, suggests the reaction to proceed via the intermediate indole-3-acetonitrile. IAA-synthase forms a tight metabolite channel committed to IAA production and occurs in shoots, roots and cell cultures of A. thaliana.

Detection of MUC1-expressing mammary carcinoma cells in the peripheral blood of breast cancer patients by real-time polymerase chain reaction

We have prospectively analyzed blood samples of 122 patients with breast disease for the presence of circulating expressing MUC1 cells before and after treatment. Among them, 28 patients had histologically confirmed benign breast disease (group 1), 34 patients had operable breast cancer (group 2), and 60 patients had advanced breast cancer (group 3). Circulating epithelial cells were isolated with BerEP4-coated immunomagnetic beads. Total RNA was extracted and reverse transcribed before analysis by real-time PCR of a MUC1-specific cDNA sequence. The sensitivity of the reverse transcription-PCR tested with blood spiked with MCF7 cells was one cell in 5 ml of blood. The immunomagnetic separation step was mandatory to obtain the maximum specificity. Control samples from healthy donors never displayed cycle threshold (Ct) values for MUC1 lower than 38. Circulating cells (Ct, <38) were detected in 3 of 28 (11%) cases in group 1, in 8 of 34 (24%) cases in group 2, and in 27 of 60 cases (45%) in group 3. A semiquantitative estimate of blood-borne cells could be derived from the Ct value when below 32 (the lowest was 28) or by the number of positive aliquots of the same blood sample. Thus, immunomagnetic separation, followed by MUC1-specific RT-PCR, allows the semiquantitative detection of circulating mammary cells. A significant correlation between the presence of MUC1-positive cells and the group of breast tumors was observed. The clinical significance of blood-borne cells in breast cancer, especially at the operable stage, may be investigated by following these patients.

Light and confocal laser-scanning microscopical evidences for complementary patterns of glial fibrillary acidic protein and Wisteria floribunda agglutinin labeled structures in human and rat brain

We investigated the pattern of glial fibrillary acidic protein (GFAP) and Wisteria floribunda agglutinin (WFA) labeled structures in the superior colliculus and in the somatosensory cortex of humans and rats of different age groups using immunohistochemical methods, light and confocal laser-scanning microscopy. We never found a double labeling of WFA and GFAP positive structures neither in the superior colliculus nor in the cortex of both man and rat. The complementary pattern of WFA and GFAP labeling was present both at the macroscopic and microscopic level. We found a clear prevalence of either WFA or GFAP expression in the arborization of the astrocytes as well as in the pattern of lamination.

Influence of androgens and age on androgen receptor and 5 alpha-reductase II transcription

OBJECTIVE

The regulation of the androgen receptor (AR) and 5 alpha-reductase II (5RII) gene in genital skin fibroblasts is of particular interest in understanding androgen-dependent embryonic formation of external male genitalia.

DESIGN

Human genital skin fibroblasts from pre- and postpubertal male individuals (aged 5 months to 51 years) were incubated with testosterone and dihydrotestosterone under various conditions to study the regulation of AR and 5RII transcript concentrations dependent on androgen concentration and donor age.

METHODS

A competitive reverse transcribed PCR (RT-PCR) protocol was designed to achieve simultaneous relative quantification (semi-quantification) of AR and 5RII mRNAs in standardized whole RNA samples from each donor.

RESULTS

Concentrations of AR and 5RII mRNAs are not influenced by androgens in genital skin fibroblasts. Moreover, comparison of AR transcript concentrations in genital skin fibroblast cell lines revealed weak variations independent of donor age, while 5RII transcription exhibited clear individual differences with a declining tendency towards higher ages.

CONCLUSIONS

The transcription of AR and 5RII is not directly regulated by testosterone or dihydrotestosterone in pre- or postpubertal human genital skin fibroblasts. However, donor age seems to play a role in gradual depression of 5RII transcription.

Highly potent inhibitors of human cathepsin L identified by screening combinatorial pentapeptide amide collections

By screening a combinatorial pentapeptide amide collection in an inhibition assay, we systematically evaluated the potential of 19 proteinogenic amino acids and seven nonproteinogenic amino acids to serve as building blocks for inhibitors of human cathepsin L. Particularly efficient were aromatic, bulky, hydrophobic amino-acid residues, especially leucine, and positively charged residues, especially arginine. Building blocks for potential inhibitory peptides were combined by random selection from their activity pattern. This random approach for the design of inhibitors was introduced to compensate for the inaccuracy induced by shifted docking of combinatorial compound collections at the active center of cathepsin L. Thereby, we obtained structurally defined pentapeptide amides which inhibited human cathepsin L at nanomolar concentrations. Among the most potent novel inhibitors, one peptide, RKLLW-NH2, shares the amphiphilic character of the nonamer fragment VMNGLQNRK of the autoinhibitory, substrate-like, but reverse-binding prosegment of human cathepsin L which blocks the active center of the enzyme. Obviously, RKLLW-NH2 carries the functions that are important for enzyme-peptide interaction in a condensed form. This hypothesis was confirmed by structure-activity studies using truncated and modified pentapeptides.

Frequency of somatic MEN1 gene mutations in monoclonal parathyroid tumours of patients with primary hyperparathyroidism

OBJECTIVES

Investigation of small numbers of parathyroid tumours by X-chromosome inactivation analysis suggests that the majority of them are monoclonal lesions most likely caused by a somatic mutation. Somatic mutations in the MEN1 gene located on chromosome 11q13 have recently been identified in 12-17% of solitary parathyroid tumours in patients with sporadic primary hyperparathyroidism, and they may be the precipitating genetic defect leading to monoclonal cell proliferation in these tumours.

DESIGN

To determine the prevalence of MEN1 gene mutations in monoclonal parathyroid neoplasias we investigated 33 parathyroid tumours of patients with primary hyperparathyroidism for clonality and mutations in the MEN1 gene.

METHODS

X-chromosome inactivation analysis was used to assess the clonal status of the tumours, direct sequencing of the complete coding region was applied to identify mutations in the MEN1 gene.

RESULTS

Twenty-eight female patients (26 patients with solitary adenoma, 2 patients with hyperplasia) were informative for the polymorphism of the androgen receptor on the X-chromosome and could be tested for inactivation pattern. Nineteen of twenty-six (73%) solitary adenomas were monoclonal. Somatic mutations in the MEN1 gene were identified in nine cases. Six of them were found in the relatively large second exon of the MEN1 gene (A49D, 193del36, 402delC, 482del22, 547delT, W126X). One was found in exon 5 (904del9), one in exon 7 (Y327X) and one in exon 9 (R415X). Of the monoclonal tumours, 5 out of 19 (26%) harboured a somatic MEN1 gene mutation.

CONCLUSIONS

In summary, 73% of the solitary parathyroid adenomas were monoclonal. In 26% of the monoclonal tumours a somatic MEN1 gene mutation has been identified. However, for 74% of monoclonal tumours of the parathyroids the underlying genetic defects are still not known.

International round-robin experiment to test the International Organization for Standardization total-scattering draft standard

An international round-robin experiment has been conducted among laboratories in different countries to test the measurement and the data-analysis procedures in the International Organization for Standardization draft standard ISO/DIS 13696 for measuring total scattering from low-scatter laser optics. Ten laboratories measured total backscattering from high-reflectance mirrors, 50% beam splitters, and antireflection-coated windows. Results were sent to the Laser Zentrum Hannover, which acted as coordinator and analyzed all the backscattering data. The results showed that the procedure in the draft standard was useful for measuring and reporting backscattering for low-scatter optics. Problems encountered in the round-robin experiment included the accumulation of particles on the surfaces, particularly on the high-reflectance mirrors.

A keyhole approach for endoscopically assisted pedicle screw fixation in lumbar spine instability

OBJECTIVE

The standard approach for dorsal transpedicular fixation in lumbar spine instability requires extensive exposure of the vertebral column. This increases the risk of potential complications and possibly destabilizes healthy neighboring segments because of the dissection and denervation of paravertebral muscles. The majority of spinal disorders are currently treated successfully via limited and tailored approaches. Accordingly, a keyhole approach for dorsal fusion of the lumbar spine was developed on the basis of an anatomic study.

METHODS

The new endoscopic technique entails the transmuscular insertion of a pedicle screw-rod fixation device via a rigid operating sheath. As a prerequisite, the endoscopic microanatomy of the target area, as visible through the operating sheath, was first evaluated on lumbar bone specimens. To localize the exact screw entry point into the pedicle, we identified the bony and ligamentous landmarks on partly macerated specimens. To determine the course of the pedicle screws, we deduced the corresponding angles of convergence from transparent polyester casting models of average vertebrae from T12 to S1. These angles were transferred into the operative situation and measured on-line with an inclinometer. The approach was finally tested on 12 cadavers for clinical feasibility and accuracy of screw placement and then successfully implemented in patients.

RESULTS

After extracutaneous localization of the pedicles at lateral fluoroscopy, paramedian skin incisions were made above the pedicles of the motion segment to be stabilized. The operative windows were exposed by use of a rigid operating sheath (length, 50 mm; diameter, 15 mm), which was inserted transmuscularly in the pedicle axis. The screw entry point into the pedicles was localized by endoscopic dissection of the mamilloaccessory ligament, bridging the mamilloaccessory notch. The pilot holes were created via insertion of a blunt-tipped pedicle probe. The adequate angles of convergence were constantly controlled during hollowing of the pedicles by an inclinometer mounted to the pedicle probe handle. The pedicle screws were then inserted through the operating sheaths. After removal of the operating sheaths, the connecting rods were inserted transmuscularly and anchored in the pedicle screw heads. Posterior bone grafting was performed after completion of the dorsal instrumentation. The dorsal fusion site was exposed by reinserting the operating sheath and tilting it medially.

CONCLUSION

This new approach significantly reduces surgical traumatization and destabilization of adjacent motion segments. An endoscopic operating sheath, adopted from thoracoscopic surgery, creates space for visualization and surgical manipulations. The newly defined anatomic landmarks provide guidance to the screw entry point into the pedicle in the center of the exposure. Observation of the exact corresponding angles of convergence during screw insertion by an inclinometer facilitates correct screw placement. In accordance with the initial anatomic studies, this approach was successfully performed on 12 cadavers and then used in six patients. Two illustrative cases are presented.

Reassessment of the corneal endothelial cell organisation in children

AIM

To assess uniformity of the corneal endothelial cell mosaic in children.

METHODS

36 healthy children (5-11 years old, 16 boys, 20 girls) were assessed by specular microscopy. Endothelial cell density (ECD) was calculated from measured cell areas, and the number of sides/cell noted.

RESULTS

Average values for ECD and cell areas were 3987 cells/mm(2) (95% CI 3806 to 4168 cells/mm(2)) and 278 (SD 85) mm(2) respectively, with normal distribution (COV 28. 2%, range 17.4 to 39.2%) and with the average percentage of six sided cells being 66.6% (8.8%). Cell area was positively correlated to number of cell sides (p <0.01, r(2)=0.993), but the percentage of six sided cells was negatively correlated to ECD (p <0.01, r=0.493).

CONCLUSION

A high ECD occurs in children, but this does not mean there is a high percentage of "hexagons".

Continuous-combined treatment of the menopause with combinations of oestradiol valerate and dienogest - a dose-ranging study

OBJECTIVES

To determine the progestational efficacy of continuous treatment with various doses of dienogest, combined with oestradiol valerate, on the basis of endometrial histology, effect on climacteric symptoms and bleeding profile in postmenopausal women.

METHODS

Patients were randomised to one of five fixed-combination treatments, oestradiol valerate 2.0 mg plus dienogest 0.5, 1.0, 2.0, 3.0 or 4.0 mg. Efficacy was assessed by endometrial biopsy, menstrual charts and change in climacteric symptoms.

RESULTS

The endometrium was classified as atrophic in 20.0, 31.3, 25.0, 55.6 and 57.1% of patients in the 0.5, 1.0, 2.0, 3.0 and 4.0 mg dienogest groups, respectively. The frequency of uterine bleeding was dose-dependent. The most favourable bleeding profile was seen in the 3.0 mg dienogest group, whereas the lower doses of dienogest had advantages with respect to the efficacy of the combined preparation.

CONCLUSIONS

Dienogest 2.0 and 3.0 mg are the optimal doses for combination with 2.0 mg oestradiol valerate for continuous-combined hormone replacement therapy.

[Late sequelae of early summer meningoencephalitis]

The incidence of tick-borne encephalitis varies widely in different geographic regions due to local difference in the rate of infected vectors (Ixodes ricinus) transmitting tick-borne encephalitis virus. In the Cantonal Hospital Winterthur a large number of cases are hospitalised due to endemic areas with infected ticks nearby. From 1976 until 1996 132 patients with tick-borne encephalitis were hospitalised (an average of 7 patients per year), compared with 535 cases (41 per year) in the whole of Switzerland during a similar period (1984-1992). While previously tick-borne encephalitis was considered to be a harmless illness with complete recovery, a postencephalitic syndrome after tick-borne encephalitis has recently been reported. Since the prevalence of sequelae differs in these publications, the aim of this study was to investigate sequelae in a Swiss population which had suffered from tick-borne encephalitis. We retrospectively analysed the patients with tick-borne encephalitis hospitalised in the years 1987-1996, to determine the clinical and functional outcome. A few weeks after discharge from hospital, 73% patients still had complaints, and one year later 56%. 32 patients were observed over 5 years and 31% still had some disability. After tick-borne encephalitis 10% of patients did not recover the same quality of life as before. The symptoms most frequently reported were fatigue, concentration deficits and impairment of memory. Objective neurological deficits were rare. Our results correspond well with experience in other countries and demonstrate the substantial morbidity of tick-borne encephalitis. We recommend therefore vaccination against tick-borne encephalitis, an effective measure with a low complication rate.