High-resolution DNA flow cytometry in oral verrucous carcinoma

The classification of verrucous carcinoma as an entity unto itself or as a variant of well differentiated squamous cell carcinoma is controversial. To contribute new insights into the biological behavior of this rare tumor, we applied DNA flow cytometry to three node-negative verrucous carcinomas of the oral cavity. All tumors expressed a single aneuploid cell population. One of the patients experienced three courses with local recurrence. All secondary tumors retained the initially established aneuploid clone. The development of aneuploidy is thus a cytogenetic event common to both verrucous and squamous carcinoma of the oral cavity.

Scrotal hernias: a contraindication for an endoscopic procedure? Results of a single-institution experience in transabdominal preperitoneal repair

INTRODUCTION

Endoscopic repair was introduced for use with inguinal hernia therapy more than 10 years ago. The technique as well as the indications for this method are debated, however. As a borderline inguinal hernia situation, the scrotal hernia in particular evokes vehement objections to an endoscopic procedure because of the anticipated problems and complications in dissecting the extended hernia sac. The efficiency of the laparoscopic transabdominal preperitoneal (TAPP) technique in the treatment of scrotal hernia therefore is discussed in this article.

METHODS

Laparoscopic hernia repair (TAPP) has been performed in our department since 1993. Data are collected by a prospective documentation of operative and follow-up results. For evaluation, a comparison of scrotal and normal hernia repair was performed.

RESULTS

Between April 1993 and June 1998 the TAPP technique was used to treat 191 scrotal hernias, 42 (22%) of which were recurrent hernias. The median operating time for a normal inguinal hernia repair was 45 min, whereas scrotal hernias required a median of 65 min and irreducible scrotral hernias a median of 68.5 min. Major complications were observed in 1.6% of scrotal and 0.6% of normal inguinal hernia repairs. The most frequent scrotal hernia repair problem was the formation of a seroma, 10.5% of which had to be evacuated. During a follow-up period of 30 months, we found a total of two recurrences (1.05%).

CONCLUSION

In scrotal hernia repair, TAPP is not associated with higher complication rates and can be performed with efficiency comparable with that in normal inguinal hernia repair.

Apoptosis in human embryonal cell carcinoma: preliminary results

Disorders in the regulation of apoptotic cell death may contribute to cancer. Furthermore, lymphocytes are supposed to play a role in counteracting tumorigenesis by inducing apoptosis in different human tumors. In this study, for the first time, tumor cell and lymphocyte apoptosis were investigated systematically in human embryonal cell carcinoma. DNA fragmentation and DNA condensation were measured simultaneously on double-fluorescence-labeled testis tumor sections using immunofluorescence microscopy. Different apoptotic indices (AIs), based either on biochemical (DNA fragmentation) or morphological criteria (DNA condensation) alone or on a combination of both, were determined in different histological regions in and around the tumor. Using morphological criteria alone, 40-75% of all apoptotic cells were not detected. Based on previous observations this finding might be related to subsets of apoptotic cells which induce the process of DNA condensation without activation of processes responsible for DNA fragmentation. Moreover, the AIs of tumor cells and lymphocytes were highest in the tumor region, compared with regions around the tumor and distant from it; these findings are discussed in the context of the Fas/FasL system.

[Plantain (Plantago lanceolata L.): anti-inflammatory action in upper respiratory tract infections]

Plantain (Plantago lanceolata L.) is used for the therapy of infections of the upper respiratory airways. While only few clinical data are available, results of experimental research confirm e.g. antiinflammatory, spasmolytic and immunostimulatory actions. A positive benefit-risk-ratio allows the recommendation of plantain in moderate chronic irritative cough, also especially for children.

[Quality aspects of the use of complementary medicine--experiences from the work of a quality circle]

OBJECTIVES

This article reports the results of a quality circle work, carried out by physicians using complementary medicine. It illustrates the problems occurring in this subject and summarizes characteristics of the daily work in relation to quality aspects. Patient characteristics were investigated; examples of mistakes in daily care are reported.

METHODS

The report is based on the two moderators' subjective impressions, on analysis of attendance lists, case reports, protocols, and surveys.

RESULTS

The quality circle was started in October 1994 and consists of a group of about 16 physicians, mainly general practitioners. Several objectives mentioned in official guidelines for quality circles could not be achieved, for example, the evaluation of results, analysis and assessment of the own performance according to established criteria, the degree to which published guidelines were followed, the development and implementation of problem-solving strategies. The quality circle was mainly a platform for exchange and continuing medical education. It also was the basis for an empirical study.

CONCLUSION

The continuing interest of patients in complementary medicine should motivate physicians to systematically evaluate these therapies. Participants of quality circles should prepare themselves extensively for the meetings. They should take measures to keep up-to-date with the current medical knowledge. Elements and objectives aiming at a higher quality standard can be examined and implemented in routine practice work. Research results should be integrated into the daily practice. Furthermore, academic or other independent institutions should carry out experimental research into traditional complementary therapies.

Warthin's tumour is not an Epstein-Barr virus related disease

BACKGROUND

The histogenesis of Warthin's tumour (WT) is controversial. A possible role for Epstein-Barr virus (EBV) has been suggested.

MATERIALS AND METHODS

Twenty formaldehyde-fixed, paraffin-embedded blocks of WT from the parotid gland were examined for the presence of EBV. In situ hybridisation was performed using EBV encoded small nuclear RNAs (EBER1/2) probes labelled with fluorescein isothiocyanate. An EBV-positive P3HR-1 cell line processed to paraffin wax was used as a positive control and a brain section as negative control.

RESULTS

EBER1/2 could not be found in the neoplastic epithelial cells in any of the tumours nor in the adjacent normal parotid tissues. Individual positive lymphocytes were present in 7 tumours.

CONCLUSIONS

These results indicated that EBV is not involved in the pathogenesis of WT.

Laparoscopic hernia repair -- the facts, but no fashion

BACKGROUND

For about 10 years now, laparoscopic hernia surgery has been introduced as an additional mode of therapy in the treatment of inguinal hernias. This method is being reproached with higher costs of surgery and rate of complications, as well as missing long-term results.

MATERIALS AND METHODS

Within a literature research, data from 25 randomised trials and 16 prospective observational studies on endoscopic and conventional hernia surgery were evaluated. Statistics were calculated using the chi2 test.

RESULTS

Compared with the conventional suture technique and tension-free surgery, the endoscopic repair proved to be advantageous with regard to postoperative pain and period of disablement. There was no significant difference between the methods when evaluating the rate of complications. In two randomised trials, there was a significant difference in favour of endoscopic repair with regard to the recurrence rates, whereas in the other studies a significant difference could not be shown. In the prospective series, recurrence rates were 0.71% for totally preperitoneal repair (TEP) and 1.06% for transabdominal preperitoneal repair (TAPP) repair.

CONCLUSION

Endoscopic hernia surgery (TAPP and TEP) represents an efficient method of treatment in the therapy of inguinal hernias. Recurrent and bilateral hernias can be seen as an absolute indication for endoscopic repair.

Laparoscopic surgery complications associated with trocar tip design: review of literature and own results

In the last 10 years, there has not been an abdominal surgical procedure that has not been performed by laparoscopic means. The enthusiasm of surgeons active in this field often neglects problems, especially with basic instruments which are important vehicles for the laparoscopic technique. The purpose of this study was to focus on trocar-related problems with special respect to the tip design. On the basis of a prospective study of laparoscopic transperitoneal hernia repair (TAPP) and laparoscopic Nissen fundoplication, we evaluated our data concerning trocar-related complications at the abdominal wall. We compared two groups of patients treated in a nonrandomized design with either sharp cutting single-use trocars or cone-shaped non-cutting reuseable trocars. The evaluation of our own data showed an incisional hernia in 1.83% of patients treated with a sharp trocar tip, a complication which could be significantly lowered, to 0.17%, with a conic tip design. Similar results could be seen with trocar-related bleeding events at the insertion site in the abdominal wall. In most publications, trocar design and related complications are unmentioned. Our data demonstrate a reasonable benefit for a conic tip design, which enables atraumatic insertion through the abdominal wall. The reuseable steel version furthermore holds a considerable cost-saving potential.

[Effect of a standardized acupuncture treatment on complains, blood pressure and serum lipids of hypertensive, postmenopausal women. A randomized, controlled clinical study]

BACKGROUND

Acupuncture according to the Chinese syndrome is often used in patients with postmenopausal complaints. Often these patients have an increased blood pressure. As experienced therapists report that acupuncture is efficient also in hypertension, our aim was to investigate whether the acupuncture used for the treatment of postmenopausal syndrome also has an effect on blood pressure.

PATIENTS AND METHODS

The efficacy of a standardized acupuncture according to the Chinese syndrome was evaluated in a randomized, single-blind, placebo-controlled cross-over study with 10 postmenopausal patients with mild hypertension. Blood pressure was measured by 24-hour ambulatory blood pressure measurement. Complaints and well-being were evaluated by validated questionnaires. In addition, serum lipids and excretion of catecholamines in the 24-hour urine were measured.

RESULTS

Blood pressure was altered neither by verum nor placebo acupuncture, however, complaints were significantly reduced and well-being was improved after verum treatment. The improvement lasted less than two months. Serum lipids did not change, but the excretion of normetanephrine was reduced by verum acupuncture.

CONCLUSIONS

Acupuncture with a standardized combination of acupuncture points according to the Chinese syndrome can transitorily reduce postmenopausal complaints, but does not alter blood pressure or serum lipids at the same time.

DNA aneuploidy by flow cytometry is an independent prognostic factor in squamous cell carcinoma of the oral cavity

BACKGROUND

The clinical significance of flow cytometric DNA content in head and neck squamous cell carcinoma is still controversial.

PATIENTS AND METHODS

We prospectively investigated the prognostic importance of tumor size (T), lymph node involvement at presentation (N), degree of histologic differentiation (G) and DNA ploidy (DNA) in 429 surgically treated patients with primary oral squamous cell carcinoma using multivariate statistics.

RESULTS

T, G and DNA were independent predictors of metastasis to the neck. N and DNA were independent prognostic factors of loco-regional recurrence development. N and T were prognostic of overall survival. N and DNA were predictive of recurrence-free survival. For the neck negative group, DNA remained as the only predictor of overall and relapse-free survival.

CONCLUSION

DNA flow cytometry adds significant prognostic information beyond that provided by established prognostic factors.

[Biliary pancreatitis--epidemiology, progress with a new therapy concept?]

In our patients with symptomatic cholelithiasis (n = 3618 in a 6-year period), we found biliary pancreatitis in 4.4% (0.4% severe pancreatitis). Because of therapeutic splitting (ERC/EPT, followed by laparoscopic cholecystectomy), we are able to reduce the hospital stay by about 60%, reduce morbidity significantly (P < 0.05) and reduce lethality.

[Herbal medicine products and drug law]

Herbal medicinal products are very popular in Germany, both with patients and physicians. On the contrary, little is usually known about the effects of the drug law on this type of drugs. The following article elucidates the definition of herbal medicinal products, the importance of the terms quality, efficacy and safety, which herbal medicinal products are available only at a pharmacy and which ones in other stores. Terms such as review procedure, authorization procedure, registration, and traditionally used herbal medicinal products are explained in detail. Additionally, the special problems of non-European drugs, which have no marketing authorization in Germany, are mentioned, and a short outlook for the development in Europe and worldwide is given.

Reliability of reporting self-measured blood pressure values by hypertensive patients

For self-measurement of blood pressure to be useful, patient reporting of test results must be reliable and accurate. Until now no study directly measured the accuracy and reliability of patients' reporting of self-measured blood pressure values. Thirty hypertensive patients (69 +/- 11 years) were instructed to measure blood pressure at home over 14 days with the highly accurate Omron IC monitor and to keep a record of all readings in a patient logbook. To assess the reliability of the records, patients were not informed about the memory capacity of the device. We compared automatically stored blood pressure readings with the respective logbook entries to analyze deletion (under-reporting), addition (over-reporting), and precision of reporting of test results. The prevalent pattern was under-reporting, averaging 36% +/- 24% (3% to 89%), which occurred significantly more than over-reporting (9% +/- 11%; 0% to 38%). The precision of reporting (identical values at corresponding times) was 76% +/- 34% (0% to 100%). This observer error did not affect group comparisons of automatically stored values and logbook entries, although the estimated limits of agreement were wide. Blood pressure control, duration of hypertension, age, or previous use of self-measurement and patterns of logbook entries were not found to be predictive of the patients' reliability. Our results demonstrate a substantial observer error in the reporting of self-measured blood pressure values. This bias may be reduced by memory-equipped blood pressure devices.

The significance of DNA flow cytometry in predicting survival and delayed clinical manifestation of occult lymph node metastasis to the untreated neck in patients with oral squamous cell carcinoma

A total number of 116 clinically neck-negative patients with squamous cell carcinoma of the oral cavity who underwent radical primary tumour surgery without simultaneous neck treatment were entered into this prospective study. The 5 year overall survival rate was 87% for patients with flow cytometrically diploid tumours and 58% for the aneuploid group (P < 0.05). By multivariate survival analysis, tumour stage (P < 0.05) and DNA ploidy (P < 0.05) were significantly associated with the outcome. The cumulative 3 year rate of delayed clinical manifestation of lymph node metastasis to the previously untreated neck was 12.6% for patients with flow cytometrically diploid tumours and 41.3% for the aneuploid group (P < 0.01). By multivariate analysis, the DNA ploidy status of the primary tumour was the only factor among tumour stage, localization and degree of histological differentiation predictive of occult metastasis development (P < 0.05). Also, patients with T1 tumours who frequently are not considered to benefit from elective neck dissection were at high risk of subclinical lymph node involvement if the primary tumours were aneuploid (47%), whereas only 10% of the diploid T1 sample showed occult neck disease. Particularly in patients with less extensive oral carcinomas, DNA aneuploidy is therefore an important decisive factor in elective neck dissection.

High-resolution DNA flow cytometry in papillary cystadenoma lymphomatosum (Warthin's tumour)

Twenty-eight examples of papillary cystadenoma lymphomatosum (Warthin's tumour) of the parotid gland were analysed by high-resolution DNA flow cytometry. The mean coefficient of variation was found to be 1.19% (SD: 0.41). All tumours were DNA diploid. These results did not correspond with expected deviations based on published chromosomal studies. Also, the homogeneously low S-phase fractions (mean: 4.8%; SD: 2.7) found did not support the hypothesis of etiologically distinctive subgroups in these tumours.

[Risks and benefits of laparoscopic hernia-plasty (TAPP). 5 years experiences with 3,400 hernia repairs]

In the present study, for the first time the aspects of risk, benefit and the costs of laparoscopic hernioplasty in the transabdominal technique with preperitoneal placement of a polypropylene mesh are examined prospectively in a very large group of patients with 3,400 hernia repairs. The median operation time was 45 min for unilateral primary hernias, 50 min for unilateral recurrent hernias and 76 min for bilateral hernias. The frequency of complications showed a significant dependence on the individual steps in the development of the method and the individual learning curve. The same is true for the rate of recurrency. Whereas initially the rate of serious complications was 2.75%, the rate of minor complications 11% and the rate of recurrences 4.5% the corresponding figures are at present 0.4%, 4.4% and 0.5%. Laparoscopic hernioplasty proved to be equally as effective in the treatment of primary hernias, recurrent hernias and bilateral hernias. The large number of 11 surgeons participating proves that laparoscopic hernioplasty can be learned and that even in a teaching hospital it can be performed safely, efficiently and cost-effectively.

Intercomparison of apoptosis morphology with active DNA cleavage on single cells in vitro and on testis tumours

Apoptosis morphology (DNA condensation) and endonucleolytical DNA cleavage (TdT assay) were measured simultaneously on double fluorescence labelled cells employing confocal laser scanning and conventional immunofluorescence microscopy. In vitro experiments on irradiated HL-60 cells revealed a high correspondence of non-apoptotic (normal) cells without detectable DNA cleavage, versus apoptotic cells and apoptotic bodies showing DNA cleavage. Experiments performed on histological slides of testis tumours reflected a heterogeneous picture: non-apoptotic (normal) cells, apoptotic cells, and apoptotic bodies appeared either with or without detectable DNA cleavage. These data allowed the characterization and quantitation of the grade of disturbance/heterogeneity of the apoptosis programme in vivo. Furthermore, the measured apoptotic index (AI) based on apoptosis morphology was lower than the AI assessed by DNA cleavage, in contrast to published work. Taken together, these methods represent a new approach and might be suitable for improved correlation with clinical parameters. In addition, the data presented confirm frequently published doubts regarding the ability of the TdT assay to detect apoptosis as defined by morphological criteria in tumours.

A single institution's experience with transperitoneal laparoscopic hernia repair

BACKGROUND

Previous evaluations of endoscopic hernia surgery mostly are based on small prospectively documented series or on a few randomized comparative studies. In the following, results of a large single-institution experience concerning the transabdominal preperitoneal patch (TAPP) technique with regard to the development of methods and the routine use are described.

METHODS

From April 1993 to March 1997, 2,700 TAPP procedures were performed at the Department of General and Visceral Surgery, Marien-hospital, Stuttgart, Germany. The follow-up was documented prospectively in all cases by use of computed data base.

RESULTS

The majority of patients (83.8%) were operated because of primary hernias. In 17.2% a first or multiple recurrence of an inguinal hernia was indicated. At a median postoperative observation period of presently 20 months and a follow-up rate of 86.5%, 28 recurrences have been determined so far (total recurrence rate 1.03%), 6 of which occurred after a recurrent hernia reparation (1.33%) and 22 after primary hernia repair (0.97%). The most common cause for recurrence was in 39.3% a mesh (12 x 8 cm) being too small. The total complication rate was 4.6%; as an expression of the learning curve it was reduced from 7.8% (operations 1 to 500) to 2.8% (operations 2,200 to 2,700).

CONCLUSIONS

According to our experience, the TAPP technique is sufficiently applicable as a standard method for an unselected group of patients in a routine setting. It is especially suited to the repair of recurrent and bilateral hernias as well as for patients with a high risk for recurrence that can profit from a tension-free endoscopic procedure, particularly in case of obesity.

Representativity of incisional biopsies for the assessment of flow cytometric DNA content in head and neck squamous cell carcinoma

DNA flow cytometry studies of squamous cell carcinoma of the head and neck have shown that patients with diploid tumours have favourable prognoses, whereas the outcomes of those with DNA aneuploid tumours are poor. DNA flow cytometry is therefore increasingly used as an integral part of diagnostic procedures. To evaluate how representative biopsies predict the DNA ploidy of oral carcinomas, incisional biopsies taken pretherapeutically from 256 tumours were compared with the corresponding surgical resection specimens. Sixty-six tumours exclusively displayed cells with flow cytometrically diploid DNA content in both the biopsy and the subsequent resection specimen, while 182 carcinomas expressed DNA aneuploid tumour cell lines in matched samples. There were only 8 tumours (3.1%) with heterogeneity in the DNA ploidy status between the biopsy and the resection specimen. These results emphasise the usefulness of incisional biopsies to reliably prognosticate the DNA ploidy status of oral carcinomas.

[Laparoscopic hernia repair: prevention and therapy of complications]

Following the surgical steps in laparoscopic (transperitoneal) hernia repair, the corresponding groups of complications relate to: (1) laparoscopy; (2) the trocars; (3) the dissection of the inguinal region; (4) the hernia sac dissection; (5) the mesh placement; (6) the peritoneal closure. Inadequate surgical technique can lead to injuries of the intestine, urinary bladder and blood vessels; peri- and postoperative bleeding and hematoma; severing of testicular blood vessels, with consecutive testicular atrophy; and nerve lesions when fixing the mesh with clips and intestinal obstruction subsequent to insufficient peritoneal closure. With an adequate surgical technique, complication rate is very low. Preconditions for this are: strict compliance with the safety tests, when establishing the pneumoperitoneum; application of blunt conical trocars; precise knowledge of the anatomy; gentle dissection in the avascular tissue layers; subtle hemostasis; absolutely no diffuse electrocoagulation or placement of any clips below or up to 1 cm above the ileopubic tract; and safe peritoneal closure by suture under reduced intraabdominal pressure.

Artichoke leaf extract - Recent findings reflecting effects on lipid metabolism, liver and gastrointestinal tracts

In various molecular, cellular and in vivo test systems, artichoke (Cynara scolymus L.) leaf extracts show antioxidative, hepatoprotective, choleretic and anti-cholestatic effects as well as inhibiting actions on cholesterol biosynthesis and LDL oxidation. Recently, active ingredients responsible for the main effects have been identified. Thus, luteolin seems to be of crucial importance for the inhibition of hepatocellular de novo cholesterol biosynthesis. The anti-dyspeptic actions ware mainly based on increased choleresis. Regarding clinical data, lipid-lowering, antiemetic, spasmolytic, choleretic and carminative effects have been described, along with good tolerance and a low incidence of side effects. Due to its specific mechanisms of action, the future use of artichoke leaf extract for the prevention of arteriosclerosis can be expected.

Structural changes in the gastric foveolar epithelium in Helicobacter pylori-positive gastritis revealed by keratin immunohistochemistry

To clarify structural changes in the gastric foveolar epithelium in Helicobacter pylori (Hp)-positive gastritis, the expression rates of keratins 8, 18, 19, and 20 were assessed immunohistochemically in normal tissue and chronic gastritis. In normal tissue, keratin 8 was found in 100% of the cells. Staining for keratins 18 and 19 was abundantly positive. Keratin 20 was not expressed in the deep foveolae, but present in the upper foveolae and on the tips. No differences were found between the antrum and the body. In chronic gastritis, both Hp-positive and -negative, keratins 8, 18, and 19 were expressed comparably to normal tissue. Keratin 20 expression in the antrum was significantly lower in Hp-positive compared with Hp-negative gastritis (P < .05) and normal tissue (P < .05). In the body, staining for keratin 20 did not differ significantly between all groups. The difference in keratin 20 expression between the antrum and the body in Hp-positive gastritis was significant (P < .05). After successful eradication, staining for keratin 20 in the antrum normalized within 6 months (P < .05). These findings indicate structural changes in the gastric foveolar epithelium in Hp-positive gastritis. They predominantly include the antral region and show full reversibility after eradication.