Normal acylcarnitine levels during confirmation of abnormal newborn screening in long-chain fatty acid oxidation defects

We report two infants identified by tandem mass spectrometry (MS/MS) of neonatal blood spot acylcarnitines and confirmed by molecular genetic analysis to have long-chain fatty acid oxidation defects. In both cases, acylcarnitine concentrations in confirmatory plasma samples were normal. None the less, molecular testing identified trifunctional protein (TFP) deficiency (McKusick 600890) and very long-chain acyl-CoA dehydrogenase (VLCAD) deficiency (McKusick 201475).

[Magnetic resonance imaging as the primary diagnostic method for ectopic discharging ureteral insertion of a dysplastic kidney]

Ectopic ureters associated with dysplastic kidneys remain a diagnostic dilemma. Ultrasound, endoscopy as well as intravenous urography do not always show correct urinary tract morphology and function. We report the case of a 6-year-old girl with continuous urine dribbling to demonstrate the diagnostic value of MR urography.

Ultrasound training: the virtual patient

OBJECTIVE

To evaluate an ultrasound training system designed to standardize teaching and learning of gynecological sonography using a virtual model.

METHODS

The 'virtual patient' was based on a three-dimensional freehand ultrasound system that allows two-dimensional sonographic offline investigations of previously recorded cases, imitating a real gynecological scan. In the first test phase designed to check the congruence of real and virtual scans, 25 doctors experienced in ultrasound examined three virtual cases. During the second test phase we assessed whether training with the virtual patient helped to establish a satisfactory practical knowledge of gynecological ultrasound. This phase was carried out with 24 medical students without ultrasound experience.

RESULTS

All 25 doctors successfully investigated the three cases and generated an accurate diagnosis for the first and second cases. In the third case 14 doctors made the correct diagnosis (uterus bicornis). The measurements of endometrial thickness and the diameter of a fibroid yielded acceptable results compared with the original investigation. After a short standardized video-based instruction, all 24 medical students were able to perform a basic transvaginal scan and to inspect the uterus, ovaries and the urinary bladder. Measurements of endometrial thickness by all students deviated minimally from the actual measurement.

CONCLUSIONS

Training with the virtual patient appears to be comparable to performing a live gynecological ultrasound investigation and allows standardized ultrasound teaching and learning.

The white-phase-specific gene WH11 is not required for white-opaque switching in Candida albicans

Phenotypic switching between white and opaque cells is important for adaptation to different host environments and for mating in the opportunistic fungal pathogen Candida albicans. Genes that are specifically activated in one of the two cell types are likely to be important for their phenotypic characteristics. The WH11 gene is a white-phase-specific gene that has been suggested to be involved in the maintenance of the white-phase phenotype. To elucidate the role of WH11 in white-opaque switching, we constructed mutants of the C. albicans strain WO-1 in which the WH11 gene was deleted. The Delta wh11 mutants were still able to form both white and opaque cells whose cellular and colony phenotypes were indistinguishable from those of the wild type. Deletion of WH11 also did not affect the activation and deactivation of the white-phase-specific WH11 promoter and the opaque-phase-specific OP4 and SAP1 promoters in the appropriate cell type. Finally, switching from the white to the opaque phase and vice versa occurred with the same frequency in wild-type and Delta wh11 mutants. Therefore, the WH11 gene is not required for phenotypic switching, and its protein product seems to have other roles in white cells, which are dispensable after the switch to the opaque phase.

Behandlung des Mammakarzinoms in der Schwangerschaft - Erfahrungen aus der Universitätsfrauenklinik Großhadern und Internationale Datenlage

With an incidence of 1 case in 3 000 to 10 000 pregnancies, breast cancer is the second common pregnancy associated malignancy besides cervical cancer. An analysis of 12 patients with pregnancy associated breast cancer, treated at the University Department of OB/GYN Grosshadern, and a review of the international literature is presented. Eight women underwent surgery during pregnancy (four radical mastectomies, four breast conserving procedures), four received CMF-chemotherapy during pregnancy (1 to 4 cycles). Three other patients were treated post partum. The tumor stages were advanced (> 2 cm: 10/11; N pos.: 8/11; G3: 7/11; ER/PR neg.: 5/11). One patient with metastatic breast cancer received palliative care only and died 1 week after diagnosis and emergency caesarean section in the 31 (st) gestational week. Median overall survival was 41 months with six patients dead of breast cancer. One pregnancy was terminated in the 20 (th) week of gestation by legal abortion, another because of intrauterine death in the 24 (th) gestational week. Of the other six pregnancies, four were terminated by elective caesarean section and two by induced vaginal delivery. One child died with trisomy 18 shortly after birth. The five healthy children (now aged 3 to 12 years) showed normal development up to now. The cases show the challenge and the opportunities associated with therapy of pregnancy associated breast cancer. Utmost attention should be turned to the psychological support of the woman and her family.

[The classification of functional psychoses: the impact of ICD-10 diagnoses (research diagnostic criteria) for the prediction of the long-term course]

One major objective of Emil Kraepelin's system of the functional psychoses was to establish a prognostically relevant diagnostic classification. Following this idea, 197 first admitted inpatients from the years 1980 - 1982 were examined 15 years later in order to determine the impact of ICD-10 diagnoses (derived from first hospitalisation) for the long-term course. The long-term course was divided into the three course types single episode, episodic-remitting course and chronic course. The results showed that 57 % of the patients with schizophrenia, 50 % of the patients with persistent delusional disorders, 20 % of the patients with acute and transient psychotic disorders, 10 % of the patients with schizoaffective disorders and only 3 % of those with affective disorders developed a chronic course type. Using a logistic regression analysis, the predictive validity of the ICD-10 diagnoses was compared with those of a dimensional model based on psychopathological and demographic data. The results revealed that the predictive validity of the dimensional model (77 %) does not exceed the predictive validity of ICD-10 diagnoses (78 %).

Fifteen-year follow-up of ICD-10 schizoaffective disorders compared with schizophrenia and affective disorders

OBJECTIVE

The nosological status of schizoaffective disorders is still unclear. The aim of the present study was to compare ICD-10 schizoaffective disorders to schizophrenia and affective disorders with respect to the clinical picture and the long-term outcome.

METHOD

Two hundred and forty-one first-admitted inpatients from the years 1980-1982 who fulfilled the ICD-10 criteria for schizophrenia, schizoaffective or affective disorders were included. Patients were examined at the time of first hospitalization and then followed-up after 15 years.

RESULTS

With respect to the clinical picture at the time of first hospitalization ICD-10 schizoaffective disorders were distinguishable from both schizophrenia and affective disorders. However, with respect to the long-term outcome ICD-10 schizoaffective disorders had a prognosis similar to that of affective disorders.

CONCLUSION

Differing prognosis implies that schizoaffective disorders should be distinguished from schizophrenia and suggests their subcategorization under affective disorders.

[Sonographically guided percutaneous needle aspiration of breast abscesses - a minimal-invasive alternative to surgical incision]

AIM

The current standard treatment of breast abscesses is surgical incision and drainage. This method, however, frequently yields poor cosmetic results. Sonographically guided percutaneous aspiration of breast abscesses and local antibiotic treatment need to be considered as an interesting alternative. The present study aimed to compare these treatment alternatives.

METHOD

The patient population analysed comprised 24 patients with 28 breast abscesses who presented to the Department of Obstetrics and Gynaecology of Munich University Hospital Grosshadern between 12/1997 and 9/2002. 25 % of these patients (6/24) suffered from a puerperal and 75 % (18/24) from a non-puerperal breast abscess. The study group of surgically treated patients comprised 15 women (16 abscesses). Ten patients (10 abscesses) were treated with the novel, minimally invasive method. The treatment success was statistically analysed using chi (2)- and t-Tests (p < 0,05).

RESULTS

The minimally invasive approach did not extend the length of intravenous antibiotic treatment or hospital stay and did not lead to an increase in the need for analgesic drugs. We encountered recurrent abscesses in 31 % (5/16) of the surgical treatment group, yet none in the group undergoing minimally invasive treatment. The aesthetic-cosmetic as well as the functional result in lactating patients was satisfactory in all cases.

CONCLUSION

Sonographically guided percutaneous aspiration of breast abscesses represents a less invasive and very promising alternative to surgical incision, showing the following advantages: no general anaesthesia required, a superior cosmetic result and shorter hospitalisation. The method was highly accepted by all patients treated.

Course and outcome of first-admitted patients with acute and transient psychotic disorders (ICD-10:F23). Focus on relapses and social adjustment

OBJECTIVE

The aim of the present study was to investigate course and outcome of acute and transient psychotic disorders (ATPD).

METHOD

A sample of 73 first-hospitalized patients was evaluated after three to seven years in order to determine the frequency of relapses and to assess social adjustment.

RESULT

Forty-two percent experienced no relapse, 46% experienced relapses without developing marked deficits in social adjustment and 12% had relapses associated with a severe social impairment. At discharge from first hospitalization the last group was distinguishable from the other two with respect to negative and depressive symptoms as well as the total score of the Strauss-Carpenter scale.

CONCLUSION

Only a minority of first-hospitalized patients with ATPD develop a severe social impairment after three to seven years. This subgroup, however, is not compatible with the concept of a "transient" psychotic disturbance, but rather with an early manifestation of a chronic schizophrenic disorder.

Uterusmyome?Behandlungsoptionen aus der Sicht des Gyn�kologen

Uterine fibroids are the most common benign tumour affecting the female reproductive tract, 20% of all women older than 35 years are afflicted. Patients with fibroids tend to be asymptomatic, but fibroids may lead to meno-, metrorrhagia, hyper- and dysmenorrhoea and urination and defecation problems. If the fibroids do not cause any clinical symptoms and if there is no suspicion of a malignant tumor, there is no need for therapeutic intervention. Otherwise, besides the medical management with gestagenes and GnRH (gonadotropin-releasing hormone) analog, surgery represents the classical treatment. Hysterectomy is the common approach for women with completed family planning. For women who wish to conserve their fertility enucleation of the fibroids can be considered. These surgical procedures can be performed endoscopically or abdominally. Uterine artery embolisation, a radiological intervention, is less invasive and represents an interesting therapeutic alternative.

[Abnormalities of external and internal genitalia]

The gynecologic examination of the female genitalia of children and young adults belongs in the hands of specialists and should be performed in the appropriate environment. The most important task of such an examination is the distinction between true developmental anomalies and anatomical findings mimicking such anomalies. Even newborn females can be successfully examined without any large effort expenditure. In most cases, the external inspection of the vestibule is enough to reach a diagnosis. In other case scenarios, vaginoscopy and gynecological speculum examination may be necessary. Additional imaging studies include abdominal sonography and magnetic resonance imaging. Normal variations of a child's hymenal membrane, fusion of the labia minora, hymenal polyps and hypertrophy of the preputium of the clitoris are the entities most likely to be mistaken for real developmental malformations. The most important asymptomatic developmental anomaly of the vagina and the uterus is the Mayer-Rokitansky-Kuster-Hauser syndrome (uterine and vaginal agenesis). Developmental malformations, such as hymenal atresia, vaginal septum formation and Millerian anomalies in general, tend to be symptomatic, presenting with hematometra, hematocolpos or dysmenorrhea. The treatment of genital developmental anomalies is generally not difficult but requires the appropriate clinical and surgical expertise.

[Diagnostic shifts of functional psychoses in the transition from ICD-9 to ICD-10]

In order to identify diagnostic changes caused by the transition from ICD-9 to ICD-10, in a sample of 218 first hospitalised patients from the years 1980 and 1981, ICD-9 diagnoses were compared with ICD-10 diagnoses. For this comparison, functional psychoses were classified into five main diagnostic groups. Results showed a decreased frequency of the diagnostic groups schizophrenia, schizoaffective psychoses, and paranoid psychoses and an increased frequency of the diagnostic groups acute psychoses and affective psychoses. With the exception of acute psychoses and schizoaffective psychoses, a high agreement between ICD-9 and ICD-10 diagnoses was found, and the Kappa value was 0.70. With regard to the homogeneity of psychopathological symptoms, ICD-10 diagnoses showed no improvement over ICD-9 diagnoses. Nevertheless, ICD-10 diagnoses have gained in predictive validity because schizophrenia was further narrowed to cases with a more unfavourable outcome.

[Primary hyperparathyroidism with persistent hypercalcemia in pregnancy]

Parathyroidectomy is effective in avoiding complications of primary hyperparathyroidism (pHPT) during pregnancy, because in about 90% of cases, it is caused by parathyroid adenomas. We present a case of severe pHPT during pregnancy of unknown etiology and without detectable parathyroid adenoma so that surgery was not a therapeutic option. The patient was a 29-year-old gravida 1 who presented with pHPT at 11 weeks of gestation. Although her serum calcium levels were elevated throughout pregnancy (>3.05 mmol/l; reference range: 2.05-2.65), a vigorous premature infant was delivered at 35 weeks of gestation. The infant received calcium intravenously, vitamin D(3) orally and was fed with raw human milk (low phosphorus) to prevent hypocalcemia. The baby did not develop clinical signs of hypocalcemia. Her initial parathyroid hormone level was suppressed (1.1 pg/ml; reference range: 15-65) and was normal at the age of 8 weeks. She was discharged from hospital at 14 days of life. Her physical, cognitive and motor development was normal through infancy and early childhood. In conclusion, pHPT during pregnancy does not necessarily lead to fetal or neonatal morbidity or mortality.

Are bipolar I depressive patients less responsive to treatment with antidepressants than unipolar depressive patients? Results from a case control study

The increasing evidence that bipolar and unipolar affective disorders have different biological etiologies and courses of illness has been associated with an intensifying interest in specific treatment regimens for both disorders during the last decade. In this context, the question arose whether antidepressants exert similar efficacy in the acute treatment of bipolar compared to unipolar depression. Although the clinical impression does not indicate substantial differences in the efficacy of antidepressants between these groups of patients, empirical databases concerning this topic are rare. The present study compared the efficacy of antidepressants in 50 unipolar and 50 bipolar depressed inpatients (ICD-9 criteria) under naturalistic treatment conditions. Both groups of patients were matched for age, gender and duration of illness. Clinical assessments of status at the time of admission and at discharge were used to rate response to antidepressant treatment. Analyses of the data revealed that both groups of patients needed the same time for treatment response and did not show any significant differences in outcome measures at discharge. These findings do not concur with the hypothesis formulated by some experts in the field of affective disorders that antidepressants are less effective in the acute treatment of bipolar depressed patients compared to unipolar depressed patients.

Myomectomy as a pregnancy-preserving option in the carefully selected patient

OBJECTIVES

To present the indications for myomectomy during pregnancy and to discuss complications possibly related and unrelated to the procedure.

METHOD AND RESULTS

A 33-year-old patient at 18 weeks of gestation underwent removal of a 1,570-gram symptomatic fundic myoma. Histologically the patient had a leiomyomatous neoplasm of uncertain malignant potential. The pregnancy was continued under sequential observation with magnetic resonance imaging and ultrasound. At 36 weeks of gestation a healthy girl with an upper extremity limb defect was born via cesarean section. Follow-up of the mother and the child was uneventful.

CONCLUSIONS

Certain known risk factors in pregnant women with myomas can predispose to complications during pregnancy. Women with such risk factors or women who have failed medical therapy should be offered the option of undergoing myomectomy as a pregnancy-preserving procedure.