ElePhant--an anatomical electronic phantom as simulation-system for otologic surgery

This paper describes the ElePhant (Electronic Phantom)-an anatomical correct simulation system based on 3D rapid prototyping models for the otologic intervention "Mastoidectomy". The anatomical structures of the head are created with plaster as base material using 3D-printing as rapid prototyping technology (RPT). Structures at risk, represented by electrically conductible material and fiber optics, are realized as an electric circuit and can be detected during the simulation of the surgical procedure. An accuracy study of 15 identical RPT-models compared to the 3D reconstructed CT-dataset of the patient showed that the mean accuracy is lower than the reconstructed CT layer thickness of 0.5 mm. An evaluation study of the ElePhant-system for "Mastoidectomy" was performed by 7 ENT-surgeons. The mean value of the study questionnaire (evaluation range from -2 (not at all) to +2 (very good)) was +1.2. The results showed that the ElePhant can simulate "Mastoidectomy" realistically. It is especially suitable for the simulation of the correct representation and position of the anatomical structures, realistic operation setting, and realistic milling properties of the bone structure. Furthermore it is applicable for training of surgeons.

Activation of adenosine A(3) receptors potentiates stimulatory effects of IL-3, SCF, and GM-CSF on mouse granulocyte-macrophage hematopoietic progenitor cells

Adenosine A(3) receptor agonist N(6)-(3-iodobenzyl)adenosine-5'-N-methyluronamide (IB-MECA) has been tested from the point of view of potentiating the effects of hematopoietic growth factors interleukin-3 (IL-3), stem cell factor (SCF), granulocyte-macrophage colony-stimulating factor (GM-CSF), and granulocyte colony-stimulating factor (G-CSF) on the growth of hematopoietic progenitor cells for granulocytes and macrophages (GM-CFC) in suspension of normal mouse bone marrow cells in vitro. IB-MECA alone induced no GM-CFC growth. Significant elevation of numbers of GM-CFC evoked by the combinations of IB-MECA with IL-3, SCF, or GM-CSF as compared with these growth factors alone has been noted. Combination of IB-MECA with G-CSF did not induce significantly higher numbers of GM-CFC in comparison with G-CSF alone. Joint action of three drugs, namely of IB-MECA + IL-3 + GM-CSF, produced significantly higher numbers of GM-CFC in comparison with the combinations of IB-MECA + IL-3, IB-MECA + GM-CSF, or IL-3 + GM-CSF. These results give evidence of a significant role of selective activation of adenosine A(3) receptors in stimulation of the growth of granulocyte/ macrophage hematopoietic progenitor cells.

[Periodic fever in children: keep in mind the PFAPA syndrome]

The autoinflammatory diseases should be considered in the differential diagnosis of recurrent fever in childhood. These diseases are characterized by inflammatory episodes without an evident cause. Some of these diseases, like the Familial Mediterranean Fever, have a genetic origin and need a chronic treatment to avoid severe complications on the long term. PFAPA syndrome is the most frequent cause of recurrent fever and is diagnosed based on unspecific criteria. The treatment is still controversial. One dose of Prednisone is able to interrupt the flare and tonsillectomy may induce a remission in the majority of the cases.

First clinical evaluation of the navigated controlled drill at the lateral skull base

Surgery on the lateral skull base puts delicate structures at risk. To support the surgeon in identifying and protecting the risk structures the principle of Navigated Control (NC) can be used for preventing iatrogenic injuries. In this paper the application of Navigated Control for surgery on the lateral skull base was investigated for the first time in clinical use. There was no risk structure damage with NC. Navigated Control in lateral skull base surgery seems to have a great potential for safe risk structure protection, a morbidity reduction and in a relief of strain for the surgeon.

Recurrent aspiration pneumonia after laparoscopic adjustable gastric banding

Laparoscopic adjustable gastric banding is a popular therapeutic option for morbid obesity. Band slippage, pouch enlargement and esophageal dilatation are occasional late complications of this procedure. There are rare reports of recurrent aspiration after banding. We report a 44-year-old female suffering from dysphagia and aspiration pneumonia 2 years after adjustable banding. Her esophagus was dilated to 6 cm, and videocinematography showed a severe achalasia-like disorder. Withdrawal of fluid from the band should be immediate, and relieved the stomal obstruction in this patient. Aspiration pneumonia is a serious late complication, which is easily treated by deflation of the band.

RHAMM (CD168) is overexpressed on the protein level and may constitute an immunogenic antigen in advanced prostate cancer disease

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Introduction: Treatment options for early stage prostate cancer are well defined, and localized prostate cancer can be cured by several strategies. However therapeutic outcome in advanced tumor stages is still disappointing. One approach is to deliver targeted therapy based on identified human tumor antigens, specifically expressed in neoplastic tissue and recognised by CD4/CD8 T-cells or antibodies. Materials and Methods: We employed serological identification of antigens by recombinant expression cloning (SEREX) and data mining in SEREX related databases to identify potential immunological target structures. Consequently, candidate antigens were screened by DNA microarrays consisting of approximately 20K genes, designed to profile benign and malignant prostate tissues. Genes overexpressed on the cDNA level were evaluated on the protein level by tissue microarrays representing various disease stages including about 900 tissue cores. Protein expression was measured by the Chromavision system. Results: Ten of the targets identified by SEREX and data mining showed a significant overexpression on the 20k cDNA array in localized prostate cancer compared to benign prostatic hyperplasia and in metastases compared to localized prostate cancer. One gene which has been identified earlier as an immunogenic antigen in leukemia by our group, CD168, showed a highly significant overexpression in prostate cancer metastases compared to localized disease (p=0.007). On the protein level CD168 was highest in metastatic tissue samples and significantly higher in neoplastic localized disease compared to benign tissue (p=0.03). High CD168 expression had an association to clinical parameters known to be associated with better clinical outcome. Patients with high CD168 expression in the primaries had a significantly lower risk for biochemical failure (log rank p=0.023; RR:0.621). In cell culture experiments, the number of viable cells was reduced in blocking experiments using hormone sensitive (LNCaP) and hormone insensitive metastatic (PC3 and DU 145) prostate cancer cell lines. Conclusion: Acknowledging the proven immunogenic effects of CD168 in leukemia, this antigen is an intriguing therapeutic target in advanced prostate cancer disease.

No significant financial relationships to disclose.

[Clinical efficiency and the influence of human factors on ear, nose, and throat navigation systems]

BACKGROUND

The aim of this study was to evaluate the Navibase navigation system for ear, nose, and throat (ENT) surgery. A new methodology for evaluating surgical and human factors is developed.

PATIENTS AND METHODS

The evaluation is based on 102 ENT surgical applications, including 89 cases of functional endoscopic sinus surgery (FESS). The evaluation of surgical and human factors was performed by seven ENT surgeons. To evaluate surgical performance, level of quality (LOQ) in the 89 cases of FESS was determined, comparing the surgeon's own impressions with those of the navigation system on a scale from 0 to 100 and further comparing them with clinical results. Intraoperative changes in surgical strategy were documented. The human factors of total confidence (trust), situation awareness, skill set requirement and workload shift were recorded as level of reliance (LOR).

RESULTS

The maximum deviation amounted to 1.93 mm. Averaging the quality of information resulted in an LOQ of 63.59. Every second application of the navigation system (47.9%) led to a change in surgical strategy. Total confidence showed a positive evaluation of 3.35 points in LOR.

CONCLUSION

Application-relevant information relevant to the application beyond only technical details permits comparison with other assisting systems.

[Manipulator assisted endoscope guidance in functional endoscopic sinus surgery: proof of concept]

BACKGROUND

Functional endoscopic sinus surgery (FESS) is characterized by single-handed preparation and guidance of the endoscope by the nondominant hand. This results in an additional extension of operation time by up to 15% and ergonomic deficits. The aim of this study is the conception of an automated assistance system for FESS in view of the following questions: (1) Which degree of surgical automation is suitable for FESS? (2) Which design is suitable? (3) What are the properties of the technical system (planning, time, accuracy, precision) of the selected system? (4) Does the system offer potential for a clinical application?

METHODS

In all 49 FESS were analyzed for surgical workflows. Measurement of the maximum forces within FESS was performed with 40 trials on an anatomical model. Three different mechanical systems were used in ten FESS and evaluated using the ICCAS Human-Machine Evaluation Scale. For realization of automated endoscope guidance an engine-driven and -braked manipulator (PA10-6c, Mitsubishi, Japan) was used. The technical parameters determined were expenditure of time for the preoperative planning of workspace, surgical accuracy and precision of the intraoperative endoscope positioning, maximal forces, and time.

RESULTS

Concept-conditioned instrument changes amount to an average of 41.1 and 18.9% (5.21 min) time requirement for each FESS side. Maximum forces on the mucous membrane during a conventional FESS were measured at 9.8 N (5.9-9.8). Usability of the mechanical endoscope holder was estimated in 18 of 20 cases to be inferior to the standard procedure. The time needed for segmenting the intranasal workspace was 15.2 min (10.0-23.0). The maximum deviation of the automatically driven endoscope from a planned position amounted to 0.85 mm (manually 4.64 mm). The maximum force was measured with 1.1 N in the z direction (manually 9.8 N). Automated guidance of the endoscope to an intranasal position needed 7.25 s (6.4-7.9); manually 12.64 s (5.9-43.0).

CONCLUSION

Guidance of the endoscope for FESS by an automated motor-driven system is possible. The conception which is based on workflow analysis favors a system with automatic definition of the workspace and a manual movement of the endoscope. The examined system offers a potential for clinical application. Definition of the automation level and development of a man-machine interface is more important than selection or reconstruction of a special manipulator for endoscope guidance in FESS from a surgical point of view.

Meloxicam, an inhibitor of cyclooxygenase-2, increases the level of serum G-CSF and might be usable as an auxiliary means in G-CSF therapy

Hematopoiesis-modulating action of meloxicam, a cyclooxyge-nase-2 inhibitor, has been evaluated in mice. Increased serum level of granulocyte colony-stimulating factor (G-CSF) after meloxicam administration has been found in sublethally gamma-irradiated animals. In further experiments hematopoiesis-stimulating effects of meloxicam and G-CSF given alone or in combination have been investigated. Granulocyte/macrophage progenitor cells counts were used to monitor these effects. Meloxicam and exogenous G-CSF did not act synergistically when given in combination, but could be mutually substituted during their repeated administration. The results suggest a promising possibility of using meloxicam as an auxiliary drug reducing the high costs of G-CSF therapy of myelosuppression.

Surgery on the lateral skull base with the navigated controlled drill employed for a mastoidectomy (pre clinical evaluation)

Patients who are treated with a mastoidectomy usually suffer from an inflammation of the petrosal bone. The intervention is a time consuming landmark based surgery and usually performed with a powered drill. Delicate risk structures must be respected. Navigated Control (NC) describes the control for a power driven instrument which is controlled by a surgeon and additionally controlled according to the position of the instrument relatively to a deliberated position known from a preoperatively segmented work space which excludes risk structures. The force of a drill can be regulated by the principle of NC. Following results were received: 1. Risk structure segmentation is feasible 2. The drill and a phantom can be registered. 3. With NC the resection is faster, more accurate and with no risk structures damage. 4. The phantom is suitable.

Asymmetrical dimethylarginine is related to renal function, chronic inflammation and macroangiopathy in patients with Type 2 diabetes and albuminuria

AIMS

Patients with Type 2 diabetes mellitus (T2DM) and micro- and macroalbuminuria are at increased cardiovascular risk. The endogenous nitric oxide synthase inhibitor asymmetrical dimethylarginine (ADMA) is increased in renal failure and could promote atherosclerosis. To determine the relationship between ADMA, renal albumin excretion rate (AER) and cardiovascular risk, we studied 103 T2DM patients.

METHODS

ADMA, symmetrical dimethylarginine (SDMA) and L-arginine were determined by high-performance liquid chromatography in plasma from 36 normo-, 40 micro- and 27 macroalbuminuric patients with T2DM (age 64 +/- 11 years; 38 women) who had comparable age, sex and metabolic parameters. Forty-six patients had macrovascular disease (MVD).

RESULTS

ADMA was significantly increased in patients with micro- and macroalbuminuria [median 0.61 (interquartile range 0.55-0.70) micromol/l and 0.62 (0.50-0.79) micromol/l, respectively] compared with those with normoalbuminuria [0.55 (0.48-0.63) micromol/l; both P < 0.05]. SDMA was elevated in micro- and macroalbuminuria [0.57 (0.42-0.80) micromol/l and 0.64 (0.50-0.96) micromol/l] compared with normoalbuminuric subjects [0.44 (0.37-0.53) micromol/l; both P < 0.01]. Patients with increased AER and MVD had higher ADMA and SDMA compared with those without MVD (both P < 0.001). L-arginine was comparable between all groups. ADMA correlated significantly with high-sensitivity C-reactive protein (hsCRP) and glomerular filtration rate (GFR) but not with the extent of albumin excretion, body mass index, fasting glucose, HbA(1c) or plasma lipids.

CONCLUSIONS

Increased ADMA in T2DM patients with albuminuria is linked to cardiovascular disease and is associated with renal dysfunction and subclinical inflammation.

Meloxicam, a cyclooxygenase 2 inhibitor, supports hematopoietic recovery in gamma-irradiated mice

Meloxicam, a selective inhibitor of cyclooxygenase 2, a nonsteroidal anti-inflammatory drug with an improved side-effects profile in terms of gastrointestinal toxicity, has been found to stimulate hematopoiesis in whole-body gamma-irradiated mice. A distinct corroboration of this positive action of meloxicam is an enhancement of the recovery of hematopoietic progenitor cells committed to granulocyte-macrophage and erythroid development, which has been demonstrated in sublethally irradiated animals treated with meloxicam at a dose of 20 mg/kg administered intraperitoneally either singly 1 h before irradiation or repeatedly after radiation exposure. The results suggest that meloxicam can be added to the list of biological response modifiers that can be used in the treatment of hematopoietic damage induced by ionizing radiation.

Drugs elevating extracellular adenosine administered in vivo induce serum colony-stimulating activity and interleukin-6 in mice

Our previous studies have shown that the combined administration of drugs elevating extracellular adenosine, i.e. dipyridamole (DP) and adenosine monophosphate (AMP), enhances murine hematopoiesis and potentiates the action of granulocyte colony-stimulating factor (G-CSF). In this study, colony-stimulating activity (CSA) of blood serum of mice treated with DP+AMP, G-CSF or all these drugs in combination, i.e. the ability of the sera to stimulate the growth of GM-CFC colonies, was assayed in vitro. Furthermore, the concentration of GM-CSF and IL-6 in the sera was determined. Administration of DP+AMP was found to enhance significantly serum CSA at all time intervals of serum sampling including 24 h after the last injection of the tested drugs. Additive effects of DP+AMP and G-CSF on serum CSA were noted at early intervals after administration of the drugs. Furthermore, IL-6 levels were significantly elevated in the sera of mice which were administered DP+AMP either alone or in combination with G-CSF. Our results show that the effects of DP+AMP are indirect, mediated through the induction of some cytokine(s) and/or growth factor(s) and that extracellular adenosine can act in cooperation with G-CSF. These findings contribute to the further elucidation of the role of adenosine in hematopoiesis.

Peroral IMUNOR, a low-molecular-weight immunomodulator prepared from disintegrated and ultrafiltered leukocytes, enhances recovery from myelosuppression induced by cisplatin or 5-fluorouracil

A single dose of IMUNOR, a low-molecular-weight immunodulator prepared from disintegrated and ultrafiltered pig leukocytes, was found to enhance recovery of murine pool of hemopoietic progenitor cells for granulocytes and macrophages damaged by a single injection of cytotoxic drugs 5-fluorouracil or cisplatin. The best results were obtained after the treatment with IMUNOR on days 3 or 4 after the injection of 5-fluorouracil or cisplatin. These results together with previous findings obtained in our laboratory suggest that IMUNOR has the potential to become a part of treatment schemes in oncological practice aimed at alleviation of myelosuppression evoked by cytotoxic anti-tumor therapy.

Translation molekularer Zusammenhänge in die klinische Anwendung

For patients with metastatic renal cell cancer (RCC), therapeutic options after cytokine failure are rather limited. There is a considerable need to identify new substances for systemic therapy. Due to upregulation after the loss of a functional von Hippel Lindau gene product, the vascular endothelial growth factor (VEGF) pathway is a promising target for a molecular based therapy. Over the last few years, therapeutic agents have been developed which inhibit this pathway at various levels. Here, we provide an overview of the molecular background and currently used drugs which have entered clinical trials in the setting of metastatic RCC disease. Until now, the results from early clinical trials are very promising, however, the best schedule, dosage, potential combination regimens, as well as long time efficacy, are still to be determined.

[Improved accuracy and precision of the automated shaver (navigated control) in functional endoscopic sinus surgery]

BACKGROUND

The feasibility of a navigate-controlled Shaver for the paranasal sinus surgery was proven in an initial study. Deficits showed up in the conversion of the planed cavity. Goal of this study is (1) the development and evaluation of a FESS demonstrator for the investigations to the surgical accuracy and (2) the evaluation of the resulting surgical accuracy for registration and conversion of the work space with an improved rigidity of the Shaver and a completely revised study design.

METHODS

As a demonstrator for the navigate-controlled resection of a volume through the Shaver a two-piece plastic head with an anatomical head and soft tissue model was designed. The investigation of the surgical accuracy takes place with 417 measurements to 4 different fiducial markers on the demonstrator head. The measurements for the deviation of the resulting cavity from the planned volume was realised with a work space by 24 x 24 x 30 mm. The 5 walls of the cavity were seized with 80 measuring points for each level and thus altogether 2000 measured values (5 models x 5 levels x 200 points).

RESULTS

The described demonstrator showed itself suitable for the close-to-application attempts to the surgical accuracy. The maximum deviation A (max) indicated position of the Shaver from the reference value amounted to 1,93 mm. The maximum average value of the exceeding of a planned cavity amounts to 1,62 mm.

CONCLUSIONS

Based on these results a virtual safety passage of 2.00 mm is sufficient. The study refers the clinical serviceability of the navigate-controlled Shaver in paranasal sinus surgery.

Genauigkeit und Präzision in der Bewertung von chirurgischen Navigations- und Assistenzsystemen

Accuracy represents the outstanding criterion for navigation systems. Surgeons have noticed a great discrepancy between the values from the literature and system specifications on one hand, and intraoperative accuracy on the other. A unitary understanding for the term accuracy does not exist in clinical practice. Furthermore, an incorrect equality for the terms precision and accuracy can be found in the literature. On top of this, clinical accuracy differs from mechanical (technical) accuracy. From a clinical point of view, we had to deal with remarkably many different terms all describing accuracy. This study has the goals of: 1. Defining "accuracy" and related terms, 2. Differentiating between "precision" and "accuracy", 3. Deriving the term "surgical accuracy", 4. Recommending use of the the term "surgical accuracy" for a navigation system. To a great extent, definitions were applied from the International Standardisation Organisation-ISO and the norm from the Deutsches Institut für Normung e.V.-DIN (the German Institute for Standardization). For defining surgical accuracy, the terms reference value, expectation, accuracy and precision are of major interest. Surgical accuracy should indicate the maximum values for the deviation between test results and the reference value (true value) A(max), and additionally indicate precision P(surg). As a basis for measurements, a standardized technical model was used. Coordinates of the model were acquired by CT. To determine statistically and reality relevant results for head surgery, 50 measurements with an accuracy of 50, 75, 100 and 150 mm from the centre of the registration geometry are adequate. In the future, we recommend labeling the system's overall performance with the following specifications: maximum accuracy deviation A(max), precision P and information on the measurement method. This could be displayed on a seal of quality.