Rapid dedifferentiating meningioma with repeated multifocal recurrences and pulmonary metastases

A 62-year-old woman presented with a convexity meningioma which, after primary surgery, was histopathologically graded as grade II. There followed three more operations due to repeated rapid local recurrences. After each of these three operations histology revealed dedifferentiated grade III tumors. At third recurrence moreover, other multiple tumor masses in the vicinity of the primary tumor site and in the lung were found. These had the same histological appearance as the local recurrences. The patient died 30 months after primary surgery from respiratory failure due to the multiple lung metastases.

Type-specific diagnostic analysis of first epileptic seizure in adults

327 adults patients presenting with a first epileptic seizure were evaluated in respect to underlying causes. The majority suffered from alcohol-related seizures, in the elderly patients vascular pathology dominated. Remote symptomatic seizures raise the question of anticonvulsant therapy.

Sarcoidosis of the spinal cord and medulla oblongata. A pathological and neuroradiological case report

A case of 68-year-old woman with symptoms of slowly progressive diffuse myelopathy, is presented, which could only temporally be reversed by immunosuppression. Contrast enhanced magnetic resonance (MR) scan demonstrated multifocal patchy enhancing lesions from cervical to mild thoracic segment and a circumscribed lesion of the whole medulla oblongata. Postmorten examination disclosed a histological confirmed, multifocal sarcoidosis of the spinal cord and medulla oblongata, with few sarcoid granulomas in one hilar lymph node and skeletal muscle of the upper extremities. Only nine similar cases of intramedullary sarcoidosis confirmed by autopsy with symptoms solely attributable to the spinal cord have been reported. A review of the pathological manifestations, diagnostic and treatment of intramedullary sarcoidosis is given.

Kappa/lambda ratio as parameter for evaluation of therapy-resistant epilepsy of childhood

In a prospective study we tested the hypothesis whether an alteration in the immunoglobulin light chain kappa and lambda is an expression of an autoimmune mechanism. We investigated 152 children (84 boys, 68 girls, age 12 months to 16 years). Immunoglobulins were analyzed by kinetic nephelometry. The patients were grouped according to clinical and laboratory parameters. A high kappa/lambda ratio caused by high concentration of the kappa-chain was found in children with therapy-resistant epilepsy. 58% showed a high kappa/lambda ratio, in 28% no distinct association was possible and in 14% false-positive results were obtained. In seizure-free children immunological markers were specific in 71%, whilst 25% could not be characterized and 4% showed false-positive results. This alteration of immunoglobulins therefore can be used as a diagnostic parameter.

[Electrocardiography and electrophysiologic findings in patients with myotonic muscular dystrophy]

Myotonic dystrophy is associated with diffuse cardiac conduction disturbances. Seven consecutive patients, all asymptomatic with respect to cardiac abnormalities, were investigated by means of ECG, Holter monitoring, and invasive electrophysiologic studies (EPS). During Holter monitoring, no abnormalities were found in any patient, except for one patient who showed single monomorphic VEBs. During EPS three patients showed conduction disturbances in the AV-node (AVN) as well as in the His-Purkinje-system (HPS) in another three patients. Except for two patients ventricular vulnerability was normal during programmed ventricular stimulation. A considerable number of asymptomatic patients with myotonic dystrophy reveals AVN- and HPS-conduction disturbances as shown during EPS.

[Results of esophagectomy in carcinoma of the esophagus and cardia]

Surgery for carcinoma of the esophagus and cardia represents potentially curative therapy in the early stage of the tumor. In the advanced stage of tumor, palliation is the only remaining therapeutic aim. In a retrospective study covering the period 1984-1992 we analyzed 51 patients who underwent surgery for esophageal or cardia cancer to determine whether palliation by surgery is feasible. We also analyzed mortality and morbidity of peri- and postoperative complications. In 88% we carried out standard esophagectomy consisting of abdomino-thoracal access, gastric interposition with thoracal anastomosis and extramucosal pyloromyotomy. In the light of postresection histology, 53% of the operations were potentially curative (UICC stage I and II) and 47 palliative (UICC stage III and IV). Perioperative 30-day mortality was nil, and perioperative 30-day morbidity 11% (3 patients developed pneumonia postoperatively, 2 patients with cervical anastomosis developed dehiscence of anastomosis which in both cases healed completely with conservative therapy, while a further patient with cervical anastomosis suffered persistent paralysis of the recurrent nerve. All patients were fully able to feed themselves at the time of discharge. 43% of patients had recurrent dysphagia and 24% underwent endoscopic dilatation. Three-year survival was 26%. From these results it may be concluded that esophageal resection represents good palliation with low morbidity for the majority of patients with non-resectable carcinoma of the esophagus.

[Polytrauma: comparison of the hospital course after air- (with emergency physician) versus ground transport (without emergency physician)]

We analyzed the influence of initial intensive care at the accident site performed by an emergency physician and followed by helicopter transport on the course during hospital stay in patients with multiple trauma. We therefore compared the dates of 107 patients transported by the swiss air rescue (REGA) and an emergency physician with 131 patients transported by an ambulance and paramedic staff. By similar case material the REGA-patients showed a higher injury severity grade. Mortality of the REGA-patients was significantly higher (21%) than of the ambulance-patients (10%), but length of stay was significantly shorter and morbidity identical. We suspect, that the higher mortality of the REGA-patients is explained by the large number of surgically nontreatable severe traumas. None of the REGA-patients arrived at hospital with circulatory insufficiency whereas 4 of the ambulance-patients were in state of shock. We assume that first of all primary treatment of the scene of injury by an emergency physician and eventually also transport by helicopter have a positive effect on the course of patients with multiple trauma during hospital stay.

Improved pregnancy outcome with gonadotropin releasing hormone agonist (GnRH-a) stimulation is due to the improvement in oocyte quantity rather than quality

The impact of gonadotropin releasing hormone agonist (GnRH-a) on the quality and quantity of oocytes harvested in in vitro fertilization-embryo transfer (IVF-ET) patients was studied by comparing the results for patients stimulated with gonadotropin alone and with gonadotropin plus GnRH-a. Adding GnRH-a significantly improved the viable pregnancies per transfer and reduced the spontaneous abortions, which seemed to improve oocyte quality. However, when oocyte quality was evaluated by the fertilization rate and the implantation and delivery rates per embryos transferred, there were no significant difference in the results, indicating that GnRH-a did not improve the oocyte quality. On the other hand, GnRH-a significantly increased the average number of oocytes harvested, fertilized, and transferred, and this increased number of oocytes transferred has been demonstrated to increase pregnancy and multiple-pregnancy rates. Multiple pregnancy with more embryos implanted would significantly reduce the abortion rate. Abortion rates decreased inversely to the number of embryos implanted. Our data strongly suggest that the efficacy of GnRH-a on IVF-ET patients was due more to the quantity increase than the quality of embryos transferred.

Microsurgical fertilization procedures: the absence of stringent criteria for patient selection

Subzonal sperm insertion and partial zona dissection were applied in 250 in vitro fertilization cycles in couples (n = 200) with abnormal semen analyses; 61 clinical pregnancies were established (24% per egg retrieval). Patients were selected without using minimal cutoff criteria. The study included patients with 0% normal sperm forms (strict criteria), no motile sperm (but some live cells), and sperm counts which could be assessed only after centrifugation. Patients were categorized into three subsets. Group A (n = 116 cycles) failed to fertilize in a previous cycle. Group B (n = 40) was excluded from IVF due to the severity of sperm profiles, such as a maximum of 2% normal forms. Group C (n = 94) constitutes those patients for whom a standard cycle could possibly result in failure. Monospermic fertilization rates were 18% (A), 19% (B), and 24% (C). The incidences of embryo replacement were 63% (A), 53% (B), and 69% (C). Rates of clinical pregnancy were 22% (A), 23% (B), and 28% (C). The presence of one, two, or three semen abnormalities did not correlate with the outcome of microsurgical fertilization. Twenty-two percent of patients with combined oligoasthenoteratozoospermia became pregnant. Moreover, ongoing pregnancies were established in instances with 0% normal sperm forms and no progressively motile spermatozoa. It is concluded that stringent cutoff criteria may not be necessary when both partial zona dissection and subzonal sperm insertion are performed efficiently.

Identification and partial purification of serum growth hormone binding protein in domestic animal species

The chemical nature and variations in serum concentrations of growth hormone binding protein (GHBP) from humans, rabbits, and rodents have been reported. To date little is known about the GHBP of domestic animals. Therefore, we initiated these studies to determine whether a serum GHBP was present in domestic animals and to purify the binding protein (BP) from serum of selected species. Using a dextran-coated charcoal separation assay, specific growth hormone (GH) binding was demonstrated in ovine, bovine, chicken, human, goose, porcine, and equine serum (listed in sequence from lowest to highest binding). Variation in BP activity was relatively high, both within and between species. Yearling ewes had higher serum GHBP than either prepubertal (4 mo) or older (5 yr) ewes. The GHBP was partially purified from chicken, ovine, and porcine serum using GH affinity chromatography. These BP had high affinity (Ka = 2 x 10(8) to 2 x 10(9) L/mol, depending on species) and low capacity (2 x 10(-10) to 5 x 10(-11) mol/unit of protein) for human GH but showed lower binding affinity for homologous GH (Ka = 2 x 10(7) L/mol). The porcine GHBP had the highest and ovine GHBP the lowest affinity for human GH. Other heterologous somatotropic hormones, ovine placental lactogen, and ovine GH displayed higher binding affinity to chicken and pig BP than the respective homologous hormones. Further chromatographic purification of the porcine GHBP resulted in an additional 1,000-fold purification. The estimated molecular weight of porcine GHBP is 50,000 to 60,000 Da. These results demonstrate that the serum from all domestic species tested contains a specific GH-binding moiety and that under the conditions described here human GH is a more efficient ligand than the homologous hormone.

No change in acrosome reaction of human spermatozoa during storage in cervical mucus

Incubation of human spermatozoa in capacitation media for 24 h results in a significant increase in acrosome reacted spermatozoa as compared to preincubation (baseline) levels. By contrast, sperm samples recovered from the cervix for as long as 72 h after coitus only showed baseline percentage of acrosome reacted spermatozoa. These results indicate that spermatozoa do not undergo the acrosome reaction during cervical storage and suggest that cervical mucus suppresses the spontaneous acrosome reaction of spermatozoa that become capacitated in the cervix.

[Dexamethasone does not normalize disordered LH pulsatility in hyperandrogenemic ovarian insufficiency]

Application of dexamethasone (DEX) is well accepted for treatment of hyperandrogenemic ovarian failure (HOI). In some cases of clomiphene resistance, additional DEX can induce ovulatory cycles. In this study, we evaluated the influence of adrenal androgen reduction on the gonadotroph during longterm therapy with 0.5 mg DEX daily in a larger group of patients (n = 25) in order to investigate subgroups of HOI. Women with elevated DHEA-sulfate levels only (DS-group); with elevated testosterone and/or androstenedione levels only (TA); with polycystic ovaries in ultrasound (PCO), with highest LH levels (LH); with secondary amenorrhea (SA); with oligomenorrhea (OL) and with elevated body mass index (BMI) were included. Blood samples were taken at 10 min intervals for 12 h sampling periods (8am-8pm) and analyzed by RIA. In amenorrhoeic patients, investigations took place at monthly intervals; in cycling women preferentially on day 5 of the cycle. LH and FSH profiles were evaluated by 3 different computerized peak identification programs ("pulsar", "ultra" and "modified Santen and Bardin"). DEX resulted in significant decreases in T, A, DS and progesterone serum levels in all subgroups. No significant alterations were found in estradiol levels and only small variations in few subgroups with estrone. Mean LH concentrations exhibited small decreases (p less than 0.05) in DS-, LH- and OL subgroups and no changes in the others. With the exception of a decrease in "pulsar" pulse frequency in the OL subgroup, no changes in pulse frequency or amplitude were found in any other group during DEX therapy. Mean FSH concentrations and pulsatility did not vary either.(ABSTRACT TRUNCATED AT 250 WORDS)

Late luteal estradiol patterns are a better prognosticator of pregnancy outcome than serial beta-human chorionic gonadotropin concentrations

OBJECTIVE

Since the corpus luteum (CL) is known to play an important role in early pregnancy, its activity could possibly be a marker for pregnancy outcome.

DESIGN

The late estradiol (E2) concentration in 48 viable pregnancies and 39 pregnancies which resulted in spontaneous abortions after in vitro fertilization and embryo transfer were used to evaluate such predictability.

SETTING

All patients studied were of the Center for Reproductive Medicine at Cornell University Medical College.

PATIENTS, PARTICIPANTS

Eighty-seven patients.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Serum E2 and human chorionic gonadotropin (hCG) concentrations on day +11, +13, +15 (day +1 = day of ovum pick-up) were measured and studied.

RESULTS

The late luteal CL activity after rescue had a positive correlation with the number and quality of the implanted embryos. Reduced CL activity was indicative of abortion. The late luteal E2 pattern when compared with hCG doubling time had a better abortion predictability (37.8% versus 63.9%, respectively).

CONCLUSION

Corpus luteum activity demonstrated to be a better prognosticator of abortion than serial beta-hCG titers.

[Octopus perimetry in neuro-ophthalmologic diseases. A contribution to the problem of optimal program choice based on 427 cases]

From the patient population of the University Eye Clinic Basel 427 cases, who had been tested with the Octopus perimeter 201 because of neuro-ophthalmologic problems, were retrospectively examined. Above all it was interesting to find out, which program to use in order to get a maximum degree of information with a minimum of examinations. The quantitative programs 31 to 34 gave most often the clinically relevant information concerning the opticus- and chiasma affections. The only exception was the anterior ischemic opticoneuropathy where the semiquantitative program 07 delivered the better information. With supragenicular affections program 07 delivered by far, and most often, the clinically relevant information. Because of our results we can make the following recommendations: if a pregenicular lesion is suspected, it is sensible to use quantitative programs with a homogenous test point distribution within 30 degrees testing area. If a supragenicular lesion is suspected, the registration of the total extension of the defect is of greater practical value than a quantitative threshold determination. In this case, the survey program 07 is suitable. If visual disturbance is present, without a hint of its location, it is recommended to start with the survey program 07 and thereafter, according to test results, specifically continue with a quantitative program.

Microsurgical fertilization and teratozoospermia

Semen parameters were correlated with the outcome of partial zona dissection (PZD) in 42 couples with male factor infertility. Although fertilization rates were reduced, 12% of the embryos implanted following replacement. Spermatozoa from teratozoospermic sperm populations were able to fuse with oocytes following zona penetration through the artificial gaps. PZD followed by insemination with less than 5% normal spermatozoa led to 20 embryos which, upon replacement, did not implant. Motility and sperm count were not clearly correlated with the outcome of PZD and are therefore less useful indicators for patient selection. Teratozoospermic patients who previously failed to fertilize were compared to a group of similar patients who had not attempted IVF before. Although fertilization was significantly improved in first-time patients, 41% of the patients whose spermatozoa were initially unable to fertilize had at least one embryo when PZD was performed. Several pregnancies were established in this group. Subzonal sperm insertion (SZI) and PZD were compared in 19 patients using sibling oocytes. A significant fraction of spermatozoa from infertile men were able to fuse with the oolemma when directly inserted into the perivitelline area. Using a sucrose solution to shrink the ooplasm, only 1% of the oocytes were damaged during SZI. Monospermic fertilization rates following PZD and SZI were 15 and 16%, respectively. Both micromanipulation methods were successful in most patients. However, in two small groups of patients, only one technique resulted in fertilization.

Gonadal agenesis in a 46,XY female with multiple malformations and positive testing for the sex-determining region of the Y chromosome

A full-term 46,XY female newborn presented with respiratory failure due to a right-sided diaphragmatic hernia. During surgical repair, exploration revealed isolated dextrocardia and hypoplasia of the right lung. Neither gonads nor wolffian or müllerian structures could be palpated. Cardiac catheterization demonstrated defects of the ventricular septum, hypoplasia of the right pulmonary artery, persistence of the left vena cava superior and a patent ductus arteriosus. Anthropometric data were normal at birth, but fell below the 3rd percentile during follow-up. Body proportions displayed a predominance of the upper compared to the lower segment. Endocrine studies indicated no defect of steroid biosynthesis and no functional gonadal tissue. Using genetic analyses of various loci within the testis-determining region of the Y chromosome, a mutation could not be detected. The patient died from pneumonia at the age of 19 months. Postmortem examination confirmed the diagnosis of gonadal agenesis.

Surgical treatment of epilepsy

Seventy patients with intractable epilepsy were surgically treated. Thirty-three patients underwent a stereotactic procedure and in all as a first-stage operation fornicotomy was performed. Because of inadequate results in 14 patients, an additional stereotactic intervention was necessary; the targets were amygdala, thalamus, and Forel's H-field, and the final outcome of these patients was 9 (27%) seizure-free, 19 (58%) improved, and 5 (15%) unchanged. In 3 patients a selective amygdalo-hippocampectomy was performed with 2 seizure-free patients and one with improvement. Topectomy in focal epilepsy in 5 patients resulted in freedom from seizures in all cases. In 23 patients a lobectomy was performed; 10 (43%) were seizures-free, 8 (35%) were improved, and 5 (22%) were unchanged. In 6 patients only a pathological lesion was resected. Our results speak in favour of ablative surgery. However, stereotactic operations are indicated in cases with secondary generalization and dissipated foci on the dominant hemisphere.