A new tongue advancement technique for sleep-disordered breathing: side effects and efficacy

We examined the efficacy and the acceptance of an oral device (SnorEx) causing a forward displacement of the tongue for the treatment of sleep-disordered breathing (SDB). Twenty-three consecutive subjects with SDB were investigated. Noncompliance (NC) of use of the oral appliance was observed in 74% (17 of 23) of the subjects. NC patients were characterized by unacceptable local side effects of the prosthesis, lacking improvement of indicators of daytime well-being, and a missing reduction of the respiratory disturbance index (RDI). The device was tolerated without side effects in 26% (6 of 23) of the subjects. In these compliant (C) subjects the RDI, EDS, and snoring improved significantly (p < 0.05) compared with baseline values. After 6 mo using the device, five of the six C patients were still using it. We conclude that the high rate of noncompliance and the low efficacy of the SnorEx prosthesis preclude large-scale use of this treatment modality in patients with SDB and snoring since the local side effects are the principal cause of NC. No useful predictive parameter of treatment compliance or treatment success was found. Thus, this dental appliance should be prescribed only for selected patients failing other treatment modalities seen by an experienced sleep-disorders specialist.

Screening for renal carcinoma associated mutations in the von Hippel-Lindau tumor suppressor gene by temperature gradient gel electrophoresis

Renal cell carcinoma is the most common neoplastic disease of the adult kidney and occurs in its sporadic and hereditary form. Approximately 57% of all renal carcinomas of the clear cell type analyzed revealed a mutation in the von Hippel-Lindau disease (VHL) gene. In the present work, temperature gradient gel electrophoresis (TGGE) is presented as a rapid and precise polymerase chain reaction (PCR)-employing methodology for the detection of mutations in the VHL gene. The theoretical efficiency of TGGE to detect mutations in every base pair of the gene was calculated. According to computer analysis, at least 92% of all known mutations in the VHL gene are detectable. This calculated figure appears to be in agreement with the experimental results. Primary difficulties in analyzing exon 1 of the VHL gene were overcome by the employment of psoralen-cross-linked PCR fragments. In addition, TGGE analysis was used in screening for possible mutations in thirteen renal carcinoma samples. With this protocol TGGE is successfully added to the array of methods for the screening of VHL mutations.

[Satisfaction of cataract patients]

BACKGROUND

Most of the presentations concerning quality assurance following cataract surgery are based upon objective data, as it should be. But the success of an eye-clinic is not limited by such objective data, but on the contentment of the patients and the local colleagues, who direct the patients. Our aim in the following study is to find out, if there is a correlation between objective data and the contentment of cataract-patients.

MATERIAL AND METHODS

101 non-selected patients were asked about their contentment following cataract surgery and lens implantation. They were asked twice; first immediately after surgery and second two months after surgery. The subjective data of the patients were compared with objective data.

RESULTS

99% of the patients were content with the surgery, but only 88% were content with their visual acuity. There was no correlation between contentment of the patients and visual acuity. 13% of the patients reached a vision below 0.2. All but one said to have a good or moderate vision. 16% claimed to have poor or very poor vision, they all had a vision between 0.2 and 1.0.

CONCLUSIONS

The ophthalmic surgeon must not be satisfied by his own good surgical results. In addition, he has to take care of the contentment of his patients. But it is even more dangerous, if the surgeon is proud because of his many content patients. Even if the patients are satisfied, he has to take care, if he really deserves the thanks of them.

Pharmacokinetics of ampicillin/sulbactam in patients undergoing colorectal surgery: measurements in serum, the colonic wall and in tissue at the incision site

The concentrations of ampicillin and sulbactam were determined in serum, colonic wall and incision site tissues from 23 patients undergoing elective colorectal surgery after infusion of a high-dose regimen (2 g ampicillin/1 g sulbactam) or a low-dose regimen (1 g ampicillin/0.5 g sulbactam). The results confirmed that ampicilin and sulbactam penetrated well into the tissues studied and reached therapeutically effective concentrations at the various sites. The high dose regimen showed higher concentrations of both compounds in serum and tissues, indicating a longer period of perioperative protection against bacterial pathogens. Thus, about 39 min after the end of the infusion of the high-dose regimen, the mean concentration of ampicillin was 68.8 +/- 31.2 mug/g and of sulbactam 23.4 +/- 6.3 mug/g in the tissue of the colonic wall. Low-dose prophylaxis, showing mean tissue concentrations of ampicillin of 35.6 +/- 7.0 mug/g and of sulbactam of 14.2 +/- 2.4 mug/g about 48 min after the infusion, is appropriate if the duration surgery does not significantly exceed 2 h.

A school-based clinic for elementary schools in Phoenix, Arizona

A community hospital, a school district, and a private pediatrician's office collaborated to ensure all children enrolled in five elementary schools had access to health care services. The school nurse at each school identified children needing health care services and obtained parental consent. The school nurse referred children to a nurse practitioner who visited one school each day. School nurses and space in the nurse's office were provided by the school district. The hospital provided a nurse practitioner as well as pharmacy, radiology, laboratory, and emergency department services. The pediatrician as medical director for the program provided vision, training, and community connections, and served as collaborating physician for the nurse practitioner.

Experimental in vitro and in vivo studies of epithelium formation on biomaterials seeded with isolated respiratory cells

Extensive tracheal defects after intensive care medicine, trauma, or large resections in tumor surgery remain a major challenge in plastic and reconstructive surgery. Defects that cannot be satisfactorily treated by complicated and costly reconstructive techniques reveal a need for an alloplastic tracheal replacement. Recent experimental and clinical studies in the development of alloplastic tracheal prostheses proved that the lack of an epithelial lining on the luminal surfaces and inadequate biophysical properties and shapes of the prostheses were the main causes for failure of these prostheses. In this study a cell-seeding technique has been used. Adhesion, spreading, and differentiation of seeded mucosa cells on biomaterials in vitro were observed by scanning electron microscopy (SEM). Chemical properties and surface structure of the material influenced the differentiation process. Epithelium formation of incorporated tracheal prostheses was tested in animal experiments. Isolated respiratory cells were seeded into implanted tubular prostheses of porous polyurethane or expanded polytetrafluorethylene. Light microscopy and SEM showed the tendency of epithelium formation on the surface of the lumen. Vigorous cell layers, predominantly as multiple cell layers of squamous epithelium, were observed. Ciliated or mucus cells were not detected. It can be stated that the epithelium formation on incorporated porous implants is possible. Further studies of the stability and the differentiation process of the epithelium on such implants is needed before an introduction of tracheal replacements into the clinical practice can be considered.

Distribution behaviour of 131-iodine labelled trans-N,N'-bis-(ethoxy-carbonyl)-N-[4-(3-iodo-4-methoxyphenyl)butyl]-N' -5- phenylpentyl)-1,4-cyclohexanedimethanamine

The title compound 9, which is a prodrug, and its active metabolite 7 were labelled with 131I (7*/9*) to investigate their pharmacokinetic behaviour, including the distribution between stomach, gut, muscle, blood, lung, liver, kidney, adrenal gland, heart, and spleen. Four hours after oral administration of 7* to mice only 3% of the dose had been absorbed from the g.i. tract. After 24 h 54% of the radioactivity still is found the gut, predominantly in the small intestine. These results explain why 7, which is a potent antiplatelet drug in vitro, shows no antithrombotic effect in vivo. In contrast, the produg 9/9* is absorbed considerably, i.e. up to 50% in 4 h from the g.i. tract depending on the dose applied and the vehicle used. At doses in the micromolar range the absorption appears to be diffusion limited. The highest concentrations are found in the liver and the kidneys suggesting a first pass effect of 7 followed by renal excretion. From the blood levels achieved, the dose necessary for an antithrombotic effect has been calculated to be about 100 mg/kg. In summary, the N-ethoxycarbonyl derivatives of oligoamines appear to be suitable prodrugs for oral administration of oligoamines.

[Foreign body reaction after lens implantation. Correlation between visual acuity and density of giant cells]

In the early postoperative stage giant cells often appear on IOLs. Independent of this, a foreign-body reaction may start about 3 months after surgery from posterior synechia. Foreign-body reaction occur more frequently in diabetic patients or patients with glaucoma. In a prospective trial, we examined the surface of the IOLs from 115 patients with diabetes or glaucoma using specular microscopy. We compared the maximal density of the cells to visual acuity. One week and 1 month after surgery, the maximal density of giant cells was between 0 und 20/mm2; vision (median) was independent of the giant cell density in all groups between 20/25 and 20/30. Three months after surgery, the maximal density of giant cells was between 0 und 35/mm2; vision (median) was 20/25 in patients with no giant cells or cell densities up to 15/mm2. Seven patients had cell densities between 16 and 35/mm2; visual acuity (median) was 20/125. The difference was significance was (P < or = 0.05). Six months and 1 year later after surgery, the maximal density of giant cells was between 0 and 41/mm2; the vision (median) in patients with giant cell densities up to 15/mm2 was between 20/20 and 20/25. In five examinations the cell densities were found to be in the range of 16 to 40/mm2; visual acuity (median) was 20/80 in these cases. The difference is not significant (P < or = 0.05). A foreign-body reaction with more than 15 giant cells/mm2 is a rare complication of cataract surgery with lens implantation. Three months after surgery, this complication correlates with poor vision.

Platelet aggregation inhibiting and anticoagulant effects of oligoamines, XXX: Absorption, organ distribution, and excretion of the oligoamine (+)-(S,S)-1,4-bis-[4-(3-iodo-4-methoxyphenyl)-butylamino]-butane-2,3-di ol and its metabolites

The pharmacokinetic behaviour of the 131-iodine-labelled title compound 3* and its metabolites in mice was investigated. A two phase, 1st order elimination profile was observed. The second phase is very slow leaving about 35% of radioactivity in the mice even 100 h after i.v. injection, because of high affinity to liver and spleen, caused by strong binding of oligoamines to phospholipids of liver and blood cell membranes. The blood-brain-barrier is not passed. No deep compartments were observed. The doses necessary for antithrombotic effects in vivo were calculated from the blood levels to be 20.5-39.7 mumol/kg for a time interval of 1-6 h after administration.

[Value of transtracheal oxygen insufflation in the weaning period after long-term ventilation]

BACKGROUND

In many cases, respiratory muscle failure is the reason for unsuccessful weaning attempts after long-term ventilation. Therapeutic measures must therefore be aimed at unloading the respiratory pump. In this present study we examined whether, in particular, the transtracheal O2-insufflation (TTO2) results in a change of breathing patterns and unloads the respiratory muscles.

PATIENTS AND METHODS

We examined 6 patients (5 males, age 65.6 +/- 3.9 years, diagnosis: chronic obstructive lung disease), who received long-term mechanical ventilation in outward intensive care units. Baseline resting data (arterial blood gas analysis, the breathing frequency and the minute volume) were obtained with the patients breathing room air for 1 hour. After receiving TTO2 with a flow of 21/min for another 1-hour-period the measurements were repeated.

RESULTS AND CONCLUSION

In our study we could show that the TTO2 leads to an impressive decrease in inspiratory work of breathing-relative to the minute ventilation by about 28%. Therefore TTO2 is of great importance in the weaning phase subsequent to prolonged mechanical ventilation due to the respiratory muscle failure.

[Increase in hypercapnia in exercise--an unloading strategy?]

BACKGROUND

Chronic hypercapnia seems to preserve the overloaded respiratory pump from manifest muscle failure. In order to get information about the regulation of the ventilation under exercise we investigated clinical stable hypercapnic patients.

PATIENTS AND METHODS

Twenty-one patients (20 males, 53.7 +/- 13.2 years) with obesity-hypoventilation syndrome (8), chronic obstructive lung disease (4), scoliosis (3), myopathy (2) and post-Tbc (2) were examined. Ventilation parameters (fb, Vt, VO2), respiratory muscle strength (PImax, PEmax), arterial blood gases (pO2, pCO2), respiratory quotient (RQ) and lactate were measured at rest and at the end of 5 minutes of maximal bicycle exercise. The control group consisted of 10 healthy persons.

RESULTS AND CONCLUSIONS

A significant augmentation of the pre-existing hypercapnia under exercise (reflecting hypoventilation in relation to the predicted value) was observed in all patients with chronically overloaded respiratory muscles. This mechanism seems to be wise because it protects the respiratory pump from failure.

[Epithelialization of porous biomaterials with isolated respiratory epithelial cells in vivo]

Extensive tracheal defects after prolonged assisted ventilation, trauma or large resections in tumor surgery are a challenge in plastic and reconstructive surgery. Defects which cannot be satisfactorily repaired reguine near of an alloplastic tracheal replacement. Previous experimental and clinical experiences in the development of an alloplastic tracheal prosthesis have demonstrated that the main cause for failure is the lack of an epithelial lining of luminal surfaces and inadequate biophysical properties of the prosthesis. With the use of a cell-seeding technique tested in vitro on biomaterials epithelialization of tracheal prostheses can be tested in vivo. In animal experiments isolated respiratory cells were seeded into implanted tubular prostheses of porous polyurethane or expanded polytetrafluorethylene. Light and scanning microscopic investigations then showed the tendency of epithelialization to occur on the luminal surfaces. Vigorous squamous epithelium cell layers that were single and (predominantly) multiple layers were found. Differentiated cilated or mucous cells were not detected in any case. The present results have shown that epithelialization of incorporated porous implants is possible. The realization of usable tracheal replacement for clinical practice must still be tested in further experiments.

[Why is the gray cataract called "star"?]

The adjective "starblind" has its origin in the 8th century. It describes the disease of eyes which are blind from cataract. This definition can be derived from the ancient Greek medicine and is the definition for a "starre" (which means inert) effusion behind the pupil. Martin Luther introduces the subject "Star" as a synonym for blindness. In the 18th century some linguists supposed this subject could be deducted from "starr blicken" (which means "to look motionless"). Even until today this misleading meaning is widespread although standard literature of linguistics as well as standard literature of the history of ophthalmology refer to the original meaning of this word.

A case of mild ocular manifestations in pregnancy induced hypertension with HELLP syndrome

There is a correlation between the degree of retinal changes and the severity of pregnancy induced hypertension. This correlation does not hold true for a subgroup of these patients with hemolysis, elevated liver enzymes and a low platelet count. This array of findings has been termed HELLP syndrome by Weinstein (1982) and may be present although the clinical picture of severe preeclampsia is absent. Pregnancies complicated by HELLP syndrome are associated with poor maternal and fetal outcome. We report a case in which minor ocular signs led to the diagnosis of a HELLP syndrome. Ophthalmologists should be aware of this rare complication of pregnancy.

[Decompression of the optic nerve after fractures of the rhino-basal skull with computer-assisted surgery]

Referring to 22 cases of surgery after frontobasal fractures of different origin with loss of vision, the surgical procedure is discussed with special consideration of the approach, technique and timing of the operation. We conclude that the external rhinological approach through the ethmoid sinus is the best and easiest access in cases of loss of vision with verified fracture or haematoma. A number of patients were operated using CAS (Computer Assisted Surgery)-Systems, a CT-based tool for three-dimensional orientation. It proved to be very useful for the surgeon, saving time and reducing the risk of additional damage. According to our experience and the results of other authors we believe that surgical intervention should be performed as early as possible.

[Autologous transplantation of nasal mucosa after severe chemical and thermal eye burns]

BACKGROUND

Extensive conjunctival scarring is common after severe chemical and thermal eye burns. There is often not enough healthy conjunctiva from the other eye available to correct the symblepharons, therefore other autologous tissues have to be transplanted.

PATIENTS AND METHODS

From February 1992 until March 1993 13 patients were treated with free nasal mucosal grafts from the inferior turbinates for reconstruction of the fornices. The newly created deep fornices were secured by a silicone band. In 3 patients an Illig plastic shell was used additionally. The surgical treatment was supplemented with an intensive treatment with topical corticosteroids to decrease the inflammatory reaction.

RESULTS

The patients were followed for an average of 7-18 months. The interval between the accident and the transplantation ranged from 2-26 months. In 10 patients a reconstruction of the fornices was achieved. In all patients, however, some slight scars could be observed. Postoperative Schirmertest was markedly improved. These results encourage us to plan a penetrating keratoplasty in 7 cases. 3 patients showed a recurrence of the symblepharon 2 months after the transplantation.

CONCLUSION

The nasal mucosa graft material is best suited for repair of extensive symblepharon. The advantages of this tissue are the availability of large pieces of mucosa and the transplantation of intraepithelial goblet-cells. Long-term effects are the improvement and stabilisation of the tear film.

[Extraction of orbital foreign bodies using a new kind of image processing system]

We present a new localization system in orbital surgery. The procedure is based on the linkage of two methods. A preoperative thin-layer CT scan is taken and the image data are fed into a high-capacity computer which computes a three-dimensional model of the orbit. Intraoperatively, the volume model of the skull is linked to a mechanical arm for position measurement. Surgical instruments can be mounted to this arm. The computer then projects the position of the instrument into the volume model of the orbit, so that the surgeon can follow the movements of his instruments on the monitor. The surgeon has a means of checking position that comes close to constant intraoperative CT monitoring. Thereby the surgeon is able to localize even small foreign bodies without extensive explorations. We present six patients in whom orbital foreign bodies had to be extracted during the past 5 years. A 44-year-old man had an iron foreign body; the external wound was treated surgically elsewhere. Two patients (25 and 22 years old) had glass foreign bodies; in one of them the splinters were not seen using conventional X-ray. Choosing the exact level with the Hounsfield window, the foreign bodies could be demonstrated on the monitor. In three patients with orbital fractures and compression of the optic nerve, dislocated bone splinters were extracted. The localization of those splinters was easy using the imaging system, but would have been rather difficult by other means.(ABSTRACT TRUNCATED AT 250 WORDS)

[Biocompatibility of silicone intraocular lenses]

BACKGROUND

In order to the biocompatibility of silicone intraocular lenses, which is described contradictory in literature, we compared IOLs made of silicone caoutchouc and PMMA-IOLs with regards to the presence of macrophages (i.e. giant cells or spindle-shaped cells) in a prospective, randomized study.

PATIENTS AND METHODS

Totally 125 patients were examined 2 months post-operatively with the slitlamp in the refractive zone. The single-piece PMMA-IOLs with an open haptic used in this study had a 6 mm optical zone and a total diameter of 11 mm; the silicone-IOLs were disc-shaped lenses with a total diameter of 9.75 mm and an optical zone of 6 or 5.5 mm, resp.

RESULTS

Giant cells were observed with 16% of PMMA-lenses and 19% of the silicone-lenses. The maximal density of the giant cells on the PMMA-lenses at the median was 3/mm2 compared to 2/mm2 on the silicone IOLs. Small and spindle-shaped cells were found in 54% of the PMMA-IOLs and 46% of the silicone-lenses. The maximal cell density at the median was 10/mm2 with both lens types.

CONCLUSIONS

The differences between the two lens materials are statistically non-significant. Thus, silicone caoutchouc and PMMA possess a comparable biocompatibility when used as material for intraocular lenses.

Experiences with ACE inhibitors early after acute myocardial infarction. Rationale and design of the German Multicenter Study on the Effects of Captopril on Cardiopulmonary Exercise parameters post myocardial infarction (ECCE)

Left ventricular damage by necrosis of myocardial tissue can lead to compromise of left ventricular function, to left ventricular volume increase and ultimately to development of heart failure. This sequence in the pathophysiology has been shown to be blunted by ACE inhibitors. Volume increase, however, can also be helpful in restoring stroke volume and ameliorate elevation of filling pressures. Furthermore, very early institution of ACE inhibition has failed to improve short-term mortality after myocardial infarction in one large trial. The aim of the ECCE trial therefore is, to investigate the early effects of the ACE inhibitor captopril on compromise of exercise capacity, thought to be a first measurable sign of developing heart failure. The ECCE trial is a randomized, seven-center investigation, studying the effects of ACE inhibition on oxygen uptake in a double blind, placebo controlled design in a group of 204 patients. Sample size was calculated on the basis of a pilot trial. The study design and first not unblinded data of 104 patients are presented. The population consists of predominantly male patients with mostly first myocardial infarction. They were admitted to hospital within five hours of onset of chest pain. End-diastolic volumes were normal, but ejection fraction was moderately compromised. ACE inhibition was started after the first day, but within 72 hours of onset of chest pain. After four and after twelve weeks, oxygen uptake was considerably below expected values and one third of the patients had severe compromise of exercise capacity.(ABSTRACT TRUNCATED AT 250 WORDS)

[In vitro contractility behavior of portal veins in normal rats and in rats with liver cirrhosis--effect of calcium antagonists and octreotide]

According to Poiseuille's law portal pressure is inversely related to r4. Thus, minor changes in radius dramatically influence intravascular pressure. Since the radius is actively regulated by contraction, this study elucidates in vitro contractility patterns of portal veins from healthy and liver cirrhotic rats. The results demonstrate that contractility amplitudes of portal veins from cirrhotic rats are increased in comparison to healthy animals. Calcium antagonists reduce amplitude and motility both in cirrhotic and healthy rats to the same degree. The same holds true for octreotide but significantly more in the cirrhotic group. Obviously, the maintenance of portal hypertension is supported by an active element of the portal vein, which can be controlled in vitro.