EPOS2020/EUFOREA expert opinion on defining disease states and therapeutic goals in CRSwNP

Severe chronic rhinosinusitis with nasal polyps (CRSwNP), a form of diffuse bilateral (usually type 2) CRS, is a debilitating disease with a significant impact on quality of life (QoL). With novel knowledge and treatment options becoming available, there is a growing need to update or revise key definitions to enable communication across different specialties dealing with CRS, and to agree on novel goals of care in CRSwNP. The European Forum for Research and Education in Allergy and Airway diseases (EUFOREA) and EPOS expert members discussed how to measure treatment responses and set new treatment goals for CRSwNP. In this paper a consensus on a list of definitions related to CRSwNP is provided: control, remission, cure, recurrence/exacerbation, treatable traits, remodeling, progression, and disease modification. By providing these definitions, the involved experts hope to improve communication between all stakeholders involved in CRSwNP treatment for use in routine care, basic and clinical research and international guidelines aimed to harmonize and optimize standard of care of patients with CRSwNP in the future.

EPOS/EUFOREA update on indication and evaluation of Biologics in Chronic Rhinosinusitis with Nasal Polyps 2023

Severe chronic rhinosinusitis with nasal polyps (CRSwNP) is a debilitating disease with a significant impact on the quality of life (QoL). It is typically characterized by a type 2 inflammatory reaction and by comorbidities such as asthma, allergies and NSAID-Exacerbated Respiratory Disease (N-ERD). Here, the European Forum for Research and Education in Allergy and Airway diseases discusses practical guidelines for patients on biologic treatment. Criteria for the selection of patients who would benefit from biologics were updated. Guidelines are proposed concerning the monitoring of the drug effects that provide recognition of responders to the therapy and, subsequently, the decision about continuation, switching or discontinuation of a biologic. Furthermore, gaps in the current knowledge and unmet needs were discussed.

[Dupilumab has an additional benefit in treatment of chronic rhinosinusitis with nasal polyps]

BACKGROUND

For patients with severe chronic rhinosinusitis with nasal polyps (CRSwNP) which cannot be controlled by continuous therapy with intranasal corticosteroids (INCS) and systemic corticosteroids and/or surgical treatment, there were no approved curative options for a long time. For CRSwNP treatment with T2-addressing biologics is possible. On October 24, 2019, the European Commission granted extended approval for dupilumab as the first biological agent for treatment of insufficiently controlled severe CRSwNP. The Federal Joint Committee (G‑BA) evaluates the benefits of reimbursable drugs with new active ingredients. This includes assessment of the additional benefit and its therapeutic relevance.

METHODS

A meta-analysis was performed using individual patient data based on two phase III studies. Both studies examined the safety and efficacy of dupilumab as an add-on therapy to INCS for treatment of CRSwNP in adults inadequately controlled with systemic corticosteroids and/or surgery compared to INCS alone.

RESULTS

Based on the present data, the G‑BA decided that there is an indication of a considerable additional benefit of dupilumab compared to mometasone furoate.

CONCLUSION

For patients with severe CRSwNP inadequately controlled with INCS and systemic corticosteroids and/or surgery, there is an indication of a considerable additional benefit for the administration of dupilumab as an add-on therapy to INCS compared to mometasone furoate alone.

Empagliflozin treatment does not affect the hypertensive response to Ang II administration to rats but decreases oxidative stress in the arterial wall, and endothelial and cardiac dysfunction

Background

Selective sodium-glucose cotransporter 2 (SGLT2) inhibitors have shown cardiovascular protection in type 2 diabetes patients with established cardiovascular disease independently of glycemic control. Angiotensin II (Ang II) and H2O2 have been shown to be strong inducers of the expression of SGLT2 and 1 in endothelial cells promoting oxidative stress and endothelial dysfunction.

Purpose

This study examined the cardiovascular protective effect of empagliflozin (empa) in a normoglycemic experimental model of hypertension in the rat.

Methods

Male Wistar rats received empa (30 mg/kg/day) provided in the diet for 5 weeks. After 1 week, rats underwent sham surgery (sham rats) or surgery with implantation of an osmotic mini-pump infusing Ang II (0.4 mg/kg/d) for 4 weeks. Systolic blood pressure (SBP) was assessed by sphygmomanometry, the cardiac function using echocardiography, the expression level of target proteins by immunofluorescence staining, and the level of oxidative stress using dihydroethidium staining.

Results

Angiotensin II administration increased systolic blood pressure from about 130 to 180 mmHg, which was not affected by the empa treatment. The 4-week Ang II treatment did not significantly affect the systolic cardiac function (cardiac output, left ventricle ejection fraction) but impaired the diastolic function as indicated by a reduced E' and IVRT values, and an increased E/E' value. The Ang II treatment increased significantly the heart and right ventricle weight whereas the left ventricle + septum weight was slightly but not significantly increased. No such functional and structural changes were observed in the Ang II + empa treatment group. An increased immunofluorescence eNOS signal in the endothelium, and a higher level of ROS throughout the aorta wall were observed in the Ang II-treated group, both of which were significantly reduced in the empa + Ang II-treated group. In the Ang II-treated group, the high level of oxidative stress in the aorta was significantly reduced by the AT1 receptor antagonist losartan, the NADPH oxidase inhibitor VAS-2871, the eNOS inhibitor NG-nitro-L-arginine and also to a greater extent by the selective SGLT2 inhibitor empa compared to the dual SGLT1/2 inhibitor sotagliflozin.

Conclusion(s)

The present findings indicate that although the empa treatment did not affect the hypertensive response of rats to Ang II, the SGLT2 inhibitor prevented the deleterious impact of Ang II on the diastolic cardiac function and remodeling, and the upregulation of eNOS expression and oxidative stress in the aorta wall. Thus, these findings highlight the protective potential of empa on the cardiovascular system in a normoglycemic hypertensive experimental model.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Boehringer Ingelheim Pharma GmbH & Co KG (Biberach an der Riss, Germany)

Positionspapier: Hinweise zur Patienteninformation und -aufklärung vor Anwendung von Biologika bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP) – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC) – Teil 1: Dupilumab

Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung der nasalen und paranasalen Schleimhaut, der oftmals eine Typ-2-Inflammation zugrunde liegt. Durch die Entwicklung von Biologika, die in diese Entzündungsmechanismen eingreifen können, steht eine neuartige Therapiemöglichkeit zur Verfügung.

Methoden Auf Grundlage des aktuellen Wissensstandes zur Immunologie der CRSwNP und der Wirkung von Biologika sowie deren mögliche unerwünschte Wirkungen werden Empfehlungen für die Patienteninformation entwickelt.

Ergebnisse Basierend auf der internationalen Literatur und bisherigen Erfahrungen hat ein Expertengremium Empfehlungen für die Patienteninformation und -aufklärung zur Anwendung von Biologika bei CRSwNP entwickelt und auf dieser Grundlage einen Aufklärungsbogen erstellt.

Schlussfolgerung Die Information und Einwilligung des Patienten ist vor der Verordnung bzw. Verabreichung von Biologika erforderlich. Das vorliegende Positionspapier enthält wichtige Informationen hierzu und einen Vorschlag für eine Patienteninformation.

Positionspapier: Anwendung von Biologika bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

Hintergrund Die chronische Rhinosinusitis (CRS) betrifft weltweit ca. 5–12 % der Allgemeinbevölkerung und wird traditionell eingeteilt in einen Phänotyp ohne (CRSsNP) und einen mit Ausbildung von Nasenpolypen (CRSwNP). Wurden Nasenpolypen bis vor kurzem eher als mechanisches Hindernis mit der Notwendigkeit einer operativen Beseitigung betrachtet, wird die CRSwNP heute als eine multifaktorielle entzündliche Erkrankung der nasalen und paranasalen Schleimhäute angesehen, der als Endotyp häufig eine T2-Inflammation zugrunde liegt. Biologika, die mit diesen Entzündungsmechanismen interferieren, stellen interessante neue Therapiemöglichkeiten dar.

Methoden Das aktuelle Wissen zur Immunologie der CRSwNP und Wirkung von Biologika wurde mittels einer Literaturanalyse durch Recherchen in Medline, PubMed sowie den nationalen und internationalen Studien- und Leitlinienregistern und der Cochrane Library zusammengestellt.

Ergebnisse Basierend auf der internationalen Literatur und bisherigen Erfahrungen werden von einem Expertengremium Empfehlungen für die Anwendung von Biologika bei CRSwNP im deutschen Gesundheitssystem auf der Grundlage eines Dokumentationsbogens gegeben.

Schlussfolgerung Das Verständnis über die immunologischen Grundlagen der CRSwNP eröffnet neue nichtoperative Therapieansätze mit Biologika für Patienten mit schweren Verlaufsformen.

IL-4 receptor α blockade prevents sensitization and alters acute and long-lasting effects of allergen-specific immunotherapy of murine allergic asthma

BACKGROUND

Allergen-specific immunotherapy (AIT) is the only causal treatment for allergy. However, success rates vary depending on the type of allergy and disease background of the patient. Hence, strategies targeting an increased therapeutic efficacy are urgently needed. Here, the effects of blockade of IL-4 and IL-13 signaling on different phases of AIT were addressed.

METHODS

The impact of the recombinantly produced IL-4 and IL-13 antagonist IL-4 mutein (IL-4M) on allergic sensitization and AIT outcome in experimental allergic asthma were analyzed in a murine model. The effects of IL-4M administration were assessed prior/during sensitization, immediately after AIT under allergen challenge, and two weeks post-treatment.

RESULTS

Intervention with IL-4M prior/during sensitization led to strong induction of IgG1, IgG2a, IgG2b, and IgG3, decrease of specific and total IgE, as well as of IL-5 in serum. Similar effects on the serum immunoglobulin levels were observed immediately after IL4M-supplemented AIT during allergen challenge. Additionally, IL4M markedly suppressed type-2 cytokine secretion of splenocytes beyond the effect of AIT alone. These effects were equaled to those of AIT alone two weeks post-treatment. Intriguingly, here, IL-4M induced a sustained decrease of Th2-biased Tregs (ST2⁺ FOXP3⁺ GATA3^intermediate ).

CONCLUSIONS

IL-4 and IL-13 blockade during experimental AIT demonstrates beneficial effects on immunological key parameters such as immunoglobulin and cytokine secretion immediately after AIT. Although two weeks later these effects were dropped to those of AIT alone, the number of potentially disease-triggering Th2-biased Tregs was further significantly decreased by IL-4M treatment. Hence, IL-4/IL13-targeting therapies prime the immune memory in therapy success-favoring manner.

[Manifestations of autoimmune disorders in otorhinolaryngology : Classical symptoms and diagnostic approach]

Manifestations of autoimmune disorders represent a diagnostic challenge. Many autoimmune disorders show typical manifestations in the ear, nose and throat and should be taken into account in the differential diagnosis. Sjogren's syndrome, various vasculitides and sarcoidosis represent the most common autoimmune disorders in otorhinolaryngology, but IgG4-related diseases, relapsing polychondritis and autoimmune disorders of the mucosa are also observed. Autoimmune diseases can lead to sensorineural deficits. Both hypo- and hyperthyroidism can be caused by autoimmune disorders. The diagnosis is usually based on the corresponding classification criteria, whose correct application can facilitate the clarification of these diseases.

EAACI Position paper on the standardization of nasal allergen challenges

Nasal allergen challenge (NAC) is an important tool to diagnose allergic rhinitis. In daily clinical routine, experimentally, or when measuring therapeutic success clinically, nasal allergen challenge is fundamental. It is further one of the key diagnostic tools when initiating specific allergen immunotherapy. So far, national recommendations offered guidance on its execution; however, international divergence left many questions unanswered. These differences in the literature caused EAACI to initiate a task force to answer unmet needs and find a consensus in executing nasal allergen challenge. On the basis of a systematic review containing nasal allergen challenges of the past years, task force members reviewed evidence, discussed open issues, and studied variations of several subjective and objective assessment parameters to propose a standardized way of a nasal allergen challenge procedure in clinical practice. Besides an update on indications, contraindications, and preparations for the test procedure, main recommendations are a bilaterally challenge with standardized allergens, with a spray device offering 0.1 mL per nostril. A systematic catalogue for positivity criteria is given for the variety of established subjective and objective assessment methods as well as a schedule for the challenge procedure. The task force recommends a unified protocol for NAC for daily clinical practice, aiming at eliminating the previous difficulty of comparing NAC results due to unmet needs.

Pollen derived low molecular compounds enhance the human allergen specific immune response in vivo

BACKGROUND

Besides allergens, pollen release bioactive, low molecular weight compounds that modulate and stimulate allergic reactions. Clinical relevance of these substances has not been investigated to date.

OBJECTIVE

To elucidate the effect of a non-allergenic, low molecular weight factors from aqueous birch pollen extracts (Bet-APE < 3 kDa) on the human allergic immune response in vivo.

METHODS

Birch and grass pollen allergic individuals underwent skin prick testing with allergen alone, allergen plus Bet-APE < 3 kDa, or allergen plus pre-identified candidate substances from low molecular pollen fraction. Nasal allergen challenges were performed in non-atopic and pollen allergic individuals using a 3 day repeated threshold challenge battery. Subjects were either exposed to allergen alone or to allergen plus Bet-APE< 3 kDa. Local cytokine levels, nasal secretion weights, nasal congestion and symptom scores were determined.

RESULTS

Skin prick test reactions to pollen elicited larger weals when allergens were tested together with the low molecular weight compounds from pollen. Similar results were obtained with candidate pollen-associated lipid mediators. In nasal lining fluids of allergic patients challenged with allergen plus Bet-APE < 3 kDa, IL-8 and IgE was significantly increased as compared to allergen-only challenged patients. These patients also produced increased amounts of total nasal secretion and reported more severe rhinorrhea than the allergen-only challenged group.

CONCLUSIONS

Low molecular compounds from pollen enhance the allergen specific immune response in the skin and nose. They are therefore of potential clinical relevance in allergic patients.

Biological effects of inhaled nitrogen dioxide in healthy human subjects

PURPOSE

Several epidemiological studies indicate that inhaled nitrogen dioxide (NO2) at low concentrations have been statistically associated with adverse health effects. However, these results are not reflected by exposure studies in humans. The aim of the study was to assess the acute functional and cellular responses to different NO2 concentrations in healthy human subjects with various techniques.

METHODS

Twenty-five subjects were exposed for 3 h to NO2 concentrations 0, 0.1, 0.5, and 1.5 ppm in a randomized crossover study design during 4 consecutive weeks. In each subject, lung function, diffusion capacity and exhaled nitric oxide were measured and inflammation markers were assessed in blood, nasal secretions, induced sputum and exhaled breath condensate.

RESULTS

From all lung function indices under consideration, only intrathoracic gas volume was borderline significantly increased after 0.5 ppm (p = 0.048) compared to 0.1 ppm NO2. Regarding the cellular effect parameters, the macrophage concentration in induced sputum decreased with increasing NO2 concentration, although these changes were only borderline significant (p = 0.05).

CONCLUSION

These results do not suggest a considerable acute adverse response in human subjects after 3 h of exposure to NO2 in the NO2 concentration range investigated in this study.

Nasal levels of soluble IL-33R ST2 and IL-16 in allergic rhinitis: inverse correlation trends with disease severity

BACKGROUND

Serum levels of IL-16, IL-33 and the decoy receptor of IL-33, soluble ST2, are elevated in allergic rhinitis. Recent studies show that IL-16, soluble ST2 or anti-IL-33 reduce type 2 cytokines (such as IL-5) and eosinophilia in murine models of allergic asthma or allergic rhinitis respectively.

OBJECTIVE

In this study, we studied the release of IL-5, IL-16, IL-33 and soluble ST2 in allergic rhinitis patients after nasal allergen challenge and natural pollen exposure.

METHODS

The nasal lavages of 15 allergic and 14 non-allergic volunteers were collected during the pollen allergy season. In addition, six allergic volunteers underwent unilateral nasal allergen and control challenge out of season and nasal secretions and sera were collected. IL-5, IL-16, IL-33 and soluble ST2 in nasal secretions and sera were measured by electrochemiluminescent assay or ELISA, respectively.

RESULTS

Nasal IL-5, IL-16 and soluble ST2 levels were significantly increased in seasonally pollen exposed allergic volunteers compared to control subjects (P < 0.001, P = 0.018 and P = 0.002 respectively), whereas IL-33 remained undetectable. Nasal IL-16 showed a weak inverse correlation trend with nasal symptoms (r = -0.48, P = 0.07). Nasal soluble ST2 concentrations were inversely correlated with nasal symptoms (r = -0.61, P = 0.02) and positively correlated with IL-16 (r = 0.56, P = 0.03). Significant increases of nasal IL-5, IL-16 and ST2 but not IL-33 were observed after nasal allergen challenge. At 24 h after allergen challenge, local ST2 and IL-5 concentrations showed an inverse correlation trend (r = -0.83, P = 0.04). Serum levels of IL-5, IL-16 and soluble ST2 rose in at least five of six volunteers tested at 5 or 24 h post-challenge.

CONCLUSIONS AND CLINICAL RELEVANCE

The observed upregulation of soluble ST2 and IL-16 after nasal allergen challenge and during peak pollination season suggests potential regulatory roles of these cytokines in the inflammatory reaction in allergic rhinitis.

[The usefulness of elastase measurement in the sperm for the diagnosis of urogenital male inflammation and infection]

BACKGROUND

Genital tract inflammation is a frequent cause of infertility among men, usually clinically silent with only leukocytospermia defined as the presence of white blood cells (WBC)>1.106/ml in semen. During the inflammation process, granulocytes discharge large amounts of proteases such as elastase. The elastase linked to its inhibitor in the form of a complex the elastase α1-protease inhibitor in semen is suggested as a potential marker of genital tract inflammation.

AIM

To assess the measurement of elastase as a biomarker of genital tract inflammation by comparing this technique with the detection of leukocytospermia according to the WHO guidelines.

METHODS

This study interested 83 infertile men attending the andrology center for semen analysis. Leukocytospermia was assessed by a peroxydase test and elastase concentration by immunoassay in the seminal plasma.

RESULTS

An elevated elastase was found in 38% of men. A similarity was found between leukocytospermia and elastase in 79% of cases, kappa coefficient concordance with leukocytospermia is good (0.78). The sensitivity of the elastase is 100%, the specificity= 75%. The positive predictive value is 47%, the negative predictive value is 100% with a Youden index=0.75. All patients with leukocytospermia>1.106/ml had an elastase>250ng/ml, 73% of them a concentration>1000 ng/ml. In the group of patients with no leucocytospermia, 75% had elastase<250ng/ml, 21% had concentration between 250 and 1000ng/ml and 4% (3 patients) a concentration>1000ng/ml.

CONCLUSION

Seminal elastase is a more sensitive marker than leucocytospermia in the diagnosis of male urogenital inflammation and infection.

Evaluation of parotid gland lesions with standard ultrasound, color duplex sonography, sonoelastography, and acoustic radiation force impulse imaging - a pilot study

PURPOSE

To evaluate the impact of standard ultrasound (US), color duplex sonography (CDS), sonoelastography (SE), and acoustic radiation force impulse (ARFI) imaging in the differentiation of parotid gland lesions.

MATERIALS AND METHODS

From September 2010 to February 2011, 33 parotid gland lesions of 32 patients were included in this study. Patients underwent high-resolution B-mode US (THI, 9 - 14 MHz), CDS, SE, and ARFI quantification. Then parotidectomy was performed and samples were analyzed by (immuno-) histology. Data was extracted via unpaired t-test and expressed in p-values.

RESULTS

There were 12 Wathin's tumors (WT), 11 pleomorphic adenomas (PA), 3 other benign tumors, 3 ductal dilatations, 2 neuroendocrine carcinomas, 1 non-Hodgkin lymphoma, and 1 malignant melanoma metastasis. In B-mode US, acoustic enhancement showed statistical significance between PA and WT (p < 0.005), and CDS determined different vascularization patterns (p < 0.0005). While SE did not visualize any significant difference between PA and WT, ARFI quantification determined different mean values for both entities (p < 0.003).

CONCLUSION

B-mode US, CDS, and ARFI quantification distinguish PA from WT. The predictive value of the modern techniques for the differentiation of benign and malignant parotid lesions has to be assessed in a larger series.

Influence of implant bed preparation using an Er:YAG laser on the osseointegration of titanium implants: a histomorphometrical study in dogs

The aim of the present study was to evaluate the influence of implant bed preparation using an Er:YAG laser on the osseointegration of titanium implants. A total of 24 implant channels were prepared in the lower jaws of four beagle dogs using (i) an Er:YAG laser device (ERL), or (ii) conventional drills (CD) according to a split-mouth design (n=6 implant channels per animal). Three screw-type titanium implants of different manufacturers were randomly inserted in both groups to evaluate submerged healing at 2 and 12 weeks. Width of the peri-implant gap (WPG) and bone-to-implant contact (BIC) were assessed histomorphometrically. There were no identifiable signs of any thermal side effects in both groups. ERL osteotomy frequently resulted in wide peri-implant gaps particularly in the apical area of the implant supporting bone. The following mean scores were assessed (+/-s.d.): WPG (2 weeks): ERL: 0.89+/-0.48 mm; CD: 0.27+/-0.09 mm (P<0.001 respectively); BIC (2 weeks): ERL: 34.5+/-7.76%; CD: 48.5+/-11.08% (P<0.001 respectively); BIC (12 weeks): ERL: 64.1+/-8.97%; CD: 68.94+/-11.23% (P>0.05 respectively). Within the limits of the present study, it was concluded that ERL may represent a promising tool for implant bed preparation.

[MALT lymphoma of the orbit]

MALT lymphomas of the orbit are rare orbital tumors; the differential diagnosis needs to exclude inflammatory pseudotumors of the orbit, but also benign lymphoproliferations, pseudolymphomas, and other orbital neoplasms. After histological confirmation of the diagnosis staging is necessary, and - as long as the disease is localized exclusively in the orbit - radiation therapy should be started. The clinical picture of MALT lymphoma and its differential diagnosis and treatment are discussed with reference to an actual case.

Total knee arthroplasty implanted with and without kinematic navigation

Between September 2000 and February 2002 we inserted 120 total knee arthroplasties. In 60 patients we used the standard technique, and in 60 patients we used the OrthoPilot navigation system. Postoperatively all patients had standing long radiographs of the lower extremity from the hip joint to the ankle. We considered the ideal value of the anatomic lateral tibiofemoral angle (LTFA) to be 174 degrees. In the standard group the mean value of LTFA was 174.9 degrees and in the navigation group 174.3 degrees. A deviation between 0 degrees and 2 degrees from the ideal value was seen in 42 cases in the standard group and in 53 cases in the navigation group. In the standard group 18 cases had a deviation of more than 2.1 degrees, whereas there were only seven cases in the navigation group with a deviation exceeding 2.1 degrees. There were no complications related to the use of the navigation system. The system affords a possibility to place femoral and tibial components precisely with less axis deviation than with the conventional technique.

Fertilité après cure hystéroscopique de synéchie

OBJECTIVE

The main aim of the study was to evaluate the efficacy of hysteroscopy in the treatment of intra-uterine adhesions with infertility.

PATIENTS AND METHODS

This retrospective study of patients with uterine synechias treated exclusively hysteroscopically included 120 cases: 109 of them (90.8%) low fertility patients, 110 (91.7%) with menstrual disorders and 2 (1.7%) with no others symptoms. Mean age was 34 years (range: 21-45 years). Operative hysteroscopy was performed in 155 cases including electrosection in 124 cases (80%) and a collapse in 31 cases (20%). A single endoscopic procedure was performed in 96 patients, 2 procedures in 17 patients, 3 in 3 patients and 4 in 4 patients. Mean follow-up was 26.8 months (range: 6-52 months).

RESULTS

Good anatomic results were achieved in 116 patients (96.7%) after 1, 2 or 3 hysteroscopic procedures. We obtained good results in 58.2% of the patients with menstrual disorders. One pregnancy was achieved in 49 of patients (44.9%) including: 35 childbirth, 13 abortions and 1 molar pregnancy.

DISCUSSION AND CONCLUSION

Hysteroscopy, easy procedure, allowing reproducible treatment with low morbidity should be proposed as first intention treatment in all cases with synechia. Fertility prognosis is tightly related to the gravity of synechia and its topography.

[Sport-related spiral fractures of the humeral diaphysis are not simple injuries]

OBJECTIVE

The objective of the submitted paper is to demonstrate the results of sports fractures of the diaphysis of the humerus and possible complications.

METHOD

During a five-year period 18 men were followed up and treated during hospitalization with a spiral fracture of the diaphysis of the humerus. Their average age was 31.3 years. The mechanism of injury was in all rotational. In ten instances a fracture contracted during a "levered" fight was involved, in the remaining eight patients the cause of fracture was a fall from a bicycle or occurred during skiing. Five patients were not operated because the position of the fragments was favourable. In the remaining patients osteosynthesis was performed. An intramedullary nail was used in 7 and osteosynthesis by means of a splint in 6. The function of the shoulder joint and elbow was evaluated and compared with the sound side, as well as the muscular strength and subjective feeling of the patients.

RESULTS

In all conservatively treated cases the fracture healed. The original function of the extremity was fully restored. In operated patients three times a pseudoarthrosis developed which was treated by surgical revision and four times injuries of the radial nerve. The subsequent rehabilitation was however quicker and in all instances complete function was achieved.

CONCLUSIONS

The majority of spiral fractures of the humerus heals after conservative treatment. Early functional treatment is essential for preserving the function of the affected extremity. Surgical treatment should be indicated carefully and the radial nerve should be carefully protected.

[Uterine adenomyosis. Clinical and therapeutic study. Report of 87 cases]

STUDY OBJECTIVE

The aim of our study is the analysis of Pound epidemiological, clinical, paraclinical and therapeutic aspects of adenomyosis.

METHODS

A retrospective analysis was carried out on 87 patients who underwent hysterectomy for a variety of reasons (except for prolapse) between January 1, 1990, and December 31, 1997; and whose Histologic analysis of hysterectomy specimen revealed adenomyosis.

RESULTS

586 hysterectomy (except prolapse) was performed during the study period: frequency of adenomyosis in hysterectomy specimen is of 14.85%. The mean age of our patients is 43.97 years (Range: 26-64 years). 29.88% of them are postmenopausal and 41.37% had a past history of uterine trauma. Main symptoms were pelvic pain (71.22%) and abnormal uterine bleeding (82.77%). Preoperative diagnosis has been suspected on hysteroscopy in 63.22% of cases, hysterography in 58.46% and transvaginal sonography in 40.5%. A radical surgery first has been indicated in 57 cases, after failure of medical treatment in 16 cases and after failure of endometrial resection in 14 cases. Histologic analysis of the hysterectomy specimen shows associated myoma in 32.18% of cases, hyperplasia in 13.79%, polyps in 5.74% and atrophy in 3.44%.

CONCLUSION

Adenomyosis, enigmatic disease, escapes always to a well-codified therapeutic strategy and bound closely related to hysterectomy. Earliest diagnosis could avoid the systematic evolution toward the radical treatments.

[Description of Phlebotomus (Synphlebotomus) saltiae n. sp. (Diptera-Psychodidae) of Lebanon]

Description of the male holotype and of the female of phlebotomus (Synphlebotomus) saltiae n. sp.. Morphological comparison with other Synphlebotomus previously described. Hypothesis on the origin of the species and its vectorial status in leishmaniasis.

[Etiological study of acute gastroenteritis in children in Tunisia]

This study was aimed at identifying the relative importance of the various agents responsible for gastroenteritis and to contribute to the etiopathogeny of this condition. Four hundred and two samples of stools of patients and 209 of control subjects, all under 3 years of age, were submitted to bacteriological, parasitologic and virologic examinations. An enteral etiology of gastroenteritis was found in 50% of the children. It consisted of enteropathogenic bacteria in 11%, rotaviruses in 29% and both associated in 19% of cases. There was a significant difference between patients and controls for bacterial (p less than 0.0001) and viral (p less than 0.00001) infestation. The most frequently isolated bacteria consisted overall of Escherichia coli. Eighty-seven isolated strains of E. Coli were tested for their enterotoxinogenic capacities. Four strains were bearing the attachment factor (EAF) and 14 were toxinogenic. Shiga-like toxin (or vero toxin) was detected in 4 strains. Campylobacter was isolated as frequently in patients as in controls and was often associated with other bacteria or rotaviruses. The presence of parasites and candidas was not significantly different in patients and in controls. Giardia intestinalis was the most frequently isolated parasite.