Becoming a neurosurgeon in France: A qualitative study from the trainees' perspective

Introduction

The training of neurosurgeons is evolving in a world of socio-professional changes, including the technological revolution, administrative pressure on stakeholders, reduced working hours, geographical heterogeneity, generational changes, to name but a few.

Research question

This qualitative study aimed to explore experiences and feedback of French neurosurgical trainees concerning their training.

Material and methods

The grounded theory approach was used with 23 neurosurgical trainees' interviews. Inclusion was continued until data saturation. Six researchers (an anthropologist, a psychiatrist, and four neurosurgeons) thematically and independently analyzed data collected through anonymized interviews.

Results

Data analysis identified three superordinate themes: (1) The Trainee-Senior Dyad, where the respondents describe a similar bipolarity between trainees and faculty (trainees oscillating between those who fit into the system and those who are more reluctant to accept hierarchy, faculty using an ideal pedagogy while others refuse to help or invest in training); (2) The difficulty to learn (describing pressure exercised on trainees that can alter their motivation and degrade their training, including the impact of administrative tasks); (3) A pedagogy of empowerment (trainee' feelings about the pertinent pedagogy in the OR, ideal sequence to progress, progressive empowerment especially during the shifts, and stress of envisioning themselves as a senior neurosurgeon).

Discussion and conclusion

Respondents emphasize the heterogeneity of their training both intra- and inter-university-hospital. Their critical analysis, as well as the formalization of their stress to become autonomous seniors, can be an important link with the reforms and optimizations currently being carried out to improve and standardize the training of young French neurosurgeons.

Personal and psychosocial factors of burnout: A survey within the French neurosurgical community

Object

The neurosurgical community is particularly exposed to burnout. The objectives of this study were to report the prevalence and associated factors of burnout within the French neurosurgical community using validated academic and psychologic scales.

Methods

A national survey was sent to 141 French residents and 432 neurosurgeons between April and July 2019. Burnout was surveyed using the Maslach burnout inventory. The survey included demographic data and several academic psychologic scales. A stepwise multiple regression was used to determine factors that are associated with burnout scores.

Results

The response rate was 100% and 23.6% for residents and neurosurgeons, respectively. Prevalence of burnout within the French neurosurgical community was 49%. There were no significant differences between residents and neurosurgeons. Two categories of factors were associated with the main dimensions of burnout during the stepwise multiple regression: personality and factors related with neurosurgical practice. Personality types such as neuroticism were negatively associated with burnout while agreeableness was protective. Work addictive profile with excessive work and absorption at work were negatively associated. Factors associated with neurosurgical practice such as conflict of work into family life, unbalanced effort to reward ratio, work duration were negatively associated. Pleasure at work was protective.

Conclusion

Prevalence of burnout is high among French neurosurgeons. Predictive models can be used to identify and prevent burnout among profiles at risk.

Functional atlases for analysis of motor and neuropsychological outcomes after medial globus pallidus and subthalamic stimulation

Anatomical atlases have been developed to improve the targeting of basal ganglia in deep brain stimulation. However, the sole anatomy cannot predict the functional outcome of this surgery. Deep brain stimulation is often a compromise between several functional outcomes: motor, fluency and neuropsychological outcomes in particular. In this study, we have developed anatomo-clinical atlases for the targeting of subthalamic and medial globus pallidus deep brain stimulation. The activated electrode coordinates of 42 patients implanted in the subthalamic nucleus and 29 patients in the medial globus pallidus were studied. The atlas was built using the representation of the volume of tissue theoretically activated by the stimulation. The UPDRS score was used to represent the motor outcome. The Stroop test was represented as well as semantic and phonemic fluencies. For the subthalamic nucleus, best motor outcomes were obtained when the supero-lateral part of the nucleus was stimulated whereas the semantic fluency was impaired in this same region. For the medial globus pallidus, best outcomes were obtained when the postero ventral part of the nucleus was stimulated whereas the phonemic fluency was impaired in this same region. There was no significant neuropsychological impairment. We have proposed new anatomo-clinical atlases to visualize the motor and neuropsychological consequences at 6 months of subthalamic nucleus and pallidal stimulation in patients with Parkinson's disease.

An update on the management of sporadic desmoid-type fibromatosis: a European Consensus Initiative between Sarcoma PAtients EuroNet (SPAEN) and European Organization for Research and Treatment of Cancer (EORTC)/Soft Tissue and Bone Sarcoma Group (STBSG)

Desmoid-type fibromatosis is a rare and locally aggressive monoclonal, fibroblastic proliferation characterized by a variable and often unpredictable clinical course. Currently, there is no established or evidence-based treatment approach available for this disease. Therefore, in 2015 the European Desmoid Working Group published a position paper giving recommendations on the treatment of this intriguing disease. Here, we present an update of this consensus approach based on professionals' AND patients' expertise following a round table meeting bringing together sarcoma experts from the European Organization for Research and Treatment of Cancer/Soft Tissue and Bone Sarcoma Group with patients and patient advocates from Sarcoma PAtients EuroNet. In this paper, we focus on new findings regarding the prognostic value of mutational analysis in desmoid-type fibromatosis patients and new systemic treatment options.

Should Treatment of Highly Differentiated Thyroid Carcinoma Be Conservative?

On the basis of three selected cases (one with clinically occult follicular and two with metastatic papillary carcinoma) the necessity of a comprehensive therapeutic concept even in highly differentiated thyroid cancer is stressed. Thyroid tissue and regional metastases should be eliminated by surgery, followed by radioiodine therapy in any event. Radiation teletherapy should be reserved to patients with invasive tumor growth exceeding the organ capsule, with lymph node metastases, and with massive angioinvasive growth.

A compact electron cyclotron resonance proton source for the Paul Scherrer Institute's proton accelerator facility

A compact electron cyclotron resonance proton source has been developed and installed recently at the Paul Scherrer Institute's high intensity proton accelerator. Operation at the ion source test stand and the accelerator demonstrates a high reliability and stability of the new source. When operated at a 10-12  mA net proton current the lifetime of the source exceeds 2000 h. The essential development steps towards the observed performance are described.

Flavor decomposition of the sea-quark helicity distributions in the nucleon from semiinclusive deep inelastic scattering

Double-spin asymmetries of semiinclusive cross sections for the production of identified pions and kaons have been measured in deep inelastic scattering of polarized positrons on a polarized deuterium target. Five helicity distributions including those for three sea quark flavors were extracted from these data together with reanalyzed previous data for identified pions from a hydrogen target. These distributions are consistent with zero for all three sea flavors. A recently predicted flavor asymmetry in the polarization of the light quark sea appears to be disfavored by the data.

Evidence for quark-hadron duality in the proton spin asymmetry A1

Spin-dependent lepton-nucleon scattering data have been used to investigate the validity of the concept of quark-hadron duality for the spin asymmetry A1. Longitudinally polarized positrons were scattered off a longitudinally polarized hydrogen target for values of Q2 between 1.2 and 12 GeV2 and values of W2 between 1 and 4 GeV2. The average double-spin asymmetry in the nucleon resonance region is found to agree with that measured in deep-inelastic scattering at the same values of the Bjorken scaling variable x. This finding implies that the description of A1 in terms of quark degrees of freedom is valid also in the nucleon resonance region for values of Q2 above 1.6 GeV2.

Q2 dependence of nuclear transparency for exclusive rho0 production

Exclusive coherent and incoherent electroproduction of the rho(0) meson from 1H and 14N targets has been studied at the HERMES experiment as a function of coherence length (l(c)), corresponding to the lifetime of hadronic fluctuations of the virtual photon, and squared four-momentum of the virtual photon (-Q2). The ratio of 14N to 1H cross sections per nucleon, called nuclear transparency, was found to increase (decrease) with increasing l(c) for coherent (incoherent) rho(0) electroproduction. For fixed l(c), a rise of nuclear transparency with Q2 is observed for both coherent and incoherent rho(0) production, which is in agreement with theoretical calculations of color transparency.

Evidence for a single-spin azimuthal asymmetry in semi-inclusive pion electroproduction

Single-spin asymmetries for semi-inclusive pion production in deep-inelastic scattering have been measured for the first time. A significant target-spin asymmetry of the distribution in the azimuthal angle straight phi of the pion relative to the lepton scattering plane was formed for pi(+) electroproduction on a longitudinally polarized hydrogen target. The corresponding analyzing power in the sinstraight phi moment of the cross section is 0.022+/-0.005+/-0.003. This result can be interpreted as the effect of terms in the cross section involving chiral-odd spin distribution functions in combination with a chiral-odd fragmentation function that is sensitive to the transverse polarization of the fragmenting quark.

Modified T-cell activation pattern during specific immunotherapy (SIT) in cat-allergic patients

OBJECTIVE

The aim of the study was to analyse early effects of specific immunotherapy (SIT) on immune functions in cat-allergic patients.

METHODS

Immunological responses of peripheral blood mononuclear cells from eight cat-allergic patients were analysed before and after SIT in comparison with 11 nonallergic controls. Cells were stimulated in vitro with either bacterial superantigen, mitogen, or cat allergen. Production of IL-12 and TH1/TH2 cytokines was analysed by ELISA and lymphocyte subset distribution was assessed by flow-cytometry.

RESULTS

We found a significantly reduced secretion of IL-12 (P < 0.05) from cells of allergic individuals compared with the controls. This finding was associated with significantly lower IFN-gamma production after stimulation with allergen (P < 0.05) that did not increase during SIT. However, no significant differences were seen after stimulation with mitogen indicating an allergen specific IFN-gamma secretion response in allergic individuals. Prior to SIT IL-5 production was significantly higher in cells of allergic donors stimulated with allergen < 0.005 or mitogen (< 0.05). After reaching the maintenance dose for SIT, allergen-induced IL-5 production returned to normal levels, whereas it remained elevated after stimulation with mitogen. These changes were associated with a reduced frequency of CD45 RO T cells following SIT.

CONCLUSION

These results suggest that SIT exerts early effects on allergen-specific T-cell responses with selective inhibition of the up-regulated TH2 immune response.

Tree-pollen allergy is efficiently treated by short-term immunotherapy (STI) with seven preseasonal injections of molecular standardized allergens

The efficacy and tolerance of short-term immunotherapy (STI) by seven preseasonal injections of tree-pollen allergens (ALK7 Frühblühermischung) was investigated in a double-blind, placebo-controlled, multicenter study with 111 rhinoconjunctivitis patients. Nasal and bronchial symptoms simultaneously analyzed, and nasal symptoms as a single end point, but not the overall score of nasal, bronchial, and conjunctival symptoms, showed a significantly lower increase with STI during birch-pollen exposure (both P=0.033, n=105, Mann-Whitney U-test). However, a selective analysis with patients from centers with high recruitment figures (n> or =10 patients, n=29 STI, n=32 placebo) showed a significantly lower increase of nasal, bronchial, and overall symptom score (STI 11.0 vs placebo 18.0, P=0.001, U-test). STI had equidirected effects on conjunctival, nasal, and bronchial symptoms analyzed as multiple end points, although conjunctival symptoms were not significantly different as a single end point. The seasonal increase in drug use was reduced by 62% in the STI group compared with placebo (P=0.032, t-test). Specific IgG4 increased only after STI (P<0.001); IgE was not significantly different. Eosinophil cationic protein remained unchanged with STI, but significantly increased with placebo in the pollen season (P=0.003). STI was well tolerated. In conclusion, STI was shown to be efficacious and safe for the treatment of patients with tree-pollen rhinoconjunctivitis.

A subset of CD8+ T cells from allergic patients produce IL-4 and stimulate IgE production in vitro

BACKGROUND AND OBJECTIVE

A subset of IL-4 producing CD8+ T cells was recently identified in HIV patients. Based on these findings we examined whether IL-4 producing CD8+ T cells would also be present in allergic patients and what would be the functional relevance of this T-cell population.

METHODS

We investigated the role of CD8+ T cells in IgE production of allergic diseases by analysing the cytokine profile of individual CD4+ and CD8+ T cells.

RESULTS

In allergic patients about twice as many CD4+ T cells and six times as many CD8+ T cells produced IL-4 as in non-allergic controls. In contrast the frequency of IFNgamma+ T-cell subsets did not significantly differ between the allergic and non-allergic individuals. The frequency of IL4+ CD8+ T cells correlated with the level of serum IgE. Coculture experiments with T cells or purified CD8+ T cells together with autologous B cells indicated that CD8+ T cells enhanced IgE in vitro, but not IgM production, even when they were physically separated from B cells. This effect could be partially blocked by addition of an IL-4 binding protein, a soluble IL-4 receptor indicating that IL-4 is involved in CD8+ T-cell mediated IgE production.

CONCLUSIONS

These data indicate a positive role of IL-4 secreting CD8+ T cells in IgE regulation in allergic patients.

Short-term immunotherapy: a prospective, randomized, double-blind, placebo-controlled multicenter study of molecular standardized grass and rye allergens in patients with grass pollen-induced allergic rhinitis

BACKGROUND

Short-term immunotherapy (STI) can be beneficial for patients who are noncompliant with long-term specific immunotherapy.

OBJECTIVE

The efficacy and tolerance of STI with seven preseasonal injections of molecular standardized allergens from grass and rye pollen has been investigated in a double-blind, placebo-controlled multicenter study with 87 patients at 12 German University hospitals.

METHODS

Symptoms of the eyes, nose, and bronchi and use of symptomatic drugs were documented daily in diaries by patients with allergic rhinitis to grass and/or rye pollen and without bronchial asthma. Patients were monitored by skin prick test titration and measurement of levels of specific IgE and IgG4.

RESULTS

The median nasal score for the 10 weeks with the strongest symptoms during the grass pollen season was significantly lower (p = 0.014) with 35.0 for STI (n = 41) versus 69.0 for placebo (n = 40); the overall symptom score was 54.0 for STI versus 97.5 for placebo (p = 0.020). Only STI-treated patients exposed to less than 40 pollen grains per cubic meter per week showed a significantly lower nasal symptom score of 39.0 versus 75.0 for placebo (p = 0.006); these patients also had fewer nasal symptoms and less use of topical nasal drugs (p < 0.001). The threshold dose in skin prick tests was significantly higher, being 9.06 histamine equivalent for skin prick test (HEP) for STI-treated patients who received the maximum dose (n = 22) versus 4.33 HEP for placebo (p = 0.005). Specific IgE levels were significantly higher, being 55.9 SU/ml for STI versus 39.2 SU/ml for placebo after seven injections (p = 0.006) and level of specific IgG4 was 5.36% for STI versus 1.28% for placebo (p < 0.001). No severe systemic reactions were observed.

CONCLUSION

STI with seven preseasonal injections with molecular standardized allergens is effective and well tolerated.

[Bradykinin level in bronchoalveolar lavage fluid in patients with extrinsic allergic alveolitis]

The presence of kinins in the tracheobronchial tree and their pharmacological properties would suggest that these peptides are involved in inflammatory responses of the airway and lungs. The aim of the study was the estimation the bradykinin level in bronchoalveolar lavage fluid (BAL) in patients with extrinsic allergic alveolitis. The investigated group consisted of 12 patients with farmers lung and a control group, of 9 healthy individuals. The statistically significant higher bradykinin concentration was found in patients BAL fluid than in the controls (675 +/- 472 pg/ml v.s., 220 +/- 57 pg/ml). No relationship was found between bradykinin level and BAL fluid cellularity and pulmonary function parameters. High levels of bradykinin in BAL fluid may suggest the increase of alveolo-capillary membrane permeability.

[Identification of wood splinters in soft tissues with ultrasound]

Two cases of wooden foreign bodies in soft tissue found by ultrasound are described. Furthermore we proved the existence of a typical sonographic pattern of wood in muscle tissue.

Effect of azelastine on substance P content in bronchoalveolar and nasal lavage fluids of patients with allergic asthma

The study was carried out to investigate the effect of azelastine on the Substance P (SP) concentration in bronchoalveolar (BAL) and nasal (NAL) lavage obtained from atopic grass pollen asthmatics and non-atopic healthy subjects. In BAL and NAL fluids there was a significant elevation in the baseline concentration of SP between asthmatics and volunteers. Allergen provocation induced a rise of SP in BAL and NAL in asthmatics, but not in volunteers. Azelastine pre-treatment resulted in a significant reduction of SP in baseline concentration of SP in BAL and NAL from asthmatics. An elevation of SP in BAL or NAL fluids after allergen provocation was not seen in asthmatics pretreated with azelastine. Azelastine did not influence the SP concentration in BAL and NAL of volunteers.

[Familial primary generalized epilepsy and drug (anticonvulsant)-induced systemic lupus erythematosus--a family study]

We report a 12-year study of a family with high mortality rate due to primary generalized epilepsy. During indicated and non-indicated therapy with anticonvulsive drugs (succinimides and hydantoines) there developed symptoms of systematic lupus erythematosus. The value of controlled immunological and genetic markers is discussed.

Suppressive effect of loratadine on allergen-induced histamine release in the nose

It has been speculated whether the recently developed non-sedating antihistamines may possess other properties than merely being antagonists at the H1-receptors. To investigate this suggestion 12 patients with strictly seasonal allergic rhinitis participated in a double-blind placebo controlled randomized cross-over study outside the pollen season. At steady state levels of 10 mg loratadine, a new non-sedating antihistamine, the patients were challenged with methacholine. This was followed by a nasal challenge with increasing doses of allergen. 24 h later the patients were rechallenged nasally with the same methacholine dose as the day before. The volume of the methacholine-induced nasal secretion was measured and the response to allergen was determined by scoring technique. In returned nasal lavage fluid the levels of histamine and TAME-esterase activity were measured. It was found that loratadine significantly reduced the immediate allergic nasal symptoms compared with placebo (P less than 0.01). Loratadine also reduced the allergen-induced release of histamine into the nasal cavity after the strongest allergen dose, from 9.6 +/- 1.5 (mean +/- SEM) to 6.4 +/- 1.4 ng/ml (P less than 0.05). A similar decrease in the TAME-esterase activity after treatment with loratadine was observed. The TAME-esterase activity decreased from 11.6 *10(3) +/- 2.47 *10(3) to 5.60 *10(3) +/- 1.45 *10(3) CMP (P less than 0.05). There were no significant changes between the active and placebo treatments regarding the methacholine-induced secretory response. This was true for the initial methacholine challenge as well as the secretory response 24 h later.(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma exudation as a first line respiratory mucosal defence

A great variety of provocations of the airway mucosa produce extravasation of plasma from the abundant subepithelial microvessels. A plasma exudate has important actions through its volume, its specific and unspecific binding proteins, its enzyme systems, and its potent peptides (of kinin, complement, coagulation, fibrinolysis and other systems). If allowed to operate on the surface of an intact mucosa the plasma exudate would have important roles in normal airway defence. Recent observations in guinea-pig tracheobronchial airways and in human nasal airways suggest that the mucosal exudation of plasma into the airway lumen is a non-injurious fully reversible process. Threshold exudative responses thus resulted in the appearance of an 'unfiltered' plasma exudate not only in the lamina propria but also on the surface of an undisrupted mucosa. Even after extensive luminal entry of exudate the epithelial lining was intact, as judged by light, fluorescence and electron microscopy. Hence, the epithelial barrier was reversibly permeable when approached from beneath by the plasma exudate. This was a distinct increase in outward permeability, because even during the exudation of plasma the mucosa remained a barrier to luminal solutes. It is possible that the exudate itself, by a slight compressive action on the basolateral aspect of epithelial cells, creates intercellular pathways for its entry into the lumen. Contrary to current beliefs, we propose that plasma exudation should be considered a first line respiratory defence mechanism operating together with other systems of the mucosal surface.

The possible role of substance P in the allergic reaction, based on two different provocation models

It was shown in two different provocation models (nasal and bronchial provocation) that substance P (SP) may play an important role in the neurogenic inflammatory response in upper and lower airway disease. (1) Pretreatment with SP augments the antigen challenge response of the nasal mucosa. (2) The baseline bronchoalveolar lavage (BAL) concentrations of SP are elevated 8-fold in allergies (pollen asthma) as compared with normals, even outside of season. (3) The SP concentration in BAL increases significantly (p less than 0.05) after bronchial allergen provocation. These findings support a previous hypothesis of an abnormally elevated activity of nonadrenergic-noncholinergic excitatory nerves and are in accordance with the results of a decreased activity of neutral endopeptidase exaggerating neurogenic inflammatory responses in the airways, including bronchomotor tone hyperresponsiveness.

Presence of vasoactive intestinal peptide receptors in nasal mucosa

In recent years several tachykinins have been identified in the airway sensory nerves. Since the physiological and pathophysiological effects of neuropeptides depend on their functionally relevant concentrations and presence of specific receptors in the target tissue, specimens of enlarged turbinates and nasal polyps were removed in 11 patients and examined for the presence of vasoactive intestinal peptide (VIP) receptors. An intensive color reaction was observed in the cytoplasm of the tubular mucosa cells in polyps and turbinates as well as in the epithelium and submucosal glands. Since both these tissues reacted with VIP receptor antibody, noncross-reacting antibody against dendritic reticular cells (DRC 6-B7), nonspecific binding is possible, however it also must be speculated that the unspecific binding is overlaying specific binding. In addition a large number of cells located diffusely or in close association in the subepithelium and interstitial tissue stained only with VIP-specific antibody, indicating specific receptor binding. The color reaction is limited to the cell membrane and the cytoplasm of these cells was clearly eosinophilic. These cells were located in close proximity of the blood vessels, very indicative for active migration. Since VIP-positive nerves are also located near the blood vessels an activation process of these cells with subsequent release of enzymes and other active proteins is possible, thus influencing the inflammatory response.

Mediator release during nasal provocation. A model to investigate the pathophysiology of rhinitis

The pathogenesis of rhinitis was investigated using a model of nasal provocation with different types of stimuli. Allergic subjects had an immediate response to antigenic challenge with symptoms of rhinitis highly correlated with increments in the concentrations of histamine, prostaglandin D2, kinins and kininogens, leukotrienes, and toluene sulfonyl arginine methyl ester esterase activity in their nasal secretions. This reaction was abated by a tricyclic antihistamine also capable of inhibiting mediator release from human mast cells in vitro and, in some subjects, by disodium cromoglycate. In a number of patients, symptoms reappeared three to 12 hours after nasal provocation. This late reaction also involves release of all of the aforementioned mediators except for prostaglandin D2, and preliminary data suggest that it can be inhibited by oral or topical steroids. Cold, dry air can induce rhinitis with mast cell mediator release from selected subjects. The pathogenesis of this reaction is unclear, but there are indications that osmolarity changes are responsible for mast cell activation. Thus, mast cells can be induced to release mediators and cause nasal symptoms by both immunologic and physical mechanisms, which may account for the pathophysiology of several types of rhinitis.

Grass pollen allergoid. A 4-year follow-up study

In an open comparative study with 31 grass pollen-allergic patients, two allergen extracts ('allergoid' extract/semi-depot extract) were examined. In the 1st year of treatment the allergoid group showed better results in relation to symptom score, drug consumption and IgG response, however, in the course of further treatment this difference was not evident anymore. Treatment was successful in both groups. A significant correlation between total antigen dose and IgG response was found. The better clinical results for the allergoid group in the first season after the 1st and 4th year of observation do indicate a better long-term therapeutic effect compared to the semi-depot group. This finding probably is due to the much higher antigen dose (4-fold) in the allergoid group.

Should treatment of highly differentiated thyroid carcinoma be conservative?

On the basis of three selected cases (one with clinically occult follicular and two with metastatic papillary carcinoma) the necessity of a comprehensive therapeutic concept even in highly differentiated thyroid cancer is stressed. Thyroid tissue and regional metastases should be eliminated by surgery, followed by radioiodine therapy in any event. Radiation teletherapy should be reserved to patients with invasive tumor growth exceeding the organ capsule, with lymph node metastases, and with massive angioinvasive growth.

The possible role of bradykinin as a mediator in bronchial asthma

A variety of antiasthmatic drugs were examined in a bioassay of uterine cornua of rats for determining their influence upon Bradykinin induced contractions. 4 different actions were seen: pronounced, moderate and weak suppression of enhancement of Bradykinin-activity. The most pronounced blocking effect was seen with Fenoterol, Adrenaline and Pheniramine, a moderate effect with Prednisolone and Tolazoline, a weak effect with Propranolol and DSCG. Noradrenaline showed a stimulating effect. It is postulated that Bradykinin acts via alpha-stimulation with concomitant cAMP-decrease after specific binding to Bradykinin-receptors. The results of the study suggest that Bradykinin still must be discussed as a possible mediator in obstructive airway-disease.

[alpha 1-antitrypsin determination in children with obstructive lung disease (author's transl)]

In 184 children and juvenile with type I respiratory allergies the AAT-content in serum was measured by the rocket technique. The results do show neither disease--nor agedependant changes. The mean of the total was 283 mg%. This value does agree very well with the normal values reported in literature. In 5 patients however (2,71%) of the total collective an intermediary AAT-deficiency was found. This frequency though lies within the percentage of occurrence in non-selected patients. The individual analysis of these cases did not give any valid connection to history, age, lung function, immunoglobulins and course of disease. On the basis of the demonstrated results it can be said, that the determination of AAT in serum patients with type-I-allergy is of no practical diagnostic value.

Histopathological Examinations of nasal polyps of different etiology

A safe differentiation between allergic and non-allergic polyps appears impossible by means of light or electron microscopical examination of polyp tissue. There are some indications, however, which point to the allergic or non-allergic origin and it seems that the relationship between eosinophils and plasma cells with a low index is characteristic for polyps of allergic origin. Eosinophils and round-cell infiltrations are present in all types of polyps. An index of eosinophils to plasma cells below 5 is indicative for allergy and should induce the pathologist to give a hint to the clinican for allergological work-up. An index above 5 is more corresponding with infective etiology. Any changes of the basement membrane, i.e., smaller or larger gaps or even absence, are found only very irregularly and are not typical findings in either way. An increased number of glands and collagenic fibres, especially under the epithelium, are more an expression of the age of the polyp. Since the conservative therapy as mentioned above leads to good therapeutical results, it is desirable that an allergological work-up should be done in any case which shows the histological findings indicative for allergic etiology. Thus, repeated operations with all the risks and uncertain therapeutical benefit can be avoided.

Recovery of pituitary-adrenal axis after withdrawal or reduction of systemic corticosteroids in patients with bronchial asthma

In 36 patients with bronchial asthma a new inhalable corticosteroid (Fluocortin-butyl-ester) was administered to reduce systemic steroids and especially to study the recovery of pituitary-adrenal function. On the basis of the present results, it can be said that patients with the least degree of emphysema and obstruction and with good coughing dynamics and productive expectoration are most suitable for therapy with inhalable corticosteroids. If the systemic steroid reduction is adequate, the recovery phase of the pituitary-adrenocortical system begins after about 5 months and the response to ACTH appraoches normal values after about 8-9 months. About 4 mg prednisolone-equivalent per day can be assumed to be the systemically effective limiting dose. The reducibility as a percentage of the initial dose-regardless of its absolute value- and the maintenance dose achieved also appear to be of equal importance for the recovery of the functional reserve of the pituitary-adrenocortical system. No relationship to the duration of the disease and the initial steroid dose could be demonstrated. The clinical picture of the corticosteroid withdrawal syndrome is dependent on endogenous cortisol synthesis. The symptoms disappear spontaneously with increasing synthesis.

The significance of nasal protease inhibitor concentrations in house dust allergy

In 57 patients with house dust allergy and 20 controls protease inhibitor concentrations in nasal secretions were measured before and after antigen challenge. A correlation was found between low inhibitor levels and long duration of disease. Furthermore, significant differences of inhibitor concentrations could be demonstrated between patients with strong or moderate reactions to antigen provocation, and between patients with isolated rhinitis or a combination of rhinitis and bronchial asthma. The clinical significance of the results will be discussed with special regard to different biochemical mechanisms in the pathophysiology of seasonal and perennial immediate-type rhinitis.

Semi-depot hyposensitization in severe hay fever: its clinical effectiveness and the therapeutic problems. (A four year study using intranasal challenge testing to monitor success)

Hyposensitization treatment for at least two years using pyridine-extracted alum precipitated (PEAP) extracts was carried out on 332 cases of severe hay fever, some of which were steroid dependent. Subjective self-assessment and weekly average use of additional medication were recorded, nasal challenge tests were conducted before and during treatment and related to the clinical picture. Successful treatment was unrelated to age, though distinctly limited where there was a history of more 15 years illness. It was however related to the pollen count from 1973 to 1976 and to the type and number of the antigens to which there was a clinical response. In spite of specific hyposensitization 4,2% of the pollinosis cases developed additional pollen asthma. In the course of treatment there were several instances of an enlargement of the individual antigen spectrum; sensitization to pollen, mould fungi, house dust and animal epithelia were recorded. In a total of 11,850 injections there were severe local reactions in 16,2% rhinoconjunctivitis in 1,6% asthma in 0,4% and urticaria in 0,4%. One female patient went into anaphylactic shock 12 hours after the administration of the antigen extract. In about 20% of the injections granulomas developed, about the size of a cherry-stone, which persisted for up to six months and which in some instances were reactivated by severe exposure to allergens. There was an unusually high percentage of organ and generalised reactions whenever the treatment was continued using a new antigen solution without reducing the dose.

[Early postoperative diagnostic management by arterial-reobstruction after vascular operations using the ultrasonic flowmeter (author's transl)]

The Doppler ultrasonic method can confirm the success of the operation in the early post-operative phase after reconstructive vascular operations as an essential non-invasive technique or clear a doubtful improvement of the blood flow. Thus an arteriography can be indicated in good time. On the basis of reconstructive cases the usefulness and the advantageous application of the Doppler ultrasonic flowmeter in the operating theater is demonstrated.