Machine learning-directed electrical impedance tomography to predict metabolically vulnerable plaques

The characterization of atherosclerotic plaques to predict their vulnerability to rupture remains a diagnostic challenge. Despite existing imaging modalities, none have proven their abilities to identify metabolically active oxidized low-density lipoprotein (oxLDL), a marker of plaque vulnerability. To this end, we developed a machine learning-directed electrochemical impedance spectroscopy (EIS) platform to analyze oxLDL-rich plaques, with immunohistology serving as the ground truth. We fabricated the EIS sensor by affixing a six-point microelectrode configuration onto a silicone balloon catheter and electroplating the surface with platinum black (PtB) to improve the charge transfer efficiency at the electrochemical interface. To demonstrate clinical translation, we deployed the EIS sensor to the coronary arteries of an explanted human heart from a patient undergoing heart transplant and interrogated the atherosclerotic lesions to reconstruct the 3D EIS profiles of oxLDL-rich atherosclerotic plaques in both right coronary and left descending coronary arteries. To establish effective generalization of our methods, we repeated the reconstruction and training process on the common carotid arteries of an unembalmed human cadaver specimen. Our findings indicated that our DenseNet model achieves the most reliable predictions for metabolically vulnerable plaque, yielding an accuracy of 92.59% after 100 epochs of training.

A Novel Three-Dimensional-Printed Ultrasound-Guided Hip Arthrocentesis Model

When evaluating patients with hip pain, clinicians may be trained to both evaluate for a hip effusion and perform ultrasound-guided arthrocentesis to evaluate the etiology of the effusion. We present a novel 3-dimensional-printed hip arthrocentesis model, which can be used to train clinicians to perform both tasks under ultrasound guidance. Our model uses a combination of a 3-dimensional-printed hip joint, as well as readily available materials such as an infant Ambu (Ballerup, Denmark) bag, syringe, intravenous line kit, and silicone. We present our experience so that others may use and adapt our model for their training purposes.

Teaching Endotracheal Intubation Using a Cadaver Versus a Manikin-based Model: a Randomized Controlled Trial

INTRODUCTION

The optimal method to train novice learners to perform endotracheal intubation (ETI) is unknown. The study objective was to compare two models: unembalmed cadaver vs simulation manikin.

METHODS

Fourth-year medical students, stratified by baseline ETI experience, were randomized 1:1 to train on a cadaver or simulation manikin. Students were tested and video recorded on a separate cadaver; two reviewers, blinded to the intervention, assessed the videos. Primary outcome was time to successful ETI, analyzed with a Cox proportional hazards model. Authors also compared percentage of glottic opening (POGO), number of ETI attempts, learner confidence, and satisfaction.

RESULTS

Of 97 students randomized, 78 were included in the final analysis. Median time to ETI did not differ significantly (hazard ratio [HR] 1.1; 95% CI [confidence interval], 0.7-1.8): cadaver group = 34.5 seconds (interquartile ratio [IQR]: 23.3-55.8) vs manikin group = 35.5 seconds (IQR: 23.8-80.5), with no difference in first-pass success (odds ratio [OR] = 1; 95% CI, 0.1-7.5) or median POGO: 80% cadaver vs 90% manikin (95% CI, -14-34%). Satisfaction was higher for cadavers (median difference = 0.5; p = 0.002; 95% CI, 0-1) as was change in student confidence (median difference = 0.5; p = 0.03; 95% CI, 0-1). Students rating their confidence a 5 ("extremely confident") demonstrated decreased time to ETI (HR = 4.2; 95% CI, 1.0-17.2).

CONCLUSION

Manikin and cadaver training models for ETI produced similar time to ETI, POGO, and first-pass success. Cadaver training was associated with increased student satisfaction and confidence; subjects with the highest confidence level demonstrated decreased time to ETI.

Abstract PD6-12: Evaluating racial disparities in breast cancer referrals for hereditary risk assessment

Background: There is a pronounced onco-racial disparity in Washington, D.C., which had the highest national incidence of breast cancer in African Americans (AA) patients in between 2010-2015 and the worst outcomes (American Cancer Society). Recent data indicates a higher incidence of deleterious BRCA1 [and BRCA2] mutations and variants of uncertain significance (VUS) in AA patients compared to Caucasian (C) patients when controlled for patients of Ashkenazi Jewish (AJ) populations (Hall 2009). Despite this, AA women meeting National Comprehensive Cancer Network (NCCN) criteria for genetic testing are less likely to complete such testing compared to C women nationally. Studies have investigated psycho-social drivers of minority patient aversion to genetic testing. We hypothesize that lack of physician referral for cancer genetic counseling and testing for AA women contributes to this disparity.

Methods: The George Washington Cancer Center (GWCC) Registry was used to identify non-Hispanic African Americans (BNH) and non-Hispanic whites (WNH) treated for breast cancer between 2014-2018. Of those individuals selected for inclusion were those who met select NCCN criteria for referral for genetic evaluation including breast cancer diagnosis under age 50, triple negative breast cancer (TNBC) under age 60, and two primary breast cancers. Only BNH and WNH individuals were included. Excluded patients were those who were not BNH or WNH or who did not meet the NCCN criteria listed above. Patients were then stratified by race according to who underwent genetic evaluation, whether at our Ruth Paul Cancer Genetics and Prevention Service (RPCGPS) or elsewhere, by reviewing GWCC, RPCGPS, and patient clinic records for genetic testing results from outside institutions. Patient charts were used to identify individuals who received a physician referral over the course of their cancer care.

Results: 1180 patients were treated at the GWCC for breast cancer (both in situ and invasive carcinoma) between 2014–2018. Of those, BNH n=502; WNH n=435. Twenty-seven percent of BNH and WNH patients met the study criteria for referral for genetic evaluation (n=252; BNH n=115, WNH n=137), including breast cancer diagnosis under age 50 (BNH n=76; WNH n=108), TNBC under age 60 (BNH n=14; WNH n=5), and two primary breast cancers (BNH n=18, WNH n=16). Several patients identified met two or more criteria for referral (BNH n=7, WNH n=8). Physician referral rates differed significantly by race (BNH 76%, n=87 and WNH 91%; n=125; χ2=11.4, p-value<0.001). Of referred patients, there was no significant difference in those who followed-up at RPCGPS by race (BNH 93%, n=81; WNH= 93%, n=116, χ2 =0.0072, p-value=0.93).

Conclusions: Low genetic testing rates for AA breast cancer patients are an impediment to resolving the prominent onco-racial breast cancer disparities. This study identified physician referral as a potential contributor to racial disparity in the utilization of cancer genetics services. Potential reasons for the discrepancy in referral may include lag in physician education on the topic of hereditary risk and barriers in physician-patient communication. These findings need to be confirmed and explored at other sites to help improve the identification of at-risk women in the AA community.

Citation Format: Pepin A, Peterson J, Thomas R, Johnson K, Stark E, Biagi T, Kaltman R. Evaluating racial disparities in breast cancer referrals for hereditary risk assessment [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD6-12.

Evaluation of a Curricular Addition to Assist Medical Students in Specialty Selection

Early hands-on experience with surgical procedures may help medical students make better-informed choices if considering a surgical specialty. Here, we evaluate a curricular addition in surgical anatomy, formally exposing second-year students to different surgical subspecialties. Students met with surgeons for 7 weeks (one afternoon per week) and practiced surgical procedures on human cadavers with supervision. About a quarter of the participants reported a change in their top choice of specialty upon completing the course, and about half of the students reported changes in their second and third choices. At the time of graduation, 85% of those surveyed reported participation in the course impacted their final choice of specialty. These results demonstrate such a course helped medical students select a specialty during early training.

Efficient assembly of multi-color fiberless optoelectrodes with on-board light sources for neural stimulation and recording

Fiberless optoelectrodes are an emerging tool to enable brain circuit mapping by providing precise optical modulation and electrical monitoring of many neurons. While optoelectrodes having an on-board light source offer compact and optically efficient device solutions, many of them fail to provide robust thermal and electrical design to fully exploit the recording capabilities of the device. In this work, we present a novel fiberless multicolor optoelectrode solution, which meets the optical and thermal design requirements of an in vivo neural optoelectrode and offers potential for low-noise neural recording. The total optical loss measured for 405 nm and 635 nm wavelengths through the waveguide is 11.7±1.1 dB and 9.9±0.7 dB, corresponding to respective irradiances of 1928 mW/mm2 and 2905 mW/mm2 at the waveguide tip from 6 mW laser diode chips. The efficient thermal packaging enables continuous device operation for up to 190 seconds at 10% duty cycle. We validated the fully packaged device in the intact brain of anesthetized mice co-expressing Channelrhodopsin-2 and Archaerhodopsin in the hippocampal CA1 region and achieved activation and silencing of the same neurons. We discuss improvements made to reduce the stimulation artifact induced by applying currents to the laser diode chips.

Abstract P3-08-09: Social media's impact on patient utilization of high-risk clinics for genetic counseling and testing services

Background: The availability and variety of cancer genetic testing services have grown tremendously in past years; testing services now offer panels that analyze more than 75 cancer susceptibility genes with results available in just weeks. Engaging the high-risk population in conversations regarding the importance of hereditary cancer screening is a prerequisite to initiating genetic testing and appropriate cancer surveillance. It has been shown that population awareness of cancer genetic testing has increased, but few studies have explored factors that contribute to actual uptake of these services.

Methods: A 36-question research survey was adapted from Cycle 3 of the 2014 Health Information National Trends Survey by NCI and distributed online to patients who received genetic counseling at the Ruth Paul Hereditary Cancer Program at the George Washington University Medical Faculty Associates. All patients who presented to the clinic, including those with and without cancer diagnoses, were invited to complete the survey. The survey was divided into four sections: (1) how the patient usually seeks health information, (2) how the patient has used media and the internet to understand cancer genetics, (3) how often the patient visits health professionals, and (4) why the patient pursued testing at the high-risk clinic.

Results: Forty-five out of 68 consented individuals completed the online survey. Most patients searched the internet regarding genetic testing in the past (64% vs. 36% who did not) but felt that they learned the most about cancer genetic testing through their health care provider and their family members/friends (49% and 35%, respectively). Though most patients access social networking sites (78%), only 4% shared information and 11% received information regarding cancer genetic testing through one of these sites. Most patients (65%) felt that information obtained from social media regarding cancer genetic testing had no impact on their decision to make an appointment. One-third of respondents (33%) felt that Angelina Jolie's decision to have prophylactic surgery for her known mutation encouraged them to make an appointment while 53% felt it had no impact on their decision. Most patients received a referral from their healthcare providers (91%) to have genetic testing, though 48% of those patients had to ask their doctor about genetic testing before receiving the referral.

Conclusions: Many patients use social media and internet resources for education regarding cancer genetic testing. However, most individuals sought genetic counseling services in our Hereditary Cancer Program after discussion with their health care providers. Half of those patients were only referred after raising the topic with their provider. While online resources can raise awareness and educate about cancer genetic counseling, improving uptake and utilization of these critical resources will require education of health care providers.

Citation Format: Toltzis S, McHenry A, Stark E, Biagi T, Kaltman R. Social media's impact on patient utilization of high-risk clinics for genetic counseling and testing services [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-08-09.

Integration of Ultrasound in Undergraduate Medical Education at the California Medical Schools: A Discussion of Common Challenges and Strategies From the UMeCali Experience

Since the first medical student ultrasound electives became available more than a decade ago, ultrasound in undergraduate medical education has gained increasing popularity. More than a dozen medical schools have fully integrated ultrasound education in their curricula, with several dozen more institutions planning to follow suit. Starting in June 2012, a working group of emergency ultrasound faculty at the California medical schools began to meet to discuss barriers as well as innovative approaches to implementing ultrasound education in undergraduate medical education. It became clear that an ongoing collaborative could be formed to discuss barriers, exchange ideas, and lend support for this initiative. The group, termed Ultrasound in Medical Education, California (UMeCali), was formed with 2 main goals: to exchange ideas and resources in facilitating ultrasound education and to develop a white paper to discuss our experiences. Five common themes integral to successful ultrasound education in undergraduate medical education are discussed in this article: (1) initiating an ultrasound education program; (2) the role of medical student involvement; (3) integration of ultrasound in the preclinical years; (4) developing longitudinal ultrasound education; and (5) addressing competency.

Applying the cognitive theory of multimedia learning: an analysis of medical animations

CONTEXT

Instructional animations play a prominent role in medical education, but the degree to which these teaching tools follow empirically established learning principles, such as those outlined in the cognitive theory of multimedia learning (CTML), is unknown. These principles provide guidelines for designing animations in a way that promotes optimal cognitive processing and facilitates learning, but the application of these learning principles in current animations has not yet been investigated. A large-scale review of existing educational tools in the context of this theoretical framework is necessary to examine if and how instructional medical animations adhere to these principles and where improvements can be made.

METHODS

We conducted a comprehensive review of instructional animations in the health sciences domain and examined whether these animations met the three main goals of CTML: managing essential processing; minimising extraneous processing, and facilitating generative processing. We also identified areas for pedagogical improvement. Through Google keyword searches, we identified 4455 medical animations for review. After the application of exclusion criteria, 860 animations from 20 developers were retained. We randomly sampled and reviewed 50% of the identified animations.

RESULTS

Many animations did not follow the recommended multimedia learning principles, particularly those that support the management of essential processing. We also noted an excess of extraneous visual and auditory elements and few opportunities for learner interactivity.

CONCLUSIONS

Many unrealised opportunities exist for improving the efficacy of animations as learning tools in medical education; instructors can look to effective examples to select or design animations that incorporate the established principles of CTML.

Extracardiac neural remodeling in humans with cardiomyopathy

BACKGROUND

Intramyocardial nerve sprouting after myocardial infarction is associated with ventricular arrhythmias. Whether human stellate ganglia remodel in association with cardiac pathology is unknown. The purpose of this study was to determine whether cardiac pathology is associated with remodeling of the stellate ganglia in humans.

METHODS AND RESULTS

Left stellate ganglia were collected from patients undergoing sympathetic denervation for intractable ventricular arrhythmias and from cadavers, along with intact hearts. Clinical data on patients and cadaveric subjects were reviewed. We classified ganglia from normal, scarred, and nonischemic cardiomyopathic hearts without scar as NL (n=3), SCAR (n=24), and NICM (n=7), respectively. Within left stellate ganglia, neuronal size, density, fibrosis, synaptic density, and nerve sprouting were determined. Nerve density and sprouting were also quantified in cadaveric hearts. Mean neuronal size in normal, scarred, and nonischemic cardiomyopathic hearts without scar groups were 320 ± 4 μm(2), 372 ± 10 μm(2), and 435 ± 10 μm(2) (P=0.002), respectively. No significant differences in neuronal density and fibrosis were present between the groups. Synaptic density in ganglia from SCAR and NICM groups were 57.8 ± 11.2 μm(2)/mm(2) (P=0.084) and 44.5 ± 7.9 μm(2)/mm(2) (P=0.039), respectively, compared with the normal group, 17.8 ± 7 μm(2)/mm(2) (overall P=0.162). There were no significant differences in left stellate ganglia nerve sprouting or myocardial nerve density between the groups.

CONCLUSIONS

Neuronal hypertrophy within left stellate ganglia is associated with chronic cardiomyopathy in humans. Ganglionic and myocardial nerve sprouting and nerve density were not significantly different. These changes may be related to increased cardiac sympathetic signaling and ventricular arrhythmias. Further studies are needed to determine the electrophysiological consequences of extracardiac neuronal remodeling in humans.

[Lymphoceles after radical retropubic prostatectomy. A treatment algorithm]

Lymphoceles represent a common complication following pelvic lymphadenectomy and radical retropubic prostatectomy. Relevant articles published in the last 25 years and our own results based on a prospective study were taken as the basis for a treatment algorithm for lymphoceles after radical prostatectomy.The type of intervention depends on the clinical situation of the patient. Symptomatic lymphoceles can be managed initially by percutaneous aspiration with or without instillation of sclerosing agents. However, lymphocele recurrence rates are high. Symptomatic, sterile lymphoceles appear to be ideally suited for drainage by laparoscopic techniques. This method is effective, usually immediately definitive, results in minimal patient morbidity, and allows for a more rapid recovery. Infected lymphoceles require percutaneous or open surgical drainage. Laparoscopic marsupialization of symptomatic lymphoceles after pelvic lymphadenectomy for prostate cancer appears to be safe and effective. Because of the minimal postoperative morbidity, rapid convalescence, and low recurrence rate, laparoscopic lymphadenectomy should be considered as a first-line treatment for symptomatic, uninfected sterile lymphoceles.

Reducing inter-replicate variation in fourier transform infrared spectroscopy by extended multiplicative signal correction

Fourier transform infrared (FT-IR) spectroscopy is a powerful tool for characterizing biological tissues and organisms, but it is plagued by replicate variation of various sources. Here, a method for estimating and correcting unwanted replicate variation in multivariate measurement signals, based on extended multiplicative signal correction (EMSC), is presented. Systematic patterns of unwanted methodological variations are estimated from replicate spectra, modeled by a linear subspace model, and implemented into EMSC. The method is applied to FT-IR spectra of two different sets of microorganisms (different double gene knockout strains of Saccharomyces cerevisiae and different species of Listeria) and compared to other preprocessing methods used in FT-IR absorption spectroscopy of microorganisms. The EMSC replicate correction turns out to perform best among the compared methods.

[The state of pediatric urological outpatient surgery]

Economic requirements and the wishes of the patients have led to a clear increase in outpatient surgery. Besides the observance of legal conditions, a well-devised structure of organization is the prerequisite for a frictionless realization. The operating surgeon decides about the suitability of the patient, is responsible for a course without complications and takes on the postoperative care. The most frequent operations are circumcision, orchidopexy and the repair of inguinal hernias. Outpatient surgery stands out for a low rate of complications and a high satisfaction of the patients.

Escalating immunotherapy of multiple sclerosis--new aspects and practical application

Recent clinical studies in multiple sclerosis (MS) provide new data on the treatment of clinically isolated syndromes, on secondary progression, on direct comparison of immunomodulatory treatments and on dosing issues. All these studies have important implications for the optimized care of MS patients. The multiple sclerosis therapy consensus group (MSTCG) critically evaluated the available data and provides recommendations for the application of immunoprophylactic therapies. Initiation of treatment after the first relapse may be indicated if there is clear evidence on MRI for subclinical dissemination of disease. Recent trials show that the efficacy of interferon beta treatment is more likely if patients in the secondary progressive phase of the disease still have superimposed bouts or other indicators of inflammatory disease activity than without having them. There are now data available, which suggest a possible dose-effect relation for recombinant beta-interferons. These studies have to be interpreted with caution, as some potentially important issues in the design of these studies (e. g. maintenance of blinding in the clinical part of the study) were not adequately addressed. A meta-analysis of selected interferon trials has been published challenging the value of recombinant IFN beta in MS. The pitfalls of that report are discussed in the present review as are other issues relevant to treatment including the new definition of MS, the problem of treatment failure and the impact of cost-effectiveness analyses. The MSTCG panel recommends that the new diagnostic criteria proposed by McDonald et al. should be applied if immunoprophylactic treatment is being considered. The use of standardized clinical documentation is now generally proposed to facilitate the systematic evaluation of individual patients over time and to allow retrospective evaluations in different patient cohorts. This in turn may help in formulating recommendations for the application of innovative products to patients and to health care providers. Moreover, in long-term treated patients, secondary treatment failure should be identified by pre-planned follow-up examinations, and other treatment options should then be considered.

[Errors and risks in ambulatory operations: circumcision]

As one of the most frequently performed operations circumcisions can entail not only typical but also rare complications with possibly fatal consequences. The following areas are of particular importance: legal aspects of the operation, indication for an operation, pre-operative information, post-operative surveillance and after-care. The amount of circumcisions carried out in different European countries vary widely. This shows a difference in indication assessment, which may suppose that a number of operations are not necessary.

Acupuncture for the treatment of cocaine addiction: a randomized controlled trial

CONTEXT

Auricular acupuncture is widely used to treat cocaine addiction in the United States and Europe. However, evidence from controlled studies regarding this treatment's effectiveness has been inconsistent.

OBJECTIVE

To investigate the effectiveness of auricular acupuncture as a treatment for cocaine addiction.

DESIGN

Randomized, controlled, single-blind clinical trial conducted from November 1996 to April 1999.

SETTING

Six community-based clinics in the United States: 3 hospital-affiliated clinics and 3 methadone maintenance programs.

PATIENTS

Six hundred twenty cocaine-dependent adult patients (mean age, 38.8 years; 69.2% men); 412 used cocaine only and 208 used both opiates and cocaine and were receiving methadone maintenance.

INTERVENTION

Patients were randomly assigned to receive auricular acupuncture (n = 222), a needle-insertion control condition (n = 203), or a relaxation control condition (n = 195). Treatments were offered 5 times weekly for 8 weeks. Concurrent drug counseling was also offered to patients in all conditions.

MAIN OUTCOME MEASURES

Cocaine use during treatment and at the 3- and 6-month postrandomization follow-up based on urine toxicology screens; retention in treatment.

RESULTS

Intent-to-treat analysis of urine samples showed a significant overall reduction in cocaine use (odds ratio, 1.40; 95% confidence interval, 1.11-1.74; P =.002) but no differences by treatment condition (P =.90 for acupuncture vs both control conditions). There were also no differences between the conditions in treatment retention (44%-46% for the full 8 weeks). Counseling sessions in all 3 conditions were poorly attended.

CONCLUSIONS

Within the clinical context of this study, acupuncture was not more effective than a needle insertion or relaxation control in reducing cocaine use. Our study does not support the use of acupuncture as a stand-alone treatment for cocaine addiction or in contexts in which patients receive only minimal concurrent psychosocial treatment. Research will be needed to examine acupuncture's contribution to addiction treatment when provided in an ancillary role.

Laparoscopic hernioplasty versus conventional hernioplasty (Shouldice): results of a prospective randomized trial

The results of our randomized trial of 176 patients comprising primary hernias [Shouldice versus transabdominal preperitoneal approach (TAPP)] showed only slight advantages for the laparoscopically operated group compared to the conventionally operated group: less subjective pain (significant only on fifth postoperative day, p < 0.05), reduced analgesic requirement (significant only on third postoperative day, p < 0.05), significantly shorter duration of hospitalization (4 days vs. 6 days, p < 0.05) and faster return to work (27 days vs. 34 days, NS). Regarding the incidence of recurrences, there was no significant difference between the groups (two recurrences vs. one recurrence) within a follow-up period of 2 years. Postoperative morbidity was similar and the total cost was less for the TAPP group.

Cocaine, Crime, Family History of Deviance-Are Psychosocial Correlates Related to These Phenomena in Male Cocaine Abusers?

This paper examines relationships among deviant behaviors such as cocaine abuse, crime, and family history of deviance; demographics; and psychological characteristics such as aggression, sensation seeking, confidence to resist taking cocaine and risk taking tendency to use cocaine in different situations; psychiatric symptoms (e.g., depression, anxiety, obsessive-compulsiveness, somatization, attention deficit); and social characteristics such as social adjustment. The sample consisted of men, mean age 35 years, who were veterans of the armed services. Canonical correlation analysis showed three significant canonical variates: The first indicated that verbal aggression, general sensation seeking, and a problem index for situations involving urges to use cocaine were positively related to number of times arrested and negatively related to age. The second revealed that experience seeking and problem indices for situations involving urges to use cocaine and for those involving pleasant times, were positively related to last cocaine use consumption level, total lifetime grams of cocaine used, and alcohol problems of the immediate family. The third showed that verbal aggression and a problem index for risk situations for use involving pleasant times were positively related, and experience seeking was negatively related, to number of times arrested, number of times incarcerated in the previous 30 days, age, and last cocaine use level. The implications of the associations found among these variables are discussed as they pertain to prevention, treatment, and future research.

Nerve irritation after laparoscopic hernia repair

BACKGROUND

Between October 1992 and May 1996, 893 hernia repairs were performed at the Surgical Clinic in Mannheim: 448 (50%) using laparoscopy (TAPP-method) and 445 (50%) using the conventional anterior approach (Shouldice).

MATERIALS AND METHODS

For this study, 723 (81%) of these repairs were followed up in a prospective trial of postoperative nerve irritations.

RESULTS

The rate of nerve entrapment in the laparoscopic group was 4.2% (n = 19), and in the group that underwent conventional surgery 1.8% (n = 8). The genitofemoral nerve was affected with particularly high frequency (2%), and the ilioinguinal nerve and lateral cutaneous nerve of the thigh (LCNT) each was affected in 1.1% of the cases.

CONCLUSIONS

Reduction in the number of clips used and careful attention to the anatomic nerve course during preparation and placement of mesh led to a significant reduction in the occurrence of nerve irritations. In the last 100 patients who underwent laparoscopic hernia repair, only one nerve lesion was seen.

Relation of neuropsychological and magnetic resonance findings in amyotrophic lateral sclerosis: evidence for subgroups

The relationship between neuropsychological impairments and changes in cranial MR images was investigated in a group of 74 consecutive patients with the sporadic form of amyotrophic lateral sclerosis (ALS). Neuropsychological tests included measures of frontal lobe function, memory, intelligence, and attention. Compared with a control group, a significant impairment of the ALS group emerged for the areas of visual attention, inhibition of response alternatives, visual memory, and word generation. These neuropsychological impairments did not show a relation to clinical status of the patients. Likewise, MR parameters derived by computer assisted planimetric analysis showed a ventricular enlargement and parenchymal atrophy in the ALS group compared with age-matched controls. When ALS patients were assigned to two subgroups differing on the basis of the neuropsychological tests by cluster-analysis the cluster with the significant impairment also showed a pronounced change for the MR-parameters while the subgroup showed essentially normal neuropsychological performance. This pattern suggests that subgroups of ALS with differential impairment of neuropsychological functions can be defined.

[Open laparoscopic approach--an alterative to the Veress needle. Experiences after 1,000 laparoscopies]

A mini-laparotomy as described by Hasson was used in a modified way in 1000 laparoscopic procedures. In comparison with the insertion of a Veress needle we find the open approach to be a safer and quicker way of obtaining pneumoperitoneum.

Effects of joining peptide (1-18) and histamine on dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulphate (DHEAS) production of human adrenocortical cells in vitro

Joining peptide 1-18 (JP 1-18), added alone in concentrations of 10(-13)-10(-7) M to collagenase-dispersed human adrenocortical cells, did not affect the basal production of corticosterone, cortisol, aldosterone, dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulphate (DHEAS). JP 1-18 potentiated the ACTH-stimulated production of steroids. When administered in combination with histamine (10(-8)-10(-3) M), JP 1-18 (10(-8) or 10(-10) M), enhanced the synthesis of DHEA and DHEAS. JP 1-18, together with histamine, may play a role in the regulation of DHEA and DHEAS production.

[Results of colorectal carcinoma surgery in elderly patients]

Between 1972 and 1995, 4434 operations for colorectal carcinoma were performed at the University Clinic of Mannheim. The increasing average age of the patients resulted in a higher lethality rate due to more emergency operations and concomitant failure of other organs. But the prognosis of patients over 70 years old can be compared with younger patients when hospital lethality is not considered. Thus the aim of treatment in older patients is also R0-resection, avoidance of emergency operations, optimum treatment of concomitant failure of other organs and multiple operations in extreme emergency cases.

Immunological and clinical response to immunosuppressive treatment in paraneoplastic cerebellar degeneration

OBJECTIVE

To report the clinical and immunological response to immunosuppressive treatment with cyclophosphamide in two patients with paraneoplastic cerebellar degeneration.

DESIGN

Case reports. Clinical and immunological follow-up data available for 4 1/2 years in the first patient and for 2 years in the second patient.

SETTING

A 1500-bed university hospital and a 1200-bed university teaching hospital.

INTERVENTION

Cyclophosphamide intermittent treatment.

MAIN OUTCOME MEASURE

Clinical disability.

RESULTS

One of the patients, who was treated from an early stage, recovered completely. The other patient showed a partial clinical response. While the two patients were receiving a maintenance regimen with cyclophosphamide, the conditions of both patients remained stable for at least 2 years. In both patients, intrathecal antibody synthesis declined considerably.

CONCLUSION

Early induction of immunosuppressive therapy with cyclophosphamide should be tried in treating patients with paraneoplastic cerebellar degeneration.

Killing the beast within: woman battering and female suicidality

This article explores the importance of woman battering for female suicidality, with special attention to the link among black women. Suicidality has classically been framed with a distinctly male bias. As a result, suicide attempts (a predominantly female event) have been defined as "failed suicides" and the distinctive social context of suicidality among women has been missed. The authors propose that suicidality among battered women is evoked by the "entrapment" women experience when they are subjected to "coercive control" by abusive men. A literature review highlights the probable importance of male violence as a cause of female suicidality. Pursuing this possibility, we assess the significance of battering in a sample of women who have attempted suicide, the characteristics of battered women who attempt suicide, and the appropriateness of the medical response. The results indicate that battering may be the single most important cause of female suicidality, particularly among black and pregnant women. The implications of this finding for theory and clinical intervention are discussed.

Comparative analysis of intrathecal antibody synthesis and DNA amplification for the diagnosis of cytomegalovirus infection of the central nervous system in AIDS patients

We evaluated 49 paired cerebrospinal fluid (CSF) and serum samples of 35 patients infected with the human immunodeficiency virus type 1 (HIV-1) for laboratory evidence of cytomegalovirus (CMV) infection. The patients were grouped according to clinical criteria as probable CMV encephalitis/polyradiculomyelitis, CMV retinitis, cerebral toxoplasmosis, progressive multifocal leukoencephalopathy, HIV-1-related cognitive/motor complex, HIV-1-associated myelopathy, and other neurological diseases. Paired CSF and serum samples were analysed for CMV deoxyribonucleic acid (DNA) by polymerase chain reaction (PCR), quantitative intrathecal synthesis of immunoglobulin G (IgG) antibodies specific for recombinant phosphoprotein 150 (pp150) of CMV and CMV-specific serum IgM. Intrathecal synthesis of pp150-specific IgG was detected in 26% of patients (9/35), serum IgM was found in 23% of patients (8/35), and PCR of CSF was positive in 11% of patients (4/35). Detection of CMV-specific DNA in CSF preceded the intrathecal antibody synthesis in three patients for whom serial samples were available. PCR results of the CSF became negative in one patient with CMV polyradiculomyelitis after successful therapy with 9-[2-hydroxy-1-(hydroxymethyl) ethoxymethyl] guanine (DHPG). PCR has a higher diagnostic specificity in the acute phase of CMV infection than intrathecal antibody synthesis. The serum IgM response to CMV cannot be used to monitor a compartmentalized immune response in the central nervous system while an intrathecal immune response seems to be associated with recovery either spontaneously or as a result of treatment.