Aliskiren, tadalafil, and cinnamaldehyde alleviate joint destruction biomarkers; MMP-3 and RANKL; in complete Freund's adjuvant arthritis model: Downregulation of IL-6/JAK2/STAT3 signaling pathway

Rheumatoid arthritis (RA) is an autoimmune inflammatory disease, which is accompanied by progressive joint damage and disability. The intolerability of conventional antirheumatic drugs by some patients necessitates the search for effective antirheumatic agents having better tolerability. In the current work, we aimed to investigate the efficacy of cinnamaldehyde, tadalafil, and aliskiren as potential antirheumatic candidates and to explore their modulatory effects on joint destruction, inflammatory response, and intracellular signaling. Arthritis was induced in female Wistar rats by complete Freund's adjuvant (CFA) 0.4 ml s.c. on days 1, 4, and 7. Treated groups received their respective drugs, starting from day 13, daily for 3 weeks. Methotrexate and prednisolone were the standard antirheumatic drugs, while cinnamaldehyde, tadalafil, and aliskiren were the test agents. Treatment with cinnamaldehyde, tadalafil, or aliskiren reduced serum levels of rheumatoid factor, and pro-inflammatory cytokines; tumor necrosis factor-alpha and interleukin-6 (IL-6), along with elevated level of IL-10 which is an anti-inflammatory cytokine. Besides, cartilage and bone destruction biomarkers; matrix metalloproteinase-3 (MMP-3) and receptor activator of nuclear factor-kappa B ligand (RANKL); were significantly reduced after treatment with the test agents, which was further confirmed by histopathological investigation. The elevated protein expressions of phosphorylated-Janus kinase 2 (p-JAK2), phosphorylated-signal transducer and activator of transcription 3 (p-STAT3), and inducible nitric oxide synthase (iNOS) in articular tissue were markedly attenuated after treatment with cinnamaldehyde, tadalafil, or aliskiren, while that of endothelial nitric oxide synthase (eNOS) was greatly enhanced. In addition, oxidative stress and inflammatory markers such as malondialdehyde, nitric oxide, and myeloperoxidase were reduced in joint tissue after treatment with the test agents, while glutathione content was elevated. Furthermore, the renin inhibitor aliskiren produced effects close to those of the normal and methotrexate, the gold standard antirheumatic drug, in most of the measured parameters.

Collectively, these findings led to the assumption that the downregulation of IL-6/JAK2/STAT3 signaling by cinnamaldehyde, tadalafil, and aliskiren could alleviate joint destruction by MMP-3 and RANKL, reduce iNOS, and enhance eNOS expressions. Moreover, aliskiren could be a promising therapeutic agent for RA, because of its ability to normalize most of the measured parameters after CFA-induced arthritis.

Breast Cancer Awareness and Barriers to Early Presentation in the Gaza-Strip: A Cross-Sectional Study

PURPOSE

Timely detection of breast cancer (BC) is important to reduce its related deaths. Hence, high awareness of its symptoms and risk factors is required. This study aimed to assess the awareness level of BC among females in Gaza.

MATERIALS AND METHODS

A cross-sectional study was performed during September and October 2017 in Gaza, Palestine. Stratified sampling was used to recruit patients from four hospitals and seven high schools. The validated Breast Cancer Awareness Measure (BCAM) was used to assess confidence and behavior in relation to breast changes, awareness of BC symptoms and risk factors, barriers to seek medical help, and knowledge of BC screening. Women (age ≥ 18 years) visiting or admitted to any of the four hospitals, and female adolescents (age 15 to 17 years) in any of the seven schools, were recruited for face-to-face interviews to complete the BCAM.

RESULTS

Of 3,055 women approached, 2,774 participants completed the BCAM questionnaire (response rate, 90.8%); 1,588 (57.2%) were adults, and 1,186 (42.8%) were adolescents. Of these, 1,781 (64.2%) rarely (or never) checked their breasts, and 909 (32.8%) were not confident to notice changes. In total, 1,675 (60.4%) were aware of the availability of BC screening programs. The overall mean ± standard deviation score for awareness of BC symptoms was 5.9 ± 2.9 of 11, and that of risk factors 7.5 ± 3.1 of 16. Feeling scared was the most reported barrier to seeking advice reported among women (n = 802; 50.2%), whereas feeling embarrassed was the most reported in adolescents (n = 745; 62.8%).

CONCLUSION

Awareness of BC symptoms, risk factors, and screening programs is suboptimal in Gaza. Educational interventions are necessary to increase public awareness of BC and to train local female breast surgeons to address barriers to early detection.

3D-printed components for quantum devices

Recent advances in the preparation, control and measurement of atomic gases have led to new insights into the quantum world and unprecedented metrological sensitivities, e.g. in measuring gravitational forces and magnetic fields. The full potential of applying such capabilities to areas as diverse as biomedical imaging, non-invasive underground mapping, and GPS-free navigation can only be realised with the scalable production of efficient, robust and portable devices. We introduce additive manufacturing as a production technique of quantum device components with unrivalled design freedom and rapid prototyping. This provides a step change in efficiency, compactness and facilitates systems integration. As a demonstrator we present an ultrahigh vacuum compatible ultracold atom source dissipating less than ten milliwatts of electrical power during field generation to produce large samples of cold rubidium gases. This disruptive technology opens the door to drastically improved integrated structures, which will further reduce size and assembly complexity in scalable series manufacture of bespoke portable quantum devices.

Lipid peroxides in the serum of asphyxiated neonates

OBJECTIVE

Lipid peroxides (LPOs) are released when free radicals react with unsaturated fatty acids in cell membranes during hypoxic ischemic insult in neonates. We aimed to assess LPO concentrations in the serum of asphyxiated and non-asphyxiated neonates and examine their correlation with the severity of asphyxia.

STUDY DESIGN

This prospective cross-sectional study was conducted on a group of asphyxiated neonates and controls. Serum LPO concentrations was measured by enzyme-linked immunosorbent assay at 4-6 h of life in all subjects. Encephalopathy was classified according to Sarnat's stages into mild, moderate and severe at 12-24 h of life. LPO was compared between groups and was correlated with severity of encephalopathy and mortality.

RESULTS

A total of 90 infants were enrolled; of them 45 had asphyxia. Serum LPO (nmol ml(-1)) was significantly greater in the asphyxia group (6.9±3.01 vs 1.78±1.09, P<0.001). It correlated positively with severity of encephalopathy (P<0.001) and negatively with Apgar score at 5 min (r=-0.532, P<0.001) and with initial blood gases pH (r=-0.664, P<0.001). LPO measured greater concentrations in infants who died compared with asphyxiated survivors (11.64±1.31 vs 6.18±2.48, P=0.0004).

CONCLUSION

LPO was increased and correlated with severity of asphyxia as well as with mortality. Further studies are warranted to examine whether it is only a marker for outcome or a contributor in the pathogenesis of hypoxic-ischemic brain injury.

The actual management of tumor and vertebral compression fractures

Tumor related fractures of the spine frequently dictate surgical management. The most critical factors influencing the need and type of surgery are degree of epidural cord compression, radiosensitivity of the tumor, presence of spinal instability and patient medical status/ estimated survivorship. There is a wide spectrum of therapeutic options: major en bloc resections in primary or oligometastatic disease; decompression and fusion in non-radiosensitive tumors with cord compression followed by adjuvant radiation therapy (RT); kyphoplasty/ vertebroplasty for stable compression fractures or minimally invasive corpectomy for more unstable fractures and RT- only for radiosensitive tumors not causing overt instability. Radiation therapy has always been essential component of the treatment algorithm although it has been displaced from principal treatment modality in the last 2 decades. However, the advent of more targeted and efficient forms of RT (radiosurgery) may be a new treatment paradigm for more radioresistant tumors and may obviate the need for major operations.

Endovascular management of pediatric aneurysms

Although the general principles of endovascular aneurysm treatment in adults hold true in children, these young patients pose unique challenges: small anatomy, longer life expectancy, associated conditions and morphological characteristics of the aneurysms. Few publications in the literature address the role of endovascular treatment for pediatric aneurysms; including series by Agid et al. (2005) (1) revisiting the Toronto series, Lasjaunias et al. (2005) (2) updating the Bicêtre series and Sanai et al (2006) (8) presenting the San Francisco series. In their conclusions, the authors of the former two publications favored endovascular treatment over microsurgery. On the other hand, the authors of the latter publication favored microsurgery over endovascular treatment. The authors reviewed Louisiana State University experience regarding endovascular treatment of pediatric aneurysms focusing on outcomes. A retrospective chart review was performed of children under 18, who underwent endovascular treatment for intracranial aneurysms between 2000 and 2009 in our institution. Twelve patients harboring seventeen aneurysms were identified. The patients ranged in age from seventeen months to seventeen years. Complete aneurysm obliteration following endovascular treatment was around 95%. Our results showed unique features for pediatric aneurysms when compared to adult aneurysms. No intra operative mortality was recorded. One aneurysm recurred (5% recurrence rate among total number of aneurysms). In this case, six months after treatment, a control angiogram showed that the coils were displaced toward the dome of the aneurysm. This recurrence occurred before the introduction of the hydro coils. One patient died during the post intervention period (8% occurrence rate among total number of patients). Outcomes were better in anterior circulation aneurysms than in posterior circulation lesions. We had no mortality, morbidity or disability in the anterior circulation aneurysm group. In the posterior circulation group, there was one death representing 14% of the nine patients with aneurysms in this group. One recurrence occurred in the posterior circulation group representing 11% of the nine aneurysms in this group. Follow-up of all patients ranged from two to eight years. Endovascular treatment of pediatric intracranial aneurysm is safe and efficacious. Endovascular treatment in many instances provides less morbidity and mortality for treatment of pediatric aneurysms in inaccessible or eloquent locations than microsurgical clipping. The result of endovascular treatment depends on the location of the aneurysms and the underlying pathology. We advocate a multidisciplinary approach when choosing the therapeutic modality for treatment of pediatric aneurysms.

Surgical anatomy of the extended middle cranial fossa approach

The extended middle cranial fossa approach includes removal of the petrous bone from its subtemporal surface in order to expose widely the internal auditory canal and the posterior fossa dura around its porus while preserving all the important and closely related anatomical structures. We have dissected 25 temporal bones and five fresh cadavers in order to define the limits of this approach. Measurements were obtained between the different structures to find reliable angles and distances that could guide working in this area. A new method of identification of the internal auditory canal is discussed based on the measurements taken.The results of the present work showed wide variations in the different structures. The arcuate eminence was coincident with the superior semicircular canal in only 48% of bones. Dehiscence of the geniculate ganglion and of the internal carotid artery was noted in 16% and 20% of specimens, respectively. The angles measured between the different structures showed great variations. However, the angle between the internal auditory canal and superior petrosal sinus was constant. Though the extended middle cranial fossa is a versatile approach, it affords a limited access to the cerebellopontine angle. A thorough understanding of the complex and variable anatomy of this area is necessary should this approach be utilized.

Decision making in acoustic neuroma management: the only hearing ear

Patients with acoustic neuroma in their only hearing ear are not frequently seen in clinical practice. Managing this group of patients is a challenge to both patient and surgeon. In this study we report on five cases of acoustic neuroma in an only hearing ear. Our decision for nonsurgical management of those patients with regular follow-up using auditory brainstem responses and magnetic resonance imaging is discussed. Other management options currently available are considered as well.

Prevalence of anaemia before major joint arthroplasty and the potential impact of preoperative investigation and correction on perioperative blood transfusions

BACKGROUND

Preoperative investigation and treatment of anaemia is recommended before orthopaedic surgery. We measured the prevalence of anaemia among admissions presenting for elective major joint arthroplasty (MJA), assessed their transfusion requirements, and investigated factors associated with perioperative blood transfusion.

METHODS

All admissions to a dedicated elective orthopaedic hospital during 2000-2001 were studied. The patients' database was merged with the haematology and transfusion databases. Population estimates for different types of anaemia and their blood transfusion requirements were generated using local reference ranges (males <130 g litre(-1); females <115 g litre(-1)).

RESULTS

One thousand three hundred and twenty-two admissions were included; haematology data were complete for 1142 (544 primary hip, 490 primary knee, 77 revision hip, 31 revision knee). About 19.6% were anaemic [7.1% haemoglobin (Hb) <110 g litre(-1); 1.6% Hb<100 g litre(-1)]. Overall, 21.3% of admissions were transfused (mean 0.58 units per case: 95% CI 0.50-0.61). For anaemic admissions, 42.0% were transfused (mean 1.11 units per case: 95% CI 0.90-1.32). Mean red cell use for admissions with normocytic normochromic anaemia (12.7% of admissions) and hypochromic anaemia (4.6%) was 1.04 (95% CI 0.78-1.31) and 1.14 (95% CI 0.71-1.57) units per admission, respectively. Factors strongly associated independently with transfusion were preoperative haemoglobin </=110 g litre(-1) [odds ratio: 13.92 (95% CI 7.77-24.9) and revision hip surgery (OR: 17.80 (9.59-33.02)].

CONCLUSIONS

The prevalence of preoperative anaemia among admissions undergoing elective MJA is approximately 20%. Patients most likely to avoid transfusions with preoperative intervention are those with low haemoglobin undergoing revision hip surgery.

Evidence for 2-Hydroxy-4(Methylthio) Butanoic Acid and dl-Methionine Having Different Dose Responses in Growing Broilers

The objective of this study was to compare the gain-response curve to dietary levels of 2-hydroxy-4(methylthio) butanoic acid (HMTBA) and DL-Met (DLM) across 4 floor pen trials in which different diets were used. Six replicates of 38 or 41 birds per pen (trials 1 to 2 and 3 to 4, respectively) were used in a 2 x 3 factorial arrangement. A control with 12 replicates was also included. The 2 Met sources were fed at 3 equimolar levels equally spaced, with the highest level added at requirements from 1 to 48, 49, 43, or 49 d for trials 1, 2, 3, and 4, respectively. Commercial-type TSAA-deficient control diets contained sorghum, wheat, corn, or corn plus meat and bone meal for trials 1, 2, 3, and 4, respectively. Performance improved at all times for most parameters after supplementing with HMTBA or DLM (P < 0.05). No differences were found in the birds fed HMTBA or DLM at any age and trial (P > 0.05), except for trial 1, in which 17-d-old birds performed better when fed HMTBA than DLM (P < 0.05). In each trial, linear, quadratic, and exponential regressions were conducted upon the gain response of birds fed HMTBA and DLM separately. Equations with better goodness of fit were used to compare the estimated gain responses to feeding HMTBA vs. DLM. In 3 trials, the shape of the gain-response curve differed when feeding HMTBA vs. DLM. In trials 3 and 4, feeding HMTBA at commercial levels resulted in greater gain responses than DLM (P < 0.05), whereas, in trials 2 and 4, at very deficient levels, DLM-fed birds outperformed those fed HMTBA (P < 0.05). When the 4 trials were combined, the dose-response curve with the best goodness of fit was linear for HMTBA and quadratic for DLM. It can be concluded that the 2 Met sources have a different dose-response form, HMTBA could outperform DLM at commercial levels, and DLM could outperform HMTBA at deficient levels.

Identification of internal acoustic canal in the middle cranial fossa approach: a safe technique

BACKGROUND

The middle cranial fossa approach (MCFA) is a very valuable functional approach in the armamentarium of the neuro-otologic surgeon. Identification of the internal acoustic canal (IAC) in MCFA is one of the most tedious steps. Many techniques have been described to locate the IAC safely when using the MCFA.

OBJECTIVE

We sought to describe a safe technique for identification of the IAC and to demonstrate its feasibility in temporal bone dissections, as well as to discuss our clinical experience with this technique.

METHODS

The surgical anatomy of the 20 temporal bones were evaluated and measured, especially by defining the medial and lateral ends of the IAC and relations to the nearby located structures. Measurements were obtained at 3 levels: the width of the IAC at the level of the fundus, the width of the IAC at the level of the porus, and the safe distance around the IAC at the meatal level. The medial and lateral IAC end widths were compared with each other and with the safe area at the meatal level.

RESULTS

The smallest, the largest, and the mean values were recorded. The mean width of the IAC at the level of the porus was found to be more than 3-fold that of the width of the IAC at the level of the Bill's bar, and the ratio between the width of the medial safe area around the IAC and the lateral end of the IAC was found to be more than 7-fold as wide.

CONCLUSION

This technique offers direct quick exposure of the IAC, without handling the facial nerve and the inner ear structures. Forty-five cases of operations with the same technique showed excellent ease and safety of identifying the IAC medially in the MCFA.

Identification of the facial nerve in the translabyrinthine approach: an alternative technique

An alternative technique for the identification of the facial nerve at the fundus of the internal auditory canal is described.

HAV and HEV infection in hospitalised hepatitis patients in Alexandria, Egypt

A total of 202 serum and stool samples from acute hepatitis patients attending the Fever Hospital of Alexandria, Egypt, have been studied to reveal markers of hepatitis virus infection. Anti-HAV IgM were detected in 21 out of 202 sera (10.4%), whereas 201 sera (99.5%) had anti-HAV IgG. The first age attack was in the class-age 0-9 years with 64.7% of anti-HAV IgM positive sera. Among 202 patients, anti-hepatitis E IgG (sample/over cut off > 1.0) was identified in 90 patients (44.5%). The anti-HEV seropositivity ranged from 17.6% to 60.0% in the different age groups, with the highest level in the class-age 20 29 years. Anti-hepatitis E IgM were identified in 49 patients with the first age attack in the class-age 10-19 years (39.4%). HAV RNA was identified by nested PCR in 7 samples out of 15, whereas HEV RNA was present in 4 out of 75 stool samples. Direct DNA sequence of the latter PCR products confirmed the presence of the HEV genome; comparison of the sequences of the isolates from Egypt with those in data banks revealed the highest homology to the Burma strain. Our data confirm that HAV and HEV are common causes of acute sporadic hepatitis in Alexandria but with different peak age positivity. Occasionally, but not infrequently, dual infections (HAV-HEV and HEV-enteric viruses) were also found. The risk analysis indicates that patients living in rural areas are exposed to a higher risk of hepatitis E infection compared to the urban population, whereas the presence of anti-HEV IgG was significantly associated with consumption of common village water and use of indoor dry pit and oral therapy for schistosomiasis.

Evidence of hepatitis E virus replication on cell cultures

Several human and animal cell lines have been used to grow hepatitis E virus. The strain SAR-55 was adapted only on PLF/PLC/5 cell line without any visible cytopathic effect. The growth of the SAR-55 was monitored by examining the positive and the negative strands of HEV-RNA. Stool samples, obtained from hospitalised acute hepatitis patients at the Fever Hospital of Alexandria (Egypt), were used to confirm the susceptibility of PLF/PLC/5 cells. After more than one-week's cultivation, three stool samples out of 17 IgM anti-HEV positive and 1 from 52 IgG anti-HEV positive patients showed a specific RT-PCR amplification product. The nucleotide sequences of the methyltransferase region of the genome in the isolates revealed the maximum homology with Burma strain with several point mutations.

Establishment of primary vestibular schwannoma cultures from neurofibromatosis type-2 patients

Primary cultures were established from vestibular schwannomas of NF2 patients. The cultured tumor cells were selectively amplified by growth factor supplemented medium and characterized by immunocytochemistry. NF2 cDNA was amplified by RT-PCR and mutations were detected by both the non-isotopic RNase cleavage assay and direct DNA sequencing, no detectable wild-type NF2 transcript was found in cDNA from the cultured cells. Distinguishable morphology and growth rate differences have been observed in different passages of the primary cells. The data suggest that a pure schwannoma primary culture can be established and could be very useful in vitro model for further understanding the NF2 gene function in Schwann cells.

Effects of different concentrations of monensin and monensin withdrawal upon the control of coccidiosis in the turkey

The efficacy of different concentrations of monensin in turkeys exposed to field isolates of Eimeria and the effect of the withdrawal of monensin from their diet were investigated. Results of a battery study indicated that 66 ppm monensin was effective against three species of Eimeria in the turkey. In floor pens in which poults were exposed to infection, use of 59.5, 79.4, and 99.2 ppm monensin resulted in reduced mortality and improved feed conversion at 3 wk of age compared with birds that had received no medication. Poults given 59.5 ppm monensin weighed more and had a better feed conversion at 3 wk than poults given 79.4 or 99.2 ppm monensin, but at 10 wk no differences in the body weight or feed conversion of poults given different concentrations of drug were apparent. At 14 wk (and from 10 to 14 wk), poults that had been given 99.2 ppm monensin had a lower feed intake and weighed less than birds that had been given 59.5 ppm of the drug but there were no significant differences in feed conversion. There was no significant difference in the weight gain or feed conversion of poults from 10 to 14 wk of age whether monensin was present in the feed or had been withdrawn. No evidence of compensatory growth was found in the present study.

The system of the modified transcochlear approach: a lateral avenue to the central skull base

OBJECTIVE

This study aimed to update the authors' experience with the modified transcochlear approach for the management of lesions of the central skull base. The surgical technique, classification, indications, and results also are presented.

STUDY DESIGN

A retrospective review of the charts of 66 consecutive patients treated in our centers by the modified transcochlear approach was conducted.

SETTING

The study was performed in two tertiary referral centers.

PATIENTS

All patients treated by the modified transcochlear approach were included. Thirty-five patients had extradural lesions, whereas 31 lesions were intradural.

INTERVENTION

All patients were treated surgically using the modified transcochlear approach either in its basic form (type A) or with its extensions (types B, C, and D).

MAIN OUTCOME MEASURES

The outcome of surgery is evaluated with particular emphasis on the incidence of morbidity, mortality, and the degree of total tumor removal.

RESULTS

Total tumor removal was accomplished in 58 cases either in single or staged procedures. A second-stage procedure for total tumor removal is planned in five other patients. Subtotal tumor removal was performed in three patients. Mortality occurred in two cases. Ipsilateral hearing loss and immediate facial nerve palsy constituted the major drawbacks of this approach. However, 67.5% recovered to grade III facial function or better 1 year after surgery.

CONCLUSIONS

The modified transcochlear approach provides a relatively safe, wide, and versatile access to large lesions of the central skull base.

Retrolabyrinthine vestibular nerve section: a current appraisal

We report our experience (1987-1993) with Meniere's disease patients treated with a retrolabyrinthine vestibular neurectomy. The current literature was reviewed and our results have been compared with those of previous reports. The overall success rate for vertigo relief was 96.7%, with no serious or permanent complications resulting from the procedure. The technical elements of the operation, as they apply to our approach and those of others, have been analyzed, with special attention given to the anatomical features of the region and their influence on success or failure. We conclude that the retrolabyrinthine approach for vestibular nerve section remains a safe and highly successful technique which merits continued use.

Lower cranial nerve schwannomas involving the jugular foramen

Schwannomas involving the jugular foramen are rare lesions, and no consensus exists on their management. This paper reports on 20 such cases treated in our centers. Nineteen cases were operated on for removal of the tumors, and the remaining case is being managed by watchful expectancy. Fifteen cases were operated on by the petro-occipital trans-sigmoid approach with or without labyrinthectomy, 2 by the infratemporal fossa approach, 1 by the modified transcochlear approach, and 1 by the jugulo-petrosectomy approach. The petro-occipital trans-sigmoid approach allowed single-stage, total tumor removal with preservation of the facial nerve and of middle and inner ear functions. Lower cranial nerve paralysis was the major complication and seemed to be inherent to the disease rather than to the approach used. No cerebrospinal fluid leak or meningitis occurred in the present series. So far, no recurrence has been detected.

Immunoglobulin-A and the pathogenesis of schistosomal glomerulopathy

Several observations suggest that the evolution of schistosomal glomerulopathy into clinically overt and progressive disease may involve pathogenetic mechanisms other than simple glomerular deposition of parasitic antigens. In a previous study, IgA was suggested to be a mediator of late glomerular lesions in this disease. This issue is further addressed in this work. The study includes 32 patients with hepatosplenic schistosomiasis, of whom 16 had overt glomerular involvement, along with four control groups: (a) 15 healthy volunteers; (b) 15 patients with simple intestinal mansoniasis; (c) 17 patients with non-schistosomal chronic liver disease; and (d) 21 subjects with primary nephrotic syndrome not associated with schistosomiasis. Routine assessment was done for all subjects including confirmatory tests for schistosomal infection, liver and renal function tests, hepatitis viral markers and abdominal ultrasonography. The total serum concentrations of IgG, IgM, IgA were measured, as well as their respective circulating immune complexes, rheumatoid factors, anti-gliadin- and anti-DNA-antibodies. Liver and renal biopsies were obtained from the relevant groups and studied by light microscopy. Renal biopsies were also examined by immunofluorescence. Patients with simple intestinal schistosomiasis had a significant increase in IgM antigliadin antibodies. Those complicated with hepatosplenic involvement also had a significant increase in the mean IgG anti-gliadin antibodies, IgG rheumatoid factor and IgM anti-DNA activity. Cases further complicated by overt glomerular disease showed a distinct IgA predominance, mainly expressed in the serum anti-gliadin antibody pool and anti-DNA activity. This profile was essentially similar to that observed in control cirrhotics. There was a significant increase in the frequency of IgA glomerular deposits in renal biopsies obtained from patients with overt schistosomal glomerulopathy, in contrast to control nephrotics. The deposits were mainly mesangial, but were also encountered in subendothelial, subepithelial and peritubular locations. Their frequency was significantly higher with more advanced lesions as seen by light microscopy. The relevance of these data is discussed, leading to the following conclusions: (a) serum IgA-anti-gliadin and -anti-DNA antibodies, and glomerular IgA deposits are markers of significant renal involvement in patients with hepatosplenic schistosomiasis. (b) IgA may be involved in the pathogenesis of advanced glomerular pathology when superimposed on parasite-induced lesions. (c) There is a significant increase in serum auto-reactivity in hepatosplenic schistosomiasis, which may also have pathogentic implications. (d) Increased production by the inflammatory bowel lesions, impaired clearance by the fibrotic livers and probable switching of immunoglobulin synthesis are suggested to explain the observed IgA predominance in those who develop renal complications.

Congenital cholesteatomas of the middle ear: a different experience

A retrospective analysis is presented of 44 cases of congenital cholesteatoma of the middle ear. Twenty-one patients had cholesteatoma localized to the posterosuperior mesotympanum in complete contrast to the commonly reported anterosuperior location seen in only two cases. The remaining 21 patients had cholesteatoma involving either the entire mesotympanum or epitympanum or both. The posteriorly located congenital cholesteatomas might represent a completely different entity and originate from the trapped epithelial cell rests in the posterior mesotympanum during the development of temporal bone. All but one patient were treated by using a closed tympanoplasty. Eight patients underwent a single-stage surgery. A preplanned second-stage procedure was performed in 33 patients, and three are awaiting their second stage. Residual disease was seen in 19 (57%) patients undergoing second-stage surgery. No patient has had recurrent disease so far. Thirty-eight (85%) patients had a preoperative air-bone gap of > or = 30 dB. Of the 33 patients considered for hearing results, 16 (48%) had a postoperative gap within 10 db.

Cholesteatoma surgery: the individualized technique

A retrospective analysis of 433 cholesteatoma cases, surgically treated at the Gruppo Otologico, Piacenza, Italy, over a 7-year period, is reported. The purpose of this study was to delineate actual indications for individualizing open and closed procedures and to compare their results as regards residual or recurrent disease and hearing. The total incidences of residual and recurrent cholesteatoma in the open cavity procedures were 10% and 2.38%, respectively, while the closed procedures showed higher incidences of residual and recurrent cholesteatoma: 31.22% and 11.16%, respectively. The problem of a persistently discharging cavity was encountered in only 1 case of an open procedure, while 2 patients had persistent otorrhea among the closed cavity cases. The hearing results, although slightly better in the closed procedures, were not significantly different from those in the open procedures.

[Meningoencephalic herniation into the middle ear]

Herniation of meningeal and/or encephalic tissue into the middle ear is a pathology which, even if rarely found by the otologist, can be life-threatening for the patient because of eventual infective intracranial complications. Four different etiological types are possible, infective, post-surgical, traumatic and spontaneous. From a pathogenic point of view, all types are characterized by a bony and dural defect localized in the tegmen through which meningeal and encephalic tissue can herniate. Symptomatology is often non-specific so that some cases are diagnosed during surgery. When there is strong suspicion of herniation neuroradiological assessment procedures must be carried out in order to make a correct pre-operative diagnosis, High Resolution Computed Tomography (HRCT) of the temporal bone in particular, can show the exact limits and location of the bone defect, while Magnetic Resonance Imaging (MRI) allows the nature of the tissue in the middle ear to be determined. Surgery is the only appropriate therapy. Different approaches have been described amongst which the transmastoid with or without temporal minicraniotomy and the middle cranial fossa (MCF) are the most frequently reported literature. From June 1982 to March 1994, 27 consecutive cases underwent surgery at the Gruppo Otologico, Piacenza. As a result of the occurrence of postoperative meningitis in one case, a new surgical technique through the MCF was standardized. The main step of this procedure consist in leaving the herniated tissue in situ so as to make a barrier between the middle ear and subdural space. The technique is indicated either in the case of large, multiple or very anteriorly located bony defects or when there is an infection in the middle ear.

Facial nerve neuromas: diagnosis and management

Facial nerve neuromas are uncommon tumors that involve the facial nerve. There is no classic presentation of these tumors. This study presents a series of 22 patients with facial neuromas managed from 1977 to 1993. Facial nerve dysfunction was the most common complaint, present in 90.5% of cases. Hearing loss was the second most common complaint and was found in 76.2% of cases. High resolution computed tomography and magnetic resonance imaging with gadolinium proved to be the most accurate methods of preoperative assessment of these tumors and are complementary in selected cases. Different surgical approaches were performed according to tumor location and preoperative hearing level. In all cases long-term follow-up showed no tumor recurrence, and acceptable return of facial function was noted in 80% of cases.

Surgical treatment of cholesteatoma in children

Treating cholesteatoma in children is still controversial. This article reviews 93 cases of pediatric cholesteatoma operated on from 1983 to 1991 in the Gruppo Otologico, Placenza, Italy, and details the results in 83 children who underwent the intact canal wall technique. During second-stage surgery, residual cholesteatoma was detected in 38% of patients. Recurrent cholesteatoma was detected in 10% of patients treated with the intact canal wall technique. Residual cholesteatoma was seen in the middle ear cleft in 63%, in the epitympanum in 26%, and in the mastoid in 11% of cases. Social hearing level (< 25 dB) was achieved in 85% of cases with suprastructure, whereas only 53% of patients without suprastructure had these levels. In the treatment of cholesteatoma in children by use of the intact canal wall technique, a preplanned second-look operation is mandatory to eradicate the disease.

Cerebrospinal fluid leak after translabyrinthine acoustic neuroma surgery

Cerebrospinal fluid leakage is the most common complication of translabyrinthine acoustic neuroma surgery. This retrospective study reviews patients who had translabyrinthine acoustic neuroma surgery at the Gruppo Otologico, Piacenza, Italy, and ENT Department of Bergamo General Hospital, Bergamo, Italy, during the last 6 years. The incidence of postoperative cerebrospinal fluid leakage was 6.2%, and 75% of these patients underwent another surgery to control the cerebrospinal fluid leakage. A modification of translabyrinthine approach was used in patients with highly pneumatized temporal bones to prevent cerebrospinal fluid leakage in these high-risk patients.

Cerebrospinal Fluid Leak after Translabyrinthine Acoustic Neuroma Surgery

Cerebrospinal fluid leakage is the most common complication of translabyrinthine acoustic neuroma surgery. This retrospective study reviews patients who had translabyrinthine acoustic neuroma surgery at the Gruppo Otologico, Piacenza, Italy, and ENT Department of Bergamo General Hospital, Bergamo, Italy, during the last 6 years. The incidence of postoperative cerebrospinal fluid leakage was 6.2%, and 75% of these patients underwent another surgery to control the cerebrospinal fluid leakage. A modification of translabyrinthine approach was used in patients with highly pneumatized temporal bones to prevent cerebrospinal fluid leakage in these high-risk patients.

Meningoencephalic herniation into the middle ear: a report of 27 cases

Meningoencephalic herniation into the middle ear is a rare and potentially life-threatening condition that may require prompt surgical intervention. Preoperative diagnosis is based on a high index of suspicion. Sometimes, however, meningoencephalic herniation is discovered during surgery. High-resolution computed tomography and magnetic resonance imaging should be performed to confirm the diagnosis and to evaluate the extension of the herniated tissue. This article discusses the diagnostic approach, management strategy, and surgical technique used in 27 patients with meningoencephalic herniation. In an attempt to avoid infective complications, the authors used the middle cranial approach in patients with large herniations.

[Incidence of normal hearing in acoustic neuroma]

Unilateral or asymetrical sensorineural hearing loss, tinnitus and instability classically represent the main symptoms for the suspected diagnosis of acoustic neurinoma. In literature there are very few studies which refer about acoustic neurinoma in patients with normal hearing. In this article we report the results of a retrospective analysis of 155 acoustic neurinoma cases with normal hearing managed in our center in the last 7 years. These patients are classified in two groups: 1) with normal hearing at the time of diagnosis and 2) with at least a mild sensorineural hearing loss. Of this 155 cases, 21 (13.5%) had normal pure tone audiogram. An important characteristic of these patients, in comparison with the group with normal hearing, is the younger age. Tinnitus, instability, sudden hearing loss with complete recovery and vertigo are the most common symptoms. The mean pure tone threshold is 14.7 dB, speech audiometry is positive in very few cases, while a large number of cases show false negative. ABR are positive in 90.5% of cases, and demonstrate its high sensitivity for retrococlear pathology. The mean tumor size shows significant differences between the group with normal hearing and this with hearing loss. We believe that the presence of this symptoms in a young patient should necessitate complete neurotologic examination and in the patients with normal hearing a high level of suspicion represents the first step for early diagnosis of small tumors; the next step is the through evaluation of patient with pure tone audiogram, ABR, and imaging studies, preferably MRI with gadolinium, as this permits the diagnosis of small intracanalicular tumor. Thus, in cases of small tumors with good hearing we feel that will be possible to adopt hearing conservation surgical approach like FCM and retrosigmoid approach in more cases.

Lower skull base: anatomic study with surgical implications

With advances in the lateral approaches to the skull base and the increasing success of the management of jugular foramen lesions, a thorough knowledge of the anatomy of this region is needed. The purpose of the present work is to study the detailed microsurgical anatomy of the lower skull base and the jugular foramen area as seen through the lateral approaches. Forty preserved skull base specimens and 5 fresh cadavers were dissected. The shape of the jugular bulb and its relationship to nearby structures were recorded. The different venous connections of the bulb were noted. The hypoglossal canal was identified and its contents were observed. The lower cranial nerves were studied at the level of the upper neck, at their exit from the inferior skull base, and in the jugular foramen. The results of the present study showed the complex and variable anatomy of this area. The classic compartments of the jugular foramen were not always present. Cranial nerves IX through XI followed different patterns while passing through the jugular foramen, being separated from the jugular bulb by bone, thick fibrous tissue, or thin connective tissue.

Intravenous drug addicts: a high risk group for infection with human immunodeficiency virus, hepatitis viruses, cytomegalo virus and bacterial infections in Alexandria Egypt

In this work the seroprevalence of HIV, HBV, HCV and CMV were studied among two groups of population; IVDA (intravenous drug addicts) (100) and control group (40). Syphilis and other bacterial infections which may be encountered among IVDA were also investigated. It was found that all serum samples (of both groups) were negative for anti-HIV. Regarding HBV markers, the prevalence of HBc antibodies was significantly higher among IVDA (62%) than the control group (27.5%). Also HBsAg was detected in 16% of IVDA while it was 75% among the control group. Prevalence of anti-HCV was significantly higher among IVDA (63%) than the control group (27.5%). The prevalence of co-infection with HBV and HCV was significantly higher in IVDA (40%) than the control group (15%). Sharing of needles and duration of drug use were positively associated with the presence of both HBV markers and anti-HCV. CMV seroprevalence was high in both groups. Antibodies to Syphilis were found in sera of 3 IVDA and one control using MHA-TP test. Although HIV infection has not yet been sufficiently introduced among IVDA in Alexandria but potentials for its spread among addicts are high as supported by observation that other infections with similar mode of transmission are common among addicts.

Surgical management of epitympanic cholesteatoma with intact ossicular chain: the modified Bondy technique

The results of 37 cases surgically treated with the modified Bondy technique during a 6-year period at the Gruppo Otologico-Piacenza, Italy, are reported. This technique, indicated in epitympanic cholesteatoma with good hearing and intact ossicular chain and pars tensa, provides a one-stage mastoid cavity exteriorization with radical removal of cholesteatoma while preserving the preoperative hearing levels. The technique, indications, results, and comparison with other current techniques are discussed in this article.

Revision stapes surgery: a critical evaluation

Fifty-six revision stapes surgeries performed during the last 9 years were evaluated retrospectively for their preoperative symptoms, intraoperative findings, and postoperative results according to the causes of failure, at the Gruppo Otologico, Piacenza, Italy. The most frequent causes of failure were found to be prosthetic misalignments, a reaction to the surgical trauma in the form of excess fibrous tissue reaction or new bony regrowth at the oval window, and ossicular chain problems. The location of the pathology was found to be an important factor in the outcome. Sixty percent of cases resulted in 0- to 20-dB air-bone gap. The causes of these failures, management, and their prevention during primary surgeries are also discussed.

Surgical anatomy of the petrous apex as it relates to the enlarged middle cranial fossa approaches

This work was designed to study the surgical anatomy of the petrous apex as it relates to the enlarged middle cranial fossa approaches, on 25 temporal bones. In this study we suggest dividing the petrous apex into two topographic areas: an anterior triangular and a posterior quadrangular area with respect to the posterior border of the Gasserian ganglion. Anatomic descriptions endorsed by relevant measurements of these areas are provided in this study.

The enlarged translabyrinthine approach for removal of large vestibular schwannomas

This study was carried out to validate the enlarged translabyrinthine approach for the surgical management of large vestibular schwannomas. A retrospective review of the charts of 53 patients with large tumours removed via the enlarged translabyrinthine approach at the Gruppo Otologico, Piacenza, Italy, during the last five years was carried out. The ability to control large tumours and the achievement of total removal with low morbidity and very few complications, demonstrate that tumour size does not influence the use of the enlarged translabyrinthine approach for managing large tumours.

[The extended middle cranial fossa approach: a morphometric analysis]

The extended middle cranial fossa (EMCF) approach calls for removal of the petrous bone from its subtemporal surface in order to well expose the internal auditory canal (IAC) and the posterior fossa dura (PDF) around its meatus, safeguarding, at the same time, all the important, closely related, anatomical structures (the Gasserian ganglion (GG) and its third trigeminal division, the internal carotid artery (ICA), the cochlea, the posterior labyrinth, the superior petrosal sinus (SPS), the inferior petrosal sinus (IPS) and the jugular bulb (JB). The middle meningeal artery, on the other hand, could be divided when necessary. We dissected 25 temporal bones preserved in formaldehyde and those of five cadavers in order to define the limits of this approach. Measurements were taken so as to establish the limits of the approach as well as to determine the most appropriate angles and distances in working in this area. As previously suggested by the Senior Author (MS), we found it safer to start working medially in order to identify the IAC and then to extend the dissection laterally. The most constant angle proved to be that between the IAC and the SPS. The distances and areas found appear to be highly variable and difficult to rely upon. A thorough knowledge of this anatomy is of most importance for the surgeon who intends to use this approach.

Vascular malformation of the internal auditory canal

A report of a case with a vascular malformation of the internal auditory canal (IAC) is presented. A review of the literature of this rather rare lesion is also made in an attempt to outline its clinical features, radiological diagnosis and management. The differential diagnosis and distinction between vascular malformations and other internal auditory canal tumours are discussed.