Adolescent survivors' information needs for transitions to postsecondary education and employment

BACKGROUND

Adolescent and young adult (AYA) survivors of cancer and central nervous system (CNS) tumors endure major life disruptions with their diagnosis, treatment, and the burden of emerging learning difficulties. Survivors and their parents often struggle to obtain more academic support as survivors transition through school. This study explored the knowledge and experience survivors and their parents need as they progress through school to college.

METHODS

This cross-sectional study examined childhood cancer and CNS tumor survivors, aged 11 to 21 years, with a known learning difficulty (Individual Education Plan, 504 Plan) and their parents. We assessed participants' knowledge of and experience with transition planning for postsecondary education and independent living.

RESULTS

Ninety-two AYA survivors and parents (45 survivors, 47 parents) completed the survey. High school-aged survivors described their learning difficulties better than middle school-aged survivors. Survivors estimated their abilities higher than did their parents. Despite a majority of survivors expecting to attend college, 68.5% of survivors and 57.9% of parents were not certain how to get special accommodations for standardized college entrance exams. Only 20.8% of survivors were aware of what a transition plan includes. Parents understood the transition planning process and when it should begin better than the students (P = 0.001), but many parents (40.0%) were still unsure.

CONCLUSIONS

AYA survivors and parents lack knowledge necessary to successfully transition to their goals after high school. Greater education is needed.

[Quality of life and job performance resulting from operatively treated tibial plateau fractures]

BACKGROUND

The aim of this article is to present the functional results and the effect on quality of life of surgically treated tibial plateau fractures in physically active and working patients with multiple and serious injuries. In addition, the relationships between functional and radiological outcome were evaluated and compared with activity in daily and professional life.

PATIENTS AND METHODS

In all, 41 injured patients were followed up a mean of 47 months after surgical treatment and examined with radiological, functional, as well as quality of life score.

RESULTS

In the radiological scoring, a mean value of 72 points (max 100 points) was achieved. In the activity score, there was an average of 63.5 points (max 100 points). When evaluating the health-related quality of life, an average score of 69.6 points was achieved. There was a significant relationship between radiological and activity scores and the radiological and life quality scores. Furthermore, the relationship between activity and quality of life scores was considered significant. Surgeon's influence on the functional outcome could be confirmed.

CONCLUSION

The functional and the radiological results were moderate. Quality of life was permanently affected by the consequences of tibial plateau fracture in 12 patients; 11 patients were not re-employed. However, the quality of life was assessed as good or very good and 28 patients had returned to work. The quality of life was firmly linked to the radiological and functional parameters, which tended to be influenced by the quality of the primary surgical treatment when looking at the overall population.

Randomized placebo-controlled study of lovastatin in children with neurofibromatosis type 1

OBJECTIVE

To assess the efficacy of lovastatin on visuospatial learning and attention for treating cognitive and behavioral deficits in children with neurofibromatosis type 1 (NF1).

METHODS

A multicenter, international, randomized, double-blind, placebo-controlled trial was conducted between July 2009 and May 2014 as part of the NF Clinical Trials Consortium. Children with NF1 aged 8-15 years were screened for visuospatial learning or attention deficits (n = 272); 146 children demonstrated deficits at baseline and were randomly assigned to lovastatin (n = 74; 40 mg/d) or placebo (n = 70). Treatment was administered once daily for 16 weeks. Primary outcomes were total errors on the Cambridge Neuropsychological Test Automated Battery Paired Associate Learning task (visuospatial learning) and the Score subtest from the Test of Everyday Attention for Children (sustained attention). Secondary outcomes measured executive function, attention, visuospatial skills, behavior, and quality of life. Primary analyses were performed on the intention-to-treat population.

RESULTS

Lovastatin had no significant effect on primary outcomes after 16 weeks of treatment: visuospatial learning (Cohen d = -0.15, 95% confidence interval -0.47 to 0.18) or sustained attention (Cohen d = 0.19, 95% confidence interval -0.14 to 0.53). Lovastatin was well tolerated, with no increase in reported adverse events compared to placebo.

CONCLUSIONS

Lovastatin administered once daily for 16 weeks did not improve visuospatial learning or attention in children with NF1 and is not recommended for amelioration of cognitive deficits in this population.

CLINICALTRIALSGOV IDENTIFIER

This study was registered at ClinicalTrials.gov (NCT00853580) and Australian New Zealand Clinical Trials Registry (ACTRN12607000560493).

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that for children with NF1, lovastatin does not improve visuospatial learning or attention deficits.

[Limits to arthroscopic treatment of degenerative triangular fibrocartilage complex lesions depending on the ulnar variance]

PURPOSE

The present prospective study investigated the influence of the static ulnar variance on the success of arthroscopic debridement of degenerative TFCC lesions.

PATIENTS AND METHODS

10 patients with an ulnar positive variance ("Ulna+") and 12 patients with ulnar neutral or ulnar negative variance ("Ulna-/0") were examined preoperatively (U0), as well as at 2 (U2) and 6 (U6) months after arthroscopic debridement of degenerative TFCC lesions and compared with each other. After the U2 investigation due to persistent complaints in 9 of 10 patients with an ulnar positive variance there was a need for further surgery, consisting of ulnar shortening osteotomy (USO). The following parameters were recorded in each case: pain at rest and with load, the summed wrist range of motion - consisting of extension and flexion, radial and ulnar deviation, pronation and supination - compared to the contralateral side, the strength of the affected hand compared to the contralateral side, the Mayo modified wrist score (MMWS), the Krimmer score and the DASH score. Preoperatively there were no significant differences between the 2 cohorts "Ulna+" and "Ulna-/0" except for the characteristic "pain at rest".

RESULTS

At 2 months postoperatively (U2), the results in the cohort "Ulna+" remained at a significantly or tendentially poorer level compared to the cohort "Ulna-/0". The subsequent surgical treatment of the subgroup "Ulna+" with USO led to almost complete approximation of the results at 6 months postoperatively (U6). In addition to this, with time (U6) within each subgroup there were tendential or significant improvements of all characteristics compared to the preoperative situation (U0). At U6 four of 22 patients were -unable to work.

CONCLUSION

Degenerative lesions of the TFCC can be treated successfully by arthroscopic debridement in cases of ulnar negative and ulnar neutral variance. Patients with ulnar positive variance and persistent complaints after debridement of the TFCC can be treated successfully with a secondary ulnar shortening osteotomy.

[Successive ruptures of patellar and Achilles tendons. Anabolic steroids in competitive sports]

Derivatives of testosterone or of 19-nor-testosterone are used as anabolics for the purpose of improving performance although the effect of anabolics is known still to be under discussion. The use of anabolic steroids continues among competitive athletes despite increased controls and increasingly frequent dramatic incidents connected with them. Whereas metabolic dysfunction during anabolic use is well documented, ruptures of the large tendons are rarely reported. Within 18 months, a 29-year-old professional footballer needed surgery for rupture of the patellar tendon and of both Achilles tendons. Carefully directed questioning elicited confirmation that he had taken different anabolic steroids regularly for 3 years with the intention of improving his strength. After each operation anabolic steroids were taken again at a high dosage during early convalescence and training. Minimally invasive surgery and open suturing techniques led to complete union of the Achilles tendons in good time. Training and anabolic use (metenolon 300 mg per week) started early after suturing of the patellar tendon including bone tunnels culminated in histologically confirmed rerupture after 8 weeks. After a ligament reconstruction with a semitendinosus tendon graft with subsequent infection, the tendon and reserve traction apparatus were lost. Repeated warnings of impaired healing if anabolic use was continued had been given without success. In view of the high number of unrecorded cases in competitive and athletic sports, we can assume that the use of anabolic steroids is also of quantitative relevance in the operative treatment of tendon ruptures.

[Implantation of matrix-free cartilage transplants in standardized defects in sheep knee joints]

The goal of the current investigation was to make a comparative analysis of regenerative tissue after autologous de novo cartilage transplantation on the femoral condyles of sheep after a chondral defect. One chondral defect measuring 4 mm in diameter was placed in the center of one medial femoral condyle of each of 48 Suffolk sheep. Twelve defects were left to heal spontaneously, 16 defects were covered with periosteal flaps, and 20 defects were filled with autologous de novo cartilage graft. Macroscopic and microscopic assessments were performed at 26 and at 52 weeks. Regeneration was significantly better (p<0.05) in the transplant group than in the control groups at both 26 weeks and 52 weeks. The differences were most evident in the grade of defect filling, cartilage stability, cell distribution, and matrix assessments. Transplantation of immature, autologous de novo cartilage leads to qualitatively better regeneration both macro- and microscopically than does periosteal flap placement alone. The transplanted, immature cartilage tissue undergoes maturation in vivo. The regenerated tissue has hyaline-like features.

[Lecture disasters - and how to prevent them]

Presentations at medical conferences can sometimes confuse or compromise understanding of current topics. Although considerable time and financial costs may be taken to be present at such events, all too often one must go through inferior presentations that are poorly structured and do not contribute to one's understanding of the topic at hand. A good presentation is distinguishable by the clear intentions of the speaker to give a good lecture. The presenter has worked extensively with his topic and is familiar with the audience. The presentation has a clear structure and finishes with a take-home message. The speaker takes the listener from his previous level of knowledge to a new understanding. To do so, both voice and body language are used. The supporting slides are simple and direct, and not overloaded with information. The speech conforms exactly with the pre-determined time limit.

Multislice-Spiral-CT zur Diagnostik beim Polytrauma

BACKGROUND

In severely injured patients, diagnostic procedures should be as brief as possible. With the use of spiral CT technology, the time required for diagnosis is minimized.

QUESTION

Do severely injured patients benefit when primary diagnostic examinations are completed in less than 30 min? How much time is required for primary emergency department (ED) care and how much in the CT scanner?

MATERIAL AND METHODS

Between 31 July 2001 and 31 December 2003, severely injured patients with ISS scores over 16 underwent total body spiral CT scans (Siemens Somatom Volume Zoom Multislice CT) after initial ultrasonography. One hundred patients (M:F=25:75) with an average age of 42 years (range: 3-81 years) were evaluated retrospectively. The average ISS score was 32.8+/-12 points (range: 17-75 points).

RESULTS

The average time in the ED, prior to CT, was 33+/-14 min. The CT scans lasted 16+/-5 min and the total diagnostic time was 48+/-14 min. Fifty percent of patients were taken immediately to the operating room. The mortality rate in hospital was 13%. The average hospital stay was 30 days, with an average ICU stay of 10 days.

CONCLUSION

The shorter the time spent in the ED, the shorter the stays in ICU and in total hospitalization were, regardless of injury severity. With structured management and shortening of diagnostic time with spiral CT, the time in the ED was decreased from 85 to 48 min.

[Multistep surgery for spondylosyndesis. Treatment concept of destructive spondylodiscitis in patients with reduced general condition]

OBJECTIVE

Retrospective assessment of multistage surgery in the treatment of progressive spondylodiscitis in patients with critical physical status.

PATIENTS

A total of 34 patients (mean age 58.6 years) with 37 progressive spondylodiscitis foci and destruction of one to three vertebral segments (1.9 mean) were recorded within an 8-year period. Time between first complaints and operative treatment was 3 months (mean). Preoperative health status was critically reduced in 11 patients (ASA IV) and poor general condition (ASA III) was seen in 23 patients when vital indication was seen preoperatively. Considerable systemic disease (n=31), further infection focus (n=18), and nosocomial trauma (n=5) were causally related. Spondylodiscitis was seen more frequently in the lumbar (n=20) and thoracolumbar than in the thoracic (n=10) and cervical spine (n=1). Staphylococcus aureus was detectable from operative specimens and hemoculture in 15 cases, MRSA in 6 of these.

METHODS

In cases of monosegmentary involvement (n=7) ventral debridement, biopsy, and application of antibiotic chains were followed by autologous interbody bone grafting in a second stage operation. In 29 cases with destruction of two (n=27) and three (n=3) segments, posterior instrumentation including laminectomy in 4 patients was completed by anterior debridement and application of antibiotic chains during a first surgical intervention. After stabilization of physical condition and having reached a macroscopically indisputable implant bed, the ventral fusion with autologous interbody bone grafting or cage in combination with a plate or internal fixation system was performed as the last of several surgical steps.

RESULTS

No case of perioperative mortality was observed. Intensive care continued 9.1 days and hospitalization 49.5 days (mean). During a 37.6-month follow-up two late recurrences were observed.

CONCLUSION

A multistep surgical procedure under protection of dorsal instrumentation can limit perioperative mortality in patients in critical general condition by avoiding an extended one stage dorsoventral spondylodesis. After eradication of further infection foci and stabilization of physical condition, ventral instrumentation is completed under elective conditions.

[Multidirectional atlantoaxial instability of an os odontoideum in an adult]

Increasing neck pain in a 29 year old woman after a frontal car collision gave reason for a conventional x-ray that presented a traumatically displaced os odontoideum positioned at the top of the dens axis. No neurological defect was seen. Dynamic flexion/extension film showed a movement to an atlantoaxial dislocation with a shift of the os odontoideum. The sclerotic structure of the corresponding bony surfaces was confirmed by computed tomography, whereas magnetic resonance imaging demonstrated a posttraumatic signal change in front of the base of dens axis and os odontoideum. Fusion was achieved by computed navigation with C1/C2 transfacetal screws as described by Magerl and interspinal fusion with a bicortical autologous iliac crest graft and a posterior tension band as described by Brooks. An exact positioning of screws past the asymmetric course of both arteria vertebrales was possible by navigation. The patient was free of pain 5 months after the fusion.

[Experience with elastic stable intramedullary nailing (ESIN) of shaft fractures in children]

The aim of this prospective clinical controlled trial was to investigate the early and midterm results of shaft fractures in children treated with elastic stable intramedullary nailing (ESIN). From January 1997 to December 2001, elastic stable intramedullary nailing was carried out on 112 children with 118 diaphyseal fractures. The mean age was 7.7 years. There were 51 fractures of the lower arm, 46 femoral fractures, 14 of the lower leg, and 7 of the humerus. A total of 92 children have been followed up for more than 12 months. The mean time of follow-up was 38 months.The mean time of fluoroscopy was 2.2 min. Open reduction was necessary in 3.4 %. In children with injuries of the lower extremity, full weight bearing was achieved after a mean period of 9.3 days. In 1.8% of the children, reoperation was necessary within the first 10 days after the operation. In 3.6 % there was painful skin irritation due to the protruding end of a nail. No infection or delayed union was observed. Implant removal was done after a mean time of 5.6 months. There was no rotational or angular deformity of more than 5 degrees in children with isolated fractures of the lower extremity. Mean lengthening of the injured leg was 2.4 mm. In three children who had fractures of the upper extremity, a deficit in range of motion of the adjacent joints was detected. The current results show that intramedullary fixation of displaced diaphyseal fractures in children with a flexible titanium nail is a safe, minimally invasive surgical technique producing excellent functional and cosmetic results.

Pitfalls und Komplikationen der elastisch stabilen intramedull�ren Nagelung (ESIN) von Femurfrakturen im Kindesalter

BACKGROUND

The aim of this prospective study was to evaluate the intra- and postoperative problems as well as the complications of elastic stable intramedullary nailing (ESIN) of femur fractures in children.

PATIENTS AND METHODS

47 consecutive children, mean age 6 years, were reviewed clinically and radiologically until hardware removal and after this annually. Mean time of follow up was 37 months.

RESULTS

Intraoperatively one cortex perforation and one displacement of a third fragment occurred. Two correction operations were necessary: In one case due to an implant displacement and in another case due to an unacceptable loss of reduction. There were no infections, non union, implant breakage, refracture or disturbance of growth.

CONCLUSIONS

ESIN is a safe procedure in femoral shaft fractures of children. Most of the problems and complications can be avoided by a careful consideration of the indication and a correct operation technique.

[Minimal invasive biological osteosynthesis of the clavicle with a titanium nail]

Until December 2001 84 midclavicular fractures in 80 patients were treated with intramedullary nailing. Postoperatively there was a significant decrease of pain and a significant increase of mobility compared to the situation preoperatively. 6 months after hardware removal the mean Constant-Score was 97.4 points. There was one none union. In one patient there was a loss of reduction with shortening of 1.5 cm. In 5 patients a shortening of the proximal end of the nail had to be performed, due to painful skin irritation. Intramedullary nailing of midclavicular fractures is a safe and minimally invasive operation technique. It should be offered to the patient as an alternative to conservative treatment.

[LISS versus condylar plate]

Up to the seventies the surgical treatment of supra- and bicondylar femoral fractures was difficult and showed a lot of complications. In most studies a conservative treatment was recommended. In the least 30 years the clinical outcome after surgical treatment improved. This was a result of the development of new implants and improved surgical techniques. However, today the primary surgical treatment is the therapy of choice. We reviewed from 1986 to 2001 n = 121 distal femoral fractures which were in 32 cases treated with a Condylar Blade Plate and in 10 cases with a less invasive stabilisation system (LISS). The final results after condylar blade plating were rated using the system that was described by Neer. The averaged follow up time was 9 years. Low postoperative infection rates and in 75% excellent and satisfactory results combined with low cost are the reference for the evaluation of the LISS results. While in our owen series according to the literature there were no significant better functional results for the LISS group than for the Condylar Blade Plate group there were only few autologous bone grafts necessary. Due to the angle-stable self-drilling and self-cutting screws and the Internal-Fixater Principle the LISS has some mechanical and biological edge on the condylar blade plate.

[Candida infection in hip alloarthroplasty]

A 46-year-old polytoxicomanic patient underwent a total hip replacement for necrosis of the femoral head. The patient suffered additionally from chronic pancreatitis with insulin-dependent diabetes and polyneuropathy. Three weeks later he developed a deep wound infection followed by surgical revision. The infection persisted despite further revision operations and systemically and locally applied antibiotics. After removal of the prosthesis,microbiology revealed Staphylococcus aureus, enterococcus,and Candida parapsilosis. Five additional revision operations, application of suction-irrigation drainage, and systemically administered antibiotics could not stop the infectious process. The patient was transferred to our institution 3 months after primary surgery. The joint defect was filled with a PMMA Palacos spacer. This time biopsies were only positive for Candida albicans. After 12 days of antifungal therapy with fluconazole,microbiological biopsies were sterile. The spacer was removed and femoral extension applied. After 4 weeks of further antifungal therapy, a revision prosthesis was implanted. Until now no signs of infection have appeared.

[Palmar lunate dislocation]

Palmar lunate dislocation as the end stage of a perilunate dislocation is a very uncommon injury. Having treated 19,534 hospitalized patients between 1 January 1986 and 1 October 2001 the diagnosis was recorded in four male trauma patients (33, 36, 37 and 62 years old). Among the operatively treated carpal dislocations and carpal fracture dislocations those of the lunate were seen in five per cent. The dislocation was caused in by an acute hyperextension injury resulting of falls from heights in three cases, and of a motorcycle accident in a further case. In two of these cases a complete palmar lunate dislocation was analysed that were produced by fall from seven meters heights of a young craftsman and by accident of a motorcyclist. First using a longitudinal palmar approach in both cases a revision of the hemorrhagic carpal canal was performed urgently, the largely denuded lunate was reduced and the repair of identified ligamentous structures was performed by means of sutures respectively suture anchors. Reduction was stabilized with Kirschner wires. Afterwards performed computed tomography identified the result of reduction and associated defects (subluxation distal radioulnar joint). In one patient a soft tissue infection prevented the dorsal ligamentous repair. In spite of a consequent after-treatment and a good functional result a scapho-lunate dissociation was proved. An avascular defect of the lunate could be excluded by magnetic resonance imaging. In case of a secondary performed dorsal repair a persisting carpal stabilization with a satisfactory functional result could achieved. At second hand an advanced carpal collapse was proved.

CONCLUSIONS

If reduction cannot be achieved by closed manipulation or a loss of reduction is shown, open reduction is indicated first by a palmar approach. An additional dorsal ligamentous repair seems to be necessary. Transfixation by Kirschner wires and suture anchors stabilize the restored anatomic relationships. Wrist immobilization in a cast for at least eight weeks is recommended. Although ligamentous insufficiency, osteoarthrosis and avascular necrosis are often proved, functional results are satisfactory.

[Linezolid--a new antibiotic for treatment of methicillin resistant Staphylococcus aureus infections in trauma surgery? Report of 2 cases]

PROBLEM

Infections with Methicillin-resistant Staphylococcus aureus are reported increasingly in intensive care unit and ward, that means not only a dangerous disease but also a considerable expenditure factor.

METHODS

In trauma surgery we could observe the Linezolid treatment of 2 patients with a MRSA infection. After treatment with Vancomycin and further evidence of MRSA the application of Linezolid was continued during 3 weeks accompanied by further microbiologic investigations.

RESULTS

In a 73 year old man with humerus shaft fracture the MRSA osteomyelitis was eradicated with Linezolid (600 mg/day per os over 3 weeks) after radical débridement and reosteosynthesis. The MRSA pneumonia in a 14 year old girl was treated successfully by Linezolid (600 mg/day i.v. over 3 weeks) and pneumotherapy. Follow up excluded further MRSA infection.

CONCLUSIONS

Linezolid represents an efficient new reserve antibiotic. In case of pneumonia, severe skin and soft tissue infections good results can be expected. The treatment of osteomyelitis has been reported only in single cases.

[Unusual removal of a Küntscher nail after 35 years]

A 68 year old patient with persistent feeling of sickness and increasing pain in the left forearm was seen. A complex both bone fracture of the distal forearm shaft had been stabilized with Küntscher nails in radius and ulna 35 years ago. The loose ulna nail had been removed after ten weeks. Reosteosynthesis twelve months later with a Küntscher nail and cerclages had led to osteomyelitis and persistent bone defect, possibly caused by galvanic reaction between the different alloyies. A lymphocyte transformation test with nickel sulphate confirmed an allergic reaction and supported the indication to late implant removal. After exposure of the nail's end by a short approach a sufficient take over of power to the implant was reached by a coupling pole. Extraction was stopped after two centimetres by a blockage of the nail. Widening the entry of nail and drilling its whole notch by means of a Kirschner wire using the radiolucent ruler and by the repeated extraction and reinsertion led finally to the complete removal of the nail. Whereas local pain is disappeared three month after removal presenting bland local findings the general condition is improved slowly. Already Küntscher described the blockage of his nail after a short distance extraction. In addition to a number of not always successful means of extraction this method is described for the first time.

[Idiopathic sclerosing mesenteritis. Case report and differential diagnosis of a rare disease picture]

We report the case of a 78-year-old woman with the endoscopic tentative diagnosis of a malignant tumor of the colon ascendens (biopsy without malignancy) that was removed by right hemicolectomy. Extensive mesenteric infiltration and colonic obstruction seemed to confirm this diagnosis. Surprisingly histology revealed invasion by sclerosing mesenteritis. The differential diagnoses include inflammatory pseudotumor, tumor-like fibromatosis at traumatized sites, idiopathic retroperitoneal fibromatosis, sclerosing malignant lymphoma, liposarcoma and drug-induced sclerosing mesenteritis, as well as mesenteric infiltration and metastases. Though preoperative diagnosis is not possible in most cases, the intraoperative macroscopic appearance and the histopathologic picture are conclusive.

CFTR channel insertion to the apical surface in rat duodenal villus epithelial cells is upregulated by VIP in vivo

cAMP activated insertion of the cystic fibrosis transmembrane conductance regulator (CFTR) channels from endosomes to the apical plasma membrane has been hypothesized to regulate surface expression and CFTR function although the physiologic relevance of this remains unclear. We previously identified a subpopulation of small intestinal villus epithelial cells or CFTR high expressor (CHE) cells possessing very high levels of apical membrane CFTR in association with a prominent subapical vesicular pool of CFTR. We have examined the subcellular redistribution of CFTR in duodenal CHE cells in vivo in response to the cAMP activated secretagogue vasoactive intestinal peptide (VIP). Using anti-CFTR antibodies against the C terminus of rodent CFTR and indirect immunofluorescence, we show by quantitative confocal microscopy that CFTR rapidly redistributes from the cytoplasm to the apical surface upon cAMP stimulation by VIP and returns to the cytoplasm upon removal of VIP stimulation of intracellular cAMP levels. Using ultrastructural and confocal immunofluorescence examination in the presence or absence of cycloheximide, we also show that redistribution was not dependent on new protein synthesis, changes in endocytosis, or rearrangement of the apical cytoskeleton. These observations suggest that physiologic cAMP activated apical membrane insertion and recycling of CFTR channels in normal CFTR expressing epithelia contributes to the in vivo regulation of CFTR mediated anion transport.

[Candida spondylitis. Case report and review of the literature]

Candida species have emerged as important pathogens in human infection. Although a variety of deep-seated candidal infections have been reported, Candida spondylitis has rarely been described. One patient with candida tropicalis spondylitis L I and L II in combination with candida coxitis is presented, and the 31 adult cases with vertebral involvement previously reported are reviewed. Candida spondylitis is noted as a simultaneous occurrence or late manifestation of hematogenously disseminated candidiasis. Spondylitis may not be prevented by a course of Amphotericin B adequate to control the acute episode of disseminated candidiasis, particularly in immune suppressed patients. Spondylitis does not present as a postoperative wound infection. The insidious progression of infection, the nonspecificity of laboratory data, and the failure to recognise Candida as a potential pathogen may lead to diagnostic delay. Diagnosis can be made by either open biopsy or CT controlled needle aspiration. Successful therapeutic regimes have employed combinations of antifungal therapy (Amphotericin B or fluconazole) with radical surgical debridement. Ventral and facultatively dorsal instrumentation is required to stabilize the spine. It is anticipated that the spondylitis will become a more commonly recognised manifestation of hematogenously disseminated candidiasis. A increasing significance of candida species as etiologic agents of infection immune compromised humans has been recognised in the recent years. In those patients whom an antecedent Candida septicaemia was documented, a striking delay of 3.3 months was found between the septicaemia and the onset of symptoms as well as the time of diagnosis.

Agents used in the prevention and treatment of nonsteroidal anti-inflammatory drug-associated symptoms and ulcers

Coprescription of gastroprotective agents is a common practice for patients requiring nonsteroidal anti-inflammatory drug (NSAID) therapy, although there is limited evidence that some of these agents are effective. The prostaglandin analog misoprostol and the proton pump inhibitor omeprazole appear to be efficacious in decreasing NSAID-associated ulcers. Misoprostol has also been shown to decrease NSAID-associated gastrointestinal (GI) complications by 40% compared with placebo. Despite the efficacy of these drugs, their effectiveness in the general population has not yet been adequately determined with respect to reduction of symptoms and improvement in patient quality of life. Sucralfate and bismuth appear to be largely ineffective, and histamine receptor antagonists, when given at traditional ulcer-healing doses, decrease symptoms and duodenal ulcers only. The issue of outcomes research, therefore, needs to be more fully incorporated into any analysis of the effectiveness or cost-effectiveness of the widespread clinical use of such gastroprotective drugs.

Coexpression of MUC1 mucin peptide core and the Thomsen-Friedenreich antigen in colorectal neoplasms

BACKGROUND

Controversial findings have been reported regarding the expression of the Thomsen-Friedenreich (TF) antigen in colorectal neoplasms when different monoclonal antibodies (MoAbs) have been used. Moreover, there is no information available regarding the carrier protein(s) of this antigen.

METHODS

Forty-five colorectal adenomas and 48 carcinomas were studied by avidin-biotin complex-peroxidase immunohistochemistry. The immunohistochemistry employed the MoAb BW835, which was reactive to a carrier specific and site specific TF antigen on MUC1 mucin, as well as reference antibodies directed to MUC1 (HMFG2) or MUC2 core peptides (4F1) and directed to TF antigen irrespective of its carrier (A78-G/A7, peanut agglutinin). To evaluate the coexpression of different epitopes by the same antigen, sandwich enzyme-linked immunoadsorbent assays were performed.

RESULTS

Although MUC1 peptide antigen and MUC1-bound TF antigen were not detectable in normal or transitional mucosa surrounding colorectal neoplasms, expression of these antigens in adenomas accompanied the development of high grade dysplasia. By contrast, MUC2 expression detected by the MoAb 4F1 was inversely correlated with the progression of the adenoma-carcinoma sequence. In well- and moderately differentiated colorectal carcinomas, the neo-expressed TF antigen is predominantly bound to MUC1. This feature could be demonstrated by antigen coexpression using peptide and the TF antigen specific MoAbs. However, in mucinous carcinomas exhibiting a weak MUC1 peptide expression in most specimens, the presence of TF antigen on the MUC2 peptide core cannot be ruled out.

CONCLUSIONS

TF antigen is strongly coexpressed with MUC1 mucin peptide core in the colorectal adenoma-carcinoma sequence, resulting in well- and moderately differentiated carcinomas. Only in mucinous carcinomas may it be coexpressed with MUC2 antigen.

Liver lectin blocking with D-galactose to prevent hepatic metastases in colorectal carcinoma patients

Animal experiments in BALB/c-mice and in DBA/2-mice confirmed that lectin blockade with D-galactose containing receptor analogues can inhibit metastatic spread into the liver. The number of liver colonies of inoculated tumor cells was significantly reduced after D-galactose treatment as compared to animals of control group. Based on experimental investigations 193 colorectal carcinoma patients (UICC stages I-III) were enrolled in a prospectively randomized clinical trial. 93 patients were treated perioperatively with D-galactose- (treatment group: 1.5 g/kg body weight and per day) or D-glucose containing electrolyte infusions (control group: n = 100). Significant side effects were not observed. There were no cases of perioperative mortality. The overall complication rate was 7.3%. Since tumor stages were unequally distributed, analysis was performed in strata. Patients were observed for a total of 6237 months. Differences in overall survival and survival free of recurrence and hepatic metastases were negligible for stages I and II. For stage III carcinoma patients (n = 75) analysis of survival free of hepatic metastases revealed a shift to delayed events (i.e. hepatic metastases or death) after D-galactose treatment within 24 months following surgery. In patients with stage III carcinoma there was an indication for an overall benefit in survival after D-galactose treatment (p = 0.102).

Colorectal carcinoma--aspects of surgery in the elderly

In accordance with the aging of the German population an increasing number of surgical procedures are performed on patients of advanced age. Perioperative data from 441 patients (223 women, 218 men, mean age 64.1 +/- 11.7 years) undergoing colorectal carcinoma resection 133 were aged 70 years and older, 308 were younger than 70 years-were prospectively recorded. Risk factors were found more frequently in the elderly (hypertonus 49% vs. 34%; coronary artery disease 18% vs. 8%; pulmonary disease 39% vs. 31%, gastrointestinal disease 30% vs. 23%). No differences were found in operative (loss of blood, duration of operation, ventilation) and postoperative parameters (intensive care, hospitalization) neither age dependent nor between elective and emergency surgery. Postoperative complications in electively treated patients, such as pneumonia, wound infection, urinary tract infection, pulmonary complications, and anastomotic leakages were not age dependent. Although cardial complications were recorded five times as often in electively treated elderly patients perioperative mortality was unchanged (0.8% vs. 0.9%). After emergency operations the rate of anastomotic leakage after perforating peritonitis was increased in the elderly (5.5%). In particular, cardial complications during emergency surgery in 50% of the elderly had a causal connection with perioperative mortality that was substantially increased by up to 28.6%.

Diagnostic yield of duodenal biopsy and aspirate in AIDS-associated diarrhea

OBJECTIVES

To evaluate the diagnostic yield of performing duodenal biopsies and aspirates in AIDS patients with chronic diarrhea.

METHODS

Retrospective review of esophagogastroduodenoscopy (EGD) records from January 1993 to March 1995 to identify those patients who underwent EGD for evaluation of AIDS associated diarrhea and had a duodenal biopsy and/or aspirate. Biopsies were examined for pathogens using routine histology and special stains, viral culture, and electron microscopy. Duodenal aspirates were evaluated for ova and parasites. All patients had previous negative stool studies. Pathology laboratory charges (hospital and professional fees) for each test and charges per positive test were determined.

RESULTS

Of the 57 patients included in this study, 56 had a duodenal biopsy and 42 had a duodenal aspirate. An established pathogen was identified in only 15 (26%) patients. One patient had both Mycobacterium avium complex and microsporidia. Pathogens were identified in seven patients by hematoxylin and eosin stain, in three patients by acid-fast bacillus stain, and in six patients by electron microscopy. No pathogens were identified with Gomori's methenamine silver stain (44 patients), duodenal aspirate for ova and parasites (46 patients), immunoperoxidase stains (4 patients), or viral culture (4 patients). Cryptosporidia were identified in six, microsporidia in five, Mycobacterium avium complex in three, and Giardia lamblia and adenovirus each in one patient.

CONCLUSIONS

In this series, the diagnostic yield of EGD with duodenal biopsy and aspirate in AIDS associated diarrhea was low. Pathogens were identified in 26% of patients; predominantly Cryptosporidium organisms and microsporidia. The routine performance of aspiration of duodenal contents for parasite examination and staining of duodenal tissue with Gomori's methenamine silver stain for fungal identification are not recommended. One should consider obtaining tissue for electron microscopy whenever duodenal biopsies are performed. The utility of EGD in AIDS associated diarrhea may improve as more effective therapies become available.

Gender related survival in colorectal cancer

The importance of patient characteristics to long term survival in colorectal carcinoma is the subject of much debate. The importance of female gender as an advantagous factor in prognosis is difficult to determine. A retrospective study based on data from 1050 patients resected for colorectal carcinoma was carried out. A complete follow-up and survival data were available. Categorical variables such as age, sex, tumor stage and location, perioperative blood transfusions, and postoperative complications were used. Standard univariate and multivariate descriptive analysis was applied. In addition to tumor staging patients' sex was a strong significant factor on prognosis. When analysed independently of tumor location, blood transfusions, and severe complications, sex was revealed to be a statistically significant independent prognostic factor in longterm survival. The 5-year survival rate for men was 43.5 % and 54.7 % for women. When the observed survival was compared with sex related life expectancy of a representive population, similar differences of survival were seen for both sexes.

Treatment of liver metastases from colorectal cancer

197 cases of distant metastases from colorectal cancer (Dukes A, B, C) were diagnosed in 664 patients after curative resection of the primary tumor. Extrahepatic progress could be excluded in 98 of 142 patients with liver metastases. These 98 patients were allocated to surgical treatment (n = 17), intraarterial chemotherapy (n = 24), transarterial chemoembolization (n = 20), systemic chemotherapy (n = 10) and syptomatic therapy (n = 27) depending on the extent and localization of the disease within the liver and the patients' general condition. Curative success in 12 of 17 patients with a 5-year survival of 47% was achieved by the careful selection of patients for surgical treatment. Prolonged median survival after systemic chemotherapy (13 months), intraarterial chemotherapy (11 months) and transarterial chemoembolization of hepatic metastases (12 months) compared with the survival of patients with a symptomatic treatment only (median 11 months) could not be demonstrated, in spite o local therapeutic effects (intraarterial chemotherapy response rate 42%, transarterial chemoembolization morphologic response 82%). Effective postoperative diagnostic screening determines the percentage of potential curative surgical treatment; nonsurgical approaches failed to demonstrate prolonged survival.

Immunostimulation by propionibacteria--effects on immune status and antineoplastic treatment

Experimental studies were performed to investigate further the effects of immunotherapy with Propionibacterium avidum KP-40 on thymocyte proliferation, maturation and emigration in BALB/c-mice. Thymus weight and thymocyte counts, especially cells presenting the immature or cytotoxic/suppressor phenotype were significantly increased. Due to enhanced emigration, peripheral blood lymphocyte and monocyte counts as well as expression of activation markers were significantly upregulated. The antimetastatic effect of Propionibacterium avidum KP-40 was demonstrated in BALB/c-mice, where RAW 117-H10 lymphosarcoma liver colonization was significantly reduced after immunostimulation. Clinical investigations proved that surgical treatment of colorectal carcinoma induced an evident decrease of peripheral blood lymphocytes as compared with preoperative counts. However, single preoperative Propionibacterium avidum KP-40 administration induced a considerable increase of peripheral white blood cell counts, especially lymphocytes. Clinical effects of preoperative immunostimulation by Propionibacterium granulosum KP-45 were investigated in a prospective randomized trial in colorectal carcinoma patients. Positive effects on survival time, local tumor recurrence and distant metastasis could be demonstrated in stages I and II, whereas no advantage of immunotherapy was found in advanced stages III and IV. A recent prospective randomized clinical trial was initiated on the quality of life of colorectal carcinoma patients. Three months after surgical treatment negative effects could not be determined after immunotherapy. Quality of life even proved to be better in patients with abdominoperineal resection as compared to non Propionibacterium avidum KP-40 treated control patients.

Middle and lower third rectum carcinoma: sphincter saving or abdominoperineal resection?

Sphincter saving resections (SSR) are performed with increasing frequency in carcinoma of the lower and middle third of the rectum. In this retrospective study local and distant recurrence and survival were compared to abdominoperineal resection (APR). In 71 women and 71 men (mean age: 64 years) with a primary adenocarcinoma between 5 and 10 cm from the anal verge 89 SSR, and 53 APR, were performed (Dukes stages--SSR--A 19%; B 30.3%; C 50.7% vs APR--A 15%; B 45.3%; C 39.6%). Patients have been followed up for a minimum of 24 months (mean time 62 months). There were no differences in intraluminal diameters of the tumours in each operative procedure. The distal tumour-free distance was more than 6 cm in 52% after APR (SSR: 10%) and less than 3 cm in 43% after SSR. Survival was not different between procedures in Dukes stages A and B. A survival advantage for patients with Dukes C carcinoma after APR did not reach statistical significance. No differences in distant spread were found for SSR (Dukes stage A 0%; B 7%; C 18%) and APR (Dukes stage A 0%; B 8%; C 14%) for local recurrence in Dukes stages A and B after SSR (A and B 0%) and APR (A 0%; B 8%) whereas a significant increase in local recurrence rate was seen in Dukes stage C after SSR (24% vs, APR 5%). Although a further resection could be performed in almost all of these patients a negative effect of local recurrence on survival occurred (25.4 months with and 80 months without local recurrence). While SSR seems to be favourable in Dukes stages A and B, APR should be considered in carcinoma of the lower and middle third of the rectum with lymphatic spread. Effective preoperative staging determines selection of the appropriate operation.

Preoperative immunostimulation by Propionibacterium granulosum KP-45 in colorectal cancer

In order to improve the perioperative resistance to the spread of cancer during operation the effect of preoperative stimulation of the immunesystem by Propionibacterium granulosum KP-45 was investigated in patients with colorectal carcinoma. In a prospective randomized trial 101 patients were allocated to either treatment (n = 51) or control (n = 50). In the treatment 10 mg of Propioni bacteria were administered intravenously between the seventh and third day prior to surgical treatment. At the time of operation 21 tumours were classified as stage I (treatment n = 12, control n = 9), 22 as stage II (treatment n = 10, control n = 2). Postoperatively wound infections requiring treatment were more prevalent in the control group (n = 4) than in the treated group (n = 0). All patients were subsequently followed up for 76 months. For stage I carcinoma the survival rates, excluding perioperative deaths, were 91% in the treated and 63% in the control group respectively. One case of tumour metastasis was seen in the control group. For stage II carcinoma the survival rate was 90% for the treated group with distant spread in 1 case and 45% in the control group where the rate of recurrence was 55%. For stages III and IV there was no statistically significant difference in survival between the treated and the control groups.

A data retrieval system for the eye clinic. I. Clinical aspects

The use of a data retrieval system for patients' ophthalmic records is described. Input is by using simple forms and output is in batch. The system is adaptable for on-line use as soon as a terminal is established in the clinic. To date there are over 6000 patients on file, of whom about one half have no other form of ophthalmic medical record.

A data retrieval system for the eye clinic. II. The programmed system

The programmed system of a data retrieval system for the eye clinic is described. The system uses an IBM 370/168 computer, involves programmes to minimize the possibility of entering errors and a magnetic tape back-up system to reduce the cost of storing rarely required material and as a safeguard against the accidental erasion of material on disc.