Preoperative breast imaging and histopathological findings in chest contouring surgery on transmen

BACKGROUND

Chest contouring is the most common surgical procedure transmen receive. Only a few articles discuss the importance of preoperative imaging and postoperative histopathological analysis of excised breast tissue. We studied the findings of preoperative breast imaging and the results of postoperative histopathological analysis in a clinical setting.

MATERIALS AND METHODS

Data from 220 patients were collected retrospectively from 2005 to 2018. Preoperative imaging modalities and their findings were recorded and classified according to the American College of Radiology Breast Imaging Reporting and Data System. The histopathological findings in breast specimens were categorized based on the World Health Organization Classification of Breast Tumors (5th edition).

RESULTS

Preoperative imaging was performed in 133 (60.5%) patients. Patients in the ultrasound-only group were younger (mean age 22.8) than the other groups (mammogram (MGR) 37 years and MGR+US 35.5 years). Preoperative imaging results were normal in 131 (98.5%) patients. Two patients needed further evaluation. Histopathological results were available on 206 (93.6%) patients. The most common histopathological findings were fibrosis (67.5%), atrophy (34.3%), and chronic mastopathy (14.5%). There were no high-risk or malignant findings.

CONCLUSIONS

The need for further examinations based on routine preoperative imaging was low (1.5%). Therefore, more individualized patient selection for preoperative imaging is justified. There were no high-risk or malignant findings in histopathological analysis, and the occurrence of benign findings was similar to that reported in previous studies. Despite our findings, based on current knowledge, histopathological examination of excised breast tissue can still be recommended. Therefore, future studies are needed to define clear guidelines.

Validation of the BODY-Q Chest module in Finnish trans men undergoing chest wall masculinization

BACKGROUND AND OBJECTIVE

The aim of gender affirmation surgery is to ease gender dysphoria. In transgender men, chest wall masculinization is the most common gender affirmation surgery. The BODY-Q Chest module is currently the only instrument developed to measure health-related quality of life (HRQL) in men undergoing chest wall surgery. Linguistic validation and cultural adaption to Finnish were performed previously. The study aims to validate the BODY-Q Chest module in transgender men who have undergone surgical chest wall masculinization.

METHODS

All transgender patients who underwent chest wall masculinization at Helsinki University Hospital between 2005 and 2018 were invited to the study. The BODY-Q Chest module comprises two scales-chest and nipple. Data were obtained using the BODY-Q Chest module, the 15D questionnaire, and specifically targeted items designed by the authors. The statistical analyses were conducted to exclude selection bias, evaluate validity of the instrument, and compare it to other instruments.

RESULTS

Of the 220 patients invited, 123 participated in the survey (response rate 56%). Ceiling effects were observed with 18.9% and 20.5% scoring maximum points. Cronbach's alpha was 0.92 and 0.88 for the chest and nipple scales, respectively. In exploratory factor analysis, both scales loaded to one factor confirming unidimensionality. Correlation with the generic 15D questionnaire was low.

CONCLUSIONS

The BODY-Q Chest module provides valid scores with sufficient consistency and reliability when measuring HRQL in transgender men undergoing chest wall masculinization. Moreover, it offers specificity that existing or generic instruments cannot provide. Ceiling effect was expected due to the postoperative status of participants.

Surgical treatment and prognosis of breast cancer in elderly - A population-based study

BACKGROUND

The aim of this study was to investigate outcome of treatment in patients over 80 years of age with early breast cancer at the time of the diagnosis with special interest in surgical treatment.

MATERIALS AND METHODS

Breast cancer patients older than 80 years of age, treated at the Breast Surgery Unit of Helsinki University Hospital in 2005-2010 were identified from electronic patient records. Patients were followed-up until the end of 2014. Patient and tumour characteristics, recurrences, co-morbidities and reasons for omission of surgery were collected from electronic patient records. Survival data was obtained from Finnish Cancer Registry.

RESULTS

446 patients were eligible for the study: 401 (90%) received surgery. The median follow-up time was 52 months. In the entire study population, local and regional recurrences/disease progression were diagnosed in 16 (3.6%) and 6 (1.3%) patients, respectively. The five-year overall survival was 50.6% in the surgical treatment and only 15.2% in non-surgical treatment group, p < 0.001. Also, the five-year breast cancer specific survival was significantly better in the patients with surgery, 82.0%, but 56.0% in the patients without surgery, p < 0.001. There was no mortality related to the surgery, but 122 (30%) patients died within three years from surgery.

CONCLUSION

Surgical treatment rate was high. OS and BCSS were better in surgically treated elderly patients. Local and regional disease control was excellent, probably due to high rate of surgical treatment. Surgical treatment also seemed safe in this elderly patient population. However, surgical overtreatment was obvious in some patients.

The quality of preoperative diagnostics and surgery and their impact on delays in breast cancer treatment - A population based study

BACKGROUND AND OBJECTIVES

This study aims to clarify quality of breast cancer surgery in population-based setting. We aim to elucidate factors influencing waiting periods, and to evaluate the effect of hospital volume on surgical treatment policies. Special interest was given to diagnostic and surgical processes and their impact on waiting times.

METHODS

All 1307 patients having primary breast cancer surgery at the Helsinki and Uusimaa Hospital District during 2010 were included in this retrospective study.

RESULTS

Median waiting time for primary surgery was 24 days and significantly affected by additional imaging and diagnostic biopsies as well as hospital volume. Final rate of breast conserving surgery was surprisingly low, 51%, not affected by hospital volume, p = 0.781. Oncoplastic resection and immediate breast reconstruction (IBR) were performed more often in high volume units, p < 0.001. Quality of axillary surgery varied with unit size. Multiple operations, IBR and high volume unit were factors prolonging initiation of adjuvant treatment.

CONCLUSION

Quality of preoperative diagnostics play a crucial role in minimizing the need of repeated imaging and biopsies as well as multiple operations. Positive impact of high-volume hospitals becomes evident when analyzing procedures requiring advanced surgical techniques. High-volume hospitals achieved better quality in axillary surgery.

Feasibility of Day Surgery in Patients With Breast Conservation and Sentinel Node Biopsy: A Randomized Controlled Trial

Background and Aims:

The aim of this study was to analyze feasibility of day surgery in breast cancer patients with breast conserving surgery and sentinel node biopsy.

Material and Methods:

The study was a randomized controlled trial comparing day surgery with one night hospital stay in breast cancer patients with breast conserving surgery and sentinel node biopsy. A total of 40 patients with ⩽3-cm tumor and clinically N0 were randomized to one night stay group and 38 patients to day surgery group. Within discharge, patients and their relatives were given questionnaires in order to evaluate their experience regarding the duration of hospital stay.

Results:

Randomized groups were similar regarding patient age and tumor stage. A total of 18 (47%) day surgery group patients were discharged the same day. The most common reason for overnight hospital stay was axillary clearance, 9 (24%). None of the patients in the day surgery group, but 2 patients in the overnight hospital stay group had re-operation due to complications. Perception and preference results were analyzed both according to randomization and actual treatment groups. Patients in both groups had rather similar experiences on the first postoperative day. Also, spouse’s or relative’s perception after discharge was similar in both groups.

Conclusion:

Day surgery was well received by the patients and their relatives. Day surgery appears as feasible in patients with breast conservation and sentinel node biopsy.

Minor histocompatibility antigens as determinants for graft-versus-host disease after allogeneic haematopoietic stem cell transplantation

Minor histocompatibility antigens (minor H antigens) are genetically polymorphic peptides that have been shown to elicit immune response when mismatched between donor and recipient of haematopoietic stem cell transplantation (HSCT). Depending on the expression profiles, mismatches in these genes may either lead to harmful graft-versus-host (GvH) reaction or desired graft-versus-leukaemia (GvL) effect. We analysed retrospectively the effect of HLA-restricted matching 11 established autosomal minor H antigens on the risk of graft-versus-host disease and relapse in 311 HLA-matched sibling HSCT of a single centre. Increased incidence of chronic GvH disease was shown to be associated with mismatches in the HA-8 and ACC-1. The mRNA expression profiles in a large set of healthy and malignant tissue samples of minor H antigen genes demonstrated in silico that the expression profiles of HA-8 and ACC-1 were surprisingly different: HA-8 gene was expressed in practically all tissues, whereas ACC-1 gene had a restricted profile. The results demonstrated that mismatches in minor H antigens HA-8 and ACC-1 predisposed to chronic graft-versus-host disease (GvHD).

Effect of exercise on bone structural traits, physical performance and body composition in breast cancer patients--a 12-month RCT

In this 12-month RCT, we examined whether aerobic impact exercise training (3x/week) could facilitate breast cancer survivors' recovery by enhancing their bone structural strength, physical performance and body composition. After the adjuvant chemo- and/ or radiotherapy, 86 patients were randomly assigned into the training or control group. Structural bone traits were assessed with pQCT at the tibia and with DXA at the femoral neck. Agility (figure-8 running), jump force and power (force platform), grip strength and cardiovascular fitness (2-km walk test) were also assessed. Training effects on outcome variables were estimated by two-way factorial ANCOVA using the study group and menopausal status as fixed factors. Bone structural strength was better maintained among the trainees. At the femoral neck, there was a small but significant 2% training effect in the bone mass distribution (p=0.05). At the tibial diaphysis, slight 1% to 2% training effects (p=0.03) in total cross-sectional area and bone structural strength were observed (p=0.03) among the postmenopausal trainees. Also, 3% to 4% training effects were observed in the figure-8 running time (p=0.03) and grip strength (p=0.01). In conclusion, vigorous aerobic impact exercise training has potential to maintain bone structural strength and improve physical performance among breast cancer survivors.

Adenosine deaminase in the diagnosis of pleural effusions

The activity of adenosine deaminase (ADA) was determined in serum and pleural fluid of 90 patients with pleural effusions of various aetiology. Tuberculous pleural effusions, empyemas and rheumatoid pleural effusions demonstrated significantly higher activities of ADA than parapneumonic , nonspecific and malignant pleural effusions and effusions in systemic lupus erythematosus and congestive heart failure. In tuberculosis, empyema and rheumatoid arthritis ADA activity was significantly higher in pleural fluid than in serum, indicating a local synthesis of ADA by cells within the pleural cavity in these diseases.

Accurate determination of serum ASAT isoenzymes

An improved electrophoretic modification for measuring aspartate aminotransferase (ASAT) isoenzymes is presented. This method fulfils the clinical requirements for sensitivity and allows the detection of 1 U/l mitochondria ASAT activity at 25 degree C. The procedure is relatively simple, requiring about one hour for a series of 8 determinations. Mitochondrial ASAT activity was found in all patients suffering from acute myocardial infarction pathological activity was observed for several days longer than that of total serum ASAT enzyme. None of the 25 healthy people studied had mitochondrial ASAT in their serum.

Maximal bioavailability of digoxin from tablets and oral solution in steady state

Comparison has been made between the absorption of digoxin from Lanoxin tablets and the absorption of international chemical reference substance digoxin from an oral solution. Plasma levels, areas under 24-hour plasma concentration curves and urinary excretion were similar by both formulations in steady state. 78% of the digoxin administered was absorbed from the tablets and 76% from the solution. Rapid dissolution in the intestinal fluids accounts for the high digoxin bioavailability of the tablets.

A multi-component exercise regimen to prevent functional decline and bone fragility in home-dwelling elderly women: randomized, controlled trial

SUMMARY

This study showed that combination of strength, balance, agility and jumping training prevented functional decline and bone fragility in home-dwelling elderly women. The finding supports the idea that it is possible to maintain good physical functioning by multi-component exercise program and thus postpone the age-related functional problems.

INTRODUCTION

This 1-year randomized, controlled exercise intervention trial assessed the effects of two different training programs and their combination on physical functioning and bone in home-dwelling elderly women.

METHODS

One hundred and forty-nine healthy women aged 70-78 years were randomly assigned into: group 1-resistance training (RES), group 2-balance-jumping training (BAL), group 3-combination of resistance and balance-jumping training (COMB), and group 4-controls (CON). Self-rated physical functioning, leg extensor force, dynamic balance, and bone mass and structure were measured.

RESULTS

Self-rated physical functioning improved in the COMB group, but was reduced in the CON group; the mean inter-group difference was 10% (95% CI: 0-22%). Mean increase in the leg extensor force was higher in the RES (14%; 4-25%) and COMB (13%; 3-25%) compared with the CON groups. Dynamic balance improved in the BAL (6%; 1-11%) and in the COMB (8%; 3-12%) groups. There were no inter-group differences in BMC at the proximal femur. In those COMB women who trained at least twice a week, the tibial shaft structure weakened 2% (0-4%) less than those in the CON group.

CONCLUSIONS

Strength, balance, agility, and jumping training (especially in combination) prevented functional decline in home-dwelling elderly women. In addition, positive effects seen in the structure of the loaded tibia indicated that exercise may also play a role in preventing bone fragility.

A comparison of intrapartum automated fetal electrocardiography and conventional cardiotocography-a randomised controlled study

OBJECTIVE

To examine whether intrapartum monitoring by means of automatic ST analysis (STAN) of fetal electrocardiography could reduce the rate of neonatal acidemia and the rate of operative intervention during labour, compared with monitoring by means of cardiotocography (CTG).

DESIGN

Randomised controlled trial.

SETTING

Labour ward in tertiary-level university hospital.

SAMPLE

A total of 1483 women in active labour with singleton term fetus in cephalic presentation.

METHODS

Women were randomly assigned to be monitored either by STAN or by CTG. Fetal blood sampling (FBS) was optional in both groups.

MAIN OUTCOME MEASURES

Neonatal acidemia (umbilical artery pH <7.10), neonatal metabolic acidosis (umbilical artery pH <7.05 and base excess <-12 mmol/l) and operative interventions: caesarean section rate, vacuum outlet (VO) rate and FBS rate.

RESULTS

There were no statistically significant differences between the STAN group and CTG group in the incidence of neonatal acidemia (5.8 versus 4.7%) or metabolic acidosis (1.7 versus 0.7%). The caesarean section rate (6.4 versus 4.7%) and the VO rate (9.5 versus 10.7%) were also similar in the STAN and CTG groups. The incidence of FBS was lower (P < 0.001) in the STAN group (7.0%) than in the CTG group (15.6%).

CONCLUSIONS

Intrapartum fetal monitoring by means of automatic STAN did not improve the neonatal outcome or decrease the caesarean section rate. However, the need for FBS during labour was lower in the STAN group.

Specific binding of baculoviruses displaying gp64 fusion proteins to mammalian cells

Viral vectors displaying specific ligand binding moieties have raised an increasing interest in the area of targeted gene therapy. In this report, we describe baculovirus vectors displaying either a functional single chain antibody fragment (scFv) specific for the carcinoembryonic antigen (CEA) or the synthetic IgG binding domains (ZZ) derived from protein A of Staphylococcus aureus. In addition, the vectors were engineered to incorporate a reporter gene encoding the enhanced green fluorescent protein (EGFP) under the transcriptional regulation of the cytomegalovirus (CMV) IE promoter. Display of the targeting moieties on the viral surface was achieved through fusion to the N-terminus of gp64, the major envelope protein of the Autographa californica nuclear polyhedrosis virus (AcNPV). Specific binding of the gp64 fusion viruses to mammalian target cells was demonstrated by using monoclonal anti-gp64 antibodies followed by fluorescence and/or confocal microscopy. The anti-CEA scFv displaying baculovirus was shown to bind specifically to CEA expressing cells (PC-3). Similarly, the virus displaying the ZZ domains of protein A was targeted to BHK cells via binding of an appropriate IgG antibody. In all cases, the reporter gene was expressed in the transduced mammalian cells as shown by fluorescence microscopy and flow cytometric analyses.

Baculoviral display of functional scFv and synthetic IgG-binding domains

Viral vectors displaying specific ligand binding moities such as scFv fragments or intact antibodies hold promise for the development of targeted gene therapy vectors. In this report we describe baculoviral vectors displaying either functional scFv fragments or the synthetic Z/ZZ IgG binding domain derived from protein A. Display on the baculovirus surface was achieved via fusion of the scFv fragment or Z/ZZ domain to the N-terminus of gp64, the major envelope protein of the Autographa californica nuclear polyhedrosis virus, AcNPV. As examples of scFv fragments we have used a murine scFv specific for the hapten 2-phenyloxazolone and a human scFv specific for carcinoembryonic antigen. In principle, the Z/ZZ IgG binding domain displaying baculoviruses could be targeted to specific cell types via the binding of an appropriate antibody. We envisage applications for scFv and Z/ZZ domain displaying baculoviral vectors in the gene therapy field.

Diagnostic significance of pleural fluid lactate concentrations

Lactate concentrations in the pleural fluid and plasma of 57 patients with pleural effusions were measured by an enzymatic method. The mean pleural fluid lactate concentrations were significantly higher in patients with empyemas and rheumatoid arthritis than in patients with tuberculosis, cancer, non-specific pleural effusions and congestive heart failure. Pleural fluid lactate concentrations correlated significantly with pleural fluid lactate dehydrogenase activities and inversely with pleural fluid glucose concentrations. An elevated pleural fluid lactate concentration is not diagnostic for empyema, as most patients with rheumatoid arthritis and some with tuberculosis and cancer also show high values.

Aetiology and detection of congenital nasal deformities

A total of 4724 newborns were screened for congenital nasal deformities with two simple tests which were performed by specialized nurses. Altogether 91 (1.9%) pathological cases were found. The parturients' external features and the course of the deliveries showed no differences from those of a control group, nor did the groups differ regarding features of the newborns. On the other hand, in the nasal deformity group, highly significantly (P less than 0.001) more cases of stuffy nose were found already during the first days after birth. In this study, no evidence of birth trauma as the cause of congenital nasal deformities was found. It is proposed that at least the majority of them originated during intrauterine life. The screening method was quite valid: every newborn who failed the screen tests showed some kind of nasal pathology and, on the other hand, those who passed had only minor deviations of the septum.

External, asymptomatic laryngocele without known predisposing factors in a middle-aged man

A laryngocele is an air-filled swelling of the upper pouch (the sacculus) of the laryngeal ventricle of Morgagni, which may herniate through the thyro-hyoid membrane to form a mass which is palpable subcutaneously in the neck. The condition is rare, but is found at times in individuals with laryngeal malignancy and in individuals who have been pre-disposed to it by increased internal laryngeal pressure. When the condition is discovered it is always an indication for a thorough examination of the larynx, with follow-up, bearing in mind the possibility of malignancy.

Comparative trial of flunisolide and beclomethasone dipropionate nasal sprays in patients with seasonal allergic rhinitis

In order to evaluate the effects of flunisolide and beclomethasone dipropionate nasal sprays on seasonal allergic rhinitis, 45 patients were included in an open parallel comparative trial. The study design was open because of the different dosage schedules for the two preparations. Strict criteria were set up for patient selection, and all patients were carefully examined and assessed before and after the 4-week trial period. Throughout the whole treatment each patient kept a detailed daily record. A substantial or complete control of symptoms was achieved in 18 of the 21 patients on flunisolide and in 20 of the 22 on beclomethasone dipropionate. No serious side effects were observed. Thus it can be concluded that both test drugs are effective and well tolerated in the treatment of seasonal allergic rhinitis.

On the rationale of the alpha-hydroxybutyrate dehydrogenase (HBD) determination

The discriminating power of HBD, LD and of the HBD/LD ratio in comparison with LD1/LD2 and LD5/LD4 ratios in acute myocardial infarction and hepatic disease is evaluated. The results demonstrate that there are no clinical reasons for the determination of the HBD when a method using the conditions of the Committee of Enzymes of the Scandinavian Society for Clinical Chemistry (SCE) is used.

Post-operative roentgenological findings and changes after mastoid obliteration

This study consisted of the evaluation of the plain X-ray findings of films taken at early follow-up (mean 1.5 months after surgery) and at late follow-up (4-14 years after the early films) of 211 ears which had been operated on radically and obliterated. Residual cells which were detected on the basis of the early films were associated with a more frequent occurrence of post-operative infection and were thus hallmarks of a poorer prognosis. Changes in the bone surrounding the surgical cavity and the radiological quality of the walls of the surgical cavity, the presence of new bone formation in the cavity and other radiological features did not yield useful information about post-operative complications. New bone formation was associated with a smaller amount of post-operative cavitation. Post-operative X-ray examination of the obliterated ear is a prognostically useful examination, but it does not significantly contribute further to the information available by clinical and otomicroscopic examination in regards to the complications of infection and cholesteatoma.

The differential diagnosis of bacterial and aseptic meningitis using cerebrospinal fluid laboratory tests

The lactate, lysozyme, C-reactive protein and serum amyloid-A protein concentrations in cerebrospinal fluid were measured in 11 patients with bacterial meningitis, 27 patients with aseptic meningitis and in 31 control patients. The mean concentration of each parameter was significantly higher (p less than or equal to 0.0001) in patients with bacterial meningitis than in those with aseptic meningitis or those without meningitis. The reliability of these tests in the differential diagnosis of bacterial and aseptic meningitis was compared with leucocyte counts in cerebrospinal fluid. Gram staining for bacteria, and protein and glucose levels. The cerebrospinal fluid lactate level proved to be more sensitive than lysozyme. C-reactive protein or serum amyloid-A protein and had a high degree of specificity.

Late post-operative hearing results correlated with the severity of tissue changes in ears with chronic otitis media

Late hearing results in 627 ears (574 patients) operated on radically for chronic otitis media are presented. Clinically, the ears were followed-up annually for 5-14 years. The results are correlated with the severity of histopathological changes in the tympanic cavity and in the mastoid air-cell system and also with the management of the tympanic mucosa and ossicular chain at operation. The mean post-operative air-bone gap was significantly better in ears with mild histopathological changes than in ears with severe histopathological changes in the middle ear (17.0 db./33.1 db.; p less than 0.001) or mastoid (29.0 db./34.2 db.; p less than 0.01) at operation. The difference in hearing results in favour of the former group was more significant in ears in which the tympanic mucosa had been saved at operation (p less than 0.01/p less than 0.001) than in ears in which the mucosa had been removed (p less than 0.05).

Late results of tympanoplasty using ossicle or cortical bone

Hearing results are presented for 164 ears with chronic otitis media which were operated on radically and obliterated with a musculo-periosteal flap (Palva flap), and in which tympanoplasty was performed. The ears were followed-up annually for 5-13 years (mean 6.8 years). Results are compared with the method of ossiculoplasty and with the condition of the stapes superstructure at operation. Ossiculoplasty using autogenous cortical bone columellas resulted in a somewhat greater improvement in the post-operative air-bone gap than ossiculoplasty with auto- or homo-graft ossicles, when compared with the pre-operative gap. Similarly, the post-operative gap improved more in ears with an intact stapes superstructure than in ears in which the stapes superstructure was absent. The use of an autogenous cortical bone columella can be recommended in cases in which the patient's own ossicles are affected by disease and cannot be used.

Post-operative ear canal volume measurements

Post-operative volume determinations have been made of the ear canals of 93 chronic ears operated on radically (removing the bony posterior meatal wall at operation, obliterating the surgical cavity by musculoperiosteal flap, and reconstucting the meatus, by soft-tissue only in 81 ears, or by cortical bone chips and soft tissue in 12 ears), and of 30 normal ears, using a liquied-filling method and by determining the compliance of the ear canal at a pressure of +200 mm. H2O.

The liquid-filling method gave more exact results than did the impedance measureemnts, and the results of the later showed more dispersion in all groups of ears. In 51 ears without post-operative cavities and reconstructed without bone chips, the mean value of the ear canal volume was 0.9 ml. by the liquid-filling method, and 1.5 ml, by the compliance method (p<0.001). The corresponding values for 30 ears with post-operative cavities, but without bony reconstruction of the meatus, were 1.5 ml. and 1.9 ml. (p<0.01). The values were 0.9 ml. and 1.2 ml. in 12 ears with posterior canal walls reconstructed with bone chips (p<0.01), and 0.8 ml. and 1.0 ml. in 39 normal ears (p<0.001). The liquid method seems to be a very exact method, but quite trouble-some in routine clinical use; the compliance method is suitable in most ears in which there has been bony reconstruction of the posterior meatal wall, but not in ears in which the posterior ear canal wasll has been reconstructed with solft tissues only, because the soft posterior meatal wall was mobile at +200 mm. H2O pressure.

Late changes in hearing results after mastoid obliteration with tympanoplasty

Hearing results are presented for 627 ears with chronic otitis media that were operated on radically and obliterated (Palva flap) and in which a tympanoplasty was performed. The ears were examined annually for five to 14 years (mean, 8.8 years). The long-term improvement (five to 14 years after the surgery) was the greatest in ears with an intact ossicular chain and in ears with ossicular reconstruction using autograft or homograft ossicles or autogenous cortical bone columellae. As a whole, the early (one year after the operation) improvement in the air-bone gap was 8.0 dB when compared with the preoperative gap and the late deterioration in gap after the first year was 6.0 dB. To detect the late changes in hearing results, the ears operated on must be followed up for a least five to ten years.

The preoperative state of infection in chronic otitis media correlated with postoperative hearing results

The postoperative long-term hearing results, with special reference to the state and management of the tympanic mucosa at operation, in 627 ears (574 patients) after an annual clinical follow-up period of 5-14 years are presented. The ears were operated on radically due to chronic otitis media, using the obliterative radical operation technique developed by T. Palva. The air-bone gap improved from the preoperative level significantly more in ears where the tympanic mucosa had been preserved than in ears where it had been removed at operation (p less than 0.001). The improvement was also significantly better in dry ears than in ears which were moist or discharging at operation (p less than 0.05). The mean late deterioration in the air-bone gap after the first follow-up year was significant in all the groups of ears (p less than 0.05), and the mean long-term change in air-bone gap from pre- to late postoperative examination was the improvement of 3.0 dB in ears with, and a deterioration of 2.0 dB in ears without ossicular reconstruction.

Post-operative cholesteatomas and retraction pockets after obliterative surgery in ears without cholesteatoma

The frequency of post-operative cholesteatomas, epidermizations and retraction pockets in a series of 343 chronically infected ears (315 patients) without cholesteatoma at primary surgery was evaluated. The ears were operated on radically, exclusively by the Palva method, with removal of the bridge in 248 ears and preservation of it in 95 ears. Musculo-periosteal obliteration and seclusion of the aditus were performed in every case with a Palva flap and with a temporalis muscle-fascia graft. The primary operations took place over the period 1964-1972, and all the ears without cholesteatoma at primary surgery were included; they were followed up annually. The evaluation of this material was carried out in 1976-1979 and the follow-up time was on an average of 8.5 years (5-15 years). Cholesteatoma was found in six (6/343; 1.7 per cent), epidermization of the tympanum in four (4/343; 1.2 per cent), and retraction pockets without cholesteatoma in six (6/343; 1.7 per cent) of the ears. Preservation or removal of the bridge at operation did not cause any significant difference in the frequency of the post-operative complications mentioned (p greater than 0.05). Most of the complications were discovered after the first postoperative year.

Symptoms of carcinoma of the oesophagus

Cancer of the oesophagus in its early stages is relatively asymptomatic, and the establishment of the diagnosis may be delayed because of the failure of the patient to seek early medical attention, or because the initial examining physician made an incorrect diagnosis. A good knowledge of the symptoms of the disease as well as an active role in diagnostic studies aid the physician in rapidly achieving the diagnosis. The most common symptoms in 162 patients with cancer of the oesophagus were: difficulty in swallowing (96%), loss of weight (42%), vomiting (25%), pain in the upper part of the abdomen (20%) and retrosternal pain (20%). The mean duration of symptoms before first presentation for medical attention was 3.1 months, and the correct diagnosis was generally established four to six weeks after the initial visit at the doctor's office. In 21.6% of cases, the initial visit did not lead to the correct diagnosis.

Symptoms and diagnostic delay in patients with carcinoma of oesophagus and gastric cardia: a retrospective study of 225 patients

A retrospective review of 225 patients was made with regard to the symptoms of carcinoma of the oesophagus and gastric cardia, and the duration of the symptoms before medical attention was sought and before the establishment of the diagnosis. The age of the patients was 37-84 (mean 62·5) years (139 male, 86 female). The most common symptoms were dysphagia (93%), loss of weight (46%), vomiting (33%), gastric pain (25%) and thoracic pain (21%).

The average duration of the symptoms before the establishment of the diagnosis was 4·1 months in carcinoma of the oesophagus and 4·3 months in carcinoma of the gastric cardia. The patients with oesophageal disease had sought medical attention on average 5 weeks earlier than those with gastric disease. The role of the physician who initially examines the patient is decisive for early diagnosis.

Bacteriological studies after obliterative mastoid operations

This study evaluates the post-operative bacteriology and the clinical state of postoperatively infected ears which were operated on using obliterative techniques and relates these bacteriological findings with the disease present. Out of the 85 ears with post-operative infection, the discharge was mucous in nine ears, mucopurulent in 18 ears, and seropurulent in 34 ears. Twenty-four ears were moist. Epitympanal or antral cholesteatoma was noticed in seven ears and meso- or hypotympanal cholesteatoma in 12 ears. The post-operative Valsalva-test was positive in 61 ears and negative in 24 ears. The types of bacteria did not significantly depend on the quality of the post-operative discharge, existence of post-operative cholesteatoma, or clinical function of the Eustachian tube (estimated by the Valsalva test). This study indicates that the bacteriology of the post-operatively moist or discharging ear does not significantly depend of the clinical state of the ear, nor can it be predicted on the basis of the clinical picture of the ear. A bacteriological examination of the ear seems to be the only way to control chemotherapy properly.

Late changes in ear canal volumes after mastoid obliteration

In this study, preoperative and postoperative ear canal volumes of ears subjected to obliterative radical mastoidectomy were assessed. The measurements were performed using sterile saline solution both at the preoperative stage (V0) and at the early (one year, V1) and the late (five to 13 years, V2) postopertive stages. The mean V0 was 0.8 mL (SD, 0.2 mL; V1, 1.0 mL (SD, 0.3 mL); and V2, 1.2 mL (SD, 0.4 mL). The differences were highly significant. Clinically, the widening of the ear canals was mainly slight and appeared evenly in the epitympanic area and in the posterior ear canal wall.

[Bacteria in the middle ear and nasopharynx in patients with chronic otitis media]

The pre- and postoperative aural and postoperative nasopharyngeal bacteriology of 104 ears (100 patients), still moist or discharging after surgery, were studied. Preoperatively aural and postoperatively dry ears (83 patients) of reference group were registered as well. All ears had been operated on radically with obliterative technique as described by Palva (1963, 1973) because of chronic otitis media with or without cholesteatoma. The preoperative bacteriology of the postoperatively moist or discharging cars did not differ statistically from that of the ears in the reference group. The same bacteria were detected pre- and postoperatively in the same ears in 44.1% of the ears in the former group and this situation was noticed highly significantly often regarding Pseudomonas aeruginosa (p less than 0.001) and almost significantly often regarding Proteus sp. (p less than 0.05). The postoperative nasopharyngeal bacteriology of the two groups mentioned did not differ statistically and only in six out of 100 cases the same pathogenic bacteria could be simultaneously cultured in the postoperatively moist or discharging ear and nasopharynx of the same patient.

Bacteriology in chronic otitis media correlated with the clinical state of ears

Bacteriologic findings in 702 cases of chronic otitis media were correlated with the clinical conditions of the ears. Statistically significant correlations with the severity of the clinical infection were noticed concerning Pseudomonas aeruginosa, St, aureus and E. coli. The bacteriological findings did not correlate with the results of Valsalva test. Pseudomonas aeruginosa was statistically more often present in ears without than in ears with cholesteatoma.

Correlation of postoperative ear canal volumes with obliteration material and with volume of operation cavity

In this study the preoperative and early and late postoperative volumes of ear canals of 131 operated chronic ears were measured by filling the ear canals with saline solution. The ears were operated on using the Palva method of obliteration of the operative cavity and reconstruction of the ear canal after removing the posterior, bony canal wall at operation. The average preoperative ear canal volume (V0) was 0.8 ml, the early postoperative volume (V1) was 1.0 ml, and the late postoperative volume (V2) was 1.2 ml. There was significantly more widening of the volume of the ear canals in the ears with a larger (greater than 7 ml) operation cavity as compared to ears with smaller (3-7 ml) operation cavity (p less than 0.05). Widening of the ear canals was smaller in the 12 ears with obliteration of the surgical cavity with musculoperiosteal flap and anorganic bone (Ossar) as compared to the 119 ears obliterated with musculoperiosteal flap only, but the difference was not statistically significant (p greater than 0.05).

Late results of obliterative cholesteatoma surgery

Radical obliterative cholesteatoma surgery was performed on 463 ears. Post-operative cholesteatomas were found in 22 of 463 of the ears during the follow-up periods that ranged from five to 15 years. Eight of them were of the residual type, and 14 were of the recidive type. A substantial portion of the postoperative cholesteatomas (11 cases) was discovered as late as the sixth to the tenth postoperative years. Four of the postoperative cholesteatomas extended to the antrum or the operation cavity from the tympanic cavity or meatus, but none of them originated in the cavity area. The surgical method that was used was safe. Annual follow-up examinations for at least ten years are recommended after the obliterative radical operation for ears with cholesteatomas.

Role of atopic allergy in chronic otitis media. Evaluation based on serum IgE and nasal/aural cytologic findings in patients with operated chronic ears

Serum IgE levels and nasal/aural secretion eosinophils and basophils cells were studied in 84 patients with ear discharge despite previous radical operation, in 83 patients with postoperatively dry ears, and in 30 normal persons. Serum IgE values suggesting atopy (greater than 100 U/ml, PRIST) were more frequent (p less than 0.05) among patients with draining ears than among persons with healthy ears. Normal IgE concentrations showed reversed frequency distribution. Nasal secretion eosinophils and/or basophilic cells were also found more frequently (p less than 0.05) among patients with discharging ears than in other groups. Analogously, those with both serum IgE of greater than 100 U/ml and 'positive' nasal cytology more often had infected than dry (p less than 0.01) or normal (p less than 0.05) ears. Aural secretions showed eosinophils and/or basophilic cells in 14 (17%) patients; 11 of them had such cells in their nasal secretions too. It would seem that atopy is probably one cause of persistent therapy-resistant otitis media and it must be taken into account when considering the treatment of a chronic ear.

Late hearing results after paraffinplasty or silastic sheeting

The long-term hearing results are presented for 135 ears operated on radically. In 59 of the ears temporary paraffin filling of the tympanic cavity was employed after the removal of the tympanic mucosa ot operation. The filling material was removed, and the ossiculoplasty was performed about 6 months later. In 76 ears a one-stage operation with tympanoplasty and Silastic sheeting was employed. There were no statistical differences between the groups of ears mentioned according to hearing results early (1 year) or late (5-15 years) postoperatively or in the deterioration of the air-bone gaps after the first postoperative year (P greater than 0.05). The late change in the air-bone gap was significant in both groups (paraffin group: 6.1 dB; Silastic sheeting group: 5.7 dB; P less than 0.05). The total improvement of hearing late after surgery (as compared to the preoperative hearing) was significantly better in the paraffin group than in ears with Silastic sheeting (P less than 0.05). Paraffinplasty seems to be a suitable way to avoid tympanic adhesions.

Comparison of pre- and post-operative bacteriology of chronic ears

The over-all distribution of the pre-operative bacteria of 806 ears and the post-operative bacteria of 109 post-operatively moist or discharging ears correlated very well, the only clear difference being the detection of diphtheroid bacilli more often post-operatively than pre-operatively. When comparing the pre- and post-operative bacteriology of 109 post-operatively infected chronic ears which had undergone radical surgery and obliteration with Palva flaps (and which were drawn from a group of 806 ears originally operated on and followed yearly for 5-14 years) it was noticed that Pseudomonas aeruginosa and Proteus sp were cultured more often post-operatively than pre-operatively in the same ears. Statistically, other bacteria were not found to be significantly present in the same ears.