[Testing and approach when non-organic visual loss is suspected]

Approximately 5% of the patients in the ophthalmological practice suffer from non-organic vision loss. In children non-organic vision loss has been observed from the age of 6 years. In order to be able to make a rapid diagnosis knowledge of the relevant clinical tests is decisive. If a patient shows signs of non-organic visual loss, diagnostic externalization of the visual function is crucial. Depending on the symptoms there are various tests, which can be used to differentiate between organic and non-organic disorders. For therapeutic and economic reasons an early diagnosis of a non-organic visual loss is crucial. Ophthalmologists need to differentiate between malingering and augmentation, where the patient is aware of the fraud and tries to gain personal benefit from it, and somatoform disorders. In the latter, a more sensitive approach is recommended.

Neuronal desynchronization as marker of an impaired brain network

Synchronization is a central key feature of neural information processing and communication between different brain areas. Disturbance of oscillatory brain rhythms and decreased synchronization have been associated with different disorders including schizophrenia. The aim of this study was to investigate whether synchronization (in relaxed conditions with no stimuli) between different brain areas within the delta, theta, alpha (alpha1, alpha2), beta (beta1, beta2), and gamma bands is altered in patients with a neurological disorder in order to generate significant cortical enhancements. To achieve this, we investigated schizophrenic patients (SZO; N=17, 37.5±10.4 years, 15 males) and compared them to healthy subjects (CON; N=21, 36.7±13.4 years, 15 males) applying the phase locking value (PLV). We found significant differences between SZO and CON in different brain areas of the theta, alpha1, beta2 and gamma bands. These areas are related to the central and parietal lobes for the theta band, the parietal lobe for the alpha1, the parietal and frontal for the beta2 and the frontal-central for the gamma band. The gamma band revealed the most significant differences between CON and SZO. PLV were 61.7% higher on average in SZO in most of the clusters when compared to CON. The related brain areas are directly related to cognition skills which are proved to be impaired in SZO. The results of this study suggest that synchronization in SZO is also altered when the patients were not asked to perform a task that requires their cognitive skills (i.e., no stimuli are applied - in contrast to other findings).

Analysis of Infants Based on Data from the German Perinatal Survey of the Years 1994-2011 in Mecklenburg-Pomerania, Germany. Classification of Infants with regard to their Gestation Duration and Birth Weight

BACKGROUND

The demographic change in -Germany describes an ongoing process of population development of which the eastern German states tend to be more affected. These ongoing changes have an influence on the reproductive behavior of the population. After twenty-three years of German reunification, the present study has investigated the question to what extent the somatic classification of newborns in Mecklenburg-Pomerania (M-P), Germany, is affected.

MATERIAL AND METHODS

Newborn singleton births (n=174,084) were classified from the existing data of the German Perinatal Survey between 1994 and 2011. The rate of premature birth, SGA, and LGA rate as well as the rate of low birth weight ≤2,499 g were determined both gender-dependently and independently. In addition, a combined analysis of the rates has been taken into account. The obtained data material from M-P made it possible for the first time to compare by values. National and international reference studies were considered in this comparison.

RESULTS

In M-P, the premature birth rate is 5.2%; the rate of newborns with low birth weight ≤ 2,499 g is 4.4%. Among newborns of ≤2,499 g and SGA newborns, girls compose a higher percentage (4.7%, 12.5%) compared to boys (4.0%, 7.4%). The premature birth rate and LGA newborns appear conversely. For these, the percentage of boys (5.6%, 12.6%) is higher than that of girls (4.8%, 7.0%). 60.6% of the gender non-specific newborns ≤2,499 g are simultaneously premature newborn infants. Only a very small percentage of 0.5% of SGA newborns is at the same time premature infants and newborns with low birth weight.

CONCLUSIONS

By getting nationwide country-specific figures, a detailed analysis of the newborns in M-P can be performed. The analysis supports the existing national values and is a helpful addition for practice-oriented advice.

Analysis of infants based on data from the German Perinatal Survey of the years 1994-2011 in Mecklenburg-Pomerania, Germany: new percentile values for anthropometric measures of infants

BACKGROUND

This communication presents precise percentile values for birth weight, birth length and cranial circumference of infants in Mecklenburg-Pomerania, Germany.

MATERIAL AND METHODS

Based on data from the German Perinatal Survey of the years 1994-2011 in Mecklenburg-Pomerania, the 3rd, 10th, 25th, 50th, 75th, 90th and 97th percentile values for birth weight, birth length and head circumference are specified. The measurements of a total of 174,084 infants from non-multiple births are shown.

RESULTS

The statistically calculated percentile values are presented in tabular and graph forms. The mean birth weight of the infants was 3,437.8 g. The average age of the mothers was 27.9 years. The average duration of pregnancy was 39.4 complete weeks.

CONCLUSIONS

The insights gained from many years of data collection are presented as standardised, regional percentile values and curves for Mecklenburg-Pomerania for the first time. The differentiated presentation for the federal state opens the possibility for individually tailored consultations in clinical practice and may provide support for recognised national curves for these values.

[Hantavirus infection due to Dobrava-Belgrade virus in a third trimester pregnant woman]

HISTORY AND ADMISSION FINDINGS

A 20-year-old woman was admitted to our hospital because of acute renal failure. She was pregnant in the third trimester. She reported on nausea, feeling of sickness, vomiting, abdominal pain and consecutively gross hematuria and sinustachycardia. Under suspicion of premature labour the patient was admitted to an external hospital. An antibiotic therapy with intravenous ampicillin/sulbactam was initiated. Because of acute kidney injury the patient was transferred firstly to the university women's hospital and finally to the department of nephrology. Obesity, the clinical signs of pregnancy, dehydration and small edema of the lower legs were the main medical findings on examination.

INVESTIGATIONS

Laboratory tests revealed hyperuricemia, virological tests detected an acute infection with Dobrava-Belgrade virus. The ultrasonography demonstrated a pregnancy in good condition and a dilated (physiological) renal pelvis but otherwise normal renal morphology.

DIAGNOSIS, TREATMENT AND COURSE

A Hantavirus associated acute kidney failure due to infection with the Dobrava-Belgrade virus was diagnosed. The course of the acute renal failure was characterised by remission of all symptoms. Intermittent evaluation by an obstetrician and a nephrologist were done to diagnose maternal and/or fetal complications. A renal replacement therapy was not necessary. At the 41st week of gestation a healthy male infant was born. The development of the newborn was age-appropriate.

CONCLUSION

Hantavirus infections should be considered in cases of pregnancy-associated acute kidney injury.

[Premenstrual Dysphoric Disorder (PMDD) as an independent disease]

This paper provides an overview of premenstrual dysphoric disorder (PMDD) and its clinical relevance in differentiation to premenstrual syndrome (PMS). Regarding recent research on epidemiology, aetiology, symptoms and therapy, PMDD is a discrete disorder and has a good prognosis in cases of appropriate diagnosis and therapy. The information provided in this review will help to better integrate PMDD into the psychiatric diagnostic process; options for diagnosis and treatment are also presented.

Phosphodiesterase-5 is a therapeutic target for peripheral neuropathy in diabetic mice

Peripheral neuropathy is a common and major complication of diabetes, the underlying mechanisms of which are not fully understood. Using a mouse model of type II diabetes, the present study investigated the role of phosphodiesterase-5 (PDE5) in peripheral neuropathy. BKS.Cg-m+/+Leprdb/J (db/db) mice were treated with sildenafil, a specific inhibitor of PDE5, at doses of 2 and 10 mg/kg or saline. Levels of PDE5 and morphometric parameters in sciatic nerve tissue as well as the motor and sensory function were measured in these mice. In diabetic mice, PDE5 expression in sciatic nerve tissue was significantly upregulated, whereas the myelin sheath thickness, myelin basic protein (MBP), and subcutaneous nerve fibers were significantly reduced. Treatment with sildenafil significantly improved neurological function, assayed by motor and sensory conducting velocities and thermal and mechanical noxious stimuli, concomitantly with increases in myelin sheath thickness, MBP levels, and subcutaneous nerve fibers. In vitro, hyperglycemia upregulated PDE5 in Schwann cells and reduced Schwann cell proliferation, migration, and expression of brain-derived neurotrophic factor (BDNF). Blockage of PDE5 with sildenafil increased cyclic guanosine monophosphate (cGMP) and completely abolished the effect of hyperglycemia on Schwann cells. Sildenafil upregulated cGMP-dependent protein kinase G I (PKGI), whereas inhibition of PKGI with a PKG inhibitor, KT5823, suppressed the inhibitory effect of sildenafil on Schwann cells. These data indicate that hyperglycemia substantially upregulates PDE5 expression and that the cGMP/PKG signaling pathway activated by sildenafil mediates the beneficial effects of sildenafil on diabetic peripheral neuropathy.

Two different entities of spontaneous ovarian hyperstimulation in a woman with FSH receptor mutation

Spontaneous ovarian hyperstimulation syndrome (OHSS) is an extremely rare event. Normally OHSS is seen in the context of IVF. In 2003 a mutation of the FSH receptor (FSHR D567N) was identified for the first time as a cause of spontaneous OHSS. In most FSHR mutations, a hypersensitivity to human chorionic gonadotrophin (HCG) or thyroid-stimulating hormone (TSH) is described. This clinical case presents for the first time two occurrences of spontaneous OHSS in a single woman with a FSHR mutation and two different entities. Pathophysiology of both pregnancies was completely different. During the first pregnancy, elevated HCG and androgen concentrations led to spontaneous OHSS and finally to miscarriage. The second pregnancy with spontaneous OHSS was dominated by a latent hypothyroidism and normal HCG concentrations and ended in a delivery of a healthy female newborn. Due to the unusual courses of the pregnancies, the study looked for a mutation in the FSHR and surprisingly identified the same mutation previously described. This report confirms for the first time the in-vitro findings in a single clinical case that TSH as well as HCG leads to spontaneous OHSS in patients with FSHR D567N mutation. Hypothyroidism has to be treated or ruled out.

Morphological and functional analysis of the loading regimen with intravitreal ranibizumab in neovascular age-related macular degeneration

AIM

To quantify and correlate the morphological and functional effects of the recommended loading regimen with intravitreal ranibizumab in neovascular age-related macular degeneration (AMD).

METHODS

In a prospective, interventional clinical trial, 29 consecutive patients (29 eyes) with choroidal neovascularisation secondary to AMD received three initial monthly intravitreal injections of ranibizumab. During this loading regimen, best corrected visual acuity (BCVA) and microperimetry (MP) testing, as well as optical coherence tomography and fluorescein angiography (FA), were performed using a standardised protocol and the results correlated.

RESULTS

Significant morphological and functional therapeutic effects were observed as early as 1 week following the first treatment. Throughout the loading-dose period, central retinal thickness, including intraretinal cysts and subretinal fluid, decreased fast and significantly (p<0.01); pigment epithelial detachment resolved less rapidly. The mean leakage area by FA decreased (p<0.01) and retinal function (BCVA and MP) increased significantly (both p<0.01). However, the change in morphology and function was only significant between baseline and week 1. There was no significant additional morphological or functional benefit following the second and third injection.

CONCLUSION

The initial administration of intravitreal ranibizumab in neovascular AMD induced a significant effect on intra- and subretinal fluid and visual function; subsequent injections had a less pronounced effect. It remains to be determined whether this loading regimen should be mandatory in all patients or if a single dose regimen would lead to a comparable functional and morphological retinal improvement.

[Gynecological and obstetric aspects of general practice]

The general practitioner called upon to provide medical care to the older woman for diseases other than gynecological or obstetric illness, should not neglect to recommend gynecological cancer screening, which is of particular importance in this group. In many differential diagnoses, the general practitioner must also give consideration to gynecological-obstetric aspects. Thus, for example, when a patient presents with lower abdominal pain, gynecological pathology must always be taken into account. Numerous preparations with differing actions and applications used in contraception or hormone therapy in the post-menopausal woman, require individual counseling by the gynecologist.

Advantage of three dimensional animated teaching over traditional surgical videos for teaching ophthalmic surgery: a randomised study

BACKGROUND/AIM

Owing to the complex topographical aspects of ophthalmic surgery, teaching with conventional surgical videos has led to a poor understanding among medical students. A novel multimedia three dimensional (3D) computer animated program, called "Ophthalmic Operation Vienna" has been developed, where surgical videos are accompanied by 3D animated sequences of all surgical steps for five operations. The aim of the study was to assess the effect of 3D animations on the understanding of cataract and glaucoma surgery among medical students.

METHOD

Set in the Medical University of Vienna, Department of Ophthalmology, 172 students were randomised into two groups: a 3D group (n=90), that saw the 3D animations and video sequences, and a control group (n=82), that saw only the surgical videos. The narrated text was identical for both groups. After the presentation, students were questioned and tested using multiple choice questions.

RESULTS

Students in the 3D group found the interactive multimedia teaching methods to be a valuable supplement to the conventional surgical videos. The 3D group outperformed the control group not only in topographical understanding by 16% (p<0.0001), but also in theoretical understanding by 7% (p<0.003). Women in the 3D group gained most by 19% over the control group (p<0.0001).

CONCLUSIONS

The use of 3D animations lead to a better understanding of difficult surgical topics among medical students, especially for female users. Gender related benefits of using multimedia should be further explored.

Unilateral ovarian agenesis: report of three cases and review of the literature

INTRODUCTION

Unilateral ovarian agenesis is a rare event and only a few case have been reported.

CASE REPORT

We present three additional cases, where patients presented with diffuse lower abdominal pain. During laparoscopy, an unilateral ovarian agenesis was observed in the three cases.

DISCUSSION

There are two possible explanations of a unilateral ovarian absence, involving an asymptomatic adnexal torsion or congenital absence. Unknown environmental factors or genetic predisposition could contribute to this kind of anomaly.

[Primary carcinoma of Bartholin's glands with HPV 18 detection]

A primary carcinoma of the Bartholin's gland is a rarely type of vulva-carcinoma. The patients median age are 55 years and the etiology of the carcinoma are still unknown. Viral influences are discussed. Most frequent types of carcinomas of Bartholin's gland are those of squamous cells and adenocarcinomas. This article reports on a 55 year old patient with a primary carcinoma of Bartholin's gland. The human papillomavirus 18 was detected by a polymerase chain reaction. The correct diagnosis was delayed because of an initial misinterpretation of the carcinoma as a Bartholin cyst, marsupialization and bad healing of the wound. The patient underwent a radical vulvectomy with bilateral inguinofemoral lymphonodectomy in combination with radiation therapy.

Influence of histamine H3-antagonists on human leukocytes

To determine the role of the histamine H3-receptor on basophils, different specific H3-antagonists were investigated. Incubation of washed leukocytes with N alpha-acylated histamine-derivatives (N alpha-ahd) induced elevated histamine levels. This process turned out to be dependent on dose, time and temperature, but independent of Ca2+ and Mg2+ ions. IgE-mediated histamine release was not modulated. [3H]-L-histidine was not decarboxylated into [3H]-histamine in spite of the observed histamine increase. Highly purified basophils did not show any histamine elevation but purified neutrophils and eosinophils were found to have increased histamine levels even after disintegration and subsequent incubation with N alpha-ahd. It seems that the increased histamine levels result from the cleavage of the applied histamine amides. Other potent H3-antagonists (e.g. thioperamide) neither produced increased histamine levels nor influenced IgE-mediated release from basophil leukocytes. The existence of H3-receptors on human basophils therefore seems unlikely.