Craniofacial Surgery over 30 Years in Göteborg

Craniofacial surgery is a new sub-specialty in the field of plastic reconstructive surgery and is dedicated to the treatment of severe cranial and facial malformations. Craniofacial surgery gradually started in Göteborg in the late 1970's and has been acting as the Scandinavian center since 1983.

Over these 30 years an almost complete change in surgical techniques has evolved. Also profound changes in timing of surgery have followed. Results have been dramatically improved based on critical evaluation of standardized registration of long-term results.

One of the most dramatic developments has been the introduction of implantable stainless steel springs. This has changed the treatment of Craniosynostosis completely and has made midfacial advancement procedures possible without relapse.

First result from the Alpha Magnetic Spectrometer on the International Space Station: precision measurement of the positron fraction in primary cosmic rays of 0.5-350 GeV

A precision measurement by the Alpha Magnetic Spectrometer on the International Space Station of the positron fraction in primary cosmic rays in the energy range from 0.5 to 350 GeV based on 6.8 × 10(6) positron and electron events is presented. The very accurate data show that the positron fraction is steadily increasing from 10 to ∼ 250  GeV, but, from 20 to 250 GeV, the slope decreases by an order of magnitude. The positron fraction spectrum shows no fine structure, and the positron to electron ratio shows no observable anisotropy. Together, these features show the existence of new physical phenomena.

Advances in Craniosynostosis Research and Management

The purpose of the present paper is to analyze the most recent advances in the field of craniosynostosis basic and clinical research and management, and to give an overview of the more frequently adopted surgical strategies. After reviewing some basic concepts regarding normal craniofacial embryology and growth, aetiopathogenesis of craniosynostosis and craniofacial dysostosis, classification and diagnosis and historical evolution of surgical treatment, the authors elaborate on a selection of topics that have modified our current understanding of and therapeutical approach to these disease processes. Areas covered include advances in molecular biology and genetics, imaging techniques and surgical planning, resorbable fixation technology, bone substitutes and tissue engineering, distraction osteogenesis and the spring-mediated cranioplasties, resorbable distractor devices, minimally invasive surgery and in utero surgery. A review of the main subtypes of craniosynostosis and craniofacial dysostosis is presented, including their specific clinical features and a commentary on the presently available surgical options.

Tetrameric dipeptidyl peptidase I directs substrate specificity by use of the residual pro-part domain

The crystal structure of mature dipeptidyl peptidase I reveals insight into the unique tetrameric structure, substrate binding and activation of this atypical papain family peptidase. Each subunit is composed of three peptides. The heavy and light chains form the catalytic domain, which adopts the papain fold. The residual pro-part forms a beta-barrel with the carboxylate group of Asp1 pointing towards the substrate amino-terminus. The tetrameric structure appears to stabilize the association of the two domains and encloses a 12700 A3 spherical cavity. The tetramer contains six chloride ions, one buried in each S2 pocket and two at subunit interfaces.

Expander elements in craniofacial surgery: an experimental study in rabbits

With the inception of craniofacial surgery elaborate surgical procedures were introduced for the treatment of craniosynostosis. Recently the use of implantable springs to aid simple strip craniectomies for these conditions has been described. Having shown the feasibility of using springs for dynamic skull reshaping, several questions remain to be answered, all of them about how to control the spring action clinically. One of the most important questions concerns force. The purpose of this study was to evaluate experimentally the effect of two springs of different strengths on the growth of rabbit calvaria after strip craniectomy. Thirty-two 6-week-old rabbits were randomised into one of four groups: sham-operation where only amalgam markers were inserted after subperiostal dissection; strip craniectomy of the sagittal suture, no expansion; strip craniectomy of the sagittal suture and insertion of an expander element made of titanium molybdenum alloy (TMA); and strip craniectomy sagittal suture and insertion of an expander element made of stainless steel (SS). SS springs delivered a range of forces from 2.42-2.18 N, whereas the TMA expander elements delivered a range from 1.39-1.09 N. The parietal bone marker separation after 12 weeks was 4.9 mm in the TMA group and 7.4 mm in the SS group. This resulted in a significant increase of the calvarian height compared with control groups. Histological examination showed intramembranous bone formation in the bone gap in all groups.

Long-term follow-up of dynamic cranioplasty for brachycephaly--non-syndromal bicoronal synostosis

We followed up 10 patients whose non-syndromal bicoronal synostosis had been operated on with a dynamic cranioplasty technique developed by this craniofacial unit in 1992. With this technique, the growth of the brain is redirected in an anteroposterior direction as wire-mediated compression and restraint are exerted on the transverse and vertical dimensions of the skull. The mean operating time was 160 minutes (range 120-275) and mean stay in the intensive care unit was 36 hours (range 23-58). There was no operative mortality and few complications. The surgical results were assessed objectively by analysis of cephalometric tracings. The mean (SD) cephalic index was 87.6 (4.9) preoperatively and 77.7 (1.8) postoperatively (p = 0.001). The modified Whitaker scale was used as a subjective outcome measurement, and nine patients were classified as Whitaker grade 1 (no additional surgery). One patient required additional intracranial surgery. A questionnaire was sent to all families to obtain an additional subjective measurement of outcome. Parents' satisfaction was high. We conclude that dynamic cranioplasty is a safe and efficient operation for treatment of brachycephaly.

Human recombinant pro-dipeptidyl peptidase I (cathepsin C) can be activated by cathepsins L and S but not by autocatalytic processing

Human dipeptidyl peptidase I was expressed in the insect cell/baculovirus system and purified in its active (rhDPPI) and precursor (pro-rhDPPI) forms. RhDPPI was very similar to the purified enzyme (hDPPI) with respect to glycosylation, enzymatic processing, oligomeric structure, CD spectra, and catalytic activity. The precursor, which was a dimer, could be activated approximately 2000-fold with papain. Cathepsin L efficiently activated pro-rhDPPI in vitro at pH 4.5 (k(app) approximately 2 x 10(3) min(-)(1) M(-)(1)), and two cleavage pathways were characterized. The initial cleavage was within the pro region between the residual pro part and the activation peptide. Subsequently, the activation peptide was cleaved from the catalytic region, and the latter was cleaved into the heavy and light chains. Alternatively, the pro region was first separated from the catalytic region. Cathepsin S was a less efficient activating enzyme. Cathepsin B and rhDPPI did not activate pro-rhDPPI, and the proenzyme was incapable of autoactivation. Incubation of both pro-rhDPPI and rhDPPI with cathepsin D resulted in degradation. Cystatin C and stefins A and B inhibited rhDPPI with K(i) values in the nanomolar range (K(i) = 0.5-1.1 nM). The results suggest that cathepsin L could be an important activator of DPPI in vivo and that cathepsin D and possibly the cystatins may contribute to DPPI downregulation.

Carica papaya glutamine cyclotransferase belongs to a novel plant enzyme subfamily: cloning and characterization of the recombinant enzyme

A full-length cDNA encoding Carica papaya glutamine cyclotransferase was cloned by RT-PCR on the basis of results from amino acid sequencing of tryptic fragments of the native enzyme. The cDNA of 1036 nucleotides encodes a typical 22-residue signal peptide and a mature protein of 266 residues with a calculated molecular mass of 30,923 Da. Five plant ESTs encoding putative QCs highly homologous to PQC were identified and the numbers and locations of cysteines and N-glycosylation sites are conserved. The plant QC amino acid sequences are very different from the known mammalian QC sequences and no clear homology was observed. The PQC cDNA was expressed in Escherichia coli as either His-tagged PQC, with three different signal peptides and in fusions with thioredoxin, glutathione S-transferase, and (pre-) maltose-binding protein. In all cases, the expressed protein was either undetectable or insoluble. Expression in Pichia pastoris of PQC fused to the alpha-factor leader resulted in low levels of PQC activity. Extracellular expression of PQC in the insect cell/baculovirus system was successful and 15-50 mg/liter of active PQCs with three different secretion signals was expressed and purified. Further, PQC N-terminally fused to a combined secretion signal/His-tag peptide was correctly processed by the host signal peptidase and the His-tag could subsequently be removed with dipeptidyl peptidase I. The expressed products were characterized by activity assays, SDS-PAGE, N-terminal amino acid sequencing, MALDI-TOF mass spectroscopy, and peptide mass fingerprint analysis.

[Gynecological problems of the aging woman]

The increasing number of old aged women requires the establishment of geriatric gynecology as a new subspecialty of our profession. The care of senior women in the gynecologists office should not be limited to the conventional gynecological diseases. These are of course dealt with in this paper; however should also be included, in a new understanding and broadening of our specialty, the women-specific diseases of old age. These extragenital diseases are therefore also touched upon. This extension of gynecology follows logically from the broad spectrum of effects of the female sexual hormones in the hands of the gynecologists and especially of long-term estrogen substitution into many neighbour medical specialties, like internal medicine, orthopedics, psychiatry and others. The gynecologist must have a working knowledge of these women-diseases including their physiopathology, differential diagnosis, treatment and, above all, prevention. The new understanding is moreover based upon the unique position of the gynecologist in the regular prevention and last, not least, upon the special confidence of the clients to their women-doctor and upon the special human intimacy in the relation between female patients and gynecologists. The care of senior women today includes life style counseling with the aim of prevention of preventable diseases. Also these points of view are touched upon. Medicine, which has given thirty additional years to the life of women, has also to take the responsibility to preserve physical and mental wellness through this segment of existence in good life quality saving the seniors from suffering of the preventable diseases of old age.

Evaluation of a surgical technique for trigonocephaly

Clinically diagnosed trigonocephaly have been treated by a standard surgical technique developed at Göteborg University Craniofacial Unit. To evaluate the technique we designed a study to include both subjective and objective assessments. Of 30 patients operated on between 1988-1997, 15 patients with at least three years postoperative follow-up have been included. An evaluation of the surgical outcome of the bitemporal width, the forehead contour, and the intercanthal distance was made both subjectively using a visual analogue scale (VAS) and objectively with analyses of cephalograms taken preoperatively and postoperatively at 3 and 5 years of age. For the subjective evaluation a control group of 10 randomly selected children from a Child Welfare Centre were selected. For the objective evaluation the control group consisted of cephalograms from children born with cleft lip and palate who were matched regarding sex and age. Both cephalometric analysis and subjective studies of the outcome indicated improvement. When the forehead contour was investigated the number of patients who had been improved or corrected completely was higher when evaluated subjectively. When interorbital distance on cephalograms and intercanthal distance scores on VAS were evaluated, again the subjective study indicated improvement in more subjects.

The long-term tolerability and efficacy of OESCLIM: results of a 1-year study

OBJECTIVES

A 1-year, open-label, non-comparative study evaluated the long-term tolerability and acceptability of a new generation matrix patch in post menopausal women with estrogen deficiency.

METHODS

Menopausal women (224) from 37 centres in five European countries received OESCLIM 50 microg/d (17-beta estradiol) for 3 months, titrated if necessary to either 25 or 100 microg/d for a further 9 months. Patients received either a continuous or discontinuous estradiol regimen with concomitant sequential progestogen (except hysterectomised patients). Skin tolerability was assessed by patient diaries and questionnaires. Global tolerability, efficacy, laboratory parameters and global acceptability were also monitored.

RESULTS

Almost two-thirds of women did not experience any kind of skin reaction and only 4.3% of all applications (752/17,702) caused site reactions. Of these, the majority caused only slight or no discomfort (63.2%). Only 0.37% of total applications required patch removal; none required therapy. A low percentage of patients withdrew due to tolerability issues: 2.7% due to skin reactions; 7.5% due to hyperestrogenism. The mean number of hot flushes experienced by symptomatic women reduced by 91% from 4.0 at baseline to 0.4 after 2 months. Total cholesterol reduced by 3.9% and LDL cholesterol by 5.1%, with no increase in triglyceride levels. Investigators assessed treatment as effective in 96.8% of cases; well tolerated locally in 93.1% and well tolerated generally in 89.5%. At the end of this 1 year study, 79% of patients wished to continue therapy.

CONCLUSION

OESCLIM is well tolerated locally and systemically in long-term therapy with a high proportion of patients wishing to continue therapy after 1 year.

Removal of N-terminal polyhistidine tags from recombinant proteins using engineered aminopeptidases

We have developed a specific and efficient method for complete removal of polyhistidine purification tags (HisTags) from the N-termini of target proteins. The method is based on the use of the aminopeptidase dipeptidyl peptidase I (DPPI), either alone or in combination with glutamine cyclotransferase (GCT) and pyroglutamyl aminopeptidase (PGAP). In both cases, the HisTag is cleaved off by DPPI, which catalyzes a stepwise excision of a wide range of dipeptides from the N-terminus of a peptide chain. Some sequences, however, are resistant to DPPI cleavage and a number of mature proteins have nonsubstrate N-termini which protects them against digestion. For such proteins, HisTags composed of an even number of residues can be cleaved off by treatment with DPPI alone. When the target protein is unprotected against DPPI, a blocking group is generated enzymatically from a glutamine residue inserted between the HisTag and the target protein. A protein with a HisTag-Gln extension is incubated with both DPPI and GCT. As above, the polyhistidine sequence is cleaved off by DPPI, but when the glutamine residue appears in the N-terminus, it is immediately converted into a pyroglutamyl residue by an excess of GCT and further DPPI digestion is prevented. The desired sequence is finally obtained by excision of the pyroglutamyl residue with PGAP. All the enzymes employed can bind to immobilized metal affinity chromatography (IMAC) matrices, and in this paper we demonstrate a simple and highly effective process combining IMAC purification of His-tagged proteins, our aminopeptidase-based method for specific excision of HisTags and use of subtractive IMAC for removing processing enzymes. Typical recoveries were 75-90% for the enzymatic processing and subtractive IMAC. The integrated process holds promises for use in large-scale production of pharmaceutical proteins because of a simple overall design, use of robust and inexpensive matrices, and use of enzymes of either recombinant or plant origin.

[Assymetric skull? Early correct diagnosis is a must! Positional skull deformities can be avoided]

During the past few years the supine sleeping position has successfully been reintroduced for infants in order to prevent sudden infant death syndrome. However, the change in sleeping position has not been accompanied by a soft pillow under the infants head, which has probably caused a higher incidence of acquired skull deformities. These positional skull deformities need to be prevented or treated.

Treatment of sleep apnoea with continuous positive airway pressure in children with craniofacial malformations

We conducted sleep studies in a consecutive series of 21 children with craniofacial malformations and suspected obstructive sleep apnoea. Thirteen had sleep apnoea, and one patient with a tracheostomy could not be tested. Twelve children were admitted for initiation of treatment with nasal continuous positive airway pressure (nCPAP). Ten patients accepted nCPAP, two did not. Seven children use home treatment successfully. Obstructive sleep apnoea in most children is completely eliminated with nCPAP. The treatment is safe, effective, and leads to a reduction in the number of operations done for children with craniofacial malformations. Aesthetic operations can be delayed until facial growth is complete.

Reconstruction of eyelid defects: a prefabricated multilayer sandwich graft

We have developed a new technique for reconstruction of full thickness eyelid defects. A composite three-layer skin-cartilage-mucosal unit is manufactured and tailored three-dimensionally. Use of this sandwich graft in our patients proved to be simple and safe for eyelid reconstruction and has given good results without complications in four patients.

Active recombinant rat dipeptidyl aminopeptidase I (cathepsin C) produced using the baculovirus expression system

An active form of rat dipeptidyl aminopeptidase I (DPPI, cathepsin C) was obtained by heterologous expression in insect cells. Baculoviruses carrying a cDNA sequence encoding the entire rat DPPI precursor was used to infect High Five cells in a serum-free medium. Recombinant DPPI (rDPPI) was secreted into the medium from which it was purified by a combination of ammonium sulfate fractionation, hydrophobic interaction chromatography (HIC), and ion-exchange chromatography. A polyhistidine-tagged form of the enzyme (HT-rDPPI) was purified from the medium by immobilized metal affinity chromatography (IMAC). In vivo activation of native rat DPPI involves at least three chain cleavages per subunit and the ability of the expression system to imitate this processing was investigated. Both rDPPI and HT-rDPPI were secreted into the medium as unprocessed and inactive proenzymes and gradually converted into their active forms in the medium. This process was not completed at the time of harvest but mature enzyme processed similarly to native rat and human DPPI could be obtained by incubating the eluates from the HIC and IMAC columns at pH 4.5 and 5 degrees C for 18-40 h. The yield of purified and matured enzyme was approximately 50 mg/liter, and it was shown that rDPPI and HT-rDPPI were active against both a dipeptide-p-nitroanilide substrate and human growth hormone N-terminally extended with an Ala-Glu dipeptide.

Spring mediated dynamic craniofacial reshaping. Case report

A new technique of using implantable springs as an adjunct after corrective surgery for craniofacial malformations is presented. A 6-month-old boy with multiple premature craniosynostoses and extreme turricephaly underwent surgery of limited extensiveness but supplemented with a set of indwelling springs for gradual postoperative skull reshaping. At spring removal three months later the skull was normalised both clinically and on cephalogram. A 5-year-old boy with Apert syndrome, severe midface retrusion, exorbitism, and sleep apnoea underwent a monobloc full face disjunction without repositioning, but was fitted with two springs for postoperative facial advancement. Three months postoperatively cephalometric analysis revealed 14 mm advancement at incisor level and at least 16 mm in the frontal region. There was no more exorbitism or clinically noticeable midface retrusion. Sleep studies revealed that the sleep apnoea was significantly improved, meaning complete cure except when sleeping flat on the back. It was concluded from these first clinical applications of spring assisted craniofacial distraction that springs hold significant promise for the future in many respects.

Reuse of tumorous calvarial bone after gamma irradiation

Reconstruction of calvarium after tumor resection may present several technical difficulties. The authors reused the resected calvarial bone in four patients after submitting the bone to a lethal dose of gamma radiation. The authors conclude that resected, irradiated, tumorous bone can be reused for the reconstruction of its own defect. This provides a simple method of reconstruction. Partial bone resorption should be anticipated but further reconstruction, if needed, will be facilitated.

13C NMR, X-ray, and differential scanning calorimetry investigations of truncated BPTI (aprotinin) analogues

Truncated BPTI missing residues 1 and 2 is investigated together with variants thereof (Lys-15, Arg-17, and Arg-42 are replaced by other residues in various combinations). A comparison of the X-ray structure of BPTI with that of 3-58BPTI(K15R,R17A,R42S) shows only minor variations for the backbone, but the lack of salt bridge between the terminals and the lack of two N-terminal residues provide a structure open at one end. Comparisons of amide exchange rates show a dramatic increase for the most slowly exchanging NH protons of 3-58BPTI and the analogues thereof, as compared to those of the wild-type despite only small differences in the structures. The amide exchange rates for truncated analogues increase with decreasing TTEP (temperature top endothermic peak) values. On the basis of the known structural changes comparisons to 13C chemical shifts are made. 13C chemical shifts are assigned using the D-isotope and HMBC techniques. Excellent resolution is obtained in these 1D natural abundance spectra. 13C NMR chemical shifts are shown to be able to gauge structural changes. A comparison of 13C chemical shifts of WT BPTI (aprotinin) and 3-58BPTI reveals effects caused by (i) the removal of the salt bridge of the terminii, (ii) the charge of the N-terminus, and (iii) the increased mobility of the side chain of Tyr-23. Small effects are also seen due to a conformational change of the aromatic ring of Phe-4. Ring current shifts at 13C chemical shifts are calculated. The difference in the calculated ring current effects are small comparing the wild-type with 3-58BPTI(K15R,R17A,R42S) provided the structures are relaxed. Protein unfolding as a function of pH and temperature is studied by DSC. Unfolding occurs at lower temperature with N-terminally truncated analogues, and the maximum is shifted toward higher pH.

Craniofacial dysostosis: airway obstruction and craniofacial surgery

Craniofacial surgery in craniofacial dysostosis on airway obstruction was studied retrospectively in a consecutive series of patients. The records of 76 patients were reviewed, 27 with Apert syndrome, 47 with Crouzon's syndrome, and two with Pfieffer's syndrome. Of 172 operations, 148 were done for cosmetic reasons, hydrocephalus, or papillary oedema, and 24 were done for airway distress. Forty patients (23%) were children less than 13 years of age, and 22 underwent midface advancement procedures. Only 13 of these operations had been done for airway distress. Two were cured by operation and seven improved. After operation had failed to relieve the airway obstruction, a nasal continuous positive airway pressure device (nCPAP) was fitted to seven patients. The nCPAP relieved or improved airway obstruction recorded by a sleep study. As midface advancement in childhood rarely results in lasting improvement in breathing or aesthetics, it may well be advisable to postpone operation until the early teens. We conclude that with nCPAP operation can in most cases be deferred until a time when a permanent result can be achieved.

Dynamic cranioplasty for brachycephaly

In craniofacial surgery, the most common techniques for treatment of brachycephaly have been either to let the forehead float on the brain or to fix it in an advanced position. Since neither of these techniques renders acceptable results with enough consistency, we have developed a different way of addressing the problem. In principle, the design of the operation is to restrict upward and transverse growth of the cranium but to allow anterior and posterior expansion. This is accomplished by producing transverse tension across the skull and letting it expand anteriorly by means of a superiorly hinged fronto-orbital flap and posteriorly by an inferiorly based occipital flap. To prevent upward expansion at the squamosal sutures when still open, these junctions are bridged with miniplates. This surgical technique has brought definite improvement to the results even in some Apert syndrome children. During a 2-year period, we have treated 14 infants with this technique and followed 10 of them with roentgencephalometry, 3 for more than 1 year, and 4 for more than 6 months. The diagnoses were the following: nonsyndromal bicoronal synostosis (4), Apert (7), bicoronal synostosis with midline cleft, Saethre-Chotzen, and Antley-Bixler (1 each). The mean age of surgery was 6.6 months (range 3 to 16 months). There were no major complications.

[Estrogen-gestagen substitution in geriatric gynecology. Long-term prevention for the third segment of life after menopause]

On average, post-menopausal women still have one-third of their lives ahead of them. It must be considered a task for the physician through the prophylactic and therapeutic application of estrogen (gestagen) replacement to secure for these women as high a quality of life as possible. The positive effects of replacement treatment affect, for example, the cardiovascular system, the urogenital system, osteoporosis and cognitive and mental functions. An absolute indication for estrogen replacement is very pronounced climacteric symptomatology that negatively influences the patient's quality of life, further marked complaints resulting from atrophic changes to the urogenital system, and manifest osteoporosis at the time of the menopause. Over and beyond this, numerous additional indications for such treatment can be listed, with only few contraindications.

HRT prescribing guidelines: dream or reality?

An international round-table meeting was held in the UK in June 1995, with the aim of developing simple, practical guidelines for hormone replacement therapy (HRT). Great emphasis was placed on initial and on-going counselling as a means of promoting compliance. The choice of preparation will depend on whether the patient has an intact uterus, and, if so, whether she is willing to accept regular bleeding. Hysterectomized women should receive continuous estrogen alone, while, for non-hysterectomized women, the first choice of treatment is continuous estrogen with sequential progesterone for at least 10 days in each month. Continuous combined treatment may be given as an alternative. Symptomatic side effects are most likely to occur at the beginning of treatment and can usually be easily managed by a change in the preparations. Despite misleading information in package inserts, there are few absolute contra-indications to HRT.

Roentgencephalometric follow-up after early osteotomies in patients with scaphocephaly

The main objective of surgical treatment of scaphocephaly is to improve the shape of the patient's skull. Since 1989 we have used a modified pi-plasty method, and the aim of this report was to study how effective surgery had been. A sample of 25 patients was investigated. All patients were operated on during their first year of life (mean: 6 months). They had roentgencephalometric records preoperatively as well as at a follow-up at age 3 years. Certain measurements were taken from the cephalograms and compared with normative data. It was found that the average skull length had decreased from a preoperative 114% of normal to 107% at follow-up. The skull width had improved from 92% to 98% of normal. The cephalic index had improved as well but was still not within the normal range. The cephalograms were also classified according to the occurrence of digital markings. Before surgery at 6 months none had these signs, but at follow-up every second patient displayed evolution of digital markings. It was concluded that the modified pi-plasty method improves skull morphology considerably but does not completely normalize the shape of the average patient's skull. The cranial length, in particular, needs further improvement.

Osteopenia in primary and secondary amenorrhea

This study aimed at investigating the prevalence of osteopenia among a hypoestrogenic group of patients with primary or secondary amenorrhea. Twenty-seven patients with amenorrhea were examined. Sixteen of them presented with secondary amenorrhea (mean age 27.8 +/- 1.9 yrs), and 11 with primary amenorrhea (mean age 21.3 +/- 1.6 yrs). Ten regularly menstruating women (mean age 28.9 +/- 1.4 yrs) served as controls. Estradiol serum levels as well as lumbar spine bone mineral density were measured. All 11 patients with primary amenorrhea showed osteopenia with a mean bone mineral density Z-score of 71 +/- 2% and mean estradiol levels of 30.6 +/- 5.9 pg/ml. The secondary amenorrheic patients were significantly demineralized with a mean Z-score of 82 +/- 3%; 10 of them had osteopenia. Their mean estradiol levels were 34.3 +/- 2.9 pg/ml. The bone density in the primary amenorrheic patients was significantly lower as compared with the secondary amenorrheic women. In comparison, lumbar spine bone density in all control women was normal with a mean Z-score of 104 +/- 3%. In summary, 21 of the 27 patients had osteopenia, higher than that reported in post-menopausal women. Since it is not proven whether the bone mineral deficit of amenorrheic patients can ever be compensated, early diagnostic steps and estrogen-progestogen replacement for the prevention of further bone loss and subsequent fractures are recommended.

[Splenopeptides for climacteric complaints. Comparison of ovarian stimulation with transdermal estradiol substitution]

256 women aged 45 to 60 years with climacteric complaints participated in an open randomized clinical study comparing spleno-peptides (SPS 1187, Solcosplen) with transdermal estrogen (CAS 50-28-2, E2) substitution (4 mg) in respect of efficacy and tolerability. The primary criterion, defined as the Kupperman Index, and the safety parameter of the drugs were estimated prior to and after 1, 4 and 8 weeks of therapy. In the pre-, peri- and early postmenopause the results of treatment with the spleno-peptides were comparable to those with transdermal E2 substitution (4 mg). Pretreatment with estrogens impaired the results of treatment significantly. Although the menopausal status (in most cases < 3 years) did not influence the results essentially, the efficacy of SPS 1187 is expected to decrease 2 to 3 years postmenopause. Therefore SPS 1187 should be used in pre-, peri- and early postmenopause only. The tolerance of SPS 1187 was found to be significantly better than that of the E2 patch. With respect to the claimed indication, i.e. climacteric complaints in the pre-, peri- and early postmenopause, SPS 1187 having an equivalent efficacy compared to that of the E2 patch shows a better tolerability (total collectives) and better benefit/risk ratio.

A three step protocol for the treatment of idiopathic subfertility

650 couples with idiopathic subfertility (mean duration: 5.7 year, range 2-21 years) were treated during 2870 cycles by three assisted conception methods (each involving mild ovarian stimulation): I timed intercourse (TI), II intrauterine insemination (IUI). III in vitro fertilization/embryo transfer (IVF/ET). Treatment started with TI in most cases and then changed to IUI after three to six cycles. Couples who failed to conceive were treated after another 3-9 cycles by IVF/ET. An overall cumulative pregnancy rate of 80.2% was reached after 18 treatment months. The pregnancy rates per treatment cycle were: TI 5.3%, IUI 6.9%, IVF/ET 15.8% (per oocyte retrieval).

[Cancer risk under hormone therapy]

Estrogens are not carcinogenic. They create however a milieu, which generally stimulates cell division and growth of the target organs, also in cases of existing early neoplastic changes. This growth stimulating effect is dependent on dose and duration of the estrogen effects. Low doses exert no significant influence, medium doses are stimulating, high doses inhibit carcinoma growth, if the tumor is hormone responsive. Cyclic application of a progestogen stops proliferation and induces the specific function of the target tissue. This influence is mediated through a reduction of the number of estrogen receptors, a stimulation of the transformation of estradiol to estrone, a decrease of intracellular metabolism and a reduction of blood perfusion of the target organs. Progestogens therefore act generally preventive against cancer development at the genital organs and probably also on the breast. They should therefore principally be given together with estrogens for at least 10, optimal 12 to 14 days at month. Whether the compromise to give a progestogen only every three or six month will be acting equally carcinoma preventive as the monthly medication, ist not known. In woman bearing risk factors - except proliferative mastopathy - an estrogen-progestogen substitution seems not to increase the inherent risk, rather to reduce it. However nevertheless the manifestation of genital and breast cancer occurs preponderately in women at risk. Familial-genetic immunologic, metabolic factors, weight, race, nutrition, chronic inflammation, regeneration, old age and other risks seem equally or even more important than hormonal factors. Women, who receive a long time estrogen-progestogen substitution, have a lower risk to develop endometrial and ovarian cancer. This is probably also true for mammary and colon cancer. Meta-analyses of all studies could not show so far an increased risk for mammary cancer in estrogen-progestogen substituted postmenopausal women. Women, who receive a postmenopausal long during estrogen-progestogen substitution show statistically a better prognosis of their genital and mammary cancers, if they occur, than unsubstituted controls. Following treated cervical, endometrial and ovarian cancer a strictly indicated estrogen-progestogen substitution is possible without causing drawbacks. The so far valid contraindication against estrogens in post-carcinoma patients does not longer exist. Positive influences on cure rates and survival have been described. In cases of estrogen-progestogen negative receptor mammary cancer cases a substitution is also possible. In all other cases hormones can be given after five years recidive free survival. It is recommended to prescribe not too high doses of estrogens and to combine them with an effective progestogen.(ABSTRACT TRUNCATED AT 400 WORDS)

Rapid increase in lumbar spine bone density in osteopenic women by high-dose intramuscular estrogen-progestogen injections. A preliminary report

This prospective pilot study has been carried out to assess the effect of high parenteral doses of estrogens and progestogens on lumbar spine bone density in osteopenic women. Thirteen osteopenic women received 40 mg estradiol valerate and 250 mg hydroxyprogesterone caproate by intramuscular injections once a week for 6 months (so called "pseudopregnancy"). One g oral calcium was added. Six out of the 13 patients (49.5 +/- 4.8 y were peri- and postmenopausal = group A. Seven patients (21.5 +/- 2.2 y) suffered from primary and secondary amenorrhea, in 4 out of them due to gonadal dysgenesis = group B. Estradiol was measured by commercial radioimmunoassay. Bone density was determined by dual-energy X-ray absorptiometry (DEXA) of the upper 4 lumbar vertebrae. Lumbar spine bone density as well as estradiol serum levels were measured before and 3 and 6 months after therapy, respectively. Estradiol increased from 34.8 +/- 7.5 pg/ml to 3226 +/- 393 pg/ml after 3 months and to 2552 +/- 254 pg/ml after 6 months, respectively, in group A. Bone density increased by 15.3 +/- 3.6% within the first 3 months to a total of 18.8 +/- 3.9% after 6 months, respectively. Two patients we have controlled for two years, maintained this increase. In group B estradiol increased from 27.8 +/- 6.5 pg/ml to 3028 +/- 728 after 3 and to 2491 +/- 684 pg/ml after 6 months. Bone density in this group increased by 11.8 +/- 1.9% within 3 and to a total of 18.2 +/- 2.8% after 6 months.(ABSTRACT TRUNCATED AT 250 WORDS)

[Prevention of conception in adolescence]

The adolescent girl needs affection and understanding for all of her problems. She often does not find a satisfying measure of both in her familiar surroundings. Very often sex instruction is faulty, although the AIDS campaigns have led to remarkable improvements (condoms). Instructions for sexual behaviour should take place at home or at school, but not in the street. Nevertheless, the first intercourse occurs mostly unprotected. Teenage pregnancies present not only physical but also psychological problems. Termination of pregnancy means an especially difficult decision for the adolescent girl, often causes crisis and occasionally leads to negative consequences for later fertility. The choice of appropriate contraceptive methods for girls under 16 years of age may also have legal problems. Condoms and barrier methods are possible alternatives to the much safer hormonal contraception with the combination, sequence or minipill. Under certain circumstances, a progestin injection every three months or the 'morning-after pill' as postcoital contraception or, in the case of an abortion or of pregnancy termination, even an intrauterine device can be an alternative for adolescent girls under those exceptional circumstances.

Effects of N-terminal extension peptides on the structure and stability of bovine pancreatic trypsin inhibitor studied by 1H n.m.r

Four N-terminal extended species of the wild-type bovine pancreatic trypsin inhibitor (WT-BPTI), Arg-BPTI (1-BPTI), Met-Glu-Ala-Glu-BPTI (4-BPTI), Ser-Ile-Glu-Gly-Arg-BPTI (5-BPTI) and Gly-Ser-Ile-Glu-Gly-Arg-BPTI (6-BPTI) have been studied by 1H n.m.r. The overall structure of the protein is largely unaffected by the addition of extension peptides. pH titration effects on the C-terminal Ala 58 H beta chemical shift indicate that the structure of 1-BPTI at neutral pH is very similar to that of the WT protein, with a salt bridge between the main chain terminal charges. A salt bridge interaction is prevented by addition of the longer extension peptides. Temperature stabilities are measured by high temperature hydrogen isotope exchange and by microcalorimetry. The stability of 1-BPTI is equal to that of WT-BPTI. A slight decrease in stability is observed for longer extensions, following the order WT-BPTI = 1-BPTI < 5-BPTI = 6-BPTI < 4-BPTI. Small changes in chemical shift are observed for 30 invariant resonances in 4-, 5- and 6-BPTI and for a subset of this group in 1-BPTI. These protons are distributed over about half of the BPTI molecule. The size of the chemical shift changes for many resonances follow the same ranking as the temperature stability. The chemical shift effects are attributed to charge and dielectric effects from extension peptides that probably share a common orientation on the surface of BPTI.

Numerical chromosome anomalies after fertilization of freeze-thawed mouse oocytes

The chromosome complement of first cleavage stage mouse embryos was analyzed to investigate the effect of slow freezing-fast thawing cryopreservation on chromosome numbers by comparing these numbers with those found fresh after fertilization of control oocytes. Fewer frozen-thawed (34.1%) than control oocytes (75.0%) cleaved to the 2-cell stage after in vitro fertilization. The incidence of hyperploidy was significantly increased by freezing (4.5% vs. 0% in controls). Polyploidy was not significantly affected (17.0% for freeze-thaw embryos vs. 26.2% for controls).

[Cytogenetics of unfertilized or uncleaved oocytes within the scope of in vitro fertilization. Relations to hormone content of follicular fluid]

Constituents of the follicular fluid (FF) have been suspected to influence fertilizability and cytogenetic constitution of human oocytes. Therefore, we analysed the FF concentrations of 17 beta-estradiol (E2), progesterone (P), testosterone (T), and prolactin (PRL) of 114 oocytes recovered for in vitro fertilisation (IVF). 46 of these oocytes were fertilised and transferred to the maternal uterus. Among the unfertilized gametes, 27 were not analysable. 30 were normal haploid, and 11 were classified as abnormal. There was no significant difference between fertilised and unfertilized oocytes for FF concentrations of E2, P, T, and PRL and for the E2/P ratios. Similarly, we detected no significant difference between normal and abnormal oocytes for these parameters.