Frey's syndrome after superficial parotidectomy: role of the sternocleidomastoid muscle flap: a prospective nonrandomized controlled trial

BACKGROUND

The prevalence of Frey's syndrome (FS) after superficial parotidectomy in correlation to the sternocleidomastoid muscle flap (SCMMF) interposition is analyzed.

METHODS

A prospective nonrandomized controlled multicenter trial included 130 patients. During superficial parotidectomy, SCMMF was dissected, if excised specimens' volume exceeded 25 mL (SCMMF group). Follow-up examinations took place after 6, 12, and 24 months and included a Minor's test.

RESULTS

SCMMF was dissected in 30 (23.1%) patients. A total of 104, 80, and 68 patients completed the 1st, 2nd, and the 3rd follow-up, respectively. FS was detectable with nonvarying prevalence (46.3%, 45.6%, and 43.4%, respectively) during follow-up. The prevalence was higher in the SCMMF group (59.9%) than in the non-SCMMF group (41.8%; P = .92). The sweating area increased during follow-up (P = .12). Overall, 89.5% of patients characterized FS as not disturbing after 2 years.

CONCLUSIONS

FS occurred with a steady and high prevalence after superficial parotidectomy. In particular, SCMMF did not lower the risk of FS.

Development of CLL in the TCL1 transgenic mouse model is associated with severe skewing of the T-cell compartment homologous to human CLL

Chronic lymphocytic leukemia (CLL) cells require complex microenvironmental and immunologic interactions to survive and proliferate. Such interactions might be best recreated in animal models; however, this needs extensive verification. We therefore investigated the composition of the T-cell compartment in the Eμ-TCL1 transgenic mouse, currently the most widely used murine model for CLL. Immunophenotyping and transplant approaches were used to define T-cell subsets at various stages of CLL. Analogous to human CLL, we observed a skewing of T-cell subsets from naive to antigen-experienced memory T cells that was more pronounced in lymph nodes than in blood. Transplantation of CLL into non-transgenic recipients was feasible without immunosuppression in a pure C57BL/6 background and resulted in the prominent skewing of the T cells of the recipient mice. Both in spontaneously developed CLL and in the transplantation setting, a loss in T-cell receptor diversity was observed, with a relevant number of clonal T-cell populations arising. This suggests that antigen-dependent differentiation toward the T memory pool is initiated by murine CLL cells. In summary, we validate the TCL1 transgenic mouse model for analysis of T-cell phenotypes and suggest a CLL-dependent antigen-driven skewing of T cells in these mice.

Arsenic trioxide induces apoptosis preferentially in B-CLL cells of patients with unfavourable prognostic factors including del17p13

In the last decade, arsenic trioxide (As2O3) has been used very successfully to treat acute promyelocytic leukaemia (APL). Much less is known about the effectiveness of As2O3 in other neoplastic disorders. In this paper, we report that after 18 h in vitro treatment with 4 microM As2O3, 75+/-18% of B cell chronic lymphocytic leukaemia (B-CLL) cells (n=52) underwent apoptosis. It is important to note that B-CLL cells harboring a deletion of chromosome 17p13, which predisposes to fludarabine resistance and has been identified as an important negative predictor of clinical outcome, were more susceptible to As2O3 toxicity than cells lacking this aberration. Furthermore, unfavourable risk profiles such as unmutated IgVH status, high CD38 expression and prior treatment were associated with significantly higher sensitivity of B-CLL cells to As2O3. As2O3 also preferentially killed B-CLL cells compared to B cells from healthy age-matched controls. Molecular analysis revealed that basal superoxide dismutase activity was positively correlated with the pro-apoptotic activity of As2O3 pointing to a role of reactive oxygen species in cell death induction. The high activity of As2O3 in B-CLL cells from high-risk patients makes it a promising drug for high-risk and/or fludarabine-refractory B-CLL patients.

Cladosporium herbarum translationally controlled tumor protein (TCTP) is an IgE-binding antigen and is associated with disease severity

Cladosporium herbarum represents one of the most important world-wide occurring allergenic fungal species. The prevalence of IgE reactivity to C. herbarum in patients suffering from allergy varies between 5 and 30% in the different climatic zones. Since mold allergy has often been associated with severe asthma, along with other allergic symptoms, it is important to define more comprehensively the allergen repertoire of this ascomycete. In this context we are reporting our successful approach to identify, clone, produce as a recombinant protein, purify and further characterize a new C. herbarum allergen which is a close homolog of the human translationally controlled tumor protein (TCTP, also called histamine releasing factor, HRF). The immunoreactivity of both pure recombinant molecules was investigated by means of immunoblot analyses, enzyme-linked immunosorbent assays as well as histamine release studies. To summarize, IgE antibodies from five out of nine individuals recognized both the human and the fungal protein in immunoblots. The latter was able to cause histamine release from human basophils with about half the efficiency compared to its human homolog HRF. Cross-inhibition assays showed that the patients' IgEs recognize common epitopes on both the human and C. herbarum proteins, but however, only pre-incubation with C. herbarum TCTP could completely inhibit reactivity with HRF. Furthermore, it appears that patients reactive to TCTP have a higher probability to suffer from asthma than other allergic patients.

Improved risk assessment in B-cell chronic lymphocytic leukemia based on sex-specific molecular profiling

7090

Background: B-cell chronic lymphocytic leukemia (B-CLL) is a heterogeneous disease with some patients having an indolent course and others a rapidly progressing one. As underlying molecular mechanisms of differential disease activity, genomic aberrations, the mutational status of the variable region of the immunoglobulin heavy chain (Ig VH) and distinct expression levels of Zap-70 and CD38 have recently been identified, and their capacity to interact with survival and proliferation signals of B-CLL cells has directly been linked to progression and response to therapy. Although male sex has also been identified as risk factor for a more aggressive disease in B-CLL, the molecular basis for this interaction remains elusive. Methods: We compared the prognostic value of the above-mentioned molecular risk factors between female (n=88) and male patients with B-CLL (n=116). Differences in their frequency was evaluated using the Chi-square test. Their impact on treatment-free and overall survival of patients was analyzed using the Kaplan-Meier method and the log-rank test. The prognostic value of each molecular risk parameter in female and male patients was determined using the Cox proportional hazards regression model. Results: High CD38 expression (=30%), unmutated Ig VH gene (=98%) and unfavorable genetic aberrations (i.e. del17p, del11q or tri12) detected in the neoplastic clone identified patients with significantly shortened treatment-free survival, irrespective of the sex of patients. In contrast, Zap70 expression in more than 20% of B-CLL cells was negatively associated with treatment-free survival only in female (RR: 3.5, 95% CI 1.5 –7.9, P=.003) but not in male patients (RR: 1.6, 95% CI 0.9 –2.9, P=.089). In addition, we identified high CD38 expression in T-cells as independent negative prognostic marker in male (RR: 2.8, 95% CI 1.5 –5.0, P=.0006) but not in female patients (RR: 1.9, 95% CI 0.8 –4.6, P=.17). Based on these results we developed a novel sex-adapted algorithm for improved risk assessment in B-CLL. Conclusions: We identified sex-specific differences in the prognostic value of Zap-70 and CD38 in B-CLL. Whether this can be explained by modulation of their specific signaling pathways by sex hormones will have to be addressed in future studies.

No significant financial relationships to disclose.

Fatal relapse of a purulent pleurisy caused by Campylobacter fetus subsp. fetus

Campylobacter fetus is associated with invasive disease, while other Campylobacter species, such as C. coli and C. jejuni, are a common cause of bacterial diarrhea. Bacteremia has been well described, but pleurisy remains very uncommon. We report the recurrent isolation of a C. fetus subsp. fetus strain during two episodes of pleural effusion with a fatal outcome.

Expression levels of CD38 in T cells predict course of disease in male patients with B-chronic lymphocytic leukemia

CD38 expression of tumor cells has been identified as an important prognostic factor in B-cell chronic lymphocytic leukemia (B-CLL). Although CD38 is involved in effector functions of T cells, the prognostic value of CD38+ T cells has not yet been addressed in B-CLL. In the present study, CD38-expression levels in B-CLL cells and T cells from 204 patients were analyzed by flow cytometry and correlated with clinical and molecular risk parameters. CD38 expression significantly differed in the neoplastic clone from patients with low versus advanced stage, irrespective of the sex of patients. In contrast, CD38 expression was generally higher in T cells from female compared with male patients but only increased in male patients in a stage-dependent manner. In male patients, combined analysis of CD38 in T cells and B-CLL cells identified 4 subgroups with significantly different treatment-free survival. Multivariate analysis including Rai stage and molecular risk parameters of the neoplastic clone identified CD38-expression levels in T cells as an independent prognostic factor in male patients. Combined analysis of CD38 in B-CLL and T cells is superior in predicting outcome of male B-CLL patients than either parameter alone. Further studies are needed to elucidate the underlying mechanisms of the sex-specific role of CD38+ T cells in B-CLL.

Carbohydrate sources and glycaemic control in Type 1 diabetes mellitus. EURODIAB IDDM Complications Study Group

AIMS

Little information is available on the relationship between glycated haemoglobin levels and the source or amount of dietary carbohydrate. The present study compares the association of carbohydrate intake with HbA1c between European individuals with Type 1 diabetes mellitus injecting insulin once or twice per day and those with > or = 3 daily injections.

METHODS

The relation of carbohydrate intake (total, cereal, fruit, vegetable, milk, and potato carbohydrate assessed by a 3-day dietary record) to HbA1c was examined in 2084 patients (age 32.6 +/- 10.2 years, duration of diabetes 14.8 +/- 9.5 years) included in the EURODIAB Complications Study.

RESULTS

In both insulin injection regimens, an increased intake of total carbohydrate (% of energy) and a higher consumption of potato carbohydrates (g) were associated with higher levels of HbA1c, whereas an increased intake of vegetable carbohydrate (g) was inversely related to HbA1c. These tendencies were all more pronounced in persons with one or two daily insulin injections. Consumption of cereal and fruit carbohydrates (g) was not related to HbA1c, irrespective of the insulin injection regimen. A trend of HbA1c to increase with higher intakes of milk carbohydrate was confined to those with one or two insulin injections per day (test for interaction: P = 0.01).

CONCLUSIONS

In particular, subjects with only 1 or 2 daily insulin injections per day should receive specific advice to correctly consider milk and potato carbohydrates. On the other hand, people with Type 1 diabetes may profit from a higher consumption of vegetable carbohydrates for their levels of HbA1c.

[Effect of nutrition on microalbuminuria in patients with type 1 diabetes: prospective data evaluation over 5 years]

The possible influence of dietary components on the progression or regression of microalbuminuria (MA) in type 1 diabetic patients was investigated prospectively over 5 years. The dietary intake of 47 patients with type 1 diabetes and MA (20-200 micrograms/min.), well instructed in diabetes management was observed in bimonthly intervals. Accuracy of 4-day diet protocols was verified by comparing the amount of documented protein intake with the measured nitrogen excretion. Non compliance was defined as deviation more than 30% between both values. These patients were eliminated from the study. Data from 37 patients with good compliance over a 5 year period have been used for multiple stepwise regression analysis. Taking into consideration Body mass index (BMI), blood pressure, HbA1c and time, MA was used as dependent variable, 16 dietary variables with a bivariate significance p < 0.05 as independent variables. The regression analysis (R2 = 0.589, p = 0.0015) showed clear associations between MA and the amount of salt intake (beta = 0.683, p < 0.002), saturated fatty acids (beta = 0.342, p = 0.029) and the amount of consumed mono- and disaccharides (beta = 0.479, p = 0.018). There was no significant association with the amount of protein intake (beta = 0.319, p = 0.152). Looking at the fatty acids in particular there were significant associations to MA with myristic acid, arachidonic acid and negatively with linoleic acid. Splitting the data in tertiles according to the amount of salt intake (I: < 6 g/d, II: 6-10 g/d, III: > 10 g/d) we could show in addition to the overall effect an intraindividual influence on the amount of MA (MA-means +/- SD: I: 45 +/- 56 micrograms/min., II: 61 +/- 59, III: 81 +/- 74, p < 0.001 between the groups). There were no significant differences between the groups in mean blood pressure, HbA1c and BMI.

[Robotics in oral and maxillofacial surgery. Possibilities, chances, risks]

Robot systems are being tested in stereotactic neurosurgical interventions, orthopedic surgery of the hip or knee and advancal endoscopic systems for minimally invasive surgery. In contrast to most industrially manufactured products, objects for medical treatment are characterized by plasticity as well as by complex and individual forms. Thus, features of robots in this field have to be further developed in terms of advanced sensory and specific micromotoric systems. Safety and cooperation between surgeon and robot on the patient in the operating room have to be guaranteed. Extensive three-dimensional diagnosis, computer-aided planning and simulation of the intervention as well as sensory systems that monitor the actual performance of the operation are mandatory parts of this concept. In our interdisciplinary study, we aim to examine whether a robot-given a complete preoperative planning and simulation procedure-is able to perform certain surgical operations more precisely than the surgeon. Examples are drilling with depth control, shaping of bone surface by milling, sawing with defined depth in cranial osteotomies, defined preparation of implant sites and the positioning and insertion of dental and other surgical implants, whereby autonomous employment of the robot is not that which is aspired to in these interventions but rather the interactive support of the surgeon.

Nutritional antioxidants, red cell membrane fluidity and blood viscosity in type 1 (insulin dependent) diabetes mellitus

The study was designed to evaluate whether the antioxidant nutrients selenium, vitamin A, and vitamin E are associated with alterations of blood viscosity in patients with insulin-dependent (Type 1) diabetes mellitus (IDDM). We assessed selenium concentrations in plasma and red blood cells (RBC), glutathione peroxidase activity in RBC, vitamin A and vitamin E, and the viscosity of whole blood and plasma in 20 patients with IDDM and 20 sex, age and body mass index-matched healthy controls. While selenium was not altered in plasma in IDDM, it was markedly decreased in RBC of IDDM (1.24 +/- 0.32 vs 0.92 +/- 0.38 mumol l-1, p = 0.006) correlating negatively with the elastic and viscous component of whole blood viscosity. Plasma viscosity increased with stage of retinopathy. Mean glutathione peroxidase activity in RBC was reduced in IDDM (5.78 +/- 0.77 vs 5.13 +/- 1.03 U gHb-1, p = 0.029). In IDDM with normal renal function (creatinine < or = 97.2 mumol l-1, no albuminuria) vitamin A was significantly reduced (1.26 +/- 0.62 vs 1.89 +/- 0.56 mumol l-1, p = 0.005). Vitamin A levels increased with impaired renal function. They strongly correlated with plasma creatinine (r = 0.86, p < 0.001) and plasma viscosity (r = 0.71, p = 0.001). However, in vitro experiments with different vitamin A plasma concentrations indicated that this particular correlation may not represent a causal one. No changes in vitamin E were found in IDDM. We conclude that reduced selenium concentrations in RBC contribute to impaired haemorheology in IDDM patients. Plasma viscosity was not affected by the plasma concentrations of vitamins A and E.

[Staphylococcus aureus resistant to methicillin. Survey of prevalence in Yvelines hospitals]

During 2 months (01.01.95-28.02.95), we noted for each Staphylococcus aureus (SA) isolates, identification and susceptibility methods, hospital size, medical speciality, source, penicillin (P) and methicillin (M) susceptibility. For each non repetitive methicillin resistant SA we noted phenotype of aminoglycoside resistance of SA to 6 antistaphylococci drugs. We isolated 399 SA, SAP sensitives 6.5%, methicillin resistant SA (MRSA) 31.8%. MRSA in acute care unit 28.4%, non acute care unit 61.7%, surgery 28.6%, medicine 36.5%, orthopedics 34.5%, pédiatrics 4%, ICU 38.8%, others 10.3%. MRSA from wound 28.2%, respiratory tract 38.3% blood 22.5%, urine 58.5%, others 25.8% - MRSA kanamycin 1.7%, kanamycin tobramycin 36.2%, kanamycin, tobramycin, gentamicin 56.9% - MRSA erythromycin 79.5%, pefloxacin 91.3%, rifampicin 53.5%, acide fusidique 8.7%, fosfomycine 18.9%, TMP SMZ 5.5%. The proportion MRSA is equivalent among medical specialities predominant in urine cultures and respiratory tract. It should be better to carry on the survey for more than two months in each hospital.

Familial acromegaly: a specific clinical entity--further evidence from the genetic study of a three-generation family

Familial acromegaly is a very rare inherited disorder, characterized by the clustering within a single family of several related cases with somatotroph adenomas and acromegaly. The causes of these dominantly inherited pituitary tumours remain unknown. Although these families have a clinical presentation distinct from that of multiple endocrine neoplasia type 1 (MEN-1), the question of this syndrome as being linked to the MEN-1 locus has remained open. Our aim was to study a three-generation family with cases of acromegaly in a mother and her son, to explore better the clinical presentation of the disease, its pattern of inheritance and to test the hypothesis of a genetic linkage to the MEN-1 locus using closely linked polymorphic genetic markers. The refined analysis of 15 unaffected relatives revealed miscellaneous non-specific endocrine dysfunctions and the presence of multiple lipomata, as noted previously in some cases. Moreover, the notion of acromegalo-gigantism in the maternal grandmother and an incomplete penetrance appeared even more typical, suggesting that familial acromegaly is a specific clinical entity. Finally, under the hypotheses assumed for segregation analysis, no clinical, biological or genetic evidence of linkage to the MEN-1 locus could be retained in this family. However, these conclusions were limited because of incomplete penetrance and uncertain definition of the carrier status. Therefore, we conclude that further identification of the genetic predisposition to familial acromegaly might be obtained from the combined molecular genetic analysis of several families presenting with the same clinical features.

[First case of human toxocariasis (?) with adult worms in the circulatory system, detected by the presence of embryonated eggs in hemolysis concentration]

Ascarids's eggs were found by blood concentration in a Cameroonese patient with hypereosinophilia. Eggs, similar to those of Toxocara canis or cati, were present in 6 blood concentrations carried out during 7 weeks. These eggs (70-75 x 100-112 microns) contained embryos and hatching of 437-504 microns long larvae was sometimes observed. The presence of adult worms in a well oxygenated localization (e.g.; the left ventricle) was supposed. A pleural effusion was also observed but the low number of eosinophils in the pleural fluid (3%) eliminated the responsibility of the parasite. The treatment by thiabendazole for an associated strongyloidosis was well tolerated but inefficient. On the contrary, the treatment by diethylcarbamazine, well tolerated, induced the disparition of the circulating eggs. This result was confirmed by 6 blood concentrations carried out during 6 months.

Diabetes care in rural area: clinical and metabolic evaluation

To evaluate the efficacy of conventional diabetes care in a rural area, metabolic control and the presence of late complications were studied in 622 diabetic patients treated by general practitioners beyond the reach of diabetic centers. Seventy-three (12%) of the patients were classified as type I diabetics (age, 38.0 +/- 16.1 yr; duration of diabetes, 12.8 +/- 9.3 yr) and 549 as type II diabetics (age, 67.0 +/- 10.8 yr; duration of diabetes, 7.3 +/- 5.8 yr). Fifty-eight percent of type I diabetic patients administered insulin once daily and 42% twice daily, whereas most (83%) type II diabetics on insulin received only one insulin injection per day. Treatment of type II diabetic patients consisted of sulfonylureas (58%), diet alone (22%), insulin (18%), and biguanides or a combination of sulfonylurea with biguanides (2%). Poor therapeutic efficacy was observed in all patients, and postprandial hyperglycemia (blood glucose greater than 160 mg/dl) was predominant both in type I diabetics (86%) and in type II diabetics on insulin (80%) as well as off insulin (55%). HbA1c above normal (greater than 5.8%) was seen in 96% of type I and in 90 and 73% of type II diabetics with or without insulin therapy, respectively. Accompanying glucosuria was present in type I (73%) and in type II diabetics (on insulin, 71%; off insulin, 33%). Mean prevalence of late diabetic complications was greatest for insulin-treated patients (type I, type II with, and type II without insulin treatment: retinopathy, 41, 56, 22%; proteinuria, 13, 14, 3%; peripheral neuropathy, 21, 51, 12%), whereas macroangiopathy (16, 53, 31%) predominated in type II diabetic patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Failure and efficacy of insulin therapy in insulin dependent (type I) diabetic patients

In order to determine the degree of metabolic control (HbA1c [normal less than 5.8%], mean blood glucose [MBG], glucosuria and lipids) and the prevalence of late diabetic complications in insulin-dependent diabetic patients treated by conventional insulin therapy both patients of a diabetes center (DC: n = 130; age 37.1 +/- 1.4 years) and a rural area (RA: n = 73; age 38.4 +/- 2.4 years) were examined within their local setting. Eighty such insulin-dependent diabetic patients were also taught a technique of near normal glycemic insulin substitution (NIS), which separates basal from prandial insulin replacement and instructs the patients to immediately correct self-controlled (3.8 +/- 0.1/day) aberrant blood glucose values. None of the groups on conventional insulin therapy was able to achieve satisfactory metabolic control or to avoid late diabetic complications, but rural patients were even worse off (BG 240 +/- 10 mg/dl; HbA1c 8.7 +/- 0.2% [normal: 3/73 = 4%]) than those of the DC (MBG 191 +/- 5 mg/dl; HbA1c 7.1 +/- 0.2% [normal: 27/130 = 21%]), while the prevalence of late diabetic complications was almost identical (RA/DC: neuropathy 22%/25%; retinopathy 41%/38%; macroangiopathy 15%/13%; but proteinuria 14%/5.4%). Metabolic control was improved by NIS with twice daily injections of basal (long acting) and separately of prandial (regular) insulin (total: 4.8 +/- 0.1 injections/day; MBG 130 +/- 2 mg/dl; HbA1c 5.8 +/- 0.1% [normal: 41/80 = 51%]. We conclude (1) that conventional insulin therapy just prevents metabolic catastrophe but in more than 79% of insulin-dependent diabetic patients lacks the ability to provide good metabolic control, while (2) NIS, a more physiological form of insulin therapy, improves this deplorable situation 5- to 12.4-fold.

[Recrudescence of imported malaria (author's transl)]

In the light of two recent cases of severe central nervous system malaria due to neglect in chemoprophylaxis, the authors report the very marked recrudescence in imported malaria and draw attention to the frequency of cases due to P. falciparum, the agent of malignant tertian fever and of malignant episodes. The necessity of early diagnosis in such cases is mentioned, together with the treatment of simple malaria and, in particular, of malignant varieties. In order to be effective, chemoprophylaxis must be begun immediately following arrival in an endemic area, continued regularly throughout the stay there and continued for 2 months after leaving. The blood of former malaria suffers, in order to avoid the risks of transfusion malaria, should be used only after seroimmunological studies have demonstrated the absence of anti-malaria antibodies.