Long-term haematological response and maintained immunological function after laparoscopic subtotal splenectomy in patients with hereditary spherocytosis

INTRODUCTION

Subtotal or total splenectomy are recommended in severe and should be considered in intermediate forms of hereditary spherocytosis (HS). Data on laparoscopic subtotal splenectomy (LSTS) in HS patients are sparse.

METHODS

Thirty three patients with HS (median age 10.7 years (yrs), range 1.8-15.5) underwent LSTS. Baseline and follow-up investigation included haematological parameters, microscopic analysis of pitted erythrocytes (pitE), and B-cell subpopulations assessed by flow cytometry. Results were compared to those of non-splenectomised HS patients, HS patients after total splenectomy (TS), and healthy individuals.

RESULTS

After LSTS, haemoglobin levels were normalised in all patients. During median long-term follow-up of 3.9 yrs (range 1.1-14.9), only four patients presented mild anaemia. Despite re-growing of the remnant spleen none of the patients required a second surgical intervention. As compared to TS, PitE in LSTS patients were significantly lower and indicated normal to only moderately decreased spleen function. Relative but not absolute IgM memory B-cell counts were reduced in both LSTS and TS patients.

CONCLUSIONS

LSTS is effective for the treatment of patients with HS. A small remnant spleen is sufficient to provide adequate phagocytic function and to induce a pool of IgM memory B-cells.

Thrombocytopenia Absent Radius (TAR)-Syndrome: From Current Genetics to Patient Self-Empowerment

Thrombocytopenia absent radius (TAR) syndrome is a rare form of hereditary thrombocytopenia associated with a bilateral radial aplasia. TAR syndrome is genetically defined by the combination of a microdeletion on chromosome 1 which includes the gene RBM8A, and a single nucleotide polymorphism (SNP) in the second RBM8A allele. While most patients with TAR syndrome harbor a SNP in either the 5' UTR region or in intron 1 of RBM8A, further SNPs associated with TAR syndrome are still being identified. Here, we report on the current understanding of the genetic basis, diagnosis, and therapy of TAR syndrome and discuss patient self-empowerment by enabling networking and exchange between affected individuals and families.

[Implementation of biosecurity measures by hoof trimmers in Switzerland]

INTRODUCTION

Biosecurity in livestock farming includes all measures preventing pathogen introduction onto a farm (external biosecurity) and pathogen transmission on the farm itself (internal biosecurity). An important risk factor for the dissemination of infectious diseases are specialised external persons working on numerous farms, such as professional hoof trimmers in Switzerland. In the present study, 49 hoof trimmers, participating in the Swiss claw health programme and working as professionals, were questioned regarding their biosecurity measures and observed by two veterinarians during hoof trimming in order to assess the implementation of biosecurity measures by hoof trimmers. Data were processed using a scoring system, in which points were allocated to the different working methods taking into account their assumed transmission potential for infectious diseases such as digital dermatitis (DD) and Salmonellosis. The working method, which complied with the ideal biosecurity measure, was always given a whole point, whereas less optimal working methods were only given an intermediate value or no point. The scoring system helped identify precisely the strengths and weaknesses of the hoof trimmers in terms of biosecurity. The level of implementation of biosecurity measures by hoof trimmers was overall quite low (53 %=average of the overall biosecurity scores of the 49 hoof trimmers). Hoof trimmers which attended specialised training courses tended to have a higher level of implementation of biosecurity measures. The answers given by the hoof trimmers and the observations made by the veterinarians were compared, whereby it was found that hoof trimmers generally evaluated themselves better in regard to biosecurity than veterinarians assessed them. In summary and based on the results of this study, the dissemination of pathogens, such as DD associated treponemes and salmonella is possible during hoof trimming performed by external persons working on numerous farms. Thus, future training and continuing education courses should place emphasis on biosecurity.

[Prevalence of claw disorders in swiss cattle farms]

INTRODUCTION

The project «Healthy claws - the foundation for the future» aims to establish a Swiss national claw health monitoring based on digital recordings by claw trimmers during claw trimming. To assess claw health on the participating farms, between-herd prevalence, within-herd prevalence and cow prevalence of all claw disorders based on the «ICAR Claw Health Atlas» were calculated during this study. Claw trimmers underwent an intensive training and examination in order to ensure data quality. To guarantee the representativity of the prevalences, only farm claw trimmings were considered, where ≥ 80 % of the cows in a herd were trimmed. The calculations were based on 7108 cows and 403 heifers from 238 farms, during the period from February 2020 to February 2021. At least one claw disorder was present in 99,2 % of the farms, with 49,6 % of the heifers and 77,7 % of the cows having at least one claw disorder. The high prevalence is seen as a result of all ICAR claw disorders being considered, whereas not all of them are painful and consequently not all of them cause lameness. The absence of lameness assessment limits the evaluation of existing herd problems. High between-herd and cow prevalences were observed for the following claw disorders: heel horn erosion (92,9 %/64,7 %), digital dermatitis (55,9 %/20,7 %), white line disease (81,5 %/17,7 %) and sole hemorrhage (66,4 %/11,6 %). Asymmetric claws, corkscrew claws, scissor claws, horn fissure, interdigital phlegmon, swelling of the coronet and/or bulb and toe necrosis had low prevalences. The proportion of cows treated with a hoof block (0,5 %) was comparatively small in regard of the cows suffering from ulcers (5,6 %) and white line abscesses (2,5 %). The median within-herd prevalence of digital dermatitis was 5,6 %, with a maximal within-herd prevalence of 87,5 %. Despite the contagious nature of digital dermatitis, no increase of between-herd and cow prevalence has been observed in the past ten years throughout Switzerland. Based on this data, the Swiss claw health situation can be monitored, compared over time and improved in the future.

T-Cell Response in a Cardiac Xenotransplant Model

OBJECTIVES

Despite the advances in preclinical cardiac xenotransplantation, the immune reactions caused by species differences are not fully understood. Hyperacute rejection can now be avoided using genetically engineered donor organs, but cellmediated rejection by the adaptive immune response has not been addressed successfully. Here we investigated the initial human pan-T-cell reaction using a pig-human blood working heart model.

MATERIALS AND METHODS

Porcine wild-type hearts (n = 7) were perfused with human blood in a biventricular working heart system for 3 hours. As control, blood from the same human donors was circulated without a pig heart. Pan-T cells were selectively extracted from blood taken before and at the end of the perfusion cycle. The relative mRNA expression of selected target genes (real-time quantitative polymerase chain reaction) and the expression of microRNAs were determined.

RESULTS

After xenogeneic organ perfusion, there was a moderate upregulation of several CD4+ marker cytokines (interleukin 2, interleukin 4, interferon γ) compared with control. We found a distinct increase in the mRNA expression of granzyme B and perforin, key markers of cytotoxic T cells. No differences in the marker genes of regulatory T cells were evident. Levels of the anti-inflammatory microRNAs miR-16 and miR-93 were significantly higher in the xenoperfused group than in the control group.

CONCLUSIONS

This study demonstrated that contact of human blood with pig endothelium activates cytotoxic T cells within the first few hours, indicating acute rejection processes. This is accompanied by upregulation of anti-inflammatory microRNAs, which may represent compensatory anti-inflammatory mechanisms.

[Evaluation of a novel training course for hoof trimmers to participate in a Swiss national cattle claw health monitoring programme]

INTRODUCTION

The main goal of the resources project «Healthy claws - the foundation for the future» is to establish a Swiss national claw health monitoring programme for cattle, similar to what has already been established in other countries (e. g. Finland, Sweden). So far in the course of the project, 30 claw trimmers have been trained to use a digital recording software. An appropriate training concept and information to the work environment of Swiss claw trimmers are necessary to ensure that the recorded claw health data is of good quality. The newly developed training programme for claw trimmers was evaluated using the 30 first trained claw trimmers of the project. The training consisted of group events and individual schooling sessions, during which the claw trimmers were trained to recognise, classify and digitally record foot and claw disorders according to the «ICAR claw health atlas». At the end of the training programme, demographic and work relevant data about the claw trimmers was collected and their abilities when using the recording software, as well as recognising and classifying foot and claw disorders using pictures or live animals, were evaluated. The demographic and work relevant data collected at the end of the training showed an ageing of the profession (43% of the participants were over 50 years old), a lack of full-time claw trimmers (23% of the claw trimmers worked 90% or 100%), a neglect of locomotion scoring during claw trimming (no locomotion scoring standing from 60% and in movement from 33% of the participants) and a broad use of the Swiss claw trimming method (90% of the claw trimmers indicate using this method). An average Cohens kappa value of 0,74, and thus an overall substantial agreement with the first author, respectively the ICAR Atlas, was achieved for the identification and classification of foot and claw disorders. It was also noted, that all the participants were capable of using the recording software in practice after their schooling. The calculation of Cohens kappa values helps to recognise claw trimmers which fall below the limiting value and therefore show an insufficient agreement. These claw trimmers can thus be excluded from the scientific evaluation or undergo further training. It was concluded that the described training concept is suitable to establish a national claw health monitoring programme.

Rapamycin-based graft-versus-host disease prophylaxis increases the immunosuppressivity of myeloid-derived suppressor cells without affecting T cells and anti-tumor cytotoxicity

The immunosuppressant rapamycin (RAPA) inhibits mammalian target of rapamycin (mTOR) functions and is applied after allogeneic bone marrow transplantation (BMT) to attenuate the development of graft‐versus‐host disease (GVHD), although the cellular targets of RAPA treatment are not well defined. Allogeneic T cells are the main drivers of GVHD, while immunoregulatory myeloid‐derived suppressor cells (MDSCs) were recently identified as potent disease inhibitors. In this study, we analyzed whether RAPA prevents the deleterious effects of allogeneic T cells or supports the immunosuppressive functions of MDSCs in a BMT model with major histocompatibility complex (MHC) classes I and II disparities. RAPA treatment efficiently attenuated clinical and histological GVHD and strongly decreased disease‐induced mortality. Although splenocyte numbers increased during RAPA treatment, the ratio of effector T cells to MDSCs was unaltered. However, RAPA treatment induced massive changes in the genomic landscape of MDSCs preferentially up‐regulating genes responsible for uptake or signal transduction of lipopeptides and lipoproteins. Most importantly, MDSCs from RAPA‐treated mice exhibited increased immunosuppressive potential, which was primarily inducible nitric oxide synthase (iNOS)‐dependent. Surprisingly, RAPA treatment had no impact on the genomic landscape of T cells, which was reflected by unchanged expression of activation and exhaustion markers and cytokine profiles in T cells from RAPA‐treated and untreated mice. Similarly, T cell cytotoxicity and the graft‐versus‐tumor effect were maintained as co‐transplanted tumor cells were efficiently eradicated, indicating that the immunosuppressant RAPA might be an attractive approach to strengthen the immunosuppressive function of MDSCs without affecting T cell immunity.

Altered selection during language processing in individuals at high risk for psychosis

INTRODUCTION

Performance in the executive function (EF) domain has been linked to symptoms and functional outcomes in psychosis. Studies have found that UHR populations have difficulty with verbal fluency, which involves multiple facets of EF. Two potentially implicated EF facets were examined to explore whether these could be dissociated in UHR populations: selection among alternatives (measured by selection costs) and retrieval from semantic memory retrieval (measured by retrieval costs).

METHODS

A total of 45 UHR individuals and 46 healthy controls (HVs) were assessed with a verb generation task. Differences in selection cost (RT difference between high and low selection demand conditions) and retrieval cost (RT difference between high and low retrieval demand conditions) were examined and participants were also assessed for clinical symptoms.

RESULTS

The UHR group showed greater selection costs relative to HVs, F (1, 91) = 4.39, p = 0.039. However, there were no group differences on retrieval cost, F (1, 91) = 0.63, p = 0.43. A positive association (r = 0.41) was found between disorganized and negative symptoms and selection costs (but not retrieval costs) in the UHR group. There was no significant association between selection costs and positive symptoms.

DISCUSSION

Increased selection costs may reflect impaired performance in the neural inhibition domain of EF in the UHR population, potentially underlying a mechanistically distinct EF subdomain that affects the group's ability to efficiently select between competing options. Findings suggest that UHR individuals may exhibit impairment in selecting among alternatives, but not in retrieval from semantic memory.

Mini photopheresis for refractory chronic graft-versus-host disease in children and adolescents

BACKGROUND

Extracorporeal photopheresis (ECP) has been established to treat graft-versus-host disease. Our mini ECP technique (mini-ECP) allows for treatment of patients with GVHD and contraindications for classical ECP or low body weight. The safety and efficacy of applying ECP for the long-term treatment of chronic GVHD (cGVHD) have not been described.

STUDY DESIGN AND METHODS

A retrospective analysis of mini-ECP treatments for children and adolescents with cGVHD was performed. Mini-ECP with 100 to 200 mL of whole blood was used to treat 14 patients. The median age at the start of treatment was 7 years (range, 1-17 years), and median body weight was 20 kg (range, 8-53 kg). A total of 703 mini-ECP treatments was performed. The median number of treatments per patient was 35 (range, 8-129), and median treatment duration was 11 months (range, 1.4-28.5 months).

RESULTS

Mini-ECP was well tolerated. Four adverse events occurred in three patients, and two of them were related to the ECP procedure. Complete or partial responses were observed in 10 patients. Steroids were discontinued in seven patients and tapered in three others. Responses were seen in the skin, mouth, gastrointestinal tract, and eyes.

CONCLUSION

Mini-ECP represents a less invasive ECP alternative for low-body-weight patients with cGVHD and contraindications for apheresis.

Apparent Diffusion Coefficient Levels and Neurodevelopmental Outcome in Fetuses with Brain MR Imaging White Matter Hyperintense Signal

BACKGROUND AND PURPOSE

One of the perplexing findings of fetal brain MR imaging is white matter T2 hyperintense signal. The aims of our study were initially to determine the main etiologies associated with white matter T2 hyperintense signal, then to examine whether the different etiologies have different ADC values, and, last, to assess the association of white matter T2 hyperintense signal with developmental outcome.

MATERIALS AND METHODS

This was a prospective cohort study of 44 MR imaging scans of fetal brains obtained for suspected brain pathologies at a tertiary medical center during 2011-2015. Clinical data were collected from electronic medical charts. ADC values were measured and averaged in the frontal, parietal, occipital, and temporal lobes. Neurodevelopmental assessments were performed with the Vineland Adaptive Behavior Scales II.

RESULTS

Half of the cases of MRI hyperintense T2 signal of the fetal brain were associated with congenital cytomegalovirus infection. The other half were mainly idiopathic. Thus, the study group was divided to subgroups positive and negative for cytomegalovirus. Both groups had hyperintense signal in the temporal lobe. The group positive for cytomegalovirus had involvement of the parietal lobe. Only this group had increased ADC values in the temporal and parietal lobes. There was no association between the neurodevelopment outcome and the etiologies or ADC values.

CONCLUSIONS

T2 hyperintense signal in fetal brain MRI associated with positive cytomegalovirus infection has increased ADC values in the temporal and parietal lobes, suggestive of brain edema in these areas. However, the association between this finding and neurodevelopment outcome requires further evaluation.

Potential Risks to Stable Long-term Outcome of Allogeneic Hematopoietic Stem Cell Transplantation for Children With Cerebral X-linked Adrenoleukodystrophy

IMPORTANCE

Allogeneic hematopoietic stem cell transplantation is the standard intervention for childhood cerebral X-linked adrenoleukodystrophy. However, the pretransplant conditions, demyelination patterns, complications, and neurological outcomes of this therapy are not well characterized.

OBJECTIVES

To identify the risks to stable neurocognitive survival after hematopoietic stem cell transplantation and to describe subgroups of patients with distinct clinical long-term outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This case series analyzed the treatment and outcome of a cohort of 36 boys who underwent hematopoietic stem cell transplantation at Charité Universitätsmedizin Berlin, Germany, between January 1, 1997, and October 31, 2014. Case analysis was performed from January 1, 2016, through November 30, 2017. During this retrospective review, the adrenoleukodystrophy-disability rating score and the neurological function score were used. Demyelinating lesions in the brain were quantified by the Loes score.

MAIN OUTCOMES AND MEASURES

Overall survival, survival without major functional disabilities, and event-free survival were analyzed. Patients' clinical symptoms, demyelination patterns, and stem cell source were stratified.

RESULTS

Of the 36 boys who underwent hematopoietic stem cell transplantation, the median (range) age was 7.2 (4.2-15.4) years; 18 were presymptomatic and 18 were symptomatic. Twenty-seven patients (75%) were alive at a median (interquartile range [IQR]) follow-up of 108 (40-157) months. Sixteen of 18 presymptomatic patients (89%) survived, and 13 (72%) had an event-free survival with a median (IQR) survival time of 49 (37-115) months. Among the symptomatic patients, 11 of 18 (61%) survived, but only 1 was an event-free survival (6%) (median [IQR] time, 9 [3-22] months). Of the 9 patients who received a bone marrow transplant from a matched family donor, all survived. Among the 36 patients, 6 disease-related deaths (17%) and 3 transplant-related deaths (8%) occurred. Deaths from disease progression (n = 6) occurred only in patients with demyelination patterns other than parieto-occipital. In total, 18 patients (50%) displayed limited parieto-occipital (Loes score <9) or frontal (Loes score <4) demyelination before transplant (favorable). None of these patients died of progressive disease or developed major functional disabilities, 15 of them were characterized by stable neuroimaging after the transplant, and event-free survival was 77% (95% CI, 60%-100%). In contrast, the other 18 patients with more extended parieto-occipital demyelination (n = 6), frontal involvement (n = 4), or other demyelination patterns (n = 8) progressed (unfavorable): 13 patients developed epilepsy and 10 developed major functional disabilities, and their event-free survival was 0%. This newly defined neuroimaging assessment correlated best with neurocognitive deterioration after transplant (hazard ratio, 16.7; 95% CI, 4.7-59.6).

CONCLUSIONS AND RELEVANCE

All patients with favorable neuroimaging who received matched bone marrow remained stable after transplant, while some of the other patients developed major functional disabilities. Newborn screening for the disease and regular neuroimaging are recommended, and patients who lack a matched bone marrow donor may need to find new therapeutic options.

Front-line imatinib treatment in children and adolescents with chronic myeloid leukemia: results from a phase III trial

A total of 156 patients (age range 1.3-18.0 years, median 13.2 years; 91 (58.3%) male) with newly diagnosed CML (N = 146 chronic phase (CML-CP), N = 3 accelerated phase (CML-AP), N = 7 blastic phase (CML-BP)) received imatinib up-front (300, 400, 500 mg/m², respectively) within a prospective phase III trial. Therapy response, progression-free survival, causes of treatment failure, and side effects were analyzed in 148 children and adolescents with complete data. Event-free survival rate by 18 months for patients in CML-CP (median follow-up time 25 months, range: 1-120) was 97% (95% CI, 94.2-99.9%). According to the 2006 ELN-criteria complete hematologic response by month 3, complete cytogenetic response (CCyR) by month 12, and major molecular response (MMR) by month 18 were achieved in 98, 63, and 59% of the patients, respectively. By month 36, 86% of the patients achieved CCyR and 74% achieved MMR. Thirty-eight patients (27%) experienced imatinib failure because of unsatisfactory response or intolerance (N = 9). In all, 28/148 patients (19%) underwent stem cell transplantation (SCT). In the SCT sub-cohort 2/23 patients diagnosed in CML-CP, 0/1 in CML-AP, and 2/4 in CML-BP, respectively, died of relapse (N = 3) or SCT-related complications (N = 2). This large pediatric trial extends and confirms data from smaller series that first-line imatinib in children is highly effective.

[Standardization and modeling of surgical processes]

BACKGROUND

Due to the technological developments around the operating room, surgery in the twenty-first century is undergoing a paradigm shift.

OBJECTIVE

Which technologies have already been integrated into the surgical routine? How can a favorable cost-benefit balance be achieved by the implementation of new software-based assistance systems?

METHODS

This article presents the state of the art technology as exemplified by a semi-automated operation system for otorhinolaryngology surgery. The main focus is on systems for implementation of digital handbooks and navigational functions in situ.

RESULTS

On the basis of continuous development in digital imaging, decisions may by facilitated by individual patient models thus allowing procedures to be optimized. The ongoing digitization and linking of all relevant information enable a high level of standardization in terms of operating procedures. This may be used by assistance systems as a basis for complete documentation and high process reliability.

CONCLUSION

Automation of processes in the operating room results in an increase in quality, precision and standardization so that the effectiveness and efficiency of treatment can be improved; however, care must be taken that detrimental consequences, such as loss of skills and placing too much faith in technology must be avoided by adapted training concepts.

Diagnose angeborener Störungen der Thrombozytenfunktion

Angeborene Störungen der Thrombozytenfunktion sind eine heterogene Gruppe von Erkrankungen, die oft erst bei Auftreten von Blutungen erkannt werden. Im klinischen Bereich haben sich nur wenige Methoden zur Diagnose und Klassifizierung von angeborenen Thrombozytenfunktionsstörungen bewährt. Für eine rationelle Diagnostik ist ein stufenweises Vorgehen empfehlenswert. Anamnese und klinische Untersuchung sind Grundvoraussetzungen. Das von-Willebrand-Syndrom und andere plasmatische Gerinnungsstörungen sollten vor einer spezifischen Thrombozytenfunktionsdiagnostik immer ausgeschlossen werden. Die Bestimmung von Zahl, Größe, Volumen (MPV) und Morphologie der Thrombozyten erlauben Rückschlüsse auf die zu Grunde liegende Störung.

Die PFA-100®-Verschlusszeit eignet sich als Screening zum Ausschluss schwerer Thrombozytenfunktionsstörungen. Die Aggrego metrie ermöglicht die Untersuchung zahlreicher Aspekte der Thrombozytenfunktion. Die Durchflusszytometrie ist zur Diagnose von Thrombasthenie Glanzmann, Bernard-Soulier- Syndrom und Freisetzungsstörungen geeignet. Molekulargenetische Untersuchungen können die Verdachtsdiagnose bestätigen oder zum Nachweis nicht beschriebener Defekte verwendet werden. Hier wird die ungekürzte Version der inter -disziplinären Leitlinie* präsentiert.

Outcomes of mismatched and unrelated donor hematopoietic stem cell transplantation in Fanconi anemia conditioned with chemotherapy only

Fanconi anemia (FA) is a genomic instability syndrome associated with bone marrow failure, myelodysplastic syndrome (MDS), and/or acute myeloid leukemia (AML) requiring hematopoietic stem cell transplantation (HSCT) to restore normal hematopoiesis. Although low-intensity fludarabine-based preparative regimens without radiation confer excellent outcomes in FA HSCTs with HLA-matched sibling donors, outcomes for FA patients with alternative donors are less encouraging, albeit improving. We present our experience with 17 FA patients who completed mismatched related or unrelated donor HSCT using a non-radiation fludarabine-based preparative regimen at Charité University Medicine Berlin. All patients engrafted; however, one patient had unstable chimerism in the setting of multi-viral infections that necessitated a stem cell boost to revert to full donor chimerism. Forty-seven percent of patients developed grade I acute graft-verus-host disease (aGVHD). No grade II-IV aGVHD or chronic graft-versus-host disease of any severity occurred. At a median follow-up of 30 months, 88 % of patients are alive with normal hematopoiesis. Two patients died of infections 4 months post-transplantation. These results demonstrate that short-term outcomes for FA patients with mismatched and unrelated donor HSCTs can be excellent using chemotherapy only conditioning. Viral reactivation, however, was a major treatment-related complication.

Impact of navigated-control assistance on performance, workload and situation awareness of experienced surgeons performing a simulated mastoidectomy

BACKGROUND

Navigated control (NC) is an advanced image-guided navigation system that provides an additional control function to enhance patient safety. It automatically stops the surgical instrument if it comes close to critical anatomical structures that need to be protected during surgery. The purpose of this study was to explore the human performance consequences of computer-based navigated control assistance.

METHODS

Seven experienced surgeons conducted a simulated mastoidectomy manually and with support of the NC system. The impact on surgical performance, workload and situation awareness was analysed.

RESULTS

NC support led to a better quality of surgical outcome and a lower level of physiological effort during surgery. Cost effects were reflected in reduced time efficiency and an increased subjectively experienced workload.

CONCLUSION

The results demonstrate the potential of NC support in terms of lower workload and enhanced patient safety. Cost effects might be reduced by remodelling the control function.

[Instrument navigation in ensonasal sinus surgery]

BACKGROUND

It is to be expected that, microsurgical operations in ENT must be partially performed without direct vision, e. g. without the possibility of controlling the preparation progress. This study provides a clinical example of how instrument navigation may be used in a safe and reasonable manner to the benefit of treatment quality. It is assumed that a median frontal sinus drainage procedure may be performed by means of a tracked sinus drill using solely instrument navigation.

MATERIAL AND METHODS

The sinus drill was registered using an optoelectric navigation system. An optical registration device was attached to the drill. In the period from 1 December 2011 to 30 April 2012 (5 months) 24 patients underwent a median frontal sinus drainage. 12 of the surgeries were performed under the condition operation navigation. The other 12 surgeries were performed using solely instrument navigation.

RESULTS

When applying mode Instrument Navigation (IN), a significantly reduced incision-to-suture time was registered within both groups. Within the group Draf IIB, it was reduced to 68.5% (from 67.1 min to 46.0 min). Resection efficiency, i. e., the ratio between the width of the frontal sinus ostium and the required total surgery time, widely differed to the benefit of group IN. Within both groups, the questionnaire revealed a high level of confidence in Surgical Management and Guidance Systems (SMGS) functionalities (100%).

CONCLUSION

The present study was designed to show for the first time a median frontal sinus drainage under the condition solely instrument navigation.

SNX10 mutations define a subgroup of human autosomal recessive osteopetrosis with variable clinical severity

Human Autosomal Recessive Osteopetrosis (ARO) is a genetically heterogeneous disorder caused by reduced bone resorption by osteoclasts. In 2000, we found that mutations in the TCIRG1 gene encoding for a subunit of the proton pump (V-ATPase) are responsible for more than one-half of ARO cases. Since then, five additional genes have been demonstrated to be involved in the pathogenesis of the disease, leaving approximately 25% of cases that could not be associated with a genotype. Very recently, a mutation in the sorting nexin 10 (SNX10) gene, whose product is suggested to interact with the proton pump, has been found in 3 consanguineous families of Palestinian origin, thus adding a new candidate gene in patients not previously classified. Here we report the identification of 9 novel mutations in this gene in 14 ARO patients from 12 unrelated families of different geographic origin. Interestingly, we define the molecular defect in three cases of "Västerbottenian osteopetrosis," named for the Swedish Province where a higher incidence of the disease has been reported. In our cohort of more than 310 patients from all over the world, SNX10-dependent ARO constitutes 4% of the cases, with a frequency comparable to the receptor activator of NF-κB ligand (RANKL), receptor activator of NF-κB (RANK) and osteopetrosis-associated transmembrane protein 1 (OSTM1)-dependent subsets. Although the clinical presentation is relatively variable in severity, bone seems to be the only affected tissue and the defect can be almost completely rescued by hematopoietic stem cell transplantation (HSCT). These results confirm the involvement of the SNX10 gene in human ARO and identify a new subset with a relatively favorable prognosis as compared to TCIRG1-dependent cases. Further analyses will help to better understand the role of SNX10 in osteoclast physiology and verify whether this protein might be considered a new target for selective antiresorptive therapies.

Endoscopic sinus surgery training courses: benefit and problems - a multicentre evaluation to systematically improve surgical training

BACKGROUND

The aim of this multicentre study was to systematically analyse the strengths and weaknesses in the surgical training for endoscopic sinus surgery (ESS) and identify measures that may improve training.

METHODOLOGY

Using a structured questionnaire, 133 participants of ESS courses in seven centres in Germany, Switzerland and Australia were asked about their experiences during their dissection courses and how they perceived their course could be improved.

RESULTS

Gaining confidence in handling of instruments and endoscopes was only a problem for participants with little experience in ESS. The majority of the participants, independent from their level of training, considered infundibulotomy and anterior ethmoidectomy as the easiest dissection steps, whilst surgery of the frontal sinus posed a considerable challenge for many surgeons even those with a higher level of training. Participants with and without ESS experience thought that emphasis on anatomy was the most important improvement that could be made during their surgical training. Virtually all participants stated that the course improved their anatomical knowledge, their surgical skills and their confidence when performing ESS.

CONCLUSIONS

ESS dissection courses are considered beneficial by surgical trainees. Participants felt that more emphasis on sinus anatomy in conjunction with private study is essential to maximize their skills in surgical dissection. For beginners with ESS, an infundibulotomy and anterior ethmoidectomy were thought to be the best initial procedures to help develop endoscopic surgical skills.

Recurrence rate, time to progression and facial nerve function in microsurgery of vestibular schwannoma

OBJECTIVE

Recurrence rate, time to progression, and facial nerve function were analysed by comparing patients with complete and near total tumor removal after suboccipital craniotomy for vestibular schwannoma surgery.

METHODS

From 1996 to 2004, 118 patients with vestibular schwannoma were operated with an interdisciplinary approach. Fifty patients fulfilled the inclusion criteria and were included in the study. Progression was defined as an increase of ⩾2 mm in the largest diameter in the magnetic resonance imaging. Preoperative tumor size, facial nerve function estimated using the House-Brackmann score (HBS), time to progression, and recurrence rate were analysed and related to the extent of resection.

RESULTS

In 28 cases (group I), a capsular remnant was left. In 22 cases (group II), tumor removal was complete. In group I, nine patients (32·1%) showed progression. In group II, two patients (9·1%) developed a recurrent tumor, no significance (P = 0·085). In groups I and II, 53·6 and 59·6% had a good function of the facial nerve (HBS I+II), 28·6% in group I and 13·5% in group II had a moderate disturbance (HBS III+IV), and 17·9% in group I and 27·7% in group II had a poor function (HBS V+VI). There was no significant difference between median preoperative tumor size and facial nerve function within patients with HBS III and IV.

CONCLUSION

Complete tumor removal may be associated with a risk of functional loss, whereas near total tumor removal may be associated with a higher risk of progression.

[The 'Surgical Deck': a new generation of integrated operational rooms for ENT]

BACKGROUND

Existing operating room concepts do not meet modern technological opportunities anymore. The "Surgical Deck" is supposed to represent a prototype for a new operating room generation. The objective of the project is to achieve a better integration of functions and to develop an innovative concept for a highly developed surgical workstation.

MATERIAL AND METHODS

3 working areas are defined: Surgical, Airway and Technical Cockpit. The evaluation was conducted on 284 surgeries carried out from 01.08. 2011 to 31.01. 2012. The evaluation team consisted of 6 surgeons, 3 surgery nurses, 3 anesthesiologists and 4 anesthesia nurses. Within a detailed analysis, the data of 50 FESS surgeries were compared to those of a control group.

RESULTS

Within the FESS group, the average slot time was reduced by 13%. 88.2% of those questioned assessed ergonomics as being better than in the conventional OR. 71.5% stated that the Surgical Deck provided an added value with regard to the surgical procedure. 91.3% confirmed that the system control required additional training. 79.3% described the cost-benefit-ratio as appropriate. For 96% of the surgeries, respondents said that they were feeling adequately supported by the technology.

CONCLUSION

The results show a clear advantage of the system architecture. The Surgical Deck may present a solid foundation with regard to the transfer of the system into the clinical practice. This is relevant for new assistance functions such as process control software or navigation-based collision warning systems. It is to be expected that the project will significantly contribute to further develop the future surgical workstation and its standardization.

[First clinical experiences with an endoscope manipulator system in endo- and transnasal surgery]

BACKGROUND

Endo- and transnasal surgery needs optical support. The use of a microscope allows bimanual manipulation. More often the endoscopic technique is used which needs one hand for endoscope guidance "loosing" it for manipulation or demanding an assistant for endoscope guidance. In this work the use of a miniature endoscope manipulator system for endonasal and transnasal surgery was evaluated.

MATERIAL AND METHODS

31 FESS with manipulator-assisted endoscope guidance were performed. The used endoscope positions, the number of position changes and conditional interruptions were documented. In addition, a transsphenoidal approach to the pituitary gland was performed in a cadaver trial.

RESULTS

Non-inferiority was shown for the use of the endoscope manipulator with reference to time and accuracy of manipulator-assisted endoscope guidance. There were 6.4 position changes for each side. Bimanual manipulation was possible in all cases. In the region of high-risk structures (lamina papyracea, frontal recess) we conceptual switched to manual endoscope guidance.

CONCLUSION

The evaluated endoscope manipulator fulfills the minimum requirements to be integrated into the surgical workflow of endo- and transnasal surgery. The number of required endoscope position changes is small allowing bimanual instrumentation. Still a disadvantage is the need for interrupting the workflow to remote the endoscope manipulator with the joystick console. Further development potential would be a forced-feedback function and hands-free navigated-controlled guidance.

[The first clinical use of an Dynamic Registration Tool for Navigation in FESS]

BACKGROUND

The effective register accuracy in an situs issues a challenge to the employment of instrument navigation in the ENT Surgery. The idea of the initially determined process Dynamic Registration Supply (DRS) is to improve the register accuracy by the automatic, and interoperability of the register.

MATERIALS AND METHODS

The aim was to determine clinical use of DRS. Opto-electrical system Navigation Panel Unit, vs. 4.0.0 with the functionality DRS was used. Experiments were carried out on 95 patients who had so called FESS. The data of a control group were available to researchers. The measuring log includes among other things following parameters: retooling time, cutting-suture time, frequency of use of the navigated pointer, frequency of additional registration.

RESULTS

At least once during the procedure DRS has been activated in 85 of 95 interventions (89.5). The time required increased by 15% accumulated 189 s per intervention. The most frequently used additional registration was in the region of sphenoid sinus. The surgeons underlined that out of 95 surveys in 75 cases the DRS rendered the instrument navigation more precise, while 1% of 93 cases considered this function as unwanted.

CONCLUSION

The first clinical study for use of an automatic algorithm for recognition and reduction of faulty registration of a CT, navigation was successful. The findings suggest that by using automatic intraoperative registration DRS consisting inaccuracy can be reduced. In practice this means an efficient quality improvement of the Navigation.

[Impact of transtympanic miniature endoscopy of the middle ear--a conceptual cadaver study]

OBJECTIVE

Endoscopic inspections of the middle ear have already been described. So far, the low optical quality due to the small diameter is limiting this type of procedure. In this study the use of a miniature endoscope for visualization of the middle ear structures has been evaluated.

MATERIAL AND METHODS

8 human cadaveric head specimens have been inspected. Following myringotomy, 2 miniature endoscopes were placed into the middle ear and the promontory, the incudostapedial joint, the round und oval window niche with stapes footplate were visualized and fotodocumentated. After endaural approach all middle ear structures were visualized microscopically and the quality of pictures was compared. Technical picture quality and anatomical visualization were evaluated by 5 ear surgeons. In addition, 2 interventional procedures were performed (control of ossicular chain mobility and intratympanic substance application).

RESULTS

Still, the technical picture quality was significantly better for the microscope. The anatomical visualization of the middle ear structures with the miniature endoscope was not inferior compared to the microscope. The feasibility of additional interventions, e.g. control of ossicular chain mobility or intratympanic substance application could be shown. An inspection of the correct prosthesis position after tympanoplasty could be evaluated, too.

CONCLUSION

This study showed that middle ear structures can be visualized by trans-tympanic miniature endoscopy equal or even better compared to conventional microscopy in spite of reduced technical quality.

Immature platelet count: a simple parameter for distinguishing thrombocytopenia in pediatric acute lymphocytic leukemia from immune thrombocytopenia

BACKGROUND

Platelet counts below normal values define thrombocytopenia. However, platelet counts alone do not reveal the underlying pathomechanism. New blood cell counters provide additional information on platelet size and volume, and enable the distinction of sub-populations. In this preliminary study, we evaluate whether one of these markers can be used for diagnosis of isolated thrombocytopenia in children.

PROCEDURE

We provide normal values for mean platelet volume (MPV), platelet distribution width (PDW), plateletcrit (PCT), platelet large cell ratio (P-LCR), platelet mean-frequent volume (P-MFV), relative immature platelet fraction (IPF%), and absolute IPF (IPF#) for 100 healthy children and analyzed 87 children with thrombocytopenia.

RESULTS

In children with platelet production defects, IPF% was low, while in acute immune thrombocytopenia (ITP), IPF% was markedly increased (median 25.2%, P < 0.01), representing accelerated platelet turnover. Interestingly, children diagnosed with acute lymphocytic leukemia (ALL) also had elevated IPF% (median 10%, P < 0.01), suggesting that thrombopoiesis is stimulated despite virtual absence of bone marrow progenitors. Low IPF# was only found in patients with acute ITP.

CONCLUSIONS

IPF% is a marker for thrombocytopenia due to defective platelet production while IPF#, representing the immature platelet count, might become a practical parameter to distinguish acute ITP from thrombocytopenia in children with newly diagnosed ALL (P < 0.01).

[Clinical experiences with an automatic collision warning system: instrument navigation in endoscopic transnasal surgery]

PROBLEM

The goal of this work is the extension of instrument navigation with a collision warning function. With the help of an additional distance display and warning system the performance of surgical navigation systems should be improved.

MATERIAL AND METHODS

The collision warning system (DCS) is an extension of an optoelectric navigation system (NPU, Karl Storz GmbH&Co.KG, Tuttlingen, Germany). The measurement of situation awareness was performed on phantom models of functional endoscopic surgery of the paranasal sinuses (FESS; Phacon, Leipzig). Altogether 450 measurement pairs for the analysis of surgical accuracy to the risk structure (frontal skull base, lamina papyracea, internal carotid artery) were available. To examine the influence on the clinical process, a prospective analysis of intraoperative complications was carried out. Of the 104 FESS patients, two groups, one of 56 patients with only navigation (NAV) and one of 48 patients (NAV+DCS), were examined. Efficiency was evaluated on the basis of times for system preparation and intraoperative application.

RESULTS

A significant increase in the assumed and actual distance values between instrument tip and risk structure using the collision warning system was seen at 76%. The complication rate was more favorable for the NAV+DCS group. The time needed for preparation of the navigation system with the application of the collision warning system increased on average by 48%, or 1.2 min. However, the relation between preparation time and utilization time was approximately the same at 53.5% in the NAV group and 57.4% in the NAV+DCS group.

CONCLUSIONS

This work supports the clinical use and efficiency of a collision warning system as an addition to well-known instrument navigation in endo- and transnasal surgery. The segmenting algorithm is suitable for clinical requirements.

Two patterns of thrombopoietin signaling suggest no coupling between platelet production and thrombopoietin reactivity in thrombocytopenia-absent radii syndrome

BACKGROUND

Thrombocytopenia with absent radii syndrome is defined by bilateral radius aplasia and thrombocytopenia. Due to impaired thrombopoietin signaling there are only few bone marrow megakaryocytes and these are immature; the resulting platelet production defect improves somewhat over time. A microdeletion on chromosome 1q21 is present in all patients but is not sufficient to form thrombocytopenia with absent radii syndrome. We aimed to refine the signaling defect in this syndrome.

DESIGN AND METHODS

We report an extended study of 23 pediatric and adult patients suffering from thrombocytopenia with absent radii syndrome in order to scrutinize thrombopoietin signal transduction by immunoblotting and gel electrophoretic shift assays. In addition, platelet immunotyping and reactivity were analyzed by flow cytometry. Results were correlated with clinical data including age and platelet counts.

RESULTS

Two distinct signaling patterns were identified. Juvenile patients showed abrogated thrombopoietin signaling (pattern #1), which is restored in adults (pattern #2). Phosphorylated Jak2 was indicative of activation of STAT1, 3 and 5, Tyk2, ERK, and Akt, showing its pivotal role in distinct thrombopoietin-dependent pathways. Jak2 cDNA was not mutated and the thrombopoietin receptor was present on platelets. All platelets of patients expressed normal levels of CD41/61, CD49b, and CD49f receptors, while CD42a/b and CD29 were slightly reduced and the fibronectin receptor CD49e markedly reduced. Lysosomal granule release in response to thrombin receptor activating peptide was diminished.

CONCLUSIONS

We show a combined defect of platelet production and function in thrombocytopenia with absent radii syndrome. The rise in platelets that most patients have during the first years of life preceded the restored thrombopoietin signaling detected at a much later age, implying that these events are uncoupled and that an unknown factor mediates the improvement of platelet production.

[Influence of an auto-motorised optical navigation camera to the surgical workflow in ENT surgery]

BACKGROUND

With the application of optical navigation systems an interruption of the line of sight (LOS) between navigation camera and the patient/instrument can occur. The goal of this work is the clinical evaluation of a newly developed system for automatic adjusting of an optical navigation camera (Navigation Camera Assistant, NCA). NCA is a miniature robot, which is able to position the navigation camera autonomously in 2 levels.

MATERIAL AND METHODS

The influence of the NCA was examined on 128 patients: 55 procedures at the paranasal sinuses and 9 procedures at the temporal bone with the NCA were evaluated and compared with available workflow data of adequate surgeries without NCA. An optical navigation system of the 3 (rd) generation was used. The following parameters were recorded: Preparation time of the system, time of using the system, LOS-interruptions.

RESULTS

The LOS-interruption decreased in the group of FESS with application of the NCA by 92%, in the group tympanic cavity by 85%. The number of corrective motions of the navigation camera was increased with application of the NCA in the group FESS by 73%, in the group tympanic cavity by 89%. The usage time of navigation increased with the application of the NCA in the group of FESS by 36%, in the group tympanic cavity by 16%.

CONCLUSIONS

With a motorized navigation camera can be the interruption rate of LOS significantly improved at frontal and lateral skull base. The technical expenditure for installation of the NCA robot is little even during, for this reason there is the potential that this module can be established for the clinical practice.

Acute lymphoblastic leukemia cells treated with CpG oligodeoxynucleotides, IL-4 and CD40 ligand facilitate enhanced anti-leukemic CTL responses

Acute lymphoblastic leukemia (ALL) is the most common pediatric malignancy. Although the majority of patients initially respond to upfront chemotherapy, relapses with poor prognosis occur in approximately 20% of cases. Thus, novel therapeutic strategies are required to improve long-term survival. B-cell precursor (BCP)-ALL cells express low levels of immunogenic molecules and, therefore, are poorly recognized by the immune system. In the present study, we investigated the effect of various combinations of potent B-cell stimulators including CpG, Interleukin (IL)-2 family cytokines and CD40 ligand (CD40L) on the immunogenicity of primary BCP-ALL cells and a series of BCP-ALL cell lines. The combination of CpG, IL-4 and CD40L was identified as most effective to enhance expression of immunogenic molecules on BCP-ALL cells, resulting in an increased capacity to induce both allogeneic and autologous cytotoxic T lymphocytes (CTL). Importantly, such CTL exhibited significant anti-leukemic cytotoxicity not only towards treated, but also towards untreated BCP-ALL cells. Our results demonstrate that the combination of CpG with other B-cell stimulators is more efficient than CpG alone in generating immunogenic BCP-ALL cells and anti-leukemic CTL. Our results may stimulate the development of novel adoptive T cell transfer approaches for the management of BCP-ALL.

[Surgical manipulators in ear surgery: a future vision?]

INTRODUCTION

Middle ear surgery bears a high risk for injury of difficult to differentiate risk structures. Thus, a precise preparation in this area must be the surgical task.

LIMITATIONS

However, there are human (tremor) and systematic limitations (OR setup, narrow access). Assistance systems in terms of manipulators are so far not part of the clinical routine. Although, they could compensate for the above mentioned limitations. MANIPULATORS: This work reviews existing surgical manipulator systems. The expected value is an elevated patient safety through improving surgical accuracy and the reduction of ergonomic deficits. CLINICAL APPLICATION AND DEVELOPMENT: In clinical application there are simply modified industrial robots, highly complex master slave systems and small miniature master slave systems which are directly located at the patient.

CONCLUSION

A disadvantage of most systems is the limited number of applicable instruments. Often, only especially designed instruments can be used. The goal in development should be to create a compact, short distance operated master slave system. The usability of standard (already available) instruments with an easy integration into the surgical and sterilisation procedure would lower the threshold for acceptance of such systems.The surgeon will remain the key player. He can only work efficiently in an ergonomic environment and will always have the responsibility for the intervention. From the authors perspective, highly automated systems should not be the research goal.