S1 Radiculopathy Initially Presenting With Sole Knee Flexion Weakness: A Case Report

Lumbar disc herniation can lead to low back pain and/or sciatica, as well as manifest with neurological symptoms in specific dermatomal/myotomal patterns due to nerve root irritation. S1 radiculopathy is the result of L5-S1 disc herniation and is usually presented with foot plantar flexion/eversion weakness and hypoesthesia in the lateral aspect of the foot. We present a case of S1 radiculopathy that initially presented with hamstring weakness and posterior knee pain as the only manifestations, leading to a delay in the initial diagnosis and treatment. To the best of our knowledge, no previous studies have reported this atypical presentation that resulted from S1 radiculopathy. This case report is of great clinical value, as it will help diagnosticians broaden the diagnostic range in patients with similar symptomatology and avoid diagnostical pitfalls.

The Need for Persistence in the Diagnosis of Mycobacterium Tuberculosis Mono-arthritis: A Unique Case Presentation

Although tuberculosis (TB) is considered to be a common disease confined to undeveloped or developing countries, it may also appear in countries that accept great migrant influx from endemic areas. In terms of the skeletal system, it can be involved in 1-6% of tuberculosis patients while the knee joint is the third most frequently affected site after spine and hip. Given that systemic symptoms are present in only one-third of patients with skeletal tuberculosis and secondary septic arthritis, TB is often indolent and diagnosis can hence be missed or delayed. As a result, a high index of suspicion is imperative. Here, we aim to report a case of mono-arthritis caused by Mycobacterium tuberculosis in a native 77-year-old man who was suffering from low-grade knee pain for six months and despite multiple presentations to the Accident and Emergency department, diagnosis had not been established.

Antibiotic therapy in the treatment of skin abscess meta-analysis

Skin abscess is one of the most common infections of skin and soft tissues. Incision and drainage under local anesthesia is the mainstay of treatment. Although previous small-scale studies failed to show a benefit of antibiotics in patients with simple abscesses, the use of antibiotic therapy is still encountered in the treatment of uncomplicated skin abscesses in our practice. The purpose of our study was to evaluate existing data assessing the effect of adjuvant antibiotic therapy on abscess management. Although as indicated by two recent multicenter studies, antibiotics may provide a positive effect in the management, it is important to consider the risk of resistance associated with antibiotic overuse and to approach each case individually.

Anterior Cruciate Ligament Remnant-Preserving Reconstruction Using a "Lasso-Loop" Knot Configuration

Anterior cruciate ligament (ACL) rupture predisposes to altered kinematics and possible knee joint degeneration. Graft fiber maturation and ligamentization may eliminate this risk during ACL reconstruction procedures. ACL remnant-sparing techniques support the theory that the preserved tissue enhances revascularization, preserves the mechanoreceptors, and leads to anatomic remodeling. The purpose of this article is to present a simple and reproducible technique of tensioning the preserved ACL remnant over the femur. A nonabsorbable suture is passed through the ACL remnant with a "lasso-loop" technique using a curved rotator cuff hook. Femoral and tibial tunnel preparation is performed according to a standard surgical technique for the EndoButton device (Smith & Nephew Endoscopy, Andover, MA). The free ends of the ACL remnant suture are retrieved through the tibial tunnel and passed through each outside hole of the EndoButton device. The hamstring graft is passed through the tibial and femoral tunnels and fixed to the femoral cortex by flipping the EndoButton and to the tibia by an interference screw. Finally, non-sliding half-stitch locking knots are made to secure the ACL remnant suture on the EndoButton device, by use of a knot pusher. This technique offers simple and secure tensioning of the ACL remnant on the fixation device.

Caudal vs transforaminal epidural steroid injections as short-term (6 months) pain relief in lumbar spinal stenosis patients with sciatica

OBJECTIVE

The aim of this study is to evaluate prospectively the efficacy of caudal epidural steroid injection (CESI) and transforaminal epidural steroid injection (TFESI) in lumbar spinal stenosis patients with sciatic pain.

DESIGN

Prospective clinical study.

SETTING AND PATIENTS

Thirty-one patients (average age 62 years) from two hospitals, with single dermotomal distribution of sciatic pain due to spinal stenosis were included in the study.

INTERVENTIONS

Patients underwent epidural steroid injections done by the same injectionist. Eleven patients from one hospital were included in the CESI group, while the TFESI group consisted of 20 comparable patients from the second site.

OUTCOME MEASURES

Primary outcome measure was the complete relief or at least 50% reduction of pain (visual analog scale [VAS]) at 6 months postinjection. Secondary outcome measures were the improvement of function (of at least 15 points of Oswestry Disability Index [ODI]) at 6 months and the changes of VAS and ODI and at 2 weeks, at 3 months, and at 6 months postinjection.

RESULTS

A significantly greater number of stenosis patients showed pain relief at 6 months postinjection with TFSI (90%) than with CESI (54.54%). All patients with TFSI showed improvement of function at 6 months while only three (27.27%) patients with caudal epidural improved functionally. Out of the total 31 patients, two patients from group A underwent a second CESI at 15 days postinjection and decompressive spine surgery between 3 and 6 months postinjection.

CONCLUSIONS

The effectiveness of transforaminal steroid injection for the stenosis patients with sciatica was superior to caudal at 6 months postinjection.

Canalith repositioning procedures among 965 patients with benign paroxysmal positional vertigo

BACKGROUND

Canalith repositioning procedure (CRP) has increasingly been utilized for the last 15 years for the treatment of benign paroxysmal positional vertigo (BPPV). We assess the short- and long-term efficacy of CRP on the treatment of patients with BPPV.

METHODS

Nine hundred sixty-five patients (481 men and 484 women, from 18 to 87 years of age) were enrolled in this prospective study during 1995-2010. Inclusion criteria were a patient history compatible with BPPV and a positive provocative maneuver (either Dix-Hallpike or Roll test). Reported duration of symptoms at the time of their first examination varied from 1 day to 18 months. Variants of the Epley and Barbeque maneuver were used for posterior and anterior canal involvement, and horizontal canal involvement, respectively. Short-term follow-up was obtained 48 h and 7 days after initial treatment, whereas long-term follow-up was obtained at repeated 6-month intervals.

RESULTS

Symptoms subsided immediately in 819 patients (85%) by the first CRP. Only 19 patients (2%) required CRP more than 3 times. Patients' mean follow-up was 74 months; symptom recurrence was noted in 139 patients. A statistically significantly higher recurrence rate was noted in elderly people or those with head trauma or a history of vestibular neuropathy (p<0.001).

CONCLUSIONS

This study provides class IV evidence that CRP remains an efficient and long-lasting noninvasive treatment for BPPV, especially for younger patients without a history of head trauma or vestibular neuropathy. Elderly people have a significantly higher recurrence rate requiring additional education to minimize potential morbidity of their falls.

Surgical treatment of lumbar spinal stenosis with microdecompression and interspinous distraction device insertion. A case series

BACKGROUND

Interspinous distraction devices (IPDD) are indicated as stand-alone devices for the treatment of spinal stenosis. The purpose of this study is to evaluate the results of patients undergoing surgery for spinal stenosis with a combination of unilateral microdecompression and interspinous distraction device insertion.

METHODS

This is a prospective clinical and radiological study of minimum 2 years follow-up. Twenty-two patients (average age 64.5 years) with low-back pain and unilateral sciatica underwent decompressive surgery for lumbar spinal stenosis. Visual Analogue Scale, Oswestry Disability Index and walking capacity plus radiologic measurements of posterior disc height of the involved level and lumbar lordosis Cobb angle were documented both preoperatively and postoperatively. One-sided posterior subarticular and foraminal decompression was conducted followed by dynamic stabilization of the diseased level with an IPDD (X-STOP).

RESULTS

The average follow-up time was 27.4 months. Visual Analogue Scale and Oswestry Disability Index improved statistically significantly (p < 0.001) in the last follow-up exam. Also, the walking distance increased in all patients but two. Posterior intervertebral disc height of the diseased level widened average 1.8 mm in the postoperative radiograph compared to the preoperative. No major complication, including implant failure or spinous process breakage, has been observed.

CONCLUSIONS

The described surgical technique using unilateral microdecompression and IPDD insertion is a clinically effective and radiologically viable treatment method for symptoms of spinal stenosis resistant to non-operative treatment.

Ipsilateral atrophy of paraspinal and psoas muscle in unilateral back pain patients with monosegmental degenerative disc disease

OBJECTIVES

The aim of this study was to assess the cross-sectional area (CSA) of both paraspinal and psoas muscles in patients with unilateral back pain using MRI and to correlate it with outcome measures.

METHODS

40 patients, all with informed consent, with a minimum of 3 months of unilateral back pain with or without sciatica and one-level disc disease on MRI of the lumbosacral spine were included. Patients were evaluated with self-report measures regarding pain (visual analogue score) and disability (Oswestry disability index). The CSA of multifidus, erector spinae, quadratus lumborum and psoas was measured at the disc level of pathology and the two adjacent disc levels, bilaterally. Comparison of CSAs of muscles between the affected vs symptomless side was carried out with Student's t-test and correlations were conducted with Spearman's test.

RESULTS

The maximum relative muscle atrophy (% decrease in CSA on symptomatic side) independent of the level was 13.1% for multifidus, 21.8% for erector spinae, 24.8% for quadratus lumborum and 17.1% for psoas. There was significant difference (p<0.05) between sides (symptomatic and asymptomatic) in CSA of multifidus, erector spinae, quadratus lumborum and psoas. However, no statistically significant correlation was found between the duration of symptoms (average 15.5 months), patient's pain (average VAS 5.3) or disability (average ODI 25.2) and the relative muscle atrophy.

CONCLUSION

In patients with long-standing unilateral back pain due to monosegmental degenerative disc disease, selective multifidus, erector spinae, quadratus lumborum and psoas atrophy develops on the symptomatic side. Radiologists and clinicians should evaluate spinal muscle atrophy of patients with persistent unilateral back pain.

Patients with horizontal gaze palsy and progressive scoliosis due to ROBO3 E319K mutation have both uncrossed and crossed central nervous system pathways and perform normally on neuropsychological testing

BACKGROUND

Horizontal gaze palsy and progressive scoliosis (HGPPS) is caused by mutations of the ROBO3 gene, which encodes a receptor associated with axonal guidance during development. Although there is evidence for uncrossed cuneatal and corticospinal tracts in HGPPS, it is unclear whether other central nervous system pathways are involved.

OBJECTIVE

To study two patients with HGPPS homozygotic for the ROBO3 E319K mutation using a variety of neurophysiological and neuropsychological tests.

METHODS

A battery of neuropsychological tests was applied to assess various cognitive and perceptual functions. The corticospinal, somatosensory and auditory pathways were evaluated using appropriate neurophysiological tests. To access motor pathways to the neck muscles, electromyographic recordings were obtained from the sternocleidomastoideus and splenius capitis muscle during active head rotation.

RESULTS

Both patients performed normally on manual dexterity, complex sensory and visuospatial functions, reading and general intelligence tests. Motor evoked potentials in both patients showed uncrossed corticospinal tracts for the extremities, although in one patient, electromyography indicated pyramidal tract crossing for the neck muscles. Although somatosensory evoked potentials showed uncrossed somatosensory fibres subserving proprioception and light touch, right median nerve somatosensory evoked potential in one patient indicated a partial lemniscal crossing. Sympathetic skin response and blink reflex showed a midline crossing of the spinothalamic and quintothalamic tracts. Brain stem auditory evoked potentials indicated a lack of crossing in the level of the trapezoid body.

CONCLUSIONS

Our patients with the ROBO3 E319Kappa mutation show normal perceptual and cognitive functions and have both crossed and uncrossed motor, sensory and auditory pathways.

Tuberculous trochanteric bursitis

A case of tuberculous trochanteric bursitis in a 40-year old man is reported. The findings of x-rays, echo, bone scanning, CT scan and MRI are shown. After one month of anti-TB therapy the bursa was excised en bloc as well as the lateral part of the trochanter. Then a continuous suction irrigation system was applied for 3 weeks using streptomycin solution. The anti-TB therapy was continued for one year. The patient was asymptomatic with no signs of recurrence 5 years postoperatively.

Prognostic implications of microvessel morphometry in diffuse astrocytic neoplasms

Astrocytic brain tumours, particularly malignant astrocytomas, are recognized to be highly vascular neoplasms with potent angiogenic activity. Recent research has shown that quantification of microvessel density (MVD), as a measure of the degree of angiogenesis, constitutes a strong prognostic indicator in patients with astrocytomas. However, the significance of other morphometric aspects of microvessel network has not been tested so far. In this report, histological sections from 70 astrocytomas (grades II to IV), immunostained for CD34, were evaluated by image analysis for the quantification of MVD, total vascular area (TVA), and microvascular branching, as well as several morphometric parameters related to vessel size or shape. Minor axis length increased with grade (P = 0.045) but MVD and TVA presented a peak in grade III (P = 0.033 and P < 0.001, respectively). Size and shape related parameters affected survival in univariate analysis of grade IV and grades II/III, respectively. In multivariate analysis, only branching counts, along with age and grade, were the independent predictors of survival. Although MVD, TVA and branching counts were adversely related to disease-free survival in grades II and III (univariate analysis), only TVA remained statistically significant in multivariate analysis. It is concluded that TVA and branching counts are prognostically more informative than MVD for patients with diffuse astrocytic tumours.

Mitosin and DNA topoisomerase IIalpha: two novel proliferation markers in the prognostication of diffuse astrocytoma patient survival

The expression of two novel proliferation-associated markers, mitosin and topoisomerase IIalpha (Topo IIalpha), was evaluated immunohistochemically in consecutive paraffin sections from 60 diffuse astrocytomas (grades 2 to 4) in relation to clinicopathologic parameters, proliferating cell nuclear antigen (PCNA) and Ki-67 (MIB-1) expression and survival. The percentage of mitosin and Topo IIalpha-positive cells (LI) increased with grade and Ki-67 LI, but could not discriminate between grade 3 on the one hand and grades 2 or 4 on the other hand. In 51% of cases, Ki-67 LI exceeded Topo IIalpha LI, especially within grade 4. Topo IIalpha and mitosin expression was adversely related to overall and disease-free survival in the entire cohort and in grades 2/3. However, only Topo IIalpha LI affected disease-free survival in grade 4 tumors. Multivariate analysis selected only mitosin LI along with the age of the patient, as the independent parameters predicting overall survival, whereas Topo IIalpha emerged as the single independent predictor of disease-free survival. It is concluded that the proliferative potential of astrocytomas, as measured by mitosin and Topo IIalpha immunostaining, conveys useful prognostic information, in addition to that obtained by standard clinicopathologic parameters.

Morphometric microvascular characteristics predict prognosis in superficial and invasive bladder cancer

Recent research has shown that neovascularization, quantitated by microvessel density (MVD), constitutes a strong prognostic indicator in patients with invasive urothelial carcinomas. These studies, however, have focused only on MVD as the only factor reflecting angiogenesis in transitional-cell carcinomas (TCCs). The objective of this report was to evaluate multiple morphometric microvascular characteristics besides MVD in superficial and muscle-invasive TCCs separately, to provide a better approach to the relationship between angiogenesis, clinicopathological parameters, and prognosis. Histologic sections from 115 TCCs [35 superficial (T1) and 80 muscle-invasive] were immunostained for CD31 and evaluated using image analysis for the quantitation of MVD, area, total vascular area, major axis length, minor axis length, perimeter, compactness, shape factor, and Feret diameter. Patients were followed-up until death (n=31) or for an average of 42.2 months (median 38.5 months). MVD increased with progressing T category (P=0.049) but area (P=0.033), major axis length (P=0.022), perimeter (P=0.043), and Feret diameter (P=0.042) were highest in T2 tumors. Area was the single independent predictor of adverse significance in T1 TCCs, whereas for muscle-invasive tumors, survival was independently predicted by MVD. Regarding disease-free survival in superficial tumors, the single significant independent parameter was compactness, whereas area was an independent favorable indicator of disease-free survival for patients with invasive TCCs. It is concluded that the prognostic significance of neovascularization is better assessed by area and shape-related morphometric characteristics, whereas MVD becomes influential only with regard to overall survival of patients with invasive tumors.

Prognostic implications of aberrations in p16/pRb pathway in urothelial bladder carcinomas: a multivariate analysis including p53 expression and proliferation markers

OBJECTIVE

To assess the prognostic value of the expression of two negative regulators of the cell cycle, namely CDKN2/INK4a gene product (p16) and retinoblastoma gene product (pRb), in urinary bladder cancer in relation to clinicopathological parameters, proliferative fraction and p53 protein accumulation.

METHODS

Paraffin sections from 139 patients with urothelial carcinomas were stained immunohistochemically with antibodies to p16 (F12), pRb (PMG3-245), p53 (DO1), PCNA (PC10) and Ki-67 (MIB-1).

RESULTS

Diminished p16 and pRb expression occurred in 29 and 74% of cases, respectively, being associated with advanced stage but not with histological grade, papillary status or proliferation rate. In most cases (53%) with some fault in the p16/pRb pathway, only one gene was affected. A double-negative p16/pRb phenotype was comparatively uncommon (25%) and was usually seen in T3-T4 tumours. In survival analysis (either univariate or multivariate) aberrant p16 expression was an adverse prognostic parameter only in T3-T4 tumours. In contrast, the abnormal p16/pRb and p53/p16 phenotypes were linked to a diminished overall and disease-free survival (univariate analysis); p53/p16 abnormal expression was also found to be an independent predictor of reduced survival in muscle-invasive tumours, while proliferation markers were the only parameters with independent significance in superficial (Ta-T1) tumours.

CONCLUSION

Our results suggest that lack of p16 immunoexpression, when combined with p53 accumulation, plays an important role in determining the clinical outcome in muscle-invasive urothelial carcinomas.

Audiologic and psychological profile of Greek patients with tinnitus--preliminary findings

Tinnitus is a common complaint among people who suffer from auditory disorders. Altering the patients' response to tinnitus and the development of coping techniques are the most important goals of the therapeutic or suppression methods. This is the first study in the Greek population to investigate the personality characteristics and coping techniques of tinnitus patients. We have studied the relation between the subjective assessment of tinnitus intensity with factors such as sex, age, duration of symptom, and degree of hearing loss. We have also studied the possible relation between the patients' personality characteristics on their attitude towards tinnitus. The participants were 80 tinnitus sufferers, men and women, between 18 and 65 years of age. The personality characteristics were assessed with the Minnesota Multiphasic Personality Inventory (MMPI). The mean MMPI scores in both men and women were within the normal range. The duration of symptoms did not prove to be an important factor for the patients' subjective assessment of the tinnitus intensity. Most patients showed "effective" coping style, were well adjusted to tinnitus, and had no significant interference in their everyday functioning. The above are discussed in the context of the influence of geographical, climatological, economic, social, and cultural factors that influence psychological functioning.

WAF1/p21 protein expression is an independent prognostic indicator in superficial and invasive bladder cancer

The inhibitor of cyclin-dependent kinases WAF1 gene product p21 is able to arrest mammalian cell cycle by mediating p53 and other factors. The prognostic value and interrelationships between p21 expression and various parameters in bladder cancer have not been fully elucidated. We retrospectively investigated the immunohistochemical expression of p21 protein in consecutive paraffin sections from 131 transitional cell carcinomas (TCCs) and related it to p53 protein expression, clinicopathologic parameters, proliferative fraction, and survival. Positivity was displayed in 45% of cases, among which one fourth was accompanied by p53 accumulation. p21 expression was statistically related to advanced T category. No association was shown between p21 and p53 or proliferation rate. Low grade invasive TCCs tended to be more often p21 positive than high grade invasive TCCs. Most superficial tumors displayed neither p21 nor p53 expression, whereas the combined phenotypes p53/p21+ and p53+/p21- predominated among invasive tumors. P21 labeling index emerged by multivariate analysis as the single independent indicator of shortened overall (P = 0.0294) and disease-free (P = 0.0414) survival in superficial TCCs. Conversely, in invasive tumors, loss of p21 expression was a predictor of shortened disease-free survival (P = 0.0234) and was associated with poor outcome when accompanied by p53 accumulation (P = 0.0033). In conclusion, our results indicate that p21 activation occurs early in tumorigenesis, appears associated with invasiveness, and is capable of cell cycle control in TCCs mostly through p53-dependent pathways. Finally, p21 expression, alone or in combination with p53 and irrespective of other clinicopathologic parameters, plays distinct roles in determining clinical outcome in superficial and invasive tumors, suggesting that urothelial bladder cancer represents two different diseases.

Apoptosis in bladder carcinomas detected with monoclonal antibody to single-stranded DNA: relation to cell cycle regulators and survival

OBJECTIVES

To investigate the incidence of baseline apoptosis in relation to p27(Kip1), p53, and p21(Cip1) expression, proliferation status, standard clinicopathologic parameters, and patient outcome. Cell cycle regulators and apoptotic cell death have been implicated in tumor aggressiveness in many human malignancies. Their interaction, however, in the prognosis of patients with transitional cell carcinoma (TCC) of the urinary bladder has not yet received intense scrutiny.

METHODS

Apoptotic fractions were quantified immunohistochemically by means of a novel monoclonal antibody recognizing single-stranded DNA regions in apoptotic nuclei in 103 paraffin-embedded primary TCC specimens. Proliferative activity was expressed as the percentage of Ki-67 positive cells (Ki-67 index). Tissue specimens were also stained for p27(Kip1), p53, and p21(Cip1) proteins. Patients were followed up until death (n = 30) or for an average of 40 months (median 36).

RESULTS

The apoptotic index increased with grade, T stage, nonpapillary status, proliferative activity, and p53 expression and was inversely related to p27(Kip1) and independently to p21(Cip1) expression. A negative correlation was found between p27(Kip1) expression and proliferation. The increased apoptotic index had an adverse impact on overall and disease-free survival (univariate analysis) and, along with T stage, was an independent predictor in muscle-invasive TCC.

CONCLUSIONS

An increased apoptotic rate, increased proliferative activity, and decreased p21(Cip1) expression are independently interrelated in TCC. More importantly, the assessment of apoptotic potential appears to be more informative than standard prognosticators in predicting overall survival in patients with muscle-invasive TCC.

Bronchoscopy for foreign body removal in children. A review and analysis of 210 cases

OBJECTIVE

A foreign body aspiration in the tracheobronchial tree is a dangerous and common medical emergency in childhood, with serious and potentially lethal consequences. It must be suspected in children with a suggestive history, even though the clinical symptoms or radiographic findings are not pathognomonic for foreign body aspiration.

METHODS

In this study 210 pediatric cases, with a suggestive history of foreign body aspiration undergoing bronchoscopy in the last 8 years in the department, were reviewed. In all cases bronchoscopy was performed under general anesthesia using a Storz ventilation bronchoscope with distal cold light illumination.

RESULTS

In 130 patients a foreign body was discovered, in 17 cases pus was aspirated and in 63 cases there were no findings. Seventy-eight (60%) foreign bodies were found in the right main bronchus, 43 (33.1%) in left main bronchus, seven (5.4%) in both bronchi and two (1.5%) were found in the subglottic area. The incidence of bronchoscopy during the last 8 years was 28 procedures per 100000 children population per year in the island of Crete.

CONCLUSION

More attention should be given to the need for a careful history and the use of radiographs as supplemental information to make the decision to perform a bronchoscopy. The parents, also, should pay attention not to allow children dry fruits and small toys, as well as, teaching their children to avoid any physical or emotional activity while having a full mouth.

Cell cycle regulators in bladder cancer: a multivariate survival study with emphasis on p27Kip1

Cyclin-dependent kinase inhibitors (CKIs) prevent cyclin-dependent kinases from phosphorylating critical substrates such as retinoblastoma gene protein (pRb), hence blocking the cascade of events leading to cell proliferation. Currently, the list of CKIs includes p21WAF1/Cip1, p27Kip1, p57Kip2 (the Cip/Kip family), p15/ INK4b, p16/INK4a, p18/INK4c, and p19/INK4d (the INK4 family). Among them, p27 plays a crucial role linking extracellular growth-regulatory signals to progression to or exit from the cell cycle. Unlike p53, p16, and Rb, mutations in Kip1 and WAF1 genes are distinctly rare in bladder cancer. We analyzed immunohistochemically the expression of p27 and other interacting G1 proteins (ie, p21, p16, pRb, p53) in 120 consecutive cases of transitional cell carcinomas (TCCs) and related it to proliferation rate, clinicopathologic parameters, and survival. p27 levels were significantly higher in low-grade (P = .001), superficial (Ta-T1) (P = .001), papillary (P < .001), and slowly proliferating TCCs (rs = -0.235, P = .05). p27 also positively correlated with p16 expression (rs = 0.212, P = .05). In univariate analysis, decreased p27 expression was associated with poor overall (P = .0109) and postrelapse (P = .0344) survival, especially if combined to increased Ki-67 expression (P = .0004 and P = .036, respectively). Furthermore, in multivariate analysis, Ki-67/p27 status had the strongest bearing on the overall survival of muscle-invasive TCCs (P = .0019). Our results indicate that low p27 expression is more common in poorly differentiated muscle-invasive TCCs and is a major player in cell cycle control in these neoplasms. More importantly, the combined Ki-67/p27 expression provides prognostic information beyond that provided by conventional parameters or other cell cycle-related proteins, concerning overall survival in muscle-invasive TCCs.

Death related to midazolam overdose during endoscopic retrograde cholangiopancreatography

We report a midazolam-related death that occurred during endoscopic retrograde cholangiopancreatography (ERCP). The acute intoxication due to midazolam overdose was confirmed by high-pressure liquid chromatography (HPLC) analysis of the blood samples taken from the patient in the intensive care unit (2.8 microg/ml) and postmortem (2.4 microg/ml). The case strongly emphasizes the necessity of the precautions that should be taken when midazolam is intravenously administered.

Carbamazepine levels in head hair of patients under long-term treatment: a method to evaluate the history of drug use

Carbamazepine (CBZ) concentrations were determined in the sections of head hair from 40 patients (22 males and 18 females), ages 5 to 81, who were receiving this drug systemically. Hair treatment included dissolution, liquid phase extraction procedures, and immunoassay (Abbott TDx) or high-pressure liquid chromatography (HPLC) analytical techniques. The mean values of CBZ levels in the hair from the 1st section (close to hair root) to the 5th section for female patients were 26.82, 19.18, 17.28, 15.09, and 14.62 micrograms/g according to HPLC measurements. Immunoassay gave generally slightly higher results. The mean values of CBZ in the hair sections according to the immunoassay technique were 30.53, 21.90, 19.83, 17.45, and 16.99 micrograms/g, respectively, from the 1st to the 5th sections. The corresponding mean values for male patients by HPLC and immunoassay techniques were 21.97, 17.30, 15.03, 13.02, and 11.21 micrograms/g and 25.98, 20.52, 17.15, 14.87, and 12.31 micrograms/g. Generally, a reduction of drug concentrations in hair from the first to the subsequent segments was observed. Higher amounts of CBZ were deposited in black, untreated hair (e.g., not dyed or permed). CBZ concentrations in hair sections were found to be dependent on the dosage (r = 0.979, p < or = 0.001) but not on the gender. The data indicate the possible use of hair section testing as a marker of the dosage history and the compliance of patients under long-term treatment with CBZ.

Expression of retinoblastoma gene product and p21 (WAF1/Cip 1) protein in gliomas: correlations with proliferation markers, p53 expression and survival

Using immunohistochemistry we evaluated the expression of two negative regulators of the cell cycle, the retinoblastoma gene product (pRb) and the WAF1/Cip1 gene product (p21), in consecutive paraffin sections from 54 gliomas (49 astrocytomas and 5 oligodendrogliomas) and related it to clinicopathological parameters, proliferative fraction, p53 expression and survival. Survival analysis was restricted to the group of diffuse astrocytomas (48 patients). pRb expression did not correlate with histological type, grade or p53 expression, while a moderately strong correlation existed between pRb expression and the percentages of proliferating cell nuclear antigen (PCNA) and MIB-1-positive cells. In 30% of cases we observed diminished pRb expression (i.e., a low pRb/Ki-67 ratio), irrespective of grade or histological type. p21 protein was elevated in 50% of cases, especially within the higher grades. The percentage of p21-positive cells was not related to histological type or grade but correlated loosely with PCNA and pRb expression. A p53-negative/p21-negative phenotype was characteristic of oligodendrogliomas and low-grade astrocytomas, whereas the p53-positive/p21-positive, p53-positive/p21-negative and p53-negative/p21-positive phenotypes were almost equally distributed among high-grade tumors. In survival analysis (either univariate or multivariate) diminished pRb expression was not a statistically significant prognostic indicator. In contrast, p21 expression emerged as an important indicator of shortened disease-free survival, in both univariate and multivariate analyses. Moreover, the double-positive p53/p21 phenotype tended to be associated with a shorter overall survival. Our results suggest that Rb gene deregulation does not significantly affect prognosis but p21 expression may play an important role in disease-free survival of astrocytoma patients.

The role of p53, MDM2 and c-erb B-2 oncoproteins, epidermal growth factor receptor and proliferation markers in the prognosis of urinary bladder cancer

The immunohistological expression of p53 and MDM2 oncoproteins was examined in paraffin embedded tissue from 106 patients with transitional cell carcinoma of the urinary bladder and was related to various clinicopathological features, the expression of proliferation associated markers (proliferating cell nuclear antigen - PCNA - and Ki-67), c-erb B-2 oncoprotein and epidermal growth factor receptor (EGFR), as well as to survival. MDM2 immunoreactivity was seen in 38% of our cases, and in 14% was accompanied by p53 positive immunohistochemistry. The rate of p53 positivity was associated with grade, stage and papillary status, whereas MDM2 immunopositivity increased with grade and stage (Ta VS T1), and MDM2 labeling index (LI) with stage. MDM2 expression was related to p53 expression and less strongly to proliferation rate (Ki-67 LI). The simultaneous p53 and MDM2 expression was more frequently observed in higher grade and stage tumours. C-erb B-2, EGFR and proliferation marker expression increased with grade, stage and non-papillary configuration. In univariate analysis high grade, solid growth pattern, advanced T-category, cystectomy, EGFR and Ki-67 expression were linked to shorter overall survival but only Ki-67 LI, along with T-category and type of therapy, had independent prognostic value. C-erb B-2 expression and stage were the two independent predictors of disease-free survival and Ki-67 LI and EGFR LI the independent predictors of post-relapse survival. For patients with superficial tumors PCNA LI emerged as the single independent determinator of survival. p53 and MDM2 expression did not appear to have any significant impact on survival, although the simultaneous expression of p53 and MDM2 turned out to be a highly significant parameter of shortened overall survival in univariate analysis.

Fatal and non-fatal outcome by accidental intoxication with paint thinner

Although poisonings (fatal and non-fatal) due to intentional or accidental acute exposure to toluene or toluene mixture fumes have been previously reported in the literature, several issues concerning lethal doses or lasting post-exposure neuropathological impairments still remain unclear. Two male painters (18 and 30 years old) were accidentally exposed to toxic concentrations of paint diluent fumes containing toluene (TL), acetone (ACT) and methyl ethyl ketone (MEK) (60:15:15 w/w/w respectively) during their work in an underground reservoir. Both workers were found unresponsive by colleagues and were immediately transferred to the regional hospital. On admission, the younger man was pronounced dead, while the other remained in the intensive care unit for 3 days and then 4 days in the internal medicine ward. TL, ACT and MEK concentrations in blood samples taken from the survivor on admission were 6.3, 30.6 and 40.5 microg/mL. Postmortem toxicology of the dead worker revealed TL, ACT and MEK blood levels of 12.4, 90.8 and 80.4 microg/mL respectively. The solvent levels in the liver, kidney, lung, brain, testis and gland were also quantified and showed a somewhat similar distribution of the chemicals among these tissues with the highest levels found in the brain and the liver. The fatal and the non-fatal outcome that resulted despite similar intoxication conditions, most probably demonstrates the interindividual tolerance among the painters who also had similar body weights. The surviving painter did not develop any neuropsychological impairment in post-exposure time. The reported case strongly emphasizes the necessity to take precautions when using paint diluents in enclosed spaces.

Death following intentional methyl bromide poisoning: toxicological data and literature review

A case of fatal poisoning due to ingestion-inhalation of methyl bromide (MeBr) is presented. In previously reported fatalities due to MeBr inhalation, only inorganic bromide levels in biological specimens were reported. Intact MeBr has not been isolated from human tissues following exposure. In the present case, MeBr was detected, confirmed and quantitated in various biological samples by headspace gas chromatography, and the clinical manifestations and autopsy findings are described. Postmortem MeBr peripheral blood concentration was 3.3 micrograms/mL and in subclavian blood was 3.8 micrograms/mL. Lung, brain, adrenal gland, kidney, liver and testis MeBr was 2.9, 3.5, 3.4, 2.6, 1.9 and 2.8 micrograms/g respectively; MeBr in bile was 1.2 micrograms/mL. Inorganic bromide concentrations were 530, 30, 310 and 130 micrograms/g in blood, brain, kidney and adrenal gland respectively.

MDM2 and p53 expression in gliomas: a multivariate survival analysis including proliferation markers and epidermal growth factor receptor

p53 and the murine double minute 2 (MDM2) oncoprotein expression was evaluated in paraffin-embedded tissue from 61 patients with central nervous system gliomas (53 astrocytomas and eight oligodendrogliomas) and related to proliferation-associated markers [i.e. proliferating cell nuclear antigen (PCNA), Ki-67 and nuclear organizer regions (NORs)] and epidermal growth factor receptor (EGFR). We used the monoclonal antibodies PC-10, MIB-1, DO-1, 1B1O and EGFR 113 and the colloid silver nitrate (AgNOR) technique. MDM2 and p53 were co-expressed in 28% of cases. A p53-positive/MDM2-negative phenotype was observed in 15% and a p53-negative/MDM2-positive phenotype in 20% of cases. There was a positive correlation of p53 and MDM2 expression with grade and proliferation indices. Univariate analysis in the group of diffuse astrocytomas showed that older age, high histological grade, high PCNA labelling index (LI) and high AgNOR score were associated with reduced overall survival (P < 0.05). p53 LI, Ki-67 LI, AgNOR score, tumour location and grade influenced disease-free survival (P < 0.05), whereas the only parameters affecting post-relapse survival were histological grade and Ki-67 LI (P < 0.1). Multivariate analysis revealed that age, radiotherapy, PCNA LI and p53 LI were the independent predictors of overall survival. p53 LI, Ki-67 LI, MDM2 LI, EGFR LI, grade and type of therapy were independent predictors of disease-free survival, and grade was the only independent predictor of post-relapse survival. Our results indicate that p53 LI and MDM2 LI, EGFR expression as well as proliferation markers (PCNA and Ki-67) are useful indicators of overall and disease-free survival in diffuse astrocytoma patients.

The role of the OR nurse

1. Cyprus health policies and strategies emphasize the value of the individual in a caring family and community framework, with the implication that health is the responsibility of the whole country and its citizens. 2. Operating room nursing has undergone many changes in the past few years, such as the introduction of the nursing process together with the team concept. 3. Many aspects of nursing care in operating theaters have improved greatly, but we face the future with aspirations for additional improvement.

The histology of laser thermo-chondro-plasty

INTRODUCTION

Giving a new shape to a cartilage graft has been a matter of continuous study. In 1991, our group managed to change the shape of human nasal septal samples using CO2 irradiation. This procedure, which we call thermo-chondro-plasty, was achieved without the macroscopic carbonization or ablation of the tissue.

METHODS

To study the thermo-chondro-plasty effect of the CO2 laser irradiation on human nasal septal cartilage, samples were irradiated in selected laser parameters and then examined with light and electron microscopy.

RESULTS AND CONCLUSION

We believe that it was primarily the proteoglycan component of the matrix in which we induced the maximum alterations. The destruction of their water-binding ability led to an uneven reduction of the interlocked tensile stresses of the cartilage and resulted in its transformation.

Prognostic significance of proliferating cell nuclear antigen (PCNA) expression in gliomas

The relationship between proliferating cell nuclear antigen (PCNA) expression and various clinicopathological indices (age, sex, tumour location, histological type and grade and treatment) and post-operative survival were studied in patients with central nervous system gliomas using univariate and multivariate analysis. The expression of PCNA (PC10 score) was examined immunohistochemically using the monoclonal antibody PC10 on paraffin sections from 45 cases. Univariate analysis showed that a high PC10 score as well as older age, high histological grade and the histological type (astrocytoma) were associated with reduced survival. However, multivariate analysis revealed that only PC10 score and histological type had independent prognostic significance. The most important feature influencing PC10 score was the tumour grade. Regarding the patients who relapsed, the survival from the time of original diagnosis was related to the relapse-free period, while the PC10 score of the primary tumour emerged as the only independent predictor of survival following the first recurrence. These results indicate that PCNA expression is an independent prognostic indicator in CNS gliomas.

Assessment of proliferating-cell nuclear antigen immunostaining in soft-tissue tumours: relationship to histological grade and mitotic activity

The proliferative activity in 70 cases of soft-tissue tumours was estimated immunohistochemically using the monoclonal antibody PC-10, which recognizes proliferating-cell nuclear antigen (PCNA) in paraffin sections. The PCNA index (i.e. the percentage of positive neoplastic nuclei) and to a lesser degree the PCNA count (i.e. the number of positive neoplastic nuclei per ten high-power fields) positively correlated with the malignancy grade (PCNA index: P < 0.001; PCNA count: P < 0.01). However, the range of values of PCNA index and PCNA count was similar between benign and grade I tumours. A statistically significant positive correlation was also established between PCNA index and PCNA count on the one hand and mitotic count on the other, but the correlation coefficient was low (r = 0.351, P < 0.01, and r = 0.290, P < 0.05 respectively). These results indicate that PCNA immunostaining may successfully be used as an adjunct to the conventional histopathological parameters in assessing the malignancy grade in soft-tissue tumours although it is of limited value in distinguishing between benign and grade I tumours.

A study on the otoscopical and audiological findings in patients with Down's syndrome in Greece

One hundred and twenty patients (children) with Down's Syndrome were examined by the Audiological Dept. at 'Aghia Sophia' Children's Hospital during the period 1988-1990. Of these 73 (60.8%) were boys and 47 (37.2%) were girls. Their ages varied from 7-18 years of age with an average age of 14.8 years. Physical examination included otoscopy, tympanometry, and in some cases auditory brainstem audiometry. It is worth noting that a high percentage of these patients were unable to cooperate in this study, therefore making it obligatory to utilize objective measures for hearing evaluation.

Laser shaping of composite cartilage grafts

INTRODUCTION

The restoration of malformations of different etiology in the head and neck area continue to be a problem to the reconstructive surgeon. Many of these problems are created by the destruction of cartilage. The success of the reconstructive effort very often depends on the selection of a composite cartilage graft of proper size, shape, and thickness, which has to replace the missing cartilage. Despite the best of surgeon's intentions, the postoperative result is not always satisfactory due to the difficulty in obtaining a cartilage of the proper shape. Using a carbon dioxide laser, composite cartilage samples 0.4 to 1 mm thick taken from rabbits ears were irradiated.

METHODS

Rabbit ear cartilage with covering epithelium was used. The thickness of the composite graft measured 0.4 to 1 mm. Specimens were reshaped, treated with a carbon dioxide laser, then immersed in saline.

CONCLUSION

It was observed that it was possible to change the shape of the cartilage, which then had the tendency to retain its new form for several days. Thicker composite grafts retained the new shape more satisfactorily. The significance of this experiment for future corrective surgery in various parts of the head and neck area is evident. We anticipate that this technique may be useful to mold grafted cartilage for use in complex reconstructions such as nasal, auricular, and tracheal deformities.

Proliferating cell nuclear antigen and nucleolar organizer regions in CNS tumors: correlation with histological type and tumor grade. A comparative study of 82 cases on paraffin sections

We investigated the expression of proliferating cell nuclear antigen (PCNA) and the number of nucleolar organizer regions (NORs) in 82 cases of CNS tumors. PCNA is a nuclear protein maximally elevated in the S phase of the cell cycle and recognized immunohistochemically in paraffin sections by the monoclonal antibody PC-10. On the other hand, NORs are loops of DNA that carry the rRNA genes and can be demonstrated in paraffin sections using an argyrophilic method (AgNORs). The present study shows a significant correlation of PCNA index and of AgNOR number with the histological grade (PCNA: I versus II, p < 0.01; II versus III, p < 0.01; and III versus IV, p < 0.05; AgNORs: I versus II, p < 0.001; II versus III, p < 0.05; and III versus IV, p < 0.001). Higher values of PCNA index (0.01 < p < 0.05) were found in recurrent tumors. Metastatic carcinomas were characterized by high PCNA indices and AgNOR numbers, similar to grade IV tumors, whereas in CNS lymphomas the malignancy grade was reflected in PCNA indices and AgNOR numbers. A wide range of PCNA and AgNOR values has been observed within each histological type and grade, probably reflecting variations in the biological behavior, but little overlap in PCNA values was present between grades II and III. The latter finding might be of importance in distinguishing between low- and high-grade CNS tumors. The linear regression coefficient between PCNA index and AgNOR number was excellent (0.91). We suggest that PCNA and AgNORs may be successfully applied in routine material to assess the growth potential of CNS tumors. Their prognostic value, however, must be validated with clinical studies.

Comparative assessment of proliferating cell nuclear antigen immunostaining and of nucleolar organizer region staining in transitional cell carcinomas of the urinary bladder. Correlation with other conventional prognostic pathologic parameters

The expression of two cell proliferation indices, the proliferating cell nuclear antigen (PCNA), using the monoclonal antibody PC-10 in the immunoperoxidase method, and the nucleolar organizer regions (NORs), using the colloid silver nitrate staining technique, was assessed in formalin-fixed paraffin-embedded material of 50 transitional cell urinary bladder carcinomas. A relationship was found between the histologic grade and each of the two indices used. A significant difference was observed, particularly between carcinomas of grade II and III (p < 0.001). A relationship was also demonstrated between each of PC-10 and AgNOR scores and the clinical stage, but it was attributed mostly to the close correlation of the latter with the histologic grade of these tumors. The linear correlation coefficient between PC-10 and AgNOR scores was 0.757 (p < 0.001). Our results suggest that PC-10 and AgNOR scores may be important prognostic indices in urinary bladder cancer.

Empty sella syndrome, diagnosed as allergic rhinitis

Unilateral cerebrospinal fluid (CSF) rhinorrhea as the only manifestation of the primary empty sella syndrome is a rare event. A case of a middle-aged male patient complaining for intermittent unilateral rhinorrhea, which started 5 months earlier, is reported. The persistence of this state was attributed to an allergic rhinitis. The initial work-up excluded the above diagnosis and an erroneous radiological diagnosis led to a puncture of the left maxillary sinus. A lateral X-ray of the skull and CT scan led to the diagnosis of empty sella syndrome, possibly due to an adenoma or a meningocele.

Use of the excimer laser in stapes surgery and ossiculoplasty of middle ear ossicles: preliminary report of an experimental approach

Surgery of the stapes may cause a number of complications, including hearing deficits and balance disorders. This has made it necessary to look for improved techniques. Small-fenestra stapedotomy has recently been popularized. Lasers have been advocated for use in fenestrating the stapes footplate. On the other hand, sculpting the middle ear ossicles during tympanoplasty is often necessary for the reconstruction of the ossicular chain and the improvement of sound conduction. Using an excimer laser with a wavelength of 193 nm, fenestrations of the footplate and ossicular sculpting were performed on ossicles obtained during ear surgery and from human cadaver temporal bones. The results indicate that the excimer laser can be used effectively and accurately on an experimental basis and that further research is needed before this method can be used for clinical purposes.