Minimal invasive decompression of the orbit in Graves' orbitopathy

BACKGROUND

Surgical decompresssion of the orbit may be considered as a suitable form of therapy if, as a result of the increased volume inside the orbit, there are motility disorders such as diplopia or a progressive decrease in visual acuity. In view of the fact that this operation will not cure the underlying disease, the treatment should be as mild as possible.

METHODS

In five subjects with Graves' orbitopathy we managed to extend the volume of the intraconal orbit by microsurgical liposuction. We carried out a lateral canthotomy to approach the orbit behind the globe. After decompression of the soft tissue, the lateral palpebral ligaments were refixed. To assess the scale of the functional rehabilitation we compared preoperative parameters (visual acuity, Hertel's index, visual field, motility) with the postoperative results.

RESULTS

In all cases we found a significant improvement of position and motility without signs of diplopia. There was a postoperative increase in the visual field and visual acuity was 0.4 and the protusion of the globe could be decreased by 3-6 mm (Hertel's index). Furthermore, the ocular hypertension we found preoperatively could no longer be detected after the operation.

CONCLUSIONS

Microsurgical decompression of the soft tissue via an approach from behind the globe proved to be a very gentle alternative to conventional methods of orbital decompression because of the satisfying functional and esthetic rehabilitation in selected cases.

Congenital arthrogryposis associated with atlantoaxial subluxation and dysraphic abnormalities. Case report

The authors report the case of a 27-year-old woman with an arthrogryposis multiplex congenita (AMC) associated with atlantoaxial subluxation. To the authors' knowledge, this is the first report of its kind. The authors review the literature with reference to dysraphic abnormalities associated with atlantoaxial subluxation and with AMC. The patient presented with severe tetraparesis following a minor traffic accident. She underwent a procedure in which transoral decompression and dorsal stabilization were performed and, postoperatively, made a good clinical outcome. The authors stress the need for diagnostic neuroimaging of the craniocervical junction in patients with AMC.

The triad of lichen planus, thymoma and liver cirrhosis-hepatoma. First reported case

We describe a patient with liver cirrhosis who presented with erosive oral and cutaneous lichen planus (LP) and incidentally was found simultaneously to have thymoma and hepatoma. We support the notion forwarded earlier that LP and chronic liver disease is more than a mere coincidence and that there is a non-coincidental association between LP and thymoma. We believe this is also the first reported case in the English Literature of coexistence of the three condition LP, thymoma and hepatoma complicating liver disease.

Massive rise in thyroglobulin with adult respiratory distress syndrome after embolisation of thyroid cancer metastasis

A patient with long-standing metastatic disease from a well differentiated papillary cell carcinoma of the thyroid underwent embolisation of a painful large sacral metastasis. Following embolisation she had a massive rise in circulating serum thyroglobulin (Tg) levels coinciding with the development of adult respiratory distress syndrome (ARDS) on the tenth day without any other obvious cause. The patient subsequently recovered. The time course suggests that ARDS in this case might have resulted from aggregation of Tg molecules in the pulmonary microcirculation.

[Initiation of rehabilitation after surgery for herniated lumbar disk: pilot study of efficacy from the viewpoint of the surgical hospital]

The initiation of rehabilitation after lumbar disc surgery in Germany is up to the operating hospital. A decision between outpatient and inpatient rehabilitation is possible. Until now this decision is not based on scientific data but on the individual experience of the hospital. This prospective study compares the effect of outpatient and inpatient therapy: In 65 patients medical and psychosocial data were collected shortly before operation, 1 week and 6 months after surgery. Of these patients, 42 underwent inpatient, 21 outpatient rehabilitation, 2 patients renounced rehabilitation. The outpatient and inpatient rehabilitation groups showed no significant difference in testing before or shortly after the operation concerning subjective state of health and somatic findings. Some 6 months later, long term outcome was identical, i.e. the groups did not differ in psychosocial or medical respects. However, the inpatient rehabilitation group had taken significantly longer to return to work. This pilot study stresses the importance of further research on rehabilitation after lumbar disc surgery. It should be shared by surgeons and rehabilitation experts.

Universal interface for exchange of medical images via magneto-optical discs

Digital images are the ever-growing basis of modern medical imaging and treatment. Despite the advent of the DICOM 3.0 standard for medical image communication it still requires cumbersome efforts to export images from imaging modalities to other computer systems. This is true especially for smaller institutions, which often have limited resources for standardized image transfer. To gain access even to these data we developed an exchange interface on the basis of magneto-optical discs (MO-discs), as they are usually available in most of the imaging modalities in use today. Unfortunately images on MO-discs are usually stored in formats specific for each manufacturer. Therefore special routines to access the data on MO-discs had to be developed for each company or even each scanner. Over 10,000 CT and MRI images including their header information from different General Electric and Siemens scanners were extracted successfully from MO-discs. The interface proved to be reliable and easy to handle by technicians. Support of additional manufacturers and of the DICOM 3.0 standard are work in progress.

No implicit memory for stories played during isoflurane/alfentanil/nitrous oxide anesthesia: a reading speed measurement

Implicit memory of intraoperatively presented stories was recently detected by using the reading speed paradigm during propofol-alfentanil-nitrous oxide anesthesia. Our main goal was to evaluate the reading speed test procedure under another anesthetic regimen, i.e., isoflurane combined with nitrous oxide and alfentanil-infusion. In both experiments, patients were premedicated with oral midazolam. In a previous experiment, patients postoperatively read "old" stories that had been presented during anesthesia quicker compared with "new," unpresented stories. The same study design and test material as in the previous experiment were used. One of two audio tapes with two short stories was played randomly to patients during lumbar disk surgery and to awake controls. Approximately 7 h later, a structured interview and the reading speed test were used to determine whether the participants had any explicit or implicit memories of the presented stories. The results of 30 patients and 30 controls were calculated. Whereas the control participants showed an intact explicit and implicit memory of the previously presented material, no such effect was found in the anesthetized patients. The present experiment shows that changing the main anesthetic in otherwise equal study conditions, i. e., propofol to isoflurane (end-expiratory 0.7%), implicit memory is abolished in anesthetized patients.

IMPLICATIONS

We showed that implicit memory during general anesthesia can be abolished by changing the hypnotic anesthetic. Increased postoperative reading speed for stories presented during propofol-alfentanil-nitrous oxide anesthesia was shown in a previous experiment, but not in our study using isoflurane for balanced anesthesia.

Disruption of intracerebral progression of C6 rat glioblastoma by in vivo treatment with anti-CD44 monoclonal antibody

OBJECT

Glioblastoma multiforme (GBM) invasiveness is a complex process that involves recognition and attachment of GBM cells to particular extracellular matrix (ECM) molecules before migrating into proteolytically modified matrix and inducing angiogenesis. The CD44 molecule, which is a transmembrane adhesion molecule found on a wide variety of cells including GBM, has been suggested as the principal mediator of migration and invasion. The aim of the present study was to demonstrate whether an antibody specific to the standard form of CD44 (CD44s, 85-90 kD) might prevent invasion and thus disrupt progression of C6 GBM in vivo.

METHODS

Immunostaining demonstrated homogeneous expression of CD44s on the surface of C6 GBM cells and tumors. Flow cytometric analysis demonstrated binding saturation of anti-CD44s monoclonal antibody (mAb) to the receptor at 1 microg/5 x 10(5) cells. Blocking of CD44s in vitro resulted in a dose-dependent progressive (up to 94+/-2.7%; mean +/- standard deviation [SD]) detachment of C6 cells from ECM-coated culture. Blocking of CD44s in vivo resulted in significantly reduced C6 brain tumors (3.6+/-0.4% [SD])--measured as the quotient: tumor surface (mm2)/brain surface (mm2) x 100--compared with untreated (19.9+/-0.9%) or sham-treated (19.2+/-1.1 to 19.3+/-2.5% [SD]) rats. Disruption of C6 GBM progression correlated with an improved food intake; treated rats were significantly less cachectic (166.6+/-16.4 g [SD]) than those that were untreated (83+/-2.7 g [SD]) or sham-treated (83.4+/-1.1 to 83+/-2.2 g [SD]) rats.

CONCLUSIONS

The authors conclude that CD44s-targeted treatment with specific mAb may represent an effective means for preventing progression of highly invasive GBMs.

CD44s-targeted treatment with monoclonal antibody blocks intracerebral invasion and growth of 9L gliosarcoma

Glioma invasiveness is a complex process involving recognition and attachment of tumor cells to particular extracellular matrix (ECM) molecules prior to migrating into proteolytically modified matrix and inducing angiogenesis. CD44 is a group of transmembrane adhesion molecules found on a wide variety of cells including gliomas that has been suggested as the principal mediator of migration/invasion. The aim of the present study was to demonstrate whether antibody specific for the standard form of CD44 (CD44s, 85-90 kDa) might prevent invasion, thus blocking growth of the 9L gliosarcoma in vivo. High expression of CD44s on the surface of 9L cells and brain tumors was demonstrated by immunochemistry. Fluorescence-activated cell sorting (FACS) demonstrated binding saturation of anti-CD44s monoclonal antibody (mAb) to the receptor at 1 microg/5 x 10(5) cells. Blocking of CD44s in vitro resulted in a dose-dependent progressive, up to 95%+/-2.5% detachment of 9L cells from ECM-coated culture surfaces. Blocking of CD44s in vivo resulted in significantly reduced 9L brain tumors (2.5%+/-0.4%)--measured as the quotient: tumor surface (mm2)/brain surface (mm2) x 100--as compared to untreated (16.1%+/-2.2%) or sham-treated rats (16%+/-3.7% to 16.1%+/-3%). We conclude that CD44s-targeted treatment with specific mAb may be an effective means for preventing glioma progression.

[Operative management of trigono-atrial lesions]

Trigono-atrial-Lesions are microsurgically serios accessible, the results of transcortical aproaches are difficult and frequently unsatisfactory. The microsurgical anatomy of the trigono-atrial region will be studied on 100 brain hemispheres (the posterior cerebral arteries were injected selective on 70 hemispheres). According to the anatomical findings, an interhemispheric microsurgical approach has been developed. The operative results of 25 patients with different atrial lesions are presented. There was no operative mortality, the postoperative morbidity was 12%, in 24% (n = 6) the preoperative state was still unchanged, in 12 cases (48%) we note a normal neurological and neuropsychological postoperative status. In 4 patients (16%) the neurological symptoms are postoperatively improved. According to these first results, the described transatrial approach seems to be a real alternative for careful selected meanly leftsided lesions of the trigone.

Lung compensator design using an electronic portal imaging device

Using a liquid filled electronic portal imaging device (EPID) installed on a linear accelerator and a composite chest phantom, exit dose measurements were carried out to establish an empirical relationship between the pixel values of the imaging detector and the corresponding equivalent thickness of the overlying phantom material. Results for 6 and 10 MV photons show that the relationship depends on the so-called input/output characteristics of the imaging device for a particular photon energy. For a chest irradiation, an EPID image obtained under treatment geometry provides the pixel value information that is used to calculate the tissue deficit over the lung region. The compensators are made of lead whose thickness is calculated from the established empirical relationship to replace the tissue deficit over lungs. The effectiveness of the method is demonstrated with thermoluminescent dosimetry (TLD) for 6 and 10 MV beams. With compensators in place, the dose uniformity was found to be within +/- 5%.

Clinical predictors of the psychosocial long-term outcome after brain injury

The correlation of clinical with psychological and social data is an attempt to find predictors of the definite long-term outcome after brain injury. 34 patients were reexamined 3 to 8 years after the accident using a number of psychological tests. Additionally, life quality was defined and evaluated. Only patients with an initial Glasgow Coma Scale-Score of 3-12, an intracranial traumatic lesion on computertomography and age 16-65 years at the time of accident were included in this study. Patients exhibited a uniform pattern of disturbances in psychosocial long-term outcome. These disturbances were compared with initial clinical data: memory, attention and learning were significantly correlated with the duration of coma and the presence of additional extracerebral injuries. From the initial computerized tomography, the findings 'compression of basal cisterns' and 'intracerebral contusion' showed to be predictors of the cerebral function. Late social status and behavior, defined as quality of life, were clearly related with initial clinical findings. In conclusion, there are early clinical predictors of the long term social and psychological outcome after brain injury.

Multilineage mobilization of peripheral blood progenitor cells in humans following administration of PEG-rHuMGDF

The most important physiological regulator of megakaryocytopoiesis is the ligand for the c-mpl receptor (thrombopoietin/megakaryocyte growth and development factor, MGDF). We examined the effect of pegylated-recombinant human MGDF (PEG-rHuMGDF): patients received PEG-rHuMGDF at doses of 0.03, 0.1, 0.3 or 1.0 microg/kg/d or placebo for 10d maximum in a double-blinded randomized study. There was a dose-dependent elevation in circulating platelet counts but no alteration in erythrocyte or total leucocyte counts. The number of bone marrow megakaryocytes was increased approximately 2-fold. The frequency of bone marrow progenitor cells was not altered. In contrast, both to the bone marrow results and to published pre-clinical data, there was a dose-dependent mobilization into the blood of progenitor cells of multiple cell lineages. Increased levels of Meg-CFC (maximum increase 30-fold), day 7 and day 14 GM-CFC and BFU-E were demonstrated at doses of 0.3 and 1.0 microg/kg/d PEG-rHuMGDF. At 0.1 microg/kg/d, mobilization of Meg-CFC alone occurred in two-thirds of patients. Maximum blood levels of progenitor cells occurred at day 12. Thus, administration of PEG-rHuMGDF to humans resulted in mobilization of progenitor cells of multiple lineages despite its 'lineage-specific' activity on mature cell development.

A novel form of hereditary sideroblastic anaemia with macrocytosis

We describe a pedigree with maternally inherited sideroblastic anaemia in which the red cells are dimorphic with a raised MCV. To our knowledge, this form of hereditary sideroblastic anaemia (HSA) has not been reported previously. 16 members of the family were investigated, revealing eight affected members. Two further family members were not tested but were presumed affected on the histories available. The proband, born in 1967, presented during pregnancy with a macrocytic anaemia (Hb 7.0 g/dl, MCV 106 fl) and a dimorphic red cell picture. Post partum, a bone marrow biopsy showed hypercellularity, mild dyserythropoiesis and ring sideroblasts. Cytogenetics were normal. Other causes of macrocytosis were excluded. Six other family members (three female, three male) have similar findings. There is no evidence of paternal transmission. An additional female relative who presented in 1992 with refractory anaemia with excess blasts in transformation and a dimorphic blood film, died from progression to AML. Affected members show a raised metal-free red cell protoporphyrin level suggestive of a defect at the level of Fe2+ incorporation into protoporphyrin. We propose that this form of HSA is due to a mitochondrial mutation. A search for deletions or point mutations in the mitochondrial DNA is currently underway.

Thrombopoietic effects of pegylated recombinant human megakaryocyte growth and development factor (PEG-rHuMGDF) in patients with advanced cancer

BACKGROUND

Pegylated recombinant human megakaryocyte growth and development factor (PEG-rHuMGDF) is a potent stimulator of megakaryocyte colony formation and platelet production. It is likely to be useful in the management of severe thrombocytopenia. To determine its clinical activity and safety, we gave it to patients with advanced cancer before chemotherapy.

METHODS

Patients were randomly assigned to receive either PEG-rHuMGDF or placebo in a three to one ratio. PEG-rHuMGDF was given at a dose of 0.03, 0.1, 0.3, or 1.0 microgram/kg body weight. The study drug or placebo were administered daily by subcutaneous injection for up to 10 days or until a target platelet count was reached.

FINDINGS

17 patients, median age 59 years, received either PEG-rHuMGDF (13 patients) or placebo (four patients). PEG-rHuMGDF produced a dose-dependent increase in platelet counts. Patients given placebo. 0.03, and 0.1 microgram/kg of PEG-rHuMGDF had median increases in platelet counts of 16%, 12%, and 39%. Those receiving 0.3 and 1.0 microgram/kg of PEG-rHuMGDF had an increase in blood platelets of between 51% and 584%. Platelets rose from day 6 of PEG-rHuMGDF administration and continued to rise after stopping the drug. The platelet count peaked between days 12 and 18 and remained above 450 x 10(9)/L for up to 21 days. There were no alterations in white-blood-cell count or haematocrit, and low toxicity. Platelets taken from patients during PEG-rHuMGDF administration and at the time of peak platelet count were morphologically and functionally normal.

INTERPRETATION

The potency with which PEG-rHuMGDF stimulates platelet production and its low toxicity indicate that this is likely to be a useful agent for the management of thrombocytopenia.

Superselective intra-arterial amytal (Wada test) in temporal lobe epilepsy: basics for neuroradiological investigations

We describe the angioarchitecture of the medial temporal region as a basis for modified superselective Wada tests in patients with temporal lobe epilepsy. Possible functional deficits following the injection of amytal, depending on the superselective placement of the microcatheter in the medial temporal arteries, are discussed. The individual blood supply in each patient determines the ideal super-selective positioning of the micro-catheter.

In vivo administration of anti-murine CD3 monoclonal antibody induces selective, long-term anergy in CD8+ T cells

The purpose of this study was to determine the short-term and long-term effects of repeated daily administration of low dose anti-CD3 monoclonal antibody (mAb) on CD4+ and CD8+ T cell number and function. Daily (7 days) administration of low doses (5 microg) of mitogenic (whole) or nonmitogenic (F(ab')2, fragments) anti-CD3 mAb resulted in depletion of CD4+ and CD8+ T cells in both lymph node and spleen that, in the case of whole mAb, persisted for several months in thymectomized animals. CD3+ cells obtained from thymectomized animals treated with whole but not F(ab')2 fragments of anti-CD3 mAb demonstrated decreased proliferation to anti-CD3 mAb in vitro (on a per cell basis as compared with control animals). Although purified CD4+ cells from animals treated with whole mAb demonstrated only slightly decreased proliferative responses to anti-CD3 mAb in vitro, purified CD8+ cells demonstrated an almost complete loss of their proliferative response. Studies in thymectomized animals demonstrated that the profound CD8+ cell hyporesponsiveness persisted for at least 5 months after anti-CD3 treatment. These effects were not observed in nonthymectomized animals, however, suggesting that recovery of CD8+ T cell function is caused by repopulation of lymphoid organs by thymic-derived CD8+ T cells. Additional studies with purified CD8+ cells from anti-CD3 mAb-treated animals indicated that the hyporesponsiveness was not caused by alterations in T cell receptor (TCR) expression. However, proliferative responses of anergic CD8+ T cells to phorbol ester and ionomycin were comparable to those of control CD8+ T cells. After in vitro stimulation, CD8+ cells from anti-CD3 treated animals did not produce interleukin (IL)-2, and although they retained their ability to upregulate IL-2 receptor expression (albeit reduced by about 50% compared with CD8+ cells from control animals), proliferative responses were not restored by addition of exogenous IL-2. In addition to IL-2 receptor expression, CD8+ cells from anti-CD3-treated animals also demonstrated an ability to upregulate CD44 and LFA-1 expression upon reexposure to anti-CD3 mAb in vitro. In conclusion, treatment with daily administration of low doses of whole or F(ab')2 fragments of anti-murine CD3 mAb induces significant T cell depletion in secondary lymphoid organs and does not seem to alter CD4+ proliferative responses in vitro, but whole mAb (and not F(ab')2 fragments) profoundly suppresses CD8+ proliferative responses. The profound hyporesponsiveness of CD8+ T cells induced by whole anti-murine CD3 mAb (1)persists for at least persists for at least several months, (2) is characterized by decreased IL-2 production and responsiveness to IL-2, and (3) recovery of CD8+ cell function is likely mediated by repopulation of lymphoid organs by thymic-derived CD8+ cells.

An immunohistochemical study of TAL-1 protein expression in leukaemias and lymphomas with a novel monoclonal antibody, 2TL 242

Fifty formalin fixed, paraffin-embedded cases of T-acute lymphoblastic leukaemia (T-ALL) from 12 bone marrow trephines and 38 lymph nodes were stained with a new monoclonal antibody, 2TL 242, raised against recombinant TAL1 protein. The antibody recognizes TAL-1 polypeptides of molecular weight 39 and 41 kD (full length). In addition, a variety of other leukaemias and lymphomas were also stained with 2TL 242. Twenty-four of the 50 cases of T-ALL showed nuclear positivity, ranging from 10 to 90 per cent of leukaemic cells. A positive staining reaction was nuclear and stippled in pattern. Nuclear staining was not seen in any other type of leukaemia or lymphoma. Five cases of follicular lymphoma showed diffuse cytoplasmic staining of variable intensity. Although some background staining is obtained with this antibody, positive nuclear staining is easily distinguishable. This monoclonal antibody has a potential role in primary diagnosis and in the detection of minimal residual disease in T-ALL.