Effects of neoadjuvant chemotherapy vs chemoradiotherapy in the treatment of esophageal adenocarcinoma: A systematic review and meta-analysis

BACKGROUND

Neoadjuvant therapy is an essential modality for reducing the clinical stage of esophageal cancer; however, the superiority of neoadjuvant chemotherapy (nCT) or neoadjuvant chemoradiotherapy (nCRT) is unclear. Therefore, a discussion of these two modalities is necessary.

AIM

To investigate the benefits and complications of neoadjuvant modalities.

METHODS

To address this concern, predefined criteria were established using the PICO protocol. Two independent authors performed comprehensive searches using predetermined keywords. Statistical analyses were performed to identify significant differences between groups. Potential publication bias was visualized using funnel plots. The quality of the data was evaluated using the Risk of Bias Tool 2 (RoB2) and the GRADE approach.

RESULTS

Ten articles, including 1928 patients, were included for the analysis. Significant difference was detected in pathological complete response (pCR) [P < 0.001; odds ratio (OR): 0.27; 95%CI: 0.16-0.46], 30-d mortality (P = 0.015; OR: 0.4; 95%CI: 0.22-0.71) favoring the nCRT, and renal failure (P = 0.039; OR: 1.04; 95%CI: 0.66-1.64) favoring the nCT. No significant differences were observed in terms of survival, local or distal recurrence, or other clinical or surgical complications. The result of RoB2 was moderate, and that of the GRADE approach was low or very low in almost all cases.

CONCLUSION

Although nCRT may have a higher pCR rate, it does not translate to greater long-term survival. Moreover, nCRT is associated with higher 30-d mortality, although the specific cause for postoperative complications could not be identified. In the case of nCT, toxic side effects are suspected, which can reduce the quality of life. Given the quality of available studies, further randomized trials are required.

[Early oral feeding does not pose a risk after upper gastrointestinal surgeries]

Bevezetés: A malignus megbetegedésekben szenvedő páciensek prehabilitációjának és rehabilitációjának kiemelkedően fontos eleme a tápláltság és a fizikai állapot felmérése és nyomon követése. Az ERAS- (Enhanced Recovery After Surgery) protokoll fontos része a posztoperatív korai, szájon keresztüli táplálás megkezdése. Az e táplálási metódusnak a felső gastrointestinalis traktus műtétei utáni alkalmazására vonatkozó adatok hiányosak. Célkitűzés: Annak igazolására, hogy a korai, szájon át történő táplálás nem jelent hátrányt ebben a betegcsoportban, a Pécsi Tudományegyetem Sebészeti Klinikáján a 2020 februárja és 2022 júliusa között ilyen módon táplált betegek adatait vetettük össze egy becsült részvételi valószínűség szerinti párosítási tanulmány során, a klasszikus módon kezelt betegek adataival. Módszer: Vizsgálatunkba olyan betegeket vontunk be, akik felső gastrointestinalis daganat miatti műtéten estek át, melynek során nyelőcsővel képzett anastomosis került kialakításra (teljes gastrectomiák és nyelőcső-resecciók). A tanulmány 50 beteget foglalt magában: 25 beteget a korai oralis táplálási csoportba, míg 25 beteget a hagyományos oralis táplálásban részesülő csoportba soroltunk. Eredmények: Az oralis táplálás átlagosan a korai táplálási csoportban a műtét utáni 2,09. napon, míg a késői táplálási csoportban az 5,52. napon kezdődött. A korai csoportban a posztoperatív kórházi tartózkodási idő átlagosan 8,875 nap volt, szemben a késői csoportban jegyzett 12,161 napos átlaggal (p<0,05). Ugyanakkor nem volt kimutatható különbség a mortalitási rátában, illetve az anastomosissal összefüggő szövődmények előfordulásában. Megbeszélés: Megállapítható, hogy a korai, szájon keresztüli táplálási csoportban statisztikailag szignifikáns csökkenés mutatható ki a bélműködés megindulásáig eltelt időben, a kórházi tartózkodási időt tekintve és a posztoperatív parenteralis táplálás időtartamában. Következtetés: Elmondható, hogy a korai, szájon keresztüli táplálás alkalmazása a felső gastrointestinalis traktus műtétei után is biztonságos. Orv Hetil. 2024; 165(1): 24–29.

Faster recovery and bowel movement after early oral feeding compared to late oral feeding after upper GI tumor resections: a meta-analysis

Background

There were more than 1 million new cases of stomach cancer concerning oesophageal cancer, there were more than 600,000 new cases of oesophageal cancer in 2020. After a successful resection in these cases, the role of early oral feeding (EOF) was questionable, due to the possibility of fatal anastomosis leakage. It is still debated whether EOF is more advantageous compared to late oral feeding. Our study aimed to compare the effect of early postoperative oral feeding and late oral feeding after upper gastrointestinal resections due to malignancy.

Methods

Two authors performed an extensive search and selection of articles independently to identify randomized control trials (RCT) of the question of interest. Statistical analyses were performed including mean difference, odds ratio with 95% confidence intervals, statistical heterogeneity, and statistical publication bias, to identify potential significant differences. The Risk of Bias and the quality of evidence were estimated.

Results

We identified 6 relevant RCTs, which included 703 patients. The appearance of the first gas (MD = -1.16; p = 0.009), first defecation (MD = -0.91; p < 0.001), and the length of hospitalization (MD = -1.92; p = 0.008) favored the EOF group. Numerous binary outcomes were defined, but significant difference was not verified in the case of anastomosis insufficiency (p = 0.98), pneumonia (p = 0.88), wound infection (p = 0.48), bleeding (p = 0.52), rehospitalization (p = 0.23), rehospitalization to the intensive care unit (ICU) (p = 0.46), gastrointestinal paresis (p = 0.66), ascites (p = 0.45).

Conclusion

Early postoperative oral feeding, compared to late oral feeding has no risk of several possible postoperative morbidities after upper GI surgeries, but has several advantageous effects on a patient's recovery.

Systematic Review Registration

identifier, CRD 42022302594.

[Robotic-assisted laparoscopic Heller-Dor's cardiomyotomy and fundoplication for achalasia]

INTRODUCTION

The outcomes of surgical interventions for achalasia treatment improved with the advent of minimally invasive surgery. Robotic-assisted Heller-Dor's (RAHD) procedure established over the last years, provides important advantages to surgeons, such as binocular three-dimensional vision and improvement of fine motor control.

METHOD

Between October and December of 2022, first in Hungary, 3 patients (37-year-old man, 55- and 72-year-old women) underwent RAHD procedure for achalasia at the Clinical Centre of the University of Pécs using the da Vinci Xi system.

RESULTS

RAHD procedure was feasible without any particular problems and the postoperative course of all three patients was uneventful. The operation times were 198, 204 and 238 minutes, including 23, 19 and 14 minutes for the setup time of the robot. By the last patient, due to an accompanying hiatal hernia, an additional hiatal reconstruction was also performed. In the first 2 cases, the patients were discharged on the 4th postoperative day, while in the last case, with the additional hiatal reconstruction, the patient was emitted on the 6th postoperative day.

DISCUSSION

There are several published studies about RAHD cardiomyotomy. The general conclusion is that, in experienced hands, RAHD procedure is easy to perform, ensures a meticulous esophageal and gastric myotomy, allowing to visualize and divide each muscle fiber with a significantly lower rate of mucosal perforations. However, by RAHD procedure, the overall costs are higher, including a longer operation time during the learning curve. At the same time, the avoidance of mucosal lacerations and their possible consequences has to be weighed against the higher overall costs.

CONCLUSION

Laparoscopic cardiomyotomy is the first standard upper-gastrointestinal operation where a clear advantage of the use of a surgical robot has been proven. Thus, wherever this equipment is available, it should be preferred for this procedure. Orv Hetil. 2023; 164(14): 542-547.

General and selective deoxygenation by hydrogen using a reusable earth-abundant metal catalyst

Chemoselective deoxygenation by hydrogen is particularly challenging but crucial for an efficient late-stage modification of functionality-laden fine chemicals, natural products, or pharmaceuticals and the economic upgrading of biomass-derived molecules into fuels and chemicals. We report here on a reusable earth-abundant metal catalyst that permits highly chemoselective deoxygenation using inexpensive hydrogen gas. Primary, secondary, and tertiary alcohols as well as alkyl and aryl ketones and aldehydes can be selectively deoxygenated, even when part of complex natural products, pharmaceuticals, or biomass-derived platform molecules. The catalyst tolerates many functional groups including hydrogenation-sensitive examples. It is efficient, easy to handle, and conveniently synthesized from a specific bimetallic coordination compound and commercially available charcoal. Selective, sustainable, and cost-efficient deoxygenation under industrially viable conditions seems feasible.

Surface chemistry of 2,3-dibromosubstituted norbornadiene/quadricyclane as molecular solar thermal energy storage system on Ni(111)

Dwindling fossil fuels force humanity to search for new energy production routes. Besides energy generation, its storage is a crucial aspect. One promising approach is to store energy from the sun chemically in strained organic molecules, so-called molecular solar thermal (MOST) systems, which can release the stored energy catalytically. A prototypical MOST system is norbornadiene/quadricyclane (NBD/QC) whose energy release and surface chemistry need to be understood. Besides important key parameters such as molecular weight, endergonic reaction profiles, and sufficient quantum yields, the position of the absorption onset of NBD is crucial to cover preferably a large range of sunlight's spectrum. For this purpose, one typically derivatizes NBD with electron-donating and/or electron-accepting substituents. To keep the model system simple enough to be investigated with photoemission techniques, we introduced bromine atoms at the 2,3-position of both compounds. We study the adsorption behavior, energy release, and surface chemistry on Ni(111) using high-resolution X-ray photoelectron spectroscopy (HR-XPS), UV photoelectron spectroscopy, and density functional theory calculations. Both Br₂-NBD and Br₂-QC partially dissociate on the surface at ∼120 K, with Br₂-QC being more stable. Several stable adsorption geometries for intact and dissociated species were calculated, and the most stable structures are determined for both molecules. By temperature-programmed HR-XPS, we were able to observe the conversion of Br₂-QC to Br₂-NBD in situ at 170 K. The decomposition of Br₂-NBD starts at 190 K when C-Br bond cleavage occurs and benzene and methylidene are formed. For Br₂-QC, the cleavage already occurs at 130 K when cycloreversion to Br₂-NBD sets in.

Surface chemistry of 2,3-dibromosubstituted norbornadiene/quadricyclane as molecular solar thermal energy storage system on Ni(111)

Dwindling fossil fuels force humanity to search for new energy production routes. Besides energy generation, its storage is a crucial aspect. One promising approach is to store energy from the sun chemically in strained organic molecules, so-called molecular solar thermal (MOST) systems, which can release the stored energy catalytically. A prototypical MOST system is norbornadiene/quadricyclane (NBD/QC) whose energy release and surface chemistry need to be understood. Besides important key parameters such as molecular weight, endergonic reaction profiles, and sufficient quantum yields, the position of the absorption onset of NBD is crucial to cover preferably a large range of sunlight's spectrum. For this purpose, one typically derivatizes NBD with electron-donating and/or electron-accepting substituents. To keep the model system simple enough to be investigated with photoemission techniques, we introduced bromine atoms at the 2,3-position of both compounds. We study the adsorption behavior, energy release, and surface chemistry on Ni(111) using high-resolution X-ray photoelectron spectroscopy (HR-XPS), UV photoelectron spectroscopy, and density functional theory calculations. Both Br₂-NBD and Br₂-QC partially dissociate on the surface at ∼120 K, with Br₂-QC being more stable. Several stable adsorption geometries for intact and dissociated species were calculated, and the most stable structures are determined for both molecules. By temperature-programmed HR-XPS, we were able to observe the conversion of Br₂-QC to Br₂-NBD in situ at 170 K. The decomposition of Br₂-NBD starts at 190 K when C-Br bond cleavage occurs and benzene and methylidene are formed. For Br₂-QC, the cleavage already occurs at 130 K when cycloreversion to Br₂-NBD sets in.

RESULTS OF RELID STUDY 2014-BUENOS AIRES, ARGENTINA RETROSPECTIVE EVALUATION OF LENS INJURIES AND DOSE

High levels of scatter radiation in catheterization laboratories may lead to posterior subcapsular opacities in the lens of the staff. The international Retrospective Evaluation of Lens Injuries and Dose (RELID) was performed in Argentina for the first time in 2010 in the context of the congress of the Latin American Society of Interventional Cardiology (SOLACI) and recently, in 2014, was carried out for the second time (SOLACI-CACI 2014). The 2014 study included 115 participants: interventional cardiologists, technicians and nurses. Posterior subcapsular lens changes typical of ionizing radiation exposure were found in 91.5% of interventional cardiologists, in 77% of technicians and in 100% of nurses, according to the Merriam-Focht scale. This RELID study (Argentina 2014) has particular importance since it allowed the follow-up of 10 professionals evaluated in 2010. The results obtained in the study population highlight the importance of the availability and proper use of the elements of radiation protection, as well as staff training.

Probing the interaction of Rh, Co and bimetallic Rh-Co nanoparticles with the CeO2 support: catalytic materials for alternative energy generation

The interaction of CeO2-supported Rh, Co and bimetallic Rh-Co nanoparticles, which are active catalysts in hydrogen production via steam reforming of ethanol, a process related to renewable energy generation, was studied by X-ray diffraction (XRD), high resolution electron microscopy (HRTEM), X-ray photoelectron spectroscopy (XPS) and low energy ion scattering (LEIS). Furthermore, diffuse reflectance infrared spectroscopy (DRIFTS) of adsorbed CO as a probe molecule was used to characterize the morphology of metal particles. At small loadings (0.1%), Rh is in a much dispersed state on ceria, while at higher contents (1-5%), Rh forms 2-8 nm particles. Between 473-673 K pronounced oxygen transfer from ceria to Rh is observed and at 773 K significant agglomeration of Rh occurs. On reduced ceria, XPS indicates a possible electron transfer from Rh to ceria. The formation of smaller ceria crystallites upon loading with Co was concluded from XRD and HRTEM; for 10% Co, the CeO2 particle size decreased from 27.6 to 10.7 nm. A strong dissolution of Co into ceria and a certain extent of encapsulation by ceria were deduced by XRD, XPS and LEIS. In the bimetallic system, the presence of Rh enhances the reduction of cobalt and ceria. During thermal treatments, reoxidation of Co occurs, and Rh agglomeration as well as oxygen migration from ceria to Rh are hindered in the presence of cobalt.

Gold intercalation of boron-doped graphene on Ni(111): XPS and DFT study

The intercalation of a graphene layer adsorbed on a metal surface by gold or other metals is a standard procedure. While it was previously shown that pristine, i.e., undoped, and nitrogen-doped graphene sheets can be decoupled from a nickel substrate by intercalation with gold atoms in order to produce quasi-free-standing graphene, we find the gold intercalation behavior for boron-doped graphene on a Ni(111) surface to be more complex: for low boron contents (2-5%) in the graphene lattice only partial gold intercalation occurs and for higher boron contents (up to 20%) no intercalation is observed. In order to understand this different behavior, a density functional theory investigation is carried out, comparing undoped as well as substitutional nitrogen- and boron-doped graphene on Ni(111). We identify the stronger binding of the boron atoms to the nickel substrate as the factor responsible for the different intercalation behavior in the case of boron doping. However, the calculations predict that this energetic effect prevents the intercalation process only for large boron concentrations and that it can be overcome for smaller boron coverages, in line with our x-ray photoelectron spectroscopy experiments.

Ultrafast x-ray photoelectron spectroscopy in the microsecond time domain

We introduce a new approach for ultrafast in situ high-resolution X-ray photoelectron spectroscopy (XPS) to study surface processes and reaction kinetics on the microsecond timescale. The main idea is to follow the intensity at a fixed binding energy using a commercial 7 channeltron electron analyzer with a modified signal processing setup. This concept allows for flexible switching between measuring conventional XP spectra and ultrafast XPS. The experimental modifications are described in detail. As an example, we present measurements for the adsorption and desorption of CO on Pt(111), performed at the synchrotron radiation facility BESSY II, with a time resolution of 500 μs. Due to the ultrafast measurements, we are able to follow adsorption and desorption in situ at pressures of 2 × 10(-6) mbar and temperatures up to 500 K. The data are consistently analyzed using a simple model in line with data obtained with conventional fast XPS at temperatures below 460 K. Technically, our new approach allows measurement on even shorter timescales, down to 20 μs.

Fabrication of layered nanostructures by successive electron beam induced deposition with two precursors: protective capping of metallic iron structures

We report on the stepwise generation of layered nanostructures via electron beam induced deposition (EBID) using organometallic precursor molecules in ultra-high vacuum (UHV). In a first step a metallic iron line structure was produced using iron pentacarbonyl; in a second step this nanostructure was then locally capped with a 2-3 nm thin titanium oxide-containing film fabricated from titanium tetraisopropoxide. The chemical composition of the deposited layers was analyzed by spatially resolved Auger electron spectroscopy. With spatially resolved x-ray absorption spectroscopy at the Fe L₃ edge, it was demonstrated that the thin capping layer prevents the iron structure from oxidation upon exposure to air.

Probing bulk electronic structure with hard X-ray angle-resolved photoemission

Traditional ultraviolet/soft X-ray angle-resolved photoemission spectroscopy (ARPES) may in some cases be too strongly influenced by surface effects to be a useful probe of bulk electronic structure. Going to hard X-ray photon energies and thus larger electron inelastic mean-free paths should provide a more accurate picture of bulk electronic structure. We present experimental data for hard X-ray ARPES (HARPES) at energies of 3.2 and 6.0 keV. The systems discussed are W, as a model transition-metal system to illustrate basic principles, and GaAs, as a technologically-relevant material to illustrate the potential broad applicability of this new technique. We have investigated the effects of photon wave vector on wave vector conservation, and assessed methods for the removal of phonon-associated smearing of features and photoelectron diffraction effects. The experimental results are compared to free-electron final-state model calculations and to more precise one-step photoemission theory including matrix element effects.

Band gap and electronic structure of an epitaxial, semiconducting Cr0.80Al0.20 thin film

Cr(1-x)Al(x) exhibits semiconducting behavior for x = 0.15-0.26. This Letter uses hard x-ray photoemission spectroscopy and density functional theory to further understand the semiconducting behavior. Photoemission measurements of an epitaxial Cr(0.80)Al(0.20) thin film show several features in the valence band region, including a gap at the Fermi energy (E(F)) for which the valence band edge is 95 ± 14 meV below E(F). Theory agrees well with the valence band measurements, and shows an incomplete gap at E(F) due to the hole band at M shifting almost below E(F).

Ethene adsorption and dehydrogenation on clean and oxygen precovered Ni(111) studied by high resolution x-ray photoelectron spectroscopy

The adsorption and thermal evolution of ethene (ethylene) on clean and oxygen precovered Ni(111) was investigated with high resolution x-ray photoelectron spectroscopy using synchrotron radiation at BESSY II. The high resolution spectra allow to unequivocally identify the local environment of individual carbon atoms. Upon adsorption at 110 K, ethene adsorbs in a geometry, where the two carbon atoms within the intact ethene molecule occupy nonequivalent sites, most likely hollow and on top; this new result unambiguously solves an old puzzle concerning the adsorption geometry of ethene on Ni(111). On the oxygen precovered surface a different adsorption geometry is found with both carbon atoms occupying equivalent hollow sites. Upon heating ethene on the clean surface, we can confirm the dehydrogenation to ethine (acetylene), which adsorbs in a geometry, where both carbon atoms occupy equivalent sites. On the oxygen precovered surface dehydrogenation of ethene is completely suppressed. For the identification of the adsorbed species and the quantitative analysis the vibrational fine structure of the x-ray photoelectron spectra was analyzed in detail.

Site blocking and CO/sulfur site exchange processes on stepped Pt surfaces

The influence of preadsorbed sulfur on the adsorption of CO on Pt(355) and Pt(322) is investigated systematically for sulfur precoverages between 0.02 and 0.30 ML by in situ x-ray photoelectron spectroscopy of the C 1s and S 2p core levels. The two surfaces have the same nominal terrace width of 5 atomic rows, but different step orientation. For both, at low temperatures (130 and 150 K), S preferentially adsorbs at the steps and passivates them for CO adsorption. The required S precoverage is significantly smaller for Pt(322), because of the lower number of steps as a result of the S-induced double-step formation. Upon heating, population of step sites with CO occurs due to irreversible CO/S site exchange. At low S precoverages, the characteristic transition temperatures of 165 K for Pt(355) and 245 K for Pt(322) are significantly different, indicating a higher activation barrier for the CO/S site exchange process for Pt(322). For medium to high S precoverages the transition temperature stays unchanged for Pt(322) but increases for Pt(355). The observed behavior is attributed to a kinetic passivation of the steps by sulfur at low temperatures, which is lifted upon heating.

Adsorption and reaction of cyclohexene on a Ni(111) surface

We studied the adsorption and reaction of cyclohexene (C6H10) on Ni(111) at different temperatures with high-resolution in-situ X-ray photoelectron spectroscopy (HR-XPS). For exposure at 125 K, we find intact cyclohexene with two distinct C 1s signals at 283.3 and 284.2 eV, due to the nonequivalent carbon atoms in the molecule. The energetic separation is significantly increased relative to the gas-phase value, due to the interaction with the substrate. Upon exposure at 210 K, complete dehydrogenation of cyclohexene to benzene (C6H6) and hydrogen is observed; coverage-dependent changes of the benzene adsorption site occur in a way similar to those for pure benzene layers, which indicates a phase separation in benzene and hydrogen islands. The thermal evolution of the adsorbed layers was studied by temperature-programmed (TP-) XPS and temperature-programmed desorption spectroscopy (TPD). Upon heating, the benzene + hydrogen layer formed at 210 K shows a coverage-dependent reorientation of the benzene molecules during partial desorption. The cyclohexene layer adsorbed at 125 K only shows partial conversion of cyclohexene to benzene and hydrogen upon heating to 185 or 210 K, with the remaining cyclohexene being stable up to approximately 300 K. We propose that upon heating these molecules are stabilized by coadsorbed benzene and hydrogen; furthermore, the mobility of benzene and hydrogen in this coadsorbed layer is reduced, so that no phase separation can occur.

A detailed analysis of vibrational excitations in x-ray photoelectron spectra of adsorbed small hydrocarbons

The vibrational fine structure of x-ray photoelectron (XP) spectra of a number of different small hydrocarbon molecules and reaction intermediates adsorbed on Pt(111) and Ni(111) has been investigated in detail. The data for methyl, methylidyne, acetylene, and ethylene can consistently be analyzed within the linear coupling model. The S factor, i.e., the intensity ratio of the first vibrationally excited to the adiabatic transition, is obtained to be 0.17+/-0.02 per C-H bond; for the deuterated species a value of 0.23+/-0.02 is obtained. Therefore, the vibrational fine structure can be used for fingerprinting in the analysis of XP spectra and for identifying unknown reaction intermediates. From the data, Deltar, the change of the minimum in the potential energy curve upon core ionization, is calculated within the linear coupling model using a first order correction. For all adsorbates, including the deuterated ones, a value of Deltar=0.060+/-0.004 A is obtained. Furthermore, from the binding energy of the adiabatic peak and from the energy of the vibrational excitation in the ionic final state some information on the adsorbate/substrate bond and the adsorption site can be derived.

A site-selective in situ study of CO adsorption and desorption on Pt(355)

Using time-dependent high-resolution x-ray photoelectron spectroscopy at BESSY II, the adsorption and desorption processes of CO on stepped Pt(355) = Pt[5(111) x (111)] were investigated. From a quantitative analysis of C 1s data, the distribution of CO on the various adsorption sites can be determined continuously during adsorption and desorption. These unique data show that the terrace sites are only occupied when the step sites are almost saturated, even at temperatures as low as 130 K. The coverage-dependent occupation of on-top and bridge adsorption sites on the (111) terraces of Pt(355) is found to differ from that on Pt(111), which is attributed to the finite width of the terraces and changes in adsorbate-adsorbate interactions. In particular, no long-range order of the adsorbate layer could be observed by low-energy electron diffraction. Further details are derived from sticking coefficient measurements using the method devised by King and Wells [Proc. R. Soc. London, Ser. A 339, 245 (1974)] and temperature-programmed desorption. The CO saturation coverage is found to be slightly smaller on the stepped surface as compared to that on Pt(111). The initial sticking coefficient has the same high value of 0.91 for both surfaces.

Anterior chamber paracentesis cytology (cytospin technique) for the diagnosis of intraocular lymphoma

AIM

To report on the diagnosis of intraocular lymphoma by aqueous cytology.

METHODS

Four patients suspected of having intraocular lymphoma were evaluated by anterior chamber (AC) paracentesis with cytology (cytospin technique). All had a history of non-ocular lymphoma and presented with at least one plus anterior chamber cells despite intensive glucocorticoid therapy. A 25 gauge needle was inserted through clear cornea (bevel up), over the iris stroma, so as to drain the AC. The aqueous humour was sent for cytopathology (cytospin technique), culture, and sensitivity tests.

RESULTS

All procedures were diagnostic. Three were lymphoma and the fourth was culture positive for Propionibacterium endophthalmitis. No secondary glaucoma, hyphaema, cataract or infections were related to AC paracentesis.

CONCLUSIONS

In this series, AC aspiration cytology enhanced by the cytospin technique was an effective, minimally invasive alternative to vitrectomy based biopsy. This technique should be considered to rule in the diagnosis of intraocular lymphoma in selected cases with cells in the anterior chamber.

I. Hypogastric artery ligation for intractable pelvic hemorrhage

OBJECTIVE

To assess the outcomes of bilateral hypogastric (internal iliac) ligation performed to control intractable pelvic hemorrhage and avoid hysterectomy.

METHODS

A review of indications and outcomes for 117 cases of bilateral hypogastric artery ligation over 15 years (1990-2004).

RESULTS

Apart from a slight lesion to the hypogastric vein, no complications were observed. Hemorrhage was effectively controlled in all 37 obstetric cases. In 13 of these cases, the uterus was preserved even when there was cervical pregnancy, placenta previa, placental abruption, uterine atony, and uterine rupture, and 4 women were delivered of mature infants. Hemorrhage was effectively controlled in 41 of 80 gynecologic cases. Prophylactic reduction of pelvic blood flow was the indication for the procedure in 39 cases, 5 of whom involving Jehovah's Witnesses adverse to blood transfusion. The uterus was preserved in only a few of the 41 controlled cases, but one woman (so far) was delivered of a mature infant.

CONCLUSION

Hypogastric artery ligation was found to be indicated if (1) life-threatening pelvic hemorrhage could not be controlled by conservative methods; (2) prophylactic reduction of pelvic blood flow was needed to prevent anticipated hemorrhage; and (3) preservation of reproductive function was desired. The procedure was found to be safe and usually effective and should be taught during obstetric and gynecologic training.

Lateral arm flap: analysis of its anatomy and modification using a vascularized fragment of the distal humerus

Soft tissue injuries with associated bone defects are difficult to manage and often require prolonged treatment with repeated interventions. Frequently, a free flap is applied as a first step and bone grafting is carried out in a second procedure. Ideally, these two procedures are combined in one operation, utilizing a soft tissue flap with an attached vascularized bone fragment. The lateral arm flap can provide such an osteoseptocutaneous flap and has been utilized clinically with success; however, the vascular anatomy of the flap, especially the humeral fragment, has not been described in detail previously, and there is broad disagreement concerning its innervation. In this study, the arteries and nerves of 24 fresh cadaver arms were dissected after injection of colored latex. The levels of origin of the periosteal arteries of the humerus were also documented. The lateral arm flap has a consistent arterial supply from three septocutaneous perforating branches that are arranged in a predictable pattern. The lateral supracondylar ridge of the humerus is vascularized by direct branches of the posterior branch of the radial collateral artery and by arteries that arise from muscular branches supplying adjacent muscles. The innervation of the lateral arm flap is by the inferior lateral cutaneous nerve of the arm. Knowledge of the consistent vascular anatomy of the lateral humerus and soft tissue of the donor site allows an osteoseptocutaneous flap to be raised safely with an appropriate technique. We recommend use of the lateral arm flap with a humeral fragment for the treatment of combined soft tissue and bone defects when a single step surgical solution is indicated.

Relationship between the descending branch of the inferior gluteal artery and the posterior femoral cutaneous nerve applicable to flap surgery

Flap surgery in the distal part of the gluteal region has to deal with a lack of detailed descriptions of the inferior gluteal artery and the posterior femoral cutaneous nerve. The existing papers are mainly clinical studies, based on low numbers of observations. Our study includes 118 cadaveric gluteal regions. The descending branch was present in 91% and gave rise to a cutaneous branch. When the descending branch was absent, this cutaneous branch came from the medial or lateral femoral circumflex artery or as a perforator of the deep artery of the thigh. The posterior femoral cutaneous nerve was found in a common sheath of connective tissue with the descending branch of the inferior gluteal artery in 72% of cases. Nerve loops around the vessel are present in 29%. Our results show that a cutaneous or fasciocutaneous flap, either local or free, in this region can be reliably lifted on a cutaneous branch of the descending branch of the inferior gluteal artery without loss of sensitivity. However, the close relationship of the artery and nerve limits the arc of rotation in the case of a local flap.

Anatomical basis for a new island axial pattern flap in the perioral region

Soft tissue defects of the perinasal and perioral regions usually result from trauma and tumor resection as well as from congenital diseases. Coverage of facial defects is frequently challenging. The goal of reconstruction is to achieve a functional and esthetically satisfactory result. The most common techniques of wound care, such as full-thickness skin grafts and primary wound closure, are not suitable in all cases and therefore transposition flaps become necessary. Despite the description of numerous flaps, the search for other reconstruction possibilities and the development of additional flaps with good color match and minimal donor site morbidity is continuing. The purpose of our study was to describe the course of the facial artery and the pattern of its branches, because clinical cases have shown that there are branches which are suitable for skin island flaps. During the anatomical dissection of 31 cadavers (62 hemifaces), we analyzed a cutaneous branch of the facial artery, which we named due to its topographical location the "cutaneous zygomatic branch". This vessel shows a highly constant origin and course, as well as a relatively wide area of supplied skin. Based on our anatomical observations, we suggest a new axial pattern skin island flap which awaits clinical application. We feel that this flap has great future potential.

Pulmonary stenosis and reactive right ventricular hypertrophy in the recipient fetus as a consequence of twin-to-twin transfusion

The present study describes an association between adverse outcome in the twin-to-twin transfusion syndrome (TTTS) and pulmonary stenosis or reactive right ventricular hypertrophy. Six discordant monozygotic twin pregnancies with TTTS are described. Ventricular hypertrophy and atrioventricular valvular regurgitation occurred in all the recipient twins with pulmonary valvular stenosis in three cases and infundibular stenosis in one case. The recipient twin in one pair and both twins in another pregnancy died as a consequence of immaturity but the remaining twins all survived. Surgical intervention was required in one baby for valvular pulmonary stenosis. Our observations suggest that elevated blood pressure in the transfusion recipient may play an important role in pathogenesis. We hypothesise that both pulmonary stenosis and right chamber hypertrophy are secondary to hemodynamic changes. Although we have found valvular pulmonary stenosis in three recipients and infundibular stenosis in only one, this (obstruction to outflow) could be due to right chamber hypertrophy.

Osteomuscular latissimus dorsi scapula flap to repair chronic, posttraumatic osteomyelitis of the lower leg

Fractures of the lower leg with soft-tissue loss may be complicated by osteomyelitis. Many treatment plans offered in the past have included the use of vascularized bone, but the soft tissue that accompanied the bone was sometimes less than ideal in quality as well as quantity. This study presents a one-step method for the surgical treatment of chronic, posttraumatic osteomyelitis that includes (1) radical debridement of the area affected by osteomyelitis, (2) use of revascularized bone for stabilization of the affected area, and (3) well-vascularized soft-tissue cover for the defect. The use of an osteomuscular latissimus dorsi scapula flap is described and illustrated by descriptions of five operations performed by the authors' department in Salzburg, Austria. The resultant healing of the bone was comparable to the primary healing of a fracture.

Biological mechanisms underlying the clinical effects of mifepristone (RU 486) on the endometrium

The abortifacient and menstrual effects of the potent antiprogestin, RU 486 (mifepriston) are associated with both endometrial hemorrhage and extracellular matrix (ECM) degradation. Such processes reflect reduced perivascular decidual cell hemostatic and increased ECM-degrading protease activity. In this review, we summarize the effects of RU 486 on different proteases involved in these processes and expressed by in vitro decidualized endometrium stromal cells. The expression of tissue factor (TF), the primary initiator of hemostasis; urokinase-type plasminogen activator (uPA); tissue-type plasminogen activator (tPA); plasminogen activator inhibitor-1 (PAI-1) as well as the potent matrix metalloprotease, MMP-3 was assessed. These endpoints of decidualization are regulated by progesterone. It was observed, that RU 486 blocks and reverses progestin-enhanced stromal cell TF protein and mRNA expression and PAI-1 protein and mRNA expression, whereas blocks and reverses progestin-inhibited stromal cell uPA, tPA and MMP-3 protein and mRNA expression. These coordinate enhancement of plasminogen activator and MMP-3 expression promotes proteolysis of the decidual ECM, which leads to endometrial sloughing during menstruation. Moreover, destabilization of endometrial microvessels resulting from degradation of their surrounding ECM is consistent with the heavy bleeding after RU 486 administration. On the other hand, with blocking the expression of TF and PAI-1, RU 486 creates a haemorrhagic and fibrinolytic milieu around the endometrial vessels, suggesting a mechanism for RU 486-induced endometrial hemorrhage. The steroid antagonist RU 486 (mifepristone) causes menstrual bleeding when given during the luteal phase of the menstrual cycle (1) and induces abortion in 64-85% of pregnant patients when administered before the 50. postmenstrual days (2, 3). These clinical actions are thought to reflect the antiprogestational effects of RU 486. Pathologic studies showed, that the effects of RU 486 on primate and human luteal phase endometrium include reduced stromal edema, increased venular diameter. Erythrocyte and leukocyte diapedesis, focal hemorrhage, degeneration of the stromal extracellular matrix, and eventual disruption of the superficial layer of the endometrium (4, 5). This antihormone acts at the receptor level and possibly also at the postreceptor level(s) (6). The most important mechanism of action is to compete with progesterone at the level of their respective binding site in the ligand binding domain of the progesterone receptors. The binding of RU 486 to the receptor leads to conformational changes in the DNA-binding site of the progesterone-receptor (7). As a consequnce of these changes, the interaction between the receptor and the progesterone-response elements in the promoter region of progesterone-responsive genes is altered (7). The menorrhagic and abortifacient properties of RU 486 are associated with the induction of endometrial hemorrhage. The physiological mechanisms by which human endometrium permits menstrual hemorrhage in the absence of pregnancy yet maintains hemostasis during endovascular trophoblast invasion (avoiding early abortion) has been investigated in our laboratory by evaluating endometrial expression of different proteins that play role in the process of hemostasis. Besides the endometrial haemostasis, we also examined the proteolytic processes leading extracellular matrix (ECM) degradation, which is also an integral part of menstruation. In this review we sought to summarize the biological mechanisms underlying the clinical effects of RU 486 on endometrial haemorrhage/haemostasis and on ECM degradation.

Apolipoprotein E allele distribution in trisomy 13, 18, and 21 conceptuses in a Hungarian population

Reports documented a higher frequency of apolipoprotein E (apoE) allele epsilon 4 among mothers of children diagnosed with Down syndrome. We studied the prevalence of apoE alleles among 56 conceptuses with trisomy 13, trisomy 18, or trisomy 21. The presence of the 3 most common apoE alleles (epsilon 2, epsilon 3, epsilon 4) was determined by polymerase chain reaction-restriction fragment length polymorphism, and trisomy status was detected by fluorescent polymerase chain reaction followed by DNA fragment analysis and by conventional cytologic methods. We found no significant difference in the distribution of apoE alleles in the group of trisomy 21 fetuses compared with samples from healthy blood donors. The odds of having trisomy 18 for the apoE epsilon 4 group was 3-fold as high as for apoE epsilon 3 allele compared with the healthy control group. Furthermore, a statistically significant association was found for those with trisomy 18 and apoE epsilon 4, while for those with trisomy 13 and apoE epsilon 4, the test showed no significant association. The observed apoE allele epsilon 3 frequencies among patients with Down syndrome and healthy control subjects may help explain and support previous work that did not find high rates of atherosclerosis among these persons. The role of apoE alleles in the development of trisomies needs further study.

The anatomy of the angular branch of the thoracodorsal artery

This study reports an anatomical investigation of the angular branch of the thoracodorsal artery, which can be used in reconstructive surgery to serve as a pedicle for gaining osseous material from the scapula. The study was performed on 135 samples and topography and morphometry of the vessel were investigated. It was found that this artery has five main types of origin. It courses in the fascial gliding layer between the serratus muscle, and the teres major and subscapular muscle to the inferior angle of the scapula. There it provides the bone with blood through periostal branches as part of the arterial rete on the costal and dorsal side of the scapula. The mean length of the angular branch and the thoracodorsal artery together was 148 mm, and when also adding the subscapular artery the overall length became 167 mm. It was found that the length of a pedicle consisting of the angular branch and the thoracodorsal artery is determined by the difference in origin of the vessels with minor influences of the body size. The internal diameters of unfilled fixated vessels measured 3.06 mm for the subscapular, 1.77 mm for the circumflex scapular, 1.30 mm for the thoracodorsal and 0. 64 mm for the angular branch. The exact knowledge of the microanatomy in this area is necessary to be able to use the osseous free flap more selectively and have less traumatization in the donor area.

Anatomical study of the perforating vessels of the lower leg

Difficulty of soft tissue defects of the lower leg demands the development of new methods to treat such defects. The aim of this study is the examination of perforators and the various ways of blood supply to the skin in the lower leg. Provided with certain regularity, we would be able to cure soft-tissue defects also in the difficult zone of the distal segment and on the dorsum of the foot not harming vessels and not affecting mobility of muscles. Subcutaneous island-flaps supplied by perforating vessels could replace free flaps. By saving the crural fascia of 10 lower legs we flayed layers of skin and fat, marked the perforating vessels with pins, and photographed and documented them. Specimens were divided into a proximal, an intermediate and a distal segment, each of them subdivided into a medial, lateral and dorsal section. The perforators, which can be classified as septocutaneous and musculocutaneous vessels, followed a reproducible pattern all over the lower leg. All vessels were sufficient in number as well as in size. Additionally these perforators can easily be identified by colour-coded sonography. The knowledge that perforators in the lower leg occur regularly enables the development of a new operative approach in therapy of soft-tissue defects in this region with the advantage, that the vessels used can be selected preoperatively.

Twin delivery after myomectomy, in vitro fertilization, and embryo reduction in an infertile woman

A 28-year-old patient had metroplasty performed because of necrosis of a uterine fibroid. During follow-up, the left adnexa were removed because of a recurrent left ovarian cyst. The triplet gestation achieved by in vitro fertilization was reduced to twins. The living premature newborns were delivered abdominally.

[Congenital heart abnormalities and cardiac dysfunction: how prenatal diagnosis changed the chances for survival]

Because of the rapid development of sonography, there are many new informations on embryonal and fetal circulation and pathophysiology of decompensation. Echocardiography is a useful tool to follow intrauterine therapy. Authors have examined the effect of prenatal diagnosis on the prevalence of heart abnormalities, terms of cardiac surgery, perinatal mortality and mortality due to heart abnormalities or decompensation. During five years they have found 187 severe heart abnormalities. Because of parental request 90 pregnancies have been terminated. Following prenatal diagnosis in 16 cases planned surgery of the newborn, in 14 cases planned cesarean sections have been done. From 64 transplacentar treatments 44 patients have survived. Authors have found, that prenatal diagnosis had good effect on short term survival rate but had no effect on long term survival rate. Fetal echocardiography has selective and therapeutic effect. The selective effect depends on second trimester screening. The therapeutic effect was significant in cases of arrhythmias and decompensation.