Dual wavelength retinal vessel oximetry - influence of fundus pigmentation

BACKGROUND

Clinical methods examining oxygenation parameters in humans have been used in many different care settings, but concerns have been raised regarding their clinical utility when assessing people with darker skin pigmentation. While saturation values can be crucial in emergency medicine, they are equally valuable in assessing disease mechanisms and monitoring change in disease progression. Retinal pigmentation varies across individuals and hence, can impact on retinal oxygen parameters. The objective of this study was to quantify and eliminate the impact of retinal pigmentation on retinal vessel oxygen saturation parameters measured in the superficial retinal arterioles and venules.

METHODS

105 healthy individuals of varying skin colour, iris colour and heritage were included. Following a full eye exam to exclude any ocular abnormality, all participants underwent intraocular pressure, systemic blood pressure measurements and dilated dual wavelength retinal photography. Rotation matrices were employed to minimise the dependency of retinal pigmentation on arterial and venous oxygen saturation measurements determined in a concentric measurement annulus.

RESULTS

Retinal oxygen saturation in venules showed a linear correlation with retinal pigmentation (y = 0.34 × x + 38.598), whereas arterial saturation followed a polynomial pattern (y = 0.0089 × x2 + 0.7499 × x + 85.073). Both arterial and venous saturation values were corrected using local fundus pigmentation. Pre-correction retinal arterial and venous oxygen saturation were 89.0% (±13.1) and 43.7% (±11.5), respectively, and post- correction values were 94.8% (±8.7) for arteries and 56.3% (±7.0) veins.

CONCLUSIONS

When assessing multi-ethnic cohorts, it is important to consider the impact of pigmentation on imaging parameters and to account for it prior to clinical interpretation.

THU0620-HPR MEASUREMENT OF LOW DISEASE ACTIVITY USING THE CLINICAL DISEASE ACTIVITY INDEX (CDAI) VERSUS THE DISEASE ACTIVITY SCORE 28 (DAS 28): IMPACT OF INFLAMMATION MARKERS ON THE COMPARATIVE EFFECTIVENESS OF BIOLOGICS FOR THE TREATMENT OF RHEUMATOID ARTHRITIS

Background:

Biologics for the treatment of rheumatoid arthritis (RA) have different modes of action to target auto-inflammatory processes causing the signs and symptoms of the disease. Different biologics may thus have different effects on inflammatory markers. For instance, previous studies have shown that the interleukin-6-inhibitor tocilizumab (TOC) decreases the level of acute phase reactants (APRs) [1]. Such direct effects on inflammatory markers may lead to an overestimation of clinical response if disease activity is measured via scores including inflammatory markers, such as the Disease Activity Score 28 (DAS 28). The detected changes in disease activity may not adequately reflect the clinical improvement of signs and symptoms.

Objectives:

In our study, we compared biologics with each other using two different disease activity scores: the DAS 28 including APRs and the clinical disease activity index (CDAI) excluding APRs. The aim of this study was to assess whether the use of the two different scores affects comparative effectiveness studies on biologics for the treatment of RA.

Methods:

We compared results on the comparative effectiveness of biologics using the corresponding thresholds for low disease activity (LDA) for the DAS 28 (< 3.2) and the CDAI (≤ 10). We performed two separate network meta-analyses (NMAs) after a thorough step-by-step evaluation of the similarity, homogeneity and consistency assumptions of the patient populations and the study data.

Our study formed part of a systematic review (including NMAs) that was largely based on clinical study reports and re-analyses of LDA using individual patient data provided by sponsors for studies conducted up to 2017. Thus, the analyses include hitherto unknown data on LDA analysed by means of the CDAI, especially data from older studies. An extensive comparison of DAS 28 and CDAI in different patient populations was possible.

Results:

For all analysed patient populations, comparisons of TOC versus other biologics yielded remarkable results: advantages for TOC were found in NMAs using the DAS 28, which were not confirmed in NMAs using the CDAI. For methotrexate (MTX)-naïve patients, using the DAS 28, TOC showed a greater benefit than abatacept (ABA), certolizumab pegol (CZP), and etanercept (ETA), which was not confirmed by the CDAI. In contrast, TOC showed less benefit than adalimumab (ADA) and ETA. For patients after MTX failure and using the DAS 28, TOC showed a greater benefit than ABA, ADA, anakinra (ANA), ETA, golimumab (GOL), and infliximab (INF). With the exception of ANA, these advantages were not confirmed by the CDAI. Similar differences between DAS 28 and CDAI were shown in patients treated with biologics in monotherapy or after failure of biologics.

Conclusion:

In comparative effectiveness studies of biologics, the assessment of LDA using the DAS 28 instead of the CDAI leads to a consistent overestimation of the benefit of TOC in all patient populations, regardless of pre-treatment or combined therapy with MTX. The inclusion of APRs in disease activity scores may thus introduce bias. A score excluding inflammatory markers should therefore be used to ensure valid results.

References:

[1]Smolen JS, Aletaha D. Interleukin-6 receptor inhibition with tocilizumab and attainment of disease remission in rheumatoid arthritis: the role of acute-phase reactants. Arthritis Rheum 2011; 63(1): 43-52.

Disclosure of Interests:

Kirsten Janke: None declared, Katharina Biester: None declared, Dietmar Krause Grant/research support from: Pfizer and AbbVie (Abbott), Bernd Richter: None declared, Christoph Schürmann: None declared, Katharina Hirsch: None declared, Beate Wieseler: None declared

Megaprepuce: presentation of a modified surgical technique with excellent cosmetic and functional results

OBJECTIVE

Congenital megaprepuce is a malformation consisting of a great redundancy of the inner preputial skin over a penis with normal shaft and glans and is combined with a severe phimosis. Patients suffer from difficulties in voiding because the urine is trapped in the large dome-shaped megaprepuce. We describe a modification of the surgical technique of reconstructing a megaprepuce initially presented by Leao et al.

PATIENTS AND METHODS

We retrospectively reviewed 7 patients aged 6-53 months (mean age 17 months, 6 were younger than 18 months) who underwent congenital megaprepuce repair between 02/2014 and 05/2018 in our institution. All these otherwise healthy children suffering from difficulties in voiding and reporting genital ballooning during micturition and urinary retention were referred to our hospital. In all cases, parents needed to express the trapped urine. Four of these patients additionally showed a glanular hypospadias, another one a distal penile hypospadias. In addition to the repair of the megaprepuce, six patients needed correction of a penile curvature, five of whom needed correction of the chordee and one a corporoplasty (Schröder-Essed). The patient showing the distal penile hypospadias additionally underwent hypospadias repair. During the follow-up, we evaluated the cosmetic result and complications such as secondary concealed penis, difficulties in voiding, urinary retention, and urinary infections.

RESULTS

Mean follow-up was 18 months. All patients following surgery showed normal voiding without urinary retention or urinary infections and good cosmetic results resembling a circumcised penis in appearance without reconcealment. No intraoperative complications occurred. One patient had a scrotal hematoma postoperatively. Mild transient edema of the penis was seen in all patients, which disappeared spontaneously within one week after surgery.

CONCLUSION

Our surgical approach is a safe and relatively simple procedure with a low rate of complications, good cosmetic results, and functional outcome. Whether the hypospadias associated with ventral curvature was a coincidence or part of the disease pattern remains unclear but will probably be the object of further investigations.

Spin-current-mediated rapid magnon localisation and coalescence after ultrafast optical pumping of ferrimagnetic alloys

Sub-picosecond magnetisation manipulation via femtosecond optical pumping has attracted wide attention ever since its original discovery in 1996. However, the spatial evolution of the magnetisation is not yet well understood, in part due to the difficulty in experimentally probing such rapid dynamics. Here, we find evidence of a universal rapid magnetic order recovery in ferrimagnets with perpendicular magnetic anisotropy via nonlinear magnon processes. We identify magnon localisation and coalescence processes, whereby localised magnetic textures nucleate and subsequently interact and grow in accordance with a power law formalism. A hydrodynamic representation of the numerical simulations indicates that the appearance of noncollinear magnetisation via optical pumping establishes exchange-mediated spin currents with an equivalent 100% spin polarised charge current density of 107 A cm-2. Such large spin currents precipitate rapid recovery of magnetic order after optical pumping. The magnon processes discussed here provide new insights for the stabilization of desired meta-stable states.

Large orbital magnetic moments of small, free cobalt cluster ions Co[Formula: see text] with n [Formula: see text]

The size dependent electronic structure and separate spin and orbital magnetic moments of free Co[Formula: see text] ([Formula: see text]) cluster ions have been investigated by x-ray absorption and x-ray magnetic circular dichroism spectroscopy in a cryogenic ion trap. A very large orbital magnetic moment of [Formula: see text] per atom was determined for Co[Formula: see text], which is one order of magnitude larger than in the bulk metal. Large orbital magnetic moments per atom of  ≈1 [Formula: see text] were also found for Co[Formula: see text], Co[Formula: see text], and Co[Formula: see text]. The orbital contribution to the total magnetic moment shows a non-monotonic cluster size dependence: The orbital contribution increases from a local minimum at n  =  2 to a local maximum at n  =  5 and then decreases with increasing cluster size. The 3d spin magnetic moment per atom is nearly constant and is solely defined by the number of 3d holes which shows that the 3d majority spin states are fully occupied, that is, 3d hole spin polarization is 100%.

[Renal transplantation: Opportunities and risks for medical refugees]

BACKGROUND

Families with children and adolescents with end-stage renal disease came to Germany from the former Eastern Bloc countries before the wave of refugees in 2015, in order to enable their children to survive with adequate kidney replacement therapy and in the best case a kidney transplant.

METHODS

In a case study, medical records of 4 childen and adolescents were retrospectively analyzed. These patients who fled to Germany for the treatment of terminal renal failure applied for asylum and were successfully transplanted after the usual waiting period.

RESULTS

Four of the eight children and adolescents who came to Erlangen for treatment of terminal renal failure between 2003 and 2013 received a functioning kidney transplant (deceased donor kidney) after dialysis therapy was difficult due to lack of compliance to drug and dietary recommendations such as fluid restriction. Since children and adolescents are treated with chronic dialysis only with the aim of kidney transplantation, a living donation was discussed but was not possible for medical reasons. 3 recipients are symptom-free with a functional graft.

DISCUSSION

The case study demonstrates that children and adolescents fleeing to Germany due to their end stage renal disease are better integrated after kidney transplantation, have better chances of obtaining a good education and can be expected to live independently with their own income in the future.

Does additional patella tendon shortening influence the effects of multilevel surgery to correct flexed knee gait in cerebral palsy: A randomized controlled trial

BACKGROUND

The aims of this study were to investigate if patellar tendon shortening (PTS) as a part of SEMLS (single event multilevel surgery) is effective for reduction of flexed knee gait in children with cerebral palsy (CP) and, if PTS leads to stiff knee gait.

METHODS

In a randomized controlled study 22 children with flexed knee gait (age: 10.4 ± 2.6 years, GMFCS Level I-III) were randomized and allocated to two groups (1: SEMLS + PTS; 2: SEMLS no PTS): SEMLS was performed for correction of flexed knee gait either with or without additional PTS. Before and after surgery (follow up: 12.7 ± 1.6 months) kinematics (3-D motion analysis) and clinical parameters were compared.

RESULTS

Two children were lost to follow up. Maximum knee extension improved significantly in both groups after SEMLS while the patients with additional PTS showed much more correction (SEMLS + PTS: 37.6° to 11.4°, p = 0.007; SEMLS no PTS: 35.1° to 21.8°, p = 0.016). After surgery peak knee flexion decreased significantly (14.6°, p = 0.004) in the "SEMLS + PTS" group while there was no relevant change in the other group. There was a trend of increase in anterior pelvic tilt after surgery in both groups, but no statistical significant difference. After surgery knee flexion contracture (15.9°, p < 0.001) and popliteal angle (27.2, p = 0.009) measured on clinical examination only decreased significantly in the "SEMLS + PTS" group.

CONCLUSION

PTS is effective for correction of flexed knee gait and knee flexion contracture leading to superior stance phase knee extension. However, additional PTS may lead to stiff knee gait and a higher increase of anterior pelvic tilt.

[Aortofemoral vascular graft infections and their prevention]

Vascular prosthesis infections are potentially severe adverse events following vascular reconstruction. They are often associated with a high morbidity and mortality, especially in the aortofemoral region. The present article outlines the diagnosis, prevention and treatment of vascular graft infections in a clinical setting. The clinical presentation, inflammatory markers, microbiological work-up and imaging studies can contribute to diagnosing a prosthesis infection. Regarding the bacterial spectrum involved in the etiology of prosthesis infections, single organism infections (monoinfections) have become less significant over the past years, whereas infections with multiple organisms now constitute the most abundant microbiological constellation. Also, infections with resistant bacterial strains have been increasing in number over the past years and deserve special consideration. It remains unclear whether both aspects are due to a true epidemiological change or are the result of advanced molecular microbiological diagnostic methods. While during the past decades perioperative antibiotic prophylaxis was regarded as the most important measure for preventing prosthesis infections in vascular surgery, other primary preventive hygiene strategies have been increasingly explored and grouped together in the sense of preventive bundles. In most cases of deep postoperative infections involving a prosthetic device in the aortofemoral region, explantation of the prosthesis will be required. In situ and extra-anatomical reconstructions are often performed in such cases and the decision process to develop an optimal treatment plan must consider several individual factors. In select patients, palliative preservation of the prosthesis despite surrounding infection (i.e. graft salvage) and best conservative management in combination with local surgical measures, such as incision and drainage and vacuum therapy, deserve consideration as a treatment option for patients with a high surgical risk.

Magnetic moments of chromium-doped gold clusters: the Anderson impurity model in finite systems

The magnetic moment of a single impurity atom in a finite free electron gas is studied in a combined x-ray magnetic circular dichroism spectroscopy, charge transfer multiplet calculation, and density functional theory study of size-selected free chromium-doped gold clusters. The observed size dependence of the local magnetic moment can be understood as a transition from a local moment to a mixed valence regime. This shows that the Anderson impurity model essentially describes finite systems even though the discrete density of states introduces a significant deviation from a bulk metal, and the free electron gas is only formed by less than 10 electrons. Electronic shell closure in the gold host minimizes the interaction of localized impurity states with the confined free electron gas and preserves the magnetic moment of 5 μ_{B} fully in CrAu_{2}^{+} and almost fully in CrAu_{6}^{+}. Even for open-shell species, large local moments are observed that scale with the energy gap of the gold cluster. This indicates that an energy gap in the free electron gas stabilizes the local magnetic moment of the impurity atom.

[Sexual risk behaviour of nursing students. A cross-sectional study at nursing schools in Saxony-Anhalt]

AIM

This work describes the sexual risk behaviour of nursing students.

METHODS

22 of 23 state-approved nursing schools in Saxony-Anhalt, Germany, participated in this cross-sectional study (study period 7/2005-5/2006). Participation was voluntarily and anonymous.

RESULTS

More male than female students (59.6% vs. 44.8%) used condoms to prevent STIs. More female students (58.9% vs. 43.4%) reported constant partnership with just one partner as an STI prevention method (chi² test, p<0.005). 29.6% of the nursing students reported >1 sexual partner in the past 12 months. 3.9% of the students demanded an HIV test from the partner, 69.3% had never tested themselves for HIV. 10.2% used no prevention against STIs.

CONCLUSIONS

Nursing students should be sensitised for sexual risk behaviour and STIs. This should be included in the content of teaching throughout the education, not least since nursing students are multiplicators and have an influence on health behaviour of the patients.

Indications and techniques for emergency carotid interventions

Mutual understanding exists among specialists of neurology, interventional radiology and vascular surgery concerning the need of interventional treatment for patients with symptomatic carotid artery stenosis. However, identification of individuals that will most likely benefit from treatment, timing of the intervention and selection of treatment mode continue to be a matter of intense debate. The aim of this manuscript was to discuss the changing attitude to this high-risk population and present evidence that points towards a resolute, fast-track approach.

Spin coupling and orbital angular momentum quenching in free iron clusters

Magnetic spin and orbital moments of size-selected free iron cluster ions Fe{n}{+} (n=3-20) have been determined via x-ray magnetic circular dichroism spectroscopy. Iron atoms within the clusters exhibit ferromagnetic coupling except for Fe{13}{+}, where the central atom is coupled antiferromagnetically to the atoms in the surrounding shell. Even in very small clusters, the orbital magnetic moment is strongly quenched and reduced to 5%-25% of its atomic value while the spin magnetic moment remains at 60%-90%. This demonstrates that the formation of bonds quenches orbital angular momenta in homonuclear iron clusters already for coordination numbers much smaller than those of the bulk.

Local anesthesia and exposure for carotid endarterectomy: background and technical realization

While carotid endarterectomy is an established method for the treatment of symptomatic as well as high-grade asymptomatic carotid artery stenoses, there is a considerable variation concerning the kind of anesthesia used as well as technical details of the operation. In the present article differing arguments on local versus general anesthesia as well as a transverse versus a longitudinal skin incision will be discussed. Furthermore, possible access routes to the carotid bifurcation, the retrojugular compared to the ventrojugular approach, will be presented in detail.

Comparison of enoxaparin and unfractionated heparin in endovascular interventions for the treatment of peripheral arterial occlusive disease: a randomized controlled trial

BACKGROUND

Although unfractionated heparin (UFH) is an effective antithrombotic agent in endovascular interventions for the treatment of peripheral occlusive arterial disease (PAOD), it produces a highly variable anticoagulant response. Intravenous (i.v.) enoxaparin might be an effective and safe alternative.

PATIENTS AND METHODS

In a prospective, open-label, randomized, single-center trial, 210 patients with PAOD (Fontaine stage IIb to IV) were randomly assigned in a 1 (UFH): 2 (enoxaparin) fashion to receive an i.v. bolus of 60 units UFH per kg body weight or 0.5 mg enoxaparin per kg body weight, respectively, before endovascular intervention. The primary composite endpoint assessed the clinical performance of enoxaparin by comparing the peri-interventional rate of thromboembolia/occlusion (efficacy) of endovascularly reconstructed areas, of bleeding according to the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) criteria (safety) and of any necessary re-intervention for any percutaneous transluminal angioplasty (PTA)-related bleeding. The secondary endpoint evaluated anti-factor (F)Xa levels during intervention.

RESULTS

The primary composite endpoint showed a better performance of enoxaparin (10.5% vs. 2.5% absolute difference - 8.0%; P < 0.05). The concomitant use of acetylsalicylic acid (ASA) significantly (P < 0.05) increased the risk of a complication in the UFH group, but not in the enoxaparin group. Within 15 min, anti-Xa levels were reached by 63.7% of patients treated with enoxaparin and only by 39.1% with UFH.

CONCLUSION

Enoxaparin has a better performance than UFH in endovascular interventions for the treatment of PAOD. In patients with concomitant use of ASA, the risk of complications with UFH increases significantly compared with enoxaparin.

Size dependence of L2,3 branching ratio and 2p core-hole screening in x-ray absorption of metal clusters

Resonant 2p x-ray absorption spectra of size-selected transition metal ions and clusters consisting of 1<or=n<or=200 atoms are reported. Remnants of atomic multiplet splitting in L(2,3)-edge x-ray absorption can be resolved up to the trimer, above which the overall line shape is already bulklike. A strong cluster size dependence of the L(2,3) branching ratio was found for titanium, vanadium, and cobalt clusters. While 3d electron delocalization increases with cluster size, the apparent 2p spin-orbit splitting remains constant within the error bars. The size dependence of the L(2,3) branching ratio can be attributed to cluster size specific screening of the 2p-3d Coulomb interaction by 3d/4s valence electrons.

Eosinophilic cellulitis (Wells' syndrome) associated with colon carcinoma. Kolon-Karzinom assoziierte Eosinophile Zellulitis (Wells' Snydrom)

Eosinophilic cellulitis (Wells' syndrome) is an inflammatory dermatosis characterized by marked eosinophilic infiltrates. Drugs and various infections are recognized causes of eosinophilic cellulitis. Eosinophilic cellulitis has been reported in non-hematological malignancies in two patients with squamous cell carcinoma and one with nasopharyngeal carcinoma. We report the association of eosinophilic cellulitis with adenocarcinoma of the colon. Curative hemicolectomy led to a complete remission, suggesting that underlying malignancies can trigger eosinophilic cellulitis.

Effect of purified allicin, the major ingredient of freshly crushed garlic, on cancer cell proliferation

The diverse health benefit effects of garlic include its anticancer activity. However, very little is known about such activity of isolated garlic compounds, among which allicin (the major ingredient of crushed garlic) has been the least studied. The aim of this work was to determine whether pure allicin exhibits the antiproliferative effect reported for garlic in in vitro models. Allicin, but not its precursor alliin, inhibited proliferation of human mammary (MCF-7), endometrial (Ishikawa), and colon (HT-29) cancer cells (50% inhibitory concentration = 10-25 microM). Two of three tested primary lines of human fibroblasts displayed a similar response to allicin (50% inhibitory concentration = 16-40 microM), whereas the third line was almost unaffected by this compound. The pure allicin and water extract of garlic powder with equivalent allicin concentrations displayed a similar potency, suggesting that allicin is responsible for the antiproliferative effect of the extract. The growth inhibition was accompanied by accumulation of cells in the G0/G1 and G2/M phases of the cell cycle (MCF-7 cells) and not by a significant increase in cell death. Allicin caused a transient drop in the intracellular glutathione (GSH) level, the magnitude and kinetics of which significantly varied depending on cell type. The extent of the decrease in GSH levels correlated well (r = 0.75) with the growth inhibitory activity of allicin. On the basis of these findings, we suggest that allicin plays a major role in the antiproliferative effect of water-soluble garlic preparations and that this effect may be attributed to the ability of allicin to transiently deplete the intracellular GSH level.

Transmyocardial laser revascularization remodels the intrinsic cardiac nervous system in a chronic setting

BACKGROUND

Prospective trials have demonstrated that transmyocardial laser revascularization (TMLR) imparts symptomatic relief to patients with refractory angina. Because peak clinical effectiveness of TMLR is usually delayed by several months, it has been proposed that ventricular denervation is one mechanism whereby TMLR imparts symptomatic relief. We have demonstrated that TMLR does not denervate the heart in the acute setting, nor does it modify the intrinsic cardiac nervous system (ICNS) in the acute setting. However, the long-term effects of TMLR on the ICNS remain unknown.

METHODS AND RESULTS

A holmium:yttrium-aluminum-garnet laser created 20 channels through the anterolateral left ventricular free wall of 10 dogs. Four weeks later, the function of cardiac sensory inputs to the ICNS was studied by applying veratridine (7.5 micromol/L) to ventricular sensory fields. Chronotropic and inotropic responses elicited by cardiac sympathetic or parasympathetic efferent neurons stimulated electrically (10 Hz, 4 V, 4 ms) or chemically (nicotine 5 to 20 microgram/kg IV) were also assessed. Chemical activation of epicardial sensory neurites with veratridine elicited expected ICNS excitatory responses. Electrical stimulation of sympathetic and parasympathetic efferent neurons induced expected altered cardiac responses. In contrast, the responsiveness of the ICNS to systemically administered nicotine was obtunded.

CONCLUSIONS

Although chronic TMLR does not affect cardiac afferent or extracardiac efferent neuronal function, it does "remodel" the ICNS so that its responsiveness to a known potent chemical agonist (ie, nicotine) becomes obtunded. Remodeling of the ICNS may account in part for the delayed symptomatic relief that TMLR imparts to patients with refractory angina.

Lycopene inhibition of cell cycle progression in breast and endometrial cancer cells is associated with reduction in cyclin D levels and retention of p27(Kip1) in the cyclin E-cdk2 complexes

Numerous studies have demonstrated the anticancer activity of the tomato carotenoid, lycopene. However, the molecular mechanism of this action remains unknown. Lycopene inhibition of human breast and endometrial cancer cell growth is associated with inhibition of cell cycle progression at the G(1) phase. In this study we determined the lycopene-mediated changes in the cell cycle machinery. Cells synchronized in the G(1) phase by serum deprivation were treated with lycopene or vehicle and restimulated with 5% serum. Lycopene treatment decreased serum-induced phosphorylation of the retinoblastoma protein and related pocket proteins. This effect was associated with reduced cyclin-dependent kinase (cdk4 and cdk2) activities with no alterations in CDK protein levels. Lycopene caused a decrease in cyclin D1 and D3 levels whereas cyclin E levels did not change. The CDK inhibitor p21(Cip1/Waf1) abundance was reduced while p27(Kip1) levels were unaltered in comparison to control cells. Serum stimulation of control cells resulted in reduction in the p27 content in the cyclin E--cdk2 complex and its accumulation in the cyclin D1--cdk4 complex. This change in distribution was largely prevented by lycopene treatment. These results suggest that lycopene inhibits cell cycle progression via reduction of the cyclin D level and retention of p27 in cyclin E--cdk2, thus leading to inhibition of G(1) CDK activities.

Adefovir dipivoxil for the treatment of lamivudine-resistant hepatitis B mutants

Lamivudine has been shown to be an effective therapy for chronic hepatitis B, but resistance to this nucleoside agent is common after prolonged use. Five patients with chronic hepatitis B virus (HBV) infection developed resistance to lamivudine after 9 to 19 months of treatment. In 4 patients this occurred after liver transplantation and the remaining individual had stable cirrhosis. In each case, resistance was confirmed to be caused by one or more mutations in the HBV-DNA polymerase gene and was associated with active underlying liver disease. The patients were treated with adefovir dipivoxil in a dose of 5 to 30 mg daily. Two to 4 log(10) reductions in HBV-DNA levels were observed in 4 cases, and the fifth patient became negative by quantitative polymerase chain reaction (PCR) after retransplantation in conjunction with hepatitis B immunoglobulin (HBIg). Virologic improvement was associated with stable or declining serum alanine transaminase levels in 4 patients. HBV-DNA suppression has been sustained during a mean treatment period of 13 months (range 11 to 15 months), including 1 patient in whom lamivudine has been discontinued. Mild changes in renal function were observed during treatment in most cases but did not require early discontinuation of the drug. This study provides evidence that adefovir dipivoxil can be an effective treatment for lamivudine-resistant HBV mutants as well as wild-type HBV.

Surgeon-patient communication in the treatment of pancreatic cancer

BACKGROUND

Effective physician-patient communication has been correlated with patient satisfaction and improved outcome. Pancreatic cancer (PC) is a disease with an overwhelmingly poor prognosis that requires a complex level of communication and emotional support. Since the treatment of PC is often surgical, surgeons play a central role in the care of these patients.

OBJECTIVES

To assess the quality of long- and short-term surgeon-patient communication. To assess the role of the surgeon in the emotional support of patients with PC.

DESIGN

Combined mail and telephone survey of a case series of patients who had undergone a pancreatic resection for PC.

SETTING

Urban tertiary cancer referral center.

PATIENTS

Forty-eight patients who underwent pancreatic resection for PC.

INTERVENTION

Pancreatic resection.

MAIN OUTCOME MEASURE

Patient satisfaction.

RESULTS

Forty-eight patients completed surveys for a response rate of 70%. Patients were extremely satisfied with the information provided by their surgeon before surgery and while in the hospital. However, 21% of patients reported an unexpected outcome of their operation and 27% had questions about their disease at the time of the survey. Patients were largely satisfied with the emotional support they had received while in the hospital and after discharge. The attending surgeon was the most commonly desired source of additional emotional support.

CONCLUSIONS

While surgeon-patient communication was extremely effective before surgery and during hospitalization, patients developed long-term questions and dissatisfaction after discharge from the hospital. Strategies to improve long-term support and communication would benefit a significant number of patients with operable PC. Surgeons play an important role in the emotional support of patients with operable PC.

The fate of retained gallstones following laparoscopic cholecystectomy in a prairie dog model

BACKGROUND AND OBJECTIVES

Reported complications of retained gallstones following laparoscopic cholecystectomy (LC) are increasing. This study was undertaken to evaluate the effects of retained gallstones following LC in a prairie dog model.

METHODS

Twenty-seven prairie dogs with diet-induced gallstones were divided into three groups of nine. Group I (control) had LC with removal of stones. Group II had LC followed by return of native stones intra-abdominally. Group III had LC followed by return of infected stones (stones dipped in Escherichia coli) intra-abdominally. Animals were euthanized at two months and the character and extent of intra-abdominal adhesions were scored.

RESULTS

Adhesions were present in 56% of animals in Group I, 89% in Group II, and 100% in Group III. The character and extent of adhesions in groups II & III were significantly greater than the control group (p < 0.03). Group III exhibited the highest degree of adhesions when compared to control (p < 0.007). Histopathology revealed evidence of micro-abscess formation, foreign body giant cell reaction, and fat necrosis adjacent to retained stones.

CONCLUSION

Retained intra-abdominal gallstones, especially if infected, are associated with increased adhesions and inflammatory response in this LC model. Further investigation into the long-term consequences of this entity is warranted.

Blunt abdominal trauma in children: risks of nonoperative treatment

This retrospective study includes 203 children who had intraabdominal injuries after blunt trauma, mainly bicycle accidents and falls. Of 145 patients with splenic injury, seven underwent surgery. There was a 100% splenic salvage rate. Twenty-nine children had hepatic injury and four underwent laparotomy. One patient who was initially treated conservatively had a complicated clinical course with rebleeding that led to two laparotomies. Three of 10 pancreatic injuries were operated on; one of them 4 weeks after the trauma because of a pseudocyst. Nineteen patients had gastrointestinal tract injuries. Of seven intramural hematomas, five were treated nonoperatively. Twelve patients had gastrointestinal perforations. Seven underwent laparotomy without delay. Three patients underwent surgery 24 hours after admission because of severe abdominal rigidity or pneumoperitoneum. There was one case of severe in-hospital delay in which splenic and hepatic injuries were thought to account for the physical findings. At laparotomy 36 hours after admission, a jejunal rupture and necrosis of the transverse colon were found. Nonoperative management of blunt abdominal trauma has been very successful regarding splenic ruptures. Conservative management of hepatic injuries is more hazardous, and treatment of pancreatic injuries is a matter of controversy. Gastrointestinal-tract perforations are difficult to diagnose and important to bear in mind while keeping a conservative attitude toward abdominal trauma.

Prophylactic antibiotics in uncomplicated appendicitis during childhood--a prospective randomised study

544 children operated upon for uncomplicated appendicitis were randomised into three groups. Group I received no antibiotics, patients in Group II were administered one single pre-operative dose of metronidazole (10 mg/kg) and patients in Group III received both both metronidazole (20 mg/kg) and cefuroxime (50 mg/kg) in a single preoperative dose. The rate of infectious complications in Group I was 6.3% but only 2.1 and 2.3 in Groups II and III, respectively. Among patients with a normal appendix or patients with simple appendicitis there was no difference in the rate of post-operative infections between the three different groups. However, in patients with gangrenous appendicitis the rate of postoperative infections was significantly lower in the two groups who received preoperative antibiotics (1.8% and 3.0% respectively) than in the group receiving no prophylactic antibiotics (infection rate 14%). It is concluded that a single preoperative dose of metronidazole significantly decreases the rate of postoperative infectious complications in children with appendicitis. No further improvement could be demonstrated if cefuroxime against aerobic organisms was added.

Optimization of irradiation conditions for photon activation analysis of biological and environmental samples using a high power electron accelerator

Using the bremsstrahlung flux density data of Tanaka et al. (1983), the PHOTAC code has been developed to calculate the activity induced in a sample during photon activation as a function of the geometrical arrangement of the electron energy and the beam profile. Some results are given for sample volumes from 1 to 1000 cm3 and sample distances from 1 to 10 cm at 25 MeV. Examples for the application of the PHOTAC code to estimate the maximum activity output and to minimize the heating up of the sample during irradiation are discussed.

High rejection ruby filter for laser light scattering experiments

A rejection filter against stray ruby laser light in scattering experiments is described. It consists of an array of sixty-four ruby crystal cubes with a doping of up to 2.3 wt. % of chromium oxide. The filter is 15 mm thick. Suppression factors of more than 10(6) are achieved with individual cubes (5 x 5 x15 mm(3)), the effective overall suppression of the assembled array being 10(4). The filter facilitates Raman calibration of the lidar Thomson scattering system of the JET tokamak.

[Stress-induced changes in blood glucose level in normotensive Wistar-Kyoto rats (WKY) and spontaneously hypertensive rats (SHR) aged 13-14 and 26 weeks]

In normotensive WKY-rats and spontaneously hypertensive rats relations were investigated between the general stress related behaviour of adaptation and the blood glucose level under fasting condition. In respect to the level of blood glucose differences were existent specifically depending on age and strain. Compared with WKY-rats, spontaneously hypertensive rats on the same age had shown a higher stress related increase of blood glucose level. Furthermore an age depending increase of blood glucose level was found in both SHR and WKY-rats. These differences depending on strain and age are discussed including the further results about the influence of peptides on catecholamins and blood pressure regulation.

Carcinoma within urethral diverticula

Because diagnosis of urethral diverticulum is often elusive the presence of a tumor within the diverticular cavity may be overlooked until it has grown beyond the confines of the diverticulum. A search of the medical records from 1940 to 1975 at the University of California Medical Center in San Francisco and Alta Bates Hospital in Berkeley has revealed only 3 cases of carcinoma within a urethral diverticulum. Two are presented here and the third was reported by Hinman in 1960. The paucity of cases in the literature reflects the rarity of such location for the tumor--or, perhaps, rather its evasive diagnostic nature. Undoubtedly, many cases are unreported but the important message for the clinician is that he suspect a urethral diverticulum (with the possibility of underlying neoplasm) in any patient with unexplained persistent irritative symptoms of the lower genitourinary tract.