Limits and chances in an unfortunate course of recurrent orbital rhabdomyosarcoma

BACKGROUND

Orbital rhabdomyosarcoma (RMS) in childhood has an excellent survival rate after chemotherapy and radiation, and mutilating surgery can often be avoided.

CASE REPORT

As a rarity we present an unfortunate disease course in a child suffering from orbital embryonal RMS which did not enduringly respond to multimodal therapy including local excision and exenteration orbitae. After short intervals and despite tumor-free margins, orbital RMS recurred twice and led to an extended exenteration orbitae including the bony margins. Because of the lack of standards for adjuvant therapy in cases of recurrences after exenteration orbitae, therapy had to be restricted to a wait- and- see strategy as the only chance of tumor control.

CONCLUSION

Although survival rates of orbital RMS are high, the possibility of recurrence should not be underestimated. In cases of refractory RMS, new concepts are needed to offer further chances for survival.

The impact of psychiatric comorbidity on quality of life in patients undergoing herniated disc surgery

BACKGROUND

Recent studies examined the role of psychiatric comorbidity in the process of rehabilitation in patients undergoing herniated disc surgery. These patients suffer from physical and psychosocial complaints or symptoms, which impact their everyday life negatively and the success of rehabilitation potentially. The objectives of this study are (1) to examine the quality of life (QoL) in disc surgery patients and to compare the findings with reference data from the general German population, and (2) to investigate the impact of psychiatric comorbidity on QoL of patients undergoing herniated disc surgery.

METHODS

This study consists of 305 patients aged between 18 and 55 years who took part in face-to-face interviews during their hospital stay. Psychiatric comorbidity was assessed with the Composite International Diagnostic Interview (CIDI-DIA-X). By means of the 36-Item Short-Form Health Survey (SF-36), QoL was assessed in patients undergoing herniated disc surgery with and without psychiatric comorbidity. These findings were compared with the QoL of a representative sample of the general German population.

RESULTS

Compared with the general population, QoL in patients with herniated disc surgery was lower in all domains of the SF-36. Psychiatric comorbidity impacts the QoL in patients with herniated disc surgery in all SF-36 domains except "physical function". The patients with psychiatric comorbidity showed significantly lower levels of QoL in the domains "bodily pain", "vitality", "social function", "role emotional", and "mental health".

CONCLUSIONS

Psychiatric comorbidity has a substantial adverse effect on QoL in patients undergoing disc surgery. Therefore, it will be necessary to diagnose psychiatric comorbidities at an early stage and to include psychosocial interventions in the treatment of herniated disc patients aimed at improving deficits in psychosocial functioning and QoL.

Two times unlucky: treatment of repeated adjacent vertebral fractures following posterolateral interbody fusion

Posterolateral interbody fusion with cages and posterior fixation is a widespread, accepted method in the treatment of lumbar instability with and without spinal stenosis. Adjacent level instability was occasionally detected in the neighbouring discs. A fracture of the adjacent vertebral body including the upper disc was not reported in the literature. The authors describe a case of a female patient with two time fractures in the adjacent levels-nontraumatic and traumatic-after posterolateral fusion. Recommendations regarding the operative treatment were given.

[Experiences with surgical management of facial basal cell carcinoma and procedures for plastic reconstruction]

BACKGROUND

No recurrences and optimal aesthetic outcomes after R0 resection and plastic reconstruction of the face are the goals in the surgical treatment of basal cell carcinoma. The aim of this study was to evaluate recurrence rates and to evaluate different reconstructive techniques.

PATIENTS AND METHODS

This study included 205 follow-up patients undergoing R0 resection of primary basal cell carcinoma and facial skin reconstruction between 1998 and 2002; data were analyzed retrospectively.

RESULTS

The most frequent locations of basal cell carcinoma were the nasal (40.5%) and orbital (22.9%) regions. The rate of recurrence after 2.5 years (6 months-5 years) was 7.3%. Local flaps, full-thickness skin grafts, and sliding flaps were usually performed; indications for split-thickness skin grafts were rare. Disturbances of sensation were found in only 3.6% of the sliding flaps and in 11.7% of the local flaps, but 22.7% in full-thickness and 38.7% in split-thickness skin grafts. The aesthetic outcome, evaluated by clinical inspection and a patient satisfaction score, was classified as "unobtrusive" and "good or excellent" for 88.4% of local flaps, 92.6% of sliding flaps, but only for 66.4% of full-thickness and 54% of split-thickness skin grafts.

CONCLUSION

Local flaps and sliding flaps result in better aesthetic and neurological outcomes after reconstruction of facial skin regions. Skin grafts have their indications as an alternative procedure in cases of critical indications for flaps.

Microstructure formation in dip-coated particulate films

The microstructure-dependence of dip-coated particulate thin films on the stability of an aqueous silica sol used as coating bath is studied. Different stability conditions are adjusted in the sol by changing electrolyte concentration and pH value. Care was taken to avoid pronounced aggregation of the particles before the coating process. The characterization of the stability behavior gives clear evidence of a non-DLVO contribution at low pH values that is attributed to hydration forces. Structural evolution of the particulate network during film formation is studied using a dialysis accumulation procedure. The viscosity of the accumulated sol is measured as a function of shear rate and related to the drying characteristic of the coating process. Atomic force microscopy (AFM), small-angle X-ray scattering (SAXS) and N2 sorption are used to obtain information on the surface and volume structure of the dip-coated films. The structure of coatings is found to distinctly vary with stability parameters. This is attributed to changing interactions during the first drying stage. Finally, the influence of coating structures on the light transmission properties is determined. A comparison between the extinction of the uncoated and the coated substrate revealed a difference of up to +/-50% in dependence on the microstructure.

Glucagon Expression Shift in a Syngeneic Single-Donor Intrahepatic Rat Islet Transplantation Model

In the native rat pancreas glucagon is expressed by alpha cells in the outer layer of the spheroid islet, producing a circular immunohistochemical staining pattern. We asked whether this pattern would remain unchanged after short-term and long-term intrahepatic islet transplantation. Islets of inbred Lewis rats were isolated with liberase, purified by discontinuous density gradients, handpicked, and cultured for 24 hours. After rats were rendered diabetic with streptozotocin, islets were implanted intraportally. Transplanted animals were sacrificed at 1 to 2 days (n = 5) or 100 days (n = 6). Islet clusters were detected by hematoxylen-and-eosin staining. Serial slides were stained for glucagon and insulin with the alkaline phosphatase and alkaline phosphate method at 1 to 2 days after transplantation islets with strong insulin expression were found within the portal vein branches. However, glucagon staining showed an incomplete circular staining pattern. After 100 days insulin expression remained strong, whereas only few glucagon-expressing cells were detected. Intrapancreatic islets showed inversion of the ratio of insulin- to glucagon-positive cells in favor of the glucagon-expressing cells that now composed the major part of the islet. Streptozotocin had selectively damaged beta cells in the recipient. In transplanted islets glucagon expression faded over time, possibly due to a functional involution process or to stress/inflammatory mechanisms during the isolation, transplantation, and the posttransplantation periods.

Pierre-Robin-Sequenz — postoperative Komplikationen nach Gaumenspaltverschluss

BACKGROUND

In a 25-year retrospective review of 1976-2000, the postoperative course after cleft palate surgery and pharyngeal flap surgery in 87 children with Pierre Robin sequence was studied.

PATIENTS AND METHODS

The study comprised 114 interventions with 87 primary palatoplasties; 17 patients required palatal fistulae repair and 10 children were treated with secondary pharyngoplasty procedures. All children were divided into three postnatal risk groups according to the severity of their symptoms at birth and in the course of the early months of life.

RESULTS

A direct correlation was seen between the incidence of early postnatal difficulties and the postoperative obstructive complications after cleft palate surgery and pharyngeal flap surgery. Thus, children experiencing obstructive problems at birth (high postnatal risk group) displayed more severe complications at the time after cleft palate repair. In children undergoing pharyngeal flap surgery not only early postoperative obstruction but also late obstructive sleep apnea can occur.

Heme oxygenase-1 protects pancreatic beta cells from apoptosis caused by various stimuli

BACKGROUND

Several problems can occur after allogeneic islet transplantation: primary nonfunction, rejection, and the recurrence of autoimmune disease, which involve attack by the recipient's cytokines, T cells, natural killer cells, and monocytes on the donor's beta cells, which leads to beta-cell destruction. Recent studies have revealed that loss of transplanted islets is caused mainly by apoptosis. Heme oxygenase-1 (HO-1) is one of the antiapoptotic genes up-regulated under stress conditions. The aim of this work was to investigate any mechanisms of HO-1-mediated protection of beta cells from apoptosis.

METHODS

Apoptosis was assessed by comparison of viable transfected cells with and without apoptotic stimuli, and with and without HO-1 overexpression. Activation and function of p38 mitogen-activated protein kinase were determined using the specific inhibitor SB203580.

RESULTS

We have shown that HO-1 mediates antiapoptotic effects in beta cells. The percentage of apoptotic cells after stimulation with tumor necrosis factor a decreased from 75% without HO-1 to 5% when HO-1 was overexpressed. Our data indicate that HO-1 acts as a signal terminator of tumor necrosis factor alpha-induced apoptosis by modulation of the p38 mitogen-activated protein kinase pathway.

CONCLUSIONS

Profound cell stress that occurs in islets after transplantation, as well as at the onset of diabetes, results in beta-cell loss through apoptosis. Protection of beta cells by HO-1 improves their survival in vitro after various proapoptotic stimuli, suggesting that HO-1 suppresses one or several signaling pathways leading to apoptosis. We hypothesize that our in vitro findings can be extrapolated to the in vivo situation, and we propose that expression of HO-1 in islets may illuminate a valuable new approach to improving diabetes treatment.

[Associated anomalies in lip-maxillopalatal clefts]

BACKGROUND

Retrospective studies of cleft lip and palate patients suggest a multifactorial aetiology for this condition. Many patients exhibit multiple defects, often removed from the orofacial region. The frequency and location of such coexistent abnormalities vary between studies.

PATIENTS

A retrospective case-note study of 1,737 individuals with orofacial cleft, treated between 1974 and 1998 at our centre, was undertaken to assess the frequency of associated malformations and syndromes.

RESULTS

Associated malformations were found to be present in 33% of all cases investigated. In nearly one half of these individuals (48%), defects could be attributed to recognisable syndromes. Patients with isolated palatal clefts (45.6%) and those with bilateral clefts of the lip and palate (35.3%) were particularly well-represented. The following problems were observed relatively frequently: Cerebral anomalies (16%), facial anomalies (14%), heart malformations (15%), anomalies of the extremities (9%) and urogenital tract abnormalities (8%). In contrast, endocrine aberrations were identified sporadically (0.5%). A partial situs inversus was found only in one case.

CONCLUSION

As clefts of the lip and palate are frequently associated with additional malformations, the importance of thorough interdisciplinary neonatal screening cannot be over emphasised.

Technique and feasibility of a dual staining method for estrogen receptors and AgNORs

A new staining method for dual demonstration of Estrogen receptors (ER) and argyrophilc Nucleolus-Organizer Regions (AgNORs) was developed. To rule out possible reciprocal effects, serial slides of 10 invasive ductale breast cancers were stained with either the single staining method or the simultaneous ER/AgNOR-staining method and investigated comparatively. By measuring the slides with the image analysis system AMBA, reciprocal effects could be excluded. It was proven that dual staining of both markers results in a reproducible and specific staining result. We concluded that it is justified to measure AgNORs in immunohistochemically stained cells.

Different proliferation patterns in breast cancer: AgNOR measurements in ER-negative and ER-positive tumor cells

The relation between estrogen receptors (ER) and argyrophilic nucleolar organizer regions (AgNORs) in situ within human breast cancer cells was analyzed. For AgNOR measurements in 49 invasive breast carcinomas, a new reproducible staining method for dual demonstration of ER and AgNORs was applied. Quantitative AgNOR variables were determined in ER-positive and ER-negative tumor cells by digital image analysis. The relationships between AgNOR parameters of ER-positive and ER-negative cells and other prognostic factors of breast cancer [Bloom-Richardson-Grading and growth fraction (Ki-67 index)] were investigated. A higher AgNOR content in ER-negative cells and a special clustering phenomenon in ER-positive tumor cells were found. Correlation with other criteria of malignant potential could be exclusively demonstrated for ER-negative cells. ER-negative cells of breast cancer can be characterized as the more malignant and possibly prognosis-dictating cell fraction. Thus, ER-negative cells probably contribute more to the progression of the tumor disease and furthermore to the prognosis than ER-positive cells. We recommend measurement AgNORs exclusively in ER-negative cells of breast cancer.

[The sitting position in neurosurgical operations. Results of a survey]

METHODS

In February 1995 a questionnaire was sent out on perioperative management during neurosurgical operations performed in the sitting position to 136 centres and hospitals within the Federal Republic of Germany that perform neuroanaesthesia. The response rate was 61.02%. Besides the question of perioperative monitoring during neurosurgical operations in the sitting position, we asked about currently used positions for patients during the following neurosurgical operations:posterior fossa, craniospinal and posterior cervical surgery.

RESULTS

Of all centres, 32.9% use the sitting position only for posterior fossa and craniospinal surgery. For posterior cervical surgery the sitting and prone positions are favoured by 25.6% of all clinics. Nonspecific basic monitoring (electrocardiogram, pulse oximetry, central venous pressure, invasive or noninvasive arterial pressure) is an accepted standard in all clinics. Capnometry, as a specific monitor for venous air embolism, is used in all centres (100%). Precordial Doppler ultrasound (US) monitoring is used in 69.2% of all clinics; 3.8% use transoesophageal Doppler US as a diagnostic method for venous air embolism.

DISCUSSION

The sitting position is the preferred position for posterior fossa and craniospinal surgery in neurosurgical patients in Germany. For posterior cervical surgery the German centres use both the sitting and prone positions. Alternative positions like the lateral or the "park-bench" positions are hardly ever used. The essential monitoring devices for neurosurgical operations in the sitting position, as recommended after the survey by the German Society for Anaesthesiology and Intensive Care Medicine (DGAI) in 1995, are predominantly used. However, the use of Doppler US (precordial or transoesophageal) for the detection of venous air embolism and the preoperative diagnosis of a persistent foramen ovale is not yet widespread.

CONCLUSIONS

To determine the effect of the recommendations by the DGAI on clinical practice, the survey will be repeated in 1997.

[Severe pulmonary complications following venous air embolism in neurosurgical operations in sitting position--2 case reports]

The occurrence of air embolism during neurosurgical operations in sitting position is described in two cases. Besides the Doppler ultrasound evidence, relevant effects on the cardiopulmonary situation during surgery were observed, which in one case forced an early end of the operation. Postoperative management in both cases was complicated by a pulmonary oedema. In severe intraoperative cardiopulmonary complications in connection with venous air embolism, the existence of pulmonary oedema should be assumed. Confirmation of the diagnosis and the correct therapy depend upon frequent postoperative chest X-rays.