Spermatogenesis after gonadotoxic childhood treatment: follow-up of 12 patients

STUDY QUESTION

What is the long-term impact of presumed gonadotoxic treatment during childhood on the patient's testicular function at adulthood?

SUMMARY ANSWER

Although most patients showed low testicular volumes and some degree of reproductive hormone disruption 12.3 (2.3-21.0) years after gonadotoxic childhood therapy, active spermatogenesis was demonstrated in the semen sample of 8 out of the 12 patients.

WHAT IS KNOWN ALREADY

In recent decades, experimental testicular tissue banking programmes have been set up to safeguard the future fertility of young boys requiring chemo- and/or radiotherapy with significant gonadotoxicity. Although the risk of azoospermia following such therapies is estimated to be high, only limited long-term data are available on the reproductive potential at adulthood.

STUDY DESIGN SIZE DURATION

This single-centre prospective cohort study was conducted between September 2020 and February 2023 and involved 12 adult patients.

PARTICIPANTS/MATERIALS SETTING METHODS

This study was carried out in a tertiary care centre and included 12 young adults (18.1-28.3 years old) who had been offered testicular tissue banking prior to gonadotoxic treatment during childhood. All patients had a consultation and physical examination with a fertility specialist, a scrotal ultrasound to measure the testicular volumes and evaluate the testicular parenchyma, a blood test for assessment of reproductive hormones, and a semen analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

Testicular tissue was banked prior to the gonadotoxic treatment for 10 out of the 12 included patients. Testicular volumes were low for 9 patients, and 10 patients showed some degree of reproductive hormone disruption. Remarkably, ongoing spermatogenesis was demonstrated in 8 patients at a median 12.3 (range 2.3-21.0) years post-treatment.

LIMITATIONS REASONS FOR CAUTION

This study had a limited sample size, making additional research with a larger study population necessary to verify these preliminary findings.

WIDER IMPLICATIONS OF THE FINDINGS

These findings highlight the need for multicentric research with a larger study population to establish universal inclusion criteria for immature testicular tissue banking.

STUDY FUNDING/COMPETING INTERESTS

This study was conducted with financial support from the Research Programme of the Research Foundation-Flanders (G010918N), Kom Op Tegen Kanker, and Scientific Fund Willy Gepts (WFWG19-03). The authors declare no competing interests.

TRIAL REGISTRATION NUMBER

NCT04202094; https://clinicaltrials.gov/ct2/show/NCT04202094?id=NCT04202094&draw=2&rank=1 This study was registered on 6 December 2019, and the first patient was enrolled on 8 September 2020.

Predictive Factors of Successful Return to Work Following Discectomy

STUDY DESIGN

Retrospective analysis of prospectively collected data.

OBJECTIVE

To identify modifiable factors associated with successful return to work 12 weeks following discectomy. Lumbar disc herniation is a common cause of sciatica and sick leave. This presents an economic burden to the individual and the society.

METHODS

Data from DaneSpine on a consecutive cohort of patients operated due to lumbar disc herniation during a 3-year period was identified and merged with data from the Ministry of Employment's register on public welfare payments. Data on welfare payments 2 years prior to the date of operation and 1 year postoperative was included. Patients were considered to be on sick leave if they received welfare payments for the week. Patients are considered to have returned to work if they did not receive public welfare payments for a 4-week period.

RESULTS

Of 1134 patients meeting inclusion criteria, 98.5% had complete preoperative surgical data available. Postoperatively, 79.1% of the patients returned to the work within 12 weeks. Physically demanding jobs, low preoperative EQ5D score, and long duration of sick leave prior to surgery were associated negatively with return to work at 12 weeks.

CONCLUSION

The results of this study indicate that patients who have a longer duration of sick leave have a physically demanding job and are in a poor health are more likely not to return to work by 12 weeks after surgery for lumbar disc herniation. Future studies are needed to determine if earlier referral to a surgeon leads to an earlier return to work.

[Current developments on digitalization : Analysis of quality and economics in healthcare]

Hintergrund

Im deutschen Gesundheitssystem und damit auch im Fachgebiet der Urologie gewinnen ökonomische Rahmenbedingungen zunehmend an Bedeutung und parallel dazu werden digitale Anwendungen vermehrt eingesetzt.

Fragestellung

Die Fragestellung betrifft die gesundheitsökonomische Auseinandersetzung mit den Rahmenbedingungen der Digitalisierung im deutschen Gesundheitssystem sowie ausgewählter Anwendungsbereiche in der Urologie.

Material und Methoden

Das Gutachten des Sachverständigenrates zur Begutachtung der Entwicklung im Gesundheitswesen (SVR) wird analysiert und eine systematische Literaturanalyse zum Einsatz der strukturierten Befundung und Analyse ausgewählter Literatur zu telemedizinischen Anwendungen in der Urologie unter gesundheitsökonomischen Gesichtspunkten durchgeführt.

Ergebnisse

Als zentrale Hemmnisse bei der Digitalisierung des deutschen Gesundheitswesens identifiziert der SVR dessen Regulierung und Komplexität sowie den Umgang mit Datenschutz und -sicherheit. Der Einsatz strukturierter Befundung kann Qualität, Effektivität und Effizienz der Befundung in der Urologie steigern. Im Hinblick auf die Kosten können signifikante Einsparungen mit zunehmender Digitalisierung in der Medizin realisiert werden.

Schlussfolgerungen

Aus medizinischer und gesundheitsökonomischer Perspektive besteht bei der Ausgestaltung von Rahmenbedingungen für digitale Anwendungen im deutschen Gesundheitssystem hinsichtlich der Informationssicherheit und des Datenschutzes weiterer Gestaltungsbedarf. Bei zielgerichtetem Einsatz von digitalen Anwendungen wie der strukturierten Befundung und der Telemedizin können optimale Voraussetzungen für den zunehmenden Einsatz von künstlicher Intelligenz im Fachgebiet der Urologie geschaffen werden.

Scapular free flap as a good choice for mandibular reconstruction: 119 out of 280 cases after resection of oral squamous cell carcinoma in a single institution

Microsurgical procedures for reconstruction after resection of head and neck tumours have become standardised and reliable. Among them, the scapular free flap is used less often, mostly to avoid excessive operating times. We hypothesise that complex reconstructions after resection of oral squamous cell carcinoma (OSCC) are successful even with time-consuming free flaps such as the scapular free flap. In this retrospective, single-centre study, we used the evaluation of medical records to investigate the postoperative outcome of microvascular reconstruction after ablative surgery of OSCC. Associations among the categorical variables were analysed using Pearson's chi squared test or Fisher's exact test. Among the continuous variables, the t test or Mann-Whitney U test were used as appropriate. For multivariate analysis, the logistic regression model was calculated. In the sample of 280 free flap reconstructions, we performed 142 radial forearm and 119 scapular free flaps. The American Society of Anesthesiology (ASA) score (p=0.006) and the duration of the operation (p=0.010) are independent factors which influence the need for operative revisions. The type of free flap is irrelevant for that. With 4.2% flap losses, scapular free flaps were successful; even in patients ≥ 70 years old (0 flap losses). Complex reconstructions after surgical resection of OSCC are successful even in aged patients. The scapular free flap is a good choice for mandibular reconstruction despite the time-consuming intraoperative repositioning of the patient. In an increasingly ageing group of patients, who have more vascular diseases, scapular free flaps could be a very successful alternative after ablative surgery of oral squamous cell carcinoma.

Characterization of efficacy and safety of pathogen inactivated and quarantine plasma in routine use for treatment of acquired immune thrombotic thrombocytopenic purpura

BACKGROUND

Auto-immune thrombotic thrombocytopenic purpura (TTP) is a morbid multi-organ disorder. Cardiac involvement not recognized in initial disease descriptions is a major cause of morbidity. Therapeutic plasma exchange (TPE) requires exposure to multiple plasma donors with risk of transfusion-transmitted infection (TTI). Pathogen inactivation (PI) with amotosalen-UVA, the INTERCEPT Blood System for Plasma (IBSP) is licensed to reduce TTI risk.

METHODS

An open-label, retrospective study evaluated the efficacy of quarantine plasma (QP) and IBSP in TTP and defined treatment emergent cardiac abnormalities. Medical record review of sequential patient cohorts treated with QP and IBSP characterized efficacy by remission at 30 and 60 days (d) of treatment, time to remission, and volume (L/kg) of plasma required. Safety outcomes focused on cardiac adverse events (AE), relapse rates, and mortality.

RESULTS

Thirty-one patients (18 IBSP and 13 QP) met study criteria for auto-immune TTP. The proportions (%) of patients in remission at 30 d (IBSP = 61·1, QP = 46·2, P = 0·570) and 60 d (IBSP = 77·8, QP = 76·9, P = 1·00) were not different. Median days to remission were less for IBSP (15·0 vs. 24·0, P = 0·003). Relapse rates (%) 60 d after remission were not different between cohorts (IBSP = 7·1, QP = 40·0, P = 0·150). ECG abnormalities before and during TPE were frequent; however, cardiac AE and mortality were not different between treatment cohorts.

CONCLUSIONS

Cardiac and a spectrum of ECG findings are common in TTP. In this study, IBSP and QP had similar therapeutic profiles for TPE.

[Surgical treatment of lumbar disc herniation]

The Danish Health Authority has recently published a new guideline on the treatment of lumbar disc herniation with radiculopathy. This paper goes through the surgical treatment and considers the evidence behind surgical treatment of these patients, along with the outcome reported in literature. The new guideline recommends referring patients to be assessed by a surgeon within 12 weeks in cases, where severe and debilitating pain persists despite non-surgical treatment. This is found to be well in line with literature, as many studies have shown time to be a predictive factor in surgical treatment of these patients.

Return to work after lumbar disc surgery is related to the length of preoperative sick leave

INTRODUCTION

Lumbar disc herniation (LDH) is associated with high morbidity and significant socio-economic impact as the majority of the patients are of working age. The purpose of this study was to determine the impact of length of sick leave on the return-to-work rate after lumbar disc herniation surgery.

METHODS

This was a single-centre study of LDH patients who underwent surgery from 18 May 2009 through 28 November 2014. Data were collected prospectively from the DaneSpine database. Questions in DaneSpine include preoperative length of sick leave and working status one year post-operatively.

RESULTS

A total of 678 patients were included and 72% of the patients had returned to work one year after their surgery. The rate of patients returning to work decreases significantly with the length of preoperative sick leave. Among the patients who were on sick leave prior to their surgery, 83% returned to work if surgically treated within three months. In contrast, only 50% of those whose sick leave exceeded three months returned to work.

CONCLUSION

The present analysis suggests that the return-to-work rate after lumbar disc herniation surgery is affected by the length of sick leave.

FUNDING

none.

TRIAL REGISTRATION

This study was registered with the Danish Data Protection Agency.

Abstract P3-09-04: Beyond CHEK2 in breast cancer: Search for additional moderately penetrant risk gene variants by analyzing the oligogenic disease course in CHEK2 mutation carriers

This abstract was not presented at the symposium.

Abstract P3-08-01: TruRisk® based next-generation sequencing in BRCA1/2-negative breast and ovarian cancer families reveal high mutation prevalence in additional risk genes

Background: 24% of familial breast cancer (BC) and/or ovarian cancer (OC) cases analyzed within the framework of the German Consortium for Hereditary Breast and Ovarian Cancer (GC-HBOC) are due to pathogenic BRCA1/2 mutations. However, the mutation prevalence of non-BRCA1/2 genes associated with familial BC and/or BC/OC is largely unknown. Methods: Here, we present the first NGS data generated using the GC-HBOC-designed TruRisk® gene panel. In this study a cohort of 2028 BRCA1/2 and CHEK2 c.1100delC negative index cases was analyzed which comprises consecutive patients from BC families and BC/OC families complying the inclusion criteria of the GC-HBOC. Sequencing was performed on MiSeq, NextSeq, or HiSeq devices (Illumina) using customized SureSelect XT enrichment (Agilent). Data analysis was carried out using the SeqPilot software (version 4.2.2), SophiaDDM (Version 3.5.0.12-p5.0.0) as well as an in house bioinformatics pipeline (Cologne Center for Genomics, varpipe_v2.X). The analysis of copy number variations (CNV) based on NGS-data is currently in process and not yet included in the present mutation prevalence. Results: By focusing on 22 BC/OC associated genes (ATM, BARD1, BRIP1, CDH1, CHEK2, FAM175A, FANCM, MLH1, MRE11A, MSH2, MSH6, NBN, PALB2, PMS2, PTEN, RAD50, RAD51C, RAD51D, RINT1, STK11, TP53, XRCC2), we identified 71 different deleterious variants in 104 unrelated mutation carriers derived from 2028 BC and BC/OC families (8%). Interestingly, we identified a high prevalence of ATM mutations (n=29, 1.4%) in the familial cases. Additionally mutations in PALB2 (n=27), NBN (n=9), CHEK2 (n=14), BARD1 (n=9), BRIP1 (n=10), RAD51C (n=11) were frequently observed and we confirmed FANCM (n=17) as a novel BC predisposing gene. No mutations in MLH1, MRE11A, PTEN, RAD51D, STK11 and XRCC2 were identified in our collective. Conclusions: Due to the unexpectedly high mutation prevalence in familial cases, our study highlights the importance of these genes to be included in BC/OC routine diagnostics. In contrast we found low occurrence or absence of mutations for a subset of our gene selection which requires further investigation to optimize the gene panel for diagnostic purposes. Nevertheless this approach confirms the TruRisk® gene panel as a reliable tool for this comprehensive analysis.

Citation Format: Keupp K, Richters L, Bülow L, Kröber S, Ernst C, Blümcke B, Versmold B, Waha A, Driesen J, Baasner A, Altmüller J, Thiele H, Nuernberg P, Wappenschmidt B, Neidhardt G, Rhiem K, Schmutzler R, Hahnen E, Hauke J. TruRisk® based next-generation sequencing in BRCA1/2-negative breast and ovarian cancer families reveal high mutation prevalence in additional risk genes [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-08-01.

[Lumbar spinal stenosis]

Lumbar spinal stenosis is the most common reason for spinal surgery in Denmark. Lumbar spinal stenosis is a clinical syndrome of pain in the buttocks or lower extremities, with or without back pain. It is associated with reduced space available for the neural and vascular elements of the lumbar spine. The condition is often exacerbated by standing, walking or lumbar extension and relieved by forward flexion. The options for non-surgical management include drugs and physiotherapy. Treatment outcomes seem to be better for surgical neural decompression than for non-operative treatment.

A molecular model for neurodevelopmental disorders

Genes implicated in neurodevelopmental disorders (NDDs) important in cognition and behavior may have convergent function and several cellular pathways have been implicated, including protein translational control, chromatin modification, and synapse assembly and maintenance. Here, we test the convergent effects of methyl-CpG binding domain 5 (MBD5) and special AT-rich binding protein 2 (SATB2) reduced dosage in human neural stem cells (NSCs), two genes implicated in 2q23.1 and 2q33.1 deletion syndromes, respectively, to develop a generalized model for NDDs. We used short hairpin RNA stably incorporated into healthy neural stem cells to supress MBD5 and SATB2 expression, and massively parallel RNA sequencing, DNA methylation sequencing and microRNA arrays to test the hypothesis that a primary etiology of NDDs is the disruption of the balance of NSC proliferation and differentiation. We show that reduced dosage of either gene leads to significant overlap of gene-expression patterns, microRNA patterns and DNA methylation states with control NSCs in a differentiating state, suggesting that a unifying feature of 2q23.1 and 2q33.1 deletion syndrome may be a lack of regulation between proliferation and differentiation in NSCs, as we observed previously for TCF4 and EHMT1 suppression following a similar experimental paradigm. We propose a model of NDDs whereby the balance of NSC proliferation and differentiation is affected, but where the molecules that drive this effect are largely specific to disease-causing genetic variation. NDDs are diverse, complex and unique, but the optimal balance of factors that determine when and where neural stem cells differentiate may be a major feature underlying the diverse phenotypic spectrum of NDDs.

[Severe constipation caused by an abnormally angled coccyx]

Constipation is a common disease among patients in all age groups, and the pathology can vary. This case report describes a 26-year-old female with severe constipation for six years. She was referred to a centre for spine surgery with a coccyx compressing her rectum causing constipation. The symptoms developed six years previously after a trauma, progressed during pregnancy and after giving birth. X-ray showed a 90-degree anterior angulated coccyx compressing the rectum. She was treated with resection of the coccyx, and symptoms disappeared after surgery.

γ-H2AX foci as in vivo effect biomarker in children emphasize the importance to minimize x-ray doses in paediatric CT imaging

Objectives

Investigation of DNA damage induced by CT x-rays in paediatric patients versus patient dose in a multicentre setting.

Methods

From 51 paediatric patients (median age, 3.8 years) who underwent an abdomen or chest CT examination in one of the five participating radiology departments, blood samples were taken before and shortly after the examination. DNA damage was estimated by scoring γ-H2AX foci in peripheral blood T lymphocytes. Patient-specific organ and tissue doses were calculated with a validated Monte Carlo program. Individual lifetime attributable risks (LAR) for cancer incidence and mortality were estimated according to the BEIR VII risk models.

Results

Despite the low CT doses, a median increase of 0.13 γ-H2AX foci/cell was observed. Plotting the induced γ-H2AX foci versus blood dose indicated a low-dose hypersensitivity, supported also by an in vitro dose–response study. Differences in dose levels between radiology centres were reflected in differences in DNA damage. LAR of cancer mortality for the paediatric chest CT and abdomen CT cohort was 0.08 and 0.13 ‰ respectively.

Conclusion

CT x-rays induce DNA damage in paediatric patients even at low doses and the level of DNA damage is reduced by application of more effective CT dose reduction techniques and paediatric protocols.

Key Points

• CT induces a small, significant number of double-strand DNA breaks in children.

• More effective CT dose reduction results in less DNA damage.

• Risk estimates based on the LNT hypothesis may represent underestimates.

Sex steroids in relation to sexual and skeletal maturation in obese male adolescents

BACKGROUND

Childhood obesity is associated with an accelerated skeletal maturation. However, data concerning pubertal development and sex steroid levels in obese adolescents are scarce and contrasting.

OBJECTIVES

To study sex steroids in relation to sexual and skeletal maturation and to serum prostate specific antigen (PSA), as a marker of androgen activity, in obese boys from early to late adolescence.

METHODS

Ninety obese boys (aged 10-19 y) at the start of a residential obesity treatment program and 90 age-matched controls were studied cross-sectionally. Pubertal status was assessed according to the Tanner method. Skeletal age was determined by an x-ray of the left hand. Morning concentrations of total testosterone (TT) and estradiol (E2) were measured by liquid chromatography-tandem mass spectrometry, free T (FT) was measured by equilibrium dialysis, and LH, FSH, SHBG, and PSA were measured by immunoassays.

RESULTS

Genital staging was comparable between the obese and nonobese groups, whereas skeletal bone advancement (mean, 1 y) was present in early and midadolescence in the obese males. Although both median SHBG and TT concentrations were significantly (P < .001) lower in obese subjects during mid and late puberty, median FT, LH, FSH, and PSA levels were comparable to those of controls. In contrast, serum E2 concentrations were significantly (P < .001) higher in the obese group at all pubertal stages.

CONCLUSION

Obese boys have lower circulating SHBG and TT, but similar FT concentrations during mid and late puberty in parallel with a normal pubertal progression and serum PSA levels. Our data indicate that in obese boys, serum FT concentration is a better marker of androgen activity than TT. On the other hand, skeletal maturation and E2 were increased from the beginning of puberty, suggesting a significant contribution of hyperestrogenemia in the advancement of skeletal maturation in obese boys.

[Implementation of the Danish national database Danespine for spinal surgery]

The purpose of this study was to evaluate the response rate at one year follow-up in Danespine (DS) and the outcome after spine surgery. Medical charts were compared to the number of patients in DS. Outcome was measured in pain reduction for legs/back and the improvement in EuroQol (EQ-5D) score. 99.5% of the patients were registered in DS at the time of surgery, 83.7% at one year follow-up. The mean visual analogue scale score for legs/back declined from 63.2/54.0 to 33.2/34.6. The patients' EQ-5D score improved from 0.33 to 0.62. The complication rate was 12.7%. We have implemented DS in order to evaluate the patient satisfaction after surgery, and the patients' benefit from spine surgery.

Bone size and bone strength are increased in obese male adolescents

CONTEXT

Controversy exists on the effect of obesity on bone development during puberty.

OBJECTIVE

Our objective was to determine differences in volumetric bone mineral density (vBMD) and bone geometry in male obese adolescents (ObAs) in overlap with changes in bone maturation, muscle mass and force development, and circulating sex steroids and IGF-I. We hypothesized that changes in bone parameters are more evident at the weight-bearing site and that changes in serum estradiol are most prominent.

DESIGN, SETTING, AND PARTICIPANTS

We recruited 51 male ObAs (10-19 years) at the entry of a residential weight-loss program and 51 healthy age-matched and 51 bone-age-matched controls.

MAIN OUTCOME MEASURES

vBMD and geometric bone parameters, as well as muscle and fat area were studied at the forearm and lower leg by peripheral quantitative computed tomography. Muscle force was studied by jumping mechanography.

RESULTS

In addition to an advanced bone maturation, differences in trabecular bone parameters (higher vBMD and larger trabecular area) and cortical bone geometry (larger cortical area and periosteal and endosteal circumference) were observed in ObAs both at the radius and tibia at different pubertal stages. After matching for bone age, all differences at the tibia, but only the difference in trabecular vBMD at the radius, remained significant. Larger muscle area and higher maximal force were found in ObAs compared with controls, as well as higher circulating free estrogen, but similar free testosterone and IGF-I levels.

CONCLUSIONS

ObAs have larger and stronger bones at both the forearm and lower leg. The observed differences in bone parameters can be explained by a combination of advanced bone maturation, higher estrogen exposure, and greater mechanical loading resulting from a higher muscle mass and strength.

Protective embolization of the gastroduodenal artery with a one-HydroCoil technique in radioembolization procedures

PURPOSE

Protective occlusion of the gastroduodenal artery (GDA) is required to avoid severe adverse effects and complications in radioembolization procedures. Because of the expandable features of HydroCoils, our goal was to occlude the GDA with only one HydroCoil to provide particle reflux protection.

METHODS

Twenty-three subjects with unresectable liver tumors, who were scheduled for protective occlusion of the GDA before radioembolization therapy, were included. The primary end point was to achieve a proximal occlusion of the GDA with only one detachable HydroCoil. Evaluated parameters were duration of deployment, and early (during the intervention) and late (7-21 days) occlusion rates of GDA. Secondary end points included complete duration of the intervention, amount of contrast medium used, fluoroscopy rates, and adverse effects.

RESULTS

In all cases, the GDA was successfully occluded with only one HydroCoil. The selected diameter/length range was 4/10 mm in 2 patients, 4/15 mm in 6 patients, and 4/20 mm in 15 patients. HydroCoils were implanted, on average, 3.75 mm from the origin of the GDA (range 1.5-6.8 mm), with an average deployment time of 2:47 (median 2:42, range 2:30-3:07) min. In 21 (91%) of 23 patients, a complete occlusion of the GDA was achieved during the first 30 min after the coil implantation; however, in all patients, a late occlusion of the GDA was present after 6 to 29 days. No clinical or technical complications were reported.

CONCLUSION

We demonstrated that occlusion of the GDA with a single HydroCoil is a safe procedure and successfully prevents extrahepatic embolization before radioembolization.

Fusion mass bone quality after uninstrumented spinal fusion in older patients

Older people are at increased risk of non-union after spinal fusion, but little is known about the factors determining the quality of the fusion mass in this patient group. The aim of this study was to investigate fusion mass bone quality after uninstrumented spinal fusion and to evaluate if it could be improved by additional direct current (DC) electrical stimulation. A multicenter RCT compared 40 and 100 μA DC stimulation with a control group of uninstrumented posterolateral fusion in patients older than 60 years. This report comprised 80 patients who underwent DEXA scanning at the 1 year follow-up. The study population consisted of 29 men with a mean age of 72 years (range 62-85) and 51 women with a mean age of 72 years (range 61-84). All patients underwent DEXA scanning of their fusion mass. Fusion rate was assessed at the 2 year follow-up using thin slice CT scanning. DC electrical stimulation did not improve fusion mass bone quality. Smokers had lower fusion mass BMD (0.447 g/cm(2)) compared to non-smokers (0.517 g/cm(2)) (P = 0.086). Women had lower fusion mass BMD (0.460 g/cm(2)) compared to men (0.552 g/cm(2)) (P = 0.057). Using linear regression, fusion mass bone quality, measured as BMD, was significantly influenced by gender, age of the patient, bone density of the remaining part of the lumbar spine, amount of bone graft applied and smoking. Fusion rates in this cohort was 34% in the control group and 33 and 43% in the 40 and 100 μA groups, respectively (not significant). Patients classified as fused after 2 years had significant higher fusion mass BMD at 1 year (0.592 vs. 0.466 g/cm(2), P = 0.0001). Fusion mass bone quality in older patients depends on several factors. Special attention should be given to women with manifest or borderline osteoporosis. Furthermore, bone graft materials with inductive potential might be considered for this patient population.

Altered expression of genes involved in ATP biosynthesis and GABAergic neurotransmission in the ventral prefrontal cortex of suicides with and without major depression

The prefrontal cortex is believed to play a major role in depression and suicidal behavior through regulation of cognition, memory, recognition of emotion, and anxiety-like states, with numerous post-mortem studies documenting a prefrontal serotonergic dysregulation considered to be characteristic of depressive psychopathology. This study was carried out to detect changes in gene expression associated with both suicide and major depression using oligonucleotide microarrays (Affymetrix HG-U133 chip set) summarizing expression patterns in primarily ventral regions of the prefrontal cortex (BA44, 45, 46 and 47). A total of 37 male subjects were included in this study, of which 24 were suicides (depressed suicides=16, nondepressed suicides=8) and 13 were matched controls. All subjects were clinically characterized by means of psychological autopsies using structured interviews. Unique patterns of differential expression were validated in each of the cortical regions evaluated, with group-specific changes highlighting the involvement of several key neurobiological pathways that have been implicated in both suicide and depression. An overrepresentation of factors involved in cell cycle control and cell division (BA44), transcription (BA44 and 47) and myelination (BA46) was seen in gene ontology analysis of differentially expressed genes, which also highlights changes in the expression of genes involved in ATP biosynthesis and utilization across all areas. Gene misexpression in BA46 was most pronounced between the two suicide groups, with many significant genes involved in GABAergic neurotransmission. The pronounced misexpression of genes central to GABAergic signaling and astrocyte/oligodendrocyte function provides further support for a central glial pathology in depression and suicidal behavior.

Screening for developmental dysplasia of the hip

The reported prevalence of established dislocation the hip in an unscreened population varies from 0.7 to 1.6 / 1000 children in European and American white populations. In clinically screened populations neonatal hip instability is reported to occur in 3 to 30 / 1000 newborns while established congenital dislocation has a prevalence of 0.1- 4/1000 of which 1/1000 is judged to be in need for surgery. Early diagnosis of DDH is essential for successful treatment and later prognosis of the disorder. Combined procedure including evaluation of both hip morphology and hip stability is currently recommended. Opinions differ about the need for universal versus selective sonographic screening for diagnosis of DDH. Currently selective screening of those infants with recognised risk factors and those with abnormal physical examination would be cost-effective and the only practicable method for most countries.

Bilateral putaminal necrosis due to methanol abuse

Symmetrical lesions in the basal ganglia are accepted as the characteristic radiological feature of methanol toxicity. A case of chronic deliberate repeated methanol ingestion is presented. The typical MRI findings of basal ganglia lesions on T1 and T2 weighted images, FLAIR, diffusion and T1-weighted post Gadolinium images are presented. To our knowledge, this is the first case in which late diffusion and post contrast MRI images, showing necrotic sequelae due to methanol ingestion, are reported.

No difference in health-related quality of life in hip osteoarthritis compared to degenerative lumbar instability at pre- and 1-year postoperatively: a prospective study of 101 patients

BACKGROUND

Total hip replacement (THR) is a very successful and refined surgical procedure when compared to crude bony fusion in degenerative lumbar segmental instability (LF). We compared the pre- and postoperative health-related quality of life status of THR and LF patients.

PATIENTS AND METHODS

We prospectively studied 51 THR patients and 50 LF patients. The outcome parameters were SF-36 and Oswestry Disability Index (ODI), measured preoperatively and at 1 year postoperatively. The status of the patients was compared to that of an age-matched healthy control group.

RESULTS

The preoperative SF-36 and ODI scores were similar between the groups, except for the subscale role emotional. One year postoperatively, only the differences in 3 subscales (physical functioning, role physical, and role emotional) and in the standardized physical component reached statistical significance; the THR-patients scored worse than the LF-patients. The improvements in SF-36 and ODI reached statistical significance in both groups.

INTERPRETATION

The differences in quality of life between the THR and LF patients were similar pre- and postoperatively. The quality of life of both cohorts improved considerably and significantly after the treatment, but they remained at a level significantly below that of a general age-matched population.

Efficacy of amphoteric surfactant- and peracetic acid-based disinfectants on spores of bacillus cereus in vitro and on food premises of the German armed forces

In mass catering facilities of the German Armed Forces, foodborne outbreaks are commonly attributed to Bacillus cereus, and spores of this organism are regularly found on equipment surfaces. B. cereus is the causative agent of foodborne emetic or diarrheic disease. Hence, the use of sporicidal disinfectants may provide a starting point for successful risk mitigation of diseases associated with B. cereus. In this study, the amphoteric surfactant-based disinfectant (product A) that has been routinely used in catering facilities of the German Armed Forces and a peracetic acid-based disinfectant (product B) were compared for their efficacy against B. cereus spores in laboratory tests and under field conditions. In a carrier test for B. cereus spores, product A displayed no efficacy against spores of the test strain. In contrast, a substantial reduction in spore concentration (>5-log reduction) was achieved with product B. In a controlled trial conducted in seven Army catering facilities, the reduction in the number of B. cereus-positive samples was significantly greater (P < 0.001) for product B (from 28% initial contamination to 3% after application) than for product A (from 33 to 21%). Product B was estimated to be 6.25 times more efficacious than product A. Field trials confirmed the higher efficacy of the peracetic acid-based disinfectant to reduce B. cereus contamination on surfaces as found for the in vitro experiments. The tests used to assess the sporicidal effects of disinfectants were adequate under practice conditions and could be used for sporicidal testing of disinfectants for catering and food production establishments.

The putative neural stem cell marker, nestin, is expressed in heterogeneous cell types in the adult rat neocortex

Nestin is a putative neural stem cell marker that is expressed in different areas of the adult mammalian brain that are known to support mitotic activity. Recently the neocortex has been proposed to support neurogenesis, however little is known of the expression pattern of nestin in neocortex. In the present study, we demonstrate that cells that express nestin can be found throughout the neocortex, and that these cells are morphologically heterogeneous. Some nestin-expressing cells had one extension arising from the cell body, reminiscent of the nestin-expressing cells that are thought to be young neurons in the hippocampus. The frequency of single extension cells in the neocortex was approximately one cell per 50,000 microm(2). Other cells had numerous extensions arising from the cell body. In all cases, cells that expressed nestin were also found to co-label with the glial marker glial fibrillary acidic protein. In addition, nestin-expressing cells in the neocortex did not express the cell cycle marker, Ki-67, indicating they were not actively engaged in mitotic activity. When small lesions were made in cortex, nestin could also be observed in reactive astrocytes as part of the inflammatory response. Approximately 94% of reactive astrocytes expressed Ki-67. These results demonstrate that there are different populations of cells in the neocortex that can express nestin, but that only reactive astrocytes in this region are mitotically active.

Deletion of the nuclear receptor Nr2e1 impairs synaptic plasticity and dendritic structure in the mouse dentate gyrus

The spontaneous or targeted deletion of the nuclear receptor transcription factor Nr2e1 produces a mouse that shows hypoplasia of the hippocampal formation and reduced neurogenesis in adult mice. In these studies we show that hippocampal synaptic transmission appears normal in the dentate gyrus and cornu ammonis 1 subfields of adult mice that lack Nr2e1 (Nr2e1-/-), and that fEPSP shape, paired-pulse responses, and short-term plasticity are not substantially altered in either subfield. In contrast, the expression of long-term potentiation is selectively impaired in the dentate gyrus, and not in the cornu ammonis 1 subfield. Golgi analysis revealed that there was a significant reduction in both dendritic branching and dendritic length that was specific to dentate gyrus granule cells in the Nr2e1-/- mice. These results indicate that Nr2e1 deletion can significantly alter both synaptic plasticity and dendritic structure in the dentate gyrus.

[Tietze's syndrome in a 2-year old boy]

A 2-year-old boy was seen with a painful swelling of the left costochondral junction. Laboratory examination revealed no signs of infection. Echography and CT-scan revealed swelling of the 4th and 5th costochondral junction and the pectoral muscle. Tietze's syndrome was suspected and a wait-and-see policy was decided on. During follow-up, the symptoms gradually decreased. Ten weeks after the onset of symptoms there was only a slight, painless swelling with normal ultrasound findings. Tietze's syndrome is defined as a benign, painful, non-suppurative and localised swelling of the costosternal, costochondral or sternoclavicular joints with spontaneous regression of symptoms. It is typically described in adults but appears in children and infants as well. Recognition of this syndrome and knowledge of its favourable outcome can prevent invasive diagnostic procedures.

[Recall and pseudo-memory. On the yearning to be a trauma victim]

Memories are not called up from "storage" but instead are constructed anew in each case. Although many experiments have proven that memories are visual and inaccurate, many psychotherapists still assume that memories which surface during therapy are realistic representations of facts. They do not take into account that reminiscences (pseudomemories) of events can be planted in the memory by the imagination or through behavioral pressure. In light of this, the question arises as to why some patients during therapy tend to invent in particular memories of traumatic early childhood experiences. The authors assume that certain suggestive elements come to bear with victimization. The advantage gained is of great importance and has many facets. The case of Wilkomirski proves that mystification of the ego via identification with victims is not only provoked in psychotherapeutic treatment but also is a means of gaining public attention and support. As concerns the therapeutic handling of actual emotional traumatization (whose pathogenic significance and long-term effects used to be underestimated), suggestive and autosuggestive processes play a large role. In this respect, modern trauma research and psychotherapy are faced with special challenges.

Prevalence of methicillin-resistant Staphylococcus aureus carriage at the time of admission in two acute geriatric wards

Studies on methicillin-resistant Staphylococcus aureus (MRSA) in the elderly have been concerned with patients hospitalized in nursing homes or long-term care facilities. Our objective was to estimate the prevalence of MRSA at the time of admission in two acute geriatric wards with high endemic MRSA incidence in a French teaching hospital. A prospective screening of MRSA carriers was conducted by swabbing nares and wounds during five weeks for all patients on the day of admission. For each patient demographic, administrative, clinical and therapeutic data were recorded. Their associations with MRSA carriage were studied by logistic regression analysis. On the day of admission, 35 patients (14.6%) were MRSA carriers. Variables independently associated with carriage were hospitalization within the six last months (OR = 4.64; P < 0.001) and the existence of wounds or bedsores (OR = 2.864; P = 0.02). The high prevalence of MRSA carriage at the time of admission could explain in part the high incidence of MRSA in these wards. A systematic selective screening targeted on patients with high risk of carriage should be helpful to implement barrier precautions and reduce cross-transmission.