Eyelid Skin Grafting in Young Patients with Facial Nerve Palsy

Background: The aim of this study is to report outcomes of eyelid full-thickness skin grafting augmentation in facial nerve palsy (FNP) patients younger than 50 years of age. Methods: In a retrospective, consecutive case series, nine eyelid skin grafts performed on eight FNP patients with skin contraction (five females; median age 42 years [range, 17-47]) are presented. In most cases, upper eyelid skin grafting was combined with levator recession and anterior lamellar repositioning. Lower eyelid skin grafting was combined with lower retractors recession in all cases. Functional and cosmetic outcomes were measured preoperatively and at early (1-3 months), intermediate (3-6 months), and late (≥12 months) follow-up. Results: The corneal score improved at early follow-up (p = 0.03) and remained improved at late follow-up (p = 0.042). The gentle closure lagophthalmos was improved at late follow-up (p = 0.042). (p = 0.048). The grades of graft color, edge/skin interface, and size improved at 3-6 months post-grafting and remained improved at late follow-up (p < 0.05). Over the follow-up, four patients (50%) were recommended to have further surgical procedures. Conclusions: The preliminary results from this small cohort suggest that eyelid skin grafting is a viable option for young patients prioritizing cosmesis. This technique warrants consideration for its functional benefits.

Material risk: vitreoretinal surgery, evisceration, enucleation and sympathetic ophthalmia-where are we currently?

Sympathetic ophthalmia (SO) is known to occur after severe penetrating eye injury, evisceration and even enucleation surgery. Recent evidence suggests that a greater risk lies after multiple vitreoretinal procedures. The risk of SO following evisceration is only minimally greater than that following enucleation surgery. This review evaluates literature on SO to date and provides figures for the risk of developing SO for the purposes of the consent process. The issue of SO and Material Risk following vitreoretinal surgery is reviewed and figures for the purposes of consent are outlined. This is of particular relevance for patients in whom the contralateral eye is and will likely remain the better seeing eye. Sympathetic ophthalmitis is known to occur after severe penetrating eye injury, after evisceration and enucleation. More recently, sympathetic ophthalmitis has been recognised to occur after vitreoretinal surgery. This article reviews the evidence on material risk when consenting patients for elective and emergency eye procedures after ocular trauma or surgery. When a globe needs to be removed because of irreparable ocular injury, previous publications dictated the procedure to be an enucleation because of the fear of an increased risk of SO after an evisceration. Perhaps the issue of material risk of sympathetic ophthalmia (SO) remains over-emphasised by ophthalmic plastic surgeons and under-recognised by vitreoretinal surgeons during the consent process for evisceration, enucleation and vitreoretinal surgery. Antecedent trauma and number of previous surgeries may actually be a more significant risk factor than the type of eye removal. Recent medicolegal cases also help us understand the importance of the discussion of this risk. We present our current understanding of the risk of SO after different procedures and suggest how this information may be included in a patient consent.

Do Prostaglandin Analogue Lash Lengtheners Cause Eyelid Fat and Volume Loss?

BACKGROUND

Prostaglandin analogues (PGAs; a first-line antiglaucoma treatment) have been remarketed as popular eyelash-lengthening serums due to their lash-lengthening and lash-thickening side effects. Periorbital volume loss is now a well-established side effect of topical PGAs used to treat glaucoma (prostaglandin-associated periorbitopathy) but has not, to date, been listed as a potential side effect of lash-lengthening serums containing PGAs.

OBJECTIVES

The aim of this study was to identify whether periorbital fat/volume loss is seen in users of PGA lash lengtheners.

METHODS

This investigation comprised a case report and an informal randomized controlled study comparing "before-and-after" color photographs displayed on the websites of manufacturers of PGA-containing lash lengtheners (PGALLs) (ie, containing bimatoprost, norbimatoprost, isopropyl cloprostenate, dechloro-dihydroxy-difluoro-ethylcloprostenolamide, or methylamido-dihydro-noralfaprostal) vs 2 control groups: non-PGALLs (NPGALL) and false eyelashes (FLs). Expert and layperson blinded graders used a purpose-designed grading system to identify subtle signs of periorbital fat/volume loss over time.

RESULTS

A 35-year-old female developed thin, wrinkled, darker skin, and periorbital hollowing after 10 months of treatment with Lash Boost (Rodan & Fields, San Francisco, CA), containing isopropyl cloprostenate, which reversed 6 months after discontinuation. Fifteen "before-and-after" pairs of photographs (PGALL, n = 10; NPGALL, n = 3; FL, n = 2) were graded by 5 graders (3 expert, 2 layperson). Mean grading score was 8.2 (of 19) in the PGALL group, 2.3 in the NPGALL group, and 3.2 in the FL group. PGALL scores were significantly higher than scores in the NPGALL (P < 0.001) and FL (P = 0.017) groups.

CONCLUSIONS

Review of commercial "before-and-after" photographs suggests that PGALL users develop changes compatible with prostaglandin-associated periorbitopathy. Consumers must be aware of the possibility of periorbital volume loss prior to commencing treatment with PGALLs. Often the customer-facing product ingredient list contains no mention of PGAs.

LEVEL OF EVIDENCE: 4

Rates of diabetic retinopathy screening in pregnant patients with type 1 and type 2 diabetes in a predominantly Indigenous Central Australian population

BACKGROUND

Pregnancy is a risk factor for the progression of diabetic retinopathy (DR) in women with pre-gestational diabetes. Australian screening guidelines recommend DR screening in the first trimester of pregnancy. The rates of DR screening in pregnant patients with pre-gestational diabetes are unknown in Australia.

AIM

To determine the rates of DR screening in pregnant women with pre-gestational diabetes at Alice Springs Hospital Diabetes Antenatal Care and Education (DANCE) clinic.

MATERIALS AND METHODS

Retrospective review of women with pre-gestational diabetes who attended the DANCE clinic between July 2016 and June 2020.

RESULTS

There were 146 pregnancies in 144 individual women included in this review. There were 93% (n = 134) who identified as Aboriginal but not Torres Strait Islander. DR screening was performed in 23 (16%) pregnancies, in which DR was present in six (26%) and no retinal abnormality was found in 17 (74%). Of seven (5%) women who had a history of DR, only three had a screen during the pregnancy period. The location of the DR screen included Alice Springs Hospital (17%, n = 4), Alice Springs general practice clinics (35%, n = 8) and remote NT community clinics outside of Alice Springs (39%, n = 9). The trimesters in which women received their DR screens were: trimester 1, 45%, n = 10; trimester 2, 39%, n = 9; trimester 3, 17%, n = 4.

CONCLUSION

The minority of pregnant women who attend the DANCE clinic at Alice Springs Hospital received DR screening in adherence with national guidelines.

The UK National Artificial Eye Questionnaire Study: comparisons between cosmetic shell and artificial eye users. Part 2: maintenance, management and quality of life

AIMS

To compare the unique experiences related to artificial eye (AE) versus cosmetic shell (CS) wear.

METHODS

In this observational, cross-sectional study, the National Artificial Eye Questionnaire was employed nationwide within the National Health Service England. This second part of the study assesses daily management and care experiences, as well as visual function and quality of life aspects.

RESULTS

Overall, 951 respondents wore an AE, while 238 wore a CS. Both AE and CS respondents rated a relatively high score for a beneficial effect of prosthesis polishing, with an average score of 80.08±0.87 versus 77.17±1.73 (p=0.13, respectively). CS respondents removed and cleaned their prosthesis more frequently than AE respondents (p<0.0001, p=0.002, respectively). CS respondents instilled lubrication more frequently than AE respondents (p=0.022) with 33.3% versus 43.7% of AE and CS wearers, respectively, lubricating on at least a daily basis. The overall QOL composite score was similar in both AE and CS groups (approximately 77%, p=0.74). Social functioning was similar, and relatively high in both groups (approximately 86%, p=0.77).

CONCLUSIONS

This study characterises unique aspects of CSs versus AEs in a large national cohort. The results should provide reinforcement to the gain in popularity of CSs.

UK National Artificial Eye Questionnaire study: comparisons between cosmetic shell and artificial eye users. Part 1: demographics, comfort and satisfaction

AIMS

To compare the unique experiences related to artificial eye (AE) versus cosmetic shell (CS) wear.

METHODS

In this observational, cross-sectional study, the National Artificial Eye Questionnaire (NAEQ) was employed nationwide within the National Health Service England. The proportions or mean values of the aetiology of sight or eye loss, demographics, length of prosthesis wear, reported adjustment time to the prosthesis, comfort, discharge and satisfaction of appearance were compared between AE and CS respondents.

RESULTS

Overall, 951 respondents wore an AE, while 238 wore a CS. In both, trauma was the leading cause for the prosthesis (47.6% and 44.1%, respectively); however, these groups differed in the proportions of the other aetiologies (p<0.0001). AE respondents were generally older (p=0.002) and had longer overall prosthesis wear (p<0.0001) compared with CS respondents. The overall comfort score was similarly, relatively high in both AE and CS respondents (80.4±0.73 vs 81.41±1.45; p=0.51). The discharge-related patient satisfaction ranking was relatively low, in both groups, with a small trend towards worse discharge scores among AE wearers (59.41±0.76 vs 62.26±1.52, p=0.094). Self-reported length of time that has taken to adjust to wearing the prosthesis was not significantly different (p=0.17). Appearance of the eye (p=0.032) and motility of the prosthesis (p<0.0001) were ranked superior by CS respondents compared with AE.

CONCLUSIONS

This study characterises unique aspects of CS versus AE in a large national cohort. The results should provide reinforcement to the gain in popularity of CS.

Does lagophthalmos change on lying supine after upper eyelid platinum segment chain loading?

BACKGROUND

Facial nerve palsy (FNP) often significantly affects blink. Platinum segment chains (PSC) improve lagophthalmos, however, debate exists as to the effectiveness of weights when the patient lies supine.

METHODS

Prospective case series of patients with FNP following PSC insertion. Lagophthalmos on blink, gentle and forced closure was observed in the seated position, lying flat supine at 0 degrees, lying supine with one pillow underneath the head and lying on the side, with the non-facial palsy side to the pillow. This side was chosen to account for the effect that the pillow may have on lagophthalmos.

RESULTS

Twenty eyes with PSC for facial palsy related lagophthalmos were assessed in 19 patients. Clinically, 12 out of the 20 eyes had no change in lagophthalmos on gentle closure when sitting up compared to supine (no pillow). The remaining 8 eyes had an increase of lagophthalmos of mean 2.3 mm (range 1-6 mm) when supine. There was no statistical difference in the amount of lagophthalmos between sitting up and lying flat with no pillow on gentle closure (P value = .0804) and blink (P value = .1567). About 50% of patients have ongoing requirements for evening lubricating ointment application but only one patient in our cohort experienced morning ocular symptoms. No patient was taping their eyelids.

CONCLUSION

In our study, the prevalence of lagophthalmos increasing on gentle closure when supine is 40%. Statistically, there is no difference between gentle closure in the sitting and supine position.

Recognising meibomian gland inversion in patients with facial palsy to improve the ocular surface

Background: Facial nerve palsy (FNP) is known to worsen Meibomian gland dysfunction on the affected side. Chronic Meibomian gland dysfunction leads to a variant of upper eyelid marginal entropion associated with excessive tarsal curling, termed Meibomian gland inversion (MGI). Surgical correction with grey line split, tarsoplasty and anterior lamellar repositioning (GLS surgery) appears to further improve the ocular surface in these patients who have previously undergone upper eyelid loading. Methods: Retrospective, 3 year, non-comparative, single-centre study of patients with FNP identified as having MGI and treated by GLS surgery under the supervision of a single surgeon. We present specific examination findings and a useful test (cotton tip test) to determine suitability for GLS surgery. We assessed changes in symptoms and CADS (Cornea, static Asymmetry, Dynamic function and Synkinesis) score, along with cosmetic grading of lash loss and contour and report complications. Results: 23 patients with acquired FNP underwent GLS surgery for MGI with or without lash ptosis. 17 out of the 23 patients (74%) demonstrated an improvement in their CADS score after GLS surgery. Seven patients had insufficient records with scores missing and no conclusion could be reached for this group. Improvement of corneal staining, static and dynamic symmetry were all statistically significant. No patient worsened. The cosmetic outcome including lashes, lid contour and lid margin appearance is acceptable. Whilst it is possible to achieve minimal difference between the operated and unoperated eyelids, many patients will have a small difference. Conclusion: We report outcomes of MGI treatment and useful diagnostic features.

How far we have come: A review of the evolution of posterior approach ptosis surgery

We revisit the evolution of posterior approach ptosis surgery. We address the early attempts at ptosis surgery, assess the more modern approach by de Blaskovics, followed by the division into "open sky" and "closed" techniques. The simultaneous developments occurring in America and Europe are described, along with refinement of surgical approaches such as conjunctival-sparing posterior approach ptosis surgery.

The mutation p.D313Y is associated with organ manifestation in Fabry disease

Fabry disease (FD) is a multisystem lysosomal storage disorder caused by mutations in the GLA gene. The clinical significance of the mutation p.D313Y is still under debate. Retrospective chart analysis of clinical (neurological, cardiac, renal, and ophthalmological), genetic, and biochemical (lyso-globotriaosylsphingosine, lyso-Gb3; enzyme activity) data was performed in all our patients carrying the p.D313Y mutation. Fourteen patients from 5 families (10 female, 4 male; age range 10-51) were included. Symptoms and organ manifestations compatible with FD could be identified in 10 patients. Cerebrovascular events occurred in 4 females. Seven patients reported pain or acroparaesthesia. Cornea verticillata was found in 1 patient, mild retinal vascular tortuosity in 5 patients. Lyso-Gb3 was elevated in 2 females with cerebrovascular involvement. Classical cardiac, renal or skin manifestations could not be identified. The mutation p.D313Y in the GLA gene may lead to organ manifestations and elevation of the Fabry-specific biomarker lyso-Gb3. Neurological symptoms (stroke and pain) and ocular manifestations seem to be the leading findings. Annual routine visits are recommended for patients carrying the p.D313Y mutation. Enzyme replacement therapy might be considered in symptomatic patients.

Ibopamine challenge testing becomes negative following successful trabeculectomy surgery

BACKGROUND

The ibopamine challenge test correlates well with a patient's peak diurnal intraocular pressure (IOP) measurement. We aimed to investigate the effect that a functioning trabeculectomy has on the ibopamine challenge test.

DESIGN

Non-randomized prospective clinical trial evaluating a diagnostic test.

PARTICIPANTS

Thirteen patients were recruited through glaucoma clinics at the Flinders Medical Centre. Of these, seven required surgical management with trabeculectomy surgery, whilst the remainder were managed medically.

METHODS

Patients underwent IOP measurement, and then two drops of Ibopamine 2% solution were instilled into the study eye of each patient. After 45 min, IOP was reassesed. A positive challenge test was considered to be a rise in IOP of greater than 3 mmHg. Changes from baseline were determined and compared between groups. Twelve months later, this test was then repeated in all patients.

MAIN OUTCOME MEASURE

Change in IOP after ibopamine challenge.

RESULTS

Following the ibopamine challenge, IOP increased by 9.2 mmHg (SD 2.8) (100% positive) for medically managed patients and 7.2 mmHg (SD 2.0) (100% positive) for surgically managed patients (P = 0.18). The surgically managed group then underwent trabeculectomy surgery. Twelve months later, the ibopamine challenge was repeated. Following the repeat ibopamine challenge, IOP increased by 7.2 mmHg (SD 2.3) for medically managed patients and 0.3 mmHg (SD 1.3) for surgically managed patients (P < 0.0001). The medically managed group remained 100% positive, whilst the surgically manage group became 0% positive (Fisher Exact P = 0.044).

CONCLUSIONS

A glaucoma patient with a positive ibopamine challenge will show a negative challenge result when re-tested following trabeculectomy surgery.

Ibopamine challenge testing differentiates glaucoma suspect, stable glaucoma and progressive glaucoma cases

BACKGROUND

An ibopamine challenge is a novel technique for assessing glaucoma using ibopamine, a topical drug which temporarily increases aqueous production. We aimed to determine whether change in intraocular pressure (IOP) and/or optic cup volume (OCV) during the test differentiated between glaucoma patients at different stages of disease; namely, glaucoma suspects (GS), glaucoma patients who are stable (SG) and glaucoma patients who have demonstrated rapid progression (PG).

DESIGN

Non-randomized clinical trial evaluating a diagnostic test.

PARTICIPANTS

Sixty-one patients were recruited through glaucoma clinics at the Flinders Medical Centre (24 GS, 24 SG and 13 PG).

METHODS

Patients underwent IOP measurement and OCV assessment using optical coherence tomography. Two drops of ibopamine 2% solution were instilled into the study eye of each patient. After 45 min, IOP and OCV were reassessed. Changes from baseline were compared between groups.

MAIN OUTCOME MEASURE

Change in IOP and OCV after ibopamine challenge.

RESULTS

Following the ibopamine challenge, IOP increased by 1.8 mmHg for GS patients, 4.5 mmHg for SG patients (P = 0.003) and 8.1 mmHg for PG patients (P < 0.0001). OCV increased by 0.2% for GS patients, 0.6% for SG patients and 5.5% for PG patients. This was not significantly different between GS patients and SG patients; however, it was significantly different between GS patients and PG patients (P < 0.0001), and between SG and PG patients (P = 0.001).

CONCLUSION

GS patients may be differentiated from those with SG or PG by their IOP response, and SG may be differentiated from PG patients by their change in OCV following an ibopamine challenge.

Vaccination during concurrent subcutaneous immunotherapy: safety of simultaneous application

BACKGROUND

During subcutaneous immunotherapy (SCIT), injections should be separated from vaccinations against infectious diseases by at least 1 week, because it is assumed that adverse reactions can result from the additional activation of the immune system.

METARIAL AND METHODS

Data of a total of 875 individuals receiving SCIT and/or vaccination in one ENT-practice were included and analyzed retrospectively. 444 individuals had received vaccination against infectious diseases, 336 allergic patients received only SCIT. Moreover, 79 allergic patients had received vaccination and SCIT injections simultaneously on one day in different locations, while 16 patients inadvertently received SCIT injections within up to 4 days after vaccination. Some of the patients were observed for consecutive years receiving several vaccinations parallel to SCIT. Systemic reactions (SRs) during SCIT were classified according to the WAO (World Allergy Organization) grading.

RESULTS

Patients exclusively receiving vaccinations did not report any drug-related SR. One SR third grade and two SRs second grade occurred in 3 asthmatic patients exclusively receiving SCIT. The patients simultaneously receiving vaccination and SCIT did not have any SR. This was also the case for the subjects consecutively receiving parallel SCIT and vaccination for up to 5 years.

CONCLUSION

The international guidelines for allergen-specific immunotherapy (SIT) recommend an intermission of at least one week between SCIT and the administration of vaccines. However, these findings demonstrate the possibility to shorten or abolish this interval without increasing the risk of SRs.

A longitudinal assessment of early childhood education with integrated speech therapy for children with significant language impairment in Germany

BACKGROUND

In Lower Saxony, Germany, pre-school children with language- and speech-deficits have the opportunity to access kindergartens with integrated language-/speech therapy prior to attending primary school, both regular or with integrated speech therapy. It is unknown whether these early childhood education treatments are helpful and effective.

AIMS

To determine the value of early language-/speech therapy treatment in combination with support of personality traits during the pre-school and primary school period on the long-term social and academic development of children with significant language-/speech delay.

METHODS & PROCEDURES

We conducted prospective longitudinal case series, following the academic progress of 71 children after they had been discharged from a speech therapy kindergarten (STK) up to 19 years previously. Data collection included details on language/speech impairment, socio-economic factors, psycho-social skills and intelligence quotient.

RESULTS & IMPLICATIONS

At the end of the follow-up period, 58 children were attending secondary schools: 44 (76%) children attended a regular secondary school, whereas 14 (24%) children were enrolled in a school with special needs education. The results suggest that self-awareness and intelligence quotient in this study cohort correlated with later academic achievements.

CONCLUSION & IMPLICATIONS

Kindergartens and primary schools which support curriculum-integrated language-/speech therapy and allow for different personality traits appear to improve longterm development and academic outcome of children with language-/speech impairment or delay.

Can intraoperative use of limbal stay suture in strabismus surgery cause epithelial ingrowth?

Epithelial ingrowth has been reported extensively as a result of some corneal procedures and secondary to trauma. The authors describe a case of epithelial ingrowth most likely caused by a limbal stay suture used during strabismus surgery. The pathophysiology of epithelial ingrowth and its differential diagnosis of fibrous downgrowth are discussed.

Objective accommodation measurement of the Crystalens HD compared to monofocal intraocular lenses

PURPOSE

Objective evaluation of accommodation with a bilateral accommodating intraocular lens (IOL) versus monofocal IOLs.

METHODS

Patients received accommodating IOL (Crystalens HD; Bausch & Lomb, Rochester, NY) bilaterally after cataract surgery. These were compared to a matched group receiving monofocal IOLs. Preoperative and postoperative distance corrected distance, intermediate, and near vision were evaluated. Objective accommodation was measured with the WAM-5500 Binocular Autorefractor/Keratometer (Grand Seiko, Pty Ltd., Hiroshima, Japan).

RESULTS

Nineteen patients were included. Ten received the Crystalens HD in both eyes and nine received one of three monofocal lenses in each eye. Mean postoperative distance corrected distance visual acuity was not statistically different between the two groups. Mean distance corrected intermediate vision was better in the Crystalens HD group (logMAR 0.24 ± 0.11 [control], logMAR 0.11 ± 0.10 [Crystalens HD], P = .033). The groups did not differ significantly for mean distance corrected near vision (logMAR 0.54 ± 0.12 [control], logMAR 0.42 ± 0.15 [Crystalens HD], P = .087). However, a significantly greater proportion of Crystalens HD eyes achieved 0.4 or 0.3 logMAR for near wearing their distance correction (P = .013). With distance correction, the mean spherical equivalent failed to show any myopia with accommodative effort in either group. Low contrast and low luminance contrast acuity were not significantly different.

CONCLUSION

The Crystalens HD showed some benefit for intermediate visual function compared to the monofocal IOLs with both groups wearing full correction for distance. There were no significant signs of accommodation in either group.

Recurrent atypical fibroxanthoma of the limbus

We report an unusual presentation of recurrent atypical fibroxanthoma of the limbus. Clinical and histological appearances, as well as management are discussed and the current literature is reviewed.

Neuroretinitis following bull ant sting

Cat scratch disease causes the majority of cases of neuroretinitis. Neuroretinitis is characterised by clinical features of papillitis, macular oedema and macular star. We report a case study of infection with Bartonella henselae most likely transmitted by a bull ant sting. The patient presented with blurred vision and reduced visual acuity after being stung by an ant in her garden some 7 days earlier. Further testing revealed positive serology to B henselae and the patient improved with appropriate treatment.

Phenylalanine tolerance in three phenylketonuric women pregnant with fetuses of different genetic PKU status

Pregnancy management in phenylketonuric women includes continuous dietary control starting before conception, aiming to maintain blood phenylalanine concentrations in a desirable range, irrespective of the fetal genetic PKU status. While the maternal phenylalanine hydroxylase (PAH) genotype will influence metabolic control, an effect of the fetal genetic PKU status on maternal metabolic control during pregnancy has not been described. We monitored three pregnancies of women with classical PKU by dietary protocols of daily phenylalanine intake, phenylalanine blood concentrations, and obstetric care. Patients 1 and 2 carried a heterozygous (not PKU-affected) fetus, while patient 3 was pregnant with a PKU-affected fetus (PAH p.R408W and p.R408W). The expected increase in phenylalanine tolerance during the course of pregnancy was observed in patients 1 and 2 in whom phenylalanine intake could be steadily increased from 400 to 1700 mg/day while phenylalanine blood concentrations remained in the desired range. Gain of body weight was 13.0 and 17.7 kg, respectively. In patient 3, the phenylalanine tolerance did not rise above 600 mg/day, and phenylalanine blood concentrations were above the desired range on several occasions. Caloric intake was therefore encouraged, which led to a weight gain of 20.0 kg. The course of pregnancy was otherwise normal in all three cases, and infants with normal birth weight and head circumference were born. The different phenylalanine tolerance in pregnancies with PKU-affected and non-affected fetuses suggests that PAH genotype and metabolic situation of the fetus influence maternal metabolic control. A phenylalanine tolerance remaining low in the third trimester of pregnancy may indicate fetal PKU.

[Long-term school-development of children with impaired language skills: 15-years follow up after dismissal from child care centres with speech therapy]

BACKGROUND

Severe language impairment (SLI) in children causes multiple developmental disturbances. Less is known concerning the long-term efficacy of Child care centres with speech therapy (CCC) and the validity of of IQ-testing.

AIM OF THE STUDY

Follow-up of school-development of SLI-children from CCC and analysis of the the prognostic relevance of IQ-testing as monitored by the surrogate-parameter "school-development".

METHODS

1. Retrospective study with questionnaires; 2. Analysis of documents from CCC. 88 children (60 males, 28 females) were included.

RESULTS

Median length of stay in CCC was 18 months (range: 12-36 months); present study was performed 0,5 to 15 years after dismissal from CCC. Due to parents;remembrance more than 90% of the children suffered on symptoms of SLI within the 2 (nd) year of life; about 30% of the children received grommets; IQ was determined by SON-R 2,5-7 in 68 children and amounted 99 (58-131). In 32 children (>10 years) school-careers were followed after termination of primary schools: 5 children visited "schools for handicapped children", 26 children attended mainstream-schools, 19 of them in schools with higher academic levels ("advanced-" and "integrated high schools", "grammar schools"). In 16 of 68 children the IQ amounted between 70 to 89, 11 of these children visited a mainstream school. In 45 of these children IQ was >90, 6 of these children had to attend a "school for handicapped children".

CONCLUSIONS

IQ-testing is thought to be a limited prognostic parameter for long-term school-development of SLI-children. Findings indicate, that about 80% of the SLI-children benefitted by the therapy in specialized CCC and visited a mainstream school.

Membrane translocation of glutaric acid and its derivatives

The neurodegenerative disorder glutaric aciduria type I (GA I) is characterized by increased levels of cytotoxic metabolites such as glutaric acid (GA) and 3-hydroxyglutaric (3OHGA). The present report summarizes recent investigations providing insights into mechanisms of intra- and intercellular translocation of these metabolites. Initiated by microarray analyses in a mouse model of GA I, the sodium-dependent dicarboxylate cotransporter 3 (NaC3) was the first molecule identified to mediate the translocation of GA and 3OHGA with high and low affinity, respectively. More recently, organic anion transporters (OAT) 1 and 4 have been reported to be high-affinity transporters for GA and 3OHGA as well as D-2- and L-2-hydroxyglutaric acid (D2OHGA, L2OHGA). The concerted action of NaC3 and OATs may be important for the directed uptake and excretion of GA, 3OHGA, D2OHGA and L2OHGA in kidney proximal tubule cells. In addition, experimental data on cultured neuronal and glial cells isolated from mouse brain demonstrated that GA rather than 3OHGA may competitively inhibit the anaplerotic supply of tricarboxylic acid cycle intermediates from astrocytes to neurons. The identification of GA and GA derivative transporters may represent targets for new approaches to treat patients with GA I and related disorders.

Cannabinoid 1 (CB1) receptors coupled to cholinergic motorneurones inhibit neurogenic circular muscle contractility in the human colon

The effects of cannabinoid subtype 1 (CB(1)) receptor activation were determined on smooth muscle, inhibitory and excitatory motorneuronal function in strips of human colonic longitudinal muscle (LM) and circular muscle (CM) in vitro. Electrical field stimulation (EFS; 0.5-20 Hz, 50 V) evoked a relaxation in LM and CM precontracted with a neurokinin-2 (NK-2) selective receptor agonist (beta-ala(8)-neurokinin A; 10(-6) M) in the presence of atropine (10(-6) M); this was unaltered following pretreatment with the CB(1)-receptor selective agonist arachidonyl-2-chloroethylamide (ACEA; 10(-6) M). In the presence of nitric oxide synthase blockade with N-nitro-L-arginine (10(-4) M), EFS evoked a frequency-dependent 'on-contraction' during stimulation and an 'off-contraction' following stimulus cessation. On-contractions were significantly inhibited in CM strips by pretreatment with ACEA (10(-6) M). These inhibitory effects were reversed in the presence of the CB(1) receptor-selective antagonist N-(piperidine-1-yl)-5-(4-iodophenyl)-1-(2,4-dichlorophenyl)-4-methyl-1H-pyrazole-3-carboxamide (10(-7) M). ACEA did not alter LM or CM contractile responses to acetylcholine or NK-2 receptor-evoked contraction. Immunohistochemical studies revealed a colocalisation of CB(1) receptors to cholinergic neurones in the human colon based on colabelling with choline acetyltransferase, in addition to CB(1) receptor labelling in unidentified structures in the CM. In conclusion, activation of CB(1) receptors coupled to cholinergic motorneurones selectively and reversibly inhibits excitatory nerve transmission in colonic human colonic CM. These results provide evidence of a direct role for cannabinoids in the modulation of motor activity in the human colon by coupling to cholinergic motorneurones.

Benchmarking as a tool of continuous quality improvement in postoperative pain management

BACKGROUND AND OBJECTIVE

Quality of acute pain management is far from being satisfactory. These deficits are not caused by the complexity of the medical problem but by difficulties in organization and hospital structures, sand procedures. Continuous quality improvement is a recommended tool to overcome such difficulties and to increase quality in the long run. This study reports the implementation of benchmarking-based continuous quality improvement to improve postoperative pain management at a university hospital.

METHODS

A specialised pain nurse interviewed patients of three surgical departments on the first day after surgery, and continuously assessed process and outcome quality parameters. A multidisciplinary team of anaesthetists, surgeons, nurses and pharmacists implemented a regular procedure of data analysing and internal benchmarking. Results and suggested improvements were fed back to the healthcare teams.

RESULTS

From 1998 to 2002, 6,756 patients were assessed. Average pain on ambulation and maximal pain were 3.7 +/- 2.4 and 5.0 +/- 2.5 (mean +/- SD) on a 11-point numeric rating scale. Pain intensity at rest was 1.9 +/- 1.8. Over time, pain intensity on ambulation decreased (P = 0.022) whereas maximal pain and pain at rest remained unchanged. There was an increase in the number of patients who received non-opioid analgesia (P < 0.001).

CONCLUSIONS

A continuous quality improvement process could be established and is now successfully used in clinical routine. Cornerstones of this project were frequent assessments of process and outcome parameters, regular benchmarking and implementation of feedback mechanisms. Changes in organization of medical management and multidisciplinary teamwork seem to be more important than medical or technical aspects.

Keratan sulphate levels in mucopolysaccharidoses and mucolipidoses

The mucopolysaccharidoses (MPS) is characterized by accumulation of glycosaminoglycans (GAGs), and mucolipidosis (ML) by accumulation of GAGs and sphingolipids. Each type of MPS accumulates specific GAGs. The lysosomal enzymes N-acetylgalactosamine-6-sulphate sulphatase and beta-galactosidase involve the stepwise degradation of keratan sulphate (KS). Deficiency of these enzymes results in elevation of KS levels in the body fluids and in tissues, leading to MPS IV disease. In this study, we evaluated blood and urine KS levels in types of MPS and ML other than MPS IV. Eighty-five plasma samples came from MPS I (n = 18), MPS II (n = 28), MPS III (n = 20), MPS VI (n = 3), MPS VII (n = 5) and ML (n = 11) patients while 127 urine samples came from MPS I (n = 34), MPS II (n = 34), MPS III (n = 32), MPS VI (n = 7), MPS VII (n = 9) and ML (n = 11) patients. KS levels were determined using the ELISA method. Plasma KS levels varied with age in both control and patient populations. In all age groups, the mean values of plasma KS in MPS and ML patients were significantly higher than those in the age-matched controls. Plasma KS values in four newborn patients were above the mean + 2SD of the age-matched controls (mean, 41 ng/ml). Overall, 85.9% of individual values in non-type IV MPS and ML patients were above the mean + 2SD of the age-matched controls. For urine KS levels, 24.4% of individual values in patients were above the mean + 2SD of the age-matched controls. In conclusion, KS in blood is elevated in each type of non-type IV MPS examined, in contrast to the conventional understanding. This finding suggests that measurement of KS level provides a new diagnostic biomarker in a wide variety of mucopolysaccharidoses and mucolipidoses in addition to MPS IV.

Decreased plasma concentration of von Willebrand factor antigen (VWF:Ag) in patients with glycogen storage disease type Ia

Despite highly increased blood lipids, patients with glycogen storage disease type Ia (GSD Ia) do not develop premature vascular complications. Since this could be due to changes of coagulation factors, coagulation tests (including von Willebrand factor (VWF) antigen (VWF:Ag) ELISA, VWF:collagen binding activity (VWF:CB) and VWF multimer analysis) were performed in 10 GSD Ia patients, single cases of other GSD types, and in both healthy and hyperlipidaemic controls. In 60% of GSD Ia patients we found abnormal results, with a decrease of VWF:Ag and multimer analysis showing reduced intensity of individual oligomers in the presence of all multimers with a normal triplet structure. We interpret these findings as an acquired 'von Willebrand syndrome type I' in GSD Ia. The underlying metabolic mechanism and a potential role in the protection from vascular complication still needs to be evaluated.

Heparan sulfate levels in mucopolysaccharidoses and mucolipidoses

Glycosaminoglycans are accumulated in both mucopolysaccharidoses (MPS) and mucolipidoses (ML). MPS I, II, III and VII and ML II and ML III patients cannot properly degrade heparan sulphate (HS). In spite of the importance of HS storage in the metabolic pathway in these diseases, blood and urine HS levels have not been determined systematically using a simple and economical method. Using a new ELISA method using anti-HS antibodies, HS concentrations in blood and urine were determined in MPS and ML II and ML III patients. HS concentrations were determined in 156 plasma samples from MPS I (n = 23), MPS II (n = 26), MPS III (n = 24), MPS IV (n = 62), MPS VI (n = 5), MPS VII (n = 5), ML II (n = 8) and ML III (n = 3), and 205 urine samples from MPS I (n = 33), MPS II (n = 33), MPS III (n = 30), MPS IV (n = 82), MPS VI (n = 7), MPS VII (n = 9), ML II (n = 8) and ML III (n = 3). The ELISA method used monoclonal antibodies against HS. MPS I, II, III and VII and ML II and III patients had significant elevation in plasma HS, compared to the age-matched controls (p < 0.0001). Eighty-three out of 89 (93.3%) of individual values in the above MPS types and ML were above the mean +2SD of the controls. In urine samples, 75% of individual values in patients with those types were above the mean +2SD of the controls. In contrast to the previous understanding of the HS metabolic pathway, plasma HS levels in all five MPS VI and 15% of MPS IV patients were elevated above the mean +2SD of the controls. These findings suggest that HS concentration determined by ELISA, especially in plasma, could be a helpful marker for detection of the most severe MPS I, II, III, VI and VII and ML II, distinguishing them from normal populations.

3-Hydroxyglutaric acid fails to affect the viability of primary neuronal rat cells

Glutaric aciduria type I (GA I) is an autosomal recessive inherited metabolic disorder caused by deficiency of glutaryl-CoA dehydrogenase (GCD) resulting in the accumulation of 3-hydroxyglutaric acid (3OHG), glutaric acid and glutaconic acid in body fluids. GA I is characterized by a specific age- and brain region-dependent neuropathology. Previous studies using organotypic slice cultures of rats and primary chick embryo telencephalon cell cultures indicated that death of neurons is a consequence of an excitotoxic mechanism induced by 3OHG. We used primary neuronal cells of neonatal rats as a model system to test cell viability after treatment with 3OHG. Western blot analysis was used to prove the expression of functional N-methyl-D-aspartate (NMDA) receptors revealing no alteration in the expression of NMDA-2a and -2b receptor subtypes in response to 3OHG. When neuronal cells cultured for 10 or 20 days were treated with 1 mM glutamate, the viability of cells was reduced by 40%. This effect could be prevented by coincubation with the NMDA receptor antagonist MK801. In contrast, incubation of cells with 3OHG for up to 24 h in concentrations of 4-8 mM did not cause increased cell death as compared with untreated control cultures. These results indicate that 3OHG is not excitotoxic in this model of neuronal rat cell cultures despite the presence of functional NMDA receptors. Therefore, alternative or additional pathomechanisms than excitotoxicity may be relevant for neurodegeneration in GA I.

Vascular dysfunction as an additional pathomechanism in glutaric aciduria type I

The metabolic hallmark of glutaric aciduria type I (GA I) is the deficiency of glutaryl-CoA dehydrogenase (GCDH) with subsequent accumulation of glutaric acid, 3-hydroxglutaric acid (3-OH-GA) and glutaconic acid. Current concepts regarding pathomechanisms of GA I focus on investigations of excitotoxic effects of 3-OH-GA. To identify pathogenetically relevant genes, microarray analyses were performed using brain material from GCDH-deficient (GCDH (-/-)) and control mice. These microarray data confirmed recent pathogenic models, but also revealed alterations in genes that had previously not been correlated to the disease, e.g. genes concerning vascular biology. Subsequent in vitro and in vivo experiments confirmed direct effects of 3-OH-GA on vascular permeability and endothelial integrity. Clinical observations underscore the involvement of vascular dysfunction. In MRI scans of GA I patients, subdural effusions as well as dilated transarachnoid vascular plexuses were detected independently of encephalopathic crises. In fact, some of these findings are already detectable shortly after birth. MRI scans of a GA I patient performed during an acute encephalopathic crisis detected a dilated intrastriatal vasculature with perivascular hyperintensity, indicating local extravasation. In conclusion, we hypothesize that 3-OH-GA affects prenatal development of vessels, thus leading to an increased vulnerability of endothelial structures and subsequent vascular dysfunction. These observations display an additional pathomechanism in GA I and might explain frontotemporal hypoplasia and chronic subdural effusions in this disease. Elucidation of the pathomechanisms of vascular dysfunction may give further insights into the pathogenesis of GA I.

Maintenance treatment of glutaryl-CoA dehydrogenase deficiency

This paper summarizes the published experience as well as results of the 3rd International Workshop on Glutaryl-CoA Dehydrogenase Deficiency held in October 2003 in Heidelberg, Germany, on the topic treatment of patients with glutaryl-CoA dehydrogenase (GCDH) deficiency. So far no international recommendation for treatment of GCDH deficiency exists. Such an approach is hampered by several facts, namely the lack of an in-depth understanding of the pathophysiology of the disease, the lack of prospective studies, including the evaluation of drug monotherapy, and lack of objective documentation of clinical changes (e.g. video documentation) during pharmacotherapy.

Efficiency of long-term tetrahydrobiopterin monotherapy in phenylketonuria

Phenylketonuria, an inborn error of phenylalanine metabolism, occurs with a frequency of about 1 in 10,000 births and is treated with a strict dietary regimen. Recently, some patients with PKU have been found to show increased tolerance towards phenylalanine intake while receiving tetrahydrobiopterin (BH(4)) supplementation. We have treated two infants with BH(4)-responsive PKU with BH(4) for more than 2 years. No additional dietary control was required to maintain blood phenylalanine concentrations in the desired range. Both children have shown normal development. Generally, our results suggest that BH(4) treatment might be an option for some patients with mild PKU, as it frees them from dietary restrictions and thus improves their quality of life.

Excitotoxicity and bioenergetics in glutaryl-CoA dehydrogenase deficiency

Glutaryl-CoA dehydrogenase deficiency is an inherited organic acid disorder with predominantly neurological presentation. The biochemical hallmark of this disease is an accumulation and enhanced urinary excretion of two key organic acids, glutaric acid and 3-hydroxyglutaric acid. If untreated, acute striatal damage is often precipitated by febrile illnesses during a vulnerable period of brain development in infancy or early childhood, resulting in a dystonic dyskinetic movement disorder. 3-hydroxyglutaric and glutaric acids are structurally similar to glutamate, the main excitatory amino acid of the human brain, and are considered to play an important role in the pathophysiology of this disease. 3-hydroxyglutaric acid induces excitotoxic cell damage specifically via activation of N-methyl-D-aspartate receptors. It has also been suggested that secondary amplification loops potentiate the neurotoxic properties of these organic acids. Probable mechanisms for this effect include cytokine-stimulated NO production, a decrease in energy metabolism, and reduction of cellular creatine phosphate levels. Finally, maturation-dependent changes in the expression of neuronal glutamate receptors may affect the vulnerability of the immature brain to excitotoxic cell damage in this disease.

A hypothesis on the biochemical mechanism of BH(4)-responsiveness in phenylalanine hydroxylase deficiency

We describe six children with tetrahydrobiopterin (BH(4)) responsive phenylalanine hydroxylase (PAH) deficiency. All patients carry two mutant alleles in the PAH gene. Cofactor deficiency was excluded. The effect of BH(4) administration was studied by correlating different oral BH(4) doses with plasma phenylalanine levels under defined protein intake. Our results indicate that oral BH(4) supplementation may be used as long-term treatment for individuals with BH(4)-responsive PAH deficiency, either without or in combination with a less restrictive diet. Previous in vitro studies have demonstrated that BH(4) inhibits PAH tetramers but activates PAH dimers. This may indicate, that BH(4)-responsiveness results from BH(4) induced stabilization of mutant PAH dimers. In addition, interindividual differences in the cellular folding apparatus may determine the tertiary structure and the amount of mutant PAH dimers and hence may account for divergent BH(4)-responsiveness reported for the same PAH genotype.

Infantile cobalamin deficiency with cerebral lactate accumulation and sustained choline depletion

A remarkable, intermittent sudden-onset vigilance and movement disorder in an exclusively breast-fed infant is reported, which was caused by cobalamin depletion due to maternal vitamin B12 malabsorption. The lack of cobalamin caused a severe encephalopathy in the infant, whose brain displayed a striking loss of volume and a delay of myelination. Proton magnetic resonance spectroscopy revealed an accumulation of lactate in the gray and white matter of the brain and a sustained depletion of choline-containing compounds in the white matter, reflecting a reversible disturbance of oxidative energy metabolism in brain cells and a long-lasting hypomyelination disorder. The clinical picture in conjunction with MRI and spectroscopic data of this case study yields more insight into the functions of cobalamin in the cerebral metabolism.

Investigation of the cerebral energy status in patients with glutaric aciduria type I by 31P magnetic resonance spectroscopy

In vivo phosphorus magnetic resonance spectroscopy (MRS) was used to investigate markers of the cerebral energy status in two patients with glutaric aciduria type I (GA-I). Besides an increased concentration of phosphomonoesters in one patient, no other significant alterations from controls were found. This might indicate increased resynthesis of dendritic processes secondary to preceding metabolic crises. In contrast to previous cell-culture studies, no cerebral depletion of phosphocreatine (PCr) was observed. In conclusion, a severe global and permanent depletion of cerebral energy supplies must be ruled out. The benefit of a permanent creatine substitution to stabilize mitochondrial energy metabolism seems thus questionable. However, as MRS was performed during stable clinical conditions, the possibility of a PCr decrease during acute metabolic crises cannot be assessed.

Glutaric aciduria I: creatine supplementation restores creatinephosphate levels in mixed cortex cells from rat incubated with 3-hydroxyglutarate

The pathogenesis of neurological sequelae in glutaric aciduria I (GA I) is still unclear. Some evidence exists for compromised energy generation in the brain of patients with GA I resulting in 'slow-onset' excitotoxicity. Previously, we have shown a reduced activity of the mitochondrial ATPsynthase in cultured mixed cortex cells from neonatal rats incubated with 2-4mM 3-hydroxyglutarate (3-OH glut) for 24h. In the present study we measured cellular contents of high energy phosphate compounds (creatinephosphate CP, ATP, and ADP) in this model after a 24h incubation period with 2-4mM glutarate (glut) or 3-OH glut. 3-OH glut specifically led to a reduction of CP content in a dose-dependent manner, whereas concentrations of ATP, ADP, and AMP remained unchanged. The drop in CP-concentration could be prevented by preincubation with the non-competitive NMDA-receptor antagonist MK 801 or coincubation with 1mM creatine. NMDA-receptor associated ion channels may be opened due to a lack of energy inside the neurons caused by a reduction of CP. This is followed by membrane depolarization which could impair electrogenic creatine transport into the cell.

Severe phenotype despite high residual glutaryl-CoA dehydrogenase activity: a novel mutation in a Turkish patient with glutaric aciduria type I

We report the first patient with the homozygous GCDH mutation M263V, displaying a high residual activity in fibroblasts of 30%, but presenting with a severe clinical phenotype.

Individual blood-brain barrier phenylalanine transport in siblings with classical phenylketonuria

Recent studies indicate that individual blood-brain transport characteristics of phenylalanine may lead to different clinical outcomes in phenylketonuria (PKU) patients in spite of comparable dietary control. To check these preliminary data, we investigated four pairs of siblings with classical PKU (and identical genotype) using in vivo nuclear magnetic resonance spectroscopy in the course of an oral phenylalanine load (100 mg/kg body weight). Patients' brain phenylalanine concentrations were different in spite of similar blood levels. Interindividual variations of the apparent transport Michaelis constant, Kt,app, ranged from 0.10 to 0.84 mmol/L. The ratio of the maximal transport velocity, Tmax, over the intracerebral consumption rate, Vmet, varied between 2.61 and 14.0. Siblings with lower values for Kt,app, higher values for Tmax/Vmet, and higher concurrent brain phenylalanine levels showed a lower IQ and a higher degree of cerebral white matter abnormalities. The results indicate that blood-brain barrier transport characteristics and the resultant brain phenylalanine levels are causative factors for the individual clinical outcome in PKU.

[The use of the infraclavicular plexus catheter for treatment of perioperative and chronic pain]

OBJECTIVES

The aim of this prospective study was to evaluate the vertical infraclavicular approach to the brachial plexus for the insertion of a catheter to achieve continuous analgesia in postoperative patients and patients with chronic upper limb pain.

METHODS

The brachial plexus was identified using the technique described by Kilka et al. and a flexible catheter (diameter 0.85 mm) was introduced 3-5 cm into the perineural sheath via the punction cannula. Regional analgesia was achieved by intermittent injection of local anaesthetic agent. Placement of the catheter, duration and effectiveness of treatment, complications and reasons for catheter removal were recorded using a standard protocol.

RESULTS

A total number of 226 plexus catheters were placed in 210 patients. Consecutive regional analgesia for at least 48 h was possible in 88%. Analgesia was sufficient in 76% of patients up to the time of catheter removal. The median (minimum-maximum) duration of catheterisation in the whole collective was 7 days (1-240) and 11 days in patients with chronic pain. Almost 30% of the patients were treated for 10 days or longer and 4.4% were treated for 1 month or longer. Major complications occurred in only three cases, while technical problems and minor complications (redness at puncture site) occurred in 10% of cases.

CONCLUSIONS

The placement of an infraclavicular plexus catheter is a suitable method for pain management in the upper limb. This approach may have advantages in patients with severe injuries who cannot abduct the arm. Our results are encouraging in terms of catheterisation time, patient comfort and incidence of complications.

Individual blood-brain barrier phenylalanine transport determines clinical outcome in phenylketonuria

Different clinical outcomes in spite of comparable dietary controls are well known in patients with phenylketonuria. Currently, reasons for this phenomenon are unknown. Kinetic investigations in 15 patients with classic phenylketonuria were performed using in vivo nuclear magnetic resonance spectroscopy before and after an oral phenylalanine load (100 mg/kg body weight). Patients' brain phenylalanine concentrations were quite different in spite of similar blood phenylalanine levels. Interindividual variations of the apparent transport Michaelis constant, K(t,app), covered a range from 0.10 to 1.03 mmol/L. The ratio of the maximal transport velocity, Tmax, over the intracerebral consumption rate, Vmet, varied between 2.61 and 14.0. Both parameters as well as the preload brain phenylalanine levels correlated significantly with the degree of cerebral white matter abnormalities on magnetic resonance images. Correlations of K(t,app), Tmax/Vmet, and the preload brain phenylalanine levels with patients' intelligence scores approached significance. In conclusion, blood-brain barrier phenylalanine transport characteristics and the resultant brain phenylalanine levels seem to be causative factors for the individual clinical outcome in phenylketonuria. This observation may lead to individual dietary recommendations in the future.

[Quality management in postoperative pain therapy]

BACKGROUND

Deficits in quality of postoperative pain management are not caused by the complexity of the medical problem or shortage of suitable drugs but by difficulties in organization and hospital structures. Moreover, there is no consensus on how to measure the quality of pain management. Quality management programs consist of strategies to overcome such difficulties and to increase quality continuously. This study reports the implementation of a quality management program to improve postoperative pain management at a university hospital.

METHODS

An interdisciplinary task force consisting of nursing staff, anesthesiologists, surgeons, and members of the hospital pharmacy was set up. This task force interviewed patients and performed an analysis of current deficits (phase 1). Then, primary and secondary outcome parameters were defined to measure quality of pain management, and strategies were defined to implement improvements (phase 2). These referred to aspects of organization, standardization, and responsibility. One of the main intentions was the involvement of nursing staff. After implementation (phase 3), a second analysis was performed (phase 4). This was followed by a continuous assessment of parameters indicating quality of procedures and results which were fed back to all participants (phase 5).

RESULTS

After implementation of the program (phase 4), significantly more patients reported no or mild (NRS < 4) postoperative pain (40.2% vs 30.1%) compared to phase 1. Also, patients' satisfaction with pain therapy improved significantly. The proportion of patients without pain treatment decreased by one-third. Opioids were given more frequently and more often intravenously. In contrast, the proportion of i.m. injections decreased from 20% to 5%. Continuous assessment of up to now more than 4,900 patients helped to identify possible reasons for problems and to maintain overall quality of pain management.

DISCUSSION

Tools of quality management consisting of deficit analysis, definition of outcome parameters, implementation of improving strategies, post-intervention analysis and continuous feed-back may be successfully used to improve postoperative pain therapy. Changes in organization of medical management seem to be more important than medical or technical aspects. Similar strategies might be used to increase quality of other medical procedures.

Normal clinical outcome in untreated subjects with mild hyperphenylalaninemia

ABSTRACT There is international consensus that patients with phenylalanine (Phe) levels <360 microM on a free diet do not need Phe-lowering dietary treatment whereas patients with levels >600 microM do. Clinical outcome of patients showing Phe levels between 360 and 600 microM in serum on a free nutrition has so far only been assessed in a small number of cases. Therefore, different recommendations exist for patients with mild hyperphenylalaninemia. We investigated in a nationwide study 31 adolescent and adult patients who persistently displayed serum Phe levels between 360 and 600 microM on a normal nutrition with a corresponding genotype. Because of limited accuracy of measurements, Phe levels should be looked on as an approximation, but not as an absolute limit in every instance. In addition to serum Phe levels, the assessment program consisted of comprehensive psychological testing, magnetic resonance imaging of the head, (1)H magnetic resonance spectroscopy, and genotyping. We found a normal intellectual (intelligence quotient, 103 +/- 15; range, 79-138) and educational (school performance and job career) outcome in these subjects as compared with healthy control subjects (intelligence quotient, 104 +/- 11; range, 80-135). Magnetic resonance imaging revealed no changes of cerebral white matter in any patient, and (1)H magnetic resonance spectroscopy revealed brain Phe levels below the limit of detection (<200 microM). In the absence of any demonstrable effect, dietary treatment is unlikely to be of value in patients with mild hyperphenylalaninemia and serum Phe levels <600 microM on a free nutrition, and should no longer be recommended. Because of a possible late-onset phenylketonuria, Phe levels of untreated patients should be monitored carefully at least during the first year of life. Nevertheless, problems of maternal phenylketonuria should still be taken into account.