The Cerebellum and Cognitive Function: Anatomical Evidence from a Transdiagnostic Sample

Multiple lines of evidence across human functional, lesion, and animal data point to a cerebellar role, in particular of crus I, crus II, and lobule VIIB, in cognitive function. However, a mapping of distinct facets of cognitive function to cerebellar structure is missing. We analyzed structural neuroimaging data from the Healthy Brain Network (HBN). Cerebellar parcellation was performed with a validated automated segmentation pipeline (CERES) and stringent visual quality check (n = 662 subjects retained from initial n = 1452). Canonical correlation analyses (CCA) examined regional gray matter volumetric (GMV) differences in association to cognitive function (quantified with NIH Toolbox Cognition domain, NIH-TB), accounting for psychopathology severity, age, sex, scan location, and intracranial volume. Multivariate CCA uncovered a significant correlation between two components entailing a latent cognitive canonical (NIH-TB subscales) and a brain canonical variate (cerebellar GMV and intracranial volume, ICV), surviving bootstrapping and permutation procedures. The components correspond to partly shared cerebellar-cognitive function relationship with a first map encompassing cognitive flexibility (r = 0.89), speed of processing (r = 0.65), and working memory (r = 0.52) associated with regional GMV in crus II (r = 0.57) and lobule X (r = 0.59) and a second map including the crus I (r = 0.49) and lobule VI (r = 0.49) associated with working memory (r = 0.51). We show evidence for a structural subspecialization of the cerebellum topography for cognitive function in a transdiagnostic sample.

Clinical features and outcomes of COVID-19 patients hospitalized for psychiatric disorders: a French multi-centered prospective observational study

BACKGROUND

Patients with psychiatric disorders are exposed to high risk of COVID-19 and increased mortality. In this study, we set out to assess the clinical features and outcomes of patients with current psychiatric disorders exposed to COVID-19.

METHODS

This multi-center prospective study was conducted in 22 psychiatric wards dedicated to COVID-19 inpatients between 28 February and 30 May 2020. The main outcomes were the number of patients transferred to somatic care units, the number of deaths, and the number of patients developing a confusional state. The risk factors of confusional state and transfer to somatic care units were assessed by a multivariate logistic model. The risk of death was analyzed by a univariate analysis.

RESULTS

In total, 350 patients were included in the study. Overall, 24 (7%) were transferred to medicine units, 7 (2%) died, and 51 (15%) patients presented a confusional state. Severe respiratory symptoms predicted the transfer to a medicine unit [odds ratio (OR) 17.1; confidence interval (CI) 4.9-59.3]. Older age, an organic mental disorder, a confusional state, and severe respiratory symptoms predicted mortality in univariate analysis. Age >55 (OR 4.9; CI 2.1-11.4), an affective disorder (OR 4.1; CI 1.6-10.9), and severe respiratory symptoms (OR 4.6; CI 2.2-9.7) predicted a higher risk, whereas smoking (OR 0.3; CI 0.1-0.9) predicted a lower risk of a confusional state.

CONCLUSION

COVID-19 patients with severe psychiatric disorders have multiple somatic comorbidities and have a risk of developing a confusional state. These data underline the need for extreme caution given the risks of COVID-19 in patients hospitalized for psychiatric disorders.

Closed loop stimulation in heart failure patients with severe chronotropic incompetence: responder versus non-responders

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Biotronik SE & Co. KG Woermannkehre 1 12359 Berlin

Background

The prevalence of chronotropic incompetence (CI) in heart failure (HF) population is high and negatively impacts prognosis. Rate-adaptive pacing (RAP) is an important treatment option for CI. However, only a proportion of HF patients treated with cardiac resynchronisation therapy (CRT) devices benefit from accelerometer-based RAP in terms of exercise tolerance, functional capacity, and quality of life (QoL). Further research is needed to identify patient characteristics predicting positive response to RAP, and to evaluate performance of alternative sensors such as closed loop stimulation (CLS) driven by cardiac impedance measurements. An optimal outcome measure is represented by ventilatory efficiency (VE) slope during cardio-pulmonary exercise test (CPX) because of superior prognostic value.

Purpose

The purpose of the BIO|Create pilot study was to assess the benefit of CLS in CRT patients with CI. In this predefined subanalysis, we identify predictors of positive response to CLS (reduction of VE slope by ≥5%) and compare study outcomes in responders vs non-responders.

Methods

The study enrolled CRT patients with NYHA class II or III and severe CI (<75% of age-predicted maximum heart rate [HR] or <50% of HR reserve utilised at end-exercise). Patients were randomised to DDD-CLS mode or to DDD pacing at 40 beats/min for 1 month, followed by crossover for another month. At 1- and 2-month follow-ups, exercise tolerance was assessed by treadmill CPX, functional capacity by 6-min walk test, and QoL by the EQ-5D-5L and Minnesota Living with HF (MLHFQ) questionnaires.

Results

Among 17 patients with full follow-up datasets, 8 (47%) were responders to CLS. Compared to non-responders, responders had larger left ventricular (LV) ejection fraction at baseline (46 ± 3 vs 36 ± 9 %; p = 0.0070), smaller end-diastolic (121 ± 34 vs 181 ± 41 ml; p = 0.0085) and end-systolic (65 ± 23 vs 114 ± 39 ml; p = 0.0076) LV volumes, and were predominantly in NYHA class II (p = 0.0498). For study outcomes, the mean difference between DDD-CLS and DDD-40 modes in responders vs non-responders was - 6.1 (-16.4%) vs +2.7 (+6.8%) for VE slope (both p < 0.05), +0.5 vs -0.2 ml/min (O2 uptake efficiency slope), +1.3 vs -0.3 ml/kg/min (peak O2 uptake), +1.4 vs -0.75 mmHg (end-exercise end-tidal CO2), 16 vs 7 m (6-min walk distance), 0.08 vs 0.06 (EQ-5D-5L index), 1.9 vs 0 (EQ-5D-5L scale), and -2.5 vs +1.75 (MLHFQ).

Conclusions

For the first time, predictors for positive outcome of RAP in CRT patients have been identified. Patients with less advanced HF were responders to RAP driven by CLS principle. In addition, a consistent increase in exercise and functional capacity and QoL in these patients could be achieved. In contrast, patients with advanced HF experienced worse exercise capacity and QoL during RAP, suggesting caution if RAP is desirable due to CI. Further clinical research is needed to evaluate if positive response to RAP can improve hard clinical outcomes.

Creation of physiologic rhythm by closed loop stimulation in heart failure patients with severe chronotropic incompetence: worldwide first results of a pilot study

Background

The prevalence of chronotropic incompetence (CI) in heart failure (HF) population is high and negatively impacts prognosis. In HF patients with an implanted cardiac resynchronisation therapy (CRT) device and severe CI, the effect of rate adaptive pacing on patient outcomes is unclear. Closed loop stimulation (CLS) based on cardiac impedance measurement may be an optimal method of heart rate adaptation according to metabolic need in HF patients with severe CI.

Purpose

This is the first study evaluating the effect of CLS on the established prognostic parameters assessed by the cardio-pulmonary exercise (CPX) testing and on quality of life (QoL) of the patients.

Methods

A randomised, controlled, double-blind and crossover pilot study has been performed in CRT patients with severe CI defined as the inability to achieve 70% of the age-predicted maximum heart rate (APMHR). After baseline assessment, patients were randomised to either DDD-CLS pacing (group 1) or DDD pacing at 40 bpm (group 2) for a 1-month period, followed by crossover for another month. At baseline and at 1- and 2-month follow-ups, a CPX was performed and QoL was assessed using the EQ-5D-5L questionnaire. The main endpoints were the effect of CLS on ventilatory efficiency (VE) slope (evaluated by an independent CPX expert), the responder rate defined as an improvement (decrease) of the VE slope by at least 5%, percentage of maximal predicted heart rate reserve (HRR) achieved, and QoL.

Results

Of the 36 patients enrolled in the study, 20 fulfilled the criterion for severe CI and entered the study follow-up (mean age 68.9±7.4 years, 70% men, LVEF=41.8±9.3%, 40%/60% NYHA class II/III). Full baseline and follow-up datasets were obtained in 17 patients. The mean VE slope and HRR at baseline were 34.4±4.4 and 49.6±23.8%, respectively, in group 1 (n=7) and 34.5±12.2 and 54.2±16.1% in group 2 (n=10). After completing the 2-month CPX, the mean difference between DDD-CLS and DDD-40 modes was −2.4±8.3 (group 1) and −1.2±3.5 (group 2) for VE slope, and 17.1±15.5% (group 1) and 8.7±18.8% (group 2) for HRR. Altogether, VE slope improved by −1.8±2.95 (p=0.31) in DDD-CLS versus DDD-40, and HRR improved by 12.9±8.8% (p=0.01). The VE slope decreased by ≥5% in 47% of patients (“responders to CLS”). The mean difference in the QoL between DDD-CLS and DDD-40 was 0.16±0.25 in group 1 and −0.01±0.05 in group 2, resulting in an overall increase by 0.08±0.08 in the DDD-CLS mode (p=0.13).

Conclusion

First results of the evaluation of the effectiveness of CLS in CRT patients with severe CI revealed that CLS generated an overall positive effect on well-established surrogate parameters for prognosis. About one half of the patients showed CLS response in terms of improved VE slope. In addition, CLS improved quality of life. Further clinical research is needed to identify predictors that can increase the responder rate and to confirm improvement in clinical outcomes.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Biotronik SE & Co. KG

[Informations on psychotropics and their adaptations for patients suffering from mental disorders in France during the SARS-CoV-2 epidemic]

The 2019-20 coronavirus pandemic (SARS-CoV-2; severe acute respiratory syndrome coronavirus 2) has dramatic consequences on populations in terms of morbidity and mortality and in social terms, the general confinement of almost half of the world's population being a situation unprecedented in history, which is difficult today to measure the impact at the individual and collective levels. More specifically, it affects people with various risk factors, which are more frequent in patients suffering from psychiatric disorders. Psychiatrists need to know: (i) how to identify, the risks associated with the prescription of psychotropic drugs and which can prove to be counterproductive in their association with COVID-19 (coronavirus disease 2019), (ii) how to assess in terms of benefit/risk ratio, the implication of any hasty and brutal modification on psychotropic drugs that can induce confusion for a differential diagnosis with the evolution of COVID-19. We carried out a review of the literature aimed at assessing the specific benefit/risk ratio of psychotropic treatments in patients suffering from COVID-19. Clinically, symptoms suggestive of COVID-19 (fever, cough, dyspnea, digestive signs) can be caused by various psychotropic drugs and require vigilance to avoid false negatives and false positives. In infected patients, psychotropic drugs should be used with caution, especially in the elderly, considering the pulmonary risk. Lithium and Clozapine, which are the reference drugs in bipolar disorder and resistant schizophrenia, warrant specific attention. For these two treatments the possibility of a reduction in the dosage - in case of minimal infectious signs and in a situation, which does not allow rapid control - should ideally be considered taking into account the clinical response (even biological; plasma concentrations) observed in the face of previous dose reductions. Tobacco is well identified for its effects as an inducer of CYP1A2 enzyme. In a COVID+ patient, the consequences of an abrupt cessation of smoking, particularly related with the appearance of respiratory symptoms (cough, dyspnea), must therefore be anticipated for patients receiving psychotropics metabolized by CYP1A2. Plasma concentrations of these drugs are expected to decrease and can be related to an increase risk of relapse. The symptomatic treatments used in COVID-19 have frequent interactions with the most used psychotropics. If there is no curative treatment for infection to SARS-CoV-2, the interactions of the various molecules currently tested with several classes of psychotropic drugs (antidepressants, antipsychotics) are important to consider because of the risk of changes in cardiac conduction. Specific knowledge on COVID-19 remains poor today, but we must recommend rigor in this context in the use of psychotropic drugs, to avoid adding, in patients suffering from psychiatric disorders, potentially vulnerable in the epidemic context, an iatrogenic risk or loss of efficiency.

A double dissociation between two psychotic phenotypes: Periodic catatonia and cataphasia

Schizophrenia as a single liability model was confronted to the multiple psychotic phenotypes model proposed by the Wernicke-Kleist-Leonhard school, focusing on two: periodic catatonia (PC) and cataphasia (C). Both are stable and heritable psychotic phenotypes with no crossed liability and are coming with the buildup of specific residual symptoms: impairment of psychomotricity for PC and a specific disorganization of thought and language in C. Regional cerebral blood flow (rCBF) was used as a biomarker. We attempted to refute the single phenotype model by looking at relevant and specific rCBF anomalies for PC and C, that would exceed anomalies in common relative to controls (CTR), i.e. looking for a double dissociation. Twenty subjects with PC, 9 subjects with C and 27 matched controls had two MRI QUIPSS-II arterial spin labeling sequences converted in rCBF. One SPM analysis was performed for each rCBF measurement and the results were given as the conjunction of both analysis. There was a clear double dissociation of rCBF correlates between PC and C, both being meaningful relative to their residual symptomatology. In PC: rCBF was increased in the left motor and premotor areas. In C: rCBF was decreased bilaterally in the temporo-parietal junctions. Conversely, in both (schizophrenia): rCBF was increased in the left striatum which is known to be an anti-psychotics' effect. This evidence refuts the single schizophrenia model and suggests better natural foundations for PC and C phenotypes. This pleads for further research on them and further research on naturally founded psychotic phenotypes.

CLINICAL TRIAL

Name of the registry: ClinicalTrials.gov Identification: NCT02868879.

[Right ventricular outflow tract tachycardia 30 years after surgical correction of tetralogy of Fallot]

This case report describes a 31-year-old man with a sustained wide complex tachycardia with left bundle brunch block morphology after surgical repair of a tetralogy of Fallot. The tachycardia was inducible after orciprenaline administration after ventricular stimulation with one extra beat. In combination with the three-dimensional electroanatomic mapping system and pace mapping technique the origin of the tachycardia was identified at the lateral free wall of the right ventricular outflow tract tachycardia (RVOT) inferior of the pulmonary valve. Successful radiofrequency ablation was performed and the patient is still free from ventricular tachycardia.

[Cardiac resynchronisation with atrial sensing: Is it feasible?]

In this article the cases of two female patients with heart failure (functional class III) and an intrinsic complete left bundle branch block are reported. Both patients have had an implanted cardioverter defibrillator (ICD) connected to a VDD lead for primary prevention of sudden cardiac death. Atrial sensing was good/acceptable with a physiological frequency histogram and normal PQ time. A system upgrade to cardiac resynchronization therapy device (CRT) was planned. The VDD lead was directly connected to the Bivent ICD. The follow up showed stable measurements and a high biventricular pacing rate. Thus, usage of VDD leads for atrial sensing in CRT seems to be possible in a selected patient population.

[Magnetic resonance imaging and implantable cardiac devices. Current status and future perspectives of MR-compatible systems]

Conventional pacemakers and implantable cardioverter-defibrillators (ICD) have always been regarded as a contraindication to magnetic resonance imaging (MRI). MR-compatible systems represent a recent and particularly important innovation, since they will provide device patients with significantly improved access to MR examinations. However, the safe application of MR-compatible technology requires a detailed understanding of the strictly defined cardiologic and radiologic requirements and conditions that are to be adhered to before and during an MR examination. The present article gives an overview of problematic MR interactions with implanted devices, illustrates the most important aspects of MR-compatible pacemaker and ICD systems, analyzes their current clinical status, and offers a critical perspective.

Unmasking of myopotential oversensing by an integrated bipolar defibrillator lead following AV node ablation

A 73-year-old man with nonischemic cardiomyopathy underwent catheter ablation of ventricular tachycardia that had resulted in frequent shocks from his implanted cardiac resynchronization therapy defibrillator (CRT-D). Coexisting atrial fibrillation required AV node ablation which rendered the patient pacemaker dependent. During follow-up, recurrent episodes of dizziness occurred caused by inhibition of pacing due to oversensing of pectoral muscle myopotentials. Surgical revision was performed and the intraoperative examination revealed an intact integrated bipolar defibrillator lead with appropriate connections to the CRT-D header. The placement of an additional pace/sense lead completely resolved the patient's symptoms and no further myopotential oversensing was recorded.

Iceman Survived due to Cooling Device

Although mild hypothermia treatment is part of the standard postresuscitation care today, no standard method for treatment of accidental severe hypothermia has been yet established. Different strategies including invasive and noninvasive methods have been described in the literature. We present the case of a 75-year-old man with accidental severe hypothermia (23°C) and demonstrate that using a surface cooling device with automatic controlled temperature feedback mechanism (ArcticSun2000 Medivance, Louisville, Colorado, USA) is an effective and safe method for controlled rewarming in this life-threatening setting.

Neutrophils in cerebrospinal fluid without pleocytosis

Neutrophils in cerebrospinal fluid (CSF) samples are commonly considered a pathological feature; however, there is little information on the frequency and significance of these cells in CSF samples without pleocytosis. Therefore, the frequency and possible clinical significance of neutrophils in CSF was investigated. In a retrospective study comprising 1556 consecutive CSF samples, cytologies and patient records were reviewed. Five hundred thirty-eight CSF samples without pleocytosis were identified. Neutrophils were detected in 35.5% of these samples. The presence of neutrophils was associated with sepsis (P < 0.01), recent epileptic seizure (P < 0.0001), and blood contamination (P < 0.01). Amongst patients without CSF pleocytosis, CNS infections were not more frequent if neutrophils were present. Neutrophils are frequently observed in CSF with normal leukocyte counts. As sepsis but not CNS infection occurred more frequently in these patients, we conclude that in the absence of CSF pleocytosis, neutrophils are not indicative of CNS infections.

Metformin-associated lactic acidosis in patients with renal impairment solely due to drug accumulation?

AIM

We suspect that the life-threatening complication of metformin-associated lactic acidosis, solely due to drug accumulation following renal impairment, occurs more frequently than that previously reported and is not necessarily associated with other predisposing factors for lactic acidosis.

METHODS

During a period of 13 months, at a tertiary referral centre, the incidence of lactic acidosis of any aetiology was 12.8% [67 of 524 total intensive care unit (ICU) admissions]. Metformin-associated lactic acidosis solely as the result of drug accumulation was diagnosed in 6% of all the patients suffering from lactic acidosis (4 of 67 patients).

RESULTS

These patients presented with severe circulatory shock due to lactic acidosis. We could not identify any predisposing factor for lactic acidosis other than renal impairment. Intercurrent deterioration of diabetic nephropathy was suspected to be responsible for the accumulation of metformin followed by lactic acidosis, finally resulting in multiorgan failure. The diagnosis was supported by extensively elevated serum levels of metformin. Two patients died during ICU treatment.

CONCLUSIONS

Our data indicate that the incidence of metformin-associated lactic acidosis solely due to metformin accumulation is possible and underestimated. Symptoms of metformin-associated lactic acidosis are unspecific and physicians should be aware that metformin, if prescribed in patients with renal impairment, can cause fatal lactic acidosis due to drug accumulation.

[On the indications for and morbidity of segmental resection of the mandible for squamous cell carcinoma in the lower oral cavity]

BACKGROUND

Segmental resection of the mandibula in oral cancer surgery leads to both functional and aesthetic problems. The decision to preserve or resect the mandible depends on the vicinity of the lesion to the bone. Consequently, based on the rules of safety margins to all planes that are recommended for soft tissues, each lesion that is closer than 10 mm to the mandible needs resection of the bone.

PATIENTS AND METHODS

To establish data-based treatment modalities, a retrospective study was initiated and the results from all preoperative staging investigations of 152 patients with intraoral squamous cell carcinoma who underwent continuity or marginal resection of the mandible were evaluated. The histological outcome of the resected bone was compared to the staging results. Functional rehabilitation and long-term follow-up including survival rates were evaluated. The study reports on typical complications following segmental resection such as fracture of the reconstruction plate and demonstrates experiences with secondary microsurgical reconstructive surgery.

RESULTS

Mainly in cases of stage T1 and T2 carcinomas which are closer than 10 mm to the bone and clinically do not show any infiltration to the mandible, a marginal resection seems to be adequate. The decision about the extension of mandibular resection can be based on intraoperative cross sectional investigation of the periosteum. The survival rate of patients with intraoral carcinomas close to the mandible who underwent marginal mandibulectomy seems to be the same as in cases of continuity resection. A more conservative management of mandibular resection seems to be adequate and a data-based concept to standardize therapy of mandibular resection is presented.

Der transparotideale Zugang zur operativen Versorgung von Collumfrakturen

AIM

Different surgical approaches for the open treatment of mandibular condylar fractures are described in the literature. We evaluated the morbidity of the transparotidean approach in a prospective study over 5 1/2 years.

PATIENTS AND METHODS

A total of 48 patients with 52 condylar neck fractures class II and IV according to the Spiessl and Schroll classification were treated by a transparotidean approach. Rigid internal fixation was performed by means of miniplate fixation. After surgery, no mandibulomaxillary fixation was performed. The occurrence of surgical and functional complications was documented both during hospitalization and 1, 3, 6 and >9 months after surgery.

RESULTS

In none of our patients were major problems in wound healing such as infection of the fracture site observed. At the beginning of the study, in four cases a fistula of the parotid gland was seen within the initial days after surgery; after careful wound closure of the parotid capsula in the following operations, no further complications involving fistulas were observed. Signs of temporary palsy of the facial nerve caused by the hooks occurred in ten (19.6%) of all patients but was completely reversible within the first 6 months after the procedure. One patient suffered temporarily from a minimal malocclusion and two patients from symptoms of the temporomandibular joint 6 months postoperatively. In three patients we observed miniplate fractures without consecutive dysfunction of the TMJ or malocclusion.

CONCLUSION

Open reduction and rigid internal fixation of condylar neck fractures by transparotidean approach is a recommendable procedure in class II and IV fractures. With the advantages of minimal tissue alteration and rare complications on the one hand and sufficient exposure of the fracture site on the other hand, this technique has been established as a standard procedure in treating condylar neck fractures by open reduction.

Calculation of individual cardiovascular risk in a primary prevention setting shows a high number of patients with a high risk score

On occasion of the annual convention of the European Society of Cardiology, general awareness was used to stage an event to inform the public about cardiovascular risk and cardiovascular disease. After the measurement of blood pressure, HDL and total cholesterol and after answering questions on smoking and medication visitors received a printout showing their individual calculated cardiovascular event rate over the next ten years. For the calculation of the expected event rate, the algorithm of the Adult Treatment Panel III was used. Of the 43,500 visitors 1513 were screened, 651 male, 862 female. Of those screened in this primary prevention setting 143 male (22.07%) and 9 female (1.02%) had an expected cardiovascular event rate of 20% or more over the next ten years requiring immediate action according to the current guidelines. The calculated risk scores are considerably lower than would be expected in a representative sample from the population. This indicates that patients with a high cardiovascular risk possibly do not take part in unstructured primary screening events.

[Polygraphy of a panic attack]

We studied a 24-year old female patient with Type 1 diabetes mellitus suffering for 4 weeks from a major depressive episode combined with panic disorder without agoraphobia. A spontaneous panic attack was serendipitously recorded by polygraph while the subject was at rest. Electrocardiogram, finger blood-flow, respiratory rhythm and muscle tone (forearm, forehead) were recorded. A triphasic course consisting of a "dynamic phase" (appr. 80 s) preceded by a discrete "initial phase" (appr. 140 s) and a "declining phase" (appr. 180 s) was observed. The dynamic phase is characterized by an acute increase of fingertip vasoconstriction and heart rate. The patient was not aware of the panic attack before the dynamic phase. The recognisable central regulation confirms previously published findings indicating a sympathetic-norepinephrine activation at the beginning of the panic attack without activating the musculoskeletal system. Furthermore, a paradoxical phenomenon involving heart and respiratory rate was observed before the onset of anxiety, i.e. an increase of the heart rate and a simultaneous decline of the respiratory rate, suggesting a non-antagonistic regulation of the ergotropic-trophotropic system. The autonomic state of the patient points to a lability in homeostasis from which panic attacks as a form of CNS response could develop.

External distraction of the maxilla in patients with craniofacial dysplasia

Patients with severe maxillary hypoplasia secondary to craniofacial dysplasia present a challenge to the craniofacial surgeon. Maxillary distraction presents a promising tool to treat these patients more successfully. Fifteen patients aged 12 to 20 years with craniofacial dysplasia and maxillary retrusion were treated with two different techniques after complete Le Fort I osteotomy: one group underwent face mask protraction (2 patients), and the other group underwent rigid external distraction (13 patients). Cephalometric evaluation was performed before and after distraction. Rigid external distraction appeared to be superior to face mask protraction. Maxillary retrusion was fully corrected in this group. The path of maxillary positioning was well controlled by changing the traction force vector. Distraction osteogenesis has certainly improved treatment of these patients.

[Mid-face distraction after LeFort III osteotomy in craniofacial dysmorphism]

BACKGROUND

The success of LeFort III-osteotomy with concurrent advancement of the midface in cases of severe, midfacial hypoplasia is limited by the soft covering tissue of the facial skeleton. There appear to be significant advantages in using distraction osteogenesis of the midface after surgery.

CASE REPORT

We discuss the use of an extraoral distraction device after the osteotomy of a 10-year-old girl with Crouzon's disease. and the use of an internal device for a 6-year-old boy with severe midface hypoplasia following Apert's syndrome.

RESULTS

In both patients a significant improvement of function, as well as harmonisation of the facial proportions, could be observed and the preoperatively planned distances of midface advancement of 18 and 15 mm respectively could be achieved.

DISCUSSION

Distraction osteogenesis is an established procedure for the treatment of mandibular hypoplasia but few reports dealing with complex midface distraction are available outside of the specialist English language literature. We report on both external and internal distraction techniques with which good functional and aesthetic results were achieved.

[Callus distraction of the maxilla. Supplement or alternative to advancement osteotomy]

Total or partial relapses after conventional surgical advancement of the maxilla following Le Fort I osteotomy in CLP patients are frequent and major complications. The aim of this investigation was to find out whether the technique of distraction osteogenesis in these patients shows more stability and whether maxillary distraction is able to replace conventional advancement. Maxillary distraction was performed in 12 patients. In two cases, a Delaire mask was used to bring the maxilla forward, ten patients were treated with the extraoral distraction device designed by Polley. In all patients, planned advancement of the maxilla could be achieved; one partial relapse occurred. The results indicate that distraction osteogenesis offers the possibility of advancement of the maxilla with the required stability. The technique presents a major improvement which is achieved with a relatively minor surgical procedure.

[Surgical therapy of basalioma of the facial skin]

The present investigation reviews the history of 673 patients having undergone surgical treatment for 1301 BCC of the face between 1977 and 1992 at our department. Based on this series the features with bearing on the surgical strategy, such as type, size and location of the lesions, will be outlined. Emphasis is put on the variants of local flap reconstruction and skin grafting techniques, particularly in the problem zones of the nose and eyelids, where no excess skin for closure of the defect is available. Throughout the whole series histologic control of the adequacy of marginal and deep tumor resection was performed. It became obvious that the required ranges for clearance to tumor edges and removal in depth cannot be predefined arbitrarily or on pure clinical judgement. Frequently a two-stage procedure of resection and repair will be necessitated. Recurrences during the mandatory follow-up were thoroughly reassessed to identify the reason for failure (e.g. accuracy of histologic category, multifocal growth, predisposition) and related to the time span from primary excision. Our series confirms that morphologically controlled surgical excision of the BCC of the face and subsequent application of reconstructive techniques produces both safe oncologic and esthetic results.

Surface-modified biodegradable albumin nano- and microspheres. II: effect of surface charges on in vitro phagocytosis and biodistribution in rats

The surface charges on biodegradable albumin nanoparticles were introduced by covalent coupling different primary amines to examine their influence on phagocytosis by macrophages under in vitro conditions. Albumin particles with a zeta potential close to zero showed a reduced phagocytic uptake in comparison with charged particles, especially nanoparticles with a positive zeta potential. The phagocytic uptake in the present study was examined using an established cell culture model based on primary mouse peritoneal macrophages and a human hematopoietic monocytic cell line (U-937) treated with phorbol-12-myristic-13-acetate to induce cell differentiation. The influence of opsonins on in vitro phagocytosis experiments was characterized using carriers pre-treated with human serum. In the presence of human serum the phagocytic activity of U-937 cells was found to be similar to primary mouse macrophages without serum. In contrast to peritoneal macrophages, U-937 cells showed no phagocytic activity in the absence of serum. In particular, only the C3b- complement deposition on the particle surface seems to promote the phagocytic process. The in vivo distribution of albumin carriers in rats was investigated using magnetic resonance imaging (MRI). No differences in blood circulation times and organ accumulation between different nanoparticle preparations with positive, neutral and negative surface charges could be observed in rats, suggesting that the in vivo fate of albumin nanoparticles is significantly influenced by factors not reflected in the in vitro cell culture models.

[New techniques in maxillofacial surgery: local injection treatment with botulinum toxin A]

Intramuscular injections of botulinum neurotoxin type A cause reversible chemodenervation and subsequent paralysis by blocking the presynaptic release of acetylcholine. Botulinum toxin type A has emerged as the most effective form of symptomatic treatment for abnormabilities in muscle movement (blepharospasm, hemifacial spasm, torticollis) and has been approved for use in these conditions. First results in the treatment of patients suffering from oromandibular dystonia, myogenic craniomandibular dysfunction and recurrent dislocation of the temporomandibular joint are presented. In most cases, therapeutic effects occurred within 1-6 days post-injection. Muscular hyperfunction was reliably reduced and involuntary activity patterns gradually ceased. No severe side effects of the local injections were noted.

[Microneural reconstruction after iatrogenic lesions of the lingual nerve and the inferior alveolar nerve. Critical evaluation]

As microneural repair techniques of the sensory mandibular branches enter the third decade of their clinical use, there are but a few long-term investigations into the value of these procedures in the treatment of iatrogenic injury to the lingual (LN), inferior alveolar (IAN) or mental (MN) nerve. To establish the efficacy of microneural repair in lesions of the LN, IAN or MN with loss of continuity, the outcome of sensory recovery was evaluated in a series of 92 patients (LN: direct coaptation n = 39, coaptation + sural nerve grafting n = 23; IAN: direct coaptation n = 11 coaptation + sural nerve grafting n = 10; MN: direct coaptation n = 11). The minimum duration of follow-up was 14 months postoperatively. The persistent sensory deficit was assessed using standardized neurosensory testing and gustometric stimuli. In addition the patients answered a multiple-choice questionnaire containing a list of complaints. To obtain a numeric estimate for interindividual and intergroup comparison the information from clinical measurements and patient reports was condensed into a 'neurological score' and a 'complaint score', respectively. Furthermore, adequate items from both scores were combined to affirm or deny the return of sensory function in terms of protective and discriminative sensation. The overall results show a broad range of variation in the scores, sometimes reflecting severe degrees of persistent sensory impairment. The lowest scores, corresponding to the best regeneration, were found after direct coaptation of the LN, IAN and NM, but even the best results did not provide sensory recovery to a preinjury level. After direct coaptation of LN 69% of the patients exhibited protective sensation and 41% regained discriminative function. In contrast, LN grafting was ensued from restoration of protective function in 39% and discriminative function in 17% of the patients. More striking differences were found between coaptation and grafting of the IAN (IAN coaptation: 91% protective function; 18% discriminative function; IAN grafting: 60% protective function, 0% discriminative function). In the LN coaptation group low scores and improved taste perception were convincingly associated with short periods since injury (i.e. timing of repair). In conclusion, we feel there is sufficient justification to optimize the potential results of microneural repair by immediate (LN/MN) or early (IAN) reexposure of the injured site in order to clarify the precise nature of the underlying nerve damage and prevent delay, if patients present with complete loss of sensory function subsequent to dentoalveolar or oral surgery. However, clinical and electrophysiologic findings suggesting impairment or partial loss of sensory function are considered a contraindication to microneural intervention, in view of the limited prospects of sensory recovery after surgical repair.

Overall and site-specific risk of malignant melanoma associated with nevus counts at different body sites: a multicenter case-control study of the German Central Malignant-Melanoma Registry

A large number of benign melanocytic nevi is the major risk factor for malignant melanoma (MM). In a multicenter case-control study, the number of common (CN) and clinically atypical (AN) nevi were counted separately at individual sites in 278 melanoma patients and 278 age- and gender-matched non-melanoma controls. Relative risk (RR) adjusted for age and sex was calculated. In men as well as women, the number of CN on the legs was the best predictor of overall melanoma risk. In men, RR for developing MM when > or = 1 AN were present on the trunk was 4-fold (vs. none). In women, presence of AN on the arms increased RR 9.5-fold. For men and women combined, after adjusting for age and gender, the RR for developing MM on the trunk and on the legs was best predicted by counts of CN at the respective body region. However, high counts of CN on the arms were associated with high melanoma risk on the legs (somewhat lower on the trunk). For AN, no site-specificity of melanoma risk was found. Our data suggest that nevus counts of the legs are the best predictor of overall melanoma risk if total body nevus counts are not feasible. Although high counts of CN on the trunk and legs are associated with a higher risk of developing MM at the respective site than at another site, our data do not unequivocally support a direct site-specific melanoma risk.

Risk factors for developing cutaneous melanoma and criteria for identifying persons at risk: multicenter case-control study of the Central Malignant Melanoma Registry of the German Dermatological Society

Different pigmentary characteristics as well as different parameters of sun exposure have previously been identified as risk factors for developing cutaneous melanoma. The aim of the present study was to identify significant risk factors, determine the related magnitude of their estimated relative risks, and define criteria for the detection of persons at risk. Five hundred thirteen melanoma patients and 498 controls matched for age and sex underwent a whole-body examination for the number and type of melanocytic lesions and were interviewed on ultraviolet exposure and other potential risk factors. The total number of common melanocytic nevi on all body sites represented the most important risk factor in multiple logistic regression analysis with a relative risk of 7.6 for subjects with more than 100 versus no more than 10 melanocytic nevi. Other significant independent risk factors were the number of atypical melanocytic nevi (relative risk, 6.1 for at least 5 melanocytic nevi versus none), the number of actinic lentigines (relative risk, 3.5 for many versus none), hair color, skin type, and reported melanocytic nevus growth. No single parameter of sun exposure was significantly related to melanoma risk in the multivariate analysis. Groups with an estimated relative risk between 1 and 121.0 were distinguished by considering common and atypical melanocytic nevi as well as actinic lentigines as the decisive criteria. In conclusion, even without any information on the case history, whole-body examination and diagnosis of pigmented lesions was found to be an effective strategy for identifying persons at risk of developing melanoma. Furthermore, clinical recognition of at least 5 atypical melanocytic nevi without histologic examination is a key for identifying subjects at high risk.

Thallium and indium antimyosin dual-isotope single-photon emission tomography in acute myocardial infarction to identify patients at further ischaemic risk

Dual-isotope single-photon emission tomography (SPET) with indium-111 antimyosin and thallium-201 chloride was performed in 54 patients with acute myocardial infarction (AMI) to detect the location and extent of myocardial necrosis (antimyosin) and viable myocardium (201Tl). All patients underwent intravenous thrombolytic therapy with either streptokinase (1.5 million units/90 min) or tissue plasminogen activator (80 mg/90 min). Sensitivity in detecting MI was 91% (49/54 patients). With regard to dual-isotope SPET patterns, patients were divided into three groups: match, i.e. antimyosin uptake in segments with thallium defect (n = 8); mismatch, i.e. no uptake of either of the nuclides in corresponding segments (presence of perfusion abnormalities in the absence of antimyosin uptake) (n = 5); and overlap, i.e. thallium uptake in segments with uptake of antimyosin (n = 41). Coronary angiography and thallium exercise tests were performed in 40 and 45 patients, respectively, 5-14 days after MI. Exercise-induced ischaemia occurred in 66% of patients with overlap, 14% with match and 0% with mismatch (P < 0.05 for overlap vs other groups). If, however, major in-hospital complications (sudden cardiac death, severe arrhythmias; five overlap, three overlap in addition to match/mismatch, two match, two mismatch) were included in the statistical analysis, there was no significant difference between the three groups (P = NS). Thus, although the dual-isotope pattern "overlap" identifies a subgroup of patients with a substantial amount of residual viable tissue after MI and a high probability of exercise-induced ischaemia, this criterion is of limited value in assessing short-term prognosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Associated factors in the prevalence of more than 50 common melanocytic nevi, atypical melanocytic nevi, and actinic lentigines: multicenter case-control study of the Central Malignant Melanoma Registry of the German Dermatological Society

Several case-control studies identified common and atypical melanocytic nevi as major risk indicators for the development of cutaneous melanoma. The present investigation was planned to detect factors associated with the prevalence of these melanoma risk markers. Whole-body examination findings and interview data of 513 melanoma patients and 498 age- and sex-matched control subjects were analyzed. Existence of more than 50 common melanocytic nevi and the presence of atypical melanocytic nevi were significantly related to age and gender, with significantly elevated relative risk for their prevalence before the age of 60 and in males. Additionally, sunburns before the age of 20 were significantly associated with both more than 50 common melanocytic nevi (relative risk = 1.7) and the presence of atypical melanocytic nevi (relative risk = 1.5). Actinic lentigines were found more frequently with increasing age, and the presence of actinic lentigines was significantly related to a tendency of freckling in adolescence (relative risk = 2.0) and to two or more sunburns after the age of 20 (relative risk = 1.6). In conclusion, sunburns before the age of 20 contribute to the development of multiple melanocytic nevi and atypical melanocytic nevi. In adulthood, this type of sun exposure is associated with the development of actinic lentigines. The relative risk of developing cutaneous melanoma increases in association with the development of these benign melanocytic lesions.

Increased UV-induced sister-chromatid exchange in cultured fibroblasts of first-degree relatives of melanoma patients

Cultured fibroblasts of 17 first-degree relatives of familial melanoma patients and six first-degree relatives of cutaneous melanoma (CMM) patients with multiple CMM primaries were tested for in vitro sensitivity to UV light. Fibroblasts of nine familial CMM patients with a known UV-sensitivity and 19 healthy probands served as a control. Sister chromatid exchange (SCE) was used as a parameter to detect UV-induced genotoxic damage. We found significantly (p less than 0.001) increased UV-induced SCE levels in familial melanoma patients, as well as in first-degree relatives of familial melanoma patients (p less than 0.001) after UV-A,B irradiation (375 J/m2), compared to the healthy probands without a family history of CMM. A significant (p less than 0.001) increase of UV-induced SCE was also observed in the relatives of CMM patients with multiple CMM primaries. In addition, the spontaneous SCE were significantly increased (p less than 0.05) in familial CMM patients. This study shows that increased UV sensitivity is a familial phenomenon. It is consistent with the concept of a genetic predisposition to CMM, which is based on increased UV sensitivity and may help to define groups with an elevated risk of developing cutaneous malignant melanoma.

Elevated frequencies of micronuclei in cultured fibroblasts after freezing and thawing

Spontaneous micronuclei (MN) were determined in 69 fibroblast lines in the first subculture after cryoconservation. 45 cultures (65%) showed micronuclei in the normal range (less than 10 MN/500 cells), but 24 (35%) exhibited an elevation up to 60 MN/500 cells. In order to determine whether freezing and thawing is responsible for the enhanced MN level we studied the persistence of elevated MN in 10 cell cultures after freezing and thawing, and found that the MN levels returned to normal after 3 subcultures. In addition, the micronucleus formation before and after freezing was investigated in 2 newly established cell cultures obtained from probands whose cells had a particularly high number of MN. Both cultures had regular MN levels before freezing but a more than doubled number of MN when frozen samples were recultivated. This effect of the freezing procedure was confirmed with 5 separate biopsies obtained from the same donor. Since a freezing-related increase in MN was constantly observed in cells from some individuals but not in others, it might be possible that it is a constitutive trait which causes cultured fibroblasts of some individuals to be hypersensitive to the freezing and thawing procedure. It is also noteworthy that fibroblasts from 8 out of 12 probands with a familial malignant melanoma exhibited this phenomenon.

Ultraviolet-induced chromosomal instability in cultured fibroblasts of heterozygote carriers for xeroderma pigmentosum

Fibroblast cultures of seven patients with xeroderma pigmentosum (XP), 19 healthy sibs or parents of XP patients (XP-heterozygotes), and 24 healthy normal controls were studied for chromosome instability induced by ultraviolet rays (UV). We used a UV source that contained predominantly UV-A and UV-B at an intensity of 500 J/m2 and evaluated the induction of micronuclei (MN) and sister chromatid exchange (SCE). the XP homozygotes had a UV sensitivity that was clearly above that of all heterozygotes and normal controls. Heterozygotes had an increased rate of UV-induced MN (4.76 +/- 1.96 vs. 1.82 +/- 2.05, p less than 0.0001) and increased UV induction of SCE (13.21 +/- 3.49 vs. 9.01 +/- 1.25, p less than 0.001), as compared to normal controls. These data support epidemiologic findings that suggest that XP heterozygotes are particularly cancer prone. In addition, the determination of the UV sensitivity in vitro as described may be used for genetic counseling of asymptomatic relatives of XP patients.

[Clinical recognition of early forms of malignant melanoma]

The clinical diagnosis of malignant melanoma (MM) is based on the subjective evaluation of objective measurable parameters (criteria). The accuracy of melanoma diagnosis by dermatologists is only 75%. Particularly difficult is the diagnosis of precursors or early stages of MM. Therefore, we have studied on the one hand the intra- and interindividual reproducibility of the clinical diagnosis of pigmented lesions, and on the other hand the clinico-histopathological correlation. In addition, we have conducted a preliminary investigation designed to evaluate whether image analysis (objective and reproducible) could be used as an auxiliary instrument to differentiate between benign and malignant melanocytic lesions. In the clinical study, the intraindividual reproducibility of the combination of criteria was 69%. The interindividual reproducibility of single criteria even exhibited a range of up to 36%. Histologically "atypical/dysplastic" melanocytic lesions were considered to require excision as frequently as histologically regular melanocytic lesions. Using image analysis (single threshold segmentation, standard deviation of intensity distribution, ratio of area to circumference, Fourier analysis), we could show that it may be possible to differentiate between benign and malignant melanocytic lesions. Therefore, image analysis may be very helpful in determining the dignity of melanocytic lesions.

[Chromosome instability in patients with malignant melanoma of the skin]

The certainty of a strong genetic predisposition to malignant melanoma was first established over 35 years ago. Since it has been shown that constitutive chromosomal instability is significantly correlated with the familial occurrence of cancer, we have studied spontaneous micronucleus rates in fibroblast cultures from 44 melanoma patients, 44 healthy probands and 78 patients with bronchial carcinoma. Here we report a significantly (p = less than 0.0005) increased spontaneous chromosomal instability in patients with cutaneous malignant melanoma compared to healthy controls and other tumor patients (bronchial carcinoma).

Ultraviolet-induced formation of micronuclei and sister chromatid exchange in cultured fibroblasts of patients with cutaneous malignant melanoma

Genetically enhanced sensitivity to ultraviolet (UV) radiation may play an important role in the development of cutaneous malignant melanoma (CMM). This was studied in cultured fibroblasts of 26 CMM patients and controls by micronucleus (MN) test and sister chromatid exchange (SCE) after UV irradiation (375 J/m2). Sister chromatid exchange and MN formation were used as parameters to detect the UV-induced genotoxic damage in the individual cell strains. We found that the UV-induced level of MN was significantly increased in CMM patients (p = 0.0005), being most pronounced in the familial cases (p = 0.0001). Ultraviolet-induced SCE was also elevated in CMM patients (p = 0.001), but there was no difference between familial and nonfamilial cases. The present findings indicate that genetic predisposition contributes to the development of CMM in a subset of CMM patients and may be due to an enhanced susceptibility to UV light.

Increased numbers of spontaneous micronuclei in blood lymphocytes and cultures fibroblasts of individuals with familial cutaneous malignant melanoma

In vitro detection of micronuclei was used to determine spontaneous chromosomal instability in cultured fibroblasts of 28 healthy normal controls, 28 individuals with nonfamilial cutaneous malignant melanoma (CMM) and 14 people with familial occurrence of CMM. Lymphocytes from 40 healthy controls, 40 CMM patients and 6 individuals with familial CMM were also compared for spontaneous expression of micronuclei in vitro. In the familial cases micronucleus frequency was found to be higher, both in cultured fibroblasts (P less than 0.005) and in lymphocytes (P less than 0.001) as compared to normal controls. There was no significant difference between nonfamilial cases and normal controls. We conclude that chromosomal instability may contribute to a genetic risk for development of cutaneous malignant melanoma.