Comparison of bone remodelling around short stem and conventional straight stem in total hip replacement: a prospective randomized radiographic and dual-energy X-ray absorptiometric study

OBJECTIVE

The aim of study was to evaluate periprosthetic bone mineral density (BMD) changes of proximal femur, osseointegration and clinical outcomes after implantation of short-stemmed and conventional straight-stemmed prostheses.

METHODS

This prospective, randomized study included 50 patients with unilateral total hip replacement. The patients were randomized into 2 cohorts: patients with a cementless short stem Metha (n=25) and patients with a cementless conventional straight stem Bicontact evaluated as the control (n=25). Periprosthetic BMD changes were measured using a DEXA performed at one-week, 3-monts, 6-months and 1-year follow up. Clinical evaluation with Harris hip score (HHS) and radiographic assessment were performed through a 1 year follow up.

RESULTS

Compared to 1-week postoperative assessment, there were differences in BMD changes between the groups at the final follow-up in all ROIs, with statistical significances in ROI 1, 2, 3, 6 and 7. The loss of periprosthetic BMD in all ROIs around straight stems at each time-point was observed. There was a tendency towards a regain of BMD in all ROIs at 1-year follow-up compared to the 3-months postoperative assessment with the short stems. Less pronounced bone loss was observed around the short stems that the straight stems in ROI 1 (‒2.9 % % vs ‒16.2 %), 5 (‒4.7 % vs ‒8.9 %) and 7 (‒8.6 % vs ‒20 %). The periprosthetic BMD exceeded baseline values in the short stem cohort in ROI 2 (+4.4 % vs ‒5 %), 3 (+5.6 % vs ‒2.5 %) and 6 (+4.3 % vs ‒10 %). All stems had a radiographically stable fixation. Stress shielding-related bone resorption was markedly lower in the short stem cohort. The HHS score was comparable between the two cohorts.

CONCLUSION

The implant-specific stress shielding altered the proximal loading condition for both stems; however, the results of this study suggest a more physiological strain distribution with the short stems versus the straight stems (Tab. 3, Fig. 3, Ref. 25).

[Our experience with the metha short hip stem]

PURPOSE OF THE STUDY

The aim of the study was to evaluate the clinical and radiographic results of total hip arthroplasty (THA) with the Metha short hip stem and their comparison with the outcomes of THA using a conventional cementless stem.

MATERIAL AND METHODS

A total of 30 Metha stems and 30 standard Biocontact stems implanted in the period from 2007 to 2012 were evaluated. The Metha patient group comprised 22 women and six men, with the mean age of 58.9 ± SD 8.7 years (43-75), mean height of 164.2 ± 6.3 cm (156-178), mean body mass of 68.2 ± 12 (48-91) and mean BMI of 25 ± 3.9 (19-32). The Biocontact group included 19 women and 11 men, with the mean age of 63.6 ± 10.8 years (45-77), mean height of 166.6 ± 6.6 cm (152-175), mean body mass of 77.6 ± 13.1 (46-104) and mean BMI of 27.6 ± 4.3 (20-37). The evaluation was based on plain X-ray findings and clinical status assessed using the Harris hip score and 10-point visual analogue scale (VAS) for pain before surgery and at final follow-up.

RESULTS

In the Metha group the mean pre- and post-operative Harris hip scores were 41.7 ± 9.9 (28-57) and 94.4 ± 5.1 (82-100), respectively. In the Biocontact group the values were 41.5 ± 11.9 (32-64) and 89.3 ± 11.2 (57-100), respectively. The mean VAS for low back and thigh pain improved from the pre-operative value of 7.41 ± 2.1 (4-9) to 0.56 ± 1.0 (0-3) in the Metha group and from 7.29 ± 2.2 (4-9) to 1.64 ± 1.8 (0-5) in the Biocontact group. The post-operative results in both rating systems were significantly better (p<0.05) in the Metha than the Biocontact group patients. All stems showed radiographic evidence of good osteointegration. Stem subsidence and calcar atrophy were recorded in one patient of the Metha group. In the Biocontact group stem subsidence was found in two patients and signs of stress shielding in 14 patients.

DISCUSSION

Short hip stems have been introduced in THA implantation with the aim to restore physiological biomechanics as much as possible and to ensure good long-term functioning of the joint replacement as well as to save the proximal femoral bone tissue for potential THA re-implantation. Our results of short hip stem implantation presented in this study are compared with the results of relevant recently published literature.

CONCLUSIONS

Short hip stems show adequate osteointegration without need for diaphyseal fixation and allow for more natural weightbearing distribution in the proximal femur. The short- and mid-term clinical results are better than with the use of conventional cementless stems. They can be recommended as an optimal choice for use in younger patients with good bone quality who are expected to require THA re-implantation.

Properties of Oxyethylenated Fatty Acid Methyl Esters and Ethyl Esters; Hydrolysis, Critical Micelle Concentrations and Foaming

Oxyethylenated fatty acid methyl esters are considered to be a promising alternative to oxyethylenated fatty alcohols widely used in laundry detergent productions. Oxyethylenated fatty acid methyl esters display propensity to hydrolysis in alkaline washing solutions, which might affect the washing process. The hydrolysis of oxyethylenated fatty acid methyl esters was found to be innocuous towards the washing process since only 10% of the overall amount was hydrolyzed at 60°C, pH = 12 in 1 hour. The cmc depends on a degree of oxyethylenation. The cmc of methyl ester and ethyl ester bearing 10 oxyethylene groups is 0.8 mmol · L−1. The cmc of esters bearing 20 oxyethylene groups is 1.2 mmol · L−1. The foaming properties of oxyethylenated methyl esters bearing between 10 and 20 oxyethylene groups is constant. In case of oxyethylenated ethyl esters the foaming was increasing with the number of oxyethylene groups.

[Right colon cancer--clinicopathological findings]

BACKGROUND

The right colon cancer (RCC) has some particularities from point of view of epidemiology, clinical aspects, therapy and prognosis.

MATERIAL AND METHODS

We retrospectively analyzed the patients operated in the First Surgical Unit Iaşi during 2004 until 2009, for right colon cancer. The patients' data from the medical files were digitally encoded and included into a MS Access database, and statistically analyzed.

RESULTS

219 cases were included into the analysis, which represents 24.17% from all the patients with colorectal cancer. The median age was 66 years old. A palpable mass into the right abdominal quadrant was founded in 41.5% and anemia in 65.3%. Abdominal ultrasound exam has been performed in all the patients, with 71.3% sensitivity for primary tumor positive diagnosis. Resectability was 89.5% but without multivisceral resections. The intraoperative complication rate was 6.8%; postoperative morbidity was 19.4% with an incidence of anastomotic leak of 1.38%. The postoperative mortality rate was 2.77%. The mean overall survival was 40.13 +/- 1.93 months (median: 49.26). The prognosis factors for the survival rate were: histologic type of the tumor, stage and tumor grading, vascular and perineural invasion. The presence of metastasis in more than 3 lymphnodes as well as resection of fewer than 11 lymphnodes were found as negative prognosis factors for the survival rate.

CONCLUSIONS

RCC has an increasing incidence and it is associated especially with elderly patients. The RCC resectability is about 90% with acceptable rates of morbidity and mortality. Perineural and vascular invasion as well as rate of positive lymphnodes and count of resected lymphnodes are prognosis factor for overall survival rate.

[The porcelain gallbladder-laparoscopic approach]

A long time porcelain gallbladder was considered a relative contraindication to laparoscopic cholecystectomy, because of a high incidence of gallbladder cancer. From 12,000 patients underwent cholecystectomy in First Surgical Clinic of Iasi, 5 (0.04%) patients had porcelain gallbladder. All patients underwent ultrasound examen. Patients with porcelain gallbladder were classified as Type I to II according to preoperative ultrasound findings: three cases with porcelain gallbladder type I and two cases with porcelain gallbladder type II (in one case we found associated gallbladder carcinoma). We describe a three cases with porcelain gallbladder type I (complete calcification of gallbladder wall) treated by laparoscopic approach. Laparoscopic cholecystectomy was difficult because of adhesions and problems with grasping the thick gallbladder wall, but the postoperative course was uneventful. The histopathologic result of the specimen established the diagnosis of porcelain gallbladder type I and no cancer in the calcified wall of the gallbladder. We conclude based on cases presented and the literature review, although there is a high conversion rate, that patients with a type I porcelain gallbladder should be considered for laparoscopic cholecystectomy using a preoperative selection based on the ultrasound findings.

Acute appendicitis--open or minimally-invasive approach?

BACKGROUND

Although laparoscopy has become the standard approach in other procedures, this technique is not generally accepted for acute appendicitis.

AIM

To evaluate the results after minimally invasive appendectomies.

METHODS

All medical records of patients operated for acute appendicitis during the last year were retrospectively reviewed. We considered only patients with diagnosis of acute appendicitis confirmed by histopathology. We designed two groups: operated by open approach (OA) and operated by minimally-invasive approach (MIA). The two groups were compared for differenced in homogeneity and main end results: morbidity, mortality, hospital stay.

RESULTS

The men/women ratio was 112/88 (1.27), with a mean age of 31.83 +/- 1.06 years. There were more women in the MIA and more men in the OA group, p = 0.001. The Alvarado score was significant lower in MIA group (5.69 +/- 0.24 versus 6.57 +/- 0.23, p = 0.009). Comorbidities were noted in 51% from the patients, most of them in MIA group: 58.8%; N = 60, p = 0.016. Mean operation time was similar in both groups: 36.96 +/- 1.48 in OA versus 37.03 +/- 1.39 minutes in MIA. The postoperative mortality rate was 0.5%. The postoperative morbidity rate was 12%. Even though the number of cases with postoperative complications were double in OA group (16 cases versus 8 cases in MIA group) it did not reach statistical significance, p = 0.073. Histopathological examinations revealed early acute appendicitis in 45.5% cases (N = 91), suppurative appendicitis in 46.5% (N = 93) and gangrenous appendicitis in 8% (N = 16); early acute appendicitis was more frequent in MIA group and suppurative appendicitis in OA group: p = 0.017. The hospital stay was similar in both groups: 4.34 +/- 0.39 in OA versus 3.58 +/- 0.25 days in MIA group; p = 0.103.

CONCLUSIONS

MIA is a safe procedure and can be performed even in the patients with comorbidities. We didn't find any statistical significant difference from point of view of postoperative morbidity; however more postoperative complications were find in OA vs MIA group. The postoperative hospital stay was similar in both groups.

Training on a virtual reality simulator--is it really possible a correct evaluation of the surgeons' experience?

Laparoscopic simulators provide a safe and efficient means of acquiring surgical skills. It is well known that virtual reality training improves the performance of young surgeons. Most of the virtual reality simulators have construct validity and can differentiate between novice and expert surgeons. However, for some training modules and trainees categories the possibility to distinguish the real surgeon's experience is still discussed.

METHODS

A total of 14 young surgeons were evaluated during a 5 days postgraduate laparoscopic course using a LapSim Basic Skills, v. 3.0 simulator and a Virtual Laparoscopic Interface (VLI) hardware. The best performances of the surgeons were included in a MS Access database and statistical analyzed.

RESULTS

There were 6 males and 8 women with a mean age of 30.21 +/- 1.01 years old (range 26-38). Nine surgeons (64.28%) were young residents without any laparoscopic surgical experience (group I), and the other 5, had some laparoscopic surgical experience (10 to 30 laparoscopic procedures) (group II). During the instrument navigation task we found that both hands performances were significant better in group II--the navigation time was 12.43 +/- 1.31 vs 19.01 +/- 1.40 seconds for the left hand--p = 0.006 and 13.57 +/- 1.47 vs 22.18 +/- 3.16 seconds for the right hand--p = 0.032); the right instrument angular path degree was also shorter for experienced surgeons (153.17 +/- 16.72 vs 230.88 +/- 22.6 - p = 0.017). The same data were noted for the lifting and grasping module. However, the suturing module tasks revealed contradictory results: the group I residents recorded better performances then the group II surgeons: total time--677.06 +/- 111.48 vs 1122.65 +/- 166.62 seconds; p = 0.043; right instrument path (m)--15.62 +/- 2.47 vs 25.73 +/- 3.13; p = 0.028; right instrument angular path (degree)--3940.43 +/- 572.54 vs 6595.5597 +/- 753.26; p = 0.017.

CONCLUSIONS

Laparoscopic simulators are useful to evaluate the surgeons' experience; the parameters of the instrument navigation and lifting and grasping modules, which require a higher degree of eye-hand coordination, were better for residents with previous surgical experience and revealed a good transfer of training (TOT). The suturing module is less influenced by surgeons' experience. This result is probably explained by a lack of TOT.

Photoluminescence of silicon nanocrystals embedded in silicon oxide

The bonding structure and the optical properties of silicon-rich silicon oxide films which were prepared using plasma-enhanced chemical vapor deposition (PECVD) with thermal oxidation were studied in detail. The composition and bonding structures were explored using X-ray photoelectron spectroscopy (XPS). The luminescent properties were studied using Raman spectroscopy and photoluminescence (PL) measurements. Results show that high-temperature (approximately 1000 degrees C) annealing of as-deposited Si-rich silicon oxide gives rise to phase separation and formation of crystalline Si phases in the oxide films. Upon high temperature annealing, the PL (550-900 nm) intensity was significantly reduced in stoichiometric oxide or in low Si-content (prepared with [N2O]/[SiH4] gas flow ratio > 2.5) films whereas an opposite trend was found in higher Si-rich samples. Particularly, for the red band (650 nm) and the infrared band (750 nm), the PL intensity was significantly enhanced by annealing slightly Si-rich samples ([N2O] / [SiH4] = 2.5) at 1100 degrees C. This observation was explained by the formation of Si nanocrystallites via phase separation reaction and the removal of defect-related absorption centers during annealing.

Probability current and antiresonances of particle tunneling through biased heterostructures

A flow of independent particles, traveling across a biased heterostructure, is shown to produce an essentially constant probability current density in the gate. Based on this observation, a phenomenological boundary condition was proposed for evaluating the eigenfunctions of the Hamiltonian and for the computing the gate probability current density in a three-layer metal-oxide-semiconductor (MOS) heterostructure. Sharp antiresonances are obtained in the probability current, which are interpreted as quasi-bound states in the heterostructure. Results show that the antiresonant states should contribute the least to the gate current as the particles are strongly localized behind the interfacial barrier. The main contribution to the gate current of the MOS structure should come from the states between the antiresonances which are always supplied with particles from the bulk.

[Struma ovarii]

Struma ovarii is a rare tumor in its pure form, but its true incidence is hard to estimate because of all the variation in the diagnostic criteria due to the fact that some authors reported it as within a teratoma and others only in its pure form. In general, it is an asymptomatic tumor, "benign-like" in most of the cases, and the diagnostic is based only on the histopathological findings.

MATERIAL AND METHOD

This is a retrospective study of all ovarian tumors treated in our departments over a period of 11 years, from January 1, 1995 to January 1, 2006.

RESULTS

All medical records of 644 patients were reviewed, of which 502 patients (77.96%) with unilateral tumors and 142 (22.04%) with bilateral involvement. 879 tumors were removed: 88.39% benign and 11.61% malignant. Struma ovarii was demonstrated in 2 patients. The only complaint in these 2 patients diagnosed and treated in our clinics was pain in the lower abdomen. The clinical examination and ultrasound suggested ovarian tumors, but the diagnosis was made on the histopathological findings. Following surgical treatment (classic or laparoscopic) the postoperative course was excellent, confirming that this approach is the only practical solution.

[Abdominal tuberculosis--a surgical reality]

Abdominal tuberculosis is a rare disease, with non-specific findings. Peritoneal tuberculosis is a frequent cause of low gradient ascites. The records of 22 patients (Il males, 11 females, mean age 41,17 years, and range 17-74 years) diagnosed with abdominal tuberculosis (TBC) in First Surgical Clinic, "St. Spiridon" University Hospital Iaşi between 1995 and 2006 were analyzed retrospectively and the literature was reviewed. From these 22 patients diagnosed with abdominal tuberculosis, there were: peritoneal TBC in 16 cases, intestinal TBC in 5 cases, mesenteric lymph nodes TBC in 1 case. The patients with intestinal TBC, were presented with complications, 2 perforations with peritonitis, 1 intestinal obstruction, and 2 as ileo-cecal "tumors" solved by right colectomy, 4 enterectomy (3 entero-enterostomies and 1 ileo-colic anastomosis). The patients with peritoneal TBC were diagnosed by laparoscopy and peritoneal biopsy in 13 cases, and by laparotomy in 3 cases. In peritoneal tuberculosis ascites was present in 15 cases. Other common findings were weight loss (12 cases), weakness (5 cases), abdominal pain (15 cases), anorexia (5 cases) and night sweat (2 cases). Only two patients had chest radiography suggestive of a new TBC lesion. In those patients with peritoneal tuberculosis, subjected to operation, the findings were multiple diffuse involvements of the visceral and parietal peritoneum, white "miliary nodules" or plaques, enlarged lymph nodes, ascites, "violin string" fibrinous strands, and omental thickening. Biopsy specimens showed granulomas, while ascitic fluid showed numerous lymphocytes. Post operatory evolution and management were applied by the TBC Medical System and the patients were treated 6 months by tuberculostatics, with favorable evolution. Abdominal tuberculosis should be considered for diagnosis, in patients with non-specific symptoms of abdominal pain, fever, loss of appetite, abdominal distension and even symptoms of acute abdomen. Laparoscopy is the best approach for peritoneal tuberculosis, and emergency surgery is necessary for acute complication like obstruction and peritonitis. Specific antituberculosis drugs are indicated in postoperative period.

[Gastric stromal tumor. Case report]

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastro intestinal tract and express the c-kit proto-oncogene protein (CD-117). We report herein a case of a 58 years old male with upper abdominal pain and anaemia. Preoperative endoscopic and barium meal exams showed a submucosal tumor in the gastric fornix. Endoscopic biopsy revealed spindle-shaped cells with elongated nuclei specific of GIST. We performed a stapled resection of the gastric fornix associated with Hiss angle reconstruction. Postoperative histologic exam revealed the same spindle-shape cells characteristic of GIST with 2-5 mitosis/50HPF. Almost all of the cells showed immunoreactivity for c-kit, CD-34 and a Ki-67 labeling index of 30%. Postoperative course was non eventful and after 3 month the patient has no recurrence.

CONCLUSIONS

GIST are rare gastric tumors and are usually associated with bleeding and abdominal pain. The preoperative diagnosis is usually established by endoscopy with biopsy or endoscopic ultrasonography fine needle aspiration and barium meal exam. Only immunoreactivity is able to differentiate GIST from other mesenchymal tumors. Surgical resection is a safe and effective treatment. The chemotherapy with tyrosine kinases competitive inhibitors (e.g. imatinib mesylate) is also recommended.

[Hydatic cyst of the liver. Considerations on 337 cases]

Hydatid disease of the liver is still endemic in certain parts of the world. The modern treatment of hydatid cyst of the liver varies from surgical intervention to percutaneous drainage or medical therapy. Surgery is still the treatment of choice and can be performed by the conventional or laparoscopic approach. The aim of the study is to analyze the results of the surgical treatment in hydatid disease of the liver in First Surgical Clinic, Iaşi. The study concerned a period of 12.5 years (1992 - 31.07.2004) and it included 337 cases. There were performed radical procedures (ideal cystectomy - 17 cases - 5.04%, hepatic segmentectomy - 8 cases - 1.48%, atypical hepatectomy - 10 cases - 2.96%) or conservative procedures (de-roofing - 37 cases - 10.97%, subtotal pericystectomy - 34 cases -10.80%, total pericystectomy - 19 cases - 5.63%, partial pericystectomy - 212 cases -62.90%). In 35 cases (10.38%) the operation was started laparoscopically and 12 cases needed conversion. Postoperative course was complicated in 112 cases (33.32%) (external biliary fistula, cavity suppuration, residual cavity hydatid relapse). Radical methods constituted operations that had excellent results, but they are feasible in few cases. Conservative procedures, relatively simple and still accepted, have a higher rate of morbidity. The laparoscopic approach is more and more used, with good results.

[Tendencies and results in rectal cancer treatment]

Rectal cancer is one of the leading cause of cancer-related death worldwide despite of multimodal treatment.

OBJECTIVE

The aim of this study is to review the management strategies for rectal cancer and to determine morbidity after multimodal therapy.

METHOD

Retrospective study about 276 patients with rectal cancer surgically treated in 1st Surgical Clinic of "St. Spiridon" Hospital Iaşi, Romania, between 1998-September 2003.

RESULTS

There were 166 men (60.14%) and 110 women (38.86%) with mean age 63.6 years (extreme 20-81 years). The tumor's staging was: stage I--12 cases (4.5%); stage II--59 cases (21.3%); stage III--134 cases (48.2%), stage IV--71 cases (25.7%). 37 patients (13.4%) received preoperative radiotherapy (20 Gy). The tumor was resectable in 204 cases (74%) with curative purpose in 190 cases (68.8%). The postoperative therapy was performed in 198 cases (71.7%). The postoperative morbidity was documented in 32 cases and 24 patients died during hospitalisation (8.7%). Long-term results are also exposed with a review of literature.

CONCLUSIONS

Rectal cancer has been notoriously difficult to treat successfully but there are numerous attempts modifying existing therapeutic regimens or designing new ones.

[Endo-Lap method in the management of biliary lithiasis (gallbladder and common bile duct)]

AIM

To present the results of the biliary endoscopic approach (ERCP) followed by laparoscopic cholecystectomy (LC) in the management of biliary lithiasis (gallbladder and common bile duct--CBD).

PATIENTS AND METHOD

From 1997 to March 2003 37 patients with biliary lithiasis were treated by endoscopic sphincterotomy (ES) with stone extraction, followed after 24-48 hours by LC. The indications for ERCP were presence of an obstructive jaundice (n=32) and a dilated CBD at the ultrasound examination (n=5).

RESULTS

Selective biliary cannulation was obtained in 35 (94.6%) cases, in all of them with successful papillotomy. Stones were found in all patients. CBD clearances for calculi (from 1 to 8) was obtained in 33 of 35 patients (94.3%), the rest of 2 being managed by open laparotomy. Antibiotics were administrated in all patients. Laparoscopic cholecystectomy was performed after 24-48 hours, with one conversion (3%). Postoperative morbidity was 12.1%: 2 transitory pancreatic reactions and 2 wound infections.

CONCLUSION

Endo-Lap method is a useful management alternative for combined gallbladder and CBD lithiasis. It has all the advantages of the two mini-invasive procedures (fast recovery, short hospitalization, low costs) and a less postoperative morbidity in patients with high risk.

[Therapeutical, and evolutive particular aspects in cataract surgery]

Even if the ophthalmic surgeons are concentrated, most of the time, on the surgery, they have to remember all other aspects related with the general status of the patient, because these could influence the ultimate visual outcome. The paper presents some cases of cataract operated in our Clinic, having particular aspects: clinical, therapeutical and evolutive aspects. In these cases, the coexisting diseases of the patients have requested special diagnostic procedures, anti-infectious prophylaxis, special postoperative management or laser treatments.

Modeling the electron field emission from carbon nanotube films

A theoretical framework for the electron field emission from carbon nanotubes (CNTs) is discussed. Using the tunneling theory, the influence of the detailed electron energy dispersion is proven to be of little importance for the electron field emission. By means of numerical computations in a simplified model, the influence of the environment on the local field on a CNT is discussed for an aligned CNT film. In a simple triangular model for the potential energy barrier at the tube end, a tunneling probability was obtained. A statistical model was developed for the structural and functional parameters of aligned CNT films. Practical CNT films of excellent alignment, obtained directly on a tungsten wire by plasma-enhanced chemical vapor deposition, were analyzed by this statistical model. Their distribution in the enhancement factors was thus deduced. An indirect method to get the average electrical parameters of the film using only a limited amount of experimental data was thus established.

[Incisional hernias after operative laparoscopy]

The objective of this study was to determine the possible risk factors of incisional hernias after operative laparoscopy. Complications involving the abdominal wall, particularly incisional hernias, were not expected when laparoscopic procedures were first introduced. With the increasing number of laparoscopies in the abdominal surgery, more incisional hernias were observed. Of the approximately 3,145 patients who underwent laparoscopy from march 1993 through march 2000 in the First Surgical Clinic Iassy, a total of 15 hernias occurred, which is an incidence of 0.477%. There were no acute complications, such as small bowel obstruction, secondary to herniation through the trocars. Risk factors such as chronic bronchitis or weight increase, which give rise to abdominal pressure, were present in some cases. Precautions such as fascial suturing must be taken to reduce the incidence of this minor complication of laparoscopic surgery.

[Laparoscopic cholecystectomy in non-lithiasis cholecystopathies]

We made a study in 1st Surgery Clinic of Iassy between March 93--November 98, with 2246 laparoscopic cholecystectomies. The reason was to define the place and role of laparoscopy in non-lithiasis cholecystopathies (81 cases). In the same period were operated classically 888 calculous cholecystitis and 38 non-lithiasis cholecystitis. The laparoscopy has a major role in diagnosis to the patients with many abdominal symptoms. We discovered pericholecystic adherences, hepatic cirrhosis, acute appendicitis, etc. Sometimes, the laparoscopy was made for "second look" after surgical treatment for neoplasia, the metastasis diagnosis, for tumors visible echographically. In many situations the laparoscopic cholecystectomy may be considered like a preventive operation. The easy postoperative evolution is an argument to enlarge the indication for laparoscopic cholecystectomy in alithiasis cholecystitis.

Selegiline in the treatment of Alzheimer's disease: a long-term randomized placebo-controlled trial. Czech and Slovak Senile Dementia of Alzheimer Type Study Group

OBJECTIVE

To evaluate the efficacy and adverse effects of the type B monoamine oxidase inhibitor selegiline (also known as I-deprenyl) in the treatment of Alzheimer's disease.

DESIGN

Long-term, double-blind, placebo-controlled trial.

SETTING

Seven cities (1 or 2 nursing homes in each city) in the Czech and Slovak Republics.

PATIENTS

A total of 173 nursing-home residents fulfilling the DSM-III criteria for mild to moderate Alzheimer's disease.

INTERVENTIONS

Selegiline (10 mg per day) or placebo (both including 50 mg ascorbic acid) administered for 24 weeks.

OUTCOME MEASURES

Clinical Global Impressions scale and Nurses Observation Scale for Inpatient Evaluation at baseline and at weeks 6, 12 and 24; Clock Drawing Test at baseline and 24 weeks, results of which were evaluated as normal or pathologic, and quantitatively on a modified 6-point scale; Sternberg's Memory Scanning test at baseline and at weeks 6, 12 and 24; Mini Mental State Examination, and electroencephalogram at baseline and 24 weeks; Structured Adverse Effects Rating Scale; physical, laboratory, hematological and electrocardiographic examinations at baseline and weeks 12 and 24.

RESULTS

A total of 143 subjects completed enough of the trial to be entered in the analysis. Subjects were analyzed by 2 subgroups depending on whether they had a normal or pathologic result of the Clock Drawing Test. Analysis of variance showed significant improvement with selegiline versus placebo among those with a normal result of the Clock Drawing Test on the Mini Mental Status Examination (total score and orientation-place subscale) and among those with a pathologic result of the Clock Drawing Test of Sternberg's Memory Scanning test (for both speed and accuracy), on the Clinical Global Impressions scale as well as in terms of the dominant frequency on electroencephalograms.

CONCLUSION

Selegiline has a long-term beneficial effect in Alzheimer's disease on memory modalities that reflect the function of the prefrontal areas of the brain, which are rich in dopamine receptors. The delayed appearance of differences between selegiline and placebo supports the notion that the mechanism of action is through neuronal rescue or neuroprotection. The differential response of patients with normal and pathologic results of the Clock Drawing Test may reflect the fact that the evaluation methods' sensitivity to change depends on the severity of dementia.

[The Wermer syndrome]

The difficult diagnostic and therapeutic management of patients having gastrinoma with multiple endocrine neoplasia type I (MEN I) has been discussed by reference to the literature and a personal experience of 2 patients with Wermer syndrome. The syndrome is often familial and might be inherited as an autosomal dominant trait with a high but variable degree of penetrance. Pancreatic islets, parathyroid glands and adenohypophyseal [correction of antehypophyseal] cells are the three localization main for endocrine involvement in MEN I syndrome.

Predicting therapeutic results with levoprotiline and maprotiline in major depression: the role of the outcome criteria

We describe a double-blind study involving 58 in-patients with major depression (DSM-III). After one week on placebo, the patients were randomly assigned to either levoprotiline or maprotiline treatment for three weeks. In the next three weeks, responders were maintained on the same medication and non-responders were shifted to treatment with the complementary drug. After the initial three weeks' treatment, 31% of levoprotiline patients and 58% of maprotiline patients had responded. Both in the initial three-week period and after shifting non-responders to the complementary drug, there were significant differences in favour of maprotiline. The comparison of properties of different outcome criteria in prediction analyses shows that the final score gives the best agreement with global evaluation; using the delta score (final minus baseline) or ratio score (final/baseline) as the outcome criterion may yield paradoxical results.

[Determination of mono-, di- and triglycerides using HPLC]

The determination of monoglycerides, diglycerides and triglycerides in the normal phase system: Separon SGX-CN (silica gel with phase-bonded cyanoethyl) and mobile phase hexane-isopropanol-formic acid by HPLC with refractometric detection, is described. It was found that the separation was according to the molecular mass of glycerides, i.e. in groups. This was demonstrated with palmitic, oleic and linoleic acids. The diglycerides and especially monoglycerides of olive and sunflower oils were partly separated according to the ECN1 values of the glycerides. The response factors related to triglycerides were estimated for the glycerides of the fatty acids and oils mentioned above. The value of response factors depends on the number of double bonds of the fatty acids.

Dynamics of the effects of levoprotiline and maprotiline on EEG in patients with major depressive episodes (DSM-III-R)

The presented study compares the effect of the well-tested antidepressant maprotiline and a new antidepressant with an atypical pharmacological profile, levoprotiline, on EEG during repeated assessment after single dose administration. From the original number of 34 patients fulfilling the criteria of a major depressive episode (DSM-III-R) on account of a low-voltage record or pathological findings 11 were eliminated. To 12 of the remaining patients levoprotiline was administered and to 11 maprotiline, after a one-week placebo period, in doses of 150 mg. The EEG was recorded after an accommodation session immediately before, 1.5, 3, 4.5, 6 and 24 hours after a single dose administration. The record was taken on a 16-channel average reference montage at rest with closed eyes. Two-minute intervals were divided into 30 four-second periods at a sampling frequency of 128 Hz. From the signal by means of FFT the spectra were estimated and the mean spectrum for the entire recording was calculated. This was then divided into 10 frequency bands. The new method of frequency analysis of alpha-entropy was also used which is a global measure of the difference between two spectra. Three hours after administration of a single dose levoprotiline had an EEG profile corresponding to the profile of tricyclic antidepressants, i.e. it increased the values of the power spectra density in the region of 5-8.5 Hz and in the entire beta band; the decline of power in the alpha band was, however, absent. As regards maprotiline, 3 hours after administration a profile typical for antidepressants was not found; obviously because of the great variance of values of power spectra density as a result of great interindividual differences in the ingestion phase. Changes of the EEG spectrum expressed as values of alpha-entropy during different periods of apparently assessment are not incidental. After the initial rise of values a decline occurs.

[Results of a clinical trial of levoprotiline]

The authors submit results of a double blind clinical trial of levoprotiline controlled by maprotiline. In the multicentre study (which is processed and interpreted in stages) participated after written informed consent 58 patients with the diagnosis of a major depressive disorder. During the first three weeks the results of levoprotiline and maprotiline (from 26 patients each) were processed. The trial lasted 42 days. The psychopathology of the patients was evaluated by independent blind raters by means of Montgomery and Asberg's scale (MADRS), Hamilton's scale for depression (HRDS) and general clinical impression (CGI). In all patients also the pharmacological and EEG response was assessed. In comparison to maprotiline, levoprotiline was clinically ineffective. Its plasma levels (40 ng/ml) were one third to one half of the values obtained with maprotiline in the same daily dosage (150 mg). Although levoprotiline has an EEG profile typical for classical thymoleptics, its clinical antidepressive action is negligible.

[Circulating heparin-like anticoagulant--2 cases of successful therapy]

In the circulation of patients with severe haemorrhagic conditions in rare instances an anticoagulant of heparin nature can be detected, the exact origin of which has not been elucidated so far. These patients can be treated by protamine sulphate. The authors present their own observations in two women where the circulating anticoagulant of heparin nature was detected during a haemorrhagic condition after spontaneous rupture of an enlarged spleen and in scleroderma with organ affection. In both instances treatment was successful.

Treatment of extrapyramidal side effects with terguride

Terguride, a partial dopamine agonist, was administered in a 4-week open clinical trial to 17 schizophrenic patients suffering from extrapyramidal side effects of neuroleptic treatment. The neuroleptic dosage was kept constant. The mean final daily dose of terguride reached 3.4 mg (SD = 2.0). Fourteen patients completed the trial. Total scores on the Rating Scale for Extrapyramidal Side Effects and the Brief Psychiatric Rating Scale showed a significant improvement of 69% and 40%, respectively. There was also a significant improvement in all BPRS factor scores.

Pharmacokinetics and tolerance of 7-methoxytacrine following the single dose administration in healthy volunteers

7-methoxy-tetrahydroaminoacridine (7-MEOTA) is a new reversible cholinesterase inhibitor. Forty-eight young male volunteers divided into six dosage groups were included into a single-dose pharmacokinetic study with either oral (p.o.) or intramuscular (i.m.) administration. The dose of 7-MEOTA was 2, 4 or 8 mg/kg body weight p.o. or 0.5, 1 or 2 mg/kg body weight i.m. in the respective six dosage groups. The plasma levels data were fitted to an open one-compartmental model. The compound showed cholinomimetic adverse effects in 2 subjects with the blood levels exceeding 1,500 micrograms/l. The red blood cells levels paralleled those in plasma and were 2.5 times higher. The tmax was 4 hours and 1 h, t1/2 8.7 +/- 3.9 hours and 6.5 +/- 5.8 hours in case of p.o. and i.m. administration, respectively. The apparent clearance (D/AUC) was 5 times higher following p.o. administration, reflecting the differences in bioavailability.

[Reliability of the psychiatric section in the 10th revision of the International Classification of Diseases]

In collaboration with WHO the authors participated in sessions on the reliability of the Vth chapter of mental disease of the 10th revision of the International Classification of Diseases. The object was to evaluate the comprehensibility and utility of the diagnosis of mental disorders, evaluate to what extent the new classification describes adequately disorders of different types of psychiatric patients and to provide information on the extent and type of diagnostic agreement and disagreement. The evaluation was done by four psychiatrists; a total of 38 written case-histories were evaluated (30 patients of the Psychiatric Research Institute and 8 case-histories from other centres). Diagnostic agreement according to Kappa was very good, best in organic mental disorders and schizophrenic disorders, approximately equal in affective and neurotic disorders. It was lowest in personality disorders. The investigation indicates diagnostic agreement practically equal to that in ICD-9. More reliable data will be obtained after summarization of the entire WHO investigation which was implemented in various departments in the world.

Neuroendocrine response to clomipramine and desipramine--the evidence of partial determination by heredity and sex

A single dose of clomipramine, 10 mg i.v., or desipramine, 25 mg i.m., was administered to seven healthy young sibling pairs in a randomized cross-over experiment. The response of serum growth hormone, prolactin and cortisol was measured. The main findings were (1) sex differences in the growth hormone and cortisol response to desipramine and (2) a significant genetic component of the prolactin and cortisol response to desipramine as indicated by significantly (p less than 0.05) lower within-pair than between-pair variance in the sibling pairs but not random pairs of the experimental subjects.

Terguride in parkinsonism. A multicenter trial

Terguride is an ergoline derivative with mixed agonistic/antagonistic dopaminergic activity. This led to a paradoxical suggestion that it is effective in the treatment of both schizophrenia and parkinsonism. A total of 65 in- or outpatients with parkinsonism mostly of vascular or idiopathic etiology were included in a 4-week, open, multicenter trial. Terguride was administered under an increasing dose schedule which was leveled off according to the clinical response. Mostly because of nausea, vomiting, and lack of improvement 25% of inpatients and 61% of outpatients were removed from the study. The average daily dose at the end of the trial was 4.2 mg, ranging from 1.0 to 5.5 mg. The average Simpson and Angus scale total score and performance in the Spiral Drawing Task improved significantly during the trial by 20% and 38% respectively. The following adverse effects were noted most frequently throughout the study (including those who withdrew): constipation (occurred in 42% of all ratings performed during the trial) drowsiness and nausea (16% each). Adverse circulatory effects were negligible. Psychotic symptoms, including depression, confusion, hallucinations, and paranoid syndrome, each occurred in 1 patient, i.e., at a lower rate than with other dopaminergic drugs. Scotopic electroretinograms in a subsample of 7 patients showed a significant transitory decrease in the B-wave amplitude at the end of the 1st week and a subsequent return to pretreatment values.

Anaphylactic reactions incidence in allergic and atopic patients

One thousand and thirty penicillin allergics of immediate type and 1344 pollen allergic patients were examined. It was noticed that none of the penicillin allergics suffered from pollen allergy and none of the atopic patients allergic to pollen had penicillin induced allergy of immediate type. The data obtained were processed through the chi square test in correlation with the incidence of penicillin and pollen induced allergy among the normal population. The conclusion was drawn that atopic patients with pollen allergy show a lower risk than the normal population to have allergic reactions of immediate type to penicillin.

Pharmacogenetic study with diazepam in twins

In a study with healthy volunteers (6 monozygotic and 4 dizygotic twin pairs) we followed up diazepam serum levels and psychotropic effects of diazepam after single-dose administration. We found that pharmacokinetic properties of diazepam as well as its influence on memory and performance are probably not under genetic control. On the other hand, genetic factors seem to contribute to effects of diazepam on affectivity.

Clinical and therapeutical aspects of cold urticaria (urticaria a frigore)

A new drug with inhibitory properties on the Mast Cell degranulation, Ketotifen, was administered in 87 patients suffering from idiopathic urticaria a frigore (iUF). The first group (A), with 52 patients effectuated prophylactic management for 4 months with Ketotifen (K) (2 mg/day) and Clemastine (C) (2 mg/day) according to the double blind crossover method. Both the drugs were administrated in stages of 2 months each. The second group (B), with 35 patients (having previously failed a prophylactic attempt with Cyproheptadine) received only K, for two months. The results of group. A were favourable (clinical improvements over 50%) in 86.6% of the patients treated with K and in 50% of the patients treated with C. The mention is made that 36.6% from favourable results obtained with C in the second stage, appeared as a continuation of the improvements determined by K in the first stage. The lowering of the skin response to Cold Test (CT) was obtained in 55.8% of the patients treated with K and only in 7.6% of them who received C. Group B obtained favourable clinical results in 62% cases and the diminution of CT in 42% cases. Finally a few lesser known clinical and aetiopathogenic aspects of iUF resulting from the analysis of the patients investigated are presented.