Der modifizierte erweiterte distal gestielte sapheno-fasziokutane Suralislappen

Zusammenfassung Nach Verifikation der anatomischen Voraussetzungen wurde eine modifizierte Technik des erweiterten saphenofasziokutanen Suralislappen für große kombinierte Knochen-Weichteil-Infekt-Defekt-Situationen sogenannte Typ-C-Läsionen bei Risikopatienten mit ersatzschwachem bzw. ersatzunfähigem Lager (traumatische ipsilaterale arterielle Hauptgefäßläsion, tiefe ipsilaterale Venenthrombose, diabetische Polyneuropathie mit Mikroangiopathie bzw. PAVK Stadium 3) in einer prospektiven Studie angewendet. Zehn Weichteildefekte zwischen 80–180 cm² im Mittel-Rückfuß- bzw. distalen Unterschenkelbereich wurden einzeitig komplett mit einem retrograd gestielten modifizierten saphenofasziokutanen Suralislappen aus dem proximalen Unterschenkel gedeckt. Alle Lappen heilten ohne Lappennekrosen ein. Die Entnahmestellen wurden siebenmal mittels primärer Naht und dreimal einzeitig mit Meshgraft verschlossen. Bei der Nachuntersuchung aller Patienten nach im Mittel 22 Monaten bestanden vitale Lappen, keine Hebedefektmorbidität, kein Suralisneurom und es war kein sekundäres Debulking oder andere lappeninduzierte Revisionen erforderlich.     

The prognostic significance of serum alpha 1-fetoprotein in children and adolescents with malignant extracranial non-testicular germ cell tumors]

The cooperative therapy study MAKEI 83/86 included an examination of the prognostic value of the AFP in children and adolescents with extracranial non-testicular yolk sac tumors. The serum AFP values of 72 protocol- and follow-up-patients were documented at diagnosis and up to the ninth month of treatment. 32 of these patients had saccrococcygeal tumors, 27 had tumors of the ovary and 13 suffered from extragonadal germ cell-tumors. 4 children showed progressive disease under initial chemotherapy and 1 patient died of therapy, 10 of 72 patients relapsed. The AFP measurements were plotted on semilogarithmic charts. They were compared to the measurements of healthy children up to the age of 1 year. According to the development of the patients' AFP values compared to the reference curves the following classifications could be made: 1. Patients with a normal AFP-decrease id est 50% in less than or equal to 6 days during the 1st month of therapy: 48/72 patients 2. Patients with slow AFP-decrease: 17/72 patients 3. Patients with transient AFP-decrease: 5/72 patients 4. Patients with no AFP-decrease: 2/72 patients According to Kaplan-Meier life table analysis, patients with a normal AFP-decrease had an event-free survival of 89% +/- 4%, whereas all other patients showed an event-free survival of 63% +/- 10% (p less than 0.05). Regarding primary therapy id est tumor resection or preoperative chemotherapy an equal distribution of the patients among those with a normal and slow AFP-decrease was observed.(ABSTRACT TRUNCATED AT 250 WORDS)     

Acute megakaryocytic leukemia in children. Clinical, immunologic, and cytogenetic findings in two patients.

An unusual presentation of acute megakaryocytic leukemia (AMKL) is reported in two young children. The first child had a 10-day history of ptosis of the right eyelid as the initial manifestation of AMKL, a clinical picture not previously described in this variant of leukemia. Computed tomographic scanning showed multiple intracranial mass lesions, and the diagnosis of AMKL was confirmed by immunophenotyping of bone marrow blasts. The second child had Down syndrome and received alkylating agents and radiation therapy for treatment of metastatic rhabdomyosarcoma of the orbit. She had AMKL as second malignancy. Both patients had acquired chromosome 21 anomalies in their leukemic blasts. The first patient, constitutionally normal, had an i(21q) in his leukemic blasts; the patient with constitutional trisomy 21 had tetrasomy 21 and additional chromosomal changes. The clinical symptoms and the results of morphologic, immunologic, and cytogenetic studies are discussed.     

Reduced genital sensitivity in female patients with multiple system atrophy of parkinsonian type.

According to the consensus statement on the diagnosis of multiple system atrophy (MSA), erectile dysfunction is required for male patients to fulfil the urinary incontinence criterion. However, there is no equivalent item for female patients. We questioned 19 female patients with MSA of the parkinsonian type (MSA-P), 28 female patients with Parkinson's disease (PD), and 27 healthy controls on their genital sensitivity. A total of 47% of the MSA patients but only 4% of the PD patients and 4% of the control group admitted to reduced genital sensitivity, a highly significant difference (P < 0.001). Moreover, the appearance of reduced genital sensitivity in female MSA patients showed a close temporal relation to the onset of the disease. If these preliminary results can be confirmed and further specified in a larger sample, a historical item of reduced genital sensitivity in female patients might become a diagnostic feature for MSA, comparable to erectile dysfunction in male patients.     

Three-dimensional reconstruction of magnetic resonance images of the temporomandibular joint by I-DEAS.

Evaluation of the temporomandibular joint has been limited by the inability of current technology to image complex morphology and motion in three dimensions. An engineering design program, I-DEAS, has been used to construct solid models from magnetic resonance images. A dried skull with an acrylic resin temporomandibular disc replica, immersed in water, provided sagittal and coronal MR images. Linear dimensions and disc volumes obtained from the models were compared with the original and found to be consistent, within the limits imposed by the slice thickness. We have applied the method to the living joint in an asymptomatic volunteer, and report our initial experience in demonstrating the spatial relationships and motion of the joint components.     

Fusion and failure following anterior cervical plating with dynamic or rigid plates: 6-months results of a multi-centric, prospective, randomized, controlled study

Anterior cervical plate fixation is an approved surgical technique for cervical spine stabilization in the presence of anterior cervical instability. Rigid plate design with screws rigidly locked to the plate is widely used and is thought to provide a better fixation for the treated spinal segment than a dynamic design in which the screws may slide when the graft is settling. Recent biomechanical studies showed that dynamic anterior plates provide a better graft loading possibly leading to accelerated spinal fusion with a lower incidence of implant complications. This, however, was investigated in vitro and does not necessarily mean to be the case in vivo, as well. Thus, the two major aspects of this study were to compare the speed of bone fusion and the rate of implant complications using either rigid- or dynamic plates. The study design is prospective, randomized, controlled, and multi-centric, having been approved by respective ethic committees of all participating sites. One hundred and thirty-two patients were included in this study and randomly assigned to one of the two groups, both undergoing routine level-1- or level-2 anterior cervical discectomy with autograft fusion receiving either a dynamic plate with screws being locked in ap - position (ABC, Aesculap, Germany), or a rigid plate (CSLP, Synthes, Switzerland). Segmental mobility and implant complications were compared after 3- and 6 months, respectively. All measurements were performed by an independent radiologist. Mobility results after 6 months were available for 77 patients (43 ABC/34 CSLP). Mean segmental mobility for the ABC group was 1.7 mm at the time of discharge, 1.4 mm after 3 months, and 0.8 mm after 6 months. For the CSLP- group the measurements were 1.0, 1.8, and 1.7 mm, respectively. The differences of mean segmental mobility were statistically significant between both groups after 6 months (P = 0.02). Four patients of the CSLP-group demonstrated surgical hardware complications, whereas no implant complications were observed within the ABC-group (P = 0.0375). Dynamic plate designs provided a faster fusion of the cervical spine compared with rigid plate designs after prior spinal surgery. Moreover, the rate of implant complications was lower within the group of patients receiving a dynamic plate. These interim results refer to a follow-up period of 6 months after prior spinal surgery. Further investigations will be performed 2 years postoperatively.     

A preventive approach to the suicidal patient

Physicians may have the opportunity to prevent suicide. An awareness of suicide risk factors, such as depression, alcoholism, drug abuse, schizophrenia, and chronic pain or disease, may facilitate suicide prevention. Recognition of acute and chronic suicidal vulnerability occurs through direct questioning. Psychiatric consultation is indicated for patients exhibiting clear self-injury risk, as exemplified by expressed suicide intent, an overt plan for death, or a "gesture." Hospitalization is usually recommended for socially isolated patients presenting with overt suicidal ideation, complicated by injurious self-harm, encephalopathy, or substance abuse. Family involvement and a "no-suicide" contract with the patient, coupled with close outpatient follow-up appointments, should suffice for those exhibiting milder or transient thoughts of suicide without manifest intent to die.     

Clinical correlates of cerebral ventricular enlargement in schizophrenia. Further evidence for frontal lobe disease.

Numerous studies have shown evidence of cerebral ventricular enlargement in schizophrenia and its relationship to severity of clinical symptoms and psychosocial dysfunction. In this large prospective study, 88 noninstitutionalized DSM-III-R schizophrenic patients were administered a CT scan and rated for positive and negative symptomatology and premorbid adjustment. The CT scans from 14 healthy controls were used for comparison of cerebral ventricular measures. Patients had an enlarged ventricle to brain ratio of the anterior portion of the lateral ventricles, the frontal horns, compared with controls. Patients with larger frontal horns had more severe negative symptoms and poorer premorbid childhood adjustment. The area of the main body of the cerebral lateral ventricles, though not elevated in patients, was correlated with the total number of prior hospitalizations. These results support the hypothesis of a structural and functional "frontal" deficit in schizophrenia.