Endoscopic cordectomy. a proposal for a classification by the Working Committee, European Laryngological Society

The European Laryngological Society is proposing a classification of different laryngeal endoscopic cordectomies in order to ensure better definitions of postoperative results. We chose to keep the word “cordectomy” even for partial resections because it is the term most often used in the surgical literature. The classification comprises eight types of cordectomies: a subepithelial cordectomy (type I), which is resection of the epithelium; a subligamental cordectomy (type II), which is a resection of the epithelium, Reinke’s space and vocal ligament; transmuscular cordectomy (type III), which proceeds through the vocalis muscle; total cordectomy (type IV); extended cordectomy, which encompasses the contralateral vocal fold and the anterior commissure (type Va); extended cordectomy, which includes the arytenoid (type Vb); extended cordectomy, which encompasses the subglottis (type Vc); and extended cordectomy, which includes the ventricle (type Vd). Indications for performing those cordectomies may vary from surgeon to surgeon. The operations are classified according to the surgical approach used and the degree of resection in order to facilitate use of the classification in daily practice. Each surgical procedure ensures that a specimen is available for histopathological examination. Received: 29 December 1998 / Accepted: 2 July 1999     

Immunological changes among workers occupationally exposed to styrene

The functional status of the immune system was investigated in a group of 71 workers exposed to styrene and in 65 control subjects, recruited according to the same selection criteria and comparable as to sex, age, and confounding variables. Air and biological monitoring were used to characterize styrene exposure (median of the main urinary metabolites in the next-morning spot samples: 106 mg/g creatinine). Phenotypic analysis of peripheral blood lymphocytes (PBL) by automated flow cytometry revealed a reduced proportion of T lymphocyte subsets (CD3⁺, CD4⁺ and CD4⁺45⁺), with no changes in CD8⁺, and a higher proportion of B lymphocytes (CD19⁺) among styrene-exposed workers. The exposed workers showed a higher proportion of activation markers, namely DR and interleukin-2 receptors (CD25). Immunoglobulin subclasses were comparable in the two groups. An increased prevalence of abnormally low values was apparent for CD2⁺, CD3⁺, CD4⁺, CD4⁺45⁺ and CD11b subsets among workers exposed to styrene, whereas CD19⁺, DR⁺ and CD25⁺ showed an increased prevalence of abnormally high values. Natural killer-related phenotypes (CD56⁺, CD56+16⁺, and CD56⁺16^–) were more expressed among styrene workers, with average increase of 30%. However, the frequency distribution of the lytic activity of natural killer cells against K-562 target cells was shifted towards lower values in the exposed workers as compared to control subjects. Dose-response relationships between indices of internal dose and prevalence of abnormal values were detectable for T lymphocyte subsets, NK phenotypes, and activation markers. These findings suggest that moderate exposure to styrene is associated with an altered distribution of lymphocyte subsets. The decreased proportion of T lymphocytes, mainly of T helper-inducer cells, could hamper regulatory functions, thus suggesting a negative modulation by styrene exposure. Since a proper balance between immunocycte subsets is important for immunological responses, such changes should be regarded as adverse effects.     

Mammographic Screening Downstages Breast Carcinomas at Time of Diagnosis: A Community-Based Experience

Abstract: To determine the effectiveness of screening mammography in a community medical setting, data from a population-based, retrospective study was analyzed. Medical records of 827 patients with newly diagnosed breast cancer in California between October 1994 and March 1996 were reviewed. The primary care physician's record was abstracted for clinical history, including recommendation of screening mammography. The facility records where final diagnosis was made were abstracted for stage and treatment data. Among the patients who did not have previous screening mammography, 65.7% were diagnosed with "advanced" breast cancer (stages II, III, IV), while only 39.9% who had previous screening mammography were diagnosed with advanced breast cancer (p < 0.001). This study has reaffirmed that screening mammography of adult females generates downstaging at the time of diagnosis of breast cancer. Despite possession of a health insurance program and receiving educational materials, only 65% of patients over 50 years of age had screening mammography. As opposed to the once-a-year mailing of general reminders to all women 40 years old and older, developing a longitudinal electronic medical record in the managed care setting will support a more coordinated and individualized intervention based on age, date of last mammogram, and relative risk, among other factors. Continuing education efforts must also be directed to referring physicians, who may not yet recognize the value of screening mammography.     

Results of Lipid-Lowering Trials in the Elderly and a Look to the Future

A lack of clinical research in the elderly hampers the creation of specific therapeutic regimens to treat dyslipidemia in this group. However, extrapolation of data from studies in middle-aged men may be appropriate since the mechanisms of atherogenesis do not appear to change significantly with advancing age. The results of the secondary prevention Scandinavian Simvastatin Survival Study (in which 52% of the patient population was 60 years of age or older) and the primary prevention West of Scotland Coronary Prevention Study (in which the mean age of the patient population was older than those of other primary prevention trials) suggest the benefit of lipid-lowering in older populations. More clinical trials that include elderly subjects are needed to evaluate fully the efficacy of lipid-regulating therapy in older patients.     

Evaluation of vesico-urethral and sweating function in disorders presenting with parkinsonism

Investigation of vesico-urethral and sweating function was performed in twelve patients with classical idiopathic Parkinson's disease and ten patients with parkinsonism associated with features suggestive of more extensive involvement of the nervous system, as in the Shy—Drager syndrome. The urodynamic studies revealed detrusor hyperreflexia with reduction of maximal cystometric capacity in only one patient with Parkinson's disease (8%), but in nine patients with parkinsonism associated with other features (90%). Urethral sphincter electromyography did not indicate denervation in any patient of either group. Delayed or incomplete relaxation of the urethral sphincter during micturition was observed in seven patients with Parkinson's disease (58%) and in two patients of the other group (20%). Decreased sweating responses were found in both groups of patients when compared with control subjects. Hypohidrosis was more pronounced in parkinsonism associated with other features than in Parkinson's disease. Differences in sweating between the two sides of the body were observed in both groups of patients. Although there are differences in vesico-urethral and sweating function, they do not precisely differentiate between patients with classical Parkinson's disease and those with parkinsonism associated with features suggestive of more extensive involvement of the nervous system.     

Widespread Horizontal Connections Arising from Layer 5/6 Border Inverted Cells in Rabbit Visual Cortex

Herein we describe the inverted cells [defined as those projection neurons having a major dendritic shaft abpially oriented (Bueno-López et al., Eur. J. Neurosci. , 3, 415, 1991)] originating a unique set of cortical connections characterized by extraordinarily widespread horizontal distribution. Single and multiple injections of wheatgerm agglutinin - horseradish peroxidase were made in areas 17 and 18 and the resulting retrograde labelling in the cortex was analysed. The findings were assessed in independent control experiments in which Fluoro-Gold was used as retrograde tracer. Following single injections in area 17 several separate patches of labelled cells comprising layers 2–6 were consistently found in area 18. In addition to these associational cells a number of labelled cells appeared at the layer 5/6 border but were distributed over most of the tangential extent of the visual occipital cortex. This widespread pattern was particularly striking in brains after multiple injections. In these brains a conspicuous band of labelled cells at the 5/6 border radiated from the injection sites, making up an apparently continuous horizontal sheet that intersected the striate - extrastriate boundary and merged with the patches of labelled cells in area 18 and beyond. Most of the cells in the 5/6 border band were inverted cells (82%; n = 2081). Injections in area 18 failed to produce such a widespread set of labelled cells in area 17. The functional significance of these connections furnished by the 5/6 border inverted cells remains to be determined, but their distribution would allow for convergent/divergent binding interactions both intra-areally (within area 17) and inter-areally (from area 18 to area 17).     

Local anesthesia in reduction mastoplasty for out-patient surgery

To perform a breast reduction under local anesthesia we need a large amount of anesthetic with lasting effects. For this I use a solution of 25 cc of lidocaine, 25 cc of bupivacaine, and 1 cc of epinephrine in 350 cc of saline solution. The bupivacaine allows a 4–6-hour operation. Once the breast is infiltrated, a great amount of anesthetic is lost in the incision, in the dissection, and in the resected tissue. Thus, a low dose remains subcutaneously to be metabolized by the liver. The serum lidocaine levels are low during these operations, as demonstrated by fluorescence polarization immunoassay. Under analgesic sedation the submammary sulcus and the retroglandular space are infiltrated, blocking the perforants of the intercostal nerves, under the areola, beneath the skin where the incision is made and where the aerola is placed. This procedure has been applied to many techniques of breast reduction by modifying the infiltration under the incision lines. For hypertrophy up to 1000 g, 200–300 cc of anesthetic solution is used for both breasts at one stage, while for gigantomastia, about 400 cc of anesthetic is used, infiltrating and reducing one after the other. As the blood loss is minimal and the recovery very fast, with an appropriate adhesive bandage and a soutien, the patient could be discharged in the afternoon. Our experience includes 94 reduction mastoplasties with local anesthesia, and also 74 other mastoplasties with equally good results. There were no patient complaints and, in general, they felt very comfortable, awakening without pain or side effects.     

The role of spontaneous portosystemic shunts in the course of orthotopic liver transplantation

Spontaneous portosystemic shunts are commonly found in cirrhotic patients. Not yet established is their role after orthotopic liver transplantation (OLTx), especially when an increase in portal pressure develops, as during early acute rejection. In this study, 34 cirrhotic patients in a series of 70 OLTx are considered. Each patient had preoperative angiographic assessment, and, in 21 (62%), large spontaneous portosystemic shunts were evident. In 12 cases the shunts were not affected by the surgical procedure and were present during the postoperative period; in 9 the hepatectomy itself involved interruption of the shunts. The patient population was divided into two groups: patients with postoperative shunts (n=12) and those without (n=22). The two groups were similar in age, sex, Child's stage, transplantation variables, and number and grade of rejection episodes. However, mean transaminases (AST) values in the first 2 weeks were significantly higher levels in shunt versus nonshunt patients (421±335 vs 183±126; P<0.025), and this was even more evident when rejection occurred (626±375 vs 195±129; P<0.001). Furthermore, during an acute rejection reaction, three cases showed a true steal phenomenon through the large reopened shunts with ischemic damage to the grafts. The data indicate a possible detrimental effect of the spontaneous shunts on graft perfusion and suggest the prophylactic surgical interruption of the residual shunts during the transplantation.