Total anomalous pulmonary venous drainage. Seventeen-year surgical experience

Between 1968 and 1985, 80 children underwent correction of total anomalous pulmonary venous drainage. There were 47 boys and 33 girls whose ages ranged from 3 days to 16 years (median 2 months, interquartile range 5 years). Seventy (87.5%) were less than 1 year of age at operation. Fifty-eight (72.5%) weighed less than 5 kg, the range being 1.6 to 42 kg (median 3.7 kg, interquartile range 2.4 kg). Forty-five (56%) patients had supracardiac, 14 (17.5%) cardiac, 15 (19%) infracardiac, and 6 (7.5%) had mixed total anomalous pulmonary venous drainage. Follow-up was complete in 78 (97.5%) and ranged from 6 to 189 months (median 58 months, interquartile range 59 months). There were 14 (17.5%) early and six (7.5%) late deaths. Analysis by various factors revealed year of operation as the only factor to affect survival at the 5% level of significance. Early mortality was 29% between 1968-1977 and 11% between 1978-1985 (p = 0.04). Postoperative pulmonary venous obstruction occurred in five (6%) patients between 6 weeks and 3 months after operation. All 5 died, three after reoperation. Five (6%) other children had reoperations, four for residual shunts and one for superior vena caval obstruction.     

Fortschritte in der systemischen Therapie des metastasierten Magenkarzinoms

In spite of a reduced rate of new occurrence, gastric cancer is still one of the most common causes of cancer related mortality. Crucial to the value of systemic therapy are the 50% of patients who already have metastasizing or locally advanced stages at first diagnosis which are not surgically curable. In comparison to merely supportive therapy, controlled studies have shown the unmistakable value of chemotherapy. Recently, cisplatin and infused 5-fluorouracil (5-FU) based combination treatments have become the therapeutic standard. The internationally best studied scheme is the “ECF” combination. The taxane and irinotecan group has limited value as monotherapy and is used in combination studies, as are oral fluoropyrimidine and oxaliplatin, with other substances. With the introduction of numerous, new, effective cytostatics, a whole series of combinations are being tested. The main aims of these studies are, on the one hand, lowered toxicity or ease of use with equivalent effectiveness, and on the other hand, higher effectiveness without significantly increased toxicity.     

Editorial

Ohne Zusammenfassung     

Gait analysis in patients with total hip endoprosthesis. Part II: Pre- and postoperative gait analysis]

35 patients have been examined before the implantation of a total hip replacement, about 7 days postoperatively and again after 12 weeks by means of the electro-ichnograph EKIG-3 of the Riga Institute of Orthopaedics and Traumatology. Before the hip-joint substitution the normal values could not approximately be attained. The step duration has postoperatively increased, and it has decreased to pre-operative values by the time of the follow-up examination. The best results were obtained concerning the change of the trunk deviation in the frontal plane. The hip mobility measured passively was remarkably better after the operation and almost reached normal values. Regarding the results it should above all be taken into consideration, that the most important fact for the patient is the alleviation and elimination of pain, respectively.     

Meningocele manqué: radiologic findings with clinical correlation.

PURPOSE: To determine whether meningocele manqué can be detected by neuroimaging techniques in dysraphic patients. METHODS: We reviewed the records and imaging studies of 16 patients with surgically proved meningocele manqué seen at our institution between 1989 and 1990. Both CT and MR imaging techniques were used. CT of the spine was performed immediately following contrast myelography. RESULTS: Nine of 16 patients (CT, four; and MR, five) showed evidence of meningocele manqué which corresponded to intraoperative findings. Fourteen of 16 patients were found to have diastematomyelia, eight with medium septum and six without a septum. Associated findings included syrinx (six), lipoma (five), dermoid cyst (one), and neuroenteric cyst (one). After completing this review, we were able to prospectively diagnose dorsal bands in two new patients; these bands were confirmed at surgery. CONCLUSION: Dorsal bands can be detected in dysraphic patients with CT or MR using operative findings as a road map.     

Serum erythropoietin levels and blood component therapy after autologous bone marrow transplantation: implications for erythropoietin therapy in this setting.

To determine the potential impact of recombinant human erythropoietin (EPO) therapy in patients undergoing autologous bone marrow transplantation (BMT) and colony-stimulating factor therapy, we assayed endogenous serum EPO levels and noted blood transfusion requirements in relapsed non-Hodgkin's lymphoma patients treated with high-dose chemo-radiation therapy and autologous BMT. Hematocrit and reticulocyte counts were determined daily, and hematocrit was maintained in the 25-30% range by transfusion according to criteria established by our hospital transfusion committee. EPO levels were measured by radioimmunoassay and were determined at baseline, throughout therapy, and 2 and 3 months after BMT. Serum EPO levels increased more than 25-fold above baseline in most subjects after initiating chemoradiation therapy. No correlation was noted between serum EPO and hematocrit, reticulocyte count or serum creatinine. Total red blood cell units transfused ranged from 4 to 15 (mean 7.7). Mean total donor exposures (red blood cell plus platelet units transfused) were 83.6 units (range 16-175). Serum EPO levels increased early in the course of preparation for autologous BMT and remained elevated for at least 2-3 weeks thereafter although at a lower level. Red blood cell transfusions were required despite very high EPO levels after BMT. Red cell transfusions, moreover, accounted for only 9.2% (69 of 746) of total donor exposures and only 5.8% (42 of 746) of donor exposures during the interval when pharmacologic doses of erythropoietin might be of benefit. In contrast to the potential benefit of colony-stimulating factors such as G-CSF and GM-CSF in BMT, our study suggests limited value for erythropoietin therapy in this setting.     

T cell activation and thymic tolerance induction require different adhesion intensities of the CD8 co-receptor.

Activation of mature lymphocytes requires in addition to the TCR contact with the corresponding antigen the binding of the CD8 or CD4 co-receptors to MHC class I or class II proteins respectively. To investigate the contribution of the CD8-class I interaction to the elimination of autoreactive T cells during negative selection in the thymus we generated two types of transgenic mice. One set expressed a modified Kb molecule which contained a human HLA-A2 alpha 3 domain, thereby missing the binding residues for the murine CD8 molecules. The second set of mice expressed an anti-Kb specific TCR. Both lines were crossed and in the resulting double transgenic mice the development of Kb-reactive T cells was followed with an anti-clonotypic antibody. Surprisingly, efficient clonal deletion in the thymus was still observed, although the reduced CD8-class I adhesion abrogated effector functions in vivo and in vitro. These results imply that even T cells with intermediate affinity for self are negatively selected in the thymus despite the fact that they are not able to react against self antigens in the periphery. Thus a safety window is created which decreases the risk of autoaggression.     

3D reconstruction of the cardiovascular and central nervous system of a human embryo Carnegie-stage 15--case report.

A human embryo at Carnegie stage 15 was serially sectioned and 3D computer aided reconstructions were made to demonstrate the cardiovascular system and cranial structures and to study developmental variations at this stage. The development of the heart and pharyngeal arteries was according to the existing literature. Differences were found in the development of the arterial circle of Willis and the central nervous system. The cranial venous system seemed to show great variability. Whereas the telencephalon was not developed according to the stage, the development of the hypophysis had occurred prior to stage 15. From the results we conclude that there are remarkable individual differences in embryological differentiation of structures which have to be taken into account during staging of human embryos.     

Electromechanical properties of perfusion/metabolism mismatch: comparison of nonfluoroscopic electroanatomic mapping with 18F-FDG PET.

The aim of this study was to compare nonfluoroscopic electroanatomic mapping (NOGA), SPECT perfusion imaging, and PET metabolic imaging for assessment of myocardial viability. In particular, we sought to elucidate differences of electromechanical properties between the perfusion/metabolism mismatch as an indicator of a potentially reversible ischemic injury and the perfusion/metabolism match indicating irreversibly damaged myocardial tissue. METHODS: Twenty-one patients with coronary artery disease underwent NOGA mapping of endocardial unipolar voltage, cardiac 18F-FDG PET of glucose utilization, and resting 201Tl SPECT of myocardial perfusion. RESULTS: Electrical activity was 10.8 +/- 4.6 mV (mean +/- SD) in normal myocardium and was unchanged in hypoperfused segments with maintained glucose metabolism (perfusion/metabolism mismatch), 9.3 +/- 3.4 mV (P = not significant). In contrast, hypoperfused segments with a perfusion/metabolism match and nonviable segments showed significantly lower voltage (6.9 +/- 3.1 mV, P < 0.0001 and 4.1 +/- 1.1 mV, P < 0.0001 vs. normal). In hypoperfused segments, metabolic activity was more closely related to endocardial voltage than was myocardial perfusion (201Tl vs. voltage: r = 0.38, SEE = 3.2, P < 0.001; 18F-FDG PET vs. voltage: r = 0.6, SEE = 2.8, P < 0.0001). CONCLUSION: In hypoperfused myocardium, electrical activity by NOGA mapping is more closely related to PET metabolic activity than to SPECT myocardial perfusion. As NOGA mapping does not differentiate hypoperfused myocardium with enhanced glucose utilization from normal myocardium, results from NOGA mapping need to be correlated with results from perfusion imaging to identify hypoperfused, yet viable, myocardium and to stratify patients for revascularization procedures.