Diffuse large B-cell lymphoma of bone: an analysis of differentiation-associated antigens with clinical correlation

Twenty-nine patients with diffuse large B-cell lymphomas presenting with bone involvement, including 18 localized primary bone lymphomas (group 1), 2 multifocal primary bone lymphomas (group 2), and 9 patients with extraskeletal disease at diagnosis (group 3), were studied. The tumors were subclassified according to the criteria of the WHO classification and evaluated by immunohistochemistry for expression of antigens associated with germinal center (GC) and non-GC stages of B-cell differentiation (bcl-6, CD10, MUM-1, VS38c, CD138, bcl-2, and CD44). The presence of a BCL-2/IgH gene rearrangement was investigated by polymerase chain reaction. All cases were characterized by similar clinicopathologic and morphologic features and had similarly good overall outcome. The patients (23 males, 6 females, median age 44 years) had tumors in long bones (14), axial skeleton (8), limb girdles (3), and multiple sites (4). Most tumors (24) were centroblastic, with multilobated cells in 12 cases. Almost half of the tumors (14 of 29, 48%) were bcl-6+CD10+ (GC-like), 9 of 29 cases (31%) were bcl-6+CD10- (indeterminate phenotype), and 6 of 29 cases (21%) were CD10-bcl-6- (post-GC like). The indeterminate phenotype was seen only in primary bone lymphoma. MUM-1 was frequently expressed in GC-like and non-GC-like categories. We found no evidence of plasmacytic differentiation by CD138, and VS38c immunoreactivity was distinctly rare (2 of 29 cases). CD44 was detected in 6 tumors, all CD10-. Bcl-2 was expressed by 70% of the tumors, but only 1 of 23 cases tested had a Bcl-2/JH rearrangement by polymerase chain reaction. A survival analysis showed that GC-like tumors had a longer overall survival duration compared with non-GC-like tumors (P = 0.0046). In conclusion, a GC-like immunophenotype characterizes roughly half of large B-cell lymphomas of bone and is associated with an improved survival.     

Psychosocial Impact of Abdominoplasty

Background

The number of patients desiring reconstructive surgery after a huge weight loss achieved with gastric banding is increasing. This study was undertaken to determine whether plastic surgical removal of an overlap flap has a psychosocial effect on patients.

Methods

Thirty-women and four men who underwent overlap flap surgery were interviewed 1 day before, and again 3 and approximately 12 months after the procedure using a series of instruments: Strauss and Appelt’s Questionnaire for assessing one’s body, the Body Perception Questionnaire by Paulus, the questionnaire for satisfaction of life by Fahrenberg, Myrtek, Schumacher, and Brähler, the Hospital Anxiety and Depression Scale (German version) by Herrmann, Buss, and Snaith, and the authors’ general questionnaire after surgery. The same clinical parameters were also investigated in a control group of persons who did not undergo plastic surgery. Comparisons were made before and after surgery between and in both groups.

Results

In contrast to the control group, surgical patients reported a highly significant increase in self-confidence and the feeling of being attractive (p?≤?0.001); 75% of the surgical patients stated that their expectations were met by the plastic surgical intervention.

Conclusion

Plastic surgery after weight loss improves body image and subjective quality of life. These results will influence the indication for a reconstructive operation in future.

     

Analysis of genes encoding laminin β2 and related proteins in patients with Galloway–Mowat syndrome

Galloway-Mowat syndrome (GMS) is a rare autosomal recessive disorder characterized by early onset nephrotic syndrome and microcephaly with various anomalies of the central nervous system. GMS likely represents a heterogeneous group of disorders with hitherto unknown genetic etiology. The clinical phenotype to some extent overlaps that of Pierson syndrome (PS), which comprises congenital nephrotic syndrome and distinct ocular abnormalities but which may also include neurodevelopmental deficits and microcephaly. PS is caused by mutations of LAMB2, the gene encoding laminin beta2. We hypothesized that GMS might be allelic to PS or be caused by defects in proteins that interact with laminin beta2. In a cohort of 18 patients with GMS or a GMS-like phenotype we therefore analyzed the genes encoding laminin beta2 (LAMB2), laminin alpha5 (LAMA5), alpha3-integrin (ITGA3), beta1-integrin (ITGB1) and alpha-actinin-4 (ACTN4), but we failed to find causative mutations in these genes. We inferred that LAMA5, ITGA3, ITGB1, and ACTN4 are not directly involved in the pathogenesis of GMS. We excluded LAMB2 as a candidate gene for GMS. Further studies are required, including linkage analysis in families with GMS to identify genes underlying this disease.     

Recurrent pleomorphic adenoma of the parotid gland: analysis of 108 consecutive patients

BACKGROUND: Surgery for recurrent parotid pleomorphic adenoma is a challenging problem. METHODS: One hundred eight patients who underwent 134 reoperations for recurrent parotid pleomorphic adenoma (follow-up, 22 years) were evaluated for histopathologic features and risk factors for recurrence. RESULTS: The number of reoperations for tumor recurrence ranged from 1 to 10. Twenty-seven patients (25%) developed permanent facial nerve weakness. The risks for clinically evident rerecurrence after 1, 5, and 15 years were 16%, 42%, and 75%, respectively. Female sex, young age at initial treatment, and enucleation instead of parotidectomy for treatment of the first recurrence were significant risk factors for rerecurrence. The mean number of recurrent tumor nodules was 26. CONCLUSIONS: Surgery for recurrent parotid pleomorphic adenoma has a high rate of facial nerve morbidity. The chance of rerecurrence is high. Extended parotidectomy seems to be the best approach for the reoperation to reduce the risk of rerecurrence.     

Female sexual desire disorders: subtypes,classification, personality factors and new directions for treatment

Lack of sexual interest is highly prevalent in the general female population and, for more than two decades, low sexual desire has been the most common presenting problem in clinical institutions. The renewed interest in female sexual dysfunction has recently focused on biological and classification aspects whilst personality- and partner-related factors, as well as theoretical concepts, have largely been neglected. After critically reviewing the current diagnostic systems for female desire disorders, this paper specifically addresses the issues of personality and life history factors. In two empirical studies, 50 patients with low sexual desire were compared to a group of 100 sexually functional women by employing both semi-structured clinical interviews and a set of self-developed and standardised questionnaires. The results of these studies indicate that women seeking help for desire disorders exhibit marked signs of mood instability and a low and fragile self-regulation and self-esteem. In addition, they tend to be more worried, anxious, introverted and conventional when compared to sexually functional women. Interestingly, no significant differences in the variables relating to partnership quality in general could be detected. Although caution is needed due to sample size and methodological limitations, our results suggest a substantial level of at least subclinical psychiatric symptoms like mood-disorders, low self-esteem and feelings of guilt in women with sexual desire disorders. These problems seem to be rather deep-rooted and particularly affect the self-regulation and the inner balance of the personality. Overall, female sexual dysfunctions and low desire, in particular, cannot be conceptualised as discrete phase disorders, but rather as a global inhibition of sexual response together with a history of mood disorder, specific personality factors and an elevated level of psychological stress. This combination calls for broad-band treatment approaches where individual and interpersonal aspects can be taken into account simultaneously. In addition, the ubiquitous comorbidity, both with other sexual dysfunctions and with various personality and psychological problems, and the developmental sequence of the sexual problems must be adequately considered.     

A specific enhanced recovery protocol decreases opioid use after thyroid and parathyroid surgery

BackgroundEnhanced recovery protocols have not been investigated previously for cervical endocrine surgery. The study aim was to determine whether systematic implementation of an enhanced recovery protocol specific for thyroid/parathyroid surgery can improve postoperative outcomes.MethodsA customized enhanced recovery protocol for thyroid/parathyroid surgery was designed and utilized systematically for all patients who underwent parathyroidectomy, thyroid lobectomy, or total thyroidectomy. Outcomes were assessed 12 months before enhanced recovery protocol implementation (n = 464 patients) and after enhanced recovery protocol implementation (n = 654 patients).ResultsEnhanced recovery protocol implementation was associated with a 72% decrease in mean oral morphine equivalents utilized in-house (before 82 ± 64 versus after 23 ± 28; P < .0001) and many enhanced recovery protocol patients were entirely opioid-free (0.2% vs 21%, P < .0001). When used, the enhanced recovery protocol was associated with a lesser mean amount of ondansetron to treat postoperative nausea and vomiting (5.5 mg ± 3 vs 4.5 ± 2: P < .0001). Duration of stay was short before implementation of the enhanced recovery protocol and did not change substantially after implementation (1.1 days ± 0.7 vs 1.1 ± 0.7; P = .26).ConclusionThe systematic use of a simple, cervical, endocrine surgery-specific enhanced recovery protocol decreased perioperative opioid use by ~70%, with significantly less postoperative nausea and vomiting. Implementation of a multidisciplinary enhanced recovery protocol may be an important initial step toward limiting opioid overuse during common operative procedures.     

Magnetic resonance imaging for assessment of radiofrequency lesions in kidney tissue immediately after ablation: an experimental study

BACKGROUND AND PURPOSE: Radiofrequency ablation (RFA) is an attractive minimally invasive treatment option for small renal masses. The purpose of this study was to investigate the morphologic imaging appearance of RF lesions immediately after the ablation of kidney tissue using standard clinical MR sequences, as well as to investigate the correlation between MR and gross lesion size. MATERIALS AND METHODS: Ablations were performed 17 times in a standardized model of ex-vivo perfused porcine kidneys using a resistance-controlled RF device (250 W, 470 kHz) and a nonexpandable bipolar applicator inserted into the center of healthy renal parenchyma. The RF current was applied for 9 minutes at 20 W. Imaging was performed after ablation using standard clinical MR sequences: morphologic T(1)/T(2)- weighted images and an isotropic post-contrast T(1) high-resolution measurement (VIBE). Maximum lesion diameters were measured in three directions and were compared with the measurements of the gross lesions. Histologic (hematoxylin + eosin and nicotinamide adenine dinucleotide staining) and statistical analyses were performed. RESULTS: The gross pathologic examination showed a firm, white-yellow ablation zone sharply demarcated from the untreated tissue. The histologic examination confirmed cellular viability outside but not in the treatment zone. The RF lesions were hyperintense on T(1)-weighted images and hypointense on T(2)-weighted images. The lesion size measured in the VIBE images correlated best with the macroscopic lesion size (N = 16). CONCLUSIONS: Morphologic MR T(1) and T(2) sequences of RF lesions immediately after ablation produce reliable and consistent imaging characteristics. The post-contrast, high-resolution sequence (VIBE) enables the extent of the lesion to be determined accurately. The potential uses of this imaging strategy in clinical practise warrant further investigation on human renal-cell carcinoma.     

Retinal function and PKC alpha expression after focal laser photocoagulation

Purpose

To examine the effects of focal laser photocoagulation on general and local retinal function and to relate electrophysiological findings with changes in protein kinase C (PKC) alpha expression.

Methods

Twelve rabbits were treated with 70 spots of laser photocoagulation in the central cone-rich retina. The operated eyes were investigated with electroretinography (full-field ERG and multifocal electroretinography, mfERG) preoperatively and at 1, 3, and 5 weeks after surgery. The expression of PKC alpha was examined at all three time points using immunohistochemistry, and PKC alpha mRNA levels were quantified using real-time polymerase chain reaction (PCR). Immunohistochemistry for glial fibrillary acidic protein (GFAP) and hematoxylin and eosin staining was employed to monitor the extent and dynamics of the morphological response.

Results

The full-field ERG revealed a significant increase in b-wave amplitudes derived from the isolated rod response (blue light) at all three time points after surgery (p?Conclusions Focal laser treatment in the rabbit eye induces local and wide-spread alterations in both rod- and cone-mediated retinal function in the form of supernormal b-wave amplitudes in the full-field ERG and increased latency in the mfERG. The electrophysiological abnormalities are accompanied by a progressive down-regulation of the PKC alpha isoenzyme in rod bipolar cells, reaching far beyond the treated area. PKC alpha is down-regulated directly by impaired protein synthesis, and also possibly indirectly by protein consumption related to GFAP up-regulation. The results indicate that focal laser photocoagulation interferes with PKC-alpha-mediated inhibitory regulation of inner retinal signal transmission.     

In diabetic retinopathy, foveal thickness of 300 μm seems to correlate with functionally significant loss of vision

Purpose To study the relationship between foveal thickness assessed by optical coherence tomography (OCT) and foveal function measured with multi focal electroretinography (mfERG) in patients with non-proliferative diabetic retinopathy, and with no previous laser treatment. Methods Twenty-six eyes from 18 diabetic patients (13 men), aged 59 years, (range 28–79 years), diabetes duration 15 years, (range 2–27 years), with a macular thickness between 200 and 600 μm were evaluated by mfERG, visual acuity (ETDRS score) and OCT. Mean amplitudes and implicit times of the mfERG responses were analyzed within the four innermost (14 degrees) of the six concentric rings. For comparison with the results from the OCT (diameter of measured area = 6 mm) we analyzed the summed response from the first and second ring (central zone), corresponding to the central area of the OCT. The third(zone 2) and fourth (zone 3)of the four innermost of the six concentric rings measured by the mfERG corresponding to the second and third area of OCT. Results An increased macular thickness in the central area of the OCT correlated to reduced amplitudes (r = −0.541; P = 0.004) and prolonged implicit times (r = 0.548; P = 0.004) in the central zone of the mfERG, and inversely correlated with visual acuity, −0.49; P = 0.045. Retinal thickness in the second area was correlated to prolonged implicit times in the second mfERG zone (r = −0.416; P = 0.034). No correlations were found for the third area of the OCT. When macular thickness exceeded 300 μm the decrease of amplitudes and prolonged implicit times, measured by mfERG, seemed to be more pronounced. Conclusion In conclusion increased macular thickness is correlated with reduced amplitudes and prolonged implicit times on the mf ERG and worse visual acuity.     

Risk of visual impairment in children with congenital toxoplasmic retinochoroiditis

PURPOSE: Reliable information is needed to counsel parents of children with congenital toxoplasmosis regarding the long-term risk of visual impairment resulting from ocular toxoplasmosis. DESIGN: Prospective cohort study of children with congenital toxoplasmosis identified by prenatal or neonatal screening. METHODS: After three years of age, ophthalmologists reported the site of retinochoroidal lesions and visual acuity and parents reported visual impairment. An ophthalmologist predicted the child's vision based on the last retinal diagram. Selection biases were minimized by prospective enrollment and data collection, high rates of follow-up, and exclusion of referred cases. RESULTS: Two hundred and eighty-one of 284 infected children who underwent ophthalmic examinations were followed up to a median age of 4.8 years. One in six children (49/281; 17%) had at least one retinochoroidal lesion, two-thirds of whom (32/49; 65%) had a lesion at the posterior pole. In children with retinochoroiditis who had visual acuity measured after 3 years of age, 94% (31/33) had normal vision in the best eye (6/12 Snellen or better), as did 91% of those with a posterior pole lesion (21/23). Analyses based on affected eyes showed that 42% (29/69) had a posterior pole lesion, of which just more than half (15/29, 52%) had normal vision, as did 84% (16/19) of eyes with a peripheral lesion alone. Vision predicted by the ophthalmologist was moderately sensitive (59%) but overestimated impairment associated with posterior pole lesions. Of 44 children with information on acuity, four (9%) had bilateral visual impairment worse than 6/12 Snellen. CONCLUSIONS: Severe bilateral impairment occurred in 9% of children with congenital toxoplasmic retinochoroiditis. Half the children with a posterior pole lesion and one in six of those with peripheral lesions alone were visually impaired in the affected eye.