Early Conquest of the Rock: Julius Lempert's Life and the Complete Apicectomy Technique for the Treatment of Suppurative Petrous Apicitis

Julius Lempert (1891–1968) was one of the most revolutionary and innovative neuro-otologists of the 20th century. He had a remarkable role in advancing the field of otolaryngology to its modern shape and form, especially through his groundbreaking introduction of the fenestration procedure for the treatment of otosclerosis. Although he is highly celebrated by many neuro-otologists for his contributions to our surgical and anatomical understanding of the petrous bone, he is not well known to the neurosurgical community. In this article, we give a detailed account of Dr. Lempert''s life and discuss his invaluable contribution to skull base petrous bone anatomy and surgery through his pioneering work on the complete apicectomy for the treatment of suppurative petrous apicitis.     

Disassociation between brain activation and executive function in fragile X premutation females

Executive dysfunction has been demonstrated among premutation (PM) carriers (55–199 CGG repeats) of the Fragile X mental retardation 1 (FMR1) gene. Further, alterations to neural activation patterns have been reported during memory and comparison based functional magnetic resonance imaging (fMRI) tasks in these carriers. For the first time, the relationships between fMRI neural activation during an interleaved ocular motor prosaccade/antisaccade paradigm, and concurrent task performance (saccade measures of latency, accuracy and error rate) in PM females were examined. Although no differences were found in whole brain activation patterns, regions of interest (ROI) analyses revealed reduced activation in the right ventrolateral prefrontal cortex (VLPFC) during antisaccade trials for PM females. Further, a series of divergent and group specific relationships were found between ROI activation and saccade measures. Specifically, for control females, activation within the right VLPFC and supramarginal gyrus correlated negatively with antisaccade latencies, while for PM females, activation within these regions was found to negatively correlate with antisaccade accuracy and error rate (right VLPFC only). For control females, activation within frontal and supplementary eye fields and bilateral intraparietal sulci correlated with prosaccade latency and accuracy; however, no significant prosaccade correlations were found for PM females. This exploratory study extends previous reports of altered prefrontal neural engagement in PM carriers, and clearly demonstrates dissociation between control and PM females in the transformation of neural activation into overt measures of executive dysfunction. Hum Brain Mapp 38:1056–1067, 2017. © 2016 Wiley Periodicals, Inc.     

Metabolic effects of antisickling amounts of nitrogen and nor-nitrogen mustard on rabbit and human erythrocytes

Nitrogen mustard (NH2) and Nor-nitrogen mustard (Nor-HN2) both inhibit the polymerization of deoxyhemoglobin S in solution and in intact erythrocytes. Metabolic studies were undertaken to determine the feasability of an extracorporeal treatment with these or related agents. Glucose utilization, hexose monophosphate shunt activity, methemoglobin reduction, and incubation with acetylphenylhydrazine for Heinz body formation were performed, as well as specific assays for hexokinase, pyruvate kinase, glucose-6-phosphate dehydrogenase, glutathione reductase, ATP, reduced glutathione (GSH), and survival of autologous mustard-treated cells in rabbits. HN2 was found to enter red cells rapidly and bind to intracellular contents. Metabolic studies revealed no significant inhibition or alteration of function by Nor-HN2 at 10 mg/ml of whole blood. Rabbit red cell survival was also normal. HN2, however, inhibited glutathione reductase and blocked the free sulfhydryl group of GSH by forming serveral addition products of alkylated GSH. Heinz body test with acetylphenylhydrazine became positive in HN2-treated cells, and rabbit red cell survival was shortened considerably in the concentration range used to inhibit sickling. Ascorbic acid stimulation of the hexose shunt pathway was inhibited by HN2, but methylene blue stimulation remained unaffected. 14-C-HN2 remains bound to red cells in vivo, and the disappearance of radioactivity is similar to that found with 14-C-DFP (disopropylfluorophosphate). Oxygen affinity of both HN2 and Nor-HN2 treated human red cells remains virtually the same as that found in control samples. It is concluded that Nor-HN2 may be a suitable agent for an extracorporeal therapy, and that each mustard needs to be evaluated individually for its antisickling effects and its suitability for extracorporeal use.     

The percentage of dense red cells does not predict incidence of sickle cell painful crisis

To test the hypothesis that the tendency of hemoglobin S (HbS) to polymerize within cells is the major determinant of the incidence of vaso-occlusive episodes, we have examined the effect of the percentage of dense cells (as measured by Percoll-Stractan continuous density gradient centrifugation) on the frequency of painful crises in a group of 36 patients with sickle cell disease. No correlation was found between the percentage of dense cells and admissions for crisis. Among the patients with known alpha-gene status (n = 25), the strong correlation between decreased dense cells and alpha-thalassemia (- alpha/alpha alpha) reported previously was confirmed (P less than .001). In addition, in this small subset, patients with alpha- thalassemia (-alpha/alpha alpha) appeared to have a marginally increased number of admissions for sickle cell crisis (t = 2.1910, P less than .05), which was independent of the percentage of dense cells. We conclude that the percentage of dense sickle cells cannot predict the incidence of painful crisis, suggesting that other factors (microcirculatory regulation or other humoral and cellular factors) are more important in the generation maintenance of painful crises than the necessary, but not sufficient, tendency of HbS-containing red cells to sickle.     

The effects of cationised ferritin and native ferritin upon the filtration coefficient of single frog capillaries. Evidence that proteins in the endothelial cell coat influence permeability

To investigate whether certain macromolecules reduce capillary permeability by binding to the surface coat of endothelial cells, the effects of cationised ferritin (CF) upon the filtration coefficient (L_p) of individually perfused frog mesenteric capillaries were compared with those of native ferritin (NF). With perfusate CF concentrations between 0.1 g 100 ml^?1 and 2.5 g 100 ml^?1, L_p was reduced to approximately 30% of its value for the same vessel perfused with protein-free Ringer solution. Electron micrographs of the perfused capillaries revealed that over this range of perfusate concentrations, CF was concentrated uniformly in the endothelial cell coat, occupying 8.5% of its volume. Neither the effect of cationised ferritin upon L_p nor its concentration in the cell coat varied significantly over this range of perfusate concentrations. When perfusate concentration of CF was reduced to 0.01 g 100 ml^?1, CF no longer reduced L_p and its concentration in the cell coat fell below 2%. Native ferritin, which is excluded from the cell coat, did not reduce L_p at a perfusate concentration of 0.1 g 100 ml^?1. At a concentration of 2.5 g 100 ml^?1, NF reduced L_p in a few very permeable vessels (L_p > 60 × 10^?3μm sec^?1 cm H₂O^?1) but had no significant effect on vessels with lower and more normal values of L_p. The effects of CF upon L_p can be described in terms of the Kozeny equation if a major proportion of the hydraulic resistance through the capillary wall is attributed to a fiber protein matrix.     

Collection of mobilized blood progenitor cells for hematopoietic rescue by large-volume leukapheresis

BACKGROUND: Mobilized blood progenitor cells rapidly reconstitute hematopoiesis in patients after dose-intensive chemotherapy. However, optimal timing and methods of mobilized blood progenitor cell collection have yet to be fully defined. STUDY DESIGN AND METHODS: The utility of large-volume leukapheresis (LVL; > 15 L blood processed) in collecting target doses of mononuclear cells (7 × 10(8)/kg) for use in autologous hematopoietic rescue was investigated. LVL was begun at a standardized interval (14 days) after a course of limited chemotherapy and subsequent daily recombinant human granulocyte-macrophage-colony- stimulating factor administration to mobilize blood progenitor cells into the circulation. With each LVL procedure, mononuclear cells, colony-forming units-granulocyte-macrophage (CFU-GM), burst-forming units-erythroid, mixed colonies, total clonogenic progenitor cells, and CD34+ cells collected per kg of patient weight were counted. After high- dose chemotherapy and infusion of cryopreserved mobilized blood progenitor cells, the days needed for neutrophils to reach levels of > 0.5 × 10(9) per L and for platelets to reach levels of > 20 × 10(9) per L were recorded. RESULTS: In 14 previously treated cancer patients, an average of 28.9 +/? 4.9 L of blood was processed per LVL (n = 35) to collect medians of 2.5 × 10(8) mononuclear cells per kg (range, 1.0- 7.4), 14 × 10(4) CFU-GM per kg (0-208), 27 × 10(4) clonogenic progenitor cells per kg (0-370), and 2.8 × 10(6) CD34+ cells per kg (0- 112.5). Fifty-seven percent of patients (8/14) required one or two LVL procedures to collect adequate blood progenitor cells (range, 1–4). After dose-intensive chemotherapy, 13 patients received medians of 6.8 × 10(8) mononuclear cells per kg (range, 5.1-9.9), 53 × 10(4) CFU-GM per kg (9-208), and 12 × 10(6) CD34+ cells per kg (3.6-112.5). Rapid hematopoietic reconstitution occurred with 10 days (range, 8–12) and 9 days (6-15), respectively, for neutrophil and platelet recoveries. CONCLUSION: Scheduled LVL, beginning on Day 14 after the administration of granulocyte-macrophage-colony-stimulating factor following chemotherapy, is a convenient and efficient method of collecting blood progenitor cells. The mononuclear cells so obtained effected consistent and rapid hematopoietic reconstitution in a highly reproducible manner in a group of heavily treated patients.     

Outcome of repeat anaesthesia after investigation for perioperative anaphylaxis

Background

Perioperative anaphylaxis (POA) is infrequent, but remains an important and potentially life-threatening complication of general anaesthesia. The diagnostic uncertainty surrounding the investigation of anaesthetic allergy poses numerous challenges. We aimed to inform practice by auditing the outcomes of repeat anaesthesia, after an investigation for previous POA.

Large-volume leukapheresis for collection of mononuclear cells for hematopoietic rescue in Hodgkin's disease

BACKGROUND: Peripheral blood mononuclear cells (MNCs) collected by leukapheresis contain hematopoietic stem and progenitor cells that provide autologous hematopoietic rescue after high-dose chemotherapy, an approach that offers a significant benefit to patients with recurrent Hodgkin's disease. However, patients with low MNC counts may require 10 or more standard leukapheresis procedures for the collection of sufficient cells for hematopoietic rescue. STUDY DESIGN AND METHODS: The effectiveness of steady-state large-volume leukapheresis (LVL; 15- 35 L blood processed) was evaluated as a method for collecting MNCs for hematopoietic rescue in seven patients with recurrent Hodgkin's disease. LVL was performed on 2 consecutive days per week to collect 7 × 10(8) MNCs per kg. The circulating MNC counts on the first day of LVL and the total numbers of LVL, of MNCs collected, and of liters of blood processed were determined per patient. After high-dose chemotherapy and MNC transfusion, days to granulocyte and platelet engraftment were recorded. RESULTS: On the first day of LVL, patients had median circulating MNCs of 1536 (range, 504–3950) × 10(6) per L. The median number of LVL procedures per patient was four (range, 1.25-6), and the median L per kg of blood processed was 1.57 (range, 0.38-4.03). Simple regression analysis plotting L per kg against initial MNCs gave a curve with the equation y = e(1.42-(6.31 × 10E-4)x) (correlation coefficient = -0.97, R2 = 0.95, exponential fit). Without posttransfusion growth- factor support, median days to granulocyte engraftment were 19 (range, 12–26) and those to platelet transfusion independence were 34.5 (range, 10–57). CONCLUSION: LVL provides a useful method of collecting MNCs for hematopoietic rescue in patients with Hodgkin's disease. The patient's baseline MNC count provides a useful estimate of the volume required for LVL.     

A new level 1 oncoplastic technique for breast conserving surgery: Rotation glandular flap

BackgroundWhen performing conservative surgery for breast cancer, breast reshaping can be a challenging procedure. Level 1 oncoplastic surgery (OPS) techniques, i.e. advancement or rotation of glandular flaps, should be performed when less than 20 per cent breast volume is excised.ObjectiveA new Level 1 OPS technique is described. A wide centro-lateral glandular flap is created after extensive undermining of the skin and nipple-areolar complex, and rotated into the cavity.DiscussionThis rotation glandular flap is a new technique for use following a wide excision, in glandular, not fatty, breasts, and when standard closure of the cavity would not leave a satisfactory cosmetic result.