Upper airway stimulation for obstructive sleep apnea-Can radiological position monitoring predict tongue motion one year after implantation?

BACKGROUND: Tongue motion patterns (TMP) can influence the outcome of upper airway stimulation (UAS) in the treatment of obstructive sleep apnea (OSA). As a postoperative control, the cuff position of the stimulation lead is monitored via X­ray imaging. A multidimensional X­ray assessment system was established and the association between these positional assessments and TMP was investigated 1 year after implantation. MATERIAL AND METHODS: The study on TMP and the X­ray assessments were carried out at a German ear nose and throat clinic as an implantation center. The TMPs were assessed under bipolar electrode configuration and were categorized according to the currently available literature as right-sided protrusion (RP), left-sided protrusion (LP), bilateral protrusion (BP) and mixed activation (MA). The X­ray assessment was carried out in five dimensions: the position relative to the mandible and hyoid, cuff steepness in the lateral view of the neck, the cuff position based on the single electrode, and the lead connection to the cuff in the anterior-posterior view. The analyses were performed by three raters with different medical backgrounds and knowledge regarding TMP. RESULTS: In approximately 60% of patients, the apnea-hypopnea index was reduced to below 15/h 1 year after implantation. The most common TMPs were RP and BP (82.9%). The interrater variability of the X­ray assessment was good except for one category. Furthermore, no relevant associations were found apart from the correlation between a favorable TMP and the cuff position with respect to the lateral position of the stimulation cable. CONCLUSION: Despite good interrater variability and convenient usage of the suggested X­ray assessment system, this approach did not enable the identification of any associations by which a TM and, therefore, a possible straightforward or complicated treatment pathway could be predicted. Attention should possibly be paid to a rotation of the cuff during implantation with a lateral position of the stimulation lead.

[Upper Airway Stimulation for obstructive sleep apnea-Can radiological position monitoring predict tongue motion one year after implantation? German version]. / Die obere Atemwegsstimulation bei obstruktiver Schlafapnoe ­ Kann die radiologische Lage des Stimulation-Cuff die Zungenbewegung vorhersagen?

BACKGROUND: Tongue motion patterns (TMP) can influence the outcome of upper airway stimulation (UAS) in the treatment of obstructive sleep apnea (OSA). As a postoperative control the cuff position of the stimulation lead is monitored via X­ray imaging. A multidimensional X­ray assessment system was established and the association between these positional assessments and TMP was investigated 1 year after implantation. MATERIAL AND METHODS: The study on TMP and the X­ray assessments were carried out at a German ear nose and throat clinic as an implantation center. The TMPs were assessed under bipolar electrode configuration and were categorized according to the currently available literature as right-sided protrusion (RP), left-sided protrusion (LP), bilateral protrusion (BP) and mixed activation (MA). The X­ray assessment was carried out in five dimensions: the position relative to the mandible and hyoid, cuff steepness in the lateral view of the neck, the cuff position based on the single electrode and the lead connection to the cuff in the anterior-posterior view. The analyses were performed by three raters with different medical backgrounds and knowledge regarding TMP. RESULTS: In approximately 60% of the patients the apnea-hypopnea index was reduced to below 15/h, 1 year after implantation. The most common TMPs were RP and BP (82.9%). The interrater variability of the X­ray assessment was good except for one category. Furthermore, no relevant associations were found apart from the correlation between a favorable TMP and the cuff position with respect to the lateral position of the stimulation cable. CONCLUSION: Despite good interrater variability and convenient usage of the suggested X­ray assessment system, this approach did not enable the identification of any associations, by which a TM and therefore a possible straightforward or complicated treatment pathway could be predicted. Attention should possibly be paid to a rotation of the cuff during implantation with a lateral position of the stimulation lead.

[Sleep endoscopy and complete concentric collapse in CPAP failure]. / Schlafendoskopie und komplett konzentrischer Weichgaumenkollaps bei CPAP-Nutzungsproblemen.

INTRODUCTION: First-line treatment for patients with obstructive sleep apnea (OSA) is continuous positive airway pressure (CPAP) therapy. However, many patients cannot use CPAP sufficiently. With drug-induced endoscopy (DISE), it is possible to assess the collapse pattern in the upper airway. The aim of this work was to evaluate a collective of patients with CPAP usage problems using DISE, in order to evaluate their usage problems and therapy recommendations. METHODS: Over a period of 5 years, all patients with an apnea-hypopnea index (AHI) of at least 15/h were retrospectively evaluated using DISE. The recommended treatment options were then analyzed. RESULTS: Data analysis of 210 patients showed that about two thirds reported mask problems as the cause of non-adherence to CPAP. A complete concentric collapse (CCC) could be excluded in 75%. These patients had a lower AHI and more frequent tonsillectomy (TE) than patients with CCC. Double the number of patients with a body mass index (BMI) > 35 kg/m2 had a CCC compared to those with a BMI < 35 kg/m2. Among patients with similar BMI and AHI, CCC was twice as likely to be found in patients without TE. CONCLUSION: The course of treatment recommended for OSA often differs, depending on CCC, BMI > 35 kg/m2, and previous TE.

[Botulinum Toxin in Functional Hypersalivation--All about Dosage?]. / Botulinumtoxin bei funktioneller Hypersalivation--alles eine Frage der Dosis?

BACKGROUND: The use of botulinum toxin injection in the salivary gland, is taking an increasing significance in the treatment of functional hypersalivation today. With due regard to the off -label use and the prospect of success, dosage levels are not yet standardized. MATERIAL AND METHODS: In a retrospective study, 54 patients resp. 117 treatments were analysed over a period of 5 years according to their dosage levels of botulinum toxin, outcome and side effects. RESULTS: In 90% of the cases, a reduction of saliva after botulinum toxin injections was reported, although a significant number of patients wished for an even greater effect. Compared to the first botulinum toxin injection, we therefore used a higher dosage plan in the following treatment in order to achieve better clinical results. Besides not enough saliva reduction, the main side effects were swallowing problems and thick or sticky saliva in patients with a tracheal cannula. With the exception of insufficient saliva reduction, the other described side effects were irrespective to the dosage level. CONCLUSIONS: Botulinum toxin injection as a treatment of hypersalivation is an effective method with only minor side effects, even in increased dosage levels. Nevertheless, certain modifications according to each individual treatment are required. Possible side effects such as swallowing problems or non-responding situations should always be part of informed consent, especially as the latter is even possible for higher dosage levels.

[Constitutive expression of the potential stem cell marker CD44 in permanent HNSCC cell lines]. / Konstitutive Expression des potentiellen Stammzellmarkers CD44 in permanenten HNSCC-Zelllinien.

BACKGROUND: Despite significant advances and the use of new diagnosic and therapy methods to treat head and neck squamous cell carcinoma (HNSCC), prognosis has improved only marginally in the last decades. Thus, there is an enormous need for novel immunotherapeutic approaches. It is becoming more and more obvious that stem cells play an important role in tumor development and progression. The identity of these cells and the underlying cellular and molecular mechanisms remain mostly unknown in HNSCC. MATERIAL AND METHODS: Solid tumors as well as cells from the peripheral blood of patients with HNSCC were analyzed by flow cytometry concerning the expression of different putative stem cell marker proteins. RESULTS: Distinct populations of CD44-positive (CD44+), lin-negative (lin-) potential stem cells could be identified in solid tumors of HNSCC patients with strong individual variations. Surprisingly, the potential stem cell marker CD44 was found to be constitutively expressed on the surface of all permanent HNSCC cell lines analyzed. CONCLUSION: These data strongly suggest that CD44+ tumor stem cells may play a key role in establishment of permanent HNSCC cell lines, selecting especially robust cell entities that in real life might drive progression and metastasis of HNSCC. Individual analysis of tumor stem cell markers will be an important tool for innovative therapies and prognosis of patients with HNSCC. Additional stem cell markers will be investigated concerning their expression and cellular function.

Recessive missense mutations in LAMB2 expand the clinical spectrum of LAMB2-associated disorders.

Congenital nephrotic syndrome is clinically and genetically heterogeneous. The majority of cases can be attributed to mutations in the genes NPHS1, NPHS2, and WT1. By homozygosity mapping in a consanguineous family with isolated congenital nephrotic syndrome, we identified a potential candidate region on chromosome 3p. The LAMB2 gene, which was recently reported as mutated in Pierson syndrome (microcoria-congenital nephrosis syndrome; OMIM #609049), was located in the linkage interval. Sequencing of all coding exons of LAMB2 revealed a novel homozygous missense mutation (R246Q) in both affected children. A different mutation at this codon (R246W), which is highly conserved through evolution, has recently been reported as causing Pierson syndrome. Subsequent LAMB2 mutational screening in six additional families with congenital nephrotic syndrome revealed compound heterozygosity for two novel missense mutations in one family with additional nonspecific ocular anomalies. These findings demonstrate that the spectrum of LAMB2-associated disorders is broader than previously anticipated and includes congenital nephrotic syndrome without eye anomalies or with minor ocular changes different from those observed in Pierson syndrome. This phenotypic variability likely reflects specific genotypes. We conclude that mutational analysis in LAMB2 should be considered in congenital nephrotic syndrome, if no mutations are found in NPHS1, NPHS2, or WT1.

[Palmar fixed angle plating systems for instable distal radius fractures]. / Palmare winkelstabile Plattenosteosynthese der instabilen distalen Radiusfraktur.

Internal fixation of distal radius fractures often shows the problem of secondary dislocation due to dorsal comminution and osteoporosis. Although dorsal plating systems provide good stabilization, the intraoperative control of reduction is difficult in the comminuted area with high incidence for the need of cancellous bone graft. Occurrence of extensor tendon complications including tendonitis and rupture is not uncommon. The use of fixed angle devices by a palmar approach has demonstrated the advantage of better visualization and control at the fracture side. The subchondrale support of the articular surface by fixed angle pegs or screws prevents secondary dislocation allowing early mobilization. Better soft tissue coverage is associated with a low complication rate. 62 patients (average age 55 years) were treated with different fixed angel devices according to the fracture type and underwent retrospective evaluation with mean follow-up of 11 months (6-23 months). According to the AO Classification there were 3 A2, 24 A3, 7 B3, 14 C1, 9 C2 und 5 C3 fractures. The majority beside the B3 types and one C3 fracture were dorsally displaced. All of them showed healing without relevant secondary loss of reduction. Mean DASH score reached 19 points.

[Long-term results of the palmar arthrolysis of the proximal interphalangeal joint]. / Langzeitergebnisse nach beugeseitiger Mittelgelenkarthrolyse1.

BACKGROUND: Palmar arthrolysis of the proximal interphalangeal joint is seldom carried out as an isolated treatment of contractures. The operation is usually performed in connection with treatment for a primary illness. Although intra-operative extension of the interphalangeal joint is normally completely achieved, the postoperative results show deficiencies in the extension. METHODS AND CLINICAL MATERIAL: The long-term results of 110 arthrolyses of the proximal interphalangeal joint of 102 patients are presented. The operations were performed on average 4.6 years ago. The analysis was made with standard questionnaires and self-made drawings along the side of the patients' maximally extended finger. RESULTS: "Successful operations" where performed on 76% of all released joints. The angle of the contracture was reduced by at least 10 degrees in these joints. The long-term results were compared in conjunction with results of injuries or operations of other illnesses: M. Dupuytren (primary), relapses of M. Dupuytren, lesions of the flexor tendons, camptodactyly, results of injuries due to the consequences of operations or other illnesses. The results in the group of lesions of the flexor tendons were on the whole unsuccessful. CONCLUSION: Even though thorough postoperative hand therapy(physiotherapy and use of splints) and above-average co-operation of the patients are prerequisites for a successful arthrolysis, it can be seen that the elimination of the underlying illness is of primary importance.

[Is chronic, untreated scapho-trapezoid arthrosis after resection arthroplasty of the carpometacarpal joint clinically relevant?]. / Ist eine verbliebene, unbehandelte ST-Arthrose nach Resektionsarthroplastik des Sattelgelenkes klinisch relevant?

Basal joint arthrosis and scapho-trapezio-trapezoid arthrosis (triscaphe-arthrosis) are common degenerative diseases with proven surgical treatment. Besides the extirpation of the trapezium during the resection-suspension arthroplasty, we have performed additional fusion of the scaphoid and the trapezoid (ST arthrodesis) in patients with heavy arthrotic changes in both locations. But the combination of these two surgical procedures results in a prolonged rehabilitation and may lead to more complications, e.g. nonunion. Thus the question arises, whether there is any clinical relevance to an untreated scapho-trapezoid arthrosis after resection-suspension arthroplasty of the carpometacarpal joint of the thumb. From 1992 to 1998, we performed resection-suspension arthroplasty of the carpometacarpal joint of the thumb without additional intervention at the scapho-trapezoid joint in 229 patients. In reviewing the perioperative X-rays of these patients, we found 55 cases with untreated arthrosis of the scapho-trapezoid joint. 36 of these patients were reviewed and re-examined. We used the wrist-score as well as new X-rays for our retrospective examination. The untreated arthrosis of the scapho-trapezoid joint does not lead to any reduction of wrist movement and only in some cases to a slight decrease of grip strength (compared with the other side). 23 of the 36 patients were free of pain. Two thirds of the reviewed patients (24 of 36) did not feel any loss of usability of the hand. Only four in 36 cases suffered a significant loss of function. The X-rays for this follow-up showed an increase in arthrotic changes of the scapho-trapezoid joint in comparison to the X-rays after the resection-suspension arthroplasty of the carpometacarpal joint of the thumb in one-third of the patients. In conclusion, in the majority of the patients there are no clinical symptoms of an untreated scapho-trapezoid arthrosis after resection-suspension arthroplasty of the carpometacarpal joint of the thumb. Individual subjective symptoms did exist, even with increased radio-morphologic changes, only in a few cases. We cannot recommend combining of the resection-suspension arthroplasty of the carpometacarpal joint of the thumb with the risky, uncomfortable fusion of the scaphoid and the trapezoid. Presently, we treat very severe arthrotic changes in both joints with a double-resection arthroplasty. These are very rare cases. If there are any advantages in this procedure, those will need to be proven in another follow-up study.

[Course of prostate cancer]. / Zum Verlauf des Prostatakarzinoms.

From the epicritical comparison of 85 histologically ascertained carcinomas of the prostate in the 10-year interval and 105 cases in the 5-year interval in the own clinic result survival times of on an average 2.7 years or absolutely of 19.5%. References to the improvement of the prognosis in early recognition, radical operation and chemotherapeutic treatment are given.

[The septic kidney]. / Die septische Niere.

After the definition of the notion of septic kidney with the help of a 10-year-survey cause, therapy and results of our clinical material are analysed. The obstructive urolithiasis is found to be the main cause of the development of septic picture of the disease. The nephrostomy is in suitable cases the operative therapy of choice. The relatively good results of the treatment are to be traced back to a close interdisciplinary cooperation of operative urology, intensive therapy and use of haemodialysis.

[Variations in the use of microscopic instruments for the examination of urinary calculi in routine professional practice and in research]. / Einsatzvarianten mikroskopischer Geräte zur Harnsteinuntersuchung in Routine und Forschung.

Generalising considerations concerning the problem of the analysis of urinary calculi as well as a longer testing within own examination prove modern microscopic methods and devices to be a scientific and practical instrumentarium for the examination of urinary calculi which has a good future. Expensive special microscopes may above all remained reserved for research examinations on urinary calculi, if simple laboratory microscopes for routine analyses of urinary calculi are supplemented by cheap additional constructing elements.