Moderate versus deep hypothermia for arterial switch operation.

BACKGROUND: We evaluated the impact of moderate versus deep intraoperative hypothermia on postoperative morbidity in patients receiving a standard arterial switch operation (ASO). METHODS: 71 newborns underwent ASO from 9/98 onwards. Patients were operated using moderate hypothermia (M, 24 degrees C to 30 degrees C, n=21) or deep hypothermia (D, 16-22 degrees C, n=50). Mean patient age was 9.5 (M) versus 10 (D) days, body weight 3.6+/-0.7 (M) versus 3.8+/-0.9 kg (D), P=n. s. Coronary anatomy was complex in 9.5% (M) versus 16% (D) of patients; additional VSD was present in 23.8 (M) versus 38% (D) of the patients, respectively. Mean follow-up is 2.3+/-1.6 years. RESULTS: Intraoperative rectal temperature was 25+/-2 degrees C (M) and 19+/-2 degrees C (D). Cross-clamping time was 95+/-24 (M) versus 108+/-31 min (D), P=n. s. Conventional ultrafiltration was performed at 114+/-46 (M) versus 129+/-69 ml/kg (D), P=n. s. One patient (D) with complex anatomy suffered myocardial ischemia required ECMO support and died. In-hospital mortality was 1.4%. All other patients were safely weaned from extracorporeal circulation with moderate inotropic support. Secondary chest closure was performed in 33% (M) versus 54 % (D) of the patients. Patients were extubated after 7.4 (M) versus 6 (D) days. There was no renal failure and no other serious complications. CONCLUSIONS: ASO can be safely performed using moderate hypothermia, even with complex anatomy, leading to comparatively good results compared to a conventional approach.

[Bone metabolism in 53 children and adolescents with chronic inflammatory bowel disease]. / Knochenstoffwechsel bei 53 Kindern und Jugendlichen mit chronisch entzündlichen Darmerkrankungen.

BACKGROUND: Osteopathy is a common clinical feature of chronic inflammatory bowel disease (IBD) in children and young adults at the time of primary diagnosis. The aim of the following study was to address the question of prevalance of a decreased bone density or increased bone metabolism in children with IBD. PATIENTS: We examined 63 patients (mean age 13 years; 5 - 18 years): 36 Crohn's disease (MC) patients, 16 colitis ulcerosa (CU) patient and one patient with colitis indeterminata (CID). 10 children who had been referred to the gastroenterological outpatient department due to suspected IBD symptoms were later found not to suffer from IBD. These 10 patients therefore were included in the study as controls. RESULTS: 8 of 10 CU patients and 18 of 28 MC patients showed a pathological bone density and abnormalities in bone metabolism. Repetitive bone density measurement was performed in 18 patients. In MC patients a - 0.39 SDS decrease of bone mineral density was found, without a simultaneous deterioration of clinical stage and inspite of a decreased cumulative prednisolon dosage. However in CU patients a + 0.06 SDS increase of bone mineral density was detected. These patients had a lower cumulative prednisolon dosage and a stable clinical course. CONCLUSIONS: In conclusion, pediatric IBD patients often show abnormalities in bone metabolism and decreased bone density. There is a need for multicentre, prospective randomised control trials to further identify therapeutic tools on the basis of the multifactorial etiology of bone disease in pediatric IBD patients.

Experiences of 100 men who have sex with men using the Reality condom for anal sex.

A self-administered, anonymous questionnaire examining opinions and experiences of using Reality, the "female" condom, for anal sex was completed by a convenience sample of 100 men who have sex with men (MSM). Eighty-six percent of respondents said they would use Reality again; 54% would rather use Reality than penile condoms. Acceptability was higher among MSM who were HIV positive, in nonmonogamous relationships, or who had serodiscordant partners. Negative experiences included: difficulty inserting (33%), irritation (17%), bunching up (12%), unpleasant texture (10%), and noise (9%). Breakage was reported three times in 334 episodes of use. Although no available data compare preferences and efficacy of Reality to penile condoms, Reality is a welcome alternative for some MSM who have difficulty consistently using penile condoms and probably reduces HIV transmission compared with unprotected anal sex. Research to more definitively assess Reality as a risk reduction method for MSM is greatly needed.

PIP: Men who have sex with men (MSM) in gay male communities do not always use condoms when having anal sex. Reasons for such risky behavior include men's objections to the lack of spontaneity demanded from condom use, decreased sensation, and condom breakage. Reality, a polyurethane pouch designed to line the vagina, was developed mainly to provide women with a contraceptive and STD prevention option. A removable inner ring and fixed outer ring keep the device in place. Some MSM use Reality when having anal sex. 750 free Reality kits were distributed by the STOP AIDS Project in San Francisco at venues frequented by MSM. Kits included 2 female condoms, instructions, a self-administered questionnaire on the users' experiences with Reality, and a stamped return envelope. 108 surveys were returned, with 100 MSM reporting use of Reality during the past 6 months in 147 episodes of insertive and 187 episodes of receptive anal sex. 86 men reported that they would use Reality again, and 54 said they would rather use Reality than conventional male condoms. Generally most liked about Reality were its heightened sensitivity and spontaneity, while insertion difficulties and high cost were the factors least liked. Acceptability was higher among MSM who were HIV-positive, in nonmonogamous relationships, or who had serodiscordant sex partners. Negative experiences included difficulty inserting (33%), irritation (17%), bunching up (12%), unpleasant texture (10%), and noise (9%). Breakage was reported 3 times in 334 episodes of use. Reality appears to be a welcome alternative for some MSM who do not consistently use penile condoms. Although use of the method probably reduces HIV transmission compared to unprotected anal sex, more research is needed to definitively assess its effectiveness as a risk reduction method for MSM.

Community screening for diabetes. Low detection rate in a low-risk population.

OBJECTIVE: To evaluate glucose-based community screening for diabetes with regard to detection rate. RESEARCH DESIGN AND METHODS: A retrospective analysis of a community-screening questionnaire data base that included a screening for blood glucose. Referred subjects had fasting glucose levels > 6.4 mM (115 mg/dl) or postprandial levels > or = 8.9 mM (160 mg/dl). An attempt was made to contact referred subjects and to ascertain whether follow-up was undertaken and current status. A random sample of subjects not meeting the glucose criteria (nonreferred) also was contacted in an analogous fashion to referred subjects. RESULTS: In 2,016 questionnaires, glucose-based referral criteria were exhibited by 148 (7.3%) individuals, and subsequent evaluation data were available for 111. Of those 111 individuals, 37 (33%) knew they had diabetes before the screening, and 39 (36%) did not seek further evaluation. Of the remaining 35 subjects, 6 (13%) were told of their new diagnosis of diabetes, and 29 were told they did not have diabetes. Three of 50 nonreferred subjects knew of their diabetes before screening. Thirty percent (14 out of 47) of nonreferred subjects underwent subsequent evaluation, although they were not told to do so. A single new case of diabetes occurred in the nonreferred group. CONCLUSIONS: Community screening for diabetes that is based on measured glucose is of low yield. The known problems of glucose-based screening, coupled with its low yield, make a glucose-based approach difficult to justify. These results indicate that glucose-based community screening should be done only under the careful supervision of a health professional who is trained both in glucose measurement instrumentation and in screening.

Early sonographic evaluation for fetal growth delay and congenital malformations in pregnancies complicated by insulin-requiring diabetes. National Institute of Child Health and Human Development Diabetes in Early Pregnancy Study.

OBJECTIVE: It has been reported that early fetal growth retardation may be a useful marker for congenital malformations in diabetic pregnancies. To test this hypothesis, diabetic and nondiabetic women were sonographically evaluated during the first trimester. RESEARCH DESIGN AND METHODS: Fetal crown-rump lengths were measured sonographically at least once during the first 15 wk of pregnancy in 329 nondiabetic and 312 diabetic women. Of these, 289 nondiabetic and 269 diabetic women had sonograms before 10 wk of gestation and 283 nondiabetic and 269 diabetic women had sonograms between 10 and 15 wk of gestation. Early fetal growth delay was defined as a sonographic gestational age of greater than or equal to 6 days less than menstrual gestational age. RESULTS: The mean crown-rump lengths at 8 wk were 17.9 +/- 4.6 mm in the diabetic and 18.7 +/- 4.9 mm in the nondiabetic groups (P = 0.13). At 12 wk, the mean fetal crown-rump length was 58.5 +/- 8.8 mm for diabetic subjects and 60.6 +/- 8.7 mm for nondiabetic subjects (P = 0.04). Between 5 and 9 wk, 28 of 289 (9.7%) fetuses of nondiabetic subjects, 34 of 259 (13.1%) normal fetuses of diabetic subjects, and 2 of 10 (20%) malformed fetuses of diabetic subjects demonstrated growth delay (P = 0.31, normal vs. malformed diabetic). Between 10 and 15 wk of gestation, 28 of 283 (9.9%) fetuses of nondiabetic subjects, 32 of 256 (12.5%) normal fetuses of diabetic subjects, and 4 of 13 (30.8%) malformed fetuses of diabetic subjects demonstrated growth delay (P = 0.06, normal vs. malformed diabetic). Early fetal growth delay did not predict a reduced birth weight at term. CONCLUSIONS: Among insulin-dependent diabetic subjects who were moderately well controlled at conception, statistically significant but mild early fetal growth delay was present but did not appear to be useful clinically in predicting congenital malformations. Recommendations that growth delay demonstrated on early ultrasound be used as a predictor of congenital malformation require careful reexamination.

Combined use of stereotaxic CT and angiography for brain biopsies and stereotaxic irradiation.

A Riechert Mundinger stereotaxic device was modified to enable artifact-free computed tomographic (CT) scanning with the stereotaxic frame attached to the patient's head. A localization system was developed allowing determination of the XYZ coordinates of the target point directly from the CT cut. Angiography was performed intraoperatively with the stereotaxic frame attached. Coronal and sagittal CT reconstructions were enlarged to the radiographic magnification to allow direct comparison with angiography. CT offered optimum localization of the target, whereas angiography determined the safest approach. Computer programs were developed to enable three-dimensional radiotherapy planning. 125I seeds were implanted for treatment of low-grade gliomas and solid craniopharyngiomas. Yttrium-90 was applied in cystic craniopharyngiomas. Intracavitary rhenium-186 application was abandoned because of frequent cyst recurrence and leakage from the cyst.

Prognostic criteria in patients with endometrial cancer.

Between 1970 and 1977 216 patients were operated on for adenocarcinoma of the endometrium at the I. Universitäts-Frauenklinik, Munich. The 5-year-survival rate for stage Ia was 79.7%, for stage Ib 86.4%, and for stage II 66.7%. Reliable prognostic criteria were tumor grading, lymphatic invasion, and myometrial tumor invasion. The 5-year-survival rate in patients with grade 1 carcinoma was 88.9% in patients with grade 3 carcinoma only 33.3% Patients with adenoacanthoma had a 5-year-survival rate of 73.3%, those with an adenosquamous carcinoma a 5-year-survival rate of 50%. Patients with no evidence of lymphatic invasion showed a 5-year-survival rate of 84.9%, those with proven invasion of lymphatic vessels a survival rate of 52.9%. In patients with tumor infiltrating one third of the myometrium the 5-year-survival rate was 90%. In patients with tumor infiltrating two thirds of the myometrium the 5-year-survival rate was 66.7%, and with infiltration of the full thickness of myometrium it was 33.3%.

Recent results of the German Thorotrast study--epidemiological results and dose effect relationships in Thorotrast patients.

The German Thorotrast Study includes 5159 Thorotrast patients and 5160 control patients. 887 Thorotrast patients and 660 control patients could be clinically and biophysically examined and followed-up. The mean age at injection or hospitalization in the case of the control group was 28 yr. The mean injected volume of Thorotrast was calculated to be 24.7 ml and the X-ray films of 249 Thorotrast patients showed paravascular deposits. In the meantime 432 Thorotrast patients and 122 patients of the control group have died. Among the deceased patients we have registered (Thorotrast vs control): hepatic tumors 152/0; myeloproliferative diseases 10/0; Hodgkin's diseases 2/0; non-Hodgkin's lymphomas 5/1; bronchogenic carcinomas 13/6; pleural mesothelioma 1/0; bone sarcoma 1/1(?); sarcoma at injection site 1/0; hepatic cirrhosis 90/6; bone marrow failure 8/1; other neoplastic diseases 46/19; other non-neoplastic diseases 151/88. The cumulative incidence of liver tumors depends on the dose rate to liver tissue and is not influenced by the age at injection. A dose effect relationship for the myeloproliferative diseases is not yet apparent.

[The prognostic importance of the stage in patients operated for carcinoma of the endometrium (author's transl)]. / Prognostische Aussagekraft des Stadiums bei Patientin-nen mit operiertem Endometriumkarzinom.

The operative specimens of 216 patients who underwent operation for adenocarcinoma of the endometrium stage I and stage II were thoroughly examined. It was found that measuring the maximal depth of infiltration of the carcinoma in relation to the thickness of the uterine wall and other morphological criteria of the tumours such as tumour grading, and carcinomatous lymphangiosis have greater prognostic value than clinical staging and the length of the uterine cavity to the sound. In contradistinction to other observations we found that patients with a short length of the uterus had more often recurrences and distant metastases than patients with a long uterine length to the sound.

Hemorrhage and cardiac arrest during laparoscopic tubal ligation.

PIP: The article describes the case of a 38-year-old woman on whom laparoscopic tubal ligation was performed on an outpatient basis. During the procedure a 14 mm. tear was caused in the aorta, possibly by the Verres needle or the laparoscopic trocar, with subsequent hemorrhage and cardiac arrest. Similar cases are rarely reported in the literature. Still, it is important that facilities for massive transfusion should be available even in outpatient clinics.^ieng