Double vitrification and warming does not compromise the chance of live birth after single unbiopsied blastocyst transfer.

STUDY QUESTION: Does double vitrification and thawing of an embryo compromise the chance of live birth after a single blastocyst transfer? SUMMARY ANSWER: The live birth rate (LBR) obtained after double vitrification was comparable to that obtained after single vitrification. WHAT IS KNOWN ALREADY: Double vitrification-warming (DVW) is commonly practiced to accommodate surplus viable embryos suitable for transfer, to allow retesting of inconclusively diagnosed blastocysts in preimplantation genetic testing (PGT), and to circumvent limitations associated with national policies on embryo culture in certain countries. Despite its popularity, the evidence concerning the impact of DVW practice on ART outcomes is limited and lacking credibility. This is the first thorough investigation of clinical pregnancy and LBR following DVW in the case where the first round of vitrification occurred at the zygote stage and the second round occurred at the blastocyst stage in the absence of biopsy. STUDY DESIGN SIZE DURATION: This is a retrospective observational analysis of n = 407 single blastocyst transfers whereby embryos created by IVF/ICSI were vitrified-warmed once (single vitrification-warming (SVW) n = 310) or twice (DVW, n = 97) between January 2017 and December 2021. PARTICIPANTS/MATERIALS SETTING METHODS: In the SVW group, blastocysts were vitrified on Day 5/6 and warmed on the day of embryo transfer (ET). In the DVW group, two pronuclear (2PN) zygotes were first vitrified-warmed and then re-vitrified on Day 5/6 and warmed on the day of ET. Exclusion criteria were ETs from PGT and vitrified-warmed oocyte cycles. All of the ETs were single blastocyst transfers performed at the University Hospital Zurich in Switzerland following natural or artificial endometrial preparation. MAIN RESULTS AND THE ROLE OF CHANCE: The biochemical pregnancy rate, clinical pregnancy rate (CPR), and LBR were all comparable between the DVW and SVW groups. The CPR for DVW was 44.3% and for SVW it was 42.3% (P = 0.719). The LBR for DVW was 30.9% and for SVW it was 28.7% (P = 0.675). The miscarriage rate was additionally similar between the groups: 27.9% for DVW and 32.1% for SVW groups (P = 0.765). LIMITATIONS REASONS FOR CAUTION: The study is limited by its retrospective nature. Caution should be taken concerning interpretation of these findings in cases where DVW occurs at different stages of embryo development. WIDER IMPLICATIONS OF THE FINDINGS: The result of the present study on DVW procedure provides a framework for counselling couples on their chance of clinical pregnancy per warming cycle. It additionally provides confidence and reassurance to laboratory professionals in certain countries where national policies limit embryo culture strategies making DVW inevitable. STUDY FUNDING/COMPETING INTERESTS: This work was supported by the University Research Priority Program 'Human Reproduction Reloaded' of the University of Zurich. The authors have no conflict of interest related to this study to declare. TRIAL REGISTRATION NUMBER: N/A.

Higher miscarriage rate in subfertile women with endometriosis receiving unbiopsied frozen-warmed single blastocyst transfers.

Background: Assisted reproductive technology treatment is recommended to overcome endometriosis-associated infertility but current evidence is controversial. Endometriosis is associated with lower antral follicle count (AFC) and oocyte yield but similar clinical outcomes compared to controls. Unaffected ovarian stimulation response and embryological outcomes but lower clinical pregnancy and live birth rates and higher miscarriage rates have been reported, implying direct impact on endometrial receptivity. With evidence emerging on the benefit of frozen-warmed and blastocyst stage transfer, we investigated ART outcomes in endometriosis using homogeneous case-control groups. Methods: This is a retrospective observational case-control study including n = 66 frozen-warmed unbiopsied single blastocyst transfers of patients with endometriosis and n = 96 of women exhibiting idiopathic sterility. All frozen-warmed transfers followed artificial endometrial preparation. Results: In control women, the mean number of oocytes recovered at oocyte pick up was higher compared to women with endometriosis (15.3 ± 7.1 vs. 12.7 ± 5.2, p = 0.025) but oocyte maturation index (mature oocytes/total oocytes at oocyte pick up) was significantly higher for endometriosis (48.2% vs. 34.0%, p = 0.005). The same was shown for the subgroup of 44 endometriosis patients after endometrioma surgery when compared with controls (49.1% vs. 34.0%, p = 0.014). Clinical pregnancy rate was not higher in endometriosis but was close to significance (47.0% vs. 32.3%, p = 0.059) while live birth rate was comparable (27.3% vs. 32.3%, p = 0.746). Miscarriage rate was higher in the endometriosis group (19.7% vs. 7.3%, p = 0.018). A significantly higher AFC was observed in the control group in comparison with the endometriosis group (16.3 ± 7.6 vs. 13.4 ± 7.0, p = 0.014). Live birth rate did not differ when comparing all endometriosis cases (p = 0.746), ASRM Stage I/II and Stage III/IV (p = 0.348 and p = 0.888) with the control group but the overall pregnancy rate was higher in ASRM Stage I/II (p = 0.034) and miscarriage rate was higher in ASRM Stage III/IV (p = 0.030) versus control. Conclusion: Blastocyst transfers in women with endometriosis originate from cycles with lower AFC but higher share of mature oocytes than in control women, suggesting that endometriosis might impair ovarian reserve but not stimulation response. A higher miscarriage rate, independent of blastocyst quality may be attributed to an impact of endometriosis on the endometrium beyond the timing of implantation.

Impact of heatwaves and environmental ammonia on energy metabolism, nitrogen excretion, and mRNA expression of related genes in the indicator model system Daphnia magna.

Due to increasing anthropogenic impacts, heatwaves and prolonged exposure to elevated concentrations of ammonia (HEA) may occur in aquatic environments as a single stressor or a combination thereof, potentially impacting the physiology of exposed animals. In the current study, common water fleas Daphnia magna were exposed for one week to either a 5°C increase in temperature, an increase of 300 µmol l-1 total environmental ammonia, or to both of these stressors simultaneously. Exposure to elevated temperature caused a decrease in MO2, ammonia excretion rates, a downregulation of mRNA coding for key Krebs cycle enzymes and the energy consuming Na+/K+-ATPase and V-type H+-ATPase, as well as the energy distributing crustacean hyperglycemic hormone Rh-protein. High environmental ammonia inflicted a lesser inhibitory effect on the energy metabolism of Daphnia, but initiated ammonia detoxification processes via urea synthesis evident by elevated urea excretion rates and a mRNA upregulation of arginase. Effects observed under the combined stressors resembled largely the effects seen after acclimation to elevated temperature alone, potentially due to the animals' capability to efficiently detoxify critical ammonia loads. The observed physiological effects and potential threats of the environmental stressor are discussed in detail.

Decrease in primary but not in secondary abdominal surgery for Crohn's disease: nationwide cohort study, 1990-2014.

BACKGROUND: Treatment of patients with Crohn's disease has evolved in recent decades, with increasing use of immunomodulatory medication since 1990 and biologicals since 1998. In parallel, there has been increased use of active disease monitoring. To what extent these changes have influenced the incidence of primary and repeat surgical resection remains debated. METHODS: In this nationwide cohort study, incident patients of all ages with Crohn's disease, identified in Swedish National Patient Registry between 1990 and 2014, were divided into five calendar periods of diagnosis: 1990-1995 and 1996-2000 with use of inpatient registries, 2001, and 2002-2008 and 2009-2014 with use of inpatient and outpatient registries. The cumulative incidence of first and repeat abdominal surgery (except closure of stomas), by category of surgical procedure, was estimated using the Kaplan-Meier method. RESULTS: Among 21 273 patients with Crohn's disease, the cumulative incidence of first abdominal surgery within 5 years of Crohn's disease diagnosis decreased continuously from 54·8 per cent in 1990-1995 to 40·4 per cent in 1996-2000 (P < 0·001), and again from 19·8 per cent in 2002-2008 to 17·3 per cent in 2009-2014 (P < 0·001). Repeat 5-year surgery rates decreased from 18·9 per cent in 1990-1995 to 16·0 per cent in 1996-2000 (P = 0·009). After 2000, no further significant decreases were observed. CONCLUSION: The 5-year rate of surgical intervention for Crohn's disease has decreased significantly, but the rate of repeat surgery has remained stable despite the introduction of biological therapy.

ANTECEDENTES: El tratamie nto de pacientes con enfermedad de Crohn ha evolucionado en las últimas décadas con un uso cada vez mayor de medicamentos inmunomoduladores desde 1990 y tratamientos biológicos desde 1998. Al mismo tiempo, ha aumentado la utilidad de la vigilancia activa de la enfermedad. Hasta qué punto estos cambios han influido en la incidencia de la resección quirúrgica primaria y repetida sigue siendo objeto de debate. MÉTODOS: Estudio de cohortes a nivel nacional de pacientes incidentes con enfermedad de Crohn de todas las edades identificados en el registro sueco nacional de pacientes entre 1990-2014, que se dividió en cinco períodos de diagnóstico: 1990-1995 y 1996-2000 con el uso de registros de pacientes hospitalizados, 2001, y 2002-2008 y 2009-2014 con uso de registros de pacientes ambulatorios y hospitalizados. Se estimó la incidencia acumulada de la primera cirugía abdominal y de las cirugías abdominales subsiguientes (excepto el cierre de estomas), por categoría de procedimiento quirúrgico, mediante el método de Kaplan-Meier. RESULTADOS: Entre 21.273 pacientes con enfermedad de Crohn, la incidencia acumulada de la primera cirugía abdominal durante los 5 años posteriores al diagnóstico de la enfermedad disminuyó continuamente del 54,8% en la cohorte 1990-1995 al 40,4% en la cohorte 1996-2000 (P < 0,001) y nuevamente del 19,8% en cohorte 2002-2008 al 17,3% en la cohorte 2009-2014 (P < 0,001). Las tasas cirugías iterativas a los 5 años disminuyeron de 18,9% en la cohorte 1990-1995 a 16,0% en la cohorte 1996-2000 (P = 0,017). Después del 2000, no se observaron más disminuciones significativas. CONCLUSIÓN: La tasa de intervención quirúrgica a los 5 años para la enfermedad de Crohn ha disminuido significativamente, pero la cirugía iterativa se ha mantenido estable a pesar de la introducción de la terapia biológica.

From high to low malaria transmission in Zanzibar-challenges and opportunities to achieve elimination.

BACKGROUND: Substantial global progress in the control of malaria in recent years has led to increased commitment to its potential elimination. Whether this is possible in high transmission areas of sub-Saharan Africa remains unclear. Zanzibar represents a unique case study of such attempt, where modern tools and strategies for malaria treatment and vector control have been deployed since 2003. METHODS: We have studied temporal trends of comprehensive malariometric indices in two districts with over 100,000 inhabitants each. The analyses included triangulation of data from annual community-based cross-sectional surveys, health management information systems, vital registry and entomological sentinel surveys. RESULTS: The interventions, with sustained high-community uptake, were temporally associated with a major malaria decline, most pronounced between 2004 and 2007 and followed by a sustained state of low transmission. In 2015, the Plasmodium falciparum community prevalence of 0.43% (95% CI 0.23-0.73) by microscopy or rapid diagnostic test represented 96% reduction compared with that in 2003. The P. falciparum and P. malariae prevalence by PCR was 1.8% (95% CI 1.3-2.3), and the annual P. falciparum incidence was estimated to 8 infections including 2.8 clinical episodes per 1000 inhabitants. The total parasite load decreased over 1000-fold (99.9%) between 2003 and 2015. The incidence of symptomatic malaria at health facilities decreased by 94% with a trend towards relatively higher incidence in age groups > 5 years, a more pronounced seasonality and with reported travel history to/from Tanzania mainland as a higher risk factor. All-cause mortality among children < 5 years decreased by 72% between 2002 and 2007 mainly following the introduction of artemisinin-based combination therapies whereas the main reduction in malaria incidence followed upon the vector control interventions from 2006. Human biting rates decreased by 98% with a major shift towards outdoor biting by Anopheles arabiensis. CONCLUSIONS: Zanzibar provides new evidence of the feasibility of reaching uniquely significant and sustainable malaria reduction (pre-elimination) in a previously high endemic region in sub-Saharan Africa. The data highlight constraints of optimistic prognostic modelling studies. New challenges, mainly with outdoor transmission, a large asymptomatic parasite reservoir and imported infections, require novel tools and reoriented strategies to prevent a rebound effect and achieve elimination.

Childhood onset inflammatory bowel disease and risk of cancer: a Swedish nationwide cohort study 1964-2014.

Objective To assess risk of cancer in patients with childhood onset inflammatory bowel disease in childhood and adulthood.Design Cohort study with matched general population reference individuals using multivariable Cox regression to estimate hazard ratios.Setting Swedish national patient register (both inpatient and non-primary outpatient care) 1964-2014.Participants Incident cases of childhood onset (<18 years) inflammatory bowel disease (n=9405: ulcerative colitis, n=4648; Crohn's disease, n=3768; unclassified, n=989) compared with 92 870 comparators from the general population matched for sex, age, birth year, and county.Main outcome measures Any cancer and cancer types according to the Swedish Cancer Register.Results During follow-up through adulthood (median age at end of follow-up 27 years), 497 (3.3 per 1000 person years) people with childhood onset inflammatory bowel disease had first cancers, compared with 2256 (1.5 per 1000 person years) in the general population comparators (hazard ratio 2.2, 95% confidence interval 2.0 to 2.5). Hazard ratios for any cancer were 2.6 in ulcerative colitis (2.3 to 3.0) and 1.7 in Crohn's disease (1.5 to 2.1). Patients also had an increased risk of cancer before their 18th birthday (2.7, 1.6 to 4.4; 20 cancers in 9405 patients, 0.6 per1000 person years). Gastrointestinal cancers had the highest relative risks, with a hazard ratio of 18.0 (14.4 to 22.7) corresponding to 202 cancers in patients with inflammatory bowel disease. The increased risk of cancer (before 25th birthday) was similar over time (1964-1989: 1.6, 1.0 to 2.4; 1990-2001: 2.3, 1.5 to 3.3); 2002-06: 2.9, 1.9 to 4.2; 2007-14: 2.2, 1.1 to 4.2).Conclusion Childhood onset inflammatory bowel disease is associated with an increased risk of any cancer, especially gastrointestinal cancers, both in childhood and later in life. The higher risk of cancer has not fallen over time.

Post-traumatic stress symptoms in Swedish obstetricians and midwives after severe obstetric events: a cross-sectional retrospective survey.

OBJECTIVE: To examine post-traumatic stress reactions among obstetricians and midwives, experiences of support and professional consequences after severe events in the labour ward. DESIGN: Cross-sectional online survey from January 7 to March 10, 2014. POPULATION: Members of the Swedish Society of Obstetrics and Gynaecology and the Swedish Association of Midwives. METHODS: Potentially traumatic events were defined as: the child died or was severely injured during delivery; maternal near-miss; maternal mortality; and other events such as violence or threat. The validated Screen Questionnaire Posttraumatic Stress Disorder (SQ-PTSD), based on DSM-IV (1994) 4th edition, was used to assess partial post-traumatic stress disorder (PTSD) and probable PTSD. MAIN OUTCOME MEASURES: Partial or probable PTSD. RESULTS: The response rate was 47% for obstetricians (n = 706) and 40% (n = 1459) for midwives. Eighty-four percent of the obstetricians and 71% of the midwives reported experiencing at least one severe event on the delivery ward. Fifteen percent of both professions reported symptoms indicative of partial PTSD, whereas 7% of the obstetricians and 5% of the midwives indicated symptoms fulfilling PTSD criteria. Having experienced emotions of guilt or perceived insufficient support from friends predicted a higher risk of suffering from partial or probable PTSD. Obstetricians and midwives with partial PTSD symptoms chose to change their work to outpatient care significantly more often than colleagues without these symptoms. CONCLUSIONS: A substantial proportion of obstetricians and midwives reported symptoms of partial or probable PTSD after severe traumatic events experienced on the labour ward. Support and resilience training could avoid suffering and consequences for professional carers. TWEETABLE ABSTRACT: In a survey 15% of Swedish obstetricians and midwives reported PTSD symptoms after their worst obstetric event.

Statistical controversies in clinical research: assessing pathologic complete response as a trial-level surrogate end point for early-stage breast cancer.

BACKGROUND: A trial-level surrogate end point for a randomized clinical trial may allow assessment of the relative benefits of the treatment to be performed at an earlier time point and potentially with a smaller sample size. However, determining whether an end point is a reliable trial-level surrogate based on results of previous trials is not straightforward. The question of trial-level surrogacy is easily confused with the question of individual-level surrogacy, and this confusion can lead to controversy. A recent example concerns the evaluation of pathologic complete response (pCR) as a surrogate for event-free survival (EFS) and overall survival (OS) in early-stage breast cancer. MATERIALS AND METHODS: The differences between individual-level surrogacy (i.e. for patients receiving a specific treatment, the surrogate end point predicts the definitive end point) and trial-level surrogacy (the results of the trial for the surrogate end point predict the results of the trial for the definitive end point) are discussed. Trial-level data used in two previous meta-analyses evaluating pCR as a trial-level surrogate for EFS and OS were re-analyzed using methods that appropriately account for the variability in pCR rates as well as the variability in the hazard ratios for EFS and OS. RESULTS: There is no evidence that pCR is a trial-level surrogate for EFS or OS, nor is there evidence that pCR could be used reliably to screen out nonpromising agents from further drug development. CONCLUSIONS: At present, neoadjuvant RCTs should continue to follow patients to observe EFS and OS to assess clinical benefit, and they should be designed with sufficient sample size to reliably assess EFS. However, one cannot rule out the possibility that future meta-analyses involving more trials and in which the patient population or class of treatments is restricted could suggest the validity of pCR as a trial-level surrogate for EFS or OS in some focused settings.

'Now I understand': consulting parents on chart design and parental information for the UK-WHO child growth charts.

BACKGROUND: Regular assessment of growth is an important part of child health surveillance in the UK and most parents are very interested in their child's growth. UK parents are given a personal child health record (PCHR), including growth charts, which are plotted during baby clinic visits. Parents were consulted as part of the process of designing new UK charts to incorporate the World Health Organization growth standard. This paper describes the main themes that emerged and how they influenced the final design. METHOD: Three sets of consultations with 47 parents were conducted to collect preliminary information, and to evaluate proposed chart designs, instructions and written information for parents. RESULTS: At every consultation, the impact of the depiction of the 50th centile line in bold was mentioned spontaneously by parents. They also found aspects of the charts unclear, including the implications of a recorded weight on any particular centile, the difficulty of understanding existing text about charts in the PCHR, their preference for using pounds and ounces rather than metric weights and confusion about how frequently babies should be weighed. This led to the production of parental information including explanation of these issues which were then tested in two further sets of focus groups. CONCLUSION: Involving parents in the process of designing growth charts and information influenced the finished design and the text in the PCHR. Ensuring information meets parents' needs is important to ensure successful growth monitoring.

[Immunonutrition after trauma]. / Immunonutrition nach Trauma.

Immunonutrition may be superior to standard clinical nutrition in specific clinical situations. After severe trauma, an enteral immuno-enhancing diet, enriched with arginine, omega-3 fatty acids, and nucleotides, decreases infectious complications. During acute respiratory distress syndrome, a continuous enteral diet with high-dose omega-3 fatty acids, gamma-linolenic acid, and antioxidants improved clinical outcome. Glutamine should be administered enterally or parenterally whenever total parenteral nutrition is indicated.

Tuning spin-orbit coupling and superconductivity at the SrTiO{3}/LaAlO{3} interface: a magnetotransport study.

The superconducting transition temperature T{c} of the SrTiO{3}/LaAlO{3} interface was varied by the electric field effect. The anisotropy of the upper critical field and the normal-state magnetotransport were studied as a function of gate voltage. The spin-orbit coupling energy epsilon{SO} is extracted. This tunable energy scale is used to explain the strong gate dependence of the mobility and of the anomalous Hall signal observed. Epsilon{SO} follows T{c} for the electric field range under study.

Microarray analysis of placental tissue in intrauterine growth restriction.

OBJECTIVE: Besides foetal or maternal disorders, placental dysfunction is a major cause of intrauterine growth restriction (IUGR). Although numerous macro- and histopathological changes have been described, little is known about the precise aetiology and the contribution of foetal/placental genes in this disorder. DESIGN: Placental tissues of 20 IUGR and control neonates were analysed by microarray technique. Four of the regulated genes with possible relevance in the pathogenesis of IUGR and its consequences were further studied in placentas of 27 IUGR and 35 control newborns. RESULTS: Elevated gene expression of leptin, corticotrophin-releasing hormone (CRH), and IGF-binding protein-1 (IGFBP-1) in IUGR placentas could be confirmed in the larger group by real-time PCR, whereas prolactin showed no significant difference. Accordingly, protein expression of leptin and IGFBP-1 depicted by Western blot was elevated in IUGR, prolactin was not different. Birthweight standard deviation score (SDS) correlated negatively to leptin, IGFBP-1, and CRH, whereas placental weight correlated only to IGFBP-1. Leptin correlated negatively to gestational age of IUGR patients and positively to placental score, a marker of severity of impaired foeto-placental circulation. CONCLUSIONS: As confirmed in a large group of IUGR and control samples, the up-regulated factors leptin, IGFBP-1, and CRH may serve as candidate genes for the prediction of subsequent metabolic consequences in IUGR newborns. These three factors may not only influence growth of the foetus, but might also interact with programming of its metabolic functions, which has to be determined in an ongoing study.

[The medical history as a historical source. As an example, the story of a war comrade of the "English patient", Count László Ede Almásy (1895-1951) is presented]. / Die Anamnese als historische Quelle. Dargestellt am Beispiel eines Kriegskameraden des "englischen Patienten", László Ede Graf Almásy (1895-1951).

The medical history is an important prerequisite for making a diagnosis and for establishing a trust- based doctor-patient relationship. Sometimes they can also serve as a historical source, as this example of an 89-year old patient shows. The patient worked with the Hungarian Count László Ede Almásy (1895-1951) during a German military secret service operation in North Africa during the Second World War. Graf Almásy became internationally famous through the novel "The English Patient" by Michael Ondaatje or rather, through the film of the same name. In the film however, the historical facts were very distorted as the medical history of our patient shows.

Auditory nerve inputs to cochlear nucleus neurons studied with cross-correlation.

The strength of synapses between auditory nerve (AN) fibers and ventral cochlear nucleus (VCN) neurons is an important factor in determining the nature of neural integration in VCN neurons of different response types. Synaptic strength was analyzed using cross-correlation of spike trains recorded simultaneously from an AN fiber and a VCN neuron in anesthetized cats. VCN neurons were classified as chopper, primarylike, and onset using previously defined criteria, although onset neurons usually were not analyzed because of their low discharge rates. The correlograms showed an excitatory peak (EP), consistent with monosynaptic excitation, in AN-VCN pairs with similar best frequencies (49% 24/49 of pairs with best frequencies within +/-5%). Chopper and primarylike neurons showed similar EPs, except that the primarylike neurons had shorter latencies and shorter-duration EPs. Large EPs consistent with end bulb terminals on spherical bushy cells were not observed, probably because of the low probability of recording from one. The small EPs observed in primarylike neurons, presumably spherical bushy cells, could be derived from small terminals that accompany end bulbs on these cells. EPs on chopper or primarylike-with-notch neurons were consistent with the smaller synaptic terminals on multipolar and globular bushy cells. Unexpectedly, EPs were observed only at sound levels within about 20 dB of threshold, showing that VCN responses to steady tones shift from a 1:1 relationship between AN and VCN spikes at low sound levels to a more autonomous mode of firing at high levels. In the high level mode, the pattern of output spikes seems to be determined by the properties of the postsynaptic spike generator rather than the input spike patterns. The EP amplitudes did not change significantly when the presynaptic spike was preceded by either a short or long interspike interval, suggesting that synaptic depression and facilitation have little effect under the conditions studied here.

Sex differences in baseline neuropsychological function and concussion symptoms of collegiate athletes.

OBJECTIVE: To investigate sex differences in baseline neuropsychological function and concussion symptoms between male and female collegiate athletes. METHODS: A post-test only design was used to examine baseline neuropsychological test scores and concussion symptoms. A total of 1209 NCAA Division I collegiate athletes from five northeastern universities in the USA completed a baseline ImPACT test. ImPACT, a computerised neuropsychological test battery, was administered during an athlete's pre-season. RESULTS: Female athletes performed significantly better than male athletes on baseline verbal memory scores (p = 0.001), while male athletes performed significantly better than female athletes on baseline visual memory scores (p = 0.001). Female athletes endorsed a significant number of mild baseline symptoms as compared to male athletes. CONCLUSIONS: Male and female athletes exhibit differences on baseline neuropsychological test performance and concussion symptoms.

[Utilizing optical coherence tomography (OCT) for visualization of urothelial diseases of the urinary bladder]. / Anwendung der optischen Kohärenztomographie (OCT) bei der Darstellung von Urothelerkrankungen der Harnblase.

PURPOSE: The technique of optical coherence tomography (OCT) has significantly improved over the last few years. This new diagnostic procedure allows imaging of tissue structure of the bladder wall during cystoscopy with high resolution. MATERIALS AND METHODS: The penetration depth of OCT is limited to 2.5 mm. The resolution is approximately 15 microm. Fifty patients with different clinical conditions of the bladder were examined. Altogether 488 OCT images were generated. RESULTS: OCT of normal bladder mucosa clearly shows a differentiation between urothelium, lamina propria, and smooth muscle. Cystitis and metaplasia are characterized by blurring of the laminated structure and thickening of the epithelial layer. In malignant areas there is complete loss of the regular layered tissue structure. CONCLUSION: OCT improves the diagnosis of flat lesions of the urothelium. It has the potential for facilitating intraoperative staging of malignant areas in the bladder.

Posterior "nutcracker" phenomenon: hemodynamic relevant aorto-retroaortal renal vein fistula leading to fatal right heart failure.

A rare complication of an aneurysm of the abdominal aorta is the so-called "posterior nutcracker phenomenon", which describes compression of a retroaortal renal vein between the abdominal aorta and the vertebral column. The clinical presentation is flank pain and hematuria, which are usually caused by a renal (respectively ureteral) calculus or neoplasia. Another rare differential diagnosis for these very common clinical symptoms is an aorto-left renal vein fistula (ALRVF), which is a spontaneous vascular fistula, usually also associated with an aortic aneurysm, infrequently a result of abdominal trauma.

[The impact of ALA (5-aminolevulinic acid)-fluorescence detection on the prognosis of superficial bladder cancer]. / Der Stellenwert der ALA-(5-Amino-Lävulinsäure)-Fluoreszenzdetektion für die Prognose des oberflächlichen Blasenkarzinoms. Eine 1-Jahres-Uberlebensanalyse.

PURPOSE: Throughout the past years, several studies have shown that fluorescence cystoscopy with ALA (5-aminolevulinic acid) improves the detection rate of superficial bladder tumors by approximately 20 % compared to standard white light cystoscopy. These results suggest a reduced rate of residual/recurrent tumors with the routine use of ALA fluorescence technique prior to bladder tumor resection. The present prospectively randomized study was performed to verify this hypothesis. MATERIALS AND METHODS: A total of 115 bladder tumor patients were randomized for initial resection under white light or ALA fluorescence. After 6 to 8 weeks, a second-look resection was performed in all patients guided by ALA fluorescence. Additional white light cystoscopies were performed after 3, 6 and 12 months. RESULTS: The second-look resection did not find a tumor in 31 of 51 (59 %) patients initially resected under white light guidance compared to 43 of 51 (84 %) patients in the fluorescence group. This difference was statistically significant (p = 0.005). At 12 months, a tumor was not found in 17 of 48 patients from the white light group vs. 25 of 47 patients from the fluorescence group (p = 0.03). Seven patients were lost to follow-up. CONCLUSIONS: By reducing otherwise inevitable re-operations, fluorescence cystoscopy decreases morbidity and lowers treatment costs.