[Management of Complex Tympanojugular Paragangliomas]. / Interdisziplinäres Management von komplexen tympanojugulären Paragangliomen Fisch Typ C und D.

Background: Tympanojugular paraganglioma (TJP) are benign, high vascularized, local destructive tumors. Despite many studies in the literature, the management of particularly complex TJP (e. g., posterior fossa and/or carotid artery invasion) remains controversial. In the current study we present our treatment strategies for complex TJP and long-term results. Patients and methods: Between 2003 and 2013, 17 patients with TJP Fisch types C and D were treated in our institution. Primary symptoms were hearing loss, followed by facial nerve palsy and lower cranial nerve impairments. 2 patients presented with recurrent tumors. Surgical treatment after endovascular tumor embolization was performed in 14 patients. 2 patients were treated by radiation therapy. Results: Gross tumor resection was achieved in 10 patients. A temporary postoperative facial nerve palsy occurred in 2 patients and permanent postoperative vocal cord palsy in 3 patients. During long term follow-up, one patient experienced regrowth of the residual tumor. No tumor progress was observed in both patients treated with radiation therapy. Outcome assessed by Karnofsky scale showed 100% functionality in 12 patients and 90% in 5 patients. Discussion: Surgical treatment of TJP after endovascular embolization is the treatment of choice in young and healthy patients. In older patients with premorbid conditions, radiation therapy is the main treatment option and is associated with high tumor control rates. Precise preoperative staging together with individualize risk-benefit assessment and interdisciplinary treatment strategy are essential for a favorable outcome.

Principles of shock wave therapy.

A shock wave is a transient pressure disturbance that propagates rapidly in three-dimensional space. It is associated with a sudden rise from ambient pressure to its maximum pressure. A significant tissue effect is cavitation consequent to the negative phase of the wave propagation. The current authors summarize the basic physics of shock waves and the physical parameters involved in assessing the amount of energy delivered to the target tissue and in comparing the various high- and low-energy devices being evaluated clinically for musculoskeletal applications.

A review of halo vest treatment of upper cervical spine injuries.

Thirty-five relevant studies involving in total 682 patients with 709 different types of injuries were evaluated in a review to determine the outcomes after immobilisation in a halo vest for various injuries to the upper cervical spine between 1962 and 1998. Studies were analysed according to the type of injury pattern and in terms of the treatment outcomes following primary treatment with a halo vest. The following types of injuries were evaluated: odontoid fractures (n = 420), hangman's fractures (n = 172), other axis fractures (n = 75), Jefferson fractures (n = 26), C1 arch fractures (n = 9), atlantooccipital (n = 2) and atlantoaxial dislocations (n = 5). The ligamentary atlantooccipital dislocations never healed. All isolated Cl ring fractures healed completely. The isolated C1 arch fractures healed in 83% of the cases. The ligamentary atlantoaxial dislocations had a 60% rate of healing. Healing was noted in all isolated odontoid type I fractures, 85% of the isolated odontoid type II fractures, and 67% of the odontoid type II fractures with combined injuries. The isolated odontoid type III fractures had a 97% healing rate. The non-classifiable odontoid fractures had a healing rate of 85%. The stable C2 arch fractures (hangman's fracture) healed consistently in 99%, and 90% success was found for other C2 fractures. A halo vest can be recommended for patients with isolated Jefferson fractures, hangman's fractures, odontoid type III and type II fractures, with a low dislocation rate. The results of treatment with a halo vest were unsatisfactory with regard to combined injuries with an odontoid type II fracture. An overall healing rate of 86%, however, allows one to conclude that this treatment continues to be a good alternative to operative stabilisation of bone injuries to the upper cervical spine.

Capillary oxygen saturation and tissue oxygen pressure in the rat cortex at different stages of hypoxic hypoxia.

The objective of this study was to generate data that allow for estimation of the validity of oxygen saturation (SO2) values in superficial cortical capillaries as calculated by a microreflectometric system (EMPHO II). Capillary SO2 and tissue oxygen pressure (PtO2) were measured simultaneously in the cortex of n = 13 Wistar rats under normocapnic (PaCO2 = 36 mmHg) arterial normoxia (PaO2 = 92 mmHg), moderate (paO2 = 53 mmHg) and severe hypoxic hypoxia (PaO2 = 31 mmHg) with microreflectometry and multiwire surface electrodes. Values were pooled according to arterial oxygenation levels, displayed as frequency histograms and compared via ANOVA (p < 0.05). In a Hill-plot (log PtO2 versus log SO2/(100 - SO2)) an in vivo tissue oxygen dissociation curve was obtained and a linear regression/correlation analysis performed. Mean +/- SD values of SO2 respectively PtO2 decreased from 45.6% +/- 14.6% resp. 26.8 +/- 8.2 mmHg during arterial normoxia to 32.6% +/- 10.2% resp. 20.2 +/- 6.6 mmHg during moderate and to 12.3% +/- 11.1% resp. 8.7 +/- 5.0 mmHg during severe hypoxic hypoxia. Linear regression analysis in the Hill-plot of values between 1% and 65% SO2 and 0.1 and 41 mmHg PtO2 revealed an excellent correlation (r2 = 0.88) with an increase of scatter below 10% SO2 or 1.5 mmHg PtO2. We conclude that SO2 values calculated by the algorithm of the applied microreflectometric system reflect very accurately cortical oxygen supply over a very wide range of oxygenation levels when compared to a gold standard reference. Only at extremely low levels (e.g. below 10% SO2) did we find possible inaccuracies with regard to truly absolute saturation values.

Pathogenic and Molecular Characterization of Three Phomopsis Isolates from Peach, Plum, and Asian Pear.

Three isolates of Phomopsis, causing shoot blight of peach, shoot tissue necrosis of plum, or bud death of Hosui Asian pear, respectively, were evaluated for their pathogenicity on apple, pear, peach, and plum. Current year's shoots of 1-year-old Stayman Winesap apple, Barlett pear, Babygold-7 peach, and Bruce plum trees were inoculated with each isolate by wounding a bud and applying agar blocks bearing young hyphae. The length of cankers on shoots was measured 10, 17, and 24 days after inoculation. Cankers developed on shoots of all hosts inoculated with the peach isolate and on peach shoots inoculated with plum and Asian pear isolates. No cankers developed on apple, pear, or plum shoots inoculated with plum and Asian pear isolates. In the first experiment, 10 days after inoculation, the length of cankers on apple trees (56.0 mm) inoculated with the peach isolate was not significantly different (P ≥ 0.05) from that on peach (42.8 mm), but was significantly greater than that on plum (25.3 mm) and pear (13.1 mm). The cankers on peach were significantly longer than those on pear, but not on plum. Cankers on all four hosts were significantly different from one another 17 and 24 days after inoculation. There was no significant difference between the length of cankers on peach shoots inoculated with plum and Asian pear isolates, and they were significantly smaller than those inoculated with the peach isolate. None of the control trees developed cankers. The three isolates differed in colony morphology, and appearance of conidiomata, conidiogenous cells, and α-conidia on potato-dextrose agar. None of the isolates produced ß-conidia in culture. Multi-locus DNA fingerprint analysis and internal transcribed spacer sequence comparisons revealed similarities between the plum and Asian pear isolates but a significant difference between these two and the peach isolate. The results indicate that the Phomopsis sp. that causes shoot blight of peach has the potential to cause disease on other stone and pome fruits, and peach may also be susceptible to isolates of Phomopsis from different tree fruit hosts.

Improved CT diagnosis of acute middle cerebral artery territory infarcts with density-difference analysis.

A new postprocessing method is described for CT detection of acute middle cerebral artery (MCA) territory infarcts by histograph analysis of density values. The density values in each CT slice were histographically recorded for each hemisphere. A density-difference diagram was calculated by digital subtraction of the histogram of the left hemisphere from that of the right. Pixels within the highest density-difference ranges were highlighted. To investigate the value of this method CT studies of 30 patients with acute MCA territory infarcts and of 15 normal CT studies were analysed by two radiologists and neurosurgeons. CT images with and without postprocessing were assessed for the presence, site and size of infarcts. Follow-up CTwas used as control. With density-difference analysis (DDA) the detection rate for infarcts increased significantly (96 % compared to 61 %). In no case was a correct diagnosis made on the unpostprocessed images falsely revised with DDA. All normal CT studies were detected correctly using DDA.

Comparison between clinical examination, cw-Doppler ultrasound and colour-duplex sonography in the diagnosis of incompetent perforating veins.

OBJECTIVES: This study was conducted to investigate the accuracy and agreement between clinical examination, continuous wave (cw)-Doppler ultrasound and colour-duplex sonography (CDS) in diagnosing incompetent perforating veins (ICPV). DESIGN: Observational cohort study. MATERIAL AND METHODS: Nineteen patients with chronic venous insufficiency (CVI) were examined clinically, by hand-held cw-Doppler ultrasound in combination with tourniquet compression and CDS. RESULTS: The low accuracy of the clinical examination and the diagnosis of ICPV by cw-Doppler were surprising. The specificity was 15% and sensitivity 29%, when CDS was taken as the "gold standard". Furthermore the results show clearly that the application of a tourniquet cannot provide reliable results. CONCLUSIONS: In patients with CVI, clinical and cw-Doppler cannot accurately diagnose ICPV when compared to CDS.

Pathogenicity of a Species of Phomopsis Causing a Shoot Blight on Peach in Georgia and Evaluation of Possible Infection Courts.

A species of Phomopsis was isolated consistently from blighted shoots of peach trees in Georgia and Alabama. Isolates of the fungus caused characteristic cankers on current season's shoots of Babygold-7 peach trees when wounded or nonwounded dormant buds, breaking buds, and natural or artificially-created leaf scars were inoculated with conidia of the fungus. Mean canker length for the isolates was 35 mm 30 days after inoculation. No disease developed on control trees. There was no significant difference between the canker length on inoculated wounded dormant buds (59 mm) and nonwounded breaking buds (54 mm). However, cankers from both sites of inoculation were significantly longer than those resulting from inoculated artificially-created leaf scars (33 mm), natural leaf scars (33 mm), and non-wounded dormant buds (30 mm). There was no significant difference in virulence among the 5 isolates of Phomopsis sp. tested, and multi-locus DNA fingerprint analysis resulted in a similarity coefficient of 0.94 among the isolates. Additionally, results of the internal transcribed spacer (ITS) regions sequence comparisons for the isolates were consistent with the multi-locus polymerase chain reaction profiles, and the nucleotide sequences of the ITS region were identical for all 5 isolates. This is the first documentation of the pathogenicity of a Phomopsis sp. associated with shoot blight of peach in Georgia. Rapid development of disease in breaking buds indicates that they may be the primary site of invasion by the fungus. Natural leaf scars and dormant buds may also serve as possible infection courts.

[Color duplex ultrasonography in the diagnosis of deficient perforating veins in comparison to cw-Doppler ultrasonography and clinical examination]. / Farb-Duplexsonographische Diagnostik von insuffizienten Perforansvenen im Vergleich mit CW-Doppler- und klinischer Untersuchung.

The study was conducted to investigate the accuracy and agreement between clinical examination, cw-Doppler ultrasound and color-duplex sonography in diagnosing incompetent perforating veins. Nineteen patients with chronic venous insufficiency (CVI) were examined clinically, by hand-held cw-Doppler ultrasound in combination with tourniquet compression and color-coded duplex sonography CDS. The accuracy of the clinical examination and the diagnosis of ICPV by cw-Doppler were surprisingly low. The specificity was 15% and sensitivity 29%, when CDS was taken as gold standard. Furthermore the results show clearly that the application of a tourniquet cannot provide reliable results. It is concluded that in patients with CVI clinical and cw-Doppler examinations are not sufficient for an accurate diagnosis of incompetent perforating veins. Color-duplex provides a new noninvasive approach for accurate anatomical and functional diagnosis, which is of great importance prior to surgical interventions and/or sclerotherapy.

Contact hypersensitivity to corticosteroids in routine patch test patients. A multi-centre study of the Swiss Contact Dermatitis Research Group.

BACKGROUND: Contact hypersensitivity to corticosteroids is increasingly reported and has been identified as a problem of considerable clinical relevance. The prevalence of positive patch tests to corticosteroids ranges from 0.2 up to 5%. OBJECTIVE: The prevalence of positive patch tests to corticosteroids in Switzerland was determined in a multi-centre study of patients undergoing routine patch tests. METHODS: As representatives of corticosteroid groups, the following substances were used for screening: tixocortol pivalate and hydrocortisone for group A (hydrocortisone type), hydrocortisone butyrate for group D (hydrocortisone butyrate type) and budesonide for both groups B (triamcinolone type) and D. Patients positive for at least one corticosteroid were retested with the screening series and 12 corticosteroids commonly used in Switzerland. RESULTS: Among 3,016 consecutive patients, 65 individuals (2.2%) with a total of 106 positive reactions were found. Retesting showed a concordance of 70-98%, depending on the corticosteroid and the score of the positive reaction. In the subsequently tested corticosteroid series including 12 substances, 19 out of 56 screening-positive patients had a positive result to one or several corticosteroids. There were only few evident cross-reactive patterns in between the corticosteroids tested. CONCLUSIONS: Corticosteroids should be included in routine patch testing, because contact sensitization to a corticosteroid is of considerable practical importance. We confirm that as markers of corticosteroid sensitization tixocortol pivalate, budesonide and hydrocortisone butyrate may be suited, because there is no single corticosteroid which is a marker for all four corticosteroid groups. Patch test reactions of 2+ or higher have a better reproducibility than 1+ reactions.

Angiosarcoma of the scalp. A case with a particularly aggressive evolution.

A 80-year-old woman presented with a spontaneously bleeding wound on her scalp. The diagnosis of angiosarcoma was made based on histopathological examination of the second biopsy 1 month later. At that time, a large hematoma was present on the scalp and forehead with two bleeding erosions and numerous small blue-black nodules as well as a right cervical lymphadenopathy. The patient was treated by wide-field electron-beam radiotherapy, which showed no effect. The particularly aggressive evolution of this angiosarcoma led to death within less than 2 months.

"Ultrahigh" dexamethasone in acute brain injury. Results from a prospective randomized double-blind multicenter trial (GUDHIS). German Ultrahigh Dexamethasone Head Injury Study Group.

In a prospective randomized double-blind multicenter trial, the efficacy and safety of a 51-hour ultra-high intravenous dexamethasone dosing regimen was investigated in patients with moderate and severe head injury. 300 patients between 15 and 55 years of age were randomized to receive either placebo or dexamethasone: 500 mg intravenous infusion within 3 h after trauma initially, followed by 200 mg after 3 h, thereafter 8 times 200 mg at 6 hourly intervals, resulting in a total administered dose of 2,3 g in 51 hours. Primary end points for assessment of efficacy were: Modified Glasgow Coma Scale (grading 3-16) on Day 5, modified Glasgow Outcome Scale (grading 1-6) 10-14 months after injury, and the time interval until consciousness improved above a level of modified GCS > or = 8. Secondary endpoints were CT results and neurological and laboratory data. The two groups were well matched with respect to important prognostic variables, such as age, severity of trauma, and interval between trauma and application of the drug. 269 patients (89.7%) were available for final examination after 10-14 months. Results were surprisingly favourable in both groups: Lethality in the dexamethasone and placebo group was 14.3 and 15.4%, respectively, and 61.7 and 57.4%, respectively, achieved social and professional rehabilitation after 10-14 months (outcome scale 6). No statistical difference was seen between the dexamethasone and the placebo group in any of the primary end points of efficacy and safety (incidence of upper gastrointestinal bleeding, infection, and thrombosis).(ABSTRACT TRUNCATED AT 250 WORDS)

Complete removal of an oculomotor nerve neurinoma without permanent functional deficit. Case report.

A case of complete operative removal of a neurinoma of the oculomotor nerve with long-time preservation of oculomotor function despite minor signs of aberrant reinnervation is presented. A review of the literature referring to the clinical appearance, radiological features, treatment, and outcome of 22 cases is given, 18 of which involved operations. To our knowledge, this is the first case to prove that complete operative removal of an oculomotor neurinoma without relevant persisting neurological sequelae is possible.

Anterior cervical discectomy and vertebral interbody fusion with hydroxy-apatite ceramic. Preliminary results.

Intervertebral plates of hydroxy apatite ceramic (HAC) have been used in three patients for cervical vertebral interbody fusion after anterior discectomy. In one case a pure HAC "Disc" was used, which proved to be too friable. Specially designed intervertebral plates, which were composed of an HAC-coated core of alumina ceramic, were used in the other two cases. Clinically and radiologically optimal results after 1-year- and 2-year-follow-up suggest that HAC-ceramic might be a very promising material for vertebral interbody fusion. Possible complications and pain due to bone removal from the iliac crest are avoided, and the operative procedure is simplified.

Resection of relevant nerve roots in surgery of spinal neurinomas without persisting neurological deficit.

In 42 patients with a spinal neurinoma or neurofibroma, resection of the affected nerve root was necessary in 24 cases for complete removal of the tumour. In 10 of these the resected nerve root was relevant for upper or lower limb function. Of this subgroup of 10 patients with a resection of a relevant motor root, only 4 showed an initial slight impairment of motor function, which was followed by complete recovery in two cases by the time of discharge from hospital. A persisting relevant motor impairment was not observed in any case. Recommendations given in the literature for the resection of spinal neurinomas vary from radical resection to strict microsurgical resection with preservation of as much of the nerve root as possible. This report together with the publication of Kim et al. suggests, that radical resection is possible without neurological deficit, if microsurgical preservation of unaffected nerve fibres is impossible or if the risk of recurrence is judged to be unduly high.

Disappearance of syringomyelia following resection of extramedullary lesion. A contribution to the aetiological enigma of syringomyelia.

A case of platybasia associated with syringomyelia is presented where the syrinx regressed nearly completely after transoral resection of the dens. This course seems to be of considerable interest because it is hardly explainable by the common theories which try to elucidate the pathogenesis of syringomyelic cysts.

Segmental neurofibromatosis of the sciatic nerve: case report.

A case of rare segmental neurofibromatosis is presented. Multiple neurofibromas along the right sciatic nerve were found. Other typical manifestations of neurofibromatosis were absent. By microsurgical dissection, it was possible to remove the neurofibromas from the nerve trunks and to preserve all motor and sensory functions. Classification of the different neurofibromatosis types is briefly reviewed. The problems of resection of benign major nerve trunk tumors in neurofibromatosis are discussed.

Dose changes in long- and medium-term intrathecal morphine therapy of cancer pain.

Intrathecal morphine analgesia for the treatment of cancer pain was administered using implanted ports and drug delivery systems (DDS) in 79 patients. Effective control of the pain was achieved in nearly all patients; in only two patients was the use of the DDS discarded because of relative ineffectiveness. Fifty-three manual drug release systems (41 lumbar, 12 ventricular) and 26 lumbar ports were used. Forty patients survived more than 2 months; the maximum survival time was 560 days (mean survival time, 80 days with a port system, 100 days with a manual DDS). Patients still alive at the time of this study, i.e., with unknown survival time, were excluded. The initial mean daily dose was 8.5 mg in lumbar ports, 2.75 mg in lumbar DDS, and 0.2 mg with intraventricular application. Dose change patterns disclosed no alteration of the initial dose in 18 of 26 port patients, an initial increase in 4, a preterminal increase in 3, and a single intermittent increase in 1 patient. Of 40 lumbar DDS patients, 13 showed a constant dose, 9 an initial, 3 a preterminal, and 5 an intermittent increase. Three patients with less than 2 months' survival time had a rather continuous increase. All long-time survivors (i.e., with more than 2 months' survival time) reached a plateau and remained there until a preterminal if any increase occurred. These findings suggest the morphine dosage to be indicative of the progress of the disease rather than of a drug tolerance.(ABSTRACT TRUNCATED AT 250 WORDS)

Inhibition of N-methyl-D-aspartate- and kainate-evoked noradrenaline release in human cerebral cortex slices by ethanol.

The effect of ethanol on the release of noradrenaline evoked by various stimuli was investigated in human cerebral cortical slices from patients undergoing neurosurgery. The slices were preincubated with [3H]noradrenaline and then superfused. Tritium overflow was stimulated by exposure to N-methyl-D-aspartate (NMDA; in slices superfused without Mg2+), kainic acid, veratridine or by increasing the K+ concentration. The NMDA-evoked tritium overflow was concentration-dependently inhibited by ethanol; an inhibition by 37% occurred at 48 mmol/l ethanol. This ethanol concentration was not yet effective when kainic acid was used for stimulation, but ethanol 150 mmol/l strongly inhibited the tritium overflow evoked by kainic acid as well. The tritium overflow evoked by veratridine or high K+ was not affected by ethanol in the concentration range investigated. These findings are compatible with the suggestion that the NMDA receptor and, with less susceptibility, the kainate receptor are sites of action underlying the effect of ethanol in the human brain.