[Pelvic reconstruction after tubular rectumresection (extended abdominoperineal resection combined with extended transpelvic myocutaneous M. rectus abdominis flap (extended VRAM) in low rectum cancer - case series)]. / Perineale Rekonstruktion nach zylindrischer Rektumexstirpation (Defektdeckung durch erweiterte, myokutane vertikale M. rectus abdominis Lappenplastik (extended VRAM) nach zylindrischer Rektumexstirpation beim tiefsitzenden Rektumkarzinom - Fallserie).

In advanced lower rectal cancer tubular abdomino-perineal resection (APR) in combination with simultaneous extended distally pedicled vertical rectus abdominis muscle flap (VRAM) facilitates a more radical tumor resection. Additionally a prolapse of small intestine into the pelvis can be blocked and a perineal defect coverage can be achieved. 4 patients have been treated with an interdisciplinary one stage combined tubular APR and extended VRAM. In all cases a R0 resection and a complete defect closure could be achieved.The extended VRAM is an appropriate technique to close the pelvic defect because it originates from a non irradiated area, has a monitor island, and the donor site does not handicap the patient as much as local flaps. This interdisciplinary approach facilitates a more radical tumor resection and thus reduces the risk of recurrence.

Validation of the Multiple Sclerosis International Quality of Life questionnaire.

This study aims to validate the Multiple Sclerosis (MS) International Quality of Life (MusiQoL) questionnaire, a multi-dimensional, self-administered questionnaire, available in 14 languages, as a disease-specific quality of life scale that can be applied internationally. A total of 1992 patients with different types and severities of MS from 15 countries were recruited. At baseline and day 21 +/- 7, each patient completed the MusiQoL, a symptom checklist and the short-form (SF)-36 QoL questionnaire. Neurologists also collected socio-demographic, MS history and outcome data. The database was randomly divided into two subgroups and analysed according to different patient characteristics. For each model, psychometric properties were tested and the number of items was reduced by various statistical methods. Construct validity, internal consistency, reproducibility and external consistency were also tested. Nine dimensions, explaining 71% of the total variance, were isolated. Internal consistency and reproducibility were satisfactory for all the dimensions. External validity testing revealed that dimension scores correlated significantly with all SF-36 scores, but showed discriminant validity by gender, socio-economic and health status. Significant correlations were found between activity in daily life scores and clinical indices. These results demonstrate the validity and reliability of the MusiQoL as an international scale to evaluate QoL in patients with MS.

A recommended treatment algorithm in relapsing multiple sclerosis: report of an international consensus meeting.

An International Working Group for Treatment Optimization in MS met to recommend evidence-based therapeutic options for the management of suboptimal responses or intolerable side-effects in patients treated with disease-modifying drugs (DMDs) for multiple sclerosis (MS). Several DMDs are now available for the treatment of MS that have been shown to alter the clinical course of the disease by decreasing disease activity and delaying the progression of disability. Nevertheless, many patients continue to experience disease activity whilst on treatment, and recommendations have been made on how the success of therapy in an individual patient can be assessed. However, even after having identified criteria for a suboptimal response to current treatments, clinicians require guidance on how to improve the outcomes. This report summarizes the conclusions from a workshop at which this issue was addressed. We suggest treatment pathways for optimizing therapy for those patients with suboptimal responses to DMDs, and therapeutic options for patients with unacceptable side-effects on their current therapy.

[Resection of tumor stenoses and stent implantations in advanced neoplasms of the esophagus, stomach and duodenum]. / Resektion von Tumorstenosen und Stentimplantationen bei fortgeschrittenen Neoplasien des Osophagus, Magens und Duodenums.

Up to now many people demand treatment only with symptoms of a progressed cancer disease. As curative therapy is often not possible any more, endoscopy offers valuable palliative treatment options. Tumor destructive methods are mainly used for soft exophytic neoplastic tissue, whereas stent implantation is the therapy of choice in all other cases, especially if severe obstruction is present. The advantage of this method is the immediate and long lasting effect. Because of the different stent types and indications there is no optimal universal stent, so that we have to choose the individual best endoprosthesis.

Neoglycoprotein-binding sites (endogenous lectins) in the Fallopian tube, uterus and blastocyst of the rabbit during the preimplantation phase and implantation.

Regulation of the initial phase of embryo implantation may involve the recognition interplay of glycoconjugates and respective receptors such as endogenous lectins on both cellular surfaces. Whereas changes in glycoconjugate composition have been detected in preparation for embryo implantation and described in detail, knowledge on endogenous lectins has remained scant. Affinity probes (carrier-immobilized carbohydrate structures as ligand part on a histochemically inert backbone) are used in the present investigation in order to gain further insights in this area. Cryostat sections of rabbit Fallopian tubes and uteri in nonpregnant and early pregnant [tubes: 3 days post coitum (d p.c.); uteri: 3, 5, 7 and 9 d p.c.] states were studied for binding patterns of a series of biotinylated (neo)glycoproteins. A high density of binding sites was detected with beta-galactosides (with decreasing intensity: beta-D-galactose-BSA, asialofetuin with its triantennary glycan chains, lactose-BSA). Considerably less binding (but with the same pattern) was obtained with beta-N-acetyl-D-glucosaminide-BSA and is interpreted to originate from a cross-reactivity of such sites which may bind physiologically to Gal-beta1,3/4-GlcNAc sequences. In contrast, no evidence for the presence of binding molecules with specificities for a-D-mannose-BSA, maltose-BSA, N-acetyl-galactosaminide-BSA and N-acetyl-D-neuraminic acid-BSA was obtained in these tissues under the same conditions. The epithelium of the Fallopian tube showed a high density of beta-galactoside-binding sites at the apical cell poles (including the cytoplasm and membrane region) already in the nonpregnant state. At 3 d p.c., a strong reaction in all epithelial cells of the isthmus and a marked decrease in the ampulla were noted. The putative lectin(s) appear(s) to be synthesized and secreted by the tubal epithelium. A physiological role in forming the mucoprotein layer of the blastocyst coverings by precipitating the appropriate mucin-type molecules can be considered. Within the endometrium, the beta-galactoside-binding molecules were almost exclusively localized at the apical cell pole of epithelial cells, whereas there was hardly any binding in the epithelial cytoplasm or in the endometrial stroma. The reaction was very weak in the non-pregnant state but increased considerably until 5 d p.c., starting in the luminal-most parts of the epithelium. While the reaction was rather homogeneous at the surface of the luminal epithelium at 5 d p.c., the degree of heterogeneity increased stepwise from 7 to 9 d p.c. In the implantation chamber, the density of these beta-galactoside-specific 'receptors' was further enhanced in particular at the epithelial surface of the placental folds. In contrast, the reaction was less intense at the antimesometrial uterine epithelium and in interblastocyst segments of the uterus, and it remained weak in the middle and deep crypts. The trophoblast showed a high density of galactoside-binding sites at its surface, and less in the cytoplasm. Neoglycoprotein binding to the blastocyst coverings observed at 7 d p.c. was strong in particular at the outer and inner surfaces. Physical factors (e.g. differential texture at surfaces) are discussed to influence the staining patterns of these extracellular coverings. Nevertheless, the observations made on the tubal and the uterine mucosa suggest that the putative lectin(s) detected here is (are) secreted by these epithelia and could be involved in the structural organization of the various layers of the blastocyst coverings with their remarkable content of oligosaccharide chains. This effect on topological aspects of the zona pellucida equivalents may be important for the interplay between trophoblast and uterine epithelium and the cascade leading to implantation initiation.

Sneddon's syndrome with anticardiolipin antibodies--complications and treatment.

We investigated 2 patients with Sneddon's syndrome, elevated anticardiolipin antibodies and systemic complications, which included stroke, habitual abortions, cardiac valvular lesions, acrocyanosis, hypertension and renal insufficiency. Treatment with a combination of immunosuppressive agents and warfarin or aspirin prevented further complications and improved renal function. It is important for those in different specialties to be aware of this potentially treatable disorder.

Systemic versus nonsystemic reperfusion of the transplanted liver.

Reperfusion of the orthotopically transplanted liver can result in severe hemodynamic instability. This instability can result in the postreperfusion syndrome (PRS), which includes decreases in mean arterial pressure (MAP), systemic vascular resistance (SVR), and heart rate, and increases in central venous pressure and pulmonary capillary wedge pressure. This syndrome appears to be mediated by the left ventricular mechanoreceptor reflex (LVMRR), which can be activated by changes in preload, afterload, or left ventricular contractility, and by the infusion of alkaloids or potassium into the right atrium. In an attempt to prevent activation of the LVMRR and PRS, we have inserted a cannula into the retrohepatic vena cava and have allowed the initial 500-600 cc of portal blood reperfusing hepatic allografts to be discarded. We compared this nonsystemic reperfusion (NSRP) of livers with systemic reperfusion (SRP), in which the initial portal blood reperfusing livers is allowed to enter the systemic circulation. In the NSRP group (n = 14) there was no decrease in MAP, heart rate, or SVR, and the serum potassium did not increase after reperfusion. In the SRP group (n = 14), six patients (42%) developed PRS and there were statistically significant decreases in MAP and SVR, and increases in pulmonary capillary wedge pressure and serum potassium, as compared with the NSRP group. In conclusion, NSRP results in less hemodynamic instability during reperfusion, and should be considered the preferred method for reperfusion of the transplanted liver.

Initial results of a program in liver transplantation.

St. Louis University established a liver transplant program in early 1988. The authors report on the program's first 10 months in operation, emphasizing the careful planning and cooperation the medical center must undertake to ensure the program's success.

Aphelion clustering of "new" comets: Star tracks through Oort's cloud.

An explanation is proposed for the observed and often discussed clustering of long-period comet aphelia on the sky. Poisson and several multinomial distributions are applied to the most conspicuous cluster, considering only the 80 "new" and 59 "intermediate" comets with the best-determined orbits. The observed number of aphelion points in adjacent areas in two tests with 24 and 36 equal sky areas, respectively, shows a large deviation from a random distribution. The expected probability frequency for this to happen by chance is <0.1% for the "new" comets alone; it is further reduced when "new" and "intermediate" comets are combined. When these comets are analyzed separately from others, it is found that the clustering is the result of perturbations of their original orbits by the passage of a star, or a stellar system, through Oort's cloud a few million years ago. Because the statistical effect on the change of a comet's angular momentum about the sun is proportional to the square of the ratio of the mass to the velocity of a star relative to the sun, it is a priori probable that passages by a few stars should produce clustering of the aphelia, as is discussed in detail.