Vitamin D supplementation in cutaneous malignant melanoma outcome (ViDMe): a randomized controlled trial.

BACKGROUND: Previous studies have investigated the protective effect of vitamin D serum levels, at diagnosis and during the follow-up period after treatment, on melanoma outcome. In the present study we assess whether vitamin D supplementation, in the follow-up period after diagnosis and surgical resection of the primary tumor, has a protective effect on relapse of cutaneous malignant melanoma and whether this protective effect correlates with vitamin D levels in serum and Vitamin D Receptor immunoreactivity in the primary tumor. METHODS/DESIGN: This study is a multicenter randomized double blind placebo- controlled phase III trial. Patients between the age of 18 and 80 years diagnosed and treated surgically for a melanoma stage IB-III are eligible for randomization in a 1:1 ratio to active treatment or placebo. The study drug is taken each month and consists of either 100,000 International Unit cholecalciferol or arachidis oleum raffinatum used as a placebo. The primary endpoint is relapse free survival. The secondary endpoints are 25 hydroxyvitamin D3 serum levels at diagnosis and at 6 month intervals, melanoma subtype, melanoma site and stage of melanoma at diagnosis according to the 2009 American Joint Committee on Cancer melanoma staging and classification. At randomization a bloodsample is taken for DNA analysis. The study is approved by the local Ethics Committees. DISCUSSION: If we can confirm our hypothesis that vitamin D supplementation after removal of the tumor has a protective effect on relapse of cutaneous malignant melanoma we may reduce the burden of CMM at several levels. Patients, diagnosed with melanoma may have a better clinical outcome and improved quality of life. There will be a decrease in health care costs related to treatment of metastatic disease and there will be a decrease in loss of professional years, which will markedly reduce the economic burden of the disease. TRIAL REGISTRATION: Clinical Trial.gov, NCT01748448 , 05/12/2012.

Miscalibration and severe complications after diode laser cyclophotocoagulation: two case reports.

Because two similar transscleral cyclophotocoagulation diode lasers with identical power & duration settings induced significantly different postoperative inflammation, we wanted to compare the real output of both lasers. Using a Power/Energy Meter (Fieldmaster) we compared the output of the two lasers (the Iridis [Quantel Medical] and the Iris Medical [OcuLight SLx]) at different energy levels. At a setting of 600, 1000, 1400, 1700, 2000 and 2500 mW, the measured output for the Iridis and Iris Medical diode laser were respectively 685 and 400 mW, 970 and 650 mW, 1470 and 875 mW, 1700 and 1000 mW, and 1990 compared to 1000 mW. On the average the output of the Iridis laser was correct and the output of the Iris Medical laser was 40% lower than the setting. Overtreatment and severe complications occurred with the Iridis laser because the manufacturer recommended using wrong power settings based on the Iris Medical laser, which was undercalibrated. The calibration of cyclophotocoagulation diode lasers should be performed prior to use when changing to a new device and whenever over- or undertreatment is observed.

High viral burden in the presence of major HIV-specific CD8(+) T cell expansions: evidence for impaired CTL effector function.

To investigate the effect of HIV-specific CD8(+) T cells on viral plasma load and disease progression, we enumerated HLA-A2-, B8- and B57-restricted CD8(+) T cells directed against several HIV epitopes in a total of 54 patients by the use of tetrameric HLA-peptide complexes. In patients with high CD4(+) T cell numbers, HIV-specific tetramer(+) cells inversely correlated with viral load. Patients with CD4(+) T cell numbers below 400/microl blood, however, carried high viral load despite frequently having high tetramer(+) T cell numbers. This lack of correlation between viral load and tetramer(+) cells did not result from viral escape variants, as in only 4 of 13 patients, low frequencies of viruses with mutated epitopes were observed. In 15 patients we measured CD8(+) T cell antigen responsiveness to HIV peptide stimulation in vitro. FACS analyses showed differential IFN-gamma production of the tetramer(+) cells, and this proportion of IFN-gamma-producing tetramer(+) cells correlated with AIDS-free survival and with T cell maturation to the CD27(-) effector stage. These data show that most HIV-infected patients have sustained HIV-specific T cell expansions but many of these cells seem not to be functional, leaving the patient with high numbers of non-functional virus-specific CD8(+) T cells in the face of high viral burden.

Bilateral cataract and high myopia in a child with trichothiodystrophy: a case report.

Trichothiodystrophy refers to a group of autosomal recessive disorders that have in common brittle sulphur-deficient hair (7). The abnormalities are usually obvious at birth and the clinical expression is variable. Ocular abnormalities are common with bilateral cataract being the most frequent one. We report on a four year old boy with trichothiodystrophy (complementation group TTD-A) who presented to us with strabismus, high myopia and bilateral cataract.

A comparison of methods for preoperative discrimination between malignant and benign adnexal masses: the development of a new logistic regression model.

OBJECTIVE: The aim of this study was to assess the complementary use of ultrasonographic end points with the level of circulating CA 125 antigen by multivariate logistic regression analysis algorithms to distinguish malignant from benign adnexal masses before operation. STUDY DESIGN: One hundred ninety-one patients aged 18 to 93 years with overt adnexal masses were examined by transvaginal ultrasonography with color Doppler imaging and 31 variables were recorded. The end points were the histologic classification of the tumor and the areas under the receiver-operator characteristic curves of alternative algorithms. RESULTS: One hundred forty patients had benign tumors and 51 (26.7%) had malignant tumors: 31 primary invasive tumors (37% International Federation of Gynecology and Obstetrics stage I), 5 tumors of borderline malignancy (100% International Federation of Gynecology and Obstetrics stage I), and 15 tumors were metastatic and invasive. The most useful variables for the logistic regression analysis were the menopausal status, the serum CA 125 level, the presence of >/=1 papillary growth (>3 mm in length), and a color score indicative of tumor vascularity and blood flow. The optimized procedure had a sensitivity of 95.9% and a specificity of 87.1%. The area under the receiver-operator characteristic curve was significantly higher (P <.01) than the corresponding values from the independent use of serum CA 125 levels or indexes of tumor form or vascularity. CONCLUSION: Regression analysis of a few complementary variables can be used to accurately discriminate between malignant and benign adnexal masses before operation.

Regulation of glycogen breakdown by glycogen level in contracting rat muscle.

The interaction of glycogen concentration, insulin and beta-adrenergic stimulation in the regulation of glycogen breakdown was studied in perfused rat muscles. Rats were pre-conditioned to obtain two groups with either normal (N) or 'supercompensated' (SC) muscle glycogen. The next day their hindlimbs were perfused with a medium containing insulin (0, 40 and 100 microU mL(-1)) and/or isoproterenol (0 and 1.5 nmol L(-1)). Contractions were induced by electrical stimulation of the sciatic nerve. Compared with N, glycogen breakdown in white gastrocnemius during contractions was greater in SC at any hormonal combination (P < 0.05). Conversely, in red gastrocnemius (RG) the higher glycogenolytic rate in SC, compared with N, faded as the insulin concentration was raised from 0 to 100 microU mL(-1). However, isoproterenol restored the higher glycogenolytic rate in SC. In any condition, RG glycogen synthase fractional activity was lower (P < 0.05) during contractions in SC than in N. Furthermore, the percentage of phosphorylase a was higher in SC except when muscles were exposed to insulin alone. In conclusion, high initial glycogen concentration in fast-glycolytic muscle causes high glycogenolytic rate during contractions, irrespective of hormonal stimulation. In contrast, due to down-regulation of phosphorylase activity, such a relationship does not exist in insulin-stimulated fast-oxidative muscle.

Shortening of muscle relaxation time after creatine loading.

The effect of creatine (Cr) supplementation on muscle isometric torque generation and relaxation was investigated in healthy male volunteers. Maximal torque (Tmax), contraction time (CT) from 0.25 to 0.75 of Tmax, and relaxation time (RT) from 0.75 to 0.25 of Tmax were measured during 12 maximal isometric 3-s elbow flexions interspersed by 10-s rest intervals. Between the pretest and the posttest, subjects ingested Cr monohydrate (4 x 5 g/day; n = 8) or placebo (n = 8) for 5 days. Pretest Tmax, CT, and RT were similar in Cr and placebo groups. Also in the posttest, Tmax and CT were similar between groups. However, posttest RT was decreased consistently by approximately 20% (P < 0.05) in the Cr group from the first to the last of the 12 contractions. In addition, the mean decrease in RT after Cr loading was positively correlated with pretest RT (r = 0.82). It is concluded that Cr loading facilitates the rate of muscle relaxation during brief isometric muscle contractions without affecting torque production.

Phosphocreatine resynthesis is not affected by creatine loading.

PURPOSE: Oral creatine supplementation has been shown to improve power output during high intensity intermittent muscle contractions. Facilitated muscle phosphocreatine (PCr) resynthesis, by virtue of elevated intracellular PCr concentration, might contribute to this ergogenic action. Therefore, the effect of creatine loading (C: 25 g X d(-1) for 5 d) on muscle PCr breakdown and resynthesis and muscle performance during high intensity intermittent muscle contractions was investigated. METHODS: A double-blind randomized cross-over study was performed in young healthy male volunteers (N = 9). 31P-NMR spectroscopy of the m. gastrocnemius and isokinetic dynamometry of knee-extension torque were performed before and after 2 and 5 d of either placebo (P) or C administration. RESULTS: Compared with P, 2 and 5 d of C increased (P < 0.05) resting muscle PCr concentration by 11% and 16%, respectively. Furthermore, torque production during maximal intermittent knee extensions, including the first bout of contractions, was increased (P < 0.05) by 5-13% by either 2 or 5 d of C. However, compared with P, the rate of PCr breakdown and resynthesis during intermittent isometric contractions of the calf was not significantly affected by C. CONCLUSION: Creatine loading raises muscle PCr concentration and improves performance during rapid and dynamic intermittent muscle contractions. Creatine loading does not facilitate muscle PCr resynthesis during intermittent isometric muscle contractions.

Effect of creatine loading on endurance capacity and sprint power in cyclists.

The effect of creatine loading on endurance capacity and sprint performance was investigated in elite cyclists according to a double-blind cross-over study design. Subjects (n = 12) underwent on 3 occasions and separated by 5 week wash-out periods, a 2 h 30 min standardized endurance protocol on their own race bicycle, which was mounted on an electromagnetically braked roller-system, whereupon they cycled to exhaustion at their predetermined 4 mmol lactate threshold. Immediately thereafter they performed 5 maximal 10 second sprints, separated by 2 min recovery intervals, on a Monark bicycle ergometer at 6 kg resistance on the flywheel. Before the exercise test, subjects were either creatine loaded (C: 25 g creatine monohydrate/day, 5 days) or were creatine loaded plus ingested creatine during the exercise test (CC: 5 g/h), or received placebo (P). Compared with P, C but not CC increased (p<0.05) peak and mean sprint power output by 8-9% for all 5 sprints. Endurance time to exhaustion was not affected by either C or CC. It is concluded that creatine loading improves intermittent sprint capacity at the end of endurance exercise to fatigue. This ergogenic action is counteracted by high dose creatine intake during exercise.

Fetal cardiac tamponade due to an intrapericardial teratoma.

A case of an intrapericardial tumor diagnosed in utero at 26 weeks of gestation is presented. The prenatal echocardiographic follow-up of an incipient hydrops fetalis determined the management and the emergency surgical treatment. Histologically, the tumor appeared to be a benign teratoma, grade I. In the postoperative period an unexpected mediastinal tumor was found and removed later. This tumor also appeared to be a benign teratoma, grade 0. Both teratomas were independent and therefore primary.

Fetal membrane closure techniques after hysteroamniotomy in the midgestational rabbit model.

OBJECTIVE: We studied closure techniques for amniotic access in midgestational rabbits. STUDY DESIGN: Twenty-eight rabbits with a total of 313 amniotic sacs were used for this study. In each animal a 1 cm hysteroamniotomy was made in two amniotic sacs at 22 days' gestation (term = 32). For 12 amniotic sacs (group 1) only the myometrium was closed by microsurgical suturing. In group 2 (n = 12), sutures included myometrium and membranes. In group 3 (n = 8), a collagen plug was placed, and in group 4 (n = 12) fibrin glue was used. Twelve sacs were left unclosed (positive controls) and the unmanipulated 257 sacs were negative controls. Eight days later (gestational age 30 days) amniotic sacs were evaluated for the presence of amniotic fluid, membrane integrity, and fetal weight and survival. Statistics were done with two-tailed Fisher's exact test and one-way analysis of variance. RESULTS: Membrane integrity (p = 0.0036) and amniotic fluid (p = 0.047) were best restored after myometrial closure. Fetal weight and survival rate were not affected by different closure techniques. CONCLUSION: In this model primary closure of the myometrium only yielded best results.

Alternative technique for Nd: YAG laser coagulation in twin-to-twin transfusion syndrome with anterior placenta.

Nd: YAG laser coagulation is used to treat severe twin-to-twin transfusion syndrome (TTS). Success of the technique depends on visualization of the placenta, the fetal membranes and the targeted vessels, as well as obtaining an optimal inclination angle for laser coagulation. In the rare case of an extensive anterior placenta, it may be difficult to achieve these conditions using the percutaneous approach. Here, we propose an alternative to the percutaneous procedure. Modifications involve an open access and the use of a flexible cannula and bent scope. An extraplacental area, usually at the fundus, is identified by B-mode and color Doppler imaging. A mini-laparotomy is made under general anesthesia. The viscera are retracted and the cannula is inserted under direct view and ultrasound control by the Seldinger technique. The curved fiberscope is passed through the flexible cannula, allowing adequate inspection of the placenta, and target vessels can be coagulated at an angle close to 90 degrees. After the procedure, the uterus is closed primarily to prevent postoperative leakage of amniotic fluid or hemorrhage. This technique has been successfully used in six patients with TTS and a completely anterior placenta, with a gestational age between 18.5 and 22.0 weeks. In all patients, the amniotic cavity was accessed without hemorrhage. The outcomes are similar to those published previously for laser coagulation. The mean interval from intervention until delivery was 10.5 weeks. All 12 fetuses were live born but four died from complications of extreme prematurity. No maternal complications occurred.

Prenatal diagnosis of a terminal short arm deletion of chromosome 8 in a fetus with an atrioventricular septal defect.

We report the prenatal diagnosis at 30 weeks of gestation of a del(8)(p21.3-->pter) in a growth-retarded fetus with an unbalanced atrioventricular septal defect (AVSD) and a hypoplastic right ventricle. This observation further confirms the association of AVSD with terminal deletions of chromosome 8p. Terminal deletions of chromosome 8p are more frequent than previously thought, but small terminal deletions can easily be overlooked. This observation illustrates that when an AVSD is diagnosed prenatally, special attention should be paid to distal chromosome 8p.

Polyhydramnios as a prenatal symptom of the digeorge/velo-cardio-facial syndrome.

Prenatal diagnosis of the DiGeorge/velo-cardio-facial syndrome has become possible since it was recognized that this syndrome is caused by a submicroscopic deletion in chromosome 22q11. In a sporadic patient presenting a conotruncal heart defect and polyhydramnios, the del 22q11 was made prenatally by fluorescence in situ hybridization (FISH) after amniocentesis. Seven additional patients with a del 22q11 were identified, who presented during pregnancy with polyhydramnios. In one of them, unilateral hydronephrosis was present. These findings further add to a growing list of clinical presentations of a del 22q11 and suggest that in patients with polyhydramnios and a conotruncal heart defect or uropathy, fetal karyotyping should be complemented by FISH for a del 22q11.

Experience with fetoscopic cord ligation.

OBJECTIVE: In the case of a monochorionic multiple pregnancy with one non-viable fetus who compromises its co-twin, fetoscopic cord ligation may be performed. We describe our fetoscopic cord ligation technique and discuss the efficacy of cord ligation for salvaging the co-twin, based on available data. STUDY DESIGN: Descriptive case series of four cases and review of the cases published up to 1996. RESULTS: We performed four successful ligations. Of the 23 reported cases, which include the present series, two ligations failed. Four fetuses died in utero, and 17 were born alive at a mean of 8 weeks following the procedure. Two babies died in the perinatal period, a third after 60 days. Preterm uterine contractions do not seem to be a clinical problem. Preterm prelabour rupture of the membranes (PPROM) complicates about 40% of cases, the majority occurring prior to 32 weeks. CONCLUSION: Fetoscopic cord ligation is a feasible procedure with a 71% survival rate and a high risk for PPROM.

Tracheoscopic endoluminal plugging using an inflatable device in the fetal lamb model.

OBJECTIVE: Intra-uterine tracheal occlusion has been proposed to reverse pulmonary hypoplasia, an important prognostic factor in congenital diaphragmatic hernia. We aimed to evaluate the feasibility and pulmonary effects of tracheoscopic tracheal obstruction with a detachable balloon. STUDY DESIGN: Fourteen mid-trimester fetuses out of 24 in 13 ewes underwent tracheoscopic balloon obstruction. Ten non-operated fetuses served as controls. Plugging was performed under fiber-tracheoscopy using a detachable balloon. Outcome measures consisted of: total operating time, tracheoscopy time, fetal survival, efficiency of plugging, and pulmonary effects. The Mann-Whitney test and linear regression were used for statistical analysis. RESULTS: Mean operating time and tracheoscopy time were 65+/-12 and 6.6+/-3.9 min, respectively. One intra-operative death occurred in each group. The post-operative mortality was 2/13 for cases and 2/9 for controls. In all 14 fetuses, the trachea was successfully obstructed. In the 11 treated animals born alive, the lung-to-body-weight ratio was 0.060+/-0.01, while in controls it was 0.031+/-0.01 (P = 0.0001). In a subset of six fetuses obstructed for 14-18 days, mean-terminal-bronchial density was 0.95+/-0.59, compared to 2.06+/-0.80 for controls (P = 0.046). CONCLUSIONS: Using fetal tracheoscopy, the trachea can successfully be obstructed with an inflatable balloon. Pulmonary hyperplasia is achieved when the obstruction lasts 2 weeks.

Intrauterine tracheal obstruction, a new treatment for congenital diaphragmatic hernia, decreases amniotic fluid sodium and chloride concentrations in the fetal lamb.

OBJECTIVE: To evaluate the effect of fetal tracheal occlusion on sodium and chloride concentrations in amniotic and tracheal fluid. SUMMARY BACKGROUND DATA: Intrauterine tracheal occlusion has been proposed to reverse pulmonary hypoplasia, an important prognostic factor in congenital diaphragmatic hernia. In early human trials, technical failure of the obstructive device has been reported. METHODS: Eight fetal lambs (gestational age = 95 days) were subjected to fetal tracheoscopy, and amniotic and tracheal fluid samples were taken. In multiple pregnancies (n = 6), amniotic fluid was also sampled from the contralateral amniotic sac and used as a control. Subsequently, endotracheal obstruction, using a detachable balloon, was performed. After 14 days, all fetuses were delivered, and sodium and chloride concentrations in amniotic and tracheal fluid were measured again. Statistical analysis was done using a two-tailed Student's t test, paired or unpaired as appropriate. RESULTS: In controls, between 95 and 109 days gestational age, no significant changes occurred in sodium or chloride concentrations in amniotic or tracheal fluid. After 2 weeks of tracheal obstruction, however, chloride and sodium concentrations in amniotic fluid decreased (chloride = 76.7 mEq/L vs. 107.6 mEq/L, p = 0.0003; sodium = 109.6 mEq/L vs. 125.9 +/- 5.2 mEq/L, p = 0.019). A concomitant increase in chloride and sodium concentration was observed in tracheal fluid (chloride = 145.4 mEq/L vs. 130.0 mEq/L, p = 0.047; sodium = 153.1 mEq/L vs. 142.9 mEq/L, p = 0.051). When comparing groups at 109 days, chloride and sodium concentrations in amniotic fluid were markedly lower in the treated group versus controls (p = 0.0004 and p = 0.05 for chloride and sodium, respectively). CONCLUSION: Complete tracheal occlusion in ovine fetuses results in a significant decrease of amniotic fluid sodium and chloride concentrations.

Tracheoscopic endotracheal occlusion in the ovine model: technique and pulmonary effects.

BACKGROUND/PURPOSE: The purpose of this study was to assess the tracheoscopic placement of a detachable balloon to obstruct the trachea in the fetal lamb model and to study the pulmonary effects 2 weeks later. METHODS: Thirteen pregnant ewes carrying 27 fetuses were used in this trial. Thirteen fetuses underwent endotracheal plugging at a mean gestational age of 95 (90 to 100) days (term, 145). Fourteen nonoperated fetuses served as controls. The intended duration of obstruction was 15 days. Study parameters consisted of operating time, fetal survival, performance of the balloon, and pulmonary changes. RESULTS: Hysterotomy time was 41 +/- 25 minutes and tracheoscopy time was 7.2 +/- 3.4 minutes. There were no intraoperative deaths in this series. Postoperative fatalities occurred in 2 of 13 plugged fetuses and 1 of 14 controls. At completion of the experiment, the balloon was recovered intact in the trachea of 12 of 13 (92.3%) fetuses. The lung weight/body weight ratio was 76 +/- 16 mg/kg for plugged animals, while in controls it was 34 +/- 8 mg/kg (P = .0001). The lung volume/body weight ratio was 101 +/- 17 mL/kg in plugged fetuses, compared with 47 +/- 4 mL/kg for controls (P = .0002). Mean-terminal-bronchial-density was 0.937 +/- 0.303 for plugged animals, compared with 1.911 +/- 0.441 for controls (P = .0002). Mean linear intercept was 60.9 +/- 5.2 microm in treated fetuses, and 46.3 +/- 5.8 microm for controls (P = .0004). CONCLUSIONS: Fetal endotracheal occlusion, using a tracheoscopically placed detachable balloon, is reliable, and results in pulmonary hyperplasia after 2 weeks of obstruction. This technique may be beneficial in treating the pulmonary hypoplasia seen in congenital diaphragmatic hernia. Further studies using this balloon device are now required to corroborate these findings.

Diagnostic echographic findings in cryptophthalmos syndrome (Fraser syndrome).

We report two male siblings with cryptophthalmos syndrome (Fraser syndrome), an autosomal recessive multiple malformation syndrome with cryptophthalmos, abnormal genitalia, and syndactyly of the fingers and toes as major clinical symptoms. Renal anomalies (uni- or bilateral agenesis) occur in 85 per cent. In the second trimester of both pregnancies (at 23.5 and 18.5 weeks, respectively), echographic examination revealed multiple anomalies: oligoamnios sequence and fetal hydrops with nuchal oedema. Contrasting with the oligohydramnios, the lungs were voluminous and hyperechogenic. Fetopathological examination revealed that the oligoamnios sequence was due to major renal abnormalities (bilateral renal agenesis in the first, and unilateral renal agenesis and contralateral multicystic renal dysplasia in the second sibling). Laryngeal substenosis had resulted in another malformation sequence consisting of overdistended lungs, and non-immune fetal hydrops. The present experience shows that in the presence of an oligoamnios sequence with contrastingly voluminous, hyperechogenic lungs, the diagnosis of cryptophthalmos syndrome should seriously be considered in the differential diagnosis.

Access techniques in endoscopic fetal surgery.

Endoscopic surgery may in the future become an attractive alternative to open fetal surgery. Herein, we present our evolving experience with minimal access techniques in sheep and nonhuman primate models. Fifty-two pregnant sheep (term = 145 d) were used. All underwent laparotomy. Cannulas were 5 mm diameter with balloon fixation device. In group I (95-105 d, n = 22, and 70-74 d, n = 19), a total of 119 cannulas were placed by open hysterotomy and pursestring suture through myometrium and membranes. In group II (n = 11), access was obtained by Seldinger guidewire technique. Eight cannulas were introduced over a dilator and 7 were radially expanding endoscopic cannulas. Fifteen cannulas were also placed in 5 pregnant Rhesus monkeys using Seldinger and radially expanding techniques. Cannula removal was followed by insertion of a collagen sponge plug and oversewing of the myometrium. Mini-hysterotomies with purse-stringing provided excellent access to the amniotic cavity, without dissection of the membranes. Classic Seldinger technique with forward dilatation was equally effective, but caused stretching of membranes. In sheep and in primates, Seldinger technique with radial dilatation allowed safe access without membrane separation. Leak-proof removal of the cannulas was achieved in all primates. Open hysterotomy with purse-string and balloon-tipped cannula provides efficient and safe access to the gravid sheep uterus. Seldinger technique allows equally secure access, and alleviates the need for hysterotomies. Radial dilatation of the porthole eliminates forward dissection of the membranes, both in sheep and primate models. This method, and collagen plug insertion upon completion of the endoscopic procedure, may provide a truly minimally invasive approach to in-utero surgery.