[On the topical tolerance of aminoglycoside antibiotics--a prospective comparative cytomorphological study]. / Zur Evaluierung der lokalen Verträglichkeit von Antibiotika an der Augenoberfläche am praktischen Beispiel eines Aminoglykosides.

BACKGROUND: The local application of drugs is an efficient method for treating diseases of the external eye. However, some active substances can also cause a chronic toxic reaction at the ocular surface. No results from clinical experiments on the local tolerance of kanamycin which would meet the requirements of evidence-based medicine are as yet available. METHODS: Thus, the cytomorphological processes of the treatment with kanamycin were examined in a prospective randomised placebo-controlled double blind cross-over study. The effect of the topical application (5 times a day for 7 days) of Kanamycin POS® eye ointment on the conjunctival epithelial barrier was studied in comparison with an eye ointment base (placebo) in 25 healthy subjects. To detect cytopathological microchanges of the epithelium, we carried out a standardised impression cytology (primary compatibility parameter). Biomicroscopy, Schirmer II test and non-invasive measurement of the break-up-time (tearscope) were also examined. The subjective compatibility parameters (itching, tearing, foreign body sensation, burning sensation, mucus) were measured on a 0 - 10 visual analogue scale. RESULTS: The cytological findings of 23 subjects were included in the final evaluation of the study. The impression cytology did not reveal a different effect of kanamycin ophthalmic ointment on the conjunctival ocular surface in comparison with the placebo. Only in one subject was a marked shift found in the nuclear-cytoplasmic ratio after application of verum. No signs of increased apoptosis ("snake-like chromatin") were found at the conjunctival epithelial barrier. The mean goblet cell count was 109 goblet cells per mm (2). No significant reduction of the goblet cell density was found in any treatment group. Among the subjective compatibility parameters, only the mean for itching constantly remained above the placebo group after application of kanamycin. Statistically significant differences were not found by the Wilcoxon test. CONCLUSIONS: In contrast to the clinical experience with the systematic application of kanamycin, the standardised evaluation of this study confirmed the very good topical tolerability of the tested kanamycin eye ointment. In view of the continuing clinically relevant aspect of the availability of a wide spectrum of antibiotics to avoid the development of resistance while at the same time keeping within what is reasonable economically, Kanamycin POS® for topical application supplements the options of ophthalmological antibacterial chemotherapy.

[Home-monitoring in ophthalmology--prerequisites for an improvement in quality of life: conclusions from the management research study Teletonometry Mecklenburg-Vorpommern]. / Homemonitoring in der Augenheilkunde--unter welchen Voraussetzungen für mehr Lebensqualität: Schlussfolgerungen aus der Versorgungsforschungsstudie Teletonometrie Mecklenburg-Vorpommern.

Home-monitoring represents an innovative and growing health service area in which suitable conditions have to be created for the attending doctor and also for the patient. For this it is necessary to offer the technical supply and also to establish simultaneously organisational structures in the cooperation between the doctor and the patient based on prevalent experiences of general ambulant care. The medical care as a whole can be optimised to be more patient-orientated by integrating assistant medical staff and by establishing modern IT communication channels. The evolving home-monitoring in consideration of the doctor-patient experiences can contribute to an improvement in the patient's quality of life.

[Diurnal variation of ocular pressure in open-angle glaucoma with telemonitoring]. / Tagesschwankungen des okulären Perfusionsdrucks im Telemonitoring bei primärem Offenwinkelglaukom.

BACKGROUND: The aim of this study was to study and analyse distribution, range and intraday variation of ocular perfusion pressure (OPP) in patients with primary open-angle glaucoma (POAG) in the framework of telemedical home-monitoring. METHODS: In the project Teletonometry Mecklenburg-Vorpommern (TTMV) patients were equipped with a home-monitoring system for self-measurement of intraocular pressure and blood pressure. All measurements were transmitted via telephone modem to an electronic patient record that automatically calculated OPP. We present the temporal characteristics of OPP in 70 patients with POAG. After the measurement of blood pressure and intraocular pressure was performed, the individual ocular perfusion pressure was calculated by the formula: (OPP=[2/3 x (2/3 x DBP + 1/3 x SBP)]-IOP). RESULTS: In 3282 OPP measurements the percentage of values less than 50 mmHg was: left eye 2273/69.2%--right eye 2362/71.9 % and less than 40 mmHg: left eye 687/20.9 %--right eye 794/24.2%. 50/51 (left eye/right eye) patients had an individual OPP average of less than 50 mmHg and 10/10 (left eye/right eye) patients less than 40 mmHg. The diurnal OPP trend showed 4 phases (7-12, 12-18, 18-22, 22-7 hour). In the intervals from 22-7 hour and 7-12 hour ocular perfusion pressure values were low. Between 7-12 hour ocular perfusion pressure was significantly depressed as in the other phases (p<0.05). CONCLUSIONS: Ocular perfusion pressure of glaucoma patients calculated using intraocular pressure (self-tonometry) and blood pressure demonstrates a feasible method to evaluate individual diurnal OPP fluctuations. However, this OPP could be described a bit more precisely as the really topical ocular perfusion. Many physiological conditions may not be included, e. g., autonomic circulation. Simultaneous measurement of blood pressure and intraocular pressure enable the detection and analysis of side effects and interactions between glaucoma and hypertension therapy. In clinical practice OPP telemonitoring presents a new way to examine ocular blood circulation in routine glaucoma work-up. The diurnal OPP variations were associated with the fluctuations of systemic blood pressure for the most of part.

[Fluctuation of intraocular pressure in 24-hour telemonitoring compared to tonometry during normal office hours]. / Fluktuationen des intraokularen Augendrucks - ein intraindividueller Vergleich zwischen 24-Stunden-Teletonometrie-Monitoring und ambulanter Augendruckmessung.

BACKGROUND: Elevated intraocular pressure (IOP) is a clinically relevant factor in glaucoma progression. As a dynamic parameter the IOP depends on various internal and exogenic influencing factors. Therefore, we analysed intraindividual IOD variations between ambulant care and 24-h home-monitoring using self-tonometry. PATIENTS AND METHODS: This study is based on paper-based glaucoma cards of 25 patients with primary open angle glaucoma. Additionally, all patients participated in a telemedical home-monitoring study with self-measurements of IOP and blood pressure stored in an electronic patient record. The glaucoma cards contained a total number of 409 IOP values with documentation periods from 0.5 to 10 years. In the teletonometry project all 25 patients were observed for 6 months with 1490 recorded IOP values. Statistical analysis was performed with SPSS software. RESULTS: Average IOP values for all 25 glaucoma patients were 16.3 +/- 2.9 mmHg for both eyes in glaucoma card documentation, whereas the electronic patient records showed IOP averages of 18.9 +/- 4.7 mmHg for right eyes and 18.2 +/- 4.4 mmHg for left eyes. Corresponding to the practice opening hours the glaucoma cards contained no IOP records from 12:00 pm to 01:30 pm as well as between 06:00 pm and 07:15 am. In these time periods 17 % of all IOP values recorded in 24-hour teletonometry were higher than 20 mmHg. However, statistical analysis and clinical evaluation of device parameters and measurement characteristics revealed sporadic measuring errors. CONCLUSIONS: The additional involvement of self-tonometry in telemedical 24-h home-monitoring is a feasible method to record and detect intraday IOP fluctuations. Compared to single IOP measurements documented in common paper-based glaucoma cards, the 24-h electronic patient record showed more frequent circadian IOP variations. As a result, self-tonometry and home-monitoring can be a useful link to fill the gap between singular ambulant IOP measurement and hospitalisation with 24-hour IOP profiles.

[Self-medication with local anaesthetics by glaucoma patients using teletonometry]. / Selbstmedikation mit Lokalanästhetika durch Glaukompatienten bei der Teletonometrie.

BACKGROUND: Self-tonometry, a supplementary measurement of the intraocular pressure in ophthalmology by glaucoma patients using an automatic tonometer, will become more and more important in the future. As long as the self-tonometry has to work in the contact modus with the ocular surface, home application of a topical anaesthetic by the glaucoma patient will be a requirement for a successful measurement. So far no severe problems within this controlled self-medication have been seen. Nevertheless, public health authorities believe patient health is put at high risk by the application of local anaesthetics during self-tonometry. As there are no clinical studies of the health care, we evaluated the local tolerability of a topical anaesthetic in line with self-tonometry employing a modified tonometer OCUTON S. MATERIAL AND METHODS: A total of 100 glaucoma patients participated in a prospective clinical study of the routine clinical service in which each was monitored for 1 year. The telemonitoring involved self-tonometry for at least 6 months in every case and Ocuton S Proparakain-POS 0.5% eyedrops (proxymetacaine-HCl) were applied by the probands before every measurement of the intraocular pressure with a modified self-tonometer. Information regarding the local tolerability of the topical anaesthetic was analysed using a standardised questionnaire. The intensity of the following subjective symptoms was listed in separate visual analogue scales for: lacrimation, burning, foreign body sensation, mucus aggregation, pruritus and pain. RESULTS: Information from 83 glaucoma patients on local tolerability of proparacaine eyedrops could be analysed. For several reasons no data could be gathered from 17 probands, which were refusal to complete the questionnaire, cancelled participation and, in two test persons, there emerged an allergic reaction (local eyelid redness and swelling) which necessitated a change to a different topical anaesthetic. In all other participants the application was carried out without any significant local or systemic symptoms or side-effects. Immediately after application of the eyedrops 36.1% of the test persons suffered a minor conjunctival hyperaemia which eased off within 1 h in 20.4% of these patients. Of the interviewed glaucoma patients 91.5% judged the single symptoms on the visual analogue scale between zero and medium intensity. The severest effects, according to the subjective evaluation, were felt in symptoms of burning with a score of 94 and lacrimation graded 96. The least intensity was established in the symptom of mucus aggregation where 72.3% rated this symptom in the visual analogue scale between 0 and 10. The other symptoms pruritus, feeling of pressure and foreign body sensation hardly differed in subjective ratings. CONCLUSION: A self-medication with topical anaesthetics on undamaged ocular surfaces for self-tonometry purposes can be performed by glaucoma patients without a high risk potential. However, the application presupposes that routine ophthalmological examinations are carried out according to the ophthalmological associations' recommendations. Therefore, medical care concepts which integrate self-tonometry into routine ophthalmological services and comply with the complex requirements of a modern glaucoma management should be applied more often.

[Digital patient record for remote monitoring of intraocular pressure, blood pressure and serum glucose]. / Elektronische Patientenakte zum telemedizinischen Monitoring von Augeninnendruck, Blutdruck und Blutzucker.

BACKGROUND: At the University Eye Hospital of Greifswald, we have developed a digital patient record that allows close monitoring of glaucoma, diabetes and hypertension. The record stores contemporary, long-term profiles containing intraday variation and interaction of intraocular pressure, blood pressure and serum glucose levels even at night. METHODS: All patients are equipped with a home monitoring system. They subsequently transmit self-measurements via the "telemedical interface" to the server. Physicians use a web front-end to access electronic patient records; this provides a PDF export filter for printing. We intend to include a total number of 120 patients from Mecklenburg-Vorpommern who suffer from glaucoma possibly combined with hypertension/diabetes. This long-term investigation was designed as a randomised cross-over study in two groups. RESULTS: Especially for this project an electronic patient record was developed and implemented. The components of the home monitoring system were modified and connected to a custom-built "telemedical interface". To date the study includes 120 patients, 60 of whom constantly measure and transmit their values to the electronic patient record, while the others are treated without home monitoring. All self-measurements are presented in a tabular form. In addition, dynamically generated graphics provide a diagrammatic view of all values. On demand, a detailed protocol for every single measurement report allows a comprehensive evaluation of the quality of the self-measurements. Ocular perfusion pressure is calculated automatically from intraocular pressure and blood pressure. The presented system documents continuously all information that is relevant for treatment and provides fast access for all attending physicians. CONCLUSIONS: Central data collection and unlocalised access improve information exchange between involved physicians. Flexible measurement periods allow the detection of pressure spikes even at night. In addition, this may help to classify glaucoma (normal-pressure glaucoma) and its causal connection to blood pressure. The patients benefit from individualised therapy adaptation and early therapeutic intervention in case of critical parameters.

The joint actions of adolescents in peer conversations about career.

Ten career conversations between adolescent peers were video-taped to examine the joint actions of adolescents that emerge in actual conversations about career. Based on an action-theoretical approach, joint action refers to the intentional behavior of a group of people attempting to realize a common goal or engage in a common process. The actual conversations and the adolescents' recall of their thoughts and feelings during the conversations were used to identify the joint actions that occurred in the conversations and the meaning that the conversations had for the adolescents. Goals of the actions included educational planning, career selection, and personal future. The functions the adolescents undertook in the conversations to reach these goals were identified as exploring, formulating, validating, and challenging. Based on these results, it was proposed that self-refinement was the project that energized and guided the joint actions and lent meaning to the conversations.

Carcinogenic alterations in murine liver, lung, and uterine tumors induced by in utero exposure to ionizing radiation.

The atomic bombing of Hiroshima and Nagasaki and the nuclear accident at Chernobyl raised the question of prenatal sensitivity to ionizing radiation-induced cancer. In this study, mice were exposed to single doses of gamma-radiation (0.2-2.0 Gy) at different embryonic stages. The tumor incidence increased with dose from 15% in control mice to 35% in mice irradiated with 2.0 Gy on 18 d of prenatal life. Various oncogenic events were investigated in lymphoid, liver, lung, and uterine tumors. We observed threefold to fivefold increases in myc expression in 25% of the lymphomas, and the expression of Ha-ras and p53 genes decreased in 40% and 60% of the lung tumors by twofold to fivefold. Point mutations were tissue specific: Ha-ras codon 61 mutations were found in about 40% of the liver adenocarcinomas, Ki-ras codon 12 mutations in about 17% of lung tumors, and p53 mutations in about 15% of the lymphomas. Amplification and rearrangement of the p53, myc, and Ha-, Ki- and N-ras genes were not detected. Loss of heterozygosity on chromosome 4 at the multiple tumor suppressor 1 and 2 genes was observed in all types of malignancies. Allelic losses on chromosome 11 at the p53 locus were found in lymphoid, liver, and lung tumors, but they were absent from uterine tumors. Multiple oncogenic changes were often detected. The frequency of carcinogenic alterations was similar in spontaneous and radiation-induced lymphoid, liver, and uterine tumors. In radiation-induced lung adenocarcinomas, however, the incidences of many oncogenic changes were different from those found in their spontaneous counterparts. This suggests that different oncogenic pathways are activated during spontaneous and in utero gamma-radiation-induced murine lung carcinogenesis.

Oncogenic changes in murine lymphoid tumors induced by in utero exposure to ionizing radiation.

We have investigated the oncogenic alterations in murine lymphomas induced by in utero exposure to gamma-radiation. The expression of the myc oncogene increased in 23% of the tumors. Alterations in the expression of the ras oncogenes and in the p53 tumor suppressor gene were not characteristic. The p53 gene was mutated in a low percentage of the tumors (12%). Ras mutations were not detected. Loss of heterozygosity (LOH) at the p53 locus was found in 30% of the tumors, and LOH at the mts tumor suppressor gene was detected in 23% of lymphomas. Multiple oncogenic changes were infrequent in the investigated tumors. There were no essential differences in the frequency of carcinogenic alterations in spontaneous and gamma-radiation-induced lymphomas.

Biliopancreatic Diversion in Prader-Willi Syndrome Associated with Obesity.

BACKGROUND: Prader-Willi Syndrome (PRWS) is an uncommon neuroendocrine disorder of genetic origin, described in 1956 by Prader, Labhart and Willi. The main clinical manifestations in the adult are mental retardation, hyperphagia with gross obesity, hypogonadismcriptorhismus and short stature. The life expectancy of the affected individual ranges between 20 and 30 years rarely beyond - due to complications related to excessive obesity. Sustained dieting combined with behavior modification programs, as well as gastric restrictive surgery for obesity, proved to have a high failure rate in PRWS, due to the patients' inability to cooperate in changing their eating habits. METHODS: Biliopancreatic Diversion (BPD), which does not require the patient's cooperation in changing eating habits after surgery, was performed in two PRWS patients (13- and 22-years-old), both with excessive obesity, severe respiratory distress, day sleepiness and limited mobility. RESULTS: Two years after surgery, the 13-year-old had lost 80% of her overweight, while the 22-year-old, after 1 year, had lost 34%. Recent laboratory tests showed normal data in both patients. Their respiratory distress had subsided completely, their mobility improved dramatically, and their self-image and alertness enhanced. CONCLUSION: BPD resulted in an improved quality of life in these patients.

Treatment of Protein Malnutrition and Uncontrollable Diarrhea Following Bilio-pancreatic Diversion with Pancreas Extract Viokase.

Thirteen patients, following a bilio-pancreatic diversion procedure for obesity, developed severe nutritional complications such as protein deficiency, anemia, hypocalcemia and/or gastrointestinal problems (uncontrollable diarrhea). They were subjected to a new therapeutic approach-the administration of pancreas extract tablets Viokase, containing protease, lipase and amylase. This, together with protein-rich food resulted after 2-4 weeks of treatment in a drastic reduction in the number of daily stools: from 10-12 per day to 4-6 per day, as well as the disappearance of the accompanying foul smell and the malodorous gas emissions. After a further 4-8 weeks of treatment of those patients with protein deficiency, the serum protein-albumin levels as well as the Hgb and Ca levels rose to near normal values: protein from 4.8-5.5 g % to 6-6.5 g %; albumin from 1.8-3 g % to 3.4 g % and above; Hgb from 7-9 g/di to 11-12 g/di; and Ca from 7.5-7.8 mg% to 8-9 mg%. None of the patients treated with pancreas extract for protein deficiency required rehospitalization for intravenous protein replacement, nor was there any need observed for operative revision or takedown in these patients.

[Experience with the management of scapula fractures]. / Tapasztalataink a lapockatörések kezelésében.

Authors have treated 37 fractures of the scapula during 3 years. The questions of the aetiology, classification, diagnosis and therapy of this injury are reviewed. It is stated that the majority of the scapula fractures heal on conservative therapy; in consequence the functional treatment has a leading role. The fractures of the articular surfaces with step formation, the fractures of the scapular neck process dislocated in a high degree, or unstable fractures of the scapular neck combined with the comminutive fractures of the operative therapy are assessed. Attention is called to the most frequent operative complications and to the possibility of their prevention.

Obstructing carcinoma of the left colon: treatment by extended right hemicolectomy.

Obstructing carcinoma of the left side of the colon causes proximal distension of the colon with subsequent thinning of the colonic wall and vascular impairment. Conventional surgical treatment is multi-staged. Each stage carries its own morbidity and mortality. An alternate treatment, extended right hemicolectomy, requires a single surgical procedure. Fifty-six cases of acute obstructing carcinoma of the left colon are presented: 16 in Group I were treated conventionally; 40 in Group II were treated by extended right hemicolectomy. In Group I, four died within one week of surgery. Six survived with a colostomy; all suffered from poor quality of life until death. For the six who received complete treatment, average total hospitalization was 54 days. Group II suffered no peri-operative mortality. Patients were discharged without a colostomy after an average hospitalization of 15.7 days. Advantages of and conditions for treatment by extended right hemicolectomy are discussed.

[Staging of rectal carcinoma by endorectal ultrasonography].

Staging of rectal carcinoma is essential for its management. 23 patients with rectal lesions were examined by endorectal ultrasonography. Of these 19 had rectal carcinoma and in 4 there was an abscess of the rectal wall, previously diagnosed by sigmoidoscopic biopsy. 10 of those with carcinoma were examined by computerized tomography as well, and 10 were operated on. In most cases the staging of rectal carcinoma by endorectal ultrasonography was accurate and compared well with the operative histological results. We conclude that endorectal ultrasonography is the method of choice for staging of rectal carcinoma prior to treatment.

Prenatal exposure to gamma/neutron irradiation: sensorimotor alterations and paradoxical effects on learning.

The effects of prenatal exposure on gamma/neutron radiations (0.5 Gy at about the 18th day of fetal life) were studied in a hybrid strain of mice (DBA/Cne males x C57BL/Cne females). During ontogeny, measurements of sensorimotor reflexes revealed in prenatally irradiated mice 1) a delay in sensorial development, 2) deficits in tests involving body motor control, and 3) a reduction of both motility and locomotor activity scores. In adulthood, the behaviour of prenatally irradiated and control mice was examined in the open field test and in reactivity to novelty. Moreover, their learning performance was compared in several situations. The results show that, in the open field test, only rearings were more frequent in irradiated mice. In the presence of a novel object, significant sex x treatment interactions were observed since ambulation and leaning against the novel object increased in irradiated females but decreased in irradiated males. Finally, when submitted to different learning tasks, irradiated mice were impaired in the radial maze, but paradoxically exhibited higher avoidance scores than control mice, possibly because of their low pain thresholds. Taken together, these observations indicate that late prenatal gamma/neutron irradiation induces long lasting alterations at the sensorimotor level which, in turn, can influence learning abilities of adult mice.

Severe acute pancreatitis as the presenting symptom of primary sclerosing cholangitis: treatment by endoscopic insertion of a biliary stent.

Primary sclerosing cholangitis is a chronic, fibrosing, inflammatory condition of unknown origin of extra and intrahepatic bile ducts. Recurrent cholangitis and jaundice are the most frequent clinical manifestation in symptomatic patients. We report a patient with primary sclerosing cholangitis presented with recurrent attacks of acute pancreatitis. Such a combination was not reported till now in the literature. The acute pancreatitis was probably due to reflux of bile and sludge into the pancreatic duct due to stricture of the distal part of a common bile and pancreatic ducts. Endoscopic insertion of a biliary stent managed to prevent jaundice and recurrent pancreatitis.

CA-15.3, TPA and MCA as markers for breast cancer.

Serum concentrations of CA-15.3, tissue polypeptide antigen (TPA) and mucinous-like carcinoma-associated antigen (MCA) were measured in 327 women: 81 controls, 93 patients with benign breast disease, 46 patients recently diagnosed with breast cancer and 107 patients during breast cancer follow-up. CA-15.3 was elevated in 16% of the controls, in 29% of the patients with benign breast disease, in 65% of the breast cancer patients and in 74% of the follow-up patients. TPA was elevated in 4%, 11%, 36% and 75%, respectively. The corresponding figures for MCA were 10%, 8%, 30% and 64%. The highest sensitivity for cancer detection (74%) was obtained with a combination of CA-15.3 and TPA, while the specificity of this panel was 75%. The negative predictive value of these combined tests was 93%. MCA scored lower values, being only 30% sensitive. The CA-15.3/TPA panel may increase sensitivity compared with single marker tests and provide additional information for clinical evaluation.

[Experience with the surgical management of rupture of the capsule and ligament of the acromioclavicular joint]. / Tapasztalataink az acromioclavicularis ízületi tok és szalagszakadások mütéti ellátásában.

Evaluating the surgical results obtained with 74 cases of acromioclavicular dislocation the authors review the problems of diagnostics and surgical treatment of the injury. It is pointed out that the restoration of the functional anatomical condition--and simultaneously the reduction of the number of posttraumatic complaints--may be ensured only with operation in cases of severity grade II and III. However the results of the operative techniques applied in a rather wide range at present do not come up to expectation. The disturbances of healing are due in the majority of the cases to the use of implants unsuitable from biomechanical point of view. The application of appropriately solid acromioclavicular plates means significant progress in this field. The time and way of restoration of the injured capsule and ligament system influences decisively the results. Sutures of the ligament applied within 24 hours after the injury heal well. If the ligaments show strong splitting up or the operation is performed delayed plastic reinforcement or completion is justified in each case owing to the partial resorption. From the viewpoint of the surgical technique the use of the softpart flaps formed from the environment appear to be the most favourable.

Primary hepatic lymphoma presenting as symptomatic immune thrombocytopenic purpura.

A 33-year old Arabian man presented with idiopathic thrombocytopenic purpura that did not respond to steroid treatment or splenectomy. A routine liver scan performed after splenectomy showed a large mass in the liver. Four years later, massive gastrointestinal bleeding led to an emergency laparotomy, which revealed well-differentiated lymphocytic lymphoma extending from the liver to the fundus and lesser curvature of the stomach. A partial gastrectomy was performed. With chemotherapy the liver mass resolved and the platelet counts have normalized for the past 30 months.