[Single intrauterine fetal death in twin pregnancy]. / Singulärer intrauteriner Fruchttod bei Gemini.

During a 11 year period (1984-1994) we identified and analysed at the Department of Obstetrics, University Hospital of Zurich, among 541 twin pregnancies 19 with single intrauterine death (SIUD) in the second and third trimester. The preterm delivery rate was 68% and much higher compared to singleton pregnancies at the same institution (17%). The caesarean section rate was 47% and also higher compared to singleton pregnancies (21%) but lower than in a normal twin collective (61%). Two of the surviving twins showed malformations. One of them has in addition of porencephaly, probably due to disruption syndrome. In 12 out of 19 case a monochorionic placenta was found including 5 with twin-twin transfusion syndrome. Surprisingly 8 out of 19 dead fetuses had a velamentous insertion of the umbilical cord. This might suggest a causal relationship to SIUD. 95% showed the same sex. Maternal blood coagulation disorders are rare. From our results we conclude that SIUD is associated with an increased preterm delivery and caesarean section rate. Monochorionic twins and twins with concordant sex demonstrate the highest risk for SIUD. The twin-twin transfusion syndrome is the main single cause for SIUD. The pathophysiologic role of velamentous insertion remains unclear.

[Influence of naso-sinusal anatomic variants on recurrent, persistent or chronic sinusitis. X-ray computed tomographic evaluation in 112 patients]. / Influence des variantes anatomiques nasosinusales sur les sinusites récidivantes, persistantes ou chroniques. Evaluation TDM chez 112 patients.

Using CT scan, we studied the influence of the most important sinonasal anatomic variants on 112 patients, aged more than 16 years, suffering from recurrent, persistent or chronic sinusitis. The series was characterized by the absence of: multifocal sinusitis, polyposis, dental or mycotic sinusitis, traumatic, tumour, actinic or prior surgery. We compared our results with those of the literature. Our findings confirmed the association between recurrent, persistent or chronic sinusitis, and ipsilateral septal ridges or spurs (33%), unusual ipsilateral deflexions of uncinate process (31%), and contralateral septal watch glass like deviation (42%). We found no correlation for the other studied variants (concha bullosa, paradoxical curve of middle turbinate, pneumatised uncinate process, hypertrophic ethmoid bulla, Haller cell and accessory maxillary ostium).

Uremic small-artery disease with medial calcification and intimal hyperplasia (so-called calciphylaxis): a complication of chronic renal failure and benefit from parathyroidectomy.

BACKGROUND: Uremic small-artery disease with medial calcification and intimal hyperplasia can lead to life-threatening skin necrosis or acral gangrene. It is a distinct complication of chronic renal failure that must be differentiated from soft-tissue calcification. An increased calcium-phosphate product and secondary hyperparathyroidism are the main underlying conditions. The benefit of parathyroidectomy is controversial. OBJECTIVE: This article is based on a literature search to determine prognostic factors and, in particular, the benefit of parathyroidectomy. METHODS: The literature on uremic small-artery disease (so-called calciphylaxis) was reviewed (full data set: 104 cases, including five of our own). The therapeutic benefit of parathyroidectomy and the relation between prognostic predictors (localization, dialysis, and transplant) and outcome were analyzed. The relation between diabetes and acral gangrene was also examined. Further epidemiologic data on the reviewed group of patients were established. RESULTS: Thirty-eight of 58 patients who underwent parathyroidectomy survived compared with 13 of 37 patients who did not undergo parathyroidectomy (p = 0.007, n = 95). Forty of 53 patients with distal localization of necrosis survived compared with 11 of 42 patients with proximal pattern (p < 0.00001; n = 95). Dialysis and kidney transplantation followed by immunosuppression showed no relation to disease outcome. No association was found between diabetes and acral gangrene (p = 0.50). CONCLUSION: Uremic small-artery disease is a distinct complication of chronic renal failure. Its recognition and early diagnosis should allow more effective treatment. In our retrospective study parathyroidectomy was significantly related to survival. Only a randomized, controlled, prospective trial (parathyroidectomy vs conservative treatment of secondary hyperparathyroidism) can establish the value of parathyroidectomy in uremic small-artery disease.

[Pregnancy after liver transplantation]. / Schwangerschaft nach Lebertransplantation.

We present a case of pregnancy and delivery after liver transplantation. Even during pregnancy immunosuppression was maintained with cyclosporin (2 x 175 mg/day). The pregnancy was uneventful and there were no side effects of the cyclosporin therapy. At term we performed a cesarean section because of transverse presentation. A healthy child was born. Successful pregnancy is possible after liver transplantation, but team approach must be guaranteed.

Low-dose CT and inflammatory disease of the paranasal sinuses.

Computed tomography (CT) is the gold standard for exact delineation of inflammatory sinus disease, especially before endoscopic surgical treatment, and in cases of postoperative recurrences. In routine CT studies, the radiation dose to the patient is not negligible. Therefore, the authors evaluated prospectively the CT scans of 44 patients with inflammatory disease of the paranasal sinuses, to define the imaging ability of low-dose CT (i.e. 60 mA-3 s, 30 mA-3 s, and 30 mA-2 s), comparatively with the standard mAs settings (130 mA-3 s). In all cases, the exact extent of the disease was correctly assessed on each of the low-dose settings, with no false negative study. The increasing graininess of low mAs sections did not induce errors of interpretation, despite a less pleasant appearance to the eyes. In cases of extensive sinus disease, the thickness and integrity of the ethmoid septa were sometimes more difficult to evaluate on low-dose CT sections. The authors recommend the use of low mAs settings in the evaluation of inflammatory disease of the sinuses, complemented, if necessary, in cases of extensive abnormalities, by one or two sections obtained with standard mAs settings, focused on questionably abnormal bone septa.

Fine-needle aspiration in the diagnosis of head and neck growths: is it necessary?

The results of fine-needle aspiration cytology performed on 150 patients at the Geneva Clinic of Otolaryngology were analyzed. The accuracy rate was 80%. The study was nondiagnostic in 10% of the cases and falsely negative in another 10%. These results are similar to those in other centers. Nevertheless, several recent reports attest to the accuracy of fine-needle aspirations cytology, and in some clinics it is now part of the initial workup of every patient with a growth in the head and neck. On the basis of our own retrospective analysis, we believe fine-needle aspiration is a useful study only in patients with a previously treated malignancy and who have a new lump in the neck suspected to be a recurrence.

[Topographic anatomy of the ethmoid labyrinth in x-ray computed tomography]. / Anatomie topographique du labyrinthe ethmoïdal en tomodensitométrie.

These last years the surgical treatment of inflammatory ethmoid disease has been completely modified, with new endoscopic conservative procedures. In a preoperative phase it is mandatory to provide optimal CT imaging of the ethmoid labyrinth, and for this purpose sections perpendicular and parallel to the nasofrontal duct axis are better than axial and coronal slices. The anatomy of the ethmoid is fairly complex; however certain constant anatomic landmarks allow a systematic analysis of the ethmoid labyrinth: the unciform process, the bulla, the middle turbinate, the superior turbinate and their respective basal lamellae.

Nasal histamine release following hyperosmolar and allergen challenge.

Allergic rhinitis is characterised by symptoms of sneezing, itching of the nose with watery secretions, and nasal obstruction. We have previously shown that patients can have the diagnosis of allergic rhinitis confirmed by nasal provocation tests and assessment of nasal inspiratory peak flow (NIPF) after specific allergen or hyperosmolar challenge. We now show that histamine is released into the nasal lavage fluid in response to such challenges. Saline lavage alone results in detectable histamine levels in the order of 5 ng/ml, but in the presence of allergen (HDM) there is a significant increase in histamine release in atopics but not in control subjects. With hyperosmolar challenge, atopics showed a biphasic response in that histamine release was increased with 1.8% and 3.6% saline but returned to baseline with 5.4% and 7.2% saline, then showing a further increase with 9.0% saline. This raises the possibility of two populations of responsive mast cells. Hyperosmolar challenge leads to symptoms of nasal itch and sneezing as well as histamine release in atopics but not in controls. This suggests that hyperosmolar challenge can be used as a simple diagnostic test for allergic rhinitis and may provide a model for nasal hyper-reactivity.

Nasal response to allergen and hyperosmolar challenge.

Rhinitis causes both clinical and social discomfort to patients, and in clinical practice is often underdiagnosed. We have examined a simple method for the assessment of a positive nasal provocation test to help in the diagnosis of rhinitis. In patients with histories suggestive of house dust mite (HDM) sensitivity and positive skin-prick tests or specific IgE to Dermatophagoides pteronyssinus, there was a fall in nasal inspiratory peak flow (NIPF) following nasal challenge with allergen. This was not seen in control subjects or in pollen-sensitive patients when challenged with house dust mite. Frequency of sneezing and degree of rhinorrhoea increased in these patients following challenge, and based on these findings we propose a simplified scoring system for the diagnosis of allergic rhinitis. We examined non-specific nasal reactivity using hyperosmolar solutions as a challenge system and found that allergic subjects responded with a fall in NIPF, although the clinical response was not identical to that seen with allergen. Control subjects did not respond to hyperosmolar challenge.