Endometrial resection for refractory menorrhagia. An alternative to hysterectomy

ENDOMETRIAL RESECTION: Whether resection is total or partial, the superficial layer of the myometrium is exposed to a certain degree of damage. SEVERAL METHODS: Radiofrequency thermal resection, the standard method, offers the advantage of allowing histology examination. Other destructive methods have also been proposed including the more recent laser Ng-Yag ablation technique. INDICATION: Ideally, endometrial resection is indicated in women with a small uterus who develop drug resistant menometrorrhagia after the age of 40 years. MODERATE RATE OF SUCCESS: In a personal series of 105 patients who underwent radiofrequency thermal resection and with a mean follow-up of 15.5 +/- 6.6 months, results were in agreement with data reported in the literature: perforation of the uterus < 5%, hemorrhage < 1%, metabolic syndrome < 2%. Patients were entirely satisfied in 58% of the cases but secondary hysterectomy was required in 14%. PRECISE INDICATIONS: Despite the advantages over hysterectomy, endometrial resection should be reserved for selected patients in order to avoid an unsatisfactory high rate of failure.     

Childhood fibrous dysplasia presenting as blindness: a skull base approach for resection and immediate reconstruction

Fibrous dysplasia is an abnormal fibroosseous process of bone of unknown cause. The incidence of skull involvement varies, painless enlargement being the most common presenting symptom. Change in vision is a rare but recognized finding. We report a 3-year-old boy with extreme fibrous dysplasia involving the skull base, who presented with blindness. He underwent exposure osteotomies of the frontal bones and orbits to provide access for skull base tumor removal. The orbital roofs were reconstructed with microplate-fixed cranial grafts. One and one half years after tumor excision followed by immediate reconstruction, the boy retains facial symmetry, and his ocular function has not deteriorated.     

Chordomas of the skull base. Radiologic and clinical evaluation

Chordomas are uncommon skull base tumors, which are locally agressive and are usually not amenable to complete surgical resection. Proton beam irradiation, following surgery, is the preferred treatment modality. For diagnosis and determination of tumor site and extension, CT and MR imaging are the imaging modalities of choice. CT delineates bone destruction and the presence of calcifications and destroyed bone optimally. MR imaging is the modality of choice for better definition of the tumor margin from brain and other soft tissue structures (pharynx) and visualization of blood vessels. The signal intensities and enhancement pattern fail to differentiate chordoma from chondroid chordoma or chondrosarcoma. Chordomas arise from the clivus and therefore are located more centrally, whereas the majority of chondrosarcomas originate in the petroclival fissure and occur more laterally, although occasional overlap occurs in about one third of cases. Immunohistochemical methods allow differentiation of pure chordoma from chondroid chordoma and chondrosarcoma. Chordomas have a lower local control rate than chondrosarcomas.     

Cisplatin-based neoadjuvant chemotherapy and combined resection for ethmoid sinus adenocarcinoma reaching and/or invading the skull base

OBJECTIVE: To review our experience with cisplatin-based neoadjuvant chemotherapy before en bloc resection via a combined neurosurgical and transfacial approach for ethmoid sinus adenocarcinoma reaching and/or invading the skull base. DESIGN: Case series. SETTING: A tertiary care center and university teaching hospital. PATIENTS: Twenty-two patients with primary untreated ethmoid sinus adenocarcinoma reaching and/or invading the skull base consecutively treated between 1984 and 1992 with cisplatin-based neoadjuvant chemotherapy and combined neurosurgical and transfacial approach. MAIN OUTCOME MEASURES: Statistical analysis of survival, local control, nodal recurrence, distant metastasis, and metachronous second primary tumor incidence based on the Kaplan-Meier actuarial method. Univariate analysis was performed to analyze the relationships between various factors, survival, and local recurrence. Clinical response, histological response, toxic effects of chemotherapy, and postoperative course were also reported. RESULTS: The Kaplan-Meier 3-year survival, local control, nodal recurrence, and distant metastasis estimates were 68.1%, 65.7%, 5.3%, and 10%, respectively. Metachronous second primary tumor was not encountered in our series. Survival was statistically more likely to be reduced in patients with intrasphenoidal tumor extent (P = .04) and local recurrence (P = .01). Local recurrence was statistically more likely in patients with intrasphenoidal tumor extent (P = .002) and no response to cisplatin-based neoadjuvant chemotherapy (P = .03). CONCLUSIONS: The results achieved suggest that cisplatin-based neoadjuvant chemotherapy before combined neurosurgical and transfacial approach should be further investigated for the treatment of ethmoid sinus adenocarcinoma reaching and/or invading the skull base.     

An experimental approach to image guided skull base surgery employing a microscope-based neuronavigation system

PURPOSE: The No2 cataractous mouse mutant displays a bilateral, congenital, hereditary nuclear opacity of the ocular lens. The aim of this work was to identify and subsequently screen an optimal candidate gene for a mutation correlated and consistent with the observed phenotype. METHODS: The No2 cataract was mapped in relation to genes and microsatellite markers by crossing to the wild mouse strain Mus spretus and then backcrossing to the inbred strain C3H/ HeH. The Cx50 (MP70) protein coding region and flanking sequences were amplified from normal parental as well as heterozygous and homozygous mutant genomic DNAs. These PCR products were then sequenced directly. Sequence data was corroborated by restriction analysis of PCR products. RESULTS: Mapping of the No2 cataract placed it in the vicinity of Gja8, the gene encoding connexin 50 (MP70), a major component of lens fiber gap junctions. Amplification and subsequent sequencing of the Cx50 protein coding regions revealed a single A-->C transversion within codon 47. This sequence change resulted in the creation of an HhaI restriction endonuclease restriction site, allowing for corroboration of the sequence data via restriction analysis using this enzyme. The sequence alteration is also predicted to result in the nonconservative substitution of alanine (Ala) for the normally encoded aspartic acid (Asp) at this position within the polypeptide. CONCLUSIONS: The identified mutation in Gja8 is both correlated and consistent with the cataract observed in the No2 mouse mutant, making it an ideal candidate for the cataract. This study provides the first evidence that a mutation in a lens connexin can result in congenital hereditary cataract, highlighting the importance of lens connexins in maintaining lens transparency.     

Endoscopically guided percutaneous repair of inguinal hernia through a 2-cm incision. Minihernia repair

BACKGROUND: The laparoscopic repair of inguinal hernia is still controversial. Transabdominal preperitoneal repair violates the peritoneal cavity and may result in visceral injuries or intestinal obstruction. The laparoscopic extraperitoneal approach has the disadvantage of being technically demanding and requires extensive extraperitoneal mobilization. The Lichtenstein repair gives good long-term results, is easy to learn, can be performed under local anesthesia, but requires a larger incision. METHODS: We describe a novel percutaneous tension-free prosthetic mesh repair performed through a 2-cm groin incision. The inguinal canal is traversed with the aid of a 5-mm video-endoscope and the canal is widened using specially designed balloons. Spermatic cord mobilization, identification and excision of the indirect sac, and posterior wall repair are carried out under endoscopic guidance. RESULTS: Between October 1993 and July 1995, 85 primary inguinal hernia repairs (48 indirect and 33 direct) were performed on 81 patients (80 men, one woman) by the author (A.D.). The mean age was 41 years (range 17-83 years). Six repairs were performed under local anesthetic. Mean operative time was 42 min (range 25-74). Mean hospital stay was 1.2 days (0-3 days). The mean return to normal activity was 8 days (2-10 days). Eight complications have occurred: a serous wound discharge, two scrotal hematomas, a scrotal swelling that resolved spontaneously, wound pain lasting 2 weeks, an episode of urinary retention, and two recurrences early in the series (follow-up 1-22 months). CONCLUSION: The endoscopically guided percutaneous hernia repair avoids the disadvantages of laparoscopy (i.e., lack of stereoscopic vision, reduced tactile feedback, unfamiliar anatomical approach, risk of visceral injury), yet the use of endoscopic instrumentation allows operation through a 2-cm incision. The minihernia repair thus combines the virtues of an open tension-free repair with minimal access trauma.     

An alternative to DSM-III.

Comments on the article by Schacht and Nathan (see record 1978-29497-001), which presented a critical analysis of the 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). Schacht and Nathan note the inappropriateness of categorizing all mental disorders as a subset of medical disorders. The current author suggests that this may result in insurers and legislators increasingly relying on psychiatrists for both diagnosis and treatment of mental problems. He suggests that the American Psychological Association should develop its on diagnostic manual to be free of the biases and limitations of the DSM-III. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Intra-operative facial nerve monitoring. Its predictive value after skull base surgery

A 65-year-old man was admitted with a diagnosis of arteriosclerosis obliterans. He had a 3-month history of intermittent claudication of the right leg. Physical examination revealed absence of pulsation of the right posterior tibial artery. Contrast angiography of lower extremities showed several obstructive lesions below the right popliteal artery. As interventional and surgical approached were not indicated, the patient was treated with exercise with heparin pretreatment (5,000 IU). As a result, walk distance on a floor was increased from 400 m to 2,000 m, and repeat magnetic resonance angiography revealed increased flow to the right lower extremity. Thus, he was successfully treated with exercise and heparin pretreatment without any side effects.     

An alternative interpretation of oneness.

Comments on L. H. Silverman and J. Weinberger's (see record 1986-15022-001) interpretation of their data as supporting the concept that subliminally induced gratification of wishes can enhance adaptation in both schizophrenic (SCZ) and non-SCZ individuals. This interpretation was strongly biased by Silverman and Weinberger's original intent. An alternative interpretation of their data is proposed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Involvement of the skull base and vault in chronic idiopathic hyperphosphatasia

OBJECTIVE: To evaluate whether mutation in the exon 10 of the fibroblast growth factor receptor 3(FGFR3) gene in common in Chinese patients with achondroplasia. METHODS: Genomic DNA from seven sporadic cases of achondroplasia was studied by using PCR-SSCP and restriction enzymes. RESULTS: All patients carried the same glycine-to-arginine mutation at codon 380(G380R) of the transmembrane domain of FGFR3. CONCLUSION: The results suggest that the G380R mutation of FGFR3 is also a frequent mutation causing achondroplasia in Chinese. Detecting FGFR 3 gene mutation with PCR-SSCP and restriction enzymes analysis is a convenient, rapid and reliable molecular diagnostic assay for prenatal and early diagnosis of achondroplasia.     

Emergenesis: An alternative and a confound.

Comments on the proposition of D. T. Lykken et al (see record 1993-16512-001) that there is a genetic explanation (emergenesis) for the similarity of monozygotic twins reared apart (MZA). Emergenesis is challenged and it is argued that the authors' research method is inherently confounded. An environmental explanation is suggested, which holds that MZAs' personalities are similarly molded because of their shared physical appearance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Chondroma of the petrous bone. A contribution to differential skull base tumor diagnosis

INTRODUCTION: Cartilaginous tumors of the mid-face and the skull base are rare. CASE REPORT: For the first time, a case report of a chondroma of the base of the ear in a 56-year-old woman is presented. In 1974 the patient developed a facial nerve paralysis while she was pregnant. Twenty-two years later the patient developed persistent headache and CT studies of the head were obtained, which showed an extensive tumorous lesion located at the base of the ear. A tumor was resected through an otoneurosurgical approach. The histological examination showed a chondroma. CONCLUSIONS: Even the rare diagnosis of a chondroma should be considered for a differential diagnosis of skull base tumors.     

Evaluation of the skull base by SPECT. A comparison with planar scintigraphy and computed tomography

Computed tomography is currently the standard diagnostic tool for the evaluation of the skull base. The complex anatomy of this area is the primary reason why planar bone scintigraphy is often unsatisfactory; exact localization of abnormalities may be very difficult. These limitations may be overcome by SPECT. Seventeen patients with clinical features of basal skull involvement were assessed by CT, SPECT, and planar scintigraphy. Subsequent clinical diagnoses were malignancy in 15 patients, vasculitis in 1 patient, and osteomyelitis in 1 patient. Computed tomography with IV contrast was performed through the skull base at 5 mm intervals. Planar scintigraphy with Tc-99m MDP was followed by SPECT. Bony involvement compatible with the clinical findings was demonstrated by CT scans in 6 patients, by planar scintigraphy in 7 patients, and by SPECT in 9 patients. The abnormalities that were identified by CT were all identified by SPECT. This study suggests that, in imaging the skull base, SPECT is more sensitive and provides better anatomical localization than planar imaging and appears useful in patients with a negative CT study.     

Mammalian base excision repair and DNA polymerase beta

OBJECTIVE: To describe six dogs with congenital abnormalities involving the portal vein, caudal vena cava, or both. ANIMALS: Six client-owned dogs with congenital interruption of the portal vein or the caudal vena cava, or both. METHODS: Portal vein and caudal vena cava anatomy was evaluated by contrast radiography and visualization at surgery. Vascular casts or plastinated specimens were obtained in three animals. RESULTS: Portal blood shunted into the caudal vena cava in four dogs and the left hepatic vein in one. Two of these five dogs also had interruption of the caudal vena cava with continuation as azygous vein, as did an additional dog, in which the portal vein was normally formed. Portal vein interruption was present in 5 of 74 (6.8%) dogs with congenital portosystemic shunts evaluated at the Veterinary Teaching Hospital during the study period. CONCLUSIONS: Serious malformations of the abdominal veins were present in more than 1 in 20 dogs with single congenital portosystemic shunts. CLINICAL RELEVANCE: Veterinarians involved in diagnosis and surgery for portosystemic shunts should be aware of these potential malformations, and portal vein continuity should be evaluated in all dogs before attempting shunt attenuation.     

Anterior approach for CT-guided biopsy of skull base and parapharyngeal space lesions

At our institution we use an anterior approach to biopsy of the parapharyngeal space or skull base lesions because it provides more direct access than the traditional lateral approach through the mandibular notch. The anterior approach follows a course lateral to the alveolar ridge of the maxilla and lateral pterygoid plate, and inferior to the zygomatic process of the maxilla. Biopsy was performed on 15 patients with either a skull base or a parapharyngeal space mass, none of which could be palpated externally or through the oral cavity by the ear, nose, and throat surgeon. In 12 patients the needle biopsy correlated with the surgical pathology. Three needle biopsies were nondiagnostic.     

The retroperitoneal incision. An evaluation of postoperative flank 'bulge'

OBJECTIVES: To determine if intercostal nerve injury is related to postoperative flank "bulge" and to determine whether the extent of the retroperitoneal incision is related to the incidence of flank bulge following abdominal aortic aneurysm repair. DESIGN: Bilateral dissection of the 11th intercostal nerve on seven cadavers; neurophysiological evaluation of five patients, three with a flank bulge and two without; and retrospective analysis of the extent of retroperitoneal incision and incidence of postoperative flank bulge in 63 consecutive patients. SETTING: Urban academic medical center. PATIENTS: Sixty-three consecutive patients who underwent retroperitoneal repair of an abdominal aortic aneurysm and neurophysiological evaluation of five volunteer patients. INTERVENTIONS: Retroperitoneal repair of abdominal aortic aneurysms. MAIN OUTCOME MEASURE: Reduction of injury to the 11th intercostal nerve by avoiding extension of the retroperitoneal incision into the intercostal space. RESULTS: Of 14 dissections of 11th intercostal nerves, there were bifurcations of the main trunk within the intercostal space in four, at the tip of the 11th rib in seven, and at least 2 cm distal to the tip of the rib in three. Neurophysiological evaluation revealed iterative discharges, polyphasia, fibrillation potentials, and altered recruitment patterns compatible with intercostal nerve injury in patients with a bulge but not in the opposite abdominal wall musculature or in patients without a bulge. Seven (11.11%) of 63 patients had a bulge. Thirty-one of 63 patients had incisions into the 11th intercostal space in which a bulge developed in six (19.35%). Thirty-two patients had incisions that avoided extension into the intercostal space; a bulge developed in one (0.03%) (P = .53). CONCLUSIONS: Postoperative bulge is related to intercostal nerve injury with subsequent paralysis of abdominal wall musculature. Intercostal nerve injury can be reduced by avoiding extension of the incision into the 11th intercostal space.     

Two-stage skull base surgery for tumours extending to the sub- and epidural spaces

The surgical management of extensive skull base neoplasms, which often extend to both the sub- and epidural spaces, is still a great challenge with considerable risk. The authors report 12 cases in which a two-stage operation was performed for such nonmalignant tumours. The series consisted of four cavernous sinus meningiomas, one sphenoid-ridge meningioma, one cerebello-pontine angle meningioma, three pituitary adenomas, two chordomas, and one fibroma. Our operative strategy involved removal of the epidural part of the tumour and extensive skull base reforming during the first stage. After approximately one month, the second stage operation was performed by removing the residual subdural parts and the affected dura, which were less vascular, with dural plasty and subsequent spinal drainage. No complications such as cerebrospinal fluid (CSF) leakage or infection were observed. During the long-term follow-up (1.4 to 4.6 years, with a mean of 2.7 years), tumour recurrence was observed in a single case. In conclusion, the major advantages of this procedure were as follows: [1] improvement of the total removal rate, [2] prevention of postoperative CSF leak and infection, [3] residual tumours were avascular, necrotic, and dwindling, and also shifted outwards resulting in less adhesions to the brain. Although it may counter the trend toward less invasive procedures, the two-staged skull base surgery warrants serious consideration as an option for the management of patients with such extensive cranial base tumours.     

Dedifferentiated (sarcomatoid) chordoma in the base of the skull. Report of a case

We report a case of "dedifferentiated" chordoma occurring in a 31-year-old man and involving the base of the skull. Morphologically, the tumor was characterized by a bifasic pattern (classical chordoma associates to sarcoma-like areas), and by coexpression of epithelial and stromal markers. Because of these traits, we believe this case shows features superimposable to those seen in sarcomatoid carcinoma.     

Mammalian base excision repair by DNA polymerases delta and epsilon

Two distinct pathways for completion of base excision repair (BER) have been discovered in eukaryotes: the DNA polymerase beta (Pol beta)-dependent short-patch pathway that involves the replacement of a single nucleotide and the long-patch pathway that entails the resynthesis of 2-6 nucleotides and requires PCNA. We have used cell extracts from Pol beta-deleted mouse fibroblasts to separate subfractions containing either Pol delta or Pol epsilon. These fractions were then tested for their ability to perform both short- and long-patch BER in an in vitro repair assay, using a circular DNA template, containing a single abasic site at a defined position. Remarkably, both Pol delta and Pol epsilon were able to replace a single nucleotide at the lesion site, but the repair reaction is delayed compared to single nucleotide replacement by Pol beta. Furthermore, our observations indicated, that either Pol delta and/or Pol epsilon participate in the long-patch BER. PCNA and RF-C, but not RP-A are required for this process. Our data show for the first time that Pol delta and/or Pol epsilon are directly involved in the long-patch BER of abasic sites and might function as back-up system for Pol beta in one-gap filling reactions.