A rare case of direct tumor extension to the right ventricle

We report the case of a 72-year-old woman with signs of pulmonary embolism and right heart failure. Echocardiographic imaging and computed tomography revealed a mass within the inferior vena cava reaching from the head of the pancreas to the right ventricle. From standard imaging procedures and clinical findings alone, differentiation of a cardiac thrombus from a metastatic tumor mass was difficult. After resection of the intravascular tumor, histopathologic analysis confirmed a metastasis of primary ductal pancreatic adenocarcinoma. This is a report of a case of mucinous adenocarcinoma of the pancreas reaching the heart by continuous intravascular spreading.

IgA NMDA receptor antibodies are markers of synaptic immunity in slow cognitive impairment

OBJECTIVE

To report that antibodies to synaptic proteins may occur in association with slow, progressive cognitive decline.

METHODS

A total of 24 patients with progressive cognitive dysfunction of unclear etiology were examined for onconeuronal and synaptic receptor antibodies. The effect of serum was examined in cultures of dissociated mouse hippocampal neurons.

RESULTS

Seven patients had immunoglobulin A (IgA), but no immunoglobulin G (IgG), antibodies against NMDA receptor (NMDAR). Anti-NMDAR IgA positive patients' serum, but not serum from control individuals, caused dramatic decrease of the levels of NMDAR and other synaptic proteins in neurons, along with prominent changes in NMDAR-mediated currents. These effects correlated with the titer of IgA NMDAR antibodies and were reversed after removing patients' serum from the culture media. When available, comprehensive clinical assessment and brain metabolic imaging showed neurologic improvement after immunotherapy.

CONCLUSIONS

A subset of patients with slowly progressive cognitive impairment has an underlying synaptic autoimmunity that decreases the density of NMDAR and other synaptic proteins, and alters synaptic currents. This autoimmunity can be demonstrated examining patients' serum and CSF for NMDAR IgA antibodies, identifying possible candidates for immunotherapy.

Epitope mapping of BP230 leading to a novel enzyme-linked immunosorbent assay for autoantibodies in bullous pemphigoid

BACKGROUND

Bullous pemphigoid (BP) is an autoimmune subepidermal blistering disease characterized by circulating autoantibodies against BP180 and BP230. For BP180, the NC16A domain has previously been identified as the main antigenic target in BP, while data about the diagnostic value of epitopes on BP230 were inconclusive.

OBJECTIVES

To identify the most appropriate epitopes on BP230 to be applied in a simple, sensitive, and highly specific enzyme-linked immunosorbent assay (ELISA) for routine detection of serum autoantibodies.

METHODS

Ten overlapping linear fragments covering the whole length of BP230 were expressed in Escherichia coli. Based on Western blot analysis with sera from patients with BP (n = 49) and healthy controls (n = 94), the diagnostic performance of the fragments was compared by receiver operating characteristics curve analysis. The BP230-C3 fragment comprising the C-terminal portion (amino acids 2326-2649) was subsequently applied in a novel ELISA. The operating characteristics of this ELISA were analysed by probing sera from patients with BP (n = 118), pemphigus vulgaris (n = 50), rheumatoid arthritis and other inflammatory arthritides (n = 170), and systemic lupus erythematosus (n = 56), and from healthy blood donors (n = 483).

RESULTS

Among all the fragments, BP230-C3 provided the best efficiency in serologically diagnosing BP by Western blot. An ELISA employing BP230-C3 revealed a diagnostic sensitivity of 56·8% and specificity of 97·6%. Its diagnostic added value amounted to 4·2% compared with the anti-BP180-NC16A-4X ELISA alone.

CONCLUSIONS

Recombinant BP230-C3 is a suitable target antigen for the detection of serum autoantibodies against BP230.

Seroprevalence and specificity of NMO-IgG (anti-aquaporin 4 antibodies) in patients with neuropsychiatric systemic lupus erythematosus

Neuropsychiatric manifestations are present in 30-40% of patients with systemic lupus erythematosus (SLE). Recently, antibodies to aquaporin-4 (termed AQP4-Ab, or NMO-IgG), a water channel protein, were reported to be present in a subset of patients with SLE and neurological involvement. To evaluate the syndrome specificity and prevalence of serum NMO-IgG/anti-AQP4 antibodies in patients with neuropsychiatric systemic lupus erythematosus (NPSLE). Sera of 76 patients with SLE and neurological symptoms, 50 of whom met the ACR case definitions of NPSLE, were tested for AQP4-Ab in an indirect immunofluorescence assay employing HEK293 cells transfected with recombinant human AQP4. Only one of the examined sera was positive for NMO-IgG/AQP4-Ab. This patient suffered from TM, ranging over two vertebral segments on spinal MRI. None of the 75 NPSLE without TM was found to be seropositive for NMO-IgG/AQP4-Ab. NMO-IgG/AQP4-Ab in NPSLE were present only in a patient with TM and were not detectable in NPSLE patients with other neurological manifestations. Testing for NMO-IgG/AQP4-Ab positivity should be considered in patients presenting with SLE and TM. Non-longitudinally extensive lesions do no not exclude NMO-IgG/AQP4-Ab in patients presenting with SLE and TM.

Anaemia in chronic respiratory failure

BACKGROUND

In patients with severe chronic obstructive pulmonary disease (COPD), anaemia is common and associated with impaired long-term survival and quality of life. Whether anaemia is also prevalent in patients with other severe, non-inflammatory respiratory diseases has not yet been systematically tested.

METHODS

In 595 patients with obstructive (OD, 54.8%) or restrictive disease (RD, 45.2%) and chronic respiratory failure (CRF), anthropometric data, laboratory parameters, lung function, blood gases and comorbidities were assessed prior to initiation of home mechanical ventilation. Patients were classified as anaemic based on haemoglobin (Hb) levels (Hb<12/13 g/dl, female patients/male patients). Patients with known causes for anaemia were excluded.

RESULTS

In patients with CRF the prevalence of anaemia was 13.3% and not different between RD (11.5%) and OD (14.7%) (p=0.276). A sex-related difference occurred only in OD [7.9% (f) vs. 17.3% (m); p=0.035]. Patients with OD and anaemia presented with higher age (p=0.003), pH (p=0.014) and arterial oxygen pressure (PaO(2) ) (p=0.012), lower body mass index (BMI) (p=0.011) and total protein (p=0.012) and higher rates of coronary heart disease (p=0.01), cardiac arrhythmia (p=0.014) and diabetes mellitus (p=0.003) in comparison to non-anaemic patients. In patients with RD anaemia was associated with higher age, (p=0.008), pH (p=0.011) and lower leucocytes numbers (p=0.006).

CONCLUSIONS

Anaemia is frequent not only in COPD but also in other severe respiratory diseases combined with CRF. It was associated with advanced age, several comorbidities, impaired nutritional state and elevations of pH and PaO(2) , probably because of hyperventilation. Its prognostic impact has to be elucidated in future studies.

[Comparison of early total care (ETC) and damage control orthopedics (DCO) in the treatment of multiple trauma with femoral shaft fractures: benefit and costs]

INTRODUCTION

Femoral fractures are common injuries in multiple trauma patients. The treatment concept of damage control orthopedics (DCO) is in competition with the concept of early total care (ETC).

PATIENTS AND METHODS

In a retrospective study (2003-2007) 73 multiple trauma patients with femoral shaft fractures were included. The cohort was subdivided according to the Injury Severity Score (ISS) (16-24, 25-39 and more than 40) and treatment strategy (ETC versus DCO). Patients were analyzed for outcome and cost aspects.

RESULTS

In the patient group with an ISS 16-24 ventilation time and intensive care treatment were longer after DCO treatment, overall costs and deficient cost cover were higher in the DCO group. In the patient group with an ISS 25-39 cost aspects showed a higher cover deficient in the DCO group.

CONCLUSION

From an economic point of view the cost deficits for the ETC group were lower than in the DCO group. The treatment strategy should be selected by the pattern of injuries. The costs should be addressed by the Institute for the Hospital Remuneration System (INEK).

Combined Transapical Aortic Valve Replacement and Minimally Invasive Direct Coronary Bypass Grafting�A New Concept for Selected High-Risk Patients

Background: Transcatheter aortic valve implantation and minimally invasive direct coronary artery bypass (MIDCAB) procedures are both off-pump treatment options for a subset of higher-risk patients. We present a new, minimally invasive surgical concept involving combining the procedures and performing them through the same thoracic access in a patient with a vascular disorder.Case Report: We report on a 78-year-old patient with symptomatic calcified aortic stenosis and a critical lesion of the left anterior descending coronary artery. In addition, Rendu-Osler-Weber disease was diagnosed. He was successfully treated with combined off-pump transapical, transcatheter aortic valve implantation and MIDCAB grafting. The initial postoperative recovery was good; however, the patient died 3 months postoperatively from septic complications.Conclusion: This combined procedure performed through the same anterolateral incision was technically feasible and may be a promising, minimally invasive approach for selected patients.

Identification of Atoxigenic Aspergillus flavus Isolates to Reduce Aflatoxin Contamination of Maize in Kenya

Aspergillus flavus has two morphotypes, the S strain and the L strain, that differ in aflatoxin-producing ability and other characteristics. Fungal communities on maize dominated by the S strain of A. flavus have repeatedly been associated with acute aflatoxin poisonings in Kenya, where management tools to reduce aflatoxin levels in maize are needed urgently. A. flavus isolates (n = 290) originating from maize produced in Kenya and belonging to the L strain morphotype were tested for aflatoxin-producing potential. A total of 96 atoxigenic isolates was identified from four provinces sampled. The 96 atoxigenic isolates were placed into 53 vegetative compatibility groups (VCGs) through complementation of nitrate non-utilizing mutants. Isolates from each of 11 VCGs were obtained from more than one maize sample, isolates from 10 of the VCGs were detected in multiple districts, and isolates of four VCGs were found in multiple provinces. Atoxigenic isolates were tested for potential to reduce aflatoxin concentrations in viable maize kernels that were co-inoculated with highly toxigenic S strain isolates. The 12 most effective isolates reduced aflatoxin levels by >80%. Reductions in aflatoxin levels caused by the most effective Kenyan isolates were comparable with those achieved with a United States isolate (NRRL-21882) used commercially for aflatoxin management. This study identified atoxigenic isolates of A. flavus with potential value for biological control within highly toxic Aspergillus communities associated with maize production in Kenya. These atoxigenic isolates have potential value in mitigating aflatoxin outbreaks in Kenya, and should be evaluated under field conditions.

First clinical experience with a novel forearm boom

The optimal forearm boom should facilitate dynamic investigation of the wrist and approaches for wrist arthroscopy. It should be safely fixed at the operating table without any contact with the patient. It must be compatible with the arm of any patient and should be sterilisable. Repositioning of distal radius fractures, fluoroscopy and insertion of Kirschner-wires should not be restricted. According to these criteria the current investigators designed a new forearm boom which was subsequently used in 19 wrist arthroscopies and 9 distal radius fracture fixations. Twenty-eight patients with heights between 150 and 205 cm and forearm lengths between 17.5 to 37 cm were treated. Preoperatively, wrist motion was tested in those 19 wrists, that underwent wrist arthroscopy, before and after fixation by the forearm boom and any restriction due to usage of the novel device was found. The new forearm boom satisfied all of the criteria cited above. Therefore the current authors believe the new forearm boom may be valuable for the indications mentioned.

Productive capacity of alveolar macrophages and pulmonary organ damage after femoral fracture and hemorrhage in IL-6 knockout mice

Alveolar macrophages (AM) play an important role in the pathogenesis of posttraumatic pulmonary failure, and have been identified as major source of pulmonary cytokines. The effects of locally generated IL-6 as well as femoral fracture on the pulmonary inflammatory response and organ damage have not been fully elucidated. In the present study we evaluated the influence of femoral fracture, isolated or in combination with hemorrhage, on the immune function of AM and remote lung injury, and investigated the role of pulmonary IL-6 within this setting. 18 wild type (WT) and 18 IL-6 knockout mice (IL-6(-/-)) underwent standardized femoral fracture, isolated or in combination with volume-controlled hemorrhage, followed by fluid resuscitation and splint fixation of the fracture. Animals were sacrificed 4h after induction of fracture and hemorrhage. Animals were randomly assigned to three study groups (each consisting of six animals). Besides sham groups, experimental groups included animals with isolated femoral fracture or in combination with hemorrhagic shock. Cytokine release of AM was determined by flow cytometry. Pulmonary damage in terms of interstitial thickening and lung neutrophil infiltration was assessed by histology and immunohistology. The productive capacity of AM for pro-inflammatory cytokines was increased after isolated femoral fracture in WT and IL-6(-/-) mice. An additional hemorrhagic insult resulted in a further enhancement of pro-inflammatory cytokine release and an increased MCP-1 secretion in WT and IL-6(-/-) animals. MCP-1 and pro-inflammatory cytokine production of AM was attenuated in IL-6(-/-) mice compared to the respective WT groups. Interstitial thickening and lung neutrophil infiltration was only observed after femoral fracture combined with hemorrhagic shock with an attenuation of the pulmonary organ damage in IL-6(-/-) compared to WT animals. These results support the role of IL-6 as a therapeutic target for posttraumatic immune modulation. With an increased pro-inflammatory mediator release, already an isolated femoral fracture seems to influence the immune response of AM.

Histopathological features of the brain, liver, kidney and spleen following an innovative polytrauma model of the mouse

OBJECT

Among the various introduced experimental traumatic brain injury models, there is a clear paucity of proper experimental polytrauma models. To overcome this experimental gap we introduced such a polytrauma model in the mouse including traumatic brain injury. Here, we report on the histopathological features of the brain, lung, kidney, spleen and liver.

MATERIALS AND METHODS

20 male C57BL mice with a mean weight of 23 g were anesthetized with ketamine and xylazine. The anaesthetized animals were subjected to a controlled cortical impact (CCI) over the left parieto-temporal cortex using rounded-tip impounder for application of a standardized brain injury. Following fracture of the right femur using a guillotine, a volume-controlled hemorrhagic shock was induced. The control groups included animals with CCI only (n=20) and animals with femur fracture plus hemorrhagic shock without CCI (n=20). Subjects were sacrified at 96 h following trauma. Brain, lung, kidney, spleen and liver of the animals underwent histopathological examinations.

RESULTS

The mortality rate at 96 h was 25% in the polytrauma group versus 10% in the control groups. Within the histopathological investigations, polytraumatized animals differ from those with a single trauma (traumatic brain injury or femur fracture with hemorrhagic shock) with various severity.

CONCLUSION

The findings of this study show that such a polytrauma model can be standardized resulting in a reproducible damage. This model fulfills the requirements of a standardized animal model. It allows adequate analogies and inferences to the clinical situation of a polytrauma in humans.

[The economic challenges of polytrauma care]

Following the introduction of DRGs ("diagnosis-related groups") in Germany, reimbursements changed from a per diem rate to a flat charge per patient. DRGs are defined by the German Institute for the Hospital Remuneration System (InEK, Institut für das Entgeltsystem im Krankenhaus) along with the respective reimbursement. The revenues are set according to the diagnoses and procedures. In complex cases like serious injury this applies for the average diagnoses and procedures. As a result, several groups reported costs of polytrauma care as high as 70,000 euro with losses as high as 20,000 euro. In the USA, a similar constellation has lead to the closure of trauma centers. The main reasons for the financial deficit are heterogeneity of polytrauma patients and contingency costs. Both are difficult to transfer to a case-based compensation system. Since the German DRG system was designed to learn during introduction, there were adjustments to reimbursements for polytrauma care in the initial phase. However, in recent years, no further improvements in the care of severely injured patients have been seen. The deficit per seriously injured patient currently runs at approx. 5000 euro. A renewed joint effort is required in order to avoid an economy-related reduction in quality of care.