[Complete parenteral nutrition in childhood]

Complete parenteral nutrition by means of continuous intravenous drip into large veins, over a long period, has already shown itself to be of therapeutic use in the field of pediatrics. While the nutritional-physiological aspect of this therapeutic method is clear -- it depends on an accurate and sufficient supply of water, salts, glucose, amino-acids, triglycerides and essential fatty acids, vitamins and trace elements -- in practice it presents difficulties which though often serious are not insurmountable. Especially are to cite the septic complications, which are nearly imperceptible during their development. They are only to accept in view of the often almost hopeless condition of the child, who would be lost without complete parenteral feeding. Similar problems arise through metabolic complications which are caused non rarely only by insufficient dosages and lack of careful supervision but it is generally possible to correct these at an early stage. Complete parenteral nutrition must be exactly indicated. It is indeed a great therapeutic help, particularly when over a longer period -- at least a week or longer -- oral nutrition is impossible or insufficient. Practicall experiences will be reported. A retrospective assessment of 50 cases has shown the tendency (through taking too much care?) to hold the quantity of liquids and supply of calories too short and to administer too much carbohydrates and too little fat.

[Ultrasonographic measurement of the sole horn thickness in bovine claw]

Ultrasonographic thickness measurement and imaging of sole horn and the encapsulated soft tissue layers was evaluated in 100 bovine claw specimens. The claws were trimmed and examined in longitudinal planes using a 7.5 MHz linear transducer. In each claw, ultrasonographic measurements of horn thickness of sole and distance from outer claw surface to distal phalanx surface were made at three marked points on the weightbearing surface. All claws were then frozen, transected and anatomical reference measurements were made after thawing. The sole horn, corium, subcutis and distal surface of the distal phalanx of all claws were clearly visualized. The sole horn had a heterogeneous hypoechoic appearance, the underlying soft tissue layer was predominantly anechoic. Corium and subcutis could be differentiated. Best imaging of these structures was achieved in claws with less than 10 mm sole horn thickness and soft sole horn. Statistical correlation coefficients of 0.88 to 0.91 were found for ultrasonographic and anatomical measurements of sole horn thickness. Therefore, B-mode ultrasonography proved to be an accurate, non-invasive technique for measurement of the sole horn thickness in bovine claws.

Nivolumab for locally advanced and metastatic cutaneous squamous cell carcinoma (NIVOSQUACS study)-Phase II data covering impact of concomitant haematological malignancies

BACKGROUND

Monoclonal antibodies, such as cemiplimab and pembrolizumab, against the programmed death receptor (PD)-1 have become the current standard of care and first-line treatment of advanced cutaneous squamous cell carcinoma (cSCC), proving remarkable clinical benefit and acceptable safety.

OBJECTIVES

To assess efficacy and safety of the anti-PD-1 antibody nivolumab in patients with locally advanced and metastatic cSCC.

METHODS

Patients received open-label nivolumab 240 mg intravenously every 2 weeks for up to 24 months. Patients with concomitant haematological malignancies (CHMs), either non-progressing or stable under active therapy, were eligible for inclusion.

RESULTS

Of 31 patients with a median age of 80 years, 22.6% of patients achieved an investigator assessed complete response, resulting in an objective response rate (ORR) of 61.3% and a disease control rate (DCR) of 64.5%. Progression-free survival (PFS) was 11.1 months, and the median overall survival (OS) was not reached after 24 weeks of therapy. Median follow-up was 23.82 months. Subgroup analysis of the CHM cohort (n = 11; 35%) revealed an ORR of 45.5%, a DCR of 54.5%, a median PFS of 10.9 months, and median OS of 20.7 months. Treatment related adverse events were reported in 58.1% of all patients (19.4% grade 3, the remaining grade 1 or 2). PD-L1 expression and CD-8+ T-cell infiltration did not significantly correlate with clinical response, although a trend towards a shorter PFS of 5.6 months was observed with PD-L1 negativity and low CD8+ intratumoral infiltration.

CONCLUSION

This study demonstrated robust clinical efficacy of nivolumab in patients with locally advanced and metastatic cSCCs and a tolerability comparable to data of other anti-PD-1 antibodies. Favourable outcomes were obtained despite involving the oldest hitherto reported study cohort for anti-PD-1 antibodies and a significant proportion of CHM patients prone to high risk tumours and an aggressive course otherwise typically excluded from clinical trials.

Renal tolerability of four different once-daily dose regimen of netilmicin in critical care patients

A prospective, randomized trial was conducted in a medical intensive care unit to assess safety and tolerability of four different dose regimens of intravenous netilmicin given once daily in the treatment of febrile episodes in critically ill patients. Eighty patients with febrile episodes during their stay in the intensive care unit were included in the study. The patients were randomized into four groups: Group 1 received a single daily dose of netilmicin based upon weight, age and renal function according to a dosage nomogram [13] (mean dose 298 +/- 29 mg, median 300 mg, range 250-350 mg), group 2 received 150% of this standard dose (mean 418 +/- 45 mg, median 400 mg, range 350-500 mg), group 3 200% (mean 525 +/- 41 mg, median 500 mg, range 400-550 mg) and group 4 250% (mean 710 +/- 39 mg, median 650 mg, range 600-750 mg). Duration of treatment was six days. Positive cultures were obtained in 29 patients. Serum creatinine and creatinine clearance, as well as netilmicin trough levels and levels of alpha 1-microglobulin showed no significant difference between the groups before, during, and after therapy. Our results indicate that with once daily dosing even high doses of netilmicin are well tolerated in patients with a creatinine clearance of > 70 ml/min before therapy. Necessary precautions include monitoring of drug trough levels (< 1 mg/L) and maintenance of adequate volume status.

[Use of sodium ceftiofur in the combined therapy of complicated septic diseases in cattle]

The use of Sodium-Ceftiofur (Excenel) with a dosage regimen of 1 mg/kg body mass intramuscularly was evaluated in the therapy of complicated claw diseases, like septic arthritis of the distal interphalangeal joint, septic tenosynovitis of the digital flexor tendon sheath or complicated interdigital necrosis. Sodium-Ceftiofur was applied in 34 dairy cattle in addition to surgical intervention. 14 cattle of the control group perceived only surgical intervention without additional antibiotic therapy. Application of the cephalosporin proved to be necessary, with the untreated animals exhibiting far more disturbance of the reconvalescence course in the postoperative phase. Treated animals had a decreasing duration of the postoperative stay at the clinic. Sodium-Ceftiofur was found to be an effective antibiotic in the therapy, an application over a five- to 10-day-period is recommended in complicated digital diseases. As a side effect five cows exhibited slight diarrhea, which disappeared without additional treatment.

Resektion einer Karpalknochenreihe bei einer Pustertaler Sprinze mit chronischer eitriger Arthritis des Karpalgelenks und Osteomyelitis

Der Fallbericht beschreibt klinische und radiologische Befunde sowie die chirurgische Therapie einer serofibrinösen Arthritis des Antebrachiokarpalgelenks und einer eitrigen Arthritis des Inter- und Karpometakarpalgelenks mit Osteomyelitis der distalen Karpalknochen und subchondraler Osteomyelitis des proximalen Anteils des Metakarpus bei einer Pustertaler-Sprinzen-Kuh. Beide Gelenkabteilungen wurden arthrotomiert und die distale Karpalknochenreihe wurde reseziert. Nach 70-tägiger Immobilisierung mittels Cast zeigte die operierte Gliedmaße bereits deutliche radiologische Zeichen der Ankylose des Karpalgelenks und nur noch eine geringe Lahmheit. Die Kuh war 6 Jahre später noch immer in der Herde und hatte sechs Kälber geboren.

[Septic arthritis of the pastern in cattle--clinical, radiological and sonographic findings and treatment]

Clinical, radiographic, sonographic, arthrocentesis and intraoperative findings in 19 cattle suffering from a septic arthritis of the proximal interphalangeal (p.i.p.) joint in 20 digits were evaluated retrospectively. In 6 cattle the p.i.p. joint was exclusively affected, in 13 animals a concurrent infection was ascertained in other 18 synovial cavities: digital flexor tendon sheath and the adjoining digital joints. As origin of the p.i.p. joint infection 11 cases showed perforating wounds, 6 cases a contiguous spread from adjacent purulent tissue affections and in 2 calves a haematogenous contamination was found. According to the progress of septic joint affection the increasing severity of the radiographic findings in this study were classified in 6 degrees. This systematic classification of the radiographic findings of septic arthritis in cattle is proposed as a basis for a comparable description and diagnosis of the radiographic signs. The sonographic imaging of the distended dorsal and plantar recesses of the p.i.p. joint in 3 cattle was proved to be a valuable adjunct to the other examination methods available. Five animals were slaughtered after diagnosis. An amputation through the distal third of the phalanx proximalis, respectively a modified disarticulation in the p.i.p. joint was performed in 14 patients. After an average hospitalization of 4.6 weeks the 13 healed patients were dismissed.

[Ultrasonographic examination of the hip joint region and bony pelvis in cattle]

Transcutaneous and transrectal ultrasonographic examination of the hip joint region and the pelvis was carried out in 7 cadavers, transcutaneous ultrasonography in 17 healthy young and adult cattle, and transrectal sonography was performed in 12 healthy cows in order to study the normal ultrasonographic appearance of these regions. 7.5 MHz linear-, 5.0 MHz and 3.5 MHz convex transducers and a 7.5 MHz rectal probe were used. The bone surfaces of the greater trochanter, the femoral neck and head, the acetabulum and the other pelvic bones were visualised as hyperechoic contours. The coxofemoral joint space was identified in all cadavers and live cattle. The joint pouch could not be visualised, neither in cadavers nor in live cattle. After experimental filling of the coxofemoral joint pouch by injection of 35-45 ml eosin-solution it appeared as a large anechoic zone between the articular surface and the echogenic joint capsule. The inner contours of the pelvic girdle, both iliosacral joint spaces, the abdominal aorta and the external iliac arteries were depicted clearly by transrectal ultrasonography. The practical application of diagnostic ultrasound in these regions is demonstrated in clinical patients suffering from a septic coxarthritis and a sequestration of a part of the tuber coxae following an open fracture. These results serve as reference data for ultrasonographic investigation of disorders of the hip joint and the pelvic region in cattle.

[Results of critical care management of patients after bone marrow transplantation]

In a retrospective study we investigated the clinical course of patients who required intensive care support after bone marrow transplantation. Out of 25 patients only 5 (20%) survived treatment in the intensive care unit (ICU) and this group showed a significantly lower age, lower APACHE III and organ-failure scores and higher serum albumin values, as well as a longer interval between bone marrow transplantation and admission to intensive care. However, no patient requiring mechanical ventilation primarily for pneumonia or other infections arising as a complication of bone marrow transplantation survived intensive care. All patients requiring ventilation for more than 24 hours died in hospital. Of the 5 patients surviving ICU treatment only 3 were eventually discharged from hospital and only one single patient was alive after 6 months. Hence, current intensive care management appears to be indicated in only a small group of patients after bone marrow transplantation.

[Cauda equina syndrome in a Fleckvieh bull after a pathological fracture of the first sacral vertebra caused by a spindle cell sarcoma]

A 9 month old Simmental fattening bull was presented with signs of a cauda equina syndrome. An epidurographic examination was made after thorough clinical, neurological and routine radiographic examination. The cause of the cauda equina compression--a spindle cell sarcoma--was revealed by the pathologic-histologic examination. This tumor caused the compression of the cauda equina and pathologic transverse fracture of the body of the first sacral vertebra and cranial epiphyseal fracture of the 1st and the 3rd sacral vertebra as well as the separation of the arcus from the first and second sacral vertebral bodies. Some other diseases which can cause cauda equina syndrome are mentioned.

[New possibilities for the diagnosis of septic tenosynovitis of the digital flexor tendon sheath in cattle using sonography--therapy and long-term results]

Sonographic examination is a new and very effective method in diagnosing of septic tenosynovitis in cattle and may be regarded as an valuable help to the classic diagnostic methods. Among 563 patients, 22 animals suffered exclusively from a serofibrinous, purulent or necrotising tenosynovitis of the digital flexor tendon sheath. In 11 cases, a resection of both flexor tendons, in 2 cases a resection of the deep flexor tendon only were performed, and in 4 cases the tendon sheath was surgically opened and irrigated. 5 animals were slaughtered after diagnosing, because both tendon sheaths of the same limb suffered from a purulent or necrotising tenosynovitis. Surgery was performed using intravenous regional anesthesia and antibiosis. Clinical, radiographic, sonographic and centesis findings are presented. Sonography enabled an accurate assessment of the extent of the inflammation and an assessment of eventual adhesions. It was therefore possible to obtain a comprehensive preoperative image about the condition of the diseased tendon sheath. Intraoperative findings are compared with sonographic diagnosis. After an average hospitalisation of 26.5 days, the patients returned to their owners. Postoperative long term follow-up from 8 months to a maximum of 8 years was evaluated in 17 animals. The minimum duration of economic use of all animals averaged 29.2 months with a range of 1 to 69 months. At the time of survey 9 cows (52.9%) were still alive. 15 cows (88.2%) produced a total of 34 calves with a maximum of 6 calves in one cow. Details on the status of the operated limb, the postoperative milk yield and reasons for culling are discussed.

[Limitations of life support in patients with anoxic encephalopathy after CPR. Results of a questionnaire to Austrian intensive care units]

A questionnaire was sent to 97 Austrian intensive care units to define the current practises of predicting neurologic outcome in patients with anoxic encephalopathy after cardio-pulmonary resuscitation. All relevant prognostic predictors, such as clinical scales, electrophysiological techniques and laboratory tests were included to examine if these procedures influence the decision to withdraw life support. The answers of 68 (70%) units were collected and analysed. The results show that tests such as somatosensory evoked potential of the determination of brain cell-specific cytosolic enzymes are without any practical importance in Austria. In addition, the methods of reducing life support were evaluated. According to the controversial discussion in the literature, there is no common approach to this problem, especially in the question of withdrawing controlled mechanical ventilation. The result of our survey show, that there is a need for general guidelines to determine the prognosis and the methods of withdrawing life support which could be used in all intensive care units regardless of their size and technical infrastructure.

Different patterns of angioedema in patients with and without angiotensin-converting enzyme inhibitor therapy

BACKGROUND

There is convincing evidence for a causal relationship between angiotensin converting enzyme inhibitor (ACEI) therapy and angioedema, but the clinical features of the patients remain unclear. The aim of the study was to compare patterns of angioedema in patients under ACEI therapy and those without ACEI therapy.

METHODS

One hundred and seventeen consecutive patients with angioedema treated in the emergency department of a 2000-bed tertiary care university hospital were included. A retrospective cohort study was performed, the exposure being ACEI therapy. The pattern of location of angioedema was the primary outcome measure.

RESULTS

Of 117 patients with angioedema, 25 (21%) received ACEI therapy. In a multivariate logistic regression model, angioedema of the cheeks, eyelids or nose was independently negatively associated with ACEI therapy [adjusted odds ratio 0.13 (95% confidence interval 0.03 to 0.49), p = 0.003]. Higher age was also significantly associated with ACEI therapy [adjusted odds ratio 1.85 (95% confidence interval 1.23 to 2.80), p = 0.003]. Furthermore, a trend towards an independent negative association between a history of allergies and angioedema under ACEI therapy was seen.

CONCLUSION

Patients with angioedema under ACE inhibitor therapy differ significantly from those receiving no ACEI therapy in terms of patterns of angioedema and age. The applicability of this observation as a tool for deciding whether to continue or terminate ACEI therapy requires prospective evaluation.

[Squamous cell carcinoma of the claw matrix in a cow]

Clinical, radiographic, gross-pathological and histological findings in a squamous cell carcinoma of the claw matrix in a three-year-old Simmental cow are described. The cow showed severe lameness of the right foreleg. Radiological examination revealed a large osteolytic focus in the medial distal phalanx. The tentative clinical diagnosis of apical pedal bone necrosis was followed by amputation and pathological examination of the claw. The horn capsule showed no lesions. Pathological examination revealed soft consistency of pedal bone and the cut surface showed a yellowish crumbling material, which had replaced most of the pedal bone. Histologically, infiltration and osteolysis of distal pedal bone by a squamous cell carcinoma was ascertained. This claw tumor has not been reported until now. Clinically, it resembles apical pedal bone necrosis and therefore should be included in the differential diagnosis.

[Acute tonsillitis: clinical symptoms; bacteriologic culture and rapid test as deciding criteria for the use of antibiotics]

In order to prevent late sequelae from an untreated streptococcal pharyngitis all patients with streptococcal tonsillitis/pharyngitis have to be treated with antibiotics, preferably penicillin. A correct diagnosis by clinical criteria is only achievable in 72% of patients with streptococcal pharyngitis. Additional criteria such as diagnosis by culture are, therefore, mandatory. Time is a major disadvantage of traditional culture methods. Slide agglutination tests show an acceptable sensitivity of 92% and a specificity of 93%. Due to the possibility of false negative test results, with consequent withholding of adequate antimicrobial chemotherapy, these test results should be used only as a valuable guide. Decision to administer an antibiotic should still be based on clinical criteria.

[Demonstration of a species specific determinant of Bacteroides fragilis lipopolysaccharides using monoclonal antibodies]

The reactivity of two monoclonal antibodies to Bacteroides fragilis was tested (ELISA) with 37 strains of B. fragilis, 1 strain each of B. thetaiotaomicron, B. ovatus, B. vulgatus and B. eggerthii, 1 strain of Fusobacterium, as well as Pseudomonas aeruginosa (6 strains), E coli (8 strains), Klebsiella (2 strains), Yersinia enterocolitica (1 strain) and LPS from Salmonella minnesota. Both monoclonal antibodies proved to be specific for B. fragilis. The determinants recognized by these antibodies are localized in the LPS of this gram-negative anaerobe.