Acute superior vena cava obstruction after rupture of a bronchial artery aneurysm

A patient was referred to our hospital with a superior vena cava syndrome after the rupture of a bronchial artery aneurysm. To our knowledge, this complication has not been reported before. An urgent thoracotomy was performed after embolization had failed.

[Decompensated acute gastric dilatation caused by a bulimic attack in anorexia nervosa]

HISTORY AND CLINICAL FINDINGS

Abdominal pain developed after a bulimic binge in a 19-year-old girl with anorexia nervosa. She had unsuccessfully tried to induce vomiting. Physical examination showed no clinical sign of peritonitis, although there was diffuse abdominal tenderness on pressure.

INVESTIGATIONS

There was leukopenia (2200 G/l) and a raised serum lactate level (58 mg/dl). No free air was seen on a plain film of the abdomen. Abdominal sonography revealed little free fluid subhepatically.

TREATMENT AND COURSE

Acute respiratory impairment during investigations required emergency intubation. As bronchoscopy revealed aspiration a bronchial lavage was performed. Under gastroscopic control gastric emptying was achieved through a large gastric tube. After early improvement the patient developed the full picture of sepsis. Ultrasonography and needle puncture having revealed purulent intraabdominal fluid, a laparotomy was performed, which showed necrosis of the anterior and posterior walls of the stomach with free perforation. The greater curvature was resected. The patient slowly recovered but a relaparotomy for a subphrenic abscess became necessary on the 10th postoperative day. A year later there was free food passage, but the anorexia nervosa was unchanged.

CONCLUSION

A bulimic binge can become life-threatening if the stomach does not empty spontaneously. Surgical intervention is required, if the patient's condition does not improve despite gastric emptying.

[Liver transplantation and diagnostic radiology: socioeconomic aspects]

PURPOSE

For calculating cost-effectiveness in the context of diagnosis related groups (DRG) we analysed all radiological examinations for 56 consecutive liver transplantations during the primary stay in the surgical department (1052 chest x-rays, 296 ultrasonographies, 216 colour coded duplex sonographies, 72 cholangiographies, 35 CT, 23 angiographies, one MRI and one embolisation).

METHODS

For calculation we used the reimbursement that the surgical wards received per patient day and the special fee for liver transplantation. We compared this with the refunds received by the department of radiology.

RESULTS

The hospital was reimbursed a total of 143785.80 DM per patient. The diagnostic and interventional procedures that were requested for the 56 patients amounted to a total of 225118.63 DM and 4019.96 DM per patient, respectively.

CONCLUSIONS

This means that only 2.8% of all the costs during and after liver transplantation were caused by the radiological examinations. This represents only a small portion of the expenses during the time in hospital, taking into account especially that patients after liver transplantation are at high risk for developing complications.

New hardware for radio frequency powered glow discharge spectroscopies and its capabilities for analytical applications

A new radio frequency (rf) hardware is developed for glow discharge spectroscopic methods. The resulting features and its capabilities for analytical applications are discussed. The electrical equipment developed allows to work as quickly, stably, reliably and easily as known from the direct current (dc) mode. Moreover, the rf power measurement has been improved. The hardware has been developed, optimised and tested for glow discharge optical emission spectroscopy (GDOES), but nevertheless it is possible to use it for all procedures applying glow discharge sources.

Quantitative depth profiling in glow discharge spectroscopies - A new deconvolution technique to separate effects of an uneven erosion crater shape

An algorithm is presented as a concept for the quantification in direct current and radiofrequency glow discharge (GD) modes for GD optical emission spectroscopy. The algorithm is divided into excitation and sputtering part and thus it is possible to distinguish between the different excitation processes and to consider equivalent sputtering crater formations in both modes. Intensity-time profiles are affected corresponding to the method by several effects. One important effect is that sputtering occurs at a single time in different depths because of curved crater bottoms, this is usually called crater effect. The main purpose is to introduce an iterative deconvolution technique which for the quantification numerically takes into account the curved sputtering crater bottom. Input data for the deconvolution technique are the calibrated mass-time profile, the partial densities of the sample constituents and the measured final shape of the sputtering crater. Using a relatively simple model for ion sputtering the deconvolution technique improves iteratively the calculated layer structure by means of information on crater formation. The mathematical handling is illustrated for the quantification of a depth profile of a multilayer sample of ten 100 nm layers. The resulting concentration-depth profile reflects excellently the real elemental distribution of the multilayer system.

[Therapeutic efficiency of of pulsed spray lysis in peripheral arterial occlusions]

PURPOSE

To determine the clinical efficacy of pulse-spray thrombolysis.

MATERIAL AND METHODS

In a prospective trial 28 patients with acute arterial (n = 14) and bypass (n = 14) occlusions of the lower extremities were treated with pulse spray thrombolysis. 23/28 legs were at risk.

RESULTS

Technical and clinical success were 89% and 68% respectively. Time interval until restitution of antegrade flow was less than two hours, the median duration of the complete intervention was 17 hours. Two patients (7.1%) needed transfusions for inguinal haematomas. After six months 50% of occluded segments remained patent, secondary patency is comparable at 53%. Bypasses show significantly lower patency (p = 0.04) and higher amputation (p = 0.009) rates than native arteries. Bad run-off (< or = 1 artery patent) is a significant predictor for clinical failure and early amputation.

CONCLUSIONS

The distinct advantage of pulse-spray thrombolysis is fast restoration of antegrade flow and thereby effective treatment of acute ischaemia. The complication rate is low without associated mortality.

Hydroxyethylstarch compared with modified gelatin as volume preload before spinal anaesthesia for Caesarean section

We studied 90 patients undergoing elective Caesarean section under spinal anaesthesia who received lactated Ringer's solution 1000 ml with up to 1000 ml of modified gelatin, lactated Ringer's solution 1000 ml with up to 1000 ml of 6% hydroxyethylstarch or only up to 1000 ml of 6% hydroxyethylstarch. Lumbar puncture was performed as soon as 500 ml of the colloid were infused. The incidence of hypotension, number of patients requiring a vasopressor and doses of ephedrine required to restore arterial pressure were significantly lower in favour of those receiving the crystalloid-hydroxyethylstarch combination. In both groups receiving the 2000 ml preload, packed cell volume (PCV) values decreased by more than 20%, which may be of concern in patients already presenting with mild anaemia. In patients who received the colloid without the crystalloid, PCV values decreased by 14% but the risk of severe hypotension was comparable with the crystalloid-gelatin combination.

[Hydrospiral CT of the pancreas in thin section technique]

PURPOSE

To evaluate a new technique for imaging the pancreas (spiral hydro-CT) based on a combination of pharmacological intestinal paralysis and water distension of the stomach and duodenum with specific reference to tumor detection rate, differentiation of malignant versus benign tumors, differential diagnosis and assessment of tumor resectability.

MATERIAL AND METHODS

In an open prospective study, 151 patients with a suspected pancreatic neoplasm based on clinical, laboratory or other imaging data were examined between May 94 and October 95. Our newly developed Hydro-CT methodology included intravenous injection of 40 mg N-butylscopolaminium bromide (Buscopan) for intestinal paralysis, gastric and duodenal wall distension by oral administration of an average of 1.51 warm tap water, 30 degrees RAO patient positioning, an individualized contrast injection technique as determined beforehand by time-to-peak measurement in the portal vein and thin-slice spiral CT (3 mm increment, 6 mm table feed and 3 mm secondary reconstruction). A detailed evaluation form was used to assess (1) tumor detection rate, (2) differentiation of malignant versus benign disease, (3) differential diagnosis, and (4) accuracy of assessment of resectability by identification of infiltration into adjacent organs and vessel structures relevant for resectability such as splenic, superior mesenteric, portal vein and celiac trunk, superior mesenteric, splenic and hepatic arteries. As the gold standard for positive tumor detection surgery and microscopic diagnosis were used, and for negative tumor detection an event-free survival of 6 months.

RESULTS

Almost all examinations were well tolerated. In only 4% was on-site administration of a gastric tube required because of vomiting. In 2% of the patients a slight allergic reaction to the contrast medium was seen. The prevalence of a pancreatic neoplasm was 38%. In tumor detection Hydro-CT reached an overall accuracy of 97.4% with a sensitivity of 100% and a specificity of 95.9%. In the differentiation of benign versus malignant disease Hydro-CT reached an overall accuracy of 89.7% with a sensitivity of 92.5% and a specificity of 83.3%. The prevalence of a pancreatic carcinoma was 24%; 4% other malignant tumors were found (distal common bile duct carcinoma, cystadenocarcinoma). Fifty-eight patients underwent surgical exploration. In those assessment of resectability reached an overall accuracy of 95% with a sensitivity of 90.5% and specificity of 100%.

CONCLUSION

The new technique of Hydro-CT based on thin slice and spiral methodology, including pharmacological intestinal paralysis and water distension, results in a high tumor detection rate and increases sensitivity and specificity of tumor differential diagnosis and of assessment of resectability.

[Hydrosonography of the pancreas. Initial results of a pilot study]

PURPOSE

To evaluate a new ultrasonographic imaging technique of the pancreas (hydrosonography), based on a combination of chemical intestinal paralysis and water distension of the stomach and duodenum, regarding its significance for tumor detection, staging and assessment of tumor resectability.

MATERIAL AND METHODS

In an open prospective study 51 patients with suspected pancreatic neoplasm were examined between July 1995 and October 1995. The technique of hydrosonography included intravenous injection of 40 mg N-butyl-scopolaminiumbromid (Buscopan) and maximum gastric and duodenal wall distension by oral administration of an average of 11 warm tap water (0.5-1.51). A detailed evaluation form was used to assess (1) overall imaging quality; (2) accuracy of identification of the pancreas in its various anatomic regions and of peripancreatic vessel structures relevant for resectability, such as splenic, superior mesenteric, and portal veins, celiac trunk, and superior mesenteric, splenic and hepatic arteries; and (3) tumor size, sonographic structure and level of organ and vessel infiltration. As gold standards for positive tumor detection and description, surgery and microscopic diagnosis were used, and for negative tumor detection, event-free survival of 6 months.

RESULTS

All examinations were diagnostic. Identification of the pancreas was complete in all 51 patients with an excellent overall imaging quality in 53%. In 86% of cases the various examined organ and vessel structures were depicted with either good or average imaging quality. In 48 of the 51 patients diagnosis positive for tumor or other organ pathology was made. A total of 16 pancreatic carcinomas and 5 benign tumors were diagnosed. Twenty-seven patients had pathology not related to a pancreatic neoplasm. For tumor detection, sensitivity was 82% and specificity 100%. For correct assessment of tumor resectability, sensitivity was 86% and specificity 100%.

CONCLUSION

The new technique of hydrosonography combines the value of routine non-invasive abdominal ultrasound with increased sensitivity and specificity for tumor detection and assessment of resectability by improved imaging accuracy.

Successful treatment of postherpetic neuralgia with oral ketamine

OBJECTIVE

To demonstrate the possibilities of the use of oral ketamine in the treatment of postherpetic neuralgia.

SETTING

A pain clinic in a university hospital.

PATIENT

A patient with postherpetic neuralgia of the ophthalmic nerve.

INTERVENTION

Subcutaneous and later oral ketamine after classical treatment had failed.

RESULTS

A complete recovery was accomplished without any sign of side effects.

CONCLUSIONS

Oral ketamine may provide an alternative in the treatment of postherpetic neuralgia. The possible mechanism of action by its N-methyl-D-aspartate (NMDA) blocking properties is discussed.

Involvement of the cholinergic system and the basal midbrain in the organization of tonic immobility in the toad Bufo paracnemis

Microinjection of 200 ng carbachol into the midbrain tegmentum of awake toads increases the duration of tonic immobility episodes induced by postural inversion maneuvers and by movement restriction. These increases were statistically significant when compared to those induced in untreated animals and in animals microinjected with an equivalent volume (0.2 microliter) of saline at the same site, and were partially blocked by pretreatment with atropine. The potentiation of tonic immobility episodes was not due to cardiovascular, respiratory, or motor changes caused by carbachol microinjection because these changes had a mean duration of 30 min and the immobility episodes induced both before and after carbachol injection did not present predictable durations but lasted either less or more than 30 min.

Human Reissner's membrane in patients with age-related normal hearing and with sensorineural hearing loss

Morphological features of Reissner's membrane were investigated in 6 patients with age-related normal hearing (ARNH) and in 4 with sensorineural hearing loss (SNHL) stemming from various causes. The membrane consisted of an epithelium, a basement membrane and a mesothelium with melanocytes. There were two major forms of epithelial cells: flat and rounded. In all specimens, the rounded cells formed whorls, clusters, strands and bands. The bands were wider and the whorls larger in the basal turn and decreased gradually in size toward the apex. The number of melanocytes was 2-4 times higher in both the upper half of the basal turn and the lower half of the middle turn than in the rest of the turns. In specimens from patients with SNHL, whorls and clusters were both more numerous and larger, and the number of melanocytes was higher in the upper half of the middle turn and in the apical turn than that in the ARNH group. Ultrastructural examination of epithelial and mesothelial cells as well as of melanocytes showed more pronounced cellular degeneration in patients with SNHL than in those with ARNH. A possible correlation between structural alterations of Reissner's membrane and sensorineural degeneration is discussed.

[The psychotropic properties of bonnecor and ethacizine]

The comparative study of the psychotropic activity of new acyl derivatives of dibenzazepine and phenothiazine--bonnecor (chlorhydrate 3-carbethoxyamino-5(dimethylaminoacetyl) dibenzazepine and ethacizine (chlorhydrate 2-carbethoxyamino-10-(beta-diethyl-aminopropionyl)phenothiazine)--in the experiments on small laboratory animals showed the presence of the antidepressive, anxiolytic, antiamnesic and antihypoxic effects. The drugs exerted the psychotropic effects at administration in the doses exceeding those which influence the cardiovascular system. By the degree of the anxiolytic action bonnecor and ethacizine are inferior to diazepam, are as potent as trioxasine and are superior to meprobamat. The noted psychotropic action by its character and degree can serve as a beneficial supplement to the spectrum of the pharmacological activity of the studied compounds.

[Detection of structural proteins in rubella virus using immunoblotting]

In partially purified virus preparations the structure proteins E1, E2 and C of rubella virus were demonstrated by immunoblotting using human sera. First tests analyse the IgG immune response by immunoblotting. Possibilities are discussed for the application of this method in diagnosis.

The effect of dydrogesterone on premenstrual symptoms. A double-blind, randomized, placebo-controlled study in general practice

The effect of dydrogesterone on premenstrual symptoms was investigated in a double-blind, randomized, placebo-controlled study comprising 161 patients from unselected practice material. Dydrogesterone 10 mg twice daily from the 12th day until onset of the following menstrual period was compared with placebo throughout 3 cycles. No clinically relevant effect of dydrogesterone was found. There was an overall therapeutic effect in 52% of the patients on dydrogesterone, and in 44% of the placebo-treated patients. Therapeutic gain ranged between -7 and +23% (95% confidence limits). Type II error risk of failure to detect a therapeutic gain of 20% was 6%. A significant effect of dydrogesterone was found on decreased libido, and statistical significance was nearly achieved for the symptoms irritability and headache. The significant effect on libido can be attributed to mass significance.

Ultrastructural findings on human Scarpa's ganglion

The morphology of human Scarpa's ganglion from two surgically removed specimens as well as from four autopsy preparations from patients without clinical evidence of vestibular dysfunction was investigated. Ganglion cell circumference varied between 45 and 160 microns. More than half of the nerve cells ranged between 90 and 110 microns. The arrangement of ganglion cells, nerve fibres and endoneural connective tissue appeared better preserved in autopsy preparation than in biopsy specimens. Electron microscopy revealed that in half of the investigated specimens, neuroglial tissue was present as far distal as the vestibular ganglion. Almost all ganglion cells were surrounded by one or several layers of satellite cells, and did not reveal myelination. From the present study we cannot predict if neuronal function in human beings differs from that in other animals, although morphological differences do exist.

[Infectious endocarditis in hypertrophic obstructive cardiomyopathy]

Clinical and pathological findings in a 37-year-old female patient with HOCM and infective endocarditis of the aortal and mitral valves were reported. The patient died of septic shock. Infective endocarditis with acute insufficiency of the aortal and/or mitral valves is a severe complication in patients with HOCM, because the left ventricle with a disturbed compliance is unable to compensate the acute volume overload. The standard use of nitrates for congestive lung failure and catecholamines for septic shock is problematic. As with other valvular heart diseases, preventive treatment for infective endocarditis is also recommended for patients with HOCM. In the case of acute endocarditis combined with HOCM early surgical intervention must be discussed.