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Gundersen IM, Bruun T, Almeland SK, Skutlaberg DH, Nedrebø T, Rath E, Oppegaard O, Guttormsen AB, Norrby-Teglund A, Mosevoll KA, Skrede S. Necrotising soft tissue infections. Tidsskr Nor Laegeforen 2024; 144:23-0720. [PMID: 38415568 DOI: 10.4045/tidsskr.23.0720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024] Open
Abstract
Necrotising soft tissue infections can affect the skin, subcutaneous tissue, superficial fascia, deep fascia and musculature. The infections are severe, they spread quickly and can result in extensive tissue loss. Although rare, morbidity and mortality rates are high. Early clinical identification is crucial for the outcome, and rapid infection control through surgery and targeted antibiotic treatment is needed to save lives. Few prospective clinical trials have been conducted for the treatment of this type of infection. Specific challenges include rapid identification of the condition and the uncertain efficacy of the various treatment options. In this clinical review article, we describe clinical characteristics, diagnostics and treatment.
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Affiliation(s)
- Ingunn Margareetta Gundersen
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Det medisinske fakultet, Universitetet i Bergen
| | - Trond Bruun
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Det medisinske fakultet, Universitetet i Bergen
| | - Stian Kreken Almeland
- Avdeling for plastikk-, hand- og rekonstruktiv kirurgi, og, Brannskadeavdelinga, Haukeland universitetssjukehus, og, Klinisk institutt 1, Det medisinske fakultet, Universitetet i Bergen
| | | | - Torbjørn Nedrebø
- Seksjon for hyperbarmedisin, Yrkesmedisinsk avdeling, og, Kirurgisk serviceklinikk, Haukeland universitetssjukehus
| | - Eivind Rath
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, og, Mottaksklinikken, Haukeland universitetssjukehus
| | - Oddvar Oppegaard
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Det medisinske fakultet, Universitetet i Bergen
| | - Anne Berit Guttormsen
- Klinisk institutt 1, Det medisinske fakultet, Universitetet i Bergen, og, Kirurgisk serviceklinikk, Haukeland universitetssjukehus
| | - Anna Norrby-Teglund
- Center for infektionsmedicin, Karolinska Institutet, Karolinska Universitetssjukhuset
| | - Knut Anders Mosevoll
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Det medisinske fakultet, Universitetet i Bergen
| | - Steinar Skrede
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Det medisinske fakultet, Universitetet i Bergen
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2
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Rath E, Palma Medina LM, Jahagirdar S, Mosevoll KA, Damås JK, Madsen MB, Svensson M, Hyldegaard O, Martins Dos Santos VAP, Saccenti E, Norrby-Teglund A, Skrede S, Bruun T. Systemic immune activation profiles in streptococcal necrotizing soft tissue infections: A prospective multicenter study. Clin Immunol 2023; 249:109276. [PMID: 36871764 DOI: 10.1016/j.clim.2023.109276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/05/2023] [Accepted: 02/28/2023] [Indexed: 03/07/2023]
Abstract
OBJECTIVE Early stages with streptococcal necrotizing soft tissue infections (NSTIs) are often difficult to discern from cellulitis. Increased insight into inflammatory responses in streptococcal disease may guide correct interventions and discovery of novel diagnostic targets. METHODS Plasma levels of 37 mediators, leucocytes and CRP from 102 patients with β-hemolytic streptococcal NSTI derived from a prospective Scandinavian multicentre study were compared to those of 23 cases of streptococcal cellulitis. Hierarchical cluster analyses were also performed. RESULTS Differences in mediator levels between NSTI and cellulitis cases were revealed, in particular for IL-1β, TNFα and CXCL8 (AUC >0.90). Across streptococcal NSTI etiologies, eight biomarkers separated cases with septic shock from those without, and four mediators predicted a severe outcome. CONCLUSION Several inflammatory mediators and wider profiles were identified as potential biomarkers of NSTI. Associations of biomarker levels to type of infection and outcomes may be utilized to improve patient care and outcomes.
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Affiliation(s)
- Eivind Rath
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.
| | - Laura M Palma Medina
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Huddinge, Sweden
| | - Sanjeevan Jahagirdar
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Wageningen, the Netherlands
| | - Knut A Mosevoll
- Department of Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Norway
| | - Jan K Damås
- Department of Infectious Diseases, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway; Centre of Molecular Inflammation Research, Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Martin B Madsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Mattias Svensson
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Huddinge, Sweden
| | - Ole Hyldegaard
- Department of Anaesthesia- and Surgery, Head and Orthopaedic centre, Hyperbaric Unit, Copenhagen University Hospital, Rigshospitalet, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Vitor A P Martins Dos Santos
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Wageningen, the Netherlands; LifeGlimmer GmbH, Berlin, Germany
| | - Edoardo Saccenti
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Wageningen, the Netherlands
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Huddinge, Sweden
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Norway
| | - Trond Bruun
- Department of Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Norway
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Gundersen IM, Berget E, Haugland HK, Bruun T, Almeland SK, Assmus J, Rath E, Norrby-Teglund A, Skrede S, Mosevoll KA. Clinical characteristics and histopathology in suspected necrotizing soft tissue infections. Open Forum Infect Dis 2022; 9:ofac571. [DOI: 10.1093/ofid/ofac571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Indexed: 11/06/2022] Open
Abstract
Abstract
Background
Necrotizing soft tissue infections (NSTIs) are severe diseases with high morbidity and mortality. The diagnosis is challenging. Several guidelines recommend tissue biopsies as an adjunct diagnostic in routine management, but neither biopsy sampling nor classification are standardized or validated. We studied the quality of tissue biopsy examination as part of routine diagnostics in NSTIs.
Method
A retrospective cohort study of adult patients undergoing surgery due to suspected NSTIs in which tissue biopsy was taken as part of routine management. Clinical data were reviewed. The biopsies were evaluated according to a proposed histopathologic classification system and independently assessed by two pathologists. Interrater reliability and diagnostic accuracy were determined.
Results
Tissue biopsies from 75 patients were examined, 55 NSTIs and 20 non-NSTIs cases. The cohorts were similar in clinical characteristics. Interrater reliability for histopathologic staging was moderate (0.53) and fair (0.37) for diagnosis. The sensitivity of histologic diagnosis was 75% and the specificity 80%. The positive predictive value was 91% and the negative predictive value 53%. Necrotizing Infection Clinical Composite Endpoint (NICCE) success was associated with a more severe histological stage, achieved by 42% and 71% of the cases in stage 1 and 2, respectively (p = 0.046).
Conclusion
Our findings suggest that tissue biopsies have low clinical accuracy. The interrater reliability among experienced pathologists is only fair to moderate. A histopathological more severe stage was associated with favorable outcome. These findings discourage the use of histopathologic evaluation as part of contemporary management of patients with suspected NSTI.
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Affiliation(s)
- Ingunn M Gundersen
- Department of Medicine, Haukeland University Hospital , Bergen , Norway
- Department of Clinical Science, University of Bergen , Norway
| | - Ellen Berget
- Department of Pathology, Haukeland University Hospital , Bergen , Norway
| | | | - Trond Bruun
- Department of Medicine, Haukeland University Hospital , Bergen , Norway
- Department of Clinical Science, University of Bergen , Norway
| | - Stian Kreken Almeland
- Department of Plastic, Hand, and Reconstructive Surgery, Norwegian National Burn Center, Haukeland University Hospital , Bergen , Norway
- Department of Clinical Medicine, University of Bergen , Norway
| | - Jürg Assmus
- Centre of Competence on Clinical Research, Haukeland University Hospital , Bergen , Norway
| | - Eivind Rath
- Department of Medicine, Haukeland University Hospital , Bergen , Norway
- Department of Clinical Science, University of Bergen , Norway
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital , Huddinge , Sweden
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital , Bergen , Norway
- Department of Clinical Science, University of Bergen , Norway
| | - Knut Anders Mosevoll
- Department of Medicine, Haukeland University Hospital , Bergen , Norway
- Department of Clinical Science, University of Bergen , Norway
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Palma Medina LM, Rath E, Jahagirdar S, Bruun T, Madsen MB, Strålin K, Unge C, Hansen MB, Arnell P, Nekludov M, Hyldegaard O, Lourda M, dos Santos VAM, Saccenti E, Skrede S, Svensson M, Norrby-Teglund A. Discriminatory plasma biomarkers predict specific clinical phenotypes of necrotizing soft-tissue infections. J Clin Invest 2021; 131:149523. [PMID: 34263738 PMCID: PMC8279592 DOI: 10.1172/jci149523] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/25/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUNDNecrotizing soft-tissue infections (NSTIs) are rapidly progressing infections frequently complicated by septic shock and associated with high mortality. Early diagnosis is critical for patient outcome, but challenging due to vague initial symptoms. Here, we identified predictive biomarkers for NSTI clinical phenotypes and outcomes using a prospective multicenter NSTI patient cohort.METHODSLuminex multiplex assays were used to assess 36 soluble factors in plasma from NSTI patients with positive microbiological cultures (n = 251 and n = 60 in the discovery and validation cohorts, respectively). Control groups for comparative analyses included surgical controls (n = 20), non-NSTI controls (i.e., suspected NSTI with no necrosis detected upon exploratory surgery, n = 20), and sepsis patients (n = 24).RESULTSThrombomodulin was identified as a unique biomarker for detection of NSTI (AUC, 0.95). A distinct profile discriminating mono- (type II) versus polymicrobial (type I) NSTI types was identified based on differential expression of IL-2, IL-10, IL-22, CXCL10, Fas-ligand, and MMP9 (AUC >0.7). While each NSTI type displayed a distinct array of biomarkers predicting septic shock, granulocyte CSF (G-CSF), S100A8, and IL-6 were shared by both types (AUC >0.78). Finally, differential connectivity analysis revealed distinctive networks associated with specific clinical phenotypes.CONCLUSIONSThis study identifies predictive biomarkers for NSTI clinical phenotypes of potential value for diagnostic, prognostic, and therapeutic approaches in NSTIs.TRIAL REGISTRATIONClinicalTrials.gov NCT01790698.FUNDINGCenter for Innovative Medicine (CIMED); Region Stockholm; Swedish Research Council; European Union; Vinnova; Innovation Fund Denmark; Research Council of Norway; Netherlands Organisation for Health Research and Development; DLR Federal Ministry of Education and Research; and Swedish Children's Cancer Foundation.
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Affiliation(s)
- Laura M. Palma Medina
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Eivind Rath
- Department of Medicine, Division for Infectious Diseases, Haukeland University Hospital, Bergen, Norway
| | - Sanjeevan Jahagirdar
- Laboratory of Systems and Synthetic Biology, Wageningen University and Research, Wageningen, Netherlands
| | - Trond Bruun
- Department of Medicine, Division for Infectious Diseases, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Martin B. Madsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Kristoffer Strålin
- Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
- Department of Infectious Diseases and
| | - Christian Unge
- Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
- Functional Area of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Bo Hansen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Per Arnell
- Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Michael Nekludov
- Department of Anaesthesia, Surgical Services and Intensive Care, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Ole Hyldegaard
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Magda Lourda
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
- Childhood Cancer Research Unit, Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Vitor A.P. Martins dos Santos
- Laboratory of Systems and Synthetic Biology, Wageningen University and Research, Wageningen, Netherlands
- LifeGlimmer GmbH, Berlin, Germany
| | - Edoardo Saccenti
- Laboratory of Systems and Synthetic Biology, Wageningen University and Research, Wageningen, Netherlands
| | - Steinar Skrede
- Department of Medicine, Division for Infectious Diseases, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Mattias Svensson
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
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Bruun T, Rath E, Madsen MB, Oppegaard O, Nekludov M, Arnell P, Karlsson Y, Babbar A, Bergey F, Itzek A, Hyldegaard O, Norrby-Teglund A, Skrede S. Risk Factors and Predictors of Mortality in Streptococcal Necrotizing Soft-tissue Infections: A Multicenter Prospective Study. Clin Infect Dis 2021; 72:293-300. [PMID: 31923305 PMCID: PMC7840107 DOI: 10.1093/cid/ciaa027] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 01/09/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Necrotizing soft-tissue infections (NSTI) are life-threatening conditions often caused by β-hemolytic streptococci, group A Streptococcus (GAS) in particular. Optimal treatment is contentious. The INFECT cohort includes the largest set of prospectively enrolled streptococcal NSTI cases to date. METHODS From the INFECT cohort of 409 adults admitted with NSTI to 5 clinical centers in Scandinavia, patients culture-positive for GAS or Streptococcus dysgalactiae (SD) were selected. Risk factors were identified by comparison with a cohort of nonnecrotizing streptococcal cellulitis. The impact of baseline factors and treatment on 90-day mortality was explored using Lasso regression. Whole-genome sequencing of bacterial isolates was used for emm typing and virulence gene profiling. RESULTS The 126 GAS NSTI cases and 27 cases caused by SD constituted 31% and 7% of the whole NSTI cohort, respectively. When comparing to nonnecrotizing streptococcal cellulitis, streptococcal NSTI was associated to blunt trauma, absence of preexisting skin lesions, and a lower body mass index. Septic shock was significantly more frequent in GAS (65%) compared to SD (41%) and polymicrobial, nonstreptococcal NSTI (46%). Age, male sex, septic shock, and no administration of intravenous immunoglobulin (IVIG) were among factors associated with 90-day mortality. Predominant emm types were emm1, emm3, and emm28 in GAS and stG62647 in SD. CONCLUSIONS Streptococcal NSTI was associated with several risk factors, including blunt trauma. Septic shock was more frequent in NSTI caused by GAS than in cases due to SD. Factors associated with mortality in GAS NSTI included age, septic shock, and no administration of IVIG.
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Affiliation(s)
- Trond Bruun
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Eivind Rath
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Martin Bruun Madsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Oddvar Oppegaard
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Michael Nekludov
- Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden
| | - Per Arnell
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ylva Karlsson
- Department of Anesthesiology and Intensive Care, Blekinge County Council Hospital, Karlskrona, Sweden
| | - Anshu Babbar
- Helmholtz-Zentrum für Infektionsforschung GmbH, Braunschweig, Germany
| | | | - Andreas Itzek
- Helmholtz-Zentrum für Infektionsforschung GmbH, Braunschweig, Germany
| | - Ole Hyldegaard
- Hyperbaric Medicine Center, Department of Anesthesiology and Surgery, Head and Orthopedic Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Norway
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Rath E, Skrede S, Oppegaard O, Bruun T. Non-purulent skin and soft tissue infections: predictive power of a severity score and the appropriateness of treatment in a prospective cohort. Infect Dis (Lond) 2020; 52:361-371. [DOI: 10.1080/23744235.2020.1726447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Eivind Rath
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Oddvar Oppegaard
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Trond Bruun
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Abstract
Necrotizing soft tissue infections (NSTIs) are severe, life-threatening infections, and early therapeutic intervention is essential. Prompt administration of potent antimicrobial agents is pivotal, but inadequate empirical therapy is unfortunately common. Optimization of the antibiotic treatment strategy in NSTIs requires consideration of local epidemiology of causative pathogens and antimicrobial resistance patterns, knowledge on common pathogenetic mechanisms in NSTIs, and adaptations to pharmacokinetic and pharmacodynamic physiological changes in critically ill patients. In the present article we address all these issues, as well as review and compare contemporary guidelines for antimicrobial treatment of NSTIs from around the world.
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Affiliation(s)
- Oddvar Oppegaard
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.
| | - Eivind Rath
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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8
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Abstract
β-hemolytic streptococci are major causes of necrotizing soft tissue infections (NSTIs), Streptococcus pyogenes (group A streptococcus; GAS) in particular. NSTIs caused by Streptococcus dysgalactiae (SD) have also been reported. In the INFECT cohort of 409 NSTIs patients, more than a third of the cases were caused by GAS (31%) or SD (7%). Risk factors of streptococcal NSTIs compared to streptococcal cellulitis have previously been largely unknown. The INFECT study confirmed blunt trauma as an important risk factor. In addition, absence of pre-existing skin lesions and a lower BMI were associated with NSTIs. The study also confirmed that septic shock is more frequent in GAS cases than in other types of NSTIs. Septic shock was also among several predictors of mortality. The role of intravenous immunoglobulin (IVIG) in streptococcal NSTIs has been unclear. In the INFECT cohort, IVIG treatment was associated with increased survival. As in other studies, a significant microbial diversity was observed, but with predominance of a few emm types. Overall, the INFECT study gives a comprehensive and contemporary picture of the clinical characteristics and the microbes involved in streptococcal NSTIs. The reported severity of disease underscores the need for new efforts aimed at identifying novel diagnostic measures and improved treatment.
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Affiliation(s)
- Trond Bruun
- Department of Clinical Science, University of Bergen, Bergen, Norway.
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.
| | - Eivind Rath
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Oddvar Oppegaard
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Steinar Skrede
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Gortzak Y, Vitenberg M, Frenkel Rutenberg T, Kollender Y, Dadia S, Sternheim A, Morag G, Farkash U, Rath E, Kramer M, Drexler M. Inconclusive benefit of adjuvant 90Yttrium hydroxyapatite to radiosynovectomy for diffuse-type tenosynovial giant-cell tumour of the knee. Bone Joint J 2018; 100-B:984-988. [DOI: 10.1302/0301-620x.100b7.bjj-2017-0867.r3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Aims Intra-articular 90Yttrium (90Y) is an adjunct to surgical treatment by synovectomy for patients with diffuse-type tenosynovial giant-cell tumour (dtTGCT) of the knee, with variable success rates. Clinical information is, however, sparse and its value remains unclear. We investigated the long-term outcome of patients who underwent synovectomy with and without adjuvant treatment with 90Yttrium. Patients and Methods All patients with dtTGCT of the knee who underwent synovectomy between 1991 and 2014 were included in the study. Group A patients underwent synovectomy and an intra-articular injection of 90Yttrium between six and eight weeks after surgery. Group B patients underwent surgery alone. Results There were 34 patients in group A and 22 in group B. Recurrence of dtTGCT was identified by MRI, which was undertaken in patients with further symptoms. At a mean follow-up of 7.3 years (2.5 to 25.4), there was residual disease in 15 patients in group A and 11 in group B (p < 0.363). The mean Musculoskeletal Tumor Society (MSTS) score at final follow-up was 85% and 83%, respectively (p < 0.91). Conclusion There were no significant differences in outcome between patients treated surgically for dtTGCT of the knee with or without an adjuvant intra-articular injection of 90Yttrium. We were unable to provide conclusive evidence of any benefits derived from the adjuvant treatment. Cite this article: Bone Joint J 2018;100-B:984–8.
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Affiliation(s)
- Y. Gortzak
- National Unit of Orthopedic Oncology,
Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel, affiliated to
the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - M. Vitenberg
- Sackler Faculty of Medicine,
Tel-Aviv University, Tel-Aviv, Israel
| | | | - Y. Kollender
- National Unit of Orthopedic Oncology,
Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel, affiliated to
the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - S. Dadia
- National Unit of Orthopedic Oncology,
Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel, affiliated to
the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - A. Sternheim
- National Unit of Orthopedic Oncology,
Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel, affiliated to
the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - G. Morag
- Orthopedic Surgery Division and Tel-Aviv
Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine,
Tel-Aviv University, Tel-Aviv, Israel
| | - U. Farkash
- Orthopedic Surgery Department, Assuta
Ashdod University Hospital, Ashdod, Israel, affiliated to the Beer Sheva
Faculty of Medicine, Beer Sheva University, Beer
Sheva, Israel
| | - E. Rath
- Orthopedic Surgery Division and Tel-Aviv
Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine,
Tel-Aviv University, Tel-Aviv, Israel
| | - M. Kramer
- Orthopedic Surgery Department, Assuta
Ashdod University Hospital, Ashdod, Israel, affiliated to the Beer Sheva
Faculty of Medicine, Beer Sheva University, Beer
Sheva, Israel
| | - M. Drexler
- Assuta
Ashdod University Hospital, Ashdod, Israel, affiliated to the Beer
Sheva Faculty of Medicine, Beer Sheva University, Beer
Sheva, Israel
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10
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Abstract
BACKGROUND In the early 20th century, the face was the predominant site of cellulitis. Despite a relative decrease in the incidence of facial cellulitis, it is still common. There are few studies on this condition during the last decades. The aim of this study was to describe contemporary aetiological and clinical characteristics of patients admitted to hospital with non-suppurative facial cellulitis. METHODS Patients were included prospectively. Clinical details, comorbidities and biochemistry results were recorded. Investigations included cultures of skin swab and blood and tests for streptococcal antibodies during the acute and convalescent stages. RESULTS Sixty-five patients were included. Serology, cultures and response to penicillin monotherapy identified probable or confirmed β-haemolytic streptococci (BHS) aetiology in 75% (49/65) of cases. Significant comorbidities were present in 54% (35/65). Fever, chills or rigors before or at admission was noted in 91% (59/65). Patients presented most often with sharply demarcated erythema and raised borders (54/64). Penicillin or penicillinase-resistant penicillin alone or in combination cured 68% (44/65) of the patients. Supplementary clindamycin was used in 28% (18/65), most often only for 1-3 days. Only four patients needed a second course of antibiotics. Clinical failure was more often seen in patients with non-BHS aetiology (p = .037). Few complications were noted; 14.5% (9/62) experienced transient diarrhoea, and only one had confirmed Clostridium difficile infection. No patients developed cerebral venous sinus thrombosis, and there were no fatalities. CONCLUSIONS Our findings indicate that BHS are the leading cause of facial cellulitis. Most patients exhibit sharply demarcated lesions and systemic symptoms. Narrow-spectrum β-lactam antibiotics and short hospital stay appear sufficient. Few complications and low recurrence rates were seen.
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Affiliation(s)
- Eivind Rath
- a Department of Clinical Science , University of Bergen , Bergen , Norway.,b Department of Medicine , Haukeland University Hospital , Bergen , Norway
| | - Steinar Skrede
- a Department of Clinical Science , University of Bergen , Bergen , Norway.,b Department of Medicine , Haukeland University Hospital , Bergen , Norway
| | - Haima Mylvaganam
- c Department of Microbiology and Immunology , Haukeland University Hospital , Bergen , Norway
| | - Trond Bruun
- a Department of Clinical Science , University of Bergen , Bergen , Norway.,b Department of Medicine , Haukeland University Hospital , Bergen , Norway
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Drexler M, Rutenberg TF, Rozen N, Warschawski Y, Rath E, Chechik O, Rachevsky G, Morag G. Single minimal incision fasciotomy for the treatment of chronic exertional compartment syndrome: outcomes and complications. Arch Orthop Trauma Surg 2017; 137:73-79. [PMID: 27670876 DOI: 10.1007/s00402-016-2569-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Chronic exertional compartment syndrome (CECS) is a common injury in young athletes, causing pain in the involved leg compartment during strenuous exercise. The gold standard treatment is fasciotomy, but most of the reports on its effectiveness include relatively small cohorts and relatively short follow-up periods. This study reports the long-term results of a large cohort of young athletes who underwent single-incision fasciotomy for CECS. MATERIALS AND METHODS This a retrospective case-series study. All patients treated by fasciotomies performed for CECS between 2007 and 2011, in a tertiary medical institution. CECS was diagnosed following history taking and clinical evaluation, and confirmed by compartment pressure measurements. Ninety-five legs that underwent single-incision subcutaneous fasciotomy were included. Data on the numerical analog scale (NAS), Tegner activity score, and quality-of-life (QOL) as measured via the short form-12 (SF-12) were retrieved from all patients preoperatively and at the end of follow-up. RESULTS The average time to diagnosis was 22 months and the mean follow-up was 50.1 months. Sixty-three legs underwent anterior compartment fasciotomy (an additional 30 legs also underwent lateral compartment release), and two legs underwent lateral and peroneal compartment releases. The average change in Tegner score was an improvement of 14.6 points. Similarly, the patients reported a significant improvement in the SF-12 and NAS scores. Satisfaction rates were high (average 75.5 %). The main complications were wound infection (2 patients) and nerve injuries (4 patients). Eight patients had recurrence. CONCLUSION Single-incision fasciotomy leads to long-term improvement in the activity level and QOL of patients with CECS.
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Affiliation(s)
- Michael Drexler
- Department of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - T Frenkel Rutenberg
- Department of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - N Rozen
- Department of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Y Warschawski
- Department of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - E Rath
- Department of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - O Chechik
- Department of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - G Rachevsky
- Department of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - G Morag
- Department of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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12
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Elbaz A, Beer Y, Rath E, Morag G, Segal G, Debbi E, Wasser D, Mor A, Debi R. A unique foot-worn device for patients with degenerative meniscal tear. Physiotherapy 2016. [DOI: 10.1016/j.physio.2016.10.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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13
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Amar E, Chechik O, Khashan M, Lador R, Rath E. Lateral epicondylitis treatment: international survey of surgeons' preferences and literature review. Int J Clin Pract 2014; 68:1383-7. [PMID: 25040243 DOI: 10.1111/ijcp.12478] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Lateral epicondylitis (LE) is a common cause of elbow pain. Despite a relatively high prevalence and morbidity, there is still no single effective ('gold standard') treatment for LE. We hypothesised that a surgeon's experience, country of origin and area of expertise would influence choices concerning patient management. The purpose of this survey was to describe the current trends and common practices in treating LE worldwide. MATERIAL AND METHODS A total of 291 orthopaedic surgeons of 12 subspecialties from 57 countries were surveyed on their choice of LE treatment modalities. Their preferences were analysed according to country of origin, field of expertise and seniority. The results were compared with current published level-1 evidence. RESULTS The most popular modalities of treatment among all of the surveyed orthopaedic surgeons were non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroid (CS) injection (38% of recommendations each). The most popular Modalities of treatment among the hand surgeons was NSAIDs (48%) and CS injection (30%). There was no significant difference in recommendations based on geography, seniority or specialisation (i.e., hand surgeons among others). CONCLUSIONS Neither geography, seniority nor medical specialty affects surgeons' preferences in the treatment of LE. There appears to be little correlation between scientific evidence and therapeutic choices for managing LE. LEVEL OF EVIDENCE Level V, Study.
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Affiliation(s)
- E Amar
- Department of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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14
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Waldschmitt N, Berger E, Rath E, Sartor RB, Weigmann B, Heikenwalder M, Gerhard M, Janssen KP, Haller D. C/EBP homologous protein inhibits tissue repair in response to gut injury and is inversely regulated with chronic inflammation. Mucosal Immunol 2014; 7:1452-66. [PMID: 24850428 DOI: 10.1038/mi.2014.34] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 04/06/2014] [Indexed: 02/04/2023]
Abstract
Loss of intestinal epithelial cell (IEC) homeostasis and apoptosis negatively affect intestinal barrier function. Uncontrolled activation of the unfolded protein response (UPR) in IEC contributes to an impaired barrier and is implicated in the pathogenesis of inflammatory bowel diseases. However, the contribution of the UPR target gene C/EBP homologous protein (CHOP), an apoptosis-associated transcription factor, to inflammation-related disease susceptibility remains unclear. Consistent with observations in patients with ulcerative colitis, we show that despite UPR activation in the epithelium, CHOP expression was reduced in mouse models of T-cell-mediated and bacteria-driven colitis. To elucidate the molecular mechanisms of IEC-specific CHOP expression, we generated a conditional transgenic mouse model (Chop(IEC Tg/Tg)). Chop overexpression increased the susceptibility toward dextran sodium sulfate (DSS)-induced intestinal inflammation and mucosal tissue injury. Furthermore, a delayed recovery from DSS-induced colitis and impaired closure of mechanically induced mucosal wounds was observed. Interestingly, these findings seemed to be independent of CHOP-mediated apoptosis. In vitro and in vivo cell cycle analyses rather indicated a role for CHOP in epithelial cell proliferation. In conclusion, these data show that IEC-specific overexpression impairs epithelial cell proliferation and mucosal tissue regeneration, suggesting an important role for CHOP beyond mediating apoptosis.
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Affiliation(s)
- N Waldschmitt
- 1] Chair of Nutrition and Immunology, Technische Universität München, Freising, Germany [2] ZIEL-Research Center for Nutrition and Food Sciences, Biofunctionality Unit, Technische Universität München, Freising, Germany
| | - E Berger
- Chair of Nutrition and Immunology, Technische Universität München, Freising, Germany
| | - E Rath
- Chair of Nutrition and Immunology, Technische Universität München, Freising, Germany
| | - R B Sartor
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina, USA
| | - B Weigmann
- First Medical Clinic, University of Erlangen, Erlangen, Germany
| | - M Heikenwalder
- Institute of Virology, Technische Universität München/Helmholtz Zentrum Munich, Munich, Germany
| | - M Gerhard
- Institute of Medical Microbiology, Immunology and Hygiene, Technische Universität München, Munich, Germany
| | - K-P Janssen
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - D Haller
- 1] Chair of Nutrition and Immunology, Technische Universität München, Freising, Germany [2] ZIEL-Research Center for Nutrition and Food Sciences, Biofunctionality Unit, Technische Universität München, Freising, Germany
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15
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Bonelli M, Ferner E, Göschl L, Blüml S, Hladik A, Karonitsch T, Kiener HP, Byrne R, Niederreiter B, Steiner CW, Rath E, Bergmann M, Smolen JS, Scheinecker C. Abatacept (CTLA-4IG) treatment reduces the migratory capacity of monocytes in patients with rheumatoid arthritis. ACTA ACUST UNITED AC 2013. [PMID: 23203906 DOI: 10.1002/art.37787] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The binding of abatacept (CTLA-4Ig) to the B7 ligands CD80 and CD86 prevents the engagement of CD28 on T cells and thereby prevents effector T cell activation. In addition, a direct effect of CTLA-4Ig on antigen-presenting cells (APCs) could contribute to the therapeutic effect. To further elucidate the mechanism of CTLA-4Ig, we performed phenotype and functional analyses of APCs in patients with rheumatoid arthritis (RA) before and after the initiation of CTLA-4Ig therapy. METHODS Peripheral blood mononuclear cells were analyzed before and at 2 and 4 weeks after the initiation of CTLA-4Ig therapy. Proportions of APCs were determined by flow cytometry. CD14+ monocytes were further analyzed for the expression of costimulatory and adhesion molecules and for their transendothelial migratory capacity in vitro. In addition, CD14+ monocytes from healthy controls were analyzed for their migratory and spreading capacity. RESULTS Proportions and absolute numbers of monocytes were significantly increased in RA patients treated with CTLA-4Ig. The expression of several adhesion molecules was significantly diminished. In addition, monocytes displayed a significant reduction in their endothelial adhesion and transendothelial migratory capacity upon treatment with CTLA-4Ig. Likewise, isolated monocytes from healthy controls revealed a significant reduction in their migratory and spreading activity after preincubation with CTLA-4Ig or anti-CD80 and anti-CD86 antibodies. CONCLUSION We describe direct effects of CTLA-4Ig therapy on phenotype and functional characteristics of monocytes in RA patients that might interfere with the migration of monocytes to the synovial tissue. This additional mechanism of CTLA-4Ig might contribute to the beneficial effects of CTLA-4Ig treatment in RA patients.
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Affiliation(s)
- M Bonelli
- Medical University of Vienna, Vienna, Austria
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16
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Bonelli M, Savitskaya A, Steiner CW, Rath E, Bilban M, Wagner O, Bach FH, Smolen JS, Scheinecker C. Heme oxygenase-1 end-products carbon monoxide and biliverdin ameliorate murine collagen induced arthritis. Clin Exp Rheumatol 2012; 30:73-78. [PMID: 22325451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 09/20/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVES Heme oxygenase-1 (HO-1) which degrades Heme to free iron, biliverdin and carbon monoxide (CO) plays an important role in inflammation. There are, however, conflicting data concerning the role of HO-1 in rheumatoid arthritis (RA) and the therapeutic potential of individual heme degradation products remains to be determined. We therefore investigated the effect of CO and biliverdin upon therapeutic administration in the murine collagen induced arthritis (CIA) model of RA. METHODS CIA was induced in DBA/1 mice. Anti-CII antibody levels were determined by ELISA. Mice were scored for paw swelling and grip strength. After the first clinical signs of arthritis one group of animals was treated with biliverdin, the second group was treated with CO. After 60 days all animals were sacrificed and analysed for histomorphological signs of arthritis. RESULTS All animals immunised with CII developed serum anti-CII antibodies. Antibody levels were decreased in the CO-treated group. Both, Biliverdin and the CO-treated animals, showed an improvement in clinical disease activity. Histological analysis revealed significantly less inflammation, erosion and reduced numbers of osteoclasts in CO-treated animals only, whereas cartilage degradation was prevented in both biliverdin and CO-treated animals. CONCLUSIONS Our data demonstrate a beneficial effect of CO, in particular, and biliverdin, on inflammation and bone destruction in the CIA mouse model.
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Affiliation(s)
- M Bonelli
- Division of Rheumatology, Internal Medicine III, Medical University of Vienna, Vienna, Austria
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17
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Bonelli M, Goschl L, Bluml S, Rath E, Smolen JS, Scheinecker C. CD4+CD25-Foxp3+ T cells are increased in systemic lupus erythematosus patients with active glomerulonephritis. Ann Rheum Dis 2011. [DOI: 10.1136/ard.2010.148981.14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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18
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Rath E, Alkrinawi N, Lebel D, Snopik P, Levy O. S-12 Post Traumatic Painful Shoulder: Ultrasound as a Primary Diagnostic Technique for Occult Fractures of the Proximal Humerus. J Biomech 2010. [DOI: 10.1016/s0021-9290(10)70065-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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19
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Rath E. P-18 Hip Arthroscopy – an Emerging Technique and Indications. J Biomech 2010. [DOI: 10.1016/s0021-9290(10)70024-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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20
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Whelan D, Milgrom C, Radeva-Petrova DR, Rath E, Barchilon V, Beyth S, Jaber S, Safran O, Whelan D. Immobilization in an external or internal rotation brace did not differ in preventing recurrent shoulder dislocation. J Bone Joint Surg Am 2010; 92:1262. [PMID: 20439676 DOI: 10.2106/jbjs.9205.ebo579] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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21
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Rath E, Byrne R, Savitskaya A, Niederreiter B, Bonelli M, Smolen JS, Scheinecker C. Analysis of polymorphonuclear neutrophil (PMN) phenotype and function at the onset of collagen-induced arthritis. Ann Rheum Dis 2010. [DOI: 10.1136/ard.2010.129643h] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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22
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Bonelli M, Ferner E, Savitskaya A, Bluml S, Steiner CW, Rath E, Smolen JS, Scheinecker C. Effects of abatacept on monocytes in patients with rheumatoid arthritis. Ann Rheum Dis 2010. [DOI: 10.1136/ard.2010.129668f] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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23
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Finestone A, Milgrom C, Radeva-Petrova DR, Rath E, Barchilon V, Beyth S, Jaber S, Safran O. Bracing in external rotation for traumatic anterior dislocation of the shoulder. ACTA ACUST UNITED AC 2009; 91:918-21. [PMID: 19567857 DOI: 10.1302/0301-620x.91b7.22263] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We undertook a prospective study in 51 male patients aged between 17 and 27 years to ascertain whether immobilisation after primary traumatic anterior dislocation of the shoulder in external rotation was more effective than immobilisation in internal rotation in preventing recurrent dislocation in a physically active population. Of the 51 patients, 24 were randomised to be treated by a traditional brace in internal rotation and 27 were immobilised in external rotation of 15 degrees to 20 degrees. After immobilisation, the patients undertook a standard regime of physiotherapy and were then assessed clinically for evidence of instability. When reviewed at a mean of 33.4 months (24 to 48) ten from the external rotation group (37%) and ten from the internal rotation group (41.7%) had sustained a further dislocation. There was no statistically significant difference (p = 0.74) between the groups. Our findings show that external rotation bracing may not be as effective as previously reported in preventing recurrent anterior dislocation of the shoulder.
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Affiliation(s)
- A Finestone
- Assaf HaRofeh Medical Centre, Zerrifin, Beer Yaakov 70300, Israel
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24
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Abstract
We evaluated 18 of 23 patients who had undergone cryopreserved meniscal allograft transplantation for compartmental pain after total meniscectomy 2 to 8 years (mean, 5.4) after the operation. The Short Form-36 scores revealed a decrease in pain with a significant improvement in function, although function remained limited. There was no significant decrease in joint space on 45 degrees posteroanterior weightbearing radiographs through the duration of the study. Eight of 22 allograft menisci (36%) tore during the study period, necessitating 6 partial and 2 total meniscectomies. Two patients subsequently underwent reimplantation. Histologic examination of the removed tissue revealed reduced cellularity as compared with normal or torn native menisci. Four specimens also underwent detailed cytokine evaluation and demonstrated reduced cytokine expression compared with controls. While successful in alleviating compartmental pain that may be a late consequence of major meniscectomy, allograft menisci are repopulated with fewer cells than are present in normal or torn native menisci. These cells also demonstrate potentially reduced function, as measured by decreased growth factor production. This decreased biologic activity may be a factor that contributes to the high frequency of retears noted in this and prior studies.
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Affiliation(s)
- E Rath
- Tufts University School of Medicine, New England Medical Center Hospital, Boston, Massachusetts 02111, USA
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25
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Abstract
Once described as a muscle remnant, and therefore treated with disrespect, the meniscus is now known to be a vital structure within the knee. Minimal partial meniscectomy performed arthroscopically, or meniscal repair when practical, have become the standard treatments. In spite of the advancements in understanding meniscal function and its preservation, much remains to be studied. In the future, availability of better repair techniques and the option of meniscal replacement with allograft or prosthetic menisci are expected to improve outcomes.
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Affiliation(s)
- E Rath
- Department of Orthopaedic Surgery, Tufts University, School of Medicine, New England Medical Center Hospital, Boston, MA, USA
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Ohana N, Sheinis D, Rath E, Sasson A, Atar D. Is there a need for lumbar orthosis in mild compression fractures of the thoracolumbar spine?: A retrospective study comparing the radiographic results between early ambulation with and without lumbar orthosis. J Spinal Disord 2000; 13:305-8. [PMID: 10941889 DOI: 10.1097/00002517-200008000-00006] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Compression fractures of the thoracolumbar spine are common in spinal trauma. Most patients are treated with early ambulation. Bracing is an option not always recommended by the treating team. There are no definite recommendations so far regarding the need for lumbar orthosis in this type of injury. The authors retrospectively compared two methods for treating patients with compression as great as 30%: early ambulation with and without lumbar orthosis. The results show that although demographic variables, type of injury, and cause of injury were similar between the groups, neither treatment emerged as superior. Thoracolumbar fractures with compression as much as 30% can be treated with early ambulation and no external support. Close clinical and radiographic follow-up is essential.
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Affiliation(s)
- N Ohana
- Orthopedic Department, Soroka Medical Center, Beer-Sheva, Israel
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Abstract
Recurrent anterior shoulder dislocation in the elderly is not as exceptional as it was once thought to be. That anterior shoulder dislocation in older patients is caused by a rotator cuff tear through the posterior mechanism is well accepted. However, in the subset of patients who have multiple recurrent or intractable dislocations develop, there may be combined pathologic conditions at work: large or massive rotator cuff tears together with anterior capsulolabral injuries such as a Bankart lesion or fracture of the glenoid rim. These patients have multiple recurrences because of disruption of both the anterior and the posterior stability mechanisms. We suggest a procedure that provides anterior stabilization with the capsular shift technique and that is supplemented by Bankart repair as necessary. The capsule transfer is performed superiorly and posteriorly to close the defect in the cuff. In this way a capsulodesis effect can be achieved that displaces the humeral head downward and produces active centering of the head in the course of abduction. Use of only the anterior capsule for the shift, and not the subscapularis tendon, does not compromise subscapularis function. Between 1990 and 1996, we used this technique to treat 16 patients older than 55 years of age with multiple recurrent anterior shoulder dislocation and massive rotator cuff tear. We report the results for the first 10 patients with a minimum follow-up of 2 years (range 2 to 7 years) and an average follow-up of 52 months. There were 7 excellent results, 2 good results, and 1 fair result according to the Rowe criteria. None of the patients had a recurrence of the dislocation. All the patients regained full or functional range of motion with stable shoulders, and most of them could perform activities of daily living without limitation. The average Constant score was 83%. This procedure appears to be successful in treating older patients with recurrent shoulder dislocation.
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Affiliation(s)
- O Levy
- Orthopaedic Department, Soroka Medical Center, Ben Gurion University of the Negev, Beer-Sheva, Israel
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28
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Iordache S, Rath E, Atar D, Vindzberg A. [Vacuum phenomenon in the hip joint: diagnostic value]. Harefuah 1998; 135:108-9, 167. [PMID: 9885654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Vacuum phenomenon is well known in degenerative spinal disease in the elderly, but is seldom seen in other joints, especially in children. The phenomenon does not represent a pathological finding, and can be used for imaging of the articular facets, mainly in the hip and knee joints. We report a patient with this phenomenon in the hip joint.
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Affiliation(s)
- S Iordache
- Orthopedics Dept., Soroka Medical Center, Beer Sheba
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29
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Rath E. [Treatment of decubitus ulcers/wound management: a dry wound is a dead wound]. Pflege Z 1998; 51:510-2. [PMID: 9752230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
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30
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Rath E, Shelef I, Avinoah E, Lichtman Y, Levy O, Atar D. [Necrotizing soft tissue infection]. Harefuah 1998; 134:695-7, 750. [PMID: 10909616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
The dramatic course of necrotizing soft tissue infection represents a medical emergency, since it is limb- and life-threatening. Most necrotizing soft tissue infections are caused by mixed aerobic and anaerobic Gram-negative and Gram-positive organisms. Most case have been reported in immuno-compromised hosts after penetrating trauma or surgery. We describe a unique series of cases of necrotizing soft tissue infection. The mainstay of treatment is early and daily debridement of devitalized tissue and broad-spectrum antibiotics. Hyperbaric oxygen therapy should be considered.
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31
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Rath E, Levy O, Ohana N, Atar D. [The painful shoulder--differential diagnosis, assessment and treatment]. Harefuah 1998; 134:563-9. [PMID: 10909605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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32
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Pawlow I, Richter E, Matthes G, Rath E, Tofoté U. [Haemonetics MCS-3 pump system: improved production quality in thrombocytapheresis with a discontinuous cell separator]. Beitr Infusionsther Transfusionsmed 1998; 32:325-7. [PMID: 9480119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
With the new cell separator MCS-3P (Haemonetics) platelet concentrates were collected in 90 min with an average yield of 3 x 10(11) platelets in 280 ml (53 donations). The most important advantage is the reduced residual leukocyte contamination of approximately 2.4 x 10(6).
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Affiliation(s)
- I Pawlow
- Institut für Transfusionsmedizin, Universitätsklinikum Charité, Humboldt-Universität zu Berlin, Deutschland
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33
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Richter E, Matthes G, Tofoté U, Rath E, Takahashi TA, Hosoda M, Sekiguchi S. [4-Log leukocyte depletion of erythrocyte concentrates--a comparison with 3 other filters]. Beitr Infusionsther Transfusionsmed 1998; 32:26-8. [PMID: 9480103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Whole blood (WB) and SAGM-resuspended red cell concentrates (RCC) were leucocyte-depleted 1 h after donation by filtration using BF 4 (PALL), Sepacell RS 200 (Asahi Med.) and Bio R01 Plus (Biotrans). We compared the handling of the filter system, focusing routine blood bank practice, filtration efficiency [residual white cell count; flow cytometry (Ortho Cytoron) and Nageotte chamber] and the loss of red cells. Spontaneous filling was found to be an advantage of the Bio R01 Plus system, whereas the BPF 4 and the RS 200 have to be filled by pressure. The filtrations were of similar duration, even those of WB and resuspended RCC. Red cell loss was found to be 10-15% on RCC higher than on WB (7-10%) and varied between the filters used: BPF 4 < Bio R01 Plus < RS 200. The residual white cell count on WB was 1.2-5.8 x 10(6) (RS 200 < Bio R01 Plus < BPF 4) and on RCC was 0.5-3.0 x 10(5) (RS 200 < BPF 4 < Bio R01 Plus). The filters used are highly effective (4-log depletion on RCC) even on fresh WB and are therefore potential in-line filters.
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Affiliation(s)
- E Richter
- Institut für Transfusionsmedizin, Medizinische Fakultät (Charité), Humboldt-Universität zu Berlin
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Richter E, Matthes G, Pawlow I, Rath E, Schultze W, Wolf G. [Stem cell pheresis and deep temperature preservation--a problem of transfusion medicine?]. Beitr Infusionsther Transfusionsmed 1998; 32:99-101. [PMID: 9480168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In Germany, Transfusion Medicine belongs to various medical disciplines. We would like to demonstrate our model of interdisciplinary collaboration in stem cell transplantation. Since 1989 we performed 339 leukaphereses in 53 patients. On average we got 1.4 x 10(8) MNC/kg body weight from one single apheresis procedure. To observe graft quality we measured the content of CD34-positive cells and the amount of CFU-GM. Despite diagnosis and therapeutical regimen the content of CD34+ cells was found to be 3.3% (0-20). The proliferation was 21.7 GM-CFU per 1 x 10(5) MNC seeded (0-393). The results of the first 17 transplantations showed a fast haematological recovery (WBS 1.0 Gpt/l after 9 days Plt 20 Gpt/l after 11 days). Close collaboration of Transfusion Medicine and Haematology leads to optimization of stem cell transplantation.
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Affiliation(s)
- E Richter
- Institut für Transfusionsmedizin, Medizinische Fakultät (Charité), Humboldt-Universität zu Berlin, Deutschland
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Weisel Y, Rath E, Ohana N, Atar D. [Pelvic lytic lesion, and the need to suspect osteoporosis-related fractures]. Harefuah 1998; 134:269-70, 335. [PMID: 10909503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Insufficiency fractures of the pelvis may be overlooked as a cause of hip or groin pain. These fractures occur in the elderly, usually those with pronounced osteopenia of the pelvis. Predisposing factors include corticosteroids, local irradiation and postmenopausal osteoporosis. These fractures are difficult to detect clinically and plain radiographs and other studies may be misleading, delaying diagnosis and treatment. A 65-year-old woman had left groin and hip pain for 2 months with no history of trauma. Plain radiographs showed lytic lesions in the left pubic rami. Bone scan revealed increased uptake in that region, suggesting metastatic bone disease. Computed tomography and magnetic resonance imaging demonstrated fractures in the left superior and inferior pubic rami, with callus formation with no involvement of soft tissues. Quantitative computed tomography indicated low calcium concentration, below fracture threshold. The diagnosis of insufficiency fractures of the pelvis was confirmed by the favorable clinical and radiographic outcome. It is therefore important to be familiar with the appearance and location of these fractures.
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Affiliation(s)
- Y Weisel
- Orthopedic Dept., Soroka Medical Center, Beer Sheba
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Levy O, Rath E, Atar D. [Combined treatment for adhesive capsulitis of the shoulder]. Harefuah 1997; 133:357-9, 415. [PMID: 9418336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Adhesive capsulitis is a problem for the orthopedic surgeon due to the difficulty of treatment. Although it is self-limited, few patients will wait for spontaneous resolutions while suffering pain and progressive loss of motion. Our aim was to modify the course of the disease and to shorten recovery time by combining intensive physiotherapy with intra-articular infiltration and gentle manipulation. 49 patients with 50 frozen shoulders were enrolled in the study. All patients were treated initially with physiotherapy for 4-8 weeks. If no improvement was noted the affected shoulder was infiltrated and gently manipulated. 27 of 49 patients (55%) improved dramatically with the initial physiotherapy regimen. They achieved full or nearly full range of motion, with significant relief of pain. 22 patients were infiltrated and manipulated. Elevation improved significantly from an average of 110.95 to 165.71 degrees (p < 0.001), external rotation from an average of 9.52 to 43.57 degrees (p < 0.001) and internal rotation also improved significantly (p < 0.001). Self assisted physiotherapy is the corner stone of treatment in adhesive capsulitis. When pain and limitation of passive range of motion persist, infiltration and gentle manipulation dramatically shortens the debilitating process.
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Affiliation(s)
- O Levy
- Orthopedic Dept., Soroka Medical Center, Beer Sheba
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Rath E, Katz T, Levy O, Atar D. [Fractures of the calcaneus--new trends in management]. Harefuah 1997; 132:424-7. [PMID: 9153862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Abstract
Simultaneous bilateral posterior dislocation of the hip is very uncommon and most cases are caused by road accidents. Simultaneous bilateral posterior dislocation of the hip due to convulsions is extremely rare. We report the case of a man who was diagnosed late and operated on 15 weeks after the injury. We discuss the treatment of chronic dislocation of the hip and review the literature.
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Affiliation(s)
- E Rath
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
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Abstract
Simultaneous bilateral posterior dislocation of the hip is very uncommon and most cases are caused by road accidents. Simultaneous bilateral posterior dislocation of the hip due to convulsions is extremely rare. We report the case of a man who was diagnosed late and operated on 15 weeks after the injury. We discuss the treatment of chronic dislocation of the hip and review the literature.
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Affiliation(s)
- E. Rath
- Soroka Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-sheva, Israel
| | - O. Levy
- Soroka Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-sheva, Israel
| | - N. Liberman
- Soroka Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-sheva, Israel
| | - D. Atar
- Soroka Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-sheva, Israel
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Abstract
OBJECTIVE To assess the role of digitalis in the development of visual symptoms severe enough to warrant ophthalmologic consultation in patients who received digitalis and who had no other clinical or laboratory evidence of digitalis toxicity. DESIGN Clinical case study. SETTING Neuro-ophthalmology referral practice. PATIENTS Six elderly patients (aged 66 to 85 years) who received digitalis were referred to ophthalmologists for evaluation of photopsia (five patients) or decreased visual acuity (one patient). No patient had chromatopsia or nonvisual clinical manifestations of digitalis intoxication at the time of examination. MEASUREMENTS All patients had serum digitalis concentrations within or below the therapeutic range. In most patients, the electroretinographic cone b-wave implicit time was longer than normal. RESULTS Discontinuation of digitalis therapy, which was possible in five patients, was followed by resolution of visual symptoms and by shortening of the b-wave implicit time. Characteristic features of digitalis-induced photopsia were its dependence on illumination and its tendency to be localized in peripheral visual fields. CONCLUSIONS In an elderly patient receiving digitalis, the development of photopsia characterized by innumerable points of light in the peripheral visual fields or a decrease in visual acuity raises the possibility that the patient's visual disturbance may have been digitalis induced. Digitalis-induced visual disturbances other than chromatopsia or disturbances of color vision may occur in elderly patients who have no other clinical manifestations of digitalis intoxication and who have a serum digitalis concentration within or below the therapeutic range.
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Affiliation(s)
- V P Butler
- Columbia-Presbyterian Medical Center, New York, New York, USA
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Pawlow I, Richter E, Matthes G, Rath E, Schultze W. [Large volume lymphocytapheresis for the collection of peripheral stem cells]. Beitr Infusionsther Transfusionsmed 1994; 32:351-354. [PMID: 9480124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
We performed 29 large-volume leukaphereses of 20 patients for collection of peripheral blood stem cells. All patients have been pretreated with cytokines after chemotherapy. In 9 patients with precounts of > or = 3 x 10(9) mononuclear cells/l we achieved a sufficient transplantation doses with one LVL. If the MNC precount was < or = 3 x 10(9)/l we had to perform more than one LVL. On 16 patients we compared a standard apheresis procedure with the LVL procedure. It seems that especially patients with a lower MNC precount can profit from LVL. From patients with higher MNC precounts we harvested the double amount of MNCs, from patients with lower MNC precounts the triple amount.
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Affiliation(s)
- I Pawlow
- Institut für Transfusionsmedizin, Universitätsklinikum Charité, Humboldt-Universität zu Berlin, Deutschland
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Richter E, Matthes G, Tofoté U, Rath E. [In-line-filtration of erythrocyte concentrates using the Leukotrap-RC system]. Beitr Infusionsther Transfusionsmed 1994; 32:29-31. [PMID: 9480110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
'In-line filtration' was performed on whole blood (WB) of 12 healthy donors. The WB was drawn into the triple-bag Leukotrap-RC system. Six red cell concentrates (RCC) were filtrated 1 h after donation either with or without buffy-coat and stored 35 days in AS-3. We measured the loss of red cells, the residual white cell count (Nageotte chamber), platelet count in fresh frozen plasma (FFP); 2,3-DPG, K+, Hbe, pH, O2Hb and pO50. The system was easy to handle but needed circular centrifugation holders because the filter is placed and fixed just at the top of the bags during centrifugation. RCC without buffy coat led to a faster filtration (15 vs, 38 min) and to an improved FFP quality (platelet count 23 vs, 54 Gpt/l). The leucocyte removal rate of the integrated PALL-RC-350 was similar, residual white cell count less than 3 x 10(6), in both preparations. All storage parameters were found within the normal range except a significant increase of O2Hb in filtrated red cells compared with the unfiltered control.
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Affiliation(s)
- E Richter
- Institut für Transfusionsmedizin, Medizinische Fakultät (Charité), Humboldt-Universität zu Berlin, Deutschland
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Rath E. [The making of fireproof dies with the duplicating system according to Rath]. Dent Labor (Munch) 1991; 39:371-2, 374. [PMID: 1860534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Rath E. [New model and duplication system. High tech finishing for greater precision]. Dent Labor (Munch) 1990; 38:1225-30. [PMID: 2227024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Diamantikos W, Heinzelmann H, Rath E, Binder H. Die Hydroborierung von Kohlenstoffdisulfid mit Natriumboranat. Pentanatrium-tetrakis(dithiomethylen)borat, ein Salz mit einem neuen ?Tetrathioborat?-Anion. Z Anorg Allg Chem 1984. [DOI: 10.1002/zaac.19845171009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Schindler HJ, Blaser W, Rath E. [T.E.N.S. (transcutaneous electroneurostimulation), a myofunctional concept for oral rehabilitation (II)]. Quintessenz 1982; 33:295-307. [PMID: 7051096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Rath E. [Independent nursing care report]. Krankenpflege (Frankf) 1981; 35:437-8. [PMID: 6172634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Kits van Heijningen AJ, Rath E, Treijtel B, Visser N, Wientjes C, Beloff-Chain A. The insulin-like effects of a glucose metabolite (bis-PEP) from muscle and erythrocytes. FEBS Lett 1976; 72:58-62. [PMID: 1001471 DOI: 10.1016/0014-5793(76)80812-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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