F. W. Sertürner and the discovery of morphine. 200 years of pain therapy with opioids

Since many centuries mankind has been aware of the poppy (papaver somniferum) and has known its product opium as an analgesic drug. Until the beginning of the 19 (th) century its compounds were not known, making it almost impossible to apply the substance in exact doses. 1803/04, Friedrich Wilhelm Sertürner (1783 - 1841) succeeded in isolating a crystalline substance from opium in the test tube, which he called morphium. In animals and in man he was able to prove that this new compound he had discovered was the principium somniferum of opium. He isolated morphine, the first pure opioid available for calculated pain therapy with one defined compound. Moreover, he laid the foundations of a new class of pharmaceutical drugs, the alcaloids.     

A case of clear cell adenocarcinoma of the müllerian duct in persistent müllerian duct syndrome: the first reported case

We report a case of a 67-year-old man with clear cell adenocarcinoma of the remnant uterus in persistent Müllerian duct syndrome. He had a normal penis, urethra, and scrotum, and there was also a vagina and uterus. He died in a traffic accident, and clear cell adenocarcinoma was discovered incidentally at autopsy. Clear cell adenocarcinoma of the remnant uterus metastasized to the retroperitoneal lymph nodes and bilateral lungs. Persistent Müllerian duct syndrome is characterized by the persistence of Müllerian derivatives in otherwise normally virilized males. A variety of germ cell tumors of the testis have been reported in association with persistent Müllerian duct syndrome. However, no malignant change of the persistent Müllerian duct structures has been reported. This represents the first reported case of malignant change of the persistent Müllerian duct structures in persistent Müllerian duct syndrome.     

Laparoscopic management of Müllerian duct remnants: four case reports and review of the literature

Several experiences with laparoscopic management of müllerian duct remnants (MDRs) have been reported to date. This report outlines our experience and reviews the present literature to evaluate the results of laparoscopic excision of MDR. Between April 2003 and December 2007, 4 male patients (age range, 6-20 years) with MDR underwent laparoscopic excision in our center. A literature search revealed 5 additional reports of laparoscopic excision of MDR, comprising 13 patients (age range, 1.5-48 years). For the 4 patients in our center, the operative time was 135-200 minutes (mean, 159 minutes) and the estimated blood loss was 20-100 mL (mean, 48 mL). For the 13 patients in the literature reviewed, the operative time was 105-360 minutes (mean, 190 minutes) and the estimated blood loss was 50-200 mL. All of these 17 patients recovered uneventfully with no complications. A small prostatic diverticulum had been found in 1 case at 6 years postoperatively; no recurrent evidence or voiding dysfunction had been found in the other 16 patients during 3-50 months of follow-up. No patient had required any further operative therapy. Laparoscopic excision of MDR is a safe and effective surgical procedure, associated with minimal invasion, minimal postoperative morbidity, and rapid recovery for the patient.     

Laparoscopic removal of Müllerian structures and orchiopexy for persistent Müllerian duct syndrome

A 1-year-old boy presented for evaluation of bilateral undescended testes. Diagnostic laparoscopy was conducted, and uterine tissue with bilateral gonads was detected in the rectovesical fossa. Chromosomal analysis revealed a 46,XY karyotype. Persistent müllerian duct syndrome was diagnosed, and laparoscopic surgery was performed to treat this condition. The uterus was incised at a distal site and withdrawn through the port. The bilateral testes were fixed in the scrotum. The patient was discharged 3 days later. We believe that the laparoscopic approach is a valid, alternative choice to traditional surgery for resolution of this condition, permitting minimally invasive surgery.     

Inguinoscrotal extension of a pancreatic collection: a rare complication of pancreatitis—case report and review of the literature

Pancreatitis associated with the extension of a pancreatic collection, pseudocyst or abscess into the groin is a rare phenomenon with few reports in the English literature. Nevertheless, it remains a clinically important differential diagnosis as it may be mistaken for more common pathologies in the groin and with a subsequent unnecessary surgical intervention. A case of this rare complication of pancreatitis is reported, together with a review of the literature.     

A short story of Klotho and FGF23: a deuce of dark side or the savior?

Fibroblast growth factor 23 (FGF23) is an osteocyte and osteoblast derived peptide hormone, which requires Klotho as a cofactor for its biologic actions. FGF23 acts as a phosphaturic agent and it is capable of reducing serum inorganic phosphate (Pi) via direct inhibition of renal NaPi-2a transporter in the proximal tubuli, as well as indirectly, via the suppression of calcitriol synthesis. In patients with chronic kidney disease (CKD), circulating FGF23 levels are markedly elevated, while Klotho production is decreased. Experimental observations indicating that lack of activities of both Klotho and FGF23 may cause decreased life span, premature aging and accelerated atherosclerosis and generalized vascular calcifications have raised the question whether FGF23 could be a new risk factor and predictor of cardiovascular (CV) disease in both renal and non-renal patient groups. Clinical studies, however, have yielded conflicting results. Some of these studies have found that serum FGF23 is independently associated with mortality and CV events in CKD patients, while others have failed to show any relationship. Furthermore, some studies have even suggested that FGF23 may have a protective role against vascular calcifications and CV disease. Thus, there is clearly a need for further research in this area, and special interest should be paid to the physiologic consequences of high FGF23/low Klotho state, which is typical for patients with CKD.     

Is procalcitonin a reliable marker for the diagnosis of infected pancreatic necrosis?

BACKGROUND: Infected necrosis in acute pancreatitis is the main factor in determining the prognosis of the disease. Early and accurate diagnosis of infected pancreatic necrosis might decrease mortality. The aim of the present study is to identify a reliable marker for the onset infection in three different experimentally induced pancreatitis models. METHODS: Ninety female Wistar albino rats were randomly divided into nine groups. In three different experimental models, including cerulein induced acute oedematous pancreatitis (AEP), sterile pancreatic necrosis due to taurocholate-induced acute pancreatitis (SPN) and infected pancreatic necrosis taurocholate-induced acute pancreatitis (IPN). Serum levels of procalcitonin (PCT), C-reactive protein (CRP), tumour necrosis factor a (TNF-alpha), interleukin 6 (IL-6) and interleukin 8 (IL-8), amylase were measured. The degree of pancreatic damage also evaluated pathologically. RESULTS: Procalcitonin levels were increased significantly in AEP, SPN and IPN compared to control groups (P < 0.05). PCT and IL-6 level were the highest in the IPN group (P < 0.05). Serum amylase, CRP, TNF-alpha, IL-2, and IL-8 levels were similar between IPN and SPN groups (P > 0.05), but higher than in other groups. The results of histological evaluation also correlated with the advent of the disease. CONCLUSION: Procalcitonin and IL-6 acts as reliable acute phase reactant in an experimental model of AEP, SPN and IPN in the rat. PCT and IL-6 combination might be surrogate marker of infected pancreatic necrosis and should be preferred to other markers assay especially in severe pancreatitis.     

Adenocarcinoma of persistent müllerian duct remnants: case report and differential diagnosis

Persistent müllerian duct syndrome is an unusual disorder characterized by cryptorchidism and retention of müllerian derivatives (uterus, fallopian tubes, and upper vagina). We report the case of a 39-year-old man with this syndrome in association with adenocarcinoma from the retained müllerian remnants of probable endocervical origin. To our knowledge, this is the first report of an endocervical adenocarcinoma associated with persistent müllerian duct syndrome.     

Müllerian duct remnant involving Wolffian system: a case report and literature review

A 14-month-old boy with repeated left acute epididymitis was admitted to our department. Ultrasonography detected a midline round cystic mass in a retrovesical region. This was easily opacified by cystourethrography and seen to have a free communication with the posterior urethra. Since urethroscopy revealed a passable orifice in the center of the verumontanum, while a cystic-wall biopsy specimen showed squamous epithelium, we considered this cystic lesion to be an enlarged prostatic utricle. Vasography showed that the bilateral vasa was implanted directly into this cystic lesion, and was the possible cause of his left epididymitis. Ligature of the left vas deferens was performed to prevent left epididymitis. An enlarged prostatic utricle involving the vasa is a rare presentation.     

Craniotomy: true sham for traumatic brain injury, or a sham of a sham?

Abstract Neurological dysfunction after traumatic brain injury (TBI) is caused by both the primary injury and a secondary cascade of biochemical and metabolic events. Since TBI can be caused by a variety of mechanisms, numerous models have been developed to facilitate its study. The most prevalent models are controlled cortical impact and fluid percussion injury. Both typically use "sham" (craniotomy alone) animals as controls. However, the sham operation is objectively damaging, and we hypothesized that the craniotomy itself may cause a unique brain injury distinct from the impact injury. To test this hypothesis, 38 adult female rats were assigned to one of three groups: control (anesthesia only); craniotomy performed by manual trephine; or craniotomy performed by electric dental drill. The rats were then subjected to behavioral testing, imaging analysis, and quantification of cortical concentrations of cytokines. Both craniotomy methods generate visible MRI lesions that persist for 14 days. The initial lesion generated by the drill technique is significantly larger than that generated by the trephine. Behavioral data mirrored lesion volume. For example, drill rats have significantly impaired sensory and motor responses compared to trephine or na?ve rats. Finally, of the seven tested cytokines, KC-GRO and IFN-γ showed significant increases in both craniotomy models compared to na?ve rats. We conclude that the traditional sham operation as a control confers profound proinflammatory, morphological, and behavioral damage, which confounds interpretation of conventional experimental brain injury models. Any experimental design incorporating "sham" procedures should distinguish among sham, experimentally injured, and healthy/na?ve animals, to help reduce confounding factors.     

Erich Mühe and the rejection of laparoscopic cholecystectomy (1985): a surgeon ahead of his time.

During the early 1980s, news of Semm's laparoscopic appendectomy was rippling through German medical circles. Erich Mühe, fascinated by Semm's technique and spurred by successes of the Erlangen endoscopists, came up with the idea of laparoscopic removal of gallstones. In 1984, Mühe had already worked out the details of an operative laparoscope, the "Galloscope," and on September 12, 1985, he carried out the first laparoscopic cholecystectomy. Later, he modified his technique and operated through a trocar sleeve. Finally, he designed an "open laparoscope" with a circular light. By March 1987, Mühe had conducted 97 endoscopic gallbladder removals. He published information about his technique at the Congress of the German Surgical Society (April 1986) and at other surgical meetings in Germany. His concept, however, was ignored. In the middle of the 1980s, the surgical community was still not prepared for the era of "minimally invasive therapy." Erich Mühe was a surgeon ahead of his time.     

Mesodermal (müllerian) adenosarcoma of the ovary: a clinicopathologic analysis of 40 cases and a review of the literature

Forty cases of mesodermal adenosarcoma of the ovary occurred in women 30-84 years of age (mean 54 years). Abdominal discomfort and distension were the usual complaints. All the patients were treated with an oophorectomy, which was accompanied by a hysterectomy in 85%, a contralateral oophorectomy in 65%, and nonsurgical therapy in 28%. Tumor rupture occurred at or before the operation in 67% of the cases. Twenty-six tumors were stage I, 11 stage II, and 3 stage III. The tumors were unilateral in 97.5% of the cases and 5.5-50 cm (mean 14 cm) in greatest dimension; most of the tumors were predominantly solid but contained numerous small cysts. Microscopic examination revealed sarcomatous overgrowth in 12 tumors. Sex cord-like elements were present in six tumors (including four with sarcomatous overgrowth) and heterologous elements in five (including two with sarcomatous overgrowth). The highest mitotic index of the sarcomatous component was 1-25 (mean 6) mitotic figures per 10 high power fields. Only 6 of 26 women (23%) who were followed postoperatively for > or=5 years were free of tumor. In the other 20 patients recurrent tumor appeared at 0.4-6.6 years (mean 2.6 years) after operation as pure sarcoma (low grade or high grade) or adenosarcoma (with or without sarcomatous overgrowth). Eight women had additional recurrences, and four women had blood-borne metastases. One patient was alive at 15.7 years after the excision of pulmonary metastases. The 5-, 10-, and 15-year survival rates were 64%, 46%, and 30%, respectively. Age <53 years, tumor rupture, a high grade, and the presence of high-grade sarcomatous overgrowth appeared to be associated with recurrence or extraovarian spread. Ovarian adenosarcomas have a worse prognosis than uterine adenosarcomas, presumably because of the greater ease of peritoneal spread. Many of the tumors caused problems in differential diagnosis.