Revaskularisation von Kolonanastomosen

Zusammenfassung Die Revaskularisation der Kolonanastomose wurde bei 9 verschiedenen stoßgerechten sowie invertierenden Nahttechniken makroskopisch, mikroangiographisch, mikropräparatorisch und histologisch untersucht. Unabhängig von der Nahttechnik hat 4 Tage p.o. die Revaskularisation begonnen, 8 Tage p.o. ist die Nahtlinie größtenteils überbrückt, 14 Tage p.o. liegt der Gefäßanschluß an die Gegenseite vor. Die Gefäßneubil-dungen gehen v. a. von der Subserosa und der Submukosa aus. Auch die Adhäsionen beteiligen sich an der Revaskularisation. Das Ausma korreliert direkt mit der Ausbildung des Granulationsgewebes, besonders deutlich wird dies an der überschießenden reaktiven Vaskularisation von Anastomosenabszessen und -ulzera. Immer resultiert später eine Gefänarbe in der Angioarchitektur der Kolonwand. Beginn and AusmaB der Revaskularisation können — im Gegensetz zu den früheren Angaben in der Literatur — nicht als Qualitätsmerkmal der Anastomosenheilung gelten.

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Revascularization of colonic anastomoses

Summary The revascularization of colonic anastomosis after colon segmental resection in rabbits in 9 different end-on-end and inverting suture techniques was examined macroscopically, microangiographically, micropreparatorily and histologically. Independently of the suture technique revascularization started 4 days after surgery. 8 days postoperatively the suture line is mainly bridged, 14 days postoperatively the vasal connection to the opposite side is completed. The new vessels mainly originate from the subserosal and submucosal tissue. The adhesions participate in the revascularization, too. It (the revascularization) directly correlates with the development of granulation tissue. This is evident from the excess reactive revascularization of abscesses and ulcers in the anastomoses. There always results a vascular scar in the angioarchitecture of the colonic wall. Start and extent of the revascularization cannot — in contrast to former literature — be looked at as a guarantee of quality for the healing of anastomoses.

     

Diagnostic Accuracy of Perioperative Measurement of Basal Anterior Pituitary and Target Gland Hormones in Predicting Adrenal Insufficiency After Pituitary Surgery

The insulin tolerance test (ITT) is the gold standard for diagnosing adrenal insufficiency (AI) after pituitary surgery. The ITT is unpleasant for patients, requires close medical supervision and is contraindicated in several comorbidities. The aim of this study was to analyze whether tumor size, remission rate, preoperative, and early postoperative baseline hormone concentrations could serve as predictors of AI in order to increase the diagnostic accuracy of morning serum cortisol.This prospective study enrolled 70 consecutive patients with newly diagnosed pituitary adenomas. Thirty-seven patients had nonfunctioning pituitary adenomas (NPA), 28 had prolactinomas and 5 had somatotropinomas. Thyroxin (T4), thyrotropin (TSH), prolactin, follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone, and insulin-like growth factor 1 (IGF-I) were measured preoperatively and on the sixth postoperative day. Serum morning cortisol was measured on the third postoperative day (CORT3) as well as the sixth postoperative day (CORT6). Tumor mass was measured preoperatively and remission was assessed 3 months after surgery. An ITT was performed 3 to 6 months postoperatively.Remission was achieved in 48% of patients and AI occurred in 51%. Remission rates and tumor type were not associated with AI. CORT3 had the best predictive value for AI (area under the curve (AUC) 0.868, sensitivity 82.4%, specificity 83.3%). Tumor size, preoperative T4, postoperative T4, and TSH were also associated with AI in a multivariate regression model. A combination of all preoperative and postoperative variables (excluding serum cortisol) had a sensitivity of 75.0% and specificity of 77.8%. The predictive power of CORT3 substantially improved by adding those variables into the model (AUC 0.921, sensitivity 94.1%, specificity 78.3%, PPV 81.9%, NPV of 92.7%). In a subgroup analysis that included only female patients with NPA, LH had exactly the same predictive value as CORT3. The addition of baseline LH to CORT3, increased sensitivity to 100.0%, specificity to 88.9%, PPV to 90.4%, and NPV to 100.0%.Besides CORT3, tumor size, thyroid hormones, and gonadotropins can serve as predictors of AI. LH in postmenopausal female patients with NPA has similar diagnostic accuracy as CORT3. Further studies are needed in order to validate the scoring system proposed by this study.     

Bcl-2 and Bax protein interaction in B-lymphocytes of peripheral blood in patients with chronic lymphocytic leukemia

BACKGROUND: Chronic lymphocytic leukemia (CLL) is a neoplastic disease characterized by the accumulation of morphologically mature monoclonal CD5+ B cells in the early phase (G0/G1) of the cell cycle. The accumulation of neoplastically transformed B-lymphocytes (CLL cells) is primarily the consequence of apoptosis blocking in these cells. Bcl-2 proteins are well-known modulators of this process. Some of these proteins are anti-apoptotic while the others are pro-apoptotic. All contain at least one of the four conserved regions called the Bcl-2 homologous domains (BH1-BH4). Evidence indicates that Bcl-2 and Bax form homo- and heterodimers. The anti-apoptotic effect of Bcl-2 protein is based on its ability to bind Bax protein in the heterodimer form, and thus to block the forming of Bax/Bax proapoptotic homodimers. The ratio of Bcl-2/Bax represents the cell autonomous rheostat which determinates the type of the cell reaction to an apoptotic stimulus. METHODS: The aim of this study was to determine the level of interaction between these two proteins in CLL cells using the co-immunoprecipition method. The study included the analysis of 20 peripheral blood specimens from 20 patients with CLL, and 20 peripheral blood specimens from healthy persons, who were in the control group. Specimens were precipitated with the monoclonal antibody for Bcl-2 protein, and immunoblotted with the palyclonal antibady for Bax protein (IP: Bcl-2/WB:Bax). At the same time, specimens were precipitated with the polyclonal antibody for Bax protein, and immunoblotted with the monoclonal antibody for Bcl-2 protein (IP: Bax/WB:Bcl-2). The intensity of Bcl-2 and Bax protein's binding compared to the control samples of the peripheral blood from healthy persons, was increased in CLL cells. RESULTS: IP: Bax/WB: Bcl-2 showed a high level of "free" Bcl-2 protein which was not bound in the heterodimer form to Bax protein. Simultaneously IP: Bcl-2/WB: Bax showed that a higher quantity of Bax protein was bound in the heterodimer form to Bcl-2 protein as opposed to the quantity of pro-apoptotic Bax protein potentialy bound in the homodimer form. CONCLUSION: Further studies involving larger groups of patients are necessary to explore the potential significance of the Bcl-2/Bax protein ratio as a prognositc parameter in the CLL treatment.     

Clinical case report atypical myopathy in a young girl with 91 CTG repeats in DM1 locus and a positive DM1 family history

Myotonic dystrophy type 1 (DM1) is an autosomal dominant inheritable disease associated with an expansion of CTG repeats in the 3' UTR of the DMPK gene. The subject is an 11-year-old girl with atypical myopathy. Because the proband's family has a positive DM1 history, a molecular-genetic analysis for DM1 was performed. This study showed that proband had a small DMPK expansion (91 CTG repeats) although the observed myopathy would not normally be associated with DM1. These results show how the phenotypic manifestation of DM1 can have unusual symptoms with a completely unexpected relationship to genotype.     

Epidemiological, clinical and laboratory characteristics of patients with human granulocytic anaplasmosis in Slovenia

Human granulocytic anaplasmosis (HGA) has been recently recognized as an emerging tick-borne disease. Several reports indicate the presence of infection with Anaplasma phagocytophilum in Europe. Between January 1996 and December 2004, 24 adult patients with proven HGA were identified in a prospective study conducted at the Department of Infectious Diseases, University Medical Center Ljubljana, Slovenia, on the etiology of febrile illnesses occurring within 30 days after a tick bite. The diagnosis of acute HGA was established from seroconversion in 18 (75%) patients or at least a four-fold increase in antibody titers to A. phagocytophilum antigens in six (25%) patients and molecular identification of ehrlichial organisms in 15 (62.5%) patients. Clinical characteristics and laboratory findings were similar to those reported from the other European countries. All the patients had an acute febrile illness with headache, malaise, myalgia and/or arthralgia. Leukopenia was found in 16 (66.7%) patients, thrombocytopenia in 20 (83.3%), abnormal liver function test results in 23 (95.8%), elevated erythrocyte sedimentation rates in 18 (75%), and elevated concentration of C-reactive protein in 23 (95.8%). The disease course was relatively mild; none of the patients died and no long-term sequelae were found during a follow-up of one year even though only 15 (62.5%) were treated with doxycycline. At the examination one year after the first visit, 16/24 (66.7%) patients tested seropositive (> or =1 : 256) for A. phagocytophilum antibody, and two years after the first visit positive titers were still present in 10/18 (55.6%) patients.     

Intrafamilial phenotypic and genetic heterogeneity of dystonia

Most cases of early-onset primary torsion dystonia are caused by the same 3-bp (GAG) deletion in the DYT1 gene. We describe a large Serbian family with significant intrafamilial variability of the DYT1 phenotype, from asymptomatic carrier status to late-onset focal, and generalized jerky dystonia. Seven mutation carriers (six proven by direct analysis and one by inferred haplotype) were identified, but only two of them were affected by dystonia (penetrance reduced to 29%). In addition, three GAG-deletion-negative family members also developed dystonia (two multifocal dystonia and one torticollis), suggesting that their involuntary movements are due to some other etiological factor(s) (i.e., another dystonia gene), or may be psychogenic.     

Procalcitonin levels in patients with Lyme borreliosis

BACKGROUND: Serum and cerebrospinal fluid (CSF) procalcitonin levels were assessed and compared for different groups of patients with Lyme borreliosis. PATIENTS AND METHODS: 50 adult patients with Lyme borreliosis, referred to our department from March to June 2001, were included in this prospective study. Patients were divided into three groups. The first group consisted of 20 consecutive patients with typical solitary erythema migrans, representing early localised Lyme borreliosis, the second group comprised 20 patients with early disseminated Lyme borreliosis (10 with multiple erythema migrans and 10 with neuroborreliosis), and 10 patients with acrodermatitis chronica athrophicans represented the group with chronic Lyme borreliosis. Blood specimens were taken from all patients included in the study, but CSF samples were restricted to those with disseminated and chronic Lyme borreliosis. The serum and CSF procalcitonin levels were determined utilizing the LUMI PCT (an immunoluminometric assay using two antigen-specific monoclonal antibodies). RESULTS: Serum and CSF procalcitonin levels were in normal range in the large majority of patients. The levels of serum procalcitonin did not differ in the three groups of patients with Lyme borreliosis (p = 0.5006). The corresponding values for patients with solitary erythema migrans (early localised Lyme borreliosis), early disseminated Lyme borreliosis, and chronic Lyme borreliosis were 0.26 (0.11-0.43), 0.22 (0.10-0.67), and 0.28 (0.13-0.66) microgram/ml, respectively. Moreover, procalcitonin levels in CSF were also low and comparable for patients with multiple erythema migrans (median 0.38, range 0.24-0.54 microgram/ml), neuroborreliosis (median 0.16, range 0.10-0.47 microgram/ml), and acrodermatitis chronica athrophicans (median 0.30, range 0.15-0.45 microgram/ml). The differences were not statistically significant (p = 0.7579). CONCLUSIONS: In the large majority of patients with Lyme borreliosis procalcitonin values are within normal range. Serum and CSF procalcitonin levels are of no value for differentiation between early localised, early disseminated and chronic Lyme borreliosis.     

Cerebrospinal fluid findings in patients with symptoms suggesting chronic Lyme borreliosis

BACKGROUND: Patients with non-specific long-lasting symptoms such as headache, concentration disturbances, and vertigo and who have positive serum borrelial antibody titres are often assumed to have chronic Lyme borreliosis. Because of the possibility that they may have central nervous system involvement they are frequently treated with courses of i.v. ceftriaxone. We assessed central nervous system involvement by examining cerebrospinal fluid samples in a group of such patients. PATIENTS AND METHODS: Adult patients who qualified for the study had non-specific symptoms suggesting central nervous system involvement for longer than six months (but without overt clinical signs of such involvement) and positive serum borrelial antibody titres and/or erythema migrans prior to the onset of symptoms. Cerebrospinal fluid was examined in all patients. RESULTS: None of the 77 patients included in the study (median duration of symptoms 18 months) had pleocytosis and there was no isolation of Borrelia burgdorferi sensu lato from cerebrospinal fluid. Mildly elevated protein concentration and intrathecal borrelial IgG antibody synthesis were demonstrated in 16 (21%) and 7 (9.1%) patients, respectively. CONCLUSIONS: In patients with non-specific long-lasting symptoms attributed to Lyme borreliosis but with the absence of overt clinical signs suggesting central nervous system involvement, the findings of cerebrospinal fluid examination are usually in the normal range. Routine treatment of such patients with i.v. ceftriaxone is not to be encouraged.     

Thrombocytopenia — A common finding in the initial phase of tick-borne encephalitis

Summary The aim of this prospective study was to assess the frequency of thrombocytopenia and abnormal liver function tests in the initial phase of tick-borne encephalitis. In 1994, 248 adult patients presented at the Department of Infectious Diseases, University Medical Centre Ljubljana, with acute lymphocytic meningitis or meningoencephalitis and serologically confirmed tick-borne encephalitis virus infection. In 180/248 (72.6%) patients, typical biphasic course of the illness was found and 28/180 (15.6%) patients with biphasic course were examined in both phases of the illness. In 20 out of these 28 (71.4%) patients, thrombocytopenia and leukopenia were found initially, in one (3.6%) patient only leukopenia was recorded and three (10.7%) patients had thrombocytopenia without leukopenia. In four (14.3%) patients leukocyte and thrombocyte values were within the normal range. The lowest leukocyte number was 1.4×10⁹/l and the lowest recorded thrombocyte number was 60×10⁹/l. Abnormal liver function tests were discovered in four out of 18 patients tested (22.2%). In conclusion, in the initial phase of tick-borne encephalitis thrombocytopenia and abnormal liver function tests may be found. Thrombocytopenia is a common finding with a frequency similar to that of well-known leukopenia, while abnormal liver function tests are relatively rare.

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Thrombozytopenie — ein häufiger Befund in der Initialphase der Frühsommer-Meningoencephalitis

Zusammenfassung Diese prospektive Studie wurde durchgeführt, um die Häufigkeit einer Thrombozytopenie und pathologischer Leberfunktionstests in der Initialphase der Zeckenencephalitis zu bestimmen. 1994 suchten 248 erwachsene Patienten die Abteilung für Infektionskrankheiten am medizinischen Zentrum der Universität Ljubljana auf, die an einer akuten lymphozytären Meningitis oder Meningoencephalitis und einer serologisch bestätigten Infektion durch das Frühsommer-Meningoencephalitis-Virus litten. Bei 180/248 Patienten (72,6%) fand sich ein typischer biphasischer Verlauf. 28/180 Patienten (15,6%) mit biphasischem Verlauf konnten in beiden Phasen untersucht werden. Bei 20 dieser Patienten (71,4%) fand sich initial eine Thrombozytopenie und Leukopenie, bei einem Patienten (3,6%) nur eine Leukopenie und bei drei (10,7%) eine Thrombopenie ohne Leukopenie. Bei vier Patienten (14,3%) waren die Leukozyten- und Thrombozytenwerte im Normalbereich. Die niedrigste Leukozytenzahl war 1,4×10⁹/l und die niedrigste Thrombozytenzahl 60×10⁹/l. Bei vier der 18 untersuchten Patienten (22,2%) fanden sich pathologische Leberwerte. Man findet folglich in der Frühphase der Zeckenencephalitis eine Thrombozytopenie und pathologische Leberwerte. Die Thrombozytopenie ist ein häufiger Befund und ähnlich häufig wie die bekannte Leukopenie. Pathologische Leberfunktionstests werden hingegen relativ selten beobachtet.