Single or multiple perforations with varying locations as a complication of intestinal Behçet's disease: Report of three cases

Intestinal ulcers in Behçet's disease (BD) tend to cause perforation with significant morbidity. The optimal surgical procedure in such cases is controversial and the postoperative period can be eventful with an unpredictable course. We report three cases of perforations with varying locations in three patients with long-standing Behçet's disease. Two patients required two and one patient required four operations. It is emphasized that the clinician must be alert in a patient with BD when abdominal symptoms accompany the clinical picture. As soon as the diagnosis is reached, surgical intervention with limited resection must be performed. Endoscopic examination and careful medication play major roles in the follow-up.     

Isolated Ruptured Inter‐Atrial Septal Cystic Echinococcosis during Pregnancy

Herein, we present a case of asymptomatic isolated cardiac cystic echinococcosis localized entirely to the inter‐atrial septum in a pregnant woman. The patient underwent successful surgery. Cardiac cystic echinococcosis is rarely seen in pregnancy. A high index of suspicion is necessary for the diagnosis of a cardiac cyst hydatid. The treatment of cardiac cyst hydatid is surgical and should not be delayed during pregnancy. Early surgery might prevent septic embolization and cardiac life‐threatening complications and save the lives of both mother and baby as in the present case.     

Interleukin 3 Stimulation Enhances Tyrosine Phosphorylation and Proliferative Activity of Human Fetal Thymocytes and Leukemic T-cell Precursors at Multiple Developmental Stages of T-Cell Ontogeny

The purposes of this study were to elucidate the biologic effects of recombinant human interleukin 3 (rhIL-3) on leukemia T-cell precursors and fetal thymocytes corresponding to discrete and sequential developmental stages of human T-cell ontogeny, and to examine the biochemical nature of the IL-3 receptor linked transmembrane signal in human T-cell precursor populations. The specific binding of biosynthetically labeled ³⁵S-rhIL-3 to leukemic T-cell precursors from T-lineage ALL patients was initially investigated. In 5 of 9 cases, the binding of ³⁵S-rhIL-3 was significantly blocked by excess cold rhIL-3, and the percentage of inhibitable binding ranged from 40% to 64% (mean ± SE = 53 ± 4%). In these cases, 5-13 femtomols (mean + SE = 7.0 ± 1.5 fms) of ³⁵S-rhIL-3/10⁷ cells were specifically bound. rhIL-3 stimulated in a dose dependent fashion the in vitro clonal proliferation of leukemic T-cell precursors with composite immunophenotypes corresponding to the developmental stages of prothymocytes/double negative immature thymocytes (3 of 5 cases) and corticothymocytes/double positive CD4⁺CD8⁺ immature thymocytes (4 of 4 cases). By contrast, leukemic T-cell precursors from 2 T-lineage ALL cases with a composite immunophenotype of medullary thymocytes/single positive CD4⁺CD8^-/CD4^-CD8⁺ mature thymocytes did not show an enhanced proliferative activity after stimulation with increasing concentrations of rhIL-3. All of the 5 cases with significant ³⁵S-rhIL-3 binding and none of the 4 cases with no ³⁵S-rhIL-3 binding showed a proliferative response to rhIL-3. Thus, there was a high correlation between ³⁵S-rhIL-3 binding and proliferative response of leukemic T-cell precursors in colony assays, indicating that functional IL-3 receptors were detected in ligand binding assays. rhIL-3 also stimulated the proliferation of immature double positive CD4⁺CD8⁺ thymocytes from 9 of 10 fetal thymuses without inducing differentiation and with no selective advantage for the development of CD4⁺CD8^- or CD4^- or CD4^-CD8⁺ single positive thymocytes. The observed differences in IL-3 responsiveness among T-cell precursor populations at distinct developmental stages indicates that IL-3 receptors may be expressed only during the early stages of human T-cell ontogeny preceding the negative or positive selection events within the thymic microenvironment. Stimulation of fetal thymocytes with rhIL-3 resulted in enhanced tyrosine phosphorylation of 8 distinct cellular substrates with molecular weights of 44 kDa, 55 kDa, 60 kDa, 69 kDa, 98 kDa, 123 kDa, 150 kDa and 190 kDa, but it did not result in stimulation of phosphoinositide turnover and increased Ins-1,4,5-P₃ production. The induction of tyrosine phosphorylation by rhIL-3 was augmented by further crosslinking surface bound IL-3 molecules with an anti-IL-3 antibody and it was abrogated by the tyrosine kinase inhibitor genistein. The ligation of the CD45 protein tyrosine phosphatase markedly suppressed the tyrosine phosphorylation of specific substrates induced by IL-3 stimulation. Thus, the mitogenic transmembrane signal triggered by the engagement of the IL-3 R on human T-cell precursors is linked to a functional protein tyrosine kinase (PTK)/protein tyrosine phosphatase (PTP) regulatory pathway. Taken together, these results indicate that IL-3 may have an important growth regulatory role in early stages of human T-cell ontogeny.     

Acute rest perfusion imaging in high risk unstable angina: association with troponin T and clinical endpoints

BACKGROUND: Troponin T (TnT) and rest perfusion imaging (RPI) have been reported to be important diagnostic tools for risk stratification in patients with chest pain. METHODS: We investigated the association between two methods in 60 patients presenting with typical chest pain at rest within the last 6 h before admission. All patients underwent Tc-99m gated SPECT imaging and serial TnT measurements and were followed for occurrence of adverse cardiac events up to 30 days. RESULTS: Perfusion defect was detected in 42 patients and elevated TnT was observed in 23 patients. All of the patients with an elevated TnT have also perfusion defect in RPI. Half of the patients with normal TnT level (51%) presented a perfusion defect detected by RPI (p = NS). The patients with elevated TnT levels had more perfusion defect numbers than those with normal TnT levels (8.2 +/- 2.9 vs. 5.3 +/- 2.2; p = 0.0007). Cardiac events occurred in 38 patients (14 MI, 24 revascularisation). In predicting cardiac events, RPI and TnT had sensitivities (97 vs. 58%; p < 0.001), specificities (77 vs. 95%, p = NS), positive predictive values (PPV) (88 vs. 96%; p = NS) and negative predictive values (NPV) (94% vs. 57%; p = NS), respectively. In predicting MI, the two tests had sensitivities (93 vs. 93%; p = NS), specificities (37 vs. 78%; p < 0.001), PPVs (31 vs. 57%; p = NS) and NPVs (94 vs. 97%; p = NS), respectively. CONCLUSIONS: These results suggest that in patients with rest angina (1) TnT elevation is associated with the extent of myocardial perfusion defect; (2) both tests are valuable, while positive RPI is more sensitive in predicting all cardiac events irrespective of TnT; both positive TnT and positive RPI predict a high probability to have MI; (3) both negative test results predict a very low probability to have cardiac event, including MI.     

The role of clinical experience,diagnosis, and theoretical orientation in the treatment of posttraumatic and dissociative disorders: A vignette and survey investigation

Controversy exists regarding the merits of exposure-based treatments for posttraumatic stress disorder (PTSD) versus a phased approach when prominent dissociative symptoms are present. The first aim of this study was to examine the degree to which diagnosing dissociation in two traumatized patients’ vignettes influenced clinicians’ preference for phase-oriented treatment and whether clinicians’ treatment experience contributed to their treatment preference. The second aim was to assess the extent to which participants had observed traumatized patients worsen when treated with exposure therapy or phase-oriented therapy and whether the theoretical orientation and treatment experience of the clinician were related to the observed deterioration. In the tradition of expert and practitioner surveys, 263 clinicians completed a survey of their diagnoses and treatment preferences for two vignettes and their treatment experience, theoretical orientation, and observations of patients’ deterioration. When a marked degree of dissociation was noted in the PTSD vignette, respondents favored phased approaches regardless of the diagnosis given. Reports of having observed patient deterioration during both exposure and phased therapy were predicted by years of experience. Psychodynamic therapists reported more observations of worsening during exposure therapy than cognitive behavior therapy therapists. Clinical experience treating PTSD may heighten awareness of negative therapeutic effects, potentially because experienced clinicians have a lower threshold for detecting such effects and because they are referred more challenging cases.     

Acute dissociative reaction to spontaneous delivery in a case of total denial of pregnancy: Diagnostic and forensic aspects

This article presents the history of a 21-year-old female college student with total denial of pregnancy who experienced an acute dissociative reaction during the spontaneous delivery at home without medical assistance where the newborn died immediately. Psychiatric examination, self-report questionnaires, legal documents, and witness reports have been reviewed in evaluation of the case. Evidence pointed to total denial of pregnancy, that is, until delivery. The diagnoses of an acute dissociative reaction to stress (remitted) and a subsequent PTSD were established in a follow-up examination conducted 7 months after the delivery. Notwithstanding the inherently dissociative nature of total denial of pregnancy, no other evidence has been found about pre-existing psychopathology. For causing the newborn’s death, the patient faced charges for “aggravated murder,” which were later on reduced into “involuntary manslaughter.” Given the physical incapacity to perform voluntary acts due to the loss of control over her actions during the delivery, and the presence of an acute dissociative reaction to unexpected delivery, the legal case represents an intricate overlap between “insanity” and “incapacitation” defenses. The rather broad severity spectrum of acute dissociative conditions requires evaluation of the limits and conditions of appropriate legal defenses by mental health experts and lawyers. Denial of pregnancy as a source of potential stress has attracted little interest in psychiatric literature although solid research exists which documented that it is not infrequent. Arguments are presented to introduce this condition as a diagnostic category of female reproductive psychiatry with a more neutral label: “unperceived pregnancy.”     

Analysis of the outcomes of cardiopulmonary resuscitation in an emergency department

OBJECTIVE: The aim of this study is to analyse the factors affecting emergency department (ED) cardiopulmonary resuscitation (CPR) outcome. METHODS: A standard CPR protocol was performed in all patients and certain pre and postresuscitation parameters including age, sex, initial arrest rhythm, primary underlying disease, initiation time of advanced cardiac life support, duration of return of spontaneous circulation were recorded. Patients were followed up to determine rates of successful CPR, survival and one-year survival. RESULTS: From December 1999 to May 2001, 80 consecutive adult patients in whom a standard CPR was performed in the ED were prospectively included in the study. The overall rate for successful CPR, survival and one-year survival were found to be 58.8% (47/80), 15% (12/80) and 10% (8/80), respectively. Survival and one-year survival rates were better in patients with an initial arrest rhythm of ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) than both pulseless electrical activity (pEA) and asystole; survival and one-year survival rates were better in patients with a primary underlying disease of cardiac origin than non-cardiac origin. Acute myocardial infarction had the best prognosis among conditions causing arrest. Presence of sudden death was found to have a better survival and one-year survival rate. CONCLUSION: Initial cardiac rhythm of VF/pVT, cardiac origin as the primary disease causing cardiopulmonary arrest and presence of sudden death were found to be good prognostic factors in CPR.     

Renal sympathetic denervation therapy in the real world: results from the Heidelberg registry

Introduction

Renal sympathetic denervation (RDN) is a novel treatment option in patients with treatment-resistant arterial hypertension. A subset of recently published randomized and non-randomized trials indicates that RDN leads to sustained lowering of blood pressure (BP) under controlled study conditions. However, registry data that allow evaluation of safety and efficacy in a real-world setting are largely missing.

Methods

Sixty-three consecutive patients with treatment-resistant hypertension underwent RDN with the radiofrequency-based Symplicity? catheter. As part of our prospective registry, treatment efficacy and safety were monitored after 3, 6, and 12 months.

Results

At 6 months follow-up, office systolic BP significantly improved by 19 + 23 mmHg as compared to baseline, while diastolic BP values reduced by 6 + 13 mmHg (p < 0.05). One year after RDN, office BP levels further improved (26 + 25 mmHg in systolic BP and 9 + 13 mmHg in diastolic BP, respectively), even though 19 patients had reduced the number and/or dosage of antihypertensive agents. The response rate, defined as reduction of office systolic BP of ≥10 mmHg, was 73 % after 6 months. Baseline BP was the only significant predictor of blood pressure response, whereas no correlation was found between the number of ablation points and the individual changes in office blood pressure. Interestingly, patients with challenging renal anatomy profited somewhat less from the procedure than those with “normal” renal anatomy. Procedure related adverse events occurred in three patients (4.7 %) and were limited to vascular access complications.

Conclusions

RDN with the Symplicity? system is safe and effective in patients with treatment-resistant hypertension also in a real-world setting.