Das akute Abdomen

Schlu?folgerungen Makroskopisch und histologisch handelte es sich um eine ausgepr?gte nekrotisierende Vaskulitis vom Panarteriitis-nodosa-Typ mit akuter Glomerulonephritis. Von klinisch rheumatologischer und serologischer Seite konnten klassische Krankheitsbilder einer Panarteriitis nodosa, Morbus Wegener oder Churg-Strauss-Syndrom ausgeschlossen werden. Immunologisch handelt es sich um eine Hypersensitivit?tsangiitis als hypererge Reaktion des Immunsystems im Rahmen einer akuten Gastroenteritis nach Hühnerfleischgenu?. Differentialdiagnostisch ist sie mit einer Vaskulitis einer Purpura Sch?nlein-Henoch vergleichbar. Nur durch kompetente interdisziplin?re Zusammenarbeit verschiedener Disziplinen war es m?glich, den Patienten optimal zu betreuen. Schwierige akute Gastroenteroitiden sollten gelegentlich an hypererge Reaktionen des Immunsystems denken lassen.     

Nonparasitic Cysts of the Liver: Results and Options of Surgical Treatment

n = 9) should be regarded as a palliative measure. Within a short period, CT-guided aspiration led to recurrence of symptoms in seven of our patients. Standard treatment of NPHC is fenestration with widest possible excision of the cystic wall, which can be performed laparoscopically ( n = 10) or by the conventional surgical mode ( n = 54). One patient was initially operated by the laparoscopic technique but developed bleeding, which necessitated conversion to the open mode. Three patients underwent synchronous laparoscopic cholecystectomy. Recurrence rates were similar: 11% in the laparoscopically treated group and 13% in the group that underwent conventional open surgery. Conventional surgical treatment was always successful in cases of solitary cysts. However, in cases of multiple cysts measuring more than 5 cm, conventional surgery was followed by recurrence of symptoms in 26% of patients (7/27), who then had to undergo a second operation. Partial resection of the liver ( n = 9) was successfully performed in cases of polycystic disease ( n = 5) with concomitant enlargement of the organ as well as in cases of large solitary cysts of the left lobe of the liver ( n = 4). In patients in whom we found that the cysts communicated with the ductal system ( n = 3), we performed a cystojejunostomy to drain the bile. The complication rate was low. In addition to frequent postoperative ascites, which necessitated no further intervention, we observed infectious complications in four patients. Twenty patients (22%) expired during a mean follow-up period of 6.2 years. Interestingly, deaths were frequently associated with malignancy (11/20). After fenestration of multiple cysts measuring > 5 cm, the patients are at high risk for recurrence. Hence partial resection of the liver is an excellent therapeutic alternative in selected patients with polycystic disease and massive enlargement of the organ in whom the disease could not be controlled by simple fenestration. The results of this study show that laparoscopic fenestration should replace the conventional surgical technique as the gold standard in cases of NPHC because the laparoscopic technique is less stressful for the patient and is associated with a rate of success similar to that of the conventional technique.     

Practical selection criteria for unenhanced cranial CT in patients with acute headache

We studied clinical predictors of cranial computed tomography (CT) abnormalities in patients with acute or acutely worsened headache. Data were collected from chart review of 333 consecutive patients presenting to an emergency department and who were clinically selected for cranial CT. Patients with a positive neurologic examination were at 10.7 times greater risk for a positive CT than the rest of the sample (p<1.5 – 10⁻¹⁰). Using only neurologic examination to select patients for CT would have missed 30.3% of the positive scans. The amnesia, depressed sensorium, and hypertension variables had CT yields approximating 10% or greater even in the presence of a negative neurologic examination. Together with a positive neurologic examination, these variables detected 87.9% of the patients in this sample with positive scans; their absence had a negative predictive value of 98.0%. Of the four patients with positive scans who would have been missed using this strategy, one was discharged directly from the emergency department anyway and the other three developed positive neurologic examinations within 24 hours. One died of causes unrelated to the intracranial pathology. Positive neurologic examination, hypertension, history of amnesia, or a depressed sensorium provide reasonable initial guidelines to select for CT patients with an acute headache.     

The beta subunit of human chorionic gonadotropin lacks specificity for malignant cells in serous effusions.

The cytologic diagnosis of malignancy is frequently straightforward. For difficult cases, multiple immunostains and immunostain panels have been investigated without consensus. beta-human chorionic gonadotropin (hCG) has been reportedly expressed in malignancies, but not in normal tissue. HCG also has been reported as a specific marker of metastases in serous fluids when detected with laboratory assays. We investigated the clinical utility of hCG in this cytologic setting. A total of 97 cases of benign and malignant effusions were studied. Each case was immunostained with monoclonal hCG using the avidin-biotin technique and diaminobenzidine as a chromogen. Additionally, a mucicarmine stain was performed on most cases. Cases were evaluated for hCG expression and mucin in a blinded fashion. After the cases were reviewed, the diagnoses were unblinded and staining patterns were evaluated. Of the 47 benign cases studied, 23 (49%) exhibited immunoreactivity to hCG in at least 5% of mesothelial cells present. In contrast, 28 of 44 (64%) adenocarcionomas exhibited a similar degree of immunostaining. In all, 21 (48%) of the adenocarcinomas were also positive for mucin; five of these mucin-positive cases were negative for hCG. The combination of mucin and hCG detected 33 of 44 (75%) adenocarcinomas. We conclude that hCG lacks the specificity for malignant cells to be of clinical use in effusion cytology.     

The future of healthcare and the pharmaceutical industry – a CEO view

In the century or so since the birth of the research-based pharmaceutical industry, there has never been a more demanding time. The most pressing issue facing virtually all big pharmaceutical companies today is research and development productivity. Despite huge investments in research and development, the number of new medicines cleared for market has declined. On the other hand, there has never been a more exciting time to do healthcare research. New sciences and technologies are opening up radically new perspectives and opportunities for the future. Medical practice is undergoing a historic shift towards more personalized medicine. Over the next 10 years we can expect significant progress in the treatment of major diseases.     

Development of specific antibody patterns and clinical symptoms following Ockelbo virus infection

Summary Sixteen patients with symptoms typical for Ockelbo disease (rash, arthralgia, fever) were enrolled in a 2 1/2 year study, during which clinical symptoms were recorded and ELISA was employed to study specific IgM, IgG and IgG subclass development. Initially, all patients presented with rash and arthralgia, and five patients still suffered from joint symptoms at the end of the study period. Ockelbo virus specific IgM was detected during the first week post onset in 6 patients and in 15 patients by day 14. One patient failed to develop specific IgM and was later diagnosed with a human parvovirus B 19 infection. All patients were IgM-negative 2 1/2 years post onset. Seroconversions or significant titer rises for specific total IgG were seen in 15 patients. IgG titers generally peaked within one year but in two patients maximum titers were seen 2 1/2 years post onset. Development of IgG1 followed that of total IgG, while IgG3, after an initial increase in all Ockelbo disease patients, remained at peak levels for one year in four patients, three of whom still had detectable IgG3 at the end of the study period. Ockelbo virus specific IgG2 or IgG4 was not detected in any of the patients.     

Amyotrophic lateral sclerosis patient antibodies label Ca2+ channel α1 subunit

Sporadic amyotrophic lateral sclerosis is an idiopathic human degenerative disease of spinal cord and brain motor neurons. Prior studies demonstrated that most patients with amyotrophic lateral sclerosis posses immunoglobulins that bind to purified L-type voltage-gated calcium channels, that titers of anti–voltage-gated calcium channel antibodies correlate with disease progression rates, and that amyotrophic lateral sclerosis patient-derived antibodies (ALS IgG) produce electrophysiological changes in the function of voltage-gated calcium channels. Using Western transfer immunoblots and enzyme-linked immunosorbent assays, the calcium ionophore–forming α₁ subunig of the voltage-gated calcium channel is now identified as the major voltage-gated calcium channel antigen to which ALS IgG binds. Additionally, the binding of an L-type voltage-gated calcium channel α₁ subunit–directed monoclonal antibody, which itself mimics the effects of ALS IgG on skeletal muscle voltage-gated calcium channel currents, is selectively prevented by preaddition of ALS IgG. Voltage-gated calcium channel–binding IgG from patients with Lambert-Eaton myasthenic syndrome appears to be differentiated from ALS IgG by the reactivity of the former to both α₁ and β subunits of the calcium channel. These assays provide further evidence linking amyotrophic lateral sclerosis to an autoimmune process, and suggest one means to differentiate immunoglobulins from patients with amyotrophic lateral sclerosis from those of patients with another autoimmune disease expressing calcium channel antibodies.