Heparin-mediated extracorporeal LDL precipitation treating a peripheral arterial disease patient suffering from repeated postoperative bypass occlusion

Acute occlusion of a peripheral artery is a serious complication in peripheral arterial disease (PAD). Traditionally open surgical intervention in combination with antithrombotic therapy is the choice for treatment but the beneficial effects of both strategies are limited often by the patient's situation and therapeutic side effects. Heparin-mediated extracorporeal low-density lipoprotein precipitation (H.E.L.P.) apheresis efficiently removes circulating atherogenic lipoproteins, fibrinogen and C-reactive proteins as well as various proinflammatory and procoagulatory factors. We first report H.E.L.P. apheresis treating a PAD patient suffering from repeated postoperative femoropopliteal bypass graft occlusion, first, intensively, followed by weekly intervals. Limb amputation was avoided and the patient is doing well now. Angiography revealed bypass graft remained patent half a year after operation. This case report might help to design the regime for preventing postoperative bypass occlusion in patients with hyperlipidemia or hyperfibrinogenemia.     

Cranial suture simulator for ultrasound diagnosis of craniosynostosis

Background: In evaluating the effectiveness of ultrasound as a screening tool for craniosynostosis it was discovered that sonologists and sonographers needed more experience scanning and visualizing cranial sutures on ultrasound. Objective: To create an ultrasound simulator to train radiologists and technologists to locate and recognize patent and fused cranial sutures in children. Materials and methods: The hypoechoic appearance of patent sutures was simulated by cutting lines into life-sized plastic doll heads and filling them with a commercial hypoechogenic material. Fused hyperechoic sutures were simulated by not cutting into the hard plastic region of a suture. The simulators teaching value was evaluated on three radiology residents and three fellows. Subjects performed pre-training scans on unknown simulators, received feedback and an opportunity to scan a training simulator, and then performed post-training scans on random unknown simulators. Accuracy was recorded as percentage of correctly demonstrated sutures. Results: The suture simulator reproduces the sonographic appearance of patent and fused cranial sutures. Accuracy of acquisition, interpretation, and overall diagnosis increased from 64 to 91%, 79 to 91%, 61 to 97%, respectively, between pre and post training scans. Conclusion: An ultrasound simulator can reproduce the appearance of patent and fused cranial sutures in children and can be used to train radiologists and technologists in the performance of a screening protocol.     

Occult, life-threatening, cardial tumor in syndactylism in Gorlin Goltz syndrome

Pediatric, orthopedic, plastic, and hand surgeons perform the surgical correction of syndactylism. It is sometimes forgotten, however, that syndactylism can be part of a syndrome. The components of such a syndrome can each be life threatening. A 7-month-old boy was hospitalized for correction of cutaneous syndactylism. The mother claimed that, with the exception of the syndactylism, her son was healthy. However, review of the admission documents found that the family physician suspected Gorlin Goltz syndrome. A preoperative echocardiography showed 3.9-cm intramural tumor in the wall of the left ventricle. Electrocardiography documented ventricular tachycardia. Because of the danger of life-threatening malignant ventricular tachycardia, the tumor was resected. Before the resection, cardiac transplantation was considered because of the size of the tumor. Histologic examination found a fibroma. When observing syndactylism, one must always be aware of the possibility of a syndromic disease. It is particularly important that screening investigations, including electrocardiography and echocardiography, are performed before surgical treatment.     

In vitro activity of extracts and constituents of Pelagonium against rapidly growing mycobacteria

Extracts of the roots of plants of the Geraniaceae family have been used for many years in South Africa as native herbal remedies and there is circumstantial evidence for efficacy in the treatment of pulmonary tuberculosis. We have examined dried roots of Pelargonium reniforme and P. sidoides for antibacterial activity against rapidly growing mycobacteria. Fractions with activity against Mycobacterium aurum and M. smegmatis were obtained from both plant species by bioassay-guided fractionation of n-hexane extracts and were found to contain mixtures of straight-chain fatty acids. Analysis by gas chromatography–mass spectrometry (GC–MS) of the corresponding fatty acid methyl esters revealed structures with chain lengths ranging from C12 to C26. Unsaturated compounds were analysed as the corresponding dimethyl disulfide adducts to determine double-bond positions. Active mixtures differed in the relative abundance of their components, but all contained 16:0 (palmitic), Δ⁹-18:1 (oleic) and Δ^9,12-18:2 (linoleic acid) as the major components. When tested against M. aurum, M. smegmatis and other rapidly growing mycobacteria (M. fortuitum, M. abscessus and M. phlei), all saturated compounds except 12:0 were devoid of antimycobacterial activity, whereas unsaturated compounds showed antimycobacterial activity related to their degree of unsaturation, their chain length and the bacterial species tested. The most potent compound was linoleic acid, with MIC of 2 mg/l against M. aurum.     

Assessing health-related quality of life data of building trade workers by means of the SF-36 questionnaire

The Lower Saxony statutory medical service of the building trade, the building trade association in Hanover and the statutory health insurance body of Lower Saxony have co-operated in the "ArGO" model project. The objective was to focus on the main areas of work-dependent health hazards and disorders. The SF-36 questionnaire was employed to ascertain how far the results obtained concerning health-related quality of life were suitable for this purpose. Hence, the data from industrial medical check-ups were compared with the additional findings for 4,334 building trade workers. Additional unfitness for work and medication data were available from the health insurance schemes for about one half of the group. The analyses revealed clear relationships between the subjectively experienced disorders on the one hand, and the stress and illness data on the other. In addition to age and the conventional stresses, e. g. strenuous physical work, the influence of psychosocial stress was also reflected in the assessment of the quality of life. The results obtained confirm the value of the SF-36 questionnaire for preventive medicine at an industrial level. It is suitable for identifying focal points of stress and can be employed for assessing preventative measures.     

Neurobrucellosis presenting as leukoencephalopathy: the role of cytotoxic T lymphocytes

A 65-year-old man developed a leukoencephalopathy associated with neurobrucellosis. The disease followed a 15-month progressive course with neurologic symptoms, and magnetic resonance imaging revealed bilateral symmetrical T2 signal hyperintensities in the white matter. Biopsy of the cerebral cortex and white matter was significant for nongranulomatous meningoencephalitis with reactive microgliosis and astrogliosis. The inflammatory infiltrate was predominantly composed of T lymphocytes, including numerous cytotoxic T cells. There was no evidence of significant myelin destruction. No organisms were detected microscopically, but elevated immunoglobulin G titers to Brucella were found in the cerebrospinal fluid. An abscess formed at the biopsy site, and Brucella melitensis was cultured from abscess contents. Neurobrucellosis is difficult to diagnose outside endemic regions and is associated with leukoencephalopathy-like pathology. Cytotoxic T lymphocytes and microglia activation play an immunopathogenic role in this rare disease.     

Long-term prevention of premature coronary atherosclerosis in homozygous familial hypercholesterolemia

Homozygous familial hypercholesterolemia (FHH) leads to severe premature atherosclerosis. A 22-year-old woman with FHH has been treated with a combination of H.E.L.P. apheresis (heparin-mediated extracorporeal LDL precipitation) and statins for 15 years. The combined treatment maintained a plasma LDL-cholesterol reduction from baseline of 840 to 122 mg/dL (85% reduction). In addition, H.E.L.P. apheresis reduced the elevated lipoprotein(a) and fibrinogen levels by 60% to 70%. All xanthomata disappeared. There is no evidence of premature atherosclerosis studied by means of electron beam computed tomography and (13)N-ammonia positron emission tomography: The entire coronary vasculature is free of calcifications. Her myocardial blood flow at rest (87 mL/100 g/min) and during stress (308 mL/100 g/min) and the coronary flow reserve (3.5) are normal after H.E.L.P. treatment. This case demonstrates the efficacy and safety of the combined treatment of H.E.L.P. apheresis and statins even in serious cases of FHH.