Plädoyer für die primäre Resektion mit primärer Anastomose bei der komplizierten Sigmadiverticulitis

Zusammenfassung Von 1973 bis 1986 wurden 107 Patienten mit einer komplizierten Sigmadiverticulitis operiert. Es handelte sich um 47 Frauen und 60 Männer bei einem Durchschnittsalter von 62 Jahren. Von 107 Patienten wiesen 14 eine perforierte Diverticulitis mit diffuser eitriger/kotiger Peritonitis auf, 68 Patienten eine perforierte Diverticulitis mit lokalisierter eitriger Peritonitis/paracolischem Absceß und 25 Patienten eine akute phlegmonöse Diverticulitis ohne Perforation. Zusätzliche pathologische Befunde waren: innere Fisteln (13 Patienten), nekrotisierende Fasciitis (3 Patienten), Stenose mit Ileus (3 Patienten) und synchrone Carcinome (7 Patienten). Die Gesamtletalität der 107 Patienten betrug 9,3% (=10 Patienten), die Morbidität der 97 überlebenden Patienten 34,0% (= 33 Patienten). Die Letalität bei 14 Patienten mit perforierter Diverticulitis und diffuser eitriger/kotiger Peritonitis lag bei 50%, die der 68 Patienten mit perforierter Diverticulitis und lokaler eitriger Peritonitis/ paracolischem Absceß bei 4,4%, die der 25 Patienten mit akuter phlegmonöser Diverticulitis ohne Perforation bei 0%. Von den 10 Patienten verstarben 7 bei Operation ihrer perforierten Diverticulitis mit diffuser eitriger Peritonitis, 1 (5) nach primärer Resektion mit primärer Anastomose, 3 (5) nach Operation nach Hartmann, 3 (4) nach alleiniger Anlage einer Colostomie. Bei Operation der perforierten Diverticulitis mit lokaler Peritonitis verstarben 3 Patienten, 2 (6) nach Operation nach Hartman und 1 (5) nach alleiniger Anlage einer Colostomie. Trotz einer hohen Zunahme der Zahl primärer Resektionen mit primärer Anasto mose im Zeitraum 1980–1986 ergab sich im Vergleich zum 7-Jahresabschnitt 1973–1979 ein Rückgang der Letalität von 35,7% auf 0% bei dieser Operation. Ihre Anwendung ist auch gerechtfertigt bei der perforierten Diverticulitis mit lokaler wie diffus eitriger oder kotiger Peritonitis.

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Primary resection with primary anastomosis in complicated diverticulitis of the sigma

Summary Of the 107 patients with complicated diverticulitis operated from 1973–1986 47 were females and 60 males. In 14 of the 107 patients a perforated diverticulitis with diffuse purulent/faecal peritonitis was found, a perforated diverticulitis with localized purulent peritonitis/paracolic abscess in 68 patients and an acute phlegmonous diverticulitis without perforation in 25 patients. Additional pathologic findings were internal fistulae (13 patients), necrotizing fasciitis (3 patients), obstruction (3 patients) and synchronous carcinoma (7 patients). The overall mortality of the 107 patients was 9.3 % (=10 patients) and the morbidity of the 97 survivors 34% (=33 patients). The mortality of the 1.4 patients with perforated diverticulitis and diffuse purulent peritonitis was 50%, of the 68 patients with perforated diverticulitis and localized purulent peritonitis 4.4% and of the 25 patients with acute phlegmonous diverticulitis 0%. Seven of the 10 patients died after operation of the perforated diverticulitis with diffuse purulent peritonitis — 1 (5) after primary resection with primary anastomosis, 3 (5) after Hartmann procedure, 3 (4) after loop colostomy alone. Three patients died after operation of the perforated diverticulitis with localized purulent peritonitis — 2 (6) after Hartmann procedure, 1 (5) after loop colostomy alone. In spite of forcing the primary resection with primary anastomosis in the years from 1980–1986 the mortality decreased for these operations from 35.7% in 1973–1979 to 0% in 1980–1986. The indication of primary resection with primary anas tomosis is justified also for perforated diverticulitis with localized and diffuse peritonitis.

Auszugsweise vorgetragen auf dem Symposium Entzündliche Darmerkrankungen der Medizinischen Akademie Carl Gustav Carus, Dresden, 20. November 1987     

Inflammatory regulation of extracellular matrix remodeling in calcific aortic valve stenosis.

BACKGROUND: Calcific aortic stenosis (AS), the most frequent heart valve disorder in developed countries, leads to the calcification and fibrous thickening of the valve. While several studies have addressed the process of valvular calcification, the molecular pathomechanisms of the extensive matrix remodeling remain unclear. Because inflammation is present in stenotic valves, we hypothesized that the proinflammatory cytokine tumor necrosis factor alpha (TNFalpha) might influence cell proliferation and regulate the expression and activation of matrix metalloproteinases (MMPs)--enzymes that are thought to be involved in calcific AS. METHODS: Immunohistochemistry for leukocytes, TNFalpha, MMP-1, and the endogenous MMP inhibitor tissue inhibitor of metalloproteinase (TIMP)-1 was performed on human stenotic (n = 19) and control (n = 8) valves. Primary cultures of human aortic valve myofibroblasts were incubated with and without TNFalpha, and cell proliferation was assessed. The expression and activation of MMP-1 were detected by Western blotting and a specific MMP-1 activity assay. RESULTS: Control valves showed scattered macrophages and low expression of TNFalpha, MMP-1, and TIMP-1. In stenotic valves, leukocyte infiltration and a strong, colocalized expression of TNFalpha and MMP-1 were present, while TIMP-1 remained unchanged. Double-label immunofluorescence localized TNFalpha mainly to macrophages. In cultured human aortic valve myofibroblasts, TNFalpha stimulated proliferation and induced a time-dependent increase in MMP-1 expression and activation, while TIMP-1 remained unchanged. CONCLUSION: The results indicate that matrix remodeling in calcific AS involves the expression and activation of MMPs. Activated leukocytes, by the secretion of TNFalpha, may stimulate valvular myofibroblasts to proliferate and express MMPs, thus regulating actively the matrix remodeling in calcific AS.     

Is one assessment enough? Patterns of helping alliance development and outcome

Early therapeutic alliance is usually measured by the rating of a single session (between the third and the fifth sessions). However, there is a strong argument in favor of viewing early alliance as a developing process. This study examined the relationship between patient's rating of the helping alliance (HAq) at each session and therapy outcome. This comparison was repeated using patterns of alliance over the course of treatment. Patterns of therapeutic alliance development were detected by clustering ratings of a sample of N = 70 outpatients across four sessions of very brief psychotherapeutic intervention. Cluster analysis revealed two main patterns (shapes) of alliance development: (i) stable alliance, and (ii) linear growth pattern. These patterns are more predictive of symptom improvement and social adjustment than single ratings, whereas single ratings measuring the strength of alliance are more correlated with patient's satisfaction. Copyright © 2004 John Wiley & Sons, Ltd.     

Cytologische und cytogenetische Untersuchungen an homologen und heterologen Lymphocyten-Mischkulturen

Zusammenfassung In Mischkulturen von menschlichen Blutlymphocyten verschiedener Spender treten auch in Abwesenheit von Phytohämagglutinin oder von spezifischen Antigenen aktivierte, blastenartige und proliferierende Zellen auf. In Erweiterung bisher vorliegender Befunde wurden Untersuchungen über die gegenseitige Lymphocytenstimulation bei der Kultivierung von Blutzellen anisogenetischer menschlicher Spender und von Milzlymphocyten der Maus und des Meerschweinchens durchgeführt. Die Ergebnisse zeigen, daß die reziproke Lymphocytenaktivierung nicht artbegrenzt ist, sondern auch in Mischkulturen der verschiedenen intra- und interspezifischen Versuchsgruppierungen vorhanden ist. Die in den homologen und heterologen Lymphocyten-Mischkulturen in wechselnder Zahl auftretenden blastenartig transformierten und proliferierenden Zellen zeigen in ihren cytologischfärberischen Eigenschaften eine weitgehende Übereinstimmung mit den unter Phytohämagglutininbzw. spezifischer Antigen-Stimulation nachweisbaren aktivierten Lymphocyten. Cytogenetische Untersuchungsverfahren erlauben mit Hilfe der Chromosomen-Marker-Technik anhand einfacher chromosomaler Erkennungsmerkmale eine Analyse der jeweiligen Herkunft der blastenartigen Zellen und liefern den Beleg dafür, daß die Lymphocyten der Spender-Partner sich gegenseitig zu stimulieren vermögen.

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Summary Blastoid transformation and proliferation of lymphocytes can be observed in mixed cultures of human white blood cells of different donors. This transformation occurs in the absence of phytohaemagglutinin or specific antigens. Observations on reciprocal activation of anisogeneic human lymphocytes of peripheral blood are supplemented by results on mixed cultures of spleen lymphocytes from the mouse and guinea-pig. It should be stressed that reciprocal lymphocytic activation is not limited to a species, but occurs in intra- and interspecific combinations from different donors. This effect can be observed in animals which show no or only a conditioned phytohaemagglutinin-response of lymphocytes. The blastoid cells occuring in homologous and heterologous mixed lymphocyte cultures display the same cytologic characteristics as the human blastoid cells induced by phytohaemagglutinin or antigenic stimulation. Cytogenetic methods provide means of identification of the individual origin of blastoid cells by using simple cytogenetic (chromosomal) markers in the different sexes or species of the donors. Thus it can be stated that mixed lymphocytic reaction leads to a mutual or two-way activation of the lymphocytes of both donors. The mixed lymphocytic reaction seems to represent a immunocytological reaction based on a membrane-bound antigen-antibody interaction of competent lymphocytes.

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Auszugsweise vorgetragen auf der 50. Tagung der Deutschen Gesellschaft für Pathologie in Heidelberg, 1966.

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Mit Unterstützung der Deutschen Forschungsgemeinschaft.     

Immunodeficiency with low expression of the T cell receptor/CD3 complex. Effect on T lymphocyte activation.

We report the consequences of low expression of the T cell receptor (TcR)/CD3 complex by T lymphocytes from a 4-year-old boy with a mild immunodeficiency. TcR/CD3 expression was found to be deficient on both resting and activated T cells, using both anti-CD3 and anti-TcR alpha/beta monoclonal antibodies. As shown by immunofluorescence and immunoprecipitation studies, residual expression (corresponding to about 10% of normal) was detectable on resting and activated TcR alpha/beta+ T cells. Other T cell membrane receptors were normally expressed. The functional consequences of this TcR/CD3 expression deficiency included an absence of T cell proliferation, interleukin 2 receptor expression and calcium flux following anti-CD3 and anti-CD2 antibody-triggered T cell activation. Antigen (tetanus toxoid, Candida and allogeneic cell)-induced proliferation was detectable. In contrast, cytotoxic T cell activity towards allogeneic cells was deficient. These findings shed light on the function of the TcR/CD3 complex and indicate that the expression of a limited number of TcR/CD3 receptors may be sufficient to trigger antigen-specific T cell activation (and, possibly, differentiation) and that anti-CD3 antibody-induced T cell activation differs somewhat from antigen/major histocompatibility complex molecule-induced activation. These results also confirm that the CD2 pathway of T cell activation is CD3 dependent.     

Neisseria sicca osteomyelitis.

Neisseria sicca was identified as the cause of vertebral osteomyelitis in a male patient who had previously suffered a nonpenetrating, traumatic back injury. The identifying characteristics and antimicrobial susceptibility patterns are presented for this rare human pathogen, which heretofore has not been reported as a cause of infection localized to bone.     

Riluzole suppresses motor cortex facilitation in correlation to its plasma level

The aim of our study was to measure the effects of the glutamate antagonist riluzole on different parameters of motor excitability, using transcranial magnetic stimulation (TMS) during 7 days of riluzole administration, and to correlate these effects with riluzole plasma levels. Nine healthy volunteers received a dose of 100 mg riluzole from day 1 to 7 of the study period. Electrophysiological examinations were performed on day 1 before and 2 h, 5 h and 8 h after riluzole administration, on day 2, day 3 and day 5 before riluzole administration, and on day 8. Plasma samples were taken simultaneously. The excitability of the motor cortex, supraspinal and spinal motor pathways was tested by studying intracortical facilitation and inhibition, the cortical silent period and motor threshold after TMS, as well as the peripheral silent period and F-wave amplitudes after electrical peripheral nerve stimulation. We found a significant reduction of intracortical facilitation, which correlated significantly with riluzole plasma levels. To a lesser extent, intracortical inhibition was enhanced on day 1, motor threshold was increased on day 8 and F-wave amplitudes were reduced. These changes did not correlate with riluzole plasma levels. We conclude that the main effect of riluzole in vivo is a reduction of intracortical facilitation, which is closely related to the drug's level in the plasma. The most probable mechanism involves an effect on glutamatergic synaptic transmission.     

pH regulation in HT29 colon carcinoma cells

The pH regulation in HT₂₉ colon carcinoma cells has been investigated using the pH-sensitive fluorescent indicator 2,7-biscarboxyethyl-5(6)-carboxyfluorescein (BCECF). Under control conditions, intracellular pH (pH_i) was 7.21±0.07 (n=22) in HCO ₃ ^– -containing and 7.21±0.09 (n=12) in HCO ₃ ^– -free solution. HOE-694 (10 mol/l), a potent inhibitor of the Na⁺/H⁺ exchanger, did not affect control pH_i. As a means to acidify cells we used the NH ₄ ⁺ /NH₃ (20 mmol/l) prepulse technique. The mean peak acidification was 0.37±0.07 pH units (n=6). In HCC ₃ ^– -free solutions recovery from acid load was completely blocked by HOE-694 (1 mol/l), whereas in HCO3 ₃ ^– -containing solutions a combination of HOE-694 and 4,4-diisothiocyanatostilbene-2, 2-disulphonate (DIDS, 0.5 mmol/l) was necessary to show the same effect. Recovery from acid load was Na⁺-dependent in HCO ₃ ^– -containing and HCO ₃ ^– -free solutions. Removal of external Cl^– caused a rapid, DIDS-blockable alkalinization of 0.33±0.03 pH units (n=15) and of 0.20±0.006 pH units (n=5), when external Na⁺ was removed together with Cl^–. This alkalinization was faster in HCO ₃ ^– -containing than in HCO ₃ ^– -free solutions. The present observations demonstrate three distinct mechanisms of pH regulation in HT₂₉ cells: (a) a Na⁺/H⁺ exchanger, (b) a HCO ₃ ^– /Cl^– exchanger and (c) a Na⁺-dependent HCC ₃ ^– transporter, probably the Na⁺-HCO ₃ ^– /Cl^– antiporter. Under HCO ₃ ^– — free conditions the Na⁺/H⁺ exchanger fully accounts for recovery from acid load, whereas in HCO ₃ ^– -containing solutions this is accomplished by the Na⁺/H⁺ exchanger and a Na⁺-dependent mechanism, which imports HCO ₃ ^– . Recovery from alkaline load is caused by the HCO ₃ ^– /Cl^– exchanger.This study was supported by DFG Gr 480/10