Multiple myeloma in a patient at risk for AIDS

An increased incidence of tumors and B-cell lymphomas development has been reported in persons with or at risk for acquired immunodeficiency syndrome (AIDS). This report focuses on a 50-year-old homosexual man with HIV antibodies who met the established criteria for the diagnosis of multiple myeloma: an IgG monoclonal spike greater than 2 g/dl and a plasma cell count greater than 20% in the bone marrow aspirate. Serum protein immunoelectrophoresis showed monoclonal IgG kappa, and in the urine no excess of kappa chains was found. Laboratory data revealed a total IgG of 38 g/l, IgA of 5.2 g/l, and IgM of 2.3 g/l; the calcium level was normal; ESR was 119/130, and no plasmocytoid cells were seen in the differential count. No lytic lesions were found in the skeletal survey. The helper/suppressor T-cell ratio was depleted with 0.1 and HLA-DR was highly elevated with 56% in the immunofluorescent analysis. The development of the most differentiated B-cell tumor broadens the spectrum of B-cell neoplasias in patients with a predominant helper T-cell defect and focuses on the role of disordered immunoregulation and chronic antigenic stimulation in predisposing to B-cell malignant transformation associated with AIDS.     

Propofol increased the interleukin-6 to interleukin-10 ratio more than isoflurane after surgery in long-term alcoholic patients

This study investigated the effect of an anaesthetic regimen on the immune response in 40 long-term alcoholic patients undergoing surgery. Patients were randomly allocated to receive either propofol or isoflurane during surgery. Plasma cytokines interleukin (IL)-6 and IL-10 were measured at defined times and rates of post-operative infections were documented. The IL-6/IL-10 ratio significantly increased with propofol compared with isoflurane on day 1 after surgery and the IL-10 level significantly increased with isoflurane on day 1 after surgery. The overall post-operative infection rate was significantly higher in isoflurane-treated patients. Our findings indicate that propofol anaesthesia might be the more favourable regimen, with the IL-6/IL-10 ratio indicating an attenuation of the immune imbalance after surgery in long-term alcoholic patients. These results support the undertaking of a properly powered clinical trial to determine if propofol anaesthesia can reduce the postoperative infection rate in this special patient population.     

Neurological and neuropsychological examination and outcome after use of an intra-aortic filter device during cardiac surgery

Cerebral embolization of particles after cardiac surgery is frequently associated with neurological deficits. Aortic crossclamp manipulation seems to be the most significant cause of emboli release during cardiac surgery. The goal of this study was to demonstrate whether the use of an intra-aortic filter device has an effect on the magnet resonance imaging (MRI) and functional neurological outcome. Twenty-four patients undergoing cardiosurgical procedures using cardiopulmonary bypass (CPB) were selected: coronary artery bypass graft (CABG) surgery (n = 17), aortic valve replacement (AVR) surgery (n = 4) or combined procedures (n = 3). Patients were evaluated by diffusion weighted MRI of the brain, neurological examination and neuropsychological assessment regarding alertness as well as divided and selective attention before and five to seven days after surgery. The patients were divided into two groups. In group I, 12 patients received a filter through a modified 24 F arterial cannula immediately before the aortic crossclamp was released. Filters remained in the aorta until CPB was discontinued. Intraoperatively, bilateral middle cerebral artery transcranial Doppler (TCD) was monitored at baseline, at the beginning of CPB, at a timepoint when the aorta was crossclamped, when the filter was inserted and while the crossclamp was switched to partial clamping until the CPB was discontinued. TCD was used for detection of microembolic signals (MES). The captured material in the filter was examined histologically. Twelve patients served as controls without aortic filtration (group II). The MRI of the brain did not show any diffusion alterations in either group before or after surgery. No patient developed a focal neurological deficit or stroke. Intraoperative quantitative MES detection revealed a four to tenfold increase in patients of group I compared with group II (5-6 versus 0.5-1 MES/min) during the filter dwell time. There was no consistent pattern regarding the neurobehavioural sequelae. Filters showed arteriosclerotic debris in 75% of the patients. The use of the intra-aortic filter device did not show a positive effect on neurological, neuroradiographical and neuropsychological outcomes. The increase of the MES rate in group I patients may be due to microbubbles generated as microcavitations by the filter or the aortic filter cannula. The intra-aortic filter was able to capture atheromatous material in 75% of the patients.     

The effect of kinesio tape on neuromuscular activity of peroneus longus

Background: Functional ankle instability is the result of sensorimotor or structural deficits. The commonly used kinesio tape (KT) is supposed to have a positive influence on sensorimotor functions. Methods: Eight women and two men (mean ± SD, age 24.4 ± 3.3 years) with functional ankle instability with recurrent ankle sprains ran downhill on a treadmill (3.3 m/s and a negative slope of 5°). The first trial was without KT, the second with KT on the peroneus longus (PL) muscle. Neuromuscular activity was measured using surface electromyography for 15 seconds. Sensation of giving way was assessed with a visual analog scale (VAS). Comparisons were made between measurements with and without KT using the Wilcoxon rank sum test. The level of significance was set at P ≤ 0.05. Results: None of the chosen parameters for preactivation, reflex activation, or total activation showed statistically significant differences between the two trials (P > 0.05). The mean values for the sensation of giving way were lower with KT (VAS, median 1.2, range 0–2.8) than without (VAS, median 1.8, range 0–3.9), but did not reach statistical significance (P = 0.102) or clinical relevance. Conclusion: KT in participants with functional ankle instability (FAI) seems to have no effect on the neuromuscular activity of PL and sensation of giving way during downhill running.     

Associations of serum EBV DNA and gammopathy with post-transplant lymphoproliferative disease

Abstract: Background: Post‐transplant lymphoproliferative disease (PTLD) is a life‐threatening complication of immunosuppression following transplantation. Epstein–Barr virus (EBV) and gammopathy in serum are associated with PTLD, but these two parameters have not been evaluated in parallel for their association with PTLD. Methods: We evaluated the incidence of EBV load positivity, gammopathy, and protein expression in sera from all PTLD patients diagnosed at our hospital during the past seven yr. Results were compared with those of a control group including matched transplanted patients who did not develop PTLD. Results: Seven of 10 PTLD patients presented EBV⁺ PTLD, for which five patients had detectable serum EBV DNA levels compared with none of 38 controls (RR between two groups =121, p < 0.0001). Five out of 10 patients had gammopathy at PTLD diagnosis compared with 5/38 controls (RR between two groups = 6.6, p = 0.022). Additionally, protein serum analysis by high‐resolution two‐dimensional gel electrophoresis and image examination failed to evidence specific abnormality in patients with PTLD compared with controls. Conclusions: Our results confirm an association between EBV in sera and gammopathy with PTLD, and highlight the high specificity of the former analysis. Whether a combination of both analyses will improve the clinical detection of PTLD remains to be evaluated in a larger prospective cohort study.     

Effects of short-term treatment strategies over 4 weeks in Achilles tendinopathy

Background

The therapeutic efficacy of non‐surgical treatment strategies in Achilles tendinopathy (AT) has not been well clarified. Time‐consuming and costly combinations of treatment for pain, physiotherapy and biomechanical procedures are often applied.

Objective

To analyse the efficacy of single therapeutic regimens commonly used over a short period of 4 weeks.

Methods

31 male runners (mileage >32 km/week) with unilateral, untreated AT completed 4 weeks of either physiotherapy (10 treatments: deep‐friction, pulsed ultrasound, ice, sensory motor training; (P)), wearing custom fit semirigid insoles (I) or remained without treatment (control group C). Before and after treatment, all patients underwent a treadmill test and a plantar flexion strength exercise. Subjective pain (Pain Disability Index, Pain Experience Scale), as well as strength performance capacity (peak torque), was analysed (mean, 95% CI, repeated measures analysis of variance, α = 0.05).

Results

Pain was reduced to <50% of the baseline value after physiotherapy or after wearing insoles (p<0.05). Individual pain reduction was >50% (25%) in 89% (100%) of subjects in I and 55% (73%) in P. Higher eccentric plantar flexion peak torques after treatment were observed in I and P.

Conclusions

Most patients with AT experience a reduction in pain after only 4 weeks of differentiated, non‐surgical treatment consisting of physiotherapy or semirigid insoles.Problems of Achilles tendon overuse are cited as one of the major pathologies that reduce physical capacity in everyday living, occupation and sports.^1,2,3 Owing to the long duration of problems and widely varying, individual responses to treatment, the efficacy of single or combined therapeutic measures still remains a matter of debate.^4,5 Thus, treatment is usually complex, time consuming and costly.^3,5It has often been assumed that Achilles tendon problems are caused by an inflammation.⁶ However, recent histological studies show that inflammatory cells and mediators, usually present after acute mechanical stress, are absent in tendon overuse.^7,8,9 On the other hand, high concentrations of glycosaminoglycans and a loss of the hierarchical collagen structure have been found.^10,11The mechanism of pain development is not well understood. Competing explanatory models describe increased mechanical tendon vulnerability, microruptures and the supplanting of collagen type I by type III. Pain is also ascribed to the mechanical irritation of ingrown nerve endings due to neovascularisation.^1,9 Reduced perfusion is now considered less important since it was demonstrated that blood supply and oxygen extraction clearly increase during physical exercise.^12,13 It thus seems certain that tendon tissue must be considered metabolically active to a far greater extent than has been assumed to date.^8,9Pain reduction has traditionally been the main outcome variable of non‐surgical treatment in Achilles tendinopathy (AT).³ In daily practice, local physiotherapeutic measures such as deep friction massages, ice and ultrasound are usually applied.^14,15,16 However, despite broad acceptance and pain reduction in individual cases, scientific evidence of short‐term physiotherapy is still lacking.¹⁴ Currently, adjuvant use of sensory motor training¹⁸ and eccentric exercises^18,19,20 are increasingly being discussed. Shalabi et al²¹ demonstrated that eccentric exercises led to an improved clinical outcome, reduction in tendon diameter and reduced intratendinous lesions. Alfredson et al^18,19 had comparably good clinical results after 12 weeks of predominantly eccentric exercise training.In addition to physiotherapy and training, custom‐made insoles are frequently used, but evidence of their efficacy is still lacking.^15,16 Recent studies using bone pins have shown that the mechanical effect of insoles, understood as an alignment of the skeleton, is unspecific and only slight during walking and running.²² Currently, sensory motor effects of semirigid insoles are being discussed.^23,24The aim of this study was to analyse whether standardised short‐term physiotherapy or wearing individually fitted insoles over a period of 4 weeks reduces pain in patients with unilateral AT.     

Seafaring stressors aboard merchant and passenger ships

Objectives:  The aim of this study was to identify stressors in seafaring aboard merchant and passenger vessels. Furthermore, their dependence on occupational and non-occupational factors was assessed. Methods:  A total of 134 male seafarers sailing under Germanflagged vessels were interviewed (response 81.3 %). The seamen rated the individual stress level of 23 different stressors aboard. Results:  Separation from their family (named 48 times), time pressure (30 times), long working days (28 times), heat in workplaces (24 times), and insufficient qualification of subordinate crew members (16 times) were regarded as the most important stressors aboard. In comparison to non-officers, officers stayed on board for considerably shorter periods (4.8 vs. 8.3 months) but had significantly more often an extremely high number of working hours (63.5 % vs. 21.1 %, Chi-square-test: p < 0.001). Correspondingly, officers complained more frequently of a higher stress level due to time pressure (52.4 % vs. 36.6 %). Conclusions:  Particular attention should be paid to preventive organizational measures such as avoiding long-time separation from family, time-pressure, extremely long working days, and a long stay on board. Submitted: 10 August 2007; revised: 25 September 2008, 16 December 2008; accepted: 23 January 2009     

Sorted averaging--application to auditory event-related responses

To isolate event-related potentials (ERPs) from the biological background noise, averaging of stimulus-locked electroencephalogram (EEG) epochs is needed. Recordings with patients often reveal a noisy background EEG, i.e., a high amplitude and multiple artifacts. Research studies have to deal with a limited number of available epochs. Therefore, averaging and efficient artifact rejection algorithms are needed. This paper focuses on the sorted averaging algorithm which was developed for the recording of auditory brainstem responses. We demonstrate the applicability of sorted averaging on ERPs by comparing three different averaging algorithms on a classical mismatch negativity (MMN) paradigm, recorded at 10 normal hearing volunteers. The resulting estimated signal-to-noise ratio (SNR) of the ERP waveforms was significantly increased compared to established averaging algorithms. Thus, the sorted averaging algorithm provides an improvement of the SNR in recordings with poor SNR (e.g., the MMN) or noisy background EEG (e.g., at Cochlear Implant users).