Verlängerungstechniken und Möglichkeiten des Segmenttransports im Ringsystem nach Ilizarov

We describe how to set up the Ilizarov ring fixator for lengthening and segmental transport in the calf and thigh.The complications encountered with lengthening (69 cases) and segmental transport (76 cases) and the results results obtained in these cases are presented.Lengthening was required for idiopathic conditions in 5 cases and for posttraumatic corrections in 64.The mean lengthening achieved was 4.5 cm, and the average distraction time required was 8.3 days/cm for the correction of idiopathic conditions and 14.9 days/cm for posttraumatic conditions; the corresponding fixation times required were 33.0 and 56.2 days/cm. After lengthening procedures 22 fixator-related and 3 procedure-related complications requiring treatment were encountered. Stability in the desired length was achieved in almost all cases. In 56 segmental transport procedures to correct defects of a mean of 7.6 cm in the calf, distraction required 16.4 days/cm and fixation, 49.7 days/cm. In these patients there were 15 fixator-related and 45 procedure-related complications that needed treatment.Ultimately, healing and stability were achieved in all these cases,and late complications proved very rare. In 20 segmental transports in the thigh to correct defects an average of 9.7 cm in length, 16.0 days/cm was needed for distraction and 47.0 days/cm for fixation.We encountered 18 fixator-related and 28 procedure-related complications that required treatment.Stability was achieved in all cases but 1. In 1 case a secondary amputation was necessary. Although late complications were rare, 1 late amputation was necessary. Our experience suggests that lengthening by means of the ring fixator should be done only in problem patients, especially after extensive osteomyelitis. For segmental transport in problem patients – patients requiring segmental transport almost always are problem patients – the ring fixator is the ideal means of fixation despite the many minor complications encountered.     

A new technique for establishing dry weight in hemodialysis patients via whole body bioimpedance

BACKGROUND: Quantitative techniques are necessary to achieve dry weight (DW) in patients with kidney failure. Bioimpedance spectroscopy (BIS) is a non-invasive method that determines the volume of body fluid compartments. The current work evaluates the use of BIS data in hemodialysis patients for the prediction of DW. METHODS: A new technique has been devised for the estimation of DW that involves the intersection of two slopes, slope normovolemia (SNV) and slope hypervolemia (SHV). These slopes characterize the variation in extracellular water (ECW) with body weight (BW) in the states of normovolemia and hypervolemia, respectively. SNV was established via measurements of ECW and BW in 30 healthy subjects. In a longitudinal study in new hemodialysis patients, successive reduction of post-dialysis weight (PDW) was attempted until clinical signs of normovolemia were presented. Measurements of ECW and BW that were acquired at the beginning of each treatment were used to determine SHV. RESULTS: SNV was found to be 0.239 L/kg and 0.214 L/kg for male and female healthy subjects, respectively. A significant DeltaPDW predicted by the new method (-4.98 kg) was highly correlated to the DeltaPDW achieved in the study (-5.85 kg, R = 0.839). Blood pressure was reduced (P < 0.001) and an 86% decrease in antihypertensive agents was achieved. CONCLUSION: The method of intersecting slopes (SHV with SNV) via BIS is a new method for the prediction DW. This approach will offer considerable improvement for the routine management of DW in the dialysis setting.     

T-cell depletion and graft survival induced by anti-human CD3 immunotoxins in human CD3epsilon transgenic mice

BACKGROUND: Anti-CD3 immunotoxins are broad-spectrum immunosuppressive agents in a wide range of organ transplantation animal models with potential use in eliciting antigen-specific tolerance. However, the anti-CD3 immunotoxins used in animal studies do not cross-react with human T cells, limiting extrapolation to humans and hindering clinical development. METHODS: Three anti-human CD3-directed immunotoxins, DT389-scFv(UCHT1), scFv(UCHT1)-PE38, and UCHT1-CRM9, were compared in vitro and in transgenic mice, tg(epsilon)600+/-, that have T cells expressing both human and murine CD3epsilon antigens. RESULTS: These immunotoxins were extraordinarily potent in vitro against human or transgenic mouse T cells, with IC50 values in cellular assays ranging from pM to fM. Systemic administration of these immunotoxins dose-dependently depleted >99% of tg(epsilon)600+/- lymph node and spleen T cells in vivo. Depletion was specific for T cells. The loss of the concanavalin A-induced, but not the lipopolysaccharide-induced, splenic proliferative response from immunotoxin-treated animals further demonstrated specific loss of T-cell function. Immunotoxin treatment prolonged fully allogeneic skin graft survival in tg(epsilon)600+/- recipients to 25 days from 10 days in untreated animals. T-cells recovered to approximately 50% of normal levels after approximately 22 days in animals with or without skin grafts; T-cell recovery correlated with skin graft rejection. All three immunotoxins elicited >100 day median survival of fully allogeneic heterotopic heart grafts. By 100 days, T cells recovered to normal numbers in these animals, but the grafts showed chronic rejection. CONCLUSION: These immunotoxins profoundly deplete T cells in vivo and effectively prolong allogeneic graft survival.     

High dose rate brachytherapy of localized prostate cancer

OBJECTIVE: We evaluated the safety and efficacy of high dose rate (HDR) brachytherapy using Iridium-192 (Ir 192) and 3D conformal external beam radiotherapy in patients with localized prostate cancer. METHODS: A total of 444 patients with localized prostate cancer underwent combined radiotherapy with interstitial Ir 192 and 3D conformal external beam radiotherapy between December 1992 and March 2001. The 230 patients, treated between December 1992 and December 1997 were analyzed. All patients underwent laparoscopic pelvic lymph node dissection to exclude patients with lymphatic involvement. Ir 192 was delivered twice with a 1-week interval in HDR remote control technique. The interstitial dose from December 1992 to December 1993 was 10Gy, after December 1993 the dose was reduced to 9Gy per treatment session. The interstitial application was followed by external beam radiation of 45Gy for cT1-cT2 and 50.4Gy for cT3 tumor (40Gy from December 1992 to December 1993). Progression was defined as biochemical failure according to ASTRO criteria, e.g. three consecutive PSA rises following the PSA nadir. RESULTS: The median PSA value decreased from 12.8 to 0.93ng/ml 12 months after treatment. Median PSA value was 0.47 after 24 months, 0.30ng/ml after 36 months and 0.18ng/ml after 60 months. 68% of the biopsies were negative 24 months after therapy. Progression-free rate was 100% for cT1 tumors, 75% for cT2 and 60% for stage-cT3 on 5-year follow-up. Five-year overall survival was 93%, 5-year disease-specific survival was 98%. Initial PSA value <10ng/ml, low stage and low grade were significantly related to 5-year progression-free survival. CONCLUSIONS: Combined HDR brachytherapy with Ir 192 is an alternative treatment option especially for patients with cT3 prostate cancer. Initial PSA value, stage and grade, are important prognostic factors.     

Brain death impairs coronary endothelial function

BACKGROUND: To characterize the impact of brain death (BD) on endothelial dysfunction after cardiac transplantation we investigated coronary circulation and vasomotor function in a canine model. METHODS: Left ventricular pressure-volume data (conductance catheter) and coronary blood flow (CBF) were monitored continuously. Endothelium-dependent vasodilatation after acetylcholine and endothelium-independent vasodilation after sodium nitroprusside were assessed before and 3 hr after BD induction (inflation of a subdural balloon). RESULTS: BD led to an initial hyperdynamic reaction with significant (P<0.05) increase of CBF. After 3 hr, CBF decreased significantly (P<0.05). Although before BD, application of acetylcholine led to a monophasic vasodilatative response, after BD a short mild vasodilatation was followed by a longer vasoconstriction. Endothelium-independent vasodilatation remained unchanged. CONCLUSIONS: BD affects coronary circulation by two means: (1) impairment of CBF to decrease in parallel in afterload with consecutive hemodynamic deterioration and (2) severe endothelial dysfunction that may be a contributing factor to posttransplant outcome.     

A comparison of the laryngeal tube with the laryngeal mask airway during routine surgical procedures

The laryngeal mask airway (LMA; Laryngeal Mask Company, Henley-on-Thames, UK) is an established airway device, whereas the laryngeal tube (LT) is relatively new and therefore not as well investigated. Therefore, the purpose of the present prospective, randomized, controlled trial was to compare the LT with the LMA in routine clinical practice. In 50 patients undergoing general anesthesia for minor routine surgery, standardized anesthesia was induced and maintained with alfentanil and propofol. Patients were randomized to controlled ventilation (fraction of inspired oxygen = 0.4; fraction of inspired nitrous oxide = 0.6; tidal volume = 7 mL/kg; respiratory rate = 10 breaths/min) with the LT (n = 25) or the LMA (n = 25). Oxygen saturation was recorded before the induction of anesthesia and after the administration of oxygen. After 2 and 10 min of ventilation with the LT or LMA, oxygen saturation, end-expiratory carbon dioxide, expiratory tidal volume, and peak airway pressure were recorded. Capillary blood gas samples were taken before the induction of anesthesia and after 10 min of ventilation. Time of insertion and airway leak pressure of each device were measured. The time of insertion was comparable with both devices (LT versus LMA, median 21 s versus 19 s; P = not significant). Blood gas samples and ventilation variables revealed sufficient ventilation and oxygenation with either device (P = not significant). Peak airway pressure (LT, 17 +/- 3 cm H(2)O; LMA, 15 +/- 3 cm H(2)O) and airway leak pressure (LT, 36 +/- 3 cm H(2)O; LMA, 22 +/- 3 cm H(2)O) were significantly (P < 0.05) higher when using the LT compared with the LMA. In conclusion, using the LT and LMA resulted in comparable ventilation and oxygenation variables in this model of ASA physical status I and II patients undergoing routine surgical procedures. The newly developed LT may be a simple alternative device to secure the airway. IMPLICATIONS: The laryngeal tube, a newly developed airway device, and the laryngeal mask airway were used to ventilate patients in the operating room. Both airway devices proved to be effective and safe; however, the laryngeal tube allowed greater airway pressure during ventilation.     

The frequency and clinical significance of congenital defects of the posterior and anterior arch of the atlas

OBJECT: In this study the authors investigated the anatomical, clinical, and imaging features as well as incidence of congenital defects of the C-1 arch. METHODS: The records of 1104 patients who presented with various medical problems during the time between January 2006 and December 2006 were reviewed retrospectively. The craniocervical computed tomography (CT) scans obtained in these patients were evaluated to define the incidence of congenital defects of the posterior arch of C-1. In addition, 166 dried C-1 specimens and 84 fresh human cadaveric cervical spine segments were evaluated for anomalies of the C-1 arch. RESULTS: Altogether, 40 anomalies (2.95%) were found in 1354 evaluated cases. Of the 1104 patients in whom CT scans were acquired, 37 (3.35%) had congenital defects of the posterior arch of the atlas. The incidence of each anomaly was as follows: Type A, 29 (2.6%); Type B, six (0.54%); and Type E, two (0.18%). There were no Type C or D defects. One patient (0.09%) had an anterior arch cleft. None of the reviewed patients had neurological deficits or required surgical intervention for their anomalies. Three cases of Type A posterior arch anomalies were present in the cadaveric specimens. CONCLUSIONS: Most congenital anomalies of the atlantal arch are found incidentally in asymptomatic patients. Congenital defects of the posterior arch are more common than defects of the anterior arch.     

T cell memory,anergy and immunotherapy in breast cancer

T cell immunity in breast cancer is suggested to play a role in tumor dormancy, a period of stability which can correspond to the time interval between primary treatment and tumor recurrence. Bone marrow in breast cancer patients seems to be particularly important because it is highly enriched with cancer specific memory T cells. Similar cells can be found in peripheral blood, but these appear to be functionally anergic. The immune system of primary operated breast cancer patients does not seem to be completely anergized. Bone marrow derived memory T cells can be reactivated ex vivo and show functional reactivity, including tumor rejection in NOD/SCID mice. Promising results were obtained from a postoperative phase-II active specific immunotherapy study. In this study, 32 patients treated with an optimal formulation of a virus-modified autologous tumor vaccine (ATV-NDV) appeared to have a significant 5-year survival benefit. Our results suggest that cancer reactive memory T cells which are enriched in the bone marrow of breast cancer patients, can be activated ex vivo via autologous dendritic cells pulsed with breast cancer tumor antigens, or they can be activated in situ via a tumor vaccine, which combines tumor antigens with virus infection. The findings should encourage further studies in breast cancer on active specific immunotherapy with tumor vaccines or adoptive immunotherapy with activated memory T cells.     

Acute paranoid psychosis as sole clinical presentation of hepatic artery thrombosis after living donor liver transplantation

Background  

Hepatic artery thrombosis is a devastating complication after orthotopic liver transplantation often requiring revascularization or re-transplantation. It is associated with considerably increased morbidity and mortality. Acute cognitive dysfunction such as delirium or acute psychosis may occur after major surgery and may be associated with the advent of surgical complications.