Tension pneumomediastinum after severe vomiting in a 21-year-old female.

A 21-year-old female with chronic membranoproliferative nephritis was admitted for suspected esophageal disruption and asthma after severe, prolonged vomiting. At the time of admission she presented with dyspnea, tachypnea, arterial hypotension and tachycardia. Physical examination showed discrete signs of ectopic air at the neck and distended cervical veins. CT-scan of the chest showed severe mediastinal emphysema with compression of the right atrium. After cervical mediastinotomy the cardiorespiratory parameters normalized immediately. Esophagoscopy showed multiple longitudinal mucosal tears between 25 and 45 cm; fluoroscopically, there was no leakage of contrast medium. Following conservative treatment the patient recovered completely and was discharged on day 8.     

Statistical relations between blood and cerebrospinal fluid serology in patients with syphilis

In any case of latent syphilis without conclusive history, an examination of the cerebrospinal fluid (CSF) is generally recommended. The present paper deals with the question whether particular findings obtained by serologic tests on the blood can supply sufficient proof to rule out any specific involvement of the central nervous system in an individual patient. Serologic investigation on 148 blood-CSF sample pairs revealed striking correlations between several blood and CSF parameters on a high level of statistical significance. Based on blood serology data alone, a multi-dimensional, non-parametric statistical test (the k-nearest-neighbor method) was able to rule out specific involvement of the CSF in more than one third of the patients. We consider our approach useful in certain cases where CSF examination should rather be avoided, especially in patients with impaired general condition due to other diseases. Yet, in any case of neurological irregularity, CSF examination should generally be carried out regardless of the results of blood serology.     

Uterine natural killer cells in a three-dimensional tissue culture model to study trophoblast invasion

The high numbers of CD56(+) cells with natural killer (NK) functions present in the uterine mucosa during the late secretory phase of the menstrual cycle and during early pregnancy have been considered to be implicated in implantation and in the regulation of trophoblast invasion. A three-dimensional organ culture model was used to study the interactions of these uterine NK cells with Jeg-3 and BeWo choriocarcinoma cells as a model of the invasive trophoblast. For this purpose, fragments of endometrial and decidual tissue were put in close contact with multicellular spheroids of choriocarcinoma cells in small silicon funnels. After the formation of stable contacts, the confrontation cultures were transferred to spinner flasks, cultivated for up to 6 days, and prepared for immunohistochemistry. During 2 days of cocultivation, the first cells started to move forward into the stromal component of the confrontation culture as demonstrated by staining of the choriocarcinoma cells using anti-human cytokeratin. Invasion advanced until, after a total of 6 days, some choriocarcinoma cells had already penetrated deeply into the host tissue. After a cultivation period of 1 week, both the endometrial and decidual tissue fragments still contained several CD56(+) uterine NK cells, and some of them expressed the proliferation-associated marker Ki-67 without any exogenous activation. A few CD56(+) cells were found directly at the invasion front, as well as between the choriocarcinoma cells. These cells also contained the cytolytic granule protein perforin indicating a migration of NK cells with cytolytic potential toward the potentially invasive cells. In conclusion, this human system closely resembles the in vivo conditions during trophoblast invasion and provides an appropriate in vitro model for studying dynamic processes involving various cell types during trophoblast invasion at the experimental level. Moreover, it enables us to study the effects of cytokines and growth factors that possibly regulate trophoblast invasion.     

Malignant fibrous histiocytoma of the lung: prognosis and therapy of a rare disease. Report of two cases and review of the literature

On the basis of 2 own patients and 18 cases reported in the literature, clinicopathological features of primary malignant fibrous histiocytoma of the lung are reviewed. Of the 20 patients (age-range: 14-75 yrs; 13 male, 7 female), 14 underwent resection. Recurrences were noted in 7 of them. 8 patients were free of disease at least 8 months postoperatively, one having undergone successful pulmonary metastasectomy. Postresection disease-free survival ranged from 8 months to 10 years. Adjuvant chemotherapy or irradiation (3/14) did not influence postoperative outcome. After chemotherapy, irradiation or conservative measures alone (6/20) survival did not exceed 12 months; remissions were not reported. The course was fatal within 12 months in 9/20 cases due to distant metastasis or local growth. 1 patient died of tumour-associated hypoglycemia. Age, sex, localization of the tumor and histologic subtype did not influence prognosis. Small tumors, asymtomatic at time of detection probably carry a better prognosis than larger ones.     

Evaluation of a novel automated non-invasive pulse pressure variation algorithm

In mechanically ventilated patients, Pulse Pressure Variation (PPV) has been shown to be a useful parameter to guide fluid management. We evaluated a real-time automated PPV-algorithm by comparing it to manually calculated PPV-values. In 10 critically ill patients, blood pressure was measured invasively (IBP) and non-invasively (CNAP^® Monitor, CNSystems Medizintechnik, Austria). PPV was determined manually and compared to automated PPV values: PPV_manIBP vs. PPV_autoIBP was ?0.19±1.65% (mean bias±standard deviation), PPV_manCNAP vs. PPV_autoCNAP was ?1.02±2.03% and PPV_autoCNAP vs. PPV_manIBP was ?2.10±3.14%, suggesting that the automated CNAP^® PPV-algorithm works well on both blood pressure waveforms but needs further clinical evaluation.     

Management of Esophageal Perforation in 120 Consecutive Patients: Clinical Impact of a Structured Treatment Algorithm

Introduction

The therapy of esophageal perforation is still challenging. The aim of this study was to assess the etiology, specific treatment, and outcome of esophageal disruption in order to generate an optimal therapeutic approach to improve patient’s outcome.

Methods

We reviewed the cases of 120 consecutive patients with esophageal perforation treated within 10 years.

Results

Iatrogenic perforation was the most frequent cause of esophageal perforation (58.3 %); Boerhaave’s syndrome was detected in 15 cases (6.8 %). Surgery was performed in 66 patients (55 %), 17 (14 %) patients received conservative treatment and 37 (31 %) patients underwent endoscopic stenting after tumorous perforation. Statistically significant impact on mean survival had Boerhaave’s syndrome (p?=?0.005), initial sepsis (p?=?0.002), pleural effusion/empyema (p?=?0.001), mediastinitis (p?=?0.003), peritonitis (p?=?0.001), and redo-surgery (p?=?0.000). Overall mortality rate was 11.7 %, in the esophagectomy group 17 % and in the patients with Boerhaave’s syndrome 33.3 %.

Conclusions

An approach considering etiology and extent of perforation, diagnostic delay, and septic status is required to improve patient’s outcome. Primary repair is feasible in patients without intrinsic esophageal disease and evidence of sepsis. The greater the diagnostic delay, the more the destruction of the esophageal wall especially in the case of septic esophageal disease, thus the stronger the argument for esophagectomy if anatomically and/or oncologically possible.     

Teledermoscopy--results of a multicentre study on 43 pigmented skin lesions

We performed a multicentre study to evaluate the agreement between the direct clinical diagnosis and the telediagnosis of 43 cutaneous pigmented lesions. Digital clinical and dermoscopic images of the 43 pigmented skin lesions (11 melanomas, 23 melanocytic naevi, three basal cell carcinomas, three lentigines, two seborrhoeic keratoses and one angiokeratoma) were sent by email to 11 colleagues (six dermatologists, two residents in dermatology, one oncologist, one specialist in internal medicine and one general practitioner) in 10 centres. These 11 colleagues had different degrees of experience in dermoscopy. With histopathology as the gold standard, an average of 85% of the telediagnoses were correct, with results varying from 77% to 95%, whereas face-to-face diagnosis by an expert dermatologist was correct in 91% of cases. The kappa value for all participants ranged from 0.35 to 0.87. The results confirm that teledermoscopy can be a reliable technique for the diagnosis of pigmented skin lesions but one that will depend on the expertise of the observer.