[Hand ischemia and increased CRP level in a 75-year-old female patient]. / Handischämie und erhöhter CRP-Wert einer 75-jährigen Patientin.

The complexity of the diagnosis and therapy as well as the deficits in care are presented on the basis of the casuistry of a 75-year-old female patient with giant cell arteritis and a complicative course.

[Pilot Project: Improved Lung Deposition via a New Nasal Inhalation Procedure]. / Pilotprojekt zur verbesserten Lungendeposition durch ein neues Verfahren der nasalen Inhalation.

INTRODUCTION: Inhaled drugs can only be effective if they reach the middle and small airways. This study introduces a system that combines a trans-nasal application of aerosols with noninvasive pressure support ventilation. METHODS: In a pilot study, 7 COPD patients with GOLD stages II and III inhaled a radiolabeled marker dissolved in water via a trans-nasal route. The mean aerosol particle size was 5.5 µm. Each patient took part in two inhalation sessions that included two application methods and were at least 70 hours apart. During the first session ("passive method"), the patient inhaled the aerosol through an open tube system. The second session ("active method") included pressure support ventilation during the inhalation process. A gamma camera and planar scintigraphy was used to determine the distribution of aerosol particles in the patient's body and lung. RESULTS: The pressure supported inhalation ("active method") results in an increased aerosol lung deposition compared to the passive method. Above all, we could demonstrate deposition in the lung periphery with relatively large aerosol particles (5.5 µm). DISCUSSION: The results prove that the combination of trans-nasal inhalation with noninvasive pressure support ventilation leads to significantly increased particle deposition in the lung.

[A 59-year-old patient with recurrent flushes and bland hepatic cyst]. / 59-jähriger Patient mit rezidivierendem Erröten bei blander Leberzyste.

A 59-year-old patient was admitted to hospital with recurrent flush symptoms and pathologically elevated 5-hydroxyindoleacetic acid (5-HIAA) levels in urine. A known cystic lesion of the liver which had been followed for years by ultrasound examinations and was regarded as a bland hepatic cyst was identified as a metastasis of a neuroendocrine neoplasm of the ileum. In two sequential surgical interventions the primary tumor with mesenteric lymph node metastases as well as the cystic liver metastasis could be resected. After surgical treatment an R1 situation at the mesenteric site and suspicious para-aortic lymph nodes remained. The long established treatment of factor-V Leiden mutation by anticoagulation with phenprocoumon was supplemented by deep subcutaneous injection of lanreotide autogel every 4 weeks. Currently, there is no evidence for progressive disease and the patient is without clinical signs of a carcinoid syndrome.

[A 79-year-old man with B symptoms and jaw claudication]. / B-Symptomatik und Kauclaudicatio bei einem 79-jährigen Patienten.

A 79-year-old patient presented with weight loss, subfebrile body temperature and unclear jaw pain. After ruling out malignant and infectious causes, positron emission tomography-computed tomography (PET-CT) revealed markedly elevated glucose utilization of the large thoracic and upper limb arteries, suggesting systemic vasculitis. Color-coded duplex sonography confirmed thickening of the wall of the external carotid artery consistent with vasculitis. The patient was diagnosed with giant cell arteritis involving the large thoracic arteries and the upper limb arteries but without involvement of the superficial temporal artery. Based on the involvement of the external carotid artery, the jaw pain could be classified as jaw claudication. Clinical and laboratory remission was achieved with systemic glucocorticoids which could subsequently be tapered. The patient is well and asymptomatic 12 months after diagnosis and 2 months without steroids.

Successful selective internal radiotherapy (SIRT) in a patient with a malignant solid pseudopapillary pancreatic neoplasm (SPN).

Solid pseudopapillary neoplasms of the pancreas (SPNs, Gruber-Frantz-Tumor) are a rare entity representing 1-5% of all exocrine pancreatic tumors. The pseudocystic lesions preferentially affect young females <30 years, are mostly benign (∼90%) and normally present with unspecific symptoms. We describe the case of a 16-years-old Asian woman that was initially diagnosed with an SPN in the pancreatic head with mesenterial and hepatic metastases. After diagnosis, an extensive tumor resection was performed including pyloric-preserving pancreatic head resection followed by sequential resection of all hepatic metastases. After the patient was diagnosed with a hepatic recurrence and high intrahepatic tumor load, we chose a multimodal procedure and performed a selective internal radiotherapy (SIRT). Four years after SIRT and 10 years after initial diagnosis of metastatic SPN, the patient is in a good condition without any evidence for hepatic recurrence. This case represents a rare clinical course of a malignant and invasive SPN with an exceptionally long survival despite of high initial tumor burden. The selective internal radiotherapy is a suitable approach for inducing long-term remissions of the strongly vascularized liver metastases.

[The descending necrotizing mediastinitis]. / La mediastinite discendente necrotizzante.

Descending necrotizing mediastinitis (DNM) is a primary complication of cervical or odontoiatric infections that can spread to the mediastinum through the anatomic cervical spaces. The delay of the diagnosis or under assessment of the disease, with no adequate draining techniques, results in high mortality up to 20%. We report our experience about 9 clinical cases of DNM observed and surgically treated in our unit from 2000 to 2006; five of these patients were admitted in the last two years. We stress the differences of management of this affection that needs a close cooperation between surgeon, intensive care unit and infectious disease specialist.

[Hemoptysis in a patient with acquired anomaly of the arterial vascularization of the lung]. / Emoftoe in paziente con anomalia acquisita della vascolarizzazione arteriosa del polmone.

An anomalous systemic pulmonary supply may be acquired and present only one symptom: hemoptysis. The incidence of this pathology is unknown. A case of acquired systemic pulmonary arterialization was observed after surgical intervention of myocardium vascularization with the left mammary artery. The diagnosis was obtained through an arteriography of the left mammary artery. In this case, the therapy consists in ablating the affected parenchyma followed by the interposition of a bovine pericardium patch between the mammary artery and the remaining pulmonary tissue.

[Hemorrhage caused by rupture into the duodenum of aneurysm of a branch of the pancreaticoduodenal artery (posterior superior or retroduodenal pancreaticoduodenal artery)]. / Emorragia da rottura in duodeno di aneurisma di un ramo dell'arteria pancreatico-duodenale (pancreatico-duodenale superoposteriore o retroduodenale).

A case of serious haemorragic shock caused by the rupture into the duodenum of a septic aneurysm of the pancreatic-duodenal artery is reported. The diagnostic difficulties and the need to carry on "blind" laparotomies, in these cases, are underlined.