Recurrent Upper Gastrointestinal Bleeding from Isolated Gastric Varices as Primary Symptom of Myelofibrosis: A Case Report on Combining Interventional and Pharmacologic Treatment Options.

Portal hypertension leads to pronounced venous collateralization and development of varices. Besides manifest liver cirrhosis, primarily left-sided portal hypertension is causal for the development of gastric varices. We present a case of a 36-year-old female patient with splenomegaly, underlying primary myelofibrosis, and detection of somatic Janus-kinase-2 driver-mutation JAK2V617F. Following first upper gastrointestinal bleeding, isolated gastric varices could be detected as a result of underlying left-sided portal hypertension. Within a few months, repeated life-threatening bleedings with transfusion requirements and frequent hospitalizations occurred. Despite multiple injections of cyanoacrylates, the proven therapy of choice, varices could not be stabilized. Combination of targeted JAK-inhibitor therapy in conjunction with the use of EUS-guided application of coils with subsequent cyanoacrylate injection resulted in acute and long-term bleeding control.

Results from the German registry for refractory celiac disease.

Refractory celiac disease (RCD) refers to a rare subgroup of patients with celiac disease who show clinical signs of malabsorption despite a gluten-free diet. RCD is divided into an autoimmune phenotype (RCD type I) and pre-lymphoma (RCD type II). To reflect the clinical reality in managing this disease in Germany, a national register was established based on a questionnaire developed specifically for this purpose. Between 2014 and 2020, a total of 53 patients were registered. The diagnosis of RCD was confirmed in 46 cases (87%). This included 27 patients (59%) with RCD type I and 19 patients (41%) with RCD type II. A wide range of diagnostic and therapeutic measures was used. Therapeutically, budesonide was used in 59% of the RCD patients regardless of the subtype. Nutritional therapy was used in only 5 patients (11%). Overall mortality was 26% (12 patients) with a clear dominance in patients with RCD type II (9 patients, 47%). In summary, RCD needs to become a focus of national guidelines to increase awareness, establish standards, and thus enable the treating physician to make the correct diagnosis in a timely manner. Moreover, we concluded that when treating such patients, contacting a specialized center is recommended to ensure sufficient management.

Patient radiation dose in percutaneous biliary interventions: recommendations for DRLs on the basis of a multicentre study.

OBJECTIVE: Percutaneous biliary interventions (PBIs) can be associated with a high patient radiation dose, which can be reduced when national diagnostic reference levels (DRLs) are kept in mind. The aim of this multicentre study was to investigate patient radiation exposure in different percutaneous biliary interventions, in order to recommend national DRLs. METHODS: A questionnaire asking for the dose area product (DAP) and the fluoroscopy time (FT) in different PBIs with ultrasound- or fluoroscopy-guided bile duct punctures was sent to 200 advanced care hospitals. Recommended national DRLs are set at the 75th percentile of all DAPs. RESULTS: Twenty-three facilities (9 interventional radiology depts. and 14 gastroenterology depts.) returned the questionnaire (12%). Five hundred sixty-five PBIs with 19 different interventions were included in the analysis. DAPs (range 4-21,510 cGy·cm2) and FTs (range 0.07-180.33 min) varied substantially depending on the centre and type of PBI. The DAPs of initial PBIs were significantly (p < 0.0001) higher (median 2162 cGy·cm2) than those of follow-up PBIs (median 464 cGy·cm2). There was no significant difference between initial PBIs with ultrasound-guided bile duct puncture (2162 cGy·cm2) and initial PBIs with fluoroscopy-guided bile duct puncture (2132 cGy·cm2) (p = 0.85). FT varied substantially (0.07-180.33 min). CONCLUSIONS: DAPs and FTs in percutaneous biliary interventions showed substantial variations depending on the centre and the type of PBI. PBI with US-guided bile duct puncture did not reduce DAP, when compared to PBI with fluoroscopy-guided bile duct puncture. National DRLs of 4300 cGy·cm2 for initial PBIs and 1400 cGy·cm2 for follow-up PBIs are recommended. KEY POINTS: • DAPs and FTs in percutaneous biliary interventions showed substantial variations depending on the centre and the type of PBI. • PBI with US-guided bile duct puncture did not reduce DAP when compared to PBI with fluoroscopy-guided bile duct puncture. • DRLs of 4300 cGy·cm2for initial PBIs (establishing a transhepatic tract) and 1400 cGy·cm2for follow-up PBIs (transhepatic tract already established) are recommended.

Pulmonary co-infection with nocardia species and nontuberculous mycobacteria mimicking miliary tuberculosis in a patient with Crohn's disease under combined immunosuppressive therapy.

Nocardiosis is a rare infection caused by ubiquitous soil-born, acid-resistant, Gram-positive bacteria that can be life-threatening in immunocompromised patients. Originally usually diagnosed in HIV-positive patients, only few cases have been reported in patients on immunosuppressive therapy for inflammatory bowel disease or rheumatologic disorders. We present a case of a 32-year-old man who was treated with infliximab, prednisolone, and azathioprine for severe terminal ileitis. Although the clinical status improved under triple immunosuppressive therapy, weight loss, weakness, and fatigue persisted. Laboratory studies revealed iron deficiency anemia, hypalbuminemia and raised inflammatory markers. Chest computed tomography scan showed multiple pulmonary nodules and a large cavity in the left upper lobe (segment 3a). Empiric tuberculostatic therapy was introduced for suspected miliary tuberculosis but stopped for lack of clinical improvement and negative tuberculosis tests (interferon-gamma release assay, microscopy, polymerase chain reaction). Finally, the diagnosis of pulmonary nocardiosis with concomitant pulmonary Mycobacterium avium infection was confirmed microbiologically, and the patient was treated with high-dose co-trimoxazole, clarithromycin, ethambutol, and rifampicin for 12 months.This case report underlines the increased risk of severe and rare infections like nocardiosis with combination immunosuppressive therapy and the necessity for thorough diagnostic screening for opportunistic infection. Although long-term antibiotic treatment for nocardiosis is mandatory, the optimal timing to restart immunosuppressive therapy remains ambiguous.

Development of visceral leishmaniasis in an HIV(+) patient upon immune reconstitution following the initiation of antiretroviral therapy.

CASE PRESENTATION: Here, we report on a case of VL in an HIV-infected patient from the Republic of Georgia who had moved to Germany 14 years before and who had travelled several times to southern Europe in between. After presenting with typical Pneumocystis jiroveci pneumonia, which was treated appropriately, the patient was started on antiretroviral therapy. Shortly thereafter, however, he developed fever of unknown origin. All laboratory assays for the diagnosis of various infectious agents including serological assays and polymerase chain reaction testing of bone marrow aspirate to diagnose VL did not yield positive results at first. Only upon repetition of these tests, diagnosis of VL could be made and the patient treated accordingly. CASE DISCUSSION: Visceral leishmaniasis (VL) is a common opportunistic infection in HIV-positive patients from endemic countries but occurs rarely following antiretroviral treatment. This case demonstrates that patients who develop VL upon immune reconstitution may not be diagnosed initially by standard laboratory assays for the diagnosis of VL and underlines the necessity to repeat serologic and molecular biologic testing for VL in cases of fever of unknown origin in patients from or with travel history to endemic countries.

[Forensic-radiological diagnosis of gunshot wounds]. / Forensisch-radiologische Diagnostik von Schussverletzungen.

BACKGROUND: Although gunshot wounds are less common in Germany than in other countries, a proportion of suicides and violent crimes are committed with firearms, which is why basic knowledge of diagnosis is important. OBJECTIVE: Fundamentals regarding forensic assessment of gunshot wounds are discussed alongside typical radiological findings. MATERIALS AND METHODS: In addition to analyzing our own cases and evaluating official statistics, this article is based on a discussion of basic research and expert recommendations. RESULTS: The article describes the characteristics of the bullet entry and exit as well as special features of the bullet trajectory, particularly in bony injuries, and discusses their significance for radiological findings. Pitfalls in interpretation, such as changes in body position and the deflection of projectile (fragments) in the body, are presented, as are the advantages of supplementary radiological diagnostics (projectile search before initiation of dissection, simple detection of an air embolism, clarity of bullet trajectory reconstruction). CONCLUSION: This article is intended to provide an overview of not only typical types of weapons and projectiles but also their effects on the body of the victim, which must be documented by the examiner.

Proposal and practicality of an alternative blue-light hazard risk assessment method for high-intensity white-light sources at workplaces.

Objectives. It is prescribed to determine blue-light hazard (BLH) weighted radiances, LB, for an assessment of spotlights with an angular subtense α≥11mrad. The BLH weighted irradiance, EB, can be used alternatively for smaller sources. Appropriate instruments are not common among persons commissioned with risk assessment (RA), and especially LB measurements may be challenging. Therefore, a practical BLH RA approach is proposed that is based on illuminance, Ev, pre-calculated blackbody BLH efficacies of luminous radiation, KB,vPlanck, and solid angle considerations. Methods. The practicality of this method was examined and compared against other RA approaches. Results. To ensure comparability of the applied instruments, measurements were performed close to a radiance standard, showing deviations within the lamp's expanded uncertainties (<4%), whereas the deviations were ±15% for longer distances. Focusing on a complex light-emitting diode (LED) spotlight, all detected values could be converted to LB by means of the RA methods within ±20%. Two field tests with several spotlights yielded maximum permissible exposure durations (MPED) obtained from the different RA approaches that agreed among each other within uncertainties largely below ±30%. Conclusion. The general practicality of the proposed Ev method can be concluded for a workplace BLH RA of white-light sources.

[Simulation in the elective subject forensic medicine in the third section of the medical examination]. / Simulation im Wahlfach Rechtsmedizin im Dritten Abschnitt der Ärztlichen Prüfung.

During the COVID-19 pandemic the third section of the medical examination could be performed on simulation patients and simulators. Their use is also beneficial in forensic medicine, as a higher level of standardization and comparability of examination performance is achieved, and the use of real corpses is often not justifiable for medicolegal reasons. This case reports on the advantages and disadvantages of a simulation in the state examination in which a death certificate was to be completely filled out on the basis of an external postmortem examination on the simulator and an external anamnesis.

Adenoma detection rate using narrow-band imaging is inferior to high-definition white light colonoscopy in screening and surveillance colonoscopies in daily clinical care: A randomized controlled trial.

BACKGROUND: Despite recent advances in endoscopic technology adenoma miss rate still is up to 20% contributing to interval cancers. Improved imaging modalities have been introduced to increase adenoma detection rate (ADR). Recently, narrow-band imaging (NBI) (Exera II series, Olympus Corporation) was not significantly better than high-definition white light colonoscopy (HD-WLC). An improved second generation of NBI (190-NBI) is characterized by better illumination of the bowel lumen and may be associated with a higher ADR. METHODS: We performed a prospective randomized study on patients referred to the Jena University Hospital for screening or surveillance colonoscopy between January 2015 and April 2017. Participating endoscopists were divided into 2 subgroups depending on their individual experience. Colonoscopy was performed by use of HD-WLC or 190-NBI upon withdrawal. RESULTS: Five hundred fifty-three patients participated in the study. Eighty patients were excluded (insufficient bowel cleansing [n = 34], anticoagulation precluding polypectomy [n=15], partial colonic resection [n=9], other reasons [n = 22]). Mean age was 66.9 years (standard deviation 10.3 years), and 253 patients were male (53.5%). Bowel preparation and withdrawal time were not different. ADR among all subgroups was 39.4% using HD-WLC, but only 29.1% were using 190-NBI (P = .02). Number of polyps per patient was lower using 190-NBI than with HD-WLC (0.58 vs 0.86; P = .02). Subgroup analysis revealed that 190-NBI was inferior to HD-WLC only in unexperienced endoscopists. CONCLUSION: In our stud,y ADR was lower by use of 190-NBI. These differences persisted only in unexperienced investigators. 190-NBI seems to be more challenging regarding ADR, requiring more intensive training prior to implementing this technology in daily clinical care. REGISTRATION: ClinicalTrials.gov (identifier: NCT03081975).

[Using simulated patients to test competency in child protection medicine in the third section of the medical examination]. / Einsatz von Simulationspersonen zur Prüfung von Handlungskompetenz im Bereich der Kinderschutzmedizin im Dritten Abschnitt der Ärztlichen Prüfung.

During the COVID-19 pandemic, the third section of the medical examination could be performed with simulation patients. Simulations enable standardized examinations of medical competency according to the educational objectives of the national learning objectives catalogue. The evaluation of student's medical response to child abuse and neglect seems to be an appropriate opportunity to increase attention of prospective physicians for potential child abuse. The presented case reports the simulation of a pediatric nonaccidental trauma.

Dramatic response of chronic ulcerating necrobiosis lipoidica to ultraviolet A1 phototherapy.

We report on a 52-year-old female patient with chronic, ulcerating necrobiosis lipoidica (NL) who dramatically responded to ultraviolet A1 (UVA1) phototherapy. The patient had NL on her right shin for more than 30 years without evidence of diabetes mellitus. Treatment with a variety of local and systemic agents failed to prevent progression into ulceration, which necessitated repeated surgical interventions in the past. When the patient presented again with torpid ulcers at the periphery of previously grafted skin, high-dose UVA1 phototherapy was initiated. Improvement occurred rapidly and after 22 irradiations and a total exposure dose of 1480 J/cm², the ulcers had healed completely. During a follow-up period of 6 years,two minor recurrences were successfully retreated with UVA1 phototherapy.

Outdoor workers' acceptance of personal protective measures against solar ultraviolet radiation.

The acceptance and usability of personal protection against solar UV radiation was evaluated in a field study with a group of tinsmiths in Austria. The personal protective measures (PPM) tested involved four categories: shirts, headwear, sunglasses and topically applied sunscreens; at least six different products per category were tested. Recommendations for the "ideal" shirt, headwear, pair of sunglasses and topical sunscreen are given based on data from questionnaires, i.e., from the point of view of the workers, independently from the actual physical level of protection (such as low transmittance or area of coverage) provided. It is argued that in practice it is important to consider the acceptance and usability of protective measures as well as the level of physical protection when providing PPM.

Rational Therapy of Clostridium difficile Infections.

BACKGROUND: Clostridium difficile infections (CDI) are increasingly important in patients with antibiotic treatments, ranging from mild, self-limiting to severe, life-threatening disease. Currently, diagnostic algorithms and treatment guidelines are being adapted to novel tests and therapeutic options for recurrent CDI. METHODS: A systematic literature search using the terms 'Clostridium difficile' and 'treatment' was carried out. Current guidelines are being discussed from a clinical point of view. RESULTS: State-of-the-art diagnostics for C. difficile diagnosis rely on the patient's history, clinical symptoms, and laboratory examination of stool. Recommendations are in favour of glutamate dehydrogenase (GDH) screening tests and confirmatory detection of C. difficile toxin genes (polymerase chain reaction (PCR)). Therapeutic strategies depend on disease severity (mild vs. severe) and endorse metronidazole and vancomycin as well as fidaxomycin for recurrent disease. In very severe cases, surgical therapy is recommended. For relapsing diseases, faecal transfer is considered as a therapeutic option if available. CONCLUSION: Current guidelines have been adapted to new pathways in diagnosing CDI and have included statements on novel therapeutic options such as fidaxomycin and faecal transplant for recurrent disease. Depending on the severity of the disease, standard therapy with either metronidazole or vancomycin is recommended.

Parameters influencing the accuracy and practical applicability of UV indicator cards.

In order to evaluate the potential hazard for the skin and the eye presented by solar ultraviolet radiation, and to take appropriate precautions, it is necessary to characterise the biological effective irradiance or dose. Recently, inexpensive UV indicator cards became available that in principle would provide an attractive means to roughly indicate the local level of erythemal solar UV irradiance. We have characterised the properties of a number of different types of UV indicator cards. Several parameters which may influence the colour of the cards were examined with both outdoor trials under solar UV as well as indoor trials using a filtered xenon arc lamp. Our findings show that the tested cards do not give an appropriate estimation of the effective irradiance due to their spectral sensitivity and their temperature dependence. The application area of the tested UV indicator cards is therefore limited to certain temperature ranges and to seasons where a certain ratio between solar UV-A and solar UV-B occurs.