The revised microRNA complement of Fasciola hepatica reveals a plethora of overlooked microRNAs and evidence for enrichment of immuno-regulatory microRNAs in extracellular vesicles.

MicroRNAs (miRNAs) are gene regulators that have recently been shown to down-regulate the immune response via extracellular vesicles in the mammalian host of helminthic parasites. Using the miRNA prediction pipeline miRCandRef, we expanded the current miRNA set of the liver fluke Fasciola hepatica (Platyhelminthes, Trematoda) from 16 to 54 miRNAs (42 conserved and 13 novel). Comparing the cellular expression levels with extracellular vesicles, we found all miRNAs expressed and enriched for miRNAs with immuno-regulatory function, tissue growth and cancer. Our findings support the hypothesis that miRNAs are the molecular mediators of the previously demonstrated immune modulatory function of extracellular vesicles.

[Often an orthopedic problem can manifest as chest pain. Cervical vertebrae syndrome mimics myocardial infarct]. / Oft steckt hinter den Brustschmerzen ein orthopädischer Befund. HWS-Syndrom mimt Herzinfarkt.

Up to 20% of all patients with pectoral symptoms have an underlying orthopedic problem. The most common orthopedic conditions that may mimic chest pain radiating into the left arm include slipped disc, cervicothoracic tension syndrome, blockage of intervertebral or rib joints, and intercostal neuralgia. Less common causes of such pain are arthrosis of the shoulder, spondylocystitis, osteoporotic fractures or tumors of the bone. Management is oriented to the underlying cause, and treatment extends from physiotherapeutic measures (rest, heat treatment) via medication (non-steroidal anti-inflammatory drugs, myotonolytic agents) to operative interventions.

Ascending myelopathy in the early stage of spinal cord injury.

A 30-year-old healthy woman was involved in a road traffic accident. She sustained a fracture dislocation of T11/12 with a complete Frankel A paraplegia below T11. She had no associated injuries. High Dose Methylprednisolone was administered according to the NASCIS III protocol (48 h) together with low molecular weight Heparin and gastroprotected medication. Complete transection of the spinal cord and an anterior haematoma from T11 to T12 were confirmed on X rays, CT's and MRI scans. Posterior surgical stabilisation was performed using Isola instrumentation, starting 8 h post injury. Her post surgical period was uneventful except for some episodes of low blood pressure (85/60 mmHg) from which she had no symptoms. On the 12th post operative day, while in the physiotherapy department, she complained of right scapular pain. This occurred every time she was sat up and was associated with paraesthesia of both upper limbs. Two days later she deteriorated neurologically and her level ascended initially to T8 and then to T3. MRI of the spine with and without gadolinium showed spinal cord oedema between C3 and T1. There was no evidence of haemorrhage or syringomyelia. The authors discussed this case making different hypotheses. They are mainly the following: (1) Gradually ascending ischaemia due to a vascular disorder; (2) Double spinal trauma; (3) Ischaemia related to repeated hypotensive episodes; (4) Low grade intramedullary tumour; and (5) Thrombus of the Radicularis Magna artery. The case has been recognised as being very rare and interesting. In the conclusions, the presenting author stresses the importance of adopting MRI-compatible instrumentation for the surgical stabilisation of the spine, and careful monitoring of blood pressure during the acute phase of spinal cord injury. Dr Aito agrees with Mr El Masry about the opportunity of forming a group of clinicians in order to discuss protocols to cope with this devastating complication.

Long-term survival of patients with coronary artery disease and left ventricular dysfunction: implications for the role of myocardial viability assessment in management decisions.

OBJECTIVES: Our purpose was to evaluate the long-term benefit of myocardial viability assessment for stratifying risk and selecting patients with low ejection fraction for coronary artery bypass grafting and to determine the relation between the severity of anginal symptoms, the amount of ischemic myocardium, and clinical outcome. METHODS: We studied 93 consecutive patients with severe coronary artery disease and low ejection fraction (median, 25%) who underwent positron emission tomography to delineate the extent of perfusion-metabolism mismatch (reflecting hibernating myocardium) for potential myocardial revascularization. Median follow-up was 4 years (range, 0 to 6.2 years). RESULTS: Fifty patients received medical therapy, and 43 patients underwent bypass grafting. In Cox survival models, heart failure class, prior myocardial infarction, and positron emission tomographic mismatch were the best predictors of survival. Patients with positron emission tomographic mismatch receiving bypass grafting had improved 4-year survival compared with those on medical therapy (75% versus 30%; P =.007) and a significant improvement in angina and heart failure symptoms. In patients without positron emission tomographic mismatch, bypass grafting tended to improve survival and symptoms only in those patients with severe angina (100% versus 60%; P =.085), whereas no survival advantage was apparent in patients with minimal or no anginal symptoms (63% versus 52%; P =.462). CONCLUSIONS: Patients with low ejection fraction and evidence of viable myocardium by positron emission tomography have improved survival and symptoms with coronary bypass grafting compared with medical therapy. In patients without evidence of viability, survival and symptom improvement with bypass grafting are apparent only among those patients with severe angina.

[Exchange of endoprosthesis using a proximal femur resection prosthesis]. / Endoprothesenwechsel mittels proximaler Femurresektionsprothesen.

Total hip arthroplasty (THA) with the use of a Mega prosthesis was performed on 24 patients with significant loss of bone stock in revision THA. A clinical and radiological examination was carried out according to the Enneking evaluation scheme on average 7 years after THA. Pain, active hip motion and strength of hip muscles, walking ability, and activities of daily living rated excellent or good and compared well with the results following conventional THA. Limp and positive Trendelenburg sign were common to all except one after Mega prosthesis implantation and were independent on the type of refixation of the hip abductors. Dislocation of the prosthesis occurred in 16.6% of cases and depended on the type of cup implanted. Remarkable was a periprosthetic callus formation surrounding the stem of the femoral implant.

Percutaneous balloon valvuloplasty compared with open surgical commissurotomy for mitral stenosis.

BACKGROUND: Percutaneous balloon mitral valvuloplasty has been proposed as an alternative to open surgical commissurotomy for the treatment of rheumatic mitral-valve stenosis. METHODS: We enrolled 60 patients with severe mitral stenosis and favorable valvular anatomy in a prospective, randomized trial comparing the two procedures. All patients underwent cardiac catheterization before the procedure and one week, six months, and three years thereafter. Hemodynamic data were analyzed by investigators who were blinded to the patients' treatment assignments. RESULTS: Mitral-valve areas improved initially in both groups, from a mean (+/- SD) of 0.9 +/- 0.3 cm2 to 2.1 +/- 0.6 cm2 in the balloon-valvuloplasty group (30 patients; P < 0.01) and from 0.9 +/- 0.3 cm2 to 2.0 +/- 0.6 cm2 in the surgical group (30 patients; P < 0.001). Although improvement was maintained in both groups, mitral-valve areas were greater in the patients in the balloon-valvuloplasty group at three years (2.4 +/- 0.6 cm2, vs. 1.8 +/- 0.4 cm2 in the surgery group, P < 0.001). Restenosis occurred in three patients in the balloon-valvuloplasty group and four in the surgery group. One patient in the balloon-valvuloplasty group died of an apparent stroke after 2.5 years; four patients in the balloon-valvuloplasty group had residual atrial septal defects, and three patients (two in the balloon-valvuloplasty group and one in the surgery group) were judged to have severe mitral regurgitation. Seventy-two percent of the patients who underwent balloon valvuloplasty and 57 percent of the surgically treated patients were in New York Heart Association functional class I (i.e., they had no cardiovascular symptoms) at three years. No patient was lost to follow-up. CONCLUSIONS: In the treatment of mitral stenosis, balloon valvuloplasty and open surgical commissurotomy have comparable initial results and low rates of restenosis, and both produce good functional capacity for at least three years. The potential complications associated with balloon valvuloplasty should be noted. The better hemodynamic results at three years, lower cost, and elimination of the need for thoracotomy suggest that balloon valvuloplasty should be considered for all patients with favorable mitral-valve anatomy.

Implantable cardioverter-defibrillator therapy in 300 patients with coronary artery disease presenting exclusively with ventricular fibrillation.

To determine outcomes of implantable cardioverter-defibrillator (ICD) therapy in a uniform population of survivors of sudden cardiac death, we used epicardial defibrillation lead systems to study 300 patients with coronary artery disease (CAD) presenting exclusively with ventricular fibrillation (VF) unassociated with acute myocardial infarction. Operative (30-day) mortality, 2.7% overall, was lower (0.6%) in patients with ejection fractions (EF) > or = 0.30. Over a median follow-up of 1.9 years, cumulative actuarial shock incidence was similar in patients who underwent concomitant coronary artery bypass graft (CABG) surgery (38%) and in those who did not. The 2-year cumulative actuarial incidences of any or appropriate shocks were 65% and 38%, respectively. Sudden death survival at 2 years was 92.5% and 99.3% for patients with EFs < or = 0.30 and > 0.30, respectively. The total mortality rate was similar in shocked and in unshocked patients. Multivariate analysis identified EF and female gender as significant predictors of any and appropriate shock occurrence (all p values < or = 0.05) and EF as a significant predictor of sudden, cardiac, and total mortality (all p values < 0.03). We conclude that in CAD patients presenting exclusively with VF unassociated with acute myocardial infarction and treated with thoracotomy-requiring ICD therapy: (1) operative (30-day) mortality is minimal for patients with an EF > or = 0.30; (2) device use is high and sudden death rates low regardless of concomitant CABG; (3) low EF is a significant predictor of cumulative shock occurrence and mortality (sudden, cardiac, and total); (4) female gender may be a predictor of shock occurrence; and (5) similar mortalities and low sudden-death rates in shocked and nonshocked ICD patients imply that ICD therapy improves survival in shocked patients to a level observed in comparable patients in whom ventricular tachyarrhythmia does not recur.

Quantitative angioscopy: a novel method of measurement of luminal dimensions during angioscopy with the use of a "lightwire".

PURPOSE: To determine the accuracy and reproducibility of luminal dimension measurements of a newly developed method of quantitative angioscopy. METHODS: A method was developed for quantitation of luminal dimensions during angioscopy, as variation in magnification with lens-object distance and ambiguity associated with identification of corresponding points about the circumference of a given discrete cross-section render subjective estimates unreliable. A transverse ring of fiberoptically transmitted light was emitted from a guidewire or its housing at a known distance from the distal end of an angioscope and discrete cross-sections of interest were observed as the ring of light was reflected from the luminal surface. Caliper measurement of the diameter of the light ring image (< 50 mW at 488/515 nm), obtained on angioscopic video recordings of cylindrical phantom vessels of known dimensions, was performed by three observers on five occasions. RESULTS: The mean absolute difference between measured and known luminal diameter (n = 405 observations) was 65 microns +/- 35 microns and the mean coefficient of variation was 4.2%, and the mean difference between measured and known areas (n = 195 observations) was 0.4 mm2, with a mean coefficient of variation of 6.5%. CONCLUSION: By use of this new lightwire method, luminal dimensions can now be measured in vitro with a high degree of accuracy and reproducibility during angioscopy.

Nerve supply of anterior cruciate ligaments and of cryopreserved anterior cruciate ligament allografts: a new method for the differentiation of the nervous tissues.

We investigated the nerve supply of anterior cruciate ligaments ((ACLs) and of cryopreserved bone-ACL-bone allografts in a rabbit model with immunohistochemical methods to establish the distribution pattern of the nervous tissues and to determine the reinnervation rate of ACL allografts. The ACL is innervated by three different classes of nerve fibre: (1) fibres of large diameter, characterized by neurofilament immunoreactivity, which are fast-conducting mechanoreceptive sensory afferents; (2) fibres of small diameter, characterized by substance P-immunoreactivity, which are slow-conducting nociceptive sensory afferents; and (3) sympathetic efferent vasomotor fibres, characterized by their immunoreactivity to the rate-limiting enzyme of noradrenaline synthesis, tyrosine hydroxylase. The ACLs showed numerous fibres of all three nerve classes; as specialised sensory nerve endings only Ruffini corpuscles were observed. All nerve fibres were located subsynovially, none within the collagen core of the ligament itself. No nerve fibres were detected in the ACL allografts at 3 and 6 weeks. Sparse fibres were detected at 12 weeks, while the 24-, 36- and 52-week specimens showed plenty of all three fibre types. No mechanoreceptors were found in the ACL allografts. To our knowledge, this method for the first time allows a differentiation of the nerve fibres of ACLs and ACL allografts into three different nerve fibre classes with known neurophysiological functions.

[Aortographic findings in children with myelomeningocele and lumbar kyphosis]. / Aortenangiographische Befunde bei Kindern mit Myelomeningozele und Lumbalkyphose.

The findings in abdominal aortography performed preoperatively in 21 children with myelomeningocele (MMC), which underwent kyphectomy due to congenital kyphosis of the lumbar spine, are reported. In no case did the aorta follow the kyphotic radius of curvature. It rather seemed to be strung over the kyphosis like a tendon over a bow. An intraoperative lesion of the aorta seems rather unlikely, and this is why we believe, that a routinely performed preoperative abdominal aortography is not necessary. We found a remarkable number of anomalies of the intercostal and segmental arteries, which were only in part associated with deformities of the vertebral bodies. The kidneys seemed to be imbedded in the kyphotic concavity, partially with the inferior pole, partially in whole. In these cases the risk of intraoperative lesion seems higher. We found a number of cases with unilateral agenesis of the kidneys in the patients examined by us. Therefore we suggest the use of noninvasive methods prior to surgery in order to evaluate the presence of malpositions or malformations of the kidneys.

[Spinal surgery on patients with myelomeningocele. Results 1971-1990]. / Die Columnotomie bei Patienten mit Myelomeningozele. Erfahrungen 1971-1990.

Between 1971 and 1990 33 kyphectomies were performed at the Orthopaedic Hospital, University of Heidelberg. The average age at time of surgery was 5 years/5 months; the follow-up period was 5 years. The best results were obtained in the group with congenital rigid kyphosis. A marked postoperative deterioration was considered in patients with a flexible paralytic kyphosis, probably due to a too short area of fusion. In 19 patients the correction of the kyphotic deformity was the prerequisite for being provided with orthotic devices. The most serious complication was the intraoperative death of 3 patients. It can be presumed, that after transection of the spinal cord a non-functioning CSF-shunt lead to an acute elevation of the intracranial pressure. Therefore an adequately functioning shunt must be secured preoperatively.

Aortography in children with myelomeningocele and lumbar kyphosis.

In 21 children with myelomeningocele who underwent kyphectomy for congenital kyphosis of the lumbar spine, aortography revealed no case in which the aorta followed the spinal curvature. Many anomalies of the intercostal and segmental arteries were demonstrated which were only in part associated with deformities of the respective vertebral bodies. The kidneys, which were frequently malformed, often lay within the kyphosis and were therefore at risk of operative damage. We conclude that the aorta is not at risk and that aortography is not usually necessary before kyphectomy, except in patients who have undergone prior abdominal surgery. Non-invasive methods (ultrasound, CT or MRI) should be used to detect malpositions and malformations of the kidneys.

[Results of surgical therapy of knee flexion contractures in patients with myelomeningocele]. / Ergebnisse der operativen Therapie von Kniebeugekontrakturen bei Patienten mit Myelomeningozele.

This study reports the results of 98 operations for correcting knee-flexion-contractures, which were performed between 1972 and 1989 in 60 patients with myelomeningocele. 13 knees had hamstring lengthening and 85 knees had radical flexor release. In 4 patients, who had flexion-contractures of more than 50 degrees, the soft tissue release was combined with supracondylar extension osteotomy. 58 patients had additional hip-flexion-contractures and 39 patients had feet deformities. The average age at time of surgery was 8 years, 3 months. The average follow-up-period was 65 months with a minimum of 1 year and a maximum of 13 years. In 92 knees a permanent extension ability could be achieved. In 6 knees a recurrence of flexion-contracture occurred making a second surgery necessary. The main problem in the postoperative period were 13 skin necroses, which were seen mainly after an s-shaped incision. As a conclusion a perpendicular midline incision is recommended. After surgery 11 patients could be provided for the first time with an orthoses. In the remaining the upright body position or the erection of the orthoses could be improved.

Osteoid osteoma of the radial styloid mimicking stenosing tenosynovitis. A case report.

An osteoid osteoma of the styloid process of the radius mimicking de Quervain's tenovaginitis in a 28-year-old man is reported. As the clinical presentation and X-rays of the wrist were not typical of an osteoid osteoma, only the histological examination led to the correct diagnosis.

Slow response to vancomycin or vancomycin plus rifampin in methicillin-resistant Staphylococcus aureus endocarditis.

OBJECTIVE: To determine the median response time to therapy with vancomycin alone or with vancomycin plus rifampin in patients with methicillin-resistant Staphylococcus aureus (MRSA) endocarditis. DESIGN: Cohort analysis of a randomized study. SETTING: University medical center. PATIENTS: Forty-two consecutive patients with MRSA endocarditis were randomly assigned to receive either vancomycin (group I) or vancomycin plus rifampin (group II) for 28 days. MEASUREMENTS: Clinical signs and symptoms were recorded, and blood cultures were obtained daily to determine the duration of bacteremia. MAIN RESULTS: The median duration of bacteremia was 9 days (7 days for group I and 9 days for group II). The median duration of fever for all patients and for each treatment group was 7 days. Six patients failed therapy, including three patients who died 5, 6, and 9 days after therapy was started, respectively. The other three patients who failed therapy required valve surgery on days 2, 22, and 27, respectively. Although patients had sustained bacteremia, no unusual complications were seen in either treatment group, and most patients responded to continued antibiotic therapy. CONCLUSIONS: Slow clinical response is common among patients with MRSA endocarditis who are treated with vancomycin or vancomycin plus rifampin. Nevertheless, few complications appear to be related solely to this sustained bacteremia.

Neutrophil chemotaxis in gastric mucosa. A signal-to-response comparison.

This prospective study compares levels of neutrophil chemotactic activity (NCA) in gastric juice to the neutrophil count in gastric biopsies. Sixty-three male patients enrolled in the study and had antral biopsies following collection of gastric juice during esophagogastroduodenoscopy. Biopsies were examined for the magnitude of gastritis, tissue PMN count, and presence of Helicobacter pylori. Secretions were assayed for neutrophil chemotactic activity. Results show an increase in NCA and in tissue PMN counts with increasing severity of gastritis. H. pylori-positive patients had higher levels of NCA and PMN than H. pylori-negative patients. Wide variability in NCA levels preclude a direct correlation between NCA and PMN counts.

Spinal growth after irradiation for Wilm's tumour.

Between 1960 and 1983, 82 children were treated for Wilm's tumour at our hospital. The secondary effects and changes in the skeleton have been assessed. Radiotherapy was found to cause growth disturbances and osteochondrosis of variable degree, but not osteonecrosis. Since irradiation produces late damage, it should be applied symmetrically to the spine and the dose limited as far as is possible. A long follow up is necessary since skeletal damage can only be assessed after the end of growth.

Percutaneous coronary laser balloon angioplasty: initial results of a multicenter experience.

A multicenter clinical trial was initiated to test the potential safety and short-term efficacy of a percutaneous coronary application of laser balloon angioplasty, which has been shown experimentally to alleviate the common causes (dissection, recoil, thrombus) of suboptimal luminal results of conventional balloon angioplasty. Fifty-five patients, the majority (62%) of whom had relatively high risk lesions, were treated in 10 centers with a laser balloon that was identical in size (3 x 20 mm) to a balloon used for conventional balloon angioplasty performed on the same lesion immediately before laser balloon angioplasty. One or more neodymium:yttrium aluminum garnet (Nd:YAG) (1,060 nm) laser doses of 250 to 450 J were each delivered over a 20 s duration per exposure. Immediately and 1 day after laser balloon angioplasty no significant adverse effects on the arterial lumen were noted in any patient. By computerized image analysis of cineangiograms initial conventional balloon angioplasty failed to achieve a minimal luminal diameter greater than 1.5 mm in 14 patients (25%), including 3 patients with acute closure. However, after subsequent laser balloon angioplasty, minimal luminal diameter exceeded this value in all patients including this subgroup. Overall, minimal luminal diameter increased from 1.74 +/- 0.46 mm after conventional balloon angioplasty to 2.32 +/- 0.31 mm after laser balloon angioplasty (p less than 0.001) with no change found on 1 day and 1 month follow-up angiograms. Thus, laser balloon angioplasty is a safe, effective procedure for improving luminal dimensions after conventional balloon angioplasty.

[Management of unstable pertrochanteric femoral fracture by alloarthroplastic joint replacement]. / Die Versorgung der instabilen pertrochanteren Femurfraktur durch alloarthroplastischen Gelenkersatz.

The treatment of trochanteric fractures of the femur should aim at the reconstruction of the joint function and should allow early weight bearing. In the case of unstable fractures and advanced osteoarthritis of the hip joint the advantages and risks of a total hip replacement have to be compared with different methods of osteosynthesis. We report on 35 patients with trochanteric fractures primarily treated with a total hip replacement. Their perioperative mortality was 9%, the most common complication was a luxation of the replaced hip joint in 3 cases. 1 patient had to be reoperated because of a soft tissue infection. Comparing the literature the primary total hip replacement shows a lower morbidity and mortality rate than complicated methods of osteosynthesis.

A new operation for the prevention and treatment of amputation neuromas.

A stump neuroma is caused by the disorganised growth of axon cylinders into proliferating granulation tissue, but this is stopped by an undamaged epineural sleeve. We report experiments in the rat in which the epineural sleeve of the stump of the sciatic nerve was freed from nerve fascicles for about 5 mm and then sealed with a synthetic tissue adhesive. Neuroma formation was largely prevented in comparison with the results of other methods. This new technique has been used to treat 68 painful neuromas in 36 patients. All but three of the patients were cured or improved and none were made worse.