Delayed occurrence of traumatic aortic dissection? Biomechanical considerations and literature.

Chronic aortic dissections and pseudoaneurysms caused by chest trauma are rare and generally have to be critically distinguished from non-traumatic dissections and aneurysms. We present a well-documented case of a post-traumatic aortic dissection that ruptured about 9 months after chest trauma. A motorcyclist sustained fractures of the forearm and chest trauma with paravertebral rib serial fractures and hemopneumothorax. Nine months after the accident, echocardiography revealed a pseudoaneurysm that ruptured 3 months later and 1 month prior to the planned surgery. An autopsy showed pericardial tamponade following a rupture of the dissected aorta. Accident scene documentation was consistent with a head-on collision of the motorcycle against the left front side of the car. The relative speed was about 55 km/h. Aggravation of unspecific symptoms after discharge, initial CT imaging, and the absence of atherosclerosis or medial necrosis hold for a post-traumatic genesis of the dissection in our case. Initially, the accident insurance company rejected the regulation. In the second instance, they revised rejection based on our interdisciplinary expert opinion.

Effect of Age on Liver Function in Patients Undergoing Partial Hepatectomy.

BACKGROUND: Postresectional liver failure is the most frequent cause of fatal outcome following liver surgery. Diminished preoperative liver function in the elderly might contribute to this. Therefore, the aim of the present study was to evaluate preoperative liver function in patients <60 or >70 years of age scheduled for liver resection. METHODS: All consecutive patients aged <60 or >70 years who are about to undergo elective liver surgery between 2011 and 2013 and underwent the methacetin breath liver function test (LiMAx) preoperatively were included. Histologic assessment of the resected liver gave insight into background liver disease. Correlation between age and liver function was calculated with Pearson's test. RESULTS: Fifty-nine patients were included, 31 were aged <60 and 28 were aged >70 years. General patient characteristics and liver function LiMAx values (340 (137-594) vs. 349 (191-530) µg/kg/h, p = 0.699) were not significantly different between patients aged <60 and >70 years. Moreover, no correlation between age and preoperative liver function LiMAx values was found (R = 0.04, p = 0.810). CONCLUSION: Liver function did not seem to differ between younger and older patients.

Metastatic behaviour of sinonasal adenocarcinomas of the intestinal type (ITAC).

The relative frequency of regional lymphogenic versus distant hematogenic metastases was evaluated in 369 patients with sinonasal adenocarcinoma of the intestinal type (ITAC). We assessed the results of neck dissections for a limited number of patients undergoing this surgical intervention. 117 ITAC patients were followed up for at least 5 years. Neck dissections were performed in 18 cases (15 primary and 3 secondary operations), 4 of which revealed carcinoma-positive lymph nodes. Metastases in lymph nodes were also diagnosed clinically in three other patients adding up to a total of seven individuals (6 % of 117) with lymphogenic metastases. In comparison, distant hematogenic metastases were identified in 15.4 % of these 117 patients. In the second group of 252 patients, the occurrence of distant hematogenic metastases and colorectal adenocarcinomas was registered but no formal follow-up procedure was applied. 50 neck dissections were performed in this group, 46 of which exhibited no histological evidence for metastases in lymph nodes, while in 1 case they were carcinoma-positive. Three additional cases showed clinical signs of metastases in regional lymph nodes. Taken together, our observations indicate that regional lymphogenic metastases are rather rare (about 2 %) in patients with sinonasal adenocarcinoma of the intestinal type. Therefore, the surgery of neck dissection appears not advised as routine intervention in these cases. ITAC patients show a normal prevalence of colorectal adenocarcinomas.

Clinical and morphological aspects of adenocarcinomas of the intestinal type in the inner nose: a retrospective multicenter analysis.

Clinical and histological parameters from 117 patients with wood dust-related sinonasal adenocarcinomas of intestinal type (ITAC) were analyzed and correlated with a follow-up period of 5 years at least. The rate of survival for 5 years was 53.1 % and for 10 years 30.2 %. Only 33 patients were free of disease. 74.2 % of patients with recurrences died in relation to ITAC. As expected, tumors of T4-category had the worst prognosis. The mucus content of a tumor was the most important histological parameter. Endonasal methods of surgery had no more positive survival rates after 5 years. An effect of radiotherapy has to be in discussion. The high incidence of tumor recurrences requires control examinations consistently.

[Diagnostic value of routine ileum biopsy in patients with chronic diarrhoea--a prospective monocentric study]. / Die diagnostische Bedeutung der Ileumbiopsie bei chronischer Diarrhö--eine prospektive monozentrische Studie.

BACKGROUND AND AIMS: In patients with chronic diarrhoea of unknown origin, colonoscopy with intubation of the terminal ileum and performance of biopsies are standard in the diagnostic work-up. While the importance of random biopsies in the colon even in cases with normal endoscopic appearance has been proven in several studies, the role of biopsies in the terminal ileum under these circumstances is not well defined. PATIENTS AND METHODS: In this prospective observational 24-month study patients with chronic diarrhoea of unknown cause were included. All patients underwent colonoscopy with intubation and biopsy of the terminal ileum. These biopsies have been analysed, their diagnostic value has been compared to the endoscopic appearance and the clinical diagnosis was investigated. RESULTS: In 159 patients, the terminal ileum showed a pathological endoscopic appearance in 27 cases (17 %). In 22 (81.5 %) of these 27 patients diagnostic pathological findings were present, in 4 cases (14.8 %) non-specific histological changes were detected and in one patient (3.7 %), histology was normal. In contrast, only in one of 132 cases with normal endoscopic appearance, did histopathology show a significant pathology (celiac disease). In 30 of the 132 patients (22.7 %) with a normal endoscopic appearance, distinctive histological features were detected (slight eosinophilia or elevated mucosal immune cell count), but not classified as diagnostic. In all cases, these features were also present in simultaneously performed colonic biopsies. CONCLUSIONS: Routine biopsy of the terminal ileum, when normal endoscopic appearance is documented, does not give any additional information and cannot be recommended as a standard procedure in endoscopic work-up of chronic diarrhoea.

Doppler ultrasound of hepatic blood flow for noninvasive evaluation of liver fibrosis compared with liver biopsy and transient elastography.

BACKGROUND: Accurate quantification of liver fibrosis is essential for therapeutic decision-making and follow-up of chronic liver diseases. AIMS: To optimize the quality of non-invasive assessment of liver fibrosis in patients with chronic hepatopathy we compared Doppler ultrasound with liver histology and transient elastography (TE). METHODS: In this prospective observational study, we performed Doppler ultrasound of hepatic blood vessels as well as TE in 125 patients who underwent liver biopsy for diagnostic work-up of hepatopathy. Hepatic venous flow was evaluated by determining resistance index (HVRI) of the right hepatic vein. Doppler and TE results were compared with histological staging, grading and degree of steatosis obtained by liver biopsy. RESULTS: HVRI showed a high reliability in predicting fibrosis stage FII or higher (AUROC 93.7 %, HVRI < 1.185; sensitivity 89.66 % and specificity 86.32 %) and was superior to TE. Neither steatosis nor inflammation had significant influence on HVRI-based estimation of fibrosis (1.45 ± 0.2; 1.26 ± 0.05; 1.06 ± 0.06; 0.87 ± 0.08; 0.46 ± 0.11 for F0-FIV, respectively). HVRI differed significantly in different stages of fibrosis. In contrast, portal vein and hepatic artery only showed significant changes in higher stages of fibrosis. Hepatic artery resistance index was elevated (0.67-0.74; p < 0.05); portal vein flow maximum and undulation were significantly reduced in higher fibrosis (p < 0.05 and p < 0.01, respectively). CONCLUSIONS: Hepatic blood flow analysis, especially HVRI, provides useful information during assessment of hepatopathy and is a reliable predictor of liver fibrosis stage FII or higher as part of the non-invasive diagnostic work-up and follow-up in chronic liver disease.

Raising awareness about chronic intestinal pseudo-obstruction (CIPO): a case report showing CIPO as initial manifestation of atypical seronegative systemic sclerosis.

Only few case studies address pseudo-obstruction, a disorder - which often frustrates clinicians and patients due to an unclear diagnosis and limited therapeutic options. Thus, the aim of this paper is to investigate a relevant case concerning a patient presenting with symptoms of acquired chronic intestinal pseudo-obstruction (CIPO). After one year of extensive diagnostic tests and unsuccessful treatment with prokinetics, the patient underwent a subtotal ileocolectomy. The histology of the intestinal specimen revealed continuous atrophy and fibrosis mainly within the circular, inner muscle layer of muscularis propria of the ileum and colon. Even though serum markers were lacking, a subsequent skin biopsy showed signs of scleroderma supporting an initial diagnosis of intestinal involvement in systemic sclerosis. Despite treatment with steroids and methotrexate, the increasingly emaciated patient died. In conclusion, there is a bias against the publishing of pseudo-obstruction studies, in particular, due to the obscure underlying causes. To raise awareness of this problem, we call for clinicians to systematically generate comprehensive data about patients presenting these symptoms.

[Tumors of Vater's ampulla]. / Tumoren der Papilla Vateri.

Tumors of Vater's ampulla are generally uncommon. In this location intestinal type adenomas are frequently found, followed by noninvasive papillary neoplasms of the pancreaticobiliary type and neuroendocrine tumors (carcinoids). Carcinomas of Vater's ampulla represent about 0.5% of all gastrointestinal malignancies. Intestinal type adenocarcinoma is the most common malignant epithelial tumor followed by the pancreaticobiliary type adenocarcinoma. Highly malignant neuroendocrine carcinomas of Vater's ampulla are very uncommon. Carcinomas of the ampullary region can be sporadic or a component of several disease syndromes. Designation of large carcinomas as tumors with an ampullary or extra-ampullary origin can be difficult but is of relevance for a TNM conform classification. Helpful in the decision are the relationship between the tumor centre and Vater's ampulla, the existence of premalignant lesions in the ampullary epithelium as well as histology and immunostaining of the tumor.

[Primary cutaneous peripheral T-cell lymphoma (not otherwise specified)]. / Primär kutanes peripheres T-Zell-Lymphom (nicht anderweitig spezifiziert).

Peripheral cutaneous T-cell lymphoma which cannot be further classified due to high morphological and molecular variability are included into the group of "primary cutaneous peripheral T-cell lymphoma--not otherwise specified" (PCTL-NOS). PCTL-NOS represent a rare, heterogeneous group characterized by rapidly progressive nodules in the absence of typical mycosis fungoides plaques. Furthermore, therapeutic options are limited and prognosis is rather poor. We report on a 62-year-old patient presenting with asymptomatic papules in the popliteal and antecubital fossae. Based on histopathological criteria, PCTL-NOS was diagnosed. Based on recent gene expression studies, a positive reaction to tyrosine kinase and histone deacetylase inhibitors is hoped for.

Value of magnifying endoscopy in classifying colorectal polyps based on vascular pattern.

BACKGROUND AND STUDY AIMS: Narrow-band imaging (NBI) has been developed as a new technique to differentiate tissue patterns in vivo. The aim of this study was to evaluate the diagnostic accuracy of NBI endoscopy with and without high magnification for the differentiation of neoplastic from non-neoplastic colorectal polyps. PATIENTS AND METHODS: Among 200 colorectal polyps from 131 patients, 100 lesions were classified according to vascular patterns by NBI endoscopy with high optical magnification and 100 lesions by high-definition endoscopy without high magnification. Additionally, the clarity of the vessel network was assessed. Histologic analysis was performed on all lesions. RESULTS: NBI endoscopy with high magnification resulted in a sensitivity of 92.1 % and a specificity of 89.2 % for the differentiation of neoplastic versus non-neoplastic lesions. This performance was statistically comparable to high-definition NBI endoscopy without high magnification, which showed a sensitivity of 87.9 % and specificity of 90.5 %. However, vessel network was significantly better visualized by NBI endoscopy with optical magnification compared with high-definition NBI endoscopy without high magnification. In comparison with NBI endoscopy, white-light endoscopy, with or without magnification, resulted in inferior discrimination between neoplastic and non-neoplastic polyps. CONCLUSION: The results demonstrate that the superior visibility of capillary vessels by the NBI technique allows the evaluation of colorectal lesions - based on the vascular patterns - with high diagnostic accuracy. In clinical routine, high-definition NBI endoscopy without high magnification may be used to sufficiently predict colorectal polyp histology, and high magnification can additionally facilitate visualization of vascular networks.

Cavitating mesenteric lymph node syndrome: a rare complication of refractory celiac disease.

Celiac disease is an immune-mediated enteropathy characterized by mucosal inflammation and villous atrophy of the small bowel upon exposure to ingested gluten. Refractory celiac disease (RCD), defined as persisting villous atrophy with crypt hyperplasia despite strict gluten-free diet, is a rare form of celiac disease with poor prognosis due to a higher rate of severe complications such as life-threatening malnutrition or the development of intestinal T-cell lymphoma. The cavitating mesenteric lymph node syndrome (CMLNS) represents a rare complication of celiac disease with unknown pathogenesis which is associated with but not restricted to RCD and not necessarily associated with a malignant course. We here report a 64-year-old patient who was referred to us with a history of refractory celiac disease. During further diagnostic work-up multiple intraabdominal cystic structures were detected by a computed tomography scan and magnetic resonance imaging. A laparotomy was performed to exclude T-cell lymphoma. Histology of the intraabdominal cysts revealed the diagnosis of cavitating mesenteric lymph node syndrome as the underlying cause of the masses. Steroid therapy was initiated which led to complete regression of diarrhoea but did not induce a diminution of mesenteric lymph nodes. Three years after the diagnosis of CMLNS, the patient presented with an acute abdomen due to a small bowel perforation caused by an enteropathy associated T-cell lymphoma. We discuss the differential diagnoses of intraabdominal masses in celiac disease and review the current literature on CMLNS.

[Primary cutaneous CD30+ ALK(-) anaplastic large cell T-cell lymphoma]. / CD30(+) ALK(-) anaplastisch grosszelliges primär kutanes T-Zell-Lymphom.

Anaplastic large cell lymphomas (ALCL) are characterized by large, pleomorphic cells with a strong expression of cytokine receptor CD 30. We present a 71-year-old patient with several nodules on the right temple extending to his right ear. Based on clinical, histological and immunophenotypic criteria, the diagnosis of a primary cutaneous CD30(+) ALK(-) anaplastic large cell lymphoma was made. After local excision and adjuvant radiotherapy no relapse occurred during a follow-up period of three months.

Respiratory Deleted in Malignant Brain Tumours 1 (DMBT1) levels increase during lung maturation and infection.

Deleted in Malignant Brain Tumours 1 (DMBT1) is a secreted scavenger receptor cysteine-rich protein that binds and aggregates various bacteria and viruses in vitro. Studies in adults have shown that DMBT1 is expressed mainly by mucosal epithelia and glands, in particular within the respiratory tract, and plays a role in innate immune defence. We hypothesized that respiratory DMBT1 levels may be influenced by various developmental and clinical factors such as maturity, age and bacterial infection. DMBT1 levels were studied in 205 tracheal aspirate samples of 82 ventilated preterm and full-term infants by enzyme-linked immunosorbent assay. Possible effects of various clinical parameters were tested by multiple regression analysis. DMBT1 levels increased significantly with lung maturity (P < 0.0001 for both gestational and postnatal age) and in small-for-gestational-age infants (P = 0.0179). An increase of respiratory DMBT1 levels was detected in neonatal infections (P < 0.0001). These results were supported by Western blotting. Immunohistochemical analyses of archived newborn lung sections (n = 17) demonstrated high concentrations of DMBT1 in lungs of neonates with bacterial infections. Our data show that preterm infants are able to up-regulate DMBT1 in infection as an unspecific immune reaction.

Notch inhibition counteracts Paneth cell death in absence of caspase-8.

Opposing activities of Notch and Wnt signaling regulate mucosal barrier homeostasis and differentiation of intestinal epithelial cells. Specifically, Wnt activity is essential for differentiation of secretory cells including Wnt3-producing Paneth cells, whereas Notch signaling strongly promotes generation of absorptive cells. Loss of caspase-8 in intestinal epithelium (casp8∆int) is associated with fulminant epithelial necroptosis, severe Paneth cell death, secondary intestinal inflammation, and an increase in Notch activity. Here, we found that pharmacological Notch inhibition with dibenzazepine (DBZ) is able to essentially rescue the loss of Paneth cells, deescalate the inflammatory phenotype, and reduce intestinal permeability in casp8∆int mice. The secretory cell metaplasia in DBZ-treated casp8∆int animals is proliferative, indicating for Notch activities partially insensitive to gamma-secretase inhibition in a casp8∆int background. Our data suggest that casp8 acts in the intestinal Notch network.

Specific resistance upon lentiviral TRAIL transfer by intracellular retention of TRAIL receptors.

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) selectively induces apoptosis in many transformed cells, suggesting TRAIL as an ideal candidate for cancer gene therapy. A main obstacle in cancer therapy is intrinsic or acquired therapy resistance of malignant cells. To study induction of resistance against TRAIL, we generated lentiviral vectors allowing efficient TRAIL expression and apoptosis induction in a variety of human cancer cell lines. Within days upon TRAIL overexpression, cells became resistant towards TRAIL, but not to CD95 ligation or DNA damage by cisplatin. Cell surface expression of TRAIL receptors 1 and 2 was completely abrogated in resistant cells due to intracellular retention of the receptors by TRAIL. SiRNA directed against TRAIL resensitized the resistant cells by restoring cell surface expression of TRAIL receptors. These findings represent a novel resistance mechanism towards TRAIL, specifically caused by TRAIL overexpression, and question the use of TRAIL expression in tumor-cell targeting gene therapy.

c-Jun N-terminal kinase 2 promotes enterocyte survival and goblet cell differentiation in the inflamed intestine.

c-Jun N-terminal kinases (JNKs) contribute to immune signaling but their functional role during intestinal mucosal inflammation has remained ill defined. Using genetic mouse models, we characterized the role of JNK1 and JNK2 during homeostasis and acute colitis. Epithelial apoptosis, regeneration, differentiation, and barrier function were analyzed in intestinal epithelium-specific (ΔIEC) or complete JNK1 and bone marrow chimeric or complete JNK2 deficient mice as well as double-knockout animals (JNK1ΔIECJNK2-/-) during homeostasis and acute dextran sulfate sodium (DSS)-induced colitis. Results were confirmed using human HT-29 cells and wild-type or JNK2-deficient mouse intestinal organoid cultures. We show that nonhematopoietic JNK2 but not JNK1 expression confers protection from DSS-induced intestinal inflammation reducing epithelial barrier dysfunction and enterocyte apoptosis. JNK2 additionally enhanced Atonal homolog 1 expression, goblet cell and enteroendocrine cell differentiation, and mucus production under inflammatory conditions. Our results identify a protective role of epithelial JNK2 signaling to maintain mucosal barrier function, epithelial cell integrity, and mucus layer production in the event of inflammatory tissue damage.

Dexamethasone desensitizes hepatocellular and colorectal tumours toward cytotoxic therapy.

The glucocorticoid dexamethasone is frequently used as co-treatment in cytotoxic cancer therapy, e.g. to prevent nausea, to protect normal tissue or for other reasons. While the potent pro-apoptotic properties and the supportive effects of glucocorticoids to tumour therapy in lymphoid cells are well studied, the impact to cytotoxic treatment of colorectal and hepatocellular carcinoma is unknown. We tested apoptosis-induction, viability, tumour growth and protein expression using 8 established cell lines, 18 surgical specimen and a xenograft on nude mice. In the presence of dexamethasone we found strong inhibition of apoptosis in response to 5-FU, cisplatin, gemcitabine or gamma-irradiation, enhanced viability and tumour growth of colorectal and hepatocellular carcinomas. No correlation with age, gender, histology, TNM, the p53 status and induction of therapy resistance by dexamethasone co-treatment could be detected. These data show that glucocorticoid-induced resistance occurs not occasionally but is common in colorectal and hepatocellular carcinomas implicating that the use of glucocorticoids may be harmful for cancer patients.

Rapid detection of urinary tract infection--evaluation of flow cytometry.

AIMS: Urogenital tract infection (UTI) due to bacteria is not only a common infection but also a complication during hospitalization. Therefore, the identification and quantification of bacteria in urine samples are routinely performed methods in microbiological laboratories. To differentiate between infection and contamination it is also important to quantify the leukocyte count. In this study, we suggest a screening procedure using the flow cytometer analyzer BACSYS-40i as tool for the diagnosis of UTI. MATERIAL AND METHODS: Each urine sample was inoculated onto agar plates (MacConkey agar, sheep blood agar and enterococcosel agar (Bio Merieux, Nütingen, Germany)) within 4 hours after collection. After 24 up to 48 hours incubation at 37 degrees C, bacteria were quantified by evaluation of colony-forming units (CFU) according to the criteria given by the German recommendation [MIQ 1997]. Additionally, each sample was submitted to the BACSYS-40i analyzer. The technological principle is a fluorescence flow cytometer with a laser and a fluorescent dye to identify bacteria and leukocytes with high analytical sensitivity. RESULTS: Coefficients of variation (CV) for examination of within-run reproducibility ranged from 1.7 - 9.0% for leukocytes and from 6.2 - 24.6% for bacteria. Linearity was found to be very good, with coefficients of determination of r = 0.9998 for leukocytes, and r = 0.9994 for bacteria. Carry-over was calculated and found to be extremely low, ranging up to 0.03% for leukocytes and up to 0.002% for bacteria. The correlation coefficient for leukocyte counting is 0.979, regression y = 1.0 x + 1.0. The number of bacteria determined with the BACSYS-40i (total cell count) is higher than the number determined by culture (viable cell count). If the cut-offs of the analyzer were fixed at > or = 10(6) and < 10(5) bacteria/microl for positive, respectively negative results, 39 out of 42 patients (93%) showing unambiguous predominant clinical signs of UTI and in addition growth of bacteria involved in UTI were recognized. Six samples were questionable. CONCLUSIONS: Results obtained by the BACSYS-40i can be reported after a few minutes. Urine samples from all 57 patients with predominant clinical signs and in addition growth of bacteria isolated from urine and known as pathogens of UTI had positive results with the analyzer (100%) for elevated bacteria and leukocyte counts. Furthermore, all patients without symptoms for UTI were negative after analysis with the BACSYS-40i (44/44; 100%).