Comparison of histopathological findings with duplex sonography of the temporal arteries in suspected giant cell arteritis.

INTRODUCTION: In clinical practice the temporal artery biopsy (TAB) in suspected giant cell arteritis (GCA) is still believed to be the "gold standard". The purpose of this study was to compare the histopathological findings of the TAB with duplex sonography of the temporal artery. PATIENTS AND METHODS: In our retrospective study we analysed 85 consecutive patients (52 female, mean age 71.5, range 55 - 91 years; 33 male, mean age 71.6, range 44 - 91 years) with suspected GCA who underwent TAB in our clinic between January 1999 - February 2011. All patients received a preoperative duplex sonography, 57 patients including description of the temporal arteries. RESULTS: 38 of 85 (44.7 %) of the artery biopsies were proven positive for GCA by histopathology. Interpretation of the duplex sonography was congruent of histopathological interpretation of the biopsy in 39 patients (68.4 %) and incongruent in 18 patients (31.6 %). Sensitivity of duplex-sonography was 44.4 %, specificity 90 %, positive predictive value 80 %. DISCUSSION: Duplex sonography is a non-invasive and very helpful diagnostic tool to guide the clinician in cases of suspected GCA but needs considerable skills. It shows a good specificity and relatively high positive predictive value as there are only few false positive results. A negative report however does not rule out GCA, so that in our opinion the TAB - at least in those cases - should still be performed.

Effects of a sensory branch to the posterior external ear canal: coughing, pain, Ramsay Hunt's syndrome and Hitselberger's sign.

BACKGROUND: A distinct nerve innervating the external auditory canal can often be identified in close relation to the facial nerve when gradually thinning the posterior canal wall. This nerve has been attributed to coughing during cerumen removal, neuralgic pain, Hitselberger's sign and vesicular eruptions described in Ramsay Hunt's syndrome. This study aimed to demonstrate the origin and clinical impact of this nerve. METHODS AND RESULTS: In patients with intractable otalgia or severe coughing whilst inserting a hearing aid, who responded temporarily to local anaesthesia, the symptoms could be resolved by sectioning a sensory branch to the posterior canal. In a temporal bone specimen, it was revealed that this nerve is predominantly a continuation of Arnold's nerve, also receiving fibres from the glossopharyngeal nerve and facial nerve. Histologically, the communicating branch from the facial nerve was confirmed. CONCLUSION: Surgeons should be aware of the posterior auricular sensory branch and its clinical implications.

High-throughput tissue microarray analysis of 3p25 (RAF1) and 8p12 (FGFR1) copy number alterations in urinary bladder cancer.

Studies by comparative genomic hybridization revealed that the chromosomal regions 3p25 and 8p11-p12 are recurrently amplified in bladder cancer. To investigate the prevalence of DNA copy number alterations in these chromosomal regions and study their clinical significance, we used probes for the RAF1 (3p25) and FGFR1 (8p12) genes for fluorescence in situ hybridization. A tissue microarray containing 2317 tumors was analyzed. The analysis revealed RAF1 amplification in 4.0% and FGFR1 amplification in 3.4% of interpretable tumors. In addition, deletions were found at the 3p25 locus in 2.2% and at the 8p11-12 locus in 9.9% of interpretable tumors. Both amplifications and deletions of RAF1 and FGFR1 were significantly associated with high tumor grade (P < 0.0001), advanced stage (P < 0.0001), and poor survival (P < 0.05) if tumors of all of the stages where analyzed together. RAF1 amplifications were associated with subsequent tumor progression in pT1 carcinomas (P < 0.05). The marked differences in the frequency of all of the analyzed changes between pTa grade 1/grade 2 and pT1-4 carcinomas support the concept of these tumor groups representing different tumor entities.

Chronic viral hepatitis B and C: an argument against the conventional classification of chronic hepatitis.

The classification of chronic hepatitis distinguishing benign chronic persistent hepatitis from severe chronic active hepatitis was constructed without knowledge of well-defined aetiological factors. Better understanding of the different hepatitis-viruses has shed new light on this subject. Chronic viral hepatitis B and C each show typical histological patterns. The validity of the conventional classification has been evaluated by a comparative study of chronic viral hepatitis B and C. 130 biopsies from 110 patients with chronic hepatitis C (CH-C) proven serologically by antibodies (second generation testing) were compared with 105 biopsies from 73 patients with chronic hepatitis B (CH-B). These were scored semi-quantatively. In CH-C, lymphoid follicles and/or aggregates were found in 88.5%, fatty degeneration in 51%, bile duct lesions in 46.2%, and Mallory body-like material in the hepatocytes in 9.2%. The portal lymphocytic infiltration generally predominated over the necro-inflammatory lesions of the parenchyma. Chronic persistent hepatitis (defined by the presence of portal hepatitis) was present exclusively in CH-C. Chronic lobular hepatitis was found exclusively in CH-B. We conclude that the histological criteria described for CH-C are highly suggestive of the diagnosis, that the artificial subdivision of chronic hepatitis into CPH and CAH is obsolete and that the histological assessment of chronic hepatitis should consist of a grading of inflammatory activity (minimal, mild, moderate, severe) and staging of fibrosis (extent of distortion of architecture). The final diagnosis should be based on the demonstration of the aetiological agent.

Magnetic resonance-guided laparoscopic interstitial laser therapy of the liver.

BACKGROUND: There is a necessity for an imaging method during laparoscopy to get a three-dimensional access to the target. In this study we evaluated laparoscopic interstitial laser therapy of the liver under magnetic resonance imaging guidance. METHODS: Five domestic pigs underwent laparoscopy in an open-configuration magnetic resonance system. Under simultaneous real-time magnetic resonance imaging interstitial laser therapy was applied to the liver. Magnetic resonance images, macroscopic aspects of the lesions, and light microscopic findings were compared. RESULTS: The interventions could be safely performed. There was no image artifact caused by instruments or by the carbon dioxide. Dynamic gadolinium-enhanced imaging proved to significantly predict the macroscopic volume of the laser lesions. CONCLUSIONS: Magnetic resonance-guided laparoscopic interstitial laser therapy of the liver combines the advantages of minimal invasive surgery and magnetic resonance imaging. Further development should focus on laparoscopic instruments and temperature sensitive sequences.

Evaluation of methods for hepatitis C virus detection in archival liver biopsies. Comparison of histology, immunohistochemistry, in-situ hybridization, reverse transcriptase polymerase chain reaction (RT-PCR) and in-situ RT-PCR.

To evaluate reliable methods for detection of hepatitis C virus (HCV) infection in routinely processed liver biopsies we analyzed formaldehyde-fixed and paraffin-embedded liver specimens of 10 patients with serological confirmed HCV infection. We compared (1) conventional histology; (2) indirect immunofluorescence using the mAb TORDJI-22 (Clonatec, Paris, France); (3) RT-PCR using total RNA and Southern blotting with chemiluminescent detection; (4) non-radioactive in-situ hybridization (ISH) with digoxigenin-labeled oligo- and cRNA probes; (5) direct in-situ RT-PCR with incorporation of labeled nucleotides into PCR-products, and (6) indirect in-situ RT-PCR using subsequent ISH for the visualization of intracellular PCR-products. Our results indicate that: (1) using the histological criteria described by Lefkowitch et al. [Gastroenerology 1993;104:595] together with clinical data, most chronic HCV infections can be diagnosed by conventional histology, if liver biopsies specimens are adequate; (2) the commercially available mAb TORDJI-22 appears to crossreact with non-HCV epitopes, resulting in false positives; (3) molecular methods performed on routinely fixed and processed liver biopsies frequently yield false negative results due to sampling problems, low viral copy number and RNA degradation in infected cells; (4) analysis of HCV-RNA by RT-PCR of extracted total RNA is more sensitive than indirect in-situ RT-PCR or ISH; and (5) direct in-situ RT-PCR is not reliable despite the use of modifications such as DNase pretreatment and hot-start procedures. It is concluded, that several molecular methods for HCV detection must await further improvements of protocols to be suitable for routine diagnostics on paraffin-embedded liver biopsies.

Experimental cryosurgery of the liver under magnetic resonance guidance.

The feasibility and the advantages of magnetic resonance (MR)-guided interstitial cryosurgery of the liver in an 0.5 Tesla open MR system have been evaluated. Cryosurgery was performed using an Erbocryo PS system with a nonmagnetic cryoprobe of 6 mm diameter. The probe was inserted into the liver parenchyma under real-time MR control. Using continuous MR imaging two freezing cycles of 12 min each were applied. After conventional and dynamic gadolinium-enhanced MR imaging, the animals were sacrificed after 30 min, 3 hr, 24 hr, 7 days, and 21 days. Each lesion was analyzed using light microscopy. A total of seven cryolesions were made in five animals without any complications from cryosurgery. During real-time imaging, cryolesions appeared as a hemispherical growing signal loss with a mean volume of 16.4 cm3. Macroscopic volumes of the lesions showed a good correlation with dynamic enhanced MR images during follow-up, whereas real-time images usually showed an underestimation of the lesion volumes. Cryosurgery of the liver in an open-configuration MR system is a feasible and safe method. MR imaging allows the guidance and the follow-up of cryolesions of the liver with good accuracy.

[Angiosarcoma of the kidney. Case report and review of the literature]. / Angiosarkom der Niere. Fallbeispiel und Literaturübersicht.

The primary renal angiosarcoma is a rarely seen highly malignant tumor. Making a diagnosis based on histology may prove difficult. Because of hematogenous formation of metastases and bad prognosis in most cases we recommend that the surgical intervention be followed by the well tolerated systemic chemotherapy with Doxorubicin and Ifosfamid.

[Crisis intervention of sexually abused women]. / Krisenberatung sexuell misshandelter Frauen.

Sexual violence on women manifests itself in most diverse forms; for example as sexual exploitation of young girls, as rape, as sexual molestation in the working place or as sexual abuse in the realm of therapy. In the following, it will be pointed out with reference to the situation of the violated woman which backgrounds of sexual violence they are and what the trauma of the violated woman means. In broader sense, the different phases of working up the process and several central aspects of crisis intervention will be presented. This is also in the knowledge of the fact that doctors are often the first ones and sometimes the only ones, to whom the violated woman relates.

[Neuroendocrine tumors of the stomach (stomach carcinoid)]. / Neuroendokrine Tumoren des Magens (Magenkarzinoide).

We report about two patients with gastric neuroendocrine tumours (carcinoids) and chronic atrophic gastritis. A 68-year-old woman presented with nonspecific dyspeptic complaints. Gastroscopy revealed a single neuroendocrine tumour of the corpus. 33 months after endoscopic therapy she is free of detectable tumour. As cause of an upper gastrointestinal bleeding in a 75-year-old woman, a small ulcerated fundic neuroendocrine tumour was found together with other multiple tumours. Repeated endoscopic removals of these and further developing similar tumours were necessary during a follow-up of 25 months. Neuroendocrine tumours of the stomach are rare and are potentially malignant. According to their clinical context they can be divided into three subtypes: 1. tumours in chronic atrophic gastritis, 2. tumours in multiple endocrine neoplasia type I, 3. sporadic tumours, not associated with particular diseases. The first two types may be gastrin-promoted; they occur often multifocal only in the nonantral mucosa and seem to behave relatively benign. Metastasis limited to regional lymph nodes has not been described often. The very rare third type appears solitary in the whole stomach and seems to have a higher malignant potential with frequent distant metastasis to the liver. Therapy should be mainly guided by subtype and tumour size.

[Abdominal pain, fresh blood in the anus]. / Abdominalschmerzen, Frischblut ab ano.

A 60-year-old lady with type II diabetes, arterial hypertension and 'melancholia' was treated with Lithium, a neuroleptic (Leponex) and an ACE inhibitor (Reniten). She was referred to our hospital because of abdominal pain, subfebrile temperatures, diarrhea and hematochezia. The radiological and sonographic examinations showed a thickened wall of the left hemicolon. Colonoscopy revealed a sharply delineated segment with pronounced inflammation in the descending colon and the proximal sigmoid colon, suggestive for an ischemic colitis. Histology of the inflamed colon was compatible with this diagnosis. Under suspended enteral feeding and antibiotic therapy the symptoms disappeared within two weeks, and a control colonoscopy six weeks later was completely normal. 1 1/2 years later the patient suffered from a second episode of ischemic colitis exactly a the same site. Again, complete cure was achieved by conservative treatment.

[Thoracic pain, shock-inducing gastrointestinal bleeding]. / Thoraxschmerzen, schockierende obere Gastrointestinalblutung.

A 65-year-old patient was referred to hospital with suspected myocardial infarction because of left-sided thoracic pain. A paresis of the left recurrent nerve of unknown etiology has been known for three years. Because of shock with anemia, upper gastrointestinal endoscopy was performed. A diverticulum-like lesion in the proximal esophagus was found to be the source of the bleeding. A contrast X-ray examination showed a cavity of approximately 2 x 2 cm originating from the proximal esophagus. Computerized tomography revealed a large mediastinal mass reaching from the thyroid to the diaphragm. An ultrasound-guided fine-needle puncture of this tumor, together with the endoscopical snare biopsies of the esophageal lesion, allowed the diagnosis of an anaplastic thyroid carcinoma with erosion of the esophagus. The patient responded well to palliative radiotherapy. The defect in the proximal esophagus refilled quickly. Nine months after radiotherapy the patient is doing well.

[Arthropathy in hemochromatosis]. / Arthropathie bei Hämochromatose.

Early diagnosis of hemochromatosis may prevent the numerous risks of iron overload. One of the most common early manifestations of this disease is arthropathy. The clinical and radiologic findings of hemochromatosis arthropathy are discussed. Diagnosis is suggested by simple laboratory tests and confirmed by liver biopsy with measurement of hepatic iron content. Treatment includes the removal of the excess body iron by phlebotomy. Unfortunately, symptoms of arthropathy tend to be resistant to phlebotomy.

Displacement of malignant cells into the portal triad of the liver results in reduced liver perfusion, mimicking segmental Fatty liver.

Liver steatosis is often observed in different clinical situations. Oncological patients undergoing systemic therapy often develop liver steatosis, which can be diagnosed with normal routine scans such as CT and ultrasound. In this case report, we show that an isolated infiltration of the portal triad with tumor cells could mimic a fatty-like infiltration of the liver. Radiologists and clinicians should be aware of this pitfall and should perform a biopsy in cases of doubt.

[Metastazation into the seminal vesicles due to primary goblet cell carcinoid of the vermiform appendix. An unusual diagnostic procedure of a seminal vesicle tumor]. / Samenblasenmetastase bei primärem Becherzellkarzinoid der Appendix vermiformis. Ein aussergewöhnlicher Abklärungsgang eines Samenblasentumors.

We report on a remarkable diagnostic work up of suspect rectal palpation results in a 54-year-old patient. According to a transrectal ultrasound-guided punch biopsy the patient was suspected of having a carcinoma of the seminal vesicles and an aggressive operational approach was considered. After a median laparotomy a generalized peritoneal carcinomatosis was found. A goblet cell carcinoid of the vermiform appendix was identified as the primary tumor. This case report deals with metastazation of a primary goblet cell carcinoma into the seminal vesicles on both sides as an extremely rare reason for suspicious rectal palpation results. The tumor valency, diagnostic work up, therapy and further differential diagnoses are described.

Exercise capacity in athletes with mouthguards.

The objective of this study was to determine the effect of wearing a mouthguard on maximal exercise capacity and cardiopulmonary parameters at peak workload, and to assess the athletes' attitudes toward wearing a mouthguard. Thirteen volunteer male athletes (18 to 27 years old) were interviewed before and after delivery of a custom-made laminated mouthguard. A visual analogue scale (VAS, 0 - 100 mm) was used for judgment of interference with breathing, speaking, concentration and athletic performance. In addition, the athletes were subjected to a cardiorespiratory examination on a cycle ergometer with and without mouthguards. Subjectively, the athletes rated the mean interference with performance to be 37 mm VAS at the beginning of the study. Mean scores of impairment decreased to 23 mm VAS (p = 0.081) after wearing the mouthguard for four weeks, and further improved to 12 mm VAS (p < 0.001) after the test on the cycle ergometer. Objectively, the maximum workload during spiroergometry was even slightly elevated during exercise with the mouthguard (330.2 W) compared to exercise without the mouthguard (314.5 W). Peak minute ventilation and oxygen uptake were not different during exercise with and without the mouthguard. The present study demonstrated that a custom-made mouthguard does not significantly affect or reduce maximum exercise performance of athletes.

[Laparoscopic cholecystectomy: heat damage to the liver caused by hooked electrode and laser]. / Laparoskopische Cholezystektomie: Hitzeschäden in der Leber durch Hakenelektrode und Laser.

To control heat damage in the liver after cholecystectomy caused by electrosurgery or Laser, gallbladders were resected at autopsy partly by the Holmium:YAG-Laser and Nd:YAG-Laser and partly by electrosurgery. Heat damage was documented by histological examinations of the liver-bed of the gallbladder. Microscopical evaluation showed that electrocautery tends to produce deeper heat damage in the liver-tissue than the Holmium:YAG-Laser.

Agranulocytosis associated with semisynthetic penicillins and cephalosporins. Report of 7 cases.

Within one year we observed in the same intensive care unit seven severely polytraumatized patients with agranulocytosis (AG) associated with treatment by semisynthetic penicillins or cephalosporins combined with aminoglycosides. Antibiotics were given because of severe bacterial respiratory or generalised infections. Five patients died, four of them without haematological remission. Bone marrow aspirates showed hypoplasia of granulopoiesis due to a lack of mature cells. Leukocyte and granulocyte counts in the blood declined continuously over a period of 8 to 11 days. In average, minimal granulocyte counts occurred after 21 days of hospitalisation and 14 days of antibiotic drug exposure. Beside the incriminated antibiotics all patients were treated sporadically with other agents of which may cause AG. Granulocyte kinetics and serial bone marrow examinations of one patient suggest a phenothiazine type of AG, which is caused by a toxic damage of granulopoiesis. Declining absolute granulocyte counts in the blood together with persisting high temperatures during antibiotic treatment should give rise to the suspicion of a beginning AG.

[Acute liver failure following tetrabamate]. / Akutes Leberversagen nach Tetrabamat.

Tetrabamate (Atrium), a composite preparation of phenobarbital, difebarbamate and febarbamate, is widely used to reduce ethanol withdrawal symptoms such as tremor, agitation and anxiety. Generally this drug is well tolerated and a few cases of reversible hepatitis as well as clinically mild symptoms of asthenia have been described. We report on a 28-year-old female patient admitted to hospital with acute liver failure after treatment with tetrabamate because of alcohol withdrawal symptoms. Liver biopsy revealed a drug-induced toxic alteration with extensive panlobular necrosis without signs of alcoholic hepatitis. Under supportive therapy liver parameters normalized in 3 months. In view of this potentially lethal adverse effect of tetrabamate, it should not be used for ethanol withdrawal symptoms.

Extra microchromosome mosaicism in amniotic cells confirmed in fetal tissues.

Mosaicism for an extra microchromosome was discovered in amniotic cell cultures of a 39-year-old woman. Using G, Q, C bands and silver staining, it was concluded that the extra chromosome was bisatellited. Parents' karyotype was normal. Parents elected for termination of the pregnancy. The presence of the extra microchromosome was confirmed in various tissues of the aborted fetus. The literature on the subject is briefly reviewed.