Options in the management of esophageal perforation: analysis over a 12-year period.

Controversies exist about the management of esophageal perforation in order to eliminate the septic focus. The aim of this study was to assess the etiology, management, and outcome of esophageal perforation over a 12-year period, in order to characterize optimal treatment options in this severe disease. Between May 1996 and May 2008, 44 patients (30 men, 14 women; median age 67 years) with esophageal perforation were treated in our department. Etiology, diagnostic procedures, time interval between clinical presentation and treatment, therapeutic management, and outcome were analyzed retro- or prospectively for each patient. Iatrogenic injury was the most frequent cause of esophageal perforation (n= 28), followed by spontaneous (n= 9) and traumatic (n= 4) esophageal rupture (in three patients, the reasons were not determinable). Eight patients (18%) underwent conservative treatment with cessation of oral intake, antibiotics, and parenteral nutrition. Twelve (27%) patients received an endoscopic stent implantation. Surgical therapy was performed in 24 (55%) patients with suturing of the lesion in nine patients, esophagectomy with delayed reconstruction in 14 patients, and resection of the distal esophagus and gastrectomy in one patient. In case of iatrogenic perforation, conservative or interventional therapy was performed each in 50% of the patients; 89% of the patients with a Boerhaave syndrome underwent surgery. The hospital mortality rate was 6.8% (3 of 44 patients): one patient with an iatrogenic perforation after conservative treatment, and two patients after surgery (one with Boerhaave syndrome, one with iatrogenic rupture). No death occurred in the 25 patients with a diagnostic interval less than 24 hours, whereas the mortality rate in the group (n= 16 patients) with a diagnostic interval of more than 24 hours was 19% (P= 0.053). In three patients, the diagnostic interval was not determinable retrospectively. An individualized therapy depending on etiology, diagnostic delay, and septic status leads to a low mortality of esophageal perforation.

Prevalence of infection with dengue virus among international travelers.

BACKGROUND: Dengue has been recognized as a potential hazard to tourists. A prospective, controlled study in the outpatient clinic of a German infectious disease clinic was conducted to assess the prevalence of dengue virus infection among international travelers. METHODS: Serum samples from 130 patients with signs or recent history clinically compatible with dengue (fever, headache, muscle and joint pain, or rash), 95 matched controls with diarrhea, and 26 patients who never visited a country endemic for dengue were investigated. RESULTS: Nine (6.9%) of the 130 patients with compatible symptoms and 1 (1%) of the 95 controls with diarrhea developed rising antibody titers against dengue virus. Of these 10 patients with probable dengue infection, 6 had been to Thailand, 2 to Malaysia, and 1 each to Indonesia and Brazil. CONCLUSIONS: Infection with dengue virus appears to be a realistic threat to travelers to Southeast Asia. Symptoms commonly associated with dengue, such as fever, myalgia, arthralgia, and vomiting, can be helpful for diagnosis when present, but the absence of typical symptoms does not exclude infection.

Proopiolipomelanocortin peptides in normal pituitary, pituitary tumor, and plasma of normal and Cushing's horses.

Using RIAs for six regions within proopiolipomelanocortin (proOLMC), gel filtration, and electrophoresis, we studied pituitary peptides in a normal horse and one with Cushing's disease caused by a pars intermedia adenoma. Almost all immunoreactive (IR) ACTH (78%) was 4,500 mol wt (4.5K) ACTH in normal pars distalis, but it was almost 100% corticotropin-like intermediate lobe peptide (CLIP) in normal pars intermedia. alpha MSH and beta MSH were found mainly in pars intermedia: equal concentrations of the beta MSH precursors, beta-lipotropin (beta LPH) and gamma LPH, were found in pars distalis. Most IR-beta-endorphin (IR-beta END) was found as beta END in pars intermedia, but roughly equal concentrations of beta END and its precursor, beta LPH, were found in pars distalis. A 33K molecule containing IR-ACTH, IR-gamma 3MSH, and IR-beta END, presumed to be proOLMC, and a variety of 15-27K presumed biosynthetic intermediates were found in both normal pars distalis and pars intermedia. The pars intermedia adenoma causing Cushing's syndrome contained high IR-peptide concentrations. Several differences in precursors were noted, including the presence of three larger presumed precursors (38.5K, 47K, and 63K) that had both ACTH and beta END immunoreactivities and both deletions and additions of 15-27K intermediates. The Cushing's horse's plasma peptides reflected tumor concentrations; 4.5K ACTH was modestly elevated, but the concentrations of CLIP, alpha MSH, beta MSH, gamma LPH, and beta END were dramatically increased. About 20% of plasma IR-ACTH and 5% of IR-beta MSH and IR-beta END were found as high molecular weight forms. Normal processing of horse proOLMC appears to be similar to that in other species, but may be altered in pars intermedia tumors of horses with Cushing's disease, the plasma of which contains disproportionately increased concentrations of pars intermedia proOLMC peptides.

Effects of preservation conditions and temperature on tissue acidification in canine kidneys.

The influence of temperature (5, 15, 25, and 35 degrees C) on the degree of tissue acidification was examined using 74 canine kidneys with simple ischemia or after protection of the kidneys with Euro-Collins solution or with the HTK-solution of Bretschneider. At an incubation temperature of 5 degrees C, the intrarenal pH value in HTK-protected kidneys is continuously higher than 7.3 during 36 hr of ischemia. In Euro-Collins kidneys the pH value decreases to a pH of 6.4 during this time. In simple ischemic kidneys pH is 6.3 after 36 hr. At 15 degrees C the pH value falls to a lower level in Euro-Collins kidneys than in purely ischemic kidneys, but the pH in HTK-protected kidneys is higher than 6.9 for 24 hr. At 25 degrees C, and especially at 35 degrees C the intrarenal acidosis in Euro-Collins kidneys is much stronger than in unprotected kidneys, and the pH in HTK-protected kidneys does not decrease below 6.7. The lactate production in simple ischemic kidneys and in HTK-protected kidneys is nearly the same (80-100 mumol/gdw), although Euro-Collins kidneys have a steeper increase and reach higher lactate levels (330 mumol/gdw). The HTK solution guarantees satisfactory protection against damaging acidosis over the whole temperature range (5-35 degrees C), but the Euro-Collins solution leads to a stronger and more dangerous acidosis the higher the temperature.

The relative nephrotoxicity of cisplatin, cis-[Pt(NH3)2(guanosine)2]2+, and the hydrolysis product of cisplatin in the rat.

An examination of the comparative nephrotoxicity in the rat of cisplatin, its hydrolysis product (mostly cis-[Pt(NH3)2Cl(H2O)]+ under the conditions applied), and cis-[Pt(NH3)2(guanosine)2]2+ revealed that these compounds differed significantly in the extent of renal damage they produced following their i.v. injection in Sprague-Dawley rats. The hydrolysis product was found to be the most toxic of the three complexes studied and produced nephrotoxicity at doses lower than those at which cisplatin was nephrotoxic. Under the conditions used, the i.v. administration of cis-[Pt(NH3)2(guanosine)2]2+ resulted in no observable signs of nephrotoxicity at levels at which an equimolar dose of cisplatin produces clear evidence of renal function impairment and morphological alterations. The nephrotoxicity of these complexes appears to be generally related to the ease with which they undergo nucleophilic substitution reactions. The lack of substantial nephrotoxicity found for cis-[Pt(NH3)2(guanosine)2]2+ suggests that the products resulting from the action of the DNA repair processes on platinated DNA do not contribute significantly to the nephrotoxicity of cisplatin. Renal platinum levels found following the administration of these compounds correlated with the degree of nephrotoxicity produced by each compound, but no general correlation of nephrotoxicity and renal platinum levels was found. The nephrotoxicity of cis-[Pt(NH3)2Cl(H2O)+ on a molar basis was estimated to be approximately 3 times as great as that of cisplatin itself.

Relative effectiveness of some compounds for the control of cisplatin-induced nephrotoxicity.

Several procedures which have been reported as effective for the control of cisplatin induced nephrotoxicity were compared in the Sprague-Dawley rat using the same dose of cisplatin. The treatments examined were based on the use of sodium thiosulfate, sodium diethyldithiocarbamate (DDTC), glutathione (GSH), sodium N-methyl-D-glucamine dithiocarbamate (NaG) and S-2-(3-aminopropylamino)ethylphosphorothioic acid (WR-2721). The differences in the effectiveness of the procedures were assessed using BUN and serum creatinine values, histopathological examination, body weight changes, and renal platinum levels as indices. The effect of such treatments on the antineoplastic activity of cisplatin were examined with both the Walker 256 carcinosarcoma in the rat and the L1210 murine leukemia in mice. Under the conditions used, GSH was found to be more effective than the other nucleophiles in protecting against the nephrotoxicity of cisplatin while providing the least amount of interference with the antitumor activity as measured against the Walker 256 carcinosarcoma and the L1210 murine leukemia. Simultaneous i.v. administration of cisplatin and any of the sulfur-containing nucleophiles leads to a significant protection against the nephrotoxicity but reduced the anti-neoplastic activity of cisplatin when measured against the Walker 256 carcinosarcoma.

Dependence on chelating agent properties of nephrotoxicity and testicular damage in male mice during cadmium decorporation.

An examination of the histopathological appearance of the kidneys of mice treated with cadmium chloride (s.c.) and simultaneously given 1 of 3 chelating agents (i.p.) reveals that the extent of nephrotoxicity is greatest when L-cysteine is the chelating agent. When either of 2 dithiocarbamates capable of mobilizing cadmium from its intracellular deposits, i.e. sodium N-methyl-D-glucamine dithiocarbamate (NaG) or sodium N-benzyl-D-glucamine dithiocarbamate (NaB) is used as the chelating agent, no morphological renal damage was evident. Under these same conditions the testes of the mice were protected to the extent of 95% by both of the dithiocarbamates, whereas the protection afforded by the L-cysteine was only about 50%. One factor governing the extent of nephrotoxicity appears to be the stability of the cadmium complexes which are formed and the manner in which this affects their behavior in vivo. Complexes which are preferentially excreted in the bile, cause little or no renal damage.

Intracellular cadmium mobilization sequelae.

The consequences of the mobilization of aged intracellular cadmium from its in vivo deposits in mice by chelating agents were examined. The chelating agents used were BAL, sodium N-benzyl-D-glucamine dithiocarbamate (NaB), Diisopropyl meso-2,3-dimercaptosuccinate(Di-PDMS) and sodium N-(4-methoxybenzyl)-D-glucamine dithiocarbamate(4-Me0), all previously shown capable of causing statistically significant decreases in either renal or hepatic cadmium burdens in rodents. They were given at a level of 400 mumol/kg (i.p.) daily for 10 days to mice previously loaded with a total of 10 mg CdCl2.2.5 H2O/kg. Under these conditions a significant decrease in the renal cadmium level occurred following treatment with BAL, NaB, and 4-MeO; hepatic cadmium levels decreased significantly following treatment with NaB and 4-MeO. Pathological examination of the kidneys, liver, and testes in these animals showed that chelate mobilization of the cadmium produced no noticeable changes in the histopathology of these organs in comparison with that observed for the animals which had been given only cadmium and had undergone no chelate treatment. The results suggest that the mobilization of such aged cadmium from in vivo deposits need not result in any deleterious changes in the kidneys, liver or testes.

Thioether suppression of cisplatin nephrotoxicity in the rat.

Six compounds containing a thioether group were examined as agents for the reduction of the nephrotoxicity caused by cisplatin (CDDP) in the rat. Of these, five were able to reduce the CDDP- induced nephrotoxicity when administered simultaneously with CDDP (8.0 mg/kg, iv). The compounds capable of reducing CDDP toxicity were L-methioninamide, cystathionine, methionyl-L-alanine, (methythio) acetic acid and 4-(methylthio) benzoic acid. Indices used to evaluate toxicity included body weight changes, BUN and serum creatinine levels and the histopathological examination of renal tissue. The platinum levels of renal tissue were determined but were found not to correlate well with other measures of renal function. Oral administration of the more effective of these compounds was found to provide a reduced level of protection against the nephrotoxicity caused by iv CDDP. The most effective of these compounds caused a very modest reduction in the anti-tumor activity of CDDP as measured against the L1210 murine leukemia.

Coadministration of dimethyl sulfoxide reduces cisplatin nephrotoxicity.

The administration of dimethyl sulfoxide with cisplatin at a mole ratio of 200:1 results in a considerable reduction in the nephrotoxicity produced when cisplatin alone is administered to Sprague-Dawley rats at 7.5 mg/kg. Observed measures of nephrotoxicity which were significantly improved by the coadministration of cisplatin and DMSO over the values found for cisplatin alone include BUN, serum creatinine, creatinine clearance and histopathological evidence of renal damage. The weight loss associated with cisplatin administration was also significantly reduced by DMSO coadministration. The use of DMSO did not result in any observable loss in antitumor activity of cisplatin against the Walker 256 carcinosarcoma.

Necrotizing hepatitis associated with a reo-like virus infection in a parrot.

A young African grey parrot was presented for necropsy following a 3-to-4-day illness consisting of lethargy, anorexia, and diarrhea. A disseminated necrotizing hepatopathy was evident upon histologic examination of the liver. Aggregates of approximately 70-nm-diameter viral particles having morphology consistent with the family Reoviridae were demonstrated by thin-section and negative-staining electron microscopy.

Pineoblastoma in a cockatiel.

Pineoblastoma, a primitive neoplasm of pineal gland origin, was diagnosed in a cockatiel based on gross, histopathological, and electron-microscopic findings.

Choroid plexus carcinoma in a dog.

Choroid plexus carcinoma was diagnosed in a 5-year-old female mixed breed dog which was euthanized due to progressive neurologic disease. Diagnosis of the tumour was based on gross and light microscopic findings following a complete necropsy. The chemical staining patterns in the case are compared with human choroid plexus tumours. The criteria for the distinction between benign and malignant variants of choroid plexus tumours are discussed.

Tonsillar granular cell tumour in a cat.

Granular cell tumour was diagnosed in a cat based on light and electron microscopic findings. Immunohistochemical findings for S-100 protein and neuron-specific enolase were negative, unlike its human counterpart.

Pleural mesothelioma in a European spotted fallow deer (Cervus dama).

An adult, captive European spotted fallow deer (Cervus dama) was submitted for necropsy due to sudden death. Gross lesions consisted of serosanguinous fluid in the thoracic cavity with multiple, often confluent, nodules covering visceral and parietal pleura. Microscopic examination revealed tubular structures lined by cuboidal cells covering a delicate fibrous stroma. Gross and microscopic morphology was consistent with a mesothelioma.

Cryptosporidiosis in a pup.

Cryptosporidiosis is a coccidian parasitism which has been implicated as a cause of diarrhea in man and a variety of animals. Cryptosporidiosis was diagnosed in a one-week-old pup which had a history of acute diarrhea. Organisms, 2 to 3 mm in diameter, covered the microvillous border of intestinal epithelium. Ultrastructurally, the cryptosporidia had one or more nuclei with prominent nucleoli and abundant cytoplasmic endoplasmic reticulum. Cryptosporidia may have played a role in the enteritis seen in this pup but further studies are needed to establish its pathogenicity.

[Choice of procedure in the surgical treatment of liver injuries]. / Zur Verfahrenswahl bei der operativen Versorgung von Lebertraumen.

We give an analysis of liver-rupture cases among our own patients and discuss the problems of diagnosis and surgical therapy. Total lethality is 29%; this is dependent on quick diagnostic procedure, the number and severity of accompanying traumas, and the type of liver rupture. The main diagnostic feature seems to be peritoneal lavage, Operative procedure depends on the type and severity of the liver rupture. We therefore propose a classification of the types of liver ruptures, together with their adequate surgical therapy. Some postoperative complications can also be avoided.

[Spontaneous uni- and bilateral Achilles tendon rupture--a frequent complication after kidney transplantation]. / Spontane uni- und bilaterale Achillessehnenruptur--eine häufige Komplikation nach Nierentransplantation.

In our clinic we observed uni- or bilateral ruptures of the Achilles tendon as a complication in 5% of all renal transplant patients. The majority of ruptures took place within the first two months following transplantation in a phase of increasing physical activity. Besides steroid treatment, elevated uric acid and hyperparathyroidism, advanced age at the time of transplantation as well as long duration of chronic hemodialysis must be considered as risk factors.

[Post-ischemia normal function of living related kidney transplants after preservation with HTK solution]. / Postischämische Normalfunktion von Verwandtennierentransplantaten nach Protektion mit HTK-Lösung.

This study reports on the first clinical use of HTK preservation solution devised by Bretschneider in renal transplantation. Using this HTK solution, nine living related donor kidneys subjected to cold ischemia for up to 4 h were consecutively transplanted between 1987 and 1989. The postoperative function of the donor and recipient kidneys is analyzed. The endogenous creatinine clearance and the plasma creatinine level are used as function parameters. Within 24-48 h after transplantation a postischemic normal graft function occurred. With triple drug therapy the transplanted kidneys showed an increase in renal function identical with that in the donor's single remaining kidney. Within 7 postoperative days no perfusion damage and no HTK or CyA nephrotoxicity was observed.

[The concept of early functional management of spontaneous Achilles tendon ruptures in patients with kidney transplants]. / Konzept der frühfunktionellen Versorgung von spontanen Achillessehnenrupturen bei nierentransplantierten Patienten.

The special risk constellation of renal transplant patients suffering from rupture of the Achilles tendon promoted the development of a therapeutic concept with early functional treatment. The significant differences to the methods usually employed so far are: local anaesthesia, additional interlacing of the tendon suture, and early functional after-treatment. In a total of ten patients, 15 spontaneous ruptures of the Achilles tendon were treated according to this therapeutic principle. Follow-up after an average of 26 months yielded in all cases a good to very good functional result. This treatment method avoids risk factors that can lead to secondary complications and is thus very suitable for treating spontaneous ruptures of the Achilles tendon in the renal transplant patient.