[Autopneumonectomie. A Forgotten Disease]. / Autopneumonektomie. Ein vergessenes Krankheitsbild.

HISTORY: An 80-year old female was referred to our hospital with left internal carotid artery stenosis and a childhood history of hemoptysis. INVESTIGATIONS AND DIAGNOSIS: The ECG showed 2nd degree Mobitz atrio-ventricular block. The chest x-ray and computerized tomography identified a shift of the mediastinum and the heart to the left. The left lung was completely destroyed whilst the right lung was enlarged and crossed the midline. Pulmonary function tests revealed a moderate restrictive ventilation disorder. The diagnosis of autopneumonectomy was based on patient history together with radiological findings. TREATMENT AND COURSE: A pacemaker was implanted with two stimulation electrodes via a left cephalic venous cutdown. A carotid endarterectomy was also performed without any complication. CONCLUSION: After autopneumonectomy, postpneumonectomy like syndrome may occur in very rare cases, whereupon operative treatment is mandatory. Any respiratory infections should be treated with antibiotics. Pacemaker electrode placement via the subclavian vein is contraindicated due to the risk of a catastrophic pneumothorax.

Phosphate binders affect vitamin K concentration by undesired binding, an in vitro study.

BACKGROUND: Vascular calcification is a major contributing factor to mortality in end stage renal disease (ESRD). Despite the efficacy of phosphate binders to improve hyperphosphatemia, data on vascular calcification are less clear. There seems to be a difference in attenuation or delay in progression between different binders. In this in vitro experiment we tested whether phosphate binders could limit bioavailability of vitamin K2 by undesired binding. Vitamin K-deficiency limits activation of the vascular tissue mineralization inhibitor matrix γ-carboxyglutamate (Gla) protein (MGP) thereby exacerbating vascular calcification. METHODS: In this experiment vitamin K2 (menaquinone-7; MK-7) binding was assessed by adding 1 mg of vitamin K2 to a medium with pH 6 containing 67 mg phosphate binder with either 7 mg of phosphate or no phosphate. Five different phosphate binders were tested. After five and a half hours vitamin K was analyzed by HPLC. All experiments were performed in triplicate. RESULTS: Sucroferric-oxyhydroxide and sevelamer carbonate did not significantly bind vitamin K2, both in solution only containing vitamin K2 or in combination with phosphate. Calcium acetate/magnesium carbonate binds vitamin K2 strongly both in absence (p = 0.001) and presence of phosphate (p = 0.003). Lanthanum carbonate significantly binds vitamin K2 in solution containing only vitamin K2 (p = 0.005) whereas no significant binding of vitamin K2 was observed in the solution containing vitamin K2 and phosphate (p = 0.462). Calcium carbonate binds vitamin K2 significantly in a solution with vitamin K2 and phosphate (p = 0.009) whereas without phosphate no significant binding of vitamin K2 was observed (p = 0.123). CONCLUSIONS: Sucroferric-oxyhydroxide and sevelamer carbonate were the only binders of the five binders studied that did not bind vitamin K2 in vitro. The presence or absence of phosphate significantly interferes with vitamin K2 binding so phosphate binders could potentially limit bioavailability vitamin K2.

[Laparoscopic surgery for colon cancer: quality requirements for (extended) right hemicolectomy]. / Laparoskopische Chirurgie des Kolonkarzinoms : Qualitätsanforderungen an die (erweiterte) Hemikolektomie rechts.

The current S3 guidelines on the surgical treatment of colorectal cancer note that with a suitable patient selection and expertise of the surgeon the same oncological results can be achieved laparoscopically as with the open procedure. This requires that the same quality requirements have to be provided for both methods. The most important quality parameters of right sided (extended) hemicolectomy are central ligation of the supplying arteries (ileocolic artery, right branch of the middle colic artery and middle colic artery) flush to the central origin of the vessel (superior mesenteric artery or middle colic artery) and the sharp dissection of the mesocolon without any preparation tears. The photographic documentation of the fresh surgical specimens for categorizing the preparation quality as well as to determine the pedicle of the vessel can capture this quality well and is also currently the best surrogate parameter to evaluate the oncological quality of the operation. At present, there are still considerable widespread deficits not only with the laparoscopic approach but also in open surgery which must be urgently fixed.

[S3 guideline--Diagnosis and treatment of colorectal carcinoma: relevance for radiologic imaging and interventions]. / Aktualisierte S3--Leitlinie zur Diagnostik und Therapie des kolorektalen Karzinoms: Bedeutung für die Radiologische Diagnostik und Intervention.

The new German S3 guideline "Colorectal Carcinoma" was created as part of the German Guideline Program in Oncology of the Association of the Scientific Medical Societies in Germany, the German Cancer Society and the German Cancer Aid under the auspices of the German Society for Digestive and Metabolic Diseases and replaces the guideline from 2008. With its evidence-based treatment recommendations, the guideline contains numerous updates and detailed definitions regarding the diagnosis and treatment of colon and rectal cancer. In particular, consensus-based recommendations regarding early detection, preoperative diagnostic method selection, and the use of interventional radiological treatment methods are detailed. The guideline also includes quality indicators so that standardized quality assurance methods can be used to optimize patient-related processes.The present article discusses the significance of the current recommendations for radiological diagnosis and treatment and is intended to enhance the quality of patient information and care by increasing distribution.

[Principles and technique of lymph node dissection in colorectal carcinoma]. / Prinzip und Technik der Lymphknotendissektion beim kolorektalen Karzinom.

Colorectal carcinoma is a common malignant tumor which shows a standard behavior for lymphogenic metastasis. Depending on the localization of the primary tumor the corresponding lymphatic area also has to be removed because lymph node metastases can already be present by every tumor even if there is no obvious intraoperative evidence. Lymphatic drainage is essentially oriented to the supplying arteries of the corresponding intestinal segment. The anatomy of arterial supply is individually variable and often deviates from the usual textbook presentation. In this review the oncological requirements of an adequate lymph node dissection in colorectal carcinoma are described with emphasis on the technical aspects to obtain an optimal specimen.

[Lymph node dissection for carcinomas of the lower gastrointestinal tract. What is evidence-based?]. / Lymphknotendissektion bei Karzinomen des unteren Gastrointestinaltraktes. Was ist evidenzbasiert?

Evidence-based analysis of the influence of lymph node dissection on the prognosis of colorectal cancer patients is complicated by the now well-established multimodal treatment strategies. In addition surgical quality criteria, such as exact preparation along the mesenterial fascia and avoiding tears have a major influence on the prognosis.Nevertheless, the overall evidence for the need of lymph node dissection in the treatment of colorectal carcinoma is high. However, there are still some questions remaining concerning the extent of pericolic lymph node dissection, inclusion of the lymph nodes along the greater curvature of the stomach and the inferior aspect of the left pancreas in carcinomas of the transverse colon and the flexures. In particular the definitive central ligation of the supplying arteries in right-sided colon carcinoma is not adequately implemented worldwide.

Sacral nerve stimulation for faecal incontinence: long-term outcome.

AIM: The efficacy of sacral nerve stimulation (SNS) to treat faecal incontinence has been demonstrated in the short- and mid-term. We analysed SNS outcome in the first patients with a permanent neurostimulator in whom follow-up ranges up to 14 years. METHOD: Of 12 patients who underwent SNS from 1994 to 1999, 9 were eligible for long-term analysis (defined as a minimum of 7 years). In 3 the device had to be removed because of pain or neurological disease. Functional outcome was monitored prospectively by standardized questionnaire. For efficacy, the recorded frequency of incontinent episodes over 2-week periods and the Wexner Score were obtained yearly after implant. Quality of life measures (FIQL scale [QoL]) were introduced in 1998. Stimulation parameter adjustments, battery longevity, and complications were documented. RESULTS: Mean follow-up in the nine patients was 9.8 years (range 7-14), over which time efficacy persisted. Clinical improvement was significant (baseline vs last follow-up): median percentage of incontinent bowel movements/week 40% (range 9-100) vs 0% (0-60%; P = 0.008), median number of incontinent episodes/week, 9 (range 2-58) vs 0 (0-29; P = 0.012); median Cleveland Clinic Score, 17 (range 12-19) vs 10 (3-14; P < 0.007); QoL improved in all categories. Pulse generator exchange was required in eight of the nine patients after a mean of 7.4 years for battery fatigue (mean 2.1 V). Complications occurred in five of the original 12 and were therapy-related, but not technique-related, in four patients. CONCLUSION: Sacral nerve stimulation is an effective and safe long-term treatment for faecal incontinence. Clinical outcome is stable over time.

The presence of antiphospholipid antibodies is not related to increased levels of annexin A5 in plasma.

Annexin A5 has been proposed to be important for shielding of negatively charged phospholipids from blood, thereby preventing the binding of clotting factors. It has been suggested that antiphospholipid antibodies can disrupt the binding of annexin A5 from negatively phospholipid-containing surfaces, resulting in uncontrolled coagulation. If this hypothesis is correct, than the plasma levels of annexin A5 will be increased in patients with antiphospholipid antibodies. Therefore, we have measured plasma levels of annexin A5 of 175 patients with systemic lupus erythematosus (SLE), of which 104 had antiphospholipid antibodies and 23 patients had primary antiphospholipid syndrome. The annexin A5 levels were compared with the annexin A5 plasma levels measured in 23 patients with diabetes mellitus type 2 and 35 healthy volunteers. We found a significant increase of annexin A5 plasma levels in patients with SLE (median 6.7 ng mL(-1)) and primary antiphospholipid syndrome (median 7.1 ng mL(-1)) as compared to patients with diabetes mellitus type 2 (median 3.3 ng mL(-1)) and healthy volunteers (median 3.9 ng mL(-1)). However, no correlation was found with the presence of antiphospholipid antibodies or with a history of thromboembolic complications. Based on these observations, we conclude that displacement of annexin A5 from cellular surfaces by antiphospholipid antibodies is not a common mechanism in patients with antiphospholipid antibodies.

Reinfusion of whole blood following addition of tobramycin powder to the wound during total knee arthroplasty.

This study prospectively examined nine human volunteers who underwent unilateral cementless total knee arthroplasty and had 600 mg of tobramycin powder added to their wound just prior to fascial closure. Serum levels of tobramycin were measured at 30 minutes, 4 hours, 8 hours, and 12 hours after surgery. Tobramycin levels in the reinfused whole blood were measured with each reinfusion. Patients were reinfused up to 12 hours after surgery and then the reservoir was left to suction drainage. All patients had significant levels of serum tobramycin 30 minutes after surgery. The average serum level was 5.5 micrograms/ml (range, 3.0-10.6 micrograms/ml). This level was achieved prior to any reinfusion and represented systemic absorption of tobramycin from the bleeding surfaces of the muscle and bone. All patients received at least one reinfusion of 400 ml of whole blood in the first 8 hours after surgery. Two thirds of the patients received a second reinfusion within the same time frame. Serum tobramycin levels measured post-reinfusion indicated that the risk of attaining potential toxic levels of aminoglycoside was not dependent on reinfusion, but on absorption from the wound. The dose of tobramycin in the drain was measured and found to be excessive and potentially toxic (range, 27-312 mg; average, 132 mg). Despite this fact, reinfusion was not as likely to produce toxic serum levels as was local uptake of the antibiotic. Although no patient in this series had any complaints relating to the high dose of tobramycin (deafness or renal failure), caution should be exercised when using antibiotics in a reinfusion system.(ABSTRACT TRUNCATED AT 250 WORDS)

Reinfusion of whole blood after revision surgery for infected total hip and knee arthroplasties.

Because of its proven effectiveness in reducing the need for banked blood transfusions following total joint arthroplasty, the indications for postoperative blood retrieval were expanded to include seven cases of infected total knee or hip arthroplasties where a one-stage exchange procedure was performed. Each joint had been aspirated after surgery and had positive cultures but no gross pus at the time of revision surgery. Each of the operations included debridement with reimplantation of a cementless prosthesis under cover of intravenous antibiotics for 48 hours followed by oral treatment until discharge. Antibiotic-soaked morselized bone graft was used in all patients to restore deficient nonstructural bone. Wound drainage blood was retrieved and reinfused during the first 8 hours after surgery, averaging 958 cc. Banked blood usage averaged 2.4 U (88% homologous) with an average blood loss of 1,974 cc. One patient experienced shaking chills during a second reinfusion of 600 cc of blood without stoppage of the transfusion. Wound hematoma occurred in one patient but did not require surgical evacuation. No patient developed evidence of septicemia.

Biochemical assessment and clinical evaluation of a bilirubin adsorbent column (BR-350) in critically ill patients with intractable jaundice.

We investigated the efficacy of an anion-exchange adsorbent column (ASAHI BR-350, DIAMED) for removal of bilirubin and bile acids in five patients with intractable jaundice of various origin. Four litres of plasma were separated by membrane plasma separation (Plasmaflow OP-05) at a rate of 22.5 ml/min. The plasma was then perfused through an anion exchange adsorbent and returned to the venous blood line of the plasma separation. In some of the patients this procedure was combined with regular hemodialysis treatment. The concentration of total bilirubin was cut by 31 to 60%; total bile acids were reduced by 20 to 74%. Three patients recovered and had a favourable outcome. Two patients died despite the bilirubin adsorption treatment. The effects of the adsorbent column on specific blood parameters, including the coagulation system, were measured. Our data suggest that bilirubin adsorption should be examined further as a treatment for critically ill patients with intractable jaundice.

Fluorinated analogues of spermidine as substrates of spermine synthase.

A series of mono- and geminal difluorinated analogues of spermidine (4-azaoctane-1,8-diamine) have been tested as potential substrates of partially purified rat hepatoma (HTC) cell or pure bovine spleen spermine synthase (EC 2.5.1.22). Substitution of the hydrogen atoms of the methylene group at position 7 by one or two fluorine atoms decreases 8-fold and 160-fold the apparent Km values for the HTC cell enzyme respectively. Similarly, the Km values of 7-monofluoro and 7,7-difluorospermidine for the pure bovine enzyme are reduced 8-fold and 100-fold respectively, in comparison with spermidine. Di-, but not monofluoro substitution, in the 6-position causes a 5-fold reduction in the affinity for the HTC cell enzyme. Gem-fluorine substitution in the 2-position abolishes substrate capability. In addition to their high affinity for spermine synthase, 7-monofluorospermidine and 7,7-difluorospermidine cause substrate inhibition. This phenomenon, which is more pronounced in the case of the difluorinated analogues is pH-dependent. These enzymatic findings are discussed with regard to the protonation sites of the spermidine analogues, determined by potentiometric titration, which vary as a function of the number and position of the fluorine substituents relative to the basic amino groups.

Determination of temporal changes in blood flow in vascularized and nonvascularized nerve grafts in the dog.

The time course of revascularization of nonvascularized and vascularized nerve grafts was followed histologically and quantitatively using microspheres in the saphenous nerve of dogs. Nonvascularized and vascularized nerve grafts were created in opposite hindlimbs of each dog. The intravascular presence of India ink was not observed until the third day postoperatively in the nonvascularized grafts, while it was demonstrated in vascularized grafts on the first postoperative day. Control blood flow in undisturbed nerves ranged from 0.06 to 0.16 ml/min/gm dry weight. On postoperative day 1, flow was not detectable in any of the nonvascularized grafts, while vascularized grafts all had increased flow with a mean of 0.73 ml/min/gm dry weight. By day 3, two of six dogs had some measurable flow in the nonvascularized grafts, while flow in vascularized grafts had reached a mean of 1.88 ml/min/gm dry weight. By day 6, blood flow rate had increased to 7.63 and 4.72 ml/min/gm dry weight for nonvascularized and vascularized grafts, respectively. By this avoidance of up to 3 days of warm ischemia, there may be some advantage to vascularized nerve grafts even in a well-vascularized bed.