[Aspiration pneumonia after spinal cord injury. Placement of PEG tubes as effective prevention]. / Aspirationspneumonie nach HWS-Verletzung. Präventiver Effekt von PEG-Sonden.

BACKGROUND: Pulmonary infections are dreaded complications in acute spinal cord injuries. The prevention of pneumonia is essential for reducing mortality and the period of hospitalization. Swallowing disorders occur frequently in patients with cervical cord injuries and are accompanied by aspiration with a high risk of pneumonia. PATIENTS AND METHODS: In this study the identification and analysis of patients with newly acquired cervical cord injuries were carried out with respect to respiratory complications, treatment and prevention. RESULTS: A total of 27 patients with a cervical cord injury (tetraplegia) were identified. Of these 20 patients (74%) were identified with a swallowing disorder and a high risk of aspiration. Of these patients 11 (PEG group) received a percutaneous feeding tube (PEG tube), 9 patients (non-PEG group) with diagnosed dysphagia were treated without PEG tube. A total of 6 patients in the non-PEG group (67%) acquired pneumonia compared to 3 patients (27%) in the PEG group. CONCLUSION: A swallowing disorder is a major risk factor for a pulmonary infection after a cervical cord injury. An early placement of a PEG tube has a preventive effect with respect to aspiration pneumonia in patients with dysphagia.

[Paraplegia after isolated rupture of the spinal cord - a rare injury]. / Querschnittslähmung nach isolierter Rückenmarksruptur - eine seltene Verletzung.

INTRODUCTION: Complex vertebral fractures can lead to injury of the spinal cord with resulting paraplegia. High-speed accidents are common causes, especially in younger patients. Malignant or inflammatory processes play an important role in the elderly. Less common reasons for a spinal cord injury are congenital malformations. We here report about a 17-year-old patient who suffered from paraplegia after an isolated rupture of the spinal cord without an injury of the vertebral bodies, intervertebral disc or ligamentous structures. This type of injury has not been reported in the literature before. PATIENT AND METHOD: We report about a 17-year-old patient, referred to our hospital, presenting with lumbal paraplegia after a high-speed accident 8 days prior to admission. After initial stabilisation of the polytraumatised patient, he was referred to our hospital for further treatment. RESULTS AND CONCLUSION: The radiological examination showed a bilateral acetabular fracture, a right anterior pelvic ring fracture and shaft fractures of the left humerus and right femur. Furthermore, the spinal cord at thoracic level 10/11 was ruptured. Interestingly, there was no injury of the vertebral bodies, intervertebral disc or ligamentous structures. A tethered cord as a possible anatomic variation could be excluded in this case by MRI. However, anatomic variations could be the reason for this injury and should be kept in mind.

[The spontaneous spinal epidural haematoma]. / Das spontane spinale epidurale Hämatom.

Spontaneous spinal epidural haematoma (SSEH) is a rare and serious condition. Four cases of SSEH are presented in this paper, three of which were in the cervical segment while one involved the entire spine. In two of these four cases the diagnosis was not made until late in the course, and persisting neurological deficits resulted; one case was diagnosed early and the neurological outcome was good; and in one the decompression achieved was inadequate, owing to intraoperative complications. Laminectomy was performed in all four cases for the purpose of decompression of the spinal cord but at different intervals after the onset of symptoms and with different neurological outcomes. The prognosis of SSEH depends heavily on the time that elapses between the onset of symptoms and the surgical treatment. The diagnostic procedure of choice is MRI.

[Intramedullary abscess of the spinal cord--a rare pathology. Case report, therapeutic regimen and review of the literature]. / Der intramedulläre Abszess des Rückenmarks--ein seltenes Krankheitsbild. Falldarstellungen, Behandlungskonzept und Literaturübersicht.

Although the presence of an intramedullary abscess of the spinal cord is extremely rare, it is most important to be aware of its existence in the differential diagnosis of neurological diseases. Existing neurological deficits with progressive symptoms of paraplegia should always be regarded as suspect and a differential diagnosis of an intramedullary abscess of the spinal cord should then be included in the therapeutical regimen. A correct diagnosis using MR-tomography followed by an early surgical treatment strategy are essential for the affected patients, simply because an early diagnosis and an immediate operative intervention represent decisive prognostic factors independent from the cause of infection. Surgical intervention must include a decompressive laminectomy, a myelotomy, and also a secure intraoperative abscess drainage. In this analysis two patients will be reported on, both of whom were already showing symptoms of paraplegia at the time they were admitted to hospital. In both cases MR-tomographically an intramedullary nodulary lesion of the spinal cord could be detected. However, due to a complete lack of any acute symptoms of inflammatory reaction in one patient, an intramedullary abscess was not actually diagnosed before surgical treatment was performed. These two cases, together with existing scientific literature, aim to present an overview of the pathogenesis, the clinical symptomatology, the treatment strategy, and the expected therapeutical outcome of an intramedullary abscess formation. It will be shown that by treating this disease as early as possible using adequate therapeutic interventions a functional improvement of the resulting neurological symptoms can be expected.

MR-monitored LITT as a palliative concept in patients with high grade gliomas: preliminary clinical experience.

The purpose of this study was to evaluate the clinical utility of laser-induced thermotherapy (LITT) as a palliative treatment for patients with high-grade gliomas. Four consenting patients with recurrent high grade III/IV gliomas near the primary language or motor areas were palliatively treated with LITT (2-5 W, 3-13 minutes; Neodym YAG Laser, Dornier, Friedrichshafen, Germany). Temperature monitoring was performed by T1-weighted turbo-fast low-angle shot (FLASH) imaging at 1.5 T (Siemens Magnetom SP 4000, Siemens, Erlangen, Germany). MRI studies before LITT included contrast-enhanced conventional scans and functional activation studies to localize the primary motor cortex or language areas using an echo-planar imaging (EPI) spin-echo (SE) sequence. Follow-up studies consisted of contrast-enhanced conventional scans as well as diffusion studies (contrast-enhanced Fourier-acquired steady-state technique and EPI-SE) and perfusion studies (EPI-SE with .2 mmol of gadolinium (Gd)/kg body weight) to differentiate post-therapeutic effects from residual or recurrent tumor growth. Local tumor control was achieved in areas with laser energy deposition with clinically stable conditions > or = 6 months. Conventional contrast-enhanced scans demonstrated strong enhancement surrounding ablated tumor components, which showed a reduction in CBV/CBF. Perfusion studies were useful to discriminate granulomatous tissue enhancement from residual or recurrent tumor growth. Careful application of LITT may evolve as an alternative palliative concept for patients with end-stage high-grade cerebral gliomas reducing clinical symptoms from circumscribed areas of pathology.

Substantial head trauma: value of routine CT examination of the cervicocranium.

PURPOSE: To evaluate the usefulness of routine performance of computed tomography (CT) of the craniocervical junction in unconscious patients with substantial head injury. MATERIALS AND METHODS: In a prospective study, CT of the head and the cervicocranium was performed in 202 patients with substantial cranial trauma (Glasgow Coma Scale scores of 3-6). Plain radiography was performed in all patients. Radiographs and CT scans were then blindly interpreted. RESULTS: Twenty-eight patients (13.9%) had C-1 or C-2 fractures; plain radiographs did not demonstrate cervical fractures in 11 of these patients. Nine patients (4.4%) had fractures of the occipital condyles; plain radiographs did not demonstrate occipital condyle fractures in eight of these patients. CONCLUSION: Because 5.4% of all patients had fractures of either C-1 or C-2 and 4.0% had occipital condyle fractures not seen at plain radiography, routine additional performance of CT of the craniocervical junction is useful in patients with substantial cranial trauma.

Increased intracranial pressure and cardiac arrest after heart transplantation. What about the Cushing response in a denervated heart? Case report.

A 13-year-old boy suffered cerebrovascular complications after heart transplantation (ischemic mass effect in the posterior cranial fossa). He had to be resuscitated from cardiac arrest with coma. After a modified cerebellar hemispherectomy the course was favorable.--The most conclusive explanation for the acute event is that a Cushing response was preserved even in the presumably denervated heart.

How many "moles" of glucocorticoids?

The entries for i.v. dexamethasone in the German National Formulary are inconsistent and can lead to differences of about 25% in calculating the dosage on a molar basis. The authors recommend a standardization of declarations of the contents of i.v. glucocorticoids.

[Sympathetic block after plexus anesthesia. Comparison with stellate ganglion block]. / Sympathicusblockade nach Plexusanaesthesie. Vergleichende Untersuchung zur Stellatumblockade.

Plethysmographic measurements of the upper extremity were performed in ten patients after axillary plexus block and in eight patients after stellate ganglion block. Axillary plexus block was followed by a mean increase of 396% in arterial blood flow. After stellate ganglion block, the arterial blood flow increased by 232% (P less than or equal to 0.001) compared to the pre-block value. There was no change in venous capacity after either method. The results indicate that both blocks can alternatively be used, as they have the same effects regarding increased arterial flow and stable venous capacity.

Dynamics of Correlated Genetic Systems. V. Rates of Decay of Linkage Disequilibria in Experimental Populations of DROSOPHILA MELANOGASTER.

The dynamic behavior of four-locus gametic frequency distributions was studied in five replicate cage populations of Drosophila melanogaster for up to 50 generations. The joint frequency distributions were resolved into gene frequencies and various disequilibrium measures. In addition, F statistics for marginal single-locus genotypic frequency distributions were followed through time. The gene frequency, disequilibrium and F statistics were obtained for four chromosome 3 enzyme marker loci [isocitrate dehydrogenase (3-27.1), esterase-6 (3-36.8), phosphoglucomutase (3-43.4) and esterase-C (3-49.0)]. The initial structure of the experimental populations featured random mating proportions, and two complementary gametic types with respect to the marker loci, thus assuring complete pairwise linkage disequilibrium among the markers.--The experimental results indicate: (1) the between-replicate variance in gene frequency varied substantially among loci, with isocitrate dehydrogenase showing the greatest between-replicate variance, and esterase-C the least. (2) The F statistics initially were strongly negative but decayed to the neighborhood of zero for all marker loci except esterase-C. The rate at which the F statistics approached zero varied among the marker loci, indicating substantial differences in the distribution of selective effects along the chromosome. The centromeric region, marked by esterase-C, shows the strongest selective effects. (3) The rate of decay of linkage disequilibrium was much faster than expected for pairs of neutral loci, averaging 1.82 times the neutral rate over all replicates and pairs of loci. This acceleration, which was observed for all six pairwise combinations of loci, was interpreted as resulting from the interaction between selection and recombination. Our experimental results are consistent with many investigations of linkage disequilibrium in natural populations of Drosophila melanogaster that show little or no disequilibrium among enzyme loci. (4) A fortuitous contamination of two cages revealed an apparent regulatory interaction between the migrant and nonmigrant chromosomes at the esterase-C locus. The migrant chromosomes were very rapidly absorbed into the recipient populations, despite this interaction. This result suggests that the dynamics of migration in populations may be phenomenologically richer than anticipated by simple theory.

The forms and transport of plasma cobalamins in normal man and in myeloproliferative states.

Seven patients with MP and four controls were injected with 0.04 to 0.05 microgram of [57Co] cyanocobalamin i.m. or i.v. in order to study the shift of binding with time and the conversion of one Cbl to another. The initial pattern of binding reflected the proportion of the apo forms of TC II and R binders. In MP there was more initial binding of the injected Cbl to R-type binders and less to TC II. During the first 48 hr after intake, the injected Cbl remained mostly as cyanocobalamin. Some adenosylcobalamin appeared transiently in both control and MP subjects. Radioactive methylcobalamin did not appear in the circulation until after 48 hr, and the conversion of cyanocobalamin to methylcobalamin within the circulation was greater in MP subjects. Serum from some subjects converted small amounts of cyanocobalamin to all other forms in vitro by a heat-stable, extracellular property which was abolished by dialysis of the serum. This property of serum could have accounted for the early conversion to adenosylcobalamin but not, at least as an in vitro phenomenon, to the late appearance of methylcobalamin. Although the expected increases and abnormal patterns of R binders were observed in MP, these abnormalities could not be correlated with the increased conversion to plasma methylcobalamin. During the first 6 hr after injection the R binder-Cbl designated as alpha 2-R-Cbl disappeared from the circulation at a rate faster than that of alpha 1-R-Cbl. Subsequently the alpha 2 and alpha 1 components of R binder-Clb cleared at the same rate, and this rate was the same for both control and MP subjects.

Dynamics of correlated genetic systems. VI. Variation in recombination rates in experimental populations of Drosophila melanogaster.

Recombination fractions among four chromosome 3 enzyme loci were measured over a 20 generation period in experimental populations of Drosophila melanogaster. The experimental populations were initiated with complete pairwise linkage disequilibria among the marker loci, thereby providing an initial structure favorable to selection for recombination modification. The recombination data show no evidence of directional changes in recombination rates among the marker loci, although variation in estimates, both between families within generations and between generations was large. These materials also yielded much lower estimates for recombination fractions for the centromeric region of the third chromosome than previously reported. Taken in total, the experimental results show no evidence for recombination modification, although the results do indicate ample genetic variance for recombination rates.

Preparation of radioactive labelled (57Co) sulfitocobalamin.

Farquharson and Adams (Br. J. Nutr. 36, 127-135 (1976)) have identified sulfitocobalamin (SO3-Cb1) as one of the naturally occurring cobalamins (Cb1s) in foods. We have devised a method of making radioactive labelled SO3-Cb1 for in vivo and in vitro studies of this form of Cb1. 57Co labelled cyanocobalamin (57Co CN-Cb1) was acid photolyzed to 57Co hydroxocobalamin (57Co OH-Cb1) followed by ligand substitution with SO3-2 ion from aqueous sodium (meta) bisulfite in the dark. The resulting 57Co SO3-Cb1 was purified by organic extraction and cation exchange chromatography. The final preparation was greater than 99% 57Co SO3-Cb1 with an overall yield of greater than 70%, stable for up to four weeks at 20 degrees C in the dark, and capable of binding to the human Cb1 binding proteins Transcobalamin II (TC II), Intrinsic factor (IF) and Salivary R. This method allows a simple 1 day preparation of high specific activity labelled 57CO SO3-Cb1 for biological studies.