Disseminated periportal fatty degeneration after allogeneic intraportal islet transplantation in a patient with type 1 diabetes mellitus: a case report.

Insulin independence after islet transplantation has been significantly improved by using new steroid-free immunosuppressive protocols and increased islet mass. Only little is known about the influence on the morphology of the liver of intraportally transplanted islets. We describe a case of disseminated periportal fatty degeneration after allogeneic intraportal islet transplantation (ITx). A 35-year-old patient with type-1 diabetes mellitus who was suffering from repeated severe hypoglycemic episodes received two sequential intraportal islet grafts. Liver structure was normal before the first ITx, based upon ultrasound and magnetic resonance imaging (MRI). One week after the first ITx, ultrasound demonstrated normal liver morphology. Four months later, at the second ITx, we detected small, disseminated, and hypodense hepatic lesions (1 to 3 mm) by ultrasound, which were confirmed by MRI and interpreted to be fatty degenerations. Histologically we found focal drop-shaped fatty degenerations with signs of mild periportal chronic inflammation. These liver alterations without clinical symptoms or pathological liver function tests matched the predicted distribution of infused islets. Glucose metabolism markedly improved after the first ITx, namely 58.6% reduction of daily insulin requirements, 1.4% decrease in HbA1c, basal C-peptide of 0.8 to 1.3 ng/dl with no severe hypoglycemia. We interpreted these benign changes in liver morphology as reactions to a local hyperinsulinemia in the neighborhood of the transplanted islets. We hypothesized that a steroid-free immunosuppression with rapamycin and tacrolimus may have contributed to changes in the portal microenvironment.

Epithelioid sarcoma of the penis--a rare differential diagnosis of Peyronie's disease.

We report on a case of penile epithelioid sarcoma in a 29-year-old man presenting with a dorsal penile plaque that primarily was misdiagnosed as Peyronie's disease. Although the initial clinical findings of these two different entities appear similar, the consequence for the patient is severe. The only way of differentiating these disorders are histological findings. The principal microscopic characteristics of epithelioid sarcoma are the distinctive nodular arrangement, central degeneration and necrosis of the tumor cells with epithelioid appearance and eosinophilia. Immunohistochemical data (cytokeratin, epithelial membrane antigen, vimentin, CD 34, desmin) confirm the diagnosis. We conclude that in cases with slightest doubts on the diagnosis of Peyronie's disease, especially in younger men suffering from a fast-growing penile induration, a bioptic clarification of the entity should be performed to exclude a high malignant disease that can be only treated as far as it is localized by radical surgery.

Measurement of glomerular filtration rate by low-dose iopromide plasma clearance.

PURPOSE: Glomerular filtration rate (GFR) can be measured by iopromide plasma clearance. As an injection of 120 ml nonionic contrast medium is expensive and especially in patients with nephropathy potentially nephrotoxic, we investigated whether iopromide plasma clearance could be measured using a tenth of that dose as 'low-dose' clearance. MATERIAL AND METHODS: Fifty adult patients scheduled for CT were recruited. Iopromide 300 mg I/ml was used for GFR measurement. Prior to CT, low-dose clearance was measured by injecting 12 ml iopromide per 75 kg b.w. At 3, 4 and 5 h after injection, plasma samples were obtained and the iodine concentration was measured by X-ray fluorescence analysis. Immediately after the last blood sample, CT was again performed following injection of 120 ml iopromide per 75 kg b.w. A further 3 plasma samples were then obtained 3, 4, and 5 h after CT and used for the determination of high-dose clearance. RESULTS: Low-dose clearance ranged from 20 ml/min to 141 ml/min (mean 78.3 ml/min). High-dose and low-dose clearance correlated excellently, with clearance (high-dose) = 1.4 + 0.994 clearance (low-dose); the correlation coefficient was r = 0.944, the standard deviation SDxy= 9.3 ml/min. CONCLUSION: Plasma clearance of iopromide is dose-independent on use of iodine amounts of 3.6 g and 36 g I/75 kg b.w. The GFR can be determined by high-dose and low-dose iopromide plasma clearance with identical accuracy.

Extensive abdominal splenosis: imaging features.

We present the case of a 22-year-old patient who had splenectomy in childhood after trauma and had a known chronic active infection with hepatitis C. Imaging procedures in different radiologic modalities diagnosed diffuse intraabdominal splenosis. Splenosis is a rare, severe complication of splenic trauma or surgery, but the pathogenesis is not clear. Imaging features play a key role in the diagnosis of ectopic splenic tissue, which must be differentiated from malignancies, especially from lymphoma. Splenosis itself may induce relapse of hematologic diseases, mainly autoimmune thrombocytopenia.

Measurement of single kidney contrast media clearance by multiphasic spiral computed tomography: preliminary results.

OBJECTIVE: We present preliminary results of a new method (hereinafter called 'CT-clearance') to measure single kidney contrast media clearance by performing multiphasic helical CT of the kidneys. CT-clearance was calculated according to an extension of the Patlak-Plot. In contrast to prior investigators, who repeatedly measured a single slice, this method makes it possible to calculate single kidney clearance from at least three spiral CTs, utilizing the whole kidney volume. METHODS: Spiral CT of the kidneys was performed unenhanced and about 30 and 100 s after administration of about 120 ml iopromide. Sum-density of the whole kidneys and aortic density was calculated from this data. Using this data, renal clearance of contrast media was calculated by CT-clearance in 29 patients. As reference, Serum-clearance was calculated in 24 patients by application of a modified one-exponential slope model. Information on the relative kidney function was gained by renal scintigraphy with Tc99m-MAG-3 or Tc99m-DMSA in 29 patients. RESULTS: Linear regression analysis revealed a correlation coefficient of CT-clearance with Serum-clearance of r=0.78 with Cl (CT) [ml/min]=22.2+1.03 * Cl (serum), n=24. Linear regression of the relative kidney function (rkf) of the right kidney calculated by CT-clearance compared to scintigraphy results provided a correlation coefficient r=0.89 with rkf(CT)[%]=18.6+0.58 * rkf(scintigraphy), n=29. CONCLUSION: The obtained results of contrast media clearance measured by CT-clearance are in the physiological range of the parameter. Future studies should be performed to improve the methodology with the aim of higher accuracy. More specifically, better determination of the aortic density curve might improve the accuracy.

Frequency of pancreatitis after endoscopic retrograde cholangiopancreatography with iopromid or iotrolan: a randomized trial.

Blood isotone contrast media is considered to be less toxic to vascular and pancreatic duct endothelium than high-osmolar contrast media. In this study we assessed the impact of a low-osmolar contrast agent compared with a blood isotone product on pancreatic damage induced by endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic retrograde sphincterotomy (EST). In a prospective trial 42 consecutive ERCP/EST patients were randomized to receive either iopromid, a low-osmolar non-ionic contrast agent (770 mosmol/kg H2O), or iotrolan, a blood-isotone non-ionic product (320 mosmol/kg H2O). The endoscopies were performed by two experienced endoscopists. Forty patients were included in the study. Blood samples were collected before and 40 min, 2, 4, 6 and 24 h after the endoscopic procedure. Samples were analysed for pancreatic serum enzymes, acute-phase proteins and blood counts. A clinical pain score was investigated. Post-ERCP pancreatitis was diagnosed in 2 patients in the iopromid group and in 5 patients in the iotrolan group. There was no significant difference between groups in the time course of pancreatic serum enzymes, acute-phase proteins or in the pain score. Due to the small number of patients in this study, only stronger differences caused by the two contrast media could have led to statistically significant results. We did not observe statistically significant differences in comparing iotrolan and iopromid concerning ERCP/EST-induced pancreatic damage.

[Calculation of renal clearance by dynamic measurement of excreted activity]. / Bestimmung der renalen Clearance anhand der dynamischen Messung der ausgeschiedenen Aktivität.

AIM: In this paper we present a new method to measure the renal slope-clearance of Tc-99m-MAG-3 in a single-shot model (Excretion-clearance). METHODS: A renal scintigraphy with Tc-99m-MAG-3 was performed in 22 patients. The excreted activity of the tracer in the kidneys and the bladder was dynamically measured using a double-head gamma-camera. Additionally the total absorption over the kidneys and the bladder was determined. The Excretion-clearance was calculated in a differential and an integral variant. Simultaneously the 2-compartment-clearance (Sapirstein-clearance), the Oberhausen-clearance and the Bubeck-clearance were calculated. RESULTS: The Sapirstein-clearance is considered as the "gold standard" in a single-shot model. The correlation of the Bubeck-clearance and the Oberhausen-clearance ranged from r = 0.96 to r = 0.97, the Excretion-clearance (differential-method) correlated with r = 0.90. The absolute difference of the clearance-values was lowest comparing the Bubeck-clearance with the Sapirstein-clearance with an average difference of 11%, whereas the Excretion-clearance revealed at least an average difference of 21% and the Oberhausen-clearance of 24%. DISCUSSION: The Excretion-clearance requires a more complicated protocol measuring the clearance in comparison to the Bubeck-clearance. The results of the excretion-clearance differ more from the Sapirstein-clearance with regard to the examined patient population than the Bubeck-clearance. Regarding the theoretical basis of the methods, we expect advantages of the Excretion-clearance compared with the Bubeck-Clearance in patients with compartmental disproportion or with a low clearance. We are going to prove this in combination with the above mentioned methodical improvements in a further study.

[ECG forward simulation with the PC]. / EKG-Vorwärts-Simulation auf dem PC.

This paper describes a simulation program for ECG modelling for use with IBM-compatible computers. The underlying three-dimensional heart model comprising 4,500 units complies with the four criteria for valid ECG-forward modelling established by Gulrajani in 1989: accurate cardiac geometry, element-to-element propagation of the excitation stimulus, definition of action potentials and a suitable means of computing the surface ECG potentials from those measured in the model. For evaluation of the model, simulations of physiological excitation and of pathologies (Wolff-Parkinson-White syndrome, complete AV-block, inferior wall ischaemia) were examined. A high level of correspondence was found between the model situation and the surface ECG. In view of the widespread use of IBM-compatible computers, this new program is well suited for teaching and training purposes.

Diagnostic value of electrocardiographic variables to predict the presence of ventricular late potentials.

To test the hypothesis that the presence of ventricular late potentials in the highly amplified, averaged and filtered surface electrocardiogram (ECG) can be predicted from the conventional surface ECG, 211 patients with and without previously documented sustained ventricular tachycardia outside the acute phase of myocardial infarction were studied. The presence of left ventricular akinesia or aneurysm was significantly correlated with the ECG score (based on Q wave duration, R wave duration and amplitude ratio). The mean ECG score in patients without ventricular tachycardia was 3.4 +/- 3.5 points compared with 5.5 +/- 3.9 points (p less than 0.001) in patients with ventricular tachycardia. The presence of late potentials was positively correlated with the ECG score in the whole cohort of patients. This was also the case in the subgroup of patients without a history of sustained ventricular tachycardia. In contrast, in patients with ventricular tachycardia, the presence of late potentials was independent of their ECG score. Using linear discriminant function analyses to predict the presence of late potentials, a history of ventricular tachycardia alone and the ECG score alone had a high predictive power (high standardized coefficients). If combinations of variables were analyzed including estimates of left ventricular function (presence of aneurysm or akinesia; ejection fraction), the ECG score and a history of ventricular tachycardia still ranked highest. The influence of ejection fraction if used in combination with other variables for the prediction of late potentials was relatively small (standardized coefficient of 0.4). In conclusion, the surface ECG can be used in patients previously free of sustained ventricular tachycardia to predict the presence of ventricular late potentials.(ABSTRACT TRUNCATED AT 250 WORDS)