[Treatment of a Patient with a Pronounced Cytokine Storm in Severe COVID-19 Pneumonia using a Hemoadsorption in Combination with the Administration of tocilizumab]. / Die Behandlung eines Patienten mit ausgeprägtem Zytokinsturm bei schwerer COVID-19-Pneumonie unter Einsatz von Hämoadsorption in Kombination mit der Gabe von Tocilizumab.

Despite growing experience due to increasing patient numbers, the intensive care treatment of patients with severe COVID-19 pneumonia continues to be a particular challenge in individual cases, which may also therefore legitimize individualized therapeutic attempts. In this context, the so-called hyperinflammation syndrome characterized by a cytokine storm accompanied by a massive increase in inflammatory markers such as interleukin(IL)-6, represents such a situation. This case report describes the therapeutic approach of using the IL-6-specific antibody tocilizumab in combination with hemoadsorption therapy (CytoSorb) in a 58-year-old male patient with severe COVID-19 pneumonia. The patient suffered a massive clinical deterioration with concomitant Horovitz index of 127 mmHg that occurred on the 6th day of ventilation. After combined application of the above-mentioned therapeutic approaches, the patient stabilized rapidly paralleled by a significant increase in the Horovitz index, and the possibility of de-escalating the ventilation regimen, which ultimately enabled successful extubation after only 13 days of ventilation. Moreover, the combined treatment was associated with significant hemodynamic stabilization and a consecutive reduction in vasopressor doses, while hyperinflammation could be kept well under control. The incorporation of the hemoadsorber into the therapeutic regimen proved to be safe and straightforward. In conclusion, the combination of CytoSorb therapy and IL-6 blockade by tocilizumab appeared, at least in this case, to be an effective measure to modulate an overshooting immune response in COVID-19 pneumonia with a concomitant clinical improvement in both respiratory and hemodynamic function, and thus could be used as a potential therapeutic option in this clinical picture.

Microradiography of microcalcifications in breast specimen: a new histological correlation procedure and the effect of improved resolution on diagnostic validity.

Introduction. Does high-resolution visualization of microcalcifications improve diagnostic reliability? Method. X-rays were taken of mamma specimens with microcalcifications in 32 patients (10 malignant; 22 benign) using conventional radiography (12 Lp/mm) and high-resolution radiography (2000 Lp/mm). Histological sections were subsequently prepared and correlated to the microradiographic image and every calcification was assigned an exact malignant or benign histological diagnosis. Five radiologists classified single groups of calcifications in both methods according to the BIRADS classification system. Results. Using microradiography microcalcifications can be shown in high resolution at the cell level including histological correlation. In some cases, the diagnostic validity was improved by the high resolution in microradiography. In other cases, the high resolution resulted in more visible calcifications, thus giving benign calcifications a malignant appearance. In the BIRADS 2 and 3 group, the probability of malignancy was 28.6% in the conventional radiography evaluation and 37.8% in the microradiography evaluation. In the BIRADS 4 and 5 group, the probability of malignancy was 34.2% in the conventional radiography evaluation and 24.4% in the microradiography evaluation. The differences were not significant. Summary. Overall, the improved resolution in microradiography did not show an improvement in diagnostic accuracy compared to conventional radiography.

Cardiac magnetic resonance imaging in daily practice in a peripheral medical centre: description of the first 383 patients.

BACKGROUND: Cardiac magnetic resonance (CMR) imaging has evolved over the last decade into an indispensable diagnostic instrument. CMR imaging noninvasively provides structural, functional and morphological information with high spatial resolution and an unlimited field of view. Since October 2006 the VieCuri Medical Centre in Venlo has a CMR scanner at its disposal. OBJECTIVES: The goal of this study was to analyse the impact of CMR imaging on diagnosis and treatment in daily practice in the setting of a medium-volume peripheral hospital. METHODS: All patients who underwent CMR imaging between October 2006 and November 2008 were included in this analysis. The medical history before and after the CMR scan, the application form for CMR imaging and the outcome of the scans were reviewed. CMR images, obtained using a 1.5-T magnetic resonance imaging system, were reviewed by a multidisciplinary team. RESULTS: In 235 patients CMR imaging demonstrated one or more abnormalities, whereas CMR imaging did not identify any abnormalities in 148 patients. CMR imaging confirmed an expected finding in 166 cases, identified an unexpected condition in 69 cases, ruled out an expected finding in 59 cases and ruled out a suspected condition in 89 cases. Due to better insight into diagnosis, CMR imaging resulted in a change of treatment in 166 of the total of 383 CMR scans (43%). CONCLUSION: In a relevant number of cases CMR imaging leads to a change in the treatment of a patient, proving the value of CMR imaging as a diagnostic modality. Therefore, CMR imaging is an excellent opportunity for peripheral medical centres to improve efficiency and the standard of patient care. (Neth Heart J 2010;18:524-30.).

[The "value" of the medical documentation assistant in trauma surgery]. / "Wert" des medizinischen Dokumentationsassistenten in der Unfallchirurgie.

BACKGROUND: Five years after implementation of a medical documentation assistant (MDA) as a pilot project in our trauma department, this paper examines the results. METHODS: We evaluate practice and integration in our daily ward/department work. The measurable parameter or "value" of the MDA is the settlement reserve demonstrated as the cost weight (CW) for better demonstration of performance. RESULTS: The MDA is now an essential part of the daily routine in our department. In addition to the advisory function in codifying medical services, relevant secondary diagnoses are documented and clinical progress is checked to identify additional profitable services. We thus achieve an average additional monthly CW benefit of 11.4046. We have not yet assessed the improved documentation of medical records, which is especially important when checked by the medical service of the health fund. Furthermore, half of the hours of one doctor can thus be saved and therefore used for proper medical activities every day.

[Training program for radiologic technologists for performing chest X-rays at inspiration in uncooperative children]. / Trainingsprogramm für MTRA zur Anfertigung von Thoraxübersichtsaufnahmen in Inspiration bei unkooperativen Kindern.

PURPOSE: A computer program was created to train technologists to perform chest X-rays in crying infants at maximum inspiration. MATERIALS AND METHODS: Videos of 4 children were used. Using a computer program, the moment of deepest inspiration was determined in the video in the single frame view. During the normal running video, 14 technologists (3 with significant experience, 3 with little experience and 8 with very little experience in pediatric radiography) simulated a chest radiograph by pushing a button. The computer program stopped the video and the period of time to the optimal moment for a chest x-ray was calculated. Every technologist simulated 10 chest X-rays in each of the 4 video clips. The technologists then trained themselves to perform chest X-rays at optimal inspiration like playing a computer game. After training, the test was repeated. Changes were evaluated by t-test for unpaired samples (level of significance p < 0.05). RESULTS: Although the differences improved in all children, minimal deviation from the optimal moment for taking an X-ray at inspiration occurred in the periodically crying child (0.21 sec before and 0.13 sec after training). In a non-periodically crying infant, the largest differences were shown. The values improved significantly from 0.29 sec to 0.22 sec. The group with substantial experience in pediatric radiology improved significantly from 0.22 sec to 0.15 sec. The group with very little experience in pediatric radiology showed worse results (improvement from 0.29 sec to 0.21 sec). CONCLUSION: The ability of a technologist to take a chest X-ray at optimal inspiration in a crying child is improved by the tested computer program.

Seroprevalence of bluetongue serotype 8 in cattle in the Netherlands in spring 2007, and its consequences.

A cross-sectional study was carried out in spring 2007, at the end of the first bluetongue outbreak season, to determine the geographical spread of bluetongue virus serotype 8 (btv-8) infection in cattle in the Netherlands and the consequences for some production parameters. Blood samples from cattle submitted to the laboratory of the Dutch Animal Health Service for other voluntary and obligatory health programmes were tested serologically for btv-8. In total, 37,073 samples were tested and 659 (1.78 per cent) were seropositive. The samples came from 5436 herds, of which 45 per cent of herds had only one sample submitted from them. The prevalence was highest in the south of the country, where the outbreak had started, and decreased towards the north. In 340 herds more than 50 per cent of cattle were tested, of which 156 herds were located in infected compartments, and in 37 of these herds (10.9 per cent) at least one positive cow was detected. The average within-herd prevalence in the 37 herds was 39.3 per cent: 2.2 per cent in 11 dairy herds, 68.4 per cent in 20 small-scale herds and 14 per cent in four suckler cow herds. The prevalence differed significantly between herd types but did not show a geographical trend. The average net return for milk production amounted to euro2417/cow/year and it decreased significantly on average by euro48/cow/year in the bluetongue-infected dairy herds during the bluetongue period. On the small-scale farms, the incidence of mortality increased by 3.2 (95 per cent confidence interval [CI] 1.2 to 9.1) times in the infected herds during the bluetongue period, but the voluntary culling rate decreased by a factor of 2.3 (95 per cent CI 1.1 to 4.8).

[Uncommon presentation of cryptogenic organizing pneumonia with miliary pattern in the thorax]. / Ungewöhnliche Manifestation einer kryptogen organisierenden Pneumonie mit miliarem Verschattungsmuster im Thorax.

A 28-year-old female with worsening dyspnea showed miliary nodules of 2 mm in diameter on chest X-ray and high-resolution CT (HRCT). Histological evaluation and clinical outcome revealed an uncommon presentation of cryptogenic organizing pneumonia.

[A new possibility for determining the size and position of the tricortical bone graft in ventral spine stabilisation]. / Eine neue Möglichkeit der Grössen- und Lagebestimmung trikortikaler Späne bei der ventralen Wirbelsäulenfrakturversorgung.

AIM: Ventral stabilisation of thoracolumbar fractures is often done with autogenous iliac crest grafts as an alternative to other filling and stabilisation systems. Today the golden standard for this kind of reconstruction is the minimally invasive thoracoscopic stabilization. Often there was a problem with the determination of the size and the position of the graft, especially on video-assisted minimally invasive stabilisation. The aim of this study was now to develop a new instrument that would be able to minimise this kind of intraoperative problems. METHOD: For measuring and for checking the exact position of the bone graft the vertebrometer as a new measuring apparatus was developed. With the simple and good handling of the vertebrometer, there is an easy possibility of determine the size and the position of the graft. As this tool is made of metal, it is possible to localise and to check the positioning and the right size of the necessary bone graft during the intraoperative radiological control. DISCUSSION: This tool may help to improve the prognosis of osseous integration of the implanted material and lower the rate of pseudarthrosis. Furthermore, the handling of the thoracoscopic ventral stabilisation may be somewhat easier and, even for the inexperienced surgeon, there is now an instrument available to fit in the graft with a satisfactory result.

[An X-ray appliance for postoperative control of osteosynthesis with locking plate in patients with distal fracture of the radius]. / Anwendung einer Röntgenvorrichtung zur postoperativen Kontrolle der distalen Radiusfraktur nach winkelstabiler Plattenosteosynthese.

PURPOSE: A possible complication in regard to osteosynthetic treatment of a lower radius fracture with a locking plate is perforation of the articular surface by screws or a malpositioned ulnar fragment. In order to create good conditions for a homogeneous, reproducible X-ray picture for post-operative imaging control, an appliance for the production of standardised X-ray views has been devised. MATERIALS AND METHODS: The X-ray device was constructed at an angle of 20 degrees to the camera. The arm was positioned on the appliance in the side beam path, in shoulder adduction as well as in the dp-beam in 90 degrees abduction of the shoulder. RESULTS: Through standardisation of the X-ray technique the appliance it is able to supply comparable and reproducible X-ray images. In practice, the representation of both the joint gap and the bolt in the resulting image could be improved. CONCLUSIONS: Better and comparable picture series can be created by standardisation of the imaging technique using this X-ray device.

Repeat 18F-FDG PET for monitoring neoadjuvant chemotherapy in patients with stage III non-small cell lung cancer.

PURPOSE: The relevance of (18)F-FDG PET for staging non-small cell lung cancer (NSCLC), in particular for the detection of lymph node or distant metastases, has been shown in several studies. The value of FDG-PET for therapy monitoring in NSCLC, in contrast, has not yet been sufficiently analysed. Aim of this study was to evaluate FDG-PET for monitoring treatment response during and after neoadjuvant radiochemotherapy (NARCT) in advanced NSCLC. METHODS: Sixty-five patients with histologically proven NSCLC stage III initially underwent three FDG-PET investigations, during NARCT prior to initiating radiation, and post-NARCT. Changes of FDG-uptake in the primary tumour at two time-points during NARCT were analysed concerning their impact on long-term survival. RESULTS: The mean maximum FDG uptake (standardized uptake value, SUVmax) of the whole group decreased significantly during NARCT (SUVmax PET 1: 14.9+/-4.0, SUVmax PET 3: 5.5+/-2.4, p=0.004). The difference between initial FDG uptake (PET 1) and uptake after induction chemotherapy (PET 2) was found to be highly predictive for long-term survival patients which had a greater than 60% decreases in their SUV change had a significantly longer survival than those below this threshold (5-year-survival 60% versus 15%, p=0.0007). Patients who had a lower than 25% decrease in their SUV change had a 5-years-survival lower than 5%. Furthermore, the difference between initial FDG uptake (PET 1) and uptake after completion of the whole NARCT (PET 3) was predictive for survival when 75% was applied as cut-off (p=0.02). However, the level of significance was considerably lower. CONCLUSION: FDG-PET is suitable for therapy monitoring in patients with stage III NSCLC. The decrease of FDG uptake during induction chemotherapy is highly predictive for patient outcome.

Depletion of the high-abundance plasma proteins.

Body fluids, like plasma and urine, are comparatively easy to obtain and are useful for the detection of novel diagnostic markers by applying new technologies, like proteomics. However, in plasma, several high-abundance proteins are dominant and repress the signals of the lower-abundance proteins, which then become undetectable either by two-dimensional gels or chromatography. Therefore, depletion of the abundant proteins is a prerequisite for the detection of the low-abundance components. We applied affinity chromatography on blue matrix and Protein G and removed the most abundant human plasma proteins, albumin and the immunoglobulin chains. The plasma proteins, prior to albumin and immunoglobulin depletion, as well the eluates from the two chromatography steps were analyzed by two-dimensional electrophoresis and the proteins were identified by MALDI-TOF-MS. The analysis resulted in the identification of 83 different gene products in the untreated plasma. Removal of the high-abundance proteins resulted in the visualization of new protein signals. In the eluate of the two affinity steps, mostly albumin and immunoglobulin spots were detected but also spots representing several other abundant plasma proteins. The methodology is easy to perform and is useful as a first step in the detection of diagnostic markers in body fluids by applying proteomics technologies.

Two years of smoking cessation does not reduce arterial wall thickness and stiffness.

BACKGROUND: Smoking cessation rapidly reduces cardiovascular risk. The pathophysiological mechanisms involved are still being debated. We measured structural and functional arterial wall properties of the femoral and carotid arteries after smoking cessation to investigate their possible role in cardiovascular risk reduction. METHODS: Out of 127 smokers, 33 proved to stop smoking for two years. They were compared with 50 nonsmokers and 55 persistent smokers in a prospective study. Cross-sectional compliance and distensibility coefficients as well as intima-media thickness of both carotid arteries and of the right common femoral artery were measured ultrasonographically at baseline and 3, 6, 12 and 24 months after smoking cessation. The nonsmoking and persistent smokers group were measured twice at an interval of 24 months. RESULTS: Persistent smoking and two years of smoking cessation did not affect cross-sectional compliance and distensibility coefficients. Although at baseline intimal-medial layers were thicker in smokers, the change over time in intima-media thickness did not differ significantly between all three groups. CONCLUSION: Two years of smoking cessation was not accompanied by a slower progression or a regression in intima-media thickness nor by an improved cross-sectional compliance or distensiblity coefficient. Nevertheless, smoking cessation should be recommended as it reduces cardiovascular risk rapidly after smoking cessation.