[Anaplastic astrocytomas of the medulla oblongata. A rare differential diagnosis in orthostatic hypotension]. / Anaplastisches Astrozytom der Medulla oblongata. Eine seltene Differentialdiagnose bei orthostatisch bedingter Hypotonie.

HISTORY AND PHYSICAL EXAMINATION: A 39-year-old women was admitted for evaluation of dizziness and hypotension. During standing the blood pressure dropped from 130/80 to 80/40 mmHg. Ten weeks before admission she had recurrent cerebral convulsions. Neurological evaluation showed a slight left hemiparesis. Computed tomography of the brain revealed a 1.5 +/- 1 cm cyst in the left tempral region. It was thought that the cause of the recurrent convulsions was alcohol abuse. During the next few weeks orthostatic hypotension increased and she was not able to work. INVESTIGATIONS: At admission abnormal findings included hypotension, horizontal nystagmus, and deviation of the soft palate to the right. After the patient was brought to an upright position during standardized passive tilt testing she showed a defect in the sympathetic limb of the baroreceptor reflex arc. Head magnetic resonance tomography showed a signal-enhancing tumour in the cervicomedullary region. TREATMENT AND CLINICAL COURSE: Before a planned biopsy could be performed the patient died of respiratory arrest. Postmortem examination revealed an anaplastic grade III astrocytoma extending form the pons to the medulla oblongata. CONCLUSION: Upright tilting leads to pooling of blood in the legs. One of the normal compensatory responses is a reflex tachycardia which our patient did not show as a sign of an afferent defect. Patients with orthostatic hypotension as a prominent symptom should be investigated with a standardized tilt test. In special patients, additional neurological investigations are necessary.

First year after head and neck cancer: quality of life.

PURPOSE: Treatment regimens for head and neck cancer patients profoundly affect several quality-of-life domains. Rehabilitative needs have been identified through cross-sectional analyses; however, few studies have prospectively assessed quality of life, included assessment of psychosocial variables, and identified predictors of long-term follow-up. PARTICIPANTS AND METHODS: The present study addresses these limitations through a prospective assessment of 105 patients with a newly diagnosed first primary squamous cell carcinoma of the oral cavity, pharynx, or larynx. Participants were enrolled onto a larger randomized controlled trial comparing a provider-delivered smoking cessation intervention with a usual-care-advice control condition. Participants completed a battery of self-report measures after diagnosis and before treatment and additional quality-of-life instruments at 1 and 12 months after initial smoking cessation advice. RESULTS: Participants displayed improvements at 12 months in functional status (P = .006) and in the areas of eating, diet, and speech; however, the latter three represent areas of continued dysfunction, and the changes were not statistically significant. Despite these improvements, patients reported a decline in certain quality-of-life domains, including marital (P = .002) and sexual functioning (P = .017), as well as an increase in alcohol use (P < .001). Predictors of quality of life at 12 months included treatment type, the Vigor subscale of the Profile of Mood States instrument, and quality-of-life scores obtained 1 month after initial smoking cessation advice. CONCLUSION: Results reinforce the need for rehabilitation management through the integration of psychologic and behavioral interventions in medical follow-up.

[Adult-onset Still's disease. Differential diagnosis in recurrent pharyngitis, fever of unknown original and excessive hyperferritinemia]. / Morbus Still des Erwachsenen. Differentialdiagnose bei rekurrenter Pharyngitis, Fieber unklarer Genese und exzessiver Hyperferritinämie.

HISTORY AND PHYSICAL EXAMINATION: Six weeks before admission a 43-year old previously healthy woman got right-sided pharyngitis, accompanied with Herpes labialis and oral candidiasis. Two weeks later she travelled to a holiday in the Caribbean. During the first week of holiday she developed pharyngitis again, this time accompanied with fever and arthralgies. Therapeutic trial with antibiotics, antimalaric drugs and antiamoebics, given at the holiday resort, did not reduce fever. Immediately after return to Germany a therapeutic trial with imipenem was was attempted, without any apparent improvement. At admission, the patient was febrile, had pinky patchy exanthema and arthralgias. EXAMINATIONS: At admission, abnormal findings included anaemia (Hb 8.8 mg/dl), severe leukocytosis (35.3/nl), increased ESR (43/89 mm), CRP (24.2 mg/dl) and ferritin (5751 micrograms/l). Ultrasound examination revealed mild splenomegaly. Computed tomography of the abdomen and chest were without apparent abnormalities. TREATMENT AND CLINICAL COURSE: Infection, autoimmune diseases and neoplasia were ruled out. The diagnosis of adult onset Still's disease was established on the basis of a typical triad of symptoms (fever, exanthema, arthritis). Treatment with 100 mg/d prednisolon (started intravenously) was beneficial for fever and arthralgia, and resulted in the normalisation of laboratory findings. After gradual reduction in the corticosteroid dosage, maintenance treatment with 20 mg/d prednisolon was continued over following months. CONCLUSION: Recurrent prodromal pharyngitis and excessive hyperferritinaemia are, in addition to the triad fever-exanthema-arthritis, further important diagnostic criteria of adult onset Still's disease.

Smoking withdrawal and relapse in head and neck cancer patients.

BACKGROUND: Smoking withdrawal and relapse were characterized among newly diagnosed head and neck cancer patients participating in a physician-delivered smoking cessation intervention. METHODS: Patients completed questionnaires at baseline, 1, 6, and 12 months following intervention delivery. RESULTS: Significant baseline predictors of smoking relapse included medical treatment (XRT versus surgical treatment), stage of change/readiness to quit (precontemplators), age of initiation (younger), and greater addiction (smoking

Extracellular matrix structure after heart transplantation.

Following heart transplantation remodeling of the donor heart causes changes in the extracellular myocardial matrix. We investigated 20 right ventricular endomyocardial biopsies taken 17+/-4 days (group I, n=9) and 63+/-13 days (group II, n=11) after heart transplantation from 16 patients transplanted for end-stage cardiomyopathy (15 dilated/1 ischemic). Immunohistochemical staining for collagen I, collagen III, collagen IV, and fibronectin was used. Evaluation was performed at a magnification of 400x using a computer-assisted image analyzing system measuring the relative area stained by the immunoperoxidase method, the number of cells in the given area, and the total area. Collagen I per cell was 13.9+/-5.9 microm2 in group I and increased significantly 66+/-13 days after heart transplantation in the perimysium around the myocardial cells as well as in the endocardium to 49.9+/-15.1 microm2 (P<0.05). No quantitative change in collagen III was noted (75.7+/-12.4 versus 75.5+/-16.0 microm2 n.s.). Collagen IV was found in the perimysial, in the capillary bed and in the vascular network. Significant quantitative change in the amount of collagen IV was not found (64.1+/-12.6 versus 61.0+/-8.9 microm2). Fibronectin was found in the entire perimysial extracellular matrix and in the endocardium in relationship with collagen I and III. An increased amount of fibronectin from 87.09+/-9.9 microm2 (group I) to 140.8+/-17.9 microm2 (group II, P<0.05) was found. The cell area and cell diameters were not significantly different (group I; cell area 772+/-227 microm2, diameter 31.3 microm; group II; cell area 776+/-224 microm2, diameter 31.4 microm). It is concluded that remodeling of the donor heart after transplantation is characterized by a specific increase in collagen I and fibronectin, whereas a change in other collagen subtypes was not observed.

Variations of segmental endothelium-dependent and endothelium-independent vasomotor tone after cardiac transplantation (qualitative changes in endothelial function).

Endothelial dysfunction is a common phenomenon after cardiac transplantation. However, qualitative differences in endothelial vasoregulation at different coronary segments and at different postoperative times have rarely been explored. To uncover the functional variations of endothelium responses we infused the endothelium-dependent vasodilator acetyl-choline (50 micrograms) followed by the endothelium-independent vasodilator 3-morpholinosydnonimine (SIN-1) (1 mg; 16 patients) or nitroglycerin (0.3 mg; 14 patients) sequentially into the left coronary artery. We investigated the responses of 120 nonstenotic coronary segments (proximal and distal left anterior descending and right circumflex coronary arteries) in 30 patients with quantitative angiography (group 1: 13 patients, 12 +/- 1 months after cardiac transplantation; group 2: 17 patients, 55 +/- 3 months after cardiac transplantation). Continuous-flow measurement was performed to exclude significant reduction of microvascular response influencing epicardial dilation. Five responses to acetylcholine administration followed by nitrates were observed. On the one end of the spectrum, segments dilate to acetylcholine administration with no further dilation to exogenous nitric oxide, indicating completely preserved endothelial function. On the other end, segments constrict to acetylcholine with no change after endogenous nitric oxide, reflecting a defective endothelial and defective smooth muscle function. The different patterns of coronary vasomotor lone responses to endogenous nitric oxide followed by exogenous nitric oxide represent different degrees of endothelial function after cardiac transplantation. In addition, the functional assessment of endothelial integrity shows qualitative time-dependent differences between proximal and distal coronary parts. The existence of coronary segments with functioning endothelium indicates that the latter is not diffusely disturbed in all cardiac transplant recipients and that the endothelial damage is perhaps not irreversibly lost.

[Evaluation of the sympathetic nervous system in silent ischemia with 123I-metaiodobenzylguanidine (MIBG)]. / Untersuchungen des sympathischen Nervensystems bei stummer Ischämie mit 123J-Metajodbenzylguanidin (MIBG).

AIM: Examination of the integrity of the sympathetic nervous system in patients with angiographically proven coronary artery disease and ECG documented asymptomatic ST-segment depression. METHOD: Stress and rest myocardial perfusion scintigraphy using either Thallium-201 or 99mTc-isonitrile was performed in SPECT technique in order to localize ischemia or scar associated perfusion defects. 15 min and 4 h p.i. static anterior 123I-MIBG uptake was acquired. In order to localize norepinephrine depletion 4 h p.i. additional 123I-MIBG SPECT acquisition was performed. Incidence of arrhythmias was investigated by Holter ECG. Patients with diabetes mellitus were excluded. RESULTS: SPECT images showed in all patients regional 123I-MIBG depletion which corresponded with scintigraphically infarcted or ischemic regions. Well perfused myocardial regions matched with regular 123I-MIBG uptake. There was no evidence of increased arrhythmias in long-term ECG. CONCLUSION: The finding of regular 123I-MIBG uptake in well-perfused myocardium and infarction- or ischemia-associated regional 123I-MIBG depletion confirms that silent ischemia is not caused by a global sympathetic nervous dysfunction in a sense of cardiac polyneuropathy.

Endothelium-dependent and endothelium-independent vasomotion in large coronary arteries and in the microcirculation after cardiac transplantation.

Endothelium-dependent and endothelium-independent vasodilation of the epicardial conduit vessels and the microcirculatory coronary vessels was investigated with cumulative doses of acetylcholine (ACh 50 micrograms and 100 micrograms i.c.), nitroglycerin (0.3 mg i.c.) and dipyridamole (0.56 mg.kg-1 i.v.) in 17 patients (3 female/14 male; age: 47 +/- 3.6 years) with angiographically normal coronary arteries 40 +/- 5.1 months after cardiac transplantation. The effect of ACh on large conduit arteries was evaluated angiographically. Coronary blood flow velocity changes were measured utilizing an 8F Judkins style 20 MHz Doppler catheter positioned in the left main coronary artery. A coronary flow index was calculated from the mean Doppler flow velocity and the computed cross-sectional vascular area. After 50 micrograms of ACh the diameter of proximal, middle and distal segments of the left anterior descending coronary artery decreased significantly by 7.6 +/- 2.06% (P < 0.05), 10.6 +/- 3.5% (P < 0.01) and 12.6 +/- 3.29% (P < 0.01) and after 100 micrograms ACh by 10.5 +/- 2.4% (P < 0.05), 13.0 +/- 3.7% (P < 0.01) and 15.3 +/- 3.9% (P < 0.01). The endothelium-independent vasodilator nitroglycerin (0.3 mg i.c.) induced an increase in vascular diameter of 14.4 +/- 3.1% (P < 0.01), 18.6 +/- 4.1% (P < 0.01) and 20.8 +/- 2.9% (P < 0.01) in proximal, mid and distal segments of the left anterior descending coronary artery.(ABSTRACT TRUNCATED AT 250 WORDS)

[Improvement in myocardial function and perfusion after recanalizing a chronic coronary artery occlusion]. / Verbesserung der Myokardfunktion und -perfusion nach Wiedereröffnung eines chronischen Koronararterienverschlusses.

The purpose of the study was to evaluate the improvement of the left ventricular ejection fraction and myocardial perfusion after recanalization of chronic coronary artery occlusions. The patients were investigated by rest and exercise radionuclide ventriculography (25/31) and rest and exercise myocardial scintigraphy (22/31). The examinations were performed 3 +/- 1 days before and within 7 days and 4 months after recanalization. Exercise-induced chest pain was present in 77% (24/31) of the patients before, in 10% (3/31) after recanalization and in 23% (7/31) during follow-up. Six of the 7 patients with exercise-induced chest pain after 4 months developed restenosis in the former reopened coronary artery. The results of the exercise-ECG present that 71% (22/31) of the patients had ST-segment-depression before, 19% (6/31) after catheter-intervention and 26% (8/31) during follow-up. Six of the 8 patients with exercise-induced ST-depression after 4 months had a restenosis in the former reopened coronary artery. Reopening resulted in an increase of global rest ejection fraction (EF) from 51 +/- 11% to 54 +/- 13% (p < 0.05) and sectorial EF from 56 +/- 17% to 61 +/- 21% (p < 0.01) after recanalization. After 4 months patients with excellent angiographic results still had an increased global and sectorial EF at rest (global: 54 +/- 9%, sectorial: 59 +/- 17%; n.s.). Patients with restenosis (note: no reocclusion) developed a decrease of global and sectorial rest EF (global: 49 +/- 14%, sectorial: 57 +/- 19%; n.s.).(ABSTRACT TRUNCATED AT 250 WORDS)

[Chronic coronary artery occlusion--age, morphology and chance of reopening. An attempt to define indications]. / Chronische Koronararterienverschlüsse--Alter, Morphologie und Chance der Wiedereröffnung. Versuch einer Abgrenzung von Indikationen.

In chronic coronary occlusions the rate of successful reopening seems to be improved with the help of new techniques; the chance of success can be judged by the age of occlusion. Frequently this age cannot be fixed exactly. The purpose of the study was therefore to find out, whether the chance of reopening can be judged by morphology. 60 patients in whom the occlusions could not be passed with a conventional wire were treated with the ROTACS system. Cine angios were reviewed carefully, morphological details in at least two projections were evaluated in graphic representations and correlated with the acute success rate and the estimated age of occlusion. Morphological parameters associated with a higher rate of success (type A) were: 1) a clearcut proximal stump with 2) no sidebranches at the site of occlusion, 3) no bridging collaterals and 4) only a slight filling of the distal vessel. Parameters with a low success rate (type B) were: 1) no proximal stump, 2) sidebranches at the site of occlusion, 3) bridging collaterals and 4) a very good distal filling. 48/60 (80%) of occlusions could be classified in type A or type B. The success rate was 17/21 (81%) (type A) versus 5/27 (18.5%) (type B) (p < 0.0002). The estimated age of type B occlusions was significantly higher than in type A: median 8 versus median 4 months (p < 0.002). It is concluded that the rate of success in reopening chronic coronary occlusions can be judged in the majority of patients using morphological parameters.

Rapid (24h) neutralization assay for the detection of antibodies to human cytomegalovirus using a monoclonal antibody to an HCMV early nuclear protein.

Neutralizing antibodies to human cytomegalovirus (HCMV) may play an important role during the course of an HCMV infection but yet detection with conventional methods remains difficult and time consuming. A new neutralization test has been developed basically corresponding to the known microtitre technique. A monoclonal antibody to an HCMV early nuclear protein is utilized to detect HCMV (AD169) infected fibroblasts by biotin/streptavidin-enhanced immunoperoxidase staining. The test procedure was thereby confined to only 24 h. Evaluation of the new neutralization test (24h-NT) was done in comparison to the conventional method (NT). Preselected serum samples (n = 217), of which n = 169 were HCMV-seropositive in ELISA (reciprocal titre greater than or equal to 40), were tested for neutralizing antibodies (NAbs) to HCMV. ELISA titres were measured by a commercially available kit (Behring, F.R.G.). NAbs could be detected in 107 sera by 24h-NT (reciprocal titre greater than or equal to 5) and in 110 sera determined by NT (reciprocal titre greater than or equal to 5). Those sera were exclusively positive in ELISA. ELISA negative sera (n = 48; reciprocal titre less than 40) yielded no detectable neutralizing titres. This specific and rapid test should facilitate HCMV-NAbs detection for a wide variety of applications including routine virology diagnostics, evaluation of HCMV hyperimmunoglobulins and medical research.

Detection of cytomegalovirus in bronchial lavage and urine using a monoclonal antibody to an HCMV early nuclear protein.

Laboratory diagnosis of 24 cases of human cytomegalovirus (HCMV) infection in patients with the acquired immunodeficiency syndrome, renal transplant recipients and premature infants was achieved. These results were obtained by a rapid, sensitive and versatile HCMV-antigen detection method, which combined cell culture and immunoperoxidase staining with a monoclonal antibody to an HCMV "early" nuclear protein. The results were compared with HCMV isolation by the conventional cell culture method. While some of these immunocompromised patients lacked a significant antibody response, infective HCMV could be detected in the patients' urine and bronchial lavage fluid. The diagnostic procedure took no longer than 24 h. The usefulness of this antigen test for an effective diagnosis in immunocompromised individuals was demonstrated. We recommend routine analysis of various specimens, since recent developments in chemotherapy of HCMV infection and the risks of long-term damage demand immediate management of the patients concerned.