[A woman in her fifties with neck pain and increased sedimentation rate]. / En kvinne i 50-årene med nakkesmerter og forhøyet senkningsreaksjon.

BACKGROUND: Spondylitis in the upper cervical spine can have an insidious onset, with symptoms mimicking low-grade infections or common musculoskeletal disorders. Some patients have neurological symptoms, and if untreated, the outcome may be fatal. CASE PRESENTATION: A woman in her fifties had general malaise, weight loss and neck pain over 6-8 weeks. Her sedimentation rate was elevated, and she developed bulbar symptoms. Biopsy and culture samples were harvested endoscopically from the prevertebral area in the C1-C2 region, and confirmed our preliminary diagnosis of localised infection. She was treated with high-dose antibiotics and rigid collar immobilisation until stability of the cervical spine was ascertained. INTERPRETATION: It is difficult to make a differential diagnosis between spondylitis, rheumatoid inflammation and malignancy in the upper cervical spine. Adequate histologic and bacterial culture samples must if possible be obtained from the prevertebral area. This is best achieved transnasally or transorally, under endoscopic and radiological guidance. The neck must be stabilised and patients must have long-term antibiotic treatment followed by permanent neck fixation if indicated.

Increased gene expression of the ABCC5 transporter without distinct changes in the expression of PDE5 in human cervical cancer cells during growth.

Carcinoma of the uterine cervix represents the second most frequent female malignancy worldwide, but few biochemical tumour markers have been implemented into clinical practice. Elevated extracellular guanosine 3', 5'-cyclic monophosphate (cGMP) levels have been reported to be a sensitive, early and reliable marker for screening relapse in carcinoma of the uterine cervix. The mechanism behind this observation remains unknown. The possibility exists that the cancer cells develop resistance to the antiproliferative effect of high intracellular cGMP levels. The enhanced cGMP expression may originate from either an increase in cellular export capacity by increased expression of member 5 in subfamily C of ATP-Binding-Cassette transporters (ABCC5), or increased substrate (cGMP) levels for this pump. The latter situation occurs with increased expression of inducible nitric oxide synthase (iNOS) and/or soluble guanylyl cyclase (sGC) and/or reduced expression of member 5 of the cyclic nucleotide phosphodiesterases (PDE5). Four transformed human cell lines derived from carcinomas of the uterine cervix (C-4 I, C-33 A, SiHa and ME-180 cells) and one non-transformed human cell line (WI-38) were included in the study in order to unveil which biokinetic components are involved. The expressions of iNOS, sGC, PDE5 and ABCC5 in the initial and final phase of the exponential growth curve were compared. Assuming that the WI-38 control cells mimic the situation in a normal tissue, iNOS remains un-expressed during proliferation, and the expression of sGC is low but shows a clear increase during exponential growth. PDE5 is highly expressed and increases (≈130%) during growth whereas ABCC5 exhibited low to moderate expression, with a moderate increase (≈40%) during growth. The malignant cells exhibited moderate ABCC5 expression with a distinct increase during exponential growth, whereas PDE5 expression remained virtually unchanged. Dysregulation of the cGMP biokinetics in growing malignant cells may account for the elevation of extracellular cGMP observed in patients with carcinoma of the uterine cervix.

The PMMA epidemic in Norway: comparison of fatal and non-fatal intoxications.

During a 6 month period (July 2010-January 2011) we observed 12 fatal intoxications and 22 non-fatal cases related to the drug paramethoxymethamphetamine (PMMA) in Norway (4.8 mill inhabitants). This toxic designer drug, also known as "Death", is occasionally found in street drugs offered as "ecstasy" or "amphetamine". The present study aimed to evaluate the cause of death, and to compare the PMMA blood concentrations in fatal and non-fatal cases. Methods for identification and quantification of PMMA are presented. The median age of fatalities was 30 years (range 15-50) with 67% males; in non-fatal cases 27 years (20-47) with 86% males. In the 12 fatalities, the median PMMA blood concentration was 1.92 mg/L (range 0.17-3.30), which is in the reported lethal range of 0.6-3.1 mg/L in peripheral blood and 1.2-15.8 mg/L in heart blood. In the 22 non-fatal cases, the median PMMA concentration was 0.07 mg/L (range 0.01-0.65). Poly-drug use was frequent both in fatal and non-fatal cases. The PMA concentrations ranging from 0.00 to 0.26 mg/L in both groups likely represented a PMMA metabolite. Three fatalities were attributed to PMMA only, six to PMMA and other psychostimulant drugs, and three to PMMA and CNS depressant drugs, with median PMMA concentrations of 3.05 mg/L (range 1.58-3.30), 2.56 (1.52-3.23) and 0.52 mg/L (0.17-1.24), respectively. Eight victims were found dead, while death was witnessed in four cases, with symptoms of acute respiratory distress, hyperthermia, cardiac arrest, convulsions, sudden collapse and/or multiple organ failure. In summary, all fatalities attributed to PMMA had high PMMA blood concentrations compared to non-fatal cases. Our sample size was too small to evaluate a possible impact of poly-drug use. A public warning is warranted against use and overdose with illegal "ecstasy" or "speed" drugs.

Expression of iNOS--a favourable prognostic marker for early-stage carcinoma of the uterine cervix.

In former studies, raised urine cGMP levels have been reported to predict adverse outcome in cervical cancer. The main objective of the present study was to investigate the value of nitric oxide synthase (iNOS) and other members of the cGMP pathway as potential biomarkers for prognosis of cervical carcinoma. Tissue samples from 85 patients surgically treated for early-stage cervical carcinoma were immunohistochemically stained for iNOS, soluble guanylyl cyclase subunits α1 (sGC-α1), soluble guanylyl cyclase α2 (sGC-α2), and phosphodiesterase 5, each sample evaluated microscopically by a semi-quantitative score. Results were correlated to recurrence and FIGO stage (depth of tumour cell infiltration). Correlation was found between high expression of iNOS in tumour cells and low risk of recurrence (p=0.019, p=0.05, p=0.022 and p=0.025). High expression of iNOS, sGC-α1 and sGC-α2 also correlated to superficial tumour growth. Our results demonstrate that iNOS expression in cervical tumour tissue is a robust prognostic marker for cervical cancer.

Renal artery pseudoaneurysm secondary to blunt trauma nine years earlier: case report and review of the literature.

This report describes a 59-year-old male with a renal artery pseudoaneurysm secondary to blunt trauma from a snowmobile accident. The patient presented with haematuria and flank pain, 9 years after the injury. This is the second longest interval between initial trauma and aneurysm rupture in published cases. The diagnosis was delayed because the doctors were unaware of the initial trauma. In cases of haematuria, flank pain and computed tomography showing a tumour in the renal hilum, the patient should be questioned about previous abdominal trauma, as pseudoaneurysms can rupture many years after the causative injury.

Prognosis of early cervical cancer (FIGO Stages IA2, IB, and IIA) in northern Norway predicted by malignancy grading score and objective morphometric image analysis.

Recurrence of early-stage cervical cancer after primary surgery represents a considerable clinical problem, and, so far, few reliable markers for prediction of recurrence exist. Thus, the prognostic value of the malignancy grading score (MGS) classification system was evaluated in 82 patients with early-stage cervical cancer (International Federation of Gynecology and Obstetrics stages IA2, IB, and IIA) and long-time follow-up (5-16 years). Recurrence or not, the likelihood of lymph node metastases and reproducibility of the MGS semiquantitative system were tested. The prognostic power of the MGS to identify high-risk cases prone to recurrence in patients lacking lymph node metastases at primary surgery was a main purpose of the present study. The semiquantitative MGS classification system was performed independently by 2 pathologists unaware of prognosis and clinical data using light microscopy. Routine hematoxylin and eosin sections from surgical specimens were used, and investigation area was defined in the deep part of the tumor. Data-based image analysis was also used to investigate if objective morphometric parameters could add any prognostic power to MGS. The 5-year survival for the whole patient group was 92%. Malignancy grading score of greater than 17 risk points was statistically highly significant in predicting relapse and lymph node metastases (n = 82). High-risk cases lacking lymph node metastases (n = 70) were also statistically associated with high MGS. Depth of invasion and vascular invasion were statistically related to recurrence. Objective image analysis of nuclear parameters was of no additional statistical value for the prediction of outcome. The MGS classification system proved to be a useful tool in predicting recurrence and lymph node metastases and, most importantly, was a predictor of high-risk patients without metastases at primary surgery.