[Intracranial hemorrhage masquerading as STEMI]. / EKG-Veränderungen bei intrakranieller Blutung.

A 56-year-old woman was found unconscious and promptly intubated. The electrocardiogram showed ST elevations in I, aVL, V1-V4. Thus, lysis therapy was performed. After admission to the intensive care unit, the patient was reassessed. Laboratory evaluation confirmed elevated troponin T. However, coronary angiography showed no coronary artery disease, whereas cerebral computed tomography revealed massive intracranial hemorrhage without neurosurgical treatment option. Brain death was confirmed after 54 hours. This case highlights electrocardiographic changes in intracranial hemorrhage that may be masquerading as STEMI.

[Online information for relatives of critically ill patients : Pilot test of the usability of an ICU families website]. / Onlineinformation für Angehörige von kritisch Kranken : Pilottestung zur Nutzbarkeit der ICU Families Website.

BACKGROUND: Relatives of intensive care patients have a very high need for information. This is due to the acute and serious, often life-threatening illness of the patients and the very complex and technical environment of an intensive care unit (ICU). Unmet needs for information can increase anxiety, sleep disorders, stress, and depressive symptoms in the relatives. OBJECTIVES: The potential of the ICU families website in terms of usability and functionality during real-time testing were evaluated. METHODS: The ICU families project created a dynamic online information platform in the form of a password-protected website. It contains pictures, written explanations, 5 movies, a forum and a diary function. The usability of the website was tested among 10 lay people and 10 experts (7 nurses and 3 physicians) according to the Think Aloud Method. RESULTS: The outcome is qualitative feedback based on video documentation by laypeople and suggestions by experts. Criticisms mentioned by the test subjects were insufficient image material, small size of the operator contact link and lack of a home button. With a mean of 9.1 (rating scale, 0 = very poor, 10 = very good), the website was almost universally recommended by the experts. CONCLUSIONS: This usability test of a website for relatives of ICU patients conducted among 20 test subjects showed the biggest challenges related to solving individual test scenarios and provided valuable hints for improving website usability. Features of the website highlighted as positive were the clear layout, the symbols, the diary and the consideration of children. This information was used to improve the site for subsequent roll-out in a randomized, controlled and multicentre study.

Anidulafungin Pharmacokinetics in Ascites Fluid and Pleural Effusion of Critically Ill Patients.

Anidulafungin concentrations were quantified with high-pressure liquid chromatography (HPLC) and UV detection of the ascites fluid and pleural effusion of 10 adult critically ill patients. Samples were collected from ascites fluid and from pleural drains or during paracentesis and thoracentesis, respectively. Anidulafungin levels in ascites fluid (0.12 to 0.99 µg/ml) and in pleural effusion (0.32 to 2.02 µg/ml) were below the simultaneous levels in plasma (1.04 to 7.70 and 2.48 to 13.36 µg/ml, respectively) and below the MIC values for several pathogenic Candida strains.

Acute wiiitis representing as thrombosis of the inferior vena cava and left pelvic veins.

Deep venous thrombosis as a result of venous wall injury provoked by trauma is a common finding. It often occurs in patients with sportive overstraining, caused by over fatigue of the body structures. In 2007, the entity of "acute wiiitis" was first described in a letter to the New England Journal of Medicine. Acute wiiitis sums up all affections, mainly skeletal and muscle affections, provoked by playing Nintendo Wii, a very common and loved video-game system. Deep venous thrombosis as a consequence of Nintendo Wii has not been described so far. We present a patient with a massive free floating thrombus of the left pelvic veins originating from the gluteal veins and reaching into the inferior vena cava after playing Nintendo Wii.

Lymphocyte-to-monocyte ratio: a novel marker for critical limb ischemia in PAOD patients.

BACKGROUND: The lymphocyte-to-monocyte ratio (LMR) is easily determined from the white blood cell count. Lymphocytes were previously investigated as a part of the neutrophil-to-lymphocyte ratio (NLR) in patients with atherosclerotic disease and an elevated NLR was negatively associated with cardiovascular endpoints. As monocytes play a leading role in the progression of atherosclerosis, especially in peripheral arterial occlusive disease (PAOD), we investigated LMR and its association with critical limb ischemia and other vascular endpoints in PAOD patients. METHODS AND FINDINGS: We evaluated 2121 PAOD patients treated at our institution from 2005 to 2010. LMR was calculated and the cohort was divided into tertiles according to the LMR. An optimal cut-off value for the continuous LMR was calculated by applying a receiver operating curve analysis to discriminate between CLI and non-CLI. In our cohort occurrence of CLI decreased significantly with an increase in LMR. An LMR of 3.1 was identified as an optimal cut-off. Two groups were categorized, one with 1021 patients (LMR < 3.1) and a second one with 1100 patients (LMR ≥ 3.1). CLI was more frequent in LMR < 3.1 patients [426 (41.7%)] than in LMR ≥ 3.1 patients [254 (23.1%)] (p < 0.001), as was also the case with prior myocardial infarction [60 (9.5%) vs. 35 (3.2%), p = 0.003] and congestive heart failure [136 (13.3%) vs. 66 (6.0%), p < 0.001). As to inflammatory parameters, C-reactive protein [median 9.0 mg/l (4.0-30.0) vs. median 4.0 mg/l (2.0-8.0)] and fibrinogen (median 438 mg/dl (350-563) vs. 372 mg/dl (316-459.5)] also differed significantly in the two patient groups (both p < 0.001). A LMR < 3.1 was associated with an odds ratio (OR) of 2.0 (95% CI 1.8-2.2, p < 0.001) for CLI, even after adjustment for other vascular risk factors. CONCLUSIONS: A decreased LMR is significantly associated with a high risk for CLI and other vascular endpoints. The LMR is an easily determinable, broadly available and inexpensive marker that could be used to identify patients at high risk for vascular endpoints.

Risk ranking of LANL nuclear material storage containers for repackaging prioritization.

Safe handling and storage of nuclear material at U.S. Department of Energy facilities relies on the use of robust containers to prevent container breaches and subsequent worker contamination and uptake. The U.S. Department of Energy has no uniform requirements for packaging and storage of nuclear materials other than those declared excess and packaged to DOE-STD-3013-2000. This report describes a methodology for prioritizing a large inventory of nuclear material containers so that the highest risk containers are repackaged first. The methodology utilizes expert judgment to assign respirable fractions and reactivity factors to accountable levels of nuclear material at Los Alamos National Laboratory. A relative risk factor is assigned to each nuclear material container based on a calculated dose to a worker due to a failed container barrier and a calculated probability of container failure based on material reactivity and container age. This risk-based methodology is being applied at LANL to repackage the highest risk materials first and, thus, accelerate the reduction of risk to nuclear material handlers.

Bosentan treatment of portopulmonary hypertension related to liver cirrhosis owing to hepatitis C.

Pulmonary arterial hypertension (PAH) with coexisting portal hypertension has been defined as portopulmonary hypertension (PPHTN). It is often related to liver cirrhosis of various aetiologies and is associated with a high mortality rate. Endothelin-1 (ET) is supposed to play an important role in the pathogenesis of PAH as well as portal hypertension. Therefore, therapy with an ET(A)/ET(B) receptor antagonist might be of use in the treatment of PPHTN. We report the case of a 76-year-old male with liver cirrhosis owing to chronic hepatitis C virus infection and PPHTN who was treated with the dual ET(A)/ET(B) receptor antagonist bosentan. The patient showed remarkable improvement of 6-min walking distance from 300 to 480 m after 2 weeks and to 540 m after 14 weeks, respectively. In addition, a significant decline of N-terminal pro B-type natriuretic peptide fraction (NT-proBNP) from 4928 ng mL(-1) to 640 ng mL(-1) was observed. Bosentan might be a promising new therapeutical option for patients suffering from PPHTN.

Ineffective off-label use of recombinant activated factor VII in a case of bone-marrow transplantation-related gastrointestinal bleeding.

BACKGROUND: For patients with a normal coagulation system, who experience serious bleeding, sound evidence for recombinant activated factor VII (rFVIIa) as an effective haemostatic agent is only scarcely available so far from controlled clinical trials. In systematic reviews on the clinical use of rFVIIa, treatment failures were only rarely reported. CASE PRESENTATION: We present a 45-year old, Caucasian male with persistent intestinal bleeding due to enterocolitis associated with cytomegalovirus infection and acute graft-versus-host-disease. He had received allogeneic peripheral blood stem cell transplantation from an unrelated HLA-identical donor because of chronic myelogenous leukaemia diagnosed two years earlier. Bleeding started at day 18 after transplantation with bloody diarrhea, which was treated with multiple transfusions of fresh frozen plasma, platelet, and red blood cell concentrates, and continued relentlessly, despite all efforts, including continued transfusions, high-dose prednisolone, broad antibiotic and antiviral coverage, and tranexamic acid. Recombinant FVIIa was started at boluses of 90-120 mug/kg every 4-8 hours. Despite more than 10 doses, recurrent severe bleeding progressed to refractory shock, multiorgan failure and death. CONCLUSIONS: Little can be concluded from single case reports of clinical improvement, because publication bias in favour of positive effects is likely. Our case suggests that rFVIIa is not a panacea, in particular for severe bleeding after bone-marrow transplantation. As long as rigorous, controlled studies or comprehensive registries are lacking, conventional interventions remain the standard of care in non-haemophilic patients with severe bleeding.

Hepatic lipase polymorphism and increased risk of peripheral arterial disease.

BACKGROUND: Hepatic lipase plays a key role in the metabolism of pro-atherogenic and anti-atherogenic lipoproteins affecting their plasma level as well as their physico-chemical properties. We hypothesized single nucleotide polymorphisms in the promoter region of the hepatic lipase gene to be associated with an increased risk for peripheral arterial disease (PAD). METHODS: A total of 241 patients with PAD and 241 controls matched for sex and age (+/-2 years) were genotyped cross-sectionally for the --250 single nucleotide polymorphism in the hepatic lipase promoter. RESULTS. The frequency for the -250 A allele in patients with PAD was 0.203, whereas it was 0.147 in the controls (P=0.022). Hepatic lipase promoter polymorphism distribution remained significantly different between cases and controls after multivariate logistic regression analysis (P=0.021). The odds ratio of the -250 A hepatic lipase allele for the PAD was 1.69 (95% confidence interval of 1.08-2.64), when adjusted for current smoking, arterial hypertension, cholesterol, triglycerides, HbA(1C), total homocysteine and high sensitivity C-reactive protein. CONCLUSION: Previous data in patients with ischaemic heart disease have suggested a pro-atherogenic role of low hepatic lipase levels. Our results extend these data to the vascular territory of the lower limbs, such that hepatic lipase promoter variation represents a genetic risk factor of PAD.

A patient with insidious onset of exertional dyspnoea.

The case history is presented of a 42 year old woman with pulmonary artery occlusion due to tuberculous vasculitis that masqueraded as chronic pulmonary artery embolism and led to severe life threatening haemoptysis necessitating emergency pneumonectomy. It is concluded that obliterative tuberculous endarteritis of the pulmonary arteries should be considered in the differential diagnosis of any acquired obstruction of pulmonary arteries.

Prenatal diagnosis of intrauterine premature closure of the ductus arteriosus following maternal diclofenac application.

We report a case of prenatal diagnosis of premature closure of the ductus arteriosus following maternal diclofenac therapy at 35 weeks of gestation. Fetal echocardiography at 37 weeks of gestation revealed a dilated right ventricle with moderate tricuspid regurgitation, pulmonary insufficiency and complete closure of the ductus arteriosus. Immediate Cesarean section resulted in an excellent neonatal outcome. Whereas the effect of indomethacin on prenatal ductal constriction is well known, widely prescribed non-steroidal anti-inflammatory drugs such as diclofenac can have an equally deleterious effect and are best avoided in the third trimester of pregnancy.

Four consecutive renal transplantations in a patient with adenine phosphoribosyltransferase deficiency.

We report a patient with complete adenine phosphoribosyltransferase deficiency and urolithiasis, in whom 4 consecutive cadaveric renal transplantations were performed; 2,8-dihydroxyadenine crystal nephropathy recurred within weeks in the first and second graft when the patient was not treated with allopurinol immediately after transplantation. In the third graft, recurrence of disease could be prevented by immediate allopurinol treatment. This graft was lost due to chronic allograft nephropathy without significant crystal deposition. After a fourth transplantation, again without initial allopurinol, the disease recurred following an initial vascular rejection. Addition of allopurinol significantly improved renal function of the 2nd and 4th graft. This case indicates that outcome of renal transplantation in patients with adenine phosphoribosyltransferase deficiency critically depends on immediate postoperative pharmacotherapy with allopurinol, which is able to prevent 2,8-dihydroxyadenine nephropathy in the graft. Furthermore, rapid recurrence of disease without allopurinol seems to be triggered by delayed graft function and acute rejection.

Molecular characterization of rabbit scavenger receptor class B types I and II: portal to central vein gradient of expression in the liver.

To further elucidate the role of scavenger receptor class B type I (SR-BI) in reverse cholesterol transport and in atherogenesis, we performed studies in the rabbit, an animal model displaying a lipoprotein profile similar to that of human, expressing cholesteryl ester transfer protein in plasma and having been demonstrated to be susceptible to atherosclerosis. In this report, we describe for the first time the isolation and characterization of rabbit cDNA fragments encoding SR-BI and scavenger receptor class B type II (SR-BII). Development of an isoform-specific Taqman Real Time PCR system and generation of isoform-specific polyclonal antibodies allowed us to measure SR-BI and SR-BII expression in various rabbit organs on mRNA and protein levels, respectively. We found the highest expression of SR-BI in adrenal gland, liver, and proximal intestine; lesser expression was found in appendix and spleen. Immunohistochemical staining of frozen sections showed SR-BI expression in the cortex but not in the medulla of adrenal gland. An increasing portal to central vein gradient of expression was found within the hepatic lobule. As shown in this report, identification and characterization of SR-BI expression in the rabbit affords a powerful tool to elucidate the role of SR-BI in cholesterol homeostasis and atherogenesis in human.

Linear scleroderma "en coup de sabre" coexisting with plaque-morphea: neuroradiological manifestation and response to corticosteroids.

A 24 year old woman in the 33rd week of pregnancy developed progressive neurological complications with right sided hemiparesis in association with the occurrence of linear scleroderma "en coup de sabre" (LSCS) and pre-existing plaque-morphea, already being treated by balneophototherapy. Further progression of neurological symptoms led to a caesarean section with the delivery of a healthy child. Brain magnetic resonance imaging (MRI) showed focal T2 signal increases in the left frontoparietal region directly adjacent to the area of LSCS. Cerebrospinal fluid analysis revealed oligoclonal bands, suggesting an intracerebral inflammatory process. Subsequent pulsed corticosteroid treatment led to a remission of neurological symptoms and to a marked resolution of the MRI lesions.

Fast and accurate measurement of taste and smell thresholds using a maximum-likelihood adaptive staircase procedure.

This paper evaluates the use of a maximum-likelihood adaptive staircase psychophysical procedure (ML-PEST), originally developed in vision and audition, for measuring detection thresholds in gustation and olfaction. The basis for the psychophysical measurement of thresholds with the ML-PEST procedure is developed. Then, two experiments and four simulations are reported. In the first experiment, ML-PEST was compared with the Wetherill and Levitt up-down staircase method and with the Cain ascending method of limits in the measurement of butyl alcohol thresholds. The four Monte Carlo simulations compared the three psychophysical procedures. In the second experiment, the test-retest reliability of MLPEST for measuring NaCl and butyl alcohol thresholds was assessed. The results indicate that the ML-PEST method gives reliable and precise threshold measurements. Its ability to detect malingerers shows considerable promise. It is recommended for use in clinical testing.

A multicenter report on 1,022 consecutively placed ITI implants: a 7-year longitudinal study.

The aim of this multicenter study was to evaluate cumulative success and survival rates of ITI implants after 7 years. A complete medical report was obtained for all 440 patients enrolled in this investigation, which involved 10 different private practices. The 1,022 consecutively placed implants were distributed between completely edentulous, partially edentulous, and single-tooth replacement cases. During the annual follow-up visit, each implant was examined both clinically and radiographically using predefined success criteria. The cumulative survival and success rates were calculated for all implants. Implant subgroups were defined according to the medical history of the patients or pooled according to various indications, locations, implant designs, or implant lengths. In each subgroup, the related cumulative success rate was statistically compared to the global cumulative success rate. Fifteen implants (1.4%) were regarded as early failures, and at the end of the follow-up, the global failure rate reached 6.6%; 30 implants (3%) were lost to follow-up. At 5 years, the cumulative survival rate was 95.4%; this declined to 92.2% at 7 years. The weakest success rates were observed for implants placed in older patients, periodontally treated patients, and completely edentulous arches. Conversely, cumulative success rates that were significantly above average were observed for patients between 40 and 60 years old without pathology, implants placed after bone regeneration, solid-screw implants, implants placed in edentulous spaces, and implants placed as single-tooth replacements. This investigation has demonstrated that in these 10 private practice settings, the success rate for ITI implants remained high for up to 5 years and declined slightly between 5 and 7 years. It should be noted that in later year intervals, a relatively small number of implants remained for the analysis of cumulative success rates.