Leber's hereditary optic neuropathy mitochondrial DNA mutations in normal-tension glaucoma.

BACKGROUND: in Leber's hereditary optic neuropathy, increased optic nerve cupping has been reported by several authors. Recently, a mitochondrial DNA (mtDNA) mutation at nucleotide 11778 typically associated with Leber's hereditary optic neuropathy (LHON) was identified in a patient treated for glaucoma but lacking typical signs of LHON. The question arises: should all normal-tension glaucoma patients be further evaluated for LHON? METHODS: we screened 54 unselected patients with normal-tension glaucoma (age range 20-96 years, 16 men and 38 women) for the primary mtDNA LHON mutations at nucleotides 3460, 11778 and 14484. RESULTS: none of the patients harboured the mtDNA mutations at nucleotides 3460, 11778 or 14484 (95% confidence intervals for each mutation ranged from 0% to 5.3%). CONCLUSIONS: primary LHON mtDNA mutations are rare or absent in unselected normal-tension glaucoma patients. Therefore, unselected normal-tension glaucoma patients should not be screened for these mutations. It is probable that only normal-tension glaucoma patients with atypical features (rapid progression, early deep central scotoma, pallor of neuroretinal rim, elevated disc, peripapillary teleangiectasia) or a positive family history of visual loss compatible with a matrilinear transmission should be further evaluated.

[Current limits in diagnosis of ocular toxoplasmosis]. / Aktuelle Grenzen in der Diagnostik der okulären Toxoplasmose.

BACKGROUND: The diagnosis of ocular toxoplasmosis has remained a merely clinical one, because the low sensitivity of established methods does not allow clinical consequences. The underlying open prospective study was undertaken to analyse the sensitivity of a combination including the newly available tests for the diagnosis of the disease. METHODS: From 27 patients included until now, aqueous humor and serum samples were collected and sent to one of two reference laboratories according to their actual availability. From all samples, total IgG and anti-Toxoplasma IgG as well as specific IgM and IgA were quantified, and from the results, the antibody ratio was calculated according to the formula of Goldmann and Witmer. From the samples sent to laboratory 2, antibody avidity was determined and Toxoplasma DNA amplified using PCR. RESULTS: A confirmation of the clinical diagnosis was achieved in 5/9 cases (56%) from samples sent to laboratory 1, and from 14/18 samples (78%) sent to laboratory 2. Calculation of the antibody ratio was confirmed to be the most sensitive method with a confirmation rate of 41%, followed by PCR (28%), determination of specific IgA (22%) and finally antibody avidity (15%). A confirmation with two independent tests was achieved in 28% of cases. CONCLUSION: None of the methods analysed was sensitive enough to establish the diagnosis in a given case. The combination of all four methods, however, achieved a sensitivity, which is high enough to justify a clinical routine analysis of aqueous humor samples.

Common bile duct obstruction due to malignancy: treatment with plastic versus metal stents.

PURPOSE: To compare the clinical efficacy and treatment costs of plastic versus metal biliary stents. MATERIALS AND METHODS: In a randomized trial, 101 patients with malignant common bile duct obstruction underwent transhepatic stent implantation and were followed up until death. Patients were stratified into risk and nonrisk groups. Forty-nine patients received 12-F plastic stents, and 52 received expandable metal stents. Plastic endoprostheses were placed in a two-step procedure; metal stent, in a single procedure. Kaplan-Meier analyses were used to compare patient survival and stent patency rates. RESULTS: The 30-day mortality rate was significantly lower for metal stents (five of 52 [10%]) than plastic stents (12 of 49 [24%]; P = .05). The obstruction rate was 19% (10 of 52; median patency, 272 days) for metal stents and 27% for plastic stents (13 of 49; median patency, 96 days; P < .01). Median time until death or obstruction was longer for metal stents (122 vs 81 days; P < .01). Placement of metal stents was associated with shorter hospital stay (10 vs 21 days; P < .01) and lower cost ($7,542 vs $12,129; P < .01). CONCLUSION: Use of self-expanding metal stents appears to show substantial benefits for patients and to be cost-effective.

[Distinguishing of scar tissue from recurrent tumor after therapy of tumors of the female pelvis]. / Differenzierung von Narbengewebe und Tumorrezidiv nach Therapie von Tumoren des weiblichen Beckens.

Patients treated for gynecological malignancies are followed up at short intervals during the first 3 years after treatment. Locoregional recurrence in the pelvis is often not detectable by palpation. Thus, efficient and sensitive follow-up of patients treated for gynecologic malignancies requires the use of imaging techniques. Computed tomography is well suited for the primary diagnoses of locoregional recurrences and lymph-node metastases after radical surgery. In addition to detailed anatomical information, magnetic resonance imaging (MRI) permits tissue characterization on the basis of signal intensity and thus differentiation between fibrosis and recurrence. After primary radiotherapy for cervical cancer, MRI follow-up can assess tumor response to treatment. Prognostic evaluation of the success or failure of treatment requires knowledge of the signal characteristics and volume of the primary tumor and of the interval since primary treatment. In our experience, conventional spin-echo sequences with heavy T2-weighting are best for distinguishing between fibrosis and recurrence.

Iliac artery stent placement: clinical experience with a nitinol stent.

PURPOSE: To determine the effectiveness of a prototype nitinol stent in the iliac arteries. MATERIALS AND METHODS: Fourteen patients with arteriosclerotic lesions of the iliac arteries (nine stenoses, five occlusions) were treated percutaneously with a prototype nitinol vascular stent (Cragg stent) after unsuccessful percutaneous transluminal angioplasty. RESULTS: In 13 patients available for follow-up, the mean ankle-brachial index (ABI) increased from 0.4 +/- 0.32 (standard deviation) before the procedure to 0.81 +/- 0.27 after the procedure (P < .01). After 6, 12, and 24 months, the mean ABI was 0.97 +/- 0.2, 0.87 +/- 0.15, and 0.89 +/- 0.1, respectively. In two patients, radial stiffness of the stent was too low to completely eliminate a high-grade, calcified stenosis; long-term patency of the vessel, however, was preserved. In all other patients, stent placement achieved good vascular reconstitution. No stent occlusion or restenosis was observed. CONCLUSION: The results with the Cragg stent were similar to those with other commercially available stents. These preliminary results require confirmation with a larger series.

[Clinical experiences with the transjugular intrahepatic portocaval shunt (TIPS)]. / Klinische Erfahrungen mit dem transjugulären intrahepatischen portokavalen Shunt (TIPS).

Twenty-five patients with liver cirrhosis and portal hypertension were admitted for creation of a transjugular intrahepatic portosystemic shunt (TIPS). The procedure was successful in 22 patients (technical success 88%). The mean portal pressure gradient was lowered from 24.5 mmHg before to 11.4 mmHg after TIPS. Two early and three late occlusions were observed (primary patency rate 78%). The rate of secondary interventions was 41%. Five times a hepatic vein stenosis was dilated and stented, two times an occluded shunt was recanalized, two times a new shunt was created parallel to an occluded (secondary patency rate within a maximum of 16 months 95%). In two patients sepsis occurred which was effectively treated with antibiotics, two patients died shortly after TIPS due to hepatorenal syndrome and hepatic failure, respectively. There was no recurrent bleeding. Two patients developed hepatic encephalopathy; both improved after protein restriction. The authors conclude that TIPS is an alternative procedure to shunt surgery, especially for patients who cannot benefit from sclerotherapy.

Stenosis of a surgical portosystemic shunt--treatment with angioplasty and placement of a Wallstent.

A case with a stenosed splenosuprarenal shunt 26 months after surgery is presented. Due to elastic recoil of the stenosis, percutaneous angioplasty was ineffective. However, stenting the stenosis with a Wallstent subsequently provided a satisfactory angiographic result and normal shunt function which is maintained at 4 months.

Malignant biliary obstruction: histologic findings after treatment with self-expandable stents.

Histologic analysis was performed of bile duct tissue from 15 patients who underwent treatment for malignant obstructive jaundice with a self-expandable stent. Stents were in place from 5 days to 21 months. Malignancies included adenocarcinoma of the pancreas or gallbladder or cholangiocellular, hepatocellular, or gastric carcinoma. Stents were blocked by sludge in two cases and tumor overgrowth in two others. Microscopic evaluation showed that stent placement caused complete denudation of the mucosa and mild submucosal inflammation with edema. In all but one patient, the stent was incorporated into the bile duct wall and was covered by a fibrogranulomatous tissue layer after 2 months. In some cases, an epithelium-like cell formation covered the inner surface of the stent. Tumor ingrowth was observed in two patients with poorly differentiated tumors. In stents placed for longer than 2 months, mild to moderate fibrosis and foreign body reaction were observed. Hyperplastic biliary epithelium was not found within the stent or at the stent ends.

Iliac artery stenting--clinical experience with the Palmaz stent, Wallstent, and Strecker stent.

A total of 82 iliac artery lesions (62 stenoses and 20 occlusions) were treated with 3 different types of endovascular metallic stents (12 lesions with the Palmaz stent, 36 with the Wallstent, and 34 with the Strecker stent). The complication rate was 12%. Occlusion of 2 Wallstents occurred 4 and 12 weeks after stent placement, respectively. Both stents were recanalized by local fibrinolysis. One Strecker stent occluded after 8 months. The observation period was 3 to 26 months (mean 9.7 months). The patency rate with secondary intervention (fibrinolysis) was 100% after 3 and 6 months, and 98% after 9 months. All 3 stent designs turned out to be effective in the treatment of complicated iliac artery occlusive disease.

[The intrapulmonary pseudo-malposition of chest tubes in the computed tomogram (CT)]. / Intrapulmonale Pseudofehllage von Thoraxdrainagen im Computertomogramm (CT).

The diagnosis of an intrapulmonary malposition of chest tubes on CT may be problematic. We report about 13 chest tubes which were suspected on CT to be in an intrapulmonary malposition. In all cases as well as clinical and radiological follow up ruled out such a malposition. The use of a stiff tube and the presence of a soft lung parenchyma obviously led to a sinking of the tube into a "channel". Whereas after removal of the tube in case of such a pseudo-malposition solely a transitory local fluid collection and later a tender scar is seen, real intrapulmonary malposition leads to parenchymal injury and concomitant complications. The diagnosis of intrapulmonary malposition should be doubted, if the drain is positioned within the pleural space after having crossed the lung parenchyma in a supposed intrapulmonary rout. The CT criteria of this pseudo-malposition are presented and discussed.

[Percutaneous recanalization of pelvic artery occlusions--fibrinolysis, PTA, stents]. / Perkutane Rekanalisation von Beckenarterienverschlüssen--Fibrinolyse, PTA, Stents.

In 42 patients with symptomatic chronic iliac artery occlusions with a length of 2-15 cm (mean 4.3 cm), percutaneous recanalization was attempted. The study population was divided into 2 groups: Group I (n = 17) is a retrospective control group, the patients were treated with fibrinolysis (FL) and percutaneous transluminal angioplasty (PTA). In group II (n = 25) the patients were treated according to a prospective protocol including FL, PTA and placement of endovascular self-expandable stents. The recanalization rate for Group I and II together was 83% (35/42). FL was effective in 47%, in 53% the recanalization was performed mechanically only. The patency rate in Group I during a maximum of 69 months was 67%, in Group II, in which residual stenoses were treated with stents, 100% during max. 18 months. Obviously stents help to improve the results after percutaneous recanalization of iliac artery occlusions significantly.

[Congenital intrahepatic arterioportal fistula as a cause of necrotizing enteritis--Doppler sonographic and angiographic detection]. / Kongenitale intrahepatische arterioportale Fisteln als Ursache einer nekrotisierenden Enteritis--dopplersonographische und angiographische Erfassung.

A case of congenital arterioportal fistulas in a girl of 4 months of age is presented. Clinical signs of necrotising enteritis developed due to portal hypertension. The diagnosis was established via Doppler-duplex ultrasound showing a pulse-synchronous bidirectional flow pattern in the portal vein and its major branches. The diagnosis was confirmed by angiography.

MR-imaging with Gd-DTPA in carcinomas of tongue, oro- and hypopharynx.

High-field MRI was performed in a series of 24 patients with squamous cell carcinomas of the tongue, oro- and hypopharynx. The value of contrast enhanced T1-weighted images in tumor staging was established prospectively. Non-contrast T1-weighted images did not provide sufficient tumor-delineation. Marked contrast enhancement produced by Gd-DTPA was observed in all carcinomas and in normal pharyngeal mucosa. In tumors of the tongue and upper pharynx clinical examination and ultrasound were equally sensitive as post-contrast MRI; in tumors of the lower pharynx the true tumor extension could be better assessed by contrast-enhanced MRI.

[The limits of the differential diagnostic capacity of CT and sonography in cystic hepatic echinococcosis]. / Grenzen der differentialdiagnostischen Aussagefähigkeit von CT und Sonographie bei der zystischen Leberechinokokkose.

In regions of only sporadic occurrence of hydatid disease, the heterogenic appearance of the cysts often causes a diagnostic dilemma. In 28 patients the reports of sonography and/or computed tomography, without and during bolus injection of 100ml anionic contrast material, were compared to the results of the indirect haemagglutination test (IHA). In six cases additionally the enzyme-linked immunosorbent assay (ELISA), and in nine the histologic specimen were evaluated. The authors discuss the value of CT and US reporting on their experience and the difficulties in establishing the diagnosis in 14 histologically and/or serologically proven cases and another 14 cases with "typical" appearance but negative serology and/or histology.

[Value of magnetic resonance tomography after primary irradiation of carcinoma of the cervix uteri: evaluation of therapeutic success and follow-up]. / Stellenwert der Magnetresonanztomographie beim primär bestrahlten Karzinom der Cervix uteri: Therapieerfolgsbeurteilung und Nachsorge.

This study investigates the reliability of magnet resonance imaging in the evaluation of response to therapy and in follow-up after primary irradiation (RTX) of uterine cervical carcinomas in 25 patients (follow-up eleven to 39 months). Most of the tumors showed six months after RTX a significant reduction of volume and signal intensity in T2 weighted images. 20/25 (80%) showed a total tumor regression, 5/25 (20%) had a residual tumor (all of them had a primary tumor volume higher than 50 ccm). Four patients got a recurrent tumor in follow-up. Residual and recurrent tumors showed like the primary in heavily T2 weighted images significant higher signal intensity than fibrosis. Therefore posttreatment fibrosis is distinguishable from residual or recurrent neoplasm. Early radiation fibrosis (less than 6 months after RTX) showed higher signal intensity than fibrosis in later stages. This fact may be the cause of false positive results in searching for residual tumor within the first six months after RTX. Our results indicate that magnet resonance imaging is a reliable method to evaluate tumor response after radiation treatment and to detect recurrent neoplasm. The results of a greater patient population over a longer period of follow-up will be presented in future.

[Color-coded duplex sonography of dysfunctional kidney transplants. Correlation of the resistive index with the histopathologic results of biopsy]. / Farbkodierte Duplexsonographie von Nierentransplantaten mit Dysfunktion. Korrelation des Widerstandsindexes mit den histopathologischen Ergebnissen nach Biopsie.

The resistive index (RI) is used as a measure of the vascular resistance in renal allografts. The sample volume for the measurement can be positioned much more exactly with color duplex US than with duplex US, resulting in more precise values for the RI. To find out which pathologic changes lead to an increase of the RI, we correlated the RI with the histopathological results obtained in 43 biopsies. Our results show that it is not possible to differentiate between vascular and interstitial rejection on the basis of the RI because there is no statistically significant difference between the RI values caused by the two types of rejection. Distinct interstitial infiltration, edema of any origin, vascular changes and also chronic rejection and arteriolosclerosis lead to elevated RI. A good correlation was found between the elevation of RI and the severity of the vascular changes. Severe tubular and glomerular changes, cyclosporine toxicity, tubular necrosis, cytomegaly infection, glomerulonephritis and dysfunctions of other causes did not lead to elevation of the RI.