[Abdominal pain in emergency service--what should I not forget?]. / Abdominalschmerzen im Notfalldienst--was darf ich nicht vergessen?

Abdominal pain for the General Practitioner (GP) is an important problem and presents as a significant challenge since the complaint emerges to the primary care provider as one of the 3 most important complaints. This paper serves as a facilitator and guide in helping the General Practitioner differentiate between the so-called normal abdominal pain versus severe abdominal pain which should be referred to a specialist. One of the most important messages the paper attempts to convey is that patients have to be seen and personally examined by the General practitioner. This is a paramount feature in establishing course of severity and outcome. Since approximately 25% of all presenting abdominal pain complaints are unclear, even to the experienced specialist, the authors attempt to direct a focused exam by means of a thorough history and physical examination and then to formulate a decision tree regarding the question of referral or continued primary care by the provider.

Imaging of chronic recurrent multifocal osteomyelitis of childhood first presenting with isolated primary spinal involvement.

OBJECTIVE: Initial presentation with primary spinal involvement in chronic recurrent multifocal osteomyelitis of childhood (CRMO) is rare. Our objective was to review the imaging appearances of three patients who had CRMO who initially presented with isolated primary spinal involvement. DESIGN AND PATIENTS: The imaging, clinical, laboratory and histology findings of the three patients were retrospectively reviewed. Imaging included seven spinal MR imaging scans, one computed tomography scan, nine bone scans, two tomograms and 16 radiographs. These were reviewed by two musculoskeletal radiologists and a consensus view is reported. All three patients presented with atraumatic spinal pain and had extensive bone spinal pathology. The patients were aged 11, 13 and 12 years. There were two females and one male. RESULTS AND CONCLUSIONS: The initial patient had thoracic T6 and T8 vertebra plana. Bone scan showed additional vertebral body involvement. Follow-up was available over a 3 year period. The second patient had partial collapse of T9 and, 2 years later, of C6. Subsequently extensive multifocal disease ensued and follow-up was available over 8 years. The third patient initially had L3 inferior partial collapse and 1 year later T8 involvement with multifocal disease. Follow-up was available over 3 years. The imaging findings of the three patients include partial and complete vertebra plana with a subchondral line adjacent to endplates associated with bone marrow MR signal alterations. Awareness of the imaging appearances may help the radiologist to include this entity in the differential diagnosis in children who present with spinal pathology and no history of trauma. Histopathological examination excludes tumor and infection but with typical imaging findings may not always be necessary.

Serine proteinase activation in esophageal cancer.

BACKGROUND: Activation of the plasminogen/plasmin system seems to contribute to tumor aggressiveness and shorter post-operative survival. In the present study we examined the relation of uPA (urokinase plasminogen activator), uPAR (uPA receptor) and PAI-1 (plasminogen activator inhibitor type 1) to the biological growth behavior of esophageal cancer, as well as their influence on survival in esophageal cancer. MATERIALS AND METHODS: The expression and distribution of uPA, uPAR and PAI-1 were analyzed by Northern blot analysis and immunostaining in 41 resected esophageal cancers and in normal esophagi. RESULTS: Northern blot analysis revealed a 5.0-, 3.6- and 5.4-fold increase in uPA, uPAR, and PAI-1 mRNA levels in esophageal cancer, respectively, in comparison to normal controls (p<0.01). These mRNA moieties were concomitantly increased in 86% of the tumors. uPA activity was 2.3-fold increased in esophageal cancer compared with normal controls (p<0.01). Statistical analysis revealed no differences in uPA, uPAR and PAI-1 immunoreactivity between well-differentiated, moderately-differentiated and poorly-differentiated tumors. Furthermore, survival analysis showed no difference in patients whose tumors exhibited positive uPA and uPAR immunostaining (median 11 months, range 4-36 months) versus patients whose tumors exhibited negative uPA and uPAR immunostaining (median 11 months, range 3-51 months). CONCLUSION: Our data revealed that overexpression of uPA, uPAR and PAI-1 is often present in human esophageal carcinomas. However, up-regulation of these factors is not correlated with tumor differentiation or survival. These findings indicate that, unlike other tumors, uPA, uPAR and PAI-1 seem not to be prognostic markers for esophageal carcinomas.

Hydrocortisone treatment of early SIRS in acute experimental pancreatitis.

This work studied the effects of hydrocortisone treatment in experimental acute pancreatitis on cytokines, phospholipase A2, and breakdown products of arachidonic acid and survival. Edematous and necrotizing pancreatitis were induced in Wistar rats by cerulein hyperstimulation and retrograde intraductal infusion of sodium taurocholate, respectively. Hydrocortisone (10 mg/kg) was administered intravenously 10 minutes after induction of acute pancreatitis. Serum was assayed for phospholipase A2; interleukin (IL) 1beta, IL-6, IL-10, thromboxane B2; Prostaglandin E2; and leukotriene B4 at five different time points. A significant release of inflammatory mediators was seen only in the severe model. Hydrocortisone powerfully suppressed arachidonic acid breakdown products and only mildly attenuated the systemic increase of phospholipase A2 and pro- and antiinflammatory cytokines. The mortality rate after 72 hr in the severe model was 86%. Hydrocortisone treatment reduced mortality to 13% (P = 0.001; Fisher's exact test). Hydrocortisone seems to be effective in the treatment of the early systemic inflammatory response syndrome associated with severe acute pancreatitis.

Cyclooxygenase 2 expression in chronic pancreatitis: correlation with stage of the disease and diabetes mellitus.

BACKGROUND: Fibrotic replacement of the exocrine pancreatic parenchyma and infiltration of inflammatory cells are the main characteristics of chronic pancreatitis (CP). Inflammation involves prostaglandin production in numerous inflammatory and noninflammatory cells, and cyclooxygenase 2 (COX-2) is the dominant regulator of prostaglandin synthesis. AIMS: In the present study, we analyzed the expression of COX-2, the key enzyme for prostaglandin synthesis in pancreatic tissues, and evaluated its relation to exocrine and endocrine tissue alterations in CP. PATIENTS AND METHODS: Pancreatic tissue specimens from 27 patients undergoing pancreatic head resection for CP were included in the study. Pancreatic tissues from 14 organ donors served as controls. The tissue specimens were analyzed histopathologically and for COX-2 immunoreactivity. RESULTS: In normal pancreatic tissue samples, COX-2 immunoreactivity was restricted to islet cells. In contrast, in early-stage CP, islets as well as ductal cells showed intense COX-2 immunoreactivity. In advanced-stage CP, ductal cells were still strongly positive for COX-2, yet islets displayed a variable COX-2 staining pattern which was associated with the distribution of insulin-positive cells and with the clinical diabetes mellitus status of the patient. Thus, patients with normal or latent diabetes mellitus status showed COX-2 immunoreactivity, whereas in diabetic patients the COX-2 immunoreactivity was decreased or absent in pancreatic islets. CONCLUSION: The presence of COX-2 in ductal cells of early and advanced CP, the relationship between COX-2 and insulin expression in the islets, and the diabetes mellitus status of CP patients suggest that this enzyme plays a role in the pathogenesis of exocrine and endocrine damage in CP.

[Acute pancreatitis--clinical and technical laboratory diagnostic and prognostic assessment]. / Akute Pankreatitis--klinische und labortechnische Diagnose- und Prognosestellung.

The incidence of acute pancreatitis within 100,000 inhabitants a year differs between 5 (Bristol) and 80 (USA). Even though the diagnosis of pancreatitis has become easier by the measurement of specific pancreatic enzymes there are still 30-40% of the fatal cases which are first diagnosed at autopsy. It is of utmost importance to assess the diagnosis and the severity of acute pancreatitis in the beginning to identify those patients with severe or necrotising disease who benefit from an early initiated intensive care therapy. Additionally, in view of new therapeutical concepts (e.g. antibiotic therapy in severe forms) and for the evaluation of new drugs, patients should be staged into mild and severe disease as early as possible. In most cases it is not possible to assess the severity clinically on hospital admission. Up to now the "gold standard" are imaging procedures (contrast-enhanced CT and MRI) which should be reserved for the severe cases to estimate the extent of pancreatic necrosis. The ideal predictor in blood or in urine should be objective, reliable, inexpensive, easy to measure, widely available, sensitive and specific. There are a variety of mediators of the "systemic inflammatory response syndrome" which are elevated in this disease (C-reactive protein, antiproteases, enzyme activation peptides like trypsinogen activation peptide (TAP) and carboxypeptidase B activation peptide (CAPAP), PMN-elastase, complement factors, chemokines and interleukins and others). Among all these mediators, C-reactive protein is the parameter best analysed. It has to be taken into account that it is not specific for AP and it's highest efficacy is reached after > 48 hours after the onset of disease. However, because usually a certain time elapses (approximately 24-48 hours) until patients are hospitalised the time delay seems not to a major disadvantage.

[Combination of surgical therapy and interventional radiology in a recurrent myxoid liposarcoma with a 37-year history]. / Kombination von chirurgischer Therapie und interventioneller Radiologie bei einem seit 37 Jahren rezidivierenden myxoiden Liposarkom.

Extreme long-term survivals of low grade liposarcomas are rare. The authors present a case of a 75 year old man with a 37 year history of recurrent myxoid liposarcoma. The tumor dynamics are obviously related to the histology subtype. The clinical and radiological findings of the sixth tumor recurrence are discussed. The combination therapy of surgical tumor reduction and interventional radiology with implantation of endovascular prostheses for iliaco-femoral vein compression due to tumor recurrence is described.

[Differential surgical therapy of popliteal entrapment syndrome 1967 to 1992]. / Chirurgische Differentialtherapie des poplitealen Entrapment-Syndroms von 1967 bis 1992.

From 1967 to 1992 at the University Hospital of Zurich 16 patients (14 male, 2 female) with 22 popliteal artery entrapment syndromes underwent a surgical treatment. In this period several different operation procedures were used. The modern operative procedure depends on the degree of the arteries wall compression. The procedure of choice for minimal compression of arterial wall is a musculo-tendinous decompression with a medial replacement of the popliteal artery. In the cases of severe compression we used autologous venous bypass from femoropopliteal I to popliteal III.

[Graft patency and saving the extremity as a function of asymptomatic/symptomatic aneurysm of the popliteal artery and the graft material used]. / Graftdurchgängigkeit und Extremitätenerhaltung als Funktion des asymptomatischen/symptomatischen Aneurysma der A. poplitea bzw. des verwendeten Graftmaterials.

A 27-year experience with 252 popliteal artery aneurysms in 167 patients is reviewed. Long-term results with respect to graft patency and limb salvage rates are analyzed. The results emphasize the importance of early surgical intervention and demonstrate the superiority of autologous saphenous vein over other graft materials.

[Volvulus of the small intestine as a surgical rarity in acute abdomen. Analysis of 47 cases]. / Der Dünndarmvolvulus als chirurgische Rarität des akuten Abdomens. Eine Analyse von 47 Fällen.

In North America and Europe small bowel volvulus is a sporadic form of mechanical intestinal obstruction. Diagnostic problems may occur. The clinical presentation is that of an acute abdomen. The cause of symptoms may be due to narrowing of the bowel itself, or strangulation of the blood supply, or both. The types (primary and secondary) and incidence of small bowel volvulus are age-related and demonstrate astonishing geographical differences. Goals for treatment of small bowel volvulus should include physician awareness and accurate work-up of this uncommon diagnosis.

The continuing challenge of aneurysms of the popliteal artery.

This report is an analysis of 252 popliteal artery aneurysms (PAA) in 167 patients treated surgically at the University Hospital in Zurich during a 27 year period from 1965 to 1991. The predominance of male patients (95 percent) was consistent with that of other reports. PAA were bilateral in 51 percent of the patients and were associated with aneurysms at other sites in 38 percent. Atherosclerosis was by far the most common cause (98 percent). PAA were symptomatic in 75 percent of the patients, the predominant findings being ischemia from emboli, thrombosis or rupture. Primary amputation was required in 23 extremities. Surgical reconstruction with bypass was performed for 229 PAA. A secondary amputation was necessary in 18 limbs. The risk of complications from popliteal aneurysms, and the good results from surgical treatment suggest that a revascularization procedure in the asymptomatic stage should be recommended unless specific contraindications exist. We conclude that surgical treatment should be performed in symptomatic and asymptomatic PAA larger than 2 centimeters in diameter. Long term results of surgical reconstruction are improved if an autogenous saphenous vein is used and if reconstruction is performed before the occurrence of complications. Polytetrafluoroethylene prostheses should be used when an autologous saphenous vein is not available. The use of Dacron (polyester fiber) grafts is no longer indicated.

[Retroperitoneal sarcoma. Therapy and course]. / Retroperitoneale Sarkome. Therapie und Verlauf.

The incidence of retroperitoneal soft tissue sarcomas is with 0.1 to 0.2 percent very low. The tumors most often present as asymptomatic masses until the lesions are quite large, compared with the anatomic part, resulting in compression of nerves, vessels, bowel etc. The recommended management is the aggressive radical tumor excision including the pseudocapsule followed by a consequent clinical, ultrasonography and CT-scan follow-up. Tumor recurrences should be attempted in the same manner as primary tumors.

[How often does an aneurysm of the popliteal artery rupture?]. / Wie oft rupturiert das Aneurysma der Arteria poplitea?

Rupture of a popliteal artery aneurysm is an unusual complication and did occur six times in our series of 252 popliteal artery aneurysms that underwent operative repair from January 1965 to December 1991. Rupture while equally serious as thrombosis of the popliteal artery aneurysm of distal embolization from the aneurysm, is reported as an exceedingly unusual complication. Reported incidence of rupture is less than 2 to 4 percent in most large series and was 2.4 percent in the present series.

[The ilio-caval confluence syndrome]. / Le syndrome de la confluence ilio-cave.

UNLABELLED: The venous confluence syndrome is the clinical consequence of the flows obstruction which are the main tributary of the deep venous system. The cava confluence syndrome is different from the aortic obstruction at the level of its bifurcation. Its causes are congenital abnormality, extrinsic, intrinsic and intramural compression. CLINICAL PICTURE: collaterization of the int. vertebral plexus of the Azigos and hemiozygos veins as well as episgastric and thoracic veins, in chronic cases. On the other hand, in acute cases, significant renal insufficiency, ascites and bilateral phlegmasia caerulea make up the clinical picture. In acute stage, surgery requires thrombectomy and endovascular prothesis whereas in chronic stage, surgery will tend to remove the cause with only a palliative action on external symptoms. In both cases, abnormalities bring about a surgical issue.

[Rupture of the patellar ligament of the tibial tuberosity as a complication after cruciate ligament-plasty]. / Ausriss des Ligamentum patellae an der Tuberositas tibiae als Komplikation nach Kreuzbandersatzplastik.

We report a complication of a rupture of the patellar ligament at the tibial tuberositas following autologous cruciate ligament reconstruction. To our knowledge, this complication has not yet been described.

Carcinoid tumors of the appendix.

OBJECTIVE: A retrospective study of 41 patients with histologically confirmed diagnosis of appendix carcinoid tumors was undertaken by reviewing the surgical records at Massachusetts General Hospital. METHODS: There were 8 male and 33 female patients (mean age 32 years). Twenty-two patients (54%) presented with signs and symptoms suggestive of acute appendicitis. In 19 patients (46%) the lesions were discovered incidentally. The tumors were located in 32 patients at the tip, in 6 patients in the middle third, and in 3 patients at the base of the appendix. The tumor was less than 1 cm in diameter in 32 patients, between 1 and 2 cm in 7 patients, and was bigger than 2 cm in 2 patients. In 29 patients, the depth of tumor penetration was confined to the submucosa or to the muscle layers of the appendix, and in 8 patients the serosa was involved. In 4 patients, evidence of tumor extension into the meso-appendicular fat was present, including one patient with a tumor bigger than 2 cm and local lymph-node metastases. Forty patients underwent appendectomy alone. One patient with a tumor size bigger than 2 cm in diameter with positive lymph nodes in the mesoappendix underwent secondary right hemicolectomy. Complete follow-up was achieved in 35 patients, and all patients remained free of tumor recurrence. CONCLUSIONS: The authors conclude that appendiceal carcinoids are rare and most often are asymptomatic. Tumors of less than 1 cm are adequately managed by appendectomy alone. The appropriate treatment for tumors of 1 to 2 cm continues to be controversial. Right hemicolectomy is recommended for all tumors larger than 2 cm, whereas preference for an aggressive approach should be given in young patients.

Randomized comparative trial of imipenem/cilastatin versus aminoglycoside plus amoxycillin plus clindamycin in the treatment of severe intra- and post-operative infections.

In a prospective, randomized, controlled study, clinical and bacteriological efficacy of imipenem/cilastatin (I/C) was compared with a standard combination of aminoglycoside + amoxycillin + clindamycin (C) in patients (pts) with severe intra- and postoperative infections. A total of 84 pts were randomly separated into two groups of 42 pts. Diagnoses were pneumonia n = 21 (14 in I/C group and 7 in C), peritonitis n = 45 (16 in I/C group and 29 in C), septicaemia n = 12 (9 in I/C group and 3 in C), and 7 other infections (3 in I/C group and 4 in C). Doses used were imipenem/cilastatin 1 g q 8 h and amoxycillin 2 g q 8 h plus clindamycin 0.6 g q 6 h, plus netilmicin according to serum concentrations. Success rates were 85.4% (n = 35: 34 cured and one improved) in the I/C group and 83.3% (n = 35: 30 cured and five improved) in the C group. Six pts in group I/C and 7 in group C failed to respond to treatment. One patient in the I/C group was not assessable. 62% of the bacterial isolates were eradicated in the I/C group and 55% in group C. 7% were suppressed in I/C and 5% in C. It is concluded that imipenem/cilastatin is an effective and well-tolerated alternative to antibiotic combinations in severe intra- and post-operative infections. It offers the advantages of fewer drug doses and less renunciation of serum drug concentration monitoring.