[Gunshot or blast injuries of the hand. Principles of treatment]

Gunshot injuries to the hand are rare in Central Europe. As a result of their special trauma morphology they are a serious threat to the functional integrity of the hand and often lead to a loss of function which can be associated with a permanent unfitness to work or disability. Blast injuries to the hand are more common in this part of the world and are usually caused by the inappropriate use of fireworks. This trauma entity is associated with a number of special kinetic features and effects which have therapeutic consequences and should therefore be discussed separately. As a result of the low incidence of these specific types of injuries in times of peace, experience-based expertise is unlikely to be available. The management of gunshot injuries to the hand is a particular challenge to hand surgeons who must have specialist knowledge and skills in order to achieve an optimum outcome. This applies even more so to the treatment of blast injuries to the hand which are associated with far more complex injury patterns. As a rule blast injuries are associated with a high risk of complications and require a rapid assessment and rigorous management of all damaged structures similar to approaches used for infections of the hand. Illustrated by several cases which have been treated at our institution the basic aspects of the development and morphology of these injuries are discussed as well as different treatment options, algorithms and possible treatment outcomes.

[Reccurent reflux … and other problems following fundoplication: indication for re-operation]

BACKGROUND

Early function diagnostics and problem-oriented management are basic requirements in cases of functional problems and complications following antireflux surgery for gastroesophageal reflux disease (GERD). HISTORY, DIAGNOSTICS, AND THERAPEUTIC MANAGEMENT: A detailed history with a focus on the development of symptoms before and after the initial antireflux operation are fundamental prerequisites for a good diagnostic work-up. The data of preoperative function tests should always be reconsidered when re-evaluating a patient and be compared to the current findings. Thus, an analysis of the indications of any previous antireflux operation and an analysis of potential new or aggravated functional defects are essential. The general criteria indicating an operative procedure in gastroesophageal reflux disease do not change following such operation. Beyond these, symptomatic functional disorders caused by an antireflux operation may represent a new indication for an operative revision. INDICATION FOR RE-OPERATION: In the case of a symptomatic reflux recurrence, three essential criteria indicate an operative procedure: (i) a progressive type of GERD (proven functional defects, hiatal hernia, presence of typical reflux symptoms, necessity of increasing PPI dosage), (ii) non acid-dependent symptoms in spite of adequate medication (aspiration, volume reflux, pulmonary symptoms) and (iii) an alternative to medical therapy (preference, dependence, side effects, quality of life). In addition to these, symptomatic mechanical problems are important additional criteria for a redo procedure: the dissolution of the fundoplication wrap, the telescope-like slippage of the fundoplication around the proximal stomach ("slipped Nissen"), a paraesophageal herniation, and the transhiatal migration of an intact fundoplication. Finally, the rather seldom occurring wrong construction of the fundoplication and a not detected primary motility disorder (e. g., achalasia) are indications for redo surgery in most cases.

CONCLUSION

The decision for any redo surgery following antireflux operations should always be based on a sound balance between symptomatic impairment and objective findings in functional disorders. This analysis allows for a responsible decision process since any redo surgery holds the risk of a lower success rate than the initial operation.

Classical HLA-DRB1 and DPB1 alleles account for HLA associations with primary biliary cirrhosis

Susceptibility to primary biliary cirrhosis (PBC) is strongly associated with HLA region polymorphisms. To determine if associations can be explained by classical HLA determinants we studied Italian 676 cases and 1440 controls with genotyped with dense single nucleotide polymorphisms (SNPs) for which classical HLA alleles and amino acids were imputed. Although previous genome-wide association studies and our results show stronger SNP associations near DQB1, we demonstrate that the HLA signals can be attributed to classical DRB1 and DPB1 genes. Strong support for the predominant role of DRB1 is provided by our conditional analyses. We also demonstrate an independent association of DPB1. Specific HLA-DRB1 genes (*08, *11 and *14) account for most of the DRB1 association signal. Consistent with previous studies, DRB1*08 (p = 1.59 × 10⁻¹¹) was the strongest predisposing allele where as DRB1*11 (p = 1.42 × 10⁻¹⁰) was protective. Additionally DRB1*14 and the DPB1 association (DPB1*03:01) (p = 9.18 × 10⁻⁷) were predisposing risk alleles. No signal was observed in the HLA class 1 or class 3 regions. These findings better define the association of PBC with HLA and specifically support the role of classical HLA-DRB1 and DPB1 genes and alleles in susceptibility to PBC.

Identification of germline susceptibility loci in ETV6-RUNX1-rearranged childhood acute lymphoblastic leukemia

Acute lymphoblastic leukemia (ALL) is a malignant disease of the white blood cells. The etiology of ALL is believed to be multifactorial and likely to involve an interplay of environmental and genetic variables. We performed a genome-wide association study of 355 750 single-nucleotide polymorphisms (SNPs) in 474 controls and 419 childhood ALL cases characterized by a t(12;21)(p13;q22) - the most common chromosomal translocation observed in childhood ALL - which leads to an ETV6-RUNX1 gene fusion. The eight most strongly associated SNPs were followed-up in 951 ETV6-RUNX1-positive cases and 3061 controls from Germany/Austria and Italy, respectively. We identified a novel, genome-wide significant risk locus at 3q28 (TP63, rs17505102, P(CMH)=8.94 × 10(-9), OR=0.65). The separate analysis of the combined German/Austrian sample only, revealed additional genome-wide significant associations at 11q11 (OR8U8, rs1945213, P=9.14 × 10(-11), OR=0.69) and 8p21.3 (near INTS10, rs920590, P=6.12 × 10(-9), OR=1.36). These associations and another association at 11p11.2 (PTPRJ, rs3942852, P=4.95 × 10(-7), OR=0.72) remained significant in the German/Austrian replication panel after correction for multiple testing. Our findings demonstrate that germline genetic variation can specifically contribute to the risk of ETV6-RUNX1-positive childhood ALL. The identification of TP63 and PTPRJ as susceptibility genes emphasize the role of the TP53 gene family and the importance of proteins regulating cellular processes in connection with tumorigenesis.

[Formation of centers in general and abdominal surgery -- necessity or trend?]

The introduction of the DRG (diagnosis-related groups) system as basis for reimbursement in the German health-care system has led to a mentality of quality orientation and verification of therapeutic results. An immediate result was the formation of medical "centres" on rather different levels and consequently the inauguration of institutions, authorities, and organisations to review these centres. Finally, a range of certifications was installed in order to stratify the rather diverse aims of different centres. This review critically evaluates the current situation in the field of general and abdominal surgery in Germany.

Association of inflammatory bowel disease risk loci with sarcoidosis, and its acute and chronic subphenotypes

Sarcoidosis is a complex granulomatous inflammatory disorder that shares several clinical and pathogenic features with inflammatory bowel disease (IBD). Postulating a common genetic basis of inflammatory diseases, we tested 106 single-nucleotide polymorphisms (SNPs) that are known or have been suggested to be associated with IBD for a potential association with sarcoidosis and its acute and chronic subphenotypes. We genotyped 1,996 German sarcoidosis patients, comprising 648 acutely and 1,161 chronically affected individuals, 2,622 control subjects, and 342 German trios with affected offspring using SNPlex™ technology. The nonsynonymous SNP rs11209026 (Arg381Gln) in the interleukin (IL)-23 receptor (IL23R) gene was associated with chronic sarcoidosis (OR 0.63; p = 5.58×10(-5)), which was supported by the result of a transmission disequilibrium test analysis in the independent family sample (OR 0.50; p = 0.031). Marker rs12035082 located at chromosome 1q24.3 was found to be associated with the acute subphenotype (OR 1.36; p = 6.80×10(-7)) and rs916977 (HERC2 locus; OR 1.30; p = 4.49×10(-5)) was associated with sarcoidosis. Our results highlight the potential importance of the IL-23 signalling pathway for the development of chronic sarcoidosis. The finding links sarcoidosis pathogenesis to other inflammatory conditions and may contribute to new hypotheses on disease mechanisms.

Genetic association of DLG5 R30Q with familial and sporadic inflammatory bowel disease in men

BACKGROUND

The association of DLG5 R30Q with IBD has been replicated in several populations, but is not statistically significant in others. We studied the incidence of DLG5 alleles in a population of IBD patients from Pennsylvania.

METHODS

DLG5 R30Q (rs1248696) and G1066G (rs1248634) were analyzed with PCR-based RFLP methods in a total of 521 subjects, that included 105 individuals with IBD and 139 without IBD from a familial IBD registry, 107 with sporadic IBD, and 170 unrelated healthy controls. R30Q was further analyzed with SNPlex Genotyping System in 473 samples.

RESULTS

RFLP genotyping data showed that, DLG5 R30Q was significantly associated with IBD overall (p=0.006), and separately with CD (p=0.009) and UC (p=0.024). The association of R30Q with IBD was entirely due to a male-associated effect (male vs female p=0.015 vs 0.241 (IBD), p=0.024 vs 0.190 (CD), and p=0.019 vs 0.575 (UC)). The frequency of the A allele carriage was elevated in both affected and unaffected members in the familial IBD cohort compared to healthy controls (p=0.037). In the family pedigrees, we observed differences in the expression of IBD in individuals carrying the A allele between families.

CONCLUSIONS

In the studied population, DLG5 R30Q was associated with all forms of IBD. An elevated presence of the R30Q variant was observed in all members of a familial IBD registry. This association of the R30Q variant with IBD was male-specific.

NOD1 gene polymorphisms in relation to aggressive periodontitis

BACKGROUND

NOD proteins are part of innate immunity mechanisms. They play a role in epithelial barrier functions and inflammatory responses to bacteria. Single nucleotide polymorphisms (SNPs) in the NOD1 gene have proven to be associated with inflammatory bowel disease (IBD) and asthma.

OBJECTIVE

To investigate SNPs in the NOD1 gene in relation to aggressive periodontitis (AgP), a multifactorial, inflammatory disease of the supporting tissues of the teeth.

MATERIALS AND METHODS

Five SNPs in the NOD1 gene (4 intronic and 1 exonic) were tested for association in a total of 415 AgP patients and 874 controls both of Northern European ancestry.

RESULTS

The frequencies of the rare SNP alleles ranged between 21% and 26% among cases, and 20-27% among controls, and were not statistically different between cases and controls. Two SNPs were in strong linkage disequilibrium (r(2) = 0.97 in cases and 0.94 in controls). The overall haplotype distributions did not differ between cases and controls. We observed 8 haplotypes with a frequency of >or=1% among cases and/or controls, but none of these haplotype frequencies differed significantly among cases and controls. Logistic regression analyses with adjustment for gender and smoking status did not reveal significant associations with AgP for any of the 5 SNPs. This study had a power of >or=95% to detect associations with variants carrying relative risks of >or=1.5 for heterozygote carriers and >or=2.25 for homozygote carriers.

CONCLUSIONS

Although SNPs in the NOD1 gene have been strongly associated with cases of IBD, the current study failed to show an association of NOD1 SNPs with AgP.

Phase I dose escalation study of continuous oral dosing of OSI-906, an insulin like growth factor-1 receptor (IGF-1R) tyrosine kinase inhibitor, in patients with advanced solid tumors

2559

Background: OSI-906 is a potent small molecule inhibitor of IGF-1R, a receptor tyrosine kinase activated by insulin like growth factor, which is overexpressed in numerous malignancies and implicated in resistance to chemotherapy. Methods: Patients with advanced cancer entered escalating dose cohorts of OSI-906. Study objectives included assessment of: safety; determination of MTD; pharmacokinetics (PK), pharmacodynamics (PD) including IGF-1R levels in peripheral blood cells; and tumor response (RECIST). Results: To date, 32 pts have been treated (22M/10F, median age 62y) at 10, 20, 40, 75, 150, and 300 mg QD and at 20, 40 mg and 75 mg BID. Median number of weeks on trial was 6 (range 0–44). No DLTs have been observed. Hyperglycemia (5/20 pts) related to OSI-906 was transient and mild (grade 1 only). In addition to hyperglycemia, grade 1–2 nausea and vomiting (5/20 pts) were the most frequent related adverse events (AEs). There was grade 3 elevated lipase in 1 pt. At doses of 10–150 mg, OSI-906 exhibited linear PK, median terminal t1/2 ranged from 2.18–4.30 hr, AUC0-inf from 284–10200 ng.hr/mL, and Cmax 76.6–1440 ng/mL. There was no relationship between glucose or insulin levels and OSI-906 plasma concentrations. Stable disease > 12 weeks was seen in 7/20 pts (range 12–34 weeks), including 1 pt each with thymic (27 w), adrenocortical (28w), and colorectal (34w) cancer. PD data on IGF-1R phosphorylation will be presented. Conclusions: Plasma concentrations of OSI-906 achieved in this trial exceed concentrations required for antitumor efficacy in preclinical models. PD target modulation and preliminary anti-tumor activity have been observed. It is interesting to note that clinically meaningful hyperglycemia has yet to occur. Minimal toxicity was observed and further dose escalation is in progress.

[Table: see text]

Association of UCP2 -866 G/A polymorphism with chronic inflammatory diseases

We reported earlier that two mitochondrial gene polymorphisms, UCP2 -866 G/A (rs659366) and mtDNA nt13708 G/A (rs28359178), are associated with multiple sclerosis (MS). Here we aim to investigate whether these functional polymorphisms contribute to other eight chronic inflammatory diseases, including rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Wegener' granulomatosis (WG), Churg-Strauss syndrome (CSS), Crohn's disease (CD), ulcerative colitis (UC), primary sclerosing cholangitis (PSC) and psoriasis. Compared with individual control panels, the UCP2 -866 G/A polymorphism was associated with RA and SLE, and the mtDNA nt13708 G/A polymorphism with RA. Compared with combined controls, the UCP2 -866 G/A polymorphism was associated with SLE, WG, CD and UC. When all eight disease panels and the original MS panel were combined in a meta-analysis, the UCP2 was associated with chronic inflammatory diseases in terms of either alleles (odds ratio (OR)=0.91, 95% confidence interval (95% CI): 0.86-0.96), P=0.0003) or genotypes (OR=0.88, (95% CI: 0.82-0.95), P=0.0008), with the -866A allele associated with a decreased risk to diseases. As the -866A allele increases gene expression, our findings suggest a protective role of the UCP2 protein in chronic inflammatory diseases.

How general practitioners manage patients with irritable bowel syndrome. Data from a German urban area

Irritable bowel syndrome (IBS) is a common functional disorder in the general Western population. The majority of patients with IBS are managed by general practitioners (GP). Therefore, it is very important that GP are well trained in the approach to functional gastrointestinal disorders. There is the impression that the knowledge of diagnostic IBS criteria may be deficient in GPs. The present study is a survey of the knowledge and management of general practitioners in Germany regarding IBS.

METHODS

All general practitioners (n=260) of an urban area with about 600,000 inhibitants were asked by mail to complete a multiple choice questionnaire concerning their knowledge on IBS and their management of IBS patients.

RESULTS

A completed questionnaire was returned by 121 of the general practitioners (46.5% response rate). The majority of the responders were male (61%) and had an experience exceeding 10 years (75%). IBS was regarded as a functional disorder by 55% (49% as a motility disorder and 66% as a psychic disorder). The diagnosis of IBS was mainly based on the patient's history, a colonoscopy was considered by 57%. Diagnostic criteria for IBS were used only by 22 GPs (18%). Referral to gastroenterologists was initiated by 26% of the GPs in all patients with suspected IBS. The majority referred patients only in case of unclear diagnosis or insufficient therapeutic results. Medical therapy was prescribed by 96% of the GPs. Psychotherapy and alternative therapies were additionally performed by 55% and 61%, respectively. The majority of the GPs (66%) estimated the percentage of IBS patients in their daily routine between 1 and 10% and stated that they have seen 1 to 5 patients during the past week.

CONCLUSIONS

Diagnostic IBS criteria such as Rome criteria are largely unknown among GPs in our area. Pathogenetic models of IBS are deficiently known in GPs. It is likely that the minority of patients who are referred to gastroenterologists have special problems. Their management should probably be different from that of the unreferred majority. Many therapeutic modalities in primary care have no medical evidence. Further studies on therapy options in IBS should also be made in primary care.

The role of intracardiac echocardiography in interventional electrophysiology

Visualization of the cardiac anatomy becomes more and more important as the complexity of interventions increases. Intracardiac echocardiography (ICE) provides good depiction of cardiac soft tissue structures and has become an important tool in today's cardiology. It has been shown to be valuable during many ablation procedures for supraventricular and ventricular arrhythmias. ICE has been used for monitoring catheter placement, observing catheter-tissue contact and lesion formation as well as titrating ablation energy. The rate of complications could be reduced, outcome of procedures improved and radiation exposure decreased. Even more, new therapy strategies have been evaluated based on ICE and it has also been used in the setting of three- dimensional imaging and image integration.

A pragmatic randomized controlled trial on the effectiveness of low concentrated saline spa water baths followed by ultraviolet B (UVB) compared to UVB only in moderate to severe psoriasis

OBJECTIVE

To evaluate whether low concentrated saline spa water baths followed by ultraviolet B (LC-SSW-UVB) are superior to UVB alone in moderate to severe psoriasis.

BACKGROUND

There is a lack of sufficiently large randomized controlled clinical trial evaluating the additional benefit of saltwater baths followed by UVB compared to UVB only in psoriasis.

STUDY DESIGN

Partly evaluator blind, multicentre, pragmatic, randomized controlled trial.

SETTING

Five German spa centres.

SUBJECTS

One hundred and forty-three adults with stable psoriasis during the last month and a Psoriasis Area and Severity Index (PASI) of > 10 and/or an affected body surface area of > 15%.

INTERVENTIONS

LC-SSW-UVB or UVB thrice a week until remission (PASI < 5) or for a maximum of 6 weeks. Sodium chloride concentrations of natural springs varied between 4.5% and 12%. Conventional UVB (broadband UVB or selective UVB phototherapy) was used as irradiation source.

MAIN OUTCOME

Reduction of PASI and/or affected body surface area of 50% at the end of the intervention period (PASI-50). Only participants receiving at least one intervention were included in the primary analysis.

RESULTS

Patients allocated to LC-SSP-UVB attained a statistically significantly higher rate of PASI-50 at the end of the intervention period than patients allocated to UVB [58/79 (73%) vs. 32/64 (50%); P = 0.01; NNT, 4.3, 95% CI, 2.4-18.1]. Benefit persisted until 3 months only for one of two secondary outcomes considered.

CONCLUSIONS

In routine clinical practice balneophototherapy using conventional UVB is superior to conventional UVB only at the end of a 6-week treatment course.

Empfehlungen zur Anorektalen Manometrie im Erwachsenenalter

This document contains the guidelines of the German Societies of Neurogastroenterology and Motility, Gastroenterology (committee for proctology), Abdominal Surgery (coloproctology working group), and Coloproctology for anorectal manometry in adults. Recommendations are given about technical notes, study preparation (equipment; patient), technique for performing manometry and data analysis, reproducibility, and indications. Minimum standards for anorectal manometry are measurement of resting and squeeze pressure, testing of rectoanal inhibitory reflex, determination of rectal sensation (first perception and urge), and calculation of rectal compliance. Anorectal manometry is indicated in patients with fecal incontinence and constipation in the context of a structured programme.

Good manufacturing practice-compliant validation and preparation of BM cells for the therapy of acute myocardial infarction

BACKGROUND

Intracoronary application of BM-derived cells for the treatment of acute myocardial infarction (AMI) is currently being studied intensively. Simultaneously, strict legal requirements surround the production of cells for clinical studies. Thus good manufacturing practice (GMP)-compliant collection and preparation of BM for patients with AMI was established by the Cytonet group.

METHODS

As well as fulfillment of standard GMP requirements, including a manufacturing license, validation of the preparation process and the final product was performed. Whole blood (n=6) and BM (n=3) validation samples were processed under GMP conditions by gelafundin or hydroxyethylstarch sedimentation in order to reduce erythrocytes/platelets and volume and to achieve specifications defined in advance. Special attention was paid to the free potassium (<6 mmol/L), some rheologically relevant cellular characteristics (hematocrit <0.45, platelets <450 x 10(6)/mL) and the sterility of the final product.

RESULTS

The data were reviewed and GMP compliance was confirmed by the German authorities (Paul-Ehrlich Institute). Forty-five BM cell preparations for clinical use were carried out following the validated methodology and standards. Additionally three selections of CD34+ BM cells for infusion were performed. All specification limits were met. Discussion In conclusion, preparation of BM cells for intracoronary application is feasible under GMP conditions. As the results of sterility testing may not be available at the time of intracoronary application, the highest possible standards to avoid bacterial and other contaminations have to be applied. The increased expense of the GMP-compliant process can be justified by higher safety for patients and better control of the final product.

Bi-weekly dosing preserves the efficacy of rituximab in elderly patients with poor-prognosis DLBCL: Results from the RICOVER-60 trial of the German High-Grade Non-Hodgkin Lymphoma Study group (DSHNHL)

7536

Background: The addition of rituximab (R) to 3-weekly CHOP-21 improved overall results in elderly patients with DLBCL, but was more effective in good-prognosis (g-p: IPI = 1,2) than poor-prognosis (p-p: IPI = 3,4,5) patients (JCO 23:4117, 2005). Similarly, addition of R to bi-weekly CHOP-14 in the RICOVER-60 trial resulted in improved time to treatment failure (TTF) in 828 elderly (61–80 years) DLBCL patients (Blood 106:9a, 2005). To study the effects of R when combined with CHOP-14 in different subgroups of elderly DLBCL patients. Methods: Intention-to-treat-analysis of the primary endpoint time-to-treatment-failure (TTF) and the secondary endpoint overall survival (OS) in the subgroup of g-p and p-p patients treated within the RICOVER trial which compared 6 and 8 cycles of CHOP-14, both with and without R. Results: Of 828 evaluable patients (61–80 years, stage I-IV), 503 had g-p (CHOP-14 = 252; R-CHOP-14 = 251) and 325 p-p (CHOP-14 = 161; R-CHOP-14 = 163). After a median observation of 26 months, there was no difference between 6 and 8 cycles in either subgroup. In contrast, addition of R resulted in a similar improvement of TTF in both g-p (67% vs. 81%, p = 0.001) and p-p (36% vs. 52%, p = 0.004) patients. The improvement of survival is not yet different in either group: g-p: 82% (CHOP-14) vs. 88% (R-CHOP-14), p = 0.458; p-p: 58% (CHOP-14) vs. 64% (R-CHOP-14), p = 0.146. Pharmacokinetic studies show a pronounced nadir of R levels after the first R-CHOP-14, with R levels increasing after each subsequent cycle. The R nadir after the first R-CHOP is expected to be even more pronounced in a 3-weekly schedule and might explain the small improvement reproted for 3-weekly R in elderly patients with p-p DLBCL. Conclusions: Our subgroup and pharmacokinetic analysis indicate that not only dose-dense chemotherapy, but also dose-dense rituximab contribute to the excellent results of the RICOVER-60 trial. Supported by Deutsche Krebshilfe.

[Table: see text]

Diabetes insipidus due to herpes encephalitis in a patient with diffuse large cell lymphoma. A case report

The major causes of central diabetes insipidus are neoplastic or infiltrative lesions of the hypothalamus or pituitary, severe head injuries and pituitary or hypothalamic surgery. Central diabetes insipidus caused by viral infections has been rarely reported in immunosuppressed patients, such as those with acquired immunodeficiency syndrome or Cushing's syndrome. We report the case of a 48-year-old woman suffering from diffuse large cell lymphoma, who developed hypotonic polyuria, hypernatriaemia and somnolence after the first course of chemotherapy with CHOEP and rituximab. Diabetes insipidus was diagnosed by low urine osmolarity and an undetectable vasopressin concentration. MRI revealed no pituitary abnormalities but encephalitis, and lumbar punction confirmed herpes zoster infection. To the best of our knowledge this is the first description of central diabetes insipidus in a lymphoma patient caused by an opportunistic CNS-infection.

Increased risk of venous thromboembolism in patients with acute leukaemia

Patients with malignancies have an increased risk for venous thromboembolisms (VTE), but data on patients with acute leukaemia are very limited so far. We found VTE in 12% of 455 patients with acute leukaemia, half of which occurred in association with central venous catheters, with equal risk of ALL and AML.

Analysis of myocardial deformation based on pixel tracking in two dimensional echocardiographic images enables quantitative assessment of regional left ventricular function

OBJECTIVE

To evaluate whether myocardial strain and strain rate calculated from two dimensional echocardiography by automatic frame-by-frame tracking of natural acoustic markers enables objective description of regional left ventricular (LV) function.

METHODS

In 64 patients parasternal two dimensional echocardiographic views at the apical, mid-ventricular and basal levels were obtained. An automatic frame-by-frame tracking system of natural acoustic echocardiographic markers was used to calculate radial strain, circumferential strain, radial strain rate and circumferential strain rate for each LV segment in a 16 segment model. Cardiac magnetic resonance imaging (cMRI) was performed to define segmental LV function as normokinetic, hypokinetic or akinetic.

RESULTS

Image quality was sufficient for adequate strain and strain-rate analysis from two dimensional echocardiographic images obtained from parasternal views in 88% of segments. Obtained radial strain data were highly reproducible and analysis was affected by only small intraobserver (mean 4.4 (SD 1.6)%) and interobserver variabilities (7.3 (2.5)%). Each of the analysed strain and strain-rate parameters was significantly different between segments defined as normokinetic, hypokinetic or akinetic by cMRI (radial strain 36.8 (10.5)%, 24.1 (7.5)% and 13.4 (4.8)%, respectively, p < 0.001). Peak systolic radial strain enabled detection of hypokinesis or akinesis with a sensitivity of 83.5% and a specificity of 83.5% (cut off value 29.1%, receiver operating characteristic (ROC) curve area 0.905, 95% CI 0.883 to 0.923). Peak systolic radial strain analysis also enabled detection of akinesis versus hypokinesis with a sensitivity of 82.7% and a specificity of 94.5% (cut off value 21.0%, ROC curve area 0.946). Peak systolic radial strain-rate analysis was less accurate than peak systolic radial strain analysis to detect cMRI-defined segmental function abnormalities. The accuracy of peak systolic circumferential strain and strain rate was similar to that of corresponding radial parameters.

CONCLUSIONS

Frame-by-frame tracking of acoustic markers in two dimensional echocardiographic images enables accurate analysis of regional systolic LV function.

Long-Term Remission in a Patient with Carcinoma of Unknown Primary Site

BACKGROUND

Cancer of unknown primary site also designated as CUP syndrome usually presents as metastatic disease with a poor prognosis and low remission as well as survival rates.

CASE

We report a 46-year-old male with para-aortal and left-sided cervical lymph node metastases. Histological examination of a cervical lymph node revealed papillary carcinoma. Despite thorough investigation, no primary tumor was found. The patient was empirically treated with six courses of the FACP regimen (5-fluorouracil, Adriamycin, cyclophosphamide and cisplatin) combined with radiotherapy (40 Gy) and has remained in complete remission for 124 months.

CONCLUSION

This case indicates that treatment of a patient with cancer of unknown primary site may be rewarded by a benign course. However, complete cure remains a very rare event in CUP. Remission can be achieved with a platinum-containing regimen combined with radiotherapy.

A rare but life-threatening complication of ventriculo-atrial shunt

Insertion of ventriculoperitoneal and ventriculoatrial shunts is routinely performed. Infarction pneumonia and atrial thrombus formation are described as very rare complications of ventriculoatrial shunts. We present the case of a female patient with ventriculoatrial shunt insertion as long term treatment for aequeductal stenosis who presented with recurrent episodes of dyspnoea, chest pain, and unilateral pleural effusion. Diagnostic evaluation revealed a positive D-dimer test, bilateral basal infiltrates and pleural effusion. Transesophageal echocardiography established the diagnosis of a thrombus in the right atrium. Laboratory testing for thrombophilia revealed a homozygous factor V Leiden mutation. In the following, a shunt revision was performed.