[Increase in extrapulmonary tuberculosis in The Netherlands associated with an increase in the number of residents with non-Dutch nationality; observational study of data from 1993-2001]

OBJECTIVE

To describe the epidemiology of extrapulmonary and pulmonary tuberculosis (TB) in The Netherlands between 1993 and 2001, with special attention given to the relationship between disease site and patient nationality.

DESIGN

Retrospective descriptive and comparative study.

METHOD

Data were collected from all patients diagnosed with TB and entered in The Netherlands Tuberculosis Register between 1 January 1993 and 31 December 2001. Information on age, sex, nationality, year of diagnosis, culture result, disease site and HIV status was retrieved and compared.

RESULTS

Of the total 13,258 TB patients, 8,216 (62%) had pulmonary TB and 5,042 (38%) had extrapulmonary TB. The proportion of extrapulmonary TB cases increased during the study period. The most common types of extrapulmonary TB were lymphatic TB, pleural TB and TB of the bones and/or joints. Patients with a non-Dutch nationality were diagnosed with extrapulmonary TB more often than Dutch patients.

CONCLUSION

The proportional increase in extrapulmonary TB was explained by an increase in the number of inhabitants with non-Western ethnic backgrounds in The Netherlands. Physicians must be aware of the changing clinical picture of TB.

Advanced cantilevers for magnetic force microscopy and high frequency magnetic force microscopy

In order to improve the spatial resolution achieved by magnetic force microscopy (MFM) technique and its derivatives, we employ here advanced MFM tips fabricated by means of focused ion beam (FIB) milling. The magnetic coating applied on these tips is a CoCr film of 10 nm thickness. The MFM measurements on hard disk test samples reveal the achieved high resolution, and the measurement on a garnet film demonstrates the low invasiveness. High-frequency MFM (HF-MFM) is a development of the MFM technique to observe the HF stray fields emerging from magnetic recording writer poles at their operating conditions. By means of HF-MFM, magnetic recording writer poles are characterized in the frequency range 100-1,000 MHz. Up to now, all HF-MFM experiments conducted were using standard MFM cantilevers. From the HF-MFM images obtained using the advanced MFM cantilevers, it is clearly seen that the spatial resolution is considerably improved over the images obtained using standard MFM tips. However, the 10 nm thick magnetic coating of the cantilevers is found to work properly only at frequencies of up to about 500 MHz.

Superconducting Interfaces Between Insulating Oxides

At interfaces between complex oxides, electronic systems with unusual electronic properties can be generated. We report on superconductivity in the electron gas formed at the interface between two insulating dielectric perovskite oxides, LaAlO3 and SrTiO3. The behavior of the electron gas is that of a two-dimensional superconductor, confined to a thin sheet at the interface. The superconducting transition temperature of congruent with 200 millikelvin provides a strict upper limit to the thickness of the superconducting layer of congruent with 10 nanometers.

Expression of the glycodelin A gene and the detection of its protein in tissues and serum of ovarian carcinoma patients

BACKGROUND

Glycodelin A (GdA), also known as placental protein 14 (PP14), has been detected in endometrial, cervical and ovarian carcinoma cells. It is suspected to be a marker of human ovarian cancer tissues.

MATERIALS AND METHODS

We investigated serum, tissue and cyst fluid samples of patients with an ovarian carcinoma in contrast to patients with benign and malignant diseases such as uterine myoma, endometriosis, cervical, uterine and breast cancer, and metastases of bladder and colon carcinoma. Used methods were enzyme-immunoassay, immunohistochemistry (IHC) and polymerase chain reaction (PCR).

RESULTS

In 81% of the control group the GdA-expression was negative, which was confirmed by IHC and PCR. Of the ovarian carcinoma group only 52% showed correspondence between IHC and PCR.

CONCLUSION

These results indicate that determination of GdA is not sensitive or specific enough for use as a tumour marker.

B-cell depletion in patients with rheumatoid arthritis refractant to multiple TNF blockers and the interleukin 1 receptor-antagonist anakinra

To evaluate the efficacy of Rituximab in a negatively selected patient cohort, with inadequate response to different disease modifying drugs (DMARDs) and to at least two biologicals. Fifteen patients with severe rheumatoid arthritis with inefficacy of an average of 5 DMARDS and 2.5 TNF antagonists were treated with Rituximab. Eight patients were ineffectively pretreated with Anakinra as well. The disease activity score (DAS28) and the morning stiffness served for assessment of the clinical response. For maintenance treatment different conventional DMARDs were used (4xMTX, 4xLeflunomide, 1xmycophenolate, 1xsirolimus, 1xhydroxychloroquine). At baseline visit the mean DAS 28 was 5.9. The mean duration of morning stiffness was 99.6 min. At month 6 the mean DAS28 was 3.95. Forty percent (6 patients) showed a good and 33% (5 patients) a moderate response. Morning stiffness improved to 43 min. In this negatively selected group of patients Rituximab was safe and effective.

Eight versus 16-week re-evaluation period in rheumatoid arthritis patients treated with leflunomide or methotrexate accompanied by moderate dose prednisone

In a step-up approach of DMARD treatment of RA a fast response and an early DMARD switch in the case of non-response is important. Therefore, we performed an open trial in which we compared an 8-week and a 16-week observation period during treatment of RA with MTX or LEF, both given in intensified starting doses and accompanied by moderate dose prednisone. MTX and LEF naïve patients with RA (mean time since diagnosis: 2.3 years) were randomised to receive either LEF in a 3-day-loading dose of 100 mg/day followed by 20 mg/day (n = 19) or MTX intramuscularly in a dose of 25 mg once weekly (n = 21). All patients received concomitant treatment with oral prednisone in an initial dose of 20 mg/day with weekly dose reductions of 5 mg/day. The disease activity was re-evaluated 8 and 16 weeks after the start of the treatment. Mean DAS28 before the start of treatment was 5.36 +/- 0.8 for the MTX-group and 5.46 +/- 0.8 for the LEF-group. After 8 weeks of treatment the DAS28 in the MTX-group was 2.59 +/- 1.0 and 3.16 +/- 0.8 in the LEF group (difference not significant). The mean DAS28 at re-evaluation 16 weeks after the starting of treatment (2.58 +/- 1.5 for the MTX-group and 3.25 +/- 1.16 for the LEF-group) was significantly different neither in between the both treatment groups nor in comparison to the week 8 evaluation. Efficiency of RA treatment with MTX or LEF in intensified doses and in combination with moderate dose prednisone can be sufficiently judged 8 weeks after its initiation.

Pattern formation in nanoporous titania templates

We have carried out a systematic investigation into the formation of nanoscaled patterns in titania (TiO2) templates under dc anodization of Ti in HF acid. At lower acid concentrations (around 0.5 wt% HF) either pores or tubes form at the surface of anodized titanium foil. The pores or nanotubes are separated from the bottom Ti layer by a thin barrier layer of TiO2. The critical voltage where the transition from pores to tubes occurs has been determined. It is observed that the transition voltage shift towards higher voltages as acid concentration is increased, with pore formation disappearing altogether at high acid concentrations. We have also carried out a systematic investigation into the dependence of pore and tube parameters on the applied dc anodization voltage. Our results indicate that the barrier layer thickness, pore and tube length increase as a function of applied voltage.

[Long-term locally-recurrent melanoma]

Malignant melanoma is a highly malignant skin tumor with a widely variable individual course. Currently, approximately 75% of German patients can be cured of malignant melanoma by early diagnosis and excision, while more than 20% die of distant metastases of the melanoma. In contrast, there are single cases of long-term locally recurrent melanomas with neither complete cure nor development of distant metastases. We report on a female patient with a nevus-associated melanoma who was treated in 1968 with X-ray radiation (Dermopan, 100 Gy) with curative intent. In the following 31 years, the patient developed four phases of in-transit and satellite metastases in a zosteriform pattern as well as ilioinguinal lymph node metastasis. Since 1999, the patient has been free of recurrence. Besides the unusual biological features of this case, this report reflects the changes of paradigms in the therapy of melanoma over the last forty years.

[Not all vocal cord failure following thyroid surgery is recurrent paresis due to damage during operation. Statement of the German Interdisciplinary Study Group on Intraoperative Neuromonitoring of Thyroid Surgery concerning recurring paresis due to intubation]

Since the phoniatrician H. Bauer described the first case of recurrent laryngeal nerve palsy most likely caused by intubation some 45 years ago, several case reports have been published. However, systematic analyses regarding the frequency of recurrent laryngeal nerve palsies due to intubation are scarce, and none of them has used the proper methods to demonstrate clearly that such a mechanism exists. Currently available data justify the assumption that not every recurrent laryngeal nerve palsy following thyroid surgery is due to the operation itself and that the damage caused by intubation, however, may only account for a minority of these cases. The differential diagnosis of postoperative recurrent laryngeal nerve palsy requires the use of specific tools which go beyond simple laryngoscopy and include stroboscopy as well as intra- and extralaryngeal electromyography. A partial palsy of recurrent laryngeal nerve due to intubation would be associated with severe dysphonia or aphonia, not with dyspnea because of the typical intermediate position of the paralyzed vocal folds with a normal electromyographic function of the cricothyroid muscle. The use of these methods to identify the nature of postoperative recurrent laryngeal nerve palsy is recommended in cases of regular intraoperative neuromonitoring but postoperatively impaired function of the vocal cords.

Zuverl�ssigkeit und Konsequenzen des intraoperativen Neuromonitorings in der Schilddr�senchirurgie

Intraoperative neuromonitoring (IONM) has yielded an increasing effect on thyroid surgery. During IONM, the recurrent laryngeal nerve is stimulated electrically and an acoustically transformed electromyographic signal is derived via either a needle electrode placed in the vocalis muscle or an electrode adjusted to the intubation tube. The IONM is used for identifying and predicting the function of the recurrent laryngeal nerve. Especially under difficult anatomic conditions, IONM has proven a valuable tool for identification of recurrent laryngeal nerves. This can lead to decreased occurrence of nerve palsy rates, as shown in numerous studies. The reliability of the IONM signal (defined as the correlation between intraoperative signal interpretation and postoperative vocal cord function) is reflected by a specificity as high as 98.2%, as shown by German multicenter studies. Thus, normal vocal cord function could be demonstrated postoperatively in over 98.2% of patients with intraoperatively unchanged neuromonitoring signals. If the neuromonitoring signal changed during operation, 39% of the patients suffered from transient vocal cord immobility and 12% had permanent loss of vocal cord function.

Intelligent training system integrated in an echocardiography simulator

Computer simulators play an important role in medical education. We have extended our simulator EchoComJ with an intelligent training system (ITS) to support trainees adjusting echocardiographic standard views. EchoComJ is an augmented reality application that combines real three-dimensional ultrasound data with a virtual heart model enabling one to simulate an echocardiographic examination. The ITS analyzes the image planes according to their position, orientation and the visualization of anatomical landmarks using fuzzy rules. An adaptive feedback is provided that colors the specific anatomic landmarks within the contours of the virtual model based on the quality of the image plane.

[Fibrosing mediastinitis: a rare cause of fever]

A 47-year-old woman was examined due to fever of unknown origin. She had been on holiday in Southeast Asia. Routine laboratory investigations confirmed the presence of inflammation. Serology for Hepatitis B virus, HIV, Borrelia, Cytomegalovirus, toxoplasmosis, lues, Epstein Barr virus, brucellosis, bartonellosis, histoplasmosis and auto-immune factors was negative. CT-scans of the chest and abdomen failed to reveal the cause. Finally, gallium-67 scintigraphy showed an increased uptake in the left mediastinum and the left side of the neck. This led to the discovery of an infraclavicular mass. On histological examination of the surgical excision biopsy the diagnosis 'fibrosing mediastinitis' was made. The patient was treated successfully with corticosteroids.

[The medical-psychiatric unit: added value for patients, physicians and hospitals]

Physical and mental illnesses commonly occur together. The quality of physical care in institutions for mental health in the Netherlands is not guaranteed. The cases of a 63-year-old woman with a schizoaffective disorder and diabetes mellitus who became delirious after surgery and a 76-year-old suicidal man with a psychotic disorder due to hydrocobalamine deficiency after major heart surgery show that the so-called medical-psychiatric unit, which is a part of the Psychiatric Department of a general hospital, may have several advantages in the treatment of combined physical and mental disorders. Both patients were admitted to such a unit. In this way, the internist of the first patient could continue to treat her and she could be treated with an infusion, urinary catheter and gastric intubation; in addition, laboratory investigations could be performed. The second patient, whose safety required primary attention, could also be treated for his somatic disorders and a delirium could be ruled out. His family was assisted in recovering from their traumatic life experience caused by his suicide attempt.