Radiological Central Vein Treatment in Vascular Access

In the last decades, the percutaneous interventional approach for the treatment of central venous obstructions (CVO) has become increasingly popular as the treatment of first choice because of its minimal invasiveness and reported success rates. CVOs are caused by a diverse spectrum of diseases which can be broadly categorized into two principal eliciting genera, either benign or malignant obstructions. The large group of benign venous obstructions includes the increasing number of end-stage renal disease patients with vascular access related complications. Due to the invasiveness and complexity of thoracic surgery for benign CVOs, the less invasive percutaneous interventional therapy can generally be considered the preferred treatment option. Initially, the radiological intervention consisted of balloon angioplasty alone, subsequently additional stent placement was applied. This was advocated as either primary placement or secondary in cases of elastic recoil or residual stenosis after percutaneous transluminal angioplasty (PTA). The efficacy of angioplasty of CVO in patients with vascular accesses, either with or without stenting, has been addressed by various studies. Overall, reports indicate an initial technical and clinical success rate above 95% and satisfactory patency rates. However, systematic follow-up and frequent re-interventions are necessary to maintain vascular patency to achieve long-term success.

[Diagnostics and endovascular treatment of venous diseases]

In venous disease, acute thromboses and chronic venous insufficiency have the highest health economics relevance. Duplex sonography is the first line diagnostic assessment tool, while cross-sectional imaging is employed as a supplementary method. Due to the availability and examination times computed tomography is preferred in the emergency setting and is supplemented by magnetic resonance imaging (MRI) for specific questions. Endovascular treatment procedures are increasingly becoming available in addition to classical conservative treatment methods.

Digital Luminescence Radiography and Conventional Radiography in Abdominal Contrast Examinations

In 326 patients abdominal contrast radiographs were compared to digital luminescence radiographs (DLR) and conventional screen-film system ones. The digital exposure dose was 50% of the conventional. In DLR, 2 different types of postprocessed images were obtained from each data set. A display with low spatial frequency enhancement filtered to look like a conventional radiograph was compared to a display with high spatial frequency enhancement. Conventional and DLR images were evaluated randomly and separately by 4 radiologists by means of a questionnaire. DLR proved to be diagnostically equivalent to the conventional technique with the exception of a slightly diminished visibility of the mucosal pattern. High spatial frequency enhancement did not provide additional diagnostic information and should be dispensed with in abdominal examinations.

CD40/CD40 ligand interactions and TNFα treatment reduce activity of P105 promoter of the human papilloma virus-18 in vitro

BACKGROUND

Cervical carcinoma cells including those infected with the oncogenic human papilloma virus (HPV) and several cervical carcinoma cell lines show a strong expression of the CD40 receptor, unlike benign cervical epithelial cells infected with HPV. The functional relevance of this up-regulated expression in the tumor is not fully understood. Nevertheless, it might offer a unique possibility to target those malignant cells due to the antiviral and antitumoral effects of the CD40/CD40 ligand (CD40L) interactions.

AIM

In vitro assessment of the effect of CD40L on HPV 18-P105 promoter activity and the subsequent release of IL-6 by the promoter transfected HeLa(CD40) cells, which express CD40 constitutively.

MATERIAL AND METHODS

Transfection of HeLa(CD40) cells was achieved by electroporation after optimizing the parameters by the pCMV-β-Gal vector and β-Gal stain. Transfected HeLa(CD40) cells were challenged with BHK(CD40L) and TNFα, in addition to BHK(wt) and medium alone as controls. HPV18-P105 promoter activity was demonstrated by luciferase reporter gene assay while IL-6 was assessed by ELISA.

RESULTS

CD40/CD40L interactions and TNFα treatment significantly reduced HPV18-P105 promoter activity (56.0 ± 10.2% and 64.1 ± 9.1% vs. control, respectively; p < 0.001). Likewise, IL-6, which is a sensitive cytokine of CD40 activation, was significantly increased in HeLa(CD40) cells in the same experiments (2.7 fold after stimulation with BHK(CD40L) and 5.2 fold after stimulation with TNFα vs. control; p < 0.01 and p < 0.001, respectively).

CONCLUSION

It is likely that the CD40/CD40L interactions and TNFα are effective against cervical carcinomas by repressing transcriptional activity of HPV promoter. This can result in new adjuvant treatments.

[Epidemiology of ocular involvement in Adamantiades-Behçets disease]

Epidemiological studies demonstrate a prevalence of Adamantiades-Behçets disease (MAB) in the range of 0.12-420 per 100,000 inhabitants with the highest rates in Istanbul, Turkey and the lowest rates in the USA. Ophthalmological data on the prevalence of ocular involvement are limited for MAB in Germany because most epidemiological studies are based on rheumatological or dermatological data. Berlin is the city with the highest number of non-native German inhabitants and its multiethnic character renders it uniquely appropriate for epidemiological studies on MAB. This article summarizes the most important epidemiological data of 140 patients (63 female and 77 male) with a mean follow-up of 6.4 years (range 0.5-22 years) which we have recently published. The mean age was 23 years at the first manifestation and 32 years when the fully developed disease was recorded. The mean age at onset of ocular involvement was 30 years, 56% of patients developed ocular involvement, which was the first manifestation in 8.6% and the second manifestation in 19.3%. More than half the patients developed ocular involvement. The calculated prevalence of ocular involvement in MAB is 1.77/100,000 inhabitants for the population of Berlin.

[Venous interventions--part 1: techniques and lower torso thromboses]

Venous thrombosis is one of the most common vascular diseases. Without treatment, pulmonary embolism is a potentially life-threatening complication. Long-term complications are chronic venous insufficiency and post-thrombotic syndrome. Medical anticoagulation is currently the standard therapy, since it prevents appositional thrombus growth although it usually can not prevent the development of post-thrombotic syndrome. The structure of the thrombotic material often leads to partial recanalisation with residual stenosis. Early and sufficient systemic thrombolysis with adequate concentration may achieve disintegration of the thrombus and preservation of venous valve function. Supplementary to conservative therapy, local catheter thrombolysis is possible even in cases with contraindications for a systemic thrombolysis therapy. Additional interventional techniques reduce the required concentration of the thrombolytic. Venous stenosis can be treated by balloon angioplasty and stent implantation. This article reviews the different percutaneous treatment options as well as their application and usefulness in thrombosis of the lower torso.

[Venous interventions. Part 2: Thromboses of the upper torso and mesenteric veins]

This article focuses on the percutaneous treatment options of venous thromboses and occlusions. Interventional therapy modalities for mediastinal, brachial, axillar, cerebral, and mesenteric thromboses are reviewed. Stenoses of the superior vena cava are most often caused by mediastinal malignomas. Balloon angioplasty together with stent implantation is an effective method for revascularisation in cases of upper venous congestion. Benign central venous stenoses are common in dialysis patients for whom interventional therapy using balloon angioplasty has proven excellent results. In the treatment of insufficient dialysis access, percutaneous techniques represent the first-choice option. Regarding cerebral and mesenteric thrombosis, interventional therapy is restricted to selected individual cases.

Current concepts in the treatment of recurrent aphthous stomatitis

The treatment of recurrent aphthous stomatitis (RAS) still remains nonspecific and is based primarily on empirical data. The goals of therapy include the management of pain and functional impairment by suppressing inflammatory responses, as well as reducing the frequency of recurrences or avoiding the onset of new aphthae. For common forms of RAS, standard topical treatment options that provide symptomatic relief include analgesics, anesthetics, antiseptics, anti-inflammatory agents, steroids, sucralfate, tetracycline suspension, and silver nitrate. Dietary modifications may also support therapeutic measures. In resistant cases of benign aphthosis or aphthosis with systemic involvement, appropriate systemic treatment can be selected from a wide spectrum of immunomodulators that include colchicine, prednisolone, cyclosporine A, interferon-a, tumor necrosis factor-a antagonists, antimetabolites, and alkylating agents.

Radiological central vein treatment in vascular access

In the last decades, the percutaneous interventional approach for the treatment of central venous obstructions (CVO) has become increasingly popular as the treatment of first choice because of its minimal invasiveness and reported success rates. CVOs are caused by a diverse spectrum of diseases which can be broadly categorized into two principal eliciting genera, either benign or malignant obstructions. The large group of benign venous obstructions includes the increasing number of end-stage renal disease patients with vascular access related complications. Due to the invasiveness and complexity of thoracic surgery for benign CVOs, the less invasive percutaneous interventional therapy can generally be considered the preferred treatment option. Initially, the radiological intervention consisted of balloon angioplasty alone, subsequently additional stent placement was applied. This was advocated as either primary placement or secondary in cases of elastic recoil or residual stenosis after percutaneous transluminal angioplasty (PTA). The efficacy of angioplasty of CVO in patients with vascular accesses, either with or without stenting, has been addressed by various studies. Overall, reports indicate an initial technical and clinical success rate above 95% and satisfactory patency rates. However, systematic follow-up and frequent re-interventions are necessary to maintain vascular patency to achieve long-term success.

Practical aspects of management of recurrent aphthous stomatitis

Treatment of recurrent aphthous stomatitis (RAS) remains, to date, empirical and non-specific. The main goals of therapy are to minimize pain and functional disabilities as well as decrease inflammatory reactions and frequency of recurrences. Locally, symptomatically acting modalities are the standard treatment in simple cases of RAS. Examples include topical anaesthetics and analgesics, antiseptic and anti-phlogistic preparations, topical steroids as cream, paste or lotions, antacids like sucralfate, chemically stable tetracycline suspension, medicated toothpaste containing the enzymes amyloglucosidase and glucoseoxidase in addition to the well-known silver nitrate application. Dietary management supports the treatment. In more severe cases, topical therapies are again very useful in decreasing the healing time but fail to decrease the interval between attacks. Systemic immunomodulatory agents, like colchicine, pentoxifylline, prednisolone, dapsone, levamisol, thalidomide, azathioprine, methotrexate, cyclosporin A, interferon alpha and tumour necrosis factor (TNF) antagonists, are helpful in resistant cases of major RAS or aphthosis with systemic involvement.

CD40 ligand-CD40 interaction induces chemokines in cervical carcinoma cells in synergism with IFN-gamma

Cellular immunity plays a major role in controlling human papilloma virus infection and development of cervical carcinoma. Mononuclear cell infiltration possibly due to the action of chemokines becomes prominent in the tumor tissue. In fact, the macrophage chemoattractant protein-1, MCP-1, was detected in cervical squamous cell carcinoma in situ, whereas absent in cultured cells. From this, unknown environmental factors were postulated regulating chemokine expression in vivo. In this study, we show high CD40 expression on cervical carcinoma cells and CD40 ligand (CD40L) staining on attracted T cells in tumor tissue, suggesting a paracrine stimulation mechanism via CD40L-CD40 interactions. We therefore investigated chemokine synthesis in nonmalignant and malignant human papilloma virus-positive cell lines after CD40L exposure. Constitutive expression of MCP-1, MCP-3, RANTES, and IFN-gamma-inducible protein-10 was almost undetectable in all cell lines tested. CD40L was able to induce MCP-1 production; however, despite much higher CD40 expression in malignant cells, MCP-1 induction was significantly lower compared with nontumorigenic cells. After sensitization with IFN-gamma, another T cell-derived cytokine showing minimal effects on CD40 expression levels, CD40 ligation led to a more than 20-fold MCP-1 induction in carcinoma cell lines. An even stronger effect was observed for IFN-gamma-inducible protein-10. Our study highlights the synergism of T cell-derived mediators such as CD40L and IFN-gamma for chemokine responses in cervical carcinoma cells, helping to understand the chemokine expression patterns observed in vivo.

Digital luminescence radiography and conventional radiography in abdominal contrast examinations

In 326 patients abdominal contrast radiographs were compared to digital luminescence radiographs (DLR) and conventional screen-film system ones. The digital exposure dose was 50% of the conventional. In DLR, 2 different types of postprocessed images were obtained from each data set. A display with low spatial frequency enhancement filtered to look like a conventional radiograph was compared to a display with high spatial frequency enhancement. Conventional and DLR images were evaluated randomly and separately by 4 radiologists by means of a questionnaire. DLR proved to be diagnostically equivalent to the conventional technique with the exception of a slightly diminished visibility of the mucosal pattern. High spatial frequency enhancement did not provide additional diagnostic information and should be dispensed with in abdominal examinations.

[Peripheral occlusive arterial diseases: comparison of diagnostic value of MRA and DSA]

MATERIAL AND METHODS

In 59 patients with arterial flow disturbances 2-D inflow sequence of the abdominal and lower leg arteries were prospectively obtained on a 1.5 T MR-imager and were compared with additional DSA examinations. Supplementary Phase Contraste RSE ("Rapid Sequential Excitation") sequences were carried out in 29 patients. MRA and DSA angiograms were evaluated in random order by 4 readers using a questionnaire. The assessment of image quality were evaluated by variance analysis. Diagnostic performance of MRA and DSA was assessed by comparison of the readers' diagnostic assessments with reference diagnoses established by a radiologist and a vascular surgeon with full knowledge of all data concerning a patient. Image quality of inflow MRA was considered inferior to i.a. DSA (p < 0.001) and comparable with i.v. DSA (p = 0.1361). Image quality of RSE-MRA was inadequate (p < 0.001). Correspondingly, i.a. DSA was the superior and RSE-MRA the inferior imaging technique. The accuracy of inflow MRA in determining stenosis grade was 66% and that of RSE-MRA 59%.

Diagnostic performance of digital subtraction angiography (DSA) and magnetic resonance angiography (MRA): preliminary results in vascular occlusive disease of the abdominal and lower-extremity arteries

Fifty-nine patients with occlusive disease of the aorto-iliac and femoro-popliteal arteries were investigated prospectively by intravenous (IV) or intraarterial (IA) digital subtraction angiography (DSA) and magnetic resonance angiography (MRA). This was accomplished using a two-dimensional (2D) Inflow- (59 patients) and a 2D Phase Contrast- (RSE--rapid sequential excitation) sequence (29 patients). The spectrum of pathology included stenoses < 50%, stenoses 50-89%, stenoses 90-99%, occlusions, aneurysms and status following reconstructive surgery. MRA- and DSA-examinations were evaluated by four radiologists. The diagnoses were made by consent decisions of a radiologist and a vascular surgeon based on clinical and radiological findings. Diagnostic performance of IA-DSA was superior to all other imaging modalities. Vascular delineation of 2D Inflow-MRA was comparable to that of IV-DSA. The image quality of RSE-MRA was not adequate for diagnosis. In conclusion, 2D Inflow-MRA is a promising method for evaluating abdominal and peripheral arteriosclerotic disease. Interpretation of MR-angiograms, however, requires profound knowledge of MRA-techniques, X-ray angiography and hemodynamics.

[Gas-forming mycosis of the kidney]

We report on the case of a 22-year-old heroin-dependent diabetic woman. She presented with a gas-forming fungal infection of the kidney caused by Candida tropicalis. The patient was successfully treated by conservative means. Problems in the diagnosis and therapy of this rare disease are discussed.