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von Stillfried S, Freeborn B, Windeck S, Boor P, Böcker J, Schmidt J, Tholen P, Röhrig R, Majeed R, Wienströer J, Bremer J, Weis J, Knüchel R, Breitbach A, Bülow RD, Cacchi C, Wucherpfennig S, Märkl B, Claus R, Dhillon C, Schaller T, Sipos E, Spring O, Braun G, Römmele C, Kling E, Kröncke T, Wittmann M, Hirschbühl K, Heppner FL, Meinhardt J, Radbruch H, Streit S, Horst D, Elezkurtaj S, Quaas A, Göbel H, Friemann J, Hansen T, Titze U, Lorenzen J, Reuter T, Woloszyn J, Baretton G, Hilsenbeck J, Meinhardt M, Pablik J, Sommer L, Holotiuk O, Meinel M, Esposito I, Crudele G, Seidl M, Mahlke N, Hartmann A, Haller F, Eichhorn P, Lange F, Amann KU, Coras R, Ingenwerth M, Rawitzer J, Schmid KW, Theegarten D, Gradhand E, Smith K, Wild P, Birngruber CG, Schilling O, Werner M, Acker T, Gattenlöhner S, Franz J, Metz I, Stadelmann C, Stork L, Thomas C, Zechel S, Ströbel P, Fathke C, Harder A, Wickenhauser C, Glatzel M, Matschke J, Krasemann S, Dietz E, Edler C, Fitzek A, Fröb D, Heinemann A, Heinrich F, Klein A, Kniep I, Lohner L, Möbius D, Ondruschka B, Püschel K, Schädler J, Schröder AS, Sperhake JP, Aepfelbacher M, Fischer N, Lütgehetmann M, Pfefferle S, Jonigk D, Werlein C, Domke LM, Hartmann L, Klein I, Schirmacher P, Schwab C, Röcken C, Langer D, Roth W, Strobl S, Rudelius M, Delbridge C, Kasajima A, Kuhn PH, Slotta-Huspenina J, Weichert W, Weirich G, Stock K, Barth P, Schnepper A, Wardelmann E, Evert K, Evert M, Büttner A, Manhart J, Nigbur S, Bösmüller H, Fend F, Granai M, Klingel K, Warm V, Steinestel K, Umathum VG, Rosenwald A, Vogt N, Kurz F. [Update on collaborative autopsy-based research in German pathology, neuropathology, and forensic medicine]. Pathologie (Heidelb) 2022; 43:101-105. [PMID: 36114379 PMCID: PMC9483541 DOI: 10.1007/s00292-022-01117-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 08/30/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND Autopsies are a valuable tool for understanding disease, including COVID-19. MATERIALS AND METHODS The German Registry of COVID-19 Autopsies (DeRegCOVID), established in April 2020, serves as the electronic backbone of the National Autopsy Network (NATON), launched in early 2022 following DEFEAT PANDEMIcs. RESULTS The NATON consortium's interconnected, collaborative autopsy research is enabled by an unprecedented collaboration of 138 individuals at more than 35 German university and non-university autopsy centers through which pathology, neuropathology, and forensic medicine autopsy data including data on biomaterials are collected in DeRegCOVID and tissue-based research and methods development are conducted. More than 145 publications have now emerged from participating autopsy centers, highlighting various basic science and clinical aspects of COVID-19, such as thromboembolic events, organ tropism, SARS-CoV‑2 detection methods, and infectivity of SARS-CoV-2 at autopsy. CONCLUSIONS Participating centers have demonstrated the high value of autopsy and autopsy-derived data and biomaterials to modern medicine. The planned long-term continuation and further development of the registry and network, as well as the open and participatory design, will allow the involvement of all interested partners.
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Affiliation(s)
- Saskia von Stillfried
- Institut für Pathologie, Universitätsklinik RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Deutschland
| | - Benita Freeborn
- Institut für Pathologie, Universitätsklinik RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Deutschland
| | - Svenja Windeck
- Institut für Pathologie, Universitätsklinik RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Deutschland
| | - Peter Boor
- Institut für Pathologie, Universitätsklinik RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Deutschland ,Medizinische Klinik II (Nephrologie und Immunologie), Universitätsklinik RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Deutschland ,Elektronenmikroskopische Einrichtung, Universitätsklinik RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Deutschland
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Klotz L, Metz I. Aktuelles aus der Forschung. Akt Neurol 2018. [DOI: 10.1055/a-0646-0803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- L. Klotz
- Klinik für Allgemeine Neurologie, Department für Neurologie, Universitätsklinikum Münster
| | - I. Metz
- Institut für Neuropathologie, Universitätsmedizin Göttingen, Georg-August-Universität Göttingen
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Thomas K, Metz I, Tumani H, Brück W, Ziemssen T. 6-sulpho LacNAc(+) dendritic cells accumulate in various inflammatory, but not ischaemic conditions of the central nervous system. Neuropathol Appl Neurobiol 2018; 42:394-8. [PMID: 26844946 DOI: 10.1111/nan.12313] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 01/25/2016] [Accepted: 02/04/2016] [Indexed: 12/14/2022]
Affiliation(s)
- K Thomas
- Department of Neurology, University Hospital, Dresden, Germany
| | - I Metz
- Department of Neuropathology, University Medical Centre, Göttingen, Germany
| | - H Tumani
- Department of Neurology, University Hospital, Ulm, Germany
| | - W Brück
- Department of Neuropathology, University Medical Centre, Göttingen, Germany
| | - T Ziemssen
- Department of Neurology, University Hospital, Dresden, Germany
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Klotz L, Metz I. Aktuelles aus der Forschung. Akt Neurol 2018. [DOI: 10.1055/s-0044-100556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- L. Klotz
- Klinik für Allgemeine Neurologie, Department für Neurologie, Universitätsklinikum Münster
| | - I. Metz
- Institut für Neuropathologie, Universitätsmedizin Göttingen, Georg-August-Universität Göttingen
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Bücher K, Metz I, Pitchika V, Hickel R, Kühnisch J. Flowable composite as a direct restoration technique for primary molars. Eur J Paediatr Dent 2017; 18:243-246. [PMID: 29254350 DOI: 10.23804/ejpd.2017.18.03.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- K Bücher
- Department of Conservative Dentistry, Ludwig-Maximilians-University, Munich, Germany
| | - I Metz
- Department of Prosthetic Dentistry, Ludwig-Maximilians-University, Munich, Germany
| | - V Pitchika
- Department of Conservative Dentistry, Ludwig-Maximilians-University, Munich, Germany
| | - R Hickel
- Department of Conservative Dentistry, Ludwig-Maximilians-University, Munich, Germany
| | - J Kühnisch
- Department of Conservative Dentistry, Ludwig-Maximilians-University, Munich, Germany
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Jarius S, König FB, Metz I, Ruprecht K, Paul F, Brück W, Wildemann B. Pattern II and pattern III MS are entities distinct from pattern I MS: evidence from cerebrospinal fluid analysis. J Neuroinflammation 2017; 14:171. [PMID: 28851393 PMCID: PMC5576197 DOI: 10.1186/s12974-017-0929-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 07/26/2017] [Indexed: 01/01/2023] Open
Abstract
Background The diagnosis of multiple sclerosis (MS) is currently based solely on clinical and magnetic resonance imaging features. However, histopathological studies have revealed four different patterns of lesion pathology in patients diagnosed with MS, suggesting that MS may be a pathologically heterogeneous syndrome rather than a single disease entity. Objective The aim of this study was to investigate whether patients with pattern I MS differ from patients with pattern II or III MS with regard to cerebrospinal fluid (CSF) findings, especially with reference to intrathecal IgG synthesis, which is found in most patients with MS but is frequently missing in MS mimics such as aquaporin-4-IgG-positive neuromyelitis optica spectrum disorders and myelin oligodendrocyte glycoprotein-IgG-positive encephalomyelitis. Methods Findings from 68 lumbar punctures in patients who underwent brain biopsy as part of their diagnostic work-up and who could be unequivocally classified as having pattern I, pattern II or pattern III MS were analysed retrospectively. Results Oligoclonal bands (OCBs) were present in 88.2% of samples from pattern I MS patients but in only 27% of samples from patients with pattern II or pattern III MS (P < 0.00004); moreover, OCBs were present only transiently in some of the latter patients. A polyspecific intrathecal IgG response to measles, rubella and/or varicella zoster virus (so-called MRZ reaction) was previously reported in 60–80% of MS patients, but was absent in all pattern II or III MS patients tested (P < 0.00001 vs. previous cohorts). In contrast, the albumin CSF/serum ratio (QAlb), a marker of blood–CSF barrier function, was more frequently elevated in samples from pattern II and III MS patients (P < 0.002). Accordingly, QAlb values and albumin and total protein levels were higher in pattern II and III MS samples than in pattern I MS samples (P < 0.005, P < 0.009 and P < 0.006, respectively). Conclusions Patients with pattern II or pattern III MS differ significantly from patients with pattern I MS as well as from previous, histologically non-classified MS cohorts with regard to both intrathecal IgG synthesis and blood–CSF barrier function. Our findings strongly corroborate the notion that pattern II and pattern III MS are entities distinct from pattern I MS.
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Affiliation(s)
- S Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany.
| | - F B König
- Department of Neuropathology, University of Göttingen, Göttingen, Germany
| | - I Metz
- Department of Neuropathology, University of Göttingen, Göttingen, Germany
| | - K Ruprecht
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - F Paul
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany.,NeuroCure Clinical Research Center and Clinical and Experimental Multiple Sclerosis Research Center, Berlin, Germany
| | - W Brück
- Department of Neuropathology, University of Göttingen, Göttingen, Germany.
| | - B Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
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Becker J, Horn P, Keyvani K, Metz I, Wegner C, Brück W, Heinemann F, Schwitalla J, Berlit P, Kraemer M. Primary central nervous system vasculitis and its mimicking diseases – clinical features, outcome, comorbidities and diagnostic results – A case control study. Clin Neurol Neurosurg 2017; 156:48-54. [DOI: 10.1016/j.clineuro.2017.03.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 03/06/2017] [Accepted: 03/07/2017] [Indexed: 11/30/2022]
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Ringelstein M, Metz I, Ruprecht K, Koch A, Rappold J, Ingwersen J, Mathys C, Jarius S, Brück W, Hartung HP, Paul F, Aktas O. Contribution of spinal cord biopsy to diagnosis of aquaporin-4 antibody positive neuromyelitis optica spectrum disorder. Mult Scler 2013; 20:882-8. [PMID: 24192218 DOI: 10.1177/1352458513510981] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 10/03/2013] [Indexed: 01/04/2023]
Abstract
Longitudinally extensive transverse myelitis is characteristic but not pathognomonic for neuromyelitis optica spectrum disorders (NMOSDs) and may mimic local tumors. In this retrospective study based on a cohort of 175 NMOSD patients we identified seven patients who initially presented with a longitudinally extensive spinal cord lesion and underwent spinal cord biopsy due to magnetic resonance imaging (MRI)-suspected malignancies. Remarkably, routine neuropathology was inconclusive and did not guide the diagnostic process to anti-aquaporin-4 (AQP4)-seropositive NMOSD. Serious postoperative complications occurred in 5/7 patients and persisted during follow-up in 2/7 patients (29%). Considering these sequelae, AQP4-antibody testing should be mandatory in patients with inconclusive longitudinally extensive spinal cord lesions prior to biopsy.
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Affiliation(s)
- M Ringelstein
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Germany
| | - I Metz
- Department of Neuropathology, University Hospital Göttingen, Germany
| | - K Ruprecht
- Department of Neurology, Charité-Universitätsmedizin Berlin, Germany
| | - A Koch
- Department of Neuropathology, Charité-Universitätsmedizin Berlin, Germany
| | - J Rappold
- Department of Neurology, Landesklinikum Thermenregion Hochegg, Austria
| | - J Ingwersen
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Germany
| | - C Mathys
- Department of Diagnostic and Interventional Radiology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Germany
| | - S Jarius
- Division of Molecular Neuroimmunology, Department of Neurology, University Hospital Heidelberg, Germany
| | - W Brück
- Department of Neuropathology, University Hospital Göttingen, Germany
| | - H-P Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Germany
| | - F Paul
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Germany
| | - O Aktas
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Germany
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Schrader C, Stingele R, Brück W, Metz I, Riedel C, Schub N, Valerius T, Deuschl G, Gramatzki M, Günther A. 9229 POSTER Severe Central Nervous System (CNS) Graft Versus Host Disease (GVHD) in a Patient Without Any Other GvHD Symptoms After Allogeneic Stem Cell Transplantation. Eur J Cancer 2011. [DOI: 10.1016/s0959-8049(11)72494-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Lee DH, Metz I, Berthele A, Stadelmann C, Brück W, Linker RA, Gold R, Schroeder A. Supraspinal demyelinating lesions in neuromyelitis optica display a typical astrocyte pathology. Neuropathol Appl Neurobiol 2011; 36:685-7. [PMID: 20618839 DOI: 10.1111/j.1365-2990.2010.01105.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lenhard T, Biller A, Mueller W, Metz I, Schönberger J, Wildemann B. Immune reconstitution inflammatory syndrome after withdrawal of natalizumab? Neurology 2010; 75:831-3. [PMID: 20805529 DOI: 10.1212/wnl.0b013e3181f07362] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- T Lenhard
- Division of Molecular Neuroimmunology, Department of Neurology, University Hospital Heidelberg, INF 400, D-69120 Heidelberg, Germany
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Reimers CD, Metz I, Schlotter-Weigel B. Differenzialdiagnostik der Myalgien. AKTUEL RHEUMATOL 2009. [DOI: 10.1055/s-0029-1234072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Brück W, Metz I. Pathologie und Therapieansprechen bei Multipler Sklerose. Akt Neurol 2009. [DOI: 10.1055/s-0029-1220412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Lucchinetti CF, Gavrilova RH, Metz I, Parisi JE, Scheithauer BW, Weigand S, Thomsen K, Mandrekar J, Altintas A, Erickson BJ, König F, Giannini C, Lassmann H, Linbo L, Pittock SJ, Brück W. Clinical and radiographic spectrum of pathologically confirmed tumefactive multiple sclerosis. Brain 2008; 131:1759-75. [PMID: 18535080 PMCID: PMC2442427 DOI: 10.1093/brain/awn098] [Citation(s) in RCA: 305] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Atypical imaging features of multiple sclerosis lesions include size >2 cm, mass effect, oedema and/or ring enhancement. This constellation is often referred to as ‘tumefactive multiple sclerosis’. Previous series emphasize their unifocal and clinically isolated nature, however, evolution of these lesions is not well defined. Biopsy may be required for diagnosis. We describe clinical and radiographic features in 168 patients with biopsy confirmed CNS inflammatory demyelinating disease (IDD). Lesions were analysed on pre- and post-biopsy magnetic resonance imaging (MRI) for location, size, mass effect/oedema, enhancement, multifocality and fulfilment of Barkhof criteria. Clinical data were correlated to MRI. Female to male ratio was 1.2 : 1, median age at onset, 37 years, duration between symptom onset and biopsy, 7.1 weeks and total disease duration, 3.9 years. Clinical course prior to biopsy was a first neurological event in 61%, relapsing–remitting in 29% and progressive in 4%. Presentations were typically polysymptomatic, with motor, cognitive and sensory symptoms predominating. Aphasia, agnosia, seizures and visual field defects were observed. At follow-up, 70% developed definite multiple sclerosis, and 14% had an isolated demyelinating syndrome. Median time to second attack was 4.8 years, and median EDSS at follow-up was 3.0. Multiple lesions were present in 70% on pre-biopsy MRI, and in 83% by last MRI, with Barkhof criteria fulfilled in 46% prior to biopsy and 55% by follow-up. Only 17% of cases remained unifocal. Median largest lesion size on T2-weighted images was 4 cm (range 0.5–12), with a discernible size of 2.1 cm (range 0.5–7.5). Biopsied lesions demonstrated mass effect in 45% and oedema in 77%. A strong association was found between lesion size, and presence of mass effect and/or oedema (P< 0.001). Ring enhancement was frequent. Most tumefactive features did not correlate with gender, course or diagnosis. Although lesion size >5 cm was associated with a slightly higher EDSS at last follow-up, long-term prognosis in patients with disease duration >10 years was better (EDSS 1.5) compared with a population-based multiple sclerosis cohort matched for disease duration (EDSS 3.5; P< 0.001). Given the retrospective nature of the study, the precise reason for biopsy could not always be determined. This study underscores the diagnostically challenging nature of CNS IDDs that present with atypical clinical or radiographic features. Most have multifocal disease at onset, and develop RRMS by follow-up. Although increased awareness of this broad spectrum may obviate need for biopsy in many circumstances, an important role for diagnostic brain biopsy may be required in some cases.
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Affiliation(s)
- C F Lucchinetti
- Department of Neurology, College of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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Metz I, Lucchinetti CF, Openshaw H, Garcia-Merino A, Lassmann H, Freedman MS, Azzarelli B, Kolar OJ, Atkins HL, Bruck W. Autologous hematopoietic stem cell transplantation: the glass seems to be half full for aggressive, early forms of MS and half empty for advanced MS. Brain 2008. [DOI: 10.1093/brain/awm181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Borer A, Metz I, Gilad J, Riesenberg K, Weksler N, Weber G, Alkan M, Horowitz J. Massive pulmonary haemorrhage caused by leptospirosis successfully treated with nitric oxide inhalation and haemofiltration. J Infect 1999; 38:42-5. [PMID: 10090507 DOI: 10.1016/s0163-4453(99)90029-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A patient with leptospirosis who developed oliguric renal failure, massive pulmonary haemorrhage and respiratory failure is described. The patient's clinical condition and arterial oxygenation failed to improve despite vigorous supportive measures. Nitric oxide inhalation and haemofiltration resulted in a marked clinical improvement and subsequent full recovery. We suggest that the addition of haemofiltration and nitric oxide inhalation therapy should be considered in patients with pulmonary haemorrhage and renal failure caused by leptospirosis, in whom conventional therapy fails.
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Affiliation(s)
- A Borer
- Infectious Disease Institute, Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Kremer H, Schierl W, Schattenkirchner M, Baumann D, Metz I, Zöllner N. [Echography of knee joint cysts (author's transl)]. MMW Munch Med Wochenschr 1977; 119:1183-6. [PMID: 409937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Because of a palpable swelling, 57 popliteal fossae were examined echographically. In 24 cases, the echography revealed a probable Baker's cyst. This diagnosis was confirmed by arthrography or at operation in 21 of the 24 cases. Two of the three findings which did not correspond were due to over-interpretation of the echographic picture and can be avoided in future by giving particular intention to the sound intensity. The causes of the discrepancy in the third case are still undetermined. These results show that echography is suitable for the discovery and assessment of Baker's cysts and should be used first as a non-invasive, painless, rapidly reproducible method.
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