[Donor liver histology : Joint recommendations of the DGP, DTG and DSO]

BACKGROUND

The indications, implementation and reporting of liver biopsies for deceased organ donation are not mandatory or regulated. Reliable data on outcome quality and prognostic relevance are therefore not available. Defined standards are thus required to enable meaningful studies and to ensure high data quality of a national transplantation registry.

OBJECTIVE

Presentation of a synopsis of available studies and literature-based recommendations.

RESULTS AND CONCLUSION

Against the background of an organ shortage and a growing number of older donors, pretransplantation liver histology is of significant relevance to guide clinical decision making. With the joint recommendations of the German Transplantation Society (DTG), the German Society of Pathology (DGP) and the German Organ Transplantation Foundation (DSO) standardized procedures are defined for the first time.

Influence of porcine circovirus type 2 vaccination on the level of antimicrobial consumption on 65 Austrian pig farms

The administration of antibiotics to farm animals is an important contemporary topic. Veterinarians, pig producers, politicians, retailers and consumers all have a vested interest in reducing antimicrobial use on farm, while ensuring adequate health and welfare of food-producing animals. Vaccination programmes may be used to reduce the overall level of clinical disease in a population, subsequently leading to a decline in antimicrobial use. In 2008, a vaccination programme against porcine circovirus type 2 (PCV-2) was initiated in Austria. In the retrospective observational study presented here, farm medication records (2008-2011) from 65 conventional pig farms were evaluated. As PCV-2 has been shown to lead to generalised immunosuppression, enabling secondary bacterial infections to occur, the authors hypothesised that PCV-2 vaccination would decrease antimicrobial consumption at farm level. Firstly, we focused on the annual antimicrobial consumption expressed as the number of administered animal daily doses per kg liveweight (nADDkg/kg/year). Secondly, a linear mixed effects model was applied to evaluate the influence of PCV-2 vaccination on the antimicrobial consumption at farm level. The interaction between farm type and PCV-2 vaccination was found to be a highly significant factor (P=0.0002) influencing antimicrobial use at farm level. The estimated impact of PCV-2 vaccination revealed a highly significant (P<0.001) decline in total antimicrobial drug use from 1.72 ADDkg/kg/year to 0.56 ADDkg/kg/year on finishing farms, whereas only a negligible decline was detectable on farrow-to-finish farms.

[Correlation between antibodies against porcine reproductive and respiratory syndrome virus and pathological-anatomical organ findings in slaughter pigs at farm level]

OBJECTIVE

The porcine reproductive and respiratory syndrome (PRRS) worldwide causes important economic losses in pig production. Its causative agent, the PRRS virus (PRRSV), is one of the most frequently detected infectious agents in relation to respiratory diseases in pigs in Austria. We investigated the correlation between the PRRSV status of pig farms, determined by detection of PRRSV antibodies in the serum of slaughter pigs, and the prevalence of pathological-anatomical lung lesions in slaughter pigs of the respective farms.

MATERIAL AND METHODS

Between December 1, 2011 and April 16, 2012, a total of 1056 serum samples of slaughter pigs from 66 pig farms were collected at an Austrian abattoir. The presence of PRRSV antibodies was tested by enzyme-linked immunosorbent assay in each sample and the PRRSV status of the respective farms was determined. No PRRSV vaccination was performed on any of the farms. In addition, the pathological-anatomical lung lesions of all slaughter pigs of the 66 farms that were slaughtered between September 1, 2011 and December 11, 2012 were recorded by authorized veterinarians at the abattoir. The prevalence of lung lesions and pleuritis in PRRSV-positive and unsuspected farms was compared and statistically interpreted.

RESULTS

Slaughter pigs of PRRSV positive farms had a significantly higher prevalence of severe lung lesions and pleuritis visceralis and parietalis than slaughter pigs of PRRSV unsuspected farms. Pigs of combined farms (nursery and fattening unit at the same location) displayed a tendency for more moderate and severe lung lesions than pigs of exclusive fattening farms.

CONCLUSIONS AND CLINICAL RELEVANCE

In the present study, the PRRSV status of pig farms displayed a significant influence on the prevalence of lung lesions in the slaughter pigs. Findings untypical for PRRS, including pleuritis, were also found significantly more often on those farms. This leads to the conclusion that other primary and/or secondary infections are involved, which can be exacerbated by the immunosuppressive effect of the PRRSV. There was a tendency for combined farms to be more severely affected than fattening farms.

Influence of porcine circovirus type 2 vaccination on the probability and severity of pneumonia detected postmortem

To evaluate the influence of porcine circovirus type 2 vaccination (PCV-2) on the probability and severity of pneumonia, postmortem findings of 247,505 pigs slaughtered between 2008 and 2011 were analysed by applying a cumulative link mixed model. Three major effects could be observed: (1) PCV-2 vaccination significantly (P<0.01) reduced the odds (coefficient: −0.05) of postmortem findings of mild, moderate and severe pneumonia for vaccinated pigs. (2) Pigs from fattening farms were less likely (coefficient: −0.44; P<0.05) to exhibit signs of pneumonia at slaughter than pigs from farrow-to-finish farms. (3) When vaccinated, the odds of detecting postmortem signs showed an even more pronounced reduction (coefficient: −0.19; P<0.001) for pigs from fattening farms. Combining PCV-2 vaccination, farm type and interaction effects between these two factors, a pig vaccinated against PCV-2 from a fattening farm had only half the chance (OR 0.51) of pneumonia being detected at postmortem than a non-vaccinated pig from a farrow-to-finish farm. The study demonstrates the benefit of a vaccination programme against PCV-2 as an important tool to reduce the risk of postmortem pneumonia findings and the severity of pneumonia in pigs at slaughter.

Rapid monitoring of Campylobacter in high-shedding flocks for targeted disease control

Broilers excreting Campylobacter spp. at high levels (>7 log CFU/g of feces) were described in the Dutch Campylobacter Risk Management and Assessment project as an important source of carcass contamination. The researchers concluded that the risk of infection to humans could be economically and efficiently minimized by eliminating these flocks from fresh poultry meat chains. In the present study, we evaluated a simple and rapid gold-labeled immunosorbent assay (GLISA) for the identification of Campylobacter spp. in flocks shedding high levels of the pathogen. Results were obtained within 2 h. Pooled samples from 102 of the 114 Campylobacter-positive flocks produced positive results, resulting in a test sensitivity of 89.5% (95% confidence interval, 82.6 to 94.2%) and a test specificity of 94.5% (86.7 to 98.2%). Given a GLISA detection limit of 7.3 log CFU/g of feces, nearly all Campylobacter-positive flocks were identified as "high shedders." Therefore, reduction of the incidence of Campylobacter infections by elimination of high-shedding flocks from fresh meat production is an unrealistic approach. Under the constraints given, a reduction in the incidence of Campylobacter spp. in Austria will require either improved hygiene or an intensive carcass decontamination strategy in fresh meat production facilities.

Renal graft outcome in combined heart-kidney transplantation compared to kidney transplantation alone: a single-center, matched-control study

BACKGROUND

Renal allograft outcome in heart-kidney transplantation (HKTx) might be affected by hemodynamic instability and high levels of calcineurin inhibitor-dependent immunosuppression.

METHODS

From November 1999 to March 2008, 13 patients who received HKTx were compared with a matched control group of 13 kidney transplantation (KTx) recipients with similar cardiovascular risk factors. Graft function, rejection periods, and patient survival were analyzed.

RESULTS

Renal allograft rejection was noted in three patients (23%) after HKTx and in four patients (31%) after KTx. Serum creatinine levels were comparable at 1 week, 1 month, 1, 2, and 3 years after transplantation. Patient survival rates at 1, 2, and 3 years were 100% for HKTx recipients and 100, 92, and 92% for isolated KTx patients. Graft survival was 92% at 1, 2, and 3 years after HKTx and 100% at 1 year and 92% at 2 and 3 years after isolated KTx.

CONCLUSIONS

Our results with excellent long-term graft function and survival after combined HKTx indicate that this procedure is a valuable option for a growing number of patients suffering from coexistent cardiac and renal failure.

Timing of conversion to mammalian target of rapamycin inhibitors is crucial in liver transplant recipients with impaired renal function at transplantation

BACKGROUND

Renal dysfunction, primarily related to long-term use of calcineurin inhibitor-based immunosuppression, is the most common complication after liver transplantation.

OBJECTIVE

To evaluate whether liver transplant recipients with impaired kidney function at transplantation can benefit from early conversion to mammalian target of rapamycin inhibitor therapy (mTORi) compared with patients with late induction of mTORi-based therapy.

MATERIALS AND METHODS

Between 2003 and 2008, therapy was changed to an mTORi-based regimen in 57 patients. Patients were divided into 4 groups: group 1, early conversion (≤3 months after orthotopic liver transplantation) to mTORi therapy, and with impaired perioperative renal function; group 2, early conversion to mTORi therapy, and with normal perioperative renal function; group 3, late conversion to mTORi therapy, and with impaired perioperative renal function; and group 4, late conversion to mTORi therapy, and with normal perioperative renal function.

RESULTS

One month after conversion, the mean (SD) increase in calculated glomerular filtration rate in groups 1 (early conversion) and 3 (late conversion) was comparable: 8 (9) mL/min vs 7 (10) mL/min. At month 3, the increase in calculated glomerular filtration rate between groups 1 and 3 was significant (15 [11] mL/min vs 9 [15] mL/min; P = .04), an effect that persisted at month 6 (16 [12] mL/min vs 10 [12] mL/min; P = .05) and month 12 (22 [14] mL/min vs 12 [15] mL/min; P = .04).

CONCLUSION

In liver transplant recipients with perioperatively impaired renal function, early conversion to mTORi therapy should be performed because this approach seems to be more effective in improving long-term renal function.

[Stoma prolapse and stoma retraction]

Prolapse and retraction of an intestinal stoma are postoperative complications which severely decrease the quality of life of patients and in some cases lead to an operative revision. Both entities should be treated with sophisticated care by specialized stoma therapists in the early phase in order to prevent secondary problems such as dermal ulceration. However, in case of additional problems, such as ileus, bleeding, incarceration or impossibility of adequate stoma care, an operative revision is indicated. It remains an individual decision whether a local or a transabdominal revision of the stoma is necessary.At present the level of information and the number of well designed studies dealing with prolapse or retraction of a stoma are unsatisfactory and there are merely studies which report on prolapse and retraction as an incidental finding rather than primarily focusing on these problems. In addition there is a lack of clear cut definitions for both entities which would allow a comparison of data obtained in different studies.There is clearly a demand for a structured scientific clarification as the occurrence of stomal retraction or prolapse may present psychological and medical problems for the patients and therefore needs to be treated, conservatively and/or operatively, by both stoma specialists and surgeons.

Chemotherapy in metastatic malignant triton tumor: report on two cases

Malignant triton tumor (MTT) is a rare, highly malignant nerve sheath tumor with rhabdomyoblastic differentiation. Initial debulking surgery followed by adjuvant therapy is the current treatment of choice, but has very limited efficacy when optimal cytoreduction is not achieved by surgical procedure. Neoadjuvant therapy for MTT, to potentially facilitate subsequent surgery, eradicate micrometastatic lesions and, therefore, improve the therapeutical outcome, has never before been presented in literature. Here, we report on the multimodal management of two cases of advanced and metastatic MTT. Treatment modalities involved neoadjuvant and adjuvant chemotherapy, surgical resection, and radiation. In both cases, integrated Positron Emission Tomography/Computed Tomography (PET/CT) emerged as an important diagnostic tool for the reliable assessment of MTT response and metabolic remission.

Endosonographic and histopathological staging of extrahepatic bile duct cancer: time to leave the present TNM-classification?

OBJECTIVES

The discrepancy between high rates of sensitivity, specificity, and accuracy for intraductal ultrasonography (IDUS) in extrahepatic bile duct carcinoma and the failure to depict different wall layers as defined by the TNM classification have not yet been elucidated sufficiently.

METHODS

In a prospective study, endosonographic images were correlated with histomorphology including immunohistochemistry. Using IDUS, we examined fresh resection specimens of patients who had undergone pancreato-duodenectomy. For histological analysis, the formalin-fixed and paraffin-embedded specimens were stained by hematoxylin-eosin, elastica-van-Gieson, and immunohistochemically by smooth muscle-actin. To confirm our hypothesis, further cases from the archives were analyzed histopathologically and immunohistochemically.

RESULTS

The various wall layers of the extrahepatic bile duct as described by the International Union Against Cancer are neither histomorphologically nor immunohistochemically consistently demonstrable. Especially, a clear differentiation between tumor invasion beyond the wall of the bile duct (T2) and invasion of the pancreas (T3) by histopathological means is often not possible. Endosonographic images using high-resolution miniprobes similarly confirm the difficulty in imaging various layers in the bile duct wall.

CONCLUSIONS

Most adaptations made by the sixth edition of the TNM classification accommodate to the endosonographic and most of the histopathological findings as demonstrated in our study. In contrast to the new edition, however, our findings suggest to combine T2- and T3-staged tumors into one single class leading to clarification, and improved reproducibility of histopathological staging.

Reticuloendothelial system blockade promotes progression from mild to severe acute pancreatitis in the opossum

OBJECTIVE

To examine the relation between hepatic reticuloendothelial system (RES) dysfunction and the development of acute biliary pancreatitis. In an opossum model, the authors tested the hypothesis that RES blockade can turn the mild pancreatitis seen after pancreatic duct obstruction (PDO) into the severe form.

SUMMARY BACKGROUND DATA

Biliary obstruction is considered the decisive event in gallstone pancreatitis. Suppression of the RES occurs during biliary obstruction.

METHODS

Eighteen opossums were placed into three groups of six animals each: group A, RES blockade with lambda-carrageenan; group B, PDO; and group C, PDO and RES blockade with carrageenan. The severity of pancreatitis was evaluated by enzyme serum levels and percentage of pancreatic tissue necrosis. RES capacity was measured by dynamic liver scintigraphy, and hepatic blood flow was documented using the hydrogen clearance technique.

RESULTS

No changes in hepatic blood flow occurred in groups A to C. RES capacity was suppressed in groups A and C; in group B, RES function remained unchanged. In group A, amylase and lipase levels remained normal, 3 +/- 1.9% of pancreatic tissue were necrotic. The animals in group B developed mild edematous pancreatitis with an increase in amylase and lipase levels and 15 +/- 10% of pancreatic necrosis. In group C, amylase and lipase increased significantly and histology revealed severe necrotizing pancreatitis, with 72 +/- 11% of necrotic areas.

CONCLUSIONS

Artificial RES blockade can promote the progression from mild pancreatitis as observed after PDO to the severe necrotizing form of the disease. Thus, RES dysfunction resulting from biliary obstruction might be an important cofactor in the pathogenesis of bile-induced pancreatitis.

[The observed and chance-corrected agreement of the computed tomographic and histological staging results in renal-cell carcinoma]

PURPOSE

To assess the diagnostic value of abdominal computed tomography in the preoperative staging of renal cell carcinoma.

METHODS

Computed tomograms of 87 renal cell carcinomas were classified according to the TNM-System. The results were correlated with the histopathological categories. The usual parameters for diagnostic tests were calculated and chance correction of the observed agreement was performed using Cohen's Kappa (kappa) test.

RESULTS

T-category staging showed an overall accuracy of 60% (kappa = 0.44). The pT1 category was correctly predicted in all cases. For perirenal invasion, an accuracy of 60% (kappa = 0.27), a sensitivity of 90.5%, and a specificity of 51% were found. For venous involvement, accuracy was 92% (kappa = 0.59), sensitivity 86%, and specificity 92%. All inconspicuous adrenals on CT were histologically normal as well. An accuracy of 80% for lymphadenopathy staging was attributable to chance (kappa = 0.04). 7 distant metastases were detected in the scanned volume.

CONCLUSIONS

Good CT staging results are obtained with discrimination between T1 tumors and higher categories, the assessment of venous invasion, the exclusion of adrenal involvement, and the detection of metastatic spread to abdominal organs. Insufficient results are seen with lymphadenopathy staging and the distinction of organ-confined and invasive tumors.

[Radiation exposure of the ocular lens and thyroid gland in digital subtraction angiography of brain-supplying arteries]

PURPOSE

To find out the individual level of radiation exposure of the ocular lens and thyroid gland during DSA of arteries supplying the brain, considering the indication.

MATERIAL AND METHOD

The study was conducted on 72 patients during aortic arch and cerebral artery angiographies using thermoluminescent dosimetry.

RESULTS

During 20 aortic arch angiographies the measured values were within non-critical limits, whereas during carotid, vertebral or cerebral four-vessel angiography of the left ocular lens exposure values of more than 500 mGy (max. 782 mGy) were stated in two of 52 cases. The highest measured exposure relating to the right ocular lens was 126 mGy, to the thyroid gland 88 mGy. However, in 51 of 52 cases thyroid gland doses of below 51 mGy were measured. In 71 of 72 cases there was a lateral difference between right and left lens exposure up to twice the measured dose for the right ocular lens during aortic arch angiographies and up to sixteen-fold in respect of the left lens during cerebral angiographies.

CONCLUSION

In addition to the fluoroscopic time, number of images, fade-in and zoom some other dose-influencing factors, radiation geometry is especially decisive for organ exposure. The risk of cataracts or thyroid gland carcinomas/hypothyrosis can be neglected with median values of 40 and 70 mGy relating to the ocular lens and 17 mGy for the thyroid gland during cerebral angiographies.

[X-ray diagnostic procedures in cases involving craniocerebral trauma]

A well working team of examinators is one of the main presummations of getting an optimal diagnostic and treatment of head injuries (examinators of different branches of medicine). The first thing to do is exclude an intracranial bleeding (correct interpretation of clinical and roentgenological findings with an application of a suitable method in time). The cerebral angiography is one of the most effective methods of haemotoma diagnostic. The results using computed tomography can be compared with. Both methods complement themselves. The ultra-sound-diagnostic is useful to exclude haematomas (80 per cent accuracy of fire).