Laparoscopic splenectomy for idiopathic thrombocytopenic purpura

Background: Laparoscopic splenectomy is a novel approach for the treatment of idiopathic thrombocytopenic purpura (ITP) in patients requiring surgical intervention. This technique was used for treatment in 16 consecutive patients. Follow-up was initiated at a median of 13.5 months after surgery to determine whether or not laparoscopic splenectomy is a safe and successful procedure that should be used in all patients requiring splenectomy for ITP. Methods: Sixteen patients underwent laparoscopic splenectomy for ITP between May 1994 and September 1996. They were evaluated prospectively prior to surgery, immediately following surgery, at discharge, and at 13.5 months following surgery (n= 14) to determine the short- and long-term results of the procedure. Results: Mean operation time was 123.4 ± 12.1 min, and there were no significant intra- or postoperative complications. Mean intraoperative blood loss was 437.5 ± 73.5 ml. Autologous blood transfusion was necessary in one patient (6.3%). Mean organ weight was 202.2 ± 47.3 g. Mean postoperative hospital stay was 4.6 ± 0.4 days. Before discharge, mean platelet count rose by 100.7%. At follow-up (13.5 months postoperatively), it was 77.7% above preoperative values. No additional surgery was necessary in any of the patients undergoing laparoscopic splenectomy, and hematologic success was achieved in 12 patients (85.7%). Conclusions: Our results clearly indicate that laparoscopic splenectomy is a safe and successful procedure in patients suffering from ITP. It offers the well-known advantages of minimal invasive surgery as well as the surgical effectiveness of the open approach. This surgical technique should therefore be considered in all patients requiring splenectomy for the treatment of ITP.     

Central neurocytoma: histopathological variants and therapeutic approaches.

The central neurocytoma has recently been added to the differential diagnosis of intraventricular tumors. Histopathologically, this tumor is characterized by a uniform neoplastic cell population with features of neuronal differentiation. Central neurocytomas occur in young adults, develop in the area of the foramen of Monro, and are usually associated with the septum pellucidum. Initial reports appeared to indicate that these tumors are benign lesions with a favorable postoperative prognosis. The authors present clinical and neuropathological findings in a series of eight patients with central neurocytoma. An anterior transcallosal microneurosurgical approach yielded good outcomes. Postoperative radiation therapy was restricted to two patients with a malignant variant of central neurocytoma and one patient with a recurrent tumor. Observations of anaplastic variants of this neoplasm in two cases and local tumor recurrences in three indicate that the biological behavior and postoperative prognosis of central neurocytoma may not always be as favorable as previously assumed.     

Respiratory health and individual estimated exposure to traffic-related air pollutants in a cohort of young children

Objectives

To estimate long‐term exposure to traffic‐related air pollutants on an individual basis and to assess adverse health effects using a combination of air pollution measurement data, data from geographical information systems (GIS) and questionnaire data.

Methods

40 measurement sites in the city of Munich, Germany were selected at which to collect particulate matter with a 50% cut‐off aerodynamic diameter of 2.5 µm (PM_2.5) and to measure PM_2.5 absorbance and nitrogen dioxide (NO₂). A pool of GIS variables (information about street length, household and population density and land use) was collected for the Munich metropolitan area and was used in multiple linear regression models to predict traffic‐related air pollutants. These models were also applied to the birth addresses of two birth cohorts (German Infant Nutritional Intervention Study (GINI) and Influence of Life‐style factors on the development of the Immune System and Allergies in East and West Germany (LISA)) in the Munich metropolitan area. Associations between air pollution concentrations at birth address and 1‐year and 2‐year incidences of respiratory symptoms were analysed.

Results

The following means for the estimated exposures to PM_2.5, PM_2.5 absorbance and NO₂ were obtained: 12.8 μg/m³, 1.7×10⁻⁵ m⁻¹ and 35.3 μg/m³, respectively. Adjusted odds ratios (ORs) for wheezing, cough without infection, dry cough at night, bronchial asthma, bronchitis and respiratory infections indicated positive associations with traffic‐related air pollutants. After controlling for individual confounders, significant associations were found between the pollutant PM_2.5 and sneezing, runny/stuffed nose during the first year of life (OR 1.16, 95% confidence interval 1.01 to 1.34) Similar effects were observed for the second year of life. These findings are similar to those from our previous analysis that were restricted to a subcohort in Munich city. The extended study also showed significant effects for sneezing, running/stuffed nose. Additionally, significant associations were found between NO₂ and dry cough at night (or bronchitis) during the first year of life. The variable “living close to major roads” (<50 m), which was not analysed for the previous inner city cohort with birth addresses in the city of Munich, turned out to increase the risk of wheezing and asthmatic/spastic/obstructive bronchitis.

Conclusions

Effects on asthma and hay fever are subject to confirmation at older ages, when these outcomes can be more validly assessed.Only a few studies, mainly in Europe, have investigated the effects of traffic‐related air pollution on human health. There is an ongoing debate about long‐term exposure to traffic‐related air pollutants, as chronic effects on respiratory health^1,2,3 and even mortality have been documented in several studies.^4,5 With respect to health effects, the most common investigated traffic‐related air pollutant is particulate matter.As a major source of particulate matter, traffic substantially contributes to the overall effect of outdoor air pollution.⁶ Although epidemiological research is needed, exposure assessment issues for traffic‐related air pollutants are complex and need to be considered before undertaking investigations of health effects. As vehicle emissions, by definition, take place on roads, people who live close to major roads might be expected to be exposed to higher concentrations of traffic‐related air pollutants and have a higher risk of adverse health effects. Several studies have shown higher rates of respiratory illness and symptoms and reduced lung functions in people living close to busy roads.^{1,7,8,9,10,11,12,13} Several studies showed that exposure to nitrogen dioxide (NO₂)^14,15 and particulate matter,¹⁶ as well as proximity to motorways,¹⁷ are associated with respiratory health symptoms.A powerful tool to estimate individual exposure to traffic‐related air pollutants is geographical information systems (GIS)‐based modelling. GIS provides the means to capture, store, process and display spatial data. In contrast with self‐reported traffic intensities, GIS models have a lot of advantages.^18,19 Assessments of exposure to traffic‐related air pollutants based on questionnaire reports, for example, can lead to serious misclassifications. Thus, individuals may overestimate the traffic intensity in their neighbourhood as high, even if the traffic load in the whole community is low.GIS‐based models can also include information from larger areas by taking different buffer zones into account. Up to now, only a few studies have combined geographical data with concentration measurements to calculate individual exposure.^2,20,21,22In the framework of the European Union‐funded Traffic‐Related Air Pollution and Childhood Asthma (TRAPCA) project, regression models were developed and applied to the residential addresses of 1756 children who lived in the city of Munich, Germany.² We extended our existing model²³ to the Munich metropolitan area, which includes the city of Munich and surrounding districts. Using the extended study population of this area, we tested the hypothesis whether increased exposure to traffic‐related air pollutants in children is associated with a higher risk of developing inhalant allergy, asthma or other chronic respiratory conditions than in children with low exposure.For this study, we developed GIS‐based regression models for particulate matter with a 50% cut‐off aerodynamic diameter of 2.5 µm (PM_2.5), PM_2.5 absorbance and NO₂ for the Munich metropolitan area and applied these models to the residential addresses of the members of two birth cohorts. Further, we analysed the association between exposure to traffic‐related air pollutants, living close to major roads and health effects at 2 years of life.     

Cigarette smoking and cancer risk: modeling total exposure and intensity

A recent analysis showed that the excess odds ratio (EOR) for lung cancer due to smoking can be modeled by a function which is linear in total pack-years and exponential in the logarithm of smoking intensity and its square. Below 15-20 cigarettes per day, the EOR/pack-year increased with intensity (direct exposure rate or enhanced potency effect), suggesting greater risk for a total exposure delivered at higher intensity (for a shorter duration) than for an equivalent exposure delivered at lower intensity. Above 20 cigarettes per day, the EOR/pack-year decreased with increasing intensity (inverse exposure rate or reduced potency effect), suggesting greater risk for a total exposure delivered at lower intensity (for a longer duration) than for an equivalent exposure delivered at higher intensity. The authors applied this model to data from 10 case-control studies of cancer, including cancers of the lung, bladder, oral cavity, pancreas, and esophagus. At lower intensities, there was enhanced potency for several cancer sites, but narrow ranges for pack-years increased uncertainty, precluding definitive conclusions. At higher intensities, there was a consistent reduced potency effect across studies. The intensity effects were statistically homogeneous, indicating that after accounting for risk from total pack-years, intensity patterns were comparable across the diverse cancer sites.     

Acute effects of ozone on mortality from the "air pollution and health: a European approach" project

In the Air Pollution and Health: A European Approach (APHEA2) project, the effects of ambient ozone concentrations on mortality were investigated. Data were collected on daily ozone concentrations, the daily number of deaths, confounders, and potential effect modifiers from 23 cities/areas for at least 3 years since 1990. Effect estimates were obtained for each city with city-specific models and were combined using second-stage regression models. No significant effects were observed during the cold half of the year. For the warm season, an increase in the 1-hour ozone concentration by 10 mug/m3 was associated with a 0.33% (95% confidence interval [CI], 0.17-0.52) increase in the total daily number of deaths, 0.45% (95% CI, 0.22-0.69) in the number of cardiovascular deaths, and 1.13% (95% CI, 0.62-1.48) in the number of respiratory deaths. The corresponding figures for the 8-hour ozone were similar. The associations with total mortality were independent of SO2 and particulate matter with aerodynamic diameter less than 10 mum (PM10) but were somewhat confounded by NO2 and CO. Individual city estimates were heterogeneous for total (a higher standardized mortality rate was associated with larger effects) and cardiovascular mortality (larger effects were observed in southern cities). The dose-response curve of ozone effects on total mortality during the summer did not deviate significantly from linearity.     

The cerebellar nodulus: Perceptual and ocular processing of graviceptive input

Current concepts postulate a decisive role of the cerebellar nodulus in the processing of otolith input. We hypothesized that nodular lesions abolish otolith‐perceptual integration, predicting alignment of perceived direction of earth vertical with the z‐axis of the head and not with gravity. In an 80‐year‐old patient with acute heminodular infarction, the subjective visual vertical deviated contralesionally by ?21.1° when the patient was upright. After subtracting this offset, perceived vertical closely matched the patient's head orientation when the patient was roll‐tilted. Otolith‐ocular reflexes remained normal. This is the first report on abolished earth verticality perception in heminodular stroke and underlines the importance of the nodulus in spatial orientation. Ann Neurol 2015;77:343–347     

Influence of the ischemic coronary bed on collateral blood flow

Summary The purpose of this study was to determine the influence of the resistance of the terminal vascular bed of an occluded coronary artery on collateral blood flow and collateral resistance. In 6 anesthetized dogs, left anterior descending coronary artery (LAD) was ligated, cannulated, and the terminal vascular bed was occluded by latex microspheres (diameter: 25). Retrograde flow was measured using a new technique, which allowed control of outflow pressure of retrograde flow (PRF) at the LAD cannula. When retrograde flow was interrupted, pressure in the occluded vessel represented collateral perfusion pressure (CPP) within the border zone of the ischemic vessel. Collateral resistance was determined dividing the pressure difference across the collateral bed (CPP-PRF) by retrograde flow. Variation of PRF was used as a model for changes in resistance of the ischemic bed. Retrograde flow fell when PRF was increased from 11.0±3.0 ml×min^–1×100 g^–1 (PRF=0) to 8.3±2.4 (p<0.01) (PRF=24.6±6 mm Hg). For the same PRF range, collateral resistance fell from 9.68±2.96 to 8.30±2.50 mm Hg×ml^–1×min×100 g (p<0.01). These results indicate that the vascular resistance of the terminal ischemic bed may considerably influence collateral blood flow and resistance.This study was supported in part by DFG grant Er 100/3-1     

Chronic Hepatitis E in Heart Transplant Recipients

Chronic courses of hepatitis E virus (HEV) infections have been described in immunosuppressed patients. We aimed to study the role of HEV infections in heart transplant recipients (HTR). 274 HTR were prospectively screened for HEV infection using an anti‐HEV‐IgG ELISA and HEV‐PCR. In addition, 137 patients undergoing cardiac surgery (non‐HTR) and 537 healthy subjects were studied cross‐sectionally. The anti‐HEV‐IgG seroprevalence was 11% in HTR, 7% in non‐HTR and 2% in healthy controls (HTR vs. healthy controls p<0.0001; non‐HTR vs. healthy controls p<0.01). Anti‐HEV tested positive in 4.0% in control cohorts of other immunocompromised patients (n = 474). Four HTR (1.5%) were chronically infected with HEV as shown by HEV‐PCR and all four patients had liver transaminases of >200 IU/L and histological or clinical evidence of advanced liver disease. In three patients ribavirin treatment was successful with a sustained biochemical and virological response while treatment failed in one cirrhotic patient after ribavirin dose reduction. Heart transplant recipients and patients undergoing cardiac surgery have an increased risk for HEV infections. Chronic hepatitis E may explain elevated liver enzymes in heart transplant recipients. Treatment of HEV infection with ribavirin is effective but the optimal dose and duration of ribavirin therapy remains to be determined.     

The German National Cohort

The German National Cohort (GNC) is a joint interdisciplinary endeavour of scientists from the Helmholtz Association, universities and other German research institutes. Its aim is to investigate the development of major chronic diseases (cardiovascular diseases, cancer, diabetes, neurodegenerative psychiatric diseases, pulmonary and infectious diseases), the subclinical stages and functional changes. In 18 study centres across Germany, a representative sample of the general population will be drawn to recruit in total 200,000 men and women aged 20-69 years. In addition to interviews and questionnaires, the baseline assessment includes a series of medical examinations and the collection of a diverse range of biomaterials. In 20% of the participants, an intensified assessment programme is foreseen. Also in 40,000 participants, magnetic resonance imaging of the whole body, heart and brain will be performed. After 5 years, a follow-up examination will be performed in all subjects and active follow-up by postal questionnaires is planned every 2-3 years. The GNC will provide an excellent basis for future population-based epidemiology in Germany and results will help identify new and tailored strategies for prevention, prediction and early detection of major diseases.