Correlations of C1q- and C3d-bearing circulating immune complexes with immunopathological disease activity in lupus nephritis patients

The serum levels of circulating immune complexes (CIC) measured by three different types of enzyme immunoassay (EIA) using monoclonal anti-C1q and antibodies and C1q as solid phase reagents were compared with clinical disease activity and immunohistological glomerular lesions in 29 SLE patients. Three types of CIC measured by these assays (anti-C1q CIC, anti-C3d CIC and C1q SP CIC) showed significantly higher levels in patients than in controls and were significantly associated with the clinical and serological disease activities. Anti-C1q CIC showed good correlation not only with mesangial IgG depositions (P < 0.01), but also with that of C1q (P < 0.05). C1q SP CIC also showed a weak correlation with mesangial C1q deposition (P < 0.05). Serum levels of anti-C3d CIC increased with the degree of mesangial IgG and complement depositions. Analysis of the clinical course of a patient with active SLE revealed a more rapid decrease of anti-C1q CIC and anti-C3d CIC along with the improvement of disease activity, including the mesangial lesion, than that of C1q SP CIC. According to these results, the CIC detected with assays using monoclonal antibodies against complement fragments, especially the anti-C1q assay, is likely to provide specific information regarding the clinical, serological and immunohistological disease activity in lupus nephritis.     

Management of severe burns during the 1st 72 hours

Early and efficient management of severely burned patients facilitates outcome improvement. Pre-hospital care includes fluid loading with 2 mL.kg-1/% burn over the first six hours, sedation and analgesia, prevention of hypothermia and ventilatory support for either critically burned patients or facial, cervical or pulmonary burn injury. The transient stay in a general hospital before transfer to a burn centre allows extension of initial care, the critical investigation for associated injuries (intoxication, multiple trauma) and to perform initial local treatment with sterile coverage or vaseline gauze after a revised assessment of the burned skin area, and possibly escharotomies. The main aim of care in the burn centre is to control hypovolaemia and to obtain maximal tissue perfusion and oxygen delivery to burned tissues, as well as to healthy organs. To manage the burn shock (initially hypovolemic and later on hyperdynamic) catecholamines are often indicated when appropriate fluid loading remains insufficient. Mechanical ventilation is indicated in case of either a deep extensive burn over 60% of total body surface area, or facial and cervical burns or severe pulmonary burn injury from smoke inhalation, carbon monoxide intoxication, tracheobronchial thermal injury and blast injury. Because of the severity of burn-related pain, and the stimulus linked to intensive care, continuous sedation is usually required. Early surgical treatment such as escharotomies, excision and grafting, which cause significant pain as well as blood loss, and hydrotherapy, often require general anaesthesia. Burn injury can modify the volume of distribution and the pharmacokinetics of anaesthetic agents. Finally, chemical or electrical burn, radiation, associated CO intoxication or multiple trauma, as well as burn injury in infants, raise specific problems. With improvement in early intensive care, the survival rate of the most severely burned patients is obviously improving. New techniques in skin substitution will probably further improve the final outcome.     

Debatable questions of surgical tactics in appendiceal infiltrates and periappendiceal abscess

The disease course in 68 patients with appendicular infiltrate (AI) and periappendicular abscess (PAA) is analysed. There were 42 men and 26 women at the age of 15-76 years. AI was detected in 12 patients, PAA-in 56 patients. In 39 patients diagnosis was made on the basis of clinical examination, laboratory tests and X-ray examination. Ultrasound examination was used in 19 cases. Conservative treatment appeared to be effective in 7 patients. The abscess developed in 4 patients. In 5 patients the diagnosis of AI was confirmed at the surgery. Opening and draining of the abscess was performed in 35 patients. The transabdominal opening of the abscess in combination with appendectomy was used in 19 patients. The median laparotomy, appendectomy and abdominal drainage were conducted in 2 patients with the break of the abscess into the abdominal cavity that led to the development of disseminated purulent peritonitis. The long-term results after the resolution of the infiltrate and opening of the abscess were analysed in 38 patients. The postoperative complications have developed in 29 patients, reoperation was performed in 7 of them. 2 of the 68 patients died after surgery. The total mortality rate was 2.9%, postoperative mortality-3.4%. Acute liver insufficiency (1) and intoxication (1) were the causes of death.     

Local mechanisms of relationship between colloid-osmotic pressure and ophthalmic tone in patients with diabetes mellitus

The paper presents 5 cases of histologically verified tuberculous peritonitis followed up by the author in 1994-1996. All patients were admitted to hospital and undergone surgical intervention for emergency indications. The main symptoms were intoxication, abdominal pain and enlargement. Two typical cases are described. Tuberculous peritonitis is recommended to be included into the differential diagnostic list of acute surgical abdominal diseases.     

Abdominal catastrophe: visceral injury as a cause of peritonitis in patients treated by peritoneal dialysis

OBJECTIVE: Peritonitis is considered an acceptable and controllable risk in patients undergoing chronic peritoneal dialysis (PD). In contrast, peritonitis due to visceral leakage represents a true "abdominal catastrophe" because of striking morbidity and mortality. To delineate the incidence, causes, and outcomes of catastrophic peritonitis, we compared patients who developed peritonitis due to documented visceral leakage with patients who developed peritonitis due to enteric organisms without evidence of visceral leakage. DESIGN: Retrospective chart review. SETTING: PD Unit located in tertiary care referral center. PATIENTS: 230 patients treated by PD between January 1988 and June 1996. MAIN OUTCOME MEASURES: All episodes of PD-related peritonitis occurring over an 8-year period. Hospital course of all patients with or without renal failure who were treated at University Hospitals of Cleveland for ischemic bowel disease, cholecystitis, viscus perforation, or diverticulitis. RESULTS: Anatomically documented visceral injury caused 32.5% of episodes of enteric bacterial peritonitis in 72 patients between January 1988 and June 1996. The overall incidence of this "abdominal catastrophe" was 11.3%, or 26 of a total of 230 patients treated by PD. Of the 26 patients, 50% died, 30.7% survived but switched permanently to hemodialysis, and only 19.2% remained on, or returned to, PD. Compared to renal failure patients treated by hemodialysis or transplantation and to non-renal failure patients, the incidence of abdominal catastrophe was 20-60 times greater in patients treated by PD. CONCLUSIONS: Evidence for injury of an abdominal organ should be sought in all patients treated by PD who develop peritonitis with enteric organisms. Surgical intervention is definitive for diagnosis, and if performed early may reduce morbidity and mortality.     

Common abdominal emergency cases a the end of the 20th century

Despite the marked decline in mortality of acute appendicitis over the past 50 years, the rate of perforation and negative appendectomy remains unchanged. The most effective means of controlling human suffering and economic cost associated with appendicitis is the identification and correction of factors responsible for perforation. Negative appendectomy rates have been relatively stable over the decades. Progress in diagnosis and diagnostic imaging still has not provided a foolproof non-invasive test to rule out the presence of appendicitis accurately. Clinical assessment determines the treatment and the clinical observation should be done by the surgeon. The use of H2-receptor antagonists has not reduced emergency admission of patients with duodenal ulcer. Mortality associated with perforated peptic ulcer remains high in spite of advances in surgical management. The patients with acute obstructed cholecystitis usually reach the surgeon with more advanced stage of the disease which results in increased morbidity and subsequently increased cost for undergoing cholecystectomy. If the patient develops severe diffuse peritonitis, the mortality could reach 30%. This is in spite of aggressive surgical treatment, potent antibiotics, modern intensive care and diagnostic procedures. To improve the results, more advanced treatment to avoid the development of peritonitis and more effective antibiotics to control the inflammation will be needed.     

Diagnostic and therapeutic management of ethylene glycol poisoning. Importance of crystalluria. Apropos of a case

During the course of a case of ethylene glycol poisoning with ensuing oliguric renal failure despite early dialysis, we show the importance of early diagnosis of this intoxication in underlined. Characteristics of ethylene glycol poisoning are: metabolic acidosis with anion gap (without lactic acidosis or keto-acidosis) and high plasma osmolarity. Awaiting the result of blood and urinary toxic values, crystalluria, by typical needle monohydrate calcium oxalate crystals finding, evokes the diagnosis and permits to start a specific treatment. This treatment is based on: principles of intensive care, ethanol administration (or 4-methyl-pyrazole now available), also thiamine and pyridoxine administration and finally, dialysis therapy. We can hope, with early and intensive management of this poisoning, to prevent the renal failure, principal complication of ethylene glycol ingestion, which can lead to chronic renal failure. Therefore, crystalluria, an easy and specific diagnosis technic, is of great interest.     

Laparostomy as a part of intensive surgical care

The presented paper is based on an analysis of 24 cases where as part of comprehensive surgical care the laparostomic procedure was used. In nine patients advanced diffuse peritonitis was involved, nine times the method was applied in patients with haemorrhagic necrotizing pancreatitis, four times in intestinal ischaemia and twice as a temporary closure of an extensive defect of the abdominal wall. In all instances a zipper of Ethicon Co. was used. Eight patients died i.e. lethality was 33%. The main contribution of the method is according to the authors the possibility of easy repetition of the surgical intervention in the abdominal cavity with elimination of septic foci and effective decompression of the abdominal cavity which has a positive impact on ventilation.     

Congenital cholesteatoma in a child carrying a gene mutation for adenomatous polyposis coli

A 53-year-old woman with a history of cervical carcinoma 14 years ago, treated with hysterectomy and radiation therapy, was admitted to the intensive care unit with severe SIRS (systemic inflammatory response syndrome) progressing to shock, multiple organ failure and death within 5 d. Bilateral hydronephrosis diagnosed by sonography and an enlarged left kidney with suspected abscesses verified in a CT-scan suggested the diagnosis of urosepsis. However, multiple microbiological examinations remained sterile. Despite surgical treatment and aggressive intensive care, she died in unresponsive shock. Pathohistologically, an angiotropic large B-cell lymphoma, a rare diffuse intravascular neoplasm of lymphoid origin, was diagnosed. The patient's history of abdominal radiation therapy 14 years earlier as well as multiple negative microbiological specimens in a patient with suspected urosepsis should have initiated the search for a non-infectious cause of the disease.     

A clinincal evaluation of abdominal paracentesis in the horse

This paper evaluates the usefulness of abdominal paracentesis as a diagnostic aid in abdominal disease in the horse and in particular considers whether or not it can be effectively utilised as an indication for surgical intervention in cases of colic. The results are based upon peritoneal fluid samples collected from 20 normal horses and from 20 cases of colic and peritonitis. Peritoneal fluid was collected from standing horses by inserting a bovine teat cannula into the horses abdomen through the linea alba after desensitisation of the skin on the ventral midline with local anaesthetic. Usually, from 3-5 ml of fluid could be collected from a normal horse. This was either clear or cloudy white or yellow in colour and contained 3310 +/- 703 leucocytes/ml consisting of 63.81% neutrophils, 1.4 +/- 1.3% monocytes, 13.5 +/- 4.3% mesothelial cells and 21.25% +/- 6.2% lymphocytes. Protein content was 1.29 +/- .4g/100ml. Changes in the volume, colour, cellular constituents and protein content of fluid, characterised abdominal disease. In cases of colic, discolouration of the abdominal fluid was found to be the most consistent, reliable and useful indication of bowel necrosis. This in turn indicated the need for urgent surgical intervention rather than conservative treatment. Discolouration commenced early in the course of the disease even while the segment of bowel involved was still viable. Increased volume of fluid, elevated leucocyte count (statistically significant at the 5% level), increased neutrophil percentage and elevated protein levels were less useful criteria for determining the integrity of the bowel. Similar changes from the normal were also found in cases of peritonitis. Here, however, microscopic examination of cells in a smear of the fluid was more useful, as phagocytosis and abnormal cell types indicating infection or inflammation could be seen readily, and a diagnosis based upon these findings. It was concluded that abdominal paracentesis, although no substitute for thorough clinical examination, was a valuable diagnostic aid for abdominal conditions of the horse.     

Jejunal perforation caused by blunt abdominal trauma in a patient with Crohn's disease: report of a case

We report herein the case of a 23-year-old man with Crohn's disease who was found to have a perforated small bowel following blunt abdominal trauma sustained in a traffic accident. The general findings of diffuse peritonitis were identified by physical examination, and a plain X-ray film showed free air in the abdominal cavity. An emergency laparotomy was performed which revealed three perforated ulcers in the affected intestine. An abrupt increase in intraluminal pressure due to the striking force of the steering wheel to the abdomen was assumed to have been the cause of these perforations.     

Management of hepatic encephalopathy

Among the general principles of the therapy of hepatic encephalopathy the authors discuss the intensive care of patients, maintenance of their volume and electrolyte balance, treatment of coagulation defect, therapy of gastrointestinal bleeding and portal hypertension, provision of central renal catheter, infection prophylaxis, monitoring of intracranial pressure, and if necessary, respiration and intubation of patients. The study also deals with possibilities of treatment based on the toxic hypothesis and on the theory of neurotransmitters. Attention is paid to the therapy of brain oedema and to the significance of hemodialysis, hemoperfusion, plasmapheresis and hybrid bioartificial liver cell treatment. The authors deal with the indications of glucagon-insulin therapy and emphasize the importance of liver transplantation in the treatment of hepatic encephalopathy.     

Acute poisoning by beta-blockers and by calcium inhibitors

beta-blockers and calcium-channel inhibitors are frequently used for self-poisoning. Propranolol and verapamil, the leading drugs in each pharmacological class, are the most toxic. They interfere with intracellular calcium concentration in muscles. Circulatory insufficiency may be due to vasodilatation, myocardial depression or severe bradycardia. If one respects a specific sequence for administration, the usual antidotes (glucagon, calcium salts, isoprenaline, epinephrine) are usually efficient. One must not underestimate the risk of worsening of an intoxication that is seen at the early stage, that occur in an old person or in a patient with heart disease, or that depress ventilation. Hence, it is important to monitor and treat these intoxications in an intensive care unit.     

The premature infant below 1000 g

74 premature infants with a birth weight of 1000 g or less were hospitalized in the period 1963-1975. 20 babies survived the first 4 weeks of life and 2 died during the second month of life from progressive lung disease. 77% of all patients were mechanically ventilated and 9 ventilated patients survived. The main causes of death were cerebral hemorrhage, severe asphyxia and septicemia. Prognosis was impaired by hypothermia, IRDS, gestational age below 27 weeks and premature rupture of membranes with bacterial infection. At the age of 1 year 8 out of 12 survivors followed up showed normal mental and motoric development. 3 children had minor or obvious signs of cerebral paresis and one further child has partial retrolental fibroplasia. Due to modern intensive care the survival rate of these very small premature babies has now reached 40%. The prognosis is favourably influenced by optimal obstetric and neonatal care, while special precautions should be undertaken to avoid hypothermia. Our results with mechanical ventilation justify the administration of full intensive care to these very small premature babies.     

Concurrent abomasal displacement and perforating ulceration in cattle: 21 cases (1985-1996)

OBJECTIVE: To evaluate the association of physical examination and clinicopathologic findings with surgical findings in cattle with concurrent abomasal displacement and perforating ulceration, to determine short- and long-term survival rates in these cattle, and to determine whether degree of peritonitis (focal vs diffuse) influences survival rates. DESIGN: Retrospective study. ANIMALS: 21 cattle with concurrent abomasal displacement and perforating ulceration and 42 cattle with uncomplicated abomasal displacement. PROCEDURE: Information on signalment, stage of lactation, physical examination findings, clinicopathologic data, surgical diagnosis, procedure(s) performed, and necropsy findings were retrieved from medical records of all cattle included in this study. Differences between physical examination findings of cattle with concurrent disease and those of cattle with uncomplicated displacements were evaluated, as were differences between survival rates in cattle with focal versus diffuse peritonitis. RESULTS: Cattle with concurrent disease had a greater probability of having pneumoperitoneum and signs of abdominal pain identified on physical examination than did cattle with uncomplicated diseases. There was no relationship between clinicopathologic data and survival time. Short-term survival rate was 38%, and degree of peritonitis significantly influenced survival time in cattle with concurrent abomasal displacement and perforating ulceration. Long-term survival rate in these cattle was 14%. CLINICAL IMPLICATIONS: Cattle with concurrent displaced abomasum and perforating ulceration have a poor chance for survival. In addition to detection of displaced abomasum, physical examination findings that can help lead to a presurgical diagnosis of this syndrome are pneumoperitoneum and signs of abdominal pain.     

Treatment of cancer chemotherapy-associated thrombotic thrombocytopenic purpura/hemolytic uremic syndrome by protein A immunoadsorption of plasma

BACKGROUND: Chemotherapy-associated thrombotic thrombocytopenic purpura/hemolytic uremic syndrome (C-TTP/HUS) is a condition involving thrombocytopenia, microangiopathic hemolytic anemia, and progressive renal dysfunction that develops in 2-10% of patients with a history of malignant neoplasms treated with certain chemotherapeutic agents. Pathogenesis of the disease may depend on the following: (1) generation of endothelial lesions in the kidney microvasculature, resulting from drug toxic effects and/or generation of small soluble circulating immune complexes (CIC), and (2) generation of autoantibodies and/or CIC that trigger aggregation and deposition of platelets around the lesions. METHODS: Extracorporeal immunoadsorption treatment of plasma (PROSORBA columns, IMRE Corporation, Seattle, WA) to remove immunoglobulin G and CIC was evaluated in 55 patients for the potential to induce significant clinical benefits (increase in platelet count, decrease in hemolysis, stabilization of renal function) and longer survival. RESULTS: Response to therapy was achieved in 25 of 55 patients examined. Response was associated with an estimated 1-year survival rate of 61%, as compared with an estimated survival rate of only 22% in those who did not respond (P = 0.0001). Patients whose malignant neoplasms were in complete or partial remission at the time of development of C-TTP/HUS had a significantly higher estimated 1-year survival rate (74%) as compared with a historic control group of patients receiving other treatments (22%, P = 0.0161). Clinical responses were correlated with normalization of serum levels of CIC and complement components C3c and C4. There were no side effects associated with 75% of treatments. Immunoadsorption therapy was associated with generally mild to moderate manageable side effects, such as fever, chills, nausea/vomiting, respiratory symptoms, pain, hypertension, and hypotension, which were reported in 25% of procedures. CONCLUSIONS: This multicenter study establishes protein A immunoadsorption as an effective and safe treatment for cancer chemotherapy-associated TTP/HUS, an otherwise fatal disease.     

Risk factors determining the outcome of a diffuse peritonitis of appendicular genesis in children

The peculiarities of pre-, intra- and early postoperative period course in 108 children, operated on for diffuse and general peritonitis of appendicitis origin, are studied. Most significant 34 prognostic factors for the disease outcome are choosed. The leading factors are the disease course duration, general condition of the patient while hospitalization, the vegetative disorders presence, the intestinal paresis degree, the biochemical inductors of stress contents, the peritoneal exudate character, the kind and composition of microorganisms in it, the character of an early postoperative period course.     

Acquisition of American sign language by a noncommunicating autistic child

Clinical and in vitro investigations were carried out to test the efficacy of gut lavage, hemodialysis, and hemoperfusion in the treatment of poisoning with paraquat or diquat. In a patient suffering from diquat intoxication 130 times more diquat was removed by gut lavage 30 h after ingestion than was removed by complete aspiration of the gastric contents. Determination of in vitro clearances for paraquat and diquat by hemodialysis showed that, at serum concentrations of 1-2 ppm, such as are frequently encountered in poisoning in man, toxicologically relevant quantities of herbicide cannot be removed from the body. At a concentration of 20 ppm, on the other hand, hemodialysis proved to be effective, the clearance being 70 ml/min at a blood flow rate of 100 ml/min. The efficacy of hemoperfusion with coated activated charcoal was on the whole better. Especially at concentrations around 1-2 ppm, the clearance values for hemoperfusion were some 5-7 times higher than those for hemodialysis. In a patient suffering from paraquat poisoning, both hemodialysis as well as hemoperfusion were carried out. The in vitro results could be confirmed: At serum concentrations of paraquats less than 1 ppm no clearance could be obtained by hemodialysis while by hemoperfusion with activated charcoal quite high clearance values were measured and the serum level dropped down to zero.     

Artificial nutrition of patients with toxic epidermal necrolysis (Lyell syndrome)

The authors report the case of a 30-year-old man treated with toxic epidermal necrolysis. Toxic epidermal necrolysis was due to anticonvulsive drug treatment. The patient was admitted with denudated skin surface similar to second-degree burn that covered 90 per cent of the patient's body surface. The patient was isolated and treated, receiving sterile wound care, broad spectrum antibiotic and corticosteroid. Total parenteral nutrition was instituted until the 5th day of care because the patient was unable to take normal food. The energy intake reached 146 kJ/kg bodyweight containing 4 g/kg bodyweight carbohydrates and 2 g/kg bodyweight fat emulsion supplemented with 10-15 g of nitrogen per day. The enteral nutrition was commenced gradually with decreasing parenteral nutrition. The nutritive solutions were supplemented with ions, vitamins and trace elements. The patient left the intensive care unit after 23 days of care. The toxic epidermal necrolysis is a life-threatening dermatological disease and should be treated at intensive care unit. The early recognition of the disease, the intensive care and nutritional therapy may improve the survival of patients with toxic epidermal necrolysis.     

Septic shock following abdominal operations (author's transl)

Septic or toxic shock is a life threatening complication after abdominal operations. The etiologic analysis of our 102 patients showed the following conditions: 1. diseases, which have already preoperatively a high incidence of septic complications, 2. sepsis developing after primary aseptic diseases, 3. septis without any etiologic connection to the primary disease or operation. An initial standarised intensive therapy must start before any irreversible organ damage may occur. First aim of all surgical measures is the eradication of the source of infection. Early relaparotomy is the only possibility for correction of intraoperativ technical defects. Only by longstanding combination of intensive personal and technical support prognosis of septic shock after abdominal operations can be improved.