Ureteral stents — materials and new forms

Summary Three different types of polymers are currently used for self-retained ureteral stents: thermoplastic materials such as polyurethanes, and thermoset elastomers such as silicone and hydrogels. Polyurethane stents are easy to form and have high drainage capacity, whereas silicone shows the best biocompatibility but a lower drainage efficacy than the former. A mock urinary system consisting of a collecting system and a 9-F tube was used to evaluate the flow characteristics of various double-pigtail stents in cases of urinary obstruction. For simulation of an unobstructed urinary system a human urogenital system was used. Inner flow polyurethane stents showed the best drainage as compared with inner flow silicone and outer flow ESWL stents in an obstructed ureter, whereas ESWL stents maintained the best flow in an unobstructed ureter or in respect to conventional stents with obstructed sideports.     

34. Akute und chronische Pankreatitis. Morphologische Grundlagen

Zusammenfassung Die akute Pankreatitis zeigt mit der jauchigen Nekrose und der Vielfalt der Fettgewebsnekrosen ein eindrucksvolles Bild. Dennoch sind einige Teilaspekte wenig bekannt und für das Verständnis der Krankheit wichtig, z. B. die häufige Aussparung des Kerns der Drüse. Die anatomischen Äquivalente von Schock, Schmerz, Ileus werden erläutert, auf das Krankheitsbild Pankreatitis ohne Pankreatitis wird kurz eingegangen. Als Komplikationen werden die Chronifizierung und die Pseudocysten dargestellt. Die chronische Pankreatitis bis zur ausgebrannten Drüse mit Stein, Diabetes und möglicherweise Carcinom wird in ihrer Entstehung anatomisch gezeigt.

---

Fundamental morphological aspects of acute and chronic pancreatitis

Summary Acute pancreatitis presents an impressive picture, with autodigestic necrosis and various types of necrosis of fat tissue. Nevertheless, some side aspects are little known, although they are important to the understanding of the disease, e.g. the frequent sparing of the kernel of the gland. The anatomical equivalents of shock, pain, ileus are exvlained, and the syndrome of pancreatitis without pancreatitis will be briefly discussed. The complications of progression to a chronic state and of pseudocysts will be shown. The development of chronic pancreatitis leading to the burnt out gland with stones, diabetes and possibly carcinoma will be shown anatomically.

     

PTSD among vietnam veterans: An early look at treatment outcome using direct therapeutic exposure

Vietnam combat veteran inpatients were evaluated after being treated in a PTSD special treatment unit. Selected pretreatment measures that included mental and physical problems, combat variables, PTSD symptoms, and the standard MMPI scales found no clinically meaningful differences between a group that was found to be successes and another group found to be failures, based on predetermined cutoff scores on the VETS scale, a reliable outcome measure for veteran patients. At 3 months post-therapy, a significantly greater number of subjects treated with Direct Therapeutic Exposure (DTE) (flooding therapy) as compared to another group treated with a more conventional individual therapy, were identified as successes as opposed to failures, based on the VETs scale. Also, the number of failures was greater for those treated with the more conventional therapy and the number of successess was greater for those treated with DTE, when compared to all other subjects in the sample. These preliminary results were interpreted as indicating that DTE, when offered as part of an inpatient milieu, shows promise as an effective treatment for chronic/severe combat veteran PTSD sufferers.     

Evaluation of urodynamic studies by computer

Summary In an attempt to simplify urodynamic evaluation, the data obtained from cystometry, urethral profile and flowmetry were analysed using the ICS recommendations for standardization and terminology. All studies were compiled from check lists feasible for computation. The aim was to establish standards and typical changes for the normal bladder and pathological states to enable automatic readout of computed data. The results did, in fact, show typical changes but failed to establish standard measurements suitable for completely computed diagnoses.     

Die Beziehungen von Geschwulstart und Lokalisation der Bronchialcarcinome zur Lungenbelüftung und ihre Veränderungen durch exogene Einflüsse (chronische Bronchitis,Pneumonie, Raucher)

Zusammenfassung Es wurde an einem Krankengut von 435 Patienten mit Bronchialkrebs untersucht, ob sich aus klinischen Daten Rückschlüsse auf die Entstehung des Leidens ziehen lassen könnten. Die Vielzahl von Faktoren einerseits und ihre große Kombinationsmöglichkeit andererseits ergab die Forderung, wenige aber eindeutige und konstante Merkmale zu finden. Als solche wurden die Geschwulstlokalisation und der Geschwulsttyp erkannt. Der Vergleich der lokalisatorischen Anordnung der Geschwülste mit der Lungenbelüftung ergab eine bemerkenswerte Parallelität:Die prozentuale Verteilung der Tumoren entspricht der Belüftung der entsprechenden Lungenabschnitte. Die Gleichsinnigkeit von Tumorbefall und Beatmung war für die Lungenflügel und Lungenlappen ebenso nachweisbar wie für verschiedene Abschnitte des Bronchialbaumes. Es wurde daraus gefolgert, daß Belüftung und Tumorbefall in einem ursächlichen Zusammenhang stehen. Darüber hinaus fand sich, daß bei prozentual gleicher Verteilung die Plattenepithelkrebse mehr zentral, die kleinzelligen Geschwulste mehr peripher im Bronchialbaum anzutreffen sind. Diese Beziehung von Tumorlokalisation und Geschwulstart müßte sich in seiner prozentualen Anordnung verschieben, sobald exogene Reize ausreichender Intensität auftreffen.Dieses wurde für die Einwirkungen chronische Bronchitis und Pneumonie sowie Raucher untersucht. Für jede dieser Gruppe stellte sich eine besondere Form der bevorzugten Tumorlokalisation heraus, für Bronchitis und Raucher war das Überwiegen der Plattenepithelkrebse ebenfalls eindeutig nachweisbar. Mit diesen Untersuchungen ist einerseits die Richtigkeit der Auffassung erbracht, daß exogene Reize als die wesentlichen Bedingungen für die Entstehung des Bronchialcarcinoms angesehen werden müssen; andererseits ist damit zugleich gezeigt, daß sich ein ätiologisches Moment für chronische Bronchitis, Rauchen und Pneumonie nicht mehr fortleugnen läßt.Mit 15 Textabbildungen.     

Preliminary experience with intracorporeal laparoscopic ultrasonography using a sector scanning probe

Laparoscopic ultrasonography is a novel technique which may be useful in screening for choledocholithiasis during laparoscopic cholecystectomy. Following concerns regarding the learning curve and accuracy associated with the adoption of this user-dependent technology, we have prospectively evaluated a commercially available 90° sector scanning laparoscopic ultrasound probe during elective laparoscopic cholecystectomy. Laparoscopic ultrasonography was performed in 60 patients and identified common duct stones in nine patients (one false positive and one false negative), and previously unsuspected duct stones were defined in three out of four patients. The gallbladder and portal vein were constantly defined anatomical landmarks throughout the study, whereas the suprapancreatic bile duct, intrapancreatic bile duct, and pancreatic duct were identified in 100%, 80%, and 85% of patients in the third consecutive group of 20 patients examined. Laparoscopic ultrasonography has the potential to accurately identify common duct stones during laparoscopic cholecystectomy and thereby implement a policy of superselective operative cholangiography. However, adequate training for surgeons unfamiliar with this technology is recommended.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, Tennessee, USA, 18–19 April 1994     

Premature craniosynostosis a retrospective analysis of a series of 52 cases

Summary A retrospective analysis of a consecutive series of 52 cases with premature craniosynostosis is presented.Excellent functional, cosmetic, and social results could be achieved by resection of prematurely fused sutures and the creation of artificial growth sutures. Pronounced skull deformities have been corrected using the basket handle, the visor plasty, and the T-bone techniques or a combination of several of these skull form correction techniques. The surgical correction of the skull base by the frontal advancement technique in combination with orbitotomy was only necessary in 2 of our cases and could have been considered in 2 additional cases viewed retrospectively.Our results support the hypothesis that the primary cause of skull deformity is the premature closure of vault sutures and not a primary deformity of the skull base.     

Urethro-vesical function during spinal shock

Summary Twenty spinal shock patients were investigated with simultaneous urethrovesical, anal and rectal pressure recordings and EMG of the external urethral and anal sphincters. Dynamic and static urethral pressure profiles (UPP) were carried out with empty and full bladder. Baldder filling was accompanied by an increased resistance in the internal sphincter zone, which in turn was paralleled in the majority of cases by an elevation of pressure in the membranous urethra without concomitant increase of its EMG activity. This is suggestive of an increased sympathetic activity in the bladder neck area and in the smooth muscle component of the external urethral sphincter. Dynamic pullthrough UPP's displayed higher resistances in the membranous urethra than static interrupted UPP's pointing to the role played by the urethral muscosal receptors in eliciting artefactual results. Higher pressures were recorded in the juxtabulbar portion of the membranous urethra than in its mid portion pointing to a gradient of pressure within the external urethral sphincter itself. The amount of EMG activity recorded in the anal and urethral sphincters at rest was somewhat decreased; high pressures and distinct reflex activity were recorded in both sphincters showing that they escape spinal shock characterized primarily by areflexia. After defining spinal shock a rational explanation based upon neuroanatomical and neurophysiological findings is offered as to why somatic activity of the sacral segments escapes it as evidenced by clincial, urodynamic, and electromyographic recordings.     

Cranioplasty of an extremely large cranial defect caused by transitional meningioma with a knitted polypropylen-polyester prothesis “Codubix”

Summary The authors report a case of transitional cell meningioma of the convexity which destroyed a large portion of the calvarium and invaded subcutaneous tissue. The tumour was totally removed and a large cranial defect/430 cm² in size/ was filled with a polypropyleno-polyester knitted prothesis Codubix with an excellent result.The problems of chronioplastic closure of such an unusually large skull defect and the advantages of the use of the material Codubix are discussed.     

Validity and interobserver agreement of a new radiographic grading system for intervertebral disc degeneration: Part II. Cervical spine

A new radiographic grading system for a more objective assessment of lumbar intervertebral disc degeneration has been described and tested in Part I of this study. The aim of the present Part II of the study was to adapt this system to the cervical spine, and to test it for validity and interobserver agreement. Some modifications of the grading system described in Part I were necessary to make it applicable to the cervical spine. Its basic structure, however, stayed untouched. The three variables Height Loss, Osteophyte Formation and Diffuse Sclerosis first have to be graded individually. Then, the Overall Degree of Degeneration is assigned on a four-point scale from 0 (no degeneration) to 3 (severe degeneration). For validation, the radiographic degrees of degeneration of 28 cervical discs were compared to the respective macroscopic ones, which were defined as real degrees of degeneration. The interobserver agreement was determined between one experienced and one unexperienced observer using the radiographs of 57 cervical discs. Quadratic weighted Kappa coefficients () with 95% confidence limits (95% CL) were used for statistical evaluation. The validation of the new version of the radiographic grading system showed a moderate agreement with the real, macroscopic overall degree of degeneration (=0.599, 95% CL 0.421–0.786). In 64% of all discs the real overall degree of degeneration was underestimated but never overestimated. This underestimation, however, was much less pronounced and the Kappa coefficients were significantly higher for the three variables: Height Loss, Osteophyte Formation, and Diffuse Sclerosis separately. The agreement between the radiographic ratings of the experienced and the unexperienced observer was substantial for the overall degree of degeneration (=0.688, 95% CL 0.580–0.796), almost perfect for the variable, Height Loss, moderate for Osteophyte Formation and fair for Diffuse Sclerosis. In conclusion, we believe that the new version of the radiographic grading system is a sufficiently valid and reliable tool to quantify the degree of degeneration of individual cervical intervertebral discs. In comparison to the version for the lumbar spine described in Part I, however, a slightly higher tendency to underestimate the real overall degree of degeneration and somewhat higher interobserver differences have to be expected.Part I of this article can be found at http://dx.doi.org/10.1007/s00586-005-1029-9     

Learning about combat stress from Homer'sIliad

Vietnam Veterans with severe post-traumatic stress disorder often report the following combat experiences: a leader's betrayal of what's right, lost responsiveness to claims outside a tiny circle of combat-proven comrades, grief and guilt for a dead special comrade, lust for revenge, renunciation of homecoming, feeling already dead, going berserk, dishonoring the enemy, and atrocities. These elements are all in Homer'sIliad account of Achilles, allowing the reader to witness them as they happen, so to speak. Homer's view of healing and regained humanity is discussed in relation to theIliad's final scene. TheIliad offers a cross-cultural look at men in battle, and raises questions about some assumptions in American military culture, particularly regarding grief and the need to degrade the enemy to make men fight. Betrayal of what's right and the berserk state are suggested as key pathogens for PTSD in combat soldiers.     

A “reverse genetic” approach to autosomal dominant polycystic kidney disease

Biochemical, anatomical, pathophysiological and clinical studies of autosomal dominant adult-type polycystic kidney disease have cast little light on the underlying biochemical defect which causes the disease. The advent of recombinant DNA technology permits a novel approach to its pathophysiology. In this approach, termed reverse genetics, the mutation which produces the disease is first localised by genetic linkage. This is followed by the identification and cloning of the disease gene itself, and the characterisation of its mutations. The recent assignment of the polycystic kidney disease mutation to the short arm of chromosome 16 is thus the first step in a reverse genetic approach to an understanding of the molecular pathology of this disorder.     

Absorptiometry and “osteoporosis”: problems

connecting the dots between diverse clinical and other matters and an updated bone physiology reveals relationships that could modify some ideas about the roles and uses of absorptiometry in osteoporosis work. Herein, absorptiometry means that part of clinical densitometry that depends on X-ray absorption by bone and other tissues, thus excluding ultrasound methods and magnetic resonance imaging. The modifications concern, in part, some limitations of bone mineral density data, the kinds of physiological information that absorptiometry can and cannot provide, the relative importance of bone mass and whole-bone strength, how to define and study bone health and osteoporosis, and two kinds of osteoporotic fractures. As those modifications concern important national health care issues, they deserve answers based on hard evidence. Identifying those modifications might help others to evaluate them.     

Development of a PC-based expert system for lower urinary tract pressure-flow studies

Summary An on-line personal computer (PC)-based expert system was constructed for pressure-flow study of the lower urinary tract. An empty expert-system shell and supplementary programs were used for this system; the latter served to compensate the defects of the shell and are referred to as data programs in this report. The data programs were written in the C programming language and were used for on-line data sampling, data entry using a photoscanner, calculation of parameters, saving and loading of data, graphic display, and printing. The urodynamic pressure-flow expert system necessitates on-line data transfer, since it requires a large volume of data. However, off-line data recorded on paper was also made available for ready input by a photoscanner. Reasonable diagnostic accuracy has been achieved by our new expert system for pressure-flow studies. It should be useful in the clinical setting as well as for teaching urological students.Presented at the 19th Annual Meeting of the International Continence Society, Ljubljana, 1989, and published elsewhere as an abstract (Neurourol Urodyn 8:409–410)     

Digital subtraction angiography (DSA): New perspectives in angiography

Summary Digital subtraction angiography (DSA) has strongly influenced angiographic procedures. Because it is less invasive it has increased the total number of angiographies in all places where it was introduced. The paper gives an introduction to the procedure explaining the roles of digital and subtraction in DSA. It is written from a technical point of view. The examples are taken from and with the DVI system.     

The distribution of extracellular matrix vesicles in healing of rat tibial bone three days after intramedullary injury

Summary The distribution of extracellular matrix vesicles on the third day of bone healing was studied by morphometric analysis of transmission electron micrographs. Detection and grouping of the vesicles was performed according to type, diameter, and distance from the calcified front. The different types were selected as follows: vesicles with electron-lucent contents (empty), vesicles with amorphous electron-opaque contents (amorphic), vesicles containing crystalline depositions (crystal), and vesicles containing crystalline structures with ruptured membranes (rupture). The majority of vesicles were between 0.07 µm and 0.12 m in diameter and were located at less than 3 m from the calcified front. The distribution of the empty, amorphic, crystal, and rupture vesicles was 23.2%, 74%, 2.5%, and 0.3% respectively. Their sequence of arrangement according to diameter was as follows: empty, amorphic, crystal, and rupture, the empty vesicles constituting the smallest and the rupture the largest type. Distances from the calcified front were similar for the empty, amorphic, and crystal vesicles, while the rupture type was located nearest to the front. The present observations support the widely acknowledged hypothesis on the role of extracellular matrix vesicles in mineralization. It is thought that the secretion of empty vesicles from the cell is followed by intravscular accumulation of amorphous Ca and Pi to form a hydroxyapatite crystal that, in turn, ruptures the vesicle's membrane. The maturation process is accompanied by an increase of the vesicular diameter and its approximation to the calcifying front.     

Elective neurectomy during open, “tension free” inguinal hernia repair

Chronic postoperative inguinal pain syndromes are potentially debilitating sequelae following elective inguinal hernia repair. Diagnosis and definitive treatment constitute challenging issues for both the surgeon and the patient. In this prospective trial, we evaluated the impact of elective iliohypogastric and ilioinguinal nerve resection on the incidence of pain, numbness, and sensory loss following anterior, tension-free herniorrhaphy. One hundred ninety-one patients were enrolled and were reviewed 1 month, 6 months, and 1 year postoperatively. Pain, numbness, or any loss of sensation were recorded and categorized on a mild, moderate, or severe scale. No persistent pain syndrome was encountered. Numbness was found in 9.42% of the patients at the first month and in 6.28% of the patients after 1 year. Sensation loss (1.04%) was never bothersome or incapacitating at the end of the follow-up period. Elective neurectomy is safe to perform, well tolerated by patients, and is not associated with chronic postoperative inguinal pain.     

Triple approach for diagnosis and grading of meningiomas: Histology,morphometry of Ki-67/feulgen stainings,and cytogenetics

Summary With regard to meningioma grading and the recently introduced atypical meningioma, we evaluated 160 cases retrospectively by conventional histology and image analysis. For that, the cell nuclei were stained with a Ki-67 (MIB1)/Feulgen-method on paraffin sections, thus enabling the assessment of both the Ki-67 proliferation index and nuclear morphometric features, such as tumour cell arrangement, nuclear pleomorphism, and cellularity.It could be demonstrated that the Ki-67 proliferation index is the most important criterion for distinguishing anaplastic meningiomas (WHO grade III) (mean Ki-67 index: 11%) from those of common type (WHO grade I) (mean Ki-67 index: 0.7%). The parameter for the relative volume weighted mean nuclear volume is another valuable morphometric feature. The atypical meningioma (WHO grade II) which should represent an intermediate category between common type and anaplastic meningiomas is characterized by a mean Ki-67 proliferation index of 2.1%. Common type meningiomas which comprise almost 50% of the cases of this series have a relapse rate of 9%. Atypical and anaplastic meningiomas recurred in 29% and 50%, respectively. Since the term atypical meningioma is confusing in the context of tumour grading, the term intermediate type meningioma is proposed.Furthermore, the results of cytogenetic analyses of 142 cases of this series were evaluated and compared with the meningioma grades. Thereby, 25 cases disclosed, independent of the typical loss of one chromosome 22, cytogenetic features assumed to be progression-associated, e.g., the gain or loss of different chromosomes and the deletion of the short arm of one chromosome 1 (hyperdiploidy, increased hypodiploidy, Ip-), when correlated to the histological and morphometric findings or the high relapse rate.For meningioma diagnosis and grading, a practical guideline is proposed based upon histology, morphometry (Ki-67), and cytogenetics.     

Cerebral reperfusion in brain death of a newborn. Case report

A case of sudden infant death after 15 minutes of successful resusciation of cardiovascular function is presented. While apnoic cranial nerve areflexia and electrocerebral silence persisted, angiography and transcranial Doppler sonography demonstrated nearly normal cerebral perfusion, which even increased day by day inspite of the persistence of other signs of brain death. The phenomenon cerebral reperfusion is concluded to be compatible with the diagnosis of brain death.