Certain problems of pyelonephritis

Relying on his own observations, the author discusses certain experimental and clinical problems of pyelonephritis. He demonstrates that infection in cases of ascending pyelonephritis is dissemeinated outside the lymph paths and not transmitted from one to another point of the kidney by the renal lymphatic apparatus. Accordingly, the term interstitial progress is suggested instead of lymphogenic infection. Animal expeeriments show that infection of varios organs induces acute pyelonephritis of focal necrosis in the kidney. It is suggested that renal lesions may be produced in a similar manner in human subjects and that their non-recognition may lead to latent chronic kidney diseases. The first part of the clinical chapter discusses prophylactic possibilities, in the first place the use of asymptomatic bacteriuria. The second part deals with a dietetic treatment of chronic nephropathies. A specific diet and the results of its employment are described.     

Traumatic intracerebral haematomas of delayed onset

Summary 25 cases of traumatic intracerebral haematomas of delayed onset were found among 775 cases of acute head injuries. All these 25 cases were analysed both clinically and with computed-tomographical studies. Their clinical features were different from those of classical traumatische Spät-Apoplexie originally described by Bollinger in 1891, in the following aspects; (A) absence of the symptom-free interval and (B) absence of apoplectic onset of symptoms after a relatively long lucid interval. These traumatic intracerebral haematomas of delayed onset were, on the other hand, characterized by the following; (1) the patient was injured when the head was in motion, (2) the injury was not necessarily severe, (3) the onset of signs and symptoms were gradual and insidious, (4) all 25 cases but 4, had cranial vault fractures and/or basal skull fractures, (5) precipitating factors could not be identified, though hypotensive episodes were present in 60% of cases, (6) intracerebral haematomas appeared within 72 hours following the head injury in most of cases, though more than 4 days later in a small number of cases, (7) the appearance of such intracerebral haematomas suggested an unfavourable outcome, (8) cerebral contusion might be a major contributory factor.     

116. Neue Anus praeter-Verfahren: Magnetverschluß

Zusammenfassung Seit Mai 1976 wurden 85 Magnetringe bei 81 Patienten implantiert. In 16 Fällen kam es zur Infektion, darunter 5 Spätinfektionen. 24 von 51 befragten Patienten tragen den Magnetdeckel regelmäßig. Größtes Problem ist eine fehlende Dichtigkeit (39 %). Die Ergebnisse ließen sich mit einem Deckel mit beweglichem Mittelstöpsel verbessern. Auf die Frage, ob das Magnetsystem die Colostomiepflege erleichtert, antworteten 37 % der Kranken mit ja, 22 % mit gering und 41 % mit nein. 56 % würden sich erneut einen Magnetring implantieren lassen.     

Methylated β-cyclodextrins are able to improve the nasal absorption of salmon calcitonin

The absorption enhancing effect of methylated -cyclodextrins on the nasal absorption of salmon calcitonin (sCT) was studied in rats and rabbits. The nasal absorption of sCT following administration without additives was low in both species. The absorption in rats could be largely improved by coadministration of cyclodextrins as apparent from the effect on serum calcium concentrations. Trimethyl--cyclodextrin (TMCD), at a concentration of 5% (w/v), was the least potent enhancer. Randomly methylated--cyclodextrin (RMCD) and dimethyl--cyclodextrin (DMCD), all at a concentration of 5% (w/v), were almost equally effective in decreasing serum calcium levels, and the hypocalcemic responses were similar to those of i.v. and s.c. injected sCT. Absorption enhancement was already achieved with 1% DMCD added to the nasal formulations. In rabbits, only the effect of DMCD on the nasal sCT absorption was investigated. A total serum calcium decrement in 4 hours of 9.4±3.9% (mean±SD) was observed following nasal administration of 12.6 IU/kg sCT with 5% DMCD, comparable to that of i.v.-injected sCT. In conclusion, the methylated cyclodextrins DMCD and RMCD are suitable absorption enhancers for nasal sCT administration, which is expected to have a clinical impact on the therapy with calcitonin.     

Simplified design of the “B” technique mammoplasty

The preoperative design of the B technique mammoplasty is somewhat complicated and less precise than that of other methods of breast reduction. A new maneuver for simplification of the design is presented.     

Multiple endocrine neoplasia type 1 in end-stage renal failure

A 59-year-old woman with chronic renal failure due to type 2 diabetes mellitus (DM) is presented. Her father and a brother had a history of brain tumor. Her blood urea nitrogen and serum creatinine levels were 102mg/dl and 4.5mg/dl, respectively. Her serum Ca²⁺ and Pi were within the normal range (9.4mg/dl and 5.4mg/dl, respectively). Her intact parathyroid hormone (PTH) level was 1730000pg/ml. A ^99mTc-methoxy-isobutylisonitrile scintigraphy showed high uptake in three parathyroid glands. A magnetic resonance image showed microadenoma in the pituitary gland. The serum gastrin level was high. Genetic examination revealed a mutation of the MEN1 gene (894–9 G A). From these findings, she was diagnosed with multiple endocrine neoplasia (MEN) type 1. Subsequently, a parathyroidectomy was performed successfully, a parathyroid gland was transplanted to her right forearm, and her serum Ca²⁺ level was controlled at 8.5–9.0mg/dl. It is very important to identify MEN1 if an end-stage renal disease (ESRD) patient has hyperparathyroidism with multigland involvement. Examination of the MEN1 gene may be valuable to make an accurate diagnosis and choose the appropriate therapy in some ESRD patients with hyperparathyroidism.     

Head and Neck Magnetic Resonance Angiography Before Coronary Artery Bypass Grafting

Purpose To evaluate the incidence of vascular lesions in the head and neck by magnetic resonance angiography (MRA), and investigate the factors correlated with severe stenosis.Methods Elective coronary artery bypass grafting (CABG) was performed in 413 patients at our center between May 1997 and April 2001. We used MRA to detect head and neck vascular lesions, then evaluated the occlusive lesions and determined their prevalence.Results Neck MRA was performed in 335 patients and head MRA was performed in 335 patients. We found 60% stenosis or total occlusion of the extracranial carotid and vertebral artery in 43 patients (12.8%) and 60% stenosis or occlusion of the intracranial carotid and basilar artery, or stenosis accompanied by poor peripheral perfusion or occlusion of the cerebral arteries in 45 patients (13.4%). Occlusive lesions of the neck were significantly correlated with mean age, peripheral vascular disease (PVD), and old myocardial infarction. Occlusive lesions of the brain were significantly correlated with age, hypertension, PVD, and left main trunk disease.Conclusions We found an equal incidence of intracranial and extracranial vascular lesions. Thus, searching for intracranial lesions is just as important as searching for extracranial lesions before CABG.     

Comparative study of nonbridging and bridging external fixators for unstable distal radius fractures

The purpose of this study was to compare nonbridging external fixators (group NB) with bridging external fixators (group B) in the treatment for unstable distal radius fractures. The subjects consisted of 84 patients, 42 in each group. Mean patient age was 64.0 years in group NB and 59.6 years in group B. According to Saitos classification, most fractures were of the comminuted Colles type. No bone graft was made in group NB. Patients of group B showed serious reflex sympathetic dystrophy (RSD). On Saitos evaluation criteria, the proportion of patients evaluated as good or better was 100% in group NB and 95.6% in group B. This finding can be taken as evidence that group NB patients showed better results.     

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.     

Blood lymphocyte subsets in patients with primary intracranial tumours. Correlation to histological tumour type and anatomical site

Summary The blood lymphocyte population of 118 patients with primary intracranial tumours and healthy volunteers was examined with respect to its size and cellular composition using various rosette tests. The patients had not undergone any surgical intervention or received any treatment with ionizing irradiation or cytotoxic drugs. However, some of them were treated with corticosteroids.It was observed that non-steroid treated patients with oligodendrogliomas, but not patients with other histological types of tumours, had a significantly reduced proportion of active T-lymphocytes forming rosettes with sheep erythrocytes (a type of T-lymphocyte which is activated by foetal calf serum). These patients as well as those with astrocytomas, malignant gliomas (anaplastic astrocytomas and glioblastomas) or miscellaneous tumours (mainly meningiomas) had normal proportions of lymphocytes with receptors for the Fc-part of IgG or C'3 and cells forming rosettes with sheep erythrocytes under more conventional conditions. Patients who were treated with corticosteroids had an increased frequency of lymphocytes with the above Fc-receptor.An association between site of the lesions and cellular composition of the blood lymphocyte population was not detected. The results give further support for the view that the immunological system may be changed in patients with oligodendrogliomas.     

66. Therapie der traumatischen Osteomyelitis

Zusammenfassung Bei der Behandlung der traumatischen Osteomyelitis müssen die Ausbreitungswege und die Entwicklungsstadien der Infektion beachtet werden. Mit Ausnahme der drohenden Infektion (allgemeine Antibiotics) ist die Behandlung chirurgisch. Bei akuter postoperativer Manifestation bilden Herderöffnung, Spüldrainage und Belassen stabiler Implantate das Verfahren der Wahl. Zur Sanierung der chronischen Stadien stehen knochenplastische Eingriffe im Vordergrund. Das Stabil-Halten oder die erneute Stabilisierung der Infektionsherde ist in allen Fällen von grundsätzlicher Bedeutung. Alle für Indikation und Behandlung wesentlichen Fakten werden erläutert.

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Treatment of exogenous osteomyelitis

Summary In the treatment of traumatic osteomyelitis it is advisable to pay due respect to the route and stage of progression of the infectious process. Except in the case of imminent infection (systemic antibiotics) the condition is treated by surgery. In cases of acute postoperative manifestation the treatment of choice consists in opening of the infected area, irrigation drainage and maintenance of stable implants. In cases of chronic infection osteoplastic surgery is necessary. In all cases, maintenance of stability or restabilization is of the utmost importance. All necessary data on indication and treatment are given.

     

124. Ergebnisse nach Bandnähten und Plastiken am Kniegelenk unter funktioneller Behandlung

Zusammenfassung 1972–1975 wurden 60 Guepar-Knie mit 28 Patella-Prothesen Münster und 40 Schlittenprothesen St. Georg implantiert. Komplikationen: 14 Knorpelnekrosen oder Luxationen der Patella, 3 Infektionen und 2 lig. patellae-Nekrosen nach Guepar-Ersatz, 3 Instabilitäten nach Schlittenprothese. Bei 10 Reoperationen wurden 2 Arthrodesen, 5 Prothesenwechsel, 3 Patellaprothesen durchgeführt. Nach 5 Mon.-21/2 Jahren hatten 35 Patienten mit Guepar-Prothesen 16 gute, 10 mäßige 9 schlechte Resultate. 15 Patienten mit Schlittenprothese erzielten 10 gute, 3 mäßige, 2 schlechte Resultate. 35 der insgesamt 46 nachuntersuchten Patienten waren schmerzfrei.     

Comparison of serial S-100 and NSE serum measurements after severe head injury

Summary We investigated the time course of neuron specific enolase (NSE) and S-100 protein after severe head injury in correlation to outcome. We included 30 patients (GCS<9), who had been admitted within 5 hours after injury, in a prospective study. Blood samples were taken on admission, 6, 12. and 24 hours and every 24 hours up to the fifth day after injury. The outcome was estimated on discharge using the Glasgow Outcome Scale. 70% reached a good outcome. All concentrations of NSE and 83% of the S-100 samples were elevated concerning the first probe (30.2 g/l NSE mean and 2.6 g/l S-100 mean). Patients with bad outcome had an NSE concentration of 38 g/l (mean) compared with 26.9 g/l (mean) in patients with good outcome. Patients with bad outcome had an S-100 concentration of 4.9 g/l (mean) compared with 1.7 g/l (mean) in patients with good outcome (p<0.05). The mean values of NSE and S-100 decreased during the first 5 days. Four patients with increasing intracranial pressure showed a quick increasing concentration of NSE, in two patients the S-100 level showed a slower rise. The NSE serum levels did not correlate with intracranial pressure values. Our results show that the first serum concentration of S-100 seems to be predictive for outcome after severe head injury.     

Trigeminal neurinomas a series of 111 surgical cases from a single institution

Summary Neurinomas arising from the trigeminal nerve are rare (0.1–0.4% of intracranial tumours; 1–8% of all intracranial neurinomas).A series of 111 trigeminal neurinomas operated on at the Institute of Neurosurgery N. N. Burdenko of Moscow, Russia, during the period 1961–1994 is presented.Clinical features, diagnostic radiology, surgery and results of treatment are discussed.We distinguished four groups of trigeminal neurinomas:a) Posterior fossa tumours; b) Tumours of the Gasserian ganglion; c) Dumb-bell supra-subtentorial tumours: d) Neurinomas of the peripheral branches.The complex clinical symptomatology is related to the actual location of the lesion.Surgery of trigeminal neurinomas may be very difficult, particularly in cases of dump-bell supra-subtentorial lesions. In this series, 3 cases died postoperatively. Out of the 108 patients surviving surgery, long-term follow-up (min. 13 months, max. 33 years, average 13.5 years) was available in 98 cases. 84 patients (86.7%) showed good-to excellent results, with partial trigeminal deficit as the only surgical sequela.13 patients (11.7%) had a symptomatic recurrence following incomplete tumour removal. Second surgery, ranging from 1.4 to 9 years (average 3.8 years) following the first operation, was judged radical in 9 cases (69.2), however, the rate of complications of repeated surgery was higher than that occurring after the first operation.The advent of microsurgery, together with the introduction of the techniques of skull base surgery and of modern diagnostic imaging tools, have improved surgical results in terms of increased radicality and reduced complications.Dr. Aldo Spallone was visiting professor, coordinator of the Skull Base group at the Institute of Neurosurgery N. N. Burdenko, Moscow, during the period when the present study has been conducted (1993–1994).     

Difference in configuration of ruptured and unruptured intracranial aneurysms determined by biplanar digital subtraction angiography

Summary ¶Summary There is an ongoing discussion about the risk of bleeding from unruptured intracranial aneurysms. Management guidelines were developed recently and some of the recommendations for decision making are based on the anatomical configuration of the aneurysm. The common assumption is that the presence of multiple lobes or a daughter sac indicates a higher risk of rupture. We have investigated the anatomical configuration of ruptured and unruptured intracranial aneurysms using biplanar digital subtraction angiography (DSA). The objective was to determine, whether there was a difference between ruptured and unruptured aneurysms regarding lobulation, the presence of a daughter sac or the shape as measured by the height/neck ratio.Biplanar DSA images of 124 patients were retrospectively analyzed. A total of 53 unruptured and 94 ruptured aneurysms were found (=147 aneurysms in total). Aneurysms of less than 10mm diameter accounted for 82% of all aneurysms. Overall, 10% of unruptured aneurysm showed a multilobular appearance on DSA compared with 20% of ruptured aneurysms (Fishers exact test, p=0.10). In the 5–9mm aneurysm group, multiple lobes were found significantly more frequent in ruptured aneurysms (26% vs. 4%, Fishers exact test, p<0.05). A height/neck ratio of less than 1.5 was not found in unruptured aneurysms (0/26) but in 21% (12/57) of ruptured aneurysms (p<0.05).Our data provide scientific support for using morphological features for the decision making process in the management of unruptured intracranial aneurysms. An irregular multilobar appearance was significantly more common in aneurysms of 5–9mm size that ruptured.Published online October 9, 2003     

Adult onset Fanconi syndrome: extensive tubulo-interstitial lesions and glomerulopathy in the early stage of Chinese herbs nephropathy

A 33-year-old woman was transferred to our hospital with a 5-month history of taking Chinese herbal medicine containing aristolochic acid. She presented with metabolic acidosis, severe anemia, hypophosphatemia and uric aciduria, and generalized aminoaciduria and glycosuria, features which were consistent with the clinical manifestations of Fanconi syndrome. Renal biopsy was performed when her plasma creatinine was 0.7mg/dl and creatinine clearance was 46ml/min per 1.73m². The renal specimen showed extensive interstitial edema with focal fibrosis, tubular atrophy, and focal glomerulopathy, which suggested the presence of glomerular endothelial damage or glomerular ischemia. Although steroid therapy ameliorated the plasma electrolyte levels, renal failure progressed, and hemodialysis therapy was initiated approximately 18 months after the time of renal biopsy. This patient demonstrated the early renal lesions of Chinese herbs nephropathy in association with various clinical manifestations. The characteristic glomerulopathy found in the present patient is considered to be an additional renal lesion, leading to the renal failure.     

Hemodynamic effects of high-frequency jet ventilation in dogs with acute right coronary arterial ligation and pulmonary arterial banding

The hemodynamic effects of high-frequency jet ventilation (HFJV), synchronized with diastole, and intermittent positive-pressure ventilation (IPPV) were studied in 10 dogs with acute right-sided myocardial ischemia and elevated right ventricular pressure. Myocardial ischemia was produced by ligation of the proximal right coronary artery (RCA), then the right ventricular pressure was elevated to facilitate the ischemia by banding the main pulmonary artery. Before and 1, 2, 3, and 5hr after the RCA ligation, cardiorespiratory variables for each ventilatory mode and creatine phosphokinase MB isoenzyme (CPK-MB) were measured. During HFJV compared with IPPV: there were significant increases in stroke index and left ventricular stroke work index at all ischemic periods, and decreases in peak and mean airway pressures and pulmonary vascular resistance at all ischemic periods, and in the product of systolic right ventricular pressure and heart rate at 2hr, 3hr, and 5hr. The difference in mean airway pressure between IPPV and HFJV correlated significantly with those in cardiac index and stroke index (r = 0.575 and 0.779, respectively). CPK-MB was significantly greater at 3hr and 5hr than that before RCA ligation. These findings suggest that HFJV synchronized with diastole offers hemodynamic advantages over IPPV to ischemic right ventricle with constricted pulmonary artery, mainly due to lowering the mean airway pressure.(Ushijima K, Oka Y, Weinberg P et al.: Hemodynamic effects of high-frequency jet ventilation in dogs with acute right coronary arterial ligation and pulmonary arterial banding. J Anesth 4: 232–241, 1990)     

Benign symptomatic lesions of the pineal gland. Report of seven cases treated surgically

Summary Seven patients with non-neoplastic symptomatic lesions of the pineal gland have been operated on in our department since 1988. Clinical symptoms were slight and there were intermittent signs of a space occupying lesion in the quadrigeminal area, i.e. visual and gait disturbances. In three patients, obstructive hydrocephalus with related symptoms was found. Diagnosis was confirmed by use of MRI in sagittal planes, revealing a cystic lesion in five and a solid tumour in two patients. All patients were operated on without complications using an infratentorial supracerebellar approach. Histological examination showed glial cysts of the pineal gland in five patients. In the two solid specimens, normal pineal tissue was found. These lesions seem to be of special interest, as the only pathological property are their size: Both lesions — too large pineal glands — caused obstruction of the outlet of the third ventricle with subsequent hydrocephalus. Surgical treatment was curative in all cases with prompt relief of the symptoms. Clinical symptoms and signs, diagnostic and pathological findings, as well as the surgical results of these cases will be reported.     

Notes on male rhytidectomy

Summary Measurements of 100 preauricular hairline distances were done, and a normal average was established. The joined male rhytidectomy and the frontal alternating fusiform excisions are described.     

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.