[Pathogenesis of Achilles tendon rupture]

The etiology underlying ruptures of the Achilles tendon is analyzed in 65 patients in a retrospective clinical study. A typical mechanism leading to a rupture of the tendon consists in an extraordinary tension force applied on a tendon in a state of active preload. A spontaneous rupture was observed in merely 3 cases. In 21 out of 65 patients risk factors such as hypercholesterolemia, hyperuricemia and arteriosclerosis were present. A systematic application of corticosteroids proved to be a decisive factor in the etiology of a tendon rupture. There was no correlation between the presence of associated risk factors and the degree of histological degeneration. During follow-up 3 re-ruptures and 6 ruptures of the contralateral tendon were registered. Our results lead to the conclusion that the etiology of the rupture of the Achilles tendon is based on a multifactorial disposition which includes the mechanism of injury, preexistent risk-factors as well as degenerative changes in the tendon structure.

[Atypical joint symptoms as initial symptoms of varicella infection in chronic myeloid leukemia]

A 25-year-old man, known to have chronic myeloid leukaemia for four years, acutely developed a fever of 39.5 degrees and severe pain in the shoulder and hip joints. There was no evidence of joint disease. Treatment with indomethacin briefly improved the symptoms, but within 72 hours the patient developed a fulminant illness with high fever and clinical as well as biochemical signs of a severe consumption coagulopathy. Herpetiform efflorescences appeared over the head and trunk shortly before death. At autopsy there was histological and immunohistochemical evidence of a varicella infection with hepatitis, oesophageal involvement and severe internal organ bleedings. In immune-compromised patients with atypical prodromal symptoms a varicella infection must be considered so that causal treatment with acyclovir and hyperimmune-globulin can be begun in time.

Well-differentiated papillary mesothelioma of the peritoneum: a borderline mesothelioma. Report of two cases and review of literature

Well-differentiated papillary mesothelioma (WDPM) is considered to be a distinct subtype of peritoneal mesothelioma. Although the WDPM is usually qualified as benign, the natural history of this lesion has not been clearly established. This report relates to two WDPMs which were found incidentally. In a 51-year-old man the WDPM developed over a period of 5 years into a typically malignant diffuse mesothelioma. Thus, although the WDPM morphologically lacks signs of malignancy, it should be regarded as a borderline mesothelioma.

Unexpected infant death attributable to cardiac tumor or cardiomyopathy. Immunohistochemical and electron microscopical findings in three cases

The pathological findings, including immunohistochemical and electron microscopical findings, in three infants who died unexpectedly of cardiac tumor or cardiomyopathy are reported. The first was a 13-month-old boy with tuberous sclerosis and multiple rhabdomyomas of the heart, who presented with a postpartal cardiac murmur and moderate cardiomegaly. The further history was unknown. The rhabdomyoma nodules were composed of spider cells containing small amounts of desmin and myosin as well as isolated myofibrils. Microscopically small glioma nodules contained high amounts of GFAP. The second case, a boy 4 months of age, died of a large benign fibrous histiocytoma of the heart after an uneventful history. Tumor cells contained alpha-1-anti-chymotrypsin and lysozyme. The third case, a girl 2 months of age, died unexpectedly of histiocytoid cardiomyopathy. The affected cells contained fat droplets, glycogen granules, many leptomer myofibrils and small amounts of myosin and desmin.

[Quantitative morphologic studies for localizing arteriosclerotic plaques in the circumference of coronary arteries]

In order to determine the distribution of arteriosclerotic plaques in the circumference of coronary arteries 150 hearts were investigated using two different methods. In 100 hearts the coronary vessels were opened longitudinally, and the sites of sclerotic lesions were mapped. The coronary arteries of another 50 hearts were filled with contrast medium, angiography was performed and the arteries were cut into 0.5-cm segments. The first 6 cm of the left anterior descending and the left circumflex arteries and the first 9 cm of the right coronary artery were studied. Segments of 1-cm length in the 100 hearts and of 0.5-cm length in the 50 hearts were examined. It was found, that arteriosclerotic lesions of the coronary arteries are most frequently located on the myocardial side of the vessel circumference. This phenomenon is most evident in the left anterior descending artery, thus possibly being caused by the most pronounced fixation of this artery on the myocardium.

Fatal accidental enflurane intoxication

Among reported cases of abuse of volatile anesthetics there is only one of enflurane intoxication. We report another fatal enflurane intoxication. A 21-year-old man found dead seemed to have experimented with enflurane. Three and one-half days after death high amounts of enflurane were detected in blood, brain, and subcutaneous fat. Gas chromatographic quantification revealed the following high enflurane concentrations: blood: 130 mg/l-1, brain: 350 mg/l-1, and subcutaneous fat: 100 mg/l-1. Histologic signs of drug-induced damage were lacking. No suicide intentions became known. It was concluded that the young man died of an accidental intoxication while abusing enflurane.

Case of cyclopia with an unbalanced karyotype attributable to a balanced 3/7 translocation

This report presents a case of cyclopia attributable to an unbalanced karyotype in a family with a balanced, reciprocal 3/7 translocation. This case was the fifth recorded in three generations of this family. From this report it is possible that the simultaneous action of partial trisomy 3p and partial monosomy 7q may be one cause of holoprosencephaly.

Cushing's syndrome due to ACTH-production of an ovarian carcinoid

The case of a 56-year old woman with severe Cushing's syndrome due to ovarian ACTH-production is described. Both clinical picture and biochemical pattern were consistent with the ectopic ACTH syndrome. ACTH was found by specific immunohistochemical staining in a carcinoid tumor of the patient's right ovary. In contrast, pituitary cells exhibited immunoreactive ACTH to only a minimum extent.

Transendothelial transport and metabolism of adenosine and inosine in the intact rat aorta

This study was aimed at defining the role of vascular endothelium in the transport and metabolism of adenosine. For this purpose, endothelium-intact and endothelium-denuded isolated rat aortas, perfused at constant flow (2 ml/min), were prelabeled with 3H-adenosine or 3H-inosine for 10 minutes at concentrations of 0.012-100 microM. Sequestration of adenosine by endothelium was determined from radioactivity recovered during selective endothelial cell removal with deoxycholic acid (0.75% for 15 seconds). In the physiological concentration range of adenosine (0.012-1 microM), fractional sequestration by endothelium was 90-92% of the total adenosine incorporation by the aorta. Endothelial sequestration of inosine at 0.1 microM was 85%. At 100 microM adenosine or inosine, fractional sequestration by aortic endothelium was 33% and 39%, respectively. Analysis of the specific radioactivity of adenine nucleotides extracted from prelabeled aortas indicated that most of the adenosine was incorporated into endothelial adenine nucleotides. Incorporation of inosine into endothelial ATP was approximately 15% that of adenosine. Inhibition of aortic adenosine deaminase with erythro-9-(2-hydroxy-3-nonyl)adenine (EHNA) did not influence sequestration of 0.1 microM adenosine, but resulted in a 49% reduction of total endothelial incorporation at 100 microM adenosine. Transfer of radioactive purines from the endothelium to underlying smooth muscle after prelabeling was equivalent to only 1%/hr of total endothelial radioactivity. Our findings suggested that 1) macrovascular endothelium of the aorta constitutes a highly effective metabolic barrier for circulating adenosine and inosine; 2) transfer of labeled adenine nucleotides from endothelium to underlying smooth muscle is rather small and most likely proceeds via dephosphorylated purine compounds; and 3) measurement of adenosine trapping in endothelial and smooth muscle compartments overestimates the transendothelial adenosine concentration gradient.

Flow pattern and structural changes at carotid bifurcation in hypertensive cynomolgus monkeys

Blood flow pattern and morphological changes within the extracranial carotid system were studied in M. fascicularis before, immediately after, and at various intervals (4 hours, 4 days, 10 days, and 4 weeks) after the introduction of systemic hypertension by surgical coarctation of the thoracic aorta. Intra-arterial hemodynamics were assessed by means of both continuous-wave Doppler signal spectrum analysis and multigate pulsed-wave Doppler flow velocity profile processing. Diminished peak frequencies throughout the carotid system and enlargement of the lumen diameter in the common carotid artery and the carotid bulb were major findings and were suspected to be due to cerebral autoregulation at high levels of intracranial vascular resistance. In the internal carotid artery of pure muscular type, the lumen diameter was diminished so the carotid bulb became an area of structural and hemodynamic transition. As a consequence, flow irregularities already observed in this region before surgery considerably increased during hypertension. In addition, endothelial disarray and leucocytic adherence and activation were associated with these hemodynamic alterations within the carotid bulb. Their mutual role in early atherogenesis is discussed.

Tetraedric and sand-glass crystals in the urine

Sand-glass and tetraedric crystals often occur in cytologic evaluations of urinary sediments as a secondary finding. The analyses show inflammation and an increase in protein casts as accompanying changes. The basic diseases are primarily renal but unspecific. The analyses of the crystals by laser-ray-technique (LAMMA-analysis) demonstrate calcium in the positive ionic spectrum in both forms. Differences can be registered in the negative ionic spectrum: sand-glasses and small tetraeders contain considerable amounts of phosphate (PO2- and PO3-), while only the larger tetraedric crystals consist of pure calcium oxalate.

[Magnetic resonance tomography of prostatic cancer. A histopathologic correlation]

A total of 52 patients with prostatic carcinoma were examined by MR imaging; 14 of them subsequently underwent radical prostatectomy and were included in this study. The resected prostates were sectioned axially and compared with the corresponding MR scans with special reference to the location and extent of the pathological changes. The prostatic carcinoma was visualized in 10 cases, but the size of the tumor was underestimated in 6 patients. In 9 of 10 patients the carcinoma was identifiable as an area of low signal intensity within the peripheral zone on T2-weighted images. The MR features of benign nodular hyperplasia are discussed.

Extracorporeal CO2-removal with a heparin coated artificial lung

Treatment of severe acute respiratory failure with extracorporeal gas exchange necessitating near complete systemic anticoagulation requires a delicate balance to be maintained between disseminated intravascular coagulation and hemorrhagic complications. The present study describes our first experience using a heparin coated extracorporeal artificial lung and circuitry during clinical extracorporeal CO2 removal. In spite of a partial thromboplastin time and activated clotting time within or close to the normal range, neither laboratory evidence for disseminated intravascular coagulation induced by the extracorporeal circuit nor thrombi in the pulmonary vasculature were found. Scanning electron microscopy of the heparin coated hollow fiber gas exchanger demonstrated only minor deposits on the surface. Use of a heparin coated artificial lung may enhance the margin of safety of extracorporeal gas exchange and ultimately broaden its indications.

[Homologous replacement of the cruciate ligament in the animal experiment]

A homologous cruciate ligament transplantation was effected in 20 Alsation dogs. Clinical, pathologico-anatomical and histological results were obtained from 16 animals after 3, 6 and 9 months, respectively, proving metaplasia of the transplant to endogenous body tissue. The clinical conclusion of this finding is that an anatomically optimally-structured ligament replacement can be inserted by means of a relatively uncomplicated operation--possibly even by using arthroscopy. The low amount of traumatization due to this type of surgery will be of advantage especially to sportsmen, who, as is well known, not only suffer from frequent cruciate ligament ruptures but also have remarkably long-term deficits by large operation wounds both in regaining their proprioceptive performance ability and their muscular power.

Usefulness of angioscopy in stenotic processes of the carotid--a comparison with morphological findings

The development of a new generation of ultrathin flexible fiberscopes permitted direct in-vivo intravascular visualization of pathological changes. But not until the construction of a double-lumen balloon catheter for simultaneous obstruction of the blood flow and rinsing of the vessel did an accurate percutaneous transluminal examination become possible. For testing the usefulness of angioscopic intraluminal diagnosis, 48 carotid arteries from 32 autopsies were examined independently by angioscopy and morphologically. There was a high degree of correspondence between the two methods, especially in cases with low-degree stenosis or complicated plaques, in which other examination methods often fail. Problems of underestimating fibrous plaques and optical projection upstream of the stenosis are discussed.

Epithelial (true) splenic cysts. Pathogenesis of the mesothelial and so-called epidermoid cyst of the spleen

Nonparasitic cysts of the spleen are classified as primary or epithelial cysts if their inner surface has a cellular lining. Depending upon the pattern of the inner surface cell layer, the primary splenic cysts are divided into mesothelial or epidermoid subtypes. In order to study their pathogenesis, five epithelial splenic cysts (two with mesothelial lining, and three with foci of stratified squamous epithelium) were investigated by scanning and transmission electron microscopy and by immunohistochemistry. In places, the squamous epithelium was continuous with a flattened mesothelial layer. Furthermore, within the stratified epithelium, a continuous spectrum of cytodifferentiation from mesothelial to squamous cells was found. Thus, the epidermoid splenic cyst seems to be a variant of the mesothelial cyst with focal squamous metaplasia. Rupture of the splenic capsule with hemosiderin deposits and infoliation of the mesothelium was seen in one case, implying a traumatic genesis. In addition, stoma-like channels providing connections between the lumen of the cyst and the sinus of the adjacent splenic tissue were detected by scanning electron microscopy. As with other cystic lesions, the influx of blood cells and proteinaceous fluid from these stomata may contribute to the growth of the cysts, which are usually of considerable size when surgically removed.

Localized benign biphasic mesothelioma of the pleura

A localized benign biphasic mesothelioma of the pleura is described. Immunohistochemically the epithelial-like cells contained vimentin intermediate filaments only, while electron microscopy revealed signs of true mesothelial differentiation demonstrating the hybrid nature of neoplastic mesothelial cells.

Correlation of abdominal CT imaging with autopsy findings in patients with malignant tumors

The value of abdominal computed tomography (CT) in diagnosing localized involvement of liver, pancreas, adrenals, and lymph nodes was evaluated in 117 patients with suspected or known malignant tumors by correlation with autopsy findings. Sensitivity, specificity, and accuracy of CT for localized liver disease was calculated to be 80% (84%), 96% (97%), and 90% (92%); for pancreatic tumors: 81% (86%), 98% (100%), and 95% (97%); for adrenal tumors: 65% (92%), 100% (100%), and 92% (98%); and for lymph node enlargement 75 (88%), 97% (98%), and 87% (94%), respectively. Results of routine evaluation could be improved, especially in the adrenal region, when scans were reevaluated by highly experienced examiners (results given in parenthesis). Computed tomography is a highly valuable diagnostic tool in the primary diagnosis and in the follow-up of tumor patients. The high costs are offset by a reduction in invasive procedures and a shortened hospital stay.

Myocardial performance and metabolism in non-ketotic, diabetic rat hearts: myocardial function and metabolism in vivo and in the isolated perfused heart under the influence of insulin and octanoate

The influence of a non-ketonic, chronically diabetic state (60 mg/kg streptozotocin) on cardiac function and metabolism was studied under in vivo conditions by inserting a Millar-tip catheter into the left ventricle and in the model of the isolated perfused heart. In vivo heart rate and maximal left ventricular systolic pressure were reduced after a diabetes duration of 4 and 12 weeks. The maximal rise and fall in left ventricular pressure progressively declined with the duration of diabetes. The reduced myocardial function was associated with a loss in ATP and adenine nucleotides. In the perfused heart of chronically diabetic rats, heart function was also impaired and could not be restored in vitro by perfusion with glucose and insulin. In the presence of octanoate--a substrate which can be metabolized independently from insulin--heart function of diabetic rats was improved, but remained lowered as compared to controls. Since the content of myocardial creatine phosphate was reduced in diabetic hearts perfused with octanoate, these findings indicate that the suppression of cardiac performance is not only a result of an impaired glucose metabolism, but of a more general defect in energy provision and utilization. In contrast to hearts of acutely diabetic, ketotic rats most often used, the rate of lipolysis of endogenous triglycerides and the contribution of fatty acids to energy production was low in the chronically diabetic state. Inhibition of fatty acid oxidation by an inhibitor of carnitine palmitoyltransferase (CPTI) did not restore the reduced responsiveness of diabetic hearts to insulin. Analysis of intracardiac metabolites revealed that in the perfused heart of chronically diabetic rats glucose-6-phosphate and citrate do not accumulate as in hearts of ketotic, diabetic rats. Therefore, the impaired glucose metabolism presumably reflects a reduced uptake of glucose rather than in inhibition of glycolysis as in hearts of ketotic, diabetic rats.