Evolution and regression of pancreatic calcification in chronic pancreatitis. A prospective long-term study of 107 patients

Pancreatic calcifications are virtually pathognomonic of chronic pancreatitis and develop in up to 90% of patients with alcoholic chronic pancreatitis in series with long-term results. We investigated the natural course of pancreatic calcification in a prospective longitudinal study over the past 23 yr. All patients were studied at regular intervals with particular regard to etiology, clinical findings, surgery, pancreatic function, and pancreatic calcification visible by x-ray (e.g., film series in three projections centered on the pancreas). We evaluated the findings of 107 patients with x-ray documentation of pancreatic calcification in at least three film series over a period of 4 yr or longer. Eighty-four patients had alcoholic chronic pancreatitis (group A) and 23 patients had nonalcoholic chronic pancreatitis (group B). Four hundred seventy-two film series of group A and one hundred forty-two film series of group B were reviewed independently by two expert teams. Both series were graded according to a score system in terms of intensity and distribution of pancreatic calcification (correlation of grading r = 0.91). The duration of calcification averaged 10 yr in group A and 12.6 yr in group B. Similar dynamic changes of pancreatic calcification were noted in groups A and B. Chronologically, three phases of evolution could be distinguished. After an initial increase (phase 1), greater than 50% of cases reached a plateau of stationary calcification (phase 2). Approximately one-third of cases showed a marked decrease of calcification in late phases of chronic pancreatitis (phase 3). Dissolution of pancreatic stones was related primarily to duration of chronic pancreatitis (duration of calcification and marked pancreatic dysfunction), and occurred frequently (but not exclusively) in patients after ductal drainage procedures. These results indicate that spontaneous dissolution of pancreatic stones is a rather common biologic phenomenon. The factors responsible for dissolution of stones remain to be elucidated.

MR and CT findings in infected ventricular aneurysm repair

The magnetic resonance findings in a case of infection at a ventricular aneurysm repair site 7 years following surgery are presented.

[An incidental finding of renal cysts: routine occurrence or a finding deserving clarification?]

Since the introduction of new non-invasive diagnostic techniques such as abdominal ultrasound and computerized tomography, simple renal cysts are diagnosed with increasing frequency. Over 30% of patients over 50 years of age are found to have simple renal cysts of different size. A cystic renal mass may represent a simple renal cyst without clinical relevance, a cystic renal carcinoma, early evidence of polycystic kidney disease in a young patient, a rare cause of renal hypertension, a source of infection in a symptomatic patient (infected renal cyst), or a manifestation of an infectious disease (renal abscess, echinococcus cyst). The differential diagnosis and management of a cystic renal mass therefore remain a clinical problem. In the past, surgical exploration of a cystic renal mass was frequently performed. Today, modern diagnostic techniques such as ultrasound-guided percutaneous cyst puncture with cytological analysis of the cyst content, or computerized tomography, are considered the methods of choice. They are particularly useful in case of doubt about the dignity of a cystic renal mass. The determination of renal venous renin levels may be useful in differentiating the causal role of a renal cyst in a patient with hypertension. The management of a cystic renal mass depends on the underlying disease.

Subclavian aneurysm producing the subclavian steal syndrome

An atherosclerotic aneurysm of the right subclavian artery causing subclavian steal syndrome is described. Complementary information obtained from digital subtraction angiography and computed tomography helped to establish a correct preoperative diagnosis.

Cranial sonography of the occipital horns and gyral patterns in the occipital lobes

Cranial sonographic examinations of 199 neonates were evaluated to determine the incidence of an echogenic pattern in the occipital lobe that simulated a mass, to relate that finding to the birth weight, and to correlate it with the gyral development of the occipital lobe. This echogenic pattern was seen in infants weighing less than 1750 g at birth and was identified on both sides of the midline on the most medial paramedian sagittal sonogram scans of the head. This pseudomass was found to be due to close approximation of a large occipital horn and calcarine fissure joining other adjacent secondary fissures. The multiple fissures formed an echogenic star, and the proximity of the occipital horn and premature brain tissue texture contributed to the relatively hypoechoic background of the pseudomass. The pseudomass is limited superiorly by the parietooccipital fissure and inferiorly by the tentorium. This sonographic pattern should be recognized as a normal variant.

Surgery and granulocyte transfusions for life-threatening infections in chronic granulomatous disease

We report two patients with chronic granulomatous disease (CGD) and life-threatening infections: a 10 10/12-year-old boy had Aspergillus fumigatus spondylitis with destruction of the 11th vertebral body and paravertebral abscess formation, and an 8 5/12-year-old boy had multiple Staphylococcus aureus hepatic abscesses with subphrenic abscess formation. Both patients failed to respond to intense antimicrobial therapy but showed a remarkable recovery following surgical drainage combined with granulocyte transfusions. These results suggest that antimicrobial therapy and surgical drainage followed by granulocyte transfusions may be the ideal mode of treatment for severe infections in patients with CGD.

Control of oxygen uptake, microcirculation and glucose release by circulating noradrenaline in perfused rat liver

The effect of noradrenaline on oxygen uptake, on periportal and perivenous oxygen tension at surface acini, on microcirculation and on glucose output were studied in isolated rat livers perfused at constant flow with Krebs-Henseleit-hydrogen carbonate buffer containing 5mM glucose and 2mM lactate. Noradrenaline at 1 microM concentration caused a decrease in oxygen uptake, while at 0.1 microM it led to an increase. Both high and low doses of noradrenaline decreased the tissue surface oxygen tension in periportal and - after a transient rise - in perivenous areas. Noradrenaline at an overall constant flow caused an increase of portal pressure and an alteration of the intrahepatic distribution of the perfusate: at the surface of the liver and in cross sections infused trypan blue led to only a slightly heterogeneous staining after a low dose of noradrenaline but to a clearly heterogeneous staining after a high dose. Both high and low doses of noradrenaline stimulated glucose release. All effects could be inhibited by the alpha-blocking agent phentolamine. In conclusion, control of hepatic oxygen consumption by circulating noradrenaline is a complex result of opposing hemodynamic and metabolic components: the microcirculatory changes inhibit oxygen uptake; they dominate after high catecholamine doses. The metabolic effects include a stimulation of oxygen utilization; they prevail at low catecholamine levels. The noradrenergic control of glucose release is also very complex, involving direct, metabolic and indirect, hemodynamic components.

[The Mirizzi syndrome]

Three cases of Mirizzi's syndrome are reported, with special emphasis on differential diagnosis and preoperative evaluation. The syndrome consists of the triad cystic duct stone, inflammatory reaction and benign hepatic duct stenosis. Endoscopic retrograde cholangiography or percutaneous transhepatic cholangiography is mandatory for preoperative evaluation. Cholecystectomy with clearance of the bile duct is the treatment of choice.

[A new artificial cushion (elastomer) as the interface for sonography]

For ultrasonographic examinations of 500 patients a new plastic cushion was applied as interface. This block is well flexible and behaves ultrasonographically like water. Long linear-array transducers can be coupled easily to irregular surfaces. The high resolution at the near focus of modern transducers can fully be used for demonstration of superficial structures. Indications are discussed.

Oral chloramphenicol therapy for multiple liver abscesses in hyperimmunoglobulinemia E syndrome

In a patient with Hyper-IgE-syndrome multiple liver abscesses developed in spite of prophylactic treatment with trimethoprim and sulfamethoxazol. Ultrasound confirmed the clinical diagnosis and percutaneous needle aspiration under ultrasonographic guidance and culture of the aspirated pus allowed specific antibiotic treatment by oral chloramphenicol alone without surgical drainage. The isolated Staph.aureus strain was resistant to trimethoprim and sulfamethoxazol.

["Learning and communication technics" in occupational rehabilitation of the handicapped: experiences wih retrainees in the metal-processing field]

Based on the special problems encountered by older and disabled workers, the authors investigate the potential of "learning and communications skills" training in enhancing the vocational and social reintegration in trade/technical-sector occupations. The experiences outlined refer to retrainees in the field of metal processing. They demonstrate that extra-functional learning goals such as communication skills and the ability to learn systematically, are more easily accomplished when the skills training occurs in association with the functional learning objectives (i.e. occupation-related skills).

[What does computer tomography and abdominal ultrasound studies accomplish in the staging of Hodgkin's disease?]

In a prospective series of 25 patients with early-stage Hodgkin's disease, abdominal assessment by computer tomogram and ultrasound was controlled by staging laparotomy. It was found that the probability of Hodgkin's disease increased with increasing diameter of the abdominal lymph nodes. 42% of the nodes between 16-20 mm in diameter had evidence of disease. Overall accuracy and specificity for the assessment of abdominal lymph nodes by CT and US was around 90%. Sensitivity was much lower than in other series, probably due to the fact that our patient sample was relatively small and consisted of patients in earlier stages with small lymph nodes. Assessment of lymph nodes by US is more, and assessment by CT less, dependent on individual factors. It is concluded that neither CT or US can replace staging laparotomy if precise information about abdominal lymph nodes is needed. Assessment of the spleen by CT and US is usually unreliable and needs histologic confirmation.

Age-related differences in nephrotoxicity of cadmium

Nephrotoxic effects can be quantified by measurement of renal excretion of p-amino-hippurate (PAH). Intraperitoneal administration of cadmium in increasing single doses to adult rats is followed by a biphasic effect on renal PAH excretion. Administration of low doses (250 or 500 micrograms/100 g b.wt. CdCl2) results in a significant increase whereas a single dose of 750 micrograms/100 g b.wt. CdCl2 is followed by a distinct diminution of renal PAH excretion. Repeated administrations of 500 micrograms/100 g b.wt. CdCl2 for 2 or 3 consecutive days result in a marked reduction of PAH excretion which is reversible 5 or 6 d following administration. In juvenile rats cadmium does not produce any statistically significant alteration in renal PAH excretion, likely caused by the immaturity of renal tubular transport processes.

[Titer variations in the rheumatoid factor reaction during the menstrual cycle. A contribution on the problem of the value of serologic data]

Sixteen healthy women showed a high variability of their titres in the antistreptolysin reaction, in the antideoxyribonuclease B reaction and in three different tests for determination of the rheumatoid factor during their cycles of menstruation. Two men of the same age had a similar behavoir. Therefore serologic results may be difficult to interpret.

Energy transduction and solute transport in streptococci

Metabolic energy in lactic streptococci can be generated by substrate level phosphorylation and by efflux of end-products in symport with protons. During growth on lactose or glucose Streptococcus cremoris maintains a high proton motive force and phosphate potential. Both energy intermediates dissipate rapidly when the energy supply stops. In the initial phase of starvation the internal phosphoenolpyruvate (PEP) pool increases rapidly and this enables the organism for a prolonged period during starvation to accumulate the energy source via a PEP-dependent uptake system.

Thermodynamics of growth. Non-equilibrium thermodynamics of bacterial growth. The phenomenological and the mosaic approach

Microbial growth is analyzed in terms of mosaic and phenomenological non-equilibrium thermodynamics. It turns out that already existing parameters devised to measure bacterial growth, such as YATP, mu, and Q substrate, have as thermodynamic equivalents flow ratio, output flow and input flow. With this characterisation it becomes possible to apply much of the already existing knowledge of phenomenological non-equilibrium thermodynamics to bacterial growth. One of the conclusions is that the frequent observation that YATP is only 50% of its theoretical maximum does not mean that the microbe corresponds to a thermodynamic system that has been optimized for maximal output power, as has been suggested. Rather, at least in some cases, it corresponds to a system that has been optimized towards maximum growth rate. When the degree of reduction of the (single) carbon source is significantly smaller than that of the biomass produced, the efficiency of biomass synthesis has been kept as high (i.e., about 24%) as is consistent with maximization of the growth rate at optimal efficiency. Mosaic thermodynamics allows an analysis of processes which in microbial metabolism may be responsible for any particular growth behaviour. Equations are derived that predict the effect of uncoupling through leaks, futile cycling, or 'slip' on microbial growth. It turns out that uncoupling is expected to affect both the growth rate-independent and the growth rate-dependent 'maintenance coefficient'. The effect on the latter is different when catabolic substrate limits growth than when anabolic substrate limits growth. In the latter case, the growth rate-dependent maintenance coefficient is negative. It is concluded that mosaic non-equilibrium thermodynamics will be a powerful theoretical tool especially in future experimental analyses of the metabolic basis for microbial growth characteristics and growth regulation.

[Use of ultrasound, ultrasound-directed fine needle puncture and aspiration in amebic abscess of the liver. Case report and short overview]

Case report on a 48-year-old Swiss male living in Burundi who suddenly fell ill with vomiting and anorexia, followed by pappy stools, weakness and impotence. He presented with hepatomegaly, while sedimentation rate and alkaline phosphatase were both elevated. Stool examination revealed cysts and vegetative forms of Entamoeba histolytica, while amebic serology was negative. Treatment with ornidazole and later with diloxanide furoate was given. Sonography showed two cystoid areas in the right lobe of the liver. In the third sonographically guided fine-needle puncture both lesions were fully aspirated. Amebic serological tests were now positive for the first time. Six weeks later the sonogram showed a normal liver feature. The symptomatology and diagnosis of hepatic amebic abscess are discussed, with special reference to the important role of sonographically guided fine-needle puncture and drainage. Sonographic technique and differential diagnosis are briefly demonstrated.

[Sonography vs. computer tomography in liver manifestations of echinococcosis]

Hepatic echinococcosis generally gives rise to typical signs by ultrasound and computed tomography, even though a relatively large number of conditions has to be considered in the differential diagnosis. Comparing the two methods in 29 patients with manifestations of hepatic involvement by echinococcosis it was demonstrated that ultrasound is only slightly inferior, in cases of small-size involvement, which fails to be diagnosed as focal disease of the liver parenchyma. But ultrasound is the primary method of investigation, especially when the differential diagnosis is still open, and it is preferred for serial studies during and after treatment. Computed tomography is the method of choice particularly when it is necessary pre-operatively to document involvement beyond the liver itself.

[Ultrasound-controlled fine needle puncture of gastrointestinal tumors with continuous view]

On account of its principle, ultrasound tomography cannot be recommended as a screening method for intestinal tumors; nevertheless, it may sometimes demonstrate larger tumors not producing typical signs. These neoplasms show a characteristic pattern ("cockade phenomenon"). In the region of the antrum they appear occasionally as a rigid thickening of the gastric wall. The nature of such an expansive lesion may be evaluated quickly and safely by a fine-needle puncture performed under sonographic control. No complications have been observed so far.

Lactate efflux-induced electrical potential in membrane vesicles of Streptococcus cremoris

We developed a procedure for isolating membrane vesicles from the homolactic fermentative bacterium Streptococcus cremoris. The membrane vesicles were shown to have a right-side-out orientation by freeze-etch electron microscopy and to be free of cytoplasmic constituents. The membrane vesicles retained their functional properties and accumulated the amino acids L-leucine, L-histidine, and L-alanine in response to a valinomycin-induced potassium diffusion gradient. Studies with these membrane vesicles strongly supported the possibility that there was a proton motive force-generating mechanism by end product efflux (Michels et al., FEMS Lett. 5:357-364, 1979). Lactate efflux from membrane vesicles which were loaded with L-lactate and diluted in a lactate-free medium led to the generation of an electrical potential across the membrane. The results indicate that lactate efflux is an electrogenic process by which L-lactate is translocated with more than one proton.

[Percutaneous cholecysto- and cholangiography (author's transl)]

Combined sonographic and radiographic investigations of the biliary duct system using direct percutaneous transhepatic fine needle puncture under constant visualisation and contrast medium demonstration were done in 37 patients. The results show numerous advantages of the method: 1. It is very safe as all tissue and organ areas are under constant surveillance. 2. There is almost no risk of infection. 3. The investigation can be performed on predamaged liver parenchyma. 4. Cytologic material can be obtained; there are no extravasates. The information value of this combined investigation method is greater in a similar group of indications than with radiographic or sonographic methods alone. It appears possible that the risks of ERCP and PTC may be reduced. Further investigations will have to establish the clinical value and risks of this new method.

[Vocational rehabilitation of heart patients. An analysis of "vocational rehabilitation cases" closed by the federal employment institute (author's transl)]

The number of heart/circulatory disease rehabilitation cases closed annually by the Federal Employment Institute has remained almost the same over the 1972-1978 period. In 1978 the national total of closed heart/circulatory disease cases amounted to 6,325, with 945 of the clients having attended vocational rehabilitation measures/courses. Some 25 percent of the cases are classified as "condition following myocardial infarction"; in male clients, this applies to about one third. Compared to the number of male clients, women are strongly under-represented in vocational rehabilitation of heart/circulatory disease patients. In relation to the structure of the gainfully employed population total, the frequency of vocational rehabilitation measures on heart/circulatory disease diagnoses varies strongly among the individual Laender employment office districts. Considerable differences are apparent when the age structure of heart/circulatory disease rehabilitation cases is compared with that of any other disability group. In case of the first, the number of cases increases with age, while the trend is the very opposite in the latter case. This fact shows that vocational rehabilitation measures for heart/circulatory disease patients need come up to special conditions, and that they have to be determined on different criteria. The rate of integrational solutions considered a positive outcome is considerably lower for heart/coronary disease rehabilitees than for the total of rehabilitees. The participation in vocational rehabilitation programmes of 14.9 percent equally is considerably lower than the corresponding percentage of the total number of rehabilitation cases (26.2 percent).

[Ultrasonic findings in renal diseases with hypertension (author's transl)]

Ultrasound investigations of the kidney were performed in a prospective study in 51 patients with hypertension. It was shown by means of characteristic changes that renovascular and renal parenchymatous diseases can be differentiated. The case of renal atrophy could be demonstrated in 14 out of 20 cases with renovascular changes and in 15 out of 18 cases wtih primary renal parenchymatous disease. There were false positive results in two out of 13 cases of essential hypertension. The importance of intrarenal cysts in the aetiology of hypertension requires further investigation.

[Sonography in the evaluation of reduced function of kidney transplants (author's transl)]

Sonography of 58 kidney transplants has been performed in 56 patients and morphological alterations have been registrated. These results have been compared with clinical examination, blood samples and histological evaluation whenever possible. It is our opinion that certain sonographical phenomena exist, which make the rejection of kidney transplants most probable and even allow for differentiation of different degrees. We found a correlation of right results between sonography and final pathological diagnosis in more than 80% of our patients. Moreover sonography permits the diagnosis of ureteral obstruction or leakage.