[Rupture of the pes anserinus--a rare concomitant injury in anteromedial instability of the knee joint]

We report about a case of rupture of the pes anserinus insertion causing an anteriormedial knee instability grade () without rupture of the anterior cruciate ligament. This case demonstrates that a grade ()-instability can be caused without rupture of the cruciate ligaments just by the rupture of a so called "dynamic stabilisator" like the pes anserinus.

Busulfan-induced hemorrhagic cystitis

We report a case of severe hemorrhagic cystitis induced by prolonged busulfan therapy. The clinical course and pathological results were similar to irradiation and cyclophosphamide cystitis. Only 1 such case has been described previously. Although hemorrhagic cystitis induced by busulfan is a rare complication it should be considered in the differential diagnosis and busulfan should be discontinued immediately.

Three mutant insulins in man

We have previously identified a structurally abnormal insulin in the serum and pancreas of a middle-aged man with diabetes mellitus which arose from a leucine for phenylalanine substitution at position 24 or 25 of the insulin B chain; further analysis of the patient's leukocyte DNA showed that one of the patient's insulin alleles had undergone mutation resulting in loss of an MboII restriction site normally present in the human insulin gene. Two additional and unrelated patients with the same clinical syndrome have now been identified (ref. 4 and unpublished results). All of these patients showed hyperglycaemia typical of diabetes and with marked hyperinsulinaemia typical of insulin resistance, but all three show normal tolerance to exogenously administered insulin. As the opportunity of examining pancreatic tissue from patients suspected of secreting insulin variants is rare, we have developed a method combining HPLC and radioimmunoassay to identify insulin variants isolated from human sera. By this method we have shown that all three patients noted above secrete structurally variant and chemically distinct insulins. In correction of our original assignment, one is identified as [LeuB25]insulin.

Diagnosis of pancreatic carcinoma by means of endoscopic retrograde pancreatography and pancreatic cytology

Endoscopic retrograde pancreatography (ERP) combined with pancreatic juice cytology, was performed in 14 patients with pancreatic carcinoma confirmed at subsequent laparotomy. ERP demonstrated duct abnormalities that were diagnosed as carcinoma in 86% of the cases and as suggestive of carcinoma in another 14%. Cytology was positive in 86% and suspicious in 7%. By combining both methods, all 14 carcinomas were correctly identified. Thus, in our hands, ERP and pancreatic juice cytology proved to be the most sensitive and reliable methods in detecting pancreatic carcinoma. On the basis of these promising results it is proposed that pancreatic juice cytology, which is a no-risk method, should be employed in all elderly patients with unexplained abdominal complaints, to screen them for early pancreatic carcinoma.

[Nerve sheath tumors: malignant schwannoma (author's transl)]

The morphology and biology of tumors of the nerve sheath show rather heterogeneous aspects. In most the site of origin seems to be the Schwann's cells. Essentially these tumors can be differentiated into three groups: 1. malignant schwannoma, 2. neurinoma, and 3. neurofibroma. Although the Schwann's cell is the common origin, the three different tumors can be well differentiated histologically with the exception of malignant schwannoma and spindle cell sarcoma. The clinical symptoms are determined by the location of the tumor and are without general characteristics. The treatment of choice is always radical surgery. In addition, radiation and chemotherapy are indicated in special cases.

[Is creatine kinase isoenzyme CK-MB a diagnostic tool for perioperative myocardial infarctions? (author's transl)]

There is still controversy of the validity of elevated CK-MB serum activity in the diagnosis of perioperative myocardial infarction after open heart surgery. CK-MB activity was investigated using myocardial and skeletal muscle biopsies and in sera postoperatively in 192 patients. In biopsies CK-MB fraction of total myocardial CPK was 37%, the total-CPK activity of human skeletal muscles still shows a 5% fraction of CK-MB. There has to be more than 8% CK-MB fraction of total CPK-serum-activity to take this as evidence of myocardial damage. 3 h postoperatively enzymatic-immunologic CK-MB test is no longer interfered by enzymes derived from hemolyzed erythrocytes. In patients without signs of myocardial lesions postoperatively mean CK-MB-activity is 11 to 27 U/1 depending on the operative procedure performed. Activity levels exceeding 50 U/1 are almost evident of myocardial infarction. Elevated CK-MB-serum activity is a sensitive parameter for myocardial lesions overestimating an event of infarction. It is a helpful tool diagnosing perioperative myocardial infarction.

The Tokamak: Model T Fusion Reactor

During the past several years there have been significant scientific and technological advances related to the tokamak magnetic confinement scheme. These are summarized in the context of a recent tokamak reactor design study which emphasizes reduced size, higher power density, and enhanced plant reliability and maintainability relative to earlier tokamak reactor design studies. The direct plant cost of the proposed reactor is estimated to be in the range $1000 to $1500 per electrical kilowatt. A three-phase strategy for demonstrating tokamak fusion power generation at a committed site is outlined. It is estimated that implementation of the three-phase program would require about 20 years and a total escalated expenditure $10 billion to $15 billion. The tokamak power plant described here is not viewed as definitive but rather as a point of departure in the development of a plan to demonstrate tokamak power generation.

[Prevention of edema during coronary perfusion with cardioplegic solution (author's transl)]

In arrested and with cardioplegic solutions perfused rabbit hearts the relation of perfusion-pressure and flow rate were examined, showing that edema of the myocardium can be avoided even using erythrocytes-free solutions by two measures. First the solution has to contain colloid active agents and secondly the perfusion pressure has to be significantly below the colloid-osmotic pressure. Furthermore the edema can be avoided by adding 300 mg 6-methyl prednisolone/1. If no attention is paid to these facts the coronary flow decreases constantly due to developing interstitial and interfibrillar edema and degenerative changes of endothelial cells of the capillaries, which even can undergo necrosis. These changes were not seen using steroids. On the contrary here we found by densitometry and increased number of lysosomes. These findings show the effectiveness of corticosteroids in stabilizing the cell membranes.

[Long-term cardiac arrest by cardioplegic coronary perfusion (author's transl)]

The Mg++ aspartate-procaine-cardioplegia has been proven in animal experiments as well as from 1970 til 1975 in more than 1000 open-heart-procedures by a myocardial temperature of 32 degrees C and aortic crossclamping time up to 40 minutes superior to all other known procedures of cardiac preservations. To guarantee a safe myocardial protection of the arrested heart for a remarkable longer period of total ischemia, we further developed the cardioplegic technique in the animal lab, and use it now clinically.

PRINCIPLE

The arrest is induced by cardioplegia (Mg++ aspartate-procaine), than the arrested heart is cooled down to 15-20 degrees C by cardioplegic coronary perfusion maintaining the oxidative metabolism. The perfusion is stopped. The begin of ischemia is still under normal ATP-levels and continuous cardioplegia.

TECHNIQUE

1. Crossclamping of the aorta; 2. cardioplegic induced cardiac arrest by Mg++ aspartate-procaine (Kirsch); 3. Surface cooling of the heart; 4. Coronary perfusion by hypothermic cardioplegic solution (8-10 min, flow 80-120 ml/min, perfusion pressure maximal 30 mmHg). Perfusate: O2-saturated, erythrocyte free, 6% hydroxyethyl starch solution added 2 mM Mg++ aspartate, 4 mM procaine, 50 mM Na+, 5 mM K+, 0,5 mM Ca++, 25 mM HCO3-, 10 mM glucose, 200 mM mannitol, 250 mg/l 6-methylprednisolone.

RESULTS

84 patients (29 ACVB; 55 valve replacements); crossclamping time: 71 min (SD 22); total time of ischemia: 57 min (SD 18; max 96, min. 27 min); reperfusion time restoring normal excitation-contraction of the heart: 3 min (SD 2); weaning off bypass: 23 min (SD 14). Hemodynamic 12 h postop.: SO2 venous 76% (SD 6). No sympathicomimetics were used. Only 30% of myocardial ATP is splitted after 120 min of cardiac arrest. Electron microscopic findings show only small, reversible alterations of fine structure.