[Standardized documentation of patho-anatomic findings using ADT (Association of German Tumor Centers) tumor forms for malignancies of the mouth, jaw and face (version III)]

The documentation form for pathohistologic findings (version III) for tumors of the maxillofacial region is presented. It is part of the site-specific documentation of the German Association of Tumor Centers (ADT). Its handling is explained by instructions which are based on the ICD-O classification and the TNM system. The prognostic relevance of the standardized documentation has already been proven by various histomorphologic investigations concerning oral and oropharyngeal cancer. By means of a multicentric observational study the German Austrian Swiss co-operative group DOSAK will develop a new prognostic model for oral and oropharyngeal cancer.

[The management of adolescents and adults with congenital heart defects: 3 years experiences with interdisciplinary consultation]

Since September 1991, 204 patients (pts), 109 male and 95 female, mean age 27.3 +/- 10.6 years, were followed in a newly established interdisciplinary outpatient clinic combining both adult and pediatric cardiologists. 61 pts predominantly presented with left-to-right shunt congenital heart disease (CHD), 32 with valvar CHD, 20 with aortic coarctation, 23 with complex acyanotic, and 49 with cyanotic CHD. The population included 19 pts with Marfan syndrome. 106 pts had had previous cardiac surgery, 32 of them with up to three reoperations. Deficits and needs in medical and social care were analyzed in 100 pts using a standardized questionnaire at the time of first examination: One-third of pts were not or only incompletely informed about their CHD, previous surgical procedures and need for antibiotic prophylaxis of endocarditis. Only a minority of pts had had vocational advice (34%) or counseling concerning contraception (40%) or pregnancy (30%). Cardiac catheterization was performed in 37 pts (18%) after being first seen in our outpatient clinic, followed by a primary surgical intervention in 19 and reoperation in eight cases. Overall, 30 pts (15%) underwent surgery (28) or interventional procedures (one closure of the arterial duct, one AV node ablation after Mustard-operation) as a consequence of admission to our unit. Successful late Fontan operations were performed in four adults aged 21 to 35 years. There was 1/30 postoperative death (M. Ebstein, thrombosis of the mechanical prosthesis). The population includes five pts with severe pulmonary vascular disease (one waiting for lung transplantation) and two pts with pulmonary artery arborisation malformations not amenable to surgery.

CONCLUSION

In a population of 204 adolescents and adults with CHD, we clearly found deficits in medical and social care and, in addition, an unexpected high percentage of necessary invasive investigations (18%) and surgical or interventional procedures (15%). Interdisciplinary management of these patients is mandatory combining the special facilities of adult and pediatric cardiologists.

Properties of a Streptococcus suis isolate of serotype 2 and two capsular mutants

Encapsulation is thought to be a critical virulence factor of Streptococcus suis. In the present study two capsular type 2 mutants of S. suis (M42 and M2) and their S. suis parent strain (89-1591) were further characterized. All three cultures reacted with group D specific antiserum whereas parent strain 89-1591 and mutant M42 but not mutant M2 reacted with specific antiserum against capsular type 2. Both mutants had higher surface hydrophobicity and showed an increased adherence to human epithelial cells and to lung macrophages of rabbits as compared to the parent strain. In phagocytosis experiments with polymorphonuclear leucocytes the encapsulated parent strain was more resistant to phagocytosis than both mutant strains. These findings might help to understand the role of encapsulation of S. suis in the process of infection.

[Fatal Aspergillus sepsis following orthotopic heart transplantation]

In a 64-year-old man heart transplantation had been performed for ischaemic heart disease. 7 months later severe vascular disease in the transplant necessitated a second transplantation. Both procedures had been performed under immunosuppression (cyclosporine, azathioprine, prednisolone, antithymocyte globulin), with a subsequent prednisolone maintenance dose of 10 mg daily. At first there were no complications, but 31 days after the re-transplantation atrial flutter developed. Although this was quickly terminated by drugs, circulatory failure set in. Because of signs of infection (white blood cell count 29,800/microliters, 17% stab cells, C-reactive protein 24 mg/l) broad-spectrum antibiotics were administered, but without response. As a trial anti-rejection treatment was started (prednisolone 250 mg daily: antithymocyte globulin 100 mg daily for 4 days). When cytomegalovirus (CMV) infection was demonstrated, ganciclovir and CMV hyperimmunoglobulin were administered and slow improvement was noted. The finding of Aspergillus in tracheal secretion was interpreted as apathogenic colonization. The patient died from cardiorespiratory failure 57 days after the second transplantation. Autopsy revealed Aspergillus sepsis.

Sympathetic re-innervation after heart transplantation: dual-isotope neurotransmitter scintigraphy, norepinephrine content and histological examination

Cardiac transplantation entails surgical disruption of the sympathetic nerve fibres from their somata, resulting in sympathetic denervation. In order to investigate the occurrence of sympathetic re-innervation, neurotransmitter scintigraphy using the norepinephrine analogue iodine-123 metaiodobenzylguanidine (MIBG) was performed in 15 patients 2-69 months after transplantation. In addition, norepinephrine content and immunohistochemical reactions of antibodies to Schwann cell-associated S100 protein, to neuron-specific enolase (NSE) and to norepinephrine were examined in 34 endomyocardial biopsies of 29 patients 1-88 months after transplantation. Anterobasal 123I-MIBG uptake indicating partial sympathetic re-innervation could be shown in 40% of the scintigraphically investigated patients 37-69 months after transplantation. In immunohistochemical studies 83% of the patients investigated 1-72 months after transplantation showed nerve fibres in their biopsies but not positive reaction to norepinephrine. Significant norepinephrine content indicating re-innervation could not be detected in any biopsy. It was concluded that in spite of the lack of norepinephrine content there seemed to be immunohistological and scintigraphic evidence of sympathetic re-innervation. An explanation for this contradictory finding may be the reduced or missing norepinephrine storage ability compared to the restored uptake ability of regenerated sympathetic nerve fibres.

[Viral hepatitis C]

Soon after the isolation of the hepatitis C virus (HCV) genome in 1988 it became evident that HCV is the most important cause of non-A, non-B-hepatitis. In recent years the structure of this (+)-stranded RNA-virus, the different genotypes of HCV and the replication in hepatic and extrahepatic sites have been investigated. HCV has a remarkable degree of genetic heterogeneity, mutates rapidly, leading to the simultaneous coexistence of different genoms in the same individual (quasispecies) and most likely to the generation of neutralization escape mutants. The cytotoxicity of the hepatitis C virus appears to be mainly immune-mediated. This review article summarizes basic, diagnostic and clinical aspects of acute and chronic HCV-infection, association with other diseases and complications such as liver cirrhosis and hepatocellular carcinoma. Interferon-alpha has been shown useful in normalizing serum aminotransferases and decreasing liver inflammatory lesions in about half of the patients with chronic hepatitis C. However, relapses after the cessation of interferon-alpha are frequent, leading to a sustained response in less than 30% of treated patients. Several clinical and biochemical parameters for response to interferon-alpha have been proposed. In patients with orthotopic liver transplantation due to progressive chronic hepatitis C and decompensated liver cirrhosis, reinfection of the donor organ frequently occurs. However, in transplanted patients under immunosuppression the course of hepatitis C reinfection is usually mild. Due to screening programs of blood and blood products the incidence of posttransfusion-acquired hepatitis C has declined. However, further efforts in understanding the transmission of community-acquired hepatitis C are necessary. The development of a hepatitis C vaccine will be difficult due to the high degree of viral genetic heterogeneity.

[Pseudo-stenosis caused by vessel wall invagination during interventional treatment of 2 coronary vessels in a patient]

We report on a 59-year-old man who underwent a combined procedure of directional coronary atherectomy (DCA) and PTCA of significant lesions of the right coronary artery (RCA) and the left circumflex artery (LCX). Already after positioning of a standard guide wire in the right coronary artery a new excentric "pseudo-stenosis" was observed in the proximal part of the right coronary artery. Since the patient remained symptom free, a 7F DCA catheter was introduced to the stenotic area in the mid RCA, which led to an extension of the narrowing, involving the total segment proximal to the DCA catheter. Directional coronary atherectomy was performed without complications. Removal of the catheter, after successful DCA, and administration of intracoronary nitroglycerin did not relieve the proximal narrowing, which disappeared spontaneously after the guide wire was pulled out. During PTCA of the left circumflex using a standard guide wire and a 3.0 mm Monorail balloon catheter, a similar tight narrowing of the origin of the LCX was observed, which could also not be influenced by vasodilator drugs, but relieved after wire removal. Until now, this phenomenon has only been described for the right coronary artery. The reason underlying intimal folding is a shifting of the intimal layer against the medial layer of the vessel wall. Our observation firstly describes this phenomenon of "pseudo narrowing" in two different vessels in one patient. We, like other authors before, recommend that interventional therapy of these pseudo-lesions should be avoided.

Systemic interleukin-1 alpha and interleukin-2 secretion in response to acute stress and to corticotropin-releasing hormone in humans

Acute stress results in activation of the hypothalamic-pituitary-adrenal (HPA) axis. ACTH and cortisol secretion is stimulated by corticotropin-releasing hormone (CRH). It has also been shown that activation of the HPA axis during stress is accompanied by changes in the immune response. However, little is known about the influence of acute stress on the release of cytokines such as interleukin-1 (IL-1) or interleukin-2 (IL-2). In this study, we determined serum IL-1 alpha and IL-2 levels in 19 patients undergoing the acute stress of angioplasty for coronary artery disease. A second protocol was devised to determine serum IL-1 alpha and IL-2 concentrations as well as lymphocyte subpopulations in 10 normal volunteers receiving 1 microgram kg-1 human CRH intravenously. Finally, IL-1 alpha concentrations were measured in CRH-incubated mononuclear cell (MNC) and monocyte cultures. In response to the stress of angioplasty, ACTH and cortisol as well as IL-1 alpha and IL-2 concentrations were clearly above baseline levels (IL-1 alpha, mean +/- SEM, baseline: 1.39 +/- 0.34 ng ml-1, after angioplasty: 2.64 +/- 0.73 ng ml-1, P < 0.05; IL-2, baseline: 1.2 +/- 0.13 ng ml-1, after angioplasty: 2.8 +/- 1.14 ng ml, P < 0.05). A similar pattern was obtained in normal subjects in response to CRH (Il-1 alpha, baseline: 0.8 +/- 0.2 ng ml-1, after angioplasty: 3.7 +/- 1.4 ng ml-1, P < 0.05; IL-2, baseline: 1.9 +/- 0.4 ng ml-1, after angioplasty: 5.4 +/- 2.2 ng ml-1, P < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

T lymphocytes, CD68-positive cells and vascularisation in thyroid carcinomas

Immunohistochemical detection and quantification of CD3- and CD45RO-positive lymphocytes and CD68-positive cells in 75 thyroid carcinomas of follicular cell origin revealed rising levels for these parameters associated with dedifferentiation. A parallel trend towards reduction of vascularisation, determined as CD31-positive blood vessels, with decreasing differentiation became evident, statistically only significant when well-differentiated follicular and anaplastic carcinomas were compared. Positive correlations could be demonstrated between the density of CD68-, CD3-, and CD45RO-positive cells as well as between the density of CD68-, and CD3-, and CD45RO-positive cells and vascularisation. These correlations were expected, as the interaction of CD68-positive cells and T lymphocytes results in the production of angiogenesis factors, ultimately leading to better vascularisation of the tumour. Nevertheless, the tumour cells themselves are variously capable of producing angiogenic substances. The obvious lack of positive correlation between the density of tumour-infiltrating cells determined in this study and vascularisation, despite reduced vascularisation in less differentiated tumours that contained increasing numbers of tumour-infiltrating cells, seems to be due to functional heterogeneity of morphologically similar tumours.

Bicaval versus atrial anastomoses in cardiac transplantation. Right atrial dimension and tricuspid valve function at rest and during exercise up to thirty-six months after transplantation

Conventional cardiac transplantation with atrial anastomoses alters atrial integrity, geometry, and possibly function. Theoretically, this may also contribute to the development of tricuspid insufficiency that is frequently observed after the operation. Thus more anatomic transplantation techniques using bicaval anastomoses were recently introduced into clinical practice. Knowledge of their efficacy, however, is scarce. Therefore right atrial size and tricuspid valve function were compared in patients with bicaval (group A) and standard atrial (group B) anastomoses in a randomized, prospective study. The results of this echocardiographic study at rest and exercise in 18 patients (bicaval n = 8; atrial n = 10) on the average 28 months after transplantation are presented. The right atrial dimension was comparable between group A patients and control subjects and larger in group B patients (p < 0.05). The incidence of tricuspid regurgitation was not different between the two groups at rest, but it was at exercise (50 watts of workload) (p < 0.05). This study suggests that up to 36 months after cardiac transplantation the technique of bicaval in contrast to atrial anastomoses preserves right atrial size and reduces tricuspid regurgitation during exercise. Whether this leads to improved hemodynamics and increased exercise capacity remains to be evaluated in a larger series of patients.

[Directional coronary atherectomy: effect of vessel size on primary results and long-term results]

Of 325 consecutive patients undergoing DCA, 263 patients with 277 stenoses were successfully treated with DCA alone and had angiographic follow-up 3-6 months later. Depending upon the initial reference diameter (RD) patients were divided into two subgroups: group I (n = 159) with a RD > 3 mm and group II (n = 104) showing a RD < or = 3 mm. In contrast to other series DCA was predominantly performed with 7F atherectomy devices using balloon inflation pressures of approximately 5 atm. Angiographic data including the minimal luminal diameter (MLD), percentage of stenosis (%D) and reference diameter (RD) were assessed by quantitative computer-assisted analysis before (pre), after (post) DCA and at a 3-6 months angiographic follow-up (FU). The percentage of diameter stenosis pre/post/FU in group I was 59.9 +/- 12.6%/18.4 +/- 12.8%/29.8 +/- 17.6%, and in group II 55.6 +/- 10.8%/17.8 +/- 12.3%/33.7 +/- 16.1% with a net gain at FU of 1.0 +/- 0.89 mm for group I and 0.86 +/- 0.66 mm for group II. Based on an angiographic restenosis criterion of at least 50% diameter obstruction at FU and or recurrence of symptoms warranting interventional re-treatment of the target lesion, the incidence of restenosis in group I was 20.6% and in group II 28.0% (p: n.s.). There was no significant difference between the two groups concerning complications. Our data show that DCA leads to a satisfying long-term result.(ABSTRACT TRUNCATED AT 250 WORDS)

Cyclosporin A and transplant coronary disease after heart transplantation: facts and fiction

From published data in the currently available literature on animal experiments, it can be concluded that CyA may be involved in the development of hypertension and renal dysfunction. These side effects are probably related to a disturbed vasomotor tone and a pathologic reaction to physiologic vasoconstrictive and vasodilative agents following administration of high doses of CyA. These effects are dose related and reversible and were undetected at clinically applied levels of immunosuppression. It therefore appears to be unlikely that this pathologic response is operative in precipitating or promoting TCD, which is supported by findings of in vivo and in vitro studies on human coronary arteries as well as by comparison of immunosuppressive protocols comparing series with and without application of CyA. Chronic graft dysfunction, as depicted by late mortality in heart and isolated lung transplant recipients and by loss of kidney allograft survival, yields an annual rate of between 4 and 6% per year. It is only in heart transplantation that TCD has been tried to be associated with CyA application. If CyA-related damage were to occur in coronary arteries independent from immunologic factors, the incidence of coronary disease should be similar in heart, lung, liver, and kidney transplants. This is not the case. Although continuous investigation on the side effects of immunosuppressive agents is definitely necessary, we should concentrate our research activities on potential prophylactic and therapeutic measures to overcome the single most important risk factor of long-term surviving patients after solid organ transplantation: chronic rejection.

[Sialadenitis at an unusual site in acute infectious mononucleosis]

Infectious mononucleosis is found worldwide. The clinical manifestations vary widely. We report a case with impressive swelling of the hard and soft palate. Inflammation in the region of the efferent ducts of the palatinal glands resulted in congestion in the region of the mucinous salivary glands. The subsequent secretory stasis caused degeneration of the acini and rupture of a salivary retention cyst. The surrounding connective tissue was soaked with mucin, and unspecific chronic granular inflammation was found. Immunohistochemical examination with a monoclonal EBV antibody was necessary to show that the exceptional clinical picture was due to infectious mononucleosis.

[Hemodynamic effects of non-ionic iomeprol 350 and ionic diatrizoate 370 during levocardiography and coronary angiography--double-blind randomized comparison of 2 contrast media]

A double-blind randomized study was performed in 49 patients to compare the hemodynamic changes induced by two contrast agents: non-ionic low osmolar lomeprol 350 (IO, n = 25) and ionic high osmolar Diatrizoat 370 (DIA, n = 24). We observed significant changes in hemodynamic parameters after laevocardiography with DIA: a decrease in LVSP from 125 +/- 14 to 113 +/- 14 mmHg, a decrease in mean aortic pressure from 96 +/- 9 to 84 +/- 10 mmHg and in max dp/dt from 2086 +/- 628 to 1861 +/- 654 mm Hg/sec. LVEDP increased from 13 +/- 5 to 17 +/- 6 mmHg and cardiac output from 5.9 +/- 1.2 to 7.7 +/- 1.2 l/min. Heart-rate also rose slightly, but insignificant. IO did not alter these parameters. After selective coronary angiography both groups did not differ significantly in systolic aortic pressure, but DIA caused a drop in diastolic aortic pressure after 10 to 15 sec and a bradycardia in the first five sec, in contrast to IO. These effects can be explained by a cardiodepressive action of contrast agents on left ventricular function, an increase in circulating volume and a reduced peripheral vessel resistance. Differences between both agents are probably due to their different osmolality. IO is a safe contrast agent, compatible in contrast to DIA. In patients with borderline left-ventricular function, IO is preferable, it exerts only very slight effects on cardiovascular function.

[Intervention and clinical aspects combined with endovascular irradiation of intimal hyperplasia of the vascular system]

After implantation of stents in femoropopliteal arteries we found restenosis or occlusions by intimal hyperplasia in up to 40% especially in the hunter's channel. Repeated balloon angioplasty and prophylactic endovascular radiotherapy with a surface dose of 12 Gy in the vessel wall using an iridium 192 source in the same investigational session is a new technique to reduce or eliminate further recurrence. All 18 patients had developed recurrent stenoses or occlusions 6-8 months after original stent implantations. The patients have not redeveloped recurrent obstructions after this treatment, which up to date showed no short term or long term complications. We conclude that the encouraging results of this pilot study justify further randomized trials.

[Hyper-IgE syndrome--two case reports of unusual complications]

The hyper-IgE syndrome (HIS) is a complex immunologic disease, caused by an unknown basic defect. We report on two cases showing complications, which have not been described so far. Case 1: A 15-year-old boy suffering from HIS developed a liver tumour with severe eosinophilic infiltration and degranulation. The transformation process of the liver histologically resembled focal nodular hyperplasia. Therapy with cyclosporine A did not lead to clinical benefit. Now, a therapeutic attempt with interferon gamma is made. Case 2: In a 17-year-old female HIS patient, multiple papillomas and ulcers of the mucous membrane, caused by infection with human papilloma virus, emerged in the ENT region. Under treatment with interferon alpha, papillomatosis could be restrained. As therapy of the hyper-IgE syndrome only symptomatic treatment has been recommended so far. Future therapies should strive for systemic immunomodulation by application of cytokines or soluble cytokine receptors like interferons or sIL-4R.

[Neurochemical studies of adrenergic reinnervation after heart transplantation]

Heart transplantation causes sympathetic cardiac denervation. Measurements of plasma concentrations of the main presynaptic noradrenaline metabolite, dihydroxyphenylglycol (DOPEG, the plasma pool of which is exclusively neuronal in origin), were used to examine sympathetic reinnervation of the transplanted human heart. We determined arterial and coronary-venous plasma concentrations of DOPEG in 27 heart transplant recipients (transplant age ranging from 0.5 to 5 years) and in 9 control patients. In each of the control patients the DOPEG concentration was higher in coronary venous plasma than in arterial plasma (mean arterio-venous increment: 57.3 +/- 8.7%; p < 0.001). However, in heart transplant recipients, 18 out of 27 patients showed an arteriovenous increment in plasma DOPEG (mean increment in all patients 12.6 +/- 2.0%; p < 0.05). The ratio of the coronary-venous to arterial DOPEG concentration was positively correlated with the time after transplantation (p = 0.02 for individual results and p < 0.01 for mean group results). Thus, our data provide evidence for a time-dependent partial sympathetic reinnervation of the transplanted heart.

Microquantitative determination of lactate dehydrogenase isoenzymes in the myocardium and the conducting system

A newly developed technique was used for the electrophoretic separation of lactate dehydrogenase (LDH) isoenzymes from lyophilized tissue samples in the nanogram range. In this study portions of 10-200 ng from the myocardium and the conducting system of cattle, sheep, pig and man were microdissected and analysed. In the heart tissues of cattle, sheep and pig, the isoforms LDH1, LDH2 and LDH3 were detected in species-specific varying amounts. In all these animals, the conducting system is marked by high LDH1 activity, which is present at a ratio of about 2:1 compared with the myocardium. The values in man, however, differ from these values, but this might be due to post-mortem changes. The findings are discussed with respect to possible aerobic-anaerobic functions.

Rapidly growing Epstein-Barr virus-associated pulmonary lymphoma after heart transplantation

There is strong evidence to show an association of Epstein-Barr virus (EBV) infection with the development of post-transplant lymphoproliferative disease. We report the rapid development of a malignant lymphoma in a heart transplant recipient, which occurred within less than eight weeks. The diagnosis of this malignant high grade B-cell lymphoma was established by open lung biopsy, and classified as centroblastic lymphoma of polymorphic subtype. Immunohistochemically, the lymphoma showed reactivity with the B-cell markers L-26 (CD20) and Ki-B5 and with the activation marker Ber-H2 (CD30). Furthermore, an expression of the bcl-2 oncoprotein was detected. Monoclonal JH gene rearrangement was demonstrated by polymerase chain reaction (PCR), indicating monoclonal proliferation of B-blasts. Although serum EBV immunoglobulin M (IgM) antibodies were negative, the association to an EBV infection could be demonstrated by EBV immunostaining pattern which revealed an expression of the latent membrane protein (LMP) of EBV in the atypical blasts. The results give clear evidence of an EBV association of this rapidly growing lymphoma developed after heart transplantation.