Improved directional hearing of children with congenital unilateral conductive hearing loss implanted with an active bone-conduction implant or an active middle ear implant

Different amplification options are available for listeners with congenital unilateral conductive hearing loss (UCHL). For example, bone-conduction devices (BCDs) and middle ear implants. The present study investigated whether intervention with an active BCD, the Bonebridge, or a middle ear implant, the Vibrant Soundbridge (VSB), affected sound-localization performance of listeners with congenital UCHL. Listening with a Bonebridge or VSB might provide access to binaural cues. However, when fitted with the Bonebridge, but not with a VSB, binaural processing might be affected through cross stimulation of the contralateral normal hearing ear, and could interfere with processing of binaural cues. In the present study twenty-three listeners with congenital UCHL were included. To assess processing of binaural cues, we investigated localization abilities of broadband (BB, 0.5-20 kHz) filtered noise presented at varying sound levels. Sound localization abilities were analyzed separately for stimuli presented at the side of the normal-hearing ear, and for stimuli presented at the side of the hearing-impaired ear. Twenty-six normal hearing children and young adults were tested as control listeners. Sound localization abilities were measured under open-loop conditions by recording head-movement responses. We demonstrate improved sound localization abilities of children with congenital UCHL, when listening with a Bonebridge or VSB, predominantly for stimuli presented at the impaired (aided) side. Our results suggest that the improvement is not related to accurate processing of binaural cues. When listening with the Bonebridge, despite cross stimulation of the contralateral cochlea, localization performance was not deteriorated compared to listening with a VSB.

In vivo perfusion analysis of normal and dysplastic ears and its implication on total auricular reconstruction

INTRODUCTION

During the first stage of total auricular reconstruction with autologous rib cartilage, according to Nagata, the cartilage framework is placed in a subcutaneous pocket. Its posterior skin flap is relatively large and can be prepared with or without a subcutaneous pedicle. This represents the crucial part of the procedure, as impaired healing and infection can occur due to low perfusion. Nothing was known about the blood supply of ear remnants or flap perfusion during reconstruction. It was not clear whether the preservation of the additional subcutaneous pedicle secures high blood supply.

METHODS

We used laser fluorescence angiography with indocyanine green dye for anatomical and functional perfusion studies in eight normal ears. Subsequently the anatomical and functional vessel architecture of 18 dysplastic ears was investigated. Finally, five patients each were operated on with or without subcutaneous pedicle during auricular reconstruction and intraoperatively monitored with laser fluorescence angiography.

RESULTS

We showed that the vessel structure of normal ears detected by fluorescence angiography is equivalent to anatomical preparations. The surrounding skin in high grade microtia remnants is biphasically perfused by deep perforators and by the cutaneous vessel network. The preservation of the subcutaneous pedicle during auricular reconstruction leads to significantly better perfusion of the posterior skin flap. No signs of critical perfusion or complications were observed in these patients.

DISCUSSION

We present the feasibility of laser fluorescence angiography to simultaneously gain anatomical and functional data about skin blood supply. The first anatomical and functional description of blood supply of ear remnants in third grade microtia is given. Functional data of skin flap perfusion during and after complete ear reconstruction were evaluated. The present study shows that the subcutaneous pedicle of Nagata's procedure is of great importance for success of the first stage operation as it prevents impaired wound healing. In contrast, patients without a subcutaneous pedicle had a broad spectrum of reduced perfusion and therefore some had complications.

[Analysis of psychosocial changes following ear reconstruction with rib cartilage - development of a short test]

BACKGROUND

The improvement of psychosocial well being in patients with microtia after ear reconstruction with rib cartilage is mainly assessed clinically. There are first prospective studies with established psychological questionnaires showing promising results but these tests are too extensive for everyday-use in clinical routine. Therefore, we examined a self-designed short version for the specific use in the head-neck-region.

METHODS AND PATIENTS

The clinically established psychological questionnaire "Frankfurter Selbstkonzeptskalen/FSKN" consists of 78 items for self-assessment of performance abilities, self-esteem, and psychosocial attitude. We downsized the FSKN to 13 items that might be relevant for plastic reconstructive surgery in the head-neck-region. The pre- and postoperative development after ear reconstruction with rib cartilage was analyzed retrospectively in 68 patients and prospectively in 21 patients. The preoperative data of the prospective study group were compared with the results of 23 patients with microtia who declined any type of reconstruction after consultation.

RESULTS

Especially the results of the psychosocial competence improved after ear reconstruction as well in the retrospective (median values 138,5 to points; p<0,01) as well as in the prospective study group (median values 126 to 141 points; p=0,01). We were able to demonstrate changes in the short version of the FSKN (median values 51,5 to 58,5 points; p<0,01 respectively, 50 to 56 points; p=0,02). Patients who declined ear surgery showed higher values in psychosocial competence (median values 126 to 154 points; p<0,01). Again, the short form displayed this difference clearly (median values 50 to 65 points; p<0,01).

CONCLUSIONS

The short version of the FSKN has promising potential for the preoperative assessment and the documentation of psychological changes following reconstructive surgery. Further studies are necessary to validate the new instrument to obtain a valuable test for use in clinical routine in plastic surgery in the head-neck-region.

[Epidemiology of auricular trauma]

BACKGROUND

Auricular trauma is rare but can seriously reduce self-acceptance and function. Epidemiologic data on the causes of trauma causes and patient characteristics are limited.

PATIENTS AND METHODS

The case notes of 141 from 197 patients with ear injuries have been reviewed retrospectively according to trauma cause and to the distribution of age and gender.

RESULTS

Two thirds of the documented cases occurred between the age of 11 and 40 years. Men outnumbered women at a ratio of 2 to 1. The most frequent causes for ear trauma were traffic accidents (43 %), accidents at home (33 %), and fights (14 %).

CONCLUSIONS

Mainly younger and active groups of the population are affected by ear trauma. Therefore, it is of particular concern in the acute setting to select those therapeutic options that have turned out good aesthetic and functional results in the long-term perspective.

Integration des aktiven Mittelohrimplantates in die plastische Ohrmuschelrekonstruktion

BACKGROUND

Patients with high-grade microtia and atresia require a sophisticated and specific treatment. Apart from the plastic reconstruction of the auricle, in some cases hearing rehabilitation is medically indicated or is desired by the patients. The long-term results of simultaneous middle ear reconstruction with tympanoplasty are often inadequate owing to a persisting air-bone gap, and new techniques in hearing rehabilitation are needed for these patients.

METHODS

We present three cases of unilateral atresia to illustrate a combined approach integrating hearing rehabilitation using the active middle ear implant Vibrant Soundbridge (VSB) into plastic auricular reconstruction. The VSB was attached to the stapes suprastructure via the titanium clip in two of these cases and in the third case a subfacial approach was used to attach it directly to the membrane of the round window.

RESULTS

The air-bone gap was reduced to 17 dB, 14 dB and 0.25 dB HL. In free-field speech recognition tests at 65 dB SPL the patients achieved 100%, 90% and 100% recognition with the activated implant. No postoperative complications such as facial nerve paresis, vertigo or inner ear damage were found.

CONCLUSIONS

The integration of active middle ear implants in auricular reconstruction opens up a new approach in complete hearing rehabilitation. The additional implantation of the VSB does not have any negative effect on the healing process or the cosmetic outcome of the auricular reconstruction.

T-level downstaging and complete pathologic response after preoperative long-term radiochemotherapy for locally advanced rectal cancer

Advantages of neoadjuvant chemoradiotherapy for locally advanced carcinoma of the middle and the lower third of the rectum are downstaging and downsizing of the tumor. Results of pathologic results are affected by post-treatment tissue changes and may influence the choice of surgical procedure. Forty-three consecutive patients (27 male, 16 female; mean age 64 years) were operated after receiving a long-term chemoradiotherapy during a period of 16 months. The data of initial staging procedure (high resolution magnetic resonance imaging) and results of pathological examination of the surgical specimens were analyzed. Regression of tumor was assessed by the absence of vital tumor cells and the post-treatment fibrotic tissue alterations. Regression of tumor size was seen in 42/43 patients leading to an improved T-stage in 27 patients. R0-resection was possible in all cases, although there was a perirectal tumor infiltration to less than 2 mm to circumference of the surgical specimen in 2 cases and unexpected small liver metastasis in 5 cases. Complete remission rate was 23.3% (10 cases). Detecting small amounts of vital tumor cells in altered tissue after chemoradiotherapy is a major problem of pathological examination procedure and should be taken into consideration by the surgeons. The choice of operation (resection vs. abdominoperineal extirpation vs. local excision) should be committed to the initial imaging procedure and not to any restaging procedure after neoadjuvant chemoradiotherapy.

[Reconstruction of the auditory canal wall with bone chips from the temporal squama--preliminary results]

BACKGROUND

The canal wall down-technique in cholesteatoma surgery with the creation of an open mastoid cavity offers many disadvantages as prolonged healing time, necessity for periodic cleaning and subsequent infections. Therefore reconstruction of the posterosuperior canal wall is the more and more preferred technique to restore the physiologic anatomy of the external auditory canal without lacking a good surgical exposure to the tympanal and retrotympanal spaces. Cartilage is the mainly used material for this technique, as cartilage is easy to prepare and to fit into the defect with good viability. However, cartilage resorption and retraction is observed increasing the risk for recurrent cholesteatoma. In contrast, by the use of bone chips from the temporal squama a stable and close restoration of the auditory canal wall can be achieved.

PATIENTS AND METHODS

In 23 patients (17 attic and 6 sinus cholesteatomas including two recurrences in each group) we have performed an anterior atticoantrostomy with retrograde cholesteatoma removal and reconstructed the posterosuperior wall of the auditory canal with bone chips harvested from the temporal squama by chisels. The bone chips and remaining gaps in the reconstructed wall were covered by bone paté and temporal fascia. In 4 cases the ossicular chain could be conserved (type-1 tympanoplasty [TP]), type-3 TP with PORP was performed in 13 and TORP-TP in 6 cases. The mean follow-up was 12.1 months (range 4 - 34 months). 8 patients had undergone a second-look procedure.

RESULTS

On follow-up all patients showed a good healing of the external ear canal with no graft insufficiency. In one case we observed a slight ear canal narrowing due to bone excess, three patients developed retraction pockets of the attic. Recurrent cholesteatoma was not seen yet. Second-look tympanotomy revealed complete ingrowth of the transplanted bone chips into the surrounding bony structures in all cases. One residual cholesteatoma had to be removed and the canal wall had to be reconstructed again with bone chips. The average postoperative air-bone gap was 7.0 +/- 8.2 dB HL for type-1 TP, 8.6 +/- 3.0 dB HL for PORP-TP (83 % [100 %] of the patients < or = 10 dB HL [< or = 20 dB HL]) and 19.3 +/- 9.2 dB HL for TORP-TP (66 % of the patients < or = 20 dB).

CONCLUSIONS

Osteoplastic atticoantrostomy allows adequate anatomic and physiologic restoration of the auditory canal even after extensive cholesteatoma removal. Bone stability may reduce recurrent cholesteatoma. However, due to the underlying impaired tubal function long-time results must be further evaluated.

Ohrmuschelrekonstruktion bei hochgradiger Mikrotie

The incidence of microtia in Germany is 100-150 per year. These cases require a specific and challenging therapy. All patients need audiologic consultation. If desired plastic reconstruction is performed, which is aiming at achieving a lifelike as possible appearance corresponding to the shape of the opposite ear including an excellent skin color. The present paper describes background information, the interdisciplinary schedule of treatment, and the results of our operative strategy in two to three steps using autologous rib cartilage. Furthermore we expand on anomalous cases of microtia which require a modified procedure. In dystopic microtia, repositioning of the rudiment is necessary before reconstruction. In cases of excessive scar tissue due to injuries or previous operations, a one-step reconstruction using an axial fascia flap can be useful.

[Transmastoidal resection of an endaural encephalocele--a case report]

BACKGROUND

There are transmastoid, transtemporal and combined approaches for surgical management of endaural encephaloceles. The advantages of a transmastoid approach are the exploration and option of surgical treatment of the middle ear cavity without craniotomy. Nevertheless there are recent studies preferring the transtemporal or combined approach because of the better survey.

PATIENT

We present a 27-year old male patient, who developed hearing loss and otorrhea of the right side. He underwent middle ear surgery associated with cholesteatoma three times before. On examination there was a smooth pulsatile mass taking origin in the roof and almost filling the external auditory canal. High-resolution CT and MRI scans of the petrous bone demonstrated a spherical soft tissue mass communicating with the middle cranial fossa. The encephalocele was exposed and resected through a transmastiodal approach. Behind the cele a relapsing cholesteatoma was found and resected in the same session. The laterobasilar defect was sealed with ear cartilage and a perichondrium flap.

CONCLUSION

There are three different surgical approaches to manage laterobasilar encephaloceles. Due to the history of a previous cholesteatoma we performed a transmastoidal approach. A transtemporal approach alone would have failed to notice the relapsing cholesteatoma and would have led to a greater trauma.

Haplotype analysis of the CD11 gene cluster in patients with chronic Helicobacter pylori infection and gastric ulcer disease

Helicobacter pylori infection leads to a broad spectrum of disease manifestations such as gastritis, ulcer disease, and even gastric carcinoma. The genetically determined immune response and subsequent inflammation influence the degree of mucosal damage. Adhesion molecules of the CD11 cluster play an important role in adherence of neutrophils to endothelial cells in inflammation. We conducted a haplotype-based analysis of the CD11 cluster in a sample of 315 patients with H. pylori infection and investigated associations with gastric erosions and ulcer disease. Twelve single nucleotide polymorphisms (SNPs) covering the genes CD11a, CD11b, and CD11c were genotyped by Taqman technology. Linkage disequilibrium (LD) was assessed within the CD11 cluster and haplotype case-control analysis was conducted. Sliding window haplotype analysis identified a haplotype consisting of the markers CD11c exon 15 and intron 31 associated with gastric ulcer disease. Patients carrying the haplotype GA bear a 2.4-fold increased risk. No significant associations of single markers with disease outcome were found. High-density LD mapping and mutation detection of CD11c in larger samples will be necessary to confirm our findings and identify the causative variant. Thus, we conclude that genetic variants in the CD11 cluster may play a role in the development of gastric ulcer in chronic H. pylori infection presumably by influencing leukocyte adhesion. The biological effect of genetic variants of CD11c in gastric inflammation needs further clarification.

[Gastrointestinal autonomic nerve tumor]

Gastrointestinal autonomic nerve tumors (GAN-tumor) are rare malignant neurogenic stromal tumors of the intestinal tract. The origin is suspected in the autonomic nerve plexus Meissner or Auerbach with the interstitial cells of Cajal as precursors. We report on a 53-year-old patient with a clinical apparent and radiological 5 cm measuring tumor of the jejunum, which was resected and immunohistochemically verified as GAN-tumor. Within the follow-up of 29 months metastases appeared within the omentum majus with a diffuse peritoneal spreading. Several trials of adjuvant chemotherapy (adriamycine/ifosamide, taxotere, gemcitabine/xyloda) were ineffective. 15 months after the second operation the patient died. Since the first description of the GAN-tumor in 1984 87 patients were reported in the literature. No recurrences or metastasis were seen in tumors with a seize less than 5 cm. A tumor seize of more than 10 cm is associated with recurrences in 64% of the cases within 2 years. Since there is no option for medical treatment, surgical resection is the treatment of choice and has to be considered also in the case of recurrence.

[A rare cause of malignant ascites--peritoneal mesothelioma]

HISTORY AND CLINICAL FINDINGS

A 56-year-old patient (case 1) with recurrent haemorrhagic ascites for one year was admitted to our hospital for further investigation. Besides massive ascites he did not show abnormal physical signs. In addition, two 45-year-old patients were admitted (case 2 and 3) with clinical signs of acute abdomen--one having muscular guarding in the epigastric angle, the other in the right lower quadrant. All 3 patients did not have serious illnesses in the past; the first 2 patients had occupational asbestos exposure.

INVESTIGATIONS

In patient 1 the ultrasound did not reveal abnormal findings besides ascites. Patients 2 and 3 underwent explorative laparotomy.

DIAGNOSIS, TREATMENT AND COURSE

In the first case a diagnostic laparoscopy revealed diffuse tumor proliferations with nodular formations over the entire peritoneum--histologically a malignant peritoneal mesothelioma of the epithelial subtype. Patient 2 showed intraoperatively metastatic spread of tumour formations with infiltration of the peritoneum and transverse mesocolon. The histologic finding was similar to that in the first case. Patient 3 had a perforated sigma diverticulitis which was treated by resection of the sigmoid. Incidentally a well differentiated papillary peritoneal mesothelioma was found in the resected specimen. The first two patients were treated with alpha-interferon subcutaneously resulting in a decrease of ascites production. Because patient 3 showed neither ascites nor evidence for malignancy no interferon was administered.

CONCLUSION

In case of haemorrhagic ascites of unknown cause a histological clarification by either laparoscopy or laparotomy is mandatory. Immunomodulation with interferon may be a promising approach.

Association between insertion mutation in NOD2 gene and Crohn's disease in German and British populations

Background Genetic predisposition to inflammatory bowel disease (IBD) has been shown by epidemiological and linkage studies. Genetic linkage of IBD to chromosome 16 has been previously observed and replicated in independent populations. The recently identified NOD2 gene is a good positional and functional candidate gene since it is located in the region of linkage on chromosome 16q12, and activates nuclear factor (NF) kappaB in response to bacterial lipopolysaccharides. Methods We sequenced the coding region of the NOD2 gene and genotyped an insertion polymorphism affecting the leucine-rich region of the protein product in 512 individuals with IBD from 309 German or British families, 369 German trios (ie, German patients with sporadic IBD and their unaffected parents), and 272 normal controls. We then tested for association with Crohn's disease and ulcerative colitis. Findings Family-based association analyses were consistently positive in 95 British and 99 German affected sibling pairs with Crohn's disease (combined p<0.0001); the association was confirmed in the 304 German trios with Crohn's disease. No association was seen in the 115 sibling pairs and 65 trios with ulcerative colitis. The genotype-specific disease risks conferred by heterozygous and homozygous mutant genotypes were 2.6 (95% CI 1.5-4.5) and 42.1 (4.3-infinity), respectively. Interpretation The insertion mutation in the NOD2 gene confers a substantially increased susceptibility to Crohn's disease but not to ulcerative colitis.

[Peripapillary melanoma; 10-year follow-up]

In early stages choroidal peripapillary choroidal melanoma may be confused with a choroidal nevus or melanocytoma.

CASE REPORT

A 41-year old female was diagnosed having a choroidal nevus in close proximity to the optic nerve head. Unfortunately the patient did not show up for annual review of this lesion. Ten years after the patient was examined for the second time. A massive increase in tumor size and prominence was noted including serous retinal detachment. Medical work up excluded any metastatic growth, and the globe was enucleated. Three years later, the patient is still healthy and there are no signs of metastatic spreading.

HISTOLOGICAL WORK UP

Heavily pigmented peripapillary choroidal melanoma with fascicularly vasocentric proliferative structure, but no infiltration of the sclera or the lamina cribrosa of the optic nerve. The tumor cells were of midgrade size and some of the nucleoli were slightly enlarged. Mitosis and a syncytial structure were present. Immunohistochemically S-100 proteins, HMB 45 and NSE were found. The TNM classification was: ICD-O C 69.3; pT2, G1, S0, V0, pNx, pMx, microscopically RO.

CONCLUSION

Pigmented juxtapapillary tumors resembling choroidal nevi require annual surveillance.

[Lipomatous hypertrophy of the interatrial septum]

The echocardiographic examination of a female, overweight patient, 71 years of age, with left-sided breast cancer, performed in another hospital, revealed a tumor of the interatrial septum of 3.2 x 4.0 cm. The patient was transferred to our clinic and the finding was identified as a lipomatous hypertrophy of the interatrial septum by echocardiography, computer tomography and nuclear magnetic resonance imaging. It was confirmed by biopsy and histological examination. The lipomatous hypertrophy of the interatrial septum is a rare, benign disease, which usually does not cause a hemodynamic significant obstruction of the blood flow. An increased incidence of atrial arrhythmias is known to occur in this condition and seems to be the only functional restriction.

Periocular accumulation of timolol and betaxolol in glaucoma patients under long-term therapy

PURPOSE

To determine if betaxolol or timolol is present in measurable concentration in the Tenon capsule in patients under long-term topical therapy.

METHODS

Small (1-cc) specimens of Tenon capsule were removed at the time of filtering surgery from 15 glaucoma patients under long-term preoperative topical therapy, nine of whom had been treated with timolol and six of whom had been receiving betaxolol. Methanol extracts of these tissue samples were analyzed quantitatively for the presence of either beta-adrenergic antagonist by high-performance liquid chromatography.

RESULTS

Drug was detected in every specimen. A mean total of 2.6 (range, 0.1-30.0) microg of betaxolol was detected per 1-cc specimen.

CONCLUSION

Timolol and betaxolol penetrate the conjunctiva and accumulate in the Tenon capsule. In patients under long-term therapy, the periocular tissue can accumulate a greater quantity of beta-antagonist than is present in a daily dosage of applied eyedrops, manyfold higher than the maximal intraocular concentration.

[Left ventricular papillary fibroelastomas without relation to a heart valve--a report of 2 cases]

Papillary fibroelastomas are rare benign tumors of the heart. We report about two cases in which these tumors do not--as characteristically--arise from a heart valve but originate from the free wall of the left ventricle. In the case of a 74-year-old woman with signs of a cerebral ischemia in the vascular system of the A. cerebri posterior, the tumor was resected transaortically. At a 67-year-old patient with symptoms of instable angina pectoris and increasing dyspnoea echocardiography or coronary angiography showed an aortic stenosis III degrees, a coronary artery disease as well as a tumor within the region of the apex of the left ventricle. Beside a fourfold aortocoronary venous bypass and an aortic valve replacement tumor excision via left ventriculotomy was carried out. In the diagnostics of intracardiac tumors transthoracic and transesophageal echocardiography provide the methods of choice to visualize quickly and noninvasively the extent, mobility, and origin of the tumor. Considering the systemic thromboembolic potential with the high risk of cerebrovascular respectively neurological symptoms total surgical tumor excision is clearly indicated.

[Solitary extramedullary plasmacytoma of the conjunctiva]

Unpigmented tumorous changes of the conjunctiva can frequently be classified as chalazion, basalioma or carcinoma.

PATIENT AND METHODS

In a 70 years old diabetic female a 2.5 x 2.5 cm tumor of the lower conjunctival fornix was observed. After complete excision the tumor was examined by histologic routine procedures and immunohistochemically. The patient was irradiated by 40 Gy with the linear accelerator.

RESULTS

The monotypical secretion of the heavy chain gamma and the light chain kappa demonstrated a well differentiated extramedullar plasmocytoma. A MALT lymphoma could be excluded by the absence of centrocytoid cells. The bone cytology and histology did not give any evidence for a medullar plasmocytoma. The patient is free from local or diffuse tumor growth since 2 1/2 years.

CONCLUSION

Since the worldwide most important ophthalmopathologic statistics of the AFIP from 1984-1989 describes only 1 plasmocytoma out of 2104 tumors of the lids and conjunctiva, the demonstrated case is an important rarity.

Allelic imbalance on chromosome 13q: evidence for the involvement of BRCA2 and RB1 in sporadic breast cancer

Recently, the breast cancer susceptibility gene BRCA2 has been identified in chromosome 13q, a region that also contains the retinoblastoma gene RB1. To elucidate a possible role of BRCA2 and RB1 in sporadic breast tumorigenesis, allelic imbalance (AI) at 13q loci was examined in 78 primary sporadic breast tumors. AI was found in 52-63% of tumors. Nine tumors showed AI only in the BRCA2 region but not at RB1. Six tumors showed AI at RB1 but not in the BRCA2 region. AI in the BRCA2 region correlated significantly with aneuploidy (P = 0.032) and AI at RB1 with small tumor size (P = 0.025). Our data suggest that BRCA2 and RB1 may be both distinct target loci for AI on chromosome 13 in sporadic breast cancer.

Structural and functional alterations of the intramyocardial coronary arterioles in patients with arterial hypertension

BACKGROUND

In hypertensive patients with angina pectoris, the coronary vasodilator reserve is frequently impaired despite a normal coronary angiogram. Experimental data indicate that structural alterations of the intramyocardial coronary vasculature contribute to an increased minimal coronary resistance and a diminished coronary flow reserve.

METHODS AND RESULTS

In 14 patients (10 men and 4 women) with arterial hypertension and 8 normotensive subjects, minimal coronary resistance and vasodilator reserve (dipyridamole: 0.5 mg/kg body wt, gas chromatographic argon method) were determined after the angiographic exclusion of relevant coronary artery disease. Coronary reserve was depressed in hypertensive patients (2.7 +/- 2.3 vs 4.6 +/- 1.3, P < or = .05) due to increased minimal coronary resistance (0.64 +/- 30 vs 0.24 +/- 0.055 mm Hg.min.100 g.mL-1, p < or = 0.002). In right septal biopsies, mean external arteriolar diameter (21.6 +/- 2.3 vs 17.2 +/- 2.5 microns, P < or = .001), mean arteriolar wall area (271 +/- 61 vs 172 +/- 62 microns 2, P < or = .01), percent medial wall area (69.9 +/- 4.0 vs 66.0 +/- 3.2%W, P < or = .05), mean periarteriolar fibrosis area (216 +/- 122 vs 104 +/- 68 microns 2, P < or = .05), and volume density of total interstitial fibrosis (3.6 +/- 1.8 vs 1.9 +/- 0.5Vv% fibrosis, P < or = .05) were increased in hypertensive patients compared with normotensive subjects. Minimal coronary resistance correlated with %W (r = .6, P < or = .003) and Vv% fibrosis (r = .62, P < or = .002). Left ventricular mass index (111 +/- 21 vs 97 +/- 17 g/m2, P = NS) and left ventricular end-diastolic pressure (12 +/- 6 vs 8 +/- 3 mm Hg, P = NS) did not correlate significantly with minimal coronary resistance. In multivariate analysis, both %W and Vv% fibrosis explained half of the variability of minimal coronary resistance (r2 = .5, P < or = .002).

CONCLUSIONS

Structural remodeling of the intramyocardial coronary arterioles and the accumulation of fibrillar collagen are decisive factors for a reduced coronary dilatory capacity in patients with arterial hypertension and angina pectoris in the absence of relevant coronary artery stenoses.

Morphometric investigation of human myocardium in arterial hypertension and valvular aortic stenosis

Both arterial hypertension and aortic stenosis lead to pressure overload of the left ventricle. As intramyocardial vasculature is confronted with pressure overload in hypertension but not in aortic stenosis, structural differences are to be expected in both forms of left ventricular hypertrophy. With the aid of morphometry, we investigated human myocardium from autopsied hearts from six patients with arterial hypertension and 10 controls, as well as myectomy specimens from cardiac surgery from 14 patients with aortic stenosis. Mean left ventricular myocytic diameter was significantly (P less than 0.05) increased compared with controls (12.4 +/- 1.5 microns) during hypertension (+27%) as well as aortic stenosis (+65%) (P less than 0.05). This was combined with a greater volume density of perimyocytic fibrosis (controls = 0.8 +/- 0.4 V upsilon %) during hypertension (+250%) and aortic stenosis (+587%) (P less than 0.05). Walls of intramyocardial arterioles (external diameter 20-40 and 40-80 microns) were thickened to 32% and 44% (P less than 0.05) during hypertension, but not during aortic stenosis. Compared with controls, perivascular fibrosis of these arterioles was increased by +215% and 61% (P less than 0.05), respectively, during hypertension, but not during aortic stenosis.

CONCLUSIONS

Myocytic hypertrophy and increased perimyocytic fibrosis accompany intraventricular pressure overload (hypertension and aortic stenosis) in human hearts. Myocardial structure as a result of arterial hypertension, but not aortic stenosis, is also characterized by intramyocardial arteriole wall-thickening and increased perivascular fibrosis. Thus, distinct structural reaction patterns are noted in the cardiac hypertrophy associated with hypertension and aortic stenosis.

[Dysplastic intramyocardial arteries with subaortic septum in patients with hypertrophic obstructive cardiomyopathy]

Abnormal, dysplastic intramyocardial arteries were reported in autopsied hearts of hypertrophic cardiomyopathy. To elucidate their significance, the operatively-excised myectomy specimens of 24 patients with hypertrophic-obstructive cardiomyopathy (HOCM), of 18 patients with valvular aortic stenosis and of 10 postmortem normal hearts were investigated. Eight patients with HOCM had dysplastic intramyocardial arteries (greater than 100 microns external diameter) as well as dysplastic arterioles (less than 100 microns external diameter). The value of the scores for the thickness and fibroelastosis of the media was nearly doubled, the tunica intima was frequently thickened, and the lumen was relatively reduced in dysplastic vessels. Neither in controls nor in aortic stenosis dysplastic arteries were found. Volume density of patchy fibrosis (scars) was increased in patients with dysplastic arterial vessels (HOCM II) (7.2 +/- 4.4 Vv%) (p less than or equal to 0.05) as compared with HOCM without dysplastic vessels (HOCM I) (0.8 +/- 2.3 Vv%), with aortic stenosis (0.9 +/- 1.6 Vv%) or with controls (0 Vv%), Patients with HOCM II were significantly (p less than or equal to 0.05) younger (30 +/- 13 years) than those with HOCM I (53 +/- 12 years), aortic stenosis (56 +/- 12 years), or controls (63 +/- 21 years). The anterior septum was significantly thicker in HOCM II (29 +/- 7 mm) than in HOCM I (22 +/- 4 mm), in aortic stenosis (19 +/- 3 mm), or in controls (12 +/- 2 mm). Syncopes were complained by about 75% (6/8) of patients in HOCM II, by 54% (9/16) in HOCM I, and by 44% (8/18) in aortic stenosis (not significant).(ABSTRACT TRUNCATED AT 250 WORDS)

[Chronic reflux esophagitis with endobrachyesophagus and multifocal adenocarcinoma]

In approximately 10% of all cases of endobrachesophagus a malignant degeneration occurs. A frequent endoscopic and bioptic control of the endobrachesophagus is the prognostic decision in order for a developing adenocarcinom to be identified in the early stages. Our casuistry demonstrates the problematic nature of the diagnostic and therapy of a multifocal adenocarcinom in an endobrachesophagus.

Ultrastructural abnormalities of mitochondria and deficiency of myocardial cytochrome c oxidase in a patient with ventricular tachycardia

A 30-year-old woman presented with life-threatening ventricular tachycardia without overt heart disease. Ultrastructural investigation of endomyocardial biopsy disclosed abnormally structured and often enlarged mitochondria. Morphometry revealed the ratio of volume density of mitochondria to myofibrils to be markedly increased to 0.667 as compared with five controls (mean: 0.46; range: 0.445-0.479). Investigation of mitochondrial respiratory chain enzymes revealed a 90% reduction in activity of cytochrome c oxidase. Our data suggest that mitochondrial cardiomyopathy may induce malignant ventricular arrhythmias.

[Metolazone in the treatment of advanced therapy-resistant dilated cardiomyopathy]

Ten patients (eight male/two female) with advanced dilated cardiomyopathy (NYHA III/IV) and a mean fractional shortening in two-dimensional echocardiogram of 20% (9 to 30%) and a mean sodium excretion of 21 mmol (8 to 40 mmol) per day, pretreated with digoxin, captopril and a mean frusemide-dose of 147 mg (80 to 500 mg) without an effective diuresis, were additional treated with 2.5 to 5 mg oral metolazone daily. All patients had a brisk diuresis within 24 hours and a mean weight loss of 8.9 kg (3 to 20 kg) until discharge. All patients improved considerably by additional metolazone-therapy. Seven patients developed a mild hyponatraemia (122 to 132 mmol/l), seven showed mild (greater than or equal to 3.2 mmol/l) and one had a serious hypokalaemia (2.8 mmol/l); spironolactone-pretreated patients developed no hypokalaemia. Notably none of the patients had serious blood pressure fluctuation or a deterioration of renal function. To avoid severe electrolyte-disturbances, additional metolazone-therapy should be practised in hospital, preferring low-dose metolazone and reducing frusemide-dose under careful biochemical monitoring after diuresis is started.

Prevalence of renal artery stenosis in diabetes mellitus--an autopsy study

The prevalence of renal artery stenosis in diabetic patients is unknown, since no noninvasive and valid screening procedures are available. We have therefore evaluated 5194 consecutive autopsy protocols from patients who died between 1980 and 1988. In addition, all available clinical records for patients with renal artery stenosis (RAS) and a random sample were evaluated. It was found that 73% of patients with RAS were hypertensive, and 53% had diabetes, all but one being Type 2 (non-insulin-dependent). Renal artery stenosis was present in 225 (4.3%) of all patients [95% confidence interval (95% CI), 3.8-4.9], and was not reported in the patients' clinical records in 93% of cases. RAS was present in 8.3% of all diabetic patients (95% CI, 6.8-9.8%), the odds ratio being 3.5 (95% CI, 2.6-4.6). The frequency of renal artery stenosis in diabetic patients with hypertension was 10.1%. Bilateral renal artery stenosis was found in 43% of patients with RAS and diabetes, and in 30% of non-diabetic patients with RAS (P = 0.059). Our results indicate that renal artery stenosis often goes undetected before autopsy. The presence of non-insulin-dependent diabetes mellitus increases the risk of renal artery stenosis. The risk of bilateral renal artery stenosis is greater in diabetic patients. These results may be of significance with regard to the diagnostic evaluation and choice of antihypertensive treatment in hypertensive non-insulin-dependent diabetic patients.

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.

[A rare form of metastasis of renal cell cancer. A case report of intra-oral soft tissue metastasis]

Metastatic lesions represent 1%-8% of all malignant tumours of the mouth and jaws, which are regarded as rare sites of metastases from different primary tumours. The vast majority of these lesions (90%) have been observed in the mandibula, and 5%-20% in the maxilla. Metastatic tumours in the oral soft tissue are very rare. The primary tumour that most commonly metastasizes to the mouth and jaws seems to be carcinoma of the lung, followed by breast cancer and renal cell carcinoma. The case of a 47-year-old woman with renal cell carcinoma and an intraoral soft tissue metastatic lesion is presented.

Renal transplantation in amyloid nephropathy

Renal transplantation was performed in 2 patients with end-stage renal disease due to AA-type amyloidosis. One patient with amyloidosis of rheumatoid arthritis (RA) origin died twelve months after renal transplantation in cardiogenic shock. AA-amyloid deposits were demonstrated in the graft even though there were excellent function and no proteinuria. The second patient with amyloid nephropathy due to familial Mediterranean fever (FMF) showed no impairment of graft function 24 months after transplantation. These 2 cases are compared to an additional 31 cases of renal transplantation for amyloid nephropathy described in the literature. Proteinuria was reported in 32.3% and amyloid was detected in the functioning graft in 41.4%. The function was excellent even when small amyloid deposits were present in the graft. Renal transplantation is indicated in cases of amyloid nephropathy of the AA-type, provided life threatening amyloid involvement of other organs is not present.

Liver biopsy findings in patients with rheumatoid arthritis undergoing longterm treatment with methotrexate

Ten histological criteria were evaluated semiquantitatively in the liver biopsies of 60 patients with rheumatoid arthritis (RA) before initiation of methotrexate (MTX) and were compared with 40 biopsies taken during MTX treatment (mean cumulative dose 1.322 mg). Mesenchymal changes (Kupffer cell proliferation, portal tract infiltration) and parenchymal alterations (nuclear variability, ballooning, fatty infiltration) were very common without statistically significant difference between the 2 groups. Slight periportal and/or portal fibrosis was present in 25% of patients without statistical difference between groups. Central fibrosis occurred in 13.5-12.5%. We conclude that liver abnormalities in RA are not related to MTX treatment.

[Intraoral soft tissue metastases of a renal cell carcinoma]

Face, mouth and jaws represent seldom localisations of metastatic lesions. 5-20% of these lesions are reported with localisation in the maxilla, whereas 90% are found in the mandibula. Metastatic tumours in the oral soft tissue are very rare. The most common primary tumour seems to be the renal cell carcinoma. Only histological examination can give a differentiation against benign tumours. The diagnostic and therapeutic management of a 46 years old woman with a metastatic intraoral lesion of a renal cell carcinoma is presented.

[Virus-associated hemorrhagic colitis in the differential diagnosis of peracute rectal bleeding]

Severe anal bleeding together with increasing abdominal discomfort occurred in an 81-year-old woman previously hospitalized numerous times because of decompensated type II B diabetes. A suspected rectal cancer was excluded by biopsy from the lower to middle rectum, but the biopsy revealed histologically indurated and bleeding ulcerations. Typical nuclear inclusion bodies provided the diagnosis of virus-associated proctocolitis. Serological tests supported the diagnosis of infection with herpes simplex and cytomegalic virus. Laser coagulation stopped the bleeding. At the same time a Guillain-Barré syndrome was noted which improved after administration of cortisone and high parenteral doses of acyclovir.

Ultrastructural findings in endomyocardial biopsy of patients with Kearns-Sayre syndrome

Kearns-Sayre syndrome is clinically defined by progressive external ophthalmoplegia, atypical retinitis pigmentosa and the potential occurrence of complete atrioventricular (AV) block. Right septal endomyocardial biopsy specimens from nine patients (four men and five women with a mean [+/- SD] [corrected] age of 36.3 +/- 14.4 years) with chronic progressive external ophthalmoplegia and mitochondrial skeletal myopathy were studied. Three patients had atypical retinal pigmentation. An atrioventricular or intraventricular conduction defect was observed in five patients. A pacemaker was prophylactically implanted in one patient because of abnormal conduction distal to the His bundle. Ultrastructural investigations revealed mitochondriosis in many heart muscle cells and an increased variability of mitochondrial form and size in all patients. In seven patients, 0.4 to 2.1% of all examined myocytes contained exclusively abnormal mitochondria. Three main types were observed: huge, mainly round mitochondria with concentric cristae; large, round or oval mitochondria with transverse or curved cristae; and small, vacuolated mitochondria. The volume density of myofibrils was reduced (41.9 +/- 11.1 compared with the normal value of 56.5 +/- 2.5 volume density [in percent], p less than 0.01) in these myocytes. Increasing numbers of vacuolated mitochondria correlated significantly with a reduction of myofibrils (r = -0.64, p less than 0.01). The data suggest that the ventricular myocardium of most patients with complete and even incomplete Kearns-Sayre syndrome is affected by disseminated mitochondrial cytopathy.