TERT expression is susceptible to BRAF and ETS-factor inhibition in BRAFV600E/TERT promoter double-mutated glioma

The BRAF gene and the TERT promoter are among the most frequently altered genomic loci in low-grade (LGG) and high-grade-glioma (HGG), respectively. The coexistence of BRAF and TERT promoter aberrations characterizes a subset of aggressive glioma. Therefore, we investigated interactions between those alterations in malignant glioma. We analyzed co-occurrence of BRAFV600E and TERT promoter mutations in our clinical data (n = 8) in addition to published datasets (n = 103) and established a BRAFV600E-positive glioma cell panel (n = 9) for in vitro analyses. We investigated altered gene expression, signaling events and TERT promoter activity upon BRAF- and E-twenty-six (ETS)-factor inhibition by qRT-PCR, chromatin immunoprecipitation (ChIP), Western blots and luciferase reporter assays. TERT promoter mutations were significantly enriched in BRAFV600E-mutated HGG as compared to BRAFV600E-mutated LGG. In vitro, BRAFV600E/TERT promoter double-mutant glioma cells showed exceptional sensitivity towards BRAF-targeting agents. Remarkably, BRAF-inhibition attenuated TERT expression and TERT promoter activity exclusively in double-mutant models, while TERT expression was undetectable in BRAFV600E-only cells. Various ETS-factors were broadly expressed, however, only ETS1 expression and phosphorylation were consistently downregulated following BRAF-inhibition. Knock-down experiments and ChIP corroborated the notion of a functional role for ETS1 and, accordingly, all double-mutant tumor cells were highly sensitive towards the ETS-factor inhibitor YK-4-279. In conclusion, our data suggest that concomitant BRAFV600E and TERT promoter mutations synergistically support cancer cell proliferation and immortalization. ETS1 links these two driver alterations functionally and may represent a promising therapeutic target in this aggressive glioma subgroup.

Preemptive endoluminal vacuum therapy to reduce anastomotic leakage after esophagectomy: a game-changing approach?

Endoluminal vacuum therapy (EVT) is an accepted treatment for anastomotic leakage (AL) after esophagectomy. A novel concept is to use this technology in a preemptive setting, with the aim to reduce the AL rate and postoperative morbidity. Preemptive EVT (pEVT) was performed intraoperatively in 19 consecutive patients undergoing minimally invasive esophagectomy, immediately after completion of esophagogastrostomy. Twelve patients (63%) were high-risk cases with severe comorbidity. The EVT device was removed routinely three to six (median 5) days after esophagectomy. The endpoints of this study were AL rate and postoperative morbidity. There were 20 anastomoses at risk in 19 patients. One patient (5.3%) experienced major morbidity (Clavien-Dindo grade IIIb) unrelated to anastomotic healing. He underwent open reanastomosis at postoperative day 12 with pEVT for redundancy of the gastric tube and failure of transition to oral diet. Mortality after 30 days was 0% and anastomotic healing was uneventful in 19/20 anastomoses (95%). One minor contained AL healed after a second course of EVT. Except early proximal dislodgement in one patient, there were no adverse events attributable to pEVT. The median comprehensive complication index 30 days after surgery was 20.9 (IQR 0-26.2). PEVT appears to be a safe procedure that may have the potential to improve surgical outcome in patients undergoing esophagectomy.

Endoscopic and histopathologic reflux-associated mucosal damage in the remnant esophagus following transthoracic esophagectomy for cancer-5-year long-term follow-up

Gastroesophageal reflux is a common problem following esophagectomy and reconstruction with gastric interposition. Despite a routine prescription of proton pump inhibitors, reflux-associated mucosal damage in the remnant esophagus is frequently observed. Purpose of this study is to evaluate mucosal damage in the esophageal remnant during long-term follow-up and to compare the prevalence of this damage between the subgroups of esophageal squamous cell and adenocarcinoma. All patients undergoing transthoracic Ivor-Lewis esophagectomy were prospectively entered in our IRB approved database. All patients underwent a routine check-up program with yearly surveillance endoscopies following esophagectomy. Only patients with a complete follow-up were included into this study. Endoscopic and histopathologic mucosal changes of the remnant esophagus were analyzed in close intervals. A total of 50 patients met the inclusion criteria, consisting of 31 adenocarcinomas (AC) and 19 squamous cell carcinomas (SCC). Mucosal damage was already seen 1 year after surgery in 20 patients macroscopically (43%) and in 21 patients microscopically (45%). At 5-year follow-up the prevalence for macroscopic and microscopic damage was 55% and 60%, respectively. The prevalence of mucosal damage was higher in AC patients than in SCC patients (1y-FU: 51% [AC] vs. 28% [SCC]; 5y-FU: 68% [AC] vs. 35% [SCC], P < 0.05). Newly acquired Barrett's esophagus was seen in 10 patients (20%) with two of those patients (20%) showing histopathologic proof of neoplasia. This study shows a high prevalence of reflux-associated mucosal damage in the remnant esophagus one year out of surgery and only a moderate increase in prevalence in the following years. Mucosal damage was more frequently seen in AC patients and the occurrence of de-novo Barrett's esophagus and de-novo neoplasia was high. Endoscopic surveillance with targeted biopsies seems to be an indispensable tool to follow patients after esophagectomy appropriately.

Combination of psychological intervention and phosphodiesterase-5 inhibitors for erectile dysfunction: a narrative review and meta-analysis

INTRODUCTION

Erectile dysfunction (ED) is an increasing health problem that demands effective treatment. There is evidence that phosphodiesterase-5 inhibitors (PDE5-Is) and psychological intervention (PI) are effective treatment options; however, little is known about their comparative efficacy and the efficacy of combined treatments.

AIM

The aim of this systematic review and meta-analysis is to evaluate the comparative efficacy of PI, PDE5-Is, and their combination in the treatment of ED.

MAIN OUTCOME MEASURES

Primary outcome was ED symptoms, and secondary outcome was sexual satisfaction of the patient.

METHODS

A systematic literature search was conducted in order to identify relevant articles published between 1998 and 2012. We included randomized controlled trials and controlled trials comparing PI with PDE5-I treatment or one of them against a combination of both.

RESULTS

Eight studies with a total number of 562 patients were included in the meta-analysis. The results of the included studies are inconclusive, though they show a trend towards a larger effect of combined treatment compared with PI or PDE5-I treatment alone. The meta-analysis found that, overall, combined treatment was more efficacious for ED symptoms than PDE5-I treatment or PI alone. Combined treatment was more efficacious than PDE5-I use alone on sexual satisfaction. No differences were found between PDE5-Is and PI as stand-alone treatments. None of the moderators (treatment duration, methodological quality, or researcher allegiance) altered the effects.

CONCLUSIONS

The combination of PI and PDE5-Is is a promising strategy for a favorable outcome in ED and can be considered as a first-choice option for ED patients. Stronger RCTs are required to confirm this initial finding.

Management of sexual dysfunction due to antipsychotic drug therapy

BACKGROUND

Psychotropic drugs are associated with sexual dysfunction. Symptoms may concern penile erection, lubrication, orgasm, libido, retrograde ejaculation, sexual arousal, or overall sexual satisfaction. These are major aspects of tolerability and can highly affect patients' compliance.

OBJECTIVES

To determine the effects of different strategies (e.g. dose reduction, drug holidays, adjunctive medication, switching to another drug) for treatment of sexual dysfunction due to antipsychotic therapy.

SEARCH METHODS

An updated search was performed in the Cochrane Schizophrenia Group's Trials Register (3 May 2012) and the references of all identified studies for further trials.

SELECTION CRITERIA

We included all relevant randomised controlled trials involving people with schizophrenia and sexual dysfunction.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated random effects risk ratios (RR) with 95% confidence intervals (CI), for crossover trials we calculated Odds Ratios (OR) with 95% CI. For continuous data, we calculated mean differences (MD) on the basis of a random-effects model. We analysed cross-over trials under consideration of correlation of paired measures.

MAIN RESULTS

Currently this review includes four pioneering studies (total n = 138 , duration two weeks to four months), two of which are cross-over trials. One trial reported significantly more erections sufficient for penetration when receiving sildenafil compared with when receiving placebo (n = 32, MD 3.20 95% CI 1.83 to 4.57), a greater mean duration of erections (n = 32, MD 1.18 95% CI 0.52 to 1.84) and frequency of satisfactory intercourse (n = 32, MD 2.84 95% CI 1.61 to 4.07). The second trial found no evidence for selegiline as symptomatic treatment for antipsychotic-induced sexual dysfunction compared with placebo (n = 10, MD change on Aizenberg's sexual functioning scale -0.40 95% CI -3.95 to 3.15). No evidence was found for switching to quetiapine from risperidone to improve sexual functioning (n = 36, MD -2.02 95% CI -5.79 to 1.75). One trial reported significant improvement in sexual functioning when participants switched from risperidone or an typical antipsychotic to olanzapine (n = 54, MD -0.80 95% CI -1.55 to -0.05).

AUTHORS' CONCLUSIONS

We are not confident that cross-over studies are appropriate for this participant group as they are best for conditions that are stable and for interventions with no physiological and psychological carry-over. Sildenafil may be a useful option in the treatment of antipsychotic-induced sexual dysfunction in men with schizophrenia, but this conclusion is based only on one small short trial. Switching to olanzapine may improve sexual functioning in men and women, but the trial assessing this was a small, open label trial. Further well designed randomised control trials that are blinded and well conducted and reported, which investigate the effects of dose reduction, drug holidays, symptomatic therapy and switching antipsychotic on sexual function in people with antipsychotic-induced sexual dysfunction are urgently needed.

[Distal clavicle edema]

PURPOSE

Distal clavicle marrow edema: frequency, MRI in the early stage and macroscopic correlation to the bone marrow distribution and to evaluate frequency and diagnostic criteria of a posttraumatic clavicula disorder with an edema pattern on MRI. An additional macroscopic study of the clavicle should elucidate anatomic peculiarities which could explain the reaction of the distal clavicle.

MATERIAL AND METHODS

285 MRI of traumatized patients were analyzed for edema pattern of the distal clavicle. Pattern A edema within the clavicle and the acromion was distinguished from pattern B edema within the clavicle only. Dissection in 20 cadavers should reveal vascular peculiarities and the bone marrow distribution within clavicle and acromion or vascular peculiarities.

RESULTS

In 38 patients (13,3%) we found edema within the distal clavicle. Pattern A was found in 28 (9,8%) and pattern B in 10 patients (3,5%). Pattern A was usually associated with swelling of the AC joint (27 out of 28). Other injuries were not evident. 18 cadavers showed hematopoietic marrow within the distal clavicle and fatty marrow within the acromion.

CONCLUSION

The distal clavicle can frequently react with edema pattern after trauma without evidence for another injury. Distinguish in cases with and cases without synovitis of the AC joint could have impact on therapy. A peculiar vascular supply of the distal clavicle could not be found.

Plica humeroradialis: Inzidenz und MR-tomographische Darstellbarkeit

PURPOSE

To determine frequency and size of a humeroradial plica and correlate it with degenerative changes, and to determine frequency of the visualization of a synovial fold on MR-Images (T1-weighted spin-echo and STIR sequences) and correlate it with degenerative changes.

MATERIALS AND METHODS

Forty-two elbow specimens were dissected and studied for humeroradial synovial folds (small, medium, large) and degenerative changes (absent, medium, strong), and 88 elbow MR-images were analyzed for a synovial fold (not visible, small, large) and degenerative changes (absent, medium, strong). Comparison was performed using the chi (2) test.

RESULTS

Dissections revealed a synovial fold in all cases. The sizes were small in n = 13 (31 %), medium in n = 24 (57 %), and large in n = 5 (12 %). Degenerative changes were absent in n = 9 (21.4 %), medium in n = 29 (69 %), and strong in n = 4 (9.6 %). On MRI the synovial fold was not visible in n = 67 (76 %), small in n = 12 (14 %), and large in n = 9 (10 %). Degenerative changes on MRI were absent in n = 65 (74 %), medium in n = 15 (17 %), and strong in n = 8 (9 %). The size of the fold correlated positively with degenerative changes in the specimen but not with degenerative changes on MRI. The T1-SE sequence was superior to the STIR sequence in revealing the synovial fold.

DISCUSSION

A humeroradial plica is a regular finding, but visualized by MRI in only approximately 20 %, probably due to its variable size. Its visualization succeeds best with T1-spin-echo sequences.

[Functional anatomy and biomechanics of the wrist joint]

The osteoligamentous guidance of the carpal bones is similar to a ring under tension. Axial load of the wrist passes through the radiocarpal compartment of the proximal carpal joint on to the forearm. Hand motions in the carpal region produce variable changes of bone position. From that many deformities in cases of carpal instabilities could be explained.

[The Architecture of the Fibrous Complex between the Palmar Aponeurosis and the Flexor Retinaculum]

Summary. During cadaver dissections of 34 adult human hands (fixed in formaldehyd solution), we examined a fibrous complex at the distal end of the flexor retinaculum. This fibrous complex was first mentioned by Legueu and Juvara (1892). It is located always ulno-dorsally to the attachment of the palmaris longus tendon into the palmar aponeurosis. Measurements of this special connective tissue show a mean length of 18.6 mm, a mean height of 4.3 mm and a mean width of 3.1 mm.Also, we looked for the fibrous complex in six adult plastinated transverse sections and in 12 fetal hands where it occurred in a constant way. We also found a very close topographic relationship between these oblique criss-crossed fibers and the palmar cutaneous branch of the median nerve. This nerve regularly gives some ulnar branches to the fibrous complex. The clinical relevance of the fibrous complex is discussed in relationship to a carpal tunnel syndrome. The described transverse fibers of the connective tissue complex are in danger as well as the ulnar branches of the palmar cutaneous nerve when releasing the flexor retinaculum during operation.

[Magnetic resonance imaging (MRI) of the bursa around the knee joint]

INTRODUCTION

Since fluid filled bursae lead to visible structures on MR images it is important to establish criteria to recognize them and to differentiate them from tumorous fluid-like structures. With this study the bursae around the knee joint were analyzed for potential differential diagnostic criteria such as localisation, size and shape.

MATERIAL AND METHODS

In a retrospective study of 133 MR exams the frequency, localization and morphology were registered. The frequency of occurrence was correlated with the frequency of an effusion by means of the chi 2 test.

RESULTS

The most frequently recognized bursae were bursa subtendinea musculi gastrocnemii medialis (54.9%), bursa musculi semimembranosi (21%), and bursa infrapatellaris profunda (18.8%). 8 different bursae were identified in complete. Size roanged from 2 to 18 mm. The shape was round and ovoid. The bursa subtendinea musculi gastrocnemii medialis and bursa musculi semimembranosi correlated with the occureance of an effusion.

CONCLUSION

Bursae around the knee are frequently visualized as asymptomatic fluid like structures. Knowledge of the typical localization, size and contour is important for identification and differentiation diagnosis against ganglia, cysts or joint recesses.

[The normal bone marrow and its variations in MRT]

Physiology and age-dependent changes of human bone marrow are described. The resulting normal distribution patterns of active and inactive bone marrow including the various contrasts on different MR sequences are discussed.

[The metacarpal ligament of the thumb. Topography and functional significance of a heretofore unknown fiber tract of the thumb and its anatomic relationship to the internal interosseus muscle]

During cadaver dissections of the thenar muscles of 81 human hands, we found a distinct ligament at the palmar side of the first metacarpal in 58% ([symbol: see text] 47 hands). This not previously described ligament crosses the princeps pollicis artery regularly. The ligament arises from the base of the first metacarpal bone in 83%. Sometimes (in 15%) it arises from the trapezium or from the middle portion of the first metacarpal bone in one case. The primary insertion of this ligament is the ulnar sesamoid. We have named these fibres "metacarpal ligament of the thumb". It could be classified into five different types. We think that this ligament is helpful in the stabilisation of the ulnar sesamoid. Besides it fixes the princeps pollicis artery to the metacarpal bone and therefore it is possible that it could compress the artery. Maybe the "metacarpal ligament of the thumb" is a rudiment of the interosseous muscles of the thumb or of the deep head of the flexor pollicis brevis muscle or of the oblique head of the adductor pollicis muscle. There is a very close topographic relationship between this ligament and the "internal interosseous muscle" of the thumb which was described by Schmidt and Lanz (1992) and which was mentioned by Henle (1858), who named it "M. interosseus volaris primus" for the first time. We could isolate this muscle in 69%.

[The nutritive vascular canals. The magnetic resonance differential diagnosis of carpal cystic lesions?]

PURPOSE

To find and describe potential MRI criteria of nutrient vessel canals of carpal bones.

METHODS AND MATERIAL

16 wrists of 13 patients with pain and radiographic depiction of cystic changes within the lunate were examined. The MRI protocol included coronal and sagittal T1- and T2-weighted SE sequences (4 mm slices, 120 FOV, 256 x 256 matrix) as well as coronal STIR images. Final diagnosis was confirmed by surgery (n = 5) and follow up. 10 cadaveric ossa lunata were studied to describe size, number, location and shape of nutrient vessel canals.

RESULTS

Ganglion cysts (n = 6) showed characteristic signs. In ulnar impaction syndrome (n = 1) small cystic lesions in the lunate were surrounded by a sclerotic rim and located near the proximal ulnar surface. In Kienböck's disease (n = 3) cystic components were irregular and surrounded by bone marrow edema. Nutrient vessel canals (n = 7) imaged as 1 to 3 small cystic lesions within the palmar or dorsal subchondral region.

CONCLUSION

MRI can aid in differential diagnosis of cystic carpal lesions. Nutrient vessel canals may not be mistaken for pathologic cystic lesions. Carpal ganglion cysts show distinct diagnostic pattern.

[Pulleys of the tendon sheath of the flexor pollicis longus muscle]

The fibrous wall of the flexor tendon sheath of the thumb is reinforced by pulleys similar to those in the fingers. As cited in the literature, there are two annular pulleys A 1 and A 2 and one oblique pulley. On the basis of our investigations, this distribution was found only in 10%. In 90%, the proximal (A 1) and the distal pulley (A 2) can be seen. However, between these two annular pulleys a Y-shaped fiber complex can be dissected at the level of the base and the shaft of the proximal phalanx. This complex can be further divided into an annular part (proximal) and an oblique part (distal). The annular part is associated with the tendon insertion of the adductor pollicis muscle. The oblique part arises distal from the annular part from the ulnar side of the tendon sheath, running to the radial side of the proximal phalanx interwoven with the interphalangeal joint capsule and the palmar plate. Some fiber strands continually pass into the cutaneous ligaments of Cleland. Thin accessory pulley fibers were found between the annular pulley A 1 and the annular part of the Y-shaped fiber complex in 9.5% and in 20.6% between the oblique part and the annular pulley A 2.

[Surgical anatomy of the distal radio-ulnar joint and the ulno-carpal joint compartment]

Variations in length ratios of both radius and ulna directly influence the profiles of the distal radioulnar joint. During pronation and supination, joint surface incongruity of the two forearm bones permits rotational and translational movements. The ulnocarpal discuss is the central part of the ulnocarpal complex. Together with radioulnar and ulnocarpal ligaments, the ulnocarpal meniscus, the tendon sheath of the extensor carpi ulnaris muscle, the ulnar collateral ligament, and accessory fiber strands the complex guides movements such as pronation and supination and stabilizes the proximal and distal carpal joint.

New Sesquiterpene Lactones from Illicium floridanum

In continuation of our phytochemical investigation of Illicium floridanum Ellis (American star anise, star bush), three new sesquiterpene lactones possessing the anisatin-type carbon skeleton (8,9-seco-prezizaane skeleton), 14-acetoxy-3-oxofloridanolide (1), 13-acetoxy-14-(n-butyryloxy)floridanolide (2), and 3beta-acetoxy-14-n-butyryloxy-10-deoxyfloridanolide (3), were isolated from fruits of this plant. Their structures were elucidated by 1D and 2D NMR measurements. The molecular structure of 1 was obtained by single crystal X-ray diffraction. The 11,3-delta-lactone structure of the compound previously described as debenzoyldunnianin in our previous communication, on grounds of NMR spectral evidence and X-ray crystallographic analysis is revised to a delta-lactone closed between C-11 and C-7 (compound 4). The neurotoxic sesquiterpene lactone anisatin (5) and its isomer 2alpha-hydroxyneoanisatin (3-deoxy-2alpha-hydroxyanisatin, 6) were also isolated and identified by spectroscopic means. The presence of the neurotoxin 5 in relatively high amounts in the fruits and leaves confirms and explains early reports on the toxicity of this plant.

Competitive binding of viral E2 protein and mammalian core-binding factor to transcriptional control sequences of human papillomavirus type 8 and bovine papillomavirus type 1

The promoter P7535 of human papillomavirus type 8 and the promoter P7185 of bovine papillomavirus type 1 are negatively regulated by viral E2 proteins via the promoter proximal binding sites P2 and BS1, respectively. Mutations of these E2 binding sites can reduce basal promoter activity. This suggests binding of a transcription-stimulating factor and may indicate that repression by E2 is due to competitive binding of viral and cellular proteins. A computer search revealed putative binding sites for core-binding factor (CBF; also referred to as PEA2, PEBP2, or AML), overlapping with P2 and BS1. Binding of recombinant CBF proteins to these sites was confirmed by band shift analysis. Competition of CBF and E2 protein for DNA binding was shown for both human papillomavirus type 8 and bovine papillomavirus type 1. The importance of CBF-E2 competition in E2-mediated repression could be demonstrated by comparing the E2 effect on P7185 activity in two cell lines containing different amounts of endogenous CBF. In cells with large amounts of CBF, E2 repressed P7185 wild-type constructs to the basal promoter activity of a mutant (50%) that could not bind this protein any more. In contrast, in a cell line containing small amounts of CBF, the promoter activities of constructs with wild-type and mutated CBF binding sites hardly differed and specific repression by E2 was not detectable.

[Clinicoradiologic anatomy of the shoulder region]

Besides the skeletal elements, i.e., the clavicle, scapula and humerus, several muscles and soft tissues also participate in the construction of the human shoulder. These elements from and surround the shoulder girdle joints, which are the acromioclavicular and glenohumeral joint. Towards the trunk a connection is achieved by the sternoclavicular joint. Ossification of the clavicle, scapula and humerus begins within the 5th to 7th embryonic week. Around the age of 20 years ossification is completed. Parallel to this development and during adulthood, age-dependent changes take place in the composition and mixture of the bone marrow from red to yellow marrow. The shoulder girdle joints are constructed to permit a wide range of motion of the arm against the trunk. At the glenohumeral joint the spherical humeral head glides within the concave groove of the glenoid cavity. Stability is attained by the fibrocartilaginous glenoid labrum, which enlarges the articulating areas and the joint capsule with its strengthening ligaments. Variation of the joint capsule insertion, the glenoid labrum or the bony surfaces may predispose to luxation. Additional support to prevent luxation is obtained by the glenohumeral ligaments and the long biceps tendon. Active movement is provided by the superficial muscles and the rotator cuff muscles. Several bursae support free movement and decrease friction of the musculotendineous systems near the joint. Despite this complex construction several degenerative diseases can impair free movement of the human shoulder.

Subacromial fat pad

The subacromial fat was studied using cadaver dissections and Magnetic Resonance Imaging (MRI). We found that the subacromial fat is not loose connective tissue, but a fat pad surrounded by a fascia. The measurements of this fat pad are presented and the clinical relevance for orthopedics and radiology particularly for the impingement syndrome of the shoulder is discussed.

[Distribution of hematopoietic and fatty bone marrow in the proximal humerus and scapula: magnetic resonance tomography and macroscopic anatomy]

PURPOSE

To establish the distribution pattern of haematopoietic and fatty bone marrow on MRI of the proximal humerus and the scapula in correlation with age, gender and nutritive factors.

MATERIAL AND METHODS

32 shoulder MR examinations (T1-weighted spin-echo and opposed-phase gradient-echo sequences) from 24 patients and 8 volunteers were analysed retrospectively. The amount of haematopoietic bone marrow within the proximal humerus and scapula was classified into four groups and was correlated with age (H-test), gender (chi 2-Test), and thickness of subcutaneous fat (H-test). The marrow distribution within 10 scapulae of cadavers over 60 years of age at death was studied.

RESULTS

With increasing age, the amount of haematopoietic bone marrow in the proximal humeral metaphysis tends to decrease from lateral towards medial (H-test, p = 0.3). Diaphysis and epiphysis did not show haematopoietic marrow. The amount of haematopoietic bone marrow within the paraglenoid region of the scapula also revealed a decrease with increasing age (H-test, p = 0.003). Females had higher amounts of haematopoietic marrow than males (chi 2-test, p = 0.03). The thickness of subcutaneous fat was independent of the marrow distribution.

CONCLUSION

The amount of haematopoietic bone-marrow of the shoulder girdle decreases with increasing age. The knowledge of marrow distribution patterns based upon these changes is important for shoulder MRI interpretation to prevent confusion with infiltrative disease.

Anatomical aspects of postintubational subglottic stenosis

The subglottic regions of 54 human adult male and female larynges were studied with regard to anatomical aspects of postintubational stenosis. Fourteen specimens were impregnated with curable polymers and cut into 600-800 microns sections along different planes. Forty formalin-fixed hemilarynges were dissected. Measurements of the upper cricoid lamina and the thickness of the endocricoid soft tissues were taken for statistical analysis. Immediately beneath the glottis, the upper part of the cricoid lamina consists of two lateral plates with an average angle of 110 degrees. Distally, the cricoid adopts a more and more rounded lumen. At the level of the cricothyroid joint, the definite airway lumen is always laterally narrowed by a prominent thickening of the endocricoid soft tissue. Large amounts of loose connective tissue facilitate the development of edema in case of injury in this region. Dorsally, the submucous stratum is smaller and consists mainly of dense connective tissue. The blood vessels are fixed to the cricoid perichondrium by collagenous fibers. Any pressure applied from the airway lumen will force the vessels against the nonresilient cartilage, resulting in occlusion and ischemia. These pathophysiologic mechanisms are important for the development of early laryngeal damage during endotracheal intubation, possibly resulting in posterior stenosis due to scarring later on.

[Clinical anatomy of the interosseous arteries of the forearm]

In recent years, several local flaps have been developed, based on the anterior and posterior interosseous arteries and their anastomoses at the wrist (e.g. posterior interosseous flap, pronator quadratus flap etc.). The anatomy of the arterial network supplying the flap is well established in both clinical and anatomical literature. Most authors agree in the constancy of the anastomoses between the interosseous arteries at the wrist and the absence of major anatomical variations excluding the use of the flap. In the present study, which is based on cadaver dissections of 60 preserved specimens, several gross vascular variations of the interosseous arteries have been found. The most frequent types were an additional anastomosis between the posterior interosseous artery and a perforating branch of the anterior interosseous artery in the middle third of the forearm, which was found in 20%. Ring-formations of the palmar and the dorsal branch of the anterior interosseous artery occurred in 5%. The point of perforation of the interosseous membrane by the dorsal branch of the anterior interosseous artery was found to vary in a larger extent, as described previously.

Vascularization of the fetal elbow joint

Unlike the adult tissue, prenatal cartilage may be well vascularized. We studied the prenatal development of vascular channels within the epiphyses of the human elbow joint. Plastinated 200-1000 microns thick sections through the right and left arms of 12 fetuses with a crown-rump-length of 90-360 mm and of a newborn infant were investigated. Cartilage canals first develop within the distal humeral epiphysis, later on within the olecranon process and the radial head. With advancing age, the canals reveal an increasingly complex pattern of distribution. However, a constant basic pattern can be recognized at every developmental stage. The cartilage canals take their origin from the perichondrium. At their point of entrance into the cartilaginous tissue, their walls are often ill-defined and consist of several fibrous layers which gradually irradiate into the cartilage. At the opposite tip, the channel wall is more clearly demarcated. Many cartilage canals contain several vessels forming loops or branching into bunch-like structures at the tip of the canals. The vessels mostly lie adjacent to the canal walls, grouped around a core of loose connective tissue. As a rule different channels run towards the centre of the cartilage and do not form any anastomoses. The vascularization of the epiphyses of the human elbow joint takes place a long time before the secondary centres of ossification develop, which normally appear after birth. Thus, a direct causal relationship seems unlikely.

Topographical anatomy of the posterior elbow region during fetal development

We studied the topography of the elbow region with special regard to the ulnar nerve during fetal life. Plastinated 600 microns thick sections through the right and left arms of ten fetuses with a crown-rump length (CRL) of 105 to 360 mm and of a newborn infant were investigated. The ulnar groove does not appear on the dorsal side of the medial humeral epicondyle earlier than at a crown-rump length of 130 mm. It provides the entrance into a formerly described fibro-osseous tunnel called the cubital tunnel. Its floor is formed by the posterior bundle of the ulnar collateral ligament, which bulges medially on flexion of the elbow joint. Up to 270 mm CRL it is composed of rather loosely arranged connective tissue fibres. Later on, its fibres are densely packed and show a parallel orientation. The ulnar nerve is pushed medially but remains behind the medial epicondyle. None of the specimens showed displacement to the anterior site of the elbow joint. An aponeurotic arch bridging the humerus and ulna and covering the ulnar nerve medially could not be identified. The findings in the newborn infant did not reveal any significant differences compared to the fetal specimens.

Two portions of the supraspinatus muscle: a new finding about the muscles macroscopy by dissection and magnetic resonance imaging

Axial MR images of the shoulder joint reveal a central linear band within the supraspinatus muscle void of signal which seems not to represent the only tendon of this muscle. Due to the importance of the supraspinatus muscle for the painful impingement syndrome of the shoulder we studied the fibrous architecture of this muscle comparing 30 MR images and 49 cadaver dissections. We found the supraspinatus muscle to be composed of two distinct portions. The mean length of the ventral portion is 88 mm and of the dorsal portion 106 mm. The angle of the central tendon which is formed by fibers of both muscle portions relative to the frontal plane is 50 degrees. Both muscle portions probably act differently in moving the arm. This finding seems to be important for the pathophysiology of rotator cuff tears which are mainly located anteriorly within the ventral muscle portion and the eccentric central tendon.

Cartilage canals in the fetal elbow joint in man

The development of cartilage canals in the human elbow joint during fetal life was studied. Plastinated 600-1,000-microns-thick sections through the right and left arms of 12 fetuses with a crown-rump length of 90-360 mm and of a newborn infant were investigated. At a crown-rump length of 90 mm, cartilage canals have started to develop well within the distal and inferior aspect of the capitulum of the humerus, and are about to enter the dorsal side of the olecranon process. The radial head shows that vascularization does not begin before the 160-mm stage. The channels reveal a centripetal orientation and do not form any anastomoses. Branching occurs mainly in a dichotomous manner. The channels never originate from those areas of the perichondrium which reveal regular and parallel or very dense but irregular anchorage of collagenous fibres into the adjacent cartilaginous tissue.

[Prenatal development of the radial annular ligament]

The prenatal development of the annular ligament of the elbow was studied by investigating 600 microns thick plastinated sections through the elbow joints of nine fetuses with a crown-rump-length (CRL) of 105-360 mm. At 105 mm CRL the annular ligament consists of one layer of circular fibres around the circumference of the radial head. At 130 mm CRL it extends further distally to the radial neck. The postero-lateral region exhibits an arrangement of three layers of fibres of different course. Stages later than the 190 mm stage show in the anterior region external fibres arising from the medial periosteum of the ulna. They pass over the anterior surface of the ulna and blend with fibres arising from the anterior margin of the ulna's radial notch to surround the radial head. At 270 mm the articular capsule can be recognized as a strong homogenous layer of fibres. With all stages investigated the annular ligament consists of circular fibres only near the attachment at the posterior margin of the ulna's radial notch. Anteriorly the annular ligament is narrower than posteriorly. With the later stages of 290, 330 and 360 mm CRL a further differentiation of the annular ligament cannot be recognized. Thus, between 105 mm and 270 mm CRL, the annular ligament develops a more and more complex structure similar to that described for the adult joint. We describe several distinct steps of this differentiation during the fetal period which are not mentioned in the literature yet.

Clinical anatomy of the subcutaneous veins in the dorsum of the hand

Ninety adult upper extremities from human cadavers were used to study the patterns of the subcutaneous veins in the dorsum of the hand, with careful dissection and measurement under magnification. In our series, the distribution of the veins was not symmetrical in the dorsum of the hand. In 83.3% of the cases, the veins were arranged in two groups, radial and ulnar, above the transverse midline of the dorsum. The area between these two groups, corresponding to the proximal halves of the second metacarpal bone, the second intermetacarpal space and the third metacarpal bone, might be called "vein lacking area". Crossing branches of veins were found in all cases. There were on average three crossing branches in each case, and their internal diameters were 0.9 +/- 0.2 mm. This study established that the subcutaneous veins in the dorsum of the hand are arranged in two layers. They communicate freely with the veins in the palmar aspect through the intermetacarpal spaces. The average number of perforating branches was 3.9, and their internal diameters were 1.0 +/- 0.4 mm. The perforating branch in the first intermetacarpal space was wide (internal diameter: 1.8 +/- 0.3 mm) and very constant (appearance rate: 100%). This branch may be the most important communication between the superficial and deep veins. We found the venous values in 70.0% of the perforating branches, which prevent the blood flowing from the dorsum to the palm.

[Clinical anatomy of the fat body in the forearm and in the palm]

In the hand the space between the deep flexor tendons and the interosseous fascia is named the midpalmar space, spatium palmare medianum. A fat body, Corpus adiposum palmare profundum, can be found there regularly. Despite the anatomical narrowness in this region, it reaches up into the carpal canal. Also in the deep forearm space there is always a fat body, Corpus adiposum profundum antebrachii, located dorsally to the deep flexor tendons, lying on the palmar fascia of the pronator quadratus muscle. Usually it is not connected to the Corpus adiposum palmare profundum. The regular occurrence of both fat bodies indicates their functional importance. It is to be supposed that they serve as a gliding layer for the deep flexor tendons. Especially the Corpus adiposum palmare profundum may provide an essential protecting function to the dorsally located deep branch of the ulnar nerve and deep palmar arch. In contrast there is a higher risk of mechanical irritation and compression of the deep branches of the ulnar nerve and artery during their more proximal course through the opponens muscle of the little finger ("opponens-canal") and the ulnar marginal septum. Characteristic features of dimensions and location of the Corpus adiposum profundum antebrachii and the Corpus adiposum palmare profundum and of the deep branches of the ulnar nerve and artery are described. The clinical relevance is discussed.

[Clinical anatomy of the digital connective tissue cord of the ulnar side of the little finger]

A fibrous cord with a length of nearly 60 mm and a width of 3 mm consistency starts near the insertion of the abductor digiti minimi muscle at the ulnar border of the little finger. The fibers pass parallel to the longitudinal direction of the little finger and at the level of the osseous ridges on the palmar side of the flexion-extension axis of the finger joints. Proximally the cord receives fibers from the periosteum at the base of the proximal phalanx, from the ulnar end of the natatory ligament, and from the pretendinous fibers of the A1 pulley. Distally the digital cord has connections to the cutaneous ligaments of Grayson and Cleland. The cord also joins the flexor tendon sheath, the neurovascular bundles, and the skin. Sometimes these cords are involved in Dupuytren's contracture.

[A rare anomaly of the superficial flexor tendons of the little finger]

A rare anomaly was found in both hands of an eighty-five-year old female. The muscle bellies of the superficial finger flexor muscle for the little finger were absent. Instead of this, a thin tendinous cord arose from the tendon of the flexor superficialis of the ring finger proximal to the carpal tunnel to pass into the radial side of the flexor tendon sheath of the little finger at the level of the annular ligament A 1. Together with an abortive tendon on the ulnar side the tendon inserted into the middle phalanx. The flexor digitorum profundus muscle of the little finger was normal.

[Clinico-anatomic studies of the carpal tunnel of the human hand]

Numerous investigations of the carpal tunnel were performed in 60 human hands of adults. In detail we determined the length, width, and thickness of the flexor retinaculum. Furthermore the dimensions of the carpal tunnel and the proximal, middle and distal cross-section areas were calculated. We found that the middle region is the narrowest portion of the carpal tunnel. The median nerve increases constantly in width from proximal to distal in the carpal tunnel whereas its thickness decreases. In 43.3% the nerve passes radially from the middle of the tunnel to the palm. In 21.7% the median nerve is located exactly under the middle of the flexor retinaculum and only in 1.7% is it shifted to the more ulnar side. The median nerve shows a winding course in the remaining cases.

[Glide amplitude of flexor and extensor tendons of the fingers of the human hand]

The gliding amplitude of the flexor and extensor tendons of the finger muscles were determined in the human hands of adults. The carpometacarpal transition area and also the middle zone of the proximal and middle phalanx were appointed as measuring marks. In the main the amplitudes on the flexor side are constantly greater than on the extensor side. Because the movements decrease from proximal to distal, also the gliding range during tendon excursion lessens in the proximo-distal direction. In the case of replantation the extensor tendons should be shortened by the same amount as the bone. To relieve tension in the suture, the flexor tendons should be kept at their original length.

The influence of heat stress on plasma volume and intravascular proteins in sedentary females

23 untrained femal subjects underwent a standardised thermal dehydration. Plasma volume (PV), hematocrit (HCT), total intravascular protein concentration (TPC), albumin concentration (AC), total globulin concentration (TGC) were determined before, immediately, 90 min and 180 min after the heat stress. The intravascular protein masses (IPM) were calculated from PV and protein concentration. In comparison to men the loss of body weight and PV was smaller. Consequently the TPC does not increase to the same amount in men. A tendency for a diminution of IPM could be observed but this shift was not significant, compared to males. According to these findings the colloid osmotic capacity remained on a relatively high level. Opposite to men the IPM of globulins increased in females after thermal dehydration.

Operative cholangiography: a case for its routine use

Images