Possibilities and limits of the morphological diagnosis of rheumatoid arthritis]

For the morphological diagnostics of rheumatoid arthritis only the judgment of the synovial membrane is of practical importance. Based on the experience gleaned on more than 2,000 synovectomy preparations the following evidence concerning the possibilities and the limits of the morphological diagnostics and the judgment of activity can be enunciated. 1. A certain histological diagnosis of the rheumatoid arthritis is possible only when rheumatoid granulomas or their equivalents are proved. 2. A probability diagnosis results from a definite combination of symptoms of proliferative and exsudative reactions of the synovial membrane. Especially the absence of proliferative signs decreases the degree of probability of the diagnostic evidence. 3. Seropositive and seronegative cases do not reveal any differences in histological respect. The possibility of the class-specific determination of rheumatoid factors by means of an immunofluorescence test and the fact the seronegative cases showed IgM and IgM rheumatoid factors, when this test was used, demands an examination of this evidence. 4. As to the synovial membranes of large joints in the same membrane so distinctive local differences of the findings may exist that thus the value of the needle biopsy is restricted. Only positive findings may be evaluated diagnostically. 5. Apart from a diagnosis the histological findings of the synovial membrane also allow a judgment of the local activity. The basis activity and the actual activity are differentiated. The basis activity is regarded as an expression of the immunological activity, the actual activity as an expression of the inflammatory activity. There are no unambiguous relations to the total clinical activity. Differences in the behaviour of the activity between seropositive and seronegative cases are not to be proved. A revision of this evidence under the aspect of the class-specific proof of the rheumatoid factor is necessary.     

Possibilities and limits of computer-assisted cardiotocogram analysis

The interpretation of cardiotocograms still relies primarily on visual analysis. This form of monitoring remains labour intensive and, being dependent on the training and experience of the specialist responsible, also subject to erroneous interpretation. Computer-aided cardiotocogram analysis has, in spite of encouraging successes, still not found wide application in everyday clinical routine. To achieve this, the programming system must be easy to operate, userfriendly and reliable. A program system for fully automatic cardiotocogram analysis is envisioned which runs on standard commercially-available personal computers. A clear graphic representation of the traces also permits visual assessment on the computer screen. The system described integrates the main assessment criteria of cardiotocogram analysis which can then be extended owing to the open system architecture used in the programming. Completely new analysis algorithms have given the evaluating system the capability of fully-automatic pattern recognition of fetal heart rate signals and uterine motility. An essential requirement of computer-aided cardiotocogram analysis is thereby fulfilled. Work is now focusing on the exact classification of the various types of deceleration and an extension of the capabilities of tocogram analysis. There should be nothing to hinder integration of the system into everyday clinical routine and connect it to obstetrical databases.     

Possibilities and limits of surgical therapy of pseudomyxoma peritonei

In a retrospective study, the potential and limitations of surgical therapy of pseudomyxoma peritonei were studied in seven patients. In all patients the pseudomyxoma had originated from the appendix. All patients were primarily treated by surgery. An R0 resection at the first operation was possible in only one patient with a benign pseudomyxoma, while significant tumor debulking with improved symptoms was achieved in all other patients. If the tumor recurred relaparotomy was performed to obtain tumor reduction. The perioperative morbidity even after multiple relaparotomies was low. The survival rates ranged between 2 and 20 years with chemotherapy (5-fluorouracil) which was of particular prognostic benefit in patients with malignant pseudomyxoma peritonei. Surgical therapy is the treatment of choice in pseudomyxoma peritonei, although an R0 resection is hardly feasible. Due to the low morbidity, relaparotomy in cases of tumor recurrence always appears to be indicated. In comparison to other gastrointestinal malignancies, the survival rates in pseudomyxoma peritonei, sometimes treated with additive chemotherapy, are superior.     

Possibilities and limits of automatic detection of pathologic intracranial pressure waves with FFT

Owing to the existence of "reserve spaces" varying individually in extent and expressed by the term compliance, space-consumption intracranial processes do not raise the intracranial pressure (ICP) primarily. Only when this compliance has been exhausted may ICP rise dramatically and may rapidly reach dangerously high levels. It has been shown in the past that "anticipatory" initiation of ICP-reducing measures--i.e. very early in the development of increasing mean ICP--may greatly benefit patient outcome. To recognize an imminent ICP crisis, the available compliance needs to be known. The classical method for determining this latter is the bolus test, which, however, has the disadvantage of being discontinuous and associated with the risk of infection. Another, less invasive and continuous, option is the recognition of pathological intracranial pressure waves. However, recognition of such patterns requires specialized knowledge, that is not widely available. Since, however, knowledge of the compliance is of general importance for intensive care, the idea of developing a PC-based automated system for the identification of pathological waves was followed up. During the course of our basic research effort, we investigated the suitability of the fast Fourier transformation (FFT) algorithm for this purpose. We were able to show that while the FFT is theoretically useful for the detection of pathological intracranial waves, its shortcomings in terms of its sensitivity to extraneous signals (noise) (of considerable importance for biological data handling) and errors in correctly estimating the amplitudes of pathological waves (of great importance for clinical evaluation) make FFT appear less than optimally suitable for this purpose.     

Possibilities and limits of electron microscopy (author's transl)

This review evaluates the electron microscopical imaging techniques used today. Reviewed are transmission method, indirect imaging of surfaces by replica and surface decoration, and direct imaging of surfaces by means of scanning, emission, and mirror electron microscopy. For each method the respective limit of resolution and the possibilities of application are described. Especially, the methods of high-resolution and of high-voltage electron microscopical techniques will be pointed out as being actual means of investigation stressing electron microscopy up to the limits given by physics and technique.     

Possibilities and limits of outpatient surgery (author's transl)

The aims of modern outpatient surgery include: the comprehensive development of ambulatory therapy especially the repertoire of operations, preclinical standardized diagnostic procedures, postoperative outpatient care and rehabilitation. The main reasons for this development are analyzed. In order to make further progress in the direction indicated the number of surgeons working in outpatient departments will have to be increased. Own experiences in outpatient saphenectomy, excisions of Dupuytren's contracture, haemorrhoidectomy, mastectomy, herniorrhaphy, enucleation of cold nodes in the thyreoid gland (171 operations between 1972 and 1974) encourage further efforts in this direction.     

Possibilities and risks of genetic diagnosis

In the recent past, cytogenetic and molecular genetic methods led to an enormous increase in knowledge on genetic information. It reveals a correlation between the genetic information and the phenotype of an individual. Therefore, new starting points concerning the origin of diseases arise. A new nosology will develop. It will force researchers to emphasize more and more on the contribution of the--disturbed--genetic information system to the development of diseases. They will routinely carry out genome analyses on the following four already established levels: 1. phenotype level, 2. biochemical level, 3. chromosomal level, 4. molecular genetic level. Practicians mustn't close their mind to these new possibilities and methods: The three classical tasks of medicine--diagnosis, prevention and therapy--will be supplemented considerably by an earlier (presymptomatic) and more precise diagnosis that is furthermore independent of the organ. Moreover, there is the increasing possibility to predict the risk to develop a disease for descendants in certain partnerships more precisely and, if necessary, to diagnose prenatally. From the medical point of view, these advances are predominantly positive and to the patient's benefit. But it is pointed out that the diagnostic progress also raises new problems which were previously unknown. The answers will have to be given by society as a whole.     

Doppler color echography in the diagnosis of impotence

This study reports the experience achieved with duplex and color Doppler ultrasonography in 120 impotent patients. The following morphodynamic parameters of the cavernosal arteries were studies before and after intracorporal injection of a mixture of vasoactive drugs: arterial diameter, wall pulsatility, morphology of the spectral waveform, peak systolic velocity, end diastolic velocity and flow volume. The veno-occlusive mechanism of the corpora cavernosa was studied directly by determination of flow along the deep dorsal vein of the penis and indirectly by serial evaluation of the diastolic flow of the cavernous arteries.     

Value of echography for diagnosis and follow-up of perforating eye injuries

The introduction of vitreous surgery with its multiple capabilities of intraocular manipulations makes it possible to operate on cases which had been considered as hopeless up to now. With these techniques the importance of ultrasonic examination increased especially in cases with severe perforating injuries and their follow-up, to detect the onset of intravitreal fibrosis and early traction detachment, when no fundus view is possible. An other indication for ultrasonic examination is the exact localization of foreign bodies. Out of 484 perforating injuries which were examined and treated in our clinic during the last 10 years, ultrasonographic diagnosis was helpful in 18% and had further therapeutic consequences: In 24% a detachment operation or vitreous surgery was necessary, in 30% ultrasonography showed severe damage and surgery was considered to be ineffective. 42% were follow-up examinations of the posterior segment.     

Possibilities and limits of intramedullary Kirschner wire osteosynthesis in treatment of metacarpal fractures

Extrasystoles and both supraventricular and ventricular tachycardias may occur as a complication of almost any underlying cardiac disease and many extracardiac causes; on the other hand, also a patient without any detectable structural heart disease may present with these arrhythmias. Refined mapping techniques of the intracardiac conduction process have let to important new informations about the pathophysiology of sustained tachycardias (focal impulse formation, macro-reentry) with practical consequences, for example when ablation of these arrhythmias by radiofrequency catheter ablation is considered. Cardiac arrhythmias may lead to both typical and atypical symptoms. Finally, the patient at risk of sudden cardiac death is characterized. One needs to differentiate patients who have survived a life-threatening event of ventricular tachycardia or have been successfully resuscitated from cardiac arrest (both situations usually need life-long antiarrhythmic interventions for secondary prophylaxis) from patients who also are at high risk, however, are asymptomatic until now. For the latter population, symptoms due to extrasystoles or assessment of the severity of ventricular ectopic beats by the Lown classification are of minor importance; most emphasis in this regard, however, must be placed on the type and severity of underlying cardiac disease.     

The role of echography in the diagnosis of pelvic masses

The authors confirm the fundamental role of the pulse-echo technique in the study of pelvic masses; they outline the usefulness of the ultrasonography in the early presumptive diagnosis of the possible neoplastic alterations of such masses. The authors present five clinical cases in which the use of the pulse-echo technique has allowed to locate, in spite of a scanty clinical symptomatology, the presence of pathologies requiring a rapid surgical resolution.     

Possibilities and limits of modern rapid procedures for process control of cleaning and disinfection methods

In food production and processing, hygienic measures and their control gain more and more importance. The disadvantage of the commonly used control methods is their time-consuming process providing results after 24 hours at the earliest. From all microbiological rapid methods developed in the past, the bioluminescence method is a suitable hygienic measure for detection of adenosine triphosphate (ATP). In this test, ATP from microorganisms and ATP from somatic cells is detected. Within 2 minutes cleaned and disinfected surfaces can be reliably evaluated. Different equipment was tested in the laboratory and in a meat processing plant. The quality of the hygiene evaluation of the cleaned surfaces is decisively depending on the surface structure of the materials and on the product residues remaining in the peak-to-valley heights. Therefore, limiting values for ATP shall be determined individually for each plant. In this case, the bioluminescence method can be recommended as suitable tool for hygiene monitoring.     

Possibilities and limits of ambulatory supportive measures in oncology exemplified by antibiotic therapy of febrile neutropenia

Neutropenia is common after intensive chemotherapy. Hospitalization and intravenous broad-spectrum antibiotics are the standard of care for febrile neutropenic patients because of the risk of serious complications and associated mortality. Short neutropenic periods (< 7 days) are considered to be at a low-risk in cases when fever occurs in clinically stable patients. Recent work suggests that such a low-risk population of febrile neutropenic patients might benefit from alternatives to inpatient care. The agents that best qualify for outpatient treatment include quinolones i.v./p.o., glycopeptides, ceftriaxone and aminoglycosides, particularly if the latter are given once daily. Response rates to antimicrobial therapy range from 80 to 95% in low-risk febrile neutropenia episodes. Treating these patients in an outpatient setting avoids hospitalization in 75 to 95%. There is no doubt that outpatient therapy may have several advantages, including lower costs and an improved quality of live. Outpatient antibiotic therapy for febrile low-risk neutropenia should be considered as an acceptable alternative to inpatient treatment.     

Value and limits of conventional mediastinoscopy in preoperative evaluation of primary bronchial cancer

PURPOSE OF THE STUDY: Retrospective evaluation of conventional mediastinoscopy in the preoperative staging of primary lung cancer. METHODS: Between 1978 and March 1997, 117 consecutive patients underwent conventional mediastinoscopy in the preoperative staging of primary lung cancer, after imaging had shown mediastinal lymph nodes larger than 1.5 cm. RESULTS: In 8 instances no material was found at mediastinoscopy, in 38 the lymph nodes showed no tumorous infiltration, and in 71 the lymph nodes were metastatic. 48 patients underwent thoracotomy in the same stage, with resection achieved in 41. Contraindications for thoracotomy (in 69) were N2 (45) or N3 (11) disease adn/or small cell lung cancer (18). Mediastinal lymphadenectomy was performed in 26 of the 41 patients who underwent lung resection; half of those with negative nodes at mediastinoscopy had in fact N2 disease, with involvement of 2 areas of more in half. There were no deaths due to mediastinoscopy but 4 complications. CONCLUSIONS: A favorable mediastinoscopy is not synonymous with resectable disease, nor does it exclude N2 disease; it does however serve to avoid unnecessary thoracotomies in more than half of cases.