Anatomical variations of the posterior intercostal arteries and the thoracic vertebral artery.

This study evaluated the occurrence and frequency of the anatomical variations of the origin and course of the posterior intercostal arteries (PIA) in 44 human cadavers. During a classical anatomical dissection of each cadaver an anomalous course of the PIA, defined as a thoracic vertebral artery, was found in six (14%) individuals. Every dorsally coursing PIA was taken into account, regardless of its origin, and their different origins and course were described. A specific dorsal course for the PIA was found in nine cases, which was bilateral in two cases. The variations that were found and that have been schematically presented will provide new information about the anatomical variations of the PIA. Consideration of the potential for anatomical variation of the PIA is important in vascular and thoracic surgery and in diagnostic and interventional radiology such as spinal angiography.

Accuracy of intra-operative frozen section analysis of ovarian tumours.

During operative treatment for ovarian tumours assistance is frequently required to make decisions regarding malignancy status and the extent of the ensuing procedure. Intra-operative frozen section analysis may be useful, provided there is adequate acquaintance with the correlation between using frozen sections and permanent histopathological sections for diagnosis at the institution where the operation is being undertaken. This retrospective study aimed to determine this correlation. Findings from 131 intra-operative frozen sections were compared with the subsequent diagnosis from permanent histopathological sections for women with benign, borderline and malignant ovarian tumours at the Maribor Teaching Hospital (now the University Clinical Centre Maribor) between 1 January 1993 and 31 December 2001. Frozen-section findings corresponded to histopathological findings in 84.7% of cases, with 15.3% false-negative and no false-positive results. For benign, borderline and malignant ovarian tumours, sensitivity was 100.0%, 76.1% and 89.0%, respectively, and specificity was 90.6%, 90.6% and 100.0%, respectively. The majority of errors occurred in diagnosing mucinous borderline tumours. Precise pre-operative diagnosis is extremely important in the treatment of ovarian tumours.

Quality of life and the effect on social status among Slovenian women after breast cancer treatment.

This study investigated whether the type of surgical procedure used to treat breast cancer (mastectomy versus breast-conserving lumpectomy) had any effect on the quality of life and social status of women. The prospective analysis included 382 women newly diagnosed with non-metastatic breast cancer who had undergone a surgical intervention for breast carcinoma at our institution: 198 patients had undergone mastectomy with axillary lymphadenectomy and 184 patients had undergone breast-conserving lumpectomy with local axillary lympha-denectomy. The post-mastectomy women reported significantly more financial problems, a lowered social status and more physical symptoms compared with the breast-conserving post-lumpectomy patients. The patients that underwent lumpectomy were more satisfied with their body image and their sexual life. Since the adverse financial effects of wage loss can significantly decrease a patient's quality of life, this study indicates that post-mastectomy patients in particular need to be protected more effectively against a decline in their social status.

Anatomical variations of coronary ostia, aortocoronary angles and angles of division of the left coronary artery of the human heart.

Classic anatomical dissection of 150 heart specimens from adults aged 18 - 80 years was performed. Anatomical variations were studied in: (i) the position of the ostium of the left coronary artery; (ii) the angle between the proximal segment of the left coronary artery and the longitudinal axis of the aorta and between the circumflex and the anterior descending branches; (iii) the angle between the anterior descending artery and the diagonal branches, and between the diagonal and circumflex branches in trifurcation of the left coronary artery; (iv) the position of the ostium of the right coronary artery in the right coronary sinus of Valsalva; (v) the angle between the initial part of the right coronary artery and the longitudinal axis of the aorta; and (vi) the position of the initial part of the left coronary artery relative to the coronary groove. Knowledge of and the ability to recognize and identify the variety of sites of origin of coronary arteries, aortocoronary angles and angles of division of the left coronary artery of the human heart may help to overcome potential difficulties in cardiosurgical procedures, such as aortic valve replacement and reinsertion of coronary arteries.

Anatomical aspects of the arterial blood supply to the sinoatrial and atrioventricular nodes of the human heart.

Classic anatomical dissection of 150 hearts from adults aged 18 - 80 years was performed. The sinoatrial (SA) node artery was most frequently a large atrial branch of the right coronary artery (63%), arising at a mean distance of 1.2 cm (range 0.2 - 2.2 cm) from its beginning, with a mean external diameter of 1.7 mm (range 1 - 3 mm). In 37% of cases the SA node artery was a branch of the left coronary artery or one of its branches, with an initial mean external diameter of 2.2 mm (range 2 - 3 mm). The origin of the SA node artery was not related to coronary arterial dominance. The atrioventricular (AV) node artery was the first and longest inferior septal perforating branch of the right (90%) or left (10%) coronary artery, arising from the U- or V-shaped segment of the corresponding artery at the level of the crux cordis. Mean external diameter was 2 mm (range 1 - 3.5 mm). The origin of the AV node artery was dependent on coronary arterial dominance. Identification of the anatomical variants of the arterial blood supply to the SA and AV nodes may help in overcoming potential difficulties in treating arrhythmias and in mitral valve surgery.

Anatomical variations of the coronary sinus ostium area of the human heart.

Classic anatomical dissection of 150 heart specimens from adults aged 18 - 80 years was performed. The Thebesian valve was absent in 20% of cases and, in these, 4% had a large ostial valve of the middle cardiac vein in front of the coronary sinus ostium. Fibres of Chiari were found in 10% of cases. Ostia of the middle cardiac vein, posterior veins of the left ventricle, small cardiac vein and deep cardiac veins were present in the distal 10 mm of the coronary sinus. Some samples had ostial and/or parietal valves or antivalves that sometimes contained muscular fibres. Distal accessory parietal valves (2%) and antivalves (1%) of the coronary sinus wall were found at a distance of 4 - 7 mm from its ostium. The frequency and variability of anatomical structures in the area of the coronary sinus ostium probably influence the haemodynamics of this area. Knowledge of and being able to identify these anatomical variations may help in identifying and overcoming potential difficulties in treating arrythmias and in cardiosurgery.

Predicting factors for severity of rheumatoid arthritis: a prospective multicenter cohort study of 172 patients over 3 years.

Rheumatoid arthritis may take an unfavourable course leading to rapid functional decline in a certain percentage of patients. Early identification of these patients is desirable. The aim of this study was to evaluate clinical and laboratory parameters for their value in the prediction of bad outcome. A total of 172 patients with early arthritis were followed for 3 years. Higher initial values for erythrocyte sedimentation rate, IgG and IgM rheumatoid factor, serum concentration of cartilage oligomeric matrix protein, Health Assessment Questionnaire score, Larsen score of feet, disease activity score, and swollen and tender joint count predicted worse outcome. An association with the presence of IgA rheumatoid factor or anti-cyclic-citrullinated peptide could not be established. We conclude that prognosis in an individual with rheumatoid arthritis depends on many factors. The determination of independent prognostic factors for progression of rheumatoid arthritis is a valuable tool in early arthritis to select patients for more aggressive therapy.

[Functional capacity and cartilage oligomeric protein (COMP) in serum of patients with maturity-onset polyarthritis]. / Funktionelle Kapazität und Cartilage Oligomeric Matrix Protein (COMP) im Serum bei Patienten mit Alterspolyarthritis.

OBJECTIVE: To compare late onset with adult onset rheumatoid arthritis. METHODS: Fifty-eight patients with late onset rheumatoid arthritis (LORA) were compared to 117 patients with adult onset rheumatoid arthritis (AORA) with respect to clinical and functional parameters. Furthermore, in 104 patients serum cartilage oligomeric matrix protein (COMP) was measured. Results were compared by means of ANOVA and possible influences of age, gender and clinical parameters were evaluated by Spearman rank correlation. RESULTS: Except a different distribution in gender (40% males in the LORA group) and a higher ESR, no differences could be found with respect to clinical parameters. However, a significantly higher HAQ score and significantly higher serum-COMP levels could be shown in the LORA group. HAQ scores correlated not only with disease activity parameters (C-reactive protein, disease activity score) but also with the age. Serum-COMP levels did show a correlation with the age as well, but not with disease activity. CONCLUSION: It is concluded that the higher serum-COMP levels in late onset rheumatoid arthritis could be due to concomitant osteoarthritic processes in larger joints, which are not symptomatic. The age dependence of the HAQ score is only weak, but may be the reason why patients with LORA show a worse functional capacity compared to patients with adult onset rheumatoid arthritis.

[Simple renal cysts and hypertension]. / Unkomplizierte Nierenzysten und arterielle Hypertonie.

BACKGROUND: Simple renal cysts are frequent findings in mid-aged people, their frequency increases with age. They are often detected by abdominal ultrasound and/or computed tomography during diagnostic procedures. Hypertension is also a frequent disease and its prevalence increases with age as well. The aim of our study was to evaluate the association between simple renal cysts and hypertension in a group of patients with normal renal function. PATIENTS AND METHODS: Ninety-one patients (58 female and 33 male; mean age 50.5 +/- 16.9 years) were included in the study, all with normal renal function (serum creatinine <100 micromol/l). The patients were examined with a real-time ultrasound device with a 2-4 MHz convex transducer. Kidney size, presence, number and diameter of cysts were examined and the presence of hypertension was determined. The presence of hypertension was defined by the administration of antihypertensive agents, systolic blood pressure greater than 140 mmHg and/or diastolic blood pressure greater than 90 mmHg. RESULTS: Simple renal cysts were found in 19 (20.88%) patients. Only cortical cysts were found in 11 (12.09%) patients, only parapelvinic cysts were found in 4 (4.39%) patients. Four (4.39%) patients had cortical and parapelvinic cysts. Cortical cysts in both kidneys were found in five (5.49%) patients, parapelvinic cysts in both kidneys were found in three (3.29%) patients. Bilateral renal cysts were present in 10 (10.99%) patients, six (60%) of them had hypertension. We found no difference in the presence of simple renal cysts according to sex. Hypertension was detected in 30 (32.97%) patients. Hypertension was significantly more frequent in patients with simple renal cysts (P < 0.041) than in with patients without cysts. Simple renal cysts were also significantly associated with age (P < 0.01). With multiple regression analysis we found a significant association with age only (P < 0.0001), but not with hypertension (P = 0.394). CONCLUSIONS: Simple renal cysts are frequent findings and their incidence increases with age. We found an association between simple renal cysts and hypertension. However, with multiple regression analysis only an association between simple renal cysts and age could be detected.

Primary breast cancer of the vulva: a case report and review of the literature.

Since 1872, 40 cases of ectopic mammary gland tissue in the vulva have been reported in the literature. Out of these, 12 had a primary cancer in the ectopic breast tissue. Seven metastases of an orthotopic breast cancer have been found in this location. We are presenting the 20th case of cancerous breast tissue in the vulva whom we classified as the 13th case of primary cancer based on clinical and histopathological criteria of primary and metastatic malignant disease. Because of the advanced age of the patient, wide local excision followed by adjuvant hormonal therapy was opted for. Nineteen months after surgery, there is no evidence of recurrent disease. Due to the rarity of this entity, its management presents therapeutic dilemmas, and variable treatment strategies are being found in the literature. In our opinion, the same basic principles used for treatment of cancers of the orthotopic breast should be applied in ectopic breast carcinoma.

Wegener's granulomatosis--a diagnostic challenge.

Wegener's granulomatosis is a systemic vasculitis characterized by necrotizing granulomatous lesions in the upper and lower respiratory tracts, glomerulonephritis and vasculitis involving other organs. Limited forms have been described in which some features of the disease may be absent. Four patients with this disease are being reported with special emphasis on differences in presentation, the ensuing diagnostic problems, and individual outcome. In three, the disease began as a limited form with upper respiratory tract and eye involvement, while in one patient, onset was systemic including affection of the lower respiratory tract. The mean delay from first symptoms to diagnosis was 20 months--much longer for the three limited forms than for the one with systemic onset, in whom the condition was recognized after 2 months following initial misdiagnosis of respiratory and urinary tract infections. One patient developed endocarditis and required aortic valve replacement. Immunofluorescence revealed antineutrophil cytoplasmic antibodies in all, three showing a cytoplasmic pattern and antibodies to proteinase 3, and the fourth a perinuclear pattern and antibodies to myeloperoxidase. Upper respiratory tract biopsies were not specific. Kidney biopsies were performed in all the patients and were crucial for definitive diagnosis and treatment of the disease, which was successful in three patients.

Dermatomyositis. Diagnosis and evaluation of dermatomyositis, polymyositis, and inclusion-body myositis.

In diseases of an unknown etiology, such as the idiopathic inflammatory myopathies, we must tackle first of all the question of classification and the degree of disease activity before we can institute treatment. The majority of idiopathic inflammatory myopathies are diagnosed clinically and confirmed by biopsy. The presently applicable methods of diagnosis and evaluation of idiopathic inflammatory myopathy have certain limitations, and hence it is necessary to apply new methods of rating the disease activities. Magnetic resonance imaging (MRI) and 99m-technetium muscle-scanning are the latest noninvasive methods for evaluation of disease activities with myositis. Future laboratory methods to determine the numerous myositis-specific autoantibodies will probably enable identification of subsets of these diseases.

Pelvic actinomycosis.

Pelvic actinomycosis is a rare chronic infection caused by bacteria of the family Actinomycetaceae. Prolonged use of an intrauterine contraceptive device (IUD) is a well known risk factor. We report six patients with pelvic actinomycosis, all of whom had an IUD inserted for over six years. Diagnostic problems necessitated a laparotomy in all patients. The pathohistological diagnosis was based on the characteristic microscopic image and specific staining. The patients were treated with penicillin and amoxycillin for several months.

[Diagnosis and therapy of common bile duct stones in a patient with a history of hypersensitivity reaction to radiologic contrast media --a case report]. / Diagnose und Therapie von Gallensteinen im Ductus choledochus bei einer Patientin mit bekannter Uberempfindlichkeitsreaktion auf Röntgenkontrastmittel--Fallbericht.

Common bile duct (CBD) stones may occur in patients who had been previously cholecystectomized because of gallbladder stones. CBD stones occur in 15%-20% of patients with symptoms secondary to cholecystolithiasis. After cholecystectomy they occur in 1%-5% of patients, either in the form of retained or recurrent choledocholithiasis. Endoscopic ultrasonography (EUS) is a novel and excellent diagnostic screening procedure for common bile duct stones. Numerous reports confirm an equal success rate for endoscopic ultrasound and endoscopic retrograde cholangiopancreatography (ERCP). However, unanimity of opinion with respect to the best diagnostic procedure for the detection of CBD stones does not exist to date. We report a 74-year-old female patient with CBD stones, who was shown to have a severe allergy to X-ray contrast medium at a previous examination. In view of the pre-existing contraindication for ERCP, we diagnosed the stones by EUS. The majority of patients would require ERCP for endoscopic treatment, but our patient rejected the administration of contrast medium as well as conventional surgical treatment. After introducing a guide wire into the bile duct to assure its position, endoscopic sphincterotomy (EST) without contrast imaging was performed successfully. The CBD stones were extracted with a basket. Based on our results we believe that EUS ranks as an important procedure in the diagnosis of CBD stones, and that successful endoscopic treatment can be performed without previous ERCP. We do realize that EST without ERCP in unsuitable as a routine procedure, but may be used successfully in specific cases such as that of the patient reported here.

[Significance of histopathologic analysis of skin lesions in scleromyxedema. Light microscopy, electron microscopy, immunohistochemistry and immunofluorescence microscopy]. / Bedeutung der histopathologischen Analyse der Hautläsionen bei Skleromyxödem. Lichtmikroskopie, Elektronenmikroskopie, Immunhistochemie und Immunfluoreszenzmikroskopie.

Scleromyxedema (SM) may be considered as a possible disease entity in the differential diagnosis of scleroderma. Clinical data and the results of light, immunohistochemical, immunofluorescence and electron microscopic study of skin biopsies taken from a 53-year old patient with SM are reported. In the patient with SM in which abnormal serum paraprotein was not identified, the skin biopsy showed mucinous material in the dermis and proliferation of fibroblasts accompanied by mild dermal sclerosis. Immunofluorescence showed scanty granular IgG along the epidermal basement membrane and IgG and C1q focally along the connective tissue fibres in the dermis of clinically involved skin. In addition to clinical findings, detailed skin biopsy studies including contemporary techniques can contribute to the diagnosis of the disease.

The significance of histologic analysis of skin lesions in porphyria cutanea tarda. Light microscopy, electron microscopy, immunohistochemical and immunofluorescence analysis.

Porphyria cutanea tarda (PCT) is one of several entities in the differential diagnosis of scleroderma. We report a 62-year-old man with PCT diagnosed since two decades. Clinical data and the results of light microscopy, immunohistochemistry, immunofluorescence and electron microscopy of skin biopsies are presented. The biopsy revealed sclerosis of the dermis mainly due to increased collagens I and III, and accumulation of collagen IV, which had caused the vessel wall to thicken. Immunofluorescence for detection of immune reactants was negative. It was concluded that the histomorphology of PCT of long duration may be similar to that of scleroderma. Nevertheless, in addition to clinical findings, detailed skin biopsy studies including contemporary techniques can contribute to the differentiation of these diseases.

[Porphyria cutanea tarda with severe clinical complications. A 20-year follow-up]. / Porphyria cutanea tarda mit schweren klinischen Komplikationen. 20jähriger Krankheitsverlauf.

A patient with porphyria cutanea tarda developed distinctive sclerodermoid changes with extensive dystrophic calcification and ulcerations in the sclerotic areas. In addition to these skin complications, over the course of 20 years other internal problems also appeared, such as diabetes mellitus, fatty cirrhosis and ocular inflammation. These severe clinical complications were related to omission of treatment and the alcohol abuse.

The clinical significance of antinuclear antibodies in connective tissue disease.

Antinuclear antibodies (ANA) are often present in connective tissue diseases. In 279 non-selected patients with connective tissue disease, inflammatory and degenerative joint disease, in some patients with chronic infectious diseases and malignancies and in the presence of some unclear pathologic conditions in patients whose serum reacted positively to ANA, we analyzed the type of immunofluorescence and the presence of extractable antinuclear antibodies (ENA). In systemic lupus erythematosus, the prevailing immunofluorescence is type H (homogenous) (60.6%), anti-Ro/SS-A appears in 24.2%, anti-Sm and anti-RNP in 12.1%. In Sjögren's syndrome, type S prevails (47.6%), anti- Ro/SS-A and anti-La/SS-B are present in 52.4%, only anti-Ro/SS-A in 28.6%. In systemic sclerosis, the prevailing immunofluorescence is type S (37.5%), in 75% a positive anti-Scl-70 antibody is present. In mixed connective tissue disease, anti-RNP appears in 85.7%. In dermatopolymyositis, the anti-Jo-1 antibody is present in 33.3%. In undifferentiated connective tissue disease, type S immunofluorescence appears in 70%. In rheumatoid arthritis the prevailing immunofluorescence is type H (homogenous) (46.4%) and type S (speckled) (41.0%), while the presence of ENA is rare (anti-Ro/SS-A in 4.6%). In spondylarthritis, type S immunofluorescence appears most often (62.5%). Patients with chronic infectious disease, malignancies, undefined conditions and degenerative joint disease present with various types of immunofluorescence; the presence of ENA is extremely rare in these patients. The results of this study underline the significance of ANA and, particularly ENA, in the diagnosis of connective tissue disease. These antibodies however, can also be identified in various infectious and malignant diseases as well as in inflammatory and degenerative joint diseases.

Malignant acanthosis nigricans and tripe palms in a patient with endometrial adenocarcinoma--a case report and review of literature.

BACKGROUND: In the world literature, uterine carcinoma associated with paraneoplastic malignant acanthosis nigricans and tripe palms has been mentioned in two review articles. Endometrial adenocarcinoma associated with malignant acanthosis nigricans without tripe palms has been cited in three case reports, and endometrial adenocarcinoma associated with tripe palms without malignant acanthosis nigricans has been cited in one case report. We present the case of a patient with endometrial adenocarcinoma associated with acanthosis nigricans and tripe palms which we have been following for the past 7 years. METHODS: Our 54-year-old patient had been operated for moderately differentiated endometrial adenocarcinoma. She had also received postoperative radiotherapy. RESULTS: Three years after surgery, tripe palms and acanthosis nigricans with generalized pruritus occurred. After treatment with etretinate, the skin symptoms were somewhat mitigated while the pruritus persisted. Six years after gynecologic treatment, a solitary inguinal metastatic lymph node of endometrial carcinoma was detected. Following lymphadenectomy there was additional but not complete mitigation of skin symptoms including pruritus. CONCLUSIONS: In clinical practice the association of malignant acanthosis nigricans and tripe palms with endometrial adenocarcinoma is found extremely rarely. Although the survival time of adenocarcinoma patients with malignant acanthosis nigricans is short, our patient has been treated and followed for more than 7 years.