[Medieval scenes of ritual circumcision as a reflection of sociopolitical circumstances]. / Mittelalterliche rituelle Beschneidungsszenen als Spiegelbild politisch-gesellschaftlicher Verhältnisse.

Ritual circumcision in males is regarded as one of the oldest surgical procedures. Whereas their medieval illustrations are mostly interpreted within a religious context, this study tries to prove the influence of the political and social situation of the above-mentioned period.Selected iconography of ritual male circumcision in the Middle Ages from Germany, France, Italy, and the Byzantine Empire was critically examined. Special attention was paid to the stained glass windows recently returned to St. Mary's Church in Frankfurt/Oder, where circumcision of the so-called Antichrist is also shown. Up to now we could not find any medical historical information about this subject. Clerical fine art of the fifteenth and sixteenth centuries shows more frequently than before illustrations of ritual circumcision, which evidently demonstrate the political, economic, and social tensions and controversies of that period. In many cases this iconography indicates a rejection of this old Jewish tradition and its confessors. Also the stained glass image of the Antichrist posthetomy could be interpreted as criticism or aversion.This study expands our approach to medieval illustrations of ritual circumcision that have hitherto mostly been interpreted in religious terms. The influence of changing political and social situations in the Middle Ages is evident.

Blunt renal trauma: biomechanics and origination of renal lesions.

OBJECTIVES: Computer-assisted simulation of trauma is supposed to improve protective systems in traffic and risky leisure activities. In case of blunt renal injury biomechanical data being concerned with kidneys as a whole are extremely sparse. To enable three-dimensional simulations this study should supply important data of the renal biomechanics and elucidate the relationship between force distribution and origination of renal lesions. MATERIALS & METHODS: The present study investigated 66 isolated uninjured porcine kidneys using a drop impactor. Changes in deformation, brake force of power, deceleration and intrapelvic pressure are depicted while varying energy application between 1.4 and 14.2J. Lesions were detected by cross-dissecting the organs into slices. RESULTS: The measured values reflect a high correlation between load energy or brake force of power and deformation. Except the intrapelvic pressure all biomechanical parameters rise under increasing energy load. Comparing the different parameters over time a simultaneous concurrence of maximum brake force of power, deceleration and intrarenal pressure can be shown, the peak of deformation was reached belatedly. CONCLUSIONS: The paths of biomechanical curves prove a viscoelastic behaviour of the kidney. In contrast to the literature the region principally bearing the load seems to be the collision zone between renal pelvis and cortex where first lesions appear. This is mainly caused by the fluid filled pelvis, an incompressible support, that is supposed to change its shape after exceeding energy application of about 4J.

Heparin-induced priapism.

Heparin-induced priapism constitutes a special form of pharmaco-induced prolonged erection, but the pathophysiological principles are not yet definitely clear. Heparin-induced antiplatelet-antibodies may lead to the aggregation of thrombocytes and thus alter the penile blood flow leading to low-flow priapism. Alternatively, this condition may be explained by initial high-flow priapism that later turns into ischemic priapism. The question remains whether hemorrhage with subsequent organisation of the hematoma and late fibrosis constitutes a pathogenetic factor. Besides this pathogenetic discussion, this paper presents the differential diagnosis of priapism as well as diagnostic and therapeutic procedures.

Apoptosis in human embryonal cell carcinoma: preliminary results.

Disorders in the regulation of apoptotic cell death may contribute to cancer. Furthermore, lymphocytes are supposed to play a role in counteracting tumorigenesis by inducing apoptosis in different human tumors. In this study, for the first time, tumor cell and lymphocyte apoptosis were investigated systematically in human embryonal cell carcinoma. DNA fragmentation and DNA condensation were measured simultaneously on double-fluorescence-labeled testis tumor sections using immunofluorescence microscopy. Different apoptotic indices (AIs), based either on biochemical (DNA fragmentation) or morphological criteria (DNA condensation) alone or on a combination of both, were determined in different histological regions in and around the tumor. Using morphological criteria alone, 40-75% of all apoptotic cells were not detected. Based on previous observations this finding might be related to subsets of apoptotic cells which induce the process of DNA condensation without activation of processes responsible for DNA fragmentation. Moreover, the AIs of tumor cells and lymphocytes were highest in the tumor region, compared with regions around the tumor and distant from it; these findings are discussed in the context of the Fas/FasL system.

[Pathogen spectrum of urethritis in the man]. / Erregerspektrum der Urethritis des Mannes.

545 male patients with a tentative diagnosis "urethritis" were examined between November 1984 and December 1994 in the Department of Dermatology and Venerology of the Military Hospital in Ulm. The patients, aged from 18 to 58 years (mean age 24.1 years), were examined according to a standardized diagnostic procedure: Smear preparations from the urethra with subsequent gram staining, bacterial cultures for aerobic bacteria, Neisseria gonorrhoeae (cultures and Phadebact gonococcus test), mycoplasma cultures (Mycoplasma hominis (M. hom.); Ureaplasma urealyticum (U. u), and Chlamydia trachomatis using several methods, primarily DIFT (Syva Micro-Trak). Trichomonas vaginalis counts in urine sediment 441 patients (81%) had 4 or more leukocytes per high-power (x1000) field in the gram stained specimens. In these 441 urethritis-patients the following germs could be detected: Trichomonas vagin 3 (1%), N. gonorrhoeae 80 (18%), Mycoplasma 94 (21%) [U. u. 59, M. hom. 24, both 11], C. trachomatis 114 (26%), other pathogenic bacteria 135 (31%). In 114 patients (26%) no bacteria could be identified. A single infection was diagnosed in a total of 242 patients (55%), a double infection was determined in 71 patients (16%) while a triple infection was found in 14 patients (3%). The spectrum determined in the single infection included the following: N. gonorrhoeae 41 (9%), Mycoplasma 45 (10%), C. trachomatis 67 (15%), other pathogenic bacteria 89 (20%) (most frequently found germs were Enterococcus, beta-hemolytic Streptococcus, Escherichia coli, Staph. aureus). In the double infections combinations with aerobic bacteria dominated. In triple infections, mycoplasma were most common. During the investigation period the number of patients with urethritis symptoms declined at a constant rate.

[Metastatic spread of renal cell carcinoma in the area of the ethmoid and frontal sinuses]. / Metastatische Absiedelung eines Nierenzellkarzinoms im Bereich von Siebbein und Stirnhöhle.

Metastatic lesions represent 1-8% of all malignant tumors of the mouth and jaws, with rare sites of metastasis originating from different primary tumors, especially the lung and breast. The vast majority of these lesions (up to 90%) have been observed in the mandible and maxilla (5-20%). Another rare type of cancer that usually metastasizes to the lungs, lymph nodes, bones, liver or brain may occasionally also show spread to the paranasal sinuses. In the present paper we report our management of a 50-year-old male with renal cell carcinoma who developed metastases to the frontal and ethmoid sinuses.

Gallbladder metastasis of renal cell carcinoma. A case report and review of the literature.

Although renal cell carcinoma is known to metastasize mainly to lungs, lymph nodes, bone, liver, brain or adrenal glands, unusual metastatic spread has been published in many case reports and autoptical studies. The gallbladder is rarely the site of distant metastases, and in most cases of gallbladder metastasis malignant melanoma is the primary tumor. A review of the literature revealed only 7 cases of renal cell carcinoma metastasizing to the gallbladder, and these were mainly found at necropsy. The case of a clinically detected gallbladder metastasis is presented.

Commitment to the underserved: evaluating the effect of an extracurricular medical student program on career choice.

BACKGROUND: This study was conducted to compare the practice locations and characteristics of physicians who participated as medical students in an extracurricular program to foster interest in careers of service to medically underserved populations with those of their classmates who did not participate in the program. METHODS: Using a mailed questionnaire, we conducted a cross-sectional study of graduates from the classes of 1983-1987 at one southwestern, public medical school. All Commitment to Underserved People (CUP) participants (n = 94) and a random sample of nonparticipating classmates (n = 188) were surveyed. CUP is an extracurricular project with components in each of 4 years of medical school that provides peer and faculty support, curriculum enrichment, and direct service to medically underserved populations. Outcome measures included the size of community of practice, practice type, and practice patient characteristics. RESULTS: Sixty seven (71%) of CUP participants and 126 (67%) of nonparticipants responded. CUP participants were more likely to be women, to specialize in family practice, to practice in the Indian Health Service (IHS) or overseas, to be located in a community of 25,000 or less, and to have participated in the state, service-payback loan program. In multiple regression, the specialty of family practice was associated with practice in a small community, the IHS, and a community health center; CUP participation was correlated with practice in small communities, the IHS, and a foreign country. CONCLUSIONS: Participation in the CUP program was associated with the specialty choice of family practice and with practice in settings associated with medically underserved populations. The CUP program has been successful in sustaining entering medical students' interests in underserved practice.

[Problems in diagnosis and therapy planning in a patient with retroperitoneal yolk sac tumor. Case report and review of the literature]. / Die Problematik des diagnostischen und therapeutischen Vorgehens bei einem Patienten mit retroperitonealem Keimzelltumor. Kasuistik und Literaturübersicht.

The case of a 26 years old patient with a primary paraaortic extragonadal yolk sac tumor is presented. After operative reduction of the tumor polychemotherapy with PEB was performed. Following chemotherapy testicular biopsy did not show histological changes typical for testicular intraepithelial neoplasia (TIN). Three years after the initial manifestation of the yolk sac tumor, a malignant tumor of the testis with components of undifferentiated teratoma and yolk sac tumor was observed. In this paper the problems of development of testicular malignancy after polychemotherapy and the validity of a small exploratory excision of testicular tissue in retroperitoneal germ cell tumors and following chemotherapy are discussed.

[Modified retroperitoneal lymphadenectomy in non-seminomatous stage I, IIa and IIb testicular tumors]. / Die modifizierte retroperitoneale Lymphadenektomie beim nichtseminomatösen Hodentumor im Stadium I, IIa und IIb.

In 60 patients with non-seminomatous testicular germ cell tumours in clinical stages I, IIa and IIb inguinal orchiectomy was performed as primary treatment, followed by modified retroperitoneal lymphadenectomy (RLA). In stage II disease chemotherapy was given in addition. After a follow-up period of at least 24 months only 5% of the patients showed progression of disease. Normal ejaculatory function was preserved in 88% of our patients. Modified RLA seems to be a safe procedure with an acceptably low rate of complications not only in stage I disease, but also in metastatic stages IIa and IIb.

Medical education for international health. The Arizona experience.

At the University of Arizona we have learned that a systematic approach to educating North Americans for international health roles makes sense. We have focused on an intensive problem-based orientation course for senior medical students and residents about to embark on a field experience. We have shared with and greatly benefited from the International Health Medical Education Consortium (IHMEC). The lessons learned at Arizona focus on the importance of long-term commitment and mentoring and on the direct relationship between health care careers internationally and among our own domestic underserved populations.

Significance of the evaluation of asymptomatic microscopic haematuria in young men.

OBJECTIVE: To evaluate the extent of diagnostic evaluation that is necessary in young men with asymptomatic microscopic haematuria. PATIENTS AND METHODS: A group of 157 men (mean age 24.8 years [range 18-53]) who presented with asymptomatic haematuria were investigated with repeated urine analysis. Addis count, urinary cultures, blood tests, ultrasonography, pyelography, cystourethroscopy and finally renal biopsy. RESULTS: The results showed pathological findings in 31.2% of patients. Of the 157 individuals, 33.1% did not complete the study. In 14.6% urological disease was found, including two patients with urothelial cancer. Renal biopsy detected glomerulopathy in 16.5% of all patients. IgA nephritis being the most common diagnosis (42% of all biopsies). CONCLUSION: Even in young patients, microscopic haematuria should be investigated and followed thoroughly. Renal biopsy seems to be optional: once a diagnosis is established repeated and unnecessary examinations can be avoided.

[Bilateral ureteroiliac fistula coincident with radiotherapy and ureteral splint]. / Bilaterale ureteroiliakale Fisteln in Zusammenhang mit Radiatio und ureteraler Splintung.

Fistulas between the iliac artery and the ureter are uncommon. Overall, fewer than 20 cases have been described in the literature. We report the first bilateral case, in which there was an association with indwelling bilateral ureteral stents and a history of radiation therapy following hysterectomy performed because of malignancy. The patient presented with massive gross haematuria.

Long-term results of therapy with intracavernousal injections and penile venous surgery in chronic erectile dysfunction.

A follow up study of 603 patients with chronic erectile failure was carried out concerning the long term effects of intracavernous injection therapy with papaverine/phentolamine (n = 172 evaluable) and venous surgery (n = 134 evaluable). Injection therapy was effective in 95.8% of injections. Side effects included prolonged erections in 0.15% of injections and fibrotic palpable indurations in 3.4%. Acceptance of therapy was high among patients and their partners and improvement of self image or partnership was reported in 77.8% and 79.5% respectively. Results of venous surgery were not satisfactory. Only 19.4% of patients achieved sufficient spontaneous erections and 35.1% needed adjuvant injections. Spongiosolysis yielded better results. Patients with neurological impairment, diabetes mellitus, postoperative onset of erectile dysfunction and age above 40 years showed poorer surgical results. Venous surgery should only be offered to a highly selected group of patients.

Arm circumference v. arm circumference/head circumference ratio in the assessment of malnutrition in rural Malawian children.

The arm circumference/head circumference ratio (AC/HC) was compared with arm circumference (AC) alone in the diagnosis of protein-energy malnutrition (PEM) in 685 Malawian children between the ages of 3 and 48 months. The AC/HC ratio correlates well, r = 0.6863 (P < 0.001), with weight-for-age (WA). The sensitivity and specificity were calculated for both indicators compared to the NCHS reference standard of WA. Compared to 80 per cent WA, the 0.310 AC/HC cut-off was 92 per cent sensitive and 41 per cent specific, while the 0.290 AC/HC cut-off was 75 per cent sensitive and 74 per cent specific. AC alone in the 6-12-month-old children was 75 per cent sensitive and 89 per cent specific at a cut-off of 12.5 cm. In the children from 12 to 48 months with a cut-off of 13.5 cm the AC was 82 per cent sensitive and 70 per cent specific. The AC alone was more sensitive than AC/HC at all levels of specificity. Adding the HC to AC offered no advantage in screening for PEM in these children. In fact, if one were to use the standard 0.310 cut-off for AC/HC, the resulting low (41 per cent) specificity would identify such a large proportion of false positives as to make this ratio impractical for field use where it is most needed--in primary health care programmes with low resources which serve populations with high prevalences of PEM.

Detecting malnutrition at age 6-12 months: international comparisons of arm circumference v. standard anthropometry.

Growth faltering, which may herald protein-energy malnutrition (PEM) usually begins between ages 6 and 12 months. However, arm circumference (AC or MUAC) has mainly been used to screen for PEM between 12 and 60 months of age, when AC is age-independent. This study of 378 infants aged 6-12 months in Pakistan, Nepal, Sierra Leone, and Papua New Guinea showed that a cut-off 12.5 cm AC selects infants < 80 per cent weight-for-age (WA) with 76 per cent sensitivity and 90 per cent specificity. Of the 378 infants studied 131 (35 per cent) had WA < 80 per cent and 126 (33 per cent) had AC < 12.5 cm. Weight-for-length agreed less well with AC. The inter-regional prevalence range of AC < 12.5 cm was 29-40 per cent, while the WA < 80 per cent range was 27-45 per cent. When AC is plotted against age, a flat 'plateau' (slope = 0.04) shows age-independence between 6 and 12 months in these 378; this contrasts to the 10 per cent AC increase in European reference populations. Because this AC plateau parallels the WA plateau seen between 6 and 12 months of age in most developing nations, AC < 12.5 cm may provide a simple and valid screening test for early PEM in this crucial age bracket. Conformatory studies elsewhere are indicated.

Family practice specialty preference before and after a required clerkship.

Medical students' specialty preferences before and after participation in a required third-year family practice (FP) clerkship were compared to National Resident Matching Program (NRMP) results. Of 714 students studied, 18 (2.5%) changed their specialty preference away from FP during the clerkship and 66 (9%) changed their preference to FP. Sixty-nine (70%) of students who maintained a preference for FP pre- and post-clerkship matched in FP. Seventy-two students changed their specialty preference to FP and 19 changed their preference from FP during the clerkship; 32% of each of these groups matched in FP. Those with both pre- and post-clerkship preferences for other specialties matched in FP at a rate of only 4% but constituted 18% of everyone entering the specialty.