Saphenous vein angioscopy: a valuable method to detect unsuspected venous disease

PURPOSE

The presence of preexisting saphenous vein lesions adversely affects graft patency. Despite careful preoperative venous duplex examination and meticulous intraoperative evaluation, clinically significant saphenous vein disease may remain undetected. We evaluated angioscopy as a means to better detect these vein lesions.

METHODS

Ninety saphenous vein remnants, obtained at bypass surgery, were perfusion fixed for subsequent angioscopic and histologic evaluation. The specimens were categorized by independent examiners on the basis of the angioscopic or light microscopic findings. Of the 90 vein remnants, 66 were normal by angioscopic criteria. Fifty-three (80%) of these angioscopically normal vein segments were normal histologically, and all 24 angioscopically abnormal saphenous vein remnants showed disease on microscopic examination.

RESULTS

Angioscopy correctly identified sclerotic vein segments (n = 20) by irregular white plaques, whereas postphlebitic veins (n = 3) demonstrated multiple lumens, fibrous strands, and thickened opaque valve cusps on angioscopic evaluation. Absence of an angioscopic lumen was confirmed histologically in occluded veins (n = 2). Angioscopy failed to identify thick-walled (n = 10) and varicose (n = 2) vein segments as abnormal; one sclerotic segment was normal angioscopically, thereby lowering the sensitivity of angioscopy.

CONCLUSIONS

Angioscopy detected unsuspected preexisting saphenous vein disease in five patients undergoing arterial reconstruction with saphenous vein. Because the use of angioscopy is a reliable means of prospectively assessing the vein for most preexisting lesions, its routine use may ultimately improve graft patency.

Separation of the rabbit ciliary body epithelial layers in viable form: identification of differences in bicarbonate transport

Sections of whole ciliary (CB) dissected from Dutch belted rabbits were incubated for 2 hr at 36 degrees C in a 30 microM Ca2+ Ringer's. This incubation resulted in the spontaneous dissociation of the two cell layers comprising this epithelium, each remaining firmly cohesive with its own basement membrane. The inner limiting membrane with its adherent non-pigmented epithelium (NPE) was then mechanically removed from the surface exposing the apical surface of the pigmented epithelium (PE). Ultrastructural examination revealed no noxious effects in most cells although gross morphological changes in the NPE cells were noted. The newly separated layers were loaded with the cell-permeable acetoxymethyl ester form of the fluorescent probe BCECF. Most cells of both layers acquired stable BCECF fluorescence indicating viability. To achieve a preliminary evaluation of differences in PE and NPE bicarbonate transport, dye-loaded tissues were perfused in a flow-through chamber which was mounted on a microscope equipped for quantitative epifluorescence. The intracellular pH (pHi) of groups of cells (5-10) was derived from the ratio of emission intensities generated by excitations at 490 and 440 nm. In Hepes-buffered Ringer's the pHis for the PE and NPE were 7.20 +/- 0.10 and 7.33 +/- 0.14 (+/- S.D., n = 6), respectively. Replacement of 28 mM Hepes by 28 mM HCO3-/5% CO2 led to a 0.13 pHi increase in the PE and a decrease of 0.27 U in the NPE. The pHi responses of the two cell layers to removal and/or reintroduction of Na+ and/or Cl- were also highly dissimilar.(ABSTRACT TRUNCATED AT 250 WORDS)

Fine needle aspiration of a renal cell carcinoma with eosinophilic globules. A case report

Fine needle aspiration (FNA) of a renal cell carcinoma with hyaline eosinophilic globules is presented. The cytology of the tumor cells was characterized by intracytoplasmic, dense, well-circumscribed globules that had a bright magenta appearance on Diff-Quik staining. Tissue sections demonstrated the globules to be located predominantly within the cytoplasm of the clear cells of the carcinoma. Immunohistochemical and ultrastructural evaluation is discussed, as is the significance of this finding.

Co-localization of von Willebrand factor and type VI collagen in human vascular subendothelium

The binding of von Willebrand factor (vWF) to subendothelium constitutes an important initial step in the process of platelet adhesion to exposed subendothelium following blood vessel injury. We previously demonstrated that vWF is present in human vascular subendothelium and recently found that a 150 kd vWF-binding protein, which we extracted from subendothelium, is type VI collagen. Although we have established that vWF and type VI collagen bind in vitro, it is not known whether these two proteins are associated in the vascular subendothelium in situ. We, therefore, 1) investigated the morphological effects of our biochemical extraction procedure on human umbilical veins by scanning and transmission electron microscopy, 2) analyzed the subendothelial extract by immunofluorescence for the presence of vWF and collagens and by electron microscopy for morphological characteristics, and 3) localized vWF and type VI collagen in subendothelium by immunofluorescence and by single- and double-label immunoelectron microscopic studies with protein A-conjugated gold particles. We found that the surface exposed following de-endothelialization is composed of microfibrils and contains very little fibrillar collagen. The subendothelium is stripped after sodium dodecyl sulfate-urea extraction, and the extract itself contains immunoreactive vWF and type VI collagen but no immunoreactive type I or III fibrillar collagens. Immunofluorescence and immunoelectron microscopic studies showed that vWF and type VI collagen are both present in subendothelium, where both co-localized to microfibrils. In conclusion, vWF that binds to type VI collagen in vitro, also co-localizes with type VI collagen in subendothelium, where both are associated with microfibrils. Type VI collagen, therefore appears to serve as a biologically significant binding site for vWF in vivo and may thereby play a role in mediating platelet adhesion to exposed subendothelium following vascular injury.

A comparison of rural family practice in the 1930s and today

Two hundred forty-four consecutive diagnoses and procedures appearing on the patient billing records between June 1934 and September 1935 of a general physician practicing in rural southwestern Minnesota were compared with 286 diagnoses and procedures taken from the billing records of patient visits made over a 2-week period to a modern family physician practicing in a comparable rural community in southwestern Ohio. The most common items on the billing records of the physician of the 1930s were follow-up incision and drainage of abscess, 26 (10.7%); diphtheria immunization, 24 (9.8%); follow-up drainage for mastoiditis, 17 (7.0%); and scrotal tap for epididymitis, 14 (5.7%). Many of these patient encounters were at the patient's home. The most common items on the records of the modern physician practicing in rural southwestern Ohio were upper respiratory tract infection, 13 (4.5%); hypertension, 12 (4.2%); hyperlipidemia, 11 (3.9%); and history-taking and physical examination (adult), 10 (3.5%). This study suggests that there are great differences between the diagnostic profiles of the first third of the 20th century and modern family physicians. Many of the common diagnoses seen by the physician of the 1930s required a procedure to be performed. Many of the problems treated by the contemporary family physician did not even exist for the early 20th century general physician. Some of the differences between the modern physician and his predecessor can be explained by the introduction of antibiotics in the late 1930s and early 1940s.

Analysis of balloon dilatation of human vein graft stenoses

Controversy continues as to whether percutaneous transluminal angioplasty (PTA) or surgical revision is the ideal modality for the treatment of failing grafts. This prompted a histopathologic analysis of failing human vein graft segments subjected to ex vivo balloon dilatation to define variables responsible for the discrepant results. Fifteen vein graft lesions from 14 patients with failing infrainguinal bypasses were recovered after surgical excision. Each graft lesion was focal and uniform in length (2.1 +/- 0.3 cm). Rings sectioned from adjacent regions of each vein graft lesion before and after balloon inflation were processed for histologic study, photomicrography, and image analysis. Angioplasty balloon size was selected on the basis of preoperative arteriograms. Graft lesions were divided into three groups based on lesion thickness and the degree of fibrosis and cellularity seen on sections stained with Masson's trichrome. The luminal area before angioplasty was not significantly different for the three groups (p > 0.2). Vein grafts with thick intimas (group 1) had significantly less luminal dilatation after angioplasty as compared with less thick intimal lesions (groups 2 and 3; p < 0.001). Those lesions with varying degrees of cellularity (groups 2 and 3) showed no significant differences in luminal diameter after angioplasty. However, the cellular lesions in group 2 consistently formed multiple intimal flaps that could produce PTA failures even with good luminal restoration. The varying histology of vein graft lesions and associated differences in intimal thickness and cellularity may be responsible for the inconsistent results following PTA. Estimates of wall thickness before angioplasty, particularly in the intimal area, may be helpful in evaluating which lesions might benefit most from PTA.

Lesions and preferential initial localization of [S-methyl-3H]bleomycin A2 on Saccharomyces cerevisiae cell walls and membranes

Extensive lesions were produced in cell walls of Saccharomyces cerevisiae by the bleomycin family of anticancer antibiotics (30 min to 4 h). Electron micrographs revealed that the alterations were most frequently large breaks and small interruptions or holes in cell walls, which sometimes extended into cell membranes. Large portions of cell walls were sometimes lost. Cell walls were frequently ruptured in one or more positions. More than 75% of bud scar regions in single-plane sections and all bud scars in serial sections exhibited many interruptions and breaks after 3 or 4 h of treatment. The discovery of extensive damage to cell walls was consistent with the preferential (approximately 70%) association of radiolabeled bleomycin with cell walls and perimeters of bud scar regions after short exposures (30 min). After longer exposures, the distribution of silver grains changed from a predominant association with cell walls (30 min) to an increased association with the cell cytoplasm (1 to 4 h). This correlated with increased ultrastructural damage, since damage to cell walls was generally more frequent and more severe with increasing length of treatment (30 min to 4 h) or dose (25 to 100 micrograms/ml). Although DNA lesions are believed to be the lethal properties of bleomycins, the lesions produced in cell walls are also lethal properties of the antibiotics. The distributions of lesions on cell walls suggested a generalized interaction of the antibiotic with a cell wall component. These results led us to hypothesize a mechanism of effective antifungal action for the bleomycin family of antibiotics.

Paneth cell-like metaplasia of the prostate gland

We report two cases of Paneth cell-like metaplasia of the prostate gland, one in poorly differentiated carcinoma and the second in benign hyperplasia. By light microscopy, the Paneth-like cells were indistinguishable from Paneth cells found in the normal small intestine and ultrastructurally showed electron-dense granules typical of Paneth cells. Immunohistochemical stains were positive for prostate-specific antigen and prostatic acid phosphatase and negative for lysozyme and alpha 1-antitrypsin. The clinical significance of Paneth cell-like metaplasia is unknown and may represent an example of the multipotential metaplastic capability of actively dividing cells.

Unsuspected preexisting saphenous vein disease: an unrecognized cause of vein bypass failure

Our prior anecdotal experience with unsuspected preexisting saphenous vein disease prompted us to study its incidence, its relation to graft failure, and to identify techniques for its detection. Thick-walled, postphlebitic sclerotic occluded, postphlebitic sclerotic recanalized, calcified, and varicose vein lesions were detected in 63 (12%) of 513 infrainguinal vein bypasses. In 13 (2% to 5%) cases, severe saphenous vein disease precluded use of the vein. In the remaining 50 cases, the entire vein or a portion thereof, with minimal or unsuspected disease, was used for bypass. Early graft failures occurred in 10 (20%) of the 50 cases. The cumulative primary patency rate at 30 months for bypasses performed with diseased veins was 32%. This was significantly less than the 73% cumulative primary patency rate for bypasses with veins without detectable disease (p less than or equal to 0.001). Retrospective evaluation of preoperative duplex ultrasonography (n = 21) originally used to evaluate saphenous vein length and diameter correctly identified thick-walled, occluded, calcified, and varicose veins in 62% of cases. Intraoperative methods of vein evaluation included inspection, palpation, irrigation, catheter or valvulotome insertion to identify obstruction, and intraoperative arteriography. Histologic examination of diseased veins demonstrated a spectrum of disease with thickening of the intima and media, vein wall calcification, and luminal recanalization. We conclude that (1) unsuspected preexisting saphenous vein disease occurs in approximately 12% of cases and results in both early and late graft failures; (2) detection, in some cases, is possible with duplex ultrasonography and intraoperative techniques; and (3) diseased veins that are recanalized, calcified, or thick-walled should not be used if an alternative vein is available.

Sudden death of an elderly man with multiple malignant neoplasms

With the lengthening of the human life span, cancer has become an increasingly important medical problem for the aged. It is not uncommon to find multiple primary neoplasms in elderly individuals. We recently investigated the death of an elderly man who had died suddenly and had three incidental malignant neoplasms, including a pleural mesothelioma, first diagnosed at autopsy. The importance of performing a complete medicolegal autopsy for epidemiological and statistical purposes is emphasized.

Malakoplakia of the female genital tract causing urethral and ureteral obstruction. A case report

Malakoplakia is an uncommon form of inflammatory response, initially described as occurring in the urinary bladder. Malakoplakia of the female genital tract is exceedingly rare. One such case was unusual in that it caused ureteral as well as urethral obstruction.

Usefulness of the nude mouse model in mesothelioma based on a direct patient-xenograft comparison

A patient with malignant mesothelioma experienced tumor recurrence 3 months after pleuropneumonectomy. Samples of the tumor were transplanted into nude mice to assess chemosensitivity. There was close concordance between the results in xenografts and the clinical outcome in this patient. Both mitomycin and to a lesser extent cisplatin were effective as single agents against the nude mouse xenografts, and the combination of these two drugs produced a complete response both in the patient and in the xenografts. The patient survived 18 months from onset of chemotherapy and 24 months from diagnosis. The duration of clinical complete response to chemotherapy was 14 months, despite the fact that mitomycin, the most effective agent against the xenografts, was discontinued after only two cycles because the patient developed pulmonary toxicity. This direct patient-xenograft correlation further validates the usefulness of the nude mouse model in the search for effective therapies for malignant mesothelioma, a tumor characterized by frequent refractoriness to most available agents.

Assessing the elements of biopsychosocial functioning

New findings are reported on the validity and reliability of an equation designed to predict the functional level of psychiatric patients. The equation employs measures of aggravating stress, biomedical impairment, coping skills, directive power, and environmental supports to predict level of functioning. A study of 95 subjects (38 patients and 57 nonpatients) found that the equation was able to discriminate significantly between psychiatric patients and persons with no history of psychiatric treatment and between the condition of long-term patients at different stages in treatment. The authors review findings from other studies that show the usefulness of the functional level equation in comparing patient groups, predicting prognosis and amount of treatment needed, improving functioning, and preventing disorder.

Predicting prognosis by means of the DSM-III multiaxial diagnoses

This clinically based retrospective study compares the DSM-III multiaxial characteristics of psychiatric inpatient and outpatient treatment-seekers with those of workmen's compensation and disability payment-seekers. It shows that 1. the groups were significantly different in their DSM-III multiaxial characteristics; 2. multiaxial diagnoses statistically predicted clinical psychiatrists' estimations of disability applicants prognosis for work; and 3. payment-seekers were more likely than treatment-seekers to have Axis II personality disorders in addition to their Axis I diagnoses.

An unusual organoid tumor. Alveolar soft part sarcoma or paraganglioma?

The histogenesis of alveolar soft part sarcoma (ASPS) is a subject of continued debate. Although many recent reports suggest a muscle origin, others advocate a neuroendocrine derivation. A tumor in the chest wall of a 16-year-old woman was diagnosed and treated as ASPS. The light microscopic, electron microscopic, and immunohistochemical findings showed features of both ASPS and paraganglioma. In addition, this lesion was positive for antibody to glucagon, a characteristic of neither ASPS nor paraganglioma, although seen in a few gangliocytic paragangliomas. This case demonstrates the need for continued inquiry into the histogenesis of ASPS.

Carcinoma of the colon in asbestos-exposed workers: analysis of asbestos content in colon tissue

Epidemiological studies have indicated an increased incidence of carcinoma of the colon in asbestos workers. The present study evaluated the colon tissue asbestos burden, by light and electron microscopic analytic techniques, in patients with a history of occupational asbestos exposure and colon cancer. Asbestos fibers and/or asbestos bodies were present in colon tissue from 14 of 44 (31.8%) asbestos workers with colon carcinoma (range 142,199 to 15,231, 543 fibers/g/wet weight, mean 2,517,823). Chrysotile was identified in 9 patients and amosite in 3 patients. Both amosite and chrysotile were found in the colonic wall in one individual. Other forms of asbestos (e.g., crocidolite, tremolite, or anthophyllite) were not found. Asbestos fibers and asbestos bodies were not found in colon tissue from 20 control patients (colon carcinoma and no asbestos exposure). Asbestos fibers frequently enter and reside in the wall of the colon and are often intimately associated with tumor tissue at the site of colon carcinoma in workers with asbestos exposure and colon carcinoma.

Chemically sensitized erythrocytes for hemagglutination reactions

The use of chemically modified indicator erythrocytes for hemagglutination reactions can result in increased sensitivity. Treatment of erythrocytes with polyvinylpyrrolidone (PVP) or dextran T40 (10% weight/volume) induces changes in the cell surface in the form of extensions and blebbing, thereby increasing the surface area. These sensitized cells can be used in forensic science when detection or quantitation of erythrocyte surface reacting antibodies is important. The effect of altering membrane lipid fluidity on erythrocyte surface antigens has also been investigated. Treatment of cells with a reagent that increases the membrane ratio of cholesterol to phospholipid results in enhanced hemagglutination capacity despite the lack of extensive spiculation.