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Thrombi and thrombus formation in nonbacterial thrombotic endocarditis (NBTE) were studied using light microscopy and immunohistology. Samples from vegetations on cardiac valves were taken at autopsy from five patients with NBTE and adenocarcinoma as an underlying disease. Morphological studies disclosed proliferative changes underneath the thrombi. In immunofluorescence microscopy, focal deposits of immunoglobulins and complement components Clq and C3 were found. The results suggest that immune complexes, elicited by the underlying malignant process, may play important role in the pathogenesis of the thrombus formation in NBTE.

During a 10-year period, intraparenchymal aneurysms were found in 38 of 748 patients at selective abdominal angiography with magnification technique. According to strict criteria, 17 patients were classified as suffering from necrotizing vasculitis of the polyarteritis nodosa group (PAN), 7 from severe arterial hypertension, and 3 from rheumatoid arthritis. The diagnoses of 5 patients remained to be confirmed, and each of the remaining 6 patients suffered from various other diseases. PAN was diagnosed histopathologically in 2 patients without angiographic aneurysms. Based on the 156 patients in whom the indication for angiography was suspicion of arteritis, the angiographic diagnosis of PAN had a sensitivity of 89 percent and a specificity of 90 percent, a positive predictive value of 55 percent and a negative predictive value of 98 percent. The mean number of both renal and hepatic aneurysms was higher in patients with PAN than in the other patients (p < 0.01 and p < 0.05, respectively). Five PAN patients had numerous and large aneurysms, whereas the aneurysms of the other 12 PAN patients did not differ from those of patients with other diseases. Patients with PAN had renal infarcts more often than the other patients (p < 0.05). Our findings suggest that visceral angiography is useful in establishing the diagnosis of PAN, but the angiographic finding of aneurysms is not pathognomonic.

An automatic sampling device has been developed for capillary zone electrophoresis. The sample is introduced to the column electrokinetically by rapidly exchanging buffer for sample in a narrow channel drilled in a plexiglass block. The autosampler is capable, under computer control, of performing multiple sample injections from a large volume sample source (such as a reaction vessel) as the sample concentration changes, and thus presents the possibility of analyzing time-varying processes by CZE. Peak area reproducibility in electropherograms obtained after use of the sampler is less than 1% and efficiency is more than 2.2 × 105 theoretical plates.

Two patients recently underwent successful repeat left ventricular anterior aneurysmectomies at our institution. Both patients had undergone a linear repair at first operation. Over time severe heart failure relapsed and echocardiography revealed the recurrence of a voluminous antero-septo-apical aneurysm in both cases, associated with severe mitral regurgitation. Because of still preserved motion of at least three of the basal segments of the left ventricle, a repeat ventriculoplasty according to Dor and a restrictive mitral valve annuloplasty was attempted. At 6-month follow-up, the patients were in the New York Heart Association functional class I and II, respectively. Left ventricular end-diastolic diameters decreased from 73 mm to 67 mm and from 81 mm to 52 mm, and left ventricular end-systolic diameters from 61 mm to 54 mm and from 70 mm to 34 mm. Mitral regurgitation was absent.

Irrigation suction drainage (ISD) is an additional method in treatment of infected bones. Two liters of saline solution daily with an antibiotic is usually recommended for ISD, although some authors suggest that more fluid should be used without antibiotics, stressing the importance of the mechanical effect. Although the method is nowadays accepted as a routine procedure, the reported results of ISD are based on treatment of a limited number of patients and the only criteria for assessment have been clinical and bacteriologic findings. The aim of this prospective study is to show the importance of the mechanical effect of an increased fluid run and the optimal time necessary for cleaning of the osteomyelitic cavity by follow-up the C-reactive protein (CRP) levels as an indicator of an acute inflammation of the affected bone.The prospective study was an open, centralized and randomized clinical investigation including over 105 patients with bone infection treated in the period 1986-1996. Two parameters with possible influence on the CRP levels were determined during investigation: 1. patients were divided in three groups depending on the duration of the irrigation suction drainage (3-6 days, 7-10 days and over 10 days) and 2. quantity of the liquid used for the irrigation suction drainage (two groups: 2000 ml per day and 6000 ml per day). Groups were similar in regard to age, sex, bacteriologic agents, duration of infection, localization and previous operations. C-reactive protein (CRP) is a nonspecific, but extremely sensitive indicator of an acute inflammatory disease. The erythrocyte sedimentation rate is not always a reliable indicator of infection. CRP as a protein of an acute phase appears and disappears quickly. Decreased values are a sign of a healing process used in this study for the estimation of the efficacy of the ISD. The CRP level was controlled semiquantitatively before operation and every third day over three weeks. If the values were below 6 mg/l, the results were classified as negative.There were not significant statistical differences in different groups as far as a preoperative average CRP values were concerned neither in the quantity of employed liquid nor in the duration of the ISD and interaction between these two groups. It was the same on the third postoperative day. The differences appear in the significantly lower average values of the CRP in patients of the second group (6000 ml/day) where the ISD lasted for seven or more days. During further follow up, (6th to 21st day) one can observe a significant statistical difference in average CRP values between the first (2000 ml/day) and second group (6000 ml/day) but there is not difference when the duration and sort of employed liquid is concerned. There is not significant difference in average statistical values of the CRP in blood for interaction of fluid quantity and time of ISD as well.The main disadvantage in the function of ISD is nonuniform rinsing of the osteomyelitic cavity. Prolonged ISD has no influence on the clinical result as well as on the average values of the CRP. Starting from the third postoperative day results indicate that the quantity of employed liquid has an important influence on the average level of the CRP, while the duration of ISD is not important. Prolonged ISD can not compensate for an inappropriate surgical intervention because it is only an additional method in the treatment of an osteomyelitic process.By observing changes in CRP levels during treatment one can conclude that the efficacy of ISD is based mostly on mechanical rinsing and the removal of debris. This points to the importance of the quantity of fluid employed in irrigation suction drainage. Application of 6000 ml liquid per day without antibiotics during 5-7 days gives opportunity of better rinsing increasing the effect of ISD and reducing the incidence of complications.

Trauma is a surgical disease and a leading cause of death in the population in the age of forties. The Institute for Surgery in Novi Sad (trauma center of the first rank) takes care of all injured people brought to the Institute either directly from the place of accident or from other centers.Retrospective analysis of the injured people treated at the Institute for Surgery in the period 1987-1996.Multivariate analysis of the traumas from the register of the Institute for Surgery according to the trauma system elements: number of injured individuals, sex and age structure, categorization of injuries, etiology of injuries, distribution of serious injuries by regions, results obtained from the treatment of serious injuries.They show a global representation of all elements involved with injured people: due to moderately serious, serious and critically serious injuries 21.6% of patients were hospitalized; in the age of 29-30 years men with traumas caused on work or in traffic were predominant, while women with injuries caused by falling were predominant in the age of 60-69 years; drastically increased injuries caused by fire-arms in the period 1991-1993 were directly caused by the state of war and these injuries are still numerous; in case of hospitalized patients isolated trauma (80%) was predominant, multiple trauma was under 20% and polytrauma was registered in 5% of patients; after surgical treatment of injuries approximately 17% of patients were indicated for postoperative prolonged treatment and in intensive care unit at the Institute for Surgery; the average mortality of hospitalized patients was 5-7% but with extremely high mortality rate (70%) in the group of patients with polytraumas.

The function of irrigation suction drainage, as an additional method in the treatment of bone infection, is associated with hydrodynamic problems that can only be experimentally examined. The visualization of liquid movement in the experimental model was realized by adding a colored ink to the input drain of the drainage system. When only 2000 ml of liquid was used daily (80 drops/min), the ink penetrated the experimental cavity only through the most proximal holes in the input drain. It spread slowly and irregularly through the liquid in the experimental bottle, forming pocket deposits and leaving sediment. When 6000 ml of liquid was applied daily (240 drops/min), ink quickly penetrated the cavity through all holes in the drain, leading to turbulence and dispersing equally in the bottle. Decoloration of the model bottle was faster because the output drainage was more efficient. With an increased flow, i.e., with more liquid used in the drainage, a better result was achieved. This was manifested in a swift decoloration and rinsing of the cavity.

This is a case report on a patient with a multiple femur's fracture where a transfixed intramedullar nailing of Grosse-Kempf type has been done. "The nail dynamization" was not carried out before the beginning of vertical loading. Seven months after the full vertical loading had begun, at a sudden torsian movement of the extremity, the nail had broken. Analyzing the cause of the fixative material fracture, a conclusion has been made that, apart from the presence of adequate trauma, the nail fracture happened also due to the development of pseudoarthrosis of femur and the unfulfilled "nail dynamization".

The homogeneous material found in the skin is commonly identified as amyloid. We describe a previously unknown disease that is caused by proteinaceous deposits and that does not fulfill the criteria of the earlier recognized amyloid diseases.The unusual deposits, which were initially found in the dermis, were ultrastructurally composed of fibrillar material with a tubular substructure. Immunohistologically, the material was tested using a large panel of antibodies, and the results revealed that it was unlike any commonly known proteinaceous material. The deposits later spread to other organs and disturbed the vital functions of the body.We describe a unique syndrome characterized by fibrillar extracellular deposits that was recognized and differentiated from other similar clinical syndromes by ultrastructural examination. Further biochemical analysis is necessary to identify the origin of the material.

An experimental study on transplantation validity of patella's ligament, when transplanting front crossed ligament, was performed on 106 knees in 53 grown-up dogs. The investigation had three stages. Three months after the transplantation of the front crossed ligament with the medial third part of the patella's ligament animals were sacrificed and in one group the static resistance and the resistance to elongation, by using special tweezers (Alfred Amsler Co., Schafhausen, Switzerland), was investigated. The results showed that the patella's ligament is very suitable for transplantation because its resistance and strength were almost identical with the same parameters of intact front crossed ligament. Revascularization of the new ligament using Spaltenholz's technique was done in the second group, and three months after the operation, complete revascularization of transplants took place. The synovial membrane which covers the new ligament represents the main source of fresh blood vessels on one side, while similar process takes place along the bone tunnels where the new ligament was fixed. The new ligament histologic analysis carried out in the third group of experimental animals showed that after three months the transplant acquires the structure which is very similar to the front crossed ligament. The obtained results of the investigation show that the patella's ligament is a very good biologic material for transplantation of the crossed ligament.

A comparative study of the anatomy of the antebrachiocarpal (AC) articulation was carried out in 30 adult dogs with 60 joints. Although a considerable degree of similarity was found between the AC joint in dogs and the corresponding wrist joint in humans, a number of differences between these two homologous joints were also noted. The distal end of the ulna in dogs directly articulates with the ulnar carpal and accessory carpal bones forming a specialized antebrachiocarpal arrangement more adapted to running. The accessory carpal bone in dogs is a massive, long bone and is strikingly different from its homologue in humans, the pisiform bone. The joint between the accessory and ulnar carpal bones, which corresponds to the piso-triquetral joint in humans, is always connected with the AC joint, whereas in humans this communication could be found occasionally. The large radial carpal bone in dogs, characteristic for carnivores, corresponds to the fused scaphoid and lunate bones in humans, in whom this type of fusion is very rarely found. The palmar ulnocarpal and radiocarpal ligaments in dogs are distinctly intra-articular, whereas in humans these ligaments are intracapsular. One of the controversies of the AC joint in dogs is a structure located between the distal-most parts of the radius and ulna forming a strong bond between these two bones and a part of the antebrachial articular surface. It is cartilage-like and is composed of typical fibrocartilaginous tissue.(ABSTRACT TRUNCATED AT 250 WORDS)

A radiogrametric assessment of the patellar height performed by three measurement methods, in the lateral views of radiograms of 136 patients with chondromalacia of the patella was aimed at the establishment of certain parameter values in the studied population and the assessment of the influence the altered patellofemoral ratio has upon the onset of the disease. The results of the study verified the remarkable advantages of the method by Insall and Salvati for the measurement of the patellar height and showed a significant involvement of patellofemoral incongruity in the development of chondromalacia, since in 15-16% of the cases the patella was not properly placed.

The results of total knee replacement in 30 patients have been analyzed. Total knees were implanted during 1990, and the shortest follow-up time after the operations amounted to 6 months. All 30 total condylar prosthesis were of Insall-Burstein posterior stabilized design. The average age of the operated patients was 61 years. Osteoarthritis caused serious knee damage in 21 patients and was the indication for the operation; in 7 patients it was rheumatoid arthritis; in 1 patient synovitis villonodularis; and severe posttraumatic osteoarthrosis in 1 patient. In 18 patients axial knee deformity was noted prior to operation in the sense of valgus or varus. The continuous passive motion machine was used in the postoperative treatment of all patients. Clinically acceptable results were obtained in 90%. Wound healing complications were noted in 2 patients. Full axial deformity correction was achieved in all the patients with a full extension and flexion of over 90 degrees in the operated knees. Preliminary results after the implantation of this type of prosthesis are very encouraging and justify it's further routine use.

A 4-year-old Labrador Retriever was examined because of progressive left hind limb lameness involving the stifle. A villous synovial mass was evacuated by synovectomy. Initially, the macroscopic and histopathologic features suggested a malignant fibrosarcomatous process; however, further histologic studies revealed lesions consistent with pigmented villonodular synovitis. Nine months later, the dog developed a large retroperitoneal tumor, with metastasis to the lungs and liver. The dog was then euthanatized. By histologic and electron microscopic examinations, the tumor was found to be a primitive plasmacytoid lymphoma.

Lesions of the anterior cruciate ligament of the knee are very frequent misfortune and the results of their suture being insufficient yet, made us to explore the possibility to replace the damaged ligament with the fascia lata as an autologous transplant. Surgical operation was performed on dogs. Instead of the anterior cruciate ligament removed, we used a piece of a rolled fascia lata. Six months after transplantation being performed, samples of the fascia lata were extracted for histological analysis to assess their structure and to evaluate the transplant as a neoligament, on the basis of its similarity with the normal structure of the ligament. After degeneration of a part of transplant because of the insufficient supply of nutrients, the invasion of the synovial blood vessels into the fascia lata was established and the young granulation tissue formed on the account of the nondifferentiated adventitial cells. In the mosaic of the transplant structure there were present parts of a more mature, dense connective tissue with longitudinal orientation of the cells, the fibers and the vascular elements, which partially made structure similar to that in ligaments. In the attachment region fibrocartilage was noticed, gradually passing into the hyaline one, to merge with the hyaline cartilage of the joint surface. After the histological analysis follows the conclusion that fascia lata functionally could replace the anterior cruciate ligament if a role was supplied with sufficient collagenic fibers on the cross-section. Time is of a high importance, too.(ABSTRACT TRUNCATED AT 250 WORDS)

A preliminary investigation of the allogenic transplantation of the meniscus without the vascular bundle was carried out in 4 adult dogs with 8 knees. In one operation session on 2 dogs at 2 operative tables and with two operative teams an identical surgical procedure in general anaesthesia was done. A medial parapatellar incision of the knee was used, the medial capsule and the collateral ligament near its proximal insertion were severed. Explanted medial menisci were exchanged and the meniscus from the other dog was put in position of the explanted one and fixed with 3 tangentially placed sutures (posterior, medial and anterior) which were taken out through the capsule and teid extra-articularly; there was no immobilisation, and after 3 weeks the identical operation was done on the other knee. The animals were sacrificed 4-5 months after the operation, the knees were dissected and observed. In all 8 knees transplanted menisci were completely healed around their periphery, however their appearance was rather changed. They were narrower, thinner, and of different colour and consistency. The transplanted menisci were removed and conserved in 10% (formalin) for the further investigation. It is concluded that the allogenic meniscal transplantation without the vascular bundle is possible and that the further investigation of this problem is justified.

Revascularization of the forearm was performed on six mature dogs of a different race. Arteria mediana was cut 2 cm above the fork of the arteria radialis and later sutured with a nonresorptive monofilament thread/Ethilonr/7-0 and 8-0 in diameter. The same process was repeated on the cefalica vein. Arteriographies were performed on the operated extremities, pre-operatively, immediately after operation and while an animal being sacrificed. The subjects were sacrificed six months after the operation. Then microscopic and histological analyses were carried out to assess the quality of the blood vessels at the suturing place. At the place of the blood vessels reconstruction, lumen did not get narrower which indicated that all the vessels were in a perfect functional condition. In a number of dogs a higher collagenic proliferation was noticed, in the vicinity of the blood vessels sutured. In the regenerative process of the arterial wall tunica mediana almost took a predominant position, like in the intact arteria. All the three strata were present with no relevant deviations in structure. In the cefalica vein the regeneration of the connective tissue support of the smooth muscles cells was insufficient. Based on the analysis of the results obtained it might be concluded that after revascularization of the forearm of the dog the regeneration of the blood vessels made the segment functionally capable with the structure not different from the normal one which existed in the blood vessels of the same part of the body.

An investigation of the size and suitability for the transplantation procedures of the knee blood vessels was made in 20 adult dogs with 40 extremities using the technique of injection of the arterial network through the femoral artery with the mixture of the methacrylic resin (SIGMAL R "Galenika", Belgrade) and the red ink. When the polymerisation of injected methacrylic resin was completed the specimens were exposed to either chemical or biological maceration of the tissues. Thirty-five specimens were chemically macerated using either 30% solution of hydrochloride acid or 40% potassium hydroxide. With this method bones were also destroyed and only the methacrylic vascular cast remained unaffected. Five specimens were exposed to the biological maceration using the insects (Dermestes vulpinus). This method proved to be better as the bones elements were not destroyed which allowed more precise study of vessel relations and topography. Calibre of the arteries was measured using the micromethod MEBA (Zagreb) with the accuracy of 0.01 mm. The main arterial vessels of the knee joint on the medial side are aa. saphena, genus descendes (branches of the femoral artery, then a. genus descendens (branches of the femoral artery, then a. genus medialis (branch of the popliteal artery), and on the lateral side are a. caudalis femoris distalis, (branch of the femoral artery), a genus lateralis (branch of the popliteal artery) and recurrent branches of the a. tibialis cranialis. Calibre of the femoral and popliteal arteries was over 2 mm which means that they are suitable for macrosurgical sutures, while the calibre of all other arteries was under 2 mm, and it is concluded that they are suitable only for microsurgical sutures.

The experiment was carried out on the four extremities of six, sexually mature dogs of a different race. Gradual reconstruction of the anatomic structures was performed as a single act after the section of the elements. To reach stability of the forearm we employed different osteosynthetic techniques and succeeded to reconstruct blood vessels, nerves, ligaments and the skin, afterwards. Numerous techniques of suturing material were used. The animals were sacrificed six months after being operated and were exposed to microscopic observation and histological analysis. The results obtained suggested the necessity of a firm osteosynthesis of the forearm bones, use of less traumatic suturing material for suturing both blood vessels and fasciculi when preparating nerves.

A histological analysis of the structure of intact knee joint menisci was carried out in adult dogs. By means of specific histochemical methods for the connective tissue and cartilage, it was found that the meniscus as a whole does not have a unique structure. The anterior and posterior horns are populated by round chondroid cells encircled by abundant interstitial substance’and branched wavy connective fibers; blood vessels are present. The outer third of the meniscus is constituted of cross bundles of connective fibers, fibrocytes and spindle-like areas of loose connective tissue with blood vessels. The inner avascular two thirds of the meniscus are filled with parallel circumferentially oriented fascicles of connective fibers, ovally elongated chondroid cells, and a small quantity of chondroid interstitial substance. In some menisci, in the inner two thirds of the body, there are isles of typical cartilage, which show metachromasia of the beta type and rarely of the gamma type. The occurrence and way of the manifestation of cartilage are of an individual character. The structural duality of the knee meniscus is accounted for by its functional duality manifested in offering resistance to the forces of traction and pressure, the latter ones favoring the process of evolution of tissue from connective, through chondroid, to cartilaginous.

Measurements of turbulent, confined, swirling flows have been obtained by means of a two-color laser Doppler velocimeter in a research combustor and compared with other experimental data and numerical results obtained by means of two two-equation models of turbulence. The combustor consists of two confined, con- centric, swirling jets whose mass flow rates and swirl numbers can be controlled independently, and which can be used to study cold flow, premixed and non-premixed reactive flows, and two-phase flows. Results are reported for cold flow conditions under co- and counterswirl. It is shown that under both conditions a closed recirculation zone is created at the combustor centerline. This zone is characterized by the presence of a one-celled toroidal vortex, low tangential velocities, high turbulent intensities, and large dissipation rates of turbulence kinetic energy. The experimental data agree satisfactorily with the numerical results, but do not agree with other ex- perimental data under coswirl flow conditions. The reasons for the discrepancies are discussed. N important application of swirling flows lies in its use to provide flame stabilization and improved mixing in many combustion chambers.1 In order to achieve enhanced flame stabilization and better control of the mixing process, multiple coaxial swirling streams can be introduced in swirl combustors. Yetter and Gouldin2 carried out a series of experiments on a model combustor which uses two coaxial swirling jets. They found that the fluid mechanical aspects play an important role in determining the operation of the combustor; combustion under coswirl conditions (jets rotating in the same direction) was found to be significantly different from combustion under counterswirl conditions. Vu and Gouldin3 performed experiments in a model combustor composed of two confined coaxial swirling jets under nonreacting conditions. They found that a recirculation zone occurs only with counterswirl near the exit of the inner jet. The recirculation zone was in the form of a one-celled toroidal vortex having very low swirl velocities. Habib and Whitelaw4 performed similar experiments in confined coaxial jets although under weak swirl conditions, i.e., no recir- culation zone at the combustor centerline appeared in their experimental work. Gouldin et al. 5 performed experiments similar to those reported here and in Ref. 3 by means of a laser Doppler velocimeter (LDV) and found that a recir- culation zone is created at the combustor centerline only under counterswirl flow conditions. The results of Gouldin et al.5 and Vu and Gouldin3 indicate that, in the geometrical arrangement employed by these investigators, coswirl does not result in a recirculation zone under incompressible flow conditions. The results presented in this paper show that a recirculation does exist under both co- and counterswirl flow conditions. Experimental work on turbulent, confined, swirling flows has also been performed by Rhode,6 Rhode et al.,7 Gupta et al.,8 and Yoon and Lilley.9 Rhode6 and Rhode et al.7 studied swirling flows in a combustor provided with a sudden ex- pansion by means of a visualization technique in which neutrally buoyant helium filled soap bubbles were employed. The results of the visualization technique were compared with a two-equation model of turbulence and showed that the model predicts the gross features of the flowfield. Gupta et

Idiopathic retroperitoneal fibrosis (IRF) is a rare disease of unknown etiol ogy. The disease is related to some therapeutic agents. Previously only in two cases methylopa has been associated with IRF. 4,5 The reported patient, a 56- year-old woman had suffered from arterial hypertension for 20 years and the only medication used was methyldopa for two years. A low back pain and a feeling of heaviness in her lower abdomen resulted in clinical examinations and an abdominal aortic aneurysm with moderate hydronephrosis on the right-hand side was found. IRF was revealed at operation. A ureterolysis and an aorto-iliac reconstruction were made using prosthesis. Postoperative recovery was un eventful. An inflammatory reaction in the outer part of the media and in the adventi tia of the aortic wall was found. The inflammatory cells were mostly lympho cytes and plasmacells but also some areas with heavy eosinophilic infiltrates were present. Vasculitis was seen in small vessels. Eleven cases of IRF associated with arteries from the previous literature are described.

The separation of prostaglandins (PG) PGE1, PGE2, PGF1α , PGF2α and PGF2β on Silasorb 600 columns with a water-containing mobile phases is described. A flexible, automated, preparative liquid-chromatographic (PLC) system has been used involving column switching, column temperature control, solvent selection and automated fraction collection.

Two-column ion chromatography was employed for the determination of Cl − in aqueous solutions. The influences of the length of the separation column and of the mobile phase flow-rate on the relative retention of Cl − and peak resolution was investigated. Some methods of calculating the void volume and mobile phase linear velocity are proposed. The difference between the performance of the system and that of the separation column has been taken into consideration. The effect of various experimental conditions on the limit of detection of Cl − was studied.

SummaryRheumatoid factor and immuno-conglutinin responses following various vaccinations were studied in a series of 381 healthy military recruits. The results suggested that both types of reaction were related to the net immune response provoked by the vaccinations. The immuno-conglutinin response took place within 2 weeks, whereas 3-4 weeks were needed for the appearance of rheumatoid factors. Immuno-conglutinin titer increases and positive rheumatoid factor reactions were not seen in the same persons.

The proper understanding of the causes, pathophysiology, diagnosis and management of the plasma hyperviscosity syndrome is based on good knowledge of malignant paraproteinaemias, properties of immunoglobulins, rheology of blood in the microcirculation, and modern plasma separation techniques. This multifaceted syndrome complicates less than ten per cent of IgA and IgG myelomas, and up to one-third of Waldenström's macroglobulinaemias. A few cases of HVS have also been reported in association with polyclonal hypergammaglobulinaemias. Excessive paraproteinaemia may cause the plasma HVS, especially when paraproteins are extraordinarily large, asymmetrical or cryosensitive, or if they aggregate into hyperviscous macroaggregates. The resultant severe microcirculatory impairment is mainly due to the combined effects of plasma hyperviscosity, significant plasma volume expansion and intense red cell aggregation. The individually variable general symptoms, bleeding tendency, ocular, neurological, cardiovascular, and renal manifestations and laboratory parameters of the HVS are summarized briefly. The majority of patients present hyperviscosity manifestations when the plasma viscosity exceeds 5-6 mPa.s. Plasmapheresis or plasma exchange have established themselves as efficient and safe modes of therapy of hyperviscosity and hypervolaemia. The therapeutic guidelines for the plasma HVS are briefly discussed with regard to recent experience with developing plasma separation techniques. Diagnostic and therapeutic advances combined with increasing haemorheological knowledge have greatly improved the proper management of this potentially lethal complication of paraproteinaemias.

The lymphographic appearances of the retroperitoneal lymph nodes in 10 patients with multiple myeloma have been analyzed. None of the patients had any signs of extramedullary involvement of myelomatosis before lymphography. In 3 cases irregular filling defects suggestive of myelomatous involvement were found. In one case they were close to a myelomatous bone lesion, whereas in the others the lymphographic abnormality was totally unexpected. In all 3 patients other nodes showed reactive hyperplasia. Such nonspecific hyperplasia was also encountered in 3 other cases. In 2 cases the myelomatous involvement of lymph node was detected before the diagnosis was recognized which is contrary to the belief that multiple myeloma involve nodes late in the disease. In addition to diagnostic aid the lymphographic demonstration of the myelomatous spread into lymph nodes may influence on the selection of the therapeutic approach to the disease.

Immune complex mediated damage, still incompletely understood, is a frequent and important pathogenetic mechanism in several major rheumatic diseases. Injury by circulating immune complexes seems to be related mainly to the size of the complexes and their ability to activate the complement system. The more circulating immune complexes are looked for to assess the nature of an activity of diseases, the more clinicians are faced with difficulties in interpretation. This is partly because of rapidly increasing number and types of immune complex assays and the conflicting data obtained. An understanding of the principles behind the commonly used immune complex assays allows the clinician to appreciate their advantages and weak points and to apply them correctly in investigating the clinicopathological aspects of immune complex mediated rheumatic diseases.

A study of blood and plasma viscosity in patients suffering from multiple myeloma or Waldenstrom's macroglobulinemia showed that, in many cases, the relative viscosity of blood was abnormally low, sometimes less than one. Analysis of the data suggests that this apparent paradox is best explained by concentration of the relatively lower molecular weight proteins or paraproteins around the red cells, forming a cell “atmosphere,” while the centrifuged supernatant plasma contains enriched quantity of relatively higher molecular weight paraproteins. It is likely that presence of monoclonal cryoglobulins or IgA M-globulins may enhance formation and/or intensity of such plasma “atmosphere” around the red cells. Analysis of the data by means of a blood viscosity equation containing a term for the internal viscosity of the red cell allowed recognition of the presence of “atmosphere” in some less obvious cases.

Aggregation of red cells was evaluated in 17 patients with macroglobulinaemia and in 30 patients with multiple myeloma by correcting erythrocyte sedimentation rates and velocities for plasma viscosity and adjusting to haematocrit of 30%. Aggregation of red cells is expressed in mm/hr, and values of up to 3800 mm/hr are noted. Aggreation of red cells in these diseases did not correlate with plasma fibrinogen concentration but did correlate ( P α 1 -, α 2 -, and β-globulins on the aggregation of red cells in this study. The response of the aggregation of red cells to the globulin/albumin ratio was about threefold steeper in the macroglobulinaemia series than in the multiple myeloma series (significance: P ⪡ 0.001). In analogous manner, the difference between the slopes of linear regressions between aggregation of red cells (ESR sl.pl.hc. ) and gamma + M-globulin levels in the macroglobulinaemia and in myeloma series was highly significant ( P ⪡ 0.001). Albumin/fibrinogen ratio showed a significant correlation with aggregation of red cells in the multiple myeloma series but not in the macroglobulinaemia series. Estimation of red cell aggregation from the sedimentation velocity was found superior to the estimates made from 1-hr erythrocyte sedimentation rates in the diseases studied.