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PubMed1987

Angioarchitecture of the CNS, pituitary gland, and intracerebral grafts revealed with peroxidase cytochemistry.

Blood vessels of the fetal, neonatal, and adult subprimate and primate CNS, including circumventricular organs (e.g., median eminence, pituitary gland, etc.), and of solid CNS and nonneural (anterior pituitary gland) allografts placed within brains of adult mammalian hosts were visualized with peroxidase cytochemistry applied in three ways: to tissues from animals injected systemically with native horseradish peroxidase (HRP) or peroxidase conjugated to the lectin wheat germ agglutinin (WGA) prior to perfusion fixation; to tissues from animals infused with native HRP into the aorta subsequent to perfusion fixation; and to tissues from animals fixed by immersion and incubated for endogenous peroxidase activity in red cells retained within blood vessels. In neonatal and adult animals receiving native HRP intravascularly, non-fenestrated vessels contributing to a blood-brain barrier were outlined with HRP reaction product when tetramethylbenzidine (TMB) as opposed to diaminobenzidine (DAB) was used as the chromogen; fenestrated vessels of circumventricular organs were not discernible due to the density of extravascular reaction product. Fenestrated and non-fenestrated cerebral and extracerebral blood vessels exposed to bloodborne WGA-HRP were visible when incubated in TMB and DAB solutions. Native HRP infused into the aorta of fixed animals likewise labeled non- fenestrated vessels throughout the brain upon exposure to TMB or DAB but obscured fenestrated vessels of the circumventricular organs. Endogenous peroxidase activity of red cells, seen equally well with TMB and DAB, outlined blood vessels throughout the cerebral gray and white matter and all circumventricular organs in fetal, neonatal, and adult animals. Application of the three peroxidase cytochemical approaches to study the development or absence of a blood-brain barrier in intracerebral allografts demonstrated that the vascularization of day 16-19 fetal/1 day neonatal CNS allografts is not well defined prior to 7 days following intracerebral placement of the grafts. CNS allografts secured from donor sites expected to possess a blood-brain barrier exhibited blood vessels that were not leaky to HRP injected intravenously in the host. Fenestrated blood vessels associated with anterior pituitary allografts were evident prior to 3 days posttransplantation within the host brain and permitted blood-borne HRP in the host to enter the graft and surrounding host brain parenchyma.

Animals↗
PubMed1989

Ultrastructure of capillary walls in human brain tumors.

Changes in capillary walls between human glial, non-glial and metastatic brain tumors were studied with conventional ultrathin section and freeze-fracture replica techniques. The following results were obtained. (1) In glial tumors, ultrathin section studies showed cell junctions of the capillaries were either short or elongate. Moreover, endothelial hyperplasia, surface infolding of endothelial cells, irregularity of the basal lamina and a large extravascular space were observed. Freeze-fracture replicas of capillary endothelium showed tight junctions as two to seven strands. In addition, pinocytotic vesicles had increased markedly and were an average of 25 per microns 2. Both ultrathin and freeze fracture studies showed that, in contrast to malignant gliomas, there were only slight changes in benign astrocytomas. (2) In non-glial tumors, ultrathin sections showed surface infoldings, increased vesicles, many fenestrations of endothelial cells, irregularity of basal lamina and enlarged perivascular space. Freeze-fracture replicas of vascular endothelium, showed that the average number of pinocytotic vesicles and fenestrations were 25 and 22 per microns 2, respectively. Moreover, the tight junction was composed of one or two strands which appeared to be a discontinuous array of particles. (3) In metastatic brain tumors, ultrathin studies showed capillary endothelia were proliferated, had marked infolding, and showed an increased number of pinocytotic vesicles and many fenestrations. Moreover, short and elongate intercellular junctions were presented but no open junction was detected. Finally the basal lamina lost its three-layered appearance and was irregular in width. Freeze-fracture replicas showed pinocytotic vesicles had increased and were 24 per microns 2 on average in four cases, but fenestrations and tight junctions could not be detected. The most fundamental feature of vessels in these three different kinds of tumors was whether they were fenestrated or not. Glial tumors were non-fenestrated, whereas non-glial and metastatic tumors were fenestrated.

Brain Neoplasms↗
PubMed1991

Intermediate procedures after first-stage Norwood operation facilitate subsequent repair.

Actuarial analysis of survival after first-stage palliative reconstructive operation for hypoplastic left heart syndrome has revealed a high out-of-hospital attrition rate over the first 18 months to 2 years postoperatively. Some of this mortality is related to development of anatomical problems such as restrictive atrial septal defect, neoaortic arch obstruction, and pulmonary artery distortion. The bidirectional Glenn shunt has proved to be an ideal adjunctive procedure for high-risk patients at the time of operation to correct such intermediate-term problems. The fenestrated Fontan procedure, which involves fenestration of the interatrial baffle placed as part of our current standard Fontan procedure, is applied for patients considered to be at moderate risk for a Fontan procedure. The decision regarding closure of the fenestration is made by hemodynamic study including temporary balloon occlusion of the fenestration. The fenestration is closed with the double-clamshell device, which is placed percutaneously in the catheterization laboratory and which is currently used for secundum atrial septal defect closure. Appropriate selection of patients for the bidirectional Glenn shunt or fenestrated Fontan procedure with or without fenestration closure has resulted in a dramatic decrease in mortality and morbidity for patients with all forms of single ventricle and for patients with hypoplastic left heart syndrome.

Actuarial Analysis↗
PubMed2000

Evolution of the Fontan procedure in a single center.

BACKGROUND: Surgical approaches to single ventricle variants include staged, fenestrated, and completed Fontan operations. This study compares outcomes with these modifications of the Fontan operation at a single center. METHODS: Preoperative risk factors and operative results were analyzed by multivariate techniques in 129 patients undergoing modified Fontan operations since March 1988. RESULTS: Overall early and late mortality was 5.4% and 0.8%, respectively. Before 1993, completed Fontan operation using right atrial to pulmonary artery anastomosis without fenestration was performed in the majority of patients (44 of 58; 76%). During this period, 10 of 17 patients at high risk had completed Fontan with three takedowns. In 1994, the staged hemi-Fontan and modified Fontan with a lateral tunnel anastomosis and with or without small fenestration (2.5 to 4 mm) were introduced. The majority of patients at high risk during this period underwent hemi-Fontan followed by fenestrated Fontan with no takedowns. Late atrial dysrhythmias occurred in 6 patients (4.7%), generally with larger fenestrations or right atrial to pulmonary anastomoses. Three patients (2.3%) had a stroke, 2 with large (> or = 4 mm) fenestrations. Of 38 fenestrations, 32 (84%) closed spontaneously by 1 year. No protein-losing enteropathy occurred. Most patients (118 of 121) were in New York Heart Association class I/II 4.5 years postoperatively. By multivariate analysis, only Down's syndrome (p < 0.001) predicted early mortality, whereas both Down's syndrome and a systemic right ventricle decreased late survival (p < 0.006). CONCLUSIONS: Proper selection of patients for modifications of the Fontan procedure resulted in excellent early and late survival with a low incidence of atrial dysrhythmia and stroke. Midterm functional outcomes were excellent.

Adolescent↗
PubMed1984

Morphometry of the ultrastructure of the blood-joint barrier in the rabbit knee.

The ultrastructure of the barrier to water and solute exchange between blood and a synovial cavity was studied morphometrically in five rabbit knees. The synovial surface consisted of 80% synoviocytes and 20% interstitium in direct contact with synovial fluid. The surface intercellular gaps were wide (0.1-5.5 microns). A rich network of capillaries lay just beneath the surface, the commonest (modal) depth of the capillary perimeter being 5 microns at its nearest point. Of these capillaries, 91% were fenestrated in adipose synovium, 44% in areolar synovium and 21% in posterior synovium; the remainder were continuous capillaries. The number of fenestrae per fenestrated capillary was low (approximately 0.5 micron-1, circumference: approximately 6 microns-2). The fenestrae (width 52 nm; membrane thickness 3-4 nm) occupied approximately 1% of the fenestrated endothelial surface-area. Nuclear segments and intercellular junctions were roughly twice as frequent in continuous capillaries as in fenestrated capillaries of the same circumference, indicating that continuous endothelial cells are of smaller surface area than fenestrated cells. The basement membranes of continuous and fenestrated synovial capillaries were relatively thick (98 and 110 nm respectively), perhaps supporting the synovial endothelium during joint motion. In both fenestrated and continuous capillaries the nuclei were preferentially oriented away from the synovial surface (92 and 67% respectively), which presumably facilitates exchange with the surface.

Animals↗
PubMed2004

Ultrastructural findings in human spinal pia mater in relation to subarachnoid anesthesia.

UNLABELLED: We examined ultrastructural details such as the cellular component and membrane thickness of human spinal pia mater with the aim of determining whether fenestrations are present. We hypothesized that pia mater is not a continuous membrane but, instead, that there are fenestrations across the pial cellular membrane. The lumbar dural sac from 7 fresh human cadavers was removed, and samples from lumbar spinal pia mater were studied by special staining techniques, immunohistochemistry, and transmission and scanning electron microscopy. A pial layer made by flat overlapping cells and subpial tissue was identified. We found fenestrations in samples from human spinal pia mater at the thoracic-lumbar junction, conus medullaris, and nerve root levels, but these fenestrations did not appear at the thoracic level. We speculate whether the presence of fenestrations in human spinal pia mater at the level of the lumbar spinal cord and at the nerve root levels has any influence on the transfer of local anesthetics across this membrane. IMPLICATIONS: The ultrastructural anatomy of the human pia mater, such as pial cells, membrane thickness, and subpial tissue at different levels of the thoracic and lumbar spinal cord and nerve roots, was studied by special staining techniques, immunohistochemistry, and transmission and scanning electron microscopy. Fenestrations were found in samples at the thoracic-lumbar junction, conus medullaris, and nerve root levels. No fenestrations were found in samples at the thoracic level. At present, we cannot determine the significance of these findings.

Aged↗
PubMed1995

Increased sinusoidal wall permeability and liver fatty change after two-thirds hepatectomy: an ultrastructural study in the rat.

Accumulation of lipids in the hepatocyte cytoplasm after partial hepatectomy (PH) has long been recognized, but the mechanism behind this phenomenon is still poorly understood. In this study, rats subjected to a standard two-thirds PH showed early and marked increase in portal venous pressure (P < .01). On scanning electron microscopy, the regenerating liver fixed by portal perfusion under hemodynamic conditions identical to that found in vivo during the first 24 hours showed a significant (P < .01) 10-fold increase in the sinusoidal wall porosity (percentage open area by fenestrations). This was paralleled by the disappearance of the sieve-plate arrangement of small fenestrations and by a significant decrease in the number of fenestrations per micrometers squared of sinusoidal surface at 6 (P < .01) and 12 hours (P < .05). In addition, there were major changes in the frequency and distribution of all three classes of fenestrations. At 6 and 12 hours, there was a marked decrease of small class 1 fenestrations and a marked increase of intermediate class 2 fenestrations and large class 3 fenestrations (P < .0001). A concurrent accumulation of lipid droplets in the hepatocyte cytoplasm produced a 20-fold increase in the hepatocyte total lipid volume. A statistically significant linear correlation (r = 0.907; P < .01) was found between the amount of intracellular lipids and the data quantitating the changes in porosity of liver sinusoids at 24 hours. It is concluded that an increased sinusoidal wall permeability to lipids may be the primum moves in the pathogenesis of transient liver fatty change after PH in the rat.

Animals↗
PubMed1978

Continuity between the ventricular and subarachnoid cerebrospinal fluid in an amphibian, Rana pipiens.

Continuity between the ventricular and subarachnoid cerebrospinal fluid has been investigated in Rana pipiens. The structure of the posterior tela, a deficient membrane situated at the extreme caudal end of the roof of the fourth ventricle, has been studied using whole membrane mounts and by light microscopy of resin embedded tissue. The ependymal component consists of columnar and rounded cells which form a regular 'syncytium' enclosing round and oval fenestrations. Small fenestrations are covered on the subarachnoid side by elongated pial cells and thus do not give total continuity between the fourth ventricle and the subarachnoid space. Large fenestrations, on the other hand, are accompanied by equivalent pial fenestrations giving direct access between the fluid compartments. Towards the caudal end the fenestrations break up and the numbers of ependymal and pial cells decrease, the caudal end itself being characterised by a small remaining clump of ependyma and pia or of pia alone. Flow through the tela has been studied using fluorescein-labelled dextran placed in the intraventricular space. Infusion into the lateral ventricle and subsequent localisation by fluorescence microscopy shows the marker to be in the fourth ventricle, in the fenestrations of the posterior tela and in the subarachnoid space overlying the tela. Infusion of the marker followed by freezing and examination of the cut heads on a freezing microtome, shows fluorescence throughout the ventricular system, in the subarachnoid space adjacent to the posterior tela and also along the dorsal subarachnoid space of the spinal cord.

Animals↗
PubMed2006

Current surgical therapy for Ebstein anomaly in neonates.

OBJECTIVE: Neonates with profound heart failure resulting from Ebstein anomaly have historically had poor outcomes. We report our institutional experience with the surgical management of Ebstein anomaly in severely symptomatic neonates. METHODS: A retrospective review of all patients (n = 16) undergoing neonatal intervention for Ebstein anomaly between 1992 and 2005 has been carried out. The indications for operation were overt heart failure, cyanosis, and acidosis associated with tricuspid regurgitation, depressed right ventricular function, and severe cardiomegaly. The magnitude of cardiac enlargement was assessed by cardiothoracic ratio and Great Ormond Street ratio (area of right atrium + atrialized right ventricle/area of functional left atrium + left ventricle). The operative strategy was first to assess for the possibility of tricuspid valve repair with or without right ventricular outflow tract reconstruction. If this was not feasible, then right ventricular exclusion was performed by oversewing the tricuspid valve with a pericardial patch. A reduction atrioplasty was done and, depending on the extent of the atrialized portion of the right ventricle, plication was performed. A modified Blalock-Taussig shunt provided pulmonary blood flow. This univentricular approach (Starnes procedure) evolved to include a fenestration in the tricuspid valve patch to allow for right ventricular decompression. Analysis included overall and group-specific survival as well as the testing of perioperative clinical, morphologic, and surgical variables for correlation with mortality and morbidity. RESULTS: Mean age and weight at operation were 8 +/-10 days and 3.1 +/- 0.4 kg. Tricuspid valve repair was undertaken in 3 patients with 1 requiring conversion to right ventricular exclusion 3 months after the initial operation. In those with right ventricular exclusion, the tricuspid valve patch was fenestrated in 10 and nonfenestrated in 3. One patient had heart transplant as the initial procedure. There were 5 hospital deaths (31%) and no late deaths among the survivors. Survival in the cohort with a fenestrated tricuspid valve patch was 80% (8/10) versus 33% (1/3) for the nonfenestrated group. This difference did not reach statistical significance, although the trend seems clinically important. There was no difference in the cardiothoracic ratio (0.82 fenestrated vs 0.84 nonfenestrated: P = .802) or the Great Ormond Street ratio (1.2 fenestrated vs 1.02 nonfenestrated: P = .477) between the two groups. Among the 9 survivors of right ventricular exclusion, 3 have had completion of their Fontan, and all 9 have undergone a bidirectional Glenn procedure. All operations including homograft placement in the right ventricular outflow tract, whether during repair or during right ventricular exclusion, ended in death. CONCLUSION: Right ventricular exclusion with a fenestrated tricuspid valve patch combined with right atrioplasty and right ventriculoplasty and a Blalock-Taussig shunt (Starnes procedure) has provided effective palliation for neonates presenting with critical Ebstein anomaly and a tricuspid valve that cannot be repaired.

Cardiac Surgical Procedures↗
PubMed2000

Endoscopic treatment of para- and intraventricular cerebrospinal fluid cysts.

This study has been made to define the role of endoscopy and the most appropriate approach and technique of endoscopic fenestration of paraventricular and intraventricular CSF cysts according to the cyst size and location. Twenty-two patients with intraventricular (13 cases) and paraventricular (9 cases) CSF cysts, operated upon by endoscopic technique in three Italian neurosurgical centers, are reviewed. Paraventricular hemispheric cysts have been treated by endoscopic fenestration from the cyst to the lateral ventricle. Midline intraventricular cysts (2 of the septum pellucidum and 4 of the velum interpositum) underwent fenestration from the right lateral ventricle to the cyst, with fenestration in both lateral ventricles in one case. Cysts of the choroid plexus have been fenestrated from the homolateral enlarged ventricle (4 cases) or from the contralateral compressed ventricle (2 cases). Twenty patients (more than 90%) were definitively cured by the endoscopic procedure, whereas only 2 patients required a shunt or a direct approach. We think that the endoscopic fenestration must be considered the treatment of choice of intraventricular and paraventricular CSF cysts.

Adolescent↗
PubMed1994

Laparoscopic management of symptomatic nonparasitic cysts of the liver. Indications and results.

OBJECTIVE: This clinical study evaluated the results of and defined the indications for laparoscopic fenestration of symptomatic nonparasitic hepatic cysts, either solitary or diffuse. SUMMARY BACKGROUND DATA: Different surgical treatments have been proposed for highly symptomatic hepatic cysts: enucleation, fenestration, hepatic resection, and liver transplantation. The advent of laparoscopic surgery has given new opportunities but, at the same time, has increased the uncertainties concerning the proper management of these patients. METHODS: Eight patients with solitary cysts and nine with polycystic liver and kidney disease (PLD) were seen during a period of 2 years. After a careful review of the symptoms, 6 patients were excluded from surgical treatment and 11 (4 solitary cysts and 7 PLD) were treated by laparoscopic fenestration. Postoperative morbidity and mortality rates, hospital stay, and clinical early and late results were evaluated. RESULTS: In the solitary cyst group, there was no surgical morbidity or deaths, and a complete regression of symptoms occurred in all patients. No recurrences were observed. In the PLD group, two patients had to be converted to laparotomic fenestration (28%). There were no deaths, and the surgical morbidity was limited to two cases of postoperative ascites. Symptomatic relief was obtained in 80% of patients, but the symptoms recurred in 60%. A subgroup of PLD at high risk for recurrence was identified. CONCLUSIONS: The best indications for laparoscopic fenestration seem to be solitary cyst and PLD characterized by large cysts mainly located on the liver surface (type 1), whereas PLD characterized by numerous small cysts all over the liver (type 2) should be considered a contraindication to laparoscopic fenestration.

Adult↗
PubMed2005

Effect of vertebral shell on injection pressure and intravertebral pressure in vertebroplasty.

STUDY DESIGN: An experimental biomechanical study conducted on osteoporotic cadaveric vertebrae. OBJECTIVES: 1) To measure the intravertebral shell pressure and injection pressure; and 2) to determine the effect of the vertebral shell on the intravertebral shell pressure and on the injection pressure. SUMMARY OF BACKGROUND DATA: Forces that govern cement flow are an essential component of the cement injection process in vertebroplasty. The vertebral shell may play a significant role in confining the flow of cement in the vertebral body and thereby affecting the intravertebral pressure and injection pressure. METHODS: A small fenestration was created in the left lateral vertebral shell of 14 vertebrae. A valve to open and close the fenestration and a sensor to measure the intravertebral pressure were attached to the opening. A closed fenestration simulated an intact shell, whereas an open fenestration represented a vented shell. Injection pressure and intravertebral pressure at the shell were recorded during a controlled injection. RESULTS: A closed fenestration resulted in a significant increase in the intravertebral pressure at the shell. During the injection, the shell pressure increased on average to approximately 3.54 +/- 2.91 kPa. Conversely, an open fenestration resulted in an instant relaxation of the shell pressure to the ambient pressure of 0 kPa. Additionally, the injection pressure was approximately 97 times higher than the shell pressure. CONCLUSION: The presence of vertebral shell seems to be important for intravertebral pressure. However, the intravertebral shell pressure adds very little to the injection pressure.

Biomechanical Phenomena↗
PubMed2002

Flow through internal elastic lamina affects shear stress on smooth muscle cells (3D simulations).

We describe a three-dimensional numerical simulation of interstitial flow through the medial layer of an artery accounting for the complex entrance condition associated with fenestral pores in the internal elastic lamina (IEL) to investigate the fluid mechanical environment around the smooth muscle cells (SMCs) right beneath the IEL. The IEL was modeled as an impermeable barrier to water flow except for the fenestral pores, which were assumed to be uniformly distributed over the IEL. The medial layer was modeled as a heterogeneous medium composed of a periodic array of cylindrical SMCs embedded in a continuous porous medium representing the interstitial proteoglycan and collagen matrix. Depending on the distance between the IEL bottom surface and the upstream end of the proximal layer of SMCs, the local shear stress on SMCs right beneath the fenestral pore could be more than 10 times higher than that on the cells far removed from the IEL under the conditions that the fenestral pore diameter and area fraction of pores were kept constant at 1.4 microm and 0.05, respectively. Thus these proximal SMCs may experience shear stress levels that are even higher than endothelial cells exposed to normal blood flow (order of 10 dyn/cm(2)). Furthermore, entrance flow through fenestral pores alters considerably the interstitial flow field in the medial layer over a spatial length scale of the order of the fenestral pore diameter. Thus the spatial gradient of shear stress on the most superficial SMC is noticeably higher than computed for endothelial cell surfaces.

Animals↗
PubMed2000

Hemodynamic effects of pressures applied to the upper airway during sleep.

The increase in systemic blood pressure after an obstructive apnea is due, in part, to sympathetically mediated vasoconstriction. We questioned whether upper airway (UA) receptors could contribute reflexly to this vasoconstriction. Four unanesthetized dogs were studied during wakefulness and non-rapid-eye-movement (NREM) sleep. The dogs breathed via a fenestrated tracheostomy tube sealed around the tracheal stoma. The snout was sealed with an airtight mask, thereby isolating the UA when the fenestration was closed and exposing the UA to negative inspiratory intrathoracic pressure when it was open. The blood pressure response to three UA perturbations was studied: 1) square-wave negative pressures sufficient to cause UA collapse with the fenestration closed during a mechanical hyperventilation-induced central apnea; 2) tracheal occlusion with the fenestration open vs. closed; and 3) high-frequency pressure oscillations (HFPO) with the fenestration closed. During NREM sleep, 1) blood pressure response to tracheal occlusion was similar with the fenestration open or closed; 2) collapsing the UA with negative pressures failed to alter blood pressure during a central apnea; and 3) application of HFPO to the UA during eupnea and resistive-loaded breaths increased heart rate and blood pressure. However, these changes were likely to be secondary to the effects of HFPO-induced reflex changes on prolonging expiratory time. These findings suggest that activation of UA pressure-sensitive receptors does not contribute directly to the pressor response associated with sleep-disordered breathing events.

Airway Obstruction↗
PubMed1999

Endoscopic approach to noncommunicating fluid spaces in the shunted patient.

INTRODUCTION: It is well known that shunted hydrocephalic patients can, over time, develop entrapped ventricles or cystic spaces not in communication with the remaining ventricles. This situation has traditionally been treated with placement of an additional catheter or shunt system in the noncommunicating fluid space. With the advent of minimally invasive endoscopic techniques, it has become possible to fenestrate trapped fluid spaces into the shunted ventricular system, thus preventing the need for additional catheters. METHODS: Fifteen shunted patients presented with noncommunicating fluid spaces over a 4-year period at our two institutions. We attempted fenestration procedures in 14 of those patients. The various procedures included: septum pellucidum fenestration, cyst fenestration, third ventriculocisternostomy and a combination of the above. RESULTS: Thirteen of 16 (81%) endoscopic fenestrations successfully prevented the need for a complicated shunting system. There were 3 technical failures (3/16, 19%) in which an additional catheter was added to the existing shunt system at the time of the endoscopic procedure. There were no adverse neurologic effects from the endoscopic procedures; however, in 4 of the 14 patients (29%) a shunt revision was performed between 2 and 30 days following the fenestration. CONCLUSIONS: These results show that the endoscopic approach to establishing communication between noncommunicating CSF spaces in the shunted patient is safe and efficacious in preventing the need for additional CSF catheters. Though we encountered failures, the majority of cases are technically feasible. In these patients early shunt malfunction may occur, most likely due to intraoperative bleeding and will require shunt revision.

Adolescent↗
PubMed1998

A personal history of stapedectomy.

Aristotle has said the essential ingredient of tragedy is first hubris. Fame leads to the hubris that offends the gods, who send great punishment. This is so true in the history of stapedectomy. The three distinct eras of surgery for otosclerosis teach us a lot about what happens in science and in life. The first stapes era began in Europe, ahead of its time, and in those halcyon days before the turn of the century, the Belle Epoch, proceeded, uncorrected to its tragic extreme, and then was stopped suddenly, quite rightly, by the establishment. The fenestration era proceeded to an extreme, when its technical master Julius Lempert would allow no criticism or improvement in "his" one-stage endaural technique, however good, nor would he accept the new mobilization and stapedectomy operations, and he and it ended badly. The fact that Jenkins and Holmgren would make an opening in the lateral semicircular canal and then close it in the epitympanum, not open to the ear canal, to expect to improve hearing is amazing. Until Sourdille went to Stockholm and saw one closed fenestration operation performed by Holmgren and devised his "open to the ear canal technique," the closed fenestration operation was not reasonable. Then Sourdille came to New York City, and Lempert heard him speak and read and reread his publication and greatly improved on his operation. It was Lempert's one-stage endaural open operation that gave the fenestration operation the worldwide acceptance it gained. The second stapedectomy era began before the fenestration era ended with the accidental and originally unrecognized mobilization of the stapes by Rosen and my resurrection of stapedectomy. I realized in reading the literature of the past that stapedectomy was not necessarily fatal to the ear or the patient as was generally believed, and what was needed was to seal the oval window with a living elastic membrane and reconstruct the sound-conducting mechanism of the middle ear with a biocompatible implant prosthesis to make it successful. But for me, in 1955-1956, the "Zeitgeist" was finally right. I realized the stapes could be removed and covered the oval window with a vein graft, and Harry Treace made me a biocompatible implant prosthesis out of the newly discovered Teflon. For a new technology to be accepted, it must be much better than what it replaces, and stapedectomy was much better than fenestration. In the new microsurgical era of otology that began, improvements in the stapedectomy operation came from everywhere and were readily accepted. Stapedectomy has now become so successful, like many treatments in medicine, the problem has now largely disappeared. If the measles virus is the cause of the growth of the otosclerotic focus, as it seems to be, then vaccination against measles eventually will eliminate the hearing loss of otosclerosis completely. What the history of stapedectomy reveals is the truth of the quotation from Ecclesiastes, "There is nothing new under the sun." Progress is only made when the Zeitgeist is right, by someone who puts together the truths of the past with the new discoveries of the present.

Ear Diseases↗
PubMed1996

Distribution and organization of peripheral capillaries in dental pulp and their relationship to odontoblasts.

BACKGROUND: Developmental and chronological changes in the peripheral capillaries of the dental pulp and their relationship to odontoblasts during dentin formation has not been sufficiently detailed. This study aims to elucidate the morphological changes of the peripheral capillaries in relation to the life cycle of odontoblasts. METHODS: Peripheral capillaries of the dental pulp were examined in the labial region of rat incisors and in the crown region of rat molars by using light, transmission, and scanning electron microscopy. RESULTS: Before the start of dentin formation, continuous capillaries formed a coarse vascular network under the odontoblast layer. With the start of dentin deposition, capillaries began to invade into the odontoblast layer and finally located close to the predentin, where they formed a dense vascular network consisting of fenestrated capillaries. In the incisors, dentin was formed actively even near the incisal tip, and fenestrated capillaries continued to locate in the odontoblast layer. In the molars, however, the activity of dentin deposition gradually decreased with the advance of dentin formation, and the fenestrated capillaries altered to continuous capillaries and withdrew from the predentin border to the odontoblastic-pulpal border shortly before the cessation of active dentin deposition. CONCLUSIONS: It is concluded that the changes in the peripheral capillaries are closely related to the secretory activity of the odontoblasts. To facilitate a rapid and sufficient supply of raw materials from the bloodstream to the calcifying front, peripheral capillaries first approach the odontoblasts, invade into the odontoblast layer close to the predentin with increases in density, and finally alter the endothelium from the continuous to the fenestrated type in compliance with the nutritional requirements of the odontoblasts, which lay down the dentin. When the activity of odontoblasts decreases, capillaries first alter the endothelium from the fenestrated to the continuous type, then retreat from the odontoblast layer, and finally locate below the odontoblast layer.

Animals↗
PubMed1993

Load transfer with the Austin Moore cementless hip prosthesis.

More than 1,300 Austin Moore hemiarthroplasties have been reviewed in the literature, with no reports of fracture of the stem. Many patients with these hip implants had good function. The lack of stem fractures in patients with good functions has not been explained and contrasts with stem fractures that have occurred in patients with cemented prostheses of other designs during the same time. We used three-dimensional finite-element analysis and free-body diagrams to explain the lack of fractures for this device by a description of the probable load-transfer mechanisms between the prosthesis and the bone. Results from our finite-element analysis indicate that, with good calcar-collar support, the stresses in the stem are small because the stem portion of the prosthesis and the bone are uncoupled and, consequently, do not share the resultant bending moment of the head and abductor forces. If the stem is coupled to the bone so that the resultant bending moment is shared, high stresses in the stem are predicted; such stresses are inconsistent with the complete absence of fractures of these prostheses. The results of the finite-element analysis further showed that loss of calcar-collar support with proximal fixation through the fenestrations resulted in high stresses in the stem and stress shielding of the proximal medial cortex. The uncoupled prosthesis also may be modeled with a free-body diagram as a three-force member loaded at the head, stem tip, and in the proximal region. With this model, it can be shown that the reaction force of the stem tip, and thus the peak bending stress in the stem, increases as calcar-collar support is decreased. If there is no calcar-collar support, proximal support must be provided by some combination of integration of bone in the fenestrations and wedging due to the lateral-medial taper of the device. Stresses in the stem are largest when there is no wedging, but high stresses develop in the cancellous bone in the fenestrations. When there is wedging, stresses in the stem can be low, but stresses in the supporting cancellous bone can be high; additional proximal support through the fenestrations substantially reduces these bone stresses. If reduced stresses in the cancellous bone are indicative of a stable device, these mechanisms indicate that fractures of the Austin Moore prosthesis have not occurred in normally loaded hips because load was transferred primarily either through the collar or by wedging, with additional support at the fenestrations.

Aged↗