Arterial shunt with pump infusion line for the treatment of chronic thoracic aortic aneurysms: the "modified shunt of Gott".

Dissection of the aneurysm is the most dangerous step during graft replacement of the descending thoracic aorta. Sudden hemorrhage may follow wall rupture or disruption of major collaterals before the aorta can be clamped. A simple modification of the classic Gott is illustrated, which makes the shunt work also as a partial bypass if needed, with rapid reinfusion of blood losses. Nineteen of 25 patients requiring resection of descending aortic aneurysms from 1982 to 1990 were treated with this method with no mortality.


Felodipine. A review of the pharmacology and therapeutic use of the extended release formulation in older patients.

Felodipine is a dihydropyridine calcium antagonist which may be administered once daily in an extended release (ER) formulation. As monotherapy in older patients with mild to moderate essential hypertension, felodipine ER once daily provides effective control of blood pressure (BP). The drug has also been effective, either as monotherapy or in combination with other antihypertensive medications, in comparisons with other antihypertensive agents, and does not adversely affect lipid profiles or, in patients with diabetes mellitus, glycaemic control. Results in patients with angina pectoris and congestive heart failure indicate a potential role for felodipine ER in these indications and data also suggest the drug reduces left ventricular hypertrophy. In addition, felodipine ER appears suitable for use in patients with concomitant respiratory disease, renal or hepatic dysfunction, cerebrovascular or peripheral ischaemic disease, or gout, making it particularly useful in the elderly who often have more than one significant clinical condition. Felodipine ER has generally been well tolerated by older patients in clinical trials, although further confirmation in the long term is desirable. Thus, felodipine ER effectively lowers BP in older patients with essential hypertension with the added convenience of once daily administration. It may be used as monotherapy or in combination with other antihypertensive agents and is a practical advance in the treatment of hypertension in the elderly.


Annular enlargement during aortic valve replacement: preliminary results with a simplified technique.

A simplified technique has been used to enlarge the aortic annulus in a series of 13 patients undergoing aortic valve replacement. The procedure basically consists of extending the aortotomy incision into the aortic annulus by dividing the commissure between the left and noncoronary sinuses, without involving the anterior mitral leaflet. Wide opening of the commissure is obtained and the resulting defect is closed, preferably using a patch of bovine pericardium sutured to the mitral annulus and aortic wall. This technique is simple, reproducible, avoids opening of the left atrium (reducing the potential bleeding sites), allows insertion of a prosthesis at least two sizes larger than the original annulus, and is also applicable in cases of mitral-aortic valve replacement. Our preliminary results are satisfactory and seem to demonstrate that in many patients, even in the young age group, more complex procedures are often unnecessary when enlargement of the aortic annulus is required.


Adverse effects of antidepressants in the elderly.

Depression is a common problem in old age and the use of antidepressant drugs is particularly prevalent among elderly patients. Limited data suggest that dose requirements may be lower in the elderly because of age-related changes in pharmacokinetics and perhaps also in sensitivity. The side effect profiles of the various antidepressants are reviewed with regard to their potential to cause specific problems in the older patients. Anticholinergic actions, orthostatic hypotension and sedative effects warrant particular care in the elderly.


Cardiac surgery in patients with human immunodeficiency virus infection: indications and results.

Ten patients with human immunodeficiency virus (HIV) infections underwent cardiac surgery using cardiopulmonary bypass. All were in Centers for Disease Control (CDC) group II. The cardiac involvement was either urgent or severely symptomatic in all cases. One patient died due to acquired immunodeficiency syndrome (AIDS) unrelated cause. No complications were encountered in this series. Eight of the nine survivors were available for follow-up. Three of these eight patients progressed to AIDS (CDC group IV) and subsequently died. Five patients are alive and in CDC group II. Prognosis of the HIV infection and the natural history of the cardiac disease are the two main elements to be considered whenever cardiac surgery is required.


Special considerations required for the formulation and administration of total parenteral nutrition therapy in the elderly patient.

Providing total parenteral nutrition (TPN) to hospitalised patients is not a benign procedure and can be associated with appreciable risks including the development of septic, mechanical and/or metabolic complications. In the older patient, the risks are heightened due to the effects of aging on vital organ function, as well as on the body's ability to respond to injury and infection. In addition, the existence of co-morbid disease will increase the rate of complications. The design of nutritional regimens must account for the changes in body composition and function with age in order to reduce the risks of nutrition-related complications. As a consequence of the reduction in lean body mass and organ function, coupled with the need to mobilise endogenous protein during acute metabolic stress, it is prudent to provide protein intakes of 1.5 g/kg/day, similar to amounts given to younger adult populations. In contrast, the caloric intake should be reduced by as much as 30% from amounts given younger adults of equivalent height and weight in order to avoid the dangers of overfeeding. Single-fuel systems may be better choices in those with acute cardiovascular disease, as glucose is a preferred fuel in this setting, whereas a mixed-fuel system will generally allow improved glucose homeostasis in the diabetic patient. Once TPN is instituted, metabolic management may be as important as nutritional support. Critical illness is associated with a variety of electrolyte disorders which are often accentuated by concurrent drug therapy and pre-existing co-morbid disease. The older patient is often less able to withstand abrupt changes in metabolic homeostasis. These points underscore the importance of the careful application of TPN therapy in the older patient.


Early and late phase events following bioprosthetic tricuspid valve replacement.

From 1961 through 1987, 9,247 patients underwent an intracardiac repair for valvular heart disease. Five hundred thirty patients had a procedure that included a tricuspid valve operation (6%), with tricuspid valve replacement performed in 175 patients (2%), of whom 154 had a bioprosthetic valve implanted (1.7%). These 154 patients with a bioprosthetic valve in the tricuspid position are the subject of this review. There were 27 males and 127 females. Ages ranged from 10 to 75 years. There was tricuspid valve insufficiency in 139 patients (90%), and stenosis plus insufficiency in 15 (10%). Carpentier-Edwards prostheses were implanted in 83 (54%), Ionescu-Shiley in 55 (35%), Hancock in 12 (8%), and Mitroflow in 4 (3%). Concomitant procedures were performed in 146 patients (95%). At least one previous operation had been performed in 86 patients (56%). Preoperatively, 139 patients were in functional Class III or IV (90%). Hospital death occurred in 20 patients (13%). Logistic regression analysis revealed that incremental risk factors for hospital death included increasing peripheral edema preoperatively (p = 0.04), and use of a Hancock prosthesis in the tricuspid position (p = 0.03). All 134 hospital survivors were followed at a mean of 66.01 months, range 1 to 162 months. There were 70 late deaths (52%). Log-rank test indicated that incremental risk factors for late death were: longer cross-clamp time at repair (p = 0.0007); higher pulmonary artery systolic pressure preoperatively (p = 0.01); earlier date of surgery (p = 0.03); and larger tricuspid prosthesis size (p = 0.06).(ABSTRACT TRUNCATED AT 250 WORDS)


Evaluation of an absorbable suture for sternal closure in pediatric cardiac surgery.

We conducted a study in a prospective fashion using 1-mm diameter absorbable sutures (polydioxanone [PDS]) for sternal closure in 50 consecutive patients, ages 5 months to 16 years, weighing 5 to 27 kg. Good wound closure and absence of any iatrogenic complications were noted. Potential benefits of this approach include disappearance of sequelae of the closure and better bone healing. This appears to be a safe alternative to standard sternotomy closure.


Pericardial complications of cardiac surgery: emphasis on the diagnostic role of echocardiography.

Pericardial effusions are common following cardiac surgery; uncommonly they are large in size and may cause tamponade, either in the early or late postoperative period. Such effusions causing tamponade may be circumcardiac, but are frequently loculated, in which case one or more cardiac chambers is selectively compressed. Fortunately, echocardiography is capable of imaging not only the presence, location, and size of the pericardial effusion, but also indicating the presence of tamponade. Constrictive pericarditis resulting from cardiac surgery is being recognized with increasing frequency and has been associated with various echocardiographic abnormalities. This review also discusses certain other pericardial complications of cardiac surgery including supraventricular arrhythmias, chylopericardium, and posttransplant problems.


Percutaneous absorption and age. Implications for therapy.

Human skin changes dramatically with increasing age. Morphological, physiological, and biochemical changes within the tissue have been investigated and documented. Considerable interest in transdermal drug delivery to produce systemic effect has occurred in recent years. However, it is not known whether the penetration barrier of aged skin changes. Morphological and physiological changes in aged skin may affect the percutaneous absorption of compounds and thus their potential for localised, as well as systemic, efficacy. This article reviews the published literature on skin aging changes from adulthood to old age, collates these changes with clinical implications pertinent to the practising dermatologist, reviews the existing data supporting a change in the barrier function of human skin with increasing age, and comments on the relevance of conclusions previous investigators have drawn from their studies.


Omental transfer for the treatment of mediastinitis in an infant.

Mediastinitis following congenital heart surgery is relatively uncommon but is usually seen in the setting of postoperative low cardiac output. Conservative treatment utilizing debridement and irrigation is associated with significant morbidity and mortality. We report the successful application of the omental transfer technique in the treatment of mediastinitis in a 6 month old.


Macromastia as a factor in sternal wound dehiscence following cardiac surgery: management combining chest wall reconstruction and reduction mammoplasty.

Major sternal wound infection occurs in nearly 2% of patients following coronary artery bypass graft surgery. The relationship of this complication to gender has not been reported in detail, nor has female breast size previously been implicated as a factor increasing the risk of sternotomy dehiscence. We report two cases of sternotomy wound dehiscence in women with large, pendulous breasts undergoing myocardial revascularization surgery and postulate that the weight of large, unsupported breasts produced inferolateral tension on the midline sternotomy incisions, contributing to dehiscence of the wounds. Chest wall reconstruction was accomplished using pectoralis muscle flaps, and the procedures were combined with amputative reduction of the size of the breasts, with subsequently successful healing in each case. Combining sternal reconstruction with breast reduction surgery may lead to improved secondary outcome, and postoperative use of supportive brassieres may reduce the frequency of this complication.


Dynamic MR imaging of human brain oxygenation during rest and photic stimulation.

Dynamic FLASH (fast low-angle shot) magnetic resonance (MR) imaging was used to monitor changes in brain oxygenation in the human visual cortex during photic stimulation. The approach exploits the sensitivity of the gradient-echo signal to susceptibility changes induced by varying concentrations of paramagnetic deoxyhemoglobin in the cerebral blood pool. After the onset of binocular photic stimulation (10 Hz, red light, checker-board), there was a distinct increase in the MR signal in the calcarine cortex within 6-9 seconds, indicating a decrease in the total deoxyhemoglobin concentration. After the stimulation was switched off, the MR signal returned to a basal value within a similar period of time. Assuming enhanced blood flow and only a minor increase in oxygen consumption (production of deoxyhemoglobin) during physiologic activation, the results reflect an enhanced supply of diamagnetic oxyhemoglobin and an increase in the partial oxygen pressure in the capillary and venous blood pools. In addition, a decrease in the basal MR signal in the calcarine cortex was observed during the first 60-90 seconds of persistent activation, which may be understood as an autoregulatory adaptation to increased overall brain activity associated with information processing due to continuous perception of visual stimuli.


Identification of aberrant right subclavian artery on MR images of the cervical spine.

Nine cases of aberrant right subclavian artery were identified after review of 674 magnetic resonance (MR) studies of the cervical spine. This common aortic arch anomaly is readily identified on sagittal MR images. All vessels were found in the typical retroesophageal location, abutting the esophagus from the vertebral C-7 to T-3 levels. Arterial flow created signal voids on T1-weighted images and confirmatory increased signal intensity due to flow-related enhancement on gradient-echo images. This anomaly should be recognized and distinguished from pathologic processes in the prevertebral space. The diagnosis may allay patient concern regarding their dysphagia and also have important ramifications in certain clinical settings.


Automated local maximum-intensity projection with three-dimensional vessel tracking.

Despite the simplicity and widespread acceptance of the maximum-intensity-projection (MIP) technique for displaying three-dimensional (3D) magnetic resonance angiographic data, several disadvantages are associated with MIP as it is applied to all of the 3D data. These include elevated noise level, reduced contrast between small vessels and background tissue, and the inability to distinguish arteries from veins. The authors have developed a 3D vessel tracking method combined with a local MIP around a given vessel to complement conventional MIP and alleviate these problems. The method is referred to as a traveling MIP (TMIP). TMIP was evaluated in both patients and healthy volunteers. The results indicate that TMIP provides better contrast between vessels and background tissue, better lumen definition, and better vascular visualization than either MIP or vessel tracking alone.


Cerebral lactate production and blood flow in acute stroke.

Eight stroke patients were examined serially in the acute phase and 1 week and 2-4 weeks after stroke with water-suppressed proton magnetic resonance spectroscopy. The time courses of lactate level and regional cerebral blood flow were studied. A high lactate level was found in the acute phase. The lactate content decreased to barely detectable levels during the following 3 weeks, while regional blood flow increased during this period. The inverse relationship between lactate level and cerebral blood flow suggests that lactate plays no substantial role in the vasodilatation underlying the hyperemia that follows reperfusion. The amount of lactate present in the acute phase reflects the severity of ischemia in the affected region. The lactate level was still above normal in the subacute phase with hyperemia, suggesting lactate production through aerobic glycolysis. Thus, the lactate level in the subacute phase probably does not reflect the degree of anaerobic glycolysis in hypoxic neuronal tissue.


Effect of hypothyroidism on phosphorus metabolism in muscle and liver: in vivo P-31 MR spectroscopy study.

Hypothyroidism is known to affect nearly every organ and organ system of the human body. The goal of the present study was to gain insight into the phosphorus metabolism and bioenergetic function of striated (calf) muscle and liver in patients with hypothyroidism before and after thyroid hormone treatment. With an ISIS (image-selected in vivo spectroscopy) magnetic resonance (MR) technique for volume selection, phosphorus-31 metabolism of the calf muscle in 10 patients and of the liver in seven patients with severe hypothyroidism was studied before and after treatment. In addition, spectra from the calf muscle and liver were obtained in 10 healthy volunteers. Relative to those from the healthy subjects, the P-31 MR spectra from patients with hypothyroidism showed a significantly diminished phosphocreatine/inorganic phosphate ratio (P less than .01). After thyroid hormone substitution therapy, this ratio returned to normal values within several weeks. No statistically significant changes in the spectra of liver tissue could be detected. The results support the theory that hypothyroidism induces a hormone-dependent, fully reversible impairment of the energy metabolism of striated muscle. Changes in liver metabolism observed with biochemical methods are apparently not detectable with state-of-the-art P-31 MR spectroscopy.


Why fat is bright in RARE and fast spin-echo imaging.

Fast spin-echo (FSE) sequences are becoming popular for T2-weighted clinical imaging because they result in a severalfold reduction in imaging time and because they provide conventional spin-echo contrast for most tissues. Fat, however, has been observed to have anomalously high signal intensity on FSE images. The present study shows that the brighter fat results from the multiple 180 degrees refocusing pulses, which eliminate diffusion-mediated susceptibility dephasing and suppress J-coupling modulation of the echo train.


Practical T2 quantitation for clinical applications.

Many studies have investigated the use of magnetic resonance relaxation times for tissue characterization. A number have been performed in vivo with clinical whole-body imagers. Unfortunately, the results have yet to establish the role of quantitative tissue relaxation time measurements in clinical diagnosis. One of the major problems is that the techniques used in many of these studies are error prone, making the results inconclusive. In the present study, the problems associated with clinical T2 measurements were systematically evaluated in an attempt to obtain reliable in vivo quantitation. The authors demonstrate that spoiler gradients are the most effective technique for artifact suppression but that they render ineffective radio-frequency phase schemes such as the Meiboom-Gill modification to the Carr-Purcell sequence to compensate experimental imperfections. The present study results in a more reliable multi-echo sequence for T2 measurement. Preliminary clinical results in brain and cervix demonstrate the performance of the new technique.


Monitoring of laser and freezing-induced ablation in the liver with T1-weighted MR imaging.

During both interstitial laser ablation therapy and cryoablation therapy for liver tumors, real-time monitoring is necessary for assessment of ongoing thermal effects in tissue. With single-section images obtained every 30 seconds with a T1-weighted RARE (rapid acquisition with relaxation enhancement) sequence, signal intensity changes in both ex vivo and in vivo animal liver were readily seen. The reversible loss of signal intensity that took place during laser irradiation and the increased intensity at the beginning of cooling can be explained mainly by altered T1 due to temperature change. The frozen area was seen as a sudden decrease in signal intensity at 0 degrees C due to a T2 decrease. This preliminary work showed that the protocol provides enough temporal and temperature resolution to accurately depict the extent of thermal damage, as confirmed at histologic examination. Signal intensity decreased linearly with temperature in the range 10 degrees C-50 degrees C, yielding a pixel-to-pixel temperature resolution of 5.37 degrees C.


MR imaging of temporomandibular joint abnormalities associated with cervical hyperextension/hyperflexion (whiplash) injuries.

Patients often have temporomandibular joint (TMJ) dysfunction-related symptoms after cervical hyperextension/hyperflexion injuries ("whiplash") caused by rear-end motor-vehicle collisions. To determine abnormalities of the TMJ associated with these injuries, 33 consecutive symptomatic patients (66 joints) with no direct trauma to the jaw, mouth, head, or face due to the accident and no prior history of TMJ dysfunction underwent magnetic resonance (MR) imaging, and the images were retrospectively analyzed. Overall, 29 (88%) patients had some type of TMJ abnormality related to whiplash injury. Displacement of the disk was seen in 37 (56%) of the TMJs as follows: 21 (32%) had anterior displacement with reduction, nine (14%) had anterior displacement without reduction, six (9%) had lateral or medial displacement, and one (2%) had posterior displacement. On T2-weighted images, 43 (65%) TMJs had abnormal joint fluid or edema, predominantly affecting the joint capsule and/or lateral pterygoid muscles. The finding that many of the patients had joint fluid and/or soft-tissue edema indicates that T2-weighted images are especially useful for assessment of patients with a history of whiplash injury.


Reduced-bandwidth method for F-19 imaging of perflubron.

A reduced-bandwidth imaging method has been developed to eliminate the chemical shift artifacts in magnetic resonance (MR) imaging of the blood substitute perflubron (PFB) and simultaneously enhance the signal-to-noise ratio (SNR). The two strongest spectral peaks, which have relatively long T2 values (247 and 471 msec), were used. When the receiver bandwidth is reduced substantially by increasing the data acquisition time Ts, the bandwidth across the object becomes less than the chemical shift frequency. The reduced bandwidth eliminates misregistration by displaying the images corresponding to multiple spectral peaks on the same image plane simultaneously. An additional gain due to the reduced bandwidth is the reduced thermal Gaussian noise. Unfortunately, the increased Ts results in an increased TE, which causes the signal to be attenuated by T2 relaxation. The optimum measured Ts (and TE) values for successful image separation and maximum SNR were 120 and 144 msec for the two spectral peaks, respectively. The long TE also suppresses the rest of the downfield spectral peak cluster of PFB. The degree of magnetic field inhomogeneity and tissue susceptibility across the object may cause some limitations in the application of this technique; however, a composite radio-frequency pulse that will allow use of additional spectral lines and/or localized volume imaging techniques may be incorporated to overcome these limitations.


MR imaging of the pericardial cyst.

Findings obtained with magnetic resonance (MR) imaging in four patients with pericardial cyst are reported. MR imaging allowed not only localization and diagnosis in all four cases but characterization of cystic content. MR imaging, including RARE (rapid acquisition with relaxation enhancement) MR hydrography, which shows only liquids with T2s greater than 500 msec, proved to be useful in characterizing the fluid content of a mediastinal lesion and monitoring follow-up. In one case, MR imaging allowed differentiation of a pericardial cyst from a suspected necrotic lymph node in a patient with colic carcinoma, with subsequent correction of staging and therapy. The authors conclude that MR imaging is the method of choice for diagnosis (especially in unusual locations) and monitoring of pericardial cysts and for differential diagnosis of malignant mediastinal cystic tumors that show a solid part.


Fast, interactive algorithm for segmentation of a series of related images: application to volumetric analysis of MR images of the heart.

Magnetic resonance (MR) cine images of the beating heart have excellent spatial and temporal resolution. Extracting the boundaries of the heart from MR images for volumetric measurements is of considerable interest; however, since the number of images involved is large, tracing the boundaries by hand is tedious and prohibitively time consuming. The authors have developed an interactive method of boundary detection that uses the correlation between the cardiac boundaries on temporally or spatially adjacent images to increase the speed of the process and reproducibility of the measurement. A simulated cine MR study of a phantom (total of 155 images) and cardiac cine studies of two patients (192 images each) were analyzed by two independent observers. Analysis of the phantom data was completed in 5.6 minutes (2.16 seconds per image) by observer 1 and 6.3 minutes (2.4 seconds per image) by observer 2. The percent measurement errors for 31 phantom volumes (30-120 mL) were 0.96% and 0.83% for observers 1 and 2, respectively. The observers analyzed the patient studies in 14-23 minutes (4.4-7.2 seconds per image), with interobserver variabilities of 5.8% and 3.7% for the two patients, respectively. The authors conclude that their flexible, semiautomatic, interactive algorithm allows rapid and reproducible detection of structural boundaries.


Minimizing TE in moment-nulled or flow-encoded two- and three-dimensional gradient-echo imaging.

A method for minimizing field-echo delay in moment-nulled gradient-echo imaging is presented. Even though ramps are accounted for, the analysis yields simple closed-form solutions. The method is then generalized to the section-select waveform for three-dimensional volume imaging and to flow encoding for phase-contrast imaging. Three strategies for first-moment selection in phase-contrast imaging are discussed, including a new strategy that always yields the minimum echo delay. Trapezoidal and triangular gradient lobe shapes are analyzed.


Rapid fat/water assessment in knee bone marrow with inner-volume RARE spectroscopic imaging.

An inner-volume modification of a spectroscopic imaging technique based on RARE (rapid acquisition with relaxation enhancement) sequences is shown to provide, in less than 1 minute, spectra suitable for fat/water peak-area integration from selected imaging columns containing more than 1,000 5 x 5 x 1-mm voxels. A limitation is the unavoidable T2 weighting of the spectral peaks, which influences estimations of true fat/water composition from the spectra. Studies obtained in the knees of healthy volunteers demonstrate the ability of the technique to enable characterization of the two major proton peaks in bone marrow. Data collected at two or more effective TEs are suitable for extrapolation of fat/water estimates to zero TE.


Chemical shift artifact along the section-select axis.

Chemical shift artifact (CSA), familiar to radiologists along the frequency-encoding axis, also occurs along the section-select axis. The authors observed a case in which CSA mimicked a renal mass. Subsequent retrospective analysis of 50 abdominal magnetic resonance (MR) imaging studies was performed to assess occurrence of CSA adjacent to the upper and lower renal poles. CSA along the section-select axis was observed in 76% of cases and adjacent to 39% of all renal poles imaged. CSA along the section-select axis is common in abdominal MR imaging and may occasionally mimic disease.


Computer-controlled flow simulator for MR flow studies.

A novel computer-controlled flow simulator for use in magnetic resonance (MR) flow experiments was evaluated. The accuracy in constant-flow mode was better than 1%. The accuracy in pulsatile-flow mode was found to be dependent on the interconnecting tubing. The short-term and long-term reproducibilities of pulsatile waveforms were less than or equal to 0.4 mL/sec (1 standard deviation). Increased response times due to the lengths of tubing required in MR flow experiments were surmounted by using a modified tubing configuration and precompensated waveforms. Piston reversal was found not to cause major difficulties in MR flow experiments.


Do current regimes of hormone replacement therapy protect against subsequent fractures?

It is now accepted that unopposed oestrogen therapy reduces osteoporotic fractures by about 50%. Although current regimes with added progestogens are thought to act similarly to unopposed oestrogens, no study has yet demonstrated an effect on fractures with the former. Using a retrospective cohort design we studied fracture rates in women attending a menopause clinic for hormone replacement therapy (HRT) and compared them with women derived from the general population. Data were analysed from 1075 women exposed to HRT and 1741 non-exposed postmenopausal women. In all 226 fractures were reported between 1977 and 1986, the commonest site being the distal radius, occurring in 28 of the HRT women and in 37 of the non-exposed women. The incidence density rate for fracture of the distal radius is 3.5/1000 woman-years (wy) in non-exposed women. This was similar to the rate in the HRT women prior to HRT use, the rate falling by 30% after exposure from 3.2 to 2.2/1000 wy. The protective effect on osteoporotic fractures increased progressively with duration of use. After 5 years of use the relative risk fell to 0.5 (95% confidence interval, 0.2-1.2) for all osteoporotic fractures and for the distal radius to 0.18 (95% confidence interval, 0.05-1.3). No similar changes were seen for non-osteoporotic fractures. There were 6 (0.6/1000 wy) reported fractures of the hip in the non-exposed group compared with none in the HRT group (when 1.7 were expected based on non-exposed rates) (p = 0.15).(ABSTRACT TRUNCATED AT 250 WORDS)


Spinal fractures during fluoride therapy for osteoporosis: relationship to spinal bone density.

Recent studies report that fluoride therapy for osteoporosis increases spinal bone density without improving vertebral fracture rate, challenging the notion that restoration of bone mass improves bone fragility. To further evaluate this issue, the relationship between spinal bone density and vertebral fracture rate was examined in a large number of fluoride-treated, osteoporotic patients. A retrospective assessment was made of clinical data collected from our observations of 389 osteoporotics treated with fluoride 30 +/- 8 mg/day (mean +/- SD) (equivalent to 66 +/- 17 mg NaF/day) and calcium 1500 mg/day for 28 +/- 18 months. Fracture rate and bone density were assessed in the same region of the spine (i.e., T12 through L4) using quantitative computed tomography (QCT). Spinal bone density increased with time on fluoride, but the relationship was hyperbolic (r = 0.99, p less than 0.0001; asymptote = 167 mg/cc on double-reciprocal plot), suggesting a plateau in the response. The spinal fracture rate decreased as a function of time on therapy (r = -0.83, p less than 0.01), and was inversely related to spinal bone density during fluoride therapy (r = 0.70, p less than 0.001 on arithmetic plot; r = -0.79, p less than 0.001 on semi-log plot). The subgroup of patients who responded to treatment with a significant increase in spinal bone density had a 48% reduction in spinal fracture rate compared with non-responders (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)


Women with climacteric symptoms: a target group for prevention of rapid bone loss and osteoporosis.

The relations of vasomotor symptoms to the rate of bone loss and to the response of forearm bone mineral density (BMD) to hormone replacement therapy (HRT) were analyzed in a 2-year non-randomized study. Forty peri/postmenopausal women who were given HRT for climacteric symptoms were compared with untreated control women, individually matched for age and length of time since the last menstrual period. The women who received HRT gained, on average, about 2% in BMD, while the control women lost about 6% (mean group difference 8%; 95% confidence interval (CI) 5.7-10.2). Adjustment for potential confounders did not change the results. Sweating frequency was inversely correlated with serum estradiol levels (p = 0.05). Among untreated women the rate of bone loss was higher in those who had frequent sweating initially than in those with less frequent sweating (9% vs. 4%, mean difference 4.3%; 95% CI 0.7-7.8, p = 0.023). Among women who received HRT, those who had the highest frequency of sweating initially, compared with those with a lower frequency, showed a greater gain in bone density (mean difference 4%; 95% CI 1.2-6.8, p = 0.007). In multivariate analysis adjusting for covariates, sweating frequency remained an independent determinant of change in bone density in women both with and without HRT. When sweating frequency and serum estradiol levels were compared in a multivariate analysis, only sweating frequency showed an independent association with rate of bone loss. The findings indicate that women with severe climacteric symptoms may have an excessive rate of bone loss and should therefore be considered as a special target group for prevention of osteoporosis.(ABSTRACT TRUNCATED AT 250 WORDS)


Are calcium intakes and physical activity patterns during adolescence related to radial bone mass of white college-age females?

The determinants of bone mass, i.e., size and density, in young adult women after cessation of growth in length of the bones are not well understood. Usual dietary calcium (Ca) intakes and physical activity (PA) patterns during the post-pubertal half-decade have been considered as two important factors contributing to bone mass. In the present hypothesis-generating cross-sectional study, radial bone mineral content and density were measured by single-photon absorptiometry at two sites containing different proportions of trabecular and cortical bone tissue in 705 healthy, Caucasian college women (18-22 years). Ca intake during high school and college, as estimated by milk and cheese intake only, was categorized into low, moderate and high groups; and physical activity, estimated during the same time frame, was also categorized into low, moderate and high groups. Bone measurements were related to both long-term dietary Ca intake from milk and cheese and long-term PA in sports, dance or other exercises, as assessed by recall. By univariate analyses, both distal and mid-radial bone mineral content (BMC) and areal bone mineral density (BMD) were found to be positively related to gynecological age (GA) (p less than 0.01). Also, independent effects of long-term Ca intake (p less than 0.05) on distal BMC and BMD, and of long-term PA (p less than 0.05) on distal and mid-BMC and BMD were observed.(ABSTRACT TRUNCATED AT 250 WORDS)


No secular increase in the prevalence of vertebral fractures due to postmenopausal osteoporosis.

We examined whether the prevalence of vertebral fractures in otherwise healthy, 70-year-old Danish women had increased during an interval of 10 years. The population-based epidemiological study included two age-matched groups of postmenopausal women. Group 1 consisted of 70-year-old women (n = 386) living in a defined area of suburban Copenhagen recruited in 1979 for an epidemiological study. Of the 285 women who were entered, 173 were judged healthy, without secondary causes of osteoporosis. Group 2 was recruited by sending questionnaires to all women aged 68-72 years living in the same area in 1989. Of the 512 women who attended a medical screening, 387 were found to be without secondary causes of osteoporosis and had a spinal radiograph. Radiographs of the thoracolumbar spine were assessed for vertebral fracture by five radiological methods. There was no significant difference between the two groups in the prevalence of vertebral fractures and the 95% confidence intervals overlapped completely in all methods. The prevalence rates varied by method from about 35% to more than 80% but the distribution of fracture types was similar in the two groups. We conclude that the prevalence of vertebral fractures due to postmenopausal osteoporosis has not increased since 1979 in otherwise healthy women residing in suburban Copenhagen, and that comparison of prevalences between studies requires that they use the same method of radiological assessment.


Measurements of broadband ultrasonic attenuation in the calcaneus in premenopausal and postmenopausal women.

We report a study of broadband ultrasonic attenuation (BUA) in the calcaneus in 248 women. Measurements were performed with a Walker-Sonix UBA-575 ultrasonic bone analyser. The populations studied were 15 healthy young volunteers (group 1, mean age 26 years), 200 healthy pre- and postmenopausal women (group 2, mean age 53 years) and 33 osteoporotic women with vertebral crush fractures (group 3, mean age 66 years). Subjects in group 1 each had 10 repeated measurements of their right heel. Duplicate BUA measurements in the right heel were performed in 96 subjects and bilateral scans in a further 87 women in group 2. The remaining 17 subjects in group 2 and those in group 3 had a single scan of the right heel. All women in groups 2 and 3 had dual X-ray absorptiometry (DXA) scans of the lumbar spine and femoral neck. The precision study on the women in group 1 gave a root mean square (RMS) coefficient of variation (CV) of 4.2%. Individual CV results showed statistically significant differences (range 1.3%-7.6%). Duplicate scans in subjects in group 2 gave a RMS CV of 4.6% while the bilateral measurements showed no significant difference between the two heels. Linear regression analysis gave the following relationship between BUA and age: BUA = 87.1 - 0.76 (Age - 40) dB/MHz (r = -0.31, p less than 0.001, SEE = 14.0 dB/MHz). Multivariate regression analysis showed that, in addition to age, years since the menopause was also a significant factor in predicting BUA.(ABSTRACT TRUNCATED AT 250 WORDS)


A screening and counseling program for prevention of osteoporosis.

Prevention of osteoporosis is an increasingly salient public health concern as our society ages. This report describes the procedures used at an osteoporosis center to which people come for screening and counseling. The patients on whom this report is based were 53 non-smoking women, 1-10 years postmenopausal at the time of their first visit to the center, who chose not to undertake estrogen therapy, and who returned for a second visit in 12-18 months. They were classified as to adequacy of calcium intake (at least 750 mg/day) and exercise (at least 3 h/week of weight-bearing exercise) at both visits; complete data on calcium intake and exercise were available on 46 of the women. Bone densities were measured at the femoral neck and lumbar spine with dual energy X-ray absorptiometry, and at the distal radius with single photon absorptiometry. At the first visit, 67% of the women reported adequate exercise and 43% reported adequate calcium intake. At the second visit, the percentages in the adequate categories had increased to 74% for exercise (p = 0.06) and 70% for calcium intake (p = 0.02). Age at the first visit was inversely correlated with femoral (r = -0.40, p = 0.003) and spinal (r = -0.36, p = 0.009) bone densities; the correlation with radial bone density did not achieve significance (r = -0.27, p = 0.55). Rather than declining, as would be expected in early postmenopausal women, bone density rose slightly, but not significantly, between visits for all three sites.(ABSTRACT TRUNCATED AT 250 WORDS)


Risk of osteoporosis in men with chronic bronchitis.

Theoretically, patients with chronic bronchitis are at risk for osteoporosis. Bone metabolism was assessed in 44 male chronic bronchitics treated with oral prednisolone (C+; n = 19) or with bronchodilatory drugs alone (C-; n = 25). In both groups, serum osteocalcin was lower (p less than 0.001) than in age- and sex-matched controls (mean (ng/ml) C+ 1.0, C- 1.9, controls 4.2), while testosterone was at the lower limit of the reference range. Low trabecular bone mineral density (BMD) was noted in the C- group (median Z score -1.0), but both cortical and trabecular BMD were depressed in the C+ group (-1.0 and -1.4, respectively). In conclusion, chronic bronchitics treated with corticosteroids, even at low doses, are at risk for osteoporosis. In both groups, additional factors such as hypogonadism might be responsible for low BMD and low osteocalcin levels. A decrease in bone formation is a possible mechanism of action.


Bone mineral content in women: trends of change.

Altogether 426 women had their forearm bone mineral content (BMC) measured with single photon absorptiometry (SPA): one group in the early 1970s, another about 18 years later. Both groups represented purportedly healthy subjects. A third group of 328 women, measured at the same time as the second group, was from the same population but chosen by random selection (the population-based group). In the two sets of non-population-based women there was a small percentage reduction in the cortical forearm bone mass in the recent measurement as compared with the earlier measurement. This was significant only in women below 70 years of age. The forearm BMC, both cortical and trabecular, was less in all age groups of women randomly selected from the same population as the healthy control sample. This difference emphasizes the importance of selecting normative data from a population-based sample.


[Status of the guideline for hospital hygiene and prevention of infection of the Federal Public Health Office].

1976 the Federal health Office published the guideline "Erkennung, Verhütung und Bekämpfung von Krankenhausinfektionen". The guideline defines the levels of hospital hygiene and gives important directions to physicians and nursing staff. The guideline has been increasingly incorporated in regulations.


[Refuse disposal in the hospital].

From the point of view of hygiene and the prevention of infection, waste products from hospitals have to be divided into three groups: household type refuse, refuse specific to hospitals, refuse from infectious wards. Particular care has to be taken in hospitals with the collection and transport of specific hospital refuse and refuse from infectious wards, but after being delivered to the central collecting point the former--in contrast to refuse from infectious wards--can be removed together with household type refuse in the normal manner by the local waste disposal service. If it is not to be incinerated, refuse from infectious wards may only be disposed to together with household type refuse after undergoing a good disinfection practice.


[Functional construction aspects of surgical units].

The historical development of Hospital hygiene is described showing in particular the demands made on the construction of operating units deduced from this evolution. Modes of infection inside operating units are considered and possible measures to interrupt these are discussed. The fundamental ideas expressed in the first version of the annex "Operating Unit" to the guidelines of the Federal Public Health Office "On the Identification, Prevention and Control of Hospital Infections" are explained in detail. The demands formulated originally are examined critically and the 1990 version is discussed. In addition, update requests are put forward such as ambulatory operation and new operating methods such as minimal-invasive operating, as well as new hygienic hazards arising from the increase of equipment inside operating theatres. An additional section deals with the fundamental ideas of DIN 1946, part 4, as far as operating units are concerned.


[Perspectives of the hospital hygiene team].

Since 1976, the training of hygiene experts exists in the Federal Republic of Germany. At the same time, the functions were formulated in the General Directions for Hospital Hygiene and Prevention of Infections of the Federal Public Health Office, Berlin. Meanwhile, there are records and statistics which show that hygiene experts are not only staff of documentation of the hospital hygiene, but realize diverse specialized and responsible functions. In June 1991, VHD carried out an opinion research poll in 600 German hospitals (= 17.1% of the hospitals in the FRG) the situation of the hygiene experts. Due to these results, a very representative statement is possible on the functions and work of hygiene experts in hospitals. Because of an improved and longer training of hygiene experts, which has been in force since January 1st, 1992, the preparation of installing more training centres is important, in order to the demand qualified hygiene experts.


[Update of DIN 19.643--treatment and disinfection of swimming pool and bathing tub water].

German Standards Specification DIN 19,643 is at present under revision for health reasons and because of both negative and positive experiences gathered in practice. To enable adaptation of the standards specification to future developments, a Part I of the specification is being created comprising the demands to be made on the quality of the water and general demands on the construction and operation of swimming pools and tubs and basins in bath houses, e.g. in spas or municipal swimming pools. The subsequent parts of the new specification (Part 2 to Part n) concern the demands to be made on individual combinations of processes; these can be supplemented at any time in accordance with technical progress without requiring revision of the entire standards specification. Essential innovations are the reformulation of the required efficiency of disinfection, the introduction of the parameters Legionella pneumophila, trihalogen methane (THM) and the reduction of the limit value for chloramines. Technically speaking, the new features concern the automatic measurement of the auxiliary parameters of hygiene such as redox potential, pH value and free chlorine, automatic control of disinfectant additions, automatic filter rinsing with fluidization of the filter-bed to a prescribed minimum bed expansion, and the sight-glas at the filter container. The demands made on Jacuzzi and warm water spouted bed besins are integrated into the specification, thus obviating the need for German Standards Specification DIN 19,644.


[Examination and evaluation of the hygiene status of natural peloids for human medical use].

For curative treatment in German spas, different muds for medical mud-baths and mud-packs are also used besides mineral springs. Muds of this kind are known by the collective term of "peloids". According to the "Definitions of the German Health Resorts Association", peloids are classified by a new geological-genetic system. After discussing hygienic aspects and problems of diverse therapeutic applications using peat, marine muds or fango, standardized methods for microbiological examinations are described. For the microbiological control parameters E. coli, Coliform organisms, Staphylococcus aureus, Pseudomonas aeruginosa and Candida albicans, suggested values and threshold values are given in detail.


[Draft of the swimming pool water regulation. Presentation, status: 17 September 1991, according to the federal hearing of 11 December 1991 in Bonn].

Comments are given on the present status of regulations concerning water in swimming pools and baths--1991--(in connection with the KOK regulations--1972--and the Federal German standard [DIN] No. 19643-1984-). Reference is made to microbiologic limits of Legionella pneumophila among others.


[Construction hygiene in the area of bathing and recreation].

Construction hygiene in the bathing and recreation areas underwent many changes during the decades. In each case it was accomplished very intensively and defined by the actual needs of the population or by those responsible for the population. With regard to the development of bathing since the Romans, the bathing habits of the Roman times, during the Middle Ages, at the 18th century, at the beginning of the 19th century and of today are characterized broadly. The respective constructional as well as the hygienic measures are also shown and discussed in this context. Whereas the Roman thermals created prerequisites for physical activity as well as possibilities for spare time, and in the early Middle Ages, sexual excesses and the risk factors connected thereby led to the transfer of infectious diseases and consequently to the elimination of the public baths. At the beginning of the 18th century first the cleaning of the body and at the beginning of the 20th century physical activity became very important. With the help of the construction plans for baths and shower-baths and swimming pools of 1906 the aims and purposes of the baths are discussed and the respective constructional changes are shown the example of warm water baths (swimming pools) in Hamburg.(ABSTRACT TRUNCATED AT 250 WORDS)


[Public health requirements in physical therapy].

Physiotherapy involves manifold measures that are partly not clearly separated from other methods of therapy. In most cases the skin or mucosa are not injured so that the danger of infectious complications is relatively low. On the other hand, patients with severe underlying diseases which are problematic from the aspect of hygiene in connection with infections, may have to be treated (for example, intensive-care patients, patients with decubital ulcers etc.) In such patients physiotherapy must comply with hygienic precautions that are employed with other diseases and treatments to prevent the transfer of pathogens. Special rules govern the composition of the water and the servicing of equipment used in hydrotherapy (German DIN standard specification No. 1964). Guidelines for the water used in municipal swimming pools and baths are in preparation. Other rules to be observed concern the recognition, treatment and prevention of nosocomial infections. In addition, every establishment must set up definite rules for regular measures to prevent infections and to monitor these measures, especially with regard to cleaning and disinfecting.


[Sanitation measures in evidence of Legionella].

Appearance of Legionella disease generally is underrated. Conclusions as to disease frequency from Legionella antibody investigations are not reliable. The number of microbes necessary to produce illness depends from individual preliminary conditions. In special areas of the hospital the rate of diseases caused by Legionella can be reduced by protection. In bathing areas generally the hitherto existing regulations of the Federal Health Authority are sufficient: Continual warm water temperature increases from 60 degrees C, chlorination if necessary, regular stepwise controls. Insufficient results are produced by intermittent temperature increases. Filters that are impermeable for microbes appear uneconomical for bathing areas.


Immunologically induced coronary artery stenosis in allografts after heart and heart-lung transplantation in rats.

The role of the lung in suppressing immunologically induced coronary artery stenosis after heterotopic allograft transplantation was studied in rats. Thirty-nine recipients were divided into two groups: untreated and treated. The untreated group was divided into two subgroups--the heart allograft TH group and the heart-lung allograft THL group. The treated group was divided further into four subgroups depending on when the graft was harvested, after 30 days or 60 days (T30-H and T30-HL group, and T60-H, T60-HL, respectively). Rejection was assessed by Lurie's classification. The percent of intraluminal stenosis (PIS) was determined by planimetry. All treated animals received cyclosporin A 10 mg/kg/day intramuscularly for 20 days. In the untreated group, heart-lung allograft survival was longer than heart allograft survival. In the treated group, all grafts were still beating when the animals were killed. The rejection grade score in the T30-H and T30-HL groups were lower than those in the T60-H or T60-HL groups. The PIS in the THL group was slightly lower than that in the TH group. However the PIS increased over time in both the TH and THL groups. This study demonstrates that the lung suppresses but does not abolish immunologically induced coronary atherosclerosis-like occlusive lesions after cardiac transplantation.


Estimated weight of the residual parathyroid gland after parathyroidectomy using plasma levels of the parathyroid hormone.

The possibility of estimating the total weight of the parathyroid glands based on the plasma concentration of the parathyroid hormone (PTH) would be of great help when searching for the parathyroid glands during surgery on patients with secondary hyperparathyroidism. Thus, we studied the relationship between the levels of carboxyl-terminal PTH (C-PTH), midportion PTH (M-PTH) and intact PTH, and the weight of the parathyroid glands resected for secondary hyperparathyroidism. The subjects studied were 11 patients with secondary hyperparathyroidism caused by chronic renal failure. The pre- and post-operative differences in the plasma C-PTH levels and plasma M-PTH levels were significantly correlated with the weight of the resected parathyroid glands (p less than 0.001 for both), but there was no correlation between the differences in the levels of intact PTH and the weight of the resected parathyroid glands. From these relationships we estimated the weight of the residual parathyroid gland after parathyroidectomy using the levels of each PTH. All patients in whom the residual parathyroid gland was estimated to be heavy based on the levels of M-PTH showed recurrence of hyperparathyroidism after the parathyroidectomy. We therefore found that estimation of the weight of the parathyroid glands from the levels of M-PTH is both possible and useful.


Marked and prolonged depression of factor XIII after esophageal resection.

Anastomotic leakage is one of the most common complications of esophagectomy and, since Factor XIII is required for normal wound healing, we investigated the temporal changes in plasma Factor XIII following esophagectomy and hepatectomy. A control group of patients undergoing other abdominal operations was also studied. Factor XIII activity was determined before surgery and on postoperative days (POD) 1, 3, 7 and 14. The plasma levels of acute phase protein were also measured. The plasma Factor XIII activity decreased significantly in both the hepatectomy and control groups until POD 7, reaching the lowest level on POD 3. In contrast, the esophagectomy group showed significant decreases in Factor XIII levels throughout the postoperative study period, with a nadir with an average activity of 56 per cent on POD 7. Preoperative transferrin levels had a positive correlation with Factor XIII levels measured on POD 3 and there was also a positive significant correlation between Factor XIII activity and alpha 2-macroglobulin levels on POD 3. These results suggest that there is a marked and prolonged depression of plasma Factor XIII activity following esophagectomy which may be attributed to accelerated tissue demands, inadequate synthesis or increased degradation. Moreover, the severe and sustained decrease in Factor XIII activity may be related to poor wound healing after esophagectomy.


A clinical study of postoperative infections following open-heart surgery: occurrence and microbiological findings in 782 cases.

A total 782 consecutive patients underwent open-heart surgery with CPB between January, 1979 and December, 1988, at the Yamagata University Hospital. We assessed the incidence of postoperative infections in relation to age, the duration of surgery and antibiotic prophylaxis, and examined the causative organisms, after which the types of infecting flora were compared between the 1st period, from 1979 to 1983 and the 2nd period, from 1984 to 1988. Postoperative infection occurred in 104 of the 782 patients (13.3 per cent); in the form of a wound infection in 41 (5.2 per cent), pneumonia in 33 (4.2 per cent), urinary tract infection in 9 (1.2 per cent), prosthetic valve endocarditis in 6 (0.8 per cent), and other infections in 15 (1.9 per cent). Patients aged under 12 months or over 60 years showed a higher incidence of infection, being 17.4 per cent and 19.2 per cent, respectively. Patients who underwent an operation of over 8 hours duration also had a significantly higher incidence compared to those whose operation time was less than 4 hours, being 32.9 per cent and 6.3 per cent, respectively (p less than 0.0001). There was no significant difference in the incidence of postoperative infection between patients given or not given preoperative prophylaxis. A total 123 species of organisms were isolated from the 104 patients, 52.8 per cent being gram-negative bacteria (GNB), and 43.9 per cent gram-positive bacteria (GPB), and a remarkable increase in the incidence of GPB was seen in the 2nd period compared to the 1st period from 31.7 per cent to 50.0 per cent.(ABSTRACT TRUNCATED AT 250 WORDS)


The relationship between lymph node metastases and DNA-ploidy status as prognostic factors in invasive breast cancer.

We evaluated the relationship between the regional lymph node metastases and the DNA ploidy status in 207 patients with invasive breast cancer, as well as their prognostic values in estimating the prognosis of breast cancer. A significantly higher incidence of aneuploidy was found in patients with a large T3 or T4 tumor, a positive axillary lymph node status, more than 4 positive axillary lymph nodes or positive internal mammary lymph nodes. In a univariate study, the overall survival was significantly correlated with tumor size, axillary lymph node status, axillary and internal mammary lymph node metastases, and DNA ploidy status. In the multivariate analysis, however, only axillary and internal mammary lymph node metastases were recognized as important independent prognostic factors on survival. In this series, the DNA ploidy status did not appear to be an independent prognostic factor either in the entire series or in negative axillary node patients, since it was closely correlated with the axillary or internal mammary lymph node metastases, and the axillary node negative patients had an extremely favorable prognosis.


The antitumor activity and immunosuppressive effects of 5-fluorouracil suppositories in rectal cancer patients.

The antitumor activity and immunological effects of the local administration of 5FU were investigated by determining the tissue concentration of 5FU, histological appearance of the primary tumor, and lymphocyte subsets of the regional lymph nodes in 23 rectal cancer patients. Twelve patients were treated with 5FU suppositories preoperatively, being the 5FU group, while 11 patients were given no preoperative treatment, being the control group. The 5FU concentrations in the primary tumors were higher than those in the regional lymph nodes and appeared to remain high for an extended period. No histological changes peculiar to the 5FU group were observed in the primary tumors. An analysis of the lymphocyte subsets in the pararectal nodes revealed that Leu2a+15- cells, or cytotoxic T lymphocytes, were significantly decreased in numbers in the 5FU group compared to the control group. These results suggest that the local use of 5FU may not only exert an antitumor effect against rectal cancer, but can also cause the suppression of antitumor immunity in the regional lymph nodes.


Hemodynamic changes after resection of thoracic duct for en bloc resection of esophageal cancer.

An en bloc resection of esophageal cancer is one of the most radical forms of esophagectomy, and includes the resection of the thoracic duct, but a relatively high hospital mortality rate has been reported. There is very little knowledge on the pathophysiological changes after resection of the thoracic duct. We examined 24 patients who underwent en bloc resection. Some patients developed severe tachycardia or shock postoperatively which subsided after a massive infusion of plasma. Analysis of the fluid balance revealed that much more fluid was necessary during surgery and the postoperative 24 h than in patients treated by a standard esophagectomy. Postoperative lymphangiography or CT revealed abnormal collateral lymphatics around the kidneys or in the pelvic cavity. This suggests the development of the lymphaticovenous shunts, which differed depending on the anatomy of each patient. One patient with chronic hepatitis developed uncontrollable ascites. These are important findings which can hopefully reduce the high rate of hospital death after this operation.


Polymorphonuclear leukocyte function and serum opsonic activity in surgical patients.

Thirty-six patients who underwent major surgery were studied in order to clarify the perioperative changes in polymorpho - nuclear leukocyte (PMNL) function and serum opsonic activity. In patients without postoperative infection, the PMNL phagocytic-bactericidal capacity and plasma elastase levels significantly increased, while the serum opsonic index remarkably decreased just after surgery, however, all returned to the preoperative levels within 1 or 2 weeks. Conversely, in patients with postoperative infection, the PMNL bactericidal capacity and plasma elastase levels remained at high levels even after 1 or 2 weeks, while the PMNL phagocytic capacity and serum opsonic index substantially decreased after 2 weeks compared with the patients without postoperative infection. Plasma leukotriene B4, which is a potent chemo-attractant for PMNL, noticeably decreased in the patients with postoperative infection on the first postoperative day compared with that in the patients without postoperative infection. Our data suggests that the most important predisposing factors to postoperative infection may be a depressed PMNL phagocytic capacity and a lower serum opsonic activity after surgery, and that the increased PMNL bactericidal capacity and high plasma elastase levels during postoperative infection may contribute to the susceptibility to multiple organ failure.


A correlation between arterial ketone body ratio and concentration of beta-hydroxybutyrate as an indicator of hepatic functional reserve.

We have investigated the correlation between the arterial blood ketone body ratio (AKBR) and beta-hydroxybutyric acid (HBAC) in the course of a 75 g glucose tolerance test. The correlation was revealed to be represented by an equation of Y = A + BX [X = log(HBAC), Y = log(AKBR)] with high significance. This expression existed in both normal individuals and patients with liver, biliary tract or pancreas disease. The postoperative course was unsatisfactory because of liver dysfunction in cases whose value B was more than -0.6 in bisegmentectomy and more than -0.45 in uni- or subsegmentectomy. The coefficient B in the equation was suggested to contribute to the evaluation of hepatic functional reserve.


Factors contributing to deficiencies in cell-mediated immunity in esophageal cancer patients.

Based on the previous data which indicated a preoperative decrease in cell-mediated immunity (CMI) is associated with the occurrence of infectious complications following surgery on patients with esophageal cancer, we examined possible factors contributing to a decrease in CMI levels. A multiple linear regression analysis was made on data from 76 patients with esophageal cancer and 53 with gastric cancer as the control. In patients with esophageal cancer, both protein-calorie malnutrition (PCM) and age factor contributed to a decrease in CMI, although the contribution of the latter was weak while the stage of the cancer and the grade of dysphagia showed no such contribution. The PCM and stage of the cancer were contributing factors in patients with gastric cancer. Thus, these results indicate that PCM and old age, and not the presence of malignant tumors, play a significant role in deficiency in CMI in patients with esophageal cancer.


Effect of intra-hepatoarterial infusion of MMC and CDDP for gastric cancer patients with liver metastases.

The influence of operative treatment and chemotherapy on the prognosis in 93 gastric cancer patients with liver metastasis was studied. Chemotherapy included the systemic administration of mitomycin C (MMC) (39 patients), an intra-hepatoarterial infusion of MMC (MMC IAC group) (19 patients) and an intra-hepatoarterial infusion of MMC and cisplatin (CDDP) (MMC + CDDP IAC group) (24 patients). Either MMC or MMC and CDDP were given in 1-4 courses every 3-4 weeks from the first one to two post operative weeks. The response rate was 4 per cent (1/23), 29 per cent (5/17) and 73 per cent (17/23) for MMC systemic administration, MMC IAC and MMC + CDDP IAC, respectively, with a significantly high rate of effectiveness for the MMC + CDDP IAC. In addition, regarding the median survival period, the MMC + CDDP IAC group showed 11.8 months, as compared with 2.9 months for other chemotherapeutic treatments, indicating a good prognosis regardless of any possible resection of the primary lesion. A Cox proportional hazard model revealed the treatment by MMC + CDDP IAC alone to be a significant independent factor. These results indicated that MMC + CDDP intra-arterial chemotherapy is an effective approach to gastric cancer with liver metastasis.


Aggressive repeat liver resection for hepatic metastases of colorectal carcinoma.

Although hepatectomy for liver metastases from colorectal carcinoma is an effective treatment, recurrence in the liver is still the most common site after hepatectomy. Thirty patients underwent hepatectomy for hepatic metastases and 17 of them had recurrence in the remnant liver during the following 12-year period. Six of the 17 patients underwent a removal of isolated hepatic recurrences. Two of the six patients underwent a third hepatectomy, and three patients underwent partial lung resection on a total of five occasions. There were no operative deaths while complications after a third hepatectomy contributed to a high morbidity rate of 40 per cent. The mean length of survival of the six patients was 28.5 months from the second hepatectomy. The prognosis of the six patients who underwent a repeat hepatectomy was significantly better than that of patients with unresectable recurrence after an initial hepatectomy (p less than 0.01). The overall 5-year survival of 29 patients excluding one in-hospital death was 44.7 per cent. Our results reveal that aggressive removal of isolated and resectable recurrent disease has the potential to improve the prognosis of selected patients with metastatic cancer.


A case of multiple leiomyomatous lesions of the lung: an analysis of flow cytometry and hormone receptors.

A 36 year old woman was admitted to our department because of a chest X-ray which showed multiple developing shadows. She underwent bilateral exploratory thoracotomies and a total 5 tumors were resected and pathologically diagnosed as benign metastasizing leiomyoma, the largest of which was positive for the progesterone receptor and negative for the estrogen receptor. A histogram of this tumor using a flow cytometer showed a diploid pattern and 4.6 percent of the S phase which was not more than that of a leiomyoma of the uterus from another patient. Two months later, she underwent a hysterectomy and bilateral salpingo-oophorectomy for treatment of the positive progesterone receptor in the pulmonary lesions. The resected uterine myoma and normal myometrium showed positive estrogen and progesterone receptors. For the subsequent 28 months she has been free of any further symptoms. Benign metastasizing leiomyoma of the uterus is a rare disease and very interesting because of its histological benignity and hormonal dependency. However, according to the literature, it is often confused in entity due to the fact that normal lung tissue also possesses hormone receptors. Considering our data on hormone receptors, it is rational to think that multiple leiomyomatous lesions in the lung should only be diagnosed as benign metastasizing leiomyomas when they possess positive estrogen and progesterone receptors.


Retrograde jejunogastric intussusception: is endoscopic or surgical management more appropriate?

Jejunogastric intussusception (JGI) is a rare complication which can develop after partial gastrectomy, gastroenteroanastomosis or enteroanastomosis. Although its management is usually surgical, an endoscopic reduction can alternatively be attempted. We present herein a case of acute JGI in which failure of endoscopic reduction required surgical resection and reconstruction. This is followed by a discussion based on the current available literature.


A rare cause of digestive hemorrhage: an aneurysm of the superior pancreaticoduodenal artery rupturing into the duodenal stump of a Billroth II partial gastrectomy.

We report herein a case of an iatrogenic superior pancreaticoduodenal arterial aneurysm which ruptured into the duodenal stump of a Billroth II partial gastrectomy. Superselective angiography was used for the diagnosis, and successful embolization performed nonoperatively. A review of the literature revealed both the etiology and site of rupture in this case to be extremely uncommon.


Anomalous arrangement of the pancreaticobiliary ductal system without dilatation of the biliary tract.

A rare case of anomalous arrangement of the pancreaticobiliary ductal system without dilatation of the biliary tract (AAPBDS without DBT) associated with mucosal dysplasia of the biliary duct is described herein. A 53 year old male with a long history of diarrhea and right upper abdominal pain was diagnosed as having AAPBDS without DBT by endoscopic retrograde cholangiopancreatography and other examinations. Excision of the gallbladder and biliary duct with a Roux-en-Y hepatico-jejunostomy was performed and subsequent pathological examination of the surgical specimens showed mucosal hyperplasia of the gall-bladder and mucosal dysplasia of the biliary duct. Considering the dysplastic changes of the biliary duct as seen in our case, and the high incidence of AAPBDS without DBT developing into carcinoma of the biliary duct, being 12.2 per cent, we suggest that pancreaticobiliary ductal diversion with excision of the gallbladder and biliary duct should also be performed for AAPBDS without DBT. However, further pathological investigations concerning the excised biliary duct in AAPBDS without DBT will be need to be carried out.


A case of localized peritonitis caused by obstructive colitis proximal to rectal carcinoma: a rare manifestation of obstructive colitis.

A case of obstructive colitis associated with rectal carcinoma in a 56 year old Japanese man is reported herein. He presented to Shinkokura Hospital with severe abdominal pain following a one month history of anal bleeding and mild abdominal pain. On palpation, muscle guarding was observed in the left lower quadrant and the white blood cell count was 14,200/mm3. An exploratory laparotomy was performed under the provisional diagnosis of acute abdomen, which revealed localized peritonitis 8 cm oral to an area of rectal carcinoma. An anterior resection of the lesion was therefore performed together with a descendo-proctostomy. The histopathologic diagnosis revealed adenocarcinoma and obstructive colitis involving the entire thickness of the sigmoid colon and resultant fibrino-purulent peritonitis. His post-operative course was uneventful and he was continuing to do well on the 30th postoperative day, at the time of writing. The clinical significance of this combination of obstructive colitis with rectal carcinoma is briefly discussed following the presentation of this case.


Living related liver transplantation.

Liver transplantation from a brain death donor has not yet been accepted in Japan. The only alternative method at present is transplantation from a living donor. After the first successful living related liver transplantation was performed by Strong in Brisbane, Australia, Japanese hepatic and transplant surgeons also began to perform such operations. As of February 1991, 16 living related liver transplantations had already been performed in Japan, mainly for children with biliary atresia. Five of these patients subsequently died, however, our patient has survived more than 1 year, and she is presently leading a normal school life. The most important issue regarding living related liver transplantation is to ensure the donor's safety. For this purpose, we conducted a preoperative banking of the donor's own blood and plasma. In addition, a selective vascular occlusion was carried out to reduce blood loss during the resection of the liver. Intraoperative color Doppler ultrasonography was introduced for evaluating the circulation of the graft. By using this modality, the following three points were able to be accurately estimated in order to obtain optimal graft perfusion: 1) The most suitable position for the graft to be fixed to the abdominal wall, 2) whether or not the abdominal wall could be closed and 3) the indication for a ligation of the collateral veins to form a porto-systemic shunt. Thanks to these procedures, living related liver transplantations have now become an acceptable transplant method, however, a transplantation from a cadaver that is brain dead but still has a beating heart is still absolutely necessary for adult recipients. Therefore, in the future, both methods should be performed.


Coronary artery bypass grafting in patients with depressed left ventricular function: operative results and long-term follow-up.

Nine consecutive patients with coronary artery disease who had a left ventricular ejection fraction (LVEF) of less than 0.4 and underwent coronary artery bypass grafting (CABG) at our institution were studied. All patients had angina pectoris and six of the nine patients (67%) had a history of congestive heart failure. The mean EF was 0.37 +/- 0.03 and the mean LV end-diastolic pressure was 10.1 +/- 4.9 mmHg. An average of 1.56 +/- 0.50 grafts per patient were placed and there was no operative death. The graft patency rate was 92.9% and the mean EF rose significantly from 0.37 to 0.53 after surgery (P less than 0.05). There was one late death, the 4-year actuarial survival rate being 88.9%. Of the eight long-term survivors, six (75%) were totally asymptomatic and only two had mild angina on exertion. This study confirmed that CABG for patients with depressed LV dysfunction can be performed safely with an acceptably low operative mortality, a significant improvement of LV function, and excellent long-term results.


Endocrine neoplasms of the pancreas: a clinicopathologic study of 24 cases and immunohistochemical remarks.

A total of 24 patients with endocrine neoplasms of the pancreas were clinicopathologically and immunohistochemically studied. They consisted of 18 patients with adenoma and 6 with carcinoma. Of the 24 patients, 13 developed attacks of hypoglycemia due to hyperinsulinemia, and 1 developed an uncontrollable duodenal ulcer caused by the hypersecretion of gastrin, however, the remaining 10 were asymptomatic. No prediction could be made as to the site of origin of the tumors. A clear difference was seen between adenoma and carcinoma in the size of the mass, the mean greatest diameter of the 18 adenoma cases being 1.7 cm, while that of the 6 carcinoma cases was 7.3 cm. One of the 13 insulinomas and a gastrinoma was malignant, while all 24 tumors were positive for neuron-specific enolase. The 13 insulinomas were diffusely positive for insulin and 5 were also shown to be focally immunoreactive for gastrin, with 3 also being immunoreactive for somatostatin and 2 for pancreatic polypeptide. The gastrinoma showed immunoreactivity for somatostatin, insulin, pancreatic polypeptide, and glucagon in addition to a positivity to gastrin. The above findings thus indicate the multiple hormone synthesis of endocrine neoplasms of the pancreas.


Low anterior resection versus abdominoperineal excision: a comparison of local recurrence after curative surgery for "very low" rectal cancer.

In the controversy regarding whether sphincter-saving resection (SSR) or abdominoperineal resection (APER) is more appropriate for the treatment of very low rectal cancer, local recurrence rates seem to play a fundamental role in patient outcome. In order to operate an effective patient selection, very low rectal cancer is defined herein as being located within 4.5 to 7.5 cm from the anal verge. This retrospective report investigates the incidence of local recurrence after curative surgery for very low rectal carcinoma in 24 consecutive patients treated by the same surgical team over a 15-year period using the above surgical procedures. In the APER group, the local recurrence rate was 45.5%, occurring in 5 of 11 cases; and in the SSR group 46.1%, occurring in 6 of 13 cases, with no significant difference between the two groups. Recurrence was found within one year of surgical treatment in all except one case. Despite the strict follow-up program, it was only possible to perform reoperation in two recurrent cases, both previously submitted to SSR and diagnosed by means of transanal ultrasonography and macrobiopsy. The high incidence of local recurrence in this series is explained by the advanced stage of disease in the majority of cases. Thus, as the choice between APER and SSR does not seem to affect the incidence of local recurrence, which is related more to tumor size, site, stage, and grading, preservation of the sphincters and restoration of digestive continuity should be achieved whenever technically possible.


Ultrasonic exploration of contralateral side in pediatric patients with inguinal hernia.

The width of low echoic region at the internal ring (WLIR) of an inguinal canal demonstrated by ultrasonography was applied in the preoperative diagnosis of the contralateral side in pediatric patients with inguinal hernia. The ultrasonic diagnosis of 39 pediatric patients with inguinal hernia and 38 children without inguinal hernia under 15 years of age were conducted at Hamamatsu University Hospital from April 1988 to January 1989. The WLIR of children without inguinal hernia were within 6 mm in boys under 15 years of age and within 3 mm in girls under 5 years of age. There were no statistically significant differences between the WLIR of the right side and that of the left side, and the WLIR of the following three age groups also demonstrated no statistical significance: under 1 year of age, 1 to 5 years of age, 5 to 15 years of age. On the other hand, the WLIR of the hernia side of pediatric patients with inguinal hernia were significantly wider than that of the contralateral side in boys and girls under 5 years of age (P less than 0.01), as well as in boys 5 to 15 years of age (P less than 0.05). Therefore, we recommend a contralateral exploration for pediatric patients with inguinal hernia when the WLIR is 7 mm or more in boys under 15 years of age and 4 mm or more in girls under 5 years of age.


The increase of low density subpopulations and CD10 (CALLA) negative neutrophils in severely infected patients.

We investigated the changes in polymorphonuclear leukocyte (PMN) subpopulations that accompany severe bacterial infection and examined their usefulness as a parameter for assessing the severity of infection. The Percoll density gradient was used to fractionate neutrophils into subpopulations of high density (1.09-1.10), intermediate density (1.08-1.09), and low density (1.07-1.08) with the majority of neutrophils from normal volunteers being of high density. By contrast, neutrophils from infected patients were of intermediate or low density, while those from severely infected patients showed a high percentage of the low density fraction with functional changes in lower chemotactic and beta-gulcuronidase activity. When each density subpopulation in the normal blood neutrophils was tested, low density PMNs had the lowest chemotaxis and minimal beta-glucuronidase activity. These results indicate that the increase in low density PMNs in patients with severe infection clearly reflects the functional impairment of PMNs. Flow cytometric analysis demonstrated that the neutrophils from severely infected patients had an decrease in CD10 expression. The percentage of CD10 positive PMNs correlated well with the severity of infection and with the clinical course of the patients. Thus, we conclude that PMN-density and CD10 expression change during severe bacterial infection, and that the measurement of PMN-subpopulations may be used to complement the clinical assessment of the severity of infections.


Initial hepatic metabolic function in canine liver and pancreas cluster transplantation.

In this study, initial hepatic metabolic function was evaluated by determining the arterial ketone body ratio (AKBR) and plasma amino acid concentrations in an experimental orthotopic combined hepatopancreatic transplantation (OHPT), and comparing the same values in orthotopic liver transplantation (OLT). In OHPT, AKBR decreased in the anhepatic phase and recovered to the preoperative value just 1 h after reperfusion. On the other hand, in OLT, the recovery of AKBR took 3 h after reperfusion with a significant difference compared to OHPT (P less than 0.05). Plasma amino acid levels, especially alanine and total free plasma amino acids increased in the anhepatic phase and recovered within 1 h of reperfusion in OHPT. However, they did not recover until 3 h after reperfusion in OLT. This rapid recovery of hepatic metabolic function in OHPT should be attributed to the order of reperfusion in which the reconstruction of arterial blood flow precedes that of portal blood flow. This model is useful for assessing the best way by which the grafted liver can for assessing the best way by which the grafted liver can control the timing, order, rate, and volume of blood that should be released.


The hemostatic effect of deacetylated chitin membrane on peritoneal injury in rabbit model.

In this study, we determined the effect of 80% deacetylated chitin (DAC-80) membrane on postsurgical bleeding after visceral and parietal peritoneal abrasion. Japanese white rabbits underwent a midline laparotomy followed either by a bilateral peritoneal sidewall abrasion (4 x 4 cm) or an abrasion of liver surface (3 x 2 cm). The injured surface was then covered with a 0.2 mm thick DAC-80 membrane. On postsurgical day 2, the rabbits were sacrificed and the amounts of postsurgical bleeding was determined by quantitating the number of red blood cells recovered in 50 ml peritoneal lavage fluid. The DAC-80 membrane was found to reduce postsurgical bleeding after the abrasion of liver surface (treated with DAC-80 membrane: 2.9 +/- 0.8; control: 24.6 +/- 5.9 x 10(8) cells/peritoneal cavity, P less than 0.005). This same hemostatic activity was not observed after application in the peritoneal sidewall abrasion model. We also measured plasminogen activator activity (PA) and urokinase inhibitory (PAI) activity in the spent culture media of macrophages recovered from the postsurgical peritoneal exudate. The DAC-80 membrane reduced the PA secretion from postsurgical macrophages after liver surface abrasion (treated with DAC-80: 2.8 +/- 0.7; control: 3.9 +/- 0.9 mPU/ml). The DAC-80 membrane also showed similar effects on PA secretion after peritoneal sidewall abrasion. No significant effects were found in the secretion of PAI by postsurgical macrophages in both surgical models. These findings suggest that the DAC-80 membrane may have hemostatic activity through the modulation of fibrinolytic activity of peritoneal exudative macrophages.


The postoperative recurrence of Crohn's disease: an analysis of 37 patients with Crohn's disease who underwent endoscopy during initial surgery.

A total 37 patients with Crohn's disease who underwent intraoperative endoscopy during resection of the affected intestine were evaluated in this study. The average age of the patients at surgery was 23.2 years. The residual lesions in the remaining intestine identified by intraoperative endoscopy were classified according to their pathologic profiles into three groups: A, B and C. In group A, comprising patients with longitudinal ulcers and/or a cobblestone appearance, 10 of 12 patients had recurrence. In 5 of these 10, the residual lesions were exacerbated and 2 required a further operation. The remaining 5 patients showed recurrence at the site of previous anastomosis and 2 of these 5 required additional surgery. In group B, comprising patients with small ulcers, aphthoid ulcers, or scars, and group C, comprising patients with no residual lesions, recurrence was observed in 13 of 16, and 3 of 9 patients, respectively. The recurrent lesions were all found proximal to, or at the site of previous anastomosis. Additional operations were performed on 3 of the group B patients. The findings of this study revealed that recurrence requiring additional surgery is more frequent at the site of anastomosis, regardless of the endoscopic appearance of the residual lesions.


Lymphangioma in the small intestine: report of a case and review of the Japanese literature.

We report herein a rare case of a 53 year old man with a benign lymphangioma of the small intestine. He presented with a complete obstruction of the small intestine and radiological examination revealed a small intestinal tumor. A long intestinal tube was passed, the intestinograms from which detected a submucosal tumor of the small intestine. Partial resection of the small intestine was thus performed and the tumor was found to be located mainly in the submucosa. The final pathological diagnosis was made as cavernous lymphangioma. This case is presented with a description of the roentgen appearance, followed by a review of the Japanese literature.


Adenoma of the nipple.

We report herein a case of a 42 year old woman with adenoma of the nipple of her left breast. The diseased nipple was enlarged, reddened and a hard elastic mass was palpable within its substance. There was an area of eczematoid erosion on the surface. Incisional biopsy revealed a picture of adenoma and therefore the nipple was excised. Five years postoperatively, there has been no recurrence of the disease. To our knowledge, only thirteen cases of adenoma of the nipple have been reported in the Japanese literature. Some clinical features and treatments are discussed in a review following the case report. Although rare, adenoma of the nipple should be borne in mind to avoid a misdiagnosis of malignancy and unnecessarily extensive surgery.


Primary malignant lymphoma of the spleen.

We treated two patients with primary splenic malignant lymphoma. One was a 63-year-old man with diffuse histiocytic non-Hodgkin's lymphoma accompanied by multiple liver metastases which were composed of necrotic tissue probably due to preoperative transarterial chemoembolization (TAE). He eventually died of liver failure two years and six months after splenectomy. The autopsy revealed that a large part of the cirrhotic liver had been occupied by a diffuse-type hepatocellular carcinoma, but no recurrence of the malignant lymphoma was found in the liver or other organs. The second patient was a 40-year-old woman with a massive invasion of the stomach, colon, pancreas, and diaphragm by a splenic tumor. The splenic tumor and the adjacent involved organs were resected. Pathologically, well-differentiated diffuse lymphocytic non-Hodgkin's malignant lymphoma was evident. No recurrence has been found for six years and two months. Based on an evaluation of the 71 patients with primary splenic malignant lymphoma reported to data in Japan, the patients treated by a curative resection in an early clinical stage have a more favorable prognosis.


A perforated non-specific ulcer of the cecum as seen in a 2-year-old female.

A 2-year-old female was hospitalized because of generalized peritonitis with pneumoperitoneum. A laparotomy disclosed a perforated ulcer of the cecum. A resection of the perforated portion of the cecum was then performed. Histopathologic examinations confirmed that the ulcer was non-specific in nature. No recurrence was observed four years since the limited operation. Pneumoperitoneum caused by perforation of non-specific cecal ulcer in a child has, to our limited knowledge, not yet been previously reported.


Pilonidal sinus on the neck.

A recurrent nuchal abscess was treated in a 21-year-old obese young man with a total excision of the lesion. In the histopathological findings, many similarities were found between this lesion and pilonidal sinus. We discuss the pathogenesis of this lesion, as well as our belief that this case was a rare example of pilonidal sinus on the neck.


A scintigraphic analysis of colonic movement in patients with colostomy: changes of colonic transit time after acquaintance with irrigation.

For the purpose of making a functional assessment of colostomy irrigation, eight patients were examined. Group A was composed of four patients whose experience of irrigation was less than one year. Group B was composed of four patients who had undergone irrigation for more than two years. The capacity of the remnant colon was determined by a barium enema. Next, 74 MBq of milking technetium 99 diethylene triamine penta-acetic acid (99mTc-DTPA) was instilled with a predetermined amount of water (37 degrees C). A dynamic scan was performed for 45 min. The mean evacuation time of Groups A and B were 6 min 56 s +/- 2 min 33 s and 13 min 27 s +/- 10 min 50 s, respectively. The mean half emptying time of Groups A and B were 142.5 s +/- 7.9 s and 309.0 s +/- 181.9 s. The results suggest that the remnant colon may be habituated with irrigation. Colostomy irrigation which uses a single instillation of a measured volume of tepid water is recommended.


Reference values for radial bone width and mineral content using single photon absorptiometry in healthy children aged 4 to 10 years.

Bone width and mineral content were measured in 420 healthy Cambridge children aged 4 to 10 years using single photon absorptiometry. The results are expressed first in the form of standard centile charts, with additional prediction charts which provide body-size-adjusted estimates for the measurements, and interpretation centiles for comparing these estimates with the actual measurements. The values obtained are similar to those reported for American children aged five to six years after adjusting for body-size differences. We suggest that appropriate application of these prediction charts will facilitate the use of single photon absorptiometry in monitoring and treating children who have disorders of bone growth and mineralization.


Human milk components cross-reacting with antibodies against bovine beta-lactoglobulin.

The human whey components cross-reacting with antibodies raised against bovine and/or equine beta-lactoglobulin were screened systematically. The milk of six women on a normal diet was collected within 72 h of confinement and whey components were fractionated by high-speed size exclusion chromatography and reversed-phase techniques. The fractions which were immunoreactive in double diffusion experiments with antisera anti-bovine and/or equine beta-lactoglobulin were subsequently purified by native PAGE and then electroblotted on Pro-blott membrane (Western blotting). Pro-blot membranes were stained in parallel with Coomassie and by immunostaining using antibodies against bovine and/or equine beta-lactoglobulin as first antibody solution. The immunoreactive bands were cut out from the membrane and N-terminally sequenced; all the immunoreactive components were clearly identified as human beta-casein or its (mainly tryptic) fragments. The strong antigenic similarity between human beta-casein and beta-lactoglobulin (bovine and equine) might be of immunological importance; it could mean that breast-fed neonates risk being sensitized to beta-lactoglobulin irrespective of the presence of cow's milk in the mother's diet.


Supplementation of an adapted formula with bovine lactoferrin. 2. Effects on serum iron, ferritin and zinc levels.

Breast milk provides an excellent supply of most nutrients for newborn infants. Infant formulae should be nutritionally comparable to breast milk especially with regard to critical nutrients like iron and other trace elements. Infant formulae supplemented with various amounts of bovine lactoferrin were given to two groups of infants. These infants were compared with infants receiving unsupplemented formula and breast-fed infants. The effects of these diets on levels of haemoglobin, haematocrit, serum iron, ferritin and zinc were examined for a study period of 150 days. At birth, concentrations of iron, haemoglobin, haematocrit and zinc were comparable in all four feeding groups. The fact that the serum zinc level was not altered by lactoferrin supplementation appears to rule out an in-vivo effect of lactoferrin on zinc nutrition of infants. Ferritin levels of breast-fed infants were significantly higher than in non-supplemented formula-fed infants at day 30 and day 90. This difference was seen only at day 30, when comparing breast-fed infants to lactoferrin-supplemented formula-fed infants. Comparing the infants receiving formulae, the formula supplemented with the higher amount of bovine lactoferrin induced significantly higher serum ferritin levels compared to the unsupplemented formula at day 90 and day 150. These observations favour the idea that lactoferrin may be involved in iron absorption. Since this effect was pronounced only after 90 days, it has to be discussed as to whether this effect is a convincing argument for supplementing infant formulae with bovine lactoferrin.


Breast feeding and the dietary habits of children in rural Somalia.

Breast feeding and dietary habits were studied prospectively in a cohort of children under the age of five years in a rural Somali community. The median duration of breast feeding was 19.5 months. However, all the children also received cow's milk by cup from the first day of life and onwards. Energy supplements (mainly sugar and oil) as well as additional water were given daily from early infancy. Staples, protein-rich foods (beans and meat), vegetables and fruits were usually introduced when the children reached the age of 12-18 months. There was a seasonal variation with the lowest intake of protein-rich and vitamin-rich foods during the rains in May to June. Thus, there was a complete absence of exclusive breast feeding. Energy-reinforced cow's milk and human milk dominated the diet up to the age of one year. Staples were mixed with oil and supplemented with milk, thereby leading to a much higher energy density in the complementary food than is usually the case in African communities.


Risk factors for early termination of breast feeding in Brazil.

A prospective study was undertaken to identify possible factors related to the duration of breast feeding. Two hundred and thirty-eight mothers who had delivered normal single babies with birth weights greater than 2.5 kg and had initiated breast feeding were randomly selected at the maternity hospital, Hospital de Clinicas de Porto Alegre, Brazil, and followed by mail questionnaires until termination of breast feeding, or until the end of the first year. If no reply was received, telephone contact or home visits were made. The group of mothers who stopped breast feeding prior to the end of the third month was compared with those who extended breast feeding beyond three months with respect to socioeconomic, biological, environmental, medical and psychological factors. The variables with a significant coefficient of association with early termination of breast feeding were maternal education, past experience with breast feeding, help of a maid, help with housework provided by a relative, breast feeding orientation during prenatal care and encouragement from the husband. These factors act simultaneously, with interactions among them.


Temperature, metabolic adaptation and crying in healthy full-term newborns cared for skin-to-skin or in a cot.

The aim of the present study was to compare temperatures, metabolic adaptation and crying behavior in 50 healthy, full-term, newborn infants who were randomized to be kept either skin-to-skin with the mother or next to the mother in a cot "separated". The babies were studied during the first 90 min after birth. Axillary and skin temperatures were significantly higher in the skin-to-skin group; at 90 min after birth blood glucose was also significantly higher and the return towards zero of the negative base-excess was more rapid as compared to the "separated" group. Babies kept in cots cried significantly more than those kept skin-to-skin with the mother. Keeping the baby skin-to-skin with the mother preserves energy and accelerates metabolic adaptation and may increase the well-being of the newborn.


The influence of the basal yellow colour of the skin at birth on later jaundice meter readings in mature newborn infants.

The yellow colour of the skin was measured just after birth in 100 mature newborns using a jaundice meter. The skin colour was significantly correlated to the cord bilirubin concentration (rho = 0.26, p = 0.009), but unrelated to cord reserve albumin concentration, cord albumin concentration, cord haemoglobin concentration, birth weight and gestational age. In 123 other mature newborns, the basal yellow colour of the skin was estimated on the basis of meter readings taken just after birth. Correction of meter readings taken on the third postnatal day for the basal yellow skin colour improved neither the correlation between the meter readings and the bilirubin concentration nor the ability of the meter readings to predict hyperbilirubinaemia.