Root canals in one-rooted maxillary second molars.

The Royal Dental College, Copenhagen, houses an extensive collection of human teeth extracted in Denmark. The collection currently contains 104 one-rooted, permanent maxillary second molars. The root complex on these teeth was sectioned at the junction between the coronal and the apical halves, i.e. mid-root, and at the junction between the middle and the apical thirds, i.e. apically. Using a stereomicroscope we then registered, mid-root and apically, the following variables: canal number, canal position, and canal cross-section. Mid-root there was 1 centrally located root canal in 25.96% of the teeth examined; 2 canals were observed either mesially and distofacially, mesiofacially and distally, or facially and lingually in 34.62%; 3 canals positioned mesiofacially, distofacially, and lingually were found in 39.42%. At the same level 63.51% of the canal cross-sections were non-circular, whereas 36.49% of the canals had a circular cross-section image. The non-circular canal cross-sections could more specifically be characterized as C-shaped, Y-shaped, hourglass-shaped or the root canal had a greater faciolingual than mesiodistal extension or, respectively, a greater mesiodistal than faciolingual extension. Apically there was 1 centrally located root canal in 35.58%; 2 canals were observed with a position either mesially and distofacially, mesiofacially and distally, or facially and lingually in 37.49%; 3 canals located mesiofacially, distofacially, and lingually were found in 26.92%. At the apical level, 64.32% of the root canal cross-sections were non-circular, whereas 35.68% of the canals showed a circular cross-section. The results presented here are aimed at: clinical dentists, endodontists, and dental morphologists.


Effects of phosphonoformic acid and 1-hydroxyethylidene-1,1-bisphosphonate (HEBP) on distribution of tetracycline in the developing rat molar.

Tetracycline was used as a marker to study the effect of phosphonoformic acid and 1-hydroxyethylidene-1,1-bisphosphonate (HEBP) on the mineralization of the developing dental hard tissues. Groups of young rats were given a single subcutaneous injection of tetracycline and at the same time were injected with a single dose of either phosphonoformic acid or HEBP (10 mg P/kg b.w.). Alternatively, rats were injected with the tetracycline after different time intervals from the phosphonate injection. Rats were sacrificed at intervals ranging from 1 to 4 days. Frozen-sections were obtained at the level of the maxillary first molar and prepared for light and fluorescence microscopy. The results of the present study indicate that the distribution pattern of tetracycline in the developing dental hard tissues is greatly affected by the pathologic changes induced by phosphonoformic acid and HEBP. Both drugs caused similar changes in the pattern of tetracycline uptake in the developing enamel. There seems to be a direct relation between the presence of developmental defects of enamel and the degree of discoloration induced by tetracycline. Aberrations in the mineralization of dentin were caused only by HEBP. As demonstrated by this study, HEBP is capable of inducing a provisional inhibitory effect on dentin mineralization.


Contribution of autogeneic membranous bone chips and bone paste to healing of rabbit skull defects.

In skeletal surgery, bone chips and bone paste are often used to facilitate bony repair. However, no comparative investigation between these forms of bone graft implantation has been undertaken. In this study four trephine skull defects were produced in each of 14 adult rabbits and inlays of bone paste and two separate amounts of bone chips were then implanted in each animal. The results were compared relative to a control defect and assessed by gross inspection, light microscopy, and contact radiography after periods of 4 and 15 wk. Bone chips offered only minor advantages over controls in the defects investigated and differences in bony regeneration between the diversified amounts of bone chips were negligible. After bone paste implantation, a cellular and mature bone was rapidly produced. The clinical significance of these findings is discussed.


Oral function in patients wearing fixed prosthesis on osseointegrated implants in the maxilla: 3-year follow-up study.

Seventeen consecutive selected patients rehabilitated by means of a full maxillary bridge on osseointegrated implants ad modern Brånemark were evaluated over a 3-yr period. Besides a subjective evaluation by means of a questionnaire an examination of the occlusal relationship, chewing force, chewing efficiency and interocclusal threshold level was performed before, immediately after, 3-6 months after, and finally 3 yr after bridge installation. All subjects were very pleased with the oral rehabilitation. The chewing force and the chewing efficiency development increased over time, while the threshold level for interocclusal detection remained unchanged. The clinical dysfunction index according to Helkimo indicated that there was no marked change in signs of dysfunction of the patients' masticatory systems during the observation period. From the present longitudinal investigation one can conclude that the replacement of a full maxillary denture with a fixed prosthesis on osseointegrated implants, facing a natural dentition or an osseointegrated implant supported bridge in the opposite jaw, leads to a progressive increase of chewing efficiency and chewing force, and a constant subjective improvement of jaw function, while no masticatory dysfunction seems to occur during the observation period.


Occlusal control of mandibular elevator muscles.

Occlusal stability and mandibular elevator muscle function was studied in 25 women (20-30 yr of age). They had 27-32 fully erupted teeth with few treated occlusal surfaces, and craniomandibular function including mandibular mobility was normal. The aim was to analyze the influence of natural patterns of occlusal contact on electromyographic activity, unaffected by pain and functional disorders. Occlusal stability was assessed in the intercuspal and in lateral contact positions as the number of teeth with physical contact and the number of opposing pairs of teeth in contact. Electromyographic activity was recorded by surface electrodes over anterior and posterior temporalis and masseter muscles. In general, positive correlations were found between occlusal stability in intercuspal position and moderate to strong static and dynamic contractions, most significant in masseter muscles, indicating that forceful contraction of these muscles implies stable occlusion. Systematically, the duration of activity during chewing was negatively correlated with occlusal stability in the intercuspal position, most pronounced in working-side muscles. This pointed to shorter contractions with stable occlusion and is interpreted as the result of less need for stabilizing activity. It is concluded, that the correlations between occlusal stability and elevator muscle function are probably based on feedback mechanisms from periodontal pressoreceptors.


Dummy- and finger-sucking habits in young Swedish and Norwegian children.

The prevalence of dummy- and finger-sucking habits in 3-yr-old children was registered in four different areas of Sweden and Norway. In Norway 245 children were examined and in Sweden 171 children. The Swedish children were more prone to develop a dummy-sucking habit as well as to prolong it. About 10-19% of the children in the different groups become finger-suckers. Very few of these finger-suckers had stopped sucking at 3 yr of age. The highest rate of non-suckers was found among the children from Karasjok/Kautokeino in northern Norway, who were mainly of Lappish origin.


Effect of temperature and duration of post-cure on selected mechanical properties of resin composites containing carboxylic anhydrides.

Resin composites containing carboxylic anhydrides have recently been formulated for use as inlay materials. To optimize the post-cure, the present study measured the effect of post-cure temperature and duration on four mechanical properties of anhydride-containing resin composites. Temperatures were varied between 37 degrees C and 225 degrees C, and durations were varied between 0 and 24 h. An optimum in strength and stiffness was found when post-cure temperatures of 125-150 degrees C were used. Strength and stiffness were found to increase with increasing duration of post-cure. Due to discoloration of the resin composites when post-curing for 6 or 24 h, a post-cure period of 1 h was preferred.


Dental caries and Streptococcus mutans in a rural child population in Iceland.

In spite of having a high socioeconomic standing, in Iceland caries prevalence has remained stubbornly high. This study reports findings from a mixed fishing and farming community in East Iceland that has traditionally been associated with the highest prevalence of caries. A total of 188 children aged 3-16 yr (96.4% of residents of that age group) were examined. At 6 yr the mean dmfs score was 4.1, DMFS 0 and 48% were caries-free. The mean DMFS score at 12 yr was 4.7 and 22.6% remained caries-free but at 16 yr the DMFS score was 11.6 and no children were caries-free. Caries was unevenly distributed within each age group and was more prevalent among residents of the fishing town than the surrounding farming district. In a pilot study conducted in 1989 mean counts of Streptococcus mutans for children aged 4-7 yr were 2.6 x 10(5) cfu/ml and declined to 4.6 x 10(4) cfu/ml in 1990 after a program of chlorhexidine brushing had been added to the routine caries preventive measures adopted in this community. It may therefore be possible to screen Icelandic children for caries risk and apply preventive measures to those demonstrated to be most in need.


Primary sclerosing cholangitis in patients with ulcerative colitis.

The prevalence of primary sclerosing cholangitis (PSC) in patients with ulcerative colitis (UC) attending the Depts. of Medical and Surgical Gastroenterology, Aalborg Hospital, during a 12-year period, was determined. All patients with an alkaline phosphatase (ALP) value above the normal range were investigated. Of 305 patients with UC, 24 patients had elevated ALP values, and 11 of these (3.6% of the study population), 4 males and 7 females, were found to have PSC by direct cholangiography. In five patients the disease worsened (two patients died of cholangiocarcinoma), in four it was stationary, and in two patients the disease improved during a mean observation period of 6 years. No differences in location of disease, disease activity, or duration of disease were found between patients with UC and PSC and patients with UC without PSC. The ALP values were raised to a mean of 3.7 times the upper normal limit (observed range, 1.5-5.5 times the upper normal limit). Aspartate aminotransferase was moderately elevated in most patients, but no other abnormal biochemical liver test results were observed at onset. The results of our study indicate that PSC is the major cause of raised ALP values in patients with UC; thus cholangiography should be performed in UC patients with unexplained elevated ALP levels. A prognostic indicator is needed to predict the individual prognosis and to determine the optimal timing of liver transplantation.


Cellular distribution of a colonic adenoma-associated antigen as defined by monoclonal antibody Adnab-9.

Adenomatous colonic polyps constitute a precursor for colorectal cancer. Antibodies to these precancerous lesions might identify specific early tumor antigens. Adnab-9 is a murine monoclonal antibody raised against membranes of colonic adenomas. Adnab-9 binding in colonic washings (effluent) correlates with the presence of colorectal cancer. Immunohistochemical staining with Adnab-9 shows cytoplasmic reactivity in scattered cells in 4 of 31 adenomatous tissue sections, 0 of 14 sections of colorectal cancer cells, and 1 of 8 normal-appearing colonic mucosa specimens examined. Adnab-9 recognized a dominant M(r) 87,000 protein species in tissue extracts in the membrane-bound fraction of effluent by Western blotting. Adnab-9 binding by enzyme-linked immunosorbent assay in adenomatous extracts is higher than cancer or normal tissue, is membrane-bound, and is absent from established colorectal cancer cell lines. This distribution and nature of immunostaining suggest that Adnab-9 recognizes a determinant associated with the membrane component of a subpopulation of adenoma cells which may have a role in early colorectal neoplasia.


Pancreatic atrophy in rats produced by the cholecystokinin-A receptor antagonist devazepide.

According to recent reports, the powerful and selective cholecystokinin (CCK)-A receptor antagonist devazepide (also referred to as L-364,718 or MK-329) is without effect on the weight of the pancreas. This has been interpreted to mean that basal and meal-stimulated endogenous CCK does not play a major role in the normal maintenance of the pancreas. In the present study we show that continuous subcutaneous infusion of devazepide effectively and dose-dependently reduced the weight of the pancreas both in normal rats and in hyperCCKemic rats (because of pancreaticobiliary diversion). The maximum reduction of the pancreatic weight was 40%. Maximum or near-maximum effects were seen with a dose of 200 micrograms/kg/h. The DNA content of the pancreas was also reduced. The reduction in weight and DNA content of the pancreas was maximal after 10 days. Provided that devazepide acts solely by inhibiting CCK-A receptors, we can conclude that endogenous CCK plays an important role in both normal and stimulated growth of the rat pancreas.


Role of the antrum in the gastric emptying of a non-nutrient liquid in the rat.

Forty male Wistar rats underwent liquid gastric emptying analysis with a non-nutrient liquid--99mTC-tin colloid in physiologic saline. Twenty then had two-thirds resection of the glandular stomach with Billroth-II-type reconstruction. Twenty served as controls: 10 unoperated and 10 with a laparotomy alone. Emptying was studied weekly for 4 weeks, then monthly for 4 months. Emptying was unchanged in unoperated controls. Laparotomy alone caused delayed emptying for 2 months (p less than 0.05). After Billroth-II resection emptying was delayed for 4 months (p less than 0.01). This delay included both the early and late phases of gastric emptying. We conclude that a laparotomy alone delays gastric emptying. The addition of an antrectomy causes a greater emptying delay, which persists for longer than that due to laparotomy alone. Thus, in a situation in which the small bowel and gastric feedback mechanisms are inoperative, the antrum is seen to play an important role in the gastric emptying of liquids. This supports the concept in man that antral contractions are important in ensuring the normal active emptying of liquids from the stomach.


Cardiovascular effects of omeprazole and famotidine.

In a randomized, placebo-controlled, double-blind, crossover comparison, 12 patients with congestive heart failure (New York Heart Association class II) and dyspeptic complaints were treated orally for 1 week each with placebo, 40 mg omeprazole daily, and 40 mg famotidine daily. Non-invasive haemodynamic measurements were taken on the last day of treatment. Although omeprazole did not alter cardiac performance in impedance cardiography and mechanocardiography, the administration of famotidine led to a significant fall in stroke volume and cardiac output as compared with placebo (both p less than 0.05). Thus, omeprazole did not exert any relevant cardiovascular effects, in contrast to the H2-receptor antagonist famotidine.


Experimental colonic inflammation and ulceration. Permeation of a water-soluble contrast medium as a measure of 'disease' activity.

The aim of this study was to investigate the permeation of an isosmolar water-soluble X-ray contrast medium (CM) from the unperforated colon after experimental induction of inflammation and ulceration. One hundred and sixty-five male rats were included. In 110 rats 0.25 ml of 40% ethanol + 15 mg or 30 mg trinitrobenzene (TNB) was instilled into the colon, 7-9 cm proximal to the anus, inducing different degrees of inflammation. Fifty-five rats served as controls and had 0.25 ml saline instilled with the same procedure. At 7, 14, 21, and 28 days 3 ml of the non-ionic CM iodixanol was applied as an enema, and subsequently all urine was collected for the next 4 h. High-performance liquid chromatography analyses of the urine showed a positive relation between the severity of inflammation/ulceration in the colonic wall as assessed by a macroscopic damage score and the amount of CM excreted in the urine. Water-soluble contrast media may have prospects of combining functional tests of intestinal membrane dysfunction with segmental exposure control.


Effects of the M1 muscarinic receptor antagonist pirenzepine on gastric mucus glycoprotein in rats with or without ethanol-induced gastric damage.

Changes in gastric mucus glycoprotein (mucin) isolated from pirenzepine-treated rats with or without ethanol (50%)-induced gastric damage were studied. The prior administration of pirenzepine inhibited significantly and dose-dependently the occurrence of macroscopically observable hemorrhagic lesions induced by treatment with ethanol. The gastric mucosa was separated into the surface mucosa, including the mucus gel layer, and the deeper mucosa by mechanical scraping, and the mucin in each was isolated. In ethanol-treated animals the mucin content of the deep corpus mucosa was significantly reduced to 68% the control value. This reduction was inhibited by pretreatment with pirenzepine. In the surface mucosa mucin content was also reduced to 48% of control value by ethanol treatment, but pirenzepine pretreatment increased mucin content to 235% the control value. Total mucin content in the entire stomach essentially resumed the control level by pretreatment with 100 mg/kg of pirenzepine. A single oral administration of pirenzepine (100 mg/kg) caused no change in total mucin content, but mucin in the deep corpus mucosa selectively and significantly increased to 124% the control. These and the results of carbohydrate analysis of purified mucin indicate that pirenzepine administration possibly accelerates the secretion of accumulated deep corpus mucus, retains this deep mucus on surface mucosal mucus, and protects the gastric mucosa in ethanol-induced gastric damage. This may be related to the antiulcerogenic effects of pirenzepine.


Simultaneous administration of lactulose and 51Cr-ethylenediaminetetraacetic acid. A test to distinguish colonic from small-intestinal permeability change.

In normal adults intestinal permeation of ingested 51Cr-ethylenediaminetetraacetic acid (EDTA) is greater than that of lactulose. This difference is abolished in patients with ileostomies, suggesting that it results from colonic permeation of 51Cr-EDTA, which, unlike lactulose, resists bacterial degradation. To investigate the effect of an increase in colonic permeability on absorption of the two molecules, lactulose (5 g) and 51Cr-EDTA (50 microCi) were given orally in isosmolar solution to 11 patients with colitis, and their 24-h urinary excretion measured. By comparison the effect of an increase in small-intestinal permeability induced by ingestion of a hyperosmolar solution (4240 mosm/l) was measured in 10 healthy adults. Hyperosmolar stress increased the 24-h urinary excretion of 51Cr-EDTA above the normal mean + 2 standard deviations (3.31%) in all 10 healthy subjects, and in all of these excretion of lactulose was also increased (greater than 1.06%). In contrast, although seven colitics had a urinary excretion of 51Cr-EDTA above the normal mean + 2 SD, in only two of these patients was recovery of lactulose increased. This suggests that simultaneous administration of lactulose and 51Cr-EDTA may enable permeability changes affecting the colon alone to be distinguished from those involving the small intestine.


Evaluation of different laboratory tests and activity indices reflecting the inflammatory activity of Crohn's disease.

In a prospective study we compared the usefulness of various laboratory tests (albumin, alpha-1-proteinase inhibitor (A1PI), cholinesterase (CHE), C-reactive protein, erythrocyte sedimentation rate, hematocrit) and activity indices (CDAI, VHAI) in relation to the disease activity by endoscopic criteria. Except for hematocrit highly significant differences (p less than 0.0005) of the mean values of all test results were found for patients without or with slight mucosal lesions compared with patients with severe inflammation of the mucosa. Further analysis of the data indicates the highest test efficiency (84%), sensitivity (80%), and specificity (88.6%) for CHE. CHE showed good correlations to all other tests; the highest correlation was found between CHE and VHAI (r = -0.78). We suggest that a suppression of CHE synthesis mediated by endotoxins and cytokines rather than an increased intestinal loss explains the decreased CHE in severe Crohn's disease. It is concluded from the data that CHE is a useful test to assess the inflammatory activity of Crohn's disease.


Interval cancers in screening with fecal occult blood test for colorectal cancer.

Interval cancers, which are cancers diagnosed in spite of one or more negative screening tests, were studied in a randomized population with Hemoccult-II for colorectal cancer in 61,938 persons between 45 and 74 years old. Three biannual screenings were performed from 1985 to 1991, and 52% of all the cancers detected after doing at least one Hemoccult-II test were interval cancers (81 persons). These were more advanced than cancers diagnosed after a positive Hemoccult-II test, of larger size, less frequently of Dukes stage A, more often invading neighboring organs, and less often resectable for cure. They were located in the rectum more often than cancers diagnosed by screening and cancers in controls. Otherwise, interval cancers did not differ from cancers in controls or cancers in non-responders, and all characteristics suggested that no delay in diagnosis resulted from one or more negative Hemoccult-II tests, compared with controls. However, even if screening with Hemoccult-II demonstrates a reduction in mortality from colorectal cancer, the present high number of interval cancers makes it necessary to look for other methods of screening populations for colorectal cancer.


Calcitonin gene-related peptide: effect on contractile activity and luminal cross-sectional area in the isolated, perfused porcine ileum.

Because calcitonin gene-related peptide (CGRP) is an abundant peptide in the enteric nervous system we studied the effect of intra-arterial infusions of synthetic human CGRP I in concentrations from 10(-10) to 10(-8) mol/l on contractile activity and luminal cross-sectional area in the isolated perfused porcine ileum, using manometry and impedance planimetry. The frequency of the basal contractile activity was 0.37 +/- 0.1 contractions per minute. CGRP induced phasic contractions, which at the highest dose were superimposed on tonic contractions, as determined by measurement of luminal cross-sectional area. The frequency of contractions dose-dependently increased to approximately 10/min at 10(-8) mol/l CGRP. The amplitude of contractions increased from a maximum of 35 cm H2O to 51 +/- 3 at 5 x 10(-9) mol/l CGRP and 52 +/- 6 cm H2O at 10(-8) mol/l CGRP. After the termination of CGRP infusion at the highest dose a short phase of up to 5 min with strong tonic contraction was observed. No phasic activity was detected by manometry during this phase. In conclusion, CGRP dose-dependently increased contractile activity in the pig ileum. CGRP may therefore participate in the regulation of small-intestinal motility in the pig.


Assessment of the neutrophil dominating protein calprotectin in feces. A methodologic study.

This study describes methods for extraction and quantification of calprotectin (L1 protein) in feces by enzyme immunoassay. This protein is a prominent antimicrobial component of neutrophils, monocytes, macrophages, and squamous epithelia. Calprotectin was stable in feces during storage for 7 days at room temperature. Small fecal samples taken from a 24-h feces collection gave a reliable estimate of calprotectin. Within-assay precision was 1.9%, and between-assay precision 14.8%. In healthy subjects (n = 33) median fecal calprotectin was 2025 micrograms/l and in hospital controls (n = 40) 10,500 micrograms/l. Median values in patients with Crohn's disease (n = 21) was 43,000 micrograms/l and in ulcerative colitis (n = 17) 40,000 micrograms/l. Fecal calprotectin was significantly correlated to fecal alpha 1-antitrypsin in the patients with Crohn's disease. Ten of 11 patients with gastrointestinal carcinomas had calprotectin level above the suggested reference limit of 6740 micrograms/l.


Gastric emptying in infants with gastroesophageal reflux. Ultrasound evaluation before and after cisapride administration.

The present study aimed to evaluate gastric emptying in children with gastroesophageal reflux (GER) by means of real-time ultrasonography, on the basis of measurements of the cross-sectional area of the gastric antrum. Twelve children with GER were studied (seven males, five females; age range, 3-13 months) and compared with 12 normal control children (six males, six females; age range, 3-13 months). The diagnosis of GER was confirmed by 24-h esophageal pH-monitoring. The GER patients had a significantly greater antral area than the controls at 90, 105, and 120 min after eating a standard meal (cow's milk formula, 300 ml/m2 body surface area); in addition, final gastric emptying time was significantly greater in the patients than in the controls (145 +/- 36.9 versus 78.7 +/- 19.3 min; p less than 0.0025). After 8 weeks of treatment with cisapride (0.3 ml/kg, three times a day) 24-h esophageal pH-monitoring and ultrasonography studies were repeated in the patients. The total percentage reflux time was significantly lower (p less than 0.038), and ultrasonography showed a decreased antral area at all the various study times, with no significant difference between patients and controls; final gastric emptying time was also significantly lower than before treatment (p less than 0.009). Furthermore, in the GER patients there was a significant correlation between gastric emptying time and the sum of the various reflux times recorded in the 2 h after all meals over the 24 h.(ABSTRACT TRUNCATED AT 250 WORDS)


Computer-aided analysis of gastrointestinal pressure recordings. Comparison with manual scoring.

The aim of the present study was to compare computer-based and visual/manual scoring of pressure recordings from the gastric antrum and duodenum. The computer system was based on three separate principles of recognition: moving average, tracking base line, and threshold filters. Computer scoring resulted in the detection of more contractions than visual/manual scoring, owing to inclusion of artefacts of duration and amplitude above the selected thresholds. Owing to its unreliability, visual/manual scoring led to inclusion of some contractions of below-borderline amplitude or duration. The median difference in the frequency of contractions was, however, 0 min-1. There was close agreement on amplitudes of contractions. As the differences between visual/manual analysis and computer-aided scoring by the present system are of an unimportant magnitude and as computer-based scoring is consistent, we conclude that computer-aided analysis is preferable to visual/manual analysis.


Treatment and prophylaxis of chemotherapy-induced gastrointestinal complaints.

Ninety-eight patients (48 male, 50 female; age median, 56 years; range, 25-85 years) with solid tumors (21 breast cancers, 6 sarcomas, 2 colorectal cancers, 1 pancreatic carcinoma, 1 hypernephroma, and 1 lung cancer) and hematologic neoplasms (24 multiple myelomas, 32 lymphomas, and 10 myeloproliferative syndromes) were recruited into the study. The patients received at least three cycles of chemotherapy with alkylating substances, anthracyclines, antimetabolites, and vinca alkaloids, with or without corticosteroids. A total of 325 cycles of chemotherapy were administered. The symptoms were evaluated by means of a score system on the basis of which heartburn, sensation of repletion, nausea, and cramps were assessed by incidence and degree of severity. Before initiation of concomitant therapy with sucralfate, 47 patients (48%) had symptoms during chemotherapy (heartburn, sensation of repletion, nausea, cramps). After initiation of therapy with sucralfate these symptoms improved in 42 patients (89%); in 6 patients there was a transitory increase in heartburn and nausea. All other patients remained without symptoms in spite of chemotherapy. The evaluation of the patient population as a whole showed a significant decrease of chemotherapy-induced heartburn (p less than 0.01) and nausea (p less than 0.01) during sucralfate therapy. This was tolerated extremely well; side effects were not observed. To summarize, this prospective clinical study shows that sucralfate is an effective and suitable therapeutic principle in long-term therapy for the treatment and prophylaxis of chemotherapy-induced gastrointestinal complaints.


Conservative treatment of stress ulcer bleeding: a new approach.

Stress ulcer prophylaxis diminishes but does not eliminate the risk of severe bleeding from this complication. In 70-80% of the cases the source of bleeding is hemorrhagic gastritis. No controlled studies exist which have in particular investigated conservative therapy in patients with stress-induced hemorrhage. Even effective measures to suppress gastric acid secretion or to reduce splanchnic blood flow are ineffective in 10-40% of intensive care unit patients with stress-induced bleeding. In these cases total gastrectomy has so far often been the only therapeutic approach. We report our experience with a new approach in treating severe stress-induced hemorrhagic gastritis after ineffective primary treatment with H2-receptor antagonists, pirenzepine and somatostatin. Continuous gastric lavage with 5-10 l ice-cold Ringer's solution was used until complete cessation of bleeding, as evident from clear lavage. Repeated administration of 12 g sucralfate (60 ml) at 2-h intervals for 24 h through a gastric tube was used to prevent recurrence of bleeding and to promote healing. Sucralfate was reduced on the 2nd and 3rd day to 20 ml 2-hourly and later to 10 ml 4-hourly. In four patients this treatment was used as an ultima ratio when the patients were already scheduled for total gastrectomy. A total of 23 patients were treated during a 7-year period; all of them responded successfully, and no patient required surgery.


Follow-up of endoscopic gastritis after healing with sucralfate or an H2-receptor antagonist.

48 patients in whom previous endoscopic signs of chronic gastritis had been abolished by treatment with either 1 g sucralfate three times daily or 40 mg famotidine at night were followed up for 3 months without further therapy. Cumulative endoscopic relapse rates at 3 months were 21.7% in the sucralfate group and 57.1% in the famotidine group (p = 0.017). All patients with endoscopic recurrence of gastritis also reported recurrence of dyspeptic symptoms of various degrees. Most patients with endoscopic relapse had persisting histologic gastritis, but up to 67% of subjects with histologic gastritis at the time of initial endoscopic healing did not have subsequent endoscopic or clinical recurrence. It is concluded that gastritis, especially if histologically active, tends to recur quickly after endoscopic healing and that early relapses are significantly more frequent after treatment with an H2 blocker than after sucralfate.


Triple therapy with sucralfate is as effective as triple therapy containing bismuth in eradicating Helicobacter pylori and reducing duodenal ulcer relapse rates.

Duodenal ulcer relapse rates after therapy with sucralfate or bismuth are lower than those after H2-receptor antagonist therapy. This may be mediated by an antibacterial effect of these drugs on Helicobacter pylori. Bismuth has become an integral part of 'triple therapy' because of its documented anti-H. pylori effect. In vitro and clinical data suggest that sucralfate may also have an anti-H. pylori effect. The aim of this randomized, prospective therapeutic trial was to compare the efficacy of triple therapy containing bismuth with that containing sucralfate and to determine the effect of therapy with these combinations on duodenal ulcer relapse. Forty H. pylori-positive duodenal ulcer patients were healed with omeprazole and randomized to receive either 1 g sucralfate four times daily or 120 mg bismuth compound four times daily. All patients received 400 mg metronidazole three times daily and either 250 or 500 mg tetracycline four times daily for 7-14 days. Thirty-five patients could be analysed. Overall eradication rates did not differ in the treatment groups (10 of 17 eradicated with sucralfate and 11 of 18 with bismuth). Relapse rates were significantly lower in the eradicated group (1 of 21 compared with 8 of 14 in the non-eradicated group) and did not differ between treatment groups in those patients not eradicated. A triple therapy regimen utilizing sucralfate appears to be as effective as the bismuth-containing regimen.


Prevention of peptic ulcer relapse by sucralfate: mechanisms of action.

Sucralfate has a complex effect on the luminal and mucosal environment of the stomach and duodenum. Some of the actions are important in ulcer healing whilst others are important in preventing subsequent ulcer relapse. Although sucralfate has little direct effect on acid secretion, there is evidence that after ulcer healing with this drug, parietal cell responsiveness is reduced. This may in part be mediated by increased somatostatin release from gastric D cells and may be important in reducing ulcer relapse. Sucralfate has been shown to increase mucosal resistance to damaging agents, such as ethanol and aspirin. Studies have shown that this protective action may be related to the drugs effect on various protective zones such as the 'mucous-bicarbonate' barrier, mucosal hydrophobicity, epithelial cell function and morphology, and mucosal blood flow. These complex actions of sucralfate are in part related to direct interaction between the drug or its components and gastroduodenal tissues, and in part related to effects on various mediators of tissue injury and repair.


Prevention and therapy of radiation-induced bowel discomfort.

In a double-blind randomized placebo-controlled study, including 70 patients treated with radiotherapy of localized malignancies in the pelvis, the effects of prophylactic sucralfate in preventing bowel discomfort were evaluated. Radiotherapy was delivered in a conventional manner with high-energy photons in a total dose of 62-66 Gy (target dose, 1.8-2.2 Gy) during 6.5 weeks. Dose granules of sucralfate or placebo were given 2 weeks after irradiation started and continued for 6 weeks. All analyses were performed blindly. The patients in the sucralfate group had significantly less problems with acute (5 weeks) and chronic (66 weeks) bowel discomfort. The consumption of loperamide was also reduced in the sucralfate group, and the weight decrease was less pronounced. No adverse effects were seen. Thus, sucralfate seems to be beneficial in minimizing the problems of bowel discomfort during and after irradiation of malignancies in the pelvis. These results are discussed in relation to other related observations.


TCR gamma/delta+ cell subsets in the synovial membranes of patients with rheumatoid arthritis and juvenile rheumatoid arthritis.

Using a peroxidase/anti-peroxidase immunohistochemical staining method, we examined sections of inflammatory synovial membranes from 13 patients with juvenile rheumatoid arthritis (JRA) and 11 with rheumatoid arthritis (RA). The relative numbers of TCR gamma/delta+ cells and the proportions of V delta 1+ and V delta 2+ subsets were recorded in the areas of the membranes most heavily infiltrated by CD3+ cells. In the JRA group, the majority (8/13) of the membranes had TCR gamma/delta+ cells which contributed between 5 and less than 10% of the total number of CD3+ cells. In the RA synovial membranes examined, 5/11 samples had between 5 and 10% TCR gamma/delta+ cells, but in another 5 TCR gamma/delta+ cells contributed to between 10 and 20% of CD3+ cells. No significant difference was noted between the two patient groups. However, the range of values found in the RA membranes appeared to be slightly higher in comparison to previously reported values for RA synovial fluid, peripheral blood and eluted synovial membrane T cells. Analysis of the relative proportions of the V delta 1+ and V delta 2+ subsets revealed a significant dominance of V delta 1+ cells in RA membranes and approximately equal numbers of the two populations in the JRA patients. As the majority of peripheral blood TCR gamma/delta+ cells use the V delta 2 segment this suggests a preferential homing or expansion of the V delta 1+ cells in both RA and JRA synovium. The overall distribution pattern of the TCR gamma/delta+ and V delta 1+ and V delta 2+ cells was also recorded. These cells mostly accumulated in the lymphoid-like tissues and in the perivascular area in the tissues of both RA and JRA patients. Occasionally, augmented numbers of these cells were found in the subsynovial layer or in the loose connective tissue. In the majority of cases, only a few TCR gamma/delta+ cells were located in the synovial layer. The function and the possible pathogenetic importance of these TCR gamma/delta+ cells have not so far been determined.


Membrane expression and function of complement receptors CR1 and CR3 on neutrophils from HIV-infected subjects: modulation by rTNF-alpha and rGM-CSF.

We evaluated membrane expression and function of complement receptors CR1 and CR3 on neutrophils from 27 HIV-positive (HIV+) subjects (14 in the CDC class III and 13 class IV) as well as their modulation in vitro by recombinant tumour necrosis factor-alpha (rTNF-alpha) and granulocyte-macrophage colony stimulating factor (rGM-CSF). While CR1 was expressed at similar levels on neutrophils from controls and HIV+ subjects, CR3 expression was significantly higher in CDC class IV subjects than in healthy controls. CR1 and CR3 expression was significantly increased after treatment of neutrophils with both cytokines, without differences between controls and HIV+ subjects. Similarly, the superoxide anion (O2-) production in response to C3-coated zymosan (C3zy) was significantly enhanced on neutrophils from CDC class IV subjects when compared with controls. rGM-CSF and rTNF-alpha treatment significantly enhanced the spontaneous as well as C3zy-stimulated O2- production by neutrophils from controls and CDC class III subjects, and induced an upward trend in the CDC class IV group. These results indicate that the neutrophils of HIV+ patients are preactivated in vivo but they also indicate that these cells may correctly respond to a subsequent particulate stimulus as well as to activating cytokines. Our findings suggest that desensitization or functional exhaustion of complement receptors are not implicated in the abnormalities observed on neutrophils from HIV+ patients.


Dopamine-induced lymphoma cell death by inhibition of hormone release.

Dopamine inhibits prolactin release from pituitary cells and seems to affect the release of several other hormones as well. We report here that dopamine may have similar effects on human B lymphoma cells leading to inhibition of production or release of endogenous factors required for cell viability and proliferation. Thus, addition of dopamine to serum-free cultures of Burkitt lymphoma cells (Raji, Namalwa, Daudi and Jijoye) resulted in rapid and extensive cell death while a myeloma cell line, SKO, appeared to be refractory to this treatment. The addition of FCS or supernatant from serum-free cultures of Raji or T24 bladder carcinoma cells could, to a variable degree, counteract the effect of dopamine, suggesting that dopamine acts by inhibiting the production of essential autocrine factors. When two of the hormones known to be under dopamine control, i.e. prolactin (PRL) and thyrotropin (TSH), were tested, they were able to prevent dopamine-induced cell death if combined with heparin. We further observed that the reducing agent 2-mercaptoethanol (2-ME), which is known to inhibit the binding of TSH to its receptor, displayed similar effects to those of dopamine and was strongly inhibitory for Burkitt lymphoma but not for myeloma cells. As expected from its blocking activity at the receptor level, the effect of 2-ME could not be reversed by adding exogenous factors. Contrary to its effect on B lymphoma cells, 2-ME is essential for growth of the murine T-cell lymphoma line CTLL. However, we show here that dopamine can fully compensate for 2-ME, suggesting that TSH or another factor under dopamine control is intimately involved in the regulation of T-cell growth. This study lends further support to the notion of an active interplay between the neuroendocrine and immune systems and emphasizes PRL and TSH as important regulators of lymphoid cell function. It also shows that these hormones may contribute to the autonomous growth pattern of B lymphoma cells and suggests a potential role for dopamine in the treatment of B-cell tumours.


Antigen-specific increases in the number of splenocytes expressing MHC class II molecules following restimulation with antigen in various physical forms.

To understand how a presentation system for antigens initiates an immune response and why it has a strong adjuvant activity, a number of parameters need to be analysed. In this study the frequency of spleen cells expressing MHC class II (Ia antigen) was determined after immunization of mice and restimulation of their spleen cells, in vitro, with influenza virus envelope proteins in different physical forms, namely iscoms, micelles and virus particles. All three forms of the antigen stimulated, in an antigen-specific manner, an increased proportion of spleen cells expressing MHC class II in the restimulation experiments. The induction of increased MHC class II expression was at least partly dependent on antigen-specific induction of IFN-gamma since an antibody to IFN-gamma partly inhibited the increase of MHC class II+ cells induced by iscom or by Concanavalin A. The iscom-borne antigens were superior to micelles to prime the immune response in vitro, indicating a capacity to induce memory cells. This primed immune response was readily recalled in vitro, as measured by IFN-gamma production and an increased number of MHC class II positive cells.


Production of basic fetoprotein in human peripheral lymphocytes during blastic transformation.

To clarify the significance of basic fetoprotein (BFP) in lymphocytes, we investigated whether BFP is produced in lymphocytes during blastic transformation. Peripheral blood lymphocytes obtained from 14 adults were cultured under the stimulation of lectins. The concentration of BFP in the culture medium (extracellular BFP) was estimated serially. The incorporation of [6-3H]-thymidine was assayed simultaneously. The intracellular BFP was measured by dual flow cytometry for DNA and BFP. A lymph node was studied immunohistochemically. Serum BFP was measured in four cases of lymphocytic leukaemia. In two cases, dual staining was performed. The intracellular BFP of the mitogen-stimulated lymphocytes was increased within 24 h. The extracellular BFP was increased exponentially from 72 h. The extracellular BFP at 96 h did not correlate with the [3H]-thymidine incorporation. The intracellular BFP increase began in G1 phase. Immunostaining showed that the B cells also produced BFP. The serum BFP level in leukaemia was high in 1 of 4 cases and the leukaemic cells in two cases showed high intracellular BFP content. These observations indicate that BFP is produced in activated human lymphocytes and in lymphocytic leukaemic cells. The production of BFP during blastic transformation will be a useful new in vitro model for studying the biological role of BFP, and BFP labelling may offer some new possibilities for the study of lymphocytes.


Use of an anti-idiotypic monoclonal antibody in studying amyloidogenic light chains in cells, urine and fibrils: pathophysiology and clinical implications.

A monoclonal anti-idiotype antibody (IgG1k MoAb 3B11D4) raised against the amyloidogenic DEP lambda chain dimer binds a conformational idiotope also present on the monoclonal DEP IgA immunoglobulin. MoAb 3B11D4 does not recognize the reduced and alkylated lambda chain monomers, nor the 15-17-kDa fibrillar light chain fragments which have the same N-terminal sequence of the urinary light chains. The lack of about 70 amino acid residues of the C terminal of the protein prevents the formation of the self-limiting dimer and may facilitate the deposition of the fragments into amyloid fibrils. MoAb 3B11D4 recognizes the plasma cell clone in bone marrow and 9% of circulating B lymphocytes. Panning experiments demonstrate that this antibody has the capability to selectively eliminate the idiotype positive cells from peripheral blood. Antibodies with these characteristics could become a useful tool for better understanding the pathogenesis of the disease and for new therapeutic options.


Epidemiological studies of penicillin resistance in Danish Staphylococcus aureus strains in the period 1977-1990.

During the period 1977-1990 the frequency of penicillin resistance increased from 78.7 to 87.5% among a total of 278,193 Danish Staphylococcus aureus strains from hospitalized patients. By combining these data with phage-type patterns the increase was shown to be caused by 1) the introduction and spread of mainly resistant strains of type 95 and the 94,96 complex; 2) an increased occurrence of strains of group II which during the observation period became more frequently penicillin resistant; and 3) a gradual disappearance of strains of group III and the 83A complex which showed a decreasing degree of penicillin resistance. During the observation period community acquired strains reached nearly the same level of penicillin resistance as the hospital-acquired strains, and the frequency of penicillin resistance did not increase during hospitalization among the predominant strains of type 95, group II and the 94,96 complex. S. aureus isolated from airways had a higher frequency of penicillin resistance mainly caused by increasing amount of penicillin resistant strains of group II. Strains from urine had a lower frequency of penicillin resistance. The total antibiotic consumption and the usage of beta-lactam antibiotics remained nearly unchanged during the observation period. The frequent use of beta-lactam antibiotics for airway infections might explain the possible selection of penicillin resistant strains of group II.


HIV-2 infection in Denmark.

A collection of 3019 selected serum samples (ss), comprising 329 ss from intravenous drug abusers, 558 ss from homosexual men, 682 samples from persons attending a STD clinic, 100 ss from individuals of African origin, 300 ss from sexual contacts to Africans, 650 ss from Danish blood donors who resided in Africa greater than 2 years prior to donating the ss, and 400 ss with equivocal antibody reactions in an HIV-1 Western blot was tested for antibodies against HIV-2 by in-house HIV-2 ELISA and Western blot. Four ss were positive for antibodies against HIV-2. Three of the ss originated from West African men, the fourth belonged to the spouse of one of these men. Three of the samples presented with an uncharacteristic reaction in a HIV-1 Western blot. The study indicates that HIV-2 infection is not yet widespread in Denmark and that it remains closely related to West Africa.


Intramuscular versus intradermal administration of a recombinant hepatitis B vaccine: a comparison of response rates and analysis of factors influencing the antibody response.

In an open controlled study 286 health care workers in Stockholm, Sweden, received 20 micrograms of a recombinant hepatitis B vaccine (Engerix B) by the intramuscular route, and 383 2 micrograms by the intradermal route. Seroconversion to protective anti-HBs levels (anti-HBs titre greater than or equal to 10 IU/l) was achieved in 94% of the i.m. and 89% of the i.d. vaccinees. Female sex, intramuscular vaccination, young age, and being a non-smoker were associated with a higher response rate and a higher geometric mean anti-HBs titre than male sex, intradermal vaccination, old age and being a smoker. If an acceptable response rate to protective anti-HBs levels of 85% is chosen, intradermal vaccination can be used as a cost reducing strategy for all women and for non-smoking men less than 30 years of age, as estimated in a logistic regression model. Due to the variable antibody response in different individuals, post vaccination testing for anti-HBs titres is recommended in health care workers, regardless of vaccination route.


Spread of subclinical Chlamydia pneumoniae infection in a closed community.

Chlamydia pneumoniae infections may spread subclinically. The present investigation took place in a military setting. Sera drawn when the conscripts had entered their military service 2 months previously had been kept frozen and were available. In a camp with 500 people, 35 (7%) developed clinical symptoms of pneumonia. The infection was serologically verified with C. pneumoniae-specific micro-immunofluorescence technique. Of 40 healthy controls, 21 turned out to fulfil the serological criteria of infection, thus, representing subclinical cases. These 21 cases, when extrapolated to the whole camp, equalled a rate of 49% which, added to the 7% of pneumonic cases, gave a total infection rate of 56%. Pre-existing IgG antibodies were demonstrated in 10% of the pneumonic cases, 48% of the subclinical cases, and 89% of the non-infected, healthy controls. Without the access to pre-epidemic sera permitting us to establish 4-fold titre rises, the spread of subclinical C. pneumoniae infection would have been noted at 5%, and not 49% as here demonstrated.


Serologically indicated pneumococcal respiratory infection in children.

Streptococcus pneumoniae infection was indicated serologically in 84 (19%) of 449 children hospitalized with middle or lower respiratory tract infection. Pneumococcal antigen was detected in acute serum in 28 patients, but in acute urine in only 2. An antibody response to type-specific capsular polysaccharides of S. pneumoniae was indicated in 27 patients and to a protein antigen, pneumolysin, in 25 patients, but to C-polysaccharide in only 10 patients. The observations mentioned above suggest that each serological test for pneumococcal etiology is insensitive, and to get an optimal result, a large panel of pneumococcal antigen and antibody assays must be used. Pneumococcal infection could be indicated serologically although no focus of infection, such as pneumonia or acute otitis media, or no laboratory evidence of bacterial infection as elevated values of C-reactive protein concentration, erythrocyte sedimentation rate or white blood cell count was present. Particularly antibody responses to pneumococcal pneumolysin were present in children without pneumonia or acute otitis media. Our results point out that no nonspecific parameter can be used for the selection of patients with probable pneumococcal etiology among children with respiratory tract infection. Concomitant viral infection, in most cases RSV infection, was present in a third of the children with pneumococcal infection. It is concluded that pneumococcal etiology should be actively sought for also in patients with viral respiratory infection, especially in young children with RSV infection.


Pneumococcal finding in a sample from upper airways does not indicate pneumococcal infection of lower airways.

The presence of pneumococcus (Pnc) by antigen detection and culture was examined in nasopharyngeal aspirates (NPA) of 315 children hospitalized with middle or lower respiratory tract infection. Pnc was found in NPA from 115 (37%) patients, being demonstrated by antigen detection alone in 34 (30%), by culture alone in 26 (23%) and by both methods in 55 (48%) of Pnc-positive samples. Pnc findings in NPA were most common, 45-46%, in patients aged 1-4 years. Serological evidence of Pnc infection, based either on detection of Pnc antigen in serum or urine, or on demonstration of an antibody response to these antigens, was present in 31 (27%) of the 115 patients with and in 28 (14%) of the 200 patients without Pnc in NPA samples. In the 48 patients positive for Pnc in NPA samples both by antigen detection and culture the isolated Pnc strains were serotyped. In 45 (94%) of these the type/group of Pnc was the same by both methods indicating that the specificity of the antigen detection tests, latex particle agglutination and counterimmunoelectrophoresis, was high. To evaluate the diagnostic significance of Pnc antigen detection and culture in NPA, sensitivity, specificity and likelihood ratios were calculated; serological evidence of Pnc aetiology was used as a reference. For both methods, sensitivity was poor, less than 0.3, but specificity was good, greater than 0.8. It is concluded that the finding of Pnc by culture or antigen detection in NPA is no indication of Pnc respiratory infection. On the other hand, Pnc etiology is unprobable, if Pnc is not present in NPA.(ABSTRACT TRUNCATED AT 250 WORDS)


Severe Pasteurella multocida infections in pregnant women.

We report 2 cases of severe infections due to Pasteurella multocida, both occurring during pregnancy in previously healthy women. Both women had contact with animals (dog and cat) but neither of them had been bitten. Apart from a slight decrease in IgG levels, no immunological defects could be detected. Both women had received oral phenoxymethylpenicillin in the early phase of the disease, but still fell ill with severe infections. One woman had meningitis while the other suffered from cellulitis with deep abscess formation.


Cell surface proteins of Helicobacter pylori as antigens in an ELISA and a comparison with three commercial ELISA.

Cell surface proteins of Helicobacter pylori were solubilized by extraction with acidic glycine buffer, N-octyl-glucoside, lithium chloride, and distilled water, and by sonication. The preparations were evaluated as antigens in ELISA to detect serum IgG responses in patients and healthy subjects. SDS-PAGE analyses of the preparations from a type strain (NCTC 11637) and of acidic glycine extracts of 4 clinical isolates showed multiple protein bands. The sera were classified as HP+ve and HP-ve by culture of biopsy and immunoblotting. Sera were considered positive for H. pylori if they detected the specific 120kD antigen or 4-5 other bands. 49 sera were HP+ve; the 51 HP-ve sera did not react in immunoblotting. 35/44 sera (80%) that reacted with the 120kD antigen demonstrated high titers in ELISA with all antigen preparations, and the remaining 9(20%) sera gave discordant results. 4/5 HP+ve sera that did not react with the 120kD antigen, demonstrated high ELISA titers with all 5 antigen preparations. Glycine extracts of 3 isolates did not exhibit the 120kD protein, but were equally sensitive in ELISA. The role of 120kD antigen in our ELISA was not clear. Immunoblotting demonstrated that the 5 antigen preparations share similar antigenic components. All preparations were similarly high in sensitivity and specificity, indicating that surface antigens could be satisfactorily used in our ELISA. Our ELISA using the glycine extract was compared with commercial H. pylori ELISAs developed by Bio-Rad Laboratories, USA (GAP ELISA), Roche, Switzerland (EIA 2G), and Whittaker Bioproducts, USA (Pyloristat).(ABSTRACT TRUNCATED AT 250 WORDS)


A pilot study of piperacillin and ciprofloxacin as initial therapy for fever in severely neutropenic leukemia patients.

We studied the efficacy of piperacillin and ciprofloxacin as initial parenteral therapy in 41 adult patients with leukemia who developed 47 febrile episodes during severe neutropenia following chemotherapy. 40 patients (98%) survived their febrile episode(s), whereas 1 patient died of infection. When assessed at 72 h after initiation of treatment (early evaluation), 24/47 episodes (51%) had been successfully treated. These 24 favourable responses were seen in 15/24 (63%) microbiologically documented infections and 9/19 (47%) fever of unknown origin (FUO). At the resolution of fever (late evaluation) 46 episodes were evaluable, and 28 (61%) had responded successfully to piperacillin and ciprofloxacin. Successful treatment was most frequently observed in microbiologically defined infections, 18/23 (78%). Three of 5 (60%) Gram-positive, 11/12 (92%) Gram-negative and 1 of 2 mixed bacteremias were successfully treated. In contrast, only 10/19 (53%) FUO and none of 4 clinically defined infections had responded. Thus, this pilot study indicates that piperacillin and ciprofloxacin may be a safe and effective combination for the treatment of febrile episodes in severely neutropenic leukemia patients, which merits further investigation in randomized trials.


Hospital-acquired infections in Norway: a national prevalence survey in 1991.

A 1-day prevalence survey of hospital-acquired infections (HAI) was carried out in Norwegian somatic hospitals in 1991. The survey aimed at assessing the problem of HAI. 950 infections were found among the 14977 surveyed patients (prevalence rate 6.3%). HAI were more prevalent in combined intensive care units (prevalence rate 22%), surgical intensive care units (17%), haematological wards (15%), special care baby units (14%), and geriatric wards (14%). Urinary tract infections were most prevalent (33% of all HAI) followed by respiratory tract infections (21%) and surgical wound infections (17%). 157 (3.6%) of the 4382 patients who had undergone surgery, had a surgical wound infection. With a high response rate (76 out of 84 hospitals) and a sensitive method of screening the patients (chart review and bedside examination), this survey gives a fairly reliable measure of the prevalence of HAI in Norwegian somatic hospitals.


Antibiotic susceptibility of upper respiratory tract pathogens in Sweden: a seven year follow-up study including loracarbef. Swedish Respiratory Tract Study Group.

The antibiotic susceptibility of Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pyogenes and Streptococcus pneumoniae was investigated in five different geographical areas of Sweden in 1990 and compared with results from similar investigations performed in 1983 and 1986. Tests on 100 isolates per species and laboratory were performed by the disk diffusion method, and 10% of the strains plus all resistant ones were sent to the central laboratory for determination of MICs of ampicillin, phenoxymethylpenicillin, cefaclor, loracarbef, erythromycin, tetracycline and trimethoprim/sulfamethoxazole. Beta-lactamase production was found in 7% of H. influenzae and 71% of M. catarrhalis, and reduced susceptibility to penicillin in 3% of S. pneumoniae. Low frequencies (1-3%) of tetracycline resistance were found in H. influenzae and in the 2 streptococcal species, in which also less than 1% of the strains were resistant to erythromycin. Resistance to trimethoprim/sulfamethoxazole occurred in 7% (range 3-14%) of H. influenzae and in 3% of S. pneumoniae. Cefaclor was active against all streptococci except against S. pneumoniae with reduced susceptibility to penicillin. It was active against beta-lactamase negative strains of M. catarrhalis but had, according to the SIR-system, intermediate activity against H. influenzae. Loracarbef was twice as active as cefaclor against H. influenzae but equally active against the 3 other species tested.


A 56-month prospective surveillance study on the epidemiology of aminoglycoside resistance in a Belgian general hospital.

In this survey, we studied the effect of extensive amikacin usage on the epidemiology of aminoglycoside resistance in a general hospital. The baseline resistance in the 12 months before amikacin was 5.8% for amikacin, 15.2% for gentamicin, 16.4% for tobramycin and 14.0% for netilmicin. During the following 44 months, amikacin was the aminoglycoside of first choice. In the first 2 years of this phase, resistance to amikacin did not change significantly. Later, amikacin resistance rose significantly, mainly due to the introduction of amikacin-resistant Enterobacter aerogenes strains. In general there was a significant decrease in resistance to gentamicin and tobramycin. Resistance mechanisms were examined in 380 strains. AAC(3)V, and AAC(6')I alone or coupled with ANT(2") or AAC(3) were the most prevalent enzymes. In the amikacin phase, we noticed a significant increase of strains harbouring the AAC(6')I enzyme, while strains with the AAC(3)V were less frequently isolated. Strains with permeability resistance did not become more prevalent during the period of extensive amikacin use.


A comparison of netilmicin and tobramycin therapy in patients with renal impairment.

We evaluated the toxicity and efficacy of netilmicin and tobramycin in 89 older adults with serious bacterial infections and pre-existing renal impairment in a prospective, blinded, randomized trial. Complete resolution or improvement of infection occurred at 34/36 (94%) evaluable sites in netilmicin-treated patients and at 26/31 (84%) evaluable sites in tobramycin-treated patients. 10/44 (23%) netilmicin- and 7/45 (16%) tobramycin-treated patients experienced nephrotoxicity during treatment. The mean serum creatinine level improved significantly at the end of therapy compared to pre-treatment in those patients who did not experience nephrotoxicity in both treatment groups. 5/19 (26%) netilmicin-treated patients and 2/18 (11%) tobramycin-treated patients assessable for ototoxicity experienced decrements in auditory thresholds. Ototoxic netilmicin-treated patients had higher serum netilmicin levels than did non-ototoxic patients. Patients who experienced ototoxicity were not more likely to have experienced nephrotoxicity. The rates of toxicity were not statistically different and were similar to those seen in studies of patients with normal pre-treatment renal function.


First-year infections after initial hospitalization in low birth weight infants with and without bronchopulmonary dysplasia.

Symptoms of infection, specific infections, antibiotic course and hospitalizations were evaluated prospectively by using monthly questionnaires after initial hospitalization in 73 low birth weight (LBW) infants (less than 1751 g) and a subgroup of 19 infants with bronchopulmonary dysplasia (BPD) compared with 63 full-term controls matched for age, sex and home locality. The immunoglobulin G, A, M and E levels of the LBW infants were measured at corrected ages of 1, 2, 4, 6, 8, 10 and 12 months. The LBW infants, the subgroup with BPD and their controls had similar frequencies of infectious symptoms and episodes of infection. Dyspnoea and lower respiratory tract infections often caused by respiratory syncytial virus (RBV) were more frequent and more severe among LBW and especially BPD infants compared with controls. Male sex, a large family and day-care were significant risk factors for illness. The IgG levels of the LBW infants were subnormal at the corrected age of 1 month, but otherwise immunoglobulin levels were normal. The results suggest that LBW infants and especially those with BPD are prone to lower respiratory tract infections and should be considered candidates for immunoprophylaxis against RBV. In order to reduce morbidity home care is preferable to day-care.


Infectious diseases and day-care centre environment.

During the period from September 1986 to May 1987 all 25 day-care centre departments in the residential district of Teleborg in Växjö were studied to discover the frequency of absence due to infection. Mean absence/department was 6.6% (SD 2.2), with a range from 3.9% to 10.2%. During the period from September 1989 to May 1990 a follow-up study used the same methods to investigate 7 departments, which in the first study had shown the highest and lowest rates of absence due to infection. In addition, the carbon dioxide content in indoor air was measured in all departments in the district. The new measurements showed that the average absence due to infection in the 7 departments had fallen from 7.5% (SD 2.9) to 5.6% (SD 1.4). It was not possible to reproduce the division seen in the first study into departments with high and low absence rates. The variations in infectious morbidity observed could not be explained by differences between the departments as regards physical environment or working routines. By contrast, a considerable difference as regards carbon dioxide content in indoor air was seen between the 3 departments housed in converted dwellings and the 4 departments in purpose-built day-care centres; the mean values were 822 ppm and 458 ppm, respectively (Mann-Whitney U-test; p = 0.028).


Rat bite fever in a Greek child.

Rat bite fever was diagnosed in a 10-year-old boy in a rural area of south-west Greece. The clinical presentation was typical for this disease and the relevant causative agent (Streptobacillus moniliformis) was isolated from blood cultures of the febrile patient. Erythromycin treatment was efficient. Although extremely rare in continental Europe, this infection must be taken into account as a potential hazard of a rat bite.


Rat bite fever (Streptobacillus moniliformis) with septicemia in a child.

A 5-year-old girl was admitted to hospital with fever, headache and nausea. Her C-reactive protein raised from less than 11 mg/l to 65 mg/l and she developed a maculopapular, petechial rash, especially pronounced on the soles and palms. After incubation for 3 days, Streptobacillus moniliformis was found in all blood cultures that had been taken. Some weeks before her admission, the girl had been playing with her grandmother's pet rats, which later had died from an unknown disease. There was no history of rat bite. Her condition improved rapidly after treatment with penicillin and chloramphenicol, and she was discharged from hospital after 10 days without sequelae.


First documented case of human babesiosis in Sweden.

A 34-year-old splenectomized man presented with fever, myalgia and dysuria. His condition rapidly deteriorated, he became anuric and developed severe haemolytic anaemia, thrombocytopenia and fibrinolysis. Peripheral blood smears revealed intra-erythrocytic parasites consistent with Babesia divergens in 40% of the erythrocytes. The diagnosis was confirmed by gerbil inoculation and by a significant rise in antibody titer. Blood exchange transfusion reduced the number of babesia infected erythrocytes to 1%. Parenteral therapy with a combination of quinine and clindamycin eradicated parasitaemia after 10 days of treatment and the patient rapidly improved. Renal failure necessitated haemodialysis for one month, whereafter the patient made a full recovery. Human babesiosis is a rare disease, but with a potential fatal outcome and should be considered as a diagnostic alternative in splenectomized and otherwise immunocompromised individuals with severe febrile illnesses.


Early detection of circulating anodic antigen (CAA) in a case of acute schistosomiasis mansoni with Katayama fever.

A 34-year-old male developed acute Katayama fever with fever, diarrhoea, joint pains, headache, urticarial rash and eosinophilia 18 days after falling into and spending 15 min in the water during water-skiing in the outlet of the Volta river. Low anti-schistosomal antibody titres were found by the immunofluorescence assay after 4 weeks, and the first Schistosoma mansoni eggs were found in faeces after 6 weeks. Both symptoms and eosinophilia increased the first days after treatment with oxamniquine, after which he improved gradually. Examination of frozen sera by the newly developed Magnetic Beads Antigen Capture-EIA (MBAC-EIA) later demonstrated a peak in schistosomal circulating anodic antigen (CAA) levels of diagnostic significance already 4 weeks after he was infected.


The role of the family in psychiatric rehabilitation.

This article describes the multiple roles that families can play in the psychiatric rehabilitation process and suggests ways for professionals to collaborate with them. The authors discuss the family's experience of loss and their process of recovery; their caregiving role; their role in supporting other families; their teaching and educational role; their advocacy role; their role as researchers and research subjects; and some suggestions for supporting family roles.


Prospective study of psychobiology in first-episode schizophrenia at Hillside Hospital.

Heterogeneity has been a consistent problem in the research and treatment of schizophrenia. Despite marked variation in the onset, phenomenology, treatment response and outcome of schizophrenic patients, our ability to identify subtypes is remarkably limited. A major problem in schizophrenia research has been the use of cross-sectional study designs and heterogeneous patient samples at different stages of the illness and who have been previously exposed to neuroleptics which have potentially confounding effects on the disease. This study intends to identify biologic correlates of the phenomenology and course of schizophrenia by using a prospective, longitudinal, repeated measures design assessing biologic and clinical parameters including measures of psychopathology, side effects, and social adjustment to examine clinical variables of treatment response, illness course, and outcome; measures of central nervous system dopamine activity and brain morphology in patients, from the onset of their illness. Patients were ascertained at hospital admission and assessed with a battery of clinical, neuropsychologic, and biologic measures before undergoing standardized treatment for the acute and maintenance phases of the illness. Upon completion, approximately 120 first-episode patients will have entered the study and will have been followed prospectively for up to 5 years and assessed at specific time intervals. Preliminary results reveal significant abnormalities in brain morphology, growth hormone secretion, eye movement function, and psychotogenic response to dopamine agonists in first-episode, treatment-naive patients which are associated with treatment response and outcome. This article describes the study's rationale, design, and methods, and a summary of the published results to date. These are discussed in terms of their significance for putative clinical subtypes and pathophysiological models of schizophrenia.


Premorbid and onset features of first-episode schizophrenia.

Most descriptive studies of the psychopathology of schizophrenia have focused on the period following illness onset. Little attention has been paid to the assessment of psychopathology before onset of psychotic symptoms. In this study, 71 first-hospitalization patients diagnosed with schizophrenia, schizoaffective, or schizophreniform disorder using DSM-III-R criteria were assessed on measures of premorbid adjustment, clinical history, and presenting symptomatology. A pattern of progressive decline was characteristic of 21 percent of the cases--primarily males with a long-term history of psychotic symptoms before first hospitalization and a trend for more severe negative symptoms at hospital admission. Patients who had a stable pattern of good premorbid adjustment experienced symptom onset and first hospitalization at a later age than those with a chronically poor premorbid adjustment. Time from onset of first psychotic symptom to first hospitalization varied from less than 1 month to over 20 years and was not associated with symptom severity or age of first psychotic symptoms. Systematic characterization of the earliest manifestations of schizophrenia may be important in identifying subgroups of patients with a similar course of illness, and may ultimately facilitate diagnosis, treatment, and understanding of the pathophysiology of schizophrenia.


Developmental Processes in Schizophrenic Disorders: longitudinal studies of vulnerability and stress.

The Developmental Processes in Schizophrenic Disorders project is a longitudinal study of schizophrenic patients who have recently had a first episode of psychosis. The project focuses on discriminating characteristics of schizophrenic patients that are "stable vulnerability indicators," "mediating vulnerability factors," and "episode indicators" by comparing normal subjects to schizophrenic patients assessed in clinically remitted and psychotic states. A parallel project goal is to identify predictors of relapse, social and work impairment, and illness course among potential psychobiological vulnerability factors and environmental potentiating factors. Hypothesized vulnerability factors and potential environmental stressors are examined first under standardized maintenance antipsychotic medication conditions for at least 1 year. Patients showing stable remission of psychosis after 1 year of maintenance antipsychotic medication are invited to enter drug crossover and withdrawal protocols to determine the need for continuous antipsychotic medication. Vulnerability and stress factors are again assessed. A summary of results to date is presented. Deficits in early components of processing visual arrays and in sustained discrimination of successive ambiguous perceptual inputs are relatively stable across psychotic and clinically remitted states in the schizophrenic patients. Performance on a vigilance task demanding active, working memory also remains abnormal during clinical remission but covaries significantly with psychotic state and is a candidate for a mediating vulnerability factor. Autonomic activation level does not appear to be an enduring vulnerability factor, but it predicts the extent of short-term symptomatic recovery and may mediate the impact of stressors. Under conditions of standardized, injectable antipsychotic medication, independent stressful life events and highly critical attitudes toward the patient in the social environment predict relapse risk. Prospective data suggest that signs and symptoms prodromal to psychotic relapse may be present in about 60 percent of patients.


Ventricle-to-brain ratio and symptoms at the onset of first-break schizophrenia.

Ventricle-to-brain ratio (VBR) was measured from the computed tomographic (CT) scans of 33 very recent-onset psychotic patients. Illness severity and positive and negative symptoms were also assessed in 21 of these patients with schizophreniform disorder. Forty-five neurology patients served as controls. Analyses revealed no significant differences between the VBR of the psychotic group as a whole, the schizophreniform subgroup, the affective psychotic subgroup, and the controls. Control subjects with a neurological diagnosis of vertigo or syncope had significantly higher VBR than the remainder of the control group and the psychotic group. When the psychotic group was compared to the control group minus those controls with syncope or vertigo, the psychotic group had significantly higher VBR. The schizophreniform subgroup also had significantly higher VBR than the control group minus subjects with vertigo or syncope. In the schizophreniform subgroup, positive symptoms and illness severity were associated with smaller VBR. There was no association between negative symptoms and VBR.


Intellectual deficits in first-episode schizophrenia: evidence for progressive deterioration.

The developmental processes leading to neuropsychological deficits in schizophrenia are poorly understood. Both early developmental defects and subsequent deterioration may occur. Intelligence test profiles are often used to estimate premorbid ability and deterioration from prior levels of functioning. These characteristics were assessed in samples of first-episode (n = 51) and chronic (n = 50) schizophrenic patients. Although the groups showed few differences on tests to estimate premorbid intellectual ability, the chronic group performed worse on measures considered sensitive to deterioration. Dextral (right-handed) patients tended to have better performance; this effect was marked in the first-episode sample, especially on verbal tests. Male patients showed more evidence of deterioration than female patients. Subgroups differing in the time course of premorbid social dysfunction also differed in intelligence test profiles, suggesting that estimates of social and cognitive deterioration may have concurrent validity. The results support the hypothesis that patients differ in the course of cognitive decline and suggest that deterioration of function may follow the onset of overt psychosis in some patients. Prospective longitudinal studies of first-episode schizophrenic patients could directly test this hypothesis.


Phenomenology and functioning in first-episode schizophrenia.

One current view of schizophrenia is that its clinical and functional features show a deteriorating course, particularly for negative symptoms. However, this is difficult to study in chronic patients who have been exposed to pharmacologic treatment and institutionalization. Examining first-episode (FE) patients can help clarify which symptoms are present initially and how the symptom pattern is linked to functioning. We evaluated a sample of 37 FE patients with schizophrenia and compared them to 70 other schizophrenia (OS) patients on standard clinical scales, measures of premorbid functioning, and quality of life. FE patients showed a symptom profile similar to OS patients; in particular, there was no evidence that negative symptoms are less severe in the FE group. Analysis of the clinical data led us to the conclusion that the symptom profile of schizophrenia exists at the outset, that negative symptoms are associated with poor premorbid and current functioning, but that the role of positive symptoms is more complex and may vary in subtypes.


Generalizability of first-episode studies in schizophrenia.

Over a 5-year period, 77 patients in their first episode of psychosis were recruited into a study of autoimmune factors in the pathogenesis of schizophrenia. In this article their demographic and clinical characteristics are compared to those of chronic patients recruited into the same study as well as to the entire outpatient population of a schizophrenia clinic in a Pittsburgh community mental health center. There were no significant demographic differences between the first-episode patients and either of the other groups of schizophrenic patients. There was a significantly higher proportion of black subjects in the clinic population compared to the catchment area from which they were drawn. Clinically, first-episode patients differed from chronic patients in having fewer negative symptoms and more of certain positive symptoms. Age of onset was not significantly different in male and female first-episode cases, although there was a trend of females to be slightly older. We conclude that if diagnosis includes followup and reassessment, findings from research cohorts such as ours can be generalized to populations of outpatient schizophrenic subjects volunteering for treatment.


Where are the women in first-episode studies of schizophrenia?

Almost all investigations of first-episode schizophrenia uncover more male than female subjects. Two possible explanations for this observation are (1) first-episode investigations suffer more or less consistent methodologic biases or (2) the incidence of schizophrenia is higher in men than in women. Data from the markers and predictors of schizophrenia (MAP) project, a community-based first-episode study, permitted an investigation of the two alternatives. The results suggest that neither recruitment nor diagnostic vagaries explain the excess of males. Instead, the MAP results, consistent with other recent investigations, suggest that the incidence of schizophrenia is lower in women than in men. The findings are consistent with the literature on gender differences in schizophrenia, which indicates that schizophrenia in women is a less severe disorder than in men. The report includes recommendations for future first-episode investigations to ensure adequate representation of women.


The Iowa prospective longitudinal study of recent-onset psychoses.

In this article, the methods of a prospective longitudinal study of recent-onset psychoses are described. Methodological issues that may be common to studies employing a similar design are discussed in the context of the rationale behind this study's strategies. Particular attention is paid to statistical strategies that maximally exploit longitudinal data.


First-episode studies in schizophrenia: criteria and characterization.

Studies of early schizophrenia offer several advantages for efforts to unravel the biology, treatment, and outcome of this disorder. A review of available first-episode studies, however, suggests marked variability in findings, frequently attributed to the presumed heterogeneity of the disorder. Another cause may be variation in definitions and criteria used. Thus, attention has turned to the study of patients experiencing their first episode of psychosis. Although this strategy will not control for the true underlying heterogeneity of the illness, it provides a valuable method for homogenizing variability due to course. For this strategy to be effective, definition and operationalization of criteria for such studies are crucial. In this article, we reviewed assessment methods used in first-episode studies in the recent literature and found marked inconsistencies. We offer a framework for definition of patient populations for studies of early schizophrenia and outline some key variables that may serve as the basis for fuller characterization of the disorder. It is important to provide data on such variables to enhance comparability among studies of early schizophrenia and to facilitate meaningful interpretation of data.


First person account: schizophrenia: some issues.

The article that follows is part of the Schizophrenia Bulletin's ongoing First Person Accounts series. We hope that mental health professionals--the Bulletin's primary audience--will take this opportunity to learn about the issues and difficulties confronted by consumers of mental health care. In addition, we hope that these accounts will give patients and families a better sense of not being alone in confronting the problems that can be anticipated by persons with serious emotional difficulties. We welcome other contributions from patients, ex-patients, or family members. Our major editorial requirement is that such contributions be clearly written and organized, and that a novel or unique aspect of schizophrenia be described, with special emphasis on points that will be important for professionals. Clinicians who see articulate patients, with experiences they believe should be shared, might encourage these patients to submit their articles to First Person Accounts, Division of Clinical Research, NIMH, 5600 Fishers Lane, Rm. 10C-16, Rockville, MD 20857.


Stimulation of regeneration of the sciatic nerve by experimentally induced inflammation in rats.

The effects of application of a chromic catgut suture (conditioning lesion) placed close to the sciatic or tibial nerves on regeneration of the sciatic nerve after a crush lesion (test lesion), that had been induced after an appropriate conditioning interval (two or four weeks) were assessed. The catgut suture induced an inflammatory reaction around the nerve during the four weeks after application of the catgut suture (conditioning interval) but no signs of degeneration of nerve fibres were seen. There was a significant increase in length of outgrowth of sensory nerve fibres as measured by the pinch reflex test when the test lesion was applied after two and four weeks' exposure to the catgut suture. The rate of regeneration was increased by about 11% when the catgut suture had been applied for four weeks before the test lesion was made. The findings indicate that an inflammatory reaction around a peripheral nerve may act as a conditioning lesion, thereby stimulating regeneration of the nerve.


Decreased muscle speed, strength and fatigability following two hours of tourniquet-induced ischaemia.

Contractile and morphological properties of the rabbit tibialis anterior muscle were measured 48 hours following a two-hour ischaemic episode. Ischaemia was induced using a specially-designed pneumatic tourniquet placed on the rabbit thigh. Maximum tetanic tension of muscle subjected to ischaemia (381 +/- 77 g) was only about 30% of the tension generated by control muscles (1,212 +/- 67 g). The rate of rise of tetanic tension of muscles subjected to ischaemia (15.9 +/- 3 g/ms) was only 33% of control values (44.5 +/- 5.9 g/ms). Muscle fatigue index increased significantly from 0.22 +/- 0.7 in control muscles to 0.55 +/- 0.09 in ischaemic muscles suggesting that muscles subjected to ischaemia had a greater endurance capacity than control muscles. Morphologically, focal necrotic regions and inflammatory cells were observed in ischaemic muscle fibers. Taken together, these data are consistent with selective damage to the fast glycolytic muscle fibers within the ischaemic tibialis anterior muscles. Thus, ischaemia results in overall decreased muscle speed, strength and fatigability.


Ischemia in wound healing. II: Design of a flap model--biomechanical properties.

A standardized reproducible H-shaped double flap model for biomechanical testing of ischemic wounds was developed in rats. After 10 days of healing all the biomechanical parameters of the flap wounds decreased significantly, compared with normal healing incisional wounds. After 20 days of healing the extensibility as well as the most important biomechanical parameters were still significantly decreased. In part I of this study we showed that on day 1 the blood flow had decreased to 7% of the flow in normal incisional wounds, though it returned to normal on day 16. Here we show that this drop in blood flow results in a significant decrease in all the biomechanical parameters and thereby caused significant delay in the healing of the test wounds. There was no correlation between any of the biomechanical parameters and the length of surface necrosis on the flaps. These necroses thus do not necessarily reflect necrosis of the dermis, where the healing is responsible for the continuity and strength of the skin.


Regenerative response to membranous and enchondral lyophilized allogeneic bone in rabbit skull defects.

The regenerative responses of inlays of lyophilized allogeneic bone of membranous (skull) and enchondral (tibia) origin were studied in an experimental cranioplasty model in rabbits. The lyophilized bone particles were also bioassayed for inductive bone production in an orthotopic critical size defect rat model. Three trephined calvarial defects were evaluated in each of 14 adult rabbits. The experimental materials were implanted into two of the defects and the third was left empty for control purposes. The implants disclosed no major structural divergences as assessed by scanning electron microscopy. Healing was evaluated by light microscopy and contact radiography after periods of four and 15 weeks. The lyophilized bone allografts of both embryonic origins displayed a similar fashion of bone regeneration, bone marrow reappearance, and volumetric density of trabecular bone substance and displayed no obvious differences between experimental groups or intervals. The two materials exhibited low osteoinductive potential.


Venous anatomy of the thumb and thenar area.

The venous anatomy of the thumb and the thenar area, including the first web space, was studied after injection of a polymerizing plastic resin into the vascular tree of six fresh human cadaveric specimens. As in the previously described parts of the hand and fingers, certain anatomical features were consistently present in all examined specimens. The topography of the vessels is different from that of veins in other parts of the hand, and we conclude that this reflects differences in mechanical demands upon the soft tissues in various parts of the hand and the digits.


Pharyngo-oesophageal reconstruction with free jejunal transplants. New design of the upper anastomosis to improve monitoring of viability of transfer.

Since 1987, 13 free microsurgical jejunal transplants for large pharyngo-oesophageal tumors have been done in 12 patients at Tampere University Hospital. The conventional technique was used for the end to end upper anastomosis in seven patients, and our new end to side anastomotic technique in six. Five patients were alive at the time of writing, the mean survival being 22 months (range 1-48). Five patients developed orocutaneous fistulas, three of which healed spontaneously. In the remaining two the fistulas were caused by rapid recurrence of the tumour. There was no significant difference in ability to feed orally or swallow among the patients operated upon by the end to end or the end to side anastomotic technique. Our results show that the free microvascular jejunal transfer is a safe procedure for repair of the hypopharynx. Our new end to side hypopharyngojejunal anastomosis makes it possible to monitor the transplanted bowel reliably by direct vision.


Long term evaluation of the unilink anastomotic system. A study with light and scanning electron microscopy.

The long term effects of the Unilink mechanical microvascular anastomosis in terms of anastomotic patency and histological changes in the vessel wall were evaluated in 10 rabbits. Both carotid arteries and facial veins were divided and reanastomosed with the Unilink device. At death two years later all 40 anastomoses were fully patent, with histological changes similar to those described previously after 16 weeks, that is, normal endothelial lining, but almost total atrophy of the media at the anastomotic site. The thinning of the vessel wall at the anastomosis caused neither occlusions nor aneurysms during the observation period.


Silicone rubber implants for arthrosis of the scaphotrapezial joint.

Between 1980 and 1983, 10 patients received high performance silicone rubber condylar implants for the treatment of isolated degenerative changes of the scaphotrapezial joint. Early clinical and radiographic results (at a mean of 15 months) were excellent. Late follow up of these 10 together with a further 11 patients, however, showed migration of the implant and radiological signs of silicone particle synovitis in all but two. We no longer recommend this operation for treatment of isolated arthrosis of the scaphotrapezial joint.


Cephalometric measurements in patients with Pierre Robin syndrome and isolated cleft palate.

To compare craniofacial structure and growth, two standard lateral cephalograms of 35 children with Pierre Robin syndrome and 30 age and sex matched children with isolated cleft palate were taken at two different ages. The mean (SD) age of the children with Pierre Robin syndrome was 9.5 (3.0) years and of the children with isolated cleft palate 7.1 (1.1) years at the start of the follow up period. The follow up time in the first group was 4.3 (1.6) and in the second group 3.8 (2.7) years. There were no significant differences between the groups in the shape of the cranial base or the maxilla. The main differences were in the mandible, which showed more recession among those with Pierre Robin syndrome. There was a significant correlation between the shape of the maxilla and that of the mandible in that group, but not in the group with isolated cleft palate. During the follow up period there were no significant differences between the two groups in the rate of growth of the jaws. The association between the maxilla and the mandible (ss-n-sm) remained unchanged, or increased, or decreased with equal frequency in both groups. There was no catch up mandibular growth among the children with Pierre Robin syndrome.


Clefts with associated anomalies and syndromes in Finland.

Probands with clefts born during an 11-year period, 1975-85, were evaluated; 1,586 probands were found of whom 345 (171 males and 174 females, 21.8%) had an associated anomaly. More male patients had cleft lips, with or without cleft palate (CL(P)) and more female patients had cleft palates (CP). The anomalies were subdivided according to anatomical site, and the biggest category was that of the extremities (29.7%) followed by cardiovascular (14.8%) and other facial anomalies (13.0%). The smallest category was chromosomal anomalies (2.7%) followed by miscellaneous anomalies (4.1%). A total of 560 malformations were found. Most anomalies per proband with clefts were found in the bilateral cleft lip and palate subgroup (mean 1.04). The lowest (0.14) was found in the subgroup with the least severe cleft deformity, the cleft lip with or without cleft alveolus. In the CP groups a similar trend was found with 0.21 in the subgroup of submucous cleft palate and 0.33 for the subgroup cleft palate, submucous clefts excluded. A total of 133 probands with 39 different recognised syndromes was delineated, 25 in the CL(P) group and 108 in the CP group (8.4% of the total 1,586 patients with clefts). There was no difference in parental age between probands with an associated anomaly and those with a solitary cleft. Anomalies were more than three times as frequent among probands with clefts as among the general population.


Craniofacial development in children with unilateral clefts of the lip, alveolus, and palate treated according to four different regimes. III. The soft tissue profile at 16-18 years of age.

The soft tissue profiles of 85 16-18 year old children with unilateral clefts of the lip, alveolus, and palate treated according to four different regimes were studied using lateral skull radiographs. Regimes that included secondary bone grafting to the alveolus in the mixed dentition gave better convexity of the soft tissue profile (excluding the nose) and better soft tissue sagittal jaw relationships compared with treatment regimens that included primary bone grafting. The soft tissue profile in regimes that excluded bone grafting was almost as favourable as those in regimes in which bone grafting was done during the mixed dentition.


Reduction mammaplasty. A comparative study of the Orlando and Robbins methods in 292 patients.

Between January 1984 and November 1990 a total of 292 patients underwent reduction mammaplasty for hypertrophic breasts. Of these 233 had a superomedial pedicle (Orlando's method) and 36 an inferior pedicle (Robbins' method). Twenty-three had various other operations. Those operated on by Orlando's and Robbins' methods were compared retrospectively, and it was found that Robbins' method was superior in younger women because of increased sensitivity, particularly of the nipple-areola complex, and better lactation. In the physician's opinion ugly scars developed in 32% of the patients (n = 287). In our opinion wound closure with a subcuticular suture might improve the quality of the scar. Of the 287 patients assessed, 281 (98%) were satisfied with the physical, and 248 (86%) with the cosmetic, outcome of the operation.


The effects of infiltration with adrenaline on blood loss during reduction mammaplasty.

Between March and November 1990 a prospective study of the effect of an infiltration of diluted adrenaline on bleeding during and after reduction mammaplasty was carried out in 12 consecutive patients. There was a significant reduction in blood loss to less than 50% of that from the non-infiltrated breasts. There was no signs of increased postoperative bleeding or reduced flap viability as a result of infiltration of adrenaline.


The circulation in the nipple-areola complex following subcutaneous mastectomy in breast cancer.

To evaluate the decrease in circulation in the nipple-areola complex after subcutaneous mastectomy and immediate implantation of a submuscular prosthesis, the blood flow was studied by both fluorescein flowmetry and laser Doppler flowmetry in 24 patients with invasive breast cancer. In 14 patients a lazy-S-shaped horizontal lateral incision was used, and 10 underwent a subcutaneous reduction mammaplasty. After subcutaneous mastectomy with a lazy-S incision there was no significant decrease in blood flow in the nipple-areola complex compared with that in the untreated contralateral breast. In the breasts in which reduction mammaplasty had been done, the blood flow was reduced by 74% as measured by fluorescein (p less than 0.01), and 70% by laser Doppler flowmetry (p less than 0.05), compared with the contralateral breast. Five patients had partial or complete epidermal, and one patient had total dermal, necrosis of the complex, but there was no deep necrosis. No fluorescence was seen within the areas in which necrosis later developed in any of these six cases. The laser Doppler signal in the corresponding areas, however, was not reduced. The results show that the circulation in the nipple-areola complex is reduced more after subcutaneous reduction mammaplasty than after subcutaneous mastectomy with a lazy-S incision.


Factors that influence the incidence of brachial oedema after treatment of breast cancer.

Six factors that may increase the likelihood of swelling of the arm after treatment of breast cancer were investigated in 136 patients who had undergone treatment. The highest incidence of oedema was among patients who had received radiotherapy in high doses with few fractions to the axilla (60%), and in patients with a history of one or more infections in the arm on the operated side (89%). Overweight, oblique surgical incision, infection in the arm, and radiotherapy correlated with arm swelling. The age of the patient and whether the operation had been done on the dominant or non-dominant side correlated less with the incidence of oedema.


Comparison of self reported and observed length, width, and colour of scar tissue.

To evaluate the reliability of self assessment as a substitute for follow up, 30 self reported assessments of length, width, and colour of abdominal scars were compared with those of clinicians. The degree of disagreement between patients and medical observers was not significant. We conclude that as long as instructions to patients are unambiguous, reliable information may be obtained by postal inquiry. Self reported measurements may thus replace time-consuming follow up visits in studies on the influence of various factors on scar tissue.