[Medical undergraduate education is outdated. From the interns' point of view].

This survey is based on a questionnaire sent to all 517 interns in Norway in December 1990, of whom 93% replied. Ten interns were interviewed personally. The majority felt they received a good theoretical basis during their medical studies, but less than a third stated that the education had adequate vocational orientation. Students from the University of Tromsø, were the exception in this respect. They were more positive towards the vocational aspects of their studies. Most interns had high expectations with regard to learning during internship, and half of them to have to face various traumatic experiences during this period. One out of two stated that, so far, their internship training had been inspiring for their career as medical practitioner. About a third replied that they doubted whether they would choose the same profession if they were to make this decision again. The results of this study emphasize the importance of the current changes in the curriculum at all four medical faculties in Norway. The results also suggest a need for better coordination of university studies and internship, and more structured teaching during the internship.


[Professionalization without management? A study of the scientific content during the internship].

The basic medical education in Norway ends with one year as house physician or surgeon and six months as assistant to general practitioner. This internship is an important period in the course of education leading to a medical degree. According to a new national standard issued in 1989 all interns should have a personal supervisor and a formal curriculum covering this period. The present survey was carried out in order to evaluate the quality of learning during internship as experienced by the trainees. A questionnaire was sent to all 517 Norwegian interns as of December 1990. 93% replied. Ten of the interns were interviewed personally. 34% of the house officers had an appointed supervisor compared with 54% in primary care. Few of the interns had a formal curriculum. Many of them felt the need for constructive feedback on their professional performance, but few received it. They nevertheless claimed that it was easy both to raise questions and to obtain assistance in solving medical problems. One out of six interns had been severely depressed during the period of internship and related this to experiences at work. Women were generally more sensitive than men in this respect and were more critical of the interpersonal relationships experienced during this period. Despite the new standard, which sets realistic and necessary goals for this part of the medical education, learning during internship is still much a matter of chance. It is a major challenge to the medical profession to take the needs of young medical practitioners seriously.


[Quality assurance, internal control and patients' security].

Quality assurance of health services includes elements of both medicine and law. The professional standard has to be defined by the medical establishment, while the legislation points out the duties that have to be discharged in order to obtain the goal of quality and a high standard of health care. A superior goal in all health care is to offer the patients adequate medical treatment. The patients' rights usually correspond to the duties of the providers of the care, and in order to satisfy the patients' requirements it is important to ensure that these providers fulfill their duties.


[Ergotherapy--more than stimulation of activities].

There are many ways of forming a caring relationship. One way is to give people the opportunity to be active, whether they have a long or a short time left to live, and irrespective of intelligence, skills, values or cultural background. The occupational therapist focuses on and emphasizes the patients' need to master their environment and stresses a person's sense of self, bringing out what she or he feels is essential to be a competent person. Quality of life depends on an internal feeling of personal worth. By being able to contribute even on a small scale, for example by making a little gift to a friend, a person may gain both self-respect and the admiration of others.


[Surgical treatment of abdominal aortic aneurysms. Risk factors and complications].

Between January 1985 and April 1991 156 patients underwent surgery for abdominal aortic aneurysm at Nordland Regional Hospital. Of these, 90 underwent elective surgery; 36 were operated on for symptomatic aneurysm; 30 for ruptured aneurysm. The mortality rates were respectively 10%, 14% and 47%. Surgery for aortic aneurysm is on the increase. Advanced age, and associated serious cardiac disease predispose to postoperative complications and death. To reduce mortality better preoperative evaluation and treatment are essential.


[Aortic aneurysm misinterpreted as pulmonary tumor].

Two cases have been reported of patients with an atherosclerotic saccular aneurysm of the descending aorta which simulated a left-sided lung neoplasm. Despite advanced diagnostic procedures, the diagnosis was not made before thoracotomy. The authors discuss some of the diagnostic problems related to thoracic saccular aneurysms.


[Abdominal aortic surgery. Transperitoneal or retroperitoneal approach?].

During the past five years a retroperitoneal approach was used in 34 patients and the transabdominal route in 49 patients for treatment of abdominal aortosclerosis. Both groups were identical with respect to age, sex and preoperative morbidity. In patients with previous laparotomy the retroperitoneal approach was always chosen. There was no significant difference with regard to postoperative complications. The only significant difference between the two groups after the operation was a trend towards earlier defecation among the patients treated by the retroperitoneal approach. We can not demonstrate any important advantage or disadvantage of the retroperitoneal approach. The transabdominal approach provides an opportunity to examine the abdominal organs for malignancy. We found one asymptomatic gastric cancer. The retroperitoneal approach is particularly suitable in patients who have undergone laparotomy before for expected severe abdominal adhesions.


[Surgical treatment of aortic occlusion and obliterating aorto-iliac arteriosclerosis].

From 1985 to March 1991, 83 patients with the diagnosis aortoiliac obliteration and aortic occlusion were operated on at the Department of Surgery, Nordland Central Hospital. The main symptom was claudicatio intermittens. 16 patients had pain while at rest, and two had gangrene. The surgical technique was either Y-prosthesis or thrombendarterectomy. Four patients (4.8%) died postoperatively, three of myocardial infarction and one of intestinal ischemia and peritonitis. In our study 66 patients with aortoiliacal atherosclerosis were compared with 17 patients with aortic occlusion. Patients with aortoiliacal atherosclerosis demonstrated by angiography had much more severe infrainguinal arterial pathology. In the occlusion group the postoperative outcome, as measured by ankle/brachial index, was significantly better (p < 0.01). The study included four female patients less than 50 years of age with total infrarenal aortic occlusion. Their symptoms and signs are discussed.


[Surgical treatment of acute intestinal ischemia. Successful treatment with embolectomy of the superior mesenteric artery].

We describe a patient with acute intestinal ischemia successfully treated with embolectomy of the superior mesenteric artery. Over the last four years, 11 patients with the same disease were treated with bowel resection at Nordland Regional Hospital. The mortality rate after bowel resection was 45%. Long duration of symptoms, and high frequency of associated cardiovascular disease was characteristic. In elderly patients with acute abdominal pain and cardiovascular disease, a diagnosis of acute mesenterial ischemia should be seriously considered. In patients with acute mesenteric ischemia and no bowel necrosis, embolectomy must be considered in preference to bowel resection.


[Familial hypercholesterolemia--intensive diet therapy combined with drug therapy].

The aim of the investigation was twofold: to study the effect of lovastatin, a potent inhibitor of 3-hydroxy-3-methylglutaryl coenzyme A reductase, alone and in combination with other lipid lowering drugs in an open 48 week single centre study, and to study if lipid lowering drugs influence adherence to diet in adult patients with familial hypercholesterolemia. Lovastatin monotherapy (80 mg daily) for 12 weeks reduced serum cholesterol, LDL-cholesterol and triglycerides levels by 36%, 44% and 24% respectively. HDL-cholesterol level was increased by 12%. The addition of 16 g cholestyramine daily further increased the reduction of total cholesterol and LDL-cholesterol levels by 17% and 24% respectively. Addition of 1 g probucol daily decreased total cholesterol, LDL-cholesterol and HDL-cholesterol levels by 9%, 5% and 27% respectively. Addition of omega-3-fatty acids (3.6 g daily) reduced total cholesterol, LDL-cholesterol and triglycerides levels by 10%, 12% and 20% respectively. Administration of potent lipid lowering agents did not influence adherence to a diet with a mean daily fat energy of 21% (CI: 20-22), cholesterol of 177 mg (CI: 157-196) and P/S ratio of 0.75 (CI: 0.66-0.84). A significant increase in liver enzymes was recorded in only one patient. One patient was withdrawn from the study because of myositis.


[Inadequate treatment of affective disorders].

Inadequate treatment of mood (affective) disorders is related to the mind/body dualism, desinformation about methods of treatment, the stigma of psychiatry, low funding of psychiatric research, low educational priority, and slow acquisition of new knowledge of psychiatry. The "respectable minority rule" has often been accepted without regard to the international expertise, and the consequences of undertreatment have not been weighed against the benefits of optimal treatment. The risk of chronicity increases with delayed treatment, and inadequately treated affective disorders are a leading cause of suicide. During the past 20 years the increase in suicide mortality in Norway has been the second largest in the world. Severe mood disorders are often misclassified as schizophrenia or other non-affective psychoses. Atypical mood disorders, notably rapid cycling and bipolar mixed states, are often diagnosed as personality, adjustment, conduct, attention deficit, or anxiety disorders, and even mental retardation. Neuroleptic drugs may suppress the most disturbing features of mood disorders, a fact often misinterpreted as supporting the diagnosis of a schizophrenia-like disorder. Treatment with neuroleptics is not sufficient, however, and serious side effects may often occur. The consequences are too often social break-down and post-depression syndrome.


[ICPC in general practice].

The aim of this pilot study was to describe the distribution of diagnoses in general practice using International Classification of Primary Care (ICPC). The study took place in a group practice in Kongsberg, Southern Norway, in May 1991. It was of particular interest to find out how often doctors could use a disease as diagnosis (ICPC component 7) after the meeting with the patient and how often they used a symptom or complaint (ICPC component 1) as diagnosis. Results from 1,189 consultations show that a disease was used as diagnosis in 61% of all cases. A complaint or a symptom was used in 21%. Women were more often given a symptom as diagnosis. The study also shows that disorders of the respiratory and musculoskeletal systems were the most common diagnoses, accounting for 18% and 16% respectively. During one month, 247 diagnoses were used. Inter-observer tests of reliability showed that 81% of all consultations were coded to the same chapter.


[Botulinum toxin treatment of spastic torticollis].

Botulinum toxin A was administered to 19 patients with spasmodic torticollis. A significant decrease of abnormal head and neck movements was recorded, and all the patients who suffered pain reported relief. Side effects were minor and transient. The results of this study indicate that botulinum toxin is an effective means of treating torticollis.


[Use of propofol in Norwegian hospitals].

Propofol is approved by the Norwegian authorities (The Norwegian Medicine Control Authority) only for anaesthesia for less than three hours in adults. 54% of Norwegian hospitals had used propofol for anaesthesia in children and 33% for anaesthesia of more than three hours duration. In hospitals with an intensive care unit, 66% had used it for sedation in adults, 24% in children. It is not illegal to use a drug without the approval of the control authority, but the sedation of children had taken place without a basis in scientific documentation. The market for propofol fell by 40% shortly after the media focused on possible severe side effects in sedated children. Many of the anaesthesiologists found the media focus useful, but many thought that it was incorrect, and most of them that it was too general.


[Quality adjustment of life years--possibilities, limitations, alternatives].

QALYs express the sum of individual utility gains from medical interventions. As such they are potentially a useful measure in deciding how to allocate resources. They should not, however, be equated with the overall value that society places on different health care programmes. The latter is determined not only by the number of QALYs gained, but also by a series of distributional and ethical considerations. This should be made clear in the presentation of QALY-calculations, particularly in cost-per-QALY league tables. More comprehensive measures of social value that may be used in cost-utility studies need investigating.


[Resistance problems in developing countries--use and misuse of antiinfective agents].

Widespread use and misuse of antiinfectiva have resulted in a problem of drug resistance linked to treatment of infectious diseases. In developing countries especially, the sale of such drugs is poorly controlled and the pharmaceutical industry is dumping obsolete products. Intensive marketing, lack of diagnostic facilities and receptive local cultural attitudes to new "wonder drugs" such as antibiotics, have resulted in dramatic unnecessary use of such. Therefore the ideal strategies for treatment of infectious diseases guided by microbiological diagnosis and resistance pattern are violated in most developing countries, leading to excessive use of antiinfectiva and development of resistance. This has serious consequences for the infections that cause most cases of infant mortality, namely malaria, diarrhoeas and infections of the respiratory tract. Improvements in this vicious circle of drug use and resistance can only be made by attacking several factors simultaneously. There is a need for general information, stricter legislation, essential drug lists, national drug policies, better knowledge of local resistance patterns, better diagnostic facilities, better knowledge about local beliefs about drugs and better communication to local health workers and the community.


[Bacteriological examination of bronchial aspirates obtained via fiberoptic bronchoscopy].

We present the bacteriological findings in 329 aspirates from fiberoptic bronchoscopy. Quantitative cultures were not performed. 92 of the patients had radiologically confirmed pneumonia, 58 possibly had infectious bronchitis or pneumonia which was not verified radiologically, 154 had other pulmonary diseases and 25 had no verified pulmonary disease. 13% of aspirates contained no bacterial isolates and 33% revealed growth of multiple bacteria, classified as "normal pharyngeal flora". Among the 54% with specified bacterial findings the most frequent bacteria were viridans streptococci, staphylococci, Haemophilus influenzae, and Streptococcus pneumoniae. The differences in bacterial flora between the patient groups were only minimal. Klebsiella and Escherichia coli were the only bacteria indicating presence of pneumonia. S pneumoniae were found more frequently among patients with no signs of infection. Bronchial aspirates obtained with a fiberbronchoscope may give false positive results and are of limited value in diagnosing pneumonia. However, the presence of gram negative intestinal rods may indicate bacterial respiratory infection in hospitalized patients. Improving sampling and culture techniques can possibly improve the value of bacteriological findings.


[Lower respiratory tract infections among the elderly in Finnøy municipality. A retrospective study of the incidence, treatment and outcome].

Based on a retrospective study of the case records of the primary health care services in a small Norwegian coastal community (Finnøy), we found an incidence of 13% for lower respiratory infections in persons aged 70 years or more. Most often the initial medication was penicillin. In 23% of recorded episodes, medication was changed, owing to unsatisfactory response. Overall mortality in the group was 9%. Three out of five deaths occurred in patients terminally ill from other diseases at the time the respiratory infection started. Problems related to diagnosis, management and prevention are discussed.


[Pseudomembranous colitis. Surgical treatment].

Pseudomembranous colitis is an inflammatory intestinal disease that is usually secondary to antibiotic treatment. The disease upsets the normal bacterial flora of the large intestine. Therapy consists of fluid replacement, discontinuation of broad-spectrum antibiotics and treatment with vancomycin or metronidazole. In severe or resistant cases surgical treatment is required. We describe one case history and give some guidelines for surgical treatment.


[Local resection of cancer of the Vater's papilla].

Tumours of the papilla of Vater are almost always adenocarcinomas and are often less than 2.5 cm in diameter. Lymph node metastases occur in one fourth of the patients with tumours with a diameter of less than 2.5 cm. Whipple's procedure has been the most common operation when attempting radical excision. Local resection has not won acclaim, even though the five year survival rates are often reported to be about the same as for Whipple's procedure. We present a patient who was operated on by local resection, and describe the operative technique.


[Necrosis of the small intestine. A diagnostic and therapeutic challenge].

The paper describes three patients with small intestinal necrosis from different causes: One patient had diabetes, and severe ketoacidosis, which may cause microthrombosis in small intestinal vessels. This patient died in septic shock during laparotomy, removing the necrotic gut. The second patient was laparotomized because of free air in the abdomen originating from a clostridial intestinal infection. The third patient caught a salmonella infection during a holiday in the Canaries, thereafter peritonitis due to small intestinal necrosis. These three patients illustrate principal aspects of the surgical management of patients with intestinal necrosis. Firstly, necrotic intestinal segments must be removed as soon as possible. Delay represents a threat to the patient's life in all situations when intestinal segments are devascularized. Secondly, relaparotomy may be mandatory in clostridial intra-abdominal infections. We report these patients to illustrate that well known surgical principles may be life-saving if effectuated without delay. This applies also in the case of patients with uncommon diseases and complications.


[Examination and treatment of gynecological bleeding disorders].

The investigation and treatment of gynaecological dysfunctional bleeding has remained largely unchanged since the problem was dealt with in a special issue of the Journal of the Norwegian Medical Association in 1976, in spite of the advent of modalities like endometrial cytology, hysteroscopy and vaginal ultrasonography, as well as knowledge about the relative lack of efficiency of dilatation and curettage in the investigation and treatment of the condition. We describe a modern programme for investigation and treatment of gynaecological dysfunctional bleeding. The programme relies on clinical assessment combined with medical therapy, with optional use of modern investigative modalities when indicated. In a strictly controlled outpatient programme the need for dilatation and curettage can be greatly reduced without jeopardizing the safety of the patient.


[Selection by consequences].

Selection made on the basis of consequences is a causal mode found only in "living" things. Selection happens at the level of species, individual and culture. Human behaviour is the joint product of the contingencies of existence responsible for natural selection and of contingencies by which the behaviour of individuals are selected, including the contingencies maintained by an evolved social environment. Behaviour is not caused by immaterial processes inside the organism. It is the contingencies for behaviour and the behaviour itself that have to be analysed, and possibly changed. The implications for treatment may be great.


[Triglycerides, HDL and coronary disease. Consensus conference: National Institutes of Health 1992].

The article describes the conclusions and recommendations of the panel. A review of the information on HDL-cholesterol and coronary heart disease provides considerable evidence of a causal relationship. In the case of serum triglycerides, the data are ambiguous; although strong associations are found in some studies, evidence of a causal relation is still incomplete. Seen in relation to the latest Norwegian programme for treatment of hypercholesterolemia in adults, greater emphasis should be placed on measuring HDL-cholesterol. A complete initial lipid profile should also include determination of serum triglycerides. When taking these factors into consideration, the present Norwegian recommendations seem to be appropriate for evaluating and treating hyperlipidemia.


[Who is long-term sick-listed in Norway? From the project Evaluation of the follow-up of long-term sick-listed].

The aim of the study was to analyse the characteristics of persons with long-term sickness certification at the end of 1990 in Norway. The study was based on data registered by the National Insurance Administration: Age, sex, place of residence, diagnoses, and prognosis as registered on Sickness certificate II. At the end of 1990 a total of 57,567 persons had been incapacitated for work for longer than eight weeks and up to 52 weeks. The prevalence was 27.9 per 1,000 employed persons, with a significantly higher prevalence among women than among men. 25% of the women certified as sick were 40-49 years old. The highest prevalence of long-term certification of sickness was found in the counties Finnmark and Troms in Northern Norway, and Hedmark in central Norway. In cases of long-term sickness certification, the most common diagnoses were musculoskeletal/connective tissue diseases and mental disorders, with a prevalence of 9.3 and 3.1 per 1,000 employed persons respectively. The study indicates the possibility of using data from existing administrative population registers to provide information on the epidemiology of long-term sickness certification in Norway. It is necessary to further improve the validity of the data.


[Obstructive lung disease in a Norwegian population group--risk factors and occurrence].

In an ordinary Norwegian population which we studied, one in 13 persons suffered from an obstructive lung disease--bronchial asthma or chronic obstructive lung disease. The prevalence of the disease was the same in both sexes, but increased with age. There was a strong association between smoking and the disease. Occupational airborne pollution was an important risk factor. Taking the longest job held as a basis for the study, the adjusted odds ratio for obstructive lung disease in those exposed to a high degree of airborne pollution was 2.5 relative to those not so exposed. There was no difference between urban and rural areas in the frequency of the disease. Allergy and bronchial hypersensitivity were both associated with obstructive lung disease. Greater efforts should be put than at present into preventing obstructive lung disease.


[Pneumocystis carinii pneumonia--not only in AIDS].

Two patients with haematologic malignancies developed Pneumocystis carinii pneumonia while under outpatient treatment, one on busulphan for chronic myelogen leukemia, and the other on prednisone plus chlorambucil for non-Hodgkin's lymphoma. The first patient was moderately ill and required hospitalization for 12 days while the second patient was critically ill and needed assisted ventilation for two weeks. Eventually they both recovered and returned to work. Tests for serum antibodies to the human immunodeficiency virus (HIV) were negative in both patients. We review the problem of P. carinii pneumonia in patients receiving immunosuppressive drugs.


[Percentage of body fat and risk factors of coronary heart disease].

This study is a cross sectional analysis using measurement of the relative amount of fat on the right upper arm by means of the near infra-red method (NIR) and computerised calculation of the percent body fat by the use of the Futrex 5000. The total sample consisted of 1,988 subjects (942 women and 1,046 men) in the two age groups 40-42 years (n = 1,180) and 65-67 years (n = 808). Average percentage of relative fat in the total sample was 26.7, average percentage of body fat was 26.5 and average Body Mass Index, BMI (kg/m2) was 24.4. The percentage of fat and the BMI would both appear to increase with age and be higher in non-smokers. The BMI was higher in men, while the percentage of body fat was higher in women. A relatively weak correlation was found between the relative amount of fat and the BMI (0.4 < or = r < or = 0.57) but there was a relatively strong correlation between the percentage of fat and the BMI (0.72 < or = r < or = 0.88). The correlation with total cholesterol, triglycerides, blood pressure (SBP, DBP, MAP) and susceptibility to cardiac infarction (calculated estimated units) was similar for both the percentage of fat and the BMI. All correlations were positive, but with a relatively low r (0.05 < or = r < or = 0.39). The interaction between the percentage of body fat and the BMI would appear to be independent of age and sex.(ABSTRACT TRUNCATED AT 250 WORDS)


[Diagnostic imaging of the gastrointestinal and biliary tracts. Pattern of examinations during the period 1975-90].

The procedures used for imaging of the gastrointestinal tract, the gall bladder and the bile ducts were registered in six Norwegian hospitals during the period 1975-90. Data obtained from all hospitals showed a significant decrease in radiological examinations of the stomach and the large bowel, and a dramatic decrease of such examinations in the case of the gall bladder and bile ducts. The changes are mainly due to the increasing use of newer methods such as ultrasonography, gastroscopy and colonoscopy. The shift in the pattern of examinations, as shown in the present study, may well have many implications for patients and for the health service as a whole.


[Subcutaneous emphysema in gastrointestinal tract perforation].

Perforation of the gastrointestinal tract can lead to retroperitoneal abscess formation. Clinical signs and symptoms are often non-characteristic. In undetected cases the first sign of perforation may be subcutaneous emphysema. The place where this first appears correlates with the localization of the perforation. The pathogenetic mechanisms and clinical features are discussed, with reference to a case report.


[Abdominal actinomycosis. Actinomycotic abscess 10 years after appendectomy].

A case of actinomycosis of the abdomen ten years after surgery for acute appendicitis is reported. The patient, a 2 1/2 years old girl at the time of operation, presented with acute abdominal pain ten years after appendectomy. Computed tomography (CT) showed a mass in the region of the right psoas muscle. Fine needle aspiration revealed pus which on culture was found to contain Actinomyces israeli. Since surgery is a well known probable cause of abdominal actinomycosis, we must assume the appendectomy and the formation of the actinomycotic abscess to be related. Discovery of an abdominal mass even years after violation of the gastrointestinal tract should arouse suspicion of an abscess involving these otherwise infrequent pathogens.


[Cell surface carbohydrates are involved in various biological processes].

All human cells show carbohydrate structures on the surface. New knowledge about the genetic mechanisms for the synthesis of these carbohydrates and the generation of monoclonal antibodies with high specificity shows that carbohydrates are involved in various cell-cell and cell-matrix interactions. For instance, cell surface carbohydrates seem to be important in connection with fertilization, embryonic development, cell differentiation, cancer, adhesion of microorganisms and immunological processes. This new knowledge will increase our understanding of various biological phenomena, and will thus be of value for diagnosis and treatment of various diseases.


[Cyclosporine in the treatment of psoriasis].

Psoriasis is a chronic inflammatory skin disease of unknown etiology. An immune-reaction mediated by T lymphocytes is important in the pathogenesis. Cyclosporin is a selective immuno-suppressant that inhibits helper T lymphocytes. Several controlled clinical studies have shown that cyclosporin is highly effective in controlling severe psoriasis. The main side effects are hypertension, nephrotoxicity and increased risk of developing malignancies, particularly after long-term treatment. Side effects during short-term therapy appear to be reversible. Some questions connected to the long-term use and safety of cyclosporin are still unsolved.


[Streptococci group B and pregnancy. Need for routine check-ups?].

Group B streptococci are a major cause of perinatal infections and affect 1-5 infants out of every 1,000 live births. Maternal vaginal colonization with these bacteria is common (5-25%), and has been associated with late abortions, foetal growth retardation, early rupture of membranes and premature delivery. Colonization with group B streptococci may be observed in more than 70% of neonates born to mothers with the bacteria in their vaginal tracts at delivery. A high number of bacteria in the maternal urogenital tract during pregnancy may predispose to early-onset disease in neonates. The estimated attack rate in colonized neonates is 1-2%. A high specific IgG antibody concentration in the mother may protect the infant, but probably not before 32 weeks of gestation. Colonized women who are unable to produce such antibodies risk having affected offspring. Neonatal infection with group B streptococci frequently results in death or permanent neurologic morbidity; especially from the early-onset type (case-fatality more than 50%) which is most often vertical transmitted. Four cases with early-onset disease illustrate the severity of perinatal group B streptococcal infections. The severity and outcome of the disease may be moderated by screening for group B streptococci during late pregnancy. This screening must be combined with special attention to irregularities in pregnancy or perinatal complications.


[Cardiopulmonary resuscitation performed by laymen--the Nord-Gudbrandsdal Project--circulatory arrest in sparsely populated regions].

Previous investigations from densely populated areas have shown that more patients with prehospital circulatory arrest caused by ischemic heart disease can be successfully treated by strengthening a chain of survival. This chain consists of immediate alarm followed by prompt cardiopulmonary resuscitation, early defibrillation and advanced medical support before transportation to hospital. This paper describes the methods used in the training of lay people in cardiopulmonary resuscitation, as well as how ambulance personnel were trained to use a semiautomatic defibrillator. During the period 1987-89 11.7% of the inhabitants in Nord-Gudbrandsdal attended a course in heart lung resuscitation and all the ambulance personnel were trained and certified to use Heartstart 2000 semiautomatic defibrillators.


[Results of treatment--the Nord-Gudbrandsdal Project--circulatory collapse in sparsely populated regions].

In Project Nord-Gudbrandsdal we aimed to reduce prehospital mortality from myocardial infarction in a sparsely populated area. The ambulance system consisted of local ambulances with semi-automatic defibrillators (the ambulance personnel were trained in the use of these), combined with advanced medical support from the local doctor and/or the air ambulance doctor. During the three-year period (1987-89) 75 prehospital cardiac arrests were observed in a population of 22,000 inhabitants. 12 patients with ventricular fibrillation were defibrillated, and eight primarily with success. Four patients were discharged from hospital in a satisfactory condition. We discuss the factors determining successful resuscitation.


[Centralization of obstetric care and perinatal mortality in Norwegian counties 1986-90. Analysis based on public statistics from the medical birth registry].

The relationship between centralization of obstetric care and perinatal mortality was studied in 19 Norwegian counties for the period 1986-90. No significant trend was found. However, during the period 1988-1990 prenatal mortality was significantly higher, with a relative risk of 1.21 (95% confidence interval 1.00-1.45), in the three counties with only one obstetric department than it was in all other counties. The analysis did not support the notion that greater centralization of obstetric care would decrease perinatal mortality.


[Embolization of bronchial arteries in severe and recurrent hemoptysis].

Bronchial artery embolization is an established treatment for massive and serious haemoptysis. We review etiology, pathogenesis and different treatment modalities of major haemoptysis, and discuss indications and outcome. Massive haemoptysis, defined as > 300 ml/24 hrs., is a rare condition with a high mortality rate (30-80%) if treated conservatively. We describe seven patients treated with bronchial artery embolization. Three patients had massive haemoptysis, and four patients were treated for recurrent and severe haemoptysis. Two patients had haemorrhage because of inactive tuberculosis, five had cystic fibrosis. All patients were successfully treated by embolization, one patient suffered recurrent haemoptysis after four weeks. The other patients have shown no further haemoptysis during the observation period (mean 20 months). No complications were observed other than the common, self-limited post-embolization syndrome (mild fever and chest pain). In patients with severely reduced lung function and progressive disease, recurrent haemoptysis of even smaller amounts might interfere with postural drainage and cause infections and deteriorate lung function. Bronchial artery embolization should be considered for these patients as well. Unless localized lesions can be cured through surgical resection, we consider bronchial artery embolization to be the treatment of choice.


[Etiology and diagnosis of chronic shoulder pain].

Shoulder pain of more than three months' duration is regarded as chronic. Activity with an elevated arm is a risk factor, due to reduced local flow of blood to the supraspinatus muscle. Knowledge about normal shoulder biomechanics and dysfunctional behaviour patterns is essential when treating patients with chronic pain. It is necessary to consider psychosocial factors in addition to local pathology. The clinical examination should enable the physician to distinguish between referred and true shoulder pain and between restricted and free passive range of movement. Diagnoses may be classified into eight groups. The association between pain and degenerative changes has yet to be solved. This emphasizes the danger of deciding treatment without matching findings from radiological examinations with clinical signs and symptoms.


[Indications for surgery in ulcerative colitis. Some aspects of a hospital case load].

From 1.1.1985 to 1.1.1992, 233 patients with ulcerative colitis were treated in the Medical Department, Aker Hospital. 30 patients (12.9%) were referred for surgery. The main indications for surgery were severe colitis and chronic persisting symptoms. The increased risk of developing colorectal carcinoma in cases of long-standing extensive ulcerative colitis is generally accepted. Many of our unoperated patients belong to this risk group. In the present sample the resection rate was lower than recently reported from Sweden and Denmark. Symptomatic patients in the risk group for developing colorectal carcinoma should be offered surgery more liberally, and asymptomatic patients in this group should be offered colonoscopic surveillance.


[Skin tests with Pityrosporum ovale extract in atopic dermatitis].

The etiology of atopic dermatitis is multifactorial. Immediate-type sensitivity to the lipophilic yeast, Pityrosporum ovale, may be important, especially in a subgroup of patients with dermatitis predominantly in the head and neck region. 100 patients with atopic dermatitis were investigated by means of skin prick tests, including Pityrosporum ovale extract. Positive tests were found more often in atopic patients with "head and neck"-dermatitis, but the correlation between a positive prick test to Pityrosporum and the severity of atopic dermatitis, estimated by means of clinical criteria and total IgE, was even higher.


[Quality assurance of medical leadership].

Quality assurance is a managerial responsibility, but the medical management itself must also be quality assured. Today quality assurance of medical management is usually performed when the organization is not functioning properly, but quality assurance should be a continuous process. Regular feedback to the management is essential from all levels of the organization. Standards must be established for good medical management. The medical profession must start this work now. There are many others who want to take it over.


[Quality assurance in psychiatry--is it possible?].

The assessment of quality depends on the eye of the beholder, the patient, the clinician and his colleagues or society/third party payers. There are already several structures that regulate quality: training requirements, judicial control commissions and public health authorities, and in psychiatry also individual supervision and extensive clinical meetings. Most clinical parameters in psychiatry are measurable, but there remains the elusiveness of mental processes, which often defies quantification. Levels of symptoms and functioning, however, can be scored. Computerisation of macro-data often permits useful comparisons, as may consensus conferences and consultations with peers. The essence of quality monitoring is to find indicators that predict results and also reflect the most important situations and problems.


[Routine determination of homocysteine in plasma. A new and improved possibility for risk evaluation and diagnosis of common diseases].

The performance of a rapid, fully automated HPLC assay for total homocysteine in plasma has made it possible to offer this analysis as a routine laboratory test. The reference interval in fasting individuals is 7-14 mumol/l. In EDTA-plasma, homocysteine remains stable for up to four days at room temperature. The most important indications for analysing homocysteine are deficiency of vitamin B12 or folate, premature cardiovascular disease and inherited homocystinuria. The clinical usefulness of the assay is based on the fact that the intracellular metabolism of homocysteine is dependent on vitamin B12, folate and vitamin B6. Moreover, homocysteine may be an atherogenic agent, and there is increasing evidence that a high level of homocysteine in plasma is an independent risk factor for developing premature atherosclerotic disease.


[Highly specialized medicine. How to assign the tasks?].

Norway has four million inhabitants and five university hospitals, each serving one health region. The authors describe the work of a governmental medical committee, whose mandate is to advise on where to locate the various highly specialized medical services. Important questions have been the relationship between experience and quality, and the desire of each university clinic to be able to provide treatment within its own region for most health problems. Their reasons are concern about research and specialist training, and the preference of patients for treatment near to home. A list of proposed national and over-regional centers for certain treatments has been prepared on the basis of the experts' report and comments from all university clinics. These recommendations have provided a medical basis for later economic and political analyses prior to final decision by the Government. Norwegian legislation permits strong governmental regulation of the highly specialized health services.


[Be wise--refer! Fact or fantasy?].

On the occasion of his retirement as an active specialist in Surgery dr. P.H.A. Poll describes the history of the development of the specialties in Veterinary Medicine in The Netherlands and carefully looks forward. As a tribute, his specialist colleagues, all related to the Companion Animal Hospital "De Wagenrenk", publish one or more case reports from there respective disciplines (ophthalmology, surgery, radiology, dermatology).


[Possible significance of spiral-shaped bacteria in the etiology of abomasal ulcers in adult cattle].

Enzyme-chemical and histological evaluations were used to examine the abomasal mucosa of adult cattle with or without mucosal lesions of the corpus. Urease activity was detected with the CLO (Campylobacter-like organisms) test in the abomasal mucosa of all cattle except one, which had mucosal lesions. Spiral-shaped bacteria were visualised histologically in the mucus layer, with the highest number being found in the pars pylorica. Variable amounts of intra-epithelial mucin were found in the corpus and pars pylorica of both test and control cattle. Most inflammatory cells were found in the lamina propria of the pars pylorica. It is suggested that spiral-shaped bacteria, together with a diminished mucosal barrier, play a role in the pathogenesis of abomasal ulcers in adult cattle.


[2 cases of 'hardware' foreign objects in ponies].

An obstruction of the small intestine was suspected in two ponies with colic. At surgery and at necropsy, the cause of the colic appeared to be an inflammation process caused by perforation of the jejunum by a piece of wire. One pony recovered after laparotomy and enterectomy, but had to be put down eight weeks later because of severe laminitis. The other pony was euthanized immediately after clinical evaluation.


[Mucosal lesions in the pars esophagus in swine: prevalence and the effect of stress].

Morphological investigations of slaughterhouse material revealed a prevalence of 63% of the sows (n = 224) and 36% of the slaughter pigs (n = 209) with mucosal lesions in the pars oesophagea. The mucosal lesions were composed of severe hyperkeratosis, erosions or ulceration. Microscopic examination showed that hyperkeratosis is attended with parakeratosis. From experiments in a climate controlled pighouse it could be concluded that mixing of unfamiliar pigs resulted in higher prevalences of gastric lesions as compared with keeping the litter together until the end of the experiment (farrow to finish system). There was no relation between gastric lesions and climatic stressors or between gastric lesions and growth and sex of the pigs. When pigs, according to social ranking, were divided in high, middle and low rank it showed that more pigs in the middle-ranked group had gastric lesions. The serum pepsinogen was not related with gastric lesions. There was a tendency that plasma cortisol increased with severity of gastric lesions. There was a strong significant 'litter-effect', which can indicate a genetic predisposition for the development of gastric lesions. Maybe that the presence of mucosal lesions in the pars oesophagea can be used as an objective indicator for welfare in intensive pig husbandry.


[Environmental pollution and attendant contamination of agricultural domestic animals. Practical conditions in the provinces].

Cattle are exposed to pollution by air, water, grass or soil. Exposure to environmental pollution is mainly through the eating of contaminated grass or feed. Case studies in the province of South-Holland show the importance of risk evaluation not just for human health but also for the health of cattle. The sequence "environment-cattle-public health" needs attention. The economic effects of pollution on agriculture may be considerable.


[Plants as transfer factor of environmental pollutants to domestic animals].

Environmental contaminants in pasture and fodder crops may be 'carried over' to animal products and thus contribute to the contaminant burden of man. The processes by which plants collect contaminants from their environment can be divided into three categories: interception (mainly atmospheric deposition), surface contamination from adhering soil, and uptake from the soil (either by roots or by leaves after volatilization). In the field all processes may operate at the same time, but one is them often predominates. Identification of the (most) relevant process is a prerequisite for effective measures to reduce the burden of contaminants in plants and animals as well as man.


[Behavior of environmental contaminants in farm livestock].

Knowledge about pharmacokinetic factors is essential to evaluate the consequences of the exposure of farm animals to high levels of environmental contaminants. The bioavailability, which depends on for instance the exposure route and the matrix in which the contaminant is embedded, is of primary importance. The exposure of an animal expressed as internal dose rate is determined by the efficiency of the various elimination processes. If the combined rate of these processes is low, high body concentrations relative to exposure rate will occur. Metabolic elimination may lead to the formation of toxic metabolites and in that case it is necessary to study these metabolites as well. Residue problems may occur as a consequence of substance properties and/or the presence of specific binding proteins in organs and tissues. Finally, pharmacokinetic studies should be conducted at various levels of exposure as some kinetic processes may be non-linear in nature.


[Toxicity of cadmium in cattle].

After having investigated the metabolism of cadmium in plants and animals, the Animal Health Service of North Brabant in 1982 instigated research into the level of cadmium in the livers and kidneys of beef cattle kept in the vicinity of a zinc processing factory. Cadmium levels in these cattle were more than twice as high as those of cattle kept in control areas. Clinical abnormalities as a result of the increased cadmium levels were not observed, although haemoglobin and iron levels, iron-binding capacity and iron saturation were lower in these animals than in control animals. Cadmium therefore appears to have an adverse effect on iron absorption. Administration of high doses of cadmium for a limited period to 14 heifers did not cause discernable clinical abnormalities. These animals retained cadmium to a much smaller extent than anticipated on the basis of data for monogastric (mainly rats) animals.


[Food products of animal origin and environment contaminants].

Environmental contaminants may reach humans via products of animal origin is obtained mainly from production animals but also from fish. Heavy metals such as lead, mercury and cadmium are present in food in minor quantities only and, in general, do not represent a serious threat to the consumer. Xenobiotics which accumulate in adipose tissue are discussed subsequently. In The Netherlands, the presence of organochlorine pesticides is not problematic anymore. HCH isomers, however, still require attention. The same applies for PCB's and dioxins in fish and in milk, respectively. Finally, some attention is paid to the way in which food of animal origin can become contaminated by certain radionuclides.


[Contamination of production animals with environmental pollutants and public health risk].

Exposure to dairy products contaminated as a result of environmental pollution can be an important route of exposure for humans. Whether this route of exposure will cause a serious health risk depends on many factors. In this paper three examples of different types of environmental pollution are discussed with regard to exposure to contaminated dairy products. Specific groups in the Dutch population could be at risk, because the "silent" chronic contamination of dairy products. Human risk assessment, on which many standards for tolerable levels of contaminants in food are based, should take into account not only exposure of the average human, but also the more than average exposure of specific groups at risk.


[Veterinary dentistry (6). From back to the roots to buck on the rock].

The Royal Netherlands Veterinary Association is organizing its yearly congress in the old city of Utrecht where all Dutch veterinarians have been graduated. 'Back to the roots' is the slogan of this meeting. The Diergeneeskundige Studenten Kring (the Dutch veterinary students association) is celebrating the 60th anniversary at the same time with the slogan: 'Bok on the rock.' On the first day of this celebration the students are organizing a symposium Veterinary Dentistry. The author has been inspired by the two slogans to a discourse in which the past and the future of animal dentistry is discussed. In 'Back to the Roots' history and anecdotes about dental treatments are presented. It is clear that dental treatment in animals is possible for every well-educated veterinarian. In 'De bok on the rock' the author shows the ropes how to develop a dental minded practice. Oral examination, a good knowledge of dentistry and a dental-minded staff are the most important factors to build up such a practice. There is an abundance of dental patients in every practice. An optimal client education and coaching is the best way to find them and to follow them.


Intravascular membrane oxygenation and carbon dioxide removal--a new application for permissive hypercapnia?

Pressure limited ventilation or "lung rest" may prevent further exacerbation of acute lung injury from high airway pressures. A therapeutic goal of an intracorporeal oxygenation and carbon dioxide removal device (IVOX) is reduction of airway pressures. We noted increased IVOX CO2 removal as mixed venous CO2 increased in experimental animals. However, we recognize the limited clinical utility of removing approximately 30% of venous CO2. Therefore, intentional hypoventilation to limit airway pressures (mild permissive hypercapnia) was used in 5 patients with respiratory failure, and again we noted improved CO2 removal with increasing mixed venous CO2 concentrations. Preliminary calculations demonstrate that a CO2 gradient of approximately 70 mm Hg is needed to remove 100 ml CO2/min. The use of more aggressive permissive hypercapnia protocols with IVOX may permit further reduction in airway pressure without problems of severe respiratory acidosis.


Temporary lung support using an intravascular gas exchanger.

Severe respiratory failure may be difficult to overcome by conventional mechanical ventilation. As an alternative to the very demanding lung support using various modalities of extracorporeal circulation (ECMO, ECLA, etc.) we evaluated an intravascular gas exchanger (IVOX) in a "reversible" bovine model. Several degrees of hypoventilation were studied with and without intravascular gas exchange in 5 endotracheal intubated, anaesthetized, and volume-controlled ventilated animals (body weight 73 +/- 4 kg). After systematical heparinization (300 IU/kg body weight) the animals were instrumented with EKG electrodes, thermodilution pulmonary artery catheter with continuous measurement of O2-saturation, central venous and femoral arterial catheter, etc. The intravascular gas exchanger made from siliconized microporous polypropylene hollow fibres was placed in the caval veins under radiofluoroscopic control. The following scenarios were studied without and with intravascular gas exchange (gas inlet 100% O2): Normoventilation (with 14-20 strokes/min) at F10(2) 0.50 and at F10(2) 0.21; Hypoventilation (ventilator frequency reduced to 50% and tidal volume reduced to 50% of normoventilation) at F10(2) 0.50 and at F10(2) 0.21. Hemodynamics, mixed venous O2-saturation, arterial and venous blood gases, and gas-exchanger exhaust were analyzed after stabilization over 15 minutes (mean +/- standard deviation). Blood gas analyses showed significant improvement with intravascular gas exchange during hypoventilation at F10(2) 0.21: pH moved from 7.10 +/- 0.17 to 7.19 +/- 0.15*, PaCO2 moved from 9.9 +/- 4.2 kPa to 8.7 +/- 2.8*, PaO2 moved from 6.5 +/- 1.2 kPa to 7.3 +/- 0.8* and mixed venous O2-saturation moved from 33.9 +/- 16.0% to 48.1 +/- 4.6* (* = p less than 0.05 for without versus with intravascular gas exchange).(ABSTRACT TRUNCATED AT 250 WORDS)


The influence of obesity on perioperative morbidity: retrospective study of 502 aortocoronary bypass operations.

The incidence of perioperative complications after coronary artery surgery was investigated by a retrospective study of all 502 patients undergoing coronary artery bypass graft (CABG) surgery in our Department between January 1st and December 31st of last year (1990). Furthermore, the influence of obesity on the early results of surgery was assessed and the effect of preoperative weight reduction on perioperative complication rates examined. Obese patients had a greater incidence of left-stem coronary artery stenosis (p less than 0.001), hyperlipidaemia (p less than 0.05), hypertension (p less than 0.05), diabetes mellitus (p less than 0.02), and were in general younger at the time of operation (57.9 +/- 8.4 vs. 60.8 +/- 8.5 years). There were no differences in the surgery performed and in operative mortality, but there were some in perioperative morbidity. Obese patients had higher rates of infection (p less than 0.02), sternal dehiscence (p less than 0.02), arrhythmias (p less than 0.02) and myocardial infarction (p less than 0.02). No significant differences were identified in obese patients with or without preoperative weight reduction, although there was a trend of better postoperative recovery and results in patients having undergone preoperative weight reduction. Analysis of our results demonstrated obesity to be an independent risk factor for perioperative complications, hospital morbidity, and length of hospitalization.


Pulmonary atresia with intact ventricular septum: results and predictive factors of surgical treatment.

Between 1970 and 1989 26 children were operated for pulmonary atresia with intact ventricular septum (PA/IVS). According to the degree of right heart hypoplasia the patients were divided into 3 groups of mild (5), moderate (17) or severe (4) hypoplasia. Palliative operations were performed in 25 children (17 male, 8 female) at a mean age of 10 days: 13 valvotomies (valv.), 5 aortopulmonary shunts, and 7 valv. plus shunt. One patient had total correction as primary procedure. A total of 17 reoperations was necessary in 12 of 26 patients (10 palliations, 7 total corrections). Total corrections were: 2 conduits and 5 patches of the right-ventricular outflow tract (RVOT). Total mortality was 14/26 (54%) children (early 10/26 = 38%, late 4/26 = 16%). After total correction mortality was 3/7 (43%) patients. After a mean follow up of 10.8 years after palliation the 12 survivors are mostly in NYHA class I. Actuarial survival after palliation was 60% after 30 days and 44% after 5 and 10 years. We analyzed 9 clinical and hemodynamic variables by univariate and multivariate analysis to assess the predictive factors of postoperative outcome. Multivariate analysis disclosed the degree of right-ventricular hypoplasia (p = 0.023) as an independent predictor for death whereas the age at palliation only approached significance (p = 0.065). We recommend the following surgical strategy, aiming in the first place at decompressing the right ventricle: in mild hypoplasia valvotomy alone or combined with a shunt for palliation, in moderate hypoplasia shunt plus patch of the RVOT and in severe hypoplasia shunting alone. In case of a restrictive foramen ovale initial balloon septostomy is performed.(ABSTRACT TRUNCATED AT 250 WORDS)


Cardiodynamic effects of dopamine and dobutamine.

On 11 patients undergoing coronary surgery, at the end of the surgical intervention, the inotropic responses to 0.4 and 0.8 microgram x kg-1 x min-1 dopamine and dobutamine given via the aorto-coronary bypass directly into the coronary artery were compared. These dosages correspond to ones 10 times greater applied intravenously. The measurements were made using needle force probes which were implanted into the myocardial offstream area in the left ventricular wall. Bypass flow was measured simultaneously by an electromagnetic flow probe. There is a significant increase in coronary bypass flow induced by both rates of 0.4 and 0.8 microgram x kg-1 x min-1 dobutamine, but there was no significant effect on bypass flow induced by dopamine. Developed myocardial force is raised more by dobutamine medication than by dopamine. However, the rate of contraction increases significantly and relaxation is significantly accelerated by dopamine at both dosages. A significant increase in rate of contraction and relaxation was only induced by the higher dosage of 0.8 microgram x kg-1 x min-1 dobutamine.


The effect of superoxide dismutase and reduced glutathione on cardiac performance after coronary occlusion and reperfusion--an experimental study in dogs.

To determine the effect of Superoxide Dismutase (SOD) and Reduced Glutathione (GSH) as free-radical scavengers on cardiac performance in the reperfusion period up to 60 minutes after occlusion of the Left Anterior Descending artery (LAD), 16 dogs were selected for study. In the 30th and 60th minutes of LAD occlusion and reperfusion periods Cardiac Output (CO), Heart Rate (HR), Mean Arterial Pressure (MAP), Pulmonary Capillary Wedge Pressure (PCWP), Coronary Perfusion Pressure (CPP), Rate Pressure Product (RPP) and Triple Index (TI) values were determined. Of the 16 dogs, 7 as controls and 7 treated with SOD and GSH could be included in the study, and 2 had to be excluded because of death. In the 30th and 60th minutes of reperfusion period, the treated dogs had higher CO and CPP (p less than 0.05, p less than 0.01 respectively), MAP values were different (p greater than 0.05, p less than 0.05 respectively) from controls, whereas lower HR (p less than 0.05, p greater than 0.05, respectively), RPP and TI values (p less than 0.05) were determined. It was concluded that the combination of SOD and GSH may improve cardiac performance in the reperfusion period.


Oxygen free radical scavengers and reperfusion injury in dog lung preserved in cold ischemia.

Oxygen-derived free radicals are now considered important contributors to tissue injury associated with ischemia and reperfusion. The purpose of this study was to determine the influence of oxygen free radical scavengers on reperfusion injury. The left lower lobes of 15 canine lungs were isolated, preserved, and then reperfused for 120 minutes. Three groups of lobes were studied: Group 1 (n = 5), without ischemia, group 2 (n = 5) four hours of cold ischemia in Euro-Collins solution, group 3 (n = 5) four hours cold ischemia+oxygen free radical scavenger glutathione (0.1 nmol/L) given at the moment of perfusion. Extravascular lung water (grams per gram of blood-free dry lobe weight) after reperfusion was 2.82 +/- 0.32, 5.06 +/- 0.45, 4.21 +/- 0.33 for groups 1 through 3 respectively (p less than 0.001 group 1 versus group 2, p less than 0.001 group 2 versus group 3). Lung tissue lipid peroxidation, measured as thiobarbituric acid reactive material was 125 +/- 11, 270 +/- 30, and 185 +/- 17 nmol/g dry lobe weight for groups 1, 2 and 3 respectively (p less than 0.05 group 2 versus 1 and group 3 versus group 2). The data suggest that oxygen free radical scavengers attenuate reperfusion injury.


Added hospital stay due to wound infections following cardiac surgery.

To determine the prolongation of hospital stay due to postoperative wound infections following cardiac surgery, a prospective cohort study was performed by matching multiple control patients without infection to each infected patient (= case). Out of 22 cases, no patient died. No case had to be excluded from the matching process because of a lack of suitable control patients. The maximum number of controls per case was 10. The mean added stay was 12.2 days constituting a considerable prolongation of stay due to wound infection in cardiac surgery.


Aortoiliac endarterectomy: a 9-year experience.

Thirty-two patients (median age: 51 years) underwent aortoiliac endarterectomy between 1982 and 1990, for disabling claudication (27), rest pain (3), and tissue loss (2). There was no post-operative death and morbidity affected 6 patients. Five patients showed insufficient or suboptimal vascularisation of a limb which justified early reoperation in four. Follow-up was obtained in 31 patients with a median time of 36 months (6 months to 8 years). Five patients experienced recurrence of claudication symptoms: two received an aortofemoral bypass at 6 and 36 months. In the other patients, distal arterial occlusive disease accounted for recurrence alone (2 patients) or in association with aortoiliac involvement (1). Technical problems or disputable indications were responsible for postoperative failure in 3 cases or early recurrence of symptoms in 2. Cumulative patency rates of aortoiliac endarterectomy were 94 and 90 per cent at 2 and 5 years, and actuarial rates of clinical improvement were 90 and 82 per cent at 2 and 5 years, respectively. Aortoiliac endarterectomy provides the advantages of avoiding foreign material. The success of this reconstruction depends on strict criteria of selection and surgical expertise. It is indicated for the relatively young patient with nonectasic disease where atherosclerosis has not attacked the external iliac arteries.


Congenital absence of the left pericardium in combination with left pulmonary artery hypoplasia, right aortic arch, and secundum atrial septal defect.

The authors describe a rare congenital anomaly--absence of the left pericardium--in one patient who was operated on for a secundum atrial septal defect. The symptomatology, diagnostic, and therapeutic possibilities are discussed.


Modified Janke net technique for exposure of the circumflex artery.

A novel method of the circumflex coronary artery exposure by rotating the heart, using a Janke net and a silicone rubber tube, is described.


Surgical treatment of solitary peripheral pulmonary artery aneurysm associated with ventricular septal defect.

In the case presented a solitary peripheral pulmonary artery aneurysm occurred in a woman with ventricular septal defect (VSD). During the operation of repairing the VSD under cardiopulmonary bypass, the pulmonary artery aneurysm (PAA) suddenly ruptured into the bronchus and a large amount of air entered the pulmonary artery and right ventricle when the anesthetist inflated the lungs. The air in the right ventricle could not be evacuated completely, so we had to remove the lobe where the aneurysm was located. The operation was successful and the postoperative course was uncomplicated.


Laser Doppler velocimetry measurement of canine mucosal circulation response to bronchial artery reperfusion after lung transplantation.

Left lung transplantation accompanied by reestablishment of the circulation of the bronchial arteries by simultaneous transplantation of part of the aorta was performed on seven dogs. Mucosal circulation of the bronchi at the anastomosis was evaluated using laser Doppler velocimetry (LDV). Since the donor lung must maintain blood supply through the bronchial arteries, the donor aorta from its ascending portion to the descending portion below the outlet for the last bronchial artery was retained with the lung graft. The distal end of the left brachiocephalic artery was sutured to the side of the recipient aorta when the blood supply to the bronchial arteries was to be restored. The LDV values before reperfusion of the bronchial arteries were 20 to 65% (mean: 42.8%) of the preoperative value. Since the LDV values increased to 36 to 125% (mean: 79.9%) of the control, blood flow to the bronchial mucosa increased evidently. Four out of seven dogs died one to two days after the operation due to bleeding and operative stress. One dog was sacrificed on the 4th postoperative day and another on the 16th. The last dog died 40 days after surgery. The unfavorable course of the LDV values in these three dogs suggest that the method used does not ensure an adequate blood supply to the bronchial arteries in the long term.


Thoracoscopic resection of a pericardial cyst.

The development of new instruments that can be applied endoscopically opens up new possibilities for minimally invasive thoracic surgery. The surgical technique is exemplified by a thoracoscopic resection of a pericardial cyst. The benefits for the patient are impressive: minimization of surgical trauma and postoperative pain, a short convalescence, and an optimal cosmetic outcome.


Thoracoscopic resection of benign schwannoma.

The recent improvement of endoscopic surgical instruments allows new therapeutical application of thoracoscopy. We report a thoracoscopic resection of a benign schwannoma of the 6th intercostal nerve in a 35-year-old patient. The operative technique and extraction of the tumor from the chest is described. Postoperative morbidity was minor. We consider the thoracoscopic resection as first choice of treatment.


Diaphragmatic cyst with elevated level of serum tissue polypeptide antigen.

A 58-year-old woman with a mesothelial cyst of the diaphragm showed high level of serum Tissue Polypeptide Antigen (TPA) and cyst fluid TPA. Mesothelial cells of the cyst may excrete TPA and TPA was accumulated in the cysts. The measurement of tumor marker such as TPA of the serum or of the content of the cyst is useful in observation of the clinical course.


Madura foot of the chest wall; cure after radical excision.

Maduromycosis is a chronic granulomatous condition caused by fungal infection and is rarely encountered in Europe. To our knowledge, this is the first report of a case of maduromycosis affecting the chest wall in the United Kingdom. Conservative excision and drainage of the lesion combined with ketoconazole treatment in a dose 400 mg daily for several months failed to cure the condition. However, radical excision of the lesion combined with myoplastic repair of the defect in the chest wall eradicated the disease. Maduromycosis can occur in the chest wall and should be suspected in the immigrant population from tropical and subtropical areas. We recommend radical resection of similar lesions, combined with prolonged treatment with an antifungal agent e.g. ketoconazole when the causative organism is madurella mycetomis.


Primary rhabdomyosarcoma of the diaphragm. Report of a case presenting with hemothorax.

A rare case of embryonal rhabdomyosarcoma of the diaphragm occurring in an adult male and presenting with hemothorax is reported. The unusual clinical features of this patient underline the need for an accurate preoperative evaluation. The surgical procedure consisted of left thoracotomy with resection of the neoplasm, including a portion of the diaphragm muscle, and then reconstruction. One month after discharge chemo- and radiotherapy were carried out. The immunohistochemical study proved to be very helpful for the pathological diagnosis. A three years follow-up with patient alive and disease-free confirms that a multimodal approach may prove effective in the long term.


The optimal temperature for 24-hour heart preservation using continuous coronary perfusion method.

This experiment was designed to compare three preservation temperatures, 0 degrees C, 4 degrees C, and 10 degrees C, in 24-hour heart preservation using a continuous coronary perfusion method in terms of myocardial extracted enzymes during preservation (CPK, LDH, and GOT), left ventricular (LV) function at reperfusion and ultrastructural changes both at the end of preservation and at reperfusion. Rabbit hearts were preserved at 0 degrees C (n = 6), 4 degrees C (n = 6), and 10 degrees C (n = 6) for 24 hours and reperfused with arterial blood from the abdominal aorta of support rabbits. The value of CPK in the 10 degrees C group was statistically higher than those of the 0 degrees C group or 4 degrees C group (p less than 0.05: 0 degrees C vs 10 degrees C, p less than 0.025: 4 degrees C vs 10 degrees C). Left ventricular developed pressures (LVDPs) at 60 minutes after reperfusion in the 4 degrees C group were statistically greater than those in the 0 degrees C group and 10 degrees C group at several LV balloon volumes (p less than 0.005: 4 degrees C vs 0 degrees C or 10 degrees C). Electron-microscopic examination at reperfusion demonstrated remarkably swollen mitochondria associated with disruption of cristae in the 0 degrees C and 10 degrees C groups, but much less morphological change in the 4 degrees C group throughout preservation and reperfusion. From an overall view point of these enzymatic, functional and ultrastructural results, 4 degrees C proved to be a superior preservation temperature of choice for prolonged heart preservation.


Retrograde coronary sinus cardioplegia in myocardial revascularization: hemodynamic evaluation of the influence on the right-ventricular function.

The problem of the efficacy of right-ventricular protection with retrograde coronary sinus cardioplegia is studied. Sixty patients undergoing myocardial revascularization were prospectively assigned to receive cold St. Thomas' Hospital cardioplegia into the aortic root (30 patients) or retrogradely in the coronary sinus (30 patients). The two groups were similar concerning preoperative and operative data. The hemodynamic recovery postoperatively was good in both groups, the increase of the heart rate, the decrease of the mean aortic pressure and the right-ventricular stroke-work index were not significantly different in the two groups. However, right atrial pressure increased significantly (p less than 0.001) in patients who received cardioplegia anterogradely and decreased, but not significantly, in the retrograde group. The data suggest that the decrease of the right-ventricular stroke-work index in the anterograde group is related to a depressed contractility and in the group with retrograde delivery of cardioplegia to a decreased preload. There were no differences between the groups with respect to clinical outcome. We conclude that retrograde delivery of cardioplegia results in an excellent protection of the right-ventricular function in elective myocardial revascularization.


Pediatric myocardial protection in the United States: a survey of current clinical practice.

A nationwide survey of institutions in the United States that perform congenital heart disease surgery was conducted to obtain an overview of the current use of myocardial protection in pediatric patients (aged 0-16 years). One hundred and one (55%) of 183 institutions responded, completing a 4-page questionnaire about pediatric cases in 1989. A total of 12,072 cases were represented. Caseloads ranged from 7 to 498 at these institutions (mean 124, median 30). Cardioplegia was used by 100 institutions (44 blood, 45 crystalloid, 11 both). Administration was guided by formulas alone in 69 and by clinical criteria alone in 32. A wide variety of compositions of cardioplegic solutions was found with no preference for any particular type. No correlation between caseloads and cardioplegic solutions was found. Hypothermia was used by all institutions, with a mean of 25.8 +/- 3.5 degrees C for a simple ventricular septal defect closure. Deep hypothermia and circulatory arrest were used in 3048 cases (25.2%). A clear trend indicated that circulatory arrest was used more frequently in larger institutions (p less than 0.0001). Fibrillation as a strategy was used in 45 institutions. Twenty-five institutions changed cardioplegia technique during 1989. The findings suggest that, even though no consensus exists about its ideal composition, cardioplegia in conjunction with hypothermia is currently the strategy most often used for pediatric myocardial protection.


Successful resection of a distal aortic arch aneurysm in a patient with Behçet's disease using an "aortic no-touch" technique and hypothermic total-body retrograde perfusion.

Resection of a false aneurysm of the aortic arch in a patient with Behçet's disease was safely performed using an "aortic no-touch" technique. This consisted of: (1) femoral artery and bicaval cannulation, (2) profound hypothermia (below 20 degrees C) by core cooling, (3) retrograde cardioplegia through the coronary sinus, and (4) total body retrograde perfusion via both venae cavae without aortic cross-clamping. The patient showed no evidence of neurological damage and the postoperative course was uneventful.


Aortic annular enlargement with the use of a homograft valve.

A technique of annular enlargement for use in homograft aortic valve surgery is described. Potential advantages of this technique, that allows convenient valve sizes in small aortic annuli, lie in the pediatric group of patients requiring aortic valve replacement.


Congenital quadricuspid aortic valve associated with aortic regurgitation.

A case of quadricuspid aortic valve is described. The aortic valve consisted of 3 equal-sized and 1 smaller cusps, and a supernumerary cusp located between the right and noncoronary cusps. A right coronary ostium was close to the accessory commissure, and in a lower position. Three fenestrations were found at the supernumerary commissure. Aortic valve replacement was performed successfully with a St. Jude Medical prosthetic valve. On histological examination, the resected cusps showed fibrotic thickening with calcification and no sign of previous inflammatory disease. Quadricuspid aortic valve must be considered a malformation capable of leading to severe valve failure in later life.


Intracardiac primary fibrosarcoma. Case report and literature review.

A 58-year-old woman was hospitalized because of shortness of breath, cough, weakness, and physical signs suggestive of mitral stenosis. Echo-Doppler examination revealed a left atrial mass. This was removed and turned out to be a fibrosarcoma. Recurrence of the tumor with metastases into the pericardium, thyroid goiter, and left kidney led to the patient's death 6 months later. The clinical and pathological features of our rare case are compared with those in the literature.


Intracardiac needle in a man with self-injurious behaviour presenting with only a heart murmur.

Symptoms of a heart murmur in a 48-year-old male schizophrenic patient with self-injurious behaviour were investigated. Immediately noticeable were multiple scars on his hands. Clinical evidence of subcutaneous needles and aortic regurgitation was found. Echocardiography revealed a linear metallic foreign body across the interventricular septum. He underwent surgery and via a right atriotomy, a needle from the same location was removed.


[Stridor in infants: sometimes not so innocent].

Stridor is a frequent symptom in the neonate. Often it consists of a discrete inspiratory stridor in an alert child or of a transient symptom of a viral respiratory infection. In both cases no specific therapy is required. Whenever stridor occurs in the first months of life, or when it is severe or chronic, or when stridor also persists throughout expiration, an underlying anatomic anomaly frequently exists. The following steps are important to the diagnostic management: besides a detailed and complete history and physical examination, an X-ray of the airways and, if necessary, laryngo/bronchoscopy, angio(cardio)graphy or computerized tomography of the chest and the cervical region. Subsequently, appropriate therapeutic management can be initiated by proficient and accomplished physicians.


[Chronically tired or the chronic fatigue syndrome in an adolescent].

To fulfill the criteria of the chronic fatigue syndrome a patient must have new onset persistent or relapsing, debilitating fatigue or easy fatigability. The symptoms do not resolve with bedrest and are severe enough to reduce or impair average daily activity below 50% of the patient's premorbid activity level for a period of at least 6 months. Other clinical conditions that may produce similar symptoms must be excluded. Using a case history the (differential) diagnosis, treatment and prognosis of the chronic fatigue syndrome are discussed.


[Complete situs inversus in one half of a monozygotic twin].

The history of a monochorial monoamniotic twin, born at 27 weeks of gestation, in which a situs inversus was present in one of the twin is given. The incidence of a situs inversus in twins and the etiologic factors as described in literature are given.


[Vertebral osteomyelitis in an infant].

Neonatal osteomyelitis is uncommon. The disease starts often without signs of infection and may lead to severe complications. A case is reported of a neonate with vertebral osteomyelitis of the cervical vertebrae. Difficulties of diagnosing the disease and several therapeutic regimes proposed in the literature are discussed.


[Ureterocele in children].

Two case reports of children with ectopic ureteroceles are presented. The embryologic development, symptoms, diagnosis and treatment are discussed. Hemi-nephroureterectomy is the treatment of choice. In instances, such as serious urinary tract infections, massive vesicoureteral reflux in other ureters and in single system ureteroceles, endoscopic incision of the ureterocele can be effective in terms of control of infection and decompression of other kidney parts. Definite surgery can be deferred until the child is in a better condition.


[Lithium poisoning in a newborn infant].

We describe a newborn with a lithium intoxication. Her mother used lithium during her entire pregnancy. The intoxication was successfully treated with an exchange transfusion.


Idiopathic dilated cardiomyopathy: lack of association between circulating organ-specific cardiac antibodies and HLA-DR antigens.

Organ-specific cardiac antibodies are serological markers of autoimmunity in dilated cardiomyopathy (DCM). HLA-DR4 and possibly DR5 are immunogenetic markers of susceptibility in DCM, but it is not known whether they are associated with autoantibody production. We studied the frequency of HLA-DR antigens and the presence of organ-specific cardiac antibodies in 80 DCM Caucasian patients from Northern Italy. HLA-DR typing was performed by serology; 289 healthy blood donors from the same region were tested as controls. HLA-DR frequencies in DCM were also compared with VIII International Workshop control data for Italy. Cardiac antibodies were detected by indirect immunofluorescence on human heart. Skeletal muscle was used to identify cross-reacting antibodies. The prevalence of cardiac antibodies in DCM was: organ-specific 34% and skeletal muscle cross-reactive 30%. The previously reported positive association between DCM and HLA-DR4 was confirmed using either the controls from the same region (21.25% vs 10.73% p = 0.02, relative risk = 2.30) or from all of Italy (21.25% vs 12.3%, p = 0.03). HLA-DR5 frequency was slightly but not significantly higher in DCM than in controls from the same region (46.25% vs 31.49% p = 0.02, relative risk of 1.87, p corrected = NS) or from all of Italy (46.25% vs 35.8% p = NS). HLA-DR3 frequency was lower in DCM than in controls from the same region (12.50% vs 29.41% p = 0.003, relative risk of 0.36, p corrected = 0.03). This negative association was not confirmed using the control data from the whole of Italy (12.50% vs 16.5% p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)


The HLA DQB1*0502 allele is neutrally associated with insulin-dependent diabetes mellitus in the Sardinian population.

In the Sardinian population a very high incidence of insulin-dependent diabetes mellitus (IDDM) and the lack of HLA-DR2 protective effect due to the high frequency of the A2, Cw7, B17, 3F31, DR2, DQw1 extended haplotype has been reported. This haplotype, carrying a Serine at position 57 of the DQB1*0502 allele, has been previously reported to be underrepresented in patients when compared to controls. In order to provide an explanation for this finding, we defined by RFLP analysis the HLA haplotype of 45 Sardinian IDDM patients and 49 controls. All DR-2DQw1 subjects were molecularly characterized at the HLA DQA and DQB loci. All DR2-positive patients and the vast majority of the DR2-positive controls had the DQB1*0502 allele at the DR2-linked DQB1 locus, with no statistically significant difference between the two groups. All DQA1 genes were the ones expected, with only two exceptions. Nine out of 10 of the DR2-positive patients were compound heterozygotes for DQB1*0201/DQB1*0502 alleles; only this allele combination was significantly increased (p less than 0.0003). Our data suggests that a) the DQB1*0502 allele is neutral for IDDM development and b) the susceptibility to IDDM in our DR2-positive patients is related to the compound heterozygous state between the neutral DQA1*0102/DQB1*0502 and the susceptibility DQA1*0501/DQB1*0201 alleles.


Population and family studies of HLA-DR4 by use of oligonucleotide typing.

Using PCR and DR4 group-specific primers and SSO's we have examined DRB1*04 nucleotide polymorphisms in a population of 123 DR4-positive individuals (86 NAC, 27 Hispanics and 10 African Americans) from New York carrying a total of 134 DR4 haplotypes. We found that the distribution of DRB1*04 alleles on DR4 haplotypes differs in these three ethnic groups. In this relatively small population, certain alleles such as DRB1*0406 and 0411 were encountered only in Hispanics, while others such as DRB1*0403, 0408 and 0409 were found only in NAC (North American Caucasians). Such differences may be important in studies of HLA-DR4 and disease associations. Evidence from MLC and PLT studies of an HLA-B/DR crossover family, which was informative for the segregation of HLA-DRB1*0406 and DRB1*0407, supports the concept that subtypes of HLA-DR4 and/or associated HLA-DP alleles elicit T-cell alloreactivity, and may thus play a role in transplantation.


HLA antigens in Tlingit Indians with rheumatoid arthritis.

HLA-DR4 has been described in association with rheumatoid arthritis (RA) in multiple populations. We have studied HLA antigens in Alaskan Tlingit Indians. HLA-DR4 was decreased in the RA group (n = 32) compared with controls (n = 62) (6% vs 21% p = 0.07). The predominant DR4 allele observed was DRB1*0403 (Dw13.1). The most striking observation in these studies was a marked predominance of the DRB1*1402 allele encoding Dw16 (DRw14). This allele was present in 91% of RA cases, but was also highly prevalent in controls (80%, OR = 2.4 p = 0.20). DRB1*1402 only was observed in 47% of cases and 31% of controls. The DRB3*0101 (DRw52), and the DQA*0501 and DQB*0301 alleles encoding a subset of DQw3 were associated with DRB1*1402 in cases and in controls. HLA-Bw62 was increased in RA cases (28%) compared with controls (8%) (OR = 4.5, p = 0.01, corrected p = ns).


HLA-DP polymorphism in Sudanese controls and patients with insulin-dependent diabetes mellitus.

Human leukocyte antigen (HLA) genes are candidates for susceptibility to insulin-dependent diabetes mellitus (IDDM). The association of IDDM with particular DR and DQ alleles has been reported in all populations studied, but its association with HLA-DP alleles has been controversial. To address this question we analyzed 19 DPB1 and 2 DPA1 alleles and their associations in well-characterized Sudanese (an admixture of Arab and Black) IDDM patients (n = 71) and ethnically matched controls (n = 86) using polymerase chain reaction-sequence specific oligonucleotide (PCR-SSO) typing. There were no significant differences between the patient and control groups in the DPB1 frequencies. DPB1*0201, *0401 and DPA1*01 were the most frequent alleles in both IDDM patients and control subjects. Significant positive and negative associations between DPB1 and DPA1 alleles were detected in both groups. A novel DPB1 allele included in DPB1*1701 was identified.


Two new HLA DRB1 alleles found in African Americans: implications for balancing selection at positions 57 and 86.

Two new DRB1 alleles have been identified (DRB1*0303 and DRB1*0805) in African Americans that differ from known DRB1 alleles only by a glycine to valine exchange at position 86. The novel DRB1*0303 allele, found in one individual, has the same DQA1*0401-DQB1*04 haplotype as DRB1*0302, suggesting that it may be a recent diversification of *0302. The novel DRB1*0805 allele, identified in 4 individuals, was found on two haplotypes, sharing a DQA1*0501-DQB1*0301 haplotype with DRB1*0804, and a DQA1*0102-DQB1*0602 haplotype found with DRB1*0801 in some African populations. DRB1*0805 differs from *0804 only at position 57 and differs from *0801 only at position 86. Assuming that DRB1*0801 and DRB1*0802 are ancestral, based on their distribution in various human populations, DRB1*0805 may have been generated twice by two independent mutations or gene conversion events at each of these positions. Alternatively, DRB1*0805 may have arisen from a single gene conversion event (or mutation) and recombined to generate multiple DR-DQ haplotypes. These findings increase the number of DRB1 allelic pairs that differ only at position 86 to 9, suggesting strong balancing selection at this position. A number of DRB1 alleles for DR8 and DR4 also differ only at position 57, a site previously postulated to be strongly influenced by balancing selection in DQB1 alleles by phylogenetic analysis.


Monoclonal antibodies specific for canine CD4 and CD8 define functional T-lymphocyte subsets and high-density expression of CD4 by canine neutrophils.

The characteristics of canine homologues of CD4 and CD8, defined by murine monoclonal antibodies CA13.1E4 (IgG1) and CA9.JD3 (IgG2a) respectively, are described. These antibodies identify mutually exclusive subpopulations of non-B lymphocytes in peripheral lymphoid organs and blood. However, in thymus the antibodies defined populations of double-positive, double-negative and single-positive cells that showed a progressive maturation consistent with that described for CD4 and CD8 in other mammalian species. Furthermore, functional studies clearly associated cytotoxic effector cell function with the subpopulation reactive with CA9.JD3 (CD8). In contrast, proliferation stimulated by allogeneic cells and mitogens was more pronounced in the subpopulation reactive with CA13.1E4 (CD4). Cell and tissue distribution studies revealed that CA13.1E4 stained neutrophils with equivalent intensity to the staining of peripheral T cells. CA13.1E4 precipitated a 60 kD protein from the surface of T cells and highly purified neutrophils under both reducing and nonreducing conditions. CA9.JD3 precipitated a heterodimer of 32 kd and 36 kD under reducing conditions, and a 70 kD protein under non-reducing conditions. The expression of CD4 by canine neutrophils is without precedent in other mammalian species; the functional significance of neutrophil CD4 expression is puzzling in light of the current understanding of the functions of CD4 which include it's role as a receptor for nonpolymorphic regions of MHC class II molecules.


[Ocular manifestations of selected zoonoses in humans].

A report is given on the epidemiology and clinical signs of some selected zoonoses that may be of significance for ocular infections in man: brucellosis, leptospirosis, Lyme borreliosis, lymphocytic choriomeningitis, Newcastle Disease, ornithosis (chlamydiosis), rabies, Streptococcus suis infection, larva migrans ocularis by Toxocara canis or Baylisascaris procyonis, toxoplasmosis and tularemia.


[The occurrence of hyena disease in young cattle].

Eight juvenile cattle with symptoms of hyena disease are described. This represents the first occurrence of the condition in the Republic of Poland. The growth of the affected animals was retarded, with a marked difference in longitudinal growth of the femoral, humeral, tibial and metatarsal bones. The animals showed altered nickel, manganese and inorganic phosphate concentrations, which may be related to the disease. The genetic studies did not reveal any aetiological factors.


[Hysteroscopy as a diagnostic aid for uterine diseases of cattle].

A method for hysteroscopy in cattle, using a rigid tube for passage through the cervical canal, is described. Using this method, passage through the cervical canal is possible independent of the stage of the gynaecological cycles. The hysteroscopic findings of 105 examinations in cows are described and discussed.


[Myocardial fibrosis and degeneration with heart failure (cardiomyopathy) in two goats].

Myocardial fibrosis and degeneration of unknown etiology is described in two adult, female goats of the Saanen and Pfauen breeds. Both animals presented with clinical signs of cardiac failure with subcutaneous edema, hydrothorax and ascites. The pathological lesions were characterized by cardiomegaly with ventricular and auricular dilatation and hypertrophy, massive subcutaneous edema and body cavity edema. The first goat additionally showed chronic liver congestion due to cardiac failure. Histologically, the most prominent changes were focally extensive cardiomyocyte degeneration and cardiac fibrosis. The clinical history and pathologic lesions are comparable to those of dilatative cardiomyopathy in SixRH cattle.


[Detection of embryonic mortality in cattle using sonography].

In 70 pregnant cattle the diameter of conceptus, the size of embryo and corpus luteum were estimated with a 5 MHz-linear array scanner on days 22, 25, 28, 35 and 42 (+/- 1 day) after insemination. Additionally, the milk progesterone level was determined. Embryonic mortality was found in 7 cases, in 3 cows on day 35, in 4 cows on day 42. The lack of embryonic heart beat was the first sign; later in pregnancy significant differences in sizes of conceptus and embryo compared with physiological pregnancies occurred. Membranes and bubble-like structures became visible in the lumen of the conceptus. The conceptus could be detected until the following oestrus, which began 8 to 42 days after embryonic death. The corpus luteum remained until proestrus. This correlated positively with the progesterone levels.


[Epidemic late abortion in swine--status of research].

This article briefly describes the PRRS (Porcine Reproductive and Respiratory Syndrome), which arose in the winter of 1990 in Germany and other European countries. The data are accumulated from the literature and own experiences. The clinical picture of this new disease, which led to important economical losses is dominated by 1. an increased rate of reduced length of pregnancy with late abortion before day 110 or an increased length of pregnancy; 2. an increase of stillborn piglets; 3. a larger scale of preweaning mortality combined with a higher frequency of secondary infections. Pathological findings in piglets are subcutaneous edema, accumulation of fluids in the body cavities and sometimes interstitial pneumonia is observed. In sows originating from affected farms examined before partus a mononuclear placentitis is present. At present a non-classified virus, isolated by Dutch researchers is proposed to be the causative agent and named Lelystad virus.


[Ocular manifestations of systemic diseases in birds. Part 1].

Among the representatives of the class Aves ocular lesions may be a particularly strong indication of systemic disorders. A causative diagnosis of ocular lesions may be vital for the avian patient, not only as a basis for effective therapy of the primary disease, but also for saving the vision, as birds orientate themselves primarily by vision. The following paper presents a synopsis of important ocular disorders in avian patients that are either pathognomonic for certain disorders or, when considered in conjunction with other organic diseases, enable a specific diagnosis to be arrived at. In part 1 bacterial and parasitic etiologies will be described. Part 2 deals with viral infections and noninfectious etiologies.


[Plasma gastrin levels in horses with colic].

The plasma gastrin levels in fasted horses (21.1 +/- 15.6 pg/ml), in horses with spasmodic colic (7.3 +/- 5.4 pg/ml) and in horses with impaction of the left ventral large colon and/or pelvic flexure (11.4 +/- 3.1 pg/ml) were not significantly different. The plasma gastrin concentrations of horses with strangulation obstruction of the small intestine, large colon displacement or adynamic ileus, and which had no gastric reflux, were 12.9 +/- 8.7 pg/ml and did not differ from fasted gastrin levels. Horses which had 5-10 litres of stomach content reflux had a higher mean gastrin level (32.2 +/- 22.6 pg/ml) (range 8.7-83.0) than the fasted horses. The mean plasma gastrin level (69.0 +/- 32.2 pg/ml) (range 27.0-122.0 pg/ml) in horses which had gastric reflux and 11-20 litres of stomach content outflow through the nasogastric tube were significantly higher (P less than 0.0004) than in fasted horses or in horses with spasmodic colic, impaction of the left ventral large colon or in horses from which no gastric reflux could be obtained.


[Early sonographic diagnosis of twin pregnancy in mares and its reduction to a single pregnancy].

The frequency of double ovulation and the chances of twin pregnancy in the mare are presented with reference to the relevant literature. A novel manual technique for reducing the embryo number from two to one is introduced and illustrated by ultrasonographic images.


[Double ovulation in mares. Clinical, hormone analytical and sonographic studies].

108 mares with a total of 135 oestrous cycles were examined. 30% of the mares showed development of double follicles, found by palpation and ultrasonography. Eight cases of double ovulation, four of them synchronous and four asynchronous, were examined closely. These cases of double ovulation showed different growth and different development of the follicular wall. This occurred at the same time in cases of synchronous double ovulation whereas it differed in case of asynchronous double ovulation. The later ovulating follicle was still growing while the first one had already burst. With both forms of double ovulation an equal concentration of progesterone was detected in peripheral blood. On the day of ovulation the rate of progesterone was low (1 ng/ml blood plasma) and it first started rising from the day +1 on. Double follicles matured slower than single follicles. Mares with synchronous double ovulation showed the typical oestrus behavior. This behavior was less distinct after the first ovulation in mares with asynchronous double ovulation. All four mares with asynchronous and two mares with synchronous double ovulation became pregnant. Twins did not occur. A possible relationship between double ovulation and twin pregnancy is discussed.


[Pathology of the cornea].

The basic pathologic mechanisms of corneal inflammation, including hereditary and degenerative-dystrophic keratopathies, are presented. Inflammatory keratopathies of non-ulcerative and ulcerative forms, which often occur in the ophthalmopathological diagnostics, are described, and special nosological entities are emphasized. The consequences of corneal ulceration are mentioned, and the incidence of neoplastic corneal processes is considered.


[Cytology of the cerebrospinal fluid in dogs with brain tumors and spinal cord compression. Part 4].

The results of cerebrospinal fluid (CSF) cytology of 9 dogs with brain tumors and 50 dogs with spinal cord compression are discussed. Of the 50 dogs with spinal cord compression, disc protrusion was diagnosed in 31, myelomalacia in 7, discospondylitis in 3 and spinal cord tumors in 9 dogs. In 4 of 9 dogs with brain tumors, tumor cells could be found by the sedimentation apparatus of Kölmel. Pleocytosis existed in 6 patients. In about 70% (29 of 41) of cases with disc protrusion, more than 200 cells could be evaluated in the CSF sediment, consisting mostly of transformed lymphocytes and activated monocytes. As the neurologic deficits increased, the amount of cells and especially cell complexes increased. This was especially evident in cases with myelomalacia of the spinal cord. Only in cases with discospondylitis or spinal cord neoplasia was the CSF cytology unchanged.


[The blood supply to the stomach of the dog--a corrosion cast and scanning electron microscopic study].

An unimpaired vascular circulation is vital for gastric function. The arteries of the stomach originate from the coeliac artery; the veins lead to the portal vein. Arteries in the right half of the organ form a perigastric circle of anastomosing vessels, which is lacking on the left side. The basal capillary network of the gastric submucosa shows no important regional differences. Territories of vascularisation are documented for the canine stomach.