Autonomic influences on colorectal motility and pelvic surgery.

The nervous control of the motility of the human distal bowel was investigated by two physiological studies of electrical stimulation of sacral parasympathetic outflow in patients with high spinal injuries and in patients with intractable constipation following pelvic surgery. Identical and reproducible motility responses of the left colon, rectum, and anal sphincters were obtained by sequential electrical stimulation of anterior sacral roots S2, S3, and S4 in patients with spinal injury. S2 stimulation provoked isolated low-pressure colorectal contractions. S3 stimulation initiated frequency-dependent high-pressure colorectal motor activity which appeared peristaltic and was enhanced with repetitive stimuli. S4 stimulation increased colonic and rectal tone. Quantitative responses were maximal at the splenic flexure and rectum. Pelvic floor activity was stimulated in increasing magnitude from S2 to S4. These results of distal bowel motility were achieved by an implanted Brindley stimulator. A newer generation of externally active stimulators are envisaged for the control of lower bowel in fecal incontinence. Women with intractable constipation following hysterectomy had significantly increased rectal volume and compliance together with deficits of rectal sensory function. Following stimulation with Prostigmine (neostigmine) a colorectal motility gradient was paradoxically reversed in the patients following hysterectomy, thus constituting a functional obstruction. Denervation supersensitivity was demonstrable in 2 patients tested with carbachol provocation. These findings suggest dysfunction in the autonomic innervation of the hindgut in some patients following hysterectomy.


Fecal incontinence: indications for repairing the anal sphincter.

Incontinent patients should be comprehensively investigated by objective tests, especially manometry, continence tests, and electromyography. Manometry can be used to predict the functional outcome and to calibrate the sphincter repair. Pure anatomical defects of the anal and pelvic musculature deserve surgical correction with or without overlapping the muscle ends. If the repair is delayed it should be done after a 3 month interval. A protective colostomy has to be performed in complex cases and in cases with septic complications. Before closing the colostomy, the ano-rectal function should be assessed. Acceptable continence can be restored in the majority of the patients, the outcome depending on the extent of local defects and the severity of concomitant pelvic floor neuropathy. Skeletal muscle transposition remains an esoteric approach to be used only in selected patients; the implantation of a neuromuscular stimulator seems to be warranted. In the presence of important functional deficits, sphincter repair may create a situation where additional conservative measures become more effective. A post-anal repair may be considered 3-12 months after rectopexy or sphincter repair. Incontinence based on pure functional defects is initially treated conservatively. A post-anal repair may improve the situation in two thirds of the patients but fails to help those who need it most. Failure seems to be related to a continuing neuropathic process. A peri-anal prosthetic band implant may be a valuable alternative in such patients. A sigmoidostomy is a measure of last resort. The prevention of fecal incontinence is most important and concerns surgeons, obstetricians, and physicians.


Treatment of complete rectal prolapse: to narrow, to wrap, to suspend, to fix, to encircle, to plicate or to resect?

Selection of the best surgical procedure for the treatment of complete rectal prolapse is difficult amid the many different techniques for which excellent results are reported. A critical review is given. It is concluded that any surgical procedure with rectal mobilization and fixation as a standard maneuver will lead to a recurrence rate of 2% to 4%. Advocacy of additional maneuvers to make the procedure easier is acceptable if it does not lead to a higher complication rate. But to obtain a better result its benefit has to be proven, either by a large prospective double-blind study, or by tests from the colorectal laboratory. New surgical techniques for rectal prolapse should therefore be based, not only on a low recurrence and complication rate, but also on tests that evaluate the effect of the procedure on fecal continence.


Solitary rectal ulcer: the place of biofeedback and surgery in the treatment of the syndrome.

Thirty-one patients with the solitary rectal ulcer syndrome were studied, the majority of whom presented with fresh blood per rectum and a rectal ulcer, mucorrhoea, or a varying degree of rectal prolapse. Fourteen patients were treated conservatively or with surgery and had a high rate of recurrence of the solitary rectal ulcer syndrome. Seventeen patients were treated with biofeedback for the associated obstructed defecation (anismus) either before or immediately after surgery with a lower recurrence rate. The final symptomatic cure rate was similar in both groups but 15 episodes of recurrence requiring further surgery were encountered in the non-biofeedback group compared to 4 recurrences in the biofeedback group.


New diagnostic imaging in rectal cancer: endosonography and immunoscintigraphy.

Endosonography of the rectum, combining the advantages of both endoscopy and sonography, provides information not at present available from other imaging modalities. It is remarkably accurate in the pre-operative assessment of tumor penetration. In the evaluation of lymph nodes, the specificity and sensitivity is 83% and 72%, respectively. For the detection of local recurrence in asymptomatic patients promising results can be obtained. In contrast, the potential benefits of immunoscintigraphy in patients with rectal cancer have yet to be determined but preliminary results indicate that immunoscintigraphy in combination with endosonography may assist the surgeon in confirming or excluding the suspicion of recurrence.


Anismus: the cause of constipation? Results of investigation and treatment.

Anismus, or failure of the somatic sphincter apparatus to relax at defecation, has been implicated as a major contributor to the problem of obstructed defecation. Current diagnostic methods depend on laboratory measurements of attempted defecation and the most complex, dynamic proctography has been the mainstay of diagnosis. Using a new computerized ambulatory method of recording sphincter function in these patients at home, we report an 80% reduction in our diagnostic rate suggesting that conventional tests fail to accurately diagnose this condition, probably because they poorly represent the natural physiology of defecation. Treatment of this distressing condition is more complex and a variety of surgical and pharmacological measures have failed. Biofeedback retraining of anorectal function of these patients has been very successful and represents the management of choice.


Results of radical surgery for rectal cancer.

This paper examines the hypothesis that a reduction in the distal mural margin during anterior resection for sphincter conservation in rectal cancer excision is safe, provided total mesorectal excision is undertaken with wash-out of the clamped rectum. One hundred ninety-two patients underwent anterior resection and 21 (less than 10%) patients underwent abdomino-perineal excision (APE) by one surgeon (RJH). Anterior resections were classified as "curative" (79%) and "non-curative" (21%); in the "curative" sub-group less than 4% of patients developed local recurrence. The series was retrospectively analyzed for the effect of mural margins on local recurrence with 152 patients undergoing "curative" anterior resections and 40 patients undergoing "non-curative" resections. In the 152 specimens from curative resections, 110 had a resection margin greater than 1 cm and 42 had a resection margin less than 1 cm. Four patients developed local recurrence in the greater than 1 cm margin group (95% confidence interval: 0.8%-7.8%) and no patients developed local recurrence in the less than or equal to 1 cm margin group (95% confidence interval: 0%-5.9%). In each patient with local recurrence a cause for failure was apparent. There was no statistically significant difference in local recurrence rate between the less than or equal to 1 cm margin group and the greater than 1 cm margin group. A reduction in resection margin therefore did not compromise survival after anterior resection. The significance of lateral resection margins is discussed. The role of deep radiotherapy and cytotoxics are considered.(ABSTRACT TRUNCATED AT 250 WORDS)


The results of pouch surgery after ileo-anal anastomosis for inflammatory bowel disease: the manometric assessment of pouch continence and its reservoir function.

Anal sphincter function after restorative proctocolectomy has mainly been investigated by anal manometry. A significant decrease of basal pressure up to 45%, has been recorded postoperatively, possibly due to sphincter stretch during endoanal mucosectomy. Both abdominal mucosectomy and anastomosis at the level of the anorectal ring have been reported to prevent anal sphincter damage and lead to better continence. The striated sphincter is not significantly affected by the surgical procedure. Pouch-anal inhibitory reflex is partly maintained in the presence of a rectal cuff which leaves the ganglionic plexus unaltered; a satisfactory continence is also retained in the absence of the reflex when the rectum is totally excised. Pouch capacity, compliance and motility have been investigated by endoluminal balloon and probes. Pouch emptying has been studied by a "porridge" test, by a semi-solid medium labelled with technetium-99, and by other methods. A more effective storage function is achieved by large capacity reservoirs which lower the bowel frequency. The motor response to pouch distension, to a meal, and to pharmacological stimuli is usually counteracted by sphincter contraction. Ileal hypermotility may lead to fecal leakage mainly in the presence of weak sphincters. Poor pouch emptying may be related to an anal stricture.


Results of pouch surgery after ileo-anal anastomosis: the implications of pouchitis.

The ileal pouch-anal operation is the procedure of choice for those suitable patients requiring surgery for chronic ulcerative colitis or familial adenomatous polyposis. The functional results are generally good but pouchitis remains a significant and poorly understood complication. This review encompasses factors relating to pouchitis, e.g., bacteriological, functional and histological changes, with emphasis on its biology and treatment, and the long-term implications.


Results of the double stapling procedure in pelvic surgery.

The double stapling technique for rectal reconstruction after resection involves closing the lower rectal segment with a linear stapler and performing the anastomosis using a circular stapler across the linear staple row. The purpose of this report is to review the results of double stapling, present our experience, and draw conclusions from the material available. We have utilized the double stapling technique in 80 patients for primary anastomoses and in 11 patients for secondary anastomoses following Hartmann procedures. Twenty-one anastomoses were at or near the dentate line. Fifty-six patients had rectal carcinoma, 29 patients had diverticulitis, 3 patients had carcinoma of the ovary, and 1 patient each had traumatic rectal perforation, volvulus, or rectal prolapse. Complications in the total 91 patients included 3 anastomotic leaks (3.3%), 1 postoperative hemoperitoneum (1.1%), and 3 strictures (3.3%). No anastomosis was protected by diverting colostomy. There were no operative deaths. Of 43 patients with cancer available for follow-up, 4 patients have developed local recurrence. The technique has been modified for ileoanal anastomosis during abdominal restorative proctocolectomy for ulcerative colitis and familial polyposis and early results are favorable. The double stapling technique provides a safe method for rectal reconstruction at or near the dentate line and offers the following advantages over other stapler techniques: (1) It eliminates the frustrating distal pursestring; (2) The rectal segment is not opened, minimizing contamination; and (3) It avoids gathering the sometimes generous circumference of the rectum on a pursestring thus allowing a more precise distal donut.


Pre-operative and post-operative radiotherapy and rectal cancer.

The appropriate role for additional radiotherapy in patients with resectable rectal cancer is not yet settled. Irradiation has been considered by surgeons and radiotherapists as superfluous since no effect on survival has been shown. However, numerous trials have demonstrated that peri-operative radiotherapy decreases an often high local recurrence rate while others believe it has a definite place in routine management. Several surgeons have, on the contrary, claimed that a skilled surgeon compared to a less skilled surgeon, will get the same acceptably low local recurrence rates. Since we will probably never have a randomized trial comparing "good" and "bad" surgeons, this argument cannot be settled. A further obstacle arises in the difficulty of persuading surgeons to organize their routine work so that it is performed in an optimal way by those specializing in this field. The question also arises whether radiotherapy should be delivered pre-operatively, postoperatively or as a "sandwich" technique, i.e., both pre-operatively and postoperatively. According to radio-biological considerations and results from reported trials, the best effect on local tumor control has been achieved using pre-operative radiotherapy.


The medical effects of conventional weapons.

The medical effects of weapons used in modern conventional warfare are, overwhelmingly, penetrating. Fragments from explosive munitions such as shells, rockets, and grenades are the predominate source of missiles, especially in high-intensity war. Bullets from assault rifles and machine guns cause fewer casualties, except in counterinsurgency operations. The threat from penetrating missiles depends upon the part of the body that is struck and, to a lesser extent, upon the physical characteristics of the missile. The missile's mass and velocity determine its potential to do physical damage, but the extent to which this potential is realized depends upon diverse factors such as shape, construction, and stability. The American experience in the wars of this century indicate that approximately 20%-25% of all casualties died on the battlefield and are therefore classified as killed in action. Approximately 3%-5% die while receiving care, and thus are classified as died of wounds. Wounds of the brain or heart and great vessels are the most common causes of death. Prevention of sepsis in soft-tissue and orthopedic wounds is the major medical treatment problem in survivors. Since it determines the quality and quantity of combat casualty care, the single most important factor determining mortality or morbidity for combat casualties is the tactical situation.


The relationship of blast loading to death and injury from explosion.

Death and injury from explosion are becoming ever more frequent. In this study an attempt is made to relate the blast loading suffered by individual victims of explosions to the injuries sustained. It includes 828 servicemen killed or injured by explosions in Northern Ireland. Two hundred sixteen servicemen were killed, most of them before any assistance could be rendered. In those exposed to a higher blast loading, blast lung was common. Those exposed to lower blast loading died primarily of head injuries. Body armour was worn by 90% of the servicemen and probably reduced the number of fatal secondary missile injuries.


Crush injury and crush syndrome.

Crush injury is caused by continuous prolonged pressure on the limbs. It is found in patients extricated after being trapped for at least 4 hours. The main injury is to the muscles of the limbs. Treatment should be conservative and fasciotomy should be avoided. If fasciotomy is performed, it should be followed by radical debridement of the injured muscle in an attempt to avoid infection of the injured limb. Infection endangers the patient's life and is the main cause of morbidity and mortality today. The outcome of conservative local treatment of crush injury is much superior to that of operative treatment. The pathophysiology of crush injury is not fully understood and no good animal model is known. Crush syndrome, which is the general manifestation of crush injury, is better understood. If not prevented, it will lead to acute renal failure. A method for preventing acute renal failure is discussed and a protocol is described. There is no doubt that prevention of acute renal failure is the goal in the treatment of crush syndrome and can be achieved.


Irradiated trauma victims: the impact of ionizing radiation on surgical considerations following a nuclear mishap.

The combination of conventional traumatic injuries and radiation exposure has synergistic consequences, the full extent of which may take days to weeks to become apparent. Our understanding of such is derived from a variety of laboratory and clinical scenarios involving both therapeutic and accidental exposures. When presented with such an individual one must discern whether the victim has been bodily contaminated versus exposed to a source or both. The former will necessitate decontamination procedures which may be as simple as declothing and showering the individual. Simply removing the victim from the source will suffice to halt further radiation induced injury. In the vast majority of cases basic life support and other emergency medical procedures should be expeditiously instituted as warranted and without fear of personal hazard for health care teams. Following stabilization, further medical/surgical support must be predicated upon the extent of the radiation injury with the circulating absolute lymphocyte count serving as both a reliable and readily accessible indicator of the degree of underlying radiation injury. As radiation has profound consequences on immune and wound healing systems, therapies must be tempered by an understanding of the impact of radiation upon these systems. Overall, the consequences of irradiation injury will be the potential for an exacerbation of the effects of conventional traumatic injuries with a higher than expected morbidity and mortality.


Triage: in austere environments and echeloned medical systems.

Although triage as a medical sorting process was originally developed and applied to echeloned military field medical systems dealing with mass casualties, the term has now permeated most aspects of medical practice. This essay attempts to refocus on triage in military and disaster settings, emphasizing the relationship of the echeloned system organization to the triage process, and the various non-medical factors which may influence triage decisions and priorities. Due to the lack of any analogous civilian experience, it is essential that all health personnel who may be involved in an echeloned care system gain and maintain proficiency by frequent involvement in appropriate training exercises, the characteristics of which are described.


Blunt and penetrating chest injuries.

The management of chest injuries begins with knowledge of what happened to the patient at the time of the traumatic incident and converting this information into possible diagnoses. The various organs of the chest cavity are discussed emphasizing the controversies that attend the management or diagnosis of each one.


The Red Cross classification of war wounds: the E.X.C.F.V.M. scoring system.

The Red Cross classification of war wounds is based upon features of the wound, not upon weaponry. It is proposed as a new means of understanding, communicating, and gathering information about war wounds and their management. The wound score is based on the skin wounds and the presence of a cavity, fracture, vital injury, or metallic bodies in the wound. All wounds so scored can be graded according to severity and typed according to structures injured; consequently, wounds are identified by their clinical significance. A study of 247 wounds shows the feasibility of scoring wounds in the field and yields surgically relevant information about bullet and fragment wounds. The applications of the classification are to wound assessment, establishing a scientific basis to war surgery, surgical audit, and collecting wound data from the field.


A new technique for the resection of gastric cancer: modified Appleby procedure with reconstruction of hepatic artery.

The Appleby operation allows resection of gastric cancer with lymph nodes around the stomach and celiac axis en bloc. Hepatic arterial blood flow after resection of the celiac axis is supplied by the superior mesenteric artery. In some patients, however, hepatic arterial flow becomes decreased after resection of the celiac axis. This abrupt reduction of hepatic arterial blood flow sometimes causes postoperative complications such as severe liver dysfunction or gallbladder necrosis. To prevent the reduction of hepatic arterial blood flow and to perform the Appleby operation more safely, we modified the Appleby operation to include reconstruction of the hepatic artery. We found that after dissection of lymph nodes around the hepatoduodenal ligament, the proper hepatic artery and gastroduodenal artery can be well mobilized and it becomes possible to anastomose the celiac axis to the common hepatic artery directly without using anticoagulants. From May, 1989 to November, 1990, 15 patients with advanced gastric cancer underwent the modified Appleby procedure at Kinan General Hospital. Postoperatively, serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were determined for evaluation of liver function. These levels were almost the same as those found after traditional total gastrectomy without resection of the celiac axis. Indocyanine green (ICG) clearance tests were performed before and 1 month after operation. There was no significant difference between the preoperative and postoperative values. Common hepatic arterial flow after celiacohepatic anastomosis was 390 ml/min on average. The modified Appleby procedure can be done quite safely.


Optimal timing of elective indirect inguinal hernia repair in healthy children: clinical considerations for improved outcome.

Experience with several incarcerations that resulted in emergent surgery for children with known indirect inguinal hernias prompted this review to determine if there is an optimal time after hernia diagnosis during which elective repair should be undertaken to avoid incarceration. Over a 30 month period, 228 children less than 10 years of age underwent 303 indirect inguinal hernia repairs. They were analyzed for age, sex, interval between diagnosis and repair, predisposing conditions, major complications, and length of hospitalization. Excluded were 21 children who presented with incarceration of a previously undiagnosed indirect inguinal hernia that required operative reduction, 13 children with conditions predisposing to indirect inguinal hernia, and 53 children for whom the interval between diagnosis and repair was unknown, leaving a study group of 141 children who underwent 190 indirect inguinal hernia repairs. Nearly 13% (18 of 141) of the children developed incarcerated hernia prior to elective repair. Compared to children who underwent repair of a reducible indirect inguinal hernia, those with incarceration were more likely (p less than 0.05): 1) to have major complications (11% vs 0.6%), 2) to have a shorter interval between diagnosis and repair (26 vs 49 days), 3) to be younger (7.5 vs 25.6 mos), and 4) to require greater than 24 hours of hospitalization. Had children with reducible incarcerated indirect inguinal hernia been hospitalized and undergone repair 24 to 48 hours later, 83% of subsequent incarcerations would have been prevented. Furthermore, this experience supports the recommendation that for healthy children less than 10 years of age, indirect inguinal hernia repair should be performed on a semi-elective basis within 7 days of diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)


Advances in treatment of vascular injuries from blunt and penetrating limb trauma.

Military and civilian experience has contributed to the current state of the art in management of extremity vascular injuries. Thorough physical examination and judicious use of emergency center arteriography and formal arteriography provide means for prompt diagnosis and treatment which is critical is limb loss and disability are to be avoided. Prosthetic graft material has provided an alternative to vein grafting in many circumstances for arterial and venous injuries. Compartment syndrome should be anticipated when an ischemic extremity is revascularized and fasciotomy should be used liberally. Vascular repairs are the first priority in extremity wounds, but associated injuries to bones, joints, soft tissues, and nerves are often critical determinants of rehabilitation once blood supply has been re-established. The best results are obtained when a multidisciplinary approach is used combining expertise in orthopedic surgery, neurosurgery, and plastic surgery.


Treatment of cystic lesions of the thyroid by ethanol instillation.

We analyzed the results of ethanol sclerotherapy in 61 patients with cystic thyroid lesions which recurred after aspiration. Cytologic study showed all of the lesions to be benign. The patients were followed clinically and ultrasonically 1 month and 6 or more months after treatment. If the cystic lesions recurred, repeated treatment was offered. During the follow-up, 36 (59.0%) patients experienced no recurrence after the initial treatment and 5 (8.2%) patients received treatments 2 or more additional times. In 44 (72.1%) of the 61 patients, the cystic lesion almost disappeared or decreased in size, but in 17 (27.9%) patients it did not decrease. Four patients underwent surgery after the ethanol sclerotherapy. Although no severe complications were observed, there were complaints of slight pain in 12 patients, severe pain in 1 patient, and a drunken feeling in 1 patient. We consider instillation of ethanol into recurrent cystic lesions of the thyroid to be a simple, safe, economical, and effective treatment.


Abdominal trauma in war.

In war, the percentage of casualties with abdominal wounds on battlefields is near 20%. Roughly half of these casualties die almost immediately from bleeding. Wounding agents are most often either bullets or fragments from various detonating devices. Severity of pathology induced by these agents and prolonged lag time between injury and treatment constitute major differences between peace and war abdominal injuries. Since the means of diagnosis is unsophisticated in war, penetrating abdominal injury leads to systematic exploratory laparotomy, although 10% to 20% of explorations are negative. The management of colon lesions remains a controversial issue. In modern war surgery manuals, primary colon repair is not totally condemned and is generally considered acceptable, but under stricter criteria than in civilian practice. In abdominal war wounds, mortality rate dropped from 53% during World War I to 18-36% at the end of World War II. In Vietnam it went down near 10% in some limited hospital series. But other data collected during that conflict show a less rosy picture. Of 476 abdominal casualties, the total mortality reached 42%. The hospital mortality among the survivors was 11.5%. Death in cases where abdominal wound was the primary lesion was due to hemorrhage in 60%, sepsis in 25%, and pulmonary insufficiency in 15%. Survivors had an average of 1.8 injured organs.


Multifactorial analysis of septic bile and septic complications in biliary surgery.

A unifactorial analysis for possible risk factors was applied to 2,700 consecutive operations for benign disease of the biliary tract. A series of high risk factors in relation to positive bacteriology and septic complication could be identified. These risk factors were patients who were elderly (greater than 70 years; p less than 0.001), those who were diabetic, those who had a serum bilirubin greater than 1.1 mg% (p less than 0.001), those who had acute cholecystitis (p less than 0.001), and those in whom choledochal stones were found (p less than 0.001). Using a multivariate analysis, we concluded that in patients with no risk factors (56.9%) the incidence of a positive bacteriology was low (10.9%) and they should receive no antibiotic prophylaxis. Patients with one risk factor (24%), had a 36% incidence of positive bacteriology and minimal pre-operative prophylaxis is recommended. Patients with two or more risk factors (19.1%) had a 77.6% incidence of positive bacteriology and full peri-operative prophylaxis is recommended, starting pre-operatively and continuing for 3 to 5 days postoperatively. The aim of this study was to identify patients at risk for septic complication in biliary surgery and to create new guidelines for the antibiotic treatment of selected groups.


Comparison of topical hemostatic agents in elective hepatic resection: a clinical prospective randomized trial.

To compare the difference in efficacy of microcrystalline collagen powder (CL) and fibrin glue (FG) in elective hepatic resection, 62 patients (female 14, male 48) with ages ranging from 51 to 75 years were randomly allocated to receive either CL or FG as a topical agent during hepatectomy. There were no significant differences between the patients treated with CL (n = 31) and those treated with FG (n = 31) regarding sex, age, liver function, coagulation function, platelet counts, type of liver resection, and operative duration. A dry cut surface of the liver was obtained during surgery in 27 (87%) patients and 25 (81%) patients treated with CL and FG, respectively. Both CL and FG showed similar hemostatic effects. The CL and FG groups were not different in terms of postoperative rebleeding, bile leakage, or morbidity and mortality rates (6% vs. 6%, 6% vs. 6%, 45% vs. 39%, and 13% vs. 10%, respectively). Of the 52 patients with a dry cut surface of the liver during surgery, 3 patients in the CL group encountered rebleeding (n = 1) or bile leakage (n = 2) from the cut surface postoperatively, while no such complications were noted in the FG group. The results seem to favor FG for reliability in the postoperative period. The application of CL or FG may be better performed with consideration of the characteristics of each agent.


Endoscopic subfascial sectioning of incompetent perforating veins in treatment of primary varicosis.

Subfascial elimination of incompetent perforating veins is the most effective therapeutic principle in the treatment of trophic skin disorders associated with varicosis. A recently developed endoscopic technique allows accurate sectioning of perforating veins with direct observation of the veins and minor trauma. From November 1986 to July 1991 endoscopic sectioning of perforating veins was performed in 72 patients (103 legs). The most frequently transected perforating veins were Cockett's veins (n = 219), 24 cm perforating veins (n = 83), and Boyd's perforating veins (n = 82). Postoperative delayed wound healing was observed in 3 (2.9%) legs with pronounced trophic skin disorders in the lower extremities. Two patients complained of dysesthesia in the area of distribution of the sural nerve. Further complications recorded were extended subcutaneous hematoma in 6 (5.8%) legs and postoperative dysesthesia in the area of distribution of the saphenous nerve in 10 (9.7%) legs. At follow-up examination (mean 27 months postoperatively) clinical investigation and Doppler sonography showed newly formed incompetent perforating veins in only 2 lower legs. Radiography at follow-up revealed one incompetent Dodd's perforating vein in 1 leg, which was the starting point of pronounced recurrent varicosis in the lower leg. After an average follow-up of greater than 2 years, we recorded the occurrence of new varices in 9 lower legs. Staging of chronic venous incompetence showed an upward trend ranging from change to a more favorable stage to complete cure. Findings were unchanged in only 10% of the patients. There was no case of postoperative aggravation.


Surgical procedures in centenarians.

Sixteen patients 100 years of age and older underwent surgical procedures at a single institution during the 11-year period ending December 1991. There were 11 (69%) females and five males. Patient ages ranged from 100 to 104 (mean, 101.1 years). Procedures included six ophthalmologic operations, three permanent pacemaker implantations, three compression hip screw fixations, two leg amputations, one hemiglossectomy, and one cystostomy. There was one (6%) perioperative death. Long-term follow-up was established for each patient. One-year survival rate in these 16 centenarians was 69%. We conclude that selected patients 100 years old and older can survive certain surgical procedures with acceptable perioperative and long-term results.


Neuroleptic malignant syndrome in a patient with neurosyphilis.

Neuroleptic malignant syndrome (NMS) is a catatonic-like syndrome of uncertain etiology occurring in patients taking dopamine blocking medications. The paper describes how NMS presents and is treated and reports the case of a patient with undetected neurosyphilis who developed NMS. The case highlights the need for a thorough organic evaluation of all patients with initial-onset psychotic features and suggests the possibility of a CNS cofactor--neurosyphilis--initiating the NMS as proposed by other researchers.


Biliary ascariasis: surgical aspects.

Presentation and management of 204 patients with biliary ascariasis seen over a period of 5 years is reported from a highly endemic area of Kashmir. Ultrasonography is the single most useful means of diagnosis. Endoscopic retrograde cholangiopancreatography is extremely helpful. Most patients respond to conservative management and around one-fifth of all patients require surgery.


24-hour intragastric pH measurement in the assessment of duodenogastric reflux.

In this study we compared the results of measurement of duodenogastric reflux using 24-hour intragastric pH monitoring and nasogastric aspiration with analysis of bile acid and alpha amylase concentrations. Eight patients were studied at least 5 months after biliary and/or gastric surgery. The correlation coefficient of pH and bile acid concentration was 0.36 (p less than 0.001) and of pH and amylase concentration was 0.48 (p less than 0.001). If a pH greater than 4.0 was taken to indicate duodenogastric reflux this had a sensitivity of 84% compared with either high bile acid or amylase concentration. Bile acid concentration has been the "standard" method of measuring duodenogastric reflux. pH monitoring is relatively simple to perform, causes little patient distress, and can measure episodes of duodenogastric reflux over a continuous 24-hour period.


Evaluating measures to control intestinal parasitic infections.

Intestinal parasitic infections are among the most common infections of humans in developing countries, but the resources available for their control are severely limited. Careful evaluation of control measures is essential to ensure that they are cost-effective. The evaluation of the effects of control on intestinal helminths and intestinal protozoa requires an understanding of the different epidemiological patterns of these two groups of parasites. The transmission dynamics and morbidity associated with the major helminth infections (Ascaris lumbricoides, Trichuris trichiura and the hookworms) are dependent on the size of the worm burdens. Thus the important parameter for evaluating the impact of control on morbidity and transmission is the intensity of infection, which can be assessed by determining the mean density of parasite eggs in faecal specimens. Estimation of intensity is subject to systematic errors, however, due to the complex pattern of worm burden distributions. The frequency distribution of burdens is highly overdispersed, and individuals exhibit predisposition to particular levels of infection. Furthermore, mean intensity is age-dependent, in a species-specific manner, and is clustered spatially and within families. These complex patterns imply that the estimation of intensity is exceptionally sensitive to the size and demographic structure of the population sample selected for assessment. They also have the effect that prevalence estimates, the most commonly used measures of infection in communities, can seriously mislead. Paradoxically, prevalence is least useful where infection is most common because the relationship between prevalence and intensity is most markedly non-linear when the prevalence is high. Thus in areas where control is most needed, evaluation using prevalence might suggest that control had failed while evaluation by intensity would, correctly, show the measure of success. With the major protozoan infections (Entamoeba histolytica, Giardia duodenalis and Cryptosporidium parvum) an estimate of intensity is of little value and the central parameter for evaluation is prevalence. Prevalence does exhibit age and spatial heterogeneity, which may be species-specific, so there remains a need to ensure a consistent sample structure, although this is less critical than for the helminths. The major constraint on evaluating the control of protozoan infections is the need to identify pathogenic species and, in some cases, pathogenic strains. Harmless commensal protozoans are ubiquitous and often morphologically very similar to pathogens, but their control is both unnecessary and impracticable. Species such a E. histolytica appear to exist as strains with differing pathogenicity, thus control will be cost-effective only if the focus is on pathogenic strains. Effective diagnosis is therefore central to the evaluation of the control of protozoan infections.(ABSTRACT TRUNCATED AT 400 WORDS)


The magnitude of mortality from acute respiratory infections in children under 5 years in developing countries.

This article reviews the available evidence of mortality from acute respiratory infections (ARI) among children aged under 5 years in contemporary developing countries and compares the findings with European populations before 1965. In European populations before 1965, the level of mortality was found to be a determinant of the proportion of deaths due to ARI. There were marked differences according to regional patterns of mortality. Deaths from ARI played a smaller role after 1950, when the use of antibiotics became generalized. In developing countries, the role of ARI mortality seems to be similar to the European experience. The age pattern is very marked. In absolute values, ARI mortality is highest in the neonatal period and decreases with age. In relative values, ARI mortality is highest in the postneonatal period. ARI, mainly pneumonia, accounts for about 18% of underlying causes of death in developing countries. Pneumonia and other ARI are frequent complications of measles and pertussis; ARI is also commonly found after other infections and in association with severe malnutrition. Virtually no data are available in developing countries to provide final estimates of the role of ARI in mortality of children aged under 5 years. However, the WHO figure of 1 out of 3 deaths due to--or associated with--ARI may be close to the real range of the ARI-proportional mortality in children of developing countries. Results are discussed in light of the definitions of ARI used in various studies, the difficulties in ascertaining and coding multiple causes of death and the quality of data from some sources.


Waterborne disease outbreaks in the United States of America: causes and prevention.

National statistics on waterborne outbreaks in the United States of America show that 1,702 waterborne outbreaks with 542,018 cases of illness and 1,089 deaths have been reported. Almost all deaths prior to 1940 were due to typhoid fever; 9 deaths from other causes have occurred since 1971. During the past decade, 291 waterborne outbreaks were reported in community (43%) and noncommunity (33%) systems, and from the ingestion of contaminated water from recreational (14%) and individual (10%) water sources. Although several large waterborne outbreaks occurred during the past decade, most were in small communities. The number of illnesses per outbreak in noncommunity systems during the past decade is much larger than that reported during any previous period, and the magnitude of these outbreaks indicates the potential effect on the travelling, transient population. During 1981-1990, contaminated, untreated groundwater or inadequately disinfected groundwater was responsible for 43% of all reported waterborne outbreaks, and contaminated, untreated surface water or inadequately treated surface water was responsible for 24% of all reported outbreaks. The use of untreated groundwater has declined in importance as a cause of outbreaks, and more outbreaks are now caused by inadequate or interrupted disinfection of groundwater. The increased occurrence of outbreaks in disinfected groundwater systems may be due to (i) increased use of disinfection with little effort to reduce or eliminate sources of contamination, and (ii) not providing effective, continuous disinfection. In surface-water systems, outbreaks occur primarily because of inadequate or interrupted disinfection in systems that do not provide filtration, but a large increase in outbreaks has recently occurred in filtered systems.(ABSTRACT TRUNCATED AT 250 WORDS)


Surveillance and control of emerging zoonoses.

"Emerging zoonoses" are defined as zoonotic diseases caused either by apparently new agents, or by previously known microorganisms, appearing in places or in species in which the disease was previously unknown. New animal diseases with an unknown host spectrum are also included in this definition. Natural animal reservoirs represent a more frequent source of new agents of human disease than the sudden appearance of a completely new agent. Factors explaining the emergence of a zoonotic or potentially zoonotic disease are usually complex, involving mechanisms at the molecular level, such as genetic drift and shift, and modification of the immunological status of individuals and populations. Social and ecological conditions influencing population growth and movement, food habits, the environment and many other factors may play a more important role than changes at the molecular level. Diseases associated with changing farming practices, trade and consumer habits. Bacterial enteric diseases due to Salmonella enteritidis and Echerichia coli 0:157 are examples of diseases associated with changing farming practices and consumer habits. The increasing trade in live animals for animal production and research led to the introduction of the New World screwworm to the Libyan Arab Jamahiriya in 1989 and an Ebola-like virus in monkeys in quarantine facilities in the United States of America. The development of the epidemics of bovine spongiform encephalopathy (BSE) in the United Kingdom is due to multiple factors including the increasing use of ruminant proteins as feed for animals. Diseases associated with changing environmental conditions which influence reservoirs, vectors and/or victim species population parameters.(ABSTRACT TRUNCATED AT 250 WORDS)


[Cholera, 1991--old enemy, new face].

The cholera epidemics of the XIXth century are described and reviewed. The extent, incidence and case-fatality rate for the disease in the seventh pandemic are described. The global epidemiological situation and its trend at the end of 1991 are analysed. A review of cholera epidemiology highlights the factors that might explain the less tragic nature of the disease today. The role of water, food and direct contagion in transmission of cholera over the last 20 years is considered in the light of recent studies and with special reference to the epidemic in Latin America, where the intense emotion aroused by the disease has prompted vigorous action that could produce significant and lasting progress in the health field.


The global epidemiology of the HIV/AIDS pandemic and its projected demographic impact in Africa.

The global epidemiology of HIV/AIDS has evolved to the point that the pandemic now predominantly affects heterosexuals, especially in developing countries. This article summarizes the status of the HIV/AIDS pandemic as of the early 1990s; provides estimates and short-term projections of AIDS mortality in a hypothetical country of sub-Saharan Africa; projects the potential demographic impact of AIDS in a hypothetical sub-Saharan country; and describes the major problems associated with modelling the long-term demographic impact of this pandemic. Estimated AIDS cases and deaths up to 1992 were extrapolated from public health surveillance data and through use of the WHO model. Estimates of HIV seroprevalence were based on available HIV serological data. For developed countries, HIV estimates developed by national experts and/or national AIDS programmes were used, and for developing countries estimates by regional experts were used or were prepared by WHO. For the first half of the 1990s, projections of AIDS cases and deaths were derived from the WHO model; beyond the mid-1990s, the potential effects of AIDS on selected demographic indicators were derived from a demographic projection model developed by the World Bank. Although estimates and long-term projections cannot be made with great precision, the general dimensions of the HIV/AIDS pandemic have been more clearly delineated now at the start of its second decade. Epidemiological data indicate that in industrialized countries, where extensive spread of HIV began in the late 1970s or early 1980s, the majority of HIV infections occurred during the first half of the 1980s.(ABSTRACT TRUNCATED AT 250 WORDS)


Control of pertussis in the world.

Available data indicate that pertussis remains an important disease during infancy and childhood, particularly among those who are inadequately immunized. Over the past 15 years, successful immunization programmes have been implemented in most countries in the world. Some problems have arisen in the industrialized world where pertussis had been well controlled previously. The underlying causes of these problems are apathy and complacency on the part of physicians and parents, negative attitudes to immunization spread by anti-immunization pressure groups and litigation over liability for alleged vaccine-related injures. In developing countries, immunization coverage with primary series of three doses of DPT vaccine in infants exceeds 80%, but there are considerable differences in coverage rates between regions and between and within countries. Failures to reach and maintain high immunization coverage in developing countries are caused by multiple factors including weak management of immunization services, missing opportunities to immunize eligible children and ineffective information and motivation of mothers to return to complete the immunization series. To effectively control pertussis in the world, all countries should use available pertussis vaccines in immunization programmes for children. Since acellular pertussis vaccines are not generally available, the widespread use of DPT vaccine containing the whole-cell pertussis component should be continued. All efforts should be directed to increase or maintain high immunization coverage with DPT immunization at the level of at least 90% in all districts. Surveillance of pertussis morbidity should be strengthened in all countries and ideally, pertussis should be a reportable disease. More information on the present epidemiological pattern of pertussis, especially age distribution of pertussis cases in developing countries, is needed to develop the policy of booster doses of DPT vaccine in children > 1 year.


Progress towards the global elimination of neonatal tetanus.

Neonatal tetanus (NT) can be effectively prevented through immunization and clean delivery practices. However, NT claimed the lives of over 433,000 infants in 1991. It is endemic in 90 countries throughout the world. Community-based neonatal tetanus mortality surveys helped to determine the true incidence of NT and revealed that, before immunization and clean delivery programmes were well established, approximately 1 million children contracted NT each year, of which 800,000 died. Mortality rates varied markedly by locale, ranging from 0 to 70 NT deaths per 1,000 live births. NT is still one of the most underreported notifiable diseases, and routine reporting systems identified only 4% of the NT cases estimated to have occurred in 1990. Based on WHO estimates, tetanus toxoid (TT) immunization and clean delivery practices prevented over 793,000 infant deaths in 1991. Of the 433,000 infants who died of NT that year, approximately 212,000 died in South-East Asia; 127,000 in Africa; 46,000 in the Western Pacific; 37,000 in the Eastern Mediterranean; and 1,300 in Europe. The Pan American Health Organization, using a separate methodology to estimate mortality, calculated that 10,500 newborns died of NT in the Region of the Americans. NT consistently clusters in geographical areas and population groups where shared practices or the environment enhance the risk of cord contamination. 80% of the newborns who died of NT in 1991 were born in South-East Asia or Africa. Of the 90 countries endemic for NT, 10% produce 80% of the world's NT deaths. NT also clusters at country level.(ABSTRACT TRUNCATED AT 250 WORDS)


Human leishmaniases: epidemiology and public health aspects.

The leishmaniases are parasitic diseases caused by different species of Leishmania, protozoa transmitted by sandflies, haematophagous biting insects. The reservoir hosts are man (anthroponotic cycle) and domestic or wild animals (zoonotic cycle). In man the disease takes four main clinical forms: visceral, cutaneous, mucocutaneous and diffuse cutaneous. Morbidity and mortality due to leishmaniasis are on the increase. Leishmaniasis, which is now found on four continents, is endemic in 82 countries (21 in the New World and 61 in the Old). The large number of endemic countries shows the global scale of the problem, though it is particularly severe in certain countries (90% of cases of visceral leishmaniasis come from 4 countries). Annual incidence is estimated at some 600,000 new clinical cases, officially reported, with a global prevalence of 12 million cases and a population at risk of approximately 350 million. It is very difficult to provide realistic estimates given the frequency of subclinical forms of visceral leishmaniasis, the large number of undiagnosed or unreported cases, the frequent absence of active screening and the fact that the leishmaniases are notifiable diseases only in a few countries (30 out of 82); nevertheless, it seems clear that official reporting of cases considerably underestimates the problem. Over the last two decades, it has become clear that leishmaniasis is a growing public health problem in terms of geographical extent and incidence with the occasional severe epidemic, such as that which occurred in Sudan.(ABSTRACT TRUNCATED AT 250 WORDS)


Chagas disease: epidemiology and prospects for interruption of transmission in the Americas.

American trypanosomiasis, or Chagas disease, is a parasitic disease caused by the haemoflagellate protozoa, Trypanosoma cruzi. The human infection occurs only in the Americas, where it is widely distributed in the periurban and rural areas of tropical and subtropical countries, from Mexico to Argentina and Chile. It is transmitted to man and other mammals mainly through insects, the triatomine bugs. As an enzootic disease, it extends from approximately latitude 42.5 degrees N (northern California and Maryland) to latitude 43.5 degrees S (southern Argentina and Chile). The results of several serological surveys indicate an overall prevalence of 16-18 million infected individuals. Up to 30% of those infected will develop the cardiac and/or hollow viscera irreversible lesions that characterize chronic Chagas disease. The endemic countries can be divided into four groups according to several indicators such as the number of confirmed human cases, the prevalence of seropositive tests in blood donors and population samples, the presence of infected vectors and reservoirs, and the existence or absence of coordinated actions towards the control of this disease. The domestic cycle of transmission, involving man and domestic animals such as dogs, cats, and domestic triatomine bugs, is the one that maintains the infections in the rural and periurban areas. Some triatomine species are well adapted to human dwellings where human and animal reservoirs are in intimate contact. The poor socioeconomic condition of the population and the domestic nature of the vector play crucial roles in maintaining the infection at an endemic level.(ABSTRACT TRUNCATED AT 250 WORDS)


Progress towards the global eradication of poliomyelitis.

Poliomyelitis has been virtually eliminated from the industrialized countries by mass campaigns conducted with oral polio vaccine (OPV). In 1988, the World Health Assembly set the goal of global eradication of poliomyelitis by the year 2000. The current WHO strategy for eradication uses three primary activities beyond routine immunization with OPV. They are: (i) improved disease surveillance, (ii) building a global network of laboratories, and (iii) supplemental immunization strategies which include mass immunization campaigns with OPV at the national level, and targeted campaigns at the local level. Eradication of polio from the Region of the Americas is close and may have already been achieved. In other regions, the number of reported polio cases has declined, largely as a result of high immunization coverage. As more countries implement polio eradication strategies, the number of polio cases will continue to fall until eradication is achieved.


The epidemiology of measles.

Measles is a highly infectious disease which has a major impact on child survival, particularly in developing countries. The importance of understanding the epidemiology of this disease is underlined by its ability to change rapidly in the face of increasing immunization coverage. Much is still to be learned about its epidemiology and the best strategies for administering measles vaccines. However, it is clear that tremendous progress can be made in preventing death and disease from measles with existing knowledge about the disease, and by using the presently available vaccines and applying well-tried methods of treating cases. Research in the coming decade may provide more effective vaccines for use in immunization programmes. An understanding of the basic epidemiology of measles is a prerequisite for effective control measures.


The XXth century dengue pandemic: need for surveillance and research.

By the last decade of the XXth century Aedes aegypti and the 4 dengue viruses had spread to nearly all countries of the tropical world. Some 2 billion persons live in dengue-endemic areas with tens of millions infected annually. Dengue pandemics were also documented in the XVIIIth and XIXth centuries; they were contained by organized anti-Aedes aegypti campaigns and urban improvements. The XXth century dengue pandemic has brought with it the simultaneous circulation of multiple serotypes and in its aftermath, endemic dengue haemorrhagic fever/dengue shock syndrome (DHF/DSS). Nearly 3 million children have been hospitalized with this syndrome in the past 3 decades, mainly in South-East Asia. Recent outbreaks of DHF/DSS in the Pacific Islands, China, India, Sri Lanka, Cuba and Venezuela are indicators of the high intensity and rapid spread of dengue transmission. The magnitude of the XXth century dengue pandemic requires urgent improvements in early warning surveillance by WHO Member States and the development of the capacity to study underlying mechanisms of the disease. A key research question is why does DHF/DSS not occur with all second dengue infections? Two answers have been suggested: (1) a human resistance gene. Data from the 1981 DHF/DSS epidemic in Cuba have demonstrated the existence in blacks of a resistance gene. The effect of such a gene in reducing disease susceptibility of American and African blacks requires more study. (2) The existence of dengue "biotypes". Some, but not all biotypes may cause DHF/DSS during a second dengue infection.(ABSTRACT TRUNCATED AT 250 WORDS)


Influenza--its impact and control.

Influenza is an underestimated public health problem. Epidemics spread rapidly from country to country and may affect as many as 500 million people across the world in a moderate influenza year. The disease, particularly influenza A, kills and the new influenza viruses which appeared in 1957 (Asian influenza) and 1968 (Hong Kong) are estimated to have caused at least 100,000 deaths in the United States of America. Deaths from influenza also occur in years when there is no new virus; at least 10,000 excess deaths have been documented in the United States during each of 18 different epidemics recorded from 1957 to 1985. Although most deaths are among the elderly, influenza occurs in all age groups with repercussions in schools and work places, and on hospital resources, at a high cost to society. As many as 79-80% of influenza cases can be prevented when the virus inducing the outbreak and the virus used in the influenza vaccine are closely related. Preventing 80% of cases would correspond in the United States to a saving of US $2.5 billion. People at the greatest risk of influenza-related complications are adults and children with chronic disorders of the pulmonary or cardiovascular systems, residents of nursing homes and of facilities for patients with chronic medical conditions. Other priority groups for vaccination are those at moderate risk of influenza-related complications such as healthy elderly persons, people with chronic metabolic diseases, children and teenagers on long-term aspirin therapy. Groups potentially capable of transmitting influenza to high-risk persons should also be vaccinated.(ABSTRACT TRUNCATED AT 250 WORDS)


[Hemodynamic effects of anti-arrhythmia substances].

Medical treatment of cardiac arrhythmias is limited by several side effects. Haemodynamic and proarrhythmic effects are the most important limitations of antiarrhythmic drug therapy. In this paper we present data from several studies on the haemodynamic side effects of antiarrhythmic drugs of Class I and III according to Vaughan-Williams. The results were discussed with special regard to the influence of these drugs on myocardial contractility. From the results presented it is concluded that there are no important differences in the negative inotropic effects among the Class I drugs. The clinically observed more marked cardiodepressant action of some of these drugs is probably due to their unfavourable effects on pre- and afterload of the left ventricle. From a theoretical point of view, Class III drugs should have a more favourable haemodynamic profile. However, after acute administration the commercially available Class III drugs also had a cardiodepressant action. A possible explanation for this finding might be other side effects of the Class III drugs currently available, since a pure Class III drug does not exist at present. Therefore, the special haemodynamic profile of each drug should be taken into consideration for antiarrhythmic treatment.


[Conventional roentgen functional diagnosis--videodensitometry. 3. Conventional roentgen videodensitometry exemplified by the heart].

It is possible to record movement parameters video densitometrically and synchronously by means of a video signal analysator at various points of the organ surface visible via fluoroscopic images (provided by videorecorder). Movement parameters of the heart surface were signed just in the same cardiac action by synchronous electrocardiography. There are some difficulties in this method according to evaluation with reference to laevocardiography in consequence of functional variety of the heart and the different exercise conditions. Small aneurysms of the cardiac apex were only seen when they were separated and located at the cardiac margin. Extended cardiac aneurysms were video densitometrically recorded as a paradoxical movement at the cardiac surface. A paradoxical movement was never seen with negative findings in laevocardiography.


[Protection from uv-light-induced oxidative stress by nutritional radical scavengers].

Two series of examinations were carried out in two voluntary test groups for the purpose of elucidating the correlation between ultraviolet light load and oxidative stress as well as the way it is influenced by nutritive radical scavengers. After a 6 to 7-hour impact of sunshine on the whole body (sunbathing beach) at n = 8 a continuous progredient increase of thiobarbituric acid reactive substances could be identified in the serum (from 5.56 +/- 0.98 to 8.91 +/- 0.99 mumol/l, p < 0.001), which after new exposure to sunshine reached 11.3 +/- 2.4 mumol/l. Likewise, a 15-minute exposure to ultraviolet light at n = 24 induced increases of TBRS concentrations lasting from 1-2 days. After 14-day supplementation with beta-carotene (n = 6), D-alpha-tocopherol (n = 6), selenium (n = 6), and ginkgo biloba extract (n = 6) the extent of the oxidative stress could be inhibited during a second exposure to ultraviolet light up to the following efficiency: Se > Ginkgo > beta-carotene > vitamin E. The clastogenous effect of sunshine and ultraviolet light must be regarded as a factor for initiating and promoting cancerogenesis in the total organism. Concerning the aetiopathogenesis of malignant melanoma the paramagnetic properties of free radicals with their nonenergetic effects of the magnetic field have to be considered more carefully in scientific examinations.


[Pravastatin, a new cholesterol synthesis inhibitor for lowering increased serum cholesterol].

The association between increased risk for coronary artery disease (CAD) and elevated plasma cholesterol has been firmly established. The beneficial effect of cholesterol lowering treatment modalities was confirmed in both primary and secondary intervention trials. Because long-term treatment is usually required for lipid lowering therapies the drugs used for lipid reduction have to be not only efficacious but also safe. Inhibitors of cholesterol synthesis that have become clinically available during the last few years, can reduce plasma levels of total cholesterol and low density lipoprotein (LDL)-cholesterol very effectively. In the Familial Atherosclerosis Treatment Study (FATS) an intensive cholesterol lowering treatment modality consisting of a combination of an inhibitor of cholesterol synthesis and colestipol reduced the progression of coronary lesions and caused a partial regression of such lesions. Among the various inhibitors of cholesterol synthesis developed recently, pravastatin appears to be tissue-specific because of its hydrophilic property.


[Nomination criteria in the history of the Medical Faculty of the Halle University. III. From the turn of the century to 1945].

The restrictions that had remained applicable in respect of the right of nomination that had been conceded to the Departments of Universities in the 19th century, were rescinded in the early 20th century. As a rule, a list of three suggested names was submitted, but it was still possible that the ministry would issue a decree of appointment without prior approval of the relevant University department. Whereas the conventional principle of nomination continued to apply on paper, additional criteria were brought into play after 1933 involving premises determined by Nazi party politics and which resulted in centrally monitored vocational decisions.


[Skeletal development in monozygotic and dizygotic twins].

The maturation and development of 27 monozygotic and 23 dizygotic twins were studied over a 10 year period with data collected at one year intervals from age 9 to adulthood. In this manner the ossification process was recorded based on X-ray films of the carpal bones. Further information was acquired through anthropometric and somatoscopic data reproduced with standard photography. Sex and phase specific genetic factors influencing the maturation process are presented and analysed.


Secular trends of stature and weight of Chinese girls.

Stature and weight were studied in 123 12-year-old Southern Chinese girls born and brought up in Hong Kong. The mean stature was 147.22 centimetres with a standard deviation of 6.65 centimetres. The mean body weight was 37.11 kilograms with the standard deviation being 7.39 kilograms. Secular trend of increased body size was demonstrated. The increase was more marked in the lower percentile groups.


Estimation of age at death from second metacarpals.

This study examined the estimation of age at death from the second metacarpal in 227 individuals aged 30-98 years. Variables ascertained from each bone were: cortical thickness and microdensitometric cortical bone density measured on radiographs of the bone and total osteon count and density recorded on microradiographs of the complete cross section at its midshaft. Based on the latter two variables, two age groups were formed; a middle age group representing those individuals aged 30-65 years, and an older group aged 65+. Stepwise regression analysis of the four variables produced a series of regression equations for age estimation for the middle, old and combined age groups for each sex and sexes combined. Sex-specific equations provided better results than nonspecific ones, especially in females. Total osteon density and combined cortical thickness were found to be the most useful estimators in the middle and the old age group, respectively. The standard error of estimate was 6.71 and 6.90 years in each age group for the sexes combined. In the combined age group, age could be estimated accurately from total osteon count, cortical thickness and MD cortical bone density with the standard error of estimate of 11.10 years. The relative error of estimate ranged within +/- 30% in almost all individuals aged above 60 years.


[Handedness in comparison with the asymmetry of the upper extremities].

In 1990 221 males (88 children, age 3.5-7.25 years and 133 adults, age 20-44 years) were investigated. The sample was divided into two groups based on handedness; 140 individuals were right-handed and 81 left-handed. 10 measurements were taken at the upper limbs. In addition, marked handedness, handclasping and armfolding were determined. The last three traits showed no statistically significant connection. It was determined that measurements of length, breadth and circumference are more often significantly asymmetric in favor of the right side in right-handers than in left-handers. Further, skinfolds of right-handed individuals are larger on the left side. Partially reverse results were found for left-handers as a whole, however, the results are more irregular. A difference in the degree of asymmetry exists between children and adults. Asymmetries of breadth and circumference measurements as well as forearm skinfold are larger in adults. Taking into account the error of measurement, frequencies of R > L, R = L and L > R for right- and left-handed individuals were evaluated using the chi 2-test for significance. Preponderance of measurements on the dominant side could often be secured statistically.


The formation of heart-proportion in fetal ontogenesis.

In the paper, the formation of basic heart proportions in the period from the 19th to 43rd week of intrauterine development was investigated. The material consisted of 1505 fetuses (930 male and 575 female). Length, width and thickness of the heart were measured to 0.1 mm on unpreserved fetus material within 24 hours after stillbirth or death, in the natural position of the organ. The material was divided into groups representing seven developmental periods, from the 5th to the 10th lunar month. Individuals from the 41st-43rd week were recognized as carried beyond term and included in the age category above the 10th month (< 10). Formation of heart proportions was investigated on the basis of a statistical analysis of the results, with both sexes considered separately. Evaluation of the research results confirmed previous results indicating a slightly different shape of the heart in the fetal period. In addition, the results show the changes that occur in heart proportions during the period of intrauterine development. A comparison of these proportions with analogous indices in adult individuals makes it possible to predict further developmental changes in the postnatal period. In comparison to the conical heart found in a grown-up individual, the fetal heart is more spherical. At the beginning of the fetal period, the length dimension of the heart is greater than its width. Beginning with the 9th month of development, a relatively slower elongation of the heart occurs in favour of a more rapid increase in its width dimension.(ABSTRACT TRUNCATED AT 250 WORDS)


Investigations on the variability of four genetic serum protein markers in Poland.

198 unrelated male and female Poles from Ostrów Wielkopolski (Central Poland) and 228 unrelated male and female Kashubes from Kościerzyna (Northern Poland) have been typed for four polymorphic serum protein systems: HP, TF, GC, and PI. Phenotype and allele frequencies of all these four polymorphic systems are quite different between Poles and Kashubes. Comparisons with some other Central and East European population samples (Slovaks, Hungarians, Matyos, Gypsies) revealed a considerable genetic heterogeneity among them. Genetic distance analysis showed that Hungarians and Matyos as well as Poles and Slovaks are found in two subclusters, which are linked up to one cluster. Gypsies and especially Kashubes exhibit a distinct position from this cluster. This genetic distance pattern can be explained satisfactorily considering the ethnohistory of the population groups under study.


Investigations on the variability of four genetic serum protein markers (HP; TF, GC and PI subtypes) in Italy.

14 population samples from various Italian regions with a total of 2.577 unrelated male and female individuals were typed for four polymorphic serum protein polymorphisms: HP, and TF, GC and PI subtypes. The regional distribution of the allele frequencies of these four polymorphisms shows a considerable heterogeneity, which is for the most part statistically significant, thus indicating an obvious genetic variability of the population of the Italian Peninsula.


[The SUVA (Swiss Accident Insurance Association) statistics and quality control].

Overall quality control in medicine takes place on various levels: Physician--Hospital--Insurer--Authorities, each having different requirements. Comparative standards are rather seldom. A model for a comparative standard for insurer purposes, the medical statistics package SUMEST' is presented. This model is diagnoses oriented and includes parameters for the severity of the accident, cost of treatment and treatment outcome, all based on 5-year data pool results.


[The decentralized documentation system '90' of the Study Group for Osteosynthesis Problems (AO)].

The new decentralized documentation system '90' of the "Arbeitsgemeinschaft für Osteosynthesefragen" (Association for the Study of Internal Fixation to ASIF) will be introduced. This system is used for gathering clinical data of operatively treated fractures and their clinical outcome.


[Quality assurance exemplified by perinatology and surgery].

Quality assurance encompasses all activities which are necessary to obtain a demanded quality of medical care. Typically, a quality assurance process ("monitoring- and evaluation-process") includes the following steps: systematic observation of quality of medical care using quality indicators, assessment of quality by comparison with standards and recognizing problems, analysis of the most important problem, realization of appropriate problem solving strategies and evaluation, if the problem is successfully solved through the corrective action. The quality assurance programs in perinatology and surgery--established in all the states of the Federal Republic of Germany--support the hospitals in the application of this quality assurance process. Uniform documentation and preparation of quality relevant information (lists of complications, profiles, charts, etc.) help the hospitals to perform a self-evaluation, to recognize problems and to verify the elimination of the problems. Hence, comparisons with local results and with results of other hospitals are possible.


[The hospital service misuse problem in orthopedics].

In a representative study for all German acute hospitals the amount of inappropriate (medically not necessary) patient care was estimated. The data material, sampling design, weighting technic and the appropriateness expert rating (retrospective, consent judging) was controlled. An overall proportion of inappropriate days of care of 18.45% were found but for orthopedic diseases this rate was 31.9% and even 37.7% for the younger than 60 orthopedic patients. Similar high rates for orthopedic diseases were found in US hospital studies of inappropriateness and should lead to an analysis of their reasons.


[Diagnosis--therapy and documentation].

The procedures of documentation of diagnostic findings are well established--but different in their graphical and structural appearance of patients histories. Out of multiple findings a retrieval with valid informations is very clumsy. In order to increase quality a complete and reliable registration of clinical data base is necessary. For this purpose the use of electronic media is profitable if the requirements of the data-base are well defined. A nationwide agreement on one key-system--including the transformation of textual structures--is proposed. Only this way leads to comparable results in therapeutic procedures.


[Basic differential documentation as conditio sine qua non for effective quality assurance].

The quality check in medicine increases not at all by judges order. This contribution shows in what point of medical-documentation quality check must begin, if she should be effective. Some examples explain, that only a discriminated and a by specialist examined basic documentation is able to give us valid statistics of clinical data. Some results of our quality checked basis documentation were presented too.


[Analysis of errors in ICD 9 diagnostic classification in compliance with the Federal health care regulation].

In the present study the diagnosis from 1221 letters of discharge of the years 1986 and 1987 were additionally coded by the documentation doctor of the orthopaedic department and compared with the documentation sheets and the computer lists of the administration. Supplementary to this after one year there was carried out an additional coding of the letters by the documentation doctor. The transfer errors of the administration were amounting to 1.72 p.c. with regard to three digit numbers and to 11.87 p.c. with regard to four digit coding. During the repeated examination the documentation doctor made an error of 4.3 p.c. for the three digit coding and of 15.6 p.c. if the maximum coding was required. The corresponding errors of the house physicians for three digit numbers (maximum) were amounting to 8 p.c. (33.6 p.c.) for frequent diagnoses, to 28 p.c. (48.5 p.c.) for rare diagnoses and totally 13.7 p.c. (37.8 p.c.). In the present documentation validity and reliability still shows a good result compared to other studies. Nevertheless a documentation with an error rate to such an extend is of no use for a base documentation, and this error rate must be taken into consideration in the interpretation of global medical statistics. Automatic coding systems integrated into medical writing service seems to be the only help in view of removing these problems.


[Analysis and assurance of complete medical documentation].

A written report on the findings of the examination forms the basis for the further procedure in the treatment of a patient--not merely in the area of orthopaedics. The examination findings should, therefore, be legible, readily understandable and complete. On the basis of 600 individual findings established at admission in the case of inpatients with diseases of the spine and hip, stemming from a total of three hospitals, the behaviour pattern of the individual examiner is analysed along with deficiencies in documentation. For a number of significant deficits, differences in the particular emphasis applied by individual physicians during the examination, the fact that the time available for such examinations is usually limited, and the lack of documentation system, are probably responsible.


[Additional coding for legally required ICD-9 as the basis for high quality patient record searches].

We are convinced, that the updating of the ID DIACOS diagnosis catalogue fits better to the today's medical language, than the former one. By using a consequent additional code we could eliminate several lacks of the ICD-9. Valid and reproducible diagnosis statistics are now possible. Subjective coding mistakes are largely avoidable. Inquiries of certain diagnosis can be answered by using the one of the two codes, that describes the diagnosis in the best form. Regarding the allotments of the best form. Regarding the allotments of the catalogue of orthopedic and traumatic diagnosis including the possibility of double-coding we got a special better version of ID DIACOS than before.


[Basic medical documentation with ID DIACOS as an instrument for quality assurance].

Standardized methods and instruments of medical documentation are prerequisites for quality assurance in medicine. Support for quality assurance measures at present can be attained by the programme systems ID DIACOS (encoding of diagnoses into ICD-9 and procedures into ICPM-GE) for daily clinical routine documentation. Administrative statistics, e.g. the L1-statistics of diagnoses according to section 16 Federal Statutory Instrument on Hospital Care Rates (BPflV) can be compiled without waste by aggregation. Supplementations of the programme system are planned caused by the introduction of new forms of Hospital reimbursement with changed classification patterns. An increasing need for computer-aided encoding will also result by the implementation of new classifications, e.g. ICD-10 and by the requirements concerning a scientific basic documentation (Selbmann, 1990; Mau, 1990) based partly on nomenclatures. The connection of the programme systems ID DIACOS and SNOMED (empirical and morphological analysis of medical texts) is possible and will be carried out (Hultsch, Diekmann, Ruhl, 1990).


On-line coupled liquid chromatography-gas chromatography (LC-GC) and LC-LC-GC for detecting irradiation of fat-containing foods.

On-line coupled liquid chromatography-gas chromatography-flame ionisation detection (LC-GC-FID) enables efficient and unambiguous determination of irradiation for some fat-containing foods (e.g. meat). Other products, however, contain interfering components or are contaminated, e.g., with mineral oil. Since more selective detection by mass spectrometry has limited success, the determination was improved by a more selective isolation of some key components among the fat degradation products, e.g. the dienes or trienes, by LC-LC-GC-FID. Applications are shown for soup mixes, some spices, fish, and shrimps.


[Long-term results of epicondylitis humeri ulnaris ("golfer's elbow") after treatment analogous to Hohmann's incision of epicondylitis humeri radialis ("tennis elbow")].

With an average follow-up of 6.1 years the results of Hohmann's operation in treatment of humeri ulnaris epicondylitis in 23 cases are presented. For evaluation a numerical rating system with subjective and objective criteria was designed. The results were excellent in 43.5%, good in 26.1% and fair in 17.5% by subjective and excellent in 47.9%, good in 26.1% and fair in 13% by objective evaluation. Three cases had a poor result. The study reviews causes, clinical tests, conservative treatment and our operative method.


[Medical applications of electronic data processing in surgery, trauma surgery and orthopedics. Results of a survey of 1,450 clinics].

With a standardized questionnaire we evaluated 1450 orthopedic and general surgery departments. The response rate was 57.2%, 52% of the departments were using computers for different purposes. The favoured system was the MS-DOS system (73%). The computers were mainly used for word processing (58%), statistics (50%), and graphics (39%). For clinical routine the leading use was patient documentation (70%) followed by patient report generation (43%). Other applications (e.g. online use of administrative data (19.4%) or the use of other patient information like blood parameters (10%)) were relatively rarely used. However, most of the users have plans to incorporate these applications in the nearest future. For the out patients care the leading application is private billing (42.5%) and statistics (30%). The majority of the departments (42.6%) only have one PC. Most of the departments use the printer for hard copies and as hard disc a the standard storage medium. The average storage capacity of the used hard discs is 40 to 80 MB. Other peripheral tools like a laser printer, a scanner, or modems are rarely used. Most of the departments invested between 5000 and 15,000,--DM. 33.3% financed the computers only with the official budget of the department. However, 25.8% only used private funds to buy the hard- and software. The distribution according to zip codes showed a slight accommodation in Bavaria and NRW. The amount of new installations showed an almost constant increase from 1975 until 1981. Between 1981 and 1990 there was a significant increase with a small drop in 1986.


Determination of the heating temperature of fishery products.

The German Fish Directive prescribes that products must be heated to the core temperature of +70 degrees C to kill existing larvae of nematodes. For subsequent determination of the heating temperature samples were extracted with water. The extracts were analysed for protein content, for protein patterns obtained by isoelectric focusing and by using the coagulation test. The suitability of these methods was investigated with heated extracts, heated minced fish flesh, and smoked herring and mackerel. Smoking was performed in the kiln of the institute at controlled temperatures. Analysis of commercial samples showed that the core temperature during smoking of herring and mackerel must have been clearly below 70 degrees C in several cases.


[Arthroscopic subacromial decompression. 1-3 year results].

In 148 patients with impingement lesion type I or type II, we performed an arthroscopic subacromial decompression (ASD). 122 patients ran a follow up one to three years post-operatively. All patients were pre- and postoperatively documented by a 100 point shoulder score. The mean score was 57.9 (+/- 11.5) preoperatively. Postoperatively there was a significant increase to 80.7 (+/- 17.9) (p < 0.05). 15% of the patients with a postoperative score less than 70 points were determined as failures. Patients with a preoperative pain history of more than one year had a significantly worse result (79.1 +/- 8.4) compared to those patients with a preoperative course less than one year (88.8 +/- 11.6) (p < 0.05). Other significant factors were the patient's age, and calcific tendinitis, whereas sex, preoperative range of motion, muscle atrophy, and degeneration of the acromioclavicular joint did not significantly influence the result. Our results after ASD in patients with subacromial pathology without a rupture of the rotator cuff are encouraging. Therefore, ASD seems to be a reasonable alternative to open acromioplasty.


Macroelements content of Common Pacific squid (Loligo opalescens).

The macroelement (sodium, potassium, calcium and magnesium) concentrations have been determined in various tissues of the Common Pacific squid, Loligo opalescens. The method of measurement was flame atomic emission (sodium and potassium) and absorption (calcium and magnesium) spectrometry. Edible tissues such as the tube (mantle), arms and crown, and fin contained: from 3.3 +/- 0.4 to 3.9 +/- 1.5 (1.9-6.8) g/kg wet weight of sodium; from 5.3 +/- 0.6 to 6.3 +/- 2.7 (3.3-14) g/kg of potassium; 38 +/- 7 to 100 +/- 34 (28-200) mg/kg of calcium; and from 510 +/- 100 to 950 +/- 280 (340-1500) mg/kg of magnesium. The other tissues or organs examined frequently contained a higher concentration of macroelements than the edible flesh. Statistically significant correlations between the body weight of squid and macroelement concentrations or between some pairs of metals in whole squid, mantle and hepatopancreas have been observed.


[Pathogenesis and prevention of spastic hip dislocation].

Based on retrospective analysis of 82 hips of 41 patients with cerebral palsy, a pathogenetic model of spastic paralytic dislocation of the hip is introduced including recent observations of the normal hip development. According to this model the reduced activity of the gluteus maximus, medius, minimus and quadriceps femoris muscles, which normally cause a decrease of valgus and anteversion, results in an increased subluxating coxa valga antetorta with a consecutive dislocation. In order to prevent a dislocation, these muscle groups have to undergo increased activation. Since walking has to be to undergo increased activation. Since walking has to be considered the strongest stimulus for the dislocation-preventing hip abductors, hip extensors, outward rotators and knee extensors, the erect gait should be encouraged with statomotorically favored children early as possible. This can be supported by muscle relaxing surgery of the antagonistically effective hip flexors, hip adductors and inward rotators as well as the knee flexors. These muscle release operations will counteract, although to a limited extent, a dislocation even with a severely handicapped child who is unable to walk.


[Postoperative infections and wound healing disorders in patients with infantile cerebral palsy].

As part of a retrospective study including 569 patients with ICP and a group of 405 controls, the risk of postoperative wound healing disorders and wound infections was investigated in surgically treated children with cerebral palsy. The higher rate of wound healing disorders in ICP patients could not be attributed to factors such as excessively long duration of operation, secondary interventions, or a high number of interventions per operation. Rather, the causes of the increased risk of infection have to be seen in connection with the symptoms of ICP itself, such as immunological weakness, increased tendency to sweat, reduced circulation in the affected extremity and disturbances of sensitivity and perception. A direct link between these parameters and increased risk of postoperative infection can only be established by prospective studies.


[Comparative studies of the Osborne protein fraction of wheat varieties with different dough and baking properties].

The proteins of flours from the wheat varieties Clement (CLE) and Disponent (DIS), which are characterized by substitution of the wheat chromosome 1B by the rye chromosome 1R (CLE) and by 1BL/1RS-translocation of chromosome segments (DIS), respectively, and which yield sticky doughs, were extracted by the Osborne procedure and compared with the good variety Kolibri (KOL). CLE and DIS delivered significantly higher amounts of water-soluble proteins (31.2 and 23.2% of the total protein) than KOL (15.5%). The proportions of ethanol-soluble proteins were approximately constant for the three varieties (31.5-33.9%) while the amounts of residual proteins after extraction with ethanol were significantly different (CLE, 16.8%; DIS, 21.6%; KOL, 26.4%). Water extracts as well as residues exhibited also marked differences in their amino acid compositions. Investigation of the water extract from DIS by gel permeation chromatography and by RP-HPLC showed the presence of prolamins: omega 1,2-gliadins and/or omega-secalins could be detected on the basis of amino acid composition and N-terminal amino acid sequence. In the case of good varieties such as KOL, these prolamins seem to remain partially in the residue of the ethanol extract under the conditions of the classical Osborne procedure, whereas they are found in the water extract in the case of such varieties as CLE and DIS. On the other hand, a modified Osborne procedure (salt/ethanol/acetic acid) delivered the prolamins, which correspond to 39-40% of the total protein, completely within the ethanol fraction in the case of all three varieties.(ABSTRACT TRUNCATED AT 250 WORDS)


[Surgical treatment of hip dislocation in patients with infantile cerebral palsy].

The results of 63 operations on 52 patients with cerebral palsy, which were performed between 1978 and 1988 to correct a subluxation or dislocation of the hip, were reviewed. The innominate pelvic osteotomy was preferably combined with intertrochanteric femoral osteotomy and soft tissue release. The average age at time of surgery was 7 years/2 months. Surgical intervention was indicated irrespective of the severity of neurologic involvement. The mean follow-up period is 3 years/4 months. The results show, that by a combinations of these surgical procedures a permanent stability of the hip joint can be achieved. Retrospectively the 5 cases of reluxation can be explained by insufficient surgical technique. The postoperative development of the CE-angle and the acetabular index reveal, that after adequate reduction of the femoral head the acetabulum is able to remodel its dysplasia. From a functional point of view actually patients with diplegia gained the most benefit from a stable hip joint, because they showed the most progress in motor activity. In tetraplegic patients the long-term success of these surgical procedures must be seen in the prevention of a painful hip in adult life, the maintenance of sitting-stability and the improvement of perineal care condition.


Application of polyuronides for removing heavy metals from vegetable oils. III. Application of alginic acid, pectic and pectinic acids for demetalization of hydrogenated sunflower oil.

Laboratory experiments have been carried out for the removal of heavy metals from hydrogenated vegetable oils using hydrated polyuronides (degree of swelling from 4 to 12.8 ml/g) such as alginic acid, pectic and pectinic acids. The effect of the type of polyuronide, degree of esterification and oil treatment on the degree of demetalization has been studied. It has been shown that with increase in the degree of esterification of the polyuronide the efficiency of demetalization decreases. The second and third treatment of the hydrogenated oil with pectinic acid resulted in a high degree of heavy metal removal. The possibility of efficient demetalization of hydrogenated oils by treatment with water solutions of pectinic acids has also been demonstrated. The degree of metal ion removal increases with decreasing concentration of pectinic acids in the water solution.


Influence of demetallization of hydrogenated sunflower oil on changes in the forms of heavy metals and their pro-oxidative effects.

The effect of removing heavy metals from hydrogenated sunflower oil using a method based on changes in the contents of the various forms of the heavy metals copper, iron, zinc and nickel and their respective pro-oxidative effects was studied. A high degree of removal of dissociated and bounded ions was observed for hydrogenated oil, while there was no change in the contents of the co-ordination form. The pro-oxidative effect of the dissociated ions and of the bound metal ions in hydrogenated oil decreased nine-fold and seven-fold, respectively, compared with that of the non-hydrogenated oil, as a result of which the oxidation stability of hydrogenated oil increased two-fold. Comparative studies confirmed as appropriate the use of wash waters and auxiliary solutions that do not contain heavy metals for the processing of the hydrogenate after the classical technology.


Tuberculosis and AIDS: European and worldwide perspectives.

To examine the possible influence of AIDS and HIV infection on the epidemiology of tuberculosis in Europe and worldwide in the coming decades an analysis of the available data on the two diseases and on the transmission of the two infections in relation to the demographic structure of the population was conducted, including projections for up to the year 2025. Globally, the effects of the AIDS pandemic on the tuberculosis situation will probably be very serious, adding some 1.5 million new cases of tuberculosis annually by the year 2025 as a result of HIV infection. However, this effect for Europe in the year 2025 may be in the range of 15,000 additional cases only. The main factor determining the scale of aggravation of Tb is the age structure of the population infected, or at risk of being infected, with tubercle bacilli and HIV. Although the influence of HIV infection on tuberculosis in Europe may not be very high due to the fact that HIV infection involves mainly younger age groups it may, however, substantially postpone the elimination of tuberculosis from Europe. Therefore it seems necessary to monitor constantly all the changes in the epidemiological situation of both tuberculosis and AIDS/HIV.


[HIV infection: feasibility of a seroprevalence study with consent of hospitalized patients].

A pilot study was carried out in order to evaluate the feasibility of determining the seroprevalence rate of HIV infection and the prevalence of risk factors among selected hospital patients at the Centre Hospitalier Universitaire Vaudois (CHUV). Consent was obtained and only blood already obtained for other purposes was used for testing. Among 850 patients between 16 and 65 years of age and residing in Switzerland who were originally selected at random, only 200 patients were accessible for an interview and for whom blood was available in order to be included in the study. Of these, 165 (83%) accepted their blood to be tested. A seropositive result was identified in 2 patients already aware of their serostatus. The age distribution, diagnosis and behavioral risk factors (when available through the interview) were not different among those accepting the test and the ones refusing. However, foreigners were more likely to refuse the blood test than Swiss nationals, even though none of them came from a country with a high rate of endemicity for HIV infection. Reasons for refusal included the following: lack of risk factors 10 (29%), doubts about confidentiality 6 (17%), blood test already performed 5 (14%), language barrier 4 (11%) and others 10 (29%). We conclude that even though the data in our sample did not suggest that patients refusing the test were at an increased risk of being seropositive, it is unlikely that with such a refusal rate, a reliable measure of seroprevalence could be determined in the population of study with the methods used, especially when one is expecting a relatively low seroprevalence rate.


Infertility in industrialized countries: prevalence and prevention.

We discuss the prevalence and aetiology of infertility and the relevance of this information for national infertility services and prevention programmes. The prevalence of infertility in industrialized countries has been said to be as high as 10-20%. This estimate, and the argument that little can be done to prevent infertility, have been used as justification for increased government investment in, or expansion of, services for medically assisted conception. However, population prevalence surveys indicate that far fewer couples of reproductive age are actually infertile. For example, a recent survey in the United States reported that 8.5% of married couples with a wife age 15-44 were infertile. 4% of the sample were childless and reported having a condition which impaired fecundity, while less than 2% were childless, had impaired fecundity and were over 35 years of age. Other studies show that nearly a third of couples have difficulty conceiving at some point during their reproductive lives but few actually remain childless. A significant proportion of infertility could be prevented through more aggressive application of standard public health measures.


Community involvement towards community objectives.

The World Health Organisation "Health for all children by the year 2000" declaration presents an exciting yet timely challenge. If these aims are to be achieved, the role of the health worker must be broadened. There must be a recognition that families will determine the true health of their children--physical, mental and social. Families must be able to identify and realise their aspirations, to satisfy their needs and to cope with and adapt to their environments. Only by advocacy, by forming a partnership with families, and by empowering families to exercise greater control over their health and their environment, will health workers begin to see positive change in the community. There is a need to collect and collate data from the community in order that the true needs of families are met. New outcome measures which address "quality of life" must be developed; these will accord closely with the WHO aims, and will enable communities to set the high standards that must be achieved for our children. "Health", interpreted in its broadest meaning, should lead to health professionals concentrating on the promotion of a healthy lifestyle and the attainment of "quality of life". There must be a move away from the "medical model" of care to the empowerment of parents who are responsible for the care for their children and the need to work towards better community resources.