Avian arterial chemoreceptor responses to steps of CO2 and O2.

The responses of avian arterial chemoreceptor preparations to 44-sec steps of inspired CO2 and O2 were quantified. Anesthetized ducks were unidirectionally ventilated, arterial pH was recorded with a fast responding indwelling electrode, and neural activity was recorded from 28 preparations consisting of dissected filaments of the vagus nerve (23 single-fibered, 5 few-fibered). We analyzed responses using cycle-triggered stimulus histograms of neural discharge, cross correlation analysis, and analysis of variance. Average responses of the chemoreceptor preparations to PaCO2 steps from 24 +/- 1 to 38 +/- 1 Torr were larger (per Torr), occurred faster, and appeared more rate sensitive than the responses to PaO2 steps from 101 +/- 3 to 56 +/- 2 Torr. Average responses to CO2 steps usually appeared more rate sensitive when measured during arterial hypoxia than during arterial normoxia. These characteristics are very much like those reported for mammalian arterial chemoreceptors, except that responses of avian chemoreceptor preparations to repetitive CO2 steps were highly variable according to statistical analysis.


Kinetics of the Root effect and of O2 exchange in whole blood of the eel.

Oxygen transfer kinetics in blood of the eel (Anguilla rostrata, A. anguilla) were measured spectrophotometrically in thin blood layers covered by Gore-Tex membranes, which allowed fast changes of the gas phase at the blood surface (Heidelberger and Reeves, 1990 J. Appl. Physiol. 68: 1854-1864). The following main results were obtained for A. rostrata (similar values were measured for A. anguilla): (1) step change in PO2 of the gas phase between 0 and 37 kPa at low PCO2 (0.19 kPa, blood pH, 8.1; 20 degrees C) yielded mean half times (t(on)) for O2 uptake of 7.1 msec, and for O2 release (t(off)), of 42.8 msec. Similar values were obtained at high PCO2 (19 kPa; blood pH, 6.9), indicating O2 kinetics to be independent of pH and PCO2; (2) decreasing the high PO2 from 37 to 14 kPa significantly prolonged oxygen uptake kinetics, but release kinetics were unaltered; (3) changing PCO2 from 0.19 to 19 kPa at constant high PO2 (37 kPa) resulted in a reduction of hemoglobin oxygen saturation (SO2) (Root-off reaction), with t(off) averaging 44.8 msec; likewise, changing PCO2 from 19 to 0.19 kPa increased SO2 with t(on) averaging 64.8 msec (Root-on reaction). As these half times comprise reactions at the hemoglobin molecule and conversion between CO2 and H(+)/HCO3-, the Root effect kinetics of the hemoglobin molecule appear to be even faster. It is concluded that the O2 exchange kinetics of eel blood are comparable with those of human blood.(ABSTRACT TRUNCATED AT 250 WORDS)


Acute changes in vasoactive lipid mediators in experimental hyaline membrane disease.

Endothelial release of the arachidonate derivative PGI2 may be increased in response to cyclic lung stretching. We therefore sought to determine if the stable metabolite of PGI2, 6-keto-PGF1 alpha, would be found in increased quantities in primates ventilated with conventional mechanical ventilation (CMV) compared to treatment with high frequency oscillatory ventilation (HFOV). We also sought to determine if other membrane-derived vasoactive substances such as LTC4, PAF and TXB2 would be elevated in plasma and lung tissue of animals developing hyaline membrane disease (HMD) and if the levels would correlate with the severity of the respiratory distress. Twenty prematurely delivered monkeys were treated with either CMV or HFOV from the first breath after Cesarean delivery until sacrifice at 6 h of age. We found a significant increase from birth to 5 min and from 5 min to 5 h in 6-keto-PGF1 alpha, and a significant increase from 5 min to 5 h in TXB2. We found a significant decline from cord blood to 5 min of LTC4, without further change by 5 h. PAF was present in all plasma samples but showed no upward or downward trend. There was no difference in the 5-h plasma level or in the lung homogenate level of any of the lipid mediators between the two types of assisted ventilation. There was no correlation between any lipid mediator level and severity of the HMD, as measured by gas exchange, radiographic or histologic criteria, when assessed by each ventilator group alone or with both groups combined. We conclude that the immediate postnatal increases in TXB2 and PGI2 and decrease in LTC4 are not altered substantially by use of HFOV.


Relationship between inspired and expired gas temperatures in a hyperbaric environment.

When breathing room air at sea level the expired gas temperature (TE) increases in proportion to the inspired one (TI). Previous studies conducted under hyperbaric conditions have assumed that the TE vs TI relationship was the same when humans breathed room air at atmospheric pressure or helium-oxygen mixture under hyperbaric conditions. We hypothesized that the use of dilutant gases, as helium (He) or hydrogen (H2), having low density but high specific heat compared to nitrogen, could change the TE vs TI regression. The present study was conducted on 3 professional divers participating in the COMEX Hydra IX experiment. Three conditions were studied: A, (23.5 ATA, He-H2-O2 mixture); B, (21 ATA, H2-O2 mixture); and C, (21 ATA, He-O2 mixture). In each condition six different inspired temperatures were tested, while minute ventilation, TI and TE values were measured simultaneously. In all cases a linear relationship was found between TE and TI, but the slopes of the regression lines obtained in conditions A and B (gas mixture containing H2) were significantly lower than in condition C (He-O2 mixture). Computation of the convective respiratory heat loss (Cr) revealed that, when the subjects breathed the coldest gas mixtures (+10 degrees C), Cr value was 1.6 times higher in condition B than in C. These data are consistent with theoretical considerations and they demonstrate that a single equation cannot be used to predict the TE vs TI relationship in all environmental circumstances.


The histologic diagnosis of Hodgkin's disease.

Histologic criteria for the diagnosis of Hodgkin's disease are being modified, primarily as a result of phenotypic analysis. It seems likely that non-Hodgkin's lymphomas have been diagnosed as mixed-cellularity and lymphocytic-depletion Hodgkin's disease on the basis of previously accepted histologic criteria. As a result, phenotypic studies are indicated in all examples of lymphocytic-depletion Hodgkin's disease and in those cases of mixed-cellularity Hodgkin's disease in which the histologic findings are unusual. The effects of genotypic analysis on histologic criteria remain to be elucidated.


Lymphocyte-predominance Hodgkin's disease.

Nodular lymphocyte-predominance Hodgkin's disease (NLPHD) has emerged as a distinct entity. It has a precursor lesion, known as follicular hyperplasia with progressively transformed germinal centers (PTGC), and a late stage consisting of transformation to a large cell lymphoma. All cellular components of NLPHD are derived from follicles, but so far no clonal population has been identified.


The distinction of Hodgkin's disease from T cell lymphoma.

With the ability to accurately detect T cell lymphoid differentiation, both by immunophenotypic and genetic probe methods available only within the past decade, pathologists have become increasingly aware of similarities between some pleomorphic T cell lymphomas and Hodgkin's disease. In Workshop Session B, nine cases were reviewed in detail. Consensus was attained on seven cases, four of which were considered Hodgkin's disease and three of which were considered non-Hodgkin's lymphomas. Two of these seven cases exhibited morphologic features that alone would have indicated Hodgkin's disease, but manifested clinical, immunophenotypic, or genetic probe findings that instead favored their classification as non-Hodgkin's T cell lymphoma. In two cases, no consensus could be reached; ie, features in aggregate overlapped Hodgkin's disease and non-Hodgkin's lymphoma with T cell differentiation, and therefore their classification remained indeterminate. It is concluded that in most cases of differential diagnostic difficulty, consideration of the pathobiology and ancillary-study findings allows assignment to either Hodgkin's disease or (T cell) non-Hodgkin's lymphoma. However, in rare cases, even with exhaustive application of such criteria, this distinction cannot be made.


The distinction of Hodgkin's disease from B cell lymphoma.

Workshop C included cases with a differential diagnosis of Hodgkin's disease and B cell lymphoma. In general, the cases could be placed into one of the following four major categories: (1) usual Hodgkin's disease versus T cell-rich B cell lymphoma; (2) syncytial Hodgkin's disease versus B large cell lymphoma; (3) nodular and/or diffuse lymphocyte-predominance Hodgkin's disease (LPHD) versus T cell-rich B cell lymphoma; and (4) LPHD with composite or discordant large cell lymphoma versus T cell-rich B cell lymphoma progressing to large cell lymphoma. A final case illustrated the differential diagnosis of B cell Hodgkin's disease, ie, nodular LPHD versus the cellular phase of nodular sclerosing Hodgkin's disease (NSHD). The cases from this session have been grouped into these five categories and tables have been constructed to highlight features favoring each of the diagnostic possibilities. A brief discussion is given after each case, and selected cases have been illustrated to demonstrate some of the unusual histologic features.


The distinction of Hodgkin's disease from anaplastic large cell lymphoma.

In this session there seemed to be general agreement on the existence of anaplastic large cell lymphoma (ALCL) as an entity defined by a characteristic morphology and by diffuse expression of the Ki-1 (CD30) antigen. The discussion indicated the lack of specific immunophenotypic and genotypic markers for such a neoplasm and the variability of the clinical patterns associated with it: these include a childhood form, an adult cutaneous form, and an adult nodal disease. While typical cases of ALCL are clearly distinct (by pathologic, cytogenetic, and clinical criteria) from Hodgkin's disease (HD), there is a variety of histologic and immunophenotypic patterns that overlap those of ALCL and HD; most of these would be classified as HD, lymphocyte depletion (LD) or nodular sclerosis (NS), syncytial subtype. No agreed-upon criteria were found that could consistently define these patterns, nor was an agreement possible on whether they are part of a continuum unifying ALCL and HD or phenotypically similar expressions of different diseases.


The interrelationship of Hodgkin's disease and non-Hodgkin's lymphomas--lessons learned from composite and sequential malignancies.

While Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL) have long been regarded as distinct disease entities, recent observations suggest a closer association. The analysis of cases in which these diagnoses are made in the same anatomic site (composite lymphomas) or in separate sites (simultaneous or sequential HD and NHL) indicates that this phenomenon occurs more frequently than would be expected by chance alone. The most common form of composite lymphoma is coexistent nodular lymphocyte-predominant Hodgkin's disease (NLPHD) and large cell lymphoma (LCL) of B cell phenotype. This finding is consistent with a B cell origin for the abnormal cells in NLPHD, suggesting that LCL represents a form of histologic progression, with the existence of a clonal relationship between the two components. The association of other forms of HD (nodular sclerosis or mixed-cellularity) and NHL is less common, but still significant. As with NLPHD and LCL, one may observe composite lymphomas, or the diagnosis of HD may precede or follow the diagnosis of NHL. The vast majority of NHLs associated with HD are of B cell origin, most commonly follicular lymphomas. An association between HD and B cell chronic lymphocytic leukemia (CLL) is also observed. In selected cases, Reed-Sternberg (RS) cells are seen in a background of otherwise typical CLL, and some of these patients have progressed to disseminated HD. These findings suggest that, at least in some cases, HD may be clonally related to an underlying B cell malignancy, and that the RS cell may be an altered B lymphocyte.(ABSTRACT TRUNCATED AT 250 WORDS)


The relationship between Hodgkin's disease and non-Hodgkin's lymphoma.

The final Workshop of the meeting focused on cases of Hodgkin's disease (HD) in combination with non-Hodgkin's lymphoma (NHL), either T, B, or anaplastic large cell (ALC) type. The cases selected for this session fell into five categories: nodular lymphocyte-predominance Hodgkin's disease (NLPHD) with NHL, B cell chronic lymphocytic leukemia (CLL) with HD-like transformation, follicular lymphoma (FL) with HD or anaplastic large cell lymphoma (ALCL) (composite or discordant), HD following mycosis fungoides (MF), and HD following ALCL. Taken together, these cases left the participants with the distinct impression that there is likely to be some biological relationship between HD and a variety of T cell and B cell NHL.


The biology and genetics of hereditary cancers.

Hereditary cancer syndromes are generally produced by the inheritance of a single mutant gene. New tools have been developed that enable research workers to locate the defective genes responsible for the inherited forms of cancer. Once a disease gene has been localized, it may be possible to identify individuals who have inherited the disease gene before cancer develops.


Retinoblastoma: a hereditary tumor in children.

Retinoblastoma, a malignant intraocular tumor of infancy and childhood, originates from primitive embryonal retinal cells. The cause of retinoblastoma is the loss or deletion of genetic information from the long arm of chromosome 13. Retinoblastoma has a hereditary form characterized by bilateral and multifocal tumors, and a nonheritable form that presents with a single tumor.


Familial breast and ovarian cancers.

Breast and ovarian cancer develop independently of each other but share some genetic commonality. Definition and identification of hereditary breast cancer are very complex. Ovarian cancer can be inherited in an autosomal dominant pattern with variable gene penetrance, a site specific hereditary pattern, or a pattern of tumor combinations. Medical management of high risk individuals, follow-up, screening, and counseling needs are important issues to the woman and other family members.


Neurofibromatosis.

The two types of neurofibromatosis are NF-1 and NF-2. Both cause abnormal cell growth in the central and peripheral nervous system. Each disease is inherited as an autosomal dominant trait, thus each child of an affected parent has a 50% chance of inheriting the disorder. Because there is no cure for either type of NF and treatment consists of amelioration of clinical symptoms, genetic counseling is the only preventive approach to this disease.


Genodermatoses with profound malignant potential.

There are a number of heritable disorders that have some association with skin cancer. Xeroderma pigmentosum, nevoid basal cell carcinoma syndrome, and familial melanoma and dysplastic nevi are three disorders associated with an extremely high rate of cutaneous malignancy. There is no known cure for these disorders, thus, patients and families need information about the disease process, treatment options, and guidelines aimed at prevention and early detection of skin cancer.


von Hippel-Lindau disease: a genetically transmitted multisystem neoplastic disorder.

von Hippel-Lindau disease is a rare hereditary disorder in which affected individuals are genetically predisposed to develop certain types of tumors and cysts in multiple organs. The most common manifestations are cerebellar, spinal and medullary hemangioblastomas, retinal angiomas, renal cell carcinomas, and pheochromocytomas. A lifelong diagnosis that requires intense follow-up for multiple and recurrent tumors, this disease can greatly impact a family's sense of emotional and physical well-being.


Informational needs of individuals and families with hereditary cancers.

Individuals and families with hereditary cancers have informational needs that differ, depending on the availability of testing for increased hereditary risk and major focus of concern (reproductive decision-making or risk to self). Cancer risk counseling helps individuals understand risk information so they can make decisions appropriate to their lives and value systems.


On content of practice. An Icelandic multicentre study, population, practices and contacts.

To establish data on the content of Icelandic family practice, a prospective practice audit was made of all Icelandic health centres with computerized contact data from 1 January to 31 December 1988. The study comprised 17 community health centres in Iceland and their target populations, 13 rural and four urban. The main subjects for study were population characteristics, practice sizes, types of health care providers, and contacts. The study population, 50,865 subjects, comprised 20.2% of the Icelandic population. Rural and urban populations were different and are described separately. The 17 health centres had a mean of 1,152 subjects/doctor. The target population had a total of 257,188 contacts: 155,526 rural contacts, 5.1/subject (3.3 office-, 1.1 phone-, and 0.4 home-contacts); 101662 urban contacts, 5.1/subjects (2.8 office-, 1.6 phone-, and 0.4 home-contacts). During 1988, 88.9% of the rural target population made contact. These data are comparable to data from other countries; the observed office and home contact rates were similar, but phone-calls were more frequent. Computer systems in family practice provide a feasible way to collect data on a regular basis for epidemiological purposes and for performance review.


Reasons for contact in family practice. An Icelandic multicentre study on content of practice.

To establish data on the patient's reasons for a contact, as a part of data on content of Icelandic family practice, a prospective practice audit was made of 16 Icelandic health centres with computerized contact data from 1 January to 31 December 1988. The study comprised 16 community health centres in Iceland and their target population, 12 rural and four urban. The reasons for contact in the study group are analysed. A total of 284348 reasons for contact were analysed; 36-39% were for symptoms and 44-50% were initiated by health professionals. The latter included renewal of prescriptions, which comprised 17-18% of all reasons for contact. Musculoskeletal symptoms were the most common symptomatic complaint, 6.6-7.3% of all reasons for contact. The five most often stated symptoms were: rash, cough, cold, lower limb symptoms, and fever. A "reason for contact" record increases the understanding of the patient's presenting complaint, as well as the patient's agenda in each contact. This record gives an opportunity to follow the presenting complaint in the continuous process of care i. e. reason for contact diagnosis, management, and follow-up. We are reminded that common things are common in family practice; nevertheless more research is needed to understand the process of care.


Organization of health care teams and the population's contacts with primary care.

The aim of the study to examine a six-year development of the panorama of contacts and diagnoses at Södra Sandby Health Centre, where care teams had been introduced, and then to compare this development with that of the rest of the Dalby primary care district, where there were no care teams. In Södra Sandby the number of contacts with general practitioners (GPs) increased between 1984 and 1989 by 8% more than expected from the increase in staff, while the number of contacts with district care (district nurses and assistant nurse) increased by 62% more than expected. The corresponding figures for Dalby were 1% and 34%, respectively. The total proportion of the population visiting GPs in Södra Sandby during 1989 was 54%, and in Dalby 58%. The corresponding figure for district care in Södra Sandby was 40%. The proportion of contacts for which no appointment was made in advance decreased in Södra Sandby from 45% in 1984 to 22% in 1989. The corresponding figures for Dalby were 61% and 64%. This study did not find any verification for the fear that the organization of care teams would lead to a reduction in the number of contacts, e.g. on account of the frequency of meetings and conferences. The nurses seemed to retain their independent role, with the population contacting them in their surgeries or the nurses visiting them at home.


Antenatal care in general practice. 1: A questionnaire as a clinical tool for collection of information on psychosocial conditions.

In pregnancy the woman's emotional sensitivity and also her receptiveness of emotional support increase. Antenatal care that is exclusively focused on somatic conditions may lead to ignorance of pregnant women's psychosocial problems, thus missing a chance of intervention. A psychosocial questionnaire, used as a clinical tool in history taking during the first two antenatal consultations, is described and evaluated. The purpose of the questionnaire was to elucidate the pregnant woman's psychosocial assets as well as problems. The information collected by means of this questionnaire is compared with the information on psychosocial conditions collected by means of the traditional antenatal care form. Screening for psychosocial conditions in pregnant women may reveal information about important life aspects that are not detected in the antenatal care form.


Antenatal care in general practice. 2: Components of clinical knowledge which indicate need for intervention in pregnancy.

In clinical work in general practice decisions are based on biomedical data as well as on clinical knowledge rarely analysed in research. In this study all accessible clinical knowledge was used by the doctor in an assessment of pregnant women's psychosocial conditions and needs for intervention during antenatal care. Components of clinical knowledge (verbal and non-verbal communication, background knowledge about the woman and her network, and the clinician's own feelings during consultation) are described and discussed. The analysis of the material showed that, when there was a discrepancy between the GP's assessment (clinical observations and background information) and the woman's own verbal description of her psychosocial situation, the GP gave precedence to the former. Different information sources seem to be closely linked. The doctor's own feelings and evaluations will influence the atmosphere in the consultation, and through this the quality of information collected.


Recurrent elderly fallers.

Factors associated with recurrent falling during a one-year period were analysed among elderly Finns (65 yrs and more) seeking medical treatment due to a fall. Recurrent falling in men was independently related to a lesser amount of depressive symptoms and to less severe injury due to the first fall. In women, recurrent falling was independently related to the non-occurrence of a fear of falling. Furthermore, recurrent falling, amount of daily movement, mental capacity, and falling during the previous year were related variables. Here the risk of recurrent falling was high among persons with poor mental capacity, who moved about a large amount daily, and who had had at least one accident during the previous year. In addition, there was an association between poor health and recurrent falling women. Demented women moving about daily, frail women, and incautious men and women seemed to be the main risk groups for repeated falling. What could general practitioners do to prevent repeated falls in the elderly? First, the overall health status and functional capacities of frail elderly women should be improved. Second, all elderly persons, especially those who have fallen, should be informed about how to minimize the risks of falls. Prevention is not easy among the demented population, however.


Sickness impact after stroke. A 3-year follow-up.

In order to study change in disability and sickness impact after stroke, 36 patients were followed during a period of three years. ADL-status (Activities of Daily Living) was assessed by means of Katz' ADL Index. Interviews according to the Sickness Impact Profile (SIP) were carried out 6-9 months and 3 years post-stroke. The results showed an increased sickness impact over time in physical as well as psychosocial aspects. Mobility and home management were the categories that deteriorated most. The highest sickness impact was found in home management, and recreation and pastimes activity. The SIP scores were strongly correlated to the level of ADL-dependence, although the ADL-status had not deteriorated between the two assessments. Subjective measures of disability together with objective measures are recommended for planning of long-term rehabilitation after stroke.


The influence of general practitioners' knowledge about their patients on the clinical decision-making process.

Continuity of care is claimed to be an important and integral part of general practice. A main result of continuity is the doctor's accumulated knowledge about his or her patients. The objective of the present study was to evaluate the modifying effects of this knowledge on the decision-making process that takes place in consultations, as experienced by practitioners. A representative sample of 133 Norwegian general practitioners evaluated a total of 3,918 of their own consultations. The main independent variable was the doctor's own subjectively evaluated knowledge about the patient's medical history, while the major outcome measures included the perceived influence of accumulated knowledge on the consultation process in general, and on the diagnostic and management decisions in particular. In two-thirds of all consultations, or in three out of four in which the doctor had previous knowledge about the patient, this knowledge was considered to be clinically useful. In more than one-third of all consultations with previously unknown patients, this lack of information was felt to be a hindrance. Among patients with new medical problems and when the doctor had prior knowledge about the patient, this knowledge was felt to have significantly more therapeutic than diagnostic impact. Accumulated knowledge was generally felt to be of most help in consultations due to psycho-social problems, and was of special diagnostic value in patients presenting new, unspecific problems such as fatigue, fever, and generalized pain. This study indicates that accumulated knowledge about the patient is felt by the general practitioners to play an important and integral part in their clinical decision-making process.


An algorithm for a selective use of throat swabs in the diagnosis of group A streptococcal pharyngo-tonsillitis in general practice.

A prospective evaluation was made of an algorithm for a selective use of throat swabs in patients with sore throat in general practice. The algorithm states that a throat swab should be obtained (a) in all children younger than 15 years; (b) in patients aged 15 years or more who have pain on swallowing and at least three of four signs (enlarged or hyperaemic tonsils; exudate; enlarged or tender angular lymph nodes; and a temperature > or = 38 degrees C); and (c) in adults aged 15-44 years with pain on swallowing and one or two of the four signs, but not both cough and coryza. Group A streptococci were found by laboratory culture in 30% of throat swabs from 1783 patients. Using these results as the reference, the algorithm was 95% sensitive and 26% specific, and assigned 80% of the patients to be swabbed. Its positive and negative predictive values in this setting were 36% and 92%, respectively. It is concluded that this algorithm may be useful in general practice.


Factors relating to the choice of antihypertensive and hypnotic drug treatment in old patients. A study of a sample of Norwegian general practitioners.

The aim of this study was to investigate factors relating to GPs' choices and opinions as regards the prescribing of antihypertensives and sedatives for old patients (75 years and above). The study was carried out by a postal questionnaire sent to all municipal GPs in Oslo (N = 114) and all other GPs who have a financial agreement with the municipality (N = 121). The response rate was 60%. Female and older doctors stated more often than male and younger doctors that they select diuretics rather than calcium antagonists and ACE-inhibitors as the first-choice antihypertensive drug. The choice of sleep medication showed a high degree of conformity, with triazolam as the predominant drug. A majority favoured drug formularies and treatment programmes. Female doctors were significantly more favourable to treatment programmes, compared with males.


Screening for diabetic retinopathy by general practitioners.

To assess the quality of screening for diabetic retinopathy by 19 general practitioners (GPs) using ophthalmoscopy, the GPs' performance was compared with the performance of ophthalmologists. The GPs had received special training in retinal examination. Direct ophthalmoscopy was performed after mydriasis of both eyes. Later, one of the ophthalmologists at the local hospital performed ophthalmoscopy in the same way as the GP. The ophthalmologist's diagnosis was used as the criterion for retinopathy. 252 NIDDM patients were analysed. The ophthalmologists found 23 cases of retinopathy, of which one patient was referred immediately for photocoagulation. The GPs diagnosed 12 and missed 11 of these 23 cases (false negatives): sensitivity 52%. In 37 of the 229 negative cases the GPs reported a retinopathy: specificity 84%. Of the 11 missed cases, 7 had stage I retinopathy and four showed more serious abnormalities (hard and soft exudates, macular oedema) Further training of GPs in the art of ophthalmoscopy is recommended.


Treatment of pelvic joint dysfunction in primary care--a controlled study.

The study evaluated the manual treatment of dysfunction of the pelvic joints. This is one of many condition causing low back pain. In 1987-1988 a general practitioner with special knowledge of physical examination and manual treatment of lumbar and pelvic dysfunctions made a survey of patients with acute or subacute low back pain as the main cause of the patient-to-doctor contact. Patients with defined criteria of pelvic joint dysfunction (n = 46) were randomized. After dropouts and exclusions, 18 patients with defined criteria of pelvic joint dysfunction received manual treatment, while 21 patients with similar dysfunction served as controls and received placebo treatment in a form of massage. Both groups were seen only once to evaluate whether a single treatment might be sufficient. After a period of three weeks, evaluation was made by an independent observer. Subjective pain measurement and a mobility test showed no significant difference. Sick-leave and consumption of analgesics (both decided by patient) were significantly less in the treatment group.


On the variation in conceptions among primary care physicians regarding hypercholesterolaemia: a phenomenographic analysis.

Twenty primary care physicians at 12 health centres in Sweden were interviewed in a semi-structured way. Analysis was conducted using a phenomenographic method. Concerning the general attitude towards cardiovascular disease (CVD), there were two categories of answers; (A) CVD is a big threat to public health, and the health care system should play an active role in treatment and prevention, and (B) CVD is a symptom of normal aging with little or no need for active health care intervention. Questions on the management of hypercholesterolaemia showed a general acceptance of diet and lifestyle alterations, with a marked reluctance to use drugs except in cases of hereditary hypercholesterolaemia. The physicians were positive to non-commercial information from official sources. Critical opinions existed, however, questioning the adequacy and applicability of the national expert recommendations. There was a general acknowledgement of the importance of patient information, whereas a lack in communication skills was expressed. The description of attitudes and conceptions can assist in the understanding of mechanism underlying physicians' behaviour and provide a base for future information programmes.


Computational aspects of analysing random effects/longitudinal models.

Random effects and longitudinal models are becoming increasingly popular in the analysis of many types of data, including medical and biopharmaceutical, because of their richness and flexibility. They can be, however, difficult to fit using traditional statistical tools. Fortunately, there now exists a burgeoning collection of newer computational methods that can be applied to draw inferences with such models. This review attempts to provide an introduction to some of these techniques by describing them as extensions of the EM algorithm, currently a standard tool for the analysis of longitudinal and random effects models. For clarity of exposition, the extensions are classified into three types: large-sample iterative; large-sample simulation, and small-sample simulation.


An overview of methods for the analysis of longitudinal data.

This paper reviews statistical methods for the analysis of discrete and continuous longitudinal data. The relative merits of longitudinal and cross-sectional studies are discussed. Three approaches, marginal, transition and random effects models, are presented with emphasis on the distinct interpretations of their coefficients in the discrete data case. We review generalized estimating equations for inferences about marginal models. The ideas are illustrated with analyses of a 2 x 2 crossover trial with binary responses and a randomized longitudinal study with a count outcome.


Evaluation of alternative statistical methods for linear model analysis to compare two treatments for 24-hour blood pressure response.

This paper evaluates alternative statistical methods for the analysis of 24-hour blood pressure data from a clinical trial which compares two treatments for hypertension. The primary objective of the study discussed here was to determine the time course for the blood pressure lowering effects of a test drug given once daily in the treatment of mild to moderate hypertension when compared with placebo. Thirty-five patients (24 on drug and 11 on placebo) were monitored for 24 hours at baseline and at two weeks post treatment, with diastolic blood pressure (DBP) measurements recorded at 22 time points within each 24-hour visit. The changes in DBP from baseline across the 22 time points are the response variables of interest. Various statistical methods for the assessment of treatment effects over the entire 24-hour dosing interval in a setting with small sample size are discussed and illustrated. The results from a special application of weighted least squares analysis of covariance, which employs a smoothed covariance matrix, support the hypothesis that a once daily dose of the drug significantly reduces DBP over the entire 24-hour dosing interval when compared with placebo. This method has the distinct advantage of enabling evaluation of treatment differences for the change in DBP from baseline at the 22 time points with the corresponding 22 baseline DBP as covariates simultaneously in a situation where the treatment group sample sizes are small.


[Aggressiveness of NSAIDs versus digestive system mucosa].

NSAID induced gastropathy is linked to the inhibition of endogenous synthesis of prostaglandins. Gastropathies are made of erythematous, erosive or ulcerative lesions. Their localization is mainly antral or prepyloric. Their incidence is quite large and very severe in the elderly patient treated for long time with NSAID. The author presents several strategies either to prevent (with administration of misoprostol) or to treat (with prescription of omeprazole) this iatrogenic gastropathy.


Methods for the analysis of informatively censored longitudinal data.

This paper describes the problem of informative censoring in longitudinal studies where the primary outcome is rate of change in a continuous variable. Standard approaches based on the linear random effects model are valid only when the data are missing in a non-ignorable fashion. Informative censoring, which is a special type of non-ignorably missing data, occurs when the probability of early termination is related to an individual subject's true rate of change. When present, informative censoring causes bias in standard likelihood-based analyses, as well as in weighted averages of individual least-squares slopes. This paper reviews several methods proposed by others for analysis of informatively censored longitudinal data, and outlines a new approach based on a log-normal survival model. Maximum likelihood estimates may be obtained via the EM algorithm. Advantages of this approach are that it allows general unbalanced data caused by staggered entry and unequally-timed visits, it utilizes all available data, including data from patients with only a single measurement, and it provides a unified method for estimating all model parameters. Issues related to study design when informative censoring may occur are also discussed.


The accelerated failure time model: a useful alternative to the Cox regression model in survival analysis.

For the past two decades the Cox proportional hazards model has been used extensively to examine the covariate effects on the hazard function for the failure time variable. On the other hand, the accelerated failure time model, which simply regresses the logarithm of the survival time over the covariates, has seldom been utilized in the analysis of censored survival data. In this article, we review some newly developed linear regression methods for analysing failure time observations. These procedures have sound theoretical justification and can be implemented with an efficient numerical method. The accelerated failure time model has an intuitive physical interpretation and would be a useful alternative to the Cox model in survival analysis.


[Current therapeutic approach in Parkinson disease].

Parkinson's disease is a neurodegenerative disorder characterized mainly by a loss of the dopaminergic neurons of the nigrostriatal pathway. The symptomatic treatment, which consists of the supply of the deficient neurotransmitter dopamine, does not, however, prevent the progression of the disease and is frequently associated with major motor and psychiatric side effects. Recent basic and clinical investigations have led to the development of new therapeutical strategies for Parkinson's disease. The authors review and describe these new approaches which include: [1] treatments aimed at slowing down the progression of the disease, [2] treatments aimed at decreasing the motor side effects and [3] the use of intracerebral transplantations.


[The concept of utility in decision strategies: application to diagnosis and treatment of renovascular hypertension].

To select a guideline in the management of diagnosis and treatment of renovascular hypertension, the clinician has to take into account many contradictory elements. He has to weight the invasive nature and the relative accuracy of the diagnostic tests, as well as the efficacy and drawbacks of medical and surgical treatments. The concept of utility in a decision making tree may lead to objective determination of best suited management for a given patient, according to the prior probability he had a renovascular hypertension.


An analysis of two-period crossover designs with carry-over effects.

The crossover design is a type of longitudinal study with subjects receiving different treatments in different time periods. When carry-over effects are absent, the usual crossover design is structured so that all the information about treatment effects is contained in the within-subject contrasts; standard analyses are based on these within-subject contrasts and ignore any between-subject information. With carry-over effects present these standard analyses can be very inefficient, especially for suboptimal designs. We describe alternative approaches based on methods for the analysis of longitudinal data.


[Interpreting hypereosinophilia].

The diagnosis of a blood hypereosinophilia requires a review of various disease processes such as blood dyscrasias, skin diseases, auto-immune diseases, asthma, parasitic infections, enteropathies, etc. A complete check-up including clinical, laboratory and radiological data allows the identification of an etiology in a majority of cases. Nevertheless, the etiology of hypereosinophilia remains obscure in some cases. Among these unexplained situations, the rare idiopathic hypereosinophilic syndrome requires special attention because of its fatal course due to cardiac involvement which can remain clinically silent for a long period of time. Therefore, the follow-up should include repeated echocardiograms. At the present time, the usual therapy for the most severe cases includes corticosteroids and hydroxyurea.


Non-linear models for the analysis of longitudinal data.

Given the importance of longitudinal studies in biomedical research, it is not surprising that considerable attention has been given to linear and generalized linear models for the analysis of longitudinal data. A great deal of attention has also been given to non-linear models for repeated measurements, particularly in the field of pharmacokinetics. In this article, a brief overview of non-linear models for the analysis of repeated measures is given. Particular emphasis is placed on mixed-effects non-linear models and on various estimation procedures proposed for such models. Several of these estimation procedures are compared via a simulation study. In addition, simulation is used to investigate the effects of model misspecification, particularly with respect to one's choice of random-effects. A relatively straightforward measure useful in selecting an appropriate set of random effects is investigated and found to perform reasonably well.


Random effects models with non-parametric priors.

We discuss the performance of non-parametric maximum likelihood (NPML) estimators for the distribution of a univariate random effect in the analysis of longitudinal data. For continuous data, we analyse generated and real data sets, and compare the NPML method to those that assume a Gaussian random effects distribution and to ordinary least squares. For binary outcomes we use generated data to study the moderate and large-sample performance of the NPML compared with a method based on a Gaussian random effect distribution in logistic regression. We find that estimated fixed effects are compatible for all approaches, but that appropriate standard errors for the NPML require adjusting the likelihood-based standard errors. We conclude that the non-parametric approach provides an attractive alternative to Gaussian-based methods, though additional evaluations are necessary before it can be recommended for general use.


Intentionally incomplete longitudinal designs: I. Methodology and comparison of some full span designs.

Longitudinal designs are important in medical research and in many other disciplines. Complete longitudinal studies, in which each subject is evaluated at each measurement occasion, are often very expensive and motivate a search for more efficient designs. Recently developed statistical methods foster the use of intentionally incomplete longitudinal designs that have the potential to be more efficient than complete designs. Mixed models provide appropriate data analysis tools. Fixed effect hypotheses can be tested via a recently developed test statistic, FH. An accurate approximation of the statistic's small sample non-central distribution makes power computations feasible. After reviewing some longitudinal design terminology and mixed model notation, this paper summarizes the computation of FH and approximate power from its non-central distribution. These methods are applied to obtain a large number of intentionally incomplete full-span designs that are more powerful and/or less costly alternatives to a complete design. The source of the greater efficiency of incomplete designs and potential fragility of incomplete designs to randomly missing data are discussed.


Graphs and stochastic relaxation for hierarchical Bayes modelling.

This expository paper describes two useful tools for the statistical analysis of processes that generate repeated measures and longitudinal data. The first tool is a graph for a visual description of dependency structures. The second tool is a stochastic relaxation method ('Gibbs sampling') for fitting hierarchical Bayes models. Graphs are concise and accessible summaries of stochastic models. Graphs aid communications between statistical and subject-matter scientists, during which formulations of scientific questions are modified. An uncluttered picture of the dependency structure of a model augments effectively its corresponding formulaic description. Stochastic relaxation is a computationally intense method that allows experimentation with broader classes of models than were previously thought feasible because of analytic intractability. Stochastic relaxation is intuitive and easily described to non-statisticians. Several sample graphs show how hierarchical Bayes models can use stochastic relaxation to obtain their fits. An example based on estimating drug shelf-life demonstrates some uses of graphs and stochastic relaxation compared with several frequentist growth curve analyses that use restricted maximum likelihood and generalized estimating equations approaches.


Multivariate methods for binary longitudinal data with heterogeneous correlation over time.

Clustered binary data occur frequently in biostatistical work. One particular application is in binary longitudinal data, where several visits are available for the same individual. Several approaches have been proposed for the analysis of clustered binary data. In Rosner, a polychotomous logistic regression model was proposed which is a generalization of the beta-binomial distribution and allows for person- and visit-specific covariates, while controlling for clustering effects. One assumption of this model is that all pairs of visits within an individual are equally correlated, which may be inappropriate if several visits are available over a long follow-up period. In this paper, this approach is extended to allow for heterogeneous correlation over time. The total time period is divided into subintervals and a beta-binomial mixture model is introduced to estimate odds ratios relating outcomes for pairs of visits both within a subinterval as well as in different subintervals. To include covariates, an extension of the polychotomous logistic regression model is proposed, which allows one to estimate effects of person-, subinterval-, and visit-specific covariates, while controlling for clustering using the beta-binomial mixture model. This model is applied to the analysis of respiratory symptom data in children collected over a 14-year period in East Boston, MA, in relation to maternal and child smoking, where the unit is the child and symptom history is divided into early-adolescent and late-adolescent symptom experience.


[Intrauterine device, the best method for spacing births in breastfeeding mothers].

Twenty-nine breastfeeding women, with a mean age of 36.5 years, were fitted with an IUD, Nova T or Multi load 375, at an average time of 3.6 months after delivery. Insertion at this time was easy, without dilatation, pain or bleeding. During a follow up of 18 months, the IUD has to be discontinued in one woman (3.4%) because of excessive menstrual bleeding, at a time when she was no more fully breastfeeding. The continuation rate was 96.56%, as compared to only 82% for a general population of 216 women fitted with IUD at the same period after delivery and followed up for the same period of time. The IUD is in our opinion the birthspacing method of choice for breastfeeding mothers.


[Prenatal diagnosis of trisomy 21: limits of chorionic villi sampling].

An analysis of the limits, risks and difficulties of interpreting trophocentesis leads to the conclusion that the method is effective and free from maternal risk. The unsuccessful cases and the "fetal losses" are however more numerous than for amniocentesis.


[The fate of very early premature babies. Mortality, morbidity and 2-year follow-up in a population of 96 very early premature babies].

The neonatal fate, and outcome at 2 years in a population of 96 premature babies born after no more than 28 weeks of amenorrhea is described. Mortality was directly influenced by the gestational age (< 26 WA = 52% vs. > or = 26 WA = 21.1%, p < 0.01) and the birth weight (< 1,000 g = 41.5% vs. > 1,000 g = 20%, p < 0.05). Two other factors with a harmful impact were identified: retarded growth (neonatal mortality doubled) and fetal multiplicity (increased fourfold). Investigation of the neonatal morbidity highlights the importance of respiratory, neurological and digestive problems. Assessment of the longer-term outcome has shown an 11.3 p. cent incidence of handicap. An estimation of the prognosis on the basis of gestational age is proposed.


[Clinical trial of lovastatin versus gemfibrozil in the treatment of primary hypercholesterolemia].

A randomized, double-blind, 12 weeks comparison of Lovastatin and Gemfibrozil in the treatment of patients with primary hypercholesterolemia was performed in 31 patients. After a placebo and diet period (4 weeks), they were assigned to either Lovastatin 20 mg nightly or Gemfibrozil 600 mg twice daily, if their total serum cholesterol was < 300 mg/dl, and to either Lovastatin 40 mg nightly or Gemfibrozil 600 mg/12 if it was > 300 mg/dl. In both cases, the Lovastatin dose was doubled after 6 weeks, if serum cholesterol remained > 200 mg/dl. The dose of Gemfibrozil kept constant. Lovastatin reduced serum cholesterol from 354 +/- 91 mg/dl to 253 +/- 62 mg/dl (p < 0.001), LDL-cholesterol from 277 +/- 104 to 192 +/- 71 mg/dl (p < 0.001) and serum triglyceride level from 125 +/- 66 a 84 +/- 41 mg/dl. The corresponding reductions achieved by Gemfibrozil were: 343 +/- 86 to 290 +/- 72 mg/dl (p < 0.01), 264 +/- 89 to 217 +/- 67 mg/dl (p < 0.05) and 152 +/- 84 to 89 +/- 41 mg/dl (p < 0.001), respectively. Lovastatin therapy caused a 30.6% reduction in total cholesterol level, while Gemfibrozil achieved a 19.47%. There were no significant changes in HDL-cholesterol. Patients had no serious or clinically significant adverse effects. The current data suggest that Lovastatin (an inhibitor of HMG-Coa reductase) may provide one important means for lipid-lowering therapy in patients with primary hypercholesterolemia.


[Uterine rupture due to placenta accreta at 28 weeks of pregnancy].

The authors report the case of uterine rupture occurring after 28 weeks of amenorrhea and related to placenta accreta and treated by means of hysterectomy. They stress the diagnostic problems and discuss possible conservative treatment.


[An unusual case of HELLP syndrome].

The Hellp's syndrome is a complication of gravidic hypertension which associates the microangiopathic hemolysis, the cytolytic hepatic anomalies and a thrombocytopenia. There are resemblences between the biologic and histologic forms of the thrombotic microangiopathy and Hellp's syndrome. In this publishing, we report one case of Hellp's syndrome which the particular character is that the hepatic and hemolytic biologic anomalies are still very discrete, where as the thrombopenia is deep; this led us to rediscuss about the authencity of Hellp's syndrome. A neurologic complication, particulary gravissim, is noticed in one case, it concerns the intracerebral hematoma with left deficiency syndrome.


[Natural history of minimal and occult breast cancers. Long term survival and mass screening].

It is commonly admitted that small breast cancer detection is usefull for mortality reduction. One must take care of both "lead time bias" and "length biased sampling". An aggressive screening could detect an increased number of prevalent cancers in young women. The annual screening of asymptomatic women could be modified in the future by some compromise strategies fixed on high risk women isolation.


[Laparoscopic surgery and CO2 laser: clinical evaluation of a system of transmission of the infraguide type].

The use of the CO2 laser in coelio-surgery is closely linked to the quality of the beam transmitted to the tissues. The development of infra-guided systems constitutes a major improvement compared to conventionally guided systems. These systems make it possible to convey an undeformed beam with no loss of power to their distal extremity. In addition, their narrow diameter, which corresponds to the trochars used in conventional coelio-surgical equipment, makes them easy to handle.


[The role of danazol in the treatment of benign mastopathies].

Benign mastopathy is defined as a non-cancerous lesion of the mammary gland, which may be dystrophic, tumoral or inflammatory. This makes clear the highly diverse nature and wide diversity of clinical forms. Borderline lesions constitute a risk factor for breast cancer.


[Sudden infant death: epidemiology].

Since 1985, in order to understand variations and factors related to the SIDS compared with the other causes of postneonatal deaths, several epidemiological studies have been carried out in France. The main results obtained so far are presented in this paper. The national rate of SIDS in France is estimated at 1.2 per 1,000 live births. The only specific risk factor for SIDS is age (2-4 months), though birthweight, prematurity and the younger age of the mother increase the probability of dying in the same manner as for accidental causes and all other postneonatal deaths. In addition we found discrepancies in the SIDS rates of babies according to the month of birth. The total probability of dying during the postneonatal period is lower in babies born during spring than in babies born during late summer or autumn. No significant differences were found in the DTP IPV immunization rates between SIDS and other causes of death or between SIDS and living controls.


[Sudden infant death: from the unexplained to the explained].

In France, 1,300 to 1,500 infants die suddenly each year. Are these deaths explained? Most clinicians agree that in more than two-thirds of the cases death cannot be formally explained by the clinical or paraclinical context or by the findings at post-mortem examination. These infants are the victims of the "sudden infant death syndrome." This syndrome consists of a transient abnormality in the maturation of the vegetative nervous system function, upon which are superimposed non-specific elements that facilitate or precipitate death. The lack of routine examination to detect this background explains why sudden infant deaths cannot be predicted in the majority of cases. Because there is no method sufficiently accurate to diagnose the abnormality of maturation, these deaths cannot for the moment be firmly ascribed to this abnormality.


[Suddenly dead infants].

The hospital management of infants who died suddenly has been facilitated in France by the ministerial note of 14 march 1986 which has made possible the development of the research in this field, with a multidisciplinary collaboration system co-ordinated by reference centers. The necropsic findings are variable, but in one out of three cases they establish a correlation between the lesions observed and the infant's death. Inflammatory lesions of the lung caused by infection, and aspiration of products from the digestive tract are particularly frequent. Necropsy is indispensable to confirm the diagnosis of unexplained sudden death and to exclude a malformation, especially when the parents wish to have another child.


[Malaise in infants].

Near-miss is the term used by English-speaking authors to define a sudden accident suggestive of imminent infant death. This is one of the most worrying problems, due to its frequency and its multiple possible causes, the most common of which are gastro-oesophageal reflux and vagal hypertonia. These accidents occur in the same age-group as the sudden infant death syndrome and in similar circumstances, even though they more often occur during waking. Near-miss therefore may constitute an abortive form of sudden infant death syndrome, which would make its study a good way for understanding the syndrome. Yet one should wait before making this assimilation as it might induce unwarranted medical procedures. The risk of recurrence (about 10%), sometimes lethal, exists, but is must be discussed after full investigation in search of a cause and a possible treatment. Electronic home monitoring is only one of the possible preventive measures; it must be decided upon and applied by a specialized medical team.


[Risks of sudden death in siblings].

The risk of sudden infant death among siblings has long been overestimated: in all epidemiological studies the risk of recurrence remains at 1% or below, thereby excluding a hereditary hazard. Compared with the general population, the risk is increased in only a small percentage of families which can be detected (familial gastrooesophageal reflux or vagal hyperreflexibility, psychosocial problems and, more rarely, hereditary pathology). In the vast majority of families the relative risk is not objectively augmented. In all cases counselling of the parents is necessary for them to accept a new child.


[Psychosocial aspects of sudden infant death].

Following the sudden death of an infant, the parents and the siblings, if any, go through a very severe crisis with repercussions on the psychoaffective and professional domain, as well as on social relations. The parents' mourning after a sudden infant death is very often morbid. The characteristics of this infantile death which predispose to a complicated mourning period are the parents' impossibility to anticipate and the lack of cause of the baby's death. One of the most adverse consequences of such a situation would be the birth of a subsequent child before mourning is completed, for this child might well be regarded as a replacement child, and this would jeopardize his future psychosocial development.


[Prevention advice for families].

SIDS is in most cases unforeseeable and unavoidable. However, present progress in knowledge about this syndrome allows practitioners to give preventive advice, for two types of infant: for all neonates--simple advice of infant care and hygiene--for some at risk babies (siblings of SIDS cases, ALTE, premature), advice on tests, or treatment or more specific medical care.


[Extrinsic allergic alveolitis in agricultural environment].

The term extrinsic allergic alveolitis involves a group of interstitial and alveolar lung diseases with an immunoallergic mechanism. These diseases are associated with chronic inhalation of usually organic particles and therefore encountered almost exclusively in an agricultural environment. The most frequent and best known of them is the farmer's lung disease and therefore is largely described by the authors. Specific points concerning pigeon breeder's disease and cheese worker's disease, are also reviewed since they are quite frequently observed in France. The diagnosis is difficult because the radiological and functional abnormalities are transient and the signs of immunization in serum and alveoles are unspecific. This problem is developed here, and a practical diagnostic approach is suggested. Treatment is essentially preventive and includes modifications of the working tools and work conditions in order to reduce exposure to airborne pathogenic antigens.


[Infectious risk in day-nursery children].

High proximity in daycare centers is a well established risk factor for upper respiratory tract infections as well as Haemophilus influenza meningitis. Many studies have also reported the development of gastroenteritis as well as hepatitis A outbreaks in daycare centers; however, because of lack of controls, these studies do not provide enough information about the excess of risk attributable to daycare attendance. Main risk factors such as age, or seasons, are still very important in daycare centers and studies have also shown that a protection occurs rapidly after the beginning of attendance, may be in relation to the stimulation of the non-specific immunity. All these results do not provide enough data to implement a rational intervention project. More studies have to be carried out to assess the long term consequences (at school age for instance) of these infections. In order to make a rational decision regarding daycare attendance, it is important to have a global assessment of all the effects related to attendance (which are numerous and sometimes opposite); studies focusing on a single aspect of daycare attendance, or on its short term effect, may result in partial and misleading conclusions.


Radiation risk estimation.

Estimation of the risk of cancer following exposure to ionizing radiation remains largely empirical, and the models used to adduce risk incorporate few, if any, of the advances in molecular biology of the past decade or so. These facts compromise the estimation of risk where the epidemiological data are weakest, namely, at low doses and dose rates. Without a better understanding of the molecular and cellular events ionizing radiation initiates or promotes, it seems unlikely that this situation will improve. Nor will the situation improve without further attention to the identification and quantitative estimation of the effects of those host and environmental factors that enhance or attenuate risk.


Nuclear installations and childhood cancer in the UK: mortality and incidence for 0-9-year-old children, 1971-1980.

Data on cancer incidence and mortality in the vicinity of nuclear installations in England and Wales have been published, covering the period 1959-1980. Several age classes and a number of cancer sites have been included. Systematic analysis has so far been limited to cancer mortality. This suggests that childhood leukemia is unusually frequent near some types of installations and the excess is greater for years 0-9 than for later ages. In the earlier decade, 1959-1969, there was questionable consistency of incidence reporting. This report uses the incidence and mortality data only for the period 1971-1980; leukemia and non-leukemia cancer data for those 0-9 years are analyzed, and consistency of incidence reporting is evaluated by comparing incidence and mortality. For comparison with reported data for grouped local authority areas (LAAs) near to 21 different installations, two sources of expected incidence are used. The first is based on regional data, and the second is based on a group of LAAs similar in location, urban/rural character and population size. Effectiveness of treatment of acute lymphocytic leukemia (ALL, the principal type among 0-9-year-old children) has improved in recent decades and this has decreased the case fatality rate, and increased the relevance of incidence data. No significant differences in the mortality/incidence ratio were found when comparing areas near installations with their matched reference areas. Although some standardized incidence ratios (SIRs) are low in comparison areas, these are a reflection of the small numbers in the denominator. Low and high SIRs are observed in both installation and comparison areas. Excluding the populations near Sellafield and Dounreay, the installations of which include nuclear reprocessing and which are reported elsewhere, children living near one of a group of six installations have significantly increased leukemia incidence. One hundred sixty-five cases were observed for the combined population group, whereas 133.6 were expected on the basis of regional data and 141.9 on the basis of comparison areas. The operations of these installations include nuclear research, nuclear fuel production, nuclear weapons manufacture, and radio-isotopic reagent manufacture and marketing. No evidence of any increase of leukemia incidence is found for populations surrounding nuclear power installations, nor in coastal communities possibly affected by Sellafield discharges.(ABSTRACT TRUNCATED AT 400 WORDS)


Trends in cancer mortality in Kanawha County, West Virginia, 1950-1984.

There has been much concern recently about possible adverse health effects related to exposure to toxic chemicals among residents of Kanawha County in southern West Virginia. An epidemiological study of trends in cancer mortality from 1950-1984 among the general population of Kanawha County in southern West Virginia was mounted. Cabell County, West Virginia was chosen to be a comparison county for Kanawha in addition to West Virginia and the total United States. The cancer mortality rates for white males and females were calculated using NCHS mortality data and Census Bureau population data available on the Mortality and Population Data System (MPDS) at the University of Pittsburgh. Mortality rates for cancer in Kanawha and Cabell Counties were evaluated over the time period 1950-1984 with an age-period-cohort (APC) analysis. In this analysis, poisson regression models were fit using the statistical program GLIM (Generalized Linear Models) to determine the separate effects of age, period of death, and birth cohort on the specific cancers of interest (lung, liver, bladder, CNS, leukemia, lympho-reticulosarcoma, all cancers). There were no significant county differences for cancer death rates between Kanawha and Cabell Counties except for leukemia among white males [O.R. = 1.27, 95% (C.I. = 1.03-1.6)], and for lympho-reticulosarcoma [O.R. = 1.66(1.24-2.07)], suggesting a possible occupational exposure. For leukemia, aleukemia, the effect observed seems to have declined. In contrast, the elevation of lympho-reticulosarcoma rates has remained in recent years (1970-1984).


Is NIDDM a risk factor for noise-induced hearing loss in an occupationally noise exposed cohort?

Little is known about what factors, other than chronic exposure to noise, predispose individuals to noise-induced hearing loss (NIHL). The current retrospective study was designed to identify risk factors for NIHL in a population of 229 men [age 55-68 (mean = 63 years)] employed at a metal assembly plant. All men had been chronically occupationally noise-exposed for approximately 30 years (> or = 89 dBA) with an average Ea noise emission level) of 104.5. The clinical examination included a pure-tone threshold audiometric evaluation, discrimination of speech in background noise [W-22 Max (> 60% indicating better hearing)], blood pressure measurement, evaluation of lifestyle (alcohol consumption, cigarette smoking, noisy hobbies) and occupational and military history. Severe NIHL was defined as > or = 65 db loss at 3, 4 or 6 kHz in at least one ear +/- 20 db threshold in the contralateral ear. History of non-insulin dependent diabetes mellitus (NIDDM) was reported by 16.4% of the 146 men with severe NIHL compared to 4.8% of the 83 men without severe NIHL (odds ratio = 3.9, C.I. 1.2-11.9, P = 0.05). Simultaneous evaluation of several potential risk factors using a multiple logistic regression indicates that the significant predictors of severe NIHL were diabetes (P < 0.05), Ea (P < 0.05) and age (P < 0.05). These results suggest that a person with NIDDM who is also occupationally noise-exposed is more likely to develop severe NIHL than those without NIDDM. Longitudinal studies are necessary to confirm the temporal relationship between NIDDM and NIHL and to determine the exact mechanisms that are involved with this increased risk of hearing loss.


Methodological problems in investigating disease clusters.

Increased reporting of disease clusters is stretching health department resources while failing to uncover many significant environmental hazards. By reviewing the methodology by which health departments respond to such reports, we argue that there is a strong bias against investigating the most hazardous situations. Failure to find serious hazards is more a reflection of the methodology used than an assessment of the existence of environmental problems. The biases arise from the selection of situations that dictate full in-house consideration, the selection of the methodology used to evaluate reported or registry-based data, and the interpretation given to anomalous observations. We argue for more rigorous evaluation of statistical cluster detection methods and for use of more objective criteria in cluster investigation protocols.


Clusters galore: insights about environmental clusters from probability theory.

The posterior probability of a causal explanation given that an environmental cancer cluster is statistically significant depends on the prior probability of an environmentally caused cluster, the sensitivity of the statistical test and its specificity. The prior probability is low, because it is rare to have enough carcinogen in the general environment to cause a relative risk of cancer high enough to achieve statistical significance in a small geographic area. The sensitivity and specificity are not great. The likelihood that a census tract escapes statistically significant elevations in all 80 types of cancer can be calculated. Many of the thousands of census tracts will, by chance alone, have at least one type of cancer whose elevation is statistically significant. Actual observation from a large cancer registry confirms this probabilistic prediction. Applying the principles of Bayes' Theorem would suggest that most statistically significant environmental cancer clusters are not due to environmental carcinogens. One would have to investigate hundreds of environmental cancer clusters to find one with a true environmental cause.


Childhood leukemia around nuclear facilities.

Epidemiologic studies on the health effects of living near nuclear facilities have been rare and, indeed, radiobiological models would not predict any detectable increase in cancer risk to the general public from the very low levels of radioactivity emitted by nuclear installations. Thus the recent evidence suggesting an excess of childhood leukemias in the vicinity of certain nuclear sites in the United Kingdom has generated considerable controversy. To help resolve the uncertainty and enhance interpretability of results, future epidemiologic studies will need to be designed with great care (and within realistic cost limits). This commentary suggests three areas for methodologic consideration: (i) definition and modelling of radiation exposure; (ii) selection of cancer sites and sensitive subgroups; and (iii) use of incidence or mortality data. Specific suggestions for further epidemiologic research are offered as well.


Priority among air pollution factors for preventing chronic obstructive pulmonary disease in Shanghai.

The problems that city environmental protection planners face are how important the air pollution exposures are in relation to chronic obstructive pulmonary disease (COPD) in local residents and which factor should be controlled most urgently. The purpose of our study is to determine the control priority among ambient sulphur dioxide (SO2) inhalable particulates (IP) and indoor use of coal to prevent COPD in residents of the city. Ambient air pollution is mainly from SO2 and IP(< 10 nm). Indoor air pollution is mainly from the use of coal for heating and/or cooking. Distribution of ambient SO2, and IP concentrations were described using a quartic trend surface simulation. When stratified by two extreme levels of ambient SO2 and IP and types of fuel used indoors, eight local area populations in four communities with different combinations of exposure levels were selected. In each community a local area population mostly using coal and one mostly burning gas was chosen. Chronic obstructive pulmonary diseases (COPD, ICD 490-493) including chronic bronchitis, asthma and emphysema, are a major cause of death in residents of Shanghai. The relationship between the three air pollution factors and their health effects were analyzed at the level of mortality (1978-1987, 232,459 person-years), prevalence of symptoms (12,037 persons) of COPD, lung function and non-specific immunologic function (514 women). The results show that indoor use of coal has stronger associations with health than estimated exposure to ambient SO2 or IP.


A 3-year cohort study on short-term effects of air pollution in Germany. 1. Influences of medication and season.

A 3-year cohort study which started in September 1987 investigates the effect of air pollution in adult patients with chronic obstructive airway disease. Of 108 patients recruited during the pilot phase in 1987 only eight patients had left the study prematurely. The most important components of the study are the daily peakflow measurements and a diary on medication and symptoms. In a preliminary analysis the influence of medication and season has been analyzed for the period September 1988 to June 1989 for 53 patients. In general, the reactions to seasonal changes were small. However, a significant decrease in peak-flow values by about 5% was found for the months of May and June compared to December for patients with chronic bronchitis, emphysema and asthma.


Associations between questionnaire reports of home dampness and childhood respiratory symptoms.

The relationship between home dampness and respiratory health was studied in two populations of children of 6-12 years old, living in the south east of the Netherlands. In one study, lung function was measured at the schools, and in both studies, information on respiratory symptoms was collected from a self-administered questionnaire completed by the parents of the children. Information on home dampness was collected by questionnaire. Information on other potential indoor determinants of respiratory health, like (sources of) nitrogen dioxide and smoking in the home was collected by questionnaire as well. Respiratory symptoms were found to be associated with home dampness. There was a weak, negative association between MMEF and reporting of mould in the home. Several potential biases were evaluated. It was not considered likely that the results could be explained by information, selection or confounding bias. However, further work is needed to conclusively exclude these biases, and to develop objective measures of home dampness for use in epidemiologic studies.


An overview of reports and current research concerning childhood leukaemia and cancer around nuclear installations in the UK.

Studies around UK nuclear installations suggest that it is possible that the incidence of leukaemia in young persons may be increased in the vicinity of such installations. However, the results of these studies are inconsistent and the cause or causes of the apparent increases are unknown; they may be at least in part attributable to chance variations in incidence, to selection factors, or to variations in completeness of recording. The cluster in Seascale, the village closest to the Sellafield reprocessing plant, may be the result of germ cell mutations in the fathers of the affected children.


An evaluation of the role of epidemiology in assessing current and future disinfection technologies for drinking water.

Six members of the International Society for Environmental Epidemiology provide a discussion of the presentations of the authors of six studies dealing with the potential chronic disease side effects of water disinfection. This symposium, which was jointly sponsored by the Society and the United States Environmental Protection Agency (EPA) also involved state epidemiologists and engineers from state drinking water programs. This article summarizes the results of the studies and the comments about them. There was a general consensus that the recent EPA sponsored studies of cancer endpoints have strengthened the evidence linking bladder cancer with long term exposure to chlorinated drinking water. The evidence for links with colon cancer is not convincing and that for serum lipid changes is quite weak. Any risks, if real, are low when compared to the risk of infection from not disinfecting water. This is particularly true for small water systems where chlorination may be the only practical option.


[Some references for Ilisarov transosseous osteosynthesis].

The advantages of secondary bone healing by callus formation--as seen in transosseous osteosynthesis--as against primary bone healing are discussed. With the Ilisarov technique, new callus and bone formation can be achieved under constant tension stress. Observations of the phenomenon of limb lengthening by callus distraction go back to Codivelli. A first apparatus for bone lengthening was described by Block as long ago as 1923. The tremendous merit of Ilisarov's work is based on fundamental research and clinical experience with investigation of the effects of tension stress on several sorts of tissue under different conditions.


[Treatment of femoral fracture with the Ilisarov fixator].

From July 1990 to December 1991, femoral fractures in seven patients were stabilized using the Ilisarov apparatus. Second-degree open communited fractures in four patients were stabilized primarily by this technique. Three other patients suffered from redislocations following internal fixation (n = 2) or a refracture (n = 1). The average duration of fixation in shaft fractures (n = 3) was 21 weeks, in supracondylar fractures (n = 4), 13.5 weeks. The fixation period we observed was thus shorter than that reported for other external fixation devices. Because of the complications that were noticed, however, the Ilisarov technique should only be used in particular cases.


[Ilisarov ring fixation and its technical application].

The Ilisarov ring fixator is an extremely versatile external fixation device. There is a wide range of indications for its use, e.g. fractures, pseudarthroses and non-unions, large defects, deformities and limb shortening. The device consists of rings or half-rings, which are connected to each other by threaded rods or plates and to the bone by wires under tension. This design allows neutral fixation, compression or distraction of the bone fragments. Because of its low axial stiffness at low loads and increased stiffness at higher loads, this fixator promotes osteogenesis and reduces strain on the tissues in functional treatment. Surgical intervention for its application is minimally invasive. This is a useful addition to the orthopaedic surgeon's armamentarium, providing proper attention is paid to preoperative planning, the principle rules of frame design and wire insertion technique, and postoperative management.


[Fracture treatment in the area of the tibia].

From May 1990 to March 1992 17 open and 6 closed fractures of tibia and fibula with second- to third-degree soft tissue injuries were treated by external fixation using the Ilisarov technique. In 14 patients this external fixation was used as the primary treatment. In nine cases it was used secondarily, mainly in patients transferred after stabilization with other internal or external devices. The mean duration of fixation for diaphyseal tibial fractures was 127 days and for metaphyseal fractures, 107 days. After removal of the fixation device, a brace was temporarily fitted for full weight-bearing. Disadvantages observed include less comfort for the patient and longer operation time compared to other external fixation systems. On the other hand, this method allows full weight-bearing soon after the operation and involves minimal damage of soft tissue. Furthermore, injured soft tissue was well protected during healing.


[Treatment of calcaneus and mid-foot fractures using closed reposition and fixation with the Ilisarov fixator].

Sixteen fractures of the calcaneus involving the subtalar joint were treated by closed reduction and external fixation using the Ilisarov apparatus. Except for four cases in which temporary arthrodesis of the subtalar or ankle joint was used, fixation was usually only used for the calcaneus. The operative technique is described precisely. Initial follow-up examinations (on average after 1 year) show advantages over conservative treatment, e.g. better anatomical reduction. In addition, early mobilization of the joint and early weight-bearing result in less pain from disuse osteoporosis. Furthermore, several case reports demonstrate the efficiency of this method in tarsal and metatarsal fracture-dislocations.


[Initial experiences with the Ilisarov method on the hand bones].

From 1 July 1991 to 1 July 1992, 23 patients were treated using an Ilisarov distraction apparatus. The apparatus was used for callus distraction in 13 patients, and for closed fracture treatment, for generating longitudinal pressure in the treatment of fractures, for corrective osteotomy and for soft tissue distraction in 10 patients. Callus distraction in the hand has advantages over conventional techniques. Furthermore, the Ilisarov technique has its merits in certain fractures of the hand.


[Treatment of post-traumatic limb shortening].

The physiological phenomenon of changes in callus formation during distraction was first described by Codivilla at the beginning of this century. Having investigated and proved the influence of tension stress on callus formation, Ilizarov used this as a method to treat limb shortening and deformities. Because of his remarkable results we introduced this method in our hospital in 1990, using the original Ilizarov ring fixator. From November 1990 to December 1991, we used this technique in 10 cases of combined post-traumatic bone shortening with deformity (the tibia was affected in six patients, the femur in three and the forearm in one). The mean shortening was 3.1 cm, the mean varus or valgus deformity 9.5 degrees, the mean anteflexion or recurvation 8.3 degrees, and the mean rotation deformity 8.5 degrees. Distraction/correction lasted between 8 and 55 days (mean: 37 days). Fixation was necessary for between 60 and 339 days. If corticotomy was performed in the diaphyseal bone, fixation lasted almost twice as long (11.33 days/mm lengthening) as in the metaphyseal area (6.55 days/mm lengthening). There were 14 complications, most of which were considered minor. The latter included pin infections (4), wire breaking (1) and restricted range of motion of the knee or ankle (5). Among the major complications were two nerve irritations, which recovered spontaneously, and two pin-induced local bone infections, which required surgical intervention. Achievement of the goals of treatment-complete correction of shortening and deformity-was not affected by these complications.


[Treatment of aseptic post-traumatic pseudarthrosis].

We report our first experience of using the Ilisarov technique in the treatment of ten patients with aseptic nonunions of fractures. In nine cases there was a nonunion of the tibia. One 76-year-old woman suffered from a nonunion of a supracondylar fracture of the humerus with concomitant rheumatoid arthritis. In this case, treatment failed. In two other cases we had to change the procedure. The mean duration of fixation for the successful cases was 22 weeks. The Ilisarov technique is sophisticated and needs special experience but has advantages in difficult cases.


[Treatment of chronic joint malposition].

We report three cases of chronically dislocated joints of the lower extremities that were treated by the Ilisarov method. As the results show, it is possible to reduce such dislocations step by step, causing less operative trauma.


[Treatment of chronic osteitis of the femur].

Since May 1990, we have treated seven patients with chronic osteomyelitis of the femur. The Ilisarov apparatus was used in three of these cases for fixation and in four cases for segment transport. The treatment of four patients is now complete. We have not found any problems in bone regeneration. The use of pins in the proximal and middle thirds of the femur has proved problematic due to the soft tissue damage. Instead of this, we recommend using Schanz screws, which can be fixed to the arch with the AO lock. Moreover, it is easier to shorten the 180 degrees arch to 90 degrees or 120 degrees using the Schanz screws. To prevent problems, it is better to assemble the apparatus before use and to take into consideration the anatomical and functional situation.


[Treatment of chronic osteitis of the tibia].

Since the beginning of May 1990, we have been using the original Ilisarov apparatus in our treatment of osteomyelitis. It has been used both statically and dynamically after corticotomy for segment transport and lengthening. So far we have treated 24 patients, of whom 13 had defect osteomyelitis, 9 had unstable infections and 2 had stable osteomyelitis with deformities. On average the bone defects measured 7.6 cm, and nine patients had soft tissue defects larger than 6 cm2. The Ilisarov apparatus performed a holding function in seven cases after defect grafting using autogeneic spongiosa. It was used in four cases for gradual compression, in seven cases for segment or fragment transport, in three cases for secondary lengthening and in three cases for correction. In all cases the infections were eliminated and stability was obtained. The duration of segment transport corresponded to the defect size, with a daily lengthening of approximately 1 mm. The fixation times ranged from 112 to 483 days (mean: 240 days). Apart from one special situation, no bone regeneration problems were observed. Some of the complications we encountered must be regarded as beginners' mistakes. We observed problems with segment transport (early corticotomy healing, deformity, non-union at the docking site) and problems with equipment, which has now been improved. For closure of the soft tissue defects it was sufficient to use mesh grafting. Its versatility and advantages as a stabilizing apparatus have made the Ilisarov fixator the instrument of our choice, especially in the treatment of circular infected defects larger than 3 cm.


[Patient positioning, everyday aids and principles of physical therapy in patients with Ilisarov ring fixator apparatus].

Directions for postoperative positioning of patients with the Ilisarov apparatus are given and devices to assist in everyday activities are introduced. Physiotherapy, especially with regard to mobilization, strengthening and training in function and movement, is described.


[Biomechanics of the ring fixator--contributions of individual structural elements].

The mechanical behaviour of the circular external fixation device using thin, pre-tensioned wires is difficult to predict, because the individual elements, such as rings, rods and wires, can be assembled in a large variety of configurations. This behaviour is of particular importance in the treatment of large segmental defects and in bone lengthening, because most of the load is transmitted through the fixator. In this study, the mathematical basis of the widely varying definitions of stiffness under axial, bending and torsional loads is presented. The principal variables influencing a particular configuration and their effects are indicated. Particular consideration must be given to the fact that the wires under tension generate a non-linear behaviour of the frame. The information needed for reporting on different fixator systems is indicated. Finally, the effect of individual structural elements, such as number, direction and tension of the wires, number of threaded rods and distance between the planes of the rings on the different stiffnesses, is presented and discussed with respect to clinical significance.


[In vivo measurements of electric potentials of the Ilisarov external fixator].

Ilisarov's idea that electrical phenomena could contribute to the efficacy of the ring fixation apparatus prompted us to carry out this preliminary investigation. Patients with lower leg fractures and a four-ring fixation apparatus were selected; the electrical potentials were measured over non-fractured and fractured bones. Patients who could not be studied in the Faraday box were subjected to great disturbances, caused by mains voltage and a neighbouring transmitter; in these cases no objective results could be obtained. Only measurements in the Faraday box yielded reproducible results. The results demonstrate that there is generally a difference in electrical potential among the four rings in patients fitted with an Ilisarov apparatus. Furthermore, weight-bearing on the fixator-bone system causes changes in the electrical potential among the rings.


[Initial modifications of the ring fixator apparatus].

To increase the practicability of Ilisarov's ring fixation apparatus, we introduced the following modifications: Clamping of the fixation wires using a quick collet with a force indicator, which enables reproducibly preuse and rapid clamping. Hardened screws to maintain the tension longer. Production of the olive wire from homogeneous implant steel by the cold-press method. Optimization of the cutting edge at the wire tip. Measurement of tension in the fixation wire. A distractor incorporating a clock and a device showing the distraction achieved so that doctor and patient can better supervise the distraction procedure. Simplifications of the wound dressing.


[An unusual example of primary weight bearing stability of a limb fracture of the oryx antelope after external fixation with the original Ilisarov fixator].

This paper reports the stabilization of an open comminuted fracture of the metatarsus of a rare white Arabian oryx using an original Ilisarov-fixator. The antelope (weighing 75 kg!) walked with its full weight on the stabilized leg immediately after operative treatment, thus demonstrating the high degree of stability of such a system. In our opinion, the Ilisarow technique is, in selected cases, an adequate method for stabilizing highly unstable open fractures in veterinary practice.


[The effect of bleeding on blood alcohol levels in an experimental model].

There are factors changing kinetics of alcohol turnover in comparison to widely accepted norm comprise e.g. effect of stomach contents on resorption of ethanol, activity of ethanol metabolizing enzyme systems, and hydration of organism (blood volume). One of possible factors--effect of bleeding on alcohol blood level--was studied in rats. Blood alcohol levels were significantly higher in a group of rats where bleeding is one hour after ethanol administration than in a group with bleeding before ethanol administration, and than in controls devoid of bleeding. That's question, this results may be applicable to man.


[Cantharidin and its detection in forensic toxicology].

Experimental detection of deadly toxic cantharidin C10H12O4 by chemical analysis was performed in imagoes of two species of cryptotoxic Meloidae beetles--Lytta vesicatoria and Mylabris variabilis. Samples were processed by extraction and sublimation and analyzed by gas chromatography. Graphic documentation proved the presence of cantharidin. A part of microcristalline sublimate was studied microscopically and determinant features of crystalline cantharidin were identified. Moreover, cantharidin levels in single body parts of the beetle were investigated.


[Tetramethyldiaminodiphenylmethane--a universal reagent for drug detection].

Many a drug was identified by thin layer chromatography when using tetramethyldiaminodiphenylmethan (TDM) as a universal reagent subsequently to chlorination. This non-carcinogenic compound yields a characteristical tint with all the drugs and their metabolites.


[Urinary diversion by means of uretero-ileostomy. Long-term results].

The authors analyze a group of 187 patients where in 1969-1991 a ureteroileostomy was performed on account of malignant tumours (89.8%) or other diseases (10.2%). Ureteroileostomy was indicated along with cystectomy in 77 patients with tumours of the urinary bladder (63 times), with gynaecological carcinoma (21 times) and in tumours of the urethra and rectum (7 times). Indications in non-tumours diseases comprised a neurogenic bladder (10 times) exstrophy of the urinary bladder (6 times), post-traumatic incontinence of urine in women (twice) and iatrogenic injuries of the ureters (once). In all patients an anastomosis between the ureter and excluded loop, as described by Wallace, was used. The surgical mortality was 5.3%. During the immediate postoperative period 96 complications developed in 91 (51.3%) patients. As to late complications, most frequently complications of the stoma of the excluded loop were involved. Ureteroileostomy gives satisfactory results in the majority of patients, however, the number of complications is not negligible. The authors discuss the selection of derivation methods under our conditions.


[Complications of continent urinary diversion].

Continent urinary diversion over its advantages, in comparison with incontinent urinary diversion, has serious complications. The authors analyse results and complications, which they registered in 26 patients 10-50 (average 20) months after supravesical continent urinary diversion. The commonest complications were in connection with the continent mechanism, these lead in 8 patients to urinary incontinence. Other serious complications were reservoir perforation during catheterisation in 3 and development of stones in the reservoir in 2 patients. All these major complications necessitated reoperation.


[Advantage of conversion of a uretero-ileostomy to a continent reservoir].

The authors refer their own experience in conversion of incontinent urinary diversion to a continent one. In 6 patients with ureteroileostomy they constructed continent reservoir. Reservoirs were formed from isolated ileocecal segment of the intestine together with the previous ileal loop. Continence was ensured by construction of a valve by method of ileal intussusception. After operation patients were followed-up clinically, biochemically and urodynamically, their subjective feelings and objective findings were analysed. Serious early or late complications were not registered during follow-up.


[An uncommon cause of testalgia].

Ten men aged 30-55 years suffered for many years from unilateral testalgia without subjective vertebrogenic complaints, and comprehensive urological examination did not reveal the cause of pain. Detailed functional examination of the spine revealed in all patients homolateral blocks of the Th-L transition, in nine men spasms of the musculus psoas, in five moreover a block of the SI synchondrosis on the same side. After a single or repeated release of the block the testalgias receded.


[A single-stage reconstruction in hypospadias using a vascularized preputial flap].

The authors submit an account of their experience with a modern method of reconstruction of hypospadias connected with the chorda. In 31 boys (10 months to 15 years) they used for reconstruction of the urethra a flap from the prepuce with a preserved vascular stalk, as described by Duckett. In the majority they transferred a double flap ("double face") where the outer sheath of the prepuce was used to cover the ventral side of the penis. In three boys the authors performed their own modification of this plastic operation. Complications developed in 12 boys (38.7%): stricture of the proximal anastomosis of the urethra (6), stricture of the meatus (1), necrosis of the skin cover (4), dehiscence (1). An open operation had to be made in the last five patients (16.1%). In all children excellent functional and aesthetic results were achieved. The above plastic operation is indicated in penile and penoscrotal hypospadias with chorda. It is a single stage operation. Due to the use of vascularized tissue and the microsurgical technique it is possible to perform a definite reconstruction of the external genitalia already by the age of one year.


[Drug-induced urolithiasis caused by N4-acetylsulfamethoxazole (Biseptol) and oxolinic acid (Desurol)].

The authors describe rare types of drug-induced urolithiasis in two female patients (N4-acetylsulfamethoxazole--a Biseptol metabolite and oxolinic acid--Desurol). To improve the diagnosis of drug induced urolithiasis the authors recommend a combination of microscopic methods and infrared spectroscopy. They findings are documented by photographs and infrared absorption spectra.


[Cystic lesions of the prostate--diagnosis, therapy and clinical significance].

The authors present an account of results of examinations in 162 patients with cancer of the prostate, benign hyperplasia of the prostate, inflammatory diseases of the prostate and patients with a normal finding on palpation of the prostate. The patients were subjected to clinical, laboratory, histopathological and transrectal ultrasonography of the prostate. In one patient a CT examination of the prostate was made. In the group were seven patients with cystic prostate lesions (4.3%). In the group of patients with inflammatory diseases of the prostate they observed cystic changes in five patients (14.2%). The most important group was formed by two patients with abscesses of the prostate and one patient with an ascended utriculus prostaticus. Transrectal ultrasonography of the prostate was the supreme method for the diagnosis of cystic prostate lesions.


[Ureteroscopy in the treatment of ureterolithiasis].

After establishment of endourological methods at our University Urological Department we have treated 36 ureteral stones in 34 patients since January 91 until April 92. Through retrograde (23) and antegrade (13) access we have successfully treated almost all calculi with the exception of one (where we hadn't been able to pass through reimplanted ureteral orificium). We have introduced double J stent in 90% patients after procedure and discharged them 3 days postoperatively on average. We have had no serious complication. Ureteroscopy with stone disintegration possibility has enabled us almost to leave open surgery in those cases, lower morbidity and shorten time spent in the hospital significantly.


[Seminal vesical abscess-diagnosis and therapy].

The authors present case-histories of two patients with abscesses of the seminal vesicles. They emphasize the asset of transrectal ultrasonographic examination for the early diagnosis of an abscess of the seminal vesicles. Antibiotic therapy, puncture of the seminal vesicles and evacuation of pus proved effective therapeutic methods.