Normal pulmonary venous flow characteristics as assessed by transesophageal pulsed Doppler echocardiography.

Twenty-seven subjects without apparent cardiac abnormalities underwent transesophageal echocardiography to evaluate normal Doppler characteristics of pulmonary venous flow. In particular, the effects of normal respiration and straining during the Valsalva maneuver were analyzed. Pulmonary venous flow during systole consisted of one forward flow wave in 15 cases (56%) and of two forward flow waves in 12 cases (44%). In all instances one forward flow wave was seen during early diastole and in 23 subjects (85%) a retrograde wave related to atrial contraction was present. Maximal velocity during systole was 57 +/- 13 cm/sec (mean +/- SD), during early diastole was 58 +/- 19 cm/sec, and during late diastole was 16 +/- 9 cm/sec. Velocity time integral during systole was significantly higher than during early diastole (11.8 +/- 4.9 vs 9.5 +/- 3.9 cm, p < 0.05), while velocity time integral during late diastole was 1.1 +/- 0.7 cm. During normal inspiration both early diastolic velocity and velocity time integral significantly decreased from 59 +/- 15 to 54 +/- 15 cm/sec (p < 0.01) and from 9.5 +/- 3.9 to 8.5 +/- 4.2 cm (p < 0.05), respectively. During normal expiration, systolic and early diastolic velocity time integral significantly increased, from 11.0 +/- 4.1 to 11.8 +/- 4.5 cm (p < 0.001) and from 9.5 +/- 3.9 to 10.1 +/- 4.3 cm (p < 0.05), respectively. Although statistically significant, the differences were small and do not seem of clinical importance. Straining during the Valsalva maneuver, however, obviously decreased pulmonary venous flow velocities. Systolic and early diastolic velocity decreased from 57 +/- 15 to 32 +/- 10 cm/sec and from 59 +/- 18 to 34 +/- 15 cm/sec, respectively, while velocity time integral during systole, early, and late diastole decreased from 12.0 +/- 5.6 to 4.3 +/- 2.6 cm, from 9.9 +/- 4.4 to 5.2 +/- 3.7 cm, and from 1.3 +/- 0.8 to 0.8 +/- 0.7 cm, respectively. In conclusion, pulmonary venous Doppler characteristics can adequately be analyzed with transesophageal echocardiography. Normal respiration only minimally influences pulmonary venous flow velocities in contrast to straining during the Valsalva maneuver; this should be considered when these variables are applied for clinical purposes.


Doppler evaluation of normalized peak filling rate in normal children and children with left ventricular outflow obstruction.

To evaluate the early diastolic peak filling rate of the left ventricle, three groups of children (normal children, patients with aortic valvular stenosis, and patients with aortic coarctation) were examined with the peak filling rate normalized to stroke volume calculated from the mitral valve inflow Doppler recording as the peak E velocity divided by the velocity time integral. The normal value for this index in children was 6.78 +/- 0.99 SV/sec and did not vary with age, weight, body surface area, or heart rate. Compared with normal subjects, both patients with aortic stenosis and patients with coarctation had increased left ventricular mass, but patients with aortic stenosis had decreased normalized peak filling rates (5.3 +/- 0.84 SV/sec, p < 0.01), while patients with coarctation had normal rates (6.79 +/- 0.98 SV/sec, p = 0.97). Compared with patients with aortic coarctation, patients with aortic stenosis had higher Doppler gradients. Thus the Doppler index of peak filling rate normalized to stroke volume is particularly useful in children because it is independent of heart rate, age, weight, and body surface area. Patients with coarctation may have normal peak filling rates normalized to stroke volume despite increased left ventricular mass because of milder obstruction or better coronary artery perfusion compared with that of patients with aortic stenosis.


Demographic prognostic factors in breast cancer.

The aim of this study was to assess the prognostic influence of the month of treatment, the year of treatment, and the patient's age at diagnosis of breast cancer in comparison with clinical and histopathological prognostic factors. This retrospective analysis from the years 1968-1990 at one university hospital in a rural area in Eastern Finland included 688 patients with invasive breast cancer followed up for more than 12 years. The breast tumours diagnosed in September and in October were larger, had distant metastases more often and, accordingly, had a worse prognosis than the tumours diagnosed during the rest of the year. The prognosis of breast tumours improved during the study period whereas the patient's age was inversely related to prognosis. The histopathological characteristics of breast tumours were not related to the month of treatment. The tumours were histologically more atypical and smaller in size, and the patients were older at diagnosis in the 1990's than in the 1980's. In conclusion, the month of treatment, the year of treatment, and the patient's age were found to be independent prognostic predictors in breast cancer, acting as confounders in survival analyses based on the biological prognostic factors.


Doppler assessment of left ventricular diastolic function: a review.

Two-dimensional echocardiography provides valuable information for the assessment of left ventricular function. Traditionally, evaluation has focused on determination of systolic performance. However, recent investigations indicate diastolic dysfunction may also contribute to symptoms of congestive heart failure in many patients despite normal systolic function. Pulsed Doppler echocardiography complements two-dimensional imaging for assessment of left ventricular filling properties that are often altered in the setting of diastolic dysfunction. The concept of diastolic function and recognition of abnormal filling patterns detected by pulsed Doppler echocardiography are reviewed.


Does inferior vena cava size predict right atrial pressures in patients receiving mechanical ventilation?

The inferior vena cava diameter and its respiratory response are used to estimate right atrial pressures in spontaneously breathing patients but its value in patients receiving mechanical ventilation is unvalidated. Forty-nine patients undergoing mechanical ventilation were prospectively evaluated in the intensive or coronary care units with two-dimensional echocardiography of the inferior vena cava and simultaneous measurements of mean right atrial pressures by central venous or pulmonary artery catheter. Correlation between inferior vena cava diameter at expiration and mean right atrial pressure was only 0.58. The correlation between inspiratory change in inferior vena cava diameter and mean right atrial pressure was poor (r = 0.13). Despite these correlations, an inferior vena cava diameter of < or = 12 mm predicted a right atrial pressure of 10 mm Hg or less 100% of the time, but sensitivity was only 25%. An inferior vena cava diameter > 12 mm had no predictive value for right atrial pressure.


Anxiety and depression in breast cancer patients at start of adjuvant radiotherapy. Relations to age and type of surgery.

Using a self-report questionnaire, the Hospital Anxiety and Depression (HAD) scale, feelings of anxiety and depression were assessed in 133 breast cancer patients referred for adjuvant radiotherapy following surgical treatment. Eighteen patients (14%) had scores indicating morbid anxiety. Significant depression was recorded for only 2 patients (1.5%). Severe anxiety was recorded for 10 out of 54 mastectomized patients (19%) and for 8 out of 79 patients treated with breast conserving surgery (10%). The difference was not significant (p = 0.13). In a subgroup aged 50-59 years, morbid anxiety was significantly more common among mastectomized patients than among patients operated conservatively, 4 out of 9 (44%) vs. 1 out of 23 (4%) (p = 0.01). Such a pattern was not discernable in the patients < 50 years of age or those > or = 60 years old. The results suggest that, at start of adjuvant radiotherapy, emotional distress is characterized by anxiety rather than depression and the risk of morbid anxiety is especially large for mastectomized women in their fifties.


Lymph node metastases in the neck from unknown primary tumour.

During a 12-year period a total of 203 patients were referred to the oncologic center of Odense with lymph node metastases in the neck. Routine examinations on admission failed to detect the primary tumour in 37 patients. During follow-up, the primary was revealed in 18 of these patients, and in a further 8 cases it was found at autopsy. The primary was most often located in the head and neck region with a possibility of curative therapy. Patients with small neck node metastases responded well to treatment with neck dissection and radiotherapy, resulting in a 5-year crude survival rate of 53%.


Transesophageal echocardiographic recognition of a fistula between a coronary artery and the left atrium.

A 58-year-old woman with a prosthetic mitral valve and an anomalous single coronary artery received transesophageal echocardiography and was found to have a coronary artery--to--left atrium fistula. Because of its superior imaging quality, transesophageal color Doppler method is a useful diagnostic procedure.


A comparison of flow convergence with other transthoracic echocardiographic indexes of prosthetic mitral regurgitation.

Prosthetic shadowing of the left atrium may prevent detection of mitral regurgitation during transthoracic echocardiography. In 60 patients with mitral valves, Carpentier-Edwards (n = 20), St. Jude (n = 22), and cage-ball (n = 18), we blindly evaluated the accuracy of three transthoracic Doppler signs of significant (> 2+) mitral regurgitation: (1) color Doppler flow convergence, (2) a color Doppler jet of significant regurgitation in the left atrium, and (3) an intense continuous wave Doppler signal. All 60 patients had transesophageal echocardiography, 26 had cardiac catheterization, and 28 had surgery. The sensitivity and specificity of flow convergence for significant regurgitation by transesophageal echocardiography was 73% and 70%, respectively, compared with 33% and 93% for left atrial color Doppler, and 15% and 97% for continuous wave Doppler. The sensitivity of flow convergence in Carpentier-Edwards, St. Jude, and cage-ball valves was 80%, 73%, and 67%, respectively; whereas the sensitivity of left atrial color Doppler was 70%, 27%, and 0%, and the sensitivity of continuous wave Doppler was 33%, 0%, and 13%. Flow convergence was the only sign of significant regurgitation in 12 of 30 patients (40%); 10 of these patients had mechanical valves. We conclude flow convergence is a more sensitive, though less specific, predictor of significant mitral regurgitation than color Doppler, spatial mapping of the left atrium, and continuous wave Doppler, especially when a mechanical valve is present.


A contribution to the comparison of the efficacy of radiotherapeutic procedures in cervical carcinoma.

This paper presents a new method in which the regression velocity of cervical carcinoma is measured by computer tomography and the results evaluated by two statistical methods: non-linear regression analysis and survival analysis. By means of this approach it was possible to compare the early effect of therapy in patients treated with intracavitary application of 226Ra plus external radiotherapy with those treated with 252Cf, 226Ra and extended radiotherapy. In the latter group a higher efficacy of the therapy was demonstrated by both statistical methods. As the timing between external and intracavitary radiotherapy was different in the two groups and as 252Cf contributed to a rather small part of the total radiation dose it could not be concluded that the difference in efficacy really was due to 252Cf. Of essential interest was, however, that an obvious difference in efficacy could be found between two slightly different treatment techniques. The statistical procedure called survival analysis, used here parallelly with weighed regression analysis seemed to give better results than a classical regression analysis and can thus be recommended for processing of clinical data of the type which is discussed in this paper.


Unruptured sinus of valsalva aneurysm and bicuspid aortic valve with aortic cusp perforation: detection by color flow Doppler mapping.

Congestive heart failure developed in a 53-year-old man with a history of bicuspid aortic valve, angina, and pericarditis. Two-dimensional echocardiography showed a sinus of Valsalva aneurysm related to the anterior coronary sinus and color flow mapping identified a perforation of the anterior aortic cusp. These findings were confirmed during surgery.


Radiation protection of male fertility in mouse and rat by a combination of 5-hydroxy-L-tryptophan and a thiol compound (AET).

Sperm abnormalities and fall in total sperm count following different doses (4 Gy, 5 Gy and 6 Gy) of whole body gamma irradiation (WBGR) were studied in adult male Swiss strain A mice. The protecting ability of a combination of 5-hydroxy-L-tryptophan (5-HTP, 100 mg/kg) and 2-aminoethyl isothiuronium bromide hydrobromide (AET, 20 mg/kg) was also investigated. Pretreatment with a 5-HTP+AET formulation i.p., 30 min before irradiation modified the fall in sperm counts significantly. Exposures to 4 Gy, 5 Gy and 6 Gy WBGR caused marked increase of sperm abnormalities which could be significantly reduced by pretreatment with 5-HTP-AET. WBGR with 4 Gy, 5 Gy and 6 Gy produced a short period of sterility associated with oligospermia but these abnormalities were corrected by pretreatment with 5-HTP+AET. This finding was supported by breeding experiments in pretreated adult male Sprague-Dawley rats which showed delivery of normal offsprings in drug-protected irradiated groups in contrast to irradiated controls.


Urination frequency and cystic pressure resistance after fractionated whole or partial irradiation of the rabbit urinary bladder.

Urination frequency and cystic pressure resistance have been used as end-points to assess x-ray-induced changes of bladder function. Whole or half bladders of adult male rabbits were irradiated, caudally or cranially. The absorbed dose was 33 Gy, 36 Gy or 39 Gy, given in 5 daily fractions. Animals which received a whole bladder dose of 39 Gy or 36 Gy showed increased urination frequency and enhanced bladder pressure resistance during the whole follow-up time of 100 weeks, compared with the sham-irradiated controls. At half bladder irradiation, only the highest doses (39 Gy to the cranial part of the bladder and 39 Gy or 36 Gy to the caudal part) gave rise to a slight increase in frequency at about 20 weeks after exposure.


Transferrin synthesis by macrophages: up-regulation by gamma-interferon and effect on lymphocyte proliferation.

We have investigated transferrin synthesis by human and mouse lymphoid and myeloid cells. It was found that transferrin synthesis is a property of mouse but not human macrophages, whereas in man T lymphocytes synthesised transferrin. Synthesis by mouse macrophages showed a dose-dependent increase in response to gamma-interferon (gamma-IFN), but iron added as ferric nitrilotriacetate had no effect. Macrophage-derived transferrin was found to contain iron already bound to it and was able to support Con A-stimulated mouse lymphocyte proliferation.


Tumour cell inhibition of macrophage cytokine activity.

Macrophages elaborate both effector and regulatory immune functions. It was hypothesised that tumours can exert a local alteration of macrophage function. Murine peritoneal macrophage-derived cytokines were assayed in the presence and absence of cells, cytosol fractions or conditioned media (TCCM) from established murine tumour lines. Interleukin-1 beta, interleukin-6 and tumour necrosis factor-alpha activities were significantly inhibited by tumour cells or their products, as were the corresponding recombinant human cytokines. Intracellular protein kinase C activation was also measured and was significantly inhibited by murine TCCM, thus suggesting one possible site of inhibitor action. Data analyses indicate that the inhibitory factor(s) is probably not an already well-characterised macrophage inhibitor.


The balance of macrophage subsets may be customised at mucosal surfaces.

Monoclonal antibodies (mAbs) can discriminate phagocytes (mAb, RFD7+), antigen presenting cells (mAb, RFD1+) and suppressor macrophages (mAbs, RFD1+RFD7+). Here we compare proportions of these subsets in normal mucosa and investigate changes associated with inflammatory disease. Biopsies were obtained from normal and inflamed lung, gut and skin. Cryostat sections were then analysed using mAbs RFD1 and RFD7. At normal mucosal surfaces the RFD1+RFD7+ suppressor cells consistently formed a major population: lung, RFD1+ 11.4%, RFD7+ 43.3%, RFD1+RFD7+ 45.2% and in gut, RFD1+ 37%, RFD7+ 12%, RFD1+RFD7+ 51% while in the skin the three subsets were in relatively equal proportions (RFD1+ 30%, RFD7+ 37%, RFD1+RFD7+ 33%). In inflamed eczematous skin the percentage of RFD1+RFD7+ increased at the expense of RFD1+ and RFD7+ cells whereas in inflamed mucosa the RFD1+RFD7+ population was significantly reduced (asthmatic lung 29%, RFD1+RFD7+, colitis 31% RFD1+RFD7+). In the lung this reduction was concomitant with a rise in RFD1+ cells while in the gut the RFD7+ population increased. It is concluded that balance of macrophage subsets may be customised at mucosal surfaces to sustain suppression of T cell reactivity. Inflammation here is associated with a loss of this suppression.


Heterogeneity of peripheral blood monocyte populations in human immunodeficiency virus-1 seropositive patients.

Monocytes from human immunodeficiency virus (HIV) patients have an increased heterogeneity of phenotype and function. In a study of 120 HIV patients we have demonstrated that they have normal monocyte differential counts but that with progression of the disease an increasing proportion of monocytes show phenotypic and functional evidence for activation or maturation. A proportion of the monocytes are larger, with increased expression of CD11b, HLA-DR, CD45 and CD16. Concomitantly there was increased expression of TNF-alpha, high constitutive synthesis of PGE2 and high plasma IL-6 levels. This suggested that there exists a more dynamic situation of recruitment, activation and maturation of peripheral blood monocytes driven by HIV infection which results in a broader phenotypic profile.


Use of enzyme microassay to detect eosinophil potentiating activity of cytokines in sheep.

Microplate assays for eosinophil peroxidase (EPO) and arylsulphatase (EAS) have been established as indices of eosinophil survival/proliferation in sheep bone marrow cell (SBMC) cultures. Cell specificity was confirmed using density-fractionated and differentially depleted SBMC populations. Several recombinant cytokines including interleukins 3 (IL-3) and 5 (IL-5), and granulocyte macrophage-colony stimulating factor (GM-CSF), but not macrophage-CSF (M-CSF), had demonstrable eosinophil-potentiating activity on the basis of enhanced EPO and EAS activities in treated, compared with untreated, SBMC cultures. Effects of IL-5 were abrogated in the presence of a specific monoclonal anti-IL-5 antibody. The results indicate that measurement of EPO and EAS in cultured SBMC offers a simple and effective method for detecting eosinophil potentiating activity in the ovine.


The development of a radiometric assay for monocyte phagocytosis and killing.

Monocyte and macrophage phagocytosis and killing has an important role in host defence against infectious microorganisms. Established methods for investigating these activities in vitro are time-consuming, expensive and prone to subjective error. An in vitro assay has been developed which measures monocyte phagocytosis and killing of Candida albicans. In this system, monocyte function is assessed by a radiometric assay based on the incorporation of [3H]uridine into viable yeast cells. This technique allows the simultaneous but independent measurement of the average number of yeast cells ingested by monocytes and the percentage of the ingested organisms killed within a defined incubation period. These tests can be carried out on a single sample of peripheral blood, are relatively easy to perform, and provide objective results within 24 h of receipt of the specimen. This method gave consistent results when monocyte-enriched harvests were obtained by four different separation techniques. This assay could prove a valuable tool for the investigation of monocyte function in individuals with recurrent infections to determine the contribution this makes to their clinical condition. It may also be used to investigate in vitro the influence of cytokines and other chemical agents on monocyte function.


Effect of blocking TNF-alpha on intracellular BCG (Bacillus Calmette Guerin) growth in human monocyte-derived macrophages.

Four agents, thalidomide, oxpentifylline, dexamethasone and a polyclonal anti-TNF-alpha antibody, were all shown by specific Elisa to block endogenous TNF-alpha production by Bacillus Calmette Guerin (BCG)-infected human monocyte-derived macrophages in in vitro culture. There was however no significant enhancement of intracellular BCG growth, over a 7-day incubation, in human monocyte-derived macrophages in the presence of any of the TNF-alpha-blocking agents, as determined by both radiometric and CFU counting methods of assessing bacterial viability and growth. The result suggests that the action of TNF-alpha alone is unlikely to be an important effector mechanism in antimycobacterial immunity within human cells.


Cell-stroma interactions in monocytopoiesis.

We have used immunohistochemistry to distinguish monocytes from early granulocyte precursors in trephine biopsies, in order to determine the distribution of monocytopoiesis within bone marrow. Developing granulocytes and monocytes have extensively overlapping immunophenotypes, but differential expression of calgranulin by monocytes and granulocytes during their maturation permitted the use of this antigen as a marker of bone marrow monocytes. In addition to morphologically normal bone marrow biopsies, in which monocyte numbers are relatively low, we studied pathological conditions in which either monocytopoiesis or granulopoiesis is selectively increased. By contrast with the highly zonal distribution of developing granulocytes, we found that monocytes were dispersed singly throughout the bone marrow. There was no evidence of preferential localisation of monocytes to particular stromal compartments. We hypothesise that developing monocytes are highly mobile within the bone marrow stroma and are relatively independent of physical stromal contacts for differentiation signals.


A comparison of the different methods available for determining BCG-macrophage interactions in vitro, including a new method of colony counting in broth.

Different methods of determining BCG viability based on colony forming unit (CFU) counting and radio-isotope labelling were comparatively assessed. These included radio-isotope labelling with [3H]uracil, [3H]uridine, [3H]glycerol, and CFU counting, by both agar plate dilution, and microcolony counting in broth. The sensitivity ranges of the different techniques were determined in both macrophage-free and macrophage-treated systems and used to assess the anti-mycobacterial potential of human monocyte-derived macrophages following BCG infection.


[Molecular cytogenetic study of an extra small chromosome].

An extra small chromosome was observed in a three-generation family. Eight members of this family were involved, but their phenotypes were normal. Molecular cytogenetic study was carried out, using cytogenetic methods and chromosome in situ hybridization with 3H-labelled rDNA probe. The results showed that this chromosome was from the short arm of chromosome of D/G group. The origin and genetic effects of this chromosome and fertility of the carriers were also discussed were also discussed briefly.


[Cloning and sequence analysis of salmon growth hormone cDNA].

cDNA clones encoding Chinook Salmon, Oncorhynchus tschawytscha, growth hormone (sGH) have been isolated from a cDNA library prepared from Chinook Salmon pituitary gland poly(A)+ RNA. Synthetic oligodeoxynucleotide mixtures based on amino acid residues 1-7 of sGH and 166-172 of sGH were used as hybridization probes to select recombinant plasmids carrying the sGH coding sequence. The complete nucleotide sequence of sGH cDNA has been determined. The cDNA sequence codes for a polypeptide of 210 amino acids including a putative signal sequence of 22 amino acids. The 5' and 3' untranslated regions of the message were 70 and 446 bases long, respectively. Comparison of the nucleotide sequence and amino acid sequence between Chum sGH and Chinook sGH indicated that there were 97% and 99% homology respectively.


[Studies of plasmids of Pseudomonas maltophilia].

Eighteen strains of P. maltophilia were screened for the occurrence of plasmid using four different methods. Five of them were harbor plasmids. The results of plasmid detection in different growth phase of P2 strain showed that the highest amount of plasmids in the strain was observed in stationary growth phase. The characteristics of plasmid of P. maltophilia P2 was investigated by methods of agarose gel electrophoresis, restriction endonucleases analysis, determination of molecular weight. The results indicated that P. maltophilia P2 contained only one type of plasmid, its molecular weight was 4.4 x 10(6) dalton and that the plasmid had single BamHI. PstI. XbaI EcoRI. HindIII sites. Thus, the plasmid of P. maltophilia P2 may be developed into a fine cloning vector.


[Isolation of vitamin B2 auxotroph and preliminary genetic mapping in Salmonella typhimurium].

The first independent vitamin B2 auxotrophs of Salmonella typhimurium were obtained by using selective medium containing extraordinarily high concentration of B2 (300 micrograms/ml) after mutagenesis. Transduction analysis showed that 21 B2 auxotrophs could be divided into four groups, which were unlinked to each other. It means that at least 4 structural genes were involved in B2 biosynthetic pathway. Preliminary genetic mapping indicated that 2 genes located in 7'-22' and other 2 located in 22'-34' and 61.5'-69' region on the genetic map of S. typhimurium respectively.


[The construction of genomic library of Alcaligenes faecalis and cloning of nifH gene sequence homologous to Klebsiella pneumoniae].

A genomic library of Alcaligenes faecalis A-15Hl which possesses rather high nitrogenase activity has been constructed. The total DNA of A. faecalis A-15 Hl was partially digested with Sau3AI. 13-20 kb of fragments recovered from agarose gel were cloned in bacteriophage EM-BL4 vector. A total number of 1.2 x 10(6) of recombinants was obtained. It is much beyond the desired capacity of a library. By using nifH gene of K. pneumoniae from plasmid pGB1 as probe, we have successfully screened the clone containing its homologous sequence. The recombinant bacteriophage DNA was digested with EcoRI. A 3.5 kb of hybridizing band appeared after southern blotting and then was cloned in pUC19 DNA. The result of southern blotting indicated that the recombinant plasmid clone contained nifH gene sequence of A. faecalis. This clone was named as pAFH.


Variation in coronary risk factors by social status: results from the Scottish Heart Health Study.

The relationship between social status and coronary heart disease in the United Kingdom is well established with the more socially disadvantaged being at higher risk. There is also evidence that the levels of most of the known coronary risk factors vary with social status in a way consistent with their relationship to coronary heart disease. Using data from the Scottish heart health study the aim of this study was to quantify, for men and women, the variation in four of the main coronary heart disease risk factors--smoking, serum total cholesterol level, blood pressure and obesity--according to a number of social factors--occupational social class, housing tenure, level of education and employment status. The analyses used both mean risk factor levels as well as the percentages above suggested cut off levels, in order to provide estimates of the percentage of people at risk. All the risk factors, apart from total cholesterol level in men, showed fairly consistent variation across social groups with the more socially disadvantaged being at higher risk. Similar social variation was found for the percentages above the cut off levels, and these indicate that nearly 60% of the Scottish population aged 40-59 years, have one or more risk factors for coronary heart disease. These results suggest that some targeting of health education and management is appropriate, and this is especially relevant as the reforms to the National Health Service set health targets for health authorities and encourage general practitioners to provide health promotion services.(ABSTRACT TRUNCATED AT 250 WORDS)


Hypercholesterolaemia: setting a Dutch national standard.

Since 1989 the Dutch college of general practitioners (Nederlands Huisartsen Genootschap) has published a total of 22 standards on different subjects. For the standard on hypercholesterolaemia a working conference was organized and attended by the most active general practitioners in the college. The conference aimed to facilitate the publication of a well balanced standard and to judge the value of the previously used procedure in which the draft standard was sent to a sample of college members for their comments on the feasibility of the guidelines. Six controversial areas of hypercholesterolaemia were discussed at the conference and the conclusions reached were compared with the opinions of the random sample responding to the postal questionnaire. The representativeness of the populations consulted and the impact of the conference on the standard were also studied. Compared with the total population of Dutch general practitioners, women and those in the youngest age group (30-35 years) were over-represented in the random sample, while at the conference general practitioners from two partner and group practices were over-represented. There were no significant differences in background characteristics between the 36 conference participants and the 52 respondents to the written inquiry. Their opinions differed on the appropriateness of an upper age limit for screening for hypercholesterolaemia and on whether the 'average' general practitioner can prescribe a cholesterol-lowering diet. The results of the conference appear to have altered the final text of the standard on four issues: screening in women, having an upper age limit for screening, the time period for blood sampling and the prescription of a cholesterol-lowering diet by the general practitioner.(ABSTRACT TRUNCATED AT 250 WORDS)


General practice in Gloucestershire, Avon and Somerset: explaining variations in standards.

Variations in standards are found in all health services. The method and amount of funding are thought to be important reasons for these variations. A cross sectional survey of all general practices in three counties in south west England was undertaken in order to explain variations in the level of development. A development score for each practice was calculated. There was wide variation in standards as described by the level of development. Multiple regression analysis showed that being a training practice, having a practice manager, the partners having a younger mean age, a larger total number of patients registered with the practice and a lower Jarman underprivileged area score were all independently related to a higher level of practice development. In addition, the responsible family health services authority was also related to the level of development. A combination of professional factors such as the decision to become a training practice, environmental factors such as the family health services authority or the underprivileged area score and economic factors reflected in the total list size determine the level of practice development. The most easily corrected factor is the employment of a practice manager. It is suggested that differences in standards in general practice may be increased rather than decreased by the fundholding scheme.


Time between presentation and treatment of six common cancers: a study in Devon.

The time between a person presenting to a general practitioner with a symptom of cancer and that person starting treatment has been studied in Devon. Retrospective analysis was undertaken of the general practitioner records of 1465 patients proven to have cancer who were registered with 245 general practitioners. During inspection of these records dates of first presentation, of referral, of first hospital consultation and of the start of treatment were noted for people with six common types of cancer (cancer of the breast, large bowel, lung, oesophagus, prostate and stomach). The general practitioner stage time and hospital stage time (pre-appointment and post-appointment) were calculated for each patient. Large differences were found in median times for the general practitioner stage according to the type of cancer, ranging from a median value of 0 days for people with breast cancer to 84 days for people with cancer of the oesophagus. For patients with cancer of the breast, large bowel, lung or prostate, median general practitioner times were shorter than median hospital stage times, while for patients with cancer of the oesophagus and stomach cancer, median general practitioner stage times were longer than median hospital stage times. Comparison of the hospital stage times for people with breast cancer and cancer of the large bowel showed notable differences between the four health districts in Devon, pre- and post-appointment times being twice as long in one district as in another. This retrospective record analysis was acceptable to participating practitioners. The results provide a basis for general practitioners and hospital staff to review their own work.


Long term use of inert intrauterine contraceptive devices in 94 women in Israel.

A 22 year retrospective survey was undertaken in an Israeli family practice to determine how long inert (plastic only, unmedicated) intrauterine contraceptive devices could be safely left in place. Ninety four women were identified who had used 100 inert intrauterine contraceptive devices continuously for between five and 19 years. Fifty nine women complained of pain, increased uterine bleeding or increased vaginal discharge, but these were the reasons for removal of the device in only 32 women. There was only one case of pelvic inflammatory disease but this was treated without removal of the intrauterine contraceptive device. Of 14 women who requested to have their device removed after between five and nine years without having had any side effects, 11 women conceived within nine months. The results of the study indicate that inert intrauterine contraceptive devices can be safely left in place until the menopause. As it will take many years before the new type of copper devices can be shown to be as safe for long term use, it seems an appropriate time to reintroduce inert intrauterine contraceptive devices for women.


Incidence and management of transient synovitis of the hip: a study in Dutch general practice.

Little is known about transient synovitis of the hip in the community. Using data from the Dutch national survey of morbidity and interventions in general practice, a study was undertaken to look at the incidence and management of transient synovitis of the hip in children under 15 years of age. Transient synovitis of the hip was diagnosed in 19 children, 17 of whom were new cases. The mean age of the children was six years six months with a sex ratio of 2.8:1.0 boys to girls. An incidence rate of 1.1 per 1000 person years was calculated. General practitioners prescribed drug treatment for six children and bed rest was advised for six children. Two children were referred for an x-ray examination. Clear follow-up arrangements were made for 16 of the 19 children. It appears that general practitioners preferred to adopt a wait-and-see approach to transient synovitis of the hip rather than referring children for diagnostic ultrasound or x-ray examination.


Management of asthma in pre-school children.

The management of asthma in pre-school children often presents physicians with challenging problems. This article addresses the diagnostic criteria by which the diagnosis may be made, discusses the prognosis of untreated asthma and states the principles underlying the treatment of asthma in this age group. The management according to a stepwise protocol is discussed with reference both to maintenance therapy, and the treatment of acute severe asthma. The methods by which appropriate medication may be delivered are also described.


Risk targeting in cervical screening: a new look at an old problem.

In the face of continuing debate about the level of effectiveness of the United Kingdom cervical cytology screening programme in preventing cervical cancer, more precise targeting of high risk groups might offer a means of enhancing its efficiency. Broad risk targeting is already practised by screening only sexually active women aged 20 to 65 years. This paper describes a risk scoring system constructed from the available literature and designed to be used by primary care health professionals and patients. The system involves four independent risk factors: educational level, current smoking habit, years of oral contraceptive use and number of sexual partners. Since the objective is simply to identify women at relatively high risk, inclusion of a factor neither requires nor implies causality. The next steps are to study the feasibility of putting the scale to practical use and to investigate its predictive value in a prospective evaluation.


ECMO in newborn infants: the Melbourne experience.

At the Royal Children's Hospital, Melbourne, extracorporeal membrane oxygenation (ECMO) has been used in the treatment of newborn infants with life-threatening respiratory or cardiac failure since May 1989. The main indications for the use of ECMO are that the disease is reversible, the surviving infant is likely to be normal and there is an 80% likelihood of death without ECMO. Sixteen of 22 (73%) newborn infants have survived at least 6 months after ECMO. Fourteen of 16 (87.5%) infants receiving ECMO (who did not have a congenital diaphragmatic hernia) were functionally normal survivors; the other two infants died. Two of six infants with congenital diaphragmatic hernia who received ECMO were discharged and survived to have normal neurological and respiratory function at 6 month follow up. These results are similar to results from other centres internationally. It would appear that ECMO is a useful therapy for near-term newborn infants with otherwise fatal cardiorespiratory failure.


ECMO in newborn infants: the New South Wales experience.

Extracorporeal membrane oxygenation (ECMO) has been used at the Prince of Wales Children's Hospital, Sydney for the treatment of newborn infants with life-threatening respiratory or cardiac failure since August 1989. The main indications are that the disease is reversible, the surviving infant is likely to be normal and there is an 80% likelihood of death without ECMO. Eighteen of 19 newborn infants have survived at least 2 months after ECMO. The 15 infants receiving ECMO (nine with meconium aspiration, six with persisting pulmonary hypertension) who did not have a congenital diaphragmatic hernia were normal survivors. One death occurred at 5 months of age from chronic lung disease. Three of four infants with congenital diaphragmatic hernia were discharged following ECMO and appeared normal at 6, 9 and 18 months of age. These results are similar to results from other centres internationally. It appears that ECMO is a useful therapy for near-term newborn infants with otherwise fatal cardiorespiratory failure.


Serum osteocalcin in normal and short Chinese children.

Serum osteocalcin was measured by radioimmunoassay in 200 normal children and adolescents, and seven growth hormone (GH) deficient and seven non-growth hormone deficient (NGHD) short children. There was a sex- and age-dependent change in the serum osteocalcin concentrations in normal children and adolescents with a pattern similar to the childhood height velocity curves. The serum osteocalcin concentration was in the low normal range in most patients with GH deficiency and NGHD short stature. GH therapy significantly increased the growth velocity in both groups of short children. GH treatment resulted in a significant rise in serum osteocalcin concentrations after 6 and 12 months in NGHD children but a more variable change was observed in GH-deficient children. Although osteocalcin levels may give some biochemical indication of growth, these measurements should be used together with auxological and other biochemical measurements to assess growth reliably.


The KEMH method for securing umbilical catheters.

A new method of fixation of umbilical catheters is described. This method utilizes a purse-string suture around the cord stump, which is then secured through the umbilical skin and fixed to the catheter with adhesive tape. This method avoids damage to the fragile skin, particularly of the preterm newborn, caused by the use of T piece strapping.


An area analysis of child injury morbidity in Auckland.

The geographical distribution of child injury morbidity in Auckland between 1982 and 1987 was examined. Analysis of total injury, pedestrian injury and vehicle occupant injury, with the census area unit as the basic spatial entity revealed distinct variations in child injury morbidity by census area unit. Morbidity rates were above average in parts of the central urban area and South Auckland and below average on the North Shore. Total injury morbidity and pedestrian injury morbidity rates were strongly correlated with census area unit unemployment rates, which were used as a measure of socio-economic deprivation. Geographical areas with high rates of child injury morbidity, to which injury prevention resources can be directed, were identified. In particular, the results suggest that injury prevention programmes should be targeted at socio-economically disadvantaged communities.


Primary staphylococcal pneumonia in childhood: a review of 69 cases.

Primary staphylococcal pneumonia is a rapidly progressive illness with well-described clinical and radiological features and a significant mortality rate. This retrospective study of cases diagnosed over a 20 year period at a tertiary paediatric hospital was undertaken to document the epidemiology and assess the management and mortality of the disease. The survey demonstrated that far fewer patients are being seen than formerly and confirmed that this is a disease primarily affecting infants and Aboriginal children. The initial radiological features were not diagnostic in the majority of cases but typical changes appeared in most at some time during the illness. The use of surgical drainage was not associated with a decrease in the duration of fever or length of hospital stay. The mortality rate has improved but remains significant.


A multicentre randomized placebo-controlled double-blind study on the efficacy of Ketotifen in infants with chronic cough or wheeze.

The efficacy of Ketotifen was examined in the treatment of 113 infants between 6 and 36 months of age presenting with a history of cough and/or wheeze in a multicentre randomized placebo-controlled double-blind study. A 4 week no-medication baseline phase preceded the 16 week treatment phase in which infants took 2.5 mL twice daily of either placebo or Ketotifen (0.5 mg) syrup; this was followed by a 4 week wash-out phase. Diary card evaluation was performed by the parent or guardian for the duration of the study and recorded wheeze and cough twice daily as well as medication used. The percentage of symptom-free days decreased significantly in both groups (P < 0.005) with placebo-treated infants experiencing significantly more symptom-free days compared with the Ketotifen group (P < 0.01), although this difference was never more than 10% in any 4 week treatment period. Symptom severity scores and use of beta-agonist medication were also less in the placebo-treated infants but did not reach statistical significance. This study was unable to show a therapeutic advantage of Ketotifen over placebo in this group of infants with chronic cough and/or wheeze and the apparent statistical advantage of placebo is not a clinically relevant finding.


Immunization status of casualty attenders: risk factors for non-compliance and attitudes to 'on the spot' immunization.

Outbreaks of vaccine preventable infections have focused attention on 'missed opportunities' for immunizing children. The immunization status of 520 consecutive children attending Casualty during a 10 day period was studied. Only 70% of children had received their diphtheria, tetanus, pertussis (DTP) and poliomyelitis immunization at the appropriate time, 13% had completed the schedule later than recommended and 17% had immunizations overdue by 4 weeks or more. For measles (mumps/rubella) vaccine (MM or MMR) 75% were up to date, 10% were given late and 15% were overdue. A subset of 171 families was interviewed to evaluate factors affecting compliance. Families possessing a Social Security 'Health Care Card', whose father was unemployed, who spoke poor English or who had lived in Australia for 5 years or less were significantly more likely (P < 0.02) to be inadequately immunized. There were 84 children whose immunization was overdue and who were well enough to be immunized. The parents of 70 (83%) of these 84 said that they would agree to 'on the spot' immunization if it were available; 14 (17%) parents refused, the commonest reason for refusal being that the parents felt that the child was too sick at the time to be immunized.


Lafora disease: a progressive myoclonus epilepsy.

Lafora disease is a rare inborn error of metabolism resulting in storage of a polyglucosan in tissues including the brain, skin and liver. Four children are described with progressive myoclonus epilepsy and intellectual deterioration in whom this diagnosis was made. In two the diagnosis was confirmed by the presence of periodic acid schiff (PAS) positive, diastase resistant, colloidal iron staining inclusion material in the liver when they were referred to a paediatric gastroenterologist with abnormal liver function tests. In one, the diagnosis was made from cerebellar biopsy, although on retrospective review the liver biopsy performed at this time was abnormal. In a fourth child, whose sibling was affected, histological diagnosis was confirmed by skin biopsy, although clinical and EEG findings had been highly suggestive for several years. The disease has autosomal recessive inheritance, is progressive and the prognosis is poor. Paediatricians should be aware of this diagnosis, which is often delayed, as early histological diagnosis allows prognostic and genetic counselling and optimal treatment. Although the diagnosis was made by liver or brain biopsy in three cases, skin biopsy offers a reliable, less invasive means of diagnosis.


The epidemiology of acute epiglottitis in children in Western Australia.

A comprehensive case definition was used to study all cases of epiglottitis that occurred in children under 15 years of age in Western Australia during a 5 year period. There was microbiological evidence of Haemophilus influenzae type b infection in 71% of 103 cases of epiglottitis. Seventy-five per cent of cases occurred in children under 5 years of age. In this age group, the estimated annual incidence (13.5 episodes per 100,000) was significantly lower than that reported in Victoria (22.7 per 100,000). The case definition of invasive H. influenzae type b disease used for surveillance purposes in Canada was more sensitive than the definitions used in the United States or England and Wales, yet even the Canadian definition could have detected only 65% of the cases of epiglottitis that occurred in Western Australia. A simple and sensitive surveillance system which could be used to monitor the impact of H. influenzae type b immunization in Western Australia is proposed.


Spondylothoracic dysplasia (Jarcho-Levin syndrome) in a Chinese baby.

Spondylothoracic dysplasia (STD) syndrome or the Jarcho-Levin syndrome has been seen commonly in Puerto Ricans. A case of STD syndrome in a Chinese baby which we believe is the first reported case in an Asian baby is reported. The skeletal disorder syndrome affecting the spine, ribs and thorax is an autosomal recessive disorder with associated non-skeletal anomalies. It should not be confused with the phenotypically similar skeletal disorder known as spondylocostal dysplasia, which is an autosomal dominant disease.


A phase I study of HGP-30, a 30 amino acid subunit of the human immunodeficiency virus (HIV) p17 synthetic peptide analogue sub-unit vaccine in seronegative subjects.

HGP-30-KLH vaccine in alum at doses of 10, 25, 50, and 100 micrograms/kg administered intramuscularly at weeks 0, 4, and 10 appear well-tolerated clinically. Local pain at the injection site, appears to be the main clinical toxicity. Laboratory parameters are not affected by administration of the vaccine candidate except for perhaps mild urinalysis abnormalities at the highest dose. This vaccine candidate has no apparent immunotoxicity and does not appear to affect lymphocyte populations or T-cell functional studies. Low levels and transient antibodies develop in a minority of subjects early after immunization with the vaccine candidate. These responses were observed in the lowest dose range. Higher doses, and longer follow-up will be needed to confirm this observation. T-cell proliferative responses to KLH and KLH-HGP-30 are consistent and may not be dose dependent, but the proliferative responses are variable and more data need to be accumulated. Preliminary, there appears to be an HGP-30-induced CTL response of HGP-30-coated EBV-transformed autologous B cell lines. This study was approved under an IND for the California Department of Health Services' Food and Drug Branch. They have provided excellent support and regulatory guidelines for this project. Future work will extend and confirm these initial observations.


Lymphocytes from some long-term seronegative heterosexual partners of HIV-infected individuals proliferate in response to HIV antigens.

A comparison of the proliferative responses of lymphocytes to human immunodeficiency virus (HIV) antigens from long-term, seronegative heterosexual partners of HIV-infected subjects, from normal unexposed controls and from healthy seropositive heterosexual partners or seropositive, asymptomatic men, reveals that lymphocytes from healthy seropositive individuals with strong proliferative responses to recall, microbial antigens respond only minimally to HIV proteins or envelope peptides, and that even these low responses do not occur in all individuals. If the frequency of responses to several HIV antigens are analyzed, lymphocytes from both HIV-exposed seropositive and seronegative partners of infected individuals proliferate to HIV antigens to a greater degree than lymphocytes from unexposed, normal control individuals. Although lymphocytes from seropositive partners proliferate to a greater degree than those from seronegative partners, the latter are more similar to seropositive partners than they are to normal controls. This observation suggests that these seronegative partners may have become sensitized to HIV antigens through sexual exposure but without infection, and/or that the presence or development of these small immune responses in some individuals might be associated with a failure to become infected.


Immunization of rhesus monkeys with high- and low-dose Tween-ether-disrupted SIVMAC.

Two vaccine trials were conducted with low- and high-dose purified Twen-ether-treated SIVmac adsorbed onto aluminum hydroxide using rhesus macaques. In the first experiment 7 macaques were immunized with a total amount of 560 micrograms protein and 3 animals served as controls. After the immunization period the vaccinees exhibited ELISA titers up to 1:1280 and 5 immunized animals showed an antigen-specific proliferative response. After the virus challenge the 3 control animals and 3 vaccinees became infected. Four of the infected animals developed a cytotoxic T-cell response beginning 8 weeks postchallenge. The 4 protected animals were rechallenged 16 weeks later and all became infected. For the high-dose experiment 5 immunized animals receiving 2 mg of antigen and 2 control animals were used. The ELISA titers of the vaccinees reached 1:20480 and 4 animals exhibited an antigen-specific proliferative response. In response to virus challenge the 2 control and 1 immunized animal became infected. From these data it can be concluded that the high-dose immunization scheme elicited higher antibody titers and increased the fraction of protected animals.


Immunogenicity and toxicity testing of an experimental HIV-1 vaccine in nonhuman primates.

A highly purified saponin from Q. saponaria (QS-21) was tested in juvenile rhesus macaques for adjuvant activity and toxicity. The QS-21 was tested alone or as part of an experimental subunit HIV-1 vaccine containing a truncated recombinant HIV-1 envelope protein (gp160D) adsorbed to alum. Antibody responses were measured using ELISA and cell-mediated immunity was measured using cellular proliferation assays. Potential toxicity was monitored by standard clinical pathology testing using peripheral blood and urine samples. No toxic effects were observed, even after the administration of the experimental vaccines three times at monthly intervals. The QS-21 saponin adjuvant enhanced total antibody production levels by greater than 100-fold and broadened the specificity of the response so that additional epitopes were recognized, when compared with alum-adsorbed HIV-1 gp160D formulation. Low-level, antigen-specific proliferative responses to HIV-1 recombinant gp160 were induced by either vaccine formulation. Proliferative responses were induced by a sham challenge with soluble recombinant HIV-1 gp160 for all of the animals that had been vaccinated. However, those that received the HIV-complete vaccine formulation containing QS-21 responded significantly better. These data demonstrated that the QS-21 adjuvant augmented both antibody responses and cell-mediated immunity and established immunological memory. The potent adjuvant activity and lack of toxicity suggest that this adjuvant should be safe and effective for use in HIV-1 vaccines.


Comparison of protection afforded by whole virus ISCOM versus MDP adjuvanted formalin-inactivated SIV vaccines from IV cell-free or cell-associated homologous challenge.

A SIV-ISCOM and a SIV-MDP adjuvanted vaccine were tested for their potential to induce protection from intravenous cell-free or cell-associated homologous SIV challenge in rhesus monkeys (Macaca mulatta). Seven monkeys vaccinated four times over a four-month period with either the SIV-ISCOM or the SIV-MDP vaccine were challenged intravenously with approximately 10 MID50 cell-free SIVmac251 (32H). They all were protected from developing viremia during a three-month observation period. Two other groups of four monkeys were vaccinated essentially in the same way with either of these vaccines. They were challenged intravenously with approximately 10 MID50 of infected PBMC of a rhesus monkey that had been infected with SIVmac251 (32H) 11 months earlier (stock prepared by J. Heeney). Two monkeys of each of these two groups proved to be protected from developing viremia during a two-month observation period. For both the cell-free and the cell-associated SIV challenge, monkeys vaccinated with measles virus ISCOMS or MDP adjuvanted measles virus antigen, served as controls. They all became viremic within two weeks after SIV challenge. This is the first demonstration that vaccinated previously unchallenged nonhuman primates can be protected from infection with lentivirus-infected PBMC from another animal. Serological analysis indicated that SIV-specific serum antibody titers were considerably higher in SIV-ISCOM vaccinated animals than in the SIV-MDP vaccinated animals. The serology also confirmed the protection data, by showing the absence of increase in SIV-specific serum antibodies in apparently protected animals after challenge.


Prevention of HIV-2 and SIVSM infection in cynomolgus monkeys by active or passive immunization.

We have established experimental infection with HIV-2 and SIVsm in cynomolgus monkeys and successfully used these models for vaccine experiments. Protection against homologous HIV-2 infection was demonstrated in two of two monkeys immunized with a Triton-X100-treated whole HIV-2SBL-6669 vaccine in incomplete Freund's adjuvant and in 2 of 4 monkeys immunized with a formalin-inactivated whole HIV-2 vaccine in RIBI adjuvant. Monkeys preinfected with a live poorly replicating HIV-2 strain were shown to develop cross-protection against SIV-induced disease. We have shown also that HIV-2 and SIVsm infection in cynomolgus monkeys can be prevented by passive immunization. These results raise hope for effective immunization against HIV infections in humans.


The urge for an AIDS vaccine: perspectives from a developing country.

AIDS is inexorably involving all parts of the country and all strata of society, with 10% of the urban and 3% of the rural population infected with HIV. It is increasingly a disease of women and children. The major cofactors for transmission are also sexually transmitted. For most developing countries, in spite of all education efforts, the "silent epidemic" of AIDS continues. AIDS is known but not understood; counselling modifies behavior in only 10-20% of at-risk persons. Under optimal conditions, HIV discordant females have seroconversion rates of 4.7% per year and pregnancy rates of 10.4% per year. The recent political unrest in Zaire and Haiti will further enhance the spread of AIDS in these countries. Despite these difficult periods, the work can and must continue. After all, during our 10th year of collaboration with a Haitian private research group, the Haitian government and Cornell University, Haiti has known seven different political rulers. Finally, I want to make a pledge on behalf of the millions of people who face a certain death from HIV infection and AIDS and who will never make the front page of any newspaper. For these people, you can make a difference. You must give us the tools to carry on this fight. The clinical trials must be done where they are most needed: the developing countries. Vaccines represent the only viable alternative despite the recognized obstacles of viral heterogeneity, immunogenicity, and delivery.


[Posterior shoulder dislocation in a patient sample of the Swiss Accident Insurance Service].

We report on 17 posterior shoulder dislocations which were investigated by SUVA's medical service during the past three years. We can confirm the information in the literature, that the diagnosis is initially often missed (4 out of 17) and that the injury is often sustained in epileptic fits (4 out of 17). Among our patients, however, the time at which the diagnosis was made did not obviously influence the results of the treatment. After treatment, over half of our patients have an impairment which, in three cases, resulted in integrity compensation, in one case in a recommendation for vocational retraining, in one case in a change of profession and in one case in a pension.


The effect of maturation on in-vitro erosion of glass-ionomer and other dental cements.

The clinical durability of restorations made using water-based materials depends upon the type of material used. Current specification tests cannot predict durability, possibly because these are carried out on samples matured for 24 hours whereas longer maturation times may be more relevant. The lactic acid jet test was selected as a test method, being believed capable of ranking materials in the same order of erosion resistance in vitro as found in vivo. The powder/liquid interaction (glass or zinc oxide with polymeric or phosphoric acid) was investigated by selecting glass-ionomer, zinc polycarboxylate, silicate and zinc phosphate cements, with emphasis placed on glass ionomers. Two test times, 24 hours and 2 months, were chosen, with eight samples for each material tested at each time. All glass ionomers showed a significant reduction in erosion rate with time; two zinc polycarboxylates also showed some reduction but not to a significant degree. The silicate and zinc phosphate cements increased in erosion rate but not significantly. It was concluded that materials using polymeric acids had erosion rates which reduced with time, significantly so for glass ionomers. This might explain their longevity over silicate cements.


[Fractures of the clavicle and secondary lesions of the brachial plexus].

The fractures of the clavicle are fundamentally minor and usually will heal by simple immobilization. When the trauma is severe, the fracture may cause a lesion of the subclavicular neuro-vascular bundle. However, if the lesion is limited it may appear clinically only a few days after the accident. In other cases, whether the clavicular fracture heals or not, the bone lesion may produce a hypertrophic callus. This phenomenon will cause a narrowing of the costo-clavicular outlet and a compression of the neurovascular bundle which will provoke a real TOS. The authors present 16 cases of clavicular fractures, two of which having had early neurovascular complications and the 14 others a late phenomenon of costo-clavicular syndrome. The pathogenesis of the lesions, the principles of treatment and the results are discussed.


An unusual foreign body in an unerupted supernumerary tooth.

A case of an unusual foreign body (a tip fragment from a plastic chopstick) embedded in one of two unerupted supernumerary teeth in the premaxillary region of a 12-year-old Japanese boy is presented.


The use of general anaesthesia for tooth extraction in children in London: a multi-centre study.

Following publication of the Poswillo report, the continued use of general anaesthesia in dentistry became the subject of a major debate. In particular, the provision of general anaesthetic services by general dental practitioners in order to carry out simple extractions for child patients has been called into question. Other authors have strongly supported the continued need for general anaesthesia and insist that for some patients it remains the technique of choice. There is, however, little evidence of current patterns of attendance from which argument may be advanced to support or refute the differing views. In this study data was drawn from three London dental teaching hospitals providing out-patient general anaesthesia for extractions. During the 12-month period investigated 7852 general anaesthetics had been administered for child patients. There was evidence of an increase in numbers at one centre when results were compared to those of a previous study and some evidence of a change in pattern of referral with time at the same centre, with an increase in the numbers of patients referred by general dental practitioners. Eighty-three per cent of the anaesthetics had been given for the extraction of carious primary teeth, with an average of 3.3 being extracted per child. Nearly one-third of the anaesthetics were for children under the age of 5 years.


Operation Wild Dog.

'Operation Wild Dog' was the title given to an incredible escapade by two Army Dental Corps soldiers who decided to mount their own two-man raid on occupied France in 1942. In an attempt to forestall claims of desertion, they involved Prime Minister Winston Churchill and, when they ultimately faced a court martial, were lauded in the press for their daredevil exploits. Inspired by raids carried out by Special Services units on Norway, Italy and France, Sergeant Peter King, a regular soldier and dental clerk orderly, and Private Thomas Leslie Cuthbertson, a trainee dental mechanic, set about their unofficial raid, outlined below.


[Baumann shoulder reposition].

An untraumatic method for the reposition of dislocated shoulders without any analgesia is presented. That the way of this method must be right, is proved by a short historical view and by case reports; On one side by the inventor of this method and on the other side by a retrospective study from the orthopedic department of the Kantonsspital of St. Gallen. How to do this reposition is clearly described by words and pictures.


Human labial orf: a case report.

A case of orf in a 59-year-old man with no direct contact with farm animals is reported. The patient presented with an ulcerating lesion on the upper lip and the diagnosis was confirmed by electron microscopy from a smear of the lesion. The unusual case history, differential diagnosis and method of diagnosis are discussed.


[Esthetic and functional scar sequelae: plastic reconstruction of soft tissue].

The irregularities of a scarred area result of the destruction or alteration of the soft tissues. Functional consequences may occur if the scar tissue directly apply on a bony structure without any protection against shocks. Finally an underlying osteitis or unconsolidated fracture cannot be cured unless a good skin coverage and sufficient local vascularization are obtained. Secondary correction of the scar deformations intend to create a new subcutaneous layer. This can be done with adjacent adipous tissue, or by transfer of a well vascularized tissue, such as a muscle, if the underlying structures make it necessary. Some recent techniques are illustrated, especially tissue expansion and pediculated or free microvascular muscle transfer.


[Massive iodine absorption after joint irrigation-suction drainage with PVP-iodine (betadine)].

Iodine is known as a local disinfectant substance for more than 100 years. Its use however was restricted due to strong local irritation. In the last 25 years Polyvinylpyrrolidon-Iodine solutions (Povidone-Iodine, PVP-Iodine, Betadine) has become more and more popular for treating traumatologic, surgical and orthopaedic infections. However several papers have reported changes in the blood chemistry (T3, T4, TSH, PBJ and Iodine excretion in the urine) after utilizing PVP-Iodine, especially in visceral surgery. We report on a patient in whom a massive iodine resorption with clinical signs of hyperthyroidism occurred, with soft tissue necrosis at the site of irrigation.


[Multicenter paragliding accident study 1990].

During the period from 1.1.90 until 31.12.90, 86 injuries associated with paragliding were analyzed in a prospective study in 12 different Swiss hospitals with reference to causes, patterns, and frequencies. The injuries showed a mean score of over 2 and were classified as severe. Most frequent spine injuries (36%) and lesions of the lower extremity (35%) with a high risk of the ankles were diagnosed. One accident was fatal. 60% of the accidents happened during landing, 26% during launching and 14% during flight. Half of the pilots were affected during their primary training course. Most accidents were caused by inflight error of judgement--especially incorrect estimation of wind conditions--and further the choice of unfavourable landing sites. In contrast to previous injury-reports, only one equipment failure could be noted, but often the equipment was not corresponding with the experience and the weight of the pilot. To reduce the frequency of paragliding-injuries an accurate choice of equipment and an increased attention to environmental factors is mandatory. Furthermore an education-program regarding the attitude and intelligence of the pilot should be included in training courses.


[Quality assurance in traumatology--initial experiences with a computer program for the selection of trauma patients for morbidity and mortality conferences].

Trauma is the leading cause of death in the under thirties age group in Switzerland and the third leading cause in the 30-64 age group. In addition to efforts in the area of prevention, optimization must also be attained in individual medical care in order to reduce mortality and morbidity. Improvements are only possible, however, when based on precise knowledge of accident epidemiology and possible weak spots in the rescue chain, which begins at the scene of the accident and ends with discharge from hospital. This information should be complied for our region with the aid of a trauma register on the basis of internationally recognized elements. The following comments describe in a shortened form the CDC-Register (Centers for Disease Control, USA). Using our own initial experiences, the practical application and use of the corresponding Register-Software ("Trauma registry", Version 2.0, 1990) for conferences on mortality and morbidity, the basic guarantee of quality, are demonstrated.


Alcohol and sudden cardiac death.

To assess the relation between alcohol intake and sudden cardiac death--ie, death within one hour of the onset of symptoms. Prospective study of a cohort of men followed up for eight years. General practices in 24 towns in England, Wales, and Scotland. 7735 men aged 40-59 at screening who were selected at random from one general practice in each of 24 towns. All deaths from ischaemic heart disease with particular reference to those that were sudden (death within one hour of the onset of symptoms). During the follow up period of eight years there were 217 deaths from ischaemic heart disease of which 117 (54%) were classified as sudden. Although heavy drinkers (more than six drinks daily) did not show a high incidence rate of fatal heart attack, they showed the highest incidence rate of sudden cardiac death. This was seen in both manual and non-manual workers and was most clearly seen in older (50-59) men. Death from ischaemic heart disease was more likely to be sudden in heavy drinkers than in other drinking groups; this phenomenon was seen irrespective of the presence or degree of pre-existing ischaemic heart disease. The positive association between heavy drinking and the incidence of sudden death was most apparent in men without pre-existing ischaemic heart disease, with heavy drinkers showing an increase of > 60% compared with occasional or light drinkers. After adjustment for age, social class, and smoking, heavy drinkers free of pre-existing ischaemic heart disease had a marginally significantly higher incidence rates of sudden death than other drinkers combined (relative risk 2.00, 95% confidence interval 0.98 to 4.8). Additional adjustment for systolic blood pressure reduced the risk to 1.7. This study suggests that heavy drinking is associated with an increased risk of sudden death. Studies that do not take pre-existing ischaemic heart disease into account are likely to underestimate the adverse effects of heavy drinking on the incidence of sudden death because the effects are not as evident in men with pre-existing ischaemic heart disease.


Streptokinase resistance: when might streptokinase administration be ineffective?

(a) To develop an assay for streptokinase resistance. (b) To determine the prevalence of streptokinase resistance in patients presenting with acute myocardial infarction for the first time. (c) To determine the prevalence of streptokinase resistance in patients after exposure to streptokinase or streptococcal infection. Open, prospective. 30 healthy volunteers. 40 patients admitted to the coronary care unit at Addenbrooke's Hospital with suspected acute myocardial infarction, 12 patients 12 months after streptokinase treatment, eight patients 24 months after streptokinase treatment, and sera from 12 patients with raised anti-streptolysin O (ASO) titres. Three assays were used; a dilution neutralisation assay, an enzyme linked immunosorbent assay (ELISA) for immunoglobulin G (IgG) anti-streptokinase antibodies, and an in vitro fibrin plate lysis assay. All measurements were performed on venous blood samples. Neutralisation and IgG antibody titres were positively correlated. Mean (SEM) antistreptokinase concentrations in the 30 controls were 87 (10) U/ml (neutralisation assay) and 28 (6.3) U/ml (ELISA). Corresponding concentrations in patients before streptokinase were 68 (6.1) U/ml and 18 (4.5) U/ml with a mean fibrin plate assay 117 (7.1)% that of controls. Resistance to streptokinase was detectable in one patient after 72 hours and in all patients by day 10. By day 10 concentrations were 4388 (919) U/ml, 773 (109) U/ml, and 17 (5.4)%. At both 12 and 24 months resistance was present in 75% of patients. Similarly 66% of high ASO titre sera showed resistance. The fibrin plate lysis assay detected significantly reduced streptokinase dependent fibrinolysis in vitro in the absence of raised total concentrations of antistreptokinase antibodies. The prevalence of streptokinase resistance in patients presenting with their first myocardial infarction is low. Resistance develops early after treatment and is still present in 75% of patients after 24 months. Retreatment with streptokinase is likely to be suboptimal even after 24 months. The fibrin plate lysis assay detects resistance in patients with normal concentrations of streptokinase antibodies. Streptococcal infection is associated with a high incidence of streptokinase resistance.


Evidence for oxidative stress in unstable angina.

To determine whether unstable angina, which is characterised by recurring episodes of myocardial ischaemia and reperfusion, is associated with oxidative stress (that is, where there is an imbalance between oxidants, such as free radicals, which are in excess and antioxidants). Between group comparison of patients with unstable angina, stable angina, and healthy controls. The coronary care unit and cardiac investigation ward of a regional cardiology centre. Twenty five consecutive patients admitted to the coronary care unit with unstable angina. Twenty five consecutive patients admitted to the cardiac investigation ward (patients with stable angina undergoing coronary angiography) were used as controls for the presence of atherosclerosis, drug treatment, and smoking habit. Thirty eight healthy controls (hospital staff and patients admitted for minor surgical procedures who were otherwise healthy) were also studied. Thiobarbituric acid related substances (TBARS) in plasma and plasma reduced thiol (PSH) as indicators of oxidative damage to lipids and proteins respectively were measured. Coronary angiography was performed in all patients with stable angina and roughly half of those with unstable angina. Mean (SEM) plasma TBARS in unstable angina and stable angina were 9.95 (0.36) nmol/ml and 9.14 (0.28) nmol/ml respectively (p = 0.08). Mean plasma TBARS in healthy controls were 8.09 (0.21) nmol/ml (p < 0.05 compared with both angina groups). Mean (SEM) PSH concentration in unstable angina was 4.21 (9) nmol/ml and in stable angina was 4.85 (9) nmol/ml (p < 0.05). Mean PSH in healthy controls was 5.64 (8) nmol/ml (p < 0.001 compared with both angina groups). The extent of coronary artery disease, use of medication, and smoking habit were not significantly different between the angina groups. Biochemical indicators of oxidative stress are more abnormal in unstable than stable angina. This is in keeping with experimental evidence that episodes of ischaemia and reperfusion lead to generation of free radicals and toxic oxygen species and depression of endogenous antioxidant activity. The clinical significance of this finding remains to be determined, although, experimentally, free radicals and toxic oxygen species have adverse effects on myocardial contractile function, myocardial electrical stability, endothelial mediated vasodilatation, and coagulation.


Early diagnosis of acute myocardial infarction by a newly developed rapid immunoturbidimetric assay for myoglobin.

To evaluate a rapid immunoturbidimetric assay for myoglobin and to investigate its clinical usefulness in the early detection of acute myocardial infarction. Prospective study. Immunoturbidimetrically determined myoglobin concentrations were compared with radioimmunoassay results obtained with the same blood samples. The diagnostic performance of myoglobin determination was compared with creatine kinase and creatine kinase MB activity (current standard of routine diagnosis). Part 1: coronary care unit. Part 2: emergency room in a university hospital. Part 1:30 patients with acute myocardial infarction admitted not later than four hours (median two hours) after the onset of symptoms. Part 2: 126 patients admitted to the emergency room with chest pain not caused by trauma (51 cases of acute myocardial infarction, 51 cases of angina pectoris, and 24 cases of chest pain not related to coronary artery disease). Part 1: routine treatment including intravenous thrombolytic treatment (28 patients). Part 2: routine emergency treatment without thrombolytic treatment. The analytical quality of the immunoturbidimetric myoglobin assay and a comparison between the myoglobin assay and creatine kinase and creatine kinase MB for diagnostic sensitivity and performance. The immunoturbidimetric myoglobin assay was fast and convenient and gave myoglobin determinations of high analytical quality. The concentration of myoglobin increased, peaked, and returned to the reference range significantly earlier than creatine kinase (p < or = 0.0001) and creatine kinase MB (p < or = 0.0002). Before thrombolytic therapy was started the diagnostic sensitivity of myoglobin was significantly higher than that of creatine kinase MB activity 0-6 h after the onset of chest pain and significantly higher (0.82 v 0.29) than creatine kinase 2-4 h after the onset of chest pain. In almost all patients (92%) plasma myoglobin concentrations were increased 4-6 h after the onset of chest pain. Myoglobin was more sensitive in detecting early myocardial infarction than creatine kinase and creatine kinase MB activity. Immunoturbidimetric myoglobin measurements could be useful in the early evaluation of patients with suspected myocardial infarction because this assay takes less than two minutes.


Short-stepping gait in severe heart failure.

Patients with severe chronic heart failure seem to take shorter steps than healthy controls when walking on a treadmill and when walking freely along a corridor. In healthy individuals the pattern of walking affects the oxygen cost of exercise, and so this observation might be relevant to the limitation of exercise in heart failure. Length of stride was analysed as stride/stature index in 15 controls, 10 patients with moderate heart failure, 10 patients with severe heart failure, and 10 patients with angina, walking at a constant speed/stature index. The stride/stature index was 0.64 in the controls in patients with New York Heart Association (NYHA) class II heart failure, and in patients with angina. It was 0.49 in patients with NYHA class III heart failure. In the patients with heart failure the stride/stature index correlated with exercise capacity determined as peak oxygen consumption VO2max (R = +0.62, p < 0.005). When healthy controls walked in time to a metronome adjusted to decrease their stride/stature index to approximately that seen in severe heart failure steady-state oxygen consumption increased by a mean of 15%. The length of stride is reduced in severe heart failure, and when healthy controls adopt this gait the oxygen cost of walking is increased. A short-stepping gait may contribute to the limitation of exercise capacity in heart failure.


Ventilation in chronic heart failure: effects of physical training.

To assess the effects of exercise training on ventilatory function in chronic heart failure. Observer blinded random allocation crossover training and detraining trial. Assessment in hospital based clinical laboratory; training home based. 22 patients with chronic heart failure (New York Heart Association (NYHA) class II or III) recruited from a tertiary referral centre. All finished the study. Bicycle ergometer exercise for 20 minutes a day, five days a week for eight weeks at 70%-80% of maximum heart rate. Exercise capacity on graded incremental exercise test, minute ventilation, oxygen consumption and carbon dioxide output. Peak work load increased from 96 W to 112 W and peak oxygen consumption from 14.1 ml/kg/min to 15.4 ml/kg/min (p < 0.01). At submaximal workloads carbon dioxide excretion (VCO2) and minute ventilation (Vi) decreased significantly (p < 0.05) though oxygen consumption was unchanged. The relation between Vi and carbon dioxide excretion changed: the slope of the Vi to VCO2 plot decreased from 38.6 to 35.3, indicating an improvement in overall ventilary efficiency. The instantaneous carbon dioxide ventilatory equivalent (Vi/VCO2) decreased at submaximal workloads, and reached a lower minimum value after training, indicating that optimum ventilatory performance improved. The exercise capacity of patients was related to the optimum ventilatory performance. It is suggested that this may in part be mediated through changes in skeletal muscles. Exercise training reduces the ventilatory abnormalities in chronic heart failure; thus some of these changes may be due to physical deconditioning.


Management of the cardiovascular manifestations of poisoning by the Indian red scorpion (Mesobuthus tamulus).

The efficacy of nifedipine and prazosin in combination or alone in the management of cardiovascular manifestations caused to Mesobuthus tamulus poisoning was investigated. Observation and study. Hospital at Mahad, Maharashtra, India. 62 patients who had been stung by a red scorpion were admitted from January to December 1990: 18 with hypertension, 15 with supraventricular tachycardia, 11 with pulmonary oedema, and 18 with local pain at the site of sting but no systemic involvement. Two patients with massive life-threatening pulmonary oedema were given intravenous sodium nitroprusside. The combination of nifedipine and prazosin was more successful in preventing myocardial damage in 16 patients with hypertension than was nifedipine alone in two other patients with hypertension. Prazosin alone helped to alleviate the cardiovascular manifestations in eight patients with pulmonary oedema and 15 with supraventricular tachycardia. One patient with pulmonary oedema died and two recovered after they were given intravenous sodium nitroprusside. Nifedipine alone did not prevent myocardial damage unless the peripheral action of venom was blocked by prazosin.


Use of casts in the necropsy diagnosis of fetal congenital heart disease.

To evaluate a casting technique in the interpretation of fetal cardiac anatomy. In 32 fetuses, the echocardiographic and cast features were compared and correlated. Three normal fetal heart specimens from spontaneous abortuses and 32 specimens from spontaneous or induced abortions with congenital heart malformation. There was close correlation between the echocardiographic and anatomical features in 32 abnormal fetuses studied. In some, additional features of diagnosis could be displayed on the cast and the relative sizes of the cardiac structures could be appreciated and defined. With increasing echocardiographic detection of congenital heart disease in early prenatal life, an increasing number of fetal heart specimens of small size are dissected for pathological confirmation. The use of silicone rubber casts to reproduce the internal anatomy proved a useful addition to dissection, providing a three dimensional model of the cardiac defect.


Left ventricular performance in children: transthoracic versus transoesophageal measurement of M mode derived indices.

To compare M mode derived indices of left ventricular performance obtained with transthoracic and transoesophageal echocardiography in children with congenital heart disease. Transthoracic and transoesophageal M mode echocardiograms were obtained under general anaesthesia before cardiac catheterisation. Recordings were digitised by dedicated software. Indices of cavity dimension and left ventricular wall dynamics were compared. 16 unselected patients with congenital heart disease. Group data for simple measurements of ventricular dimension and wall thickness were similar with the two techniques and had acceptable coefficients of repeatability, but there were considerable individual differences. Correlation was poor with unacceptable repeatability for derived indices of cavity and ventricular wall dynamics. Both transthoracic and transoesophageal echocardiography can be used to obtain M mode derived indices of left ventricular performance but the resultant measurements are not directly comparable, presumably because of regional non-uniformity of function.


Transoesophageal echocardiography in neonates, infants and children: applicability and diagnostic value in everyday practice of a cardiothoracic unit.

To determine the applicability of and information obtained by transoesophageal echocardiography in neonates, infants, and children in every day practice of a cardiothoracic unit. Four month prospective study. Supraregional centre for paediatric cardiothoracic services. 58 patients aged between four days and 16 years with a wide range of cardiovascular disease underwent transoesophageal echocardiography under sedation or general anaesthetic. One of two paediatric probes (6 or 7 mm diameter), or an adult probe (13 mm in diameter) was used. Whenever possible the investigation was immediately preceded by precordial echocardiography. Success, failure, technical difficulties, and complications of probe introduction and, when possible, comparison of the information obtained with that obtained from precordial echocardiography. Introduction of the probe was successful in 57 of the 58 patients. The only complication encountered was transient bradycardia during manipulation of the probe in a 2.2 kg baby. The adult (13 mm) probe was successfully used in children as small as 7.0 kg. Below this weight a smaller paediatric probe was required. In 56% of cases transoesophageal ultrasound provided information not obtained from the precordial approach. The technique was of particular value perioperatively and in the immediate postoperative period in neonates and infants and in the presence of valve prostheses and the investigation of mediastinal tumours in older children. Transoesophageal echocardiography is a valuable additional investigative tool for children of all ages. It is of particular value when acquisition of precordial image is impaired around the time of and after operation and in children with prosthetic valves or mediastinal tumour. Image quality was superior with the adult probe and we recommend the use of this probe unless the patient's weight is below 7 kg, when a paediatric probe allows this technique to be used usefully and safely in babies as small as 2.2 kg.


Comparative value of transthoracic and transoesophageal echocardiography before balloon dilatation of the mitral valve.

To assess the relative merits of transthoracic and transoesophageal echocardiography before balloon dilatation of the mitral valve. Transthoracic and transoesophageal echocardiograms were prospectively performed in 35 patients being considered for balloon dilatation of the mitral valve. Echocardiograms were analysed for image quality, the assessment of valve morphology, the detection of left atrial thrombus, and the assessment of mitral regurgitation and other valvar pathology. 35 consecutive patients with symptomatic dominant mitral stenosis. 30 eventually underwent balloon dilatation of the mitral valve by the Inoue technique. Five patients had mitral valve replacement. Echocardiographic and surgical detection of left atrial thrombus and successful, uncomplicated balloon dilatation of the mitral valve. Left atrial thrombus was detected in 1/35 patients by transthoracic studies compared with 6/35 from transoesophageal studies. Otherwise both techniques gave comparable results. Thrombus was confirmed at mitral valve replacement in five patients. Successful dilatation of the mitral valve was performed in 30 patients. Transthoracic echocardiography is a useful screening procedure but transoesophageal echocardiography is mandatory before balloon dilatation of the mitral valve for the detection of left atrial thrombus.


Echocardiographic demonstration of important abnormalities of the mitral valve in congenitally corrected transposition.

Whereas abnormalities of the morphological tricuspid valve are common in the setting of discordant atrioventricular connections, there are only a few postmortem reports of abnormalities of the mitral valve in this condition. This report describes two patients with discordant atrioventricular connections, in whom important abnormalities of the mitral valve were found during life by cross sectional echocardiography.


An analysis of the incidence of myocardial metastasis from solid cancers.

Metastasis to the heart is compared with that to other target sites in terms of incidence, tissue susceptibility, and cancer cell injury within the microcirculation. At necropsy the myocardium is the sixth most common site for arterial metastasis among eight target organs in ten different types of disseminated primary cancer. However, the metastatic efficiency index (incidence/blood flow) indicates that the myocardium is no less susceptible to metastasic per unit of cancer cells delivered than most other sites examined. The analyses also indicate that cancer cells causing myocardial metastasis are mainly derived from metastatic or primary tumours in the lungs. Experiments on laboratory animals suggest that the failure to develop myocardial metastasis in 80 to 98% of patients with metastatic cancer is at least partially due to lethal, deformation-associated, mechanical damage inflicted on cancer cells trapped within the myocardial microvasculature.


Conservative surgery of the mitral valve: a report of the first 100 cases from one unit and one surgeon.

To report the first 100 mitral valve repairs performed in a unit with an aggressive approach to conservative mitral valve surgery. Case notes were reviewed retrospectively and patients invited for clinical examination and cross sectional and Doppler echocardiography. Tertiary cardiothoracic referral centre. Between December 1985 and April 1991 mitral valve repair was carried out on 100 patients (66 males). Patients with pure mitral stenosis were excluded. Sixty seven had degenerative and 15 rheumatic mitral valve disease. Median age was 66 (range 12 to 79) years, with an interquartile range of 59 to 71 years. Operative procedures included annuloplasty ring in 97, resection of the posterior leaflet in 67, resection of endocarditic portion of posterior leaflet in four, commissurotomy in six, and correction of anterior leaflet abnormalities in seven. Thirty nine concomitant cardiac procedures were performed in 32 patients. Six operations were emergencies, and three of these required concomitant procedures. Mortality, operative failure rate, patients' functional state and degree of residual mitral regurgitation, incidence of thromboembolism, and endocarditis. Follow up ranged from one to 59 months, median 14 months, and an interquartile range of four to 23.5 months. Early mortality was 1%, late mortality 5%, and there was a 2% reoperation rate. Eighty four patients had moderate to severe mitral regurgitation preoperatively. At follow up mitral regurgitation was absent or mild in 78. Eighty six patients were in New York Heart Association (NYHA) class I-II at follow up compared with 80 in NYHA class III-IV preoperatively. There were no thromboembolic events. This study shows that satisfactory results can be obtained with mitral valve repair in a fairly elderly population with a high incidence of concomitant cardiac disorders. We suggest that these encouraging results will lead to earlier mitral valve repair in mitral regurgitation.


Transoesophageal Doppler echocardiographic measurement of cardiac output by the mitral annulus method.

To compare cardiac output measured by the transoesophageal Doppler and thermodilution techniques. Prospective direct comparison of paired measurements by both techniques in each patient. Intensive care unit in a cardiovascular centre. 65 patients after open heart surgery (mean (SD) age 53 (12) years). Cardiac output was measured simultaneously by the transoesophageal Doppler and thermodilution techniques. Cardiac output was measured again after a mechanical intervention or volume loading. The limits of agreement were -2.53 to +0.83 1.min-1 for cardiac output measured by the Doppler and thermodilution techniques. This suggests that the Doppler method alone would not be suitable for clinical use. The second measurement of cardiac output by thermodilution was compared with cardiac output estimated from the first and second Doppler measurements and the first thermodilution measurement. The limits of agreement (-0.55 to +0.51 1.min-1) were good enough for clinical use. After cardiac output had been measured simultaneously by both the Doppler and thermodilution techniques, subsequent transoesophageal Doppler alone gave a clinically useful measurement of cardiac output.


Comparison of trends in ischaemic heart disease between North Karelia, Finland, and Kaunas, Lithuania, from 1971 to 1987.

To compare the long-term trends in mortality and attack rate of ischaemic heart disease in North Karelia, Finland, and in Kaunas, Lithuania, from 1971 to 1987. Data on routine mortality statistics were obtained from the Central Statistical Office of Finland and from the Central City Archives of Kaunas. In addition, data from the community based myocardial infarction registers were used. The registers used similar diagnostic criteria and had operated in both areas during the entire study period. The province of North Karelia in Finland and the city of Kaunas in Lithuania. The target populations were the people of North Karelia and Kaunas aged 35-64 years. Mortality from ischaemic heart disease and the attack rate of acute myocardial infarction. In North Karelia mortality from ischaemic heart disease and the attack rate of acute myocardial infarction declined steeply both in men and women. This decline was accompanied by a decrease in total mortality. In Kaunas, both mortality and the attack rate increased in men but remained unchanged in women. In 1985 to 1987, age standardised total mortality per 100,000 inhabitants was similar in the two populations in men (1081 (95% confidence interval (CI) 1013 to 1149), in North Karelia; 1082 (95% CI 1032 to 1132), in Kaunas). The proportional mortality from ischaemic heart disease was considerably higher in North Karelia (40%) than in Kaunas (28%). In women, age standardised total mortality was lower in North Karelia (350 (95% CI 312-388)) than in Kaunas (440 (95% CI 413 to 467)). The proportional mortality from ischaemic heart disease in women was also higher in North Karelia (28%) than in Kaunas (13%). Despite the remarkable decline in the occurrence of ischaemic heart disease, it still remains the most important cause of premature mortality in North Karelia. In Kaunas ischaemic heart disease mortality and attack rate increased in men. Experiences from successful cardiovascular disease prevention programmes in western countries, such as the North Karelia Project, should be exploited to prevent an increasing epidemic of ischaemic heart disease in eastern Europe.


Intravascular ultrasound to assess left main stem coronary artery lesion.

A man of 70 underwent coronary arteriography for the assessment of angina. The appearance of the left coronary main stem was slightly abnormal but no definite stenosis could be delineated. Intracoronary ultrasound examination with a 4.8 French intravascular ultrasound probe showed an extensive plaque in the distal left main stem and proximal left anterior descending coronary artery, with a shelf-like projection causing 60% narrowing at one point in the distal left main stem. Since coronary bypass surgery the patient has been free of angina.


Rapid reversal of heart failure in a patient with phaeochromocytoma and catecholamine-induced cardiomyopathy who was treated with captopril.

A patient with a phaeochromocytoma and severe left ventricular heart failure caused by a catecholamine-induced cardiomyopathy is described. The clinical signs of congestive heart failure resolved rapidly on treatment with captopril and myocardial performance became normal within two weeks of medical treatment with captopril for one week and with captopril in combination with phenoxybenzamine for another week.


Delayed complications after myocardial contusion.

A 45 year old farmer was kicked in the chest by a horse. In the days following the injury episodic breathlessness developed and he was admitted to hospital with right ventricular failure and pulmonary emboli. Echocardiography showed global right ventricular dysfunction but a right ventricular mural thrombus, the likely source of the pulmonary emboli, was not seen. He gradually recovered after treatment with anticoagulant. One month later he presented with a further complication--complete atrioventricular dissociation--that required a dual chamber pacemaker implantation. This patient had few initial manifestations of right ventricular myocardial contusion and this case illustrates that such patients should be closely monitored for delayed complications.