P5743Overweight and obesity in adolescent men in Sweden and risk of early stroke

Background

Increasing numbers of stroke cases in the young are reported in many countries, potentially at least partly due to rising rates of overweight and obesity. Most data on the effect of obesity on stroke is derived from middle aged populations; there is a comparative lack of information on the effect of excessive body weight in young people.

Purpose

We aimed to determine whether body mass index (BMI) at age 18 predicted early stroke events among men in Sweden.

Methods

Population-based Swedish cohort study of conscripts (n=1,668,921; mean age at baseline, 18.3 years) who enlisted during 1968–2005. Follow-up was done through linkage to the nationwide Swedish patient and death registries. Risk of a first hospitalization for stroke (any type) during follow-up (5–46 years) was calculated with Cox proportional hazards models. Objective baseline measures of fitness and cognition were included in the models in a second set of analyses.

Results

During follow-up there were 12,512 first hospitalizations for stroke (mean age at diagnosis, 48.5 (SD 9.4) years, maximum 64 years). Compared with men with BMI of 18.5 to 20.0 kg/m2, men with BMI 20 to <22.5 and 22.5 to <25.0 kg/m2 had hazard ratios (HR) of 1.06 (1.00–1.12) and 1.23 (1.14–1.31), respectively, for hospitalization for stroke, after adjustment for age, year of conscription, comorbidities at baseline, parental education, blood pressure, IQ, muscle strength, and fitness. Those with a BMI of ≥35 kg/m2 had an HR of 3.33 (2.46–4.51) for an event before the age of 65, compared to slim men. The multiple-adjusted risk per 1-unit increase in BMI was 1.07 (95% CI, 1.06–1.08).

Conclusion

We found a rise in risk of early hospitalisation for stroke detectable already at normal levels of body weight at age 18, and rising to more than 3-fold in the highest weight category. Given increasing levels of body weight, and prevalence of overweight, obesity, and severe obesity in young adults, the increased incidence of stroke in the young may potentially partly be explained by rising body weight, with an obvious potential for prevention.

P4493Microvesicles from patients with pulmonary arterial hypertension modulate bFGF from endothelial cells

Background

Pulmonary Arterial Hypertension (PAH) is a progressive condition with remodeling of precapillary arteries. Cytokines involved in angiogenesis have been found elevated in PAH but the role of proangiogenic factors and their regulation is far from fully understood. Microvesicles (MVs) can act as intercellular messengers and modify cell production of proteins.

Purpose

To evaluate whether MVs from patients with PAH modulate proangiogenic factors in plasma and endothelial cells.

Methods

62 patients with PAH and 20 healthy controls were enrolled in the study. The number of MVs were determined in whole blood by flow cytometry. For in vitro studies, MVs were isolated from plasma and a primary endothelial cell line of human pulmonary artery endothelial cells between passages 3 to 7 were used. Protein levels in plasma and conditioned media were analyzed by electrochemiluminescence whereas protein levels in cell lysates were analyzed by western blot (WB).

Results

The majority of the MVs in whole blood were derived from platelets and patients with PAH had higher concentrations compared to healthy controls (p<0.0001). In plasma both basic Fibroblast Growth Factor (bFGF) and vascular endothelial growth factor receptor 1 (Flt-1) were increased in the patients as compared to healthy controls (median in pg/ml (IQR) Pat. vs Ctrl: bFGF 4.2 (2.5–9.2) vs 1.2 (0.9–2.1); Flt-1 143.0 (88.5–234.5) vs 53.9 (47.7–59.67); p<0.001 for both).

Endothelial cells were incubated with or without MVs for 18 hours and effects were monitored by analyzing eNOS and ICAM-1 levels by WB. Both markers were significantly altered, i.e. an about 50% decrease of eNOS and a 50% increase of ICAM-1, by patient MVs but not by the control MVs. The endothelial cells were then incubated with MVs for 6h, 12h, 24h, and 48h and bFGF and Flt-1 were measured in the conditioned media. The presence in media of both proteins were increased over time, but only bFGF was significantly regulated by MVs from PAH patient as compared to MVs from the control group at 24h (2.8 fold increase) and at 48h (12.7 fold increase).

Conclusions

An increase of two important proangiogenic proteins were found in PAH patients. The MVs from these patients modulate the endothelial response and contribute to a release of bFGF, whereas the Flt-1 levels are regulated by other currently unknown mechanisms. Further studies of the MVs from PAH patients are needed to elucidate how they are involved in the angiogenic process.

Acknowledgement/Funding

Swedish Research Council, Science For Life Laboratory Sweden

P2495Poor cardiorespiratory fitness in adolescence predicts cardiomyopathy risk in mid-life

Background

Cardiorespiratory fitness and physical activity have well–known cardio–protective effects. Along with reports on declining levels of physical activity globally, heart failure caused by cardiomyopathy is increasing among young people. Still, it is unknown whether poor fitness in adolescence can be associated with cardiomyopathy in adulthood.

Purpose

To study a possible link between cardiorespiratory fitness in adolescence and being diagnosed with cardiomyopathy in adulthood.

Methods

A nationwide register-based prospective cohort study of 1,668,893 young men (mean age 18.3 years, SD 0.7), enlisting for compulsory military service 1969–2005. Body mass index (BMI) and blood pressure were registered at baseline, along with test results for fitness. Values were trichotomized and about 13.5% were classified as having poor cardiorespiratory fitness. Cardiomyopathy diagnoses were identified from the National Hospital Register and Cause of Death Register, during an up to 46-year follow-up, and divided into categories: 1) dilated, 2) hypertrophic, 3) alcohol/drug-induced, and 4) other. Hazard ratios (HR) were calculated with Cox proportional hazards models.

Results

During follow-up (median 27 years; interquartile interval 19–35 years), 4,477 cases of cardiomyopathy were registered, of which 2,631 (59%) were dilated, 673 (15%) were hypertrophic, and 480 (11%) were alcohol/drug-induced. Poor cardiorespiratory fitness was strongly associated with elevated risk of both dilated (HR 1.59, 95% confidence interval (CI) 1.38–1.83) and alcohol/drug–induced cardiomyopathy (HR 2.32, 95% CI 1.68–3.20), adjusted for BMI, age at conscription, conscription year, test center, and baseline comorbidities (diabetes, hypertension, congenital heart disease).

Conclusion

The present study shows that poor cardiorespiratory fitness in adolescence may be associated with both dilated and alcohol/drug–induced cardiomyopathy in adulthood. This strengthens the evidence of fitness as a cardio–protective factor, and brings further support to the importance of interventions promoting physical activity already in childhood.

Acknowledgement/Funding

The Swedish Research Council, The Swedish Heart and Lung Foundation

P5297Body weight in adolescent men in Sweden and risk of an early acute coronary event

Background

To improve cardiovascular disease (CVD) prevention, knowledge of early key risk factors, especially those that are modifiable such as overweight and obesity, is essential.

Purpose

We aimed to determine whether body mass index (BMI) at age 18 predicted early acute coronary events among men in Sweden.

Methods

Population-based Swedish cohort study of conscripts (n=1,668,921; mean age at baseline, 18.3 years) who enlisted during 1968–2005. Follow-up was done through linkage to the nationwide Swedish patient- and death registries. Risk of an acute coronary event (hospitalization for acute myocardial infarction or coronary death) during follow-up (5–46 years) was calculated with Cox proportional hazards models. Objective baseline measures of fitness and cognition were included in the models in a second set of analyses.

Results

During follow-up there were 22,412 acute coronary events (mean age at diagnosis, 50.2 (SD 7.4) years, maximum 64 years). Compared with men with BMI of 18.5 to 20.0 kg/m2, men with BMI 20 to <22.5 and 22.5 to <25.0 kg/m2 had hazard ratios (HR) of 1.17 (1.12–1.43) and 1.51 (1.44–1.59), respectively, for an acute coronary event, after adjustment for age, year of conscription, comorbidities at baseline, parental education, blood pressure, IQ, muscle strength, and fitness. Those with a BMI of ≥35 kg/m2 had an HR of 3.47 (2.75–4.39) for an event before the age of 65. The multiple-adjusted risk per 1-unit increase in BMI was 1.10 (95% CI, 1.09–1.10).

Conclusion

We found a rise in risk of an early acute coronary event detectable already at normal levels of body weight at age 18, and rising to more than 3-fold in the highest weight category. Given increasing levels of body weight, and prevalence of overweight and obesity in young adults, the current decrease in coronary heart disease incidence in Sweden may flatten or even reverse in the near future.

Acknowledgement/Funding

The Swedish Heart and Lung Foundation [2015-0438]; the Swedish Research Council [2013-5187,2013-4236]

4949Diverging secular trends in cardiovascular disease 21-year incidence in Swedish men born in 1950–1978

Background

Cardiovascular disease (CVD) mortality is decreasing in Western countries, including Sweden. However, there are reports of increases in incidence in young people with respect to heart failure (HF) and atrial fibrillation (AF). The magnitude and causes of these changes are only partly known.

Aims

We investigated secular trends in incidence in CVD outcomes and their attenuation by changes in body mass index (BMI). The outcomes were risk of acute myocardial infarction (AMI), heart failure (HF) and atrial fibrillation (AF) as well as cardiovascular and all-cause death in a population of Swedish adolescents.

Methods

We followed a cohort of Swedish men enrolled for military service conscription in 1969–1996 (n=1,326,082; mean age=18.3) until December 2016, collected from the national inpatient (IPR) and outpatient registries (OPR). Cox-proportional hazard models were used to analyse the longitudinal change in incidence by with respect to early (0–21 years) of follow-up for subgroups with conscription 1968–1971, 1971–1976, 1976–1981, 1981–1986, 1986–1991, 1991–1996 (with the group born 1971–1976 as reference). Adjustments for potential confounders including BMI were performed.

Results

We found that CVD and all-cause mortality and MI decreased progressively during the follow-up with hazard ratios (HR) of 0.51, 95% confidence interval (CI) 0.43–0.62, HR 0.51 CI 0.57–0.62, and 0.60 CI 0.50–0.72, respectively. In contrast, we found increases in the incidence of HF (HR 1.86, CI 1.48–2.33], and AF (HR 8.26, CI 6.87–9.92). Adjustments for changes in BMI partly attenuated the changes in secular trends. Cubic spline models showed where the changes in secular trends were most prominent.

Conclusion

The incidences of cardiovascular outcomes show diverging secular changes. While MI and cardiovascular mortality are continually decreasing, there is an increase in HF and AF. The associations appear to be partly explained by changes in index BMI over time.

Acknowledgement/Funding

grants from the Swedish Government and the county councils, the ALF–GBG-719761, ALFGBG-751111, Swedish Stroke Association, Göteborg Medical Society

Tissue Factor/ FVIIa prevents the extrinsic pathway of apoptosis by regulation of the tumor suppressor Death-Associated Protein Kinase 1 (DAPK1)

INTRODUCTION

This study determines the impact of tissue factor (TF)-signaling on the extrinsic pathway of apoptosis in cancer cells and propose death associated protein kinase-1 (DAPK1) as a novel key regulator.

MATERIALS AND METHODS

In MDA-MB-231 breast and PC3 prostate cancer cells, mRNA levels were analyzed by real-time PCR and protein expressions were assessed by flow cytometry or western blot. Caspase-8 and -3 levels, cell size, and changes in nuclear morphology were recorded using the ArrayScan microscope and 84 apoptosis-related genes were screened with the RT2 Profiler™ PCR Array.

RESULTS

In serum starved MDA-MB-231 cells, a TF/FVIIa-sensitive upregulation of apoptosis markers was recorded. Similarly, TRAIL-induced apoptosis was negatively regulated by TF/FVIIa (10 and 100 nM) and TF/FVIIa/FXa but not by active-site inhibited FVIIa. FVIIa, moreover, decreased the transcription of DAPK1 and thereby diminished the association between DAPK1 and FADD in the caspase-8 activating death-inducing signaling complex (DISC). TF/FVIIa regulation of caspase-8 and DAPK1 was dependent on PI3-kinase/AKT and independent of the protease activated receptors (PAR) 1 and 2. Despite of receptor expression and functional signaling, both PAR-agonist treatment and PAR-blocking antibodies in combination with FVIIa failed to influence the anti-apoptotic signal.

CONCLUSIONS

We hereby report that TF/FVIIa-induced signaling governs the extrinsic pathway of apoptosis by reducing the levels of DAPK1 in the DISC independently of PAR1 and PAR2. This implies the conceivable involvement of cell surface components other than the PARs and entails the search for TF-dependent regulators of DAPK1 transcription.

Transfusion of intra-operative autologous whole blood: influence on complement activation and interleukin formation

BACKGROUND AND OBJECTIVES

Transfusion of autologous whole blood is one available method to reduce the need for allogenic blood transfusion. The objective of this study was to investigate the safety of transfusion of intra-operative autologous whole blood by monitoring plasma concentration of laboratory variables and adverse events after transfusion with the Sangvia(®) system.

MATERIALS AND METHODS

The clinical trial was designed as an open, prospective, multi-centre study, and a total of 20 patients undergoing primary hip arthroplasty were included. Systemic blood samples were taken and analysed preoperatively, at transfusion start and end and at 3, 6, 24 and 48 h after the transfusion.

RESULTS

Elevated values of complement activation and pro-inflammatory cytokines were seen in the intra-operatively collected blood but the impact on systemic levels were limited with low peak levels, systemic elevations before transfusion and normalization during the study period. Elevated levels of free haemoglobin and potassium were also detected in the intra-operatively collected blood, but systemic values were within reference values after the transfusion. No clinically relevant adverse event occurred during the study.

CONCLUSION

Inflammatory mediators and plasma haemoglobin were increased in intra-operatively salvaged and filtered blood compared to circulatory levels. Intra-operative retransfusion of autologous whole blood caused a transient systemic increase that normalized in the early postoperative period. There were no significant adverse events reported in the study. These data suggest that the Sangvia(®) system can be used for intra-operative collection and retransfusion of salvaged blood.

Considerations in evaluating new treatment alternatives following peripheral nerve injuries: A prospective clinical study of methods used to investigate sensory, motor and functional recovery

The current problem finding reliable and objective methods for evaluating results after peripheral nerve repair is a challenge when introducing new clinical techniques. The aim of this study was to obtain reference material and to evaluate the applicability of different tests used for clinical assessment after peripheral nerve injuries. Fifteen patients with a history of complete median nerve transsection and repair, and 15 healthy volunteers were included. Each subject was investigated using a battery of conventional and new tests for functional, sensory and motor recovery including questionnaires, clinical evaluations, neurophysiological and physiological findings. The results were statistically analysed and comparisons were made within the patient group and between patients and healthy volunteers using a 'per protocol' and an 'intention to treat' approach. Criteria for success were stipulated in order to be able to judge the usefulness of each method. The results showed that 19 of 34 variables, representing six of 16 methods, were not able to fulfil the criteria and were thus questionable for the evaluations of nerve repair in a clinical trial setting. However, 2pd, sensory recovery according to the non-modified British Medical Research Council, sensory neurography, manual muscle test, electromyography, questionnaires (i.e. DASH and the 4 question form) and performance tests (i.e. AMPS and Sollerman's subtests 4 and 8) did fulfil the criteria defined for being useful.

Utilisation of antihyperglycaemic drugs in ten European countries: different developments and different levels

AIMS/HYPOTHESIS

The aim of this study was to compare developments in the utilisation of antihyperglycaemic drugs (AHGDs) in ten European countries.

SUBJECTS AND METHODS

Data on the yearly utilisation of insulin and oral AHGDs were collected from public registers in Denmark, Finland, Norway, Sweden, Belgium, England, Germany, Italy, Portugal and Spain, and were expressed as defined daily doses per 1,000 inhabitants per day.

RESULTS

Total AGHD utilisation increased everywhere, but at different rates and levels. Insulin utilisation doubled in England and Germany, but hardly changed in Belgium, Portugal or Italy. Sulfonylurea utilisation doubled in Spain, England and Denmark but was reduced in Germany and Sweden. Metformin utilisation increased greatly everywhere. There were two- to three-fold differences in AHGD utilisation even between neighbouring countries. In Finland, there were more users of both insulin (+120%) and oral AHGDs (+80%) than in Denmark, and the daily oral AHGD doses were higher. In Denmark and Sweden, AHGD utilisation was equal in subjects aged <45 years, but in those >or=45 years of age, both insulin and oral AHGD utilisation were twice as high in Sweden.

CONCLUSIONS/INTERPRETATION

The ubiquitous increase in AHGD utilisation, particularly metformin, seems logical, considering the increasing prevalence of type 2 diabetes and the results of the UK Prospective Diabetes Study. However, the large differences even between neighbouring countries are more difficult to explain, and suggest different habits and attitudes in terms of screening and management of type 2 diabetes.

Microwave detection at 110 Ghz by nanowires with broken symmetry

By using arrays of nanowires with intentionally broken symmetry, we were able to detect microwaves up to 110 GHz at room temperature. This is, to the best of our knowledge, the highest speed that has been demonstrated in different types of novel electronic nanostructures to date. Our experiments showed a rather stable detection sensitivity over a broad frequency range from 100 MHz to 110 GHz. The novel working principle enabled the nanowires to detect microwaves efficiently without a dc bias. In principle, the need for only one high-resolution lithography step and the planar architecture allow an arbitrary number of nanowires to be made by folding a linear array as many times as required over a large area, for example, a whole wafer. Our experiment on 18 parallel nanowires showed a sensitivity of approximately 75 mV dc output/mW of nominal input power of the 110 GHz signal, even though only about 0.4% of the rf power was effectively applied to the structure because of an impedance mismatch. Because this array of nanowires operates simultaneously, low detection noise was achieved, allowing us to detect -25 dBm 110 GHz microwaves at zero bias with a standard setup.

A prospective double blind randomized study comparing the need for blood transfusion with terlipressin or a placebo during early excision and grafting of burns

INTRODUCTION

Early excision and skin grafting has become the standard of good burn management, but it is associated with major blood loss.

AIM

To determine the haemostatic effect of terlipressin compared with placebo.

MATERIAL AND METHODS

Fifty-one patients with burns of 10-20% total body surface area had early excision and split skin grafting of deep burns. The surface area of the burn wound and of the healed graft were measured by planimetry. The patients were randomly allocated to medication, either terlipressin or placebo. Blood loss and number of transfused units of blood were recorded.

RESULTS

Twenty-one patients received terlipressin, 13 received terlipressin late (cross-over) and 17 received placebo. Six out of 21 patients exposed to terlipressin were transfused with eleven units of packed red blood cells. Seven out of 13 patients crossed over from placebo to terlipressin (late terlipressin) were transfused with 17 units of blood. Eight out of 17 patients exposed to the placebo were transfused with 22 units of blood (P < 0.05). Graft healing was 1055 +/- 609 cm2 out of 1452 +/- 11 cm2 in terlipressin and 914 +/- 633 cm2 out of 1288 +/- 720 cm2 in the placebo group (n.s.).

CONCLUSION

Terlipressin reduced the need for blood transfusion by a factor of 2.5 compared to a placebo without impairment of graft healing.

HIV infection reduces skin graft survival in burn injuries: a prospective study

Impaired survival of skin grafts has been noted in human immunodeficiency virus (HIV) infected patients, but the reason is not known. Alterations in inflammatory response, which might be recorded as an imbalance in cytokine production, have been implicated. The aim of this study was to determine the impact of HIV infection in patients with burn injuries by comparison of split skin graft survival, T lymphocyte count and cytokine levels in HIV-infected and non HIV-infected patients in relation to healthy and HIV-infected nonburnt volunteers.Fifty-four patients with deep dermal burns were included. Fifteen patients' were HIV-infected. Thirteen healthy and 15 HIV-infected, volunteers were recruited as controls. The burnt surface area was traced on a transparent plastic sheet and converted to area. Graft survival on day of discharge/regraft for non HIV-infected patients was 69%, and in HIV-infected 22%, (p<0.05). The median length of hospital stay for early excision among non HIV-infected patients was 21 (12-53) days and for HIV-infected, 41 days (p<0.05). Serum protein levels in HIV-infected patients were elevated compared to non HIV-infected patients (p<0.05). CD4+ lymphocytes were depressed in HIV-infected volunteers and HIV-infected burn patients compared to healthy volunteers (p<0.05). CD8+ lymphocytes were elevated in HIV-infected volunteers compared to non HIV-infected burn patients. Pro-inflammatory cytokine levels of Interleukin-2 (IL-2), Interleukin-6 (IL-6), Interferon-gama (IFN-gamma) and tumour necrosis factor alpha (TNF-alpha) were depressed in HIV-infected volunteers compared to healthy volunteers and non HIV-infected burn patients. The pro-inflammatory cytokine IFN-gamma did not increase after burn injury in HIV-infected burns patients as did IL-2, IL-6 and TNF-alpha (p<0.05). Anti-inflammatory cytokine levels of IL-4 were elevated in HIV-infected volunteers compared to healthy volunteers and burn patients (p<0.05).

CONCLUSION

Graft survival after split skin grafting of burn wounds in HIV-infected patients is impaired and hospital stay is prolonged. HIV infection result in immune dysregulation, which might be related to impaired skin graft survival.

Dermabrasion of large congenital melanocytic naevi in neonates

We describe our findings in a series of 12 patients with large congenital melanocytic naevi treated with dermabrasion between the first and fourteenth week of life. Postoperative follow-up ranged from 1-16 years. In all but two cases dermabrasion resulted in an appreciable and stable reduction of the hyperpigmentation, possibly by reducing the number of pigmented cells in the epidermis. In six of our 12 patients, reconstruction using grafts and flaps was done to improve the aesthetic result. Seven years after dermabrasion, one patient developed a minimal deviation melanoma in the treated area, but his subsequent clinical course has been uneventful.

A prospective study of suicidal burns admitted to the Harare burns unit

The aim of this study was to obtain prospective information on suicidal (attempted suicide) burns patients admitted to the Harare burns unit during 1995-1998. Forty-seven patients, 42 females (89%) and five males (11%), evenly distributed throughout the period of study, were included. The median age was 25 years, range 13 to 50 years. Thirty were housewives (64%). Women married according to customary law were the group most at risk. All patients were burnt by flame after dousing themselves with paraffin or petrol. Conflict in love relationships was the most common circumstance leading to attempted suicide. The median Total Body Surface Area (TBSA) burnt was 60%, range 10-90%, for all patients, 25%, range 10-40%, for those who survived and 65%, range 20-95%, for those who died. Surgery was performed on 16 patients (34%). Mortality was 68%. The overall median hospital stay for all patients was 10 days, range 0-322 days, and 5 days, range 0-322 days, for those who died.

Facial growth in a cleft palate patient treated with the Herbst appliance: a long-term profile roentgenographic and roentgen stereometric analysis of profile changes and displacement of the jaws

OBJECTIVE

To monitor facial development in a patient with cleft palate who was treated with the Herbst appliance. Monitoring was in terms of changes in the skeletal profile and growth in the circummaxillary sutures and temporomandibular joints (TMJs).

DESIGN

Prospective profile roentgenography (between the ages of 6 and 20 years) and roentgen stereometric analysis (between the ages of 8 and 19 years).

SETTING

Center for Craniofacial Anomalies and Department of Plastic and Reconstructive Surgery, Malmö University Hospital, Malmö, Sweden.

PATIENT

Boy with cleft of the soft and posterior part of the hard palate and marked facial convexity.

INTERVENTIONS

Surgical repair of the soft palate at age 9 months, velopharyngeal flap at age 8 years, and insertion of implants under general anesthesia and treatment with the Herbst appliance at age 11 years. Roentgen examinations were performed in connection with continued clinical evaluations and treatment.

MAIN OUTCOME MEASURES

Profile roentgenograms were traced and measured by one of the authors using conventional point-based analysis. Stereo roentgenograms were digitized by the Department of Orthopedic Surgery, Malmö University Hospital.

RESULTS

The direction of profile changes was partly discordant with the direction of articular growth in the circummaxillary sutures and TMJs. The successful treatment result was accomplished by a temporary influence on sagittal growth direction in the circummaxillary sutures and on rotational growth direction in the TMJs, combined with a favorable natural remodeling and articular growth pattern.

CONCLUSIONS

The mode of growth by which treatment aims were reached was partly unexpected, i.e., discordant with the generally accepted principal concept that treatment with the Herbst appliance positions the mandible forward.

A Prospective study on the epidemiology of burns in patients admitted to the Harare burn units

The purpose of this study was to record the causes and the magnitudes of burn injuries prospectively and to evaluate the outcome of treatment of patients admitted to the burn units in Harare. The median age of the 451 patients included was 6 years (range: 1 month to 71 years), 54% were female and 46% male. The burn injuries were caused by flame in 51% of the cases and hot liquids in 47%. The overall median total body surface area burnt was 13% (range: 0.5 to 99%). Parasuicidal burns (attempted suicides) were noted in 11% of the patients with a median total body surface area burnt of 30% and mortality of 73%. Lodgers were overrepresented in the material. Delayed split skin grafting was done on 26% of the patients and early primary excision and skin grafting on 3%. The overall median hospital stay was 15 days (range: 0 to 229 days). The median hospital stay for patients with delayed split skin grafting was 42 days and that for those with primary excision and split skin grafting was 17 days. The overall mortality was 22%. All patients with burns larger than 65% of the total body surface area died. Burn injuries were more frequent and larger with higher mortality in females than in males. Flame was the major cause of the burns. Self-inflicted burns, noted mainly in young women, resulted in 73% mortality. Primary excision and grafting reduced hospital stay by 60% compared to delayed skin grafting.

Mandibulofacial dysostosis--variability in facial morphology and growth: a long-term profile roentgenographic and roentgen stereometric analysis of three patients

OBJECTIVE

To monitor and compare facial morphology and growth in three individuals with variable expression of mandibulofacial dysostosis (MFD) in terms of changes in the skeletal profile and in terms of growth in the circummaxillary sutures and temporomandibular joints (TMJs).

DESIGN

Retrospective conventional profile roentgenography (mean age 9 to 18 years) and prospective roentgen stereometric analysis (RSA) (mean age 7 to 17 years).

SETTING

Center for Craniofacial Anomalies and Department of Plastic and Reconstructive Surgery, Malmö University Hospital, Sweden.

PATIENTS

The first three MFD patients seen by one of the authors (B.R.).

INTERVENTIONS

Surgery was performed at the Department of Plastic and Reconstructive Surgery. Implants were inserted at surgery under general anesthesia. Roentgen examinations were performed in connection with continued clinical evaluations and treatment.

MAIN OUTCOME MEASURES

All profile roentgenograms were traced and measured by one of the authors (K.-V.S.) using a conventional point-based analysis.

RESULTS

The more afflicted patient showed a greater total difference in profile morphology and growth from the norm and more pronounced effects of articular growth restriction. Little change in the skeletal profile was associated with considerable displacement of the jaws.

CONCLUSIONS

The variability in MFD expression and surgical procedures in our patients is reflected less in the skeletal profile morphology and growth and more in the displacement of the jaws.

Bone grafts to the nose in Binder's syndrome (maxillonasal dysplasia): a follow-up of eleven patients with the use of profile roentgenograms

Bone grafts are used to lengthen the dorsum and elevate the tip of the nose in patients with Binder's syndrome. Disappointing long-term results in some patients generally have been assumed to be a result of resorption and/or displacement of the grafts. Treatment outcome was studied in 11 patients with the use of serial profile roentgenograms. At 40 months, the mean values after surgery were reduction of the initial transplant length by 28 percent and reduction of the transplant angle by 4 degrees. The initial nose length was increased by 1 mm, and nose tip projection was increased by 2 mm. Although the mean changes of nose length and nose tip projection seemed small, treatment outcome varied considerably between patients. In contrast with earlier assumptions, no correlation could be found between the degree of transplant resorption and/or displacement and the effect of surgery on nose length and nose tip projection.

Staged reconstruction of hypospadias with chordee: outcome and costs

One-hundred-and-forty patients with hypospadias and chordee were reviewed from the points of view of surgical results and hospital costs. Ninety cases constituted a historical series, and 50 patients a current personal series. All were operated on by Byars' two-staged protocol with release of the chordee followed by urethral reconstruction. Complementary surgery was necessary in a total of 37 instances, particularly in cryptohypospadias with tight chordee and in penoscrotal hypospadias. Increasing personal experience with the operative technique has gradually reduced the need for such procedures. The final results were satisfactory in all but one patient, who has had recurring strictures. The hospital cost for a patient according to basic assumptions was 100,280 SEK (about US$ 14,000). If the time in operating theatre could be shortened by 10 minutes, the stay in hospital reduced by one day, and the complication rate halved, the overall cost would be reduced by 14.3%. Consequently we believe that staged reconstruction remains an attractive alternative in cases of hypospadias with marked curvation of the penis.

Myotonic dystrophy revealed at videoradiography of deglutition and speech in adult patients with velopharyngeal insufficiency: presentation of four cases

Patients with velopharyngeal insufficiency (VPI) without cleft palate, who appear for the first time in adulthood for treatment, will probably reveal a high percentage of undiagnosed myotonic dystrophy (MD). Videoradiography of deglutition and speech reveals the diagnosis. Eleven adult noncleft palate patients with VPI were studied with videoradiography of the pharynx and esophagus. Three exhibited functional radiographic manifestations of MD during deglutition and speech. The diagnosis confirmed by neurologic examination was not known or suspected prior to videoradiography. An additional patient with VPI and suspected MD displayed the same constellation of radiographic findings. Follow-up examinations confirmed the diagnosis of MD. Three of the four patients had had symptoms of VPI since childhood, but none had complaints of deglutition problems except for accidental nasal regurgitations.

Basal cell carcinoma. An epidemiologic study in a defined population

BACKGROUND

The incidence of basal cell carcinoma (BCC) in a defined population is unknown.

METHODS

The incidence of histologically diagnosed cases of BCC in a defined population of a city in southern Sweden was studied. Four 2-year periods were examined from 1970 to 1986. Cases from 1970 and 1980 were reexamined microscopically.

RESULTS

From 1970 to 1986, the age-standardized incidence of BCC was doubled. BCC was equally common in male and female patients. It was possible to trace another BCC in the medical history of 41% of the patients. The risk of development of BCC increased rapidly with age greater than 55 years. Approximately two-thirds of the tumors were found in the head and neck region. There was a possible increase in superficial multicentric tumors on the trunk but otherwise an essentially unchanged pattern in type and distribution.

CONCLUSIONS

The age-standardized incidence of histologically diagnosed BCC was doubled from 1970 to 1986. The rapid increase should be taken into consideration when planning allocation of medical resources.

Effects of desmopressin acetate (DDAVP) and dextran on hemostatic and thromboprophylactic mechanisms

The effects on hemostatic and thromboprophylactic mechanisms of intravenous desmopressin (DDAVP, 0.3 micrograms/kg) and dextran 40 and 70 given both separately and in various combinations were evaluated in five male volunteers. Dextran did not inhibit the DDAVP-induced hemostatic changes. The dextran-induced decrease in platelet adhesiveness and the prolonged bleeding time were totally reversed by DDAVP. Hematocrit decrease was seen after both drugs, lasting longer when they were combined. We conclude that DDAVP and dextran may be used concomitantly, each with maintained beneficial properties. DDAVP will still act hemostatically by increasing platelet adhesiveness, factor VIII and von Willebrand factor and by shortening the dextran-induced prolongation of bleeding time. Dextran and DDAVP may even have additive antithrombotic effects due to the DDAVP-induced stimulation of the fibrinolytic activity, which is not inhibited by dextran, and to rheologic changes such as hematocrit decrease induced by both drugs.

Effects of normovolemic hemodilution on blood flow in the rabbit ear

The effect of isovolemic hemodilution using dextran-60 on arterial blood flow in the rabbit ear was investigated. The animals were anesthetized and an electromagnetic flow probe was applied around the central artery of the ear. Isovolemic hemodilution was performed during a 15 min exchange period. Two degrees of hemodilution were investigated [8.5 and 17 ml dextran-60/kg body weight (b.w.)] and compared with a nontreated control group. The two levels of hemodilution induced reductions in hematocrit to 29 and 21%, respectively, from the control level of about 40%. In all groups, blood pressure maintained constant levels throughout each experiment, which lasted 240 min. In the controls, ear artery blood flow was unchanged or decreased slightly during the experiment. The lower level of hemodilution caused a slight increase of blood flow after 4 h. In the group treated with 17 ml/kg b.w. dextran, blood flow gradually increased after 90 min following hemodilution. After 240 min, flow rates had increased to two- or threefold the initial rate in this group. Although other possibilities exist, the increased blood flow following hemodilution may be interpreted as reflecting a decreased resistance to flow in the tissue due to the decreased viscosity of the blood.

Infected wounds and repeated septicemia in a case of factitious illness

During 19 years an assistant nurse, now 35 years old, has been repeatedly treated for several malingered and self-induced disorders escalating to self-mutilation. An ulcer of her right leg never epithelialised in spite of various local treatments and surgical intervention. During repeated attacks of self-induced septicemia altogether 11 different bacterial species were isolated; on 8 occasions Rhodococcus equi. The septicemias were successfully treated with antibiotics. The underlying psychiatric problem, a borderline personality disorder, has not been possible to treat in a conventional manner. Probably due to collaboration between the plastic surgeon and the psychiatrist she has had fewer attendances and shorter hospital stays lately. Her prognosis is still dubious as regards further self-mutilation and other expressions of self-destructive behaviour.

Reconstruction with a free vascularized fibular graft for malignant bone tumor

Seven patients with a bone tumor were operated on with local excision and a free vascularized fibular graft. Four of the patients received both chemotherapy and radiotherapy. The blood flow in the grafts was evaluated by scintigraphy within 1 week after the operation. The median follow-up time was 4 (1-5) years. All but one graft-host junction healed primarily. There were 5 graft fractures in 3 patients. Four of the fractures occurred in 2 patients who received preoperative and postoperative chemotherapy and radiotherapy. Three of these fractures healed without surgery. Resorption of the grafts was never seen, whereas hypertrophy was observed in 6 patients. None of the patients had any permanent morbidity at the donor site. One patient had tumor recurrence and died after 2 years. Our findings indicate that a vascularized bone graft is also a useful alternative for reconstruction of large bone defects in patients receiving both chemotherapy and radiotherapy.

The effect of triglycyl-lysine-vasopressin (terlipressin INN, Glypressin) on skin blood flow, measured with laser Doppler flowmetry, thermography and plethysmography. A dose-response study

Triglycyl-lysine-vasopressin (TGLVP) has been shown to reduce blood loss in connection with early excision of experimentally induced burns in pigs. In order to determine an appropriate dosage of TGLVP in patients with burns, a dose-response study was undertaken. TGLVP was administered intravenously in various doses to healthy volunteers, and skin blood flow was measured with laser Doppler flowmetry, thermography and plethysmography. Blood pressure, heart rate and electrocardiac activity were monitored as well as serum and urine changes. The doses of 5, 10 and 20 micrograms TGLVP/kg b.wt. caused statistically significant reduction of skin blood flow; minimal values were 35, 26 and 25% of predrug values for the three doses, respectively. Thermography and plethysmography were less sensitive for detecting effects of TGLVP than laser Doppler flowmetry. Minor effects on blood pressure and heart rate were recorded after TGLVP, but no disturbances in electrocardiac activity. Urinalyses revealed an antidiuretic action of TGLVP. The study supports earlier findings and suggests a dose level of TGLVP for the use in excision of burns.

The influence of dextran and saline solution upon platelet behavior after microarterial anastomosis

Microarterial anastomoses were performed on the central arteries of the ears in rabbits. An untreated control group was compared with two groups treated with saline solution and dextran 70 in saline solution respectively. Anastomotic bleeding times were prolonged in both treated groups. In vivo accumulation of 32phosphorous labelled platelets infused prior to any treatment was measured at the anastomotic sites for two hours after anastomosis. Treatment with saline solution resulted in prolonged periods of platelet accumulation--desaggregation processes and abnormally high levels in 50 per cent of the rabbits. Treatment with dextran resulted in increased quantitative accumulation of platelets at all times compared with the control groups. In some rabbits treated with dextran, platelet accumulation patterns indicated microembolization due to increased platelet thrombus fragility. Despite increased platelet accumulation in the dextran groups all vessels showed good patency and only small amounts of thrombosis material compared with the control and saline solution groups. Poor patency was registered only in one instance in the control group and two instances in the saline solution group. Using ex vivo platelet aggregometry, saline solution slightly decreased and dextran slightly increased platelet aggregability. The conclusion is that dextran does not act as an antiplatelet agent but minimizes formation of dangerous solid fibrin platelet thrombi due to a defective fragile fibrin structure adn perhaps increased fibrinolysis.

Circulatory and renal effects of triglycyl-lysine-vasopressin and excision in experimental burns

The circulatory and renal effects of a deep dermal burn, covering one third of the total body surface area were studied in 12 thiopentone/N2O anesthetized piglets. Central circulation and renal function was monitored during 24 h and regional blood flows were determined before burn, 5 and 24 h after burn using radioactively labeled microspheres. One group was treated conservatively with fluid infusion only (control group) and the other with fluids, intermittent injections of a long-acting hormonogen, triglycyl-lysine-vasopressin (TGLVP), and excision 5 h after burn. There was earlier circulatory recovery in the TGLVP excision group with significantly higher arterial blood pressure and cardiac output than in the controls. TGLVP induced a major redistribution of blood flows, favoring the liver at the expense of the gastrointestinal tract, carcass and skin, while the blood flows were unchanged to the brain, heart and kidneys. There were also increased excretions of sodium and potassium and a temporarily increased diuresis. The earlier circulatory stabilization and blood flow redistribution might have clinical implications in burn care.

Reduction of blood loss by triglycyl-lysine-vasopressin during early excision of burns in pigs

In a burn model using anesthetized piglets, the circulatory and renal effects and the blood loss during and after excision were compared in two groups, one treated by triglycyl-lysine-vasopressin (TGLVP) given as intermittent bolus injections and the other serving as control. The third degree burn covered approximately 33% of the body surface area, and a solution containing 100 mmol NaCl/l in 2.5% glucose was infused at a rate of 2.4 ml/kg/% burn. Regional blood flows were determined before burn, 5 and 24 h after burn with the aid of radioactively labeled microspheres. Cardiac output (CO) decreased about 30% after burn and there was a slight further decrease of CO after the first TGLVP dose. After the excision there were similar restitutions of CO in the two groups. TGLVP induced an increase of blood flow to the hepatic artery, did not change flows to the brain, heart and kidneys and decreased flows to the preportal organs, carcass and skin 5 h after burn. After 24 h the perfusion of the skin and pancreas remained low but there were no differences in other organs. There was a significant decrease of blood loss associated with burn excision performed 5 h after burn in the TGLVP treated group, mean blood loss 39 g/25 kg versus 145 g/25 kg in the control group. There was a temporary increase in diuresis following TGLVP and also increased excretions of sodium and potassium. The results obtained in this study and possible clinical applications are discussed.

Endothelialization following end-to-end and end-in-end (sleeve) microarterial anastomoses. A scanning electron microscopic study

Eighteen microvascular end-to-end and eighteen end-in-end anastomoses were performed on the central arteries (diameters 0.8-1.2 mm) of rabbit ears. Specimens taken after intervals of 1-2 hours and 3, 7, 14, 30 and 90 days were studied using a scanning electron microscope. At 1-2 hours platelets and to a minor extent erythrocytes and fibrin had accumulated in defects between the vessel ends on sutures and at the suture holes of all end-to-end anastomoses. This had also occurred at the distal end of the telescoped segment in all end-in-end anastomoses. At 3 days endothelial desquamation at anastomotic sites and clamp sites was found in both end-to-end and end-in-end anastomoses. The exposed subendothelial surface was covered with a carpet of platelets, and frequently numerous leucocytes were found. Between 3 and 7 days, new endothelial cells appeared at the junction between the vessels in end-to-end anastomoses and in all areas damaged by vascular clamps. At the ends of the sleeved segments reendothelialization was observed over platelet aggregates. Between 7 and 14 days neo-endothelialization seemed to be virtually completed in both types of anastomosis. In the vicinity of the anastomoses, the appearance of the new endothelium was frequently abnormal with irregularly formed cells. Characteristic clefts and holes were seen between these abnormal (pleomorphic) endothelial cells. Histological findings from the same vessel specimens show that areas with abnormal endothelialization correspond to segments with intimal hyperplasia. Such areas were found in specimens throughout the entire period studied.(ABSTRACT TRUNCATED AT 250 WORDS)

Triglycyl-lysine-vasopressin or lysine-vasopressin in early excision of burns. An experimental study comparing the effects on blood loss, hemodynamics and renal function

Twelve piglets were submitted to a third degree burn covering one third of total body surface area under general anesthesia. Fluid treatment was given in amounts corresponding to 2.4 ml/kg/% burn/24 h, and hemodynamics and renal function were monitored for 24 h. Regional blood flows were determined with the aid of the radioactive microsphere technique before burn, 5 and 24 h after burn respectively. One group was treated with triglycyl-lysine-vasopressin (TGLVP) as bolus injections and the other with lysine-vasopressin (LVP) in infusion. Both groups were submitted to excision of the burned tissues after 5 h. Total blood loss was 39 +/- 9 g in the TGLVP group and 51 +/- 7 g in the LVP group (n.s.). TGLVP changed the distribution of cardiac output (CO) more than LVP did, leading to smaller blood flows to the splanchnic organs, skin and carcass while the perfusion of the brain, heart, liver and kidneys was similar after 5 h. The burn caused a 30% decrease of CO in both groups. After the first TGLVP injection there was a small further decrease in CO but after excision there were similar recoveries of CO in both groups. After 24 h the CO redistribution remained during LVP infusion, but those effects had almost vanished in the TGLVP group. Total diuresis and the glomerular filtration rate tended to be larger during LVP treatment but there was no significant difference in serum creatinine after 24 h. Thus both drugs decrease blood loss during early excision and they seem to have similar effects on circulation and renal function.(ABSTRACT TRUNCATED AT 250 WORDS)