Incidence of HIP Fractures among the Elderly in Satakunta, Finland

Background and Aims:

The aim was to describe the incidence rate of hip fractures in the elderly in a specific region in Finland and circumstances around them.

Material and Methods:

Retrospective analysis of 461 women and men aged 65 or older undergoing an operation for hip fracture during a two-year period between 1999 and 2000. 80 variables in all were obtained from the hospital discharge register and patient documents.

Results:

The age-specific incidence of hip fractures was higher in women than in men (women 6.88/1000 person/y vs. 3.50/1000 person/y). Prior to the fracture, patients were primarily doing well; 63.4% lived at home and 65.1% used no mobility equipment or aids. Altogether 41.9% of hip fractures occurred in institutions. Both women and men more often suffered their injury indoors (91.1% and 75.7% respectively), and only a slight seasonal variation was observed. More than every fourth (26.9%) had experienced a previous fracture.

Conclusions:

The age-specific incidence of hip fractures was higher in women than in men. The fractures took place mostly indoors and often in institutions. Therefore the measures that impact on indoor safety are particularly important for the elderly.

Pulse pressure and subclinical peripheral artery disease

Ankle-brachial index (ABI) measurement offers an easily available method to diagnose peripheral artery disease (PAD) and systemic atherosclerosis in early stage and thus to identify high-risk individuals for preventive interventions. The objective of this study was to assess the most practical criteria for the measurement of ABI in subjects with high cardiovascular risk. We examined 972 asymptomatic, middle-aged high-risk subjects without manifested cardiovascular disease or previously diagnosed diabetes. The prevalence of PAD (defined as ABI0.90) and borderline PAD (0.91-1.00) were 5% (95% confidence interval (CI) 4-7%) (49/972) and 20% (95% CI 18-23%) (192/972), respectively. In multivariate analysis, female gender (odds ratio (OR) 0.71 (95% CI 0.53-0.97)), current smoking (OR 2.14 (95% CI 1.47-3.11)) and pulse pressure (OR 1.03 for each increase of 1 mm Hg (95% CI 1.01-1.04)) were associated with low ABI. Measuring ABI in subjects who smoke or have pulse pressure >65 mm Hg seems to be worthwhile.

High-sensitivity C-reactive protein and ankle brachial index in a finnish cardiovascular risk population

High-sensitivity C-reactive protein (hsCRP) has been previously linked to different forms of vascular disease. However, some studies have not found any relationship between hsCRP and atherosclerosis. Also, studies investigating correlation between hsCRP and ankle brachial index (ABI) are scarce. We studied hsCRP in a cardiovascular risk population with a special interest in correlation between hsCRP and ABI. All men and women aged 45 to 70 years from a rural town Harjavalta, Finland were invited to participate in a population survey. Diabetics and people with known vascular disease were excluded. Seventy-three percent (n = 2085) of the invited persons participated and 70% of the respondents (n = 1496) had at least one risk factor to cardiovascular diseases. These subjects were invited to further examinations. From them we measured ABI, hsCRP, leukocyte count, glucose tolerance, systemic coronary risk evaluation (SCORE), body mass index (BMI), and waist circumference. Mean hsCRP was 1.9 mg/L. Smokers had higher hsCRP (mean 2.2 mg/L) than nonsmokers (mean 1.8 mL/L). hsCRP in women was higher than in men (mean 2.0 mg/L versus 1.8 mg/L). Mean ABI was 1.10, and the prevalence of peripheral arterial disease was 3.1%. ABI correlated weakly with hsCRP (r = -0.077, p = 0.014), leukocyte count (r = -0.107, p = 0.001), and SCORE (r = -0.116, p = 0.001). It did not have correlation between age, weight, BMI, or waist circumference. hsCRP correlated with BMI (r = 0.208, p < 0.0001) and waist circumference (r = 0.325, p < 0.0001). When we excluded subjects with hsCRP >10 mg/L, ABI no longer correlated with hsCRP. In a cardiovascular risk population, hsCRP has only a weak correlation with ABI, and this correlation disappeared when we excluded subject with hsCRP >10 mg/L. Instead, hsCRP was correlated to the measures of obesity (waist circumference and BMI), indicating its role as a marker of adipose tissue-driven inflammation. hsCRP does not seem to be a suitable screening method for peripheral arterial disease.

Withdrawal of psychotropic drugs decreases the risk of falls requiring treatment

This non-randomized, controlled trial assessed the effects of ceasing fall-risk-increasing drugs (FRIDs) (psychotropics or opiates or potent anticholinergics) on the risk of falls requiring medical treatment as a sub-analysis of a randomized, controlled multifactorial fall prevention. The population in this 12-month study consisted of 528 community-dwelling subjects aged 65 years or older with a history of at least one fall. The subjects were divided retrospectively into three groups according to the use of any FRID, any psychotropic drug, and benzodiazepine or related drug (BZD/BZDRD). The subjects in the intervention group (IG) ceasing the drug use were compared with the subjects in IG and the control group (CG) not ceasing the use of the corresponding type of drugs during the intervention period. Falls were recorded from medical records. For the year after the 12-month intervention the relative risk ratio (with 95% confidence intervals=CI) for controls in CG compared with the withdrawal group in IG was 8.26 (1.07-63.73) among the users of psychotropics and 8.11 (1.03-63.60) among the users of BZDs/BZDRDs. Withdrawal of psychotropics, especially BZDs/BZDRDs may have played an important role by lowering the risk of falls requiring medical treatment during the year after the 12-month multifactorial intervention.

Cervical hip fracture in a Finnish population: incidence and mortality

BACKGROUND AND AIMS

Our aim was to describe the incidence of cervical hip fractures and to describe the relationships between selected background variables and mortality at 30 days, 6 months, and 3 years postoperatively.

MATERIAL AND METHODS

The basic material consisted of population-based data set of patients aged 65 years or older who had sustained a hip fracture and were treated operatively between 1999 and 2000. Out of these, we identified 266 consecutive patients with cervical hip fracture.

RESULTS

The age-adjusted incidence of cervical hip fractures in women was 1.3-fold compared to men. In age-adjusted analysis, occurrence of chronic lung disease, cardiovascular disease or 2-5 comorbidities, male gender, the need for 2-person mobility assistance, and poor ambulation postoperatively were associated with excess mortality at least at one evaluation point.

CONCLUSIONS

Only chronic lung disease and male gender were independent predictors of increased mortality at each follow-up assessment in multivariate analysis.

A multifactorial fall prevention programme in home-dwelling elderly people: a randomized-controlled trial

OBJECTIVES

To describe the implementation and the effects of a multifactorial fall prevention trial on the specified risk factors of falling, incidence of falls and injurious falls, and on specified secondary outcome measures; to describe the design of the study and to assess the success of randomization.

STUDY DESIGN

Randomized-controlled trial.

METHODS

Recruitment started in March 2003 and lasted until the end of January 2005, when a total number of 591 participants was reached. Participants were randomized into two age groups (65-74 years and 75 years and over), then into an intensive multifactorial risk-based prevention programme or into a one-time counselling on fall prevention. The intervention included individual geriatric assessment, guidance and treatment, individual guidance on fall prevention, physical exercise in small groups, psychosocial group activities, lectures, home-exercises and home hazards assessment.

RESULTS

A total of 293 people were randomized into the 1-year prevention programme and 298 into the control condition. The mean age was 73.5 years in both groups; 84% of the participants were women. The groups were well balanced at baseline in relation to risk factors of falls, and the only statistically significant difference was found in the amount of regularly taken medicines, which was significantly lower in the control group: mean 3.7 (SD 3.0) vs. 4.2 (SD 3.1), P=0.028.

CONCLUSIONS

Participants were successfully randomized into a multifactorial fall prevention trial.

Comparison between flutter valve drainage bag and underwater seal device for pleural drainage after lung surgery

AIM OF THE STUDY

The purpose of the present study was to compare the use of a conventional underwater seal device with suction and a flutter valve drainage bag for pleural drainage after lung surgery.

PATIENTS AND METHODS

Altogether 59 patients undergoing elective lung surgery except pneumonectomy between February 2001 and April 2002 were prospectively randomized to receive postoperative pleural drainage by 28F chest tube(s) attached to underwater seal device placed on negative pressure of 15 cm of water or flutter valve drainage bag. Following withdrawal of four patients from the study, 55 patients were evaluated (31 patients in the underwater seal device group and 24 patients in the flutter valve drainage bag group).

RESULTS

In the conventional underwater seal device group the mean drainage time was 2.6 (SD +/- 2.0) days and in the flutter valve drainage bag group the mean drainage time was 3.3 days (SD +/- 4.0); difference -0.8, 95% confidence interval (CI) -2.4 to 0.9. The mean length of hospitalization in the surgical ward was 3.6 (SD +/- 2.7) and 4.1 (SD +/- 4.4) days respectively (difference -0.5, 95% CI -2.5 to 1.4).

CONCLUSIONS

The results of this study suggest that flutter valve drainage system is a safe and feasible alternative in managing postoperative air leaks and haemorrhage after lung surgery other than pneumonectomy if air leaks are not extremely massive.

Glove perforation in orthopaedic and trauma surgery

The spread of viral diseases such as HIV has highlighted the importance of protecting medical personnel against contamination from blood. We have assessed the frequency of the perforation of surgical gloves during orthopaedic and trauma surgery and compared the efficiency of single and double gloving.

We examined all the gloves used by surgeons for a period of two months. There were 1769 gloves from 349 operations. Perforations occurred in 18.5% of conventional and 5.8% of arthroscopic procedures. The risk of contamination from blood was 13 times higher when using single compared with double gloves. Surprisingly, the combination of two regular gloves was much less efficient than double indicator gloves when comparing the rate of perforation of the inner glove when the outer had been damaged (24% vs 4.9%; p = 0.02).

We recommend double gloving in orthopaedic surgery in general and also in long arthroscopic procedures.

Glove perforations in open and laparoscopic abdominal surgery: the feasibility of double gloving

BACKGROUND AND AIMS

According to the traditional view, the glove protects the patient from the bacterial growth of the surgeons' hands and doing so prevents infections. Today, with growing incidences of HIV and Hepatitis B and C, surgical gloves are also important as protection for the surgeon. We compared the safety of double indicator gloves to standard single surgical gloves by investigating how often surgical gloves are punctured in laparoscopic and open gastrointestinal surgery.

STUDY

As study material we gathered all gloves that had been used in gastrointestinal surgery in Satakunta Central Hospital during two months. 814 gloves from 274 operations were tested by using standardized water filling test method.

RESULTS

In open surgery 67 gloves out of 694 had been punctured (9.6 percent). Puncture occurred in 22.5 percent of operations (53 out of 236). During open surgery 24 holes out of 35 were undetected with single gloves (69 percent). With double indicator gloves, only 3 out of 31 holes were unnoticed (10 percent). Long duration of operation increased the risk of puncture. In laparoscopic operations 4 gloves out of 120 had been perforated (3.3 percent).

CONCLUSION

Double surgical gloves give markedly better protection in surgery. This is important especially in high risk operations.

Endovascular treatment of aortic aneurysms in Finland: the first four years' experience

BACKGROUND AND AIMS

In this study the results of endovascular treatment of aortic aneurysms in Finland are presented and compared to the results of the Eurostar registry.

MATERIAL AND METHODS

A total of 229 patients with aortic aneurysm were treated in five different Finnish centres during 1996-2000. The data of these patients were collected prospectively by surgeon or interventional radiologist involved. During the same period of time 2464 patients were registered in the Eurostar registry.

RESULTS

The procedure was performed successfully in 97% of patients in Finland, and the 30-day mortality was 0,9%. A graft limb thrombosis was detected in 9% of the patients in Finland. A permanent primary endoleak at the first 30-day control was seen in 23 patients (10%). During the follow-up 17 secondary endoleaks (7%) were detected. A secondary intervention was necessary in 26% of the patients. Three patients (1.3%) had late rupture of the abdominal aortic aneurysm.

CONCLUSIONS

According to the Finnish short-time results, endovascular treatment of aortic aneurysms is safe and associated with relatively low morbidity and mortality. The mid-term results are more disappointing with relatively many graft thromboses and endoleaks, and a frequent need of secondary interventions.

Flutter valve drainage bag is a useful device for the pleural drainage

BACKGROUND AND AIMS

The purpose of the present study was to compare the use of the flutter valve pleural drainage bag and the conventional underwater seal system for the pleural drainage in the treatment of pneumothorax and pleural effusion.

PATIENTS AND METHODS

Altogether fifty patients who needed the pleural drainage at our hospital between February and October 1999 were randomized to this prospective study either into the flutter valve pleural drainage group or into the conventional underwater seal pleural drainage group, 25 patients in each.

RESULTS

In the conventional underwater seal system group, the mean drainage time was 4.1 (SD +/- 4.0) days and in the flutter valve drainage bag group 4.8 (SD +/- 4.9) days (difference -0.7, 95% confidence interval (CI) -3.3 to 1.8). The mean length of hospitalization was 16.3 (SD +/- 20.9) days and 18.7 (SD +/- 27.0) respectively (difference -2.4, 95% CI -16.1 to 11.3).

CONCLUSIONS

The results of this study suggest that flutter valve drainage bag is a safe and feasible system in the most cases when pleural drainage is needed in the treatment of pneumothorax and pleural effusion.

Insulin secretion and glucose kinetics during exercise with and without pharmacological alpha(1)- and alpha(2)-receptor blockade

The mechanism behind exercise-induced decreases in plasma insulin concentrations was examined in eight healthy young men. In addition, the influence of specific alpha(1)- and alpha(2)-adrenoceptor blockade on glucose kinetics during exercise was studied. To test the hypothesis that exercise-induced decreases in insulin secretion are mediated via alpha(2)-adrenoceptors, all subjects exercised for 60 min on separate occasions under four conditions: with and without alpha(1)-receptor blockade (1 mg prazosin) and with and without or alpha(2)-receptor blockade (15 mg yohimbine). Glucose kinetics were measured using [3-(3)H]glucose. During exercise with alpha(2)-receptor blockade, the insulin concentration initially increased (first 20 min) then decreased, whereas it continually decreased in the corresponding control experiment. The C-peptide concentration did not change during exercise with alpha(2)-receptor blockade but decreased in the control experiment. During exercise with alpha(1)-receptor blockade and corresponding control experiments, insulin and C-peptide levels always decreased. With alpha(1)-receptor blockade, the glucose concentration increased (first 30 min) and then decreased, whereas it slightly decreased in all other experiments. In addition, with alpha(1)-receptor blockade, the glucose rate of appearance (Ra) increased rapidly (because of higher catecholamine concentrations in alpha(1)-receptor blockade versus control) and the glucose rate of disappearance (Rd) was higher compared with control. During exercise with alpha(2)-receptor blockade, the Ra and Rd were always lower compared with control. Therefore, we conclude that exercise-induced decreases in insulin secretion are mediated via alpha(2)-adrenoceptors and that blockade of alpha(1)- and alpha(2)-adrenoceptors during exercise elicits opposite responses in glucose Ra and Rd.

How often does glove perforation occur in surgery? Comparison between single gloves and a double-gloving system

BACKGROUND

In surgery, intact gloves protect the surgeon from bloodborne pathogens and the surgical wound from microorganisms on the skin of the surgeon. However, glove perforation is very common, and puncture rates as high as 61% are published in the literature. One objective of this study was to compare puncture rates between a unique double-gloving puncture indication system and single-use gloves, and another was to determine the extent to which glove perforations remain undetected during surgery.

METHODS

The study material comprised all gloves used in surgical operations at our hospital for a period of 2 months. The analysis was made by the glove type in a prospective and randomized manner. Gloves were tested immediately after the surgical procedure using the approved standardized water-leak method for 2 minutes to detect any holes. The gloves used in this study were either a double-gloving puncture indication system or the standard glove used at our hospital.

RESULTS

In 885 operations altogether, 2,462 gloves were tested; 1,020 single gloves, 1,148 double-glove systems, and 294 combination gloves were studied. The overall perforation rate was 192 out of 2,462 gloves (7.80%), and 162 out of 885 operations (18.3%). The detection of perforation during surgery was 28 out of 76 (36.84%) with single gloves, 77 out of 89 with the double-gloving system (86.52%), and 9 out of 27 with combination gloves (33.33%; P <0.001). The inner glove of the double-gloving system was punctured in 6 out of 88 outer glove perforations (6.82%).

CONCLUSIONS

In view of the critical importance of safety at work by having a sterile barrier between surgeon and patient, it is very important to use a double-gloving puncture indication system, at least in operations where there is a high risk of glove perforation.

Glove perforation rate in vascular surgery--a comparison between single and double gloving

BACKGROUND

In surgery intact gloves act as a sterile barrier between surgeon and patient. The impermeable gloves protect the surgeon from bloodborne pathogens such as HIV, hepatitis B, and hepatitis C. On the other hand, the surgical wound is protected from micro-organisms from the skin of the surgeon. One objective of this study was to compare puncture rates between the double gloving color indication system and single-use gloves and the other to determine the extent to which glove perforations remain undetected during the course of vascular surgical operations.

PATIENTS AND METHODS

The study material comprised all gloves used in vascular surgical operations at Satakunta Central Hospital for a period of two months. The analysis was made by the glove type in a prospective and randomised manner. Gloves were tested immediately after the surgical procedure using the approved standardized water-leak method. With this method the glove is filled with water using a special filling tube, and the water-filled glove is then checked for two minutes to detect any holes. The gloves used in this study were either double gloves with indicator, or the standard glove used at our hospital.

RESULTS

In 73 operations altogether 200 gloves were tested, half of them were double gloves and half were single gloves. The perforation occurred in the double gloves 3 times and with single gloves 12 times. The overall perforation rate was 15 out of 200 gloves (7.5%). The detection of perforation during surgery was 60%. Most frequently the perforation was located in the second finger of the left hand, 9 out of 15 perforations.

CONCLUSION

In view of the critical importance of safety at work both transmitting the pathogens from the skin of the surgeon to the wound and transmitting the bloodborne pathogens from the patient to the surgeon, it is very important to use double gloving at least in operations where there is a high risk of glove perforation.

A new method for surgical consultations with videoconference

BACKGROUND

The aim of our prospective study was to examine the technical ability and the medical suitability of a realtime teleconferencing system in surgical consultations.

METHOD

A personal computer-based-videoconferencing system was used over an architecture of the IP (Internet Protocol) over ATM (Asynchronous Transfer Mode) area network connecting Satakunta Central Hospital, Pori with a health center in the community of Noormarkku (15 km apart from Pori). A document camera was used for transfering the radiographs and paper documents. The material consisted of 50 patients who needed surgical consultation. The patients were examined by a physician in the health center of Noormarkku, and the surgeon interviewed and observed the physical examination with the aid of teleconference.

RESULTS

Technically the videoconferencing system functioned reliably, and the visual quality of the videopicture was good after more powerful personal computers (Pentium II with a 266 MHz prosessor and 64 Megabits RAM-memory) were changed for the videoconferencing system. All patients, except one, saved the travelling to the face-to-face appointment because they got a definite decision of the treatment already at the videoconsultation. According to the opinion of the consulting surgeon, the decision which was made in the teleconference was good or very good, except in one case very poor. The physicians of the health centers were satisfied both with the decisions of the treatment of their patients and with the educational effect of a consultation where two physicians are present at the same time. All patients thought that it was good to be in consultation with two doctors.

CONCLUSION

Surgical videoconsultations are a reliable method and a real alternative to sending a patient to a distant place for consultation.

User satisfaction with teleconsultations for surgery

We carried out a prospective study of realtime videoconferencing in surgical consultations. Videoconferencing equipment at the Satakunta Central Hospital, Pori, was connected by ISDN at 384 kbit/s to two health centres in the cities of Kankaanpää and Huittinen (55 and 60 km from Pori, respectively). A document camera was used to transmit images of radiographs and paper documents. Fifty patients who needed a surgical consultation were examined by a doctor in the health centres, and the surgeon interviewed and observed the physical examination by videoconference. The consultation time ranged from 12 to 23 min (mean 15 min). Technically the equipment functioned reliably and the quality of the video-picture was good. According to the consulting surgeon, the decision made in the videoconference was reliable in 48 cases (96%). According to the doctors in the health centres, the consultation was useful in 49 cases (98%) and was considered satisfactory in one. The doctors thought that the teleconsultation was as reliable as an outpatient appointment in 49 cases (98%). The educational benefit of the consultation was excellent or good in 38 cases (76%). The overall satisfaction of patients was very good or good in 45 cases (96%). All patients, except one, avoided travelling to a face-to-face appointment because they received a definite treatment decision during the teleconsultation.

Healing of bronchial allografts in pigs

Our purpose was to investigate the healing of bronchial grafts in a porcine experimental model. Via left thoracotomy, a 2.5 cm long bronchial stump was anastomosed back to the same animal (autograft) or to another pig (allograft). Autotransplanted bronchi (six pigs) healed very well without infection. Allotransplantation without immunosuppression (eight pigs) was followed in all cases by rejection with formation of major bronchopleural fistula. After allotransplantation with triple-drug immunosuppressive medication (seven pigs), three pigs showed infection-free healing, but the anastomoses were slightly stenosed at the time of sacrifice (mean 30 d), while four had bronchopleural fistula. The study thus showed the healing ability of totally avascular bronchial graft in pigs to be very good when it is autotransplanted, but poor when allotransplanted without immunosuppressive treatment.

Percutaneous dilational tracheostomy or conventional surgical tracheostomy?

OBJECTIVE

Percutaneous dilational tracheostomy (PDT) is increasingly used in intensive care units (ICU), and it has a low incidence of complications. The aim of this study was to compare the costs, complications, and time consumption of PDT with that of conventional surgical tracheostomy (ST) when both procedures were performed in the ICU.

DESIGN

The study was a prospective, randomized trial.

SETTING

The procedures were performed routinely in the ICU of Satakunta Central Hospital.

PATIENTS

During a 23-month period from December 1995 to November 1997, 30 patients underwent PDT and 26 patients had ST. In one patient, PDT was converted to ST. All patients were receiving ventilation in the ICU, and all tracheostomies were performed at the patient's bedside in the ICU. The Portex percutaneous tracheostomy kit was used for all PDTs.

RESULTS

The mean time to perform PDT was 11 mins (SD, 6; range, 2-40), and the mean time to perform ST was 14 mins (SD, 6; range, 3-39). In the PDT group, five patients had moderate bleeding during the procedure. In three patients, the bleeding was resolved with compression; in one patient, it was resolved with ligation of the vessel; and in one patient, it was resolved with electrocoagulation. Bleeding did not cause any complications afterward. In the PDT group, one patient had minimal oozing from the wound edge on the first postoperative day and it was resolved spontaneously. In the ST group, there were no intraprocedural complications. One patient had bleeding from the wound on first postoperative day. The sutures were removed, and the bleeding vessel was ligated. The mean cost (in U. S. dollars) of PDT was $161 (SD, 10.4; range, $159-$219), and the mean cost of ST was $357 (SD, $74; range, $239-$599). The cost of PDT was significantly lower than the cost of ST (p < .001).

CONCLUSION

We found that PDT is a cost-effective procedure in critically ill ICU patients. Although we performed ST at the bedside in the ICU to avoid the risks associated with moving critically ill patients to the operating room, we found PDT to be a simple and safe procedure.

Using IP-videoconferencing systems in a surgery consulting

In this paper we describe how to use IP-videoconferencing systems in medical surgery consulting. We started to think about how we could use special doctor's services without patients having to travel a long way. The answer to this question is that the information goes from one place to another, not the patient. First we had a pilot project, where we used the 3xISDN transmission rate and now we are using ATM. We have here in Satakunta a local area network between our Satakunta Central Hospital and the Health Care Center in Noormarkku and Kankaanpää, so we have very good environment to do this kind of research. Our network is quite fast, we can use the 10 Mbps bitrate and in this network there are no other activities in this moment, so there are not any interferences. There is a surgery specialist in the hospital and a doctor in the health care center with a patient. The specialist looks at the monitor, where there is a videopicture of the patient from the health care center. Then the specialist makes the treatment plan for the patient.

End-user point of view to establish real-time broadband ATM connection over Europe

There have so far been few discussions about how the international broadband services will be created in practice. In this paper we concentrate on two separate international telemedicine trials in which Satakunta Central Hospital took part in the HIM project. In these trials we tested real-time video consultation over the international point-to-point ATM network connection between hospitals in Finland, Portugal and Germany. The quality of the consultations were clinically first-rate in both trials. The technological lesson learned from these trials was valuable for the operators in establishing broadband connections in Europe. The network connection was analysed based on transmission capabilities of the network connection.

Vascular Clips in Anastomoses of Femoropopliteal Arterial Reconstruction

The vascular anastomoses are usually made with sutures. Some mainly experimental studies have been published about a new method of doing the vascular anastomoses with metal clips. We studied the suitability of vascular closure staple (VCS) clip applier system for making the anastomoses in femoropopliteal and femorotibial arterial reconstruction. During an 11-month period, VCS clips were used in 17 out of 27 patients who were operated due to severe claudication or incipient gangrena of the foot. Altogether 26 anastomoses were made with VCS clips using either great saphenous vein or PTFE graft. The making of anastomosis was easy and reliable. No postoperative bleeding was noticed. All anastomoses were patent 4-6 weeks postoperatively studied by palpation and measured by ankle brachial pressure index (mean 0.96). In Duplex Doppler examination all studied patients had well patent anastomoses on an average 11 months after the operation. With VCS clip applier system, it is possible to do anastomoses in arteriosclerotic arteries like in femoropopliteal reconstructions. This method helps making reliable anastomoses more easily.

Abdominal disorders arising from 71 Meckel's diverticulum

BACKGROUND AND AIMS

The study was done to investigate the frequency of Meckel's diverticulum, and its manifestations as the cause of abdominal disorders.

MATERIAL AND METHODS

The material consisted of 71 patients with Meckel's diverticulum treated in our hospital during the years 1988-1998. From the material the age and sex were analyzed as well the outcome of patients. The histological findings of diverticulectomies were evaluated.

RESULTS

In a retrospective analysis 46 males (65.5%) and 25 females (34.5%) were found. At the same eleven-year study period Meckel's diverticulum was found during 55 out of 3758 appendicectomies (1.5%). The age of patients ranged from 11 months to 87 years (mean 30.4 years). Preoperatively the diagnosis was made in three cases: two patients with TC-99m scanning and one patient with intestinal passage radiography. 46 Meckel's diverticles were asymptomatic, but 25 (34.5%) cases were symptomatic. Nine patients had ulcer in the diverticulum, which was perforated in five cases. Eight patients had intestinal occlusion, five patients had Meckel's diverticulitis, two patients had invagination, and in one case a sharp piece of plastic material had perforated the Meckel's diverticulum.

CONCLUSION

Meckel's diverticulum should be searched in the laparotomy due to acute abdomen. It can be the cause of serious abdominal complications.

A prospective study of teleconferencing for orthopaedic consultations

We carried out a prospective study of teleconsulting in orthopaedics. A commercial videoconferencing system was connected by three ISDN lines between the Satakunta Central Hospital in Pori and the Orton Orthopaedic Hospital in Helsinki, 240 km away. A document camera was used to transfer radiographic images and paper documents. Twenty-nine patients who needed an orthopaedic consultation were studied over three months. They were examined by a surgeon in Pori with the aid of teleconferencing and again later in a traditional, face-to-face appointment in Helsinki. Patients and doctors completed questionnaires after the consultations. Technically, the videoconferencing system functioned reliably and the quality of the video was judged to be good. Twenty patients (69%) would not have needed to travel for a face-to-face appointment, because the teleconsultation afforded a definite treatment decision. The orthopaedic surgeons considered all the treatment decisions arising from the teleconsultation good, except in one case which was considered satisfactory. The quality of the radiographic images transferred with the document camera was good or very good in 17 cases and satisfactory in three cases. None of the patients had experienced videoconferencing before; 87% of them thought that teleconsultation was a good or very good method and the rest felt that it was satisfactory. All patients wanted to participate in teleconsultations again and most would have recommended it to other patients.

Bioabsorbable self-reinforced poly-L-lactide, metallic, and silicone stents in the management of experimental tracheal stenosis

The aim of the present study was to compare, in rabbits, the biocompatibility and suitability of a bioabsorbable spiral stent made of self-reinforced poly-L-lactide (SR-PLLA) in the management of experimental tracheal stenosis with stents made of metal and silicone. Tracheobronchial stenosis, and its management, is still problematic because stenoses are not always amenable to surgical resection and reconstruction, especially concerning anastomotic problems and stenosis after lung transplantation. Stenosis can be handled with stenting, although the ideal stent has yet to be developed; all the stents available have their disadvantages. Because stenting of the airways can be only temporary, stents made of bioabsorbable materials, theoretically, offer benefits. Tracheal stenosis was created in rabbits by the extramucosal resection of cartilaginous arches of the cervical trachea. After a few weeks, the animals were operated on again, and those stenoses that had developed were dilated with a balloon. Stents then were implanted in the area of stenosis to keep the dilated trachea open. All the animals in the group with silicone stents had to be killed because of respiratory difficulties: their stents had a tendency to occlude because of internal encrustation, and they developed a hyperplastic polyp at the ends of the stents. The SR-PLLA and metallic stents were tolerated well, and after follow-up ended the animals were put to death. This experimental study showed that silicone stents had a tendency to occlude and that stents made of metal and of SR-PLLA were well tolerated and can be used in the management of airway stenosis.

Use of the Heimlich valve for treating pneumothorax

BACKGROUND AND AIMS

The aim of this retrospective study was to compare the use of a small caliber tube connected to Heimlich flutter valve with a conventional thoracic drainage system in the treatment of pneumothorax.

MATERIALS AND METHODS

Patients with simple pneumothorax during the years 1991-1995 in Satakunta Central Hospital were included in this study. Nineteen patients were treated with the Heimlich flutter valve and 57 patients were treated with the standard drainage tube connected to an underwater seal device. The data were collected from hospital records focusing on the duration of chest drainage, the number of chest roentgenograms and the length of hospital stay.

RESULTS

In the Heimlich valve group the mean drainage time was 2,2+/-0.9 days and in the standard thoracic drainage group 3.4+/-3.8 days (p <0.05) respectively. The mean length of hospitalization in the Heimlich valve group was 3.3+/-2.2 days and in the standard thoracic drainage group 5+/-4.9 days (p < 0.01). The number of chest roentgenograms in the Heimlich valve group was 3+/-1.1 and in the standard thoracic drainage group 4.6+/-2.7 (p < 0.001).

CONCLUSION

We believe that the treatment with a small caliber tube and Heimlich valve is a safe and effective procedure. It also reduces the duration of chest drainage and the length of hospital stay.

Raised endothelin content in bronchoalveolar lavage fluid during lung allograft rejection in pigs

Various pathophysiologic mechanisms are implicated in the rejection of transplanted lungs, for example production of vasoactive substances such as endothelin. In this study the measured endothelin content of bronchoalveolar lavage (BAL) fluid was correlated to the grade of lung allograft rejection. Left lung allotransplantation was performed in seven piglets (weight 16-24 kg). Triple-drug immunosuppression (cyclosporin, azathioprine, methylprednisolone) was given, and episodes of acute rejection were induced by withdrawing the medication. The development of acute rejection was monitored with computed tomography and bronchoscopy with BAL and transbronchial biopsy. In 46 BAL samples the endothelin content was radioimmunologically assayed. Transbronchial biopsies taken simultaneously showed grade 0 rejection in 17 tissue samples, grade 1 in 21 and grade 2 in eight. The endothelin content of BAL (pg/ml) increased from 34.3 +/- 6.1 in grade 0 rejection to 54.6 +/- 6.8 in grade 1 and to 98.5 +/- 35.6 in grade 2. The increase from grade 0 was statistically significant to grade 1 (p < 0.05) and to grade 2 (p < 0.02). The increased endothelin content of BAL may have harmful effects on the lung, as endothelin is a potent vaso- and bronchoconstrictive peptide with mitogenic properties.

Comparison of tissue reactions in the tracheal mucosa surrounding a bioabsorbable and silicone airway stents

BACKGROUND

Treatment of tracheobronchial stenosis is problematic. Conservative methods include stenting the stenotic area, but an ideal stent has not yet been developed. Bioabsorbable airway stents offer benefits; the extraction of the device is unnecessary, and the airway preserves its normal function after stent resorption. The aim of this study was to examine the suitability of self-reinforced poly-L-lactide as a material for an airway stent.

METHODS

A spiral airway stent made of 0.7-mm wire of self-reinforced poly-L-lactide was implanted operatively in 9 rabbits intratracheally; silicone stents served as controls.

RESULTS

Silicone stents had a tendency to become stenosed with encrustation material and to develop a hyperplastic polyp at both ends. Self-reinforced poly-L-lactide stents were well tolerated and caused no foreign body reaction, and they had a tendency to penetrate into the tracheal wall. They had disappeared at the end of the follow-up of 10 months.

CONCLUSIONS

This experimental study showed that bioabsorbable self-reinforced poly-L-lactide is a promising material for an airway stent for treatment of airway stenosis.

Experimental piglet lung transplantation: histological bioptic changes and autopsy findings

To investigate difficulties in diagnosing pulmonary rejection and to create a new model to observe long-term histological consequences, 21 piglets were subjected to left single lung transplantation. Five of these transplants served as targets for unmodified rejection in piglets without immunosuppression (Group I), 13 recipients were treated with cyclosporin A, azathioprine and methylprednisolone (Group II), and in 3 cases reimplantation of an autograft was performed (Group III). In the course of postoperative graft monitoring, transthoracic/bronchial biopsies were obtained on days 3, 5, 7, 10, 14, and 20, and thereafter less frequently up to 134 days. In the unmodified rejection group, grafts consolidated in one week and histologically presented perivascular mononuclear cell infiltrates, except for one case which showed vasculitis. Lymphocytic bronchiolitis and or peribronchiolar infiltrate was present in three of the four autopsied grafts. In Group II acute rejection was detected six times in three piglets, and all except one of these specimens had a peribronchiolar component. Although no incontestable bronchiolitis obliterans developed, mild to moderate chronic obliterative vascular lesions were detected in all immunosuppressed piglets (n = 3) surviving more than 80 days. Contralateral lungs and Group III autografts showed mild changes related to the operation itself and interstitial swine endemic pneumonia (SEP). Chronic changes related to rejection were limited to the vascular wall. The mainly inflammatory bronchiolar changes are thought to present an incipient phase leading to obliterative lesions.

In vitro pulmonary arterial relaxation after experimental lung transplantation with extracorporeal circulation

OBJECTIVE

In search of an agent to attenuate the increased pulmonary vascular resistance after lung transplantation with extracorporeal circulation, we investigated contractions and relaxations of isolated porcine pulmonary arterial rings in organ chambers.

METHODS

Rings of arteries from three groups were studied. Rings from the heart-lung block were studied immediately after Euro-Collins flush (n = 6). Rings from the recipient's native (n = 5) and transplanted (n = 5) lung were studied after 3 h of right heart bypass following transplantation. The duration of cold ischemia of the transplanted lung was 3-4 h. Contractions to potassium chloride and phenylephrine were measured. In order to study relaxations, the rings were preconstricted with phenylephrine. Relaxations to acetylcholine, adenosine diphosphate and isoproterenol were determined in rings with endothelium, and relaxations to sodium nitroprusside in rings without endothelium.

RESULTS

Sodium nitroprusside induced complete relaxations (100%) in rings of arteries from all three groups. Relaxations to acetylcholine and adenosine diphosphate were comparable among the three groups, but relaxations to isoproterenol were significantly depressed in pulmonary artery rings from the transplanted lung, compared with those from the native lung.

CONCLUSIONS

Lung transplantation with extracorporeal circulation is associated with depressed beta-receptor-mediated vasodilation, but the pulmonary vascular smooth muscle cell's ability to relax is not affected.

Acute rejection diagnosed with computed tomography in a porcine experimental lung transplantation model

The role of computed tomography (CT) in the diagnosis of acute rejection was studied in an experimental lung transplantation model, with 15 left lung allotransplantations and six autotransplantations performed on piglets weighing 16-24 kg. There were 31 episodes of acute rejection. In the allotransplantation group the development of acute rejection was monitored 115 times with CT, transbronchial biopsy (TBB) and bronchoalveolar lavage (BAL). The stages of acute rejection were 1) ill-defined centrilobular micronodules or minimal patchy ground-glass opacities. 2) dense, small-nodular infiltration or extensive ground-glass opacities, and bronchial wall thickening. 3) lung volume loss and dense, patchy ground-glass opacities and 4) consolidation of the lung. In the autotransplantation group monitoring was done 42 times. After allotransplantation, TBB and BAL suggested rejection 60 times and infection 23 times. CT had 86.7% sensitivity and 85.6% specificity. During the first month these figures were, respectively, 71.4% and 84.2%. Rising histologic grade was associated with increasing stage of acute rejection on CT, which thus proved to be a sensitive and specific method for diagnosing acute rejection of lung transplant.

Detection of acute rejection by 133Xe radiospirometry after single lung transplantation in an experimental porcine model

Aim of this experimental study was to evaluate acute rejection in a porcine single-lung transplantation model by using 133Xe radiospirometry. Left lung allotransplantation was performed on 11 and autotransplantation on 5 piglets. Postoperative monitoring consisted of 77 radiospirometric examinations with assessments of regional perfusion (Qtx), ventilation (V) and ventilation/perfusion ratio (V/Qtx). Results were compared with transbronchial biopsy. A significant decrease in Qtx (p < 0.01) and an increase in V/Qtx (p < 0.01) were observed during acute rejection, whereas V remained unaltered. These changes were significant already at minimal rejection (grade A1), and further increased at moderate rejection (grade A3). Sensitivity and specificity of Qtx were 82 and 74%, and those of V/Qtx, 87 and 65%. 133Xe radiospirometry detects even minimal acute rejection after single lung transplantation.

Effects of acute rejection and antirejection therapy on arteries and veins from canine single lung allografts

Experiments were designed to compare the function of the endothelium and smooth muscle in intralobar pulmonary arteries and veins of transplanted lungs during acute rejection and after treatment of rejection. Single lung allografts were performed in dogs. Dogs were monitored for 5 days to allow good recovery from the operation and resolution of early chest radiographic changes. In group I, immunosuppression (cyclosporine A, azathioprine, and methylprednisone) was withdrawn to allow rejection, which typically occurred after 3 days. In group II, immunosuppression was reinstituted at this time during acute rejection until the chest roentgenograms again cleared (approximately after 6 days). The blood vessels were studied at this time. Rings were cut from intralobar pulmonary arteries and veins of the allotransplanted lungs and suspended for the measurement of isometric force in organ chambers. Contractions of arteries and veins to phenylephrine but not endothelin-1 were significantly reduced during acute rejection. In arteries and veins, endothelium-dependent relaxations to bradykinin but not the calcium ionophore A23187 were reduced with rejection. Relaxations of the smooth muscle to histamine increased with rejection in both blood vessels. Relaxations to nitric oxide were reduced with rejection in veins but not arteries. Treatment of rejection reversed all responses toward those observed in arteries and veins in lungs from dogs not undergoing transplantation. These results suggest that responses of the endothelium and smooth muscle of pulmonary arteries and veins of transplanted lungs are altered similarly during rejection. Further, treatment of rejection restores function of the pulmonary blood vessels of lung allografts toward that observed in unoperated lungs.

Endothelin in bronchoalveolar lavage fluid is increased in lung-transplanted patients

Animal studies have shown increased endothelin in bronchoalveolar lavage (BAL) fluid during unmodified rejection. We performed radioimmunoassay of endothelin in 59 BAL fluid samples from ten patients at different times after lung transplantation. All patients received immunosuppressive therapy (cyclosporin, azathioprine and methylprednisolone). Reference BAL samples were obtained from six controls. Of the 59 test samples, five were collected during rejection episodes, confirmed by clinical outcome, BAL cytology and radiology (rejection group), and 19 were taken during bacterial, viral or fungal infection (infection group). The endothelin content of BAL (pg/ml) was significantly greater in the rejection group than in the infection group (61.1 +/- 3.8 vs 40.6 +/- 2.0) or in the 35 samples taken in uncomplicated course after lung transplantation (40.9 +/- 5.4), p < 0.01. The endothelin level in BAL fluid from the controls was only 3.0 +/- 1.4 pg/ml, significantly less (p < 0.005) than in all the lung-transplanted groups. Endothelin in BAL fluid thus was increased after lung transplantation, and still further during rejection.

Endothelin content of bronchoalveolar lavage fluid from allotransplanted pigs is increased during unmodified rejection

To find a new method for detection of rejection of allotransplanted lungs, we studied the endothelin content of bronchoalveolar lavage fluid by radioimmunoassay. Left-sided lung allotransplantation was performed in pigs. One group of animals received no treatment with immunosuppressive drugs (rejection group), the other group of animals (treated group) was treated with a triple-drug immunosuppressive regimen (cyclosporine, azathioprine, and methylprednisone), and nontransplanted lungs were controls. The endothelin content in bronchoalveolar lavage fluid was significantly elevated in the group of pigs with unmodified rejection (29.20 +/- 1.96 pg/ml) compared with that in the immunosuppressed group (15.3 +/- 2.4 pg/ml) and control group (4.27 +/- 1.23 pg/ml). The measurements were made from 5, 33, and 11 samples of bronchoalveolar lavage fluid from the rejection, treated, and control groups, respectively. These results suggest that endothelin content of bronchoalveolar lavage fluid could be a marker of lung allograft rejection.

Autonomic modulation of contractions to endothelin-1 in canine coronary arteries

Endothelin-1 contracts vascular smooth muscle and inhibits release of neurotransmitter from adrenergic and cholinergic neurons. Experiments were designed to investigate the interaction of these mechanisms in a blood vessel that receives both adrenergic and cholinergic innervation. Rings cut from canine left anterior descending coronary arteries were suspended in organ chambers for the measurement of isometric force. In some rings, the endothelium was removed. Endothelin-1 caused concentration-dependent increases in tension in all rings. During electrical stimulation (1 Hz, 9 V, 2 msec), the contractions to endothelin-1 were reduced significantly. In rings without endothelium, this decrease was greater in the presence of atropine (10(-6) M) and was eliminated by a combination of phentolamine (10(-5) M) and propranolol (5 x 10(-6) M). Contractions to endothelin-1 during electrical stimulation in rings with endothelium were significantly less than those without endothelium. This difference was eliminated by atropine and NG-monomethyl L-arginine (10(-4) M). The presynaptic effects of endothelin-1 were studied by measurement of tritium-labeled norepinephrine. Phasic electrical stimulation induced release of norepinephrine; this was inhibited by endothelin-1 at high concentrations (4 x 10(-7) M) in the presence of atropine. These results suggest that the major effect of endothelin-1 is postsynaptic in canine coronary arteries. However, contractions to endothelin-1 may be modulated by the level of sympathetic and parasympathetic tone. In situations in which innervation to the coronary arteries is altered, for example, in hearts used for transplantation, the contractile effects of endothelin-1 would prevail.

Sequential CT in monitoring experimental lung transplant

The criteria for diagnosis of lung rejection remain controversial. In this study early changes in lung rejection were characterized using sequential CT with the aim of developing a sensitive and safe monitoring method, which would also provide specific information on graft status. Twenty-one experimental single lung transplants (SLTs) in piglets, including unmodified rejections, immunosuppressed recipients, and autogenic reimplants, were scanned using CT on days 3, 5, 7, 10, 14, 22 up to 134 days after operation. In addition to morphological analysis, bilateral densitometric CT measurements of the peripheral lung parenchyma were used to evaluate the intensity of interstitial infiltration of lung grafts. Altogether 67 postoperative CT studies were carried out. Simultaneous transbronchial/thoracic biopsies were undertaken. The mean follow-up time was 28 days (range 0-134 days). The experience obtained was then used in relation to SLT in a male patient for chronic obstructive pulmonary disease. All piglets had a typical hilar reimplantation response, which disappeared in 10-20 days. Two distinct patterns of radiological acute rejection were found. Increasing peripheral alveolar infiltrates reflected early massive rejection in untreated animals. In immunosuppressed animals, after the initial reimplantation response, acute rejection was detected as densitometrically measured diffuse interstitial infiltration over the whole graft. Local findings, like focal infections, were seen later in the lingula and basal portions of the graft. In the SLT patient, density changes preceded clinical rejection episodes, which responded to steroid therapy. In the experimental study, the lung graft was compared to normal contralateral lung. In the SLT patient, however, this was not possible, and, therefore, the subsequent repeated CT studies formed the basis of clinical follow-up. Sequential imaging and densitometric measurements allowed objective estimation of diffuse interstitial infiltration relating to rejection.

Long-term blood flow potentials in sequential internal mammary artery grafts. Exercise thallium scan for myocardial perfusion study

In two groups of patients, coronary artery bypass surgery for angina pectoris included internal mammary artery (IMA) sequential grafts (group I) or single grafts (group II). At postoperative angiography all grafts were patent. In addition, the patients received on average 1.8 vein grafts into other coronary arteries. The mean interval to postoperative follow-up was 9.5 years in group I and 9.7 years in group II. The preoperative incidence of acute myocardial infarction was 44% and 45% in groups I and II. Exercise thallium scan at follow-up showed IMA graft-related ischemia in 33% of the patients with sequential graft and in 64% of those with single graft (ns). Our results indicated that sequential IMA grafts functioned at least as well as single grafts and maintained adequate myocardial supply even 10 years postoperatively. Internal mammary arteries are superior graft material and can be recommended both as single and as sequential graft in coronary artery bypass surgery.

Cytomegalovirus myocarditis in transplanted heart verified by endomyocardial biopsy

Cytomegalovirus infections are common disorders after heart transplantations. Manifestation of the virus without a clinical disease is still more prevalent. Differentiation of clinical infections from cytomegalovirus activations without major pathogenetic importance issues a challenge in the follow-up of patients with cardiac transplants. The case describes a 56-year-old female patient with a multiple organ lethal infection and myocarditis due to cytomegalovirus diagnosed during life with endomyocardial biopsy.

Pleural and pulmonary complications after bilateral internal mammary artery grafting

The long-term patency of internal mammary artery (IMA) grafts in coronary bypass surgery is superior to that of saphenous vein grafts. To investigate if bilateral IMA grafting increases the complication rate, especially pleural problems, 100 patients with bilateral and 100 with unilateral IMA grafts were retrospectively studied. Preoperatively the groups did not differ in age, previous myocardial infarction, ejection fraction, NYHA classification or previous respiratory disease, but the coronary artery status was poorer in the bilateral IMA group. Postoperative pleural drainage was greater after bilateral IMA grafting (1074 vs. 497 ml, p less than 0.0001). Reoperation was required for bleeding in 10% of the patients with unilateral, and 20% of those with bilateral IMA grafting (p less than 0.05), and more blood was transfused in the latter group (5.9 vs. 4.7 units, p less than 0.01). Pleural effusion at discharge from hospital or 3 months postoperatively, pain in the sternotomy wound, pain on breathing and postoperative use of nitroglycerin did not differ significantly between the groups. Bilateral IMA grafting thus led to more bleeding and reoperations than single IMA grafting, but did not cause excessive pulmonary complications.