Diagnosis of biliary strictures in conjunction with endoscopic retrograde cholangiopancreaticography, with special reference to patients with primary sclerosing cholangitis.

BACKGROUND AND STUDY AIMS: Strictures of the bile ducts due to malignant changes are difficult to distinguish from benign changes, particularly in patients with primary sclerosing cholangitis (PSC). The aim of this study was to evaluate diagnostic methods for malignancy in biliary strictures in conjunction with endoscopic retrograde cholangiopancreaticography (ERCP). PATIENTS AND METHODS: Bile duct strictures were identified during ERCP in 57 patients, who were thus included in the present study. Brush samples from the strictures were taken for cytology and for evaluation of DNA content by flow cytometry. The tumor markers CA 19-9 and CEA were determined both in serum and bile fluid. Two independent radiologists evaluated all cholangiograms. The diagnostic sensitivity, specificity, and accuracy of each diagnostic method were evaluated separately and in combination. RESULTS: 32 patients were found to have malignant strictures and when the four methods: brush cytology, DNA analysis, serum CA 19-9 and serum CEA were combined, a diagnostic sensitivity of 88 % and specificity of 80 % were reached. Seven of the 20 patients with PSC were found also to suffer from cholangiocarcinoma, yielding a sensitivity and specificity of 100 % and 85 %, respectively. Analyses of CA 19-9 and CEA in bile fluid had no diagnostic significance. CONCLUSION: An ERCP procedure with brush cytology, a DNA analysis, combined with serum analysis of CA 19-9 and CEA, can increase the possibility of distinguishing between malignant and benign biliary strictures, especially in PSC patients.

A method of applying Fourier analysis to high-speed laryngoscopy.

A new method for analysis of digital high-speed recordings of vocal-fold vibrations is presented. The method is based on the extraction of light-intensity time sequences from consecutive images, which in turn are Fourier transformed. The spectra thus acquired can be displayed in four different modes, each having its own benefits. When applied to the larynx, the method visualizes oscillations in the entire laryngeal area, not merely the glottal region. The method was applied to two laryngoscopic high-speed image sequences. Among these examples, covibrations in the ventricular folds and in the mucosa covering the arytenoid cartilages were found. In some cases the covibrations occurred at other frequencies than those of the glottis.

Voice source characteristics in Mongolian "throat singing" studied with high-speed imaging technique, acoustic spectra, and inverse filtering.

Mongolian "throat singing" can be performed in different modes. In Mongolia, the bass-type is called Kargyraa. The voice source in bass-type throat singing was studied in one male singer. The subject alternated between modal voice and the throat singing mode. Vocal fold vibrations were observed with high-speed photography, using a computerized recording system. The spectral characteristics of the sound signal were analyzed. Kymographic image data were compared to the sound signal and flow inverse filtering data from the same singer were obtained on a separate occasion. It was found that the vocal folds vibrated at the same frequency throughout both modes of singing. During throat singing the ventricular folds vibrated with complete but short closures at half the frequency of the true vocal folds, covering every second vocal fold closure. Kymographic data confirmed the findings. The spectrum contained added subharmonics compared to modal voice. In the inverse filtered signal the amplitude of every second airflow pulse was considerably lowered. The ventricular folds appeared to modulate the sound by reducing the glottal flow of every other vocal fold vibratory cycle.

[Endoscopic ultrasound in the investigation of gastric tumors]. / Endoskopiskt ultraljud vid utredning av magsäckstumörer.

Preoperative staging has been considered to be of importance in gastric cancer. Recently, 133 patients were examined preoperatively using endoscopic ultrasound, and 77 of these had gastric cancer. Preoperative staging (T + M) using endoscopic ultrasound coincided with findings at surgery in 84% of the cases. The depth of penetration was accurate in 92% of the cases. It is concluded that endoscopic ultrasound is more reliable for preoperative staging than conventional ultrasound, computer tomography or magnetic resonance imaging for gastric cancer. Whether or not improved preoperative staging has a bearing on the treatment of patients with gastric cancer, depends largely on whether or not cytostatic therapy is used. We believe that centralizing diagnosis and treatment of gastric cancer is beneficial.

Rectal tumour staging: MR imaging using pelvic phased-array and endorectal coils vs endoscopic ultrasonography.

The aim of this study was to compare MR imaging and endoscopic ultrasonography (EUS) for the local staging of rectal tumours. Forty-nine patients were examined on a 1.5-T MR unit using either a pelvic phased-array coil (n = 37) alone or combined with an endorectal coil (n = 12). Sagittal and axial sequences with T2-weighted fast spin-echo and axial T1-weighted spin-echo techniques were employed. The EUS technique was performed using a flexible endosonoscope. The results were compared with findings at histopathological sectioning of the specimen. The T-stage on MR correlated with histopathology in 32 of 49 patients and on EUS in 29 of 49 patients. The N-stage on MR correlated with histopathology in 22 of 49 patients and on EUS in 26 of 49 patients. Tumour penetration of the rectal wall was predicted by MR with 86 % sensitivity and 65 % specificity, and by EUS with 89% sensitivity and 33% specificity. Preoperative radiotherapy was administered to 40 of the patients after the examinations which may explain some of the overstaging by MR and EUS. Three patients with surgically and histopathologically confirmed invasion of neighbouring organs in the pelvis were detected preoperatively on MR but none on EUS. Tumour penetration of the rectal wall and local lymph node metastases cannot accurately be predicted with MR or EUS. Magnetic resonance, however, seems to be more useful for preoperative identification of clinically occult advanced disease.

Botulinum toxin injections for essential voice tremor.

Fifteen patients, 13 women and 2 men, with a mean age of 72.7 years (56 to 86 years) and a clinical diagnosis of essential voice tremor, were treated with botulinum injections to the thyroarytenoid muscles, and in some cases, to the cricothyroid or thyrohyoid muscles. Evaluations were based on subjective judgments by the patients, and on perceptual and acoustic analysis of voice recordings. Subjective evaluations indicated that the treatment had a beneficial effect in 67% of the patients. Perceptual evaluations showed a significant decrease in voice tremor during connected speech (p < .05). Acoustic analysis showed a nearly significant decrease in the fundamental frequency variations (p = .06) and a significant decrease in fundamental frequency during sustained vowel phonation (p < .01 ). The results of perceptual evaluation coincided most closely with the subjective judgments. It was concluded that the treatment was successful in 50% to 65% of the patients, depending on the method of evaluation.

Laparoscopic myotomy without fundoplication in patients with achalasia.

OBJECTIVE: Analysis of outcome after laparoscopic myotomy for achalasia. DESIGN: Prospective audit. SETTING: Teaching hospital, Sweden. SUBJECTS: All patients with achalasia who had a laparoscopic myotomy without a simultaneous fundoplication. INTERVENTIONS: Questionnaire, pH-measurements, radiography and manometry. MAIN OUTCOME MEASURES: Operative and postoperative complications and reoperations. RESULTS: Twenty-one patients were scheduled for laparoscopic myotomy. Three were converted to open operations, and four were reoperated on transabdominally for persistent or recurrent symptoms. All patients were satisfied afterwards. Follow-up in 14 patients, after a median of 22 months (range, 6-40), included manometry, questionnaire, and 24-hour pH measurements, and showed significant reduction in the lower oesophageal sphincter pressure together with relief of symptoms. Three patients had reflux symptoms and abnormal pH readings. An additional five patients had abnormal pH measurements but no symptoms of reflux. CONCLUSIONS: Heller myotomy can safely be done laparoscopically. Whether a simultaneous antireflux procedure is needed remains to be seen.

Anticardiolipin antibodies predict early recurrence of thromboembolism and death among patients with venous thromboembolism following anticoagulant therapy. Duration of Anticoagulation Study Group.

PURPOSE: To compare the risk of recurrent venous thromboembolism in patients with and without antiphospholipid antibodies. PATIENTS AND METHODS: Anticardiolipin antibodies were tested 6 months after a first or second episode of venous thromboembolism. Of the patients with a first episode of venous thromboembolism only the 412 who received 6 months of anticoagulation were studied. Two hundred and eleven patients with a second episode received oral anticoagulation for 6 months or indefinitely. The therapy was targeted at an international normalized ratio (INR) of 2.0 to 2.85. All patients were followed up for 4 years after enrollment. RESULTS: Among the 412 patients with a first episode of venous thromboembolism the risk of recurrence was 29% in patients with anticardiolipin antibodies and 14% in those without antibodies (P = 0.0013). In those with antibodies, there was an increased risk during the first 6 months after cessation of anticoagulation. The risk of recurrence increased with the titer of the antibodies. Four-year mortality rate was 15% in those with antibodies and 6% in those without (P = 0.01). Among 34 patients with a second event of venous thromboembolism and anticardiolipin antibodies, there were no recurrences during anticoagulant therapy versus 20% in those who received only 6 months of treatment (P = 0.08). CONCLUSIONS: The presence of elevated titers of anticardiolipin antibodies 6 months after an episode of venous thromboembolism is a predictor for an increased risk of recurrence and of death. Patients with anticardiolipin antibodies and venous thromboembolism seem to benefit from prolonged oral anticoagulation.

Air enema used in the evaluation of acute colitis. A comparison between instant radiography and endoscopy.

PURPOSE: The purpose of this study was to evaluate air enema as a method of assessing acute colitis. MATERIAL AND METHODS: Twenty-seven patients with symptoms of acute colitis underwent plain abdominal radiography, air enema, and colonoscopy within 48 h. The films were evaluated by 3 observers with different levels of experience, both independently and together, and the results were then compared to the findings at endoscopy. RESULTS: Air enema visualized a greater part of the colon than plain abdominal radiography. When air enema was compared to endoscopy as the reference, it showed good correlation, with a positive predictive value of 92% (sensitivity 62%, specificity 85%). Evaluation of the rectum was less accurate, a finding that emphasized the importance of rigid sigmoidoscopy. CONCLUSION: Air enema is a useful diagnostic method in acute colitis, it is easily performed and tolerated well with no observed complications. It is also easy to interpret, as shown by a high level of agreement (kappa = 0.67) among the 3 independent observers with very different levels of experience.

A 6-month venographic follow-up in 164 patients with acute deep vein thrombosis.

UNLABELLED: A total of 164 patients were recruited from a randomized trial comparing a low molecular weight heparin, dalteparin, given subcutaneously once daily with a continuous intravenous infusion of unfractionated heparin in the initial treatment of acute deep vein thrombosis. The primary objective of this follow-up study was to investigate whether there were any differences between the two treatment groups with respect to Marder score changes 6 months after the initial diagnosis using repeated venography. The secondary objectives were to analyse whether certain haemostatic and acute phase parameters or patient characteristics influenced the venographic outcome. RESULTS: Complete lysis of the thrombus was observed in 38.4% of the patients and a partial lysis in another 54.3% assessed by venography 6 months after the acute event. Extension of the thrombus was seen in 7.3% of the patients. There were no significant differences in the change in mean Marder score before treatment and at the 6 month follow-up between the two treatment groups, irrespective of thrombus localisation. In a regression model, male gender, low levels of orosomucoid and increased levels of d-dimer in plasma on day 5 were independently associated (p <0.05) with an enhanced absolute resolution of the thrombus at 6 months. No differences in symptoms and signs in the thrombotic leg at follow-up, comparing the treatment given, or thrombus extension at diagnosis and 6 months later, were demonstrated. CONCLUSION: Dalteparin given once daily subcutaneously was as effective as continuous intravenous infusion of unfractionated heparin in the initial treatment of deep vein thrombosis assessed by Marder score evaluation 6 months after the acute event.

Leukocyte migration in acute colonic inflammatory bowel disease: comparison of histological assessment and Tc-99m-HMPAO labeled leukocyte scan.

UNLABELLED: Noninvasive leukocyte scintigraphy for assessment of localization, extent, and degree of active inflammation in acute colonic inflammatory bowel disease have been shown to correlate well with endoscopy. This study compared findings of mucosal leukocyte migration assessed histologically with those of technetium 99m hexamethylpropylene-amineoxime-labeled leukocyte scintigraphy. PATIENTS AND METHODS: Twenty-one patients hospitalized because of a first attack or a relapse of known inflammatory bowel disease were investigated using leukocyte scintigraphy followed by total colonoscopy with multiple biopsies within 24 h. Histological interpretation focused on the degree of segmental mucosal leukocyte infiltration. RESULTS: Fourteen patients with ulcerative colitis (UC) and seven with colonic Crohn's disease (CD) were included. With the use of histology as the reference method, maximal proximal disease extent was correctly assessed by the leukocyte scan in 11 patients (8 with UC, 3 with CD), although the rectal involvement was not visualized in 5. In seven patients, the extent assessments almost matched (+/- one segment), and in the remaining three patients (two UC, one CD) the scan grossly misinterpreted active histological inflammation (> or = +/- two segments). In patients with UC, the sensitivity, specificity, and diagnostic accuracy concerning the extent of inflammation were 0.84, 0.79, and 0.83, respectively. In patients with CD, the sensitivity was 0.79, and the diagnostic accuracy was 0.78. The relative leukocyte scan activity score was less concordant with the degree of mucosal leukocyte infiltration but still significantly correlated (r = 0.616, p < 0.0001 in UC patients and r = 0.441, p < 0.003 in CD patients). CONCLUSION: Images created by the technetium 99m hexamethylpropylene-amineoxime-labeled leukocyte scan in acute colonic inflammatory bowel disease correlate to mucosal leukocyte migration in terms of proximal disease extent and, to a lesser degree, also to the intensity of mucosal inflammatory infiltration.

The duration of oral anticoagulant therapy after a second episode of venous thromboembolism. The Duration of Anticoagulation Trial Study Group.

BACKGROUND: A consensus has not been reached about the optimal duration of oral anticoagulant therapy after a second episode of venous thromboembolism. METHODS: In a multicenter trial, we compared six months of oral anticoagulant therapy with anticoagulant therapy continued indefinitely in patients who had had a second episode of venous thromboembolism. Of 227 patients enrolled, 111 were randomly assigned to six months of anticoagulation and 116 were assigned to receive anticoagulant therapy indefinitely; for both groups, the target international normalized ratio was 2.0 to 2.85. The initial episodes of deep-vein thrombosis (n = 193) and pulmonary embolism (n = 34), as well as recurrent episodes, were all objectively confirmed. RESULTS: After four years of follow-up, there were 26 recurrences of venous thromboembolism that fulfilled the diagnostic criteria, 23 in the group assigned to six months of therapy (20.7 percent) and 3 in the group assigned to continuing therapy (2.6 percent). The relative risk of recurrence in the group assigned to six months of therapy, as compared with the group assigned to therapy of indefinite duration, was 8.0 (95 percent confidence interval, 2.5 to 25.9). There were 13 major hemorrhages, 3 in the six-month group, (2.7 percent) and 10 in the infinite-treatment group (8.6 percent). The relative risk of major hemorrhage in the six-month group, as compared with the infinite-treatment group was 0.3 (95 percent confidence interval, 0.1 to 1.1). There was no difference in mortality between the two groups. CONCLUSIONS: Prophylactic oral anticoagulation that was continued for an indefinite period after a second episode of venous thromboembolism was associated with a much lower rate of recurrence during four years of follow-up than treatment for six months. However, there was a trend toward a higher risk of major hemorrhage when anticoagulation was continued indefinitely.

Twenty years' colonoscopic surveillance of patients with ulcerative colitis. Detection of dysplastic and malignant transformation.

BACKGROUND: Endoscopic cancer surveillance in patients with ulcerative colitis has been performed for almost 3 decades. There is still no consensus on its clinical value. METHODS: This study evaluates a 20-year prospective study of 143 patients with extensive ulcerative colitis and a disease duration exceeding 10 years. Colonoscopy with double biopsy specimens from nine locations of the colon was performed every 2nd year. Biopsy specimens showing dysplasia were reviewed at the end of the study. RESULTS: Through the surveillance dysplasia/cancer was detected in 55 patients; 7 of these patients had carcinomas, and 2 were in a possibly curable stage (Dukes A). The predictive value of low-grade dysplasia for either high-grade dysplasia or cancer was 41%. CONCLUSIONS: Although impaired by limiting factors, colonoscopic surveillance of chronic extensive colitis may identify patients with dysplasia and thereby prevent malignant transformation.

Instant technetium 99m hexamethyl propylenamine oxime-labeled leukocyte scan compared with colonoscopy in early assessment of disease extent and activity in acute colitis.

AIM: This study was undertaken to evaluate technetium 99m (Tc 99m) hexamethyl propylenamine oxime (HMPAO)-labeled leukocyte scintigraphy for assessment of disease extent and activity in acute colitis. PATIENTS AND METHODS: Twenty-seven patients, hospitalized because of acute watery and/or bloody diarrhea, were investigated using both total colonoscopy and Tc 99m HMPAO-labeled leukocyte scintigraphy within 48 hours after admittance. RESULTS: Final diagnoses were ulcerative colitis in 14 patients, Crohn's disease in 7 patients, and infectious colitis in 6 patients. Using colonoscopy as the reference method, the maximum extent of colitis was correctly assessed by the leukocyte scan in 18 patients (67 percent), although rectal engagement was not visualized in 5 (19 percent). In six additional patients, there was almost complete agreement between the two methods. One other patient, with leftsided ulcerative colitis, was erroneously assessed as having total extent. Two other patients (one with Crohn's colitis and one with infectious colitis) had different segments incorrectly assessed. Sensitivity, specificity, and diagnostic accuracy of scintigraphy in detecting active inflammatory segments were 0.85, 0.83, and 0.85, respectively. Intensity of inflammatory activity assessed by the leukocyte scan correlated significantly with colonoscopic assessment (r = 0.719; P < 0.0001). CONCLUSION: Information regarding extent, localization, and disease activity in patients with acute colitis of inflammatory or infectious origin may be satisfactorily obtained using Tc 99m HMPAO-labeled leukocyte scanning. The noninvasive nature of the method makes it an attractive early alternative to other investigational procedures such as total colonoscopy or barium examination, particularly in cases with an established diagnosis of inflammatory bowel disease.

Once-daily subcutaneous dalteparin, a low molecular weight heparin, for the initial treatment of acute deep vein thrombosis.

The aim of the study was to compare the efficacy and safety of once-daily subcutaneous injection of dalteparin, a low molecular weight heparin, with that of intravenous unfractionated heparin in the treatment of deep venous thrombosis (DVT). Patients were included if they had deep venous thrombosis distal to inguinal ligament and were randomised either before, if it was considered necessary, or after phlebographic verification of the diagnosis. There was no pre-inclusion treatment with unfractionated heparin. One hundred and twenty patients received dalteparin, administered subcutaneously once-daily at a fixed dose of 200 IU anti-factor Xa/kg, and 133 patients received a continuous intravenous infusion of unfractionated heparin (UFH). Oral anticoagulation was started on the first or second day, and initial treatment with dalteparin or UFH discontinued when the prothrombin time was in the therapeutic range (2 < INR < 3) on two consecutive days. Control phlebograms were taken within 4 days, thereafter. There were no significant differences between the two initial treatment groups in improvements in Marder score. Two major bleeding events occurred in the UFH group versus none in the dalteparin group. One patient in each group experienced clinically significant pulmonary embolism. During a mean follow-up period of 6.9 +/- 1.5 months, recurrent DVT occurred in four patients in the dalteparin group and in two of the UFH group. These results confirm those of a previous study on dalteparin in the initial treatment of DVT, and suggest that dalteparin administered once-daily at a fixed dose of 200 UI/kg is as effective and well-tolerated as UFH in patients with DVT below the inguinal ligament. The present study also demonstrates that dalteparin can be started as soon as the diagnosis of DVT is suspected and without pre-treatment with UFH. Given that the administration of once-daily subcutaneous injections needs not require a patient to be hospitalised, studies to investigate the possibility of using dalteparin for the initial treatment of DVT in the outpatient setting are warranted.

Ten years' experience of bone marrow transplantation for Gaucher disease.

Six patients underwent allogeneic bone marrow transplantation (BMT) because of severe Gaucher disease. Their ages was from 2 to 9 years at the time of transplantation. The donors were 4 HLA-identical siblings, a father with one incompatible HLA antigen and an HLA-A, -B, and -DR-identical unrelated donor. Among the donors, three were heterozygous for glucocerebrosidase and three were healthy homozygotes. Four patients underwent total splenectomy and two patients partial splenectomy prior to transplantation. In the former group one patient developed pneumococcal meningitis. In the latter group transfusion requirements were increased. The parental graft was rejected, but 4 of 5 other patients have donor enzyme levels from 2 up to 11 years after BMT. Two patients became mixed chimeras with around 40% of donor erythrocyte markers for one and 80% for the other. One of these had low enzyme activity in his lymphocytes, but the clinical outcome is excellent. This case gives good hope for future trials with gene therapy in Gaucher disease. Glucosylceramide in plasma was within the normal range in all other patients with engraftment, but glucosylceramide in erythrocytes were in the upper normal range in the two chimeric patients with heterozygous donors. Glucosylceramide levels in the liver decreased markedly in the two patients where it was studied. Gaucher cells disappeared in the bone marrow and liver size normalized or decreased within two to three years after BMT. All patients with engraftment had a growth spurt. Skeletal kyphosis was unaffected by BMT in three patients and became apparent in one patient 8 years after BMT. The patients had a favorable psychological development after BMT, with an excellent IQ between 112 and 120 ten years after BMT in the longest survivor. The data suggest that in advanced Gaucher disease BMT still may be a treatment of choice if an HLA-identical related or unrelated donor is available.

Comparison of once-daily subcutaneous Fragmin with continuous intravenous unfractionated heparin in the treatment of deep vein thrombosis.

Two hundred and four consecutive patients with venographically confirmed deep vein thrombosis (DVT) were randomised either to a low molecular weight heparin, Fragmin, administered subcutaneously (s.c.) once daily as a fixed dose of 200 IU anti-factor Xa/kg or to continuous intravenous infusion of unfractionated heparin (UFH). The UFH dose was adjusted to maintain the activated partial thromboplastin time between 1.5 and 3.0 times the upper limit of the reference value at each centre. Fragmin or UFH was given for a minimum of 5 days until anticoagulation with warfarin, given from day 1, was established (i.e. an Internation Normalised Ratio, of 2.0-3.0). A second venogram was obtained after Fragmin or UFH treatment. There were no significant differences in the change in mean Marder score before and after treatment between the two treatment groups, irrespective of thrombus localisation. No major bleeding events, symptomatic pulmonary embolism, symptomatic thrombosis progression or death occurred during hospitalisation. Eight documented venous thromboembolic events occurred before the follow-up visit 6 months after randomisation: 5 in patients treated with Fragmin and 3 in those treated with UFH. Six of these events occurred after cessation of warfarin treatment. In conclusion Fragmin given s.c. once daily in a fixed dose adjusted for body weight, is no less effective or safe than a continuous infusion of UFH in the initial treatment of acute DVT.

Postoperative follow-up of patients with colorectal carcinoma by colonoscopy.

OBJECTIVE: To find out if colonoscopy is of use in the follow-up of patients who have been operated on for colorectal carcinoma. DESIGN: Retrospective study. SETTING: Department of diagnostic radiology, university hospital. SUBJECTS: 390 consecutive patients operated on for colorectal carcinoma during the 10-year period 1981 to 1990. MAIN OUTCOME MEASURES: Number of recurrences, synchronous of metachronous tumours, and number and size of adenomas found on colonoscopy. RESULTS: Neoplastic lesions were found in 175 (45%) of the 390 patients studied. There were 14 anastomotic recurrences and 12 new primary carcinomas. At operation for recurrent tumours Dukes' A or B lesions were found in half of the 14 patients who had no symptoms, and a quarter of the 12 who had had symptoms. Those with recurrent carcinoma were younger than those without. Adenomas 1 cm in diameter or more were found in 44 patients and 104 had adenomas less than 1 cm. In addition one carcinoid was found. CONCLUSION: Colonoscopy gave a high yield of neoplastic lesions when used to follow-up patients after resection of colorectal carcinoma, particularly at six months, and resulted in half the recurrent carcinomas being diagnosed before the patients had symptoms. We recommend its use for follow-up of high risk patients, but further studies are needed to establish the optimum time intervals.

Mixed colorectal polyps. An immunohistologic and mucin-histochemical study.

The morphology of mixed colorectal polyps was analysed. Thirteen such polyps were found out of 2700 colorectal polyps (0.5%). Histology showed a spectrum of hyperplastic crypts from almost pure goblet cell population (two polyps) to hypermature serrated epithelium with scanty goblet cells (seven polyps). Tubular adenomas occurred in 12 polyps, and a tubulovillous adenoma was found in the largest polyp. Moderate dysplasia was seen in the five large polyps. The border between neoplastic and hyperplastic cells was usually sharp. Mucin histochemistry showed similarities between the mixed polyps and colorectal carcinomas--namely, the reduction/absence of sialomucin in both mature hyperplastic crypts and adenomatous glands. The expression of carcinoembryonic antigen within the hyperplastic crypts and within the neoplastic crypts showing moderate dysplasia was similar to that seen in colorectal carcinomas, whereas it was normal within the neoplastic crypts with low-grade dysplasia. IgA was reduced or absent in both components. Blood group antigen was found only within the adenomatous component of the largest polyp showing also moderate dysplasia.

Two daily subcutaneous injections of fragmin as compared with intravenous standard heparin in the treatment of deep venous thrombosis (DVT).

In a prospective, randomized, open study 119 consecutive patients with phlebographically verified deep venous thrombosis (DVT) of the leg (36% distal and 64% proximal) were treated either with a low molecular weight heparin (Fragmin, Kabi-Vitrum) subcutaneously (120 anti-FXa U/kg) twice daily or standard heparin (SH) as continuous intravenous infusion (480 IU kg-1 day-1). The Fragmin doses were adjusted to achieve an anti-FXa activity of 0.2-0.4 U/ml before injection and not greater than 1.5 U/ml 4 h after the morning injection. The SH dose was modified to prolong the APTT 2-3 times. Repeat phlebography after 5-7 days showed improvement in 34/45 patients (76%) in the Fragmin group and in 30/49 patients (61%) in the SH group and progress in 2/45 (4%) and 3/49 (6%), respectively. The mean Marder scores decreased from 18.7 +/- 12.1 to 15.7 +/- 12.7 in the Fragmin group and from 16.9 +/- 12.0 to 14.4 +/- 11.8 in the SH group (ns). Two patients in the SH group and none in the Fragmin group had major bleedings. After 22 +/- 7 months follow up 6 rethromboses had occurred in the SH group and 4 in the Fragmin group. Postthrombotic signs and symptoms were similar in both groups. We conclude that two daily sc Fragmin doses seem as effective and safe as continuous SH in the treatment of DVT of the leg.