Prolonged healing of venous leg ulcers: the role of venous reflux, ulcer characteristics and mobility.

OBJECTIVE: To assess whether a difference in venous reflux pattern, ulcer size or duration, regular medications or the daily use of walking aids can predict the healing of a chronic venous leg ulcer (VLU). METHOD: In this prospective, randomised, single-centre study, 110 consecutive patients with chronic leg ulcers were assessed. Ninety-nine patients met the inclusion criteria and a controlled, conservative 3-month treatment period was initiated, in which 90 patients were managed with standardised local treatment combined with compression therapy. In this group, 62 VLUs healed within 12 weeks and 28 were still open after 12 weeks. The study group consisted of 22 patients with non-healed ulcers and a control group (n=28), which was selected randomly from the healers. In both groups, venous reflux profiles were assessed using colour-flow duplex imaging. RESULTS: The study and control groups did not differ in smoking habits, age, gender or daily oral medications. On average, the healing wounds were 5cm² before starting controlled treatment (range 1-80cm²) and had been open for 7 months (range 2-48 months); the non-healing wounds were on average 11.2cm² (range 1-31cm²) and had been open for 26 months (range 8-106 months). Venous disease severity scores were similar for both groups (12.6 vs. 13.4). Five patients (18%) with healed ulcers regularly used walking aids, the use of which was more frequent (36%) among non-healers (p<0.001). Venous reflux profiles differed significantly between the groups, with isolated superficial reflux noted in 64% of healers, compared with 36% of non-healers. In addition, isolated deep reflux was found in 14% of the healers, compared with 41% of non-healers (p=0.0002). The rate of popliteal reflux was significantly higher in non-healers (59% versus 21%; p=0.0004). CONCLUSION: Long duration of a chronic venous ulcer may predict a poor outcome. The presence of deep venous reflux, especially in the popliteal vein, is typically found in those legs with non-healed ulcers. .

Ten-year prognosis of Puumala hantavirus-induced acute interstitial nephritis.

Nephropathia epidemica (NE) is a hemorrhagic fever with renal syndrome caused by Puumala hantavirus. Its long-term prognosis is considered favorable. There are, however, some reports about subsequent hypertension, glomerular hyperfiltration, and proteinuria after previous hantavirus infection. Therefore, we studied 36 patients 5 and 10 years after acute NE, with 29 seronegative controls. Office blood pressure, ambulatory 24-h blood pressure (ABP), glomerular filtration rate (GFR), and proteinuria were examined. Hypertensive subjects were defined as those patients having increased ambulatory or office blood pressure, or receiving antihypertensive therapy. Office blood pressure was used to define hypertension only if ABP was not determined. At 5 years, the prevalence of hypertension was higher among NE patients than in controls (50 vs 21%, P=0.020). At 10 years, the difference between the groups was no more significant (39 vs 17%, P=0.098). Five years after NE, patients showed higher GFR (121+/-19 vs 109+/-16 ml/min/1.73 m(2), P=0.012) and urinary protein excretion (0.19 g/day, range 0.12-0.38 vs 0.14 g/day, range 0.09-0.24, P=<0.001) than controls. At 10 years, there were no more differences in GFR or protein excretion between the groups (GFR: 113+/-20 vs 108+/-17 ml/min/1.73 m(2), P=0.370; proteinuria: 0.14 g/day, range 0.07-0.24 vs 0.13 g/day, range 0.06-0.31, P=0.610). In conclusion, the 10-year prognosis of NE is favorable, as glomerular hyperfiltration and slight proteinuria detected at 5 years disappeared during the longer follow-up. However, the possibility exists that NE may predispose some patients to the development of hypertension.

Altered levels of Smad2 and Smad4 are associated with human prostate carcinogenesis.

Alterations have been demonstrated in ligand and cognate receptor system of the transforming growth factor beta (TGF-beta) pathway in prostate cancer (PC). Still, little is known about changes in the activity of the intracellular Smad cascade of TGF-beta signaling during prostate carcinogenesis. We used immunohistochemistry to analyze phosphorylated Smad2 (p-Smad2), nuclear Smad4 and inhibitory-Smad7 in epithelial cells of normal, hyperplastic and malignant prostate. Specimens comprised 49 tissue cores of PC, 10 benign prostate hypertrophies and three normal prostates. Nuclear p-Smad2 (P<0.001) and nuclear Smad4 (P=0.023) were significantly decreased in PC with remarkable variations in cytoplasmic Smad7 levels. Substantial decreases in p-Smad2 and Smad4 levels were found in specimens with primary Gleason grades 3 and 4, whereas in grade 5, levels were markedly higher. Our results provide the first evidence for changes and reversible attenuation in the Smad system of the TGF-beta pathway during prostate carcinogenesis.

Relationship between clinically detected joint swelling and effusion diagnosed by ultrasonography in metatarsophalangeal and talocrural joints in patients with rheumatoid arthritis.

OBJECTIVE: To assess the relationship between clinically detected swelling and effusion diagnosed by ultrasonography (US) in metatarsophalangeal (MTP) and talocrural (TC) joints in patients with rheumatoid arthritis (RA). METHODS: Thirty consecutive patients with RA were studied. Altogether 288 MTP joints and 60 TC joints were evaluated. The clinical investigations were carried out by one doctor and the US investigations by another and they were blinded to each others' results. RESULTS: The clinical examination and US gave similar results in 194 MTP joints, whereas they differed in the remaining 94 MTP joints, and correspondingly the results were similar in 34 TC joints and differed in 26 TC joints. The kappa coefficient between these investigations was 0.165 in MTP joints and 0.043 in TC joints, showing very poor agreement. CONCLUSION: These preliminary results showed poor agreement between the clinical assessment of swelling and effusion detected by US in MTP and TC joints. Thus US may considerably improve the diagnosis of synovitis in patients with RA.

Cost-effectiveness of an innovative four-year post-discharge programme for elderly patients--prospective follow-up of hospital and nursing home use in project elderly and randomized controls.

The cost-effectiveness of a post-discharge programme on the use of hospital care and the continuity of care was assessed in an elderly cohort (n = 204) discharged from the city hospital. The participation rate was 97.6%, and the patients were aged 75 years or over and lived alone. The randomized controls (n = 204) received standard aftercare. During the follow-up the costs of university hospital care decreased by 52% in the intervention group and by 24% in the control group per patient year, compared with the costs in the year preceding the project. This happened despite the higher morbidity in the intervention group in terms of fractures and the use of university hospital care in the year preceding the project. There was also a tendency in the intervention group for the previous non-users of university hospital care to remain non-users during the follow-up. The costs of city hospital care increased by 16% and 5%, and of all hospital care by 1.3% and 0.2%, respectively. There were no differences in admissions to permanent care in the nursing homes. The intervention group did not make their first contact with the hospitals or permanent care in nursing homes earlier than the control group during the follow-up. The co-operation between hospital and domiciliary care and voluntary workers was well-suited to the innovative care of the elderly people.

Treatment of primary tracheal carcinoma in Finland in 1967-1985.

The treatment results of all the 95 primary tracheal carcinomas recorded by the Finnish Cancer Registry in 1967-1985 are evaluated. Six of the 95 patients were treated by surgery, 60 received radiotherapy and 29 were left untreated or received only palliative endoscopic or cytostatic therapy. The prognosis of the disease was poor. Among the 44 squamous cell carcinoma patients treated by radiotherapy, the median survival time after the diagnosis was 8 months (range 1-81 months). Complete response to radiotherapy was a favourable prognostic sign; after complete response the survival rates at 1, 2 and 5 years were 45%, 18% and 9% respectively. Patients with adenocystic carcinoma had the best prognosis.