[Patient based care registries as a tool to follow up services]. / Individbaserade vårdregister en hjälp vid verksamhetsuppföljning.

The Federation of Swedish County Councils and six medical specialties are working together in a project aiming to support and stimulate the development of patient based case registers as a tool to follow up, evaluate, develop and manage medical units. The project is based on participation on the part of the medical professions in a process-oriented way. Each case register shall be based on the individual patient, and will integrate inpatient and outpatient care, all medical professions and important procedures. In hematology the project also seeks to merge case costing data with the patient based case registers in order to facilitate more comprehensive cost analysis and comparison. This episodic perspective is useful for providers per se as well as in discussions between purchasers and providers as a method for understanding and analyzing medical services. The six specialties are hematology, obstetrics and gynecology, ophthalmology, otorhinolaryngology, dermatology and sexually transmitted diseases, and lastly psychiatry.

[Prosthetic replacement of the ureters]. / Le remplacement prothétique des uretères.

STUDY AIM: The aim of this study is to demonstrate the reliability of silicone prosthesis for the replacement of ureters. This prosthesis derives from the biliary prosthesis developed after a personal experimental study continued by Triboulet. PATIENTS AND METHODS: In 38 patients suffering from a malignant disease, a right silicone prosthesis was used for the replacement of an ureter during a 20-year period. There were 30 female and eight male patients. The mean age was 71 (range: 51-88 years). Forty one prostheses were used; one patient underwent two successive operations on the same side with a change of prosthesis, and two patients required a bilateral prosthesis. There were 12 gynaecological carcinomas (three with ureteral fistula), three prostatic carcinomas, 16 cancers of the rectum and recto-sigmoid junction, four cancers of the right colon with retroperitoneal carcinomatosis, and three ureteral fistulas after extended colonic resection. RESULTS: Early complications were limited to ureteral fistulas (n = 6, 16%) in patients who had already a preoperative fistula (n = 3) and in patients with peritoneal metastases on the superior wall of the bladder. The secondary destruction of the kidney (four secondary nephrectomies) occurred when the function of the kidney was already impaired at the time of the procedure. There were no secondary fistulas, no secondary obstruction of the prosthesis. The longest follow-up was 69 months. CONCLUSION: The silicone prostheses used for the replacement of ureters are reliable and still permeable beyond 5 years. The protection of the renal function in patients often submitted to chemotherapy improves the duration and quality of survival. These prostheses must be reserved to advanced malignant diseases with a rather long life expectancy.

Lipoprotein abnormalities are associated with increased rate of progression of human chronic renal insufficiency.

BACKGROUND: Chronic renal insufficiency is accompanied by specific alterations of the lipoprotein metabolism. It has been suggested that the renal dyslipoproteinaemia of renal insufficiency contributes to the progression of glomerular and tubular lesions, with subsequent deterioration of renal function. The objective of this prospective study was to investigate whether the specific lipoprotein abnormalities of renal insufficiency are associated with the rate of decline of renal function in patients with moderately advanced chronic renal failure. METHODS: A patient population of 73 adult non-diabetic patients with primary chronic renal disease were followed with repeated measurements of the glomerular filtration rate (GFR) for an average of 3.2 (SD 0.7) years. Forty-three of these patients had chronic glomerulonephritis as the underlying renal disease. Patient characteristics including plasma levels of lipids and apolipoproteins were determined at entry and were prospectively related, using linear regression, to the rate of progression. RESULTS: The mean GFR at entry was 41.3 (SD 15.3) ml/min x 1.73 m2 BSA. The average rate of progression was a decline in GFR of -2.8 (SD 3.7) ml/min x 1.73 m2 BSA per year. In the whole patient study group total cholesterol, low-density lipoprotein (LDL) cholesterol, and apolipoprotein B (apoB) were all significantly associated with a more rapid decline in renal function, whereas triglycerides, high-density lipoprotein (HDL) cholesterol, and apolipoprotein A (apoA) were not. In the more homogeneous subgroup of patients with chronic glomerulonephritis the association between dyslipidaemia and the rate of progression was even more pronounced. In this subgroup of patients also serum triglycerides and apoE were significantly associated with a higher rate of progression. Both the initial blood pressure and proteinuria were also significantly associated with a more rapid decline in renal function in the whole study group as well as in patients with chronic glomerulonephritis. The associations between these variables with the rate of progression were all independent of the entry GFR values. CONCLUSIONS: These results indicate that the lipoprotein abnormalities of renal insufficiency contribute to the progression of renal failure in human chronic renal disease.

Effect of gemfibrozil on lipoprotein abnormalities in chronic renal insufficiency: a controlled study in human chronic renal disease.

BACKGROUND: Renal dyslipoproteinemia is characterized by the accumulation of intact and partially metabolized triglyceride-rich lipoproteins. Reduced lipolytic enzyme activities may be one of the major pathophysiological mechanisms contributing to a retarded catabolism of these lipoproteins in patients with renal insufficiency. OBJECTIVE: To evaluate the effect of gemfibrozil treatment on renal dyslipoproteinemia. STUDY DESIGN: A randomized, controlled open study with 2 parallel groups. OUTCOME VARIABLES: Plasma concentrations of lipids, apolipoproteins and lipoprotein particles. PATIENTS AND METHODS: Fifty-seven non-nephrotic, non-diabetic patients with moderately advanced renal insufficiency were randomized to either treatment with gemfibrozil at dosages from 300 to 900 mg/day (n = 28) or dietary counseling (n = 29). The intervention period was 12 months. Plasma concentrations of lipids, apolipoproteins and apoA- and apoB-containing lipoprotein particles were determined at the entry and after 6 and 12 months of treatment. RESULTS: No serious adverse effects occurred during the study. Six patients experienced mild gastrointestinal symptoms and prematurely withdrew from the drug treatment. In the group treated with gemfibrozil the plasma concentrations of triglycerides, total cholesterol, very low density lipoprotein (VLDL) and low density (LDL) cholesterol decreased significantly by 47, 13, 43 and 14%, respectively, in comparison to baseline. High density lipoprotein (HDL) cholesterol increased significantly by 18%. ApoB, apoC-III, apoC-III in heparin-manganese precipitate (reflecting apoC-III in VLDL and LDL) and apoE decreased significantly by 21, 18, 26 and 49%, respectively. Furthermore, gemfibrozil treatment resulted in the reduction of plasma concentrations of complex (LP-Bc) and simple (LP-B) apoB-containing lipoprotein particles by 22 and 7%, respectively. However, these changes were not statistically significant. There was a slight, insignificant increase in the levels of LP-A-I:A-II particles and no change in the levels of LP-A-I particles. In contrast to the effect of the pharmacological intervention, the dietary counseling only resulted in minor changes in the plasma lipid and apolipoprotein profiles. The only significant changes were a 10% increase in HDL cholesterol and a 35% decrease in apoE. CONCLUSIONS: Gemfibrozil treatment significantly reduces both plasma lipids and apoB, apoC-III and apoE concentrations in patients with moderately advanced renal insufficiency. The results of this study indicate that gemfibrozil enhances the clearance of apoB-containing triglyceride-rich lipoproteins.

[Musculo-aponeurotic flap in the treatment of inguinal hernias, apropos of 1,600 operations]. / Intérêt du lambeau musculo-aponévrotique dans la cure des hernies inguinales, à propos de 1,600 interventions.

Morbidity, absention and duration of cares are important factors for the treatment of groin hernias. Deep and tension free cure is a key element to decrease the rate of recurrence. Utilization of prosthesis cannot provide a rate of 100%. This must be taken into consideration for indications. Beside we must take into account specific risks of each technique. Hernia treatment cannot be unique. This parietal surgery must remain a technique with low morbidity. As for treatment of unilateral hernia, we have qualified a technique of hernioplastia depending upon theses criteria, by inguinal incision, without prosthesis. Our technique includes: A complete dissection of the inguinal canal. The resection of the sac of the hernia at the internal ring. A deep cure of the fascia transversalis. A systematic incision of discharge on the anterior face of the rectus sheath. This incision is extremely internal and constitutes a large musculo-aponeurotic flap of 8 to 12 cm that makes this cure tension free possible. In the term of 10 years, our recurrence rate is below 1% for type I or II hernias in Nyhus classification. Consequently we discuss the indications for prosthesis. They must be reserved for hernias with high recurrence risk, bilateral hernias of for recurrent hernias.

[Role of pre-slit Crinofil prostheses in the treatment of inguinal hernias by extra-peritoneal approach. Apropos of 400 cases]. / Place des prothèses en Crinofil préfendues dans le traitement des hernies inguinales par voie extra-péritonéale. A propos de 400 observations.

Surgical treatment of inguinal hernia has progressed over the last 15 years, particularly due to the development of new prosthetic material. Strong pre-slit yet flexible plastics adapted to the size of the posterior inguinal wall were implanted in 400 patients over a 15 year period and have given excellent results. When reoperation was required, these plaques were not an obstacle to dissection of the vascular pedicles since no staples are needed, reducing the risk of nerve injury.

[Abdominopelvic actinomycosis. Apropos of 2 clinical cases]. / L'actinomycose abdomino-pelvienne. A propos de 2 observations. Cas cliniques.

Actinomycosis is a chronic infection due to an anaerobic Gram positive commensal bacteria harbored in the healthy cavities. From the main localizations in facial, respiratory and gynecology cavities, the infection can progress forming abdominothoracic or pelvis tumors simulating pseudo-neoplastic formations. Macroscopic diagnosis of this uncommon disease is difficult even intraoperatively. The extemporaneous pathology examination confirms the presence of actinomyces grains. We report two cases of abdominopelvic actinomycosis which developed on a "forgotten" intrauterine device leading to torpid severe disease. Actinomyces are sensitive to penicillin if treatment is continued for several months but infiltrations into the urinary and digestive tract may lead to fistulae and hydronephrosis.

[French modification of the Bassini technic in a series of 1500 successfully treated cases of inguinal hernia in males over 25 years]. / Technique de Bassini modifiée "à la française" sur une série de 1500 cures de hernies inguinales chez l'homme en 25 ans.

The high frequency of inguinal hernia leads to a major economic impact. Hospitalization duration and work loss time, post-operative pain, recurrences, risk of sepsis and complications directly related to prostheses are all factors which must be taken into account. We report our experience with the "French" modification of the classic Bassini technique. In our hands this technique involves: deep cure of the fascia transversalis, complete dissection of the inguinal canal, resection of the lateral oblique sac and the inner orifice of the inguinal canal, a off-loading incision in the right sheath to release tension. Recurrence rate under 1% after 10 years in type I and type II hernias according to the NYHUS classification led us to discuss the indications of prostheses which, in our opinion should be reserved for voluminous type II hernias and for bilateral or recurrent hernias.

Determinants of furosemide delivery to its site of action.

We have investigated the pharmacokinetic determinants of delivery of furosemide to its site of action in the renal tubules in patients and healthy volunteers. The bioavailability of furosemide is low and variable. Patients with renal disease may also have a low renal extraction of furosemide. In clinically relevant concentrations the free fraction of furosemide is inversely proportional to the plasma albumin concentration. A change in the free fraction of furosemide will change Clr, Clnr, and Vd in the same direction and that will cause minimal changes in the excretion rate of furosemide and its t1/2. A change in RBF will change the secretory clearance of furosemide to the same proportion and consequently also the excretion rate and its t1/2.

Acute tolerance to furosemide. Pretreatment with captopril or prazosin does not influence diuresis and natriuresis.

To investigate whether the development of acute tolerance to furosemide in human subjects could be prevented or delayed by angiotensin converting enzyme inhibition or alpha 1-receptor blockade, a study was conducted on healthy volunteers. The protocol on the experimental days was identical except for pre-treatment with placebo, captopril or prazosin. During continuous furosemide infusion with urinary furosemide excretion at a constant rate, the subjects became progressively dehydrated, with a maximal decrease in plasma volume of 9-11%. The diuretic/natriuretic response to furosemide was similar in the three protocols. Acute tolerance to diuresis developed earlier than that to natriuresis, again with no differences between the protocols. Not until the plasma volume had decreased by 9% did the natriuresis diminish significantly. In the placebo and captopril protocols acute tolerance was caused mainly by a decreased glomerular filtration rate, and in the prazosin protocol mainly by increased tubular reabsorption. It is concluded that neither ACE inhibition nor alpha 1-receptor blockade prevented or delayed the acute tolerance to furosemide. The results suggest that acute tolerance to furosemide can be induced through different but complementary homeostatic mechanisms in the kidney.

Lipoprotein abnormalities without hyperlipidaemia in moderate renal insufficiency.

To characterize lipoprotein metabolism during early renal insufficiency, plasma lipid and apolipoprotein profiles were determined in normotriglyceridaemic (NTG, n = 31) and hypertriglyceridaemic (HTG, n = 30) middle-aged patients with primary renal disease and with moderately impaired renal function (GFR 20-55 ml/min, mean: 37.2). Mean GFR was similar in the two patient groups. They were compared with 102 normolipidaemic control subjects. In comparison with controls the NTG patients (plasma triglycerides TG < or = 1.7 mmol/l, mean TG: 1.16 mmol/l) had significantly increased plasma concentrations of apo C-III and apoB. The apoA-I levels tended to be lower and as a consequence the apoA-I/apoC-III ratio, considered to represent the hallmark of the altered apolipoprotein profile in renal dyslipoproteinaemia, was markedly lower in NTG patients (8.7 versus 16.8, P < 0.001). There was also a reduction of the antiatherogenic ratio apoA-I/apoB and an increase of the apoC-III/apoE ratio. The HTG patients (mean TG: 3.22 mmol/l) showed the same, but even more accentuated, qualitative changes as the NTG patients. There was a fourfold increase of apoC-III in VLDL-LDL lipoprotein fractions with little change in HDL in the HTG patients. In NTG patients the increase of apoC-III was found in VLDL-LDL and in HDL. Plasma insulin and PTH levels both correlated with the apoA-I/apoC-III ratio independently of GFR and BMI. This suggests a pathogenetic relationship between PTH-mediated alterations of insulin metabolism and the lipoprotein abnormalities.(ABSTRACT TRUNCATED AT 250 WORDS)

Changes in renal clearance of furosemide due to changes in renal blood flow and plasma albumin concentration.

We have shown that, within therapeutic plasma concentrations, the unbound fraction of furosemide changes in direct proportion to the reciprocal of the plasma albumin concentration (correlation coefficient 0.99). Changes in the albumin concentration were produced by ultrafiltration of human plasma using a haemofiltration filter. Thus, we propose that, when studying changes in the pharmacokinetics of a highly protein bound drug, calculated changes in the unbound fraction offer an alternative to actual measurement of the unbound concentration, which is often difficult. Nine healthy volunteers receiving a continuous furosemide infusion were studied in normovolaemia and after dehydration (-1.4 kg), with and without pretreatment with an angiotensin converting enzyme inhibitor (captopril) or an a1-adrenoceptor blocking agent (prazosin). Significantly larger changes in the renal clearance of furosemide were found that could be explained by changes in the unbound fraction. Following dehydration, the unbound fraction of furosemide was decreased by about 5%, while its renal clearance fell by 27%, 33% and 13% after pretreatment with placebo, captopril and prazosin, respectively. The secretory clearance of the unbound furosemide changed substantially and in parallel with changes in the renal blood flow. It is suggested that changes in the renal clearance and excretion of furosemide and its t1/2 are much more dependent on changes in renal blood flow than on changes in its unbound fraction.

[Surgical silicone prostheses in the treatment of biliary tract cancers: long prostheses or short prostheses? Results apropos of 500 cases]. / Les prothèses chirurgicales en silicone dans le traitement des cancers des voies biliaries: prothèses longues ou prothèses courtes? Résultats à propos de 500 observations.

The interest of surgical prostheses in the palliative treatment of biliary tract cancer is well established, on the basis of their good tolerance, the more than 15 year follow up experience and the number of patients operated upon. After exeresis, they allow re-establishment of continuity, either by use of a prosthesis in Y when the right and let ducts can be dissected, or by using two prostheses, a multiperforated long prosthesis reimplanted in the duodenum and a short prosthesis reimplanted in the common bile duct without attaining the sphincter of Oddi. Of the 1000 cases treated, 500 were the object of a statistical analysis, 46 being operated upon by the author, in 60% of cases for biliary tract cancer, either primary or as an extension from the gallbladder. One-third of the patients had advanced lesions and a short survival of less than 3 months. Two-thirds a median survival of 9 months. In 10%, a radical exeresis was performed with survival of more than one year without recurrence of jaundice. Failure of treatment with persistence of jaundice was due to advanced disease for which surgery is unsatisfactory. Essential complications were premature bile leaks (5%) without serious consequences if sufficient drainage was maintained, since it stopped spontaneously, and angiocholitis (6%), the result of territory exclusion or reflux. Recurrence of jaundice was related to extension of the neoplasm to the secondary bile ducts, and to hepatic metastases. Obstruction of the prosthesis before two months was rare (6%) and was preceded by angiocholitis. In the absence of recurrence of the cancer the prosthesis can be replaced surgically without difficulty.

Type 2 diabetes. Primary vascular disorder with metabolic symptoms?

It is postulated that in the resting state insulin-dependent tissue uptake of glucose is limited by the rate of blood flow, capillary permeability, and the number of perfused capillaries in the skeletal muscles. A mathematical model, simulating these relations, is developed. According to this model, changes in the indicated parameters might cause type 2 diabetes.

DNA methyltransferases: activity minigel analysis and determination with DNA covalently bound to a solid matrix.

We describe two methods that facilitate detection and characterization of DNA methyltransferases: activity gel analysis and the use of DNA-cellulose or DNA-Sepharose in DNA methylation reactions. The first permits identification of catalytic subunits, determination of the influence of proteolysis, and evolutionary or developmental studies. The second allows accurate and fast determination of DNA methyltransferase activities in crude extracts and during purification.

[Silicone biliary prosthesis. 150 cases]. / Les prothèses biliaries en silicone. Cent cinquante observations.

The silicone biliary prosthetic devices presented here are useful not only for biliary bypass but also for transtumoral intubations and to re-establish biliary tract continuity after certain types of excision. They are perfectly well tolerated. In this series of 150 cases, post-operative morbidity and mortality were low and the long-term results excellent. Good results were observed in 95% of patients with cancer of the hilum. Unlike percutaneous or endoscopic prosthetic devices these do not migrate or become obstructed. Survival exceeded 2 years in 60 patients with limited lesions.