Deep venous thrombosis after surgery for Achilles tendon rupture: a provoked transient event with minor long-term sequelae.

BACKGROUND: Deep venous thrombosis (DVT) occurs frequently in patients undergoing orthopedic surgery, but there is a lack of knowledge regarding long-term sequelae of DVT after different types of surgical procedures. OBJECTIVE: To describe the long-term effect of symptomatic (SDVT) and asymptomatic (ADVT) deep venous thrombosis on venous function and subsequent incidence of post-thrombotic syndrome (PTS) in patients who have undergone surgery for Achilles tendon rupture. PATIENTS/METHODS: This observational follow-up study includes 83 patients with postoperative DVT, examined after a mean of 7 years. There were two series of patients: 45 with SDVT and 38 with ADVT. In both series, more than 90% of the DVTs were limited to calf veins. Follow-up examinations comprised color duplex ultrasonography (CDU), strain-gauge plethysmography (SGP), clinical examination including scoring for venous disease and questionnaires for quality of life (QOL). RESULTS: A mild degree of PTS was found in 11% of the patients: 13% in SDVT and 8% in ADVT patients. The rate of recurrent ipsilateral DVT was 2%. Deep venous reflux was more common in patients with SDVT than in ADVT patients (84% vs. 55%, P < 0.01). Only a few patients had plethysmograpically abnormal findings without difference between the two groups. CONCLUSION: DVT after surgery for Achilles tendon rupture consists mainly of distal DVTs and are associated with a low risk for PTS. Deep venous reflux was more common in SDVT than in ADVT patients, probably as an effect of larger DVTs in the former group.

Asymptomatic deep venous thrombosis is associated with a low risk of post-thrombotic syndrome.

UNLABELLED: Post-thrombotic syndrome (PTS) is a well-recognized condition that develops after symptomatic deep venous thrombosis, but the clinical significance and late complications of asymptomatic deep venous thrombosis (ADVT) are unclear. OBJECTIVE: To determine whether ADVT following minor surgery affects venous function and contributes to the later development of PTS. PATIENTS/METHODS: The study included 83 patients operated on for Achilles tendon rupture; 38 patients with postoperative ADVT and 45 patients without (control group). The follow-up examinations five years after the operation comprised computerised strain-gauge plethysmography, colour duplex ultrasonography, clinical scoring of venous disease, and quality of life (QOL). RESULTS: Villalta scores, CEAP classification and QOL did not differ between groups. PTS (=Villalta score > or =5) was found in three ADVT patients (8%) and in two controls (4%). Ultrasonography revealed post-thrombotic changes in 55% of ADVT patients and in none of the controls. Deep venous reflux occurred in 22 ADVT patients and in three controls (P<0.001). There was no difference between groups in plethysmographic variables, demonstrating that the ultrasonographic abnormalities were of negligible haemodynamic significance. CONCLUSIONS: PTS is not a common sequel to ADVT after minor surgery. Although more than 50% of patients with ADVT developed post-thrombotic changes according to ultrasound, these changes did not result in haemodynamically significant venous dysfunction.

High sensitivity with color duplex sonography in thrombosis screening after ankle fracture surgery.

BACKGROUND: Phlebography is regarded as the reference standard for diagnosing asymptomatic deep vein thrombosis (DVT) in studies of thromboprophylaxis. However, technical advances with noninvasive color duplex sonography (CDS) have made this procedure an interesting alternative. OBJECTIVES: The objective of the present prospective study was to compare the sensitivity and specificity of CDS with those of phlebography. PATIENTS: The first 180 consecutive patients included in a larger randomized trial for prolonged thromboprophylaxis were subject to unilateral CDS and to phlebography after ankle fracture surgery. The patients were examined 6 weeks after surgery, all examinations being evaluated blindly. After patient drop outs and exclusions, 144 patients were left for analysis. RESULTS: Phlebography and CDS examinations were inconclusive or were not completed for 19% of these patients (28/144). DVT was diagnosed by phlebography in 21% (24/116) of the remaining patients. Most of the thrombi were isolated calf DVTs (18/24). In contrast, DVT was diagnosed by CDS in 31% of these patients (36/116): only one case diagnosed by phlebography was missed by CDS. The specificity of CDS is thus 86% and its sensitivity is 96%. The positive predictive value is 64%, and the negative predictive value is 99%. CONCLUSIONS: CDS is a safe method for detecting asymptomatic distal DVT. It has a high sensitivity and high negative predictive value, which means that the method is highly reliable to rule out DVT. Our results indicate that CDS could be considered as an alternative method for DVT screening.

Self-reported stress levels predict subsequent breast cancer in a cohort of Swedish women.

The association between stress and breast cancer has been studied, mostly using case-control designs, but rarely examined prospectively. The purpose of this paper is to describe the role of stress as a predictor of subsequent breast cancer. A representative cohort of 1,462 Swedish women aged 38-60 years were followed for 24 years. Stress experience at a baseline examination in 1968-69 was analysed in relation to incidence of breast cancer with proportional hazards regression. Women reporting experience of stress during the five years preceding the first examination displayed a two-fold rate of breast cancer compared with women reporting no stress (age-adjusted relative risk 2.1; 95% CI [1.2-3.7]). This association was independent of potential confounders including reproductive and lifestyle factors. In conclusion, the significant, positive relationship between stress and breast cancer in this prospective study is based on information that is unbiased with respect to knowledge of disease, and can be regarded as more valid than results drawn from case-control studies.

An evaluation of a six-week intervention designed to facilitate coping with psychological stress.

Community dwelling Korean adults (N = 40) coping with the stress of severe mental illness were randomly assigned to a six-week differentiation furthering intervention (experimental) or a directed problem-solving treatment program (control) and administered pre- and posttreatment measures including the Morey Personality Assessment Screener (PAS) and Group Embedded Figures Test (GEFT). As predicted, the experimental group showed greater improvement on 6 out of 10 mental health subscales (PAS) and on the GEFT than the controls. For the entire sample, differentiation gainers showed more improvement on three PAS subscales compared with the no change or loss in differentiation groups. A three-month follow-up showed greater attendance at mental health appointments for the experimental group over controls and for total sample differentiation gainers over nongainers. Implications are discussed of this empirically tested model of a community intervention to facilitate coping with stress and enhancing competence.

Dynamics of intramolecular contact formation in polypeptides: distance dependence of quenching rates in a room-temperature glass.

Quenching of the triplet state of tryptophan by cysteine is an important new tool for measuring the rate of forming a specific contact between amino acids in a polypeptide chain. To determine the length scale associated with this contact, tryptophan was embedded in a room-temperature glass containing a high concentration of cysteine. The decay of the triplet population is extended in time, consistent with a rate coefficient that decreases exponentially with distance. Solving the diffusion equation with this distant-dependent rate reproduces the observed bimolecular rates in water and shows that quenching at low viscosities takes place less than or similar to A from van der Waals contact between the tryptophan and cysteine.

Cancer risk in Swedish women: the relation to size at birth.

The relationship between fetal growth as indicated by weight and length at birth, and cancer risk in 1080 adult Swedish women was examined. Birth factors were retrieved from original midwife records for the years 1914, 1918, 1922 and 1930, and primary cancer cases were identified by matching with national and regional cancer registries through the year 1998. A positive and statistically significant increased risk for cancer was found with increasing birth weight or birth length for all site cancer and non-hormone related cancer, defined as all cancer sites excluding breast, uterus and ovary. Addition of factors suspected to influence cancer risk, maternal proteinuria, birth order, own parity and age at menarche, did not attenuate this relation. Previously only breast cancer has been reported to be related to size at birth in adult women and this is the first study to report that cancer sites other than the major hormone-related sites may be influenced by size at birth, as measured by either weight or length at birth; these findings warrant further investigation.

[No connection between the number of amalgam fillings and health. Epidemiological observations from a population study of women in Gothenburg]. / Inget samband mellan antal amalgamfyllningar och hälsa. Epidemiologiska erfarenheter från populationsstudie av kvinnor i Göteborg.

Number of dental amalgam fillings and baseline serum mercury concentration were assessed with respect to a number of health related variables as part of a population study of women. There was no increased incidence of symptoms, no derangement of laboratory variables of clinical significance, nor any increased mortality or increased risk of myocardial infarction, stroke, diabetes or cancer in women with many amalgam fillings compared with those with few fillings, nor in women with higher serum mercury concentration compared with those with lower serum mercury concentration.

Poor agreement between self-reported birth weight and birth weight from original records in adult women.

Data from an ongoing prospective population study of women in Göteborg, Sweden, were used to assess agreement between self-reported birth weight and birth weight obtained from original delivery records of women aged 44-60 years. Of the eligible population with traced delivery records (n = 693), only 28% (n = 192) could report their own birth weight. Spearman correlation between self-reported birth weight and birth weight from original records was r = 0.76. However, a difference plot, with limits of agreement at -1,028 to 1,038 g (95% confidence limits: lower limit, -1,157 to -901 g, upper limit, 910 to 1,166 g) revealed poor agreement between methods. Of the self-reported birth weights, 53% were in error by 250 g or more, and 31% were positively or negatively discordant by 500 g or more. Application in an analysis of cardiovascular risk factors in adulthood found conflicting results between self-reported and recorded birth weights. Low reporting rate, poor reporting accuracy, and misleading findings in application led to the conclusion that self-reported birth weights from middle-aged women would not be a satisfactory replacement for birth weights from original records.

Differences in associations of familial and nutritional factors with serum lipids between boys and girls: the Luxembourg Child Study.

BACKGROUND: Sex differences in the effects of genetic and environmental factors on circulating lipids have been examined mainly in adults, in whom the influences of sex steroid hormones are well known. OBJECTIVE: Our objective was to determine the effect of sex on genetic and environmental influences on serum lipids in prepubertal boys and girls. DESIGN: Children aged 6-8, 8-10, and 10-12 y (n = 1028) were selected at random in the Belgian province of Luxembourg, a region in Europe with a high prevalence of risk factors for cardiovascular disease and diabetes. Blood glucose and serum cholesterol, triacylglycerol, and insulin concentrations were measured, and anthropometric data and blood pressure were recorded. Familial data were obtained from standardized questionnaires. Nutritional status was obtained from a 3-d record. Participation was 70.3% of the primary cohort. RESULTS: Cholesterol, triacylglycerol, and insulin values were among the highest recorded in studies of children. In girls, cholesterol correlated positively with the energy density of intake of saturated fat (r = 0.13, P = 0.001), cholesterol (r = 0.11, P = 0.006), and protein (r = 0.12, P = 0.007) and negatively with the ratio of polyunsaturated to saturated fat intake (r = -0.14, P = 0.001) and the energy density of carbohydrate intake (r = -0.11, P = 0.019). In boys, no such relations were found. Triacylglycerol was not significantly related to nutritional factors. Consistent, independent relations were found between reported elevated cholesterol concentrations in the parental and grandparental generation and cholesterol (r = 0.101, P = 0.011) and triacylglycerol (r = 0.09, P = 0.03) in boys. No such associations were found in girls. CONCLUSION: Environmental and genetic factors may have different effects on serum cholesterol in girls and boys.

Fast kinetics and mechanisms in protein folding.

This review describes how kinetic experiments using techniques with dramatically improved time resolution have contributed to understanding mechanisms in protein folding. Optical triggering with nanosecond laser pulses has made it possible to study the fastest-folding proteins as well as fundamental processes in folding for the first time. These include formation of alpha-helices, beta-sheets, and contacts between residues distant in sequence, as well as overall collapse of the polypeptide chain. Improvements in the time resolution of mixing experiments and the use of dynamic nuclear magnetic resonance methods have also allowed kinetic studies of proteins that fold too fast (greater than approximately 10(3) s-1) to be observed by conventional methods. Simple statistical mechanical models have been extremely useful in interpreting the experimental results. One of the surprises is that models originally developed for explaining the fast kinetics of secondary structure formation in isolated peptides are also successful in calculating folding rates of single domain proteins from their native three-dimensional structure.

Relations between Helicobacter pylori, thyroid disease and cardiovascular risk factors in a 56-65-year-old population.

OBJECTIVE: To estimate the prevalence of and relation between Helicobacter pylori (HP) and thyroid disease in a 56-65-year-old population with cardiovascular risk factors. DESIGN: Cross-sectional study including every second individual in the age group. SETTING: The primary health care district of Mölnlycke, with about 14,000 inhabitants. PATIENTS: 170 men and 217 women aged between 56 and 65 years. MAIN OUTCOME MEASURES: Anthropometric (body mass index (BMI), waist/hip ratio (WHR)) and blood pressure measurements, biochemical analyses, including s-TSH, s-FT4 and HP serology. RESULTS: There was a high prevalence of metabolic risk factors in this pre-retirement group of individuals. The prevalence of HP was 42% in both men and women. Only a significant correlation between HP and WHR was seen in men. CONCLUSIONS: No reason could be found for including analysis of HP and thyroid tests in screening programmes for cardiovascular risk factors in men and women.

Measuring the rate of intramolecular contact formation in polypeptides.

Formation of a specific contact between two residues of a polypeptide chain is an important elementary process in protein folding. Here we describe a method for studying contact formation between tryptophan and cysteine based on measurements of the lifetime of the tryptophan triplet state. With tryptophan at one end of a flexible peptide and cysteine at the other, the triplet decay rate is identical to the rate of quenching by cysteine. We show that this rate is also close to the diffusion-limited rate of contact formation. The length dependence of this end-to-end contact rate was studied in a series of Cys-(Ala-Gly-Gln)(k)-Trp peptides, with k varying from 1 to 6. The rate decreases from approximately 1/(40 ns) for k = 1 to approximately 1/(140 ns) for k = 6, approaching the length dependence expected for a random coil (n(-3/2)) for the longest peptides.

Sociodemographic characteristics influencing birth outcome in Sweden, 1908-1930. Birth variables in the Population Study of Women in Gothenburg.

STUDY OBJECTIVE: To identify variables available in early Swedish delivery records and their relation to birth outcomes for home and hospital deliveries in Gothenburg at the early part of this century. DESIGN: A retrospective recovery of original delivery records and social variables in a cross sectional population. SETTING: Gothenburg, Sweden. PARTICIPANTS: 851 fullterm singleton female births with known gestational age born into five birth cohorts on selected dates (1908, 1914, 1918, 1922 and 1930). MAIN RESULTS: Delivery site, maternal parity, gestational age, and social group were significant factors influencing birth outcome as birth weight and length. The mean birth weight and length of hospital born infants was consistently lower than for home deliveries across all cohorts. Site of delivery changed significantly during the period of births under study, 1908-1930. CONCLUSIONS: In this study, which was based on original delivery records from the early part of this century, it was found that delivery site was an important factor influencing birth outcome across five birth cohorts. Utilisation of delivery services changed during the period of study. Thus, to avoid selection bias, the application of delivery records should reflect the birthing practice of the time period in question.

Blood pressure and hypertension in middle-aged women in relation to weight and length at birth: a follow-up study.

OBJECTIVES: To examine the relationship between indicators at birth and adult blood pressure and risk for developing hypertension at two age levels. DESIGN: Original midwife records of 438 women born at term participating in a prospective population study in Göteborg, Sweden with blood pressure and hypertension assessment at both 50 and 60 years of age. RESULTS: Systolic blood pressure at both age levels showed a U-shaped relationship to weight and length at birth. Hypertension prevalence at 60 years was significantly and inversely related to both weight and length at birth, but not at 50 years. Significantly higher risk for hypertension was found in the lowest birth weight quintile [odds ratio (OR) = 2.0, 95% confidence interval (CI) 1.1-3.8] and lowest birth length tertile (OR = 1.8, 95% CI 1.1-3.0), in relation to the middle quintile/tertile, with or without adjustment for adult body size (as body mass index), at 60 years but not at 50 years. At 50 years, hypertension risk decreased by 3% (95% CI 0.92-1.01) for every 100 g increase in birth weight and 6% (95% CI 0.83-1.05) per cm birth length. At age 60 years, hypertension risk decreased by 4% (95% CI 0.92-0.99) per 100 g birth weight and 10% (95% CI 0.81-0.99) per cm length. CONCLUSIONS: Size at birth was a predictor of hypertension risk in women at 60 years but not 50 years. This study supports the hypothesis that poor fetal growth, as measured by low weight or length at birth, may contribute to the development of hypertension in later life and that this relationship became stronger with age.

Socioeconomic and psychosocial conditions of parents and cardiovascular risk factors in their children: the Belgian Luxembourg Child Study III.

Socioeconomic and psychosocial handicaps are often associated with disease. There is a large body of information on adults on such relationships, but data are sparse on children. In a cohort of 1028 boys and girls, selected at random from school classes in Province de Luxembourg, a mainly rural area of Belgium, these problems were analysed in age strata of 6-8, 8-10, 10-12 years. Participation rate was 71%. Information was collected from questionnaires,. Anthropometric variables, blood pressure and glucose as well as cholesterol, triglycerides and insulin were measured in the children and related to the psychosocial and socioeconomic factors, organized into rural, psychosocial, socioeconomic and alcohol/smoking clusters of observations. Rural: Duration of living in the area of the child and parents correlated with diastolic blood pressure, particularly in boys (p < 0.01). Psychosocial: Housewives (p = 0.002) and their children (p = 0.002) had higher body mass indexes (BMI) than other mothers and their children. Sons of housewives also had higher blood pressure (systolic, p = 0.0007, diastolic, p = 0.007). Socioeconomic: Socioeconomic factors of parents (profession, unemployment) played relatively minor roles. Alcohol/smoking: Alcohol consumption was related to skinfold thickness in boys (p = 0.022), but not in girls. Girls, but not boys, with smoking parents had higher BMI (p=0.014). Multiple regression analyses suggested that psychosocial factors, such as housewives as mothers of large families, may be important for associations with cardiovascular risk factors in their children. There were apparent differences in the findings between girls and boys, suggesting that boys are more vulnerable to the impacts of the factors analysed.

Serum mercury concentration in relation to survival, symptoms, and diseases: results from the prospective population study of women in Gothenburg, Sweden.

A prospective population study of women in Gothenburg, Sweden was started in 1968-69 and comprised 1462 women aged 38, 46, 50, 54, or 60 years at baseline. Follow-up studies were carried out in 1974-75, 1980-81, and 1992-93. The baseline study included an extensive medical and dental examination. Serum mercury concentration (beta-HG) was determined in deep-frozen samples from all participants in 1968-69 and in a random subsample of sera from participants in 1980-81, about 20 years after the baseline examination. S-Hg was statistically significantly correlated with number of amalgam fillings at both examinations. Of 30 defined symptoms and 4 different clusters of symptoms, no one was independently correlated with S-Hg measured in the samples from 1968-69, while there was a negative statistically significant correlation with over-exertion and poor appetite in 1980-81. Blood hemoglobin and serum B-12 concentrations in 1968-69 were statistically significantly and positively correlated with S-Hg, while erythrocyte sedimentation rate and the serum concentrations of potassium and triglycerides were significantly and negatively correlated with S-Hg, also after including potential confounders. Blood hematocrit examined in 1980-81 was negatively correlated with S-Hg. When including potential confounders, serum IgA was also statistically significantly correlated with S-Hg, but not in univariate analysis. No statistically significant correlation was observed between S-Hg, on the one hand, and the incidence of diabetes, myocardial infarction, stroke, or cancer on the other, while a statistically significant negative correlation was observed with overall mortality when age and education were included as background variables. There were some correlations between biological variables and S-Hg, probably of no negative clinical significance, and we conclude that there is no association between disease and S-Hg on a population basis in middle-aged and older women.

[Spiral computed tomography--solution to diagnostic problems in pulmonary embolism?]. / Spiraldatortomografi--lösningen på lungembolidiagnostikens problem?

Clinical diagnosis of pulmonary embolism is difficult and often dependent on radiological methods. In Sweden scintigraphy has hitherto been the method most commonly used, though all too often it leaves the diagnosis in doubt. Spiral computed tomography, performed during continuous infusion of contrast medium, clearly depicts the pulmonaries arteries, emboli appearing as filling defects. The examination takes less than one minute. Although the method has yet to be fully evaluated, it is already available at most Swedish hospitals. Results presented so far suggest that the technique has great potential, and may become the method of choice in the diagnosis of pulmonary embolism.

Pharmacokinetics and pharmacodynamics of melagatran, a novel synthetic LMW thrombin inhibitor, in patients with acute DVT.

Forty-eight patients with acute proximal deep vein thrombosis (DVT) were randomised to intravenous infusions for 4 to 6 days with melagatran, a novel synthetic low molecular weight thrombin inhibitor, or unfractionated heparin adjusted by the activated partial thromboplastin time (APTT). The aim of the study was to investigate the pharmacokinetics, pharmacodynamics and the safety of melagatran therapy at three different doses. Steady-state plasma concentrations were rapidly achieved and maintained throughout the infusion period. The mean plasma concentrations in the low, medium and high dose groups were 0.17, 0.31 and 0.53 micromol/l, respectively. The prolongation of APTT was stable during the melagatran infusions and correlated to the plasma concentration. Phlebographically verified regression of thrombus size measured as decrease in Marder score was seen after 4 to 6 days in 8 of 12 patients, 6 of 12 patients and 5 of 11 patients in the low, medium and high dose groups of melagatran and in 5 of the heparin-treated patients. In the low dose group with melagatran, thrombus extension was seen in one patient. At the dose levels studied, melagatran was well tolerated with no clinically significant bleeding problems, suggesting that melagatran could safely be given to patients suffering from DVT.

Secular increases in waist-hip ratio among Swedish women.

INTRODUCTION: Secular increases in obesity have been documented in numerous populations. However, little is known about trends in fat distribution. Because men and women with elevated waist-hip ratios (WHR) constitute a high cardiovascular risk group, it is relevant to document secular changes in WHR. This paper compares WHR in three cohorts of women, one cohort recruited in the late 1960s and the others after 12 y and 24 y intervals. SUBJECTS AND METHODS: In 1968-1969, a randomly selected sample of women aged of 38 y and 50 y, was given anthropometric examinations (n = 761, total). The same measurements were taken on representative cohorts aged 38 y and 50 y in 1980-1981 (n = 677) and 1992-1993 (n = 167). All analyses of trends in WHR as a function of time are age-specific and body mass index (BMI)-adjusted. RESULTS: An interesting feature of this population is that BMI was stable from 1968-1969 to 1992-1993. However, WHR increased significantly in those aged 38 y and 50 y, independent of BMI (P = 0.001, both ages). The source of these changes in WHR was a combination of increasing waist circumferences and decreasing hip circumferences. Skinfold measurements, taken only at the first two examinations, also increased significantly. CONCLUSIONS: This female population appears to have experienced some changes in body shape and composition. However, we cannot explain the increasingly centralized fat patterning by changes in BMI, subcutaneous skinfold thickness or those obesity-related aspects of the modern lifestyle that we were able to measure.