Severe adverse effects related to dermal exposure to a glyphosate-surfactant herbicide.

This is a case of severe chemical burns following prolonged accidental exposure to a glyphosate-surfactant herbicide. The patient developed local swelling, bullae and exuding wounds. Neurological impairment followed affecting finger flexion and sensation with reduced nerve conduction. Imaging revealed oedema of the soft tissue and juxta-articular osteopenia, and a causal relationship to exposure is suggested.

[Thrombolytic therapy in acute lower extremity ischemia]. / Trombolysebehandling ved akut underekstremitetsiskaemi.

During a period of four and a half years 37 lower extremities with acute ischaemia were treated with thrombolysis. Angiographically, 35 cases demonstrated no suitable arteries for distal reconstruction. In two cases vascular surgery was not performed because of cardiac incompensation. Two patients died within one month and limb salvage was 69%. During 22 months (3-48) of follow-up another six patients were amputated two to nine months later. The 18 salvaged lower extremities (49%) had an ankle-brachial pressure index of 0.63 (0.30-1.-09). Review of all angiograms revealed a demonstrable effect of thrombolytic therapy only in 13 (35%) cases. In conclusion, thrombolytic therapy should be considered in the case of acute lower extremity ischaemia unsuitable for reconstructive procedures. Even though the effect of thrombolytic therapy cannot be demonstrated on the angiogram, that should not necessarily deem the treatment to be a failure.

[4 years of experiences with Karbase. A tool for quality development in vascular surgery]. / Fire års erfaringer med Karbase. Et redskab til kvalitetsudvikling i karkirurgi.

Karbase, a Danish register for vascular surgery is presented with data from four years experience. The register consists of 65 variables centered on risk factors, the perioperative course as well as follow-up information. During the four-year period 1989-1992 a total of 4902 admissions were registered in 3810 patients. Surgery was performed during 4005 admissions. Output data from Karbase is presented with results on survival and postoperative complications, related to preoperative risk factors. The incidence of surgical wound infections was 3.9%, with a significant reduction during the years (p = 0.004). Karbase is now used by all vascular surgical units in Denmark. We conclude that the establishment of a continuous registration has been beneficial to the department. We have achieved valid data on treatment, outcome and complications in relation to individual risk factors. In the future the use of Karbase will be extended with the aim of further quality development, locally as well as nation wide.

[Acetylsalicylic acid treatment after peripheral vascular surgery]. / Acetylsalicylsyrebehandling efter perifer karkirurgi.

Antiplatelet drugs (acetylsalicylic acid) have been widely used in arteriosclerotic patients during recent years. We have reviewed the literature to find out if this treatment also is indicated in patients operated with reconstructive vascular surgery for lower limb ischemia. It is concluded, that all patients should receive life-long treatment with acetylsalicylic acid 300-500 mg per day following peripheral vascular surgery. This will improve the patency rate of certain vascular procedures, and in all patients it reduces the incidence of cerebral stroke and the risk of myocardial infarction in the years following peripheral vascular surgery.

Multifocal osteonecrosis related to steroid treatment in a patient with ulcerative colitis.

A case of multifocal steroid related osteonecrosis in a patient with ulcerative colitis is presented. The pathogenesis, diagnosis, natural history, and treatment of the disease is discussed briefly with emphasis on the importance of early diagnosis--preferably by magnetic resonance imaging. Early diagnosis often depends on the gastroenterologist considering the possibility of osteonecrosis.

Observer variation in the Lauge-Hansen classification of ankle fractures. Precision improved by instruction.

We investigated whether instruction can decrease the variation in the classification of ankle fractures. The radiographs of 100 consecutive ankle fractures were twice assessed by 8 observers, using the Lauge-Hansen classification system. 1 group of 4 observers was given special instruction between 2 assessments. Without instruction the interobserver variation was identical at the first and second assessments. After instruction, the agreement increased from 0.66 to 0.75. These results show that the variation in the Lauge-Hansen classification system can be reduced by instruction.

Comparison between reference values for 201thallium uptake and washout from the myocardium after exercise and after dipyridamole.

A slow washout of 201Thallium has a high diagnostic and prognostic value for coronary artery disease. The aim of the present work was to contribute with reference data on 201Tl uptake and washout from the myocardium. With a quantitative method using circumferential profiles and interpolative background subtraction we performed 201Tl myocardial imaging in two groups of subjects with a low probability of coronary artery disease. Washout in per cent is defined as (1-D/I).100, where D is the delayed uptake rate and I the initial uptake rate. In group A (n = 16) myocardial hyperaemia was induced by maximal exercise, in group B (n = 15) by intravenous infusion of dipyridamole. In group A, the mean washout was 52%, and in group B it was 34% (P < 0.001). The delayed uptake rate D was significantly higher after dipyridamole, 58.4 cps, than after exercise, 44.5 cps (P < 0.05). There was no significant differences in I between the two groups. The findings regarding D and I explain that the washout is slower after dipyridamole than after exercise, as the mean D/I ratio was 0.48 in group A and 0.66 in group B (P < 0.001).

[Excimer laser-assisted balloon angioplasty of the femoro-popliteal segment]. / Excimer-laser-assisteret ballonangioplastik af det femoropopliteale segment.

In the Department of Vascular Surgery RK, The University Hospital in Copenhagen, the authors have treated 16 patients with ischaemia in the lower limb by means of laser-assisted balloon angioplasty. A pulsed ultraviolet excimer-laser was employed. It proved possible to break down the occluding arterial lesion in 12 patients (75%). In one patient, this was not followed-up by balloon angioplasty and, in another patient, the reconstruction closed on the first day after operation. The primary success of the procedure, defined as breaking down of the occlusion with the laser-catheter followed by balloon angioplasty and an increase in the ankle/brachial index of greater than 15%, was found to be 10/16 or 62%. The remaining four patients, in whom it did not prove possible to break down the arterial lesion with laser, were treated by means of conventional vascular surgical reconstruction. On follow-up examination after an average of nine months, nine out of the ten patients (90%) still had a patent reconstruction after laser-assisted balloon angioplasty. This new endovascular laser-procedure appears to be suitable for selected patients, but must be assessed more meticulously before it is possible to determine its future placing in the vascular surgical therapeutic armamentarium.

A comparison of dipyridamole thallium 201 scintigraphy and clinical examination in the determination of cardiac risk before arterial reconstruction.

Preoperative clinical examination, including a 12-lead resting ECG, and planar dipyridamole thallium imaging (DTI) were compared in a prospective study of 65 vascular surgical patients in regard to their value for predicting postoperative cardiac complications. Fifty-three patients underwent abdominal vascular procedures and 12 were operated on for peripheral artery disease. Thirty-six patients had ischemic heart disease (IHD) and/or abnormal findings from 12-lead resting ECG. Of these 36 patients, 11 had nonfatal cardiac complications. The remaining 29 patients were free of IHD and had normal results from ECG. No complications occurred among these 29 patients. There was no postoperative death. Thallium imaging results were abnormal in 45 patients, showing either redistribution and/or scar tissue or low washout. In 18 of these patients major changes with redistribution were present in all projections. Among these patients, 9 had a nonfatal cardiac complication. In the 27 patients with abnormalities in only one or two projections, only 2 had a cardiac event postoperatively. No cardiac complications occurred in patients with normal thallium scintigraphy findings. The patients were operated on irrespective of the results of the scans, and all recovered from any cardiac complications that occurred. In vascular surgical patients with previous IHD and/or abnormal findings from resting ECGs further risk stratification is achieved with DTI.

Massive hematuria due to iliac artery-ureteral fistula. Case report.

Massive hematuria in a 73-year-old man, who 17 years previously had undergone aorto-iliac-femoral thrombendarterectomy, was found to originate from an iliac artery-ureteral fistula due to a false aneurysm. Fistula formation should be kept in mind when investigating such hematuria in patients with a history of vascular surgery in the iliac segment.

Thallium-201 myocardial scintigraphy during dipyridamole-induced coronary hyperaemia. First experiences with a new regional washout programme.

Eight patients with severe peripheral vascular atherosclerosis scheduled for abdominal aortic surgery were investigated to detect coexisting coronary artery disease. None of the patients had a history of angina pectoris or previous myocardial infarction. Preoperative computerised thallium-201 dipyridamole myocardial scintigraphy was abnormal in all patients, showing either myocardial scar tissue and/or ischaemia with redistribution and/or low washout. In all but one patient, the serum level of creatin kinase was elevated during the first postoperative days. In two patients, the serum concentrations of aspartate aminotransferase and lactate dehydrogenase were elevated. None of the patients showed clinical or electrocardiographical signs of acute myocardial infarction. Thallium-201 dipyridamole myocardial imaging is a new noninvasive method for detection of ischaemic heart disease in patients with severe peripheral atherosclerosis who are unable to perform a bicycle exercise test. The new programme for determination of regional washout appeared to be very precise and may be especially applicable in the case of low washout values.

Evaluation of radiocardiographic methods for determination of cardiac output and right and left ventricular ejection fractions using a cardiac phantom.

Cardiac output and ejection fractions of the cardiac ventricles are valuable measures of cardiac function. Noninvasive radionuclide techniques for determination of these measures are based on analysis of different data: first passage low frequency, first passage high frequency and multigated equilibrium data. We have evaluated the principles of these methods using a dynamic cardiac phantom. Radiocardiographic determinations of cardiac output and right and left ventricular ejection fractions showed excellent correlation against true phantom values: r = 0.993 (p less than 0.001), r = 0.978 (p less than 0.01) and r = 0.943 (p less than 0.05), respectively. Thus, the findings of the present study demonstrate a high validity of current radiocardiographic measures of cardiac function.

Determination of cardiac output by first passage radiocardiography: theoretical considerations and phantom studies.

Non-invasive determination of cardiac output by aid of precordial first passage radiocardiography may prove a useful tool in the management of cardiac disorders. The basic concepts of a method together with theoretical assumptions necessary for the clinical application of the method are described. The principle of the technique was tested in a cardiac phantom model with adjustable stroke volume and heart rate, in which background problems were avoided. First passage radiocardiography gave highly accurate cardiac output determinations compared with the 'true' phantom values, r = 0.998 (p less than 0.001).

Validity of clinical symptoms in benign esophageal disease, assessed by questionnaire.

A questionnaire designed to test the value of questions identifying benign esophageal disease was sent to patients representing four well-defined entities: angina pectoris (n = 30), benign esophageal disease (n = 25), gastroduodenal ulcer or former gallstones (n = 27) and normal subjects (n = 38). By means of logistic regression, three key-questions were selected. A combination of an affirmative answer to "difficulty in swallowing solid food" and to "pain in the chest" or "heartburn at night" or both did not occur in the group of normal subjects, while occurring in 68% of the patients with esophageal diseases. The combination occurred in only 10% of the patients with angina pectoris and 15% of those suffering from gastroduodenal ulcer or gallstones. The predictive accuracy of the combination of the three questions is estimated for various hypothetic prevalences of esophageal disease. These questions appear to identify approximately two-thirds of individuals with esophageal disease with acceptable false-positive rates and can therefore be used in epidemiological studies.

Ceruletide and neostigmine in postoperative intestinal paralysis. A double-blind clinical controlled trial.

A double-blind and randomized clinical trial, which included 48 patients with postoperative intestinal paralysis on the third day after laparotomy, demonstrated no difference between treatment with ceruletide (0.3 microgram/kg body weight) and neostigmine (5.0 micrograms/kg body weight) in restoring normal intestinal function.

Ceruletide vs. metoclopramide in postoperative intestinal paralysis. A double-blind clinical trial.

Sequential analysis of a double-blind clinical trial involving 26 patients demonstrated a statistically significant superiority of ceruletide over metroclopramide in restoring peristalsis in intestinal paralysis after abdominal surgery (P less than 0.05).