Screening for abdominal aortic aneurysm among patients referred to the vascular laboratory is cost-effective.

UNLABELLED: Screening for abdominal aortic aneurysm (AAA) in high-risk groups has been recommended based on a high prevalence of disease, while being questioned due to a high frequency of co-morbidities and inferior life-expectancy. We evaluated the long-term outcome and the cost-effectiveness of selective AAA screening among patients referred to the vascular laboratory for arterial examination. METHODS: A total of 5,924 patients, referred to the vascular laboratory of a university hospital, were screened for AAA with ultrasound (definition: slashed circle>or=30 mm), 1993-2005. Outcome data were gathered through hospital records and the national population registry. A Markov model was used for health-economic evaluation. RESULTS: An AAA was detected in 181 patients (mean age 72.8 years), of whom 21.5% underwent elective repair (perioperative mortality 5.1%) after 7.5 years of follow-up. Four of six patients diagnosed with AAA rupture were operated upon. Relative 5-year survival compared with the general Swedish population, controlled for age and sex, was 80.4% (95% confidence interval (CI): 70.8-88.8). The cost-effectiveness was robust in base-case (11,084 Euro/life year gained) and in sensitivity analyses of prevalence, cost and survival. CONCLUSIONS: Patients in whom AAA was detected at selective screening had inferior long-term survival and were operated on less frequently, compared with AAA patients described in previous studies. Yet, selective screening at the vascular laboratory was cost-effective.

Selective screening for abdominal aortic aneurysm among patients referred to the vascular laboratory.

BACKGROUND: Patients examined for peripheral arterial disease at the vascular laboratory, Uppsala University Hospital, are since 1993 screened for abdominal aortic aneurysm (AAA). The objective of this study was to study the prevalence of AAA found at this selective high-risk screening. METHODS: All files in the vascular laboratory were retrospectively reviewed. Of 9296 persons examined with arterial duplex between 1993 and October 2005, 5924 were screened for AAA. The primary target vessel was the carotid arteries in 3772 subjects, the renal arteries in 1529 subjects and the lower extremity arteries in 1457 subjects. An AAA was defined as an infrarenal aortic diameter >/=30mm. RESULTS: 179 subjects were found to have an AAA. In a logistic regression model male gender, age and duplex-verified arterial stenosis were independently associated with AAA (odds ratio 3.2, 2.0/20 years and 2.0, respectively, p<0.001). In men <60 years the AAA prevalence was 0.9% (95% confidence interval 0.2-1.6%) when arterial stenosis was absent and 1.5% (0.0-3.2%) when present. In men >/=60 years the AAA prevalence was 4.0% (3.0-5.1%) when no arterial stenosis was found and 7.3% (5.7-8.9%) when found. The corresponding prevalences in women were 0%, 0%, 1.2% (0.5-1.8%), and 3.1% (1.9-4.3%), respectively. CONCLUSIONS: Men >/=60 years referred for arterial examination have a significant risk of having an AAA while only women >/=65 years with a duplex verified arterial stenosis have a sufficient risk of having an AAA. Studies to evaluate the benefit of selective high-risk screening are warranted.

Outcome after cup hemiarthroplasty in the rheumatoid shoulder: a retrospective evaluation of 39 patients followed for 2-6 years.

33 rheumatoid patients, treated with hemispherical cup resurfacing hemiarthroplasty of the shoulder without medullary fixation (6 bilaterally), were reviewed after mean 4.4 (2-6) years. The median Constant score was 30 (15-79), mean proximal migration of the humerus 55 (SD 5.2) mm and mean glenoid erosion 2.6 (SD 1.7) mm. Proximal migration and glenoid erosion did not correlate with shoulder function or pain. Radiographic signs of loosening (changes in cup inclination combined with changes in cup distance above the greater tuberosity) occurred in one quarter of the shoulders. At follow-up, 26 patients were satisfied with the procedure, despite poor shoulder function and radiographic deterioration.

Occipito-cervical fixation in rheumatoid arthritis--an analysis of surgical risk factors in 163 patients.

163 patients with rheumatoid arthritis (RA) and atlanto-axial subluxation treated by posterior occipito-cervical fixation (OCF) over a period of twenty-one years (November 1970-January 1991) were followed. Common complaints prior to surgery were occipital headache, neck pain, radicular pain and myelopathy. The mean age at time of surgery was 61 years. The mean follow-up time was 54 months. Clinical improvement was obtained in 88% of the patients, whereas 7% were unchanged and 5% had progressive symptoms in spite of surgery. There was no pre-operative or immediate postoperative mortality. In 79 patients, one or more potential surgical risk factors were identified. Twenty-four reoperations were performed in the neck. The most common cause for reoperation was mechanical failure due to wire-break or spinous process fracture. Wound infection in the neck was recorded in 16 patients. Five were deep and required removal of the fixation material. Following OCF, new or progressive subaxial subluxation (SAS) led to further surgery in 4%. The study offers support for the beneficial effect of OCF in rheumatoid AAS. We conclude that, in spite of a number of identified risk factors, OCF with the Brattström-Granholm technique remains a safe and effective method for stabilization of upper cervical subluxations in RA.

Work-related persistent neck impairment: a study on former steelworks grinders.

The possibility of a work-acquired acceleration of the physiologic degenerative process affecting the cervical spine was studied in 15 Swedish former steelworks grinders. They were compared clinically with 15 age- and sex-matched white collar workers and radiographically compared with another reference group of matched individuals with light work. The now obsolete grinding machine placed extremely heavy load on the neck and shoulders, to the extent that all grinders had to retire after varying numbers of years and take a disability pension, or take up light work because of persistent pain and stiffness in the neck-shoulders; in this series after on average 8 (2-16) years. At follow-up 18 (11-29) years later, their mean age was 56 (48-62) years. All had persistent neck pain and stiffness and widespread paresthesia. Goniometric recordings showed impairment of active neck motion range as well as motion speed in all three planes and an altered motion pattern. Vibration sense was decreased in all extremities. Radiographically, foraminal encroachment was significantly increased both from spondylosis and spondylarthrosis, while disc height, lordosis, and alignment did not differ from that in the reference group of individuals with light work.

Dynamic posturography among patients with common neck disorders. A study of 15 cases with suspected cervical vertigo.

We have studied a consecutive series of 15 patients with long-lasting common neck pain combined with vertigo and/or unsteadiness by dynamic posturography with the head in different positions. The evaluation of disturbed equilibrium was done in the anteroposterior direction. Results were compared with 15 sex- and age-matched healthy controls and 10 patients with long-lasting neck complaints without vertigo or unsteadiness. The otoneurological, audiometrical, and electronystagmographical examination was normal in all individuals. The dynamic posturography on a sway-referenced forceplate showed significantly lower equilibrium scores in the patients with vertigo/unsteadiness than in the controls when recorded in neutral position of the head, in rotation and in lateral flexion. The patients with vertigo also had significantly lower equilibrium scores in the position most prone to elicit their vertigo/unsteadiness as compared with the patients with only neck pain. Dynamic posturography was found to be of diagnostic value, indicating the presence of vertigo of cervical origin.

Work-related chronic neck impairment. Neck motion analysis in female traverse crane operators.

Twenty-one female steel industry traverse crane operators with long-term sick-leave (3 (1-8) years) due to chronic neck disability underwent careful analysis of case history, physical status and electrogoniometric three-dimensional recordings of active neck motion. Results were compared with those from working female crane operators having identical work posture and tasks and, further, with a group of working female clerks. The sick-listed crane operators had previous frequent contacts with the primary health care because of complaints from the neck and back. In comparison with the reference groups, the sick-listed crane operators showed tenderness of the trapezius and levator scapulae muscles and a short neck stature in combination with impaired active neck motion range with reduced motion speed. The motion pattern was however unchanged. The findings are consistent with the clinical picture of chronic neck myalgia that persisted despite long-term absence from the previous exposure to high static work load upon the neck-shoulders.

Dynamic posturography in cervical vertigo.

Cervical vertigo, the entity of neck disorder and associated vestibular symptoms, was investigated in 15 suspected subjects and results were compared with 15 age-matched controls. A modified dynamic posturography investigation with different head positions was used. Head position was recorded 3-dimensionally with electrogoniometry. Differences on a sway-referenced forceplate were found.

Three-dimensional analysis of neck motion. A clinical method.

A clinical method is described for simultaneous recording of neck motion in three different planes using electrogoniometric equipment. Results correlated with those reported in the literature regarding separate examinations of the motion range in the separate planes. Correlation with conventional gravity goniometer was good as to flexion-extension and lateral flexion, whereas, for rotation, a compass goniometer showed poor correlation and, also, unsatisfactory reproducibility. The electrogoniometric recordings showed good correlation with radiographically determined flexion-extension occiput-C7 as well as lateral flexion C1-T1. Graphical recordings made in the three different planes demonstrated in detail the different movements that contribute to the complex motion pattern of the neck. This three-dimensional motion analysis affords a more objective functional evaluation of common neck disorders that may supplement radiographic examination.

Realignment and surgical fixation of atlanto-axial and subaxial dislocations in rheumatoid arthritis (RA) patients.

One hundred consecutive patients with atlanto-axial dislocation(s) were subjected to posterior occipito-cervical fusion and followed up to 16 1/2 years postoperatively (mean: 4 1/2 years). The mean age at surgery was 60.3 years. At the time of follow-up, 45 patients had died, mostly due to cardiopulmonary disease. Out of the 100 patients, 67% showed a major improvement and in an additional 14% there was a slight or moderate improvement. Some patients with a stable fusion later developed subaxial dislocation(s) necessitating an anterior fusion which in patients with RA is difficult due to poor bone quality. MRI revealed pannus formation around the odontoid peg in many patients, in several to such a degree that cord compression was evident. Following the posterior fixation, the pannus disappeared or was reduced which may at least partly explain the generally favourable operative outcome following the fixation procedure. Early occipito-cervical fusion appears to prevent further vertical dislocation or upwards migration of the odontoid which is a more severe condition, and does not appear to result in increased incidence of subsequent subaxial dislocation(s). Such luxation(s) pose a technically difficult problem since the quality of the patients' own bone usually does not permit a common anterior fusion procedure with autologous graft. In such cases with cord compression, acrylic cement may be used to obtain a normalized realignment.

Juxtaglomerular cell activity during hemorrhage and ischemia as revealed by quinacrine histofluorescence.

Quinacrine (QC) binds with high affinity to the intracellular storage granules of juxtaglomerular cells (JG-cells) in the afferent arteriolus of the glomerulus of the kidney. The present study tests whether QC bound to JG-cells can be released. The cells were stimulated by renal ischemia and hemorrhagic shock combined with immobilization stress. 1 h after onset of renal ischemia QC-JGI (modified Hartroft & Hartroft 1953) in 14C-QC-treated rats had decreased to about 40% in the ischemic kidney compared to a not ligated control kidney. The 14C-contents in the ischemic kidney had decreased to 33% of that in the untouched control kidney. Hemorrhagic shock was obtained by bleeding into a reservoir for 15 min or 1 h. Rats who received QC or 14C-QC 1 h before onset of bleeding showed no change in QC-JGI (15 min shock) or 14C-contents (1 h shock) as compared to controls. This was probably due to formation of new QC-binding granules, which took up still circulating quinacrine thereby masking a release. If the time between the QC injection and the onset of shock was extended to about 15 h, when circulating amounts of QC are very low, a decrease of QC-JGI (about 30% of controls) was seen in the kidneys of the shocked rats. The results are compatible with the possibility that QC in vivo bound to granules of JG-cells could be released together with the content of the granules following stimuli known to induce renin release. Quinacrine-binding therefore possibly provides a new method to study endocrine cells in the way it has been used in the present study as a marker of JG-cell activity.

Release of [14C]quinacrine from peripheral and central nerves.

Incubations of intestinal mouse smooth muscle sheets including Auerbach's plexus and slices of the spinal cord in buffer containing low concentrations of labelled quinacrine ([14C]QC) result in a high affinity binding of QC to certain nerve fibres. Various means of depolarization, such as veratridine, high potassium and electrical field stimulation, were used to assess quantitatively the release of QC from nerves. Under optimal release conditions, all 3 types of depolarizations induced a clearcut increase in radioactivity of a continuously superfused buffer. When intestinal muscle sheets were incubated in high concentrations of QC (5 . 10(-6)--5 . 10(-5) M) the depolarization-induced release was blocked. Similarly, high concentrations of QC (10(-5) M) blocked release of [3H]noradrenaline from adrenergic nerves. Low QC concentrations did not affect the depolarization induced release of [3H]noradrenaline from adrenergic nerves but caused a moderately increased spontaneous overflow of noradrenaline. The present data, together with previous studies, permit the conclusion that QC in low concentrations can be used to label selectively a population of non-adrenergic nerve fibres. This binding is closely related to the transmitter storage and release mechanisms and can be used to study the activity of such nerves.

Substance P, VIP, enkephalin and somatostatin immunoreactive neurons in intestinal tissue transplanted to the anterior eye chamber.

Tissue pieces of small and large intestine from pre- and postnatal and adult rats, respectively, were transplanted to the anterior eye chamber of the rat. Immunohistochemical studies revealed high numbers of substance P-, vasoactive intestinal polypeptide (VIP)- and enkephalin-containing nerve fibers, especially in the circular smooth muscle layer and in the myenteric plexus of the intestinal tissue transplants. A small number of somatostatin-containing fibers were observed. The distribution patterns of the various peptide-containing neurons in the grafts resembled those which have been described in the intact gastro-intestinal wall. Substance P, VIP, enkephalin and somato-statin immunoreactive fibers were seen also in the host irides. No obvious differences in peptide innervation in grafts and host irides were observed between normal and sympathectomized animals and animals lesioned in the trigeminal ganglion. These findings suggest that most of the peptide-containing fibers in the intestinal transplants and the host irides originate in the transplanted tissue. Thus, it is shown that peptide neurons can survive in this transplantation model, which may be useful for functional studies of intestinal physiology including peptidergic mechanisms.

Quinacrine-binding nervous elements in intraocular grafts of intestinal smooth muscle tissue.

Quinacrine (QC) histofluorescence demonstrates a population of nerve fibres in the intestine that are probably non-adrenergic and non-cholinergic. To discover whether these nerves are intrinsic to the intestinal wall smooth muscle layers of distal ileum from foetal mice and foetal and adult rats were homologously transplanted to the anterior chamber of the eye of adult animals. Transplants were well organized although devoid of their normal extrinsic nervous connections. QC-positive beaded nerve terminals were found in the smooth muscle layers of the grafts and QC-positive cell bodies in Auerbach's plexus. Since QC-binding nerves are not normally present in the host iris it was concluded that the gut contains intrinsic QC-binding neurons.

Quinacrine-binding nerves: presence in the mouse ano-coccygeus muscle, disappearance after muscle transsection.

The anococcygeus muscle exhibits non-cholinergic, non-adrenergic, inhibitory neurotransmission. In the present paper we describe the presence of quinacrine-binding beaded nerve fibres in the mouse anococcygeus muscle. A large number of fibres were running parallel to the smooth muscle bundles. A second distribution of fibres formed an irregular plexus. No quinacrine-binding nerve cell bodies were found within the muscle. When the anococcygeus muscle was cut close to its insertion in the rectum, the proximal part lost most of its quinacrine-binding nerves 2-7 days after transsection. The results demonstrate a correlation between presumed non-cholinergic non-adrenergic neurotransmission and quinacrine-binding nervous elements.

Depolarization-induced decreases in fluroescence intensity of gastro-intestinal quinacrine-binding nerves.

Quinacrine, a fluorescent antimalarial acridine derivative, selectively binds to a population of nerve cell bodies and nerve fibers in Auerbach's plexus and elsewhere in the gut. This quinacrine-binding, as measured by fluorescence intensity, is reduced if the nervous elements are depolarized by high K+ (80--150 MM) or veratridine (5 x 10(-5) M) during quinacrine incubation. A reduction of quinacrine-content in nerve terminals is also seen when depolarization (veratridine) takes place for 2 min after quinacrine-incubation, indicating a release of already bound quinacrine. If terminals are depolarized (high K+ or veratridine) before quinacrine incubation, a reduction of quinacrine content is also seen. The depolarization-induced reduction of quinacrine-binding is blocked by Ca2+-removal and, in the case of veratridine by tetrodotoxin. Our findings suggest that quinacrine binds to a compound that is released by nervous activity. Binding mechanism remains to be elucidated. The possibility that quinacrine visualized purine-rich structures is discussed.

Semiquantitative estimations of quinacrine fluorescence in intestinal nerve fibres.

Quinacrine has been shown to bind selectively to a population of nerves and ganglion cells in the mouse, rat and guinea-pig gut. In the present report a method for semiquantitation of nervous quinacrine contents using semiquantitative estimations of fluorescence intensity and nerve fibre density is presented and evaluated. Estimation of fluorescence intensity and nerve fibre density is based on a scale with eleven steps from 0 to 5. Preparations were incubated in 14C-labelled quinacrine hydrochloride. Reliability of the scale was expressed as the correlation coefficient between two consecutive blind estimations of the same preparations with recoding and remixing specimens in between. This correlation was found to be 0.95 or higher. Validity was expressed as the correlation between the semiquantitative estimations and 14C-quinacrine uptake measurements into the same specimens. Also this correlation was found to be strongly positive. It was concluded that nervous quinacrine content and amount of quinacrine binding nerves can be reliably estimated by fluorescence microscopy.

Locus coeruleus fibre growth in oculo induced by trigeminotomy.

Locus coeruleus from fetal donors was homologously grafted to the anterior eye chambers of adult rats whose eyes were sympathetically denervated. After intraocular maturation, outgrowth of noradrenaline-containing fibres from the locus coeruleus neurons on the host iris was studied by Falck--Hillarp fluorescence histochemistry. In control animals locus coeruleus grafts produce a halo of noradrenaline-containing nerve fibres around the graft, covering approximately one third of the surface of the host iris. Sensory denervation of host eyes carrying maturated locus coeruleus grafts was produced by intracranial lesions of the trigeminal nerve. Such lesions induced a rapid growth response in the grafted locus coeruleus neurons, leading within three weeks to complete innervation of the host iris. It was concluded that removal of non-sympathetic, non-parasympathetic nerve fibres on the host iris elicits a strong fibre-growth response in the grafted locus coeruleus.

Surgical complications after radiation therapy for carcinoma of the breast.

Surgical complications were studied randomly in 137 women with operable carcinoma of the breast, receiving preoperative irradiation or no preoperative irradiation. Wound infections and severe seromas are shown to be more frequent in patients in the irradiated group. On the whole, radiation induced complications were mild and easily manageable.