Reduction mammaplasty. A comparative study of the Orlando and Robbins methods in 292 patients. Between January 1984 and November 1990 a total of 292 patients underwent reduction mammaplasty for hypertrophic breasts. Of these 233 had a superomedial pedicle (Orlando's method) and 36 an inferior pedicle (Robbins' method). Twenty-three had various other operations. Those operated on by Orlando's and Robbins' methods were compared retrospectively, and it was found that Robbins' method was superior in younger women because of increased sensitivity, particularly of the nipple-areola complex, and better lactation. In the physician's opinion ugly scars developed in 32% of the patients (n = 287). In our opinion wound closure with a subcuticular suture might improve the quality of the scar. Of the 287 patients assessed, 281 (98%) were satisfied with the physical, and 248 (86%) with the cosmetic, outcome of the operation.


The effects of infiltration with adrenaline on blood loss during reduction mammaplasty. Between March and November 1990 a prospective study of the effect of an infiltration of diluted adrenaline on bleeding during and after reduction mammaplasty was carried out in 12 consecutive patients. There was a significant reduction in blood loss to less than 50% of that from the non-infiltrated breasts. There was no signs of increased postoperative bleeding or reduced flap viability as a result of infiltration of adrenaline.


The circulation in the nipple-areola complex following subcutaneous mastectomy in breast cancer. To evaluate the decrease in circulation in the nipple-areola complex after subcutaneous mastectomy and immediate implantation of a submuscular prosthesis, the blood flow was studied by both fluorescein flowmetry and laser Doppler flowmetry in 24 patients with invasive breast cancer. In 14 patients a lazy-S-shaped horizontal lateral incision was used, and 10 underwent a subcutaneous reduction mammaplasty. After subcutaneous mastectomy with a lazy-S incision there was no significant decrease in blood flow in the nipple-areola complex compared with that in the untreated contralateral breast. In the breasts in which reduction mammaplasty had been done, the blood flow was reduced by 74% as measured by fluorescein (p less than 0.01), and 70% by laser Doppler flowmetry (p less than 0.05), compared with the contralateral breast. Five patients had partial or complete epidermal, and one patient had total dermal, necrosis of the complex, but there was no deep necrosis. No fluorescence was seen within the areas in which necrosis later developed in any of these six cases. The laser Doppler signal in the corresponding areas, however, was not reduced. The results show that the circulation in the nipple-areola complex is reduced more after subcutaneous reduction mammaplasty than after subcutaneous mastectomy with a lazy-S incision.


Factors that influence the incidence of brachial oedema after treatment of breast cancer. Six factors that may increase the likelihood of swelling of the arm after treatment of breast cancer were investigated in 136 patients who had undergone treatment. The highest incidence of oedema was among patients who had received radiotherapy in high doses with few fractions to the axilla (60%), and in patients with a history of one or more infections in the arm on the operated side (89%). Overweight, oblique surgical incision, infection in the arm, and radiotherapy correlated with arm swelling. The age of the patient and whether the operation had been done on the dominant or non-dominant side correlated less with the incidence of oedema.


Comparison of self reported and observed length, width, and colour of scar tissue. To evaluate the reliability of self assessment as a substitute for follow up, 30 self reported assessments of length, width, and colour of abdominal scars were compared with those of clinicians. The degree of disagreement between patients and medical observers was not significant. We conclude that as long as instructions to patients are unambiguous, reliable information may be obtained by postal inquiry. Self reported measurements may thus replace time-consuming follow up visits in studies on the influence of various factors on scar tissue.


Basal cell carcinoma in a BCG scar in a young woman. Case report. A 31 year old woman presented with a crusting lesion on the scar of her BCG vaccination. Histological examination showed it to be a basal cell carcinoma, which only rarely arises in vaccination scars, and is particularly unusual in BCG vaccination scars.


Multicystic lymphatic malformations of the penis. Report of two cases. Two patients presented with multicystic lymphatic malformations of the penis. These were congenital and progressive, and both were successfully treated by excision after injection of methylene blue.


Motoneuron activity and muscle fibre type composition in hemiparesis. The firing of single motor units (MUs) in musculus tibialis anterior (TA) was studied during maximal voluntary effort and maximal speed of walking in 10 patients with severe chronic hemiparesis and the findings compared to normal data. As shown in a previous study, the paralysed TA exhibited an increase in proportion of type 2 fibres as compared with normal muscle. Thus, 57% of the muscle fibres were type 1 and 43% type 2, while the normal percentages were 80% and 20% respectively. The present findings indicate that in the paralysed muscles a little less than half of the fibres, i.e. roughly the equivalent of the type 2 population, was not tonically active either during sustained voluntary contraction or during locomotion. Normally high threshold MUs reached high rates during both modes of activation. The findings paralysed muscles also indicate that a little more than half of the fibres, i.e. roughly the equivalent of the type 1 population, could be brought into tonic firing during voluntary contraction as well as during walking. Their maximal firing rate was, however, no more than two thirds of that of normal low threshold MUs.


Gait evaluation in hemiparetic patients using subcutaneous peroneal electrical stimulation. In hemiparetic patients with an implantable peroneal stimulator for correction of drop foot the gait pattern was studied over several years. The gait parameters and M-waves of subcutaneously stimulated muscles were compared with the results obtained before implantation and their variation was observed over time. Of a group of 35 patients with previously implanted electrodes 19 were evaluated. Significant improvements of gait were found although in some cases an excessive eversion of the foot was observed. Nine of these patients had reimplantation because of displacement of the stimulation electrodes after an average time of 3.5 years of proper functioning of the implant. After the reimplantations, similar gait patterns and muscular responses to stimulation were observed as after the initial implantation.


Symmetry of electro- and acoustic myographic activity of the lumbar paraspinal muscles in normal adults. The symmetry of paraspinal muscle activity was examined in 15 healthy adults (aged 31-60 years). Acoustic myography (AMG), which provides a measure of force, was recorded with electromyography (EMG) to assess electromechanical relationships during contraction. Bilateral recordings of EMG and AMG were made over the paraspinal muscles at the level of the 4th lumbar vertebra during a fatiguing test manoeuvre. Subjects were strapped to a hinged couch in the prone position. When the upper part of the couch was lowered, subjects maintained the upper body (above the anterior, superior iliac spines) unsupported, in the horizontal position for 60 sec. The EMG and AMG signals were full-wave rectified, integrated (IEMG, IAMG) and recorded on an ink-jet oscillograph during the fatigue test. By 60 sec of activity, IEMG had increased (right 122% +/- 8.7; left 125% +/- 11.8; mean +/- 1 SD as a percentage of initial values) while IAMG (reflecting force) remained unaltered (right 99% +/- 8.2; left 100% +/- 5.3). The IAMG:IEMG ratio (reflecting efficiency of activation) thus declined (right 0.81 +/- 0.08; left 0.80 +/- 0.08). The similarly of changes on both sides of the spine have quantified normal symmetry of paraspinal muscle activity and could be used to assess asymmetry in patients with spinal pathology.


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.


Mechanical performance, level of continuous contraction and muscle pain symptoms in home care personnel. The interrelationships between reported complaints, clinical status, mechanical performance and EMG pattern of the shoulder flexors and the knee extensors, respectively, during maximum dynamic contractions were investigated. A group of 97 randomly selected women employed in the home care service participated. Those who reported complaints had more clinical findings, such as reduced mobility, tender points and muscle tightness, than non-complainers. The level of muscle activity during the passive part of the contraction cycle was significantly higher in the shoulder flexors than in the knee extensors. Subjects without reported complaints who had been employed for more than ten years had a significantly lower activity level in the shoulder muscles than subjects without complaints who had been employed for a shorter time. We suggest that a high muscle tension level between contractions might precede muscle pain. A cluster analysis including sociodemographic, clinical and physiological variables revealed different subgroups, which points to the need to investigate the work situation in a multivariate way.


Rehabilitation and Parkinson's disease.

Rehabilitation and Parkinson's disease. In this study we evaluated the efficacy of physical therapy together with drug therapy in a group of parkinsonian patients, compared with a group of patients treated using drug therapy only. The physical therapy program lasted four months and included passive and active mobilization exercises, adopted for postural control and equilibrium, walking and prevention of contractures and ankylosis. The assessment was accomplished by means of clinical rating scales and motor performance tests. Patients treated by means of physiotherapy showed an improvement at the end of the study in both clinical scales and motor performance tests. This improvement was noted in both patients with less severe and more severe symptoms as well as in those with shorter and longer disease duration. It is not easy to assess the role played by physical therapy due to the difficulty of an objective evaluation; our results, however, show an improvement in the functional performance of patients and suggest the usefulness of physical therapy associated with drug therapy in a comprehensive treatment for Parkinson's disease.


Clues to cancer etiology from studies of farmers. This article summarizes cancer risks among farmers to clarify the magnitude of the problem and to suggest directions for future research. Significant excesses occurred for Hodgkin's disease, multiple myeloma, leukemia, skin melanomas, and cancers of the lip, stomach, and prostate. Nonsignificant increases in risk were also noted for non-Hodgkin's lymphoma and cancers of connective tissue and brain. These excesses occurred against a background of substantial deficits among farmers for total mortality and mortality from many specific diseases. The tumors vary in frequency, histology, and prognosis and do not fall into any obvious grouping. Two commonalities may be important. Several of the tumors excessive among farmers appear to be rising in the general population and are excessive among patients with naturally occurring or medically induced immunodeficiencies. Therefore epidemiologic studies on specific exposures among farmers may help explain the rising trend of certain cancers in developed countries and provide clues to mechanisms of action for environmental carcinogens.


Cancer incidence and mortality among Swedish Baltic Sea fishermen. A 25% lower cancer mortality was found for 1360 Swedish fishermen who fished on the Baltic Sea than for the general population. The fishermen consumed twice as much fish as the population in the same county. In spite of the low overall cancer mortality, increased mortality from myeloma, as well as increased incidences of gastric carcinoma and squamous cell cancer of the skin and lips, was observed in the cohort. The decrease in risk for ischemic heart disease was not significant. Whether the dietary intake of fatty acids and selenium from fish contributed to the decreased risk was difficult to evaluate. Moreover, whether the consumption of fish from the Baltic Sea, contaminated with, for example, polychlorinated dioxins and dibenzofurans and other persistent organochlorine substances, contributed to the observed increased specific cancer risks is not known. However, the net health effect of high fish consumption from the Baltic Sea seems to be positive.


Occupational exposure to sulfuric acid in southern Ontario, Canada, in association with laryngeal cancer. A case-referent study, designed to test associations between asbestos, nickel, and the development of laryngeal cancer, was conducted in southern Ontario in 1977-1979. The cases were individually matched to neighborhood referents for gender and age. This constituted the primary study. Personal interviews had secured tobacco, alcohol, and detailed work histories. To 183 of the male pairs was added retrospective assessments of sulfuric acid exposure for each job, blind of disease status; this constituted the data base for an augmented secondary analysis. Logistic regression revealed statistically significant odds ratios when tobacco and alcohol were controlled. Exposure-response gradients were strongly positive with odds ratios in the range of 1.97 [95% confidence interval (95% CI) 0.63-6.13] for short duration-low level exposure through 6.91 [95% CI 2.20-21.74] for long duration-higher level exposure employing progressively more specific definitions of exposure. Asbestos as a confounder and the interaction terms examined were nonsignificant. These findings are corroborative of those of other studies.


Empirical assessment of the effect of different summary worklife exposure measures on the estimation of risk in case-referent studies of occupational cancer. The effect of different summary measures of worklife exposure on the estimation of risk is reported. Two matched case-referent studies associating sulfuric acid exposure and cancer from Baton Rouge and southern Ontario were used. Five summary exposure measures were converted to discrete levels of exposure through the selection of equivalent percentile points on each measure's respective percentage frequency distribution for logistic regression modeling purposes. The southern Ontario data set exhibited only minor differences across all five exposure measures. The Baton Rouge data set, however, produced different results, and the time-dependent measures appeared to underestimate risk. It is possible, therefore, to obtain different estimates of risk depending on the exposure measure selected. It is recommended that, in the absence of proved models for assessing exposure, a variety of summary measures be used to estimate risk. This approach would facilitate the comparison of findings across studies.


An apparently incongruous exposure-response relationship resulting from the use of job description to assess magnetic field exposure. Empirical data are presented to support the observation that nondifferential misclassification of subjects classified according to an ordinal scale can result in an artifactual nonmonotonic exposure-response curve. This phenomenon can be interpreted erroneously as an indication that an observed relationship is not causal. The occupational exposure of 40 subjects to extremely low-frequency magnetic fields was estimated on the basis of their job description while their "true" exposure was determined by direct dosimetry. A "true" risk was assumed to exist, and estimates of risk that could be obtained through hypothetical case-referent or cohort studies were calculated.


Agreement on medical fitness for a job.

Agreement on medical fitness for a job. Five experienced occupational physicians independently reviewed the uniformly structured, concise records of 180 applicants who had applied for a job in one of three categories. All had undergone a preemployment medical examination by the Governmental Occupational Health and Safety Service. Agreement was assessed by calculating the percentage of disagreement and Cohen's kappa. Agreement between the five panel physicians and between the panel physicians and the Service appeared to be poor, with overall percentages of disagreement of 31 and 37%, respectively, and kappa values of 0.38 and 0.37, respectively. On the average 31% of the applicants judged as unfit by one physician had been assessed as fit by the others, whereas agreement was only marginally better when detailed medical criteria for fitness were available. Lack of consensus on the medical fitness of an applicant, as evidenced by this study, suggests that the validity of such a judgment may be questionable even when detailed fitness criteria are available.


Lack of renal changes in stainless steel welders exposed to chromium and nickel. Biochemical markers of kidney damage were examined in 52 male stainless steel welders (manual metal arc welding) exposed to chromium and nickel. No difference was found in the mean urinary excretion of total proteins, albumin, protein 1, transferrin, retinol-binding protein, lactate dehydrogenase, lysozyme, or beta-N-acetylglucosaminidase in a comparison with matched referents. Beta 2-microglobulin was slightly increased in those welders with a urinary chromium concentration of greater than 64.5 nmol.mmol-1 creatinine. The prevalences of abnormal values did not differ from those observed in the reference group. No correlation was found between the concentrations of chromium or nickel in urine and that of proteins or enzymes. No consistent or clinically significant renal impairment was revealed among the stainless steel welders exposed to a chromium air concentration slightly above the current threshold limit value of the American Conference of Governmental Industrial Hygienists for water-soluble hexavalent chromium compounds (50 micrograms.m-3).


Seasonal variation in neck and shoulder symptoms. The objective of the investigation was to study the course of neck and shoulder symptoms and the predictors for these symptoms among women in light sedentary work. Postal surveys were conducted among 351 tellers (age 20-50 years) of a bank company in September, December, March, and May. The response rates were 74-90%. The outcome was the frequency of the symptoms during the previous three months. In the analysis, univariate explorations and random-effects logistic binomial regression for distinguishable responses were used. A change in the frequency of neck and shoulder symptoms was seen in 40.5% of the subjects during the follow-up period from autumn to spring. The frequency of the symptoms decreased from autumn and winter towards spring. The stability of the frequency of the symptoms was positively associated with age. Seasonal variation in symptoms should be considered when preventive programs against neck and shoulder disorders are planned and evaluated.


Electromyographic signs of shoulder muscle fatigue in repetitive arm work paced by the Methods-Time Measurement system. Surface electromyographic (EMG) recordings from the lateral and cervical portions of the descending trapezius muscle and from the infraspinatus muscle were assessed for six female subjects performing a standardized repetitive work simulation task for 1 h. The work pace was determined according to the Methods-Time Measurement system to 2466 cycles.h-1. The variation in load levels were high and indicated dynamic muscle activity. A decrease in the EMG mean power frequency and an increase in the root-mean-square amplitudes, both indicating muscle fatigue, developed in all muscles of most of the subjects. EMG signs of fatigue, analyzed separately for each 5-min period, showed variable fatigue patterns both between muscles and between subjects. It is therefore suggested that dynamic work movements do not protect the muscles of the shoulder and neck from fatiguing processes in highly repetitive work with short cycle times.


Screening for occupational cancer.

Screening for occupational cancer. The main strategy for preventing occupational cancer is an environmentally based approach or primary prevention. However, it should be combined with screening, early diagnosis, and treatment. This review discusses screening for occupational cancer but not from the point of view of medical screening. Instead it focuses on asbestos exposure and asbestos-related cancer in Finland and the role screening plays in the current Finnish asbestos program. For example it is the feeling in Finland that screening is a very effective way of preventing further occupational exposure to asbestos and of organizing antismoking campaigns. An individually oriented strategy in cancer prevention should include the modification of exposures by behavioral change, the monitoring of early effects of exposures, and health examinations. The termination of exposure, antismoking campaigns, improved diagnostics, and careful attention to compensation issues combined with the study of other opportunities for prevention are seen as the key issues in screening.


Workplace cancer prevention.

Workplace cancer prevention. Safety and health matters should be an integral part of the decision making of management. Cancer prevention at the workplace requires cooperation between management, occupational health personnel, and workers. At the planning stage of a new production facility the safety and health personnel should actively participate and bring their experience and special knowledge to the planning process. The basis for cancer prevention is exact information about exposure and real risk levels. Modern technology can essentially minimize both exposure and health hazards.


Carcinogen metabolism and individual susceptibility. Many chemical carcinogens need activation by drug metabolizing enzymes, principally cytochrome P450 enzymes, to become capable of binding to deoxyribonucleic acid and initiating the carcinogenic process. The activity and inducibility of drug metabolizing enzymes are regulated by interplay between genetic, host, and environmental factors. Consequently, individual differences in cancer susceptibility might be explained somewhat by genetic differences in metabolic activation. Three examples, the induction of aryl hydrocarbon (benzo[a]pyrene) hydroxylase by polycyclic aromatic hydrocarbons, polymorphic debrisoquine/sparteine oxidation, and polymorphic acetylation, are briefly reviewed. Despite useful animal models and promising early human findings, no consensus has been reached about the significance of genetically based differences in drug metabolism in cancer etiology. It is expected that, with the use of molecular biological methods, the genetic background of study subjects can be investigated without bias caused by the disease, age, treatment, or other factors which have plagued investigations thus far.


Analysis of deoxyribonucleic acid adducts in workers. Repeated blood samples were obtained from volunteers who were occupationally exposed to polycyclic aromatic hydrocarbons in a Finnish iron foundry. Aromatic adducts were determined in white blood cell deoxyribonucleic acid of the subjects with the 32P-postlabeling technique after nuclease P1 treatment and butanol extraction, which showed no major difference. When repeated samples were analyzed, it appeared that the oldest ones displayed the lowest adduct levels, probably due to the instability of the adducts upon storage at -20 degrees C. The workers tended to maintain their adducts at a uniform level, a finding suggesting the contribution of host factors in the control of adduct levels.


Design strategies, results and evaluations of long-term chemical carcinogenesis studies. Long-term toxicology and chemical carcinogenesis experiments typically involve both sexes of two species of rodents divided randomly into sets of 50-60 animals per control and exposure groups. Ordinarily three exposure concentrations are gradated down from a top level likely to show some chemically associated toxicity, but which should not compromise the normal well-being or growth and survival patterns of the animals unduly. Duration of exposure is generally two years. Single, intermittent, or varied exposures are used to mimic specific occupational or environmental situations. Exposures are started prior to conception, during gestation and lactation, or at specified times thereafter. Extensive gross observations and microscopic pathology are performed on each animal, and incidences of neoplastic and nonneoplastic lesions are evaluated in age-adjusted statistical comparisons. The collated findings are then interpreted, evaluated, and presented for scientific peer review in public meetings, the aim being to identify qualitatively those environmental and occupational exposures that may likely induce cancer in humans.


Use of molecular biology techniques in cancer epidemiology. Biochemical techniques have been applied for years in clinical medicine to unravel disease indicators and mechanisms. The study design, resembling that of a case-referent study, has been to compare diseased and healthy individuals. Conclusive results have been obtained for diseases in which relatively few factors cause high risks. The same study design has been maintained with sophisticated methods of molecular biology, which have revealed many types of deoxyribonucleic acid lesions associated with cancer. It is likely that the relatively simple cross-sectional and case-referent studies require input from epidemiologists to unravel multifactorial etiologies. Longitudinal approaches may be the only alternative with which to evaluate the role and usefulness of the application of molecular biology markers in studies of cancer.


The molecular epidemiology of oncoproteins. Oncogene activation, which appears to play a critical role in carcinogenesis, can be conveniently studied in biological samples via immunologic detection of oncoprotein products with monoclonal antibodies. Immunohistochemical and immunocytochemical detection of oncoproteins can be used to differentiate normal cells from cancer cells, including those of cancers of occupational concern such as lung, bladder, and liver. Furthermore, oncoproteins appear to reach the extracellular environment and are detectable with immunoblotting techniques in the urine and serum of cancer patients. Similar techniques applied to the screening of sera of occupational cohorts with carcinogen exposures indicate that oncoproteins can be detected in workers at increased risk of the development of cancer, and thus oncoprotein detection may be a useful molecular epidemiologic biomarker of preclinical response for the surveillance and prevention of occupational cancer.


Exposure from occupational versus other sources. There is an increasing need to consider the various routes of exposure to individuals in occupational settings, as well as the exposure of the general public to a broad spectrum of carcinogens. The need to consider indoor environments is increasingly recognized in light of the amount of time spent indoors by a large majority of the population and the recognition that levels of certain toxicants are higher indoors than outdoors. This overview highlights (i) a general comparison of exposure to indoor and outdoor levels of 12 volatile organic compounds and (ii) the exposure of workers and the general public to benzene, 1,3-butadiene, formaldehyde, styrene, tetrachloroethylene, phthalate esters, polychlorinated dibenzofurans, radon, and electromagnetic fields.


Cancer morbidity by occupation.

Cancer morbidity by occupation. Data on cancer morbidity by occupation are available from surveillance systems, such as linkage studies based on census data and cancer register data. These data serve various purposes. First, they show the social distributions of cancer diseases. Second, they can form the background for generating hypotheses about chemical carcinogens by identifying occupations at high risk of cancer. Third, cancer morbidity data can be used in the interpretation of results from hypothesis-testing studies. Fourth, the data can facilitate the identification of cancer risks associated with new technologies and way of life in the service society. Finally, the data can be considered for inference about future trends in cancer mortality. Data from the Danish occupational cancer study are used for illustration.


Proposal for future uses in epidemiology for cohort studies on the prevention of work-related cancer. A new use of the cohort method in cancer prevention is proposed involving individual collection of information on past exposure to dominating cancer determinants. It is assumed that it is possible to determine individual cancer risk and, subsequently, to estimate the individual risks of cause-specific cancers on the basis of accurate individual data on exposure to cancer determinants. Individuals at given risk levels should subsequently be assigned to defined risk categories to establish groups designed for risk-determined screening programs and risk-determined information intervention. As increased risk to work-related cancer is generally more strongly related to past than to current exposure, a large proportion of those who are at high risk are no longer employed and thus not in reach of occupational health physicians. Therefore, risk-determined intervention should be integrated into the daily work routines of both occupational health physicians and primary care physicians.


Identification of carcinogens within the IARC monograph program. Fewer than 50 chemicals, groups of chemicals, or mixtures have been causally linked with cancer in humans. Some 250 chemicals have, however, been found to be carcinogenic to rodents. Carcinogenic risk factors that have been identified for humans occur in clearly quantifiable exposure situations, but epidemiologic information on cancer in humans is missing or inadequate for the great majority of chemicals. Extrapolation of animal data to humans is complicated because long-term carcinogenicity studies on animals are carried out under simplified conditions, whereas humans are exposed to a multitude of exogenous and endogenous agents. Furthermore, the carcinogenic process includes multistage and multifactorial aspects, and human populations are genetically and physiologically heterogeneous. Although the science of carcinogenesis is making rapid progress in terms of understanding some of these processes and interactions, there is still a need to err on the side of safety and accept animal data as a warning signal for possible human effects.


A historical perspective on the classification developed and used for chemical carcinogens by the National Toxicology Program during 1983-1992. To evaluate, interpret, and better communicate the data and findings from long-term chemical carcinogenesis studies on laboratory animals, the National Toxicology Program began using five categories or levels of evidence of carcinogenicity in 1983 (clear, some, equivocal, and no evidence and inadequate experiment). Through July 1991 these defined terms had been used to describe 144 chemical carcinogenesis studies comprising 530 sex-species experiments. Together with a selected descriptor of the chemically associated level of evidence for each experimental unit (male rats, female rats, male mice, female mice), mention is made of the length of the experiment, route of exposure, and the particular tumor type or types for each organ or system affected. The scientific judgements are comprised of this relevant information to inform the readers and users of these evaluations. In this paper the background rationale for the development and proper use of these categories of evidence of carcinogenicity are detailed, together with some personal reflections.


Perspective and overview of the concepts and value of hazard identification as the initial phase of risk assessment for cancer and human health. The identification of potential human health hazards stems from the obvious need to prevent, avoid, reduce, and eliminate exposure to hazardous agents, mixtures of agents, or exposure circumstances. The first step in the risk assessment process centers on determining if a hazard exists. The following strategies are used for this purpose: (i) epidemiologic investigations, (ii) long-term chemical toxicology and carcinogenesis studies on laboratory animals, (ii) shorter-term in vivo and in vitro assays, and (iv) physicochemical structure-activity relationships. Indicator 1 is the most relevant and reliable if adequate data are available; indicator 2 is the most valid and useful alternative for human experience; indicator 3 allows certain toxicologic end points to be identified, but generally needs confirmatory and supportive information; and indicator 4 has made gains in the area of predictivity. The advantages and limitations of each are given. The magnitude of the overall cancer hazard identification effort and a likelihood number of eventual chemical carcinogens have also been estimated.


Quantitative assessment of human cancer risk. Because exposure to carcinogens cannot be eliminated, it has become important to define exposure levels which are acceptable to society or are irreducible. Quantitative assessment of cancer risk is part of this process. This paper presents a definition of risk and discusses the role of epidemiologic observation in the quantitative assessment of cancer risk, the estimation of risk from epidemiologic data, and the role of animal cancer bioassays in the quantitative assessment of cancer risk. It is emphasized that quantitative risk assessment is inevitably based on multiple assumptions. Where possible, the magnitude of errors associated with these assumptions should be stated, even to the extent of an acknowledgment of complete ignorance.


Technological changes in cancer prevention. Exposures and technologies in the workplace are changing due to a variety of factors, including newly developed technologies, mechanization and automation, and improvements in industrial hygiene primarily effected in many developed countries. In addition substitution and removal of carcinogenic constituents in the workplace and general environment are increasing in a number of instances, particularly in North America, Western Europe, and Japan, and they are being accompanied as well by remediation either by source reduction, recycling, or compliance to more stringent national and international regulations and standards. This overview highlights some of the strategies employed in the technological changes in cancer prevention and cites examples in source reduction, changes in formulation, product or process changes, recycling, and hazardous materials management.


[Treatment of movement disorders using botulinum toxin]. Intramuscular injections of botulinum toxin (Botox) are followed by a dose-dependent focal paresis which can be used to treat several focal movement disorders. Botox injections are recommended as effective for the treatment of blepharospasm, hemifacial spasm, and cervical dystonia (torticollis). Focal dystonias elsewhere (for example, writer's cramp) can often be treated with similar success. Others, such as oromandibular dystonia, are more difficult to treat. In the case of more generalized dystonias, some focal muscle spasms can be treated with success by local intramuscular injections. New indications are still being investigated, for example in focal tremors and spasticity. Side effects are in general slight and disappear at the end of toxin effect. In general, it is necessary to repeat the injections after a couple of months, due to a cessation of effect after regrowth of nerve terminals. New injections have similar effects even over years of treatment.


[Diagnostic value of ambulatory daily blood pressure profile: comparison with measurements performed by a laboratory technician]. Office blood pressure measured by a physician is often higher than under the usual ambulatory conditions. Therefore, alternative methods such as self-assessment of blood pressure and ambulatory blood pressure measurements are increasingly promoted. The purposes of this study, covering 613 referred patients, were (1) compare office blood pressure with continuous ambulatory blood pressure measurements, (2) compare office blood pressure with blood pressure values recorded by a trained technician in the absence of a physician and (3) analyze the interpretation of the blood pressure profiles by the referring physicians. Office blood pressure exceeded average ambulatory blood pressure in 94% of the patients and also the blood pressure values recorded by a technician in 88%. According to the office blood pressure there were 523 patients with elevated blood pressure, 20 with isolated increased systolic blood pressure and 70 with normal blood pressure. Office blood pressure was higher (systolic +17 +/- 18 and diastolic +9 +/- 12 mm Hg, p less than 0.0001) than the average value of the ambulatory blood pressure profile, whereas the latter did not differ significantly from blood pressure values measured by the technician (systolic -1 +/- 12 and diastolic -2 +/- 9 mm Hg). 190 of the 523 (36%) patients had white-coat hypertension according to the ambulatory blood pressure measurements. Conventional blood pressure measurements by the technician yielded a high sensitivity (84%) and specificity (87%) for distinguishing white coat hypertension. Analysis of the questionnaires showed that opinions about normal limits of ambulatory blood pressure vary considerably.(ABSTRACT TRUNCATED AT 250 WORDS)


[Cost-benefit analysis of a new treatment concept in patients with indwelling catheters]. An earlier and a new treatment concept for patients equipped with long-term indwelling bladder catheters were compared with regard to cost, expenditure of time, and equipment in a retrospective study involving 58 patients treated by the earlier concept and 60 treated by the new one. The new concept dispensed with the need for bladder irrigation and routine replacement of the indwelling catheters. Under the earlier concept, 18 indwelling catheter replacements and 53 bladder irrigations were required per patient and year during the years 1979/80. This compares with 6 indwelling catheter replacements and 0.05 bladder irrigations per patient and year for the years 1989/90 under the new concept. The use of analgesics and spasmolytics fell from 55 to 21 units per patient per year. Significantly fewer urinalyses were performed during 1989/90. The use of antibiotics remained unchanged. When compared with the earlier one, the new concept for the management of patients with indwelling catheters provides savings of 1265 minutes (21 hours) of nursing time and sFr. 405 for equipment per patient per year. Applied to our geriatric hospital (120 beds, 80 nursing staff), this translates into annual savings of one full nursing post and sFr. 34,000 for equipment.


[Acute alveolitis due to mesalazine].

[Acute alveolitis due to mesalazine]. A 66-year-old male developed lymphocytic alveolitis with bronchiolitis after 3 month's treatment with mesalazin for ulcerative colitis. The patient's symptoms disappeared after halting mesalazin and increasing the steroid dose, the reduced diffusing capacity ameliorated and the thoracic X-ray normalized. The question whether this was a case of pulmonary involvement in inflammatory bowel disease or a drug side effect.


[Leiomyosarcoma of the breast 16 years following successful treatment of a rhabdomyosarcoma of the orbit in childhood]. A case of a mammary leiomyosarcoma in a 23-year-old woman is presented. The tumor appeared 16 years after successful treatment of an embryonal rhabdomyosarcoma of the orbit. Rhabdomyosarcomas are the most frequent soft tissue tumors of childhood, the orbit and the paratesticular region being the most common primary site for this tumor. In contrast, leiomyosarcomas other than those evolving from the viscera or the urogenital organs are rare neoplasms at any age. With the improvement of cancer treatment and survival rates, the risk of late effects after successful treatment for malignant tumors during childhood is increasing. Growth, development and fertility may be impaired and cosmetically disturbing facial and dental complications are common. Development of novel primary tumors is a known further consequence of successful treatment of brain tumors, retinoblastoma and acute leukemias. This is the case when high dose local radiation therapy and/or chemotherapy, especially alkylating agents, were used. Development of novel primary tumors is also known after treatment of childhood rhabdomyosarcomas. This report is intended to show that a second primary tumor may occur many years after a first successfully treated malignant neoplasm, and that young people are at risk for development of tumors at sites that are uncommon to this age group.


[Respiratory rehabilitation].

[Respiratory rehabilitation]. Pulmonary rehabilitation is directed at all patients with severe chronic respiratory insufficiency of any origin. Patients with chronic obstructive pulmonary disease clearly represent the majority. In a pulmonary rehabilitation programme, the patient must gain a better understanding of his disease and of the goals of the treatment. He benefits from permanent teaching on methods of independent self-treatment and follows a regular programme of exercise training and nutritional support aimed at increasing effort capacity. The ultimate goal of the programme is to send the patient home with improved quality of life and a higher degree of independence.


[Staging and prognosis of colorectal carcinoma]. Three different systems in staging colorectal cancer (TNM3, ACPS, TNM4/Dukes) have been compared in 318 patients treated at some stage of their disease at Berne University Hospital. Simultaneously, the role of some prognostic factors for survival and relapse has been analyzed. The estimated 5 years' survival rate for all patients is 42%. After complete removal of the tumor 49% of patients relapsed. In a multivariate analysis the stage, age above 80 years and the site of the primary tumor have an influence on survival and relapse. Blood transfusions had no effect on either in this analysis. The concordance of the three staging systems is good and the resultant survival curves are similar. TNM3 puts some patients with a bad prognosis into stage I. ACPS classifies patients with residual tumor after surgery with patients with distal metastasis. It has no further advantages over TNM4. TNM4 seems at present to be the best staging system. It incorporates the advantages of the well-known Dukes classification and, with possible refinements, has the qualities to be used as a standard method.


[Pulmonary changes in ulcerative colitis]. We report on a 54-year-old patient who developed symptoms of bronchitis 3 months after colectomy for ulcerative colitis. Bronchiectases were documented by high resolution computer lung scan. Several cases of ulcerative colitis associated with alterations of the airways, of the pulmonary parenchyma, of the lung vessels and of the pleura have been published. Symptoms of bronchitis, often on the basis of bronchiectases, are the most commonly observed pulmonary problems in this inflammatory bowel disease. Furthermore, abnormal pulmonary functions have been found even in asymptomatic patients. Our patient was treated with oral and topical corticosteroids. The symptoms disappeared and pulmonary function returned to normal.


[Improved glucose regulation and microalbuminuria/proteinuria in diabetic patients treated with ACE inhibitors. A meta-analysis of published studies of 1985-1990]. In patients with diabetes mellitus, metabolic control, hypertension and kidney function are important prognostic factors. In this respect ACE inhibitors exhibit, according to previous publications, a potentially beneficial effect on diabetic patients. To further clarify this effect of ACE inhibitors, a meta-analysis of 21 studies of type I and II diabetics under therapy with ACE inhibitors was performed. Altogether 325 cases were analyzed. The duration of diabetes varied between 2.5 and 22 years. Therapy with ACE inhibitors under long-term treatment (up to 12 months) reduced diastolic blood pressure (-25%) and, both for type I and II diabetics, fasting blood sugar (-14%) and HbA1 (-9%). Microalbuminuria/proteinuria was reduced by 33% under short-term treatment with ACE inhibitors (up to 3 months) and by 66% under long-term treatment. Analysis of the subgroups with microalbuminuria (30-300 mg/day, n = 48) or clinical proteinuria (greater than 300-1500 mg/day, n = 9) showed similar results. The outcome of this meta-analysis shows that the treatment of diabetic patients with ACE inhibitors not only effectively reduces high blood pressure but also reduces microalbuminuria/proteinuria and, in addition, exhibits an anti-hyperglycemic effect by improving blood sugar levels.


[Current aspects in the diagnosis and therapy of narcolepsy]. Narcolepsy is a potentially invalidating disorder of the sleep and wakefulness structure, characterized by attacks of sleepiness, cataplexy, hypnagogic hallucinations, sleep paralysis and disturbed night sleep. The diagnosis is mainly based on the history. Additional sophisticated examinations, such as nocturnal polysomnography, are primarily indicated to rule out other causes of excessive daytime somnolence. The recently detected high correlation between a certain HLA status and cataplexy has led to new pathogenetic concepts. The primary aim of the therapy is to keep the patient at work rather than attempting a symptom free state. Measures to organize his day with planned naps should precede the use of medication. Besides stimulants against daytime somnolence and tricyclic antidepressants to suppress cataplectic attacks, some new drugs have been administered successfully against the various symptoms of narcolepsy in recent years.


[Measurement of pulmonary artery occlusion (wedge) pressure using the Swan-Ganz catheter: various pitfalls]. The Swan Ganz pulmonary artery catheter is widely used in the intensive care unit. It allows the determination of important hemodynamic parameters. Among these, pulmonary artery occlusion pressure ("wedge" pressure) is often considered to reflect accurately left ventricular preload and pulmonary capillary hydrostatic pressure. However, many interferences may render data interpretation difficult, especially in patients undergoing mechanical ventilation. This article reviews some of these pitfalls.


[Eosinophilic colitis--an unusual cause of acute abdomen. Case report and literature review]. Eosinophilic gastroenteritis (EGE) is an etiologically obscure and rare inflammation which can affect all sections of the gastrointestinal tract from esophagus to rectum in a diffuse or segmentary manner. An infiltrate of eosinophilic granulocytes is found to varying degrees in all wall layers. The clinical symptoms depend on the site and extent of organ involvement. Diagnosis can only be established histologically. Peripheral eosinophilia is inconsistent and not diagnostic. ESR, leukocyte count, serum IgE, and RAST tests in foodstuffs may be normal or elevated. Two women patients are described with tumorous eosinophilic colitis of the cecum and colon ascendens, who underwent surgery for clinical acute abdomen. A further woman patient was hospitalized with bloody diarrhea and marked eosinophilia in the blood findings. Eosinophilic colitis was likewise found histologically in the mucosa which appeared with reddened patches in sigmoidoscopy. Eosinophilic colitis associated with eosinophilic gastroenteritis is rather rare and may therefore be overlooked. Our literature review contains only 64 such cases, in only 6 of which was the tumorous form found. Counting our own patients as well, eosinophilic colitis occurs somewhat more frequently in women (27 = 56%) than in men (21 = 44%). The clinical symptoms, possible causes and therapeutic approaches are discussed in the light of the literature.


[Spontaneous reporting system for the assessment of new, unknown and rare undesirable effects of drugs]. The Swiss Drug Monitoring Center SANZ operates the spontaneous reporting system in Switzerland. Spontaneous reporting schemes represent the systematic approach to the collection of individual case reports on suspected adverse drug reactions (ADR). ADR spontaneous reporting systems are an important component of the postmarketing surveillance of drugs. Spontaneous reporting systems are primarily designed to detect new and unexpected ADR; they generate signals about possible ADR and create hypotheses to be tested in pharmaco-epidemiological studies. Besides collecting, analyzing and evaluating single case reports it is important to extract those cases from the data pool which can be used to produce signals. A computer-assisted early warning system enables SANZ to detect cases with signal function and thus to track down new, rare and unexpected ADR. Carefully selected parameters can help to identify important new hazards. However, the detection of new and unexpected ADR depends to a large extent on the minds of alert physicians and the practicing clinician's awareness of and cooperation with ADR reporting.


[Decrease in general health status, febrile state and sinusitis in renal insufficiency]. A 59-year old man, dialysed for 9 years because of chronic renal failure of unknown etiology, was also suffering from a hypertensive cardiopathy and anemia. He has received more than 70 units of blood over the past few years. An elevated blood aluminium level prompted treatment with desferrioxamine for 3 years. Following episodes of melena, an intestinal-wall lesion, located 8 cm above the ileo-caecal valve was discovered. Blood serotonin levels were elevated; biopsy of the liver revealed tumor cells with round-shaped nuclei which stained positive for synaptophysin, findings compatible with a carcinoid tumor or a pancreatic islet-cells tumor. Considering the whole clinical situation, aggressive diagnostic of therapeutic measures were not pursued any further. The patient lost 8 kg over the next few months and was finally hospitalised with fever. Physical examination revealed ascites, edema and a gingival abscess which was drained. Blood cultures grew Klebsiella pneumoniae. Antibiotics were prescribed. A month later the patient complained again of fever accompanied by myalgias, edema and pain of the eyelids, mainly on the right side, pain in the maxillary area and on right eye motion. ENT examination revealed a necrotic lesion of the right middle turbinate which on histology was diagnosed as acute purulent rhinitis without granuloma or vasculitis. A CT-scan demonstrated mucosal thickening of the left sphenoidal, ethmoidal, frontal and maxillary sinuses without any osteolytic lesions. The patient suffered a sudden right eye blindness with signs of retinal ischemia accompanied by an elevated sedimentation rate of 130 mm. Steroid treatment for suspicion of a temporal arteritis was introduced. 2 days later the patient was rehospitalized in a semi-comatose condition. No new information was gained from the usual laboratory investigations and the physical examination was comparable to the previous hospital stay. Blood cultures remained sterile. He died a few hours later. The discussant, A. de Torrenté MD, accepts the diagnosis of a hypertensive cardiopathy, renal failure of unknown origin and a carcinoid of the terminal ileum with hepatic metastases. The role of iron overload as a contributory factor for the cardiac disease is discussed. More problematic are the manifestations of the terminal disease with involvement of the sinuses, the eyes and the mouth. The "lethal midline granuloma" (a syndrome and not a disease entity) covers many different diseases which can be considered in this case: Wegener's granuloma, various lymphomas, parasitic, bacteria- and fungus-induced diseases.(ABSTRACT TRUNCATED AT 400 WORDS)


[Hepatitis and HIV infection in users of illegal drugs]. The prevalence of markers for ongoing or past infections with the hepatitis viruses A (HAV), B (HBV), D (HDV) and C (HCV) and with HIV are analyzed in i.v. drug users. The relevant serological parameters were measured in 1989, 1990 and 1991 in 220 to 380 sera each of drug users who frequented the open drugscene "Platzspitz" in a recreational area in the center of Zürich. The prevalence of viral markers for ongoing and past infections was many times higher in drug users than in the Swiss population. Over the three years the prevalence of HAV-markers rose from 50% to 72%, remained stable for HBV (52%, 57%, 58%) and most probably also for HCV. It slightly declined for HIV from 21% to 18% in one series and from 17% to 2% in another series. 10-34% of all individuals tested showed signs of at least one ongoing infection. Combined infections were frequently observed. The prevalence of viral markers was significantly dependent on the duration of drug use and if needle-sharing was practiced or not. Our data were analyzed in the context of the official notifications of these viral infections and related disorders to the Swiss Health Ministry. The risk of infections with the viruses analyzed here is 100-200 times higher in drug addicts than in the Swiss population. Drug users account for 42 to 52% of all infections (and clinical sequelae) notified in Switzerland. In the light of the fact that drug users also represent a potential source of spread of these viruses into the general population, the prevention effort in drug users should have first priority.


[Comparison of the efficacy of omeprazole/bismuth subcitrate or triple therapy in Helicobacter pylori gastritis. A prospective controlled study]. In a controlled, prospective, randomized trial, 10 patients with Helicobacter pylori positive gastritis were treated either with triple therapy (tetracycline, ornidazole, bismuth subcitrate; T, Or, CBS), or omeprazole/CBS (O/CBS) to test the eradication rate of each treatment, its effect on gastritis and meal stimulated gastrin release. 6 patients were treated with triple therapy and 4 patients with O/CBS for 2 weeks. Initially, and 0.5, 1, 3, 6, and 12 months after therapy, patients were investigated by a highly specific, quantitative Helicobacter serology, 13C-urea breath test and measurement of meal-stimulated gastrin release. After 3 and 12 months antral biopsies were taken endoscopically for rapid urease testing and culture. Activity of histological gastritis was graded. Eradication for at least 12 months was achieved in 5 out of 6 patients with triple therapy. Serology normalized and gastritis activity improved. In all patients treated with O/CBS, HP was suppressed only temporarily. No eradication was achieved. Urease testing and histology proved to be reliable tests for detecting HP. Culturing of HP was successful in only 66% due to technical problems. The 13C-urea breath test was correct in all cases. The initially, increased meal-stimulated gastrin release was normalized after eradication of HP. (1) Triple therapy is also successful in short term treatment in up to 80% of patients with HP gastritis and improves gastritis activity. (2) The combination O/CBS failed to eradicate HP in all treated patients. (3) The 13C-urea breath test and HP serology are reliable non-invasive parameters during follow-up. (4) Normalization of meal stimulated gastrin release after eradication of HP supports the hypothesis that HP induces increased gastrin release and hyperacidity.


[Patients returning after transplantation]. Numerous reports have dealt with patient survival and prognostic factors after renal replacement therapy. However, few data exist for patients after a failed renal transplant and who start dialysis again. With this purpose, we retrospectively studied 36 patients who returned to dialysis after a mean transplantation time of 42.8 +/- 7.8 months. Actuarial patient survival on dialysis after the failed renal transplant (D2) was 78%, 74%, 69% and 41% at 1, 2, 3 and 5 years after restarting dialysis respectively. In comparison, survival of patients who started dialysis without a previous history of a renal transplant showed rates of 91%, 85%, 79% and 64% at 1, 2, 3 and 5 years respectively. The difference was statistically significant only at one year after beginning dialysis therapy (78% vs. 91%, p < 0.025). There were no differences in plasma urea concentration by the time of starting both first (D1) and second (D2) dialysis treatments (37.4 +/- 1.9 and 38.8 +/- 2.9 mmol/L respectively). Instead, a statistically significant difference was found between corresponding serum creatinine values (1100.1 +/- 47.1 and 856.9 +/- 50.0 mumol/L respectively, p < 0.05). When actuarial survival and serum creatinine values at the start of D2 were analyzed, there was a statistically better survival at 1 year for patients with serum creatinine values under 900 mumol/L, as compared with those above 900 mumol/L (85% vs. 52%, p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)


[Polymyositis: disease course and therapy with intravenously administered immunoglobulins]. Corticosteroids and immunosuppressive agents are standard treatment for polymyositis (PM) and dermatomyositis (DM) respectively. Recent reports have emphasized a potentially successful regimen with intravenous immune gammaglobulins (IVIG). The short term success of this treatment in a personally observed case is described. IVIG treatment resulted in normalization of the serum concentrations of the muscle enzymes after continued inflammatory activity under treatment with azathioprine, cyclophosphamide and methotrexate in combination with corticosteroids. The improvement of PM by IVIG was further documented by an increase in muscle strength of up to 367% of the initial value and a regression of the myositic changes in the muscles of the thighs as evidenced by magnetic resonance imaging (MRI). The therapeutic response was paralleled by reversal of peripheral lymphopenia. Experience with IVIG treatment in PM/DM is reviewed and the potential role of this regimen in the management of PM/DM is discussed.


[Risk assessment in professional drivers with coronary heart disease: experiences with the evaluation program for locomotive drivers by the Swiss Federal Railroad 1986-1991]. For operational reasons in 1985 the question arose for the Swiss Federal Railways (SBB) whether engine-drivers (ED) with coronary heart disease (CHD) could be licensed for unaccompanied driving on certain well-defined premises. Until that year, such ED were allowed to drive only when accompanied by an apprentice ED. No generally accepted directives have operated in Switzerland for licensing ED or other professional drivers with CHD. Based on data in the recent literature and assuming an acceptable mortality risk of about 0.75% per year, admission criteria were devised for licensing of ED with CHD for unaccompanied driving. Since 1986 every ED with CHD has been investigated according to these criteria by the medical service of the SBB in close cooperation with free practising and clinical cardiologists, and classified for driving alone, driving with accompaniment or as unfit to drive. ED who were fit to drive (either alone or accompanied) have checkups at least every three months by their family doctor and yearly by the medical service of the SBB and by a cardiologist for early recognition of any deterioration of their individual risk. From 1986-1991 a total of 114 ED were enrolled in the investigation program, 80 of whom proved to have CHD. 30 out of these 80 ED (37%) were cleared to drive alone at least for several months, 36 were licensed to drive with accompaniment for cardiac and non-cardiac reasons, and 14 were classified as unfit to drive. Among the ED driving without accompaniment, there was one death from heart failure during a total observation period of about 90 person-years, in an ED who had previously been re-classified for accompanied driving. One ED of the accompanied driving group died while on duty but not while driving. The annual incidence of new non-fatal CHD (non-fatal infarction, angina pectoris, ECG abnormality of proved coronary origin) was 0.25% in 1987 through 1991, for non-fatal infarction alone 0.14%. Our relatively restrictive licensing procedure served to identify an acceptable number of ED with CHD who could resume unrestricted work without compromising public safety in the short run. Framing of similar criteria for public service vehicle drivers is advocated.


[Arterial blood pressure measurement--which cuff?]. In order to evaluate the influence of cuff size on blood pressure (BP) measurement, we compared values obtained with a standard cuff of 12 x 23 cm with those obtained with a large cuff of 15 x 28 cm in a group of 554 consecutive outpatients. Higher values were obtained with the standard cuff (systolic/diastolic 133.9 +/- 22/80.5 +/- 12 mm Hg) compared to the large cuff (128 +/- 21/76.5 +/- 11.6 mmHg (m +/- SD). This difference reached an average of 10/7 mm Hg for the large arm circumferences (AC) and for high blood pressure values. With the standard cuff, hypertensive values were found twice as often as with the large cuff. Thus the choice of a cuff adapted to AC is of great importance in identifying and treating hypertensive patients. In 77 subjects with a range of AC from 16 to 48 cm, the values measured with the standard and the large cuffs were then compared to those obtained with a reference triple cuff fitting to AC of 8.5 x 26-12 x 36-15 x 46 cm. The measurement of BP was most accurate when the ratio between cuff breadth and AC was between 0.42 and 0.44. The error increased by 0.6-0.7% per centimeter of AC above and below this ratio for the short inflatable bladders (twice as long as broad) of the standard and large cuffs. However, the use of long bladders (3 times as long as broad) combined with the triple cuff appreciably decreased this error.(ABSTRACT TRUNCATED AT 250 WORDS)


[Monotherapy with the ACE-inhibitor ramipril or the calcium antagonist nitrendipine in essential hypertension]. Angiotensin-converting enzyme (ACE) inhibitors and calcium antagonists have, by reason of their potentially favourable pharmacological profile, become increasingly established in the treatment of hypertension in recent years. In a double-blind randomized study with an initial placebo phase, carried out by practising physicians and thus aimed at the "usual" practice patients with essential hypertension, we assessed (1) the antihypertensive effect and tolerability of an ACE inhibitor (ramipril, 5 mg/d) or a calcium antagonist (nitrendipine, 20 mg/d) given in a single daily dose, and (2) a possible age-dependent blood pressure (BP) effect of these therapies. In the 4 weeks' placebo phase, the two treatment groups were comparable as regards average age (49.6 and 49.4 years), age-range (27-67 and 25-64 years) and BP. Fifty-two patients completed the following 6 weeks' phase with active drug therapy. On ramipril (n = 26), the BP measured 24-25 hours after the last drug administration was reduced in the supine position from an average of 155/102 to 142/91 mmHg (mean reduction -10.1%) and in the upright position from 156/106 to 141/96 mmHg (-9.3%). Nitrendipine (n = 26) reduced the average BP from 155/102 to 147/94 mmHg (-6.8%) and from 155/106 to 146/99 mmHg (-6.6%) respectively. BP-lowering effects of both treatments were largely independent of age. Including the patients who discontinued the study prematurely because of side effects (1 on ramipril, 4 on nitrendipine), the "intention to treat analysis" shows BP normalization rates (diastolic < or = 90 mm Hg) of 55% (ramipril) and 30% (nitrendipine) respectively.(ABSTRACT TRUNCATED AT 250 WORDS)


[In-vitro fertilization--progress in a method of sterility treatment]. The first IVF-baby (in-vitro fertilization) was born in England in 1978 and was greeted enthusiastically. But, despite the enormous effort invested, pregnancy rates were disappointingly low. Although in recent years the clinical pregnancy rate has increased worldwide to 15-20% per retrieval, a vast number of people remained unaware of this improvement. To demonstrate and analyze the progress of IVF we evaluated all 196 IVF treatments effected from 1988-1991 at Zürich University Hospital. With an initial clinical pregnancy rate of only 6% per retrieval in 1988, the rate improved to 35% (p < 0.025) in 1991. The crucial factors relating to this improvement were the 1990 introduction of the programmed short-term protocol for ovarian stimulation and reevaluation of the previously used embryo freezing technique. After a difficult start, IVF has become, if accurately indicated, a method of sterility treatment with a realistic pregnancy and delivery prospect.


[Pericardial effusion in patients with malignant neoplasms]. Pericardial effusions are often present in patients suffering from tumoral diseases, especially lung and breast cancers. Between September 1984 and February 1991 we observed 21 patients with "malignant pericarditis", of whom 57% had carcinoma of the bronchus and 33% a carcinoma of the breast. The symptoms most frequently seen were dyspnea (in 76% of the patients) and tachycardia (67%), accompanied by enlargement of the heart on chest radiograph. The effusions were bloody in all the patients, and the pericardial fluid cytology was positive in 9 of 10 of the lung cancer patients. 16 patients were treated by pericardiocentesis and in 10 of these thiotepa and hydrocortisone were instilled intrapericardially. In this manner it was possible to avoid recurrences of major effusion. The survival of the patients who received the intrapericardial instillation seems to be longer than that of the remaining patients.


[Prevalence of anti-HCV (C100-3) antibodies in 20.373 blood donors]. The anti-HCV antibody (C100-3) is present in the serum of 70-90% of patients that are carriers of posttransfusion non-A non-B hepatitis. This marker appears to be associated with a viral replication and infectiousness state. Since 1st August 1990 the Swiss Red Cross Transfusion Service has operated a systematic search for anti-HCV antibodies for every blood donation. The aim of the study was to establish the prevalence of anti-HCV antibodies in a donor population, look for the risk factors in the anti-HCV positive group, look for biological symptoms and signs of chronic hepatitis, and compare the data with that from an anti-HCV negative control group. From August to March 1991, 20,373 donors were tested by EIA (Ortho). The presence of anti-HCV antibody was confirmed by a neutralization test (Abbott). The donors in which both tests were positive formed the group studied (55 subjects). Their data was compared with that of a control group of anti-HCV negative donors. The prevalence of anti-HCV antibody in the group of 20,373 donors was 0.29%. Possible parenteral exposure to hepatitis C virus was found in 47% of anti-HCV positive subjects (30% blood transfusion, 9% i.v. drug addiction, 8% tattooing). 42% of the anti-HCV positive donors had no risk factor presently known for hepatitis C. 27% of anti-HCV positive donors had elevated transaminase levels. Until more effective screening tests are introduced it appears necessary to stress the previous history of future blood donors in order to search for hepatitis C risk factors.(ABSTRACT TRUNCATED AT 250 WORDS)


[Pertussis in clinical practice--critical evaluation of diagnosis and epidemiology]. In the Swiss Sentinel System pertussis is reported according to a clinical case definition. In our Sentinel practice, we have investigated in detail nine patients fulfilling these criteria. Seven of the nine patients have previously been vaccinated with whole cell vaccine. The clinical diagnosis could be confirmed in three cases by the detection of elevated serum IgA to filamentous hemagglutinin (FHA), and in one infant based on the peripheral blood lymphocytosis and the detection of pertussis in other family members. The likely diagnosis in another brother and sister pair was a parainfluenza virus infection, possibly with concomitant pertussis. Two sisters probably had a mycoplasmal infection, which in one was accompanied by pertussis. In two patients an infectious etiology could not be determined. The laboratory tests which have been used in these cases are discussed. The occurrence of pertussis in previously vaccinated adolescents and adults has been recognized worldwide and is of epidemiological concern in view of current vaccination policies. The Swiss Sentinel System could play an important role in the surveillance of pertussis in Switzerland.


[Cardiovascular effects of everyday coffee consumption]. Whereas the earlier literature contains several studies on the acute cardiovascular effects of caffeine, systematic studies of the cardiovascular effects of regular daily coffee consumption have appeared only recently. Acute caffeine administration (total daily amount in one dose following caffeine abstinence) increases both systolic and diastolic blood pressures by 10-15 mm Hg and lowers the pulse by about 2-5 beats/min. Repeated caffeine administration leads to a rapid decline in the blood pressure response. Chronic switching between decaffeinated and caffeine-containing coffee showed no more than marginal changes in blood pressure. Plasma lipids are probably independent of caffeine consumption, but increase slightly with boiled (compared with filter) coffee. The question of the thermogenic effect of coffee consumption remains open. The prevalence of coronary disease appears to be epidemiologically independent of coffee consumption.


[Molecular genetics diagnosis of Steinert's myotonic dystrophy]. Myotonic dystrophy (DM) is the most common neuromuscular disease with adult onset (incidence 1 in 8000). The biochemical basis of this autosomal dominantly inherited disease is still unknown. The most striking features are myotonia and progressive muscular wasting. There is high variability of disease severity in patients from different families, but also within the same family. For practical reasons three subtypes can be defined: The classical adult onset form of the disease, a mild form with late onset and/or very moderate symptoms, eg. cataracts only, and the most severe congenital form which is transmitted by affected females. Furthermore, the progression of DM in affected families may exhibit an increase in the severity of the disease in successive generations. This observation is called anticipation. Very recently the DM gene has been cloned and an unstable DNA sequence specific for the disease has been characterized. Detection of an enlarged DNA fragment due to the expansion of a trinucleotide (CTG) repeat within the DM gene can be used for direct DNA diagnosis in affected individuals and persons at risk. Furthermore, there is a strong correlation between the length of fragment expansion and the degree of disease severity in gene carriers. We report here our preliminary results of the investigation of over 70 patients and demonstrate the clinical usefulness of this new method by the findings in three families.


[Non-enzymatic marking of gene probes using digoxigenin for the diagnosis of sickle cell mutation and beta thalassemia]. A method is described in which allele-specific oligonucleotides (ASO) are labeled non-enzymatically with digoxigenin (DIG). The ASOs were synthesized in a DNA synthesizer. A primary C6-alkylamine was incorporated at the 5'end of the ASO. The derivative was coupled to digoxigenin-3-0-methylcarbonyl-epsilon-aminocaproic acid-N-hydroxy-succinimide ester. The DIG-ASO probes were isolated from the crude preparation and hybridized with amplified genomic DNA. The annealed probes were detected with an ELISA test. The DIG-ASO probes were successfully used for the identification of sickle cell disease genotypes and the most common beta-thalassemia mutations.


[The effect of first aid and care times on the clinical course and treatment results in multiple trauma. Initial interim results of an interdisciplinary trauma registry in the St. Gallen district hospital]. To date little is known about the influence of variable rescue (i.e. transportation/preclinical care) and clinical care times on the clinical progress and outcome of patients suffering injuries ranging from average to severe. Having examined this question within the framework of an ongoing study of trauma, we present the first provisional results and compare them with existing documentation. Since 15 June 1990, all cases of multiple injury have been recorded in a trauma register. The present interim investigation of 143 patients covers a period of 13.5 months. We have recorded the rescue and clinical care times and compared them with survival, disability, complications and length of stay in hospital or intensive care unit. 106 (74%) of the total of 143 patients were operated on an average of 5.5 hours after the accident. In cases of intracranial or intraabdominal bleeding, there was an average time lag of 220 minutes after the accident before the patient could undergo surgery. Overall, 70% of the total rescue time was spent on medical attention and waiting time in the emergency unit. The secondary transfer rate is 46%. In the case of 4 patients, it is possible that the delays involved contributed appreciably to mortality (19%. i.e. 4/21). Generally, however, no coherent and conclusive correlation could be established between prolonged rescue and clinical care times and a worsened outcome. False negative results cannot be totally excluded, since the classification of the individual degree of injury by means of ISS and TRISS is unreliable, the variable quality of medical care prior to arrival at our emergency unit has not been taken into account, and the case figures are low (possibly of a large-scale beta error). The database for the assessment of standard times is still inadequate. For a reliable analysis, a total number of at least 500 patients is necessary (beta error acceptable). Our own data and the meagre results of other studies support the supposition that it is not the absolute time-lapse which has prognostic significance but the qualified medical assistance provided within a critical, individual, but extremely variable time-span. The increased employment of highly qualified emergency staff and a more efficient "triage", in the sense of a clearly directed trauma regionalization, could thus lead to optimization of trauma care.


[Severe thrombocytopenia in systemic Boeck's disease]. We present a case of sarcoidosis-associated severe thrombocytopenia, a rare but well known complication. Diagnosis of sarcoidosis was based on radiologically enlarged hilar and mediastinal lymph nodes and on histology of biopsies taken from them by mediastinoscopy. In most cases an autoimmune etiology is assumed and platelet-associated antibodies can be demonstrated. Therapy resembles that of chronic idiopathic thrombocytopenia; an early start, sufficient duration and slow reduction of the corticosteroid medication is crucial. If bleeding complications occur, high-dose human gamma-globulins are indicated. In the light of the literature the pathophysiological, diagnostic and therapeutic aspects of this potentially lethal complication are discussed.


[Fish diseases in Switzerland. A statistical evaluation of the diagnostic material of the Fish Research Institute from 1979-1988. II. Special aspects]. The frequency of fish diseases diagnosed at the Fish Disease Laboratory at the University of Berne from 1979 to 1988 is presented. Parasitic infections have been found to be the most frequent diagnosis. Among noninfectious diseases poisonings were predominant. Six infectious diseases have been considered to be economically relevant. These diseases (according to their frequency: Gyrodactylosis, Costiosis, Ichthyophthiriosis, Viral Hemorrhagic Septicemia (VHS), Saprolegniosis and Furunculosis) were further analysed. Their incidence varies with season, species, origin and length of fish. Possible explanations for these findings are discussed.


[Ehrlichiosis in dogs: literature review and case description]. A case of E. canis in a 7 year old intact female bearded collie is described and possible clinical signs of Ehrlichiosis are discussed. Non-specific findings included elevated rectal temperature, depression and anorexia. Additional findings were generalized lymphadenomegaly, myalgia and painful swollen joints. Significant changes in the CBC were leucopenia and thrombocytopenia. The positive E. canis titer of 1:40 and rising titer to 1:160 were specific for Ehrlichiosis. Doxycycline and prednisolone were needed to obtain clinical remission, which underlines, that immune-mediated processes are important in the pathogenesis of Ehrlichiosis.


[Bacteriology and mycology of otitis externa in dogs]. The bacterial and fungal flora of 1118 ears of dogs with otitis externa and 100 ears of healthy control dogs were studied in order to isolate the causative agents. The yeast Malassezia pachydermatis (56%) was by far the most common organism in otitic dogs followed by the bacteria Staphylococcus intermedius (23%), Pseudomonas aeruginosa (12%), Proteus spp. (6%) and Streptococcus canis (5%). A statistical analysis of observed results showed that the incidence of these organisms is significant in otitic dogs. Many strains of S.intermedius, P.aeruginosa and Proteus spp. are resistant to antimicrobial agents commonly used to treat otitis externa. Therefore an antimicrobial susceptibility testing was performed using "Cobas Bact" for these bacterias. Furthermore, 80 strains of M.pachydermatis were submitted to identification-kits (API 20 CAUX, API STAPH, Cobas Micro). The observed results showed that an identification with these tests was not possible.


[Arthroscopy of the shoulder].

[Arthroscopy of the shoulder]. Shoulder arthroscopy has grown considerably for several years in a row. The progress obtained nevertheless should not lead to an underrating of both clinical and para-clinical investigations. Arthroscopic technique as applied to the shoulder joint has now reached a mature state. Diagnostic benefits due to arthroscopy are scant because the recent development of medical imaging techniques made its usefulness less obvious. A great number of reliable therapeutic acts are currently performed as well in the glenohumeral joint, as in the sub-acromial space.


[Physical performance and sedation: comparative study of the effects of a benzodiazepine (temazepam) and of a non-benzodiazepine hypnotic (zolpidem)]. It is well-known that many athletes experience some form of precompetition stress that may result in insomnia during the night before their competition. Yet, sleep withdrawal even if only partial, has a negative influence on performance, particularly when the type of exercise requires good psychomotor performance The purpose of the present study was to investigate whether the intake of a hypnotic drug would have negative effects on physical performance capacity. The authors have compared the effects of oral temazepam, a medium half-life benzodiazepine vs oral zolpidem, a short half-life non-benzodiazepine drug, vs placebo. A randomized double-blind trial was used to assess endurance, resistance, strength and coordination in 26 athletes. The results did not show any differences between the three groups, neither in physical performance characteristic nor in coordination. It is concluded that as regards the performance capacity, there is no risk for stressed athletes to use sleep inducers the night before their competition.


[Medicolegal aspects of mountain rescue for the emergency physician and personnel]. The remarkable spread and growth of mountain sports, as well as of their unfortunate succession of injuries sometimes give rise to medico-legal problems which up to now have been dealt with only in a very little number of publications. We discuss here briefly the main problems of setting up and organising the first aid and rescue squads and the resulting legal responsibility the health and medical staff may be exposed to.


On the epidemiology of sports injuries in Switzerland. A review of the current literature and of insurance data sources on sports injuries in Switzerland during the latest decade is presented. Epidemiological denominator data to determine the population-at-risk and the exposure time are scarce and it is therefore recommended that both the quantity and the quality of Swiss research in this field will be enhanced. It is also proposed that at least one academic institution in Switzerland would assemble systematically all available data of standard format on sports and recreational injuries to ensure a continuous analysis of these data.


Mountain sickness.

Mountain sickness. The varied and subtle symptoms of this potentially lethal disorder humble many who scale the summits. But the problem is often preventable.


Histones as regulators of genes.

Histones as regulators of genes. Histones were once dismissed as little more than packing material for nuclear DNA. In fact, these proteins can both repress and facilitate activation of many genes.


[New aspects in the evaluation of Doppler blood flow curves: three- dimensional image and analysis of Doppler shift frequencies within the heart cycle]. Since the introduction of Doppler ultrasound to the area of medical diagnostics, there have been numerous improvements and important technical refinements. In obstetrics, Doppler examination allows a more accurate and encompassing evaluation of the foetal condition than was previously possible. Combined with today's sophisticated computer technology, it has a great potential in research and to expand our knowledge about the physiology and pathophysiology of foetal and maternal haemodynamics. This paper describes a new way of integrating another factor into the evaluation of Doppler blood flow waveforms, namely, the intensities of various frequencies. One result should be more detailed information about the given haemodynamic situation; another, a valuable tool for the quality control of Doppler blood flow measurements. Although our work was on applications in the field of obstetrics, the method we have developed can be used in all medical areas.


[Comparison of different blood flow parameters for evaluating blood flow spectra in fetal growth retardation]. Uteroplacental and foetoplacental vascular resistance is generally high in pregnancies complicated by intrauterine growth retardation. Assessment of flow velocity curves using angle-independent indices as A/B ratio, resistance index (RI) or pulsatility index (PI) cannot classify all cases with pathological flow velocity profiles. Beneath the pulsatility the maximum frequency outline of the flow velocity waveform offers additional clinical information. The evaluation of flow velocity curves using polynome analysis (including III degrees) provides additional data including occurrence of diastolic notching and can be used as a more sensitive indicator of impaired uteroplacental blood flow. In such pregnancies accurate evaluation of the maximum flow velocity outline with polynome analysis has been shown to be an important qualitative criterion in the assessment of blood flow velocity waveforms.


[Doppler sonography of the umbilical artery for evaluating the fetoplacental vascular tree: a prospective histologic comparison]. We compared the clinical data, Doppler sonographic results and histological placental findings of 252 patients prospectively. A normal flow velocity wave form may be related either to a normal placenta villous and vessel architecture or to an at least focal leason with compensatory angiosis and/or high placental weight, whereas in cases with missing compensation phenomenon the end-diastolic blood flow velocities in the umbilical arteries are reduced.


[Umbilical blood flow relations in different segments of the umbilical cord. Part 1. Physiologic index constellation]. Based on a collective of 500 women with normal singleton pregnancies we examined the indices of flow resistance along the umbilical cord. Measurements were taken at the foetal abdominal side of the Aa. umbilicales on the one hand and at the placental insertion of the vessels on the other. According to our results we were able to establish a physiological constellation of the indices for each week of gestation, and - subsequently - for the whole duration of pregnancy. These constellations could be considered physiological. They may serve as a basis for the definition of pathological conditions.


[The normal vascularization of the female breast in Doppler ultrasound]. Specific Doppler-Ultrasound methods for the differentiation of benign and malignant lesions by measurement of abnormal flow, have been known for more than 10 years. We used this method also in many patients without pathological breast problems and found a high physiological variation of blood flow. As basic definition of normal flow, to be compared with patients under medical treatment of mastopathy, we studied flow variations during menstrual cycles in normal volunteers. In both breasts we measured the amount of vessels, average frequency shifts according to flow velocity and the sum of all Doppler shifts, as measurement of the overall vascularity. Between different individuals the range of Doppler shifts was between 500 and 1000 Hz. However, in individual subjects the variation was only between 50-200 Hz, average 100 Hz. We also found between contralateral breasts no remarkable difference in vascularity. Flow increased at the 10th day after onset of menstruation, in 9 cycles with ovulation and in 8 cycles with a lack of gestagen production. Dramatic flow increase occurred in one early pregnancy. It appears that influences of drugs can be controlled, after basic measurements of individual vascularity.


[Ultrasound image of endometrial cancer]. In this prospective study 571 patients with postmenopausal bleeding/discharge (group I) and 300 patients without symptoms (group II) were ultrasonographically examined. The sonographic findings were compared with those of histology to evaluate the value of ultrasonography in endometrium diagnosis. The main parameters which we considered in the diagnosis of malignancy of the endometrium, were the thickness of the endometrium, the boundary of the endometrium, homogeneity and collection of fluid in the uterine cavity. However, the size of the uterus and the central endometrial echo were found not to be sensitive signs of malignancy. The sensitivity of sonography in group I was 86.3% higher than group II which is 75%. The rate of false-positive and false-negative in the total study population was 7.1%. We believe that ultrasonography is the easiest, most painless out-patient based and non-invasive diagnostic method in comparison to all other endometrium diagnostic measures, and is an advance towards better approach in the early diagnosis of endometrial carcinoma.


[Attempt at three-dimensional imaging in obstetrics]. Different attempts have been already made to present sonographic findings in 3 dimensions. In most of computer assisted systems the time for acquiring and data processing is too long to allow for an instantaneous interaction between the examiner and the machine; furthermore, valuable data; concerning the organ structure were lost. The aim of the system presented here is to acquire short time a sample volume for 3 dimensional display without employing an expensive periphery, containing all relevant sonic data and without substantial changes in handling the equipment. The technical details, advantages and shortcomings of the equipment are discussed. First results in obstetrics and gynaecology are presented.


[Ultrasound diagnosis of lumbar intervertebral disk displacement--a clinically relevant method?]. In a prospective clinical study, 102 patients suffering from low back pain were examined by ultrasound. In all patients the segments L3/4, L4/5, and L5/S1 were evaluated. We analysed a total of 306 lumbar disc segments. Ultrasound evaluation was transabdominally performed by using a 3,5 MHz scanner. The results of the ultrasound documentation were compared to MRI or if the patient was operated on with the intraoperative findings. In 25 disc the dorsal border of the disc could not be demonstrated by ultrasound. The statistical analysis resulted in the following values: [table: see text] Comparing these results with the results of other imaging modalities like myelography, CT, or MRI, ultrasound scores are significantly inferior. With the present technique ultrasound does not seem to be of diagnostic value for patients with herniated disk.


[Color-coded duplex sonography and ultrasound contrast medium in the study of peripheral arteries--initial clinical experiences]. Ultrasound contrast agents (US-CA) amplify reflected sound waves. Most substances used as contrast agents are destroyed when passing the lungs. SH U 508 is a new US-CA that can pass the lungs without impairment after peripheral intravenous application. In a clinical trial of this US-CA, we investigated its effect on the visualization of blood movement in peripheral arteries by color-coded Duplex sonography (CCDS). The leg arteries of 20 patients with severe chronic arterial occlusion were examined by CCDS (QAD I and Platinum) after i.v. application of the US-CA. After passage of the pulmonary capillaries, the US-CA amplified blood flow signals in the arterial system in a dose-dependent manner with both systems used. Undesired side-effects were not observed. The amplification produced by appropriate concentrations of the US-CA markedly improved the visualization of blood movement. Further studies are required to determine the optimal dosage and application technique as well as the indication for using this US-CA.


[Diagnosis of cephalothoracopagus--a case report]. Cephalothoracopagus twins were diagnosed at 22 weeks' gestation, hence this case was diagnosed early enough antenatally to allow vaginal pregnancy termination. This case underlines the need for exact ultrasound screening during early pregnancy.


Outcome after thymectomy for myasthenia gravis: a retrospective review. This is a retrospective study of 54 patients, who in the period November 1977 to November 1986 underwent thymectomy as treatment for myasthenia gravis. Patients in whom difficulty attempting complete excision of the gland was anticipated were selected for a transthoracic procedure. All others underwent an initial transcervical approach, proceeding to an upper sternal splitting incision if further access was required to remove adequately a large gland. The sample was split almost equally between the two surgical procedures. Patients in the transthoracic group were significantly older and experienced significantly greater peri-operative morbidity or mortality. There was no significant difference in outcome between the two groups, 52% achieving a good result (defined as remission or clinically significant improvement of symptoms) that was sustained over the five year follow-up period. In our opinion, complete removal of the thymus should be the goal of surgical treatment for myasthenia gravis.


Malaria in Aberdeen: an audit of 110 patients admitted between 1980-1991. All 110 patients seen in North East Scotland after contracting malaria from foreign travel were treated in the Regional Infection Unit in Aberdeen. Those patients managed there from January 1980 to March 1991 are described. There were 54 episodes of Plasmodium falciparum malaria (49%) and 26 episodes (23%) of Plasmodium vivax malaria. The remainder had either mixed infection or were diagnosed as malaria on high clinical probability. The majority of the patients were male (80%) and under 40 years of age (84%). Most patients were either caucasians born in the UK (69%) or native Africans (23%) who were students recently arrived for further education or who had returned from visiting their country of origin for summer holidays. The British residents acquired infection either while on oil related business in West or Central Africa (46%) or after travelling on holiday (30%). The peak incidence of presentation was August and September. 93.5% of patients with falciparum malaria had returned or originated from Africa. 42% with vivax malaria had visited Africa and 27% Papua New Guinea. 70% had been prescribed antimalarial prophylaxis but less than half of these took their medication correctly. The majority of patients with falciparum malaria presented within two weeks of arrival in Britain while patients with vivax malaria presented at varying (but generally longer) intervals, 42% being diagnosed more than three months after exposure. Falciparum infection was more severe although there have been no deaths in the unit from malaria. Our experience seemed of interest and worth reporting because of the number of patients whose infection reflected travel related to the off shore oil industry, which is centred in Aberdeen.


Thrombolytic therapy: impact on coronary care in a district general hospital. The introduction of routine thrombolytic therapy in the Cardiac Care Unit (CCU) of a District General Hospital has resulted in an increased demand for admission particularly in the 70+ age group. Complications and side effects of such treatment have been similar to those reported in several large multicentre trials. The percentage of patients with myocardial infarction receiving thrombolysis has increased to 60% with the commonest reason for withholding of such treatment being the lack of ECG changes. Mortality rates have fallen and there has been an increased referral rate for urgent angiography. To maximise benefit CCU's should encourage early direct admission and ensure that, if not present on site, facilities for angiography can easily be arranged.


Time trends and geographical variation in Parkinson's disease in Scotland. Parkinson's disease is a common and disabling condition which principally affects the elderly. The time and space distribution of Parkinson's disease has been examined to determine if it provides clues as to aetiology and factors affecting its distribution. Previous studies have used mortality data, data from epidemiological studies, and prescribing information particularly with regard to the use of levodopa. These studies have looked within countries and between countries.


Streptococcus milleri and complex groin abscesses in intravenous drug abusers. Intravenous drug abuse is an increasing problem. Septic complications occur frequently at the injection site, especially in the groin where large abscesses around the femoral vessels can threaten life or limb. We report four patients with extensive or complex groin abscesses following attempted self-injection into the femoral vein. Streptococcus milleri was cultured from all of these abscesses and prompted a review of the isolation of this organism in this hospital.


Astrocytoma presenting with vasculitis.

Astrocytoma presenting with vasculitis. A cerebral astrocytoma which had remained quiescent possibly for 12 years, presented with blackout, vasculitis and a lupus-like (L-E like) syndrome. The association between tumours and "L-E like" syndromes is reviewed briefly.


"A beloved physician" John Abercrombie MD (EDIN) FRCSE, FRCPE, MD (Oxon) 1780-1844. This son of an Aberdeen minister, graduating MD in Edinburgh in 1803, established a leading practice in that city, attracting apprentices to study medicine and patients of all classes of society from throughout Scotland. Sir Walter Scott in his later years was one who relied on his medical expertise. Dr Abercrombie, a Fellow of both the Royal College of Surgeons and Royal College of Physicians, Edinburgh, was in the forefront of Edinburgh medicine. An extensive author, primarily on medical subjects and laterally turning to metaphysical, moral and religious works, he gained a reputation among intellectuals world-wide. A philanthropist, he gave large amounts of financial aid to Missionary Societies, both at home and overseas. A founder member of first President of the Edinburgh Association for Sending Medical Aid to Foreign Countries (two years later renamed the Edinburgh Medical Missionary Society).


Odontoid fracture in the elderly: a case report of the screw fixation technique. The case of a type II, highly unstable, odontoid fracture in a 92 year old patient is reported. This fracture was treated by a new technique for anterior odontoid screw fixation with excellent results. The authors discuss this technique and treatment options for odontoid fracture in the elderly.


Research in context (or if you want to study how fox and chickens relate, go to the hen house, not the zoo). The context in which the research is carried out frequently is as important as the research question being investigated. The fact certainly is the etiology for many of the problems practicing physicians face when applying traditional research findings to clinical practice. The recent development of a family practice research network in South Dakota brought the investigators face to face with divergent views on this issue. This article provides some insight into different research philosophies.