Thoracic actinomycosis

Nine cases of thoracic actinomycosis treated in the period 1966-1987 are reported. Three of the patients presented with a clinical picture of empyema and six were admitted for suspected primary pulmonary neoplasm. No case was correctly diagnosed preoperatively. The final diagnosis was based on direct microscopy (2) or culture (1) of drained pus in the empyema cases and on histologic examination of resected tissue in the others. In one case the correct diagnosis was missed when a palpable tumour mass was not extirpated at exploratory thoracotomy, and was made only when clinical deterioration necessitated a second operation. Good clinical results can be expected from surgical eradication of an intrathoracic focus of actinomycosis in conjunction with appropriate antibiotic therapy.

Spontaneous pneumothorax and fibrin glue sealant during thoracoscopy

The prophylactic treatment of the application of fibrin glue to the pulmonary surface during thoracoscopy in idiopathic spontaneous pneumothorax resulted in rapid and total pulmonary expansion in 33 of 35 patients. The 2 failures were due to apical cysts larger than 2 cm. The successfully treated patients were hospitalized for a median of 4 days (range 2-12). No complications were observed. All regained full working capacity within 1 month of discharge. Post-treatment X-ray examination of the chest was uniformly normal. During an observation time ranging from 7-24 months (median 12 months), 3 recurrences (9%) were seen at 7, 12, and 16 months, respectively. The treatment seems (1) to reduce the need for thoracotomy (2) to be associated with a high success rate, short and long-term, (3) to minimize the duration of hospital stay and (4) not to disturb the normal pleuro-pulmonary anatomy.

Nervous system damage and nutritional factors in chronic alcoholics

Dietary habits in 45 chronic alcoholics were assessed by the dietary history method, and plasma albumin and serum transferrin. These variables as well as clinical findings did not indicate general malnutrition, but a moderate deficiency in folate intake was found. There was no correlation between the nutritional variables and central and peripheral nervous system function investigated by neuroradiological, neuropsychological, and neurophysiological methods. Transketolase and thiamine-pyrophosphate effects were measured in a subgroup of alcoholics and compared to a control group. No differences were found and there was no correlation to central nervous system impairment. These findings do not support the hypothesis that nervous system damage found in chronic alcoholics is of nutritional etiology.

Sinus tarsi syndrome: presentation of seven cases and review of the literature

Seven cases with sinus tarsi syndrome are presented. The literature about the sinus tarsi syndrome is reviewed. A relationship between subtalar joint instability following lesion to the ligamentous structures in the sinus and canalis tarsi, and the sinus tarsi syndrome is discussed.

Thoraco-pleural actinomycosis presenting like diffuse pulmonary embolism

Actinomycosis is an uncommon infection. The regions mostly involved are the cervico fascial area, the thorax and the abdomen. The thoracic variety accounts for approximately 15% of the cases. Clinical pictures of pulmonary neoplasm, abscess, and empyema have been described. Misleading symptoms often delay the right diagnosis. The present study describes a case of actinomycosis with pleuro-pulmonary involvement. A 48-year woman had been well until two and a half years previously, when she developed symptoms suggestive of pneumonia. When referred to a medical clinic with thoracic pain and tiredness, pulmonary embolism was suspected. Inhalation and perfusion scintigraphy showed several perfusion defects. There were several relapses, with clinical pictures suggestive of pulmonary embolism, before an abscess in the left axilla appeared. Drained pus showed no growth of Actinomycetes. Correct diagnosis of the true cause was only possible by direct microscopy. Possible symptoms and the diagnostic difficulties when Actinomycetes is involved are discussed.

The Ottosson repair in lateral instability of the ankle

A follow-up study is presented of 27 patients with 29 ankles treated for disabling lateral instability by a modification of the Evans repair, previously described by Ottosson. The median follow-up period was 39 months. Excellent or good results were found in 93% of the ankles. We recommend this modification, as it is technically simple and efficient.

Detection of left ventricular ischemia during atrial pacing: simultaneous assessment by echocardiography and invasive hemodynamic measurements

The ability of cross-sectional echocardiography to detect myocardial ischemia induced by atrial pacing was assessed during cardiac catheterization in 11 patients with coronary arterial disease. Angina pectoris was precipitated in all patients with increase in left ventricular end-diastolic pressure after pacing by 5 +/- 6 (mean +/- standard deviation) mm Hg (P less than 0.01). Regional left ventricular dysfunction occurred during pacing in all patients as determined by quantitative echocardiographic assessment of wall motion. Simultaneously, systolic reduction in parasternal short-axis area decreased (from 42 +/- 13 to 28 +/- 9%, P less than 0.01) with concomitant decrease in ejection fraction as determined in the apical four-chamber view (from 49 +/- 5 to 40 +/- 8%, P less than 0.01). In conclusion, echocardiography may detect pacing-induced myocardial ischemia through detection of regional and global left ventricular dysfunction. Inadequate regional perfusion may be indicated by echocardiography even in patients without apparent evidence of ischemia as determined by invasive hemodynamic measurements.

Long-term observation following perforation and rupture of the esophagus

A follow-up study of 35 patients was performed 1.5 to 22 years after simple closure and drainage of the esophagus for nonmalignant intrathoracic perforation or rupture, with special attention to dysphagia. Of the seven patients with spontaneous rupture, only one required supplementary postoperative treatment, for severe reflux esophagitis. None of the eight patients with iatrogenic lesion and no prior esophageal disorder had any dysphagia postoperatively. Postoperative swallowing problems were absent in 13 of the 20 patients with perforation caused by examination or treatment of an already diseased esophagus. Four required repeated esophageal dilation and three underwent further surgery. Simple closure and drainage of nonmalignant intrathoracic perforation or rupture of the esophagus is concluded to be a safe procedure in regard to late postoperative dysphagia.

Therapeutic consequences of oesophageal function studies in patients with benign oesophageal disease

Evaluation of oesophageal function was performed in 91 patients referred to a specialized department of cardiothoracic surgery for surgical treatment of benign oesophageal disease. Standard manometry was used in addition to radiology and endoscopy, and in some patients, an acid perfusion test, an acid clearing test, and a prolonged monitoring of pH in the distal oesophagus were additionally performed. The aim of this study was to evaluate whether assessment of oesophageal function is needed in such a patient group, and whether the results of these investigations were taken into account when making the final decision for therapy. Eleven percent of the patients referred with a diagnosis of hiatal hernia or reflux had achalasia or oesophageal spasm. Nine percent of the patients referred for motility disorders had reflux-related disease. The referral diagnosis was changed to a diagnosis with a different therapeutic approach in 16% of the patients. In 33%, a diagnosis of disordered oesophageal function was considered either at referral or during the routine assessment for oesophageal disease. Eighty-one percent of the patients with achalasia were treated in accordance with the manometric results. In all cases where an anatomical diagnosis was replaced by a diagnosis of disordered function, the treatment was in accordance with the findings of the motility studies. None of the patients with oesophageal spasm were suspected of having this disease. It is concluded, that not only anatomical features, but also functional considerations have to be taken into account when selecting treatment for benign oesophageal disease. Treatment failure and unnecessary surgical intervention can thus be avoided.

Characterization of binding equilibrium data by a variety of fitted isotherms

Experimental binding equilibrium data, resulting from measurement of ligand binding to macromolecular carriers, are usually described by fitting of binding constants. These constants are often highly variable, as illustrated in the present paper by two examples, binding of salicylate to human serum albumin and of oxygen to hemoglobin. In order to avoid over-interpretation of binding constants it is pointed out that the best-fit solution, obtained by least-squares fitting, may be supplemented by several, e.g. thirty, acceptable solutions. It is further shown how the 30 sets of acceptable binding constants, plotted as Klotz' affinity profiles, can serve for evaluation of cooperative effects.

Brain microvascular function during cardiopulmonary bypass

Emboli in the brain microvasculature may inhibit brain activity during cardiopulmonary bypass. Such hypothetical blockade, if confirmed, may be responsible for the reduction of cerebral metabolic rate for glucose observed in animals subjected to cardiopulmonary bypass. In previous studies of cerebral blood flow during bypass, brain microcirculation was not evaluated. In the present study in animals (pigs), reduction of the number of perfused capillaries was estimated by measurements of the capillary diffusion capacity for hydrophilic tracers of low permeability. Capillary diffusion capacity, cerebral blood flow, and cerebral metabolic rate for glucose were measured simultaneously by the integral method, different tracers being used with different circulation times. In eight animals subjected to normothermic cardiopulmonary bypass, and seven subjected to hypothermic bypass, cerebral blood flow, cerebral metabolic rate for glucose, and capillary diffusion capacity decreased significantly: cerebral blood flow from 63 to 43 ml/100 gm/min in normothermia and to 34 ml/100 gm/min in hypothermia and cerebral metabolic rate for glucose from 43.0 to 23.0 mumol/100 gm/min in normothermia and to 14.1 mumol/100 gm/min in hypothermia. The capillary diffusion capacity declined markedly from 0.15 to 0.03 ml/100 gm/min in normothermia but only to 0.08 ml/100 gm/min in hypothermia. We conclude that the decrease of cerebral metabolic rate for glucose during normothermic cardiopulmonary bypass is caused by interruption of blood flow through a part of the capillary bed, possibly by microemboli, and that cerebral blood flow is an inadequate indicator of capillary blood flow. Further studies must clarify why normal microvascular function appears to be preserved during hypothermic cardiopulmonary bypass.

Sequence analysis of the Alcaligenes eutrophus chromosomally encoded ribulose bisphosphate carboxylase large and small subunit genes and their gene products

The nucleotide sequence of the chromosomally encoded ribulose bisphosphate carboxylase/oxygenase (RuBPCase) large (rbcL) and small (rbcS) subunit genes of the hydrogen bacterium Alcaligenes eutrophus ATCC 17707 was determined. We found that the two coding regions are separated by a 47-base-pair intergenic region, and both genes are preceded by plausible ribosome-binding sites. Cotranscription of the rbcL and rbcS genes has been demonstrated previously. The rbcL and rbcS genes encode polypeptides of 487 and 135 amino acids, respectively. Both genes exhibited similar codon usage which was highly biased and different from that of other organisms. The N-terminal amino acid sequence of both subunit proteins was determined by Edman degradation. No processing of the rbcS protein was detected, while the rbcL protein underwent a posttranslational loss of formylmethionyl. The A. eutrophus rbcL and rbcS proteins exhibited 56.8 to 58.3% and 35.6 to 38.5% amino acid sequence homology, respectively, with the corresponding proteins from cyanobacteria, eucaryotic algae, and plants. The A. eutrophus and Rhodospirillum rubrum rbcL proteins were only about 32% homologous. The N- and C-terminal sequences of both the rbcL and the rbcS proteins were among the most divergent regions. Known or proposed active site residues in other rbcL proteins, including Lys, His, Arg, and Asp residues, were conserved in the A. eutrophus enzyme. The A. eutrophus rbcS protein, like those of cyanobacteria, lacks a 12-residue internal sequence that is found in plant RuBPCase. Comparison of hydropathy profiles and secondary structure predictions by the method described by Chou and Fasman (P. Y. Chou and G. D. Fasman, Adv. Enzymol. 47:45-148, 1978) revealed striking similarities between A. eutrophus RuBPCase and other hexadecameric enzymes. This suggests that folding of the polypeptide chains is similar. The observed sequence homologies were consistent with the notion that both the rbcL and rbcS genes of the chemoautotroph A. eutrophus and the thus far characterized rbc genes of photosynthetic organisms have a common origin. This suggests that both subunit genes have a very ancient origin. The role of quaternary structure as a determinant of the rate of accepted amino acid substitution was examined. It is proposed that the sequence of the dimeric R. rubrum RuBPCase may be less conserved because there are fewer structural constraints for this RuBPCase than there are for hexadecameric enzymes.

Blood loss in transurethral prostatectomy: epidural versus general anaesthesia

The peroperative and postoperative blood loss was determined in 36 patients undergoing transurethral prostatectomy (TUR-P) using a photometric method. Seventeen patients were randomly allocated to epidural and 19 patients to general anaesthesia. No significant differences were found between the two groups in the total blood loss peroperatively, the corrected blood loss peroperatively (ml/g/min) or the blood loss postoperatively. The systolic blood pressures were equal in the two groups and no correlation between blood loss and blood pressure was demonstrated. The blood loss per g resected tissue was fairly constant and independent of prostatic weight, but bleeding per minute operating time increased significantly with prostatic size. As the total peroperative blood loss increases with operating time, rapid surgery is a possibility of reducing blood loss in TUR-P. Visual estimation of blood loss during TUR-P of larger glands was unreliable with underestimates of about 100 per cent in one third of the patients, when bleeding exceeded 400 ml. Therefore we recommend an accurate determination of blood loss during resection of larger glands.

A double-blind evaluation of electroconvulsive therapy in Parkinson's disease with "on-off" phenomena

Eleven patients with severe Parkinson's disease and on-off-phenomena were included in a controlled double-blind study on the effect of electroconvulsive therapy (ECT). Pharmacological treatment was optimally adjusted before the trial. The severity of extrapyramidal symptoms was measured before, during and after the treatment. The patients were randomly allocated into one group, receiving active ECT and another, receiving sham treatment. The patients given active ECT showed significantly (P less than 0.05) prolonged duration of "on"-phases after ECT, in comparison to the sham-treated group. When collecting data from the controlled part of the study and the subsequent with open administration of ECT, the treatment was in addition found to significantly decrease the time and number of steps required to walk 10 meters. Moreover it reduced the severity of parkinsonian symptoms according to the Webster scale. The improvement induced by ECT was generally short-lasting. Lumbar punctures were performed before and after ECT. The concentrations of monoamine metabolites in cerebrospinal fluid were not affected by the treatment. The results indicate that ECT has an antiparkinsonian effect which probably is mediated via changed responsiveness of dopamine receptors and that further improvement is possible in patients, therapy resistant to the presently available medication.

Genetic and physical mapping and expression in Pseudomonas aeruginosa of the chromosomally encoded ribulose bisphosphate carboxylase genes of Alcaligenes eutrophus

We have previously shown that functional ribulose bisphosphate carboxylase (RuBPCase, rbc) genes in Alcaligenes eutrophus ATCC 17707 are present both on the chromosome and on the indigenous plasmid pAE7. Here we demonstrate that the chromosomal rbc locus encodes both a large (rbcL)- and a small (rbcS)-subunit gene. A 2.3-kilobase DNA fragment containing both subunit genes was subcloned into the broad-host-range vector pRK310 to yield plasmid pAE312. This plasmid was transferred into Pseudomonas aeruginosa in which expression of both the rbcL and rbcS genes took place, as demonstrated by Western blot analysis. A high level of RuBPCase activity was observed for P. aeruginosa(pAE312), suggesting that assembly of the subunits took place. Plasmid pAE312 was mutagenized with Tn5 in Escherichia coli. Complementation of A. eutrophus RuBPCase structural gene mutants with pAE312 containing mapped Tn5 insertions allowed functional analysis of the rbc gene region. The polar effect of the Tn5 insertions suggested that the two subunit genes were cotranscribed in A. eutrophus, with rbcL located promoter proximal. Northern blot analysis of total RNA from P. aeruginosa(pAE312) confirmed cotranscription of the two subunit genes. DNA probes containing both the rbcL and rbcS genes, or fragments of each gene, all hybridized to a predominant transcript about 2.1-kilobases long. These observations indicate that the chromosomally encoded rbcL and rbcS genes of A. eutrophus constitute an operon.

Treatment of clavicular fractures. Figure-of-eight bandage versus a simple sling

Seventy-nine out-patients with midclavicular fractures were included in a prospective, randomized trial comparing treatment with a figure-of-eight bandage and a simple sling. Sixty-one patients completed the study and were reevaluated clinically and radiographically after 3 months. We found that treatment with a simple sling caused less discomfort and perhaps fewer complications than with the figure-of-eight bandage. The functional and cosmetic results of the two methods of treatment were identical and alignment of the healed fractures was unchanged from the initial displacement.

Teratomas of the mediastinum

Mediastinal teratomas are rare, constituting only 8-13% of tumours in this region. Teratomas often contain structures from all three germ layers, and 15-20% are malignant. A report is presented of eight patients operated on in 1978-1985 for mediastinal teratoma histologically classified as benign. Radical excision was performed in seven cases, but one tumour could not be radically removed because of infiltrative growth into vital structures, and the patient died 9 months postoperatively. In the other seven cases, including four with unusually rapid and dramatic tumour development, no signs of recurrence have appeared.

Bronchoplastic procedures for bronchial carcinoma

In a 22-year period from 1962 to 1984, 51 patients with malignant lung disease had a sleeve resection performed. In 33% of the patients, pneumonectomy was contraindicated because of limited lung function. The operative mortality was 8%. Six per cent of the patients developed complications after the operation. The 5-year survival of the total group of patients was 30%. Patients with lesions classified as stage 1 and stage 2 had the best prognosis, with a 5- and 10-year survival of 43.5% and 27%, respectively. In patients classified as stage 3 and stage 4, the 5- and 10-year survival was 20%. A postoperative measurement of regional ventilation and perfusion indicated that the function of the remaining lung was presumably undisturbed by the operation. Also, the vital capacity and FEV 1 were only minimally reduced as a result of the operation. The amount of functional lung tissue spared by the operation compared to pneumonectomy was estimated to 39%. Because of these functional results and the promising 5-year survival figures, we suggest that sleeve lobectomy should be the operation of choice for tumors localized to the upper lobe orifice involving the main bronchus.

Detection of glass foreign bodies by radiography

During a 14-month period patients with suspected glass foreign bodies were radiographically examined before removal of the glass. In 25 out of 26 patients the glass foreign bodies were detected. In 9 patients the glass foreign bodies had been overlooked on previous visits to doctors or hospitals, where the examination had been limited to inspection and sometimes probing of the wound. Almost all glass foreign bodies can be detected radiographically. With high-resolution or mammographic techniques even minute splinters may show up.

Left main or proximal left anterior descending coronary artery disease: detection by echocardiographic evaluation of interventricular septal function during exercise

Forty patients with coronary artery disease were studied prospectively to investigate whether stenosis of the left main (LMCA) or left anterior descending coronary artery, proximal to the first septal branch (proximal LAD), could be detected by M-mode echocardiography during exertion. The interventricular septum was visualized in 30 of the patients during bicycle exercise in the semisupine position, all with simultaneous occurrence of electrocardiographic evidence of myocardial ischaemia. Fifteen of these had LMCA or proximal LAD stenosis. Systolic motion and thickening of the septum decreased significantly from rest to peak exercise in patients with LMCA or proximal LAD disease while it increased in those without. The results suggest that M-mode echocardiography during exercise in patients with coronary artery disease might identify those with LMCA or proximal LAD stenosis.

Brain oedema and blood-brain barrier permeability in pulsatile and nonpulsatile cardiopulmonary bypass

In pigs subjected to pulsatile or nonpulsatile cardiopulmonary bypass (CPB) at normothermia for 3 hours, evaluation was made of water content in brain tissue (specific gravity measurements), blood-brain permeability to serum proteins (immunocytochemical demonstration of extravasated proteins, using peroxidase-antiperoxidase technique) and histopathology (paraffin sections). The specific gravity in parietal cortex was higher after pulsatile than after nonpulsatile CPB or in control pigs, the change corresponding to a 6.3% water increase. The tissue water content was unchanged in the internal capsule, basal ganglia and nucleus accumbens after CPB. The vascular permeability to serum proteins was unchanged after nonpulsatile CPB, but after pulsatile CPB minute foci of extravasated serum proteins appeared. All the animals showed dark neurons in cortical and subcortical regions, but these could have been artefacts in immersion-fixed tissue. There were no other signs of ischaemic tissue damage. The study indicated that cortical oedema may follow pulsatile CPB, the cause being altered permeability of the blood-brain barrier to serum proteins.