Reasons for and costs of hospitalization for pediatric asthma: a prospective 1-year follow-up in a population-based setting

The aims of this study were to examine the frequency of, and the reasons for, emergency hospitalization for asthma among children. In addition, the costs of hospital treatment, preventive medication, and productivity losses of the caregivers were evaluated in a population-based setting during 1 year. Data on purchases of regular asthma medication were obtained from the Social Insurance Institution. In total, 106 (2.3/1000) children aged up to 15 years were admitted 136 times for asthma exacerbation to the Kuopio University Hospital in 1998. This represented approximately 5% of all children with asthma in the area. The trigger for the exacerbation was respiratory infection in 63% of the episodes, allergen exposure in 24%, and unknown in 13%. The age-adjusted risk for admittance was 5.3% in children on inhaled steroids, 5.8% in those on cromones, and 7.9% in those with no regular medication for asthma. The mean direct cost for an admission was $1,209 (median $908; range $454-6,812) and the indirect cost was $358 ($316; $253-1,139). The cost of regular medication for asthma was, on average, $272 per admitted child on maintenance. The annual total cost as a result of asthma rose eight-fold if a child on regular medication was admitted for asthma.

Hyperbaric oxygen therapy in acute necrotizing infections. With a special reference to the effects on tissue gas tensions

Clostridial gas gangrene and perineal necrotizing fasciitis or Fournier's gangrene are rare but serious infections with an acute onset, rapid progression, systemic toxemia and a high mortality rate. The aim of this study was to investigate the efficacy of surgery, antibiotic treatment, surgical intensive care and in particular the role of hyperbaric oxygen (HBO) in the management of these infections. An experimental rat model was used to investigate the possibilities for measuring tissue oxygen and carbon dioxide tensions during hyperbaric oxygen treatment. In addition to this preliminary experimental study, Silastic tube tonometer and capillary sampling techniques were tested to measure the effect of hyperbaric oxygen treatment on subcutaneous oxygen and carbon dioxide tensions in patients with necrotizing fasciitis and healthy controls. Between January 1971 and April 1997, 53 patients with Clostridial gas gangrene were treated in the Department of Surgery, University of Turku. The patients underwent surgical debridement, broad spectrum antibiotic therapy and a series of hyperbaric oxygen treatments at 2.5 atmospheres absolute pressure (ATA). Twelve patients died (22.6%). Hyperbaric oxygen therapy in gas gangrene seems to be life-, limb- and tissue saving. Early diagnosis remains essential. Patient survival can be improved if the disease is recognized early and appropriate therapy instituted promptly. Between February 1971 and September 1996, 33 patients with perineal necrotizing fasciitis were treated in the Department of Surgery, University of Turku. The management included surgical debridement of the necrotic tissue with incisions and drainage of the involved areas, antibiotic therapy, hyperbaric oxygen treatment at 2.5 ATA pressure and surgical intensive care. Three patients died giving a mortality rate of 9.1%. The survivors received hyperbaric oxygen therapy for 2-12 times. Our results indicate that hyperbaric oxygenation is an important therapeutic adjunct in the treatment of Fournier's gangrene. Electrical equipment should not be used unsheltered in a hyperbaric chamber due to the increased risk of fire. The subcutaneous tissue gas tensions of rats were therefore measured using a subcutaneously implanted Silastic tube tonometer and a capillary sampling technique. The method was succesfully adapted to hyperbaric conditions. The subcutaneous oxygen tension levels increased five fold and the carbon dioxide tension levels two fold compared to intial levels. The PO2 and PCO2 of subcutaneous tissue and arterial blood were measured directly in six patients with necrotizing fasciitis and three healthy volunteers in normobaric conditions and during hyperbaric oxygen exposure at 2.5 ATA pressure. The measurements were carried out in healthy tissue and at the same time in the vicinity of the infected area of the patients. During HBO at 2.5 ATA subcutaneous oxygen tensions increased several fold from baseline values and carbon dioxide tensions also increased, but to a lesser degree in both healthy and infected tissues. When examining the subcutaneous PO2 levels measured from patients with necrotizing fasciitis, the PO2 was regularly higher in the vicinity of the infected area than in healthy tissue. In general, HBO treatment resulted in a marked increase in tissue oxygenation in both healthy tissue and in the vicinity of infected tissue. The hyperoxygenated tissue zone surrounding the infected area may be of significance in preventing the extension of invading microorganisms.

Diffusion and perfusion MR imaging in acute ischemic stroke: a comparison to SPECT

Diffusion (DWI) and perfusion (PWI) magnetic resonance imaging are relatively new methods of clinical imaging that probably can detect infarcted (DWI) and hypoperfused but still salvageable tissue (PWI) in acute human stroke. Forty-six acute stroke patients were imaged within 24 h of ictus, on the second day and after a week. SPECT was also performed on 23 patients in the acute phase (first or second day). On the first day, mean volume of hypoperfused tissue was significantly greater (P<0.001) than the infarcted tissue. The initial hypoperfusion volume correlated significantly with the final infarct size (P<0.001). The initial perfusion-diffusion mismatch correlated significantly with the infarct growth (P< or =0.001). The hypoperfusion volumes measured from PWI and SPECT correlated significantly (P<0.001). In conclusion, combined DWI and PWI is a powerful tool in evaluating the hemodynamics of acute ischemic stroke and can predict the infarct growth during 1 week.

Mechanical ventilation in children with severe asthma

Hospital admissions for childhood asthma have increased during the past few decades. The aim of this study was to describe the need for mechanical ventilation for severe asthma exacerbation in children in Finland from 1976 to 1995. We reviewed medical records and collected data retrospectively from all 5 university hospitals in Finland, thus covering the entire population of about 5 million. The endpoints selected were the number of admissions and readmissions leading to mechanical ventilation, duration of stay in the hospital, and mortality. Moreover, asthma medications prescribed prior to admission and administered in the intensive care unit (ICU), as well as the etiology of the exacerbation associated with mechanical ventilation were examined. Mechanical ventilation was required in 66 ICU admissions (59 patients). This constituted approximately 10% of all 632 admissions for acute asthma to an ICU. The number of admissions decreased from 1976 to 1995: 41 admissions between 1976 and 1985 vs. 25 admissions during the next 10-year period. The mean age at admission to the ICU was 3.6 years, and 46% of the patients were boys. Prior to the index admission, 70% of the patients had used asthma medication such as oral bronchodilator (50%), inhaled bronchodilator (20%), theophylline (38%), inhaled glucocorticoid (18%), oral glucocorticoid (5%), and cromoglycate (7%). Respiratory infection was by far the most common cause of all the exacerbations (61%), followed by food allergy (8%) and gastroesophageal reflux (3%). In 28% of cases the cause of the severe asthma exacerbation could not be identified. In the mechanically ventilated patients readmissions occurred 38 times between 1976 and 1985 vs. 5 times between 1986 and 1995. Five of the patients who received mechanical ventilation died, and in 3 of these patients asthma was the event causing death. In conclusion, there has been decrease in the number of first and repeat ICU admission for asthma requiring mechanical ventilation between 1970 and 1995. This trend occurred despite a simultaneous 5% yearly increase in hospital admissions for childhood asthma during these 2 decades.

Hyperbaric oxygen therapy in acute necrotizing infections with a special reference to the effects on tissue gas tensions

Clostridial gas gangrene and perineal necrotizing fasciitis or Fournier's gangrene are rare but serious infections with an acute onset, rapid progression, systemic toxemia and a high mortality rate. The aim of this study was to investigate the efficacy of surgery, antibiotic treatment, surgical intensive care and in particular the role of hyperbaric oxygen (HBO) in the management of these infections. An experimental rat model was used to investigate the possibilities for measuring tissue oxygen and carbon dioxide tensions during hyperbaric oxygen treatment. In addition to this preliminary experimental study, Silastic tube tonometer and capillary sampling techniques were tested to measure the effect of hyperbaric oxygen treatment on subcutaneous oxygen and carbon dioxide tensions in patients with necrotizing fasciitis and healthy controls. Between January 1971 and April 1997, 53 patients with Clostridial gas gangrene were treated in the Department of Surgery, University of Turku. The patients underwent surgical debridement, broad spectrum antibiotic therapy and a series of hyperbaric oxygen treatments at 2.5 atmospheres absolute pressure (ATA). Twelve patients died (22.6%). Hyperbaric oxygen therapy in gas gangrene seems to be life-, limb- and tissue saving. Early diagnosis remains essential. Patient survival can be improved if the disease is recognized early and appropriate therapy instituted promptly. Between February 1971 and September 1996, 33 patients with perineal necrotizing fasciitis were treated in the Department of Surgery, University of Turku. The management included surgical debridement of the necrotic tissue with incisions and drainage of the involved areas, antibiotic therapy, hyperbaric oxygen treatment at 2.5 ATA pressure and surgical intensive care. Three patients died giving a mortality rate of 9.1%. The survivors received hyperbaric oxygen therapy for 2-12 times. Our results indicate that hyperbaric oxygenation is an important therapeutic adjunct in the treatment of Fournier's gangrene. Electrical equipment should not be used unsheltered in a hyperbaric chamber due to the increased risk of fire. The subcutaneous tissue gas tensions of rats were therefore measured using a subcutaneously implanted Silastic tube tonometer and a capillary sampling technique. The method was successfully adapted to hyperbaric conditions. The subcutaneous oxygen tension levels increased five fold and the carbon dioxide tension levels two fold compared to initial levels. The PO2 and PCO2 of subcutaneous tissue and arterial blood were measured directly in six patients with necrotizing fasciitis and three healthy volunteers in normobaric conditions and during hyperbaric oxygen exposure at 2.5 ATA pressure. The measurements were carried out in healthy tissue and at the same time in the vicinity of the infected area of the patients. During HBO at 2.5 ATA subcutaneous oxygen tensions increased several fold from baseline values and carbon dioxide tensions also increased, but to a lesser degree in both healthy and infected tissues. When examining the subcutaneous PO2 levels measured from patients with necrotizing fasciitis, the PO2 was regularly higher in the vicinity of the infected area than in healthy tissue. In general, HBO treatment resulted in a marked increase in tissue oxygenation in both healthy tissue and in the vicinity of infected tissue. The hyper-oxygenated tissue zone surrounding the infected area may be of significance in preventing the extension of invading microorganisms.

Predictors of asthma three years after hospital admission for wheezing in infancy

OBJECTIVE

To evaluate the influence of early antiinflammatory therapy in the development of asthma 3 years after hospitalization for wheezing in infancy. In addition, the effects of allergic sensitization and respiratory syncytial virus (RSV) infection on the development of asthma were investigated.

DESIGN AND SETTING

A randomized, controlled follow-up study in a university hospital that provides primary hospital care for all pediatric patients in a defined area.

PATIENTS

Eighty-nine infants under 2 years of age who had been hospitalized for infection associated with wheezing and followed up for 3 years.

INTERVENTION

Early antiinflammatory therapy was given for 16 weeks; 29 patients received cromolyn sodium and 31 received budesonide. Twenty-nine control patients received no therapy.

OUTCOME MEASURES

Clinical diagnosis of current asthma, defined as having at least 3 episodes of physician-diagnosed wheezing and either a wheezing episode during the preceding year or ongoing antiinflammatory medication for asthma.

RESULTS

Fourteen (48%) patients in the former cromolyn group, 15 (48%) in the former budesonide group, and 16 (55%) in the control group had current asthma. The significant predictors of asthma were age over 12 months (risk ratio [RR] 4.1; 95% confidence interval [CI] = 1.59-10.35), history of wheezing (RR 6.8; CI = 1.35-34.43), and atopic dermatitis on study entry (RR 3.4; CI = 1.17-9.39). Skin prick test positivity at the age of 16 months significantly predicted asthma (RR 9.5; CI = 2.45-36.72). In addition, all of the 18 (20%) children sensitized with furred pet developed asthma. RSV identification (RR 0.3; CI = 0.08-0.80) and early furred pet contact at home (RR 0.3; CI 0.10-0.79) were associated with the decreased occurrence of asthma.

CONCLUSIONS

Antiinflammatory therapy for 4 months has no influence on the occurrence of asthma 3 years after wheezing in infancy. Early sensitization to indoor allergens, especially to pets, and atopic dermatitis predict subsequent development of asthma. RSV infection in wheezing infants may have a better outcome than other infections.

Acute childhood asthma in Finland: a retrospective review of hospital admissions from 1976 to 1995

The prevalence of childhood asthma has increased markedly in many Western societies during recent decades. We wanted to study whether the incidence and severity of childhood asthma in Finland had changed during the time-period 1976-95. Hospital admission rates from 1976 to 1995 were obtained from the National Hospital Discharge Register and the individual intensive care unit (ICU) registers of the five university hospitals in Finland. The number and length of treatment periods for childhood asthma in all Finnish hospitals and at the ICUs of the five university hospitals were analyzed. The number of children receiving special reimbursement for asthma medication costs was obtained from the central register of the Social Insurance Institution. The data showed that during the time-period investigated, hospital admissions as a result of asthma had increased by 2.8-fold, but the mean length of hospital stay had more than halved (from 7.3 to 2.6 days). The increase in hospital admissions showed greatest significance in the 0-4-year age-group among both sexes (p <0.001). In contrast, a significant reduction in hospital admissions was found among the 10-14-year age-group (p <0.001). No discernible change in admission to ICUs was seen. During the same time-period, the number of children receiving special reimbursement for asthma medication costs increased 7.5-fold. Hence, a major increase has occurred in the number of children diagnosed with asthma that has not been paralleled by a proportionate increase in the number of hospital admissions. While the prevalence of mild and moderate asthma has increased, the occurrence of severe asthma has remained essentially unchanged.

Pregnancy outcome in carriers of fragile X

OBJECTIVE

To evaluate pregnancy outcome in women who are carriers of fragile X.

DESIGN

Cross-sectional case-control study.

SETTING

Department of Obstetrics and Gynaecology, Kuopio University Hospital, Finland.

SAMPLE

Sixty-three singleton pregnancies in carriers of fragile X who were referred for genetic counselling and prenatal diagnosis to Kuopio University Hospital.

METHODS

Logistic regression analysis was used to compare pregnancy outcome in women who are fragile X carrier with outcome of the general obstetric population.

RESULTS

Carriers of fragile X often experienced more bleeding in late pregnancy than did the reference group. Otherwise, the course and outcome of pregnancy were comparable in both groups.

CONCLUSION

Pregnancy outcome in women who are carriers of fragile X is favourable. There is no need to initiate special fetal monitoring because of the fragile X status of the woman.

Genetic evidence for somatic haploidization in developing fruit bodies of Armillaria tabescens

Armillaria spp. have vegetative hyphae with diploid uninucleate cells, but the fruit bodies of many species contain clamped dikaryotic hyphae. Earlier observations suggest that somatic haploidization takes place in developing fruit bodies. To verify this, a uninucleate diploid cell was isolated from each of the 49 mating combinations between single-spore isolates of Armillaria tabescens and they were fruited. Twenty-four isolates produced fruit bodies with at least a partially dikaryotic subhymenium. Dikaryotic hyphae were isolated from fruit-body primordia and homokaryons were obtained by micromanipulation or by protoplasting. Approximately half of the isolates proved to represent recombinant mating types in respect to parent homokaryons, and most of them contained recombinant haploid DNA, based on random-amplified microsatellite markers. The results show that the nuclei in dikaryotic hyphae found in fruit bodies result from somatic haploidization. The mechanism of haploidization remains unclear.

Tissue gas tensions in patients with necrotising fasciitis and healthy controls during treatment with hyperbaric oxygen: a clinical study

OBJECTIVE

To investigate the effect of hyperbaric oxygen (HBO) treatment on tissue oxygen and carbon dioxide tensions in patients with necrotising fasciitis and healthy volunteers.

DESIGN

Clinical study in patients and healthy controls.

SETTING

University hospital, Finland.

SUBJECTS

6 patients with necrotising fasciitis and 3 healthy volunteers.

INTERVENTIONS

Subcutaneous tissue PO2 and PCO2 tensions were measured directly in patients with necrotising fasciitis and in healthy volunteers during normobaric and hyperbaric conditions. Arterial blood PO2 and PCO2 tensions were measured only in the patients. Tissue gas tensions were measured with a Silastic tube tonometer implanted in the brachial subcutaneous tissue of both patients and controls as well as in the subcutaneous tissue of the patients in the immediate vicinity of the necrotising process. The diagnosis of necrotising fasciitis was made on the basis of the presence of typical clinical signs and symptoms, intraoperative findings, and microbiological observations.

MAIN OUTCOME MEASURES

Arterial and subcutaneous tissue PO2 and PCO2 tensions.

RESULTS

In patients with necrotising fasciitis the arterial PO2 rose about 7-fold whereas the arterial PCO2 increased only slightly during exposure to 2.5 absolute atmospheres (ATA) of oxygen. During HBO the subcutaneous tissue PO2 increased four to five fold from the baseline and CO2 tensions also increased, but to a lesser degree, in both healthy and infected tissues. In patients with necrotising fasciitis, the PO2 was higher, but not significantly so, in the vicinity of the infected area than in the healthy tissue.

CONCLUSION

Under hyperbaric conditions the subcutaneous PO2 in patients with necrotising fasciitis rose higher in the vicinity of the infected area than in the healthy tissue, which may be the result of vasodilatation and increased microcirculation induced by the inflammatory process associated with infection or it may be the result of decreased local tissue oxygen utilisation, or both. The tissue PCO2 values tended to rise during HBO probably from hypoventilation or reduced CO2 washout from tissue because venous blood haemoglobin was fully saturated with oxygen.

Subcutaneous tissue oxygen and carbon dioxide tensions during hyperbaric oxygenation: an experimental study in rats

OBJECTIVE

To investigate the response of subcutaneous tissue oxygen (O2) and carbon dioxide (CO2) tensions to hyperbaric oxygenation.

DESIGN

Experimental study.

SETTING

University hospital, Finland.

SUBJECTS

10 Wistar rats.

INTERVENTION

Subcutaneous tissue PO2 and PCO2 were directly measured with an implanted Silastic tube tonometer and capillary sampling technique while breathing air and exposed to hyperbaric oxygen (HBO) at 2.5 or 2.8 ATA pressure. Hyperbaric exposures were carried out in a large multiplace chamber pressurised with air.

MAIN OUTCOME MEASURES

Subcutaneous tissue PO2 and PCO2.

RESULTS

The mean subcutaneous PO2 rose from the baseline of 8 kPa (60 mmHg) to 16 kPa (112 mmHg) when rats breathed room air during pressurisation to 2.8 atm. When the rats breathed oxygen at 2.5 ATA the maximal mean tissue PO2 was four times higher than the mean starting value. During the HBO treatment at 2.8 ATA the tissue PO2 rose to a value about five times above baseline. The tissue PCO2 values almost doubled during the exposure to HBO at 2.5 ATA, probably because elimination of carbon dioxide was impaired.

CONCLUSION

Measurements of tissue PO2 and PCO2 with an implanted Silastic tonometer and a capillary sampling technique can successfully be adapted to hyperbaric conditions. The method yielded reproducible results and is applicable to clinical use in hyperbaric medicine.

Combined diffusion and perfusion MRI with correlation to single-photon emission CT in acute ischemic stroke. Ischemic penumbra predicts infarct growth

BACKGROUND AND PURPOSE

More effective imaging methods are needed to overcome the limitations of CT in the investigation of treatments for acute ischemic stroke. Diffusion-weighted MRI (DWI) is sensitive in detecting infarcted brain tissue, whereas perfusion-weighted MRI (PWI) can detect brain perfusion in the same imaging session. Combining these methods may help in identifying the ischemic penumbra, which is an important concept in the hemodynamics of acute stroke. The purpose of this study was to determine whether combined DWI and PWI in acute (<24 hours) ischemic stroke can predict infarct growth and final size.

METHODS

Forty-six patients with acute ischemic stroke underwent DWI and PWI on days 1, 2, and 8. No patient received thrombolysis. Twenty-three patients underwent single-photon emission CT in the acute phase. Lesion volumes were measured from DWI, SPECT, and maps of relative cerebral blood flow calculated from PWI.

RESULTS

The mean volume of infarcted tissue detected by DWI increased from 46.1 to 75.6 cm(3) between days 1 and 2 (P<0.001; n=46) and to 78.5 cm(3) after 1 week (P<0.001; n=42). The perfusion-diffusion mismatch correlated with infarct growth (r=0. 699, P<0.001). The volume of hypoperfusion on the initial PWI correlated with final infarct size (r=0.827, P<0.001). The hypoperfusion volumes detected by PWI and SPECT correlated significantly (r=0.824, P<0.001).

CONCLUSIONS

Combined DWI and PWI can predict infarct enlargement in acute stroke. PWI can detect hypoperfused brain tissue in good agreement with SPECT in acute stroke.

Management of clostridial gas gangrene and the role of hyperbaric oxygen

BACKGROUND AND AIMS

Clostridial gas gangrene is one of the most dreaded infections in surgery. The aim of this study was to investigate the efficacy of surgery, antibiotic treatment, surgical intensive care and especially the role of hyperbaric oxygen in the management of clostridial gas gangrene.

MATERIAL AND METHODS

53 patients, 42 of them submitted from other hospitals in Finland. After the diagnosis had been made the patients underwent surgical debridement, broad spectrum antibiotic therapy and a series of hyperbaric oxygen (HBO) treatments at 2.5 ATA pressure. The necrotic tissue was excised and incisions were made in the affected areas. Amputations were performed when necessary.

RESULTS

Twelve patients died (22.6%). Hyperbaric oxygen therapy decreased the systemic toxicity and prevented further extension of the infection thereby improving the overall outcome of the patients.

CONCLUSION

Hyperbaric oxygen therapy of gas gangrene seems to be life-, limb- and tissue saving. Early diagnosis remains essential. Patient survival can be improved if the disease is recognized early and appropriate therapy applied promptly. Surgical and antibiotic therapy as well as HBO treatment combined with surgical intensive care must be started as soon as possible.

Occupational exposure to chemical and biological agents in the nonproduction departments of pulp, paper, and paper product mills: an international study

As part of an international epidemiological study of workers in the pulp and paper industry, previously unpublished exposure measurements were assembled in a database. This article describes 7293 measurements in nonproduction departments from 147 mills in 11 countries. The greatest variety of agents was measured in the maintenance, construction, and cleaning department, where high exposures to asbestos, chromium [VI] compounds, copper, mercury in urine, nitrogen dioxide, ozone, styrene, sulfur dioxide, trichloroethylene, and welding fumes were observed. Measurements in the storage, yard, loading, and shipping department indicated high exposures to asbestos, carbon monoxide, fungal spores, nitrogen oxides, sulfur dioxide, and total dust. The steam and power generation department had high exposures to methyl mercaptan, silica, and total dust. Measurements in process and effluent water treatment, laboratory and research, engineering, and office, administration, and cafeteria areas had few elevated exposures. Throughout the nonproduction departments, measurements of pulp-production chemicals such as chlorine and sulfur compounds tended to be low, with many below detection limits. There were some problems with the available data; in particular, detection limits were often not specified, and the data tended to be clustered in such a way that sources of exposure variability could not be distinguished. Despite these problems, the data provide new insight into the exposures of nonproduction pulp and paper industry personnel.

Lung function in school-aged asthmatic children with inhaled cromoglycate, nedocromil and corticosteroid therapy

Two-thirds of the children with asthma in our area use cromones and only one-third steroids as the maintenance therapy. This study aimed to evaluate our treatment policy based on the international consensus. Peak expiratory flow (PEF), dynamic spirometry and bronchodilation test results were therefore collected in 195 school-aged patients who visited our outpatient clinic in 1995. Sixty-four children (33%) used cromoglycate, 86 (44%) nedocromil and 45 (23%) inhaled steroids. Twenty-five (12%) needed combination therapy, mainly with salmeterol. Lung function results were good, and there were no significant differences between the therapeutic groups irrespective of whether pre- or postbronchodilator values were considered. PEF was decreased in eight (4%), forced expiratory volume in one second (FEVI) in four (2%) and maximum mid-expiratory flow (MMEF) in 33 (17%) patients. At least one result was decreased in 39 (20%) cases, in most cases (77%) MMEF alone. Significant rises after salbutamol inhalations were observed in 17 (9%) in PEF, in two (1%) in FEV1 and 20 (10%) in MMEF values. Thus, the bronchodilation test was positive in 33 (17%) cases, and in 22 (11%) cases it was the only sign of bronchial obstruction. Over 70% of the children with asthma can be treated with cromones by a stepwise treatment modality. Inhaled steroids can be restricted to those not controllable by cromones. Lung function tests, including postbronchodilator values, should be part of the follow-up of continuous maintenance medication for asthma.

Hyperbaric oxygen in the treatment of Fournier's gangrene

OBJECTIVE

To investigate the efficacy of operation, antibiotic treatment, hyperbaric oxygen, and surgical intensive care in the management of Fournier's gangrene.

DESIGN

Retrospective study.

SETTING

University hospital, Finland.

SUBJECTS

33 patients, most of them referred from other hospitals.

INTERVENTION

Debridement, broad spectrum antibiotics, and hyperbaric oxygen (HBO) treatment at 2.5 atmospheres absolute pressure. Excision of necrotic tissue and incisions in the affected areas. Urinary and faecal diversions when necessary.

MAIN OUTCOME MEASURES

Morbidity and mortality.

RESULTS

Only three patients died (9%). Hyperbaric oxygen reduced systemic toxicity, prevented extension of the necrotising infection, and increased demarcation, thereby improving the overall outcome.

CONCLUSION

To reduce mortality and morbidity, effective treatment of Fournier's gangrene should be started promptly. Debridement and antibiotics combined with surgical intensive care must be started as soon as possible. Hyperbaric oxygen is both life and tissue saving. It is an important adjunct that prevents extension of necrosis and reduces systemic toxicity.

Accuracy and precision of clinical estimation of leg length inequality and lumbar scoliosis: comparison of clinical and radiological measurements

The results of 196 clinical determinations of leg length inequality and postural pelvic tilt scoliosis in 21 patients were analysed and compared with reliable radiological measurements. Clinical methods proved to be inaccurate and highly imprecise, the observer error being +/- 8.6 mm for direct and +/- 7.5 mm for indirect measurement of leg length inequality, and +/- 6.4 degrees for the estimation of postural lumbar scoliosis. More than half (53%) of the observations were erroneous when the criterion of leg length inequality was 5 mm. Failure to determine the presence or absence of length inequality of more than 5 mm occurred in 54 measurements (27% of the total). In 12% of the direct and in 13% of the indirect measurements, the observers erred in deciding which leg was longer; discrepancies occurred even when radiological reading gave a leg length inequality of as much as 25 mm.

Exposure to asbestos during brake maintenance of automotive vehicles by different methods

Asbestos concentrations were measured during the different operations of brake maintenance of passenger cars, trucks and buses in 24 Finnish workplaces. The estimated average asbestos exposure during the workday (8-hr time-weighted average) was 0.1-0.2 fibers/cm3 during brake repair of trucks or buses, and under 0.05 f/cm3 during repair of passenger car brakes when the background concentration was not included in the calculations. The background concentration was estimated to be less than 0.1 f/cm3. During brake maintenance of buses and trucks, heavy exposure, 0.3-125 (mean 56) f/cm3, was observed during machine grinding of new brake linings if local exhaust was not in use. Other short-term operations during which the concentration exceeded 1 f/cm3 were the cleaning of brakes with a brush, wet cloth or compressed air jet. During brake servicing of passenger cars, the concentration of asbestos exceeded 1 f/cm3 only during compressed air blowing without local exhaust. The different methods of decreasing the exposure and the risk of asbestos-related diseases among car mechanics are discussed.

Quantitative radioisotope measurement of duodenogastric reflux in patients with ulcer or gastrectomized for ulcer

In this work the duodenogastric reflux was quantified as the amount of radioactivity entering the stomach after an i.v. administration of 99mTc-HIDA in ulcer patients and in patients who had undergone BI gastrectomy. The results were compared with visual evidence of gastric activity in the gamma camera images and biochemical determination of gastric bile reflux. The method is useful in quantifying the reflux if the activity is above the background activity. It allows the determination of an upper limit for the reflux when the reflux is evident visually. Only two or three images are needed for the quantitation. No correlation was found between biochemical measurement of fasting bile reflux in the stomach and radioisotopic quantification.

Quantitative Radioisotope Measurement of Duodenogastric Reflux in Patients with Ulcer or Gastrectomized for Ulcer

In this work the duodenogastric reflux was quantified as the amount of radioactivity entering the stomach after an i.v. administration of 99mmTc-HIDA in ulcer patients and in patients who had undergone BI gastrectomy. The results were compared with visual evidence of gastric activity in the gamma camera images and biochemical determination of gastric bile reflux. The method is useful in quantifying the reflux if the activity is above the background activity. It allows the determination of an upper limit for the reflux when the reflux is evident visually. Only two or three images are needed for the quantitation. No correlation was found between biochemical measurement of fasting bile reflux in the stomach and radioisotopic quantification.