Recurrent pilonidal sinus after excision with closed or open treatment: final result of a randomised trial

OBJECTIVE

To find out the recurrence rate of chronic pilonidal sinus after excision and primary suture compared with open excision and healing by second intention.

DESIGN

Randomised trial.

SETTING

Teaching hospital, Norway.

SUBJECTS

120 Patients treated between 1987 and 1989.

INTERVENTIONS

60 Patients were treated by excision and primary suture and 60 by open excision. The median follow-up period was 4.2 years.

RESULTS

Recurrent pilonidal sinus was seen in six patients (10%) after primary suture compared with three patients (5%) after open treatment (p = 0.49); 57 (95%) and 55 (92%), respectively, were satisfied with the outcome of treatment at follow-up (p = 0.72).

CONCLUSION

Excision and primary suture compares favourably with open excision and healing by second intention in the treatment of chronic pilonidal sinus.

Clinicopathological features, survival and prognostic factors of primary central nervous system lymphomas: trends in incidence of primary central nervous system lymphomas and primary malignant brain tumors in a well-defined geographical area. Population-based data from the Danish Lymphoma Registry, LYFO, and the Danish Cancer Registry

It has been claimed that Primary Central Nervous System Lymphomas (PCNSL), a rare neoplasm accounting for only a small fraction of malignant brain tumors and extranodal non-Hodgkin lymphomas (NHL), occur with increasing frequency in immunologically normal as well as in immunocompromised individuals. In an attempt to characterize the clinicopathological features, outcome and prognostic factors of PCNSL we here report our experience in a large unselected series of patients from a well-defined region. In addition, we present data on trends in incidence of PCNSL and primary malignant brain tumors in a well-defined geographical area. In a Danish population-based NHL registry (LYFO) representing a population of 2.7 million all new cases of NHL were registered during the approximate 11-year period from 1st January 1983 to 31st May 1994. Incidence data of primary malignant tumors of the brain and central nervous system in western Denmark for the period 1971-1990 have been obtained from the Danish Cancer Registry. During the approximate 11-year period 3124 new cases of NHL were registered. Of these, 1152 (37%) were extranodal and 48 were non-AIDS related PCNSL accounting for 4.2% of extranodal NHL and 1.5% of all NHL, respectively. The average annual incidence rate of non-AIDS related PCNSL during the period was 1.56 cases per million population (age range: 15-85 yrs, median: 62 yrs, M/F ratio: 1). In a 23-year period there was no trend towards an increasing incidence of non-AIDS related PCNSL in a well-defined population. PCNSL accounted for 1.7% of all primary malignant brain tumors. Incidence of primary malignant brain tumors was stable, except for age ranges over 70 years. However, diagnostic artifacts might be responsible for this apparent increase. Histologically, 85% were high grade. Using the Kiel classification centroblastic diffuse (60%) and immunoblastic lymphoma (13%) were the most common subtypes. Forty-three patients had B-cell lymphoma and no T-cell lymphoma was detected. Forty-seven cases were diagnosed pre mortem. Treatment included surgical resection (26 patients), whole brain irradiation (WBRT) (43 patients) and chemotherapy (28 patients). Median survival for those receiving either WBRT or WBRT and chemotherapy was 8 months and 20 months, respectively (p = 0.78). Overall survival was 53%, 38% and 26% at 1, 2 and 5 years. Cox-regression analysis identified only one factor having independent impact on survival in PCNSL: performances score > or = 2 (p < 0.001, RR = 5.8).

[What happens to patients not granted disability pension?]

Subsequent to a recent (1991) narrowing of the medical legibility criteria for granting disability pensions in Norway, we wanted to follow up rejected applicants with regard to main sources of income. As setting were chosen five mainly rural municipalities on the North-West coast of Norway and the city of Trondheim. The study was carried out as a historic prospective study of a sample of rejected applicants for a disability pension, mainly based on follow-up data from local social security offices. Among a sample of 146 applicants rejected in 1990/91 and 1992, 143 (87 women and 56 men) were available for the analysis in March 1994. A rather stable 20% of the sample were occupationally active throughout three years of follow-up, this percentage being slightly higher among women than among men. In spite of the initial rejection, 25% had been granted a disability pension after two years. The rest received other kinds of public social support, or had left the labour market and had no social security support (mostly women).

[Surgical treatment of symptomatic pancreas divisum]

Pancreas divisum is found in 5% of the population. It is linked to three clinical entities; recurrent epigastric pain, and acute and chronic pancreatitis. The relation between chronic pancreatitis and pancreas divisum is, however, uncertain. Pancreas divisum is controversial as a cause of acute pancreatitis and abdominal pain. However, this association probably exists as surgical sphincteroplasty of the minor papilla alleviate symptoms in a high proportion of patients. We have treated two patients surgically. Patient 1 was hospitalized 11 times because of recurrent acute pancreatitis. Two and a half years after sphincteroplasty he has had no further attacks of abdominal pain. Patient 2 had had recurrent epigastric pain, mostly related to meals, since early childhood. Secretin stimulation initially showed normal pancreatic duct dilatation and emptying. After sphincteroplasty, and reoperation for stricture, she can eat normally without pain one year after the last operation. We conclude that in selected patients surgical treatment of symptomatic pancreas divisum is beneficial. Sphincteroplasty should be considered as treatment in patients with pancreas divisum and recurrent acute pancreatitis or pain, as long as other causes are excluded.

[Restriction of medical criteria for disability pensions. Effects on the local level]

The objective of the analysis presented in this article is to assess the impact on a local level of the revised eligibility criteria for disability pensions in Norway. The setting was five mainly rural municipalities on the North-West coast of Norway and the city of Trondheim. The project was carried out as a document analysis of a sample of rejected applications for disability pensions, as they appeared in social security records from 1990/91, before the revision to the law, and from 1992, after the revision. Among a total of 146 such cases, 118 (81%) were available for the document analysis. Some national statistics were used for purposes of comparison. The percentage of rejected applications increased in all municipalities for both men and women. The new regulations accounted for 25% of the rejected cases. 31% of the rejected applications from women were based on the narrower criteria, as opposed to 17% of the men's. The impacts of the 1991 regulations have been considerable. The increased rejection rate adds to a falling rate of applications for disability pensions since 1989/90, accounting for an almost 50% reduction in the yearly incidence rate of granted pensions in Norway from 1989 to 1993.

[Herniography. A 3-year material from a central hospital]

Herniography is the roentgenographic demonstration of hernias in the pelvic region by positive contrast peritoneography. The main indication for herniography is obscure groin pain and the suspicion of a hernia not visible at clinical examination. In a review of the last 75 patients from 1991-93, 30 hernias and 18 other findings were demonstrated. 13 patients have been operated till now, and their results are presented. Only 5.6% of Norwegian hospitals perform ten or more herniographies a year. We find herniography to be a reliable and safe diagnostic method that should receive more attention.

Patient characteristics and symptoms in chronic pilonidal sinus disease

Three hundred and twenty two patients with pilonidal sinus disease were studied to determine factors for the development and maintenance of the disease. A calculated incidence of the disease of 26 per 100,000 inhabitants was found. It occurred 2.2 times more often in men than in women. Age at presentation was 21 years for men and 19 for women. Patients had two years (median) disease history before being referred for treatment. A family history could be found in 38% of the patients. 50% had normal body weight, and 37% were overweight. Local trauma or irritation preceded the condition in 34%, and a sedentary occupation was reported by 44%. Male sex, adolescence or youth, and a familial disposition seem to be associated with the development of pilonidal sinus. Local trauma and overweight are the most important conditioning factors for development of symptomatic pilonidal sinus disease.

Bacteriology and complications of chronic pilonidal sinus treated with excision and primary suture

Two prospective studies were undertaken to examine the role of bacteria in the outcome after excision and primary suture for chronic pilonidal sinus disease. In the first study 52 consecutive patients were given cloxacillin as prophylaxis. In a second randomised study 51 patients were given 2 g cefoxitin intravenously (n = 25) or no prophylaxis (n = 26). From 49 out of 98 patients (50%) no microorganisms were isolated from sinuses preoperatively. Wound complications were observed postoperatively in 61% of the patients (63/103). A postoperative bacteriology sample was positive in 47 of 49 samples (96%). Preoperative presence of bacteria was not significantly associated with wound complications. Anaerobe isolates were present in 40% of patients preoperatively whereas aerobes were cultured in 43% postoperatively. After an observation period of 30-42 months, recurrences were 13% among the patients (7/52) who had been given cloxacillin. No recurrences were seen in the last study after an observation period of 18-30 months, for an overall 7% in both studies. We conclude that preoperative bacterial isolates, usually anaerobes, in chronic pilonidal sinuses do not influence the complication rate since bacterial isolates from infected wounds are mostly aerobes.

Treatment of blunt injury of the spleen: is there a place for mesh wrapping?

OBJECTIVE

To describe our experience of treatment of blunt injury to the spleen and to assess the contribution of observation and mesh wrapping to outcome.

DESIGN

Retrospective study.

SETTING

Teaching hospital, Norway.

SUBJECTS

50 consecutive patients with blunt injuries to the spleen treated between 1987 and 1992.

INTERVENTIONS

36 of the 50 were operated on (15 of whom had other injuries as well). 19 Underwent splenectomy and the others had various conservation measures including 8 who had absorbable mesh wrapping applied.

RESULTS

14 Patients were successfully treated by observation alone (mean 8 days, range 4-14). 24 were operated on within 3 hours, and 12 after a period of observation, by a total of 18 surgeons (9 of whom dealt with only one such injury each). Half the eight patients who had absorbable mesh applied developed complications (rebleeding and pleural effusion, n = 2 each). Two patients died: one was a baby with an associated severe head injury and one had cirrhosis of the liver and had initially refused treatment but was admitted in a critical condition and died of coagulopathy after splenectomy.

CONCLUSION

Conservation with absorbable mesh wrapping should be attempted more often, but experience is necessary to do it properly. Given a protocol with explicit criteria for operation, we suggest that haemodynamically stable patients who require little or no blood transfusion should be observed carefully in the first instance.

Effects of cooling and heating of the tooth on pulpal blood flow in man

Laser Doppler flowmetry (LDF) was used to study the changes in pulpal blood flow (PBF) evoked by application of cold or heat to the palatinal surfaces of teeth 11 or 21 in nine young subjects. Switching from a thermode temperature of 33 degrees C to 5 degrees C on average induced a slow decrease of PBF to about 80% of control, and also warming to 39 degrees C evoked a small reduction in most subjects. Interindividual differences were large, however, and both cooling and warming sometimes triggered a rise in PBF. In contrast, skin blood flow, as recorded with LDF in the forearm, invariably rose during warming and fell during local cooling. The results suggested a more complex interaction between local and nervously mediated effects of moderate changes in temperature in the tooth pulp than skin, and that the previously held view of cold and heat decreasing and increasing PBF, respectively, is wrong.

[Ureteral obstruction and hydronephrosis. A complication after aortic bypass surgery]

Ureteral obstruction is a rarely reported complication of reconstructive surgery on the aorta. It is often an asymptomatic condition seen several years after the initial operation. The true incidence is unknown, but is estimated to 1%. As delayed hydronephrosis appears to be a marker of present graft complications, the patients should be closely evaluated. Two cases of ureteral obstruction are described and the management of this complication is discussed.

Non-Hodgkin's lymphoma of the gastrointestinal tract: a population-based analysis of incidence, geographic distribution, clinicopathologic presentation features, and prognosis. Danish Lymphoma Study Group

PURPOSE

To evaluate incidence, time trends, geographic distribution, clinicopathologic presentation features, and prognostic factors for survival and relapse in gastrointestinal (GI) non-Hodgkin's lymphomas (NHLs).

PATIENTS AND METHODS

Over a 9-year period (1983 to 1991), 2,446 new NHL cases were recorded in a Danish population-based NHL registry (Danish Lymphoma Study Group [LYFO]). Of these, 306 (12.5%) were GI NHL (175 gastric, 109 intestinal, and 22 both sites). LYFO registry data were used for incidence rate (IR) assessment, and time-trend and geographic distribution analysis. Relative risk (RR) values for survival and relapse were identified by multivariate analysis.

RESULTS

The mean annual, age-standardized IRs for gastric and intestinal NHL were 0.71/10(5) and 0.48/10(5) per year, respectively. Age-specific IRs for both localizations showed an exponential increase as a function of age. Time-trend analysis for the period 1983 to 1991 showed stable IRs for both localizations. Intestinal NHL was more frequent in males (male-to-female ratio, 2.0 v 1.3), and had a higher occurrence of disseminated disease, constitutional symptoms, high-grade histology, and T-cell phenotype (10% v 2%). Gastric NHL had more low-grade cases (38% v 19%), and almost all were of the mucosa-associated lymphoid tissue (MALT) type. The cause-specific 5-year survival rate was 63% for gastric NHL and 49% for intestinal NHL. The Musshoff staging system was an excellent discriminator between truly localized (stage I and II1) and disseminated cases (stage II2 to IV), particularly for gastric NHL, for which no survival difference was found between surgically and conservatively stage localized cases.

CONCLUSION

(1) No increase in the incidence of GI NHL was found over a 9-year observation period; (2) nonrandom spatial distribution of new GI NHL cases was observed; (3) factors that significantly increased the risk of death in gastric cases were presence of B symptoms (RR = 3.3), clinical stage is more than II1 (RR = 3.0), age more than 72 years (RR = 2.4), and elevated serum lactate dehydrogenase (s-LDH) level (RR = 2.0); and factors that increased the risk of death in intestinal cases were presence of B symptoms (RR = 3.2), age more than 58 years (RR = 2.8), and clinical stage more than I (RR = 2.1); (4) factors that significantly increased the risk of relapse in gastric cases were male sex and no radiotherapy in primary treatment; and in intestinal cases were T-cell phenotype and no surgery in primary treatment; (5) surgical staging, as opposed to thorough noninvasive staging, did not improve staging accuracy and final outcome in localized gastric NHL.

[Breast cancer in the county of Viborg during 1983-1989. A quality control study]

The aim of the present study was to compare the quality of treatment for breast cancer in Viborg County to that provided in the rest of Denmark during the period 1983 to 1989. Women younger than 70 years of age with the diagnosis of invasive breast carcinoma and registered in the DBCG (Danish Breast Cancer Cooperative Group) were included, 435 from Viborg county and 11,434 from the rest of Denmark. No differences were found between the two patient-groups with regard to tumoursize, degree of anaplasia, number of axillary lymph nodes removed or number of positive lymph nodes. There were also no differences in overall survival or recurrence-free survival (RFS). It was concluded that the quality of treatment for breast cancer in Viborg County was equal to that in the rest of Denmark. Moreover, the magnitude of registration of breast cancer patients in the DBCG from Viborg county was evaluated. More than 90% of all breast cancer patients were registered.

T-cell receptor v-alpha and v-Beta gene usage in interleukin-2-cultured tumor-infiltrating lymphocytes from patients with breast-cancer

Tumor-infiltrating lymphocytes (TIL) are often found in malignant breast tumors, and have been claimed to be of prognostic value. It has been proposed that TIL may represent an enriched population of tumor-specific cytotoxic lymphocytes, reacting with antigenic determinants on the tumor cell surface through the T cell receptor (TCR) complex. We have studied the phenotype, cytotoxicity, and expression of TCR variable (V) alpha and beta chain on in vitro IL-2-cultured TIL isolated from primary malignant breast tumors from 11 patients. 10/11 cultures were dominated by CD4(+) (T-helper) cells. The different TIL cultures exhibited varying levels of cytotoxicity against the natural killer (NK)-sensitive cell line K562 and breast cancer cell line T47D. The level of clonality, as measured by PCR-based analyses of usage of the different V segments was low, as only a few tumors showed patterns of restricted V gene expression. The mean number of V alpha segments per TIL culture was higher than the number of V beta segments per culture. A significant negative correlation was observed between the number of CD4+ cells and the number of V beta segments per culture, and no other correlations between phenotypes and expression of any particular V segments were found. Neither was there any correlation between the expression of specific V alpha/V beta segments and cytotoxicity against allogeneic tumor cells.

Incidence, clinicopathological features and outcome of primary central nervous system lymphomas. Population-based data from a Danish lymphoma registry. Danish Lymphoma Study Group, LYFO

BACKGROUND

Primary Central Nervous System lymphomas (PCNSL), a rare neoplasm accounting for only a small fraction of malignant brain tumors and extranodal non-Hodgkin's lymphomas (NHL), seems to occur with increasing frequency in immunologically-normal as well as immunocompromised individuals. In an attempt to characterize the clinicopathological features, incidence rate and outcome of PCNSL, we here report our experience in a large unselected group of patients from a well-defined region.

PATIENTS AND METHODS

In a Danish population-based NHL registry (LYFO) representing a population of 2.7 million, all new cases of NHL were registered during the 10-year period from 1st January 1983 to 31st December 1992. The number of malignant brain tumors reported to the Danish Cancer Registry from the region covered by LYFO, during the 7-year period from 1st January 1983 to 31st December 1989, is compared to the number of PCNSL.

RESULTS

During the 10-year period 2687 new cases of NHL were registered. Of these, 1004 (37%) were extranodal and 42 were non-AIDS-related PCNSL, accounting for 4.2% of extranodal NHL and 1.6% of all NHL, respectively. The incidence rate for PCNSL during the ten-year period (age range: 21-85 yrs, median: 62 yrs, M/F ratio: 0.9) was 15.6 cases per million population. Eighteen and 24 cases were diagnosed during the first and the second 5-year period, respectively (p > 0.05). During the 7-year period 1866 primary malignant brain tumors were registered in the region covered by the LYFO study group. In the same period 30 cases of PCNSL were detected. Thus, PCNSL accounted for 1.6% of all primary malignant brain tumors diagnosed in Western Denmark. Histologically, 83% were high-grade. Using the Kiel classification centroblastic diffuse (62%) and immunoblastic lymphoma (12%) were the most common subtypes. Thirty-seven patients had B-cell lymphoma; no T-cell lymphomas were detected. Forty-one cases were diagnosed pre mortem. Treatment included surgical resection (23 patients), whole brain irradiation (WBRT) (37 patients) and chemotherapy (22 patients). Median survival for those receiving either WBRT or WBRT and chemotherapy was 7.5 months and 12 months, respectively (p > 0.05). Survival was 43.9%, 31.7% and 7.3% at 1, 2 and 5 years.

IL-2 promoter-driven lacZ expression as a monitoring tool for IL-2 expression in primary T cells of transgenic mice

A transgenic mouse system has been established to follow the pattern of IL-2 expression at the level of single T cells. This was achieved by introducing a human IL-2 promoter-driven reporter gene (Escherichia coli lacZ) into the germline of mice and monitoring its product, beta-galactosidase (beta-gal), by FACS analysis. Ex vivo experiments confirmed that the regulated expression of the transgene is comparable with that of the endogenous IL-2 gene. Transgene expression is inducible by mitogens, restricted to T cells, and diminished by immunosuppressive agents, such as cyclosporin A, at concentrations known to suppress IL-2 transcription. Depending on the mitogens used, 30-50% of peripheral T cells produced IL-2 with an asynchronous induction pattern, as measured by transgenic beta-gal activity. Both helper (CD4+CD8-) and cytotoxic T cells (CD4-CD8+) respond with comparable heterogenous expression levels but they show different frequencies of beta-gal production. Transgenic beta-gal-producing T cells were detectable as early as 2 h after mitogen stimulation. These cells represent a transitional IL-2 secreting, IL-2 receptor alpha-chain negative T cell population, which occurs in the autocrine process of T cell activation. Administration of staphylococcal enterotoxin A (SEA), a bacterial superantigen, resulted in a T cell specific (Thy-1.2) increase (2.5-fold) of reporter gene expression in vivo. In summary, we could demonstrate that IL-2 promoter-driven reporter gene expression in transgenic mice is a sensitive tool to characterize IL-2 expressing cells phenotypically.(ABSTRACT TRUNCATED AT 250 WORDS)

New serum markers for small-cell lung cancer. I. The ganglioside fucosyl-GM1

The ganglioside fucosyl-GM1 (FucGM1) has been suggested as a marker for small-cell lung cancer (SCLC). Immunohistochemical analyses have shown the expression of the ganglioside in tumors in 75 to 90% of patients with SCLC. We have demonstrated that the ganglioside is shedded from SCLC cells both in vitro and in vivo, and that the antigen can be detected in sera from SCLC patients by an immunochemical analysis. The FucGM1 antigen has recently been shown to act as a target for antibody-dependent cellular cytotoxicity. This may provide a rationale for developing immunotherapy against SCLC. We used an immunoassay based on the scintillation proximity assay to analyze the concentrations of FucGM1 in sera from 112 SCLC patients, 21 patients with non-SCLC, 4 patients with other cancer forms, and 20 healthy controls. Sera were collected at the time of diagnosis before initiation of chemotherapy. The expression of FucGM1 was related to age, sex, blood group of the patient, and to the stage of disease and organ site involvement of metastases. The sera of 50% of the patients with SCLC were positive for FucGM1, and 12 of 21 sera from non-SCLC patients were markedly elevated. In SCLC sera, the concentration of FucGM1 in positive sera ranged from 7 to more than 3000 ng/ml FucGM1. None of 20 controls were positive. FucGM1 correlated to organ site involvement of metastases (p = 0.0016). The ganglioside was detected both at significantly higher concentrations (p = 0.0005) and in significantly more patients (p = 0.0026) with metastases to both the liver and bone marrow, compared to patients with metastases to the liver only.(ABSTRACT TRUNCATED AT 250 WORDS)

Variations in family visiting policies in neonatal intensive care units in eleven EC countries. EC Study Group of Parental Involvement in Neonatal Care

The paper addresses the lack of information concerning parental visiting in neonatal intensive care units (NICU) across European Community (EC) countries. It reports on a study involving 11 EC countries and 38 units carried out under the auspices of a Concerted Action project. Information gathered from the 38 units yields data on the parental and family visiting policies. The study reveals a wide variation in the policies from considerable parental access to the infant in the NICU to restricted visiting. Policies concerned with unit facilities and unit support staff reflect the orientation of the overall unit policy with regard to visiting.

Incidence, presenting features and prognosis of low-grade B-cell non-Hodgkin's lymphomas. Population-based data from a Danish lymphoma registry

During the period January 1983 to January 1988 1597 newly diagnosed cases of non-Hodgkin's lymphoma (NHL) were included in a Western Danish population-based NHL registry. Of these, 31% (N = 496) were low-grade NHL (LG-NHL) consisting of (Kiel): 9% lymphocytic (LY), 27% lymphoplasmacytic/-cytoid (IC), 53% follicular centroblastic/-centrocytic (CB/CCf) and 11% unclassifiable low-grade. LG-NHL (age range: 26-94 yrs, median: 64 yrs; M/F ratio: 0.8) had an age-standardised incidence rate (IR) of 2.7/10(5)/yr. Age-specific IR's showed an age-related exponential rise in all subtypes except for CB/CCf. Compared with the intermediate (IG)- and high-grade (HG) group, LG-NHL had more female cases (M/F ratio: 0.79 vs. 1.2; p = 0.0002), a higher frequency of stage III-IV disease (66% vs. 53%; p < 0.00005) and of bone marrow involvement (39% vs. 19%; p < 0.00005). A later revision of all IC cases (N = 132) distinguished 79 non-polymorphic (ICnp) from 25 polymorphic (ICp) cases; 28 cases were differently classified. In 34 LG-NHL patients histologic transformation was verified: CB/CCf to CB diffuse (22 pts) and LY to immunoblastic or CB type (6 pts). The 7-yr survival for LG-NHL was 63% (IG: 48%, HG: 38%; p < 0.00005). A Cox-regression analysis identified the following adverse prognostic factors for survival in LG-NHL: age > 50 with a relative risk (RR) of 3.2, hepatic involvement (RR = 2.1), elevated s-LDH (RR = 1.9), B-symptoms (RR = 1.8) and IC histology (ICnp+ICp) (RR = 1.7).(ABSTRACT TRUNCATED AT 250 WORDS)

A rapid and simple method for counting crevicular polymorphonuclear leucocytes

The techniques presently available for counting crevicular polymorphonuclear leucocytes (CPMNs) require special equipment and are only semi-quantitative. The present new and simple method is based on the property that Durapore strips have to harvest a maximum number of crevicular cells and to release them when shaken in a suitable buffer. Durapore strips were inserted into periodontal crevices or pockets, shaken in PBS and the liberated PMNs counted in a Neubauer chamber. The validity of the method was ascertained in 5 experiments. First, it was shown that 90% of the harvested cells were released from Durapore strips after being shaken in buffer. Second, decreasing numbers of CPMNs were found when performing sequential samplings. Third, when counting CPMNs before and after therapy, a significant decrease in the number of cells was found. Fourth, we could confirm that sites with bleeding on probing did contain a much higher number of CPMNs as compared to non-bleeding sites. Finally, our counting technique confirmed that deeper pockets contain a significantly higher number of CPMNs.

Spontaneous liver hematomas induced by anti-coagulation therapy. A case report and review of the literature

We report on a case of massive bleeding into the liver parenchyma during treatment with a combination of warfarin sodium and trimethoprim-sulfamethoxazole. A fifty-five-year-old woman was put on long-term anticoagulant therapy with warfarin sodium. Two years later a course of trimethoprim-sulfamethoxazole was given to treat bronchitis. Following a bout of severe epigastric pain, ultrasonography and computed tomography (CT) then showed an enlarged liver containing several large hematomas. Subsequent CT scans, after tentative treatment only, showed regression of the liver hematomas, with almost complete disappearance after eight months. Bleeding complications and drug interactions related to this case are discussed, together with a review of the only six previous reports in the world literature of liver hematomas following anticoagulant therapy. Also mentioned are five patients in whom thrombolytic therapy gave rise to the same adverse reaction.

A study of cholinergic and beta-adrenergic components in the regulation of blood flow in the tooth pulp and gingiva in man

In 10 subjects, laser Doppler flowmetry was used to study whether cholinergic or beta-adrenergic pathways are involved in the control of tooth pulp blood flow (PBF) in response to isometric hand grip and the cold pressor test. We also examined if differences exist between the regulation of blood flow in the tooth pulp and the nearby gingiva (GBF). Isometric hand grip (35% of maximum force, 2 min) and the subsequent ischaemia (2 min) induced a brief rise in PBF and a more long-lasting rise in GBF. Atropine increased heart rate about by 40% and changed the pulpal response to a fall in flow, without altering gingival flow. Propranolol, causing a 20% reduction in heart rate, had no effect on either flow during the actual test, but induced a rise in GBF after the ischaemic period. The cold pressor test (2 min at 0.5 degrees C) resulted in a reduction in PBF and GBF, unaffected by the blocking drugs. With atropine, however, PBF increased immediately after this test. The relative changes in arterial pressure and heart rate were unaffected by the drugs. Our study has demonstrated the existence of cholinergic nervous vasodilation in vessels serving the tooth pulp. Non-adrenergic non-cholinergic mechanisms probably contribute to the evoked rise in GBF during exercise. Beta-adrenoceptors are involved in the control of GBF immediately after isometric exercise. While the two tests under control conditions evoked mostly parallel changes in PBF and GBF, the use of blocking agents showed that blood flow is controlled by different mechanisms in the two adjacent vascular beds.

Molecular mechanisms of immunosuppression by cyclosporins

Despite the successful clinical application of the immunosuppressive drug cyclosporin A (CsA, Sandimmun), its precise mechanism of action in the process of T cell activation remains elusive. CsA binds to the high-affinity cytosolic receptor cyclophilin whose peptidyl-prolyl cis-trans isomerase activity is inhibited upon binding. The linkage of this effect with the inhibition of the T cell receptor-mediated signal transduction pathway, which leads to a suppression of lymphokine gene transcription, is still unclear. We analyzed the relationship between cyclophilin-binding and immunosuppressive activity (e.g., effect on IL-2 transcription) of cyclosporin derivatives in vitro. The results show that binding to cyclophilin is required, but not sufficient for immunosuppression. Cyclosporin analogues which completely lack immunosuppressive activity but fully retained their cyclophilin-binding capacity antagonize the immunosuppressive activity of CsA. These derivatives inhibit the isomerase activity of cyclophilin, which clearly demonstrates that inhibition of the cyclophilin isomerase activity does not lead to immunosuppression. In analogy to the other immunosuppressants of microbial origin, FK-506 and rapamycin, a specific structure of the "effector" domain of CsA, which is unrelated to the cyclophilin-binding domain, determines the biological activity. In the nucleus, CsA interferes with the DNA-binding of inducible transcription factors to their respective DNA motifs within lymphokine promoters by affecting intracellular translocation of transcription factor subunits.

[Non-traumatic (spontaneous) splenic rupture]

Non-traumatic (spontaneous) rupture of the spleen is a rare condition. Predisposing factors such as haematological disease, malignant tumour, inflammatory disease, infection, connective tissue disease and miscellaneous disorders have been reported. This report describes two patients with ruptured spleens, one of whom used warfarin, the other had a ruptured haemangioma.