Simultaneous fracture of the ankle and disruption of the superior tibiofibular joint. A case report

We report a case of fracture-dislocation of the ankle occurring together with a disruption of the superior tibiofibular joint. The simultaneous occurrence of these two lesions does not seem to have been reported previously.

[Surgical treatment of lung cancer in Denmark in 1982-1986. Special attention to the surgical procedure and mortality]

The operative activity and hospital mortality for lung cancer in Denmark, were investigated for the five year period from 1982 to 1986. Of the 2,898 operations performed 38.3% were pneumonectomies, 34.2% lobectomies, 6.0% lesser resections (segmental or wedge) and 21.5% were exploratory thoracotomies. The total hospital mortality was 7.2% (208 patients). Following pneumonectomy, the hospital mortality was 11.2%, after lobectomy 3.5% (p less than 0.001). Lesser resections carried a 2.3% mortality, not statistically different from lobectomy. Exploratory thoracotomy was connected with a mortality of 7.2%. In patients under the age of 60 years the mortality was 4.7% and in patients at the age of 60 to 69 years 7.9% (p less than 0.01). Patients over 70 years carried a mortality of 9.7%, not statistically different from patients from 60 to 69 years. The hospital mortality was significantly higher in the nonspecialized departments.

IN CONCLUSION

Lung cancer is still increasing. Compared to the past the resectability rate is decreasing and hospital mortality is almost unchanged. To improve the results of efforts to increase the proportion of curable patients have to go hand in hand with efforts to reduce the numbers of exploratory thoracotomies and pneumonectomies as well as the number of operative and postoperative complications. Further centralization must be considered, in order to obtain better selectionscriteries and optimal treatment modalities per- and postoperatively.

[The usefulness of thallium-201 scintigraphy in the diagnosis of coronary disease]

Stress thallium scintigraphy was performed in 60 patients with chest pain of uncertain origin. Myocardial ischemia was identified in 91% of the 47 patients who had angiographically significant coronary artery stenoses. Sensitivity of thallium scintigraphy was highest in patients with stenosis in the left descending coronary artery (LAD); 91% of the patients had abnormal thallium as compared with 67% of the patients with normal LAD but significant stenoses in the circumflex artery and/or the right coronary artery. Perfusion defects in the circumflex in only 50% of the patients with multiple vessel disease. We conclude that stress thallium scintigraphy is a useful diagnostic procedure in patients with chest pain of uncertain origin and identifies the patients to be selected for coronary artery angiography.

Adenocarcinoma arising in a foregut cyst of the mediastinum

A case of malignant transformation in a mediastinal cyst of the esophageal reduplication type is presented. The cyst had been recognized 39 years previously, but remained asymptomatic until sudden growth occurred. It was resected totally from the esophagus and the patient recovered well. A review of the literature showed that malignancy in mediastinal foregut cysts is extremely rare.

Tooth displacement analysed on human autopsy material by means of a strain gauge technique

Tooth displacement was analysed on human autopsy material for various types of orthodontic force systems using an electronic strain gauge technique. Tooth movements were registered in two dimensions with low force clip gauges on three sections of the mandible, containing the first premolar and the first molar. The sensitivity was 0.1 microns when horizontal forces of 50, 100, and 150 cN were applied at different horizontal levels producing different M/F ratios. The relationship between a force system and the resulting tooth movement was described by the position of the centre of rotation, CR, and the angle of rotation. The centre of resistance was determined for the three autopsy specimens, and depended on tooth geometry, root length, and level of bony margin. Important differences in location were found. The dynamics of initial tooth movement were analysed within the first minute of load application. Force/displacement curves were generated to evaluate the behaviour of the periodontal ligament. There was a linear correlation between the two variables. Freezing the autopsy material some days before testing had no detectable effect. The results from measurements on human autopsy material were compared with previously derived in vivo measurements.

Inter- and intrasexual dimorphisms in the vocal control system of a teleost fish: motor axon number and size

In one species of vocalizing fish, the plainfin midshipman (Porichthys notatus), large, nest-guarding males ('type I') use striated muscles to produce acoustic communication signals that include short duration (less than 1 s) 'burps' important in agonistic encounters and long duration (in the order of minutes) 'hums' which function in attracting females to nest sites during the breeding season. Females, and a second group of smaller reproductively active males ('type II') that 'sneak' spawn, do not generate hums, although they produce burps. Differences in vocal behavior are paralled by a relative increase of 6-fold in the sonic muscle of type I males. Inter- and intrasexual dimorphisms in sonic muscle mass were matched by those in the cross-sectional area of sonic motor axons, but not by those in number of axons. Thus, axon size was 2- to 3-fold larger in type I males than in females, type II males, or juveniles, none of which differed significantly from each other. Axon number was similar between type I males and females of a similar body size, despite the extreme dimorphism in sonic muscle mass. Axon number, however, was slightly greater (0.1-fold) in type I males and females compared to the smaller-sized juveniles and type II males. Type II males, in comparison to the non-reproductive juvenile males, have gonads that are about 20-fold larger and produce mature sperm. Nevertheless, the two groups resemble each other in body and swimbladder size, as well as sonic motor axon size and number. This suggests that type II males represent a subset of juvenile males that undergo precocious gonadal hypertrophy and spermiogenesis, but retain juvenile-like nongonadal traits. The results are discussed within the context of the development of vertebrate motor systems as well as the evolution of alternative reproductive tactics among teleost fishes.

[Induction of labor. Prostaglandin E2 vaginal tablets compared with intravenous oxytocin for induction of labor in premature rupture of the membranes and immature cervix]

In a material of 88 patients with premature rupture of the membranes and unripe cervix, a comparative investigation was undertaken to compare the effects of prostaglandin E2 (PGE2) vaginal tablets and intravenous oxytocin on induction of labour. The patients were subdivided at random into two groups: 42 patients treatment with PGE2 and 46 treatment with intravenous oxytocin. The results did not reveal any significant differences in the numbers of successful inductions regardless of the Bishop score at the commencement of stimulation but the duration of induction was found to be briefer in the oxytocin group. No significant differences were observed in the numbers of instrumental interventions in the two groups nor in the frequencies of side effects and in the employment of analgesics. Treatment with PGE2 vaginal tablets is considered to be more acceptable by the patients and easier for the staff to use. The tablets were just as safe and reliable in use as intravenous oxytocin for induction of labour in cases of premature rupture of the membranes and Bishop scores less than 6, but the duration of induction was significantly longer.

A direct method for fast three-dimensional serial reconstruction

A method for accurate three-dimensional reconstruction of openly connected porous structures is described. The method is based on embedding of a specimen in a contrast coloured epoxy resin and serial sectioning in a standard hard tissue microtome. A PC-based image processing system is used for direct digitization of the cut surface, and by thresholding two-phase images are obtained. The process is fully automated, and about 170 sections can be produced, digitized, dichotomized, and stored per hour. As an example of its applications, the method is used on trabecular bone, which is an anisotropic porous structure.

Electronic determination of centres of rotation produced by orthodontic force systems

A strain gauge measurement device with low force clip gauges, for measurement of initial tooth displacement in two dimensions has been developed. An experimental model simulating a maxillary central incisor is loaded with different known and controlled force systems. The resulting tooth displacements are described by the position of the centre of rotation and the generated angle of rotation for the total tooth movement. The effect of a single force, a moment, and force-moment combinations producing different moment to force ratios were studied. From these results the required force system needed to produce tooth movements with different centres of rotation for a central incisor of average root length are calculated. Furthermore, the model allows us to measure the accuracy of the measuring device by comparing results to analytical and laser holographic data, obtained on similar models. Some preliminary measurements and results, using human autopsy material are presented.

[Treatment of esophageal achalasia using Heller's method]

The long-term results after Heller's myotomy for oesophageal achalasia were illustrated by questionnaire sent to 38 out of the original 47 patients submitted to operation during the ten-year period 1.7.1973-30.6.1983. Nine patients had died from other causes during the follow-op period. The minimum period of observation for the remaining patients was five years and the mean period of observation was 10.3 years. Thirty-six questionnaires were returned (95%). 75% of the patients were satisfied with the results of operation but only 25% were symptom-free. The commonest symptom was dysphagia (56%) followed by reflux problems (50%). Every third patient had discomfort from the scar. All of the 25% of the patients who were not satisfied with the result of operation had dysphagia. On the basis of these observations, the authors consider that Heller's myotomy should be reserved for patients on whom dilatation treatment has proved unsatisfactory.

Bennett's fracture

The relationship between the quality of reduction and the occurrence of arthritic changes, symptoms and disability was studied in 41 Bennett's fractures. Excellent position was obtained in five of nine fractures treated by closed reduction and plaster immobilisation, in four of six fractures treated by percutaneous K wire fixation and in 18 of 26 fractures treated by open reduction. After a median interval of 7.3 years, 15 of 18 reviewed patients with fractures healed in excellent position were free of symptoms, but this was so in only six of 13 fractures with residual displacement. The remainder had intermittent slight pain. Radiographic signs of arthritis was found in ten of 24 patients: three of 14 patients with excellent reduction and seven of ten patients with residual displacement.

Malignant melanoma. Changing trends in factors influencing metastasis-free survival from 1964 to 1982

Seven hundred fourteen patients with cutaneous melanoma in clinical Stage I treated between 1964 and 1982 were included in this study. In an analysis of metastasis-free survival, thickness of the tumor, ulceration, gender, epithelioid cells as predominant cells in the tumor, and localization of the tumor were found to be independent prognostic factors. In a time trends analysis, the distributions of three of the prognostic factors (thickness of the tumor, ulceration, and inflammatory cell infiltrate) were found to shift during the last decade in the direction of improved prognosis, indicating that tumors are detected earlier than before. The distributions of two other factors (cell type and location of the tumors) shifted in the direction of deteriorated prognosis, suggesting partly that the biologic nature of the disease may have changed and partly that other behavioral factors may have played a role.

[Sore throat. Rapid detection of beta hemolytic group A streptococci by a coagglutination method]

In Norway anually half a million consultations are for acute sore throat. The clinical differentiation between streptococcal and non-streptococcal infection remains poor. A reliable diagnosis of beta-hemolytic streptococcal infections requires a screening test. In a multicenter study from general practice the rapid test Phadirect Strep A was compared with cultivation at two microbiological laboratories. 257 patients were included and the prevalence of beta-hemolytic streptococci was 41.6%. The results of valid calculations were: Sensitivity 70-77%; Specificity 86-89%; Positive predictive value 74-82%; Negative predictive value 81-88%. The results were considered in relation to body temperature and signs of local infection in the throat. There was no correlation between clinical signs and occurrence of beta-hemolytic streptococci. The Phadirect Strep A test was acceptably sensitive and specific for use in general practice. The test is easy to perform, and the results are available after five minutes. The test seems to be useful, and is an improvement in the daily management of patients with acute throat infections, especially in relation to the question of whether or not to prescribe antibiotics.

[Utilization of medical services for children in an area of Copenhagen]

As part of the development of models for community services for children, the utilization of the medical services for children in a local area in Copenhagen viz the catchment region of the Osterbro Social Centre was reviewed. By means of contact investigations in the above mentioned region with the general practitioners and duty roster doctors in two selected weeks and by information from the Casualty Department Register in the University Hospital and from the National Danish Patient Register, the pattern of illness for children aged 0-14 years and utilization of medical services in the year 1986 was described. Utilization of casualty departments was uniform throughout childhood. In the course of one year, every third child, on an average, had had contact with a casualty department. This is in contrast with other sections of medical services where utilization decreases with increasing age of the child. The frequency of admission to hospital was high, particularly for the youngest children. The majority of all contacts were on account of infectious diseases. A community, multidisciplinary effort to reduce ill health is suggested to combat the many illnesses due to infection, the numerous contacts with doctors and hospital admission. Choice of doctor in cases of acute illness in children is discussed.

[An analysis of massive prescription of tranquilizers and hypnotics]

Investigation of the prescriptions for tranquilizers and hypnotics issued in a provincial Danish town with approximately 30,000 inhabitants, revealed that 12% of all users over 40 years had received massive quantities of tranquilizers and hypnotics within one month, viz more than 100 defined daily doses/user. Only four recipients of massive prescriptions were found in the age group 16-39 years. In the group of recipients of massive prescriptions over the age of 60 years, it was found that persons entitled to medicine free-of-charge comprised every third or forth user. Recipients of massive prescriptions over the age of 40 years did not differ as regards age and sex from recipients of ordinary quantities, viz less than or equal to 100 defined daily doses/user/month. Differences in the frequencies of prescription of massive quantities could be demonstrated between the various general practices. These differences could not be correlated with differences in the ages of the general practitioners, types of practice or sizes of practice. A series of prescribing habits on the part of the practitioner appear to be of particular significance for prescription of massive quantities of tranquillizers and hypnotics. These include; the decision to prescribe hypnotics, choice of hypnotic and prescription of several tranquillizers and/or hypnotics simultaneously.

[Prescription of tranquilizers and hypnotics in the municipality of Holbaek]

On the basis of an investigation of prescriptions of tranquillizers and hypnotics for individuals resident in the Municipality of Holbaek, a description was made of which tranquillizers and which hypnotics were prescribed and the quantities provided. 96% of the prescriptions were written by the general practitioners in the town. Only 2% of the patients had obtained medicine from various doctors. Benzodiazepine derivatives constituted 93% of all tranquilizers and 96% of the hypnotics prescribed. Diazepam, nitrazepam and triazolam were the preparations most frequently prescribed. Diazepam, flunitrazepam and the older hypnotics were prescribed in quantities which suggested that these preparations were preferred by chronic users with massive drug intake. The smallest portions available were employed for 17% of the prescriptions for tranquillizers and in 2% of the prescriptions for hypnotics. The favourite amount prescribed was 100 tablets. Where triazolam was concerned, strikingly high defined daily dosages were prescribed. As only brief or episodic use is rational, half of all the tranquilizers and four out of five prescriptions for hypnotics are considered unsuitable.

A case of squamous cell lung carcinoma with tetrasomy 7 and chromosome 1 C-band polymorphism

Hyperdiploidy was observed in about 20% of the metaphase cells from a short-term culture of a squamous cell carcinoma of the lung. C-, G-and R-banding of both tumour and lymphocyte preparations showed constitutional C-band abnormalities in both homologues of chromosome No. 1. Based on these banding studies, the tumour karyotype was determined as: 48, XY, inv(1)(pter----q11::q21----qter), -1, -11, +7, +7, +19, +del(1) (pter----q11::q21----qter).

Relationships between plasmids and phenotypes of presumptive strains of Vibrio anguillarum isolated from different fish species

On the basis of plasmid composition as well as serological and biochemical properties, 26 strains identified as Vibrio anguillarum isolated from diseased fish could be assigned to two different groups. Except for three reference strains, these++ strains were isolated from Norwegian fish. The four strains isolated from rainbow trout (Salmo gairdneri), the only strain isolated from char (Salvelinus alpinus), and three of six strains isolated from Atlantic salmon (Salmo salar) harbored a plasmid of 47 megadaltons (MDa). Restriction endonuclease analysis showed that this plasmid and the virulence plasmid pJM1, carried by V. anguillarum strain 775, were very similar but not identical. Strains harboring the 47-MDa plasmid had nearly identical biochemical properties and were serotype O1. Strains isolated from reared coastal cod (Gadus morhua), turbot (Scophthalmus maximus), halibut (Hippoglossus hippoglossus), free-living saithe (Pollachius virens), and partly from reared Atlantic salmon differed from strains harboring the 47-MDa virulence plasmid by not containing this plasmid, by having different biochemical traits, and by being serotype O2. Rainbow trout which were experimentally infected with a strain isolated from cod suffering from vibriosis developed clinical symptoms similar to those in cod but quite different from those usually seen in rainbow trout.

Virulence studies based on plasmid profiles of the fish pathogen Vibrio salmonicida

Strains of Vibrio salmonicida isolated from Atlantic salmon (Salmo salar) and rainbow trout (Salmo gairdneri) suffering from cold-water vibriosis could be divided on the basis of plasmid profiles into four different categories. Of 32 strains, 19% harbored three plasmids of 24, 3.4, and 26 megadaltons (MDa), 69% harbored the 24- and 3.4-MDa plasmids but not the 2.6-MDA plasmid, and 9% harbored only the 24-MDA plasmid. The fourth category, which consisted of only one strain, harbored a plasmid of 10 MDa. In spite of different plasmid patterns, the strains of V. salmonicida were very similar with respect to biochemical reactions. The one-third of the V. salmonicida strains which were serotyped were of the same type. The 50% lethal doses, which were determined by intraperitoneal injection, ranged from 4 x 106 to 1 x 108 CFU per fish.

Vitamin B-12 and folate function in chronic alcoholic men with peripheral neuropathy and encephalopathy

Forty-six male alcoholics hospitalized with polyneuropathy or intellectual impairment were studied after at least 2 wk of alcohol abstention. Neurological evaluation included neurophysiological examination of the sural nerve and tibial nerve, neurophysiological examinations, and CT-scanning of the brain. Alcohol and vitamin intakes were quantified by the interview method. Vitamin B-12 and folate status included examinations of peripheral blood and bone marrow aspirate, plasma vitamin B-12, plasma and erythrocyte folate, formiminoglutamic acid excretion test (FiGlu), methylmalonic acid excretion, and deoxyuridine suppression test (dU) on phytohemagglutinin-stimulated peripheral lymphocytes. The liver function was assessed by galactose elimination capacity and plasma clearance of antipyrine. There was no hematological sign of folate or vitamin B-12 deficiency. About 8% had low plasma folate, while neither erythrocyte folate nor plasma vitamin B-12 were decreased. However, half of the patients had functional folate deficiency as determined by abnormal FiGlu or dU. Compared to the remaining patients, those with abnormal FiGlu or dU had significantly more abnormal neurophysiological tests, and lower folate intake. There was no correlation between FiGlu or dU and the quantitative liver function tests. It is concluded that 1) folate deficiency may contribute to the development of alcoholic polyneuropathy, 2) the classical parameters for folate deficiency (blood concentrations, peripheral blood, and bone marrow examinations) are not reliable in diagnosing folate deficiency and 3) functional tests like FiGlu and dU are necessary to diagnose folate deficiency in alcoholics.