Finnish flow diverter study: 8 years of experience in the treatment of acutely ruptured intracranial aneurysms

Background

Flow diversion of acutely ruptured intracranial aneurysms (IAs) is controversial due to high treatment-related complication rates and a lack of supporting evidence. We present clinical and radiological results of the largest series to date.

Methods

This is a nationwide retrospective study of acutely ruptured IAs treated with flow diverters (FDs). The primary outcome was the modified Rankin Scale (mRS) score at the last available follow-up time. Secondary outcomes were treatment-related complications and the aneurysm occlusion rate.

Results

110 patients (64 females; mean age 55.7 years; range 12–82 years) with acutely ruptured IAs were treated with FDs between 2012 and 2020 in five centers. 70 acutely ruptured IAs (64%) were located in anterior circulation, and 47 acutely ruptured IAs (43%) were blister-like. A favorable functional outcome (mRS 0–2) was seen in 73% of patients (74/102). Treatment-related complications were seen in 45% of patients (n=49). Rebleeding was observed in 3 patients (3%). The data from radiological follow-ups were available for 80% of patients (n=88), and complete occlusion was seen in 90% of aneurysms (79/88). The data from clinical follow-ups were available for 93% of patients (n=102). The overall mortality rate was 18% (18/102).

Conclusions

FD treatment yields high occlusion for acutely ruptured IAs but is associated with a high risk of complications. Considering the high mortality rate of aneurysmal subarachnoid hemorrhage, the prevention of rebleeding is crucial. Thus, FD treatment may be justified as a last resort option.

Functional imaging with 11C-metomidate PET for subtype diagnosis in primary aldosteronism

OBJECTIVE

Endocrine Society guidelines recommend adrenal venous sampling (AVS) in primary aldosteronism (PA) if adrenalectomy is considered. We tested whether functional imaging of adrenal cortex with 11C-metomidate (11C-MTO) could offer a noninvasive alternative to AVS in the subtype classification of PA.

DESIGN

We prospectively recruited 58 patients with confirmed PA who were eligible for adrenal surgery.

METHODS

Subjects underwent AVS and 11C-MTO-PET without dexamethasone pretreatment in random order. The lateralization of 11C-MTO-PET and adrenal CT were compared with AVS in all subjects and in a prespecified adrenalectomy subgroup in which the diagnosis was confirmed with immunohistochemical staining for CYP11B2.

RESULTS

In the whole study population, the concordance of AVS and 11C-MTO-PET was 51% and did not differ from that of AVS and adrenal CT (53%). The concordance of AVS and 11C-MTO-PET was 55% in unilateral and 44% in bilateral PA. In receiver operating characteristics analysis, the maximum standardized uptake value ratio of 1.16 in 11C-MTO-PET had an AUC of 0.507 (P = n.s.) to predict allocation to adrenalectomy or medical therapy with sensitivity of 55% and specificity of 44%. In the prespecified adrenalectomy subgroup, AVS and 11C-MTO-PET were concordant in 10 of 19 subjects with CYP11B2-positive adenoma and in 6 of 10 with CYP11B2-positivity without an adenoma.

CONCLUSIONS

The concordance of 11C-MTO-PET with AVS was clinically suboptimal, and did not outperform adrenal CT. In a subgroup with CYP11B2-positive adenoma, 11C-MTO-PET identified 53% of cases. 11C-MTO-PET appeared to be inferior to AVS for subtype classification of PA.

Gendered Citizen Constructs in Beer Commercials as a Metatext of Alcohol Control Policies

This study examines gender constructs in advertising in European beer commercials ( N = 59). It employs a lens of “citizenship” for discerning techniques by which male and female realms are portrayed as nonrelated, competing, and of unequal worth. This lens provides an explanation for why the connotations are problematic from a public health perspective. The citizenship-related tensions that the commercials entailed concerned taking the lead versus being governed, being free versus being controlled, being seen as a threat versus being welcomed as a friend, and being worthy of solidarity versus being excluded from group bonding. The article argues that these tensions not only involve the ethical issue of encouraging the consumption of potentially harmful substances (alcohol) and reproducing repellent gender stereotypes. The controlling, moralizing, and dull female characters are construed as infringing on the knowledgeable, skillful, and free alcohol-consuming male citizens. Gender thus unfolds as a crucial dimension in the mediation of commercial views on the relationship between the consumer and the state in alcohol policy.

Chronic Infarcts Predict Poor Clinical Outcome in Mechanical Thrombectomy of Sexagenarian and Older Patients

BACKGROUND

The impact of lacunar and cortical chronic ischemic lesions (CILs) on the clinical outcome of mechanical thrombectomy (MT) has been little studied. Clinical trials suggest that older patients benefit from MT. We investigated the effect of CILs on the clinical outcome of sexagenarian and older patients with acute middle cerebral artery (MCA) or distal internal carotid artery (ICA) stroke who received MT to treat large-vessel occlusion (LVO).

METHODS

We prospectively collected the clinical and imaging data of 130 consecutive MT patients of which 68 met the inclusion criteria. We limited the analysis to sexagenarian and older subjects and occlusions no distal than the M2 segment. Baseline clinical, procedural and imaging variables, technical outcome, 24-hour imaging outcome, and the clinical outcome were recorded. Differences between patients with and without CILs were studied with appropriate statistical tests and binary logistic regression analysis.

RESULTS

Twenty-one patients (31%) had at least 1 CIL. Thirty-eight percent of patients with CIL(s) compared with 62% without (P = .06) experienced good clinical outcome (3-month modified Rankin Scale ≤ 2). A similar nonsignificant trend was seen when lacunar lesions, lesion multiplicity, and chronic white matter lesions were examined separately. Absence of CIL increased the odds of good clinical outcome 3.7-fold (95% confidence interval 1.0-10.7, P = .05) in logistic regression modeling.

CONCLUSIONS

Chronic cortical and lacunar infarcts in admission imaging are associated with poor clinical outcome in sexagenarian and older patients treated with MT for LVO of the MCA or distal ICA.

Internal Carotid Artery and the Proximal M1 Segment Are Optimal Targets for Mechanical Thrombectomy

Background and Purpose

Mechanical thrombectomy (MT) is an established treatment of acute anterior circulation stroke caused by large vessel occlusion (LVO). We compared the clinical outcome (3-month modified Rankin Scale, mRS) in hyperacute (<3h from the onset of symptoms) ischemic stroke between an MT and an intravenous thrombolysis (IVT) cohort in proximal (ICA and the proximal M1 segment of the middle cerebral artery) and distal (the distal M1 and the M2 segment) LVOs.

Methods

We prospectively reviewed 67 patients who underwent MT with newer-generation stent retrievers. The IVT cohort consisted of 98 patients who received IVT without MT. We recorded baseline clinical, procedural and imaging variables, technical outcome, 24-h imaging outcome, and the clinical outcome. Differences between the groups were studied with theoretically appropriate statistical tests and binary logistic regression analysis.

Results

The proportion of patients who had a proximal LVO and experienced good (mRS ≤2) or excellent (mRS ≤1) clinical outcome was significantly larger in the MT group (62 vs. 7%, p < 0.001; 47 vs. 3%, p < 0.001, respectively). In a regression model including relevant confounding variables, good clinical outcome was seen significantly more often among patients with proximal occlusions (OR = 6.0, CI 95% 1.9-18.3, p = 0.002). In a similar model, no statistically significant differences were observed in patients with more distal occlusions.

Conclusions

MT is superior to IVT in achieving good clinical outcome in hyperacute anterior circulation stroke in the most proximal occlusions (ICA and proximal M1 segment). In the distal M1 and M2 segments neither of these therapies clearly outperforms the other.

TREVO and Capture LP have equal technical success rates in mechanical thrombectomy of proximal and distal anterior circulation occlusions

PURPOSE

Mechanical thrombectomy (MT) is a proven method to treat large vessel occlusions in acute anterior circulation stroke. We compared the technical, imaging, and clinical outcomes of MT performed with either TREVO or Capture LP devices.

METHODS

There were 42 and 43 patients in the TREVO and Capture LP groups, respectively. Baseline variables, technical outcome (Thrombolysis In Cerebral Infarction, TICI), 24 hours imaging outcome, and 3-month clinical outcome (modified Rankin Scale, mRS) were prospectively recorded. The patients were stratified according to clot location, groups compared, and logistic regression models devised to study the effect of device selection on the clinical outcome.

RESULTS

The technical success rates were equal in both proximal (internal carotid artery and proximal M1 segment) and distal occlusions (distal M1 and M2 segments). The proportion of TICI 2b or 3 was 96% and 87% with TREVO and 87% and 89% with Capture LP (p=0.25 and p=0.80, respectively). Device selection did not significantly predict good clinical outcome (mRS ≤2) in either proximal or distal occlusions. In multivariate analysis, selecting Capture LP borderline significantly increased the odds of an excellent outcome close to sixfold both in proximal and distal occlusions (OR 6.7, 95% CI 0.82 to 53.7, p=0.08 and OR 5.7, 95% CI 0.88 to 37.8, p=0.07, respectively).

CONCLUSIONS

TREVO and Capture LP perform equally well in proximal and distal occlusions in the anterior circulation when technical and good clinical outcome are considered. Capture LP may have a small advantage in reaching mRS ≤1 at 3 months. However, this needs to be confirmed in a randomized study.

[Mechanical thrombectomy in the treatment of acute disturbance of cerebral circulation]

An essential aim of acute treatment of brain infarction is to restrict the size of the infarct by rapid and permanent recanalization of the obstructed artery. Thrombolytic therapy based on intravenous administration of alteplas (IV-tPA) exhibits the highest efficacy in the treatment of cerebral artery thrombi that are fairly small or intermediate in size. Intra-arterial thrombolysis (IA-tPA) and mechanical thrombectomy can be considered, if IV-tPA turns out to be ineffective or is contraindicated. In situations where the expected effect of IV-tPA:n is modest per se, mechanical thrombectomy should be taken into account as part of the therapeutic strategy.

The Silk Flow-Diverting Stent in the Endovascular Treatment of Complex Intracranial Aneurysms: Technical Aspects and Midterm Results in 24 Consecutive Patients

Background:

The flow-diverting stent is a new option in endovascular therapy specifically designed for the endovascular reconstruction of a segmentally diseased artery. The safety of flow-diverting stents is still equivocal.

Objective:

To evaluate the technical aspects, thromboembolic events, adjunctive therapies, and midterm results in patients with complex intracranial aneurysms treated with a flow-diverting stent (Silk; Balt Extrusion, Montmorency, France).

Methods:

We retrospectively examined angiographic images and clinical reports of 24 consecutive patients (29 stents) treated (n = 23) or attempted to treat (n = 1) with a flow-diverting device in 2 Finnish centers between March 2009 and October 2010.

Results:

The primary technical success rate was 67% (16/24). Adjunctive therapies were required in 6 (25%) patients, including 4 cases where intra-arterial abciximab was administered for the treatment of intraprocedural thromboembolic events. Technique-related complication rate and the 30-day mortality rate were each 4% (1/24). Follow-up imaging revealed 1 case of delayed in-stent thrombosis resulting in permanent disability of the patient, 1 asymptomatic occlusion, and 1 asymptomatic stenosis of the stented artery. Complete occlusion of the aneurysm with fully patent parent artery was observed in 16 of the 23 aneurysms (70%) where follow-up images were available.

Conclusion:

Many previously untreatable cerebral aneurysms may be successfully treated with the Silk flow-diverting stent, but the associated risk of thromboembolic events is justifiable only if conventional endovascular or surgical treatment options are not applicable. Perioperative thromboembolic events should be prepared for and treated without unnecessary delays because they frequently respond to adjunctive medical therapy.

[Chemoembolization of hepatocellular carcinoma with drug eluting beads]

Rates of hepatocellular carcinoma are increasing worldwide, and most patients can only be offered palliative treatment. Recent advancement is chemoembolization with drug eluting beads (DEB, Biocompatibles). We treated 12 patients with DEB. Tumour response was evaluated by computer tomography two months after each procedure and clinical data and survival of patients was collected from case reports. Tumour necrosis was found in nine, but not in three patients. Eight of twelve patients were alive after one year. Severe procedure-related complications were not seen. Our primary experience is that chemoembolization with drug eluting beads is an effective and safe procedure for treatment of hepatocellular carcinoma.

Serum tartrate-resistant acid phosphatase 5b in monitoring bisphosphonate treatment with clodronate: a comparison with urinary N-terminal telopeptide of type I collagen and serum type I procollagen amino-terminal propeptide

Osteoclastic tartrate-resistant acid phosphatase activity in serum (S-TRACP 5b) was measured in postmenopausal women ( n =59, mean age 56.1 years) with vertebral osteopenia before and during 2-year treatment with an 800-mg daily dose of clodronate, with a non-amino bisphosphonate. Changes in TRACP 5b were compared with those in urinary excretion of type I collagen amino-terminal telopeptide (U-NTX), corrected for creatinine excretion, a well-established marker of bone resorption, and to serum type I procollagen amino-terminal propeptide (S-PINP), a marker of bone formation. Marker changes 1 year after start of treatment were correlated with changes in bone mineral density (BMD). The least significant change (LSC) for each marker and BMD was calculated from values for subjects receiving placebo. Responders to treatment were those exhibiting a change larger than LSC. In response to clodronate treatment S-TRACP 5b (mean change up to -18%) decreased less than did U-NTX (up to -51%) or S-PINP (up to -46%). Marker changes correlated with changes in lumbar spine and trochanter BMD. The most efficient marker for finding responders to treatment was S-PINP, which changed more than the LSC (32%) in 72% of the subjects at the 1-year time point and in 79% at the 2-year time point. S-TRACP 5b change exceeded the LSC (27%) in 40% and 34% of the subjects at each time point, while U-NTX change exceeded the LSC (55%) in 55% and 40%, respectively. We conclude that, in terms of the proportion of subjects exhibiting any change exceeding the LSC, S-TRACP 5b did not appear to be superior to U-NTX and S-PINP in the follow-up of clodronate treatment. The reason may lie in the mechanism of action of clodronate, which rather than reducing the number of TRACP 5b-secreting osteoclasts, reduces the activity of bone proteolytic enzymes and thus the rate of bone organic matrix degradation. This is seen in decreased amounts of type I collagen breakdown products (U-NTX), and through coupling of bone resorption with bone formation, in a decrease in circulating levels of the marker that reflects new collagen formation (S-PINP).

Prevention of bone loss by clodronate in early postmenopausal women with vertebral osteopenia: a dose-finding study

This double-masked, placebo-controlled study was undertaken to determine the efficacy and safety of oral clodronate in the prevention of bone loss in early postmenopausal women with vertebral osteopenia. Altogether 610 women with a mean age of 53 years were recruited for the study. They were 1-5 years postmenopausal and their lumbar spine bone mineral density (BMD) was at least 1 standard deviation below the mean of premenopausal women ( T-score < or =-1). The subjects were randomized into five study groups to receive either placebo, clodronate 65 mg, 400 mg or 800 mg daily, or intermittent clodronate in 3 month cycles with 400 mg daily for 15 days followed with no treatment for 75 days for 3 years. One hundred and eighty-seven of 509 women who completed the primary study continued in the extension study of 2 years in which previous placebo users were switched to clodronate 800 mg daily, while previous users of 400 mg or 800 mg of clodronate used either placebo or 800 mg of clodronate daily. In the primary study clodronate was administered in the evening, and in the extension 1 h before breakfast on an empty stomach. In the primary study mean changes in lumbar spine BMD were -3.4% in the placebo group and +0.4% in 800 mg clodronate group [difference between groups at 3 years 3.8% (95% CI 2.7% to 4.9%, p<0.0001)], and in the trochanter area BMD -1.1% in the placebo group, and + 0.4% in the 800 mg clodronate group [difference between groups at 3 years 1.5% (95% CI 0.05% to 2.9%)]. During the extension study mean changes in lumbar spine BMD were +1.5% in the clodronate group and -0.2 % in the placebo group [difference between groups 1.7% (CI 0.4% to 3.0%, p = 0.010)] and in trochanter BMD were +2.5% in the clodronate group and no change in the placebo group [difference between groups 2.1% (CI 0.3% to 3.9%, p = 0.007)]. No statistically significant differences between the placebo and 800 mg clodronate groups were found in the femoral neck BMD. In the primary study the urinary excretion of type I collagen aminoterminal telopeptide (NTX) decreased by 44% ( p<0.0001 compared with placebo) and that of deoxypyridinoline by 18% ( p<0.0001) in the clodronate 800 mg group. In the extension study urinary NTX decreased by 51% ( p<0.0001) in those who were switched to 800 mg of clodronate and increased by 67% ( p<0.0001) in those who stopped using that dose. There was no difference in the frequency of gastrointestinal complaints between clodronate- and placebo-treated patients in the primary study, but they were more common among women who received clodronate in the extension phase. Clodronate in daily doses of 400-800 mg caused a slight elevation of aminotransferase levels, usually within the reference range. In bone biopsies no defect in mineralization was found. In conclusion, clodronate in a daily dose of 800 mg prevents early postmenopausal bone loss at the sites of the skeleton in which cancellous bone predominates. It effectively reduces bone resorption and bone turnover rate. Antifracture efficacy of clodronate remains to be established by prospective, placebo-controlled trials.

Expression of fibroblast growth factor (FGF)-8 isoforms and FGF receptors in human ovarian tumors

FGF-8 is a mitogenic growth factor, which is widely expressed during embryonic development but only at a very low level in adult tissues. Alternative splicing of the human FGF-8 gene potentially allows coding for 4 protein isoforms (a, b, e, f), which differ in their transforming capacity. The FGF-8 isoforms preferentially activate the receptors FGFR1IIIc, FGFR2IIIc, FGFR3IIIc and FGFR4. FGF-8 is over-expressed in human breast and prostate cancers. Expression has also been found in RT-PCR studies of human ovarian and testicular cancers. The present study was undertaken to examine which FGF-8 isoforms are expressed in ovarian cancer and whether FGF-8 receptors are also expressed. Specimens from 5 normal human ovaries and 51 ovarian tumors (1 benign tumor, 8 borderline malignancies, 42 malignant tumors of different histopathological types) were studied by RT-PCR and immunohistochemistry. FGF-8 isoform b was expressed in all ovarian tumors and in all 7 ovarian-cancer cell lines studied. Isoform a was co-expressed in 9 malignant ovarian tumors. FGF-8 mRNA was not detected by RT-PCR of 3 normal ovary samples. Immunohistochemical staining localized FGF-8 protein to cancer cells. In general, the increased intensity of FGF-8 staining was associated with loss of differentiation within the tumors (Bowker's test, p = 0.37). FGF-8 staining of surface epithelium observed on 2 normal ovaries was very faint. RT-PCR showed that FGFR1IIIc, FGFR2IIIc and FGFR4 were the FGF-8 receptors expressed in normal ovaries and in ovarian tumors. FGF-8 receptor immunoreactivity was preferentially found in normal ovary surface epithelium and tumor cells but also in some stromal cells. Collectively, our results show that ovarian cancers of a wide variety of histological types expressing receptors for FGF-8 have acquired the capacity of expressing FGF-8. This suggests that FGF-8 has an important role in ovarian tumorigenesis.

Clonality of Vibrio anguillarum strains isolated from fish from the Scandinavian countries, Sweden, Finland and Denmark

In order to investigate whether outbreaks of vibriosis in the Baltic region were caused by the spread of certain pathogenic clones, 291 Vibrio anguillarum isolates from Finland (n = 156), Sweden (n = 88) and Denmark (n = 47) were studied with respect to serogroup, ribotype, plasmid content, and biochemical phenotypes as expressed with the PhenePlate (PhP) typing system. For comparison, 54 V. anguillarum serogroup O1 from other countries worldwide were included. Most isolates from Finland, Sweden and Denmark belonged to serogroup O1 (255), followed by O2 (30). Four Finnish isolates cross-reacted strongly with antisera against two new serogroups VaNT2 and VaNT4, whereas two strains were non-typeable. The serogroup O1 isolates displayed ten different ribotype patterns, whereas the other strains were considerably more diverse with respect to ribotypes. Most of the O1 isolates carried the 67 kb virulence plasmid and a group of Finnish isolates, in addition, carried an 86 kb plasmid. Additional plasmids with molecular weights of 63, 76, 135 or 260-290 kb were found in single O1 isolates. With few exceptions, strains of serogroup O2 either had no plasmids or carried one or two small plasmids. PhenePlate typing revealed considerable diversity within the species, serogroup O1 being the most homogeneous. A few PhP types were dominant, whereas other types were observed only in one to four isolates. The prevalence of the different types changed significantly from one year to another but in Finland, one clonal lineage became increasingly important from 1992 (20% of isolates) to 1996 (80%). Remaining clones were mostly restricted to specific geographic areas. By cluster analysis, it was demonstrated that most of the isolates from Finland, Sweden and Denmark belonged to two clusters, and most of the strains from Southern Europe fell into two other, distinct clusters. Most isolates from the UK, North America, Chile and Tasmania grouped together in a distinct cluster. For the typing of V. anguillarum, O-serotyping should be the primary method. For isolates belonging to serogroups other than O1, plasmid profiling in combination with ribotyping gives a very good discrimination between strains, whereas for serogroup O1, another method is required. It is concluded that PhP typing is a tool that provides a good discrimination between O1 isolates.

Growth and weight gain in children with vesicoureteral reflux receiving medical versus surgical treatment: 10-year results of a prospective, randomized study. International Reflux Study in Children (European Branch)

In children with vesicoureteral reflux (VUR) and urinary tract infection, retardation of growth and weight gain at the time of diagnosis and catch-up growth during follow-up, mostly after operating for VUR, have been reported. A controlled trial comparing the effect on growth of surgical treatment and long-term prophylactic antibiotic treatment has not been reported previously. Between 1980 and 1985, 306 children younger than 11 y with non-obstructive grade III or IV VUR, with a history of symptomatic urinary tract infection, were randomly allocated to surgical or medical treatment. Of these, 236 were followed for 10 y, 118 randomized to surgical treatment (mean age at entry 3.5 +/- 2.3 y) and 118 to medical treatment (mean age at entry 3.8 +/- 2.5 y). All children had renal function and blood pressure in the normal range. Body height, measured at start and after 1, 5 and 10 y, was transformed to standard deviation score of height for chronological age (SDSH-CA) and body weight to percentage of ideal body weight for height (%IBW). The evolution of SDSH-CA and %IBW was similar in both treatment groups (SDSH-CA: surgical: start, 0.23 +/- 1.4; 10 y, 0.40 +/- 1.0; medical: start, 0.14 +/- 1.2; 10 y, 0.44 +/- 1.2; %IBW: surgical: start, 99 +/- 9%; 10 y, 107 +/- 14%; medical: start, 98 +/- 10%; 10 y, 105 +/- 16%). While children starting the study below the age of 3 y (SDSH-CA 0.55 +/- 1.34) started significantly taller than those older than 3 y (SDSH-CA -0.1 +/- 1.39), the young ones demonstrated a significant drop in SDSH-CA during the 1st year (SDSH-CA 0.19 +/- 1.23), which was regained up to the 10th year (SDSH-CA 0.6 +/- 1.13), and the older ones steadily gained height up to an SDSH-CA of 0.28 +/- 1.05 at 10 y. During all of the study period, treatment protocol, grade of VUR, renal parenchymal scars at entrance and urinary tract infections did not influence growth and weight gain. Age at entry and gender were the only significant correlates with growth and weight gain.

Detection of toxigenic Pasteurella multocida infections in swine herds by assaying antibodies in sow colostrum

Toxigenic Pasteurella multocida is the causative agent of progressive atrophic rhinitis (PAR), a serious respiratory infection of swine. Diagnosis of the disease has hitherto been based on clinical signs, pathologic findings, and subsequent isolation of the agent. The best Finnish pig breeding herds participating in the Finnish Pig Health Scheme have been surveyed for PAR since 1963, and the disease has been eradicated from these herds. In this study, a total of 5,650 colostrum samples from 188 Finnish Pig Health Scheme herds were analyzed with a new serologic screening method: an enzyme-linked immunosorbent assay (ELISA) able to detect antibodies to the toxin of P. multocida (PMT). Although the herds had been continuously controlled for PAR, 1 herd with PMT antibodies was found. The positive reactions in the ELISA were confirmed by isolating the causative organism. The origin of the infection also appeared to be obvious. The serologic ELISA is a suitable method for the detection and screening of toxigenic P. multocida-infected pig herds.

Antibodies against 12 serotypes of Actinobacillus pleuropneumoniae in finnish slaughter sows

To determine the prevalence of A. pleuropneumoniae serotypes in Finnish pig populations, 692 blood samples of sows were randomly collected from Finnish slaughterhouses. These were assayed with a direct ELISA for 12 Actinobacillus pleuropneumoniae serotypes. The specificity of the ELISA was tested using rabbit antisera against these serotypes. Cross-reactions were detected between serotypes 6 and 8 and between serotypes 1, 9 and 11, and serotype 5 antiserum reacted with serotype 6 antigen, but the other serotypes did not cross-react. When assaying the blood samples serotype 3 and 2 antibodies were found in 51% and 26% of samples, respectively. Other serotypes were found only in smaller numbers. Most of the samples, 61%, had antibodies towards some serotype of A. pleuropneumoniae. Antibodies towards serotypes 2 and 3 were found in pigs throughout Finland.

Effect of concomitant administration of clodronate and estramustine phosphate on their bioavailability in patients with metastasized prostate cancer

Estramustine phosphate is generally used as a second-line treatment in patients with advanced prostate cancer. The bone metastases due to the cancer are often treated simultaneously with clodronate in order to relieve the bone pain. Therefore, the interaction of clodronate (800 mg orally four times daily) and estramustine phosphate (280 mg orally twice daily) on their bioavailability was studied in twelve patients with prostate carcinoma and bone metastases. The drugs were first given separately, each to six patients, for five days, and then concomitantly for the same period. The bioavailabilities of the drugs were calculated on the last day of each treatment period. When clodronate was given alone, its concentrations in serum and AUC for one dose interval (6 hr) did not differ from those obtained with the drug given concomitantly with estramustine phosphate, nor did the combination of estramustine phosphate change the excretion of clodronate in urine. The serum concentrations of estramustine phosphate were elevated by about 80% when the drug was given together with clodronate. The AUC for one dose interval (12 hr) was also significantly higher for estramustine phosphate with clodronate than without clodronate. The urinary excretion of estrone, a major metabolite of estramustine phosphate, was also significantly higher after the admission with clodronate. The results suggest that clodronate increases the oral bioavailability of estramustine phosphate.

Actinobacillus pleuropneumoniae serotype-2 antibodies in sow colostrum in Finnish pig-health-scheme herds

A direct ELISA with phenol-extracted antigen for Actinobacillus pleuropneumoniae serotype 2 was developed. The test was specific when tested with rabbit antisera prepared against different A. pleuropneumoniae serotypes. It had better-than-moderate repeatability and it made a clear distinction between positive and negative samples. A total of 5477 colostrum samples from breeding sows from herds participating in the Finnish Pig-health Scheme were tested using the ELISA test. A total of 1307 positive samples were found in 129 out of 154 herds, thus indicating that most of the disease-control herds in Finland are infected with A. pleuropneumoniae serotype 2. These infections were almost entirely subclinical.

Surgical results in the International Reflux Study in Children (Europe)

In the European part of the International Reflux Study in Children (7 participating centers) 151 infants and children were randomly allocated to surgical treatment of primary grades III and IV vesicoureteral reflux. Reimplantation was performed unilaterally in 65 patients and bilaterally in 86, for a total of 237 ureters reimplanted. The patients were followed at regular intervals for 5 years. Reflux was absent in 231 of the reimplanted ureters (97.5%) at the end of 5 years. No patient underwent reoperation for reflux. In 10 ureters (4.2%, 10 patients) obstruction developed postoperatively and 7 needed reoperation. All reoperations were performed on the left side. Of the obstructed kidneys new scars developed in 6 during the 5-year followup. Including these cases, the number of new renal scars was equal in the surgical and medical groups (20 each). The number of pyelonephritic episodes during followup was significantly less in the surgical group (without chemoprophylaxis) than in the medical group (on chemoprophylaxis). No kidneys were lost and no child became hypertensive. If voiding cystourethrography and excretory urography were normal 6 months postoperatively, the reflux had been permanently eradicated and postoperative obstruction could be ruled out. In this study the patients who underwent reimplantation had a 74% (112 of 151) chance of an uncomplicated postoperative course (no persisting reflux, obstruction, pyelonephritis or severe renal damage).

Imipenem-cilastatin vs. tobramycin and metronidazole for appendicitis-related infections

The efficacy of imipenem-cilastatin was compared with that of tobramycin and metronidazole for the treatment of appendicitis-associated abdominal infections in children in an open, randomized trial. Two hundred eighteen patients between 2.5 and 16.8 years of age hospitalized for appendectomy because of suspected acute appendicitis were allocated to 5 treatment groups. The appendix was perforated in 54 (33.8%) of the 160 cases with appendicitis. All patients responded favorably to treatment. Infection in the wound occurred in 15 of 125 (12.0%) of those without preoperative antibiotic therapy and in 5 of 83 (6.0%) of those given imipenem preoperatively (P = 0.12; 95% confidence interval, -2.2 to 14.2%). C-reactive protein decreased significantly faster in those with perforated appendix treated with imipenem than in those treated with tobramycin and metronidazole (58.2 mg/liter vs. 89.4 mg/liter, P less than 0.05 on the third postoperative day). Imipenem-cilastatin was at least as effective and economically comparable as tobramycin and metronidazole for the treatment of appendicitis-associated infections in children.

Effect of oral clodronate on bone pain. A controlled study in patients with metastic prostatic cancer

Although osteosclerotic metastases are characteristic of prostatic carcinoma, bone resorption is also accelerated. Since clodronate inhibits bone resorption and relieves bone pain, we have given it to patients with painful bone disease from prostatic cancer after failure of hormonal therapy. All patients received estramustine phosphate orally. Simultaneously they were randomly allocated to clodronate (36) and placebo (39) groups. Clodronate was given by mouth. The dose was 3.2 g for the first month, thereafter 1.6 g. Pain relief was more distinct in the clodronate group where one third of patients were totally free of bone pain. The use of analgesics stopped in 38% of patients on clodronate and in 18% on placebo which effect probably belongs to estramustine phosphate. Serum calcium concentration decreased more markedly in the clodronate group. Clodronate dose of 3.2 g seemed to be more potent than that of 1.6 g. Side effects were uncommon and occurred equally in both groups. No significant differences were seen in median survival or survival rates between the groups.

Aetiological and precipitating factors for childhood enuresis

Aetiological factors for enuresis in 68 nightwetting (NW) and 73 day and mixed day and nightwetting (DW/MW) children were examined against a random sample of 142 control children drawn from a population of 3,375 seven-year-old children. Twenty-six variables concerning age, sex, social background, life changes, familial and perinatal history, development, growth, neurological damage, psychic structure and urinary tract disorders were included in the logistic regression analysis. The familial influence on enuresis was clearly seen in both nightwetters and daywetters. The NW children were further discriminated from the controls by items connected with delayed development, such as slower growth and poorer visuomotor and spatial perception. Marital separation or birth of a sibling were also found to be precipitating factors especially for nightwetters. The DW/MW children were discriminated from the controls by perinatal risk factors, signs of neurological dysfunction and smaller voided volume, and especially secondary daywetters by urinary tract infections. These models showed that there are similarities between nocturnal and diurnal enuresis, although there are still many differences and every individual case requires consideration of all these disposing factors.

Screening of urinary tract abnormalities among day and nightwetting children

In order to detect possible urinary tract abnormalities among wetters, assessments of previous history completed by ultrasonography of the urinary tract and uroflowmetry were obtained for 145 wetting children and a random sample of 156 sex-matched non-wetting children drawn from a population of 3,375 seven-year-olds. Ultrasonography revealed abnormalities, including both morphological ones and cases with incomplete bladder emptying, in 5 out of 73 nightwetters (6.8%, 95% confidence limit, CL, 1.1-12.6), 10 out of 72 day and day and nightwetters (hereafter daywetters) (13.9%, CL 5.9-21.9) and 4 controls (2.6%, CL 0.1-5.0), the figure for the daywetters differing significantly from that for the controls (p less than 0.01). A fractioned voiding curve was recognized in 1 nightwetter (1.4%, CL -1.3-4.0), 7 daywetters (9.7%, CL 2.9-16.6) and 7 controls (4.5%, CL 1.2-7.7) the difference between the nightwetters and daywetters being significant (p less than 0.05). Depending on the previous history and abnormal findings in ultrasonography or uroflowmetry, examinations were continued with intravenous pyelography, voiding cystography, cystoscopy and/or by cystometry. Finally, marked structural or functional disorders of the urinary tract were detected in 11 out of 72 daywetters (15.3%, CL 7.0-23.6), 1 out of 73 pure nightwetters and 1 out of 156 control children. It is concluded that imaging of the urinary tract is not necessary for pure nightwetters, while ultrasonography or uroflowmetry and more sophisticated radiological or urological methods should be focused on those children with daytime wetting and clinical symptoms of voiding disturbances.

Are cystometric and cystoscopic examinations of any value for disabled incontinent elderly?

According to assessments made by the personnel and patients' own reports 42% of males and 54% of females aged 65 years or over and attending the day hospital in the town of Tampere were found to be incontinent. Incontinence was related to the frequency of urinating in the daytime. All incontinent patients of the day hospital were referred to the urologist at the University Hospital. Only about one third of these patients participated in the cystometric and cystoscopic examinations. The main reasons for non-attendance were unwillingness of the patient, referral of the patient to another place of care and resistant urinary infection. Urinary retention and small bladder capacity were common findings by cystometry and cystoscopy. A surgical management was recommended to seven per cent and conservative management to 93% of the patients. The concordance rates between the classification of the incontinence by anamnestic questions and the classification made by the urologist were not very high: the overall percentage of agreement was 40%. It is concluded, that not all incontinent elderly patients should be sent for cystometric and cystoscopic examination. Residual urine should be measured, if urinary retention is thought to be associated with incontinence. Furthermore, the classification of incontinence cannot be made only by using anamnestic questions.

Intrarenal concentration-time profile of ampicillin after administration of bacampicillin to patients before nephrectomy

Nineteen patients with renal cancer who were to undergo nephrectomy received a single oral dose of bacampicillin 800 mg at approximately three (N = 5), six (N = 7), or nine (N = 7) hours before nephrectomy. Serum samples were taken at 30, 60, and 90 minutes after administration and at nephrectomy. Urine was collected immediately before operation. Samples of medulla and cortex tissues were immediately and carefully dissected from a healthy part of the removed kidney and homogenized with a buffer solution. All concentrations were determined by bioassay. Bacampicillin was well absorbed, with a mean +/- SD serum concentration of 16.0 +/- 11.4 mg/L at one hour. The concentrations in renal tissues were higher than the serum levels taken at the same time, and the highest concentrations were found in the urine. the mean ampicillin elimination half-life was approximately the same in the cortex, medulla, and urine, (2.7, 2.3, and 2.4 hr, respectively) but it was shorter in the serum (1.4 hr). Bacampicillin 800 mg produced concentrations in the renal tissues that were higher and more sustained than in the serum and were well above the minimum inhibitory concentrations for common urinary pathogens even ten hours after the dose.

Trimethoprim and methenamine hippurate. A new theoretical combination for the treatment of urinary tract infections

The antibacterial interaction of methenamine hippurate (MH) and trimethoprim (TMP) was tested in vitro in 3 different media: urine, brain-heart broth and Mueller-Hinton broth. MH and TMP were found to have a synergistic interaction in chequer-board titration against 11/11 bacteria in urine. Low concentrations of MH (1/2 MIC) had an additive or synergistic effect with TMP against 14/14 bacteria in brain-heart broth and 20/26 bacteria in Mueller-Hinton broth. In addition, the growth of bacteria in urine from healthy subjects treated with TMP (200 mg), MH (1000 mg) or a combination of TMP + MH (200 + 1000 mg) twice a day for 5 days was compared. A synergistic or additive effect of TMP and MH was found against 14/16 strains. Antagonistic interaction was not found in any of the tests. Preliminary pharmacokinetic studies with TMP and MH showed no marked interaction between the drugs. The hydrolysis of MH to formaldehyde was inversely related to urinary pH, and at pH 5 most of the formaldehyde released from MH in urine was generated within 3 h. The results suggest that the combination of TMP and MH may be more efficient than TMP alone in the treatment of urinary tract infections.

A prospective comparative study on serum acid phosphatases in the diagnostics of prostatic cancer

The diagnostic efficacy of two prostatic tumor markers, S-AP and S-PAP, was compared in a prospective clinical series consisting of 101 BPH- and 39 PCa-patients. As a predictor of prostatic cancer the specificity of S-AP (greater than or equal to 12 U/1) and S-PAP-RIA (greater than or equal to 4 micrograms/1) was 0.97 and 0.96, and the sensitivity 0.21 and 0.41, respectively. The S-PAP-RIA value of over 8 micrograms/1 always predicted an inoperable prostatic cancer (T4 or M1). The authors conclude that neither of these enzymes is suitable for the screening of early prostatic cancer, but the S-PAP-RIA might be a good predictor of inoperability of advanced prostatic cancer.

Splenogonadal fusion

A case of splenogonadal fusion of the discontinuous type in a 7-year-old boy is reported. The literature is reviewed and the common clinical features of the malformation are discussed. The condition should be considered in the differential diagnosis of scrotal tumours.

Combination of trimethoprim and methenamine hippurate in the treatment of acute urinary tract infections

A new antimicrobial drug combination of trimethoprim and methenamine hippurate (TMP + MH) at 2 different dosages (100 + 500 mg and 200 + 1000 mg b.i.d.) was compared by a random double-blind technique with plain TMP (200 mg b.i.d.) and TMP-sulfamethoxazole combination (160 mg + 800 mg b.i.d.). Each of the 4 test groups of 40-47 patients with acute UTI was treated for 2 weeks. The successful response in the test groups varied from 91 to 98% and no statistical difference could be found between the groups. The side-effects were least common in the group treated with the lower dose of TMP-MH combination.

Fine-structural evidence for vascular injury in patients with interstitial cystitis

Bladder vessel walls of 20 patients with interstitial cystitis were studied by the electron microscope. 14 (70%) had severe endothelial injury. 10 (50%) showed injured smooth muscle cells. Odd basement membrane proliferations and disruptions were seen. Clusters of microfibrils about 10 nm in diameter and numerous partially membrane-bound vesicles of 100-600 nm with granular or tiny vesicular content ("granulovesicular bodies") were also seen. Intercellular junctions of endothelial cells were open and there was emigration of polymorphonuclear leucocytes and platelets. The findings show pronounced vascular injury to have taken place, with neoformation of elastic tissue. It is suggested that the injury is immunologically mediated and that particularly those clusters of connective tissue microfibrils not yet covered by an amorphous elastin component may be involved in the pathogenesis of this disease.

Pharmacokinetics and clinical experiences of the combination sulfadiazine-trimethoprim in the short-term treatment of acute urinary tract infections

The pharmacokinetics of sulfadiazine (SD) combined in a small dose (250 mg) with trimethoprim (TMP, 160 mg) and given twice daily were studied in eight healthy subjects. Both drugs were rapidly absorbed from the gastrointestinal tract and their concentrations in serum as well as in urine could be considered high enough for the treatment of acute urinary tract infections (UTI). In none of the subjects did the concentration of SD in urine exceed the experimental limit established for crystallization of the drug. Serum half-lives of SD and TMP were 10.8 and 11.8 hrs, respectively. In microbiological assay synergistic interaction was found in human urine with both the combination of SD + TMP and SM (sulfamethoxazole) + TMP on all the tested strains of E. coli, Str. faecalis, Str. agalactiae, Klebsiella pneumoniae and Proteus mirabilis. A double-blind clinical trial was carried out with patients having acute UTI, using either the combination SD + TMP (250 mg + 160 mg) or the combination SM + TMP (800 mg + 160 mg) twice daily for one week. The results of the treatment were equally successful in both groups. Treatment failed in only 4 out of 85 cases, although in 12 cases the causative micro-organism was resistant in vitro to the combination of SM + TMP.