Implementation of an extracorporeal resuscitation (ECPR) program for out-of-hospital cardiac arrest in Stockholm, Sweden: Feasibility, safety, and outcome

Background

The aim of this study was to evaluate the implementation of a novel extra corporeal cardiopulmonary (ECPR) program in the greater Stockholm area with focus on feasibility, safety aspects and clinical outcomes.

Methods

Prospective observational study of ECPR program including patients with OHCA from January 2020 to December 2022, fulfilling ECPR criteria: age 18-65 years, initial shockable rhythm or pulseless electrical activity, witnessed arrest, bystander cardiopulmonary resuscitation and refractory arrest after three cycles of advance cardiac life support. The predefined time threshold from collapse to extracorporeal membrane oxygenation (ECMO) initiation was set at 60 min.

Results

We included 95 patients. Of these, 22/95 (23%) had return of spontaneous circulation before ECMO initiation, 39/95 (41%) were excluded for ECMO and 34/95 (36%) had ECMO initiated out of which 23 patients were admitted alive to the ICU. ECMO-initiation within 60 min was met in 9%. In 6 patients vascular access was complicated, 2 patients had severe bleeding at access site requiring intervention. Survival to discharge among all cases was 25% (24/95). Among patients admitted to ICU on ECMO 39% (9/23) survived to discharge, of these 78% had cerebral performance category scale score 1-2 within 12 months. 8 out of 9 survivors had time from OHCA to ECMO-initiation >60 min.

Conclusion

The implementation of an ECPR protocol was feasible without any major, unexpected safety aspects but did not meet the intended target time intervals. Despite this, survival rates were similar to previous studies although most survivors had >60 min to ECMO-initiation.

Comparison of preoxygenation using a tight facemask, humidified high-flow nasal oxygen and a standard nasal cannula - a volunteer, randomised, crossover study

BACKGROUND

Preoxygenation before anaesthesia induction is routinely performed via a tight-fitting facemask or humidified high-flow nasal oxygen. We hypothesised that effective preoxygenation, assessed by end-tidal oxygen (EtO 2 ) levels, can also be performed via a standard nasal cannula.

OBJECTIVE

This study compared the efficacy of preoxygenation between a traditional facemask, humidified high-flow nasal oxygen and a standard nasal cannula.

DESIGN

A volunteer, randomised, crossover study.

SETTING

Karolinska University Hospital, Stockholm. The study was conducted between 2 May and 31 May 2023.

PARTICIPANTS

Twenty cardiopulmonary healthy volunteers aged 25-65 years with a BMI <30.

INTERVENTIONS

Preoxygenation using a traditional facemask, humidified high-flow nasal oxygen and standard nasal cannula. Volunteers were preoxygenated with all three methods, at various flow rates (10-50 l min -1 ), with open and closed mouths and during vital capacity manoeuvres.

MAIN OUTCOME MEASURES

The study's primary outcome compared the efficacy after 3 min of preoxygenation, assessed by EtO 2 levels, between the three methods and various flow rates of preoxygenation.

RESULTS

Three methods generated higher EtO 2 levels than others: (i) facemask preoxygenation using normal breathing, (ii) humidified high-flow nasal oxygen, closed-mouth breathing, at 50 l min -1 and (iii) standard nasal cannula, closed-mouth breathing, at 50 l min -1 , and expressed as means (SD): 90% (3), 90% (6) and 88% (5), respectively. Preoxygenation efficacy was greater via the bi-nasal cannulae using closed vs. open mouth breathing as well as with 3 min of normal breathing vs. eight vital capacity breaths. Preoxygenation with a facemask and humidified high-flow nasal oxygen was more comfortable than a standard nasal cannula.

CONCLUSION

The efficacy of preoxygenation using a standard nasal cannula at high flow rates is no different to clinically used methods today. The standard nasal cannula provides less comfort but is highly effective and could be an option when alternative methods are unavailable.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT05839665.

Pre-oxygenation using high-flow nasal oxygen versus tight facemask in trauma patients undergoing emergency anaesthesia

BACKGROUND

Patients suffering from major traumatic injuries frequently require emergency anaesthesia. Due to often compromised physiology and the time-sensitive management, trauma patients may be more prone to desaturate during induction of anaesthesia. We hypothesised that pre-oxygenation using high-flow nasal oxygen would decrease the risk of desaturation during induction of anaesthesia in trauma patients and the study therefore aimed to compare the frequency of desaturation when pre-oxygenation was performed with high-flow nasal oxygen or a traditional facemask.

METHODS

This exploratory, prospective, before-and-after study was conducted at the Karolinska University Hospital, Sweden. Adult (≥18 years of age) patients suffering major traumatic injuries needing emergency anaesthesia were included around the clock. Patients were pre-oxygenated using a tight-fitting facemask during the first nine months of enrollment. High-flow nasal oxygen was then introduced as a method for pre-oxygenation of trauma patients. The primary outcome was the proportion of patients desaturating <93% during induction of anaesthesia, assessed from the start of pre-oxygenation until one minute after intubation. Secondary outcomes included perceived difficulty of pre-oxygenation among anaesthetists (assessed on a scale between 1 and 10) and safety outcomes, such as incidence of regurgitations and intracranial gas (assessed radiologically).

RESULTS

Data from 96 patients were analysed. Facemask pre-oxygenation was performed in 66 patients, while 30 patients were pre-oxygenated with high-flow nasal oxygen. The most frequent trauma mechanisms were stabbing injuries (n = 34 (35%)) and fall injuries (n = 21 (22%)). There were no differences in patient characteristics between the groups. Eight (12%) versus three (10%) patients desaturated <93% in the facemask and high-flow nasal oxygen group respectively, OR 0.81 (95% CI 0.20-3.28), p = .76. Anaesthetists assessed pre-oxygenation using high-flow nasal oxygen as easier compared to facemask pre-oxygenation. No patient in any group showed signs of regurgitation. Among patients with facial or skull fractures requiring anaesthesia before radiology was performed, intracranial gas was seen in four (40%) patients pre-oxygenated with a facemask and in no patient pre-oxygenated with HFNO (p = .23).

CONCLUSION

In this prospective study investigating trauma patients undergoing emergency anaesthesia, we could not see any difference in the number of patients desaturating when pre-oxygenation was performed with high-flow nasal oxygen compared to a tight-fitting facemask. Pre-oxygenation using high-flow nasal oxygen was assessed as easier compared to facemask pre-oxygenation.

Pre-oxygenation using high-flow nasal oxygen in parturients undergoing caesarean section in general anaesthesia: A prospective, multi-centre, pilot study

BACKGROUND

Parturients undergoing caesarean section in general anaesthesia have an increased risk of desaturating during anaesthesia induction. Pre- and peri-oxygenation with high-flow nasal oxygen prolong the safe apnoea time but data on parturients undergoing caesarean section under general anaesthesia are limited. This pilot study aimed to investigate the clinical effects and frequency of desaturation in parturients undergoing caesarean section in general anaesthesia pre- and peri-oxygenated with high-flow nasal oxygen and compare this to traditional pre-oxygenation using a facemask.

METHODS

In this prospective, non-randomised, multi-centre study we included pregnant women with a gestational age ≥30 weeks undergoing caesarean section under general anaesthesia. All parturients were asked to participate in the intervention group consisting of pre-oxygenation using high-flow nasal oxygen. Parturients declining participation were pre-oxygenated with a traditional facemask. Primary outcome was the proportion of parturients desaturating below 93% from start of pre-oxygenation until 1 min after tracheal intubation. Secondary outcomes investigated end-tidal oxygen concentrations after tracheal intubation and the proportion of parturients with signs of regurgitation.

RESULTS

A total of 34 parturients were included, 25 pre- and peri-oxygenated with high-flow nasal oxygen and 9 pre-oxygenated with facemask. No difference in patient or airway characteristics could be seen except for a higher BMI in the high-flow nasal oxygen group (31.4 kg m-2 [4.7] vs. 27.7 kg m-2 [3.1]; p = .034). No woman in any of the two groups desaturated below 93%. The lowest peripheral oxygen saturation observed, in any parturient, was 97%. There was no difference detected in end-tidal oxygen concentration after tracheal intubation, 87% (6) in the high-flow nasal oxygen group vs 80% (15) in the facemask group (p = .308). No signs of regurgitation, in any parturient, were seen.

CONCLUSION

Pre- and peri-oxygenation with high-flow nasal oxygen maintain adequate oxygen saturation levels during induction of anaesthesia also in parturients. Regurgitation of gastric content did not occur in any parturient and no other safety concerns were observed in this pilot study.

Gamma spectrometric measurement of uranium isotopic composition and mass in sintered UO2 pellets using the efficiency transfer method

Gamma spectrometric measurements to determine the isotopic composition and total uranium mass in UO₂ pellets (D = 7.5 mm; H = 3.5 mm, ρ = 10 g/cm³) were carried out. The required efficiency curve was obtained by applying the efficiency transfer method from a calibration standard (D = 65 mm; H = 20 mm) of a slightly acidified water solution. The average isotopic composition of ten UO₂ pellets was consistent with values of natural uranium given by IUPAC. The average relative bias for the ²³⁵U/²³⁸U amount ratio was -0.73% using the 1001 keV gamma line for ²³⁸U and 0.50% using the 63 keV gamma line (186 keV was always used for ²³⁵U). For the total uranium mass, the mean deviation as compared to mass determinations using a balance was 5.5% using the 1001 keV gamma line for ²³⁸U and 4.3% using the 63 keV gamma line.

Characteristics and outcome of traumatic cardiac arrest at a level 1 trauma centre over 10 years in Sweden

Background

Historically, resuscitation in traumatic cardiac arrest (TCA) has been deemed futile. However, recent literature reports improved but varying survival. Current European guidelines emphasise the addressing of reversible aetiologies in TCA and propose that a resuscitative thoracotomy may be performed within 15 min from last sign of life. To improve clinician understanding of which patients benefit from resuscitative efforts we aimed to describe the characteristics and 30-day survival for traumatic cardiac arrest at a Swedish trauma centre with a particular focus on resuscitative thoracotomy.

Methods

Retrospective cohort study of adult patients (≥ 15 years) with TCA managed at Karolinska University Hospital Solna between 2011 and 2020. Trauma demographics, intra-arrest factors, lab values and procedures were compared between survivors and non-survivors.

Results

Among the 284 included patients the median age was 38 years, 82.2% were male and 60.5% were previously healthy. Blunt trauma was the dominant injury in 64.8% and median Injury Severity Score (ISS) was 38. For patients with a documented arrest rhythm, asystole was recorded in 39.2%, pulseless electric activity in 24.8% and a shockable rhythm in 6.8%. Thirty patients (10.6%) survived to 30 days with a Glasgow Outcome Scale score of 3 (n = 23) or 4 (n = 7). The most common causes of death were haemorrhagic shock (50.0%) and traumatic brain injury (25.5%). Survivors had a lower ISS (P < 0.001), more often had reactive pupils (P < 0.001) and a shockable rhythm (P = 0.04). In the subset of prehospital TCA, survivors less frequently received adrenaline (epinephrine) (P < 0.001) and in lower amounts (P = 0.02). Of patients that underwent resuscitative thoracotomy (n = 101), survivors (n = 12) had a shorter median time from last sign of life to thoracotomy (P = 0.03), however in four of these survivors the time exceeded 15 min.

Conclusion

Survival after TCA is possible. Determining futility in TCA is difficult and this study demonstrates survivors outside of recent guidelines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-022-01039-9.

AB0804 Associations between ultrasound chronic lesions in peripheral entheses and radiographic structural spinal changes in men and women with ankylosing spondylitis

Background

Ankylosing spondylitis (AS) is characterised by spinal bone formation and enthesitis. Whether patients with spinal bone formation have a generalised bone formation phenotype also involving the peripheral entheses is not fully known.

Objectives

To assess in cross-sectional analyses the association between chronic ultrasound (US) lesions in peripheral entheses with spinal bone formation and factors associated with spinal bone formation, overall and by sex.

Methods

The entheses at 14 sites at the extremities were examined in 173 patients (54 % men, mean age (SD) 55 (13) years and symptom duration 29 (13) years) with AS (modified NY criteria) using US. Entheses were assessed for structural components (enthesophytes, calcifications and erosions) according to the OMERACT definition [1]. Each lesion was evaluated 0 or 1 and summarised to a damage score (0-42). Spinal radiographs from the same time point were graded according to the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) and presence of syndesmophytes were determined. The associations between US damage score and mSASSS and factors associated with spinal bone formation were analysed with Spearman´s correlation analysis overall and by sex. Also, Mann Whitney´s test and multivariable logistic regression analysis with presence of ≥ 1 syndesmophyte as dependent variable and age, sex, BMI, smoking status, CRP, and US damage score as independent variables were used.

Results

Presence of any US structural component was found in 158 (91 %) of the patients with no significant difference between men and women (95 % vs 87 % respectively, p = 0.15). The US damage score was median (IQR) 4 (2 to 6) in the total group with a higher score in men compared to women, 4.5 (2 to 7) vs 3 (2 to 5), p = 0.002. In analogy, more men had presence of syndesmophytes in the spine compared to women, 63 % vs 35 %, p <0.001 and men had higher mSASSS compared to women; median (IQR) mSASSS in men 14 (3 to 43) compared to 2 (0 to 11.5), p<0.001. Men had higher body mass index (BMI), but there were no sex differences for age, symptom duration, CRP, and smoking status.

The results from correlation analyses for US damage score and mSASSS, age, symptom duration, CRP, smoking status, and BMI are presented in the Table 1. Spinal bone formation (mSASSS) was positively correlated with the US damage score in the total group and in men. In both men and women, higher age was associated with higher US damage score. A comparison between patients with and without syndesmophytes showed that patients with syndesmophytes had higher US damage score than patients without syndesmophytes, median (IQR) 5 (3 to 7) and 3 (1 to 5) respectively, p<0.001. In the multivariable logistic regression analyses the US damage score was not independently associated with presence of syndesmophyte in the total group or in men. If age was excluded from the analyses though, the US damage score was significantly associated with presence of syndesmophyte, odds ratio (95 % CI) for total group 1.20 (1.05 to 1.37) and for men 1.26 (1.05 to 1.51).

Table 1.Ultrasound damage scoreTotal group (n=173)Men (n = 94)Women (n = 79)rsp-valuersp-valuersp-valueAge, years0.44<0.0010.43<0.0010.51<0.001Symptom duration, years0.28<0.0010.34<0.0010.270.015BMI, kg/m20.210.0060.110.280.190.10Current or past smoking0.0390.610.180.090-0.100.37CRP, mg/L0.120.130.0280.790.200.073mSASSS, score0.31<0.0010.270.0100.200.084

rs: Spearman´s correlations coefficient

Conclusion

Structural lesions were common in the entheses in patients with long-standing AS. Men had more severe bone formation in the spine and the peripheral entheses compared to women. Chronic lesions at the entheses accumulate with increasing age and US damage score could not independently identify patients with syndesmophytes in this cohort with long-standing AS. However, if age was not considered, there was an association between bone formation in the peripheral entheses and the spine in men with AS.

References

[1]Balint, P et al. Ann Rheum Dis 2018;77:1730-1735

Disclosure of Interests

Anna Deminger: None declared, Mats Geijer Speakers bureau: UCB Pharma, Novartis, Abbvie, Nicklas Nilsson: None declared, Martin Hedberg: None declared, Lennart T.H. Jacobsson: None declared, Helena Forsblad-d’Elia: None declared

Factors associated with changes in volumetric bone mineral density and cortical area in men with ankylosing spondylitis: a 5-year prospective study using HRpQCT

Patients with ankylosing spondylitis (AS) have impaired volumetric bone mineral density (vBMD) assessed with high-resolution peripheral computed tomography (HRpQCT). This first longitudinal HRpQCT study in AS shows that cortical and trabecular vBMD decreased at tibia and that signs of inflammation were associated with cortical bone loss at tibia and radius.

INTRODUCTION

Patients with ankylosing spondylitis (AS) have reduced volumetric bone mineral density (vBMD) in the peripheral skeleton assessed with high-resolution peripheral quantitative computed tomography (HRpQCT). The aims were to investigate longitudinal changes in vBMD, cortical area, and microarchitecture and to assess factors associated with changes in vBMD and cortical area in men with AS.

METHODS

HRpQCT of radius and tibia was performed in 54 men with AS at baseline and after 5 years. Univariate and multivariable linear regression analyses were used.

RESULTS

At tibia, there were significant decreases exceeding least significant changes (LSC) in cortical and trabecular vBMD, mean (SD) percent change -1.0 (1.9) and -2.7 (5.0) respectively (p<0.001). In multivariable regression analyses, increase in disease activity measured by ASDAS_CRP from baseline to follow-up was associated with decreases in cortical vBMD (β -0.86, 95% CI -1.31 to -0.41) and cortical area (β -1.66, 95% CI -3.21 to -0.10) at tibia. At radius, no changes exceeded LSC. Nonetheless, increase in ASDAS_CRP was associated with decreases in cortical vBMD, and high time-averaged ESR was associated with decreases in cortical area. Treatment with TNF inhibitor ≥ 4 years during follow-up was associated with increases in cortical vBMD and cortical area at tibia, whereas exposure to bisphosphonates was associated with increases in cortical measurements at radius. No disease-related variables or treatments were associated with changes in trabecular vBMD.

CONCLUSION

The findings in this first longitudinal HRpQCT study in patients with AS strengthen the importance of controlling disease activity to maintain bone density in the peripheral skeleton.

Pre-oxygenation using high-flow nasal oxygen vs. tight facemask during rapid sequence induction

Pre-oxygenation using high-flow nasal oxygen can decrease the risk of desaturation during rapid sequence induction in patients undergoing emergency surgery. Previous studies were single-centre and often in limited settings. This randomised, international, multicentre trial compared high-flow nasal oxygen with standard facemask pre-oxygenation for rapid sequence induction in emergency surgery at all hours of the day and night. A total of 350 adult patients from six centres in Sweden and one in Switzerland undergoing emergency surgery where rapid sequence induction was required were included and randomly allocated to pre-oxygenation with 100% oxygen using high-flow nasal oxygen or a standard tight-fitting facemask. The primary outcome was the number of patients developing oxygen saturations <93% from the start of pre-oxygenation until 1 min after tracheal intubation. Data from 349 of 350 patients who entered the study were analysed (174 in the high-flow nasal oxygen group and 175 in the facemask group). No difference was detected in the number of patients desaturating <93%, five (2.9%) vs. six (3.4%) patients in the high-flow nasal oxygen and facemask group, respectively (p = 0.77). The risk of desaturation was not increased during on-call hours. No difference was seen in end-tidal carbon dioxide levels in the first breath after tracheal intubation or in the number of patients with signs of regurgitation between groups. These results confirm that high-flow nasal oxygen maintains adequate oxygen levels during pre-oxygenation for rapid sequence induction.

DEVELOPMENT OF A MODELING APPROACH TO ESTIMATE RADIATION FROM A SPENT FUEL ROD QUIVER

Before encapsulation of spent nuclear fuel in a geological repository, the fuels need to be verified for safeguards purposes. This requirement applies to all spent fuel assemblies, including those with properties or designs that are especially challenging to verify. One such example are quivers, a new type of containers used to hold damaged spent fuel rods. After placing damaged rods inside the quivers, they are sealed with a thick lid and the water is removed. The lid is thick enough to significantly reduce the amount of the gamma radiation penetrating through it, which can make safeguards verification from the top using gamma techniques difficult. Considering that the number of quivers at storage facilities is foreseen to increase in near future, studying the feasibility of verification is timely.

In this paper we make a feasibility study related to safeguards verification of quivers, aimed at investigating the gamma and neutron radiation field around a quiver designed by Westinghouse AB and filled with PWR fuel rods irradiated at the Swedish Ringhals site. A simplified geometry of the quiver and the detailed operational history of each rod are provided by Westinghouse and the reactor operator, respectively.

The nuclide inventory of the rods placed in the quiver and the emission source terms are calculated with ORIGEN-ARP. The radiation transport is modeled with the Serpent2 Monte Carlo code. The first objective is to assess the capability of the spent fuel attribute tester (SFAT) to verify the content for nuclear safeguards purposes. The results show that the thick quiver lid attenuates the gamma radiation, thereby making gamma radiation based verification from above the quiver difficult.

Randomized clinical trial of Appendicitis Inflammatory Response score-based management of patients with suspected appendicitis

BACKGROUND

The role of imaging in the diagnosis of appendicitis is controversial. This prospective interventional study and nested randomized trial analysed the impact of implementing a risk stratification algorithm based on the Appendicitis Inflammatory Response (AIR) score, and compared routine imaging with selective imaging after clinical reassessment.

METHOD

Patients presenting with suspicion of appendicitis between September 2009 and January 2012 from age 10 years were included at 21 emergency surgical centres and from age 5 years at three university paediatric centres. Registration of clinical characteristics, treatments and outcomes started during the baseline period. The AIR score-based algorithm was implemented during the intervention period. Intermediate-risk patients were randomized to routine imaging or selective imaging after clinical reassessment.

RESULTS

The baseline period included 1152 patients, and the intervention period 2639, of whom 1068 intermediate-risk patients were randomized. In low-risk patients, use of the AIR score-based algorithm resulted in less imaging (19·2 versus 34·5 per cent; P < 0·001), fewer admissions (29·5 versus 42·8 per cent; P < 0·001), and fewer negative explorations (1·6 versus 3·2 per cent; P = 0·030) and operations for non-perforated appendicitis (6·8 versus 9·7 per cent; P = 0·034). Intermediate-risk patients randomized to the imaging and observation groups had the same proportion of negative appendicectomies (6·4 versus 6·7 per cent respectively; P = 0·884), number of admissions, number of perforations and length of hospital stay, but routine imaging was associated with an increased proportion of patients treated for appendicitis (53·4 versus 46·3 per cent; P = 0·020).

CONCLUSION

AIR score-based risk classification can safely reduce the use of diagnostic imaging and hospital admissions in patients with suspicion of appendicitis. Registration number: NCT00971438 ( http://www.clinicaltrials.gov).

Betamethasone in hernia surgery: a randomized controlled trial

BACKGROUND

Post-operative pain and nausea may be a problem in day-case surgery. This study aims to investigate the effect of betamethasone on pain and nausea in inguinal hernia surgery.

METHODS

Patients aged 18-70 years scheduled for open inguinal hernia surgery at two Swedish hospitals, March 2005-December 2009, were eligible for inclusion. Patients were randomized, to either treatment with 12 mg betamethasone intravenously or placebo. Post-operative pain was assessed using a visual analogue scale on the recovery ward, each day the first post-operative week and at 1 month after surgery. One year after surgery, residual pain was estimated by the Inguinal Pain Questionnaire.

RESULTS

A total of 398 patients were included (21 women, 377 men). Pain at rest on the day of surgery was significantly lower in the treatment group (p = 0.012). The pain was also significantly lower in the treatment group the day after surgery (p < 0.001), but not during the remaining part of the first post-operative week. Bleeding complications were reported by 17 patients (8.5%) in the Betamethasone group and seven (3.5%) in the placebo group (p = 0.028). One month after surgery, 21 out of 173 (12%) in the betamethasone group still had pain, compared to 33 out of 159 (21%) in the placebo arm (p = 0.049). After 1 year, no significant difference in pain was seen.

CONCLUSION

A 12 mg betamethasone reduced pain during the first 24 h and at 1 month after inguinal hernia surgery. If combined with diclofenac, however, this dose may increase the risk for bleeding complications.

Stroke after cardiac surgery--hemispheric distribution and survival

OBJECTIVES

Stroke following cardiac surgery may occur either in association with surgery (early) or occur postoperatively (delayed). The hemispheric distribution of lesions may provide information about embolic routes, which was analyzed here.

DESIGN

In 10,809 patients undergoing cardiac surgery, early (n = 223) and delayed stroke (n = 116) were explored. Symptoms and computed tomography findings were evaluated to categorize hemispheric distributions. This was compared with pre- and intra-operative characteristics and survival, using logistic regression and Kaplan-Meier statistics.

RESULTS

Early stroke had preponderance for the right rather than the left hemisphere (P = 0.009), whereas delayed stroke had a uniform distribution. Several intraoperative variables predicted the development of bilateral stroke compared with its unilateral counterpart. At multivariable analysis, the use of tranexamic acid was associated with bilateral stroke (P = 0.017), but was also associated with right rather than left-hemispheric stroke (P = 0.001). Bilateral lesions dramatically impaired survival versus those with unilateral lesions (P < 0.001). There was no survival difference between left and right-hemispheric stroke.

CONCLUSIONS

When stroke, after cardiac surgery, is subdivided into early and delayed forms, it becomes evident that early, but not delayed stroke, demonstrates a hemispheric side difference. The preponderance for right-hemispheric lesions may indicate embolic mechanisms routed via the brachiocephalic trunk.

Characterizing uranium oxide reference particles for isotopic abundances and uranium mass by single particle isotope dilution mass spectrometry

Uranium and plutonium particulate test materials are becoming increasingly important as the reliability of measurement results has to be demonstrated to regulatory bodies responsible for maintaining effective nuclear safeguards. In order to address this issue, the Institute for Reference Materials and Measurements (IRMM) in collaboration with the Institute for Transuranium Elements (ITU) has initiated a study to investigate the feasibility of preparing and characterizing a uranium particle reference material for nuclear safeguards, which is finally certified for isotopic abundances and for the uranium mass per particle. Such control particles are specifically required to evaluate responses of instruments based on mass spectrometric detection (e.g. SIMS, TIMS, LA-ICPMS) and to help ensuring the reliability and comparability of measurement results worldwide. In this paper, a methodology is described which allows quantifying the uranium mass in single micron particles by isotope dilution thermal ionization mass spectrometry (ID-TIMS). This methodology is characterized by substantial improvements recently achieved at IRMM in terms of sensitivity and measurement accuracy in the field of uranium particle analysis by TIMS. The use of monodisperse uranium oxide particles prepared using an aerosol generation technique developed at ITU, which is capable of producing particles of well-characterized size and isotopic composition was exploited. The evidence of a straightforward correlation between the particle volume and the mass of uranium was demonstrated in this study. Experimental results have shown that the uranium mass per particle can be measured via the ID-TIMS method to a relative expanded uncertainty of about 10% (coverage factor k=2). The availability of reliable and validated methods for the characterization of uranium particles is considered to be essential for the establishment of SI-traceable measurement results. It is therefore expected that the method developed in this study is valuable for the certification of particulate materials in which the isotopic composition and the content of uranium must be accurately known.

Early and delayed stroke after coronary surgery - an analysis of risk factors and the impact on short- and long-term survival

OBJECTIVE

Stroke is a serious complication to cardiac surgery, and is generally considered as a uniform disease regardless of its temporal relationship to surgery. Our hypothesis suggests that stroke, in association with surgery, reflects other characteristics than stroke occurring with a free interval. This issue was here explored for risk factors and survival effects.

METHODS

Data were collected from 7839 procedures of isolated coronary artery bypass grafting (CABG), 297 off-pump CABG, and 986 combined CABG and valve procedures. Records of patients with any signs of neurological complications were reviewed to extract 149 subjects with stroke at extubation (early, 1.6%) versus 99 patients having a free interval (delayed, 1.1%). Survival data were complete, with a median follow-up time of 9.3 years (maximum 16.3 years). Independent risk factors were analyzed by logistic regression and survival by Cox regression.

RESULTS

Risk factors for early stroke were advanced age, high preoperative creatinine level, extent of aortic atherosclerosis, and long cardiopulmonary bypass time (all P<0.001). Factors associated with delayed stroke were female gender (P<0.001), unstable angina (P=0.003), previous cerebrovascular disease (P=0.009), inotropic support requirement (P<0.001), and postoperative atrial fibrillation (P<0.001). Stroke explained mortality not only in the early postoperative period (P<0.001), but also at long-term follow-up (P<0.001). Early and delayed stroke were associated with mortality hazard ratios (HRs) of 1.44 and 1.85 (P=0.008, P<0.001), respectively. However, for patients surviving their first postoperative year, early stroke did not influence long-term mortality (HR 1.07, P=0.695). This was in contrast to delayed stroke (HR 1.71, P=0.001).

CONCLUSIONS

Early and delayed stroke differed in their related risk factors. The influence of stroke on short-term mortality was obvious and devastating. Mortality in association with early stroke mainly presented itself in the acute period, whereas for delayed stroke survival continued to be impaired also in the long-term perspective. Our report emphasizes that early and delayed stroke should be considered as two separate entities.

Characterization of the DNA of a Nonoccluded Baculovirus, Hz-1V

The DNA of the nonoccluded baculovirus (Hz-1V) obtained from the IMC-Hz-1 cell line was characterized by physicochemical and restriction endonuclease techniques. Hz-1V DNA isolated from purified virus had buoyant densities of 1.58 and 1.54 g/ml in CsCl-ethidium bromide density gradients, which corresponded to supercoiled and to relaxed circular and linear DNA, respectively. Neutral CsCl equilibrium centrifugation indicated that the Hz-1V DNA had a buoyant density of 1.7024 g/ml, which corresponded to a guanine-plus-cytosine (G+C) content of 43%. Thermal denaturation indicated a high G+C domain(s) in the Hz-1V genomic DNA. The domain(s), which included about 11% of the total genomic DNA, exhibited a T(m) of 97 degrees C. The remaining portion (89%) of the DNA had a T(m) of 86.5 degrees C. The T(m)s corresponded to G+C contents of 42 and 67%, respectively. The mean genetic complexity of Hz-1V DNA determined by DNA reassociation kinetic analysis was found to be 152 x 10(6). A possible rapidly reassociating component comprising approximately 13% of the genome was observed. The mean molecular weights from restriction endonuclease digests were 159 x 10(6) for both HindIII and EcoRI. Genomic heterogeneity was found in both the wild-type Hz-1V stock and in two plaque isolates. Of 12 single-plaque isolates, 3 basic restriction endonuclease DNA fragment patterns were observed. The molecular size estimates from electron microscopic contour lengths of uncloned viral DNA ranged from 70 to 158 megadaltons, and the mode was the 130- to 140-megadalton class.

Muscle function and morphology in myotonic dystrophy

Patients with myotonic dystrophy classified clinically into function groups were studied. Muscle strength for knee extension and flexion was, with few exceptions, moderately or markedly reduced with successively more severe clinical disability. The reduction in maximal walking speed showed a similar tendency. There was a large percentage of both type I and in relation to normal findings of type II C fibers in biopsies from most patients. The fiber area varied greatly even in the patients in the best function groups, some of whom had large type II fibers. The most common-histopathological changes, found in all function groups, were fiber atrophy with small angular fibers, internal nuclei, splitting, fibrosis and moth-eaten fibers. A high percentage of type I fibers can already be seen in patients with practically no other morphological changes and without significant functional deterioration.

Characterization of beta-lactam-resistant Bacteroides fragilis isolates by use of PCR fingerprinting

PCR fingerprinting was used for characterization of 35 beta-lactam-resistant Bacteroides fragilis strains isolated in Sweden and Hungary. Ten B. fragilis strains showed unique PCR fingerprints by use of the M13 core primer. Their main product was a DNA fragment with a length of 2000-bp which was absent in the other 25 strains and the reference strain B. fragilis ATCC 25285. The 2000-bp fragment from four imipenem-resistant strains gave rise to positive reactions in a specific PCR for detection of ccrA. Printed by the T3B primer, five B. fragilis strains, including the imipenem-resistant strains showed unique PCR fingerprints. The investigated imipenem-resistant strains produced carbapenem-hydrolysing metallo-beta-lactamases. The study indicates that the unique PCR fingerprinting profiles shown in highly beta-lactam resistant B. fragilis strains are correlated to antimicrobial resistance. The PCR fingerprinting technique is a useful tool for differentiation of Bacteroides fragilis strains with high-level beta-lactam resistance.

Examination of cfiA-mediated carbapenem resistance in Bacteroides fragilis strains from a European antibiotic susceptibility survey

Of 1284 Bacteroides strains collected in Europe in 2000 for antibiotic susceptibility surveillance, 65 isolates displayed imipenem minimum inhibitory concentrations (MICs) > or =1 mg/L and were chosen for a thorough analysis of their resistance mechanism. Twenty-five of the isolates were positive for the cfiA carbapenem resistance gene. The resistance rates were 0.8% and 1.3% for imipenem and meropenem, respectively. In six of the strains, insertion sequence (IS) elements (IS613, IS614B, IS1186 and IS1187) activated the cfiA gene. However, other strains displayed at least elevated carbapenem MICs or were carbapenem resistant and produced measurable carbapenemase activities but did not harbour IS elements in the region upstream of the cfiA gene. The major determinant of carbapenem resistance in Bacteroides fragilis is production of CfiA metallo-beta-lactamase via activation of the cfiA gene by IS elements (higher level resistance) or by activation of its putative own promoter.

Cerebrovascular accidents after cardiac surgery: an analysis of CT scans in relation to clinical symptoms

There is a link between aortic manipulation, particle embolization, and cerebrovascular accidents (CVA) in cardiac surgery. The present aim was to study hemispheric side differences of CVA. Cardiac-surgery patients with CVA and with computer tomography (CT) performed (n = 77) were analyzed within a total group of 2641 consecutive cases. CT data were reviewed for hemispheric and vascular distribution, and compared with CVA-symptom data of immediate and delayed type. Of the included patients, 66% had positive CT. In the group of 'cardiac-type' operations (e.g., routine clamping and cannulation) and having immediate CVA, right-hemispheric lesions were more frequent than of the contra-lateral side (p = 0.005). Patients with aortic dissections had strong dominance of bilateral findings, which was different from the unilateral pattern of 'cardiac-type' operations (p = 0.001). The middle-cerebral artery territory dominated, and when involved showed a significant (p = 0.022) right-sided distribution. Both CT and clinical symptoms confirmed that CVA after cardiac surgery has a right-hemispheric predominance. These observations may imply that aortic manipulation directs embolic material towards the brachiocephalic trunk.

31P MRS evaluation of fatigue in anterior tibial muscle in postpoliomyelitis patients and healthy volunteers

Changes in concentration of high energy phosphates and pH were studied during rest, exercise and subsequent recovery in the anterior tibial muscle of 10 patients with late effects of poliomyelitis and 10 age- and sex-matched healthy volunteers using 31P MRS. The exercise was dynamic and isometric, and the force levels were individually adapted to each subject and stepwise increased. In general, there were no differences in metabolite changes between the groups, except for lower Pi and Pi/PCr for the volunteers during the recovery phase, also reflected by shorter recovery half-time for Pi. The interindividual variation was much higher for the patient group. Some of the patients showed deviating results probably because of differences in muscle fibre type.

Antimicrobial susceptibility of Bacteroides fragilis group isolates in Europe

OBJECTIVE

To evaluate the activity of old and newer antianaerobic drugs against clinical isolates of Bacteroides fragilis group strains from different parts of Europe.

METHODS

Bacteroides fragilis group isolates from 37 laboratories in 19 countries were biochemically characterized. The MICs of seven antimicrobial agents were determined by the agar dilution method as recommended by the NCCLS. Production of beta-lactamase was detected by nitrocefin.

RESULTS

There were 1284 B. fragilis group isolates included in the study. Abdominal infections and wounds were the most common sources of isolation and B. fragilis was the dominating species. Ninety-nine percent of the strains were resistant to ampicillin (breakpoint 2 mg/L), 6% to cefoxitin (64 mg/L), 15% to clindamycin (8 mg/L) and 9% to moxifloxacin (8 mg/L). Less than 1% were resistant to imipenem (16 mg/L), piperacillin-tazobactam (128 mg/L) and metronidazole (32 mg/L). Ninety-six percent of the isolates were beta-lactamase producers.

CONCLUSIONS

Antimicrobial resistance among the B. fragilis group is increasing.

Depleted uranium particles in selected Kosovo samples

Selected soil samples, collected in Kosovo locations where DU ammunition was expended during the 1999 Balkan conflict, have been investigated by secondary ion mass spectrometry (SIMS), X-ray fluorescence imaging using a micro-beam (micro-XRF) and scanning electron microscopy equipped with an energy dispersive X-ray fluorescence detector (SEM-EDXRF), with the objective to test the suitability of these techniques to identify the presence of small DU particles and measure their size distribution and the 235U/238U isotopic ratio (SIMS). Although the results do not permit any legitimate extrapolation to all the sites hit by the DU rounds used during the conflict, they indicated that there can be "spots ' where hundreds of thousands of particles may be present in a few milligrams of DU contaminated soil. The particle size distribution showed that most of the DU particles were <5 microm in diameter and more than 50% of the particles had a diameter <1.5 microm. Knowledge on DU particles is needed as a basis for the assessment of the potential environmental and health impacts of military use of DU, since it provides information on possible re-suspension and inhalation.

Distress in everyday life in people with poliomyelitis sequelae

The prevalence of distress in aspects of perceived health and its relation to involvement of poliomyelitis sequelae were studied with the Nottingham Health Profile (NHP) in 113 outpatients (mean age 57 years). The leisure and employment situation was also recorded. Most distress was found in the NHP dimensions physical mobility, pain and energy, and least distress in social isolation. Most health-related problems were reported in housework, employment and leisure. Three-quarters of the persons were satisfied with their leisure, although many of them had problems. Fifty-nine per cent of the subjects of working age were in gainful employment, and no difference in employment rate due to the distribution of polio involvement was found. In comparison with norm values for the respective age groups, the subjects with poliomyelitis sequelae aged below 45 and 45-65 years had more distress in a larger number of NHP dimensions than older subjects.

Physical activity, muscle performance and quality of life in patients treated with chronic peritoneal dialysis

OBJECTIVE

Today's medical treatment of patients with end-stage renal failure has increased their opportunities for an active lifestyle. The aim of this study was to describe the muscle performance, level of physical activity, independence in activities of daily living and quality of life in patients treated with chronic peritoneal dialysis.

MATERIAL AND METHODS

The study investigated 33 patients (30-81 years old) treated with chronic peritoneal dialysis. The results were compared with an age-matched healthy reference group. Muscle mass was determined by measuring total body potassium, while maximal grip strength was measured with an electric force transducer. The ability to perform heel-lifts, walking speed and level of physical activity were also assessed, along with the extent to which patients were independent in activities of daily living (ADL) and satisfied with their health.

RESULTS

Total body potassium was 97 +/- 11.6% of normal and correlated positively with the maximal grip strength (r = 0.658, p < 0.0002) and the maximal walking speed (r = 0.558, p < 0.0027). Maximal grip strength was 70% of the reference, the ability to perform heel-lifts was 49% of the reference, the walking speed was 85% the reference and the level of physical activity was 56% of expected. The patients were independent in ADL to a great extent and 52% of the patients were satisfied with their health.

CONCLUSION

The peritoneal dialysis patients had a relatively good quality of life and were largely independent in ADL Further studies are needed to investigate whether it is possible to improve muscle performance and the level of physical activity with exercise and muscle training in these patients.

Muscle performance in an urban population sample of 40- to 79-year-old men and women

An urban population sample of 40 to 79-year-old men and women was investigated to evaluate the influence of age and activity level on muscle strength and endurance and to establish a reference material. During the investigation 144 persons were tested bilaterally, except for ankle strength, when only the right side was examined. Isometric muscle strength was determined in the knee extensors and flexors. Isokinetic (at 60 degrees/s and at 180 degrees/s) muscle strength was determined concentrically and eccentrically in the knee extensors and flexors. The dynamic and static endurance of the extensors was measured. Isometric strength was determined in the ankle plantar and dorsiflexor muscles. Isokinetic ankle plantar flexion strength was determined concentrically at 60 degrees/s with and without prior eccentric muscle contraction. Hand-grip strength was evaluated with a dynamometer. Walking velocity and the number of heel-rises were recorded. Physical activity level was assessed by questionnaire. Muscle biopsies were taken from the vastus lateralis muscle for histochemical and enzymatic analyses. Walking and the different muscle tests declined with age, and with a slight gender difference. Muscle biopsies showed a trend toward smaller muscle fibers with age. The results of our study can be used as reference material for clinical studies in different age groups.

Ecological disturbances in intestinal microflora caused by clinafloxacin, an extended-spectrum quinolone

BACKGROUND

The quinolones developed over the past few years have enhanced in vitro activity and a broader spectrum of antimicrobial activity compared to many other antimicrobial agents including the older quinolones. The present study focuses on the effect of clinafloxacin, a member of the new broad-spectrum quinolone class of antibiotics, on the normal intestinal microflora.

SUBJECTS AND METHODS

A total of 12 healthy volunteers received clinafloxacin orally, 200 mg twice daily for 7 days. Fecal specimens were collected at defined intervals before, during and after the administration in order to study the effect of clinafloxacin on the intestinal microflora and to correlate this effect with fecal clinafloxacin concentrations. Intestinal microorganisms isolated before, during and 2 weeks after clinafloxacin administration were tested for their suseptibility to clinafloxacin.

RESULTS

Oral administration of clinafloxacin resulted in high drug levels in feces (mean value 176.2 mg/kg on day 7) and pronounced ecological disturbances. The aerobic microflora was eradicated in 11 of the 12 subjects and the anaerobic microflora was strongly suppressed during administration. There was a significant emergence of clinafloxacin-resistant Bacteroides spp. strains (MIC > or = 4 mg/ml) during administration. The elevated MIC values still remained 2 weeks after discontinuation of the antibiotic (p < 0.001).

CONCLUSION

The emergence of clinafloxacin-resistant Bacteroides spp. demonstrates the necessity of restricting prescription for particular indications in order to preserve the efficacy of the highly active broad-spectrum quinolones.

Electrophysiologic evaluation of muscle fatigue development and recovery in late polio

OBJECTIVES

To study aspects of fatigue in late-polio patients and healthy controls. We hypothesized that late-polio subjects would develop more peripheral fatigue, assessed with surface electromyography (EMG), and that no major differences would exist between the two groups in neuromuscular junction transmission.

DESIGN

Case-control study.

SETTING

University hospital laboratory.

SUBJECTS

Ten patients with a history of polio (mean age, 54 yrs, SD = 5; mean time since polio onset, 49 yrs, SD = 7) and a matched control group (mean age, 52 yrs, SD = 8).

METHODS

A protocol with a stepwise force increase up to 80% of maximal voluntary contraction ending with an 8-minute recovery period was performed twice, first with surface EMG and then with electrical stimulation and surface-recorded evoked M-response.

MAIN OUTCOME MEASURES

Surface EMG analysis of voluntary activity and evoked M-response.

RESULTS

No significant differences existed between groups in the relative decrease during the fatigue protocol. The recovery of force was slower in the late-polio subjects. A reduction in the root mean square (RMS) value during recovery was seen in the polio group, although a normalization of the mean power frequency (MPF) was seen in both groups.

CONCLUSION

The weakness during the fatigue procedure was not caused by neuromuscular blockade, because electrical nerve stimulation evoked a normal response. The weakness after exercise was the result of a slow recovery that may reflect both central and peripheral fatigue.

Activities of synthetic hybrid peptides against anaerobic bacteria: aspects of methodology and stability

The increasing problem of antibiotic resistance among pathogenic bacteria requires development of new antimicrobial agents. One line of investigation is the synthesis of antimicrobial hybrid peptides. The aim of the present investigation was to determine the in vitro activities of 16 cecropin-melittin hybrid peptides (CAMEL analogues) against 60 anaerobic bacterial strains, to compare their activities with those of seven clinically used antimicrobial agents, and to compare different methods for anaerobic susceptibility testing of these peptides. The stability of one of the peptides, temporin B, with different stereoisomeric configurations was investigated in a fecal milieu. The CAMEL analogues showed antimicrobial activity against the anaerobic bacteria, with MICs ranging from 0.125 to 32 microg/ml. The overall activities (the MICs at which 90% of isolates are inhibited) of the CAMEL analogues against anaerobic bacteria were mainly inferior to those of imipenem, clindamycin, and piperacillin but were equal to or superior to those of metronidazole, cefoxitin, ciprofloxacin, and chloramphenicol. The agarose dilution method was found to be an accurate method for the testing of large numbers of bacterial strains. The D isomer of temporin B was inactivated more slowly in feces than the L isomer. This study shows that the CAMEL analogues are potential agents for the treatment of anaerobic infections.

Long-term effects on the regulation of pancreatic secretion after gastric surgery

BACKGROUND

Apart from smoking, known risk factors for the development of pancreatic carcinoma are few, gastric resection being proposed as one. The trophic effect of cholecystokinin (CCK) on the pancreatic gland is well known from animal experience and increased concentrations of CCK in plasma have been shown to induce pancreatic neoplasia experimentally. In several studies the release of CCK in response to food ingestion has been shown to be increased following gastric surgery. However, in those studies, the time between surgery and investigation of the CCK response was short, and methods of CCK analysis have since improved.

PATIENTS AND METHODS

In patients, partially gastrectomized 8 years (median) earlier, we studied the plasma concentrations of CCK, insulin and gastrin, as well as some specific pancreatic enzymes. The findings were compared to an age-matched control group of individuals not subjected to gastric surgery.

RESULTS

Basal CCK concentrations in the operated group were found to be lower, but increased postprandially to the same level as in controls. Serum levels of specific pancreatic enzymes were equal in the 2 groups.

CONCLUSION

It is possible that a disturbed regulation of pancreatic secretion, or a secretory dysfunction within the gland, following partial gastrectomy, could contribute to the development of pancreatic carcinoma. However, our findings do not favor the idea of plasma CCK as a promotor of pancreatic carcinoma.

Survival following pancreatic carcinoma: a follow-up study of all cases recorded in Malmö, Sweden, 1977-1991

BACKGROUND

The aim of this follow-up study was to assess whether there has been any increase in the percentage of patients offered attempted curative surgery for pancreatic carcinoma and whether the overall survival rate has improved, during the time period 1977-1991.

METHODS

Details of new cases of pancreatic carcinoma arising in the population of Malmö during the study period were retrieved from the Local Tumour Register in Lund, Sweden. In all, 740 patients were found; 575 of these were diagnosed before death. Kaplan-Meier analysis was used to calculate overall survival rates, and Cox regression analysis was used to assess survival in relation to year of diagnosis after adjustment for sex, age at diagnosis and stage of disease.

RESULTS

Cytological or histopathological evidence of the disease was given in 95 per cent of cases. The overall 5-year survival rate was 0.5 per cent (three of 575). Curative surgery was attempted in 24 patients (4.2 per cent); the proportion undergoing curative surgery increased in the last part of the study. Two of the 24 patients in this group survived for 5 years.

CONCLUSION

The prognosis in pancreatic carcinoma remains dismal. Attempted curative surgery still is the only hope for cure, but the group of patients that can be offered this possibility is very limited. In this study, an increase was found in the proportion of patients who were offered attempted curative surgery, but there was no statistically significant increase in the 5-year survival rate following surgery.

[Choose preparations that affect the intestinal ecosystem as little as possible!]

The administration of antimicrobials often causes ecological disturbances in the normal microflora, such as decreased colonisation resistance which may result in overgrowth of potentially pathogenic micro-organisms such as yeasts and Clostridium difficile. Another possible consequence is the establishment of resistant strains which may spread within the host, or from person to person, causing infection. Resistant bacteria can also transfer resistance genes to their own or other species. The article consists in a review of studies performed by various investigators during the past 20 years, and illustrating the impact of different antimicrobial agents on the human gastrointestinal microflora.

Impact of endogenous thrombopoietin levels on the differential diagnosis of essential thrombocythaemia and reactive thrombocytosis

By using the newly commercialized Quantikine human TPO immunoassay, plasma thrombopoietin (TPO) concentrations were measured in 12 patients with essential thrombocythaemia (ET), 13 patients with reactive thrombocytosis (RT) and 11 healthy volunteers. For the healthy volunteers the mean plasma TPO concentration was 21.1+/-11.0 pg/ml. The mean plasma TPO concentration in the group of RT was slightly lower (16.4+/-8.6 pg/ml) but did not differ significantly from the control group. The mean plasma TPO concentration in ET patients (44.1+/-45.2 pg/ml) was significantly (p<0.05) higher than the mean for RT patients, but did not differ statistically from the mean of healthy volunteers. These data suggest a defective clearance of plasma TPO in patients with ET.

Muscular performance in heart failure

BACKGROUND

Some of the major symptoms in patients with chronic heart failure are muscle weakness and fatigue. However, not much is known about muscle performance in these patients compared to healthy controls.

METHODS AND RESULTS

Activity level, gait speed, hand grip strength, muscle performance of the knee extensors and flexors along with the plantar and dorsal flexors of the foot were evaluated. Muscle biopsies from the lateral vastus lateralis were taken. Sixteen patients in New York Heart Association class II or III were tested and compared to 112 reference subjects. Compared to the reference subjects, there was a reduction in activity level, gait speed, isometric and isokinetic peak torque for knee extension at different velocities, hand grip strength, peak torque for plantar and dorsal flexion of the ankle and isometric and isokinetic endurance for the knee extension. Recovery was faster. There were small differences in fiber composition. 3-Hydroxy-acylCoA-dehydrogenase and citrate synthase were lower, and lactate dehydrogenase was increased.

CONCLUSIONS

Muscle performance is affected in terms of both strength and endurance, which might affect performance in everyday activities. The more pronounced reduction in hand grip compared to the other muscles tested could be an indication of intrinsic abnormalities in the skeletal muscle.

Pancreatic carcinoma following gastric resection. A case-control study based on 21,660 consecutive clinical necropsies at Malmö University Hospital

CONCLUSION

In this necropsy-based case-control study, there was no relationship between pancreatic carcinoma and previous gastric resection. Based on the association between lung cancer and gastric resection, it is suggested that the relationship between pancreatic carcinoma and gastric resection shown in other studies may have been confounded by smoking.

BACKGROUND

This case-control study was designed to assess whether in patients dying from pancreatic carcinoma, there is a relationship to previous gastric resection for peptic ulcer disease.

METHODS

By linking the autopsy data base in Malmö with the national Cause of Death Register, we identified 439 autopsied individuals who had died of pancreatic carcinoma between 1970 and 1982. The 21,660 individuals in the data base represent 64% of all deaths during that time period. For each of these individuals who died of pancreatic carcinoma, we randomly chose three controls who were matched for age at death, gender, and year of death. In order to assess the specificity of the assumed relationship, we also used as a control group the 1337 autopsied individuals who had died of lung cancer.

RESULTS

The prevalence of previous gastric resections was 3.4% in patients dying from pancreatic carcinoma, 7.6% in patients dying from lung cancer, and 4.4% in the age- and sex-matched control group. The odds for previous gastric resection in patients dying from pancreatic carcinoma was 0.9 [95% confidence interval (CI) 0.5-1.7] in comparison with this age- and sex-matched control group. The lower odds for previous gastric resection in patients dying of pancreatic carcinoma than in patients dying of lung cancer remained in the logistic regression analysis after controlling for age at death, gender, and year of death (odds ratio [OR] 0.5; 95% CI 0.3-0.9).