Employment status in cancer patients the first five years after diagnosis-a register-based study

PURPOSE

Work is important for identity formation, social status, and economic independency. Although some evidence within the field of work and cancer survivorship exists, no study has so far investigated employment status across all cancer diagnoses. Thus, the aim of the present study was to investigate the impact of all cancer diagnoses on employment status.

METHODS

Danish cancer patients aged 20-60 years, diagnosed between 2000 and 2015, were identified through Danish registers and matched 1:5 with cancer-free controls. Logistic and linear regression was performed separately in 11 cancer types to assess and compare work status and work participation between cancer patients and cancer-free controls one, three, and five years after diagnosis.

RESULTS

A total of 111,770 cancer patients and 507,003 cancer-free controls were included. All cancer types had lower chances of working one year after diagnosis (ORs between 0.05 and 0.76), with lung, colorectal, upper gastrointestinal, and blood cancer patients having the lowest chances. After three years, 10 of 11 cancer types had lower chances (ORs between 0.39 and 0.84). After five years, there were minimal differences between cancer patients and controls among most cancer types (ORs between 0.75 and 1.36).

CONCLUSION

Most cancer patients had lower chances of working compared with the general population until five years after diagnosis. However, patients with certain cancer types experienced lower chances of working all years, despite improvement over time.

IMPLICATIONS FOR CANCER SURVIVORS

The knowledge will help increase awareness on challenges regarding work-life after cancer. Furthermore, the distinguishing between diagnoses can inform to more targeted vocational rehabilitation.

The development of medical infographics to raise symptom awareness and promote communication to patients with cancer: A co-creation study

Objective

The study aims to develop medical infographics that have a potential to raise symptom awareness and promote symptom communication between patients diagnosed with cancer and healthcare professionals.

Methods

This study comprised four phases: 1) development of medical infographics, 2) user testing with healthcare professionals and patients, 3) selection of specific medical infographics, and 4) interviews on these specific medical infographics with patients using the think-aloud method.

Results

Design students created 22 medical infographics conveying information about six symptoms and concerns. Patients (n = 28) with cancer said that the colourful infographics evoked individual emotional responses and associations, and they facilitated their narratives of experiences with symptoms. Healthcare professionals (n = 29) thought the infographics were eye-catching and may promote dialogue on symptoms.

Conclusions

The design of medical infographics must target a specific population. When introduced, the use of medical infographics may be influenced by the physical surroundings. Medical infographics can facilitate symptom communication by creating symptom awareness and providing patients with the vocabulary to describe their symptoms and concerns.

Innovation

Medical infographics are engaging visual messages with the potential to help prepare cancer patients to communicate their symptom experiences and reduce the feeling of being alone in experiencing certain symptoms.

Dissatisfaction and persistent post-operative pain following total knee replacement – A 5 year follow-up of all patients from a whole region

Introduction

Total knee replacement (TKR) is the treatment of choice for the millions of individuals whose osteoarthritis related pain can no longer be managed through non-invasive methods. Although most patients report improvement in pain and functioning following TKR, up to 30% report after 1–2 years persistent pain that interferes with their daily function. Further knowledge on long term results are highly demanded. The present study is the first 5 year follow-up of all patients from a whole region.

Methods

Patients were interviewed by letter concerning pain, overall satisfaction and forgotten joint score (FJS). In 2011, 607 patients in the region of North Denmark had a primary TKR, of which 20 was bilateral. Still alive are 546 patients. A total of 498 answered by letter (91%) of which 13 were not able to answer detailed due to psychological reasons.

Results

A total of 290 (59%) patients were very satisfied with their TKR, 140 (30%) were satisfied and 58 (12%) dissatisfied. Pain free were 269 (55%). 163 patients (33%) experienced moderate pain and 55 (11%) had strong pain. Dissatisfaction and pain were highly correlated, especially pain at walking: Among patients reporting strong pain, 35 (64%) scored higher than 6 on the VAS-average pain last 24 h versus 46 (84%) that scored higher than 6 on the VAS-pain after 30 min’s walk.

Conclusions

Among an unselected series of patients having TKR, 12% were dissatisfied and 11% still had strong pain 5 years later. Dissatisfaction was especially correlated with pain when walking. Thus, the association between dissatisfaction, pain at activity and the individual expectations should be further focused.

Feasibility of self-directed learning in clerkships

BACKGROUND

Self-directed learning has been well described in preclinical settings. However, studies report conflicting results when self-directed initiatives are implemented in clinical clerkships.

AIM

To explore the feasibility of self-directed learning stimulated by clinical encounter-cards (CECs) in clinical clerkships.

METHODS

Two focus groups of year-four and year-five students were interviewed about the usefulness of CECs to their learning in clerkships. The CECs were then introduced in two cohorts of 248 year-four and 250 year-five medical students and evaluated on a nine-point scale with regard to usefulness and feasibility.

RESULTS

The pilot groups reported that the CECs had positive effects in terms of engaging in diagnostic reasoning, reflection on management plans, and professional identity formation. However, the two large cohorts of students rated the usefulness of the CECs on learning in clerkship low (year-four: mean 2.92, SD 1.54; year-five: mean 2.28, SD 1.06) along with preceptor support (year-four: mean 2.68, SD 1.62; year-five: mean 2.59, SD 1.78, p = 0.34).

CONCLUSION

Self-directed CECs can have a positive effect on participation and clinical reasoning but are highly dependent on the context of use. Self-directed learning initiatives that aim to increase participation in communities of practice may not be feasible without major faculty development initiatives.

The Value of Dihydrouracil/Uracil Plasma Ratios in Predicting 5-Fluorouracil-Related Toxicity in Colorectal Cancer Patients

This study investigated the relationship between the dihydrouracil/uracil (UH2/U) plasma ratio, a surrogate marker of dihydropyrimidine dehydrogenase (DPD) activity, and 5-fluorouracil (5-FU)-related early toxicity. Plasma UH2/U ratios were determined in 68 colorectal cancer patients and 100 healthy controls. A cutoff value indicative of DPD deficiency was calculated using receiver operator characteristics. Patients experiencing toxicity were screened for the DPD G-to-A point mutation within the 5′-splicing donor site of intron 14 (IVS14+1G>A). Overall, 24/68 patients (35%) experienced toxicity (all grades) and abnormal UH2/U ratios were demonstrated in 21/24 (87.5%) patients. Drug concentrations up to 130 times the recommended level were found in 13/24 (54%) patients experiencing toxicity. One patient experiencing toxicity was a heterozygous carrier of the IVS14+1G>A mutation. A low UH2/U plasma ratio had a sensitivity of 0.87 and specificity of 0.93 for predicting 5-FU-induced toxicity. Systematic detection of DPD-deficient patients using the UH2/U ratio could optimize 5-FU-based chemotherapy and minimize life-threatening toxicity.

Intramuscular adrenaline does not reduce the incidence of respiratory distress and hypoglycaemia in neonates delivered by elective caesarean section at term

AIM

To test whether intramuscular injection of 30 microg adrenaline decreased the incidence of respiratory distress and hypoglycaemia in term infants delivered by elective caesarean section before active labour.

METHOD

The study was randomised and double-blinded. A total of 270 neonates were assigned to intramuscular treatment with saline (0.30 ml) or 30 microg adrenaline (0.30 ml) immediately after birth. The primary endpoint was referral to the neonatal ward because of respiratory distress or a blood glucose level <1.8 mmol/l measured 2 h after birth. The first 50 infants were monitored with pulse oximetry to disclose potential side effects.

RESULTS

Pulse-oximetry recordings revealed a modest systemic effect by intramuscular adrenaline as the heart rate and the haemoglobin oxygen saturation were significantly higher in infants who received adrenaline. In contrast, the incidence of respiratory distress and hypoglycaemia was 14% among infants treated with adrenaline compared with 7% in those who received saline injection (p = 0.048).

CONCLUSION

Intramuscular injection of 30 microg adrenaline does not reduce the incidence of respiratory distress or hypoglycaemia after elective caesarean section.

Influence of ionizing radiation on nucleus 24 cochlear implants

HYPOTHESIS

To evaluate the influence of conventional or hyperfractionated radiotherapy on Nucleus CI24M or CI24R(CS) implant systems.

BACKGROUND

As a consequence of more than 70,000 cochlear implant recipients worldwide, the potential need for radiotherapy is an issue requiring consideration by both implantees and implantation centers. Conditions requiring radiotherapy of the head may include head, neck, or brain tumors.

METHODS

The study examines the effect of ionizing radiation on cochlear implant function. The implanted devices examined were the Nucleus CI24M and Nucleus CI24R(CS). In a modeled study, two implants of each type were treated with fraction schemes most frequently used in clinical routine (e.g., conventional fractionation [total dose, 120 Gy] and hyperfractionation [total dose, 116 Gy]). Parameters quantified were the implant output amplitude changes at high and low current level (current levels 255 and 100, respectively), the charge balance of the biphasic pulse, and the accuracy of the impedance telemetry function.

RESULTS

Within the clinically relevant dose range (< 80 Gy), implant function in all four devices was normal. Failure occurred in one Nucleus CI24R(CS) device treated with hyperfractionation. A dramatic drop in the output amplitude at 106 Gy was observed, and the impedance measurement failed at a total dose of 111 Gy.

CONCLUSION

The results suggest that conventional or hyperfractionated radiotherapy can be applied safely at Nucleus CI24M or CI24R(CS) implant systems in a patient-like setting. Therefore, the authors propose that the results of the study can be applicable in clinical practice.

Evidence that the Cys282Tyr mutation of the HFE gene originated from a population in Southern Scandinavia and spread with the Vikings

Hereditary hemochromatosis has been recognized as a clinical disorder for more than 100 years. The common form of the disorder is caused by the Cys282Tyr mutation (C282Y) of the HFE gene. Hereditary hemochromatosis affects predominantly people of Northern European origin. The C282Y mutation probably occurred on a single chromosome carrying the ancestral hemochromatosis haplotype, which subsequently was spread by emigration and the founder effect. It has been estimated that the C282Y mutation appeared 60-70 generations ago. It was initially suggested that the ancestral C282Y mutation occurred within the Celtic group of peoples. However, we hypothesize that the distribution of the C282Y mutation in Europe is more consistent with an origin among the Germanic Iron Age population in Southern Scandinavia. From this area, the mutation could later be spread by the migratory activities of the Vikings. The aim of the present study was to evaluate the validity of these two hypotheses. Several arguments are in favor of the 'Viking hypothesis': first, the highest frequencies (5.1-9.7%) of the C282Y mutation are observed in populations in the Northern part of Europe, i.e. Denmark, Norway, Sweden, Faeroe Islands, Iceland, Eastern part of England (Danelaw) and the Dublin area, all Viking homelands and settlements. Second, the highest allele frequencies are reported among populations living along the coastlines. Third, the frequencies of the C282Y mutation decline from Northern to Southern Europe. Intermediate allele frequencies (3.1-4.8%) are seen in the populations in Central Europe, which is the original Celtic homeland. Low allele frequencies (0-3.1%) are recognized in populations in Southern Europe and the Mediterranean.

Children with nutritional rickets referred to hospitals in Copenhagen during a 10-year period

AIM

To describe the prevalence of nutritional rickets among children admitted to three large paediatric departments in the Copenhagen area during a 10 y period.

METHODS

Retrospective analysis of cases identified from the diagnosis registers fulfilling the diagnostic criteria for nutritional rickets.

RESULTS

Forty cases were identified, distributed in two distinct age groups: 0.5-4 y (n = 31) and 9-15 y (n = 9). All cases were immigrants, of whom 95% were born in Denmark. The main symptoms in the younger age group were bowed legs and clumsy walk, and in the peripubertal group were painful joints. Two children had generalized convulsions. None of the cases had received vitamin D supplementation.

CONCLUSION

Nutritional rickets is still present among immigrants in Denmark, and it is likely that the prevalence of mild cases is high. Prevention through vitamin D supplementation is important, but requires a dedicated health education effort.

HFE mutations and hemochromatosis in Danish patients admitted for HFE genotyping

Analysis of the common C282Y and H63D mutations in the HFE gene is widely used to diagnose hereditary hemochromatosis (HH). The aim of this study was to evaluate the efficiency with which different hospitals and general practitioners select patients for HH genotype and to determine the distribution of HFE mutations in such patients. Nine hundred unrelated patients from Danish hospitals and general practitioners (group A) and 69 consecutive patients from a specialized liver unit (group B) were examined for HFE substitutions using multiplex real-time polymerase chain reaction. In group A we found 13.0% (0%) C282Y homozygotes, 5.8% (2.6%) H63D/C282Y compound heterozygotes and 1.9% (3.1%) S65C heterozygotes. The values for 420 Danish blood donors are shown in parentheses. The distribution of genotypes in group B was similar to that of the blood donors. Serum ferritin, transferrin iron saturation and pathological data were collected from 38 randomly selected C282Y homozygotes, 36 H63D/C282Y compound heterozygotes, 19 H63D heterozygotes, 17 S65C heterozygotes and 144 wild-types. All of the C282Y homozygotes and 28% of the compound heterozygotes were diagnosed as HH patients. There was no evidence of HH in the H63D homozygotes or S65C heterozygotes. Moreover, 7 wild-type patients, 2 C282Y heterozygote patients and one H63D heterozygote patient fulfilled the criteria for HH. The significant enrichment of HH among associated genotype samples submitted for HFE testing indicates that the clinical selection is generally adequate. However, the study showed substantial deviation in the selection efficiency among the various hospitals and general practitioners.

Clinically overt hereditary hemochromatosis in Denmark 1948-1985: epidemiology, factors of significance for long-term survival, and causes of death in 179 patients

The object was to analyze, in a nationwide survey, the incidence and course of hereditary hemochromatosis in relation to the degree of iron overload and the presence of organ damage. The study included 179 Danish Caucasian patients with clinically overt hemochromatosis diagnosed between 1948 and 1985. A cohort of 158 patients was followed for a median of 8.5 years (range: 0.2-29.5). From 1951 to 1975, the yearly relative incidence rate was constant: 0.58/100,000 persons >20 years of age. From 1981 to 1985, the yearly relative incidence rate rose to 1.40/100,000 persons >20 years of age. Survival was reduced in the entire series when compared with a matched control population ( p<0.0001). There was a steady increase in survival from 1948 to 1985 ( p<0.002). Survival was significantly reduced in patients with liver cirrhosis and/or diabetes mellitus ( p<0.01). In contrast, survival in patients without cirrhosis or diabetes was similar to rates expected. Survival in patients with arthropathy was higher than in patients without joint affection ( p<0.004). Patients adequately treated with phlebotomy ( n=66) had a higher survival than inadequately treated patients ( n=62; p<0.0001). Adequately treated patients with cirrhosis and/or diabetes had better survival than inadequately treated patients with similar organ damage ( p<0.001). The main causes of death were hepatic failure due to cirrhosis (32.0%) and cirrhosis with liver cancer (23.1%). Sharpened diagnostic awareness has improved early diagnosis and increased the diagnostic frequency of clinical hemochromatosis. Adequate phlebotomy treatment was the major determinant of survival and markedly improved prognosis. Early detection and treatment of this common iron overload disorder is crucial and can completely prevent any excess mortality caused by hemochromatosis.

Cerebral response to electric stimulation of the colon and abdominal skin in healthy subjects and patients with irritable bowel syndrome

BACKGROUND

Visceral hyperalgesia may play an important part in the pathophysiology of the irritable bowel syndrome (IBS). We investigated the neuronal afferent pathways in healthy volunteers and IBS patients by recording evoked potentials (EPs) elicited by electrical stimulation of the colon and abdominal skin inside and outside the referred pain area.

METHODS

Six healthy subjects and nine IBS patients met the inclusion criteria. Morphology and topography of EPs to painful electrical stimuli were estimated in the rectosigmoid junction and on the skin inside/outside the referred pain areas.

RESULTS

The EPs to painful stimuli of the gut showed a shorter latency and a smaller amplitude of the first positive peak (P1) in the IBS group. The controls had a mid-latency frontal positive component after 100 ms, whereas no reliable early activation was seen in the IBS patients. In controls, a single late (>150 ms) positive component was seen, whereas the late component was biphasic in the IBS group. The EPs to painful stimuli of the two skin areas differed in IBS patients, but not in controls.

CONCLUSION

Differences in the EPs to electrical painful stimulation of the sigmoid colon and skin inside/outside the experimentally evoked referred pain area were seen comparing healthy subjects and IBS patients. The results indicate altered central nervous system responses.

Nonsteroidal progesterone receptor ligands with unprecedented receptor selectivity

We have characterized a series of nonsteroidal progesterone receptor ligands, the tetrahydropyridazines. Compounds in this series, exemplified by RWJ 26819, demonstrate high affinity and unprecedented specificity for the progesterone receptor relative to other steroid hormone receptors. Like steroidal progestins, RWJ 26819 induces binding of the receptor to a progesterone response element in vitro, and stimulates gene expression in and proliferation of T47D human breast cancer cells. When administered to rabbits orally or subcutaneously, the compound induces histological changes in the uterine lining comparable to those induced by levonorgestrel. It also inhibits ovulation in monkeys. Though less potent in cells and in animal models than would be predicted from binding affinity alone, their enhanced selectivity suggests that they could be effectively used in a clinical setting. Most of the tetrahydropyridazines synthesized are progestin agonists or mixed agonists and antagonists in vitro; however, one compound with antagonist activity in the rabbit uterine transformation assay has been identified.

[Cryptorchism. Outcome of treatment and referral patterns in an unselected group of patients in a 3-year period]

The age of diagnosis and referral together with the efficacy of HCG treatment were studied retrospectively in 196 unselected cryptorchid patients seen over a period of three years. The median age of diagnosis was 2 years and 7 months, whereas the median age of referral was three years later. During the period of study, guidelines for referral and therapy were published in a nationwide journal and in the local region, and a slight but significant fall in age of referral was seen thereafter. The median age of treatment with HCG, 92 patients, was 6 years and 11 months, and median age of surgery, was 7 years and 7 months. The rate of success with HCG was for bilateral testes 41% and for unilateral testes 21%, giving an overall success rate of 30%. This result is lower than previously reported, which is most likely explained by a higher suprascrotal position of testes before treatment. Guidelines and recommendations for referral and therapy seem to influence the time of referral, which is, however, in this study not in accordance with the consensus of definitive treatment before the age of two years. Early diagnosis is recommended and should be followed by referral to a paediatric department with particular interest and knowledge about cryptorchidism.

A polymorphic variant in the human electron transfer flavoprotein alpha-chain (alpha-T171) displays decreased thermal stability and is overrepresented in very-long-chain acyl-CoA dehydrogenase-deficient patients with mild childhood presentation

The consequences of two amino acid polymorphisms of human electron transfer flavoprotein (alpha-T/I171 in the alpha-subunit and beta-M/T154 in the beta-subunit) on the thermal stability of the enzyme are described. The alpha-T171 variant displayed a significantly decreased thermal stability, whereas the two variants of the beta-M/T154 polymorphism did not differ. We wished to test the hypothesis that these polymorphisms might constitute susceptibility factors and therefore determined their allele and genotype frequencies in (i) control individuals, (ii) medium-chain acyl-CoA dehydrogenase-deficient patients homozygous for the K304E mutation (MCAD E304), (iii) a group of patients with elevated urinary excretion of ethylmalonic acid (EMA) possibly due to decreased short-chain acyl-CoA dehydrogenase activity, and (iv) in patients with proven deficiency of very-long-chain acyl-CoA dehydrogenase (VLCAD). No significant overrepresentations or underrepresentations were found in the first two patient groups, suggesting that the polymorphisms studied are not significant susceptibility factors in either the MCAD E304 or the EMA patient group. However, in the VLCAD deficient patients the alpha-T171 variant (decreased thermal stability) was significantly overrepresented. Subgrouping of the VLCAD patients into three phenotypic classes (severe childhood, mild childhood, and adult presentation) revealed that the overrepresentation of the alpha-T171 variant was significant only in patients with mild childhood presentation. This is compatible with a negative modulating effect of the less-stable alpha-T171 ETF variant in this group of VLCAD patients that harbor missense mutations in at least one allele and therefore potentially display residual levels of VLCAD enzyme activity.

Epidemiology of respiratory syncytial virus infection requiring hospitalization in East Denmark

BACKGROUND

Prophylaxis against infection caused by respiratory syncytial virus (RSV) with high titered RSV immunoglobulin or humanized antibody may soon be available in Europe.

OBJECTIVE

To study the epidemiology of RSV infections requiring hospitalization in infants <6 months in East Denmark to provide a rational basis for decisions concerning prophylaxis against RSV.

METHOD

Populat ion-based retrospective review of case records of infants <6 months admitted to pediatric departments with RSV infection in East Denmark from November 1, 1995, to April 30, 1996.

RESULTS

Data were obtained from 459 infants. Seventy-three had predisposing conditions: prematurity, 49; pulmonary disease, 2; congenital heart disease, 7; neurologic disease, 6; others, 9. One preterm infant had bronchopulmonary dysplasia. The incidence of RSV infection requiring hospitalization in East Denmark among infants <6 months was estimated to be 34/1000/season. It was 32/1000/season among term infants and 66/ 1000/season among preterm infants (P<0.001). Infants with predisposing conditions and/or nosocomial infection (n = 24) had significantly more severe courses than otherwise healthy infants (P<0.01). One-hundred thirty infants received respiratory support by nasal continuous positive airway pressure, but only six required mechanical ventilation. No infants died.

CONCLUSION

The course of RSV disease in East Denmark was milder than reported elsewhere, possibly as a result of the low prevalence of bronchopulmonary dysplasia in Denmark. However, RSV constitutes a considerable burden to the Danish pediatric health care system, and therefore prophylaxis against RSV is desirable.

Small intestinal transit time and intraluminal pH in ileocecal resected patients with Crohn's disease

The pH and transit times of the gut are important for the delivery of active drug from several tablets used in the treatment of Crohn's disease (CD). Many patients with CD undergo an ileocecal resection, which might influence small intestinal pH and transit time. The effect of ileocecal resection on these variables has not previously been studied. Intraluminal pH and transit time were measured in nine ileocecal-resected CD patients and 13 healthy volunteers using pH-sensitive radiocapsules. Small intestinal transit time (SITT) was significantly shorter in ileocecal-resected patients (5.2 hr, controls 8.0 hr). The pH levels of the small intestine were identical in patients and controls, whereas cecal pH was 0.9 pH units higher in resected CD patients. The time spent with pH higher than 5.5, 6.0, 6.5, and 7.0 was significantly shorter in patients than in controls. There was no correlation between the SITT and the length of resected ileum or between the SITT and the time elapsed since the resection. We conclude that ileocecal resection decreases the SITT and the time with pH higher than 5.5-7.0. The study indicates that this reduction of the SITT is mainly due to the resection of the ileocecal valve and is, to a certain extent, independent of the length of resected ileum. An ileocecal resection might therefore affect the delivery of active drug from tablets with pH-dependent delivery.

[Myocardial rupture during exercise ECG]

We report a case of heart rupture in connection with a stress test performed nine days after an otherwise uncomplicated myocardial infarction. The Danish Association of Cardiologists recommend stress testing 5-20 days after myocardial infarction. We question whether this timing is appropriate considering the vulnerability of the myocardium at that time.

[Acute admissions in pediatric psychiatry]

This is a case study of 49 acute admissions to the Child Psychiatry Department at the Copenhagen County Hospital in Glostrup over the four year period 1.1.1990-31.12.1993. The aim is to appraise the concept of acute child psychiatric admission, examine the relation between definition and practice and evaluate the acute service and its viability. A retrospective analysis of the case notes shows that the 42 children involved constitute a selected group of mainly 11-14 years old girls, the most frequent diagnosis at referral- and at discharge-being anorexia nervosa. Most cases are referred from paediatric departments. Eighty percent of the acutely admitted children have had previous contact with one or more institutions. Time interval breakdown shows that more than a quarter of the cases were admitted some weeks after referral. The acute group had on average fewer hospital days than all other cases and only 12% were discharged without needing of further treatment. A further analysis revealed an inconsistency in terms of definition and practice. Only 39% of the patients were admitted within a 24-hour period after the acute referral, while 74% were admitted within the first week. The explanation is offered, that the definitions of and the indications for acute child psychiatric hospitalisation were loosely formulated and different from the more stringent medical terms and that some cases must be seen as being more of a subacute nature or representing clinical or social relapses. The question is raised whether the concept of acute admission in child psychiatric terms is viable.

Oral ciprofloxacin versus intravenous cefuroxime as prophylaxis against postoperative infection in vascular surgery: a randomised double-blind, prospective multicentre study

OBJECTIVES

To test the hypothesis that oral ciprofloxacin is equally effective as intravenous cefuroxime in preventing postoperative infectious complications in patients undergoing peripheral arterial surgery involving the groins.

DESIGN

Prospective, randomised, double-blind multicentre study.

MATERIALS

580 patients undergoing arterial surgery involving the groins were randomised to ciprofloxacin (Ciproxin, Bayer) 750 mg x 2 p.o. or cefuroxime (Zinacef, Glaxo) 1.5 g x 3 i.v. given only on the day of surgery. The primary endpoint was wound/graft infection within 30 days postoperatively. Wound infection was defined as pus.

RESULTS

The wound infection rate in the ciprofloxacin group was 9.2% (27 patients) and in the cefuroxime group 9.1% (26 patients) according to intention to treat. For correct treatment the corresponding numbers were 9.5% (23 patients) and 9.7% (22 patients), respectively. There were three graft infections (0.5%). The infection rate was 7.1% (31/433) in the absence and 14.9% (22/147) in the presence of distal ulcers (p < 0.05). S. allreus was the most common bacteria isolated. Forty percent of the wound infections were localised to the groins. By multivariate analysis presence of distal ulcer was the only factor of prognostic significance.

CONCLUSIONS

The infection rate was similar in the two groups. Thus, oral administration of ciprofloxacin is an attractive, cost-effective and safe alternative to prophylaxis in vascular patients capable of taking oral medication on the day of surgery.

[The social recruitment of medical students at Copenhagen University 1992/1993]

As part of a prospective survey of medical students' conditions and of the different kinds of influence they are subjected to during their study periods, we looked into the question of from which social strata the students were recruited. Two hundred and fifty-four (79%) of 323 medical students matriculated during the summer of 1992 answered a structured questionnaire forwarded to them. One hundred and thirty-one (52%) medical students were recruited from the highest social class (I), whereas only 19 (7%) were recruited from the lowest social class (V). In comparison, the underlying population in the age groups relevant for the survey is made up as follows: 7% in social class I and 20% in social class V. A comparison with earlier surveys shows that only insignificant changes in the medical students' social class profiles have taken place in spite of the introduction of better possibilities of financing medical studies irrespective of social class affiliations.

An overview of European chiropractic practice

OBJECTIVE

The aim was to survey chiropractic practice in Europe.

DESIGN

A postal questionnaire survey of all chiropractors in the European Chiropractors' Union (1990) yielded demographic information and practice characteristics. Patient case forms, completed by randomly selected practitioners, revealed the demographic features, presenting complaints, diagnoses and management procedures used.

SETTING

The survey was conducted in private chiropractic practices of 13 European countries.

PARTICIPANTS

Nine hundred five practitioner questionnaires (70% response) and 1014 patient case forms were used.

MAIN RESULTS

Demographic features of chiropractors and patients compare well to previous studies. Most chiropractors, one-quarter of whom are now females, were European trained. Many practice in groups and in cooperation with other health professions, especially in relation to radiology. Radiographs are used in nearly two-thirds of cases, yet only 25% of patients were X-rayed in chiropractic clinics. Nearly half of the patients consulted in the first month of their complaints, which were mainly of musculoskeletal pain. Virtually no evidence appeared of attempts to manage viscerosystemic disease. The manual techniques used varied considerably according to country. Most patients were at work during the course of their treatment.

CONCLUSIONS

The results reflect a considerable maturation of the profession over the past two decades. The study highlights the socioeconomic potential for the treatment of chronic and severe musculoskeletal pain.

Rehabilitation after amputation following lower limb fracture

Twenty-two patients were interviewed after lower limb amputation above the ankle joint following fractures. Their median age at the time of the injury was 44 years (range, 14-77 years), and median amputation delay was 2 months (range, 0-213 months). Of the 15 patients who were working before the injury, ten returned to gainful employment after amputation. Amputation delay did not affect the ability to return to work. Twenty patients could walk outdoors; two patients aged 69 and 71 years could not, but regularly went outdoors using a wheelchair or a three-wheeled moped. Eleven patients were more or less dependent on help from others. The study indicates that most patients have an acceptable functional result, but with increasing age the chance of a return to employment decreases, and the need for help with everyday demands increases.

The efficacy of Na-naproxen after diagnostic and therapeutic arthroscopy of the knee joint

The purpose of the study was to evaluate the effect of na-naproxen after diagnostic arthroscopy and arthroscopic surgery of the knee joint. In a double-blind trial, 41 patients were randomized to treatment with na-naproxen, and 46 patients were given placebo after surgery. For additional analgesia, patients got acetaminophen if necessary. In patients who underwent arthroscopic surgery, there were no differences between those treated with na-naproxen and those who received placebo in pain levels, but patients receiving na-naproxen had significantly less need for additional analgesia and returned significantly more quickly to work than patients receiving placebo (median 10 versus 30 days). In patients who had only diagnostic arthroscopy, there were no differences between the na-naproxen and placebo groups.

Metastatic choriocarcinoma with coexistent term pregnancy following four recurrent consecutive moles

A case is reported of a 38-year-old woman with metastatic choriocarcinoma which followed four recurrent consecutive hydatidiform moles occurring within the preceding 5-year period. She conceived while having pulmonary metastasis, had a coexistent normal pregnancy and delivered a normal infant at term. Surgical resection of the lung lesion together with chemotherapy accomplished a sustained remission, with no evidence of disease after 20 months' follow-up.

Bone densitometry of excised vertebrae; anatomical relationships

Bone mineral density (BMD) was determined in 32 excised vertebrae using three methods: (1) dual-energy quantitative computed tomography (QCT), (2) dual-photon absorptiometry (DPA) with 153-Gd in an anteriorposterior projection and (3) scanning slit X-ray absorptiometry (SSXA) in both AP and lateral projections. The QCT region-of-interest in the anterior vertebral body had a lower density than that of the total trabecular portion of the body, but was highly correlated to this larger region (r = 0.96; SEE = 8 mg/cm3). The anterior QCT region also correlated moderately with BMD from DPA (r = 0.77; SEE = 18 mg/cm3). Measurements of the vertebral body in lateral projection were less well correlated (r = 0.5-0.7) to QCT densities. Both the anterior QCT region (r = 0.81; SEE = 18 mg/cm3) and the BMD from DPA (r = 0.86; SEE = 16 mg/cm3) and the BMD from DPA (r = 0.86; SEE = 16 mg/cm3) were similarly predictive of density of the integral vertebral body. Differences among densitometric methods on the spine depend on the projection used and the region examined.

Normal pregnancy after curative multiagent chemotherapy for choriocarcinoma with brain metastases

A case is reported of a metastatic gestational choriocarcinoma in a 25-year old woman. Extensive pelvic, pulmonary and brain metastases were associated with clinically manifest thyrotoxicosis. Multiagent chemotherapy alone was successful in achieving a durable remission and euthyroid state. The chemotherapy regimen consisted of cis-platinum, etoposide, actinomycin-D, and intrathecal methotrexate (PEA-M). The Patient conceived 2 years after completing therapy and gave birth at term to a normal infant.

[New illuminated spectacles for vestibular diagnosis]

Frenzel's spectacles have been essential tools for the clinical examination of the vestibular system since 1925. However, they may lead to false-negative results because they enable the patient to fixate, or to false-positive results because they induce pseudospontaneous nystagmus. Both pitfalls originate from direct illumination of the patient's eyes, and we propose a new design using indirect illumination.

Long saphenous vein saving surgery for varicose veins. A long-term follow-up

The autologous saphenous vein is widely recognised as the graft material of choice in infra-inguinal arterial reconstructions. This study was undertaken to evaluate the long-term results of long saphenous vein saving surgery compared with standard stripping. Forty-two patients with varicose veins were randomly allocated to treatment, either with standard stripping of the long saphenous vein or high ligation. In both groups, local varicosities were avulsed and insufficient perforators ligated, on the basis of physical examination and phlebography. Follow-up was performed 52 +/- 5 months postoperatively. The recurrence rate was 12 and 11% in the stripping and the high ligation group respectively. At follow-up, the venous return time was increased significantly in both groups (P greater than 0.001). Vein mapping by means of high-resolution, real-time ultrasound at follow-up showed that 78% of the preserved saphenous veins were suitable for use as arterial conduits. These results suggest that removal of the long saphenous vein per se is of no therapeutic value if insufficient perforators have been ligated. It is possible to perform elective vein surgery for varicose veins with good results and preserve the long saphenous vein, which in turn can be used for future arterial reconstruction in most cases.

Combined treatment with indomethacin and low-dose heparin after total hip replacement. A double-blind placebo-controlled clinical trial

We studied the safety of combining the postoperative use of a non-steroidal anti-inflammatory drug with low-dose heparin. In a double-blind, placebo-controlled clinical trial we reviewed the complications in 235 patients after total hip replacement, all treated with low-dose heparin and either indomethacin or a placebo. The incidence and type of complications in the two groups were nearly equal; indomethacin-treated patients had no increase in complications related to bleeding. Postoperative bleeding into drains was marginally greater in the indomethacin group, although the difference was not statistically significant. We conclude that treatment with indomethacin and low-dose heparin after hip replacement does not significantly increase the bleeding or other complications. We also found that patients receiving indomethacin were mobilised an average of one day before those on placebo.

Effect of catabolic hormone infusion on protein turnover and amino acid uptake in skeletal muscle

Increased plasma levels of the catabolic hormones glucagon, epinephrine, and cortisol have been implicated in mediating various metabolic alterations in trauma and sepsis. Their role in altered protein turnover and amino acid transport in skeletal muscle during sepsis, however, is not known. In the current study, rats were infused with a mixture of the catabolic hormones for 16 hours. Control animals were infused with vehicle solution. Protein synthesis and degradation rates were measured in incubated, intact soleus muscles as incorporation of 14C-phenylalanine into protein and release of tyrosine into incubation medium, respectively. Muscle amino acid uptake was determined by measuring the intracellular to extracellular ratio of [3H]-alpha-aminoisobutyric acid after incubation for 2 hours. Infusion of catabolic hormones for 16 hours resulted in elevated plasma glucose and lactate levels, reduced plasma concentrations of most amino acids, and accelerated muscle protein breakdown, similar to previous findings in septic rats. Protein synthesis rates and amino acid uptake in incubated muscles were not significantly different in control and hormone-infused rats. The current study suggests that increased muscle proteolysis in sepsis and severe injury may be mediated in part by catabolic hormones. In contrast, reduced muscle protein synthesis and amino acid uptake are probably signaled by other substances or mechanisms.

[Clinical use of click evoked oto-acoustic emissions at the Freiburg ENT clinic]

Click-evoked otoacoustic emissions appear to be an efficient way to assess cochlear function in infants and neonates. A new technique developed by Bray and Kemp (1987) enables data to be gathered under clinical conditions. A total of 310 children aged between one day and five years were examined in a realistic clinical situation: 204 of them were admitted to the authors' outpatient department for evaluation of a hearing impairment and 106 were special-care babies or normal newborns. Otoacoustic emissions were successfully tested in 244 of these 310 children at the first attempt after performing behavioural tests. A classification of the emissions by the coefficient of the cross-correlation function and the frequency response spectrum was used. Emissions were observed in 95% (n = 181 ears) of the three- to five-year-old children with a mean behavioural threshold better than 20 dB. In 82% (40/49) of the special-care babies and in 89% (51/57) of the normal newborns a successful emission recording was be obtained. Such findings suggest that this technique for detecting emissions may be useful in early diagnosis of hearing impairments, especially when combined with simple behavioural tests.

[The use of digital subtraction angiography/phlebography in pediatrics]

In a retrospective analysis of fourteen digital subtraction angiographies and phlebographies on 12 children during the last 18 months the diagnostic accuracy and safety were evaluated. Accurate diagnosis was possible in all cases and no complications occurred. The subtraction procedure most likely could not be replaced by other modes of investigation. It is superior to conventional angiography and phlebography and can be performed quickly and safely.

Erythrocyte sedimentation rate and heterotopic bone formation after cemented total hip arthroplasty

The erythrocyte sedimentation rate (ESR) was analyzed in 176 patients treated with cemented total hip arthroplasty (THA) for primary osteoarthritis and correlated with the degree of heterotopic bone formation (HBF) one year after the THA. Ninety patients were treated with indomethacin in the first six postoperative weeks, and 86 patients had no antiinflammatory treatment during that same period. The ESR was measured with the Westergren method and estimated preoperatively and six and 12 weeks after THA. Patients treated with indomethacin had no or only Grade I HBF and no significant elevation in the six- and 12-week ESR. In the placebo group, 44 patients (51%) developed Grade II or Grade III HBF, and six weeks after THA, patients with Grade III HBF had a significant elevated ESR when compared with patients without or with Grade I HBF. Moreover, in patients not treated with indomethacin in the first six postoperative weeks, an ESR above 35 mm/hour 12 weeks after THA was found to be a reliable predictor for the development of severe HBF.

[Pseudoaneurysm of the deep femoral artery after osteosynthesis of a pertrochanteric fracture of the femur]

A woman aged 66 years developed a pseudoaneurysm from the deep femoral artery after osteosynthesis of a pertrochanteric fracture of the femur. During operation, it is important to avoid boring into the soft tissues on the medial aspect of the thigh and a screw of the correct length should be chosen.

Protein synthesis in liver following infusion of the catabolic hormones corticosterone, epinephrine, and glucagon in rats

The mediator(s) and mechanism(s) of acute-phase protein synthesis in the liver following injury and sepsis are not fully known. Elevated plasma levels of the catabolic hormones cortisol, glucagon, and epinephrine have been reported in trauma and sepsis. In previous reports, when these hormones were infused simultaneously (triple hormone infusion), several, but not all, of the metabolic alterations characteristic of sepsis occurred. In the current investigation, the effect of triple hormone infusion on hepatic protein synthesis was studied. Rats were infused intravenously during 16 hours with a solution containing corticosterone (4.2 mg/kg/h), glucagon (2.5 micrograms/kg/h), and epinephrine (6 micrograms/kg/h). Control animals were infused with a corresponding volume of vehicle. Total hepatic protein synthesis in vivo was measured with a flooding dose technique using [14C]-leucine. The synthesis of total secretory proteins and of the individual proteins albumin, complement component C3, and alpha 1-acid glycoprotein was measured in isolated, perfused liver using [3H]-leucine and a recirculating technique. Urinary excretion of nitrogen and plasma concentration of glucose were higher and plasma total amino acid concentration was lower in hormone-infused than in control rats. Total hepatic protein synthesis in vivo, expressed as the proportion of the protein pool that was replaced each day, was increased from 39% +/- 2% per day to 48% +/- 3% per day (P less than .05) by hormone infusion, but synthesis of secretory proteins in perfused liver was not significantly altered. The results suggest that although total hepatic protein synthesis may be increased by catabolic hormones, other mediator(s) are probably responsible for the stimulation of acute-phase protein synthesis in sepsis.

Early radiolucencies following cemented total hip replacement. Influence of postoperative treatment with indomethacin

The influence of treatment with indomethacin in the first 6 postoperative weeks on the incidence of early loosening and radiolucencies following cemented total hip replacement were studied in 102 hips. Ninety-nine hips in 99 patients without postoperative antiinflammatory treatment served as control group. One year after surgery, two patients in the indomethacin group and five patients in the control group were suspected of having loosening of one or both prosthetic components. However, no patients had a revision. The lateral acetabular cement-bone interface most frequently showed a radiolucent line. Concerning the incidence of radiolucent lines in any acetabular or femoral cement-bone interface zone, no difference could be shown between the two groups. When evaluated 1 year after surgery, postoperative treatment with indomethacin does not increase the incidence of aseptic loosening or cement-bone interface radiolucencies in cemented total hip replacement.

Factors associated with heterotopic bone formation following total hip replacement

In order to delineate groups of patients suitable for treatment to prevent heterotopic bone formation (HBF) following total hip replacement, 99 patients were examined to evaluate predisposing factors. One year after surgery, HBF was found in 73% of the patients. A significantly increased frequency of HBF was found among men. There was no correlation between age, severity of osteoarthritis, size of osteophytes, or preoperative hip movement and HBF. Previous ipsilateral hip surgery did not increase the risk of HBF. Although not significant, all patients who developed heterotopic bone after previous ipsi- or contralateral hip surgery showed HBF of the same or even a higher grade after the present replacement.